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S. HRG. 114–595 

KEEPING THE PROMISE FOR ARIZONA VETERANS: THE VA CHOICE CARD, MANAGEMENT 

ACCOUNTABILITY, AND PHOENIX VA MEDICAL 

CENTER 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

DECEMBER 14, 2015 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

RICHARD BLUMENTHAL, Connecticut, Ranking 

Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

TOM BOWMAN, Staff Director 

JOHN KRUSE, Democratic Staff Director 

(III) 

C O N T E N T S 

DECEMBER 14, 2015 

SENATORS 

Page 

Sullivan, Hon. Dan, Acting Chairman, U.S. Senator from Alaska ...................... 1 

McCain, Hon. John, U.S. Senator from Arizona ................................................... 3 

Flake, Hon. Jeff, U.S. Senator from Arizona ......................................................... 5 

WITNESSES 

Byers, Charles ‘‘Chuck,’’ Vietnam Veteran ............................................................ 6 

Prepared statement .......................................................................................... 8 

Mitchell, Katherine L., M.D., former employee of the Phoenix VA Health 

Care System ......................................................................................................... 9 

Prepared statement .......................................................................................... 12 

Morris, Nicole, U.S. Navy Veteran ......................................................................... 39 

Prepared statement .......................................................................................... 39 

Shulkin, David J., M.D., Under Secretary for Health, U.S. Department of 

Veterans Affairs; accompanied by Thomas Lynch, M.D., Assistant Deputy 

Under Secretary for Health Clinical Operations; and Kathleen Fogarty, 

Interim Director, VISN 18: Southwest Health Care Network ......................... 42 

Prepared statement .......................................................................................... 44 

Letter clarifying testimony .............................................................................. 88 

McIntyre, David J., Jr., President and Chief Executive Officer, TriWest 

Healthcare Alliance .............................................................................................. 49 

Prepared statement .......................................................................................... 52 

(1) 

KEEPING THE PROMISE FOR ARIZONA VETERANS: THE VA CHOICE CARD, MANAGEMENT ACCOUNTABILITY, AND PHOENIX VA 

MEDICAL CENTER 

MONDAY, DECEMBER 14, 2015 

U.S. SENATE

COMMITTEE ON VETERANS’ AFFAIRS

Gilbert, AZ 

The Committee met, pursuant to notice, at 11:08 a.m., at Gilbert 

Town Hall, 50 East Civic Center Drive, Gilbert, Arizona, Hon. Dan 

Sullivan presiding. 

Present: Senators Sullivan [presiding], McCain, and Flake. 

OPENING STATEMENT OF HON. DAN SULLIVAN, 

U.S. SENATOR FROM ALASKA 

The CHAIRMAN. The Senate Veterans’ Affairs Committee oversight hearing will now come to order. I would like the first panel 

of witnesses to take their seats. 

Good morning, everybody. My name is Dan Sullivan. I am a U.S. 

Senator from Alaska, a Member of the Senate Veterans’ Affairs 

Committee, and a veteran myself with 22 years of Active Duty and 

Reserve service as a Marine Corps infantry officer. 

Today’s hearing is a continuation of oversight hearings we have 

been conducting on how the VA has been implementing a series of 

laws passed in 2014. I am very pleased to be joined by my distinguished Senate colleagues, Senator John McCain and Senator Jeff 

Flake. 

Alaska and Arizona are big States, proud States. While our winter temperatures might differ some, we have many things in common, in particular a large population of veterans. 

As many of you know, Arizona has over 535,000 veterans making 

up over 8 percent of this State’s population. I am sure my colleagues from Arizona would agree that it is our strong population 

of proud veterans that truly makes the States of Arizona and Alaska resource-rich. 

This morning, we are here to continue the important work of ensuring that each and every veteran in Arizona, in Alaska, and 

throughout the country, gets the care they have earned and the 

care they deserve. 

Less than 2 years ago here in Arizona at the Phoenix VA, our 

country learned that our veterans here and across the Nation were 

not getting the care that they deserved, the care that they need, 

and the care that they have earned. From hidden waitlists and 

2 

poor reporting, the VA was simply not doing its job, and veterans 

were falling through the cracks. 

Rightfully, the country was outraged; our veterans were outraged. Then, their elected officials in Congress acted. 

A few months after these issues came to light, Congress came together and passed the Veterans Access, Choice and Accountability 

Act of 2014, better known as the Choice Act. This bill was passed 

by a very bipartisan majority in the House and Senate. Within a 

week of its passage, the Choice Act was signed into law. 

One of the many reasons I am honored to be on this dais with 

Senators McCain and Flake today is that they were two of the 

leaders in the U.S. Senate to make this happen. Senator McCain, 

in particular, has been advocating for the Choice card and choice 

issues for years. 

However, since this bipartisan effort to pass the Choice Act, the 

implementation of the law has been rocky at best. Our veterans are 

still not seeing the quality of care or access to it that they deserve. 

They are still waiting too long for appointments. 

Twice Congress has had to correct issues with implementation 

since the passage of the Choice Act, once when improperly calculated distance requirements by the VA had to be changed in law; 

and, again, when the VA ran out of money to implement the Choice 

Act. 

Thus far, we have seen that while Choice is working in some 

areas, it is failing in other places like my State of Alaska, and is 

having serious implementation problems here in Arizona. 

I understand that the implementation of such a large program 

like the Veterans Choice Act is difficult. However, the fact that 

something is difficult cannot and should not be used for justification for delay or failure. Regardless of how challenging the task 

may be, our veterans always deserve the maximum effort and the 

best results from the VA and Congress. 

When the call went out for our veterans to serve, they put their 

country first and answered the call. We are here in Arizona today 

because, as a Nation, it is our turn to answer the call and put them 

first. 

Today’s oversight hearing marks the sixth one that the Senate 

Veterans’ Affairs Committee has held on the Veterans Choice program, the sixth one just this year: three in DC and field hearings 

in Alaska, Georgia, and now Arizona. 

The Committee felt it was particularly important to have such a 

hearing here, given that many of the problems were originally recognized here, and, as I mentioned, the leadership of Senators 

McCain and Flake in playing such an important role in devising 

the comprehensive solution to some of our VA problems throughout 

the country. 

I would also like to mention, under the strong leadership of the 

Veterans’ Affair Committee, Chairman Johnny Isakson of Georgia 

has sought to remind the senior leadership of the VA who they 

really serve—not Congress, not the President, but our veterans. 

We have an outstanding group of witnesses today. As you see, 

with regard to the first panel, we have a former VA employee and 

a whistleblower who took a lot of courageous actions. It will be very 

interesting to hear from her. That is Dr. Mitchell. We have two ArVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 Z:\ACTIVE\121415.TXT PAULIN
3 

izona veterans, Mr. Byers and then Ms. Morris, who is stuck and 

a little bit of traffic but she should be joining us soon. 

I would like to welcome all the veterans who are here today in 

the audience. It is important to recognize that although we will not 

be taking testimony from everybody, we will have the opportunity 

to hear from all of you. If you would like to submit written testimony, you can do so at this address. It is public_testimony@ 

Sullivan.Senate.gov. We can provide that again. I know that some 

of the veterans here wanted to make comments. You can submit 

written testimony that will be part of this official Senate hearing 

record. We will certainly be reading that. 

Without further delay, I now would like to recognize the chairman of the Senate Armed Services Committee, a veteran, a war 

hero, my good friend, Senator John McCain, for his opening 

remarks. 

STATEMENT OF HON. JOHN McCAIN, 

U.S. SENATOR FROM ARIZONA 

Senator MCCAIN. Thank you. I appreciate Senator Sullivan from 

the great State of Alaska being here to chair this field hearing of 

the Senate Veterans’ Affairs Committee today. Senator Sullivan is 

a proud Marine, and he has worked diligently and tirelessly over 

the past year to improve our Nation’s security and fight for those 

who have served in uniform. Veterans of this country are fortunate 

to have Senator Sullivan advocating on their behalf. 

I want to thank the Chairman of the Veterans’ Affairs Committee, Senator Johnny Isakson from Georgia, who was unable to 

be here with us today. He is doing a great job as Committee chairman. He is examining many things, including how veterans are 

using and in some cases how the VA is not helping the use of the 

VA Choice card. 

I am grateful to the city of Gilbert for hosting us in this facility. 

Being here is very helpful to our having a full discussion. I would 

like to take a minute to recognize and thank the city of Gilbert for 

their support of veterans through their various programs such as 

Operation Welcome Home and support of homeless veterans 

through the Homeless Veterans East Valley Partnership. I would 

also like to congratulate the city of Gilbert, which was recognized 

this year as being in the top five best cities in the United States 

for veterans. 

I will never forget the town hall forum I hosted in Phoenix where 

I heard directly from the families of four veterans who passed away 

in recent months. They came and stood before a crowded room to 

tell their stories. With tears in their eyes, they described how their 

loved ones suffered because they were not provided the care they 

needed and deserved. They recalled countless unanswered phone 

calls and ignored messages, wait times and delays, mountains of 

bureaucratic red tape, while their loved ones, those who selflessly 

served their country, experienced painful, debilitating, and ultimately fatal conditions. 

No one should be treated this way in a country as great as ours. 

But, to ignore the pleas for help and care from those who have sacrificed on behalf of the United States is unconscionable. We should 

all—all of us—be ashamed. 

4 

The scandal at Phoenix led to revelations of similar problems at 

other VA medical centers around the country where bureaucrats 

were gaming the system to get better bonuses by denying care to 

our veterans. This strategy created a crisis of confidence toward 

the VA, the Federal agency that was established to care for them. 

I am happy to note that Congress responded quickly in a bipartisan manner to this crisis in a matter of weeks. The House and 

Senate passed the Veterans Access, Choice and Accountability Act. 

This bill provided an unprecedented $15 billion in immediate emergency appropriations that was added on the Veteran Health Administration’s regular annual budget of about $60 billion to hire 

more doctors and nurses and to issue the VA Choice card for those 

veterans who could not get into a VA for their health care. 

The bill also gave the VA direct hiring authority so that all of 

the cumbersome rules and regulations for bringing on board new 

Federal employees could be waived to fill vacancies. 

We will be discussing more about the budget and resources provided to the VA on the next panel. 

Congress also provided the Secretary of the VA with nearly unprecedented ability to terminate senior executives who fail to care 

for our veterans. No other Cabinet official has this powerful tool to 

ensure performance and results from its department’s top officials. 

I continue to be disappointed that Secretary McDonald has not 

used this authority to its fullest extent. As I have said, it is past 

time for accountability and leadership at the VA. 

I want to thank our witnesses today on the first panel. Dr. 

Mitchell is a former employee of the VA Medical Center and a 

whistleblower. She will have very interesting comments to make. 

Mr. Charles ‘‘Chuck’’ Byers is a Vietnam veteran himself and an 

advocate for all veterans here in Phoenix. His ability to receive 

care through the Choice program is a success story. 

Finally, Ms. Nicole Morris, who is still not here. 

I am sure everyone in this room agrees we owe a solemn debt 

to those in uniform who fought on our behalf in faraway places. 

I just want to make a brief comment on the makeup of our second panel, which will consist of VA witnesses, as there has been 

a last-minute change. 

Last Friday, my staff was informed that the VA determined that 

a senior manager at the Phoenix VA, who was originally due to testify today, retaliated against a VA whistleblower. In light of this 

recent information, he will not be testifying this morning while we 

determine what has occurred with his case. 

Needless to say, all of us take issue with whistleblower retaliation at the VA very, very seriously. We have been discussing the 

matter with Secretary McDonald, especially in light of concerns 

about systemic problems in this regard that the Office of Special 

Counsel raised directly with the President a few months ago. 

After today’s hearing, Senator Flake and I are sending a letter 

to Secretary McDonald to find out exactly what occurred in this retaliation case we were just made aware of and how it was handled. 

With that in mind, we have a number of issues that more broadly impact Arizona veterans to cover, and many of those veterans 

are here today to tell us about their experiences. Today, we will be 

5 

focusing on the Choice card implementation and continuing problems with excessive wait times that our veterans face. 

For the 9 million American veterans who are enrolled in the VA 

today and for the families who lost loved ones awaiting care that 

never came and are still grieving their losses, it is time to live up 

to the VA’s mission today, ‘‘To care for him who shall have borne 

the battle and for his widow and his orphan.’’ 

I thank you again, Senator Sullivan, for being here. I am very 

pleased to note, we did not have this hearing in Alaska. I thank 

you. [Laughter.] 

The CHAIRMAN. Thank you, Senator McCain. 

As I mentioned, it is truly an honor to be on a panel with both 

Senator McCain and Senator Flake, who, in my discussions with 

him over the course of the last year, I know is fully committed to 

taking care of our veterans. Again, the two Senators from Arizona 

played such leadership roles in addressing the issues that it is an 

honor to be here with both of them. 

Senator Flake, your opening statement? 

STATEMENT OF HON. JEFF FLAKE, 

U.S. SENATOR FROM ARIZONA 

Senator FLAKE. Thank you, Chairman Sullivan. Thank you for 

chairing this hearing, and thank you for coming all this way and 

bringing Alaska winter weather with you anyway. 

I just want to say, from the beginning, with problems long before 

that, Senator McCain has been advocating for veterans. Throughout this issue, with the Phoenix VA as the epicenter of this latest 

problem that we had, Senator McCain from the beginning was 

pushing hard to make sure that veterans received Choice and that 

there is accountability. This field hearing is part of that. 

I am glad to have had the Choice Act passed. Yet, as Senator 

McCain and Senator Sullivan both said, there are issues with its 

implementation. We want to make sure that it goes forward. 

Also, in light of the October VA Inspector General report, noting 

problems still in the urology department in particular at the Phoenix VA, talking about substandard care there and delays that may 

have contributed to the deaths of veterans, we remain concerned 

and want to make sure that those issues are fixed. It is beyond unacceptable if we are still having those kinds of issues. 

Obviously, we want to make sure that, as I mentioned, the 

Choice Act continues to be implemented, and that the problems we 

had early on are dealt with. 

Thank you, Senator Sullivan, for coming here and thank you, 

Senator McCain, for pushing this issue all the time. 

I can tell you, being in the Senate, Senator McCain is always 

pushing veterans’ issues and making sure that the veterans here 

and across the country get the care that they deserve. So, thank 

you for being here. 

The CHAIRMAN. Thank you. 

Now we will begin with our first panel. I would ask the witnesses 

to please try to keep their opening statements to 5 minutes. Our 

goal is to have each panel for about an hour. 

Mr. Byers, the floor is yours. 

6 

STATEMENT OF CHARLES ‘‘CHUCK’’ BYERS, 

VIETNAM VETERAN 

Mr. BYERS. Thank you, Senator Sullivan, Senator McCain, and 

Senator Flake. Thank you for inviting me today to speak about the 

VA Choice card, management accountability, and the Phoenix VA 

Medical Center, and, as we say, keeping the promise to Arizona 

veterans. 

In August 2013, I moved to Arizona from New Jersey. I was enrolled in the Philadelphia VA health care system. I knew I had to 

transfer my eligibility to the Phoenix VA hospital care system. In 

September of that year, I applied to the Southeast Clinic in Mesa 

Arizona. 

I was told it would be at least 1.5 years before I could get a primary care doctor. I was even told that it might be sooner if I go 

down to the Tucson VA. I could not wait because I was receiving 

medication from my VA in Philadelphia. But, if the doctors do not 

see you, they will not renew your prescriptions. 

I went downtown to the Phoenix VA Hospital, which is about 50 

miles away from my home and was told the same thing. Then I 

spoke to an advocate. I was able to get an appointment in about 

9 months. They told me the reason for such a long wait time was 

due to a decrease in staffing and staff leaving for better paying opportunities outside the VA system. 

I was not satisfied so I called the Office of Inspector General in 

Washington, DC, and filed a complaint. In about 2 weeks, I received a call from a VISN that oversees the Phoenix VA system 

and was given an appointment for a primary care physician at the 

Mesa Southeast Clinic. 

I know how to advocate, but there are a lot of veterans out here 

who do not. Some of them will just give up. 

Now I am officially enrolled in the Phoenix VA health care system, and I am out there seeing my primary care physician and receiving my medication. 

Before I left the Philadelphia VA, I was being seen for a 

urological condition and should have a follow-up. I requested an appointment for urology to my primary care physician. I waited over 

a year for my request for a urology appointment and was finally 

contacted by TriWest to see an outside urologist. 

I received excellent care with multiple visits with the outside 

group. At this time, the Phoenix VA offered very little urological 

services, and there were a lot of veterans who were referred out to 

this group for their care. 

After a follow-up visit, I was told the urology practice has 

dropped their contract with TriWest because of delayed payments 

for services provided. I understand that that issue has since been 

resolved. 

The Phoenix VA hospital has taken back my urology appointments now and also in the future. I feel the Phoenix VA health 

care system is improving and correcting some of the previous shortfalls. But, I am concerned that the level of care for veterans like 

myself will continue and not repeat some of the problems that we 

have had in the past. There are a lot of dedicated employees at the 

Phoenix VA system, and they are starting to see more and more 

veterans working in the health care system. 

7 

I think it is important to continue the Veterans Choice card. 

However, I feel that there are still barriers that prevent the veterans from using it. For instance, the language states, ‘‘40 miles to 

the closest VA facility that has a primary care physician.’’ There 

are multiple CBOCs here in Arizona within those 40 miles. However, they cannot provide all the services that are needed for veterans and still have to travel great distances for care to the local 

VA hospitals. Sometimes this can be over 200 miles here in Arizona. 

I understand no system is perfect and a lot of these programs are 

new. But, I think it is important that we veterans keep the Choice 

card for an added insurance policy for our earned and deserved 

health care from our government. 

Us Vietnam veterans, we say, never will one generation leave behind another generation. Thank you. 

[The prepared statement of Mr. Byers follows:] 

8 

PREPARED STATEMENT OF CHARLES G. BYERS, VIETNAM VETERAN


1214psBYE1.eps

Keeping The Promise To Arizona Veterans 

Thank you tor itwiting me today to speak about 1he VA Choice- Card. 

Managernc-n1 Accountabilit~·. The: Phoenix VA Modi~al Center 

In August 2013 I rnovod 10 Arizona from New Jorse:~·. 

I was onrolle:-o in tho Philadelphia VA Health-8am S~·stom. I kne:v.· I hao to 1ransfor my 

eligibility 1o tho Phoenix VA Health Cam Sys1om. In Sc-p1ombor of 1hat 1•c-ar I applioo to 

1hc- SE VA Clinic in Mesa and was 10id it woul-o bo at loas1 a ~·oar or more botoro I could 

•;JOt a primary Doctor 1horo. I was o~en tol-o it might bo soone-r if I e-nrolle-d in tho Tucson 

VA. 

I could not ·,•,.ail because: I was recoi~·ing rnedica1ion from my VA in Phila-aolphia but if 

1he: Dr"s don't se:o you-thoy will ne-t mnow your proscriptions. I we:n1 dmvntown to the 

Phoonix VA Hospital which is about 50 mile-s from my home- and was 10id 1hc- samo 

1hing, I thon spoko 1o an Advocate: and w·as able: to got an ap!)::lintrnon1 in 9 mon1hs. 

1hey 1old me the reason for such a long wait time was ouo 10 oocroaso in stating anG 

staff lc-a·.·ing for bottor paying op!)mtunitios ou1sidc- tho VA Syste-m. 

I was not satisfiM and called tho OIG's office in Washington and tiled a complaint. In 

ab-:::;ut 1wo we:oks I rocoivod a call from tho V!SN tha1 overse-es tho Phoenix VA Syste-m 

ana was givon an app:::;in1mc-m1or a Primary Physician at 1hc- Mosa SE Clinic . 

I know h·8·oto' to aovoca1o bu11hc-rc- arc- a lot of vo1orans 1hat would havo gi•Jc-n up. 

Now I am officially onrollod in the Ph-:::;onix VA Hoalth care: syste-m. sooing my primaty• 

care: Physician and rocoiving my medication. Bofmc- !left Phila-:Jolphia VA .I ·was being 

soon for an Urological Condition and should have a follow up. I roquos1od an 

appointmon1 for Urolog·y 10 my primar•r plwsician. I waited ove-r a 'roar fe-r IWr roquost 

lor Urolog•y Appointment and was cotWl·8tod by Tri-wes1 teo sec- an outside Umlogis1. 

I rocoivod e:xcollon1 caro with mul1iplo visits from this outsido group. At this limo thePhoenix VA ottorod vor~· little Urological Services and thoro woro a lo1 -s-f ~·oterans that 

woro mforrod -c·ut to this gwup tor thoir care. Aftor a follow up visit I was tola tha11he: 

Urol-8·gy Practice: has droppM their contrac1 ·,•,.ith Tri-we:s1 t·e:causo of delayed payments 

lor Sc-rvi-~o proviood. I believe tha1 is suo has boon rosolvo-o. 

Tho Pl1oonix VA Hospital has taken back m•r Urology appoin1mon1s now and in tho 

future-. 

I te:c-1 the: Phoonix VA Hoalth Caro System is improving and correcting some- ot 1he 

provio us shor1 ta II s but I am -8oncornod that 1h c- lovol of care for Vot()rans I ike myse If 

will continue and not repeat some ot tho problems wo ha-o in tho pas1. 

Thor() aro a Jot c-f dooicatod e:mploy()es 1he: th() Phoenix VA Systom and W() aro s1ar1ing 

10 soo moro ano moro votorans working in 1he Ho;:;lthcaro Sys11Jm. 
9 

The CHAIRMAN. Thank you, Mr. Byers. 

Dr. Mitchell? 

STATEMENT OF KATHERINE MITCHELL, M.D., FORMER 

EMPLOYEE OF THE PHOENIX VA HEALTH CARE SYSTEM 

Dr. MITCHELL. I am deeply grateful for the opportunity to testify 

today. I am a former VA nurse and current VA physician with over 

16 years’ experience working within the Phoenix VA. A little over 

1 year ago, I transferred from the Phoenix VA to the VA network 

office in Gilbert, AZ. However, I have maintained my Phoenix VA 

contacts. 

In April 2014, following in the steps of Dr. Sam Foote, I became 

a public whistleblower to report dangerous ER nursing triage, ER 

staffing shortages, whistleblower retaliation, and facility scheduling violations, among other issues. 

In my opinion, not much has changed with these issues since 

that time, except the scheduling rules are now being followed and 

there are certainly more staff in the ER. 

Throughout the last 20 months, Phoenix VA employees have privately contacted me to describe instances of poor patient care, 

delays in care, violations of policy, and retaliation for reporting 

problems. I was also made aware of significant problems for patients scheduling appointments through the Choice program. 

Although I continue to advocate for improvements within the 

Phoenix VA ER, in my current position, I have been told that I am 

not allowed to address issues that are still there. The continued 

presence of dangerous triage conditions in the Phoenix VA ER, as 

well as problems in the mental health clinic triage, were substantiated in a VA Office of Medical Inspector (OMI) report that was 

released internally to the national VA in March of this year and 

publicly released in September by the Office of Special Counsel. 

This official VA report called the Phoenix ER nursing triage ‘‘a 

significant risk to public health and safety.’’ 

Although there were serious flaws in the OMI investigation, it 

still found many problems, including grossly inadequate nursing 

triage, nurses who failed to perform EKGs when ordered and failed 

to act upon orders for serious patient complaints such as chest 


1214psBYE2.eps
10 

pain. The triage in the walk-in mental health clinic was substandard and nursing triage protocols were called inadequate. 

After this OMI report’s internal release to the VA in March, the 

Phoenix VA ER nurses were trained in a triage tool called Emergency Severity Index, or ESI. Unfortunately, while ESI is a valuable adjunct to triage care, ESI training does not teach triage 

symptom recognition nor imply a mastery of triage skill. In fact, 

the ESI fits on this small slip of paper and consists of only six 

questions. 

Watching the news, in my opinion, the Phoenix VA has misled 

the public into believing that ESI training resolved the safety deficits in triage. Problems, however, are still reported to me by Phoenix VA ER staff. 

Despite my formal recommendation, there has been no in-depth, 

standardized nursing triage training that would give the nurses 

the broad knowledge base needed to effectively evaluate patient 

symptoms. There are still no minimum qualifications to be a triage 

nurse. 

Nurses who jeopardize patient safety by not following patient 

care orders are still working in the ER. 

I have been told that there have been additional episodes of unstable patients escaping from the Phoenix VA ER since February 

2015. 

Ill patients still wait too long, greater than 6 hours to be seen. 

The ER continues to be flooded. 

An email series just last week stated that all rooms were full and 

there were 30 people waiting in the waiting room. This email series 

also reported other conditions that were described in the email as 

‘‘a recipe for disaster.’’ 

I also remain extremely concerned about delays for consult care 

and appointments. I have encountered recent cases in the spring 

and summer where the failure to receive a timely VA appointment 

or consult may have contributed to a veteran death or, at a minimum, taken away quality-of-life before the veteran died. 

I am prepared to discuss some of these incidents today with the 

Committee, if it so chooses. 

Since the VA scandal erupted, there has been no significant 

change in the dysfunctional institutional culture there. Several of 

the offending senior administrators have voluntarily left the Phoenix VA without ever facing any consequences for their retaliatory 

behavior. Other unscrupulous Phoenix VA administrators and supervisors remain in positions of power. 

In fact, one administrator remains in a key leadership position 

although he has caused problems in several areas. According to a 

2014 VA Office of Accountability and Review investigation, this 

same administrator retaliated against a whistleblower. 

Because your committee monitors the entire VA, I want to make 

you aware that the issues of which I speak are not only at Phoenix 

but potentially across the Nation. The national VA has never established standardized nurse triage training nor developed standardize nursing triage protocols, even though such training and protocols are readily available in the private sector at low cost or free. 

Whistleblower retaliation is rampant throughout the VA. Retaliation against physician whistleblowers has driven physicians out of 

11 

the Phoenix VA specifically and elsewhere, which is discouraging 

others from applying. 

Because of time limits for this opening statement, I cannot go 

into detail regarding multiple other issues, including the dangerous 

design of the new ER that is obsolete even before it is built, gross 

difficulties with telephone access within the Phoenix VA, lack of 

digital faxes needed to avoid delays in record receiving, and the inappropriate switching of consults type without the ordering provider’s approval. 

I must say that I am grateful to the many dedicated Phoenix VA 

staff both in and outside the Phoenix ER who have brought forward the issues of which I have spoken today. The Phoenix VA has 

the potential to be a stellar VA facility, because of the staff, but 

desperately needs your help to achieve this goal. Thank you. 

[The prepared statement of Dr. Mitchell follows:] 

12 

PREPARED STATEMENT OF DR. KATHERINE L. MITCHELL, FORMER EMPLOYEE OF

PHOENIX VA HEALTH CARE SYSTEM


1214psMIT2.eps
13 


1214psMIT3.eps

Section 1: Introduction & Summary 

My name is Dr. Katherine Mitchell. I am a VA physician who worked within the Phoenix VA 

Emergency Department (ED) for almost 10 years until I involuntarily was transferred to a defunct 

VA clinic in retaliation for repeatedly identifying dangerous ED patient safety deficits. After years 

of having my reports of life-threatening conditions ignored by internal Phoenix VA mechanisms I 

publically became a whistle blower in April 2014 in an attempt to have the VA resolve those many 

serious problems. I alerted the public and Congress to unsafe conditions in the Phoenix VA 

Emergency Department, whistleblower retaliation, facility scheduling irregularities, and other 

issues. After the Veterans Health Administration (VHA) formally acknowledged the workplace 

retaliation against me, I accepted a position within the VA Veterans Integrated Service Network 

(VISN) 18 office as a Specialty Care Medicine coordinator. Although I continually advocate for 

improvements at the Phoenix VA ED and Mental Health Clinic, in my current position I have been 

told by VA administrators that I am not allowed to actively address the known dangerous 

conditions that still exist there. 

The presence of these dangerous conditions was substantiated in a September 2015 Office of 

Special Counsel (OSC)/ VA Office of Medical Inspector (OM I) report that was released internally to 

the VHA in March 2015. This official report called the Phoenix VA Emergency Department triage 

"a significant risk to public health and safety" and detailed substandard nursing care in the 

Phoenix VA ER and Mental Health Clinic, a significant lack of nurse triage training, and inadequate 

nursing triage protocols. The report also substantiated "that nurses failed to perform EKGs when 

ordered, and ... failed to act upon orders for serious patient complaints such as chest pain". 

After the OSC/OMI report's March 2015 internal VHA release, Phoenix VA ED triage nurses were 

trained in a triage algorithm called Emergency Severity Index (ESI). Unfortunately, while the ESI is 

a valuable adjunct to triage care, this ESI training does not convey triage symptom knowledge nor 

imply a mastery oftriage skills. 

The Phoenix VA has misled the public into believing that ESI training resolved the safety deficits in 

the ED. In fact, there has been no significant standardized triage training that would actually give 

the nurses the knowledge base to effectively evaluate patient symptoms. There are no minimum 

qualifications formally required for a nurse to work in triage and no definitive policy regarding 

triage standards. Nurses who chose not to follow patient care orders for serious patient 

complaints still remain within the ED. Issues with patient elopement still occur. 

Unlike the private sector, there is a lack of standardized triage nurse training within the entire VA 

system, no minimum qualifications to be a triage nurse, and an absence of standardized VA triage 

nursing protocols. Therefore, the problems present within the Phoenix VA Emergency 

Department and Mental Health Clinic are likely mirrored at VA medical facilities throughout the 

nation. 

There are recent cases where a Phoenix VA veteran died potentially because of lack of timely follow-up 

appointment or consult. I encountered these cases after being alerted to the method of Phoenix VA 

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closure of consults for deceased veterans. Although the VA is supposed to disclose situations were a 

delay in care could have contributed to a patient's death, there was no evidence on the charts to 

indicate the charts had ever been reviewed by Phoenix VA quality management staff. 

Since the Phoenix VA access scandal erupted there has been no significant change in the 

dysfunctional institutional culture of the Phoenix VA Medical Center or sister VA facilities. In 

Phoenix and elsewhere administrators who are known to retaliate still occupy positions of 

leadership. Based upon conversations I have had with VA staff throughout the country, VA 

employees today still risk backlash for bringing up patient care problems, identifying misuse of 

facility resources, and questioning violations of VA policies and procedures. 

Therefore, the purpose of my written testimony is to outline the dangerous conditions that still 

exist in the Phoenix VA Emergency Department and Mental Health Clinic, emphasize the potential 

for these deficiencies to be mirrored in VA ERs and mental health clinics throughout the nation, 

cite examples of Phoenix VA patient care delays potentially contributing to veteran death, and 

highlight the persistent culture of retaliation against whistleblowers at the Phoenix VA and other 

VA facilities. 

By focusing on these issues, I am hoping Congress and the public will demand that national VA 

correct these deficiencies immediately in order to reduce the imminent risk of patient harm in 

Phoenix as well as other VA facilities, improve employee recruitment and retention efforts in our 

grossly under-staffed VA system, and enable the VA to meet and exceed the standards of high 

quality health care. 

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Section II: Dangerous Conditions Persist within the Phoenix VA Emergency Department 

Background 

Emergency Department (ED) nursing triage should be the first step in patient assessment upon 

arrival to an ER. Such triage will determine how soon the patient will be referred for medical care 

in the Emergency Department setting. It is vital that nurses who perform initial triage have 

adequate training and follow standardized protocols for evaluating patients. Without adequate 

nurse triage training or standardized triage protocols, significant medical complaints will not be 

recognized or evaluated properly on arrival to the ER. As a result, serious ill patients may not be 

treated in a timely or appropriate manner resulting in potentially life-threatening delays in care. 

The need for appropriate nurse triage extends into urgent mental health clinics. Symptoms of 

psychological crises must be recognized by the triage nurse so the patient's care can be expedited. 

Long-standing Phoenix VA triage deficits in the ER and Mental Health Clinic. 

For the last 6 years, there have been significant patient safety issues within the Phoenix VA 

Emergency Department (ED) triage. During the years 2006-2012 when I was a Phoenix VA ED codirector and director, nurse triage mistakes were rampant during high volume patient flow 

because of inadequate nurse staffing and inadequately trained and/or overwhelmed triage nursing 

staff. Hundreds of actual serious triage nursing errors were reported by me through the Phoenix 

VA nursing and medicine chains of command without any significant attempt by the facility to 

correct the clearly identified gaps in nursing triage knowledge or lapses in triage judgment. 

Though not all ED patients suffered actual harm from those nurse triage mistakes, there were 

serious negative consequences for many veterans and the potential for irreversible patient harm 

was ever-present. 

After I was transferred from the Phoenix ED for retaliatory reasons, the nursing mistakes 

continued but were not consistently reported because the remaining staff did not want to suffer 

retaliation. In my new position, I became aware of continuing triage errors and significant delays 

in care related to poor nursing triage. One example was a patient who was sent from clinic with 

stroke-like symptoms and was told to just sit in the waiting room because the nurses were too 

busy with other patients. 

Although a few Phoenix ED triage nurses were sent to triage nurse training in either late 2011 or 

early 2012, there have been no attempts to provide structured, formal didactic training for the 

majority of Phoenix VA ED triage nurses since that time. Those nurses who received formal 

training classes in 2011/2012 eventually left the ED. In 2015 the Phoenix VA did initiate 

Emergency Severity Index (ESI) training for its ED triage nurses in response to an investigation. 

However, ESI training is merely a very brief step-wise tool for assigning triage priorities and 

doesn't teach nurses how to recognize when symptoms are serious. 

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In the interim since I was Phoenix VA Emergency Department medical director, the facility has not 

enacted any in-depth standardized triage nurse training even though it has improved overall VA ED 

staffing and expanded the quantity of patient care rooms. While the Phoenix ED may state it has 

hired experienced triage nurses, a recent investigative report from the VA Office of Medical 

Inspector indicated there may be a significant absence of formalized didactic triage training among 

those new hires. Mistakes and lapses in nursing care still occur. 

Problems with mental health nursing triage became obvious to me in 2013 when I was assigned to 

the Phoenix VA Post-Deployment Clinic. Unenrolled patients who presented for mental health 

triage were referred to the Eligibility Clinic for enrollment prior to a nurse triage screening exam. 

Patients who presented to the Walk-in Mental Health Clinic would often leave because of 

extended delays either before or after nursing triage. There were many occasions I noted that the 

triage nurses did not appear to notify any physician regarding patients in mental health crisis who 

left prior to being seen by a provider. There remains no routine follow-up for patients who leave 

the clinic without being seen. 

There was a particularly egregious mental health clinic nurse triage case where a veteran seeking 

help reported in triage that he was randomly shooting at individuals whenever he was inebriated. 

Without escalating his care or immediately notifying the physician on duty, the triage nurse told 

the veteran not to own a gun and then simply gave him the Substance Abuse Clinic phone number. 

Alone in the lobby, the veteran eventually left prior to being seen by the mental health physician. 

The mental health clinic triage nurse also never alerted any provider to this patient's complaint or 

initiated any follow-up. Unfortunately, this veteran did not return for any mental health care 

because he was arrested shortly thereafter by community police investigating a rash of random 

shootings. 

When I raised concerns regarding the quality of his triage care, the Phoenix VA nursing service 

inexplicably stated the triage nurse met the standard of care. This stance is ridiculous because a 

well-trained triage nurse or, frankly, even a lay person with common sense nurse would have 

recognized this veteran was in obvious mental distress and would have escalated his care so the 

patient could be seen immediately to a provider. Any individual with common sense also would 

have known to initiate follow-up for this patient if the patient left without being seen by a mental 

health provider. 

Subsequent disclosure of safety deficits to federal agencies after internal Phoenix VA mechanisms 

failed. 

In 2013 I filed an Office of Inspector General complaint (OIG) regarding these serious Phoenix VA 

nurse triage issues, other safety concerns, and scheduling irregularities. Phoenix VA 

administrators denied the existence of any problems and the truncated OIG investigation 

subsequently was closed. I publicly became a VA whistleblower in April 2014 and openly discussed 

the dangerous triage conditions at the Phoenix VA as well as other issues. I disclosed the Phoenix 

patient safety deficits the Office of Special Counsel (OSC) which subsequently requested that the 

VA Office of Medical Inspector (OM I) investigate. 

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OMI investigation into my allegations of unsafe conditions in Phoenix VA triage areas & other 

issues. 

That OMI investigation into my allegations occurred over 2 site visits in late 2014 and early 2015 at 

the Phoenix VA. The investigative team reviewed more than 110 examples of potentially lifethreatening nurse triage errors that I identified. Although the overall quality and depth of that 

OMI investigation was extremely poor, it still substantiated 3 out of 4 of my allegations and stated 

the fourth allegation was true at the time of my complaint but had since been corrected. 

That OMI report was released internally to the VA in approximately March 2015 so that the VA 

could start remedying the severe deficits noted. 

September 2015 public release of Phoenix VA OSC/OMI report identifying dangerous conditions in 

Phoenix VA Emergency Department triage and Mental Health Clinic triage. 

On 9/17/15, the Office of Special Counsel (OSC) publicly released a key letter, summary OSC 

report, and related Office of Medical Inspector (OM I) reports regarding the conditions found 

within the Phoenix VA Emergency Department (ED). Despite the significant deficits involving the 

depth of the OMI investigation and the nature of some of its recommendations, the OM I still 

verified the presence of extremely poor nursing triage at the Phoenix VA ED as well as the 

presence of nurses who "failed to perform EKGs when order, and .. .failed to act upon orders for 

serious patient complaints such as chest pain". (The entire report as well as my analysis of the 

report deficits can be found at osc.gov in the 2015 public files.) 

As per the OMI investigation based on 110+ cases presented to it, the OMI concluded there was"!! 

significant risk to public health and safety" because of poor triage in the Phoenix ED. (Please note 

that the phrase "significant risk to public health and safety" is a direct quote from the OMI 

investigative team.) The investigators also found evidence of poor triage in the walk-in mental 

health clinic, inadequate local triage protocols, and inadequate staffing of the vascular lab. 

The report findings indicated only 11 out of 31 nurses had any training in Emergency Severity 

Index (ESI), a common triage tool used in the VHA. The report did not specifically list whether any 

of those nurses had completed any didactic training for triage skills but the wording appeared to 

imply none of the nurses had completed any type of formal classroom triage training. The report 

did not analyze the triage training of nurses in the Mental Health Clinic. 

The OSC summary report not only recommended ESI training but also stated that the OMI "further 

recommended a review of training and educations records to assess whether nurses have 

appropriate training and experience necessary to work in the ED, in accordance with Emergency 

Nurses Association (ENA) guidelines." Those ENA guidelines recommend that a triage nurse 

complete a formal, didactic training course prior to being placed in a triage role. 

Phoenix VA misleading response to OSC/OMI report. 

The Phoenix VA publicly responded to the September 2015 OSC letter/OM! report by stating that it 

has since completed training of ED triage nurses in ESI as recommended in the OMI report to 

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which it had internal access since March 2015. Because the ESI training has been completed, the 

Phoenix VA indicated to the media that the issues have been addressed. By implying all ED triage 

nurses are now adequately trained to be in the triage role, the Phoenix VA is grossly misleading 

the public. (In fact, any VA facility that cites ESI training as "proof" of adequate triage nurse 

training is being deliberately deceptive.) 

In actuality, the ESI found is merely a very short algorithm or brief step-wise guide used to classify 

a patient by assigning a number of 1 to 5 inversely based on the number of interventions (labs, xrays, IV fluids, etc.) that the triage nurse estimates that the patient will require. In general, the 

more resources that a patient is estimated to require, the lower the number and the more 

critically ill the patient. As a rule of thumb, patients assigned a 1, 2, or 3 have much more serious 

complaints than patients assigned a 4 or 5. If all relevant aspects of a patient's complaint are 

identified, patients that are rated with a 4 or 5 should never require hospitalization. However, if 

the triage nurse doesn't understand that a symptom is serious or doesn't have the experience to 

elicit relevant symptoms, the nurse will misinterpret the algorithm and grossly underestimate the 

number of resources the patient will require. As a result, patients will be assigned an 

inappropriate ESI number and potentially experience serious delays in medical care. 

Because the ESI tool cannot be used to determine the potential seriousness of a symptom, ESI 

training is never a substitute for in-depth triage training or triage expertise. If the triage nurse 

doesn't understand that a symptom is serious, the ESI number will be inaccurate and critically ill 

patients potentially will wait hours for care while their medical condition deteriorates. In fact, the 

agency that developed the ESI specifically writes in its ESIImplementation Handbook "The ESI is 

intended for use by nurses with triage experience or those who have attended a separate, 

comprehensive triage educational program." (It should be noted that the number of years in triage 

does not equate with mastery of triage skills. If a triage nurse is poorly trained, then there will 

likely be deficits throughout his or her career.) 

The need for standardized formal Phoenix ED nursing training is evident. Based on my 10 years of 

working at the Phoenix VA ED, many of the nurses who have spent years in Phoenix VA ED triage 

have continued to make the same triage mistakes because they were never properly trained and 

never completed formal, didactic triage training. Unfortunately, at least for those trained within 

the Phoenix VA ED, the triage nurses doing the training were grossly inexperienced and thus 

produced trainees who were underprepared for the role of ED triage nurse. {I do not know the 

training background for the mental health triage nurses at the Phoenix VA Mental Health Clinic.) 

Failure to timely address key nursing issues identified by the OMI report. 

The OMI report on my Phoenix VA allegations was released internally within the VA in March 

2015, 6 months before the public September 2015 release. The Phoenix VA should have had 

ample opportunity to address the all issues identified. However, to the best of my knowledge, the 

Emergency Department only remedied the lack of ESI training and did not address the 

fundamental lack of standardized triage training. Most importantly, administration has not 

addressed the complicit willingness of certain nurses there to commit retaliation against 

physicians by withholding/slowing down the completion of physician orders. The Phoenix VA 

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remained silent on the state of mental health triage training or the qualifications of the triage 

nurses there. 

Based on Phoenix VA employee anecdotal reports to me, there are still pervasive issues with the 

Phoenix ED nursing triage and elements of basic ED nursing care. Ill patients frequently wait 

excessive amounts of time in the waiting room. Telemetry monitors remain without a dedicated 

staff member to monitor them. Alarms still ring while nurses, blocking out the sound of those 

alarms, fail to investigate. Although the majority of ED nurses conduct themselves professionally, 

anecdotal stories indicate there is a group of nurses who are still routinely rude to patients, fail to 

follow procedures, and are willing to retaliate against physicians who report improper care. 

The OSC/OMI report with grave implications nationally for every VA Emergency Department & VA 

mental health clinic. 

The Phoenix VA ED is not unique. The national VA has never set minimum standards for nurse 

triage qualifications, instituted standardized triage training, nor developed national standardized 

nursing triage protocols. Therefore the quality of nursing triage can vary widely on arrival to any 

VA Emergency Department depending on the time of day, day of week, and nursing staff present. 

As a result, veterans are at high risk for receiving substandard care. Although every veteran who 

presents to a VA Emergency Department deserves high quality care, in reality receiving proper 

nursing triage care can be a matter of pure chance. 

In contrast, Emergency Department nursing triage care outside the VA is quite different. The 

Emergency Nurses Association, the professional body representing emergency room nurses, has 

set minimum recommended training standards required before a nurse can perform ED triage. In 

community hospitals, triage nurses have in-depth ER experience in addition to focused, 

standardized triage training. In the private sector, triage nurse protocols are quite common. In 

conjunction with adequate triage training, such protocols ensure a standardized, expedited 

approach to patient symptom evaluation. 

Community standards for ED nurse triage training and triage qualifications. 

The Emergency Nurses Association (ENA) has minimum criteria set for ED triage nurse training. 

Within its guidelines is written "A specific amount of time and experience in emergency care alone 

may not ensure that a registered nurse is adequately prepared to function as a triage nurse. To 

perform triage with a high level of accuracy and competence, registered nurses should complete a 

triage-specific educational program, as well as other appropriate courses and certifications, and 

should demonstrate qualities ... that facilitate successful triage ... Emergency nurses should 

complete a standardized triage education course that includes a didactic component and a clinical 

orientation with a preceptor prior to being assigned triage duties." 

To ensure that veterans have access to appropriate nurse triage processes, the VHA needs to 

recognize and adopt the community standards for triage nurse qualifications. The VHA also needs 

to prioritize the development of standardized nurse triage protocols. 

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VHA failure to prioritize the standardization of nursing triage. 

The VHA has not responded to multiple avenues by which I have emphasized the importance of 

implementing standardized triage training, establishing minimal nurse qualifications, and 

developing triage protocols. Conversations with VA administrators locally and nationally have not 

resulted in any known actions. My Phoenix ED nurse triage training suggestion never received a 

response. Most recently, I even submitted the idea through the MyVA Idea House. The feasibility 

was rated as "easy", the effectiveness was rated as "extremely", and veteran/employee/outcome 

categories were rated as "high". Unfortunately, the idea was not elevated to the next level of VHA 

consideration because it was rated low at only a "3" on a scale of 1-10 in terms of "urgency" and 

given only a "6" on a scale of 1-10 in the category of "importance". Because the VA mission is to 

care for "those who have borne the battle" it is inconceivable to me that triage nursing care, a 

critical element in patient care, is ranked so low on the priority list. 

Availability of inexpensive online triage training modules & nursing triage protocols. 

Within the private sector market there are many face-to-face and online triage training modules 

that cover the ED nurse triage basics and separate courses that teach that teach geriatric ED triage 

and psychiatric emergency triage. To my knowledge, despite the availability of these courses, 

neither the local VA nor national VA administration has attempted to make those modules 

available for triage nurses. The VHA has not developed its own triage training modules. Ironically, 

while ignoring nurse triage training, the VHA remains the leader for physician resident training. 

(One example of inexpensive on-line training courses are those produced by the ENA. The ENA 

fee for general nursing triage review is $500 total for a group of up to 20 nurses who would then 

be able to take the intense online triage training modules. It would take $1000 total to provide 

modules to the 34 nurses at the Phoenix VAMC. The fees for geriatric and psychiatric emergencies 

are reasonable but substantially higher because those costs are on a per nurse basis.) 

Standardized nursing triage protocols are quite common in the community. Unfortunately, VHA 

has never adapted any for use within VA facilities. The OMI found deficiencies in the Phoenix VA 

ED nurse triage protocols. These deficiencies would likely be mirrored in the triage protocols in 

other VA facilities because there are no national VA standardized triage protocols. 

Specific strategies to ensure Phoenix VA and other VA medical centers review & improve ED triage 

nursing care. 

In order to promote safe, consistent care in VA Emergency Departments across the nation, the VA 

should formally define VA ED nurse triage qualifications in order to perform triage, implement 

standardized triage training, and establish standardized ED nurse triage protocols. This is the best 

method to ensure that veterans presenting to VA Emergency Departments receive high quality 

care. 

In the interim, based on the 2015 OMI Phoenix VA ED report recommendations, Exhibit A contains 

items that would serve as positive steps toward swiftly and proactively ensuring the safety and 

10 

quality of care for patients presenting to the Phoenix Emergency Department or walk-in Mental 

Health Clinic. 

In addition, elected officials have the ability to evaluate how well his or her respective home state 

VA facilities/VA Emergency Departments are performing. Initial strategies for monitoring VA ED 

performance at Phoenix and elsewhere are listed in Exhibit B. 

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Section Ill: Phoenix VA Consult/Appointment Delays Contribute to Deaths 

The VHA has stated that any consult not completed after 90 days be reviewed if a veteran has died 

before that consult could be completed. The purpose of the review is to determine if the delay in 

consult completion could have contributed to a patient's death. When a delayed consult does 

contribute to the death of a veteran the local VA facility is supposed to disclose this information to the 

family. 

The national VA has offered no guidance on what to do with consults less than 90 days old if the 

veteran has died. Some facilities will do a review to determine if the delay in consult contributed to 

the veteran's death. Other facilities simply close the consult and never look deeper to see if the delay 

in consult care contributed to the veteran's death. 

In the event of a patient's death there is no quality mechanism at the Phoenix VA that automatically 

reviews consults less than 90 days old. 

When a Phoenix VA patient dies with a recent consult (<90 days old) that has not been completed, the 

consult is administratively closed. There is no automatic review of those consults to determine if the 

veteran's death could have been delayed or prevented had he or she had the consult completed. 

There are recent cases where Phoenix VA veterans potentially died because of lack of timely follow-up 

appointment or consult. 

The VA Office of Inspector General issued a 2015 report regarding the life-threatening delays in 

Phoenix urology consults. When I reviewed the OIG's Phoenix VA 2014 report regarding deaths on the 

waiting list, I found several instances where delays in care reasonably contributed to a patient's 

untimely death. However, these are not the only areas that were affected. I recently have found cases 

where a consult delay potentially appeared to have shorted patients' lifespans. 

I became aware of these cases a few months ago when I was contacted privately by a Phoenix VA 

employee who was concerned about the closing of recent consults (<90 days old) belonging to 

deceased patients without actually ever reviewing the chart. Based on information received, I 

reviewed 78 charts wherein a pending consult was discontinued because a veteran died. None of the 

charts appeared to have been reviewed by quality management staff or a clinical reviewer. 

Based on my review, in 74 cases a delayed consult did not appear affected the veteran's lifespan. 

However, there were 3 cases where the consult, if done in an appropriate time frame, potentially 

could have delayed or prevented death. There was one additional case where the delay may not have 

affected lifespan but certainly constituted inhumane/callous treatment. Those cases are as follows: 

Case 1: A veteran with severe heart disease/cardiomyopathy was eligible for an lCD (implantable 

cardiac defibrillator) that would prevent death by shocking his heart back to a normal rhythm if he 

developed a life-threatening heart rhythm. The original consult for the lCD placement was ordered on 

in late Spring 2015 to be done at Tucson VA. However, per Tucson consult note done 5 days later, the 

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patient was symptomatic from abnormal heart rhythms yet the VA could not place the lCD in a timely 

fashion. The vet opted to have Fee Basis consult for lCD placement so it could be placed sooner. The 

Tucson provider indicated the Phoenix provider would order the Fee Basis/non-VA care consult. 

However, there was no evidence of the fee basis consult/non-VA care consult ever being ordered in 

the chart. As a per a chart note about 16 days after the Tucson appointment, the patient had a 

pending cardiology appointment but doesn't specify where the appointment was to be 

done. Unfortunately, the patient died on about one week later with no evidence of a cardiology 

follow-up appointment having been done and no evidence of a non-VA care consult for lCD placement 

even though he clearly was symptomatic with heart arrhythmias 25 days earlier. (I don't have access 

to TriWest portal to confirm that there was no private lCD appt.) 

Issues of Concern: The community standard would have been to place the lCD within one week at the 

latest if no symptoms were present. When a patient is symptomatic from arrhythmias, the community 

standard would be to place the lCD within 24 hours. Unfortunately, this high risk cardiology patient at 

risk for life-threatening arrhythmias died one month after his cardiologist first recommended lCD 

placement that could have treated those arrhythmias immediately and prevented death. 

Case 2: A veteran had a cardiac catheterization in Spring 2015 that showed significant abnormalities 

which would indicate he needed cardiac bypass surgery (CABG). The veteran was told the 

results/options at a cardiology clinic appointment 2 weeks later. Because the patient desired surgery, 

a consultation to discuss CABG surgery with Tucson VA surgeons was placed at that appointment. For 

reasons not entirely clear, the patient stated it was a burden to travel to Tucson and desired a surgery 

locally. A non-VA care consult was ordered about 9 days later. The patient died the next day, about 3 

weeks after the initial cardiac catheterization that clearly identified the need for CABG surgery to 

prevent death. 

Issue of Concern: In the community the CABG surgery would have been discussed at the time of the 

heart catheterization and a consult would have been placed immediately for the patient to have the 

surgery. There would not have been a 3+ week delay to refer him to a community provider who could 

perform the CABG. 

Case 3: A very elderly male with new onset aflutter (heart arrhythmia), worsening ejection fraction 

(ability of the heart to pump), and bilateral blood clots in his legs was discharged from the hospital and 

scheduled for a post-hospitalization cardiology follow-up in a reasonable time frame in Spring 

2015. The cardiology provider was sick so the post-hospitalization follow-up appointment was rescheduled for almost a month later for this high risk patient. The patient died about 2 weeks before 

that follow-up appointment. 

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Issue of Concern: In the community a post-hospitalization visit for such a high risk patient would have 

been completed sooner and may have been able to address/prevent medical complications that 

ultimately led to the patient's death. 

Case 4: A veteran with newly discovered gastrointestinal cancer mass died before he had the work-up 

completed for the cancer and before he was ever told his prognosis. A large cancerous tumor was 

seen on VA endoscopy in midsummer but a VA staging CT scan was not done for 2 weeks. There was 

no evidence of an oncology appointment for the patient. The veteran was doing poorly at home from 

a physical standpoint with difficulty eating/drinking fluid/caring for self. The wife pleaded with VA 

staff to have the patient admitted for work-up/cancer treatment. In desperation, the wife finally took 

the veteran to a private hospitallO days after the CT scan. The VA was notified by the private hospital 

and approved stat non-VA care consults for radiation and surgery to be done at the private 

hospital. Unfortunately the patient died on the same day those stat consults were ordered. 

Issue of Concern: Cancer staging work-up was not expedited/completed for this patient with gross 

evidence of cancer nor did he have timely referral to oncologist prior to his death. Without actual 

work-up results it is unclear if a timelier work-up would have changed the course of this suspected 

advanced disease but it is clear that such a work-up/oncology appointment would have been a more 

humane method of dealing with this veteran/family instead of leaving them in limbo for 3+ weeks until 

the wife initiated taking the veteran for private care. 

(In general, because the system is so complicated to navigate, the national VA should recommend the 

facilities have a cancer care coordinator to expedite appointments/work-ups. Such a coordinator 

would help prevent patients from needless delays in care and stop patients from "falling through the 

cracks" in the VA system.) 

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Section IV: Persistent Culture of Whistleblower Retaliation within the Phoenix VAMC 

and Other VA Facilities 

Publicly coming out as a Phoenix VA whistleblower in April 2014, I reported many Phoenix VA 

issues including unsafe conditions in the Emergency Department, whistleblower retaliation, and 

facility scheduling irregularities. I eventually was able to transfer away from the Phoenix VA senior 

administration that condoned years of retaliation against me. 

I currently work within the VA Veterans Integrated Service Network (VISN) 18 Gilbert, Arizona 

office as a Specialty Care Medicine coordinator. I have been able to freely report serious patient 

care safety deficits to the VISN leadership who have been receptive to such notifications. 

Unfortunately, I am not told the outcome of the care situations I report. Although I have not been 

allowed to be involved in Phoenix VA ER/Mental Health Clinic issues, I have been able to do other 

quality management projects to help improve patient care elsewhere. 

My interaction with Phoenix VA employees amid persistent culture of retaliation within the 

Phoenix VA. 

Although I do not physically work inside the Phoenix VA, I have maintained communication with 

Phoenix VA employees. Over the last 20 months since the access scandal broke, I have been 

contacted privately by staff in the Phoenix VA service lines of medicine, nursing, social work, 

mental health, and environmental management. The information they have shared has varied 

upon the circumstances, but the common concern remains a strong fear of facility administrator 

retaliation for reporting patient safety deficits, inappropriate staff behavior, policy violations, and 

consequences of delayed care. 

Although I have not been allowed to actively address the known deficits at the Phoenix VA 

Emergency Department or the Mental Health Clinic, I peripherally have dealt with patient care 

issues inside the Phoenix VA in both an official capacity and as a private citizen. I have provided 

some Phoenix VA employees with suggestions on how to address issues for those who fear 

retaliation if they openly report conditions to Phoenix VA administration. For immediate patient 

care concerns I rapidly notify VISN leadership of the patient care issues while keeping anonymous 

the identity of the Phoenix VA employee. 

VISN 18 leadership has been receptive to my notifications and have stated they will investigate. 

However, in my current position I am not routinely privy to the outcome of those investigations. 

Some issues I have reported include inadequate stroke care for veterans in the ED, deliberate 

understaffing of a busy mental health clinic for the convenience of supervisor's personal schedule, 

inappropriate actions of ER nurses, and patients whose deaths may have been prevented iftheir 

consults had been completed in a timely fashion. 

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Phoenix VA administrators who retaliate remain in key positions. 

I am not surprised that there remains persistent Phoenix VA front-line employee fear of senior 

management's willingness to retaliate. Several of the offending senior administrators have 

voluntarily left the Phoenix VA without ever facing any consequences for their retaliatory 

behavior. Other unscrupulous Phoenix VA administrators and supervisors remain in positions of 

power. 

Within the last 20 months, Phoenix VA employees in mental health, medicine, and social work 

service have described to me ongoing retaliation for reporting poor patient care and violations of 

policy. Brandon Coleman, a Phoenix VA mental health specialist, has remained on administrative 

leave for most ofthis year. Based on all available evidence, it appears he was placed on that leave 

in retaliation for publically reporting the series of patient elopements from the Phoenix VA ER. 

The case of which I am most aware involves the senior executive who flatly declined in April 2012 

to ever investigate the overt ED nursing retaliation against me that greatly impeded my ability to 

care for ill veterans. He refused to investigate even though five other ER physicians and I 

simultaneously told him that nurses were delaying my orders, not giving me verbal reports, 

refusing to hand me EKGs, and not answering my questions in the nurses' station. Not only did 

that his refusal to investigate violate local and national VA policy, but it also violated basic medical 

ethics. 

An internal VA Office of Accountability and Review (OAR) investigation in August 2014 cited this 

same administrator as retaliating against me. Unfortunately, the OAR team never interviewed any 

of the physician witnesses to the administrator's actions during that April 2012 meeting so the 

OAR report listing his retaliatory behaviors is grossly incomplete. I subsequently learned that this 

administrator had retaliated against two other Phoenix VA physicians who reported patient care 

deficits in other areas of the Phoenix VA. Unfortunately, this senior administrator has not been 

held accountable and remains in a position of power. It is concerning that this unethical and 

ineffective executive is making daily decisions that affect the quality of medical care for all Phoenix 

VA veterans. 

In December 2014 Jose Riojas, VHA Chief of Staff, sent a letter to the Office of Special Counsel 

stating that an administrative board of investigation (AlB) would be convened "to resolve 

leadership accountability issues presented in the [November 2014 OM I] report and in related 

retaliation claims". I have not been notified of any such AlB. 

(Please note that the OAR investigators also concluded that two mid-level management physicians 

had also retaliated against me when they were my supervisors. Although these individuals 

enacted retaliatory measures, I believe they were simply following orders from their respective 

senior administrator in a system that did not allow these physicians to do anything other than 

carry out such orders from senior executives. If they had refused to do those orders/perform 

those retaliatory actions, both physicians immediately would have jeopardized their own VA 

careers and risked suffering a cascade of events leading to their own termination. They had no 

practical avenues to seek help. Although I did not agree with their actions, I truly believe both 

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men are deeply dedicated to the VA system and are extremely effective administrators except on 

those rare occasions when their superiors backed them into an untenable situation. I do not 

believe it is either just or wise to discipline these physicians who were at the mercy of unethical 

senior executives.) 

Phoenix ED nurses who retaliate remain in the Emergency Department. 

Phoenix VA ED nursing retaliation against me is not a pressing issue by virtue of my transfer from 

the area. However, it remains very disconcerting that several nurses who compromised patient 

safety via retaliation against me are still actively working within the Phoenix VA Emergency 

Department (ED). Their demonstrated willingness to jeopardize patient care poses an inherent 

danger to all future Phoenix VA ED patients if those nurses choose to penalize a particular 

physician or colleague for identifying ED triage issues. In addition, lack of accountability for their 

retaliatory actions has a chilling effect on physician willingness to call attention to those ED 

nursing care problems which are still present today. 

National VA investigation into Phoenix VA retaliation against me deliberately obscures evidence of 

nursing retaliation. 

Despite a VA Office of Medical Inspector (OM I) investigation, I have never been asked by any VA 

administrator or investigator locally or nationally to identify the nurses who retaliated against me. 

While the OMI report substantiated nurses' complicit disregard for my orders, it failed to 

substantiate my allegations of nurses withholding verbal report from me or other types of 

retaliation. 

Unfortunately, even though the VHA restructured the OMI in July 2014, the VA OMI investigation 

into those nurses' behavior appeared to be deliberately geared not to find any results of such 

retaliation. The VA OMI investigators failed to ask any pertinent questions of the Emergency 

Department (ED) physicians with whom I had worked closely for 3+ years and who had first-hand 

knowledge of the retaliation I experienced. Although the original investigative team spoke with 4 

of these physicians during a September 2014 investigation, I was informed by some of those 

witnesses that no questions were asked about specific retaliatory actions toward me. On the 

second site visit, none of these physicians were interviewed even though locating these ED 

physicians should have been a very simple task- all of them are still currently employed within the 

Phoenix VA ED. On both site visits for the OMI investigation, the OMI team did not interview ED 

front-line nursing staff including any of the nurses with whom I worked for up to 10 years prior to 

my involuntary transfer from the ED. Many of those nurses are still employed by the Phoenix VA 

and were witness to the retaliatory actions of a select group of ED nurses. Investigation witnesses 

on the second site visit told me that no questions were asked about the retaliation against me. 

In stark contrast, the VA OMI investigators did take the time to interview 6 nursing administrators 

and executives, all of whom were part of the nursing chain of command that repeatedly failed to 

halt the overt retaliation against me that was impeding the care of ill patients in the ED. That 

nursing chain of command was also the group that refused to launch any systematic 

improvements in nurse triage care despite the hundreds of cases of serious triage mistakes that I 

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reported to them. Those nursing administrators have a strong motive to deny that such retaliation 

occurred. The OMI team also accommodated interviewing 3 other VA executives who were 

directly responsible for retaliatory actions against me through the chains-of command for 

medicine and human resources. 

"Sham" professional peer reviews at VA facilities nationwide discourage/discredit actual VA 

physician whistleblowers and prevent appropriate physician retention and recruitment. 

In the private health care arena, a professional peer review board is initiated by a health care 

facility 9.D.lv when there is legitimate concern a particular physician may not be following medical 

standards of care. The impartial members ofthis peer review board complete a formal, lengthy 

review done of a physician's cases to determine if the medical care was appropriate. The 

physician who is the subject of the peer review has the opportunity to review all cases in advance 

and appear in front of the peer review board to answer questions or explain medical decisionmaking. The final outcomes are based on objective findings of the peer review board, not 

subjective opinion or hearsay. 

If the professional peer review board determines the physician's professional practice constitutes 

substandard care or grossly inappropriate behavior, the physician often will lose some or all 

privileges to practice at that medical facility. When the medical performance deficits are 

significant, the professional peer review board will report a physician to the state medical licensing 

board. In either case, the consequences for the physician are severe and can impede further 

employment opportunities in any setting. 

In the VA system, illegitimate professional peer reviews are used to strategically punish physician 

whistleblowers and discourage other physicians from openly identifying facility care issues. For 

instance, if a physician has repeatedly reported facility safety issues, the physician's supervisor 

may suddenly announce the physician's practice is substandard and place the physician on 

administrative leave. The peer review board will be assembled and usually consists of an 

unscrupulous administrator and his or her cronies. Without having any legitimate care concerns 

identified, a crooked professional peer review board will pull a random assortment of the 

physician's patient charts and state those charts contain evidence of substandard care even 

though no violations of care exist. 

Even though no legitimate medical care issues found in the patients' charts, this board will still 

hold a hearing. The physician is often not provided the patient records in advance and cannot 

prepare any defense. At the board hearing, patient cases are generally not reviewed but instead 

there is discussion of problems reported by unnamed employees. Without any objective evidence 

of substandard care or legitimate testimony of improper physician conduct, the professional peer 

review board then concludes the physician is "unsafe" or "undesirable" and can no longer be 

employed by the VA. In many cases the peer review board reports the physician to a state medical 

licensing board. 

The purpose of the "sham peer review" is to sabotage a physician's credibility/professional 

reputation, scare the physician into silence, and, in the extreme, prevent future employment in 

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any facility. Although a physician can overturn a sham peer review, the process can take years 

during which the physician is professionally and financially devastated. I am aware of 5 instances 

of such sham peer reviews over the past few years with Dr. Huttam's case being an example from 

the Phoenix VAMC. (Of note, Dr. Huttam's case involved the same administrator who retaliated 

against me.) 

Unfortunately, such sham peer reviews are not defined by legal statute as a prohibited personnel 

practice so the Office of Special Counsel generally does not intervene. VA supervisors and peer 

review board members face no VA repercussions for participating in such reprehensible and overt 

retaliation against whistleblowers. 

There are many other common tactics commonly used against physicians and other VA employees 

in order to discourage the reporting of serious VA problems and ostracize/fire employees who 

dare voice concerns. The end result of physician retaliation is that veterans are denied the skills of 

talented, well-qualified physicians when those providers are relieved of patient care duties or fired 

due to unjustified accusations of poor medical skills or substandard conduct. Patient care is 

delayed as yet another VA physician chooses to resign or retire instead of facing a sham peer 

review. VA physician vacancies go unfilled as promising physicians avoid the VA's well-known 

reputation for retaliation against employees. 

Sham professional peer reviews and other tactics endanger patient safety by suppressing 

legitimate care concerns. 

In a system where there is rampant whistleblower retaliation or fear of such retaliation, qualified, 

dedicated VA employees from all service lines are prevented from providing high quality care and 

services for veterans. Every veteran suffers when legitimate patient care safety concerns in the 

medical facility are ignored or suppressed by dishonest administrators. Potentially dangerous 

health and safety problems perpetuate when front-line advocates for quality care are removed 

from clinical settings. 

The VA will only be able to fulfill the mission to "care for him who has borne the battle" when 

employee whistleblower retaliation ends and supervisors are held accountable for their actions. 

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Exhibit A: Specific Steps to Ensure the Phoenix VA Compliance with OMI Report 

Recommendations 

The following actions, based on OMI Phoenix VA report recommendations, would serve as positive 

steps toward swiftly and proactively ensuring the safety and quality of care for patients presenting 

to the Phoenix Emergency Department or walk-in Mental Health Clinic: 

1. Request the facility formally verify that it has followed the OMI recommendation to 

perform "a review of training and educations records to assess whether nurses have 

appropriate training and experience necessary to work in the ED, in accordance with 

Emergency Nurses Association (ENA) guidelines. " (Those ENA guidelines require that a 

triage nurse complete a formal, didactic training course prior to being placed in a triage 

role.) 

While the OMI did not specifically state the mental health triage nurse training 

records/qualifications should be reviewed, the OMI identified unsafe conditions in the 

mental health clinic triage. Therefore, it the training and qualifications of nursing triage 

staff there should be reviewed. 

2. Request that the Phoenix VA provide specifics regarding the number of ED and Mental 

Health triage nurses that currently have completed a formal didactic triage training course 

(other than ESI training) and the dates/types of those training courses. (This allows 

baseline assessment of triage training in those high risk areas. This specifically should not 

include any TMS or ESI training because neither type of course confers basic triage 

assessment skills.) 

3. Request that the Phoenix VA leadership verify and provide evidence of a concrete plan with 

an actionable time table for providing timely, standardized training to all triage nurses in 

the Phoenix VA ED and Mental Health Clinic who have not completed formal, didactic 

triage training. (This forces the Phoenix VA to develop a specific, concrete action plan 

instead of allowing it to brush off the inquiry by stating the issues are "being reviewed". 

The management still has not come up with a plan even though it has had access to the 

OSC/OMI report internally since March 2015.) 

(They do have a proposal to have out-of-state VA personnel come to "assess" triage in 

likely December 2015 but that is an extremely limited/slow plan considering the magnitude 

of the problem and there has been internal assess to the OSC report for 8+ months. 

Phoenix VA leadership have known that the OMI called the Phoenix VA ED a "significant 

risk to public health and safety" since at least March 2015 and yet have done nothing 

significant to improve the triage skills except to have the nurses complete a short ESI 

training module. As previously stated, ESI training is ineffective if the nurses aren't able to 

recognize serious symptom presentation.) 

4. Request that the Phoenix VA provide proof that it has updated all nursing triage protocols 

to address the inadequacies noted by the OMI report, specifically following the OMI 

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recommendation to "revise all diagnosis-based protocols to make sure they are symptombased". 

5. Request that the Phoenix VA verify and provide evidence that it has established a local 

performance metric for ED nurses on timeliness of procedures, e.g., EKGs and medication 

orders, to make sure that ED nurses adhere to standards of care. 

6. Request that the Phoenix VA verify and provide evidence that it has established a local 

performance metric for ED staff on proper specimen labeling procedures to eliminate 

processing errors, and repair the label printers to prevent labels from being improperly 

printed. 

7. Request that the Phoenix VA provide verify and provide evidence of 24-hour coverage of 

the Vascular Service by qualified vascular technicians as recommended by the OSC/OMI 

report. 

8. For any negative responses to items 4-8, request that the Phoenix VA provide a detailed 

explanation why it hasn't completed the recommendations of the OMI report that has 

been available internally to the VHA/Phoenix VAMC since March 2015. 

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Exhibit B: Evaluating Nurse Triage Care & Staffing in VA Emergency Departments Nationwide 

In order to promote safe, consistent care in every VA Emergency Department (ED) across the 

nation, I urge Congress and the public to demand that the VA to establish minimum qualifications 

for VA ED nurse triage, define appropriate triage training, and develop ED nurse triage protocols. 

These are the best methods to ensure that veterans presenting to any VA Emergency Department 

consistently receive high quality triage care. 

In the meantime, each elected official has the ability to evaluate how well his or her respective 

home state VA facilities/VA Emergency Departments are performing. Initial strategies include: 

1. Ask the facility to provide the number of patients with an ESI rating of "4" and "5" who 

were admitted to the hospital each month. According to the ESI system, only patients with 

ratings of 1, 2, or 3 are considered to have symptoms severe enough to potentially require 

admission. According to the ESI, patients assigned a "4" or "5" rating should have only 

minor medical problems and, with extremely rare exceptions, never require admission. If a 

patient rated as a "4" or "5" was admitted, then quality management should review the 

case. This could indicate a severe problem with ED nurse triage symptom evaluation. 

2. Ask the facility to provide the number of ED patients who "left without being seen". This 

represents the number of ED patients who were triaged but left without seeing a medical 

provider. This number can easily be generated on a daily basis by the facility. It indicates 

that patients were waiting so long that they chose not to remain. Although this may not be 

reflective of poor quality triage, this does indicate an issue with ED patient flow and 

capacity. Typically, in poorly staffed Emergency Departments this number flares on 

weekends, the day before a holiday, and the first business day after a holiday. With the 

exception of Thanksgiving and Christmas, most holidays will also have a high number of 

patients who left without being seen if that ED hasn't specifically prepared for the 

onslaught of veterans presenting for care. 

3. Ask the facility to provide the number of patients who waited "more than 6 hours". This 

number is tracked on a daily basis and is easy to obtain. Large numbers of patients waiting 

greater than 6 hours indicates problems with flow and capacity either within the ED or 

within the hospital. Often, when this number is high, the quality of triage deteriorates and 

seriously ill patients can wait hours for treatment. As noted above, flares in this number 

will occur during peak flow times such as weekends, the day before a holiday, the first 

business day after a holiday, and on most holidays except Thanksgiving and Christmas. 

4. Ask the facility to provide the number and type of patient advocate complaints regarding 

any aspect of care in the Emergency Department. If the patient advocates are 

documenting patient complaints appropriately, those complaints are logged into tracking 

software and can be recalled by specific clinic name including "Emergency Department". 

5. Ask the facility to report any ED complaints logged into the EPERS (Electronic Patient Event 

Record System). EPERS reports include actual bad outcomes as well as "near misses" 

22 
32 

The CHAIRMAN. Thank you, Dr. Mitchell. 

I believe we are still waiting on Ms. Morris. If she arrives, you 

can please let her know that she can join the witness panel. We 

will submit her written testimony, which I have read, for the 

record for this hearing. 

Now, what we would like to do is begin with some questioning 

of the witnesses to have a discussion of these issues. Out of respect 

for my colleagues from Arizona, I will defer my questions until 

after they begin. We will begin with Senator John McCain. 

Senator MCCAIN. Thank you, Dr. Mitchell. Would you pull that 

a little bit closer so that we can hear you a little better? Thank 

you. 

Dr. Mitchell, you have watched the evolution of events, legislation, the Choice card, and all of that since the beginning of the terrible scandal here at the Phoenix VA, as we all know. What would 

you say has been the degree of progress or lack of progress since 

that happened? 

Dr. MITCHELL. The VA has made progress. It was so far down 

in the hole as far as being behind in its ability to care for patients 

that any improvements are greatly welcomed. However, there are 

still too many patients waiting to be seen. 

It is very difficult to get appointments through the Choice program, now patients are no longer delayed waiting on the Phoenix 

VA waitlist, now they are delayed waiting on a Choice waitlist either through problems or difficulty reaching them. 

There certainly has been more staffing across the board—physicians and other ancillary service personnel—so that is an improvement. However, there is still incredible difficulty getting things 

scheduled in the VA. Consults that are needed are delayed because 

they do not have adequate providers. 

Senator MCCAIN. I do not often talk about my own involvement, 

but I negotiated with Senator Sanders for the VA reform legislation 

that was passed overwhelmingly by both houses of Congress. I 

wanted a Choice card for everybody, no matter what. In the negoVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6601 Z:\ACTIVE\121415.TXT PAULIN

1214psMIT23.eps
33 

tiations, I had to agree to the 40-mile distance or time on waiting 

list. 

Do you believe that we should go back over the criteria with the 

Choice card and make it available for every veteran, no matter 

where they are geographically located or any amount of wait time? 

Dr. MITCHELL. I think the Choice card is a great idea, especially 

for specialists for which the Phoenix VA and other VA’s are shortstaffed, and for which there are considerable delays in care. 

The VA infrastructure is incredibly good. Although I am talking 

about the cracks in the VA care, the actual VA nationwide has millions of high-quality episodes in patient care every single year. The 

veterans who are able to get into the system, in general, are very 

happy with the care, and they get better care than they would in 

the community. 

I do think that the Choice program needs to be restructured because veterans are still waiting, and whatever structure changes 

can be made to decrease the wait are important. 

The other thing is that you need to look at the reimbursement 

for Choice providers. Part of the problem is not the fact that Choice 

cannot make appointments. It is that Choice cannot make appointments because they do not have providers signing up. The Choice 

reimbursement is much lower than the payments for non-VA care 

under other programs, and lower than Medicare. That should not 

be the case. 

Senator MCCAIN. Mr. Byers, do you have a view on the Choice 

card? 

Mr. BYERS. Yes, I actually concur, that we keep the Choice card 

and again remove some of those barriers that veterans are having 

difficulty with, and some of the language. The language is still not 

very clear to a lot of the veterans that we see. 

When it works, it works well. I can say that because I used the 

Choice card with TriWest, and they were able to get me a provider 

that provided the services for me. Yet, I still feel that we should 

have the Choice card. It is an insurance policy for us veterans. I 

think it is important that we keep it. 

Senator MCCAIN. Well, I thank you both for being here. 

Dr. Mitchell, we will continue to rely on you. 

I guess just one final question to Dr. Mitchell. Maybe this is not 

a fair question, but I feel compelled to ask it. Would you go to the 

Phoenix VA emergency room for care? 

Dr. MITCHELL. Absolutely not. There is a reason for that. There 

are physicians in that ER that are the best in the State of Arizona. 

There are nurses that fill that ER who are the most professional 

I have ever worked with. The problem is that you have to get past 

nursing triage, and you have to get past the flood of patients. 

Right now, the Phoenix VA health care system does not have a 

good way of dealing with urgent care patients, patients who do not 

need emergency care but certainly have issues that cannot wait 

until the next business day or the third business day or whenever 

the clinics can schedule them. As a result, you have a whole pool 

of people bearing down on this very small emergency room which 

dilutes getting care to people who are really sick, as opposed to getting care to people who can just wait. 

34 

There is no standardized triage training. Without that, it is the 

luck of the draw if you have a triage nurse who knows what they 

are doing. 

Frankly, in my particular case, the nurses who retaliated against 

me by impeding my care for ill patients, most of them still work 

in the ER, and I do not trust their professionalism not to impede 

my care. 

Senator MCCAIN. Thank you. 

Mr. Chairman, I think I would like to just add a comment for 

the record. 

We are deeply concerned, or we would not be having these hearings, we would not be passing legislation to try to fix it. 

On Veterans Day, after the parade, I went down to Phoenix VA 

and people who are in the hospital there are well-treated. We do 

have many dedicated people who are working there. There has 

been some improvement. 

Having said that, I think we should give credit to a lot of the outstanding men and women who are serving there. I think fundamental changes still have to be made in order to allow these dedicated men and women who are working at the VA to exercise their 

full capabilities. Right now, I do not think that is exactly the case. 

If there is one issue I would like for us to continue, which you 

and I and Senator Flake have had numerous conversations with 

Chairman Isakson, is to make the Choice card completely available. 

I thank the witnesses. 

The CHAIRMAN. Thank you, Senator McCain. 

Senator Flake? 

Senator FLAKE. Thank you. 

Mr. Byers, just to get an idea of how things have improved or 

have not improved, if you were to arrive today just like you did a 

few years ago from New Jersey, not knowing what you know now 

about how to navigate through the system, how long do you think 

your wait time would be for the same issues and needs that you 

had? What would be the change today from what it was before? 

Mr. BYERS. I can answer that because I deal with a lot of veterans who come to me for eligibility and they need to get into the 

VA health care system. 

They go through eligibility and at least within 30 days they are 

assigned a primary care doctor. That is what the appointment says, 

and that is where they go. 

Senator FLAKE. That would have taken how long when you got 

here? 

Mr. BYERS. I got here in August and I saw a doctor in November, 

but I was told it would be almost a year before I could even see 

a primary care doctor. 

For the veterans today, at least in my CBOC, here in Gilbert, the 

eligibility works very well. If you are in the system, they can get 

you a primary care doctor within 30 days. 

Now the problem is that you have a primary care doctor, but if 

you need any kind of specialty care or anything else that you have 

to have, that is where the bog-down occurs. I have some people who 

have to wait 6 months for an appointment. 

Senator FLAKE. Thank you. 

35 

I should have mentioned in my opening statement, like Senator 

McCain, I appreciate what the city of Gilbert does, the programs 

that they have and the effort that they make to make sure that 

veterans here are treated well and receive the care that they can. 

Dr. Mitchell, you mentioned that the culture has not changed at 

the VA. What will it take to have a change in culture? Is that a 

decades’ long process? How can we expedite that to make sure it 

changes faster? 

Dr. MITCHELL. In my opinion, the Central Office has the ability 

to stop whistleblower retaliation today. They just have not sent out 

the memo that specifically states the penalty for whistleblower retaliation. 

For example, there is a significant amount of retaliation against 

physicians. There are sham professional standards boards, basically peer reviews where they say the physician is incompetent 

when they are not. These boards are held without notifying the 

physician of the accusations, without giving them access to the patient records, without having an impartial board given. 

Then, the ‘‘not impartial’’ board makes a finding, says the physician is incompetent, and either fires them or fires them and reports 

them to their professional standards board. There are very clear 

policies about how professional standards boards are supposed to 

be done. 

In the community, they are done only when there are there serious concerns that a physician is incompetent. I know of seven physicians in the VA system, either current or former, who have either 

undergone these sham peer reviews or are currently undergoing 

them. VA administrators have not followed the rules in each particular case. 

All Central Office has to do, all the Under Secretary has to do, 

is send out a memo that says, at this point, all professional standards board reviews are to be on hold until you get the memo that 

is coming in 10 days. In that memo, we are going to specify that 

the rules need to be followed. Whatever findings your boards have, 

they have to be verified by an independent third party. 

I think that is important because there are physicians who do 

not practice quality of care that need to be covered. Right now, it 

is a tool for retaliation. It is not considered a prohibited personnel 

practice, so the Office of Special Counsel will not get involved. 

Because Phoenix administrators and administrators elsewhere 

have retaliated against physicians—this is becoming well known in 

the community—physicians are not applying for the jobs we desperately need them for. The Central Office needs to come through. 

It needs to declare that it stops today, and then give teeth to it so 

that every chief of staff, every service chief who is involved in a 

sham peer review is held accountable immediately instead of just 

letting the physician fight on their own, which can take years and 

can be financially and professionally devastating to the physician. 

Senator FLAKE. Thank you, Senator Sullivan. 

The CHAIRMAN. Thank you, Senator Flake. 

Mr. Byers, I wanted to follow up on a couple questions. 

Can you explain a little bit about the handoff when you went 

from New Jersey to Arizona. I am sure that is obviously common 

for a lot of veterans to be moving. How did that work? 

36 

Mr. BYERS. From New Jersey, you mean? 

The CHAIRMAN. Leaving New Jersey. I know this is a beautiful 

State, so a lot of veterans are coming here, just like my great State 

of Alaska. 

So, how does that work in terms of the handoff, in terms of the 

ability to just track veterans from one VA center to another? Are 

there lessons that you learned that we could focus on that could 

help improve that handoff? 

Mr. BYERS. I think it should be seamless. OK, you are in a 

VA—— 

The CHAIRMAN. Was yours seamless? 

Mr. BYERS. No. It was not. It was seamless for me to contact and 

work with the Philadelphia VA while I was here because I used My 

HealtheVet. My HealtheVet is a tool that we veterans can use to 

contact our primary care physicians, we can instant message them 

and be able to talk. 

But, when they do not see you, or they cannot, they cannot prescribe medication. So, the medication was the main issue for me for 

that. That is why it was important for me to get a primary care 

physician. 

I had the eligibility. I am priority one. I should not have any 

problems whatsoever going into the VA health care system. But the 

wait time, because they did not have a primary care doctor, that 

was the problem. That was not seamless at all. 

Then when you get into the VA system, they do not seem to be 

talking to one another. 

I understand that we have this great computer system, this 

CAPRI system, where everybody should be able to look at the medical records and see. It took quite a while for that to get transferred 

here to the Phoenix system. I am sure that that process, hopefully, 

has been improved. 

The VA should be portable. It should be portable. If I have to go 

somewhere, I am in the VA health care system, I should be able 

to use it anywhere. 

The CHAIRMAN. Another element about your testimony focuses on 

the delays—obviously, that is something that the Choice Act was 

focused on addressing is these lengthy delays. 

In your written testimony, you noted that you waited over a year 

for your urology appointment. Did it actually take a year or did 

something intervene? 

Mr. BYERS. I requested a urological appointment because I had 

to follow up. This is what the Phoenix VA said when I came to 

Phoenix, to please follow up. 

So, I went to my primary care doctor. As we talked, I said I 

would like to have a referral for urology. I do not know at that time 

if urology was taking referrals. My understanding is that the urology department at the Phoenix VA were very, very thin. I understand there was probably one urologist at that time, and he was 

retiring. He was not taking any new patients. 

I stayed in the process until finally I complained. How I had to 

complain? I had to change my primary care doctor. I changed my 

primary care doctor. I got a new doctor. Probably in all that time 

with all of what was happening here with the Phoenix VA, that is 

when the referral went out, and I got my TriWest appointment. 

37 

The CHAIRMAN. So, initially, they told you 1 year. You complained, and it took how long to get that appointment? 

Mr. BYERS. It took me over a year to get my urological 

appointment. 

The CHAIRMAN. I hope the panelists on our next panel are listening to all of these incidences, because I think that a lot of the explanations have to come from the officials, whether at TriWest or 

the VA, on why 1.5 years after the Choice Act, we still have veterans who are waiting a year—a year—for an appointment. It is 

unbelievable. 

Mr. BYERS. Senator Sullivan, this was before the Choice Act. 

The CHAIRMAN. Let me turn to Dr. Mitchell. I want to follow up 

on Senator Flake’s comments about changing the culture. 

Senator McCain mentioned, and I think we all agree, that the 

VA has many, many great employees who are very dedicated at the 

hospitals throughout the country. But, your written testimony actually ends by saying you do not think the culture has moved in 

terms of addressing it almost at all. 

If you had a magic wand to address not only the facilities that 

you are familiar with here in Arizona, but the VA more broadly, 

how would you focus on starting to address the culture that you 

are still saying has not really moved a bit in terms of being able 

to address some of the huge systemic problems we have in the VA? 

Dr. MITCHELL. I would make sure that everyone sees the consequences for whistleblower retaliation. Frankly, any leader who 

has been confirmed to have done whistleblower retaliation through 

an OSC investigation or an Office of Accountability investigation 

needs to be removed. 

Right now, Senior Executive Service are held to a different 

standard of behavior than the rest of the frontline employees. The 

frontline employees are grossly aware of that. Things that senior 

administrators do and get away with are things that frontline employees would be fired for immediately on the spot. That needs to 

change. 

It is not that there is a lack of people who are really good and 

dedicated to the VA, you are right. It is a problem that there are 

a few in positions of leadership who are making bad decisions for 

the entire VA. 

I am appalled at the lack of accountability for leadership. Frankly, I am really disappointed in the Central Office, that they have 

not come down and truly held—Senior Executive Service, they 

should be held to a higher standard of behavior than the rest of 

us. 

I would also like to state, although the Senior Executive Service, 

I certainly have known several that were less than stellar, there 

is one, Lisa Freeman out of Palo Alto, who rotated to the VISN office where I worked; she embodies some of the best characteristics 

of the Senior Executive Service I have ever met. The Central VA 

Office needs to take recognition of leaders like her and have them 

train the newest leaders coming up. 

The CHAIRMAN. Let me ask you two follow up questions that relate to culture. You mentioned it. Senator McCain mentioned that 

the Choice Act does provide the Secretary of the VA with significant authority to remove officials who have underperformed or perVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6601 Z:\ACTIVE\121415.TXT PAULIN
38 

formed in a way that should require their termination. Do you 

think that the VA is actually doing that or utilizing that authority? 

Is that a way in which to help change the culture, to hold more 

officials accountable? 

Dr. MITCHELL. I do not think the VA is investigating the issues 

of retaliation seriously enough. In my particular instance, there 

was an Office of Accountability review investigation. I was interviewed last. 

The team refused to interview any of my physician witnesses, 

which could describe clearly multiple episodes of retaliation. The 

administrator who was involved was found guilty of retaliation in 

one instance when actually he was guilty of retaliation in multiple 

instances that not only showed a lack of leadership skills but 

showed a lack of basic medical ethics. 

Someone who refuses to investigate when six physicians tell him 

nurses are impeding care for ill veterans in the ER does not need 

to be in a leadership position, as he lacks basic medical ethics. 

The CHAIRMAN. What about the issue of funding? Since the implementation, since the passage of the Choice Act, the VA has actually received an additional $15 billion to implement this new law 

on top of significant increases in the VA’s budget over the last several years. Do you believe it is a lack of funding for the VA? Or 

is it another issue? 

Some say it is a lack of funding. Others have actually said that 

might even be the problem, in terms of thinking the budget has 

been dramatically increased. 

How do you believe that the funding issue, either too little or too 

much, relates to changing the culture? 

Dr. MITCHELL. I think that the funding issue is part of the problem with the VA, but certainly not the entire problem. 

The CHAIRMAN. Meaning that they are underfunded? 

Dr. MITCHELL. That they are underfunded. The VA provides tremendous high-quality care. Every time we provide high-quality 

care to the veteran, it attracts another veteran. 

Frankly, even in the ER, when they were able to get additional 

staffing to be able to care for veterans, once they had more staffing, 

more veterans came. It is the same across the Nation. There has 

been a 10 percent increase in appointments. 

I do not think the public realizes how big the medical needs are 

for the veteran population. 

What I do think needs to be done also is that some of the funding 

needs to be better managed. I, like other people, have listened to 

the media reports, where I find that funding is being spent on public relations that it should not be or other issues. To give any more 

detailed answer, I am not qualified, because this issue is too complex. 

I do think there needs to be an expert panel looking at it, and 

a panel not of VA employees, but of outside people, such as Secretary McDonald gathering a panel to look at issues. I think that 

those would be invaluable to seeing where the improvements need 

to be made. 

The CHAIRMAN. Thank you. 

Ms. Morris, welcome. We are glad you are here. We would welcome the opportunity to hear your testimony. Please keep it to 5 

39 

minutes, then we will also have a few questions for you. So, welcome. 

STATEMENT OF NICOLE MORRIS, U.S. NAVY VETERAN 

Ms. MORRIS. Thank you. My name is Nicole Morris. I am a Navy 

veteran. I served overseas in Kuwait in 2004. When I came home, 

I was told I was eligible for VA benefits. 

My first experience was a positive experience. There was a procedure that I needed done, which they did not do at the VA. They 

were able to get me to a civilian doctor and have the surgery paid 

for. So, it was a very positive experience. 

However, a few years later, I was experience excruciating stomach pains. I did not have any other medical coverage. I went to the 

ER at the facility downtown at the VA, and I waited for 2 days in 

the ER to be seen. 

The first day, I waited until about 1 in the morning. I was told 

I was not going to be seen anytime soon. Then I went home and 

came back. It was probably around 11 o’clock at night when I was 

finally seen. 

When I was seen, it was very brief. They saw me in the back 

room for about 5 minutes, gave me some pain medicine, and told 

me to go on my way. There was not really an exam of what was 

going on with me physically. There was no follow-up. I was just 

given pain medication and told to go home. 

There were other veterans in the ER at the time waiting that 

had more serious problems. I talked to some of the veterans who 

had strokes, seizures, who were waiting in the ER for a very long 

time. 

I was told there was a priority list. It was not first come, first 

serve, but there was a priority list and I was down at the bottom 

of that priority list. 

After that experience, I did not want to go back to the VA. I am 

a single mom. I am a student. I do not have any other health coverage. It was very disheartening for me. 

I often have to pay out-of-pocket. If I have to go to the doctors, 

I have to pay hundreds of dollars out-of-pocket to go somewhere, 

to the urgent care, if I am sick. 

I have tried scheduling appointments. I no longer have a primary 

care physician. I never saw my primary care physician. It takes a 

month, 2 months to get in, if I want to. 

It is just very disheartening. It is very stressful to try to get an 

appointment. I am on the phone a long time waiting to get an appointment. 

I have been talking to fellow veterans, and they share the same 

stories. 

I appreciate having the VA coverage. I really do. I am thankful 

for it. But, I think that there are big improvements that could be 

done so I can be seen, I do not have to pay out-of-pocket, and that 

my fellow veterans can be seen as well. 

[The prepared statement of Ms. Morris follows:] 

PREPARED STATEMENT OF NICOLE MORRIS, NAVY VETERAN

Good morning. My name is Nicole Morris. I am a Navy veteran who deployed to 

Kuwait in 2004 for Operation Iraqi Freedom. Immediately after leaving active duty, 

40 

I was told I was eligible for VA health care. I needed to see a doctor and the VA 

actually referred me out to the private sector and paid the bill. It was a pretty positive experience. However, several years later and I was still eligible for VA health 

care and was experiencing severe stomach pains. I went to the VA emergency room 

at Phoenix at 8:30 a.m. and waited for someone to see me. Hours and hours went 

by without me being able to see a doctor. I ended up leaving that night because it 

was clear I wouldn’t be seen by anyone. I came back the next day and ended up 

waiting again until 10 p.m. I was finally seen however it was extremely brief and 

I was not given the proper medical checkup to determine the issue. I was issued 

pain meds and released without knowing what my medical issue was. 

There were other times I tried unsuccessfully to get appointments through the 

VA. It was always a hassle. Most of the appointments would be offered one to two 

months in the future. I’m not sure why I am supposed to stay sick for two months 

while waiting for a doctor to be available. Other times I would call and be put on 

hold for 30 to 45 minutes or more. 

Another massive inconvenience was the policy that female veterans who needed 

specific health care specialists could only be seen on Wednesdays. I’m not sure who 

made that policy but it doesn’t make sense to be the VA and only see female veterans one day a week. I work and go to school and also take care of my child and 

the VA’s scheduling just does not meet my needs. 

I also have a close friend from my unit who has more serious complications from 

our deployment than me. She also cannot get seen by the VA for her conditions and 

it is extremely frustrating and disappointing to hear how she struggles and how the 

VA is failing to take care of her. 

I am sure the VA does provide for some military servicemembers’ medical needs. 

But for me it just doesn’t fit. It would be ideal for veterans like me to just have 

regular insurance that others have such as military retirees who are allowed to use 

TRICARE. That way I could call the doctor I choose when I am sick to schedule 

my appointment and not have to work through the VA. It would also help if my 

son/daughter and I could be covered on the same insurance policy. 

Thank you for allowing me to share my experiences with the VA today. I hope 

that this will lead to reforms of the current system and improved care for those of 

us that served. 

The CHAIRMAN. Thank you very much for that testimony, and 

thank you for your service. I will ask Senator McCain or Senator 

Flake if they have any questions for Ms. Morris. 

Senator FLAKE. During that emergency room visit, I cannot 

imagine being there 2 days with just an intervening short time at 

home. What was said during that time? Did they come out and 

check on you? 

Ms. MORRIS. Not at all, no. I often checked in with them. 

Senator FLAKE. There were others in the same condition or similar condition? 

Ms. MORRIS. Worse. There was a gentleman who had a stroke, 

a mild stroke, who I was sitting next to. He was there with his 

wife. 

Senator FLAKE. Did it seem to be just too few personnel there? 

What seemed to be the issue, that you could tell? 

Ms. MORRIS. I do not know. I do not know. 

Senator FLAKE. Dr. Mitchell, is that typical of some of what you 

have talked about? 

Dr. MITCHELL. Yes. What happens is that there is a priority list, 

so the sickest patients are supposed to be seen first. However, that 

depends on if the triage nurse is skilled enough to actually elicit 

the appropriate symptoms. If not, then you are not put in the correct order and priority, and you wait longer than you should. 

There have been instances, which I have reported through the 

VISN office, the network office, even this year where strokes were 

being delayed in being evaluated, which there is this specific stroke 

protocol and that should never happen. There were strokes that the 

41 

nurse did not recognize as a stroke. There were strokes where a 

physician did not recognize it is a stroke, and the veteran was sent 

home only to return 3 days later with an inability to walk, a loss 

of vision, and having to be sent out to another facility that handles 

strokes. 

The other problem is that the ER is physically very small. Originally, it was 11 beds, eight rooms. Now they have expanded, so 

there are 22 rooms, but there are still only approximately eight 

beds that have cardiac monitoring abilities. So, if the facility is 

backed up as far as admissions, then those patients have to be held 

in the ER, and then everything else gets backed up. 

The facility does not allow us to close the ER, or at least it did 

not during the time I was there for 10 years. That means that although you can go on diversion and no ambulances show up, it does 

not stop very ill patients from coming to the ER. If they come to 

your ER and you do not have the capacity to care for the ill patient, 

our facility, at least at the time I was there, did not allow you to 

send them to another ER where they could get care quicker. 

That is an issue that needs to be addressed because there are ill 

patients. 

When you hear from panel two, you are going to hear a lot of 

really good statistics, and the statistics are good in some areas. 

But, there are certain things they are not going to want to mention. One of them is the greater than 6-hour waits in the ER. Those 

are calculated on a daily basis. Another thing that they are not 

going to want to mention are the extreme delays for non-VA care 

consults, which are outside the VA, that are greater than 90 days, 

and also the consult delays that are inside the VA that are greater 

than 90 days. Those numbers are huge. They are huge across the 

Nation. The VA is trying to figure out how to close them all and 

get people the appropriate care. 

You are also not going to hear about statistics like the all-employee survey where the Phoenix VA was in the dumps, as far as 

confidence in leadership and psychological safety, which all play 

into fear of retaliation. 

There are some serious problems in the ER that need to be addressed. There needs to be a way of managing these urgent care 

patients so that they get seen as well as the sickest patients. 

Right now, you are ethically obligated to see the most sick patients. You rely on your triage nurse to be able to identify the sickest patients. If they make a mistake, then sick patients wait too 

long while their conditions deteriorate. 

That has been an ongoing problem since I was there in 2003. It 

just got worse when our intake numbers increased. 

Senator FLAKE. Thank you. 

The CHAIRMAN. Ms. Morris, I had a question relating to your testimony where you talked about the limited hours available to receive gender-specific health care as a huge inconvenience for veterans. Can you talk a little bit more about that, your experience, 

and what you would recommend try to fix that? 

Ms. MORRIS. Sure. For years, the Well Women’s Clinic has only 

been open on a Wednesday. Once again, it was very hard to get 

into that, if I needed something right away. I would have to wait 

a month, 2 months. 

42 

Just recently, they actually changed it so the primary care physician can do the Well Women checkups, if they are designated to. 

However, they have to be accepting new patients in their network, 

they have to be your primary care physician, so not every woman 

probably has a primary care physician who can provide that service. Otherwise, you would have to wait on a Wednesday to receive 

that service. The waiting list is long. 

I think the recent change is a step in the right direction to enable the primary care physician to give those services. Maybe if we 

could open it up so it is not just on Wednesdays at the VA downtown, that would be a good suggestion as well, as I cannot get in 

to see my primary care physician, because right now they are only 

there on Wednesdays. 

The CHAIRMAN. Great. I want to thank the panelists very much. 

I want to thank you all for your service to our country, and, Dr. 

Mitchell, to the VA. 

We will take a brief recess to move from panel number 1. I want 

to invite the witnesses for the second panel to please come to the 

witness table. Thank you again. [Recess.] 

The CHAIRMAN. I want to welcome the second panel. The second 

panel will consist of Dr. David Shulkin, who is the Under Secretary 

for Health at the Department of Veterans Affairs. He is accompanied by Dr. Thomas Lynch, the Assistant Deputy Under Secretary for Clinical Health, and Ms. Kathleen Fogarty, Acting Director, Veterans Integrated Service Network (VISN) 18: Southwest 

Health Care Network. 

We also have Dr. David McIntyre, Jr., who is the President and 

CEO of TriWest Healthcare. 

Dr. Shulkin? 

STATEMENT OF DAVID J. SHULKIN, M.D., UNDER SECRETARY 

FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY THOMAS LYNCH, M.D., ASSISTANT DEPUTY 

UNDER SECRETARY FOR HEALTH CLINICAL OPERATIONS; 

AND KATHLEEN FOGARTY, INTERIM DIRECTOR, VISN 18: 

SOUTHWEST HEALTH CARE NETWORK 

Dr. SHULKIN. Good morning, Senator Sullivan, Senator McCain, 

Senator Flake. Thank you for the opportunity to discuss the improvement of access to and the timeliness of veterans’ health care 

in the Phoenix VA health care system. 

As you mentioned, Senator Sullivan, I am accompanied by Dr. 

Thomas Lynch to my left, who is the Assistant Deputy Under Secretary for clinical operations at VA, and Ms. Kathleen Fogarty, who 

is acting director of the VISN here in the Phoenix region. 

I would like to thank Mr. Byers and Ms. Morris, for their service 

to the country and for their testimony today. I would also like to 

thank Dr. Mitchell for her testimony. We must depend on our employees to be vigilant about potential sources of harm to our patients and to voice their concerns, if patient safety is at risk, and 

they need to feel safe in doing so. 

In September 2014, the GAO issued its report on managing the 

oversight of the consult process. VA concurred with all six recommendations and is taking actions to address the concerns raised 

by the GAO. 

43 

During this past year, VHA completed a national assessment of 

progress note completion and created the technical capability to assess and complete consults. Solutions were implemented by extensive national consult training within all the VISNs, weekly national consult calls, and the creation of a consult training module. 

In October of this year, VA’s OIG Office of Health Care Inspections delivered its evaluation of access to care concerns in the urology service here in Phoenix. It was determined that Phoenix suffered a significant urology staffing shortage, and its leaders did not 

have a plan to provide urological services during that shortage of 

providers. 

To fill this need, VHA has hired six new urology employees since 

January 2013. As of December 7 of this year, the urology service 

had no patients waiting on its electronic waitlist. It had three 

consults waiting greater than 90 days. All three of those have now 

scheduled appointments. Now 99 percent of new patients are seen 

within 30 days. 

Appointment volume doubled from the previous year, while the 

average wait time from the preferred date was at 3 days, 8 days 

lower than it was 1 year ago. Urgent care appointments in urology 

are available the same day. 

VHA’s efforts to issue disciplinary actions in Phoenix and to resolve the administrative leave status of two employees have been 

delayed by our inability to interview witnesses who have not been 

cleared by the U.S. Attorney’s Office, and only recently were we 

given additional evidence by the VA OIG that we had been requesting for the last several months. 

Until we have reviewed all of that relevant new evidence that we 

received, we have been unable to make a determination on what 

disciplinary action may be warranted related to the patient scheduling waitlist issues. These employees are going to remain on administrative leave. 

VA has reached expedited settlements with the Office of Special 

Counsel on the whistleblower retaliation allegations made by three 

employees at the facility. Since some of the subject officials in these 

retaliation cases are the same as those in the patient scheduling 

wait time case, we have not issued disciplinary actions related to 

these retaliation allegations. 

VHA is taking a number of actions in response to the events in 

Phoenix, such as: building partnerships with care in the community providers; reducing wait times; holding a national stand down 

for access this past November; and adding over 630 full-time equivalent employees to the medical center. 

In November 2014, the former medical center director was terminated. On October 20, 2015, Ms. Deborah Amdur was appointed as 

the permanent director. Today is actually her first day. 

VHA is continually monitoring wait times and making adjustments as needed to ensure that veterans have access to the best 

care they rightly deserve. 

During fiscal year 2015, Phoenix VA increased completed primary care appointments by 7.72 percent, mental health appointments by 18.38 percent, and specialty care by 15.25 percent. During this period, Phoenix completed over 680,000 outpatient appointments. Overall, the Phoenix VA has completed 95 percent of all paVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00047 Fmt 6633 Sfmt 6601 Z:\ACTIVE\121415.TXT PAULIN
44 

tient care appointments in fiscal year 2015 within 30 days of the 

date the veteran preferred and the average wait time for all patients in primary care has decreased to 6 days, as of December 7 

of this year. 

The average wait time for all patients in specialty care is 9.1 

days, mental health 4.8 days, and urology 3 days. 

On November 14, 2015, VA medical centers across the country, 

including Phoenix, participated in the first national access stand 

down. Prior to this stand down, there were 1,650 open priority one 

level consults at Phoenix open greater than 90 days. After this 

stand down, there were just 91 priority consults that still needed 

to be addressed and were authorized for care in the community. 

I should say most of those we have been unable to contact. That 

is why there are 91 still left open. 

Although the intent of this effort was to reach those veterans 

with the most urgent care needs, we will not rest until we fix our 

system in order to better serve the health needs of all veterans. 

VHA is also improving access through extended hours into the 

evenings and weekends to leverage limited space and enhance convenience for veterans. Designated patient care teams perform extended hours on a rotational basis. 

In October 2015, VHA delivered the new Veterans Choice program to Congress, proposing improvements for health care delivery 

to veterans. The plan addresses enhanced partnerships between 

VA and community providers to deliver care in the community 

more seamlessly. With the new Veterans Choice plan, enrolled veterans will have greater choice and ease in use of access to health 

care services at VA facilities in the community. 

Through September 2015, contractors have added over 9,100 

Choice authorizations for approximately 7,200 veterans in Phoenix. 

Additionally, the Phoenix VA created nearly 43,000 authorizations 

to veterans to receive care in the private sector between October 1, 

2014, and September 30, 2015, a 45 percent increase in authorizations when compared to the previous year. 

The VA is committed to providing the highest quality care to our 

veterans who have earned and deserve this care. Our work to effectively and timely treat veterans continues to be a top priority at 

the Phoenix VA health system and throughout VHA. 

We really appreciate Congress’ support and look forward to answering any questions you may have. 

[The prepared statement of Dr. Shulkin follows:] 

PREPARED STATEMENT OF DAVID J. SHULKIN, M.D., UNDER SECRETARY FOR HEALTH, 

VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

Good morning, Senator Sullivan, Senator McCain, and Senator Flake. Thank you 

for the opportunity to discuss this important topic regarding the improvement of access to and timeliness of Veterans’ health care at the Phoenix VA Health Care System (PVAHCS). I am accompanied by Dr. Thomas Lynch, Assistant Deputy Under 

Secretary for Health for Clinical Operations, Kathleen Fogarty, Acting Director, Veterans Integrated Service Network (VISN) 18, and Dr. Darren Deering, PVAHCS 

Chief of Staff. 

PVAHCS

The Veterans Health Administration’s (VHA) mission is to honor America’s Veterans by providing exceptional health care that improves their health and wellbeing. By extension, this is also PVAHCS’ mission and providing timely access to 

45 

that care is critical. Access enables VHA to provide personalized, proactive, patientdriven health care; achieve measurable improvements in health outcomes; and align 

resources to deliver sustained value to Veterans. 

VHA has taken a number of actions in response to events in Phoenix, such as 

building partnerships with Care in the Community providers, reducing wait times, 

holding a National Stand Down, and adding over 500 employees. In November 2014, 

the former Medical Center Director was terminated by VA and on November 20, 

2015, Ms. Deborah Amdur was appointed as the permanent Director of PVAHCS. 

As previously mentioned, Ms. Kathleen Fogarty serves as the Acting Director for 

VISN 18 while VHA continues to recruit for a new VISN Director. 

VHA is continually monitoring wait times and making adjustments, as needed, to 

ensure that Veterans have access to the best care they rightfully deserve. During 

Fiscal Year (FY) 2015, PVAHCS increased completed primary care appointments by 

7.72 percent, mental health appointments by 18.38 percent, and specialty care by 

15.25 percent. This means that during this period, PVAHCS completed over 680,600 

outpatient appointments. Through September 2015, the contractors have created 

over 9,100 Choice authorizations for approximately 7,200 Veterans. Additionally, 

Phoenix created nearly 43,000 authorizations for Veterans to receive care in the private sector from October 1, 2014 through September 30, 2015—a 45 percent increase 

in authorizations when compared to the same period in previous years. Overall, 

PVAHCS completed 95 percent of all patient appointments in FY 2015 within 30 

days of the date the Veteran preferred and the average wait time for all patients 

in primary care has decreased to 6 days (as of December 7, 2015). This means that 

PVAHCS is serving more Veterans and providing this service when they need it. 

On November 14, 2015, VA medical centers (VAMC) across the country participated in the first ever National Access Stand Down. Prior to this Access Stand 

Down, there were 1,650 open priority level 1consults at PVAHCS (as of November 6, 

2015). After the Access Stand Down, there were 91 priority level 1 consults that still 

needed to be addressed (as of November 16, 2015) and were authorized for care in 

the community. Although the intent of this effort was to reach those Veterans with 

the most urgent needs, we will not rest until we fix our system in order to better 

serve the health needs of those who need our help most. 

PVAHCS opened a new Community-Based Outpatient Clinic (CBOC) in northeast 

Phoenix in May 2015. Additional CBOC locations have been identified in southwest 

and central Phoenix, with both activations planned for August 1, 2016, and reassigned specialty care clinic space to the second floor of the Community Living Center. Vacated space in the Ambulatory Care Center has been reallocated to primary 

care for additional exam rooms and future growth. PVAHCS is also improving access through extended clinic hours into evenings and weekends to leverage limited 

space and enhance convenience for Veterans. Designated Patient-Aligned Care 

Teams (PACT) perform extended hours on a rotational basis on Saturdays at the 

main facility and Southeast Clinic for a full shift. A limited number of PACTs also 

provide extended hours on Thursdays. 

Since January 2014, PVAHCS has seen a net gain of 630 full time employee 

equivalents (FTEE), or an increase of 25.5 percent. As of October 2015, PVAHCS increased primary care staffing of physicians, nurses, and clerks by 77 additional fullVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00049 Fmt 6633 Sfmt 6621 Z:\ACTIVE\121415.TXT PAULIN

1214psVApg3.eps
46 

time employees from April 2014 to present. PVAHCS has approximately 160 FTEE 

on board, who are funded through the Veterans Access, Choice, and Accountability 

Act (Choice Act). The graph above shows a history and foundation for sustained 

high-production hiring for the local Human Resource (HR) office. We are confident 

that PVAHCS leaders are monitoring operations closely and are in position to continue making H.R. improvements throughout the facility. 

VETERANS CHOICE PROGRAM (VCP)

Implementation of VCP, established by the Choice Act, has helped generate an 

87-percent increase in the number of PVAHCS consults going out to the community 

for Veteran care from FY 2014 to FY 2015. PVAHCS is located in the same metro 

area as the TriWest Healthcare Alliance. PVAHCS has used this geographic access 

to develop strong working relationships with TriWest leadership and staff. As a result, PVAHCS has undertaken initiatives such as actively participating in the redesign of the TriWest Portal; enabling streamlined communication of records between 

the agency and vendor for all VAMCs served by TriWest; discussing potential new 

initiatives with TriWest to physically locate two to three TriWest staff members 

within PVAHCS to address Veteran/vendor issues more promptly; and holding periodic meetings and teleconferences between the leadership and staff of PVAHCS and 

TriWest to address issues raised directly from Veterans. 

In October, VHA delivered to Congress a plan for how VA could consolidate all 

purchased care programs into one New Veterans Choice Program (New VCP) to deliver care in the community more seamlessly. With the New VCP, enrolled Veterans 

will have greater choice and ease of use in access to health care services at VA facilities and in the community. The New VCP will clarify eligibility requirements for 

care in the community, build on existing infrastructure to develop a high-performing 

network of community providers, streamline clinical and administrative processes, 

and implement a continuum of care to improve coordination of services. Clear guidelines, infrastructure, and processes to meet VA’s community care needs will improve 

Veterans’ experience and access to health care. As VA continues to refine its health 

care delivery model and examine how the Veterans Choice Program interacts with 

other VA health programs, we look forward to providing more detail on how to convert the principles outlined in the New VCP Plan into an executable, fiscally-sustainable future state. In addition, we plan to receive and potentially incorporate recommendations from the Commission on Care and other stakeholders. 

VA OFFICE OF INSPECTOR GENERAL (OIG) REPORT

In August 2014, VA OIG published its final report, ‘‘Review of Alleged Patient 

Deaths, Patient Wait Times, and Scheduling Practices, the Phoenix VA Health Care 

System,’’ which noted delays in care and quality of care concerns. Of the 24 recommendations, OIG agreed to close three by the time the report was published and 

VHA has completed action leading to OIG closure on another 15 as of November 25, 

2015. Six are still in progress. We will continue to focus on rebuilding employee 

commitment and morale and moving forward to provide accelerated, timely access 

to the high-quality health care Veterans have earned—when and where they need 

it. 

U.S. GOVERNMENT ACCOUNTABILITY OFFICE (GAO) REPORT

In September 2014, GAO issued its report, ‘‘Management and Oversight of Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient 

Specialty Care.’’ GAO found that VHA’s management of the consult process had not 

ensured that Veterans always receive outpatient specialty care in a timely manner. 

VA concurred with all six recommendations and is taking actions to address the concerns raised by GAO. During the past year, VHA completed a national assessment 

of progress note completion and created technical capability to assess for incomplete 

consults. VHA implemented an interim consult standard operating procedure that 

standardizes consult management processes and developed a comprehensive compliance audit tool and protocol for robust oversight. 

Additionally, VHA established business rules outlining appropriate use of cancellation and discontinuation and defined the circumstances requiring clinical determination and documentation of the reasons for discontinuation. VHA standardized 

the procedures for future care consults and authorized future care consults as the 

only approved method for managing consult requests for care intended to take place 

beyond 90 days from the date the consult was created. Facility level consult steering 

committees were established to identify and share best practices for managing 

consults. VHA also developed national guidance for management of patient noshows and canceled appointments. Solutions were implemented by extensive naVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00050 Fmt 6633 Sfmt 6621 Z:\ACTIVE\121415.TXT PAULIN
47 

tional consult training with all VISNs, weekly national consult best practice/training 

calls, and creation of a consult training module. 

Although VHA has greatly increased access through more hires and expanded 

clinic hours, demand has also significantly increased, resulting in Veterans waiting 

longer for care longer than VA’s wait time performance standards. As mentioned 

above, on November 14, 2015, VAMCs across the country participated in the first 

ever National Access Stand Down. A team of clinical leaders, administrators and 

volunteers was on site at every VAMC to reach out to all Veterans identified as having the most important and acute needs to make sure that VHA is meeting their 

health care needs immediately. VHA’s efforts to fix access issues will continue until 

our system can improve the health needs of those that need our help most. 

VA OIG OFFICE OF HEALTHCARE INSPECTIONS (OHI) ACCESS TO UROLOGY REPORT

On October 15, 2015, VA OIG’s Office of Healthcare Inspections (OHI) delivered 

its evaluation of access to care concerns in the Urology Service at PVAHCS. OHI 

determined that PVAHCS suffered a significant urology staffing shortage, and its 

leaders did not have a plan to provide urological services during the shortage of providers in the Urology Service. To fill this need, VHA has hired six Urology employees since January 2013. 

OHI also determined that non-VA providers’ clinical documents were not consistently available for PVAHCS providers to review in a timely manner. OHI concluded 

that referring providers may not have addressed potentially important recommendations and follow-up because they did not have access to these Care in the Community clinical records. Even in the event that further recommendations were not 

needed, or there were no critical findings, this disconnect between the referring provider and the specialist compromised the overall management of the patient. 

OHI also concluded that PVAHCS Urology Service and non-VA Care Coordination 

staff did not provide timely care or ensure that timely urological services were provided to patients needing the care. OHI identified 12 patients who experienced significant issues that may have affected their clinical outcomes. Two were quality of 

care issues and the other 10 were wait time issues. Such delays placed patients at 

unnecessary risk for adverse outcomes. Of these, VHA conducted further reviews 

and found eight requiring institutional disclosure, six of which are already complete. 

VHA concurred with all three of OHI’s recommendations and provided acceptable 

improvement plans. To address OHI’s recommendation that PVAHCS ensures that 

resources are in place to deliver timely urologic care to patients, the facility has 

hired additional staff to provide urologic care. Currently, PVAHCS has a Chief of 

Urology, two full-time urologists, and one part-time urologist, a nurse practitioner, 

and three physician’s assistants. Recruitment continues for another staff urologist, 

which is the only unfilled position in Urology Service. According to data on PVAHCS 

as of December 7th, the Urology Service has no patients waiting on an Electronic 

Wait List (EWL); 3 consults aged greater than 90 days (all with scheduled appointments); and 99 percent of new patients are seen within 30 days. Appointment volume doubled from the previous year while the average wait time from preferred 

date was at 3days—8 days lower than it was 1 year ago. Urgent appointments are 

available within 1 day. 

To address OHI’s recommendation that PVAHCS ensure that Care in the Community providers’ clinical documentation is available in the electronic health records 

in a timely manner for PVAHCS providers to review, PVAHCS meets with TriWest 

leadership on a monthly basis to improve communication and assess the timely 

availability of records. PVAHCS developed a system by which patient records are 

downloaded from the TriWest portal on a daily basis. As the patient records are 

taken from the TriWest portal, they are placed in a facility folder where they are 

uploaded to Document Manager and linked to complete the Care in the Community 

consult in the Computerized Patient Record System (CPRS) in portable document 

format (pdf). The completion of the consult notifies the Ordering Provider automatically via CPRS Alert that the non-VA care consult results are available. All TriWest 

non-VA care providers are obligated by contract to provide medical records within 

14 days. TriWest is obligated by contract to load those records into the portal within 

48 hours of receipt so VA staff can retrieve the information. 

To address OHI’s final recommendation of ensuring that the cases identified in 

this report are reviewed and for patients who suffered adverse outcomes and poor 

quality of care, PVAHCS conducted in-depth quality of care reviews of the 12 identified cases and determined that 8 protected peer reviews and 8 institutional disclosures were warranted. Additionally, external reviews are being conducted to validate these findings. 

48 

HUMAN RESOURCES RESTORATION AND REVITALIZATION (HR3) SITE EVALUATION REPORT

As part of the H.R. 3 Report, VA conducted a needs assessment for the PVAHCS 

human resources (HR) team, and the resulting report focused on 65 actions needed 

for improvement. The most notable finding of the assessment was the poor state of 

the office culture which was having a negative impact upon H.R. operations, ultimately impacting their core mission of hiring those who could provide access to care. 

Action plans were developed and implemented locally which provided a framework 

for PVAHCS H.R. operations. 

MYVA

At the enterprise level, the work that is underway to transform VHA operations 

also supports an effective response to past events in Phoenix. MyVA is our transformation from VA’s past way of doing business to one that puts Veterans in control 

of how, when, and where they wish to be served. It is a catalyst to make VA a 

world-class service provider. It will modernize VA’s culture, processes, and capabilities to put the needs, expectations, and interests of Veterans and their families first. 

The MyVA vision provides a seamless, unified Veteran experience across the entire 

organization throughout the country. 

One of the five pillars of MyVA is improving the Veteran’s experience. At a bare 

minimum, every contact between Veterans and VA should be predictable, consistent, 

and easy. But we are aiming to make each touch point exceptional. This means that 

Veterans should be able to make appointments for timely treatment. Events such 

as the National Stand Down and practices such as extended care hours improve the 

accessibility of health care in Phoenix and the Veteran’s experience. 

Another of the five pillars is to enhance strategic partnerships that will allow us 

to extend the reach of services available for Veterans and their families. We are 

making it easier for Federal, state, and local government, as well as private sector 

organizations, to partner with VA by standardizing our partnership processes. This 

improves health care for enrolled Phoenix Veterans by making it easier for a Veteran to access Care in the Community, when VA care is inconvenient or unavailable. 

CONCLUSION

VA is committed to providing the highest quality care our Veterans have earned 

and deserve. Our work to effectively and timely treat Veterans continues to be a 

top priority at PVAHCS and throughout VHA. We appreciate Congress’ support and 

look forward to responding to any questions you may have. 

LETTER OF REVISED DATA FROM HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. 

DEPARTMENT OF VETERANS AFFAIRS

The CHAIRMAN. Mr. McIntyre? 

49 

STATEMENT OF DAVID MCINTYRE, PRESIDENT AND CHIEF 

EXECUTIVE OFFICER, TRIWEST HEALTHCARE ALLIANCE 

Mr. MCINTYRE. Good morning, Senators Sullivan, McCain, and 

Flake. I appear before you today on behalf of TriWest Healthcare 

Alliance nonprofit owners led by Blue Cross Blue Shield of Arizona 

and our nearly 2,500 employees, most of whom are veterans or 

family members of veterans, to discuss the support that we are 

privileged to provide VA in 28 States and the Pacific, including the 

great States of Arizona and Alaska, as they execute their noble 

mission of caring for our Nation’s warriors. 

Our core job is to establish a provider network and make sure 

that care is placed with it when it is unable to be provided by VA 

because of wait times or the care exceeds 40 miles from their home. 

I am pleased to appear alongside the team from VA, led by new 

Under Secretary for Health David Shulkin, with whom I have been 

very impressed in the short time I have had the privilege of working in support of his leadership. I would like to thank him for coming to the furnace and stepping in to lead the way. 

Most importantly, I would like to say thanks to Chuck Byers and 

Nicole Morris and all the veterans in attendance today for their 

service. We are inspired and humbled by your presence. Know that 

we will not rest until the final refinements of Choice are in place 

and the program has achieved its potential. 

Mr. Chairman, I ask that my written testimony be accepted into 

the record. 

The CHAIRMAN. Without objection. 

Mr. MCINTYRE. General George Patton once said, ‘‘A good plan 

violently executed now is better than a perfect plan executed next 

week.’’ 

I cannot speak to pre-April 2014, but all of us associated with the 

effort since to ensure that access exists for veterans when and 

where it is needed here in Arizona and elsewhere know firsthand 

the definition of a good plan violently executed. In fact, it was the 

result of a collaboration that we were able to collectively in Phoenix 

work off the waitlist of nearly 15,000 veterans, as the country was 

learning about Phoenix and the fact that it was not the only place 

where supply did not match demand. 

Though the Department of Defense took nearly 3 years for the 

design and implementation of TRICARE, the situation post-April 

2014 in VA called for a schedule for more aggressive, 2 months for 

design and 1 month for execution. 

I would say that our fellow citizens who bore the costs of battle 

deserve such intensity. Senators, initial success was achieved with 

the design, production, and mailing of the Choice cards to veterans, 

with more than 9 million delivered. The phone systems were fully 

operational on day 1 and care began to be placed in the community. 

Most in industry said it would take 12 to 15 months just to do 

that, but we all got it done in 30 days, a good plan violently executed. But, that was a year ago. 

Since then, as you know, you and your colleagues in Congress 

have broadened the definition of an authorization so that cancer 

patients, pregnant moms, and post-surgical cases will no longer 

face a 60-day care authorization limit. You broadened the definition 

50 

of 40 miles, and you removed the pre-August 2012 enrollment 

limit. 

For our part, we and VA have been collaborating fully, implementing a program to support the Phoenix VA medical center in 

its emergency room to ensure that when patients show up with 

mental health emergencies and cannot be handled directly by VA, 

then we are able to place them downtown. We placed 166 veterans 

in the last couple of months, providing them with needed 

protection. 

We have identified and are working to close gaps in operation. 

We have developed and refined tools to better support the needs of 

veterans, providers, and our staffs. We have identified unmet demand and further expanded the provider network to bring care 

even closer to home. We are identifying resolutions to claims challenges that are needed, just like we did in the early days of 

TRICARE, on our road to becoming the fastest and most accurate 

payer in the marketplace. 

While we are not done and we are not where we want to be, I 

think we are making progress. Today, there are more than 11,600 

providers in the network in Arizona, more than 156,000 across the 

28 States that we are privileged to serve. Three hundred to 500 are 

being added still daily. 

Second, the number of appointments sought has grown from 

2,000 in November 2014 to an expected 110,000 this month. For 

those of you who did your math quickly, that is an increase of 

4,900 percent in that period. In Arizona, we will be delivering on 

more than 4,000 appointments this month. 

Our staff has had to grow from March at 400 to now almost 

3,000 individuals. 

Third, we have handled 3.8 million veteran calls in that period, 

volume that has grown at 20 percent a month, with more than 

690,000 in November alone. 

Our abandonment rate is a mere 3 percent. We are not where we 

want to be yet. We do not like it at 3 percent. We would like lower. 

We want to be at the same industry-leading performance that we 

were in TRICARE, as validated by five successive J.D. Power 

awards. 

Full success? Not yet. However, we believe that together we can 

get there faster than we did in TRICARE, and our Nation’s veterans deserve no less. 

So, what is the work that remains, from our perspective? 

First, we are implementing major improvements in provider experience that was developed in collaboration with the providers 

from our network and our longtime partners at the Arizona State 

University (ASU) customer service institute. 

Second, we are approaching the second round of demand forecasting with VA to determine where a network is optimally placed. 

Third, we are soon going to train the behavioral health providers 

in our network on veteran experience in combat, just like we did 

in the early days of the war under TRICARE. 

Fourth, we will soon be implementing the expansion and care authorizations for cancer, pregnancy, and post-surgical patients. 

51 

Fifth, we are going to be embedding staff at the VA facilities here 

in Phoenix and in Alaska to re-create the successful service center 

concept that we developed in TRICARE. 

Sixth, we will be relentlessly focused at the start of next year on 

gaining feedback from veterans and partnering with ASU to improve veteran experience. 

Senators Sullivan, McCain, and Flake, I believe the overall experience is getting better, but we have a lot of work to do before we 

achieve the vision that you and your colleagues had in the unprecedented action to both authorize and fund the Choice Act in one bill. 

It is with deep humility and profound respect for our fellow citizens who put it all on the line for our freedom that we continue 

to lean forward. The same is true for our owners who by the end 

of March 2016 will have invested nearly $60 million of their own 

money in an effort to scale, stabilize, and ultimately refine our operation, so that we achieve our potential and honor the commitments we made when we stepped forward to be the high-performing partner to VA that we were to DOD in TRICARE. 

We take our responsibility very seriously for VA, for veterans. 

This Committee can rest assured that our entire focus is on ensuring that our work in support of VA and the veterans who rely on 

them for care is fitting of the sacrifices of our heroes and is worthy 

of their trust. 

It is for this reason that we will remain impatiently focused on 

the path of violently executing the plan until we achieve the success that we know is possible. 

Mr. Chairman, this concludes my testimony. 

[The prepared statement of Mr. McIntyre follows:] 

52 

PREPARED STATEMENT OF DAVID J. MCINTYRE, JR., PRESIDENT AND CEO, 

TRIWEST HEALTHCARE ALLIANCE


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TriWest Healthcare Alliance has a long and proud association with the health care community 

here in the state of Arizona and with our fellow citizens who have proudly worn the cloth of this 

nation. From 1995 to 2013, we worked alongside the Department of Defense (DoD). Today, we 

arc privileged to lean forward shoulder to shoulder with VA, doing the same thing we have 

always done- facilitating the provision of private sector care to our nation's heroes when it is 

unavailable directly within the federal system. ln order to assess TriWest's role in this effort, I 

believe it is important to provide a brief history ofTriWest and how our history lead to the 

present effmis in support of VA, as we seek to assist VA in honoring this nation's commitment 

to those who have borne the battle. 

A Historical Perspective 

During TriWest's 20-year history, the company I was fortunate to help found with a group of 

non-profit health plans and university hospital systems and have been privileged to lead since as 

President and CEO, we have focused exclusively on providing access to needed care when it is 

not able to be provided by the federal systems on which those in uniform rely. Our first 17 years 

were spent helping the Department of Defense (DoD) stand-up and operate the TRlCARE 

program in a 21-state area that included both Arizona and Senator Sullivan's home state of 

Alaska. 

While we no longer support the DoD in that line of work, I'm proud of the work that we did to 

assist DoD in making TRICARE the most popular health plan in the country and meet the needs 

of millions across the TRICARE West Region who relied on us for that support. And, as those of 

us who were around in the early days ofTRICARE can attest, we know it was neither an easy 

nor painless road. Now, working together with VA, while the challenges of implementing a new 

program have been similar to the early TRICARE days, due to the added layer of complication 

that led the Choice Program to be brought forth so quickly, I believe we can achieve the same 

results for Veterans who look to VA for their health care needs. 

In our experience under the TRICARE program, we had nine months to focus solely on standing 

up the program before the demand for services arrived which allowed time to work through start 

up program issues. Today, I am proud to say that although we did not have the same 

implementation timeframe to stand up the Choice Program, we are maturing the program and we 

WILL achieve the expectations that you and your fellow members of Congress had when you 

mandated the creation of the Choice program to more optimally meet the health care needs of our 

nation's Veterans. 

That said, I think it's impmiant to consider the historical landscape of Veterans health care in 

this community in order to then speak to the present and future efforts for this program. 

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Where We Started: PC3 

In September 2013, TriWest was awarded a contract to stand-up and implement the brand new 

Patient Centered Community Care (PC3) program across 28 states and the Pacific. TriWest rose 

to the occasion by leveraging the existing networks and strong relationships already in place due 

to our prior work under the TRICARE contract. Initial access to specialty care from our existing 

network providers began in January of2014 with the ongoing expansion and addition of primary 

care providers coming online over the months that followed. That network building continues to 

this day as VA and we learn more about where demand exists that was otherwise not being met 

before this program began. And, we thank the nearly 150,000 providers from our communities of 

responsibility who have now stepped forward and said I will serve a few of my fellow citizens 

when VA is unable to do so directly. 

PC3 was intended to be a nationwide program giving VA Medical Centers (V AMC) an efficient 

and consistent way to provide access to care for Veterans from a network of credentialed 

specialty care providers in the community- one ofTriWest's primary missions as a TRICARE 

contractor. We are pleased to be sharing this work in support of VA with our long-time 

colleagues in the TRICARE space, Health Net Federal Services. Together we (along with VA) 

are working very collaboratively to leverage our collective knowledge with the common goal of 

optimizing V A's direct delivery system and supplement that care with access to care in the 

private sector when and where it is needed. 

PC3 started well here in the State of Arizona and was available to VA to provide access to 

specialty care in the community when VA was unable to meet the demand directly. As we know, 

though, the true need for expanded access to care for Veterans was just about to come to light 

just shortly after the launch of PC3. 

The Furnace Lights Off A Historical Perspective o(Choice Program 

We all remember the miiclc on the front page of the Arizona Republic in April2014, which 

brought national attention to the significant issues faced by Veterans attempting to access care 

here in Phoenix. When the "furnace lit off' in Phoenix, it served as the catalyst for fueling a 

focus on VA reform throughout the nation. At that time, nearly 15,000 Veterans were discovered 

to be on waiting lists for care in Phoenix alone. It is but one example of the re-setting that was 

needed and has since begun under the leadership of Secretary Bob McDonald, Deputy Secretary 

Sloan Gibson, and Under Secretary for Health Dr. David Shulkin. Since then there have been a 

number of Office of Inspector General reports published outlining similar findings all pointing to 

the reality that Veterans were not getting the care they needed and deserved in a timely manner. 

The recognition that further reform was needed to meet Veteran health care needs gave birth, as 

you know, to the Veterans Access, Choice and Accountability Act (VACAA) and ultimately to 

the Veterans Choice Program. In August 2014 Congress appropriately passed V ACAA and, in 
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tum recognizing this program needed to be stood up fast in the marketplace, VA leaned on its 

two PC3 contractors, TriWest and Health Net, to help implement the new Choice Card Act. In 

fact, we had just over 30 days to go from the policy specs being received from Congress and 

interpreted by VA to having a program designed and stood up by November 5, 2014- just 13 

months ago. 

Within record time, we created the infrastructure, hired and trained hundreds of staff, and mailed 

Choice Cards to the four million Veterans in our area of responsibility. TriWest stood up a 

contact center with a personalized message on its toll-free line from Secretary McDonald. This 

was the first greeting Veterans heard in calling the line and all accomplished within 30 days 

which was the timeframe mandated in the law. 

I recall vividly sitting in a meeting that VA held with industry in mid-September 2014, as they 

were seeking to determine how to implement this necessary new program, and hearing many say 

that a program of this magnitude would take a minimum of 12-18 months to stand up and that 

DoD had been given about 36 months to design and then stand up a similar program with 

TRICARE. 

However, that was not an option. Just as those who serve are not afforded such luxuries of time 

when our nation sent its Veterans to a place where they were needed. So, we swallowed hard and 

agreed to lean all the way forward to stand up the program knowing that it would be imperfect, 

just as TRICARE was in the early days, but that getting it in place and refining as we went 

forward would be critical to helping our fellow citizens who were standing in line because they 

were in need of care that was not available directly within VA. 

So, we and Health Net stepped into the fire at the side of VA and did what others said could not 

be done and jointly stretched ourselves to stand up this critical new program in weeks (not 

months or years). And, in honor of those whom we are privileged to serve alongside VA, we did 

it. The phones worked, the cards went out, and care started to be rendered in the community 

when it could not be directly provided by VA. 

The partnership between VA and TriWest has matured substantially over the past year. We 

continue to refine and strengthen operational processes and communication, both on our end and 

VA's end. Do we still have work to do? You bet we do 1 But, I am very proud of what we have 

all accomplished in such a short timeframe. And, I am confident that the trajectory on which we 

are all on to refine this much needed program will produce the same results as experienced with 

the refinements that came quickly within the TRICARE program. 

One of the core challenges when the PC3 program was first implemented was that we didn't 

have a clear view of the demand for care. Thus, it made it difficult to ensure a precise supply of 

network and the subsequent infrastructure of systems and people needed to support that demand 

as a company. Additionally, we faced programmatic and statutory challenges with the new 

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Choice program when it was first launched (which is discussed in detail later). But, we had to 

start moving and then refine later ... which is exactly what we have done and continue to do with 

intensity, and will continue to lean forward until you, Veterans and VA say that we can stand 

more upright and throttle back a bit. But, that will not be until the job is finished ... and we are 

all comfortable that our fellow citizens are receiving that which was envisioned with the 

enactment of Choice! 

Volumes were low in the beginning as program adoption was low. Care requests were about 

2,000 for that first month of 2014. While volume increased each month, care requests under PC3 

only reached their peak at about 20,000 per month by the end of that year when the Choice 

program came into the picture. 

The second iteration of the program, beginning in January 2015 (the past 12 months), focused on 

implementing Choice and finding solutions to some of those challenges- both internally at 

TriWest, as well as within VA itself. We saw steady increases in care requests month by month 

with about 75,000 appointment requests per month by August. Just last week that number 

surpassed II 0,000. 

Network Growth 

Foreseeing the likely increase in utilization, we initiated a process with the team from VA to sit 

and assess demand and determine the distribution and supply of network that would be needed in 

the community to support that demand. We call it the Demand Capacity Assessment Process 

which last summer was conducted with every VAMC within our service area. We met one on 

one with each medical center to assess which specialists were still required to meet the needs of 

that geographic area and the associated demand for those needs. This included not only the 

demand that was already known but that which seemed ready to materialize with the added 

policy decisions regarding Choice coming out of Congress. We then took the output of this datadriven process and turned to our owner/network subcontractors, including Blue Cross Blue 

Shield of Arizona, and started to grow the network on a tailored basis. 

We birthed the tools for this process Memorial Day weekend of2014 for the work that we were 

tasked with to assist the Phoenix VA in working off the backlog of nearly 15,000. Those tools 

allowed us to assess the demand and the needed provider and staff supply that resulted in the 

successful elimination of the backlog by the end of August 2014. 

This month, will have us finishing Version 1.0 of the network build portion of the Demand 

Capacity Assessment Process. The first quarter of 2016, armed with the added changes to the 

program that have come from Congress, we will come back together for Version 2.0. 

The map below highlights the results of this extremely targeted approach, which has resulted in a 

23% increase in providers who have answered the call from July to October 2015 to join the 

network- responding to the jointly identified need. 

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Over the past 12 months, we tailored our network and expanded our base of 98,000 providers in 

January 2015 to 156,000 unique providers today (representing over 300,000 provider locations)-

more than a 59% increase, and counting- to help ensure that we are available to help serve the 

VA health care system for their primary, specialty and behavioral health care needs. The map 

below shows the location of those providers. 

December 2015- All Providers 

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While expanding the provider network was of primary focus, we also recognized that assuring 

the quality of our provider network also deserved special focus. To that end, in August 2015, 

TriWest was awarded full health care network accreditation pursuant to the Health Network, 

Version 7.1 from URAC, a Washington, D.C.-based health care accrediting organization that 

establishes quality standards for the health care industry. TriWcst demonstrated that we meet key 

quality benchmarks for network management, provider credentialing, utilization management, 

quality management and improvement, and consumer protection. The full accreditation is valid 

for three years. Receiving that accreditation this past summer helps ensure our nation's Veterans 

have access to the highest standard of quality health care providers available through our high 

quality network of providers. 

And, as we continued to focus on the expansion of our network, this past Summer 2015, 

Congress refined the design of the Choice Program by enacting changes to help expand 

eligibility, and thus greater access to care for Veterans. And as a result, the number of care 

requests we received for private care has continued to grow dramatically. 

Phoenix Tnitiatives 

Now I would like to turn our focus to Phoenix- our hometown: the site in which the furnace lit 

off, leading to the focus on re-setting the largest health care system in the United States. 

Twill tell you that it was right after the revelation of the issues that I received an outreach from 

the Phoenix VA asking how we might partner with them to assess the backlogs and assist in 

resolving them. That effort, at the time, was led by Chief of Staff Darren Deering with the two of 

us on personal speed dial until the backlogs were resolved. That formed the foundational work 

for a strong partnership between the Phoenix VA and TriWest that continues to this day. 

That collaborative work to resolve the backlog of nearly 15,000 Veterans, including 3,300 

urology patients, has extended over the months to a full blown partnership with the Phoenix VA 

relying heavily on the Choice Program to ensure that care is accessed in the community for 

Veterans when it is not available within the VA Medical Center itself. 

The entire team at TriWest, including our Arizona owner, Blue Cross Blue Shield of Arizona, 

would like to thank the nearly 7,000 providers in Maricopa County who stepped up and agreed to 

serve those Veterans standing in line. And, we would like to thank the team at VA for leaning 

forward since April2014 and for allowing us the privilege of supporting you in this critical work 

of ensuring that our nation's heroes receive needed care when you are unable to deliver it 

yourself. We could not be more proud to be your partner. 

With regard to our provider network in Arizona, in July 2015, we had 9,000 providers in the 

network. Just four months later, we have increased the Arizona network by 23%, and proudly 

have over 11,600 unique providers in the network who have stepped forward to provide care for 

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our nation's heroes. The following map shows the distribution of those providers, as of 

November 2015: 

ArlzonaSp41claltyProvid•rs 

_.-.J.c 

Yellow represents PC3; Green represents Choice 

As most of us here today know, the providers in this community shoulder the increasing demand 

experienced as a result of our snowbird population during the winter months. Researchers 

estimate 300,000 snowbirds in Arizona during winter months, including many Veterans. 

Additionally, some of those visitors in Arizona mTive with care needs, or continuing care needs. 

It makes the challenge of access for all of us more difficult at this time of the year, and thus the 

necessity to share the privilege of serving Veterans between VA and community providers 

essential to meeting demand. I just don't think we can say thank you enough to those providers 

who have agreed to lean forward and help provide the needed care for Veterans, particularly 

during the winter surge months in Arizona. 

Delivering an exceptional Veteran and provider experience with the Veterans Choice Program is 

our objective. It is important to Veterans, providers, VA and those of us at TriWest. In fact, it is 

exactly what we successfully accomplished nearly every time in TRICARE as we became the 

standard against which others were often measured. We didn't do it for ourselves. We stretched 

ourselves to that place for a reason ... it was our way to honor those whom were privileged to 

serve and those providers who joined us in that noble cause. And, believe me when I assure you 

that we will not rest until we achieve the same in this work. 

And, while we hear regularly from Veterans who are delighted with their experience, we also 

hear from those whose experience at this early stage of the program that leaves something to be 

desired. It is the latter group that has our attention as we want our work to be worthy of those 

whom we are honored to count as our customers. 

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As part of our commitment to achieving the same performance outcome as we produced in 

TRICARE, we turned to a 20-year partner of ours to repeat an effort we undertook in that work. 

Once we had a few months of experience under our belt at the side of VA, we started a very 

focused and intentional effort to assess and understand current experience, identifying gaps and 

opportunities for improvement by conducting in person, "blueprinting" sessions alongside the 

industry leading Arizona State University's world-renowned Center for Services Leadership 

(ASU CSL). In fact, it is they who train such industry leaders as Proctor and Gamble, Starbucks, 

Disney, and the like in the techniques of customer service mapping and process improvement. 

One of the initial blueprinting sessions held this summer included Veteran representatives, 

Phoenix V AMC leaders, Veterans Service Organization leaders and TriWest stakeholders. As a 

result of the blueprinting effort, TriWest and VA made changes to processes, program materials, 

and training to improve the experience for Veterans. The very early indications are that this timetested approach, mirroring that of the most highly regarded customer service brands in America, 

is beginning to yield results that matter. TriWest has also introduced the ASU CSL process 

known as "service recovery" to address customer service breakdowns identified in our 

complaints and grievance process for inquiries received from Veterans, providers, Congressional 

offices and VSOs. This process ensures that root causes are analyzed by the leadership so that 

process improvements to customer service can be made. 

Similarly, the provider experience is critical to both TriWest's and our network subcontractors' 

ability to build and maintain networks to serve Veterans. We recognize that many of the 

requirements placed on providers to participate in the PC3 and Choice programs create a 

significant administrative burden, and often go beyond what is typically required of providers to 

treat patients. It is for this reason that we are making efforts to reduce this burden, where it can 

be controlled by TriWest, by streamlining our processes. As a result of the provider blueprinting 

effort, TriWest is now revising our provider letters and redesigning our Provider Portal (similar 

to what we did this past year with the VA portal) to improve the overall provider experience. We 

call this upgraded experience, "Provider 2.0"- as we take the provider experience to another 

level, for the 156,000 plus providers in our network who serve the health care needs of our 

nation's Veterans. 

In an effort to lean forward further in the critical space of behavioral health here in our 

hometown, in response to an outreach from the Phoenix VA, we initiated a pilot project to care 

for Veterans in urgent need of behavioral health services, who present themselves to the VA 

emergency department. TriWest has committed to helping place such individuals into the private 

sector for their emergency behavioral health needs in a timely manner, and to date has ensured 

that more than 166 Veterans received the urgent behavioral health care they needed. That 

number represents saved lives. We want to thank the team at VA for having the confidence to 

turn to us as a teammate, so that together we might address a challenge they were facing. 

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Another example which illustrates the great partnership we have developed with VA- a 

partnership aimed at taking care of the Veterans that we are so privileged to serve- occurred 

right here in Phoenix (as well as nine other locations in the regions where we operate). 

On Saturday, November 14th, TriWest stood alongside VA on a special initiative- "Stand Down 

Day" to advance efforts to reduce the number of Veterans with high-priority or urgent care 

problems waiting longer than 30 days and to learn together what should constitute our focus in 

the months to come as we seek to further refine the operation of Choice. 

In a collaborative eff01i with VA, TriWest assembled a team to provide real-time, onsite support 

for the Stand Down efforts within l 0 pre-determined V AMCs. Through this collaborative effort, 

TriWest worked 6,500 Choice Veterans and the associated refe1nls. On Saturday, November 

14th, TriWest stood in support of the Stand Down with 868 employees working across all hub 

locations. The TriWest staff responded to inbound phone calls from Veterans and VAMC 

representatives, responded in real-time to VA comments posted through the shared web portal, 

data entered all new referral requests received on the I 4th, and placed outbound phone calls to 

Veterans to initiate the appointment process. In addition, TriWest staff(including myself and 

other senior leadership) joined the VA staff in 10 specific V AMCs to provide real-time, onsite 

support. 

As a result of VA initiating the Stand Down project, VA and TriWcst were able to close the gap 

on outstanding health care service requests at VA and place a significant number of Veterans in 

the care of a community provider. The results for clinically urgent care were particularly strong 

as the large majority of care requests were appointed within 5 business days. 

Right here in Phoenix, the Phoenix VA submitted a file to TriWest containing Choice referrals 

for approximately 298 V ctcrans. TriW est identified 502 referrals for this population. Beginning 

on November 14th (and scheduled to continue through December ll) TriWest staff researched 

all unresolved referral requests and initiated contact with Veterans, providers, and VA staff. 

Overall, TriWest has been successful in reducing the number of pending referrals to less than 30. 

The results for Phoenix demonstrate the growth of the network of community physicians as well 

as the tremendous collaboration between TriWest and VA to drive favorable outcomes in a 

timely manner. 

In the area of educating V etcrans, providers and others about this program and its operation, 

TriWest has shown its presence at a number of local town hall meetings around the state of 

Arizona, as well as attendance and support at a number of Congressional Veteran Resource 

Clinics. We have briefed government, non-profit and civic leaders on the program and efforts to 

improve the processes and will continue to do so as we move into 2016. We are also very active 

with our support of the Veterans Economic Community Initiatives program that was launched by 

Secretary McDonald in June 2015. This program is committed to providing employment 

opportunities for Veterans and their families through a network of support at the community 

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level. In fact, many of our operations centers we have opened throughout the country arc located 

in VECI communities, to include Phoenix, where this program launched and where we had the 

opportunity of joining Mayor Stanton in the announcement of this program as one of the first 

companies in Phoenix to take up the mission of hiring America's Veterans. 

At the end of the day, Phoenix is our hometown. Our company, which was formed here 20 years 

ago, remains headquartered here in Phoenix, and employs over I ,000 employees in both our 

Tempe and Phoenix locations- most of whom are either Veterans or family members of 

Veterans. This number represents a 150% increase in staffing and a significant job growth 

impact to these communities dating back to one year ago today. We essentially operated as a 

startup company when we began this work with VA back in 2013, and have ramped up quickly 

to keep pace with the increasing Choice program demand. 

Operalional Growth. Innovations and Program Improvements 

Beginning in May 2015, TriWest responded to the growth in care requests by ramping up our 

workforce, expanding our footprint and our network, and working on operational efficiencies. To 

meet the increase in demand of care requests that is on pace to hit over II 0,000 authorization 

requests by the end of this month, we have added six new operations centers across our 

geographic areas of responsibility and implemented a VISN-centric strategy with each of our 

locations, to better serve those geographic areas "on the ground". Over the past few months, 

TriWest has opened operations centers in: San Diego (225 employees), Kansas City (over 500 

employees); Tempe, AZ (300 employees); Nashville (225 employees); Honolulu (50 

employees); and Sacramento (225 employees). We are opening another location next month in 

New Orleans (250 employees) and a final location in March in El Paso, which will bring us to 10 

total locations (including our Phoenix hub and our Puget Sound operations center which were 

already in place). My expectation is that once we arc fully staffed at each of these sites (based 

upon the eligibility criteria that exists today), with all new staff online, that we will be able to 

adequately handle the increasing demand coming through this program, which frankly has 

continued to be a bit of a struggle, as demand has continued to exceed all of our projections! 

The following chart outlines the growth in demand of authorizations; specifically, the number of 

authorizations per month and TriWest's approach to scaling to meet that demand- location by 

location, and within a very short timeframe. 

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120,000 3,500 

100,000 3,000 

2.500 80.00:: 

2,000 

60.00::: 

1.500 

40,00::: 

1,000 

20,00::: # Auths - # FTEs sec 

Houston 7empe KansasC·tv San D•ego Nashv···e Northern New E: Paso 

l)u.~· 2015) IJu\' 2015) \Sep 2015) (Sep 2015) \Oct 2015) CA \Nov (Mar 2016) 

2.015) I) an 2016) 

-Author:zaronsper month -Fac'l't~· rE Capac'D,· 

At the same time, TriWest spent 2015 focused on innovations to help improve program 

operations across the enterprise. In addition to standing up contact centers, hiring thousands of 

new employees and building networks, a large focus has been on upgrading systems. We stood 

alongside our partners at the Phoenix VA almost one year ago today to obtain their requirements 

for a new portal- a region-wide system that enables VA staff to seamlessly order and track 

health care services between themselves and TriWest. We had a team of people working in 

shifts, around the clock for three months, to develop the upgraded portal, which was 

implemented in several phases beginning in May 2015. The new portal was available to every 

VAMC within our region by July 2015. Today, VA has over 2,500 trained users on the system, 

and they rely on this system to manage most aspects of community health care delivered through 

the Choice program. 

Another major initiative TriWest implemented to help manage the surge in program volume and 

growth in usage among Veterans, and aimed at customer service, was a new Customer 

Relationship Management System. This new tool will ultimately assist our staff in delivering 

effective and efficient customer service encounters, just as we did in TRICARE and USAA for 

those who have served. The system also brings improvements to the user interface and the ability 

to document outbound and inbound calls with Veterans -all aimed at improving customer 

service. 

And within the contact center, we recently have also implemented a Behavioral Analytics Call 

Monitoring System which helps improve staff interactions with customers, VA staff, providers 

and Veterans alike. Our contact centers are being built just as they were under our TRICARE 

contract- which was recognized for call center operation customer satisfaction excellence for 

five consecutive years under the J.D. Power and Associated Call Center Certification Program. 

That distinction acknowledges a strong commitment by TriWest call center operations to provide 

"An Outstanding Customer Service Experience." It is how we have always operated, and we are 

committed to that high level of customer service operations again under this program. 

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On the provider side, we have worktd to streamline the claims payment process whereby 

providers submit their claims electronically and receive their payment within four days. This 

helps improve provider satisfaction as we approach a better place with claims processing. Today, 

we are two years ahead of the cycle over where we were in TRICARE. And, TriWest pays clean 

claims at a rate of 95% in less than 30 days. 

With all of these initiatives, tools and expansions in mind, I would be remiss ifl did not mention 

that all these needed upgrades that have been implemented over the past 12 months or so, do not 

come without cost. Our company's sole line of business is to care for Veterans it's who we are; 

it's what we do. And from all we have done in dedicating ourselves to this mission, we have put 

the priority on getting this right for our nation's Veterans because our non-profit owners believe 

that is the right thing to do. 

Investing around $60 million of our owners money thus far to further our and V A's joint 

objectives to develop more optimal tools, tailor networks, and scale and rc-footprint the company 

to more optimally deliver customer service at the side of VA, we are pleased with the refinement 

that is starting to materialize. The fact is that we continue to work hard alongside VA to do 

whatever it takes to make this program meet the vision from which it was created! 

Focus on Customer Service 

At the end of the day, the most important tool and resource we have is the feedback from our 

customers- our nation's Veterans and our network providers- and that we take into account all 

input received, acknowledging that customer service breakdowns lead to service n;covery 

opportunities as well. To that end, l would like to provide a few examples of Veterans who 

exemplify the work we are doing in this regard and how we arc taking a "service recovery" 

perspective to fixing issues for these Veterans and those who will follow: 

Case Study #I: When Contract Cont1icts With Care 

Under TriWesfs contract with the government (and as prescribed by Congress for Choiceeligible Veterans), TriWcst is limited to authorizing follow-up care for a period of60 calendar 

days from the date of the original date of service. In some instances, such a timeframe is 

appropriate for the initial appointment, procedure and follow-up care. However, we have seen 

many examples of Veterans (and providers) who are unnecessarily stifled by this authorization 

limitation while in the midst of receiving treatment. Three examples of note: 

1) TriWest has worked with a Veteran who requires a specific type ofblood transfusion 

treatment for a chronic condition he contracted during his time in Vietnam. This 

treatment must occur on a monthly basis for the rest of his life. In the past, he has been 

able to secure an annual authorization for this treatment, but under Choice he and his 

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provider must now request six authorizations a year- a significant additional effort and 

expense for all parties involved. 

2) We have a female Veteran in the community who is pregnant and was being seen by a 

community provider through the Choice program until a few weeks ago, then the facility 

indicated they were dropping all matemity patients because they did not want to deal with 

the "back and forth of getting authorizations ... " In speaking with the office administrator 

for the facility, they indicated that their practice made the decision to no longer treat any 

patients related to the Choice program because they are unable to receive an authorization 

up front for the entire period. While TriWest was able to place her with another provider 

in the community and ensure the remaining authorizations are in place for the remainder 

of her pregnancy, changing a matemity provider mid-pregnancy is certainly not a 

desirable outcome for any Veteran. 

3) TriWest has handled several cases of Veterans beginning or in the midst of cancer 

treatments where the same authorization challenges apply. In this and all other examples, 

the cmTent model has TriWest "layering" authorizations in our system to track for 

coverage of when the next authorization will be necessary, but the requirement for the 

provider to request that next authorization prior to the end of the 601

h day still remains. 

TriWest and VA brought this matter to the attention of the congressional committees of 

jurisdiction earlier this year to explain this challenge to coordinating care for these types of longterm needs. We were successful in securing this needed legislative change, and are looking 

forward to this change taking place at the beginning of 2016. 

Case Study #2: Growing Pains Lead to Systemic Customer Service Issues 

I) As discussed earlier, the expedited timeframe for standing up this program has led to 

challenges for all parties involved (Veterans, providers, VA staff and TriWest staff), and 

in some ways those challenges have been magnified given that the growing pains of a 

new system (that is still frankly in its infancy) are far greater than those of a program that 

had time to work out the bugs before going live. We have seen many examples of those: 

a. We had a provider group in metro Phoenix contact us in March of this year, that 

had been having significant difficulties getting secondary authorizations approved 

for services dating back to October of the previous year. Our research identified 

that the provider had sent in multiple Secondary Authorization Requests (SARs) 

for care, some of which were the responsibility ofTriWest, while others fell on 

the end of the Phoenix VAMC. Situations like this one led to our effort to 

collaborate with the Phoenix VAMC, and then seek the input of the other VAMCs 

across our area of responsibility, to create the next generation VA portalstreamlining both communications and workflow for both parties. 

2) We received a written complaint from a Veteran in the Valley who was upset with the 

conduct of two patient service representatives that his wife had received calls from about 

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her husband, believing that the staff were "disrespectful and argumentative." The 

Veteran's wife was authorized to make and receive phone calls regarding all respect of 

her husband's care, as a signed authorization to release information form was on file with 

our Privacy Office, but the contact center staff were not identifying this information 

during the calls. In this case, the staff in question were subcontracted call center staff who 

were not well versed in TriWest's customer service protocols (which is standard for all of 

our new contact center staff) and who were unaware of the process for confirming this 

information. TriWest's CRM system mentioned earlier now provides an alert at the 

beginning of a call if such information is on file with TriWest, enabling our staff to speak 

with a Veteran's designated representative about their health care from the beginning of 

the communication. 

3) Historically, we have experienced frustrations from some Veterans who have found 

themselves appointed to providers anywhere from 60-150 miles or more away from their 

residence, even though local providers or options much closer were available. Such was 

the case for an Arizona Veteran earlier this year who, while speaking with a contact 

center representative in Louisiana, was appointed for a colonoscopy provider located 90 

miles from where the V cteran resides. Increases in the provider network across our 

region, combined with the VISN-centric approach to contact center operations (which 

enables us to train our staff on the state( s) they serve and better grasp the communities 

and referral patterns that exist in those states), has lessened these types of frustrations for 

Veterans. 

While there are certainly other examples of breakdowns in the overall process- some VAcentric, some solely on TriWest's shoulders, some policy and contract-related and still others 

that are best described as "perspective-driven problems" given the attention to this program by 

the media and the heightened sensitivities to the way the system "should" work- we will 

continue to identify, research, resolve, track and trend these opportunities for program 

improvement for the benefit of those we serve and those providers who pledge to serve alongside 

us in this effort. 

This work is intense and focused, just as should be ... as we are trying to quickly address the 

processes we all know need attention in order to improve this critical program and meet the 

intended objective of Choice. 

While I will submit that challenges still remain as the program continues to mature, the customer 

experience under VCP is getting better with each passing day. Information provided by TriWest 

staff is more consistent and more accurate; providers are more familiar with the program; and we 

have recently implemented an initiative that allows any provider in our region to register online 

with us to be a VCP provider. Knowing who is willing to treat a Veteran under VCP, even if they 

arc not already a TriWest network provider, goes a long way towards speeding up the appointing 

process. 

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On a daily basis, our focus is on improving the program. l say this because each challenge 

presents an opportunity to make the system better and prove to Veterans that good can come 

from their utilization of this benefit bestowed on them by you and your fellow members of 

Congress. Whether it's the 95-year old Veteran in northwestern Arizona who used to drive three 

hours to Phoenix for care (and now gets his physical therapy l 0 minutes from home) or the 

Veteran who spoke with one of our staff after his knee replacement, noting he's had 20 surgeries 

in his life and the process through Choice was "the easiest of them all" and "perfect", we know 

that Veterans are beginning to recognize the benefit of this program as utilization increases. 

That said, l was honored to receive a copy of a letter received just this past week from a V cteran 

in Meadview, Arizona- one of the most remote and rural parts of northwestern Arizona- where 

the Choice program is often of greatest benefit to our Veterans. The letter reads as follows: 

"I am a Veteran, having served in the US Army from 1969 through 1971. Today I had the 

pleasure of calling the VA Choice Program and talking to Jocelyn. After 25 minutes, 

Jocelyn had understood my problem and solved it. She was knowledgeable, knew the 

right questions to ask, exhibited professionalism, patience and perseverance! I am very 

pleased at the outcome. This is only the second time I have used the VA Choice Program 

and both times there were no problems, just relatively easy solutions. I hope the 

government will make it a pe1manent program. It is really a blessing to Veterans I have 

talked to. Please make Jocelyn aware that she did a magnificent job! I also talked to her 

supervisor to get this address and she was friendly and appreciative. Thank you tor hiring 

such good people to work with Veterans." 

"P.S.- Desiree just called with my appointment! Five hours to get it done! Simply 

wonderful. Thank them all for me." 

This is but one individual Veteran, but such statements (which come with increasing frequency) 

reflect a belief that as this program is allowed to mature, more and more Veterans will find 

similar benefit in this choice afforded to them through your efforts. Such statements will also 

continue to charge our batteries as we work relentlessly to make this program into what Congress 

envisioned less than 16 months ago. 

TriWest Per(ormance- Becoming "the Answer" to VA 

General George Patton said "a good plan violently executed now is better than a perfect plan 

executed next week". I think we now know personally the definition of"violently executed", as 

that has been required of us. We adopted this mindset to begin working off the significant care 

backlogs in place when we were awarded the contract. And while more time to implement the 

program would've been ideal, it was necessary to begin coordinating Veteran's health care 

immediately. 

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Beginning in 2014 when PC3 was implemented, the program started out slowly with a couple 

thousand care requests per month. Networks were being developed, and we phased our 

implementation by region beginning in January of 2014. Then, in April 2014, the furnace lit off 

in Phoenix, which ignited a rapid increase in program utilization nationwide. Over time, program 

adoption grew, and by the end of2014, TriWest received almost 22,000 care requests from 

V AMCs throughout our regions, as displayed below: 

PC3 Authorization Volume 2014 

25,000 

20,000 

15,000 

10,000 

5,000 

0 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

At the tail end of2014, and moving into 2015, the Choice implementation was birthed. At the 

start of the Choice program, we received requests for only 2,000 Choice Card appointments for 

the entire month. This number has skyrocketed and expected to surpass I I 0,000 this month -just 

one year into the program. For those of us who are math minded, that's over a 4,900% increase 

in volume. The chart below shows the upward trajectory for the number of authorizations 

received per day in 2015: 

Choice Authorization Volume 2015 

80,000 

60,000 

40,000 

20,000 

0 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov 

Although this massive growth is a positive indication that more and more Veterans arc receiving 

the care they deserve, it docs not come without operational challenges. Despite having added six 

operations centers over the past six months, increasing staffing by thousands, adding numerous 

innovations to systems and process, we are still not able to fully keep up with demand. 

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It should not be surprising then, that Phoenix experienced similar growth as a result of the 

furnace lighting off in April2014, when the most significant growth occurred, as pictured below: 

3,000 

2,500 

2,000 

1,500 

1,000 

500 

0 

Phoenix PC3 Auths 2014 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

The next period of substantial growth in Phoenix occurred as the result of the several initiatives 

that Congress passed in the summer 2015 to help open eligibility for our nation's Veterans. As 

the following chart shows, Phoenix also underwent extreme growth in Choice program usage this 

past year: 

4,500 

4,000 

3,500 

3,000 

2,500 

2,000 

1,500 

1,000 

500 

0 

Phoenix Choice Auths 2015 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov 

This surge in demand over time is being tackled through several strategies, both on the policy 

side and also operationally, and progress is being made. For example, most recently VA 

implemented a change order to our contract in early October, which is aimed at lessening the 

wait lists and speeding the Veteran's access to care. That change involves using a more proactive 

approach to making health care appointments for Veterans, through the use of outbound calling. 

That is, through a streamlined process with VA, we now reach out to call the Veteran directly 

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versus waiting for the Veteran to call us. The new outreach processes we have developed jointly 

with VA keep the care requests moving rapidly through the system, so the Veteran receives care 

more expeditiously. 

In addition, TriWest continues to scale to meet the demand. Our staffing will grow by another 

500 employees over the next couple months, and we will assess any additional locations that may 

be needed- depending on volume - at that time. In the meantime, we are supplementing with 

using overtime and other external resources until the opening of our next facility in New Orleans 

in January and the facility in El Paso at which team we will have nearly 3,000 staff engaged in 

this critical work. 

Further, we continue to collaborate ann-in-arm with I 0 V A-identified V AMCs to research and 

respond to a significant number of authorizations, through the Stand Down Project. This ensures 

Veterans needing clinically and administratively urgent appointments receive them in a timely 

manner. 

Finally, processes improvements continue to be worked as we implement additional operations 

centers to round out our presence in each of the VISNs within our regions. As with any new 

implementation or new job, there is a learning curve. Our employees will continue to become 

more efficient in their work, systems will continue to be tailored, and processes refined, 

ultimately resulting in a favorable outcome for the Veteran- which is meeting the overall goal of 

this program. 

Refinements in Policv 

At the outset of this program, Congress acted quickly to implement a program which provided 

enhanced access to Veterans health care. Since then, many legislative changes have occurred to 

address some nuances of this program that were unforeseen in the beginning. 

The first of such changes began in January 2015, under the Omnibus Appropriations Act, when 

Congress addressed the rate issues present in the state of Alaska given the very unique area under 

Senator Sullivan's jurisdiction. This change helped align rates in the area with the marketplacea key component to provider satisfaction and contracting in that state. 

Several months later, in July 2015, to further improve the program from a policy perspective, the 

"Surface Transportation and Veterans Health Care Improvement Act of2015" modified several 

requirements of the Veterans Choice Act of2014. 

First, the Act repealed the 60-day limit on follow up care. Instead, the authorization extends for 

the entire episode of care. When we receive the formal modification to implement this change, it 

will open doors for many Veterans who need urgent services lasting beyond 60 days, and will 

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help with certain provider groups who desire to provide care to Veterans, but arc stifled by this 

60 day authorization rule. We expect that this much anticipated change officially will be 

modified into our contract in early 2016. When this occurs, patients who face serious conditions 

(such as the case studies I shared with you earlier) will be able to receive the entire episode of 

care (chemotherapy treatment, maternity care, etc.) that is required to complete their treatment. 

Second, the Act repealed the August I, 2012 enrollment limitation on eligibility of Veterans in 

the patient enrollment system. This critical change removed the requirement that you have to be 

enrolled in VA prior to August 2, 2014, to be eligible for Choice Program. The impact was great 

to Veterans, allowing ncar instantaneous determination of eligibility by the VAMC. 

Third, the Act extended provider eligibility to any health care provider meeting VA criteria - this 

change helped open the pool of providers who could provide health care to this deserving 

population. 

Finally, the Act based the 40-mile distance requirement as the distance traveled from a VA 

medical facility instead of 'as the crow flies', including one offering primary care for a Veteran 

seeking primary care. This gave more Veterans access to the program, especially in complicating 

geographic areas. 

Another program change last summer that was directed at improving access was the 

Administration's implementation of the Choice First program- which immediately expanded 

eligibility and opened the flood gates to care by giving a Veteran the ability to obtain services in 

the network, when such specialty was not available at all within their local VA medical facility. 

Congress continued assessing necessary program modifications later into 2015. In September 

2015, TriWest received a contract modification regarding outbound calls, and elimination of 

blind appointing, and were authorized to begin working these changes on October 1. This more 

proactive approach to making health care appointments for Veterans prevents an authorization 

from sitting and aging, awaiting a phone call from the Veteran. And as a result, more Veterans 

receive health care, and they receive it more timely. 

This past month, Congress expanded access to private doctors where its Community Based 

Outpatient Clinics lacked sufficient provider access, expanding the number of patients who are 

eligible to seek care in the community under the Choice program. As a result, if VA has no 

primary care doctor on staff, a referral for private care is not required. This change alone should 

open the program up to about 160,000 more Veterans. 

And finally, we recently received federal approval within our contract to allow TriWest to staff 

employees at V AMCs with the execution of an appropriate Memorandum of Understanding. 

Moving forward, TriWest will have several cells of embedded staff within a multitude of 

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medical centers, including right here Phoenix ... where V etcrans will be able to be walked right 

down the hall after a medical appointment that identified need for care in the community. In that 

office, they will get educated about the program, we will learn of their preferences, and we will 

start the process of securing them an appointment in the community. We know from our work 

during the TRICARE program that having staff embedded in a medical facility can go a long 

way toward making the usc of the program a more seamless experience. Those TriWest staff got 

to know the government staff, the beneficiaries, and also the providers in the community. All of 

that helped speed the process of getting care provided in a timely manner downtown. We have 

that opportunity again here in Phoenix. TriWest staff working every day alongside their VA 

colleagues will identify process challenges quickly and implement solutions even faster. That 

structure will provide care authorized in a timelier manner and ensure better daily coordination at 

a personal level instead of faxes, phones, internet portals and emails. We have one such cell in a 

pilot phase at present at a V AMC within our service area, and will expand to several more 

facilities- including Phoenix- this year. 

Overall, I commend Congress for all the steps it has taken this past year which have driven great 

program improvements. In addition to the changes that have already been modified into our 

contract, we are awaiting for the 60 authorization to change to an episode of care (as mentioned 

above) and we also anticipate a change in Medicare payment, whereby providers no longer have 

to be Medicare participating in order to see one of our nation's Veterans. This will be another 

piece to the puzzle of opening up more access to care for those providers who wish to provide 

care for Veterans nationwide. 

The pace is swift and, as you can see, changes are plentiful, but we are implementing at 

lightening pace, changing programs and refining processes along the way, and MUCH has been 

done to set the groundwork to improve the overall program and enhance access to care for our 

nation's Veterans. 

Looking Forward- the Art o{lhe Possible 

Now that we have had a glimpse into the past, let me take you to a very important part- the 

future and where this program will take us in the way of the 'next generation' of the program, so 

that Veterans get the best care they need and deserve. Here's what I see over the next six months 

that is part of the formula for success moving forward. 

At this point, I can confidently say that the Choice program is well on its way to working. 

Veterans are receiving more of the care they need, when they need it. But there continues to be 

unmet need. And while the program is working, it's still not working fast enough. 

One thing we know for certain is that through all of this, the VCP brought significant availability 

to health care for Veterans by making many community providers available to enhance access 

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when access to care in VA in sufficient to meet the need. As the Deputy Secretary, Sloan Gibson, 

stated during the House VA Committee hearing on November 18, there have been seven million 

more appointments scheduled this year, compared to last year. While not all of this has flowed 

through Choice, the volume is continuing to increase as we refine our capability and enhance our 

supply of network and staff to match demand. Despite all the maturation that still needs to occur 

to perfect the program, this to me, is great progress because millions more Veterans are receiving 

health care under this program than they were last year. Now, Veterans are demonstrating that 

they arc gaining trust in the program, and TriWcst, and arc seeking the care they need. 

Demand for health care will grow as Veterans who may have become discouraged and given up 

seeking care return as the backlogs across the system and we continue to work together to 

effectively address access issues. We expect that as Veterans continue to build trust in the Choice 

Program, they will continue to seek out this care when VA is unable to meet the need directly. It 

is for this reason that we will continue to expand our operations over the next six to nine months 

- and beyond. 

The network will continue to expand and be high performing, so that the Veterans we serveand the V AMCs we serve alongside- will continue to have the ability to access needed care in a 

timely fashion. 

Additionally, Choice 1.0 will have been given more time to mature, allowing time for 

operational efficiencies to take hold. We are working daily and hourly with our partner, VA to 

get this right. 

Legislative advances to help move this program forward will have taken a strong foothold. For 

example, the final contract modification will have been provided to us, giving us the ability to 

implement legislation that removed the 60-day authorization limitation and instead authorizes 

care for an entire episode of care. This will open doors for many areas, including those services 

that typically are needed for more than 60 days such as chemotherapy treatment. 

We arc also working arm-in-arm with our VA partners to encourage other legislative changes 

that will promote less hassle from a provider's point of view, which aligns with standard market 

practices in local communities. Most recommendations for standard care practices require 

additional review and authorization either by TriWest or VA. Those processes are frustrating to 

providers and to Veterans, delay care, and ultimately impact the cost and quality of the program. 

It is our hope that one day we might get to a position where providers arc able to efficiently 

provide care to Veterans in an accepted standard of practice. Similar to the work we did under 

the TRICARE program, this will just take time for maturation, and we are working toward that 

end. 

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In summary, VA's health care system was originally designed to meet the needs of America's 

Veteran population when inpatient care traditionally was associated with long admission stays. 

The last major reform of the VA health care system occurred when Congressed passed the 

Eligibility Reform act of 1996. The result of this legislation was enhanced eligibility and access 

to care. Prior to that, the biggest change in delivery design occurred when Dr. Ken Kizer 

introduced his Vision and Journey for Change in the early 1990s. 

In 2002, the VA system was re-examined and assessed changes in geographic concentrations of 

Veterans and ways in which medical treatment was provided. A process called CARES (Capital 

Asset Realignment for Enhanced Services) occurred to 'update' the VA health care system. 

Now we are in the midst of another VA health care refonn, and we have the opportunity to make 

the health care delivery model the most efficient it can be. In my opinion, the best system for 

V etcrans is a VA public-private partnership that builds on what VA docs best, while leveraging 

private sector provider networks and best business practices created by TriWest. But, VA must 

ultimately be the backbone, focusing on their core mission of taking care of its soldiers inside the 

four walls of VA. And VA must allow their private sector partners, TriWest, to do what we do 

best which is to build and enhance networks, process claims, schedule appointments, and help 

coordinate care for the best outcomes for the Veteran, with flexibility, effectiveness and 

efficiency. We must continue to work together for the betterment of VA health care, alongside 

VA and Congress, and we all must continue to build upon the core that we have already 

developed. 

Conclusion 

Mr. Chairman, I hope my testimony here has provided some useful information as to how 

TriWest became a part of this effort, where we are today, and where we are headed in the future. 

I also hope it has convinced you that the company I am proud to lead considers it an honor and 

privilege to work every day to provide access to care for those who have served this nation in 

uniform. We have always stood ready to implement VA health care needs within record speed 

and record time, and will continue to dedicate ourselves to this critical task, all in support of our 

nation's Veterans. It is an awesome responsibility and our owners, and we look forward to 

continuing to be a large part of the formula for future success, as we continue to be part of the 

"relief valve" for VA. 

I want to conclude by thanking my fellow panel members, the leaders from the VA health care 

system at VA Central Office, the VISN, and the Phoenix V AMC, for their leadership, their 

commitment, their partnership, their tolerance of us as their partner, and their commitment to 

ensuring that our nation's heroes receive that which they have earned with their service ... when 

and where it is needed. I want to thank the amazing providers of this community who have 

leaned forward and said l will serve a few when VA is unable to meet the need directly. And, I 

want to thank you, Senators McCain, Flake and Sullivan, for your leadership in working to 

23 
75 

The CHAIRMAN. Thank you, Mr. McIntyre. 

I know we have a number of questions. I will begin with Senator 

McCain. 

Senator MCCAIN. Thank you for your testimony. 

Dr. Shulkin, you have made a very favorable impression on those 

of us who have had dealings with you. I believe that you are working very hard, and I also appreciate your efforts to improve our 

communication and relations with Members of Congress, including 

the Veterans’ Affairs Committee. I thank you and Dr. Lynch for 

coming out here to be at this hearing today. 

Mr. McIntyre gives a rather optimistic view. 

In front of you is a chart that shows that obviously veterans 

waiting over 30 days for appointments, it kind of contradicts what 

Mr. McIntyre said, because if TriWest was doing the great job that 

he claims, I would think that veterans waiting over 30 days for 

medical appointments would show a decline. 

Maybe you can respond to that, whether you disagree with that 

chart, or what your comments are about that. 

Dr. SHULKIN. Thank you, Senator. 

First of all, I do want to thank you as well. I think that all three 

of you, your willingness to speak out on behalf of veterans and to 

work with us to improve the system is very much appreciated. As 

you know, Senator, I believe unless we do this together, we are not 

going to achieve the best results. I thank you again. 

The wait times that currently exist are not acceptable to VA. 

That is why we are working so hard to make this better. 

The way that we are working is really a dual approach. We are 

hiring additional staff in the Phoenix VA. We have hired over 600 

new employees. We are adding space; we recently added some 

space and have additional plans to add significantly more space. 

We are improving our efficiencies, so we are working internally. 

Most importantly—again, thanks to Congress, because of your 

leadership with the Choice plan, we have really utilized care in the 

community. We are about 80 percent in terms of care in the community from where we were. 

Now we have a lot more to go, but I want to make one additional 

point. 

As we have been saying recently—really I think Dr. Mitchell 

made this point—as VA gets better and veterans regain their trust 

in the VA, we are going to see more veterans coming back to get 

care in the VA system. So, our overall wait times are probably not 

going to go down. 


1214psMC24.eps
76 

What we are really focused on now is making sure that nobody 

who is waiting is being harmed. We are focusing on those veterans 

who need care with the highest priority, the most urgent care. 

We can really tell you that is what our stand down was about, 

making sure that people who need care are getting in to see VA 

or getting into care in the community. We are not satisfied with 

that, Senator. So, we are making sure that people are not waiting 

and being harmed. 

Senator MCCAIN. It seems to me, then, from what you are saying, that wait times will not go down anytime soon. That is an urgent call to make the Choice card universal. 

Dr. SHULKIN. Senator, I think that is accurate. We are not saying 

that wait times overall are going to go down significantly or at all. 

In fact, as we improve the system, they may actually go up. 

That does mean that we need to make sure that we are working 

better with providers in the community using the Choice program. 

We are focused on improving the Choice program. That is why we 

submitted a new plan to Congress that asks for your help in making sure that we can make this system work better for veterans. 

We need legislation for new provider agreements. We need the 

flexibility to have funding for care in the community be in a single 

pot rather than separate programs. We want to make this program 

that you gave us work even better than it is working now. 

Senator MCCAIN. Well, I do not want to belabor the point, but 

I think the prospect of veterans waiting over 30 days, no matter 

what their medical need, is not acceptable. If they had a Choice 

card, they would not have to wait 30 days. They could go out the 

next day and get an appointment with the physician of their choice. 

Ms. Fogarty, do you have full confidence in your emergency room 

today? 

Ms. FOGARTY. Senator, thank you. The emergency room has really experienced quite a lot of change over the past year and made 

several improvements. I would like to give you a sense of what 

those are. 

We have increased the ER and mental health staffing. We have 

increased the space, as Dr. Mitchell identified, and we currently 

have a construction project underway. 

We have added 24/7 social work coverage that was not there before. We have approved and recruited additional psychiatry to also 

have 24/7 coverage. We have added five mental health RNs to the 

ER. We have established a standard medical clearance protocol for 

patients that need to be admitted to our mental health. 

We really thank our partners with TRICARE and TriWest because they do allow us, when we are full, to have care in the community, they would be allowed to take our patients that we could 

not. 

We have had standardized training in documentation for patient 

safety, observers called sitters, who are sitting and watching any 

suicidal ideation patients that come in. We redesigned four of those 

exam rooms and a restroom to make them safer for suicide ideation 

patients, to help prevent a serious elopement. 

Senator MCCAIN. You are aware of the Clay Hunt Suicide Prevention Act? 

Ms. FOGARTY. Yes, Senator, very much. 

77 

Senator MCCAIN. Is that helpful? 

Ms. FOGARTY. It is, and we thank you for that. 

It is one of those that we worry the most about, those coming 

with suicide ideation. We really have to be the most diligent on 

those who come. 

Senator MCCAIN. Do you have some examples of intervention 

that have saved some lives? I do not ask for them, but you do? 

Ms. FOGARTY. Oh, absolutely. 

Senator MCCAIN. Are physicians leaving the Phoenix VA? 

Ms. FOGARTY. Are physicians leaving? 

Senator MCCAIN. Are physicians leaving the Phoenix VA? 

Ms. FOGARTY. No, sir. 

Senator MCCAIN. They are not. 

Ms. FOGARTY. As you saw here, of what we have netted of 600 

FTE, we have hired over 160 on the Veterans Access, Choice and 

Accountability Act funding for us. I can give you some specifics on 

the physicians. 

Senator MCCAIN. That is all right. 

Ms. FOGARTY. We do have attrition, as you know, physicians who 

retire or do leave with family moves. We have had six. 

Senator MCCAIN. You do not have physicians leaving the VA. 

Thank you. 

Mr. McIntyre, what has been your experience with the Choice 

card? Does it need to be made universal? 

Mr. MCINTYRE. I think it is starting to take hold in terms of its 

use. The fact that there are 110,000 appointments that are going 

to come our direction this month from 2,000 at the start of this indicates that we are on the right—— 

Senator MCCAIN. Mr. McIntyre, the fact that there were only 

2,000 at the start is because they did not know about it. So, please 

do not keep throwing that one up at me. 

I want to know whether you think the Choice card should be 

made universal or not. 

Mr. MCINTYRE. I think the people’s ability to access care downtown when it is not available in the VA and when it is not close 

to their home is exactly the right thing to be doing. 

Senator MCCAIN. What impediments to you see to better usage? 

Mr. MCINTYRE. I think that people understanding the program, 

first of all, from an education perspective, which we all can share 

in, is valuable. Second, I think changing the kinds of policies that 

have been changed will help smooth this out. Third, I think our operations need to continue to get stronger and more integrated in 

order to make this process work more effectively. 

Senator MCCAIN. Thank you. 

Dr. Shulkin, one of the sources of great frustration to many of 

us, especially here in Phoenix, is the fact that it is undeniable that 

there were really people who did not do their job. Otherwise, we 

would never have had 50 veterans who were on a nonexistent waiting list. 

Yet, to our knowledge, maybe you can help us out, there is only 

one person—one person—that has been removed from office. People 

do not understand that when 50 people die on a nonexistent waiting list and there is only one person that is held responsible, and 

78 

many others are on ‘‘administrative leave’’ with full pay, paid for 

by the taxpayers. Please help us out on that one. 

Dr. SHULKIN. Senator, we hear that frustration loud and clear. 

There is no question about that. We did remove the director, as you 

said. We placed two other officials on administrative leave. 

Senator MCCAIN. That means paid. That means being paid. 

Dr. SHULKIN. Paid administrative leave. 

We would very, very much like to conclude our administrative 

and disciplinary actions against those two officials. The U.S. Attorney, as I said in my statement, has prohibited us from interviewing 

those individuals. The OIG just 30 days ago gave us 10,000 additional pages of evidence on these individuals, and last week an additional 1,000 pages. As soon as we can go through that evidence, 

we are committed to making an action. 

On December 9, Deputy Secretary Gibson testified before the 

House committee and said we are no longer going to wait for the 

IG to act. VA will act independently as soon as we can. 

We are committed not to putting additional people on administrative leave, but we will detail them to work. If the taxpayers are 

paying these individuals, they need to be working. 

Those are changes in the way that we are going to be dealing 

with this in the future. 

Senator MCCAIN. Well, I thank you, but I would remind you 

what you know, and that is the Senior Executive Service is a 

unique situation, as opposed to your average civil servant. The SES 

people are eligible for many benefits and rewards for excellent performance, but they are also liable or can be fired and removed from 

office with much less reason than an ordinary member of the civil 

service. 

Many of these individuals who were in charge are members of 

SES, and yet that option has not been exercised. Maybe you can 

respond to that. 

Dr. SHULKIN. Yes. Since Secretary McDonald was sworn in, July 

2014, there have been eight SES removed by the Secretary. That 

option is available to him. 

I think that we are all firm believers—the Secretary, the Deputy 

Secretary, and myself—in accountability. We have articulated that 

we believe we must do this principally based. There has to be evidence to match the actions or the punishment or the reward. 

We are making sure that the evidence does match this. We hear 

you loud and clear, and VA is committed to moving quicker. We 

will not wait for IG actions in the future because it is very important that people understand that if people are not following our 

values, they do not belong in the VA. 

Senator MCCAIN. Thank you. 

I thank you, Senator Sullivan. 

I just want to repeat again, Dr. Shulkin, you have been, I believe, admirably involved with Members of Congress in communicating with us and being frank in your assessments. That is appreciated by Members of this Committee. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator McCain. 

I want to make a quick comment, just on what he mentioned to 

Ms. Fogarty. The Clay Hunt Suicide Prevention Act, which was the 

79 

first bill that I cosponsored in the U.S. Senate, named after a 

young Marine sniper who suffered through despair and did not get 

the service that he needed from the VA and ended up taking his 

own life. 

The number 1 cosponsor of that bill in Congress, which passed 

unanimously, was Senator McCain. That is what he was referring 

to. Let us talk about an issue that really matters, veteran suicide, 

and the one member of the U.S. Senate who has led on that more 

than anyone is Senator McCain. 

I am glad to see that is having an impact, because there is nothing worse—nothing worse—whether it is a Vietnam vet or a vet 

from Iraq or Afghanistan, coming back experiencing depression and 

despair and having nowhere to go. That is probably our highest responsibility, to take care of those veterans. 

Senator Flake? 

Senator FLAKE. Thank you. 

Ms. Fogarty, if Ms. Morris were to go to the VA emergency room 

today like she did before and present the same symptoms, what 

would be her experience? 

Ms. FOGARTY. First, I would like to acknowledge how disappointing to hear those statements of a veteran coming to our 

emergency room and having that wait. It just is not what our 

standard of care should ever be. 

Today, I believe that she would have a very different experience 

in what we have approved and made. I would also believe that 

there is that opportunity with the Choice card that she could seek 

care in a private facility and have that reimbursed as well. 

Senator FLAKE. If she were to go down to the ER, her wait time 

in the ER itself would be considerably shorter, and she would have 

a different experience than she had before? 

Ms. FOGARTY. I would truly hope that is the experience, because 

that is what we are working on, always to have exceptional experiences, and have done great things in our emergency department to 

make that experience be—— 

Dr. SHULKIN. Senator Flake, let me just add, the average wait 

time in our Phoenix E.D., from the time that you register to when 

you see a physician or provider, the average is 35 minutes. That 

is an average. 

You will still find times in an emergency department where there 

are critically ill patients and patients like Ms. Morris, that do not 

have a critical illness, will wait a lot longer than the patient wants 

to. 

This is a national issue with emergency department overcrowding. So, we would not want to say that this would be her experience, but there would be times when patients will wait. 

Senator FLAKE. All right. Thank you. 

Dr. Shulkin, I, like Senator McCain, believe we need to get to a 

point where the Choice card is used universally and not with restrictions on mileage or whether there is a clinic or whatever else. 

But, that gets to the nut of the whole issue here, how much Choice 

can the VA withstand? 

If a significant number of veterans choose that option, at what 

point does it impact the ability of the VA to have the funds and 

resources to operate at facilities and have the level of care that vetVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00083 Fmt 6633 Sfmt 6601 Z:\ACTIVE\121415.TXT PAULIN
80 

erans should expect? Are we close to that tipping point? Is that 

why we have the restrictions that we do? 

Can you explain that conundrum that we are in? 

Dr. SHULKIN. Sure. Senator, it is a very complex issue, as you 

said. First of all, as I previously said to Senator McCain, we are 

very grateful for Congress’ leadership in providing us the Choice 

program. We think it was the right thing to do and we want to 

make this program work better for veterans. We know too many 

veterans have experienced the complexity of it, the confusion, the 

lack of knowledge about it, as has been mentioned. We are committed, as Mr. McIntyre said, to making this program work. 

We have submitted what we think is a very thoughtful plan to 

Congress that we delivered approximately a month and one-half 

ago that lays out how we want to take the original Choice legislation and make it work better. We need your help. 

We need provider agreements as soon as possible. We need the 

flexibility to make the spending easier for us to serve veterans and 

offer care in the community. 

We are very much in support—VA has been providing care in the community for years. Over $10 billion of our dollars were spent for 

care in the community. 

We think our plan is a very thoughtful balance of keeping the 

VA strong, because America needs a strong VA, and serving veterans by allowing them the ability to seek care in the community 

with the highest quality providers. 

Senator FLAKE. Mr. McIntyre, has the VA done enough to advertise the Choice plan among veterans and to ensure that they understand their rights and ability to access private care? 

Mr. MCINTYRE. I think the VA has done a remarkable job over 

the last couple of months of really stepping up the focus in that 

arena. Part of the thing we are all hampered by—— 

Senator FLAKE. Your comment implies that it is only a recent 

phenomenon? 

Mr. MCINTYRE. No. At the very front end, we had 30 days to 

stand this up. It is hard to educate people internally and externally 

in an effective manner. There has been a real effort within the VA 

to figure out which populations need to be reached and how we do 

that collectively more effectively. 

What I will tell you, though, is part of the challenge we all face 

is that the policies have not yet stabilized for how this all works 

and where you access and what the limitations are. 

I would encourage that once that is done by, essentially, what is 

going to be the end of January, that there is dramatic new push 

by everybody, including the media and Members of Congress, ourselves, and the VA, to make sure that people really understand 

what it is that they have. 

It is rather remarkable. We have providers all over this State, 

so that if you live in a rural area, the number of primary care providers that are accessible to you is rather dramatic. You have new 

rights under the Choice program to actually go and seek care in 

the ZIP Code in which you reside, not to have to drive a long distance in order to get that care. 

Senator FLAKE. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Flake. 

81 

I want to echo Senator McCain’s comments about Dr. Shulkin. 

For the audience’s knowledge, he came on board as the Under Secretary, the number 3 official at the VA, just in August. As I have 

said, he certainly did not cause these problems. He is someone from 

the private sector, an accomplished doctor who has run hospitals. 

He wants to do what is right to fix the problems, and he is aware 

that the Committee will not be standing by if we do not see the 

problems are being fixed. 

So, Dr. Shulkin, I did want to follow up on what Senator McCain 

talked about on accountability. I think it is really important for 

Members of Congress but, more importantly, members of our veteran community across the country to see that something is being 

done. 

You mentioned that we hear you loud and clear what you said 

to Senator McCain. I was disturbed by reading a recent article in 

The Washington Post on a House Veterans’ Affairs Committee 

hearing just last week with Deputy Secretary Gibson not sounding 

like he is hearing us loud and clear at all. 

He said, when asked about accountability of members of the VA, 

he was pushing back, saying, ‘‘You cannot fire your way to excellence. In my many years in the private sector, I have never encountered an organization where leadership was measured by how 

many people you fire.’’ 

‘‘We will not administer punishment based on IG opinions, referrals to the Department of Justice, recycled and embellished media 

accounts, or external pressure. It is simply not right.’’ He called 

some of these cases ‘‘failures of judgment, but not ethical breaches.’’ 

Last week, the number 2 guy in the VA sounded like he was 

pushing back against Congress’ very legitimate questions about 

who is being held accountable in the VA. So, I think one of the 

things that we would want you to do is take back to the Deputy 

Secretary and the Secretary of VA that I certainly do not think 

that those kinds of statements are appropriate. It does not sound 

like he is getting the message at all loud and clear. 

To go back to Senator McCain’s question, how many VA officials 

in the last 2 years over all these scandals and wait times and our 

veterans not being treated the way they should be treated, how 

many VA officials have been terminated from their jobs? 

You come from the private sector. You have a very, very stellar 

record in the private sector. I know that the hospitals you worked 

at would be firing a lot of people had things like this that happened 

in Phoenix. 

What is the number? 

Dr. SHULKIN. Senator, as you said, I have been in the system 

only a few months. I will tell you, I spend a fair amount of my time 

with Deputy Secretary Gibson and Secretary McDonald talking 

about these issues. I will tell you these are two of the finest leaders 

I have ever worked with in my career. They take this very seriously. I do not think that is an accurate representation of the 

Deputy. 

The CHAIRMAN. I was simply quoting him. 

Dr. SHULKIN. Yes, absolutely. 

Where the Deputy stands on this, I know the Secretary as well, 

is that we are committed as leaders, and I stand right with them, 

82 

that we are going to take a look at the evidence and we are going 

to make decisions about who deviates from values and policies, and 

we are going to hold our employees accountable. 

What we are not going to do, we are not going to have people 

tried in the press and tried through allegation. We are going to 

treat people fairly, because that is the way you run great 

organizations. 

The data that you asked for, eight SES have been removed since 

the Secretary was confirmed in July 2014, and 2,100 employees 

have been terminated. We will continue to hold people up to these 

accountability standards and we are going to use the evidence. 

What the Deputy said in that hearing was that he welcomes anybody else, a Member of Congress, to come and look at that evidence 

and show him if we are not making good decisions. But, he is going 

to uphold his leadership responsibility, and I stand with him on 

that. 

The CHAIRMAN. Twenty-one hundred VA employees have been 

terminated for wrongdoing since these scandals? 

Dr. SHULKIN. Since July 2014 when the Secretary was confirmed. 

The CHAIRMAN. Perhaps for the record you can provide us the details on those and the eight that you mentioned. 

Those have been fully terminated or, as Senator McCain mentioned, are on leave? 

Dr. SHULKIN. No, those SES have left service. They have either 

been terminated, have resigned, or chosen to retire. 

The CHAIRMAN. So, I would like, for the record, the detail on all 

of those for the Committee’s review. 

Dr. SHULKIN. Yes, sir. I will be glad to do that. 

The CHAIRMAN. Thank you. 

Another quick question is something that you and I saw in Alaska that I continue to see, which I think is something that we need 

to continue to work on. I still see veterans who come up to me talking about appointments they have had—you and I saw this when 

we were up there—that have been approved by the VA and somehow the reimbursement is not happening quick enough and these 

veterans are now being sent to collection agencies. I am still seeing 

that. 

I would like to get your commitment to work with the Committee 

to put a halt to this. The idea that a veteran gets approved by the 

VA for an appointment, goes to it, the provider either through 

TriWest or the VA does not reimburse what has happened with regard to who is providing the service, and then a debt agency is collecting upon the veteran is outrageous. 

You saw it when we were up in Alaska. I am still seeing it. I 

would like to get your commitment to work, both of you, Mr. McIntyre, on this issue, which just obviously adds enormous stress for 

our veterans, when a collection agency is calling them, saying they 

have a $50,000 bill. 

Dr. SHULKIN. Yes. First of all, I heard this with you, absolutely. 

It is outrageous. We do not want that to be happening. If the VA 

authorizes care, the veteran should not be held accountable for 

that. You have my commitment. That should not be happening. 

83 

I would like to get the names and the specifics of anybody you 

are hearing about from any of your offices, and we will intervene 

to make sure that it does not happen. 

The CHAIRMAN. Thank you. 

Mr. McIntyre, you mentioned in your testimony that the relationship between the VA and TriWest has matured substantially. What 

more needs to be done to develop that relationship in a way that 

ultimately does what you are supposed to be doing, which is benefiting our veterans. 

Mr. MCINTYRE. Senator, I would like to thank you for that question. I would also like to state that I, too, am committed to make 

sure that if you have cases where veterans are getting billed inappropriately by providers, that we would like to understand what 

they are so we can work those issues out, and we will do that in 

support of Dr. Shulkin. 

With regard to the maturation of this program, we believe that 

the inner-threading relationship that is starting to develop at the 

ground level is really important. One of the things that we are 

going to be launching in Alaska, as you know, effective January 11, 

is the opportunity to have a joint service center at the ground level. 

I will tell you that it is one thing for us to have policy-based discussions and operational-gap discussions up at the top, but it is 

quite another thing when you get down to the deck plate where 

veterans are being served on a day-to-day basis. 

Your concept, which we are also going to be rolling out, Senators 

McCain and Flake, here in Phoenix of having an integrated service 

center that is located close in proximity to the veteran could not 

be more right on the money from the standpoint that you could 

walk a veteran down the hall after an appointment in the VA, educate them about Choice so that there is no lack of understanding, 

give them some materials, and find out what their preferences are 

in terms of appointments, how they would like to be contacted and 

the like. It is exactly what we ought to be doing. 

Dr. Shulkin, our organization, and our entire teams are working 

to make sure that it is going to get prototyped in both Alaska and 

Phoenix. 

The CHAIRMAN. Are you looking at, in terms of your call centers, 

which I know have been an enormous frustration for veterans 

across the country, because there is no localized component. So, a 

veteran from Arizona calls—I do not know where your call centers 

are located—but someone calls from Arizona or Alaska and they 

are having issues. Are you looking to start localizing and integrating those call centers throughout the country? 

Mr. MCINTYRE. Great question. Thank you for the question, by 

the way. 

When we started Choice, we had 30 days to go from a blank 

sheet of paper to full on operations on November 5. We had to hire 

850 people, but we did not know the number until we were 10 days 

out. So, we turned to a third-party vendor that supports other organizations in managing backup in their contact center operations. 

That was separate from how we were running our operation in 

PC3. We took all the calls, directed them to that organization. We 

have been weaning ourselves off of that when we came to the conVerDate Mar 15 2010 15:18 Apr 10, 2017 Jkt 000000 PO 00000 Frm 00087 Fmt 6633 Sfmt 6601 Z:\ACTIVE\121415.TXT PAULIN
84 

clusion in the summer, when we were at 37,000 appointments a 

month, that we were going to face a meteoric rise in demand. 

Tomorrow we will announce in El Paso the tenth operations center. Eight of them are now up and fully operational. The one that 

serves Arizona is right here near Gilbert. It is in Tempe, and we 

have a number of employees here. The operation for Alaska is 

served out of Puyallup, which very effectively served Alaska for 

PC3. 

Then, what we are doing is we are inserting, on a test case to 

start with, these customer service staff at the local level, integrated 

with the VA staff, much like we did in TRICARE. 

If you can think about it, it is a hub-and-spoke operation. You 

have a hub that is subgeographic in its location, and you have 

these nodes facility-by-facility-by-facility. 

That is how we hit world-class service in TRICARE. Our intention is to roll out the same and be done with that by the beginning 

of March, which is the trajectory that we are on. 

The CHAIRMAN. Thank you. 

On the pilot program we talked about in Alaska, what is the date 

that it is going to be implemented? 

Mr. MCINTYRE. There are three phases. The first phase was to 

take all calls and route them into Puyallup for Alaska. That happened right after the Alaska field hearing in August that you 

chaired. 

The second phase is to place staff colocated in a service center 

within the Anchorage VA. We are also going to have other staff in 

Alaska on the ground in Fairbanks and probably in Southeast. 

That will go live January 11 and there, as we will do in every other 

location where we roll this out, we are taking seasoned staff that 

already know the market to go there first. Then, we will hire right 

behind that, so we can make sure we do not miss a beat. 

The third phase, as you know for Alaska and unique to Alaska, 

is that the scheduling configuration will change. We will have more 

engagement between the VA staff in Alaska and the veterans and 

the providers in that community. We are in the process together of 

finishing the design with that, so that will next be able to roll out. 

The CHAIRMAN. Let me ask a final question. 

Mr. Byers talked about the problem with providers being reimbursed and how there was an issue with the lack of reimbursement, and then all the veterans who had appointments with that 

provider doing urological services were going to be dropped. 

Have both of you been focused on making sure that those kind 

of things do not happen? That is a key element of the Choice Act. 

If the providers do not have any kind of clarity, it is going to be 

difficult for them to provide the services they need to our veterans. 

Dr. SHULKIN. Senator, I will be glad to start, and then if Mr. 

McIntyre wants to add to this, that is fine. 

Actually, TriWest does a very good job of paying its providers. I 

think, if I am not correct, you are close to 100 percent within 30 

days. So, this is actually a problem for VA because TriWest pays 

the Choice bills. VA pays the care in the community bills. 

We have not been doing as good a job as we need to, in my opinion, in paying our providers. Coming from the provider side where 

I spent my life, when you give a service, when you see a patient, 

85 

you deserve and expect to get paid. We are about 75 percent payment within 30 days. 

We have antiquated roles and antiquated systems. We have 

asked for some help in this in simplifying the care in the community funds from Congress because we need this to get better. 

Our new plan says that we are going to take a look at VA’s ability to pay and make a build-by decision, because, quite frankly, we 

either need to invest and improve a lot better in our payment or 

we need to get out of the payment business and give it to people 

who know how to do this. The status quo is not acceptable. 

Here in Phoenix, we, frankly, have too large of an accounts receivable for your big systems like Banner and Dignity and your 

other providers. We have our teams on site here in Arizona working out those payments right now because is it not acceptable to 

me that providers have to wait this long. 

Mr. MCINTYRE. If I might follow that, and thank you for the kind 

comments, we have our own challenges from time to time in this 

space. 

My dad was a doc. He served as an Army doc in Vietnam, and 

then went on to operate in private practice, including in the great 

State of Alaska as an ophthalmologist. 

What I will tell you is that it is really important, as we discovered in TRICARE, to make sure that the payment is timely and accurate, because we are asking people to stretch themselves and 

take this patient population, which they very much want to do, 

make it the least bureaucratic as we can, and make sure that the 

timing of the payment works right. 

What I will tell you is that we are gaining on where we want to 

be, but we are not there yet. We are spending a lot of time with 

providers trying to figure out where the gaps are so that we can 

make sure that we are able to give feedback to the VA on operations changes that we want to make and they might think about 

making. We are collaborating very closely on that. 

The Banner situation, we own a part of it, the VA owns a part 

of it. We are working together very closely to try to resolve those 

issues. I am confident that we will. 

Here is what I will tell you. We are at 95-plus percent for paying 

claims within 30 days. That is 1 year in. It took us longer to get 

there with TRICARE. What I am going to commit to all of you and 

to the veterans that we are privileged to lean forward for at the 

side of VA, and the providers in this community and elsewhere is 

we will get this right. We will get it right together. It is really important that it is right so that people do not feel like, ‘‘The bill is 

not going to get paid over here, so I am going to send the veteran 

to collections in order to be able to pay my bills.’’ 

The second thing is, in urology in Phoenix, AZ, when the furnace 

lit off in April, we ultimately came to find that of the 14,700 on 

a waitlist, 3,300 of them were urology patients. At the time, there 

were 72 urologists in Maricopa County. The VA had us on speed 

dial. We rolled up our sleeves together. We figured out how to design a demand capacity mathematical process together, which we 

are using to grow our network together across the 28 States and 

the Pacific. Then, we figured out what it would take to place providers, how to do it on a severity basis, and make that happen. 

86 

While Chuck was testifying, I had the information pulled with 

regard to his experience, because it was a while ago. I was having 

a hard time remembering it. 

We received his care requests from VA on June 10. We had him 

appointed on June 17. The practice that saw him took more than 

50 percent of the 3,300 urology patients and processed them within 

7 weeks. They should be sainted. Their patients agreed to step 

aside in their own calendars and serve people like Chuck. Chuck 

got seen initially on the 20th, 3 days after he was appointed. 

That is the way this should work. There are providers in this 

community and your great State and all over this country that 

said, ‘‘I do not want to replace the VA, but I will be there if I am 

needed. Just hand me a few; and, like what we did with TRICARE, 

let me take care of them and then make sure that I get paid properly for the work I have done and on time.’’ 

That is our commitment. I know from the work I have done with 

these three, that is our collective commitment in terms of where we 

want to be. We want to get there as fast as we possibly can. 

The CHAIRMAN. Well, they should be sainted, but they are not 

going to continue to be committed to our veterans unless they are 

reimbursed. I think that is a key issue. 

Senator McCain? 

Dr. SHULKIN. They have been and they are still in the network. 

Senator MCCAIN. I want to refer you, Dr. Shulkin, back to that 

chart that shows the veterans waiting over 30 days. 

The Phoenix VA line is roughly double that of the national average. That, obviously, is very disturbing to anyone who represents 

the State of Arizona, that we should be almost double the percentage of people who are waiting over 30 days. 

We are not proud of the fact that this whole thing really was ignited by what happened at the Phoenix VA. I would hope that extraordinary efforts would be made at least to bring that orange line 

down to the blue line. That part is really something that is not acceptable to those of us who care about our veterans in Arizona. 

Dr. SHULKIN. Senator, it is not acceptable to me, as well. As you 

know, the country is experiencing a shift from VAs that were in the 

rustbelt down to areas like Arizona that are very attractive to veterans particularly who are retiring. We saw a 6 percent increase 

in unique veterans using the Phoenix VA last year, so we are growing. We have to plan for that. That is, in part, making this more 

difficult. 

We will not rest until we can add capacity. We have 738 positions we are recruiting for today. We are adding new space. Our 

new director started today. We need stable leadership in order to 

make this work. I have extreme confidence in our new leader to be 

able to do this. 

I can assure you, extraordinary efforts are what we are going to 

make to get this fixed. 

Senator MCCAIN. Thank you. 

I want to again thank the Senator from Alaska for being here, 

as one of the most important Members of Veterans’ Affairs Committee, to conduct this hearing. I thank you, Senator Sullivan. 

The CHAIRMAN. Thank you, Senator McCain. 

87 

I want to thank the witnesses from both panels. I want to thank 

my colleagues. It is an honor to be up here on the dais with Senator McCain and Senator Flake, two leaders in the entire U.S. Congress on these issues, as I mentioned earlier. Their names are on 

the legislation that we are talking about, and I think that is great 

not only for Arizona, but for the country. 

Finally, I want to thank our veterans who joined us today. I assure you, as Dr. Shulkin said, this Committee and the entire U.S. 

Senate will not rest either until we have addressed these issues in 

a way that is faithful to the service you provided our great Nation. 

I will mention one more time, if there are those of you in the audience who are interested in submitting written testimony to this 

hearing for the Veterans’ Affairs Committee in the U.S. Senate, the 

email again is public_testimony@Sullivan.Senate.gov. You have 2 

weeks to submit that written testimony, which would be Monday, 

December 28. 

This hearing is now adjourned. 

[Whereupon, at 11:08 a.m., the hearing was adjourned.] 

88 

CLARIFICATION OF TESTIMONY OF DAVID J. SHULKIN, M.D., UNDER SECRETARY FOR

HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS

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