U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

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

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

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

97–996 2016

EXAMINING THE QUALITY AND COST OF VA 

HEALTHCARE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, JANUARY 28, 2015 

Serial No. 114–5 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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


VACREP0180 with DISTILLER
(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

GUS M. BILIRAKIS, Florida, 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

RALPH ABRAHAM, Louisiana 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


VACREP0180 with DISTILLER
(III) 

C O N T E N T S 

Wednesday, January 28, 2015 

Page 

Examining the Quality and Cost of VA Healthcare ............................................. 1 

OPENING STATEMENT 

Dan Benishek, Chairman ........................................................................................ 1 

Prepared Statement ......................................................................................... 27 

Julia Brownley, Ranking Member .......................................................................... 2 

Prepared Statement ......................................................................................... 28 

WITNESSES 

Matthew S. Goldberg, Deputy Assistant Director, National Security Division, 

Congressional Budget Office ............................................................................... 3 

Prepared Statement ......................................................................................... 29 

Carl Blake, Associate Executive Director for Government Relations, Paralyzed 

Veterans of America, On behald of the Co-Authors of the Independent 

Budget ................................................................................................................... 5 

Prepared Statement ......................................................................................... 47 

Louis Celli Jr., Director Veterans Affairs & Rehabilitation Division, The 

America Legion ..................................................................................................... 7 

Prepared Statement ......................................................................................... 57 

James Tuchschmidt M.D., Acting Principal Deputy Under Secretary for 

Health Veterans Health Administration, U.S. Depart of Veterans Affairs ..... 9 

Prepared Statement ......................................................................................... 64 


VACREP0180 with DISTILLER

VACREP0180 with DISTILLER
(1) 

EXAMINING THE QUALITY AND COST OF VA 

HEALTHCARE 

Wednesday, January 28, 2015 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON HEALTH, Washington, D.C. 

The subcommittee met, pursuant to notice, at 10:15 a.m., in 

Room 334, Cannon House Office Building, Hon. Dan Benishek 

[chairman of the subcommittee] presiding. 

Present: Representatives Benishek, Bilirakis, Huelskamp, Coffman, Wenstrup, Abraham, Brownley, Takano, Ruiz, Kuster, and 

O’Rourke. 

OPENING STATEMENT OF CHAIRMAN DAN BENISHEK 

Dr. BENISHEK. The subcommittee will come to order. Good morning and thank you all for joining us for today’s oversight hearing, 

‘‘Examining the Quality and Cost of VA Healthcare.’’ 

This Congress I am honored to return as the chairman of the 

Subcommittee on Health, and to be joined once again by my colleague and friend Congresswoman Julia Brownley as our ranking 

member. And Ranking Member Brownley and I are joined by several senior and returning committee members and one freshman, 

Dr. Ralph Abraham. Five of us are doctors, five of us are veterans, 

and all of us share the same primary goal: To create a Department 

of Veterans Affairs Healthcare System that provides timely, accessible, and high-quality care that our veterans can be proud to call 

their own. 

Our work will require open and ongoing cooperation and communication with veterans, stakeholders, and most importantly, VA 

leaders. Unfortunately, it became painfully apparent last year that 

the Veterans Health Administration, which operates the VA 

Healthcare System, was either unable or unwilling to provide basic 

information about the services it provides. 

Using a simplistic equation, dividing the 9.3 million veterans 

who are enrolled in the VA health system by VHA’s annual budget 

of $57 billion, the VA spends just over $6,000 per veteran patient. 

However, we know from the VA’s own data that fewer than 30 percent of veterans rely on VA for all their healthcare needs, meaning 

VHA’s providing for the total healthcare needs of approximately 2.4 

million veterans at a per-patient cost of more than $23,000. 

This is obviously a very rough calculation that I am sure the VA 

will argue fails to take into account certain unique aspects of the 

veteran population and the VA Healthcare System. However, that 


VACREP0180 with DISTILLER
2 

is the granular data that we need in order to move the VA 

Healthcare System forward. 

Recently, the Congressional Budget Office released an analysis 

comparing the cost of VA health system with the cost of the private 

sector healthcare system. In their report, the CBO found that, 

quote, ‘‘Limited evidence and substantial uncertainty make it difficult to reach firm conclusions about the VHA’s relative costs,’’ unquote. The limited evidence and substantial uncertainty that CBO 

references is the direct result of the VA’s failure to provide the information that is needed to assist policymakers and the public in 

evaluating the efficiency and the effectiveness of VA services. 

VA’s lack of transparency is echoed in the disappointing testimony, absent substance or detail, that VA provided for this morning’s hearing. Coming on the heels of last year’s astounding access 

and accountability failures, the VA’s testimony provided for this 

hearing is unacceptable, and I have begun examining measures 

that will require the VA to be much more open with the American 

people moving forward. 

Today’s hearing is just the first in what will be a year-long effort 

by this subcommittee to achieve greater clarity into the cost considerations that impact VA’s Healthcare budget and therefore the care 

our veterans receive. 

[PREPARED STATEMENT OF CHAIRMAN DAN BENISHEK APPEARS IN

THE APPENDIX] 

I thank you all for being here today. And with that, I now recognize Ranking Member Brownley for any opening statement she 

may have. 

Ms. Brownley. 

OPENING STATEMENT OF RANKING MEMBER JULIA 

BROWNLEY 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

And good morning to everyone, and thank you all for being here 

today in support of military veterans. 

Thank you, Mr. Chairman, for holding this hearing. I look forward to working with you this Congress to better the lives of veterans and their families. 

According to the Veterans Health Administration’s report, ‘‘Blueprint for Excellence,’’ veterans enrolled in the VA Healthcare System have a significantly greater disease burden than the general 

population, even after accounting for age and gender mix. Forty 

percent of the nearly 9 million enrollees have service-connected disabilities and their care in fiscal year 2013 accounted for about half 

of VHA’s $54 billion in total obligations. Clearly there is a high reliance on VA Healthcare for veterans who are disabled. 

Today, we will examine the quality and cost of VA Healthcare. 

The Congressional Budget Office released a report late in 2014 that 

looked at comparing the cost of the veterans healthcare system 

with private sector costs. What CBO found was that it is very difficult to compared costs because of a variety of factors. Veterans 

who are enrolled in the VHA system receive most of their 

healthcare outside the system, about 70 percent. Veterans have different clinical and demographic characteristics, and cost-sharing 


VACREP0180 with DISTILLER
3 

requirements are much lower for VA care than for care received 

from private sector providers. 

Another very important point to remember is that VHA’s mission 

is to address the total health of veteran patients, not just provide 

care for illness or disease. This is a much different approach than 

the private sector practices. 

Additionally, CBO points out in their report that there are differences in financial incentives for providers. For example, most 

private sector providers, whether in hospitals or physicians practices, generate revenue for each unit of service that they deliver. 

Because of that, they may have a financial incentive to deliver 

more services, whereas the VA providers do not. 

CBO suggests that an annual report, much like that of the Department of Defense’s TRICARE health system, which includes operating statistics, trends among beneficiaries, and their demographics, among other things, would facilitate comparisons between 

VHA and the private sector. However, these comparisons would 

still be challenging, in part because private sector data might also 

be incomplete or unavailable or difficult to make comparisons with 

VHA data. 

Instead of looking at comparing costs to the private sector, I 

think we should focus on improving access to veteran healthcare, 

ensure that veterans receive the best care possible, and continue to 

hold important oversight hearings on the quality and safety of the 

care provided to veterans. We absolutely need to complete and be 

transparent in terms of costs within the VA, and there is still much 

to learn from the private sector and their practices, particularly 

when it comes to IT and better access to healthcare within the VA. 

Thank you, Mr. Chairman. And I yield back. 

[PREPARED STATEMENT OF RANKING MEMBER JULIA BROWNLEY

APPEARS IN THE APPENDIX] 

Dr. BENISHEK. Thank you, Ms. Brownley. 

We have these votes this morning that we are going to have to 

go deal with, but I would like to get as much testimony in as possible before we have a recess. 

Joining us on our first and only panel is Matthew Goldberg, the 

deputy assistant director of the National Security Division of the 

Congressional Budget Office. Carl Blake, the associate executive director for government relations for the Paralyzed Veterans of 

America, who is testifying today on behalf of the coauthors of The 

Independent Budget. Louis Celli, Jr., the director of Veterans Affairs and Rehabilitation Division for the American Legion. And Dr. 

James Tuchschmidt—I hope that is right. 

Dr. TUCHSCHMIDT. That is very good. 

Dr. BENISHEK. The acting principal deputy under secretary for 

health for the Department of Veterans Affairs. 

Thank you all for being here this morning. 

Mr. Goldberg, could you please proceed with your testimony. 

STATEMENT OF MATTHEW S. GOLDBERG 

Mr. GOLDBERG. Thank you Chairman Benishek and Ranking 

Member Brownley and members of the subcommittee. Thanks for 

the opportunity to testify on CBO’s understanding of the cost of 


VACREP0180 with DISTILLER
4 

healthcare provided to veterans by the Veterans Health Administration, VHA. 

CBO regularly examines issues related to veterans healthcare, as 

well as other benefits that are provided the Veterans Benefits Administration, or VBA. Most recently, in December 2014, CBO released a report to compare the cost of healthcare provided directly 

at VHA facilities with the cost of private sector care. My submitted 

statement today reprises that report. 

Although the structure of VHA and some published studies suggest that VHA care has been cheaper than care provided by the 

private sector, limited evidence and substantial uncertainty make 

it difficult for CBO to reach firm conclusions about those relative 

costs or whether it would be cheaper to expand veterans’ access to 

healthcare in the future through VHA facilities or in the private 

sector. 

CBO also produces budgetary baselines and cost estimates for 

legislative proposals that would modify veterans’ benefits. Among 

other measures, over the past 8 months CBO has estimated the 

budgetary effects of the Veterans Access, Choice and Accountability 

Act of 2014, including earlier versions of that legislation, and the 

Department of Veterans Affairs Expiring Authorities Act of 2014, 

which amended certain portions of the earlier legislation. 

In recent years, at the request of both the Senate and House 

Committees on Veterans’ Affairs, CBO has reported on several related topics. First, veterans’ disability compensation. Second, the 

VHA’s treatment of post-traumatic stress disorder and traumatic 

brain injury among recent combat veterans. And third, the potential costs of providing healthcare to veterans of all eras. 

Among the many analytical challenges in conducting those studies are the problems CBO sometimes encounters in obtaining appropriate data from the VHA or the VBA. For instance, comparing 

healthcare costs in the VHA system and the private sector is difficult, partly because the VA has provided limited data to the Congress and the public about its costs and its operational performance. 

Additional data, particularly if it was provided on a regular and 

systematic basis, could help inform policymakers about the efficiency and cost-effectiveness of VHA’s services. For example, the 

Department of Defense, in response to a statutory requirement established in the National Defense Authorization Act for fiscal year 

1996, publishes an annual report to the Congress about its 

healthcare system known as TRICARE. The most recent of those 

reports contains more than 100 pages of operating statistics, including trends among beneficiaries and the demographics, funding 

by appropriation category, use and cost of inpatient, outpatient, 

and pharmacy services, beneficiaries’ cost sharing, and patient satisfaction with their care. 

A virtue of the annual recurring nature of those reports is that 

each contains consistent trend data from previous years and a 

longer data series can be compiled by comparing past years’ volumes. A corresponding annual report on VHA, if one existed, would 

facilitate comparisons between VHA and the private sector. 

Another example is CMS, which administers Medicare, through 

its Research Data Assistance Center provides individual level data 


VACREP0180 with DISTILLER
5 

to researchers who can demonstrate the utility of that type of data 

to their research design, who agree to handle the data in a way 

that preserves patients’ confidentiality, and who consent to possible 

audits and publication restrictions. That information provided by 

CMS is used by a wide variety of researchers to study the health 

of American seniors, the cost of providing their care, and the effectiveness of different treatments in managing their health. 

The best study that CBO could identify to compare the cost of 

healthcare directly provided by VHA with the private sector was 

published in 2004, based on data from 1999. The authors of that 

study had access to detailed administrative data from six VHA 

medical centers and the clinical charts from veterans treated at 

those centers in 1999. 

CBO cannot replicate that study with more recent data, both because it had limited time and resources to perform its analysis and 

because, with few exceptions, VHA does not make either administrative data or clinical records, even with personal identifiers removed, available to researchers in other government agencies, universities, or elsewhere. 

Additional system-wide data from VHA would have facilitated 

the comparison of costs between VHA and private sector care. For 

example, it would be useful to know the average salaries, performance pay, and other elements of compensation that VHA provides 

to its physicians in various specialties and for its other clinicians, 

the number of patients its clinicians treat per unit of time, for example in a typical week, and the length and intensity of those encounters, and the average prices that VHA pays for pharmaceutical 

products. But VHA does not report that systematically and publicly. 

Again, I thank you, Mr. Chairman, and for inviting me, and I 

look forward to taking your questions. 

Dr. BENISHEK. Thank you very much, Mr. Goldberg. 

[THE PREPARED STATEMENT OF MR. GOLDBERG APPEARS IN THE

APPENDIX] 

Dr. BENISHEK. Mr. Blake, you are now recognized for 5 minutes. 

STATEMENT OF CARL BLAKE 

Mr. BLAKE. Thank you, Mr. Chairman, Chairman Benishek, 

Ranking Member Brownley, and members of the subcommittee, on 

behalf of the four coauthors of The Independent Budget. I would 

like to thank you for the opportunity to testify today. 

We believe that two clear conclusions can be drawn from the 

CBO report. First comparing the cost of healthcare administered by 

the VA to care provided by the private sectors is not an apples-toapples comparison. The second observation that can be drawn from 

the report is that it expresses no definitive conclusion on the question of which model of healthcare is more cost-effective, and any assertion that it does is simply rhetoric. 

The CBO report clearly outlines some important distinctions that 

further explain why a direct comparison between VA Healthcare 

and private sector healthcare is difficult, to say the least. Foremost 

among these distinctions is the fact that VHA serves a patient population that is distinctly different from the general U.S. population. 

The entire VHA system is designed to address this situation. 


VACREP0180 with DISTILLER
6 

Representatives of private sector healthcare organizations have 

testified to this very issue. In fact, last summer at a hearing before 

the full House Committee on Veterans’ Affairs, a number of the 

witnesses representing private healthcare organizations and entities expressed their challenge in understanding veterans as patients. They admitted that they would gladly provide services to 

veterans seeking care, but they also admitted that they could not 

guarantee care that was veteran specific. 

The second major distinction that the IB coauthors believe is the 

crux of this problem deals with how the VA is funded versus how 

the private sector determines its funding mechanism. Under ideal 

circumstances, this would not be a challenge if the administration 

requested and Congress provided necessary resources to meet all 

demand placed on the system, but we know that this does not really happen. 

Congress has asserted in recent years that it has provided all the 

resources the administration has requested. The IB cannot dispute 

that assertion. However, we also know that the administration 

rarely has requested the resources that VA needed to properly address the demand. We only need to reexamine the unacceptably 

long wait times and the lack of access to healthcare that was exposed last spring and summer to prove that point. 

Deputy Secretary Gibson offered an interesting observation before the full House VA Committee last summer that has long been 

a complaint of the IB. Secretary Gibson testified at that hearing 

that the VA has been in the business of managing to budget, not 

to need. We have the Office of Management and Budget to thank 

for that fact. 

Ultimately, we believe the central question when comparing VA 

Healthcare to private sector healthcare should focus on the quality 

and value of care. While we recognize that there is much debate 

underway about the quality of care being delivered at VA medical 

facilities around the country, we believe that the private sector 

healthcare system by and large could not stand up to the same 

level and intensity of scrutiny that the VA is under. 

We will not dispute the idea that timely access to high-quality 

care remains a clear objective VA is not achieving in a satisfactory 

manner. Let me repeat that. We will not dispute the idea that 

timely access to high-quality care remains a clear objective that VA 

is not achieving in a satisfactory manner. 

Access to healthcare, along with the cost and quality of care, are 

generally considered the three major indicators for evaluating the 

performance of a healthcare system or provider. Prevalent delays 

in delivering timely care result in patient dissatisfaction, higher 

costs, and an increased risk of adverse clinical outcomes. 

However, while an argument could be made for primary care or 

other types of care for some veteran patients to be delivered outside of VA, it is an indisputable fact that most of VA’s specialized 

services, such as spinal cord injury, blinded care, amputee care, 

and polytrauma care, are incomparable resources that are not duplicated and not successfully sustained in the private sector. 

Are there similar systems that attempt to provide this type of 

care? Yes. But they are not duplicative of what the VA does and 

not on the same level. 


VACREP0180 with DISTILLER
7 

Moreover, the viability of the VA Healthcare System depends 

upon a fully integrated system in which the organization and management of services are interdependent so that veterans get the 

care they need, when and where they need it, in a user-friendly 

way to achieve the desired results and provide value for the resources spent. There certainly could be some question about whether VA care is user friendly these days, but by and large we believe 

it is. And yet, CBO points out that fully integrated systems are not 

particularly common in the private sector. 

The CBO report in previous discussions and hearings make it 

clear to the IB coauthors that comparing VA Healthcare and private sector healthcare is at a minimum complicated and at the 

most a fool’s errand. Too many uncontrollable variables would confuse any outcomes or conclusions. A common refrain we hear from 

those clamoring for increased access is the lack of data from the 

VA on its services and performance. I won’t even disagree with that 

fact. Clearly they need to be more transparent about the data and 

information that is available. 

However, the CBO report clearly explains that comparisons 

would be challenging because private sector data also may be incomplete, unavailable, and difficult to make comparable with VHA 

data. To be clear, the IB coauthors believe that VHA should be 

more forthcoming with its data that allows a thorough examination 

of the timeliness and quality of services and the capacity that the 

VA needs to meet those demands. However, the concern over VA’s 

apparent lack of transparency on data cannot be set aside when 

the private sector does not always choose to provide the same data. 

Again, Mr. Chairman, I would like to thank you for the opportunity to testify, and I would be happy to answer any questions 

that you may have. 

Dr. BENISHEK. Thank you very much for your testimony, Mr. 

Blake. I truly appreciate your perspective. 

[THE PREPARED STATEMENT OF MR. CARL BLAKE APPEARS IN THE

APPENDIX] 

Dr. BENISHEK. At this time we are going to head off and do our 

voting. I ask your indulgence for the remaining panel members to 

wait until we return. We will recess for the time necessary it takes 

to do this voting. Thank you. 

[Recess.] 

Dr. BENISHEK. We will call the subcommittee back to order. Is it 

Celli. 

Mr. CELLI. It is Celli. 

Dr. BENISHEK. Mr. Celli, would you please proceed with your testimony? 

STATEMENT OF LOUIS CELLI JR. 

Mr. CELLI. I will, thank you. 

And I quote, ‘‘All told, CBO expects that if the bill was fully implemented, some veterans would ultimately seek additional care 

that would cost the Federal Government about $54 billion a year, 

after accounting for savings to other federal programs . . . Thus, 

CBO estimates that the implementation of sections 2 and 3 of the 

House bill would roughly cost $500 million in 2014, $16 billion in 

2015, and $28 billion in 2016.’’ 


VACREP0180 with DISTILLER
8 

Chairman Benishek, Ranking Member Brownley, and distinguished members of this Health Subcommittee, on behalf of Commander Helm and the 2.4 million members of the American Legion, 

I thank you and your colleagues for examining CBO’s recent analysis in an attempt to achieve greater clarity into the cost considerations impact the VA Healthcare has on its budget, and as well the 

quality and care and patient satisfaction. 

The CBO estimate I just read came from the original estimate 

from the Veterans Access to Care Act of 2014, a bill that many of 

us here in this room worked on together. The shocking $54 billion 

price tag that is quoted, which includes a $7 billion credit based 

on a discount to other federal programs that CBO talks about, is 

a savings to the Medicare account, because when Medicare-eligible 

services are performed by VA, VA is statutorily prohibited from 

billing Medicare for reimbursement, regardless of whether the care 

provided was service connected or not. So VA would have to eat 

those costs as well. 

The analysis goes on to say, ‘‘Because the bill would increase enrollment in VA Healthcare in 2015 and 2016, the demand for VA 

Healthcare services would probably increase in 2017 and subsequent years. If lawmakers wanted to accommodate that increase in 

demand, additional appropriations would be necessary after 2016. 

This estimate does not include those costs of providing such care 

and additional services after 2016,’’ end quote. 

There has been a lot of discussion over the years that suggests 

that veterans might be better off if we privatized some or all of VA. 

The American Legion believes that this concept is shortsighted, 

prohibitively expensive, and fails to take into consideration the specialized care that veterans receive and deserve at VA. 

Those who suggest that veterans would be better off if VA were 

privatized, we ask only that you take a moment to look at DoD’s 

TRICARE program for retirees, and then let us know if you still 

think that veterans should trust that a privatized VA would be 

there for them or their sons and daughters the next time we are 

all asked to share in some fiscal budget belt tightening. 

Veterans have been battling Congress and the administration 

every year for the past 10 years trying to stave off TRICARE reduction attacks, and every year for the past several years we have 

been losing more and more of the retirement benefits we spent 20- 

plus years of our lives working to earn. So now, some think that 

it might be a good idea to see if we want to start taking more and 

more services off VA campuses too? Really? 

As CBO has clearly demonstrated in past reports, and as highlighted by my written testimony here today regarding this report, 

despite an embarrassing lack of comprehensive data available from 

VA, contracted care, even at Medicare rates, which a large number 

of private providers refuse to accept, will ultimately cost American 

taxpayers 30 to 40 percent more in the short run and even more 

long term, because one of the consequences of private care, as CBO 

and others consistently point out, is less frequent trips to the doctor, resulting in future complications and an overall increase in 

acute care needs. 

In addition to saving taxpayer money and having one of the highest patient satisfaction rates in the industry, VA is a driving factor 


VACREP0180 with DISTILLER
9 

in innovative technology and serves as a teaching hospital for hundreds of doctors every year. No commercial healthcare system in 

the United States can say the same. 

Chairman Benishek, Ranking Member Brownley, and members 

of this committee, the American Legion has worked for more than 

80 years to build and support a comprehensive Department of Veterans Affairs worthy of the sacrifices our veterans have made to 

protect the freedoms every one of us here in the United States and 

abroad enjoy today. We will continue to work toward that goal with 

this Secretary and this Congress and with the next hundred Secretaries and Congresses to come. Thank you. And the American Legion looks forward to working with you and your staff as we build 

a better VA in the 114th Congress. 

Dr. BENISHEK. Thank you, Mr. Celli, for your perspective and 

your testimony. 

[THE PREPARED STATEMENT OF MR. LOUIS CELLI APPEARS IN THE

APPENDIX] 

Dr. BENISHEK. Dr. Tuchschmidt, you are recognized for 5 minutes. 

STATEMENT OF JAMES TUCHSCHMIDT 

Dr. TUCHSCHMIDT. Thank you. Chairman Benishek, Ranking 

Member Brownley, and distinguished members of the House Committee on Veterans’ Affairs Subcommittee on Health, thank you for 

the opportunity to discuss with you the Department of Veterans Affairs’ cost of healthcare provided to our patients. 

VA is committed to providing safe, high-quality, accessible, and 

efficient healthcare for America’s veterans. Our most important 

mission is to make sure that veterans know that the VA is here 

to care for them. 

Recently the Congressional Budget Office conducted a limited examination of how the costs of healthcare provided by VHA compares with the costs of care provided in the private sector. As stated in the report, distinctive features of the VHA system, such as 

its mission, mix of enrollees, and financing mechanisms, complicate 

cost comparisons with other sources of healthcare. 

The VHA system is designed to serve a unique patient population, veterans. These veterans have carried the burden of war. As 

a result, they suffer from a disease burden that is higher than the 

general population. Many have more than one injury or disability, 

incurred during their military service. And 40 percent of our patients have a major mental health diagnosis. Others lack social 

support or face socioeconomic challenges. 

This unique patient population has complex needs, and we at the 

VHA are committed to providing them with really unparalleled 

care. VHA provides a large social support system to a vulnerable 

population addressing many of the social and economic causes of 

poor health. The social programs provided by VHA, our outreach to 

the homeless and those at risk, fall outside of the typical scope of 

healthcare provided to patients in the private sector. 

VHA’s social workers provide individual assistance connecting 

veterans to a range of resources, such as financial assistance, housing, job training, and the like. Our caregivers support program and 

our readjustment counseling services provide counseling and finanVerDate Aug 31 2005 15:05 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 Y:\97-996.TXT PAT

VACREP0180 with DISTILLER
10 

cial support to veterans and their families. Beneficiary travel payments are available to veterans who meet eligibility criteria to help 

them get to their medical appointments. These are all examples of 

our mission to address the total health of our veteran population, 

and it is not simply to take care of illness and disease. 

VHA is a world leader in treating combat-related issues and disabilities. We offer access to a variety of services and benefits. Our 

services are not widely covered under most insurance plans, including Medicare and other public forms of insurance. An example of 

this is our robust mental health programs, particularly for posttraumatic stress disorder and substance abuse treatment. VHA 

also provides the most technologically advanced prosthetics for 

those veterans who need those assistive devices. Some private insurance plans cover prosthetic services, but generally not to the extent and kind that we provide America’s veterans. 

Veteran care is complex, and these are just some of the reasons 

why it is challenging, I believe, to fully compare VHA care with private sector. We realize that access to care has been our Achilles 

heel. We are thankful for the Choice Act, which has provided funding and resources to help us address many of these issues. 

We have been working diligently with your staff to discuss the 

lessons learned and will continue to do so. As the CBO report stated, VHA currently does not publish a yearly report about our 

healthcare system. I understand that we used to. I don’t know 

what happened to that and why we don’t do that anymore. But I 

commit to you today that we will produce an annual report. We 

thought the TRICARE report was an outstanding document. 

But you have my commitment today to work with your staff, 

with the veteran service organizations and other stakeholders, to 

figure out what should be in such a report, and we will produce 

that report on an annual basis. 

I meet with committee staff on a weekly basis to discuss the deployment of the Choice program, and that has, in my opinion, been 

a fantastic relationship. Certainly helpful to me in terms of understanding intention and collaboratively trying to figure out where 

we go with that critical program. And you have my commitment 

today to sit down with your staff and figure out what data you 

would like to see about the cost of VA healthcare, and we will do 

our very best to get that together for the committee. 

In conclusion, VHA has made I think many distinctive contributions in clinical care, in medical research, and the education of future healthcare providers. VHA recognizes the uniqueness of the 

veteran’s health needs and provides a continuum of services to address not just the medical needs, but the psychosocial needs of this 

population. We are proud of our documented record in the health 

industry, and VHA, I believe, provides high-quality, safe, and effective care for veterans. 

I thank you for the opportunity to be here today, and I will do 

my very best to answer your questions. 

Dr. BENISHEK. Thank you, Dr. Tuchschmidt. 

[THE PREPARED STATEMENT OF DR. JAMES TUCHSCHMIDT APPEARS

IN THE APPENDIX] 

Dr. BENISHEK. I will now yield myself 5 minutes for questions. 

And let me just say I really appreciate you guys being here today 


VACREP0180 with DISTILLER
11 

and your perspectives, especially from the veteran service organizations. 

I worked at the VA for 20 years off and on, and I realize that 

the VA provides a service to our veterans that can’t be duplicated 

in the private sector. Yet we need to have some sort of idea beyond 

the total amount of money we are spending at the VA and what 

we are getting, because, frankly, I have in my career seen a lot of 

money which I think has been wasted. There are a lot of things 

that we could do better, that money could be put to use for, and 

I want to make that happen. With that spirit, I have a couple of 

questions I want to go for. 

Mr. Goldberg, what specific data would you need to see in order 

for the CBO to complete a better cost comparison between the VA 

and the private sector? 

Mr. GOLDBERG. Mr. Chairman, there are three levels of data that 

we think would be useful, not only for our work, but for the committee’s oversight role, and in fact to bring in the broader research 

community to look at VA, because just as it has done in DoD and 

particularly in Medicare, I think that is very healthy, to have a lot 

of people looking at your system. 

So the first level of data would be basic demographic and systemwide data, how many veterans are being seen, what are they being 

seen for, and to what extent are we providing care for service-connected disabilities and to what extent are we providing care for 

non-SCDs. In other words, to link up the VBA and the VHA data 

so they talk to each other. And we can make sure that at a minimum we are caring for the service-connected disabilities. That 

would be high-level data. 

Second level is more detailed data. There would be things like 

the panel sizes and the compensation rates of the different personnel, the staffing levels by medical specialty. For example, information about facilities, information about overhead and accounting 

practices. This is finer data that would probably be of interest to 

us as analysts, not necessarily the broader committee. It is the 

kind of data that some of it goes a little bit deeper than the 

TRICARE report, but it is the kind of data that we would really 

need to take a close look at VHA and ask why is it, what is the 

plausible case that perhaps VHA is cheaper than the private sector. Well, if we knew about panel sizes, if we knew about how 

many patients a provider sees in a week, that sort of thing, we 

could start to tell that story better. That is the second level. 

The third level of data would be the kind of data that CMS 

makes available to researchers as was studied in the Medicare program, individual level data, so that you can actually look at a veteran who is seen in VHA and a veteran who is seen out in purchased care and look at the treatment regimen and look at the 

number of visits and the costs. And there are privacy issues with 

providing individual level data, but those issues, I think there is 

a good precedent in the way that CMS handles the Medicare data. 

For example, a researcher has to submit a plan how they would 

use the data, how they would guard the confidentiality. They have 

to destroy the data often at the end of the project, and there are 

limitations on cell size that they can report data in, table size, so 

that we can bring in the broader community. 


VACREP0180 with DISTILLER
12 

And it was really an opportunity for natural experiment, because 

with the Veterans Choice Act we have a lot more veterans who will 

be seen in the private sector, and there is language in, I think, Section 101 of the Veterans Choice Act that calls for high-level reporting, like how many veterans are being seen. But if we got individual data on the veterans being seen in the private sector, we 

could ask, if a veteran has a certain condition, like diabetes, and 

is seen in the VHA, look at utilization, and look at the costs there, 

and then take a matched group with similar comorbidities and 

similar demographics that is being seen out in the private sector 

and see what kind of care they are getting and what the health 

outcomes are, and to match that would be a great research project. 

Dr. BENISHEK. Thank you, but I want to ask another question 

and there are limits on my time. 

Dr. TUCHSCHMIDT. do you know what the average cost for specialty care is for the VA, for example like a routine colonoscopy 

within the VA versus in the private sector? 

Dr. TUCHSCHMIDT. I don’t have that in my head. We can probably 

get that kind of information. 

Dr. BENISHEK. I don’t think you can. See, that is the whole point 

of what we are doing here, is that we don’t know what it costs to 

do some of the routine things within the VA, because we have inquired on this in the past, and I think that is the kind of data we 

need to have, and we need to be able to provide oversight. I agree 

with these other gentleman here, the VA provides care to our veterans that can’t be provided in the private sector. And yet, a lot 

of the stuff that we do within the VA can be. In those areas I think 

a comparison is in order so that we can provide the best specialty 

care for our veterans. 

I am unfortunately out of time, so I am going to yield 5 minutes 

to the ranking member, Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman. And I will try to follow up on your line of questioning here. 

Dr. TUCHSCHMIDT. the CBO just gave three recommendations in 

terms of the type of data that would be helpful to the committee, 

to the VA, and certainly our oversight going into the future to continuously improve the quality of healthcare to our veterans and 

with the best amount of efficiencies that we can yield from it. Is 

that something that you think that you would be able to begin to 

develop and provide to the committee and I think internally within 

the VA? In terms of your own decision-making and optimizing that 

decision-making, it sounds like this kind of data would be very 

helpful. 

Dr. TUCHSCHMIDT. Sure. I am not an expert on our financial and 

accounting systems, which I think go back to the 1940s, but we do 

have a cost accounting system. So I think we can actually get the 

cost per colonoscopy in our system. I think certainly some of our 

researchers have looked at that level of data in a much more focused way. 

But I think that the answer or asking the question what is the 

cost of care is actually the wrong question to be asking. The question I think is really, what is the return on investment? What is 

the value that my dollar is buying for us? And I think there are 


VACREP0180 with DISTILLER
13 

many issues around case mix and risk adjustment, and just comparing cost is flawed thinking. 

And in my mind, value is really about quality divided by cost, 

right? And when I look at the system that we have in VA, I can 

tell you that looking at our data, we track the 44 HEDIS measures 

that everybody in private sector tracks, and if you look at our performance we beat Medicaid, Medicare, and indemnity insurance on 

every one of them last year. If you are a veteran, you are more likely to be screened for cancer if you are in the VA system. You are 

more likely to get your diabetes, hypertension, and lipidemia managed appropriately. You are less likely to die from coronary bypass 

surgery. In fact, if you look at the data, you are 20 percent less 

likely to die in a VA hospital or have a major adverse event in a 

VA hospital than if you are in a private hospital. 

I think asking the question about what is the cost of care is certainly a legitimate question, as long as we are focused really I 

think on the value proposition that is here, because I think we do 

serve a different population of people. And I think efficiency is an 

extraordinarily reasonable expectation of any system, any 

healthcare system, including the VA. And I would not hold American healthcare up to that standard, because all of the data shows 

that American healthcare is probably the most expensive of any industrialized nation with probably the worst outcomes. 

I think the questions that are being asked and the data that has 

been proposed are certainly something that we can go back if we 

have clear stipulation of what it is. I am more than happy to go 

back and try and figure out how to get that. 

Ms. BROWNLEY. Thank you. 

And just then to ask the CBO, based on what was just stated, 

based on looking at models in terms of yielding the very best value 

and the best care for our veterans, understanding that we may 

never get to an apples-to-apples comparison with the private industry, is there a study that you could look at to look at that to help 

inform us how we are doing. I know it is tough because we are in 

some sense not comparing ourselves to anything else. But is there 

a way for you to analyze what the VA just said about being cautious about just strictly looking at cost, not looking at the risk, but 

determining what is the real value that we are getting on our investment in terms of care for our veterans? 

Mr. GOLDBERG. Yes. Let me say two things, if I may. One is, I 

am heartened by Dr. Tuchschmidt’s commitment to provide the 

kind of data that DoD provides to the oversight committees 

through the TRICARE report. 

In the time we had, and our question from Senator Sanders was 

pretty narrowly focused on cost, but I would agree with the sentiment in the room that the other side of the equation is to look at 

the quality of care and satisfaction. That would be a big study. I 

am not sure I would just divide cost by satisfaction, I think the 

math is a little harder. But I agree to get a fuller picture you would 

have to look at all those various aspects, and perhaps we could be 

helpful to that in future studies. 

Ms. BROWNLEY. Thank you. 

Mr. Chairman, I yield back. 

Dr. Benishek. Mr. Coffman. 


VACREP0180 with DISTILLER
14 

Mr. COFFMAN. Thank you, Mr. Chairman. 

We need to know what procedures cost, and we don’t know that 

right now. And we need transparency, and we don’t have that right 

now in the VA system. And we are talking about a system that, 

I mean, when you are talking about the quality of care, that just 

excluded veterans by virtue of manipulating wait lists, appointment wait lists, so that people could get cash bonuses. That is the 

system that we have. And, quite frankly, I don’t think that we have 

the leadership, supposedly the new leadership in place, new Secretary, is not changing the culture of the VA as far as I can see. 

Let me tell you, I deal with healthcare both on the active duty 

side and on the VA side. And as a marine combat veteran, as a 

military retiree, I will continue to fight to make sure that our 

wounded coming back from the battlefields of Afghanistan and potentially now Iraq don’t go into the VA system. Right now, our Active Duty, when they are injured in combat, remain on active duty 

for the rehabilitation. Used to be during Vietnam when the wounded came home they would be stabilized in the military system and 

then sent on to the VA for the rehabilitation. Now that is not the 

case. 

Until the VA cleans up, until we are able to make sense out of 

this organization, I want to make sure that our wounded, double 

amputee above the knees, 2-year rehabilitation, remains on active 

duty, as a marine, as an airman, as a sailor, as a soldier. That is 

my obligation to them. 

But my obligation to the veterans of this country is to make sure 

that the VA can function and meet the obligation to our Nation’s 

veterans, which it is not doing in the healthcare system. And we 

can all gloss it over here. I have heard some great comments about 

how fine the system is. Let me tell you, you are not talking to the 

veterans that I am talking to. 

So to the Congressional Budget Office, Mr. Goldberg, we got all 

these comments about how different this population is, but a heart 

bypass operation, a colonoscopy that was mentioned, I mean procedure by procedure, were you able to discern the costs of those relative to the private sector in the VA system? 

Mr. GOLDBERG. Congressman Coffman, we were not able to do 

that. We had to go to the report that was published in 2004 where 

the researchers had access to the individual patient records and 

were able to do that kind of comparison, look at how much it actually cost to provide care in VHA and price it out at Medicare rates. 

Because we did not have access to that individual patient-level 

data, we really could not reproduce that study, and so our report 

basically takes that study from 2004 and asks, is it still relevant 

today? That is about as far as we could go lacking the kind of data 

that the researchers had access to back then. 

Mr. COFFMAN. Okay. 

Well, Dr. Tuchschmidt, you say you are going to provide this information now. I don’t know why you haven’t provided it in the 

past, but you are going to now provide it to Congress. Let me tell 

you this, given the record of the Veterans Administration in providing information to this committee, I absolutely have no confidence in your remarks. 


VACREP0180 with DISTILLER
15 

What I believe has to happen is we have to have a mandate from 

the Congress of the United States to the Veterans Administration 

on what information that they are going to provide public, that 

they are going to have to be transparent, and that they are going 

to have to provide the same information that the Department of 

Defense provides for the healthcare of our Nation’s Active Duty. In 

Medicare, that population, that information is provided. 

But I am disheartened by the testimony today, and I think that 

certainly it gives a responsibility to this committee to move forward, I believe, with legislation to accomplish, I think, what the 

CBO has said and what the taxpayers need. And I believe that 

changes like the Veterans Choice Act actually will make the VA 

system better by giving veterans an opportunity, if they can’t get 

an appointment within a given wait time, that is excessive, to be 

able to go outside the system and be compensated and to have that 

provider compensated on the Medicare rate. 

Mr. Chairman, I yield back. 

Dr. BENISHEK. Dr. Ruiz, 5 minutes. 

Dr. RUIZ. Thank you, Mr. Chairman and Ms. Ranking Member, 

for holding this hearing. I am honored to again represent my district’s veterans on this subcommittee and veterans around the 

country as well. And I look forward to working with my fellow 

members to ensure our veterans receive the high-quality, veterancentered care they have earned. 

Last Congress this committee worked hard to create the Veterans Access, Choice and Accountability Act, which expands opportunities for veterans to seek private care if the VA cannot provide 

the care they need when they need it. I am working currently with 

medical professionals in high-demand specialties in my district to 

help my constituents utilize the Choice program, but to maximize 

the effectiveness of private care we must be able to adequately 

measure its value against the VA services. 

However, making an apples-to-apples comparison between the 

VA and private sector health system is difficult due to the limited 

available data, varying methodologies, and divergent patient population. I think one of the things you are stuck with is that in doing 

a meta-analysis, you don’t have the data to determine what procedures cost, but every hospital knows what those procedures are, 

but you are limited by your own methodology in being able to acquire that information. 

It is not if you can compare the VA to private care. It is what 

will you compare between the VA and private care that is the question presented to us. While cost is important, our number one priority must not be a spreadsheet void of a human story, but the 

health and well-being of our veterans. And that is something that 

we can measure in terms of morbidity, mortality, and the performance of different VAs with their hospital performance that can be 

compared to other private hospitals. 

And some hospitals are great, but some hospitals are terrible. 

And even those that are great have problems with their wait lists. 

So if you tell a veteran that your VA hospital is great or has good 

scores or that provides cheap, affordable, good-quality healthcare, 

but they can’t be seen by a physician, then it doesn’t matter. So 

let’s take a step back, look at the big picture, and make sure that 


VACREP0180 with DISTILLER
16 

we are measuring the right things, that we are providing a highquality, veteran-centered care. As the CBO remarks, quote, ‘‘Cost 

comparisons do not reflect such important considerations as the 

quality of the care provided, its effects on patient health, and patient satisfaction with a given healthcare system.’’ 

So my question to the CBO, which actually goes in line with your 

return on investment, is were these costs compared to the cost savings that the care of the VA provides for those who get care and 

therefore you reduce their morbidity and the severity in future 

years and compared those cost savings that we have? Does the 

study look at that? 

Mr. GOLDBERG. Dr. Ruiz, it is an excellent question. We were not 

to do that. But that would be a great follow-on research if the data 

were available to follow individual veterans, and follow their outcomes. I might say not only for CBO, but for the larger research 

community it would be a great question. 

As I said earlier, if I could restate, the time we had and the narrow focus of the question from Senator Sanders and the data available forced us to look narrowly at cost, recognizing, according to 

your question, that quality and satisfaction are also important dimensions of the problem, we didn’t have time to look at it. 

Dr. RUIZ. Well, that is why I want to caution the committee 

when we look at any cost-benefit analysis because they are full of 

assumptions and they are full of creative ways to determine what 

are the costs now and what are the costs in the future that you 

are saving. And therefore we need to make sure that we incorporate those aspects of not only individual costs for the individual 

veteran, but for the community, the country, and overall our economy. 

The other question is, if we talk about quality care, how do you 

measure veteran-centered care that we can include as part of this 

cost-benefit analysis? 

Mr. GOLDBERG. Well, there were a lot of quality measures that 

are used for the healthcare system in general, and VHA has been 

good about reporting those kinds of measures for their own population. I think the other —— 

Dr. RUIZ. Hold on one second. You know, they are good, but 

many of those are institution-centered measurements, in terms of 

how many medications you provide or how many, you know. Veteran-centered care is asking the veteran what was their experience, 

what was their quality, did they receive the medications that they 

believed was adequately explained and understood, et cetera. So 

that is what I am talking about in terms of veteran-centered measurements. 

Mr. GOLDBERG. I understand. Along those lines what I would say 

is we have to survey veterans. I am actually not that familiar at 

the moment with the questions in the survey instruments. But if 

they don’t already, the VA could be asking this question of the veterans, satisfaction kinds of questions, exactly the considerations 

you have. I am not sure the degree to which that is done. We could 

check with VA and find out. 

Dr. RUIZ. Thank you very much. I am done with my time. I yield 

back my time. 

Dr. BENISHEK. Thank you, Dr. Ruiz. 


VACREP0180 with DISTILLER
17 

Mr. Bilirakis, 5 minutes. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it. It really is an honor to serve on this subcommittee. And thank you very 

much for holding the hearing. And I thank the panel for their testimony. 

I want to ask a question for Dr. Tuchschmidt. 

Doctor, in your testimony you state the VA has surveyed 72,000 

veterans each month on their patient experiences since 2002. Does 

that number reflect how many surveys were sent out or how many 

were answered and returned? 

Dr. TUCHSCHMIDT. That is the number, I believe, of surveys that 

we sent out to veterans. We have in general about, I am going to 

say, about a 40 percent response rate, I think, on the mailed surveys that we have. 

We are moving right now actually to beginning to get satisfaction 

surveys at the point of care. So we will get much more real-time 

feedback. We are putting it on our kiosk. We put them on TV 

screens actually in our hospitals. We are working actually to put 

them on handheld devices that we can either provide in our waiting rooms or that they can use on their own phones. 

We do a lot of satisfaction survey, have for a long time, and publish that data. You know, when you look—— 

Mr. BILIRAKIS. Do you make the data public? 

Dr. TUCHSCHMIDT. The data is publicly available. 

Mr. BILIRAKIS. How can my constituents access that data? 

Dr. TUCHSCHMIDT. I am happy to get it for them, absolutely. 

Mr. BILIRAKIS. Can they go to a particular Web site? 

Dr. TUCHSCHMIDT. So if you go to our Web site you will be able 

to look at that data. 

Mr. BILIRAKIS. They can access the data? 

Dr. TUCHSCHMIDT. I am pretty sure that it is there. 

Mr. BILIRAKIS. Okay. Well, get back to me on that. 

Give me an example of maybe a question. Can they write comments on this survey or is it A, B, C? 

Dr. TUCHSCHMIDT. I believe they can write comments on the survey, but it is also a set of questions about your experience with 

your clinician. So we can tie that data actually back now to individual primary care teams. 

That data shows actually that veterans say—so they have two 

issues really. I will start with the poor end of the spectrum, which 

is access. So we know access has been an issue. And the second one 

is really I would put in the category of coordination of care, of kind 

of knowing what the next steps in my care process is. 

I think that when you look at overall in terms of their satisfaction with their experience, and of course there is heterogeneity in 

the population of responses that we get back, but generally people 

are very satisfied with the quality of the care and the experience 

of that care once they get in the system. So clearly getting in, getting access, both in terms of how quickly I can get an appointment, 

but then also how timely does that happen when I get there, how 

long do I have to wait in the waiting room, have been challenges 

for us. But we collect that data, and I will make sure that your 

staff have a link to that—— 


VACREP0180 with DISTILLER
18 

Mr. BILIRAKIS. Yes, please get that. I would like that available 

for the subcommittee. I know my constituents need to see it. 

Dr. TUCHSCHMIDT. Absolutely, we will get you that. 

Mr. BILIRAKIS. Give me the Web site as well. You gave me that 

40 percent figure of the 72,000, I want to get that confirmed as 

well. 

Dr. TUCHSCHMIDT. Sure, absolutely. 

Mr. BILIRAKIS. Thank you. 

The next question is for Mr. Goldberg. Have you done any analysis on how, if at all, the Affordable Care Act has impacted the cost 

of care provided by the VA health system? 

Mr. GOLDBERG. Actually, Mr. Bilirakis, we have not done that 

analysis. We understand that VHA counts as minimum medical 

coverage and so alleviates the need for veterans to pay a penalty. 

But the data are just coming in, it is early, and we do not have 

that analysis yet. 

Mr. BILIRAKIS. Do you anticipate having an analysis—— 

Mr. GOLDBERG. In the next few years—— 

Mr. BILIRAKIS [continuing]. In the near future? 

Mr. GOLDBERG. In the next few years I am hoping to get that. 

Mr. BILIRAKIS. In the next? 

Mr. GOLDBERG. Do we have a timeline? 

I will have to get back to you on what is a reasonable timeline. 

We don’t have enough data yet to answer that question. 

Mr. BILIRAKIS. Please. 

Mr. GOLDBERG. But I will get you a timeline. 

Mr. BILIRAKIS. Please do. 

Mr. GOLDBERG. Thank you very much. I yield back, Mr. Chairman. 

Dr. BENISHEK. Thank you. 

I will call upon the gentlewoman from New Hampshire, Ms. 

Kuster. 

Ms. KUSTER. Thank you very much, Mr. Chairman. and, again, 

it is an honor to serve on this committee, and I appreciate all the 

time and effort. 

It is interesting listening to my colleagues’ comments because I 

share the concerns, but I have reached a slightly different conclusion than Mr. Coffman about what this all means. This is a field 

that I am familiar with in the private sector and this type of analysis is very difficult to come by. This triangle of cost, quality, and 

access has been a major challenge all over the country. And really 

that is what the Affordable Care Act is all about, how do we increase access to high-quality care and make sure we are getting the 

value preposition that Dr. Tuchschmidt is discussing. 

So I want to focus in on that a little bit, talking about the design 

of such a study, how would you tease out. And I want to pick up 

on my colleague Dr. Ruiz’s comments about the cost savings. It is 

a touchy subject up here, but a little bit like dynamic scoring, 

where we know now from the private sector, if you take something 

like rehospitalization, the cost to the system for not providing, first 

of all, access to high-quality care in a timely way, but second of all, 

to managing the recovery process. 

So elderly patients that get a hip replacement go home and don’t 

have sufficient home care services and end up falling again and 


VACREP0180 with DISTILLER
19 

they land back in the hospital. And that is the core of where the 

Affordable Care Act came from, is that the hospitals were getting 

paid for every reentry, right, so money is coming over the transom, 

nobody is focused on that. 

But what we know as consumers, as taxpayers, if you can provide the care at home and avoid the rehospitalization, it is much 

less costly and, oh, by the way, people feel better. They get better. 

And so I guess I would just open it up, if any of you have experience in that type of analysis—maybe start with Mr. Goldberg—and 

what types of information would be helpful. 

Granted, they are elusive in both the private sector and the public sector, but as the flow of information increases over the next few 

years, what can we look at to focus in on that value proposition so 

that, as Members of Congress, we can protect the taxpayers’ funds 

and serve the best interests of our veteran population? 

Mr. GOLDBERG. That is a great question, and it is one we have 

struggled with not only for care for veterans but in the bigger 

healthcare system. 

The logic might seem compelling that avoiding rehospitalizations, 

for example, not only makes the patients better but would save 

money. It has been very hard for us to find evidence, statistical evidence, in studies to quantify that effect. 

So, while most people would think as a matter of public policy 

you want to avoid the rehospitalizations and the like, it has been 

very hard for us to find that effect in the data we have looked at— 

not specifically at VHA, because we have not had those data yet, 

but for the bigger healthcare system. It is an ongoing research subject. It is very hard to tease out that effect. 

Ms. KUSTER. Are there other examples, though? 

For example, I know in New Hampshire in workers’ compensation we were able to bring down the costs dramatically by getting 

people the treatment that they needed in a more timely way rather 

than delaying care, which had been, sort of, the managed-care 

model of trying to keep people from getting the surgery, keep going 

back to PT, keep going to back to PT. 

Instead, if you get the care in a timely way, make the right diagnosis, that you can get people back on the job. And, as I say, the 

silver lining is you feel better. You are cured from—or any of the 

type of chronic illnesses—diabetes, obesity, all of the measures— 

and maybe, Dr. Tuchschmidt, if you want to comment on—— 

Dr. TUCHSCHMIDT. Well, I was just going to say, you know, I 

mean, I think doing these studies is incredibly difficult. In getting 

ready for this, I had an opportunity to talk with some of our research people. I mean, it is incredibly difficult when they sit down 

to try and do this work. 

I actually think that Dr. Ruiz made one of the most important 

points for me, which is the point I think you are making, and that 

is that managing chronic disease today has a future savings. It 

avoids—— 

Ms. KUSTER. Yes. 

Dr. TUCHSCHMIDT. Savings in terms of fewer legs amputated, 

fewer patients on dialysis, fewer people who are blind because of 

retinopathy. And that is, you know, I think, a very complicated 

piece of the puzzle. 


VACREP0180 with DISTILLER
20 

And when you look at our patient population, I mean, our average veteran enrolled in our system has 10 major chronic conditions. 

Ms. KUSTER. Yeah. 

Dr. TUCHSCHMIDT. That is not private healthcare. 

Ms. KUSTER. Right. 

Dr. TUCHSCHMIDT. When you look at the dually enrolled veteran 

who is enrolled in the VA and Medicare, it is up over 13—highest 

I have seen is 19—chronic conditions in those patients. 

And, interestingly enough, when you look at the studies that 

have combined Medicare and VA data to do that and look at that, 

the overlap of those diagnostic codes, the HCCs, for which we are 

treating the patient and Medicare is treating the patient are extraordinarily different. And it only overlaps in about two of conditions at the individual patient level. 

So I think that, you know, we have a patient population that has 

an enormous amount of chronic disease, particularly as they age. 

And thinking about the cost of the intervention today is fine, but 

then what is the value, not just in terms of, you know, I don’t have 

to pay for that amputation or that dialysis, but in terms of quality 

of life, improving the lives of American veterans. 

Ms. KUSTER. Right. Well, thank you. My time is well up, but that 

is a point that I would like to keep focused on going forward. 

Thank you. 

Dr. BENISHEK. Thank you. 

Dr. Abraham. 

Dr. ABRAHAM. Yes, sir. 

This will be for the good doctor and Mr. Goldberg. 

I will make a comment first, that we are talking about the quality of cost of the healthcare, and I think we are getting a little bit 

confused. 

It is fairly easy, certainly in the private sector—because, up until 

4 weeks ago, I was a practicing physician in family practice, seeing 

VA patients in concert with the local VA clinic. 

The chair asked about the cost of a colonoscopy. Well, that is a 

pretty objective test. You are talking managing chronic disease— 

diabetes, long-term hypertension, long-term congestive heart failure. So I understand that is hard to measure. But it is not hard 

to get figures, I don’t think, on the cost of a procedure—a chest xray, a CBC—and compare that to the private sector. 

The question is—I guess for you, Doc—on the VA providers, the 

doctors, the nurse practitioners, the PA, are there computer data 

that they are given to show that the treatment that they have 

given that particular veteran is working and is the best treatment 

for the best cost? 

Dr. TUCHSCHMIDT. So we provide our clinicians a lot of feedback 

on all of our performance goals, right? So we measure all the 

HEDIS metrics on performance. We measure satisfaction on our 

patients. I mean, we have, actually, the last time I saw, 200-andsomething things that we count. And we do provide feedback to our 

clinicians, and we have been working, actually, on more sophisticated ways of displaying and providing that information back. 

You know, I think that a lot of it is about system performance, 

though. It is not individual performance, right? So it is, how do we 

perform as a system? And, certainly, the individual clinician conVerDate Aug 31 2005 15:05 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 Y:\97-996.TXT PAT

VACREP0180 with DISTILLER
21 

tributes to that performance, but it is really a collective thing. And 

many of our clinicians, while they have individual effort contributed to those things, don’t control space and the number of support 

staff, et cetera, et cetera. But they do get information back about 

global system performance. 

Dr. ABRAHAM. It is like what Dr. Ruiz mentioned. Certainly, 

there are different hospitals that perform much differently across 

this Nation. Some have great ratings, and some have very poor ratings. 

I will refer back to the private sector. Every quarter, every 3 

months, I would get a detailed evaluation of my performance, comparing me to the peers within the insurance systems, whether it 

be Blue Cross, whatever. Every month, I would get however many 

insurance companies we had gone along with. 

And I am just thinking, it should not be that difficult in the VA 

system to compare doctors among their peers and doctors among 

the different hospitals with the VA to see which ones are rising to 

the top and then which ones maybe are more mediocre. 

Dr. TUCHSCHMIDT. We do that. So I am happy to have our staff 

come over and brief you on our SAIL—it is called our SAIL report. 

So we have a data tool that displays that information graphically, 

and you can drill down into that data. And I am happy to have 

somebody come over and show you that tool. 

Dr. ABRAHAM. Thank you. I appreciate that. 

And going back to the objective colonoscopy, CBC, as compared 

to the more subjective chronic management over years of a chronic 

disease, where are we going in that direction? What is happening 

in the near future to try to resolve those issues? 

Dr. TUCHSCHMIDT. So we do have a cost accounting system; it is 

called DSS. And both people’s time is allocated in that system as 

well as dollars. You know, I don’t have it with me, but I am pretty 

confident that we can come up with a cost for a colonoscopy. I am 

sure my CFO is sitting back there about ready to strangle me when 

I get back. But I am pretty confident that our systems would allow 

us to produce that data. 

Dr. ABRAHAM. Okay. Thank you. 

And I yield back. 

Dr. BENISHEK. Thank you. 

Dr. Wenstrup. 

Dr. WENSTRUP. Thank you, Mr. Chairman. 

You know, we talk a lot about the cost. Obviously, that is one 

of the things we are here to talk about today. And you can measure, maybe, cost per RVU, relative value unit, right? 

So can you tell me what goes into determining how much you are 

spending per RVU produced, either per hospital or across the VA? 

What numbers go into that? 

Mr. GOLDBERG. Could I defer to Dr. Tuchschmidt on that? I think 

he is probably in a better position to answer that question. 

Dr. WENSTRUP. Okay. Sure. 

Dr. TUCHSCHMIDT. Sure. 

So we do measure RVU data, and I can actually get you some 

costs per RVU—— 

Dr. WENSTRUP. That is not what I am asking. I am asking what 

goes in to determine how much it costs the VA per RVU. In other 


VACREP0180 with DISTILLER
22 

words, is it just what you paid the physician? Is it what you paid 

the physician and all the staff per RVU? Is it what you paid the 

physician, the staff, the administration per RVU? Is it what you 

paid the physician, staff, administration, and what your bills are 

for the physical plant that you are working in? 

Because, in private practice, if I have a free place to have my 

clinic, I would do a little better than if I am paying for my own 

building or paying rent. 

So when we are talking about costs, I mean, I am looking at the 

big picture here. When you talk about how much it costs per RVU, 

I would like to know what are you actually including in that cost. 

Because, to me, physical plant and everything else comes into play. 

Dr. TUCHSCHMIDT. Yes. So I think, actually, you could probably 

calculate it multiple ways. You could do the fully allocated cost per 

RVU. You can do salary cost per RVU. And we benchmark with 

MGMA and UMHM standards, which is against take-home salaries 

of clinicians and—— 

Dr. WENSTRUP. I guess what I would like to see within the VA 

hospitals is just start with the standard, put down how many 

RVUs were produced in all the VA hospitals and clinics across the 

country and what was the bill for everything—everything. 

Dr. TUCHSCHMIDT. So we have our SPARC tool. I think you have 

seen that tool. So we have our SPARC tool, which looks at the RVU 

data, and it has cost data in there as well. And it is also marked 

against access at the local site for GI or whatever it might be. 

So we do have that information, and we are going out and getting that data independently validated. So we have a contract with 

Grant Thornton to look at the tool and the methodology and how 

we are doing the math to tell us whether, in fact, you know, we 

have done this in a reasonable way, against industry standards or 

whether, you know, we have made up something that doesn’t fly. 

Dr. WENSTRUP. So someone could tell us—it would be just one 

number—how much it costs per RVU across the entire VA, including all of your expenses. 

Dr. TUCHSCHMIDT. I will try and get that. 

Dr. WENSTRUP. I think that would be a good landmark. 

Another question I have for you is, are there areas that you 

think that the VA—because there are areas I think the VA could 

be centers of excellence compared to other sectors, especially things 

that are military-specific. 

Do you think that we should have a focus toward some of those, 

such as TBI, PTSD, the effects of agent orange? And, as you said, 

a lot of the comorbidities—so many of the patients, compared to the 

regular population, have comorbidities. 

Dr. TUCHSCHMIDT. That is right. 

Dr. WENSTRUP. That can be another center of excellence. 

And prosthetics, for example, do you think that we should have 

a focus towards that in our VAs? 

In other words, are there things that you think the VA can do 

better than anyone else? 

Dr. TUCHSCHMIDT. Well, I think—— 

Dr. WENSTRUP. In the long term. 


VACREP0180 with DISTILLER
23 

Dr. TUCHSCHMIDT. I think there are things that we do do better 

than anybody else. And I think your suggestion, Congressman, is 

a great one. 

We do have those centers today. So we have centers of excellence 

in spinal cord injury and in TBI around the country that are both 

engaged in clinical care as well as in research and training, you 

know, future healthcare providers. Those are all part of our mission. So we do have those. 

And, you know, I think looking at where are the things that we 

do really well and, quite frankly, where are some of the things 

maybe as a system we don’t do so well but a center of excellence 

could help drive that. 

We have taken that model through our query process, where we 

have funded, for a couple decades, actually, centers for 

translational research, to go out and say, okay, what are the best 

practices in managing congestive heart failure, and how do we 

then, as a system, figure out how to deploy that and get it from 

the bench to the bedside. Because if we can’t get it to the point of 

care, all that knowledge and expertise doesn’t really help us. 

So I think the suggestion that you have made is an excellent one. 

Dr. WENSTRUP. And I am just thinking of our long-term focus 

here and what we want the VA to look like down the road. And 

those are areas where, because of the patient population, the VA 

can be better than just the everyday setting. But there may be 

other things that we say, we can let that go, because that can be 

done down the street, Anywhere, USA, so maybe we don’t need to 

focus that much on that in the VA in particular. 

Just a thought. And I am always curious to get the feedback on 

that. Thank you. 

And I yield back my time. 

Dr. BENISHEK. Thank you, Dr. Wenstrup. Dr. Huelskamp five 

minutes. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. 

I appreciate the hearing on this matter, although I will note, I 

think we have had numerous hearings with the same conclusion, 

which is: We are not for sure what we know, but we are trying to 

find out a little bit more. 

And near as I can tell from the four folks on the panel, if you 

ask the question, are we getting good-quality care, we are not for 

sure. Is it cheaper or more expensive in a private setting? Well, we 

are not for sure. 

But I want to follow up and dissect a little bit more—first of all, 

I want to know from VA, what percent of your care is spent on the 

specialized care that Mr. Blake mentioned? 

Dr. TUCHSCHMIDT. On the specialized care for? 

Dr. HUELSKAMP. Mr. Blake made reference to the specialties that 

are provided by VA that are not accessible elsewhere. What percent 

of your total care is for that type of care? 

Dr. TUCHSCHMIDT. I will have to take that for the record and get 

you a number, which I am happy to do. I think it depends a little 

bit on what you put in that category of stuff. 

Dr. HUELSKAMP. Yes. 

Dr. TUCHSCHMIDT. But we can get you a breakdown specifically 

around the—— 


VACREP0180 with DISTILLER
24 

Dr. HUELSKAMP. Yeah. And I understand the difficulty. I mean, 

that is why we are here today, because that is the kind of question 

that I thought we would have a ready, accessible answer and say, 

okay, yeah, we know. 

Is it in 10 percent? Twenty-five percent? Five percent? Any 

guesstimates there at all just for today? I understand we will get 

something for the record. 

Dr. TUCHSCHMIDT. I think it is much higher than that, actually. 

It is over 35 percent, I think, of our total costs go into treating 

service-connected disabilities. 

Dr. HUELSKAMP. That is only available at the VA. Okay. And I 

will look forward to hearing a little more on that. 

Dr. TUCHSCHMIDT. I want to turn and ask Mr. Goldberg with 

CBO, in the CBO score of the Vet Choice bill that we passed, the 

provisions dealing with choice, if I remember correctly, $8.16 billion 

of the cost of that bill was for the vet choice over the next 2 years. 

Can you dissect that a little bit more for the committee? Because, 

as I understood from the CBO report, you don’t know if it is more 

or less expensive in the private sector. And so how do you know 

it is going to cost $8 billion more? What proportion of that $8 billion is attributable to access, greater access? Or are you saying it 

is just more expensive? 

Can you shed a little light on that? I mean, that was a very big 

number. And, in my district, actually, I believe it is cheaper and 

better for vet choice, but you are saying it is a lot more expensive. 

Can you describe and dissect that? 

Mr. GOLDBERG. Unfortunately, I am not the best person to describe that. So if I could take that for the record, and we could get 

you a breakdown on that. 

Dr. HUELSKAMP. I would appreciate that. 

Dr. TUCHSCHMIDT. And do that in light of your statements that 

we are not for sure, we don’t know, we don’t have good enough data 

to compare that. So, I mean, you might come back and say, it was 

all about additional access, all about reduced waiting time. 

Because what I hope in the long term is, instead of worrying 

about necessarily what the studies say and what experts in Washington, D.C., say or some big university, some big hospital, what 

I am worried about is what my constituents say. And, frankly—and 

my district is different than others—they are tired of driving 200, 

300 miles for care that they could get right down the road at their 

local hospital. 

And the VA has not been very helpful in making that happen. 

And we are slowly implementing this, but what I have heard lately 

from the VA is soon that 2-year period will be up and then we go 

back to the old way of doing things, which is restricting choice 

rather than expanding choice. 

And so I would like to allow veterans and their families to make 

those choices. So if we could find out what proportion of your estimate—again, $8.16 billion for veterans’ choice is a pretty hard 

thing to pass around here again. And so I want to know what that 

means in the future and how you arrived at that figure, because 

I really can’t pull that out of the data. 

One thing I will note, as well, for the CBO and the VA and for 

the chairman, as well—again, glad that you had this hearing, but 


VACREP0180 with DISTILLER
25 

we have had a multitude of hearings where I think we have—the 

summary of hearing after hearing on data issues is the data is not 

valid and not reliable. And then, every time, somebody comes back 

and says, well, we think we know this information. 

But the core of this problem was we were being told things, as 

Members of Congress, that didn’t match up with what was really 

happening—you know, that there was no waiting time, that we 

have taken care of all these veterans—which led to a real catastrophe, came to a head about a year ago. So I want to keep that 

in mind. 

I look forward to the data from both the VA and CBO, because 

I want to put those together. We want to know what it is really 

going to cost. 

But then, you know, I think the crux of the matter is that we 

have an entire system, in comparison, called the Medicare system, 

where you don’t drive to one hospital to get medical care in the entire congressional district. I mean, people would be outraged. But 

we make veterans in my district, every single one of them, if they 

want care, they have to drive to a hospital outside a congressional 

district. That is two-thirds of the State of Kansas. And my goal will 

continue to be to make certain they can go to 1 of 70 community 

hospitals and get their care that they deserve rather than driving 

hundreds of miles. 

So I appreciate it. And we are going to continue to work on this, 

Mr. Chairman. I look forward to the data from our conferees. 

Dr. BENISHEK. Thank you, Dr. Huelskamp. 

I want to thank all the Members here this morning and to the 

witnesses as well. 

We are just starting to look into this issue. And I know that we 

could go on and on with questions today, but, you know, I am, 

frankly, disappointed with the VA. We want to talk about the cost 

of healthcare within the VA. 

Dr. TUCHSCHMIDT. you mentioned you have a lot of data, but yet 

you didn’t give us any data in your written testimony. I am very 

disappointed. 

We are going to really work on trying to, pass some legislation, 

and I would appreciate the rest of your help to be able to, actually 

mandate the fact that VA presents data similar to what the DoD 

is doing with TRICARE, at least to get a handle on what is happening with our costs. 

I know that we are going to continue to work on this issue in our 

committee to get input from everyone on the committee and in the 

private sector and from the VSOs, as well, as to how we should 

proceed with this. But I think the American people need to know 

a little bit more about what is happening in the VA so that we can 

provide better care for our veterans. 

We may be submitting some further questions for the record. I 

would appreciate your assistance in getting that stuff done. 

Dr. BENISHEK. If there are no further questions, then you all are 

now excused. 

I ask unanimous consent that all Members have 5 legislative 

days to revise and extend their remarks and include extraneous 

material. 

Without objection, so ordered. 


VACREP0180 with DISTILLER
26 

Dr. BENISHEK. I would like to once again thank all the witnesses 

and the audience members for joining us here this morning. 

And the hearing is now adjourned. 

[Whereupon, at 12:03 p.m., the subcommittee was adjourned.] 


VACREP0180 with DISTILLER
27 

APPENDIX 

PREPARED STATEMENT OF THE CHAIRMAN DAN BENISHEK M.D. 

Good morning and thank you all for joining us for today’s oversight hearing, ‘‘Examining the Quality and Cost of VA Healthcare.’’ 

This Congress, I am honored to return as the Chairman of the Subcommittee on 

Health and to be joined once again by my colleague and friend—Congresswoman 

Julia Brownley as our Ranking Member. 

Ranking Member Brownley and I are joined by several senior and returning Committee Members and one freshman—Dr. Ralph Abraham. 

Five of us are doctors, five of us are veterans, and all of us share the same primary goal—to create a Department of Veterans Affairs (VA) healthcare system that 

provides timely, accessible, and high-quality care that our veterans can be proud to 

call their own. 

Our work will require open and ongoing cooperation and communication with veterans, stakeholders, and—most importantly—VA leaders. 

Unfortunately, it became painfully apparent to me last year that the Veterans 

Health Administration (VHA)—which operates the VA Healthcare System—was either unable or unwilling to provide basic information about the services it provides. 

Using a simplistic equation—dividing the 9.3 million veterans who are enrolled 

in the VA healthcare System by VHA’s annual budget of $57 billion—VA spends 

just over $6,000 per veteran patient. 

However, we know from VA’s own data that fewer than 30 percent of veterans 

rely on VA for all of their healthcare needs, meaning VHA is only providing for the 

total healthcare needs of approximately 2.4 million veterans at a per patient cost 

of more than $23,000. 

This is obviously a rough calculation that—as I am sure VA will argue—fails to 

take into account certain unique aspects of the veteran population and VA 

Healthcare System. 

However, that is the kind of granular data that we need in order to move the VA 

Healthcare System forward. 

Recently, the Congressional Budget Office (CBO) released an analysis comparing 

the costs of the VA Healthcare System with the costs of private sector healthcare 

systems. 

In their report, CBO found that, quote ‘‘ . . . limited evidence and substantial uncertainty make it difficult to reach firm conclusions about [VHA’s] relative costs . . . 

’’ end quote. 

The ‘‘limited evidence’’ and ‘‘substantial uncertainty’’ that CBO references is the 

direct result of VA’s failure to provide the information that is needed to assist policymakers and the public in evaluating the efficiency and effectiveness of VA’s services. 

VA’s lack of transparency is echoed in the disappointing testimony—absent substance or detail—that VA provided for this morning’s hearing. 

Coming on the heels of last year’s astounding access and accountability failures, 

VA’s testimony provided for this hearing is unacceptable and I have begun examining measures that would require VA to be much more open with the American 

people moving forward. 

Today’s hearing is just the first in what will be a year-long effort by this Subcommittee to achieve greater clarity into the cost considerations that impact VA’s 

healthcare budget and, therefore, the care our veterans receive. I thank you all for 

being here today. 


VACREP0180 with DISTILLER
28 

PREPARED STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

Good morning. Thank you all for being here today in support of military veterans. 

Thank you, Mr. Chairman, for holding this hearing. I look forward to working 

with you this Congress to better the lives of veterans and their families. 

According to the Veterans Health Administration’s report Blueprint for Excellence, veterans enrolled in the VA Healthcare System have a significantly greater 

disease burden than the general population, even after accounting for the age and 

gender mix. Forty percent of the nearly 9 million enrollees have service-connected 

disabilities, and their care, in Fiscal Year 2013, accounted for about half of VHA’s 

$54 billion in total obligations. 

Clearly there is a high reliance on VA Healthcare for veterans who are disabled. 

Today we will examine the quality and cost of VA healthcare. The Congressional 

Budget Office released a report late in 2014 that looked at comparing the costs of 

the veterans’ healthcare system with private sector costs. 

What CBO found was that it is very difficult to compare costs because of a variety 

of factors. Veterans who are enrolled in the VHA system receive most of their 

healthcare outside that system—about 70 percent. Veterans have different clinical 

and demographic characteristics, and cost-sharing requirements are much lower for 

VA care than for care received from private-sector providers. 

Another very important point to remember is that VHA’s mission is to address 

the total health of veteran patients, not just provide care for illness or disease. This 

is a much different approach than the private sector practices. 

Additionally, CBO points out in their report that there are differences in financial 

incentives for providers. For example, most private-sector providers, whether in hospitals or physicians practices, generate revenues for each unit of service that they 

deliver. Because of that, they have a financial incentive to deliver more services, 

whereas the VA providers do not. 

CBO suggests that an annual report, much like that of the Department of Defense’s TRICARE health system, which includes operating statistics, trends among 

beneficiaries and their demographics, among other things, would facilitate comparisons between VHA and the private sector. However, these comparisons would still 

be challenging, in part because private-sector data might also be incomplete, unavailable, or difficult to make comparisons with VHA data. 

Instead of looking at comparing costs to the private sector, I think we should focus 

on improving access to veterans healthcare, ensure that veterans receive the best 

care possible, and continue to hold important oversight hearings on the quality and 

safety of the care provided to veterans. 

We absolutely need complete transparency in terms of costs within the VA, and 

there is still much to learn from the private sector and their practices—particularly 

when it comes to IT and better access to healthcare within the VA. 

Thank you Mr. Chairman and I yield back my time. 


VACREP0180 with DISTILLER
29 


VACREP0180 with DISTILLERInsert offset folio 1 here 97996.001
30 


VACREP0180 with DISTILLERInsert offset folio 2 here 97996.002
31 


VACREP0180 with DISTILLERInsert offset folio 3 here 97996.003
32 


VACREP0180 with DISTILLERInsert offset folio 4 here 97996.004
33 


VACREP0180 with DISTILLERInsert offset folio 5 here 97996.005
34 


VACREP0180 with DISTILLERInsert offset folio 6 here 97996.006
35 


VACREP0180 with DISTILLERInsert offset folio 7 here 97996.007
36 


VACREP0180 with DISTILLERInsert offset folio 8 here 97996.008
37 


VACREP0180 with DISTILLERInsert offset folio 9 here 97996.009
38 


VACREP0180 with DISTILLERInsert offset folio 10 here 97996.010
39 


VACREP0180 with DISTILLERInsert offset folio 11 here 97996.011
40 


VACREP0180 with DISTILLERInsert offset folio 12 here 97996.012
41 


VACREP0180 with DISTILLERInsert offset folio 13 here 97996.013
42 


VACREP0180 with DISTILLERInsert offset folio 14 here 97996.014
43 


VACREP0180 with DISTILLERInsert offset folio 15 here 97996.015
44 


VACREP0180 with DISTILLERInsert offset folio 16 here 97996.016
45 


VACREP0180 with DISTILLERInsert offset folio 17 here 97996.017
46 


VACREP0180 with DISTILLERInsert offset folio 18 here 97996.018
47 


VACREP0180 with DISTILLERInsert offset folio 19 here 97996.019
48 


VACREP0180 with DISTILLERInsert offset folio 20 here 97996.020
49 


VACREP0180 with DISTILLERInsert offset folio 21 here 97996.021
50 


VACREP0180 with DISTILLERInsert offset folio 22 here 97996.022
51 


VACREP0180 with DISTILLERInsert offset folio 23 here 97996.023
52 


VACREP0180 with DISTILLERInsert offset folio 24 here 97996.024
53 


VACREP0180 with DISTILLERInsert offset folio 25 here 97996.025
54 


VACREP0180 with DISTILLERInsert offset folio 26 here 97996.026
55 


VACREP0180 with DISTILLERInsert offset folio 27 here 97996.027
56 


VACREP0180 with DISTILLERInsert offset folio 28 here 97996.028
57 


VACREP0180 with DISTILLERInsert offset folio 29 here 97996.029
58 


VACREP0180 with DISTILLERInsert offset folio 30 here 97996.030
59 


VACREP0180 with DISTILLERInsert offset folio 31 here 97996.031
60 


VACREP0180 with DISTILLERInsert offset folio 32 here 97996.032
61 


VACREP0180 with DISTILLERInsert offset folio 33 here 97996.033
62 


VACREP0180 with DISTILLERInsert offset folio 34 here 97996.034
63 


VACREP0180 with DISTILLERInsert offset folio 35 here 97996.035
64 


VACREP0180 with DISTILLERInsert offset folio 36 here 97996.036
65 


VACREP0180 with DISTILLERInsert offset folio 37 here 97996.037
66 


VACREP0180 with DISTILLERInsert offset folio 38 here 97996.038
67 


VACREP0180 with DISTILLERInsert offset folio 39 here 97996.039
68 

Æ 


VACREP0180 with DISTILLERInsert offset folio 40 here 97996.040