Transcripts For CSPAN2 Lawmakers Press Veterans Affairs Secr

health care, decreased wait times and modernize the va i.t. system. >> good morning here today we're pleased to welcome back our good friend dr. david shulkin, the new secretary of the department of veterans affairs. the last time you appeared before our committee you were v under sector for health. now you've been kicked upstairsp after a unanimous senate confirmation vote, we become unanimous and that says a lot in this political environment so congratulations. we come with your background i know you a great background inph philadelphia. i just learned -- you certainly bring a lot of experience to the job. although i'm sure these days the challenges are very daunting for you. we realize this ring is a bit unusual.ua rather than a typical budgeting where you have at this time of year we are limited tod discussion of the skinny budget, the skinny budget mentors that omb sent to the hill in march. the two page entry for the va doesn't give us much to go on in terms of program priorities or plans for the choice successor program but skinny budget does give us one remarkable bit of news for the va. apparently the administration is proposing a $4.4 billion, or 6%, funding increase for the agency. in addition there's $2.9 proposed in new mandatory funding for the va. you must come you'll probably the only domestic federal agencs not facing a substantial cut and so i suspect i'm going to need kevlar vest when talking to my fellow appropriations subcommittee chairman. so when we see your full budget later this month we will be asking some tough questions about the merits you propose increases, we know others will be struggling. despite not having a completes budget i'm sure the members will find plenty of topics ask youu about this morning. how you envision va strike a balance between care and va facilities versus non-va community facilities, making making electronic health recordd work for veterans especially as they see more doctors through choice, your efforts to appointment scheduling problems, how you plan to approach disability claim backlogs and appeals, your plans to decrease veteran suicide and homelessness, your campaign to limit opioid abuse amongns veterans, plans to access care for rural and female veterans. and that's probably just a start. they will think of other things i'm sure. we will include your full statement today in hearing record and will be pleased to have your oral statement but before you begin i'll ask our ranking member ms. wasserman schultz hs any opening, she would like to make and then after that and the ranking member of the full committee. with that, ms. wasserman schultz is recognized. >> thank you, mr. chairman. and welcome, mr. secretary, it's been a pleasure to talk with you over the last few weeks and i'm good to have you in my office yesterday. we do appreciate you being here in your new capacity, and i go to chairman scott meant, particularly given it's been awkward in the choice we find ourselves in a secure operating on a bigger stage than previously and with greater responsibility that come with the duties of being on thee secretary of the va. mr. chairman, since the screw 2008 the va have seen a tremendous 70% increase in accounts, medical care accounts have grown from 36.7, 64.6 by note and the overall discussion accounts have increased from 43.6 billion, have increased from 43.6 million, the $74.3 billion. fy '20 teen is certificate the president skinny budget evenue request $78.9 billion, or 6%8. increase from the 2017 enacted level. in 2018 budget requestority legislative authority, $3.5 billion in authority to continue better veterans choice program. and what is a question that arises is that this would support a program that was initially met as a stopgapin temporary fund. while i am certainly thrilled to have you heard today, it's unfortunate we won't be able to discuss the specifics of the vau budget because and the lack ofic detail makes it extremelydg challenging for the committee to properly do our job. moreover, given this 70% increase over the past ten year it's critical this committee has the opportunity to analyze and understand these numbers as well as know more about why the va continues to issues oft mismanagement, wait times and less adequate care. while i can understand the degree of growth has its growing pains it is crucial we understand how these issues are being addressed. once we were fully understand the issues at one point to ask if this continued growth issecrt unsustainable? mr. secretary, i ask these questions with a genuine concern for the future of the va for obviously our driving concern must be to provide the best cari to our veterans. if we don't control costs and d ensure the resources thiss committee provides, or use inappropriate and efficient fashion, we actually hurt our ability to help veterans and deliver on our mission of providing top-quality care. it comes to mind that while we are providing additional resources, we're not seeing what would normally come as the commensurate response from the people who are receiving the services because of the challenges that the va salving in providing those servicesef efficiently. top-quality care is really our top priority and we need to make sure that we help you deliver on that mission.mi with that in mind it's imperative we discussed a number of key issues including the choice program and the state of the das electronic health records. has the va and vision choice, a program which with committee care, and discussion program. after creating the committee care account which includes $9.4 billion in advance, white is a budget request also include $3.5 billion for the choice program? where is of the v the va in in d approving its electronic health record system and executing congresses mandate for full interoperability with dod systems? as we discussed this past monday in my office, mr. secretary, a solution is long overdue. and finally i hope you can address a significant number of vacancies that the department and when disposition type of expected refill. 11 senate confirmable position remained vacant including the undersecretary for benefit of the sector for health, the undersecretary for memorial affairs, the general counsel, this is a subject of information technology mss and second for policy and planning, thesis executive for management and the chairman of the board of veterans appeals. and by the way the veteransss appeals process is an absolute mess and so for it to have no chair for as long as that has occurred is really unacceptable. from our discussions i really believe you always want reform and approve the va pickett is reflected in the confidence and was placed in you with unanimous vote in your confirmation from t the united states senate. it's our duty at least to ensure that you adequate resources to do so in the proper oversight is in place to go out after abusive.av we have a lot to discuss today. thank you for the opportunity to chairman concerns and i yield back. >> at this time i like to recognize that chairman of the full committee. >> thank you, chairman dent and ranking member wasserman schultz. first of all i want to give you a shout out for passing your bill last year, september. thank you for the effort. you were the pacesetters. i wish we could've followed youd base, but in reality we didn't. but i can't think of a moret important department done the department of veterans affairs. those who have served our country and serve our country right now in dangerous places deserve when they get home they get the best care possible. i know you from your time in nef jersey and wonderful things you did there. and for good reason to her nana is the senate. there's not a lot of unanimity over there but i'm glad they focus their attention and support for you. two areas of interest to me, i don't want to take time away from your marks for your questions, continuing the appeals and benefits backlog. it's a nightmare. i've even shared with you some of the three or four year waiting periods where people obviously evidence has to be collected and verified, but in reality it's pretty nightmarish prospect since early the confirmation of your undersecretary might be hel heln that regard. hopefully that will happen. the last year has been continual interest to me, is electronic medical records. i think three years ago then chairman rogers posted chuck hagel, secretary of defense, and reduction seki, one of yourri predecessors, and we received a committee, commitment from i think former general since i keep that we have within a year some sort of solution. i know that department ofan defense, and given the resources they been given is getting up to speed i do view your systems as sort of the weak link. i personally feel this is something which is enormously important in a day and age when with so much information passing back and forth obviously, encrypted and protected. that did not at that available to our healthcare providers is pretty inexcusable, but good luck and godspeed and thank you, mr. chairman. >> ms. lowey, i'd like to recognize you. >> thank you very much, and i would like to thank chairman dent and ranking member wasserman schultz for holding this important hearing. and i welcome secretary shulkin today. we as members of congress, and you as the secretary of veterans affairs, have a duty to provide the best care available to our veterans who have sacrificed and faithfully served our nation. the va faces serious challenges in meeting their health need. after working for years to reduce the claims backlog, it is once again increasing, and the choice program will soon run oua of money and is in need of reform.nd and the va and department of defense national closer to the interoperability of electronicni health records than they were years ago. we owe it to all current and former, future veterans to tackle these challenges now. the subcommittee is committed to achieving that goal. i must say after reading your resume, i am so optimistic, as was referenced before, chairman rogers and i had i think for hearings, right, chairman frelinghuysen? we also met in closed door sessions but we haven't been able to resolve this. now, i have my own personal preference about who' who is to blame, as we're talking about it before, but that's irrelevant now. and looking at your resume, i am so enthusiastic, and i know you're going to get this done. in my own district, i worked to secure federal funding to improve rehab facilities, and ensure that veterans can receive a high quality of care. but for too many the va is unable to provide the types of services they require, from women struggling to find care in a health if so -- help system that is traditionally served we men, to veterans who are turned away from va facilities when they are most in need, the va has a responsibility to serve all veterans who seek the careca and treatment they ever earned. in light of these challenges, congress awaits the details of the presidents fy '18 budget request. the budget framework requests an increase of 6% to the va, but lacks detail. providing just seven bullet points of vague proposals.s why you may not be able to speak to details of the budget proposal now, i hope you will return after its release so we can fully discussit.in thank mr. secretary, i again thank you for being here today. thank you for your commitment to improving the lives of veteransr and thank you for assuming the responsibility i look forward to hearing about all your success sooner rather than later, so wew won't come in a bipartisan way, continue to talk about backlogs and the lack of records. so we have confidence in you, and i thank you for appearing here today.ou, at >> thank you, ms. lowey. at this time i like to recognize secretary shulkin for five minutes. [inaudible] >> maybe that's better. okay. chairman frelinghuysen, chairman dent, ranking member lowey, ranking member wasserman schultz, and all of you who are here today, i was so impressed with your opening statements, so many topics that you thought about and that you care about, and i know are serious issues here and we're trying to do things differently at the va,, that i have a terrific opening statement, but i'm willing to, mr. chairman, to actually forgo it and get right into your questions and then she would prefer me to go through the opening statement people because i think we have so many issues and a want to use your time most valuable.. i have submitted it for the record, but be glad to read through it, read through my oral say that but i will leave it up to you. >> you would like to hear? good, okay. okay, i told it was terrific. >> the abridged version, about five minutes. >> i will try to do it quickly, but thank you. so thanks an opportunity to be a today to talk about the presidents 2018 budget. i also want to all for your support of the 2017 budget that really gave us for the first time our full budget from the start of the fiscal year. it really speaks well of thee u.s. congress and really of the american people that despite all these differences, and you thint to the sometimes, though we can come to get on this topic to support our nation's veterans. i have submitted the full statement for the record. the president's 2018 budget reflects a strong personal commitment to our nation'sid veterans, provides this a resources to continue ongoing modernization of the va system. the budget request $78. $78.9 bn in discussion of funding or va, 6% increase from the 2017 enacted level. it provides 4.6 billion more foe medical care, 7.1% increase, and a 3.5 billion more and mandatore budget authority was mentioned to continue the veterans choice program.ng for more veterans are opting for choice than ever before.ef i've times more in fiscal year 2016 that fiscal year 2015. an choice authorizations are still rising.% more we've issued 35% more authorizations in the first quarter of fiscal year 2017 that in the same quarter of 2016. all told, including both care at the facility anthony kennedy, we project a 6.6% increase in ambulatory care for 2018 over 2016. i urge you to support and fully fund our 2018 request to enable va to meet increasing demands for va services to modernize the va systems and to invest in choice. as you know i came to va during a time of crisis when it is clear that veterans were not giving the time access to high-quality health care they deserved. i know va has made significant progress in improving care and services to veterans but i alsoi know that much more must be that if va is to continue keeping president lincoln's promised to care for those who are borne the battle. last week i had an opportunity to meet to courageous young americans, michael and sarah of rhode island. all michael ever wanted to do was be a soldier, and he became a soldier serving his army, serving in the 82nd airborne division. then he lost a leg and part of his arm in an ied explosion afghanistan. he suffered other ones as well. they told it when he sought care from the va in 2014 they did not receive the care. we cannot allow ourselves to ever again fail our american heroes. meeting michael answer underscored for me the urgency va modernization. i-5 prayers of secretary are greater choice for veterans, to modernize our systems come to focus resources more efficient efficiently, to improve the timeliness of our services, and suicide prevention among veterans. we are already taking bold steps towards achieving these birds. to reach of the president signed a reauthorization of the veterans choice act ensuring that veterans can continue to get care from community providers. just last week thepresident ordered the establishment of a va accountability office and removing as quickly as we can within the limits of the law to remove bad employees. va has renewed medical center directors in san juan, shreveport louisiana and recently we have relieved the medical center director writer in washington, d.c., and remote three of the senior executive service leaders to misconduct or deplorable service bu. we simply cannot tolerate employees who count --who are counter values trick since january of this u.n. authorized an estimated 6.1 million committee care appointments, 1.8 million more than last year, 42% increase. we.en we now have same-day services for primary care and mental health at all of our medical centers across the country. veterans can now access wait time data for the local va facilities using the easy online tool where they can see this week i'm spared no other healthcare system in the country has this type of transparency. va setting nutrients with public-private partnerships. last month we announced a public-private partnership of ambulatory care department center with a donation of roughly $30 million in omaha nebraska thanks to your help. veterans now have or will have a facility that is being built with far fewer taxpayer dollars in the past. finally, he is saving life. my top clinical by gordi gordy s suicide prevention on average 20 veterans a day die by suicide. a few months ago the veterans crisis line had a rollover rate to a backup sin of more thanid 30%. today, that that rate is less than 1%.rollover in support of her efforts reduce suicides we launched new predictive modeling tools that allow va to provide proactive care and support for veterans who are at the highest risk of suicide. and recent announced va will be providing emergency mental health care to former service members with other than honorable discharges at all of her medical facilities. we know that these veterans are at greater risk for suicide and we are now caring for them as well as we can. these are just a few other efforts in underway but already. improving the lives of veterans but to keep moving forward we need your help we need congress. to help us realize our capital infrastructure, to dispose of property we don't need and to support facilities wherere veterans can get better soon. we need congress to fund our i.t. modernization to keep our legacy system from bailey and increase the interoperability of electronic health records essential to any high-performance integratedel health system to also weighing options adopting a commercial off-the-shelf alternative to our legacy systems are at scheduled a decision for this in july. if it makes sense to go to off-the-shelf route we will need some additional support from u.s. will. we need congress authorized thes overall for a broken and failing claims appeals process that many of you have mentioned. t working closely with veterans service organizations and other stakeholders, va has drafted legislation to modernize the system. we submitted our proposal to the 100 14th congress and we've resubmitted it in this current congress. we need congress to act on this. most of all we need congress to ensure the continued success of choice for veterans, extended the choice program passed its august and it was an absolute necessity, and thank you forontd that. but extending the program was just the next step towards the modernization of committee care and better teaser pic with charted a course for modernization and already moving forward but we need your help to keep up with the choice programs growth, maintain our momentum and make our community care plan a reality for all veterans for generations to come..we in closing, let me again express my thanks to the appropriations committee and to the subcommittee for the support unit shown veterans in recent years. without the support we could non expanded choice to a record number of veterans were also curing so many veterans of hepatitis c. s you have made that possible, ana 77,000 veterans are now free of hepatitis c as a result. thank you for the opportunity to be here today. i look forward to all the questions that you may have.yo >> at this time i'd like to recognize the chair of the full committee and if he has any questions? >> very briefly. you are talking at the legacy system, the acronym is vista. now you're looking at an off-the-shelf system. isn't the issue here you have i.t. systems, give it i.t. systems at every hospital? so where are you in the overall, very pretty, where are you in terms of a be some good news in the next? >> right. well, we only have 130 different systems, okay? the vista system is something that frankly va should be proud of. it invented it. it was a leader in electronic health records but, frankly, that's old history.. we have to look at keeping up to modernize the system. i said two things, mr. chairman, in the faster i said, never one is va has to get out of the business of becoming a software developer. this is not our core competency. i don't see why it service veterans. i think we are doing this in a way that frankly can't keep upuh with. so i said that we're going to get out of that business. we are you going to find a i' commercial company that will take over and support vista or we'll go to an off-the-shelf product and that's really what we are evaluating now. we have an rfi out for essentially commercialization of vista that we wouldn't, longer be doing interlude. the second thing i said is, i think it was referenced in several of your comments, you have asked the department ofr defense and va to work together probably for ten or 15 years. and we've always done ways not to do that. secretary mattis and i talked about this. we believe that we need to find ways to work together. when i come out in july on going to be talking about a process that led to a decision to get us out of a software developer business and to a way to work even closer with the department of defense than we have. we are working rapidly towards that decision and i'm committed to that date. [inaudible] >> at this time i like to recognize ms. lowey. >> thank you so much, mr. chairman. there are so many questions but he must continue this discussion, having been part of this issue of records for the last five, six, seven years. and i gather we had spent $1.4 billion on this. i don't even know what i want to call it, project search, interoperability. but what i'm confused about,, it's my understanding that the defense department has already rolled out the system.m. it seems to me you make a lot oa sense saying we're not going to be in this business anymore. we want an off-the-shelf system here however, an audit to ensure there's interoperability, what's wrong with the defense program and why wouldn't you at least at the outset explore that?'t because if you choose another system and they have their system, what going to become another billion dollars that wee could use for suicide prevention, for treatment, for all kinds of important things. i have to tell you, as the ranking member, chairman frelinghuysen and i go to a lot of committee hearings, but this affects my heart. and what i talked to veterans in the district, and i know the challenges they are facing, and i know that you all the confidence, background to do it, why wouldn't you start, or are you look at the system, the defense department has rolled out? >> yeah. so first of all, i hear your -- >> frustration. >> that's probably a good word. >> we've had hearings with anger was -- >> listen, congress has been very clear on this or years and years and that's what i believea that you anti-american people and the veterans deserve a clear direction on this, and i'm committed to doing that. i can tell you we are exploring all options but i ensure i am sure you understand this is a highly complex issue. i've lived through personal electronic medical record conversions in hospitals i've ie led. these are not easy projects in single hospitals, let alone talk about the size of the va system. so we're taking this very seriously. i can assure you we areng exploring all those options. we also as we get more veterans out in the community, out into the private sector hospitals, we have to be very concerned about interoperability with thoseons. partners as well. so if there was an easy solutios here, i am sure it would've been made already. but we're going to make a decision and we're going to move forward with it and we will need your help in being able to implement that. >> i-26 thank you, mr. chairman -- i just want to say -- and i want to thank you for assuming the responsibilities that are veterans certainly looking for and they deserve, and i wish you the best of luck. and i look forward it to coming back sooner rather than later, because i do want to have another hearing on interoperability. >> right. >> antiwhite remind you again, $1.4 billion has already been spent on trying to get theto get defense department and the vad coordinate. so thank you so much again. we look forward to hearing from you, as soon as possible. >> thank you. >> thank you, ms. lowey. mr. secretary, we understand that your flute edges for a system to consolidate the various non-va care programs including choice. while we realize your proposal are by no means locked down, it sounds like you're contemplating a plan that will allow veterans to seek urgent care outside the va system followed by discussion with a va care provider and about whether the veteran should be seen in the community or by the va. that decision would be based on the results of the local health market analysis identifying the capacity, quality and cost of the first service at the local va. iis the basic premise of this proposal to keep services within the va subject to availability, quality, capacity, rather than open the doors more broadly to non-va care? >> let me to describe it, mr. chairman, although thatt differently than that. first of all i think you are correct that what we identify. coming out of the 2014 wait time crisis out of phoenix was that the va i don't believe had the appropriate management systemsms in place. and the way i believe you write a critical system is that you put your clinical urgency first -- i believe you run -- somebody shouldn't be waiting if they have a tumor in her chest or if they have blood coming out of parts of the product that they shouldn't have it coming out of. that needs urgent care right away. so we're going to prioritize and to make sure veterans are not waiting. secondly, we're trying to build an integrated system of care. that means if you look at this from the veterans perspective which is really the only perspective we should be looking at this from, you want to take what the va does best for veterans, that you can't find as well in the private sector. and you want to take what the private sector does best, that the va doesn't do as well. and you want to make that an integrated experience for the better. that's what we're trying to do. currently when third of our care happens outside the va walls, two-thirds inside.e and we are working out to get the proper mix in each of thehe committees because it will look different in nooks and then it will in arkansas. and try to figure out in the committee what is the proper mix of inside va and working with the community. that's what we're hard at work at doing. and i think that this will benefit the better the most.i tn >> just to follow up on that. what cost would you -- to keep the costs manageable?e >> i am very sensitive to cost and my belief is, is that one of the reasons why we got into the problems that we did in va is because we were not properly funding the actual demand. that's why i think it's so important that we and you work with us to get what the president has requested for the 2010 budget, because i think we need that. but i am not looking for nonsustainable increases year after year the way we have in the past.ar the w i think as congressman wasserman schultz said, that is an unsustainable solution. the problems we have in the va are not primarily financial. these are primarily system issues that we haven't kept up with and we haven't modernized. i am looking for an investment this year to help us modernize our systems.stems, t the i.t. system with one example of where we need to come back but i'm not going to be seekinge increases of this type in future years to come.ty so we do need to put cost mitigation strategies in place. one of the areas where focusing on a barrientos is fraud waste and abuse. i think there are huge opportunities to identify waste and abuse in the current systema they are not the proper safeguards in place, and we're going to be taking some aggressive actions to do that. the cost mitigation strategies that i seeking as part of choice. one of them would be for the va to be able to do value-based purchasing. the private sector has been moved towards this where there are accountable care organizations to focus on quality in cost and we canan purchase care based on the besto value, which is cost over quality. we don't have those tools in the theater in fact, we are restricted from using that. we had to be a flat medicare fee schedule. i'm seeking the same tools that the private sector has to control costs and improve quality. we han't i just quickly follow up? if congress were to adopt your ideas what would that mean for workforce and facility infrastructure needs? >> in this budget? n >> yes. >> we are seeking the budget so that we can hire the proper healthcare professionals. we have now 45,000 clinical openings in the veterans health administration, and another 4000 openings outside of the veterane administration, so for a total of 49,300 employees that we are seeking. i think that frankly the crisis that we went through and the lack of good press, so the impact on the morale of the workforce has really hurt us in recruiting. of course we had a hiring freee in place up until april 12. so we have come in particular my priority is the priority areas like mental health i need 1500 new mental health professionals to join the va. so we will really prioritize that right now and this budgetri would allow us to get up to that staff. >> thank you. at this time i like to recognize ranking member wasserman schultz for five minutes. >> thank you, mr. chairman. first and foremost i just wanted to suggest that as an up of members have mentioned it, because the secretary is limited to only speaking about the skinny budget, it would be incredibly helpful and important once we have the president's budget released for us to ask him to come back and hold a hearing on the actual full budget request. so i would ask both the chair, both chairs to please consider doing that. just so we can get into more detail. thank you. i want to focus on the choice. program for a moment. you have asked for an additional $3.5 billion and we talked about it yesterday a little bit, but we recently extended as you mentioned the choice program passed the august exploration date -- expiration date.e in part obviously rather than letting that funding to languish and considering there still a need, that made a lot of sense. we did envision a choice program to be a temporary program initially. my understanding, and correct me if i'm wrong,, was that was supposed to be a bridge for the va to transition to the committee care program until hen can get the committee care program in a place where it's able to provide the kind of timely services that we need ite to. if that's not the case then can you explain the differences between the two? youth also proposed choice 2.0, so we have choice, choice 2.0 and community care. i'm not sure how it would ultimately help us realize our goal of efficiency if we have three different programs in the private sector to help make sure we can meet the needs of ourpr veterans.ctor t >> right. i couldn't agree with you more. i'm looking for one program. three programs doesn't work. we now know having to programs that didn't work very well. we confused veterans. we had to programs, community care and choice. they had different rules. they put veterans at risk in their credit, because some paid first dollar and others didn't,, and juridical different numbers to use them. we are proposing a single program for community care. as far as the intent of congress with three years, look, congress stepped up in a big way after the crisis when basically the w country and congress agreed that the current situation with veterans waiting for care was unacceptable. va did exactly what congress asked us to do, which is to putc into place additional options for veterans to get care in the community. and now we are seeing those authorizations and appointments occurring in the community. when i started va a little bit, although less than two yearsve ago, we had 20 20% of our care n the community. today it is about 32%. you can see where expanding the options. i don't think there's any turning back from this. so whether it was intended to be authorized for three years or not, i know that's what the legislation said, i think what we've seen is veterans need that care. they are coming to be to seek that care and we need to continue to support that. that's my opinion. the 3.5 billion that was built into the program is very much i needed resource for our vetera veterans. >> i understand, given that you go is one program, are you analyzing which program ultimately would be phased out? because we have a tendency to, instead facing a programs, because their people with vested interest in them, simply going along to get along rather than rocking the boat. so if you're adding $3.5 billion to the choice program and it has 950 million left, there have been challenges with the choicee program and confusion, and are still challenges with the community care program. in what direction is the va thinking of going when we come and what is the timeline for ultimately phasing out one program and only having one? >> with almost certainty i can tell you that will not be three programs the current choice program will run out of money by the end of this calendar year.st so the program is going to go away. and should be through december of this year.through what we are hoping to do is to work with you so that we can introduce our community care funding program, the chevy referred to as choice 2.0, which is which is a program that makes sense for veterans, which is avs single program that operateses under one set of rules for how e community. and that new legislation, which would lead needs to be introduced by late summer, early fall in order to make the late u timeline, would end up with a single program. >> so you would eventually envision phasing out community care with the advent of choice 2.0?ity care >> yes. >> thank you. i yield back. >> at this time i like to recognize the gentleman from florida for five minutes. >> thank you, mr. chairman. i'd like to just sort of continue on the same linee briefly or just maybe make a statement that our chairman of the full committee as well as ms. lowey, ms. wassermanairman schultz, remit of the other, we've been getting all a lot of money. i've been on this committee with gentian seki who i served under at fort hood with mr. mcdonough, a military man, mr. mcdonnell,in businessman, you're a doctor. by the way web a lot in common in the i am from florida. i up in philadelphia, pittsburg connection so i'm rooting for you. but come and he talked about working with general mattis and trying to get this continue to get well talk about on the stump when we are down in our districts that if you put the uniform on and serve this country were going to take caren of you, as you mentioned, lincoln can we often reference washington. the ketchikan measured something out treats it treats its veterans. one of the things we say from a time that you list or the time that you get commission to the time that you die you will not be left out in the cold.nl we will take care of you. one of the things that people asked me about is where does it fall through the cracks?e we often talk about how, even though we are giving you all the money that you need, that thee difference between dod and theee va is way too big, and whether it is the electronic records are just the fact that chapter basically start all over when you leave the military and you get into the veterans program, whatever it is. i guess my first question to you is, if the general mattis has a better idea than you do, you agreed to go to his program just to get this moving? i ask you this for this reason. you could be the best va secretary of all time if youu solve this one problem. i mean, every time we sit up here and talk to people at the stable, we always keep asking the same question or i know there's a lot of bureaucracy at a know that there's a lot of pride in whatever the problem is but we just hope that this come if it means using, you're right, you have a better program, will you do it?ight, >> first of all, thank you for your comments.av i appreciate your perspective on this issue, how important it is. i'm only here for one reason and that's to solve the problems that have plagued va. i wish it was only one problem by the way. but i agree with you. this is certainly an important problem for us. anybody, whether it's secretary mattis or anyone else was bu bui did and i have, i'm going to take it. the answer to question is yes.th we want to resolve this issue in the best way, and if it means taking someone else's idea,, we're going to do that. >> it would be so good to give to go home and stand up on the m stump and tell these guys, i come from a district with a lot of retirees in florida, a lot of military retirees, and tell these guys if you put on a uniform for this country we are going to take care of you. basically, if you need the help, the mental health after you served, it's one of the you advantages of joining is that you know joe going to be taken care of when you get out. so that would be a huge help to all of us up here who are trying to convince people that fighting for this country has benefits well beyond just the price of service. one quick thing since i'm running out of time and this is more specific to my district. i'm having my constituentsrvices services representative brown of florida are telling me that we're getting a lot of people that are moving to florida as it always do from other parts of the country, and they're going in to get care at our va. because of whatever breakdown in coverage, they are told that in my district that they are told start a new treatment plan or return to the state from where he came from when are we getting care for whatever problems they were having. this is kind of absurd from the standpoint that we've actually got five or six pacific cases where people that live inas florida can't get the care that they're getting in the other states of their rather than serving over in florida, going back to the state where they came from and using that fear because you are in a specific busy tickets to the system wher you should be any lapsed incomes but there is the can you talk about that? have you heard about this at all? >> i haven't heard about your specific situations, but i hope your directors are watching this right now. because what you describe is unacceptable. we have one va system, better and should be able to get care at any va that they go into. and that is our commitment. i am not at all doubting that it doesn't work all the time. i certainly here many examples what does work and people are able to get care that a traveling, they lose their medications. they are able to get to va, get them refilled, get the care that they need. that is a system, that's our expectation of how we manage the system. i will re-clarify that to our field. >> thanksthanks, doctor. good luck. >> thank you. >> thanknk you. if i could just interject on that point for a moment. did you describe the current joint legacy and what it can do to share records just for the benefit of some of the members? >> i'm sorry that congresswoman lowey left for this because i didn't say this to her. but we did certify interoperability with the department of defense in april 2016. that is through the joint legacy, that if i were a lotot upper $1.4 billion went to, although i don't think it was not much. and what this does, this allows any va clinics, any dod clinician to build access records from the other system. so it is a read-only system. it is being used tens of thousands of times a month by clinicians in both systems. so it does work and it's a lot better than before when we didn't have that ability. it's better care. but it is not the complete interoperability that i thinkit that all of us would hope for. it's a read only system this point. read >> thank you for the codification. mr. bishop. >> thank you very much, and welcome, mr. secretary. let me join my colleagues and congratulate you and thank you for your commitment to get this problem, these problems fixed. let me go to third-party uncollected billing. the fy '16 appropriations act directed the va to submit an annual report identifying the amount of third-party help build links that are owed to the va, aand annual amount that is collected. additionally require the va conclude a plan to capture uncollected third-party billings. billings. the va was directed to initiate a power program and figure out best to capture the uncollected billings.re out h the difference between buildings and elections in fy '15 was $4.7 billion. in fy '16 it was $5.164 billion. this is alarming because it means that billions in uncollected dollars is not available to the vha to provide services to veterans. what is the status of the pilot program, and to in the department is responsible for the fiscal management of third-party billings and collections? and if you could answer that quickly, i want to move to another -- >> i will try to answer this quickly. i think you identified an area of significant risk for us, that we have opportunity to do this in a much better way that we are currently doing. so i think you correct. we currently collect around $3.4 billion a year. we actually will be asking for it are new choice legislation, we hope to work with you on the ability to do this better. we right now are not allowed to require that veterans give us their other health insurance. so i thought of that gap is because we don't know their insurance numbers and we don't know their insurance company in which to collect it from. but are looking at and we have an rfp that the group released in the next couple of weeks to be able to see whether the private sector can actually help us to collections better. that is part of our pilot work that we're doing.the pi we're using another federal agency to help us with these collections. that does seem promising pics i can teach you a more detailed answer because a double to take the time now about the results of the pilot project. >> thank you very much and i w projecorward to that. >> yes. >> mr. secretary, your predecessor mr. mcdonald started an initiative known as my va to modernize the va.ti my va fission was provide a seamless expense across the entire organization and throughout the country. in your test when you mention you intend to -- modernize va's will. can you tell us how your plaintiff is from the other how you plan, and was not you plan to build upon that my va? can you provide update of the better integrated service networks realignment? that's a first part of the question. the other has to do with the soldier realignment.irst p you mentioned and national infrastructure realignment strategy.yo the last time made the effortt for needless capital asset realignment to enhance services. do you envision that the department will embark on a similar effort? if so, when will we see your plan and divest va capital assets, a strategy that you plan to propose similar to the base realignment, the bracket process? >> there's a lot there, congressman kozol tried to doo this quickly. the my va program undersecretary mcdonald i think no doubt has the correct intent which is to design a better centric experience and focus on that experience. and we know that there was significant and good improvement being done for the program because we could measure. what i said to the department s that one of the benefits of me having been in the department under secretary mcdonald is that i would know what was working. i don't want to stop the progress that was being made but also don't believe we are making progress fast enough. so i'm looking to essentially continue the part of the program that work but i'm seeking much broader, boulder transmission of this department because i thinke it's what's needed and that's why it said my priority four. in terms of the vision realignment, we step 21 stations. we are now down to 18. whether 18 is right number or not, i think we always continuing to take a look at that. we're going to change the role and function of the vision frome what he currently has, which is another layer of administrative complexity, some people may call that red tape, to a much more tu profound function in managing their local markets in moving towards this value-based purchasing concept and making sure that veterans get the best care in the commune of the best in va care. so we're working on that transformation as were building our choice program. the realignment, the cares program, i was in here when that was implemented. i do know that wehave closed 1000 facilities so that there has been progress made in that in the past, but i don't fore anybody with enthusiasm bringing back the cares model. i think that we learned a lot of lessons in that. whether the bra bracket is a mol we should take a look at, we're beginning to discussions with members of congress about their suggestion we do believe that we have, i know today, 431 vacant buildings and 735 underutilized buildings. we want to stop supporting our use of maintenance of billings that we don't need everyone to reinvest that in the buildings that window that have capital needs. so we're going to be looking for to working with you on that. >> thank you very much, mr. secretary. >> thank you. mr. secretary, welcome and thanks for the breakfast yesterday and the opportunity to engage you in conversation before this hearing jerk it has been my experience down through the years that organizations,th particularly large organizations that find themselves in a bit of trouble, sometimes, many times,n stem from the fact that they get away from their core competencies and they expand into areas where they are not terribly knowledgeable, capable, and certainly not efficient. and they sometimes serve as a weight, an albatross if you will come around the neck of the organization and it causes a lot of other things to be compromised in the process. i suspect that the va probably fits into this category, and so specific my question is this. you have spent some time talking about i.t., which i'm beginning to believe it's not the core competency of the va we have had many indications that the construction of property is not, in aurora colorado probablyt, being the poster child for it recently, not a core competency. you talked about collections just a moment ago, and that would not message will be a core competency. so i'm going to throw this on the table and let you respond. is it your intent as the secretary of va to protect the core competencies of the va by outsourcing, for lack of a better term, some of the other things that a third to kind of bog down the system?hings th .. e bog down the system? >> i think your assessment of what is happening at the va is pretty accurate. i think we have learned the hard way and taking too long to make decisions in areas that frankly we don't deserve to be in that business. i think you have identified a few. my only modification if you wouldn't mind is i think i.t. has to be a competency of any organization. we don't want to be in the software and product development business but managing i don't know whether outsourcing is the right word. i do believe if we are going to serve veterans, we need to work with the core group of employees and staff that functions on our core functions, but when we strayed outside, building buildings, doing software development, doing claims and billing, i do think we should be looking towards private-sector solutions or private public partnerships where we can get the competencies into the federal government. >> the last question i have is that one of the problems facing the congress in many previous congresses, is the fact that many entitlement programs we know continues to chew up available revenues and putting a lot of downward pressure on the discretionary piece of the budget and that is getting worse and not better. i think part of that iss because people are living longer, they are receiving benefits from those systems for longer time than actuarially expected. do we have a pretty good handle on the number of people entering the va system so we can write size the funding request to meet those needs and not play from a position of weakness by being behind. i've only got about 45 seconds left, but can you help me have confidence in knowing that we know what's going to fill that pipeline over the next generation. >> we certainly have a handle on the demographics of the veteran population.n we have 22 million veterans today and that is expected to decline. what we can predict our new conflicts that could happen because that could change the picture. we can't protect new science that would show additional mandatory coverage needed to include, as science shows there's a connection between military service and disabilities, and that work is always ongoing.i thin we do have actuarial models in both healthcare and benefits that we can share some of the parameters for needs, but they are not fully accurate because of the unknowns out there. i think for what w you areou asking, we can share that with you. >> thank you for your service and congratulations on your appointment. i yield back. >> thank you. good to see you mr. secretary. i too want to congratulate you and say i'm glad you're at the helm of the va. up couple questions that i'll ask very quickly. one relates to the oakland va regional office. there have been significant delays in processing claims and management didn't provide oversight needed to ensure timely and accurate processing. we had about 1248 informal claims. that was before the national work queues. now we are on the national work you and i want to know if that helped reduce the back claims significantly and is it streamlining and reforming benefit claim processing regarding the oakland va regional office. second question has to deal with what we briefly discussed as minority veterans.th i've looked at your health disparities report which is very thorough, and of course it cited the fact that minority veterans were diagnosed with ptsd than rates higher than white veterans. also in the report, you go to some of the recommendations to begin to address not only ptsd in terms of the disparity and all the others and it says we need more research and more ente information. i'm wondering, as it relates to the report and recommendations, as its basi specifically relates to minority veterans, where are we and are the recommendations being followed?e i can't help but wonder why more research is needed. we have an office of minority health at hhs so i'm not sure if you're coordinating in terms of health disparity with health and human services.th anh just exactly what's going on? this is a very good report and i know many minority veterans who are struggling with healthcare and ptsd. finally, i asked this at the oa ig and the va hospital, in terms of utilization of minority and women. it's my understanding you don't separate the data. i'd like to know how were doing as relate to african-american, asia-pacific islander and firms. i still haven't been able to drill down to get the report. the va is a significant entity that contracts a lot of money out and i would like to find how minority owned contractors are faring but we need to understand what the data is showing so we can do better.tado i've had a lot of complaints from minority owned businesses that they can't penetrate and get into the system for a fair shot. >> okay, thank you congresswoman lee.ngress these are all really important issues. on the claims backlog and what the impact of the national workflow has been, we do believe that has been helpful and we are seeing improvements in productivity. i would like to get back to you, for the record, the impact from where you are measuring it in oakland and see where we are today so we can track that progress together because i think that's important.ou. on the health disparities report, i agree with you, i think the work that our national center is doing has identified significant issues. this is an example where i think va is actually leadingt a and addressing issues that are important for all of thehe american public and in healthcare we know disparities is a very significant issue, particularly in many of our geographies across the country. i think va is leading in this area but we still have additional work to do. we are treating this as a priority issue and looking at the recommendations you'veda talked about. the research that the report recommended is research on disparity in veterans. va research has significants health services research components to it and the differences between the health services research and va and hhs is our research is specific to veterans so we do believe there is some question that are important to ask in order to understand what the most effective interventions are, but i don't think that's a reason for us not to be implementing the other recommendations. there is important work to be done and we are focused on but now. >> let me just comment on thats because i know the research is very important, but i know specifically when you look at african-american veterans with ptsd, you have other factors that weigh in and the office of minority health could liketo you know what those external determinants are that couldw help come up with treatment that makes sense right away. >> i completely agree. the research is only good if you act on it and there are some things we are ready know and i think this is where we are looking at this in terms of implementing the recommendations that we know need to happen and it's a way that the va can lead and help the rest of american healthcare implement these.re >> you have a working group put together. >> yes we do. >> great. >> i would like to talk to you more on that. i don't know how the data can be centrally categorized on your last question. let me look into that and get back to you. >> i recognize the gentlemanan from california for five minutes. >> thank you chairman, thank you mr. secretary. as i'm sure you are aware, in 2002 the va reinterpreted the language of the agent orange act to apply only to veterans who stepped foot in the republic of vietnam or the waterways or brown water. veterans who served on ship oror blue water were not included and must prove exposure to agent orange. however proving exposure to bluewater veterans is nearly impossible due to a lack of record-keeping and inability to know the precise location of agent orange in the air or water runoff. they continue to deny claims from brown water navy veterans despite showing signs of higher rates of cancer and lymphoma. this year i introduced legislation to right this wrong, hr 299 blue water navy veterans act which has over 270 bipartisan cosponsors including over half this distinguished subcommittee. i stand ready to work with my colleagues to pass this bill and the department of veteran affair has the ability to write the wrong itself without the help of congress. have you been made aware of this issue since you have taken over as secretary and to your knowledge is the va working towards a solution on this issue? >> thank you for that question. yes i have been made aware of ehe issue. i would say 20% of my inboxes on this issue so i hear from a lot of people. what i have done is i have sat down and met with some of the leaders in this blue water navy movement to understandthe d exactly what they believe the science shows, and what they're recommending. commander wells is one of them , john rossi is another i've met with in my office. they have followed up with additional information which i really appreciate because i'm trying to bring myself up to speed on this. the va's position on this has been pretty much that the science isn't there. i'm not convinced that thece full story and so i have asked for additional information and additional recommendations so, as you said, if the department of veterans affairs has the ability, and i agree with you, to change some of these, and if the evidence suggests that's the right thing to do, i am going to recommend that. so, this is very active, i can tell you this week alone i have been reviewing additional studies. i will certainly be willing to engage in further conversation with you. i am aware of your legislation. >> thank you.n i appreciate your knowledge that there are other sciencewa out there because there are studies, especially with the way they treat the water and clean the water that actually says it concentrates the chemicals and makes the situation worse and i appreciate you bringing that up. mr. secretary, i also understand the air force is conducting a clinical human trials at tinker air force base to investigate transcranial magnetic resonance therapy on veterans suffering from ptsd and tbi. after four weeks of active treatment, compared to the baseline treatment, does it reduce pcl m score from 66 down to 37, the air force concluded the preliminaryd results suggest that it is a promising treatment to help veterans suffering from ptsd. with this information can you share with the va is doing to capitalize on this promising new treatment to address ptsd and the veteran community? >> i am very familiar with the technology and i'm very concerned about finding new therapies that help our veterans with ptsd as well as other conditions related to the brain. we do use, the va has extensive use already of transcranial magnetic stimulation. the issue is whether the mercks. technology adds additional value to what we are currently using.g. i have recently, in the past ten days, visited walter reed. i've talked to them about this. we are looking at the science. i would like to see the results of the air force study as we are becoming aware because basically if there is evidence in science suggesting this is helpful and effective, especially in noninvasive technology, we absolutely want to use it. today i am not aware of evidence that suggests that mertz adds advantages over the transcranial magnetic stimulation that the va and walter reed and others are using. i have talked to my dod colleagues. with new information coming out of the air force, i am open to seeing that. >> thank you again. >> at this time i recognize the gentleman from west virginia for five minutes, mr. jenkins. >> thank you, mr. chairman. mr. secretary, thank you for the opportunity to visit with you in advance of this meeting d to talk about your leadership.bout let me start off with a word of complement. i learned yesterday from the discussion yesterday about your push to provide transparency and quality data, information about wait times, our veteran patient satisfaction and you shared with us the website access to care.va.gov. >> thank you for that plug. >> you didn't ask for this, but i give it to but i did look, after you mention this and as i understand from our discussion, this data has been out there and available but nobody was willing to authorize the switch gets flipped to make this available and you did that so thank you for doing that. i encourage people to take a look. transparency is good.ment i want to make mention of this most recent executive order relating to some of the whistleblower and accountability efforts. i can't tell you the number of times from whether it's a va employee or others about frustration or concern, may be very briefly described this executive order and what kind of reassurances to those on the ground, at the grassroots feel as though their concerns and voices are going to be heard about reforming the system and truly holding it accountable and holding people accountable for the need for good performance. >> i think it's very important that people understand we are taking these issues extremely seriously, but any organization in trouble have to look towards its own leadership, so we want to make sure the people serving in our leadership positions are consistent and fulfilling thee values that we owe our veterans. when we become aware of issues of poor performance or people who have strayed from the values, we are taking action. i think you can see there has been a large number of those actions taken recently. because of that, we have established the executivee order has asked us to establish an accountability office that will report directly to me. as part of that we are putting our whistleblower office in that accountability office ton l make sure our employees know that if they raise issues to us and if they are legitimate issues, those employees will be protected.su we do not tolerate retaliation and that's the way we learn and get better as an organization, by addressing issues that are brought to our attention. these two concepts of adhering to values and protecting our employees that raise issues are absolutely essential to our success.d >> one area i would like you to have staff look into, we get a number of calls to our office relating to the payment of processes to the va. you described an effort to work collaboratively with academic health centers, local hospitals that have real connections to the va. make one plus one equals three working together. one of the challenges i have heard, starting with the restructuring of the payment system of the va from june 2015 and continuing today, i have an academic medical center that really values and appreciates their good working relationship. the problem is the va doesn't pay in a timely fashion. they have hundreds of thousands of dollars in accounts receivable, from theirs standpoint, over 120 days. i have a local hospital with over $10 million in accounts receivable from the va, over 120 days past due. i'm not sure what's going on in the accounts payment and claims processing, but i think we have some timeliness issue and i hope that will be taken seriously. >> yes, you have to understand this is the world i came from. i do believe if you deliver a service that you don't deserveyo to be paid and paid timely. it's too hard operating those healthcare operations and not get paid for the work you're doing. i absolutely believe we have to get better at that and i am not being defensive. we are not doing a good enough job in that area. the way that i would suggest we proceed is, when you find a community hospital that thanks i have $10 million we owe, please let us know. when we dug into these, we absolutely owe them money, but it's usually not the 10 million. there's duplicate claims are rejected claims and sometimes they're looking at charges instead of the fee schedule we pay them. we can work through that, we can put a team on that and get them the money they deserve and get it to them quickly. >> thank you. >> thank you for being here today. we understand there is nothing little about the big challenges you face in your current position. we appreciate you for that.te i come from an area which is hampton va which is one of the fastest-growing of them womenki va issues. this is something i'm passionate about and looking forward to working with you to figure out these challenges and fix them. a quick question, if one of us submits a question for your office, what is your policy in terms of the response, how many days. >> we categorize them into two types of responses. there are some that need urgent responses, and i think were shooting for that, i know i'm gonna get this wrong because we just shorten the time frame but i think that was 14 days for our short one and 30 days for our longer one. he said i got it right. if there is something really urgent, we will do it in 14 days. otherwise 30 days, and i know that has not been the past experience from va to your offices. this is our new commitment to respond to you and a more reasonable, timely way. >> thank you. let me touch on, i have a bunch of questions but let me touch on the most urgent one. suicide was something that was touched on in its dear to me. we have these issues in our area. one of the questions i submitted and hasn't received yet is the uniform policyhere a currently with people who are trained to intake folks who, physically that either exhibit signs of suicide or say they are suicidal. furthermore is there uniform policy for the crisis hotline which i understand is being manned by call centers. what is the uniform policy and the training those folks at the call centers get. >> i have seen some communication, are you saying where over 30 days already.>> ae >> yes. >> yes secretary. >> okay. my you will be getting an answer pretty soon. i do understand there was a lack of training between suicide prevent jen call centers and crisis center respond centers. they are different professionals. arvida veteran crisis line are mental health professionals. our suicide prevention ordinator's don't have to be that. they're doing different functions.to many of them came out ofof different disciplines and so there are different trainings, but among those twoo categories, there should be consistency among veterans crisis line responders and suicide prevention coordinators. we will take a look through for your correspondence to make sure he you get a response ration. >> i appreciate that. one other thing on suicide, is there any openness to potential public-private type things with qualified nonprofits. for example, when i say that there's a lot of veterans are not comfortable going to theth va or walking up or calling but may need help or may feel more comfortable with some ofy the nonprofits that are out there. is there any option for public-private's to help with that. >> not only in openness, we think it's absolutely essential. there's no other way to do this. of the 20 veterans a day that are taking their life by suicid suicide, 14 of them do not get their care in the va system. they are out in the community. six are within the va system. if we don't reach out and do the types of partnerships were talking about and getting everybody involved, there is no way we can adequately address this. we have been outreaching, we are working with several organizations. we have public service announcements, if your group, there's a new group just reached out to called headstrong. the galleon organization. if you have new partnerships you would like us to explore, we are absolutely open to those. >> thank you mr. secretary.foll >> i will have follow up in the next round. you mentioned some of the under utilized boeing 735 and how many were vacant. >> 435. >> thank you mr. secretary. >> thank you i recognize the gentleman from ohio, mr. ryan. >> thank you. it's good to see you again. i appreciate our meeting yesterday. let me say publicly i thinkll what you are doing in your patient centered care area is some of the most exciting stuff going on, not just in the va but in government of really figuring out quality solutions, integrating care, all the rest. i just want to say thank youg for throwing your weight behind that. i think it's really important and we will start seeing a lot of savings because of that and healing a lot of vets. in our conversations that we've had already, i appreciate the balance that you are trying to strike between the va clinics and the choice program and i know that's not always easy.m. one problem area that we've become aware of in my office is that despite the choice programming authorized and appropriated, we still have veterans traveling significant distances to try to get their care. if a veteran has a clinic within 40 miles but the clinic doesn't offer the services they need, the veteran is being told they are ineligible for the choice program and being referred to the nearest va clinic with the services offered. there appears to be no policy that places a cap on the distance the veteran would have to travel if they fall into this loophole. in my district, which includes veterans in one ohio, traveling three or four hours round-trip weekly, sometimes more than once a week to receive treatment in cleveland, and i was at my son's soccer practice and i had a couple vets at the same time grab me about this issue. the primary care physician or coordinator benefits has independent authority to assign a veteran to travel and extreme distance with no limit established by the va or they can refer them in the community of care to a local dr. they can elect to refer them to choice, however it requires a justification there's an excessive burden on the veteran. you mentioned in the testimony establishing a priority on transparency, however we cannot find a readily issued pamphlet, flyer or billboard which would explain what defines a burden that would make them eligible for choice in this particular situation. i have cosponsored legislation with representatives to correct this issue.y question my question to you is do you have the authorities he would need to fix the problem, and what can we do quickly, instantly to provide more transparency to help our vets in the decisions for their care and if we can't fix it immediately is there a legislative issue we need to deal with and lastly, will the choice two-point oh consolidation with community care correct this problem? >> lots of important questions that you have. so, in designing a healthcare system, i would not necessarily have picked mileage and wait time as my criteria th criteria for how to design the system. i understand why congress did and frankly to put a national program up so quickly, i think it was a very well thought out effort that congress had. now that we've had time to experience this, i believe a healthcare system should have a clinical basis to the way it's designed. it is my intent in working with you to present an alternative to 40 miles in 30 days, in other words to eliminate that and replace it with something that makesrd sense from a veterans clinical needs. so to look at access and clinical quality as the alternative to geography and wait time. under the current system that we have, which is still having to follow the rules that were set by congress 40 miles in 30le days, we do have the ability to define excessive burden. what we found after i became secretary was that we had put u out five bullet points about examples of excessive burden. the field had interpreted that as those were the only exceptions they could use. we have now clarified that. what we are trying to do is get the veteran and their doctor or their provider to have an interaction about what excessive burden is. we've now loosened up the requirements so the field can make reasonable judgments about excessive burden because some of the examples like thee ones you're giving really aren't acceptable.mr. ch >> thank you, mr. chairman. >> it's time to recognize the gentleman from nebraska. >> thank you.. welcome. >> are you enjoying the new job. >> yes. >> i appreciate your attitude of innovation and compassion for this mission particular very much. in your opening statement youan reference the new idea that has emerged that has been empowered by legislation of a unique public-private partnership that will happen in omaha. i want to unpack that a little bit more for the committee so everyone understands how potentially transformative this could be. the community wanted to go on the point. community leadership came to congressional leadership and said we've built housing for bettering and troops, could we possibly participate through some charitabl charitable entity in updating and upgrading the hospital which is in serious need of not only a facelift but innovation and modernization. working with my predecessor, brad ashford, we got the empowering legislation to you. the community has committed 30 million to build upon the money that had been set aside of over 50 million and we will move forward. i think it's exactly the model you're talking about in terms of 21st century architect for modern va that is looking for community resources when available, looking forward charitable funds for donations but also an integrated service environment. this new facility will be an add-on to the existing hospital, be approximate to creighton medical school and the university of medical school we already work with. the synergies designed will become a bit seamless. the veteran won't know the distinction between the type of care they're getting. they're just getting the best possible care using private-sector resources, charitable monies because that's the objective.at is i want to spend a little time unpacking that further and hopefully given the very difficult, sad experiences we've had with watching cost overruns in the denver hospital being the poster child, that this way of proceeding forward is undoubtedly going to tap into a large pool of goodwill that exist out there in the country among charitable organization i and leadership in communities to assist you in modernizing it, innovating and creating the types of partnerships that utilize the best of the private sector but always under va hospices. i'm excited by this. i'm sorry to spend so much time on it. i also want to mis mentioned 50 miles down the road in lincoln we have a traditional, beautiful campus for a va clini clinic, a similar dynamic is occurring where a charitable foundation with the city has agreed to build out veterans housing on the siteesst of the old clinic. we are awaiting the decision as to what will happen with the new clinic so if you could give us some update on that process that would be helpful. again, the synergy being created with existing facilities preserving existing, beautiful architecture in proximity to the city's medical resources is a new opening dynamic of what i hope is a new chapter of the va. the third point, i've become aware and a little bit involved with the charitable organization called project hero.etary your undersecretary has given a memorandum of understanding that they can partner with this organization using recreational activity, bicycling, primarily, to be integrated into va services. studies, there's metrics on this already showing improved healthcare outcomes, lower cost, sense of well-being, drops in suicide. i just wanted to highlight for you because i think this is a program consistent with what i said earlier that's been developed because of compassion and initiative by the private sector, looking to partner with the va and we have a great opportunity here.portun >> thank you. i think just briefly on your three points, the project in omaha nebraska is exactly what i think we are looking to do in the va which is do things differently. in this case we will build a new facility. it will be good for veterans and absolutely good for taxpayers. this is going to leverage the federal dollars in ways that in the past we would've been able to do before. if there really wasn't for your leadership and support in getting this through legislatively, it will be happening. i think this is a transformative bottle. we have four other sites you authorized after omaha nebraska that we can do. i'm hoping other community members are listening because we have a list of 20 sites that now are eligible for this. i think this should become the way we build future modern healthcare system. thank you for your leadership on that. secondly, on lincoln, absolutely, we are moving forward with the new clinic. it should be awarded this fall and through the whole building design process, even though i pushed really hard, probablyop the opening date will be early 2020. it takes a while to do this but it is under way and it is toward the top of our list. on your third point, project hero, one of the great things about va is that it defines healthcare much broader than just physical illness. it defines it as physical, s psychological, social,xa economic, and example of using sports and adaptive sports to help people get better and have a sense of well-being is something the va taught me a lot about. this is a great example. we are very supportive of this and other work around the country and thank you for bringing this to our attention. >> thank you. at this time i move into our second round of questioning's and i will start. doctor shulkin, in the one page fy 18 skinny budget, there is a va request fornew $2.9 billion in new mandatory funding, presumably to complete the fy 18 funding for the choice program after it's completely exhausted in january. does this indicate the administration's intent to fund the choice program out of mandatory funding. >> yes. >> okay, next question. being an appropriate or i'ven always tried to keep my eye on the bottom line of new initiatives. i'm aware of at least two proposals. while we support them from policy perspective, we send out our budget intent, you've announced you intend to provide emergency health services to veterans who havebli other than honorable discharges. you've also testified in the senate that you are interested in expanding veterans before the post- 911 era. how do you plan to fit these added cost into your budget when you're already struggling to cover expenses for your current va patients. >> german, maybe this doesn't fit into the budget, but basically i don't care. i sat in a session that wasor organized by members of congress and the house where there was a young man who sat in the capitol rotunda who said he had been deployed to afghanistan six times and on his return he found out his wife left him and so he took off across the country to try to find her. he was declared a wall and other than honorable.other you could see he was sufferingul from severe mental and emotional disorders and he went to a va and he shows up at a va and says i'm here because i need help, i'm suicidal and the va says i'm sorry, you're not a veteran he had served our country six times, six tours. that is not acceptable. when we say there are 20 veterans taking their life every day, we know it is this group that is among the highest. no one wants to help them. i'm not going to sit by. i don't want more money for this. we are going to find a way to help these people and connectlp them in the community to resources and get them help because that's the right thing to do. i will find a way to do that because i think this is our c responsibility. >> that is a compelling story and i'm glad your taking that initiative. what was your other question. >> that was it oh caregivers.cai sorry. >> the caregivers program is really important. we were authorized to be able to do that for post- 911 veterans and there has been tremendous successes, but we frankly didn't get this program right.we have we have been issuing up to 90% relocations of caregivers that we had authorized.d something is wrong there. we just issued a national suspension of revoking caregiver status and we are now in a pause where we look at what are the right policies in order for veterans to get access to caregivers. it is our intent to be able tot bring this to pre-911 caregivers because the most vulnerable group are elderly veterans and the worst situation is when someone is in their home and they have to leave their home to go to an institution because most veterans don't want that, most people don't want that andnd it's the most expensive way to care for elderly people. if we can keep them in their home with caregivers, we should be doing that. we are looking at how do we use the current money and potentially come up with even better policy than what we have today. we will be announcing that in probably the next couple months. thank you. >> the antiquated scheduling system has been of concern to you, i know. we understand you are on a dual track to modernize it, piloting a commercial systemem as well as upgrading your existing system. it seems like these efforts might lack a unified strategy. why are you interested in investing into systems simultaneously and will be w further tinkered with in the electronic overhaul. >> on the surface, i agreeni with you, this makes no sense at all, why would you invest in two different paths. we awarded a commercial product called mass. that is the system that we think meets our solutions and that's the one we are implementing. we are working right now on a pilot site to be able to create the interfaces so we can do that. the rollout of that system as big as ours will take several years. in the meantime we had developed an internal system, one of the last that i hope we ever developed but this one is developed with taxpayer dollars and we did an evaluation in the month of february, we had rolled out to eight sites, it's actually working, it's much better than what we have right now, so as an intermediate stopgap measure we are rolling it out across the country becausewe it's already developed and it will help in that intermediate period of time until we can get a commercial off-the-shelf system up. >> thank you. at this time i like to recognize the ranking member for five minutes in the second round. >> thank you, mr. chairman. i want to focus on military quality of life because at the hearing we had in march when we had an opportunity to meet with the senior commissioned officers, we discussed the marines united scandal which we discussed in my office yesterday. many of the victims of that horrific social media site are now veterans and i've met with a number of them outside many of the women members, and i would like to know what the va is doing to provide them with the necessary care and support they need because these are women who have had, without their permission, new photos of themselves posted and being subject to extreme humiliation. with regard to the military sexual trauma section that the va has, how have you letav veterans know this service is available and what outreach have you had. >> the va has an extensive system for treating military sexual trauma. we worked with the department of defense of the va is a place where people can go confidentially and get treatmen treatment. women or men who have suffered military sexual trauma can come to any veteran center and there will not be a connection of their medical record back to the department of. >> thank you and i appreciate that, but specifically what kind of outreach are you doing to not only make sure victims of sexual assault in the military are aware of those services, but also specifically victims of the marines united scandal. >> when we met in your office you suggested that something we should be doing. i don't believe that something we have done but i believe we should be doing it and so as a result of our conversation we are putting together a plan for that outreach. thank you for that suggestion. >> thank you. you're welcome. we have female veterans that are committing suicide at a rate of six times that of women civilians and identifying ways and implementing strategies to address the unique mental health needs of women is critically important so i'd appreciate it if you and your staff would follow up with us on that. the other question that i wanted to touch base on is what i mentioned in my openingme remarks and that is the opening that you have in all of your senate confirmed positions, and you mentioned you were going to be making an adjustment and how you fill those positions, but i'm actually wondering if there any problems with the the a administration in identifying candidates for those positions or are you having trouble filling them, and in particular i find it troubling that the under secretary for health, the assistant secretary for information technology, given the serious w problems we've talked about, and the chairman of the board are all positions that remain empty. what is the timeline forme filling those and do you have candidates that you are considering and are you having trouble filling them? >> i appreciate your concern about that. i am very impatient and of course i want my team inin place. we have very good career acting professionals that are handling this right now but i want permanent people in place. the under secretary for health and undersecretary for benefits, it's mandated that we form commissions to search for those positions. the under secretary for benefits commission met ten days ago to go through candidates and recommending several of them for me to see and me to recommend to the president, and the under secretary for health commission, i just saw the committee members appointed this morning, that will be going forward in the next two weeks as well. for cio, i have met a number of candidates.omt.t. we are vetting them right now, trying to move forward with an offer and at the board of veteran appeals we are also trying to that a candidate also. i hope these processes, having gone through it myself, the vetting process, 13 months, it takes too long and we are looking to move through this as soon as we possibly can. >> thank you. i will have one in the third round. i appreciate it. i yield back. >> thank you for this time i recognize mr. rooney for five minutes. >> thank you. mr. secretary, i want to say your office is watching this hearing and is in my office discussing some of the issues with our constituents and i want to give a shout out to mary kay in lake city and if you're still watching i have another issue for you to work on. that is with regard to a lot of my district is very roll and i do have some of theun coast but a lot of the people that live in my district live in the countryside and one of the issues they complain about with the choice program is that there are long wait times , the receiving complaints about long wait times for va appointment referrals and payment through the programre and the payment and reimbursement to the providers is difficult and it's exacerbated probably because it is role.obviou obviously in that situation you have smaller hospitals and clinics and many of the providers that are technically participating in the choice program are refusing to acceptwy choice patients because they know they will have to wait a long time to get paid themselves so some providers that don't accept the choice patients will only do so if the veteran agrees to pay for the services up front and that leaves the veteran in the same bind they were in before choice which was either face the excessive wait times at the va facility with no option to obtain immediate care elsewhere without paying out-of-pocket first. that is obviously that's not the point or that's not what weree looking to do. you as a doctor can probably appreciate these people who want to take the choice program and help veterans but they know it will take forever to get reimbursed. they say will you pay me first and will deal with getting reimbursed later, i don't know if that's the rationale but it sounds like that.getting the oig has criticized the va's monitoring oversights for these contracts and reported that these contracts still don't have performance measures to ensure the contractors pay their providers in a timely manner and the oig made this recommendation january 30 of this year. as you were to expand the choice program, how are you implementing the oig recommendation specifically with regard to timely reimbursements? >> there is no doubt this is an area of significant risk for us. monitoring and making sure the providers are paid is critical because of the issues you are saying. the veterans are being put in the middle. i would not recommend that veterans put out money for this. that is not the point of it. what we have done is we have done multiple contract modifications and advanced money to the third-party administrators, i've suspended the requirement that providers have to provide their medical records to us in order to get paid, we are improving ourbu payment cycles through the choice program but it's not perfect by any means. we have to get better at our auditing of these processes and we are working on doing that. this is a significant area of risk for us in the reauthorization or the redesign of the choice program. we want to eliminate the complexity of this process. the private sector does not have to do the type of adjudication of claims that we do. they do online adjudication and electronic claims payment. we are just not able to under this legislation, do all the things that we know are best practices. to recogn >> thank you. i recognize the gentleman from ohio for five minutes. >> thank you.man. it's nice of you pennsylvania guy to let an ohio guy participate. >> we beat ohio state last year, that's why. >> blinds squirrel finds and not every now and again. [laughter] quick question, one with regard to the choice program, there are a lot of people who want to access, i've seen in the past few years that our d.c. va and other va's rehab centers of excellence where there's all these complementary services being provided letter showing significant success in reducing pain, managing pain, reducing opiates which is a huge thing for us to be able to do, providing these alternative approaches. i just want to make sure as were moving to try to better administer the choice program that these evidence-based programs are covered in the choice program so that they can access whether it's acupuncture or mindfulness -based stress reduction, i've seen programs like project welcome home troops where they do a lot of breathing exercises that are having transformative effects. there's a lot of videos online you can watch where these bets are on ten or 12 prescription drugs and after going through some of these therapies that are traditional, they are going down to just two or three meds which is a huge savings for us and you're actually giving them the toolsnd they need to be able to go out into the world and function and get a job and be productive members of society. want to make sure as we moveve with the choice program that evidence-based programs are covered by the choice program. >> those types of services and providers are part of the choice program. we are expanding the network to have more access to thosemo types of providers. >> great. i think that will be a big thing, not just for the bats but out in society as well. the other issue is talking about dealing with the appeals process. we had this conversation yesterday.fect the legislation currently is not going to affect the hundreds of thousands, almost 500,000 people already caught up in the stagnant appeals process. i say this not to you because i've already said it, but members of the committee and the public, i think it's important for us to figure out how we can help you start to reduce the backlog. how do we get more appeals judges may be out of retirement to get into this program, congressman and i are working on legislation to be able to do that and so if your department can provide us with the necessary metrics we needen to figure out how many retired appeals judges on the board of appeals we need to get back on the system, even on a part-time basis to start getting through this backlog.m, if you could do. >> i appreciate that suggestion. we have 470,000 backlog claims so even after legislation is fixed and we fix the process going forward we still have the backlog. i appreciate your offer to work with us and help. we have already worked up some numbers would be glad to share with you in the congressman. >> i think that is an important step for us to try to dig into this 470,000 number with the appeals that some of them are 30 years in the making. for every additional piece of evidence or paperwork they add it just slows up the process. we need to make an effort, talking about a surge for judges to help dig through this. thank you again for all your leadership. m appreciate it. >> mr. taylor from virginia is recognized for five minutes. >> this is been a great day. there's been a lot ofions a information and a lot of questions answered. i appreciate your time. a couple things on the budget, you mentioned the demand was not fully funded. i would just like to briefly touch on that. first i want to applaud you for taking this field and helping veterans who may have h been dishonorably discharged the because of affects and stresses they had on their own personal lives from war.rsonal l that being said, even in our own va, we walk through it and we notice and ask questions and certainly saw folks that were being treated that maynl not be eligible.s about talks about a couple areas where there are veterans, when they need a knee replacement it's not service-connected. that's a huge cost with zero embarrassment. one of the things we sent in there, don't know if there's a study for now but if you exacerbate that across the vas system, that significant dollars and veterans either knowingly or not knowingly, this is a popular thing to say and i am a veteran and i don't care. if you know they're not supposed to be treated there and you're not treated there because you're taking away from other veterans. i'm fearful in the political climate that maybe the va is seeing folks that shouldn't be there that should be using their own private entrance. have there been any studies across the va regarding what that is costing.t >> we absolutely have looked at this. they're classified in a priority groups. the first three generally are service-connected.si the next three, four through six are generally income related. when you start getting 27 and eight, these are people that fall outside of that and currently that is frozen. not all veterans are eligible for care in the va system and so we are focused on those that are service-connected and lowerinlower income. >> if i may, has there been any review where that may not be the case? i know we are focused on the folks that need care but has there been review across the spectrum to figure out in fact , i'm not trying to say it's fraud, necessarily, but theyie may not know otherwise. has there been a report on what the costs are for the va?e : ot the priority groups, sorry to interrupt you. it's the people who are getting care that are getting treated? >> i'm not aware of any veterans that are getting care that shouldn't be. if they are, we have to address that and stop that. if they're not eligible for care, we generally are telling them that. now, maybe you're aware of some situations and i'd really like to understand that better because i think you're correct in your assumption that our care needs to be focused on those that are eligible for care, particularly when we have access issue so i'd be glad to talk to you about that. i want to mention two things. our policy is for emergency mental health care nor other hand honorable, dishonorably discharged we're not -- >> i applaud you for -- i know there are a lot of wounds that are mental, i get that. applaud nowor foes efforts. >> the other thing i want to mention is your letter of march 29th, we did respond by april 6th. we thankfully made it in that 14 days. there's additional information that your office wants on the protocols on the veterans crisis line so we're providing that to you and want to get you the detail. >> thank you. i appreciate it. >> thank you, mr. taylor. at this time i guess we move into a third round of question for those who remain. you mr. thought i'd just emic quickly touch on a kentucky couple of issues first. we included $50 million in the omnibus appropriations bill considered on the floor right now for vp opioid abuse prevention and treatment efforts. realize the va has come a long way in opioid management efforts since the stories in wisconsin, the candyland doctor situation. what are the most effectiveon. approaches the va has identified to keep severely injured verns to keep away from opioid dependency. >> thank you for that additional support. can tell you it is money worth spent. we have seen the 32% reduction of opioid use the va since 2010, but we have a lot more work to do. so, this is really a good investment. i'd say very briefly, the va approach to this -- we're leading american medicine in this -- is a multifacetted approach. one is veterans need to sign an informed consent. secondly we actually monitor the profile of doctors so they can compare themselves to how otherr doctors are prescribing. third, we mandate participation in the state prescription data monitoring programs. fourth, we do academic detailing where expert goes out and actually educate our clinicians on this, and, fifth, we're suggesting strong alternatives to opioids and providing those, like integrated medicine in our facilities. >> also like to ask you, too, on -- related to the disability claims backlog management issue. we're pleased to learn last year that the va has reached an effective zero on the size of the disability claims backlog. know some claims with always be -- exceed the target deadline bus the va is waiting for additional information but your bringing the number counsel from 16en. but we understand the backlog i creeping back up. we know that the bur jobbing petses caseload needs to be tackled but this highlights the management dilemma you face and congressman ryan touched on that. what's your long-term plan to bring a balance between activity on initial claims and appeals workloads? that's the main issue i want to hear about today. >> well, i don't think we are where we want to be on this. so, we have to make continued progress. we're at 100,000 disability claimed over 125 days and they needs to come down significantly. we're changing processes, oned called depression reading claims. that will allow a veteran to seek a much quicker resolution to their disability claims, and give them a choice when they have all their information available to be able to do that. we're -- so advancing technologies new of moving towards a paperless system, ten sites are completely paperless, that moved everything through faster and we're looking at number of other alternatives to do that. so we do have plans to get this down, and we're not seeking additional funds to do that. we see it through process improvements. >> thank you. and finally, jared kushner's white house office has chosen the va as the first target to reshape the federal bureaucracy by meeking it leaner and more effective. has his office fanned out staff the very to analyze operations and make suggestions at this point? >> we're in close contact with mr. kushner's office. they have been extraordinarily generous with their time and what they've really been doing is trying to bring industry partners and industry best practices in to help the va. so i don't think they're staffed to come in and do their ownn assessments and nor dithink it's their bent. it's more to fie solutions that already exist in the private sector bring them in and modernize our system. >> thank you for sharing that. all federal agencies have received an executive orderour re-organizing the departments by september in like with their fy18 cost cutting proposals. the acting deputy said the va would like to get started sooner. what changes do you expect? >> we are underway with this right now.ni i don't know the specific solutions because we're still working on it. what you should expect is we're looking to have a smaller central office function, more streamlined.wo looking to move towards morewe shared services rather than siloed services in each administration, and we're actually looking across federal agencies to see other things that maybe other agencies are doing better than they should bi doing for us, or vice versa, whether va should be taking on functions other agencies are doing. we're working with other secretaries on that.er >> thank you. that complete us my questioningn now i recognize the ranking member for five minutes. >> thank you, mr. chairman. i wanted to just ask you about to the veterans crisis line because when we went to the d.cw va hospital, we had a rather confusing conversation with their personnel that made it evident there were a number of serious issues with theio centralized nature of the veterans crisis lines there being a national hotline as well as a hotline at each hospital. and so the ig's report that came out highlighted how significant the concerns are and within daye of the igs report, the va saider the issue had been fixed. can you explain how fix it -- fix end it is and what that means and what you're doing to ensure thea that the veterans are absolutely able when they're in crisis because of the risk of suicide being so high, are ablen to get the services they need. >> i apologize for the confusion. there is only one centralized veterans crisis line. each of the medical centers do not have decentralized crisis lines. what the ig was referring to was the fact that when the va responders on the veterans crisis line receive more calls than they could handle they went to backup centers that were located around the country. those backup centers are certified samsa backup centers so they're trained responders as will but they're not va responders. we did not think that was satisfactory so we hired over 200 new responders, had to get them trained. they came online in the early part of 2017. we opened up a second center in atlanta, georgia, and now, because of these new responderss and the second center that its online we're able to handle the calls coming in. we have less than a one percent backup center rollover rate at this point. that's why we came out and said we fixed that problem. we have many days where we have zero rollover calls, probably the last two months we averaged less than ten rollover calls on a given day. we are responding to over 2,000 calls a day to veterans in crisis. we typically will send out 60 to 65 emergency responses to save veterans' lives. >> when we were the va hospital here, they described a system that was one that was based with their personnel, and one that kicked to the national system when it was after hours. >> well, every va has a mental health service, we have same-day center field available. so if a veteran calls and is in crisis they will be seen that day or their issue will be debt with that day. so that does happen. every one of our medical centers has a suicide prevention coordinator, many of them more than one. that is there to deal specificed live with the followup issues and to address people in crisis on that day. but there's only one national veteran crisis line and that is run out of two locations in upstate new york and one in atlanta. >> do they all receive the same training. >> well, as i was explaining to the congressman, the veterans crisis line responders all receive the same training because they're licensed healthcare professionals and the suicide prevention coordinators receive the same training but different training than the veterans crisis line respondersr because they're not all credentialed orlined mental health professionals. >> you mentioned the reorganization and jared kushner's office. are those goals aligned with yours? are you waiting for mr. kushner's reorganization recommendations before you begin hiring? >> no. again, the american innovation office is not intended to come in and do assessments and give recommendations. that's the executive order has asked the department to do that. so that's what we're doing. mr. kushner's office is helping us in identifying industry beste practices and strategic partners that help us advance the modernization goals. we're going. >> we're going to leave the last future minutes of the their today's white house briefing. his spokesman sean spicer. >> i missed you all tremendously. now that i realize we can do that more i'll spend more time the pentagon.

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