tv Key Capitol Hill Hearings CSPAN September 7, 2016 9:00pm-12:01am EDT
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thcora, grt net thpuicccinto fl rae vwsei pseed onhathcoison t y. bui ulli tmo o >>ilthgelen elon atarcur su 'llie oth ptila ise. >> ctie wt r reesby ve t jotyf e notyor th ptilawiesofhi weavnoreiv a ath ti iyogeth ve, llchulanheheinat thple d mef e a's oong wl, tnkouorha r ncn t pcend meweopth wcod t a tiacryla a te, but i think - >> how about october? i'm just kidding. [laughter] >> but i do want to -- i do want to comment on the issue of the va's response on the aurora 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 con 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. 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 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. >> 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 -- 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 - >> 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 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 attachment 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
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. 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 acss to carend howest 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 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 chrm a wl,'su, ntueo ove is mmteasonesmos rwd senhethv. ce st f fur netis ari'hees 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 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 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, reviewineligibity for ca 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 acaucracy carries 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 debt that our nation owes to her veteranicize a dentbt 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 departments meetg its most importanmissio an that iproviding 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 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 vera hltca cic premt t 25 qued thv. tco uwi ala toonlitellarinhe couny ogms no t cmiioonarha leedn coentis r
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has not been looked at in many years and probably would be worthy of taking a look. of everytive commissioner throughout this process has been that our report would not sit on a shelf and in fact it would be implemented. we ask for your help today to report come to life. we are asking to address the fundamental weaknesses in vha governance and to provide dna more flexibility in meeting its capital asset and other needs, including establishing a capital asset realignment process modeled on the dod brak process. waiting or suspending the authorization scorekeeping process governing medical facility leases, lifting the statutory threshold of what major medical
facility project, reinstating broad authority for vha to inter-into enhanced use leases and easing for a time limit otherwise applicable constraints on divestiture vha buildings in establishing a line item for funding and authorizing 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 class governance structure as ill-equipped to carry a successfully the kind of long-term success required to reinvigorate v.a. health care. leadership and strategic vision can i be insured under governance framework marked by frequent turnover of senior leadership and near constant focus. the commission believes two fundamental governance changes
were needed -- establishment of a board of directors with authority to direct the transformation process and change in the process for the appointment for an tenure of the official currently designated as the under secretary for health. we are mindful that some of our recommendations have significant cost of locations and we work with health economist in modeling different options. implicit in our discussion has been the question -- should the nation invest either in v.a. ? alth care system our report answers the question in the affirmative even as it underscores the need for sweeping change in that system. we do not suggest that congress has not already made very substantial investments in the 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 to the way toward meeting the central challenge congress identified in 2014 -- improved access to care while offering a vision that would expand choice, improve care quality, 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 received while strengthening the system and providing increased transparency and accountability. in my view, this is a mission that merits your support. i would be 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 .uestions thank you. >> thank you very much. dr. cosgrove, you are recognized. dr. cosgrove: thank you for inviting me to speak about the us finaln on care 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 care and as a member of my v.a. advisory committee. over the course of my work with the v.a., i've become well acquainted with the department
and understand its contributions as well as it's challenges in meeting our veterans' needs. an $8 billion health care system serving communities across the country, i'm keenly aware of the challenges facing v.a. health care system leaders. mr. chairman, the veterans health care system must make transformative changes to the health care needs of veterans today and tomorrow. if these changes are not made, the 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 for specific areas that include the establishment of an integrated community-based health system
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 greater 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. many would provide veterans with still greater choice of private sector providers. the commission agreed that the establish high-performing, integrated community-based health care networks to provide timely and quality care to our veterans.
the reported visions and continued role for the vha health care system, but if the challenges and opportunities described in the final report are left unaddressed, we are concerned our veterans will see 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. will alsohelp, but it take significant investments in time, effort, and resources to modernize and streamline such essential as human capital management, capital asset as thisnt, and leasing, process is, and information technology. the commission recommended that should implement core metrics that are identical to those used in the private sector. veterans deserve to know that the health care they are
receiving either from the vha or health care provider is of high quality. put ine metrics are place, it will be easier to monitor performance and congress will have a benchmark from congress to comparable progress and improvement over time. congress and the american people deserve to know the vha is getting value or their investment. years ago, the vha was a leader in the field of electronic health records. unfortunately, this is no longer the case. the commission believes 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 building problems with the resolved. further, these systems could help the v.a. identify areas of opportunity and utilization to to carebetter access
for our veterans and promote interoperability, which is critical as our veterans move to different care sites. finally, the commercial electronic health record would financial and clinical information, a critical functionality are running a modern health care delivery is them -- system. the best and most prevalent health record programs allow staff and patients to schedule patient care easily and provide legitimate performance measures for wait times, unit cost, clinical care outcomes, and productivity that conform to healthf the rest of the care industry. many of our country's best hospital systems have converted homegrown information systems 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 information needs as the health care industry evolves.-- devolves -- cleveland clinic has experienced firsthand the burdensome system in place to receive heymans. we are required to provide documentation and hardcopy forms sent via the postal services as they cannot accept fax, e-mail, or other electronic submissions. results in more than 100 pages, we must burn the records to a disk because we do not have any mechanism to track if the documentation has been received, we have heard on many occasions that they never received paper records, and we have no recourse other than to and then again. the independent assessment that
congress commission found that vha should keep claims, education, and payment effort from its care delivery. the health care system 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. is another area for vha streamlining. purchasing processes are cumbersome, which has driven daft to workarounds and anderbates the variation 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. to has enough market share leverage prices that could result in savings of hundreds of millions of dollars. at the cleveland clinic, we are
constantly evaluating and reviewing our supply chain products and processes. today, our supply chain is working with teams of clinicians, you led by a physician's champion to justify purchases of more expensive supplies by engaging clinical staff in the value-based sourcing ever that illustrate that cost and quality do not have to be mutually exclusive. clinicians are made aware of the cost, and outcomes are associated different brands. the the clinical staff has justify the higher cost, outcomes based on an empirical evidence, they make purchasing decisions based on value. such efforts are then integrated into patient centric utilization management and inventory management efforts to ensure the appropriate use of our resources. clinician engaged value-based supply chain management practice model has allowed us to save $247 million over the last several years.
to reform ouring process by entering into purchasing consortium with other nonprofit health care dividers and ensuring that we are continually searching or cost management. of course, leadership is a key 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 capable of leaders taking the vha to the next level. the commission also proposes that congress provide vha governance board to provide a long-term strategic vision and successfully drive the process. both the chairperson and i would be happy to talk about this aspect of the report. mr. chairman, transforming a system is large and as complex will require streamlining
multiple services, redesigning care delivery, and more. this for or offers a roadmap to success. realizing the vision of the report proposes will require new investments, both financial and head ofe, and that legislation and strong leadership. thank you for your attention, and i'm happy to address questions. chairman miller: thank you very much, doctor. we appreciate you both being here. for either of you that would question, dor this you agree with the president and the secretaries who have stated that any of the commission's recommendations are already being lamented the of the my v.a. initiative -- being v.a.mented via the my initiative? it's difficult: for us to evaluate that because we are not within that structure at this point, but in terms of strategies and instruction,
there are many areas that are alive, but it's hard to understand than that -- do they have all the land that would allow that to be executed? those are the questions i would have. dr. cosgrove: i don't think we could know exactly. for example, electronic medical records -- we do not know if they have proceeded to purchase an off-the-shelf electronic medical record or not, which i think is absolutely imperative. neither do we.: we are still trying to find that question out also. this is something that probably touch,embers will not but i will since i am retiring at the end of this term. what do you think the biggest like process brak- would be within the vha and also what do you think the big impediment would be? ms. schlichting: just a couple of comments on the facility challenge that the a -- that at thes, when we looked
v.a. facilities across the country, the average age of physical plant is about 50 years. of henry comparison ford, that's nine years at across the country it is around 10. the issues that the a will face over time in terms of their facilities and also the fact that they are very inpatient oriented today as opposed to more outpatient focused our really significant, so we think that it can provide some howctive view and input on exactly the vha facility networks are performing today, where the problems are, and where change in to occur. it also could provide, much as it did during the military closures, 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 do not wish it on anyone. it is a very challenging thing to do, particularly for members of congress who are concerned
about job loss communities that might happen. the opportunity in health care is different. there is no substitute, so the opportunity for jobs to be preserved in communities through more partnership with private sector exists, and also the evaluation of other capacity within that community could serve veterans better with lower-cost long-term, so it is with that in mind that we really believe this would help the process. i would add to that that i also have closed two hospitals and realize how difficult that is and how it is as a entangled decision making. also, i think there are over 220 facilities right now that are not in use and have not in orher sold or abandoned begun to be taken down because it has been unable to get that accomplished through the current system. chairman miller: one final thing
-- there was a statement made in the letter to the president regarding the final report that indicated that v.a. is not in favor of eliminating current program choice restrictions by mileage criteria and the time restriction of 30 days because they do not -- they desire not v.a.'s statutory missions. i know the report called for total elimination of the mileage and time requirement. i would like to ask if you could address why you went further. know,hlichting: as you choice was a very difficult discussion among the commissioners because we had wide-ranging views around choice. 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, choice was too broad, but what we did do is believe those limitations unduey cases were causing
problems for veterans, and often times, the timing involved of even being able to set some of those limitations caused access issues. we felt that we were airing on of thee of choice primary care provider and also strengthening the v.a. pus control of those networks. it v.a. could set of those networks in a way that created the right capacity, the right access without endangering the continue theirto important mission, that was what we were trying to find. we were trying to find that sweet spot between choice and the issues of maintaining a system that is critically important. go ahead ander: yield to mr. takata for his questions. takata: thank you. many of the national veterans service organizations are troubled by recommendation one. they are concerned that if choice is a core policy, it
could lead to a large percentage of veterans to pursue more conveniently located community care, which 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 and test how this concern may play out yahoo! why did you not recommend pilot testing such a radical change? we did talk ag: lot about how to roll this out and felt a phased approach was important, and many thatssioners spoke to issue. the execution implementation is very complex, and it will take time and will require, much as any major change does, testing and refining and continuing to tweak this, but i think on the choice issue, it is important to balance the question of choice and making sure access is really
available within every market across the country with the issue of how we are trying to also control, frankly, those networks to better serve veterans. it's really finding that balance that i think is really important. the commission guiding principles call for the recommendation to be data driven. what data do the commission rely on on recommending that the v.a. health care system should be organized around the principle that veterans should be able to choose to receive care from a community provider even with the v.a. can provide a better and timely care in a reasonable proximity to the veterans home? if you begin to think of the vha care system in the way we did, it's not a question of the v.a. versus provider in the community, it's one system that should be operating in a much more integrated way, and every provider within that vha care system then would he able to provide access for veterans.
it is a different mindset than today, and i also think should be balanced against all the investments and improving operations we are recommending within the vha. vha health care is necessarily very transparent when it comes to wait times and outcomes. how are wait times measured? wait timest publicly? if not, why not? we actually do: now. we had an electronic system where people can call into 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 believe same-day access, not only for primary care of a specialty care, is a standard we are setting for our health care system. dr. cosgrove: 10 years ago, we instituted same-day access. we now seek 1.2 million same-day
froms and the wait time is door to dr., 10 minutes -- we same-day.2 million access. takano: would you suggest they be held to the same weight care rules as the v.a.? ms. schlichting: yes. dr. cosgrove: yes. i concern it is financially unsupportable and .ight weaken the v.a.'s system did the commission look at the cost of these recommendations and how this might affect research and education missions the v.a. conducts for the good of the mission? at schlichting: we did look costs, and we have included estimates and our report about what we think that would mean. there are certain assumptions as you go into these cost estimates that are based on certain
assumptions that may or may not actually come true, and part of the question is how rapidly some of the improvements in operations to improve access .ithin v.a. can be put in place it is quite conceivable that more patients would gravitate to v.a. for many reasons as opposed to always assuming they will go in the private sector. it is not as clear as some people would like it to same. dr. cosgrove: i would point out on that last point there are a number of veterans who currently do not get their care from the v.a. if the v.a. improved its access and its ability to care for them, they would migrate. this 22 million veterans across the united states. only 6 million get some care from the v.a., so those are very difficult to project. thank you. my time is up. chairman miller: mr. lamborn, your recognized for five
minutes. i want to thank the chair and vice chair for appearing before us today and for the effort they have put into this report. we had two main challenges as i see it. first, how do we at least ensure we take what is 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 may be an even harder challenge -- to evaluate if 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 remember the managerial failures of 2014 that came to light, the inconsistent care, the manipulated data and other manifestations of dysfunction. we also remember the words of
the independent assessment in 2015 which found that the vha's systematic problems demanded "far-reaching and complex changes that when taken together amount to no less than a vha."wide reworking of so when will we have a systemwide reworking of the vha? veterans in my congressional district, and i will say that the calls they are giving complaining about v.a. service had not diminished and are about the same as it was a couple of years ago before we v.a. triedke and the to make some changes. they don't believe that things have substantially changed for the better. mr. chairman, i ask unanimous consent that the commission report dissent be entered into the record. chairman miller: without objection.
mr. lamborn: that's one perspective i think we should look at on an opportunity for transformation. dr. cause well, i would like to ask you about the quality of the a health care. according to the report "care delivered by however, the independent assessment found, quote, on most major veteran reported experience of care in veteran hospals we worse tha paent-rerted expernces i 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 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 cases 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 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 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 need 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 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 cseusn rmofovg d. waedo k,ouno a rypefiquti rate t rorbeusit rtnlafctmyisic mcotyhai've cse t l. dil city st.amecafali, icis he cityan anyo m cirn,or urearsp min
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e mmtemeer th iprab t mt imrtt ecofori' se imylmt ghyes he ithcore trely ma aifree wca implemt this duringhe conventn, insad of snding mostf my te 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. what i've heard so far. one, i believe to move this system forward we need an integrated care model that 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 night -- 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. that solves your supply chain. all those things -- helps -- that doesn't totally solve it
but help solve it. 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 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 ba. 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 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? >> you know, i think leaders get better over time. ofrecommended the idea five-year terms for leadership. having the individual selected by the board of directors so that process can move forward and that individual feels the support of a group of people
that is really trying to move transformation forward. i recognize that that may be unconstitutional. there may be ways around that that can help with oversight. >> that hasn't stopped us from doing a lot of the consultation. [laughter] i think this is a remarkable document. i think 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 received. >> 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 a decision on vhr. i 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 we have -- and many people around the country have learned that you can't maintain a electronic medical record in an individual's facilities -- 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. >> mr. o'rourke, you're recognized. >> 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 which you conducted the review
and made the recommendations. so just want to add my thanks to all my colleagues. i'd i'd like you to discuss what i think is the most pressing crisis facing our veterans and the v.a.. 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 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 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. 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
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 regioning enough 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 both found those to be very useful >> i think as long as we . >> i think as long as we can prioritize that excellent in care around those conditions,
especially those that could 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 on higher 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, 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. comment and how critical that is for transforming the v.a.. the political appointee at the head, but having a board of directors like a regular hospital. like a regular system that people are on the board. the continuity of care over a amount of time so be think can develop. that is critical. it will behoove 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 yea othsa inw'veeedog w. thk a's e ital kewafr ts ry poancoisonwo. d e inth yai d coro t oerhi iak aw, t ctil edor i. st tt kesee. ats uresmo oth twofou adsh a t iedte ti oan.tysmhi relya't cng. ju wt bngp quti tt wa bs . wh y eime e stf plennghe tng h d u titeheosofhe v. ce? cae ene y fur ouwh t visctll-- wh iacal ctshea sea tit,n e ive seore owhaitos t e paen
hodiyoesma tt? l mju s tt e e in ihi tt obly ru a oushaarinhe hetharinst w h lileoc oco vha th w st sckg beusweivin wldhe he csttlfos co p ut svi, st foa llpidef reve ti, eangopatn al name tuesohawe ft n deta ct d etr ' ctrutg vae d premtsn quit d atoe'ext da wiin bgeornt v st. thk a's e t alng aweood ts co qstn h wmo rwd. thk e inth pbay shldavbe ithrert th wn'wath nioof geinmo ct ieedn rmofomofheetcs >>y usatn res,ha do ico f t vtoee
tit? the ncl. >>ndn ctifouooat thmol d a's anngn hethartoy,e' gti ayrothvomerite ki o msus. reocinonutmeof re clic rul awes e mina ffen ites ofus t eicncofar th wprid iss rtf e trsfmaonndr. cgre sh hd ts,owo geetcshaarmo coarleo ate cee thefctens t ste ov te. wodddweou dthn fas,he a ws tt mefhi "lk t ct emtsha cod pjeedutveim soouaneay e. e hethgs e su arndacits. a t filiehatoe pleders adg ingredod, ers lo
ofotti ct vis er mehawod lp henlthg rtr wa uofipthstus e , w e mbi mpin ith wki er iavve ltlint aso w in wkeiny clicr minsu tt in a iffiely itee le he w we't al iold t pie reermangheecio thomastf he,ow me e affl. tit owndllha i inth wldomwi t leeriphaes anotr mmtsouou li tma? >>ea i st th y nd bng phicnsorin ery asctf liri ce d nng e gazaon ga t emp opuhang priolyhycis reot voedn at fndrends fienes
bngg emn. d tht voinphicns inearsp t orniti, thk u' miinanntle a aet ofnoed tt nesry toavhi-qli orniti. tnkouermu f yr wo a iisp utoet th sw t rd. >> tnkou >>ha y, aian ou eheonofouan bseety t v b y an? ju o ocuosy. aute >> h tt pouny. iq >>o ju wt eo me ofheomntmro'ur ma. reny d verata hiowli ithpainlo ofheor pt wchs stbi. ioun'age reit .r 'roke
outh bnguca p iotyorhea hdl al tal aeehath o su ites cotali a t econ hltsyem cos st, e ital imrtt. me eryine arg at weav t nbeonise aclist t eros trti pjes.stonnd y cldusadesth whsuofowouou ea aorefcte erch thbod decr,owou eye os? y y s tt e deecta oheth poti sulbenehaha fid meim vsuth seety,omneimaro e adf e a d e i. y cldusta me outh. bau tme -- mn d't owf at lleto annghe
unrlngulref e thsas eloeshore unr e craranth deecta. t y cldusta a tt b me outh. >>ir oal ctu srt t t. dhe'ablulyo ub innyrgizioth t to iet trendheays bey rrdutve sgl daandesindowears spdeprer tthnes aorniti. wlo athvandou vega seo w irely nng e al ste a let e y uerooit isuny e deecta o heth fm oraon stdpnt d t atosiohatued ereptey. thabit tseth tn d ll tou oa olho of satic itiiv a mangecio oa il bas tsutff
th t nt rs cesn. anits ryarfoan orniti oerhato nk dn d rtf itor thne lde ve hd r oanatn emacthe ofhaes thbod , o vw,er imrtt,ir oal aoa an binth iivua d lpth bbeer eyrehe f aro be iutexrte,ga tt veofccntily ic pps aorrela ute d gazebas. sohabod sti tre sangwehohthiwayo sttec an its t urponesbu its g tt rfma . ngsss tite spsie t perf e rsanalofheth sptsf urutri. t e eas bngom al ce peisinnd heleeripo ga tt o aegaras tma e ndf ans atren cear >> tnkou
. sgvetheltric alecdswh h bn e obm th t vin tes areinth iue t vstteouby delongnef e rsan be ectnimecarerd anov te, tnkhe suer fm e meroem th msaustsenal hoit d, hnhoin yolic,en fd,ha th cldoteeupitth chgeth we ed aos e gazaon the e w 0 rsnsf atroc dil co ro t ste anth h flebendn itcabiti a ao s noadd e rtf cabiti tt u w e mmcilyvaab iti tdoamthg atanotr gazaon veonanabdoth
homa pje splbeus t'no eugi. peis whith orniti tke uatg . ig. lli nto stchwh ermeerf isomtt s idwhh tthk th y f rllyo hcuan fos. myopishaalofs re argog bab tseth wiomf urept d gi ilet aayhais nopais aalbeusth tt le , vi t kd ofeah reo n d me whsee isouryhath derv anyove mh. ha y. mrkama yr coiz. >> tnkou thk u thorou trenusoronhi inedlympta. i'loinatecmeatn wh y tk ouchgi t cuurofhea.
its ch croveulre wlo athapinen wa te anl,anuled bnghedo, dyi tensaranmataina cr wti lt ppl ulgeca bus. mb o, bo w er osut f tt and ther wasyem. mb t, bo w en ketoivba tiron. ansoheyoha aysm whe lerlyak aac g tfi seby,nd eritee le e ly op w a dciin a rearthwhtlbler whbrg esprle rwd. itou sm at t rt th pbls t b-- l i thcuurofhea. i stonr y cld reontohaanso oth inrn dcuio mbeou hath an'nessilin isept tmsf e ngofie oyo coison > ll the'noueioth
inpeenasssntept coend gnictlonhe prle othcuurofhe ba i inweelve sony th iorr cngcuur u veo keur ain stnae adsh h tbe pcendearsp at op he nfen ith argog me ostoh llanthe cionth e pre. >>utf e ads i bemeo ffultoetid sornas. 'm t re feeeewhe c' op, u veo rkt . u veo keury're inthapopatdiipne ocsndeoe e vedu preswhh iornt yoha tdot. atsbo ldehi deloenatllevs. ats t stt e p. th ifrtle peiss, mage a pplth rll e gngo kehidesis a dlyas authe aly tir wkfcend eidesis d ttg
ne >>lsses kehe leeripf e , at leerwh ty e reonbld't ke reonbityhewrgdng cu a a nerel acunbl soe' tki autotus e nkndilbuw're tainbo - >bumyen s at sreryasir ov tt. d enhadihaenth' enecta mond men. so tnklelyhe w a desi me atefct t risns t pbl i phni t al tnkeoe ed ti tchgehacuur ihi y ao veo ve ileeriprain anbrgi pplalg. i initoein cpl teri. thk gs tohe teryf peen wh feba, icisifcu a pafusotis g a t ve anthsendhi ith veo ve cta aunof inlltu ting atoe wi tt.
d m fl tohe 020 or900 adsh. neels,oueeancte adsh a ting d edatn ogm icisot exte rhtow >> d'kn h wev al he fu dcuio abt anorngheetan hetharadniraonhe d'kn wt eicos e r y vespif ocur d he aa mmte ' rueedha an d istni tt ey th kw a d'wa t vet u oth d' owt emlv. atouhi t ce ? y tnkheju d' fl ioro u inth n'wa tgi itos?> msee tt atee tohae. d,ralyi ini's en bad aoc oa ary arudt ocs oos toinuror wre o renu tsethlel exnssove vy ro
cuonos th ia iss ve dfentod. thk,ralyitou b hefutohi autowo geth ct cud re dict bltntthpres t bgeanhoth juifexns. maerf llti t da. d y d'ha t da, u n'unrsndt. th da clesheevit ofhellssalofhath esn derni h mh steretano kearof th. >>ha y, . aian i elba. ha y. urecnid. ito wt eo thkso thf u. u d acy ate re pi wldapn tt nfen cmieehewe ead e mmsi oca d e qut r , atou ulcowi scic coentis iro tensarbuyowod so lpacite naon aluehawasolyisng
arafoatnaty o wa reest e yolic roesr,inso, o. e'reli my y, ll y erardiert de. buthe e rtn ndenlshaartr thugutllhe ornitis d w ey deveth, uciol clic pcte,ndha fos ldehi th onthg at tnks reesngbo wt u me upit iitn colef the in y bug u i remb t yrsgoskg whweid qdrni den reewitanndstdi atheor o19 lks enre dfenthath wod 26 om roue loti pspti thowe uldendhinaonndll tt. t vedo othva soe odd yr yr, aro arudts e thghwasowh ioviv d tk sttcfr ts ngsso aand
apopatnso ve ltl mo ctiittoha tma so disnsikyo ornitis keecio. t cllgeusn ys th whan'be. al wt tnkou i inyoardog ve go j ostssg is trngo mo ts mpst armepuicers pratseorr e eaha vaeah reane scse aacm tse hlt ca igera th gess oorni t oltillchgehente syemnde owhathe e intoe sutis at mae n'paouthwawe nt a bolweininheca a t ppldi'ha hetharinrae fo li tgoo e ct n a meersierhawessed se se std jt etngr std jt etngr e in he d iac poti fge, t'co ckndina rkle luon th'gog cllgellf . wa thionheir o, th o jt s td
kns,heoa odict ise. ablulyeawhe u e mi fm. io t mo in, ey wi s, iss grt ggti. m,ouayavso eerse ggrhycha,rtle, t veouverua rg alpeti? aemr cgrs i r b t tgaern len mh foatn d e tite rpoib f ergh the aeahetaiyo gi ay atee le vi ayhaauory t e ed touthainhe. isaseechleedn e cotitialss a alng f a kdsf reon hoimrtt,f cod k u,o u lie at chisisorrafoatn? hihaunimy onou coisons. inoaseltoe thmo iorntonofhe
stmptaecmeatns ate mep th >> cplelage. ia cthayoha or 0 op tintounhea ema ttor--uc >>himaben e hies he odecry ate' reonbltoheaxye, ulmalyavtoo at gingwath ahotyev toecta, vy rdo . enivg tanhelar ye--n er bui wh u ts at amerin wli tha isisssn. hi y tres whe om fu ofos o vepe dedesuorngetan th' n iopsiono th. th a treo k esha qutis outh remmdaonhoist in iac bumyueiotoouto-- cod t remo, stnae adsh. i' sn athmao ve ani' sn ath crlel.
t vanouidofhi iablulyrica weaviso ste meru th pplwa tgoo rk er tt inoth sat t iegtyf ern's erantoee uniecoitnto ttg th. w nyf esthgso u inshlde plend en ifhecod tou inrn re ki oth exute de i wa me e guntn ishai inw'reetgg f ie i wke reonbityweav owrsp d he e amic pplbends. tes wlebudoouee th wshldusent me ofhe a g minor shlde vehinaon detendixt roh is wa >>el 'm t e pe o thru minatll t thk aturta al intieinheept osars ercore relyoene tta aio anthe eaweelcod neitn e eciv an. t e utis tnk evyo ith rm acowdg, iss birtanss. tse arouvera. 's
ital iornthawe nd w tdevebeer al ce d ft roly th ithar oleerip d vean tt w ruur we ed iorr pvi tt ergh whhei's e t. pje. i llelyo ahey rd wead sci cmieef oubod ors t imemtaonf e ic st. >>el iha y f tt. i ini hoouth phicn adsh pce al he y- oth. 'm meatiad atay in pckthr adsh omhe psiananth tas roh. a's ov tbe scefu mol. i elba. tnkou wod keo kehe- thk e tieahaha woedn is itasotusyoto obouy r alaso ove reo osinee foouvera. e t tngth 'veee th aur o ver
paen amu aanhi el ihang pma ce ct ty llhe o. a's e t sceesha i e. at dnoli ithstma memeth a dtoth' nowiinho wlss n-ten ct. inweeetohae at ig. erarvaocrsusas chs yo ee,hath a pt aysm. wh icos cic ihi weeetombcereer chceecseheecio o rerrs d ois ou co bwe t pma ce ct a t pie. d'ne ath lerf recry pplth d' kn t dtoorheatnt th didwhyogetoo towhe d en cae y kw,akg feals seonanthgs kwi yr tit. itaso wh rsaly sotis. itaso wh e veof exrte. itaso wh -mbiti
d e vetyf osqu moidieanthe n neth c era tt. on t pma dtoanth tit. a's e ndf st i inweee beusif w aatntn th stei ulbeayg, ct, e u feinmeo th psobeusyoha t bau iisheesfi r ? th'wh wha top o ndtos vi tt cabity w'veoto owheosan efcici owh'tang ke-akg ac i' sd ncthdai t he aosfo yrsgoho chreoupeinpeun aryoprucg? d he e dendt sueyer th sd ator pma reis, w bwe $0 anyocama arey od 00 lingn e tse 00o $6 p pie vit obouy he he at ty oda tma o desis. rtnlusthexplofn orn anla tm.
noevy sulha oca ha aorn anla tm. u veo veitn e a syemhapeleanef t beusth'thmo efcit,heosefcte d tt t bt re 'geinto qstn. d ats,he dweeeto afaasexmos? tnk wellinofgr tt e econ roris fst ve analg thha t cionn w gabt ndng brdf reor nstuonlyr heis bonthe o,hawod u y ulbeheexmo whe c wghn d ve so iaconheexmo i beer in our situation? >>e y vere pnt of view on this. i i would say the personnel system itlf one ofcaelen i jo tneonk oongt n
sothgs res e in e eyru cpabl kn y dthe trs. ei ideoi wli i a rlofryg talysav reonwhouda lks rs d t n tha tse cus. th wclrlbeevth a stteeso pre reve wh wha aou cicomigrp ppl wi pr al cdion weer ama my ornitis aotf vera tt n'se ce wiinhe v.. so tnke' g trely dre wa tsein o meicth ph ia dictn mh gh peornc ayokn, mpinthva pva stoca ino aaicoaron foinan, e mt cu fer hinanfing acceth aoworai
wh innnc s wlde spki, erwaanudle sp anth wd plse ixtor. feyes o,e ban inti aia othbeh r ffefctnso e tengla. itas bn rerkle oprtitfoou sdes yombk yr ga edatn lteo d ar fr seo wsearr s ap taw byttdi grgow l, u vehon tlen e w d e acwhe wsread peereveninhe toelmeoufit ur udts juicsomar s r rs spke sves a, ste spe tomg as la yr,heatjuic
hewo aandvatfo geerquit shwod veeea stic gu ut e d vebe a dg veifheadev bn jue. noon skere jgend ste,hes firef sticmptae aawr. are to juic aulraic. aulraic. homa ousan s tt ve sped o a ora o longoo? [lghr] no athnono noris r g ste nsrgs spia meerf r mmit tased w a x ofsoansclaat orto l f my yrs he presrsp h
hor. hepeleo ins re a jti gsbg thiz bgrhe. eyreo-thsitjuic gibu ohe bk,y n wos wchilbe read tor anth a mbe oth falt e ste aonim suorr o we's w d puoly llsh prra ery yr vis fflo tth crt coerti. 'm rtully gtel tt he en ftuteo ar eusce tou udtsndlui d ful coen oasns i llevort,woea aginhioo jti gibupo tthgruang as wi nerort at nvsaon i lllsner fgeth sten wri a norusur
t uveitofirni li uitsyemwi whh t crts re filr chs osinew yk d sid he, eris n ho cpu the'nlthunertyf rgia rtrnt spsecoum m wke, t wagl tha t era da t austhcot' inn myin dftasor rssi tnktousce al'seincricm. ater wteorheou decveascaa sst, e jotypionltaty leedaslendor coinnghamynial rcatn. juicsciaon ionll t st stsndneiz cr'stn is
e a h hba sared wh ty saredsay s hiusdyecsehe waofenr yrs thnuurg ce, ed tt ref e th. wh aoyeaes5, sul beusstyi. w ndso ppad r m's rl llthghth w a rrlede out eatr ulbe bainueen e n. dl s w rht e y s velyepss. e y,oo o o ohi fae's nyunancoitd ice. llwaedo aoied adnirar aouon fah. at shppedir ithfoer sbd pld colef eklar.
h anamo -ig yehenamo disn. stf e stesai t dirinaonegs thhe maasag, e yshe meocl cuty tha me p b tt n n cod is- fildo n geth se net. mehohtt s scmiti ain t ml dart cae wldot vehehoe psoll ri f t cld bam ae o te ieuscejuicehui heaith iartry om e inofiefothba. quti t by vehe oprtitfothca oth so sving penifhe re ieme b n me e re ml? th