Transcripts For CSPAN2 Veterans Affairs Secretary David Shulkin Testifies On The VA Choice Program 20170310

Focused on the future and how we can Work Together to create a better, brighter healthier one for the Healthcare System rather than on rehashing the mistakes we made long ago. As we begin to move forward, we must not lose sight of where we started. Years ago, next month in this very room, the Committee Heard testimony from a veteran named barry coates who spoke about waiting almost a year for care at the department of Veterans Affairs facility of south carolina. He was finally seen long after he should have been. He was diagnosed for colon cancer that had spread to his liver and to his lungs. He passed away in january last year. It was garys story and accompanying allegations that 40 veteran patients had died while waiting to receive care for the Va Medical Center in phoenix arizona that kicked off a nationwide access and accountability scandal the likes of which the da had never seen. It also led directly to the creation of the Choice Program and to the allocation of billions more taxpayer dollars to increase access to care for veterans nations and the three years since then, more than 2 million authorizations for care had been approved and over 1 million veterans have been able to get care that otherwise might not have been readily available. However,all of us around this dais youre from veterans day after day , experiencing lengthy and frustrating delays when attempting to schedule an appointment through the va using choice. In fact a couple weeks ago, i was contacted by a veteran with a story much better. This veteran was diagnosed with cancer last fall and refused treatment. While im relieved to say he is now receiving the care that he needs from the provider of his choice, he suffered through weeks of doubt through a series of mishaps and miscommunication between the da, thirdparty administrative managing choice in this particular region and the Community Providers who had agreed to treat him. It appears that three years after various testimony, a lot had changed but too much had stayed the same. Whats more, the recent work proforma to be a Inspector General antigovernment Accountability Office illustrates clearly that choice is not fed up to succeed at its primary mission. Providing timely care to veterans who cannot access that care within the va because its either not offered, unavailable or a reasonable amount of time or would entail travel to make visible. Gol testified this evening that veterans could potentially wait at the 81 calendar days before receiving care due to the burdensome bureaucratic process they imposed on choice. That is unacceptable to me and im sure everyone in this room. I ran a practice for over 30 years and i assure you it does not have to be this complicated. It should not and should most certainly not take this long. Luckily, choice is not the same program today as it was before the da in the ig last year and its certainly not the program that was first created. For a series of four legislative changes in 70 contract modifications in county, the choice has been continually improved upon and made stronger. What remains far from perfect, far too many cases have failed the veterans it was created to serve. Im working diligently with the Ranking Member walt, the secretary and his Senior Leaders and what are Senate Colleagues were our Veterans Service Organization Partners in to chart a path forward for choice, all the care and the Community Programs in short order. We all have draft language that we shared in the coming weeks and have the va healthcare reform bill on the president s death this year. However, the first step is to reform choice is making sure theres a smooth transition to lead the way. This is why its critical this committee tomorrow markup hr 369, a bill i introduced earlier this year to move for a sunset date from Choice Programs. Acid legislation, the choice will begin shutting down in just a matter of weeks and will end completely in five short months from today. That setting off a key access at a time when veterans are seeking care in the community more than ever before. And critically at a time when va nonjewish Community Care account is unable to absorb additional demands for care. Va has already faced a 3. 4 billion deficit in the Community Care next fiscal year and va leaders have told the committee about the required additional address. And by removing the sunset Choice Program, we are not enforcing the program in its current state but we are ensuring that emergency funds the congress made available for critical veteran care are used for that purpose until theyare expended. Community care performances have increased by 61 percent overall in choice. And the defense choice was created and the last year, 30 percent of all va appointments were held in the community rather than through va medical facilities. That is what i am committing to once again this evening. With that i will now yielded to Ranking Member walz for any statement that he may have. Thank you chairman crowley to support hearing and a special thank you to senator mccain. Always a champion for veterans and its a pleasure to have you over here. A special thank you to secretary shulkin. That sounds very good and we appreciate you being here. Also had Inspector General and the gao as well as the Committee Members were here, those who sit behind any American Public all who have the same mission, the same goal, buys quality care, the most timely manner for veterans. Im grateful to each and everyone of you. Last congress we heard from both experts at va including secretary shulkin. Our Veterans Service organizations, independent assessments Blue Ribbon Panel and the commission on care about how we should shape the deity of the future. Now its time to get to Work Together to make some decisions, passed legislation to ensure our veterans receive the health care they deserve. What of this committee size players to ensure veterans receive the highest quality healthcare in a timely manner in a safe environment. This includes care at the va medical facilities and through Community Health care providers. Can all agree care must be utilized so veterans do not have to wait too long or travel too far to receive care. However from listening to our veterans and constituents are still waiting too long to receive care we need to make changes. Our witnesses, the Inspector General and the gao will testify to survey and audit data that back up with her constituents have been telling us. Veterans are still waiting too long, and in many cases have been forced to mince care on their own. As dr. Rose that it should never take 80 days to get an appointment in the committee. Veterans in need of Mental Health care and her elder veteran should not be struggling to make their own appointment and coordinate complex care. Care decision should be made between the doctor and the veteran. The va should be there to make sure the veteran gets the time appointment to make sure a doctor has a health care record to treat the veteran and make sure the veteran isnt stuck with a huge medical bills addressing that doctor. As the moves forward, i hope we can take some of the lessons we learned from choice we need strong leadership at the va hospitals are committed to putting a plan in place. Our facilities are responsible for filling in inadequate Communication Networks under choice and providing the staff to support vista program. They should be involved in this new committee care Program Every step of the way. We need technology to support our providers at the va and documentary providers treating veterans. This requires va to the modern Electronic Health record and an ib system to reduce the time it takes the va to coordinate care and process claims. Va current ib system or lack of to support care coordination are contributing to delays and increasing workload for staff for manually processing them. To get this plan right this will cost a significant amount of money. Our presiden present as it is cd to increasing funding for veterans but this does not mean to be a gets a blank check to continue programs that are not working or that this money should all go to Community Care when veterans need to Specialty Care and coordination that only the va can and should provide. This means the va must be able to better forecast the resources and staff it to provide better and secure the facilities through its network of committee providers. Tomorrow will be marking up legislation that will allow for the rain Choice Program finds to spent. I think we come to a bipartisan agreement that va should be built first before a veterans bill for receiving committee care and that providers should have access to veterans medical records. This is a bipartisan agreement working with experts and i applaud dr. Roe and his folks for making this happen. I hope we can continue working together and make decisions that move forward to improve health care for our veterans and good stewards of our taxpayer dollars. Thank you chairman roe and i yield back. Thank yothank you very much. Its my pleasure to welcome a fellow veteran, American Hero and recalling from across the capital the honorable john mccain. Senator from the great state from arizona. Both in uniform and in the senate on the health of our service members, veterans and their families. I appreciate your willingness to be with us as we need to talk about a topic i know is a very personal and passionate one for you and for all of us. You are now recognized for five minutes here. I thank you very much, chairman roe and Ranking Member walz and thank you for your kind words, mr. Chairman. Im one of those whose number of landings does not match the number of takeoffs. [laughing] and i thank you for allowing me to be here. Id like to submit my full statement for the record, and i will try to be brief since its past my bedtime. [laughing] without objection. I would also like to comment on my strong support for dr. Shulkin as the head of the va and i think all of us have Great Respect for his work. Mr. Chairman, yesterday the front page of the Arizona Republic reported that there was a 2. 5 million settlement to individual named steve cooper, an army veteran of 18 years. Steve waited for almost two years before seeing a doctor at the phoenix va. By the time he received care is routine neurology appointment had turned into a diagnosis of terminal cancer. Everyone in this room has heard a similar story. Its not acceptable. It needs to be stopped and i want to thank every member of this committee for the dedication to our veterans and to make sure that never again there is another steve cooper who served his country with honor and then because of the failure to get an appointment is terminally ill. He wasnt alone in his date for care. In 2014 our country was shocked to learn that steve was one of 15,000 veterans stand in line for care in phoenix, 3300 of whom were urology patients. This disgrace served as a catalyst for the veterans access choice accountability act particularly the veterans Choice Program which is enabled veterans to seek providers in the community for the healthcare needs. More than 7 trillion appointment with committee providers for everything from diagnostic tests and urology screening to lifesaving heart and cancer treatments has been a result. Theres been significant progress in improving Veterans Health care. Were a long way to go to change the status quo plaguing the va and thats why i know none of us will abandon our effort to provide choice and flexibility in Veterans Health care and one must consider the hard work of refining and improving the veterans care Choice Program. We need as you mention, mr. Chairman, reauthorized veterans Choice Program which is set to expire in a few short months. He would at the Program Lapse hundreds of thousands of veterans will lose their ability to visit a community provider. The va system once again become overwhelmed. I come from a rural state. Members of the committee come from large and small states. I dont want to have a veteran to drive for 50 miles or 40 miles in order to go to the va when he can go to a local healthcare provider. It isnt more complicated than that. But i say that choice authorization expiration is approaching. I understand that va already has begun limiting care under the veterans Choice Program for veterans whose treatments would extend on august 7, 2017. I think that lends urgency to your action. I am concerned that veterans nationwide may encounter significant lapses in care if we dont act quickly. The outcome is not only affordable but it is unacceptable and we in Congress Must ask. Today i was pleased in the senate side the place with the snobs reside and we took a critical step forward by joining senate Veterans Affairs Committee Chairman johnny isakson, Ranking Member tester, senator jerry grant and others to introduce the veterans Choice Program improvement act. Let me be clear. No one is advocating that we privatize the va. Many veterans are satisfied with the va, known for providing superior specialized treatment in the areas of Mental Health, posttraumatic stress disorder and traumatic brain injury. At the same time we cant afford to go back to the pre scandal days when it va bureaucrats as the final say on where and when a veteran received care. Such thinking was what resulted in nearly 15,000 veterans stand in line for care in phoenix. I know this committee agrees as does secretary shulkin, and i look forward to working with all of you and my colleagues in the senate to extend the veterans Choice Program and continue to keep faith with our nations veterans. My dear friends, the world is in turmoil. And i believe that well be sending our young men and women into harms way in a lot of places in the world for years to come and they will be veterans and they will come home someday. And i believe that the work that you are doing is the lords work. Because you are committed as all americans are to giving the veterans that care that they need and deserve and they earn i defending this nation. I thank you for allowing me to appear before you. God bless. [applause] i was going to think senator mccain but he got out of here too quick. Didnt get a chance to do it. I will now invite a second home to the witness table where i am honored to welcome the newest secretary of Veterans Affairs who will be testifying for the first time in his new role, dr. David shulkin. I so enjoyed with the Ranking Member being at the white house during your swearingin with your lovely family. Thank you for being here and congratulations once again on your confirmation. 100 to zip i might add. I look looked very much forward to working with you, beginning with two nights hearing. The secretary is accompanied tonight by dr. Baligh yehia, the deputy under secretary for health, to medicare. Thank you for being here. Also finally w also joined by te honorable michael missal va Inspector General and randy williamson, healthcare director for the government Accountability Office. Thank you for joining us tonight. Secretary shulkin, we will begin with you. You are recognized for five minutes. Greedy chairman roe, Ranking Member walz, members of the committee. Thanks for being here so late and thank you for this opportunity to discuss communique. I also didnt want to thank centered in the game but he ran out so quick for his leadership. I couldnt agree more with him that we have to act now to ensure our veterans have time access to the care that they need. I also just want to offer my condolences tonight to the film dr. Thomas stars oconnor World War Ii Navy veteran and the father of modern transplantation who work in the va and with veterans for over 50 years and conducted the very first liver transplant at va in 1963. As you know va has provided Community Care to veterans for over 70 years. Since august 2014 we have also provided care through the veterans Choice Program and we appreciate your support providing this legislation of funding to better serve our veterans. As directed in the lobby implemented this program in 90 days nationwide. Thats unprecedented for a program of the scope and complexity. Because of the design of law and its quick implementation we did run into challenges, many of which will be identified tonight in the evaluations by the gao and the va Inspector General. But since then the Choice Program has evolved. We work with those of congress on four different amendments and with contractors over 70 70 different contract modifications to improve access and efficiency. Efficiency. As a result, shortcomings identified in both the gao and ig reports are not outdated. Choice is not the program it once was that these evaluations were released. I called living, growing program. Since the start of the program over 1. 2 million veterans have received some Community Care. 1 million appointment in fiscal year 2015 now has increased the 5. 5 million in fiscal year 2016. Even with these improvements and increases went much more work to do. We are not satisfied with it. Our overarching concern is veterans have access to highquality care when they need it regardless of whether its in that va facility or in their communities. Our goal for va Community Care is delivered program thats easy to understand, simple to administer and meets that her needs. We know we are not there right now. Both of the empty medicare are critical. Better to rely heavily on both. Despite the large increases in these, only 5000 veterans used the Choice Program as their sole healthcare provider. The overwhelming use both va and choice, and as you know many veterans prefer only to use the va. Va looks for to continue to partner with congress to address the requested budget and legislative change including provider agreements making va the primary coordinate of benefits and recording obligations at the time of payment. Weve worked with veterans, committee providers and other stakeholders in the past and will continue to seek their input moving forward. We do need your help. The veterans Choice Program is going to expire in less than six months but our veterans, committee care needs will not expire. This looming expiration is a cause for concern among veterans, providers and staff and we need help in eliminating the Expiration Date of the Choice Program on august 7, 2017. So that we can fully utilize the remaining choice funds. Without congressional action, but inflected face longer wait times for care. Second, we need your help in modernizing and consolidating communique. Veterans deserve better and now is a time to get this right. We believe they modernize and revise Community Care program must have 70 elements. First, maintain the highperformance integrated network that includes va, federal partners, academic affiliates in Community Providers to second, increase choice for all veterans starting with those with serviceconnected conditions. Third, insurer and will veterans get the care they need closer to their home when appropriate. Fourth, optimize coordination of Health Care Benefits with the Health Insurance that and it wont veteran already has. Fifth, maintain affordability of Health Care Options for the lowest income enrolled veterans. Six, assisted court nation of care for veterans served by multiple providers, and last, apply industry standards for performance quality Patient Satisfaction paper models and healthier outcomes. We look forward to working with congress and other stakeholders to enact these changes for veterans. Within six months we hope to present a plan, although were still early in developing this. We actively are seeking input from vsos and veteran advocates and continue to do so as we move forward. We know our number one priority is to buy veterans access to highquality care they have earned. Any va facility or as close to them as possible in the communities where they and their families live. Thank you for this opportunity to be before you today. I look forward to any questions spirit thank you, dr. Shulkin. Mr. Chairman, Ranking Member walz and members of the committee, thank you for the opportunity to discuss the office of Inspector Generals work concerning the eighth Choice Program and the future of the aids Community Care program. My written statement includes details of our extensive work in this area and i invite your attention to those matters. For years the has relied on non va programs in helping carry out its mission of providing medical care. Today the is Purchase Care Program includes a veteran Choice Programs, patience and Community Care, individual authorization and other non va care programs. We have reported in our audits, reviews and healthcare inspections and discussed in hearings the challenges that va faces administering these programs. In october 2015 via provide congress with a plan to consolidate all the Purchase Care Programs into vas committee care. Under consolidation va continues to have problems determining eligibility for care, authorizing care, making accurate payments, providing timely payments to providers and ensuring the necessary coordination of care provided to veterans outside the va Healthcare System. Without improvement in these areas these issues will continue to be obstacles to ensuring veterans receive timely access to quality care. To increase the programs overall effectiveness, va and Congress Must understand the historical barriers and control weaknesses that have plagued das Purchase Care Programs and ensure there adequately addressed in the future of kurt programs for perspective that is Choice Program, weve recently completed audits and reviews concerning the Choice Program at our findings have substantiated problems with authorizing a schedule appointments, consult management, Network Adequacy and timeliness of payments to providers moreover, our hotline has received hundreds of contacts about the veterans Choice Program. Most of these complaints were about appointments, scheduling, referrals, authorizations and consults. We identified issues in the patient centered Community Care program. The pc three program is a vha nationwide program that provides eligible veterans access to healthcare contract to certain medical and Mental Health services. The pc three program is used at the va medical facility exhaust other options for purchase care and when local va medical facilities cannot readily provide the needed care to eligible veterans due to lack of available specialists on white times, geographic and accessibility or other factors. We publish a series of five reports on pccc in fiscal year r 201516. We reported pccc Program Prior to including the veterans Choice Program did not achieve its estimate cost savings, provide them access to care or ensure that contractors provide a clinical documentation and reported critical findings as specified in the contract performance requirements. In addition, we reported that pccc and adequate Provider Network contributed significantly to va medical Facilities Limited use of the pccc and that pccc contracts were not adequately developed and awarded. At the end that was clear from our work was of that va clinical and support staffs were dissatisfied with his e3 in such areas as authorizing care, scheduling appointments and veterans waiting for care. These are some of the same issues we hear today about the Choice Program. In summary, our audits and revis and inspections have highlighted that va has had a history of challenges in administering the Purchase Care Programs. Veterans access to care, proper expenditures of funds, timely payment of providers and necessary coordination of care are at risk to the extent of the a lack adequate processes to manage funds and oversee program execution. While purchasing Healthcare Services from Community Providers affords flexibility and expand access to care and services that are not readily available to va medical facilities. It also poses a significant risk to va when adequate controls are not in place. We will continue to provide significant oversight of the committee care programs. Mr. Chairman, this concludes my statement. I be happy to add to any questions you or members of the committee may have to. Tend to be much mr. Williamson you are recognized. Thank you. In august 2014 Choice Legislation was enacted for the express purpose of providing more Time Healthcare access for eligible veterans. Currently, however, vha has established it cumbersome bureaucratic scheduling process that sometimes does not provide timely Healthcare Access for veterans. This process allows up to 81 days for the better to receive routine care from the time that dh a provider determined that better needed care. But in many cases document by gao, the office of Inspector General and the press and wait times have been longer for this veteran who have opted into the Choice Program. For example, one of the Va Medical Centers we visited referred a veteran to the Choice Program for maternity care. Since the a Medical Centers did not offer this care. Va confirmed her pregnancy at six weeks but waited almost a month and half before send an urgent referral to the va thirdparty contractor who was responsible for making a prenatal appointment for her. It took another two weeks for the contractor and attempt to make an appointment for her. At this point she was 15 weeks pregnant. Finally when she was 1 18 weeks pregnant, almost halfway through her pregnancy, it still was not an appointment. She made her own appointment with the choice provided. There was no way to know whether this case or cases like these are typical because va has no reliable data to measure how long the entire process takes. At the current program, Choice Program slated to sunset in august 2017, and the congress is considering proposals to reauthorize what has been referred to as choice 2. Oh program, vha faces daunting challenges that must be addressed. One major challenge involves streamlining its current appointment scheduling process. Currently both Va Medical Center staff and thirdparty contractor are involved in this process. But in the choice 2. 0 program va is considering Medical Center staff would perform all of the scheduling and contractors would build Provider Networks and pay claims. A key to achieving a streamlined appointment scheduling process is having an uptodate and userfriendly i. T. Capability to help process aliens of choice referrals linked with committee providers and schedule appointments, and connect with both the providers and the contractors to transfer medical records and process claims. Va is in a very early stage of procuring such an i. T. System. This would be a complex undertaking, one that will likely take years not months to become fully operational. Another major challenge is establishing a Robust Network of Community Providers who can offer veterans the services they need. This has been somewhat problematic through much of the current programs almost threeyear implementation. Especially in rural areas. Finally, substantial resources will likely be needed to carry out choice 2. 0. Resources needed to find i. T. Upgrades and new applications for choice are largely unknown but could be costly. Proposed changes in choice eligibility requirements such as eliminating 30 day, 40mile requirement for eligibility could potentially greatly increase the number of veterans seeking care through Community Providers and drive costs up considerably. Also with Medical Center staff begin schedule all appointments under choice 2. 0 as va curling visions. Hiring more va staff will likely be costly and tediously slow. Already since choice was established, the a Medical Center staff devoted to helping veterans access nonva care have increased threefold or more at many locations. Vha is not fully analyze the cost or feasibility of increasing staffing at its Medical Centers to schedule choice 2. 0 appointments. Vha is proceeding down the path towards the its invasion of 2. 0. As it does so it needs to do so thoughtfully and carefully, with the goals that embody timely access for veterans to quality care in the community at a reasonable cost. Achieving his goals will require a clear approach, datadriven analysis of the costs of various proposals. A plan and roadmap for successfully implementing choice 2. 0, including specific time frames and resources needed, and a robust system to measure performance, including wait times that can be used to identify Program Improvement and hold vha staff accountable for delivering Timely Services to veterans. This concludes my opening statement. Thank you. Now ideal to our vice chair, mr. Thank you, mr. Chairman. Thank you, mr. Secretary. Appreciate the entire panel for testifying this evening. Thank you to your service to our true American Heroes. I look forward mr. Secretary of working with you on your role and im hopeful that together we can find the right balance the entire committee, the va and providing both va and committee care to our nations true American Heroes. We have spoken about credentialing private providers desire to see va patients as va providers in the community. How do you think we can best equipped these providers to understand the nature of the wounds, both visible and invisible text are more fighters occur during military service, and how do we direct private providers interested in providing service for veterans through choice that are currently not qualified providers in the Va Health Network . Well, thank you, congressman. This is a big challenge for us. Our studies have shown that a lack of military competency among Community Providers is quite significant. Indicates a Mental Health providers we found that only 13 of community Mental Health providers have inadequate sense of military competency to be able to perform the right type of psychosocial counseling. Va is very active in trying to work with its committee providers and thats why were trying to develop a core network of providers so we can go out and provide education. We do it through webinars. We do it through facetoface academic detailing as well. We believe our federal partners, federal Health Care Providers and are academics partners in particular are very eager to increase these relationships with us and have the military, and see we know that we need. How do you speed up the process . We advertise at the Choice Program when we talk to our constituents, and in a lot of cases is not working. The wait times are too long and they kind of get disgusted and they deserve the best healthcare, the best timely care. So i mean, whats going wrong . How can we fix it . I know we talked about the thirdparty administrators, what have you buy to hear this a daily basis. Its unacceptable to me. Congressman, i hear it, too. I travel around the country. I get letters from all of you and from veterans directly. We are now embarking on listening sessions to make sure we have a good copy has a sense about what they believe the solutions are so we can design a system that works for them to we are eager to continue our dialogue with all of you to get your ideas. But heres what we do know. The system was designed, it was too complex and too difficult to maneuver. Ill agree with that. So we have proposed, thats what we have 70 contract modifications. We have issued letters of correction to our tpas. Weve come back to you four times to give helped us change the law that we have more that we need to happen. We have identified for specific changes to the program that we need now that we help would be considered, including provider agreements, flexibility and funding, the ability for us to obligate our funds when we use them. And all, and to be able to correlate of the Health Insurance in a way that makes sense for veterans so theyre not finding themselves getting billed inappropriately. And so we want to work with you to get this right, and we believe right now we have to extend the Choice Program because of veterans want to get our getting caught in the middle, but we want to come back and get this program so it works well. Very well. Thank you. And interviews, why were the clinically indicated dates changed by the va staff . What reason did they give and what response did you receive from va community leaders, care leader, when you brought this to their attention . Thats an excellent point. One that i find quite disturbing because out of the we used a sample of 196 cases, and out of the 196, in 60 cases, those clinically indicated dates were changed. We tried to get to the bottom of finding out why but we could not. One could only surmise what happened. As you know, va policy only allows the provider, the clinician who first sets that, date to change it, and its not supposed to be changed because va couldnt deliver the care in 30 days. So, we dont know but its a dog gone good question. Okay. I have a couple more questions but in the interest time as expired. I yield back. Well, thank you, mr. Chairman. Again, thank you all for being here. Again, that commitment all of us have to make this work. Sect shulkin you talked about the complexity of the program. That was due to how congress wrote it or the implementation between va and the thirdparty provider. Theres enough blame to go around. Certainly no ones intent was to do that and thats why we write it, sent it out, tried to make got there is a way, do you feel comfortable were working together and very clear on our intent, very clear on how we want it to be delivered . Weve learn a great deal. I come from the private sector, i will tell you we would not have designed a system quite as complex but the managed care industry, which developed over the last two, three decade, also at one point was extremely complex and not userfriendly with gate koepping and preorganizations and all that and that industry learned. We had 90 days to do this, tricare did this over a period of years the system is working much better than when it started in 2015. We have all the knowledge together to go back and make city system work for veterans. I share the gaos concern that the Technology Interface piece is critical and if its not stood up when you try stand up your community, based coordination, that seems to be that were setting offers up for failure ourselves up for failure. I couldnt agree more. Putting 35,000 schedulers in a va system and have to make decisions how to record appointments. We have to do this through technology. Our in the scheduling system being rolled out actually records this in a technologically coordinated way. What do you think best think to do out of choice was. I think we happened a lot of veterans. That was be intent. I applaud congress for doing this itch think there was a National Emergency and i think it was the right thing to do and i think we all tried to get it up as soon as we possibly can. We have helped seven million appointments scheduled for veterans who needed care and should not wait for care. It was essential. We were discussing the positives and you think we got a more honest transparent look at real wait times, they were no longer hidden because of choice. One thing that surprised us all, with choice the wait times grew longer and that men there war a demand we werent adequately addressing or meeting and it exactly did that. Showing us the real demand. Do you concur with the doctor that there are that increased care and explosion that maybe came out of that could account for that in addition to choice being complex . Yes. I think it could. What we saw in vision 6 is limited but its not inconsistent with what we saw in wait times with what the gao found and other work. To the gao, what is going to take to get them off the high risk list . What can i do now to get off the high risk list. The main thing is to improve oversight and accountability, and i think one of the early steps is to have also a detailed action plan that talks about time frames, talks about resources needed and so on. Its just not a simple matter of addressing gao recommendations. There are five different criteria for getting off the list, and certainly leadership is among them as well. Leadership commitment which i think va has bought into. My time over my time with this that has been bun constant in facilities is the leadership from the top, the conditionability, personnel accountability, whether it we acquisition all of the things that go to that. I would encourage and mr. Secretary i know its your desire, too, whatever you need to help us do that, restoring that faith, expanding that care, we all have the same mission, and i think this communitybased initiative will be critical for what the va will look like in the future. Congressman, last week i brought my team over to meet with the head of the gao. He and his team were very open. I told them its my commitment to make significant progress to get us off the list and thats my commitment. Youre recognize for five minutes. Thank you, mr. Chairman. I guess to the gao representative, on the so in 2014 we had our appointment wait time scandal. Past the choice act. Im sorry . Im sorry,y 2014 we had the appointment wait time scandal pass the choice act. Right. Because that at that level of the va in terms of those who did the appointments, responsible for appointment,s, secretarily cooked the books to receive cash bonuses and left veterans a number of veterans without treatment on the secret waiting list is. Started in phoenix and we found it in other parts. Understand the objective now is to give the appointment process back to those same employees. How does that make sense . I really dont know on that one. It is a very difficult situation to deal with, i think. Mr. Shulkin, how does that make sense, doctor. We have a choice and the is is a choice we are seeking feedback on. When we gave it to a contractor, outside of va, that we had a lot of problems with that, and so what we have done in 54 of our Medical Centers is we have actually brought the tpa staff back in, working with our Medical Centers. So, whether its a combination of outside and inside people, but whether its va staff that under new leadership and new policies, no incentives to cook the books, as you said, and really strong oversight, which is what the gao is recommending, we believe the most important thing is to meet the veterans needs and thats what were committed to doing. So va couldnt manage it own employees. Doesnt surprise me it couldnt manage the contract with the appointment process, and so im not sure were really making progress. What congressman listen, the very, very best solution is to let veterans schedule it themselves with the selfscheduling applications. Were working on that as well. So, my feeling is i share your concern. I do not want to go backwards on this and well have to approach this in multiple avenues and ultimately make sure that we get the most direct way for a veteran to get an appointment. I was talking to some of my Healthcare Providers back home, and the pc3 these pc3 grandmas came agreements cape up where the vamp has va has the ability to he direct negotiation with providers and have an agreement to refer veterans directly to those facilities. Every agreement is negotiatinged separately and theres no a boilerplate framework and yet we have the medicare system with its wellestablished reimbursement rates. Why dont we simply use that in these provider agreements . Well, one of the areas we have had Great Success on is in getting providers into our network, today its over 480,000 providers, triwest who are here today, 180,000, and because of the choice law we use medicare rates with some exceptions of rural areas. So i think we are trying to simply identify this. We have been successful billing the network. We dont do a lot of rate negotiation because of the way the law was written. On the pc3, why dont use medicare rates. We probably should we want to move toward one set of rules. Maintaining two different systems and two different rules and fee schedules, added to administrative complexity and confuses providers. So im in favor of a simple woe cull it funding flexibility. Maybe that thats different. Consolidation issue. Thats rate. What we are talking being here is do you have the art to use the authority if you can negotiate never rate structure and do it separately with each particular intent on the pc3 i assume you have the ability to say, this is what well do. Going to do medicaid ream burstment, period. Reimbursement. On the rate issue i agree with you. On the rules we have to do to manage the separate problems we need legislation, but there is some flexibility in their, like youre saying, yes, sir. Time expired. In tacoma youre recognized for five minutes. Thank you, mr. Chairman. Ive long said the lack of continuity the va is a challenge to the organization and im glad were joined by secretary shulkin tonight, and many of the other familiar faces the table. We need the Institutional Knowledge that the secretary and his team provide to make the longlasting improvements the va. Now, as we have heard tonight the Choice Program was a temporary fix to improve veterans access to care. Unfortunately, was a have also heard the fix still resulted in long wait times, confusion about payments and administrative headaches for veterans and staff the va. Its our task now to come up with a longterm solution that gives vas the care they deserve and strikes a bale between the care in the va and care in the community and keeps the vas central role to improve care coordination. Id like to third turn my attention to Staffing Levels the barn, and how that has been impacted the program. The ig found that in vision 6, the nonva care coordination staff workload increased of 200 since the implementation of choice and that vision 6 does not provide sufficient staff to meet the greg work growing work rites, causing appointment delays and lack of oversight. Are the positions exempt from the federal hiring freeze . This is one of those up intended consequences we learned. We thought if we outsourced all of our care to a Third Party Administer temperature, work lead would go down. In fact as the ig found the work load went up because we were making more calls and chasing down veterans. So we have been in catchup mode and have been adding to the staff. The clinical staff are exempt from the hiring freeze. We made that request and that was granted. Business staff would not be at this point, so, sort of have to separate out the functions. And were developing staffing guidelines and grids to make sure we are staffing up to meet the vas needs but youre absolutely right, cause it by surprise. But the fact some of your business staff are not exempt. That has complicated youre act to do your job. We made the request of the white house of 37,000 clinical staff and support staff we think are essential. That has been granted. We are looking the additional approximately 8,000 staff we look at almost every week to see if theyre impacting our ability to deliver care. When we do fine thered impacting the ability to do care, we made some additional questions. Are the visions across the country hiring more staff to reduce processing times. Ill let you answer that. We are seeing an increase in staff but i dont want is to miss the key point. This protest is too complicated. The gao report and the ig report both show the traditional Community Care Program Works better so doesnt make sense to keep putting staff in a system that needs to be fixed. I hope win we work on choice 2 pot we make it simpler to implement. The va that an essential roll to how does va plan to address potential fragmentation of care between va and Community Providers . You can take that. Care coordination is critical. Were developing an integrated system so the more integrated we become, the more we have to coordinate care. We are testing processes across the country that allow doctors to access our medical record, completely for every lab, every radiology test. We want to make sure they get the information they need to take care of veterans in the community. So we are front and center focused on this and know weeing can do mow coordination when we do more Community Care. One study caution that veterans being seen in two david Health Systems, the va and the care in the community, with different electronic records and different policies and procedures fate risk from dual System Health care that should not be ignored. What do you say about that. Thats why we want to give. The readaccess only to medical records so they dont repeat unnecessary tests, dont order drugs that should not be ordered. So we are trying to prevent that by giving them full access to a record for those patients theyre seeing. Mr. Chairman, my time is expired. Thank you the gentleman for yielding. Thank you, mr. Chairman. Mr. Secretary, congratulations and welcome back. You mentioned about military exceptsy of the provide come ten si of providers and you mentioned Mental Health related to ptsd and i can think of other areas like treating tbi, effects of agent orange. What other medical categories have you identified where you feel theres a strong need for that level of competency . Well, i think that the primary areas were thinking about are in primary carry and Mental Health and the primary care provide ever has to understand the nature of supporting wellbeing. The exam i use is that when a veteran who comes back from conflict comes in and talks to their primary care provider or Mental Health provider and say ied and the response is what it is an ied, you lose the confidence and trust. I agree. And other years of health, thing things epidemic to the areas where they serve they should be versed on those things or where to turn. Use wow be in favor of the system allow egg primary care doctor exwhen working with the patient to have the authority to decide who they can see in choice or choice or not choice. In other words, you may need to see an ophthalmologist but you may to see one that specializes in good luck comb. Pgh maria so just because the va has an ophthalmologist doesnt mean thats the best one to see. Would you be in favor of awe lowing the primary care door to i need you to see the glaucoma specialist and thats the referral i want to make without jumping through hoops. As long as i state my conflict of interest that im a primary care provider, do support that. Secondguessing our physicians and providers is never a good idea. I would support that. I think thats a deterrent to recruitment if thats the system you operatey. Just one last question. Solution for the delay in payment to providers. The system is too complicated and youre going through two systems, as i understand it. , that . And so the money is not flowing the way it should. What would your recommendation be to solve that problem . Well, were doing a number of things. First, before coming to va, i spent me life trying to get paid by insurance companies, so i am a firm believer, of you deliver a service, you deserve to be paid for it. Today we are 83 part of payments 83 of payments within 30 days. Thats not good enough. We need to have greater electronic claims, the va is now 63 electronic claims and should be 90 and were 43 over last year but we have more progress to go. We have to automate more and looking at other options including if it can be done better outside va, were looking at those openings in our new rfp process. Thats all i have. Thank you, mr. Chairman. Monday bradley, youre reask nationed. Thank you, mr. Chairman. I also want to say congratulations. Im delighted youre the helm of the va where the buck stops with you. But i cant think of a better leader so thank you very much. I think the gao report i think identified very well where the choke points are in the process, and we keep talking about the process is too complicated and lack of control and all that. Think the underlying issue in all of this to me is our i. T. System. Still feels like were driving a modelt down an l. A. Freeway trying to keep up with the teslas and the bmws, and i when i see this report and just even one step saying if we depth reach the veteran by telephone, then well send them a letter, and its just mind boggling were still in sort of this bureaucratic maze that is prolonging and can be prolonged up to ten days. Thats nobrainer. Why cant we fix that now . But the area for all of the hearings that we have had, the area that i have the least confidence in, is all of the automation and i. T. And i guess my question is, how do you alleviate my fear that we will always be as slow as an unautomated process will be, and how do you how are you going to amy fears were on the dismiss will get it right. I dont want you stop worrying until we do something that gives you confidence that we have this right. I think i, too, and many of you, have shared your concerns that you have heard us make promises before in this area and failed to deliver on it. Ive come to the conclusion that va building it open Software Products and doing its own Software Development inside is not a good way to pursue this. Hallelujah. We need to move towards commercially tested products. If somebody can explain to me why Veterans Benefits from va being a Good Software developer then maybe id change my mind. Right now we should focus on the things veterans need to us focussen and work with companies who know how to do this better than we do. So youll see that change in direction but i dont want you to stop worrying about it until we can actually show you we do it differently. Well, im delighted to hear that answer. Think we all are. Thank you very much for that. Mr. Williamson do you have a comment to make with regard to statement i just made and where the choke points are and improvement and do you think this Consolidation Program will help to improve that process . Yes. As i said in my opening comment, think i. T. Is a critical component, and i think secretary shulkins willingness to look at commercially available off the shelf systems is a really good move, and i think, even with that, they still have to integrate with legacy systems like vista and other things, and its also integrate with providers systems and the tpa. So, its not a slamdunk, but i think i. T. Is the number one issue i would say. Thank you for that. The other mr. Williamson, the other thing that popped out at me in your report, very troubling aspect, was when you identified 88 returned toes that were found, veterans sent to choice for appointments and then returned to va for various ropesnot only does this greatly increase the length of time veterans have to wait for care but gao was unable to determine if 20 of those veterans received any care at all. They got lost right. We shared those with va so they can make sure that those veterans did get care. And mr. Shulkin in terms of rectifying that, is it rectified now in the system . Yeah. We have look at every one of the Different Cases to make sure the veterans come the care they needed. Thank you very much. Yield back, mr. Chairman. Thank you chairman, and Ranking Member wolf. Add my congratulations, mr. Secretary. Id like to briefly highlight the different challenges American Samoa and the u. S. Communities face regarding community. While living a Tropical Island in the pack ocean may be mess isnt but also means the territories veterans live far away from my fully equipped Va Health Care facility, well outside the 40mile range or other distance qualifiers, 3,000 miles away in fact, compounding the issue, small island hospitals like the lbj tropical Medical Center in American Samoa may not be sufficiently equipped or staffed to provide veteran care and veterans cannot take advantage of the choice act even if they wanted to. Having said this would anyone on the panel please tell us what the va is doing or planning to do to ensure that our veterans who would otherwise qualify for the choice act but do not have access to nearby facilities are receiving the care they need in a timely manner and are there any other insights youd like to share regarding access to care for veterans in remote rural areas. Well, we have talk about this several times and i appreciate and really acknowledge your continued advocacy on behalf of the people you represent. We know american a mow paper a know American Samoans are patriotic and they deserve the very best we can give them. The challenge we have whether youre in a Pacific Island 3,000 miles away or other aparts in Rural America are actually similar, and while we need Health Care Professionals in those areas were not always able to get people to go to those areas. So, were looking primarily at Technological Solutions and we are looking at the use of telehealth which were doing across va on a scale that no other Health System in america is approaching. 2. 1 million visits over 700,000 vas getting access through Telehealth Services and so we are looking at this very seriously, about dramatically expanding it use to be able to support where we dont have health professionals. Thank you, mr. Chairman. Yield back. Thank you. Thank you, mr. Chairman. And thank you, secretary for being with us. Were delighted have you confirmed and get to work and this is very big news that you Just Announced about looking into an awful the shelf it program off the shelf i. T. Program. I want to speak about Rural America. Just had a va roundtable in northern part of my district in new new hampshire. I want to quote a nurse who was there with her husband, and she just cautioned about all this care outside the va. I dont want to see the val Medical Centers close itch dont know where this va choice card will take us mitch concerns that thebanding of brother and sisterhood will be lost. They wont have the symbols, the flaggings, the stories, the jokes, crying together, laughing together. I am afraid that will be lost. And she was very eloquent, and i said i wish she could have come here to testify, but how can you reassure veterans across the country as we move into this patient centered care and the programs such as the one we are about to test out in northwestern new hampshire, the coordinated care program, which im excited about but how welcome we reother assure our veteran wed wont lose the camaraderie of the Veterans Administration care . This is a significant issue for us. This is not just the camaraderie which we think is important but these are the real expertise that we have in our Va Health Care system. We have four missions. The Clinical Care is what we always talk about also have an education mission. We train more American Healthcare professionals than any other organization in the country. We have research that is dedicated solely to the improvement of the wellbeing of veteran and we also serve a National Emergency preparedness role. So all four missions are very important to us. Would just say two things. One thing is we know from the Choice Program that only 5,000 of the several of more noun a million veterans have used the program, chose only to use the Choice Program. Theyre saying what your constituent told you is which is that the va its important to the. Were not going to allow the va programs to be diluted and one reason why thats so important is that we need to modernize the va system. Our lack of capitalizing in the barn system in terms of building, equipment, i. T. Systems could make it a noncompetetive still put were going to make sure the payments opened facility opened are the best for veterans and vas will want to get their care there. The Community Care program is a way to make sure we supplement the va in an integrated fashion. Well, think you have our bipartisan support about providing access bus just a reminder on making sure we keep that veteran centric focus we have. I just want to speak briefly the founder and cochair of our congressional Bipartisan Task force to address the Opioid Epidemic and the use of opioids from surgery or high rates of opiate medication being used for Pain Management. Could you comment on what is being done in the va and i would like to work with you Going Forward in your team to work on Pain Management techniqued that would reduce the use of opioid medication and treat addiction and abuse disorders for veterans. We recognize and understand that this is a Public Health crisis, not only in va but across america. Va recognizes this as a crisis in 2010 before the was a lot of attention across the general media. We started a campaign with a number of strategy to reduce opioid use and now patients have to use informed consent to start the medicationed. We do academic detailing to our physicians and use Information Systems to prescribe to be able to help remind providers of other alternatives and built up complimentary care and coordinate with the state prescription data monitoring programs. So were doing a number of things and place its around the country are coming to to us learn how we have done this. Wed be glad to work with you and developing research in alternative Pain Management priorities. Mr. Chairman, congratulations, mr. Secretary. Look forward to working with you. Im going to go down at bit of different road. Im a little concerned and the department itself has estimated that it can treat and cure most of the remaining 124,000 diagnosed cases of hepatitis c within the next three years. Is it the vas commitment that the timeline will be held to, and that these will be treated regardless of the level of their Liver Disease or where they might be at . Yes. Thanks to the support from congress, we were provided the resources to meet that timeline. I actually think were going to beat it, but with one caveat. What we have learned is that our initial outreaches, we were getting thousands of veterans to come in and to get treatment. We have a treatment, of course, that now cures more than 59 of hepatitis c so its a tremendous medical advance. The doctors to my right is one of those doctors and does this in his clinical work. What were finding now if the doctor wants to comment were finding were n. O. W. Seeing less and were now seeing less and less veterans coming in to get cured. Theres a substantial number of veterans for number of reasons, either psychological reasons or social reasons, who are not taking advantage of this care and so this is now becoming a Research Question for us. How do we have to begin to approach people that are saying, i have a disease that may end up killing me but im not interested in the treatment. And so i think well beat your threeyear timeline but still a subset of veterans that dont want to come in and get care. So i dont know if the doctor is exactly right. We call this linkage to carry and we have effective treatment when people get in, but getting them through the door is now our by biggest challenge. We have the sea him that thing when the hiv epidemic started. We have effective thats and cooperate get people in the door. Now we figure out how to do outreach, work with homeless coordinators coordinators and other things to get people into the va. Is its lack of towarding that the cure there is or something other than that . Thats very shocking to hear that. A lot of it has to do with the social behavioral aspects of not only health care but of peoples situations. So issue think a lot of folks understand theres therapy there but are they ready to take that next step . Well, thank you for the answer on that. I have a couple more questions inch regards to what we want to do tomorrow, the importance of extension that were going to be working on in our markup tomorrow, what would happen if we didnt make that extension go past the august 7th and what would be the final cutoff if we dont get it passed. Well, first of all, if we dont do this extension, this is going to be a disaster for American Veterans. Well see the same situation we saw in april 2014, that senator mccain started tonight witch that we saw in phoenix. So heres the timeline. We do need to do this now. As i thick chairman rowe referred to. Already today, veterans are not able to use the Choice Program because the law states that we have to obligate the funds now for when the care is going to be delivered. To so a pregnant veteran who comes us and says they want to get care for the Choice Program they no longer can because nine months from now is past august 7th. This is beginning to happen with care that is multiple months in length, like oncology and chemotherapy. We have a chart that shows that when you start getting towards the end of april to may, this where is you start seeing a large number of veterans not being able to get access to care because episodes of care that were used to like hip replacement and other things, are generally three to four months. So, we think the time is now we need to act. Okay. So, what were doing is not any intention to privatize or anything like that. This is just making sure that those people on the Choice Program, that we are moving forward to make sure the services are provide it. Not only that but this is not going to cost any additional money. Were just thinking the authority to spend the money you have already given us past august 7th of this year. Thank you, mr. Chairman. Yield back. Thank you. Mr. Orourke your recognized. Thank you, mr. Chairman. Secretary shulkin when you started at undersecretary for vha in el paso was ranked worst in the country as far as Mental Health treatment and we were able to Work Together on a Pilot Program in el spas sew that allows the va to focus on ptsd, tbi, military trauma. And the doctors and providers in our community have stepped up to fill in the gap and care for those veterans and other conditions that are not unique to service and combat. We also had the partnership of Texas Tech Health Science Center and its making difference. Were focusing on hiring Mental Health care professionals the most serious crisis for veterans is veteran suicide which you estimate is 20 a day. Thats the best estimate that the va can come up with. Im convinced that its czeched to access to connected to Mental Health care. We talk about what your proposing and how that will impact the ability to access Mental Health care and reduce the number of veteran suicide in the country. Thank youor your leadership on this issue. Youre always pushing us and frankly its welcome. There is no other clinical issue that i am as concerned about or that has my attention than veterans suicide. Number one for sure. What we are dog now doing now is not enough and were continuing to look for new approaches to be able to address this issue. Were reaching out to the very best and brightest from the academic world and the Community World to come in and say, tell us what else we can do because we need to do something else. So stay tuned for that. But i will tell you something tonight, that they make more more news than the i. T. News and that i want to thank representative kaufman for this. Its is a program i went to that he was at that his bill changed my view. Were going to start providing Mental Health care for those that are other an horn honorably discharged for Urgent Health and we walk to work with the representative on this and do as much as we can. It cant wait so well start doing that now. Thats in the secretarys authority to be able to do that. So many veterans that we see are just disconnected from our system. Thats the frustration of the 20 addai, 14 are not getting care in va and yet we have this great comprehensive Mental Health system. Want to work with you and representative coffmman to get this. Its unacceptable. I want to thank you for the decision you made and not waiting for congress to force the administration to do and it showing the leadership and getting that done. Also, i want to put a plug in for your vet centers. Visited one in laredo, met with the Vietnam Veterans and thats the most veteran suicide and they have access to the Va Medical Center but prefer being the vet center where they have Group Therapy pa facilitated to one therapist and they all swore to it to a person. Quick question, the report says va cannot calculate the average number of die this Medical Centers to make Choice Program referrals. Are you able to calculate that today . What is the number . Yes, we are working on getting those numbers. How long before you have that number . We do have those numbers. The problem is that we want to make it automated so that its easier to pull. Can you share that with us. Happy to share it. Right now. Dont have it off the top of my head. I think when we talk about wait times and we were reminds of the wait time manipulation scandal, we need to know real wait times and hold you accountable for that and were not doing our job in an oversight mat if we dont know the real wait time across all care delivery the va or through a choice arrivedder provider, how soon can it i get that. Tomorrow. Thank you. Thank you, very much mr. Charm. Mr. Shulkin, congratulations to see you again, sir. Want to from the bottom of my heart the for the great work you did coming up to northern maine. We really appreciate you reauthorizing that Program Since that veterans in in the most rural part of the state. One of the most rural parts of the country can get the health care close to home instead of driving five hours when the snow is blowing sideways. Mr. Chairman, we recommended that he fly into portland, maine to drive here and he knew how difficult it. Mr. Secretary, im very concerned about the claims processing part of the organization. You have a very big job mitchell understanding is that when claims are processed at medicare, about 90 of the claims to pay out providers never touch a human hand, and then over at for the tricare program, 75 . But heres what im concerned about. This is the accounts receivable of at Eastern Maine Medical Center in n bangor and shape one of the larger Health Care Providers in the state. They have Inland Hospital and waterville and the Medical Center in prescott and im looking at this and theyre owed 13 million by you folks and about 60 of the claims have been outstanding for over a year. Thats a real concern. This is another graph of the claims excuse me mr. Chairman of the claims backlog over the last year. Flatliked and this for maine Medical Center, which has another network of hospitals throughout the state. So you can see its not getting any better. They were oweed nine million buck. My understanding is that there are about 95 claims Processing Centers around the country toe that do this work, and unlike for tricare and unlike for medicare, theyre processed map allly. So my question to you is the following. What does that mean . What does the manual claims process look like . Thats the first question. So, let me try to do this and ill invite my colleagues who probably knows five times as much as me on this topic. Youre exactly right, congressman. The va is not using as much automation as you would find in industry were moving towards that and seeing our percent go up. One reason is the complexity of the program. We have to determine on each claim writ was serviceconnected or not. Medicare or tricare does not have to do that. We have to adjudicate claims more thoroughly so the process of come mexty going back to why its taking so long. In terms of maine Medical Center and Eastern Maine Medical Center, this is the business i was. In i will tell you that they think that we owe them more money than we think we owe them and this is not uncommon because claims are rejected i know you err on the side of maine. Right. Thank you very much. We heard that. So we have been in touch with Eastern Maine Medical Center and we will send a team or have a team go over those claims and we do want to settle those as quickly as possible. If i may interrupt you, too, doctor, before you speak, again, sir, this is 13 million. Were a small state. Could you give is an idea Eastern Maine an idea its not just eastern its all the Healthcare Providers in their when you think theyll get their 13 million . We actually had a conversation with them today. We have a meeting later this week and have been working with them. Think we d i dont want to miss this point. We wanted to work like medicare. Help dues that. The choice law has eight different eligible criteria. We have to determine theyre service connected. If they have another health, inn we promise we want to get to point. I only have 13 second left. Doctor, can you tell me, so everybody can hear, when eastern med with get theyre 13 million and men med medical gets help. I dont its actually 13 million but were meeting with. The this week. So, just to be clear, they think its 13 million, we dont. Whatever number we agree with, well cut them a check. Exactly. And soon. Make his day. Within three weeks we can do it in three weeks. The weather is clearing up. No more snowstorms coming good to time good to maine. Thank you. Thank you, mr. Chairman. Thank you, Ranking Member and the committee for organizing this Committee Hearing and secretary, congratulations. I live in a community in southern california, very multiethnic, a lot of new americans who english is their second language. First question to you the number of latino veterans has rapidly rising in the country. Over the next decade probably make up 15 of all the veterans. So, with that in mind, maybe language challenges, how are latino veterans finding and faring under the veterans Choice Program . I have not seen a specific study on that issue. Its probably good thing for our office of minority and diversity to take a look at to make sure theyre not faring any worse. Our work force tends to reflect the makeup of our veterans since more than 40 of our work force are veterans. So we do have a large contingent of latino work force as well, and i hope that we are certainly meeting the needs of all of our veterans. Thats something i think wed like to work with you on. Mr. Chair, id like to see some goals or maybe some data on that area. A lot of them are their families are spanishspeaking and english irthis second language as well. Want to make sure that language is not barrier to them receiving the proper benefits in services that theyre entitled to. Second question, an important one. Under existing immigration laws, if a legal permanent resident veteran is convicted of a crime, even nonviolent offense or minor infraction, some face deportation. They have defended our country with honor yet their lives are disproportionately affected. Were degree anything to make sure the resident veterans who fall into these categories have access to Health Care Without fearing deportation . That is something that i think that were going to have to work with our general counsel on. I understand the concern. Im not aware of any particular circumstances but we have a Veterans Court program, a veterans justice outreach program. We work very closely with veterans who do get into trouble with the law, and we work with judges in particular on those issues. So i would hope we can work in a way that would love to work with you on this issue. Orange county was the first in california to have a Veterans Court. This is a unique issue and unique wrinkle in the sense that legal permanent residents who violate the law or convict lose their residency and are being deported. So a different rinkle and i know a lot of them are now concerned about what do they access and do they face deportation . There is a growing group of these veterans right south of the border who are now living there because of course theyve been theyve lost their legal permanent residency and like to make explore this issue with you a bit further. Thank you. Thank you, sir. Thank you, mr. Chairman and thank you for spending your evening with us. Im sure its exciting for you to be here. I also thank the secretary for mentioning dr. Tom starsle who passed away. He was a champion for veterans and a champion and pioneer in the transplant surgery realm and i was fortunate to study under him. Mr. Secretary, just yesterday, a veteran i represent provided to my office an account of his experience receiving Specialty Care through the Choice Program, and he underscored a number of the challenges we discussed here today in particular the veteran encounter poor communication between the va and the thirdparty administrator, and also between the va and his choice provider. And it severely delayed his access to care and although he did get an appointment with a provider through the Choice Program the nearest provider was hours away from his home and he had some difficulty getting his prescribed custom prosthesis and orthotics and he did the math on the multiple round trips to these and the prosthesis was cheaper and the medical care was cheaper out of his pocket. And thats what he did. And this letter is actually amazingly lucid and articulate and polite letter. It reads like a Marx Brothers skit. What should this committee keep and mind in regard to the particular needs of the Specialty Care patients and how is this different from the primary care referrals . These is a special situation. Yeah. Well, what we are doing to make sure that we get this right is we are doing community by Community Assessments because theres just like real estate, all health care is local, and so theres some areas that have oversupply of specialists and some undersupply and sounds like your constituent lives in an area where theres a shortage. I know there are specialists near him but for whatever reason theyre not on the panel. We are continuing to grow our network so if there are available specialists in the area, were continuing to grow that wear. We have a slide of his where you can see the progress were making in provider growth right now. It might not pop up. It there is. 133 growth. But we need to continue to build out the network and stories like that are impactful so im glad youll make it part of the record. My practice, we were on your choice network, and i will say that a lot of types the problem was not that the the veterans there are in town, were in town, we have slots and can see them but the problem was authorization. This system in a number of ways is dysfunctional. The Payment System is pretty dysfunctional. Basically its important to get them in, get them taken care of and they had 0 go back for authorizations again and again and again, just to see the same doctor about the same problem. What are we going to do to make that system work better . Well, when we started our authorizations were only good for 60 days. We dade contract modification and made it for a year. And so as we learned the problems in the program, much like the way that youre describing, we are doing these modifications and have 70 of them since the contract started. So, come to see me and wouldnt be able to get xrays. Could see them and prescribe medicine which they would have to get the va but couldnt get the xrays and couldnt see the xrays. The delays were just atrocious. In addition to lengthening the care what were doing now is doing bundles. If youre get ing your hip replaced, the pt comes with is, the xray, the mri comes with it so were trying to tackle the problem as an episode together. So we dont split up and we maintain continuity of care. Thank you. We look forward to working with you. Were all excited about the possibilities. Thank you, mr. Chairman. I yield back. Thank you, youre recognized. Thank you very much, and good morning, everyone. Where im from its 11 00 in the morning. I know hive been now nodding off a bit. When it takes you 25 hours to get here, you get tired. Because its so far away, mr. Secretary, congratulations on your appointment and your confirmation. I truly wish you all the success in your term in office. You were successful in your previous job running a huge hospital. But the veterans in my district believe that our country has forgotten them. When i first got in 2009, i dont stop over anywhere in the country going home or coming back but i estopped over in hawaii. Met doctor hastings and urged him to complete the program he was gorging with one doctor who provide service to a certain number of veterans. The only doctor on the island providing service to veterans. And then we now have one va employee vha employee, but the department the country the veterans feel that the department that is staffed with administering Veterans Benefits of services have done little to change their feelings about theyre being forgotten. Over the years, we have had va cases but in the last nine months my office has seen a significant increase in complaint busy va service from veterans, family members, advocates and Service Providers they have taken it responsible themselves i nono use of va resources have brought in people who helped with teaching methodding and for people with ptsd, i brought in this documentary and tom bloss who walked the country to learn how to handle his demons we just had a resource fair two weeks ago and i have never had a more successful fair for veterans. We put together all potential resource providers and brought our veterans in and all Three Islands and were very successful, and then all of us come see your administrator from hawaii and his or her deputy and couldnt make it to in the fair but now theyre having a one and a half hour town hall. After stopping in guam for the night. So my question is, will you please work with me, mess to improve the quality of and access to veteran va services for our veterans . Im from in the northern marian ya islands. Mariana islands. We need your service, sir. Id like to come and see you and lets try to figure this out together. Thank you very much. Thank you very much. Its important. Mr. Miso thats you, sir. Yes. Your Inspector General. Yes, sir. In your evaluation of the Choice Program implementation what have you found to be the experience of veteran patients in the outlying areas or territories or some people say the colonies, such as the northern mariana in accessing health care in a timely manner under the Choice Program. We have looked at it in a number of different ways. We have not isolated it in those particular areas you mention but the same issues we found whether its with vision 6, when we looked at it, more nationally, the same issues that impact people in those more rural areas, which are the complexity of the programs make it very difficult to administer, which increases the time involved, and then one of the other issues i know we have talked about already is the care coordination to make sure that when a veteran leaves the va system one strength of the va system is a integrated system where they can watch very closely the care for the patient. When they leave that system, you have to make sure the records go out with the patient and make sure they come back in. We have seen challenged to both situations where theyre not going out as quickly and coming back as quickly as they should. Well, my question was, so thats the experience you have found in veterans accessing health care in a timely manner or an answer that says you dont know what youre talking about . I would hold that answer and well come back. Measure ruth areford youre rex niced for five minutes. My time is up. Well, thank you, mr. Chairman. Mr. Secretary, thank you for your long testimony here tonight. You probably heard the old situation vision without action is just daydreaming and action without vision is chaos. And sometimes i hear from veterans in my district im from florida 4, the Northeast Corner of florida. We have a very large veteran population. Sometimes they talk about the chaos of the system. But ive heard a couple things here tonight that really struck me. One was that your number one concern is happens to be mine as well is veteran suicide. Yes, sir. Im very pleased to hear that. In addition to that i heard that another vision that you have is that the va is going to get out of developing i. D. I. T. Soft square look for off the shelf type package. Those are significant culture shifts within the va. Can we give me one or two more that you have visions that you have about the va and how to what will change the culture . Yes. The three biggest areas that im focused on are, in one, giving veterans additional choice, and i think that ive already explained tonight, this means keeping the va system strong. I happen to believe the way you keep the va system strong is by allowing veterans to decide where they want to get care. And giving them more choice, and i believe thats going to make us a stronger system. I think it goes along with, secondly, what dr. Rowe has introduced, which is accountability. For me accountability we have had this discussion with the chairman and the Ranking Member as well account ability its making sure if you lose your have i and your values you should not be working in the va and also that the secretary has the tools to recruit and retain the very best in health care and i believe we have among the very best Health Care Professionals in country working at the va today. Want to keep them there third is i want the system to be modernized. I believe veterans deserve the very best this country can offer. That means modern i. T. Systems and modern facilities and modern programs and professional asks and technology. Those three areas are what is driving the transformation of the va. Thank you, mr. Secretary. And i can say a i believe the entire Community Looks forward to working with you and making that happen and in light of the hour, mr. Chairman, ill yield back. Thank you. Thank you, mr. Chairman. Thank you, mr. Secretary and all those who are staying in the late ours with us. The hospital sent him a 36000dollar bill. This is someone recovering from surgery, already qualified and served this country and is over 65. That is shameful and wrong. We need a system where that cant happen. They cant send that kind of bill. I heard the same issue with er care. Again veterans getting the er bill, they dont know what to do. They are told they have a bill to pay. They panic. They dont pay other bills and they pay the er bill. Thats wrong and we need clarification about what these roles are. It should not take a 150 page manual and it shouldnt be that hard. On military suicide we are heartened to hear your commitment around that. I find its people who have not come in the system at all. You may have the best care available but if no ones coming into the system, i know our veteran systems are providing care for our veterans. We need to figure out how to reach out to these veterans because are not in the system. We are getting the calls in office. Weve had suicide calls coming into our office and had to patch people in and track down there provider. You shouldnt have to call your member of congress to get help. We need to Work Together to figure out how to bring people in so were not saying we have great care but you will never see her see it. One of the issues you will not see is women veterans. That needs to be a priority. We are integrated our forces. There has been unwelcome to news out of the marine in the last few days. If you want to talk about the damage that does to attract and retain the brightest, that does real damage. As we look at care outside of the system, those distances become an issue. My district is in connecticut and its role. The northwest corner of my state looks like vermont or maine. Too actually get to a va facility might be 60 or 70 mil 70 miles. We need to deal with that issue of where you might have outpatient that is really close, but actually what you need is further. I would like your feedback on whether or not we can recognize the difference between a facility thats within the 40 miles and actually what you need, and it may not even be that specialize. If youre talking women veterans, it may be more specialize. You have identified so many different issues but i dont know how to begin to address them. Putting your veteran in the middle with these bills, its horrible. I will tell you what to do. Call 18778778817618. That is the special hotline for veterans who are in a situation where they are playing tilt inappropriately we will get them out of that situation. On the suicide recognition, thank you for that. The va cant do this alone. We are strongly looking for community groups. On the issue of women veterans, its an oversight not to mention it as our key areas. Its the Fastest Growing group, we have done a lot but we need to do a lot more. Its not uniform across all of our facilities, but we are getting there. On our Choice Program, if i were designing a program, i would not have picked mileage and wait time as my criteria. I tend to think more critically about how you meet Health Care Needs of patients. Thats what we look forward to working with you, if i didnt mention it, we are very supportive of an Extension Program for choice but we want to come back and work with you on a redesign choice twopoint oh. We will have a better name for that we really want to get that done by september. Thank you and i see my time has expired. Thank you, mr. Chairman. Secretary, i very much support hr 369, the extension of veteran Choice Program. The remaining 1 billion of american treasure needs to be dedicated to American Veterans. In your testimony you noted congress should pass legislation to clarify criteria for veterans to receive care closer to home, to facilitate the development of a network of Community Care providers and to better coordinate veteran benefits. I would like to bring our conversation completely closer to home, all the way to the home. As you know, many of our most severely wounded veterans prefer to receive their care from their family at home. Specifically, as we move forward with what you refer to as choice twopoint oh, with an eye toward making a real difference in the lives of American Veterans that are seeking healthcare and needed, do you believe its in the best interest of American Veterans to expand the program of comprehensive assistance of family caregivers to include pre911 vets whereby they can receive their care from those that know them the best, their loved ones. Would you please give us your feedback. One of the parts of va that im most proud of is our support for caregivers. I think we have demonstrated when we send someone off for war, were not just sending them off, we are sending their entire family and family needs to be part of the solution when they come back home, and our support for caregivers is vital. As you mentioned, it was only authorized for veterans post 911. I believe it needs to be for all veterans, particularly our older veterans who want to stay at home, and then maybe they would have to leave their home for an institution. The cost of that program would be scored around 4 billion. I believe thats not an accurate reflection on the true cost. I think we will save money by not institutionalizing people. We are beginning to come back with a true reflection of the cost and i am supportive of that. Thank you for that answer. Its very encouraging. God bless you for that. As the lowest Ranking Member of this committee, i had a great honor of asking the last question and i yield my time. Im sorry. [laughter] you snuck in on me. Thats my boss by the way. Thank you for yielding. Mr. Banks you are recognized for five minutes. Thank you. Secretary its an honor to have you here. You answered so many questions and addresses so many issues. As a recently deployed veteran, post 911, i am especially interested in transition assistance programs, to get to the heart of the veteran suicide rate among post 911 veterans. What can we do at the outset. My personal experience was in the Navy Transition program which was attribute terrific prt benefited me greatly on my return home trip from afghanistan. What lessons have you learned about other programs in the other branches. I understand the navy has a model program, can we protect it or model it in the other branches. What can this committee do to support you with these programs . First of all, thank you for your service. I would like to work with you because it sounds like you have some experience that maybe we could benefit from. I do believe this transition period and the taps program is an area thats right for even doing better in and we hear too many stories where people just didnt think about the transition in the way we would like them to, and then they find themselves without knowing how to seek help. I was speaking to the president about this last night, and one of the things we are going to do a secretary mattis and i get together to talk about how we can get organizations to focus on this in a different way and d Work Together. With your input i think we would be better prepared for that conversation. I look forward to working with you on that. We have a number of veterans in indiana who are interested in alternative treatments like hyperbaric oxygen chambers or other treatments to the traditional treatments. What can we look forward to under your leadership in opening up new avenues of treatment . I was just in indiana last week visiting the vas there and toured the va with the governor. The areas im most concerned about are areas that veterans have a high rate of that today we do not have great stateoftheart treatment centers. Im not as worried about treating pneumonia because we have penicillin. In the areas i think we have to be looking for new solutions and treatments. We have established a new office called the office of compassionate innovation where ideas such as hyperbaric, where the va had traditionally been very close to having an opening to come in and work with them to explore new ideas. It so happened the very first one of these that we looked at and we granted access to is the use of service dogs for veterans who have ptsd or other emotional disorders. While there isnt, believe it or not, great Science Behind the fact that service dogs help, i think its common sense that service dogs help. We hear it every day from veterans. Weve started to make them available. Ideas such as what you are talking about, hyperbaric is a very interesting story. They have studied it three times and found a negative association but yet we are finding veterans who say they been helped by it. We want to continue to look at issues like that. Thank you. Im excited about your leadership and look forward to working with you. I yield back. To sheltie dogs and a bluegrass guitar keep me sane so i believe in it. We will have a roundtable later in the year. I had several meetings over the recess, and just yesterday on trying to bring a lot of the people out in the community who are working with veterans, try to bring together and coordinate some of these efforts. There are many people, ive met with three people in the past four days, theyre doing something over here and over here but lets get everybody around the table and figure out how we can coordinate this with the va. Gentleman you are recognized for five minutes. Thank you. I am last, right . Thank you for being here tonig tonight. Just before coming in i had a town hall with 2000 people dialed in. About 50 of the questions that came were related to veterans. Michigan has a higher than average percentage of veterans. Weve got a lot of folks in our district that laid it all on the line for the country and we need to laid on the line for them. By the way, mr. Missile, did i get it right . Thats how you pronounce it. Okay, just wanted to make sure. Pronunciation counts. In your written testimony you discuss how the va accounts for Community Care expenses. The topic is extremely complex. Let me try to state in laymans terms, as i understand it. Im a marine. Currently the va estimates how much each individual episode of care is going to cost and set aside funds for that care. That doesnt happen quickly or accurately. When the estimate is too hi, the excess funds remain set aside in the va have to do an adjustment to put them back in the pot. Those adjustments dont happen very quickly either. The department wants to change this to stop estimating each case of care and do one big estimate at the beginning of the year. If we allow this change, but they dont get more accurate in their estimates, what are the potential downside consequences that could result . They are pretty significant downsides. Accounting for dollars in the community would be seen as a material deficiency in the audit that we conducted of the financial statement. Obviously, as you get into estimating, its very tricky. By doing it at the beginning of the year where youre doing it as a more broad task, you could have more issues than you when youre doing it casebycase. You also mention that the report that was released publicly that included shortcomings within choice, particularly that most veterans reviewed were waiting an average of 84 days to receive care. Your staff informed the committee that it provided va its findings around august of 2016 for agency review. In the seven months from when they were provided to va until the report was released publicly, did the oig make any substantial changes to the findings, and if so what types of changes were made. We did make some changes. Our process, when we finish a report, we do say share a draft with the va. We want to make sure we get it right. We did meet with Senior Leadership to talk about it, we wanted to clarify some things that i would put it more in terms that we didnt change our findings we just clarified to make it absolutely clear what we have looked at, what the methodology was that we used, and any comments from va. The under secretary responded with some comments that are included in our report. I yield back. You are finding out its always good to do a town hall because you never have to answer any questions. When you are here he never has to answer any questions. Lets take some things weve heard. Number one, we all believe we need choice extension sooner than later. Number two, i think we need the choice consolidation, and what im hearing is a reform of the Choice Program and i will ask a specific program. Number three was a wrath of fresh air to hear that there can a quit developing it and try to be microsoft or apple and let some of the elves do that. We will absolutely work with you. I think if we can accomplish getting the it started and those other two things it wouldve been one of the most successful years in va history. I believe that. I think we can do that. We know where weve been and we know where we are now. Id like to hear, you tell us what youre personal vision is for transforming the va and how we can be of help for you. Thank you. Having sessions like this where we really do get a chance to share opinions is an important start because any solution will have to be all of us wanting to get this done together. I think the vision for the va is to transform this organization to be a veteran centered organization. Its not rocket science. You have to have the right people caring for veterans. I think we are very fortunate that we have a great workforce but weve all seen examples where there are people that shouldnt be working in va and its been too hard to get them to leave. I think your accountability bill is an important step forward in that. I also need the tools, and i appreciate your willingness to consider both the carrots and the sticks because thats the dual part of accountability, getting the right people in the door and getting the great people to stay in the organization. I think we need to transform the culture in many ways that we learned our lesson in 2014 by having the wrong incentive systems in place by not having management understand their jobs and by not being transparent enough. I think we need to change our culture that way. I think we do need to put the control of healthcare back into the hands of veterans so its their choice on where they get healthcare. They are the ones who make their appointments. They are the ones that say whether were doing a good job or not and we have to do that. Finally, the last piece, as weve talked about several times, is modernizing the va system. Is probably not enough money to completely modernize the system so we have to be creative. We have to Leverage Existing Technology thats out there in the market. We have to partner with our Community Partners to provide the right types of facilities. It may mean the va will not build as many brandnew hospitals but working with Community Hospitals to share resources with the department of defense and other facilities. Its doing differen business di. Its being willing to take some risks that we havent and i think us doing it together will be the right formula for success for veterans. You are thinking consolidation on the private side. Yes. Just a couple quick questions. You believe, i dont think there are, but you think the Provider Networks are robust enough to provide care for veterans in a timely fashion . I think weve come a long way, but i think we have much more to do. Our vision is a network of providers that have made commitments on the service side for caring for americas veterans and thats what we want to work toward developing. I would suggest that you and i take the suits off one day and probably go to the va and put our stethoscopes back on and go into an exam room and find out the frustrations. I would say if you are back in the exam room and you had a patient you felt needed to see a cardiologist or rheumatologist, and how hard we just described how that is in the links of times people go months to get an employment, the rest of the ha hair, the few that are still on my head, would fall out. I wante you to tell me, if you e making that appointment, what would you expect to happen . You just gave me a softball. Im inviting you to join me next time i put on my stethoscope because i see paents in manhattan and oregon. You can decide where you want to go with me. We have focused on making sure urgent care is delivered at the right time. Thats where we have sameday access in every Medical Center for Mental Health and primary care. We are focused on getting stat conflicts down. There are less than a hundred across the va. Its a functional zero. We are working to make all of our Specialty Care more accessible but we do need to use Community Care to do that. My time has expired. Wim going to open it up for a second round for one minute. The chairman will be very careful about the one minute. Mr. Walts. Thank you mr. Secretary. Your vision is where we are all out. I appreciate it. Know that we are here to give you the tools. We will have our discussions and have family discussions and deliver you something. The Veterans First act, we want to give you accountability but im glad you mentioned. What i can tell you is we will say we will remove people fast, but without hiring and due process, these wont give you the tools. We will work to deliver that but your vision is solid. We been followed online by a lot of folks watching who care deeply about this. I can tell you the veteran suicide issue resonated. There was a Military Spouse who said im a wife and a mother and my brother and father have served and my son will not ser serve. I appreciate the chairman being there. The folks sitting behind you have your back and theyve been out there. Lets get this done together. Thank you, mr. Chairman. There have been many incidents of issues related to veteran care in which the va has attributed those values to poor training. An emphasis when a va is engaged in criminal activity such as fraud, falsification of patient records or failures that have led to patient harm, are they authorized to investigate . Yes we are. Under the Inspector General act of 1978, we do have the authority to work with the department of justice and other lawenforcement to bring criminal charges. We have done that on a number of occasions or the years. Host very good. Thats what i wanted to know. How do you prioritize these particular cases brought to your attention. We looked at it in a number of different ways. We look at the extent of the harm in the number of veterans impacted, the amount of dollars impacted, how long the conduct has been going on. We look at a variety of different factors and try to prioritize the one that are of the most serious nature. We are hearing from veterans online who want to ask you questions. Many of the questions are about healthcare. What can we do to ensure access to Mental Health care and how can we recruit and train providers. I think we are working on two things. One is, we need to hire more Mental Health professionals. People following us on mine, if theyre interested in coming to work for the va, we are interested in talking to them. We need about a thousand more Mental Health providers. We are leveraging our areas of the country where we do have a good supply of Mental Health providers which are what we call our hubs for tele Mental Health so were providing those professionals to the more rural areas of the country where we dont have the providers. We are trying to leverage it that way. We are working with Community Providers. At sometime i would like to ask about the medical school and how we are using those but my time is up. Thank you again for your service to this country. The one question i have, doesnt the va, ive read that the va has a certification system for Mental Health professionals within the community, outside the va where they can be certified to deliver care to our veterans. I think you mentioned your concern that the average provider of said va may not understand the culture of the military and thats a real concern. I wondered if you could explain how this certification Program Works. We are doing outreach to our Community Providers to make sure they do have the education and the materials to be able to see veterans. This is part of our concept of our goal to get providers in their who want to and are committed to see veterans. It is a formal certification process, is it not. Yes. So tell me, can you give some metrics in terms of how that program is going right now. We have a number of providers to take care of that. I can get you an more information on the number of providers. I think that is a multiplayer capability, in terms of having resources and certifying them and making them go through a process, a training process where we know they meet the requirements for the va. I think we have more work to do on formalizing the program but thats the direction we are headed. He recognized for one minute. Thank you, mr. Chairman. Mr. Secretary, i would like to say you must be a real man of action because the Mental Health service dogs for the mentally ill, there are members who are suffering from ptsd and pdi were told three years ago there would be a study to determine the efficacy of it, and at the end of the three years they said it would be another three years before the report will be finalized. Youve done it in like 30 days. Let me tell you about the study. It will be another three years before we get the results but im not willing to wait because there are people out there suffering. When they did the study, this is what i learned. Like any good study, there are two arms. One that should be with dogs and one without dogs. They couldnt find a single veteran not willing to take a dog. I think that tells you something right there. I said give them all dog. Thank you very much, because i can tell you that is going to be a resounding success back in my hometown. God bless you. Thank you very much. Let me go back again, i dont mean to be disrespectful in any way. I know you said he looked another rule areas, im talking about my area, my districts of the northern islands. They have experience in rule areas that are not the same. Im asking you to consider looking at the veteran experience in the outlying areas like my district. You are out of hawaii and we sat down for an hour and a half today. Its been a while since anyone has been. I would like to work with you again. Thank you. Im going to yield my time to the doctor who i rudely ignored the other moment ago. I want to go to something about the gmc residency program. As you know, most doctors in america spend some time in the va as part of their training. What are you looking at with that where we can be of help as far as what specialty we may want to engage with further such as in Mental Health, but also association with academic institutions and making those more robust program. We are doubling down on our relationships with our academic centers. We think its one of the best and strongest features of the va that benefits not only bas but all americans in the way that we train our healthcare professionals. The Choice Program, as you know, gave us the additional spots and weve taken advantage of those. Almost all have gone to Mental Health or primary care. We believe we could still do more. I would like to look at how to get them into the role part of the countries that dont have teaching programs. That would be a big addition to helping us increase the quality of the environments that our veterans get care in. We would like to work with you for ways to expand it. As you know the country needs more medical education spots. Somehow, that formula will not work out if we don expand the e spots. Im a veteran, i represent a portion of my state, my district with the highest density in the state. Only about 20 of my fellow veterans regularly access the Healthcare System. Weve seen improvements in the Choice Program and im confident it will allow greater access to healthcare for all veterans if we penetrate that number and help more have access to healthcare that they earn and deserve. Have a high degree of confidence that tomorrow the sunset window will go away and the billing in dollars will be invested as it should in the lives of our veterans that have earned it. Will you work with this committee and this body to help us develop a further Choice Program and continued improvement. Please share with us in the remaining three seconds, a resounding yes. Yes. Thank you, sir. I yield back. General bergman you are recognized. Congratulations, you are now the dog that has caught the ti tire. Some of the rest of us are in the same vote. The vehicle has multiple tires and theres a lot with our teeth into it right now. I believe it has some visibility within the veterans program, a proposed data project, cherry tree out of michigan that involves not only healthcare for veterans but education, jobs, housing, and im looking to working forward with the Veterans Administration to bring project cherry tree to a level that gives a good look at whats possible. We are all in this together and the result that we are going to achieve will only be limited by our desire to achieve them. Thank you very much. I yield back. Thank you all. The question now have ceased. I want to thank the panel. You have been very generous with your time. I think you can see the interest for a number of members who have stayed around this long and the folks in the audience that have stayed. It is truly one of the most important things we will have tasked to us as congressmen and women, to help make the va. We learned what the problems were pointed those out clearly and weve had help with gao and ig in clarifying that. I think now we need to solve the problems. I look forward to doing that with you all. They are huge and not easy. I understand that. Weve mentioned and brought up a lot more tonight. I am optimistic and more optimistic after tonight heari hearing. I think we all have the oars in the right and we are pulling in the same direction. I think that will get some results. I ask unanimous consent to submit to the record a statement on case study work on choice. That is so ordered. To have any closing comment. I do not i would just like to echo the comments that we are in this together. We are grateful. The right people are on the bus. We are here to do what we can do. Thank you for all your work. I ask unanimous consent that all members have five days to extend the remarks. The hearing is now adjourned. [inaudible conversation] [inaudible conversation] [inaudible conversation] [inaudible conversation] your documentary has been selected as this years grand prize winner. Seventh and ninth grade sisters ava and mia lazar were selected. Their winning documentary explores refugee and immigration policy. A refugee is defined as someone who has been forced to live his or her country due to persecution war or violence and cannot return safely. With so many people leaving the country, policymakers are arguing over one question, should the u. S. Allow more refugees into the country . This year we asked middle and High School Students to prepare documentaries asking what is the most urgent issue for the president and administration to address in 2017. They competed to win one of 150 probabl150prizes totaling 150,n prizes. We received 3000 entries from 46 states and the district of columbia, england, germany, singapore and taiwan. Now we are happy to announce our first place winner. In the middle School Category come the first prize winner is a failure Molly Doherty and ava decker in scranton pennsylvania for their documentary u. S. Gun violence, a complicated puzzle. The first place winner for the High School East category is 11th grader Matthew Gannon from washington d. C. His documentary was titled invisible which deals with homelessness. He also won the fan favorite contest but he will receive an additional 500. In a High School Central category, the winner is 12th grader jared clark from the high school in royal oak michigan. His piece entitled enough is enough dealing with pharmaceutical pricing. [inaudible] congratulations to our winners. Thank you to all the students and their teachers for competing and making this years student can competition a success. The top 21 winning entries will air on cspan in april, and you can watch all 150 winning documentarys online at student cam. Org. Cspan, where history unfolds daily. In 1979, cspan was created as a Public Service by the Cable Television companies and is brought to you today by your cable or satellite provider. The House Oversight and Government Reform Committee held a hearing on the death of an immigration and Customs Enforcement agent in the line of duty and other controversial operations regarding the bureau of alcohol, tobacco, firearms and explosives. Several representatives did not appear as requested for the hearing. The chair of the committee issued subpoenas on the spot for the absent witnesses. This is about two and half hou hours. Ome to we come to order and without objection there declaring a recess at any time. We are here to talk about atf failures in the death of ice agent. There is nothing more difficult than dealing with the person who