Transcripts For CSPAN Secretary Robert McDonald On 2016 And

>> veterans affairs secretary testified on capitol hill tuesday on the 2016 veterans affairs budget request. the proposed budget is $168.8 billion, including funding to expand v.a. care to veterans and transform the v.a. into a customer centric department. this is about one hour and 15 minutes. >> tom fuller was a vietnam veteran and the marines and presented himself to the heinz the a with chest pains and went to see the head of cardiology. he did not want to be at a whim loss record, referred him to the floor and there, tom expired of a heart attack. we want to make sure that kind of thing never happens to our veterans, that we have a confident and strong administration of people. mr. secretary, i have raised this issue a number of times. behind that is the story of a cardiologist who witnessed this whole thing and felt there was an outright malpractice happening in this case. i know you have a 10 minute opening. secretary mcdonald: thank you mr. chairman. i have a brief opening statement. i want to thank the chairman for his leadership on this subcommittee and i want to -- i want to welcome secretary mcdonald and thank you for your work as you appear before the subcommittee. mr. secretary, it is good to see you. thank you for coming to montana. it was a great trip. moving forward, i hope we can work closely together to address the issues raised during our trip and some of the issues that will be raised today. i have an impressed by your leadership, your candor, your willingness to accept responsibility and confront issues. the v.a. is an agency under siege every day and you experience that every day. we have seen several scandals that have shaken the confidence of the v.a. and it has created mistrust with some of our veterans and created mistrust with some of our public. restoring that trust is one of your tasks but a lot of that responsibility. our shoulders. it is critical we provide you with tools we need to get the job done and i firmly believe we need to hold accountable those who would abuse their authority for personal gain. we also need to apply the dedication of the employees who come to work every day with the single goal of helping veterans whose lives they touch. dedicating our time, it is not a recipe for reform or success and our veterans deserve more than that. at the end of the day, we are in this together. america's veterans are entitled to a health care system and program that is superior to any benefits and for very good reason. the model of providing care to our nations veterans is something our veterans have come to rely on and is something congress has enshrined in law. we each have a responsibility here to sustain this model of service. the v.a. must improve its delivery of service to veterans and congress needs to step up and fulfill the responsibility to fully fund the v.a.'s model of service. i want to thank you again, mr. secretary for testifying before this subcommittee and i look forward to your testimony. secretary macola -- secretary mcdonald: thank you for the opportunity to discuss the v.a.'s 2016 and 2017 advanced appropriations request and budget. we appreciate your steadfast basher steadfast report for veteran services organization. as v.a. moves from a serious crises, we have a critical opportunity. we intend to take full advantage to make v.a. a model agency and an experience comparable to the best private sector businesses. currently, a million veterans aren't rolled and use at least one service. the cost of the filling obligations grows over time because veterans demand continue to increase. in 2014, 40 years after the war ended, 22% of vietnam veterans were receiving service-connected disability benefits. we expect that percentage to continue to increase. from 1960 two 2000, the percentage of veterans receiving v.a. compensation was about 85%. in the last 14 years, that has more than doubled to 19%. in 2009, vba completed about 980,000 claims. in 2017, we project we will complete over 1.4 million claims , a 47% increase. there has been a huge growth in the number of medical issues in claims and a projected 5.9 million in 2017. that's a 150% increase over just a years. from 1950 to 1995, the average degree of disability among veterans was 30%. since 2000, it has risen to 47.7%. while the total number of veterans is declining the number of those seeking care and benefits is increasing due to more than a decade of war, agent orange related claims, and unlimited appeals process increased claims issues, far greater survival rates of the wounded and more sophisticated medical treatments. it is important to understand why. the most important consideration is an aging veteran population. 40 years ago, 2.2 million veterans were 65 or older. that's 7.5% of the population. in 2017, we expect 9.8 million will be 65 years or older 46%. we now serve and older population with a greater demand for care more chronic conditions, and less able to afford private sector care. as veterans see positive changes at the and as the military downsizes, those choosing v.a. will continue to rise. we are listening hard to veterans, congress, employees and vs owes tell us, -- vso's tell us, making veterans the center of everything we do. we call it my v.a.. my v.a. focuses on five objectives to revolutionize culture and focus on veterans outcomes rather than internal metrics. first, improving the veteran experience so every veteran has a seamless integrated, and responsive customer service experience every single time. second including employee experience by elevating barriers to customer service and focusing on our people and culture to better serve veterans. third, improving our internal support services, fourth establishing a culture of continuous improvement to identify and correct problems and replicate solutions at all facilities. and last, enhancing strategic partnerships. we cannot do this by ourselves. strategic harder to become critical. organizing the department geographically is the first that to achieving this goal. in the past and the v.a. had nine disjointed geographic structures. our new organizational framework has one national structure with five districts, aligning the a's disparate organizational boundaries. veterans will see one v.a. rather than multiple disconnected organizations. last, my v.a. is about ensuring sound stewardship of taxpayer dollars. we will integrate systems to make sure of operational efficiency, but we need congressional help. no business would carry such a portfolio. it is time to close substandard and underutilized facilities. 900 v.a. facilities are over 90 years old. more than 1300 are over 70 years old. v.a. has 336 buildings vacant or less than 36% occupied. that's 10.5 million square feet of empty space costing $24 million annually. we can use these funds to hire 200 registered nurses four-year. pay for 144,000 primary care visits for veterans or support 900 nursing days for veterans. in the long term, they will enable us to better ernst services. our 2016 budget request allows us to continue transforming under my v.a.. it requests 168.8 elliott dollars. 95 $.3 billion in mandatory funds. to continue serving a growing number of veterans receiving care and benefits. the research required in the budget request are in addition to those congress provided in the veteran's choice act. we don't know how many veterans will use it for non-v.a. care. we do know a recent decision to change the definition of the 40 mile provision of the act from straight line to road distance will approximately double the number of veterans eligible for care under the act. as secretary sloan gibson testified last week, we proposed the funding of our denver hospital by requesting funds from the act. the denver project has a long history. while poor the a project and contract management contributes to problems, decisions made years ago brought us to this point. the significant increase in the cost of the project results from four factors -- first not locking down design early in the process. second, some design aspect that added cost. third, increases to construction cost of the denver market while we have not negotiated a firm target price and fourth, premiums paid to contractors for perceived risk due to problems with the project. we have learned from these past mistakes and we are taking meaning full corrective actions to improve performance. among those are requiring major construction projects to achieve at least 35% design prior to cost and schedule information. second implementing a deliverables control process. any changes in scope or cost will be approved by me. third, institutionalizing a project review board similar to what the core of engineers district office uses. conducting preconstruction reviews of major projects and fifth, integrating medical planners into the construction team rum contract through activation. those measures will help us in the future but they will not finish denver. after analysis by the corps of engineers, we inform the committee the total estimated cost will be $1.73 billion. an increase of $930 million and additional funding of $830 million. we believe requesting funds from the choice act is the best approach. now we must work with this committee to secure the funding. last, if the president's budget request is cut by a $1.4 billion imposed by your colleagues in the house, those reductions would have these effects -- it would cut veteran care by $690 million, the equivalent of over 70,000 fewer veterans receiving v.a. medical care compared to the president's request. it would eliminate the funding for four main construction requests. it would reduce the v.a. possibility to provide additional outpatient services and will impact the following projects -- the planned rehab therapy building in st. louis missouri, the initial phase of the alameda, california event. construction of the french camp california community based clinic. the replacement 155 bed community living center in carry point, maryland. it would eliminate funding for cemetery expansion projects in st. louis, portland, riverside and pensacola and a new column in alameda reducing our ability to provide burial honors for as many as 18,000 veterans. it is unacceptable to me, and i know it's unacceptable to members of congress. chairman ranking member, members of the committee, thanks again for your support for veterans and for working on these budget requests. we look forward to your questions. thank you, chairman. >> on denver, i'd ask unanimous consent if i can put in a statement that cory gardener gave us on this issue. so at $1.173 billion, the denver hospital would take up so much money, it would fund missile defense for 7.9 years. in the case of -- it would also take up four years of mill con for special operations. that's a big hit. i would add to your list of things that were done wrong in denver, is that you didn't have the army core of engineers overseeing the construction of the facility. i want to make sure by june 1st, you have already done that. >> mr. chairman, we've already done it as of today. i mean, the core of engineers is active on the ground. we're working with them in concert. we continue to want to use the core of engineers in other major projects. may i make a statement, mr. chairman? this is not really a hospital. it's a medical complex. this is what the complex looks like. as you can see, it's many buildings. it's not one building. it's very close to the university of colorado medical school, who is a partner of ours. so this is a major undertaking of many buildings, not just one hospital. just wanted to be clear on that, sir. >> i would say that your proposal has been to take $1 billion from the care act to sink into this thing. that would eliminate about 20% of the care act money. the promise we've already made to american veterans, we don't want to go back on that promise because of the mismanagement of the denver facility. we need to have the people involved with this fired and no longer a part of the payroll. >> the gentleman in charge of construction at v.a. is no longer with us. we conducted an administrative investigation -- >> no longer with us, meant he quietly retired. he's collecting from the taxpayer? >> he retired the day after the interview he had. to the best of my knowledge, both in the private sector and the public sector, it is impossible to claw back a retirement, unless malfeasence is proven, and the investigation is ongoing. >> we had evidence of a whistleblower who sent an e-mail very early on and said this project is likely to go $500 million over budget. that whistleblower was fired by the v.a. because of that e-mail. we want to make sure this process of nailing whistleblower is wiped out in the v.a. how would we have that happen? >> i'm not familiar with the situation you're describing. i would love to be able to get more information on that and follow up. we have been working with the office of special council to make sure all of the whistleblowers who have been retaliated against -- >> let me get it for the record. the person you're talking about was glenn hegstrum. the person saying we would go $500 million over budget was delano grosby. that person was let go and turned out to be exactly correct on all of our warnings to v.a. >> we have said it's unacceptable to retaliate against anyone who is criticizing our operation. in fact, we believe, we want employees to help us improve our operation. we've worked with the special council to get certified in our activities around whistle blowers. we have reinstituted several whistle blowers to new jobs. we celebrated with a national award. retaliation. it's unacceptable. >> i want to make sure we don't wipe out the cares money for the overrun in denver that we standby our veterans there. >> we just don't know how much of the care money would be used. >> i understand if we wrap up the denver situation that caused -- costs are $3 million a month to maintain that. do you understand that to be true? >> we don't have that, but we'll check on it. >> let me go to mr. tester. >> thank you, mr. chairman. everyone knows how important this committee is to our veterans in this country and how we need to do a job together. you team in a below the request. and they achieved this largely by freezing the major construction level of fy '15 levels. there have been a lot of folks that have criticized the v.a. for not being frank about what you need for money. a lot of criticism was warranted led to funding shortfalls and subsequently had to be addressed through emergency legislation such as choice act. and now, a lot of the folks who demanded from you are the same folks that refused to give you the resources you need to achieve the results our veterans need when they come to see you. is it fair to say that this is inadequate? >> as i said in the committee meeting budget, we put in this budget knowing it was going to be tight versus the demand we faced. you are looking to be in money if we want to flexibility to money. we can't predict whether veterans are going to go for community care with a choice act or whether they're going to go with v.a. care. because of the way the budget is formed, i don't have the flexibility to move money where the veteran goes. >> are you getting more demand on your facilities? .ini to me with that $1.4 billion spending the cash would be >> the spending cut means that and less veterans are going to are in a get care it's been cut by the equivalent of 70,000 veterans receiving v.a. medical care. we won't have the money to care for them. >> we have given increased funding and mechanism to address workforce shortage in the v.a. we could be losing ground. not only attracting new physicians and medical personnel. the v.a. needs the authority to let them do their jobs and then crushing the ability to address the workforce needs we have in montana. who are doing their job, working with the veterans. even if it means less pay and longer hours. to what extent has this impacted your ability to recruit to the v.a.? >> well, senator tester, as you know, i've been to over a dozen medical schools and talked to candidates to become nurses and doctors at the v.a. and the has affected the perception on the v.a. we have increased the salary bands of our doctors. we are looking at competitive pay of providers within our system. we have hired more doctors. we currently have hired over 800 more doctors, over 2,000 more nurses. and we have opened new facilities. we opened about 17 new facilities a year. but the demand as you've suggested has increased. we've gone from roughly 4 million outpatient patients to nearly 6 million. and that demand's going to increase as we continue to improve the system and improve our customer service. and we've not even seen the full effect of the iraq and afghani wars yet and the veterans who fought those wars. we have to build a capability today to be ready for five years, ten years, 20 years from now. and that's what our plan does. >> i'll talk more about those capabilities next round. >> let me add on to that. i understand that glenn hegstrum, responsible for the debacle in denver got a $60,000 bonus according to senator gardner. >> and if we're giving big bonuses like that, how can we ever take care of veterans? >> i believe that bonus was for 2013 or before. and not for recently. we've got the administrative investigation going on. and as we get to the bottom of this, we will figure out what the appropriate action is. >> mr. boseman. >> thank you, mr. chairman. and i agree with the senator from montana. the vast majority of the v.a. personnel are doing a great job working very, very hard. i think the thing that shows that is how few have actually accessed the program that we were trying to stand up so they'll have to travel. you know, many of them are traveling even though they can stay home. but it's hard. i'm going to bring up an issue that was before your time. yet, it is hard in the sense that, you know, people are losing faith, congress is losing faith. we have an issue in little rock. congressman hill has been looking into this very vigorously. where we have a situation in february of 2012, the v.a. received an $8 million grant to build a 1.8 megawatt panel system at the veterans hospital . in august of 2012, the v.a. approved a parking deck project, which is located in the same place as the solar panels. in january of 2013, construction on the solar panels began on the same location as the planned parking garage. v.a. officials were aware of the conflict at the time. in august of 2013, the solar panel constructions completed in april 2015. then, you know, the v.a. dismantles them to build the parking lot and it's still not clear as to how much it's going to cost to put them back. and whether or not they were ever able to function in the grid to begin with. so, i guess, what i'd like is, you know, we've got these things going on. what are the safeguards that we've got? how are you dealing with this kind of stuff? >> well, i've mention some of the changes we've made to the process of construction in my comments. i've also mentioned we've changed the leader. we have a new leader named greg gibbons. he's got experience across many sectors of government and has done this before. i also happen to be an engineer. my certification was an engineer in training. i studied in engineering at west point, from the state of pennsylvania. and our deputy secretary's a former cfo of a bank, very bright, intelligent guy. we're digging into this in the best -- in the strongest possible way, and i would just simply say that's not going to happen. i mean, that happened in 2012. i appreciate you bringing it up. but that's not going to happen in the future. it's just not going to happen. what we're doing is we're having design committees, we're having outside people review our processes, we're using the corps of engineers, the best practices available in industry today in order to make our system better. >> one thing we have to be careful of, that process started then. and i don't know how forthcoming v.a. was in admitting the process was there. and even now, when you ask how much is it going to cost to reinstall, we get terms like, i think, procurement sensitive or something like that. that's not appropriate. >> i agree. we are trying to be more transparent than ever before. and i would hope that since i've become secretary, you've seen an increase in my presence and the transparencies as a department. i do catch instances where i wish we were more transparent and better about customer service. >> the other thing i'd like to mention. we had a group get together in little rock to discuss reimbursement to providers that have provided outside care. you'll have situations that arise, now with this 40-mile rule that the v.a. owes this money, it appears the v.a. owes a lot of people in arkansas a lot of money. and has not been very forthcoming in paying those bills. it's another thing that makes it such that the trust issue that we talk about. the other problem is, if you don't pay your bills, they're going to quit dealing with you. and then, that's the greatest thing. and that really is going to affect quality of care. can you quickly mention that? >> i will, and maybe i'll ask carolyn to comment. i talked about the five strategies from my v.a. one of them i talked about was improving our internal support services. and going to assured services model where we centralize the bill paying. so that's all the people do is something that we're in the process of doing. we're not done yet. we have more work to do. carolyn? >> yes, i would just add that we are tracking this rates of payments and how old the claims are on a weekly basis. and i am pleased to say that what had been struggling for a while is actually improving faster than other networks, but we will keep a very close eye on it. because you said it well senator, if you don't pay your bills, people are going to say gee, i'd love to help you, but i have to pay rent to veterans and that's not going to work. >> mr. chairman. and, again, your people were very helpful and did a good job in arkansas. >> thank you, sir. >> mr. udall. >> thank you very much, mr. chairman. and let me along with the rest of the members echo your new aggressive leadership in what you're doing in terms of, in terms of veterans. i really respect the team that you brought in and this more business like approach to what is an incredibly important issue for veterans in my state and across the country. and let me thank you, too, for the constructive dialogue we've been able to have moving the v.a. forward as you near the b end of your first year as secretary. as we discussed during last week's visit, new mexico's key issues can be narrowed down to ensuring the veterans have access to care. too often they're prevented from receiving the care they deserve. many veterans are not able to have their claim adjudicated in a timely manner. in new mexico, progress to reduce the backlog is stagnated. and that's this chart i have behind me here. i think i've showed you that before where we've come down dramatically. we've made good progress, but it's stagnated. and i'm hopeful we can get the resources to make progress in reducing the backlog once again and where it's stagnated started in a downward turn. with regard to scheduling and the scheduling issue around the veterans v.a., last summer showed we had a lot of work to do to ensure that veterans are seen on time and that the scheduling system was not being utilized in a fraudulent manner. as i mentioned, i asked the v.a. oig to look into this matter. i'm awaiting their findings, furthermore, we need to do more to find creative solutions to the recruitment and retention problem facing the medical community in rural clinics. that is not something solely a v.a. problem, but i believe that it is an area that v.a. can take a leadership role to address. based on the budget requirements and the vha's experience, which would be the best way, and this has been mentioned by several questioners here and some of your answers. which would be the best way to improve access to quality care and expanded fee for service program? or a program which aims to recruit and retain rural physicians and nurses at rural and which helps to expand telehealth? and which would be the most cost-effective way for the american taxpayer? >> well, sir, i think we need to do both. a combination of v.a. care and community care, working together in a network to make sure our veterans get the care they want. i'd like to briefly comment on your chart. >> please. >> i think if you back the time period up, you'd see a more dramatic decline in the claims backlog, and also -- >> go back a couple of years? >> yes, sir. >> and i also think the reason it leveled out was we had 660 additional head count because we'd been working mandatory overtime in the administration to drive this backlog down to zero. as i was doing town halls. i was seeing increasingly, not surprisingly, increasing conflict between labor and management. you did not give us, continuing to drive it down. that straight line is when we took off mandatory overtime. it didn't work, we had to put it back on. so we're still doing mandatory overtime, which we've been doing now for several years, which is not a good idea. we've got more people in the 2016 budget that we need in order to get the backlog down. we're going to get to zero by the end of the year, but we need those people. also, i think there's a couple of months that are not on your chart. danny, could you update us on that? >> yes, senator. first of all, great chart. your numbers are dead on. did a really good job on it, your staff. if we -- >> we should say we published our numbers every two weeks. so we want to be transparent and we want you to know what our numbers are. >> and we appreciate that. >> you see the dark orange that's your number pending. that's come down as of right now in april, you're down to 40%. 47% backlog, claims pending and 1,500 of those claims in the backlog. you'll see the continued downward slope you saw earlier at your chart for the next three months and a huge dropoff this summer because pretty soon every claim we're going to be working going to be in the backlog and that won't be just for your state, that'll be for the entire nation. >> this is a really important -- >> i've run out of time. just if you could just very briefly, carol. >> i would simply say that new mexico is really a model with dr. aurora at the university of new mexico working closely with us. this is a matter if the veteran can't come to the medical center. we can use telehealth to bring that expertise to the clinicians working out in the rural communities. we're using it in other parts of the system, as well. >> thank you for your courtesy. >> thank you, mr. chairman. and i want to thank the secretary and others for being here today. it's nice to see you, again. is legally give your willingness to do miles an hour car i really how i would like to thank you for your willingness to work before mile an hour there -- rule. making this change helps veterans across the country. thank you, i know you're aware of this issue. we've talked about it. there's an outpatient clinic there. it's been closed three times. i think i read it's going to be serving the 2,400 veterans in that area. i know this is specific. but if you had any other alternatives that you're going to replace that facility, or what your plans are for that. >> i'd like carolyn to comment about the specifics by just simply like to reiterate what i said. our facilities are too old. hvac systems need to be replaced every 25 years. i talked to you about facilities over 100 years old, 90 years old, this is unacceptable. and we've got to decide which facilities to close. i talked about that. and which to refurbish so we don't have these chronic problems. we can't do that with a budget marked down 1.4 billion by the house and the major construction part has been gutted by almost half. >> so i would say that we are hopeful for the moment that we may actually be able to resolve these air quality issues. i also want to point out that in terms of 40 miles from what that cblock is not part of that calculation anymore. that should offer more flexibility to the extent there are community providers and the mobile unit. those are the plans that we have right now. this will remain high on our agenda. >> thank you, yes, it's definitely a problem. and obviously. and i understand the facilities. i would just briefly ask you. and i wanted to ask you this. this is my last question because i ran out of time. but since you were on it on the facilities, you mentioned excess properties, 336 buildings are empty. you said you need help with that. how do we help you that? it's not just budgetary. is it statutory? >> the president's put forward what i would call a civilian brac. to have an up or down vote across the federal government, i think that's a brilliant idea. we've got to become more efficient. i would suggest it be passed and we go at it. >> you mentioned these are my v.a. regions. >> yes, ma'am. >> and dr. clancy mentioned vision. so this is v.a. 101 for me. is it gone? >> we've started a process where we're aligning the visens and seeing if there's an opportunity to reduce the number of vizons. and this is a huge issue in accountability. 91% a new lich team member. we're really weak on leadership right now. we have new leaders in place. and what i don't want to do is reduce the spans, increase the spans of control so much that we take immature leaders or leaders with less experience and put them under more pressure. so what we're looking at right now is a modest reduction in the visns and align them to state boundaries. >> i notice we're in the same my v.a., three different visns which makes no sense. >> that's one of the things we want to fix over time. >> and the leadership issue, the clarksburg v.a. in clarksburg, west virginia has, unfortunately, lagged behind as one of the top people who had the biggest wait times. or just had a leadership change at that v.a. are you seeing anything yet? too early to tell? do you have anything to report there from clarksburg? >> i would be happy to follow-up with you on that. i want to make a point for you and all of your colleagues that we are tracking the access in quality issues on an almost daily basis. but i'd be delighted to follow up. >> ok. well, thank you for that. >> we would be happy to invite any of you to come to our daily stand-up that we do where every morning we review the data. and take action. >> all right. thanks so much. thank you. >> i know the chairman is working with dod so the two can share medical records electronically, but progress, as you know, has been slow. gao specifically cited the lack of progress as an issue when it added v.a. to its 2015 high-risk list. according to gao, quote, the two departments have engaged in a series of initiatives intended to achieve electronic health record interon rablt, but accomplishment of this goal has been continuously delayed and has yet to be realized. the ongoing lack of electronic health records interoperability limits the v.a. clinician's ability to readily access records and so on. so what kind of progress are you going to be making? and when can we expect for you to be off the goa high-risk list? >> well, first of all, i -- when i met with the head of gao, i asked to be put on that list. with the crises that have occurred, i that thought it was appropriate we are on the list. the transparency and disability is important. second, we've made a lot of progress on the electronic health record. and i would like to offer to represent the community that we would be happy to come to europe with an demonstrate the interoperability. once you see it, you become much more conversant in the progress that has been made. >> very briefly. >> yes sir. from a standpoint, we've been hitting on three levels. the first one is moving the data within the existing systems. and we share more data than any health care system in the nation or in the world. our future is how do we get all of the data in a single view? and that is the demonstration that the secretary offered. where today you can now see all the v.a. data for any medical center and dod data as well as third party provider data in the same screen. so the data's been normalized, the providers can look at it and they can actually make decisions based upon a continuum of time in terms of what data -->> so what remains to be done? >> so the two next things that need to happen is the viewer that chose that data is just for viewing. we're not able to actually go in and change the data. that's the next generation. >> is that a data base breakthrough? doesn't sound hard. >> it's a two-part. the first part is making sure there are common standards. >> ok. >> so working with onc to come up with national standards where there are no national standards, we work with dod -- >> clinical standards? >> database, so we have the same units, same definition. a lot of effort over the next couple of years to make sure the right standards are in place. the second piece is to make sure the tools there that shows the data at the same time, we can start changing the data at either end. and so -- >> time frame for all of this? >> the enterprise health management platform, we are programmed -- >> let me step in here and deliver a threat i've been saying to dod if they insist on having different standards that we will go with just the v.a.'s standards because you represent ten times the number of patients in the population. >> a lot of strong work and if i can bring the third party in the office of the national coordinator. does the standards for third party providers. and with more care going outside, it's knot justnot just the dod, but how do we get the private providers in the same standard so their data can come in and be part of that continuum? >> so start to finish, able to use this work as you're moving along. what's your total to completion time? >> the enterprise health management platform will be at 33 sites by the end of the calendar year. by the demo, next generation. and we'll be adding capability on over the next three years till we phase out what we have today. >> thank you, and mr. secretary, i want to ask you quickly about the vets center i've talked to you a couple of times about it. this will double the availability of clinical services for about 1.2 million people and tens of thousands of veterans in the sitting county of honolulu. could you give me an update? >> so this is going through the planning process right now. we suspect it'll be advertised late fall of this calendar year. and then the award will probably happen in the first quarter of fiscal year 2018. so it's going to take time, but we're very, very excited about the access opportunities. >> you said it'll advertise this year and then the award will go out in '18? or did you mean to say '16? >> no, the actual final award and construction will happen in fiscal year 2018. and the construction will be complete in the last part of 2020.>> ok. my time has expired, but i'd like to understand, we can take it offline. i'd like to understand why you go two years from advertising to the award and beginning of construction. thank you, mr. chairman. >> thank you very much, mr. chairman. mr. secretary, i, too, want to thank you for working with many of us on the 40-mile rule to change it from as the crow flies to actual driving distance like senator capito, i represent a state where as the crow flies and the driving distance are two very different things. but the v.a. still does not consider whether or not the type of care that the veteran needs is available at a v.a. facility that is within that 40-mile limit. for example, in western maine there's a university that operates only two days a week. we're glad to have it, but obviously, it's nowhere near a full-fledged facility that can provide and meet the needs of our veterans. now, that means that veterans in jackman, maine could go to a hospital, local hospital that's 35 miles away, still a distance, but much, much closer than going to the v.a. hospital for care. or they could go to the local community health center right there in jackman to get care if the 40 miles were considered to be measured in terms of whether the service is actually available. the service obviously is not available at a two-day a week mobile clinic. it is available at the community health center and data hospital that's 35 miles away. but these are not options available to our veterans in this area. due to the interpretation of the 40-mile rule. are you giving any thought to being more flexible in that area, as well? >> we're in the process of analyzing it and working with members of congress on what we discover. first of all, the idea that whether or not you can get care from your local facility is actually written into the law. it's not an interpretation. that was the way the law was written. so if you would like it changed, you need to change the law. secondly, our initial calculation suggests that if we were to make that change, the minimum increase would be about $10 billion a year. not over the three-year period of the choice act, but a year, and it could be as high as $40 billion a year. if we opened up that capability or that appiture very veterans. and have the discussion if that's a law change that you would like to make. >> in the case i gave you where the facility is not even cboc it's a mobile unit open only two days a week, it just doesn't seem like a reasonable interpretation. >> there's a middle ground point we can take to in a sense change the geographic burden to give the secretary more flexibility to allow people with a geographic burden of some kind to use the choice care, the community care, and that we're also working on and we'll come back to you with the definition of that and how that will affect and how many people that will affect. >> thank you. i also want to associate myself with the comments of the senator from arkansas about slow payment to physicians and hospitals. this is a problem in my state, as well. and the problem is that if the v.a. ultimately denies the claim, the hospital has missed the deadline for filing a claim for reimbursement to a secondary insurer such as medicare. what happens is the health care provider ends up not getting paid at all. >> it's one of our most important strategies, we have to get it right. >> thank you. live in, and resolution with the state veterans home began working on regulations that would govern adult day care. so there could be respite care for our veterans who are living at home but may be suffering from alzheimer's or other dementias. and that has been in process since october of 2008. far proceeds you. but that's more than six years ago. and for the record, since i'm now out of time, i would ask you to give me an update. this would make such a difference to so many of our veterans and their family members. and it also would reduce nursing home costs and costs that your state -- the veterans, the state veterans homes. so i really think this is something that should be finalized and should not have taken six years and still be pending. >> we agree and we'll get back to you. >> thank you very much, mr. secretary. >> thank you, mr. chairman, and ranking member for this hearing today. secretary mcdonald, you noted in your testimony that the v.a.'s really at a crossroads. and you struggle with significant challenges including internal management controls as well as the delivery of safe, appropriate care. and we've talked a number of times as i have with dr. clancy about how these two failures have had really tragic results at a particular medical hospital in wisconsin, the v.a. medical facility. and i look forward to working with the members of this committee on a number of steps we can take including legislation. dr. clancy, your clinical investigation into -- into the v.a., you have initial and interim findings, and i know it's ongoing. but with regard to opioid prescribing, you found it was double the national average when it comes to diagnosing concurrently, which is an unsafe practice at the v.a.'s own clinical practice guidelines for opioid therapy warns against. one of the patients prescribed both of these drugs if you believe the v.a. adequately managed the implementation of the clinical practice guidelines for opioid therapy at local v.a. medical centers. >> i'd say we made a good start and that's what we're doing right now. the initial approach that predates both of us to start at the network level and then go down to the facility. and if we had a chance to brief you and your colleagues, this is now getting down to the individual clinician level because we can do a much, much better job. the irony, of course, is at that facility, toma, you are -- veterans are less likely to be on narcotics than in the network or the national average, but if they're on them, they're getting very high doses. and far more likely to be on benzodiazapines. one is as you would expect to reduce the use of opioids probably were most successful with those veterans struggling the least. and what we have now is a group of veterans with the most challenges with chronic pain and other complications. i think we desperately need to figure out, what is the risk point at which someone transitions taking narcotics sometimes safe for low back pain. is it a month? a couple of months. the academic detailing initiative that has now been mandated and will be required for full implementation by the end of june. >> i want to follow up on two points you just raised and then answer. one, you know, one of the problems was the dangerous prescribing practices were considered within the bounds of acceptable care. do you believe that the current prescribing guidelines which were last updated in 2010 are due for an update? and then the second question and may have to wait for a second round relates to driving these down to the patient level and involving patients and their families protocols. >> so two quick responses, happy to follow up with more. first is that the guideline which was developed jointly will be updated this year. they're going to be starting that process this fall. we know that practice guidelines need to be updated about every five years absent some kind of new breakthrough evidence. that's the first thing and the second thing is that we now require that all patients on narcotics actually sign an informed consent and that's part of their medical record every year. i would say that's a down payment on the kind of thing you just referenceded and happy to follow up further. >> thank you for calling me. first of all, mr. chairman, chairman kirk and senator tester, i would just really like to congratulate you and the work you've been doing in v.a., you've had the usual sense of bipartisanship that's been characteristic of this committee and both of you have been fighting for our veterans. the vice chair, the full committee, i want to thank you for the job and do what i can to get you a juicy allocation. i would like to, first of all, say hello to secretary mcdonald and to his team here. i'm going to engage, though, in a bit of a maryland question. thank you for the job you've been doing, but you've got a big job and i think you're finding under every rock is another rock. and we found the same thing in maryland. i asked the inspector general of the v.a. to investigate claims that have come to my attention in my constituent area. somebody who didn't get mental health appointments and then later committed suicide. it was not me to finger point but to pinpoint and the inspector general came back with findings. the facilities in maryland didn't follow the outpatient feeding policy, that they needed to comply with policies related to basic protocols or mental health services. what the inspector general did was come out with nine specific recommendations. rather than taking the time of the committee to read them, you know them. i had the report here now. could i have -- can i have your commitment that you'll do whatever you can to follow up on the recommendations? >> yes, ma'am. i'm a big fan of the inspector general and the work the inspector general does. when i was confirmed, i had, i think, about 1030 i.g. investigations pending. i think we're down to something less than 70 now. so they're still coming out, and most of them date a year to two years ago. but we take them very seriously because they're an -- and we remediate every finding they come up with, and we will certainly do that in the case of maryland. >> did you want to say something, dr. clancy? >> no, i just added to exactly what the secretary said. we will follow up on this closely. >> are you familiar with this? >> yes. >> some of it is kind of surprising. first of all, i appreciate it and look forward to staying in touch in the follow-up recommendations. they're not only for maryland but they're also for the rest of the country. like home feeding tube protocols, mental health response time protocols, the basic really bread and butter. the other is the question related to choice, the implementation of choice and i've been an advocate of that. have you all covered that in the questions? >> yes, ma'am. somewhat in my -- but go ahead and ask and we'll fire away as quickly as we can. we've also covered the replacement that's been stripped out of the house budget. >> you're replacing perry point. >> yes, we had in the 2016 budget money to replace the community living center in perry point. and that was stripped out of the house mark-up. >> well, i would like to, mr. chairman, mr. vice chair talk with you about this. this is a facility oriented to mental health. and it takes care of veterans with significant mental health challenges as well as alzheimer's unit. some parts of that building are, oh my gosh, preworld war i. and i won't ask the committee to come up if the staff would -- i think it's a compelling need. >> we do, too. >> but on the choice card, i understand that, and it's a program that i supported to shrink the waiting list. but i understand of the 8.5 veterans that have been issue d choice cards, only -- less than 1% have been authorized care, none v.a. facilities. could you give us the status of the choice program? is it working the way we hoped? if it's not working, is it bureaucratic delay? what's the issue here? because this was meant to be an opportunity. >> first, let me start, senator, with a thought that community care is important to the future of v.a. currently today, even before the choice act, about 20% of our appointments are community care, meaning outside the v.a. we haven't had a number of veterans go outside the system and use the community care. we've redefined the 40 miles, how you measure the 40 miles driving distance. we think that will double the amount of veterans using the choice card. we think that's a big improvement. we're also looking at other improvements. we're doing marketing, and we're doing websites. we have a public service ad, we're writing letters, making sure they understand the system. many of the cards went out over the holidays, and admittedly people don't look at their mail over the holidays. marketing is necessary. we're looking at everything we can to maximize the impact of the choice act. >> well, thank you. my time is up. i would just say to my colleagues the choice act does offer opportunity. and perhaps you could use the 535 members of congress. our news letters to help trubador that. we hear the complaints, we'd like to be able to share with them an opportunity. >> that's a great idea. >> not political, nothing political, but really about this opportunity, particularly for the primary care that this could provide. >> we'd love to join you in writing letters, we'd also love to put a link on your website to the choice care website. anything we can do to increase communication. we'd love to work with you on that. >> i think that would be fantastic. thank you very much for letting me come in. >> dr. cassidy. >> listen, a friend of mine, tells me that the budget for treating hepatitis c has been exhausted. that currently, the only folks that can access the medicine used to clear hep c are those with cirrhosis. if you have cirrhosis, that's great. but really, you want to catch it before it gets to cirrhosis. once you have it, you have a lifelong risk to cancer. first, any comments on that, then i have a follow-up once that asked. >> as you're aware, the treatment for hepatitis c is krr very expensive. in the private sector, it's roughly $1,000. a pill. we get it for about $650 a pill. so our treatment is cheaper and arguably, we have the best protocols of any medical system. so we do want to use it. but it has become a huge proportion of our budget. and as a result of that, we've asked for incremental money in a supplemental appropriation for hepatitis c specifically. because i think it's a moral and and legal issues that we treatment. we know what to do and we have patients that need it. because our population is disproportionately has hepatitis c. and we can't use it. carolyn, you want to go ahead? >> sure, we are doing a far better job than the private sector in terms of screening and identifying veterans who have hepatitis c and actually getting them identified and so forth. we have a cure rate almost twice as high. >> it's about 90% in the private sector. >> but the proportion of eligible veterans who have been cured. i used the wrong terminology. >> just a follow-up. the fellow told me, listen, what we're told is send someone out to get their prescription from an outside provider, which would trigger the choice act fund of money, but then they can get their -- once they have the rx they can get the follow-up in the v.a. you alluded to this. if the pot of money for the choice act is not being used for pharmaceuticals, we cannot -- that's not fungible, i'm gathering. we can't say, listen, no one's treating hepatitis c except the him v.a. docs, so let's let them access the pharmaceutical portion of the money. is that correct? i'm asking. i don't know. >> your point is correct. that the inflexibility of moving him money causes us to try to do different things with different pots of money. so by sending one out, we can use the choice care of money and get them treated whereas if they were internal, given our budget issues in the pharmacy, we may not be able to treat them. >> so the pharmaceutical portion of the patient's care is under the choice act. it's also the pharmaceutical? >> our doctors have very, very strong opinions because we have build tremendous capacity in the case. we would refer eligible veterans to a community provider but they would come back and get the medications from us, which we think would be -- it would be what we pay. >> but going back to your protocol, if you've got a good protocol of whom to treat and whom not to treat. i would not like that discriminated we will send you here because this is where the money is, but then you're going to be here because of the better protocol for management. it's critical at the outset. should we treat this person and have them counselled, et cetera, is there no way around that? >> we're trying to get as many veterans access to this life saving treatment as possible. this probably wouldn't be the ideal design. it would have some payoff, i think, of expanding the capacity in the private sector to take care of other patients with hepatitis c. but it would require a lot of very close coordination back and forth between v.a. docs and docs in the community. and it wouldn't work everywhere. it's not going to work, for example -- >> there's no way for the v.a. doc to access that choice account for pharmaceuticals. you see, it almost seems like we're trying to really -- >> right now, that's not the case. and it gets back to the secretary's point about inflexibility. >> i yield back. >> we would not need a liver transplant as i know. it's about $1,000 a pill. a liver transplant is about $300,000. if we can avoid that by curing the veteran, it's a much better outcome. >> speaking as a liver dr. there's four stages with , cirrhosis. you really want to catch in that third stage. the third stage slides into the fourth. so if there's any way to expand coverage, and i was going over and i thank you for your indulgence. >> mr. chairman, could i just -- for speaking as vice chair here. >> i have referred to -- >> oh. first of all, there's the medical reason of staying with one place. in other words, the v.a. is your medical home. and it seems, then, this sending them out is because your inability to have flexibility in money. so here is what i'm suggesting to my leadership here. i'd like to hear what are the -- why -- what is it that you need from us to give you the flexibility to do that? and number two, what are the impediments to do that? either we have to go to authorizing, could we do language here. could we do something because it would seem patient/doctor relationship, you want a medical home. >> yes. >> you actually get these pills at a cheaper price because you can buy in bulk. >> correct. >> and now there seems to be just bureaucratic rigidity maybe based on our law or something that did. so i would -- in both your capacity and with the concurrence of senator cochran to talk with you about this. i think dr. secretary mcdonald: we are putting our doctors in the position of making a decision about some of these life or death, whether they go to community care or our care. this is an important issue for the committee in general. we are allowing the veteran to choose where they want to go. i don't have the ability to move money from v.a. care to choice care, yet we have introduced the invisible hands of adam smith allowing the veteran to choose and i don't have the money to care for them. my biggest nightmare is 70 goes for care and i have money in the wrong pocket. you would not run a business this way. senator mikulski: -- >> i think you have hit it right on the head. the challenge is going to be congress is the problem. congress is pointing fingers at the secretary say you did not promote the choice act. i think he needs the flex ability of transfer both directions depending where the veteran demand is. >> thank you very much, mr. chairman and thank you for taking time with us today. we have probably -- let me just add another wrinkle as you are thinking about how to implement this in a way that works and i agree with senator tester. you are going to have to prove you have extended the reach of the choice program before you are going to get the ability to transfer money. let me add another way in which that may happen. it was largely meaningless in the state of connecticut. when it moved to 40 miles by way of car travel, that help, but it ignored one reality in connecticut, which is probably not exclusive to connecticut. the 40 mile car ride review into new york city which is a route veterans are not going to make. but because they are 40 miles away from a new york v.a. facility, they don't get access to v.a. choice in their hometown because they could get in their car and wait in traffic for three hours to get into manhattan, queens, or the bronx. i know this is tough to solve for, because you are trying to figure out adding the ways in which people commute to the very basic numbers you have assigned but is this something you are thinking about in terms of how you make sure you are bringing as many people in to the program as possible. ? secretary mcdonald: yes. we are looking at the burden statement and allowing me secretary to have the flexibility to determine that burden and that would solve the problem you are describing. and so, we're working with the interpretation that currently exists. we're looking to reinterpret it and we were going to work with you on that.>> ok. good. thank you very much. west haven, our facility, first of all has been a really great facility for veterans in connecticut. notwithstanding the wait times backlogs, accounting scandals in other vas. we've been able to get veterans in pretty much on time to west haven. they've done a really phenomenal job there but it is an old facility, it's got an h vac system. it's still got ward style bedding in the hospital. no parking which is a big deal in connecticut. big deal everywhere. so if you don't get the ability to transfer the dollars to the extent that they are unused by va choice, where else do you go for these kind of capital dollars? you're just going to have projects that simply aren't going to get done and dollars that are going to go unused potentially if you don't get this transfer authority? >> that's exactly right. we have about 70-plus line items that money is not movable from one to the other. as we talked about the house mark-up on the construction bill, virtually cut it in half. eliminating many of the projects that are very important to us. we don't have anner an alternative. it is ironic to me congress passes laws to tell us what benefits we need to execute to give to veterans. we're all for that. but if we don't get the money to do it, i can't make the two match. and i think when i look back at what happened in 2014 to the va before i became secretary, i would say it was a total mismatch of demand versus supply. you would not run a business that way the way that an agency has been run is working to a budget, not working to requirements. not working to what customers needs are. so i'm going to change the department, get us much more focused on veteran needs. i need the wherewithal to do that. i can't print the money myself. so there is a choice for congress. the choice is decide some different benefit profile for the veteran or provide the money that's needed for the benefit profile you've already approved.>> i have a long question but i'll save it for the second round or for the record. thank you, mr. chairman.>> just very quickly because i've got to go. i've got several questions for the record on billings regarder er in mental health. we'll look forward to the response. thank you for your service.>> thank you, mr. chairman. secretary, welcome to the committee. dr. clancy. and i appreciated the opportunity that we had to visit last week as you kind of walked us through some of the changes. i was so appreciative that you took the time to visit with katherine gottlieb who of course is not only an alaska leader but truly a national leader in innovation and working between systems, federal systems whether it is ihs and nba but to really provide for an innovative level of care. i'm excited about this proposal. mr. chairman and ranking member, and to our you aaugust vice chair -- she didn't hear that -- i do think that at some point in time it, wolfnderfully instructive for this committee and those around the country to understand the very innovative models we are utilizing in alaska where given large spaces and limited facilities, we are figuring out a partnering through systems working for the i had. ihs, working through our many times our community health centers and it is providing a level of service to our veterans that is immediate. we're breaking down some silos. i think we can look to some models that may work in rural parts of our country that will provide the ben if its that our veterans have so honorablebly earned but in a way that is -- is good care. we call it care closer to home. i don't know about you, but when i'm on the road, i'm always sicker than when i'm away from home. if i can get back home where you've got family and with our native people being with their native foods, being in a place that is comfortable. so it's something that i'd like to talk to the committee about further an let you know what we are doing. in that vein, secretary and dr. clancy, you can also jump in on this, we do have these partnerings that are going on and i think it the range of choices is good but i also recognize that we are still offering range of choices within systems that still have their structure. i worry about moving of records and sharing of data and really making sure that these separate rules within these differing programs don't cause more confusion. and thus limit our veterans in terms of their abilities to access these. so either dr. clancy or secretary mcdonald, can you give me any greater assurances to how we're coming along with a more fully integrated system with this very unique model that we're seeing play out in alaska? >> we have a lot of work to do together to get to a single model that's integrated. let me give you one example. we have five different ways that a veteran can get care in the community. of those five different ways each one has a different reimbursement profile. so when senator tester and i were in montana and he organized a town hall meeting of providers, doctors, hospital systems and so forth, everybody there wanted arch. they loved arch as a system. well, arch pays medicare-plus. choice, pc3, made medicare-medicaid minus. to get to the right integrated system we need to get all the providers on board. to get the providers on board we need one integrated reimbursement system and we'll come together, come to you and hopefully get that passed so that we can have no question as to get providers on board and veterans having a place to go outside va.>> the sooner that can be done i think it is so the veterans' benefit.>> if i can add, in alaska what is working well is sharinge ing arrangements with services. we're thrilled about that, about $10 million from va has gone to those services.>> i appreciate that. know that we want to work with you. i will make one comment. we had an opportunity so sit down and talk about this regional alignment or the re-alignment. i have to tell you, i am concerned because as i look at these divisions, it seems that we're getting bigger. it looks like the territory that alaska is in is almost identical to what the 9th circuit court of appeals looks like. we've been fighting to break that up for a long time. so i'm just sending the heads-up to you that i am concerned that when you have one region that's covering thousands of miles, three different time zones, the concern that the regional offices will be able to provide for that level of care that our veterans expect. i'm sending out the signals. i have several different questions that i would like to ask. we've talked a little bit about how we're focusing on reducing the backlog and i know it's always about numbers but at the end of the day for the veteran they want to know have you heard me, have you sat with me, what kind of care have you provided me. i know that my case workers in my offices back in alaska work hard and we're not pushing them to close out constituent cases boom, boom, boom and we're assessing you on that, in that level. sometimes it is hard. but when we have one great success with our veterans it makes our staff feel better like they've really provided a service. i'm concerned that as we focus on, we've got to reduce the numbers, we're forgetting the customer service. and as we forget the customer service, we're forgetting not only the satisfaction to the veteran but the satisfaction to the va employee who gets great personal satisfaction in knowing that they have provided a level of care. they've fixed a vet's problem today. and if they can't feel that they're doing that, if they feel that they're j uft processing numbers, the difficulty in recruiting and retention is going to continue which means that our backlog is going to continue.>> i agree entirely. this is why we're all doing this. it is not because of the stock options you get from government. we are doing this because of the inspirational mission that we have of caring for those that have protected us. we can't lose sight of that. it is more than numbers. it is the picture of the gentleman behind you. every one of those we feel -- it is exactly the reason i gave out my cell phone number during the first national press conference in september. i take calls every single day from veterans and i listen to them because you got to keep that visceral empathy of what we're trying to do. it is all very personal.>> well with shall thank you for your dedication. thank you, mr. chairman. i do have some questions that i will's submit to the record.>> thank you, mr. chairman. also, secretary, thank you for being here today. appreciate it. i've visited with you before about legislation that i've put forward. the veterans access to extended care. it's all about making sure that we can encourage nursing homes to take va reimbursement for veterans by eliminating the small business contracting requirements that they're currently under when they take va reimbursement but that they don't have to deal with when they take medicare reimbursement. that's a burden that really makes no sense for them. and they even have to undergo separate inspections so there's a lot of red tape, lot of splins ish compliance issues so many nursing homes won't take that reimbursement. just comment, if you would, on how you can help advance that legislation so that we can get it put in place.>> we're very much in favor of it so we'd like to talk to everyone who is going to vote and make sure they vote in favor because we think that that's the way to go. we got to focus on veteran outcomes, veteran customer experiences and there's just so much red tape that's getting in the way of it. since our people are trying to work in a system where they're prisoners of the system, in a sense, rather than working on meeting veterans' needs. we're very much in favor of legislation you have described and want to work with you on it.>> thank you, mr. secretary. that's very helpful. i recently had a roundtable in my state and many nursing homes were represented there. they said if we could get this passed that they would then look at taking the va reimbursement so i think we'd be very helpful and appreciate your willingness to help. second question for you, it's similar with you been it goes to the health care, medical care from local providers. you've touched on it here in a number offy you are responses, but i'm co-sponsor -- senator moran is the prime sponsor and there are others of us on the bill be but it is similar. it is the veterans access to community care. you've touched on that and some of the cost factors. but essentially the idea is to get veterans care closer to home when they have to go a long distance to a health center. they may have a cbot. in my hospital we have one va health center. covers most of north dakota and western minnesota. they do a good job but it is an 800-mile round trip from places like williston which i think is the fastest growing community under 50,000 in the country now. maybe over 50,000 now. i don't mow. but where they can't get that efforts that is cbot, we have real geographical issues here. your thoughts on what we can do to address in a way that serves our veterans and then makes sense in terms of dollars and cents to affordability.>> i think job one is to really execute the redefinition of the 40-mile limit and do that as quickly as possible so we can really determine how many people will want to use community care. we really don't know today how many people we want to use community care. we know that the redefinition of the 40-mile limit will virtually double the number of veterans who will take advantage of it. that's what we think, but we need to find that out. secondly, i want to redefine or reinterpret the geographic burden so that we have more flexibility, i have more flexibility to provide the ability for people to call it a geographic burden and go to community care. then the third thing we're looking at which we talked earlier is whether or not we look at whether we define it as a va facility that can provide that service or a va facility that doesn't. opening up that aperture could potentially be extremely costly, as i said earlier. could be $10 billion a year to $40 billion a year. and of course, the whole choice act, this part of it, was $10 billion over three years. so that's a conversation we'll have to have. but we need the numbers. we need some experience to be able to develop that ael gore ism algorithm.>> i think that's a really important area to be a ibl to figure out how to do this. again, if they're in 40 miles of a va health center, then that 40-mile rule works pretty well. but if you have these really long geographic distances, it is a real problem because there is a big difference. if they have to have open heart surgery, well, sure, maybe that trip, i understand, and so do this they. but there are a lot of situations in between where a cbot can provide and where it would actually be cost-effective for the va, too, because that veteran may have to travel one day, get the selves is the second day, travel the third day and you're going to pay for both the travel and the accommodations as well as the service. it's not only about figuring out how to do this for the veteran but i think it can be cost-effective for the va, too if we do it as you say, if we figure out numbers and how to do it. there is a difference between carte blanche and doing it in a way that makes sense. thank you for your help and look forwarded to working with you on it.>> thank you very much. mr. chairman. mr. secretary, good to see you again. last year i introduced legislation to expand the caregiver support services that va offers and to finally make the full program available to veterans of all eras. i'm going to be reintroducing that legislation tomorrow. senator collins is my co-sponsor on that. i want to work with you to make sure we strengthen the program and make sure it has the resources it needs to take on an additional work load. i really was happy to see the department requested a significant increase in funding for that program and i've also asked for additional resources for the department to hire more caregiver support coordinators. i want to ask you today, do you know how many more caregiver support coordinators you think you'll need over the next two years to support the current needs, and to take care of new veterans while eras coming into this program.>> i don't know exactly but i do know we are very supportive of the legislation you've written. we think that pre-9/11 caregiver caregivers should get the same benefits post-9/11 get. i spend a lot of time with caregivers myself. they are the unsung heroes of our nation. many of them have to give up their jobs.>> absolutely.>> and many of them have to purposely not take on work and not take on income because then they would fall out of the program. so it is a real conundrum for them and it is life changing for families. we've got to do this and we are eager to take it on and we're eager to hire the people we need. i've been to several college campuses. there are people who want to join the va to do this job. they're really eager to. we'd love to work with you on the legislation.>> if you can let us know what you think you are going to need over the next few years, particularly with the addition of this i think it is absolutely vital, so thank you. i also wanted to ask you about the spokane va medical center. as you are very aware, the emergency room at the spokane medical center has dramatically cut back its operations because of staffing problems. the medical center has repeatedly pushed back the date to resume full-time operations and now i'm being told that isn't going to be until next fall. the spokane va has also recently asked for its surgical complexity rating to be downgraded. i'm really concerned about that request and the potential impact on the access to care for our veterans in that region. last year i asked secretary shinseki and the under secretary whether there were any plans to reduce programs and services at the spokane medical center and they assured me there were not. yet we now see this facility being downgraded. the medical center is not getting the job done, so i want to know what you're going to do to restore emergency services and surgical care for veterans that rely on the spokane va.>> so one of the big challenges that we've had, senator -- we've discussed this previously -- is actually recruiting top-notch -->> i've been hearing that for ten years.>> yes. well, i'm meeting with the college of emergency physicians either next week or week after that to try to see if we can help with them. american legion also has some idea about how we might work with some of the hospitals in there. we've also raised the available salaries that we can be paid to people there. ultimately if we can't recruit top-notch talent i think we're going to need to explore some kind of partnership between the spokane facility and local hospitals vis-a-vis emergency care.>> well, look. this has been ongoing forever and it's not being resolved and it is a huge issue for our spokane veterans. so i want to talk with you again, mr. secretary. we've got to get this resolved, however we do it.>> while i know it's been going on forever -- we accept full responsibility for it -- i have been to over a dozen medical schools recruiting doctors. i've been to the osteopathic convention recruiting doctors. we are the canary in the coal mine. we see the problem that exists in american medicine. we need more primary care doctors, we need more doctors that will live in rural areas and we need more mental health professionals. we're working extremely lard to do that and to find them identify them and convince them. then give them a monetary incentive to locate there. we're going to continue to work very hard until we get that spokane facility up and running.>> i really appreciate it. one other question. i just have a few seconds left. right now the vnseterans affairs committee is holding a hearing on va service for women. i want to stress how important it is to prepare for the needs of a growing population of women veterans. i was pleased to work with senator heller to introduce the women's access to quality care act this year. that legislation will go a long way to helping the va provide safe, private health care for women. va already has a serious backlog in construction but it is the number of women veterans increase, as and they age, there is going to be a need for more space dedicated to gender-specific care. so i wanted to ask you what the va's going to do to meet the treatment space for women veterans over the next ten years.>> some of our budget that was cut dramatically in the house mark-up was slated for women's clinics. we're installing women's clinics in our facilities. we're hiring the gynecologists and other specialties that we need in order to staff those clinics. and to us, this is critically important. 11% of veterans today are women. it is going to go up to 20% by 2017 or so. so we've got to get this done. many of our buildings, as i said earlier, are over 70 years old.>> they don't have private space for women, i assure you.>> and they have single-gender bathrooms. we've got to get this fixed. that's why our construction budget was as high as it was.>> mr. chairman, i am out of time now. i'll submit the rest of my questions but i really appreciate that. i want to keep working with you on this.>> mr. secretary, let me talk about the hippopotamus smoking a co- cohiba in the room. where do we go in your view? >> where do we go in terms of -->> what is your end state for denver? >> our end state for denver is to finish constructing the medical complex. we would use -- >> i would say finish constructing the medical complex under the supervision of the army corp of engineers.>> yes. they're already on the project. and they would complete the project with us. and we plan to use the army corp of engineers in the future for major construction projects. >> i'll make it simple for you. my position is cory gardner's position to make sure you work very closely with senator gardner.>> we agree.>> thank you.>> in fact, the deputy secretary was out in denver yesterday and has been there i think seven times since he's come in to position.>> let's go with senator baldwin.>> thank you, mr. chairman. hopefully three questions i can get in this second round. i'm sure there will be follow-up, for the record, also. dr. clancy, you were at the field hearing in wisconsin on march 30th. i joined the -- i'm member of the senate homeland security committee that jointly held that with the house veterans affairs committee. it was -- we heard incredibly powerful testimony from family members of veterans who had lost their lives at that facility or after care there, as well as whistle blowers. now several months into this investigation, even at that hearing we were hearing of more deaths that were unexplained that we hadn't heard before. in fact, i sent you another letter today, not based on testimony at that hearing, but somebody who came up to me after the hearing and said, my husband was treated there and i have concerns related to all of those that you've been hearing testimony about. and so i just want to stress how important it is to have the investigation, sufficiently expanded to review those deaths and i want your assurances that the degree that we can follow up on every one that has been reported during the conduct of your investigation that you will follow those -- follow the evidence where it leads.>> you have my full commitment. absolutely.>> i appreciate that.>> if the senator would yield, let me add i would associate my comments with senator baldwin because a lot of illinois veterans would use the toma facility. we want to make sure we fix the candy store, it was called -- >> candy land.>> candy land. yeah.>> on the issue of property treatment for pain, secretary mcdonald, not only do we have to increase -- to crack down on individual use of narcotics, we have to better manage. we're here in the appropriations committee so i want to ask you how the va budget request supports the expansion of complimentary and alternative medicine and wellness programs that would help veterans dealing with accuse and chronic pain.>> as we look at va opioid use, which is -- dr. clancy said we closely, it is moving down. the reason it is moving down is i think because we are the largest users of alternative approach in the country. we had tremendous success with acupuncture, with yoga, with electronic stimulation, and we want to continue that. anything we can do to provide a different approach than opioid use we want to do. and as i've been touring all of our facilities, i think i visited about 125 so far. imooh always i'm always inspired by those people teaching yoga. in one location there was an art instructor who was helping use art as a way to allow people to become themselves again without opioid use. equine therapy in placed like bedford, massachusetts. anything we deem to be a successful program we also want to do.>> i woulded add we are doing a lot of research in this area to predict better responses to opioid use because that's very, very critical. that gets back to the notion of an informed conversation between a clinician and a veteran, family and so forth.>> right. one final question. we were just talking about the health workforce at the va. one of the things that i've certainly observed in rural medicine, for example, if you receive your training there perhaps if you were born and raised in a rural environment, you're likely to make a commitment in your career to remaining there. i think the same is very much true with regard to the va. in the va reform law passed lat year i authored a provision that included an increase by 1,500 over five years the number of gme residency positions. it is my understanding in this first year of implementation 204 new resident positions were added. i would like for you to give me a status update on the program's implementation.>> so, senator, first, thank you for that additional residency slots because i think that's something that will keep paying dividends in terms of capacity. we didn't actually think that we could start residency positions until a year from this july because of the slow ramp up. however, what we did was go to our existing partners and ask do you have additional spaces. that's where we got the 204 slots. we don't know what the uptake has been. every year for the national match for medical students -- it's kind of like "the dating game" -- primary care slots tend to go unused and so forth so we can get you a report on the 204. match day was just two weeks ago. back to rural care what we're working on is try to figure out how do we work with facilities pand communities that would desperately like to do what you just described but may not have the infrastructure there. how do we do that to make sure we can get them the faculty support that we need so that the residents that are trained there get the proper education and so forth. but it is a very exciting opportunity so thank you for that.>> we're also pursuing osteopathic doctors. d.o.s. they tend to be more primary care physicians. they also tend to locate in rural areas because that's also where the medical school is. today less than 1% of our doctors in the va are d.o.s. we're looking at a way to get more d.o.s in order to get more people to locate in rural areas.>> let me call this to a close. we'll keep the record open until tuesday, april 27th so that members may have a chance to submit their questions for record. call it adjourned. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] [captions copyright national cable satellite corp. 2015] >> it tomorrow, defense officials will provide an update on where they stand with full combat integration since the 2013 decision allowing women to serve in combat. live beginning at 12:30 eastern on c-span3.

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