Coverage for example in one market where we are the narrower provider we found they had no access to pet scans. Another glitch we found as their exclusive Network Provider they had not contracted with any Lamp Services or radiation therapy. We can provide these services but frankly getting Outpatient Lab testing at your hospital may not be as convenient as some of the labs that are available with better parking and hours. Finally id like to reemphasize the reality of the marketplace is that price dominates. Premiums is what people are most likely to look at. Those with low income still leave outofpocket medical expenses that are unaffordable below this operation. As a result, even modest out pocket costs create affordability programs. This is from one of our markets. A married couple. Income 48,000 a year. They chose a bronze plan. Their premium is subsidized. They have a 3,600 deductible and a 12,000 potential outofpocket maximum. If one of this group needed a jant re placement or hthe premiums, deductibles and expenses would result in 30,000. These high deductible plans not only are they unaffordable but they lead to poor care. Its well documents that when people lay seebing their care or they will have difficult adhe adhering to the treatment plans when faced with large outofpocket costs. Moving forward its important to develop policies based on antitotal information. The reality is that we need more rigorous information. We need to know whats working an not working around the nation. What works in one community may not work in another community. The one priority we have for education providing transparency for the consumer. So they know how available these providers will be to them. How much cost shares and the quality that can be provided by those providers. Is this more rigorous information. We believe its important to remain flexible to respond to any egregious situations coming up, responding with compassion to meet the patients needs as best we can. Thanks catherine. Lets turn to brian webb from naic. Thank you very much. Good afternoon everybody. Im with the National Association of insurance commissioners. We represent the commissioners from the 50 states. Washington d. C. , which just became more important to some people in the room last year. Also, the five u. S. Territories which is clarified last week are not states for title one of the Affordable Care act. One of our jobs to develop model law its, rules, regulations that states can use. Were bringing stakeholders from all over is number 74. The model advocacy act. It with a developed in 1996. Looking around the room it looks like half of you were in ginter garden. Were looking at it again see iffi ing if it needs to be updated. Making sure carriers when they set up their care is that theres reasonable insurance that somebody can be get to in tough numbers and types in a reasonable amount of team states can look at the networks to make sure that that definition of reasonable is reasonable. When you look at the time it takes people to get to them, any waiting periods, any distance issues that you make sure that everybody can get to somebody in a sufficient way. If not, if there is an insufficient network the carrier makes sure the patient can go to another doctor or provider and that they would be not charged more for going to them. They require the carriers to file an access plan with the commissioner prior to offering the new managed care plan. What goes in that is a description of the network and also say how they are going to monitor the network on an ongoing basis. What their egregious procedures will be if somebody has a problem or question about the network. Notification. How do they notify if theres a change. Also, the continuity of care if somebody is dropped how are you going to make sure that person gets the care they need through that provider or a separate provid provider. You want to make sure the contracts being set up are done in a zrim toor way. You want to make sure they are basically giving inducements to providers to make sure they cant discuss certain kinds of care. All of those are rolled together in our model act. About ten states have taken and adopted our model verbatim. Taken it just as it is. Another ten have something similar. Even in those 20 states through guidance and other adopted concepts. They work with the carriers. The carriers do use a lot of these standards in developing the networks. If you want a copy go to store and free. We also have a paper that we did on this going back a couple of free interest. We have set up a sub group that is currently doing regular phone calls. They are open phone calls. Anybody in this room is sit in them if you have Nothing Better with you to do with your lee. You can do that. Anybody and everybody can provide comments. Suggested changes. However you want to do it t. Weve gone through the carriers, providers, consumers, of course. Others that have come in and brought us our ideas. We will soon started the process that we need to update. One is the concept of essential community provider. Thats not something we were looking at before. Are those included in your networks. Are we applying it to all managed care. Some states only did it in the old Network Types of plans. Do you go out to ppo. Go out to everybody to pab sure everybody is doing with a they need tow dough. Were having another meeting at 1 00 on thursday when we start looking at amendments. We started receiving comments and we will see where we need to update our model. If you want information, the webb site is there. You can go and get the exact call in information. What are the issues . One is the flexibility to reflect state needs. This will always be our number one point we dont want a federal point. The government comes in and says this is exactly same and distance for each type of provider. I dont know about you but tw e wyoming is a tad different than los angeles. What about certain populations and maybe very populace areas but maybe some transportation issues. States have been looking at these issues and are best to address these issues given their needs. We need to balance. Theres no sense of going in because we need to balance quality, affordability, access. How do you do that in the model and make sure everyone is protected is our number one concern. We will be looking at teared networks. They are if you go to this group you pay this much, that group, this much. They are teiered up. How are those set up . Narrow networks. One issue in particular well be looking at in a couple of states, carriers said if you purchase in the state, we will cover you either as in network or out of network. If you go to any provider outside the state, we will not pay nothing. Not covered. Were going to have to look at that. Well also have to look at provider updates. I think that was already addr s addressed here. Cant have a free market when people cannot get access to information. We had that this year. It was a rough year trying to get plans on, get it run and get it out there. Weve got to do about thor open enrollment period. Consumers need to know if they purchase that plan is their provider in there or not. They need to have clear access. To tell you the truth, provide kers groups needs to make sure everybody has the information they need. If there are updates that those notifications are going out so the consumer is well aware of what their options are. We do want options. There are many plans and we will have more plans on the exchanges next year across the country. Are some of them narrow . Some are not narrow. Do people know the differences and accurate Consumer Education. Do they have the right choices before them . Another issue well be looking at is the surprise bills. How many of you like surprises . I like surprises but not when its a bill. This is when you go in for a procedure. Your doctor is in the network. Your hospital is in the network and your anesthesiologist is not. Thats called surprise. Youll be charged higher for that. States have been doing stuff on this n. Federal governments will be looking at to make sure of that. I will leave you with this last slide. If you have any questions please call joel ee. She was spupposed to be here. If you do have any questions, please call her. Shed be able to help you out. If you are you interested in this, please, join the calls. We hope to be done by november of this year with a brand new model states can use to update their procedures. If you want to be apart of that and know whats going on, jump on the calls. Wide love to have you. Thanks. Brian has agreed in the course of a q and a session. You now have a chance to join the conversation. Im going to exercise a little bit of prerogative to clarify things. At the appropriate time you can fill out a card thats in your pocket. You can also go to one of the microphones that are in the room. You can tweet a question using it the network so youve got all sorts of channels. What i want to do is a factual clarification. Weve heard a lot about in network and out of network. How many people dont know the difference between in network and out of network for purposes of this discussion. The question is is there a typical pricing pattern . In other words whats the penalty maybe not out of state being zero but in a typical plan if you are in a Narrow Network and have to go out for some reason or think you do, is there a substantial differential or is it fairly nominal . How important is this is what im asking . Dan, do you have any sense of that. Sure, again, i think its critical from the point of view providing value to consumers that we allow these High Value Networks to be a choice as many of you heard from a number of the speakers today many consumers are buying based on premiums. To get that down to an affordable rate. Its a choice there. If youre in a plan that does have a specific net whork then there are certain requirements to go outside that network. Plans say you cant do that but they will work with the individual on their specific needs. If theres a particular type of specialist that simply is not in the network and the plan has an on liging obligation to work with that customer to provide that medically necessary service. Part of it depends on the type of plan. If youre in an hmo that does not have out of Network Coverage than its far more restrictive than if youre in a hmo with point of Service Coverage but i think the differences are substantial. I think they have to be for the Narrow Network approach to work. Its not just that youll pay a higher coinsure fans rates but you wont be benefitting with the insurers negotiating ability if so youll be reliable for beyond what the insurer allows for in addition to the coinsh e coinsurance. The coinsurance counts but not what we call the balance billing. Okay. Do you want to identify yourself. Sure. My name is daniel davis. Im with the administration for Community Living in hhs. One of the considerations that were looking at quite a bit right now is the access to providers for people with disabilities in Narrow Networks. There are considerations where theres been a number of studies on subspecialties where theres 20 to 40 of providers according to secret shopper test that they dont serve mobile patient disabilities. To what extent do aic and the private Service Industry taking that into consideration and making saur there isnt inadvertent Health Discrimination . With the neic that is something that has been raised as an issue. Its something we need to look at. Its something that state regulators need to look at when they are reviewing the various plans. Not just that but especially with mental parity and things coming on. EnvironMental Health, et cetera. Theres a lot of issues that we need to take into consideration. We would agree. I would just add that networks very hard to comply with all the laws, rules, regulations. They submit their plans for review. They are approved in the state and if they are qualified they are approved by the federal government and are certified. They have to meet the standards set in leg rags to be able to meet the requirements. If you dont meet those youre not able to be in the market. Having the gentleman asking that question reminds me of a question that was submitted in advance that is related. It makes reference to the fact that the administration had communicated with plans not so long ago that they were going to focus on areas that have and the question actually votes historically raised Network Adequacy concerns including among others Mental Health providers. Do we have any elab rags of how the current discussions where the current controversies is for that matter deal with Behavioral Health issues. Kcatherine do you have anything to add on that. I would just add that clearly thats a consideration. We focus so much on first the what are the physicians and the hospitals in those networks. That becomes the bulk. As brian pointed out than you have the anesthesiologist. My point is theres also outpatient access that needs to be considered. Mental health. Home health. All of the care continuum for a network to be successful has to be considered. I absolutely agree with your point. Im dr. Caroline poplin im a primary care physician. I have two questions. One in the satisfaction surveys that i think you presented, did they break out people with chronic illnesses or people who have had a serious illness in the last year versus Healthy People paubecause most people a helmy most of the time. If people dont lose their network they will be received with. It sounds like each Insurance Company in an exchange are required to present a variety of plans maybe bronze, gold, platinum. People get very confused when they have too many choices. When they have five Insurance Companies offering 50 plans. Thats hard to deal with especially every year. In part d there was a study that most people didnt change their primary plan. They just kept the same plan year after year even though it wasnt the best plan for them. First on the Commonwealth Fund survey that i mentioned in my survey was very comprehensive. I dont have the actual data in front of me but if you go to the website you can see or whether it separated the specific operations because you will get a different answer from different people. That survey also included those that actually have used their plan too. Theres data on that as well. I encourage you to go to their website. It is very kprocomprehensive. With regard to your second question. Could you repeat that for me. Do you worry. About the fact that people are going to get confused having too many choices. Each one has a lot of information. Had the part d experience hasnt been all that reassuring on the question of whether can make a good choice. Thats a very good question. It really depends on the individual. Some are very savvy and sophisticated about looking through the websites and finding whats best for them. Thats why the aca provides more navigator assisters. You have broke trerz as well. Others that can help the individual review plans and make the joyce thats best for them and their families. Health plans are doing a will the too in terms of basic education to help individuals make the best choice including cost calculators are. If you know youre going to have a specific procedure what your outofpocket costs would be for that and the like. I think the structure of the offering defined by value probably helps consumers a lot going through this because i suspect that most consumers first decide what tier what medal they want to get so the number of plans arent as great. Actually wanted to followup a little bit. One of the questions that has been raised at least in the material its that have been given out. Presumably they arent two Different Things. There is a blend. There is a range of narrowness if you will. Are there some standard formulations that are being used either on the marketplace websites or among the plan its that can help people who dont deal with this kind of term innologist everyday to understand which of the choices they are making along that spukt rum. I can can answer that. In reading the mcenzie im thinking there is nothing like this out here. They came up with their own definitions whether it was ultranarrow or just. I probably it would be a good idea go forward in the same way that we have four medal tiers of plans to also they will be arbitrary but say that a kplan has below a certain plan of providers is called a Narrow Network plan. Consumers can put some aside. There wont be standardization but it would help the consumer simplify their search. Any talk about that . Tirks not at this time as far as nor model. As far as choices and information, i think states would like to look at. In the past weve seen carriers really try to hide things like that. They want information and distinguish between one plan and the other. How thats done and how clear it is, well work toward that. Its probably not something in our models specifically trying to standardize it in any way. Models do provide a standard benefit of coverage on healthcare. Gov. That provides Important Information to shop around. Theres other information on healthcare. Gov, new information will be coming in the future specifically with regard to quality and consumer satisfaction. Were currently building that in and working to produce that. You know, i think just with part d it will take a while for the Website Health care, healthcare. Gov can provide information that it needs to. I think in state based exchanges that states have tried to do too much and ran into some real challenges. A lesson learns there but plans are committed to providing the necessary information so consumers can make the best choice for their families. Lauren kennedy. My question flows nicely. Your last comments which is i wonder if any of the panelists can speak to what can be have been sub is hesful strategies specifically with regard to Quality Performance data. I think it was in everybodys presentation that this was a key criteria but also the consumers ability to access that information, understand it and use it to make informed choices. Specifically with regards to exchanges. How do we support consumer not just planned performance so being able to rate plans based on quality data but also consumer access to how providers are performing on quality metrics. We would make the choice through narrow choice that consumers have a distinct interest in understanding how individual provides are forming in a way thats consumer friendly and understandable to them. No one disagreed apparently. Its not an argument. I wonder if youre able to share some strategies that youve seen successful or contemplating in order to propel this type of consumer access to provider and facility level. Can you do it directly or do you have to do it by in feskt requi, effect requiring the plans to provide data in some way. I did notice that two of our panels organizations together were promoting the idea of standardizing quality measurements. I think that as we get better at measuring quality and as we get some consistency, than it will be far more possible for plans to really advertise or inform about the quality of providers in their network because ultimately what you said, i think what matters most to people is the quality of the provide certifies. Paul, is it a Fair Assessment of the stateoftheart that the people who measure quality arent very happy with the state of quality measurement . At this point, yes. Yes. I think theres a consensus on the direction of the getting rid of a lot of the process measures of quality and replacing them because now we have ability to do more in the way of outcome measures. Catherine. I believe we would advocate for collaboration and make it more universal as i stated earlier. So many different ways of measuring quality. With so many different ways you get completely different conchugss mco conclusi conclusion. You dont get conclusions as to who is providing the best quality. I think this area needs to be personal. Can i ask just one followup. Do you feel thats best done in the private sector, Public Sector or in sort of collaboration with both if were sort of aiming toward better alignment and standardization. It will part in multiple areas public and private. I think the ultimate goal should be be single. It should be something that were all accustomed to and understand. I think in the interim we will work with insurers to help narrow the number of kwaquality indicators but make them more understandable and comprehensive. Let me digress and say that the man who runs the United Hospital fund of new york city once observed because of all of these various rating systems, new york city contained 40 of the top 20 hospitals in the country. In the Mental Health field, a lot of services are provided by peer support both in Mental Health and substance use. In an aligned area, can be provided by Nurse Practitioners and physician i guess its too fast. Its of the same issue. Is that something that they are lacking at in the revised model. Its not something that we will be looking at. We tend not to get involved in who provides the care. If its something youd like us to look at, yeah. You he tknow its not something the past weve dealt much with. I. I wonder are there states have taken steps to define adequacy to include some of these nonphysician providers . Anybody know . Theres a crowd source question for you. If anybody knows the answer to that question we will send it to us at healthcare. Gov. Im a consumer and care giver. Catherine, you come across conveying caring for the consumer and yet lamenting that your Narrow Network lacked an Outpatient Laboratory that the Narrow Network included a Hospital Laboratory but it didnt seem easy for the consumer related to parking issues. Which i totally understand but it would seem that they have all of their information that that thrill parking ticket can be valuated at the lab so it would no necessitate hiring outside the lab. Thats a simple thought bubble i would have. Appreciate that. Wed be happy to serve all lab testing there. Even just getting them from the garage in. Some folks have trouble walking frk that parking lot up to the entry. Folks may not want to come to the big hospital campus. They may want to go to the quest thats sitting half a mile from their home. Most of the parking lots that ive been in for hops, they have a button as you enter the parking area if you need assistness. Sure. Wed be happy to buy that. Im a pediatrician. My background is also that i ran epsdt in the office of child Health Working for a man by the name of leonard shaffer. Obviously my question will be on pediatrics what are we really doing for kids that absolutely must have terariy care and so on. I just talked to a man who had a child born with a very complex Heart Disease that wanted to send his child to a surgeon who hadnt done any heart surgery on kids in about ten years. We luckily got him into a childrens hospital. So how are you addressing these things especial ly with kids wih very complex needs. I think thats where choice comes in. In this current marketplace, theres a lot of choice whether you want to choose a very Broad Network or a very Narrow Network or something in between. Its important that consumers have the right information so they can make the best choices for their families to get the care they need. I have an answer to the question. This sounded like a case of the need for a very speedy appeals process to provide access for very specialized care to those providers who are really experienced at it. In the various work ive done over the years in health care mark tets, one of the observations is that often the pediatric ophospitals are by fa the highest cost in the area. The inclination to make a Network Without them. Irk i would just add Consumer Education and involvement. Yeah. If i could just add to that because often the departments of insurance, the commissioners do get involved. They work very closely where the consumers to see if it is insufficient to resolve the issue. Did you got to deal with this situation wi situation. Thats why there is regulation just to make sure that frerve can everybody can resolve the issue. Most often it does. If i can ask you to forebare. I wanted to followup with a question on a card. I should say we have enough cards to carry us through tuesday of next week. You might want to use the microphones if you absolutely positively have to get your question answered or addressed. This one is directed to you, brian. Whats the naic position if there is one on mid year network removal as were seeing with the Medicare Advantage plans and want to go back to the Medicare Advantage pant but what happens when you sign up for a plan that has the physician you want and then she or he drops out halfway through. In our current model deals with that by making sure everybody is notified of those changes and then make sure if theres an issue of continuity of continui care. We dough have a policy here. We are going year after year. We are looking at how that can be resolved if something needs to be done there. We have no position on yet whether it should or shouldnt but it is something were looking at given the new environment. Ed do you want to comment on that . Is there a general industry practice for that kind of situation . Well, he mentioned Medicare Advantage. Their plans are under extraordinary pressures. You know the aca reduced payments by over 200 billion over ten years for ma plans. The administration has added some additional Cost Reduction on top of that through the regulatory process. So plans have to find a way to provide value to consumers. Some of that is by, you know, taking a closer look at their networks and see if he there are ways that they can, you necessity, tailor their networks to provide value to consumers. Theres a lot of discussion about adequate notification to consumers. We feel that is important. Were working toward that goal. Im not sure how we get there but i think to the degree that i believe limited Narrow Networks are going to be april important part of the landscape for a long time, we should start thinking about how to move the system so that all Network Agreements between plans and providers conform to the dates of the plans so fp they are on a calender here so this issue of dropping out the network would be very limited to a provider that got out of practice or Something Like that. I will just add too which i think is an important part of this debate there have been numerous studies out there that show tremendous place variation with little or no correlation to quality. So that is something that we have to take a close look at. Plans are trying to deal with that by saying lets focus on those providers that provide value. Given the tremendous price variation in this country you can provide Good Quality Service by finding the providers that provide High Quality Services at a lower price. Thats the premise behind doing networks that are focused on value. If we open it up to everyone were stuck in this fee for volume type system which we all agree we have to move away from. This is one of the ways that plans are helping to move us toward a value based system. Jeyes, sir. That was actually my tweet and youve answered all of my followup questions now. I will sit down. Let the record show we respond to tweeted questions. Go right ahead. My name is martial. This question is for brian but going back a couple of questions when you mentioned stepping in that pediatric example when a network was termed to be inadequate. What other tools do you have at your disposal when they are determined to be inadequate. Are their bans on them offering to continue insurance in a state or do they have to promise to get better or improve the problem. It depends on the state and whether its actually in the law. They will file their plan at the beginning of the year whenning they are saying we want this plan. They will file their access plapla plan. The state will look at that. If they dont approve that they will ask them to refile that. During the year if there are a lot of grievances and issues, then of course the state as the regulator can step in and talk to the company. Can ask them to make some changes to fix issues. Eventually you could find them and width drawl their license. You have all of those at your disposal. You talk to the company and usually you can resolve issue that way t. Youve have said they can provide that product in that state. Bob with the institute of community health. There are two issues that i havent heard addressed so far and yet they are trends in the health care marketplace. One of them is concierge medicine. How will this focus on Network Adequacy deal with doctors who want to collect a special fee just for the privilege of going to them. Secondly, the subject of conscious clauses since we have a representative of the Catholic Hospital systems, when providers choose not to provide certain fda approved it medical services, what obligations does the health plan or provider have to ensure that that patient is able to get the medically necessary treatment that they want . Im not sure that the provider has the soul responsibility here theres a matter of disclosure up front about what providers are providing what serve sises. People do sign agreements and waivers. I may be wrong on this and id be interested on dans comment but if youre a plan you have the responsibility for making sure the services are available through one or none of the providers. It really depends on the state. Theres a lot of variation on this particular issue. Okay. Well, i will comment generally that, of course, being our mission base we would not provide ethically we follow ethical religious directives but as patients and families ak is hes these plans and our services, its expected to get them the access that they need. How do you do that if youre the only hospital in a geographical area and a provider and you decide that something is not consistent with your religious with the providers or the owners religious beliefs how does the patient get the medically necessary treatment. I cant comment on all. I can tell you in our markets, were not the Soul Provider in our markets, i dont want to belabor it but we are getting a little bit off the question of adequate network was at the plan level. I want to make sure that we dont miss out on the opportunity to get to these questions. That means calling on you at the moment. Thank you. I represent a number of provider organizations. This has been a real terrific panel discussion. Im glad the topic of Network Advocacy with respect to plans has been brought up subsequently there is adequate networks of providers. I will add that senator sharon brown has introduced legislation pertaining to those midyear terminations but on the topic of Network Adequacy. I know the question was raised what do you do if you determine a network is inadequate also importantly what are the tools being used to ascertain whether or not a network is adequate. Mr. Ginsburg you raised a very good point at the beginning of this conversation. I would welcome a response from mr. Durham or mr. Webb. If a plan looked at its network and says we have 30 ophthalmologist and they are looking at the specialty z. Should they be taking it down to the cpt level to find out do we have an adequate number of retina specialists in our network to be caring for patients with specific needs. Ive heard of health plans using the g it so id welcome any thoughts that they would have on, you know, ascertaining whether truly there is Network Adequacy. Let me Say Something quickly about subspecialties and move onto the others questions. Were in a lairing process but how to regulate and have trance par transparency for limited network plans. I know this fairly well about the issue of retina specialists was raised through the academy of ophthalmology it went to the insurer who just responded. Oh, we didnt know that. We will make sure to put retina specialists in the plan. Its discovery this is an issue. I would say yes, the detail thats going to be needed in some specialties probably will have to go by subspecialty. It will make it more complex but this is going to be a big part of our market environments so we mine as well just do that. It does very by state but some do a deep dive and they go down to subspecialists. Not Medicare Advantage. We dont get to write that. Were excluded. Go right ahead. My name is jesse bushman. Weve been doing a survey of the plans that offer exchanges through the plans calling and asking about the inclusion of midwives in the plans. What we discovered is those that responded to our survey which is about a third the plans, 15 of them flat out do not include a nurse or midwife in their network at all. About 40 do not cover Birth Centers either and 35 do not pay the midwives the same rate that they pay the physician for the services provided. Cns stayed away from what types of providers need to be insured in the plan. My question is in our case, the cnns are attending 8 of the births that occur in the country. Which is fairly significant. Maternity is part of the health package. I would look at that and argue that thats a provider type that should be included in a plans network. Im wondering how you make sta s decision about what types should be in their network or not. So my question is where is the line and how do you decide when is a certain provider type necessary for inclusion in your network . Is that an naic question brian. No, we checked to see if all the ones required by law are in there. Thats what we do. Dan, youre the default second place answerer. Sure. Again, we talked about this previously. To be a qualified health plan, plans have to be certified. Part of that certification process is review of how they meet the Network Adequacy standards. If you dont meet those standards, youre not a qualified to participate on the exchange. This year they required health plans to submit a lot more information in terms of who is in their Provider Networks, the names of their doctors and the like. They have all of this data now so they can do a test of using the software that they have to make a determination whether or not they believe the network is adequate based on their standards. If its not they can work with the plan to get it to a place that it needs to be to get certified. It depends largely upon the rules and regulations that aring applied to meet certification. I would also add that theres a measure of choice here. Some plans go beyond other plans and may have a higher price level because of that. Broader network twz, lower out of pocket deductibles but usually comes with a higher premium. I would offer just one followup to that. That is from an insurers standpoint, im not so much complaining about them as wanting to say that theres this huge opportunity for savings for the insurer to make advantage of because the practice pattern of the Nurse Midwife releases levels of invention and therefore reduces cost. I think we can educate them to say here is an opportunity for savings. I agree with you. A lot depends on state laws. Wed like states to go to a place where Nurse Practitioners can practice to the top of their license and for other providerers as well so we can make advantage of those types of cost savings all in quality. If i can ask you to suspend for just a moment. I wanted to take a couple of the questions that have come in on cards. Actually dove tails nicely with a couple of questions we received in advance. It has to do with the question of essential Community Providers. I want to make sure everyone knows what that is. Id like one of our expert panelists to take a crack at that. The aca requires plans to include numbers, whatever they are. They are important to the moderate income folks. How threatening is the regulatory device which is saying you need to have 20 of the Community Providers with a chance to raise it to 30 . Is that the appropriate way that folks can find the providers that they need . I mean as far as our work on the model, we le hawill just ha put in what that requirement is. As far as the regulation, were looking at whether we can get a contract with them or not. Thats a question. There are a lot of thing its in that. It would have to be something that evolves over time. We have the thresholds in place. Now well have to look at how do i enforce that. Get the threats many. So it will take time but were working catherine. I couldnt comment r comment on this. 20 , 30 , it depends on market access, et cetera. Were supportive of recent shal provider requirements. Given our history and footprint. So we are just proponents for making sure thats coverage there to serve the poor and the vulnerable. Ill just add the threshold has increased for 2015, so in 2014 plans participating in the exchange had to include 20 of essential Community Providers in their area. Now its 30 for 2015 so plans are meeting that regulation, but again it comes at a tradeoff in terms of price to the extent you continue to expand the Network Access requirements and health plans, that in turn will lead to higher premiums, so we have to be cognizant of that tradeoff as we look to further regulate and restrict a plans ability to provide that kind of high value to consumers. We have just a few minutes left. Were going to get this question and maybe a couple from cards before we finish, but id ask you to fill out the blue evaluation forms while were finishing up the conversation so we can get some feedback from you about this program and others that we might do. Yes, sir. Thank you. Hi, im doug jacobs a medical student and also an intern with hhs, and i understand that health Insurance Companies, theyre using value as a way to select physicians. My concern is that they would also exclude physicians who treat sicker patients because those physicianins would be mor costly to include in the network. I was wondering is this happening, and also if anything is being done to prevent it from happening. I have seen no evidence of that. I would say that when insurers are trying to look at value, which to me has two dimensions besides price. Theyre looking at broader measures of costs to see, you know, for an episode of care or for a period of time which provider is less expensive, and then theres a quality dimension. I would think that insurers would want to adjust for different patient populations, but what they can effectively do is an open question, and so, you know, its probably not ideal now. Hopefully it will get better. And i would just note that in our model and something states look for is that nondiscrimination, that youre not contracting with people just because or providers because they happen to care for certain types of diseases or groups of people. So that is something that we look for and will continue to kind of look at that as we move forward. Thank you. Weve got a question here, i guess, that would go initially anyway to dan. Providers listed on planetwor networks may not be accepting new patients. How do plans inform potential enrollees about which providers are truly available . Well, thats an important question, and thats one thing that plans are committed to, to provide up to date Provider Networks on their website but ill add its a twoway street. If a provider is no longer taking new patients and they fail to communicate that to the plan, then the plan tries to make it very easy for them to do so through special callin lines and the like, but part of this rests on the provider to let the plan know when theyre no longer taking new patients. So, you know, we have to work on this collaboratively to make sure that consumers have the latest information. Katherine . Thats a fair comment. The providers need to be in contact with the plans for sure. I can tell you in our hill system if someone is calling for an appointment and that physician has reached capacity, cannot take the patient, well ensure that they get referred to someone who can within the area, but thats our practice. I dont know that thats any regulation or requirement. Im sorry, brian, anything . If i can go back to the related question of the maybe not completely accurate directories or midyear cancellations as opposed to physicians who arent taking new patients, who bears the burden of the lag in information . Is it the patient . Is it the provider . Is it the plan . What happens when that surprise bill shows up . Whose surprise is it . It depends on the circumstance. We think its important that, for example, hospitals that are in the network employ anesthesiologists or pathologists or other specialists in their hospital that are not in the plan. You know, they have a responsibility to notify the patient before they go under surgery to say, well, you know, this particular anesthesiologist is not participating in the plan that the hospital is, and so it could result in higher out of pocket costs. We think there is some responsibility there on the hospital side in that type of situation. You know, one thing i can add is that outside of this issue of networks, that a number of states have put restrictions as to how much these out of Network Physicians can charge just because, you know, these anesthesiologists and other hospitalbased physicians where consumers are just not in a position to be able to make those judgments. You know, id like to add just one comment to this point, and i do believe that, yes, the providers are standing in the relationship with the patient, and as weve done, were educated, were working with them to know which providers are in their networks and not, but i do come back to as the patient or family is signing up for a network, theyre entitled to know whos in, whos not, and we do see that education requirement needs to be provided by the plans and probably something in much more robust than just directories. Probably something more like examples, scenarios, things to ask so that, again, the patient can be more informed. Okay. I think that probably is a very good note on which to bring our discussion to a close. We didnt get i really apologize to those of you who spent the time to write some very good questions on the green cards, but its a subject that we are not letting go. Obviously there is a high level of interest in it. There are a lot of complex pieces of it, and so we plan on revisiting this issue in the fall, probably with a briefing, perhaps with a webinar. Keep tuned, and well try to explore this question of Network Adequacy as it develops. Thanks to our friends at wellpoint for helping us put this program together. Thanks to our emergency panelists who filled in so greatly, i think, and thanks to you for asking all the questions that we have tried to address. R penalty of perjury, what he swears the whole truth and nothing but the truth . Okay, thank you so much. Please go ahead with the first panel. Your complete written statements will be made a part of the record. You are now recognized for five minutes. Thank you, chairman miller, ranking member, members of the committee. Thank you for the opportunity to testify today about the u. S. Office of special counsel and our ongoing work of the department of Veterans Affairs. Im joined today by eric bachmann, who is supervising our efforts to protect the va employees from retaliation. I would like to acknowledge the many employees here who have been working tirelessly with all of our va cases and there are too many to identify by name, but several are here with us this evening. I see been tonight will focus on three areas, first, the special counsel and whistleblower disclosure cases. Second, an overview of the current caseload and there, some encouraging signs of progress. We are an independent Prosecutorial Agency with jurisdiction with over 2 million federal employees and we have a staff of about 120 and the lowest budget of any federal Law Enforcement agency. We provide a safe channel for employees to disclose this government wrongdoing and if it is not, then we send it to the head of the agency who is in turn sending a report asked me. It was within this statutory framework that we received and are still receiving dozens of disclosures from employees across the country. The office also protects federal practices, especially retaliation and in these cases we conduct to determine if retaliation occurred. Turning first to the whistle lower disclosures, we have found that rather than using the valuable information provided as an Early Warning system, the va often minimizes problems. His approach has allowed issues to fester and grow. The numerous cases before the agency we see a pattern where the va has an office of medical inspector that admits to serious deficiencies in patient care yet implausibly denies any impact Veterans Health. The impact of this denial has been to hide many issues that have recently come to light. My written testimony provides several examples of this approach and i want to highlight one egregious example of outpatient neglect and a longterm Health Care Facility in massachusetts. Specifically the report substantiated allegations that two veterans with severe psychiatric conditions waited seven and eight years to get Mental Health treatment. Despite the findings, they denied that this had any negative impact on patient care. This conclusion is indicative of many other cases we have reported on. Turning now, we have received scores of complaints for this and we currently have 67 active investigations into complaints from those who reported health and safety concerns. These complaints come from 28 states and 45 separate facilities, and the number increases daily. Since june 1 we have received 25 new retaliation complaints we are taking several steps to resolve the complaints and we have reallocated Staff Resources and we now have this to take process for the cases. In an effort to work constructively with the va, but my staff and i have met with many va officials, including the active secretary. I think its her important to note the encouraging signs and there appears to be a willingness to listen to concerns raised by whistleblowers come act on them appropriately, and ensure that employees are protected from speaking out. When i met recently with acting secretary gibson, he committed to meritorious whistleblower commitments on an expedited basis. It will avoid the need for lengthy investigations and help whistleblowers who have suffered retaliation get back on their feet quickly. It will also send a powerful message to other va employees that if they have the courage to report wrongdoing, the va will take action to protect them from retaliation and in conclusion, i want to applaud the courageous employees who are speaking out and these problems would not have come to light up for the information that they provide it. We look forward to working with the whistleblowers and with the va to find solutions to these ongoing problems and we look forward to answering any permission in turn questions at the va may have. Thank you. Doctor, you are now recognized for five minutes. Thank you, good evening. Chairman miller, ranking member, i come here tonight with my credibility in question and there is no doubt about that. And i have some prepared remarks, but i would rather speak my mind. We failed in the trust that america has placed in us to fulfill our mission. Patients have clearly waited too long with the care they have earned and i would agree that it took a whistleblower in a crisis and just focus on correcting those deficiencies. As i sat and listened to the first panel, quite rightly i was very disheartened with the staff feel that they cannot fix problems that affect safety and the quality in our business integrity. I think that this is unacceptable and the acting secretary has made it clear that it is unacceptable. He sent a memo on june 13 indicating that that kind of behavior was unacceptable and we would not tolerate a retaliation. And so the stories i heard tonight clearly depict, in my mind, a broken system. And i have to believe and i have to hope that these things are exceptions and that they are not the rule. I know that there are many good employees in this organization who work tirelessly on behalf of veterans. There are many managers and executives to do the same. There is someone out there who is quiet and he tries and who cannot make any effort into his goes away. Those, unfortunately, the risks in our system and the deficiencies that are not fixed or bad. I apologize to everyone of our employees who feel their voice has been silenced and that there passion has been stifled. That is not acceptable and it is certainly not what i stand. Quite frankly, i am past being upset and mad and angry about this. I am very disillusioned and sickened by all of this. And i cannot believe that im at a point in the organization where we are in a place that we worked so hard for to make it a great place. And i left private mess and come work and i did that because i thought there was no more greater devotion than what i am doing. I did not come to work for a mediocre Health Care System but for one of the best Health Care Systems in the country and i believe that the system can be the best system in the country once again. The problems that we have can be fixed and we went to one of the greatest transformations in the Health Care Industry in the 1990s to become what i think was a greek system. And i have hope and confidence that we can do that again. Mr. Chairman, that concludes my remarks and i promise to i will do my best to answer questions. Thank you for your comments. And there are a lot of things that we need to cover. I was looking over this where they described an issue of the montgomery va were in fact we are writing accurate notes were a patient was confirmed to have copied and pasted pulmonologist notes to 1241 separate record and yet astonishingly he still worked for the va. Can you explain how this can be . I dont want to go into a detailed for a number of reasons. There are ongoing investigations and a number of areas around the country by other entities and there are potential issues around privacy and employees and patients here and we would view that are discussing that and im happy to do this. Its better for you but not better for this committee. I understand. We havent developed this with any patient names. Do you accept the fact that it says that they found where he pulmonologist did in fact do this . Absolutely, i do not dispute this. So how in the world can this person still be employed at the va . As i said, i dont feel like i can really go into the details. However, i would say this. And i think that we very much are interested in the quality of care with the va and the documentation is an important part of that. It is a common practice to take store all information and prior note and that doesnt change. But we dont copy and paste material from old records into new record is evidence of a current encounter with a patient. We would not tolerate that. We would not support that in the organization and that would be a part of inpatient care. Maam, could you comment on what is going on . You may not share the same fear that the doctor made clear tonight or discuss something that may be a source of a va investigation. The theme is that we do look at this as medical inspector. It confirms the allegations and then says that its not a problem. So here the whistleblowers said that this is happening as a doctor surgeon who discovered that another physician was cutting and copy and paste patient records. Including information for the surgeon to have, very Important Information for the surgeon have before they operate. And they substantiated that it was over 1200 patient records that evolved. The problem is that they put that position on a review plan and there is a specific name for it. It is fppe. While he was on the review, he was still cutting and pasting and instead of them taking disciplinary action against a physician, they ended the fppe and as far as we know no serious disciplinary action was taken. So this fits the problem and the pattern that we are concerned about where allegations are confirmed. No harm is found to Patient Health and no corrective action is taken against wrongdoers. So that is really what i think needs to be fixed. Whos luckier . Doctor or the veterans who didnt get harmed by the egregious incident but the doctor, in fact, that he perpetrated on the patients. I cannot answer that question. But i do think that again the cutting and pasting of information misrepresents things and would not be acceptable and would not be acceptable to us. Im happy to discuss those details. There is an issue of harm and when they do the briefing and put out the reports and say that they found no harm, i have looked at some of these cases clearly. While there might not be evidence that someone was actually harmed in the process, that doesnt mean that we as agency would say that what happened is appropriate. I believe that those are Different Things in terms of the work that they did and we would not disclose what was actually harmed by that. But i want to reiterate that i do not believe that i personally interpret that and i dont think her agency does either as necessarily condoning appropriate behavior. I would submit to you before i yield, this person is still employed by the department of Veterans Affairs and it does give the signal that it is an appropriate thing to do. I understand. Sir . Thank you very much, mr. Chairman. A press release today says the acting secretary spends some restructuring in order to create a strong internal audit function that will ensure that issues of care, quality, and Patient Safety remains in the forefront. Would you believe is the primary mission that it should be . It was set up as a Quality Improvement process within the organization. And i think it is clear with respect to these cases they were done prior to this in a different way and we took over the quality of those and everyone agreed that at the request of this. And today i think that we realize that we need a different function within the organization this includes an internal all the control function that has been proposed. I can tell you today that the calls are going together and they are not taking new cases in this interim period. So all the issues, whether they are from this area or the oig or whistleblowers, they are now being handled by a team of people at the Department Level that report directly to the secretary. Citing that the organization is trying desperately to address the issues with respect to doing these investigations and the secretary has made it clear that not only will we expedite those investigations, but where appropriate we will expeditiously take a disciplinary action to hold people accountable. How many more employees of the Department Plan to add for this internal audit function . I do not believe at this time that the plans for that i i, in fact, dont have an answer to that question. Man, does this press release by the department today, vowing to restructure this issue you have raised time and again regarding va responses to complaints . That is a tough question to answer because we dont really know what the restructuring is going to look like. But i am encouraged by the vas sort of new response to this issue including by the active secretary and other leaders. I am an optimist and i believe that it is very possible to make improvements and solve this problem. And so i dont know the answer to your question but definitely willing to talk. How will they ensure that the recommendations and the result of the investigations undertaken are acted upon . Well, we have, for a long time, we have taken the recommendations of the findings and we have talked about how we have developed plans to make corrective actions. And i think that one of the things that we need to do Going Forward in this new process is clearly to tighten up those various steps of the process from discovery and investigation and Action Planning and accountability in a much tighter way. Up until now they have been distributed over different silos of the organization. And so in any system like that, that is prone for things to fall through the cracks and etc. So part of the process is really starting to tighten things up and also draw a clear line through them. Following up on the chairmans point, how we achieve real accountability . I think that this itself, i dont know that it would ultimately be doing this work, but it will not be responsible for the accountability part. That is a management function of buyers its own set of activities to be able to do the factfinding and say that this is an appropriate disciplinary process that needs to happen swiftly and systematically and also with fairness. Thank you. Mr. Lamborn, you are recognized. Thank you, mr. Chairman. Maam, you hurt my questions to doctor mitchell and her responses that the Veterans Health and safety was compromised because the warnings as a whistleblower were not heeded even to the point of patients dying according to what she said. As thanks for her efforts she was tallied against it to make it even worse. So how can we strengthen Whistleblower Statutes are already on the books to better protect whistleblowers like doctor mitchell in the future . The whistleblower protection enhancement act has all the elements that are necessary to protect whistleblowers everywhere. It has to be enforced and people need to feel comfortable coming forward. The Employer Needs to create a welcoming environment for whistleblowers and Welcome Change as well that the whistleblowers recommend and not minimize it. The agency enforces this and i think it is a good actor and i think the structure is in place now for whistleblowers to be protected and i think that robust enforcement is very important and im not positive what changes i would recommend making to the act to provide this protection. Well, if its not working as well as it is intended to work, and he just said that needs to be better enforced, what has to change the terms of the culture of the va to prevent these problems in the future . One step that can happen is that the va can become certified under this section and it is a Pretty Simple program that we help to implement and i have gotten a commitment from secretary gibson to have them become certified under the program and its things that require more training and having posters put up in the facilities and having a link to my agencys website with Pretty Simple steps in a very good step for the va to take. I think another important step is for them to actually take expedited actions once retaliation cases are before us and if we are trying to work with them to resolve them and not let them go through a prolonged investigation in getting believe quickly, sending a positive message and it would put some meat on the bones of the promised not to retaliate. So im very hopeful that that would happen and if it does, i think that that would be a positive step. There are other things that agencies do and they have a problem with culture of retaliation and many agencies, one that comes to mind is the air force where we got serious complaints about retaliation and misconduct happening. We heard repeatedly about the culture there being very bad. Once the air force decided to take steps to send a strong message to its employees, we got reports back that things were much better and i dont think this is an insurmountable problem. The because the va is so big, it will require a lot of effort to train supervisors at the regional level as to how important it is not to retaliate and value the information we are getting from the whistle lowers. There is legislation that the house has passed, making it easier to fire a certain number of people with the top 400 or so people in the va. So that would send a very powerful signal, even if its just the threat of not being available. That is possible. I havent reviewed that legislation. I dont feel comfortable commenting on that. But i dont think it requires this. What you are saying is not minimal disciplinary action, but i would like to see at least some disciplinary action being taken. In some cases it probably requires termination. But i think again there is a structure in place that would provide for that type of disciplinary action and we just havent seen a lot of it. As we are not sure if it is necessary rather than enforcing the law as it exists today. Thank you very much, mr. Chairman. Youre recognized for five minutes. Enqueue, mr. Chairman. Thank you. Are you saying that the Current Civil Service protections are not so onerous press we will to impose discipline and dismissal of in this case copying and pasting medical records . You can be terminated for misconduct under the federal Civil Service laws. There is a current framework for doing that. Whatever reason, it is just not happening. Can you speculate as to why it is not . Is it because we are not adequately trained . Its quite extraordinary for college. So it points to our management here in this instance. We have one case that he has taken disciplinary action in retaliation case. It is not impossible to do it at all, there just has to be willingness to do this. But we have seen for the most part in our cases is that people are not really disciplined, or if they are, its a mild discipline. What is going on with the va in terms of why they are not doing that, i can only speculate. But it is certainly possible and we have seen it done. Im just curious. This case of this particular position, the copying and pasting, and generally heard positive reviews by some doctors. Some people tell me that it is not but its not incredibly userfriendly. We could find relevant data which is difficult. One doctor i spoke to is retired from retired private practice. And he evaluates records for the purposes of determining whether people are eligible for this disability. He reviews a lot of records and he says that he will get a record from the va that will be like a phone book. And this includes other record systems as well and he has to go through pages and pages to be able to get the relevant information. So is there truth to this, and is part of the reason because this doctor thought that he could did away with this, that there is one ability with the system . Our patients tend to have multiple complex diseases and a lot of visits in the organization. Including the average agent. And i think that computerized patient record system, without going into specifics, i can talk a little bit about what is a common practice so that i am seeing a patient and night but this into the record the patients problem was, a list of things that are wrong with them, the medical history about when they had surgery or when they are hospitalized in the past, those facts do not change. So it is common practice on paper look at the chart and rewrite the things on a new note or an electronic record system to copy that and paste it. So if someone is not careful, they may capture more than what they intend to end inadvertently places in a new note. I am actually not defending what happened in this situation, but rather explain a common practice with what could happen. I want to say couple of things. And we have many elements of whistleblower certification including training for a long time. We have had some discussions about that. And so its important that we continue because we want to do that. And so accountability, we heard so much tonight about culture. You can change structure and processes and people. In the end it is about leadership and it is about accountability in the organization. That is the commitment that the secretary has made and the commitment that i am making tonight. And i think one of the biggest issues that i have heard tonight was that there are people who felt they suffered while the process was being resolved. I would like to make a commitment tonight and i will give you my cell phone number. You can call me and i will do whatever i can to intervene the moment that you know so that those employees do not suffer adverse consequences while you do your investigations. Thank you. Youre the second person who has given me the cell phone number for this very reason. I am encouraged. Mr. Chairman, my time has expired. He didnt say he would answer his cell phone. [laughter] sir, youre recognized for five minutes. Mr. Vice chairman, youre recognized for five minutes. Thank you, mr. Chairman. Doctor, how many employments excuse me, employees have been reprimanded or terminated which negatively affects the Health Care Industry through the va. I cannot give you a number tonight, sir. What we have, in some of these cases cited and looked at those action plans and where there is administrative action recommended. We have taken administrative action. You cannot give me a rough estimate . I can take it to the record and we can get that to you. How many employees have been placed on the ministry of weve or terminated for actively retaliating whistleblowers . Again, i would have to take that further. Thank you. How many whistleblowers have been placed on administrative leave and reprimanded or terminated to expose misconduct within the department . Can you give me a rough estimate . I do not have that information. But i can tell you that we have to range from 67 whistleblowers that are active in our agency. Im going to turn to my deputy, mr. Bockman, and see if he can add to that. In these three areas, those who have come forward recently, that we have been able to get disciplinary action against them. That includes when they come forward or hit with a 14 day were sevenday suspension. We have contacted the va and persuaded them while they conduct the investigation. That is one role that we are able to play in all of this and i would be happy to go back and check records to see if we have exact numbers for you in terms of the administrative leave. Would you say that there are more whistleblowers being reprimanded as opposed to those who have received misconduct and negligence . If what you are asking is do they come to us, do they suffer adverse consequences more so than maybe someone who is committing negligence or malpractice. Unfortunately, i do not know the goings on. Can anyone on the panel answer the question . No, i dont think i can. I would like to get that information as soon as possible. When cases are referred to ose, what disciplinary action is taken . Anyone . Sure, one of the things we look for when we get the agencys report of investigation is what disciplinary action, if any, is taken. Most of the cases we have reviewed, there has not been disciplinary action taken and i cannot give you exact numbers, but i can tell you that it is the exception and not the rule. One last question. Sir, what consequences for those who provide false information, what do they face . I dont know that i can answer that question specifically. But when we do believe that disciplinary action needs to be taken, there is a set of criteria that depend upon the egregiousness. Can you give me a hypothetical case . Im not i am not sure that i can make up a hypothetical case, but there is a table of penalties that exists. And that is judged by what has happened before because the it intention of disciplinary action is not to be in punitive, but to try to change the behavior of the employee were refilled it we cannot change that behavior, its a hopeless situation anonymously separation is what has to happen then. They usually that is the end result of a series of processes to remediate. So if they give us information that would be criminal imax. I would think. Thank you very much, i yield back. I would like to have that information as soon as possible. We will get you what we can. Youre recognized for five minutes. Thank you, mr. Chair. Maam, you spoke about the Whistleblower Program and certification being a good first step. So why is this an optional one, and why isnt nonmandatory . It is now mandatory. Recently the president issued an order requiring agencies to go through that certification process and their plans for doing so are supposed to be hosted by june of this year. So i dont know why was initially made a voluntary program. But we made this in the early 90s and unfortunately a lot of agencies have been certified. To the va compiler that by the deadline of june . Or are they saying that they will go through the steps for the certification . I do not know if this has been posted. I was told last week by the acting secretary that they would be doing so very soon. So im going to train a followup. Our agency will help them become certified and i signed a little certificate so i will know the minute that they reach that milestone. Very good. And we heard from our panelists earlier today, those whose identities were compromised in the process of working with the ig and you heard the testimony. So can you give me an idea of what your office does and what about the igs office . What steps are taken to ensure production of the whistleblower . Yes. If someone comes to us with the Disclosure Committee have the option of remaining anonymous. If they they choose not to, we referred to the agency. So we dont do independent investigations for disclosures once we make a finding of a substantial likelihood, we then send it to the agency or investigation. And then we review the agencys investigation for this and reported to those in congress. So, the first step in keeping information confidential, the second is when the we remind them of the need to protect and they have to protect that person from retaliation. And so in order to do this full investigation sometimes, sometimes we have to speak to the whistleblower and one problem that we found is that often with the investigations it doesnt actually talk very early and sometimes they dont even interview them. And that is a problem of themselves because this is a subject Matter Expert in the have to speak to them or get the full picture. So its very hard to do an investigation without disclosing identity. Part of the certification program, will it help with enforcement . In terms of the protection piece . Program in itself does not directly involve enforcement. But by making sure that when someone does come forward that it is part of this and i do think it will have a derivative of fact asserting a purpose. Thank you. Doctor, i understand youre relatively new to this position. Yes, i am. Inure formally lift the transformation efforts. Yes smacks i presume that that means that as part of the vas transformation . So im just curious to know how you thought you were doing. To hold people accountable. You cant say i didnt know those rules anymore. So that program has the potential to have a pretty positive impact. I think the chairman. I think as you know theres this thing very important its called trust. You said the va was great. And a lot of good people tomorrow are going to get up and go to work and take the very best care of patients they can. How can we lose trust anything they say when we have panel after panel explained these agree just things that have occurred and let me give you an example it is almost impossible to make a politician speechless but the va has done that. When you have to severely ill veterans a second veteran was admitted to the facility in 2000 through the chronic mentalhealth issues yet First Comprehensive psychiatric evaluation didnt occur until 2011. How in the world in a healthcarh care system in america could that have been anywhere . And let me go on. No modifications occur until 2011 when another doctor mack came along and reevaluated this veteran. Despite these findings, they would not acknowledge the confirmed neglect of residence in the facility had any impact on patient care the typical answer is a harmless era approach completed in the field but in some areas that are in could have been better taken care of not like a word for each years, but the omi doesnt feel the rights were violated. How in the world with a straight face can you do that. That is someone that is dishonest. And me when i have a consultant and ive been to the operating room thousands of times ive got to know what they are telling me is truthful and i can promise you this. If that has occurred in my practice, they would have been fired on the spot. If they found out in the hospital where i practiced for over 30 years they would have been fired on the spot. And what we are hearing is that the people, the whistleblowers that bring this up as mr. Bilirakis said suffer more consequences than the people that actually did the egregious act. I dont understand that at all. Can you and lighted me a little bit . Quite frankly i am speechless. I am appalled. I dont know what else to say. We may have some comments about the process, but i can tell you that i dont think that any of us think that is acceptable for a patient to be in one of our facilities for eight years and did not have a major psychiatric exam acceptance of ones. It is comprehension to me that not one but two veterans have read the facility. And i know you said this a moment ago, but we bring information up here if someone knowingly lies to them you are out of here today but dont go by your fired into right now there doesnt appear that they are doing that as we tap dance around all these things. My time is about also. Basically how can you and i know that you are new in this position under the damage that you have done to this physician and others whose career have been damaged by this. What do you do to repair their reputations . I dont know the answer to that. In some cases the damage clearly has been done. I dont know. But we do over some people in apology and we need to figure out how we can make people who whole. The most important thing is that we have to go forward. I cant undo the past, but i can do something to change i appreciate that. And i feel very badly for the people that are going to go to work tomorrow. You are doing a good job working hard. It had something done for him the va you have a reasonable expectation when you are in the hospital that people being honest i handed off cases that we would turn over the duty and cuba tincuba to take the beeperw it is a cell phone you expected your partner to tell you the truth because peoples lives depended on it. This isnt a game that we are playing. Peoples lives are at stake. Youre recognized for five