To thank you and the Ranking Member who is currently not here, but you all in this committee have done such a great job in responding to this crisis. I think showing excellent leadership. We heard from the va directly. Weve heard from the gao, the office of Inspector General, hearing from the private sector. Each of us in our individual capacities are listening directly to the veterans in our community. I ask we have a panel of vet vans and Veterans Service organizations if we are talking about veterancentered care, we need to hear from them. And add to mr. Mcclains excellent suggestion of having a Management Organization identified structural and organizational weaknesses and complement that with the veterans and what they are missing in their care right now. I think one of the issues that has to be included in that review is the issue of accountability. Weve talked about and described our frustrations with the amount of money thats been authorized and appropriated. Virtually lost within that system and not making its way to those veterans. I think that really is an issue of accountability. We see it throughout the performance of the va. An issue i would like to get your thoughts on, and i really loved ms. Titus idea about getting more residencies in rural or hard to serve communities like ours. Is this a question of where we are going to get the doctors in the capacity we need . Already in el paso, which as my colleague mentioned is about a tenhour round trip drive from the nearest vha hospital. We have a va clinic, but do not have a hospital. Our patienttodoctor ratio is on par with syria or panama. Its a developing countrys doctortopatient ratio. We are having a hard time already. I like the idea of more incentives and ways to attract doctors and providers to our community, but when i meet with doctors, to your excellent suggestion of listening to the providers, they complain of having to perform functions that could much better be done by clerical staff. One doctor told me he actually had to write out a prescription for a veteran to be picked up by a van, taken to the greyhound station where he boards a bus to go to albuquerque, new mexico, five hours upstream on the rio grande. He says why cant somebody else do that . I would love to get each of your comments and thoughts about how we do more to support the current providers we already have, who by the way i think are doing be a excellent job. I do spot inspections in the parking lot of our vha clinic and talk to veterans leaving. I have not heard from a veteran yet who told me they had a bad experience. They feel they are treated like kings and queens, princesses and princes by providers there. They have nothing but good things to say. What can we do to better support those providers . Maybe 20 seconds down the line starting with mr. Mcclain. I think once again you could bring in some people that really understand process reengineering and reengineer that process. There are a lot of things a doctor does not have to do and its still within the standard of care. Could easily be done by a physicians assistant or rn or lvn. You begin with that voice of the provider. We have to make sure none of this testimony sounds like we demonize the provider. The nonvalue added work steps those providers are going through today. This is not unique to any industry. Thirdly, in section 301 of this bill, there are two provisions that will make it more difficult for doctors, civilian doctors to provide the care that a vet is asking for with the choice card. So i would hope that you read those two passages. Its about like page 24. Read those two passages and see if you can alleviate some of that paperwork burden that the civilian doctor would face if he agreed to treat that veteran. Thank you. Mr. Chair, yield back. Thank you very much. For the committees knowledge, our intent is to have a single hearing in a couple of weeks with just the vsos, to not have them in these hearings, but give them the entire hearing to be able to look at all the testimony thats been provided. So they obviously are the stake holders in all this. Dr. Winstrup, you are recognized. I am grateful for this day to have arrived. It took disastrous findings within the va to get to this point. Its a step in the right direction. I can tell you as a physician, face to face with secretary three times how we could do things better. Every time i was told, yeah, well do that, never happened. Right before this broke we set up a meeting with the four doctors on this committee, bipartisan, with several of the administrators, with the va, to talk about efficiency and access to care and quality to care. There is a different in different systems. If you have a system where many people work there are saying thats not my job, thats a problem. What you have mentioned many times today i couldnt agree with more. Thats the physician input. If they can have the input how things could be better, youve got to go that route. The difference in responsibility in private practice and in other settings which is the va. If i had a patient that missed an appointment, i want to know why. Also, if they were postop, i tell them, theyve got to be here, ive got to see them. Its my responsibility. That tends to be missing if you dont know whos coming or going. Measures such as standard of care are great. Obviously, we need to do that. If youre seeing one patient a day and giving outstanding care, it doesnt mean very much. You also have to look at the access to care and the efficiency of operations. What youre saying today is spot on. The problem i found within the va system is you had too many people who dont know what they dont know. Because they have always been in that system. Theyve never seen anything different. They think they are doing something great, but they dont know that others are doing it much better. Thats where we need the outside input and the best practices. We are hearing a lot of the same things here today. I think thats great. Ronald reagan once said if you have a message thats important, tell it over and over again. To me the best practices and efficiencies are driven by choice, which we heard so many times today. When a patient is a liability rather than an asset, we have a problem. Patients need to have choice. For me, my level of success and how well i was doing is how many wanted to see me when they know they have a choice. Thats really where we need to be redriven. Was mentioned before, too. The aca and throughout, we are really not addressing the doctor shortage. If you dont have providers, and not just doctors, could be nurses, pas, et cetera, you need to address those shortages in our country, and oftentimes in the rural areas especially. Those are other things we need to focus on. Im pleased the door is open to change. Everybody here is open for change. I didnt know this day would come. Again, im sorry it took what it took to get to this day. Weve got to drive on. I like what mr. Wahl says, get the big idea out there. One thing i found interesting several months ago, i asked dr. Petzel if va was reimbursed 500 of medicare rates with you be in the black . He said yes. Some of the doctors on this committee politely disagreed they would be able to pay their bills and be in the black with the system theyre running. From your observations, what is your opinion on that . I really dont have any data. I have not looked at that. I have no idea. Lift up the hood on the question. When you compare yourself to yourself, theres probably not a lot of accuracy you can get. When you take a look at those organizations in the va that actually do submit data to publicallyreported bases you have a way to measure against the other. When we continue to, whether its patient perception, they use a tool called shep versus hcaps, when you see those simply dont submit the data, outcomes data, we are stuck in this vicious cycle of, as you said, you dont know what you dont know because you are comparing yourself only to yourself. It would be like taking a Blood Pressure on a patient without any degradations. Medicare used to pay 92 cents for every 1 of care delivered. After the Affordable Care act they are paying less than that. The reason i raise that, one provision of the bill you are going to be considering this week says that civilian doctors who take the choice card will be paid not more than the medicare rate. So its important to alert everyone to what you probably heard from your constituents back home, that finding a doctor to take medicare is getting harder and harder. Mr. Walsh, you are recognized for five minutes. Thank you, mr. Chairman. Thank you for being here today. Dr. Wenstrup is hitting on it. I thought you brought up really great points. I see the books there. In our office every new employee reads good to great and we talk about organizational design and system performance and trying to get there. This was a description of a highperforming medical institution. Multidisciplinary team work, patientcentered culture. Is it about that simple . They followed up. This is commonwealth. I dont want to bait you on this. They followed up with this. Information continuity, care coordination, transition, system accountability, peer review, team work for high valued care, continuous innovation and easy access to appropriate care with multiple entrants into the system. The data i shared with you today comes 100 from the Commonwealth Fund site. At the risk of being oversimplified, yes. Very good. You agree . I dont have any comments. All right. I bring this up because weve got to believe we see this and its not as if jim collins is all of a sudden the va. They read it and theyve seen it. What im trying to get at it is how do we incentivize this . There is first and foremost the care of veterans. There is a cost factor that figures into this. How, when we do this big idea i do believe if we get this wrong now, we are going to set the care for veterans the next two decades will be very difficult to change. This is an opportunity, but it must be thought out and right. It must not be driven by ideology. Your position this is not the issue, if you simplify this into the public versus private sector, we are going to go down a road that looks just like this. Why do you think this never went into the scheduling because this is, again commonwealth. Weve seen this in practice in hospitals. Patient scheduling system uses auger rhythms. It takes into account patient availability, time and sequencing, Laboratory Tests procedures and travel time between appointments. If youve been in a medical system that does this, you leave with a sense of wonder. They were there to move from you place to place. Is this a cultural barrier why this wasnt implemented . One of the issues is just that. The notion of patient flow. Whether its flowing the patient through a facility or through a series of recommendations and consults through different facilities, part of this is the efficient of patient flow, which again is a whole other hearing. When we do this, and we are going to have human nature, incentivize, oversight and Everything Else that goes into this, this goes back to you and the work, i see this representing the district that the mayo clinic and hospitalacquired infections, hundreds of thousands of americans die by these every year. Its incentivized on this hospitals that dont get a handle on this and bring it down are going to be penalized in reimbursement to medicare. Does that make sense . Makes absolute sense. The data beneath that, those incentives and the outcomes with which are just irrefutable. If you look at a patients perception of a hospitals responsive knopf while the patient is in the hospital, there is almost a linear correlation between the patients perception. We get hung up on that. Its just perception. How does the patient know how good we are . When you pull the data, across 3,900 facilities you see a linear correlation between patients perception and actual cases per 1,000 patient days, associated infections. Why do you think it took us so long for the private sector in states to be willing to put that information up . Actually, its our perversion to the data. When you go to the website you go to the experience or go to the quality. Its the very same data set. So when you pull the entire data set and look at those correlations, its right there in front of our eyes. How do we meld va experiences in that . It does seem like we are on two parallel realities here on reporting and experiences. What would be your suggestion . We wont suffer from a shortage of data. Its how we bring the data together. Its the ability to bring some organizations. If you go on the Commonwealth Fund site, you will pull 83 or 84 va hospitals that submit that data. Thats right. Thats what i was able to do. I ran the custom report prior to the hearing to make sure we had a good current sense. Thats only 83 or 84 of the va hospitals. Where are the others and how could we get away from this comparing ourselves to ourselves . The solution is out there. The will of the American People to get it, and now its a matter of getting it in place, is that you bet. We have folks that have md and d. O. On their name badges. They are scientists and driven by good credible data, not anecdote. As well as our physicians in the va could lead to these answers. Very good. I yield back. Thank you very much. Thank you, mr. Chairman. I am grateful, as well, as most of the members you heard from that youre here today. I feel like we have a copilot now and the solution is there. We can see light at the end of the tunnel. Its been a very dark story. I dont have questions. I wanted to thank you for being here. I wanted to echo what mr. Walsh just said. You see the relief in this room around most of this place today that the solutions are there. I would agree, the attention of the American People is on this. The continuing drive by the American People to seek out the absolute best solution, the big idea, the step forward, and i think many of us today see light at the end of the tunnel. Im grateful. When we saw the story getting darker and darker and 69 criminal investigations and kinds of things happening, i think most of us knew there are solutions there there are private sector, private industry folks that certainly are here to come alongside and guide this into the kind of success we know the va can be. I wanted to add my comments that you coming today and just broadening the light here, for us to be able to see how it can work and give us something to shoot for as our jurisdiction of oversight continues is the most welcomed news i think ive seen since we got into this whole situation. On behalf of the veterans in my district, were grateful. I do see light at the end of the tunnel. Mr. Chairman, thank you for your leadership. I yield back my time. Thank you very much. Ms. Brown, youre recognized five minutes. Thank you. I want to thank the veterans to work at the va hospitals for their service because basically the veterans to tell us over and over again once they get in the system, they are very satisfied with the service. So thats not a misnomer. Ms. Mccaughey. We are looking at advantaged care and tricare. You are referring to Medicare Advantage . Exactly. Okay. In your testimony, it seems as if you are recommending that as no. I was pointing out that a large number of vets have enrolled in Medicare Advantage, and yet they are going to the va hospital for their care. So, in fact, we are paying for it twice. I was pointing out that literally 10 of the va budget is going to vets who have another kind of coverage. Its a tragic inefficiency when you look at we are discussing money and where to get enough money to care for vets, then you find Something Like that which was documented recently in the new england journal of medicine. Im happy to show you the article. Why arent people figuring out that such a large number of vets are paying for care, were paying for their care twice . We are paying to the Insurance Companies that run Medicare Advantage plans and paying again to the va system. Lets at least sort it out and get it straight. Thats what i was suggesting. Im trying to be clear that the va system is a system that the veterans prefer. Part of the challenges we experience, for example, people that dont have hospitals in their areas, all of this is formdriven. We may need to come up with additional ways to serve veterans. Until recently, we have not built a va hospital in 15 years. We have not built additional hospitals. Are we going to build additional hospitals for veterans or come up with a partnership that the veterans and the va because the testimony we had last week when we sent a veteran outside of the system, weve got to make sure its a certain quality of care. Of course. If that continuity is not there, you are still going to have the exact same problem we are experiencing today. In addition to that, im a person if i have an appointment and i dont keep that appointment, there is a charge. We dont do that to veterans. If they have an appointment, and they dont make that appointment, there isnt a penalty to them. There is a terrible penalty to them. Its not a monetary penalty. It means they are waiting longer and longer for care. When vets dont show up for their appointments, im not blaming the vets. In many cases they waited as long as six month for that appointment. The fact is that they, the va hospitals and clinics should be calling the vets 24 to 48 hours or emailing them ahead of time to remind them of their appointments. It is unrealistic to think a vet will remember an appointment four months ahead. I am saying on the other side of the world, if you dont make that appointment, there is a financial penalty you receive. Mmhmm. And what is your point, madam . I made my point. Thank you. The point is we have additional veterans in the system because we open the va system up to the vietnam veteran. Each one of them did not have to prove they had a certain disability. So we got thousands of additional veterans into the system. The secretary did it, and im very grateful he did it. Now we have to figure out how to serve them. I am saying that the va system is one of the best systems in the United States. That is what im saying. I read your expertise which is in the area of infectious diseases, which is a problem. The bill we have before us and im hoping and the chairs recommendation, and the senate bill, i hope we can work out what is the best way to move forward with the va system. Thank you for your kindness and time. Thank you. Mr. Jolly, youre recognized. No question. Thank you very much. I want to thank the chairman and committee for allowing me to partici