thank you again for your leadership and the opportunity to be a part of make it in america. and next from the state of pennsylvania, representative cartwright who has introduced the job creation through energy efficient manufacturing. >> thank you. and thank you all for coming today. i want you to notice a couple things about the people standing before you on this stage. we're all wearing two things. we're wearing our congressional badges and we're wearing our make it in america pins. we wear the first because we care about this country. we wear the second because we know that part of caring about this country is caring about making manufacturing jobs resurface in this country. and i thank mr. hoyer on his leadership and in the make it in america plan, to strengthen businesses and create high paying jobs in this country. i'm also gratified to have had hr-4162, the job creation through energy efficient manufacturing act, added to this program. energy efficiency is not just about being green, it's something that saves money. investing in energy efficiency creates jobs and by investing in energy efficiency, the american manufacturing sector will save money on energy costs which can then be reinvested in modernizing facilities, hiring new workers and making american manufacturing more competitive. i'm happy to report that my bill has already been included in the senate manufacturing for america initiative, as well. i look forward to continuing this work with mr. hoyer and my colleagues here and on both sides of the aisle as we continue to promote good paying jobs and manufacturing jobs in america. thanks so much. >> thank you very much. i'm not sure that i mentioned in my opening statements, but senator kuhns from delaware and john carney is here from that great state of delaware. he is the congressional delegation from the great state of delaware, former lieutenant governor. but senator kuhns and many of his colleagues have introduced a manufacturing initiative. they don't call it make it in america, but it is essentially the same. we have many of the bills in common that have been introduced in the senate and introduced in the house. now let me introduce representative nolan from minnesota who has put in what i think is an excellent piece of legislation. all of these are good pieces of legislation. to recognize people who are doing things to make it in america, presidential make it in america awards act sponsor representative nolan. >> thank you. thank you for the introduction. thank you for being here. it's no secret that over the last three decades, 8 million jobs and 50,000 manufacturing operations have been moved overseas. and that has been incredibly harmful to the american promise and the opportunity to be able to have a good paying job with a living wage. it's at the heart of the growing disparity between the rich and the poor. i want to thank our leader, our democratic party, mr. hoyer in particular, for this made in america initiative and my colleagues and tell you how proud i am to be a cosponsor of all these initiatives and how proud i am of our party and our caucus to lead the way too bring manufacturing around the world back to america. and as mr. hoyer pointed out, you know, it's a number of things. tax policy, it's trade policy, it's education, it's finance, it's a plan and it's encouragement. so my bill establishes three presidential awards. one is an award to the company that moves its manufacturing overseas and has moved it back to america. to take advantage of just in time and the great workforce that we have. the second award would go to the investors who have chosen to establish a new made in america manufacturing here. and the third one would be to a foreign investment group that has chosen to invest in good manufacturing jobs here in america. that is how we restore the promise of america, by all the initiatives that are represented here at this press conference. i am proud to be a part of it. i'm proud of my party. this is how we restore good paying jobs to the american people. and restore the promise of america. that is what this is all about. and that is why it is so fundamentally important to our future. thank you, mr. chairman. >> mr. besera had to leave, but i asked congressman crowley from new york, the vice chairman of the caucus, just to say a few words and give the cautious aups perspective of the make it in america agenda. >> just very briefly, i'm proud to be here today to not only stand with our whip, steny hoyer, and my colleagues here today who proudly stand here to endorse the make it in america agenda. to manufacturing things here in america again and to make it here in america. and one of my bills is also included in the 50 some odd bills in terms of on-the-job training and making resources available to those who would employ americans and give the opportunity to learn those new skills that they need to have here in the 21st century. but more directly, in terms of our caucus, our caucus is solidly behind the make it in america movement that mr. hoyer has led throughout the past few years. we stand solid behind him, not just the members here before you, but our entire caucus, entire caucus is behind this movement. >> thank you very much, joe. >> okay. questions? >> how is the democrats leveraged that -- [ indiscernible ]. >> look, i don't think that election has change our focus on energy or the things that we think will help people make it in america. as you know, we are proponents of putting the unemployed insurance on the floor. it helps our economy overall. we think the minimum wage needs to be raised. we think that helps the economy and individual americans. we think we need to pass a comprehensive immigration bill, which cbo scores at $900 billion positive to our budget deficit over the next 20 years. and the overwhelming majority of the american people reflect all of those. there are a number of others. we need to pass a voting rights act. none of that has change by the election yesterday. all of those are priorities that we strongly form. we think we need to pass indiscrimination in employment piece of legislation. so the election didn't change our priorities. this press conference about make it in america, that's what people sent us here to make sure that they could do. that is why people came to america because they need to seize it. >> well, look, these prospects are supported by the overwhelming majority of the american people who sent all of us, republicans and democrats, to the congress of the united states. if we want to represent them, that's our title, representative. if we want to representative them, all of the issues i just spoke of are supported by a overwhelming majority of them, including democrats, republicans and independents or anyone else. the fact of the matter is, we still have a responsibility. just as much as we had on monday, we have a responsibility on wednesday to represent the american people and do the best we can to make their country the best it can be and make sure that they can, in the context of our policies make it in america. [ inaudible question ]. >> do you think his loss would be bad for democrats, make cause more -- >> it's hard to figure out how you can cause more gridlock than we've had. but, you know, we've unfortunate focused on doing mostly negative things and/or messaging. secondly, i think we have seen on display over the last three years a party that is deeply divided and dysfunctional. i think that last night was an evidence of that, but i've been asserting that for a long period of time. the american public want us to work together. as i've just said, the issues that we have made priority items are overwhelm going supported by the american people and irrespective of the election last night, we're hopeful that we can move ahead now, not the next congress, not ten years from now, now on moving legislation that's important to the american people. >> the authorization of u.s. export/import bank is on your agenda. >> it is. >> and that's something that you've been working with mr. cantor with hoping to get around. >> yes. >> does mr. carton's loss change the dynamic in terms of getting -- >> well, i called mr. cantor this morning. i have not yet talked to him. but i certainly intend to work with him on -- we'll have to see what the context is, continue to do that. i make the occupation, you know, i've worked with a lot of leaders on the other side. i've worked with trent lot, i worked with tom delay, i've work with roy blount, i've worked with eric cantor. it seems we have a lot of people. i'm going to work with whoever is there. because the export/import bank, the reason it's part of the make it in america agenda is if we're going to be competitive, if we want people to manufacture things here creating american jobs here, for our constituents, then we want to make sure that we are competitive worldwide and without the export/import factor we won't be. mr. cantor believes that. i'm hopeful we can continue to to work on that. when it came to the floor and we voted on it, as you know, it got over 300 votes. it got the majority of republicans and every democrat voting for it when we authorized it. i think the reauthorization would get a large number of votes, too. i hope we can get to the floor soon. >> you said yesterday the meeting was -- on the rights act and have continued to do so. where do you see that going at this point? he's a pretty powerful ally in terms of trying to get that through. >> and i hope he'll continue to be an ally. it hasn't been brought to the floor yet and it hasn't had committee hearings yet, all of which we're concerned about and we had meetings as recently as yesterday was as you know, as many of the bipartisan and nonpartisan groups who are trying to ensure that americans have not only the right to vote, but are facilitated in casting that vote. we think the supreme court decision in shelby very substantially limited the protections that americans have and we want to see the senson slr brenner bill passed. senson brenner, republican, in a bipartisan fashion. i'm going to continue to work with whoever is willing to work with us to get that bill passed. [ inaudible question ]. >> it wasn't moving very fast. so whether it will slow it down or not, we'll see. i'm still hopeful that mr. cantor will try to be a leader in this effort. he could be very helpful. is that it? thank you very much. and we're live on capitol hill this morning as a health veterans affairs committee hear is about to get earn way assessing veterans health care issues. witnesses today will include the va acting undersecretary for health, dr. robert jeffy along with humana president tim mcclain. congressman miller of florida is the chairman of this committee. we expect to have live coverage on c-span3. the committee will come to order. thank you very much for coming to this hearing this morning. we have numerous members that are on their way. but we want to respect the time of our witnesses. we appreciate them being with us today. before i begin, i want to ask in an unanimous consent to allow congressman mcnerney to participate in today's hearing. without objection, so ordered. welcome to today's full committee hearing and examination of bureaucratic areas to care for our veterans. as we all know very well now, during our committee othersight with the results of a committee investigation that had uncovered evidence suggesting that dozens of veterans died while waiting for care at the phoenix department of veterans health care system. just over two months later, we know now that in addition to 23 veteran deaths at the department linked to delays in care earlier this spring, aft least 35 more veterans died while awaiting care in the phoenix area alone. what's more a va audit released earlier this week found over 57,000 veterans have been waiting 90 days or more for their first va medical appointment and 54,000 veterans who have enrolled in the health care system never received the appointment that they requested. that's 121,000 veterans who have been waiting for care to be provided that they earned. that number exceeds the population of several medication sized u.s. cities like athens, georgia, abilene, texas, or even evansville, indiana. and i fear there is more yet to come. yesterday, i spoke to a group of va providers from across the country at an event for the national association of va physicians and dentists. speaking about the current crisis engulfing the department, they've said va's procedures and processes are inconsistent, inconsistently applied and often prevent efficient use of personnel. the statement echos the serious calls that we've heard from others other recent weeks. during a recent committee hearing, the inspector general testified that va suffers from, and i quote, a lack of focus on health care delivery as priority one, unquote. as a result of several organizational issues that impede the efficient and effective operation of the va health care system place patients at risk of unexpected outcomes, end quote. in an article published last week, a former under secretary of va for health dr. kenneth kaiser wrote that the systemic data manipulation and lack of incident tegty va experiences are but, quote, symptoms of a deeper pathology because simply va has lost sight of its primary mission of providing timely access to consistently high quality care, end quote. all of these remarks go to prove what we have already known. the va health care system and the bureaucratic behemoth that accompanies it and its problems are even more complex. i believe that the majority of va's workforce, in particular the doctors and nurses who provide our veterans with the care they need do, in fact, endeavor to provide high quality health care. unfortunately, va leadership has failed those employees almost as much as it has failed our veterans. in correcting those failures is going to take a lot more than the bandade fixes the department has proposed thus far. it's going to take wholesale systemic reform of the entire department starting with holding senior staff accountable. va hasn't gotten where it is today due to ineffective management or lack of training for professional development for administrative staff or cumbersome and outdated i.t. infrastructure. the department got where it is today due to a perfect storm of settling for the status quo. va cannot continue business as usual. it's very clear the status quo is not acceptable and it's time for real change. again, beginning with accountability up to the highest levels of va bureaucracy, and i hear repeatedly from the va about its delivery of high quality patient center care. but this committee, republicans and democrats alike, will not rest until we hear that same assessment from every single veteran seeking care. it's time for va to tell us the bad news, not just the good news. with that, i yield to our ranking member, for any opening statement he might have. >> thank you very much, mr. chair, for having this very important hearing. examine the barrier toes care for our veterans. this is a unique time in the history of the department of veterans affairs. we as a committee have been responsible for bringing to light systematic problems, many dating back over a decade. but as we are shining the light on these problems, we must also begin to take steps to address them. i'm proud that this committee has addressed these problems in a by-p partisan fashion and i'm hopeful this continues as we roll up our sleeves and begin to find solutions. the va is a sprawling organization with over 6 million unique patient facilities spread all over the country and nearly 275,000 employees and a $56 billion budget. it put va the largest integrated health care system in the country in perspective, dha is roughly the equivalent of five mayo clinics combined. recent admissions of wrongdoing are shameful and the practice will not be tolerated. the systematic collapse confirmed by the axis audit and the va oig points to a bureaucratic bureaucracy that has seemed to have lost its way in its focus. i think with these problems the time is right to begin discussing how best to address these challenges and the time might be now to effect big changes that will put the focus back on the veteran s and away from the culture of complacency. in our discussion of reform, i want to make sure that we are not just rearranging the desk chairs. all the reorganization in the world will be futile without a strong base of value. i do not doubt the commitment of the vast majority of va employees. however, sometimes we all know that we need to be reminded of who we are here to work for. we are here to work for the veterans. brave men and women who have sacrificed so much for our freedom, men and women who right now deserve better. i strongly suggest that vha develop a code of conduct or a caregiver culture that will become engrained throughout the organization regardless of whether there is one vision or 50. working in the va requires an utmost integrity. as dr. roe pointed out the other night, all va employee needs to do without a doubt is they have to be reminded that they are working for the veteran. not a bureaucracy. as with most things, there are tradeoffs when looking at structural reform, centralization versus decentralization, standardization versus innovative. these discussions have been ongoing for years if not decades. i'd like to think vha is an adaptable learning organization that can make needed transformation. but let me be clear. the only way we're going to truly address the litany of problems is to look at the fundamental change within the department. and rightfully, we're all looking at ways to address the problems as we see today. but i'm hopeful that our ambitious schedule of hearings in the weeks ahead will think anew about how best to provide the quality comprehensive care to our veterans in a timely fashion. and i hope that they challenge us to think anew about how to refashion systems and infrastructure, management and personal policy and procedures to address the axes issues head on and to help the va live up to its ideal. i believe it is essential that we look at structural and cultural root causes that got us in this position in the fist place. we have heard that the leadership of the medical center feels disenfranchised. we have real concerns over the effective level of accountability. we need to shorten the feedback loop from the front line provider to vha leadership. and one of the discussions we must have is over the right administrative structure of the vha. how to ensure that policies and procedures follow nationally while making sure that va is not a one size fits all system. we have heard many times about the excessive, intrusive administrative burden providers experience which takes time away from caring for our veterans. we need to do what we can to eliminate this administrative work. many are pointing to the i.t. infrastructure. there is no doubt that an outdated scheduling system contributes to the current problems and needs emergency upgrades. at the same time, we need more detail and what's happening in the millions of dollars congress has appropriated for i.t. before we can look at investing even more money here. i want to know why the va did not do a better job in planning strategically, anticipating the needs of facilities systems population and putting in place actions, including things like i.t. upgrades to address these anticipated needs. the time is right to leverage outside expertise. there is no monopoly on good ideas. i look forward to hearing from the panels today and hope to continue this excellent discussion throughout the coming weeks. once again, mr. chairman, i thank you very much and to yield back. thank you very much to the ranking member joining us today. we actually have two panels on our first panel already seated at the table is the honorable tim mcclain, president of humana government business, mr. dan collard, chief operating officers for the studor group and dr. betty mccoy, chairman of the committee to reduce infectious deaths. we appreciate all of you being here with us today. with that, mr. mcclain, you are recognized for five minutes. >> thank you, mr. chairman. thank you for holding today's hearing to examine bureaucratic barriers to health care for veterans. i will focus my remarks on the very complex of organizational impediments in the veteran's health administration not conducive to the delivery of good health care to veterans. in my written statement that i ask be made part of the record -- >> without objection, all your statements will be entered into the record. i make four specific recommendations to improve organizational alignment in vha. but in this oral statement, i want to address just one and it's probably the one that is most disturbing to veterans in congress. and that's a failure of ethics. there is a pervasive va culture that puts personal gain and the system over the needs of the veteran. and hthis is wrong. and i want to make two points to the committee. let's not have congress and va just put band-aids on the current crisis. without resolving the systemic causes. and, two, i believe any long-term solution must include a cultural and organizational assessment by a nationally recognized company. the current crisis differs from previous va crises by the fact that it reflects a serious cultural deficit throughout va at certain levels of management. this is a -- to the culture of what should be at va. now, i want to emphasize and make it clear that from my experience at va, i found the vast majority of va employees to be competent, professional and dedicated to the primary mission of severaling veterans. but the culture at certain management levels reflects an attitude of personal gain over service to veterans. some major changes are required. but before making any major changes, i propose in my written statement that va be directed to contract with a nationally recognized company to conduct a top to bottom assessment of the current culture. a gap analysis can then be performed to determine the current state and then what is needed to move the va system to a veterans centric 21st century system. the experience will be influenced by what i will call the voice of the veteran, which essentially is direct veteran input into what this culture should look like going forward. if congress of va fails to seize the once in a generation opportunity to deliver a modern va health care benefit system, we will all be back in this hearing room in the future lamenting the then current crisis. mr. chairman, this concludes my oral statement. i'd be glad to answer any questions. >> thank you very much, sir. mr. collard, you're recognized for five minutes. >> thank you for this hearing, as well. thank you for the opportunity to address the committee on the issues of veterans health and the underlying elements of culture and leadership. i listened with interest monday night when i heard mr. griffin from the inspector general's office talk about the fact that if you've seen one visn, you've seen one visn. it seems both the testimony and your questions centered around questions in variance. it's clear that those that implement standardized approaches to care produce the very best outcomes. these organizations build culture of accountability, alignment, consistency and sustainability. we also find that their evidence based approaches extend beyond evidence-based care to a framework of evidence-based leadership. this approach ensures that leaders are not only held accountability for the right goals, but these leaders are given the skills and the tools and knowledge to achieve those goals. these leaders ensure consistency in the workplace for their employees, they also ensure consistency in the care environment for their physician colleagues. and as the public has watched the vha issues unfold over the past 60 days, it's clear that the tolerance for variance is cheap among its ailments. the am of variance has created an unfortunately predictable outcome as we would say what you permit, you promote. the data that demonstrates these connections is quality outcomes, patient experience and lower costs continue to mount. when one reviews the publicly supported data, it's clear better health care is less costly health care. data suggests a strong correlation between patients' perception of care and the clinical outcomes. further, there's data that correlates specific questions like preparation for at-home care with the likelihood of a readmissi readmission. a review of the vha facilities that report show only a handful show a few just above the national mean and unfortunately way too much in the lower ranks of health care. >> you connect this proof with the fact that employee engagement and one begins to see definite trends. a study published recently at the university of birmingham shoeg showed clearly the correlation between the level of employee engagement and the likelihood of the creation of work arounds which equals impact on safety. i was reminded of that as i read the various reports of what we now know from the whistle blowers about the wait list and the related mortalities. largest health care systems in the united states have driven improvements by harvesting and implementing best practices across their system. when organizations like community health systems identify a best practice, they move quickly to put the practice in place across all 205 facilities. this includes patient safety protocols, caregiver to patient interactions about medications and a leader accountability platform. i was concerned when i heard the wednesday on monday refers the amount of time they thaw it would take to make change. as john cotter would have us remember that the biggest okbjet tackle to achieving performance is high confidentsy. no matter what is decided, the va must embark upon change with a never before seen sense of urgency with a proven outcomes based solution. we open at the studor group that it can be as straightforward as transforming the rigger where they compel into an area where they are subpar. imagine if the vha electronic medical record which is hailed ad as cutting edge would be the oomph tuesday for creating the scheduling software which is today archaic at best. imagine in a high performing facility is referenced in the testimony that stand out as models could be toss modeles and indeed replicated with what mr. mccofsky referred to as exceptional leadership and culture. we wouldn't have tolerated the operation of 21 different navys or armys, air forces marines or coast guard when these veterans were on active duty. why do we tolerate 21 versions today? our veterans ensured readiness by putting in place systems of validation for skills for soldiers as well as those leaders. we find safe, effective timely health care to be no different. and finally, we have to make sure that the veterans health administrative doesn't continue to fall victim to this disease process known as terminal weakness. many have large geographic footprint wes a corporate office thousands of miles where the care is being delivered. many organizations serve a large incident gent indigent population and these organizations find a way to survive but thrive. i ask if this committee would propel the secretary and his leadership team to move forward expediently, ensure methods of validation and verification and make sure this supports outcomes leadership development tone sure the consistency. i ask this today not only as a health care professional, but as the son of a deceased marine corps veteran whom i saw all too often let down by the va. thank you. >> dr. mccoy. >> thank you. i'm betsy mccoy, former lieutenant governor -- and chairman of the committee to reduce infectious deaths. i've spent a good deal of my career in prevention of infection in hospitales and i admire many of the achievements in the va in that area. but i'm here today to express my concern that this bill passed in the senate yesterday, the mccain standards bill, will not save the lives of vets stuck on the wait list. this bill, as currently written, is designed to protect union jobs, not ailing vets. in fact, the va is run largely by unions and for unions. and one of the culprits is this 316 page unit contract full of mind numbing rules that prevent assigning an employee to a new task, a new work shift, a new building or reprimanding someone on the staff for misdeeds or just poor performance. nine months ago, the va rolled out a $9.3 billion initiative to allow vets who were stuck on wait lists to access civilian care. but the unions fought it as hard as they could. the american federation of government employees labeled it in their newsletter the worker an attempt to dismantle the va brick by brick. that's not true, but they vilified it that way. and this current bill sabotages the ability of vets to access civilian care in three ways. first of all, it requires -- and i'm referring to section 301 starting on page 21 since i'm sure you'll be reading the bill. it requires any vet wanting to access care get a letter from the secretary of va confirming the vet has waited an unacceptable amount of time for treatment or lives more than 40 miles from a va medical center. good luck getting that letter. i talk to vets all the time who have contacted the va, called them, e-mailed them every day for six months and couldn't get a reply. secondary, if the va does manage to get the letter and get the choice card and get to a civilian doctor, he has to hand the card to the doctor who has to call the va and get prior approval before treatment. good luck getting somebody to answer that phone call. thirdly, most preposterously, this bill states this choice program will end in two years. in other words, a few hours after the va manages to get the hot line up and get the cards distributed to vets, it will be over. there is a way to solve. >> prok and pthis problem and pt the solution in the hands of the veterans. many of these vets are seniors, they're 65 or older and on medicare. if they were encouraged to seek age related care such as angioblasty at hospital, particularly teaching hospitals, it would reduce the baglogs by as much as half solving this national crisis. and in many cases, vets would get better care because the mortality rates at the teaching hospitals associated with many of these va medical centers are much lower. they're high volume hospitals and they do these age-related procedures all the time. what is holing the seniors back is lack of knowledge about that resource and secondly the co-payments, the out-of-pocket expenses. we could give those vets who are already on medicare a special vamedigap card. it's budget neutral. you're already paying for the care. and yet it would allow them to access better care, it would reduce the wait list, and it would allow vets who have fought for our freedom, it would allow them to get the care they need. thank you for this opportunity. >> thank you, dr. mccoy. mr. collard, i'll start with you, but anybody that wants to answer this question, feel free. each member will have five minutes for -- and we also have a round of votes. that's why evening hearings on return nights are so good. we don't get interrupted with votes. but my staff recently obtained an e-mail and a supervisory chain how many levels there are between the scheduler and the secretary and, of course, the scheduling clerks called medical support assistant. it shows 12 layers of bureaucratic and middle managers between those two people. is that surprising? >> it's not surprising. but it's clearly an indicator of the issue. on the private sector, you wouldn't think about care that could be rendered in a safe, timely fashion with 12 layers of leadership between someone in the trenches and someone making the decision. it creates the greater opportunity for the variance in communication, the variance in setting expectations, the layers just create the permanent ation for communication within the va. >> and how about the time it takes, all that communication? this is time. you know, one of the studies that recently came out showed that when an older vet is forced to wait 90 days or more for treatment, it increases the risk of stroke by 9%. that's a study right out of the boston va medical center. so this time is critical to saving the lives of these vets. that's why they're dying in these wait lines. >> tell me, if you would, how does this structure compare to your experience in observing other medical centers or systems? mr. mcclain. >> i don't have a lot of experience in observing other medical centers. human aye for the most part is a health and wellness medicare advantage company. we do a lot of business with va. and we have seen the difficulty that we have as a contractor in also getting certain answers and certain things changed or done for the betterment of the veteran. >> mr. collard. >> we would find traditionally no more than three or four layers. i was with an organization yesterday and it was the traditional structure of a senior leadership team, directors, managers and right to the front line. >> and i think you also -- i think, mr. collard you may have, but others of you may have alluded to this, as well. the number of health care networks that exist across this country, 21? i mean, you've got a large network. i mean, system. how many networks should there be? surely it should be broken up somehow, but 21? >> even if the number stayed 21, the ability to standardize across the 21 is really the key. there are, you know, health care is always local, no matter whether it's private sector or government. health care is always local because we're serving local veterans. but the ability to say whether it needs to be 21 or six, really the underpinnings of that, when you lift up the hood on that is the ability to standardize across no matter how many regions or visns or divisions that you have. >> dr. mccoy. >> yes. one of the problems is really quite simple. .it's been pointed out in many of the reports that have been submitted to congress over the last decade, including the one that was presented on monday and the one that was presented by the general accountability office in march of 2013. and that is that vets are assigned an appointment and months go by and nobody calls them to remind them a day or two before the appointment that they're supposed to come. that is a practice that is always done in private sector medicine. every doctor's office, every clinic, every hospital calls patients and reminds them to show up for their appointment. the result of this failure is that in some departments, like ophthalmology, according to the gao report submitted to you last march, the no-show rate is 45%. so when you say you don't have enough appointments and enough doctors, almost half of them are going to waste. and yet why, every year, does another report have to remind the va to call the patients and nothing is done about it? >> my time is about to expire, but i'd like, if you could, as succinctly as possible, what's the greatest single barrier that exists out there today within the va to providing timely health care? >> and i'm going to go off of what mr. collard said is standardization. you've all heard it. if you've seen one va, one va. and it's too much, i guess, flexibility or variability in how services are delivered and how veterans can access services at each of the va facilities. >> when you standardize your practice, you create greater predictability and outcomes, whether it's an attorney, a finance expert, a health care expert, they all agree when you standardize your mode of practice, you predict greater predictability and outcomes. and it's the outcomes this panel needs to address and not just the care measures that we're talking about. >> dr. mccoy. >> i'd like to to focus on the failings of this bill. because pretty soon you're going to be voting on it or compromising with the vote you took in the house to create a final bill. and that final bill that you create has to remove these practical impediments, otherwise you are not passing a bill to give vets access to civilian care. it will be a charade if they have to get a letter from the secretary and if there has to be a call made to get prior approval for the treatment. just remember that, please, as you compromise with the senate. thank you. >> thank you. >> thank you very much, mr. chairman. mr. mcclain, one of your recommendation is to review all personal evaluation metrics and ensure that all vha employees from clerk to clinicians to senior managers are evaluated based on outcomes for veterans who are seeking and receiving care from vha. mr. collard, you also urged us to focus on leadership. my question to you two is the overreliance on metrics has been mentioned as one of the factors leading to the current wait time problems. how do you explain the metrics and outcomes. >> thank you. my short answer to that would be that most of the metrics that are reported today in vha, and there are hundreds of them, are process oriented. and simply checking a box or doing something is -- versus actually measuring what that accomplishes or the outcome. so my point in making that was that we should be rewarding and measuring outcomes for veterans. >> it's just the sheer size of the number of metrics. if you went the hr route and pulled the evaluation within the va today, you would see metrics scored by the dozens. and if you think about that many metrics, how can a leader give any proper attention and proper priority when you have a way to evaluation around those that are outcomes versus process, you have the ability to create focus and priority and that's what i would say is not just the metrics, but the sheer number of metrics that we're looking at. >> thank you. is it valid to have a strategic metric, mr. mcclain? >> i think it's valid to have a strategic goal. as to what the outcomes might be. and be measured against that goal. i think that's valid. valid. >> look over on the -- >> i wanted to point out. >> many mccullough, would you answer? >> we know the fact that a tactic like a post-hospitalization phone call has the ability to -- in the publicly reportedly websites that you would find, you would find the actual readmission rates for folks within certain disease categories. >> some within the va have raised the concern there are inadequate number of -- this causes physicians to spend undue time with paperwork and routine clinical work. mr. mclain what does the private sector use as a benchmark for the physicians to -- >> mr. collard? >> i would defer to mr. mccklai. >> i'm interested in your comments on the v.a. paying for care for patients already covered by medicare advantage and the potential for the government paying for care twice. what policy changes could remedy the situation? >> well, it's very interesting that such a large percentage of vets actually have insurance. only about 10% of vets being treated at the v.a. are, quote, uninsured. and it's probably tragic that they weren't included in the affordable care act. but nevertheless, many of these vets who are insured, either with employer-based insurance or medicare advantage or regular medicare or medicaid resist going outside of the v.a. system because of the out-of-pocket expenses. as i explained before, if we gave them a medigap card for the seniors, particularly, a medigap card, special v.a. medigap card that absorbed out of pocket expenses, they could seek a lot of care in civilian hospitals. particularly teaching hospitals that are high volume for -- they'd be getting in many cases better outcomes. always always better but often better. it's budget neutral for us as a nation. it's budget neutral. >> thank you. incidentally, under the affordable care act, 3,000 -- were denied access because our governor refused to expend medicaid to the 70,000 mainers of which 3,000 were veterans. >> thank you. >> i thank the panel. my first question is for the entire panel. many have mentioned and stated the v.a. has lost its focus on their primary responsibility of caring for our veterans. do you agree? let's start with mr. mclain, please. >> yes, i do agree. >> also mr. collard. >> yes. >> yes. doctor? >> yes. >> all right. now, tell me where you think their focus has been. we can start with mr. mclain. >> the current focus, i think, has gone off the veteran and has gone into preserving the current system. i think that there's a lot of -- if it's not invented here, we don't want to hear about it. so there is not a lot of invitation for innovation to come in and partner with v.a. in order to move it into a more modern health care system. so where i see it is, it's as dr. kaiser stated, a more insular system right now. >> mr. collard. >> two answers, really. i spent some time with a v.a. leadership group in one of the western regions last year. i heard for probably two hours more reasons about why we couldn't do something versus why we could do something. i also think that sometimes we feel that standardization stifles innovation. and i don't think it could be any further from the truth. when you have a standardized platform in any industry, you actually have pretty fertile ground for innovation. because once an innovation takes hold, you now have a platform by which you can harvest, distill and disseminate those best practices through innovation across an enterprise. i think what happens as i would associate with mr. mcclain's comment, the ability to attach to the way we've always done things is really probably that barrier of focusing on veteran centered care. >> doctor? >> yes. i'd like to point out two things. one is that as i mentioned in my opening statement, in the '90s the v.a. really took an admirable lead in patient safety and particularly attention in hospital acquired infections. lately we've seen less and less of this. dr. jane who has now taken a bigger job at the v.a. has done some wonderful work in the work of meth sillen resistance. in general, that pioneering effort to protect patient safety that i saw in the '90s has disappeared somewhat from the culture. that, and as i pointed out before, how can you have a focus on the patient when you have 316 pages of rules about what employees can and cannot do just for one union? just for one. this contract governs the work rules for 200,000 people who work at the v.a. and it is preventing a focus on the patient. >> thank you. next question, do you believe the v.a.'s shortcomings and failed benchmarks was the result of inadequate funding or management or resources. mr. mcclain. >> i personally don't think it was the result of inadequate funding. the v.a. budget has really increased significantly in the past five or six years. but i think pretty obviously it's a misallocation of the those resources. >> mr. collard. >> not only a misallocation, but perhaps just looking the other way when you have the resources. i think i heard on monday night the fact, chairman miller, that you raised a specific financial number that's been invested or been provided for i.t. and i.t.-related services. the question was raised, where's the money? and so whether it's -- whether it's misallocation or just, perhaps, an ignoring of those funds available, perhaps, leads to the current state. >> dr. mccaughey. >> yes. the v.a. budget has increased 173% from the year 2000 through 2012. that in inflation adjusted terms is 72%. the increase in total v.a. patients was 69%. so the funding increased at a faster pace than the number of patients who had to be treated. and the number of acute care patients who need costly care increased only 49%. so the v.a. funding should have been adequate to meet the increased demands on the system. >> last question. very important question. how would you rate v.a.'s urgency to change its culture and become more patient-centered for the veteran? we'll start with mr. mcclain again. >> i don't see any urgency. >> mr. collard? >> could i have you restate the question again? >> okay. how would you rate v.a.'s urgency to change its culture and become more patient-centered for the veteran? >> on a numeric scale, very low. if we're rating it in current state. >> dr. mccaughey. >> i agree with that. >> thank you very much. i yield back, mr. chairman. >> thank you. mr. tokano, you're recognized for five minutes. >> thank you, mr. chairman. mr. mcclain, your testimony encouraging the v.a. to adopt a more inclusive approach to contract care along the lines of the kaiser permanente model and the, quote, kaiser experience. how do you respond to vha concerns with the continuity of care and record transfers? >> well, i respond it, and we have some direct experience in this having done project hero and currently doing project arch. is that v.a. doesn't favor outside care for the most part. in other words, they favor the biases to treat everything within the walls. the success of the kaiser experience is that they view all care that is delivered in one of their networks as part of kaiser care. that's part of the kaiser experience. in other words, the people who are going outside into a community provider feel that that is just part of the kaiser system. part of the issue is that currently, v.a., although the vista system is a terrific system for electronic health records, it does not have the ability to collect those consults and primary care charts that are on the outside. and that is one of the things in my written testimony that i proposed. is there is i.t. currently available that will consolidate and aggregate all of the care of a veteran. whether it's delivered inside of a v.a. medical center or outside. so that the provider in the vamc has a complete picture of the veteran's health. >> could you comment on the capacity of the private sector care providers, what percentage of them are ramped up to be able to utilize the software? i've heard that, you know, a relatively small percentage of providers have the capacity or have updated to electronic records. >> i don't have that number in front of me. i couldn't testify to that, sir. >> well, thank you. mr. collard, mr. mcclain, do you -- regarding cost management, would you find that the veterans -- the vha and the way they deal with prescription drugs and pharmaceutical costs is a good thing? i've heard that they actually use their size to leverage down those costs. >> the answer is yes. i think they do a pretty good job. by statute, v.a. actually purchases drugs in bulk for dod and v.a. and the indian health and coast guard. by statute the manufacturer is required to give them a discount off of commercial rates. so, actually, v.a. does a very good job in purchasing drugs. >> mr. collard? >> i would concur. >> so does that same sort of approach exist with medicare? >> not to my knowledge. >> would that contribute to out-of-pocket costs for senior citizens generally, do you think? >> you know, i haven't -- sir, i haven't looked at that. i don't have an opinion on that. >> you know, well, thank you. you know, mr. walls, is there -- would you like to -- i yield my time to you if you have any question. i'm kind of done. >> we can come back to it. mr. mcclain, you're right. i really appreciate some of the ideas that are coming out of this. this idea that is being brought up of how do we get to the big idea? i guess one of my concerns is, and i would ask on a comparison, this is to you, dr. mccaughey. you carried around this. this is the selective agreement between st. mary's hospital, the mayo clinic and their health care providers. it doesn't make as good a theater as a big one but it's still there. i would make the argument the mayo health care provides quality health care. your assertion is the -- i don't believe in any way moves this argument forward. my question to you is, when was the last time you personally were in a v.a. hospital. tell me about your experience there as you talked to the viders and talked to those nurses a at the nursing station. >> i actually just talked to some of the people at the v.a. hospital here in d.c. a few minutes ago. and let me explain that they are -- i haven't been to their hospital yet. but i have talked to them. and let me explain that they are also concerned about the mismanagement or misallocation of staff resources. it's so bad, for example, that at some of the v.a.s, and i know you'll probably confirm this, the physician has to spend a lot of time going out to the waiting room, getting the patient, explaining how to disrobe, doing a lot of things that in a -- in another hospital or clinic, would be done by ancillary staff. so that doctors can see not two patients an hour or three, but maybe six. some of this is a problem with union rules. and to say that it isn't is just preposterous. i haven't read their agreement. but to say that unions are not part of this problem is just -- read -- read the american federation of government -- just let me finish. you asked me to come here. >> you answered. >> mr. chairman, i'll yield back my time. >> time is expired. >> thank you. >> i would like to explain, sir. >> i apologize. we're very short on time. dr. row? >> thank you, mr. chairman. mr. mcclain, i think you're 100% correct when you -- the v.a. needs to go through a top down look from an outside agency. it doesn't need to be evaluated within anymore. it needs to have an outside look. and what i -- what mr. michaud said is absolutely correct. the v.a. could do one thing today. i said this monday night at the hearing. the years i spent in clinical practice in medicine, i knew who i worked for, and that was the patient. that was the center of why i was there. if i didn't have patients to see, i had no reason to be in an office. and if you ask anybody on a v.a. campus who they work for, they'll say the v.a. the answer should be we work for veterans. that should be the answer. and that's a simple change in philosophy. i don't have any reason to be at this v.a. if they're not veterans there for me to care for. i think you could do that one thing. i think the top down approach, i think you're spot on. several things were brought up. just interestingly, mr. mcclain you mentioned in a cboc you ran at the v.a. had four to five personnel to help, ancillary people to help. in our office, and i practiced for 31 years, it's about three people. and you can even get more efficient the bigger you get. you don't need another scheduler if you add another doctor. need another medical assistant. you may need another lab person, whatever. but you get much more efficient. typically, it's three to one. sometimes even less if you're very good at it. we were very good at it and very efficient. the incentives that the v.a. has, doctor, you mentioned this about -- about consults. i said this monday night. this is really simple. we had almost 100%, 95% of our consults that we saw, kept their appointment. why? because if i miss that appointment, that's a slot that wasn't filled. i didn't have any revenue. so we made sure that we contacted that patient over and over to be sure that they kept their appointment and came in. almost all of them did. if you mailed a letter out two months ahead, three months, your appointment is august 7th, you don't ever check up, you should expect a huge number. for someone at a v.a. if you don't have anybody show up, that's a snow day. it's perfectly -- it's free time. you're not doing anything. i've heard over and over and over again from my doctor friends who are at the v.a. that they do all kinds of things that ancillary people ought to be doing. and if you go to a private doctor's office, they're going to have those people calling to make the appointments. all of those things. your time is focused on seeing the patients and taking care of patients. i think also something that's mentioned in this bill that absolutely has to change, there's no way on this earth that a veteran can go get a letter and do all of this and then go to my office and me do 1-800-hold. that's what it's going to be. and you're going to spend an hour and a half trying to get somebody in my office. the doctors are not going to see them. we can't afford to waste our time doing that. we're able to see the patient, we ought to be able to do the care. that's something, mr. chairman, we go to conference, has to be changed or this will be a waste of time. i certainly don't mind the sunset. i think many laws ought to be sunset and be looked at after that length of time. i certainly appreciate your all's frank testimony. it's refreshing to hear someone from the outside not tell us how great everything is on the inside, and we find out it's really a disaster on the inside. also, mr. collard, you mentioned something that i totally agree with. there are many hard working, good, dedicated people working at v.a.s today. they're seeing veterans, taking great care of them. but there's a culture there that does need to be changed. and i certainly -- i'm going to stop and let you make any comments you want to. >> dr. roe, i agree completely. i would like to make a comment regarding the no-show rate. dr. mccaughey has mentioned it and you've mentioned it in a commercial setting how important that is. our experience for 5 1/2 years, we provided services under project hero, which was a contract with v.a. where we provided administrative services. and we set the appointments. we essentially would get the veteran on the line with the doctor's office and do a three-way conference call to set the appointment. and then not only send a letter, but we would follow up within 48 hours before the appointment to remind the veteran of the appointment, plus the directions to the doctor's office. our no-show rate in project hero was less than 5%. >> same as ours. i think you show right there, that's a metric in the private world that you use because, again, your incentives are different in the private sector versus where you have just a v.a. budget that you have this much money to spend at the end of the year and you spend it, you send it back. >> that's exactly right. we were not compensated at all for a no-show. that was not part of the contract. we knew that. but we were very diligent in getting the veterans to their appointment. >> thank you, mr. chairman. i yield back. >> thank you, dr. roe. mr. brownly, you're recognized for five minutes. >> thank you, mr. chair. my first question is to mr. mcclain. i certainly agree with your assessment of the culture and, as you described it, personal gain over -- over the veterans. and if we're really going to create a system that is truly veteran centric, then i think certainly i think we could all agree that we need to hear from the veterans. so my question is, are there any specific recommendations made by the vsos at this time that you would actually endorse? >> ma'am, i am not familiar with all of the recommendations from the vsos. i have not listened to all of their testimony nor read their resolutions. >> but in terms of, as you described, a great need for outside assessment of the organization before we begin to make any of the big changes that we need to make, you would include vsos -- >> oh, that's part of the voice of the -- they're a huge stakeholder. there isn't any question about it. >> thank you. and, mr. collard, i certainly agree, i think we all probably agree of your assessment that the i.t. system for scheduling is archaic. is there -- are there systems out there that you would recommend? >> not a particular system, but just knowing that they're present and they're used. and if i could just extend upon an i.t. element or a pre-call or a post-call, what we're really talking about is not fundamentally the reimbursement around or the productivity that's impacted like a snow day for a no-show. what we're really talking about is that quality outcome again. so if a precall is made and we know the veteran shows up fully prepared for the procedure or the treatment. they know where to come, they know when to come, that's going to drive quality. the post-call efforts that are in place also, again, not just a unit of a box checked, but the imempirical evidence on the private sector side that reduces readmissions, improving medication compliance rate. there was a study in the annals of sbesintern medicine about a and a half ago that -- improved just the propensity to stop at walgreens and cvs and fill the script. again, private sector example. i think we all have to eventually come -- we're doing a really good job today talking about the what and the how. we've always got to return to the why. i think each of us have recognized the why of these conversations. >> thank you. mr. collard, again, from your vantage point, how do you think we can better instill integrity into the v.a. management? i mean, how do we instill, you know, starting yesterday, starting today, how do we begin to instill a sense of urgency within the -- within the veterans health administration? >> as with any organization, urgency begins at the top. accountability begins at the top. what we have to be able to do is narrow the focus. the one big idea, again, i come back to monday. this doesn't have to leave a committee and take on 50 things. but the one big idea that could create momentum and confidence in our veterans, provide clear expectations out of that sense of urgency, out of an assessment that could be done. make sure that the training is adequate for those, asked, perhaps, to do something new or do something differently. then make sure that we just utilize methods of verification and validation like any other industry would do to ensure in realtime that things are happening so that we don't find the firestorms that exist when either whistle blowers make a call or finally data reaches its -- its peak. >> thank you. and you -- i think in your testimony you talked about, you know, big change with proven outcome solutions. and that if the v.a. -- we can't -- the v.a. is unique, but we can't say -- we can't be terminal about its uniqueness. that we have to look to better outcomes. >> mm-hmm. >> so is there anything about the v.a. medical system -- i'm not quite sure how to ask this, because i agree with your assessment, but that is unique? that we don't have another place to look to for best practices? >> i just think we have to get beyond that as the question that would be asked from internally. the single most improved hospital in the united states of america is trinitybirmingham, a. they're in a 40 to 50-year-old physical plant. they don't have private rooms. they have a call light system. when it rains to the patient rooms it rings to the pbx operator of the hospital. they ring the nurse's station. they've decreased call light time in excess of 60% to 70% with the hand that's dealt them. >> thank you. i yield back. >> mr. flores, you're recognized for five minutes. >> thank you, mr. chairman. i thank all the witnesses for being here today. dr. mccaughey, thank you for the quick feedback on the senate bill. that's very helpful. mr. collard, one of the things i would ask you to do in future testimony, when you use the word "standardized" be sure to mean that doesn't mean centralized. one of the issues we've got is centralization sometimes cannot be the solution. mr. mcclain, you hit the nail on the head today. you said we have a unique opportunity to reform the v.a. and that if we don't do it well we'll be here again. and with that in mind, that generates my question. i'd like each of you to spend about 90 seconds telling me what the v.a. of the 21st century would look like. and totally disregard what the v.a. is today. disregard the people, the bricks and mortar. disregard everything. what does the v.a. of the 21st century look like? but what does it have in terms of people, culture, systems, leadership, use of private sector resources? is there a need for a union in the v.a.? and so let's touch on that. i'm down to actually about a minute for each of you. and i'd really appreciate it if you would provide some feedback in writing afterwards. i know you're doing this as volunteers. but you have the best interest of our veterans at heart. so if you can follow up in writing that would be awesome. just a minute from each of you. let's start with you, mr. mcclain. >> thank you, sir. to put it in as few words as possible, i would say it has to be veteran centric. in other words, you put the veteran in the middle and you build the system around. so you have teams in an integrated fashion providing care coordination and integrated care to the veteran. and the metric is outcomes. health outcomes. how long did you extend the life of this particular veteran? how long did you extend the quality of life of this particular veteran? and right now we're not measuring any of that. >> okay. mr. collard. about a minute. >> i think it's a veterans health care administration that has as one of its chief focal points the ability to reduce variance in all practices or as many practices as can be. what that can mean is the -- the acts, the practice of access for our veterans, the practice of care, the practice of care environment for our physicians. on the private side we joke a physician typically works in four hospital ps p the daytime hospital, nighttime hospital, weekend hospital and holiday hospital. i can just imagine how many different versions there are in veterans hospitals too today. the ability to reduce that variance, standardize those practices. when identified as a true vetted best practice, the ability to move very quickly across the system to implement those best practices. >> okay. dr. mccaughey. >> yes. let me point out, and i'm very grateful to be here today. that your time is valuable. but time is also extremely valuable for these vets who are waiting, who are stuck in these waiting lists. 3 63,000 who waited a decade and never got a first appointment. now 57,000 currently waits for their first appointment over 90 days. i would point out that this bill that you will be considering establishes two commissions. one, to study the issue of v.a. construction. what's gone wrong, the delays, the cost overruns and where construction is needed. >> i don't want to talk about -- >> i wanted to make this point. don't waste your time with another commission. in 2012, you had a commission do that. read the report. i'm sure that the new commission will find exactly what the commission found two years ago. they discussed las vegas, denver, st. louis, all the places that had those construction problems. and, secondly, this bill calls for another commission to discuss staffing and health care needs, particularly the need for physicians. you had a study like that done two years ago in 2012. i urge you to read it. it will save you a lot of time if you want to fix this while the vets who are sick are waiting for care. >> again, i'd ask each of you to think about this. you know, back out of the weeds a little bit and think about this from a $50,000 review put on you. what does the v.a. of the 21st century look like? if we could start all over again and not worry about any of the past sins or postmortems or any of that crud. what does the v.a. of the 21st century look like? again, i agree, it should be veteran centric. so if that's the vision, i want you guys to tell me what the structure is. i'm going to -- i don't have time for that. so if you can follow up in writing, that would be awesome. thank you. i yield back. >> thank you very much, mr. flores. m ms. titus. >> over the past week we've had a lot of discussion about how to integrate metrics into evaluating the system. we keep hearing metrics this, metrics that. then just recently the v.a. said they're dropping the metric of 14 days as a way to measure the scheduling appointments because that was unrealistic. now they've changed it to 30 days. i know we can't abandon performance metrics. but when i talked to the people at the las vegas hospital and they go into all these details, then they tell me, but this doesn't really measure what we're doing because it doesn't count the first appointment that they have when they come in on the very same day. so it's not an accurate reflection. i wonder if we're not suffering from the ecological fallacy. we just can't see the forest for the trees. do you have some suggestion about how we better use metrics or we get rid of some metrics or how we can do evaluation better? anybody? >> yeah. you know, in our industry, we tend to be gluttons for punishment when it comes to metrics. i think it's important that we create a stop doing list. if you look at the medicare value based purchasing formula even itself, just in the last couple of rounds, is that there's been a decreased focus on process measures and a very much increased focus on outcomes measures. so not did you give the aspirin with an acute mi in the e.d. we've all gotten pretty good at that now. how about mortality index? how about mortality rates? how about surgical site improvement initiatives there? again, narrowing a focus and a much more -- a much fervent shift from process to outcomes. >> i would like to second that. i fully agree with that. and, in fact, the -- the article in the new england journal of medicine that the chairman referred to in his opening remarks underscores how besieged, how suffocated doctors are by the requirements to enter so many metrics in the charts. that you lose sight of the really important ones, and not only that, but you lose the doctor/patient relationship. i'm sure you've experience third-degree ed this recently. you go to see your cardiologist, internist. instead of having a face to face conversation the doctor is there trying to get everything into the computer while you're in the office with him or her. so we need fewer metrics. we need outcomes measures instead of process measures. and i'd like to applaud those involved in formulating this bill and working with the v.a. to make their metrics transparent. because for a long time, they have not made available to the public their outcomes measures, just to the distress of all of us who wanted to see them. >> thank you. >> i think that the one thing i would say is that we have to obviously measure the right thing. there's a lot of things out there in medicare that i think show some quality outcomes. indicators of quality outcomes. even though v.a. is a fairly unique system just by the way that it is structured, it is delivering health care just like a lot of other systems are delivering health care. and they shouldn't be afraid to take a look at those metrics from the outside. >> one other question. we keep feeling this push to send veterans out of the v.a. into the private sector for care, where they can get doctors who may be available to them that aren't in the v.a. and that's fine. but in the areas like las vegas and some rural parts of the country, you've got a shortage of doctors. so pushing them out there on already overloaded doctors is not going to solve the problem. i've got a bill working with some members of this committee to create more residences at v.a. hospitals and areas where there aren't enough doctors. do you think that's a good idea or do you have other ideas how we might address that? >> i think that's one thing you can do. certainly there are several other things we're currently looking at to discuss with v.a. in order to provide some solutions. especially in the rural health areas. tele health is a big one. there are, perhaps, mobile facilities that might go around to service some veterans. there are a lot of different things that you can hire what are known as locums or locem doctors in a particular area to serve for a particular period of time. and there are some innovative solutions that i know v.a. is looking at, but they haven't pulled the trigger yet on some of it. this may be the opportunity to do it. >> doctor? >> yes. i was just going to add to that that most m.d.s in training at a teaching hospital do rounds at a v.a., do some of their training at a v.a. hospital. it's just standard practice. and, of course, in rural areas it's a bit different. but i would change the use of one word you chose. we're not pushing them out of the v.a. we're just allowing them out. giving them the choice if they wait so long or don't have another place. if they can't get an appointment at a convenient v.a. so i don't think anybody in this room wants to push vets out of the v.a. or eliminate the v.a. >> well, my point is, if they go out into the private sector, we need to have some doctors out there who are available to help them. >> you are so right. >> and there are shortages of doctors and you have v.a. hospitals that might be a place where you could do additional residencies. i yield back. thank you, mr. chairman. >> thank you very much, ms. titus. mr. runon, you're recognized for five minutes. >> thank you, mr. chairman. mr. mcclain, it's in some of your written testimony. can you give me a couple metrics that the v.a. uses that are the most harmful? >> well, i think the most obvious was the 14-day. when you say harmful, i guess you're talking about harmful to health care delivery? >> yes. >> i would point to most of the metrics that just measure process and check a box, rather than health care outcomes. >> okay. and this really for all of you to touch on. i know it's been touched on. and i just want to confirm it and have it on the record. because i think -- we'll start with mr. collard. i think you've said it a couple times here. some of the stuff, health care record, the v.a. does very well. we've only scratched the surface on what this is. i cha ir the subcommittee on disability claims. so that is the next step. okay. now we're tying in the private sector, the v.a., and another government agency, the dod, that don't communicate very well. are there private sector platforms today that you could buy out of the box that could accomplish that. >> not that i'm aware. i think what we have to be able to do, if you look at the v.a. electronic health record which, again, is hailed as cutting edge, clearly there's an architecture there that even the private sector could look towards for some learning. the trouble in the private sector is you have a number of vendors that are positioning themselves as the most prolific electronic health record. what that does is that actually stifles the layers of communication, the ability to communicate between private health systems. so, again, it's an opportunity for us to look to the v.a. where there could be some good things going on. and perhaps move from there. but on the private sector, it's probably as fragmented as can be. >> chairman, i think it goes to what mr. johnson was saying the other night. they won't show us what their architecture is a lot of times. so no one could even build a system that could be even remotely compatible with it. it's part of the problem. really i just want to make this point. then i'll yield back my time. i want to let some other people -- i think we've came to the conclusion also we do this in government all the time. continuing to throw money at a system that is broken structurally is not going to solve the problem. i know you all agree with that. i just wanted to make that statement. until we fix it, throwing money at it is going to do nothing but cause us to throw more money at it. so with that, what i remembchai back. >> thank you very much. dr. reese, you're recognized for five minutes. >> thank you, mr. chairman. thank all of you for being here and giving your input to this very important topic. there are some terminologies that have been said that are very important to me. the most important is to be veteran centered. to be patient centered. and i appreciate dr. roe's comments on that. because as a physician, it's our life blood. it's what we live for. it's the outcome that we see. it's to make sure that our patients, we reduce their suffering and promote their wellness in whatever we do. and at that moment, that patient is our world and our universe. and i believe that is the sentiment that we should have here in congress as well with our constituents, but also in the v.a. with the whole apparatus focusing on that. and i believe that the urgency is very much needed. and i believe that with the working in collaborations with the v.a. and this committee can make sure that that urgency is highlighted. you mentioned things that are also very important. which is standardization. and i'm familiar with that as an emergency medicine physician. you know, you come in with a patient. they don't know -- you don't have any information. it's a multiorgan trauma or emergency, medical emergency. and you just have to figure it out. the way we do is we have clinical guidelines and training after training after training to help us with a framework to treat that patient. and i believe that in standardizing the care with the v.a.s throughout the system is very important. but when i did my veterans initiative back home in the coachella valley in california, some of my veterans there said they have to reregister and they have difficulties going from one v.a. to another v.a. even if they, you know, are here for the summer or the winter break or whatnot. and so how do we create that intraoperability within the v.a.s throughout the country. >> i guess that's more of an i.t. question. i know that that's been a goal of v.a.'s that they haven't accomplished yet. i think that several years ago, there was the vler. the veteran lifetime electronic record. which was a composition of all of the v.a. benefits that a veteran could get in one place. in other words, you could go for your health care, but if you had a disability claim, it would also be reflected. and if you had a v.a. home loan, it would also be reflected. i think that's still a great goal. i don't know where v.a. is along the timeline for doing that. but just getting a single medical record where you do not have to reenroll every time you, you know, go north or south or wherever you're going in the v.a., i think has to be a goal that would really assist veterans across the board. >> wonderful. and the next question, mr. collard, is we talked just now about the difficulties of communication and sharing of that information from one v.a. hospital to another. but how about the communication structures with non-v.a. providers with the v.a.? we know there are some barriers to doing that. and what can we do to minimize those barriers so that the family doc in the rural area, if there are enough physicians, can receive the information from the v.a. that they need to provide the continuity of care that the veterans need, but also provide those same standards of reporting to the v.a. so that they can enter that information to their outcomes measurements that they -- that they need for the patient? >> so being as far from an i.t. expert on the panel today, i would say from what mr.clain referenced before in terms of a more open source environment with the v.a.'s system itself. let me go off the answer for just a little bit. because a lot of this also has to do with the manner with which a veteran is received at a different facility. let's just call it first impressions. if i go from the veteran to the person on the other side of the desk as well, i think many of us have -- whether it's at an airline counter with b whether it's a a hospital, an emergency room, sometimes we get an impression that the person on the other side of the counter doesn't have quite the empathy that they would need to project to a new veteran. i think we have to even be able to go -- this is a little bit of a hearts and minds conversation as well. it's off the hearts and midnind perspective. >> thank you. i ran out of time. i yield back whatever i had. >> thank you very much. dr. benner scheck, you're recognized. >> thank you, mr. chairman. well, i really appreciate your testimony this morning. i completely agree with you that we cannot waste this opportunity to revamp the entire v.a. system. as i think you said, mr. mcclain, we'll be back here once again. you know, i was just looking at the v.a. health administration organizational chart. what is it going to take? do we have to get a -- i mean, arraign for bidding for outside consultants to tell the v.a. how to reorganize itself? obviously, they can't -- i don't believe that they can reorganize themselves. mr. mikulski, the assistant deputy undersecretary was here on monday. he seemed to think that a few fixing here and there in the system is going to make everything honky dory. i completely agree with as all of you sort of said, the whole system needs to be evaluated and a structure of management put in place that allows more communication between the management and the people that actually deliver care. as a physician, i worked a t the v.a. i, by the way, don't think that the health record is all that great. but it's often better than many of the other health records. we need to have better communication between, i feel like the physicians would actually take care of patients and the top management. because often physicians are put in circumstances that waste their time, are bad for patients and, you know, don't get things done in an efficient manner. so how do we make that happen? what -- can anybody give me some more ideas? expound upon what you said before? maybe each of you could take a minute of this? how could we make this happen, the v.a. change the entire structure so that it's much more efficient. >> doctor, i would start off with contracting with people who are expert in organizational design. there are companies out there that that's exactly what they do. it is a skill. it's an expertise. and i really wouldn't expect the v.a. to be able to determine exactly what that next organization should be. because that's not their expertise. but there are companies that that's all they do and they do it very well. so that's where i would tart sto look. >> all right. mr. collark. >> if i can extend mr. mcclain's comments, we can assess all day lo long. once the assessment is final -- we used aspirin with an acute mi earlier. that's probably a pretty successful metric across the united states. then let's talk about hand washing. we've been talking about hand washing for as many centuries as they are medicine essentially out there. for some reason we've not gotten good at hand wash. the difference between one metric like aspirin with an acute mi and hand washing is we continue to talk about it. and those organizations that find a way to put the structure in place for clear expectations, execution, verification and validation are those organizations that find themselves the ability to reduce infections by just improving something as common sense, uncommonly practiced, as hand washing. >> now you're really close to my heart. but i would say in addition to looking at the top down structure, and we know leadership is important from the top, spend more time listening to what the doctors in the v.a. say. here's what i hear. they're very frustrated when they see a patient and they say, i'd like to see this patient again in 30 days. right? then all that malarky goes on and they never see that patient again. patient never gets an appointment with that doctor again. there's not enough continuity of care with the same physician. and when dr. ruiz said before, this has got to be patient centered, it's really got to be patient centered, it's really got to be the doctor/patient relationship. that is what is being lost in this huge bureaucracy. we really have to make sure that it's protected. because that's, in essence, what's going to make these vets better. that's what's going to save their lives. and so in addition to looking at the top down structure, i would really make sure you're talking to the physicians who are working inside the organization. >> well, i don't disagree with you at all. as a physician that worked there, i was very frustrated by the fact that ideas that i had, you know, just weren't taken up. were dismissed because they were my ideas and they weren't coming from the management. that's what needs to be fixed by this basic restructuring of the entire system. i'm out of time. thank you. >> thank you, doctor. mr. gretay mccloud, you're recognized for five minutes. >> okay. thank you, mr. chair. i have found out that the v.a. audit of loma linda, we actually have three members on this committee that while it's not directly for -- okay. four, mr. cook. we have four members that it doesn't sit right in our district, but all of our people around it is where they focused their care about. it has right now current patients only have to wait four days for rescheduling of an appointment. new patients have to wait an average of 43 days for primary care. and appointment. 50 days for specialty care. only 28 days for mental health care. loma linda has the lowest wait time for mental health care. and coming as a kaiser member for 42 years, myself, i remember that when i first joined kaiser, people used to say, oh, you're a kaiser member. now people say, oh, you're a kaiser member. so, you know, being there i have seen the evolvement of kaiser from those kind of negative remarks to those kind of glare -- really favorable remarks. because it -- kaiser has evolved, in california, at least. i don't know about other states. but that is the -- the plan that everybody wants to emulate. because they have got all of their stuff together. their medical records are on time. everything. i have had the same physician for 30 years. so i get to see my own physician. and so i don't know why the -- the v.a. couldn't emulate something like kaiser. and while now we have had tons of hearings of what is wrong with the system, we as a policy committee, and there's a whole lot of physicians on here, we're the policy committee. we should find out how we fix it. and then all of our focus should be on how we fix it and no more about recriminations. but let's get -- let's move forward as the nation's policy committee on this particular issue. thank you. >> thank you very much. mr. hults camp, you're recogn e recognized for five minutes. >> thank you. a couple follow-up questions on comments that were made. particularly, mr. mcclain, mr. collard. your companies have apparently either operated multiple facilities or oversaw those and looked closely at those in reports. have you found any other health system in this country which is similarly situated and so poorly situated as the v.a. is today? start with mr. collard whose company has done many, many, many of these examinations. >> sure. the first ones that come to mind would be organizations that might even look a lot like the v.a. the safety net hospitals. so organizationing that are typically, perhaps, inner city serve a particularly disadvantaged patient population. they typically tend to be trauma center. they tend to have all the right reasons not to succeed. and yet those are the organizations that we can show time and time and time again when decisions are made, when strong leadership leading with good cultures around alignment and accountability succeed. which, again, just causes the question, why couldn't with emulate that? >> i'm looking for -- i'm trying to determine how -- how bad off the system is. >> mm-hmm. >> when you say that, boy, if we just did a -- a good review and looked closely, we'd have a whole cultural of nonaccountability p p so if you make a bunch of recommendations, we've got stacks and stacks and stacks of them. the doctors mentioned those. tell me how you would implement those. that's another study if you have leadership or that's pretty -- not a very descriptive term in my opinion of what's going on. how do you actually implement? we know what the answers are. the doctor mentioned that. we need to put the veterans back in the driver's seat. get the administrators out of the way. let them see their doctors. whether they want to do it in a clinic or in hospital or elsewhere. so how do you -- would you implement them? maybe mr. mcclain, how would you implement any suggested reforms? i think we know what we need to do, it's nobody's done it. >> well, it's very difficult. anyone that's done any sort of changed management realizes that trying to do it from the inside is very difficult. so i would think that a -- some company that specializes in this to assist v.a. in making the change to the veterans centric system i think would be a good investment for v.a. >> mr. mcclain, i understand your company, if i read correctly, operates a number of try-care facilities? >> in my segment of v.a. wp we have the tri-care south region. so we're the managed care support contract for tricare. >> if a tricare subscriber, customer, whatever you call them, doesn't like the care they're getting what do you do? >> well, we're an administrative services organization for tri-care. in other words, we maintain a network of provider and specialists for the tri-care beneficiary. and we also have a -- a patient advocate. if they don't like the care that they're providing, they can come back to us and we can try and resolve the issue. >> do they have to get permission from the facility you've assigned them to. >> no. >> so they actually have a choice? >> yes. they can -- >> well, very good. i think the v.a. might learn from that as well. one thing, doctor, i'd like to hear from one question on the union rules, how they should provide those to us. i've heard stories like that. >> they make good reading. let me point out your very interesting question, however. competition usually provides improvement. and if we develop some avenue that provides broader choice for vets on where they receive care, not dismantling the v.a. by any means, but whether it's a medigap card just for v.a.s or -- versus older vets, whatever it is, to give more vets a choice. right? you hear on the radio and on television, you see the hospitals advertising. come to our hospital. we have the best care. right? the cleanest room. whatever it is. the v.a. doesn't have to do that. but their budget every year is dependent on how many vets are enrolled in that system. it is absolutely by statute dependent on that. so they don't want to see their vets going other places for care. competition will improve system. >> yeah. that would be great to see the v.a. having to advertise. and actually, i would argue their budget's not dependent on their standard of care. what i think we've determined here, the last few months, is there's a standard of care. it's just ridiculously low. >> although some v.a. hospitals are quite good. there are some that are really good. they have great leaders. >> but the veterans -- and i could believe that. but we have 70 criminal investigations going on right now. so as a member of congress awaiting data, the data has been tampered with. it's hard to accept anything from the v.a. because the data is being falsified. thank you, mr. chairman. i yield back. >> ms. custer, you're recognized for five minutes. >> thank you, mr. i remembchair. thank you all for being here with us today. and i share your concerns that came out of the v.a. oig report. it does seem that the vha has lost its focus on the primary mission of safe, quality care for our veterans. i want to focus in on this discussion about competition and get at the notion of veterans having choice. because in my district, i had -- i meet with veterans every time i'd go home. and just recently around these issues, we had a veterans round table to talk about the quality of care in new hampshire. my veterans go to manchester to our veterans health center and also white river junction on the border with vermont. and the question that came up was the one you've raised about going outside of the network. i was presuming that that was a logical conclusion. but the veterans actually that i spoke with want to have their care at the veterans facility. they feel more comfortable there. they feel that they're going to be better understood there. so my question is, how -- and i like this idea of the medigap card. i'm interested in that. beyond that, how can you use -- let's just start with you, mr. mcclain, about the tri-care. when you're working with that network, what are the wait times there for someone that seeks an additional appointment? >> depending on what the specialty is or what the follow-up is, we can get them in within 30 days. >> and that's similar -- that's actually very similar to what it is in new hampshire in the veterans system. i guess the question is, are there things that we could be doing with the facilities in terms of one of the issues was about residencies brought up with representative titus. are there other ancillary care providers? could we be doing something? is there something that you do in the private sector that we could be doing with nurse practicers or people other -- because i agree with you. we need to focus in on the relationship with the patient and their health care provider. can you give us examples of what we can be doing from the private sector and maybe, mr. collard, do you have a suggestion on that? >> sure. a couple quick fixes that have been mentioned in numerous testimonies. just the ability to recruit at a more rapid pace mid-level providers. if you take a look at the private sector folks whose names typically make the headlines, every single one of those folks today are talking about access to care. it's not a different issue. one of the ways they accomplish improved ak soesz to care is the provision of mid-level providers as that first wave of patient intersection. it just, again, steeems to work. outcomes tend to be there. >> do you think it would make a difference to have a policy of alleviating debt for people who come out of medical school or other schools for health care providers providers that they serve within the veterans system and that we would aleavate that debt, would that make a difference? >> it's already been proven to work. having operated hospitals in some of the medically underserved counties in the southeast united states, we have programs when residents will come and agree to practice in rural or underserved areas. that's a proven program. i think this is no less noble a cause than for these veterans. >> that would certainly describe my district in the rural parts in the north country. i'm very pleased by the way we were working hard to get increased access to telemedicine for vets that have to travel. we have bad weather, mountains, such, but we also were successful and will be opening two new health clinics in the northern parts of my district. i want to focus in on this issue about hiring. one of the most troublesome things that i've heard about the vha has to do with how positions are filled and that there's not a priority for clinic positions. i was shocked by that. the leadership can make a decision about filling administrative positions. how can a surgery team operate and function at a high efficient level if they lose a nurse and that position isn't filled. what is your comment, for any on the panel the way positions are filled in the vha and how can we do better? this is the most bipartisan committee in the entire congress. trust me, we know a lot about institutions that do not function well, but we can function together. help us understand a policy that we could change that put a priority on the filling positions on the front line. >> it indicates the danger of levels of bureaucracy. behavior follows incentive. i bet if we looked at how folks are driven for performance reviews, et cetera, would you find perhaps not a disconnect between the ability to fill administrative position versus the ability to fill a clinical position. >> if we focus on those outcome measures rather than these process measures? >> outcome is getting the physicians and caregivers in place. >> if the outcome is good results, you are going to need to have those positions filled. >> yeah. >> i want to point out a report that was presented in 2012 deals specifically with this issue of assessing how many physicians are needed. i have it in my purse and will give it to you at the end of the session because you'll find a lot of answers there. the other point i want to make is there is in other state that has been short changed more about va facilities than new hampshire. there are so many vets in new hampshire who ride way over 100 miles to go to a va hospital in boston or white river because there is no really acute care hospital for vas in the state. that needs to change. whatever decisions you make about constructing another hospital, new hampshire should be near the top of the list. >> well, i'm pleased to report to you that the surgery is going to be resumed in manchester. i used to think 100 miles was a long way until i met my colleague o'rourke who told me his veterans travel ten hours to get to any type of facilities. we have a great deal of discussion being the only state in the country that does not have a full service hospital, we are very, very fortunate that the two hospitals that serve our veterans are very high quality. we do have an issue about people going to boston, but i am well past my time. >> thank you very much. mr. kauffman, she just ate half your time. >> thank you, mr. chairman. thank you for yielding to me. i've got a question. i'm intrigued by this notion of this metagap policy. i become eligible for tricare next year when i reach age 60. as a reserve military retiree. i think when i would be 65 then, i go on to medicare then does tricare pay for supplemental? how does it work for military retirees? >> tricare for life. that is a program when a military retiree reaches age 65, becomes a medicare fee-for-service patient. there is no more tricare prime, extra, whatever. you are a medicare fee-for-service patient. you do have a tricare wraparound. it's one of the richest programs out there for medicare. >> most vets aren't eligible for tricare. >> tell me about the system you're advocating here today. then i would like you to also reflect on it. >> this is a simple proposal, as i pointed out. almost half the vets using the va are on medicare. they are 65 and older, virtually all covered by medicare. the out-of-pocket expenses under medicare are too much for many of them. so they continue to get care at the va even when they have an age-related problem like they need a bypass surgery, and there is a teaching hospital down the street where they could be getting the care. they are worried about not so much inpatient deductible but outpatient deductibles and co-pays. if we gave them a medigap card just for vets, a special red, white and blue one to pick up those out-of-pocket expenses, then they would have the choice of going to another type of hospital for that care. if you look at the outcomes measures, particularly for these age-related procedures, with the exception of just a couple of the va hospitals, other teaching hospitals are producing better survival rates. we would get a two-for. it's budget neutral because it's all coming out of federal dollars, and they would have a better chance surviving their procedure. >> my two colleagues at the table are much more resident experts on the notion of payer sources and what the structure looks like. i want to come back to the choice issue a while ago though. there is a demonstration project under way as a structure for those of you that would be familiar with the captain james lowell federal health center in chicago which is one of the first demonstrations of the ability to combine veterans health with active military health. i remember one of the very first conversations i was part of two years ago, interestingly enough the leaders of the lovell federal health care center were less worried about the veterans being forced to come there and more about the choice to have advocate health care at the time. i think there is another opportunity to look within the industry. i couldn't say what their results are today, but this was a conversation two years ago where federal health care leaders were already focused on this notion of patient choice. >> i just want to say that i want to preserve the system right now until we fix the va by whatever means, we are keeping our wounded coming back from afghanistan out of the va system by virtue they do their rehabilitation on active duty, unlike those who came home from vietnam who were stabilized in the military system then sent on to the va and our morale of our wounded is much higher, keeping them all in the military system. mr. mclean? could you comment on this notion of providing this supplemental, paying for a supplemental social security, not the co-payments, whereby veterans 65 or over meet the income qualifications for care or have service connected issues would qualify. >> i think it could be part of the solution. really you are talking about funding here. you're talking about appropriations as to what bucket it comes out of. there's been a lot of discussions over the years about medicare as to whether va can be reimbursed by medicare. the answer so far has been no. it would take significant legislation for that to occur. i do want to make a point. i know we are short on time. one of the things that baffles me about some of the waiting lists, i certainly get the fact that if the veteran wants to go to the va for care, we need to honor that. as long as he or she understands this is going to be a little bit of a wait, that's great. but there were so many other means that some of these waiting lists could be taken care of by sending it out to fee-based care, sending it out under a contract, sending it to an affiliate, there are a lot of different ways this could have been handled. for some reason, which i haven't heard anybody talk about yet, not sure why those other sources of care were not used. >> why mr. chairman, i yield back. >> i can tell you why they didn't want to use it because the va thinks it's their money. they don't want to relinquish it. the problem is it belongs to the veteran. instead of saying we took an $8 million hit for non-va care to their budget, they need to say we took and gave $8 million worth of health care to the veteran. mr. o'rourke, you're recognized for five minutes. >> thank you, mr. chairman. to add to the point dr. rowe made earlier and mr. mcclain made about the success that hospitals and health organizations have and reminding patients of their visits, in the midst of this hearing i got a text telling me my appointment june 16th is at 9:00 a.m. to confirm hit c and reply. i hit c, confirmed the appointment, give me a phone number to call up if i had a question. those systems are out there not to beat the horse any more, but let's get that done.

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