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tv   Commission on Care Members Testify on the VA Health Care System  CSPAN  September 7, 2016 10:15am-12:31pm EDT

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veterans health care. members of the house veterans' committee will examine a report on commission of care and the future of the va health care system. they'll begin with subpoena motions and the construction of a va hospital in aurora, colorado. live coverage here on c-span3, the hearing should start in just a moment.
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good morning, everybody. thank you for being here today. before we begin, i want to take care of one item of committee business, by hearing a motion for the issuance of a subpoena to the secretary of veterans affairs to produce documents relating to va spending on art work and ornamental furnishings as well as the denver construction project aiv report. i want to say it is unfortunate that va's continued lack of transparency led us to this
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decision, but we have not done so without ample jurisdiction. or justification. on july 31st of 2015, i made the original request for art contracts at the time related to the palo alto health system. i think most of you remember that. what followed was a year long back and forth between myself and the va where i sought an explanation on va's policy of approval procedures, oversight practices for art purchasing nationwide as well as an accounting of art work and ornamental furnishings purchased since 2010. it was not until i set this business meeting that va made any attempt to respond to my request for an accounting of their spending. however, true to form, what they gave us is wholly incomplete. for example, va claims who have
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spent approximately $4.7 million on art nationwide from january of 2010 to july 2016. yet the committee has already substantiated over $6.4 million spent during this period in the palo alto health care system alone. which is merely one health care system out of 21. spending data that va finally did provide even admits art purchases in the palo alto health care system that the committee had already substantiated. for example, both the sculpture blue eclipse, which i'll ask the clerk to put up on the screens, and you have a copy of this slide with you at your desk today purchased for $250,000 and the sculpture harbor also pictured on the screen was purchased for $220,000 were
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omitted from va's $4.7 million total figure that was provided. additionally va took it upon themselves to admit amounts spent on site preparation for art work installation, which amounts to millions of dollars in palo alto. for instance, remember the rock? the art work that is a rock? supposed to cost $250,000 by the time it was purchased it was $500,000, and it cost this -- this was not included, it cost almost $1 million to do the site prep to put the rock up. that was admitted from the number that va provided to us recently. when taken into account, the va provided no data at all from 3,
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11, and, quote, negative responses, end quote from 2, 7, 9, 16, 18 and 20. i am confident that we're not receiving the whole picture from the department. this is compounded by the fact that va compiled the data by searching for all contracts under the budget operating code 31-26, which indicates art work. by definition, art work purchases that were not categorized as artwork, not made on bona fide contracts and passed through larger contracts for construction or design. committee has seen too many instances in the past of questionable va purchases, bundled on unrelated contracts or passed through larger contracts. as for the denver construction, aib, the committee received a very similar lack of information.
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we have seen -- been seeking evidentiary documents related to the denver aib since receiving the memorandum summarizing the va investigation, which omitted that documentation back in march. va has claimed to have provided the committee thousands of pages of documentation supporting its conclusion in the aib, yet its august 19th letter to this committee highlights that that is simply not the case. in this letter, va lists 16 groups of documents that it has provided, yet most are either congressionally mandated, or required for some other purpose or in one case an advertising contract that was totally unrelated to our request about the aib. further, va outright stated in the letter that it does not intend to release certain evidentiary documentation essentially relying on a privilege that is entirely within the authority of this committee to accept or to reject. we will not accept va trying to
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pull the wool over the eyes of this committee or the american people for poor decision-making and a waste of funds made on the part of the department. as such, today we vote to issue a subpoena which will demand complete answers on both of these issues, a subpoena will cover spending on artwork, and ornamental furnishings from 2010 to present and evidentiary documentation associated with the aurora, colorado, replacement medical center construction project, administrative investigation report. prior to voting, whether any members have any questions to ask or wish to speak on this issue. mr. kauffman. >> thank you, mr. chairman. thank you for your leadership on these two very important oversight matters. as everyone on the committee is now painfully aware, it has been a long struggle to get straight
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answers from the department about the problems with the aurora project. as late as april 2014, at a field hearing in colorado, despite the findings on numerous oversight hearings and scathing gao review, va senior officials continued to tell congress that the va hospital on aurora could be built with funds already on hand. keep in mind that as far back as 20 10 va officials were internally discussing how the va project was broken, and at least at five separate committee hearings were held to -- were held detailing evidence of va's construction failings up to that point. it wasn't until december 2014 when the va lost its case in the civilian board of contracting appeals on all counts that it was forced to publicly admit it had a construction problem.
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a full three months later, in march 2015, just weeks before a costly shutdown of the project would be required, va first told congress that as much as a billion dollars in additional funding was needed. still, mr. chairman, if the department's effort to hide the problems in aurora sound bad, the department's efforts to avoid subsequent accountability have been worse. a full six months after deputy secretary gibson told members of the colorado delegation that the aib was completed and following numerous congressional requests, the committee was provided with what is purported to be a 31-page summary of the aib. this document lays blame squarely on a handful of va officials who conveniently had moved on from the agency who -- or who had retired with full pay and benefits. one va official now collecting a taxpayer funded pension collected over $60,000 in
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bonuses while overseeing a project that had been spiraling out of control. i believe this committee and the american people are entitled to review all the documents associated with aurora aib and to draw their own conclusions. as to what went wrong and who should be held accountable. as far as this project is concerned, i believe there is an understandable lack of trust in the va's explanation. i urge all my colleagues to support this motion and i yield back. >> thank you, mr. kauffman. chair recognizes the ranking member. >> thank you, mr. chairman. i just want to remind my friend, my colleague from colorado that the congress in the late hours of the night, wee hours of the morning, approved over a billion dollars to augment the aurora project by voice vote over the concerns of the minority that more conditions should have been attached and that the funding
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should have been sunlighted more carefully. i'm pleased to engage in this discussion about how we should be holding the va more accountable for the construction snafus, but, again, i find it a bit rich that the congress approved that funding in the middle of the night, over, i think the concerns of the minority. this committee has always worked in a bipartisan manner. we have worked together to what is best for veterans. we have voted to issue subpoenas before when we believe the va is not providing the information we need to make decisions as lawmakers. we have invited witnesses to testify before this committee so we can get the full story. today, however, i'm concerned that you're asking us to exercise our subpoena power when it might be unnecessary. you have denied my request for a witness to testify before a
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committee day, violating our committee rules. how can we work together to make the right decisions for veterans when you're unwilling to listen to our concerns? we expect to receive the ig report on the denver va construction mismanagement and cost overreturns before the end of this month. i'm requesting today that we hold a full committee hearing on the ig report as soon as it is released so we, veterans, and the taxpayers know who is responsible for the waste and mismanagement tied to the denver hospital construction, and so we can demand that those responsible be held accountable. va employees, before both the administrative investigation board and the ig provided information critical to the investigation. now you're asking us to subpoena unredacted documents that you will be outing employees who are honest with investigators, exposing those employees to potential retaliation and make it more difficult for va and the
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ig to conduct thorough investigations in the future. i believe only a subpoena for redacted documents that protect potential and possible future whistle-blowers is acceptable. in this same subpoena you're asking us to subpoena any and all documents related to the purchase of art at va hospitals. this overly broad subpoena is not only unrelated to the va investigation, it also seems to be unnecessary if as i understand correctly va is working to provide you answers on the amount it spent on art. i think it is important we work together to resolve these issues together and judiciously use our subpoena power only when necessary. now, if we can protect whistle blowers by amending the subpoena before we vote today, i am
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prepared to support the subpoena. but only if we, minority, has assured that the subpoena will be amended and i would like to see the language changed in the subpoena, actual subpoena before we actually vote. >> i want to echo this committee has always worked in a very bipartisan way and i just want to give a little back and forth because this seems -- you use the word rich, seems too little too late. we have been looking into this aurora situation ever since i joined the committee. i'm ranking on the oversight and investigations committee. i was delighted to go out to mr. kauffman's district in april, assuming that the topic would be asking the taxpayers of the united states of america for $1.6 billion to build the taj mahal in aurora, and we got there and that wasn't the topic. and the topic was opiates, which was fine, that's an issue i care
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a great deal about. and we had some excellent discussion and i appreciated the opportunity, but it wasn't until we are on the third round of questioning and i said to mr. kauffman, i've got one more question i want to ask about aurora. so why didn't we ask for these documents before we took this vote in the middle of the night. this is a lot of money where i come from, $1.6 billion on one hospital. and so, you know, i'm prepared, i support the amendment with the redaction, i do want to protect whistle blowers, but i just don't want to lose the moment here that what are we 60 days out from an election, suddenly we're all worried about the documents, why haven't we been working with these documents the entire time and isn't that the role of the oversight and investigations subcommittee. so that's just my comment. >> any other members wish to spout off? >> i want to spout off.
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why, i concur with what you said. question is, why in the world doesn't the va bring the documents up here? why are we having to do this? i have been here now almost eight years, and you hear this over and over again from these people. they should be up here bringing them, we shouldn't even have to ask for them. they should be saying how do we make this better? we mess this up royally. the fact we have to do this annoys me to no end. and it is time for this to stop. >> no, but with all due respect, i agree. i'm just saying if the oversight and investigations subcommittee went to aurora for a hearing, why weren't we asking for this information at that point and time? i don't disagree with you. >> i can answer that question as the chairman of the full committee as we have been asking for the documents, we didn't have to go to aurora to ask for the documents. we have been asking for them over -- for over a year.
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i'm surprised at this point to hear anybody on the minority side talk about votes in the dark of night. but we are, and the fact is i was not wanting to approve the additional dollars for aurora. mr. kauffman is very well aware of how seriously we debated that particular issue. i want to -- a couple of things, just -- i think i have earned the trust of the minority side. i think i've earned the trust of the majority side. when i say that va has not provided us the documents in a timely fashion, i'm not talking about writing them a letter on monday and asking for a response on friday in issuing a subpoena on monday. i have 176 outstanding deliverables at va right now.
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some going back years. in fact, the oldest is december 4th of 2012. i have not received a response. the average response time now is 80 days to get a response. i would ask any person in this room to tell me if that hanging light fixture is a light or is it artwork. and if they're claiming it is a light fixture, why in the world are they spending that kind of money for a light fixture, which is exactly what va did. they called it a light fixture instead of artwork. there is half a million dollars on two things. number two, the ranking member said i denied his request for a witness at this hearing. i want to set the record straight. that is not true.
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we have two witnesses, and i offered and it was declined to substitute miss schlichting for the person that the ranking member requested. i was very happy to allow that to be done. i also said that if a majority of the minority per our rules voted to want another witness that i would accept that as well. according to the rules. at a place and a choosing of my time. that's what the rules say. i was told that was not necessary. we're not talking about an office of inspector general report that is supposedly coming. we're talking about the aib. the administrative investigation on the aurora debacle. we have had people talk about, and the ranking member said, we
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were going to out certain people. i will tell you, this committee has never allowed personally identifiable information out to anybody. period. nobody has ever been identified. so to say that and insinuate that this committee would in fact be prepared to do that is a red herring. and to talk about the overly broad language, this is exactly the language that we used for phoenix, and exactly the language that we used for philadelphia. so it is not overly broad. again, to insinuate that we at the 12th hour in the last days of this congress that we are suddenly concerned, i will remind some of the members who are new to this committee that until i became chairman, the department of veterans affairs had never had a subpoena served
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on it. never by this committee. that's ludicrous. we need to be doing our job. and so the question of personally identifiable information as it relates to the aib, i get it. i don't -- i don't intend to release it, i never have released anything like that. but i'm willing to have that discussion. mr. waltz and i actually had a discussion on the floor yesterday afternoon whether or not it is necessary in the actual language of the subpoena or what i'm asking is that, again, you trust me enough as the chairman of this committee not to release that information -- it isn't going anywhere. the problem is we don't know what we don't know.
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about what is going on. we think we know who the folks are that should have been held accountable. we protect whistle-blowers every single day. we have hundreds of them across this country that we meet with, talk with, trying to gather information. so again i understand the concern. i really do as far as the release of information, how we go about getting the assurance that the minority wants is, i think, this colloquy should be sufficient in this process. i think we are potentially hurting our committee investigation by allowing the va to redact what they want to redact versus giving it to us and allowing us to control the information which is what we should be doing. any other comments?
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>> i would like to yield to mr. kauffman my time. >> i'd just like to address an issue raised by mr. fitzpatrick. we did do -- kirkpatrick is the prior ranking member for the committee, who was present in 2014 when we did a field hearing in colorado on the hospital. and that was done prior to you. but ranking member custer, i have a letter here that came from both of us, requesting these very documents and this letter is dated october 5th -- october 9th, 2015, you signed. it has a demand date on it for friday, october 23rd, 2015. and they have not turned over the very documents that you'll be voting on today in this subpoena that you requested last year. and so i just want to set the record straight on that.
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i yield back. >> mr. chairman, the -- with regard to the issue of the witnesses for the commission on care report, i see no harm and actually asserting the minority would like to see an additional witness, you only have two witnesses. your concern was that the hearing would be too long, but i think that the main key point is a contention with which our witness has dissented on that report would be very, very important for the american people to hear. and you can -- you raise concern that with precipitate other people, namely one or two others. i see no harm in actually -- to
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the contrary, a great benefit to the public accruing to a full range of views being presented on what the commissioner has to say. but i would like to move on. >> will the gentleman yield on that particular issue? >> i'll yield on that particular issue. >> i continue to wait for a request by a vote of the majority of the minority for that particular witness of which we have not received and at that time if you get that vote, i will schedule another hearing at the place and time of the chair's choosing. >> well, i thank you for that. our concern is the place and time, we hope that we could get a satisfactory place and time, but i think -- >> how about october? i'm just kidding. >> but i do want to -- i do want to comment on the issue of the va's response on the aurora
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project in denver, the aib. the committee has released names of individuals involved. so this is not a matter of speculation about whether or not the committee in the past has done so, it has happened. in a letter to chairman kauffman, sloan gibson has detailed the thousands of pages of documents related to the aurora construction project, including the -- unredacted copy of the final aib report, which states the factual find agz and c conclusions. i could go on and on, there is a huge long list that the chairman has that the -- that the va has been responsive to. he further goes on to say that the va does not intend to release the underlying individual employees interview transcripts or the unsubstantiated documents and opinions of va employees reviewed as part of the aib.
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the primary reason is not to disclose the individual statements, is to ensure that the future efficacy of essential executive branch fact finding processes like the aib to bring to light wrongdoing of the federal agency, in a federal agency. in order to get to ground truth, those charged with interviewing department witnesses must be able to count on employee witnesses to be completely forth coming and candid, not just with the facts, but the opinions, perceptions and theories about what happened and why. the best way to ensure complete candor to the fact finder is to remove any fear that a witness may suffer adverse consequences for speaking up. for employees, especially the rank and file, to expect the opinions, insights, concerns, they provide to executive branch fact finders are going to be provided too and potentially judged and second guessed by the legislative branch will chill our ability to get relevant
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information regarding the root causes of systemic processes or leadership failures within the department and risk creating the appearance of politicizing executive branch fact finding functions. i submit to you that the minorities request is very reasonable. therefore, we are prepared to support the subpoena if you will amend the subpoena and take out any references to unredacted documents. >> hang on just a minute. let me see if i can figure out how we can make it happen appropriately because i do want to satisfy yours, the va's, and ours. so we're talking about whether we can insert a sentence that would satisfy you and protect the whistle blowers.
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>> we might suggest that what we look through the subpoena, take out any reference to unredacted, and -- >> we can't do that. we can't -- the unredacted, i mean, you're talking about one particular area. we need to move on to the hearing. i don't know if we can do this, but i'd like to try to do this. can we take a vote, no, we're going to do it now. we're going to do it now. we're either going to take a vote, subject to an agreement, that way if some of you need to depart, our side or your side, we're going to lose a quorum because we have an armed services hearing going on at the same time, i want this done today. and if not, then we'll push --
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if it won't satisfy you, we're going to go ahead and push, and if it falls into a partisan vote, it falls into a partisan vote. >> i would request we push this vote until next week until we can work together on a satisfactory -- >> i don't think it is necessary to delay this any further. we have gone months and months and months. what i'm asking is for you to, again, trust me, and the ranking member to work on a solution that is sufficient and if so, if we do, then the vote that is taken right now, if it is procedurally approved and i think we can do this, then the subpoenas will be issued. but we're looking for, if not, i'm going to go ahead and take a vote. if the ranking member doesn't want to do that, then say no. and then move -- >> mr. chairman, will the issuance of the subpoena be contingent upon my being satisfied -- i would be happier if we -- in other words --
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>> i just said that. >> so we can work together on this, on the language, between now and next week -- >> no, no. right now. it is going today. it is either it is going today with your votes on our side, or it is going today with the majority as it is. your choice. >> okay. i want to -- >> here's what we're going to do. we're going to go ahead, i'm going to take a motion for the subpoena, and we'll move forward, because we have got a very important hearing that we need to move on. pursuant to rule 11, clause 2, m 1 b of the house of representatives and rule 3 clause g of this committee i will now hear a motion from mr. lambborn for the issuance of this subpoena. >> mr. chairman, i move that the committee authorize the issuance of a subpoena to the honorable robert mcdonald, secretary of the u.s. department of veterans affairs, of the department of veterans affairs to produce all
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documents indicating the amounts spent and in the process of spending on artwork and ornamental furnishings from fiscal year 2010 to present. as well as the entire investigative file, all interviewed transcripts attachme attachments, exhibits and other related documentation pertaining to the administrative investigation board or aib report on the aurora, colorado, replacement medical center construction project. >> do i hear a second? >> point of clarification -- >> we're moving forward with a vote on the subpoena as -- >> as is? >> all those in favor -- >> we're done. i gave that opportunity to the ranking member, i did not get an act we acquiescence. the motion carries. i'm now signing the subpoena for
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the production of documents and here by direct its issuance forthwith. this concludes the business meeting for today. >> i'll go ahead and ask our two witnesses to come to the table. thank you so much for allowing us to take care of a piece of business that was important to both sides. i will now call the committee to order.
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thank you everybody for joining us for today's oversight hearing from tumult to transformation, the commission on care and the future of the va health care system. you will remember that the commission established two years ago by the veterans access choice and accountability act, and it was tasked with examining access to care and how best to organize the department of veterans affairs health care system and deliver care to our nation's veterans over the next two decades. the commission's final report was delivered at the end of june. and with us today to discuss it and the 18 recommendations it includes are commission on care chair person ms. nancy schlichting and vice chair person mr. toby cosgrove, dr. toby cosgrove. i want to thank them for being here today and i truly want to express my gratitude to them and all the commission members for their time and effort that they put into the important work of
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the commission. i want to say thanks to the many veterans service organizations and other stake holders that provided statements for the record for today's hearing. the advice, counsel, and support offered by our vso partners is vital to the work of our committee as we work every day on behalf of america's veterans. i am personally grateful for the input they have provided me as chairman and will, i'm sure, continue to provide this committee as congress moves forward to strengthen the v.a. health care system for future generations of america's heroes. like me, the vsos and by and large, we're supportive of many of the recommendations that the commission has made. the commission rightly recognizes the current v.a. health care system has many strengths, many strengths, as well as weaknesses. moving forward, it will be important to insure that any
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transformative effort that v.a. undergoes preserves those strengths, which include in many cases the provision of care equal in quality to that that is available outside of the department walls. however, v.a.'s weaknesses, which include persistent access failures. noncompliance with federal pay laws, a lack of accountability, a bloated and self-preserving bureaucracy and billions of dollars lost to financial mismanagement of construction projects, i.t. programs, bonuses for poor performing employees and more are legion and growing. this is evidenced not only by the commissioned almost 300-page final report but also by the thousands of pages that made up last year's independent assessment. the years of work performed by this committee, the gao, the va inspector general and others, and most importantly, by the daily experiences of the
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millions of veterans who rely on v.a. for care, are all too often left disappointed. i wholly agree with the commission's call for created an integrated v.a. community care system, modernizing v.a.'s outdated i.t. systems, better managing v.a.'s vast capital assets, reorganizing the massive and unfocused veterans health administration central office, reviewing eligibility for care in light of the modern health care landscape, and much, much more. however, i disagree, as does the administration, and many of the vsos with the commission's call for the establishment of a board of directors to provide governance, set long-term strategy, and direct and oversee reform. the commission is right to recognize that v.a.'s position as our nation's second largest federal bure aucracy carries
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challenges, however, given the crises that seem to erupt anew on a daily basis where v.a. is concerned and any efforts to shield the v.a. health care system from executive and legislative branch oversight is a nonstarter. outsourcing the crucial role of a cabinet secretary to an independent board that is neither elected nor accountable to the american people would be irresponsible, in my opinion, and inappropriate, not to mention unconstitutional. the dent that our nation owes to her veteranicize a debt we all share, and the commission's work represents the culminitation of a unique moment in history for v.a. and the veterans that v.a. exists to serve. there have been and likely will be other commissions devoted to examining v.a. and how well the department is meeting its most important mission. and that is providing
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accessible, high quality care to our nation's veterans, but it is incumbent on all of us not to let the work of this commission fall by the wayside like so many other studies have. and i assured you both, this is not one that will sit on the shelf and gather dust. ignoring this opportunity would be a dereliction of our duty. the scandals that have characterized v.a. for the last several years have opened the door to finally changing the systemic culture and deeply entrenched problems that face v.a. and their health care system. translating that momentum into lasting and meaningful reform will require a commitment to having uncomfortable conversations about how as a nation we can begin to pay the debt we owe the men and women of our armed forces and to taking the risks that are necessary to challenge the status quo that has left them wanting and
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waiting. whoever sits in this chair after me will be responsible for, and i am sure, will be more than capable of moving the ball forward, and i am hopeful that today's hearing will help set the tone for that effort. with that, i will yield to the ranking member, mr. takano, for an opening statement. >> thank you, mr. chairman, for calling today's hearing. since we first learned of the wait time controversy in phoenix, this committee has been on a path toward reforming the veterans -- department of veterans affairs. the passage of the veterans access choice and affordability act in the 113th congress required the independent assessment of the health care delivery systems and management processes of the department of veterans uz fairs. this gave us a good view of the v.a. health care delivery systems and management processes. a year later, the enactment of the surface transportation and
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veterans health care choice improvement act of 2015 required the v.a. to come up with a plan to consolidate all care in the community programs. now, the commission on care has released in recommendations for transforming veterans health care over the next 20 years. now, i am pleased to receive these recommendations, but i'm disappointed that the v.a. was not invited to respond and share its input this morning, per the legislation, the v.a. has 60 days to comment on these recommendations and just provided its response to us late last week. i have already indicated my disappointment that the witness we requested, commissioner michael bleker, was not allowed to join other witnesses to testify here today. i thought the issues and concerns he raised in his disent letter were insightful and needed to be part of the discussion as the committee weighs the best path forward. i ask unanimous consent that his dissent be entered into the record. with all the reports and studies
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we have seen over the past two years, it is clear to me that the status quo, the v.a. as we know it is unacceptable. that said, i don't believe that completely remaking the v.a. is the right answer either. there is an important balance between transforming the v.a. while maintaining the services and support that millions of veterans rely on. now, i am concerned that some of the commission on care's recommendations might in fact weaken the v.a. health care system. much like i have seen happen with charter schools, proposals to funnel funding to private contractors and for-profit care will take desperately needed resources away from our veterans and should be immediately rejected. shifting resources to pay for the privatization of care will have impacts throughout the spectrum of care for our veterans. in addition to reducing quality and access to care, it could deprive the v.a. of cutting-edge
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medical research and i.t. innovation. top notch clinician training and stifle the v.a.'s critical role in responding to national emergencies and national disasters. we cannot view expanded choice or the private sector as the panacea for solving the challenges the v.a. faces. long wait times and work force shortages impact private care, too. care in the community should be locally targeted to augment, not supplant or replace the v.a. instead of stripping additional resources from veterans health care, our first priority should be making sure the v.a. has the staff and resources it needs. downsizing and dismantling the v.a. in favor of veterans with unique conditions and urgent mental health needs to navigate the private sector is bad
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policy. lastly, another big concern i have is the cost associated not just with the recommendations made in this report but with whatever solutions we agree upon that makes the v.a. more efficient and capable of providing more timely health care to our veterans. it is incumbent upon us to keep the promise we made to our veterans by insuring they can access their first choice for care and to defend the rights and workplace protections of the 114,000 veterans who work at the v.a. and their coworkers who serve veterans every day. again, i appreciate the work on the commission -- that the work the commission on care has done in the past year and i look forward to hearing your testimony today, and thank you, mr. chairman. i yield back the balance of my time. >> thank you very much. members, as i mentioned earlier, joining us on our first and only panel is ms. nancy schlichting, the chair person of the commission on care, the chief
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executive officer of the henry ford system, and dr. delos cosgrove, better known to many of you as toby, vice person of the commission on care. i appreciate both of you being here with us, and for all of the hard work and many hours you have put in to the work of the commission. i understand you're both going to be presenting oral testimony this morning just as you both have provided written testimony. with that, ms. schlichting, we will begin with you. you're recognized for five minutes, and i will tell you that if you do go over and the red light starts blinking, we will not gavel you down because we're anxious to hear your remarks. you're recognized. >> thank you very much for the invitation. >> push your mike button one more time. >> okay.
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there we go. chairman miller, ranking member takano and members of the committee, thank you very much for the invitation to discuss the report of the commission on care for your support of the commission over these months, and also the extension of time to complete our work. it is truly been a privilege and an honor to chair the commission charged with creating the road map to improve veterans health care over the next 20 years and i'm very pleased to be here today with my colleague, dr. delos toby cosgrove, the ceo and president of the cleveland clinic, who will also present after my testimony. for 35 years, i have served in senior leadership roles in large hospitals and health systems, and for the last 18 years, i have been in detroit at henry ford health system for 13 years as its president and ceo. henry ford is an integrated health system with $5 million in annual revenue and 27,000 employees that owns both a large delivery system as well as an insurance company. my experience in leading henry
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ford health system through a major financial turnaround and navigating our organization through years of massive job loss in michigan, population decline and bankruptcies of our city and major employers while still growing substantially making major capital investments in our community and winning the 2011 malcolm balderage national quality award have prepared me very well for the demands and complexity of the commission's work. i am proud to be here today with one of our veterans at henry ford, spencer hoover, who is vice president of planning and business development. he served as an airborne infantryman in the 82nd tour with two combat tours, one in afghanistan and one in iraq. he was honored with six medals and is now 76% disabled from his combat and training. spencer, if you would recognize yourself. [ applause ]
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also with me today are the commission's executive director, susan webman, and three staff, john goodrich, john and ralph are also veterans. our commission was composed of 15 talented and diverse leaders, two thirds of whom are veterans. five have served in health leadership roles. three have served in v.a. four have been leaders in veterans service organizations, four physicians, two nurses and even two lawyers. we developed several principles to guide our work, including creating consensus and being data driven, and creating sustainment recommendations and focused on veterans receiving health care with optimum quality and source. the report your commissioned was invaluable as a foundation for our work. it's a comhensive systems focused detailed report that
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revealed weaknesses in the performance and capabilities. our work took place over ten months with 12 public meetings over 26 days and we sought to have the broadest input possible, and we had intense debate and dialogue over the issues. but our unified focus throughout the process was what is best for our veterans. i believe we have produced a very good report, strategic, comprehensive, actionable, and transformative. 12 of the commissioners signed the report signaling bipartisan support, and the three who didn't had divergent views. two felt we had not gone far enough, and one felt we went too far. the vha requires transformation which is the focus of our recommendations. there are many glaring problems including staffing, facilities, information technology, operational processes, supply chain and health disparities that threaten the long-term viability of the system. perhaps even more importantly,
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the lack of leadership continuity, strategic focus, and a culture of fear and risk aversion threaten the ability to successfully make the transformation happen over the next 20 years. transformation is not simple or easy. it requires stable leadership, expert governance, major strategic investments and a capacity to re-engineer and drive high performance. some of our commissioners believe ed in moving v.a. to a payer only model. they believed government can't run a complex health system and that veterans should have the same choice that medicare ben officiaries have. we believe at the end of the day that v.a. and v.h.a. under current leadership are making progress and are aligned with most of our recommendations and we believe that vha should be invested in for several reasons. one is the model of integrated care much like kaiser or even henry ford. the clinical quality that is
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comparable or in some cases better than the private sector. the history of clinical innovation and veterans focused research, medical education, and emergency capacity. the specialty programs, especially mental health, poly trauma, rehabilitation rarely replicated in the private sector. the role as a safety net provider for millions of complex and low-income veterans who may not or could not be filled by the private sector in many markets. in fact, as we have seen the implementation of the affordable care act, it's been difficult in many instances to meet the access needs simply because of the shortages of primary care physicians and mental health providers in many markets across the country. our recommendations fall into four major categories. first, creating a vha care system which fully intergreats vha, private sector, and other federal providers. vha would continue to provide care coordination and would fully vet the provider network to insure that veterans receive
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care from individuals who understood military competency, understood the need for access, transparency of their performance and many other critical criteria. we also included the fact that veterans should have a choice of primary care providers within those networks to insure the ease of access and meeting their needs. the second category is leadership system and govern nls, again, focusing on continuity and leadership development to insure susta sustainable leadership over time. and we also recommended a board of directors to provide oversight and the expertise in health care that is critically needed. we also in the third category focused on operational infrastructure, information technology, facilities management, performance management, human resources and workforce, supply chain, and diversity and health care equity. and finally, we have a category around eligibility, focusing on the needs of other than
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honorable discharge veterans who have health care needs and in retrospect deserve them, and also eligibility design, which has not been looked at in many years and probably would be worthy of taking a look. the objective of every commissioner throughout this process has been that our report did not -- would not sit on a shelf. and in fact it would be implemented. and we ask for your help today to make our report come to life. we ask that you provide v.a. needed authority to establish integrated care networks through which enrolled veteraned could receive care from credentialed providers without regard to geographic distance or wait time. we're asking to address the weaknesses in governance and provide v.a. more flexibility in meeting its capital asset and other needs including establishing a capital asset realignment process models on the dod process. waiving or suspending the
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authorization and score keeping requirements governing major v.a. medical facility leases, lifting the statutory threshold of what constitutes a major v.a. major medical facility project, reinstating broad authority for vha to enter into enhanced use leases and easing the time limit period on divestiture of unused buildings and establishing a line item for i.t. funding and authorized advanced appropriations for that account and also creating a single personnel system for all vha employees to meet the unique staffing needs of our health care system. i would like to amplify one very key point, which other commissioners view as foundational. the commission saw vha's govern nls structure as ill equipped to carry out successfully the long-term transformation required to reinvigorate health care. it cannot be insured under a governance framework marked by
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frequent turnover of senior leadership. the commission believed that two fundamental governance changes were needed, a establishment of a board of directors with authority to direct the transformation process and set long-term strategy and changing the process for the appointment for and tenure of the undersecretary for health. we are mineful that some of our recommendations have significant cost implications and we work with health economists in modeling these options, and implicit is the question, should the nation invest in the health care? we answer in the affirmative. we do not suggest at all that grsz has not made already substantial investments in system. rather, we call for strategic investments in a much more streamlined system that aligns v.a. care with the community. in my judgment, our report points the way to meeting the central chaj congress identified
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in 2014. improved access to care while offering a vision that would expand choice and contribute to improved patient well being. it's a vision that puts veterans first. my experience tells me that veteran-centered focus will ultimately improve the service veterans receive while strengthening the system and providing increased transparency and accountability. in my vus, this is a vision that merits your support. i would be very pleased to be a continued resource to this committee as you continue on your work, and i would also be very happy to answer any questions as i know toby will after his presentation. thank you. >> thank you very much. dr. cosgrove, you're recognized. >> chairman miller, ranking member takano, and members of the committee, thank you for inviting me to speak about the commission on care's final report today. as a former air force surgeon, i care deeply about the welfare of the nation's veterans and i'm honored to serve as vice chairman of the commission on
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care and as a member of my v.a. advisory committee. over the course of my work with the v.a., i have become well acquainted with the department and understand its contributions as well as its challenges in meeting our veterans' needs. as the ceo of the cleveland clinic, an $8 billion health care system serving comuns across the country and internationally, i'm aware of the magnitude of the challenges facing v.a. health care system leaders. mr. chairman, the veterans health care system must make tranls formative changes to meet the health care needs of veterans today and tomorrow. if these changes are not made, vha's many systematic problems threaten the long-term viability of v.a. care. the final report contains 18 different recommendations. today, i'm going to address four specific areas that include the establishment of an integrated community-based health system.
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the quality metrics, information technology, specifically the electronic health records and supply chain. given the commission's charge to examine veterans access to care, it was concluded early on that great reliance on and closer integration with the private sector held the greatest promise for improving not only access but affording veterans greater choice. as you know, the commission considered and debated options that would provide for different degrees of choice. the recommended option in the commission's final report reflects a consensus position, so many supported an option to provide veterans with greater choice of private sector providers. the commission agreed that the vha must establish high-performing integrated community-based health care
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networks to provide timely and quality care to our veterans. the report envisions a continued role for the vha health system but as was said, if the challenges and opportunities described in the final report are left unaddressed, we're concerned that our veterans will not receive the kind of high-quality care that they deserve. among our proposals, the commission recommends that the vha adopt a continuous improvement methodology to engage staff and improve the culture. this will help, but it will also take significant investments in time, effort, and resources to modernize and streamline such essential functions as human capital management, capital asset management, and leasing, business processes and information technology. the commission recommended that the vha should implement
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coremetrics that are identical to those used in the private sector. veterans deserve to know that the health care they're receiving either for the vha or from the community provider is of high quality. that these metrics are put in place, it will be easier to evaluate the system's performance and congress will have a benchmark from the private sector to compare both its progress and the improvement over time. congress and the american people deserve to know that vha is getting value for their investment. years ago, the vha was a leader in the field of electronic health records. unfortunately, this is no longer the case. therefore, the commission believes that vha should transition to the same type of commercial off the shelf electronic health records as other providers. by using a proven product, many of the scheduling and billing problems would be resolved.
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further, these systems could help the v.a. identify areas of opportunity and utilization to promote better access to care for our veterans and promote interoperability which is critical as our veterans move to different care sites. finally, the commercial electronic health record would also allow vha to link financial and clinical information. a critical functionality for running a modern health care delivery system. the best and most prevalent commercial electronic health record programs allow staff and patients to schedule patients' care easily and provide legitimate performance measures for wait times, unit costs, clinical care outcomes and productivity that conform to those of the rest of the health care industry. many of our country's best hospital systems have converted home-grown information systems
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to commercially-based systems. vha must do the same to remain in the current and engage the rest of the health care delivery system. it must also have its own leadership, specifically a chief information officer for the vha information system that allows vha to adjust its information needs as the health care industry evolves. as a vha contractor, cleveland clinic has experienced firsthand the burdensome, antiquated system that is currently in place to receive payments. we are required to provide documentation and hard copy of forms sent via the postal services as they cannot accept fax, e-mail, or other electronic submissions. if a request results in more than 100 pages, we must burn the records to a disc because we do not have any mechanism to track whether the documentation has been received, we have heard on
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many occasions they never received the paper records and we have no recourse other than to send them again. the independent assessment that congress commissioned found that the vha should keep claims adjudication and payment separate from its care delivery. the health care system that the commission envisions for the vha will continue to expect exceptional performance from its network of providers and providers should expect timely and accurate payment in return. supply chain is another area ripe for vha streamlining. the commission's report stated that purchasing processes are cumbersome, which has driven v.a. staff to work arounds and exacerbates the variation in process the v.a. pays for products. the v.a. should consolidate and reorganize procurement and logistics for medical and surgical supplies under one leader. vha has enough market share to
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leverage prices that could result in savings of hundreds of millions of dollars. at the cleveland clinic, we constantly eval and review our supply chain products and processes. today, our supply chain is working with teams of clinicians led by a physical champions to justify purchases by engaging clinical staff and the value based sourcing effort that illustrates that cost and quality do not have to be mutually exclusive. clinicians are made aware of the cost and outcomes are associated with different brands. once the clinical staff has to justify the higher cost and understands whether it will add value to the care, outcomes based on empirical evidence, they make purchasing decisions based on value. such efforts are then integrated into patient management and inventory management to insure the appropriate use of our resources.
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a clinician engaged value based supply chain management practice model has allowed us to save $247 million over the last several years. we are continuing to reform our process by entering into purchasing consoershm with other providers and are continually searching for improvements and cost management. leadership is the change to transformational change. the commission speaks to the need to create a pipeline of internal leaders and to make it easier for private sector and military clinical and administrative leaders to serve in the vha. market-based pay is critical to bringing in leaders capable of taking vha to the next level. the commission also proposes that congress provide vha govern nls board to provide a long-term strategic vision and successfully drive the transformation process. both the chair person and i would be happy to talk more
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about this aspect of the report. mr. chairman, transforming a system as large and as complex as vha will require streamlining multiple services, redesigning care delivery and more. this report offers a road map to success. realizing the vision the report proposes will require new investments, both financial and in expertise, enactment of legislation and strong leadership. thank you for your attention, and i'm happy to address questions. >> thank you very much, doctor. we appreciate you both being here. for either of you that would want to answer this question, do you agree with the president and the secretaries who have both stated that many of the commission's recommendations are already being implemented via the my v.a. initiative? >> i think that it's difficult for us to really evaluate that because we're not within that
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structure at this point. but i think in terms of strategies and direction, there are many areas that are aligned. but it's hard to understand within that, do they have all of the plans that will allow that to be executed? those are the questions i would have. >> dr. cosgrove? >> i don't think we can know exactly. example, electronic medical record, we don't know if they purchased an off the shelf record or not, which is imperative. >> neither do we. we're still trying to find out the answer to that question also. this is something that probably other members won't touch but i will since i'm retiring at the end of this term, but what do you think the biggest benefit of a brak-like process within the v.a. would be for vha and also what do you think the big impediment would be? >> just a couple of comments on the facility challenge i think
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that v.a. has. when we looked at the breadth and depth of all the vha facilities across the country, the average age of physical plant is 50 years. to give a comparison, at henry ford, that's nine years, and across the country, it's around ten. so the issues that v.a. will face over the time in terms of their facilities and also the fact that they're very in-patient oriented today as opposed to out-patient are really significant. we think it could provide some objective view and input on how exactly the vha facility networks are performing today, where the problems are, and where change needs to occur. it also could provide much as it did during the military closures, you know, the opportunity for some objectivity and protection from the political challenges. closing hospitals is a very hard thing to do. i have closed three in my career, and i don't wish it on
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anyone. it is a very challenging thing to do. and particularly for members of congress who are concerned about job loss in communities that might happen. the opportunity, though, in health care is different than the military closures. there's no substitute. so the opportunity for jobs to be preserved in communities through more partnership with the private sector exists, and also the evaluation of other capacity within that community could serve veterans better with lower cost long term, so i think it's with that in mind that we really believe this would help the process. >> i would just add to that that i also have closed two hospitals and realize how difficult that is and how politically entangled this is a decision making process. also, i think there are over 220 facilities right now that are not in use and have not been either sold or abandoned or begun to be taken down because
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it's been unable to get that accomplished through the current system. >> one final thing. there was a statement made in va's letter to the president regarding the final report that indicated v.a. is not in favor of eliminating the current choice program restrictions by mi mileage criteria and the time restriction of 30 days. because they don't -- they desire not to sacrifice v.a.'s four statutory missions. i know the report called for a total elemination of the mileage and time requirement. i wouik you could address why you went further. >> well, as you know, choice was a very difficult discussion among the commissioners because we had wide ranging views around choice. i think we felt that we had to find a balance because we understood the fact that there was the danger of weakening the current vha system if in fact
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choice was too broad. but what we did do is believe that those limitations in many cases were causing really undue problems for veterans, and oftentimes, the timing involved of even being able to assess some of those limitations caused access issues. we felt that we were erring on the side of choice of primary care provider and also strengthening the v.a.'s control of those networks. because if v.a. could set up those networks in a way that really created the right capacity, the right access, without endangering the ability of vha to continue their important mission, that was what we were trying to find. we were trying to find that sweet spot between choice and also the issues of maintaining a system that is critically important. >> go ahead and yield to mr. takano for his questions. >> thank you, mr. chairman. many of the national veterans
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service organizations are very troubled by recommendation number one. they are concerned that instituting choice as a core policy could lead to a large percentage of veterans to pursue more conveniently located community care. this could end up jeopardizing the viability of unique v.a. services. your own economist projected a steep migration to community care. i have one question for you both. what analysis did you conduct to test how this concern may play out, and second, the follow-up would be, and why did you not recommend pilot testing such a radical change as this? >> well, we did actually talk a lot about how do you roll this out, and felt that probably a phased approach to really test some of the assumptions was important. there were many commissioners that spoke to that issue. the execution implementation is very complex, and it will take time. i think it will require, much as any major change does, some testing and refining and
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continuing to tweak this. but i think on the choice issue, it's important to balance this question of choice and making sure access is really available within every market across the country with the issue of how we're trying to also control frankly those networks to better serve veterans. so it's really finding that balance that i think is very important. >> okay, well, the commission's guiding principles called for recommendations to be data driven. what specific data did the commission rely on in recommending that it should be organized on the principle veterans should choose to receive care from a community provider even when the v.a. can provide the veteran timely care in reasonable proximity to the veteran's home. >> if you think about the v.a. system in the way we did, rirt not a question of v.a. versus the provider in the community. it's one system that should be
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operating in a much more integrated way, and every provider that is within that vha care system then would be able to provide access for veterans. so it's a different mindset than today. and i also think it should be balanced against all of the investments in improving operations we're recommending within the vha. >> okay, let me ask you this. as you know, the v.a. health care system is necessarily very tranls pair rnt when it comes to wait times and health outcomes. how does the ford health care system and the cleveland clinic measure wait times? do those health care systems or for that matter, any private health care system, post wait times publicly, and if not, why not? >> we actually do. we have an electronic system where people can call in to clinics and find out wait times for that day, for same-day access. the other thing we have really changed is the whole notion of access. we now believe that same-day access not only for primary care but specialty care is a standard we're setting for our health system.
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>> ten years ago, we instigated same day access. we now see 10.1 million same-day. >> would you expect for private providers participating in this system in an integrated network to be held to the same wait time rules and requirements as the v.a.? >> yes. >> yes. >> so i'm also concerned about your recommendations to expand veterans choice to all veterans regardless of the day's waiting or distance, i'm ceoncerned tha it's financially unsupportable and may weaken the v.a.'s health care system and increase the share of veterans care provided outside of the v.a. did the commission look at the cost of these recommendations and how this might affect the vital research and education missions that the v.a. conducts for the good of the nation? >> we did look at cost, and we have included estimates in our report around what we think that would mean.
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it is hard to know, though, i will tell you, there are certain assumptions as you go into the cost estimates that are based on certain assumptions that may or may not actually come true. and part of the comequestion is rapidly can some of the improvements in operations to improve access within v.a. be put in place. because it's quite conceivable that more patients would gravitate to v.a. for many reasons as opposed to always assuming that they're going to go in the private sector. it's gnaw as clear as some people would like it to seem. >> a point on the last point, there are a number of veterans who currently do not get their care from the v.a. since the v.a. improved their access and improved their ability to take care of them that they would migrate to. there's 22 million veterans across the united states, only 6 million get some care from the v.a. so the assumptions are very difficult to project. >> okay, thank you. bl chairman, my time is up.
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>> thank you very much. mr. lamborn, you're recognized for five minutes. >> thank you, mr. chairman, for having this important hearing. i want to thank the chair and vice chair of the commission for appearing before us today and for the time and effort they put into this report. we have two main challenges today as i see it. first, how do we at least insure that we take what's good in the report and make it a reality? 137 previous reports on v.a. health care have already been presented and are sitting on the shelf gathering dust. second, and this is the -- maybe an even harder challenge, to evaluate whether the proposed recommendations go far enough. we like to use words like transformation and reform, but how willing are we really to challenge the status quo and consider bold reform? we all recommend the managerial failures of 2014 that came to light, the inconsistent care,
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the manipulated data and other manifestations of dysfunction. and we also remember the words of the independent assessment in 2015 which found that the vha systematic problems demanded, quote, far reaching and complex changes that when taken together amount to no less than a system-wide reworking of vha, end quote. so when will we have a system-wide reworking of the vha? i have 100,000 veterans in my congressional district, and i'll say that the calls they're giving complaining about v.a. service haven't diminished and are about the same as it was a couple years ago before we tried to make and the v.a. tried to make some changes. they don't believe that things have substantially changed for the better. with that, mr. chairman, i ask unanimous consent that the commission report dissent from commissioner hickey and
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commissioner sellnic be entered into the record. >> without objection. >> that's one perspective i think we should look at on an opportunity for transformation. dr. cosgrove, i would like to ask you a question about the quality of v.a. health care. according to the report, quote, care delivered by v.a. is in many ways comparable or better in quality to that generally available in the private sector, end quote. however, the independent assessment found, quote, on most major veteran reported experience of care in veteran hospitals were worse than patient-reported experiences in non-v.a. hospitals, unquote. is v.a. care better than the private sector, the same, or worse? i know it's very broad, but it's very critical. >> it's difficult to answer that. there's only a handful of comparative studies published comparing the two care. some suggested it's better. some of them suggested it's not
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equal or not as good as. and i think part of the problem is that they have not been reporting the same as is reported in the private sector. and one of the suggestions that we made so that you can begin to compare the quality is to have exactly the same metrics as reported in the private sector. for example, the society of thoracic surgeons reports the mortality rates and morbidity rates of cardiac surgical racas across the country. vha is not a member of that and does not report. that's not to say it's better or worse. they just don't report. >> okay. i mentioned earlier that commissioners hickey and sellnic signed a dissenting letter. what accommodations were made to their views, if any? >> well, both of them participated in all of our discussions and had the same
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opportunity as everyone to put their ideas forward, which they did. and at the end of the day, we built a consensus around the report recommendations which 12 of the commissioners approved, and their dissent opinions were included on the website as well. you know, with all due respect, neither stewart hickey nor darren sellnic have ever run a complex health system, and to say what we're proposing is not transformative, i think is a complete -- it's just untrue. the integration process of creating vha care system is a significant transformative process that will take many, many years to complete. recognizing the complexities of both facilities and staffing issues and leadership and all of the components that we included in our report as well as i.t. interoperability to allow that to take place is very transformative. neither of those individuals have ever implemented a major
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change in a health system, as dr. cosgrove and i have, and i think we recognize the transformative aspects of what we're proposing. >> thank you, mr. chairman. >> mrs. brownley, you're recognized. >> thank you, mr. chairman. i want to thank both of you for your time and commitment on putting this road map together. i know it's an inordinate amount of time you have put in, and quite frankly, all the commissioners. i just want to thank you for it. there's much to it that i like very much, and i think it's critically important that we have a clear road map by which we can base a discussion. i think this is really the most important discussion this committee needs to undertake, we naed to figure out what the transformation is and what it's going to look like for now and into the future. i clearly believe that community partnership with the v.a. is
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part of the solution. i just -- particularly for primary care and some specialty care, i think that partnership is critically important. i think there are some services that the v.a. provides that the community can't provide. and so that partnership, i think, is really important. and it is, i think as we talk about this, you know, to me, i see it sort of in a sliding scale and where is exactly, you know, the sweet spot in terms of what that partnership really means going forward. so i really, really do appreciate the report very much, and mr. chairman, i hope that we'll spend a great deal of time having future discussions on this until we can all come to, i think, a consensus in terms of moving forward. i wanted to ask, you know, a very specific question relative to the report because it certainly affects my district. in my county that i'm very close
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to the l.a. medical facility, west l.a. medical facility, which is a huge facility, and thank you, mr. chairman, for your leadership on moving forward with the west l.a. facility, but my veterans also are by mileage, are close enough to the facility but by traffic and getting there, you know, it can take a day to have a visit. and so we're working hard to try to expand our v.a. facility within the district. it's been authorized and so forth, but the way the v.a. does their leasing arrangement, and you're probably aware of this, is the way the cbo accounts for it, makes it very difficult for us or anyone to approve the resources when you're counting a 20-year lease or a 30-year lease all up front. so i'm just wondering, i actually have a bill that is called bill of the better v.a.
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act, but what my bill would do is to sort of harmonize the way the v.a. does this, the way general services does this for other federal facilities so that we can break down this barrier the way cbo is scoring it. do you have any comments relative to that or did you discuss that at all? >> probably not spisecifically, but i will say around the facility questions, there was a tremendous desire on the part of our commission to simplify and make things more agile for people leading these health care facilities today. as you know, health care is changing dramatically. there's probably as much change taking place today in the delivery of care as we have seen in 50 years. rapid changes in terms of technology and where care can be delivered safely and effectively and the ability to really create those access points from an outpatient facility standpoint. you know, we're at henry ford, we continue to built more
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outpatient care all the time. i mean, it's a constent effort to keep up with the access needs. for the reasonses you mentioned, that's one of the reasons we took out the time limit and the distance, mainly to create -- because every market is different. sometimes you're having huge barriers that are unintentional just because of the way that market might function. >> i think that's also really important as we look at this that we have to really look at each sort of area and community and region because everybody is going to have very different needs. what about in terms of this vision and road map, where does telemedicine fall into all of this? >> i think telemedicine is an integral part of it, and v.a. has taken a lead in many aspects. we think this is going to be something that will be ubiquitous across the country, and will greatly eliminate the
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need for traveling great distances. as you stop and think about the health care system in the united states, it was developed in a time where there was not a lot you could do for people in the hospital and very poor transportation. now there's a lot that you can do for people and great transportation and added on top of that is virtual visits, which are going to reduce the travel and the access and improve the access enormously, particularly in areas of chronic disease. so we're moving ahead very, very fast on that, and the v.a. has taken a nice lead there. >> one thing i would add on that point is there's also a lot of digital health development going on today, where patients themselves can self-monitor and report information, communicate differently, and that is, i think, a great frontier as well. >> thank you very much, and i yield back. >> can i just add one thing? you know, going back to the electronic medical record. you know, once you have a commercially available electronic medical record, it
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allows you to make your appointments yourself on your electronic medical record, and that electronic medical record should be available to all patients. and so you have to begin to engage the patients, and one of the ways to do that is through electronic medical record. >> and i do want to salute the v.a. with the new person in charge of i.t. i think she gets what's necessary, and i hope that that progression will continue. mr. bilbilirakis, you're recognized. >> i thank the panel for their testimony. thank you for all these great suggestions. what do you think is a realistic timeframe for the large-scale transformations that the commission's report calls for, assuming the v.a. is already implementing some of the recommendations that claim they are making? when do you think veterans should expect to see meaningful change in the care they are
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receiving in terms of quality and access? >> i think realistically, we're looking at a five to ten-year transformation process, but i also think any time you go through that, you're looking for those early wins, those things that veterans can see quickly that improve their patient care experience. so there are some things, particularly in the area of technology and certainly just customer service aspects that can be improved very quickly to help veterans feel more confident in that change process. >> very good. >> can i just add that i had an experience with changing the culture of the cleveland clinic, and it took me five years, and the organization was only 80,000 individuals. and something that is as large as the v.a., i think it's going to take even longer. >> thank you. again, we're building on that. what benchmarks should we be looking for as the v.a. implements these recommendations and do you blink the v.a. has
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the capability and forsight to track these relative data? >> much like dr. cosgrove does at the clinic and we do at henry ford, we have balanced scorecard, if you will, that provides data on a frequent basis that scores on patient engablie engageme engagement, all of the metrics that dr. cosgrove referenced that are comparable to the private sector should be available, i think, in a transparent way for people to assess the quality as well as the service provided in each v.a. facility. i think that level of transparency and having a scorecard that focuses on regular accountable results is very critical in this process. >> for example, we report almost 100 quality metrics to the federal government on an annual basis, and in fact, we have quarterly scorecard meetings with all of our department heads
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going over all of these metrics, and i think you have to be completely data-driven, metric organization in order to achieve these transformations. >> thank you. understanding that not just one solution will solve all of the agency's shortfalls, how, or if you had to identify the single biggest problem, the biggest problem, what would that be effecting the v.a. health system, and what is the solution to that problem? >> you know -- >> single biggest problem. >> i think all of us felt this truly is a systems-oriented approach that many of the recommendations are interdependent. but if i were to put one on the table, i would talk about leadership sustainability. because it is virtually impossible, i mean, toby has been at the cleveland clinic how many year snz. >> 13. >> yeah, and both of us have served in ceo roles, 13 years in our organizations. when you have turnover in the
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undersecretary position every couple of years, it's very difficult to sustain change. and i think that really is holding back the kind of transformative work that potentially could happen and obviously needs to happen. >> i think -- do you agree, doctor? >> i would say that it's one thing you can do rapidly that will change the organization, and that's the electronic medical record. that can be done in a short period of time. the rest of the transformation is going to be much longer. >> thank you very much. i yield back, mr. chairman. >> ms. kuster, you're recognized. >> thank you, mr. chairman, and thank you for being with us today. this is a critically important report and certainly at the heart of what our role is, so we appreciate the time that you both have put in and your wisdom. i want to dive right in. i spent a great deal of time with my veterans and visiting our clinics and hospitals during
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the august district period. and you talk about data driven, and i agree with you. i just want to point out one example of an unintended consequence that we face, many of us around our districts. and that's with regard to the heroin epidemic that's threatening the country. what we discovered, and this is broader than the v.a., but that the use of quality metrics with regard to bringing down the pain surveys, bringing down the numbers inadvertently incentivized physicians to push opiate medication which then led to high rates of addiction. we have a wonderful project that the white river junction v.a., dr. julie franklin, getting out in front of this with our veterans. i met with a number of them using alternative remedies for
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pain maintenance, pain medication, including acupuncture, yoga, all these different criteria. and i just wanted to see if you would oip yacht problem is multi-dimensional and it is going to require a lot of creative thought. i think certainly other alternatives are going to be part of it. also i think education,
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expectations of patients is going to be an important aspect of beginning to change that. but this is an epidemic. in ohio, it is a huge epidemic. >> you've been very hard hit. we have a bill we are hoping to get attached as an amendment that would provide a pilot project for vas to do this type of alternative remedies for pain management, try to -- we've had a reduction at this one hospital. 50% on opiate prescriptions. i got to tell you, the one-on-one conversations i had and the quality of life for people whose lives have been turned around. so i just want to bring that one up. >> congratulations. i think that's a great piece of work. >> good. thank you. the other one is you talked about the safety net provider. i think that's an important consideration that we can't lose sight of. many times as i visit our veterans facilities, it is the
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lower income veterans who don't have access to private care can be don't have access to private insurance. this is their provider of choice. you mentioned about a shortage of primary care and mental health professionals. my colleague mr. o'rourke in el paso will discuss that. we also have a bill about physician assistance coming out of our military. i just welcome your thoughts on that approach where we can sort of grow our own and use the skill set of veterans coming out of our military. great experience. and how we could put that to work to reduce the shortage of providers. >> i would say that the military providers are tremendous workforce for health care. we've hired over 1,000 veterans in the last five years because we recognize they are highly
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trained, experience and a great culture. >> great work ethic. . >> great work ethic. we're delighted to have them. we actually recruit both nurses and physicians assistants coming out of the military and go to the bases to do that. >> great. >> i would just add the concept of growing your own is very important within the va system. the dedication of the veteran wo workforce is incredible and an opportunity to really leverage that makes a lot of sense. we are looking at similar issues of growing our own in areas that we simply can't find the talent that we need. thank you for your good work and thank you, mr. chair, for indulging the shameless promotion of my two bills left to be attached as amendments going forward. thank you. >> i understand you did a field hearing in aurora, colorado -- [ laughter ] >> and it was excellent. it was great work. i want to thank my chair. >> dr. rowe, you are recognized.
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>> thank you. i want to start out by thanking the committee that put this together. it was a remarkable piece of work. thank you for taking the time away from your shops. all the committee members. this is probably the most important piece of work i've seen in my almost eight years here in the congress to really make a difference if we can implement this. during the convention, instead of spending most of my time politicking, i spent afternoons at cleveland clinic. the way you evaluate your needs is you build the needs to the entire health care system and the entire health care system is undergoing radical changes in the u.s. right now. shifting from the big concrete silos to outpatient, more and more surgery. 100-bed hospital today can do what a 500-bed hospital did 30 years ago. i think the va's still stuck at the 500-bed. a couple things. let me just sum miz what imariz heard so far. one, i believe to move this system forward we need an integrated care model that
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involves the private sector and the va sector in primary care. two, dr. cosgrove, you pointed out to have an electronic health system that's 20th century -- remember this, three years ago where dod and va tried to make these two antiquated systems interact and they could not. i've been all over the place trying to see how these experiments failed. a modern system solves a lot of the scheduling problems, payment problems, data problems that you talk about right now. they've done a remarkable job of working around these problems. but there's new technology out there. the dod made that decision. the va set there right and tried to convince the dod to put in a 20 or 30-year-old system andthy didn't do it. they took it off the shelves. i think that would be something they need to do. that solves your supply chain. all those things -- helps -- that doesn't totally solve it but helps solve it.
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lastly i think is the brak. i think we have to sit down and evaluate what those assets are and where -- look, where you can get the best care. the best heart surgery is at cleveland clinic. it is about providing the best care for veterans. i think that's what this is all about. not sustaining a bureaucracy but providing the best care and where that care can be given most cost-effectively. i admire what you have done. to say our committee has not provided the resources for the va. when i came here in 2009 we spent $95 billion, $97 billion on all va care, cemeteries, disability and health care. today it is $165 billion without choice. i would say that congress has done a job. it's just -- we've gone from 250,000 employees to 330,000. in the private sector, you've had to figure out how to do it more efficiently with less people because your revenue, i
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promise you, has not been going up like it did. you've had for better manage. i commend you for that. my last question. do you think if we can come to the consensus -- those four things i pointed out. and it won't be easy. if we pass it, do you think the va can carry it out? and i know that you said -- i hate to put you on the spot, but you pointed out that leadership is the key for transformational change. is that leadership there? >> you know, i think leaders get better over time, also. the current leadership has been in place a very short amount of time, actually. and i have, i think, made some progress in key areas and have set the right tone for improving access. but i also think they need some time. it's hard to judge whether that can happen unless there's sustainable leaders in place which is why we recommended the idea of five-year terms for the under secretary and having that individual actually selected by
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the board of directors so that that process can move forward and that individual feels the support of a group of people that are really trying to move transformation forward. i recognize that that may be unconstitutional. there may be ways around that that can help with oversight. but -- >> that hasn't stopped us from doing a lot of the consultation. so -- the question is do you think we can? because i think this is a remarkable document. i think it has a chance to put veterans and doctors back in charge of their care and not a system. i just wonder if you think we can do it. because if you could, i think you would truly transform the health care system that veterans receive. >> i think it is going to take time. this is not going to be quick. this is going to be incremental. and it is going to take continuing change of a very big system. >> i think the key one is making
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a decision on vhr. i think that one is one that begins to solve a lot of these other problems. you are trying to do with different software systems that now don't work well together. >> i would just say one other point to move to that. we have -- and many people around the country have learned that you can't maintain a electronic medical record in an individual facility. it is moving too fast. that's why the commercial aspect of this has kept up with the changes and made them uniform across the country. so i think it's absolutely imperative. >> thank you, mr. chairman. i yield back. >> mr. o'rourke, you're recognized. >> thank you, mr. chairman. i'd also like to thank the chair and vice chair for their work and sacrifice of their time and, frankly, their commitment to their day jobs in order to be able to fulfill this commitment to the veterans in this country and to the american people. really appreciate the way in
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which you conducted the review and made the recommendations. so just want to add my thanks to all my colleagues. i'd like you to discuss what i think is the most pressing crisis facing our veterans and the va. the single greatest unmet need right now in the system, and that is the tragic number of veterans who are taking their lives every day in this country. the new data from all 50 states is that it is 20 veterans a day who are taking their lives. think that's the single greatest opportunity to stop these preventable deaths. if we take this seriously, confront it, and organize to provide far better care that's being delivered to veterans right now, as i hope you remember from our discussion. in el paso, because of the high number of veterans suicide, the
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inability for too many veterans to be able to see a mental health care provider. never mind the wait time, originally estimated at 14 days. we now know it is over two months on average. but one-third of veterans in el paso couldn't get in at all. that has prompted us to propose a solution in el paso that we're trying to pilot right now to focus va care specifically -- that care that's delivered in house -- on those conditions that are unique to service or combat. ptsd, traumatic brain injury, traumatic amamputations. military sexual trauma. there is a lot of list of these that i believe we want someone who knows how to treat veterans, perhaps only treats veterans and active duty service members, knows things to look for, questions to ask, the treatments to prescribe. is there a way to resolve that idea with this idea of a network where you do leverage capacity
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in the community? and for those conditions perhaps that are not connected to combat or service, we prioritize community care. but for those conditions that are unique to that experience of being a veteran, we make the va the center of excellence for treatment of those conditions. love to get your take on that idea. >> actually, we agree with that. the recommendation that we put forward really focuses on those unique capabilities of vha absolutely being supported, invested in, continue to grow and develop. because it is -- it has been shown -- my understanding is that it's been shown that those veterans that actually seek care within the system end up with much lower suicide rate because they're being managed, their care's being managed and they are in touch with health professionals who provide that kind of support on a daily basis which is really critical for those types of needs. but, unfortunately, it's how do you embrace and get people in to the system who otherwise may not
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be willing to go there. i think that's one of the challenges. you're right about the fact that in the private sector, doesn't mean that people are well equipped to handle the complex mental health needs of veterans. in fact, in many cases we have the same problems, if not more acute problems, of have regiingh mental health providers in our community today. >> i would just say, think there are a couple things we have begun to recognize. one is the shortage of mental health providers. increasingly i think you will see virtual visits begin to augment the shortage and help the shortage of mental health providers. similarly, group visits and group therapy for those individuals. we've found both of those to be very useful. >> i think as long as we can prioritize that excellent in care around those conditions, especially those that could
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potentially lead to veteran suicide, and are able to reduce the number of veterans who take their own lives, improve outcomes, improve access, i think the system that you're proposing makes all the sense in the world. we learned this summer that the vha has 43,000 positions that are authorized, have the funds appropriated for, but are unhired today. and we're fools to believe that we will ever hire all 43,000 of those. so let's prioritize within the va on those areas where we can do the most good, make the greatest positive difference for those veterans. for me that's clearly mental health in reducing the number of veteran suicide. and then we face another issue which you raised which is how do we produce enough countries -- enough doctors in the country generally to ensure that we have capacity for veterans in the community. but i think if we can leverage the two, what we should do really well in the va, with what exists in the community today,
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and follow our ranking member's lead in creating more graduate medical education positions, then i think we are going to be on the path to fixing this. my time is up. but again, thank you for your work on this. really grateful for the effort. >> mr. chairman, thank you so much for the great work you did. i don't know exactly where to begin with all the things that have come up today. which strikes me about many answers to the questions is your comment about the leadership and how critical that is to transforming the va. having not so much political appointee at the head, but like a regular hospital, a regular system that people are on the board. i was on the board. and a continuity of care over a period of time so that these
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things can be developed. i think it behooves us to make that happen. i see that as a challenge to this committee to take the bold step necessary to basically implement your plan. i don't say i agree with everything, but if we don't do this, we're going to be faced with 30 more years of the same thing we've been doing now. i think that's the critical take-away from this very important commission's work. and the thing that you said, dr. cosgrove, the other think i take away, is the critical need for an i.t. system that makes sense. to me, that's your testimony of the two of you. is leadership, and the immediate action on an i.t. system which really can't be changed. i just want to bring up a question that always bugs me. and that is, when you estimate the cost of implementing these things, how did you estimate the cost of the va care? because when we try to figure out what the va is actually --
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what it actually costs the va to see a patient, in the private sector we know what it costs to see a patient. all right? the va doesn't do that. how did you estimate that? because we haven't been able to get a figure on that. >> let me just say that one of the things i think that probably struck all of us that are in the health care industry was how little focus on cost va has. that was sort of shocking because we live in a world where we have to constantly focus on cost per unit of service, cost for a full episode of care over time, creating population health management techniques so that we in fact can understand cost and whether we're contributing to value and improvements in quality. and that doesn't exist today within a budget oriented va system. i think that's one of the challenges as we looked at this cost question of how we move forward. i think one thing that probably should have been in the report that wasn't was this notion of
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getting more cost oriented in terms of some of the -- >> my frustration here is, what does is cost for the va to see a patient? there is like no clue. >> and in fact, if you look at the model and what's changing in health care today, we're getting away from the volume oriented kind of measures. we're trying to if he cuss on o -- focus on outcomes of care, clinical results, as well as are we making a difference in terms of-- focus on outcomes of care, clinical results, as well as are we making a difference in terms - outcomes of care, clinical results, as well as are we making a difference in terms - outcomes of care, clinical results, as well as are we making a difference in terms of outcomes of care, clinical results, as well as are we making a difference in terms o outcomes of care, clinical results, as well as are we making a difference in terms fo outcomes of care, clinical results, as well as are we making a difference in terms fo the efficiency of care that we
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provide. how do we get metrics that are more comparable so that in fact we can determine the effectiveness of the va system over time. but i would add that i think -- if you view this in phases, there are ways to test some of these assumptions and begin to look at those cost elements that could be projected out over time so that you can really see. the other thing is this issue around facilities. if all the facilities had to be replaced versions creating this integrated model, there is a lot of potential cost savings around cost mitigation over time that i think would help. >> the only thing further i want to bring up, it is related to the way -- the status quo of the va, now one of my big complaints is that working there, i have very little input as to how things worked in my clinic or in making sure that things ran efficiently. it seems like others who weren't really involved in the patient care were making the decisions as to how manile staff to have, how to make the staff flow. patient flow and all that.y sta how to make the staff flow. patient flow and all that. i think that would come with the leadership changes. but is there any other comments you would like to make on that? >> yeah. i just think that you need to bring physicians more into every aspect of delivering care and running the organization.
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i gave the example of purchasing. previously physicians were not involved in that. we found tremendous efficiencies by bringing them in. and without involving physicians in leadership of the organization, i think you're missing an intellect and a set of knowledge that is necessary to have high-quality organization. >> thank you very much for your work and it is up to us to get this show on the road. >> thank you, doctor. >> thank you, chairman. would either one of you want to be secretary of the va, by any chance? just out of curiosity. [ laughter ]. >> i had that opportunity. thank you. >> so i just want to echo some of the comments that mr. o'rourke made. we recently had a veteran take his own life in the parking lot of the north port va which is so disturbing. so i couldn't agree more with mr. o'rourke about this being such a top priority for the va
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to handle. i also totally agree that the two issues in terms of accountability and the electronic health system, records system, are critically important. i mean every single hearing that we have, the number one issue that we talk about is accountability, whether it is for treatment of -- how whistle blowers are treated by higher-ups, wait times, the enormous cost overruns for construction projects. the list goes on and on. if you could just address the whole issue of how you would create a more effective hierarchy. the board of director, how would they be chosen? why do you say that the undersecretary of health position should be one that has a fixed time limit versus the secretary, someone similar to the head of the cia and the fbi. if you could just talk more about that. because to me i -- i mean i
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don't know if that will get to changing the underlying culture of the thousands of employees who are under the secretary and the undersecretary. but if you could just talk a little bit more about that. >> sure. well, first of all, culture starts at the top and there is absolutely no doubt in any organization that the tone that is set and the way it's deliberately carried out every single day in decisions in how leaders respond appropriately to the needs of an organization. as we look at the va and you have again someone who is really running the health system, at least the way we understood it, it run by the undersecretary of health from an operational standpoint. and yet that position has turned over repeatedly.
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so the ability to set that tone and follow through on a whole host of strategic initiatives and making decisions on a daily basis gets cut off. then the next person comes in. and it is very hard for an organization other than to hunker down and sort of wait for the next leader. very hard for an organization to embrace those kinds of changes. the board is, in our view, very important, first of all, a board stands behind that individual and helps them be better. they are there for a broad base of input, expertise, again that level of accountability which has on a more regular, routine and organized basis. so that board is sitting there saying, we thought this was your strategic plan. it is not to usurp congress but it is to get that performance up. congress is ultimately responsible as the power of the purse and all of the other suspects of your authority. but the idea is to bring some health care expertise in and
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other leadership to engage that ceo on a regular basis to make the kind of changes that are necessary. >> thank you. dr. cosgrove, the electronic health records, just what has been the problem within the va in terms of addressing that issue? >> the va started out by developing one of the first and best electronic medical records. and over time, i think they suffered from the same problem that massachusetts general hospital did, johns hopkins, mayo clinic, henry ford, that they could not keep up with the changes that were needed across the organization. so they -- there was -- there are now 130 versions of that electronic medical record across the system. and that has fallen behind in its capabilities and also has not added the sort of capabilities that you now see
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commercially available. this is -- it is time to do the same thing that many other organizations have done and abandon the homemade project simply because there's not enough i.t. expertise within the organization to keep updating it. >> right. well, i want to just echo what every member of this committee has said, which is to thank both of you for really your herculean efforts. my hope is that all of us here are going to be able to see the wisdom of your report and begin to implement it in a way that is not partisan at all because the bottom line is, giving the kind of health care to men and women who serve this country that they deserve. thank you very much. thank you, mr. chairman. >> thank you very much, mr. kaufman, you are recognized. >> thank you, mr. chairman, and thank you bot for your tremendous work on this. just incredibly important. i'm looking at recommendation 10
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when you talk about changing the culture of the va. . it is such a corrosive culture. if we look at the appointment wait time scandal, manipulated to bring them down, by denying veterans care and maintaining a secret waiting list so people could get cash bonuses. number one, nobody was ever prosecuted for that and there was systemic. number two, nobody was even asked to give back their bonus. and so when you have a system where it literally takes an act of god to fire somebody, and where it seems like the only people who are disciplined and fired are the whistle blowers who bring these problems forward. i mean two seem that the root of the problems at the va are -- lie in the culture of the va. i just wonder if you could respond to that and some of the internal discussions maybe you had that aren't necessarily in this report in terms of the
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range of views on your commission. >> well, there's no question the independent assessment report commented significantly on the problems of the culture of the va. i think we felt very strongly that in order to change culture you have to make sure, again, sustainable leadership has to be in place and leadership that people have confidence in that are going to make those tough calls and those decisions that are appropriate. >> but if the leaders -- it become so difficult to get rid of subordinates -- >> i'm not sure i believe that. >> then over time people just don't even try. >> well, that's the problem. people, frankly -- i've seen it in our own organization. people say, well, we can't fire people. i say oh, yes, you can. you have to work at it. you have to make sure that you're going through the appropriate discipline process, that people are given due process, which is important. but that you have to do it. that's about leadership development at all levels. that's not just at the top. that's front line supervisors,
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that's managers, and people that really are going to make those decisions on a daily basis about the quality of their workforce and their decisions and getting it done. >> also seems like the leadership of the va, that leaders when they are responsible don't take responsibility when wrongdoing occurs and are never held accountable. so we're talking about not just the rank and file but we're talking about -- >> but my sense was that a secretary was fired over that. and when that did happen, that's when secretary mcdonald came in. so i think clearly there was a decision made that reflected the seriousness of the problem in phoenix. but i also think people need time to change that culture. >> i think you also have to invest in leadership training and bringing people along. i think it goes into couple categories. i think it goes into the category of experience with
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feedback, which is difficult and painful sometimes to get and to give. and the second thing is they have to have a certain amount of intellectual training that goes with that. and it may fall into the 80-20 or 90-10 leadership. nonetheless, you need an active leadership and training and education program which is not available now. >> i don't know how we ever really have a full discussion about transforming the veterans health care administration when we don't know what their costs are for any given specific procedure. and we have -- as a committee we've requested that. and it is stunning that they either know it and don't want to give it to us, or they don't know it themselves. what do you think the case is? do you think they just don't flow it or do you think they don't want to give it to us? >> my sense is that that needs to change. and, frankly, i think it's been based on a focus on a year by
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year budget process as opposed to, in our world we rely on revenues to set the level of expense so we have a very strong focus on cost. this is a very different model. i think, frankly, it would be helpful to think about how to get that cost focused more directly built into the process of the budget and how they justify expenses. >> i also think there is a matter of collecting the data. and if you don't have the data, you can't understand it. that data includes the severity of the illness, all of that that goes in to determining how much cost per veteran to take care of them. >> thank you, mr. chairman. i yield back. >> thank you, mr. chairman. i, too, want to echo my thanks to both of you. you did exactly what we were hoping would happen in that conference committee when we created the commission of care and the request for it, that you
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would come up with specific recommendations to improve veterans care but you would also help facilitate a national dialogue that was sorely missing in a transformational type of way. i represent the mayo clinic in rochester, minnesota, too. they're, like many of you, will say there are different models. but there are certain fundamentals that are true throughout all these organizations and how they deliver that, educational clinical practice, and that focus on leadership. the one thing that i think is so refreshing about what you came up with, i hit on a couple of those points you brought up, i remember ten years ago asking why we did a quadrennial defense review with an understanding that the world of 1986 looks entirely different than the world of 2016 from a resource allocation perspective to how we would defend this nation and all of that. but never done on the va. so we plodded on year to year, year to year budgets. we actually did something i thought was somewhat innovative and it took a stretch from this
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congress to do advanced appropriations to give a little more continuity to that, to make some decisions like your organizations make decisions. but it challenges us in ways that we haven't been. i also want to thank you. i think you are doing a very good job of stressing this, trying to remove this simplistic argument of public versus private sector or the idea that va health care can be discussed in a vacuum outside of health care in general. this gives us an opportunity to wholistically change the entire system and we know that there are going to be assumptions that maybe don't pan out the way we want. lo and behold we find in the aca a lot of people didn't have health care insurance before like to go to the doctor now and some were sicker than we assumed in some cases. those things have an impact. instead of just fretting or pointing fingers, let's come back and find a workable solution. that's going to challenge all of us. i want to hit on the first one, this one just has me tied in knots, the board of director issue. i absolutely hear where you are
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coming from. if i go to the mayo clinic, they will say, this is a great suggestion. tim, you may have some expertise in geography, china, artillery, but have you ever run a large health operation? as a member of congress it is our job to try to gather an learn as much information and we are ultimately responsible for oversight. there is a real hesitanciy to give away what feels like giving away that authority but the need to put that in there. this has been challenged on the constitutional issue and challenged for all kinds of reasons. how important, if i could ask you, do you believe that mechanism is for transformation? how -- if we're going to fight this fight, it is going to be big. and it is going to be transformational with the big "t." how do you see it, if i asked you, if we do this and you answered a little earlier, do some of these recommendations separately but you really need to look at wholistically, how important prioritized is this board of directors? >> i will tell you that probably of all of the recommendations, this had unanimity among our
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commissioners and i think it was felt to be, if not the most important, one of a very small number of the most important recommendations that we came up with. >> i completely agree. it is a fact that you have over 500 people trying to run the va seems a little more. >> this may be on the achilles heel of democracy that we're responsible to the taxpayers, we ultimately have to do that, giving atwla authoriway that au to a secretary is very, very hard to do. then giving it to another layer in there. but i am with you on this that i am certainly willing to have this discussion. behind you there is a whole room full of folks who have spent decades supporting veterans. they're not in opposition to this. they are there to ask these hard questions about this recommendation, how is it going to impact. but my question to you, too -- i could not agree more, sustainable leadership.
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i've seen it at the macro level and i've seen it at the microlevel. in the va and outside of this. . it is absolutely critical. we have is to restore some trust that people want to go to work there, that it is not this assault on the integrity of everyone's there and to see a unified commitment to getting this. how many of these things do you think should be implemented even if they could be through internal rule making on the executive side? i always make the argument on this that i think we're bet egg off if we do it, we keep responsibility, we have ownership and we have the american people behind us. it takes a while, but do you see that we should just enact some of these and get moving or should we have this national debate and fix it through this way? >> well, i'm not the expert on the rule making at all. but i think that our staff really identified in the report those areas where congress really does need to take action, and those areas we felt could be done within the executive branch. but the truth is i think
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everyone in this room acknowledges, this is a bipartisan issue. these are our veterans. it's critically important that we find a way to deliver better health care and we felt strongly that in the area of leadership and governance that new structures were needed in order to provide that oversight, whether it's the i.t. project. i will tell you, at henry ford, we had a special committee of our board to oversee the implementation of the epic system. and without that i'm not sure we would have done as well. >> well, i thank you for that. i think i echo you, this physician leadership piece i really have buy-in on that. i'm somewhat biased that mayo clinic plucks their leadership from their physicians and that rotates through. that's proven to be a successful model. i yield back. >> thank you, mr. chairman. i would like to thank you and the entire team that worked on this. it was not just you two, as you will acknowledge, as you are shaking your head. obviously our goal was to
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provide care to those in need, for our veterans. one of the things that i've seen that assures our veteran patients as much as anything else is having a primary care doctor they call their own. that's one of the successes that i see. what i do not like is the stigma sometimes that any doctor that's not within those walls is a non-. va doctor. i think we need to change that stigma. there are va doctors just as much as anyone else, that this he are part of a system. dr. rowe referred to that. when it comes to choice, i think we need to embrace greater choice because the decisions on referrals and choices should come between the primary care doctor and the patient. we don't need another layer of bureaucracy of people that don't know the doctor or the patient that decide who you get to go to, where and when. because as you know, making a referral is based on many things in knowing your patient. it has to do with personality sometimes. it has to do with the level of expertise. it has to do with co-morbidities
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and the severity of those quo morbidities and there is no panel that can embrace that. only the primary doctor and the patient. that's the kind of system i think we need. because if i was a patient in that system i would be saying, doctor, are you referring me to this person because you have to, or because it is the best fit for me? that's what we have to open our minds to is having that capability. then it comes to reality. we've got to know the cost and efficiencies of what's taking place. i've said since the day i got here almost four years ago, how much are you spending per unit are you producing? we did have one independent survey here. they said that for a primary care visit, it was between $400 and $600. you can make a pretty good living on the outside $400 to $600 per patient visit. obviously we have to have that type of data to make our decisions. certainly use the example of an
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organ transplant team. not every va should have or can have an organ transplant team. you have to have within the va a system that people can refer to because that's the most efficient, the most effective and the best care. we've heard a lot today. i'm getting to a question. and that is, where do we need to go as far as next moves? i think we all kind of agree that the electronic record is a first move. and along with that, the decision on how we go about handling a board of directors constitutionally or otherwise. so beyond those two, what would you say would be the next move where we can weigh in and have some impact on the next move in bettering our situation? >> we may have different points of view on this. i would say the personnel system itself. one of the critical elements is attracting talent. there is still a lot of openings within the va system in all types of jobs, whether it's leadership or front line or
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physicians. and i think that looking at how to create a more organized system that ensures that in all positions there is an ability to attract that talent. i actually think that with that, va would do a much better job attracting talent across the country, because there are many people, including some at henry ford, that have gone to work for the va because they want to help veterans. i think that if they felt that this system were more efficient and effective, they'd be there. >> i think you clearly need that. but i think ultimately at the end of the day cl, it is about people that make it work. it is not about bricks and mortar changing the culture. that's going to require sustainability at the leadership and a sustained push at changing the culture of the organization. the focus clearly has to be

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