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

                  ASSESSING THE IMPLEMENTATION OF THE
        VETERANS ACCESS, CHOICE, AND ACCOUNTABILITY ACT OF 2014

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

                                HEARING

                               before the

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      THURSDAY, NOVEMBER 13, 2014

                               __________

                           Serial No. 113-89

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

         Available via the World Wide Web: http://www.fdsys.gov
         
         
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority 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

                              ----------                              

                      Thursday, November 13, 2014

                                                                   Page

Assessing the Implementation of the Veterans Access, Choice, and 
  Accountability Act of 2014.....................................     1

                           OPENING STATEMENTS

Jeff Miller, Chairman............................................     1
    Prepared Statement...........................................    51
Michael Michaud, Ranking Minority Member.........................     4
    Prepared Statement...........................................    52
Corrine Brown, Minority Member
    Prepared Statement...........................................    53

                                WITNESS

Hon. Sloan Gibson, Deputy Secretary, U.S. Department of Veterans' 
  Affairs........................................................     6
    Prepared Statement...........................................    54
    Accompanied by:
        James Tuchschmidt, M.D., M.M., Acting Principal Deputy 
            Under Secretary for Health, VHA, U. S. Department of 
            Veterans' Affairs
    And
        Gregory L. Giddens, Executive Director, Enterprise 
            Program Management Office, U.S. Department of 
            Veterans, Affairs

                             FOR THE RECORD

Story by Jeremy Schwartz, Introduced by Hon. Flores..............    56

 
   ASSESSING THE IMPLEMENTATION OF THE VETERANS ACCESS, CHOICE, AND 
                       ACCOUNTABILITY ACT OF 2014

                              ----------                              

                      Thursday, November 13, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 10:01 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present:  Representatives Miller, Lamborn, Bilirakis, Roe, 
Flores, Denham, Benishek, Huelskamp, Coffman, Wenstrup, 
Walorski, Jolly, Michaud, Brown, Takano, Brownley, Titus, 
Kirkpatrick, Ruiz, McLeod, Kuster, O'Rourke, Walz.
    Also Present: Representatives Murphy, LaMalfa.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. If everybody could take their seats, please. 
The committee will come to order. Welcome back, everybody. It 
is great to have you back. Appreciate everybody joining us for 
this full committee hearing, an oversight hearing today.
    I want to ask unanimous consent that several of our 
colleagues be allowed to join us at the dais, Representative 
Murphy from Pennsylvania and Representative LaMalfa from 
California. They have asked to join us, and I would ask 
unanimous consent. Without objection, so ordered.
    As everyone sitting around this dais today is aware, on the 
7th of August, the President signed into law the Veterans 
Access, Choice, and Accountability Act of 2014, which is now 
Public Law 113-146.
    This law was carefully and thoughtfully crafted after 
months of aggressive oversight by this committee to address the 
unprecedented access and accountability scandal that had 
engulfed the Department of Veterans Affairs following 
allegations, that were first uncovered in this room, that some 
VA medical center facility leaders were keeping secret waiting 
lists in an effort to manipulate wait time data and ensure 
their own executive bonuses.
    We are here today to evaluate the progress that VA has made 
to implement this law in accordance with both statutory 
requirement deadlines and congressional intent. This includes 
the effective and timely implementation of the Veteran Choice 
Program that was designed to provide relief to veterans who 
reside 40 miles or further from a VA facility or who cannot get 
a timely appointment.
    It also includes the required independent assessment of 
VA's healthcare system which, in my opinion, should necessarily 
inform decisions about staffing and infrastructure that are to 
be made under the law.
    Finally, and most importantly, it includes accountability, 
on which I will focus my remaining remarks. Section 707 of the 
law authorizes the secretary to fire or demote senior executive 
service employees for misconduct or poor performance.
    It should go without saying that veterans deserve the very 
best leadership that our government has to offer. Yet, the 
events of the last year have proven that far too many senior VA 
leaders have lied, manipulated data, or simply failed to do the 
job for which they were hired.
    It is also clear that VA's attempt to instill 
accountability for these leaders has been both nearly 
nonexistent and rife with self-inflicted road blocks to the 
reform that each of us expects.
    When I originally drafted this provision, I believed that 
it would provide Secretary McDonald with the tools that he 
needed and wanted to finally hold failing leaders accountable. 
When President Obama signed it into law, he agreed by saying, 
and I quote, ``If you engage in an unethical practice, if you 
cover up a serious problem, you should be fired, period. It 
shouldn't be that difficult,'' end quote.
    Based on these comments, as well as similar statements by 
Secretary McDonald, I am both perplexed and disappointed at the 
pace at which employees have, been held accountable.
    Even more worrisome is what Secretary McDonald said on 
November 6th, and I quote, ``The new power I was granted is the 
appeal time for senior executive service employee of the VA has 
been reduced in half. That is the only change in the law. So 
the law didn't grant any kind of new power that would suddenly 
give me the ability to walk into a room and simply fire 
people,'' end quote.
    Now, it is clear that the secretary and those advising him 
remain confused about what the law actually does which is much 
more than simply reduce the appeal time. The secretary can't 
simply walk into a room and fire an SES employee without 
evidence warranting that action. But the law does give him the 
authority to remove that employee for poor performance or 
misconduct.
    The secretary has also cited a plethora of numbers that he 
says illustrates the department's commitment to holding 
individuals accountable. For example, he says there is one list 
of a thousand names of employees being removed and another list 
of 5,600 names of employees being removed and yet another list 
of 42 names of senior executives that VA is proposing action 
on.
    So let me take a moment and try to set the record straight. 
Based on a briefing that VA provided to committee staff 
yesterday, VA only has one year of aggregated data on 
disciplinary actions taken against any of its over 330,000 
employees making meaningful comparisons against previous years 
impossible.
    Further, the list of over 5,000 mentioned by the secretary 
is a list of proposed disciplinary actions only and the list of 
over 1,000 is a list of proposed removals for any type of poor 
performance, and not necessarily connected to the debacle that 
we have discussed at length in this committee. Only the list of 
42 provided at my request on a weekly basis includes employees 
proposed for discipline due to the crisis, which has engulfed 
the VA over the last year.
    What is more, since August 7th, only one SES employee has 
been removed under the new law and this person's removal was 
not directly related to patient wait times or data 
manipulation. I do not understand, in the wake of the biggest 
scandal in the history of the Department of Veterans Affairs, 
how just 42 employees, only four of which appear to be senior 
executive individuals, have been proposed for discipline with 
none yet removed.
    Further, VA has taken the liberty of creating an additional 
bureaucratic office, the Office of Accountability Review, to 
review proposed removals and an have created additional 
bureaucratic delay, a five-day advanced notice of removal which 
essentially operates like a new internal appeal process.
    These questionable actions are nowhere to be found in the 
law that we wrote and the President signed. In my view, the 
five-day advanced notice of removal only serves to incentivize 
poor-performing senior leaders to drag out the disciplinary 
process while continuing to collect a hefty paycheck or 
ultimately retiring with full benefits.
    Further, it perpetuates the perception that VA cares more 
about protecting bad employees than protecting the veterans of 
this country. We should not be providing credit towards a 
taxpayer funded pension for a time period during which an 
employee's action caused harm to a veteran.
    That is why I am going to be introducing a bill that would 
give the secretary the authority to reduce a SES employee's 
pension to reflect the years of service during which they 
participated in actions that made them subject to their 
removal.
    This proposal is a fair and equitable way to emphasize to 
poor-performing senior employees that retirement credit is not 
earned by failing veterans and that their actions have long-
lasting and meaningful consequences.
    I am not going to get into individual personnel actions at 
this time since there are serious legal issues at hand that 
must be dealt with respectively and appropriately. However, I 
want to make it clear today that I continue to have serious 
concerns about accountability at the Department of Veterans 
Affairs in response to what is without a doubt the largest 
scandal that has ever impacted VA. I am not seeing the 
corresponding efforts to hold those at fault accountable for 
their actions.
    Deputy Secretary Gibson, as we discussed on the phone 
yesterday, I have an increasing worry that Secretary McDonald 
and you are simply getting some bad advice from some of those 
around you within VA's bureaucracy. I just hope that is not the 
case.
    This is the same issue that I think doomed Secretary 
Shinseki's tenure. I hope you take my suggestion seriously when 
I tell you that VA's entrenched bureaucracy must be shaken up 
in order for any true reform, reform that is so desperately 
needed to better serve our veterans, to succeed.
    I truly appreciate your service and for you being here this 
morning.
    And with that, I now recognize and welcome back the ranking 
member, Mr. Michaud, for his opening statement.

    [The prepared statement of Chairman Jeff Miller appears in 
the Appendix]

      OPENING STATEMENT OF MICHAEL MICHAUD, RANKING MEMBER

    Mr. Michaud. Thank you very much, Mr. Chairman, for having 
this very important oversight hearing.
    We are here today to get an update from the Department of 
Veterans Affairs on the implementation of the Veterans Access, 
Choice, and Accountability Act of 2014. This law, as you know, 
was passed in August, addressed a number of serious issues the 
department had with providing timely, quality healthcare to 
veterans. Long wait times are the problems that got us where we 
are today.
    We shouldn't make veterans wait for the solutions to be 
implemented. While today is a first public update of the VA's 
implementation of this law, staff level updates have been 
occurring on a regular basis since early September.
    So I would like to thank you, Dr. Tuchschmidt and Mr. 
Giddens, and I appreciate the time you have invested in openly 
communicating with the staff on both the House and Senate side 
of the committee on the implementation issues and the progress 
you have been making on those implementation issues.
    This is a marked change in the VA congressional relations 
and I hope that it is a precedent for improving working 
relationships as we go forward.
    The law provided additional resources and authorities to 
provide for key improvements for veterans, timely access to 
healthcare, expansion of VA's internal capacity for care, 
improved accountability, and additional educational benefits.
    Today I hope to hear tangible ways veterans are getting the 
improved outcomes intended. If there are real and reasonable 
road blocks to implementation, we need to know what they are 
and how can we fix those road blocks.
    With regard to timely access to healthcare, I am aware that 
the department has expressed serious concerns with the 90-day 
deadlines under Section 101, the Choice Program. The program 
requires VA to determine eligibility, authorize and coordinate 
care, manage utilization, set up a call center, and implement a 
new payment system.
    VA has taken a phased rollout approach in order to balance 
expedience with effective programs. This may be reasonable, but 
I want to understand the overall timing and how the Department 
of Veterans Affairs is handling eligible veterans' access to 
care through the phased approach. A phased approach to 
administrative rollout may be okay, but a phased approach to 
access to care is not.
    The law provides $5 billion for the department to augment 
staffing and infrastructure. I know the secretary has 
personally been out recruiting, and I look forward to hearing 
how successful that effort has been and how many new doctors 
and nurses VA expects to bring on board and when they expect to 
bring them on board.
    I am also interested in hearing how VA will implement the 
funds and authority for new infrastructure. We have seen many 
problems with the Department of Veterans Affairs, constructions 
problems in the past, and I look forward to hearing the changes 
VA is making to the process in order to deliver these new 
projects on time and within budget.
    With regard to accountability, I understand that removing a 
federal employee is not as simple as many think it should be 
even with the new authority in the law. I appreciate the 
difficult position the department is in when it comes to 
holding employees accountable for wrongdoing and poor 
performance in a highly charged and very public environment.
    That being said, we need to feel that the Department of 
Veterans Affairs is taking the necessary action to move swiftly 
as possible and decisively as possible to get rid of those 
employees who failed the American veterans. The explanation for 
delays need to be clear, concise, and compelling not just to 
Congress but to veterans and the American public.
    And while much of the focus of the law has been on access 
and accountability provisions, we should not forget that the 
law also includes substantial enhancements to the education 
benefits for veterans and their families, and I look forward to 
hearing what is being done to implement these provisions of the 
law as well.
    And beyond the Veterans Access, Choice, and Accountability 
Act of 2014, I know Secretary McDonald has announced a number 
of reforms aimed at addressing the cultural and structure of 
the Department of Veterans Affairs. Many of these reforms 
reflect ideas we have discussed in the past and I am pleased to 
see them being embraced and actively pursued as well.
    And I would encourage the secretary to quickly define 
detailed execution plans for these concepts and not get stuck 
in analysis and processes and figure out what actions need to 
be taken and then take them. Be fearless enforcing these 
reforms just as our Nation's veterans are fearless in their 
battles.
    Once again, I want to thank the panel for appearing before 
us today. Look forward to hearing your testimony. We appreciate 
your time and effort and want to thank each of you for all that 
you are doing to make sure that our veterans and their families 
get the access to quality care in a timely manner for our 
veterans.
    I know you have been under a lot of pressure over the last 
year and look forward to hearing how the new law actually helps 
relieve some of that burden in what you are doing 
administratively to help complement the law that was passed and 
signed by the President.
    So, once again, thank you very much, and thank you, Mr. 
Chairman. I yield back the balance of my time.

    [The prepared statement of Ranking Member Michael Michaud 
appears in the Appendix]

    The Chairman. Thank you very much.
    Today we are going to hear from one panel already seated at 
the table. Joining us from the Department of Veterans Affairs, 
the Deputy Secretary, the Honorable Sloan Gibson. He is 
accompanied today by Dr. James Tuchschmidt, the Acting 
Principal Deputy Under Secretary for Health, and Gregory 
Giddens, the Executive Director of the Enterprise Program for 
Management Office.
    I appreciate you all being here this morning. Deputy 
Secretary Gibson, please proceed with your testimony.

STATEMENT OF SLOAN GIBSON, DEPUTY SECRETARY, U.S. DEPARTMENT OF 
  VETERANS AFFAIRS, ACCOMPANIED BY JAMES TUCHSCHMIDT, ACTING 
 PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH 
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, GREGORY L. 
  GIDDENS, EXECUTIVE Director, ENTERPRISE PROGRAM MANAGEMENT 
          OFFICE, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Mr. Gibson. Chairman Miller, Ranking Member Michaud, 
distinguished Members of the committee, our guiding principles 
for implementation of the Choice Act have been to do what is 
right for veterans and to be good stewards of taxpayer 
resources.
    While our challenges are clear, we are turning those 
challenges into opportunities to improve the care and service 
we provide to veterans. We are reorganizing VA for success to 
make sure we maximize those opportunities. We call that 
reorganization my VA and associated customer service solution 
that goes along with it because we want veterans to view us as 
an organization that belongs to them, providing quality care in 
the ways they need and the ways they want to be served.
    My VA entails combining functions, simplifying operations, 
improving processes, leveraging technology, enhancing 
efficiency, increasing productivity, and effectively 
implementing the Choice Act, a 360-degree effort to provide 
veterans with a seamless, integrated, and responsive VA 
regardless of how they come to us.
    Since May, our top priority has been accelerating care to 
veterans, moving them off wait lists and into clinics. For 
example, we have reduced the number of veterans waiting the 
longest for care by 57 percent.
    From June through September, we completed 19 million 
appointments, an increase of 1.2 million over the same period 
in 2013. Over a half a million completed appointments were 
conducted during extended hours of operation, nights and 
weekends.
    We have also improved access using non-VA care. From June 
to September, we approved 1.1 million authorizations for seven 
million, more than seven million care appointments in the 
community. That is about a 47 percent increase from the prior 
year.
    We appreciate the enhanced authorities funding and programs 
the act provides to ensure veterans have access to healthcare. 
We will continue to make the best use of them all to get 
veterans the high-quality care they deserve.
    We also appreciate enactment of the Department of Veterans 
Affairs' expiring Authorities Act of 2014 signed in late 
September which amended and fine tuned key provisions of the 
Choice Act. We will continue to work collaboratively with you 
and your staff to address remaining implementation challenges.
    As VA worked through the appropriate rule-making 
implementation process as required by the law, we conferred 
frequently with the committee, with veteran service 
organizations, and with other stakeholders.
    We are especially thankful for the opportunity to engage 
with your staff, Chairman Miller, and those of Ranking Member 
Michaud and the Senate Veterans' Affairs Committee to 
understand your intent and to hear your concerns and to work 
together on making improvements in implementation.
    We look forward to continuing this partnership as we 
implement this complex legislation in a way that allows us to 
do again the right thing for veterans while being good stewards 
of taxpayer resources.
    Among the challenges that we face in implementing the act's 
requirements are an estimated $400 million in unfunded 
requirements and resources that will be required to implement 
the provisions of the act over the next couple of years, 
resources that are not provided by the act.
    As mentioned previously, one of the things the act does is 
it streamlines the process to remove or demote senior 
executives based on poor performance or misconduct. As 
Secretary McDonald wrote to the chairman last week, VA is 
committed to building a culture of sustainable accountability 
throughout VA. Employees at all levels must understand what VA 
expects of them in terms of their performance and their conduct 
and must be held accountable if they fail or refuse to meet 
those expectations.
    I think it is important to understand what the new law does 
and what the new law does not do. The new law does shorten the 
time to resolve an appeal. The law does not give VA leaders the 
authority to remove executives at will. Any removal must still 
meet stringent evidentiary standards and provide due process. 
It does not do away with the appeal process.
    The law also does not give VA the authority to deprive a 
senior executive of their property including earned retirement 
benefits. Only a criminal conviction for treason, sedition, 
aiding the enemy, or terrorism as provided in statute can 
deprive a federal employee of an earned benefit.
    The objective behind our process, this removal process is 
for VA removal actions to withstand appeal. If our actions fail 
to meet the preponderance of evidence standard that the MSPB 
has established or failed to provide the due process expected 
under case law, then the Merit System Protection Board will 
simply overturn the decision, order the employee returned to 
their position, and direct that their back pay and legal costs 
be awarded. That would not be what is right for veterans or for 
taxpayers.
    Another critical element of the act is the Veterans Choice 
Program. As we have discussed with your committee staff during 
a dozen meetings, VA has identified a number of areas within 
this section that could present implementation challenges or 
potentially confuse veterans.
    First, there were significant challenges inherent in the 
90-day time line. We had to establish a new plan, produce and 
distribute Veterans Choice cards, determine patient 
eligibility, authorize and coordinate care, manage utilization, 
establish new provider agreements, process complex claims, and 
stand up a call center.
    Despite these challenges, VA launched the Choice Program 
last week with a responsible staged implementation focused on 
delivering the best possible veteran experience.
    Second, we recognize the challenges associated with 
maintaining continuity of care to ensure the best possible 
healthcare outcomes for veterans. This is a vital distinction 
between the Choice Program and a health plan in the private 
sector.
    As an example, we have made significant investments to 
provide veterans' access to mental health services in the 
primary care clinic as part of the holistic, integrated care we 
want to provide.
    As one-third of veterans receiving VA care have a mental 
health diagnosis, coordinating care including mental healthcare 
is essential. However, community mental health resources are 
often readily not available, particularly in rural areas, and 
are rarely integrated into the private sector primary care 
experience.
    Third, we know that healthcare systems across the Nation 
face challenges in efficiently sharing treatment information 
and healthcare records. In order to ensure sufficient 
continuity of care for veterans who are treated in both VA and 
non-VA settings, we will continue to work to share information 
and knowledge with these providers.
    Lastly, we modified the 30-day timeliness standard that was 
set in law for the purpose of Choice Program access to measure 
wait time from the date preferred by the veteran or the date 
that is medically determined by their physician.
    While this will help ensure that veterans receive timely 
access to the benefits of the Choice Program, it is not a 
clinical standard for timely care. To the veteran that needs to 
be seen today, a 30-day goal is irrelevant. VA's goal will 
always be to provide timely, clinically appropriate access to 
care in every case possible in the shortest amount of time 
possible.
    That is really what My VA is all about. We want to provide 
and veterans to see an organization that belongs to them and 
provides timely, quality care in the ways they need and want to 
be served.
    We will continue to work closely with the committee on any 
issues involving implementation of this vital legislation. I 
thank the committee again for your support. We look forward to 
working with you in making things better for all of America's 
veterans.
    This concludes my opening statement. Dr. Tuchschmidt and 
Mr. Giddens and I are prepared to answer any questions you or 
the other Members of the committee may have.

    [The prepared statement of Sloan Gibson appears in the 
Appendix]

    The Chairman. Thank you very much for your testimony.
    I am going to jump to the independent assessment for my 
first question. There has been some criticism that the 
department hasn't taken sufficient steps to fully meet the 
intent of Congress with regard to the independent assessment.
    VA has only contracted, as far as I know, with MITRE to 
include their federally funded Research and Development Center, 
the CMS Alliance to Modernize Healthcare, and the Institute of 
Medicine. This is not an expert team of independent entities 
with private sector healthcare expertise as we intended.
    Is there any intention to subcontract or competitively 
compete for industry experts who can effectively assess each of 
the 12 elements to be covered by this assessment? What, if any, 
information about the assessment and contracts that have been 
let have been made public so far? How much money has been 
expended on the independent assessment to date?
    Mr. Gibson. I will start, Mr. Chairman. I am going to pass 
it then to Dr. Tuchschmidt. And I expect that some elements of 
those questions we will have to take for record because I don't 
think we have got all that data with us.
    We actually contracted. The entity that we contracted with, 
as you accurately stated, is MITRE. The element within MITRE 
that will be the integrator of the 12 different components of 
the independent assessment is an organization called CAMH which 
happens to be an organization, an FFRDC that works closely with 
the Health and Human Services organization. So we specifically 
went for an organization that carried the specific 
qualification of a healthcare organization.
    In fact, they will be looking to engage a number of 
different entities and to ensure that throughout this entire 
process that what we are doing is tapping into very independent 
and objective expertise all across the private sector.
    Dr. Tuchschmidt.
    Dr. Tuchschmidt. Sure. So the part of the assessment that 
they are doing will be done by the CAMH folks. Some of that, 
they have partnered with other entities outside of MITRE. So 
they have partnered with the RAND Corporation to do some of the 
assessments.
    There are some options in there that all the options have 
been awarded or all of the 11 assessments to the coordinating 
entity which would be CAMH. They are assembling an expert panel 
of healthcare executives from private sector across the 
country, an expert panel that will help guide the assessments 
that are being done and will help look at the various 
recommendations coming back from the independent assessments to 
come together with a unified and common set of recommendations 
out of that which ultimately we will pass to the commission for 
their deliberation.
    But we thought it was the intention of Congress that this 
would be independent, so we sought an entity outside of VA to 
do this. Clearly the law says that if we have different people 
doing different parts of the assessment we need an integrator. 
That is what CAMH is.
    And I think that the healthcare nature that you want, the 
expertise that you wanted will be there in this essentially 
blue ribbon panel that they will be assembling.
    The Chairman. My time is about to expire, too, but I think 
that we need to sit down and discuss it a little bit. I think 
Congress's intent was not that a panel would be brought in to 
testify before this group but that people who were experts in 
their field would have that opportunity.
    While I still have about a minute left, I am referring to 
the public law. And, you know, the biggest concern that I have 
about the accountability portion is that there was a 30-day 
requirement for notice before you removed an employee; is that 
correct?
    Mr. Gibson. That is provided in Title 5.
    The Chairman. Title 5. And the law removed that. It 
basically says the procedures under Section 743(b) of Title 5 
shall not apply to the removal or transfer under this section.
    So where did the five days come from?
    Mr. Gibson. Mr. Chairman, the clear and unequivocal advice 
from legal counsel has been----
    The Chairman. Wait, wait. Okay. It is counsel. Okay. But 
the law is clear. The law says there is no period for appeal on 
the front end, but there is on the back end.
    Mr. Gibson. The case law is very clear that we have to 
provide a reasonable opportunity to respond to charges. And as 
you note, under Title 5, that is 30 days. That was shortened to 
five days. The view is that if we fail to provide that 
opportunity to respond that the MSPB will view that as a 
failure to provide due process----
    The Chairman. But, Mr. Secretary, please----
    Mr. Gibson [continuing]. And, therefore, overturn the 
decision.
    The Chairman [continuing]. Please. If we had intended for 
there to be an appeals process at the beginning and we put it 
in at the end, why didn't you just keep it at 30 days? If you 
are not going to follow the law as it is written, why did you 
come up with this phantom five-day appeal?
    Mr. Gibson. We came up with five days because we understood 
that the intent of Congress was to move expeditiously, but we 
also balanced that against the requirement to provide due 
process or risk that our decisions be overturned. That simple.
    The Chairman. I understand the risk part, but the secretary 
keeps going out and saying the law needs to be changed if we 
want people to be fired immediately. No, it doesn't. The law is 
clear. It says they should be fired.
    Now my question is, should somebody continue to accrue 
benefits while they await disciplinary action which includes 
being fired? If you think so, justify that and, if not, will 
you help me change the law to prevent that from occurring 
because the taxpayers are tired of paying bonuses and benefits 
to people who are not serving veterans?
    Mr. Gibson. The law requires that federal employees be paid 
until a disciplinary action has been effected which, in fact, 
is in this case a removal decision, not a proposed removal, but 
a removal decision. As soon as that removal decision is made, 
they no longer are compensated and they no longer continue to 
accrue benefits.
    The Chairman. Why can't you remove somebody without pay, 
suspend them without pay? Why do you allow them to continue to 
accrue that benefit when you know there is a problem? Just from 
a personnel standpoint, why don't you or why can't you do that?
    Mr. Gibson. Suspension without pay is a disciplinary action 
that would be subject to review by the Merit System Protection 
Board. Again, if we take action, disciplinary action without 
evidentiary support, we are going to find that that gets 
overturned.
    The Chairman. Has anybody that has been involved been 
suspended without pay?
    Mr. Gibson. No. It is disciplinary action.
    The Chairman. Mr. Michaud.
    Mr. Michaud. Thank you very much.
    Just to follow-up on that same line, so if I understand you 
correctly, what you are saying is even though we have loosened 
to give you more authority to discipline employees, the concern 
you have if you fire someone or discipline them and you move 
too quickly, then that actually could be overturned?
    Mr. Gibson. It is not literally moving too quickly. There 
are two requirements. The MSPB in their implementing 
regulations stipulated that we are required to meet the 
preponderance of evidence standard whether it is removal for 
misconduct or removal for performance.
    And so that is one piece. We have to have evidence. The 
second piece is that we believe case law is clear that we have 
to provide a reasonable opportunity to respond to the charges.
    What we are talking about here is five days, five days to 
be able to protect these actions, we hope, from an overturn on 
appeal for our failure to provide due process.
    Mr. Michaud. And do you think five days is long enough?
    Mr. Gibson. Obviously we think it is because that is what 
we proposed. We felt like it was the appropriate balance 
between what is provided in Title 5 and the intent of Congress.
    Mr. Michaud. Okay. Thank you.
    I understand that the Choice cards are being rolled out in 
phases right now. For veterans who have waited longer than 30 
days on a wait list but have not yet received their Choice 
card, what is VA doing to reach out to those veterans to let 
them know that they are eligible?
    Mr. Gibson. Many of those veterans are already being called 
to determine whether or not they want to exercise their option 
for Choice. We are going through the entire list of veterans 
that are waiting more than 30 days, uploading those to what we 
call the Veterans Choice list so that we hope as early as next 
week we are able to activate the 30-day group as well and be 
able to contact those veterans to schedule appointments or to 
offer them that choice.
    Mr. Michaud. And of the veterans who are in the Choice 
Program, do you have any sense on how long it took them to get 
an appointment?
    Mr. Gibson. I don't know if I understand your question.
    Mr. Michaud. As far as the veterans that are in the Choice 
Program that are going to try to get an appointment, do you 
know how long it is taking them to get an appointment?
    Mr. Gibson. We are still only about five or six days into 
implementation of the program, so we know that we see the 
number of calls that are coming in every day, the number of 
authorizations, and the appointments are beginning to be 
scheduled. There is a standard stipulated within the contract 
within which they have to get that appointment scheduled.
    How many days, Jim?
    Dr. Tuchschmidt. So the authorization has to be made within 
five days and an appointment within 30 days. We have only had 
about a week's worth of experience. I can tell you as of 
yesterday, I think we had about 6,000 of the people in the 40-
mile group, here was about 320,000 people in the 40-mile group, 
had about 6,000 of those contact either Health Net or TriWest. 
And I believe that first week we have had something around 
maybe 40 appointments scheduled.
    Mr. Michaud. And are you keeping an eye to make sure that 
what the private sector is not going to do, what some of the VA 
facilities have done as far as gain in the system on 
timeliness? Do you have metrics in place or measures in place?
    Dr. Tuchschmidt. We do have metrics and we, of course, will 
be auditing and monitoring what goes on with third-party 
administrators. I have to say that both of them, both TriWest 
and Health Net have done an amazing job of really helping us 
stand up this program in the time frame that we had. And I 
believe that they are sincerely doing everything in their power 
to make sure that those veterans are referred into the 
community.
    As you know, sometimes waits in the community are also 
long. So one of the, I think, tests when the rubber hits the 
road here is what is the capacity in private sector to really 
absorb patients in a more timely way than we have been able to 
provide that care.
    Mr. Michaud. Thank you.
    And how is VA tracking the use of the $10 billion that had 
been allocated for the Choice Program?
    Mr. Gibson. All of that will be accounted for separately 
under the Choice program. This is actually a mechanism very 
similar to what we set up back in May for the accelerating care 
initiative where we were allocating specific amounts of funding 
out into the field.
    So we had already established a separate accounting chain 
to be able to track and record all this information so we will 
know exactly at any point in time what has been expended and 
ensured that that only been expended for those Choice Program 
activities.
    Mr. Michaud. Great. Thank you.
    Thank you very much, Mr. Chairman.
    The Chairman. Mr. Lamborn, you are recognized for five 
minutes.
    Mr. Lamborn. Thank you, Mr. Chairman.
    Mr. Secretary, you have said that an SES employee cannot be 
fired without what the chairman called a phantom five-day 
notice period. This is not required within the letter of the 
law, the bipartisan law that Congress just passed and the 
President just signed.
    As long as poor performance has been documented, I believe 
and I think the committee believes there is no need for a five-
day notice period. In effect, this amounts to an additional 
appeals period. There is an appeals period that the new law 
allows for and that the old law, slightly different terms, 
allowed for as well.
    So no one has been fired for poor performance. Maybe some 
will re--excuse me, for the data manipulation like we saw in 
Phoenix, Arizona that I am aware of. Correct me if I am wrong. 
And there is now two appeals processes, a five-day and then the 
existing or the new appeals process after a person gets notice.
    And in addition to that, you are setting up a new office to 
review administrative removals, and I heard that this new 
office is going to have up to 30 people in it. So not only has 
no one been fired for data manipulation and you say the law 
doesn't allow for an immediate firing. As long as poor 
performance has been documented, we believe the law says that, 
and the chairman made a very eloquent description of what the 
law says, but you are setting up a new layer of bureaucracy 
with up to 30 people in this new office.
    This is what sends a bad message to the public and to 
veterans and to employees, poorly performing employees at the 
VA. Nothing is being done.
    And how could the law be any clear--that is my first 
question to you--how could the law be any more clear that 
someone, as long as poor performance has been documented, can 
be removed by the secretary without a notice period? How can we 
make the law more clear than it already is?
    Mr. Gibson. Well, let me answer with a question of my own. 
Do you want to propose removal of employees that is overturned 
on appeal?
    Mr. Lamborn. I would like it to survive on appeal.
    Mr. Gibson. We would too. And so we have adopted a process 
that allows us to meet the evidentiary standard and that we 
believe will withstand the appeal process with the Merit System 
Protection Board.
    Mr. Lamborn. You are adding to what the law says though.
    Mr. Gibson. That and nothing----
    Mr. Lamborn. You are adding to what the law says, Mr. 
Secretary.
    Mr. Gibson. The law isn't just what is sitting in the 
statute. The law is also the case law that has evolved over a 
period of years around the removal of federal employees. And 
the case law is very clear. We have to provide a reasonable 
opportunity to respond to the charges. And if we fail to do 
that, we are going to be vulnerable to these decisions being 
overturned on appeal.
    Mr. Lamborn. But there is an appeals process. There was 
under the old law and with modifications, there is still one 
under the new law.
    Mr. Gibson. This is not an appeal process. It is an 
opportunity to respond to the charges. That is what it is. It 
is not an appeal process.
    Mr. Lamborn. So what happens during the five days is not an 
appeal?
    Mr. Gibson. It is not an appeal process. It is an 
opportunity, a reasonable opportunity to respond to the 
charges. That is all it is.
    The Chairman. Or resign or retire.
    Mr. Gibson. Let me also make a comment here. The issue has 
come up a couple of times about the Office of Accountability 
Review. I am the person. So if somebody doesn't like what we 
did there, I am the person that you need to blame for that.
    There were comments that you made, Mr. Chairman, and you 
were absolutely right. I think historically we fail to hold 
people accountable for misconduct and for management negligence 
in the organization.
    And so as we waded into this situation where we had at the 
peak, I think, 95 or 97 different IG reviews underway all 
across the organization, we realized, A, that we were going to 
have a large number of disciplinary actions to consider and, B, 
where we knew that we were going to have to go through a 
process of recalibrating accountability within the 
organization.
    And, quite frankly, I was not willing to take those actions 
as they came out of the end of the IG's pipe and turn them over 
to VHA as normally would have been the practice in the past. 
You would return those to VHA and go form an administrative 
investigative board and do your own investigation, come up with 
your own charges and decisions.
    Mr. Lamborn. Mr. Secretary----
    Mr. Gibson. I did not believe that that was adequate.
    Mr. Lamborn. Mr. Secretary, my time is about up. In the 
view of this Member of Congress, you send the right message to 
the country, to veterans, and to poorly performing employees by 
removing them, not giving them an additional appeals process of 
five days and not setting up a new layer of bureaucracy.
    Mr. Chairman, I yield back.
    Mr. Gibson. We are going to send the wrong message to 
veterans if we wind up having our removal decisions overturned 
on appeal because there is no further appeal after that. They 
come back to us and we have got no recourse at that point. We 
are stuck with them. We are not able to take any additional 
disciplinary action. We make up all their back pay, all of 
their legal costs, and I don't think that is what veterans want 
or expect and I don't think that is what taxpayers expect.
    The Chairman. Mr. Secretary, I wrote a letter to Secretary 
McDonald and asked for specific statute or case law that led to 
the department creating the requirement for the five days. I 
got a response, but I got no case law and I got no statutory 
requirement.
    In his response, he said it would be unconstitutional to 
fire a career employee without telling him or her why and 
providing them with an opportunity to respond. Obviously you 
are going to tell them why when you walk in and you fire them. 
They have an opportunity to respond after the fact.
    Again, we will beat this thing, til the sun goes down and 
we are going to get up the next day and we are going to be 
doing it again.
    What I perceive you doing is when you give them five days, 
if that person wants to quit, they just quit. In the past, VA 
has said that is a disciplinary action. Something has happened. 
They are not in VA anymore. Well, that is not a disciplinary 
action.
    That person goes on to another agency somewhere in the 
federal government or they put their papers in and they retire 
with all the whistles and bells just like happened in Georgia 
where there was this great fanfare. This person did 42 years of 
great service. When they knew they were going to be fired, they 
went ahead, because they had that five-day notice.
    So that is the concern that we all have and I think we will 
all work together in trying to fix it. You claim there is a 
constitutional requirement. We don't believe that there is. It 
may take going all the way to the Supreme Court to figure it 
out, but I think the taxpayers deserve accountability swiftly 
and correctly. You wouldn't take the effort to fire somebody if 
you didn't have it. I trust you there.
    So, you know, again, I am perplexed, but several other 
people are probably perplexed as well.
    Ms. Kirkpatrick.
    Mr. Gibson. I will see that we provide you the case law, 
Mr. Chairman.
    Ms. Kirkpatrick. Thank you, Mr. Chairman.
    Thank you, Under Secretary, for being here today.
    My two questions are going to be about critical pieces of 
the Choice Act. But before I ask my questions, I just want to 
say that I find it outrageous and my constituents find it 
outrageous that Sharon Helman is still collecting her salary of 
$170,000 after being put on leave in May. And we just want you 
to know that we are calling for her immediate firing. We want 
that to happen immediately.
    Now I will go to my questions. A critical piece of the 
Choice Act is the $5 billion that we provided for the hiring of 
new medical professionals, but it is a competitive environment 
out there. We know that.
    And so my question really goes to the hiring process and 
here is why, because if I am a physician's assistant or a nurse 
and I want to work at the VA and I apply, but it takes six 
weeks, three months, six months, a year to process my 
application, I have got to be working, so I am going to find a 
job somewhere else.
    So what are you doing to be competitive within the hiring 
environment for these medical professionals?
    Mr. Gibson. A couple of things. One, we know we have got 
extensive opportunities to streamline our hiring processes with 
providers. Bob McDonald recently approved increased salary 
ranges for providers to allow us to be more competitive to 
attract and retain great talent.
    I am aware of instances on a case-by-case basis across the 
country where particularly, for example, with nurses, we have 
gone in and done market surveys in order to be able to justify 
changing salary ranges in that particular market area.
    We are looking now at doing that same process all across 
the country in every market to ensure that, in fact, what we 
have got are salary ranges that are competitive.
    We are taking a hard look at the credentialing process and, 
in fact, ultimately we will move to the same system that the 
Department of Defense uses for documenting credentialing so 
that we are able to work very transparently between the two 
systems.
    No doubt that we have got opportunities to streamline. The 
other thing that we have been doing as part of the push for 
accelerating care is to accelerate our hiring activity. 
Oftentimes we wait until the position is vacant and then we 
study it for a while. We bring it to some kind of a board and 
then the board finally decides and it is months before we even 
post the position.
    Now we actually, particularly for certain positions, hire 
into turnover so that we are already out there recruiting and 
hiring in anticipation of the turnover.
    We looked specifically at hiring activity during the second 
half of 2014, the months from April through September, and I 
think most of this really happened in the last four months of 
the year. Net increases in nurses, 1,700, 600 net increase in 
doctors, 700 net increase in schedulers, all across the 
organization.
    So material improvement, meaningful improvement there in 
the staffing levels, and we will keep after that. But to your 
point, we have got continued room to improving the process.
    Ms. Kirkpatrick. Thank you.
    My second question goes to the Choice Program. I know that 
you are sending out the Choice cards now. My concern is that a 
lot of rural veterans have post office boxes and what I am 
hearing is that a letter is first sent to them. They have to 
verify their post office box.
    Here is the problem in my district. I think there is an 
assumption that they have to go pick up a utility bill. But in 
my district, we have thousands of veterans who don't have 
running water or electricity. They rarely go to their post 
office box because there is nothing there.
    What are we doing specifically to reach out to those 
veterans who have post office boxes? And let me just say that 
the VSOs have offered to help reach these veterans, actually 
physically go out to their homes. And so I would just like your 
thoughts and comments about that.
    Mr. Gibson. Sure. We are actually in the process of sending 
letters to all of the veterans whose address, post office box 
address would suggest that they may reside more than 40 miles 
from the nearest VA medical facility, offering them several 
different, as easy as possible ways in order to be able to give 
us their residential address so that we can determine 
definitively their eligibility, not their eligibility, their 
access to the benefit under the Choice Program.
    I had not considered instances where veterans don't go to 
their post office box or the opportunity for us to enlist the 
help of VSOs. That is a wonderful idea and we will pursue that.
    Ms. Kirkpatrick. Thank you very much.
    I yield back my time.
    The Chairman. Thank you.
    Mr. Bilirakis, you are recognized.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much.
    Thank you, Mr. Secretary, for your attendance and your 
testimony.
    A sum of $5 billion was appropriated in the VA reform bill 
to increase the hiring of physicians and other medical staff to 
improve VA's physical infrastructure. However, no report has 
been given to Congress, to my knowledge, by the VA on how the 
department intends to use the funds.
    Without the proper staffing assessment, how does the 
department know how many positions and which facility will 
yield optimal benefits for veterans seeking the quality of care 
they have earned and deserve?
    Dr. Tuchschmidt. Sir, I think we have shared our 
preliminary information with your staff on our intentions for 
the spend plan, but we will be sharing a formal plan with you 
as soon as that is ready.
    Mr. Bilirakis. Well, when do you anticipate that being 
ready?
    Dr. Tuchschmidt. Probably within the next couple weeks here 
it should be finalized, I would think. We are putting a 
document together that not only has the plan but kind of 
exactly what each of those line items entails and some 
information about it so that it is more than just looking at a 
spreadsheet.
    We currently have plans to hire about 9,600 staff with that 
money. Some of the money is for staffing. Some of the money is 
set aside for IT-type things. So when we hire a new person, 
they have got to have a workstation to sit at. And when we have 
new space, we have to put, you know, LANs, WANs, and cabling 
and all that other stuff in there.
    And then the balance is really for leases and NRM projects 
and those kinds of things. But we plan to hire about 9,600 
staff across the country. We have gone through a very detailed 
process of literally reaching out to each medical center, 
asking them to look at what additional staff they need or 
space, for that matter, to improve access and specifically how 
will it improve access. And then that plan has been aggregated 
at a national level.
    Mr. Bilirakis. How far along are you with that? I mean, 
have you reached out to every medical center in the country?
    Dr. Tuchschmidt. Every medical center is done. That work is 
basically done and it is now being put together in a final plan 
that is in draft form right now.
    Mr. Bilirakis. Who makes the determination as to what 
staffing, the regional Director, which staffing is needed as 
far as the services provided?
    Dr. Tuchschmidt. We have asked the facility, each facility 
to come up with that plan, that it be aggregated at the VISN 
level, and then come back to us.
    Mr. Bilirakis. When you mention facility, is that 
hospitals, clinics----
    Dr. Tuchschmidt. Hospitals.
    Mr. Bilirakis [continuing]. CBOCs? Just hospitals?
    Dr. Tuchschmidt. The CBOCs all work for the facility, 
right? So we have asked the facility leadership to take on that 
project.
    Mr. Bilirakis. Okay. Thank you.
    Mr. Secretary, included in the Veterans Access, Choice, and 
Accountability Act, it authorized 27 facility leases including 
one in Pasco County, Florida. Authorizing these leases will 
surely improve the timeliness for veterans to receive the care 
they need in my district and in 17 other states around the 
country.
    While I am encouraged that veterans in my district will 
have the option to visit a one-stop consolidated clinic, I 
remain concerned regarding the time expected and the completion 
of these facilities.
    What is the process for VA to keep members who have these 
leases in their districts apprised of the progress of these 
initiatives and what engagement with the community of the 
leases does the VA intend to conduct to ensure the necessary 
services will be offered at these various facilities?
    Dr. Tuchschmidt. So we have a number of leases that we are 
standing up. We have two that are in the works right now and 
then we have a number that will be coming in fiscal year 2016. 
We will absolutely be working through the process with the 
community and the stakeholders in the community both to find 
property in the first place and to make sure that the services 
that are being placed there are appropriate.
    Mr. Gibson. Let me jump in, Jim.
    Dr. Tuchschmidt. Yes.
    Mr. Gibson. You know, the other issue, I happen to agree 
with you, it takes too long to get these off the ground. And so 
we have looked at the typical time line from where we are right 
now with an authorization in place to completion. It is as long 
as four or five years. And I think that is unacceptable.
    We have already visited with OMB. They are going to work 
with us on finding ways to compress that time line to be able 
to accelerate that. We are already doing things with 
standardized design so that we are not reinventing design with 
each facility that we go look at.
    To your point, we have got to work through the site 
selection issues because those oftentimes add an awful lot of 
time and effort to the overall process, but we have got to find 
ways to deliver these more quickly. My guess is that in the 
private sector, they would be able to go from where we are to a 
completed facility in three or four years. We have got to find 
a way to do it faster.
    Mr. Bilirakis. Thank you, Mr. Secretary. I want to ask you 
a couple questions.
    Just briefly, Mr. Chairman, with regard to this, just 
follow-ups.
    Will you assure me that the community will have input----
    Mr. Gibson. Yes, absolutely.
    Mr. Bilirakis [continuing]. On the site location?
    Mr. Gibson. Yes.
    Mr. Bilirakis. And the services provided, the future 
services provided----
    Mr. Gibson. Yes.
    Mr. Bilirakis [continuing]. The additional services? You 
will assure me of that?
    Mr. Gibson. Yes. Yes.
    Mr. Bilirakis. All right. Thank you, Mr. Chairman. I 
appreciate it. I yield back.
    The Chairman. Dr. Tuchschmidt, did you say they would be 
initiated in 2016 or they would be finished in 2016?
    Dr. Tuchschmidt. I think that the contracting action 
happens in 2016. We are not going to have anything. Out of 
these 27 leases, we are not going to be seeing patients at any 
of those facilities in 2016.
    The Chairman. Again, but you are going to start the 
contracting in 2016?
    Dr. Tuchschmidt. No. Looking down through the 27 leases 
that we have got here----
    The Chairman. Leases that are already way, way, way behind.
    Dr. Tuchschmidt. And what we will do is work through the 
finalization of the requirements to inform the design process. 
That then sets the stage for the contracting action to 
commence. Somewhere in there, we have got to get GSA to 
delegate authority for us under these leases. They have to 
delegate everything.
    Seventeen of the 27 leases are actually above GSA's 
authority to delegate, so we have got to figure out some way to 
work around those particular issues and then we have got to 
give the contractor, whoever we wind up contracting with the 
time to build the facility.
    The Chairman. Okay. Thank you.
    Dr. Ruiz.
    Dr. Ruiz. Thank you. Thank you, Mr. Chairman, ranking 
member.
    Our veterans have spoken and I join them in their message 
in saying that anything less than the highest standard of 
healthcare that is veteran centered will not be tolerated. In 
implementing the Veterans Access, Choice, and Accountability 
Act, that must be the sole standard by which we judge 
ourselves.
    I hosted a workshop that educated 70 medical professionals 
in high-demand specialties for the VA in my district about how 
to work with the VA Loma Linda and TriWest to provide veterans 
with healthcare in their communities. Our goal was to get more 
veterans high-quality, veteran-centered care and recruit 
physicians to see our veterans in the community. And we will 
continue to speak with the medical professionals that attended 
to measure the success of the event.
    I received a call from Secretary McDonald, which I really 
appreciate, to discuss the event and I shared with him the 
lessons that we learned. And I think that it is important that 
we discuss these lessons learned so that all of us on the 
podiums here can implement these in our own district as well.
    But based on the feedback that we got with the debrief and 
the phone calls that we did, the three take-aways was, one, our 
physicians don't even know who to begin to call, so there is 
not a very clear streamlined understanding of who can they call 
to sign up for TriWest or Loma Linda VA folks.
    So I think helping them navigate the system very clear and 
concise and streamline is very important and I think that 
creating a how-to guide and frequently asked questions and 
answers about how they can provide care to veterans would be 
very beneficial and start putting it out there now and 
standardizing that around the country.
    And I will continue to hold these workshops and 
collaborating, and I look forward to working with all of you so 
that we can create benchmarks that can be replicated throughout 
our country for our veterans.
    However, we can't recruit physicians in areas that have 
shortages already to begin with, areas in rural America where 
that is where we need the physicians in the VA to begin with. 
In my area, I represent Riverside County, which has the ninth 
largest veteran population in the country, more than 50,000 
veterans reside in my district.
    But, unfortunately, the Inland Empire where I am from in 
Southern California has one of California's lowest numbers of 
physicians per capita. So we definitely have a physician 
shortage plan. And I understand part of the law is to recruit 
more physicians through GME programming.
    How do you plan to implement the new GME positions in the 
Veterans Access, Choice, and Accountability Act to increase 
access to care for veterans in under-served areas or areas with 
high physician shortages to begin with like the Inland Empire 
in my county?
    Mr. Gibson. I think your suggestion on more robust 
communication of the provider community is a great idea. We 
will take that for action.
    Let me ask Dr. Tuchschmidt to talk about our effort in the 
GME area.
    Dr. Tuchschmidt. Yeah. And let me just start by saying that 
for providers in your community who would like to participate 
in the Choice Program, the 800 number actually has an option. 
So option one, I know we all hate these things, but option one, 
press one if you are a veteran, press two if you are a 
provider, press three if you are someone else.
    So they can call the third-party administrators, TriWest or 
Health Net directly to get information. And we are working to 
put together a provider information packet that will help them 
understand.
    With respect to the GME, I am actually really excited about 
this. We have a plan to stand up 300 new resident positions in 
under-served areas and particularly in areas where we need 
physicians, the 300 per year.
    This year, quite frankly, I think we were all talking and 
were not anticipating that we would get a great response given 
the short time line between now and when the academic year 
starts, but for the 300 potential slots we are targeting for 
the next academic year got over 400 requests for additional 
resident slots.
    So some of those may be established programs that want to 
expand those programs. Some of them may be wanting to start new 
programs. Some of them may be community medical centers who 
want to start a family practice residency program. So we are 
working with those.
    I think the challenge is going to be for those sites to 
actually stand up those programs.
    Dr. Ruiz. I appreciate that and I appreciate you 
prioritizing the low physician to population ratios that exist. 
And it is time now to begin building pipelines of individuals 
who want to serve in the VA. And the place you can find those 
is in the military.
    When I was in Haiti working with the 82nd Airborne as a 
medical Director for a nonprofit right after the earthquake, 
there were plenty of medics that were pre-med. And, in fact, I 
wrote a letter of recommendation for several for medical 
school.
    If we can identify them early while they are in the 
Department of Defense, put them in a pipeline program, into 
those GME slots after the medical schools that contract with 
the VA and the Department of Defense, then those are the ones 
that will be committed to providing high-quality, veteran-
centered care in our VAs.
    Dr. Tuchschmidt. I couldn't agree with you more.
    The Chairman. Dr. Roe.
    Dr. Roe. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here.
    And I am just going to go. I am going to sort of take the 
theme of providing care. You all have some work to do in your 
shop. Let me just give you an example of what happened in my 
district recently.
    A GI doctor was hired, all cleared by the local, cleared to 
the VISN, and quit his job. He is waiting to be hired at the 
VA, but his paperwork is at some central office, some black 
hole here in Washington.
    So during this political campaign, I have got my staff on 
the phone to somewhere here in Washington to get this doctor 
who is approved, who could be seeing patients. So he goes out 
and gets another job as locum tenens during that time until the 
VA finally bumbles along and gets him hired. Those things are 
so frustrating. You cannot imagine how frustrating that is to 
see that after all this.
    And I walk out of the VA hospital Monday from a ceremony 
there. I bump into a veteran that doesn't even live in my 
district, but he has driven two and a half hours to get there 
for his appointment that he has waited four months for. And he 
got three calls to come to that clinic appointment. And he 
shows up that day and his doctor is not there.
    And the guy has got severe pain in his neck. He has had a 
spinal fusion surgery from a neurosurgeon who is a very close 
friend of mine. The man needs an epidural steroid injection. He 
is fuming. He has got to ride two and a half hours back to 
Knoxville now.
    But, fortunately, I have some friends there. I made some 
calls to friends of mine and these are VA friends I am talking 
about. We then get this man an appointment down in Knoxville so 
he doesn't have to come back.
    That is the kind of thing that every person sitting at this 
dais hears every time you go to a VA. And my question is, when 
is it going to stop?
    And that is the thing I am so frustrated with is that I 
spent, as Dr. Ruiz did, an enormous amount of time during this 
October period listening to people at the VA.
    Let me tell you what else you have to do. I want to work 
with you on this. I am a primary care doctor. Until you reform 
how the primary care doctors--that is the tip of the spear--
provide the care. You can't hire enough doctors or train enough 
doctors ever to get it done.
    I look at what they have to go through to actually see a 
patient and what I had to go through to actually see a patient. 
And Mr. Michaud is not here. There is not going to be any gain 
in the system on the private sector. Patient shows up. I take 
care of him. I get paid. If the VA will write the check, I will 
get paid.
    And they have incredible teams. You guys have teams put 
together that I could have only dreamed of in private practice. 
And, yet, they are so bureaucratic and slow, they can't see 
many patients.
    So I wish you would sit down with a private practitioner 
like myself and like several others sitting around here and let 
us help you, show you how to do that and then use that as a 
metric across the country to create more efficiencies.
    We had a young psychiatrist here from St. Louis that the 
psychiatrists were seeing six people a day. We can't train 
enough psychiatrists in 50 years to see to the needs at the VA.
    And I appreciate the effort you are doing, but there is a 
real shakeup that needs to happen. And this mid-level 
bureaucracy that is apparently a filter that is slowing all 
this down, you need to get after that. And I can't imagine why 
it would have taken anybody but a piece of paper, a signature 
to have a doctor working.
    Mr. Gibson. Let me offer up quick. Your story of the 
physician hiring frustrates me at least as much as it 
frustrates you. And I run into those stories still and do 
everything I can to clear away the bureaucratic obstacles that 
get in the way.
    What we have got to do is revise the system so that we 
don't have to intervene, either of us individually on a case-
by-case basis.
    I am deeply disappointed in the story you tell me about the 
veteran that came for his appointment and the doctor was not 
there. Thank you for intervening on his behalf.
    I want to ask Dr. Tuchschmidt to comment on the third 
observation that you have made about primary care physicians.
    Dr. Tuchschmidt. Yeah. Let me also just say I am the black 
hole in central office. I admit that. That is my job to approve 
those. I try and approve them immediately when they come in. 
But as of the beginning of this month, we delegated approval 
out in the field up to $350,000 a year. They don't have to come 
to me below that level as of the beginning of this month.
    We have actually, to your suggestion, been benchmarking 
with Kaiser Permanente and others and we are in the process 
right now of developing practice management standards and tools 
to deploy to try and improve some of those processes.
    Dr. Roe. My time is about up, so I don't want to interrupt 
you, but you can't have physicians doing clerical work.
    Dr. Tuchschmidt. Yes.
    Dr. Roe. You can't have them going out and walking out and 
having to call to make the appointment. I mean, I know when I 
saw somebody, the most valuable time you have is the 
physician's time. And so when someone comes in, you have got to 
be able to put that in the record, hit a button, have somebody 
else do all that stuff.
    The other thing I want to talk just very--Mr. Chairman, if 
you would give me ten more seconds--is the spacing. I hear all 
the time that the physicians don't have enough room to work in. 
I can tell you as an efficient primary care provider, it takes 
three to four rooms for me to work. I can be very efficient 
with that.
    You give me one or two rooms, you have slowed me down by 30 
percent. It does take time for a woman or a man to get their 
clothes off. Somebody has got to do that. That takes time. 
While they are doing that, you can be seeing somebody else.
    I had a different motivation where I was to be efficient in 
my practice. I don't see that in the VA system, but I think you 
have got real problems with space and then the way your 
clinical, the primary care people I am talking about work. So I 
am willing to work with you on that.
    Dr. Tuchschmidt. We are in agreement with you.
    Dr. Roe. I yield back. I appreciate it.
    The Chairman. Thank you.
    Ms. Kuster.
    Ms. Kuster. Thank you, Mr. Chairman, and thank you very 
much for being with us today.
    I want to just tell a quick anecdotal story that a member 
of my staff who is a veteran received his card last week and we 
were all very excited. We walked through the letter that 
veterans received.
    And I just want to make sure in terms of the volume of 
calls and questions because it was great to receive the card 
and it was nice to celebrate that for Veterans Day, but it was 
very clear that the card wasn't going to do anything until you 
went through the steps of eligibility and making sure that you 
are authorized to use the card.
    So, number one, I worry a little bit about veterans that 
somehow think the card has some magic to it and they go to a 
private provider and then end up with a big bill they didn't 
expect.
    Number two, the question that was raised in a memo provided 
to us by the staff about the co-pays and deductibles and is 
there sufficient communication for the veteran to understand 
that they may end up with a financial obligation that they 
would not have had if they had been seen through the VA?
    And I have another question, but I would love to have 
someone address that.
    Mr. Gibson. I will start out and Dr. Tuchschmidt may want 
to jump in.
    We took great pains as you would expect with the drafting 
of the communication. We also went out to VSOs and had VSOs not 
only review it but actually get it in the hands of veterans and 
have veterans review it and provide us that feedback.
    So part of what you are seeing and the tension that you 
have just described between, they have to take some steps to 
access the care that they are eligible for. This would have 
been someone in the 40-mile group. And that is one of the 
reasons because there is a potential liability associated with 
co-pays just like there is with VA.
    If a veteran is out seeking care for a nonservice-connected 
condition or they have third-party insurance and different 
circumstances, there may be instances where the veteran is 
accountable for some of that cost.
    We have done things in interpreting the legislation and 
with policy decisions that we have made and regulation that we 
have promulgated to make the operation of the Choice Program 
from the standpoint of co-pays look absolutely as close as we 
could possibly make it look to traditional non-VA care because 
we didn't want to set up a situation where the veteran was 
going, oh, well, I want care in the community, but I want to 
use this. I don't want to use the Choice card.
    Ms. Kuster. Yes.
    Mr. Gibson. And so we eliminated those obstacles, but there 
are, in fact, instances where the veteran could be obligated 
for some of the cost.
    You want to----
    Dr. Tuchschmidt. Yeah. And I think we have, you know, we 
have said from the get-go that in designing this program, we 
want to do the right thing by the veteran, right? That is 
number one priority.
    I think that we have pretty much resolved the issue with 
the VA co-pay, so we will be setting that at zero at the time 
that the veteran is being seen so they don't have an out-of-
pocket cost at the visit. We don't honestly believe we can 
determine what that co-pay is until after we get a statement, 
an explanation of benefits back.
    With respect to third-party co-payments, technically that 
is a contract between the patient and his or her insurance 
company which we have no control over. However, the way we have 
tried to implement this, I think that most of the time we will 
be able to cover that co-pay through the way the Choice payment 
is made.
    But if the patient has expensive care, has 
hospitalizations, procedures, has let's say Medigap insurance 
with a high deductible, the fact of the matter is is that they 
may be subject to co-payments. And we have done everything we 
can to educate VSOs, our partners, and we will be educating 
veterans to the fact that that is part of the way the Choice 
Program has been designed.
    Ms. Kuster. Okay. So I think communication and education 
through the VSOs.
    The other question I have and just hearing from my 
colleague, New Hampshire as we just recognized Veterans Day and 
had a wonderful celebration, turns out we have one of the 
highest percentages in the country, 11 percent of our citizens 
are veterans which is pretty incredible in terms of the 
service.
    But as you can imagine, then we have a lot seeking service. 
And the ARCH Program has been very popular and I understand the 
Veterans Access, Choice, and Accountability Act allows for 
continuation of that.
    But could you address for me how that will happen? It is 
important for our rural veterans and they like it. It works for 
them. And I just wanted to get clarification in terms of how it 
is impacted by the Choice card.
    Dr. Tuchschmidt. So the legislation extended the ARCH 
Program. We have extended the contract temporarily while we are 
renewing the ARCH Program. So it will remain in place 
essentially as it has existed in the past going forward.
    Ms. Kuster. Okay. I appreciate that.
    I yield back. Thank you.
    The Chairman. Mr. Flores.
    Mr. Flores. Thank you, Mr. Chairman.
    Mr. Secretary, I appreciate you joining us. I also 
appreciate the work that you and Secretary McDonald and the 
team are doing to work with Congress and this committee in 
particular to build the VA for the 21st century.
    A few weeks ago, the Austin American-Statesman Newspaper 
published an article about the VISN Waco Center of Excellence 
for Research on returning war veterans. And I will ask the 
chairman if he will introduce this in the record.
    I am not trying to change subjects because we are still on 
the same subject and the subject is what is the underlying root 
cause of the issues that the VA is struggling with. And it 
turns out that it is a troubled culture that needs to be fixed 
and that needs to have a change in personnel to do that.
    And you are working on that. Now, we are not necessarily 
happy with the direction you are going with that, but the 
comments have been that that has been discussed already.
    What I would like to do is talk a couple of other things. 
One is this committee and my office have requested an update, a 
briefing with someone from the VA regarding the Center of 
Excellence between now and December the 11th. I would like for 
your all's commitment that you would do that.
    The second thing is is that the Center of Excellence 
totally failed in its objective to try to find the underlying 
causes of TBI and PTSD and to try to help the VA come up with 
some groundbreaking research to address these critical issues 
that are facing today's war fighters, but it just utterly 
failed. Not one MRI was produced in order to assist with this 
project. And, you know, tens of millions of dollars were wasted 
in the process.
    A whistleblower brought this to our attention. And this is 
where I get back to the culture. That whistleblower and some of 
the other whistleblowers who participated in letting America 
know about the problems faced incredible retaliation. And you 
saw the hearings we had back in the summer where when the 
waiting list issue came up, the bureaucracy retaliation against 
whistleblowers, it goes beyond the pale.
    And so I urge you to continue to work on that part of the 
culture as well. There should be no retaliation. They should be 
celebrated as people who are trying to make the system better.
    Anyway, so two things and I will be brief. One is I would 
like your commitment to have that briefing for this particular 
Center of Excellence and, two, that you will remember that we 
need to fix the culture of retaliation as part of our overall 
attempts to fix the culture at the VA.
    Thank you.
    Mr. Gibson. One, we will commit to having that briefing to 
you before the 11th of December as you have requested. Two, I 
have said repeatedly and continue to say we will not tolerate 
whistleblower retaliation.
    I have worked very closely with Carolyn Lerner, the special 
counsel of the United States, first on restoring employees who 
have been the object of retaliation and ensuring that they are 
basically made whole in that process and then coming in 
immediately behind that through the much maligned Office of 
Accountability Review to conduct the investigations into the 
retaliatory behavior to ensure that we are holding those 
individuals accountable for that behavior.
    I agree with you that they should be put up on a pedestal 
and I have agreed to participate, I think it is the 4th of 
December, with the Office of Special Counsel where they are 
going to be recognizing two whistleblowers from Phoenix. And I 
will be joining them in that forum.
    Mr. Flores. Okay. Thank you for your responses.
    I yield back.
    The Chairman. Thank you.
    Mr. O'Rourke.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Mr. Secretary, I wanted to first start on a positive note. 
I hear from a number of veterans in my community that go to the 
VHA clinic in El Paso that they receive exemplary care in a 
timely fashion. And more importantly, I am beginning to hear 
from veterans who did not used to receive that care in a timely 
fashion and they are telling me that they are now able to get 
appointments.
    And so I appreciate your leadership and the VA.
    Mr. Gibson. We have both been working on that for a while.
    Mr. O'Rourke. That is right.
    Mr. Gibson. So I am glad for that feedback.
    Mr. O'Rourke. Your visit to El Paso, I think, had an 
impact, so appreciate that.
    But I want to follow Dr. Roe's lead in using an anecdote to 
describe the challenges that remain. I was recently at the VA 
and while there and asking veterans about the quality and 
access to care that they have been receiving ran into a 
gentleman who was there for a mental healthcare appointment. 
And he had called the day before to confirm that appointment.
    I have no idea how many months in advance that appointment 
was made nor do I know how many miles he drove to be there. The 
appointment was confirmed the day before. He showed up on the 
appointed day at the appointed time only to be told that the 
mental healthcare provider that he was there to see no longer 
worked at the VA and had not worked there for months.
    And that was obviously deeply disappointing, but what was 
unforgivable to me was that he was then told to go back home, 
call back tomorrow to schedule another appointment. Luckily I 
was there. We were able to take him up to the third floor to 
the executive suite. And we waited for the Director to come out 
of a meeting and were able to obtain an appointment for him the 
next day.
    So that brings me to my question. You have ten mental 
healthcare vacancies still in El Paso despite all of the good 
work. And to Dr. Ruiz's question about getting these providers 
in historically under-served areas like El Paso which had the 
worst wait times for existing patients in the entire country, 
fourth worst for new patients for mental healthcare, what are 
we doing to attract and retain those providers?
    You mentioned earlier that you are increasing what we are 
paying. We talked about GMEs. Tell me a little bit more about 
how we are going to close the gap on mental healthcare.
    Dr. Tuchschmidt. So I think we have all of the recruitment, 
retention efforts that we have underway for both physicians and 
for nurses. With respect to physicians, we have worked to get 
expert healthcare consultants, recruiters to help us bring in 
physicians.
    I think that the story that you tell of a patient who gets 
there for an appointment and doesn't have a provider is just 
unacceptable. I mean, whether there is a vacancy and somebody 
left or not, there should be contingency planning at every one 
of our facilities. We have been communicating that. And it just 
should not happen.
    Mr. O'Rourke. So I would love by the numbers to understand 
what you are doing, how much more you are paying to attract 
somebody to a clinic like El Paso. And I have learned that when 
you recruit a psychologist or a psychiatrist to a clinic 
instead of a hospital, they are earning less and they are being 
offered less.
    And so do we need to harmonize those levels so that you are 
getting folks to the right place, but----
    Dr. Tuchschmidt. I don't----
    Mr. O'Rourke. And I am sorry to interrupt, but it brings up 
the more important issue, I think, of accountability. And were 
the anecdote I just described to have happened a year ago, it 
would still be unforgivable. But to have happened after all the 
scrutiny and attention and focus that we have brought to this 
issue, how are those people still there who are running the El 
Paso VA?
    And so, you know, to the chairman's point and so many 
others who have made this, I 100 percent accept Secretary 
Gibson's explanation and fully believe that you are doing the 
right thing to ensure that once disciplinary action is taken, 
it is sustained and is not overruled and we don't reintroduce 
these bad actors into the system.
    But having said that, when can we expect to see these 
changes? I mean, it is straining credibility for us and the 
American public to know that these folks responsible for such 
egregious malfeasance and negligence are still in their jobs. 
When are we likely to, within this calendar year, within the 
next six months, to see the firings that we have been 
expecting?
    Mr. Gibson. I will come back to you within 24 hours to 
answer your question definitively. I am aware of certain 
actions, but I don't know exactly where we are in that process. 
And so rather than give you a speculative answer, I would 
rather give you a definitive answer.
    I would tell you the question in my mind remains in this 
particular instance whether there is malfeasance or misconduct 
or whether we have got a situation where it is a really, really 
tough situation and we are not bringing to bear the resources 
that we need to be able to bring to bear, but I will be back to 
you within 24 hours with a definitive answer to your question.
    Mr. O'Rourke. Thank you. And then I will share that with 
the committee.
    Thank you, Mr. Chair.
    The Chairman. Thank you.
    Mr. Huelskamp, you are recognized.
    Dr. Huelskamp. Thank you, Mr. Chairman.
    If I might follow-up on the information request from my 
colleague from Texas, he did say earlier that I guess not a 
single VA employee had been suspended without pay.
    Is that an accurate statement that you made earlier?
    Mr. Gibson. Well, suspension without pay is a disciplinary 
action, so I can't tell you. I have not suspended anyone 
without pay.
    Dr. Huelskamp. I misunderstood you. I thought----
    Mr. Gibson. It is a disciplinary action. So in order to 
take the disciplinary action, we----
    Dr. Huelskamp. No. I understand that. I understood you to 
say earlier that not a single VA employee had been suspended 
without pay. Was that--did I misunderstand that statement 
earlier from you?
    Mr. Gibson. No. That is exactly what I said.
    Dr. Huelskamp. Okay. Okay.
    Mr. Gibson. And I said it in the context of the question 
about suspending in the process of a disciplinary action being 
brought.
    Dr. Huelskamp. Okay. I would also like----
    Mr. Gibson. I couldn't tell you of the 5,600 actions that 
we referred to earlier whether or not any of those----
    Dr. Huelskamp. Have any VA employees----
    Mr. Gibson [continuing]. Involved suspension without pay or 
not.
    Dr. Huelskamp [continuing]. Lost their bonuses?
    Mr. Gibson. Pardon me?
    Dr. Huelskamp. Have any VA employees lost their bonuses as 
a result of these scandals?
    Mr. Gibson. Well, in fact, no VA senior executive in VHA 
will receive a bonus in 2014.
    Dr. Huelskamp. Prospectively has any lost their bonus?
    Mr. Gibson. There was----
    Dr. Huelskamp. Mr. Gibson----
    Mr. Gibson. I think we have had this conversation before in 
here. There was one instance of one employee where a bonus was 
paid in error and we were able to, I am going to use civilian 
language, claw that back. But now that action itself has been 
appealed under statute. Otherwise, once a bonus has been paid, 
it becomes the employee's property and we don't have the 
authority to take that property.
    Dr. Huelskamp. Has any VA employee been fired? Have you 
gone through the entire process of removing an employee yet?
    Mr. Gibson. Yes.
    Dr. Huelskamp. Okay. If you would provide a list. Obviously 
we won't know the names, but a list of how many of those have 
actually lost their jobs as a result of this.
    I want to follow-up with some questions on the VA Choice 
and how that was implemented. Why exactly did you decide to 
implement that in phases?
    Mr. Gibson. The fundamental concern was that if we send out 
nine million cards to veterans on the 5th of November, 
realizing that approximately 8.3 million of those veterans 
would not have an immediate benefit under the act, what we 
would do would be to create chaos and jam the phone lines with 
people calling to get explanations----
    Dr. Huelskamp. Nobody has immediate access?
    Mr. Gibson [continuing]. That would prevent veterans that 
do have access to care.
    Dr. Huelskamp. I understand that. But the folks that were 
waiting for months, you have chosen to wait even longer. Why 
are those that were waiting, that was the focus of so much 
scrutiny, why have you decided you have got to wait longer than 
those that were in this 40-mile radius?
    Mr. Gibson. Many of those people that have been waiting, we 
have been working those in the ordinary course of business as 
part of what accelerating access to care has been about for the 
last five and a half months, since the middle of May, if I am 
counting the number of months correctly.
    Dr. Huelskamp. What I am not clear on is what is the start 
date? When you say, okay, the clock has now started, does that 
continue to move back because you have yet to start that phase?
    Mr. Gibson. The start date for the group in the 40-mile 
section is----
    Dr. Huelskamp. No, the wait time.
    Mr. Gibson [continuing]. The 5th of November. Those in the 
wait time, what has been posted in regulation is the 5th of 
December. Our expectation is the start date is going to be 
sooner than that. And we will post that start date within the 
next several days.
    Dr. Huelskamp. So if you don't get the cards out or you 
don't officially start then, that phase just waits and waits 
and waits until you actually pick a start date?
    Mr. Gibson. That group waits until we post in regulation to 
say we are now activating the 30-day wait time standard under 
the Choice Program. It does not necessarily wait for them to 
receive their card because as I mentioned earlier, we are 
populating the Veterans Choice----
    Dr. Huelskamp. Well, I am not worried about when they 
receive the card so much as when they get the care.
    Mr. Gibson. Correct, yes.
    Dr. Huelskamp. And I don't remember anything in the law 
that said that you get to pick when the 30-day start time or 
30-day wait time actually becomes the start date for that 
second phase. If you could provide that to me, I would 
appreciate it.
    Mr. Gibson. We could have rolled this program out in such a 
way that it would have been a disaster for veterans and we 
chose not to do that.
    Dr. Huelskamp. Well, if you are still waiting for care, I 
would say, Mr. Gibson, it is still a disaster for that veteran.
    One of the other items I would like to note as well, and 
this has been a failure from various folks in the department, 
just a local issue, but I think it raises broader concerns in 
Liberal, Kansas which has a very limited VA facility, not full 
services. You promised again and again to have a full-time 
doctor there, promised and never delivered. That is happening 
again and again.
    Now you are still telling them just because they have 
limited services that if they want any services, they still 
have to drive the six-hour round trip to Amarillo to get those 
services when we have got a great hospital just down the street 
less than a mile away. And you say, no, you can't receive it 
there because of limited services that are available at the VA 
clinic there.
    Is there a reason you have chosen to say a VA clinic is a 
restriction? If you had that one in your community, all of a 
sudden, you can't go to your local hospital and pick your 
doctor. But could you describe how you come to that reasoning 
because there are veterans in Liberal who would like to go to 
the doctor and you don't even have a full-time clinic there, 
don't have a full-time doctor? You are saying too bad, you 
still have to drive six hours for care.
    Mr. Gibson. The language in the statute was very clear, to 
the nearest VA medical facility. I would ask the question back 
to you.
    Dr. Huelskamp. That is the current law, Mr. Gibson.
    Mr. Gibson. What was Congress's intent? And if Congress's 
intent was to make it 40 miles from where----
    Dr. Huelskamp. Well, it wasn't Congress's intent to wait 
until December to take care of the wait times.
    Mr. Gibson. And we don't intend to wait.
    Dr. Huelskamp. And under the current law before this one 
passed, you had plenty of options for non-VA care. You could 
have let them go, before August 6th, you could have let them go 
to the Liberal Hospital. Your VA chose not to do that. Don't 
you have that authority?
    Mr. Gibson. We had a budget in fiscal year 2014 for non-VA 
care of about $6 billion and we spent it.
    Dr. Huelskamp. So you do have that authority to allow them 
to go to the local hospital?
    Mr. Gibson. Within the constraints of our budget, we do 
have that authority where we deem that it is clinically 
necessary to do so.
    Dr. Huelskamp. Okay. Well, driving six hours. Mr. Gibson, 
you don't drive six hours for care. Veterans in Liberal, Kansas 
do today and we have got to fix that.
    I yield back, Mr. Chairman.
    The Chairman. Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman.
    And, Deputy Secretary Gibson, thank you and gentlemen for 
being here.
    And you are here and I think it is important for you to 
hear each of our stories. We have heard this and both the bad 
and the good that come out of it because we know our role is to 
improve upon what is working and to make those changes.
    I, like my colleagues, Mr. O'Rourke, Dr. Roe, had a 
gentleman was waiting, excessive wait time, 75 days, continued 
to feel bad, feel bad. Finally, one day, he couldn't take it 
anymore. Drove to the Mayo Clinic where he was told he needed 
immediate prostate cancer surgery.
    That is the bad obviously that he waited excessive wait 
time. The good is is that we called and within six hours, we 
had the fee for service agreement. And the next day he was in 
for his surgery. Two weeks ago, I was with he and his family 
and Steve is now in the recovery.
    The family is incredibly grateful, but I am embarrassed 
that they are grateful to me because that veteran should have 
been able to do that on their own. And I think as long as these 
stories go, and I think we all know here, that is one veteran 
whose wife called with no other where to go, called the 
congressional office and got some action.
    But I do think we should note the responsiveness and the 
cultural attitude on the fee for service, and it is a 
challenge.
    I think, Dr. Tuchschmidt, you were very right, the private 
sector capacity. Mayo Clinic said it is not that he might not 
have waited for us in that initial appointment. It is just that 
there has to be a way to triage these cases that are so 
critical. And they convinced me that there are ways to do that, 
to make sure that if it wasn't so pressing, we could have put 
them in there.
    My question to you is, and I think this is a conversation 
that should be done, and this committee is doing the exact work 
it should be doing, asking how we implement that, and 
Congress's intent is an important part of this. What I am 
curious about is the implementation of this law, and this is 
one small piece, where is that intersection with the 
restructuring of VA that we know needs to be done? Is it 
helping? Is it promoting? It was meant to be a catalyst in that 
direction, but I don't think anyone on this committee thought 
that this was the end. It was the first step.
    So maybe if you could just articulate a little bit to me 
how it fits into the broader restructuring and how it enables 
us to get to that.
    Mr. Gibson. I think it gets at the very essence of 
creating--or focusing on the veteran experience, and focusing 
everything we do around the veteran. So what the Choice Program 
does is, is it basically allows us to accelerate care using 
additional resources in the community, thanks to the funding 
that Congress provided, to be able to accelerate care while we 
are doing the internal capacity building the, you know, points 
that have been brought up about primary care protocols, and the 
number of treatment rooms, and compensation issues associated 
with physicians, and streamlining hiring practices while we are 
engaged in all of that activity, the Choice Program gives us 
the time to be able to do that while we are still delivering 
the care that veterans deserve.
    So I see that as a central part of what we are doing, I 
think it's also clear that it drives us toward the more 
holistic view of VA. We have been providing substantial amounts 
of non VA care, and I think this pushes us harder to ensure 
that we are maintaining continuity of care for veterans, and 
ensuring that veterans we are managing that care--this is 
beyond what a health plan does--that we are managing the care 
and delivering the kind of healthcare outcomes that veterans 
need.
    Mr. Walz. We need to figure out a way--and I say all of us, 
and this includes the VSOs and how you are communicating with 
them because this is truly the real challenge because the 
ultimate cost of this, and to be very clear, Steve and Matt 
Kerry got--and he believes it too, he could have got equal care 
that he got at the Mayo Clinic for the treatment of that had he 
been able to get in.
    Now, the question I have is, is that I don't think your 
budget would allow just for all the things if it has to go the 
way that this one was solved. And how are we figuring out how 
to communicate that triage then, and Mr. Huelskamp's issue is 
exactly right and it's the same with mine, in this case Steve 
lived hours away from the nearest facility too, and it wasn't 
that he wasn't willing to go, it's just that in a crisis 
situation the Mayo Clinic was next door. How are we trying to 
come to grips with that, an honest dialog on both capacity? 
Because I see it, and we heard about this--I thought that was a 
great hearing we had where a gentleman said he looks out his 
window and he sees four private sector hospitals, and he knows 
that they are 72 percent capacity every day, he saw that as 28 
percent capacity that could be utilized in another way. Are we 
getting at that?
    Dr. Tuchschmidt. Yes. So I think this is a really important 
point, and, you know, what I would say is that we have 
traditionally been a provider of care and we make a decision 
when we can't provide it in a timely way to go out and buy it 
for somebody. What the Choice Program has done--and we are 
having discussions right now, quite frankly, that are, for many 
people, very anxiety producing--that in our future is not about 
being a provider organization only. We are now entering a realm 
where we, quite frankly, are running a health plan.
    Mr. Walz. Yeah.
    Dr. Tuchschmidt. Where the veteran, the patient decides 
what happens to them, and where they go, and how they get care, 
and what care they get. And this is a huge cultural shake up, 
quite frankly, for us as an organization. And I think that we 
are now engaging in discussions about what does that mean for 
our future? What does that mean for our traditional purchase 
care program?
    So the Choice Program, if the legislation expires in three 
years and goes away, will have bought us time to build our 
capacity. But it's proposing, quite frankly, much more 
significant care.
    Mr. Walz. I couldn't agree more. As I yield back my time, 
my suggestion was is on the vision of the defense, quadrennial 
defense review, and that that's what we need there, and that so 
I--this is a small piece, but I yield back, but thank you for 
that.
    Mr. Bilirakis [presiding]. Thank you. Mr. Wenstrup, you are 
recognized for five minutes.
    Dr. Wenstrup. Thank you, Mr. Chairman, thank you all for 
being here today. When we are talking about the Veterans Choice 
Program, where can I get information specifically for providers 
that are private sector providers that want to be providers for 
VA, whether it's a hospital system? Because I've had that 
question come to me in my district where a hospital system 
would like to help with the backlog, even if it's a short term 
event. And also they would be willing to do it at a lower rate 
than the standard rates for the procedures and things that they 
could engage in.
    Dr. Tuchschmidt. So, again, the 800 number that we have, 
there's a line there for both veterans but also for providers 
who want information. We have been talking with the American 
Hospital Association, with the AMA, I have a meeting coming up 
with American Hospital Association specifically to try and help 
use those two entities to get information out to providers, but 
any provider that wants to I am sure can contact TRICARE or 
Health Net directly. And I am happy to have them contact me, 
and I will serve as a functionary to make sure something 
happens.
    Dr. Wenstrup. Yeah. If there's something that you could get 
to me to provide some details, I will share it with those----
    Dr. Tuchschmidt. I would be happy to do that.
    Dr. Wenstrup [continuing]. That come to me in that realm. 
And then the other question I have is as we are trying to do 
the independent assessment. How much information is being 
gathered, or how much are we engaging with the private sector 
to really assess the VA system?
    Dr. Tuchschmidt. So I think the, as I mentioned earlier, 
the KNH entity, so MIDR is working with other partners in the 
community, so they are very committed to finding people with 
the right competencies to do those various assessments. There 
are some of them that they will do, so their expertise, quite 
frankly, is in kind of policy and modeling, but they will have 
already reached out to RAND Corporation to do some of this 
work, the Institute for Medicine is doing part of the work, and 
as I said there will be--they have put together a group of 
healthcare industry executives from around the country to 
really be a private sector benchmark panel to help guide not 
only the assessment --so they put together a set of tools that 
can be used in terms of when people are doing these assessments 
making recommendations, how do we know what is good and what is 
bad coming out of this, and that group is helping to vet that. 
And then will ultimately be the group of people that help craft 
the final set of recommendations that come out of this process.
    Dr. Wenstrup. That's great, I think that's important. 
Obviously, we have a lot of successful providers and systems in 
place in the private sector, and so their input is key. Thank 
you very much, I yield back.
    Mr. Bilirakis [presiding]. Thank you. Ms. Brownley, you are 
recognized for five minutes.
    Ms. Brownley. Thank you, Mr. Chairman. And thank you, Mr. 
Secretary, for the work that you are doing, and I know that my 
veterans at home are starting to feel hopeful that there's real 
change taking place, and I appreciate all of your efforts.
    I wanted to ask a specific question on how is the VA 
implementing Section 401, and 402, and 403, and educating 
service members about eligibility to seek VA care for military 
sexual assault?
    Dr. Tuchschmidt. So we have already reached out and started 
reaching out to guard units to educate them about the services 
that are available through--for military sexual trauma 
counseling within our organization. We have both outpatient 
programs and we have inpatient programs around the country.
    We are currently--the part we struggle with most is really 
around the issues with active duty service members. So we 
clearly believe it was the intent of Congress that by providing 
this service available through the VA it would be a safety 
valve for service members who have military sexual trauma to be 
able to come to the VA anonymously to be able to get that care.
    We have been in conversations with DoD about how that might 
work. They have concerns that the care would be anonymous, and 
that they would not have information that might reflect on the 
fitness for duty of active duty service members. And it's 
really hard to try and figure how when a patient might need to 
go to an in patient unit for a couple weeks of intensive 
therapy that they leave their active duty station and nobody 
kind of knows about that.
    So we are trying to work through those issues with the 
Department of Defense now, with a clear intention of being able 
to implement that part of the law in a timely way.
    Ms. Brownley. So when you say you have reached out, does 
that include training?
    Dr. Tuchschmidt. Well, right now what we are--the training 
for?
    Ms. Brownley. The training for all of the folks that need 
to know and how to present, you know, this right to be able to 
receive treatment.
    Dr. Tuchschmidt. For guard members we have begun that work, 
right? That was the easiest part of this----
    Ms. Brownley. Okay.
    Dr. Tuchschmidt [continuing]. To put in place. The harder 
part of this is for the active duty people.
    Ms. Brownley. So on the DoD side then, do you have a 
solution that you are trying work through with DoD?
    Dr. Tuchschmidt. We are in constant ongoing meetings with 
them to try and work through these issues, and try and figure 
out how this will actually work. We routinely exchange medical 
record information. In fact, that when we would go to bill, for 
example, TRICARE for an episode of care, we would submit 
medical record documentation. We don't believe that's what you 
intended, and so that's why we are in conversations with them 
to try and figure this out. I don't think we have locked 
everything down that we need to at this point.
    Ms. Brownley. Thank you. And another question is regarding 
your process for implementing our long-term space plan, and 
wanting to know the steps the VA is taking to ensure that there 
are periodic updates, you know, based on new data on terms of 
what real wait times are, and the increased demand on services, 
and wanting to know, you know, the status, how that's going, 
and do we--should we expect--are we going to receive a new 
updated plan during the next fiscal year?
    Dr. Tuchschmidt. Yeah, I would anticipate that there would 
be a new plan. We are doing something, I think, for the--I have 
been in the system for 20 something years and it will be the 
first time we do this--so we are essentially adopting the PPBE 
model used by DoD and other places in federal government.
    So for the first time this year we will be going out, with 
a lot of planning data, to every facility and asking them to 
begin developing requirements from the bottom up for their 
program. People, space, things that they need to be able to be 
effective and to close performance gaps.
    I think that we have our enrollee health projection model, 
which is a great actuarial tool to tell us how many people we 
are going to take care of, what kinds of services they need, 
what that is likely to cost, but then we have to get to the 
next step of saying, okay, to effect that, what are the 
requirements necessary to do that, and what is that going to 
take in each place in which we deliver care. People, things, 
and space to be able to be effective.
    And we are about--we have been piloting the tools and the 
process, we have been working, actually, with people from the 
department in the department VA Office of Policy and Planning 
to do this work. And I think it's going to really fundamentally 
change the planning process for us in terms of trying to get to 
the requirements that you are talking about.
    Ms. Brownley. Thank you, Mr. Chairman, I yield back.
    Mr. Bilirakis [presiding] Thank you. Ms. Walorski, you are 
recognized for five minutes.
    Ms. Walorski. Thank you, Mr. Chairman, and gentlemen, thank 
you for coming today and providing answers to our questions. I 
wanted to just take a second and publicly individually reach 
out, thank VA Secretary McDonald who told us, when we met him, 
that if he could be of service that he would individually reach 
out, and he reached out in an emergency in my district and the 
Second District in Indiana with a young couple, Erin and Eric 
Olson, he had been mis-diagnosed at a C block in my district, 
and his health was degenerating at a rapid rate, no diagnosis 
whatsoever.
    And I called the Secretary, they moved in our behalf and on 
behalf of this family, and he too was diagnosed with cancer, 
and they moved and facilitated him to IU Research Medical 
Center in Indiana which is very close to the VA hospital. He 
since has been diagnosed, he is under treatment right now, and 
he is beginning to improve, and there's light at the end of the 
tunnel. I appreciate his commitment to honor that.
    And to echo what Representative Walz just said, and some of 
my other colleagues, it just kind of adds--that kind of a 
scenario is good and bad. We are grateful when that happens 
because we just saved a life of a veteran, but we can't make 
calls on behalf of, in my district, 57,000 veterans and their 
families, and it just kind of, to me, just sheds light on the 
fact that to all of us, and I think to our districts in 
America, this is still a very, very urgent matter, this is 
still a five alarm fire, and I think America is willing to give 
a little bit of time to say we understand the comprehensiveness 
of this but I think they are going to want to see action at 
probably the same rapid rate that we do. So I just wanted to 
pass that along.
    But just a clarifying question. For those senior executives 
that retired during that five day interim period, that new five 
day period, in lieu of possible removal they leave, is there 
anything on the record to say that they were slated for removal 
so there's some kind of a trail that says these folks possibly 
left because of that, they were at least on that list?
    Mr. Gibson. Whether an employee resigns or retires, the 
proposed removal action winds up becoming a permanent part of 
their file. So any other federal agency will, if they were 
considering hiring this particular individual, would see that 
as part of the file.
    Ms. Walorski. And my other question, which again is a 
follow-up from many hearings we have had before, is this issue 
of the VA and IT, and I have a bill coming up in a couple of 
weeks that we are going to have a hearing on, but the new law 
required a technology task force to conduct a review to look at 
that VA scheduling system. The Northern Virginia Technology 
Council conducted visits at VA medical centers in Richmond and 
Hampton to observe the scheduling operations and interview the 
staff. Do you consider the results of that--what they obtained 
at those medical centers to be representative of the entire 
system?
    Mr. Gibson. I think as we have gone through the findings in 
the NVTC report, I would say that it affirmed an awful lot of 
what we believe we knew already. It also reiterated a fair 
amount of information that was part of the Booz Allen Hamilton 
report that was done back in 2008. I think it was useful and 
very helpful. It's an independent point of validation in many 
instances, you know, the point that came up that Dr. Roe 
mentioned earlier about the need for treatment rooms, that was 
one of the things that showed up in the NVTC report. Didn't 
have anything to do with the scheduling system, basically they 
were looking and saying, one of your obstacles to providing 
access to care is you got medical facilities here that only 
have one treatment room per provider. We are never going to 
make optimal use of our providers when we have got that kind of 
constraint operating.
    Ms. Walorski. Can I just follow up real quickly before you 
answer? So that 2008 report, it's six years later now, have all 
the issues been addressed in that 2008 report as far as 
inconsistences and recommendations?
    Mr. Gibson. You mean from the 2008----
    Ms. Walorski. The 2008 report. If it paralleled----
    Mr. Gibson. No. No.
    Ms. Walorski. So why haven't they, if it's been six years?
    Mr. Gibson. Well, that--you may or may not recall that was 
a report where there was a--questions were asked back in May 
with other individuals sitting here about the report, and by-
and-large the comment was folks were not even aware of the 
existence of the report. I had not been--I had only been here 
for three or four months, but that report got issued and 
basically it went in somebody's desk drawer.
    Ms. Walorski. Right. But as you recall in some of the 
hearings that have gone on only in the last two years since I 
have been here, there were a lot of the information given to 
this committee that there was no problem whatsoever with the 
scheduling system with the VA, nobody ever said it was a 1985 
system, the gentleman in charge of your IT system sat right 
there and when I said, do you have everything you need, 
resources and money, and we are good to go, the answer was an 
overwhelming yes, even during the budget time. So here we are 
now 2014, the Booz Hamilton report was out there in 2008, 
there's a mandate in this new law, where are we with the 
scheduling system and this whole idea of mandatory compliance 
now?
    Mr. Gibson. Yeah, the Booz Hamilton report went far 
beyond----
    Ms. Walorski. Right.
    Mr. Gibson [continuing]. The scheduling system, as did the 
NVTC report.
    Ms. Walorski. Right. But where are we specifically on the 
scheduling system?
    Mr. Gibson. Specifically on the scheduling system, four 
different tracks--I will call it three different tracks of work 
that are underway right now. A whole series of patches to the 
existing system, we are on the tail end of that, probably 
within the next couple of months we will have completed all 
those patches. We have led a contract for major enhancements to 
the existing scheduling system. Those are supposed to start 
coming online in the spring of 2015, so a near term solution.
    Those also include creating the ability for us to field 
some apps that have been created that will actually allow 
veterans to request appointments, and one of the other apps 
actually allow veterans to directly schedule an appointment, 
but we have got to have the ability to catch it when the 
veteran sends it. And then in parallel, and we think we are 
literally a matter of days away from a contracting action for 
the acquisition of a commercial, off the shelf, state of the 
art scheduling system.
    Now that system, in all likelihood, won't be up and running 
until sometime in '17 which is why we are doing these other 
things in the meantime. I should indicate though, and it's 
reaffirmed in the NVTC report, the schedulers that they talked 
to in field said the scheduling system isn't the impediment, 
it's the lack of appointment slots. They basically came back 
and said, well, schedulers say it's okay. We know it needs to 
be replaced----
    Ms. Walorski. Right.
    Mr. Gibson [continuing]. We know it doesn't provide the 
functionality that we need to have, and so we are pressing on 
to get that done. But that's not the obstacle from the 
schedulers' perspective.
    Ms. Walorski. Thank you. I yield back, Mr. Chairman. Thank 
you.
    Mr. Bilirakis [presiding]. Thank you. Ms. Titus, you are 
recognized for five minutes.
    Ms. Titus. Thank you. And thank you all for what you have 
been doing to try to fix these problems and implement this 
bill. I would like to go back to the issue of the shortage of 
doctors in the private sector because this is very serious in 
Nevada and in Las Vegas. We are at the bottom, like 50th or 
45th or something, for all different types of specialists. So I 
would like to go back to that issue.
    Several of us worked very hard to get the provision in the 
bill to create the new residencies. And I heard you say that 
you are given, I think, 300 a year and you have already got 400 
applicants. I want to be really reassured that those 
residencies are going to go to places where there's the need, I 
don't want them to just to go UCLA because its already got a 
great program, or Johns Hopkins, or--go where the need is.
    The second part of that is where there is a need is also 
where they may not be able to support residencies at this time, 
so it's kind of a double hit. That's true in Las Vegas, we are 
getting a new medical school, Terro is growing, we have got the 
new hospital, but we are not going to be able to apply this 
year, hopefully next year. Can you explain kind of how you are 
going to distribute those, and how--I have got a working group 
right now that's meeting to be sure we will be eligible for 
some of them, what you might recommend to that group that you 
look at for some of the qualifications?
    Dr. Tuchschmidt. Sure. So we can get you--I can get you 
specifically information about kind of what the requirements 
are so that you personally have that information. But, you 
know, I think that the intent of the law as we interpret it is 
that those slots are to go to meet underserved areas and needs, 
and not go to UCLA necessarily. Not that there's anything wrong 
with UCLA.
    Ms. Titus. No, right, right.
    Dr. Tuchschmidt. So I think the intention is there. There 
are, you know, many community hospitals that establish family 
practice residencies and other residency programs that are not 
medical schools. We do not own residency slots, they are owned 
by an academic partner, so those slots are--they set up a 
program and get approval through the ACGME for those positions. 
We fund them essentially, and in return, those residents rotate 
through our institutions, and we provide some of the training.
    I think the challenge clearly is for a place that has not 
had a residency program to be able to recruit and retain 
faculty, to be able to teach, to be able to meet all the 
accreditation standards that ACGME has for those programs, and 
it certainly takes a critical mass of residents to be able to 
meet all the work hour restrictions and everything else that 
they have, and maintain a viable program.
    But I can certainly make sure that you get information that 
you can pass along. And I think the best thing that you all can 
do, actually, is encourage hospitals or other institutions in 
your districts that are interested in that to contact our 
Office of Academic Affiliations to get information.
    Ms. Titus. Maybe I can get somebody from the office to come 
meet with that group in Las Vegas----
    Dr. Tuchschmidt. I would be happy to----
    Ms. Titus [continuing]. To provide that.
    Dr. Tuchschmidt [continuing]. Make that arrangement for 
you.
    Ms. Titus. That would be great. And then kind of related to 
that, you also mentioned that you are worried about these kind 
of middle man organizations like TriWest being able to find 
enough people in the private sector to be part of this program.
    I remember asking the Director of that, who was sitting 
right where you are, if wasn't this going to be a problem, and 
his exact words were, ``oh, no, we are going to just ask 
doctors to step up, they will just step up to help veterans.'' 
Well, if they are not there they can't step up, and I think 
that was a little optimistic anyway. Can you tell me what you 
are doing to monitor those groups to be sure that they are 
providing the services?
    Dr. Tuchschmidt. So we monitor today the referrals that we 
make to TriWest and Health Net through PC3, our PC3 contract. 
And we know how quickly they can place patients, we know how 
quickly--or how often those authorizations are returned because 
they can't find a provider.
    The good thing about, I think, the Choice Program, I mean, 
so we set up PC3 really to be our preferred provider network, 
and TriWest and Health Net established contracts with those 
providers.
    Under the Choice Program, you have provided, I think, a 
really good tool in terms of the provider agreement authority 
that we have, which allows--so the veteran will be able to 
choose any willing provider that meets certain criteria, they 
have to be Medicare provider, federally qualified health 
center, et cetera, et cetera. But once that's done, TriWest or 
Health Net will be able to reach out and get an agreement with 
that person for the Choice Program, even if the provider 
doesn't necessarily want to be part of the PC3 network.
    Ms. Titus. Okay.
    Dr. Tuchschmidt. I think the one issue that we have that 
really does need to be addressed expeditiously is the fee 
structure in Alaska. The Medicare rates will not buy much care, 
not many willing providers in Alaska that are interested there. 
I know that you all are aware of that and your attention to 
that in a timely way would be really helpful.
    Ms. Titus. Thank you. Just really quickly, Mr. Gibson, as 
you were talking about expanding, and improving, and changing 
the VA, kind of as Mr. Walz was suggesting, this is just the 
beginning, not the end. I hope you will look at those maps, all 
those different maps that divide the country up into different 
regions. In Nevada, we are split into three parts for VHA, and 
then at the same time we are in with California for VBA, they 
just don't make sense. Will you look at that?
    Mr. Gibson. We don't think they make sense either.
    Ms. Titus. Okay, good. Thank you.
    Mr. Bilirakis [presiding]. Thank you. Dr. Benishek, you are 
recognized for five minutes.
    Dr. Benishek. Thank you, Mr. Chairman. Thanks, gentlemen, 
for being here this morning. I think the Mr. O'Rourke incident 
where this veteran was told to go home and call back for an 
appointment, I mean, just the fact that that would happen to 
somebody, it really emphasizes to me the need for change in the 
culture. I mean, that an employee would think that was the 
satisfactory thing to do to somebody who had been waiting that 
period of time. And I know that you all realize, you know, that 
you got a lot work to do in order to change that culture.
    And I want to talk about a couple specifics. You know, I 
used to do colonoscopies at the VA, and I have been hearing 
that there's still a backlog of colonoscopies within the VA. 
How many veterans have been waiting 12 months or longer for a 
screening colonoscopy? Dr. Tuchschmidt, do you have any idea?
    Dr. Tuchschmidt. I don't have that number, but I can get 
you that number.
    Dr. Benishek. Yeah. I wish you would. And, you know, the 
associated number of cancers that are discovered, you know, to 
me, you know, the cohort of veterans that we have fits the age 
group for colon cancer, and I know that in my own 
circumstances, you know, we found more advanced cancers than 
should have been found because of the delay. Is there anything 
in particular that you are doing to address these backlog 
issues?
    Dr. Tuchschmidt. Well, I think there's two things. So the 
first thing I would say is that under the Choice Program that 
you all generously gave us, veterans will be able to go out for 
that care today.
    Dr. Benishek. Are they being told that?
    Dr. Tuchschmidt. Yeah. So under the--we are--if you are in 
the 40 mile group, you have already gotten your card and been 
informed of that benefit. We have polled the list of patients 
who are waiting for appointments or a procedure.
    Dr. Benishek. Well, I'm kind of concerned about this 40 
mile thing, too. You know, like for example, in my district 
with most patients are within 40 miles of a VA facility, but 
there may not be any doctors there, there may not be any 
facilities to do a colonoscopy, and that type of thing. And I 
am concerned that we are not going to get--they are not going 
to get their care yet because they are technically within the 
40 miles but there's no provider there. Are those people going 
to get the care they need in a timely fashion?
    Dr. Tuchschmidt. So if we can't provide that care within 30 
days of a clinically appropriate date or the veterans preferred 
date, they will go to the Choice Program. We will offer them 
that option. So we are polling people today who are waiting 
more than 30 days, electronically, and we will be providing 
that list----
    Dr. Benishek. All right. Well, that's what I wanted to 
hear, but let me ask you another thing. You know, when I was 
doing colonoscopies at the VA, they were doing three a day, and 
then when I came we started doing ten a day, you know, with the 
same amount of staff and everything. That kind of stuff is 
still happening within the VA. So what is being done to make 
sure that the performance numbers that, you know, in order to 
address these backlogs that people are doing things efficiently 
and effectively enough, and have the tools to do that so we are 
not having these backlogs. What's been happening there that's 
different than what's been happening in the past?
    Dr. Tuchschmidt. Right. So we have put a number of practice 
management tools in place so that we are training and educating 
supervisors on how to manage some of these kinds of issues. We 
have our----
    Dr. Benishek. Who is in charge of that? Is that you?
    Dr. Tuchschmidt. No, it's our----
    Dr. Benishek. Is this happening differently in each 
different VISN, or is there somebody central in the VA----
    Dr. Tuchschmidt. So there's a national program----
    Mr. Benishek [continuing]. That's kind of been acting on 
this?
    Dr. Tuchschmidt [continuing]. National program in the 
ADUSHOM's office under Philip Matkovsky to be able to develop 
the training materials and to roll out this program. 
Additionally that we have our productivity tool, I can tell you 
in GI in the last half of the year, the productivity amongst 
gastroenterologists increased in the double digits. So I 
think----
    Mr. Benishek. Like ten percent you are saying, at least?
    Dr. Tuchschmidt. It was about 15 or 16 percent.
    Mr. Benishek. Well, you see that's the type of thing that I 
run across talking to physicians within the VA, is that there 
seems to be a lot of inertia into getting change done that will 
affect the efficiency within the VA, and I----
    Mr. Gibson. Let me just touch on that for a moment. We have 
been talking about accelerating care across the department. 
Every morning--we didn't happen to meet this morning--every 
morning at 9:00 a.m. there's something called the Access Care 
Stand Up. Senior leaders from VHA and from all across the 
department are in our integrated operations center and we are 
going through hard data about steps that are being taken to 
accelerate access to care, all across the entire organization. 
Report outs on wait times, and appointments, and the like. Once 
or twice a week we have the senior leaders from the particular 
medical centers joined by VTC, and they deliver us a specific 
report on the things that they are doing to deliver--to 
accelerate access to care.
    I was in Birmingham Monday and Tuesday of this week, and 
over the last couple of months they have gone in looking at 
their appointment blocks and they have created an additional 
900 slots across 14 different clinics, all of this using some 
of the productivity tools that Dr. Tuchschmidt is talking about 
to be able to manage to these requirements.
    This is a fundamental change for VA, managing to 
requirements, as opposed to simply managing to the budget, and, 
you know, if somebody gets seen they get seen.
    Dr. Tuchschmidt. We can poll calls in some of our data but, 
you know, if you look at our completed appointment data today, 
98 percent of our appointments are completed within 30 days.
    Mr. Benishek. I wish I could trust you with all those 
numbers, but.
    Dr. Tuchschmidt. I know.
    Mr. Benishek. I would like those numbers for the 
colonoscopies.
    Dr. Tuchschmidt. I will get you those.
    Mr. Benishek. Thank you.
    Mr. Bilirakis [presiding]. Thank you. Mr. Takano, you are 
recognized for five minutes.
    Mr. Takano. Thank you, Mr. Chairman. Dr. Tuchschmidt, you 
may be aware that one of my top priorities as a member of the 
conference committee that produced the Veterans Access Choice 
Accountability Act was the inclusion of graduate medical 
education residency slots, and I was very pleased to see that 
1,500 additional slots were included.
    I also represent Riverside County as does Dr. Ruiz, and I 
share the same issue that Ms. Titus has in Nevada. Just be 
clear, the process you followed for this first year of 
allocating the 300 slots, you have reached out exclusively to 
those medical schools that have preexisting academic 
affiliations with the VA medical facility; is that correct?
    Dr. Tuchschmidt. I am not sure that we only reached out to 
facilities that we already have affiliations with. I think we 
put a general announcement out so that other partners, I mean, 
we were out looking for--we are interested in having partners 
that are not currently affiliated with us.
    Mr. Takano. So those slots--so you are interested in going 
beyond those medical schools that already have existing 
relationships with the VA?
    Dr. Tuchschmidt. Yes. Now, some of those medical schools 
may, like the WWAMI program in the Northwestern part of the 
United States, may, in fact, be supported by, like the 
University of Washington, but they run many rural residency 
programs. But we are definitely looking for new affiliates.
    Mr. Takano. Are you interested in thinking outside the box, 
maybe funding residencies that may address ambulatory care that 
may not be centered at a hospital?
    Dr. Tuchschmidt. The answer is yes. So as I said, we know 
that there are many community hospitals that, for example, that 
will run family practice residency programs, so we definitely 
are interested in those kinds of partnerships.
    Mr. Takano. I am very glad to hear that. Will the VA 
Central Office determine both the number of slots going to a 
VISN as a whole, and the number going to each medical facility 
or medical school? In other words, will you be delegating this 
decision to the VISN in terms of----
    Dr. Tuchschmidt. No.
    Mr. Takano [continuing]. Or will you be making direct 
decisions about----
    Dr. Tuchschmidt. The Office of Academic Affiliations awards 
specific slots to qualified applications.
    Mr. Takano. Well, I, like Ms. Titus, would be interested in 
having folks from the VA come out. We have a new medical 
school, the newest of the university medical school's 
established, we are certainly--and we have, as Dr. Ruiz 
mentioned, the ninth largest veterans population by county in 
the country, we certainly would appreciate an ability to locate 
some of these slots at a public university, medical school, 
that is subsidized by the taxpayers that ostensibly would offer 
probably a less expensive education, further inducement for 
those medical students to maybe locate at the VA.
    Dr. Tuchschmidt. I would be happy to have that done.
    Mr. Takano. And as you know, just a question, and I'd hate 
to be doing Mr. O'Rourke's representation, but the shortage of 
psychiatrists within his district, is there no medical facility 
in his district now that currently trains the VA doctors?
    Dr. Tuchschmidt. That I can't answer, but I can tell you 
that, you know, there's a shortage of mental health 
practitioners both psychiatrists and mental healths, you know, 
advance practice nurses and social workers in the country in 
general. We went through an enormous hiring process a few years 
ago, hiring about 3,000 mental health practitioners into the VA 
organization.
    I live in Oregon and I can tell you that I know that we 
recruited most of the mental health practitioners, oftentimes 
out of some of those counties. We have actually, about a year 
ago, took the kind of caps off of hiring of psychiatrists in 
terms of salary so that we could make much more flexible hiring 
decisions, competitive decisions, with psychiatrists.
    Mr. Takano. Well, as you know, this whole GME issue is very 
salient here because there's a 60 percent chance, greater 
chance, that a physician is going to locate where they do their 
residency. So, hence, it's really important that we don't 
privileged the preexisting agreements of the medical schools 
with the VA hospitals that we look to alternatives so that we 
can get physicians to locate in communities where there are 
indeed shortages. Unless GME how we use--how we deploy these 
GME slots is going to be very, very important.
    Dr. Tuchschmidt. Really important point.
    Mr. Takano. Well, thank you so much. I yield back.
    Mr. Bilirakis [presiding]. Thank you. Mr. Jolly, you are 
recognized for five minutes.
    Mr. Jolly. Thank you, Mr. Chairman. And thank you all for 
being here today. Thank you. And, Secretary Gibson, I want to 
say thank you personally for the spirit with which you have 
tried to bring change and I know Secretary McDonald has as 
well. I have a question more on the VBA side, in fact, entirely 
on the VBA side, so I apologize to come at you from left field.
    We have all had the stories of VHA wait list and the human 
consequences of those. I can tell you, at least in our 
district, the sheer number of concerns are on the VBA side, and 
the wait times on VBA. Not really a specific question but just 
kind of a question about changing culture since you arrived, 
and Secretary McDonald, with all the focus on the VHA, my 
concern is there's this pending--it's just going to take a 
media story or two and all of a sudden we are going to be 
talking about VBA a few months from now. What is being done on 
the VBA side, or is there a plan for future action?
    Mr. Gibson. Sure. We continue to be very much on track for 
eliminating the backlog, that is disability claims more than 
125 days since submission, by the end of fiscal year `15. I am 
still--I remain confident that that's going to happen.
    And we continue to refine processes, centralized mail, the 
imaging processes, and some of the automated decisioning tools 
that we are being able to bring to bear to expedite that, the 
growth, and fully developed claims. Almost 40 percent of our 
incoming claim volume is fully developed claim, and that's 
really not being felt yet fully in terms of our productivity 
because we continue to work older claims before we work newer 
claims. So I think that's all augurs very positively on the 
disability claim side.
    I would tell you where I am concerned is in non-rating 
claims, things like dependency claims and the like, fiduciary 
administration, administering fiduciary relationships on behalf 
of veterans, and claims that are in the appeal process, not 
necessarily that have been sent to the board formally but that 
are still in VBA because that's where the majority of the 
claims sit.
    You know, we have got a laundry list of initiatives--
automation initiatives, staffing initiatives, and the like--
that we are executing within the context of the resources that 
we have got. But you may or may not recall when I came in on 
the 24th of July and said we need $17.6 billion, there was 
actually $360 million in there for VBA, for us to be able to 
hire staff, for non-rating claims, appeals, and fiduciary work.
    Mr. Jolly. So still a personnel and resources----
    Mr. Gibson. It is still a personnel and resource intensive 
issue for us.
    Mr. Jolly. Is there any room to begin to look at how we 
assign presumptions in certain cases based on an MOS or where 
somebody was deployed? I know there is some use of that right 
now but, for instance, I think we talked in here before the 
number one benefit application being hearing loss, and can we 
increase the presumptions based on an MOS perhaps as a way of 
expediting some----
    Mr. Gibson. That's a good question. I don't know the extent 
to which that specific idea has been aired out, and we will 
take a look at it and come back to you.
    Mr. Jolly. And the last one I would bring to your attention 
and I know it's resources so I'm not expecting an answer today. 
The sheer number now has gotten to the point where even the 
Congressional backlog, and the regional offices are being very 
honest and working very well with us, but they are happy to 
share with us that--listen now, I don't know if this number is 
exactly right, but I think about 1,700 Congressionals in our 
region and so I understand how the staff balance all those 
Congressionals, but then we have--it's changing the model of 
casework a little bit in Congressional offices because 
constituents are coming back saying, what really is the benefit 
now of coming to a member of Congress, where historically they 
had seen a benefit. And we are able to work closely with the 
regional office and improve the timeliness, and also in some 
very specific cases certainly be of help together with the VA.
    I would just bring that to your attention as well as the 
department continues to look at the VBA side. Again, the more 
human stories are on the VHA side, but the sheer number of 
calls out of frustration are really on the VBA side.
    Mr. Gibson. I understand. Thanks for raising the 
Congressional issue because I really hadn't heard that 
anywhere.
    Mr. Jolly. Sure. Well, and understand the climate, right. 
So right now given some of the new stories, folks go to their 
member of Congress, and rightfully so, that's our job to fight 
for them, and that's just increasing the volume that then we 
are bringing to the regional office and asking for assistance.
    Mr. Gibson. I will do a deeper dive.
    Mr. Jolly. Thank you very much. Thank you. Thank you.
    Mr. Gibson. Yes, sir.
    Mr. Bilirakis [presiding]. Ms. Brown, you are recognized 
for five minutes.
    Ms. Brown. of Florida. Thank you. And thank you, Mr. 
Secretary, and thank you for staying on, and it's been a real 
joy working with you. And also with the secretary when he 
visited Florida--we went to the medical school together, and he 
talked to those residents and they were just very interested in 
the program, and I think you all going out talking to the 
medical schools is very--they were very engaged, and very 
interested in participating.
    I just want to clear up a few things since it's been a lot 
of discussion about what constitutional rights that the VA 
employee have as relates to their jobs. And I understand that 
the United States Supreme Court has ruled that you have to have 
these posts, and posts action process for appeal or else they 
can throw the whole cases out. Can you elaborate on that a 
little bit?
    Mr. Gibson. Ma'am, I am not--I don't know that I am 
familiar with the Supreme Court decision there, but I do 
believe that Congress' ultimate decision to provide an appeal 
mechanism and the authority that was passed, I think, reflected 
the body of case law that existed, and the conclusion that you 
would need to do that in order to withstand judicial scrutiny.
    Ms. Brown of Florida. I know you cut down, I think it used 
to be longer, but now it's five days, but that process has to 
be there in order for it to be legal.
    Mr. Gibson. The case law is very clear about providing a 
federal employee an opportunity to respond to charges. And so 
that really happened--today's under Title V, it's 30 days, as I 
mentioned earlier, trying to adhere to the spirit of Congress' 
intent, we shortened that to the minimum amount that we thought 
we could and still meet the requirement to provide a reasonable 
opportunity to respond. And then, that then is not really an 
appeal, that is just an opportunity to respond, a final 
decision is made, and then the appeal process happens after 
that.
    Ms. Brown of Florida. Afterwards.
    Mr. Gibson. Very expeditiously in line with provisions of 
the law.
    Ms. Brown of Florida. One of the concerns when we the 
process at the Gainesville hospital, some attention was brought 
to it because of the scheduling process, they hadn't been 
trained or they didn't have the equipment, so they were doing 
part of it on paper, and we corrected that issue.
    Mr. Gibson. That absolutely has been corrected, yes, ma'am.
    Ms. Brown of Florida. One other thing. I think it's very 
important that we have a comprehensive program. When you think 
about the mental health, which we are all interested in, and 
making sure we have the adequate providers, but it's not just 
the mental health, it's also the housing issue. It's 
comprehensive. What are we doing to work with our stakeholders 
to make sure we have the partners we need to address some of 
the homelessness or some of the other problems that we 
experience in the system?
    Mr. Gibson. That's a great question. I oftentimes point to 
the work going on in veteran homelessness as what I would 
characterize as really best in class collaboration across the 
federal government, up and down government through federal 
government, states, and local government, and then across into 
the nonprofit sector and the private sector.
    When you get inside of the work that is going on on veteran 
homelessness, it's really remarkable that the way that 
government has come together with the private sector, true 
partnership kind of collaborative effort, and I think that's 
the reason we are making the traction, that we are getting the 
traction that we are in reducing veteran homelessness. Still 
not as fast as we want to reduce it, so we've got more work to 
do. But we are making progress there.
    Ms. Brown of Florida. And those stakeholders, what are we 
talking about? Companies like CSX and others that--they are 
coming to the table, and I want to thank you all for bringing 
them to the table.
    Mr. Gibson. Yes, ma'am.
    Ms. Brown of Florida. Because that is making a difference 
in how we address the needs of the veterans. We all 
participated in the November the 11th celebration, but the 
point is we have got to work together with our stakeholders.
    Mr. Gibson. Yes, ma'am, you are absolutely right. I think 
my perspective, there are three areas where we have to rely on 
that kind of broad collaborative engagement, veteran 
homelessness is certainly one of those, mental health is one of 
those, and then I was at the U.S. Chamber of Commerce last 
night career transition. Those are really the three where 
looking for these kind of public private partnerships are 
absolutely essential if we are going to meet the needs of our 
veterans.
    Ms. Brown of Florida. Once again, thank you for staying on, 
thank you for your service. I mean, I think it's a misnomer to 
let the veterans think that we are in a crisis mode. I mean, I 
appreciate the leadership and the fact is they should be 
confident that we are going to work together as a team to make 
sure we address their issues.
    Mr. Gibson. Yes, ma'am, thank you.
    Ms. Brown of Florida. Thank you.
    Mr. Gibson. Secretary Bob said I can't leave, so I don't 
think I am going anywhere.
    Ms. Brown of Florida. Thank you, and I yield back the 
balance of my time.
    Mr. Bilirakis [presiding]. Thank you. Representative 
Lamalfa, you are recognized for five minutes.
    Mr. Lamalfa. Thank you, Mr. Chairman and committee members, 
for allowing me to sit in on this hearing here, and Mr. 
Secretary and your colleagues for being here today, you have a 
hard job. I know the frustration and anger directed sometimes 
for new people on the block, you know, there's a context there, 
but hang in there. You're trying, I think, so.
    When you look at the map of America, especially the red and 
blue one, you see that much of America, most of it is very 
rural, not in population, but in its geography, and so we have 
many veterans that live in those rural areas. And so a big part 
of the Choice Act was to give some of them the opportunity to 
have a better opportunity to get to care they need that's 
proximate to them. Take northern California for example.
    Now when we see that Ms. Kirkpatrick was talking about post 
office, for example. We see that in the Redding area they are 
threatening to close a mail processing center. All mail in 
northern California that's in land will go to Sacramento to an 
area that's probably the size of Illinois. So we know the mail 
is going to slow down, that's just one factor.
    We see that the facilities veterans need for specialty care 
are generally going to be in Sacramento or the bay area, if 
they are going to go to a VA facility. Now we have great 
facilities in Chico, California, and Redding, California, that 
can do much of these same things.
    So let's say you live in Tulelake, California, an area 
which the federal government incentivized World War II vets to 
settle after the war, and you are a long ways from anywhere up 
there as far as that. So if maybe Yreka is nearby, what has my 
understanding one doctor in a broom closet there. Or maybe you 
have to go to Medford, or maybe you have to go to Reno, all 
those are least an hour and a half away with the geographical, 
weather, other challenges for that veteran to go to. And when 
they get there, do they even have the facilities they need to 
do specialty care such as chemo or the more difficult things to 
administer.
    So what we are looking at is that we are hearing that the 
interpretation by the VA is that Congress didn't write this 
wide enough or narrow enough, whatever it is, to define that 
the veterans have more choices. And so we are frustrated 
because this is the intent. Certainly wasn't the intent of the 
Committee here or the House for veterans to--that are within 40 
miles of a facility but there's no specialty care there that 
somehow like--have an example, and we will take Yreka, 
California, haters of VA facility here. And so that means you 
are within now the VA web, but you don't have any chance of 
getting what you need, you have to go to another VA one since 
you are within, as the crow flies, 40 miles.
    Now you are in that category of having to stay in VA. You 
have to go all the way to the bay area which is a five hour 
drive for probably at the speed of which a veteran in their 80s 
may drive, or if they can get the shuttle bus at 4 a.m.
    So you see where we are going here is that the 
interpretation of what we are looking for is that I always 
think the tie should go to the veteran. They have served 
honorably, and that they are still being put through these 
hoops. I know there is still more time you need to get this 
opened up and get the cards out, but what can you tell me 
today--and going backwards just a little bit under the old law 
into the new law--how often did the VA use that authority 
really to previously allow that veteran to go to that private 
service that is nearby?
    Mr. Gibson. Sure. A couple of comments, and then Dr. 
Tuchschmidt may have a thought or two to add.
    First of all, as I mentioned a couple of times in my 
opening statement, at every turn when we were interpreting 
actions under the law, we were looking to do the right thing 
for veterans, and be the best stewards we could be of taxpayer 
resources.
    So, we haven't seen the final numbers on fiscal year '14 
appointments completed in the community, but I am going to 
guess somewhere in the neighborhood of 18 million. Eighteen 
million appointments completed in the community, not in VA, 
that were referred out of VA into the community during fiscal 
year '14.
    Mr. Lamalfa. Pardon me. And you said you were limited by $6 
billion----
    Mr. Gibson. Correct.
    Mr. Lamalfa [continuing]. In budget to do that? Is that 
what you are----
    Mr. Gibson. Correct.
    Mr. Lamalfa [continuing]. Saying the real limitation is?
    Mr. Gibson. Correct, yes. And so first of all, we are 
already referring an awful lot of veterans, including rural 
veterans for care in their community.
    Secondly, as we look at the Act, and if we look and try to 
understand the intent of Congress, and then we go talk with the 
Congressional Budget Office to learn how it was scored, clearly 
the legislation was scored based on 40 miles geodesic distant 
from the nearest VA medical center.
    Mr. Lamalfa. As the crow flies, right?
    Mr. Gibson. As the crow flies, that's right.
    Mr. Lamalfa. We don't have a lot of crows that do--anyway.
    Mr. Gibson. So one of things that we did is we were looking 
at this trying to make the right decision here, so we say okay, 
how can we evaluate the--is there some way that we could afford 
to open the aperture here and interpret this differently? And 
so we took, for example--and I will get Jim to help me with the 
numbers, if he recalls them--so we took, for example, and says 
okay, how many veterans have we got that live 40 miles from a 
level two medical facility? Still not a level one, still don't 
do everything at a medical center, at a level two medical 
center, but we do a lot of things, lot of specialty care. And 
it was somewhere on the order----
    Mr. Lamalfa. Would chemo be one of those? Because we have a 
veteran that has to--that can go 15 miles--and then we are 
getting way into time here--but 15 miles instead will be 
required to go 85 for 15 minutes, five days a week. So does 
level two include chemo? Because that's the kind of thing we 
are looking----
    Mr. Gibson. Level two I would expect would include 
chemotherapy. And he will correct me if I say something wrong.
    Mr. Lamalfa. Okay. We are really going to have to come back 
and talk----
    Mr. Gibson. Because what happens when you do that is you 
then open up about a fourth of your veteran population for 
eligibility for that care. Round numbers, we are talking 
somewhere in the $30 billion range----
    Mr. Lamalfa. Okay.
    Mr. Gibson [continuing]. Be able to fee all that care out 
to the community.
    Mr. Lamalfa. I am going to have to stop here because of 
time again. But I would like to confer with you on that because 
our--a stat we got is that 438 veterans in northern--the north 
half of California, the stat would be--is that they would be 
the ones to be able to use this card in this context here, 
which is not going to do anything for the backlog, so I would 
like to clarify that with you at a later date.
    And also just a moment on due process. We are talking about 
due process for employees that you can hardly touch, we have 
had a veteran where they came to his door, two agents, seized 
his DD-214, and they have cut off his benefits, he and his wife 
are in their 80s, they need this, and this document is 
somewhere now without a receipt, and also they have not had 
their day in court. Meanwhile, their benefits are cut off. If 
they have been accused of something, they have a right to at 
least have that day soon because their benefits are gone.
    Mr. Gibson. Please provide me the veteran's name.
    Mr. Lamalfa. Okay. This and--well, anyway. Thank you, I 
appreciate the indulgence, committee.
    Mr. Gibson. Thank you.
    Mr. Bilirakis [presiding]. Member yields back, correct?
    [No response.]
    Mr. Bilirakis [presiding]. Okay. Yeah, Representative 
Murphy, thank you for your patience, you are recognized for 
five minutes.
    Mr. Murphy of Pennsylvania. Thank you, Mr. Chairman, and as 
a former member of this committee, I appreciate the opportunity 
to come back and ask some questions as a followup to the 
Pittsburgh nightmare which goes on.
    The Pittsburgh VA Hospital had a problem with Legionnaires' 
disease where several people died and several were sickened by 
it. Part of the problem that occurred is the VISN Director 
received a bonus of some $60,000 and we raised questions about 
that, even though it was being investigated at that time, they 
still went ahead and gave this--and the award was for infection 
control, of all things.
    Other things have come up with this too. As of today we 
learned that the former head of the hospital has just been let 
go permanently, but there's another problem that occurs and 
that is the deputy secretary--excuse me--the deputy Director of 
the hospital, David Cord, was involved in a chain of emails 
which we found that--where decisions were made to withhold 
information from the media while Legionnaires' disease was 
discovered, and while Legionella was found in the water system.
    A time when it would have been critically important to 
notify the public, if you have these symptoms and you have been 
to the VA, tell us. Instead they intentionally withheld 
information.
    We also found emails where they disparaged Senator Bob 
Casey of Pennsylvania and myself as if somehow asking questions 
was wrong as opposed to asking themselves what did they do 
wrong.
    Now we find out that David Cord has been promoted to head 
of the Erie VA. I think that is indefensible and 
incomprehensible, and it sends a terrible message to the 
employees of the VA system that, you know what, if you hide 
information, and even though people die, you are going to get 
promoted. Even Terry Wolf, the former Director who just got 
fired, she told Cord, don't withhold this information.
    And let me tell you an incident that I was involved person 
to phone. Mr. Cord called me, along with the Director Wolf was 
on the phone too, but he told me, he says, ``We just want you 
to know there's no waiting list at the Pittsburgh VA.'' And I 
said, ``Well, first of all, coming from you I am not sure I 
believe it because you guys distorted and withheld information 
before. But secondly, why are you calling me out of the blue to 
tell me this? Somehow I don't trust this information. You mean 
you have no waiting list on''--and I began to name every 
possible medical specialty I could think of, oncology, 
dermatology, everything. ``No, no waiting list, no waiting 
list, we get to everybody withing 30 days, oh, podiatry is a 
little bit longer.'' I said ``Something still doesn't smell 
right here, but okay.''
    Forty minutes later I got call from Congressman Mike Doyle, 
represents city of Pittsburgh and the Pittsburgh VA, and he 
said, ``Did you hear about this waiting list?'' ``What waiting 
list?'' ``Well, they had 700 names on the list that went back 
two years for people for the near list, and I guess they didn't 
call that a waiting list because they weren't really waiting 
for an appointment because they didn't have an appointment 
yet.'' And I said, ``What do you call that time between when 
they first call to say I need service from the VA, and the time 
you get back to them? I call that waiting.''
    Mr. Gibson. I call that a waiting list too.
    Mr. Murphy of Pennsylvania. Exactly. Now you just promoted 
him. Disparaging comments he made about a senator and me as if 
we are doing something wrong by investigating. People died in 
this process, he is involved in a chain of people withholding 
information from the public, and now this as well where he 
directly misled me on information. I want you to look into 
that, because if you are trying to change the morale of the VA 
and hold people accountable, again, it is incomprehensible to 
me that a man like this is told he is promoted.
    The comments I have heard from employees in the VA is, what 
are we supposed to do? Whistle blowers get fired. Whistle 
blowers get demoted. We get disparaged and here is someone 
who--I will be a witness if you want to testify in this--who 
has been lied to. I hope you will look into this, it's an 
important issue.
    Mr. Gibson. I will look into the allegations that you raise 
about the wait list conversation. I am, obviously, not aware of 
that. I would also tell you, very early on--if I am not 
mistaken I believe it was shortly after I became the acting 
secretary--I went back on Pittsburgh, and asked folks to go 
back and look at all of the investigative material.
    There were, as you might expect, thousands and thousands of 
pages of material, IG review, criminal review, FBI, and the 
like. Because the question I was asking was, were there 
instances where there was misconduct or management negligence 
where accountability action should have been taken that had not 
been taken. And what I was able to determine was that in every 
instance where there was some culpability identified, there had 
been some action taken.
    Now, I would tell you I might not have agreed, and in all 
likelihood, would not have agreed with the nature of those 
actions, but I had no leeway to go back and address those 
because those actions had been closed out completely. I had no 
new evidence to use to be able to pursue those particular 
instances, except in one instance, and that's the one instance 
that you referred to just a moment ago.
    Mr. Murphy of Pennsylvania. Well, I hope you will continue 
to review these things. I sent a letter a year ago asking to 
give us some information on what were some of the other 
instances and problems that people had, and what disciplinary 
action was going to take place, and we have yet to hear back on 
those. It's been a year and I would love to have that 
information. There's other things I look for----
    Mr. Gibson. We will go back and look at the response to 
that, because I am not aware that we have had any congressional 
responses that are outstanding for the period of time.
    Mr. Murphy of Pennsylvania. Thank you. The Chairman has 
been gracious enough to let me ask some questions, there's 
several other things I would like to discuss with you and the 
new secretary to make some recommendations. I am a Lieutenant 
Commander in the Navy and I do my drill time at Walter Reed 
Bethesda Hospital, and I know we still have problems with the 
continuity between DoD and VA, and that sometimes people are 
kept in the military beyond retirement, or beyond the date of 
separation just to try and continue to get them care because 
they feel if they get into the VA system they will be lost and 
won't get the same qualitative care.
    We shouldn't have a system like that, we should have one 
with a smooth, easy handoff where people are confident about 
the care they will get, and I would love to talk to you about 
some more ideas with that. With that, Mr. Chairman, I thank 
you, and I yield back.
    Mr. Bilirakis [Presiding]. Thank you. If there are no 
further questions, anyone--yes? You are recognized.
    Ms. Brown of Florida. Yes. I just want to make one comment 
as to what he just said about DoD and the VA. We have worked a 
long time to get that continuity between the VA and DoD, and I 
don't know necessarily it's necessarily the VA's resistance, 
but we in Congress keep pushing for it because it needs to be 
seamless, that transfer, that is one of the problems.
    For a long time, you know, the veterans couldn't get the 
service because we couldn't get the files because it burned up 
in St. Louis place, somewhere. So, I mean, it's not necessarily 
just the VA's problem with the system. Can you respond to that?
    Mr. Gibson. I think that's a fair statement. I would tell 
you over the past several years it's clear that there's been a 
vast amount of progress made, but I would also tell you that 
there's still a gap, and too many servicemen and women fall 
through that gap, and that we are committed to do everything we 
can, working collaboratively with the Department of Defense to 
close the gap.
    Ms. Brown of Florida. Thank you, and I yield back my time.
    Mr. Bilirakis [presiding]. Thank you. The ranking member 
has no further comments, the panel is now excused. Thank you 
very much, Mr. Secretary, for your testimony.
    Mr. Gibson. Thank you, Mr. Chairman.
    Mr. Bilirakis [presiding]. I ask unanimous consent that all 
members have five legislative days to revise and extend their 
remarks, and include extraneous material.
    Without objection, so ordered.
    Once again, I thank all of our witnesses and audience 
members for joining in today's conversation. This hearing is 
now adjourned. Thank you.
    [Whereupon, at 12:35 p.m., the committee was adjourned.]

                                APPENDIX

              Prepared Statement of Jeff Miller, Chairman

    Good morning and thank you all for joining us for today's Full 
Committee oversight hearing.
    As everyone sitting around this dais today is well aware, on August 
7, 2014, the President signed into law the Veteran Access, Choice, and 
Accountability Act of 2014 (Public Law 113-146).
    This law was thoughtfully and carefully crafted after months of 
aggressive oversight by this Committee to address the unprecedented 
access and accountability scandal that engulfed the Department of 
Veterans Affairs (VA) following allegations--first uncovered in this 
very hearing room--that some VA medical facility leaders were keeping 
secret waiting lists in an effort to manipulate wait time data and 
ensure their own executive bonuses.
    We are here today to evaluate the progress VA has made to implement 
it in accordance with both statutorily required deadlines and 
Congressional intent.
    This includes the effective and timely implementation of the 
Veteran Choice Program, designed to provide relief to veterans who 
reside forty miles from a VA facility or who cannot get a timely 
appointment.
    It includes the required independent assessment of VA's healthcare 
system which, in my opinion, should necessarily inform decisions about 
staffing and infrastructure that are to be made under the law.
    Finally, and most importantly, it includes accountability, on which 
I will focus my remaining remarks.
    Section 707 of the law which authorizes the Secretary to fire or 
demote Senior Executive Service (S-E-S) employees for misconduct or 
poor performance.
    It should go without saying that veterans deserve the very best 
leadership that our government has to offer.
    Yet, the events of the last year have proven that far too many 
senior VA leaders have lied, manipulated data, or simply failed to do 
the job for which they were hired.
    It is also clear that VA's attempt to instill accountability for 
these leaders has been both nearly non-existent and rife with self-
inflicted roadblocks to real reform.
    When I originally drafted this provision, I believed that it would 
provide Secretary McDonald the tools he said he needed and wanted to 
finally hold failing senior leaders accountable.
    When President Obama signed it into law, he agreed with me by 
saying, ``If you engage in an unethical practice, if you cover up a 
serious problem, you should be fired. Period. It shouldn't be that 
difficult.''
    Based on these comments--as well as similar statements by Secretary 
McDonald himself--I am both perplexed and disappointed at the pace at 
which employees have, in fact, been held accountable.
    Even more worrisome is what Secretary McDonald said on November 6th 
that, and I quote, ``The new power I was granted is the appeal time for 
a senior executive service employee of the VA has been reduced in half. 
That's the only change in the law. So the law didn't grant any kind of 
new power that would suddenly give me the ability to walk into a room 
and simply fire people.''
    It is clear that the Secretary, and those advising him, remain 
confused on what the law actually does, which is much more than simply 
shorten the appeals process.
    No, the Secretary can't simply walk into a room and fire an S-E-S 
employee without evidence warranting that action, but the law does give 
him the authority to remove that employee for poor performance or 
misconduct.
    The Secretary has also cited a plethora of numbers that he says 
illustrate the Department's commitment to holding individuals 
accountable.
    For example, he has said there's one list of a thousand names of 
employees being removed, and another list of five-thousand six hundred 
names of employees being removed, and yet another list of forty-two 
names of senior executives VA is proposing disciplinary actions on.
    So let me take a moment to set the record straight.
    Based on a briefing VA provided to Committee staff yesterday, VA 
only has one year of aggregated data on disciplinary actions taken 
against any of its over 330,000 employees, making meaningful 
comparisons against previous years impossible.
    Further, the list of over 5,000 mentioned by the Secretary is 
proposed disciplinary actions only and the list of over 1,000 is a list 
of proposed removals for any type of poor performance.
    Only the list of 42--provided at my request on a weekly basis--
includes employees proposed for discipline due to the crisis which has 
engulfed VA this year.
    What's more, since August 7th, only one S-E-S employee has been 
removed under the new law and this person's removal was not directly 
related to patient wait times or data manipulation.
    I do not understand, in the wake of the biggest scandal in VA's 
history, how only 42 employees--only four of which appear to be senior 
executives--have been proposed for discipline with none yet removed.
    Further, VA has taken the liberty of creating an additional 
bureaucratic office--the Office of Accountability Review--to review 
proposed removals and an additional bureaucratic delay--a five-day 
advance notice of removal--which essentially operates like a new 
internal appeal process.
    These questionable actions are nowhere to be found in the law we 
wrote and the President signed.
    In my view, the five-day advance notice of removal only serves to 
incentivize poor-performing senior leaders to drag out the disciplinary 
process while continuing to collect a hefty paycheck before ultimately 
retiring with full benefits.
    Further, it perpetuates the perception that VA cares more about 
protecting bad employees than protecting our nation's veterans.
    We should not be providing credit towards a taxpayer-funded pension 
for a time period during which an employee's actions caused harm to 
veterans.
    That is why I will soon be introducing a bill that would give the 
Secretary the authority to reduce an S-E-S employee's pension to 
reflect the years of service during which they participated in actions 
that made them subject to removal.
    This proposal is a fair and equitable way to emphasize to poor-
performing senior employees that retirement credit is not earned by 
failing veterans and that their actions have long-lasting and 
meaningful consequences.
    I won't get into individual personnel actions at this time since 
there are serious legal issues at hand that must be dealt with 
respectfully and appropriately.
    However, I want to make it very clear today that I continue to have 
very serious concerns about accountability at the Department of 
Veterans Affairs.
    Again, in response to what is without a doubt the biggest scandal 
that has ever impacted VA, I am not seeing the corresponding efforts to 
hold those at fault accountable for their actions.
    Secretary Gibson, as we discussed yesterday on the phone, I have an 
increasing worry that Secretary McDonald and you are getting bad advice 
from some of those around you within VA's bureaucracy.
    I hope that is not the case.
    This is the same issue that I believe doomed Secretary Shinseki's 
tenure and I hope you take my suggestion seriously when I tell you that 
VA's entrenched bureaucracy must be shaken up in order for any true 
reform--reform that is so desperately needed to better serve our 
veterans--to succeed.
    I thank you all once again for being here this morning.

                                 

        Prepared Statement of Ranking Member Michael H. Michaud

    Thank you, Mr. Chairman.
    We are here today to get an update from the Department of Veterans' 
Affairs on implementation of the Veterans Access, Choice, and 
Accountability Act of 2014.
    This law, passed back in August, addressed a number of serious 
issues the Department had with providing timely, quality healthcare to 
veterans. Long wait times are the problem that got us here. We 
shouldn't make veterans wait for the solution to be implemented.
    While today is the first public update on VA's implementation of 
this law, staff-level updates have been occurring on a regular basis 
since early September.
    Dr. Tuchschmidt and Mr. Giddens, I appreciate the time you have 
invested in openly communicating with staff from the House and Senate 
Veterans Affairs Committees on implementation issues and progress.
    This is a marked change in VA--Congressional relations, and I hope 
it is a precedent for improved working relations going forward.
    The law provided additional resources and authorities to provide 
four key improvements for veterans--timely access to healthcare, 
expansion of VA's internal capacity for care, improved accountability, 
and additional education benefits.
    Today, I hope I hear tangible ways veterans are getting the 
improved outcomes intended. If there are real and reasonable roadblocks 
to implementation, we need to know what they are and how to fix them.
    With regard to timely access to healthcare, I am aware that the 
Department has expressed serious concerns with the 90-day deadlines 
under section 101, the Choice Program.
    The program requires VA to determine eligibility, authorize and 
coordinate care, manage utilization, set up a call center, and 
implement a new payment system.
    VA has taken a phased roll-out approach in order to balance 
expediency with an effective program. This may be reasonable, but I 
want to understand the overall timing, and how the Department of 
Veterans' Affairs is handling eligible veteran's access to care 
throughout the phases. A phased approach to administrative rollout may 
be okay, but a phased approach to access to care is not.
    The law provided $5 billion for the Department to augment staffing 
and infrastructure. I know the Secretary has personally been out 
recruiting. I look forward to hearing how successful that effort has 
been and how many new doctors and nurses VA expects to bring onboard 
and when.
    I am also interested in hearing how VA will implement the funds and 
authorities for new infrastructure. We have seen many problems with the 
Department of Veterans' Affairs construction problems in the past, and 
I look forward to hearing the changes VA is making to the process in 
order to deliver these new projects on time and within budget.
    With regard to accountability, I understand removing a federal 
employee is not as simple as many think it should be, even with the new 
authorities in the law. I appreciate the difficult position the 
Department is in when it comes to holding employees accountable for 
wrong-doing and poor performance in a highly charged and very public 
environment.
    That being said, we need to feel that the Department of Veterans' 
Affairs is taking the necessary actions to move as swiftly and 
decisively as possible to get rid of those people who failed America's 
veterans. The explanation for delays needs to be clear, concise and 
compelling, not just for Congress, but for veterans and the American 
public.
    While much of the focus of the law has been on the access and 
accountability provisions, we should not forget that the law also 
includes substantial enhancements to the education benefits for 
veterans and their families. I look forward to hearing what is being 
done to implement these provisions as well.
    Beyond the Veterans Access, Choice and Accountability Act of 2014, 
Secretary McDonald has announced a number of reforms aimed at 
addressing the culture and structure of the Department of Veterans' 
Affairs. Many of these reforms reflect ideas we have discussed in the 
past, and I am pleased to see them being embraced and actively pursued.
    I encourage the Secretary to quickly define detailed execution 
plans for these concepts. Do not get stuck in analysis and process--
figure out what actions need to be taken, and then take them. Be 
fearless in facing this reform, just as our nation's veterans are 
fearless in their battles.
    Mr. Gibson, Dr. Tuchschmidt Mr. Giddens, thank you for appearing 
today. We appreciate your time, efforts and look forward to your 
testimony.
    Thank you Mr. Chairman and I yield back the balance of my time.

                                 

                Prepared Statement of Hon. Corrine Brown

    Thank you, Mr. Chairman and Ranking Member, for calling this 
hearing today.
    I am pleased the Deputy Secretary is here today. I enjoyed working 
with you as Acting Secretary and am glad you stayed on at the VA. I 
also appreciate you deciding to keep the Baldwin Park VA Medical Center 
open after the Orlando facility opens. Thank you for your service.
    I was pleased to be on the conference committee that negotiated the 
Veterans Access, Choice, and Accountability Act.
    As the most senior member of the House Veterans' Affairs Committee, 
I strongly believe that the VA provides the best care for our nation's 
servicemembers returning from protecting the freedoms we hold most 
dear, and I am committed to VA continuing their critical mission of 
serving our veterans. VA has served the special needs of returning 
veterans for over 75 years and has expertise in their unique healthcare 
needs, including prosthetics, traumatic brain injury, Post Traumatic 
Stress Disorders (PTSD), and a host of other veterans specific 
injuries. My focus continues to be on ensuring that the VA retains the 
ultimate responsibility for the healthcare our veterans receive, 
regardless of the provider.
    The VA operates 1,700 sites of care, and conducts approximately 85 
million appointments each year, which comes to 236,000 healthcare 
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 incumbent upon us to ensure the VA has final authority over 
the care that veterans receive whether at the VA or at non-VA 
providers. We need to continue to work with our veteran stakeholders to 
ensure the VA has all the resources it needs to provide superior 
healthcare to our veterans. This includes providing the necessary 
resources to address the ever increasing population of women veterans.
    I have been on this committee for 22 years. In fact, when I came 
here, Jesse Brown was the Secretary and his motto was ``Putting 
Veterans First.'' I am encouraged by the current Secretary, Bob 
McDonald, and his plan for ``My VA.''
    The VA is the best system we have to serve the healthcare needs of 
the veterans returning from war. We cannot destroy this system. I feel 
very strongly about that and I don't want to be the only one saying 
that. We need to protect the system for the veterans.

                                 

                Prepared Statement of Hon. Sloan Gibson

    Chairman Miller, Ranking Member Michaud, and Distinguished Members 
of the House Committee on Veterans' Affairs, thank you for the 
opportunity to discuss with you the Department of Veterans Affairs' 
(VA) implementation of the Veterans Access, Choice, and Accountability 
Act of 2014 (Public Law 113-146), also known as ``the Act.'' VA's goal 
has been, and always will be, to provide Veterans with timely and high-
quality care with the utmost dignity, respect and excellence. However, 
we as a Department are aware of the challenges we face. We want to turn 
these challenges into opportunities to improve the care and services we 
provide to our Nation's Veterans. That is why our Veterans and VA 
employees nationwide understand the need for reform and are pleased 
Congress passed and President Obama signed into law the Veterans 
Access, Choice, and Accountability Act on August 7, 2014. We are 
committed to providing Veterans with the best possible care-experience, 
while also meeting our obligations to be good stewards of the Nation's 
tax dollars.
    Prior to the law's enactment, VA was already making progress moving 
Veterans off of wait lists and into clinics. From May 15, 2014, through 
the end of fiscal year 2014, the Electronic Wait List went from over 
57,000 appointments to under 24,000, nearly a 60-percent reduction. The 
New Enrollee Appointment Request list went from 64,000 to 2,000, which 
is nearly a 97 percent reduction. The Veterans Health Administration 
completed over 18 million appointments from May 15 through September 
30, 2014, an increase of 1,200,000 over the same period in 2013, and 
made more than 1,089,202 total non-VA care authorizations from May 15 
to September 30, 2014, a growth of 346,393 (47 percent) over the same 
period in 2013. On average, each authorization results in 7 
appointments, thus these non-VA care authorizations have the potential 
to generate 10.8 million appointments. While this is encouraging 
progress, the Department's goal is to provide all Veterans with timely, 
high-quality, clinically appropriate care. Veterans are our customers--
we will use all authorities we have to continue get Veterans off wait 
lists and into clinics.

Overview of the Veterans Access, Choice, and Accountability Act

    VA appreciates the enhanced authorities, funding, and programs now 
available under the Act to ensure Veterans have timely access to safe 
and high-quality healthcare. The Department has been working hard to 
implement this highly complex piece of legislation in a way that 
provides Veterans with the best possible care-experience. This 
legislation appropriated $5 billion to hire physicians and other 
medical staff and improve VA's infrastructure to reduce the shortfall 
in our capacity to meet the healthcare needs of Veterans in a timely 
way. As we have shared with the Committee, the Department is finalizing 
the required plan for spending the $5 billion, but we are also striving 
to ensure that we allocate these incremental resources as good stewards 
for our Nation. We have also come to realize that implementation of 
some of the legislation's requirements will require additional 
resources not covered by the $5 billion. The 27 leases authorized in 
the Act begin the process of implementing our long-term space plan. The 
Act also provided $10 billion to purchase needed care from the 
community while we build that internal capacity.
    The legislation also provided us with great tools that we believe 
will improve our ability to recruit and retain high-quality clinical 
staff. At the same time, the Act also gave VA enhanced authority to 
propose the removal or demotion of senior executive employees based on 
poor performance or misconduct. We know that we cannot tackle our long-
term issues without cultural change and accountability. While the new 
law shortens the time a senior executive, proposed for removal by VA, 
has to appeal VA's decision, it does not do away with the appeal 
process or guarantee VA's decisions will be upheld on appeal. Secretary 
McDonald and I have been clear that when evidence of wrongdoing is 
discovered, we are holding employees accountable and taking action as 
quickly as law and due process allows.
    VA appreciates enactment of the Department of Veterans Affairs 
Expiring Authorities Act of 2014 (Public Law 113-175), which was signed 
into law on September 26, 2014, that amended and fine-tuned key 
provisions of the Act to improve our ability to deliver Veterans the 
best possible care-experience. VA believes, with the help of Congress, 
more work is necessary to further refine the Act and address remaining 
implementation challenges. As VA engages in the appropriate rulemaking 
and implementation processes required by the law, we will continue to 
communicate openly where such challenges exist. We will work to address 
sources of confusion and continue to solicit input from stakeholders. 
We are grateful for the ongoing engagement of members of Congress and 
their staff in the discussions we have held to date. VA will continue 
to work with other Departments, Congress, Veterans Service 
Organizations, and other stakeholders to ensure that our implementation 
of this legislation optimally benefits Veterans in a manner consistent 
with our obligation to be good stewards of taxpayer dollars.

Addressing Challenges within the Veterans Choice Program

    One program required by the Act that is particularly critical to 
Veterans is the Veterans Choice Program authorized by section 101. As 
we have informed the Committee in over 10 telephonic and in-person 
meetings held between Committee staff and VA personnel regarding 
implementation of the Veterans Choice Program, VA has identified a 
number of areas within section 101 that could present implementation 
challenges or result in confusion for Veterans.
    For example, as you are aware, the 90-day timeline to establish a 
new health plan capable of producing and distributing Veterans Choice 
Cards, determining patients' eligibility, authorizing care, 
coordinating care and managing utilization, establishing new provider 
agreements, processing complex claims, and standing up a call center 
has been particularly challenging. In fact, we received overwhelming 
feedback from the marketplace about the significant challenges of 
meeting the law's aggressive timeline. Despite the timeline, VA 
launched the Choice Program on November 5 with a responsible, staged 
implementation focused on delivering the best Veteran experience.
    We remain concerned, however, about the potential fragmentation of 
care and our ability to ensure Veterans receive appropriate preventive 
health and screening. As you are aware, the average enrolled Veteran is 
older, sicker, and poorer than the general population. We have made 
significant investments to ensure that our patients have access to 
mental health services in the Patient Aligned Care Team clinic. 
Community mental health resources are often not readily available, 
particularly in rural areas, and are rarely integrated into a private-
sector primary care-experience. As
    one-third of Veterans receiving VA care have a mental health 
diagnosis, coordinating care and providing timely access to high-
quality mental healthcare is of the highest importance to us.
    Additionally, the success of interoperability depends on the 
integration of records from non-VA providers into the VA's electronic 
medical record and clinician's workflow at the point of care. The 
current state of national health information exchange continues to 
evolve in response to known challenges. In order to ensure sufficient 
continuity of care for Veterans who are treated in both VA and non-VA 
settings, we will continue to work at finding solutions to deliver the 
greatest healthcare outcomes for our Veterans.
    Pursuant to the Act, we successfully re-defined and published a new 
wait-time standard for appointments. The new wait-time standard is 30-
days from either the date that an appointment is deemed clinically 
appropriate by a VA healthcare provider, or if no such clinical 
determination has been made, the date the Veteran prefers to be seen. 
While this standard will help ensure that Veterans receive timely 
access to the benefits of the Choice Program, it is not a clinical 
standard for timely care. As we have long maintained, for the Veteran 
who needs care today, VA's goal will always be to provide timely, 
clinically appropriate access to care in every case possible.

Conclusion

    VA is committed to providing Veterans with the best possible care-
experience by implementing this legislation effectively to deliver 
timely access to high-quality care for Veterans. We are grateful for 
the close working relationship with Congress to ensure that we are 
making forward progress.'' Congress can be assured VA's staged 
implementation of the Act will ensure the Veteran's best possible 
experience.
    To the extent that there are significant challenges, we are working 
to overcome the challenges while meeting the intent and requirements 
set forth in the Act. We will continue to share with the Committee any 
issues to ensure we have a common understanding of the implications of 
the Act.
    Lastly, I thank the Committee again for your support and assistance 
in fine-tuning the Act as we work to implement this vital legislation, 
and we look forward to working with you in making things better for all 
of America's Veterans.
    This concludes my testimony. Dr. Tuchschmidt, Mr. Giddens, and I 
are prepared to answer any questions you or the other Members of the 
Committee may have.

                                 

                             FOR THE RECORD

  Story By Jeremy Schwartz, American-Statesman Staff on Sept. 7, 2014

    On the morning of July 1, 2008, Department of Veterans Affairs 
officials gathered to unveil a state-of-the-art brain scanner they 
predicted would help revolutionize the understanding of traumatic brain 
injury and post-traumatic stress disorder in combat veterans.
    The timing, and location, seemed perfect. One of the first studies 
would scan nearby Fort Hood soldiers before and after they deployed to 
war in Iraq or Afghanistan--a unique opportunity to study physical 
changes in soldiers' brains due to combat.
    Six years later, the $3.6 million machine sits unused in an out-of-
the way corner at the Olin E. Teague Veterans Medical Center in Temple.
    Not a single study based on the machine's scans has been published.
    Not a single veteran has received improved treatment because of 
advances ushered in by the scanner.
    The machine has sat dormant for the past three years, plagued by a 
series of delays caused by mismanagement, mechanical failures and 
bureaucratic roadblocks. Officials at the Waco Center of Excellence for 
Research on Returning War Veterans, which oversees the program, aborted 
the scanner's first and only brain study in 2011 when they declared its 
image quality too poor to use.
    In a grim internal assessment, the center's associate research 
Director, Dena Davidson, wrote in March 2013: ``I think there should be 
serious consideration of returning the MRI from where it came because 
we do not have the expertise to use it or care for it.''
    The scanner idles 24 hours a day because it's more expensive to 
turn an MRI machine off and on than to keep it running. A full-time 
technician diligently performs daily maintenance checks on the unit.
    By early 2014, VA staffers were seeking alternative purposes for 
what was once envisioned as support space for the multimillion-dollar 
scanner.
    One idea: housing for lab rats.
    ``Can I store my 14 rodent housing racks (2,x6,x7,) in there?'' one 
VA employee asked colleagues in a January email. ``This is not a 
joke.''
    It was an inglorious decline for a machine once hailed by VA 
leaders as the most powerful mobile MRI on the planet. The scanner, 
housed in a semi-truck trailer, was supposed to travel between Fort 
Hood, the nation's busiest deployment hub for war-bound soldiers, and 
the VA hospitals in Temple and Waco.
    Internal VA emails, reports and documents detail a program that was 
bungled almost from the start. Yet the story of how one of the agency's 
most powerful diagnostic tools devolved into a ghost machine also 
stands as a stark symbol of the VA's shortcomings in responding to the 
specialized needs of soldiers returning from the longest-running 
conflicts in the country's history.
    ``Everyone involved in this effort felt this was a unique 
opportunity to help our troops, not just at Fort Hood, but throughout 
the country,'' said former U.S. Rep. Chet Edwards, D-Waco, who had 
worked to bring the center and mobile MRI to Waco. ``I had hopes that 
this project would work at a time when troops were still deploying to 
Iraq and Afghanistan. I don't understand why that didn't happen. There 
may be a good reason. I simply do not know.''

VA Research Arm Escapes Public Scrutiny

    In recent months, a burgeoning national scandal over how long 
veterans have to wait for medical care has spurred congressional and 
criminal investigations and toppled the former VA secretary. Lawmakers 
have also probed the agency's disproportionate use of painkillers, high 
rate of veteran suicide and massive backlogs of disability claims.
    The scrutiny, however, has largely ignored the VA's $2 billion-a-
year research arm. A 10 month American-Statesman investigation suggests 
that the VA's research arm, charged with developing the military's 
treatments of the future, also merits close examination.
    The newspaper reviewed more than a thousand pages of documents 
obtained through Freedom of Information Act requests and interviewed 
six former and current employees of the Center of Excellence, which was 
to house the mobile MRI and oversee the research.
    The documents and interviews show that leaders took charge of the 
scanner without a clear plan for success and then were unable to 
recruit enough researchers, as staffing at the center fell to just 15 
employees in January despite initial plans for 75. Later, 
administrators became mired in red tape; internal VA squabbles 
paralyzed the imaging program after workers appeared close to 
restarting research in 2012--delays that launched a cascade of new 
problems. The Waco center lost at least seven federally funded grants 
for what researchers hoped would be groundbreaking brain injury 
research.
    ``They didn't want people to know how much of a failure it was,'' 
said one former Center of Excellence employee, who requested anonymity 
because he feared retaliation from the VA. ``Unless someone says 
something, they will think it's OK to do what they've done and continue 
to do.''
    The program's failures came just as it was needed most. Since 2008, 
more than 150,000 U.S. service members have returned from war with 
diagnoses of PTSD or TBI. Yet research has yielded few significant 
advancements in treatment of the two maladies, experts say.
    For many vets, ``PTSD or TBI are factors in their inability to 
reintegrate--they come back a changed person, they know it, but they 
can't identify why,'' said Steve Hernandez, the McLennan County 
veterans service officer. ``To know we had seven years where we could 
have helped find breakthroughs in understanding, that's 
disheartening.''

Troubled Beginnings

    Waco MRI research project had roots in failed UT program.
    Waco resident Timothy Priddy, who suffered a traumatic brain injury 
when he deployed to Iraq with Fort Hood's 1st Cavalry Division in 2004, 
wonders if the scanner could have led to advances that might have 
helped him get better treatment.
    ``The way they were talking, (the scanner) could see more 
thoroughly into the brain and better detect brain injuries and 
everything,'' Priddy, 35, said. ``(The center's failures) were a slap 
to all veterans that go out there. There's no telling how many Vietnam 
veterans have TBIs.''
    The tumult at the Waco Center of Excellence also caps nearly a 
decade of VA futility in Central Texas when it comes to researching 
brain injuries. Five years ago, the VA shut down research at a similar 
program at the University of Texas in Austin--the Brain Injury and 
Recovery Laboratory, which didn't scan a single veteran before its 
assets were transferred to Waco. Between them, the two imaging programs 
cost taxpayers more than $12 million and squandered almost a decade of 
opportunity.
    Today, VA officials say they are trying to revive the Waco program 
and find a researcher to take charge of the troubled scanner. They have 
hired a new center Director, added employees and hope to eventually 
grow to 50 staffers.
    ``You know, I can do what I can do,'' said the center's new 
Director Michael Russell. ``I'll get it going, and I think there's 
going to be a continuing (operational) tempo of deployments for at 
least some time. It will be smaller numbers, but there will still be 
deployers.''
    The VA did not respond to a request for comment from administrators 
who oversaw the program during the previous six years.

New Understanding of Brain Function

    While the VA is best known for providing healthcare and disability 
benefits to veterans, it also operates one of the nation's largest 
research operations. With unique access to millions of veterans and 
their medical records, the VA in 2014 spent $586 million on research 
and prosthetics and oversaw nearly $2 billion in total research 
funding.
    In 2015, the VA plans to spend about $35 million--or less than 6 
percent of its research budget--on TBI and neurotrauma study 
nationwide. The most advanced research occurs at specialized mental 
illness centers such as the Waco Center of Excellence, which opened at 
a time when increasingly powerful scanning instruments were 
revolutionizing how the medical profession viewed the brain.
    ``For much of the last three to four decades, (research) was 
predicated on the idea that brains can't heal,'' said Jim Misko, a 
former board member of the Brain Injury Association of America. ``But 
in the last 10 years, that's been completely replaced by the data 
driven, informed view that a lot of damage from concussion or TBI isn't 
black and white. It's not a question of healthy vs. dead tissue. Most 
of the damage is in between, in tissue that can be repaired. Now the 
lid is off with people (wanting) to do research.''
    He added, ``If you have access to the best imaging, you're getting 
to see damage where we could never see it before.''
    But few brain injury studies in recent years have scanned soldiers 
before and after deployments. Such a comparison would allow researchers 
to observe changes in individual soldiers' brains as the result of 
exposure to war.
    ``It's a perfect study design,'' said Martha Shenton, Director of 
the Psychiatry Neuroimaging Laboratory at Harvard University and 
scientist at the VA Boston Healthcare System. ``The gold standard is 
the pre-deployed brain.''
    Waco's research plans represented more than just a better 
understanding of PTSD and TBI; they were part of an effort to 
resuscitate the sprawling, 75-year-old Waco VA complex, which officials 
had targeted for closure in 2003. Thanks to local veterans advocates 
and lawmakers, a federal panel recommended in 2005 that the red brick 
buildings in Waco not only be kept open, but expanded. At the 2008 
ceremony, Edwards declared: ``This is like the phoenix rising from the 
ashes.''
    The centerpiece of the rebirth was the Philips Achieva Quasar 
mobile MRI unit. The VA hailed the unit as ``the world's most powerful 
research (mobile) magnetic resonance imaging (MRI) machine.'' It 
featured a magnet twice as strong as nearly every other mobile unit at 
the time, which should have given researchers greater speed and image 
detail.
    ``They were swinging for the fences,'' said Russell. ``There's only 
half a dozen of those ever built. So this was like pushing the limits 
of science, right?''

Trouble From the Beginning

    In 2009, the VA signed an agreement with Fort Hood to study 
soldiers before and after they deployed to war. An early contract 
called for the scanner to make up to 100 trips per year to scan 
veterans and soldiers.
    Yet moving the scanner, giving researchers access to more subjects, 
proved problematic.
    Technical problems surfaced almost immediately. Images suffered 
from ``artifacts'' or lines and spots caused by vibrations and other 
disruptions in the scanner's magnetic field.
    In a statement to the Statesman, Philips said the scanner suffered 
from ``out-of-specification environmental conditions at the site that 
affected system performance,'' but wouldn't elaborate. The OshKosh 
Corp., which manufactured the trailer, didn't respond to a request for 
comment.
    ``You have to recalibrate it, anything in the environment has be 
factored, it has to be shimmed,'' Russell said, adding that it costs 
thousands of dollars each time it is moved. ``So you don't move it that 
often,'' he said.

Gaps in Research

    Waco research center was to play a big role in government brain 
studies on soldiers before and after deployment.
    At the same time, the Center of Excellence was struggling to find a 
Neuroimaging Director and recruiting imaging researchers.
    ``They ventured into MRI research projects without having anyone on 
board who knew what they were doing,'' said another former center 
employee, who asked for anonymity because he feared retaliation for 
speaking out. ``They threw money at it, but didn't have anyone in place 
to get it going. Waco was a tough draw, but a congressman pushed for it 
in Waco, and so that forced the VA to try and bring people there. It's 
hard to build a program from scratch.''
    The employee added that the imaging problems came after the VA 
failed to conduct proper acceptance testing, which is routinely done to 
determine if a new research scanner is working as the manufacturer 
claims.
    ``It's all good intentions,'' Russell said. But ``by the time we 
actually had somebody on board who could do those studies, a period of 
time had already passed. But that's the difference between being a 
startup organization and purchasing something for an existing 
institution.''

Shut it Down

    The scanner's first project was a study seeking to determine the 
genetic and physical root causes of PTSD, conducted by Keith Young, who 
served as Acting Director of the Neuroimaging Program, even though, 
colleagues said, he had little imaging experience. By early 2011, Young 
had scanned more than 200 veterans with the machine, according to VA 
documents.
    After leaving the Waco Center of Excellence, former center Director 
Suzy Gulliver, former imaging Director Deborah Little and Baylor 
University researcher Lea Steele joined forces at Scott and White's 
Warrior Research Institute to study traumatic experiences, brain 
injury, and toxic exposure. The trio is pictured here in the April 
edition of The Catalyst, the magazine of the Scott and White Healthcare 
Foundation.
    But the image quality was so concerning that in March 2011 the VA 
brought in an outside expert, Deborah Little, the Director of MRI 
research at the University of Illinois-Chicago, to investigate, 
according to documents.
    Little's verdict was devastating: The scanner wasn't capable of 
conducting the research it had been purchased to do and needed massive 
repair. The center's then-Director, Suzy Gulliver, immediately shut 
down the PTSD study and suspended research on the scanner. (Greg 
Harrington, an MRI physicist and former researcher at the center, 
disputed Little's assessment, saying that when he left the VA in May 
2011, the scanner was ``fully capable'' of performing most research.)
    In July 2011, the scanner suffered a massive failure called a 
quench, in which the liquid helium used to cool the powerful magnet was 
released as a gas after the scanner's cooling system failed. Unplanned 
quenches can permanently damage magnets or lead to repeated quenching, 
and in this case it required several weeks of repair.
    The next month, Little joined the VA to permanently oversee the 
machine and imaging program. A press release announcing her hiring made 
no mention of the dire situation facing the center's signature piece of 
equipment.
    For much of the next year, Philips repaired and redesigned the 
scanner, at no cost to the VA. The machine was finally returned to the 
VA at the end of 2012.

    Timeline of the Center of Excellence Scanner

    Adversarial at Best

    Yet there were more glitches. Little told her superiors she needed 
a research agreement with Philips, which she said would give her the 
necessary software codes to properly calibrate the machine for advanced 
research.
    For over a year, Little and her staff haggled over the agreement, 
with no success. Her biggest obstacle wasn't Philips, but her 
colleagues: According to internal VA emails, the VA's own contracting 
officials in Illinois refused to release the documents that Center of 
Excellence staffers needed to execute the agreement.
    ``We cannot conduct research on our MRI until we have a research 
agreement in place,'' Little wrote to her contracting colleagues in a 
Jan. 7, 2013, email. ``This is a critical issue.''
    Little, who in an internal memo called her relationship with 
contracting and legal officials ``adversarial at best,'' said the 
resulting delays cost half a dozen studies that might otherwise have 
been done--a malaise that bogged down the program's work even more.
    ``Because of the events of the last year, there has been no 
recruitment attempted to fill support positions in the Neuroimaging and 
Genetics Core,'' she wrote in a February 2013 report. ``As such, the 
Core is woefully and completely understaffed and no other scientists 
have been trained on management of the MRI.''
    A month later, Little resigned, leaving the program in total 
disarray.
    ``We are at a complete loss for managing this unit without an 
expert and as far as I understand, Dr. Little was the only person in 
the VA who had the knowledge to manage this specialized equipment,'' 
the center's interim Director, Mira Brancu, wrote in July 2013.
    Potential partners outside the center began to take notice of the 
internal struggles. Baylor University researchers had been eager to use 
the scanner as a key part of their investigation into the array of 
poorly understood symptoms facing Gulf War veterans. But in April 2013, 
they decided to pull the plug.
    ``We're hoping to start patient recruitment this summer, and really 
can't afford additional delays,'' Baylor's Lea Steele wrote to 
Davidson, the associate research Director. ``I am also very sorry to 
add something else to the list of bad news that you and everyone there 
has been dealing with for so long.''
    Davidson's reply reflected the growing feeling of gloom at the 
center. ``Indeed I suspect it will be many months before we have 
everything in place to use the MRI,'' she wrote. ``So I think you are 
making a very wise choice. I only regret if we in any way contributed 
to the delay of your research.''
    In fact, without Little, VA officials were soon forced to 
acknowledge that not only did they not know how to use the 
sophisticated machine--they had no idea if it was functional at all 
after its long period of inactivity.
    Two months later, the scanner suffered its third quench.

Other Problems at Waco Center

    The problems in the imaging program were among wider issues 
plaguing the Center of Excellence. A $10 million permanent home for the 
center was supposed to debut in 2011; three years later it still hasn't 
opened, leaving staffers in temporary quarters. In early 2013, 
Gulliver, the center Director who had hired Little, left the VA under a 
cloud of allegations over dubious financial transactions related to 
recruiting and outside grants.
    A series of VA employees serving as interim Directors took over the 
troubled center. The first, Brancu, expressed distress upon learning 
the full extent of problems with the scanner.
    ``We have been left with a multimillion-dollar unique mobile MRI 
unit that is not being overseen by an expert and not being utilized for 
research,'' she wrote in July 2013. The day before she handed off her 
interim Directorship to her replacement, Jennifer Runnals, Brancu 
added: ``I think at this point, we are concerned about whether this 
magnet is in any condition to be used.''
    For her part, Runnals conceded she knew little about the 
sophisticated machine she'd inherited. ``It became apparent to me that 
my lack of expertise regarding MRIs would be a significant obstacle,'' 
she wrote.

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    She contacted the VA's other MRI experts for assistance. But her 
colleagues were no help: ``Despite several emails I received no 
response or assistance prior to my term,'' she said in a report.
    So Runnals next turned to the University of Texas--where the VA had 
halted research at the Brain Injury and Recovery Lab three years 
earlier. ``What I am looking for is to run some information by a person 
who knows how magnets function, their upkeep etc.,'' she wrote to UT 
professor Jeff Luci.
    Luci's prognosis was grim: ``Once a magnet starts quenching, the 
pattern usually repeats itself,'' he wrote. ``I doubt you've seen the 
last quench.''

    The Future

    Earlier this year, the VA hired Russell, who had previously 
overseen the Army's TBI screening program, as a permanent Director for 
the Center of Excellence. Russell said he has doubled the staff and has 
found someone to oversee the Neuroimaging program--though he'll start 
with modest expectations.
    ``His challenge is going to be to make the machine function 
properly,'' Russell said. He conceded that it's still not clear if the 
vibration problem has been solved or if it can ever be used as 
originally intended. Russell added the machine might have to be taken 
out of its trailer and bolted to the ground.
    In the meantime, he has suggested using it to conduct simple 
medical scans on veterans to reduce wait times for patients. ``It's 
available if somebody wants it,'' Russell said. ``It hurts me to see it 
sitting there, honestly. I wish we could be using it clinically.''
    So far, however, Central Texas VA leaders have declined.
    Russell said he hopes the eventual completion of the Center of 
Excellence's permanent home will help recruiting.
    ``It's hard to do that kind of cutting edge science without the 
right facilities,'' he said. ``We have to give people the 
infrastructure to be able to do it. . . . I'm pretty comfortable that 
if we build it right, it'll fly. It's just not ready yet.''

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