Transcripts For CSPAN3 VA Secretary Shulkin Testifies On VA Department 20180120

Committee for q a. Let me say at the outset, this meeting is not about whats happened in the past, its whats happening right now to correct some of the things that happened in the past. This is an accountability hearing. I told the secretary we want to take the legislation we passed last year on accountability, on appeals, all the things that we passed to give them the tools to address the significant problems confronting the veterans of america, vsos of america and this committee to begin moving away from the problems of the past and towards the solutions of the future. In particular, on appeals, in particular on accountability, in particular on the g. I. Bill, in particular on all those things that are important to the veterans and their family. And particularly on the leadership of the v. A. As well. And i want to thank secretary shulkin. Ive always been complimentary of him. A lot of people say youre too nice to him. Im not too nice to him. Hes been good to the veterans. He has been a forthright leader that the administration is lucky to have. I believe the veterans are lucky to have and i feel this committee is lucky to have. But we are at the time where there are no excuses, no excuses for why we dont correct the problems weve had with hiring, i. T. , no excuse for the problems with veterans appeals and all those areas. This is it all about accountability, all about standing forward, looking at the past and what we did and looking for the results that are to come in the future so that we do a good job for the veterans of the United States of america. Is he still coming . Mr. Secretary, im going to swear you in for purposes of this hearing. If you raise stand and raise your right hand. Do you solemnly swear or affirm that the testimony youre about to give before the Senate Committee on Veterans Affairs will be the truth, the whole truth, and nothing but the truth, so help you god . I do. You may be seated. Mr. Secretary, im going to recognize you for your five minutes and well get to the Ranking Member when he shows. Welcome. Thank you. Chairman isaacson, senator more an, senator bozeman, thanks for inviting me here to talk about the v. A. s progress. More importantly, on behalf of the veterans that we serve, thank you for your staffs tireless bipartisan work, its been great. We certainly appreciate and respect your leadership, mr. Chairman, and partnership in establishing those issues that were trying to tackle at the v. A. Headon. Some of them, as you said, we know have lingered for years. Ive always said i think we have the best committees in congress and thats in large part due to leadership. We agree with that, by the way. Well, i wouldnt say it if it wasnt true. I took an oath, so joining me today, seated behind me, i just wanted to introduce you in case i need a lifeline today. Peter shelby, our secretary for Human Resources administration. Sharon masson, chairman of the board of veterans appeals. Our acting deputy undersecretary for health for Community Care. Our director of appeals management. Peter orourke, the executive director of accountability and whistleblower protection and mr. Robert worely, our director of education services. A year ago at my confirmation hearing before this committee, i testified that id seek major reform and transformation of v. A. Today, the v. A. Transform and reorganization were focused on five priorities. The first, to provide greater choice for veterans. Second, to modernize our systems. Third, to focus our resources and whats most important to veterans. Fourth, to improve the timeliness of how we deliver our services, and, fifth, to prevent veteran suicide, which is our top clinical priority. The president s executive order, transitioning veterans with Mental Health issues during the first year is a critical step. Thanks in large part to your leadership which helped us pass legislation in 2017, the legislation i hope well be discussing today, were making progress on all five of those priorities. Modernizing antiquated systems and focussing resources while giving veterans more Timely Services and greater choice. Accountability and whistleblower protection is essential to our unwavering commitment to honoring veterans. It, too, is about sensible responsive modern systems that process and support our people to make the v. A. Better. The forever gi bill gives veterans more choice. More profoundly, its about greater opportunity, especially veterans returning to communities to pursue careers and fulfill dreams. Beyond the reforms, weve announced same day services for primary care and Mental Health at every v. A. Facility across the country. Weve extended Mental Health to veterans with other than honorable administrative discharges. So far, weve disposed of 111 out of 130 vacant or underutilized buildings. Published data on wait time, quality data, Customer Satisfaction data and last week we published our opioid prescription rates across the country. There are no other Health Systems in the country that publish this type of data. And because of that i hope its because of that were earning our Veterans Trust back. At the end of this last year, 70 of veterans who responded to our survey said that they felt like valued customers at v. A. Thats up from 46 in 2014. Mr. Chairman, members of the committee, were deeply grateful for your role and support in all of those changes and others like them. Theyre immensely important, but when i look back over this year, were still largely managing through incrementalism. Patching and repairing old systems and processes and reacting to crises. V. A. Still is far short of the kind of bold transformation at change that we need to serve veterans in the decades ahead. From health care to benefits, we have to fundamentally and wholistically change our Service Delivery paradigm. My objective when it comes to health care for our veterans is to have a fully integrated interoperationally Efficient Health care system that is easy for veterans, employees and Community Partners to navigate. A full spectrum of care for veterans that capitalizes on our foundational services, delivering on our promises to provide world class services. We need a consistent, seamless experience for veterans at every v. A. Facility across the country. We need a National Network of modern facilities that meets the changing needs of veterans locally. And simple convenient choice for eligible veterans among a network of highquality Community Providers and a single consolidated program. Mr. Chairman, i applaud your efforts to get this done. Your draft legislation that passed out of this committee is highly responsive to the needs of veterans and were all grateful for the work that you and the committee have done so far to make this a reality. Benefits are a gateway to v. A. Services and we need benefit determinations to be simpler. Veterans should know what to expect and have more predictability. They shouldnt have to endure the burden of filing claim after claim after claim. Benefits should better enable lifetime of independence and success for veterans. Physical and Mental Wellbeing and Financial Security for the severely disabled. In short, we need to begin an earnest dialogue with stakeholders about veterans benefits. Mr. Chairman, in the days and months ahead, i and invite your support and leadership in helping us to find and then pursue the kind of worthy transformational change the v. A. Needs so we can all achieve what we hope to achieve. I look forward to your questions today. Thank you, secretary shulkin. I appreciate those remarks very much. And i hope the Ranking Member is coming. Is he still coming . I beg your pardon. Yes. He is coming, okay. You can start the clock on me. Let me make what somewhat may appear to be an announcement at the beginning of the hearing. The secretary and i have been in a lot of conversations over the last month or so and i want to thank the secretary for his stated support for what the committee passed out of committee. As we all know, we had a 141 vote and we all know we had some differences of opinion on the veterans choice bill and the care bill that we passed out of committee. I did everything i could to bring about a unanimous Common Ground, but i didnt get that totally done. So i made a phone call to the white house and talked with the president. I believe if im not mistaken the secretary was on that phone call as well as a number of other people of interest, and the president , and this is my remember repeating what i remember him saying to me, he said youre all good guys. Youve got Good Solutions on both sides. Yall see if you cant work it out. We tried to get together a couple of meetings to work it out but that didnt materialize one way or the other. My goal as chairman of the committee is to find a positive resolution to no matter what problem i confront. And not because it comes from my wisdom but my persistence to see to it we keep our eye on the goal. And the goal is choice for our veterans, better Quality Health care, more accountable v. A. It is my understanding the president and the administration is going to send our committee in the next couple of days some suggestions that theyre looking for that might help us bring about a resolution. I intend to work with senator more moran and the other members of the committee. To see if we cant take to the floor a unanimously supported bill or a bill that everybody had the chance to support and have their chance to amend on the floor. One way or another, its time our veterans had a better veterans policies that served their choices, gave them the choices they need, funded them so they werent subject to last minute were out of money routines, which this bill, does by the way. We consolidated the stove pipes from seven to one, correct, secretary . And get those things done we have to do. I want to announce that thats forthcoming. When it gets here, ill get it to the committee, well begin work on it and try to get ourselves into regular order to find a bill we can unanimously get to the floor one way or another. If we cant, i know ive made every every effort i have. Whatever the case, our veterans deserve the best of us. The best of us is to pass a bill that we can agree on and the best of us is to find the Common Ground to set up that meeting. So i intend to do that and i appreciate the input that the administration has given us and i look forward to continuing to work with them. Im going to extend ive got a little time left. Three or four things i want to talk about, mr. Secretary. One thing that concerns me, and deeply, are the four positions that remain unfilled at the department. One is your former position. We plucked you out of v. A. Leadership to become the leader of v. A. That was a good idea. The bad idea is it still didnt have anybody in your place in terms of where you were as the secretary of health. The assistant secretary of accountability and whistleblower protection is not in place. That american needs to be in place. The undersecretary for benefits, which is a critical position at the v. A. , needs to be in place. And the secretary for information technology, which is absolutely critical, particular with the new information coming in, its got to be filled somewhat sooner rather than later. Ive asked these questions privately and i know youre trying, but this is one of those things where we a for effort is not good enough. Weve got to find a way to get the best people in the United States of america in these disciplines working for the Veterans Administration and our veterans. Can you tell us what progress you dont have made and what youre doing on those in particular . Yeah, let me give you a quick update on that. If our cio candidate, we have made a selection and that person is now going through a vetting process at the white house. Our indications are that thats moving along smoothly. Four, the undersecretary of benefits, we had a commission. As you know, by law we have to form a commission. They selected three candidates. We made our top choice. That person withdrew. Weve now gone on to our second choice. Fortunately, all three candidates are excellent candidates and that persons also going through vetting the the white house. They understand the critical nature of this. On the undersecretary excuse me, on the undersecretary of health, we have this is now going to be our Third Commission. Weve had two commissions prior that did not select a candidate. The Third Commission will be chaired by deputy secretary bowman on january 25th and 26th. We have 11 candidates who have applied for that. We hope to have a successful selection out of that Third Commission process by january 26th. Of which we would then forward three names on to the president for consideration that would go through vetting. On the assistant secretary for accountability and whistleblower protection, mr. Orourke is the executive in charge of the accountability and Whistleblower Protection Office and hes here today. That prompts me to tell you what happened this morning in the health committee. We had testimony on disasters and preparedness and out of the blue one of the chief people in charge of that for our country took a point to compliment the Veterans Administration on what the veterans hospitals and medical personnel did to help in the rescue of Senior Citizens in houston during the terrible flood we had, which magnified for me the importance of remembering that the v. A. Health care system is a huge Delivery System that serves by the nature of its veterans, a more senior population and i want to compliment you and the doctors to do what they did to earn that praise because thats a real good thing to have. Thank you. From a standpoint of accountability, i want to see some accountability with regard to the appeals process. I read your report and i read your remarks. I know youre working on demonstration project on appeals, is that correct . Yes. What timetable do you have or working towards to move away from a demonstration project to a project that is fact of the matter, exactly how were going to handle the appeals in the future to stop the backlog from growing and continue to anticipate the backlog. Today the backlog stands at 470,000 appeals. So we have a lot of work to do. Because of your legislation, were now implementing a new process, of course. That will be fully implemented in early 2019. But weve actually started to make major improvements already. This year, we are on track to do 81,000 appeals. That would be 30,000 more than last year. Just at this period right now of this fiscal year, were at 21,000 appeals. Thats 10,000 more than this time last year. So were Getting Better and faster and weve brought on new staff. Secondly, weve begun, and this was actually because of the feedback that we got the last time that we were together, we begun to offer veterans now the choice in their legacy appeals to opt into the new process. So they dont have to wait. Weve had 3 of veterans opt in. These are people with long appeals. Opt in. This is the Pilot Project to the new process. And heres the good news, theyre getting their decisions within 30 days and 75 of those decisions are going in favor of the veteran. So its actually a pretty good deal. Instead of waiting five or six years, if they opt in, 30day decision, 75 approval rate, and thats beginning to address those legacy appeals. So im hoping through our Veterans Service organizations and through your offices well encourage more veterans to consider, because this is an elective option, to choose to opt into the new process. Theyll get faster decisions and we hope accurate, good decisions for them. My time is up, but as it ends i want to say this, i know our vsos are represented here today. We didnt ask them to testify because this is dr. Shulkins day. The vsos are going to have the chance to address the house and Senate Committees in our annual report and we look forward to their input. I hope the vsos and the agency will do everything they can to disseminate the fact that our veterans who had the pending appeals have the option to opt out and go into the new modernized program, 3 of those have done and s. O. And those have gotten a response in 30 days. That is a light years improvement. I commend you on what you started. Lets help him finish by getting our veterans a timely appeal. Ener moran . Mr. Chairman, thank you very much. Im going to depart our hearing as soon as my questions have been answered, but i would pay honor in this setting to senator dole, who we will all be in the capitol to honor today. In kansas and perhaps the country there is no more esteemed public servant, but in my view, while his Public Service was tremendous, his military service and then his commitment to those with disabilities and the veteran community is exemplary. No one meets that standard. So i pay a tribute to senator dole. Let me just raise a few points and then im going to make a comment and ask a question, mr. Secretary. First, i want to know that your cancellation of contract the contract for region 4, for Community Care, troubles me. I understand that senator helenor is going to raise this topic with you today. You have a request from my subcommittee on appropriations to explain what happened in that regard and i look forward to that answer. Secondly, i will be submitting several questions for the record. Im interested in knowing the v. A. s efforts in regard to full implementation of the Toxic Exposure Research act, something that senator blumenthal and i sponsored and became law in december of 2016. And then finally, youve had conversations with me about Electronic Health records, originally about a reprogramming, and now i see that there are other reasons that youre not proceeding and im concerned about whats taking place here. Ive sent you a letter and i would ask you to respond to it. Then let me talk about the topic that the chairman mentioned in regard of the bill that passed the committee. I want to direct this not to the chairman but to you, secretary shulkin. Ive been working closely, in my view, with the chairman and the Ranking Member, other members of this committee and those in the v. A. That you designated for me to work with and with the white house to make certain that the future of Community Care for veterans works and works well for veterans and the providers who serve those veterans. Its of utmost importance to me to reform choice and to pass the right policies that will work for veterans in accessing health care that they deserve. Its also critical that members of congress continue to push for a change in the v. A. Culture and to promote implementation of policies directed by Congress Instead of the v. A. Often narrowing the scope and thwarting the intent of congress. This is, in fact, the conversation you and i had almost exclusively during your confirmation hearing in february of 2017. Pushing for a culture that transforms the v. A. In my view, we have to hold you and other v. A. Leaders accountable, and in my view, too often commitments and pledges made to this committee and individual members regarding legislative efforts on behalf of our veterans, the followup, the experience is typical of what ive found with implementation of congressionalpassed legislation. The v. A. Changes course and it thwarts the intent of congress. You and i had this conversation during your confirmation hearing. On numerous occasions, you and i have met in my office. We have had numerous telephone conversations and in those meetings and in those telephone conversations you expressed support for access standards in the eligibility of choice reform. In every instance, in my view, you led me to believe that you and i were on the same page. What i have what i remember you saying is this, the need for specificity in legislation is there, and then i quote you, if its left to the reg process, nothing in the v. A. Will change. You told me that. I learned, though, that you have said something quite different to the chairman and to the Ranking Member, and im of the opinion that our inability to reach an agreement is in significant part related to your ability to speak out of both sides of your mouth, doubletalk. My understanding is that others have had this experience and there is a shared frustration about this circumstance. So, mr. Chairman, you have been sworn to give testimony today. Im looking for a straightforward answer. A yes or no would be good. Do you believe that the Eligibility Criteria to determine if a veteran can receive care in their community ought to be explicitly linked to the access standards . Yes or no . Of course i believe that Eligibility Criteria should be explicitly linked to access standards and i believe that those access standards need to be developed by the v. A. And, mr. Chairman, then mr. Chairman, let me ask the secretary, do you support the access standards that are in our bill, youve told me that, true . I support the access standards that are in the bill that the Senate Committee passed 141. And those access standards are very similar. The issue is whether they are then tied to eligibility. Why would you not tie the access standards to eligibility . Why have access standards if they dont matter in who is eligible for Community Care . Well, senator moran, first of all, i applaud your efforts to get this right. I think it is grossly unfair to make the characterizations that youve made of me and im disappointed that you would do that, but i think that you have i do not disagree with where you want to get to. I do believe that it is our job to give veterans more choice about how and where they get their health care. Okay. I think the issue is that i am trying to do this in a way that will work for veterans and work for v. A. Ive seen, as you said before, Congress Pass legislation that does that makes it more complicated and that makes it not work for veterans, and what i am trying to do is give you my best advice about how this works. The best way that i know how to do it is the way that the committee 141 passed their vote, and i do believe that because of your efforts we can make those Eligibility Criteria, those access standards clearer to veterans so they understand it. That should be our goal. And to make sure that they do have choice based upon their clinical needs of their condition. Thats what you do in a Health Care System. Thats what im driving to get at. I dont believe that we are at a far away position here. Were now talking about the best way to implement what we all want for veterans, which is the best care and giving them the most choice that they can get in that care. Mr. Secretary, im sorry that you take youre disappointed in my approach to this hearing today. I chose my words intentionally. I believe it to be the case. I think you tell me one thing and you tell others Something Else and thats incompatible with our ability to reach an agreement and to work together. I intend to be a member of congress who holds you accountable for what you tell me. The white house was sending language, i certainly would welcome a conversation of discussion among the members of this committee, the Ranking Member and the chairman, the white house and you. This is, as you say, not that difficult, but it is an important issue. Its not one that is a matter of a few words, it matters in the result of accountability that we get at the v. A. Mr. Chairman, thank you for the opportunity to question the witness. Thank you for your attendance. I want to do two things. First of all, i want to echo your praise for senator dole, a Great American, a Great American hero, a guy Whose Campaign i won in the southeast United States in 1988, i might add. Been proud of it. Got the political edge because of it. Hes a great humanitarian and a great human being. I appreciate the secretary and senator morans candor in their feelings about what were trying to do. As chairman, im trying to get us to a point where our dirty laundry is clean, folded, in the cabinets and what were doing is working for the veteran. And you do that when everyone has the chance to get their say, the facts are on the table and were all willing to work together. Thats what its all about. And i hope when it comes from the white house will be a catalyst for in the next couple of days. I found out about today, you found about today, but youll get a knowsis from me when we have the hearing. I welcome that. Please tell the dole family we appreciate them. Senator tester. You have an Opening Statement. As big as you are, you can do whatever you want. Ill ask questions. The Opening Statement will be later and i apologize to the members on my side. I usually kick it over to you but ive got another committee i need to get to very quickly. When it came to the first of all, welcome, mr. Secretary. When it came to the caring for our veterans bill, we had consulted with the vsos, and, in fact, got support of the 26 vsos. We consulted with you and the v. A. To make sure this stuff would work, members on this committee and members off this committee, and in your written testimony, you said the v. A. Believes the future of Community Care should include eight tenants. Those tenants are improve veterans choice of Community Providers in meeting their Health Care Needs top to simplify veterans eligibility with a focus on veterans clinical needs. To pave the way for consolidation of all Community Care programs. Add convenient care benefits. Set timely payment standards. Include provider agreements with flexible payment rates and streamline how we pay for care, including care in state veterans homes. Medical record sharing in the network when needed for veterans care. And addresses clinical staffing shortages through expansion of graduate medical education and by improving v. A. Hiring and retention of staff. I would just tell you that the caring for veterans act checks every one of those boxes. And it checks every one of those boxes because when we drafted it we had those tenants in mind. And so i would really look forward, and i think i look forward to a strong press release in support of this bill. Ill tell you why, there is a certain amount of frustration, as you can tell with senator moran and others on this committee that youve been silent. Okay . So, thank you. Section 211 of the accountability requires the v. A. To track the usage of new authorities granted to you and weve given you a lot of new authorities over the past year, thanks to the good work of the chairman. When will we see this report . The report was due in december of 2017. So i apologize that it is not there. The staff has had extreme difficulty tracking what youve required in that report sure. Prior to the implementation of the accountability act. Ive instructed them to give whatever data they have to you and tell you what data they cant collect. So when can we expect it . Is it reasonable to ask for two weeks . Two weeks it is. Well hold you to it. Your predecessors have testified that leadership includes working with underperforming employees to make them better at their jobs rather than just firing them, is that your philosophy, too . Yes, it is, that every good manager works with their employees to make them better, to give them feedback. When an employee deviates from a professional moral standard, sometimes you cant coach them, sometimes you have to help them find the door. Do you believe your leadership is doing that within the v. A. . Well, i think we have room for improvement because when you look at our Employee Engagement scores, theyre not improving the way that i believe that they shutd so were relooking at our efforts to do that better. Okay. On the c. H. O. I. C. E. Bill, Congress Expanded your direct bill for hiring where there was a shortage of highly qualified candidates. Does the v. A. Still not use this authority to hire . The direct Hire Authority was given to us for Medical Center directors and network directors. Yes. And i think unintentionally it capped the salary that were able to offer at a at a salary that is lower than what we currently offer. So weve not been able to utilize okay. The direct Hire Authority in the way i believe it was intended to be used. So how can that how can that how can that be fixed . A very small technical fix. Youre going to have to do it legislatively, but its a very small technical change that weve given some Technical Advice okay. And it gave you authority on those positions. Yes. But it also gave you authority for employees that you would deem critical. Yes. And weve gone to opm with 15 different critical occupations that they have agreed to move forward with us on direct Hire Authority that i believe we will start to implement in the next several weeks. So, okay so weve had the conversation before. I had a town hall meeting in great falls, montana on monday. I will tell you the first question that came up was workforce vacancies. This is just montana. Sorry about being selfcentered on this. But im i just want to tell you that were in a crisis. We may be in a crisis in alaska and we may be in a crisis in North Carolina and every other state, too, i dont know that. But i can tell you in montana, were in a crisis. Let me give you an example. Billings are supposed to have seven docs, weve got four and two of those are looking for a new position. When you overwork employees, they tend to hit the road. Yeah. So my question is, whats the problem . Ive talked to you many times. I know youre committed to this. But it seems like it is getting worse. In fact, it doesnt seem like it, in my state, its getting worse. Yeah, well, in montana, as you know, you have an 11. 2 turnover rate of your employees but for physicians its 23 . Thats thats a problem. You have a 24 vacancy rate for practical i got all that. So what can we do to fix it . What are you doing to fix it . Heres what were doing. First of all, we have to we have to hire more staff and we have to make sure is that we keep them. We have announced for montana an increase of up to 120,000 for primary care physicians in educational debt reduction. Yes. For nurses im sorry, for psychologists and nurse practitioners, a 10,000 hiring bonus and for social workers, a 5,000 hiring bonus. Thats a beginning to start to address people to look at the v. A. As a place to as a place to come to work. Then we have to, as you said, if we cant fully staff, it puts more pressure on our current staff that are there and so its a vicious cycle so we are working to recruit. So thank you for that. Time is of the essence. I dont speak for senator rounds. Hell speak for himself. As you well know, there is a house bill that was going to have a break done. They could shut down every facility in montana if they did that because we have no staffing. This is really, really, really important. It is. Absolutely. Thank you, mr. Chairman. Thank you, john. Let me just say for the record, the Ranking Members cooperation throughout the price of working on c. H. O. I. C. E. Legislation has been stew pen zis. We st i appreciate it very much. Mr. Bozeman senator bozeman. Thank you, mr. Chairman. And thank you, secretary, for being here, we do appreciate your hard work. Id like to talk to you a second about a bill which we were able to be the vet tech act, which we were able to include in the forever g. I. Bill. Its a Technical Education pilot. I know that we dont have a deputy undersecretary for economic opportunity. Hes retired. Id like to know who is going to be responsible for implementing it. And how were doing in the, you know yeah. Talk a little bit more about yeah how you fill that spot and, again, you might also elaborate even more about how we can help you with these really key, you know, things that are deficient in the sense of not being able to fill your staff. Right. Well, first of all, i think you helped a great deal with the forever g. I. Bill. I think this is a Great Success story of what this committee was able to do in 2017. As you know, of the g. I. Bill, the forever g. I. Bill, weve enacted already 13 of 34 of the provisions, but the one that youre talking about, the tech act, which is more the s. T. E. M. , the scientific technical training, that is going to require thats one of the ones that we havent yet implemented because its going to require some i. T. Solutions. And what were doing is we have an rfi out now to look to how we can get private industry to help us implement that. Otherwise were going to need to build that inhouse, which is going to be more expensive. So we are looking for the best way to get that implemented and committed to getting it implemented. But on many of these, of the 34, 22 of the provisions require i. T. Assistance. How will you determine the courses that are eligible . Such as coding, things like that. Under the tech act. Yeah. Well, you asked who is responsible for it. Our acting undersecretary for benefits, mr. Tom murphy, has accountability under that area. Okay. Rob worlrelly is the directo of educational benefits. Okay. Well follow up with him. Thank you. According to the v. A. Oig report on the consolidated patient account centers, in 2013, the v. A. Billed thirdparty pairs 7. 2 billion for medical treatment, i think we collected 2. 5 billion. It considers that has revenue in its annual budget projections. How does the v. A. Project its expected collections for each year and how does that match up with what were actually collecting . Yeah. We do give our projected collections as part of our budget request, because as youve said, its an offset to essentially our whats given to us in our budget. Our finance team does the projections based upon actuals of last year and then sets a target for improvement. And this is something that we have targeted, improved collections. One of the one of the provisions that i think is being considered under the current legislation is a requirement to disclose thirdparty insurance because thats part of the challenge that we have if we dont know a veteran has other insurance, its very hard for us to go and to collect it. So thats something that were working on. Right. I believe we have a Pilot Program going on in five areas . Yes. In relation to this. Do you have any on the on the thirdparty collection efforts. Exactly. So i know thats not done. Do you have any preliminary things you can talk to us about . I dont i dont have an update and i dont know if anybody behind me has an update on that. I dont think there is an expert on that but we can get you that update. Okay. Thank you, mr. Chairman. Thank you, senator bozeman. Before i go to senator manchin, let me just take the liberty, if i cant, to ask Gretchen Blum stand up behind me. Gretchen . Gretchen has been with the committee since i came to the committee three years ago. She is going to Greener Pastures in oregon. She has been a tremendous help to our veterans and this committee. We want to acknowledge and thank you for your service. Thank you. [ applause ] senator manchin . Thank you, mr. Chairman. I appreciate it. Thank you, dr. Shulkin, for being here. I need to bring something of local interest to your attention. On december 20th, a highrisk veteran contacted my office after his bypass surgery was cancelled while he was laying on the operating table in the clarksburg, v. A. Its a great hospital. But the reason being that the spots were found on the tools processed by the autoclave. Thats the reason. Now let me tell you the time lapse. Weve been told theyve estimated at least ten weeks just before a temporary sterilization unit will be operational, but it will also take a whopping 16 to 18 months to replace the one that is deficient. It has been reported, i understand, up to what the region 5, the visna 5 level. Thats your region. I dont know if its gotten to you all. There has to be something, doctor, when something this egregious happens. We cant do anything. Were done. This is a big hospital. Of course we need your help. Im sorry. Thank you for letting me know about that. Next of all, i sent a letter last week after the reading of the New York Times story that the v. A. Medical center tried to improve their quality metrics. We started looking at this how it affects us in our state. The Emergency Department medium time for administering pain medicationmedian time. On the Hospital Website is listed as nonavailable. And is also footnoted as no cases met the criteria for this information. That seems unacceptable to me for an Emergency Department. How are you equipping local v. A. Medical center staff to track and record these types of vital data . And who in West Virginia v. A. S are responsible for collecting the data . We couldnt find out from my office. Yeah. On hospitalcompare. Gov, which is run out of the department of health and human services. Are you all working with the v. A. Used to have all of its data up there. And due to contract issues with the department of health and human services, not v. A. , they lost the ability to take v. A. Data. They are now actively working to get it back up. By the end of this year, they will have all of that data back up. We still collect and produce all the data. We publish the data ourselves on accesstocare. Va. Gov. We wish it were up on the Hospital Compare site because we think its a great site. By the end of the year, hhs will have that up for us. Opioid addiction is something of grave concern. The president basically declared a medical a Public Health emergency. Public health. Ive asked him, im very appreciative of that. I wish it would have gone farther. Im appreciative of what were getting, but we havent gotten anything. I dont know how its affecting you all with the fight on opiate addiction. And if it will help you to get the money flowing. Not based on population but on need where the greatest occurs are. Have you seen any changes there . And also, yall need to be you need to be recognized in an affirmative way for basically not allowing your v. A. Patients to dictate the dispensing as part of the overall care theyre getting in what quality of care, which can penalize your hospitals. I think youve changed that and help that move all the way through the whole department of human services. Right. Well, first of all, i participated in the president s commission. We think its important. We brought the members of the committee to the cleveland v. A. That has a 3 prescribing rate. The lowest in the country. To see the best practices. And that did make it into the into the report. Right. Last week, we started to publish at v. A. Every Medical Centers prescribing rate for opioids. No other system in the country, no other hospital in the country does this. So it is available now so everybody can see. Its on your website . Its on our website. The opioid posting. And, finally, let me just say, weve made a 41 reduction since our efforts began in 2010 with our opioid safety initiative. We have more work to do. What this website says, it shows us where we have a lot more work to do. But, remember, the key is not just simply withdrawing opioids. Sure. These are patients who are in pain. The question is we recognize that. Before we start opioids, before you reach for it first, are there alternatives that you can do to help relieve pain and not put your patient at risk of addiction . So thats what were really focused on. A lot of veterans think this is about we have targets to withdraw opioids. We do not. We want doctors to continue to eliminate pain, but we want them to make smart choices, give veterans informed choice. Right. Were doing the same thing. We dont want any patient to think theyre being penalized whatsoever and being withheld. There are alternatives to that and alternative drugs being developed that arent addictive. With that being said, the one that still haunts me and bothers me more is the homelessness and weve had an increase in homelessness from 2016 and 2017. Yes. I cant fathom how any veteran should ever not have a roof over their head and a place to sleep for what theyve done for us. Right. Whats happening there . So, as you know, from 2010 until now weve had a 46 reduction in Homeless Veterans. We still have 40,000 Homeless Veterans. Way, way too many. Females going up female veterans is up 7 homelessness. Last year, the rate went up 2 . Which is going wrong direction. Overall. If you take a look, its five major cities in the country. But los angeles and seattle are the two that went up the most. So what we are doing is, we need a reboot of our program. This is not less money in the program. We actually want more in this program. We need to do this better. Were focused and prioritizing doing this better. Were going to target seattle and los angeles in particular, but not give up on progress everywhere else. And were going to be coming out with a new, improved approach, but it is not less resources, it is going to be more resources and more focus. Im so sorry. I just want to follow up real quick. For us to know how many Homeless Veterans we have, we have to have them on record somewhere. Yes. There has to be contact. Its not like saying, well, theyve fallen off the records system. We actually now know by name who most of the Homeless Veterans are. We do once a year whats called a point we have case workers with them . Absolutely. We have case workers for our Homeless Veterans. We do whats called a point in time count, a p. I. T. Count. Were going to do it here in washington on january 28th. Ill be out there at midnight making sure we accurately do that assessment. I did it in laepgts two years ago. After we do our point in time counts, well be able to know what the progress or if there are more veteran whos are homeless. But were committed to continuing to stay at this until we end veteran homelessness. Thank you. Thank you, senator manchin. Senator tillis . Thank you, mr. Chair. Thank you to secretary shulkin. One thing you mentioned in your opening comments, i just wanted to get a little more information on is i knew and i was glad that the department is showing some latitude in providing services to veterans with other than Honorable Discharge. Can you tell me a little bit about the scope of that and maybe the numbers of people that have been served to this point. Yep. Yep. As you know, with trying to decrease veterans suicide and doing the right thing for our veterans, when you take a look at where our highest risk for veteran suicide is, its in several categories. Homelessness and Homeless Veterans who dont have access to care, clearly, and thats why were targeting an end to that. Our other than Honorable Discharge veterans, very higher risk as well because they dont have access to services. So what weve provided them with is an emergency Mental Health benefit that provides all all they have to do is show up. Were going to give them 90 days of emergency Mental Health care. Make sure we stabilize a crisis and get them into longer term treatment if thats whats required. So far weve treated and have come to us for help 3,200 veterans with other than Honorable Discharge. We are actually hoping the numbers are higher. Over what period of time . Since we started this, i think it was one of the earliest things i did as secretary, so i would say ten months ago, maybe. Were actually hoping the numbers will get higher so we continue to get that message out that if youre a veteran with that type of other than Honorable Discharge and you need help, please come and were going to help you. Now what happens if you get somebody to maybe a stable yep. Condition and you improve their commission. This is emergency Mental Health benefit. What next . Lets say they get sick and it doesnt relate to the Mental Health illness. Oh, it doesnt relate genera health benefit. That is something that wed be glad to work with you or other members of congress on. That would be something that wed have to work on legislatively. I dont feel i have the authority to be able to do that. I didnt think you did. We had a hearing, and the personnel subcommittee for senator armed services, and it was focused on concussion, and more data that were getting, that at least could make you argue that perhaps discharges in some cases for bad behavior actually related to other circumstances. So i think this is a good step. The first thing is to try and stem any real tide of suicides through the emergency Mental Health service. Yeah. But i think we need to talk more about how we would manage this. And consider the full life cycle. What we talked about are the probabilities that this sort of job that a man or woman did in the military were exposed to events that now the science suggests could have actually had an impact on their mental faculties, or perhaps behaviors that led to their discharge. That would be something id like to talk with you more about. Maybe you can give me a quick update on i know the medical Health Record project is going to go through phases and take a while to get done. It looks like youre using a template similar to the d. O. D. , resources in there. And in that case, just tell me what we can do to help you. Because i think thats a very, very important project we want to see to conclusion. You need to make sure you tell us when we set a new priority that taps your ability to what about other you mentioned in your opening comments you still feel like youre making incremental not breakthrough things, what are we likely to see, but what the breakthrough things youre looking at that may require our help to get it moving . Well, i think what im doing is trying to put out there that we need those breakthrough ideas. And i want to see an opportunity to get those ideas from you as well as our veteran advocacy groups and other ideas. They could come many different ways, they could come technologically or Management Practices or policy and legislation. Weve seen legislatively that i think that this committee has been in the lead in doing this past year, like appeals modernization. Thats going to make a difference. I think that, and ive said this, that we need to reorganize the way we do business at va from having a large central bur r rocksy rocksy we need to change Management Practices that have grown stale. Whats happening in the private sector on health care and technology is the type of transformation that needs to happen within government as well. Were going to need to do that clab collaboratively. Thank you, mr. Chairman. Thank you, mr. Shulkin and thank you to the men and women of the v. A. For their extraordinary, dedicated work. I am going to be sending you, today, a letter that cites the need for stronger protections to the post 9 11 veterans under the post9 11 g. I. Bill benefits. I raised this issue with your during your confirmation hearings in january of last year. It has been almost a year. In fact, on february 13th it will be a year since your confirmation. And quite honestly, i am deeply dissatisfied with the lack of action under existing authority, 38 United States code, section 3696, to crack down on the predatory practices of for profit schools, like corinthian and i. T. T. , that have exploited our veterans. This letter sets forth in detail what those actions have been, and why i think that the lack of action by the v. A. Has been troubling. And i know that you are sympathetic to this cause. But id like to see good words followed by action, and i will appreciate a response to my letter. I ask that it be made part of the record, mr. Chairman. Im asking that my letter to dr. Shulkin secretary shulkin of today be part of the record. I want to focus right now on deeply troubling, in fact appalling incident in west haven. Im sure youre aware of it by now. The west haven v. A. Has been sued by a veteran who is alleging apparently a truly egregious act of malpractice. The veteran claims a scalpel was left in his abdomen during a 2013 surgery, and it was discovered only after years of pain and dizziness. It was removed in april of 2017 after an mri by the v. A. On june 6th, 2017, the veteran says that he initiated an administrative claim under the federal tort claims act regarding this case of medical negligence. Over six months later the v. A. Has still not responded, incredibly, to the claim beyond a simple acknowledgment of its receipt. And so the veteran has now filed suit in federal court. My first question to you is, is the Department Investigating these specific allegations . Yeah, yeah. First on this case, i think the way that you characterized it is accurate. Its an event that should never happen. And i am deeply sorry that any veteran should have to undergo this. Of course this was inadvertent on the surgeons part. When the surgeon discovered this, both he, who is extraordinarily well trained on the yale faculty, practices not only at the v. A. , but at yale new haven hospital, went to the veteran with the chairman of surgery at the v. A. And acknowledged their mistake and apologized and takes responsibility for it. And while this is an extremely rare event, happens in the country 1,500 times a year. In the v. A. , it does happen. It happened 12 times in the v. A. Thats a rate in the v. A. Much less than what happens outside the v. A. Thats no excuse. This should never happen, and we are looking and a root cause analysis has been done. Its actually been presented at the yale new haven mortality and morbidity conference so this could be evaluated by peers, who are surgical peers across the yale new haven system. So we do acknowledge responsibility for this. This veteran has suffered enough. Fortunately, his first surgery, which was done, was a successful surgery, but he should not have to go through anymore hassle in being acknowledged for what happened. And we will take responsibility for that. Part of taking responsibility is to acknowledge and act on his claim. Absolutely. And to, in fact, respond positively to the request that he made for relief under the federal tort claims act. I agree with that. It doesnt require any court proceeding. Yes. The v. A. Has an administrative and moral responsibility to respond, and im disappointed it hasnt done so. Will you commit to doing so . Everything youre saying, i share your sentiments, and absolutely we will commit to that. And i would also like commitment, and i know because of your own background professionally as head of the university of pennsylvania medical system, and other positions that youve held, you are very, very attentive to the standards of professional responsibility. Id also like a commitment that the v. A. Protocol and practices will be reviewed so that, in fact, this incident can be a teaching moment. Well, you have that commitment. Patient safety is my passion. I personally spoke to the chairman of surgery at the west haven v. A. I know that she and this surgeon have taken this extremely seriously, and are using this for the way that you and i both believe we should learn. The v. A. Does have a practice across the v. A. System for xrays to be done in some highrisk cases. Were reevaluating whether we should be doing more on top of that. These events should never happen, and were going to commit to making it a safer environment. I appreciate your being so forthcoming. And im going to follow up. Yes. And stay on it. Thank you. Stay on you. Yes. Because i know youre committed to it. Ive seen the xray. Yes, so have i. Showing the scalpel, and frankly i was appalled and stunned. Sure. And surprised and grateful that this veteran is still alive. Yes. So thank you for your responses to my questions. Thank you, sir. Thank you, mr. Chairman. Mr. Chairman, thank you, thanks for holding this hearing, and i want to thank the secretary for being here also. I think this committees done a great job. I want to thank you both you and the Ranking Member. Weve passed out, i think, this session, ten pieces of legislation, some which have been mine, and all of them have contained my priorities. I just want to tell both of you i really do appreciate being part of this committee and for the leadership we have. This committee has passed legislation, for example, that have already been mentioned like the g. I. Bill for life, access to s. T. E. M. Programs in education, which was also mentioned. But also the appeals process for faster disability claims efforts. And i want to thank you, mr. Secretary, for your hard work and effort on that. But clearly the works not over. This committee has already shared that with you a few times. Youre getting to your first year anniversary. I actually believe its february 14th. I dont know what youll be doing on february 14th. But that will be your oneyear anniversary. How do you like the job . Weve had several discussions, and i know youve been with the v. A. For a while, but not capacity as the secretary. How is your first year . How do you feel about the work that is progressing . You know, senator, first of all, its an honor and a privilege to be able to serve our veterans. Thats why im here. Im a tough grader. Im a tough grader on myself and my staff. And im impatient. I know all of you are too. Theres a lot of work to be done, and we have to make more progress. And were going to stick at it to be able to do that. But i do believe, and i believe a lot of credit goes to you and to the house also whos doing good work on their side to be able to make the progress that were making. But i think we can all do better. I appreciate your visits to my state, being accessible, and it has been very, very helpful to the 300,000 veterans we have in the state of nevada. Now, i happen to be traveling around a little bit last weekend in some of the rural portions. They have expressed some concerns and probably the one that caught my attention the most, and frankly for that matter my staff was the cancellation of the Community Care network for region 4. And for those who dont know region 4 is a big region. The Ranking Members in that region, as is nevada, but so is alaska and hawaii, california. We can go down the list. But its quite the region. Can you explain to me what the situation is, and why my staff and congressional offices did not hear about this . We found out on friday. I dont know if it was out earlier than that. We found out on friday. I also found out last week too. The federal contracting process is a complex process, one that is difficult sometimes to understand. It is designed to keep the people run the business like myself out of negotiating these contracts. Thats why i found out the same week that you did. In this case we divided the country up into four regions. This was hopefully our first award in region 4. So im disappointed we werent able to award it as well. I will tell you the reason why we were not able to award is because our Contracting Officers did not believe that it was in the interest of taxpayers to proceed with that contract. That means they did not believe that they should be paying the price that was being bid out there. They did not feel it was reasonable. This is going to be rebid. And we hope, and weve spoken to those that have bid, that they will rebid again because we believe that the quality of the contractors were there. It just wasnt we werent able to reach something that made sense for the taxpayers. So its my understanding that the competitive process has been closed down. Is that correct . Yes, weve put it what does it mean short term, for someone who lives in elco or eli or eureka for someone to dra travel long distances . Were talking about right now your veterans are being served by a third party administrator, and that will continue. We think that that contractor right now is doing a good job improving its service to your veterans. Weve been in direct contact about issues, and theyve been very responsive about fixing them. So business as usual. It will continue to serve the veterans. I know the contractor currently is committed to that. And we hope to have a competitive rebid process that will result in a good outcome for veterans, contractors. But importantly, the taxpayers. Mr. Secretary, my time has run out. I again want to thank you for coming to the state, spending time with our veterans, your accessibility, understanding of the issues and problems we have, and willing to work to improve the issues that we have in front of us. I think this Community Care contractor is one of them, i look forward to working with you trying to solve this particular problem. Thank you very much. Thank you, mr. Chairman. The fact that the v. A. Has a large number of vacancies throughout the country, and not just in montana, but also in hawaii and you were given tools, v. A. Was given tools to make the hiring process work a lot more efficiently. And yet we seem to be continuously behind the eight ball. Have you put your finger on why it is that it is so hard . I realize there are lack of certain kinds of medical professionals, et cetera, if thats the overall problem. Are there additional tools we can give the v. A. To enable you to hire the necessary people . Well, yes, yes, i do think that theres more we can do. But let me, senator, let me tell you, last year we actually made progress. We have annette increase of 8,303 employees. We hired close to 40,000, but its a net increase of 8,303. We have critical vacancies, and we want to move towards a direct Hire Authority. O. P. M. Has been very helpful to us and indicated support in doing that. And there is this technical fix that we talked about that will help us implement your intent last year when you gave us direct Hire Authority for Medical Center directors and network directors. So do you need additional tools . We do. We do. We want to continue we want to continue to right now we have three hiring authorities that we have to hire employees under. Its complicated. Title 5, title 38, and a hybrid system. The more that we can move for our Health Care Employees towards a title 38, it makes the process faster and more competitive with the private sector. Is that going to take legislation . Its something that i think we have the authority to do ourselves, and thats what were moving towards. But weve come to you in the past for help. Youve always helped us with that, and well continue to ask you if we need additional help. Well, please let us know because i know for a fact that in hawaii we have Something Like 166 medical staff vacancies that need to be addressed. Last week the white house released an executive order supporting our veterans during their transition to civilian life and ensuring access to quality Mental Health care and Suicide Prevention, which you talked about, as a priority. So one of the provisions calls for access for veterans to receive Mental Health care. And i want to know whether you have health care professionals, and what do you plan to do to devote Additional Resources to recruit and maintain Mental Health professionals. I assume thats one of your shortage categories. Right. First of all, thank you for acknowledging the executive order. Because if you look at any group thats at the high risk for suicide, it is that 12month period from transition. So this is targeted to providing every single transitioning Service Member with a Mental Health benefit. I think thats critically important. In order to do that, v. A. Does need more Mental Health professionals. Senator tester made this point as well. We have identified a need for 1,000 Mental Health professionals. Unfortunately the country at large has a shortage of Mental Health professionals. So this is going to be difficult. But we are committed to increasing the number of trainees in Mental Health residency programs. We work very hard with nurss, social workers as well as psychologists and psychiatrists to train as many as we can, we want to do more, and well continue to use efforts like our recruitment bonuses and to acknowledge that v. A. Is actually a terrific place to work if youre a Mental Health professional. Hawaii would be a great place to be. So were going to do whatever we can. Thank you. I want to get to the i. G. Report that showed overpayments and payment errors in the Choice Program. Since im running out of time, clearly we need to be assured that you are taking the appropriate steps to make sure that you have processes in place so that these kinds of overpayments and erroneous payments are not occurring. Yes. So i need your assurance that youre doing that. Turning to homelessness, your predecessor made a commitment that he would end veteran homelessness. As mentioned by senator man chan, we seem to be going to wrong direction, particularly with regard to women that are homeless. Why are we heading in the wrong direction . Where is ending homelessness in your order of pripriorities for v. A. . The commitment to ending veteran homelessness was made in 2010. We absolutely are committed to that. We will not back down from that goal. And we will continue to drive to do everything we can to end veterans homelessness. So there is no there is the same firm commitment. What ive said is because of this last year, where we actually went up 2 , we have to rethink our effort. In any good business, looks at what theyre doing and says if theres a better way to do it we should. So were going to come out with a new approach that doubles down on the things that are working, and maybe uses resources from things that arent working as well. So heres what we know is working, and ill tell you whats not working. When veterans get jobs, it keeps them in sustainable housing. It helps in so many ways. Were going to redouble down on working with employers around the country to find our Homeless Veterans to train them and get them jobs. Number two, the hud Voucher Program works really well. We want to continue that partnership with hud, and we look towards areas, hawaii is one, but los angeles and seattle, too, where the value of your hud voucher, you cant find people who want to rent you apartments. We have to continue to increase the value on that. Were working on that. We have a shortage of Affordable Housing units. We need to partner with construction people and landlords and actually create more inventory of low inventory housing. We need more Community Partnerships. Because v. A. Cant do this alone. Hud cant do this alone. This is a countrywide commitment. So were going to double down on the things that work and were going to come out with a fresh new approach here. Wed like to work with you on this. Because im not satisfied with the progress were making. Let us know how thats going, especially hawaii has per capita, the highest number of homeless in the entire country. And the housing market, you know, is so expensive. So thank you. Senator cassidy. Hi, secretary shulkin. A lot of what im going to be asking today, is from a news article, how the v. A. Fueled the National Opioid crisis thats killing thousands of veterans. As you might guess from the title, its critical. Yes. So i heard today, or read, that you have now published facilityspecific statistics as regarding the prescriptions. Yes. Ive been interested in big data in terms of applying to the v. A. And knowing facility specific. For whatever reason weve not quite got there yet. But the article speaks of in huntington, West Virginia, the local v. A. Prescribes takehome opiates to roughly 18 of its patients, a rate 230 higher than the National Average for all adult male patients. I have not looked at these statistics youve released. But does this v. A. Still prescribe as an outlier such as that . What we publish now, and senator cassidy, i hope youll appreciate this, no other system has ever published this data. Were hoping that they will join us. Because we believe, like you, that this is how you get better, by sharing your data and understanding it. What you will see for every single one of our v. A. Facilities, not only what their rate is now, but it was what it was in 2012 and whether theyve made improvements. Every single site, except for one, has made improvements in their prescribing rates in opioids. The one that didnt maybe somewhat unique in the philippines, its manila. But every domestic site in the v. A. Has made improvements. Some made a lot more than others. Thats where we hope theyre going to learn from each other. I dont recall huntington, wies virginias improvement rate, but i know it has improved. Something i asked the last time, the v. A. Sharing prescribing data with the state physician. And this article states that by the end of last year, which would have been 2016, 18 state programs still werent reporting. Is that still the case a year out from this . I do not believe thats the case anymore. Im going to want to confirm with you that were in 100 compliance, but that is our commitment. And if were not in 100 compliance, im going to want to know about that because weve committed to that, and we should be. Okay. The article also suggests that your vista Electronic Medical Record Program is incapable of flagging drug interactions between benzodiazepines like valium and opioids, and details, gives anecdotes with polypharmacy, everything in every case, one patient got 130 i think i recall this, 130 morphine tabs. Thats kind of eye popping. Why would you get so much . Is vista capable of flagging this, are the pharmacy programs incapable of seeing these drug interactions and flagging them . We do we do measure and follow the statistics on patients who are on both benzodiazepines and opioids because of the danger. I am not able to tell you right now. We do have drug interactions that come up on vista. I see them when i use vista. But im not able to tell you why we wouldnt be able to do that. Pharmacy quoted the pharmacist quoted here says it does not flag it. He apparently testified that under oath. Yeah, yeah. And again, i just dont know the answer to that. I would like to and id be glad to confirm with you very shortly whether that is the case or not, or whether thats been fixed. I dont know a technological reason why we wouldnt be able to do it. I may not understand that. You mentioned fewer patients, opioid dosing is going down. Does the v. A. Have any spot checks as to how many veterans have gone from receiving prescription opioids to perhaps seeking out illicit sources of opioids. We have an apparent victory or is it documented to be a real victory . Yeah, well, i dont know what theyre doing illicitly. I mean, we just dont have a way of tracking that. Do we have, for example, drug screens of patients who have been taken off opioids, but a drug screen might show theyre still taking. Those that returned and have been on opioids sign an information consent that says we will do the urine screenings and we dodo them, and we report on that in terms of general statistics. So but if a veteran doesnt return to us, we dont have any way of tracking that. Do we have any sense of the number or the percent of opioid overdoses in people whom theoretically are no longer taking opioids. Good question. Ive never seen the statistic that way. We do track narcan use and we distribute a lot of narcan that hopefully would be a measure of people who have overdosed and weve been able to resuscitate. Ive never seen the data broken down in the way youve asked. That would be helpful to the committee. It would let us know whether or not were making progress. Lastly as the v. A. Using medicationassisted therapy for those who are addicted . Yes, saboxone and other treatments. Were seeing a rise in that, and certainly we are keeping up with the contemporary literature on that. A rise could be from a small baseline and still be very small. Can you perhaps submit for the record the percent of patients whom you think have opioid addiction, disuse orders and how many have been transitioned, et cetera . Id be glad to get you those statistics. My impression is, although i havent looked at this in detail in the recent, is that your representation is probably correct, starting from a small baseline, beginning to use it more, probably still underutilized. And an opportunity for us to do better. I yield back. I apologize for going over. Senator murray. Thank you very much, mr. Chairman, secretary, thank you for being here today. Last year the department tried to quietly take money away from essential programs, hud vash, child care, and move the money to general purpose accounts to where it could be spent on anything. Youve come to us repeatedly, sometimes days or weeks letter saying v. A. Will run out of funding for the Choice Program earlier than expected. The department has to start being transparent with congress, about its budget needs and not rating critical programs to cover the short falls. To give us finally a realistic picture of Community Care spending. Those are really basic expectations, how much youre spending, and ask for what you really need. So i want to ask you today, will there be any changes in how v. A. Manages its business operations, or is it time to consider a new approach to these functions . Well, first of all, i think those are fair criticisms. And i have to take responsibility for some of the observations that you have. I will tell you that there is no desire to do anything underhanded or hide things. This is a system that were trying to do so much and so fast that were obviously making some mistakes. And we have to do better at that. So let me just address things. First of all, the projections on the Choice Program, financial projections, are very, very complex to do. Largely because not only, but largely because of this issue that we hope to get fixed with your committees bill that we have to commit the money at the time of we have to obligate the money at the time that we order the service, not when it was rendered. Its a little bit of a guessing game that makes financial projections hard. But were doing better. We projected that the money that was left in the Choice Program, before you renewed it right before the break was going to run out the first or second week in january. It ran out the first or second week in january. You gave us 2. 1 billion. Today we have 2 billion left, which means weve spent 100 million already of what you gave us. Were Getting Better. We have a grand new c. F. O. Who was just confirmed, thanks to you, in the last two weeks. But its a hard job to do it and were never going to be totally accurate unless we get some of these rules changed. On this issue of us doing Something Like taking money away from hud vash vouchers or Womens Services, absolutely never, never our intent to spend less money for Womens Services or hud vash or Mental Health or anything else. Here was our intent, and i stopped it because of the reason that you said, it was not accurately being rolled out or communicated. So its not happening now. But let me just tell you what my intent was. If you disagree with it id like to talk to you. Right now everything is controlled out of washington at a central office. We tell people across the field, this is how much you get and this is where you need to spend it. My idea of management is, you let the people closer to where youre serving the veteran be more involved in how they should spend their money. And they have to be accountable for the results, treating more Women Veterans, getting more Homeless Veterans off the street, but you allow them to understand whats better in seattle than whats better in h honolulu. I was trying to advocate a management philosophy that has worked for me that i believe in. It was not rolled out well, ask so i stopped it. But were going to think about how to make this system work better. That was in my Opening Statement. We need to do more, we need to do better, and im going to continue to try to do it. But i am going to commit, were going to do a better job at being transparent and collaborative with you. Thats what we will be watching for. I got it, thats fair. We had a rough year, thats what well be watching for. Thats fair. Let me move to another topic an Inspector General report from december found six of seven Medical Centers it reviewed primary care provider panels were significantly below required levels and that vha did not provide oversight of that requirement. That resulted in decreased access for our veterans, and hundreds of millions of dollars of waste in appointments that were not filled. That report also found, once again, that v. A. S reported wait times are misleading. In this case, by the i. G. s calculation, more than half of the newly enrolling veterans waited longer than 30 days for their first appointment. Another i. G. Report found that the eastern colorado Health Care System is still keeping secret waiting lists for group Mental Health care therapy. And finally according to to v. A. Data from november, there are more than 35,500 vacancies. Those are senior level shortcomings, across the system that end up with reducing access to veterans for care and wasting taxpayer dollars. Whos accountable here . Im accountable, but and theres no but about the accountability. The statistics youre reporting, and this is not being defensive, i just want you to understand what they are. 35,000 vacancies, we have 370,000 employees, a 9 vacancy rate. So youre always going to have 40,000 vacancies during the course of the year. The 35,000 are part of that turnover rate. As i already mentioned, we had annette gain of 8,303 employees last year. Weve got secret waiting lists for group Mental Health care, wait times. This is all from the i. G. Im not making this up. No, i got it. We have a big system. Secret wait times, we have clearly said to all of our leadership not to occur, not acceptable. If we find them, theyre disciplinary actions. In colorado, i think that this was one clinic, and it was if i believe, and i may stand corrected, i believe that the facility actually identified that, dealt with that issue. So that was there, it was dealt with, a deviation thats not acceptable. This is not representative of whats happening across the country. Wait times we continue to struggle with. Weve made progress. Theres no doubt the data says we made progress, but were not anywhere near where we need to be. No, were not. I agree. And were working on it, were making progress every day. What weve indicated our progress in is in matching clinical urgency and need to access. This goes back to my original question. We need you to tell us how much youre spending. Yes. And what you are asking us for these veterans. Yes. We need to know that. Yeah, thank you. Okay. Sullivan is recognized for the patience of job award. Thank you, mr. Chairman. Mr. Secretary, good to see you. Im going to start with thanks and kudos to you and your team. We finally passed out of the committee here the serving our rural veterans act, which was senator tester and is bill. But you were kind of the brainstorm on that when you and i were in alaska. Your team and i worked, we all worked together well on that. Hopefully we get that across the senate floor. I want to thank you for helping inspire the idea and having the team. I want to thank you, dr. Ballard in skae alaska is doing a great job. Weve added a hundred employees, including two docs, in the matsu valley. It was kind of the crisis situation that senator tester was talking about. We filled it. I know you had a focus on that. I was in the kenigh yesterday with constituents. One of them asked me, what are we doing, senator, on suicide . Just an older gentleman really concerned, i talked about the clay hunt Suicide Prevention act, i talked about some of the other issues. But could you literally talk to this constituent right now and say heres what else were focusing on . I know you are focused a lot. Sometimes it doesnt get out. Having a secretary here to answer to a constituent of mine would be beneficial. Real briefly, last week the president signed an executive order so 100 of transitioning Service Members are going to have a Mental Health benefit for 12 months. Weve expanded Mental Health services, Emergency Services for those thorough vulnerable. Were making sure our veteran crisis line is being answered, less than 1 of dropped calls and calls answered within 11 seconds. Were adding a thousand Mental Health professionals, offered Sameday Services for Mental Health in any one of our facilities where people present. Were identifying those at highest risk and going out and actually contacting them, and bringing them in. Were using Community Partnerships like given hour and the Cohen Veterans Network as a way to supplement the Services Available to veterans. Our vet services are available for walkin service, family members as well as veterans to be able to help them. Were looking at a number of other things that can help reduce this crisis, quite frankly. Thank you for that. The committee is interested, a lot of bipartisan support on that. Let owe ask you another quick kind of, you know, senator horono talked about homelessness. Were all focused on it. Probably one of the best ways to deal with it is grow the economy. The administration deserves credit, and a lot of kudos on that, were having Fourth Quarter of last year is probably going to be another really strong 3 , maybe 4 gdp growth. We havent grown like that in over a decade. Theres a lot the v. A. Can do. If you dont have a strong economy, youre going to have more homelessness. I commend the administration for its focus on that. Let me turn to an alaska specific issue. You know the uniqueness of our state. Youve been up there. I look forward to getting you up there again as a secretary. The v. A. Central office made a policy call which would change the reimbursement rates for military partnerships to be in line with medicare rates. And this would have a very negative impact on our v. A. Partnerships with some of our d. O. D. Partners, the 673rd medical group there at jay bear. Can you commit to me to make sure that you are taking fe feedback from all local v. A. S, and ensure that they understand the kind of ramifications of this policy change, as you know in this country of ours, one size never fits all, what works in alaska doesnt work in connecticut or other places, and vice versa, but can you just make sure i get your commitment on this issue before theres some kind of big change, you look at the ramifications in alaska, but other places, and get the feedback from leaders like dr. Ballard and others before you guys make a one size fits all call . Which my folks back home are saying this would be very negative, at least in terms of alaska. Absolutely. I think youve always been effective at describing the situation in alaska and other parts of the country that need different types of programs in it. We certainly are open to that feedback, and we will we will reach out to you to make sure that were connecting with the people you think we should connect with. I appreciate that. This is more of a comment. I know earlier in the hearing you talked about and the chairman asked about making sure that we get you guys get them out, and i ask my colleagues here, no foot with these nominees, get them confirmed, get them going, we dont need 40 hours of debate on some of these. But the delays and delays on particularly as it relates to the v. A. Would be a shame. So we want to work with you on that, and i certainly hope everybody on this committee wants to do that. Senator, yeah, i dont think you were here when i said i think we have the best committee in the senate. We have not seen any of those games. You guys have done everything that we have asked. We owe you the nominees, and then i am sure i agree with that. The games dont occur on the committee. The games occur on the floor of the senate where this administrations nominees have been. Fortunately and the way its been unfortunately historic and shouldnt happen at all, but it definitely shouldnt happen with nominees to go fill senior v. A. Thats right, thank you. Thank you, mr. Chairman. Thank you very much for your service, and thank you. By the way ill point out our secretary of the day was the only cabinet member unanimously approved in his nomination confirmation, which is a testimony to him and the job the v. A. Is doing. I think senator blumenthal and be as brief as possible. Senator blumenthal. Thank you very much, mr. Chairman. And thank you for spending the extra time with us. And being so forthcoming in your responses. I want to come back to some of the questions that have been asked about the vacancies. And the 9 turnover that you described. Yes. Has the composition of that turnover or the vacancies changed at all, in other words, are they more physicians, more psychiatrists . I know weve talked about the difficulty of recruiting people in particular specialty to the v. A. They do, and they change by location. In montana, our biggest vacancy is physician assistance, so 36 vacancy rate. But we have about 15 occupations that we see as critically hard to hire right now. They are the ones that weve gone to the to opm, office of Personnel Management for direct Hire Authority that theyre working with us on. We have difficulty we have 2,428 vacancies for physicians right now. Last year we had annette gain of 266. While were making an improvement, its only about 10 of the improvement we need. We have 5,507 nurse vacancies right now, last year we had a gain of 1,494. They vary by region. Thats how we recruit by region. We had a recruitment problem in little rock last year we were desperately short of nurses. We had a hiring fair where we hired 87 nurses in a single day. Were approaching this by a regional effort. The most important is for us to know where our shortages are, and we do have that data. And i want to ask about the education issue that i mentioned. Could you give me some idea of what action has been taken, whats your plan and so forth . Yeah. So the biggest thing that weve done, and i really i think you got it right. I do want to do something on this. I think that there is an issue, and i know you believe that too. We have put caution flags up on our comparison tool for veterans. When a veteran goes to our education site and looks at what their options are, there are actually caution flags for the deceptive marketing and some of the other practices. We do about 5,000 compliance visits a year to these schools. And where we find concerns the way that i know you have them, we actually share that information with our veterans. Now, a lot of veterans still go on and choose to enroll in those schools. As long as they have a state accreditation, our current policy, is that we will continue to pay for that. Weve been battling sometimes publicly with schools that have struggled with their state accreditations. And we are trying to hold firm to protecting veterans and doing the right thing. Do i think we can do more . I do. And look forward to working with you on that. I would welcome that. To be absolutely frank, ive been unhappy with some of the flagrant and lacking action on the part of the department of education which has much bigger impact on these practices than predatory actions of for profit schools around the country. So i very much welcome your dedication to this cause. Thank you. Thank you. Thanks, mr. Chairman. Senator tester. Thank you, mr. Chairman. And thank you for being here, secretary shulk, i would add under senator sullivans comments that you continue to put forth good people, and some of them are behind you that weve confirmed. We want to get them out of this committee as soon as possible. And ill put pressure. Youve put forth good candidates. Thats the key. An editorial comment very quickly, timing for the allocation of dollars for services for the new Community Care program is in the caring for veterans act, the medical director hiring provision we talked about, in the caring for veterans act. The serving rule of veterans act you worked hard on with senator sullivan is in the caring for veterans act, we talked about the shortage of docs nationwide. The 1,500 residency slots in the caring for veterans act. Yet a number of other reasons we hope to get your support of this bill publicly. Because i think this bill would have been passed already if we could have gotten you on board. Yes, yes. Look, i dont want to be hard core about this, but im going to be hard core about this. I would really like to get a list of about five specific things the v. A. Central office is going to do above and beyond what youre currently doing to address the clinical vacancies in our state. My staff says they wanted it done by the end of the week. Its already wednesday. Could you get that to me in a week . Yes. Perfect. You know, i sent out for online questions for you. Yeah. And i think its important the facebook page. Yes. And weve got a bunch of excellent questions. Ill just pick this one. What have you done to remove the barriers for Womens Health care . And how are you responding to veterans with well, i believe that weve done a lot to remove barriers for Womens Health care. But we have a lot more to do. One of the things that were doing is were continuing to train more providers in specialtyspecific practices to care for Women Veterans so we can expand their access. I believe were holding a conference in the very near future in orlando to train another 332 v. A. Providers in womenspecific care in which theyll be certified to be able to go out and to expand practices throughout the country. I think thats critical. And we continue to look at sites that are not providing Womens Health care clinics and making sure they are developing them as well. Women are our Fastest Growing demographic. We know our culture has not traditionally been as sensitive to them as needed. Thats why we have a federal Advisory Committee telling us how we can do a better job for Women Veterans. Were listening to their advice. We have a director for the center of womens veterans and were trying to do as much as we can. If you think theres more we can do or anybodys making suggestions, please let us know. We will do that. One last thing, we talked about opioids. Its a huge problem. We all know its a huge problem within the v. A. , outside the v. A. Its a problem. I know that attorney general sessions has said no more marijuana, going to be nowhere. Moe montana is a state thats legalizing for medical purposes. The v. A. Is a big dog, and if marijuana helps people with chronic pain, we ought to be researching it. I know you came out with a statement that said no more research. No, actually, let me clarify that. Perfect. What i said is that, first off, the v. A. Has done research on marijuana, but its not been dispencing marijuana and testing its impact. Its in observational, or lets say data analysis. But v. A. Can do research on marijuana, but i said that were restricted because its a class 1 substance. So we have to go through multiple agencies, and it is very challenging to work our way through that process. We do have the ability to do it. Ive said im in favor of exploring anything that will help our veterans and be able to relieve some of their sufferings. So it is challenging to get through that process. Our researchers are working through that process right now. If congress made it easier to go through the process it would probably happen faster. Well, i would just tell you this. Look, i do not have chronic pain. I know people that do. And i dont care if its marijuana or thistle or cactus, i dont give a damn if that helps them, especially when were fighting the Opioid Crisis we are today, we ought to be doing research to make sure its real. Thank you, mr. Chairman, for your flexibility. Thank you, mr. Tester, i appreciate your contribution, and the contribution of all members. I want to wish gretchen von the best in her wishes, and thank you for what youve done for our committee and our veterans. Thank you to everyone today, and well hear from the vso members. The record will be kept open for seven days for any member who would like to include their written statement or ask questions for the record, or any other comments we might want to have. And we have a long to do list, a lot of things to do. This is a hearing to reflect on what we talked about, and we wanted to do. The bills we passed to cause it to happen, and now the accountability phase. Were not just at this meeting, but every year we want to analyze where weve been and where were going. Hopefully were always improving services to our veterans, lessening wherever possible the cost to taxpayers, but most importantly making sure we give back to the veterans of the United States of america. That said, is there any other business . My staff, have i forgotten anything . Were good. This meeting is adjourned. This weekend the cspan cities tour takes you to new port, rhode island. With the help of Cox Communication partners, well explore newports rich life. Well visit redwood library, the nations oldest working library, and peter keernan on his book. The middle class has been our center piece, our dna, has become our Central Nervous system. When it prospers, the rest of the economy prospers. When it doesnt, what it tends to do is create sort of a barbell effect where the two uncertainties are, a few people get really, really rich. And the poor get really, really poor. And the balance between these two, the key sort of fulcrum position is the middle class. On sunday at 2 00 p. M. On American History tv, hear about newports history has the largest slaving trade port in north america. Settled in 1639 over the course of the next 100 years newport and the colony of rhode island would grow to become not only one of the most active ports in british north america, but it also became the most active slave port. Between 1705 and 1805, newport merchants along with bristol merchants were responsible for nearly a thousand slaving voyages from rhode island to the west african coast. They transported 100,000 africans to the new world during that 100year period. Watch cspan cities tour of newport, rhode island, sunday at 2 00 p. M. On American History tv on cspan3. Working with our cable affiliates as we explore america. This weekend on American History tv on cspan3, saturday at 8 00 p. M. Eastern on lectures and history, Depaul University art and photographs. Mr. Lincoln, give me back my 500,000 sons, meaning the soldiers that have been lost in the war. This is during the civil war, the darkest hours of the civil war, 1864. And then lincoln who the artist shows with his legs slung over his chair, like hes a country bumpkin, right, the reputation for being so inelegant and crude, the fact is, by the way, that reminds me of a story. Which was another part of his reputation. He was always telling stories. And homiles and tall tales and jokes, sometimes to a really irritating extent. At 10 30 p. M. From the american historical Associations Annual meeting, a discussion on free speech in college campuses. Sintellectual diversity is healthier than many people suspect. That doesnt mean theres an issue where certain student views and groups have received less active attention from the faculty and the administration. And i include conservative students in that group. They have received less public attention. And i think we need to meet those students where they are and to help them to develop a place in our public conversation where they feel more included. And sunday at 4 00 p. M. Eastern on real america, the 1987 film drug abuse, meeting the challenge. Anyone that says cocaines not addictive, they lie. When you do cocaine, you lie to yourself about being in control. Cocaines not hip, its hype. Anyone who tells you its okay watch American History tv every weekend on cspan3. Sunday night on after words, womans march on washington leader Linda Sarsour is interviewed. What do you say to them . I say what do you say to them to say to their sisters who may not have marched but are otherwise share their culture and their belief . I say to them it may not feel like this, but are fighting for them, too. We believe in their potential to do the right thing. I know that they continue often times to disappoint, including disappoint their white sisters, the ones the 49 or 47 who dont vote for republicans. What i ask people to do i do this myself. Im not loyal to any political party. I have been known as a big critic of the Democratic Party for a long time. I say to people, vote your values and principals. Dont assume what this movement is about. I say that in the last year we had got into a controversy about proabortion, prolife, can prolife women be a part of the movement. We never said we were a proabortion movement. That wasnt the language that we used. We were intentional. We are prochoice. We are a movement that believes that a woman should have the agency to choose whatever it is that she feels is right for her and her family and her body. Watch sunday at 9 00 eastern on book tv on cspan2. Next on cspan3, a discussion with