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[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]

                   EVALUATING THE CAPACITY OF THE VA
                      TO CARE FOR VETERAN PATIENTS

=======================================================================

                                HEARING

                               before the

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                          Monday June 23, 2014

                               __________

                           Serial No. 113-76

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                         JEFF MILLER, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida Vice-      Member
Chairman                             CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O' ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida

                       Jon Towers, Staff Director

                 Nancy Dolan, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

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                                                                   Page

                          Monday June 23, 2014

Evaluating The Capacity Of The VA To Care For Veteran Patients        1

                           OPENING STATEMENT

Hon. Jeff Miller, Chairman
    Statement....................................................     1
    Prepared Statement...........................................     2

Hon. Mike Michaud, Ranking Minority Member
    Statement....................................................     4
    Prepared Statement...........................................     4

Hon. Corrine Brown
    Prepared Statement...........................................     7
Hon. Gloria Negrete McLeod
    Prepared Statement...........................................     8

                               WITNESSES

Thomas Lynch M.D., Assistant Deputy Under Secretary for Health 
  for Clinical Operations Veterans Health Administration, U.S. 
  Department of Veteran Affairs
    Statement....................................................     5
    Opening Statement............................................     8
    Prepared Statement...........................................    12

                  Accompanied by:

Carolyn M. Clancy M.D., Assistant Deputy Under Secretary for 
  Quality, Safety, and Value Veterans Health Administration, U.S. 
  Department of Veteran Affairs

                                APPENDIX

            STATEMENT FOR THE RECORD.............................    48

PVA Statement....................................................    48
Letter to Gibson From Michaud....................................    51
Questions........................................................    51
Responses........................................................    52

 
     EVALUATING THE CAPACITY OF THE VA TO CARE FOR VETERAN PATIENTS

                              ----------                              

                         Monday, June 23, 2014

              U.S. House of Representatives
                     Committee on Veterans' Affairs
                                           Washington, D.C.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The committee met, pursuant to notice, at 7:30 p.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present: Representatives Miller, Lamborn, Bilirakis, Roe, 
Flores, Benishek, Huelskamp, Coffman, Wenstrup, Walorski, 
Jolly, Michaud, Takano, Brownley, Titus, Kirkpatrick, Ruiz, 
Negrete McLeod, Kuster, O'Rourke, and Walz.
    The Chairman. Good evening. The committee will come to 
order.
    Welcome to tonight's full committee oversight hearing 
evaluating the capacity of the VA to care for veteran patients. 
During our proceedings this evening, we hopefully will assess 
the Department of Veterans Affairs efforts to increase the 
capacity and efficiency of medical facility operations and 
ultimately to improve access to care for veteran patients who 
have been facing unacceptably long wait times at VA facilities 
across the country.
    Important to those efforts is the status of VA's 
Accelerating Access to Care Initiative. The initiative was 
launched in late May in response to the Department's current 
wait time crisis, and information released last Thursday 
suggests that it, in coordination with VA's other efforts, has 
led to the scheduling of approximately 200,000 appointments 
from May 15th to June 1st.
    I am glad to see the Department seems to be taking its 
access failure seriously and is taking steps accordingly to 
improve the timeliness of care for veteran patients; however, I 
do have serious concerns about VA's efforts to date. One of my 
concerns is the continued lack of detailed information that 
Congress has received about the initiative, making this yet 
another in a long and continually increasing list of examples 
of VA failing to act in an open and transparent manner.
    The committee requested a briefing from the Department on 
the Accelerating Access to Care Initiative on June the 2nd. I 
followed up this request with a formal letter to Acting 
Secretary Gibson on June 5th, requesting an immediate briefing 
on the initiative. It has now been 19 days since that request 
for an immediate briefing, and no further information or 
acknowledgement of our request has been received. It baffles me 
as to why the Department failed to provide this committee with 
the information we requested on a program of this size and this 
importance. If VA's work has indeed led to 200,000 more 
appointments for veteran patients so far, what is there to 
hide?
    More importantly, over the last several weeks, 
investigations by the Inspector General's office and the 
Department itself have proven that the VA healthcare system 
suffers from a systemic lack of integrity. Data manipulation 
and patient waiting times were found to be widespread, and 
given that, how can Congress, the American taxpayer and our 
Nation's veterans and their families have any confidence in 
these latest numbers that the Department has released? 
Furthermore, if there were actions that VA could have taken to 
increase access to care for veteran patients, why were those 
actions not taken long before now?
    As part of the Accelerating Access to Care Initiative, VA 
claims to be taking steps to, in the Department's own words, 
systematically review clinical capacity, ensure primary care 
clinic panels are correctly sized and achieving the desired 
level of productivity, extend or flex clinic hours on nights 
and weekends, increase the use of care in the community, and 
reach out to veterans to coordinate the acceleration of their 
care.
    Each of these actions should have been operational 
components of regular VA business long before now, and VA has 
had the statutory authority to use these options previously.
    We know that at least 35 veterans in the Phoenix area alone 
died while waiting to receive VA care, though I suspect that 
number may rise in the coming weeks and months. We know that 
57,000 veterans nationwide have been waiting 90 days or more 
for their first VA appointment and we know that 64,000 veterans 
who were enrolled in the system over the last decade never 
received the appointment that they requested. It is too late 
for those 35 Phoenix area veterans and it may be too late for 
other veterans who have been waiting for weeks, months and in 
some cases years.
    So I ask again, if there were actions that VA could have 
taken to increase access to care for veteran patients, why were 
those actions not taken long before now?

          PREPARED STATEMENT OF JEFF MILLER, Chairman

    Good evening. The Committee will come to order.
    Welcome to today's Full Committee oversight hearing, 
``Evaluating the Capacity of the VA to care for Veteran 
Patients.''
    During tonight's proceedings, we will assess the Department 
of Veterans Affairs' (VA's) efforts to increase the capacity 
and efficiency of medical facility operations and, ultimately, 
improve access to care for veteran patients who have been 
facing unacceptably long wait times at VA facilities across the 
country. Important to those efforts is the status of VA's 
Accelerating Access to Care Initiative.
    The Initiative was launched in late May in response to the 
Department's current wait time crisis and information released 
last Thursday suggest that it - in coordination with VA's other 
efforts - has led to approximately two-hundred thousand 
increased appointments from May 15th to June 1st.
    I am glad to see that the Department seems to be taking its 
access failures seriously and is taking steps accordingly to 
improve the timeliness of care for veteran patients. However, I 
do have serious concerns about VA's efforts to-date. One of my 
concerns is the lack of detailed information Congress has 
received about the Initiative, making this yet another in a 
long and continually increasing list of examples of VA failing 
to act in an open and transparent manner.
    The Committee requested a briefing from the Department on 
the Accelerating Access to Care Initiative on June 2nd. I 
followed-up this request with a formal letter to Acting 
Secretary Gibson on June 5th requesting an immediate briefing 
on the Initiative. It has now been nineteen days since that 
request for an immediate briefing and no further information or 
acknowledgment of my request has been received. It baffles me 
as to why the Department failed to provide this Committee with 
the information we requested on a program of this size and 
importance. If VA's work has indeed led to two-hundred thousand 
more appointments for veteran patients so far, what is there to 
hide?
    More importantly, over the last several weeks, 
investigations by the VA Inspector General and the Department 
itself have proven that the VA health care system suffers from 
a systemic lack of integrity. Data manipulation of patient 
waiting times was found to be widespread. Given that, how can 
Congress, the American taxpayer, and our nation's veterans and 
their families have any confidence in these latest numbers the 
Department has released?
    Furthermore, if there were actions that VA could have 
taking to increase access to care for veterans patients, why 
were those actions not taken long before now? As part of the 
Accelerating Access to Care Initiative, VA claims to be taking 
steps to, in the Department's own words, -
    - ``systematically [review] clinical capacity;''
    - ``[ensure] primary care clinic panels are correctly sized 
and achieving the desired level of productivity;''
    - ``[extend or flex] clinic hours on nights and weekends;''
    - ``[increase] the use of care in the community;'' and,
    - ``[reach] out to veterans to coordinate the acceleration 
of their care.''
    Each of these actions should have been operational 
components of regular VA business long before now and VA had 
statutory authority to use these options previously. We know 
that at least thirty-five veterans in the Phoenix-area alone 
died while waiting to receive VA care - though I suspect that 
number may rise in the coming weeks and months.
    We know that fifty-seven thousand veterans nationwide have 
been waiting ninety days or more for their first VA 
appointment. And, we know that sixty-four thousand veterans who 
enrolled in the VA healthcare system over the last decade never 
received the appointment they requested. It is too late for 
those thirty-five Phoenix area veterans and it may be too late 
for other veterans who have been waiting for weeks, months, and 
- in some cases - years.
    So I ask again, if there were actions that VA could have 
taking to increase access to care for veterans patients, why 
were those actions not taken long before now? With that, I now 
yield to Ranking Member Michaud for any opening statement he 
may have.
    With that, I yield to the ranking member, Mr. Michaud, for 
his opening statement.

       OPENING STATEMENT OF MIKE MICHAUD, RANKING MEMBER

    Mr. Michaud. Thank you very much, Mr. Chairman, for once 
again having this hearing tonight.
    Providing timely, quality, safe care to veterans is the 
primary mission of the Department of Veterans Affairs. Integral 
to accomplishing this mission is the ability to successfully 
measure the capacity and capability of the organization.
    Mr. Chairman, at this point in time, I do not have much 
confidence that VA has been able to do that analysis. I firmly 
believe that if you do not have good numbers on which to base 
calculations, then you cannot possibly begin to accurately 
measure the capacity or demand. Anticipating capacity and 
demand is central to good strategic planning. Clearly, VA is 
struggling to get a handle on how many veterans are undergoing 
or waiting for treatment. It seems to me having a significant 
number of patients on the waiting list indicates a system that 
is overwhelmed and unprepared. VHA simply cannot handle the 
increasing number of veterans to whom we have a moral 
obligation to provide sound treatment.
    The VA OIG reported in testimony on March 2013 that VHA 
Office of Productivity, Efficiency and Staffing conducted 
studies in 2006 of 14 specialty care services. The report had 
nine recommendations. One of the recommendations was to have 
the VHA develop relative value unit productivity standards and 
staffing guidance for the field. I recognize this is a complex 
process and VA healthcare has continued to change over the 
years, but 8 years to develop this system is too long and is 
unacceptable.
    While Dr. Lynch states in testimony that by the end of 
September 2014, all VHA physicians will have productivity 
standards in place, I am skeptical of the usefulness of those 
standards, due to the current crisis.
    Today, I would like to hear from VA how they are measuring 
capacity and a timeline for when this will be done, and most 
importantly, any additional resources that may be needed to 
ensure VA is fully fulfilling the primary mission of providing 
healthcare to our Nation's veterans.
    Mr. Chairman, I know that the vast majority of the 
Department employees are hardworking and dedicated to caring 
for our veterans, for that I applaud them, but we still have a 
responsibility and duty to take care of all of our veterans.
    And I look forward to hearing from the VA tonight, and I 
want to thank you for coming this evening. With that, I yield 
back.

       PREPARED STATEMENT OF MIKE MICHAUD, Ranking Member

    * Thank you Mr. Chairman.
    * Providing timely, quality, safe care to veterans is the 
primary mission of the Department of Veterans Affairs.
    * Integral to accomplishing this mission is the ability to 
successfully measure the capacity and capabilities of the 
organization.
    * Mr. Chairman, at this point in time, I do not have much 
confidence VA has been able to do that analysis.
    * I firmly believe if you do not have good numbers on which 
to base calculations, then you cannot possibly begin to 
accurately measure capacity or demand.
    * Anticipating capacity and demand is central to good 
strategic planning.
    * Clearly VA is struggling to get a handle on how many 
veterans are undergoing or waiting for treatment. It seems to 
me having a significant number of patients on waiting lists 
indicates a system that is overwhelmed and unprepared. VHA 
simply cannot handle the increasing number of veterans to whom 
we have a moral obligation to provide sound treatment.
    * The VA OIG reported in testimony on March 2013, that 
VHA's Office of Productivity, Efficiency, and Staffing 
conducted studies in 2006 of 14 specialty care services. The 
report had nine recommendations. One of the recommendations was 
to have VHA develop Relative Value Unit productivity standards 
and staffing guidance for the field.
    * I recognize this is a complicated process and VA health 
care has continued to change over the years, but eight years to 
develop this system is too long. It's unacceptable.
    * While Dr. Lynch states in testimony that by the end of 
September 2014, all VHA physicians will have productivity 
standards in place, I am skeptical of the usefulness of those 
standards due to the current crisis.
    * Today, I would like to hear from VA how they are 
measuring capacity, a timeline for when they will be done, and 
most importantly, any additional resources that may be needed 
to ensure VA is fulfilling the primary mission of providing 
health care to the nation's veterans.
    * Mr. Chairman, I know that the vast majority of the 
Department's employees are hard-working and dedicated to caring 
for veterans. For that, I applaud them.
    * I look forward to hearing from the VA today and thank 
them for coming.
    The Chairman. Thank you very much, Mr. Michaud.
    We are honored to be joined this evening by Dr. Thomas 
Lynch, the Assistant Deputy Under Secretary for Health for 
Clinical Operation's, and he is accompanied by Dr. Carolyn 
Clancy, the Assistant Deputy Under Secretary for Health for 
Quality, Safety and Value.
    We appreciate you both for being here tonight, and Dr. 
Lynch, we appreciate you coming for your return engagement to 
an evening function.
    You are recognized for your opening statement.

                 OPENING STATEMENT OF DR. LYNCH

    Dr. Lynch. Good evening, Chairman Miller, Ranking Member 
Michaud and members of the committee.
    Thank you for the opportunity to discuss the provision of 
timely, accessible and quality care for veterans. I am 
accompanied today by Dr. Carolyn Clancy, Assistant Deputy Under 
Secretary for Health, for Quality, Safety and Value.
    At the outset, let me address the significant issue that 
has been the focus of the committee, the VA and the American 
public: that is, the issue of wait times. No veteran should 
ever have to wait an unreasonable amount of time to receive the 
care that they have earned through their service and their 
sacrifice. America's veterans should know they will receive the 
highest quality healthcare from VA. While we realize the 
timeliness of these services is in question, VA acknowledges 
and is committed to correcting the unacceptable practices in 
patient scheduling. As my colleague, Philip Matkovsky, stated 
on June 9th, this is a breach of trust. It is irresponsible, it 
is indefensible and it is unacceptable.
    I also apologize, as he did, to our veterans, their 
families and loved ones, members of Congress, the Veterans 
Service Organization, our employees, and the American people. 
These practices are not consistent with our values as a 
Department, and we are working to fix the problem.
    VA has a physician workforce of more than 25,000 physicians 
representing over 30 specialties. VA now has comprehensive 
information about the staffing levels at each medical center, 
as well as the productivity of our physician workforce, 
utilizing a standard healthcare measure of relative value 
units, or RVUs. RVUs consider the time and the intensity of 
medical services delivered.
    Optimizing physician productivity is critical to our 
ability to determine clinical capacity and mobilize our 
clinical assets to rapidly address unacceptable delays in 
service.
    Supporting a productive workforce requires appropriate 
support staff ratios as well as the necessary capital 
infrastructure to ensure that the clinics run as efficiently as 
possible. The difference between the estimated capacity and our 
current workload represents the amount of additional care we 
could provide to address veterans waiting for care. VA has 
accelerated the adoption of productivity standards because they 
are critical in determining VHA's capacity and improving timely 
access to quality care for veterans.
    We are about a year ahead of schedule in completing action 
plans based on the recommendations of the OIG in late 2012. We 
will have productivity standards in place for all physicians in 
VHA by the end of this fiscal year.
    Like all of healthcare, VA has transitioned to a system in 
which outpatient care is increasingly important, especially for 
the management of chronic conditions. VA has established the 
Nation's largest medical home approach to primary care, in 
which people receive care from teams, and in addition, to face-
to-face visits, they receive advice and consultation, which can 
be provided through technology, through telephone calls, secure 
emails and tele-health.
    Leveraging these capabilities to deliver veteran-centric 
care requires investments in education, training, and the 
ongoing evaluation to assure that services are focused on the 
needs and preferences of individual veterans. Since the 
majority of U.S. physicians receive some training in a VA 
facility, we have also invested in contemporary approaches to 
undergraduate and graduate training that reinforce the 
importance of teamwork and technological skills, and leverage 
research investments to assure that the promise of these new 
models achieves the goal of personalized veteran-centric care.
    Mr. Chairman, the health and well-being of the men and 
women who have bravely and selflessly served this Nation 
remains VA's highest priority. The work continues, and we will 
not be finished until VA can assess capacity, productivity and 
staffing standards for all specialties, and provide ready 
access to high quality, efficient care available to our 
Nation's veterans. We must regain the trust of the veterans we 
serve. VA leadership and our dedicated workforce are fully 
engaged.
    This concludes my testimony. My colleague and I are 
prepared to answer any questions you and the other members of 
the committee may have.

          PREPARED STATEMENT OF THE HON. CORRINE BROWN

    Thank you, Chairman Miller and Ranking Member Michaud for 
calling this hearing tonight.
    My many years of serving on this committee and meetings 
with veterans have opened my eyes to the many services the VA 
provides for our veterans.
    One issue that I was recently exposed to was tele-health 
and tele-medicine. I was prepared to dislike remote controlled 
health care. How could a veteran receive care in his home? But 
I was pleasantly surprised to find out the care was equivalent 
to going to the VA clinic, but not having to travel all that 
way.
    And the veteran loved it! VA medical staff reviewed the 
information and advised the veteran on what actions to take. 
Emergency personnel would be called if that was deemed 
necessary. I thank Mr. Michaud for making tele-health a 
priority for the VA.
    This brings me to my main point. Veterans love VA care. 
However, there is not enough VA to go around. As the recent 
experiences of VA hospitals being built show, including in my 
Orlando, building a hospital is not the VA's strong point.
    The VA operates 1,700 sites of care, and conducts 
approximately 85 million appointments each year, which comes to 
236,000 health care appointments each day.
    The latest American Customer Satisfaction Index, an 
independent customer service survey, ranks VA customer 
satisfaction among Veteran patients among the best in the 
nation and equal to or better than ratings for private sector 
hospitals.
    It is not necessary to get veterans to a VA facility to get 
VA quality care. The VA is an admitted leader in treating the 
issues veterans suffer from: TBI, PTSD, prosthetics and Agent 
Orange maladies.
    If we bring community organizations into VA care, veterans 
could get care where they live. Allowing private practice 
doctors to treat veterans would not be fair to the veteran or 
the doctor. If there is no follow up on the care, who is 
responsible? However, if community non-profit health providers 
are contracted with the VA, that follow up can be tracked. In 
addition, the VA could open an office or a wing in the 
community facility which would bring VA care to the veteran 
also.
    I look forward to hearing from the witness on this issue.

        PREPARED STATEMENT OF HON. GLORIA NEGRETE MCLEOD

    Thank you, Mr. Chairmen. There are serious problems at the 
VA that must be resolved so veterans can be treated in a timely 
manner. VA must work diligently to implement new metrics that 
accurately show how many doctors and hospitals it needs to care 
for our growing veteran population. VA doctors must be willing 
to embrace best practices from the private sector. The belief 
that VA is a unique public health system does not excuse 
inefficiency.
    Private sector care can complement but cannot replace 
health care at the VA. It is my hope that the current crisis in 
providing health care will compel all VA employees to think 
outside the box on how to improve care for our veterans.
    That also means that Congress must work with VA as a 
partner and not just as a critic. It is right for Congress to 
hold VA accountable for the harm caused toward veteran 
patients. Yet holding hearings without working on solutions 
does not help veterans find timely care.
    I look forward to working with VA to move through this 
crisis and will continue to support the Inspector General and 
Department of Justice's efforts to investigate and prosecute 
those who have committed malpractice.

                     STATEMENT OF DR. LYNCH

    The Chairman. Thank you very much, Dr. Lynch.
    How quickly can VA hire clinical staff under current 
authorities?
    Dr. Lynch. Mr. Chairman, I don't have the answer to that 
question. I know that our current processes, particularly in 
human resources, are slow. We are putting processes in place to 
speed those processes, to speed that process so that we can 
hire physicians more efficiently and more quickly.
    The Chairman. Are there any impediments that we as a 
legislative body can do to assist in removing some of the 
barriers?
    Dr. Lynch. At the moment, Mr. Chairman, I can't think of 
any.
    Dr. Clancy. I would simply add that -- sorry. Sorry about 
that.
    I would just add that some part of the reason it takes a 
bit of time is the credentialing and privileging process, which 
I think you would want us all to be rigorous about. We are 
investigating ways to try to speed that up, but the human 
resources part is part one.
    The Chairman. What is the expected cost of the Accelerating 
Access to Care Initiative and how are you funding it currently?
    Dr. Lynch. Right now the expected cost that we have 
invested is approximately $312 million. It is being funded 
based on monies that we have been able to recover from across 
VHA.
    The Chairman. Can you tell me if any additional authorities 
have been granted to VA medical centers as a result of the 
initiative?
    Dr. Lynch. What do you mean by additional authorities?
    The Chairman. Any authorities being granted to help speed 
the process along.
    Dr. Lynch. Other than asking the facilities to look at 
their processes and the efficiency of their processes, see if 
they can identify internal capacity, and if they cannot, to let 
us know what resources they need to provide that care in the 
community. That process has occurred. The facilities have made 
their requests, and to date, we have distributed approximately 
$312 million, of which approximately $152 million have been 
obligated at this point.
    The Chairman. Dr. Lynch, according to the Physician's 
Foundation 2012 survey of America's physicians, over 80 percent 
of the primary care physicians in the United States see between 
11 and 61 patients per day, and U.S. physicians in general see 
an average of over 20 patients per day. Can you tell us what 
the average daily patient load of a VA primary care physician 
is?
    Dr. Lynch. Right now the average patient load is 
approximately 10 patients per day. If I could qualify that by 
saying that I think we need to assure that we understand what 
support staff our physicians have and what capacity they have 
in the way of rooms to facilitate their ability to see 
patients. I think it is not just the physician's ability and 
willingness to see patients, it is also the support that we 
provide them and it is the rooms that we give them so they can 
see patients in an efficient fashion.
    The Chairman. But you --
    Dr. Lynch. The range, by the way, is from 6 per day up to 
about 22 per day for our physicians.
    The Chairman. But you are the agency that designs the 
clinics, designs the hospitals, designs the facilities, so you 
would know how many rooms would be needed, I would suspect, in 
order for patients to be seen.
    Dr. Lynch. Congressman, many of our facilities are 50 or 60 
years old and were designed in an era when outpatient 
healthcare was not the predominant mode of healthcare delivery. 
VA in the mid 1990s converted from an inpatient model to an 
outpatient model. We are still challenged by facilities that 
were not constructed for the outpatient model of care.
    The Chairman. So if I went to a new facility, I should 
suspect that the doctors there will be seeing more patients 
than those in the older facilities?
    Dr. Lynch. The VA has been working to put in place 
templates that facilitate the delivery of care using the 
medical home model, so that we are redesigning new clinics in 
our outpatient facilities to optimize the ability of our 
physicians to provide care and to see patients in that model, 
yes, congresswoman -- Congressman.
    The Chairman. One other question, if you would. The Office 
of Special Counsel wrote a letter to the president today.
    Dr. Lynch. Yes.
    The Chairman. The OSC cites the case of a veteran with a 
100-percent service-connected psychiatric condition that 
resided in a Brockton, Massachusetts, medical health facility 
for 8 years. Are you familiar with that particular incident?
    Dr. Lynch. Yes, sir.
    The Chairman. And in those 8 years at the facility, this 
veteran apparently had only one psychiatric note in his chart. 
Is that true?
    Dr. Lynch. That is true, sir.
    The Chairman. One note in 8 years.
    Dr. Lynch. That is unacceptable, sir.
    The Chairman. Despite the fact that the Office of the 
Medical Inspector substantiated that this occurred, it also 
stated in the same letter, it had no impact on that patient's 
care. Can you believe that?
    Dr. Lynch. Congressman, the Office of the Medical Inspector 
is unique in healthcare. We don't see it in the private sector. 
It is VA's arm to evaluate objectively outside of the facility 
concerns about the quality of care.
    I understand that the Office of Special Counsel has raised 
concerns. VA and our Acting Secretary have taken those concerns 
very seriously. We need to take them seriously, because VA is 
in a position where we have to reestablish our integrity.
    He has established a group, a commission, who will evaluate 
those concerns. The report is due in 14 days. I think it is 
important we understand what that review shows before we draw 
any conclusions.
    The Chairman. Thank you.
    Mr. Michaud, you are recognized.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Once again, thank you Dr. Lynch and Dr. Clancy for coming 
here this evening.
    We understand that the Accelerated Access to Care 
Initiative is designed to ensure access to care by enhancing 
resources within VA facilities and also sending veterans 
promptly to community-based care and non-VA care when needed 
care is not readily available at the VA facility.
    What is the role of PC-3's in VA Accelerating Access to 
Care Initiative?
    Dr. Lynch. PC3 as it develops will be another model that we 
can use to provide care in the community. PC3 is just in the 
process of being stood up. Some sites have greater availability 
of PC3 services than others. It is, however, an option that we 
can use to identify community providers who are willing to 
provide care and to meet certain conditions of the contract 
which specify that care will be provided within 30 days, that 
we will receive reports in a timely fashion.
    So PC3 is an enhanced method of providing care in the 
community that gives benefit to the VA, because it assures 
timeliness and assures that we get records back in a timely 
fashion.
    Dr. Clancy. I would also just add that they assure some 
minimal level of quality, I mean, foundational level of quality 
in terms of contracting with hospitals that are accredited by 
the joint commission or a relevant accreditor, that the plans 
that they are contracting with have met standards for the 
National Committee on Quality Assurance and so forth, and we 
are going to be working with them to figure out how do we even 
make those standards a bit higher.
    Mr. Michaud. Thank you. The committee is aware that the VA 
had conducted several pilot projects, such as Project HERO and 
Project ARCH before implementing PC3. VA also has indicated 
that in designing PC3, it used lessons learned from these pilot 
programs to develop a solution which is coordinated, convenient 
and consistent with VA quality standards.
    My question, then, is now that PC3 is up and running across 
the country, are all VA medical centers using this program as 
part of the solution?
    Dr. Lynch. I believe the answer, Congressman, is when it is 
available and when the services are available, it is being 
used, yes.
    Mr. Michaud. So it is not throughout all of VA medical 
centers, then?
    Dr. Lynch. In certain areas, the contractors are having to 
identify providers and are standing up their services. In other 
areas, services are available and PC3 is being used, to the 
best of my knowledge.
    Mr. Michaud. Okay. We understand that PC3 is not a 
mandatory program. How can we have a VA medical center fully 
utilizing PC3 and utilizing the potential of this program if it 
is not a mandatory program?
    Dr. Lynch. It would be my hope, understanding the benefits 
of the PC3 process, that it would be advantageous to the 
medical centers to use that program. As I mentioned, there are 
standards for timeliness of providing services and there are 
standards for the receipt of work product after the services 
have been provided.
    Mr. Michaud. Okay. How does the VA distinguish between 
short-term and long-term capacity shortfalls and how does the 
VA respond different to the long-term and short-term 
shortfalls?
    Dr. Lynch. I think as our data becomes more reliable and as 
we see increasing use of the electronic wait list, which has 
now been mandated, we will have the option to see our demand 
handled in one of two ways: either as a completed appointment 
or as a patient who ends up on the electronic wait list. 
Depending upon whether this is a short-term increase in the 
requirement for services, in which case the VA may find it very 
convenient to buy that in the community, there was also the 
possibility that this is part of a longer term trend, in which 
case, the VA may want to consider how much is it going to cost 
me to buy this and ultimately do we need to make a decision 
that it will be more cost-effective for us to identify the 
providers and make the service in-house.
    So I think short term, PC3, non-VA care provides the 
opportunity for us to offer prompt services to veterans when we 
don't have the capacity. In the long-term, when we see trends, 
it gives us the option of making decisions about whether we 
should continue to buy this in the community, because of its 
complexity, or whether we think we can offer it in-house.
    Mr. Michaud. Thank you, Mr. Chairman.
    The Chairman. Mr. Lamborn, you are recognized for 5 
minutes.
    Mr. Lamborn. Thank you, Mr. Chairman.
    Dr. Lynch, in the last 2 weeks, the number of veterans in 
my district in Colorado Springs that contacted my office asking 
for help while trying to see a doctor has more than doubled. 
One veteran described how he was referred to get a biopsy done 
on his thyroid to determine whether or not he had cancer only 
to be told he couldn't be seen for 2 months. I can't imagine 
having to wait for 2 months to even just get a test done when 
you have a possible cancerous growth.
    Tell me what options, please, are available to the Denver 
VA Medical Center to expedite a biopsy appointment in 
particular, especially based on medical necessity and if there 
is the possibility of a life-threatening condition?
    Dr. Lynch. Congressman, based on what you are telling me, 
if services cannot be provided in less than 30 days, that is an 
unacceptable waiting time, and the Denver VA facility should be 
able to identify a community provider to offer those services.
    Mr. Lamborn. Okay. That would be the fee basis approach 
that we have talked about?
    Dr. Lynch. That would be the use of non-VA care or the fee 
basis approach, yes.
    Mr. Lamborn. Okay, so 55 days for that type of procedure is 
unacceptable, you would agree?
    Dr. Lynch. That would certainly be my impression, 
Congressman.
    Mr. Lamborn. All right. Thank you. Now, the data included 
in the VA's bi-monthly access data update makes me worry that 
this problem might be getting worse before it gets better, 
especially in Colorado. And myself and Representative Mike 
Coffman have a lot of these same concerns.
    Although the report shows the number of veterans on the 
electronic wait list across the country dropping slightly, the 
electronic wait list at the Denver VA Medical Center, where 
many of my constituents receive care, doubled in the last 15 
days. It went from 1,632 to 3,331. What could have caused that 
number to double in 15 days when around the country, it was 
dropping slightly?
    Dr. Lynch. I don't have the specifics on Denver, 
Congressman. I will be happy to try and get that information 
for you.
    I can tell you that at the moment, the electronic wait list 
is going to be dynamic. There are two processes that are 
occurring. We are working down the near list, the new enrollee 
appointment request. Those patients are either being given 
scheduled appointments or they are being put on the electronic 
wait list.
    So it is possible that some of the patients that were on 
the near list have been moved to the electronic wait list, but 
exactly, you know, why they are accumulating on the electronic 
wait list, I don't know, but I think we have the capacity to 
find that out.
    Mr. Lamborn. Okay. Well, if you could get back to me on 
that, I would appreciate it.
    Dr. Lynch. I will do that, Congressman.

            PREPARED STATEMENT OF THOMAS LYNCH, M.D.

    Good morning, Chairman Miller, Ranking Member Michaud, and 
Members of the Committee. Thank you for the opportunity to 
discuss the capacity and demand for services in VHA. I am 
accompanied today by Carolyn Clancy, M.D., Assistant Deputy 
Under Secretary for Health for Quality, Safety and Value.
    At the outset, let me address the significant issue that 
has been the focus of this Committee, VA, and the American 
public the last many weeks. That is the issue of wait times. No 
Veteran should ever have to wait an unreasonable amount of time 
to receive the care they have earned through their service and 
sacrifice.
    America's Veterans should know they will receive the 
highest quality health care in a timely manner from VA. Last 
year, we scheduled 85 million outpatient visits and acted upon 
25 million consults for specialized services. While we realize 
that the timeliness of these services is in question, VA 
acknowledges and is committed to correcting unacceptable 
practices in patient scheduling. These practices are not 
consistent with our values as a Department, and we are working 
to fix the problems.
    VHA has a physician workforce of more than 18,000 full time 
equivalents (FTEs) representing over 30 specialties. The 
largest components of the physician workforce include our 
Internal Medicine (largely primary care) physicians and 
psychiatrists. VHA maintains a comprehensive database of the 
physician workforce that provides information about the 
staffing levels for each Medical Center and calculates the 
productivity of our physician workforce utilizing a standard 
health care measure of relative value units (RVU) per physician 
clinical FTE. RVUs consider the time and the intensity of the 
medical services delivered and have been utilized by Medicare 
since the early 1990's. VHA is currently using this database to 
establish productivity standards and to assess the capacity of 
our provider workforce. For our primary care physicians there 
are clear panel size expectations that define the number of 
active patients assigned to each primary care provider. Panel 
sizes vary depending on a number of factors. The current 
average panel size is 1,194, but panels may be adjusted up or 
down depending on levels of support staff, space (exam rooms) 
and patient complexity. VHA is assessing the current demand for 
services in relation to primary care panel capacity as well as 
the productivity of the primary care providers and all 
physicians and associate providers at each of our medical 
centers.
    During a February 2014 hearing before the Subcommittee on 
Health, we reported VHA's progress in implementing an industry-
accepted RVU-based approach for assessing productivity and 
efficiency for specialty care physicians. More recently, on May 
1, 2014, VHA briefed the physicians on the Subcommittee on the 
RVU-based productivity and staffing work. Although our focus on 
establishing an RVU-based model to assess specialty physician 
productivity did not initially include Internal Medicine/
Primary Care, the foundation we put in place for specialty care 
is now being leveraged to assess productivity, efficiency, 
staffing and capacity within our primary care services. Ready 
access to care is our highest priority and we are mobilizing 
our workforce accordingly.
    VHA delivers care that encompasses nearly three dozen 
different specialties in a variety of settings, and access to 
care varies across those specialties and settings. Our large 
acute care academic facilities generally employ the full 
complement of specialty physicians and have the capability to 
provide comprehensive services while our smaller or rural 
facilities may be challenged to recruit and retain specialty 
physicians. Aligning the current demand with our ability to 
provide these services is part of our active work.
    Optimizing physician productivity is critical to our 
ability to determine clinical capacity and mobilize our 
clinical assets to rapidly address unacceptable delays in 
services to our Veterans. Supporting a productive workforce 
requires appropriate support staff ratios as well as the 
necessary capital infrastructure, e.g., exam room capacity, to 
ensure that the clinics run as efficiently as possible. The key 
elements of capacity include: (1) the supply of clinical 
providers (physicians, psychologists, optometrists, 
podiatrists, and associate providers such as nurse 
practitioners and physician assistants) within VHA; (2) the 
amount of services that each of these providers can safely 
deliver (productivity); and (3) a modern information technology 
infrastructure that supports and enhances clinical information 
for the patient and providers. We currently know the supply of 
our provider workforce and, assuming a productivity 
expectation, we can estimate what our capacity could be. The 
difference between this estimated capacity and our current 
workload represents the amount of additional care we could 
potentially absorb to address Veterans waiting for care.
    Productivity expectations are critical in determining VHA's 
capacity and, VHA has accelerated the adoption of productivity 
standards for all physicians, modeled on an industry-accepted 
RVU-based approach. By the end of June 2014, VHA will have 
standards in place to measure productivity and efficiency for 
29 different specialties, representing 91 percent of VHA's 
physicians, psychologists, optometrists, podiatrists, and 
chiropractors. All VHA physicians will have productivity 
standards in place by the end of September 2014.
    The same results-oriented approach we have taken to 
implement physician productivity and staffing standards will be 
applied to address today's challenge to measure and maximize 
our clinical capacity. The work continues, and we will not be 
finished until VHA can assess capacity, productivity, and 
staffing standards for all specialties, and provide ready 
access to high quality, efficient care to our Nation's 
Veterans.
    To fulfill VHA's primary mission of providing patient care 
and to assist in providing an adequate supply of health 
personnel to the Nation, VA is authorized by Title 38 Section 
7302 to provide clinical education and training programs for 
developing health professionals. VA conducts the largest 
education and training effort for health professionals in the 
U.S. This provides VA with a unique opportunity to recruit 
these medical professionals, already familiar with the VA 
health care system.
    VA recognizes that rural communities face challenges in 
ensuring access to health care providers. VA is working to 
develop an effective rural workforce strategy to recruit 
locally for a broad range of health-related professions. These 
strategies include training, technology, collaboration, and 
academic affiliations. Empowering Veteran patients with 
telehealth technology and targeted health communications have 
proven to be an important way to provide quality care in the 
daily lives of Veterans.
    In addition, VA collaborates with Federal partners such as 
the Department of Health and Human Services to establish pilot 
projects with community-based providers; the Department of 
Defense to improve access to care for Service members and 
Veterans through sharing agreements; and the Department of 
Housing and Urban Development (HUD) to coordinate the HUD-VA 
Supportive Housing program.
    Conclusion
    Mr. Chairman, the health and well-being of the men and 
women who have bravely and selflessly served this Nation 
remains VA's highest priority. We must regain the trust of 
Veterans we serve one Veteran at a time, and VA leaders and our 
dedicated workforce, over a third of who are Veterans 
themselves, are fully engaged. This concludes my testimony. My 
colleague and I are prepared to answer any questions you or the 
other Members of the Committee may have.

    Mr. Lamborn. Okay. Thank you.
    Now, you stated in your written statement that the average 
current number of patients assigned to each primary care 
provider is 1,194. How does that compare with the private 
sector?
    Dr. Lynch. The private sector medical home model can vary, 
with panels of anywhere from 1,000 up to about 2,000. It 
depends on the complexity of those patients, it depends on the 
resources available and the support for the physicians seeing 
those patients. VA patients are often older. Patients in the 
private sector may be younger, healthier and may not require 
the intensity of care that VA patients require.
    Dr. Clancy, would you have any comment?
    Dr. Clancy. No. Sorry. I would agree with all of that. We 
also -- the VA's medical home in the primary care setting is 
also unique for being integrated in many of our facilities with 
mental health providers who are right there if those needs 
arise.
    Mr. Lamborn. Okay. Thank you. One last question I want to 
get in. You note in your written testimony that the VA is 
adopting productivity standards that are modeled on industry-
accepted standards. I am really glad to hear that, but what has 
been the case, what has been the standard up until now?
    Dr. Lynch. Sadly, Congressman, there hasn't been a standard 
to this point. We are now using the relative value unit to 
evaluate the productivity of our providers. We are then using 
that information to determine, number one, are they meeting 
minimum productivity standards, number two, if they are not, 
why not.
    It could be a matter of support and available resources. It 
could be a matter that there are not enough patients for them 
to see, and in that case, either we need to identify more 
patients or we need to figure out a way that we can move their 
capacity to another facility, perhaps using something like 
tele-health.
    Mr. Lamborn. Thank you.
    The Chairman. Ms. Negrete McLeod, you are recognized for 5 
minutes.
    Ms. Negrete McLeod. I really have no questions. I yield 
back.
    The Chairman. Mr. Takano, you are recognized for 5 minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    And thank you, Dr. Lynch and Dr. Clancy, for appearing 
before us today.
    I understand that from 2008 to 2013, non-VA care outpatient 
visits grew from 8.9 million, or 9 million, to 15.3 million, a 
72 percent increase. Do we have any way of knowing about the 
comparison between non-VA care versus in-house care, its 
efficacy and its costs?
    Dr. Lynch. I don't have the comparative data from those 
years. I can tell you in the last fiscal year, we spent 
approximately $4.8 billion on non-VA care, but I would have to 
try and get previous data to see how our use of non-VA care has 
increased or has changed as we have seen increasing outpatient 
requirements.
    Mr. Takano. It seems to me that if we want to expand access 
for veterans to non-VA healthcare, it will be extremely 
important that there is a continuity of care and that health 
records can be transferred seamlessly, and that is part of what 
you were talking about, I guess, when you were trying to do a 
quality check on the PC3 and finding those community providers. 
What can we do to ensure that this happens?
    Dr. Lynch. I think that is a very good question, and it is 
a challenge. Right now our community providers do not have 
ready access to the VA's electronic health record. I can't tell 
you as we move forward and establish more permanent 
relationships whether we can begin to give certain providers 
access to the VA healthcare system. When I was in Omaha, we 
were able to do that for several of our community providers who 
gave regular service to the VA.
    Mr. Takano. Well, you know, I know that as part of the ACA 
and the High Tech Act, which passed around the same time 
Congress created incentives for healthcare providers to make 
the transition to electronic healthcare records. Do you have 
any idea if this digitization has been done with 
interoperability with electronic health record systems already 
in place at the VA, the VistA system?
    Dr. Lynch. I am going to defer to Dr. Clancy on that 
question, if I may.
    Dr. Clancy. I will say that complying with the standards 
set out by meaningful use, is the popular term for those sets 
of incentives from CMS, although VA does not get money from 
CMS, but we are actually complying with all those standards, 
yes.
    Mr. Takano. But the private healthcare providers, which who 
were given incentives to digitize their records --
    Dr. Clancy. Correct.
    Mr. Takano. -- is the standard set forth by CMS, will that 
provide interoperability with VistA?
    Dr. Clancy. It should.
    Mr. Takano. It should.
    Dr. Clancy. Yes. And in some cases, we are starting to 
explore this, for example, with some pilot projects on allowing 
veterans for example, to get immunizations in a Walgreen's 
health facility. We can exchange that kind of information. So 
there is a difference between people meeting the same standards 
and being able to share freely across platforms, but that would 
be the ultimate goal.
    Mr. Takano. So you are saying it should.
    Dr. Clancy. Yes.
    Mr. Takano. Theoretically, people, physicians who have been 
incentivized under the ACA to digitize, that those standards 
set forth, you said it was set forth by CMS, the --
    Dr. Clancy. Yes.
    Mr. Takano. -- digitization standards? That they should all 
-- that should provide the platform for interoperability with 
VistA?
    Dr. Clancy. Yes. That certainly provides the first 
foundation for it.
    Mr. Takano. So part of being able to facilitate this 
ability to access -- for our veterans to access care in the 
private arena would be to facilitate this interoperability, and 
so maybe part of the answer, Dr. Lynch, would be that if there 
were further incentives for our physicians to digitize to those 
standards, that this would be one part of the problem -- one 
part of the solution, interoperability?
    Dr. Clancy. I guess I would say that this is a very strong 
priority for HHS right now, both CMS and the Office of the 
National Coordinator, and we are actively part of that 
strategic planning effort in terms of how do we accelerate the 
path towards interoperability, but that would make it much, 
much easier.
    Right now what community partners do is they send a report, 
PC3 makes this a little bit easier because it is a condition of 
their getting paid, and that gets attached into the Vista 
record essentially as a portable downloadable file.
    Mr. Takano. Would this incentivizing through PC3 be helpful 
if we put it also an incentive for them to digitize?
    Dr. Clancy. That might be an option down the road for sure.
    Mr. Takano. Great. Thank you.
    The Chairman. Mr. Bilirakis, you are recognized for 5 
minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much.
    Sir, Dr. Lynch, of the 70,000 veterans who were contacted 
that were on the waiting list, and the point is to remove them 
from the waiting list -- well, first of all, how many were 
contacted and they actually spoke to a person, a VA person, or 
-- tell me what the contact was, did they have an actual 
conversation with them?
    Dr. Lynch. We don't have that breakdown yet Congressman, we 
will. There were attempts made to contact all veterans. The 
process is that there were three attempts made. If we could not 
contact the veteran, they then received a certified letter.
    We will be developing the data as we collect it, and we 
should be able to provide you with the information that would 
tell you how many patients were directly contacted, how many 
patients were contacted by mail, how many patients could we not 
contact, and also the disposition of the patients contacted --
    Mr. Bilirakis. Okay. If they received --
    Dr. Lynch. -- did they wish to receive VA care or not?
    Mr. Bilirakis. If they received something in the mail and 
they contacted the VA, would they speak to someone immediately?
    Dr. Lynch. That would be my expectation, because --
    Mr. Bilirakis. But you don't have any data on that?
    Dr. Lynch. I don't have the data right now, no.
    Mr. Bilirakis. Okay. Now, what about as far as the waiting 
time? So they contacted somebody, let's say, the contact was 
made, there was a conversation between a VA individual and the 
patient, the veteran. How long would they have to wait for an 
appointment?
    Dr. Lynch. The expectation is that we would explain to them 
how long they would have to wait for care in VA. If they did 
not find that acceptable, we would provide care for them in the 
community.
    Mr. Bilirakis. Okay. Now, you don't have any information to 
give me so far, any results as far as, let's say that they had 
to wait within, you know, how long would they have to wait to 
get a VA appointment within the VA?
    Dr. Lynch. I don't have that information, but the 
expectation would be that if we could not see them within 30 
days, we would offer them care in the community.
    Mr. Bilirakis. Where did this 30-day period come from, this 
expectation, this policy?
    Dr. Lynch. At the moment, there is not science behind it. 
There is evidence that in the community, patients are waiting 
anywhere from 15 to 30 days or longer to see care, and so I 
believe we chose that as a reasonable number. It does depend --
    Mr. Bilirakis. Who chose that?
    Dr. Lynch. VA chose that. It does depend on the acuity of 
the patient. If the patient needs to have care immediately, we 
would provide that. If there was an urgency, we would provide 
it within 30 days or offer it in the community.
    I might turn to Dr. Clancy and ask if she has any further 
insight on the ability for the community to provide care in a 
more timely fashion than 30 days.
    Dr. Clancy. Well, I would guess, Congressman, that you and 
your colleagues have probably seen data from recently released 
surveys of how long it takes to get a new patient appointment, 
which ranges from somewhere 10 days or a little bit less in 
Dallas, up to 45 or so in Boston. Obviously doesn't have a lot 
to do with the number of doctors in the area, because Boston 
has a lot of doctors.
    The problem is there is no industry standard. I will say 
that when veterans contact the facility and are given a wait 
time or an expected wait time, and if that is not acceptable an 
option to go out into the community, they are also counseled 
that if they have a more urgent need, that they should come 
into an urgent care, or an emergency room for more immediate 
care.
    Mr. Bilirakis. On the average, how long would it take if, 
let's say, it is decided they have to go outside the VA for 
care, how long it would take for them to -- the patient to get 
the appointment?
    Dr. Clancy. A lot of that is going to depend on what 
existing capacity is in that community, so --
    Mr. Bilirakis. On the average?
    Dr. Clancy. We don't --
    Mr. Bilirakis. The average patient?
    Dr. Clancy. -- have a number for that yet. In the Dallas 
area, it would be much faster, given the data I just mentioned 
a moment ago that wait times there are shorter. I would expect 
it would be much, much tougher in the Boston area, for example.
    Dr. Lynch. However, I would just add that with the PC3 
contract, it is the contractual expectation that patients will 
be seen within 30 days.
    Mr. Bilirakis. Okay. Yeah. One last question, Mr. Chairman.
    Under the Department of Veterans Affairs Healthcare 
Programs Enhancement Act of 2001, the VA is mandated to 
establish a nationwide staffing policy for all VA medical 
facilities. Can you briefly describe what that policy is? 
Specifically, how does VA medical centers know which positions 
are needed, who they report that information to, and what is 
done with that information to address the staffing shortage?
    Dr. Lynch. Congressman, I will have to take that for the 
record. I am not familiar with that policy or the data 
associated with that policy. I know that we currently have 
information through our Office of Productivity, Efficiency and 
Staffing that is looking at the number of physicians that we 
have, the specialty of those physicians and their ability to 
provide care in an efficient fashion using the RVU model.
    Mr. Bilirakis. Please report back to me, because I feel you 
should have that information with you now today.

    Mr. Bilirakis. So anyway, thank you very much.
    Mr. Chairman, I yield back.
    The Chairman. Thank you.
    Mr. Walz, you are recognized for 5 minutes.
    Mr. Walz. Well, thank you, Mr. Chairman. And thank you both 
for joining us again.
    I am going to start out and just, as the chairman made note 
of this, a lot of this stems from just the inability to get 
information and for us to do our constitutionally-mandated job.
    Over 3 weeks ago now we sat in here, and after the audits, 
several of our members here mentioned our facilities were 
flagged, and we were guarantied we would be told why that was. 
Nothing has been said and every day I get calls asking, what is 
wrong with these facilities? So I will ask all you, why don't 
you take that back and let them know we are waiting.
    Dr. Lynch. Congressman, I actually had a discussion with 
Mr. Matkovsky before I came down here tonight. We knew this 
issue would be raised.
    Mr. Walz. That is good foresight. I appreciate that you are 
thinking ahead that it is --
    Dr. Lynch. He and I agreed that it is important that we 
brief the committee, and we will be making arrangements to do 
that, and then also provide briefings to other congressional 
staffs on a VISN by VISN basis.
    Mr. Walz. Dr. Lynch, I think, and you have been coming down 
here a lot and I am very appreciative of the work you do, and 
as so many others, but I think the time has come when you know 
you don't get the benefit of the doubt on anything right now 
and after today's OSC, you mentioned that that was an 
unacceptable situation. Basically we had a veteran for 8 years 
that we warehoused. I would call that a national tragedy more 
than unacceptable.
    And I guess for me, I am trying to get at the heart of 
this. I still think we are flirting around the edges here 
instead of getting at this. I am going to come back to this 
leadership and structure issue. If I asked a director of a 
medical center what our national strategy on veterans was, how 
would they answer?
    Dr. Lynch. I hope they would answer that our strategy is to 
provide timely care to our veterans that is quality care --
    Mr. Walz. Is that a strategy or a goal?
    Dr. Lynch. It is probably a goal.
    Mr. Walz. So if I am -- and I will go back to this from a 
national security standpoint. We have a national security 
strategy, we have the Quadrennial Defense Review, and then that 
identifies requirements and then DOD and the directed forces 
come back to fill those requirements. Do you do that at VA? 
Because I am getting back to this, that we have been trying 
this issue since 2005 on measuring capacity. Actually, I went 
back. We started in the 1980s. And so my question is, I am not 
convinced if I walked into Dallas or Minneapolis or Sioux Falls 
that I would get a strategy answer.
    Dr. Lynch. I think, sir, I can offer that we are developing 
a strategy as it relates to access and as it relates to 
scheduling. We have in place a seven-step process that we are 
developing that will address the issue of accelerating care, 
that will address the development of demand capacity models, 
that will develop the policies and directives to drive 
scheduling and access.
    That will relook at our performance assessment measures so 
that we can develop the measures and the goals appropriate to 
drive our system to the appropriate end point, which is 
quality, timely care. We are developing the processes to put 
together program oversight and integrity, to recruit people and 
to train them, and to integrate our care processes with the 
non-VA care model when necessary to meet --
    Mr. Walz. Where does that guidance come from?
    Dr. Lynch. Sir, this is an organizational plan that was 
developed within VHA over the last 3 to 4 weeks in response to 
the issues that we have faced regarding veteran access.
    Mr. Walz. Is there White House input into any of this?
    Dr. Lynch. Not to my knowledge, sir.
    Mr. Walz. I want to have a specific one on this as we look 
at this care model, I want to give you an example that I went 
and did a little research over the last week in preparing for 
this, and there is a Mayo Clinic Phoenix down there, and prior 
to all this coming out, it was brought to my attention that 
they were doing some of the prostate surgeries in a fee for 
service, that they had that capacity. Is that correct?
    Dr. Lynch. That is my understanding.
    Mr. Walz. Now, what they said was is when they would have 
them come in, they would say, we can do the surgery in 48 
hours. VA would say then, yeah, but we have to do the ECG's, 
and that will take 6 to 8 weeks, and so we had it going out 
into the community and we had a community partner ready to do 
it, and yet we went back in-house again to delay that care.
    How will this be different? How will what you are doing now 
be different than that? If you have got prostate surgeons, 
urologists ready at Mayo Clinic, how are you still going to 
speed up the prep for that surgery, which is standard practice?
    Dr. Lynch. Part of our non-VA care process would allow 
those providers to do certain basic studies that are essential 
to their either clinical assessment or pre-operative evaluation 
outside.
    Mr. Walz. So the whole package will go?
    Dr. Lynch. I would say that we would look at very high-cost 
studies, but routine studies should certainly be done in the 
community, not brought back to the VA.
    Mr. Walz. Okay. I yield back. Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Walz.
    Dr. Benishek, you are recognized for 5 minutes.
    Mr. Benishek. Thank you, Mr. Chairman.
    I liked your questions, Mr. Waltz.
    Mr. Walz. Well, thank you, Dr. Benishek.
    Mr. Benishek. It very much concerns me in the whole 
management system of the VA, the whole structure of it to me is 
really -- needs to be reevaluated, and I hope we can get to 
that, you know, at least move in that direction, because what 
is happening here is just not right.
    A couple of ideas that came up from your testimony here 
today, Dr. Lynch is, you mentioned the fact that you weren't 
sure how much of this out -- you know, the community-based 
healthcare is proper, and it should be a temporary thing or a 
full thing, or should be kept in the VA, because it, you know, 
the extra expense associated with the private sector care, but 
then it occurs to me that I don't think you have any idea what 
it actually costs to take care of a patient within the VA. I 
mean, you know, in the private sector, basically we are talking 
about paying them at Medicare rates, but you don't have any 
idea if you are actually caring for veterans, at what rate it 
is costing us, do you?
    Dr. Lynch. The VA actually does have a DSS model that does 
track the amount of cost that goes into the care of each 
patient. It hasn't been used extensively --
    Mr. Benishek. You don't use it --
    Dr. Lynch. -- but it is available at the medical centers --
    Mr. Benishek. You don't use it for RVUs, like -- and if you 
are doing, you know, a certain code, you don't have any idea of 
like, how many RVUs you produce in the VA in a year for of the 
$50 billion for the VH healthcare system that we spend.
    So we have a pretty good idea how many -- for Medicare, for 
example, how many units we are getting for the millions of 
dollars we are spending on Medicare, but I don't believe there 
is any comparison like that at the VA, so you don't really know 
if doing within the VA costs more money or doing it outside 
costs more money, do you?
    Dr. Lynch. I do know that when I was in Omaha, we were able 
in our facility and across the network to begin looking at the 
cost of specific operations.
    Mr. Benishek. Yeah, begin looking at does not mean you have 
an idea.
    And another thing that I want to bring up -- oh, something 
that -- Mr. Takano, there is no interoperability amongst the 
electronic medical records. That does not exist. You can't get 
somebody's medical record from somewhere else just because you 
have electronic. That does not happen, it is impossible. I 
mean, that would be the ideal, but it doesn't work that way.
    I have another question. The expectations of having this 
RVU unit and how many physicians you need and how much 
productivity they should have, are you aware that the VA has 
been informed that there has been a pipeline problem with 
physicians and the productivity problems for the last 30 years, 
and that the Inspector General eight times over the last 30 
years has said that the VA needs to develop a plan, and it 
hasn't been done?
    And last year when I had my subcommittee hearing, they told 
me it would be 3 years before there would be some kind of a 
plan to develop physician staffing? And then you talk about it 
a lot, but, I mean, I don't know how that would -- I don't know 
what you are actually going to do it?
    Dr. Lynch. Congressman, that plan is in place. We will have 
productivity standards for all of our medical specialties by 
the end of this fiscal year.
    Mr. Benishek. Well, I would like to see that, because when 
they testified, they said it would be 3 years before they had a 
staffing plan.
    Dr. Lynch. They are about a year ahead of schedule.
    Mr. Benishek. Well, I would like to -- can you please 
provide that? You know, in December 2012, there was a report by 
the IG that said that all the five facilities that the IG 
visited, were operating contrary to VA policy, which requires 
medical facilities to develop staffing plans that address 
performance measures, patient outcomes and other care 
indicators. So in December of 2012, they said that all the 
facilities they visited didn't operate according to VA policy; 
what has been done to change that?
    Dr. Lynch. That is what the Office of Productivity, 
Efficiency and Staffing has been working on. Since the IG made 
those recommendations in late 2012, they have been developing 
the standards for each of our medical specialties.
    Mr. Benishek. Do you know who is in charge of that?
    Dr. Lynch. It is run by Dr. Carter Mecher works in that 
unit.
    Mr. Benishek. Carter?
    Dr. Lynch. Mecher.
    Mr. Benishek. Mecher.
    Dr. Lynch. M-e-c-h-e-r, and Eileen Moran.
    Mr. Benishek. Okay.
    Dr. Lynch. I believe they have been down and have 
testified, or not testified, but briefed some of the physicians 
of this committee.
    Mr. Benishek. Well, it is just so -- you know, it is one 
thing to have a plan and then it is actually one thing to carry 
out the plan. So, I mean, the Inspector General told us back in 
this report that he went to five facilities, and none of the 
five facilities were carrying out, you know, the policy that 
was in place, and you don't have any idea, then, if anybody 
was, if any action was taken over the fact that these five 
places didn't --
    Dr. Lynch. No, sir --
    Mr. Benishek. -- comply with the rules --
    Dr. Lynch. -- I don't.
    Mr. Benishek. -- do you?
    Dr. Lynch. I do not, sir.
    Mr. Benishek. All right. I am out of time.
    The Chairman. Yes, you are.
    Ms. Brownley, you are recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman. And thank you to the 
panel for being here this evening.
    I wanted to talk a little bit about SCIP and so we 
obviously now have some new information that we have gleaned 
from the audit, and -- so when will the VA take in this new 
information that we have learned, you know, about the real wait 
times as opposed to the previously reported wait times and the 
increased demand thereof, and does the VA plan on updating the 
SCIP plan to reflect those new data points?
    Dr. Lynch. The VA, as we are beginning to look at the 
information we have regarding productivity and our resources, 
is also seriously discussing the space needed to address the 
delivery of that care. That has been under active discussion 
this week, in fact.
    Ms. Brownley. So if the VA is evaluating the capacity, 
space being one of them, I would imagine as you evaluate 
capacity, you are looking at space, the need for more 
personnel, in some cases it may be very extreme, you need much 
more space and many more personnel, and other places maybe it 
can be resolved by increasing hours at a particular facility.
    Are you gathering all of that information and putting it in 
a matrix so that by each location across the country, we know 
exactly what the underlying issues are and how the VA will 
approach that, and most specifically, sort of timelines? I 
mean, space is something very concrete. Personnel might not be 
as concrete, but it is pretty concrete. You know, will you have 
that evaluation location by location and a timeline of which 
you believe you can accomplish what is needed?
    Dr. Lynch. We already have most of that information 
location by location. We have physician information, we have 
staff support information, location by location. I cannot 
confirm whether we have space information, but it is critically 
important in making decisions regarding efficiency, and we are 
working and discussing the implications of space as we put our 
models together.
    Ms. Brownley. So you will have a model of space, then, and 
timelines location by location, and you say you have -- you 
already have that for personnel? Is that what exists currently, 
or what exists currently and what is needed and the timeline?
    Dr. Lynch. Yes and yes. We have the information based on 
what we currently have and we have been looking aggressively 
over the last several weeks at what may be required to either 
increase the efficiency of our providers, or if they are 
functioning efficiently, whether we need to consider adding 
additional physicians to meet that capacity.
    Ms. Brownley. So could you share that information with me, 
then, on the personnel side?
    Dr. Lynch. Certainly. Let me see if I can set up a briefing 
for you with the folks who put that together.
    Ms. Brownley. Okay. And then on the -- what is your, I 
guess, timeline for space, what is your timeline to put 
together a matrix to identify what are the space needs 
throughout the country?
    Dr. Lynch. I would have to get back to you on the space 
issue. That is still being discussed, and I don't have a 
definite timeline for that.

    Ms. Brownley. Okay. The chairman in his opening comments 
talked about asking the question how quickly can the VA hire a 
doctor, and you talked about the fact that you weren't really 
sure, but I am wondering -- but you know it is too long. We all 
agree on that.
    So can you just share with me just your -- at least the 
VA's initial thinking on what some of the barriers are and what 
might be some mechanisms for shortening that period and 
expediting the process?
    Dr. Lynch. I think we are clearly going to have to work at 
improving the efficiency of our human resource process for 
handling new recruits. You are absolutely right: it is clearly 
too long, oftentimes we lose people during the process. Some of 
it is essential, the credentialing and privileging process is 
essential, but some of the other processes involved in human 
resources can clearly be improved in terms of their efficiency.
    I think, interestingly, some of the things that we are 
learning in Phoenix as we are working with that facility to 
increase their capacity to add new physicians may help the rest 
of our system to function more efficiently in the HR process.
    Ms. Brownley. Thank you.
    I yield back.
    The Chairman. Mr. Huelskamp, you are recognized for 5 
minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman.
    Dr. Lynch, as part of the VA's Accelerating Access to Care 
Initiative, you have committed to ensuring primary care clinic 
panels are correctly sized to achieve the desired productivity. 
What are these desired productivity standards that you are 
using for primary care providers?
    Dr. Lynch. Right now the standards they are using are the 
number of patients per physician. They do have models that they 
can use to see whether we can increase that capacity based on 
staffing or based on room availability or based on patient 
complexity.
    We are also beginning to implement the use of the 
productivity model to look at primary care and see if we can 
use that to take a look at not only the number of patients a 
physician is seeing, but the complexity of those patients and 
their productivity.
    So, for instance, perhaps a physician is seeing six 
patients a day, perhaps they are new patients or complex 
patients that have a high relative value unit. That physician 
may actually be more productive than a physician who is seeing 
15 established patients during the course of the day. So I 
think --
    Mr. Huelskamp. And I do follow that. How do you monitor 
that, though?
    Dr. Lynch. Right now we are monitoring that by looking at 
the RVU productivity of our physicians.
    Mr. Huelskamp. Is that monitored at the national level, the 
vision level, the facility level?
    Dr. Lynch. Yes, at the facility level.
    Mr. Huelskamp. At the facility level. Now, given the gaming 
strategies and other things that have suggested or have shown 
that the data is not valid or maybe not reliable, do we have 
potentially the same problems with what you are attempting to 
measure here? Why would we not have similar problems with 
knowing exactly what is going on with productivity?
    Dr. Lynch. Dr. Clancy?
    Dr. Clancy. I think that is an incredibly important 
question and one that we share your concerns, and also 
recognize that since integrity of data has been a problem for 
us, we not only need to clean up our policies and streamline 
them, but that we also need to have some independent validation 
that these processes are both effective and that the integrity 
can be assured by an independent third party, and we will be 
doing just that.
    RPTS MCCONNELL
    DCMN CRYSTAL
    [8:29 p.m.]
    Mr. Huelskamp. So that has not been done?
    Dr. Clancy. Not yet, because the scheduling new policy --
    Mr. Huelskamp. So any of the data you have shared here has 
not been independently confirmed?
    Dr. Lynch. The RVU data is validated based on what we are 
recovering from the way that physician activities --
    Mr. Huelskamp. But if we have falsified data -- and we have 
shown that, the VA has admitted to that, the gaming strategies, 
4 years ago admitted that was going on -- I don't know how the 
data could be valid or reliable in either case based on what 
Dr. Clancy just said. So I am trying to find out how you can 
assure me that the numbers you gave here actually match what is 
really happening in the real world.
    Dr. Lynch. Congressman, point well taken. VA does need to 
establish the integrity of their data. I will take your 
comments back to the Office of Productivity, Efficiency and 
Staffing and ask them how we can validate the information we 
have so that we can establish the integrity of that data and 
assure you of the confidence that we have in that data.

    Mr. Huelskamp. But the range you gave was 6 to 22 patients 
a day. That is your claim today?
    Dr. Lynch. Yes, sir.
    Mr. Huelskamp. That is not valid?
    Dr. Lynch. I think that information is valid. I think it is 
very difficult to try to figure out --
    Mr. Huelskamp. I had a whistleblower has approached my 
office from a facility -- and I am in my congressional district 
in four different VISNs, we are lucky that way, I guess -- but 
claims that there are primary care physicians that see as few 
as five patients in an entire day. That would be definitely 
outside the range. Could that be possible?
    Dr. Lynch. I would have to look at the information and 
evaluate it. At this point, anything could be possible. And I 
am certainly willing to look at anything --
    Mr. Huelskamp. I agree. And that is my problem here. When 
you say anything can be possible, this is not independently 
confirmed, but how do you make decisions when you don't know if 
your data is accurate? And, you know, gaming strategies, we 
have heard, actually the falsifying data, and what I have heard 
from this whistleblower. And there are some really hard-working 
physicians out there, but there are some that are working very, 
very hard, and then physicians across the hallway that see five 
patients a day, which basically half the day they are sitting 
there waiting for something. And obviously, when we are looking 
at ways to provide better access to care, ways we can do that 
by enhancing productivity, but we don't have the data, I think, 
to answer any of these questions.
    And so I look forward to you showing us how the data is 
valid and reliable.

    Mr. Huelskamp. But if this whistleblower identifies 
physicians that are not working as hard as they should be, we 
have got a serious problem in the system.
    Dr. Lynch. Congressman, I think we need to understand that 
further.
    Mr. Huelskamp. Okay. Thank you, Mr. Chairman. I yield back.
    The Chairman. Dr. Ruiz, you are recognized for 5 minutes.
    Mr. Ruiz. Thank you, Mr. Chairman.
    The discussion on ways that technology and innovation can 
increase the capacity of the VA to provide timely, accessible, 
and high quality veteran-centered care is very important. 
However, today this committee learned that the Office of 
Special Counsel, whose job it is to protect whistleblowers and 
investigate their claims, found that the VA has failed to use 
information from whistleblowers to correct troubling patterns 
of deficiency of patient care that negatively impact the health 
and safety of our veterans, and they failed to correct these 
troubling patterns of these deficient patient-care practices. 
They describe quote, ``A culture of nonresponsiveness,'' 
unquote. The OSC revealed that the VA's Office of the Medical 
Inspector frequently refused to acknowledge the systematic 
problems in the VA that exist or acknowledge how they 
negatively affect veteran care. In other words, it was an 
institution-centered and not a veteran-centered response.
    We need to create a veteran-centered culture of 
responsiveness. The Office of the Medical Inspector of the VA 
needs to either come forward with a serious explanation or get 
out of the way so solutions can be found and implemented and 
veterans can receive the care they need when they need it.
    Today we are talking about accelerating access to care. 
What we need is an accelerated access to high-quality care, not 
inadequate care. My question is, how are you ensuring that the 
care to veterans is high quality? You know, as a physician in 
clinical practice, we have quality review mechanisms, and some 
of these mechanisms begin with credentialing, board 
certification, risk management, continuing medical education 
requirements, an evaluation of patient requests, and also chart 
audits. What systematic method are you ensuring from your 
healthcare providers or the system in order to ensure high-
quality care?
    Dr. Lynch. Congressman, I am going to defer to Dr. Clancy 
to answer that question.
    Dr. Clancy. So you often hear it said that once veterans 
can get in they often think that the quality of care is very 
good. And in fact, by the numbers, whether you are looking at 
information reported to Hospital Compare, we use the same 
metrics, or the same metrics that are used to evaluate health 
plans, as a system VHA looks quite good.
    In addition to that, at a very high level we have all of 
the regulations that the private sector has, plus additional 
investigations by the Inspector General, the GAO, and other 
parties. So we have quite a bit of oversight in that regard.
    VA, before there was a famous Institute of Medicine report 
on not harming patients, ``To Err is Human,'' actually stood up 
a National Center for Patient Safety. As a result of that and 
other efforts, there is a very, very strong focus on 
psychological safety and encouraging all employees to step 
forward. If you see something, say something -- we actually 
have a video about this that has been shown widely -- stop the 
line. And I think Secretary Gibson was very, very clear with 
respect to whistleblowers where you started out here today in 
accepting the Office of Special Counsel report.
    Mr. Ruiz. So I think that there are definitely good 
practices, and Loma Linda University is one of the better VA 
hospitals in our country and they serve the veterans in my 
district. However, even amongst the best, there are always 
issues that we need to improve. And if there is a report saying 
that there is a culture of unresponsiveness to these grave 
scenarios that is systematic, then I think that we need to get 
to the bottom of it and figure out where that disconnect 
between the whistleblowers and the responsiveness of those 
responsible to make sure that these practices don't happen.
    Let me get to the next question. Do we have a count of 
full-time equivalent primary care physicians per veteran ratio 
within the VISNs?
    Dr. Lynch. Yes, I am sure we do.
    Mr. Ruiz. Do you know what it is?
    Dr. Lynch. It would vary by VISN.
    Mr. Ruiz. Of course.
    Dr. Lynch. I would have to get you the specific information 
for VISN or for a facility.

    Mr. Ruiz. And are they used to determine where your 
resources are spent?
    Dr. Lynch. They are certainly used in association with 
information regarding demand to make resource decisions, yes, 
sir.
    Mr. Ruiz. The national recommendation is one full-time 
equivalent physician per 2,000 Americans. To be considered 
medically underserved, it is one full-time equivalent physician 
per 3,500. So it would be important to determine whether a 
physician-per-veteran ratio reveals an underserved VA system 
per area so that we can start addressing these underserved 
areas with priority.
    Thank you. I believe that is the end of my time, and I 
yield back my time.
    The Chairman. Thank you very much, Doctor.
    Mr. Coffman, you are recognized for 5 minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    Dr. Lynch, how long have you been with the VA system?
    Dr. Lynch. About 30 years, sir.
    Mr. Coffman. How long have been in senior leadership with 
the VA system?
    Dr. Lynch. About a year-and-a-half.
    Mr. Coffman. About a year-and-a-half. And what surprises 
me, and I certainly commend the VA for having this Access to 
Care Initiative, I think the problem is, and I think we need to 
be convinced, because what we are asking is the same people 
that drove us into this ditch to figure out how to get us out 
of this ditch.
    And what amazes me is the fact that under the leadership 
within the VA, all of the issues have come forward through 
whistleblowers. And I know that you went, when the story I 
think that was the catalyst for all of this, which was the 
Phoenix VA scandal, and I think you personally went down there 
to look at it, I mean, you didn't talk --
    Dr. Lynch. I have been to Phoenix four times.
    Mr. Coffman. Well, when you testified before this 
committee, you went there, you came back, you didn't talk to 
the schedulers that were actually doing the work. You didn't 
talk to Dr. Foote, the key whistleblower. You made no outreach 
to him. And you didn't talk to any veterans, and you testified 
to that effect here.
    And so we are counting on you to get us out of the ditch. I 
just don't think it is going to happen. I just don't think you 
can do it. And I think what we need is we need a new Secretary 
of the Veterans Affairs that is going to come in and is going 
to clean house. Because you have been in the system for a long 
time, and you are not outraged. The reality is, you are not 
outraged. And you have testified before this committee a number 
of times; always been defensive, always been defensive. 
Covering, concealment, escape, and evasion, those are terms I 
learned in the military as a ground combat officer. And you 
have used those brilliantly, I think, before this committee. 
And the VA has not been transparent. It has admitted a lack of 
integrity.
    So tell us how we can count on you and the leadership team 
that exists there now to get us out of this ditch and to be 
honest with this committee and with the American people, with 
the veterans that you are here to serve.
    Dr. Lynch. Congressman, I value the VA system greatly. I 
think it is a good system.
    Mr. Coffman. Well, it is not a good system. How could you 
say, tell me how you could say it is a good system.
    Dr. Lynch. I think it is a good system, Congressman.
    Mr. Coffman. Really?
    Dr. Lynch. Yes, I do.
    Mr. Coffman. Not if you are a veteran, it is not a good 
system.
    Dr. Lynch. I think it provides good quality care. I think 
Dr. Clancy can confirm --
    Mr. Coffman. Not there. Here is the problem.
    Dr. Lynch. Our system compares favorably with the private 
sector in terms of quality of care and in patient satisfaction. 
I think that, yes, we are challenged right now. We are 
challenged because of data integrity. And we certainly need to 
re-earn the confidence of the public, of the Congress, and of 
our veterans, and we are working to do that, sir.
    Mr. Coffman. You are just glossing this stuff over.
    Dr. Lynch. I am not glossing over --
    Mr. Coffman. I mean, you ought to outraged. It is not a 
good system. It is not serving the needs of our veterans.
    Dr. Lynch. I take this all very seriously.
    Mr. Coffman. And you are part of the problem. I just don't 
see you as part of the solution. I don't see you able to get us 
out of this ditch, and we are in a ditch, and you are in denial 
that we are in the ditch.
    Dr. Lynch. Congressman, I am not denying at all that we 
have a significant problem. If you want to call it a ditch I 
will not disagree with you.
    Mr. Coffman. We just had testimony --
    Dr. Lynch. I think we do have a way forward. I think we do 
have plans. I think we do need to reestablish our integrity. I 
think we can do that. And I think we can salvage a system which 
does provide good care and we can make that system provide 
timely access.
    Mr. Coffman. I am absolutely stunned that you would call 
this, with all of the information that has come out, and I 
don't think we are at the bottom of all of this yet, that you 
would call this a good system I think is absolutely stunning. 
And I think that the Veterans Administration is the most 
mismanaged agency of the Federal Government. And I think that 
it has not been there to serve those who have served this 
country, but the leadership of the VA has been there to serve 
themselves.
    And we had testimony before this committee about all the 
bonuses, all the bonuses, despite the incredible bureaucratic 
incompetence and cultural of corruption. That is the only thing 
you all seem to be effective in, is writing checks to each 
other.
    Mr. Chairman, I yield back.
    The Chairman. Mrs. Kirkpatrick, you are recognized for 5 
minutes.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman. And I want to 
thank you and Ranking Member Michaud for continuing to have 
these hearings. I feel like we are not getting to the bottom of 
this.
    And, Dr. Lynch, we have had a number of hearings. You have 
been here a number of times. And I just want to focus on the 
scheduling delays. That is the problem that we are trying to 
get to the bottom of. But we have heard, this committee has 
heard that there are five reasons for these scheduling delays: 
that there was an unexpected surge of new patients; there was 
not enough funding; obsolete facilities and obsolete 
technology; a lack of patient extenders and personnel; a lack 
of consistent policy across the system.
    But that just further describes a problem, and my question 
is, why? Why did the VA not anticipate a surge in new patients 
when we know that we have an aging population. Why did the VA 
not have enough funding when we have given them all of the 
funding that they have requested?
    And so we are starting to think as a committee that this is 
a systemic problem, but we are still just not getting to the 
bottom of why. Can you answer that for me?
    Dr. Lynch. I think part of the reason may be relatively 
self-evident. We were not getting good data from the system. We 
didn't have a good measure of those patients that were waiting.
    Mrs. Kirkpatrick. But why? Why?
    Dr. Lynch. I think we know why. I think we have 
acknowledged that the system was not honest. We were not 
getting the information we needed. We had performance measures 
that were misguided, and we need to reform that so we have 
accurate information and we can resource our system 
appropriately based on demand and capacity.
    I think we have the tools to do that. I think we have the 
information to do that. We need to assure that our data is 
accurate. We are working very hard to do that. We are making 
demands on both our VISN directors and medical center directors 
to assure that the practices in their clinic are according to 
policy. We acknowledge that we are probably going to have to 
have an independent third party confirm that that information 
is accurate, because at the moment we have to verify to you, we 
have to justify to the American public that our information is 
real and accurate and we can provide timely care and we can 
give the information that we need to assess demand and 
capacity.
    Mrs. Kirkpatrick. Well, I appreciate your answer, but I 
feel like we are still not getting to the bottom of this.
    And let me just say, why is the VA so slow? Why are they so 
slow in responding to Mr. Walz's office? Why have they been so 
slow in responding to this committee. It is just why, why, why? 
Is it because there aren't enough --
    Dr. Lynch. Congresswoman, I apologize for our slowness. It 
is not correct. I think we do have to work with this committee 
and we do have to work with Congress if we are going to build a 
better VA system. And we do need to give you the information 
that you need.
    Mrs. Kirkpatrick. Dr. Lynch, let me ask you just one other. 
Is it a system that can innovate?
    Dr. Lynch. Yes, I think it is a system that can innovate, 
and I think we have shown that we can innovate in the past, 
particularly in response to crisis. If you look back in the 
mid-1980s, there were concerns about surgical care in the VA. 
The VA developed a risk-adjusted model of outcomes assessment 
that has now become the model for the private sector. In the 
1990s, the VA was criticized, and the VA innovated with the 
electronic health record. That has now become a standard for 
the private sector.
    I think we can innovate and I think we have an opportunity 
here in VA to respond to this crisis with an innovative model 
of staffing, of assessing demand and capacity that can become a 
standard for the industry as well.
    Mrs. Kirkpatrick. Please do it.
    I yield back my time.
    Dr. Clancy. Well, if I could just add one thing to what Dr. 
Lynch just said.
    Mrs. Kirkpatrick. Okay.
    Dr. Clancy. I think all of your questions are critically 
important, and frankly, are tearing us up as well. But right 
now we are focused 100 percent on trying to get veterans into 
the system and using all the tools available at our disposal. 
There will be time for the ``why'' questions and the much 
tougher analytical questions that all of you are asking about 
how do we fine-tune capacity and demand. But right now the 
number of veterans waiting is an emergency, and that gets the 
highest priority. That does not mean anything else is off the 
radar screen.
    And I just have to say in response to the innovation 
question, I did have the pleasure and opportunity of visiting 
VISN 1, which happens to encompass the State of Maine, and some 
of the innovations that they have tested and deployed up there 
are really terrific. I think our challenge is figuring out how 
to spread it and to achieve the same successes as we have seen 
in surgery and in other areas.
    Mrs. Kirkpatrick. Thank you. Thank you, Dr. Clancy.
    The Chairman. Dr. Wenstrup, you are recognized for 5 
minutes.
    Mr. Wenstrup. Thank you, Mr. Chairman.
    You know, as we sit here and talk about all this, I think a 
lot of times as people are watching it, it almost seems like we 
are talking about patients as through they are Monopoly pieces. 
And when Mr. Walz brings up the point of the possibility of 
getting surgery within 48 hours, but it is 6 weeks until they 
can get their preop work done at the VA, it is disappointing 
that that surgeon can't make something happen sooner, or that 
there is nowhere to go, that these types of things aren't 
corrected. And I am sure that these have gone on for years.
    And there is a lot of things that we are hearing tonight, 
and you share our concerns. Well, when did you start? When I 
got here, I went to General Shinseki three times saying I would 
be willing as a physician to go into the clinics and go into 
the ORs -- I come from private practice, I trained at a VA -- 
and to discuss why it is so much slower, why there are so many 
fewer patients being seen. Never got a response. Never got 
action on that.
    You talked about RVUs, and for our fans watching at home, 
they probably don't know what those are. Relative value units. 
And so a new patient has a higher value than an established 
patient. A short procedure has fewer value units than a long 
procedure, those types of things. So when people hear that, 
they know what we are talking about.
    When did you start looking at the RVUs?
    Dr. Lynch. The RVUs, I believe, became part of our 
evaluation process after the OIG report in late 2012.
    Mr. Wenstrup. Okay, so just in the last couple of years. 
And, of course, that has been around for a while as some type 
of measure. But my question is, are you measuring how many RVUs 
per patients, per day, per month, per provider, per facility, 
per VISN?
    Dr. Lynch. Yes, sir, we are.
    Mr. Wenstrup. Okay. Well, that would be nice, because if 
you could just maybe pick one VISN and give me all that 
information tomorrow, I would appreciate seeing how you are 
going about doing that. I would be very curious.

    Mr. Wenstrup. And Dr. Benishek brought up a very good point 
when he said, how much are you spending per RVU? So if you take 
all the money that you are spending on these patients and then 
tally up how many RVUs that have been built up, how much are 
you spending per RVU? Because I can tell you, Medicare knows 
how much they spend per RVU because it is already established. 
So your budget is out there. You are measuring RVUs, but not 
how much you are spending per RVU, and I think that is key. And 
I also think it is key that you look at how many patients a 
doctor is seeing each day, or a facility is seeing each day. 
There is more than one way to measure these types of things.
    In our practice, if one doctor is seeing 60 patients and a 
similar doctor is seeing 30, we are talking to the one with 30 
and see how we can help them get that up and continue the 
quality that they have to have. But when you are comparing to 
yourself, I don't think you are getting anywhere. And that is 
part of the problem.
    So my next question is, when you talk about doing these 
evaluations of efficiency, who is doing this? Because if it is 
somebody that has been in the VA system their whole life they 
don't know what they are measuring, they don't compare to 
successful, healthy healthcare systems. So who is doing this 
currently?
    Dr. Lynch. Right now it is being done by Dr. Carter Mecher 
and Eileen Moran.
    Mr. Wenstrup. And are they from the private sector? Have 
they been in academia? Have they been in the VA? Where have 
they been through their careers that make them qualified to be 
very good at this?
    Dr. Lynch. I don't know Dr. Mecher's history. I know that 
he has met with the physicians on this committee, so I think 
you have talked with him.
    Mr. Wenstrup. Yes.
    Dr. Lynch. I think he does have a good handle and a good 
understanding of the RVU system and productivity. I think he 
has some very innovative concepts of how we can use that to 
resource our system and to look at rightsizing the number of 
physicians and the capacity that we have.
    Mr. Wenstrup. And that is helpful, but I would definitely 
look at someone who has had great success in these areas, and 
they exist throughout our country without a doubt.
    Dr. Clancy. I would just add that we are speaking to Kaiser 
and a number of leaders from private sector systems, and if you 
had other suggestions we would be all ears.
    Mr. Wenstrup. Well, and those are good suggestions. And I 
would also suggest that you encourage the President and the 
Senate to confirm someone who has some administrative 
experience in the private sector in these areas. I think it 
would be a great benefit to our veterans and to our country.
    And lastly, I do want to point out that the Cincinnati VA, 
I represent that area, has been flagged. I have asked for why 
they were flagged and have not received my notification yet as 
to why. And certainly somebody knows why. So I hope we get that 
very quickly as well. So I look forward to seeing one of those 
reports on the RVUs as well.
    And I yield back. Thank you.
    The Chairman. Ms. Kuster, you are recognized for 5 minutes.
    Ms. Kuster. Thank you very much, Mr. Chairman.
    And thank you, Dr. Lynch and Dr. Clancy, for being with us 
this evening.
    I think what all of us are trying to do is to be helpful. I 
think our chair opened the hearing asking how can Congress help 
you? And our challenge is that this whole process feels like a 
Rubik's cube. Every time we think we have got a piece in order 
and we think we understand what the problem is, is it not 
enough physicians, then we offer to help on that, but maybe 
that is not the problem, it is a space problem. If it is not a 
space problem, it is the support staff. And the list goes on 
and on.
    I am very fortunate to have experience with the VA in New 
Hampshire. My father-in-law got very excellent care within that 
system. But obviously the concern that we have is that that be 
replicated for every veteran around the country. So the focus 
of my comments is, how do we ensure access to high-quality care 
at a cost that the taxpayers can afford for every veteran?
    And I have spent 25 years in the private sector on policy 
issues. I know this isn't easy, this conundrum of high-quality 
care, access, and cost is sometimes a wobbly three-legged 
stool. But in your case it seems that the problems of 
scheduling and wait time data has called into question the 
whole basis for your staffing and capacity calculations.
    And I think, Dr. Lynch, you just mentioned it. You are 
trying to match supply and demand, but you don't have an 
accurate picture on the demand side, and so trying to determine 
what the staffing model would be is of limited use. And when 
you tell us the average is a physician seeing 10 patients a 
day, does that include the data that we have heard in this 
committee of 50 percent no-shows? So is that actually a 
physician that has 20 slots per day, but only 10 patients walk 
through the door?
    And we want to help you with this. We want to get the 
policy right. We have legislation that we are offering this 
week, it will be bipartisan, that is about getting residents 
involved, give you greater capacity. We would be happy to help 
talk about what the space issues. But how can you help us with 
where to start helping you?
    Dr. Lynch. Congresswoman, I think we can start by trying to 
give you the information that you ask for. And I apologize if 
you have not seen that. We have provided a briefing to members 
of this committee on the productivity model that we have.
    I acknowledge that until we can assure the accuracy of our 
scheduling data that information is going to be flawed, 
although I am confident at this point that I think we do have 
reasonable information on productivity, and we can begin to use 
the productivity information to begin to look at what we need 
in the way of additional staffing to increase the efficiency of 
physicians, or in those practices that are very efficient, who 
we may need in the way of additional physicians.
    So I think we have a start, but I think we need to gather 
more data. I think we need to have accurate data on access 
before we can come to a final answer.
    Ms. Kuster. And then if we could add Dr. Benishek's 
analysis about the cost in-house and outside the VA because it 
is difficult for us to make that recommendation as to how to 
make these adjustments. We want veterans to be seen in a timely 
way, but it is not unlimited, the funds that can be put toward 
this. If it is less expensive within the VA, then let's expand 
your capacity. If it is less expensive outside the VA, then 
let's use private facilities. But we are not able to measure 
this at this point.
    Dr. Clancy. No, but I think that all of the information 
that you have heard and we look forward to briefing you more 
on, on the productivity and staffing, will be a huge puzzle 
piece here that will be foundational to getting to this second 
order question, after the emergency of addressing people 
waiting in line right now, about what kinds of resources do we 
need.
    And the issues that Dr. Lynch brought up a couple of times 
about a make-or-buy decision at the very local level because 
that is where it needs to happen, the answer to that is not 
going to be thumbs up, thumbs down all the way. It is probably 
going to be make in some areas, primary care, for example, and 
buy in some other specialty areas, and so forth. And a lot of 
that will be a very dynamic relationship with community 
capacity and so forth.
    Ms. Kuster. My time is up, but I do have a specific 
question I would like to get to later about women being served 
in the VA, because I think that is a unique situation as well, 
and problematic at best.
    So thank you, Mr. Chair. I yield back.
    The Chairman. Mrs. Walorski, you are recognized for 5 
minutes.
    Mrs. Walorski. Thank you, Mr. Chairman.
    Dr. Lynch, I would like to ask a question about the VA 
staffing and productivity standards. The IG that was here a 
couple of weeks ago made an interesting kind of assessment. He 
pretty much said be careful what you wish for to our committee 
in this issue of fee-basis care versus VA care. So I did some 
investigation in my State. I learned there are a number of VA 
hospitals, including the one in Fort Wayne, Indiana, the VA 
medical center, that are not functioning at full capacity, they 
are turning patients away, sending them to non-VA hospitals due 
to a lack of appropriate staffing or facilities.
    In this case, the Fort Wayne VA, their ICU is closed. The 
ER is now using criteria over what patients they will accept 
and those they will turn away based on their facilities. By 
paying for non-VA care in addition to operating half-empty 
hospitals, VA appears to be paying for two systems of care. So 
do you know how many VA hospitals fit this description?
    Dr. Lynch. I don't.
    Mrs. Walorski. Can you give me that number? I mean, I found 
the Fort Wayne one pretty quickly.
    Dr. Lynch. I think there are facilities that we are 
struggling, they are older facilities, not always like Fort 
Wayne where they are in larger communities. Sometimes they are 
in smaller communities. The population that they support is 
small and oftentimes it is difficult for them to support an 
ICU. Those are difficult decisions. But we need to look at our 
facilities, where they are, and we need to assure that we are 
using them optimally.
    Mrs. Walorski. And then I guess my follow-up question would 
be what the IG warned us about, which is, who is looking at 
those numbers to figure out? For example, in Fort Wayne, those 
numbers for fee-basis care are skyrocketing every year. Well, 
once I looked at that and found out there is no ICU and they 
are using criteria who they can take and who they can't take, 
they may have to send somebody across the street for some kind 
of a risk-basis procedure because there is no ICU.
    So who looks at those numbers? Is that just a regional, 
statewide, or just that specific hospital looks at those 
skyrocketing numbers? And at someplace who makes the assessment 
of, are we paying for two facilities or are we paying for one?
    Dr. Lynch. So part of the challenge we have is that, based 
on the volume in some of our facilities, we cannot support an 
ICU, not because we can't afford it, because we don't have the 
patient volume to maintain competence. And so there is a 
balance, and oftentimes it is felt that because of the volume 
and because of the competence, it is better to send these 
patients into the private sector.
    I understand your concern, and we do need to look at where 
our costs are going and how we are using our facilities.
    Mrs. Walorski. We do need to look at, or is somebody 
actively looking at this now that all this information really 
is coming to us from the Inspector General? Is somebody ongoing 
going to look at that to see this cost-benefit analysis of what 
are we paying for, are we paying for two systems, or is that 
something you are going to look at in the future?
    Dr. Lynch. I don't know whether we have an active exercise 
in place, but we certainly do need to have one moving forward.
    Mrs. Walorski. And I just got a note from a constituent 
that says there must be some kind of a CNN program on tonight 
and that there is a new revelation. It says, ``Records of dead 
veterans were changed or physically altered, some even in 
recent weeks, to hide how many people died while waiting for 
care at the Phoenix VA hospital, a whistleblower told CNN in 
stunning revelations that point to a new coverup in the ongoing 
VA scandal. 'Deceased' notes on files were removed to make 
statistics look better so veterans would not have to be counted 
as having died while waiting for care.'' And the quote is from 
Pauline DeWenter.
    So you have been to the Phoenix facility four times. Are 
you aware of this new revelation?
    Dr. Lynch. I am not aware of the revelation. I am aware 
that the OIG is looking carefully at all of the deaths that 
occurred. I do not know of any attempts to hide deaths, 
Congresswoman.
    Mrs. Walorski. And I guess my follow-up question to this, 
because I am guessing this is going to be big news in the 
morning, or probably big news tonight when our constituents are 
all watching their late news, but again it is so hard, I guess 
to echo the comments on this committee, it is so hard to take 
the information seriously that you give us tonight when there 
are these ongoing investigations by new whistleblowers that 
they are taking stickers off of files, removing names still, 
while we have been doing these hearings for a couple of months, 
and Americans are literally wondering, when is this going to 
stop? This looks like a new revelation tonight.
    Under all the scrutiny, all the lights, all the spirit of 
full disclosure, Phoenix is still doing this kind of stuff, and 
you guys have had them under a microscope, and you have 
physically been there four times, and this is new?
    Dr. Lynch. Congresswoman, I don't know the details of the 
accusation.
    Mrs. Walorski. Could you provide that to us? I think the 
details are out, but could you provide us the VA answer to that 
in a timely manner?
    Dr. Lynch. I will certainly try as I understand it.

    Mrs. Walorski. Thank you, Mr. Chairman. I yield back my 
time.
    The Chairman. Mr. O'Rourke, you are recognized for 5 
minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Dr. Lynch, you mentioned earlier that $312 million has been 
made available to accelerate access to care to veterans who 
have been unable to receive it thus far. Where did that money 
come from?
    Dr. Lynch. The money was recovered from funds that were not 
being used across VA. I believe that there was some activation 
moneys that was repurposed to cover the Accelerated Care 
Initiative.
    Mr. O'Rourke. And what are activation moneys?
    Dr. Lynch. Activation moneys are sometimes moneys that are 
used for new projects. I don't know the details, but I would 
assume that it was felt that the moneys were not absolutely 
necessary at this time and could be repurposed to address the 
immediate concern, which was the provision of timely care to 
veterans.
    Mr. O'Rourke. And will you or the VA be coming back to 
Congress to recover those moneys after we get through this 
crisis?
    Dr. Lynch. I don't think that is our intention, 
Congressman.
    Mr. O'Rourke. Okay.
    Dr. Lynch. I think our immediate attention is to provide 
timely access to care, and at the moment we are trying to use 
the funds that we have.
    Mr. O'Rourke. What I am trying to get at, and I agree with 
you that that should be our focus, and I appreciate Dr. Clancy 
saying that earlier that, that the number one priority before 
us is to connect veterans who need care to those providers who 
can give it to them, but I do want to get to the chairman's 
question and one that my colleague, Ms. Kuster, brought up, 
which is, what will you be likely be asking for from Congress?
    I think this is a time where the American people and their 
representatives here would be very open to a request from the 
VA to say, to get to the level of care that we have promised to 
our veterans we need X. And you say that you have provided $312 
million. Is there more to be found among those funds from which 
you have taken it so far? Will there be more needed in the 
coming days? I mean, we are really only weeks out from the 
revelations, and as Mrs. Walorski pointed out and others, 
myself included, in our districts we are still finding new gaps 
and shortfalls that need to be met.
    So I am thinking, and you may not have a number in mind, 
but wouldn't you say that you are likely going to come back to 
Congress to request additional funds?
    Dr. Lynch. I can't answer that question right now. I can 
tell you that we are beginning to look at the resources, 
particularly personnel resources that we need to increase our 
capacity, and we will be working with the Congress to develop a 
proposal that would allow us to hire more personnel to provide 
that care.
    I know that we are looking carefully at the money we are 
spending on fee-basis services. We have been able to find some 
central money to send those patients out. Facilities and 
networks have also been able to identify moneys as well. It is 
anticipated that we will probably increase VA funding on fee-
basis care from about $4.8 billion to about $5.4 billion this 
year.
    Mr. O'Rourke. And I would also ask you to, and you 
essentially committed to this earlier in previous answers, but 
pay special attention to the providers that we have within the 
VA system today and retaining them there. When I met with 
providers in El Paso a couple of months ago morale could not 
have been lower, and a lot of it had to do with the amount that 
they were being paid, seeing so many of their colleagues leave 
service within the VA to work with DOD, which paid more, to 
work within the private sector, which paid more. In some cases 
they were single parents. These are nurses, nurse 
practitioners, providers of all kinds.
    And I have just got to think that as you are repurposing 
these funds and perhaps asking more from Congress, I think it 
is really important that we ensure that we are attracting the 
absolute best within the VA system that we are actually then 
able to retain them. One primary health provider told of 
prescribing for mental health patients and seeing the mental 
health caseload that is coming in there, which he said he 
didn't feel good about at all. He said, this is not right, but 
I am not going to let that person go untreated even though I 
wasn't trained to treat somebody for these kind of problems. 
That raises a number of questions and issues in itself, but it 
gets back to this issue of resources for providers.
    I have a number of other questions specific to El Paso, but 
we will continue to reach out to you in between these hearings 
and at these hearings to follow up when we don't get an answer. 
I appreciate your responsiveness so far. And I do ask Dr. 
Clancy and Dr. Lynch and the leadership, as we get through this 
immediate crisis, if we lose this opportunity to address the 
real systemic, structural, cultural problems within the VA, I 
think that we will be right back here again in another couple 
of years, 5 years, 10 years, having this very same discussion.
    So while addressing care and connecting veterans to care is 
important, let's make sure that we don't stop there. We need to 
address the culture, the operations, and the system. So anyhow, 
thank you for your answers and your work on this.
    And, Mr. Chair, I yield back.
    The Chairman. Thank you very much.
    Mr. Jolly, you are recognized for 5 minutes.
    Mr. Jolly. Thank you, Mr. Chairman.
    Dr. Lynch, I want to give credit where credit is due. I 
recently hosted in my congressional district what I call the VA 
intake day, invited the community to come in and talk about 
their care, their compliments, their concerns at both Bay Pines 
and Haley. We had about 300 people come in, and I will tell 
you, we had a lot of people come in simply to defend the VA 
health care that they receive.
    The other thing I want to compliment you on is Secretary 
Gibson said several weeks ago the Department was in the process 
of contacting 90,000 people who were on a waiting list. I 
actually heard from people in my district who had been 
contacted by phone. One of them was told, your dermatology 
appointment is 4 months away, and if you would like, we can 
move that up and fee you out.
    So I want to compliment the Department for that, yourself, 
the Secretary as well.
    I will also tell you just as a matter of a metric, we gave 
a questionnaire to folks, and for those of the 200 that filled 
out surveys, of those who had sought to go outside the system 
for non-VA care, fully 50 percent rated that experience in 
trying to get the VA to fee them out as either poor or very 
poor, expressing a lot of frustrations with the ability to get 
outside the system. It was a self-selected group. I recognize 
that. Those were some quick metrics we got.
    Mr. O'Rourke mentioned mental health and behavioral health. 
Over Memorial Day I was approached by a mom whose son had 
committed suicide while he was waiting for mental health 
services. The fiscal year 2014 MILCON-VA bill directed the 
Department to competitively contract with non-VA providers in 
certain communities where there was a need for additional 
mental and behavioral health capacity, as well as where there 
was also a non-VA infrastructure that could actually provide 
that.
    Are you aware of that direction, and can you update us on 
whether or not that has been pursued or is in the process of 
being implemented?
    Dr. Lynch. I know that the VA has been actively working 
with the community. They have been holding almost on a yearly 
basis mental healthcare summits to inform the community of 
opportunities to participate in the care of veterans. So I 
think we are moving aggressively to involve the community where 
they are available in the care of veterans if it is necessary.
    Mr. Jolly. I understand that reflects a spirit. But the 
Department was directed by the Congress. Congress determines 
the budget. Congress makes directions when it comes to how that 
money is to be spent. And in the 2014 bill, Congress directed 
the Department, didn't ask, directed the Department to have a 
demonstration project to competitively contract out in certain 
communities, at the choosing of the VA, mental and behavioral 
health non-VA care to do a demonstration project, to relieve 
capacity in certain areas. I guess particularly given the 
position you have, are you aware of that in the 2014 budget?
    Dr. Lynch. Yes, I am aware of that.
    Mr. Jolly. And has anything been done to implement that?
    Dr. Lynch. Yes, it has.
    Mr. Jolly. What has been done?
    Dr. Lynch. We have developed demonstration projects, I 
believe, at five or six of our facilities to involve the 
community in veteran care, and we are evaluating the results. 
That is in process, yes.
    Mr. Jolly. Okay. I would very parochially tell you how 
wonderful the Bay Pines and Haley system is, and the fact that 
stone claw season starts in October and we have the best 
beaches in the world. So to the extent that Tampa fits that 
profile and the Pinellas County community, I would encourage 
you to look at it.
    Two last questions. One, for non-VA care right now, those 
who ask to go outside, I understand that folks who need a 
specialty care service that is not available from within the VA 
are likely the most candidates. What about for the VA patients 
who simply aren't satisfied with the quality of care and ask to 
see a different primary physician outside the system? Is that 
ever accommodated through non-VA care?
    Dr. Lynch. I think the VA would attempt to find the patient 
another provider within VA if he was unsatisfied with his 
current provider.
    Mr. Jolly. Is there any -- and I understand there is some 
statutory guidance -- any feasibility of going outside of the 
VA?
    Dr. Lynch. In rare instances, if the patient is very 
unhappy, and I am speaking from personal experience, as chief 
of staff, I had authorized patients to receive care outside the 
VA.
    Mr. Jolly. Okay. And my last question. Mrs. Walorski just 
shared the story that is breaking, and I understand it is 
breaking. You haven't had an opportunity to review it. But I do 
have a very specific question, because the IG talked about 
criminal investigations, or investigating allegations that rose 
to the criminal level. We have had several hearings thus far. 
Were you, Dr. Lynch, personally aware that this was a matter 
being investigated, that the word ``deceased'' or the label 
``deceased'' had been or was being removed from files? Did you 
have actual awareness of that, that that was being 
investigated?
    Dr. Lynch. This is the first I have heard of it.
    Mr. Jolly. So you weren't aware it was being investigated?
    Dr. Lynch. No, I was not.
    Mr. Jolly. Okay. Thank you very much. I appreciate it.
    Yield back.
    The Chairman. Ms. Titus, you are recognized for 5 minutes.
    Ms. Titus. Thank you, Mr. Chairman.
    I would like to go back to a point that Ms. Kuster was 
making at the end of her comments. We are talking about 
evaluating the capacity of the VA to care for veteran patients. 
I want to look specifically at the VA's capacity to serve our 
female veterans. They are often referred to as the hidden 
veterans or the silent veterans because they are less likely to 
seek service because it is not very accommodating. And the 
statistics that have just come out in an AP story certainly 
show that.
    With regard to capacity, last year the VA served 390,000 
female vets, and yet a quarter of the VA hospitals do not have 
a full-time gynecologist on staff. A quarter. With regard to 
quality, half of the women veterans received medication through 
the VA healthcare system that could cause birth defects, 
despite the fact that many are of child-bearing age and the 
majority were not on contraception. This is much higher than 
would occur in the private practice.
    With regard to care coordination, the VA OIG has said that 
60 percent of female veterans at community clinics didn't 
receive the results of their normal breast cancer exam within 
the required 2 weeks, which is your own policy, and even more 
disturbingly, 45 percent of those results never made it into 
the electronic health records data system.
    I mean, I find these statistics are as bad, if not worse 
than some of the others that we have been talking about just 
generally speaking, and they indicate that the issues of access 
to quality care and proper coordination of care may be even 
worse for our female veterans than they are for the general 
population.
    Now, I understand you have some plan to ensure that there 
is a designated female provider, women's provider in each 
facility, so I would like to ask you, what is your timeline for 
achieving that goal? When are you going to start doing some 
training of VA providers on healthcare concerns like drugs that 
can cause birth defects? And just what is your plan for looking 
at the female population, because that is a group of veterans 
that is going to increase in number?
    Dr. Clancy. You are absolutely right, Congresswoman, and I 
thank you for your questions. We were concerned by some of the 
findings reported in the story as well. About 80 percent of our 
facilities do have a designated women's health provider. And in 
some of the other facilities there has been a challenge 
identifying someone to do that, so we are looking into training 
some existing staff, for example some of the current primary 
care clinicians to be able to meet that role.
    I should just point out this is not something that we just 
came up with on the spur of the moment for women. I mean, this 
is an area where we have had other similar sorts of experience 
training people with specialized expertise, for example when 
there is a particular problem that is much more common in one 
facility. We figured out how to bring specialist expertise to 
the primary care facility. We are going to be trying to do the 
same thing so that we can get up to 100 percent as soon as 
possible.
    The issue on mammograms, as I understand it in terms of the 
timely follow-up, particularly for abnormal findings, has been 
the focus of some substantial improvement efforts, and we can 
get you more details on that.

    Dr. Clancy. The other thing I would just point out in terms 
of women's health is that obviously women have issues that 
relate to their unique needs, and issues as women, as well as 
all the other stuff that human beings get, whether that is 
heart disease, lung disease, and so forth. VHA is the only 
system in this country that actually routinely reports publicly 
and transparently about how we do for women and men. That is 
not true for any other payors in this country. And in fact, the 
disparities are minimal to nonexistent between the care 
provided to women and men. I am talking mainstream heart 
disease and so forth. The issue of gynecological care is one 
that has improved quite substantially, but clearly we have more 
room to go.
    Ms. Titus. I don't think that is accurate. I am glad it has 
been improving, but a recent opinion by the American Congress 
of OB-GYN says that there is urgent need to continue training 
providers in this area. And you mentioned that you have done 
some work with the reporting back, especially of abnormal 
results, and it says that they are typically informed within 3 
days, and ``typically'' is in quotation marks, said that you 
don't really show how widely the improvements have been adopted 
or what specific progress has been made in this area. It is 
kind of hit or miss like so many of the things that we have 
been hearing about.
    So I am concerned that you are just going to train primary 
caregivers to be experts on women's health. Maybe that is an 
interim measure, but it is certainly not the same as having 
somebody who is qualified in that field. And again, I go back 
to these clinics that exist, say in rural Nevada, where it is 
very hard to find somebody who is an expert, or even in our 
urban centers like Las Vegas where we lack providers. And this 
is something that we need to address.
    Even if you send them out into the community, and then you 
don't track their results out in the private sector, or if you 
send them out and there are no providers in the private sector, 
we really have just kind of traded the devil for the witch. We 
haven't solved the problem.
    Dr. Clancy. I very much appreciate that, Congresswoman, and 
I want to be clear about one thing. I wasn't suggesting that we 
would send primary care providers to camp for 3 weeks and then 
they would be OB-GYNs by any stretch of the imagination. This 
was more to serve in the coordinating role and to be able to 
provide some basic services, but also to make sure that people 
got the services that they needed in a timely fashion. And I 
would just say that our top consultants in women's health, 
urgency would be her middle name, but I will be happy to get 
back to you about the mammography issue specifically.

    Ms. Titus. Thank you. I yield back.
    The Chairman. Dr. Roe, you are recognized for 5 minutes.
    Mr. Roe. I thank the chairman.
    And I am certainly glad that it is not 3 weeks. It took me 
4 years and then 30 years of experience to get to OB-GYN camp. 
So I am glad to hear that, that you can't do it in 3 weeks.
    Look, we want to as a group here, and I think you hear it 
from both sides of the aisle, we want to be able to go from 
good to great. And to be able to do that, though, we have to 
have information that is accurate and timely. And I looked at 
the memo today we were sent on the RVUs, and I know this is not 
a big thing, but I think it is a symptom of what goes on in the 
VA. If you look at a law that was passed in 2002, it appears to 
me when you look at the evaluation that the IG did with these 
five medical centers in Boston, Houston, Indianapolis, 
Philadelphia, and looked at the staffing levels we are talking 
about for specialty care services, it has taken 12 years and we 
still don't know what they are. I mean, this law was passed in 
2002, and it is 2014, and we are still talking about, well, we 
don't know what our staffing needs are.
    Well, that is not complicated. I can tell you, having spent 
30 years doing what I did, it is not hard to figure out what 
your staffing needs are. If you can't get somebody in to see a 
cardiologist, you need a cardiologist. You don't need another 
study or anything to figure that out.
    And I don't understand, again, the accountability. When 
this didn't happen for 12 years, and then last week, last 
Friday, we found out that 80 percent of the people in senior 
levels at the VA got rewarded for doing a great job, and yet we 
completely ignored this metric, it doesn't appear that there is 
any penalty whatsoever for not following the law. Am I wrong? I 
mean, why wasn't this done?
    Dr. Lynch. Congressman, I can't speak to what happened 
before I got here. I can speak to the fact that following the 
IG report the recommendations were taken seriously. We are a 
year ahead of time in meeting those recommendations. By the end 
of this year we will have productivity standards for all 
specialties in VA and we will be able to use those moving 
forward to make decisions about where we need to supplement 
support for physicians or to provide additional physicians.
    Mr. Roe. Let me just ask a question again. Is there any 
accountability at all? I mean, because this 12 years went by. I 
mean, this information should have been available to you all 
where you could use it to help prevent what just happened.
    So anyway, I want to also go on to a couple of other 
things. Mr. O'Rourke brought up, and I totally agree with this, 
is that really there are two issues at stake. Look, the backlog 
is not going to be a big deal. We can fix that one very 
quickly, I think. And today I got a call from Memphis, 
Tennessee, a physician down there put together in 3 days, with 
the University of Tennessee system, with the Methodist 
Hospital, they will see any veteran, primary care or specialty 
care, including oncology, in 72 hours. They can do that. Our 
group can do that. It can be done across the country. So the 
backlog is very simple to solve.
    A much more difficult decision is the culture of the VA, 
where we go 12 years we don't follow what the law is, where we 
reward people at senior levels for doing I don't know what. 
Maybe some of them did a really good job, but others clearly 
did not because we see the failings right now. And let me just 
give you an example, a brief example.
    I went to my eye doctor today right here in Washington, a 
retina, I have a little retina problem. The doctor said he had 
been trying to get to the VA here, the retina specialist, to 
help out. He had a patient that was supposed to see a doctor in 
January this year with a retina problem, at the VA. It snowed 
that day. The doctor couldn't get in. So they made the next 
appointment in June. That is this month. Well, when the retina 
guy finally saw him, the doctor saw him at the VA, they rushed 
him over to the retina specialist because the guy had a 
detached retina. For 5 months he didn't get treated.
    We had another call today, this physician I talked to in 
Memphis had a fellow who took 8 months to get to an oncologist 
outside the VA, recommended a biopsy. That took 4 months. The 
man has cancer they probably can't treat now.
    We cannot have a system that treats our veterans this way. 
And we have a system out there of private physicians who want 
to help. They want their veterans, like me, and Dr. Wenstrup, 
and others, like this young man right here. I should show you 
this when we get through today, Dr. Lynch. I want you to see 
this because they want to help. And I think they are there to 
help. I think their intentions are right. I think your 
intentions are right. I truly believe that you want to make 
things better for veterans.
    But we do have that second one. That first one, the 
backlog, we can take care of that. I have no doubt in a year we 
can get that. Last six months we can get it fixed. That second 
one, though, that culture in the VA is going to be much, much 
harder and it is going to take a lot of work and honesty and 
transparency from the VA senior people to us so we can help you 
go from good to great.
    I yield back, Mr. Chairman.
    The Chairman. Thank you very much, Doctor.
    Mr. Michaud.
    Mr. Michaud. Thank you.
    When you figure the cost as far as putting out services 
from the VA, do you also consider the savings; i.e., we heard 
from Kris Doody in charge of the ARCH program. Actually we are 
able to save the VA about $600,000 during that pilot program 
for mileage. So do you consider the cost savings as well or 
just the cost compared --
    Dr. Lynch. I think when we look at how we manage excess 
demand, we need to determine whether we can provide that 
service more economically within the VA or whether it is better 
for us to buy that in the community. I think that is an 
important decision. We do know the community costs, we can 
calculate. We do have the information to determine what it 
would cost us to hire those physicians and to provide care in 
the VA. And I think if we can do it more economically, and at 
less cost in the community, then that would be an appropriate 
thing to do.
    Mr. Michaud. Yeah, but considering all of the factors, I 
mean, it might cost X within the VA for a certain specialty 
care, it might seem to cost more outside for that same 
specialty care, but when you look at the savings with mileage 
reimbursement, it is most cost efficient to do it outside 
versus inside. So do you look at the whole cost?
    Dr. Lynch. Yes, sir, I think we do, and we will.
    Mr. Michaud. Okay. My second question is, of the three key 
elements of capacity, supply for clinical providers, amount of 
services providers can deliver, modern IT infrastructure, of 
these three, which one poses the greatest challenges to the VA?
    Dr. Lynch. I would say, based on our aging infrastructure, 
our greatest challenges are providing the physicians adequate 
space to see patients and giving them the support they need to 
see patients efficiently. It is hard to separate. I think IT is 
a challenge as well, but I do think we do have an electronic 
medical record. It is not a perfect record. It is in the 
process of evolution and improvement. But I think our greatest 
challenges are in our support for our physicians and then the 
space for them to provide care in efficient fashion.
    Mr. Michaud. Okay. My last question is, when you look at 
the wait lists, I know some facilities have an automated system 
where they call in, it is automated. Depending on how long it 
takes them to get through the menu, they might hang up. Say, 
the heck with that, they are not going to bother. Are they 
counted into that wait list, and if so, how can you track them?
    Dr. Lynch. People call into the VA for a number of reasons, 
so it is going to be difficult to know what they are calling in 
for. We do measure, however, abandonment rates, and we do 
measure time to answer our telephone system. And we are working 
to improve those so that that won't be a problem.
    Mr. Michaud. Thank you, Mr. Chairman.
    RPTS HUMISTON
    DCMN HUMKE
    [9:29 p.m.]
    The Chairman. Dr. Wenstrup? Mr. Takano.
    Mr. Takano. I just want to follow up with a question.
    The Chairman. Yes, sir.
    Mr. Takano. So I am a little confused by interoperability 
of records. Can you help me explain maybe what Dr. Benishek was 
trying to tell me about there is no interoperability?
    Dr. Clancy. Well, this is a case where you are both right. 
The second stage of the so-called meaningful use, this is the 
series of stepped incentives, right, that CMS has put in place 
incentivizing private sector providers to adopt electronic 
health records and the like, not just to buy the stuff, but to 
actually use it in such a way as to improve quality of care, 
that second stage of meaningful use actually requires that 
providers be able to share some information with other 
providers. So you are right that meaningful use is actually a 
path to getting us to a place where we can share all the 
information.
    I think it is fair to say that many providers are finding 
this challenging, so Dr. Benishek is also correct when he says, 
give me a break, because if you are thinking about actually 
just uploading all information from one to another, that is 
actually much, much steeper and likely a bit far off, but I 
think your original assertion that, in fact, the incentives put 
in place by the High Tech Act are setting us in the right 
direction, and I just wanted to make the point that VHA is 
complying with all of those.
    Mr. Takano. Well, because my understanding, having spoken 
to some physicians who do work at VA hospitals is that, they do 
appreciate the VistA medical record, and I am quoting him, the 
information is all there, and it seems common sense to me that 
if the records are integrated --
    Dr. Clancy. Right.
    Mr. Takano. -- that enhances the integrated care within the 
system, so within the VA system, doctors can --
    Dr. Clancy. Absolutely.
    Mr. Takano. -- pass this information around.
    Dr. Clancy. Yes.
    Mr. Takano. And so the concern that was raised in many 
hearings was the lack of interoperability with DOD and their 
medical record system and the billions of dollars that we have 
not been able to spend in a way that we have interoperability, 
and we listen to situations and cases where service members and 
veterans, their healthcare was greatly compromised.
    And so I have been listening to these hearings and 
understanding that the challenge with being able to move into 
opening greater opportunities for our veterans to access non-VA 
care is this interoperability challenge. So that is why, you 
know, I was raising the question.
    So it would seem to me that if we want to move more in this 
direction, that we are going to have to encourage private 
physicians and care groups to be able to communicate with the 
VA's record system.
    Dr. Clancy. Yes. And so I think your other question or 
statement was that if this were written into the PC3 contracts, 
that the providers who had met the meaningful use requirements 
and so forth would get preference, or to the extent that they 
could contract with such providers, that would be a good thing 
in terms of coordinating care is a very fabulous idea, so we 
will take that back as well.
    Mr. Takano. Thank you. I yield back.
    The Chairman. Ms. Brownley. Ms. Titus. Mr. Jolly.
    Mr. Jolly. Sure. Mr. Chairman, I just have a very quick 
follow-up.
    Doctor Lynch, I want to go back to the fiscal year 2014 
appropriations question I asked you for a point of clarity.
    I understand you mentioned the VA's in the process of 
working with outside providers. Is that just a general 
statement or are you suggesting that the demonstration project 
congressionally directed in the fiscal year 2014 budget is 
currently being implemented?
    Dr. Lynch. It is being implemented, Congressman. Can I get 
you the information on the sites where that is being provided 
at this time?
    Mr. Jolly. Yeah, you certainly could. There are about six 
or seven of us that actually wrote a letter to the secretary on 
May 7th asking for an update on the implementation. I know you 
have got a lot of letters coming your way right now, but it is 
a matter of concern, because it was done with such specificity. 
Even the criteria were put in the congressional report as to 
how the centers were to be evaluated, so I just want to make 
sure we are talking apples and apples here, that this is fiscal 
year 2014 demonstration project.
    Dr. Lynch. Let me work with our Office of Mental Health 
operations --
    Mr. Jolly. That would be great.
    Dr. Lynch. -- get you the information that you need and 
make sure we have talking apples and apples.
    Mr. Jolly. Sure. And I will leave a copy of the letter. It 
was May 7th, there were seven of us that signed it. I will put 
it in your hand when we leave tonight, and I appreciate a 
response. Thank you very much.
    Dr. Lynch. Thank you.

    The Chairman. Ms. Kirkpatrick, you are recognized for 5 
minutes.
    Ms. Kirkpatrick. Thank you.
    Dr. Lynch, I just have two questions. Is there a complaint 
system within the VHA, something like a hotline that a veteran 
can call and someone gets back to them about their complaint?
    Dr. Lynch. Dr. Clancy, do you want to take that?
    Dr. Clancy. Yes. Every facility has a patient advocate. 
And, in fact, they get complaints, they get all kinds of calls, 
and that is actually tracked in terms of time to resolution and 
so forth. That all of the patient advocates now come under an 
Office of Patient Center Care and Cultural Transformation.
    So we have begun working with them a bit from the quality 
and safety side to try to figure out how could we learn more 
from what they are hearing, because we are noticing that a 
number of private sector organizations are taking to heart just 
how important and useful it can be to learn from the patients 
themselves. So --
    Ms. Kirkpatrick. So is that information looked at 
nationally, nationwide, not just -- it doesn't just stay at the 
local facility?
    Dr. Clancy. Yes. There is a national database.
    Ms. Kirkpatrick. And my second question is, are you 
consulting with the VSO's on how to engage innovation in the 
system when it comes to scheduling these appointments?
    Dr. Lynch. We have not been communicating directly with the 
VSO's. I think we certainly have been looking at ways that the 
VSO's can help us understand how the veterans are perceiving 
our care and the timeliness of that care. I think there is a 
huge opportunity there.
    Ms. Kirkpatrick. I agree.
    And you know, Chairman Miller, I think it might be good to 
have a hearing where we hear from the VSO's about their 
suggestions about how to fix this problem.
    I yield back. Thank you so much.
    The Chairman. Thank you very much, Ms. Kirkpatrick.
    We do have one hearing that will be coming up in several 
weeks that will be specifically geared towards the VSO's, and 
it is at that particular hearing that we will invite the 
Secretary to be here to hear their recommendations as well.
    Dr. Ruiz? Ms. Kuster.
    Ms. Kuster. No, sir.
    The Chairman. Mr. O'Rourke? Anybody -- oh, Mr. Walz, I am 
sorry. You are recognized for 5 minutes.
    Mr. Walz. Thank you, Mr. Chairman. And again, thank you 
both for being here. And listening to the testimony, I 
appreciate it.
    I have sat here almost in this exact same seat for seven 
and a half years and just like you with the VSO's and the VA as 
partners and advocates to get this right for veterans, but I am 
going to come back to -- and I oftentimes in those years 
prefaced and said that I am your staunchest supporter, but I 
will be your harshest critic when it needs to be.
    I am going to come back to something you said, Dr. Clancy. 
You said, and Dr. Roe brought this up and Mr. O'Rourke, and I 
brought it up with several others that this is the time to 
think fundamental change, this is the time to think big, and I 
found it interesting that you focused, Dr. Clancy, on the 
triage, which of course needs to be done with these veterans 
right now, and called what we were talking about a second order 
question. I would argue, had you addressed that earlier, we 
would have never had Phoenix, we would have never had those 
things. So I am going to ask you, are both of you clinically 
credentialed?
    Dr. Lynch. I am not currently -- well, not clinically 
credentialed at this time. I certainly have been for the last -
-
    Mr. Walz. Can you see patients?
    Dr. Lynch. I cannot see patients, no.
    Mr. Walz. Dr. Clancy?
    Dr. Clancy. I haven't for a number of years. I have 
actually looked into what would be required --
    Mr. Walz. But you are both doctors?
    Dr. Clancy. Yes.
    Mr. Walz. And we don't have enough doctors. So I am going 
say what -- the Vietnam Veterans of America made this 
suggestion to you, and you said -- and the question was asked, 
you have a contract with them.
    This is what they said you needed to do to fix this in 
Phoenix. All VHA staff with clinical credentials and training 
who are not currently in direct service providers need to see 
patients 4 days a week. Get out of the administrative office 
and go see patients.
    If you are serious about this triage, I would think you 
would be turning over every stone to find a physician who is 
already in the system and the reason I am bringing this up, it 
may not seem like a fair question, but the ability to call 
fundamental cultural change a second order question, and we 
will get to it when we get this done.
    Dr. Roe is right, you can multitask. Get that done. That 
is, of course, a priority, but not addressing this, we are 
going to come back here again and that is more of a statement 
and believe me, it pains me that we are at this point, it pains 
me if all the good work we do gets erased by this, but it once 
again confirms to me this is cultural, it is leadership, it is 
structural, and it runs deep.
    I yield back.
    The Chairman. Thank you very much, Mr. Walz.
    Following up with your line of questioning, how many 
physicians are there in the system who don't see patients 
because they are in administrative roles?
    Dr. Lynch. I don't know, Mr. Chairman.
    The Chairman. Would you find that out for us?
    Dr. Lynch. Yes, sir.
    The Chairman. Thank you very much.

    The Chairman. And in your testimony, you mentioned that--or 
in answer to a question that somebody had about how much money 
was being spent to help solve the backlog problem, I think the 
number that you used was about $312 million being made 
available for your access initiative, you mentioned the funds 
were centrally located. Can you give me an idea of where the 
funds were supposed to be spent?
    Dr. Lynch. I will get that information for you.
    The Chairman. Is the one hundred and--or $312 million part 
of the planned $450 million carryover that the department had 
already budgeted for 2015?
    Dr. Lynch. I can't answer that, Mr. Chairman. I will get 
the information for you.
    The Chairman. I can answer it.
    The Chairman. It is. And I guess the big question is if 
almost half a billion dollars sitting there in the bank, then 
why do we have a backlog the size of the one we have? How did 
we get here?
    I don't think anybody even to this day knows how the 
culture became so corrupt that people would falsify records, 
and in some cases I believe criminally, that we would cause 
veterans to wait months and years, that we would -- and, look, 
that is $500 million for carryover this year. We have had a 
couple of years just recently that have been a billion dollars 
carried over, and I don't think the public understands.
    People are running around saying more money, more people, 
more money, more people. Five hundred million sitting there 
that could have solved this, and nobody within the central 
office or the department was blowing the whistle saying, we 
needed to spend that. It was almost as if they were trying to 
keep it for a nest egg for next year, because if you carry it 
over, then it goes into the base budget and we have got to fund 
it again, and that is how the bureaucracy grows.
    So with that, thank you so much for being here. We 
appreciate both of you.
    Members, thank you for attending. This hearing is 
adjourned.
    [Whereupon, at 9:41 p.m., the committee was adjourned.]
                                APPENDIX

                        STATEMENT FOR THE RECORD
                     PARALYZED VETERANS OF AMERICA
    HOUSE COMMITTEE ON VETERANS' AFFAIRS
    CONCERNING EVALUATING THE CAPACITY OF THE DEPARTMETN OF
    VETERANS AFFAIRS TO CARE FOR VETERAN PATIENTS
    JUNE 23, 2014

    Chairman Miller, Ranking Member Michaud, and members of the 
Committee, Paralyzed Veterans of America (PVA) would like to thank you 
for the opportunity to provide our views on the capacity of the 
Department of Veterans Affairs (VA) to care for veterans. No group of 
veterans understand the full scope of care provided by the VA better 
than PVA's members--veterans who have incurred a spinal cord injury or 
dysfunction. PVA members are the highest percentage of users among the 
veteran population, and the most vulnerable when access to health care 
and other challenges impact quality of care.
    PVA believes that the quality of VA health care is excellent, when 
it is accessible. In fact, VA patient satisfaction surveys reflect that 
more than 85 percent of veterans receiving care directly from the VA 
rate that care as excellent (a number that surpasses satisfaction in 
the private sector). The fact is that the most common complaint from 
veterans who are seeking care, or who have already received care in the 
VA, is that access to care is not timely. PVA believes that VA's access 
issues result from the broad array of staff shortages within its 
Veterans' Health Administration (VHA), which brings into question the 
VA's capability to provide care to veterans when it is needed--VA's 
capacity. Evaluating the capacity of the VA to care for veterans will 
require comprehensive analysis of veterans' health care demand and 
utilization measured against staffing, funding, and VHA infrastructure.

    Demand and Utilization

    Evaluating VA's capacity to provide health care to veterans must 
include an accurate depiction of the demand for specific health care 
services. Unfortunately, it is obvious by the thousands of veterans who 
have been placed on wait lists for VA care that the demand for VA 
health care is much higher than what has been presented by the VA over 
the past several years. The VA has manipulated scheduling practices and 
uses inadequate staffing ratios to misrepresent the demand for VA 
health care services. For instance, a shortage of nurses within the 
SCI/D system of care has resulted in VA facilities restricting 
admissions to SCI/D centers (an issue that we believe mirrors the 
larger access issues that are being reported around the country). 
Reports of bed consolidations or closures have been received and 
attributed to nursing shortages.
    When veterans are denied admission to SCI/D centers and beds are 
consolidated, leadership is not able to capture or report accurate data 
for the average daily census--demand. The average daily census is not 
only important to ensure adequate staffing to meet the medical needs of 
veterans; it is also a vital component to ensure that SCI/D centers 
receive adequate funding. Since SCI/D centers are funded based on 
utilization, refusing care to veterans does not accurately depict the 
growing needs of SCI/D veterans and stymies VA's ability to address the 
needs of new incoming and returning veterans.
    Additionally, within the SCI/D system of care recent projections 
for long term care SCI/D beds are questionably low. In VISN 22 
(Southern California and Southern Nevada) the VA called for 30 long 
term care beds per the Capital Asset Realignment for Enhanced Services 
(CARES) model, which estimated demand for health care services in order 
to determine capacity of its infrastructure to meet that demand. It 
seems logical to presume that more aging veterans over time will need 
extended care services in Southern California, not fewer. However, VA 
advised us that new, lowered projections based on the Enrollee Health 
Care Projection Model (EHCPM) dictated a decrease in scope of new 
construction for the San Diego SCI/D center in VISN 22. This leads to 
serious concerns about future timely access to specialized care. 
Moreover, the EHCPM fails to account for suppressed demand that can 
lead to false assumptions about future utilization and negatively 
impact hiring and staffing. Such situations severely compromise patient 
safety and serve as evidence for the need to enhance the nurse 
recruitment and retention programs to build capacity.
    Evaluating VA's capacity to provide care will require the VA's 
commitment to transparency and the implementation of policies, 
procedures, and systems that will allow for the collection of data that 
accurately reflects the demand for VA health care in primary care and 
specialty care, and specialized services.

    Staffing

    PVA believes that the issues we are facing involving veterans' 
access to VA care are primarily a reflection of insufficient staffing 
and by extension a lack of capacity. The SCI/D system of care is one of 
the crown jewels of the VA health care system. Spinal cord injury care 
is provided using the ``hub-and-spoke'' model. This model establishes 
the 24 spinal cord injury centers that exist within the VA system as 
the hubs of care. All other major medical facilities in the system 
serve as outpatient clinics (spokes) that direct and refer care back to 
the hubs. This model has proven to be very successful in meeting the 
complex needs of PVA's members. In fact, this model system of care has 
been so successful that the VA used the same model to establish the 
poly-trauma system of care.
    Unfortunately, the ability of the SCI/D centers to function 
properly is dictated by the numbers of qualified SCI/D trained staff 
that are employed within the system. As a result of frequent staff 
turnover and a general lack of education and training in outlying 
``spoke'' facilities, not all SCI/D patients have the advantage of 
referrals, consults, and annual evaluations in an SCI/D center. This is 
further complicated by confusion as to where to treat spinal cord 
diseases, such as Multiple Sclerosis (MS) and Amyotrophic Lateral 
Sclerosis (ALS). Some SCI/D centers treat these patients, while others 
deny admission.
    VHA Directive 2008-085 mandates 1,504 bedside nurses to provide 
nursing care for 85 percent of the available beds at the 24 SCI/D 
centers across the country. This nursing staff consists of registered 
nurses (RNs), licensed vocational/practical nurses, nursing assistants, 
and health technicians. Unfortunately, the SCI/D centers recruit only 
to the mandated minimum nurse staffing required by VHA Directive 2008-
085. As of April 2014, the actual number of nursing personnel 
delivering bedside care was 161.9 FTEEs below the minimum nurse 
staffing requirement. Factoring in the actual average acuity level, 
there is a deficit of 746.2 FTEE between nurse staffing needed and the 
actual number of nurses available. The low percentage of professional 
RNs providing bedside care and the high acuity level of SCI/D patients 
put these veterans at increased risk for complications secondary to 
their injuries. This lack of adequate staffing can also lead to 
veterans being denied care or placed on wait lists, and despite their 
need for care, these veterans are not taken into account when VHA 
staffing ratios are established or the demand for care is evaluated. 
Thus, allowing VA to operate below capacity.
    In order to monitor staffing issues and ensure they are addressed 
by the VA, PVA developed a memorandum of understanding with the VA more 
than 30 years ago that authorizes site visit teams managed by our 
Medical Services Department to conduct annual site visits of all VA 
SCI/D centers as well as spoke facilities that support the hubs. This 
opportunity has allowed us to work with VHA over the years to identify 
concerns, particularly with regards to staffing, and offer 
recommendations to address these concerns. Our most recent site visits 
have yielded the information that is included below. This information 
reflects the Bed and Staffing Survey as of April 2014 for beds, 
doctors, nurses, social workers, psychologists, and therapists in the 
SCI/D system of care.
    Physician personnel across the SCI/D system are below the required 
staffing level by 21.8 FTEEs. Social workers are below the requirement 
by 15.2 FTEEs. Psychologists are below the required level by 15.4 
FTEEs. Finally, therapists are 33.4 FTEEs below the required level. As 
mentioned previously, the actual number of nursing personnel delivering 
bedside care is 161.9 FTEEs below the minimum nurse staffing 
requirement. The nurse shortages alone resulted in 114.0 SCI/D beds 
staffed below the minimum required number. Factoring in the actual 
average facility acuity level, this amount increases to 372.9 SCI/D 
beds staffed below the requirement. This means that there are currently 
281 unavailable SCI/D beds throughout the system. If this number is 
adjusted based on the actual average facility acuity level, this amount 
increases to 539.9 unavailable SCI beds throughout the system. This 
absurdly staggering number has proven easy to dismiss by leaders within 
VHA who insist that we provide by-name lists of veterans with SCI/D who 
languish on waiting lists rather than interrogate the merits of our 
claim and objectively examine their own data.
    These facts are simply unacceptable. The statistics reflect the 
fact that many veterans who might be seeking care in the VA are unable 
to attain that care. We believe that these staffing shortages exist not 
only in the SCI/D system of care, but across the entire VHA. Therefore, 
we recommend that an evaluation of VA's capacity include a 
comprehensive analysis of VHA staffing needs to include the recently 
identified veterans who were denied care, or are on wait lists for 
primary care. We also recommend the VA conduct outreach in its 
specialized systems of care to identify eligible veterans in need of 
care and ensure they have access to the VA.

    Funding

    While insufficient staffing can be traced in some areas to the VHA 
inefficiently managing the resources it is provided, limited funding 
provided over many years has superseded the savings that can be 
generated from operational efficiencies and increased demand for health 
care services. The Administration (and previous Administrations) has 
requested wholly insufficient resources to meet the ever-growing demand 
for health care services. Meanwhile, the VA has also committed to 
operational improvements and management efficiencies that are not 
adequate enough to fill the gaps in funding and not realized anyway. 
Similarly, Congress has been equally responsible for this problem as it 
continues to provide insufficient funding through the appropriations 
process to meet the needs of veterans seeking care.
    For many years, the co-authors of The Independent Budget--AMVETS, 
Disabled American Veterans, Paralyzed Veterans of America, and Veterans 
of Foreign Wars--have advocated for sufficient funding for the VA 
health care system, and the larger VA. In recent years, our 
recommendations have been largely ignored by Congress. Our 
recommendations are not ``pie-in-the-sky'' wish lists based on nothing. 
They reflect a thorough analysis of health care utilization in the VA 
and full and sufficient budget recommendations to address current and 
future utilization. Moreover, our recommendations are not clouded by 
the politics of fiscal policy. Despite the recommendations of The 
Independent Budget for FY 2015 (released in February 2014), the House 
just recently approved an appropriations bill for VA that we believe is 
nearly $2.0 billion short for VA health care in FY 2015 and 
approximately $500 million short for FY 2016.
    While we understand that significant pressure continues to be 
placed on federal agencies to hold down spending and Congress has moved 
more towards fiscal restraint in recent years, the health care of 
veterans outweighs those priorities. Until Congress and the 
Administration provide sufficient resources so that adequate staffing 
and capacity can be established in the VA health care system, access 
will continue to be a problem.

    VA Infrastructure

    Inadequate funding for VA infrastructure has weakened the capacity 
of the VA to provide care to veterans. This year the Administration 
requested $561 million for Major Construction. This included funding 
for only four primary projects and secondary construction costs--this 
despite a backlog of construction projects that requires a minimum of 
$23 billion over the next 10 years in order to maintain adequate and 
serviceable infrastructure.
    If the Administration refuses to properly address this construction 
funding problem, then we ask Congress to fill this void. Ultimately, if 
VA is not provided sufficient resources to address the critical 
infrastructure needs throughout the system, then it will have no choice 
but to seek care options in other settings, particularly the private 
sector. Maintaining the capacity of the VA as a comprehensive health 
care provider and increasing the number of veterans seeking care within 
the private community is fiscally impossible. Therefore, funding VA's 
infrastructure needs is critical to its ability to provide safe, 
quality health care.

    VA's Capacity to Provide Care to Disabled Veterans

    Within the VA health care system, the capacity to provide for the 
unique health care needs of severely disabled veterans--veterans with 
spinal cord injury/disorder, blindness, amputations, and mental 
illness--has not been maintained as mandated by P.L. 104-262, the 
``Veterans Health Care Eligibility Reform Act of 1996.'' This law 
requires VA to maintain its capacity to provide for the specialized 
treatment and rehabilitative needs of catastrophically disabled 
veterans. As a result of P.L. 104-262, the VA developed policy that 
required the baseline of capacity for the spinal cord injury/disorder 
system of care to be measured by the number of staffed beds and the 
number of full-time equivalent employees assigned to provide care (the 
basis for PVA's site visits today). This law also required the VA to 
provide Congress with an annual ``capacity'' report to ensure that the 
VA is operating at the mandated levels of ``capacity'' for health care 
delivery for all specialized services. Unfortunately, the requirement 
for the capacity report expired in 2008.
    PVA's Legislation staff, in consultation with PVA's Medical 
Services Department, identified reinstatement of this annual 
``capacity'' report as a legislative priority for 2014. We have also 
worked extensively with our partners in the VSO community, as well as 
with Congressional offices to formulate legislation that would 
reinstate the annual ``capacity'' report. This report affords the House 
and Senate Committees on Veterans' Affairs, and the veteran 
stakeholders, the ability to analyze the accessibility of VA 
specialized care for veterans in the areas such as SCI, mental health, 
women's health, and polytrauma. Currently, legislation is pending in 
the House Committee on Veterans' Affairs--H.R. 4198, the ``Appropriate 
Care for Disabled Veterans Act''--that would reinstate this report. We 
urge the Committee to consider this legislation as soon as possible. 
While this legislation focuses on VA specialized services, such a 
reporting requirement for all of VHA every few years would allow VA and 
Congress to have a more accurate reflection of what is needed to 
maintain VA's health care system.
    Mr. Chairman and members of the Committee, we appreciate your 
commitment to ensuring that veterans receive the best health care 
available. We also appreciate the fact that this Committee has 
functioned in a generally bipartisan manner over the years. We call on 
this Committee, Congress as a whole, and the Administration to ensure 
that veterans get the absolute best health care provided when they need 
it through the VA. PVA's members and all veterans will not stand for 
anything less.
    Information Required by Rule XI 2(g)(4) of the House of 
Representatives
    Pursuant to Rule XI 2(g)(4) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.
    Fiscal Year 2013
    National Council on Disability--Contract for Services--$35,000.
    Fiscal Year 2012
    No federal grants or contracts received.
    Fiscal Year 2011
    Court of Appeals for Veterans Claims, administered by the Legal 
Services Corporation--National Veterans Legal Services Program-- 
$262,787.

                     Letter to Gibson From Michaud
    June 27, 2014
    The Honorable Sloan Gibson
    Acting Secretary, U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW., Washington, DC 20420
    Dear Mr. Secretary:
    Committee practice permits the hearing record to remain open to 
permit Members to submit additional questions to the witnesses. In 
reference to our Full Committee hearing entitled, ``Evaluating the 
Capacity of the VA to Care for Veteran Patients'' that took place on 
June 23, 2014, I would appreciate it if you could answer the enclosed 
hearing questions by the close of business on August 8, 2014.
    In preparing your responses to these questions, please provide your 
answers consecutively and single-spaced and include the full text of 
the question you are addressing in bold font. To facilitate the 
printing of the hearing record, please e-mail your response in a Word 
document, to Carol Murray at [email protected] by the close 
of business on August 8, 2014. If you have any questions please contact 
her at 202-225-9756.
    Sincerely,
    MICHAEL H. MICHAUD
    Ranking Member, MHM:cm

                  Questions: From Rep. Negrete McLeod
    1. One criticism of VA is that doctors do not see enough patients 
in a single day compared to the private sector. Former VA doctors have 
explained to my staff that VA does not have enough ancillary staff to 
allow doctors to only perform direct patient care. A physician in the 
private sector can come in and immediately begin addressing the 
patient's medical condition because other staff have already checked 
their vitals and completed other preparatory work. Why does VA not have 
as much ancillary staff as the private sector and if they need more 
funding, why have they not asked for it?
    2. How is prioritizing appointments for veterans with service-
connected disabilities?
    a. Is VA tracking the population of veterans that are seeking care 
for service connected conditions?
    b. How long they have to wait for an appointment?
                           Responses: From VA
    HOUSE COMMITTEE ON VETERANS' AFFAIRS
    FULL COMMITTEE HEARING
    ``EVALUATING THE CAPACITY OF THE VA TO CARE FOR
    VETERAN PATIENTS''
    JUNE 23, 2014
    1. One criticism of VA is that doctors do not see enough patients 
in a single day compared to the private sector. Former VA doctors have 
explained to my staff that VA does not have enough ancillary staff to 
allow doctors to only perform direct patient care. A physician in the 
private sector can come in and immediately begin addressing the 
patient's medical condition because other staff have already checked 
their vitals and completed other preparatory work. Why does VA not have 
as much ancillary staff as the private sector and if they need more 
funding, why have they not asked for it?
    VA Response: As the Nation's largest integrated health care 
delivery system, the Veterans Health Administration's (VHA) workforce 
challenges mirror those of the health care industry as a whole. 
Internal Medicine physicians, largely primary care providers, are the 
largest component of the Veterans Health Administration's (VHA) 
physician workforce. The support staff ratio for VHA primary care 
providers is targeted at 3 support staff per primary care provider. 
Similar to the private sector, VHA support staff are trained to support 
patient care efforts and enhance productivity of providers by 
performing many ancillary functions. The second largest component of 
our physician workforce is psychiatric physicians. The support staff 
ratio for psychiatric physicians is approximately 6 staff per 
psychiatrist. While there are no nationally accepted mental health 
staffing standards, VA continues to evaluate whether this represents 
the optimal ratio. For specialty physicians (e.g. cardiology, 
gastroenterology) the support staff ratios are markedly lower than that 
of the private sector, with VHA on average at 1.4 support staff per 
physician versus the external benchmarks of 3 support staff per 
provider. VA is working with facilities to assess staffing levels, 
align them with productivity demands, and address any shortfalls 
through the use of alternate strategies. As VA continues to refine 
staffing models, we will ensure our Veterans receive their care in a 
timely and efficient manner.
    2. How is VA prioritizing appointments for veterans with service-
connected disabilities?
    VA Response: Regulation 38 CFR 17.49 explains that Veterans with a 
need for serviced-connected care or those with service-connected 
disabilities rated 50 percent or greater based on one or more 
disabilities or unemployability have priority when scheduling 
appointments for medical services or inpatient care.
    Veterans on the Electronic Wait List for appointments are taken off 
by priority group. Those with service-connected disabilities rated at 
100 to 50 percent are removed first; 50 to 0 percent are removed next; 
and then Veterans without a service connected disability.
    a. Is VA tracking the population of veterans that are seeking care 
for service
    connected conditions?
    VA Response: Yes. As an example, in fiscal year 2013, Veterans 
Health Administration treated 2,085,991 Veterans for a service- 
connected condition. Of our 1,451,775 Priority 1 Veterans who have a 
service-connected disability rating of 50 percent or more, 1,237,698 
had some service-connected care. Therefore, 85 percent of Priority 1 
Veterans had some service-connected care.
    b. How long do they have to wait for an appointment?
    VA Response: As of July 2014, the data report from the VHA Support 
Service Center indicates for new patients, the average wait times are 
as follows: Primary Care = 26 days; Specialty Care = 24 days; Mental 
Health = 15 days. New patient wait times are calculated using the date 
the appointment was created. For Established Patients, calculated from 
the Desired Date, the average wait times are Primary Care = 5.13 days; 
Specialty Care = 5.70 days; and Mental Health = 3.46 days. For 
additional details and updates regarding VA patient access data visit 
our web site; http://www.va.gov/HEALTH/docs/VAMC--Patient--Access--
Data--20140731--CondensedChart.pdf

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