DEPARTMENT OF VETERANS AFFAIRS Washington DC 20420 February 3, 2020 In Reply Refer To: 001B FOIA Request: 19-09094-F Austin R. Evers Executive Director American Oversight foia@americanoversight.org Dear Mr. Evers: This is the Fourth Initial Partial Initial Agency Decision (IAD) to your Freedom of Information Act (FOIA) request to the Office of the Secretary, U.S. Dept. of Veterans Affairs (OSVA) dated July 11, 2019, referred to this FOIA office on July 2, 2019, and assigned FOIA tracking number 1909094-F. You requested, as you phrase it: “All emails sent or received by former Secretary David Shulkin or former Chief of Staff and Acting Secretary Peter O’Rourke on any personal, non-governmental, or nonofficial email account regarding official agency business. [...] Please provide all responsive records from November 9, 2016, through March 28, 2018.” Fourth Partial IAD & Reasonable Searches Dated 8/2/19 On August 2, 2019, OSVA received approximately twenty-two thousand (22,000) pages of emails from David Shulkin working on VA business on his aol.com and gmail.com email addresses. OSVA now releases to you one thousand nine hundred fifty-four (1,954) pages, Bates-numbered 1659-3638. OSVA releases partial email addresses of Laurie Perlmutter (lperl), Marc Sherman (mbs), Bruce Moskowitz (brucem), whereas redacting their email addresses would not identify them as the recipients or senders. OSVA releases the names of Marc Sherman’s associates Michael Zinner, Terry Fadem, and Clifford Ko, as well as Perlmutter associate Marisol Garcia. OSVA releases names of RFP panelists Amy Cooper, Stan Huff, Stephanie Reel, Jon Manis, Karson, Ed Marx, Frank Opelka, Aneesh Chopra, Cris Ross, Carla Smith, Ryan Howells, Paul Sutton, and Kenneth Mandi. VA elects to release the names and VA contact information of VA Senior Executives. VA also releases photographs of the VA Secretary, as well as public photographs. After reviewing the one thousand nine hundred fifty-four (1,954) pages, Bates-numbered 16593638, OSVA redacts some information with FOIA Exemptions 4, 5, and 6. 5 U.S.C. § 552(b)(4) exempts from disclosure “trade secrets and commercial or financial information obtained from a person and privileged or confidential.” “Where commercial or financial information is both customarily and actually treated as private by its owner and provided to the government under an assurance of privacy, the information is “confidential” within Exemption 4’s meaning.” Food Marketing Inst. v. Argus Media, No. 18-481, at *2 (U.S. June 24, 2019). Redacted information includes details of a contractor deliverable for the government, proposals, proposed technical approaches, proposed solutions, teaming or partnership agreements, and assessment methodology. Contractors typically treat such as commercially private information or having received an assurance of privacy from the VA. Austin Evers Page 2 February 3, 2020 Exemption 5 protects interagency or intra-agency memorandums or letters that would not be available by law to a party other than an agency in litigation with the agency. For information on five (5) pages, VA redacts communications between the VA and the President’s advisers. The presidential communications privilege protects agency communications to or from the President or his advisers. Loving v. DOD, 550 F.3d 32, 37-38 (D.C. Cir. 2008) (Exemption 5 "incorporates" Presidential Communications Privilege, which protects "'communications directly involving and documents actually viewed by the President,' as well as documents 'solicited and received' by the President or his 'immediate White House advisers'" (internal citations omitted)); Berman v. CIA, 378 F. Supp. 2d 1209, 1219-20 (E.D. Cal. 2005) (same), aff'd on other grounds, 501 F.3d 1136 (9th Cir. 2007); Judicial Watch, Inc. v. DOJ, 365 F.3d 1108, 1110 n.1 (D.C. Cir. 2004) ("embrac[ing] the definitional analysis set forth" in In re Sealed Case, 121 F.3d 729, 74950, 752 (D.C. Cir. 1997), protecting documents covered by Presidential Communications Privilege); Amnesty Int'l USA v. CIA, 728 F. Supp. 2d 479, 522 (S.D.N.Y. 2010) ("all twenty documents reflect or memorialize communications between senior presidential advisers and other United States government officials and are therefore properly withheld"). Out of the four thousand one hundred fifty-two (4,152) pages released to you, OSVA redacted information per the presidential communications privilege on only twenty-one (21) pages. FOIA Exemption 5 also permits an agency to withhold material reflecting the thoughts, opinions, and recommendations of federal officials reviewing an issue. Under the deliberative process privilege and FOIA Exemption 5, OSVA redacts internal government deliberations, thoughts, opinions, recommendations, and solutions from federal employees reviewing in their professional capacities: VA programs, potential responses to news or Congressional inquiries, talking points, a proposed Executive Order, and unsubstantiated allegations. The information contained in the responsive records is both predecisional and deliberative because it reflects preliminary opinions, proposed solutions, recommendations, potential responses to news or Congressional inquiries, talking points, a proposed Executive Order, and unsubstantiated allegations, which do not reflect VA's final decision. Exposure of premature discussions before a final decision is made could create undue public confusion. The release of the redacted information would negatively impact the ability of federal employees to openly and frankly consider issues amongst themselves when deliberating, discussing, reviewing, proposing changes to, and making recommendations on: VA programs, potential responses to news inquiries, talking points, a proposed Executive Order, or unsubstantiated allegations. The information reveals the thoughts, deliberations, and opinions that, if released, would have a chilling effect on the ability of federal officials to discuss, opine, recommend or be forthcoming about the agency’s issues which require full and frank assessment. Here, the disclosure of the withheld information is likely to compromise the integrity of this deliberative or decision-making process. Moreover, the predecisional character of a document is not altered by the passage of time. Bruscino v. BOP, No. 94-1955, 1995 WL 444406 at *5 (D.D. C. May 15, 1995), aff’d in part, No. 95-5212, 1996 WL 393101 (D.C. Cir. June 24, 1996); Bruscino v. BOP, No. 94-1955, 1995 WL 444406 at *5 (D.D. C. May 15, 1995), aff’d in part, No. 95-5212, 1996 WL 393101 (D.C. Cir. June 24, 1996); Access Reports v. DOJ, 926 F.2d 1192, 1196-97 (D.C. Cir. 1991) ("talking points" memoranda are predecisional); ACLU v. DHS, 738 F. Supp. 2d 93, 112 (D.D.C. 2010) (“’talking points’ are predecisional . . . the document itself suggests that a public statement was anticipated at the time of its creation, and given that no official statement has yet been made, the talking points remain ripe recommendations that are ready for adoption or rejection by the Department"); Sec. Fin. Life Ins. Co., No. 03-102-SBC, 2005 WL 839543, at *11 (D.D.C. Apr. 12, 2005) ("The undisputed evidence establishes that these [talking points] are deliberative."); Judicial Watch, Inc. v. U.S. Dep't of Commerce, 337 F. Supp. 2d 146, 174 (D.D.C. 2004) (protecting "talking points" and recommendations on how to answer Austin Evers Page 3 February 3, 2020 questions); St. Louis Sewer Dist., No. 10-2103, at *18 (E.D. Mo. Mar. 2, 2012) (protecting email communications, "press releases, talking points and 'Q & A,'" drafts, and briefing materials); Citizens for Responsibility & Ethics in Wash. v. DHS, 514 F. Supp. 2d 36, 44 (D.D.C. 2007) (protecting briefing materials concerning Hurricane Katrina response including proposed "solutions and approaches"); Judicial Watch, Inc. v. DOE, 310 F. Supp. 2d 271, 317 (D.D.C. 2004) (protecting briefing materials for Secretary of the Interior), aff'd in part, rev'd in part on other grounds & remanded, 412 F.3d 125, 133 (D.C. Cir. 2005); Klunzinger v. IRS, 27 F. Supp. 2d 1015, 1026 (W.D. 1998) (protecting paper to brief commissioner for meeting); Thompson v. Dep't of the Navy, No. 95-347, 1997 WL 527344, at *4 (D.D.C. Aug. 18, 1997) (protecting materials to brief senior officials responding to media inquiries, as "disclosure of materials reflecting the process by which the Navy formulates its policy concerning statements to and interactions with the press" could stifle frank communication within the agency), aff'd, No. 975292, 1998 WL 202253, at *1 (D.C. Cir. Mar. 11, 1998) (per curiam); Williams v. DOJ, 556 F. Supp. 63, 65 (D.D.C. 1982) (protecting "briefing papers prepared for the Attorney General prior to an appearance before a congressional committee"). 5 U.S.C. § 552(b)(6) exempts from required disclosure "personnel and medical files and similar files the disclosure of which would constitute a clearly unwarranted invasion of personal privacy." FOIA Exemption 6 permits VA to withhold a document or information within a document if disclosure of the information, either by itself or in conjunction with other information available to either the public or the FOIA requester, would result in an unwarranted invasion of an individual’s personal privacy without contributing significantly to the public’s understanding of the activities of the federal government. Specifically, the information being withheld, as indicated on the enclosed documents, under FOIA Exemption 6, consists of names, identities, photographs, email addresses, phone numbers, cellular numbers, facsimile numbers, resume details, medical details, and photographs of: federal employees, federal contractors, veterans, private citizens, and their family members. Federal employees, federal contractors, veterans, private citizens, and their family members retain a significant privacy interest under certain circumstances, such as in instances where the release of their information could represent a threat to their well-being, harassment, or their ability to function within their sphere of employment. The federal employees, federal contractors, veterans, private citizens, and their family members whose information is at issue have a substantial privacy interest in their personal information. In weighing the private versus the public interest, we find that there is no public interest in knowing the names, identities, email addresses, phone numbers, cellular numbers, facsimile numbers, resume details, medical details, and photographs of: federal employees, federal contractors, veterans, private citizens, and their family members. The coverage of FOIA Exemption 6 is absolute unless the FOIA requester can demonstrate a countervailing public interest in the requested information by demonstrating that the FOIA requester is in a position to provide the requested information to members of the general public and that the information requested contributes significantly to the public’s understanding of the activities of the Federal government. Additionally, the requester must demonstrate how the public’s need to understand the information significantly outweighs the privacy interest of the person to whom the information pertains. Upon consideration of the records, I have not been able to identify a countervailing public interest of sufficient magnitude to outweigh the privacy interest of the individuals whose names are redacted. The protected information has been redacted and (b)(6) inserted. “Withholding a telephone number or e-mail address, alone, is not sufficient to protect that [privacy] interest; alternate means of contacting and harassing these employees would be readily discoverable on the Internet if this court ordered their names disclosed.” Long v. Immigration & Customs Enf’t, 2017 U.S. Dist. LEXIS 160719 (D.C. Cir. 2017). Austin Evers Page 4 February 3, 2020 Out of the twenty-two thousand (22,000) pages received, OSVA has now reviewed about ten thousand two hundred (10,200) pages, of which OSVA has released four thousand one hundred fifty-two (4,152) redacted pages. About six thousand (6,000) pages predate November 9, 2019 and, thus, are non-responsive to your FOIA request. Of the released four thousand one hundred fifty-two (4,152) pages, one thousand five hundred thirty-eight (1,538) relate to the three (3) informal advisors. On or about January 14, 2020, OSVA released seven hundred six (706) pages to you, redacted with FOIA Exemptions 5 and 6. On January 6, 2020, OSVA released to you five hundred fortythree (543) pages, non-consecutively Bates-numbered 10033-11500, redacted with FOIA Exemptions 5 and 6. The other four thousand two hundred seventy-nine (4,279) pages, within pages Bates-numbered 10033-14999, predated November 9, 2016 and, thus, are nonresponsive to your FOIA request. On January 6, 2020, OSVA also re-released to you nine hundred forty-nine (949) pages, Bates-numbered 1-949, released to you on November 21, 2019, but with fewer redactions. Approximate 25,000 Pages of Emails Received on or About 1/15/2020 On or about January 15, 2020, Mr. Shulkin submitted approximately twenty-five (25,000) thousand pages of emails in which he copied another VA employee. For your past FOIA request 18-07426-F, OSVA has released to you all of Shulkin’s aol and gmail emails, possibly redacted, in which Shulkin directly communicated with the three (3) informal advisors and copied another OSVA Senior Executive. For your FOIA request 18-11960-F, OSVA has produced and will continue to produce all of Shulkin’s aol and gmail emails referencing the three (3) informal advisors and copying another OSVA Senior Executive. Those twenty-five thousand (25,000) pages, with Shulkin copying another VA employee, are compliant with the Federal Records Act. Those emails entered VA Systems of Records and servers at time of transmission and are agency records, not personal emails. As such, those twenty-five thousand (25,000) pages are non-responsive to your FOIA request. FOIA Mediation As part of the 2007 FOIA amendments, the Office of Government Information Services (OGIS) was created to offer mediation services to resolve disputes between FOIA requesters and Federal agencies as a non-exclusive alternative to litigation. Using OGIS services does not affect your right to pursue litigation. Under the provisions of the FOIA Improvement Act of 2016, the following contact information is provided to assist FOIA requesters in resolving disputes: VA Central Office FOIA Public Liaison: Name: Doloras Johnson Email Address: vacofoiaservice@va.gov Office of Government Information Services (OGIS) Email Address: ogis@nara.gov Fax: 202-741-5769 Mailing address: National Archives and Records Administration 8601 Adelphi Road College Park, MD 20740-6001 Austin Evers Page 5 February 3, 2020 FOIA Appeal This concludes OSVA’s Fourth Partial IAD to request 19-09094-F. Please be advised that should you desire to do so, you may appeal the determination made in this response to: Office of General Counsel (024) Department of Veterans Affairs 810 Vermont Avenue, NW Washington, DC 20420 If you should choose to file an appeal, please include a copy of this letter with your written appeal and clearly indicate the basis for your disagreement with the determination set forth in this response. Please be advised that in accordance with VA’s implementing FOIA regulations at 38 C.F.R. § 1.559, your appeal must be postmarked no later than ninety (90) days of the date of this letter. Sincerely, Richard Ha, JD, CIPP/G OSVA FOIA Officer Attachments – Redacted one thousand nine hundred fifty-four (1,954) pages Message From: Darin Selnick [(b) (6) Sent: 4/25/2017 1:42:25 AM To: David shulkin [Drshulkin@aol.com] Fwd: VA question Subject: @gmail.com] I wanted to confirm with you that the two statements from the speechwriter is correct. Darin ---------- Forwarded message---------EOP/WHO <(b) (6) From: (b) (6) Date: Mon, Apr 24, 2017 at 6:37 PM Subject: RE: VA question To: Darin Selnick <(b) (6) @gmail.com>, "(b) (6) (b) (6) < who.eop.gov> Cc: Darin Selnick who.eop.gov> EOP/WHO" Thanks. Are the following statements (b) (5) From: Darin Selnick [mailto:(b) (6) @gmail.com ] Sent: Monday, April 24, 2017 9:31 PM To: (b) (6) EOP/WHO <(b) (6) Cc: (b) (6) EOP/WHO <(b) (6) Subject: Re: VA question who.eop.gov> who.eop.gov>; Darin Selnick Hi (b) (6) (b) (5) . Darin VA-19-0799-D-000001 OS 00001659 On Mon, Apr 24, 2017 at 6: 12 PM, (b) (6) EOP/WHO <(b) (6) who.eop.gov> wrote: Hi Darin can you answer this question from (b) (5) Thanks > On Apr 24, 2017, at 9:06 PM, (b) (6) wrote: > > (b) (5) EOP/WHO <(b) (6) who.eop.gov> VA-19-0799-D-000002 OS 00001660 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/25/2017 2:27:18 AM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Meeting Who is best to present the inventory system we use? Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 24, 2017 at 6:57:56 PM EDT To: Poonam Alaigh <(b) (6) hotmail.com> Cc: David shulkin Subject: Re: Meeting mac.com> We will make it another time. Sent from my iPad Bruce Moskowitz M.D. On Apr 24, 2017, at 6:56 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Bruce - good idea but we are having an offsite strategy retreat with the field and medical center leadership to engage them and galvanize them around performance, accountability and David/Presidents priorities that day - I will leave the meeting to make it just in time for the Presidents visit. Let's plan time right after the event if we can make it work Sent from my iPhone On Apr 24, 2017, at 11 :03 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: Prior to signing If it helps to have a breakfast meeting to discuss inventory initiative in detail let me know. Also how we prevent over utilization in private sector. Any other issues up to you Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000003 OS 00001661 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/24/2017 10:57:56 PM Poonam Alaigh [(b) (6) hotmail.com] David shulkin [drshulkin@aol.com] Re: Meeting We will make it another time. Sent from my iPad Bruce Moskowitz M.D. > on Apr 24, 2017, at 6:56 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Bruce - good idea but we are having an offsite strategy retreat with the field and medical center leadership to engage them and galvanize them around performance, accountability and David/Presidents priorities that day - I will leave the meeting to make it just in time for the Presidents visit. Let's plan time right after the event if we can make it work > > Sent from my iPhone > >> on Apr 24, 2017, at 11:03 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >> >> Prior to signing If it helps to have a breakfast meeting to discuss inventory initiative in detail let me know. Also how we prevent over utilization in private sector. Any other issues up to you >> >> Sent from my iPad >> Bruce Moskowitz M.D. VA-19-0799-D-000004 OS 00001662 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/22/2017 6:13:10 PM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) [(b) (6) gmail.com]; Bruce Moskowitz [(b) (6) Press is covering us better gmail.com]; Marc Sherman (b) (6) [(b) (6) mac.com]; (b) (6) mayo.edu] http ://www.bradenton.com/opinion/editorials/article 145999214.html Sent from my iPhone VA-19-0799-D-000005 OS 00001663 Message David shulkin [Drshulkin@aol.com] 4/23/2017 4:59:44 PM [(b) (6) va.gov] (b) (6) (b) (6) [(b) (6) va.gov] Re: [EXTERNAL] Re: Hepatitis paper -Final version for submission From: Sent: To: CC: Subject: Ok thanks (b) (6) please print Sent from my iPhone On Apr 23, 2017, at 11 :31 AM, (b) (6) (b) (6) va.gov> wrote: Attached is the cover letter - with your signature Dr. Shulkin. (Please make sure I have your contact information correct, and feel free to edit if you see fit). Once you approve, I will plan to submit directly to the journal. (b) (6) From: David shulkin [ mailto:Drshulkin@aol.com] Sent: Friday, April 21, 2017 3:27 AM To: (b) (6) Cc: Poonam Alaigh; (b) (6) Subject: [EXTERNAL] Re: Hepatitis paper -Final version for submission Looks great- congratulations I do not need to be the corresponding author but the cover should come from me as i am known to the Editors- i had an article there this week Thanks again Sent from my iPhone On Apr 21, 2017, at 1:47 AM, (b) (6) (b) (6) va.gov> wrote: Hi, I am attaching the final version of the Hepatitis C paper for your approval before submitting for publication. As mentioned, I would suggest we try and submit to Annals of Internal Medicine given that they have recently published the piece on the National Strategy for hepatitis Elimination. We can submit under their "Medicine and Public Issues" section (Articles related to the economic, ethical, sociological, or political environment in medicine [Peer reviewed] ). http://annals.org/aim/pages/authors. If it comes back then we can submit to a clinical hepatology journal. VA-19-0799-D-000006 OS 00001664 I have it set up to the Annals of Internal Medicine specifications (2500 words) and have added the abstract. Also added figure descriptions. Please double check the title page to make sure I have the affiliations and disclosures correct. Dr. Shulkin, would you like to be the corresponding author? Also, I can create a cover letter, but would you like the cover letter to have your signature on it? Just let me know either way, what you prefer. There are two versions - one clean copy and one with the tracked changes so you can see the final edits. These edits were made to bring it down to meet the required word count. Because there are no author limits, we have added Dr. (b) (6) as an author given his role as Director of the HCV program and his spearheading of these initiatives. Thankyouforyoursupport! (b) (6) (b) (6) 'Pfiarm'D, 'BC'PS, .JL'A.J-lYV'P National Public Health Clinical Pharmacy Specialist Patient Care Services/Population Health (10P4V) Department of Veterans Affairs Phone: 310-922-(b) 310-478-(b) (6) Email: (b) (6) va.gov (6) From: Poonam Alaigh [ mailto:(b) (6) hotmail.com] Sent: Tuesday, April 18, 2017 4:24 AM To: David shulkin (b (b) (6) Cc: ) Subject: Re: [EXTERNAL] Hepatitis paper I am in concurrence with Dr Shulkin- thanks Sent from my iPhone On Apr 18, 2017, at 7: 16 AM, David shulkin wrote: Thank you Sent from my iPhone On Apr 18, 2017, at 1:06 AM, (b) (6) <(b) (6) va.gov> wrote: Hi Dr. Shulkin and Dr. Alaigh, VA-19-0799-D-000007 OS 00001665 Please find attached the data on the number of veterans we have treated and our SVR (cure) rates among those we have treated since the availability of the oral DAAs. In the attached spreadsheet (HCV VA data sources.xis), please find three tabs: Tab 1 shows the daily cumulative total of veterans starting on oral HCV DAAs. We started prescribing in VA in Jan 2014, though they were FDA approved in Nov 2013. This summary graph is also posted and is available at the first link listed below. Number of veterans treated since DAA availability: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth /pophealth/hcvantivirals/default.aspx Tab 2 of the spreadsheet shows the number of veterans awaiting treatment at periodic intervals beginning with FY14 ( DAAs introduced in VA in Q2 FY14). This is data captured from the HCV Clinical Case Registry. Those in the paper reflect the end of March (Q2 FY17). This data is also posted and is available at the link listed below: Numbers awaiting treatment - this is updated quarterly. https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth /pophealth/hcvantivirals/HCV%20Viremic/viremicfib4.aspx Tab 3 of the spreadsheet shows the raw data that relates to the "Cascade of HCV Care" (figure 3) with a brief sentence about the methods used to calculate each "step". For more detailed methods, refer to the attached Maier et al paper. We used the same methods for the current cascade as we did in this previously published paper. Note that the cascade numbers represent all HCV patients in care ever treated (even with earlier non-DAA regimens before 2014) which is why the SVR percentages in the cascade graph are lower than what the SVR rates are with all oral DAA regimens (shown in link below - which represent SVR rates of only oral DAA regimens from 2014 and beyond). SVR (cure) rates with all oral DAA regimens are posted here and updated every two weeks: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth /pophea lth/hcva ntivi ra ls/HCV%20Antivi ra ls%20Tests/H CV Direct Acting Antivirals.aspx VA-19-0799-D-000008 OS 00001666 From table at above link, SVR rate calculated as SVR12/(NoSVR+SVR12) = 94.98%; Published data on SVR rates available in the attached article. HCV testing rates are updated and posted quarterly, (those in the paper reflect the end of March, Q2 FY17) : https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth /pophealth/hcvbirthcohort/hcv cohorts fiscal year/def ault.aspx Please let me know if you have any additional questions about the data or would like to have copies of any of the other references in the paper. Best, (b) (6) From: David Shulkin [ mailto:drshulkin@aol.com] Sent: Sunday, April 16, 2017 9:59 AM (b) (6) To: (b) (6) (b) (6) hotmail.com Subject: [EXTERNAL] Hepatitis paper (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has (6) occurred at VA. I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here VA-19-0799-D-000009 OS 00001667 David Shulkin MD VA-19-0799-D-000010 OS 00001668 Message (b) (6) From: Sent: To: CC: Subject: Attachments: [(b) (6) va.gov] 4/23/2017 3:31:59 PM David shulkin [Drshulkin@aol.com]; Shulkin, David J., MD [David.Shulkin@va.gov] Poonam Alaigh [(b) (6) hotmail.com]; (b) (6) [(b) va.gov] (b)(6)(6) RE: [EXTERNAL] Re: Hepatitis paper -Final version for submission Cover Letter Curing HCV in VA.docx Attached is the cover letter - with your signature Dr. Shulkin. (Please make sure I have your contact information correct, and feel free to edit if you see fit). Once you approve, I will plan to submit directly to the journal. (b) (6) From: David shulkin [mailto:Drshulkin@aol.com] Sent: Friday, April 21, 2017 3:27 AM To: (b) (6) Cc: Poonam Alaigh; (b) (6) Subject: [EXTERNAL] Re: Hepatitis paper -Final version for submission Looks great- congratulations I do not need to be the corresponding author but the cover should come from me as i am known to the Editorshad an article there this week Thanks again Sent from my iPhone On Apr 21, 2017, at 1:47 AM, (b) (6) (b) (6) va.gov> wrote: Hi, I am attaching the final version of the Hepatitis C paper for your approval before submitting for publication. As mentioned, I would suggest we try and submit to Annals of Internal Medicine given that they have recently published the piece on the National Strategy for hepatitis Elimination. We can submit under their "Medicine and Public Issues" section (Articles related to the economic, ethical, sociological, or political environment in medicine [Peer reviewed] ). http://annals.org/aim/pages/authors. If it comes back then we can submit to a clinical hepatology journal. I have it set up to the Annals of Internal Medicine specifications (2500 words) and have added the abstract. Also added figure descriptions. Please double check the title page to make sure I have the affiliations and disclosures correct. Dr. Shulkin, would you like to be the corresponding author? Also, I can create a cover letter, but would you like the cover letter to have your signature on it? Just let me know either way, what you prefer. VA-19-0799-D-000011 OS 00001669 There are two versions - one clean copy and one with the tracked changes so you can see the final edits. These edits were made to bring it down to meet the required word count. Because there are no author limits, we have added Dr. (b) (6) as an author given his role as Director of the HCV program and his spearheading of these initiatives. Thankyouforyoursupport! (b) (6) (b) (6) 'Pfiarm'D, 'BC'PS, .JL'A.J-lYV'P National Public Health Clinical Pharmacy Specialist Patient Care Services/Population Health (10P4V) Department of Veterans Affairs Phone: 310-922-(b) 310-478-(b) (6) Email: (b) (6) va.gov (6) From: Poonam Alaigh [ mailto:(b) (6) hotmail.com] Sent: Tuesday, April 18, 2017 4:24 AM To: David shulkin (b (b) (6) Cc: ) Hepatitis paper Subject: Re: [EXTERNAL] I am in concurrence with Dr Shulkin- thanks Sent from my iPhone On Apr 18, 2017, at 7: 16 AM, David shulkin wrote: Thank you Sent from my iPhone On Apr 18, 2017, at 1:06 AM, (b) (6) wrote: (b) (6) va.gov> Hi Dr. Shulkin and Dr. Alaigh, Please find attached the data on the number of veterans we have treated and our SVR (cure) rates among those we have treated since the availability of the oral DAAs. In the attached spreadsheet (HCV VA data sources.xis), please find three tabs: Tab 1 shows the daily cumulative total of veterans starting on oral HCV DAAs. We started prescribing in VA in Jan 2014, though they were FDA VA-19-0799-D-000012 OS 00001670 approved in Nov 2013. This summary graph is also posted and is available at the first link listed below. Number of veterans treated since DAA availability: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/default.aspx Tab 2 of the spreadsheet shows the number of veterans awaiting treatment at periodic intervals beginning with FY14 ( DAAs introduced in VA in Q2 FY14). This is data captured from the HCV Clinical Case Registry. Those in the paper reflect the end of March (Q2 FY17). This data is also posted and is available at the link listed below: Numbers awaiting treatment - this is updated quarterly. https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/HCV%20Viremic/viremic-fib4.aspx Tab 3 of the spreadsheet shows the raw data that relates to the "Cascade of HCV Care" (figure 3) with a brief sentence about the methods used to calculate each "step". For more detailed methods, refer to the attached Maier et al paper. We used the same methods for the current cascade as we did in this previously published paper. Note that the cascade numbers represent all HCV patients in care ever treated (even with earlier non-DAA regimens before 2014) which is why the SVR percentages in the cascade graph are lower than what the SVR rates are with all oral DAA regimens (shown in link below - which represent SVR rates of only oral DAA regimens from 2014 and beyond). SVR (cure) rates with all oral DAA regimens are posted here and updated every two weeks: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/HCV%20Antivirals%20Tests/HCV Direct Acting Antivirals.asp X From table at above link, SVR rate calculated as SVR12/(NoSVR+SVR12) = 94.98%; Published data on SVR rates available in the attached article. HCV testing rates are updated and posted quarterly, (those in the paper reflect the end of March, Q2 FYl 7) : https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv birthcohort/hcv cohorts fiscal year/default.aspx Please let me know if you have any additional questions about the data or would like to have copies of any of the other references in the paper. Best, (b) (6) From: David Shulkin [ mailto:drshulkin@aol.com] Sent: Sunday, April 16, 2017 9:59 AM VA-19-0799-D-000013 OS 00001671 (b (b) (6) To: Subject: [EXTERNAL]) Hepatitis paper (b) (6) hotmail.com (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has occurred at VA. (6) I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here David Shulkin MD VA-19-0799-D-000014 OS 00001672 Christine Laine, ~ID, MPH Editor in Chief, Annals of Internal Medicine RE: Manuscript submission April 24, 2017 Dear Dr. Laine, We wish to respectfully submit the manuscript entitled "Curing Hepatitis C Infection: Best Practices from the Department of Veterans Affairs" for consideration for publication in Annals of Internal Medicine as a Medicine and Public Issues article. This manuscript directly addresses a recently published April 4th Annals of Internal A1edicine Ideas and Opinions article by Buckley et al, which summarized the National Academies of Sciences, Engineering, and Medicine expert committee Report on a National Strategy for the Elimination of Viral Hepatitis. With VA' s advancements and progress in treating veterans with hepatitis C virus infection (HCV), and as the nation's largest provider of care to patients with HCV, VA is uniquely suited to inform this Strategy. In the attached manuscript we have highlighted VA's successes and best practices relating to each of the 5 areas identified in the National Strategy report that can be extended to other healthcare organizations and providers delivering hepatitis C care. The work underway in VA over the past 3 years has focused on a comprehensive approach to identify and manage veterans with hepatitis C. This manuscript informs the readers of our experiences, innovations, and outcome metrics across the care continuum for this population which has led to the successful treatment of over 86,000 veterans in 3 years. This manuscript has not been previously published nor is it being considered for publication elsewhere. I attest to the fact that all authors have had a significant intellectual contribution to this work and have read and approved the submitted manuscript. Thank you in advance for the consideration shown to this manuscript. We would appreciate the opportunity to contribute to Annals qfInternal Medicine. Sincerely, David J. Shulkin MD Secretary of Veterans Affairs Office of the Secretary for Health Department of Veterans Affairs Washington, DC 202-461 -7000 David.Shulkin@va.gov VA-19-0799-D-000015 OS 00001673 Message David shulkin [Drshulkin@aol.com] 4/21/2017 10:26:31 AM [(b) (6) va.gov] (b) (6) Poonam Alaigh [(b) (6) hotmail.com]; (b) (6) Re: Hepatitis paper -Final version for submission From: Sent: To: CC: Subject: [(b) (b)(6)(6) va.gov] Looks great- congratulations I do not need to be the corresponding author but the cover should come from me as i am known to the Editorshad an article there this week Thanks again Sent from my iPhone On Apr 21, 2017, at 1:47 AM, (b) (6) (b) (6) va.gov> wrote: Hi, I am attaching the final version of the Hepatitis C paper for your approval before submitting for publication. As mentioned, I would suggest we try and submit to Annals of Internal Medicine given that they have recently published the piece on the National Strategy for hepatitis Elimination. We can submit under their "Medicine and Public Issues" section (Articles related to the economic, ethical, sociological, or political environment in medicine [Peer reviewed] ). http://annals.org/aim/pages/authors. If it comes back then we can submit to a clinical hepatology journal. I have it set up to the Annals of Internal Medicine specifications (2500 words) and have added the abstract. Also added figure descriptions. Please double check the title page to make sure I have the affiliations and disclosures correct. Dr. Shulkin, would you like to be the corresponding author? Also, I can create a cover letter, but would you like the cover letter to have your signature on it? Just let me know either way, what you prefer. There are two versions - one clean copy and one with the tracked changes so you can see the final edits. These edits were made to bring it down to meet the required word count. Because there are no author limits, we have added Dr. (b) (6) as an author given his role as Director of the HCV program and his spearheading of these initiatives. Thankyouforyoursupport! (b) (6) (b) (6) 'Pfiarm'D, 'BC'PS, .JL'A.J-lYV'P National Public Health Clinical Pharmacy Specialist Patient Care Services/Population Health (10P4V) Department of Veterans Affairs Phone: 310-922-(b) 310-478-(b) (6) Email: (b) (6) va.gov (6) VA-19-0799-D-000016 OS 00001674 From: Poonam Alaigh [ mailto:(b) (6) hotmail.com] Sent: Tuesday, April 18, 2017 4:24 AM To: David shulkin (b (b) (6) Cc: ) Hepatitis paper Subject: Re: [EXTERNAL] I am in concurrence with Dr Shulkin- thanks Sent from my iPhone On Apr 18, 2017, at 7: 16 AM, David shulkin wrote: Thank you Sent from my iPhone On Apr 18, 2017, at 1:06 AM, (b) (6) wrote: (b) (6) va.gov> Hi Dr. Shulkin and Dr. Alaigh, Please find attached the data on the number of veterans we have treated and our SVR (cure) rates among those we have treated since the availability of the oral DAAs. In the attached spreadsheet (HCV VA data sources.xis), please find three tabs: Tab 1 shows the daily cumulative total of veterans starting on oral HCV DAAs. We started prescribing in VA in Jan 2014, though they were FDA approved in Nov 2013. This summary graph is also posted and is available at the first link listed below. Number of veterans treated since DAA availability: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/default.aspx Tab 2 of the spreadsheet shows the number of veterans awaiting treatment at periodic intervals beginning with FY14 ( DAAs introduced in VA in Q2 FY14). This is data captured from the HCV Clinical Case Registry. Those in the paper reflect the end of March (Q2 FY17). This data is also posted and is available at the link listed below: Numbers awaiting treatment - this is updated quarterly. https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/HCV%20Viremic/viremic-fib4.aspx VA-19-0799-D-000017 OS 00001675 Tab 3 of the spreadsheet shows the raw data that relates to the "Cascade of HCV Care" (figure 3) with a brief sentence about the methods used to calculate each "step". For more detailed methods, refer to the attached Maier et al paper. We used the same methods for the current cascade as we did in this previously published paper. Note that the cascade numbers represent all HCV patients in care ever treated (even with earlier non-DAA regimens before 2014) which is why the SVR percentages in the cascade graph are lower than what the SVR rates are with all oral DAA regimens (shown in link below - which represent SVR rates of only oral DAA regimens from 2014 and beyond). SVR (cure) rates with all oral DAA regimens are posted here and updated every two weeks: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/HCV%20Antivirals%20Tests/HCV Direct Acting Antivirals.asp X From table at above link, SVR rate calculated as SVR12/(NoSVR+SVR12) = 94.98%; Published data on SVR rates available in the attached article. HCV testing rates are updated and posted quarterly, (those in the paper reflect the end of March, Q2 FYl 7) : https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv birthcohort/hcv cohorts fiscal year/default.aspx Please let me know if you have any additional questions about the data or would like to have copies of any of the other references in the paper. Best, (b) (6) From: David Shulkin [ mailto:drshulkin@aol.com] Sent: Sunday, April 16, 2017 9:59 AM (b) (6) (b) (6) To: (b) (6) Subject: [EXTERNAL] Hepatitis paper hotmail.com (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has occurred at VA. (6) I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. VA-19-0799-D-000018 OS 00001676 Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here David Shulkin MD VA-19-0799-D-000019 OS 00001677 Message From: Sent: To: CC: Subject: Attachments: (b) (6) [(b) (6) va.gov] 4/21/2017 5:47:57 AM Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [Drshulkin@aol.com] [(b) va.gov] (b) (6) (b)(6)(6) RE: Hepatitis paper -Final version for submission Curing hepatitsC 4-20-17 clean.docx; Curing hepatitsC 4-20-17 tracked changes.docx Hi, I am attaching the final version of the Hepatitis C paper for your approval before submitting for publication. As mentioned, I would suggest we try and submit to Annals of Internal Medicine given that they have recently published the piece on the National Strategy for hepatitis Elimination. We can submit under their "Medicine and Public Issues" section (Articles related to the economic, ethical, sociological, or political environment in medicine [Peer reviewed] ). http://annals.org/aim/pages/authors. If it comes back then we can submit to a clinical hepatology journal. I have it set up to the Annals of Internal Medicine specifications (2500 words) and have added the abstract. Also added figure descriptions. Please double check the title page to make sure I have the affiliations and disclosures correct. Dr. Shulkin, would you like to be the corresponding author? Also, I can create a cover letter, but would you like the cover letter to have your signature on it? Just let me know either way, what you prefer. There are two versions - one clean copy and one with the tracked changes so you can see the final edits. These edits were made to bring it down to meet the required word count. Because there are no author limits, we have added Dr. as an author given his role as Director of the HCV program and his spearheading of these initiatives. (b) (6) Thank you for your support! (b) (6) '(b) (6) 'Pfiarm'D, 'BC'PS, .JL'A.J-lYV'P National Public Health Clinical Pharmacy Specialist Patient Care Services/Population Health (10P4V) Department of Veterans Affairs Phone: 310-922-(b) 310-478-(b) (6) Email: (b) (6) va.gov (6) From: Poonam Alaigh [mailto:(b) (6) hotmail.com] Sent: Tuesday, April 18, 2017 4:24 AM To: David shulkin (b (b) (6) Cc: ) Hepatitis paper Subject: Re: [EXTERNAL] VA-19-0799-D-000020 OS 00001678 I am in concurrence with Dr Shulkin- thanks Sent from my iPhone On Apr 18, 2017, at 7: 16 AM, David shulkin wrote: Thank you Sent from my iPhone On Apr 18, 2017, at 1:06 AM, (b) (6) (b) (6) va.gov> wrote: Hi Dr. Shulkin and Dr. Alaigh, Please find attached the data on the number of veterans we have treated and our SVR (cure) rates among those we have treated since the availability of the oral DAAs. In the attached spreadsheet (HCV VA data sources.xis), please find three tabs: Tab 1 shows the daily cumulative total of veterans starting on oral HCV DAAs. We started prescribing in VA in Jan 2014, though they were FDA approved in Nov 2013. This summary graph is also posted and is available at the first link listed below. Number of veterans treated since DAA availability: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/defaul t.aspx Tab 2 of the spreadsheet shows the number of veterans awaiting treatment at periodic intervals beginning with FY14 ( DAAs introduced in VA in Q2 FY14). This is data captured from the HCV Clinical Case Registry. Those in the paper reflect the end of March (Q2 FY17). This data is also posted and is available at the link listed below: Numbers awaiting treatment - this is updated quarterly. https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/HCV% 20Viremic/viremic-fib4 .aspx Tab 3 of the spreadsheet shows the raw data that relates to the "Cascade of HCV Care" (figure 3) with a brief sentence about the methods used to calculate each "step". For more detailed methods, refer to the attached Maier et al paper. We used the same methods for the current cascade as we did in this previously published paper. Note that the cascade numbers represent all HCV patients in care ever treated (even with earlier non-DAA regimens before 2014) which is why the SVR percentages in the cascade graph are lower than what the SVR rates are with all oral DAA regimens (shown in link below - which represent SVR rates of only oral DAA regimens from 2014 and beyond). SVR (cure) rates with all oral DAA regimens are posted here and updated every two weeks: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/HCV% 20Antivirals%20Tests/HCV Direct Acting Antivirals.aspx From table at above link, SVR rate calculated as SVR12/(NoSVR+SVR12) = 94.98%; Published data on SVR rates available in the attached article. VA-19-0799-D-000021 OS 00001679 HCV testing rates are updated and posted quarterly, (those in the paper reflect the end of March, Q2 FY17): https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvbirthcohort/hcv cohorts fiscal year/default.aspx Please let me know if you have any additional questions about the data or would like to have copies of any of the other references in the paper. Best, (b) (6) From: David Shulkin [ mailto:drshulkin@aol.com] Sent: Sunday, April 16, 2017 9:59 AM (b) (6) (b) (6) To: (b) (6) Subject: [EXTERNAL] Hepatitis paper hotmail.com (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has occurred at VA. (6) I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here David Shulkin MD VA-19-0799-D-000022 OS 00001680 Curing Hepatitis C Infection: Best Practices from the Department of Veterans Affairs Pamela S. Belperio PharmD1, Maggie Chartier PsyD MPH2, David B. Ross MD PhD MBI2, Poonam Alaigh, MD 3 , David Shulkin MD4 1 Population Health Services, Department of Veterans Affairs, Palo Alto Health Care System, Palo Alto, CA 2 Office of Specialty Care Services, Department of Veterans Affairs, Washington DC 3 Office of the Under Secretary for Health, Department of Veterans Affairs, Washington DC 4 Office of the Secretary, Department of Veterans Affairs, Washington DC Short Running Title: HCV Best Practices in VA Financial Support and Disclosures: This work was prepared independently without financial support. Drs. Belperio, Chartier, Ross, Alaigh, and Shulkin have no financial, professional or personal disclosures to report. Corresponding Author- Pamela S. Belperio, Pharm D, Patient Care Services/Population Health Services, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304 Phone: 310-478-371 lx4471 l, Fax: 650-849-0266, Email: Pamela.Belperio@va.gov Word Count: 2499 Keywords: Veteran, access, direct acting antiviral, cascade 1 VA-19-0799-D-000023 OS 00001681 Abstract (245) The Department of Veterans Affairs (VA) is the nation's largest care provider to patients infected with hepatitis C vims (HCV) and is uniquely suited to inform national efforts to eliminate HCV. An extensive array of delivery of services, policy guidance, outreach efforts and funding has broadened the reach and capacity of VA to deliver direct acting antiviral (DAA) HCV therapy, supported by an infraslmcture lo effectively implement change and informed by e:s.1:ensive population health data analysis. VA has treated over 86,000 HCV-infected veterans since the availability of all-oral DAAs in January 2014 with cure rates exceeding 90%; only 58,000 known veterans in VA care remain potentially eligible for treatment. Key actions advancing VA's aggressive treatment ofHCV include: expanding treatment capacity with non-physician providers, video telehealth and electronic technologies; expansion of integrated care to address psychiatric and substance use co-morbidities; and electronic data tools for patient tracking and outreach. Critical to effective implementation has been building infrastmcture through the creation of regional multidisciplinary HCV Innovation Teams whose systems redesign efforts have produced innovative HCV practice models addressing gaps in care while providing more efficient and effective HCV management for the populations they serve. Financing for HCV treatment and infrastmcture resources coupled with reduced dmg pricing has been paramount lo VA's success in curing HCV. VA is well poised to share and extend best HCV practices to other healthcare organizations and providers delivering HCV care, contributing to a concerted effort to reduce the burden of HCV. 2 VA-19-0799-D-000024 OS 00001682 Introduction Since the introduction of Direct Acting Antivirals (DAAs) for hepatitis C virus (HCV), the Department of Veterans Affairs (VA) has made e:s.1:ensive progress in advancing HCV care and curing substantial numbers ofHCV-infected veterans in VA care. As the nation's largest provider of care to patients with HCV, VA is uniquely suited to inform the recently released National Strategy for the Elimination of Viral Hepatitis, produced by a National Academies of Sciences, Engineering, and Medicine expert committee, which emphasizes prevention, screening, and universal treatment ofHCV-- areas in which VA has become a recognized leader (1-3). The National Strategy presents specific actions to reduce the burden of HCV and outlines 5 distinct areas-Information, Interventions, Service delivery, Financing, and Research (1,2). VA's best practices and successes, informed by extensive population health data analysis capabilities and national guidance and policies, may be useful for other healthcare providers and organizations to reduce the burden of HCV in their populations. VA has made a substantial commitment to prioritizing HCV care as ret1ected in dedicated funding for HCV treatment in VA, unrestricted access to DAAs, detailed guidance on individualizing care and the establishment of Veterans Integrated Service Network (VISN) Hepatitis C Innovation Teams (HITs) (4). This work, in collaboration with other key VA offices. is largely supported by the VA's National Viral Hepatitis Program which also develops national guidance and policy. trainings, and resources for patients and providers, easily accessible on its comprehensive website (5). The significant resources and efforts VA and its HCV providers have dedicated to prioritizing this disease at every level of the organization are being tangibly realized. Between January 2014 and March 2017, 86,000 HCV-infected veterans in VA care have received oral DAA treatment, achieving cure rates of over 90% (6-8). Currently, only 58,000 knovvn veterans in VA care remain potentially eligible for treatment, 3 VA-19-0799-D-000025 OS 00001683 compared to over 168,000 three years ago (9, 10). While elimination appears attainable, VA recognizes the reality of the HCV epidemic and population; namely, many of those in care remaining to be treated have complex substance use, mental health, and medical co-morbidities, and many are challenged by homelessness, transportation, and rurality which pose significant barriers to engagement in care and treatment. The curve of elimination for HCV in VA will include a long tail of persistence driven by system, patient and care delivery determinants (Figure 1). Information: Population Health Management Using national databases and analytics, VA employs population health management strategies to measure, monitor and identify trends in HCV care, gaining insight into patterns of access and tailoring care provision programs accordingly. Veterans in VA care diagnosed with HCV are followed in VA' s National Hepatitis C Clinical Case Registry (CCR), developed in part to ensure veterans with chronic HCV were linked to care (11). The HCV CCR, used for both local and national population reporting, provides data on the number of patients lmovm to be infected with HCV together with critical clinical information such as patient and disease characteristics, where care is received, receipt ofDAA treatment and clinical outcomes. The VA's Central Data Warehouse, a repository of electronic medical record data, has spurred the creation of local and regional HCV dashboards which offer providers access to patientspecific data reports for real-time intervention and tracking. These sources allow for comprehensive monitoring of incidence, prevalence, and disease course to identify and address barriers and assess outcomes. National, regional and individual facility level data is posted regularly, allowing providers, teams, and leadership to assess progress and goals. This leveraging of health systems data transforms numbers into knowledge and guides providers and the VA toward more informed and effective delivery of care for each veteran. 4 VA-19-0799-D-000026 OS 00001684 Essential Interventions Diagnosis and Testing Improved case idenii/zcation: A critical first step for improving HCV care is to identify those infected. In 2012, the Centers for Disease Control and Prevention (CDC) and subsequently the United States Preventive Services Task Force developed recommendations for testing any person born between 19451965, a cohort determined to have the highest HCV prevalence (12, 13). Prior to 2014, VA guidance recommended risk-based testing and testing of Vietnam-era veterans, a group which largely overlaps with the 1945-1965 birth cohort (3). Using information systems lo track screening, VA has been able to identify and target additional populations at risk for HCV, which include: African American males, for which the prevalence is double that of Caucasians (17.7% versus 8.3%); the homeless, for which the prevalence is over three times higher when compared to non-homeless (13.4% versus 3.5%); and persons who inject drugs (14, 15). Most recently, VA has screened over 78% of the 2.5 million veterans in the 1945-1965 birth cohort, and of note, 89.6% of its homeless population (15). Using updated annual prevalence calculations, VA estimates there are only approximately 15,000 remaining veterans in VA care who would test positive for HCV if the entire at-risk population were screened. Testing initiatives: Several initiatives undertaken within VA lo increase HCV testing have significantly impacted these results. These include national electronic point-of-care clinical reminders for HCV risk assessment and testing, automated letters recommending HCV testing which dually serve as a laboratory order when presented to a VA lab, weekly primary care panel reviews identifying patients with upcoming appointments who require testing, and calling patients directly. To emphasize this as a priority, VA added 5 VA-19-0799-D-000027 OS 00001685 birth cohort testing as a national performance measure in 2015 and reports quarterly screening rates by facility and region. To ensure complete testing while simultaneously providing an efficient and patientcentered approach, VA adopted CDC recommendations into policy so all patients tested for HCV with a positive antibody automatically had reflex confirmatory HCV RNA testing performed with the same laboratory sample, with over 97% compliance in 2015. As a result of these collective factors, the proportion of veterans in VA care screened for HCV have increased annually by 3% to 4% and are substantially higher than other large healthcare systems (16). Building Infrastructure Hepaiitis Innovation Team (HIT) Collaborative: Recognizing that care is not delivered the same way in all settings, regional HITs, comprising a multidisciplinary group of 15-30 healthcare providers, administrators, information technology and system redesign specialists, have implemented Lean Process Improvement methods to maximize clinical expertise and redesign the process of HCV testing, treatment, and management to provide care in the most efficient and effective way possible for the populations they serve (17). The HIT Collaborative has enabled a clinically focused foundation to share and implement best practices across and within teams, supported by local and regional administrators. The development of the HIT infrastructure which has leveraged and supported the work of dedicated VA providers has been a critical implementation arm that has allowed VA to respond to challenges in funding variability and other access issues that have arisen since the introduction of DAA.s. Service Deliverv: Improving Linkage and Access Population health data, the HIT infrastructure, and legions of dedicated providers on the ground have been instrumental in enhancing VA' s outreach and engagement. Efforts have focused on raising provider 6 VA-19-0799-D-000028 OS 00001686 and staff awareness about HCV testing and treatment availability, promoting direct outreach to at-risk veterans leveraging technologies like mobile phone applications and secure messaging. as well as outreach to the veteran community more broadly through national and local social media and advertising campaigns. Expanding Capaci(y Telemedicine and electronic technologies: VA has focused on increasing specialist capacity through telemedicine and clinical video telehealth (CVT), or real-time video teleconferencing, whereby HCV clinicians provide care lo patients and/or consultation lo other providers at another location. Largely modeled off of the ECHO project (18), the expanded HCV VA-ECHO model includes urban and rural sites, homeless care clinics, incorporates a pharmacist-led provider program, and a mental health and substance use program to aid providers in treating HCV in patients with these co-morbidities. Leveraging electronic databases HCV teams identify potential treatment candidates, notify primary care providers through the electronic medical record and provide HCV management recommendations. Similarly, primary care providers can efficiently consult HCV specialists regarding HCV care management aud treatment recommendations via inter-provider electronic consults, eliminating the need for a specialty visit. Non-physician advanced practice providers: VA has emphasized the expansion of HCV care beyond specialty providers. A substantial portion of HCV treatment has shifted outside of liver and infectious disease specialty care clinics at larger medical centers to primary care aud community clinics. Treatment is often being delivered by non-physician providers such as Clinical Pharmacy Specialists, Nurse Practitioners aud Physician Assistants, who have been recognized as delivering the same quality of care aud providing more timely access to HCV treatment (19,20). 7 VA-19-0799-D-000029 OS 00001687 In 2016, almost one-third of VA DAA prescriptions were initiated by a network of nearly 200 Clinical Pharmacy Specialists (21 ). VA has also recently granted foll practice authority to nurse practitioners therefore expanding the potential for further use of these providers in providing hepatitis care. Targeted use of the limited number of specialists while expanding non-physician provider roles is an important practice that can be adapted from the VA system into other healthcare systems ( 19). Barriers to Care Based on VA HCV provider data collected in 2014 and 2015, it was estimated that up to 30% of veterans awaiting treatment were not currently willing or were unable to initiate HCV treatment. Major reported reasons included active alcohol/substance use, serious mental illness, documented non-adherence to medical appointments or treatment, unstable/uncontrolled medical comorbidities, inability to contact a veteran and veterans unwillingness to start treatment. As VA continues to treat more patients. an increasing number of those remaining in the untreated pool present with these challenges and accompanying resource demands to potentially modify these patient, system, or care delivery factors. Frequent reassessment is required of healthcare systems and providers to adapt their approach and resources as the barriers in untreated HCV populations shift overtime. Addressing substance use: Recognizing alcohol and substance use as a considerable barrier to HCV treatment, VA took aggressive steps to eliminate non-evidence based, abstinence policies for HCV treatment and provided clinical guidance on effectively assessing alcohol and substance use, matching a patient's use with the actual risk of non-adherence. VA studies have consistently shown cure rates achieved among veterans with alcohol, substance use and mental health disorders are similar to those without these conditions (7,22). 8 VA-19-0799-D-000030 OS 00001688 Integrated care: Accessible mental health and addiction specialists, care coordinators, case managers and social workers are invaluable resources to address the significant impediments to HCV treatment for VA' s most vulnerable populations so that a veteran's treatment candidacy may be reassessed as barriers are addressed. VA has emphasized that integrated care practice models be implemented where resources permit. For facilities with more limited resources, individual aspects of this comprehensive care can be leveraged within the facility, or region via innovative practice models as detailed above. Financing HCV Treatment VA has faced significant financial challenges as a result of highly priced DAAs. With strong advocacy from VA HCV providers, veterans and VA leadership, expanded special purpose funding for HCV medications was made available through Congressional appropriations (4,23). Dramatic reductions in DAA pricing made possible by the steadfast negotiations of VA Pharmacy Benefits Management leadership in early 2016, simultaneous enactment of additional appropriations and removal of restrictions based on stage of Ii ver disease solidified VA' s ability to provide consistent access to HCV treatment for all veterans. Figure 2 depicts the significant impact of funding variability on DAA uptake in VA in recent years. To comprehensively address HCV infection VA recognized e;,,.1:ending resources beyond purchasing medications would be required. In 2016, VA boldly allocated 5% of the HCV dmg budget for each VA medical center to non-dmg HCV clinical resources and infrastmcture. This has allowed medical facilities to independently address local barriers and identify tangible solutions to increase treatment by dedicating resources towards the initiatives described above. 9 VA-19-0799-D-000031 OS 00001689 Research to Inform The comprehensive data sources within VA and the VA's diverse HCV population provides a broad milieu for examining scientific and clinical outcomes, cost-effectiveness, patterns of care, and the impact of specific interventions. For decades, VA HCV researchers have actively contributed to the medical literature influencing and informing patient care, implementation strategies, operations and policy. Given the large number of BCV-infected veterans treated, real-world outcomes in special populations can be assessed to a greater degree than in many other healthcare environments thus providing valuable insight for other payors and healthcare systems. Cascade of HCV Care in VA The impact ofDAAs on HCV has been transformational, making elimination seem a tangible goal, as the National Academies of Sciences, Engineering, and Medicine report highlights. Elimination can only occur when every individual with HCV infection is identified, linked to care. treated with HCV antivirals and achieves a sustained virologic response (SVR), or cure. These steps comprise the "hepatitis C cascade of care", a series of key components describing a population health approach to HCV care and a mechanism lo assess performance (10, 16,24-26). Figure 3 depicts VA's HCV care advancements in each of the cascade steps between 2014 and 2016. VA estimates that 92% of veterans with HCV who have come to the VA for care in 2016 have been diagnosed, and of those, 93% have been linked to HCV care. The most significant change in the cascade has occurred in the treatment step. Among HCV-infected veterans in VA care in 2014, 27% of those linked to HCV care had ever received HCV treatment -- including all veterans treated prior to the 10 VA-19-0799-D-000032 OS 00001690 availability of DAAs. At that time, 51 % of those ever treated had achieved SVR. By comparison, among BCV-infected veterans in VA care in 2016, 59% of those linked to HCV care had ever received HCV treatment, with 84% ever receiving HCV treatment achieving SVR. Overall, 84,192 BCV-infected veterans in VA care in 2016 who had ever received HCV treatment had been cured. Summary The widespread availability of curative oral DAA medications have made the possibility of HCV elimination seem achievable. VA is steadily approaching this goal and remains committed to diagnosing and treating all veterans with HCV who are willing and able lo be treated. An extensive array of delivery of services, policy guidance, outreach efforts and funding has broadened the reach and capacity of VA lo deliver treatment, supported by an infrastructure to effectively implement change. The key actions that have advanced VA' s HCV elimination efforts include: expanding treatment capacity with non-physician providers; use of video telehealth and modified ECHO models to expand treatment; expansion of integrated care and improvement in addressing psychiatric, substance use and medical co-morbidities; use of electronic data tools for patient tracking and outreach; and dissemination and implementation of best practices developed through the Systems Redesign efforts of regional HITs. However, it must be underscored that financing for HCV treatment and infrastrncture resources coupled with reduced drug pricing has been paramount to VA's success in curing HCV and is the lynchpin in achieving elimination for any health care system and the US nationally. Recognizing the resources necessary to realize this goal and the infrastrncture and innovations that could make it possible, VA is well poised to share and extend best practices to other healthcare organizations and providers delivering HCV care. 11 VA-19-0799-D-000033 OS 00001691 !Acknowledgments: ' he authors would like to acknowledge Dr. Lisa Backus for her Commented [PB1]: Unfortunately we wont be able to include this acknowledgement to veterans and providers and congress. Based on author guidelines only the following is contributions related to the generation of data used for reporting HCV testing rates, treatment allowed: Acknowledge only persons who have contributed to the scientific content or provided technical support. Authors must rates, and cascade of care steps. obtain written permission from anyone they list in the Acknowledgments section, including confirmation of the nature of the contribution. I would really like to add Lisa Backus since she generated much of the data for the cascade and uptake utilization Commented [MC2]: Love it, if we can't include David as an author- we should include him here as well: Suggested language ... The authors would also like to acknowledge, Dr. for his advocacy of HCV and vision for how VA could become a national international leader in HCV testing, care and treatment. (b) 12 VA-19-0799-D-000034 OS 00001692 References I. National Academies of Sciences, Engineering, and Medicine. A national strategy for the elimination of hepatitis Band C: Phase Two Report Phase Two Reportphase nvo report. Washington, DC: The National Academies Press; 2017. doi: 10.17226/24731. Available from: http://www.nationalacademies.org/hmd/Reports/2017 /national-strategy-for-the-elimination-ofhepatitis-b-and-c.aspx 2. Buckley GJ, Strom BL. A National Strate6'Y for the Elimination of Viral Hepatitis Emphasizes Prevention, Screening, and Universal Treatment of Hepatitis C. Ann Int Med. 2017; Apr 4. doi: 10. 7326/M 17-0766. http://annals.org/aim/article/2616344/national-strategy-eliminati on-viralhepatitis-emphasizes-prevention-screening-uni versal-treatment 3. Beste LA, Ioannou GN. Prevalence and treatment of chronic hepatitis C vims infection in the US Department of Veterans Affairs. Epidemiol Rev.2015; 37: 131-143. 4. H.R.3236 - Surface Transportation and Veterans Health Care Choice Improvement Act of 2015, 114th Congress (2015-2016). 5. US Department of Veterans Affairs Viral Hepatitis Website. https:/hvvvw.hepatitis.va.gov/ 6. Veterans Health Administration Patient Care Services/Population Health. Hepatitis C Antiviral Uptake Report. March 31, 2017. 7. Backus LI, Belperio PS, Shahoumian TA, Loomis TP, Mole LA. Real-world effectiveness and predictors of sustained virological response with all-oral therapy in 21,242 hepatitis C genotype-I patients. Antivir Ther. 2016 Dec 9. doi: 10.3851/IMP3117. 8. Ioannou GN, Beste LA, Chang MF, Green PK, Lowy E, Tsui JI, et al. Effectiveness of sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ritonavir/ombitasvir and dasabuvir regimens for treatment of patients with hepatitis C in the veterans affairs national health care system. Gastroenterology. 2016;151:457-471. 13 VA-19-0799-D-000035 OS 00001693 9. Veterans Health Administration Patient Care Services/Population Health. HCV Viremic Veterans in VHA Care Awaiting Treatment Report. April 10, 2017. 10. Maier MM, Ross DB, Chartier M, Belperio PS, Backus LI. Cascade of care for hepatitis C virus infection within the US Veterans Health Administration. Am J Public Health. 2016; 106:353-358. 11. Backus LI, Gavrilov S, Loomis TP, Halloran JP, Phillips BR, Belperio PS, Mole LA. Clinical case registries: simultaneous local and national disease registries for population quality management. J Am Med Inform Assoc. 2009; 16:775-783. 12. Smith BD, Morgan RL, Beckett GA, Falck-Ytter Y, Holtzman D, Teo CG, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012;6l(RR-4): 1-32. 13. Moyer VA; U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013:159:349-357. 14. Backus LI, Belperio PS, Loomis TP, Mole LA Impact of race/ethnicity and gender on HCV screening and prevalence among U.S. veterans in Department of Veterans Affairs Care. Am J Public Health. 2014;104 Suppl 4:S555-561. 15. NoskaAJ, Belperio PS, Loomis TP, O'Toole TP, Backus LI. Engagement in the hepatitis C care cascade among homeless veterans, 2015. Public Health Rep. 2017; 132: 136-139. 16. Jonas MC, Rodriguez CV, Redd J, Sloane DA, Winston BJ, Loftus BC. Streamlining screening to treatment: the hepatitis C cascade of care at Kaiser Permanente mid-Atlantic states. Clin Infect Dis. 2016;62: 1290-1296. 17. Ross DB. Best practices in HCV screening, diagnosis, and treatment. Federal Practitioner. 2017; February I. 18. Arora S, Kalishman S, Thornton K, Dion D, Murata G, Deming P, et al. Expanding access lo hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52: 1124-1133. 14 VA-19-0799-D-000036 OS 00001694 19. Rongey C, Shen H, Hamilton N, Backus LI, Asch SM, Knight S. Impact of rural residence and health system structure on quality of liver cam PLoS One.2013;8:e84826. 20. Backus LI, Belperio PS, Shahoumian TA, Mole LA Impact of provider type on hepatitis C outcomes with boceprevir-based and telaprevir-based regimens. J Clin GastroenteroL 2015;49:329-335. 21, Ourth H, Groppi J, Morreale AP, Quicci-Roberls K. Clinical pharmacist prescribing activities in the Veterans Health Administration. Am J Health Sysl Pharm. 2016;73: 1406-1415. 22. Tsui JI, Williams EC. Green PK, Berry K, Su F, Ioannou GN, Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents. Drug Alcohol Depend. 2016; 169: 101-109, 23. US Department of Veterans Affairs. VA expands hepatitis C drug treatment Published March 9,2016. https://vvww. va.gov/opa/pressrel/pressrelease.cfm ?id~2762, Accessed April I 0, 2017, 24. Yehia BR, Schranz AJ, Umscheid CA Lo RY The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014;9:e101554. doi: 10.1371~joumaLpone.0101554. 25. Spradling PR, Rupp L, Moorman AC, et aL Hepatitis Band C virus infection among L2 million persons with access to care: factors associated with testing and infection prevalence. Clin Infect Dis. 2012;55: 1047-1055, 26. Holmberg SD, Spradling PR, Moorman AC. Denniston MM. Hepatitis C in the United States. N Engl J Med. 2013;368: 1859-186L 15 VA-19-0799-D-000037 OS 00001695 180,000 u "' :;:: :;:: 160,000 +-'"""'__,,_.--________________________ 140,000 + - - - -• ,:-- - - - - - - - - - - - - - - - - - - - - - C. 1"' ... 120,000 .. + - - - - -~ ~ . ....-- - - - - - - - - - - - - - - - - - - C: :~ ~100,000 ~ ~ ...~ 80,000 60,000 + - - - - - - - - --"Ilk : - - - - - - - - - - - - - - - - - - + - - - - - - - - - - -=- -"""_,_ _ _ _ _ _ _ _ _ _ _ __ 40,000 + - - - - - - - - - 20,000 + - - - - - - - - - - - - - - - - - - - - - - --=----.;; 0 +---~---+----~-----+---~----+---~------i 10/1/2013 10/1/2015 10/1/2017 10/1/2019 10/1/2021 Figure 1. Number of Veterans with hepatitis C virus (HCV) in Veterans Affairs (VA) Care, reqniring HCV antiviral treatment over time. In October 2013, 168,708 veterans in VA care were identified with chronic HCV and requiring treatment; by March 31, 2017, 58,406 veterans in VA care were identified as having chronic HCV and requiring treatment. R 2 , coefficient of determination. 16 VA-19-0799-D-000038 OS 00001696 2000 _..,1800 .,., :S:1500 :. b. Limited use of funds for HCV drugs made avilable through c. Enactment of additional C. f 1400 . . tii E1200 ~ 1!!1000 f- "ii! ·s; ., 800 C: <( .,.,u"' . ., 600 400 C. ::c 200 0 ............: ... , .... , .. ··:····,···· Figure 2. bnpact of hepatitis C virus (HCV) drug funding availability on HCV treatment starts per week within Veterans Affairs 17 VA-19-0799-D-000039 OS 00001697 200,000 "'C ~ ~ 150,000 -., 0 .c § 100,000 z 50,000 Chronic HCV (estimated)* Di agnosed with chronic HCVt Linked to HCV caret Treated with HCV antivira ls§ Achieved SVR 11 Figure 3. Cascade of HCV care in the Veterans Health Administration (VHA) in 2014, 2015, and 2016. The proportion of patients in each step of the cascade from the patients in the preceding step is presented in the arrows between each bar. SVR ~ sustained virologic response *Estimated from diagnosed plus the ratio of prevalence in birth cohort strata in those tested in prior two years applied to those still untested tDiagnosed with chronic HCV defined as ever had a detectable HCV RNA or genotype. tLinked to HCV care required an outpatient visit in the year, entry in the VHA's HCV registry and HCV entered on the patient's medical record problem list. §Treated with HCV antivirals defined as ever received HCV antivirals from VHA as of31 December of the year. IIAchieved SVR defined as undetectable HCV RNA on all tests after end of treatment including at least one test at least 12 weeks after the end of treatment 18 VA-19-0799-D-000040 OS 00001698 Curing Hepatitis C Infection: Best Practices from the Department of Veterans Affairs Pamela S. Belperio PharmD1 , Maggie Chartier PsyD MPH2, David B. Ross MD PhD MBI2,Poonam Alaigh, MD 3 , David Shulkin MD4 1 Population Health Services, Department of Veterans Affairs, Palo Alto Health Care System, Palo Alto, CA 2 Office of Specialty Care Services, Department of Veterans Affairs, Washington DC 3 Office of the Under Secretary for Health, Department of Veterans Affairs, Washington DC 4 Office of the Secretary, Department of Veterans Affairs, Washington DC Short Running Title: HCV Best Practices in VA Financial Support and Disclosures: This work was prepared independently without financial support. Drs. Belperio, Chartier, Alaigh, and Shulkin have no financial, professional or personal disclosures to report. Corresponding Author: Pamela S. Belperio, Pharm D, Patient Care Services/Population Health Services, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304 Phone: 310-478-371 lx4471 l, Fax: 650-849-0266, Email: Pamela.Belperio@va.gov Word Count: 2499 Keywords: Veteran, access, direct acting antiviral, cascade 1 VA-19-0799-D-000041 OS 00001701 Abstract (245) The Department of Veterans Affairs (VA) is the nation's largest care provider to patients infected with hepatitis C vims (HCV) and is uniquely suited to inform national efforts to eliminate HCV. An extensive array of delivery of services, policy guidance, outreach efforts and funding has broadened the reach and capacity of VA to deliver direct acting antiviral (DAA) HCV therapy, supported by an infraslmcture lo effectively implement change and informed by e:s.1:ensive population health data analysis. VA has treated over 86,000 HCV-infected veterans since the availability of all-oral DAAs in January 2014 with cure rates exceeding 90%; only 58,000 known veterans in VA care remain potentially eligible for treatment. Key actions advancing VA's aggressive treatment ofHCV include: expanding treatment capacity with non-physician providers, video telehealth and electronic technologies; expansion of integrated care to address psychiatric and substance use co-morbidities; and electronic data tools for patient tracking and outreach. Critical to effective implementation has been building infrastmcture through the creation of regional multidisciplinary HCV Innovation Teams whose systems redesign efforts have produced innovative HCV practice models addressing gaps in care while providing more efficient and effective HCV management for the populations they serve. Financing for HCV treatment and infrastmcture resources coupled with reduced dmg pricing has been paramount lo VA's success in curing HCV. VA is well poised to share and extend best HCV practices to other healthcare organizations and providers delivering HCV care, contributing to a concerted effort to reduce the burden of HCV. 2 VA-19-0799-D-000042 OS 00001702 Introduction Since the introduction of Direct Acting Antivirals (DAAs) for hepatitis C virus (HCV), the Department of Veterans Affairs (VA) has made extensive progress in advancing HCV care and curing substantial number~ of HCV-infected veterans in VA care with hepatitis C virus (HGV) infeetion. As the nation's single-largest provider of care to patients with HCV, VA is uniquely suited to inform the recently released National Strategy for the Elimination of Viral Hepatitis, produced by a National Academies of Sciences, Engineering, and Medicine expert committee, which emphasizes prevention, screening, and universal treatment of HCV-- areas in which VA has become a recognized leader (1-3). The National Strategy presents specific actions to reduce the burden of HCV and outlines 5 distinct areas-Information, Interventions, Service delivery, Financing, and Research (1,2). VA' s best practices and successes, informed by extensive population health data analysis capabilities and national guidance and policies, may be useful for other healthcare providers and organizations to reduce the burden of HCV in their populations. Based on US :National Health and :NHtrition Eirnmination Survey data from 2010, it was estimated that appro1Eimately 13°'6 of all patients diagnosed with HGV in the United States (US) rneeive ears within the VA, highlighting the disproportionate lmrden among veterans.(3,4} In 2013, before the availability of HGV DAAs, there were approximately 1€ig,ooo veterans diagnosed with HGV infeetion in VA earn who were potentially eligible for treatment and an additional estimated 45,000 Hndiagnosed in eare.(5) With sHpport from the US HoHse and Senate Appropriations Committees (4), VA has made a substantial commitment to prioritizing HCV care as reflected in dedicated funding for HCV treatment in VA, Hniversal unrestricted access to DAAs, detailed guidance on individualizing care and the establishment of Veterans Integrated Service Network (VISN) Hepatitis C Innovation Teams (HITs) (LI)_. This work, in 3 VA-19-0799-D-000043 OS 00001703 collaboration with other key VA offices, is largely supported by the VA's National Viral Hepatitis Program which also develops national guidance and policy, teels,trainings, and resources for patients and providers, easily accessible through illtemal ehanllols and on its comprehensive website (5). VA's sueeess and best praetiees am illformed by si..tellsive populatioll health data analysis eapaliilities and llatiollal guidanee and polieios. The significant resources and efforts VA and its HCV providers have dedicated to prioritizing this disease at every level of the organization are being tangibly realized. Between January 2014 and March 2017, 86,000 BCV-infected veterans ~ cure rates of over 90% (6-8). in VA care have received pe-teat-oral DAA treatment, achieving As of Marsh 2017Currently, only 58,000 known veterans in VA care romaill to boremain potentially eligible for treatmentoo, compared to over 168,000 three years ago (9, 10). While elimination appears attainable, VA recognizes the reality of the HCV epidemic and population; namely, many of those in care remaining to be treated have complex substance use, mental health, and medical co-morbidities, and many are challenged by homelessness, transportation, and rurality which pose significant barriers to engagement in care and treatment. The curve of elimination for HCV in VA will include a long tail of persistence driven by system, patient and care delivery determinants (Figure 1). Information: Population Health Management Using national databases and analytics, VA employs population health management strategies to measure, monitor and identify trends in HCV care, gaining insight into patterns of access and tailoring care provision programs accordingly. Veterans in VA care diagnosed with HCV are followed in VA' s National Hepatitis C Clinical Case Registry (CCR), developed in part to ensure veterans with chronic HCV were linked to care (11). The HCV CCR, used for both local and national population reporting, provides data on the number of patients known to be infected with HCV together with critical clinical 4 VA-19-0799-D-000044 OS 00001704 information such as patient and disease characteristics, where care is received, receipt ofDAA treatment aud clinical outcomes. The VA's Central Data Warehouse, a repository of electronic medical record data, has spurred the creation of local and regional HCV dashboards which offer providers access to patientspecific data reports for real-time intervention and tracking. These sources allow for comprehensive monitoring of incidence, prevalence, and disease course to identify and address barriers and assess outcomes. National, regional and individual facility level data is posted regularly, allowing providers, teams, and leadership to assess progress and goals. This leveraging of health systems data transforms numbers into knowledge and guides providers and the VA toward more informed and effective delivery of care for each veteran. Essential Interventions Diagnosis and Testing Improved case identification: A critical first step for improving HCV care is to identify those infected. In 2012, the Centers for Disease Control and Prevention and subsequently the United States Preventive Services Task Force developed recommendations for testing any person born between 1945-1965, a cohort determined to have the highest HCV prevalence (12,13). Prior to 2014, VA had-guidance H!flaee whi£h-recommended risk-based testing as well as aud testing of Vietnam-era veterans, a group which largely overlaps with the 1945-1965 birth cohort (3). Using FOOHS-t-information systems to track screening, VA has been able to identify and target additional populations at risk for HCV, which include: African American males, for which the prevalence is double that of Caucasians (17. 7% versus 8.3%); the homeless, for which the prevalence is over three times higher when compared to non-homeless (13.4% versus 3.5%); aud persons who inject drugs (14,15). 5 VA-19-0799-D-000045 OS 00001705 gilloo tho rapid adoptioll of those oiqiandod sornollillg rnoommolldatiolls, Most recently, VA has screened over 78% of the 2.5 million veterans in the 1945-1965 birth cohort, and Qf particular note, ~ sornollod 89.6% of its homeless population (15). Using updated annual prevalence calculations from tho Humber ofllow illfootiolls amollg those tested, VA estimates there are only approximately 15,000 remaining veterans in VA care who would test positive for HCV if the entire at-risk population were screened. Testing initiatives: Several initiatives undertaken within VA to increase HCV testing have significantly impacted these results. These include national electronic point-of-care clinical reminders for HCV risk assessment and testing, automated letters recommending HCV testing which dually serve as a laboratory order when presented to a VA lab, weekly primary care panel review~ identifying patients with upcoming appointments who require testing, and calling patients directly. To emphasize this as a priority, VA added birth cohort testing as a national performance measure in 2015 and reports quarterly screening rates by facility and region. To ensure complete testing while simultaneously providing an efficient and patientcentered approach, VA developed ado ted CDC recommendations into olicy ill 2009 whoroliyN all patients tested for HCV with a positive antibody automatically hae-had reflex confirmatory HCV RNA testing performed with the same laboratory sample, with over 97% compliance in 2015. As a result of these collective factors, the proportion of veterans in VA care screened for HCV have increased annually by 3% to 4% and are substantially higher than other large healthcare systems (16). Building Infrastructure Hepatitis Innovation Team (HIT) Collaborative: Recognizing that care is not delivered the same way in all settings, regional HITs, comprising a multidisciplinary group of 15-30 healthcare providers, administrators, information technology and system redesign specialists, have implemented Lean Process 6 VA-19-0799-D-000046 OS 00001706 Improvement methods to maximize clinical expertise and redesign the process of HCV testing, diagnosis, treatment, and management to provide care in the most efficient and effective way possible for the populations they serve (17). The HIT Collaborative has enabled a clinically focused foundation to share and implement best practices across and within teams, supported by local and regional administrators. The development of the HIT infrastructureon the ground which has leveraged and supported the work of dedicated VA providers, has been one of the 1Lcritical implementation arm that has allowed VA to respond to challenges in funding variability and other 6fiti£al-access issues that have arisen since the introduction ofDAAs. Service Delivery: Improving Linkage and Access Ones an enrolled veteran is diagnosed with HGV, the emphasis shifts to timely linkage to evaluation and rnfeFFal for appropriate treatment. Robust p):'.opulation health data, the HIT infrastructure of the HIT eollaborativs, and legions of dedicated providers on the ground have been instrumental in enhancing VA's outreach and engagement~ . Efforts have focused on raising provider and staff awareness among providers and staff about the need for HCV testing and treatment availability of trnatmsnt, as-wellas--promoting direct outreach to at-risk veterans leveraging technologies like mobile phone applications and secure messaging, as well as outreach to the veteran community more broadly through national and local social media and advertising campaignG, mobile phone applieations, and seeUFe messaging. Expanding Capacity Telemedicine and electronic technologies: VA has focused on increasing specialist capacity through telemedicine and clinical video telehealth (CVT), or real-time video teleconferencing, whereby HCV clinicians provide care to patients and/or consultation to other providers at another location. Largely 7 VA-19-0799-D-000047 OS 00001707 modeled off of the University oOfow Meirieo ECHO project (18), the expanded HCV VA-ECHO model includes urban and rural sites, homeless care clinicsLincorporates a pharmacist-led provider program sines mush of HGV treatment in VA is managed liy elinieal pharmaeists, and an---MC-¥-1!_mental health and substance use program to aid providers in treating HCV in patients with these co-morbidities. Interprovider eleetronie eonsults offer another effeetive and effieient way to prepare patients for treatment avoiding the need for additional appointments. Using Leveraging electronic databases, registries or dashboards, _HCV teams team members ean identify potential treatment patients who may lie candidates, for treatment_notify primary care providers eleetronieally through the electronic medical record ~ withand provide- HCV reeommend management recommendations. Similarly, primary care providers can efficiently consult HCV specialists regarding HCV care management and treatment recommendations via inter-provider electronic consults, eliminating the need for a specialty visit. Non-physician advanced practice providers: Importantly, VA has emphasized the expansion of HCV care beyond specialty providers. A substantial portion of HCV treatment management has shifted, partieularly treatment, outside of liver and infectious disease specialty care clinics at larger medical centers to primary care and community clinics. Furthermore, this earn Treatment is often being delivered by non-physician providers such as Clinical Pharmacy Specialists, Nurse Practitioners and Physician Assistants, who have been recognized as delivering the same quality of care and providing more timely access to HCV treatment (19 ,20). In 2016, almost one-third of VJ\. all HGV antiviral DAA prescriptions were initiated by a network of nearly 200 Clinical Pharmacy Specialists (21). VA has also recently granted full practice authority to nurse practitioners therefore expanding the potential for further use of these providers in providing hepatitis care. Targeted use of the limited number of specialists while expanding the skills of non- 8 VA-19-0799-D-000048 OS 00001708 physician provider roles is ans of ths most an important practice that can be adapted from the VA system into other healthcare systems (19). Chall.enging Populaiions Barriers to Care EarrieFs te Cal'/3: Based on VA HCV provider data collected in 2014 and 2015, it was estimated that up to 30% of veterans awaiting treatment were not currently willing or were unable to initiate HCV treatment. Major reported reasons included active alcohol/substance use, serious mental illness, documented non-adherence to medical appointments or treatment, unstable/uncontrolled medical comorbidities, inability to contact a veteran and, in some eases, _veterans unwillingness to start treatment. As VA continues to treat more patients, an increasing number of those remaining in the untreated pool present with these challenges aud accompanying resource demands to potentially modify these patient, system, or care delivery factors. Frequent reassessment and refoeusing is required of healthcare systems aud providers to adapt their approach and resources as the 1IBOOS-barriers inef-its untreated HCV population!, and barriers to initiating treatment ehangeshift overtime. Addressing substance use: Recognizing alcohol and substance use as a considerable barrier to HCV treatment, VA took aggressive steps to eliminate non-evidence based, abstinence policies for HCV treatment and provided clinical guidance on effectively assessing alcohol and substance use, matching a patient's use with the actual risk of non-adherence. VA studies have consistently shown cure rates achieved among veterans with alcohol, substance use and mental health disorders are similar to those without these conditions (7,22). 9 VA-19-0799-D-000049 OS 00001709 Integrated care: Accessible mental health and addiction specialists, care coordinators, case managers and social workers are invaluable resources to address the significant impediments to HCV treatment for VA's most vulnerable populations so that a veteran's treatment candidacy may be reassessed as barriers are addressed. Where resoHrees permit, VA has emphasized that integrated care, practice models earo eoordination, ease management, and mental health and sHbstaneo Hse sorvieos are in plaeebc implemented where resources permit to address factors that pose significant impediments to HGV treatment for YHlnerable popHlations. For faci lities with more limited resources, individual aspects of this comprehensive care can be leveraged within the facility, or region via innovative practice models as detailed above .. This eomprehonsivo management approaeh faeilitates earn sHeh that veterans' treatment candidacy can be reassessed. This has boon particHlarly important for "lllnorablo popHlations. Accessible mental health and addietion speeialists, earo eoordinators, case managers and social workers are ill'ralHablo resoHrees to meet the individHalized needs of this popHlation. Financing HCV Treatment Like all healtheare systems, VA has faced significant financial challenges as a result of highly priced DAAs. With strong advocacy from VA HCV providers, veterans and VA leadership, expanded special purpose funding for HCV medications was made available through Congressional appropriations (4,23). ]2Th0-dramatic reductions in the price of DAA pricing made possible by-¥A the steadfast negotiations of VA Pharmacy Benefits Management leadership steadfast negotiations in early 2016, simultaneous enactment of additional appropriations and removal of restrictions based on stage of liver disease solidified VA~s ability to provide consistent access to HCV treatment for all veterans. GHrrently, VA has no restrictions on DAAs which are available to all HGV patients regardless of stage of liver disease. Figure 2 depicts the significant impact of funding variability on DAA uptake in VA 0¥SF-in recent years. 10 VA-19-0799-D-000050 OS 00001710 Reeognizing that in order tio comprehensively and sueeessfully treat address HCV infection in--¥A,--VA recognized extending resources beyond purchasing medications would be required. In 2016, VA boldly allocated 5% of the HCV drug budget for each VA medical center to non-drug HCV clinical resources and infrastructure to further inerease treatment starts. This has allowed VUlN HITs medical facilities to independently address local barriers and identify tangible solutions to increase treatment by dedicating resources towards the initiatives described above . . These funds have sueeessfully been used to Sl(fland HGV or liver disease Vl1, ECHO programs, inerease treatment eapaeity through a Clinieal Pharmaey Speeialist initiative, inerease integrated earn, implement HIT innovations, host HGV testing events and fund loeal testing and treatment advertising eampaigns. Research to Inform The comprehensive data sources within VA and the VA's diverse HCV population provides a broad milieu for examining scientific and clinical outcomes, cost-effectiveness, patterns of care, and the impact of specific interventions. For decades, VA HCV researchers have actively contributefl to the medical literature influencing and informing patient care, implementation strategies, operations and policy. Given the large number of BCV-infected veterans treated, real-world outcomes in special populations can be assessed to a greater degree than in many other healthcare environments thus providing valuable insight for other payors and healthcare systems. Cascade of HCV Care in VA 11 VA-19-0799-D-000051 OS 00001711 The impact of DAAs on BCV has been miivorsally transformational, making elimination seem a tangible goal, as the National Academies of Sciences, Engineering, and Medicine report highlights. Elimination can only occur when every individual with BCV infection is identified, linked to care, treated with BCV antivirals and achieves a sustained virologic response (SVR), or cure. These steps comprise the "hepatitis C cascade of care", a series of key eare-components !!S6El-t& on Apr 24, 2017, at 3:43 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > Yes I am concerned about this > > Sent from my iPhone > >> on Apr 24, 2017, at 3:42 PM, David >> >> Would you be interested in meeting the WH is going a different direction room? I wont be able to join you but shulkin wrote: with Darin selnick about the Apple strategy? Im a little nervous than you want and maybe its good for everyone to get in the same i can arrange >> >> David >> >> Sent from my iPhone VA-19-0799-D-000061 OS 00001723 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/24/2017 7:54:08 PM To: CC: Bruce Moskowitz [(b) (6) mac.com] Ike Perlmutter [(b) (6) frenchangel59.com] Subject: Re: Me too Sent from my iPhone > on Apr 24, 2017, at 3:43 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > Yes I am concerned about this > > Sent from my iPhone > >> on Apr 24, 2017, at 3:42 PM, David >> >> Would you be interested in meeting the WH is going a different direction room? I wont be able to join you but shulkin wrote: with Darin selnick about the Apple strategy? Im a little nervous than you want and maybe its good for everyone to get in the same i can arrange >> >> David >> >> Sent from my iPhone VA-19-0799-D-000062 OS 00001724 Message From: Bruce Moskowitz [(b) (6) Sent: 4/24/2017 7:43:27 PM To: CC: David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com] Subject: Re: mac.com] Yes I am concerned about this Sent from my iPhone > on Apr 24, 2017, at 3:42 PM, David shulkin wrote: > > Would you be interested in meeting with Darin selnick about the Apple strategy? Im a little nervous the WH is going a different direction than you want and maybe its good for everyone to get in the same room? I wont be able to join you but i can arrange > > David > > Sent from my iPhone VA-19-0799-D-000063 OS 00001725 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/24/2017 7:42:22 PM Bruce Moskowitz [(b) (6) mac.com]; Ike Perlmutter [(b) (6) frenchangel59.com] Would you be interested in meeting with Darin selnick about the Apple strategy? Im a little nervous the WH is going a different direction than you want and maybe its good for everyone to get in the same room? I wont be able to join you but i can arrange David Sent from my iPhone VA-19-0799-D-000064 OS 00001726 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/24/2017 8:00:27 PM Ike Perlmutter [(b) (6) frenchangel59.com] Roe accepted dinner Issakson is trying but due to health no confirmation yet Sent from my iPhone VA-19-0799-D-000065 OS 00001727 Message David shulkin [Drshulkin@aol.com] 4/24/2017 7:16:07 PM IP [(b) (6) frenchangel59.com] Poonam Alaigh [(b) (6) hotmail.com]; Re: Dinner Attendees From: Sent: To: CC: Subject: (b) (6) frenchangel59.com Ive extended the invites- waiting to hear Working on the DoD nsme Email is vacodjsl@va.gov Sent from my iPhone On Apr 24, 2017, at 1:07 PM, IP <(b) (6) frenchangel59.com > wrote: Poonam and David: We need to know the information below: 1. 2. 3. Please let us know if you invited Senator Isakson and Representative Roe to the dinner and if they accepted. Please let us know the name of the gentleman in the DOD that you would like the White House to invite. David, please let Marisol know your business email address so she can share with Johnson and Johnson Thank you, Ike VA-19-0799-D-000066 OS 00001728 Message IP [(b) (6) frenchangel59.com] 4/24/2017 5:07:54 PM Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [drshulkin@aol.com] (b) (6) frenchangel59.com Dinner Attendees From: Sent: To: CC: Subject: Poonam and David: We need to know the information below: 1. 2. 3. Please let us know if you invited Senator Isakson and Representative Roe to the dinner and if they accepted. Please let us know the name of the gentleman in the DOD that you would like the White House to invite. David, please let Marisol know your business email address so she can share with Johnson and Johnson Thank you, Ike VA-19-0799-D-000067 OS 00001729 Message David Shulkin [drshulkin@aol.com] 4/25/2017 1:47:59 AM (b) (6) [(b) (6) Fwd: Non-addictive pain meds From: Sent: To: Subject: gmail.com] Print Sent from my iPad Begin forwarded message: From: "(b) (6) (NIH/OD) [E]" <(b) (6) od.nih.gov> Date: April 24, 2017 at 8:58: 19 PM EDT To: "drshulkin@aol .com" Cc: "(b) (6) (NIH/NIDA) [E]" <(b) (6) nida.nih.gov>, (b) (6) (b) (6) < speakergingrich.com> Subject: Non-addictive pain meds Hi David, Newt shared with me your ideas about having the VA join the effort to deploy non-addictive pain meds. NIH is organizing a series of three workshops with industry and FDA in the next three months to make a plan. Can you recommend one or two VA experts in pain management who might be interested and available to attend? Best, F(b) (6) From: (b) (6) [mailto:(b) (6) speakergingrich.com1 Sent: Monday, April 24, 2017 1:17 PM To: (b) (6) (NIH/OD) [El <(b) (6) od.nih.gov>; Jared Kushner < WHO.EOP.GOV> Subject: Shulkin eager to collaborate on non addictive pain effort see below newt (b) (6) Sent from my iPad Begin forwarded message: From: David shulkin Date: April 19, 2017 at 7:24: 18 PM EDT To: (b) (6) <(b) (6) speakergingrich.com> Subject: Re: Ending the Opioid Crisis fyi newt Newt- this is very effective and well stated. Pain is such a big issue in VA- what about making VA a fast tract FDA site to get help to veterans faster? We dont want to be experimenting on veterans but why not let veterans have the choice to receive these breakthroughs first? VA-19-0799-D-000068 OS 00001730 Also VA researchers could join your list of those than can help speed further discoveries. Great job- keep it up! David Sent from my iPhone On Apr 19, 2017, at 4:52 PM, (b) (6) <(b) (6) speakergingrich.com> wrote: Sent from my iPad VA-19-0799-D-000069 OS 00001731 Message David shulkin [Drshulkin@aol.com] 4/25/2017 1:33:55 AM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Non-addictive pain meds From: Sent: To: Subject: (b)(6)(6) Can you get me names? (b) Sent from my iPhone Begin forwarded message: From: "(b) (6) (NIH/OD) [E]" <(b) (6) od.nih.gov> Date: April 24, 2017 at 8:58: 19 PM EDT To: "drshulkin@aol .com" Cc: "(b) (6) (NIH/NIDA) [E]" <(b) (6) nida.nih.gov>, (b) (6) (b) (6) < speakergingrich.com> Subject: Non-addictive pain meds Hi David, Newt shared with me your ideas about having the VA join the effort to deploy non-addictive pain meds. NIH is organizing a series of three workshops with industry and FDA in the next three months to make a plan. Can you recommend one or two VA experts in pain management who might be interested and available to attend? Best, F(b) (6) From: (b) (6) [mailto:(b) (6) speakergingrich.com1 Sent: Monday, April 24, 2017 1:17 PM To: (b) (6) (NIH/OD) [El <(b) (6) od.nih.gov>; Jared Kushner < WHO.EOP.GOV> Subject: Shulkin eager to collaborate on non addictive pain effort see below newt (b) (6) Sent from my iPad Begin forwarded message: From: David shulkin Date: April 19, 2017 at 7:24: 18 PM EDT To: (b) (6) <(b) (6) speakergingrich.com> Subject: Re: Ending the Opioid Crisis fyi newt Newt- this is very effective and well stated. Pain is such a big issue in VA- what about making VA a fast tract FDA site to get help to veterans faster? We dont want to be experimenting on veterans but why not let veterans have the choice to receive these breakthroughs first? VA-19-0799-D-000070 OS 00001732 Also VA researchers could join your list of those than can help speed further discoveries. Great job- keep it up! David Sent from my iPhone On Apr 19, 2017, at 4:52 PM, (b) (6) <(b) (6) speakergingrich.com> wrote: Sent from my iPad VA-19-0799-D-000071 OS 00001733 Message Blackburn, Scott R. [Scott.Blackburn@va.gov] 4/26/2017 2:22:20 AM David Shulkin [drshulkin@aol.com] (b) (6) [(b) (6) gmail.com]; Wright, Vivieca (Simpson) [Vivieca.Wright@va.gov] RE: [EXTERNAL] Fwd: MyVA Advisory Committee From: Sent: To: CC: Subject: This is great. This shouldn't be a problem. From: David Shulkin [mailto:drshulkin@aol.com] Sent: Tuesday, April 25, 2017 10:17 PM To: Blackburn, Scott R. Cc: (b) (6) Wright, Vivieca (Simpson) Subject: [EXTERNAL] Fwd: MyVA Advisory Committee I said yes Sent from my iPad Begin forwarded message: [JJCUS]" <(b) (6) its.jnj.com > From: "(b) (6) Date: April 25, 2017 at 3:59:42 PM EDT To: "' Drshulkin@aol.com '" Subject: MyVA Advisory Committee Dear Secretary Shulkin, Thank you for your warm invitation to serve on the MyVA Advisory Committee. It is a true honor to be considered for such a role-one that helps rebuild trust with veterans and other stakeholders, improve service delivery focusing on veteran outcomes and set the course for longer-term excellence and reform. As a veteran, I share your strong commitment to improving the lives of all veterans through a healthy and well-functioning VA system. I am also pleased with your focus on reconstituting the MVAC to develop a comprehensive approach toward these goals, by sharing innovative approaches and ideas from many different areas across government, academia, and the private sector. Sharing best practices through the MVAC will help significantly advance your objectives of improving and building a world-class VA system. While I would be honored to serve on the MVAC, given the other commitments I have on my calendar, I am concerned about being able to commit the time to attend every meeting throughout the year. Although I would certainly be able to arrange my schedule to participate in several of the meetings, I would ask if it would be possible to also designate one of Johnson & Johnson's senior leaders to serve as my proxy for those meetings I am unable to attend. Please let me know if this is possible. Thank you and best wishes for continued success in your role as secretary. Sincerely, VA-19-0799-D-000072 DS 00001734 (b) (6) • Chairman and Chief Executive Officer Tel: (732) 524-(b) (b) Fax: (732) 524-(6) New E-mail: (b) (6) its.jnj.com (6) VA-19-0799-D-000073 DS_00001735 Message David Shulkin [drshulkin@aol.com] 4/26/2017 2:17:13 AM Scott R. Blackburn [Scott.Blackburn@va.gov] (b) (6) [(b) (6) gmail.com]; Vivieca Wright Simpson [vivieca.Wright@va.gov] Fwd: MyVA Advisory Committee From: Sent: To: CC: Subject: I said yes Sent from my iPad Begin forwarded message: From: "(b) (6) [JJCUS]" <(b) (6) its.jnj.com> Date: April 25, 2017 at 3:59:42 PM EDT To: "' Drshulkin@aol.com '" Subject: MyVA Advisory Committee Dear Secretary Shulkin, Thank you for your warm invitation to serve on the MyVA Advisory Committee. It is a true honor to be considered for such a role-one that helps rebuild trust with veterans and other stakeholders, improve service delivery focusing on veteran outcomes and set the course for longer-term excellence and reform. As a veteran, I share your strong commitment to improving the lives of all veterans through a healthy and well-functioning VA system. I am also pleased with your focus on reconstituting the MVAC to develop a comprehensive approach toward these goals, by sharing innovative approaches and ideas from many different areas across government, academia, and the private sector. Sharing best practices through the MVAC will help significantly advance your objectives of improving and building a world-class VA system. While I would be honored to serve on the MVAC, given the other commitments I have on my calendar, I am concerned about being able to commit the time to attend every meeting throughout the year. Although I would certainly be able to arrange my schedule to participate in several of the meetings, I would ask if it would be possible to also designate one of Johnson & Johnson's senior leaders to serve as my proxy for those meetings I am unable to attend. Please let me know if this is possible. Thank you and best wishes for continued success in your role as secretary. Sincerely, (b) (6) VA-19-0799-D-000074 DS 00001736 Chairman and Chief Executive Officer Tel : (732) 524-(b) (b) Fax: (732) 524-(6) New E-mail: (b) (6) its .jnj.com (6) VA-19-0799-D-000075 DS_00001737 Message IP [(b) (6) frenchangel59.com] 4/23/2017 4:50:14 PM Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [drshulkin@aol.com] (b) (6) FW: (b) (6) I Time.com From: Sent: To: Subject: fyi EOP/WHO [mailto:(b) (6) From: (b) (6) Sent: Sunday, April 23, 2017 12:19 PM To: (b) (6) EOP/WHO; IP Cc: Kushner, Jared C. EOP/WHO; (b) (6) (b) (6) Subject: RE: (b) (6) I Time.com who.eop.gov] EOP/WHO Reaching out to NIH on the below. The institutions/ leaders that Ike assembled is literally second to none. From: (b) (6) EOP/WHO Sent: Saturday, April 22, 2017 7:09 PM To: IP <(b) (6) frenchangel59.com > Cc: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov>; <(b) (6) who.eop.gov>; (b) (6) (b) (6) Subject: Re: (b) (6) I Time.com Adding (b) (6) (b) (6) EOP/WHO <(b) (6) EOP/WHO who.eop.gov> also Sent from my iPhone On Apr 22, 2017, at 6:56 PM, IP <(b) (6) frenchangel59.com > wrote: The following session was just brought to my attention. It would benefit your program if all of the five CEOs from the Academic Medical Centers that are helping us with the VA effort and The Health Care Reform were to participate. They are (b) (6)(b) (6) from The Mayo Clinic, (b) (6) (b) (6) from Johns Hopkins, (b) (6) (b) (6) from The Cleveland Clinic, (b) (6) from Partners Healthcare. Are from Kaiser (about whom I just wrote you) and (b) (6) (b) (6) you able to include them on the invite list? https://www.bloomberg.com/politics/articles/2017-04-21 /white-house-to-meet-biotech-researchchi efs-after-cuts-proposed From: (b) (6) EOP/WHO [ mailto:(b) (b)(6)(6) Sent: Friday, April 21, 2017 6:29 PM To: IP Cc: Kushner, Jared C. EOP/WHO; (b) (6) (b) (6) Subject: Re: (b) (6) I Time.com who.eop.gov] EOP/WHO Thanks for sending this along. VA-19-0799-D-000076 OS 00001738 On Apr 21, 2017, at 6:24 PM, IP <(b) (6) frenchangel59.com > wrote: Jared, (b) (6) and (b) (6) (b) (6) I would like to share with you an article on (b) (6) the Chairman and CEO of Kaiser Permanente and one of the 5 Academic Medical Center CEOs who are helping us in our effort. (b) (6) has been named by TIME magazine as one of the 100 most influential people in the world. This is a wonderful recognition of his work and his impact on the Heath Care industry. In 2016, he was named the 2nd most influential person in Health Care by Modern Healthcare. (b) (6) is one of the top leaders in the health care industry and has also been a tremendous advisor and resource in our work with the VA He a strong advocate on mental health issues and supporter for the expanded use of technology in medicine. He advocates that the right technology ensures clean, aggregated data from patients' health care records which is used to avoid inconsistent treatment and errors. This is a major focus of ours which prompted our discussions with (b) (6) and Apple. Working with (b) (6) together with the others, has allowed us to make such great progress in such a short period of time. All my Best, Ike http:!/time. com/collection/2017 -time-100/4 7427 45/bernard-j-tyson/ https://share.kaiserpermanente.org/article/chairman-ceo-bemard-j-tyson-kaiserpermanente-named-no-2-modem-healthcare-list-influential-health-care-leaders/ https://www.bloomberg.com/ graphics/2015-how-did-i-get-here/bemardtyson.html VA-19-0799-D-000077 OS 00001739 Message IP [(b) (6) frenchangel59.com] 4/22/2017 11:52:48 PM Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [drshulkin@aol.com] (b) (6) FW: (b) (6) I Time.com From: Sent: To: Subject: FYI - this is for the May 8th summit. From: (b) (6) EOP/WHO [ mailto:(b) (6) Sent: Saturday, April 22, 2017 7:09 PM To: IP Cc: Kushner, Jared C. EOP/WHO; Bremberq, (b) (6) (b) (6) Subject: Re: (b) (6) I Time.com Adding (b) (6) who.eop.gov] P. EOP/WHO; (b) (6) EOP/WHO also Sent from my iPhone On Apr 22, 2017, at 6:56 PM, IP <(b) (6) frenchangel59.com > wrote: The following session was just brought to my attention. It would benefit your program if all of the five CEOs from the Academic Medical Centers that are helping us with the VA effort and The Health Care Reform were to participate. They are (b) (6)(b) (6) from The Mayo Clinic, (b) (6) (b) (6) from Johns Hopkins, (b) (6) (b) (6) from The Cleveland Clinic, (b) (6) from Partners Healthcare. Are from Kaiser (about whom I just wrote you) and (b) (6) (b) (6) you able to include them on the invite list? https://www.bloomberg.com/politics/articles/2017-04-21 /white-house-to-meet-biotech-researchchi efs-after-cuts-proposed P. EOP/WHO [ mailto:(b) From: Bremberq, (b) (6) (b)(6)(6) Sent: Friday, April 21, 2017 6:29 PM To: IP Cc: Kushner, Jared C. EOP/WHO; (b) (6) (b) (6) I Time.com Subject: Re: (b) (6) who.eop.gov] EOP/WHO Thanks for sending this along. On Apr 21, 2017, at 6:24 PM, IP <(b) (6) frenchangel59.com > wrote: Jared, (b) (6) and (b) (6) (b) (6) I would like to share with you an article on (b) (6) the Chairman and CEO of Kaiser Permanente and one of the 5 Academic Medical Center CEOs who are helping us in our effort. (b) (6) has been named by TIME magazine as one of the 100 most influential people in the world. This is a wonderful recognition of his work VA-19-0799-D-000078 OS 00001740 and his impact on the Heath Care industry. In 2016, he was named the 2nd most influential person in Health Care by Modern Healthcare. (b) (6) is one of the top leaders in the health care industry and has also been a tremendous advisor and resource in our work with the VA. He a strong advocate on mental health issues and supporter for the expanded use of technology in medicine. He advocates that the right technology ensures clean, aggregated data from patients' health care records which is used to avoid inconsistent treatment and errors. This is a major focus of ours which prompted our discussions with (b) (6) and Apple. Working with (b) (6) together with the others, has allowed us to make such great progress in such a short period of time. All my Best, Ike http:!/time. com/collection/2017 -time-100/4 7427 45/bernard-j-tyson/ https://share.kaiserpermanente.org/article/chairman-ceo-bemard-j-tyson-kaiserpermanente-named-no-2-modem-healthcare-list-influential-health-care-leaders/ https://www.bloomberg.com/ graphics/2015-how-did-i-get-here/bemardtyson.html VA-19-0799-D-000079 OS 00001741 Message Marc Sherman [(b) (6) gmail.com] 4/24/2017 2:22:43 PM David shulkin [Drshulkin@aol.com] Bruce Moskowitz [(b) (6) mac.com]; L Perl [(b) (6) (b) (6) (b) (6) [ hotmail.com]; IP [ frenchangel59.com] Re: Hopkins From: Sent: To: CC: Subject: gmail.com]; Poonam Alaigh Or dinner reservation is confirmed for 7pm at i Ricchi on Wednesday evening. Once we know who is attending I can send out specifics. Everyone on this email knows where to go or has me with them as a guide. Marc Sherman (202) 758-(b) (6) On Apr 23, 2017 4:43 PM, "David shulkin" wrote: Sounds like a great plan- with the pilot starting in baltimore Sent from my iPhone On Apr 23, 2017, at 11 :06 AM, Bruce Moskowitz <(b) (6) (b) (6) mac.com> wrote: (b) (6) is part of the team we need to advance the plan I proposed in the document at the end of the email. He has the ability to adapt to any existing or future EMR platform so we do not lose time on critical issues. The other part is the team that has the device registry and the team from responsive health.org will be critical to have all 3 in the meeting at the Baltimore VA At the end of the day we will have a unique product that will be of great interest to all health care systems. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (b) (6) From: (b) (6) <(b) (6) cs.jhu.edu> Date: April 23, 2017 at 10:40:51 AM EDT To: Bruce Moskowitz <(b) (6) mac.com> Cc: Aaron Moskowitz <(b) (6) brefnet.org> Subject: Re: VA Thanks for sharing! As promised, here is a first draft of a one-pager on accelerating data-driven advances in healthcare. This a quick synopsis of my thinking. If you think it has legs, I can also bring in more of a brain trust around it. Look forward to your thoughts/comments. (b) (6) (b) (6) (b) (6) Director, Malone Center for Engineering in Healthcare VA-19-0799-D-000080 OS 00001742 Mandell Bellmore Professor, Dept. of Computer Science Assistant: (b) (6) ((b) (6) jhu.edu) On Apr 22, 2017, at 2:44 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: This is what I sent the Secretary David Shulkin. Aaron and his team have the device registry part. The Secretary wants to move quickly and for everyone to see what they have at the Baltimore VA This should be looked at as a business that you all put together and own. I believe if done correctly it will be widely purchased throughout the medical industry. I welcome your trouts and additions to this plan The usual is to have a management system in place that does central purchasing keeping strict control of cost and distribution. We want to go beyond this and have: 24-7 alert for device recalls that not only goes to central purchasing and automatically checks if the device is still on the shelf and if it was implanted, directly alerting the physician and the patient. A device registry that barcodes every device and adds it to the patient record. An added feature to tract over utilization of implantable devices or physicians who are receiving stipends from a device manufacturer. Tract if a particular VA is using more inventory than could be explained by patient volume to prevent pilfering of supplies. Aside from this we are looking how to tract patients who are being treated in the private sector from having unnecessary testing, surgery or medical treatment. Sent from my iPad Bruce Moskowitz M.D. On Apr 22, 2017, at 11 :07 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Sent from my iPad VA-19-0799-D-000081 OS 00001743 Bruce Moskowitz MD. Message David shulkin [Drshulkin@aol.com] 4/23/2017 8:32:41 PM Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com]; (b) (6) [(b) (6) gmail.com] Re: Hopkins From: Sent: To: CC: Subject: gmail.com; IP [(b) (6) frenchangel59.com]; L Perl Sounds like a great plan- with the pilot starting in baltimore Sent from my iPhone On Apr 23, 2017, at 11 :06 AM, Bruce Moskowitz <(b) (6) (b) (6) mac.com> wrote: (b) (6) is part of the team we need to advance the plan I proposed in the document at the end of the email. He has the ability to adapt to any existing or future EMR platform so we do not lose time on critical issues. The other part is the team that has the device registry and the team from responsive health.org will be critical to have all 3 in the meeting at the Baltimore VA At the end of the day we will have a unique product that will be of great interest to all health care systems. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (b) (6) From: (b) (6) <(b) (6) cs.jhu.edu> Date: April 23, 2017 at 10:40:51 AM EDT To: Bruce Moskowitz <(b) (6) mac.com> Cc: Aaron Moskowitz <(b) (6) brefnet.org> Subject: Re: VA Thanks for sharing! As promised, here is a first draft of a one-pager on accelerating data-driven advances in healthcare. This a quick synopsis of my thinking. If you think it has legs, I can also bring in more of a brain trust around it. Look forward to your thoughts/comments. (b) (6) (b) (6) (b) (6) Director, Malone Center for Engineering in Healthcare Mandell Bellmore Professor, Dept. of Computer Science Assistant: (b) (6) ((b) (6) jhu.edu) VA-19-0799-D-000083 OS 00001745 On Apr 22, 2017, at 2:44 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: This is what I sent the Secretary David Shulkin. Aaron and his team have the device registry part. The Secretary wants to move quickly and for everyone to see what they have at the Baltimore VA This should be looked at as a business that you all put together and own. I believe if done correctly it will be widely purchased throughout the medical industry. I welcome your trouts and additions to this plan The usual is to have a management system in place that does central purchasing keeping strict control of cost and distribution. We want to go beyond this and have: 24-7 alert for device recalls that not only goes to central purchasing and automatically checks if the device is still on the shelf and if it was implanted, directly alerting the physician and the patient. A device registry that barcodes every device and adds it to the patient record. An added feature to tract over utilization of implantable devices or physicians who are receiving stipends from a device manufacturer. Tract if a particular VA is using more inventory than could be explained by patient volume to prevent pilfering of supplies. Aside from this we are looking how to tract patients who are being treated in the private sector from having unnecessary testing, surgery or medical treatment. Sent from my iPad Bruce Moskowitz M.D. On Apr 22, 2017, at 11 :07 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000084 OS 00001746 Message From: Sent: To: CC: Subject: Attachments: (b) (6) Bruce Moskowitz [(b) (6) mac.com] 4/23/2017 3:06:14 PM David shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) hotmail.com] mbs(b) (6) @gmail.com; IP [(b) (6) frenchangel59.com]; L Perl [(b) (6) gmail.com] Hopkins FourSteps-Moscovitz-Healthcare-Vl.docx; Untitled attachment 04128.htm (b) (6) is part of the team we need to advance the plan I proposed in the document at the end of the email. He has the ability to adapt to any existing or future EMR platform so we do not lose time on critical issues. The other part is the team that has the device registry and the team from responsive health.org will be critical to have all 3 in the meeting at the Baltimore VA At the end of the day we will have a unique product that will be of great interest to all health care systems. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (b) (6) From: (b) (6) <(b) (6) cs.jhu.edu> Date: April 23, 2017 at 10:40:51 AM EDT To: Bruce Moskowitz <(b) (6) mac.com> (b) (6) Cc: Aaron Moskowitz < brefnet.org> Subject: Re: VA Thanks for sharing! As promised, here is a first draft of a one-pager on accelerating data-driven advances in healthcare. This a quick synopsis of my thinking. If you think it has legs, I can also bring in more of a brain trust around it. Look forward to your thoughts/comments. (b) (6) (b) (6) (b) (6) Director, Malone Center for Engineering in Healthcare Mandell Bellmore Professor, Dept. of Computer Science Assistant: (b) (6) ((b) (6) jhu.edu) VA-19-0799-D-000085 OS 00001747 A Four Step Plan to Advance High-Value Healthcare (b) (6) (b) (6) Draft 1: 4/23/17 Today's healthcare landscape is fragmented, inconsistent, and costly. The same patient can go to two different clinics, get two different diagnoses and treatments, and pay two (sometimes startlingly) different costs. This is wrong for the patient individually, and costs the nation as a whole. Thus, the key question we seek to address is: How can we ensure that every patient can go into any clinic or hospital and ensure that patient gets the same high quality of care for the same cost no matter where they go? There is only one answer to this question: data describing both patient and the performance of healthcare organizations must be made accessible, sharable and actionable. We must promote a culture of openness, discovery, sharing, and action, and create an innovation system that finds value in data, and drives that value into the world. The solution must bridge the gap between existing health records systems, which are typically unique to an organization, and the power of private-sector innovation to mine, structure, and produce actionable results from data. To make this operational, we need to spur private-sector R&D to address immediate, high-priority challenges that exist today, and expand those efforts to "get ahead of the curve" and address the challenges of tomorrow now. Our proposal has four key points: 1) Create very low barriers to entry to healthcare data for both the private sector and research organizations so that more organizations can rapidly explore the opportunity space. Accelerate this by creating consistent and standardized linkages into existing EHR systems to reduce needless replication of effort. 2) Create a standardized value return system, together with standardized legal and privacy safeguards, for all stakeholders. More specifically, any value created by a company from the EHR that is adopted and scaled will be returned, in part, to the providers of the data. The government can help spur this development through public/private partnerships that define and create common infrastructure and convene a group to define the "rules of engagement." 3) Create a "clearing house" of high priority problems for the VA as a starting point, and develop 3-5 focused "loss-leader" pilot projects that can identify common barriers and which can explore the common infrastructure and policy issues necessary to address them. 4) Define mechanisms for external companies to implement with healthcare organizations to accelerate deployment and testing of new technologies in patient monitoring and care. VA-19-0799-D-000086 OS 00001748 On Apr 22, 2017, at 2:44 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: This is what I sent the Secretary David Shulkin. Aaron and his team have the device registry part. The Secretary wants to move quickly and for everyone to see what they have at the Baltimore VA This should be looked at as a business that you all put together and own. I believe if done correctly it will be widely purchased throughout the medical industry. I welcome your trouts and additions to this plan The usual is to have a management system in place that does central purchasing keeping strict control of cost and distribution. We want to go beyond this and have: 24- 7 alert for device recalls that not only goes to central purchasing and automatically checks if the device is still on the shelf and if it was implanted, directly alerting the physician and the patient. A device registry that barcodes every device and adds it to the patient record. An added feature to tract over utilization of implantable devices or physicians who are receiving stipends from a device manufacturer. Tract if a particular VA is using more inventory than could be explained by patient volume to prevent pilfering of supplies. Aside from this we are looking how to tract patients who are being treated in the private sector from having unnecessary testing, surgery or medical treatment. Sent from my iPad Bruce Moskowitz M.D. On Apr 22, 2017, at 11:07 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000087 OS 00001749 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/24/2017 7:09:56 PM To: (b) (6) Subject: Attachments: gmail.com slides april25thtoppriorities.pptx VA-19-0799-D-000088 OS 00001750 , IA V'"' I U.S. Department ofVeterans Affairs Leadership Priorities for VA David J. Shulkin, MD Secretary of Veterans Affairs April 19, 2017 VA-19-0799-D-000089 OS 00001751 Don't Plan on Incremental Change 38 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000090 OS 00001752 The Next Phoenix? Draft/ Pre-dec1s1onal / For Internal VA Use Only 3 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000091 OS 00001753 Ask the Right Questions Two Things Every Leader Needs to Know: • Am I pushing too hard or not hard enough? • What don't I know that is likely to damage the organization? 4 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000092 OS 00001754 "What Else Don't "We Know? Identify the Risk • Wait Times- 144 sites with Primary Care waits greater than 30 days 51 sites with Mental Health waits greater than 30 days 68 sites with Specialty care waits greater than 30 days • Infrastructure and Equipment- 1.4 Billion in projects on hold • Systems- Inventory Control • Staffing- Loss of nurses in Buffalo • What Else? Draft/ Pre-dec1s1onal / For Internal VA Use Only 5 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000093 OS 00001755 Why Wow? What happens if we don't change? / I BUSINESS AS USUAL Draft/ Pre-dec1s1onal / For Internal VA Use Only 6 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000094 DS_00001756 7 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000095 DS_00001757 Making Tough Decisions (Quicker) 8 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000096 OS 00001758 United's Response Ill r'::itertJayseDavid 4:51 PM ET UNITED DRAGS PASSENGER FROM OVERBOOKED FLIGHT THE LEAD Draft/ Pre-dec1s1onal / For Internal VA Use Only 9 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000097 OS 00001759 Draft/ Pre-dec1s1onal / For Internal VA Use Only 10 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000098 DS_ 00001760 Demonstrate Your Commitment to the Mission 11 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000099 OS 00001761 Take on the Tough Issues Run Towards the Gun Fire 12 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000100 OS 00001762 From: Inc. United Airlines To: Vet eran Sm ith Important update about your checked baggage Today at 9:09 AM We're sorry, but your checked bag will arrive on a later fl ight to Philadelph ia. When you arrive, please see a Baggage Service representative in Baggage Claim to arrange your choice of delivery or pickup. We apologize for this disruption to your plans today. VA-19-0799-D-000101 OS 00001763 Focus On Your People I,_ My VA Organizational Hicrard1y _ ~ • .._ ( ., ~ Dr D111ld Shulkln, VA Under Se Sent: Saturday, April 22, 2017 11:56 AM To: Poonam Alaigh Subject: This morning http://www.cbsnews.com/videos/va-secreta ry-david-sh u Ikin-on-cha Ile nges-faci ng-the-age ncy/?ftag=CN M-0010aa b4i VA Secretary David Shulkin on challenges facing the agency www.cbsnews.com President Trump signed a law this week extending a pilot program on health care for veterans that allows some to receive treatment through private providers. Veterans Affairs Secretary David Shu Ikin joins "CBS This Morning: Saturday" to discuss the challenges facing the agency and the issues affecting veterans. --------------------································································································································································································· Sent from my iPhone VA-19-0799-D-000126 OS 00001788 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/22/2017 3:56:28 PM Poonam Alaigh [(b) (6) hotmail.com] This morning http ://www. cb snews.com/vi deos/va-secretary-davi d-shulkin-on-chall enges-facing-the-agency/?ftag=CNM-00l 0aab4 i Sent from my iPhone VA-19-0799-D-000127 OS 00001789 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/21/2017 10:42:20 AM David shulkin [Drshulkin@aol.com] Re: What do you think I thought your view on consultants had changed- anyway, we should discuss this on the train- if we collectively have to succeed- we need the right team - otherwise our traction will only be short lived this has to be our #1 priority - surrounding ourselves with the right people!! Sent from my iPhone > on Apr 21, 2017, at 6:24 AM, David shulkin wrote: > > You of course can do what you want > > I think you need a strong pdush and dushom for what you need > > Cos needs to be string too but cannot manage your issues outside- where the crises occur > what has he done? what is he > Blackburn wont do it and even if he would dont see him as strong doing? He is a consultant that talks a good game but does very little > > Sent from my iPhone > >> on Apr 21, 2017, at 6:04 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >> >> Jon Perlin and I had lunch together yesterday and one big advice he gave was regarding the criticality of the chief of staff- I don't think I have the right executive in that role - I have been thinking about it all night- suddenly it struck me that scott Blackburn could do it- what do yuh think - I trust him, he has somewhat of a strategic sense and I think because of his other roles, he will be able to implement and address things - Jon spent the entire lunch helping me understand how we needed to elevate this role from a "super secretary" to an executive that is the #2 person. I realize now that I have been drowning because I am working with supersecrtaries >> >> Sent from my iPhone > VA-19-0799-D-000128 OS 00001790 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/21/2017 10:24:27 AM Poonam Alaigh [(b) (6) hotmail.com] Re: What do you think You of course can do what you want I think you need a strong pdush and dushom for what you need Cos needs to be string too but cannot manage your issues outside- where the crises occur Blackburn wont do it and even if he would dont see him as strong He is a consultant that talks a good game but does very little what has he done? what is he doing? Sent from my iPhone > on Apr 21, 2017, at 6:04 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Jon Perlin and I had lunch together yesterday and one big advice he gave was regarding the criticality of the chief of staff- I don't think I have the right executive in that role - I have been thinking about it all night- suddenly it struck me that scott Blackburn could do it- what do yuh think - I trust him, he has somewhat of a strategic sense and I think because of his other roles, he will be able to implement and address things - Jon spent the entire lunch helping me understand how we needed to elevate this role from a "super secretary" to an executive that is the #2 person. I realize now that I have been drowning because I am working with supersecrtaries > > Sent from my iPhone VA-19-0799-D-000129 OS 00001791 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/21/2017 10:04:03 AM David Shulkin [drshulkin@aol.com] What do you think Jon Perlin and I had lunch together yesterday and one big advice he gave was regarding the criticality of the chief of staff- I don't think I have the right executive in that role - I have been thinking about it all night- suddenly it struck me that scott Blackburn could do it- what do yuh think - I trust him, he has somewhat of a strategic sense and I think because of his other roles, he will be able to implement and address things - Jon spent the entire lunch helping me understand how we needed to elevate this role from a "super secretary" to an executive that is the #2 person. I realize now that I have been drowning because I am working with supersecrtaries Sent from my iPhone VA-19-0799-D-000130 OS 00001792 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/22/2017 3:13:09 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Aww No its not easy Sent from my iPhone On Apr 22, 2017, at 11: 10 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: In addition, his wife is leading an organization that is pro- ACA- not an easy situation From: David shulkin Sent: Saturday, April 22, 2017 8:28 AM To: Poonam Alaigh Subject: Fwd: Aww http://m.ndtv.com/world-news/i nd ia n-a me rica n-su rgeon-ge ne ra I-asked-to-ste pdown-by-tru m p-government-1684567 Trump Admini strati on Asks IndianAmerica n Surgeon General To Step Down m.ndtv.com Indian-American Surgeon General Vivek Murthy, app by the previous Obama regime, has been asked to st down by the Trump administration to put its own lea in place. VA-19-0799-D-000131 OS 00001793 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/22/2017 3:10:13 PM David shulkin [Drshulkin@aol.com] Re: Aww In addition, his wife is leading an organization that is pro- ACA- not an easy situation From: David shulkin Sent: Saturday, April 22, 2017 8:28 AM To: Poonam Alaigh Subject: Fwd: Aww http://m.ndtv.com/world-news/indian-american-surgeon-general-asked-to-step-down-bytrump-government-1684567 Trump Administration Asks IndianAmerican Surgeon General To Step Down m.ndtv.com Indian-American Surgeon General Vivek Murthy, appointed by the previous Obama regime, has been asked to step down by the Trump administration to put its own leadership in place. VA-19-0799-D-000132 OS 00001794 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/22/2017 12:33:44 PM (b) (6) [(b) (6) Re: Aww gmail.com] How long is the aha presentation for? Sent from my iPhone On Apr 22, 2017, at 8: 15 AM, (b) (6) <(b) (6) gmail.com> wrote: http ://m.ndtv.com/world-news/indian-american-surgeon-general-asked-to-step-down-by-trumpgovemment-1684567 VA-19-0799-D-000133 OS 00001795 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/22/2017 12:28:55 PM (b) (6) [(b) (6) Re: Aww gmail.com] I heard this am Sent from my iPhone On Apr 22, 2017, at 8: 15 AM, (b) (6) <(b) (6) gmail.com> wrote: http ://m.ndtv.com/world-news/indian-american-surgeon-general-asked-to-step-down-by-trumpgovemment-1684567 VA-19-0799-D-000134 OS 00001796 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/22/2017 12:28:43 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Aww http ://m.ndtv.com/world-news/indian-american-surgeon-general-asked-to-step-down-by-trumpgovemment-1684567 VA-19-0799-D-000135 OS 00001797 Message From: (b) (6) Sent: 4/22/2017 12:15:47 PM David Shulkin [drshulkin@aol.com] Aww To: Subject: [(b) (6) gmail.com] http ://m.ndtv.com/world-news/indian-american-surgeon-general-asked-to-step-down-by-trump-government1684567 VA-19-0799-D-000136 OS 00001798 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/19/2017 10:24:53 AM Poonam Alaigh [(b) (6) hotmail.com] Re:Today Ok Sent from my iPhone > on Apr 19, 2017, at 6:06 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Would've been so sweet for me to be with you when Brian is there - want so much for that!! Next opportunity for sure! > > Sent from my iPhone VA-19-0799-D-000137 OS 00001799 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/19/2017 10:06:27 AM David Shulkin [drshulkin@aol.com] Today Would've been so sweet for me to be with you when Brian is there - want so much for that!! Next opportunity for sure! Sent from my iPhone VA-19-0799-D-000138 OS 00001800 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 6/11/2017 2:09:59 PM Marisol Garcia [(b) (6) frenchangel59.com] L Perl [(b) (6) gmail.com]; (b) (6) hotmail.com; David shulkin [Drshulkin@aol.com]; mbs(b) (6) @gmail.com; (b) (6) frenchangel59.com Re: PRE-CONFERENCE CALL TODAY SUNDAY, JUNE 11TH AT 10:30 AM -- PLEASE NOTE THAT WE HAVE A DIFFERENT CONFERECE TELEPHONE NUMBER FOR THIS CALL Saw this will use this call in Sent from my iPad Bruce Moskowitz M.D. On Jun 11, 2017, at 10:02 AM, Marisol Garcia <(b) (6) frenchangel59.com > wrote: (b) (6) Good morning - Any questions please call me at 212-576Sunday, June 11th 10:30 AM - 10:50 AM EST Dial-in Information: US: 1-605-475-5604 Passcode:521933# Participants: Laurie (Optional) Marc Sherman - Not sure if able to participate Secretary David Shulkin and Poonam Alaigh Dr. Bruce Moskowitz and Ike All my Best, Marisol 212-576-(b) (6) (Office) 212-576-(b) (6) (Weekend) 646-668-(b) (6) (Cell) Email: (b) (6) frenchangel59.com VA-19-0799-D-000139 OS 00001801 Message From: Sent: To: Subject: Marisol Garcia [(b) (6) frenchangel59.com] 6/11/2017 2:02:12 PM L Perl [(b) (6) gmail.com]; (b) (6) hotmail.com; David shulkin [Drshulkin@aol.com]; Bruce Moskowitz (b) (6) [ mac.com]; mbs(b) (6) @gmail.com; (b) (6) frenchangel59.com PRE-CONFERENCE CALL TODAY SUNDAY, JUNE 11TH AT 10:30 AM -- PLEASE NOTE THAT WE HAVE A DIFFERENT CONFERECE TELEPHONE NUMBER FOR THIS CALL (b) (6) Good morning -Any questions please call me at 212-576Sunday, June 11th 10:30 AM - 10:50 AM EST Dial-in Information: US: 1-605-475(b) (6) (b) (6) Passcode: Participants: Laurie (Optional) Marc Sherman - Not sure if able to participate Secretary David Shulkin and Poonam Alaigh Dr. Bruce Moskowitz and Ike All my Best, Marisol 212-576-(b) (6) (Office) 212-576-(b) (6) (Weekend) 646-668-(b) (6) (Cell) Email: (b) (6) frenchangel59.com VA-19-0799-D-000141 OS 00001803 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/23/2017 2:39:08 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Stan sure Sent from my iPhone > on Apr 23, 2017, at 9:23 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Do you have time to Join stan and I for dinner on 5/22- Monday. He called yesterday, has been going through a lot- he will be in de that day > > Sent from my iPhone VA-19-0799-D-000142 OS 00001804 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/23/2017 1:23:18 PM David Shulkin [drshulkin@aol.com] Stan Do you have time to Join stan and I for dinner on 5/22- Monday. He called yesterday, has been going through a lot- he will be in de that day Sent from my iPhone VA-19-0799-D-000143 OS 00001805 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/26/2017 2:39:26 AM (b) (6) [(b) (6) hotmail.com] Re: [EXTERNAL] RE: two questions 645- I may get home sooner Sent from my iPad On Apr 25, 2017, at 10:08 PM, (b) (6) <(b) (6) hotmail.com> wrote: Great what time do u pick me up? Sent from my iPhone On Apr 25, 2017, at 10:04 PM, David shulkin wrote: Sent from my iPhone Begin forwarded message: (b) (6) (b) (6) From: "(b) (6) <(b) (6) va.gov> Date: April 25, 2017 at 6:58:45 PM EDT To: 'drshulkin' Subject: FW: [EXTERNAL] RE: two questions -----Original Message----From: Marisol Garcia [(b) (6) frenchangel59.com] Sent: Tuesday, April 25, 2017 06:29 PM Eastern Standard Time (b) (6) To: (b) (6) (b) (6) Cc: Subject: RE: [EXTERNAL] RE: two questions Yes. We have (b) (6) From: (b) (6) as attending. Thank you (b) (6) [ mailto:(b) (6) (b) (6) va.gov] Sent: Tuesday, April 25, 2017 12:25 PM To: 'Marisol Garcia' Cc: (b) (6) Subject: RE: [EXTERNAL] RE: two questions VA-19-0799-D-000144 OS 00001806 Dr. Shulkin' s wife - (b) (6) Shulkin From: Marisol Garcia [mailto:(b) @frenchanqel59.com] (6) Sent: Tuesday, April 25, 2017 12:24 PM (b) (6) To: (b) (6) Cc: (b) (6) Subject: [EXTERNAL] RE: two questions I am sorry who is (b) (6) We are trying to get the names of the CEO's as soon as possible. Thank you From: (b) (6) (b) (6) [ mailto:(b) (6) (b) (6) a.gov] Sent: Tuesday, April 25, 2017 11:51 AM To: Marisol Garcia ((b) @frenchanqel59.com) (6) Cc: (b) (6) Subject: two questions Hi Marisol, Would it be ok for (b) (6) with Ike, Jared etc? to attend the dinner tomorrow at 7pm Do you know the names of the ceo's that want to attend with Ike on Thursday here at VA for the Potus event? The Secretary mentioned- (b) (6) and (b) (6) (b) (6) Thanks VA-19-0799-D-000145 OS 00001807 (b) (6) MBA Special Advisor to the Secretary Department of Veterans Affairs 202-461-(b) (6) 202-834-(b) (6) VA-19-0799-D-000146 OS 00001808 Message From: Sent: To: Subject: (b) (6) [(b) (6) hotmail.com] 4/26/2017 2:08:14 AM David shulkin [Drshulkin@aol.com] Re: [EXTERNAL] RE: two questions Great what time do u pick me up? Sent from my iPhone On Apr 25, 2017, at 10:04 PM, David shulkin wrote: Sent from my iPhone Begin forwarded message: (b) (6) From: "(b) (6) <(b) (6) Date: April 25, 2017 at 6:58:45 PM EDT To: 'drshulkin' Subject: FW: [EXTERNAL] RE: two questions va.gov> -----Original Message----From: Marisol Garcia [(b) (6) frenchangel59.com] Sent: Tuesday, April 25, 2017 06:29 PM Eastern Standard Time (b) (6) To: (b) (6) (b) (6) Cc: Subject: RE: [EXTERNAL] RE: two questions Yes. We have (b) (6) as attending. Thank you (b) (6) [ mailto:(b) (6) From: (b) (6) Sent: Tuesday, April 25, 2017 12:25 PM To: 'Marisol Garcia' a.gov] Cc: (b) (6) Subject: RE: [EXTERNAL] RE: two questions Dr. Shulkin' s wife - (b) (6) Shulkin @frenchanqel59.com ] From: Marisol Garcia [mailto:(b) (6) Sent: Tuesday, April 25, 2017 12:24 PM (b) (6) To: (b) (6) VA-19-0799-D-000147 OS 00001809 Cc: (b) (6) Subject: [EXTERNAL] RE: two questions I am sorry who is (b) (6) We are trying to get the names of the CEO's as soon as possible. Thank you (b) (6) [ mailto:(b) (6) From: (b) (6) Sent: Tuesday, April 25, 2017 11:51 AM To: Marisol Garcia ((b) q@frenchanqel59.com) (6) va.gov] Cc: (b) (6) Subject: two questions Hi Marisol, Would it be ok for (b) (6) etc? to attend the dinner tomorrow at 7pm with Ike, Jared Do you know the names of the ceo's that want to attend with Ike on Thursday here at VA for the Potus event? The Secretary mentioned - (b) (6) and (b) (6) (b) (6) Thanks (b) (6) MBA Special Advisor to the Secretary Department of Veterans Affairs 202-461-(b) (6) 202-834-(b) (6) VA-19-0799-D-000148 OS 00001810 9-0799-D-000149 1 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/26/2017 1:59:38 AM To: (b) (6) Subject: [(b) (6) hotmail.com] Fwd: [EXTERNAL] RE: two questions Sent from my iPhone Begin forwarded message: (b) (6) From: "(b) (6) <(b) (6) Date: April 25, 2017 at 6:58:45 PM EDT To: 'drshulkin' Subject: FW: [EXTERNAL] RE: two questions va.gov> -----Original Message----From: Marisol Garcia [(b) (6) frenchangel59.com] Sent: Tuesday, April 25, 2017 06:29 PM Eastern Standard Time (b) (6) To: (b) (6) (b) (6) Cc: Subject: RE: [EXTERNAL] RE: two questions Yes. We have (b) (6) as attending. Thank you (b) (6) [ mailto:(b) (6) From: (b) (6) Sent: Tuesday, April 25, 2017 12:25 PM To: 'Marisol Garcia' va.gov] Cc: (b) (6) Subject: RE: [EXTERNAL] RE: two questions Dr. Shulkin' s wife - (b) (6) Shulkin @frenchanqel59.com ] From: Marisol Garcia [mailto:(b) (6) Sent: Tuesday, April 25, 2017 12:24 PM (b) (6) To: (b) (6) Cc: (b) (6) Subject: [EXTERNAL] RE: two questions I am sorry who is (b) (6) VA-19-0799-D-000150 OS 00001812 We are trying to get the names of the CEO's as soon as possible. Thank you (b) (6) [ mailto:(b) (6) From: (b) (6) Sent: Tuesday, April 25, 2017 11:51 AM To: Marisol Garcia ((b) @frenchanqel59.com) (6) a.gov] Cc: (b) (6) Subject: two questions Hi Marisol, Would it be ok for (b) (6) to attend the dinner tomorrow at 7pm with Ike, Jared etc? Do you know the names of the ceo's that want to attend with Ike on Thursday here at VA for the Potus event? The Secretary mentioned - (b) (6) and (b) (6) (b) (6) Thanks (b) (6) MBA Special Advisor to the Secretary Department of Veterans Affairs 202-461-(b) (6) 202-834-(b) (6) VA-19-0799-D-000151 OS 00001813 Message From: (b) (6) Sent: 4/25/2017 10:58:45 PM 'drshulkin' [drshulkin@aol.com] FW: [EXTERNAL] RE: two questions To: Subject: (b) (6) [(b) (6) va.gov] -----Original Message----From: Marisol Garcia [(b) (6) frenchangel59.com] Sent: Tuesday, April 25, 2017 06:29 PM Eastern Standard Time (b) (6) To: (b) (6) (b) (6) Cc: Subject: RE: [EXTERNAL] RE: two questions Yes. We have (b) (6) as attending. Thank you (b) (6) From: (b) (6) [mailto:(b) (6) Sent: Tuesday, April 25, 2017 12:25 PM To: 'Marisol Garcia' va.gov] Cc: (b) (6) Subject: RE: [EXTERNAL] RE: two questions Dr. Shulkin's wife - (b) (6) Shulkin From: Marisol Garcia [ mailto:(b) (6) renchangel59.com ] Sent: Tuesday, April 25, 2017 12:24 PM (b) (6) To: (b) (6) Cc: (b) (6) Subject: [EXTERNAL] RE: two questions I am sorry who is (b) (6) We are trying to get the names of the CEO's as soon as possible. Thank you (b) (6) From: (b) (6) [ mailto:(b) (6) Sent: Tuesday, April 25, 2017 11:51 AM To: Marisol Garcia ((b) @frenchanqel59.com) (6) va.gov] Cc: (b) (6) Subject: two questions Hi Marisol, Would it be ok for (b) (6) to attend the dinner tomorrow at 7pm with Ike, Jared etc? Do you know the names of the ceo's that want to attend with Ike on Thursday here at VA for the Potus event? The Secretary mentioned - (b) (6) and (b) (6) (b) (6) Thanks VA-19-0799-D-000152 OS 00001814 (b) (6) MBA Special Advisor to the Secretary Department of Veterans Affairs 202 -461 ·(b) (6) 202·834· (b) (6) VA-19-0799-D-000153 DS_00001815 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 5/3/2017 12:48:32 AM (b) (6) @gmail.com Re: Senate Accountability Bill That's good news. -----Original Message----From: Darin Selnick <(b) (6) @gmail.com> To: David Shulkin Sent: Tue, May 2, 2017 7:12 pm Subject: Senate Accountability Bill I am told by Rubio staff to keep this confidential, but there will be a surprise announcement by noon tomorrow on an agreed upon accountability bill sponsored by Rubio, Tester and Isakson. Darin Sent from my iPhone VA-19-0799-D-000154 OS 00001816 Message From: Darin Selnick [(b) (6) Sent: 5/2/2017 11:12:00 PM To: David Shulkin [Drshulkin@aol.com] Senate Accountability Bill Subject: @gmail.com] I am told by Rubio staff to keep this confidential, but there will be a surprise announcement by noon tomorrow on an agreed upon accountability bill sponsored by Rubio, Tester and Isakson. Darin Sent from my iPhone VA-19-0799-D-000155 OS 00001817 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/29/2017 2:35:05 AM Poonam Alaigh [(b) (6) hotmail.com] Re: This was the clip that they played introducing me Thursday That was so perfect Sent from my iPad On Apr 28, 2017, at 7:00 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Miguel found this on Y ouTube and surprised me as part of the intro to my opening session https://m.youtube .com/watch?v=dhj GO XeWRDM Sent from my iPad VA-19-0799-D-000156 OS 00001818 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/28/2017 11:00:25 PM Drshulkin@aol.com This was the clip that they played introducing me Thursday Miguel found this on Y ouTube and surprised me as part of the intro to my opening session https ://m.youtube.com/watch?v=dhjGOXeWRDM Sent from my iPad VA-19-0799-D-000157 OS 00001819 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/20/2017 2:47:54 AM brucem(b)(b) (6) @mac.com (6) Re: [EXTERNAL] Forwarding Email with Attachments on Behalf of (b) (6) Diabetes Centers Inc. MD - Sa lick Comprehensive Sounds good- Let me see what he proposes specifically and forward to youDavid -----Original Message----From: Bruce Moskowitz <(b) (6) mac.com> To: David shulkin Sent: Wed, Apr 19, 2017 7:45 pm Subject: Re: [EXTERNAL] Forwarding Email with Attachments on Behalf of (b) (6) Diabetes Centers Inc. MD - Salick Comprehensive I know him very well. Perhaps when you get these offers I can assist in nicely telling them if they want to donate their expertise great. Sent from my iPad Bruce Moskowitz M.D. On Apr 19, 2017, at 7:11 PM, David shulkin wrote: Bruce- any thoughts on this before I respond? David Forwarding Email with Attachments on Behalf of (b) (6) Centers Inc. MD - Salick Comprehensive Diabetes Dear Dr. Shulkin, Forwarding the attached to you on behalf of (b) (6) M.D. as follows: 1. Letter Dated April 19, 2017 2. (b) (6) M.D. - Bio 3. Salick Comprehensive Diabetes Centers, Inc. - Executive Summary I have also listed Dr. (b) (6) contact information: (b) (6) M.D. Chairman of the Board Chief Executive Officer Salick Comprehensive Diabetes Centers, Inc. 9777 Wilshire Boulevard, Suite 512 Beverly Hills, California 90212 Direct: 310-967-(b) (6) Fax: 310-967-(b) (6) Mobile: 310-729-(b) (6) 310-729-(b) (6) (b) (6) aol.com Please respond directly to (b) (6) at: (b) (6) aol.com Thank you. VA-19-0799-D-000158 OS 00001820 Sincerely, Sent Via Assistant's Email (b) (6) Executive Assistant to: Dr. (b) (6) Salick Comprehensive Diabetes Centers, Inc. 9777 Wilshire Boulevard, Suite 512 Beverly Hills, California 90212 (b) (6) salickcenters.com 310-967-(b) (6) (0) 310-967-(b) (6) (Fax) This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing, or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email or contact the sender at the number listed. <(b) (6) MD Bio.pdf> VA-19-0799-D-000159 OS 00001821 Message From: Bruce Moskowitz [(b) (6) Sent: 4/19/2017 11:45:31 PM To: David shulkin [Drshulkin@aol.com] Re: [EXTERNAL] Forwarding Email with Attachments on Behalf of (b) (6) Diabetes Centers Inc. Subject: mac.com] MD - Sa lick Comprehensive I know him very well. Perhaps when you get these offers I can assist in nicely telling them if they want to donate their expertise great. Sent from my iPad Bruce Moskowitz M.D. On Apr 19, 2017, at 7: 11 PM, David shulkin wrote: Bruce- any thoughts on this before I respond? David Forwarding Email with Attachments on Behalf of (b) (6) Diabetes Centers Inc. MD - Salick Comprehensive Dear Dr. Shulkin, Forwarding the attached to you on behalf of (b) (6) M.D. as follows: 1. Letter Dated April 19, 2017 2. (b) (6) M.D. - Bio 3. Salick Comprehensive Diabetes Centers, Inc. - Executive Summary I have also listed Dr. (b) (6) contact information: (b) (6) M.D. Chairman of the Board Chief Executive Officer Salick Comprehensive Diabetes Centers, Inc. 9777 Wilshire Boulevard, Suite 512 Beverly Hills, California 90212 VA-19-0799-D-000160 OS 00001822 Direct: 310-967-(b) (6) Fax: 310-967-(b) (6) Mobile: 310-729-(b) (6) 310-729-(b) (6) (b) (6) aol.com Please respond directly to (b) (6) at: (b) (6) aol.com Thank you. Sincerely, Sent Via Assistant's Email (b) (6) Executive Assistant to: Dr. (b) (6) Salick Comprehensive Diabetes Centers, Inc. 9777 Wilshire Boulevard, Suite 512 Beverly Hills, California 90212 (b) (6) salickcenters.com 310-967-(b) (6) (0) 310-967-(b) (6) (Fax) This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing, or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email or contact the sender at the number listed. <(b) (6) MD Bio.pd±> VA-19-0799-D-000161 OS 00001823 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/19/2017 11:11:23 PM Bruce Moskowitz [(b) (6) mac.com] Fwd: [EXTERNAL] Forwarding Email with Attachments on Behalf of (b) (6) Diabetes Centers Inc. April 19 2017 Shulkin Letter.pdf; Untitled attachment 04290.htm; (b) (6) 04293.htm; SCDC Executive Summary.pdf; Untitled attachment 04296.htm MD - Sa lick Comprehensive MD Bio.pdf; Untitled attachment Bruce- any thoughts on this before I respond? David Forwarding Email with Attachments on Behalf of (b) (6) Centers Inc. MD - Salick Comprehensive Diabetes Dear Dr. Shulkin, Forwarding the attached to you on behalf of (b) (6) M.D. as follows: 1. Letter Dated April 19, 2017 2. (b) (6) M.D. - Bio 3. Salick Comprehensive Diabetes Centers, Inc. - Executive Summary I have also listed Dr. (b) (6) contact information: (b) (6) M.D. Chairman of the Board Chief Executive Officer Salick Comprehensive Diabetes Centers, Inc. 9777 Wilshire Boulevard, Suite 512 Beverly Hills, California 90212 Direct: 310-967-(b) (6) Fax: 310-967-(b) (6) Mobile: 310-729-(b) (6) 310-729-(b) (6) (b) (6) aol.com Please respond directly to (b) (6) at: (b) (6) aol.com VA-19-0799-D-000162 OS 00001824 Thank you. Sincerely, Sent Via Assistant's Email (b) (6) Executive Assistant to: Dr. (b) (6) Salick Comprehensive Diabetes Centers, Inc. 9777 Wilshire Boulevard, Suite 512 Beverly Hills, California 90212 (b) (6) salickcenters.com 310-967-(b) (6) (0) 310-967-(b) (6) (Fax) This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing, or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email or contact the sender at the number listed. VA-19-0799-D-000163 OS 00001825 SALi CK COMPREHENSIVE DIABETES CENTERS, \NC. April 19, 2017 Via Priority Federal Express and Email David Shulkin, M.D. Secretary of Veteran's Affairs Department of Veteran's Affairs 810 Vermont Avenue, NW Washington DC 20420 Dear David: Congratulations on your appointment as the head of the Veterans Administration! I recently called (b) (6) and (b) (6) , both dear friends of ours, so that I could get your private email, and quickly speak to you, to avoid inevitable delays in governmental systems. Stan, Steve, and I agree that there is no better person than you to run the Veterans Administration health care system, with your background, credibility, and experience in all aspects of medicine. I remember being involved with you a number of times when I was back East, negotiating with a variety of New York and New Jersey health systems including Continuum (Beth Israel, Maimonides) and Montefiore Medical Center and adjoining areas. My company, Salick Healthcare, Inc, (SHC), was one of your first clients for Doctor Quality, and I know we benefited from our mutual relationship as we both sought to increase transparency in health care. As you may remember, I have been a pioneer in the creation of successful comprehensive outpatient diagnostic and treatment centers for catastrophic diseases such as cancer, end-stage renal disease (ESRD), and now diabetes mellitus, for the past 50+ years, I was able to open the first 24/7 outpatient comprehensive cancer center at Cedars Sinai Medical Center in Los Angeles, subsequently developing 18 cancer centers around the USA and eventually selling my company for $500mm to AstraZeneca. After leaving AstraZeneca because I rejected an emeritus position, I continued as Bentley Health Care for several years. Throughout my career, I have dealt with private, for-profit, academic centers, governmental agencies such as the National Health Service (NHS) in the UK, CMS (Medicare), and the archdioceses of New York and Brooklyn, and the Daughters of Charity in California. I have continued to explore the establishment of Salick Health Care-type facilities at academic centers and private carriers throughout the country. l have focused my attention to the diagnosis and treatment of diabetes mellitus, especially its microvascular complications, which I now believe is, in my opinion, the most important and catastrophic illness, both for patient morbidity, mortality, and increasing financial costs. I was offered the CEO position at Harvard's Joslin Clinic in Boston by its then CEO and board, approximately five years ago. I rejected this offer because Joslin did not provide the kind of comprehensive approach which I had already 9111 WILSHIRE BOULEVMW, 5U!TE ; 12, !.lEVl.aRLY 1-HlLS, CAUFORN!A 90212 l'HONE 3l0 967.(b) (6) FAX J!O 961.(b) (6) VA-19-0799-D-000164 OS 00001826 developed at Salick Health Care. I have spent the last several years learning more about the disease and care delivery in multiple settings, and have met with many health care providers and academic centers throughout the country, to present my new paradigm to greatly improve the quality and lower the cost of care, similar to the methods I had employed at SHC. I was dismayed to learn, having participated in both teaching and research at the VA-Sawtelle system in Los Angeles during my training, is the tremendous incidence of diabetes and complications of diabetes in the Veteran population, likely the single biggest disease driver of morbidity and costs for the VA. I believe I could add my methodology to the VA system with dramatic improvements in both the cost and quality of care of the disease. I could also significantly develop a capitated program with assumption of financial risk, based on practice guidelines and outcome measurements ("value health") as I have done at my SHC facilities. I have already discussed with a leading health care insurance provider to have them support me in my risk assumption. I am committed to my successful model of diagnosis and treatment of catastrophic illness, and am confident we can be successful in working together using this model to provide all aspects of diabetic care to patients with diabetes mellitus (Type 1 and Type 2). I would very much like to discuss a potential relationship with the VA. I have already met with some of the VA leadership in diabetes in Washington DC, including Leonard Pogach and Rajiv Patel two or three years ago. Dr. Patel recommended that it would be useful for me to meet with the Department of Defense (DOD), since their system of health care services was a very different system from the VA. He thought I might also provide a combined proposal to the DOD and the VA. I have also met with Mr. Guy Kiyokawa of the DOD at the Pentagon, and with senior officials of their own insurance provider, Tri Care. I was accompanied to these meetings by members ofmy team, and with Congressman Henry Waxman, a long-time consultant and friend. I had follow up phone conferences with all of them. I also met with Congressman Mac Thornberry, Chairman of the House Armed Services Committee, in Washington D.C. My staff has.also had discussions with Representative Kay Granger, who is the Chairperson of the House Defense Appropriations Subcommittee in Health Care. I am hoping to speak with you to share details of my program, and to meet with you. Salick Comprehensive Diabetes Centers, Inc. ('"SCDC"), is a national diabetes program, which includes a network of comprehensive outpatient diabetes centers in affiliation with academic centers for inpatient services, research, and teaching, and a national dialysis provider of dialysis services for ESRD. The network will be affiliated with academic medical centers and/or major for-profit providers of health care services. The network will focus on the prevention, diagnosis, and treatment of all forms of diabetes mellitus, with the major emphasis being on the microvascular complications of diabetes (retinopathy, cardiovascular disease and peripheral cardiovascular disease, and ESRD). Approximately 93% of the $250 billion annual cost of health care in diabetes are secondary to these complications. VA-19-0799-D-000165 DS_00001827 (b) (6) and (b) (6) who are very familiar with all my programs, send their best wishes to you. Best personal regards. Very truly yours, (b) (6) M.D. Chairman of the Board Chief Executive Officer Salick Comprehensive Diabetes Centers, Inc. BS:GS encl: (b) (6) M.D. Bio; Executive Summary VA-19-0799-D-000166 OS 00001828 (b) (6) (b) (6) M.D. Chairman of the Board and Chief Executive Officer Salick Comprehensive Diabetes Centers, Inc. Dr. (b) (6) is widely recognized as a visionary, pioneer, and leading expert in the field of diseasestate management. The founder and former Chainnan and CEO of Salick Health Care, Inc., he developed industry-changing concepts and solutions that fundamentally transformed how patients with chronic and catastrophic illnesses are diagnosed and treated. While leading Salick Health Care, Inc., he created a managed care subsidiary, the first to offer fixed-price insurance products for the treatment of catastrophic diseases such as cancer and end-stage renal disease. He established a series of practice guidelines and outcome measurements for cancer treatment which were instituted nationwide at the eleven Comprehensive Cancer Centers, and the eight Comprehensive Breast Centers operated by Salick Health Care, Inc. These diagnostic and treatment centers were open 24 hours a day, seven days a week, providing quick, userfriendly, and high quality out-patient care in a cost-effective manner. In 1997, Salick Health Care, Inc. was sold to Zeneca PLC (Astra-Zeneca). (b) (6) then created Bentley Health Care, providing diagnostic and therapeutic services to patients with chronic and catastrophic illness including cancer, end-stage renal disease, and AIDS. Bentley Health Care, Inc. and all of (b) (6) health care companies, are dedicated to advancing the field of disease-state management through innovative and unique solutions to patients, physicians, and payors seeking quality care and cost-effective, diseasestate programs. Based on his disease-specific paradigm that he has previously pioneered, he developed the concept of Comprehensive Cardiovascular Centers. Salick Cardiovascular Centers, Inc. in affiliation with Private Equity Partners, proposed a broad range of innovative services for the diagnosis and treatment of cardiovascular disease (including cerebrovascular, coronary artery, coronary heart and peripheral vascular disease) and cardiovascular end-stage renal disease on an out-patient basis, with in-patient affiliations. These centers will offer state-of-the-art procedures and techniques for the treatment and diagnosis of cardiovascular disease, including surgery, angioplasty, angiography, electrophysiologic procedures, sophisticated radiology, and other diagnostic testing and medical services. Leading practitioners, to develop the researchers and educators in the cardiovascular field indicated their desire to join (b) (6) Centers on a national basis. These essential services will be available to patients, physicians and payors in a multidisciplinary, high quality, user-friendly, cost-efficient environment, open 24 hours a day, seven days a week and will be incorporated with the Salick Comprehensive Diabetes Centers, Inc. In addition, (b) (6) worked with Members of the Harvard Business School and Harvard Medical School Faculty in developing a plan for a Personalized Medicine Molecular Biology entity headed by Dr. (b) (6) (b) (6) received his B.S. degree from Queens College, New York in 1960, and his M.D. from the University of Southern California in 1964. He completed his internship and residency in Internal Medicine at Cedars-Sinai Medical Center and a National Institutes of Health Postdoctoral Fellowship in Nephrology at Cedars-Sinai Medical Center and the University of California, Los Angeles. (b) (6) is currently licensed in California, New York, and New Jersey. He has served on the board of the Queens College Foundation, and Crossroads School for Arts and Sciences in Santa Monica. He is and has been a member of the Visiting Committee and the Leadership Council of the Harvard School of Public Health. VA-19-0799-D-000168 OS 00001830 He is a regular visiting lecturer at and has been a member of the Healthcare Initiative Advisory Board and served on both the Harvard the Centennial Committee of the Harvard Business SchooL In 2005, (b) (6) Business School panel for the Healthcare Innovation and Opportunities in Southeast Asia and also was a guest speaker for the India and Its Neighbors Conference, He served on the Board of Directors of Nephros, Inc. (AMEX:NEP) from 2005 to 2007 and in addition, he served as a member of the Board of Trustees for established a the United States Equestrian Team Foundation from 1991 to 2011. In 2004, (b) (6) fellowship at Harvard School of Public Health to provide annual scholarships for selected students pursuing studies related to cancer and/or cardiovascular disease, He also provides funds for fellowships and scholarships at Yeshiva University, Queens College, and Stuyvesant High School, was offered the position of Chief Executive Officer of Harvard's Joslin Clinic by its ln 2010, (b) (6) Board of Trustees, an offer that (b) (6) declined, (b) (6) is presently working on the development of (b) (6) a nationwide program of Comprehensive Diabetes Centers. received his academic appointment as Professor of Medicine, Cedars-Sinai Medical Center on January l, 2017, (b) (6) and his wife Gloria reside in Los Angeles and New York, They have three daughters who have each completed graduate school in New York and post-graduate school in New York and in Washington, DC. (b) (6) and (b) (6) presently have five grandchildren. Tribute by Shlomo Melmed, M,D. Honoring (b) (6) M.D, ,,, Alumnus of the Year Cedars-Sinai Alumni Association Cedars-Sinai Medical Center December 2, 20 I0 .Jfis a pleasure for me to honor (b) (6) here tonight. (b) (6) has had a major impact nationally and internationally in the development of new clinical programs for the diagnosis and treatment of patients in many areas of medicine Including Nephro!ogy, Cancer, Organ Transplant, Cardlovascular Dlsease, and Personalized Medicine. He is a world renowned medical entrepreneur whose companies have striven to provide compassionate and advanced care to patlents with catastrophic diseases in a user-friendly, high quality outpatient care in a cost effective manner. He early on realized the benefits of a 24-hour a day, outpatient diagnosis and treatment center. His clinics developed standards for care of cancer treatments lndudlng a vast database of cancer drug use and treatment outcomes such as chemotherapy for colon cancer, bone marrow transplants for breast cancer, and the use of antl-nausea drugs, He has been intimately involved in developing these centers with academic medical centers and governments throughout the United States, the United Kingdom, Europe, Israel, and Southeast Asia, Proudly, he developed the first Cancer Center at Cedars-Sinai, dedicated to excellence in patient care, and delivery of 24/7 service, Regarded by fellow professionals as one of the nation's leading and most innovative health care entrepreneurs, (b) (6) also boasts an lmpresslve career as a physician and leader of many national civic causes, He has served on multiple committees at Harvard University Schoo! of Public Health, Business School, and Medical School. He has served cm the National Advisory Board for the National Kidney Foundation (1988-1990}, was a member of the Board of Directors for American Woman's Economic Development Corporation (1990-1991) and Nephros, Inc. {2005-2007), and was on the Board of Trustees for the Hereditary Disease Foundation {1975-1985). (b) (6) has been instrumental in providing a unique mode! of innovative and effective treatment for patients with catastrophic diseases. He Is a world renowned health care innovator who has had tremendous Impact on national and worldwide medical delivery practices, I congratulate him and Glo for this we!! deserved honor, as a veteran member of the Cedars~Sinai family, Cedars Sinai is proud of you, (b) (6) and we wish you good health and energy to continue contributing to society wlth your unique passion and energy, (b) (6) , MD Senior Vice President of Academic Affairs, Dean of the Medical Faculty Cedars-Sinai Medical Center 9 Re11: Apr!l 19, 2017 VA-19-0799-D-000169 OS 00001831 SALi CK ■ COMPREHENSIVE DIABETES CENTER S, I <: . EXECUTIVE SUMMARY (b) (6), (b) (4) (b) (6) 1 Revised: April 19, 2017 STRICTLY CONFIDENTIAL VA-19-0799-D-000171 DS_00001833 (b) (6), (b) (4) (b) (6) (b) (6) (b) (6) 2 Revised:April19,2017 STRICTLY CONFIDENTIAL VA-19-0799-D-000172 OS 00001834 (b) (6), (b) (4) (b) (6) 3 Revised:April 19, 2017 STRICTLY CONFIDENTIAL VA-19-0799-D-000173 DS_00001835 Message Poonam Alaigh [(b) (6) hotmail.com] 5/3/2017 3:00:09 AM brucem(b) (6) @mac.com David Shulkin [drshulkin@aol.com] Fwd: Top 5 disability problems in our patients From: Sent: To: CC: Subject: Bruce - you are right to focus on Tinnitus- please see below, the top disability. The rest of the 9 disability areas are listed. Let's try to schedule the call with the ENT researcher next week - thanks Sent from my iPhone Begin forwarded message: From: "Alaigh, Poonam, M.D." Date: May 2, 2017 at 10:53:15 PM EDT To: 'Poonam Alaigh' <(b) (6) hotmail.com> Subject: FW: Top 5 disability problems in our patients Sent with Good (www.good.com) -----Original Message----From: Crump, Regan Sent: Tuesday, May 02, 2017 08:58 AM Eastern Standard Time To: Alaigh, Poonam, M.D. (b) (6) Cc: (b) (6) Hyduke, Barbara; (b) (6) Subject: Top 5 disability problems in our patients Dr. Alaigh: Here are the top 5, plus the next 5. We used the latest update from VBA in their end of year FY2014 data and found the following most prevalent Service Connected Disabling conditions. Recent conversations with VBA indicate that these conditions remain the most common conditions. They are specifically rated as disabling and compensable by VBA, though they do not represent a list of the top most expensive chronic disabilities in the general VHA population. The most expensive conditions will be available tomorrow. Diagnosis 6260 9411 7913 5237 Description Tinnitus, Recurrent. Posttraumatic Stress Disorder. Diabetes Mellitus. Lumbosacral Or Cervical Strain. Category The Ear Neurological Conditions And Convulsive Disorders The Endocrine System The Musculoskeletal System Number of Diagnoses 1,271,638 Most Frequent Rating Level 10% 772,274 482,112 70% 20% 436,328 10% VA-19-0799-D-000175 OS 00001837 8520 Sciatic Nerve, Paralysis. Neurological Conditions And Convulsive Disorders 435,754 10% 5260 5242 6100 5010 5271 Leg, Limitation Of Flexion. Degenerative Arthritis. Hearing Loss Arth~~.DueToTrauma. Ankle, Limited Motion. The The The The The 405,995 331,252 318,213 282,611 260,711 10% 10% 10% 10% 10% Musculoskeletal Musculoskeletal Ear Musculoskeletal Musculoskeletal System System System System Note that these conditions are the most prevalent service-connected conditions. They do not include conditions that are not related the veteran's service. The list does not make any adjustment for severity of the condition, or the cost to treat the condition. -----Original Message----From: Alaigh, Poonam, M.D. Sent: Monday, May 01, 2017 06:37 PM Eastern Standard Time To: Crump, Regan Subject: RE: Top 5 disability problems in our patients Any update on this? Sent with Good (www.good.com) -----Original Message----From: Crump, Regan Sent: Saturday, April 29, 2017 10:46 PM Eastern Standard Time To: Alaigh, Poonam, M.D. Subject: RE: Top 5 disability problems in our patients Thank you. Regan From: Alaigh, Poonam, M.D. Sent: Saturday, April 29, 2017 4:08 PM To: Crump, Regan; Hyduke, Barbara Subject: RE: Top 5 disability problems in our patients VA-19-0799-D-000176 OS 00001838 Let's just use your data based on VBA info Sent with Good (www. good.com) -----Original Message----From: Crump, Regan Sent: Saturday, April 29, 2017 01 :38 PM Eastern Standard Time To: Alaigh, Poonam, M.D.; Hyduke, Barbara Subject: RE: Top 5 disability problems in our patients We can and will use our VBA data on service-connected condition determination to answer the question by Wednesday. Ours is based on official disability determinations for veterans by VBA, not utilization or cost. If you want prevalence data on the conditions or diagnoses noted when the enrolled Veteran population presents for treatment, the data source for that question rests within 10P4, Patient Care Services, or in l0E, with the analytics group led by Dr. Joe Francis. Would you like us to ask them or do you want to just ask them directly to get that other more proximal assessment on top 5 disability problems? You asking might clarify the importance. Regan Sent with Good (www.good.com) -----Original Message----From: Alaigh, Poonam, M.D. Sent: Saturday, April 29, 2017 11 :47 AM Eastern Standard Time To: Hyduke, Barbara; Crump, Regan Subject: RE: Top 5 disability problems in our patients Can we look at it both ways and that way can also see if there is an overlap Sent with Good (www.good.com) -----Original Message----From: Hyduke, Barbara Sent: Saturday, April 29, 2017 10:23 AM Eastern Standard Time To: Crump, Regan; Alaigh, Poonam, M.D. Subject: RE: Top 5 disability problems in our patients Dr. Alaigh - please advise - thanks VA-19-0799-D-000177 DS 00001839 From: Crump, Regan Sent: Saturday, April 29, 2017 10:14 AM To: Hyduke, Barbara; Alaigh, Poonam, M.D. Subject: RE: Top 5 disability problems in our patients Are you talking about service connected disabilities or do you mean most costly patients with multiple chronic disabling conditions? What's the context so I ask the right question? Sent with Good (www.good.com) -----Original Message----From: Hyduke, Barbara Sent: Saturday, April 29, 2017 09:31 AM Eastern Standard Time To: Alaigh, Poonam, M.D.; Crump, Regan Subject: RE: Top 5 disability problems in our patients Sure- will tap Regan's team for this information -----Original Message----From: Alaigh, Poonam, M.D. Sent: Saturday, April 29, 2017 9:31 AM To: Hyduke, Barbara Subject: Top 5 disability problems in our patients Can we get information on that Sent with Good (www.good.com) VA-19-0799-D-000178 OS 00001840 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/20/2017 1:45:29 AM Bruce Moskowitz [(b) (6) mac.com] David Shulkin [drshulkin@aol.com] Re: Internship slots I have had some initial discussion with our Office of Academic Affairs. Unfortunately our lead for this area has been diagnosed with a grave illness so things have slowed a bit. However, some members of his team are coming to meet me in DC early May when I was planning to discuss with them in person the possible opportunities since you had secured a funding source. If you think its time sensitive on your end, I will expedite the discussions, otherwise we should have more information on this early May. From: Bruce Moskowitz <(b) (6) mac.com> Sent: Wednesday, April 19, 2017 7:33 AM To: Poonam Alaigh Subject: Internship slots Any update? Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000179 OS 00001841 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/24/2017 7:12:30 PM To: brucem(b) (6) Re: Thursday Subject: @mac.com I am trying to get the executive order that they have prepared so we can see it. I am pretty sure they are going to use the one that established an Accountability Office for VA but I am confirming this. -----Original Message----From: Bruce Moskowitz <(b) (6) To: David shulkin Sent: Mon, Apr 24, 2017 1:34 pm Subject: Thursday mac.com> What bill is being signed Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000180 OS 00001842 Message From: Bruce Moskowitz [(b) (6) Sent: 4/24/2017 5:33:17 PM To: David shulkin [drshulkin@aol.com] Thursday Subject: mac.com] what bill is being signed Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000181 OS 00001843 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/21/2017 1:08:29 AM Bruce Moskowitz [(b) (6) mac.com]; Marc Sherman [(b) (6) gmail.com] (b) (6) L Perl [ gmail.com]; David shulkin [drshulkin@aol.com]; IP [(b) (6) frenchangel59.com] Re: Kaiser Permanente Bruce, I have reviewed the article and know that we at the VA have similar pharmacist detailing programs, controlled substance contracts, dispensing of these medications in small quantities, pain management teams, and opioid prescribing reviews. But I do think there is significant value in getting our VA team together with the Kaiser team on the phone so that we can share our mutual practices for additional learning. This is especially a critical part of our suicide prevention program. Really appreciate this, as we collectively work on improving the care for our Veterans. How do you suggest proceeding Bruce? From: Bruce Moskowitz <(b) (6) mac.com> Sent: Thursday, April 20, 2017 1:21 PM To: Marc Sherman Cc: L Perl; David shulkin; Poonam Alaigh; IP Subject: Re: Kaiser Permanente I have all the information and can set up a call after article is reviewed Sent from my iPad Bruce Moskowitz M.D. On Apr 20, 2017, at 12:50 PM, Marc Sherman <(b) (6) gmail.com > wrote: Should we first have (b) (6) introduce is to the person in charge of that effort and pick his/her brain. Then we can put a plan together from what we learn. Marc Sherman (202) 758-(b) (6) On Apr 20, 2017 11:04 AM, "Bruce Moskowitz" <(b) (6) mac.com > wrote: This is a good wake up call. Our academic partner Kaiser Permanente has in place an important program to prevent and treat opioid addiction since 2010! ! We need to form a committee see what is available and borrow it. This would be the best chance to fix problems in an expedited way. The article appeared in the NEJM today. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000182 OS 00001844 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/20/2017 10:50:20 PM Bruce Moskowitz [(b) (6) Re: Kaiser Permanente mac.com] Ill review this weekend We are part if christies committee on opiod addiction and can help lead the way Sent from my iPhone > on Apr 20, 2017, at 11:04 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > This is a good wake up call. our academic partner Kaiser Permanente has in place an important program to prevent and treat opioid addiction since 2010! ! > We need to form a committee see what is available and borrow it. This would be the best chance to fix problems in an expedited way. The article appeared in the NEJM today. > > > > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000183 OS 00001845 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/20/2017 10:49:35 PM (b) (6) [(b) (6) va.gov] Fwd: Kaiser Permanente Untitled attachment 04327.pdf; Untitled attachment 04330.htm Print Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) mac.com> Date: April 20, 2017 at 11 :04:23 AM EDT To: David shulkin , Poonam Alaigh <(b) (6) hotmail.com> gmail.com>, mbs(b) (6) @gmail.com Cc: IP <(b) (6) frenchangel59.com>, L Perl <(b) (6) Subject: Kaiser Permanente This is a good wake up call. Our academic partner Kaiser Permanente has in place an important program to prevent and treat opioid addiction since 2010! ! We need to form a committee see what is available and borrow it. This would be the best chance to fix problems in an expedited way. The article appeared in the NEJM today. VA-19-0799-D-000184 OS 00001846 ADDRESSING THi:'. OP!O!D !£Pl DEM IC PERSPECTIVE Addressing the Opioid Epidemic- Opportunities in the Postmarketing Setting Bruce M. Psaty, M.D., Ph.D., and Joseph 0. Merrili, M.D., M.P.H. T he Food and Drug Administration (FDA) recently devel~ oped a multipart action plan in response to the opioid epidemic.1 As part of that initiative, it invited recommendations from the National Academy of Medicine about a regulatory framework that might allow public health considerations to be factored into drug-approval decisions. The FDA, however; may already be able to take some public health-related actions in the postmarketing setting, includ~ ing those related to the generation of evidence and the regulation of marketing. The preapproval evaluation of drugs is meant to ensure that they are safe and effective for their intended use. Nonetheless, vvidespread use of approved drugs often leads to identification of safety issues, including rare ad-verse events that may not be d~ tected in preapproval trials. Black:box warnings are not uncommon, and a small percentage of dl'Ugs are withdta\vn from the market. Prescription opioids, however, are outliers when it comes to safety: since 1999, they have been implicated in 165~000 overdose deaths. By the mid-20th century, legal restrictions on opioid pr.escribing had led to widespread unde1trear:ment of pain. In the late 1980s and early 1990s, it was argued "largely on Ul(ltal grounds" that opioids should be available for chronic pain.1 The management m9dd that \Vas adopted was based on the success of opfoids for acute and end-o:f.Ufe pain; a "titrate-to-effect" principle was applied, and a numerical rating became the chief metric. Pain came to be kuovvn as the "fifth vital sign." In this setting, the combination of aggressive marketing of prescription opioids by manufacturers, promotion by marquee professors, and endorsement by pa.in societies contributed to a cultural transformation. The long--standing convention of trying to avoid opioids for chronic pain gave way to a new culture in which the drugs were favored for chronic noncancer pain, despite a lack of evidence to support their use. A 2009 article summarized the promotlon of O:xyContin (oxycodone) by Purdue Pharma between 1996 and 200:l.3 Those efforts included hosting 40 all-expensespaid speaker-training conferences for 5000 practitioners, as well as 20,000 pain "education" programs. Purdue used physician profiling to target high-volume opioid prescribers ,,vi.th sales representatives who were encouraged by a generous bonus system. Branded promotional items and free starter coupons for patients were available. The company also misrepresented the addiction risk posed by O:xyContin in its materials fur patients and physicians? The campaign paid off: annual sales increased from $48 million to $1.1 billion. Misleading statements about addiction risk amounted to misbranding, and they eventually cost the manufacturer and executives $634 million in fines. But evidence-based trea~ ment fur opioid addiction in patients whose addictions derived from treatment for chronic pain has been slow to emerge. And promotional efforts continue even now, a manuJ:acturer's coupon for 80% off OxyContin is available online. In the United States, direcHer consumer advertising promoting "a pill for every ill" has helped create ru:i epidemic of prescription-drug use, ;,vith U.S. sales reach~ ing $425 billion in 2015. As part of tbat trend, a whole generation of physicians was trained to t11rn readily to opioids w,hen patients talked about pain. _Between 1999 and 2009, both opioid sales and opioid-related deaths increased fourfold. In the process, some clinics unintentionally became pill mills. At our clinic in Seattle, the low threshold for prescribing opioids attracted same young, healthy drug users who considered it an easy place to obtain narcotics. Even today, the risk-benefit profile of opioids used for chronic pain remains unknown. A recent review identified no studies lasting longer_ than 1 year tbat eva.lu, ated pain, function, or quality of life as a primary ontcome.4 The harms associated with opioid use, however, are well documented and often dose~dependent. They include abuse, addiction, hyper~ algesia., overdose, fracture, pneumonia, erectile dysfunction, motor vehicle crashes, cardiovascular events, and death. Drug labels need to point clearly to the known VA-19-0799-D-000185 DS_00001847 APDRSS51NG THE OP!O!D El'IOEMIC PERSPECTIVE harms and limited e1ridence of abuse, the FDA should have the efficacy for long-term opioid use, povver to limit or prohibit prescribespecially in high doses. er profiling and off.label promoWhen safuty signals are detect- tion as well as the use of coupons ed, the FDA can mandate post- or other forms of direct-to-con-marketing studies, including clin- sumer marketing. In light of the k.al trials, to better assess the ongoing opioid epidemic, the rasafety of approved products. Long~ _tlonale for permitting aggressive term, placebo--ccmtrolied, random- sales efforts is unclear. Although ized studies of opioids are diffi- the FD.Ns authority w regalate off.. cult to conduct, hmvever, because label marketing is the subject of of high dropout rates. An unan- several active cmrrt cases, opioids swered question, for example, is represent a special case, given the whether to start patients with devastation and death they have chronic pain on short-acting or caused. First Amendment argu-long-acting opioids. Although ments fur reducing the amount long-acting agents are valuable for of evidence required for market:asymptomatic conditions such as ing drugs fur ofiHabel uses do not hypertension, in which patients rise above the compelling public may not adhere to frequent dos- health arguments favoring limiing, they may be unnecessary in t:ations on opioid marketing. If the treating pain. And given that func- FDA were to require new st:atetion is also an outcome of inter- ments on opioid labels about the est, do long-acting or extended- absence of evidence of long-term release opioids add value or just safety and efficacy in order to toxicity? In this case, the FDA limit or prohibit companies from could call for a randomized trial marketing those drugs for o.fFfabel similar to the l?RECISION trial, uses such as long~term treatment v,rhkh it mandated to assess the of chronic noncancer pain, physi-cardiovascular safety of the non- cians' prescribing options wouldn't steroidal antiinflammatory drug necessarily be limited. If it's not celecoxib.5 Also needed, but out- clear that the EDA has the authorside the jurisdiction of FDA-man,- ity to limit the off.label marketing dated safety studies, are trials at of controlled substance~, Congress the health-system level that evalu- could expand the agency's author~ ate the best methods for reducing ity to modify what has been one opioid prescribing while retaining of the main drivers of the opioid patients in care and adequately epidemic. controlling their pain. Most interventions available to The epidemic of opioid abuse the FDA to limit opioid prescriband addiction has its origins in ing and abuse are no match for the pharmaceutical industry and the force of the culture that the meqica1 community. The FDA emerged ffom the confluence of regulates industry, not medical interests of industry, influential practice. It may be possible, how- academ!cs, and pa.in societies durever, for the agency to use label~ ing the 2000s. Now that opioid in.g changes to affect marketing prescribing is widespread, systemand promotion - and thereby level and not simply individualinfluence prescribing p:atte.ms. level interventions will be required For controlled substances that to change medical practice. pose a high risk of addiction and Beginning around 2010, our N >iNGLJ MEO '.l7e;:u; NEJM,om::; APRIL 20, ;1.0l7 clinic made several changes to improve the risk-benefit profile for management of chronic pain. We adopted controlled--subst.ances agreements, implemented urine testing and prescription-drugmonitoring programs, convened an opioid review committee to assist clinicians -with difficult cases, started using pharmacists to help oversee opioid prescriptions at the clinic level, and provided education, support, and access to pain,,mauagement specialists. More recently, we fully integrated medication-assisted treatment fur addiction into the primary care setting, providing a crucial evidence-based tool for treating high-risk patients. These system- and cliuidevel activities have shifted the culture surrounding pain management in a way that could never have been accomplished by providing only continuing medical education about opioids to individual physicians. fu':ports describing the re~ sults of systemwide interventions at other facilities have come to similar conclusions. Reducing unnecessary exposure to opioids and impro1ring physician education about pain management (not limited to opioid IJrescribing)i as recommended in recent guidelines from the Centers for Disease Con~ trol and Prevention, represent ad~ ditional and important primary prevention efforts. Disclosure forms pro•,rided b}, the authors are available at NJW,Lorg. From the Card!ovasc:ular Health Research Unit (B, M.P.) and the Departments of Medicine (B.M.!'., J.O.M.) and Epidemiology ,md Health Services (ELM.P.), University ofWashington, and the Kaiser Permanente Washington Health Research Institute (B.M,P.} - both in Seattle. ' 1. DliffKM, Woodcock I, OstroffS. A pro· ""live response to prescr.iptlon opioid B.buse. N Engl J Med 2016;374:1480-5. 2. Ballantyne JC, Su:lliv:m MD. Intensicy of '.l.503 VA-19-0799-D-000186 DS_ 00001848 Sent from my iPad Bmce Moskowitz MD. 87 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/20/2017 5:21:34 PM Marc Sherman [(b) (6) gmail.com] L Perl [(b) (6) gmail.com]; David shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) [(b) (6) frenchangel59.com] Re: Kaiser Permanente hotmail.com]; IP I have all the information and can set up a call after article is reviewed Sent from my iPad Bruce Moskowitz M.D. On Apr 20, 2017, at 12:50 PM, Marc Sherman <(b) (6) gmail.com> wrote: Should we first have (b) (6) introduce is to the person in charge of that effort and pick his/her brain. Then we can put a plan together from what we learn. Marc Sherman (202) 758-(b) (6) On Apr 20, 2017 11 :04 AM, "Bruce Moskowitz" <(b) (6) mac.com> wrote: This is a good wake up call. Our academic partner Kaiser Permanente has in place an important program to prevent and treat opioid addiction since 2010! ! We need to form a committee see what is available and borrow it. This would be the best chance to fix problems in an expedited way. The article appeared in the NEJM today. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000188 OS 00001850 Message From: Sent: To: CC: Subject: Attachments: Bruce Moskowitz [(b) (6) mac.com] 4/20/2017 3:04:23 PM David shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) hotmail.com] IP [(b) (6) frenchangel59.com]; l Perl [(b) (6) gmail.com]; mbs(b) (6) @gmail.com Kaiser Permanente Untitled attachment 04338.pdf; Untitled attachment 04341.txt This is a good wake up call. our academic partner Kaiser Permanente has in place an important program to prevent and treat opioid addiction since 2010! ! We need to form a committee see what is available and borrow it. This would be the best chance to fix problems in an expedited way. The article appeared in the NEJM today. VA-19-0799-D-000189 OS 00001851 ADDRESSING THi:'. OP!O!D !£Pl DEM IC PERSPECTIVE Addressing the Opioid Epidemic- Opportunities in the Postmarketing Setting Bruce M. Psaty, M.D., Ph.D., and Joseph 0. Merrili, M.D., M.P.H. T he Food and Drug Administration (FDA) recently devel~ oped a multipart action plan in response to the opioid epidemic.1 As part of that initiative, it invited recommendations from the National Academy of Medicine about a regulatory framework that might allow public health considerations to be factored into drug-approval decisions. The FDA, however; may already be able to take some public health-related actions in the postmarketing setting, includ~ ing those related to the generation of evidence and the regulation of marketing. The preapproval evaluation of drugs is meant to ensure that they are safe and effective for their intended use. Nonetheless, vvidespread use of approved drugs often leads to identification of safety issues, including rare ad-verse events that may not be d~ tected in preapproval trials. Black:box warnings are not uncommon, and a small percentage of dl'Ugs are withdta\vn from the market. Prescription opioids, however, are outliers when it comes to safety: since 1999, they have been implicated in 165~000 overdose deaths. By the mid-20th century, legal restrictions on opioid pr.escribing had led to widespread unde1trear:ment of pain. In the late 1980s and early 1990s, it was argued "largely on Ul(ltal grounds" that opioids should be available for chronic pain.1 The management m9dd that \Vas adopted was based on the success of opfoids for acute and end-o:f.Ufe pain; a "titrate-to-effect" principle was applied, and a numerical rating became the chief metric. Pain came to be kuovvn as the "fifth vital sign." In this setting, the combination of aggressive marketing of prescription opioids by manufacturers, promotion by marquee professors, and endorsement by pa.in societies contributed to a cultural transformation. The long--standing convention of trying to avoid opioids for chronic pain gave way to a new culture in which the drugs were favored for chronic noncancer pain, despite a lack of evidence to support their use. A 2009 article summarized the promotlon of O:xyContin (oxycodone) by Purdue Pharma between 1996 and 200:l.3 Those efforts included hosting 40 all-expensespaid speaker-training conferences for 5000 practitioners, as well as 20,000 pain "education" programs. Purdue used physician profiling to target high-volume opioid prescribers ,,vi.th sales representatives who were encouraged by a generous bonus system. Branded promotional items and free starter coupons for patients were available. The company also misrepresented the addiction risk posed by O:xyContin in its materials fur patients and physicians? The campaign paid off: annual sales increased from $48 million to $1.1 billion. Misleading statements about addiction risk amounted to misbranding, and they eventually cost the manufacturer and executives $634 million in fines. But evidence-based trea~ ment fur opioid addiction in patients whose addictions derived from treatment for chronic pain has been slow to emerge. And promotional efforts continue even now, a manuJ:acturer's coupon for 80% off OxyContin is available online. In the United States, direcHer consumer advertising promoting "a pill for every ill" has helped create ru:i epidemic of prescription-drug use, ;,vith U.S. sales reach~ ing $425 billion in 2015. As part of tbat trend, a whole generation of physicians was trained to t11rn readily to opioids w,hen patients talked about pain. _Between 1999 and 2009, both opioid sales and opioid-related deaths increased fourfold. In the process, some clinics unintentionally became pill mills. At our clinic in Seattle, the low threshold for prescribing opioids attracted same young, healthy drug users who considered it an easy place to obtain narcotics. Even today, the risk-benefit profile of opioids used for chronic pain remains unknown. A recent review identified no studies lasting longer_ than 1 year tbat eva.lu, ated pain, function, or quality of life as a primary ontcome.4 The harms associated with opioid use, however, are well documented and often dose~dependent. They include abuse, addiction, hyper~ algesia., overdose, fracture, pneumonia, erectile dysfunction, motor vehicle crashes, cardiovascular events, and death. Drug labels need to point clearly to the known VA-19-0799-D-000190 DS_ 00001852 APDRSS51NG THE OP!O!D El'IOEMIC PERSPECTIVE harms and limited e1ridence of abuse, the FDA should have the efficacy for long-term opioid use, povver to limit or prohibit prescribespecially in high doses. er profiling and off.label promoWhen safuty signals are detect- tion as well as the use of coupons ed, the FDA can mandate post- or other forms of direct-to-con-marketing studies, including clin- sumer marketing. In light of the k.al trials, to better assess the ongoing opioid epidemic, the rasafety of approved products. Long~ _tlonale for permitting aggressive term, placebo--ccmtrolied, random- sales efforts is unclear. Although ized studies of opioids are diffi- the FD.Ns authority w regalate off.. cult to conduct, hmvever, because label marketing is the subject of of high dropout rates. An unan- several active cmrrt cases, opioids swered question, for example, is represent a special case, given the whether to start patients with devastation and death they have chronic pain on short-acting or caused. First Amendment argu-long-acting opioids. Although ments fur reducing the amount long-acting agents are valuable for of evidence required for market:asymptomatic conditions such as ing drugs fur ofiHabel uses do not hypertension, in which patients rise above the compelling public may not adhere to frequent dos- health arguments favoring limiing, they may be unnecessary in t:ations on opioid marketing. If the treating pain. And given that func- FDA were to require new st:atetion is also an outcome of inter- ments on opioid labels about the est, do long-acting or extended- absence of evidence of long-term release opioids add value or just safety and efficacy in order to toxicity? In this case, the FDA limit or prohibit companies from could call for a randomized trial marketing those drugs for o.fFfabel similar to the l?RECISION trial, uses such as long~term treatment v,rhkh it mandated to assess the of chronic noncancer pain, physi-cardiovascular safety of the non- cians' prescribing options wouldn't steroidal antiinflammatory drug necessarily be limited. If it's not celecoxib.5 Also needed, but out- clear that the EDA has the authorside the jurisdiction of FDA-man,- ity to limit the off.label marketing dated safety studies, are trials at of controlled substance~, Congress the health-system level that evalu- could expand the agency's author~ ate the best methods for reducing ity to modify what has been one opioid prescribing while retaining of the main drivers of the opioid patients in care and adequately epidemic. controlling their pain. Most interventions available to The epidemic of opioid abuse the FDA to limit opioid prescriband addiction has its origins in ing and abuse are no match for the pharmaceutical industry and the force of the culture that the meqica1 community. The FDA emerged ffom the confluence of regulates industry, not medical interests of industry, influential practice. It may be possible, how- academ!cs, and pa.in societies durever, for the agency to use label~ ing the 2000s. Now that opioid in.g changes to affect marketing prescribing is widespread, systemand promotion - and thereby level and not simply individualinfluence prescribing p:atte.ms. level interventions will be required For controlled substances that to change medical practice. pose a high risk of addiction and Beginning around 2010, our N >iNGLJ MEO '.l7e;:u; NEJM,om::; APRIL 20, ;1.0l7 clinic made several changes to improve the risk-benefit profile for management of chronic pain. We adopted controlled--subst.ances agreements, implemented urine testing and prescription-drugmonitoring programs, convened an opioid review committee to assist clinicians -with difficult cases, started using pharmacists to help oversee opioid prescriptions at the clinic level, and provided education, support, and access to pain,,mauagement specialists. More recently, we fully integrated medication-assisted treatment fur addiction into the primary care setting, providing a crucial evidence-based tool for treating high-risk patients. These system- and cliuidevel activities have shifted the culture surrounding pain management in a way that could never have been accomplished by providing only continuing medical education about opioids to individual physicians. fu':ports describing the re~ sults of systemwide interventions at other facilities have come to similar conclusions. Reducing unnecessary exposure to opioids and impro1ring physician education about pain management (not limited to opioid IJrescribing)i as recommended in recent guidelines from the Centers for Disease Con~ trol and Prevention, represent ad~ ditional and important primary prevention efforts. Disclosure forms pro•,rided b}, the authors are available at NJW,Lorg. From the Card!ovasc:ular Health Research Unit (B, M.P.) and the Departments of Medicine (B.M.!'., J.O.M.) and Epidemiology ,md Health Services (ELM.P.), University ofWashington, and the Kaiser Permanente Washington Health Research Institute (B.M,P.} - both in Seattle. ' 1. DliffKM, Woodcock I, OstroffS. A pro· ""live response to prescr.iptlon opioid B.buse. N Engl J Med 2016;374:1480-5. 2. Ballantyne JC, Su:lliv:m MD. Intensicy of '.l.503 VA-19-0799-D-000191 DS_ 00001853 Sent from my iPad Bruce Moskowitz M.D. Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/22/2017 3:28:50 PM (b) (6) [(b) (6) gmail.com] http ://www. cb snews.com/vi deos/va-secretary-davi d-shulkin-on-chall enges-facing-the-agency/?ftag=CNM-00l 0aab4 i Sent from my iPhone VA-19-0799-D-000193 OS 00001855 Message From: IP [(b) (6) frenchangel59.com] Sent: 4/25/2017 5:07:19 PM To: 'David shulkin' [Drshulkin@aol.com] RE: Thinking about thursday Subject: David, We are working to get you the answers you need. Please let me know what time we need to be available for the tour of Walter Reed. Thank you, Ike -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Tuesday, April 25, 2017 9:46 AM To: Ike Perlmutter; Marc Sherman; Bruce Moskowitz; Laurie Perlmutter subject: Thinking about thursday I want to use our time on thursday as valuable as possible - and trying to balance this with what is also a very full schedule that I already had planned- here are some suggestionsId like your feedback: I have a breakfast with all veteran service groups in the morning I cannot cancel - after that I have a long planned tour of Walter Reed thursday mid morning - ive been hearing about the amazing medical and rehab services they have for soldiers and they want to show it to me- one possibility would be for you all to join me We can also set up brief meetings on Inventory control Telehealth eMR planning Access/Wait time issues Apple Facility planning Would any of these be of particular interest? Finally- i was thinking of holding a reception in the afternoon for you all and members of congress and wounded warriors- we have to be seated an hour before the president arrives (secret service requires) soi would limit it to 30 minutes Too much to do in a day so wanted to get your feedback David Sent from my iPhone VA-19-0799-D-000194 OS 00001856 Message From: Sent: To: CC: Subject: Marc Sherman [(b) (6) gmail.com] 4/20/2017 12:23:45 AM David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) [(b) (6) mac.com] Re: From John Ullyot -- CBS News Response gmail.com]; Bruce Moskowitz That is great. Congratulations. The problem is so obvious, trying to hide from it just compounds the problem and PR nightmare. Very well done the way you handled it. I had just seen the CBS piece and was about to email you as I was opening your email. I am looking forward to seeing the later edition to see if/how they handle it. On Wed, Apr 19, 2017 at 6:59 PM, David shulkin wrote: Just had a major story tonight on cbs news - a story of a veteran waiting way too long for prosthetic legs- our PR team put out a draft statement on how we deliver the best care etc etc. i ripped it up and said I wanted to say that there were no excuses for this- see below and CB S's surprise at our response We are sending a strong message to VA and the country that this is not acceptable David Subject: FW: From John Ullyot -- CBS News Response Dr. Shulkin: See below response based on our conversation with you on the request from CBS News' David Martin we received this afternoon. As you can see, we informed the WH and they (b) (5) . FYI the reporter David Martin called us right back once he received it and said, "Just wanted you to know, this is an incredibly forthright statement. Congratulations." The piece will air on tonight's CBS Evening News. Thanks again for your prompt and clear direction to us on this inquiry. All the best, John U. From: "Hutton, James" Date: Wednesday, April 19, 2017 at 4:06 PM To: " (b) (6) who.eop.gov" (b)(b)(6)(6) who.eop.gov>, " (b) (6) who.eop.gov" (b) (6) < who.eop.gov> Cc: Department of Veterans Affairs Department of Veterans Affairs , "Leinenkugel, Jake" , "Tallman, Gary" VA-19-0799-D-000195 OS 00001857 Subject: From John Ullyot -- CBS Response Kaelan (from John Ullyot): FYI -- per John's call with you right now: CBS News (David Martin) is doing a piece for tonight's Evening News about a former USMC SgtMaj who is a double amputee and who has had to wait up to 3 months at a time (up to 6 separate occasions) for replacement prosthetics from VA Medical Center in Fayetteville NC, whereas the same Veteran happened to visit Walter Reed Medical Center (DoD) and received same-day service there for new prosthetics. David knows we can't comment on a specific patient, but is asking for comment on why VA takes so much longer than DoD to take care of our Veteran amputees? We spoke with Dr. Shulkin and, based on his input, we have drafted the following statement, attributed to the Department: Statement by Department of Veterans Affairs April 19, 2017 At VA, we do not believe Veterans should have to wait for care when they are in need, as in the case of this Veteran. This President and this Secretary of Veterans Affairs stand committed to fixing wait-time issues at VA, and to providing our Veterans with the best possible care. VA-19-0799-D-000196 OS 00001858 VA has been under-resourced for a long time in this area, but that's no excuse - we own these issues and our job is fixing them as quickly as possible for our Veterans. Thanks, John U. 202-701-0138 James Hutton Deputy Assistant Secretary (Acting) Office of Public Affairs Department of Veterans Affairs 810 Vermont Ave, NW Washington, D.C. 20420 Office: 202-461-7558 Email: james.hutton@va.gov Twitter: @jehutton VA on Face book . Twitter . Y ouTube . Flickr . Blog: VA-19-0799-D-000197 OS 00001859 Message From: Sent: To: BCC: Subject: David shulkin [Drshulkin@aol.com] 4/19/2017 10:59:58 PM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) gmail.com]; Bruce Moskowitz [(b) (6) mac.com]; Marc Sherman [(b) (6) gmail.com]; David Shulkin [drshulkin@aol.com] Poonam Alaigh [(b) (6) hotmail.com] Fwd: From John Ullyot -- CBS News Response Just had a major story tonight on cbs news - a story of a veteran waiting way too long for prosthetic legs- our PR team put out a draft statement on how we deliver the best care etc etc. i ripped it up and said I wanted to say that there were no excuses for this- see below and CB S's surprise at our response We are sending a strong message to VA and the country that this is not acceptable David Subject: FW: From John Ullyot -- CBS News Response Dr. Shulkin: See below response based on our conversation with you on the request from CBS News' David Martin we received this afternoon. As you can see, we informed the WH and they (b) (5) . FYI the reporter David Martin called us right back once he received it and said, "Just wanted you to know, this is an incredibly forthright statement. Congratulations." The piece will air on tonight's CBS Evening News. Thanks again for your prompt and clear direction to us on this inquiry. All the best, John U. From: "Hutton, James" Date: Wednesday, April 19, 2017 at 4:06 PM To: " (b) (6) who.eop.gov" <(b) (6) who.eop.gov>, " (b) (6) who.eop.gov" <(b) (6) who.eop.gov> Cc: Department of Veterans Affairs Department of Veterans Affairs , "Leinenkugel, Jake" , "Tallman, Gary" Subject: From John Ullyot -- CBS Response Kaelan (from John Ullyot): VA-19-0799-D-000198 OS 00001860 FYI -- per John's call with you right now: CBS News (David Martin) is doing a piece for tonight's Evening News about a former USMC SgtMaj who is a double amputee and who has had to wait up to 3 months at a time (up to 6 separate occasions) for replacement prosthetics from VA Medical Center in Fayetteville NC, whereas the same Veteran happened to visit Walter Reed Medical Center (DoD) and received same-day service there for new prosthetics. David knows we can't comment on a specific patient, but is asking for comment on why VA takes so much longer than DoD to take care of our Veteran amputees? We spoke with Dr. Shulkin and, based on his input, we have drafted the following statement, attributed to the Department: Statement by Department of Veterans Affairs April 19, 2017 At VA, we do not believe Veterans should have to wait for care when they are in need, as in the case of this Veteran. This President and this Secretary of Veterans Affairs stand committed to fixing wait-time issues at VA, and to providing our Veterans with the best possible care. VA has been under-resourced for a long time in this area, but that's no excuse - we own these issues and our job is fixing them as quickly as possible for our Veterans. VA-19-0799-D-000199 OS 00001861 Thanks, John U. 202-701-0138 James Hutton Deputy Assistant Secretary (Acting) Office of Public Affairs Department of Veterans Affairs 810 Vermont Ave, NW Washington, D.C. 20420 Office: 202-461-7558 Email: james.hutton@va.g:ov Twitter: @ jehutton VA on Face book . Twitter . Y ouTube . Flickr . Blog: VA-19-0799-D-000200 OS 00001862 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) 4/20/2017 1:50:34 AM Bruce Moskowitz [(b) (6) Marc Sherman [(b) (6) Re: Thanks hotmail.com] mac.com]; IP [(b) (6) frenchangel59.com] gmail.com]; David shulkin [Drshulkin@aol.com]; L Perl [(b) (6) gmail.com] Also, if you have some names of folks that would be good to be part of the Fraud task force, please send them along. I know Marc is also working on it as we add to a potential list of candidates. From: Bruce Moskowitz <(b) (6) mac.com> Sent: Wednesday, April 19, 2017 8:16 AM To: IP Cc: Marc Sherman; David shulkin; Poonam Alaigh; L Perl Subject: Re: Thanks If you proceed with a fraud prevention unit you need people on the factory floor who are in active practice and are up to date with new tactics of deception. There is a huge disconnect in previous approaches of using semiretired CEO's or physicians who want big incomes and have no clue of current deceptive practices. Those physicians I know who have the street smarts are passionate about this issue and would do it for free as a public service. Sent from my iPad Bruce Moskowitz M.D. On Apr 19, 2017, at 7:58 AM, IP <(b) (6) frenchangel59.com > wrote: I agree with Bruce and I recommend to sell off all the rea l estate as well. From: Bruce Moskowitz [ mailto:(b) (6) Sent: Wednesday, April 19, 2017 7:27 AM To: Marc Sherman mac.com] Cc: David shulkin; Poonam Alaigh; L Perl; IP Subject: Re: Thanks My recommendation is you lead an independent fraud unit and it should have a fix it before it breaks mission. We have two major problems the internal one is the easiest and external contracts especially with medical devices will be the most difficult. My concern is the device manufacturers have so many ways to game the system. The other area is when VA patients are seen outside the VA Sent from my iPad VA-19-0799-D-000201 OS 00001863 Bruce Moskowitz M.D. On Apr 18, 2017, at 9:34 PM, Marc Sherman <(b) (6) gmail.com> wrote: Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -- see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively Can an EO give you the authority, or can that be part of the Accountability bill it goes both ways? VA-19-0799-D-000202 OS 00001864 Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) hotmail.com> wrote: Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) > > Thanks for the great conversation ... And humoring me. gmail.com> wrote: VA-19-0799-D-000203 OS 00001865 > > Marc Sherman > (202) 758-(b) (6) VA-19-0799-D-000204 OS 00001866 Message From: Bruce Moskowitz [(b) (6) Sent: 4/19/2017 12:58:01 PM To: David shulkin [Drshulkin@aol.com] mbs(b) (6) @gmail.com; IP [(b) (6) frenchangel59.com] Re: Thanks CC: Subject: mac.com] Yes and what I would recommend is a multi specialty panel. Also it needs to represent different geographic regions to be effective. Also it is a mix of seasoned active physicians in private practice and academic center practice combined with those who are in practice just a few years who are more tech savvy. They love the challenge and that is why they would donate their time. Sent from my iPad Bruce Moskowitz M.D. On Apr 19, 2017, at 8:45 AM, David shulkin wrote: Can you suggest some names? Sent from my iPhone On Apr 19, 2017, at 8: 16 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: If you proceed with a fraud prevention unit you need people on the factory floor who are in active practice and are up to date with new tactics of deception. There is a huge disconnect in previous approaches of using semiretired CEO's or physicians who want big incomes and have no clue of current deceptive practices. Those physicians I know who have the street smarts are passionate about this issue and would do it for free as a public service. Sent from my iPad Bruce Moskowitz M.D. On Apr 19, 2017, at 7:58 AM, IP <(b) (6) frenchangel59.com> wrote: I agree with Bruce and I recommend to sell off all the real estate as well. From: Bruce Moskowitz [ mailto:(b) (6) Sent: Wednesday, April 19, 2017 7:27 AM To: Marc Sherman mac.com] Cc: David shulkin; Poonam Alaigh; L Perl; IP Subject: Re: Thanks My recommendation is you lead an independent fraud unit and it should have a fix it before it breaks mission . We have two major problems the internal one is the easiest and external contracts especially with medical devices will be the most difficult. My concern is the device manufacturers have so many ways to game the system. The other area is when VA patients are seen outside the VA VA-19-0799-D-000205 OS 00001867 Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 9:34 PM, Marc Sherman <(b) (6) gmail .com> wrote: Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -- see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively VA-19-0799-D-000206 OS 00001868 Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) hotmail.com> wrote: Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam VA-19-0799-D-000207 OS 00001869 Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) gmail .com> wrote: > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) VA-19-0799-D-000208 OS 00001870 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/19/2017 12:45:57 PM To: Bruce Moskowitz [(b) (6) Re: Thanks Subject: mac.com] Can you suggest some names? Sent from my iPhone On Apr 19, 2017, at 8: 16 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: If you proceed with a fraud prevention unit you need people on the factory floor who are in active practice and are up to date with new tactics of deception. There is a huge disconnect in previous approaches of using semiretired CEO's or physicians who want big incomes and have no clue of current deceptive practices. Those physicians I know who have the street smarts are passionate about this issue and would do it for free as a public service. Sent from my iPad Bruce Moskowitz M.D. On Apr 19, 2017, at 7:58 AM, IP <(b) (6) frenchangel59 .com> wrote: I agree with Bruce and I recommend to sell off all the real estate as well. From: Bruce Moskowitz [ mailto:(b) (6) Sent: Wednesday, April 19, 2017 7:27 AM To: Marc Sherman mac.com] Cc: David shulkin; Poonam Alaigh; L Perl; IP Subject: Re: Thanks My recommendation is you lead an independent fraud unit and it should have a fix it before it breaks mission . We have two major problems the internal one is the easiest and external contracts especially with medical devices will be the most difficult. My concern is the device manufacturers have so many ways to game the system. The other area is when VA patients are seen outside the VA Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 9:34 PM, Marc Sherman <(b) (6) gmail.com> wrote: Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. VA-19-0799-D-000209 OS 00001871 I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail .com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? Eo might be an idea here- we will explore and see if this works the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the VA-19-0799-D-000210 OS 00001872 items to see if we can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) hotmail.com> wrote: Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) gmail .com> wrote: > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) VA-19-0799-D-000211 OS 00001873 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/19/2017 12:16:03 PM IP [(b) (6) frenchangel59.com] Marc Sherman [(b) (6) gmail.com]; David shulkin [Drshulkin@aol.com]; Poonam Alaigh [(b) (6) hotmail.com]; L Perl [(b) (6) gmail.com] Re: Thanks If you proceed with a fraud prevention unit you need people on the factory floor who are in active practice and are up to date with new tactics of deception. There is a huge disconnect in previous approaches of using semiretired CEO's or physicians who want big incomes and have no clue of current deceptive practices. Those physicians I know who have the street smarts are passionate about this issue and would do it for free as a public service. Sent from my iPad Bruce Moskowitz M.D. On Apr 19, 2017, at 7:58 AM, IP <(b) (6) frenchangel59 .com> wrote: I agree with Bruce and I recommend to sell off all the real estate as well. From: Bruce Moskowitz [ mailto:(b) (6) Sent: Wednesday, April 19, 2017 7:27 AM To: Marc Sherman mac.com] Cc: David shulkin; Poonam Alaigh; L Perl; IP Subject: Re: Thanks My recommendation is you lead an independent fraud unit and it should have a fix it before it breaks mission. We have two major problems the internal one is the easiest and external contracts especially with medical devices will be the most difficult. My concern is the device manufacturers have so many ways to game the system. The other area is when VA patients are seen outside the VA Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 9:34 PM, Marc Sherman <(b) (6) gmail.com> wrote: Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -- see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. VA-19-0799-D-000212 OS 00001874 On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively Can an EO give you the authority, or can that be part of the Accountability bill it goes both ways? Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) hotmail.com> wrote: VA-19-0799-D-000213 OS 00001875 Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) gmail.com> wrote: VA-19-0799-D-000214 OS 00001876 Message From: Sent: To: CC: Subject: IP [(b) (6) frenchangel59.com] 4/19/2017 11:58:48 AM 'Bruce Moskowitz' [(b) (6) mac.com]; 'Marc Sherman' [(b) (6) gmail.com] 'David shulkin' [Drshulkin@aol.com]; 'Poonam Alaigh' [(b) (6) hotmail.com]; 'L Perl' [(b) (6) RE: Thanks gmail.com] I agree with Bruce and I recommend to sell off all the real estate as well. From: Bruce Moskowitz [mailto:(b) (6) Sent: Wednesday, April 19, 2017 7:27 AM To: Marc Sherman mac.com] Cc: David shulkin; Poonam Alaigh; L Perl; IP Subject: Re: Thanks My recommendation is you lead an independent fraud unit and it should have a fix it before it breaks mission . We have two major problems the internal one is the easiest and external contracts especially with medical devices will be the most difficult. My concern is the device manufacturers have so many ways to game the system. The other area is when VA patients are seen outside the VA Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 9:34 PM, Marc Sherman <(b) (6) gmail.com> wrote: Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -- see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? VA-19-0799-D-000215 OS 00001877 We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) hotmail.com> wrote: Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) gmail.com> wrote: VA-19-0799-D-000216 OS 00001878 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/19/2017 11:27:05 AM Marc Sherman [(b) (6) gmail.com] David shulkin [Drshulkin@aol.com]; Poonam Alaigh [(b) (6) [(b) (6) frenchangel59.com] Re: Thanks hotmail.com]; L Perl [(b) (6) gmail.com]; IP My recommendation is you lead an independent fraud unit and it should have a fix it before it breaks mission . We have two major problems the internal one is the easiest and external contracts especially with medical devices will be the most difficult. My concern is the device manufacturers have so many ways to game the system. The other area is when VA patients are seen outside the VA Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 9:34 PM, Marc Sherman <(b) (6) gmail.com> wrote: Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -- see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively VA-19-0799-D-000217 OS 00001879 Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) hotmail.com> wrote: On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) wrote: > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) gmail.com> VA-19-0799-D-000218 OS 00001880 Message David shulkin [Drshulkin@aol.com] 4/19/2017 1:50:21 AM Marc Sherman [(b) (6) gmail.com] Re: Thanks From: Sent: To: Subject: Ok thanks Sent from my iPhone On Apr 18, 2017, at 9:34 PM, Marc Sherman <(b) (6) gmail.com> wrote: Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -- see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? VA-19-0799-D-000219 OS 00001881 Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) hotmail.com> wrote: On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) wrote: > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) gmail.com> VA-19-0799-D-000220 OS 00001882 Message From: Sent: To: CC: Subject: Attachments: Marc Sherman [(b) (6) gmail.com] 4/19/2017 1:34:59 AM David shulkin [Drshulkin@aol.com] Poonam Alaigh [(b) (6) hotmail.com]; L Perl [(b) (6) (b) (6) Moskowitz [ mac.com] Re: Thanks Dinner Discussion Agenda 041717.docx gmail.com]; IP [(b) (6) frenchangel59.com]; Bruce Thanks for the responses. I got home so late last night I didn't get a chance to send the dinner agenda as promised ... sorry Poonam -- see attached. An EO on the competitive salaries could also have a dual benefit with some good White House PR impact as well as serving to solve your staffing leakage. I gave Ike an update on the possible real estate plan tonight that you shared with me, including the congressional committee. I am available to serve on it as we discussed and ready to help formulate more thoughts about it when you are ready. Also ready to help with the Fraud plan. On Tue, Apr 18, 2017 at 9: 17 PM, David shulkin wrote: Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. VA-19-0799-D-000221 OS 00001883 Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) hotmail.com> wrote: On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) gmail.com> wrote: VA-19-0799-D-000222 OS 00001884 Dinner Discussion Agenda Reputation on the line I 21 months I Ammunition (see article highlights below) Crisis Management Discussion 1. 2. 3. System is in crisis - Engage crisis management program - URGENCY Can't afford another DC I Almost guaranteed Need Crisis plan - EXECUTE NOW a. Need to understand the immediate risks NOW b. ID trusted people in field I reassign I increase filed based reliable intelligence i. Wharton's Mack Center for administrator assessment c. NLC NOW - Use DC as a catalyst to show urgency and send message d. Make managers/administrators responsible I Report Card (back to HQ) e. ID problems now i. Outside quality/ standards reviewers - report back to HQ with immediate action (Bruce can help to arrange - SEE OUTSIDE QUALITY REVIEW STANDARDS LIST BELOW) f. ii. Talk to medical staff in private iii. Fix problems immediately iv. Understaff v. Reduce each facility to available skills and resources Curtail risks stage) g. I Procedural experience I shutdown & ID alternatives I Publicize new sheriff's in town I Reduce blame ammo (DC article sets the I Partner with Tester etc to manage risk and get authority Plan progress within next week Restructure Discussion 1. 2. Telemedicine Exec Order I Opioid impact Corruption of Supply Chain I Purchasing a. Expect significant deviation from expectations b. Need full assessment of existing system c. d. Revamp system to remove risks Examine P-Cards to curtail cost and quality issues e. Tie in Device Registry f. Tie in inventory system Other Discussion Items 1. 2. 3. 4. Real Estate (continuation of last week's I Congressional Commission FW&A (Medicare system - participate in program demo Cerner vs EPIC - Procurement issues CIO VA-19-0799-D-000223 OS 00001885 OUTSIDE QUALITY REVIEW STANDARDS (first cut) • Arrive unannounced and tour all areas of the hospital WITHOUT THE ADMINISTRATIVE STAFF so staff can speak freely of their concerns. • Spot check for adequate supplies in every department • Account for adequacy and quality of equipment in the ED, radiology, pathology, ICU, OR, LABS, cardiac cath lab and cardiac monitoring. • Review medical personnel staffing and close any area of the hospital that would jeopardize • Suspend any low volume procedure that does not meet proficiency of care standards. For patient care from understaffing. instance if the cath lab does not have the volume found safe by the American College of Cardiology. • From the administrative staff request to see any personnel issues that are now under report and if those critical to patient care have been suspended from current patient care. • Review all onsite and off-site storage units and inventory system operations and how recalled medical equipment has been accounted for. • Review narcotics inventory and management system and reporting, Review all reported breaches in securing or prescribing addictive medication • Review all patient and staff reported concerns regarding quality of care issues . ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• EXCERPTS FROM MARCH 12, 2017 ARTICLE A downplayed risks at Chicago facility, watchdog says By Drew Griffin and Curt Devine CNN Investigations Updated 3:34 PM ET, Sun March 12, 2017 Story highlights • • Doctor alleged life-threatening delays in care and unnecessary heart procedures at VA hospital Watchdog agency disputes VA findings of no "specific danger to public health or safety" (CNN) Six years after a whistleblower warned of poor care at a VA hospital near Chicago, a top government watchdog is warning that the Department of Veterans Affairs downplayed the risks. The concerns were first raised in 2011 by Dr. Lisa Nee, a cardiologist at Edward Hines Jr. VA Hospital, just west of Chicago. VA-19-0799-D-000224 OS 00001886 Her claims: Veterans were being subjected to unnecessary coronary artery bypass surgeries. She also said that the hospital's echocardiogram laboratory had a one-year backlog and that many patients had died or suffered complications before their echocardiograms were reviewed. She says her concerns were ignored and she left the VA in 2013. Nee became a whistleblower and took her case to the U.S. Office of Special Counsel, which protects government workers who report damaging information about the agencies where they work. "I have absolutely no doubt patients died as a result of the care they did not get at the VA Hines facility," Nee told CNN from Chicago, where she now works as chief medical officer for a medical start-up. No VA investigation has made that determination. The letter also described a "lack of accountability," stating that the V A's medical inspector identified repeated errors by one physician without taking any disciplinary action. The physician is still at Hines. The Office of Special Counsel's letter says the VA took some corrective actions, but added that Nee had raised unresolved issues. A Hines VA spokesperson said in a statement to CNN that the facility has hired additional cardiologists and responded to recommendations by the Inspector General by changing diagnostic and post-procedure review processes. "Providing a safe environment and quality care for our Veterans is the top priority at the Hines VA Hospital," the statement said. "All Cardiology Peripheral Vascular procedures in 2016 were completed without adverse complications and with good outcomes. Hines V AH has implemented an ongoing Cardiology Quality Improvement Plan that includes validation of the accuracy of the interpretation and technical quality of echocardiography studies, and ensures that all echocardiography technicians have the opportunity for continuing education and training." Recently sworn-in VA Secretary David Shulkin has vowed to improve patient access to quality VA health care. "I think that we have a system that is doing terrific things with very dedicated people, but we all know we have a lot of work to do and that's what I plan to do as secretary," Shulkin said in February. Nee is not convinced, and is disappointed no one from the Trump administration or transition team has met with her regarding her allegations. "You can't have a system that is supposed to take care of patients, and have a system that never takes account for its own mistakes," said Nee. VA-19-0799-D-000225 OS 00001887 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/19/2017 1:17:00 AM Marc Sherman [(b) (6) gmail.com] Poonam Alaigh [(b) (6) hotmail.com]; L Perl [(b) (6) Moskowitz [(b) (6) mac.com] Re: Thanks gmail.com]; IP [(b) (6) frenchangel59.com]; Bruce Sent from my iPhone On Apr 18, 2017, at 7: 10 AM, Marc Sherman <(b) (6) gmail.com> wrote: I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? We can- its a process- first we have to do a market survey to show OPM- we need our leadership to do this sooner and more aggressively Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? Eo might be an idea here- we will explore and see if this works - the key is to speed up our process 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. Agree - we are standing up a Committee and we need to message this effort - we are talking to the White House about this tommoroW 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Ok- lets plan on another get together soon Marc Sherman (202) 758-(b) (6) VA-19-0799-D-000226 OS 00001888 On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) hotmail.com> wrote: Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) gmail.com> wrote: VA-19-0799-D-000227 OS 00001889 Message From: Marc Sherman [(b) (6) Sent: 4/18/2017 11:10:27 AM To: Poonam Alaigh [(b) (6) hotmail.com] L Perl [(b) (6) gmail.com]; IP [(b) (6) frenchangel59.com]; David shulkin [drshulkin@aol.com]; Bruce Moskowitz [(b) (6) mac.com] Re: Thanks CC: Subject: gmail.com] I totally agree. Thanks for taking the time. I will send the plan in Word when I get to into the office in a while. I was also thinking about a few other things that we should catch up on. 1. Why can't you match the nursing salaries in a competitive market personnel crisis? How can we change that? Let's brainstorm. Can an EO give you the authority, or can that be part of the Accountability bill - it goes both ways? 2. We didn't have time to discuss fraud and real estate last night. We need to do that right away for practical (Medicare system review) and messaging purposes. 3. We didn't discuss all steps in my agenda on the crisis plan last night since we ran out of time. We should discuss the rest of the items to see ifwe can figure out which ones are valuable to implement and then discuss them so we can come to the best approach on each. Marc Sherman (202) 758-(b) (6) hotmail.com> wrote: On Apr 18, 2017 4:38 AM, "Poonam Alaigh" <(b) (6) Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > On Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) gmail.com> wrote: VA-19-0799-D-000228 OS 00001890 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/18/2017 8:38:27 AM Marc Sherman [(b) (6) gmail.com] David shulkin [drshulkin@aol.com]; (b) (6) Perlmutter [(b) (6) gmail.com] Re: Thanks mac.com; Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Marc- it was so good catching up in a relaxed setting with an incredible ambiance where we could simply brainstorm and problem solve as we together bring about the transformation of the organization. Let's try to meet regularly, monthly if possible. Also, please send the proposed approach/plan as an attachment so that we can start to activate it. Thanks again, all of you are helping us serve our nations heroes better- and we can't possibly achieve what we are/will without your invaluable support and input. David and Poonam Sent from my iPhone > on Apr 17, 2017, at 9:28 PM, Marc Sherman <(b) (6) gmail.com> wrote: > > Thanks for the great conversation ... And humoring me. > > Marc Sherman > (202) 758-(b) (6) VA-19-0799-D-000229 OS 00001891 Message David shulkin [Drshulkin@aol.com] 4/19/2017 11:27:06 PM (b) (6) [(b) (6) (b) Fwd: Invitation - (from (6) From: Sent: To: Subject: gmail.com] Intrepid Salute to Freedom Gala Info (Thurs May 25, 2017) Lets discuss Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) cushwake.com > Date: April 19, 2017 at 11:39:54 AM EDT To: "David Shulkin (DRShulkin@aol.com )" Subject: Invitation - {from (b) (6) Intrepid Salute to Freedom Gala Info {Thurs May 25, 2017) Good Afternoon Sec. Shulkin, Bruce invites you and your wife to join his table at the Intrepid Salute to Freedom Gala, held on Thursday May 25 th , 2017. The event takes place in New York City, onboard the Intrepid Museum itself. Below are further details regarding this gala. Kindly please RSVP directly to this email. Thank you, (b) (6) VA-19-0799-D-000230 OS 00001892 INTREPID SEA, AIR & SPACE MUSEUM HONOR. EDUCATE. INSPIRE. THURSDAY, MAY 25, 2017 aboard the historic aircraft carrier Intrepid HONORING (b) (6) Chief Executive Officer, SL Green Realty Intrepid Salute Award (b) (6) (b) (6) President, SL Green Realty Intrepid Salute Award THE HONORABLE JOHN F. KELLY Secretary of Homeland Security Intrepid Freedom Award AND THE MEN AND WOMEN OF THE UNITED STATES ARMED FORCES SALUTE TO FREEDOM 2017 GALA CHAIRMEN I (b) (6) Fisher Brothers (b) (6) I Cushman & Wakefield (b) (6) Paul Hastings LLP Cocktails: 6:00pm Dinner & Awards : 7:00pm INTREPID SEA, AIR & SPACE MUSEUM W 46th Street and 12th Avenue, New York City VA-19-0799-D-000231 OS 00001893 The information contained in this communication is confidential, may be privileged and is intended for the exclusive use of the above named addressee(s). If you are not the intended recipient(s), you are expressly prohibited from copying, distributing, disseminating, or in any other way using any information contained within this communication. If you have received this communication in error please contact the sender by telephone or by response via mail. We have taken precautions to minimize the risk of transmitting software viruses, but we advise you to carry out your own virus checks on any attachment to this message. We cannot accept liability for any loss or damage caused by software viruses. VA-19-0799-D-000232 OS 00001894 Message From: Poonam Alaigh [(b) (6) Sent: 4/24/2017 12:43:15 AM To: IP [(b) (6) frenchangel59.com] David shulkin [drshulkin@aol.com] Re: Thank you CC: Subject: hotmail.com] Thanks Ike- a very important meeting with all the key areas needed to be discussed. David and I will see if there is anything else to add to the agenda, but looks really good thus far. Sent from my iPhone On Apr 23, 2017, at 5:26 PM, IP <(b) (6) frenchangel59.com> wrote: From: IP [mailto:(b) (6) renchanqel59.com ] Sent: Sunday, April 23, 2017 5:25 PM To: (b) (6) ho.eop.gov Cc: (b) (6) Subject: Thank you @who.eop.gov Jared, Thank you for getting back to me and for committing the time to join us for dinner on Wednesday, April 26 th . Especially thank you for the generous invitation to dine at your house. We expect between IO to 13 people in total. The final number will depend on whether Senator Isakson and Representative Roe accept our invitation. I totally understand if that is too large a group to host and hope you will be honest about your willingness and ability now that you know how big it is. Best, Ike DRAFT Agenda Items to be defined around finalized attendee list. Attendee list and agenda items subject to change. VA-19-0799-D-000233 OS 00001895 Message From: Sent: To: Subject: IP [(b) (6) frenchangel59.com] 4/23/2017 9:25:49 PM Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [drshulkin@aol.com] FW: Thank you From: IP [mailto:(b) (6) frenchangel59.com] Sent: Sunday, April 23, 2017 5:25 PM To: (b) (6) who.eop.gov Cc:(b ) Subject: Thank you @who.eop.gov Jared, Thank you for getting back to me and for committing the time to join us for dinner on Wednesday, April 26th . Especially thank you for the generous invitation to dine at your house. We expect between IO to 13 people in total. The final number will depend on whether Senator Isakson and Representative Roe accept our invitation. I totally understand if that is too large a group to host and hope you will be honest about your willingness and ability now that you know how big it is. Best, Ike DRAFT Agenda Items to be defined around finalized attendee list. Attendee list and agenda items subject to change. VA-19-0799-D-000234 OS 00001896 Agendd item to be considered PmS1ble Attendee Cooper ton be 000 een DOD <'W'!d VA on men al and phys teal heal h ra eed to Determine - Medical re deno; slots tha are lin ed o veteran care ( almos every [Iden fled Physician oongressJonalmee ng ls orusedonla o medical ring theVA huge phys,c,an shorta In the private secrorthere is no soluuon). Resi dency Un J L tu e House 2. 000 dls:;sio~o Sen :~=: or l s Represen ng o preven medical and men lheaJth ~sues w h son nd 1. and Ith the , Cerner v. Epic. Procurement, one t ime legl~l a ve e emp on. 2. lhe inl)ediments of saving 11 ~ s. procuremen rules and the ris to , e nd JVe ~e lnven o,y managemt!n sys ms, de ce reg1 ry and supplyc.haln- also a procuremen mue lte 1-buse Congressmen Telemedidne Ex nr ive Orde Choice 2.0 l. 000 2.. Identified Ph scan PTSD Residency Un 1. i e House 2. cong,ess 1. Call)e ' ti11e medic.a l hiri~ e ·bni . 2. Accou ability VA-19-0799-D-000235 OS 00001897 Message From: (b) (6) Sent: 4/19/2017 10:49:52 PM Bruce Moskowitz [(b) (6) mac.com] David Shulkin [drshulkin@aol.com]; (b) (6) phone numbers and email? To: CC: Subject: [(b) (6) gmail.com] (b) (6) va.gov] Good evening Dr. Moskowitz, By chance would you have an email or phone number for the following - we are working to get these schedule and notice their resumes do not have any contact information, Dr. Dr. (b) (6) (b) (6) - Yale - Yale University thanks, (b) (6) VA-19-0799-D-000236 OS 00001898 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/21/2017 1:08:09 PM To: Bruce Moskowitz [(b) (6) Re: Meeting at Whitehouse Subject: mac.com] Were looking into the presidents flexability Sent from my iPhone On Apr 21, 2017, at 8:20 AM, Bruce Moskowitz <(b) (6) So far only (b) (6) mac.com> wrote: responded to positive for following week Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (b) (6) From: "(b) (6) <(b) (6) ccf.org> Date: April 21, 2017 at 8: 18:52 AM EDT To: Bruce Moskowitz <(b) (6) mac.com> Subject: RE: Meeting at Whitehouse Unfortunately I would be unable to attend either day because of commitments here at Cleveland Clinic I cannot move. (b) (6) (b) (6) (b) (6) MD CEO and President 9500 Euclid Avenue, NA4 Cleveland, OH 44195 Phone: (216) 444-(b) (6) Fax: (216) 444-(b) (6) (b) (6) @ccf.org -----Original Message----F rom: Bruce Moskowitz [mailto:(b) (6) Sent: Thursday, April 20, 2017 6:42 PM To: (b) (6) partners.org; (b) (6) (b) (6) (b) (6) < jhmi.edu>; (b) (6) <(b) (6) mayo.edu>; (b) (6) (b) (6) (b) (6) . kp .org Subject: Meeting at Whitehouse mac.com] (b) (6) <(b) (6) ccf.org>; (b) (6) M.D. (b) (6) (b) (6) < mayo.edu>; What is chance of feet in everyone to be at a bill signing and half day meeting with President and we would try to get Tim Price there either next Thursday or following Tuesday VA-19-0799-D-000237 OS 00001899 Sent from my iPhone Please consider the environment before printing this e-mail Cleveland Clinic is ranked as one of the top hospitals in America by US.News & World Report (2015). Visit us online at http ://www.clevelandclinic.org for a complete listing of our services, staff and locations. Confidentiality Note: This message is intended for use only by the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please contact the sender immediately and destroy the material in its entirety, whether electronic or hard copy. Thank you. VA-19-0799-D-000238 OS 00001900 Message From: Bruce Moskowitz [(b) (6) Sent: 4/21/2017 12:20:31 PM To: David shulkin [drshulkin@aol.com] Fwd: Meeting at Whitehouse Subject: So far only (b) (6) mac.com] responded to positive for following week Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (b) (6) From: "(b) (6) <(b) (6) ccf.org> Date: April 21, 2017 at 8: 18:52 AM EDT To: Bruce Moskowitz <(b) (6) mac.com> Subject: RE: Meeting at Whitehouse Unfortunately I would be unable to attend either day because of commitments here at Cleveland Clinic I cannot move. (b) (6) (b) (6) (b) (6) MD CEO and President 9500 Euclid Avenue, NA4 Cleveland, OH 44195 Phone: (216) 444-(b) (6) Fax: (216) 444-(b) (6) (b) (6) @ccf.org -----Original Message----From: Bruce Moskowitz [mailto:(b) (6) Sent: Thursday, April 20, 2017 6:42 PM To: (b) (6) partners.org; (b) (6) (b) (6) < jhmi .edu>; (b) (6) (b) (6) (b) (6) < mayo.edu>; (b) (6) Subject: Meeting at Whitehouse mac.com] (b) (6) <(b) (6) ccf.org>; (b) (6) (b) (6) (b) (6) M.D.< mayo.edu>; (b) (6) kp .org What is chance of feet in everyone to be at a bill signing and half day meeting with President and we would try to get Tim Price there either next Thursday or following Tuesday Sent from my iPhone Please consider the environment before printing this e-mail Cleveland Clinic is ranked as one of the top hospitals in America by US.News & World Report VA-19-0799-D-000239 OS 00001901 (2015). Visit us online at http ://www.clevelandclinic.org for a complete listing of our services, staff and locations. Confidentiality Note: This message is intended for use only by the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please contact the sender immediately and destroy the material in its entirety, whether electronic or hard copy. Thank you. VA-19-0799-D-000240 OS 00001902 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/20/2017 2:43:46 AM To: (b) (6) Subject: amazon amazon.docx Attachments: gmail.com Please print VA-19-0799-D-000241 OS 00001903 amazon.com " ,;, I've been reminding peo le that it's Day 1 for a cou le of decades. I work in an Amazon building named Day 1, and when I moved buildings, I took the name with me. "Day 2 is stasis. Followed by irrelevance. Followed by excruciating, painful decline. Followed by death. And that is why it is always Day l." ifo be sure, this kind of decline would ha1men in extreme slow motion. An established company might harvest Day 2 for decades, but the final result would still come. I'm interested in the question, how do you fend off Day 2? How do you kee the vitality of Day 1, even inside a farge organization? I don't know the whole answer, but I may know bits ofit. Here's are some essentials for Day 1 defense: customer obsession, and high-velocity decision making. '1'here are many ways to center a business. You can be competitor focused, you can be roduct focused, you can be technology focused, you can be business model focused, and there are more. But in my view, obsessive customer focus is by far the most rotective of Day 1 vitality. Why? There are many advantages to a customer-centric approach, but here's the big one: customers are alway_s, beautifully, wonderfully dissatisfied, even when they report being ha py and business is great. Even when they don't yet know it, customers want something better, and your desire to delight customers will drive you to invent on their behalf. Staying in Day 1 reguires you to experiment patiently, accept failures plant seeds protect saplings, and double down when you see customer delight. A customer-obsessed culture best creates the conditions where all of that can hapP,en. Day 2 companies make high- uality decisions, but they make high-guality decisions slowly. To keep the energy and dynamism of Day 1, you have to somehow make high- uality, high-velocity decisions. Easy for start-u sand very challenging for large organizations. The senior team at Amazon is determined to keep our decision-making velocity high. S eed matters in business - plus a high-velocity decision making environment is more fun too. We don't know all the answers, but here are some thoughts. Most decisions should robably be made with somewhere around 70% of the information you wish you had. If you wait for 90%, in most cases, you're probably being slow. Plus, either way, you need to be good at quickly recognizing and correcting bad decisions. If you're good at course correcting, being wrong may be less costly than you think, whereas being slow is going to be expensive for sure. Second, use the hrase "disagree and commit." This hrase will save a lot of time. If you have conviction on a articular direction even though there's no consensus, it's hel ful to say, "Look, I know we disagree on this but1 will you gamble with me on it? Disagree and commit I disagree and commit all the time. We recently greenlit a articular Amazon Studios original. I told the team my view: debatable whether it would be interesting enough, coml)licated to J)roduce, the business terms aren't that good, and we have lots of other op__22rtunities. They had a completely different opinion and wanted to go ahead. I wrote back right away with "I disagree and commit and hope it becomes the most watched thing we've ever VA-19-0799-D-000242 OS 00001904 made." Consider how much slower this decision cycle would have been if the team had actually had to convince me rather than simply get my commitment. iNote what this exam le is not: it's not me thinking to myself"well, these guys are wrong and missing the point, but this isn't worth me chasing." It's a genuine disagreement of 02inion, a candid ex2ression ofmy view, a chance for the team to weigh my view, and a uick, sincere commitment to go their way. And given that this team has already brought home 11 Emmys, 6 Golden Globes, and 3 Oscars, I'm just glad they let me in the room at all! '1'hird, recognize true misalignment issues early and escalate them immediately. Sometimes teams have differen~ objectives and fundamentally different views. They are not aligned. No amount of discussion, no number of meetings will resolve that dee misalignment. Without escalation, the default dispute resolution mechanism for this scenario is exhaustion. (b) (6) (b) (6) Founder and Chief Executive Officer Amazon.com, Inc. 1997LETTERTOSHAREHOLDERS (Reprinted from the 1997 Annual Report) Amazon.com, Inc. VA-19-0799-D-000243 OS 00001905 Message From: Sent: To: Subject: With (b) (6) David shulkin [Drshulkin@aol.com] 4/19/2017 10:24:33 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Train on Sunday Dad im not sure yet Sent from my iPhone > on Apr 19, 2017, at 6:13 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Let me know what and if you are taking the train on Sunday > > Sent from my iPhone VA-19-0799-D-000244 OS 00001906 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/19/2017 10:13:56 AM David Shulkin [drshulkin@aol.com] Train on Sunday Let me know what and if you are taking the train on Sunday Sent from my iPhone VA-19-0799-D-000245 OS 00001907 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/16/2017 1:24:12 PM To: Marc Sherman [(b) (6) gmail.com] Bruce Moskowitz [(b) (6) mac.com]; L Perl [(b) (6) (b) (6) [ frenchangel59.com] Re: From yesterday's discussion CC: Subject: gmail.com]; (b) (6) hotmail.com; IP This is a great start- Lets us work on a checklist like this and get back to you Sent from my iPhone On Apr 16, 2017, at 8:35 AM, Marc Sherman <(b) (6) gmail.com> wrote: Totally agree. Great ideas. From my non-medical perspective, couldn't agree more with the "tour... WITHOUT THE ADMINISTRATIVE STAFF" approach. Marc Sherman (202) 758-(b) (6) mac.com> wrote: On Apr 16, 2017 8: 12 AM, "Bruce Moskowitz" <(b) (6) Ifwe adapt the fix it before it breaks slogan then the 18 regional managers need to be held accountable for the following (probably many if not all are in place now): That they arrived unannounced and proceeded to tour all areas of the hospital WITHOUT THE ADMINISTRATIVE STAFF so staff can speak freely of their concerns. Personally spot checked for adequate supplies in every department Account for the radiology, lab, pathology, intensive care units and surgical suites and cardiac monitoring units have updated equipment to meet the new standards of care. Review medical personnel staffing and close any area of the hospital that would jeopardize patient care from understaffing. Suspend any low volume procedure that does not meet proficiency of care standards. For instance if the cath lab does not have the volume found safe by the American College of Cardiology. From the administrative staff request to see any personnel issues that are now under report and if those critical to patient care have been suspended from current patient care. Request to see all onsite and off site storage units and how recalled medical equipment has been accounted for. Request to see any reported breach in securing or prescribing addictive medication Request to see patient or staff reported concerns regarding quality of care issues. VA-19-0799-D-000246 DS 00001908 Bruce Moskowitz MD. Message From: Sent: To: CC: Subject: Marc Sherman [(b) (6) gmail.com] 4/16/2017 12:35:39 PM Bruce Moskowitz [(b) (6) mac.com] L Perl [(b) (6) gmail.com]; David shulkin [drshulkin@aol.com]; (b) (6) [(b) (6) frenchangel59.com] Re: From yesterday's discussion hotmail.com; IP Totally agree. Great ideas. From my non-medical perspective, couldn't agree more with the "tour ... WITHOUT THE ADMINISTRATIVE STAFF" approach. Marc Sherman (202) 758-(b) (6) mac.com> wrote: On Apr 16, 2017 8:12 AM, "Bruce Moskowitz" <(b) (6) Ifwe adapt the fix it before it breaks slogan then the 18 regional managers need to be held accountable for the following (probably many if not all are in place now): That they arrived unannounced and proceeded to tour all areas of the hospital WITHOUT THE ADMINISTRATIVE STAFF so staff can speak freely of their concerns. Personally spot checked for adequate supplies in every department Account for the radiology, lab, pathology , intensive care units and surgical suites and cardiac monitoring units have updated equipment to meet the new standards of care. Review medical personnel staffing and close any area of the hospital that would jeopardize patient care from understaffing. Suspend any low volume procedure that does not meet proficiency of care standards. For instance if the cath lab does not have the volume found safe by the American College of Cardiology. >From the administrative staff request to see any personnel issues that are now under report and if those critical to patient care have been suspended from current patient care. Request to see all onsite and off site storage units and how recalled medical equipment has been accounted for. Request to see any reported breach in securing or prescribing addictive medication Request to see patient or staff reported concerns regarding quality of care issues. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000248 DS 00001910 Message David shulkin [Drshulkin@aol.com] 4/16/2017 8:17:12 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Questions about DC VAMC From: Sent: To: Subject: Lets discuss Sent from my iPhone Begin forwarded message: From: "Slack, Donovan" Date: April 16, 2017 at 4:08:08 PM EDT To: David Shulkin Subject: Fwd: Questions about DC VAMC I wanted to tell you personally what I am up to here with these questions below. I am turning my sites on those layers of bureaucracy between u, dr Alleigh and the field. I hope and pray you see it as a gift to drive internal change : ) D Donovan Slack White House and Veterans Affairs Correspondent USA TODAY dslack@usatoday.com (703) 854-8926 Office (202) 415-9493 Cell Begin forwarded message: From: "Slack, Donovan" Date: April 14, 2017 at 4:34:35 PM EDT (b) (6) To: "(b) (6) ((b) (6) va.gov)" <(b) (6) "Hutton, James (James.Hutton@va.gov)" Subject: Questions about DC VAMC va.gov>, (b) (6) and James, I have some questions below about the DC VAMC and what led up to this week's crisis. Can I speak with someone about this? My deadline is end of business Monday. Thanks, Donovan -According to the IG report, the VHA Procurement and Logistics Office, policy assistance and quality, found no VA approved inventory management system in place and infection control issues in multiple clinical supply areas at DC VAMC Jan. 24-26, 2017. -The Deputy Undersecretary for Health for Operations and Management, Steven W. Young, sent a memo on March 21, 2017, directing the VISN 5 Director and the medical center director to provide a corrective action plan. VA-19-0799-D-000249 OS 00001911 1) Why did Mr. Young wait two months to ask for this? 2) What prompted him to ask for it? 3) According to the timeline (see below), the VISN took the lead in addressing issues at VAMC and repeatedly suggested they were being remediated, so why was the medical center director relieved of duty pending investigation and not the VISN officials? 4) Is VISN director Joseph A. Williams, Jr., being held accountable and how? If not, why not? 5) He was previously assistant deputy undersecretary for health for operations and management. Why the demotion and when? 6) Who is the VISN deputy chief medical officer that visited DC VAMC on March 22, March 30 and March 31? (And who was asked to help get vascular patches but didn't) Is he or she being held accountable? How and why or why not? 7) Why were the deficiencies noted by the IG missed or not remedied by all the various VISN officials? 7) Did the various VACO officials who received VISN reports have confidence in them? Why or why not and what did they do? (Deputy Undersecretary for Health for Operations and Management, Steven W. Young; Thomas lynch, Assistant Deputy Under Secretary for Health for Clinical Operations at Department of Veterans Affairs; Tammy Czarnecki, Assistant Deputy USH for Administrative Operations; (b) (6) Director of the National Center for Patient Safety; Ricky Lemmon, Acting Chief Procurement and logistics Officer; Sharon Ridley, executive director network support) 8) Did the Deputy Undersecretary for Health for Operations and Management, Steven W. Young, brief the (acting) Undersecretary for Health Dr. Poonam Aleigh? If so, when and what did she do about it? If not, why not? 9) Did Dr. Aleigh brief Secretary Shulkin? If not, why not? If so, what did he do about it and when? 10) How will he prevent this from happening again? TIMELINE: -On March 21, 2017, VISN 5 submits an "issue brief" on the situation that says a "comprehensive action plan" has been created and is being executed. VISN 5 supply chain office is migrating to new inventory management system, staffing within DC supply chain was 45% vacant and positions were posted, says the VISN 5 Supply Chain Office will "continue to review all facets of the supply chain, and provide guidance and assistance in rectifying any deficiencies that exist." These people were part of the communication on the brief: Raymond Chung, MD, Chief Quality Management Officer, VISN 5; (b) (6) Medical Officer, VISNS; (b) (6) , patient safety officer , deputy network director, VISN 5; and (b) (6) VISNS. These people received the brief: Deputy Undersecretary for Health for Operations and Management, Steven W. Young; Thomas lynch, Assistant Deputy Under Secretary for Health for Clinical Operations at Department of Veterans Affairs; Tammy Czarnecki, Director of the Assistant Deputy USH for Administrative Operations; (b) (6) National Center for Patient Safety; Ricky Lemmon, Acting Chief Procurement and logistics Officer; Sharon Ridley, executive director network support. -On March 22, VISN S's deputy chief medical officer and patient safety officer conducted a "focused review" at the DC VAMC and found ... "no issues were identified that posed an immediate risk to patient safety, however, several policy and practice inconsistencies and Environment of Care concerns were validated that could potentially impact patient safety," but said immediate risks were corrected at time of review VA-19-0799-D-000250 OS 00001912 -On March 30-31, VISN 5 deputy chief medical officer again visited the DC VAMC to "check the status of critical supplies that if not present, could adversely affect patient care and put patients at risk" -Over the April 1-2 weekend, the "Tiger team" working at the DC VAMC included the VISN 5 chief logistics officer, VISN 5 deputy chief logistics officer (and eight logistics employees from Martinsburg VAMC) -Per the IG, on March 30, facility ran out of dialyzer bloodlines, and other equipment deficiencies on April 4, 5 and 11 (OR runs out of vascular patches despite asking VISN 5 deputy chief medical officer two weeks earlier) ### Donovan Slack White House and Veterans Affairs Correspondent USA TODAY (703) 854-8926 office (202) 415-9493 cell VA-19-0799-D-000251 OS 00001913 Message From: Sent: To: Subject: (b ) [(b) (6) frenchangel59.com] 4/18/2017 12:01:59 PM David shulkin [drshulkin@aol.com] FW: WSJ - Trump's Promise to Veterans Lets discuss before I answer. Thank you https://www.wsj.com/articles/trumps-promise-to-veterans-1492123100 Trump's Promise to Veterans Corruption at the VA isn't punished, while the Pentagon claws back signing bonuses. VA headquarters in Washington, D.C. PHOTO: ASSOCIATED PRESS By Rebecca Burgess April 13, 2017 6:38 p.m. ET 71 COMMENTS Donald Trump pitched himself as a friend to the American military, and to veterans in particular. His campaign pledged to fix the Department of Veterans Affairs "by firing the VA-19-0799-D-000252 OS 00001914 corrupt and incompetent VA executives who let our veterans down." Since taking office, however, President Trump hasn't defined what, if anything, his administration will do to make good on that promise. Here are a couple of obvious wrongs he can easily make right. In 2015, a pair of senior VA officials were accused of defrauding the department to the tune of $400,000. Diana Rubens and Kimberly Graves, the directors of two regional VA offices, had allegedly manipulated the department's hiring and transfer systems for personal financial gain. Ms. Rubens was accused of pressuring a subordinate to leave the VA's Philadelphia office so she could take the job herself, move from Washington, and collect a $288,000 relocation payout. Similarly, Ms. Graves received more than $129,000 by engineering a move from Philadelphia to St. Paul, Minn. Allison Hickey resigned in October 2015 as the VA undersecretary for benefits amid investigations into her role in the scheme. Ms. Rubens and Ms. Graves were called to appear before the House Veterans Affairs Committee that November, but they refused to testify, invoking their Fifth Amendment right against self-incrimination. Instead of being fired, the pair were demoted. Due to a VA "paperwork mistake," however, the demotion had to be rescinded in December 2015 and reissued. ♦ - ADVERTISEMENT - 111.1 Then the two got a reprieve from the Merit Systems Protection Board, the quasijudicial agency whose mission, in part, is to review the disciplining of federal employees. The MSPB is the successor of the U.S. Civil Service Commission, originally set up to protect federal workers from partisan recrimination. VA-19-0799-D-000253 OS 00001915 In early 2016 the MSPB fully reversed the punishments of Ms. Rubens and Ms. Graves. Furthermore, the VA did not to try to recover the taxpayer funds that the pair had collected for relocating. It seems that since "senior officials" approved the $400,000, it would have been somehow improper to ask for the money back. Yet the Los Angeles Times revealed in October 2016 that the Defense Department had been forcing National Guard veterans to repay re-enlistment bonuses-sometimes up to $20,000they had received during the mid-2000s. The Pentagon said the bonuses were improperly awarded. Nearly 10,000 soldiers, the Times reports, have faced everything from retroactive interest to wage garnishment to tax liens. Debt collectors and tanked credit scores, the result of the retroactive action, will haunt many of them for the foreseeable future. Unlike the senior VA officials, these soldiers weren't accused of conspiring to game the system. Rather, each signed a service contract and happily took the bonus that the military, under pressure to make up enlistment shortfalls, was eagerly offering. Many consequently deployed for multiple tours. What a way to thank them for their service. Auditors later determined that the incentive program of the California Army National Guard had been operated like a slush fund, with as much as $100 million misspent. The program's onetime leader, former Master Sgt. Toni Jaffe, was sentenced in May 2012 to 30 months in prison after pleading guilty to filing $15.2 million in false claims. Three other officers were put on probation and forced to pay restitution. Yet, for some reason, the Pentagon decided to claw back money from the veterans who had received the bonuses. Congress, it turns out, knew about the situation-or at least the California delegation did. When the story hit the press, then-Defense Secretary Ash Carter ordered a halt to the bonus hunting. But the order focused mostly on reviewing and streamlining the process. 'This process has dragged on too long, for too many service members," Mr. Carter's statement said. 'Too many cases have languished without action." Little was said about the underlying injustice of the matter. Process is certainly important. As Alexander Pope mused: "For Forms of Government let fools contest; Whate'er is best administer'd is best." But Alexander Hamilton countered the point in Federalist 68. 'The true test of a good government," he wrote, "is its aptitude and tendency to produce a good administration." The rules at the Defense Department and the VA must apply to senior officials and enlisted soldiers alike. Without consistency, even the best process fails from the standpoint of justice. VA-19-0799-D-000254 OS 00001916 Exhibit A: the VA, where employees are rewarded because they technically followed a process. Exhibit B: the Pentagon, which cou]d not protect even itself with its own processes. Ifl\t1r. Trump wants to do right by veterans and the mihtmy, he could begin by insisting on consistency. A1s. Burgess manages the Program on American Citizenship at the American Enterprise institute. Appeared in the Apr. 14, 2017, print edition as 'Trump's Promise to Veterans. 1 VA-19-0799-D-000255 OS 00001917 Message From: Sent: To: Subject: (b) (6) [(b) (6) hotmail.com] 4/21/2017 10:29:44 PM David [drshulkin@aol.com] Fwd: The Alaigh's Celebration of Friendship We cant go, should i rsvp Sent from my iPhone Begin forwarded message: From: (b) (6) and Poonam Alaigh Date: April 21, 2017 at 5:58: 19 PM EDT To: David Shulkin <(b) (6) hotmail.com> Subject: The Alaigh's Celebration of Friendship hotmail.com> Reply-To: Evite <(b) (6) ~Vite™ You're Invited The Alaigh's Celebration of Friendship VA-19-0799-D-000256 OS 00001918 1/ou/Jte 1/llli,/dl (b) (6) and Poonam Alaigh sent you an invitation. J RSVP Now! View Invitation J Download the Evite Mobile App llillriii.... I GET IT ON ,,..... Google Play I Evite respects your privacy. For more information, please review our privacy policy. Add info@mailva.evite .com to your address book to ensure that you receive Evite emails in your inbox. Have a question? Visit Evite's support page . Don't want to receive any Evite emails from this person? Block this host. This email was sent to (b) (6) hotmail.com Evite® and Life's Better Together® are registered trademarks of Evite, Inc. in the United States and other countries. The Evite logo and all other Evite-related trademarks are trademarks of Evite, Inc. Please use this mark only to refer to our services. Other names may be trademarks of their respective owners. (9vite™ • VA-19-0799-D-000257 OS 00001919 Message David shulkin [Drshulkin@aol.com] From: Sent: 4/18/2017 11:05:39 AM To: (b) (6) CC: (b) (6) [(b) (6) hotmail.com; (b) (6) Re: [EXTERNAL] Hepatitis paper Subject: va.gov] [(b) (b)(6)(6) va.gov] Thank you Sent from my iPhone On Apr 18, 2017, at 1:06 AM, (b) (6) (b) (6) va.gov> wrote: Hi Dr. Shulkin and Dr. Alaigh, Please find attached the data on the number of veterans we have treated and our SVR (cure) rates among those we have treated since the availability of the oral DAAs. In the attached spreadsheet (HCV VA data sources.xis), please find three tabs: Tab 1 shows the daily cumulative total of veterans starting on oral HCV DAAs. We started prescribing in VA in Jan 2014, though they were FDA approved in Nov 2013. This summary graph is also posted and is available at the first link listed below. Number of veterans treated since DAA availability: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/default.aspx Tab 2 of the spreadsheet shows the number of veterans awaiting treatment at periodic intervals beginning with FY14 ( DAAs introduced in VA in Q2 FY14). This is data captured from the HCV Clinical Case Registry. Those in the paper reflect the end of March (Q2 FYl 7). This data is also posted and is available at the link listed below: Numbers awaiting treatment - this is updated quarterly. https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/HCV%20Viremic/virem ic-fib4.aspx Tab 3 of the spreadsheet shows the raw data that relates to the "Cascade of HCV Care" (figure 3) with a brief sentence about the methods used to calculate each "step". For more detailed methods, refer to the attached Maier et al paper. We used the same methods for the current cascade as we did in this previously published paper. Note that the cascade numbers represent all HCV patients in care ever treated (even with earlier non-DAA regimens before 2014) which is why the SVR percentages in the cascade graph are lower than what the SVR rates are with all oral DAA regimens (shown in link below -which represent SVR rates of only oral DAA regimens from 2014 and beyond). SVR (cure) rates with all oral DAA regimens are posted here and updated every two weeks: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/HCV%20Antivirals%20 Tests/HCV Direct Acting Antivirals.aspx From table at above link, SVR rate calculated as SVR12/(NoSVR+SVR12) = 94.98%; Published data on SVR rates available in the attached article. VA-19-0799-D-000258 OS 00001920 HCV testing rates are updated and posted quarterly, (those in the paper reflect the end of March, Q2 FY17): https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvbirthcohort/hcv cohorts fiscal year/default.aspx Please let me know if you have any additional questions about the data or would like to have copies of any of the other references in the paper. Best, (b) (6) From: David Shulkin [ mailto:drshulkin@aol.com] Sent: Sunday, April 16, 2017 9:59 AM To: (b) (6) (b) (6) (b) (6) Subject: [EXTERNAL] Hepatitis paper hotmail.com (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has occurred at VA. (6) I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here David Shulkin MD VA-19-0799-D-000259 OS 00001921 Message From: Sent: To: CC: Subject: Attachments: (b) (6) [(b) (6) va.gov] 4/18/2017 5:06:43 AM David Shulkin [drshulkin@aol.com]; (b) (6) hotmail.com [(b) va.gov] (b) (6) (b)(6)(6) RE: [EXTERNAL] Hepatitis paper HCV VA data sources.xlsx; Maier_AJPH201512546R3_2nd_ProofCXs.pdf Hi Dr. Shulkin and Dr. Alaigh, Please find attached the data on the number of veterans we have treated and our SVR (cure) rates among those we have treated since the availability of the oral DAAs. In the attached spreadsheet (HCV VA data sources.xis), please find three tabs: Tab 1 shows the daily cumulative total of veterans starting on oral HCV DAAs. We started prescribing in VA in Jan 2014, though they were FDA approved in Nov 2013. This summary graph is also posted and is available at the first link listed below. Number of veterans treated since DAA availability: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/default.aspx Tab 2 of the spreadsheet shows the number of veterans awaiting treatment at periodic intervals beginning with FY14 ( DAAs introduced in VA in Q2 FY14). This is data captured from the HCV Clinical Case Registry. Those in the paper reflect the end of March (Q2 FY17). This data is also posted and is available at the link listed below: Numbers awaiting treatment - this is updated quarterly. https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/HCV%20Viremic/viremic-fib4.aspx Tab 3 of the spreadsheet shows the raw data that relates to the "Cascade of HCV Care" (figure 3) with a brief sentence about the methods used to calculate each "step". For more detailed methods, refer to the attached Maier et al paper. We used the same methods for the current cascade as we did in this previously published paper. Note that the cascade numbers represent all HCV patients in care ever treated (even with earlier non-DAA regimens before 2014) which is why the SVR percentages in the cascade graph are lower than what the SVR rates are with all oral DAA regimens (shown in link below -which represent SVR rates of only oral DAA regimens from 2014 and beyond). SVR (cure) rates with all oral DAA regimens are posted here and updated every two weeks: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcvantivirals/HCV%20Antivirals%20Tests/HCV Direc t Acting Antivirals.aspx From table at above link, SVR rate calculated as SVR12/(NoSVR+SVR12) = 94.98%; Published data on SVR rates available in the attached article. HCV testing rates are updated and posted quarterly, (those in the paper reflect the end of March, Q2 FYl 7) : https://vaww. vha. vaco.portal. va.gov /sites/PublicHealth/pophealth/hcvbirthcohort/hcv cohorts fiscal year/ default.asp ~ Please let me know if you have any additional questions about the data or would like to have copies of any of the other references in the paper. VA-19-0799-D-000260 OS 00001922 Best, (b) (6) From: David Shulkin [mailto:drshulkin@aol.com] Sent: Sunday, April 16, 2017 9:59 AM (b) (6) (b) (6) To: (b) (6) Subject: [EXTERNAL] Hepatitis paper hotmail.com (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has occurred at VA. (6) I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here David Shulkin MD VA-19-0799-D-000261 OS 00001923 RESEARCH AND PRACTICE Cascade of Care for Hepatitis CVirus Infection Within the US Veterans Health Administration I Marissa M. Maier, MD, David B. Ross, MD, PhD, MBI, Maggie Chartier, PsyD, MPH, Pamela S. Belperio, PharmD, and Lisa Hepatitis C virus infection is the most common blood-borne infection in the United States. An estimated 2.7 to 3.9 million Americans are chronically infected, representing 1.0% to 1.5% of the US population.1·2 The Veterans Health Administration (VHA) is the single largest provider of HCV care in the United States. The burden of chronic HCV is known to be higher among patients seen in the VHA than among the general population. 3 Prior to 2014, HCV antiviral therapies required long treatment durations, had numerous treatment-limiting side effects, and resulted in sustained virologic response (SVR) or cure rates of approximately 500/o overall; cure rates were even lower among those with genotype 1 infection, 4 ·5 the most common genotype in the United States. New direct-acting antiviral agents require shorter durations of therapy, have favorable side effect profiles, and yield cure rates of greater than 900/o in clinical trials, even among genotype 1-infected patients. 6 ·7 Curing chronic HCV is associated with reduced all-cause mortality. 8 - 10 With widespread use of more efficacious treatment regimens, it is helpful to use a population health approach to assess a health care system's ability to identify individuals with chronic HCV, link them to care, provide antiviral treatment, and achieve clinical cure. Doing so allows for identification of gaps in care and of foci for improvement. Yehia et al. proposed a 7-step cascade of care methodology that estimated that among individuals in the United States with chronic HCV, 160/o had received antiviral therapy and 90/o had achieved SVR.11 The cascade proposed by Yehia et al. may be limited in its applicability to large health care systems. For example, insurance status was used as a marker of access to outpatient care, which may not be applicable for a health care system trying to assess performance across the Cascade of Care among enrolled patients who, by definition, have health insurance. In Published online ahead of print November 12, 2015 I. Backus, MD, PhD Objectives. We measured the quality of HCV care using a cascade of HCV care model. Methods. We estimated the number of patients diagnosed with chronic HCV, linked to HCV care, treated with HCV antivirals, and having achieved a sustained virologic response (SVR) in the electronic medical record data from the Veterans Health Administration's Corporate Data Warehouse and the HCV Clinical Case Registry in 2013. Results. Of the estimated 233898 patients with chroni c HCV, 77% (181168) were diagnosed , 69% (160794) were linked to HCV care, 17% (39388) were treated with HCV antivirals, and 7% (15983) had achieved SVR . Conclusions. This Cascade of HCV Care provides a clinically relevant model to measure the quality of HCV care within a health care system and to compare HCV care across health systems. (Am J Public Health . Published on line ahead of print November 12, 2015: e1-e6 . doi :10.2105/AJPH .2015.302927) addition, liver biopsy was included in their model, which in many cases may no longer be indicated. Finally, because their model concentrated on the entire US population, national seroprevalence surveys and patient self-reported survey data were used, which is not routinely available in a health care system. We sought to create a cascade ofHCV care that captured the current state of HCV care using steps applicable to a large health care system and that could be calculated with data generally available from an electronic medical record. We included an assessment oflinkage to HCV-specific care because it is a more stringent measure than access to insurance or general medical care. We did not include patient awareness of infection, access to care, or liver biopsy as steps in our cascade. We developed and applied our cascade of HCV care in the VHA health care system. METHODS To create our cascade of HCV care, we determined the following: 1. number of patients with chronic HCV, 2. number of patients diagnosed with chronic HCV, 3. number of patients linked to HCV care, I American Journal of Public Health 4. number of patients treated with HCV antivirals, and 5. number of patients with an SVR. For the first 2 steps, we used the VHA's Corporate Data Warehouse, a national database that captures birth dates, gender, race, ethnicity, health care encounters, and laboratory tests from October 1, 1999, onward for patients who received VHA care. The analysis included all patients in VHA care in 2013, where "in care" was defined as having at least 1 VHA outpatient visit (including telehealth) in 2013. We required only 1 outpatient visit in 2013 to capture as broad a population as possible while still ensuring that the patients were using VHA health care to some extent. We identified all HCV antibody, viral load, and genotype tests that had been obtained between October 1, 1999, and December 31, 2013, for patients in care in 2013. We considered individual test results "informative" if the result could be categorized as negative or positive for antibody tests, detectable or undetectable for viral load tests, and detectable for genotype tests if a recognized HCV genotype was reported. For each patient in care in 2013, we detemiined if the patient ever had positive or negative antibody tests, and detectable or undetectable HCV RNA testing from all identified Maier et al. I Peer Reviewed I Research and Practice I e1 VA-19-0799-D-000262 OS 00001925 RESEARCH AND PRACTICE tests. We considered patients with a positive enzyme immunoassay HCV antibody test result who had a subsequent negative recombinant immunoblot assay test result to have negative antibody testing. For this analysis, we accessed Corporate Data Warehouse data on January 15, 2014. Number of Patients With Chronic HCV The estimated total number of patients with chronic HCV in the population receiving VHA health care in 2013 is the sum of 3 subgroups: (1) those already identified with chronic HCV, (2) estimated additional cases from the projected prevalence among HCV antibody-positive patients who had not received RNA testing, and (3) estimated additional cases from the projected prevalence among the untested population. Patients already identified with chronic HCV Patients were considered to have chronic HCV if they ever had positive RNA-based testing (a detectable viral load or genotype). Estimated additional cases from the projected prevalence among HCV antibody-positive patients who had not received RNA testing. We applied the observed prevalence of chronic HCV among HCV antibody-positive patients who had received RNA testing to the population that was HCV antibody positive but had not received RNA testing to estimate the prevalence of HCV in the latter population. Estimated additional cases from the projected prevalence among the untested population. To project the prevalence of HCV among untested individuals (i.e., individuals without any HCV antibody, viral load, or genotype tests), we first determined chronic HCV incident diagnosis rates per year of testing for those in care in 2013 (i.e., the number of people with their first detectable HCV RNA test result in the year divided by the total number of people with informative HCV testing in the year). Since chronic HCV prevalence is known to vary by gender, race/ethnicity, and birth cohort (born before 1945, born 1945-1965, and born after 1965),12 .1 3 we determined incident diagnosis rates separately among these demographic subgroups. In addition, since incident diagnosis rates in the VHA are decreasing over time as more people undergo HCV testing, we approximated the estimated prevalence rate for the e2 I Research and Practice I Peer Reviewed I also extracts information from the VHA electronic medical record, which includes laboratory results, pharmacy information, and ICD-9 diagnosis codes from inpatient hospitalizations, outpatient visits, and problem lists of HCV-infected patients seen at all VHA medical facilities. HCV Clinical Case Registry data for this analysis was available through December 31, 2013. We considered a patient with an outpatient visit in 2013 to be linked to HCV care if the patient was entered into the HCV Clinical Case Registry and had HCV entered on his or her problem list in the electronic medical record. untested population as the incident diagnosis rate in 2013 multiplied by the ratio of the 2013:2012 rates. 12 For those subgroups for which the incident diagnosis rate in 2013 was actually higher than the rate in 2012, we used the 2013 rate as the estimated prevalence rate for the untested population. We calculated estimates of the projected prevalence of chronic HCV in the untested population by applying the projected prevalence rate to the people in the untested population. For example, among non-Hispanic White men born from 1945 to 1965 who were in care in 2013, 72 723 had their first informative HCV testing in 2012, of whom 3686 had detectable HCV RNA, for an incident diagnosis rate of 5.07; 77 083 had their first informative HCV testing in 2013, of whom 3304 had detectable HCV RNA, for an incident diagnosis rate of 4.29. Thus, the projected prevalence rate among those untested in this demographic cohort is the ratio of the 2013:2012 rates multiplied by the rate in 2013 ([4.29/5.07] x 4.29=3.62). Applying the projected prevalence rate of 3.62 to the 567 756 non-Hispanic White men born between 1945 and 1965 in care in 2013 and untested for HCV yields 20 553 additional cases of chronic HCV that would be found with complete testing of this demographic cohort. Number of Patients Treated With HCV Antivirals Among patients in the HCV Clinical Case Registry linked to HCV care in 2013, we determined the number who had ever received HCV antiviral medications, including boceprevir, consensus interferon, interferon, pegylated interferon, ribavirin, and telaprevir, from the VHA at any time up to and including December 31, 2013. Number of Patients With an SVR We evaluated SVR rates using all HCV RNA results available after the end of treatment for those patients linked to HCV care in 2013 who had a calculated end of treatment included in the available data. We calculated the end of treatment as the last day covered by any HCV antiviral medication, using the cumulative number of days of medication supplied and the dispensed dates. We considered that patients with an undetectable HCV RNA on all tests after the end of treatment, including at least 1 test 12 weeks or more after the end of treatment, had achieved SVR; patients with a detectable HCV RNA after the end of treatment were considered not to have SVR. SVR status could not be definitively determined for patients who were still on treatment at the end of the available date, who had not had HCV RNA testing after the end of treatment, or who had an undetectable HCV RNA result after the end of treatment but no test 12 weeks or more after that date. We then applied the SVR rate among those evaluable for SVR to all those who had started HCV antiviral treatment to determine the number of patients in care in 2013 who would be expected to achieve SVR. Number of Patients Diagnosed With Chronic HCV The number of patients in care in 2013 diagnosed with chronic HCV included those patients who had ever had a detectable viral load or genotype. Number of Patients Linked to HCV Care The VHA maintains a registry of HCV patients known as the HCV Clinical Case Registry, which was originally designed in part to ensure that patients with chronic HCV were linked to HCV care. 14 The registry software identifies patients as potentially having HCV on the basis of International Classification of Diseases, Ninth Revision (ICD-9) 15 codes or laboratory results and adds such patients to the list of "pending" patients. HCV Clinical Case Registry coordinators at each facility review the lists of pending patients to confirm the diagnosis of HCV. The HCV Clinical Case Registry Maier et al. American Journal of Public Health I Published online ahead of print November 12, 2015 VA-19-0799-D-000263 OS 00001926 RESEARCH AND PRACTICE an additional 20 124 patients with chronic HCV from RNA testing without preceding antibody testing. Overall, we identified 181 168 individuals who had an outpatient visit in 2013 as ever having chronic HCV, for a prevalence of 5.8% among those with informative testing. Estimated additional cases from the projected prevalence among HCV antibody-positive patients who had not received RNA testing. Among those with positive antibody results, 9218 patients did not have RNA-based testing. Applying the observed prevalence among HCV antibody-positive individuals who did have RNA-based testing (77.1%) to the 9218 who did not have RNA-based testing, we estimated that an additional 7107 individuals would be identified with chronic HCV by RNA-based testing of these individuals. Estimated additional cases from the projected prevalence among the untested population. Of the patients in VHA care in 2013, 2 460 782 had not been tested for HCV (excluding the 552 RESULTS Results for the 5 steps of our cascade of HCV care appear in Figure 1. Comparisons to national estimates for these same 5 steps appear in Figure 2. Number of Patients With Chronic HCV Overall, 5 596 178 patients had a VHA outpatient visit in 2013 and 3 135 396 (56.0%) had ever had any HCV testing (HCV antibody, viral load, or genotype) in the VHA; 3 11 7 014 (9 9.4% of those with any testing) had HCV antibody testing, 502 378 (16.0%) had viral load testing, and 191 552 (6.1 %) had genotype testing. Patients already identified with chronic HCV Of 218 111 patients with positive antibody tests, 208 893 (95.8%) had RNA-based testing for chronic HCV. Of those with positive antibody tests who received RNA-based testing, 161 044 (77.1 %) had positive RNA test results and therefore had chronic HCV. We identified 250000 233898 (100%) 200000 ..., V, C Cl) .::; Number of Patients Linked to HCV Care In 2013, 172 857 patients in the HCV Clinical Case Registry had at least 1 outpatient visit in the year. Of these, 160 794 had HCV entered on their problem list By this definition, 88.8% of all patients in VHA care in 2013 with diagnosed chronic HCV had been linked to HCV care. Number of Patients Treated With HCV Antivirals Of the 160 794 patients linked to HCV care, 39 388 (24.5%) had ever received VHA HCV antiviral therapy as of December 31, 2013. CL ...... d Number of Patients Diagnosed With Chronic HCV As noted in the previous paragraph, 181 168 (79.9%) of an estimated 233 898 patients in VHA care in 2013 with chronic HCV had been diagnosed with chronic HCV. 1 50000 (\J 0 patients without gender [n = 26] or birth-date information [n = 526]). If the projected prevalence rates in each demographic cohort were applied, an estimated additional 45 623 patients with chronic HCV would be identified among the untested population in VHA care (Table 1). The estimated total number of patients with chronic HCV (n=233 898) thus reflects the sum of (1) those already identified with chronic HCV (n= 181168), (2) estimated additional cases among those known to have positive HCV antibody without RNA testing (n = 7107), and (3) estimated additional cases among untested patients (n=45 623). 100000 z 50000 0 Chronic HCV Diagnosed with (estimated)' chronic HCVb Linked to HCV care' Treated with Achieved SVR' HCV antiviralsa Cascade Steps Note. SVR = sustained virologic response. The proportion of patients in each step of the cascade from the patients in the preceding step is presented in the arrows between each bar. 'Chronic HCV was estimated from the sum of those already identified with chronic HCV plus estimated additional cases from projected prevalence among HCV antibody-positive patients who had not had RNA testing plus estimated additional cases from projected prevalence among the untested population. b"Diagnosed with chronic HCV" was defined as ever had a detectable HCV RNA or genotype. c"Linked to HCV care" required an outpatient visit in 2013, entry in the VHA's HCV registry, and HCVentered on the patient's medical record problem list. d"Treated with HCV antivirals" was defined as ever received HCV antivirals from the VHA as of December 31, 2013. '"Achieved SVR" was defined as undetectable HCV RNA on all tests after end of treatment, including at least 1 test at least 12 weeks after the end of treatment, with the SVR rate among those evaluable for SVR applied to those without definitive SVR status. FIGURE 1-Cascade of HCV care in the Veterans Health Administration (VHA) in 2013 (n = 233 898). Published online ahead of print November 12, 2015 I American Journal of Public Health Number of Patients With an SVR Of the 39 388 patients in care in 2013 who had ever received HCV antivirals from the VHA, SVR status could be determined for 37 069, of whom 15 041 (40.6%) achieved SVR. Conservatively, applying this SVR rate to the 2319 who did not have definitive SVR status and adding it to those known to have SVR, the projected number with SVR among those in care in 2013 who had received HCV antivirals was 15 983, or 6.8% of the entire population projected to have chronic HCV. DISCUSSION The high prevalence of chronic HCV, the rapidly changing treatment climate, and the Maier et al. I Peer Reviewed I Research and Practice I e3 VA-19-0799-D-000264 OS 00001927 RESEARCH AND PRACTICE measure of "linked to care" is difficult to define; we believe our definition is most appropriate given the availability of the Clinical Case Registry as a resource, as well as the relative ease of using electronic medical records to extract problem list entries. This cascade illuminates important opportunities to improve care within a health care system. Within the VHA, as of the end of 2013 before the availability of interferon-free regimens, only 1 7% of patients with chronic HCV (24% of those linked to HCV care) had received antiviral treatment. This figure is similar to that of Yehia et al., who estimated that 160/o of HCV-infected individuals have received treatment in the United States.11 The model also documents the historically low SVR rates from prior interferon-based HCV antiviral regimens. In the VHA, approximately 410/o of the patients who had ever been treated with HCV antivirals through Dec 31, 2013-and 7% of all patients with chronic HCV-achieved SVR, comparable to the estimated national SVR rates of 9%.11 Although all steps of the cascade require attention, within the VHA health care system increasing treatment initiation will have the largest impact on increasing cure rates. Both the treatment rates and SVR rates have already improved markedly with the availability of shorter-duration, highly efficacious treatment regimens. This cascade provides a health care system with a method to assess and monitor over time the quality of its HCV care and to identify performance metrics that require improvement. The information this model generates is useful across a broad range of reporting units, so that a large health care system may identify variation between regions or facilities and appropriate targets for performance improvement interventions. The cascade uses data that are typically available within a health care system's electronic medical record, thereby encouraging health care systems to use this model to monitor their own HCV care and enabling them to compare the quality of their HCV care with that of other systems. Additionally, since it mirrors the flow of clinical care from diagnosis to cure, it provides relevant information to clinicians and administrators: How many patients do we have with chronic hepatitis C? How many have been treated? How many have been cured? 100 'cf- >' u ■ 90 □ VHA National United States I u 80 C 77% 0 ..c u 70 ~ 60 ..c ..., C 0 .::; .!!:! 50 ::::l C. 0 40 CL "'C ...,Cl) 30 (\J E .::; V, 20 LU "'iu ..., 0 10 I- 0 Diagnosed with chronic HCV' Linked to HCV careb Treated with HCV antivirals' Achieved SVRa Cascade Steps Note. SVR = sustained virologic response. Total estimated chronic HCV population in the VHA in 2013 was 233 898. Source. National US estimates were derived from the following sources: diagnosed with chronic HCV, 16 linked to HCV care, 17 treated with HCV antivirals and achieved SVR. 11 VHA estimates were derived from the VHA Corporate Data Warehouse and the HCV Clinical Case Registry. '"Diagnosed with chronic HCV" was defined as ever had a detectable HCV RNA or genotype. b"Linked to HCV care" required an outpatient visit in 2013, entry in the VHA's HCV registry, and HCV entered on the patient's medical record problem list. c"Treated with HCV antivirals" was defined as ever received HCV antivirals from the VHA as of December 31, 2013. d"Achieved SVR" was defined as undetectable HCV RNA on all tests after end of treatment, including at least 1 test at least 12 weeks after the end of treatment, with the SVR rate among those evaluable for SVR applied to those without definitive SVR status. *P < .001. FIGURE 2-Cascade of HCV care within the Veterans Health Administration (VHA) and relative to national US estimates in 2013. high cost of antiviral therapies all warrant the use of a population health approach to HCV care. Our cascade of HCV care demonstrates that the VHA performs very well in the initial steps of the cascade and outperforms national US estimates (Figure 2). For example, the VHA has diagnosed an estimated 77.5% of its patients in care with chronic HCV. This compares with national US estimates from the Chronic Hepatitis Cohort Study that suggest that only 5 7% of those with chronic HCV have been diagnosed. 16 The VHA also performs well in linking patients to HCV care: 690/o of patients with chronic HCV (89% of those with diagnosed chronic HCV) have been linked to e4 I Research and Practice I Peer Reviewed I HCV care. National US estimates indicate that only 380/o of patients with chronic HCV (77% of those with diagnosed chronic HCV) have been linked to HCV care, when linkage to care is defined as self-reporting a visit with a health care provider after receiving a positive HCV test.17 We posit that the decrement between being diagnosed with chronic HCV and being linked to HCV care is smaller within the VHA (a decrement from 77% to 690/o within VHA, vs 570/o to 380/o within the United States; Figure 2), in part because of higher HCV diagnosis rates within VHA, as well as differences in definitions of "linked to care." A clinically meaningful, readily accessible Maier et al. American Journal of Public Health I Published online ahead of print November 12, 2015 VA-19-0799-D-000265 OS 00001928 RESEARCH AND PRACTICE TABLE 1-Projected Prevalence of HCV in 2013 Among Veterans Health Administration Patients Who Were Previously Untested, by Sociodemographic Characteristics: United States Born Between 1945-1965 Born Before 1945 Characteristic Projected Prevalence,' % No. Estimated No. of Cases No. Projected Prevalence,' % Born After 1965 Estimated No. of Cases No. Projected Prevalence,' % Estimated No. of Cases Women American Indian/Alaska Native 122 0.00 0 618 0.84 5 819 0.00 Asian 99 0.00 0 505 0.90 5 1447 0.00 0 0 Black 1184 0.00 0 16 940 1.18 200 19 323 0.13 25 White 15190 0.05 8 34294 1.04 357 33 605 0.54 181 Hispanic 390 0.00 0 2103 0.64 13 6136 0.13 8 Native Hawaiian/Pacific Islander 148 0.00 0 443 0.50 2 687 0.00 0 2 675 1.52 41 8 514 1.92 163 10 896 0.22 24 Mixed, other, or unknown Subtotal 49 745 238 Men American Indian/Alaska Native 4 497 1.71 77 6 379 5.87 374 3185 0.26 Asian 6157 0.58 36 6 734 0.72 48 5 728 0.11 6 Black 66442 1.86 1236 122 370 6.85 8382 53 566 0.27 145 White 820 785 0.45 3694 567 756 3.62 20553 198 289 0.80 1586 29245 1.57 459 35 512 4.84 1 719 28 687 0.41 118 6445 0.67 43 5529 1.70 94 2 811 0.23 6 169155 0.86 1455 113 287 3.90 4 418 51533 0.26 134 Hispanic Native Hawaiian/Pacific Islander Mixed, other, or unknown Subtotal 7 000 35588 8 2 003 Note. The total estimated number of HCV cases among those untested was 45 623. 'Projected prevalence is based on the incident diagnosis rate in those first tested in 2013 multiplied by the ratio of the 2013:2012 incident diagnosis rates. Although our model offers many benefits, there are limitations to this approach. Even after incorporating the decline in incident diagnosis rates from 2012 to 2013 and the variability by gender, race/ethnicity, and birth cohort, the projected prevalence rates for the untested likely still overestimate the number of additional cases that would be identified with complete population testing, particularly in the birth cohorts born before 1945 and after 1965. For these 2 cohorts, risk-based screening is recommended.18 Thus, the observed incident diagnosis rates are likely higher for these patients who have been identified as at risk and tested compared with the rate that would be observed among those who are untested and theoretically not at risk. Even with this overestimation, however, only 9290 (20.4%) of the estimated 45 623 additional cases that would be found with testing the untested occur among those born outside the 1945 to 1965 birth cohort. Although changes in the estimates of the undiagnosed would change the absolute percentages, the Published online ahead of print November 12, 2015 percentage changes from preceding steps along the cascade would not change. The percentages of each preceding step provide useful information for identifying gaps in care-for example, regardless of the estimate of the undiagnosed, only 240/o of those linked to HCV care have received antivirals. Another limitation is that our definition of "linked to care" relies partly on the entry of patients with chronic HCV into the HCV Clinical Case Registry, a VHA registry of individuals with chronic HCV that is not available in other health care systems. However, other health care systems may have similar ways of tracking HCV among their patient populations. Finally, the SVR estimates provided here reflect a static number that relies heavily on patients who received therapy during a period of less efficacious interferonbased treatments. Although SVR rates are increasing with the rapid uptake of more efficacious regimens, there will be a delay in observing the impact of this increased effectiveness at the population level. Moreover, our I American Journal of Public Health SVR estimates would not capture patients who received HCV antiviral therapy and achieved SVR outside the Department of Veterans Affairs health care system. Our cascade of HCV care offers health care systems the ability to readily measure and monitor performance during a period of rapid change in the field of HCV treatment and care. The dramatic improvements in HCV treatment effectiveness pose parallel challenges to public and private health care systems grappling with high treatment costs and inadequate numbers of trained providers to meet the demand for HCV care. This cascade is a useful tool for systems aimed at maximizing provider and fiscal resources to improve the overall quality of HCV care. ■ About the Authors Marissa M Maie:r is with the VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. David B. Ross is with the VA Washington DC Health Care System, and the Office ofPublic Health/HIV, Hepatitis, and Maier et al. I Peer Reviewed I Research and Practice I e5 VA-19-0799-D-000266 OS 00001929 RESEARCH AND PRACTICE Public Health Pathogens Programs, VHA, Washington, DC. Maggie Chartier is with the VA San Francisco Health Care System, VHA, San Francisco, CA, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Pamela S. Belperio is with the VA Greater Los Angeles Health Care System, VHA, Los Angeles, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Lisa I. Backus is with the VA Palo Alto Health Care System, VHA, Palo Alto, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Correspondence should be sent to Marissa M Maier, MD, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Mail Code P3ID, Portland, OR 97239 (e-mail: Marissa.Maier@va.gov). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints" link. This article was accepted September 28, 2015. Contributors MM. Maier and M. Chartier contributed to data analysis. P. S. Belperio and L. I. Backus were instrumental to data production and analysis. All of the authors contributed to the study design and the preparation and revision of the article. Acknowledgments We are indebted to Timothy Loomis, PhD, who compiled the HCV screening data from the Computerized Data Warehouse and who is instrumental in maintaining the Clinical Case Registry. Human Participant Protection Under guidance from the VHA Office of Research Oversight, the Office of Public Health has the authority to perform the analyses presented here as part of their health care operations work, which does not require institutional review board approval. References 1. Denniston MM, Jiles RB, Drobeniuc J, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003-2010. Ann Intern Med. 2014;160(5):293-300. 2. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1992 through 2002. Ann Intern Med. 2006;144(10):705-714. 8. Dieperink E, Pocha C, Thuras P, Knott A, Colton S, Ho SB. All-cause mortality and liver-related outcomes following successful antiviral treatment for chronic hepatitis C. Dig Dis Sci. 2014;59(4):872-880. 9. Backus LI, Boothroyd DB, Phillips BR, Belperio P, Halloran J, Mole LA A sustained virologic response reduces risk of all-cause mortality in patients with hepatitis C. Clin Gastroenterol Hepatol. 2011 ;9(6):509. el-516.el. 10. Morgan TR, Ghany MG, Kirn H, Snow KK, Shiflinan ML, De Santo JL. Outcome of sustained virological responders with histologically advanced hepatitis C. Hepatology. 2010;52(3):833-844. 11. Yehia BR, Schranz AJ, Umscheid CA, Lo RV. The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014;9(7):e101554. 12. Backus LI, Belperio PS, Loomis TP, Mole LA Impact of race/ethnicity and gender on HCV screening and prevalence among US veterans in Department of Veterans Affairs care. Am] Public Health. 2014;104(suppl 4): S555-S561. 13. Smith BO, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born 1945-1965. MMWR Recomm Rep. 2012;61(RR-4):l-32. 14. Backus LI, Gavrilov S, Loomis TP, et al. Clinical case registries: simultaneous local and national disease registries for population quality management. J Am Med Inform Assoc. 2009; 16(6):775-783. 15. International Classification of Diseases, Ninth Revision. Geneva, Switzerland: World Health Organization; 1980. 16. Spradling PR, Rupp L, Moorman AC, et al. Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence. Clin Infect Dis. 2012;55(8):1047-1055. 1 7. Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. N Engl] Med 2013;368(20):1859-1861. 18. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR Recomm Rep. 1998;47(RR-19):l-39. 3. Backus LI, Belperio PS, Loomis TP, Yip GH, Mole LA Hepatitis C virus screening and prevalence among US veterans in Department of Veterans Affairs care. JAMA Intern Med 2013;173(16):1549-1552. 4. Fried MW, Shiffman ML, Reddy KR, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl] Med. 2002;347(13):975-982. 5. Manns MP, McHutchinson JG, Gordon SC, et al. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Lancet 2001; 358(9286):958-965. 6. Afdhal N, Reddy KR, Nelson DR, et al. Ledipasvir and sofosbuvir for previously treated HCV genotype 1 infection. N Engl] Med. 2014;370(16):1483-1493. 7. Afdhal N, Zuezem S, Kwo P, et al. Ledipasvir and sofosbuvir for untreated HCV genotype 1 infection. N Engl] Med. 2014;370(20):1889-1898. e6 I Research and Practice I Peer Reviewed I Maier et al. American Journal of Public Health I Published online ahead of print November 12, 2015 VA-19-0799-D-000267 OS 00001930 Message From: David Shulkin [drshulkin@aol.com] Sent: To: (b) (6) Subject: Attachments: 4/16/2017 4:59:22 PM va.gov; (b) (b)(6)(6) va.gov; (b) (6) hotmail.com Hepatitis paper hepatitsC.docx (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has occurred at VA. (6) I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here David Shulkin MD VA-19-0799-D-000268 OS 00001931 Curing Hepatitis C Infection: Best Practices from the Department of Veterans Affairs David J. ghHlkin MD+, Poonam L. Alaigh, MD~,~Maggie Chartier PsyD MPH~, Pamela S. Belperio PharmD Poonam Alaigh, MD, David Shulkin MD4 Office of Specialty Care Services, Department of Veterans Affairs, Washington DC 4 Population Health Services, Department of Veterans Affairs, Palo Alto Health Care System, Palo Alto, CA Office of the Under Secretary for Health, Department of Veterans Affairs, Washington DC 1 Office of the Secretary, Department of Veterans Affairs, Washington DC ~ Offise of the Under gosretary for Health, Department of Veterans Affairs, Washington DC ~ Offise of gposialty Care gervises, Department of Veterans Affairs, Washington DC 4 PopHlation Health gervisos, Department of Veterans Affairs, Palo Alto Health Care gystem, Palo Alto, CA Keywords: Veteran, access, direct acting antiviral, cascade Corresponding Author: Pamela S. Belperio, Pharm D, Patient Care Services/Population Health Services, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304 1 VA-19-0799-D-000269 OS 00001932 Phone: 310-478-37 llx44 711, Fax: 650-849-0266, Email: Pamela.Belperio@va.gov Word count: 2729 2 VA-19-0799-D-000270 OS 00001933 Introduction Since the introduction of Direct Acting Antivirals (DAAs) in 2014, the Department of Veterans Affairs (VA) has made substantial progress in curing the large number of veterans in VA care with hepatitis C virus (HCV) infection. As the nation's single largest provider of care to patients with HCV, VA is uniquely suited to inform the recently released National Strategy for the Elimination of Viral Hepatitis, produced by a National Academies of Sciences, Engineering, and Medicine expert committee, which emphasizes prevention, screening, and universal treatment ofHCV-- areas in which VHA has become a recognized leader. 1.2 The proposed national strategy presents specific actions to reduce the burden of HCV and outlines 5 distinct areas-Information, Interventions, Service delivery, Financing, and Research. 1.2 Merein-,-VA's best practices and successes may be useful to other healthcare providers and organizations in helping to reduce the burden of hepatitis C infection. in eaeh of these areas are highlighted. Based on US National Health and Nutrition Examination Survey (NHANES) data from 2010, it was estimated that approximately 13% of all patients diagnosed with HCV in the United States (US) receive care within the VA, highlighting the disproportionate burden among veterans. 3 •4 In 2013, before the availability ofHCV DAAs, there were approximately 168,000 veterans diagnosed with HCV infection in VA care who were potentially eligible for treatment and an additional estimated 45,000 undiagnosed in care. 5 With support from the US House and Senate Appropriations Committees, VA has made a substantial commitment to prioritizing HCV care as reflected in dedicated funding for HCV treatment in VA, universal access to DAAs, detailed guidance on individualizing care and the establishment of Veterans 3 VA-19-0799-D-000271 OS 00001934 Integrated Service Network (VISN) Hepatitis C Innovation Teams (HITs). 6 This work, in collaboration with other key VA offices, is largely supported by the VA's National Viral Hepatitis Program which also develops policy, tools, trainings, and resources for patients and providers, easily accessible through internal channels and on its comprehensive website. 7 VA' s success and best practices, informed by extensive population health data analysis capabilities, and national teel-s;--guidance and policieG, is the dedicated providers a!!d teams 011 ooe to the grmmd. The significant resources and efforts VA and its HCV providers have dedicated to prioritizing this disease at every level of the organization are being tangibly realized. Between January 2014 and March 2017, 86,000 BCV-infected veterans enrolled in VA care have received potent oral DAA treatment, achieving cure rates of over 90%. As of March 2017, only 58,000 known veterans in VA care remain to be treated, compared to over 168,000 three years ago. While elimination appears attainable, VA recognizes the reality of the HCV epidemic and population; namely, many of those in care remaining to be treated have complex substance use, mental health, and medical co-morbidities, and many are challenged by homelessness, transportation, and rurality which pose significant barriers to engagement in care and treatment. The curve of elimination for HCV in VA will include a long tail of persistence driven by system, patient and care delivery determinants (Figure !). Information: Population Health Management Using relmst-national databases and analytics, VA employs population health management strategies to efficie11tly track, measure, monitor and identify trends in HCV care, gaining insight into patterns of access and tailoring care provision programs accordingly. Every-Veteran§. in VA care diagnosed with HCV is followed in VA's National Hepatitis C Clinical Case Registry (CCR), developed in part to ensure veterans with chronic HCV were linked to care .8 The HCV CCR, used for both local and national 4 VA-19-0799-D-000272 OS 00001935 population reporting, provides data on the number of patients known to be infected with HCV together with critical clinical information such as patient and disease characteristics, where care is received, receipt of DAA treatment and clinical outcomes. The VA' s Central Data Warehouse, a repository of electronic medical record data, has spurred the creation oflocal and regional HCV dashboards which offer providers access to patient-specific data reports for real-time intervention and tracking. These sources allow for comprehensive monitoring of incidence, prevalence, and disease course to identify and address barriers and assess outcomes. National, regional and individual facility level data is posted regularly, allowing providers, teams, and leadership to assess progress and goals. This leveraging of health systems data transforms numbers into knowledge and guides providers and the VA toward more informed and effective delivery of care for each veteran. Essential Interventions Diagnosis and Testing Improved case identification: A critical first step for improving HCV care is to identify those infected. In 2012, the Centers for Disease Control and Prevention (CDC) and subsequently the United States Preventive Services Task Force (USPSTF) developed recommendations for testing evoryolleveterans born between 1945-1965, a cohort determined to have the highest HCV prevalence _9- 10 Prior to 2014, VA had guidance in place which recommended risk-based testing as well as testing of Vietnam-era veterans, a group which largely overlaps with the 1945-1965 birth cohort. 3 Using robust information systems to track screening, VA has been able to identify and target additional populations at risk for HCV, which include: African American males, for which the prevalence is double that of Caucasians (17. 7% versus 8.3%); the homeless, for which the prevalence is over three times higher when compared to non-homeless (13.4% versus 3.5%); and persons who inject drugs.11· 12 5 VA-19-0799-D-000273 OS 00001936 Since the rapid adoption of these expanded screening recommendations, VA has sueeessfally screened over 78% of the 2.5 million veterans in the 1945-1965 birth cohort. Of particular note, VA has screened 89 .6% of its homeless population. 12 Using updated annual prevalence calculations from the number of new infections among those tested, VA estimates that there are only approximately 15,000 remaining veterans in VA care who would test positive for HCV if the entire at-risk population were screened. Testing initiatives: Several initiatives undertaken within VA to increase HCV testing have significantly impacted these results. These include national electronic point-of-care clinical reminders for HCV risk assessment and testing, automated letters recommending HCV testing which dually serve as a laboratory order when presented to a VA lab, weekly primary care panel review identifying patients with upcoming appointments who require testing, and calling patients directly. To emphasize this as a priority, VA added birth cohort testing as a national performance measure in 2015 and reports quarterly screening rates by facility and region. To ensure complete testing while simultaneously providing an efficient and patientcentered approach, VA developed policy in 2009 whereby all patients tested for HCV with a positive antibody automatically had reflex confirmatory HCV RNA testing performed with the same laboratory sample, with over 97% compliance in 2015. As a result of these collective factors, the proportion of veterans in VA care screened for HCV have increased annually by 3% to 4% and are substantially higher than any-other large healthcare system§..13 Building Infrastructure Hepatitis Innovation Team (HIT) Collaborative: Recognizing that care is not delivered the same way in all settings, regional HITs, comprising a multidisciplinary group of 15-30 healthcare providers, administrators, information technology and system redesign specialists, have implemented Lean Process Improvement methods to maximize their clinical expertise and redesign the process ofHCV testing, diagnosis, treatment, and management to provide care in the most efficient and effective way possible for 6 VA-19-0799-D-000274 OS 00001937 the populations they serve. 14 The HIT Collaborative has enabled a clinically focused foundation to share and implement best practices across and within teams, supported by local and regional administrators. The development of the HIT infrastructure on the ground which has leveraged and supported the work of dedicated VA providers has been one of the critical implementation arms that has allowed VA to lli-mhly respond to challenges in funding variability and other critical access issues that have arisen since the introduction ofDAAs. Service Delivery: Improving Linkage and Access Once an enrolled veteran is diagnosed with HCV, the emphasis shifts to timely linkage to evaluation and referral for appropriate treatment. Robust population health data, the infrastructure of the HIT collaborative, and legions of dedicated providers on the ground have been instrumental in enhancing VA's outreach and engagement efforts. Efforts have focused on raising awareness among providers and staff about the need for HCV testing and availability of treatment, as well as promoting direct outreach to at-risk veterans and the veteran community more broadly through national and local social media and advertising campaigns, mobile phone applications, and secure messaging. Expanding Capacity Telemedicine and electronic technologies: VA has focused on increasing specialist capacity through telemedicine and clinical video telehealth (CVT), or real-time video teleconferencing, whereby HCV clinicians provide care to patients and/or consultation to other providers at another location. Largely modeled off of the University of New Mexico ECHO project,15 the expanded VA-ECHO model includes urban and rural sites, homeless care clinics and incorporates a pharmacist-led provider program since much of HCV treatment in VA is managed by clinical pharmacists and an HCV mental health and 7 VA-19-0799-D-000275 OS 00001938 substance use program to aid providers in treating patients with these co-morbidities. Inter-provider electronic consults offer another effective and efficient way to prepare patients for treatment avoiding the need for additional appointments. Using electronic databases, registries or dashboards, HCV team members can identify patients who may be candidates for treatment, notify primary care providers electronically through the medical record of their eligibility and recommend management. Similarly, primary care providers can efficiently consult HCV specialists regarding HCV care management and treatment recommendations eliminating the need for a specialty visit. Non-physician advanced practice providers: Importantly, VA has also emphasized the expansion of HCV care beyond specialty providers. A substantial portion of HCV management has shifted, particularly treatment, outside of liver and infectious disease specialty care clinics at larger medical centers to primary care and community clinics. Furthermore, this care is often being delivered by non-physician providers such as Clinical Pharmacy Specialists, Nurse Practitioners and Physician Assistants, who have been recognized as delivering the same quality of care and providing more timely access to HCV treatment. 16· 17 In 2016, almost one-third of all HCV antiviral prescriptions were initiated by a network of nearly 200 Clinical Pharmacy Specialists. 18 Targeted use of the limited number of specialists while expanding the skills of non-physician providers is one of the most important practices that can be adapted from the VA system into other healthcare systems. 16 VA has recently granted full practice authority to nurse practitioners therefore expanding the potential for further use of these providers in providing hepatitis Challenging Populations 8 VA-19-0799-D-000276 OS 00001939 Barriers to Care: Based on VA HCV provider data collected in 2014 and 2015, it was estimated that up to 30% of veterans awaiting treatment were not currently willing or were unable to initiate HCV treatment. Major reported reasons included active alcohol/substance use, serious mental illness, documented non-adherence to medical appointments or treatment, unstable/uncontrolled medical comorbidities, inability to contact a veteran and, in some cases, veterans being unwilling to start treatment. As VA continues to treat more patients, an increasing number of those remaining in the untreated pool present more challenges. with accompanying resource demands to potentially modify these patient, system, or care delivery factors. Frequent reassessment and refocusing is required of healthcare systems and providers to adapt their approach and resources as the needs of its HCV population and barriers to initiating treatment change. Addressing substance use: Recognizing alcohol and substance use as a considerable barrier to HCV treatment, VA took aggressive steps to eliminate non-evidence based, abstinence policies for HCV treatment and provided clinical guidance on effectively assessing alcohol and substance use, matching a patient's use with the actual risk of non-adherence. VA studies have consistently shown cure rates achieved among veterans with alcohol. substance use and mental health disorders are similar to those without these conditions. 19· 20 Integrated care: Where resources permit, VA has emphasized that integrated care, care coordination, case management, and mental health and substance use services are in place to address factors that pose significant impediments to HCV treatment. This comprehensive management approach facilitates care such that veterans' treatment candidacy can be reassessed. This has been particularly important for vulnerable populations. Accessible mental health and addiction specialists, care coordinators, case managers and social workers are invaluable resources to meet the individualized needs of this population. 9 VA-19-0799-D-000277 OS 00001940 Financing HCV Treatment Like all healthcare systems, VA has faced significant financial challenges as a result of highly priced DAAs. With strong advocacy from VA HCV providers. veterans and VA leadership expanded special purpose funding for HCV medications was made available through Congressional appropriations. 6 .2 1 The dramatic reductions in the price of DAAs made possible by VA Pharmacy Benefits Management leadership steadfast negotiations in early 2016, simultaneous enactment of additional appropriations and removal of restrictions based on stage of Ii ver disease solidified VAs ability to provide consistent access to HCV treatment. Currently, VA has no restrictions on DAAs which are available to all HCV patients regardless of stage of Ii ver disease. Figure 2 depicts the significant impact of funding variability on DAA uptake in VA over recent years. Recognizing that in order to comprehensively and successfully treat HCV infection in VA, resources beyond purchasing medications would be required. In 2016, VA boldly allocated 5% of the HCV dmg budget for each VA medical center to 11011-dmg clinical resources and infrastructure to further increase treatment starts. This has allowed VISN HITs to independently address local barriers and identify tangible solutions to increase treatment. These funds have successfully been used to expand HCV or liver disease VA-ECHO programs, increase treatment capacity through a Clinical Pharmacy Specialist initiative, increase integrated care, implement HIT innovations, host HCV testing events and fund local testing and treatment advertising campaigns. Research to Inform 10 VA-19-0799-D-000278 OS 00001941 The comprehensive data sources within VA and the VA' s diverse HCV population provides a broad milieu for examining scientific and clinical outcomes, cost-effectiveness, patterns of care, and the impact of specific interventions. VA HCV researchers actively contribute to the medical literature influencing and informing patient care, implementation strategies, operations and policy. Given the large number of BCV-infected veterans treated, real-world outcomes in special populations can be assessed to a greater degree than in many other healthcare environments thus providing valuable insight for other payors and healthcare systems. Cascade of HCV Care in VA The impact ofDAAs on HCV has been universally transformational, making elimination seem a tangible goal, as the National Academies of Sciences, Engineering, and Medicine report highlights. Elimination can only occur when every individual with HCV infection is identified, linked to care, treated with HCV antivirals and achieves a sustained virologic response (SVR), or cure. These steps comprise the "hepatitis C cascade of care", a series of key care components used to describe the population health approach to HCV care and a mechanism to assess performance_ 5.1 3 .2 2 -24 Figure 3 depicts VA's HCV transformation since the availability ofDAAs and the impact on each of the steps of the care cascade from 2014-2016. As of 2016, VA estimates that 92% of veterans with HCV in care have been diagnosed, and of those, 93% have been linked to care. The most significant change in the cascade has occurred in the treatment step. In 2014, the VA had initiated HCV treatment in 27% of veterans linked to VA care. In tum, 51 % achieved SVR. By the end of 2016, HCV treatment had been initiated in 59% of veterans linked to VA care, and 84% of the veteran population ever receiving HCV treatment had achieved SVR. Overall, 84,] 92 veterans have been cured ofHCV, the overwhelming majority since 2014. 11 VA-19-0799-D-000279 OS 00001942 Summary The widespread availability of oral DAA medications that cure HCV have made the possibility of elimination seem achievable. VA is steadily approaching this goal and remains committed to diagnosing and treating all veterans with HCV who are willing and able to be treated. An extensive array of delivery of services, policy guidance, outreach efforts and funding has broadened the reach and capacity of VA to deliver these disease-curing medications, supported by an infrastructure to effectively implement change. The key actions that have advanced VA 's HCV elimination efforts include: expanding treatment capacity with non-MD providers; use of video telehealth and modified ECHO models to expand treatment; widespread use of integrated care and improvement in addressing psychiatric, substance use and medical co-morbidities; use of electronic data tools for patient tracking and outreach; and dissemination and implementation of best practices developed through the Systems Redesign efforts of regional HITs. However, it must be underscored that financing for HCV treatment and infrastructure resources coupled with reduced drug pricing has been paramount lo VA's success in curing HCV and is the lynch pin in achieving elimination for any health care system and the US nationally. Recognizing the resources necessary to realize this goal and the infrastructure and innovations that could make it truly possible, VA is well poised to share and extend best HCV practices to other healthcare organizations and providers delivering HCV care. 12 VA-19-0799-D-000280 OS 00001943 References 1. National Academies of Sciences, Engineering, and Medicine. 2017. A national strategy for the elimination of hepatitis B and C. Washington, DC: The National Academies Press. ~-------l Formatted: Default Paragraph Font _ _._n_at_i_on_ a_l_a_c _ad_e_m _ie_s_.o_r-g_/h_m _d_/_R_e_p_o_rt_s_/2_0_1_7_/n_a_t_io_n_a_l-_s_tr_a_te~gy ~ --fo_r_-t_h_e_-e_l_im _ in_a_t1_·o_n_-o_f_-_ _ _p_tt~p_:/_/www hepatitis-b-and-c.aspx 2. Gillian J. Buckley, PhD, MPH; Brian L. Strom, MD, MPH. A National Strategy for the Elimination of Viral Hepatitis Emphasizes Prevention, Screening, and Universal Treatment of Hepatitis C. Ann -------l Formatted: Default Paragraph Font Int Med 4 April 2017. Jittp://annals.org/aim/article/2616344/national-strategy-elimination-viralhepatitis-emphasizes-prevention-screening-universal-treatment 3. Beste LA, Ioannou GN. Prevalence and Treatment of Chronic Hepatitis C Virus Infection in the US Department of Veterans Affairs. Epidemiol Rev (2015) 37 (1): 131-143. 4. Denniston MM, Jiles RB, Drobeniuc J, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003---2010. Ann Intern Med. 2014; 160(5):293300. 5. Maier MM, Ross DB, Chartier M, Belperio PS, Backus LI. Cascade of Care for Hepatitis C Virus Infection Within the US Veterans Health Administration. Am J Public Health. 2016 Feb; 106(2):353358. 6. H.R.3236 - Surface Transportation and Veterans Health Care Choice Improvement Act of 2015, 114th Congress (2015-2016). 7. US Department of Veterans Affairs Viral Hepatitis Website. Jittps://www.hepatitis.va.gov/ 8. Backus LI, Gavrilov S, Loomis TP, Halloran JP, Phillips BR, Belperio PS, Mole LA. Clinical Case -------l Formatted: Default Paragraph Font Registries: simultaneous local and national disease registries for population quality management. J Am Med Inform Assoc. 2009 Nov-Dec; 16(6):775-83. 13 VA-19-0799-D-000281 OS 00001944 9. Smith BD, Morgan RL Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012;6l(RR-4): 1-32. 10. Moyer VA; U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med.2013 Sep 3; 159(5) 349-57. 11. Backus LI, Belperio PS. Loomis TP, Mole LA Impact of race/ethnicity and gender on HCV screening and prevalence among U.S. veterans in Department of Veterans Affairs Care. Am J Public Health. 2014 Sep;104 Suppl 4:S555-61. 12. NoskaAJ. Belperio PS, Loomis TP, O'Toole TP, Backus LI. Engagement in the Hepatitis C Care Cascade Among Homeless Veterans, 2015. Public Health Rep. 2017 Mar/Apr; 132(2): 136-139. 13. Jonas MC, Rodriguez CV. Redd J, Sloane DA, Winston BJ. Loftus BC. Streamlining screening to treatment: the hepatitis C cascade of care at Kaiser Permanente mid-Atlantic states. CID 2016; 62 1290-1296. 14. Ross DB. Best Practices in HCV Screening,Diagnosis, and Treatment. Federal Practitioner 2017. February 1. 15. Arora S, Kalishman S, Thornton K, Dion D, Murata G, Deming P, Parish B, Brown J, Komaromy M, Colleran K, Bankhurst A, Katzman J, Harkins M, Curet L, Cosgrove E, Pak W. Expanding access to hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010 Sep;52(3): 1124-33. 16. Rongey C, Shen H, Hamilton N, Backus LI. Asch SM. Knight S. Impact of rural residence and health system structure on quality of liver care. PLoS One. 2013 Dec 26;8(12):e84826. 17. Backus LI, Belperio PS, Shahoumian TA, Mole LA. Impact of provider type on hepatitis C outcomes with boceprevir-based and telaprevir-based regimens.J Clin Gastroenterol. 2015 Apr:49(4):329-35. 18. Ourth H, Groppi J, Morreale AP, Quicci-Roberts K. Clinical pharmacist prescribing activities in the Veterans Health Administration. Am J Health Syst Pharm. 2016 Sep 15;73(18): 1406-15. 14 VA-19-0799-D-000282 OS 00001945 19. Tsui JI, Williams EC, Green PK, Berry K, Su F, Ioannou GN, Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents.Drug Alcohol Depend. 2016 Dec 1;169:101-109. 20. Backus Ll, Belperio PS, Shahoumian TA, Loomis TP, Mole LA Real-world effectiveness and predictors of sustained virological response with all-oral therapy in 21,242 hepatitis C genotype-I patients. Antivir Ther, 2016 Dec 9. 21. US Department of Veterans Affairs. VA expands hepatitis C drug treatment http://www.va.gov/opa/pressrel/pressrelease.cfm?id~2762. Published March 9,2016. Accessed April 10, 2017. 22. Yehia BR, Schranz AJ, Umscheid CA, Lo RV. The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014;9(7):e101554. 23. Spradling PR, Rupp L, Moorman AC, et aL Hepatitis Band C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence. Clin Infect Dis. 2012;55(8): 1047-1055. 24. Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. N Engl J Med.2013;368(20): 1859-186 l. 15 VA-19-0799-D-000283 OS 00001946 Figure 1. Number of Veterans with HCV in VA Care Reqniring Antiviral Treatment Over Time 180,000 ... 160,000 s"' 140,000 C: QI ~ . C: ·;: ·;; 120,000 100,000 C" 80,000 "'C: 60,000 ~ ~ QI Qi > 40,000 20,000 0 10/1/2013 10/1/2015 10/1/2017 10/1/2019 10/1/2021 16 VA-19-0799-D-000284 OS 00001947 Figure 2. Availability of Funding and Impact on HCV Treatment Starts per Week 2000 .,.1800 + - - - - - - - - - ------tt·mited--t!se---e>----- - - - - - - - - - - - - QI QI Specia I funds ~1600 :;; C. f 1400 tii"' additional Funding + - - - - - - - - - - - ~ ~ ------.--........_- ,.,ppropfiati0n,,.,.,s·----- - - - - - constraints begin reduced drug pricing 'E1200 ~ "' !!!1000 ~ f- ·s; 800 :;:: C: Date: April 18, 2017 at 7 :23 :40 AM EDT To: David shulkin Cc: "(b) (6) <(b) (6) va.gov>, "(b) (6) (b) (6) (b) (6) < va.gov> Subject: Re: [EXTERNAL] Hepatitis paper I am in concurrence with Dr Shulkin- thanks Sent from my iPhone On Apr 18, 2017, at 7: 16 AM, David shulkin wrote: Thank you Sent from my iPhone On Apr 18, 2017, at 1:06 AM, (b) (6) wrote: (b) (6) va.gov> Hi Dr. Shulkin and Dr. Alaigh, Please find attached the data on the number of veterans we have treated and our SVR (cure) rates among those we have treated since the availability of the oral DAAs. In the attached spreadsheet (HCV VA data sources.xis), please find three tabs: Tab 1 shows the daily cumulative total of veterans starting on oral HCV DAAs. We started prescribing in VA in Jan 2014, though they were FDA approved in Nov 2013. This summary graph is also posted and is available at the first link listed below. Number of veterans treated since DAA availability: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/default.aspx VA-19-0799-D-000288 OS 00001954 Tab 2 of the spreadsheet shows the number of veterans awaiting treatment at periodic intervals beginning with FY14 ( DAAs introduced in VA in Q2 FY14). This is data captured from the HCV Clinical Case Registry. Those in the paper reflect the end of March (Q2 FY17). This data is also posted and is available at the link listed below: Numbers awaiting treatment - this is updated quarterly. https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/HCV%20Viremic/viremic-fib4.aspx Tab 3 of the spreadsheet shows the raw data that relates to the "Cascade of HCV Care" (figure 3) with a brief sentence about the methods used to calculate each "step". For more detailed methods, refer to the attached Maier et al paper. We used the same methods for the current cascade as we did in this previously published paper. Note that the cascade numbers represent all HCV patients in care ever treated (even with earlier non-DAA regimens before 2014) which is why the SVR percentages in the cascade graph are lower than what the SVR rates are with all oral DAA regimens (shown in link below - which represent SVR rates of only oral DAA regimens from 2014 and beyond). SVR (cure) rates with all oral DAA regimens are posted here and updated every two weeks: https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hcv antivirals/HCV%20Antivirals%20Tests/HCV Direct Acting Antivirals.asp X From table at above link, SVR rate calculated as SVR12/(NoSVR+SVR12) = 94.98%; Published data on SVR rates available in the attached article. HCV testing rates are updated and posted quarterly, (those in the paper reflect the end of March, Q2 FYl 7) : https://vaww. vha. vaco. portal. va .gov/sites/Pu bl icHealth/pophealth/hcv birthcohort/hcv cohorts fiscal year/default.aspx Please let me know if you have any additional questions about the data or would like to have copies of any of the other references in the paper. Best, (b) (6) From: David Shulkin [ mailto:drshulkin @aol.com] Sent: Sunday, April 16, 2017 9:59 AM (b) (6) (b) (6) To: (b) (6) Subject: [EXTERNAL] Hepatitis paper hotmail.com (b) and (b) (6) and Poonam- you did a spectacular job writing this up and its a remarkable story that has occurred at VA. (6) I think this is exactly the type of manuscript that is needed so others can benefit from your experience and also that VA can be appropriately recognized for its' leadership in this area. VA-19-0799-D-000289 OS 00001955 I surprisingly made very few edits or corrections in the paper which is a real tribute to you all. Please take a look and make sure you agree with these few changes. The one request I would make is to be an author on this paper I feel it is important that I review the data that you used to put the statistics in the paper about how many veterans we treated and our success rates. Do you have any reports or data that you could share so Dr. Alaigh and I can review before we put our names on the manuscript? I don't know if Dr. Alaigh has had time yet to review. The annals seems appropriate or if not a hepatology journal surely would be interested. Thanks so much for your leadership here David Shulkin MD VA-19-0799-D-000290 OS 00001956 Message From: Bruce Moskowitz [(b) (6) Sent: 4/18/2017 6:35:54 PM To: (b) (6) (b) (6) CC: IP [ Subject: J&J mac.com] [(b) (6) its.jnj.com] frenchangel59.com]; Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [drshulkin@aol.com] Thank you for taking the time to discuss with me how to move this important mental health initiative forward in time for mental health awareness month. As we discussed both your CEO (b) (6) and my CEO's representing the five academic centers know and respect Terry Fadem's ability to get the precision medicine, clinical trials and preventive medicine done in a timely manor. Let's move quickly on the narrative and marketing material as discussed. Again I am available 24-7 to assist. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000291 OS 00001957 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/22/2017 3:29:16 PM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) gmail.com] From this morning http ://www. cb snews.com/vi deos/va-secretary-davi d-shulkin-on-chall enges-facing-the-agency/?ftag=CNM-00l 0aab4 i Sent from my iPhone VA-19-0799-D-000292 OS 00001958 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/20/2017 1:37:32 AM To: (b) (6) Subject: Attachments: gmail.com Fwd: healthdatapoolza.pptx You did a good job. Attached are my revisions Good to go if you can fill in the big data announcement slide and make sure the clip works VA-19-0799-D-000293 OS 00001959 U.S. Department of Veterans Affairs Health DataPalooza David J. Shulkin, MD Secretary of Veterans Affairs April 25, 2017 VA-19-0799-D-000294 OS 00001960 ff . i·'.r "To care for him who shall have borne the · battle, and for his widow and his orphan." President Abraham Lincoln, 1865 1 Our Mission ~ ·~ To care for those "who shall have borne the battle" and for their families and their survivors. VA Today ~;,(. . / \. VA-19-0799-D-000295 OS 00001961 ?Out of crisis comes clarity.? Randolph O?Toole Greater Choice Modernize Systems _,:::. --.::-\;;} Improve Timeliness Focus Resources •••• •• ••• Suicide Prevention VA-19-0799-D-000297 OS 00001963 1- Greater Choice for Veterans • Redesign the 40/30 Rule • Build a high-performing, integrated network of care • Empower Veterans through transparency of information VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000298 OS 00001964 VA Digital Health Platform FUTURE DEVELOPMENTS c1 VA~ Providers ◄Department of Defense \ '' .,,,, .,,,, ' -'' Veterans /D Supply Chain -► ' .... 1~ 1 Decision Support Community Providers VA-19-0799-D-000299 OS 00001965 Delivering Care Where We Don?t Have Facilities VA Telehealth Services 2.14 million episodes to 677,000 Veterans {12%} Home Telehealth 156,000 Veterans Video Telehealth 282,000 Veterans Store-and-Forward Tele health 298,000 Veterans 45% of our Telehealth services are for rural Veterans 336,000 TeleMental health visits 8 VA-19-0799-D-000301 OS 00001967 VISN 10 Tele-ICU program (Cincinnati) Tele-ICU Hubs Connects to other fa cilities Intensive Care Units I I Telehealth - Clinical Genomics Tele-ICU hub · ·· I •-= TeleRadiology Program .- .VHA Genomic Medicine . ....... 0 .... VA-19-0799-D-000302 DS_ 00001968 2- Modernize Our Systents lt lcit{one, St J D ~ · liil lB • EMR interoperability and IT modernization • Infrastructure improvements and streamlining services -., ►, h,ro W., ~~ H .""i1·~~ ~ - :.-~:•.m fll:K.l~ • llliil ~::':'~ :~ m ~ ?i .II l ...... • i ~ ~ 11 II, ~ • ... ~ ll ~ . VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000304 OS 00001970 VA Mobile Apps ---------1 . --. ... _ II ~ Om"-_,.., _ _ _ _ .,. ___ . 1111 _ _ , ,._... _ _ --· ..... 111 . u u ... ...,.,_,.,c....... . .. -·- ,.......,,,.,_ ~ • -----~-.. ~ [! Veteran Appointment Request (VAR) - Allows Veterans to directly schedule and cancel selected primary care appointments directly through the app Veteran Appointment Usability Study: .. □ 76% satisfied with the app □ 95% feel that it has the potential to □ htt~:l[mobile.va.gov[a~~store improve access to care VA-19-0799-D-000305 DS_00001971 3- Improve Timeliness of Services • Access to care and wait times • Decisions on appeals • Performance on disability claims VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000306 OS 00001972 How quickly does my VA see patients? How satisfied are veterans like me with the timeliness of their care? How well does my VA's care compare to other hospitals? VA-19-0799-D-000307 OS 00001973 Wait times at local facilities Walt Times for Appointments at VA Facillties '""" What Veterans are saying about access What Veterans Say About Access to Care at VA facilities SortR111bty s~rt~mb Sy Appo!r.l:nlnLTypt P~Cn(Rolitrel f atltyN.nt ~ "''"' ,onoo,CAA! illd~~Wil """"" COll'\\UE'IS HI.TH """""""""" Waill'tnesasofl/2 LIE'4"AL!EAI..Tk Fandliaittsllil be oo!t edaa:ll!dltl§JlOJ'O',l Percent o! IJe:erans 'MID rl!jlorted tllat llieywm Always or Usually able !Cl get 1111ppo'1tment when needed. Tht clo'1''1! Yo,o,111~ierorr.,,,Dea-trttt F11~l"OIIICt"~ nm 111 qtr:,,sb~~IWWl$lltll••~(iol; N}Q,l'l,at ... i.'t'lo;rgert..3011-,SICl.l~oilli!d•;h:: ., .. --!lVl'•U., t l : l " - ~ I D IJ>Ol o - \ ' , 1 0 . VA-19-0799-D-000308 OS 00001974 4- Focus Resources More Efficiently • Strengthening of foundational services in VA • VA/DOD/Community coordination • Deliver on accountability and effective management practices VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000309 OS 00001975 World Class Foundational Services Milliun Veteran Program: A Partnersnip with Veterans 0 Important Contributions to Society 9-0799-D-000311 v~"f Nee~ Pa~~Aers_anN~CTe• • IM,iiDI ~ """""'' - "·"""'"""""'-· [ml Rffr """' a@a1on G I r-. Cleveland Clinic 0 0 9 e >H GrantThornton accenture ~ISNEf \\' J,\arnott. Q ... Virginia Mason- T,eRm -CAA,mN" pwo ~ BCG ~ • •~ ~ ologe ri1 ~ ~ ~n ~ • STARBUCKS' ,., JOHNSHOPKI S ~----=------i•DmtH'.:'.jij Jollibee ~ KAISER PERMANENTE® I Booz Allen fjj~ I Hamilton • M ' 0 ' • ' " ' ® MU -- ~~§~ ~ c VA-19-0799-D-000312 DS_00001978 Watson Health 3 DS 00001979 https://www.youtube.com/watch?v=38pl8hc9aso&feature=youtu.be 21 VA-19-0799-D-000314 OS 00001980 5- Suicide Prevention G(TTING TO Z[RO , II\ VI-I I'9' JC\ ofVeterans U.S. Department Affairs VA-19-0799-D-000315 OS 00001981 Predictive Analytics Suicide Oncology PTSD TBI Center for Compassionate Innovation To enhance Veterans health and well-being by offering safe and ethical therapies after traditional treatments have not been successful VA-19-0799-D-000317 OS 00001983 VA Research Nicotine Patches First Liver Transplant Barcoding of Medications Cardiac Pacemaker 3 Nobel Prizes Artificial Kidney CT Scanner 25 VA-19-0799-D-000318 DS_ 00001984 Million Veteran Program: A Partnership with Veterans I< I I n I! 11 Re: )'lr h0SOevelopm nt VA-19-0799-D-000319 OS 00001985 Taking the Lead in Healthcare Big Data • Big Data Announcement Slide VA-19-0799-D-000320 OS 00001986 ThankYou -- ,. ,.c.-' -·· "THE PRICE OF FREEDOM IS VlSIBIF HF r · VA-19-0799-D-000321 OS 00001987 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/16/2017 7:10:02 PM (b) (6) hotmail.com; brucem(b) (6) Re: Buffalo VA @mac.com Thanks Poonam -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: Bruce Moskowitz <(b) (6) mac.com>; David shulkin Sent: Sun, Apr 16, 2017 1:43 pm Subject: Re: Buffalo VA Bruce and David, my team just concluded speaking to Medical Center Director, COS for Asst Sec of IT, the local Administrator on Duty, and the ED with the following facts : • • • There are no tickets or reports of any IT issues in the VA Medical Center or Clinics in Buffalo with all systems operating normally There are some routine switch replacements occurring in the Buffalo VA with periodic blips in system, but all this is routine, planned with no disruption in patient care services or problems reported However, the Erie County Medical Center did take their system down earlier this week because of attempts to infiltrate, presumably by hackers and are slowly brining it back on line. It is safe to say that everything is operating appropriately at Buffalo VA between the on the ground confirmation and the medical center directors validation at this time. Thanks Bruce, really appreciate the heads up so that we can fix any issues preemptively. From: Bruce Moskowitz <(b) (6) mac.com > Sent: Sunday, April 16, 2017 12:39 PM To: David shulkin; Poonam Alaigh Subject: Buffalo VA Are you aware of the hacking they can't use the computer system? Sent from my iPhone VA-19-0799-D-000322 OS 00001988 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) 4/16/2017 5:43:06 PM Bruce Moskowitz [(b) (6) Re: Buffalo VA hotmail.com] mac.com]; David shulkin [drshulkin@aol.com] Bruce and David, my team just concluded speaking to Medical Center Director, COS for Asst Sec of IT, the local Administrator on Duty, and the ED with the following facts : • • • There are no tickets or reports of any IT issues in the VA Medical Center or Clinics in Buffalo with all systems operating normally There are some routine switch replacements occurring in the Buffalo VA with periodic blips in system, but all this is routine, planned with no disruption in patient care services or problems reported However, the Erie County Medical Center did take their system down earlier this week because of attempts to infiltrate, presumably by hackers and are slowly brining it back on line. It is safe to say that everything is operating appropriately at Buffalo VA between the on the ground confirmation and the medical center directors validation at this time. Thanks Bruce, really appreciate the heads up so that we can fix any issues preemptively. From: Bruce Moskowitz <(b) (6) mac.com> Sent: Sunday, April 16, 2017 12:39 PM To: David shulkin; Poonam Alaigh Subject: Buffalo VA Are you aware of the hacking they can't use the computer system? Sent from my iPhone VA-19-0799-D-000323 OS 00001989 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/16/2017 4:51:39 PM To: brucem(b) (6) Re: Buffalo VA Subject: @mac.com no not sure what this is about -----Original Message----From: Bruce Moskowitz <(b) (6) mac.com> To: David shulkin ; Poonam Alaigh <(b) (6) Sent: Sun, Apr 16, 201712:39 pm Subject: Buffalo VA hotmail.com> Are you aware of the hacking they can't use the computer system? Sent from my iPhone VA-19-0799-D-000324 OS 00001990 Message From: Sent: To: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/16/2017 4:39:15 PM David shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) Buffalo VA hotmail.com] Are you aware of the hacking they can't use the computer system? Sent from my iPhone VA-19-0799-D-000325 OS 00001991 Message To: Bob McDonald [(b) (6) gmail.com] 4/16/2017 8:54:56 PM 'David shulkin' [Drshulkin@aol.com] Subject: RE: From: Sent: Thanks for your note, David. I wish you all well. Getting the right team in place is the most difficult, most time-consuming, and most important thing to do. I regret it took me so long in every job I have held. Please say hi to everyone for me. Thanks again. Bob -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Sunday, April 16, 2017 4:16 PM To: bob mcDonald <(b) (6) gmail.com> subject: Bob- just a quick note to say hello and let you know I think of you often. Scott and I are holding the fort and continuing to build on the progress you madeNo doubt your missed but everyone knows that you'd want us to carry on. There is so much going on and without a full team i am so busy that time rushes by- but i wanted to let you know that i hope you are doing well and hope to see you soon David Sent from my iPhone VA-19-0799-D-000326 OS 00001992 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/16/2017 8:15:31 PM To: bob mcDonald [(b) (6) Bob- just a quick gmail.com] note to say hello and let you know I think of you often. Scott and I are holding the fort and continuing to build on the progress you madebut everyone knows that you'd want us to carry on. No doubt your missed There is so much going on and without a full team i am so busy that time rushes by- but i wanted to let you know that i hope you are doing well and hope to see you soon David Sent from my iPhone VA-19-0799-D-000327 OS 00001993 Message David shulkin [Drshulkin@aol.com] 4/19/2017 7:30:41 PM Ike Perlmutter [(b) (6) frenchangel59.com] Fwd: Florida Governor Joins Trump To Sign Veterans Bill At White House - CBS Miami From: Sent: To: Subject: Clip below Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) gmail.com> Date: April 19, 2017 at 3 :29:06 PM EDT To: David Shulkin Subject: Florida Governor Joins Trump To Sign Veterans Bill At White House - CBS Miami http ://miami .cbslocal .com/2017/04/ 19/florid-governor-trump-sign-veterans-bill-whitehouse/amp/ VA-19-0799-D-000328 OS 00001994 Message From: (b) (6) Sent: 4/19/2017 7:29:06 PM David Shulkin [drshulkin@aol.com] Florida Governor Joins Trump To Sign Veterans Bill At White House - CBS Miami To: Subject: [(b) (6) gmail.com] http ://miami .cbslocal .com/2017/04/ 19/florid-governor-trump-sign-veterans-bill-white-house/amp/ VA-19-0799-D-000329 OS 00001995 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/18/2017 1:17:25 AM To: IP [(b) (6) frenchangel59.com] Re: RE: Subject: Thanks Ike Sent from my iPhone > on Apr 17, 2017, at 8:47 PM, IP <(b) (6) frenchangel59.com> wrote: > > David, > >Weare very happy that the Senator is willing to help. > > We definitely can use his help. > > We have "fires" in too many locations. > > We need all the support we can get. > > Please note you copied the wrong Marc. > > Please send to Marc Sherman. > (b) (6) gmail.com > > > > > > > > Thank you, Ike -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Monday, April 17, 2017 8:10 PM To: Ike Perlmutter; Laurie Perlmutter; Bruce Moskowitz; subject: (b) (6) > it > Not sure if i told you I had a good conversation with Senator Tester > was a great suggestion of all of you to make- he wants to work with us on > accountability > >Bruce-if you get the Annals of internal medicine> (on line) on Veteran wait times have an article today > > David > > Sent from my iPhone > VA-19-0799-D-000330 OS 00001996 Message From: Bruce Moskowitz [(b) (6) Sent: 4/18/2017 12:59:15 AM To: IP [(b) (6) frenchangel59.com] David shulkin [Drshulkin@aol.com] Re: RE: CC: Subject: mac.com] Excellent will look at article Sent from my iPhone > on Apr 17, 2017, at 8:47 PM, IP <(b) (6) frenchangel59.com> wrote: > > David, > >Weare very happy that the Senator is willing to help. > > We definitely can use his help. > > We have "fires" in too many locations. > > We need all the support we can get. > > Please note you copied the wrong Marc. > > Please send to Marc Sherman. > (b) (6) gmail.com > > > > > > > > Thank you, Ike -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Monday, April 17, 2017 8:10 PM To: Ike Perlmutter; Laurie Perlmutter; Bruce Moskowitz; subject: (b) (6) > it > Not sure if i told you I had a good conversation with Senator Tester > was a great suggestion of all of you to make- he wants to work with us on > accountability > >Bruce-if you get the Annals of internal medicine> (on line) on Veteran wait times have an article today > > David > > Sent from my iPhone > VA-19-0799-D-000331 OS 00001997 Message From: Sent: To: CC: Subject: IP [(b) (6) frenchangel59.com] 4/18/2017 12:47:17 AM 'David shulkin' [Drshulkin@aol.com] (b) (6) mac.com RE: David, We are very happy that the Senator is willing to help. We definitely can use his help. We have "fires" in too many locations. We need all the support we can get. Please note you copied the wrong Marc. Please send to Marc Sherman. gmail.com (b) (6) Thank you, Ike -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Monday, April 17, 2017 8:10 PM To: Ike Perlmutter; Laurie Perlmutter; Bruce Moskowitz; subject: (b) (6) Not sure if i told you I had a good conversation with Senator Tester it was a great suggestion of all of you to make- he wants to work with us on accountability Bruce- if you get the Annals of internal medicine(on line) on Veteran wait times have an article today David Sent from my iPhone VA-19-0799-D-000332 OS 00001998 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/18/2017 12:09:59 AM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) [(b) (6) mac.com]; (b) (6) gmail.com]; Bruce Moskowitz yahoo.com] Not sure if i told you I had a good conversation with Senator Tester of you to make- he wants to work with us on accountability it was a great suggestion of all Bruce- if you get the Annals of internal medicine- i have an article today (on line) on Veteran wait times David Sent from my iPhone VA-19-0799-D-000333 OS 00001999 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/23/2017 12:34:14 PM Darin Selnick [(b) (6) @gmail.com] Re: DPC and other Updates Thanks I think just pushing the senate is all we need from Potus I agree with you comments on the majority bill I think I agree with your recommendation but I'd like to review it with you in person- maybe we can get the design group together again soon Sent from my iPad On Apr 22, 2017, at 7: 15 PM, Darin Selnick <(b) (6) @gmail.com> wrote: WH Thursday event: (b) (6) from DPC called me. He wanted to know for the WH event on Thursday if there was anything specific you wanted the President to say about the Accountability bill stalled in the Senate. They are still firming up his remarks and this is a good opportunity to push again on the Senate bill. SVAC draft "Veterans Choice Act of 2017": Just a heads up that I received from (b) (6) from McCain a copy of the new red lined version of SVAC majority draft choice legislation. It is terrible and would cost a fortune. Basically veterans can pick any provider in the network when they want, no cost mitigation, VA is primary payer and can only collect from OHi on the back end for non-service connected. Here is a couple of quotes: "the decision to receive care or services under this section , including the decision to receive care or services from a particular individual or entity health care provider specified in subsection (c) , shall be at the election of the veteran ." h) Treatment of Other Health-care Plans.-(1) In any case in which a covered veteran is furnished care or services under this section with an individual or entity specified in subsection (c)(S) if the individual or entity meets criteria established by the Secretary for purposes of this section. for a nonservice-connected disability described in subsection (a)(2) of section 1729 of this title , the Secretary may recover or collect reasonable charges for such care or services from a health-care plan described in paragraph (3) in accordance with such section. I expect this to be rejected immediately from conservative Senators like Lee and in the House like Dr. Roe. CBO score will be huge. Staff from McCain and Moran have indicated this plan is just a starting point. I will be meeting with them on Friday to discuss. Choice 2.0. recommendation: In order to maximize our revenue at the VAMC and minimize the payout in Choice 2.0., we should be more like the private sector and follow what the independent assessment recommended. - All enrolled veterans must be required to declare their OHi and we should check and update our records when they see their providers. All staff should be required to ask the OHi question. To make Choice affordable, VA needs to collect from the 80% OHi as much as possible at the VAMC and for Community Care have OHi pay as much as possible upfront to reduce our spend. - All VAMC providers should be required to more narrowly and correctly identify all treatments that are service-connected. Poonam gives the example how she just checks off routinely service VA-19-0799-D-000334 OS 00002000 connected. That practice must stop if in 2.0. we are going to collect all we can from OHi. If a private sector provider like what I used to work for had that restriction, they would be making sure they were collecting every dollar they could, and so should we. Part of changing the culture to a private sector mentality. Darin VA-19-0799-D-000335 OS 00002001 Message From: Sent: To: Subject: Darin Selnick [(b) (6) @gmail.com] 4/22/2017 11:15:48 PM David shulkin [Drshulkin@aol.com] DPC and other Updates WH Thursday event: (b) (6) from DPC called me. He wanted to know for the WH event on Thursday if there was anything specific you wanted the President to say about the Accountability bill stalled in the Senate. They are still firming up his remarks and this is a good opportunity to push again on the Senate bill. SVAC draft "Veterans Choice Act of 2017": Just a heads up that I received from (b) (6) from McCain a copy of the new red lined version of SVAC majority draft choice legislation. It is terrible and would cost a fortune. Basically veterans can pick any provider in the network when they want, no cost mitigation, VA is primary payer and can only collect from OHi on the back end for non-service connected. Here is a couple of quotes: "the decision to receive care or services under this section , including the decision to receive care or services from a particular individual or entity health care provider specified in subsection (c), shall be at the election of the veteran." h) Treatment of Other Health-care Plans.-(1) In any case in which a covered veteran is furnished care or services under this section with an individual or entity specified in subsection (c)(S) if the individual or entity meets criteria established by the Secretary for purposes of this section. for a non-service-connected disability described in subsection (a)(2) of section 1729 of this title, the Secretary may recover or collect reasonable charges for such care or services from a health-care plan described in paragraph (3) in accordance with such section. I expect this to be rejected immediately from conservative Senators like Lee and in the House like Dr. Roe. CBO score will be huge. Staff from McCain and Moran have indicated this plan is just a starting point. I will be meeting with them on Friday to discuss. Choice 2.0. recommendation: In order to maximize our revenue at the VAMC and minimize the payout in Choice 2.0., we should be more like the private sector and follow what the independent assessment recommended. - All enrolled veterans must be required to declare their OHi and we should check and update our records when they see their providers. All staff should be required to ask the OHi question. To make Choice affordable, VA needs to collect from the 80% OHi as much as possible at the VAMC and for Community Care have OHi pay as much as possible upfront to reduce our spend. - All VAMC providers should be required to more narrowly and correctly identify all treatments that are serviceconnected. Poonam gives the example how she just checks off routinely service connected. That practice must stop if in 2.0. we are going to collect all we can from OHi. If a private sector provider like what I used to work for had that restriction, they would be making sure they were collecting every dollar they could, and so should we. Part of changing the culture to a private sector mentality. Darin VA-19-0799-D-000336 OS 00002002 Message From: Sent: To: CC: David shulkin [Drshulkin@aol.com] 4/18/2017 11:56:13 PM Jennifer Lee [(b) (6) gmail.com] Poonam Alaigh [(b) (6) hotmail.com] Lets discuss the telehealth eo in the am Sent from my iPhone VA-19-0799-D-000338 OS 00002004 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/18/2017 11:34:38 AM (b) (6) [(b) (6) va.gov] Fwd: Today's JAMA article on VA hospitals outperforming non VA hospitals Please print article Sent from my iPhone Begin forwarded message: From: Poonam Alaigh <(b) (6) hotmail.com> Date: April 18, 2017 at 5:26:55 AM EDT To: Marc Sherman <(b) (6) gmail.com>, Laurie Perlmutter <(b) (6) gmail.com>, Ike (b) (6) Perlmutter < frenchangel59.com>, "brucem(b) (6) @mac.com" Cc: David Shulkin Subject: Today's JAMA article on VA hospitals outperforming non VA hospitals http ://www.beckershospitalreview.com/quality/va-hospitals-outperform-non-va-hospitals-onpati ent-outcome-measures .html Ideas for communicating this? Sent from my iPhone VA-19-0799-D-000339 OS 00002005 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/18/2017 11:24:20 AM Marc Sherman [(b) (6) gmail.com] David shulkin [Drshulkin@aol.com]; L Perl [(b) (6) gmail.com]; IP [(b) (6) frenchangel59.com]; Poonam Alaigh (b) (6) [ hotmail.com] Re: Today's JAMA article on VA hospitals outperforming non VA hospitals The way data is collected raised every red flag among my colleagues and even discussed in the article. It is easy to show how easily the data can be manipulated and proved to be a false outcome. However the VA does do somethings in the article that is better than the whole sum of the private sector. I am afraid that will get lost in the rebuttal. There are articles like the VA telemedicine for mental health study that is research excellence that had no coverage and of great importance. Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 7: 17 AM, Marc Sherman <(b) (6) gmail.com> wrote: But it is also a tool of great value. We should discuss live. Marc Sherman (202) 758-(b) (6) On Apr 18, 2017 7:09 AM, "David shulkin" wrote: Ok thanks Bruce- we will be cautious Sent from my iPhone On Apr 18, 2017, at 6:47 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: I would be concerned about communicating this I read the full article and letter. Both point out the data may be incorrect for a variety of reasons. Also the full article points to the many deficiencies. Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 5:26 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: http ://www.beckershospitalreview.com/quality/va-hospitalsoutperform-non-va-hospitals-on-patient-outcome-measures.html Ideas for communicating this? Sent from my iPhone VA-19-0799-D-000340 OS 00002006 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/18/2017 11:04:54 AM Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com]; Marc Sherman [(b) (6) gmail.com]; Laurie Perlmutter [(b) (6) gmail.com]; Ike Perlmutter [(b) (6) frenchangel59.com] Re: Today's JAMA article on VA hospitals outperforming non VA hospitals Ok thanks Bruce- we will be cautious Sent from my iPhone On Apr 18, 2017, at 6:47 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: I would be concerned about communicating this I read the full article and letter. Both point out the data may be incorrect for a variety of reasons. Also the full article points to the many deficiencies. Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 5:26 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: http ://www.beckershospitalreview.com/quality/va-hospitals-outperform-non-vahospitals-on-patient-outcome-measures.html Ideas for communicating this? Sent from my iPhone VA-19-0799-D-000341 OS 00002007 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/18/2017 10:47:42 AM Poonam Alaigh [(b) (6) hotmail.com] Marc Sherman [(b) (6) gmail.com]; Laurie Perlmutter [(b) (6) gmail.com]; Ike Perlmutter (b) (6) [ frenchangel59.com]; David Shulkin [drshulkin@aol.com] Re: Today's JAMA article on VA hospitals outperforming non VA hospitals I would be concerned about communicating this I read the full article and letter. Both point out the data may be incorrect for a variety of reasons. Also the full article points to the many deficiencies. Sent from my iPad Bruce Moskowitz M.D. On Apr 18, 2017, at 5:26 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: http ://www.beckershospitalreview.com/quality/va-hospitals-outperform-non-va-hospitals-onpati ent-outcome-measures .html Ideas for communicating this? Sent from my iPhone VA-19-0799-D-000342 OS 00002008 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/18/2017 9:26:55 AM Marc Sherman [(b) (6) gmail.com]; Laurie Perlmutter [(b) (6) (b) (6) (b) (6) [ frenchangel59.com]; mac.com David Shulkin [drshulkin@aol.com] Today's JAMA article on VA hospitals outperforming non VA hospitals gmail.com]; Ike Perlmutter http ://www.beckershospitalreview.com/quality/va-hospitals-outperform-non-va-hospitals-on-patient-outcomemeasures.html Ideas for communicating this? Sent from my iPhone VA-19-0799-D-000343 OS 00002009 Message From: (b) (6) [(b) (6) Sent: To: 5/21/2017 8:16:30 PM David shulkin [Drshulkin@aol.com] Subject: Re: gmail.com] Ok On May 21, 2017 4: 12 PM, "David shulkin" wrote: For tommorow with (b) (6) lets add Telehealth comms plans Other active Executive orders Sent from my iPhone VA-19-0799-D-000344 OS 00002010 Message From: David shulkin [Drshulkin@aol.com] Sent: 5/21/2017 8:12:27 PM To: (b) (6) For tommorow with [(b) (6) (b) (6) gmail.com] lets add Telehealth comms plans other active Executive orders Sent from my iPhone VA-19-0799-D-000345 OS 00002011 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/18/2017 8:35:56 PM Jennifer Lee [(b) (6) gmail.com] Younshould get the myva meetings on yiur calander Sent from my iPhone VA-19-0799-D-000346 OS 00002012 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/16/2017 4:19:21 PM To: (b) (6) Subject: Attachments: gmail.com print please choice redesign version 2 choicedesign.pptx VA-19-0799-D-000347 OS 00002013 C 1n1ca System Design Clinical Analytics and Choice Eligibility Board Clinical Groupings with Poor Performance l VA Does Not Offer Service Foundational Services Clinical Groupings with Good or Su ~ Full Choic erformance I VA Care/Community Care Whole Health Model of Care Coordination, Telehealth, Caregivers, Homelessness Draft/ Pre-dec1s1onal / For Internal VA Use Only 1 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000348 OS 00002014 C 1n1ca System Design VA TRIAGE SYSTEM Urgent Issues \ l VA Does Not Offer Service Foundational Services Chronic Care and Non Acute Issues I / Full Access to Community * VA Care/Community Care Whole Health Model of Care Coordination, Telehealth, Caregivers, Homelessness Draft/ Pre-dec1s1onal / For Internal VA Use Only 2 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000349 OS 00002015 Veterans Speak with their Feet VA must be comparable to the private sector lncrementamism is not the answer to additional improvements VA and Veterans need. 3 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000350 OS 00002016 Building a Seamless (Integrated) Network n! \l'lr'IJU?. \"Jrf?w 03330002017 Message From: Marc Sherman [(b) (6) gmail.com] Sent: 5/12/2017 9:31:22 PM To: David shulkin [Drshulkin@aol.com] Subject: Re: On a call. Will call you when finished. Marc Sherman (202) 758-(b) (6) On May 12, 2017 4:47 PM, "David shulkin" wrote: Marc- what is your cell phone? Sent from my iPhone VA-19-0799-D-000352 OS 00002018 Message To: Marc Sherman [(b) (6) gmail.com] 5/12/2017 9:00:13 PM David shulkin [Drshulkin@aol.com] Subject: Re: From: Sent: See below Marc Sherman (202) 758-(b) (6) On May 12, 2017 4:47 PM, "David shulkin" wrote: Marc- what is your cell phone? Sent from my iPhone VA-19-0799-D-000353 OS 00002019 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 5/12/2017 8:47:29 PM (b) (6) gmail.com Marc- what is your cell phone? Sent from my iPhone VA-19-0799-D-000354 OS 00002020 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/20/2017 12:59:28 AM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Ending the Opioid Crisis fyi newt Just fyi Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) speakergingrich.com> Date: April 19, 2017 at 8:42:35 PM EDT To: David shulkin Subject: Re: Ending the Opioid Crisis fyi newt I agree and will add to the paper newt Sent from my iPhone On Apr 19, 2017, at 7:29 PM, David shulkin wrote: Newt- this is very effective and well stated. Pain is such a big issue in VA- what about making VA a fast tract FDA site to get help to veterans faster? We dont want to be experimenting on veterans but why not let veterans have the choice to receive these breakthroughs first? Also VA researchers could join your list of those than can help speed further discoveries. Great job- keep it up! David Sent from my iPhone On Apr 19, 2017, at 4:52 PM, (b) (6) <(b) (6) speakergingrich.com> wrote: VA-19-0799-D-000355 OS 00002021 Sent from my iPad Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/28/2017 1:04:45 AM Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com]; mbs(b) (6) @gmail.com; lperl(b) (6) @gmail.com; IP [(b) (6) frenchangel59.com] Re: Baltimore meeting for inventory Got it Sent from my iPhone > on Apr 27, 2017, at 8:37 PM, Bruce Moskowitz <(b) (6) > > Ike wants to be sure comes out of effort. (b) (6) mac.com> wrote: is aware and provides the ability to protect any intellectual capital that > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000357 OS 00002023 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/28/2017 12:37:03 AM David shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) hotmail.com] (b) (6) hotmail.com; mbs(b) (6) @gmail.com; lperl(b) (6) @gmail.com; IP [(b) (6) frenchangel59.com]; drshulkin@aol.com Baltimore meeting for inventory Ike wants to be sure comes out of effort. (b) (6) is aware and provides the ability to protect any intellectual capital that Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000358 OS 00002024 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/24/2017 3:11:14 PM To: (b) (6) [(b) (6) gmail.com] can you get me tbe blue water navy paper they prepared for me? Sent from my iPhone VA-19-0799-D-000359 OS 00002025 Message From: David shulkin [Drshulkin@aol.com] Sent: 5/1/2017 4:40:00 PM To: Bruce Moskowitz [(b) (6) mac.com] The ENT research looks good- we will follow on the tinnitus test should we followup With you or Dr (b) (6) ? Sent from my iPhone VA-19-0799-D-000360 OS 00002026 Message From: Sent: To: CC: David Shulkin [drshulkin@aol.com] 4/19/2017 11:40:16 PM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) Marc Sherman [(b) (6) gmail.com]; Bruce Moskowitz [(b) (6) gmail.com] mac.com] This is the real clip from today https ://m.youtube.com/watch?v=AufMXIGtr-O Sent from my iPad VA-19-0799-D-000361 OS 00002027 Message From: Bruce Moskowitz [(b) (6) Sent: 4/18/2017 9:35:29 PM To: David shulkin [Drshulkin@aol.com] Re: Star ratings Subject: mac.com] Aware I spent the last three hours understanding what they did and it does not get us to where we need to be. They were looking at metrics that would not pick up supply and staffing problems etc. If you need full report I have it. From all that I read if we outsource some high priority things like the inventory we will solve many problems. Staffing is getting to be impossible in the private sector. Telemedicine will solve mental health staffing problems and I am busy looking at platforms the medical centers are using. I am meeting with (b) (6) tonight who does your public private partnerships and was on J&J call. Perhaps a committee that looked at what can be outsourced or brought in from the private sector would help. Sent from my iPhone > on Apr 18, 2017, at 5:21 PM, David shulkin wrote: > >Bruce-all facilities are jcaho approved and we have full access to all of their reports and findings > > Sent from my iPhone > >> on Apr 18, 2017, at 3:38 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: >> >> Yes reviewed it it really does not get us to where we want to see if quality measures are being enacted and followed. >> >> Sent from my iPad >> Bruce Moskowitz M.D. >> >>> on Apr 18, 2017, at 2:47 PM, David shulkin wrote: >>> >>> They already gave this >>> >>> Sent from my iPhone >>> >>>> on Apr 18, 2017, at 1:59 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>>> >>>> Is there any reason why we can not have every VA obtain Joint >>>> Commission of Accreditation status? >>>> >>>> Sent from my iPad >>>> Bruce Moskowitz M.D. >>>> >>>>> on Apr 18, 2017, at 1:52 PM, David shulkin wrote: >>>>> >>>>> The date that we will have comparable quality data with the private sector is July 1st. >>>>> >>>>> We have to rely upon Medicare to do this as its their data set. We are calling Medicare to see if they can accelerate this. >>>>> >>>>> David >>>>> >>>>> Sent from my iPhone >>> > VA-19-0799-D-000362 OS 00002028 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/18/2017 9:21:24 PM Bruce Moskowitz [(b) (6) Re: Star ratings mac.com] Bruce- all facilities are jcaho approved and we have full access to all of their reports and findings Sent from my iPhone > on Apr 18, 2017, at 3:38 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > Yes reviewed it it really does not get us to where we want to see if quality measures are being enacted and foll owed . > > Sent from my iPad > Bruce Moskowitz M.D. > >> on Apr 18, 2017, at 2:47 PM, David shulkin wrote: >> >> They already gave this >> >> Sent from my iPhone >> >>> on Apr 18, 2017, at 1:59 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>> >>> Is there any reason why we can not have every VA obtain Joint >>> Commission of Accreditation status? >>> >>> Sent from my iPad >>> Bruce Moskowitz M.D. >>> >>>> on Apr 18, 2017, at 1:52 PM, David shulkin wrote: >>>> >>>> The date that we will have comparable quality data with the private sector is July 1st. >>>> >>>> We have to rely upon Medicare to do this as its their data set. We are calling Medicare to see if they can accelerate this. >>>> >>>> David >>>> >>>> Sent from my iPhone >> VA-19-0799-D-000363 OS 00002029 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/18/2017 7:38:31 PM David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com] Re: Star ratings Yes reviewed it it really does not get us to where we want to see if quality measures are being enacted and fo 17 owed . Sent from my iPad Bruce Moskowitz M.D. > on Apr 18, 2017, at 2:47 PM, David shulkin wrote: > > They already gave this > > Sent from my iPhone > >> on Apr 18, 2017, at 1:59 PM, Bruce Moskowitz <(b) (6) >> >> Is there any reason why we can not have every VA obtain Joint >> Commission of Accreditation status? mac.com> wrote: >> >> Sent from my iPad >> Bruce Moskowitz M.D. >> >>> on Apr 18, 2017, at 1:52 PM, David shulkin wrote: >>> >>> The date that we will have comparable quality data with the private sector is July 1st. >>> >>> We have to rely upon Medicare to do this as its their data set. We are calling Medicare to see if they can accelerate this. >>> >>> David >>> >>> Sent from my iPhone > VA-19-0799-D-000364 OS 00002030 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/18/2017 6:47:36 PM Bruce Moskowitz [(b) (6) mac.com] Ike Perlmutter [(b) (6) frenchangel59.com] Re: Star ratings They already gave this Sent from my iPhone > on Apr 18, 2017, at 1:59 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > Is there any reason why we can not have every VA obtain Joint > Commission of Accreditation status? > > Sent from my iPad > Bruce Moskowitz M.D. > >> on Apr 18, 2017, at 1:52 PM, David shulkin wrote: >> >> The date that we will have comparable quality data with the private sector is July 1st. >> >> We have to rely upon Medicare to do this as its their data set. they can accelerate this. We are calling Medicare to see if >> >> David >> >> Sent from my iPhone VA-19-0799-D-000365 OS 00002031 Message From: Bruce Moskowitz [(b) (6) Sent: 4/18/2017 5:59:21 PM To: David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com] Re: Star ratings CC: Subject: mac.com] Is there any reason why we can not have every VA obtain Joint Commission of Accreditation status? Sent from my iPad Bruce Moskowitz M.D. > on Apr 18, 2017, at 1:52 PM, David shulkin wrote: > > The date that we will have comparable quality data with the private sector is July 1st. > > We have to rely upon Medicare to do this as its their data set. can accelerate this. We are calling Medicare to see if they > > David > > Sent from my iPhone VA-19-0799-D-000366 OS 00002032 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/18/2017 5:52:21 PM To: Ike Perlmutter [(b) (6) frenchangel59.com] Bruce Moskowitz [(b) (6) mac.com] Star ratings CC: Subject: The date that we will have comparable quality data with the private sector is July 1st. We have to rely upon Medicare to do this as its their data set. can accelerate this. We are calling Medicare to see if they David Sent from my iPhone VA-19-0799-D-000367 OS 00002033 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/20/2017 10:48:46 AM Poonam Alaigh [(b) (6) hotmail.com]; (b) (6) (6) Great picture [(b) (6) yahoo.com] https ://www .heal thdatamanagement. com/news/va-tool-provi des-pati ent-wai t-times-quali ty-of-care-data Sent from my iPad VA-19-0799-D-000368 OS 00002034 Message From: Sent: To: CC: Subject: Marc Sherman [(b) (6) gmail.com] 4/19/2017 12:45:01 AM Bruce Moskowitz [(b) (6) mac.com] David shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) [(b) (6) frenchangel59.com] Re: (b) (6) hotmail.com]; L Perl [(b) (6) gmail.com]; IP There is no equal!!! Marc Sherman (202) 758-(b) (6) mac.com> wrote: On Apr 18, 2017 8:05 PM, "Bruce Moskowitz" <(b) (6) I am at dinner with an equal to David and Poonam. She has been with the VA 15 years and has done amazing VA partnerships with IBM, Bristol Myers and is accomplishing in real time many of the initiatives we are working on. Fantastically bright like David and Poonam. Sent from my iPhone VA-19-0799-D-000369 OS 00002035 Message From: (b) (6) [(b) (6) Sent: To: 4/16/2017 4:04:40 PM David Shulkin [drshulkin@aol.com] Subject: Re: gmail.com] I'll share there matrix they say it's a lot of events in May more than they have ever seen. Will print there working sheet for you to see what they are working on. Some of it the items were not needed. On Sun, Apr 16, 2017 at 9:20 AM David Shulkin wrote: What could they possibly be doing? I don't get what they are doing -----Original Message----- From: (b) (6) <(b) (6) gmail.com> To: David Shulkin Sent: Sat, Apr 15, 2017 7:20 pm Subject: Re: Yes. I told the speechwriters I would work on be they are overwhelmed. VA-19-0799-D-000370 OS 00002036 On Sat, Apr 15, 2017 at 6:48 PM David Shulkin wrote: Here are some slides for SMAG- we may need to fix them up Sent from Gmail Mobile Sent from Gmail Mobile VA-19-0799-D-000371 OS 00002037 Message To: David Shulkin [drshulkin@aol.com] 4/16/2017 1:20:07 PM (b) (6) gmail.com Subject: Re: From: Sent: What could they possibly be doing? I don't get what they are doing -----Original Message----From: (b) (6) <(b) (6) To: David Shulkin Sent: Sat, Apr 15, 2017 7:20 pm Subject: Re: gmail.com> Yes. I told the speechwriters I would work on be they are overwhelmed. On Sat, Apr 15, 2017 at 6:48 PM David Shulkin wrote: Here are some slides for SMAG- we may need to fix them up Sent from Gmail Mobile VA-19-0799-D-000372 OS 00002038 Message From: (b) (6) [(b) (6) Sent: To: 4/15/2017 11:20:14 PM David Shulkin [drshulkin@aol.com] Subject: Re: gmail.com] Yes. I told the speechwriters I would work on be they are overwhelmed. On Sat, Apr 15, 2017 at 6:48 PM David Shulkin wrote: Here are some slides for SMAG- we may need to fix them up Sent from Gmail Mobile VA-19-0799-D-000373 OS 00002039 Message From: Sent: To: Attachments: David Shulkin [drshulkin@aol.com] 4/15/2017 10:48:34 PM (b) (6) gmail.com smag2017.pptx Here are some slides for SMAG- we may need to fix them up VA-19-0799-D-000374 OS 00002040 , IA V'"' I U.S. Department ofVeterans Affairs David J. Shulkin, MD Secretary of Veterans Affairs April 19, 2017 VA-19-0799-D-000375 OS 00002041 United's Response Ill r'::itertJayseDavid 4:51 PM ET UNITED DRAGS PASSENGER FROM OVERBOOKED FLIGHT THE LEAD Draft/ Pre-dec1s1onal / For Internal VA Use Only 2 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000376 OS 00002042 Events at the DC VA Draft/ Pre-dec1s1onal / For Internal VA Use Only 3 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000377 OS 00002043 We need Transformation Change and Actions 38 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000378 OS 00002044 V A's 5 Priorities 1. Greater Choice for Veterans 4. Improve Timeliness of Services 2. Modernize our Systems 5. Suicide Prevention 3. Focus Resources More Efficiently 5 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000379 OS 00002045 1. Greater Choice for Veterans • Redesign the 40/30 Rule to use clinical criteria for veteran choice • Build a high-performing, integrated network of ca re • Empower Veterans through transparency of information ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000380 OS 00002046 C 1n1ca System Design Clinical Analytics and Choice Eligibility Board Clinical Groupings with Poor Performance l VA Does Not Offer Service Foundational Services Clinical Groupings with Good or Su ~ Full Choic erformance I VA Care/Community Care Whole Health Model of Care Coordination, Telehealth, Caregivers, Homelessness Draft/ Pre-dec1s1onal / For Internal VA Use Only 7 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000381 OS 00002047 Veterans Speak with their Feet VA must be comparable to the private sector lncrementamism is not the answer to additional improvements VA and Veterans need. 8 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000382 OS 00002048 Building a Seamless (Integrated) Network n! \l'lr'IJU?. \"Jrf?w 03330002049 2- Modernize Our Systems • Infrastructure improvements and streamlining services • EMR interoperability and IT modernization ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000384 OS 00002050 Infrastructure Improvements Gas Station Minneapolis, MN 1932 Fort Thomas, KY Circa 1895 11 Palo Alto VAMC ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000385 OS 00002051 VA/DoD/Federal Coordination VA and DoD Hospitals 12 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000386 OS 00002052 EMR Interoperability & Modernization VistA Scheduling Enhancement e ~ --t.lHl.-.l Opo:'IM! ~ - - - - - - - - - - ~, · ~Tii)-8119!1111 feb 2m TIHE 19 111 tl\lI n21 I I 111111111111 111 111 21 lll <'4 I 111111 111 111111111111 111 1125 11126 fi17 I I 111 [1][11111111 111 111 Ill 111111 111 112 I 11 I I 111!11111111111111 I I 111!11111111111111 I 111111111111 I 111!11111(11111111 I I 12 I ll I 14 I I 111!11111(1) 111 !11 111111111111 lir211S I 111111 111 I I llllll 111111111111 1111 11 141 111 12 I 111!11111111111111 I I lll lSI 111111 111[11 [111 I I 111!11111111111111 I 111111111111 fi l6 I 111 [II 111111 111 I I 111 !11 111111111111 111191 I 111111 1111 111111 111111 111111 [111 I I 111!11111111111111 I 111111111111 I I 1111 111111111111 Sel ~ t,W.intBIKIIOO(lIST Attlllff>~Hon: I VistA Legacy Scheduling 13 ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ The point here is VistA was outdated (left), so we've made some improvements (right), but what we really need is a new system that's fully interoperable with what our partnering providers are already using. VA-19-0799-D-000387 OS 00002053 3. Focus Resources More Efficiently • Strengthening of foundational services in VA • VA/DOD/Community coordination • Deliver on accountability and effective management practices ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000388 OS 00002054 "World Class Foundational Services 15 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000389 OS 00002055 Accountability Legislation Increased flexibility to remove, demote,or suspend VA employees for poor performance or misconduct. Direct Hire for Medical Center Directors and Network Directors Ability to fully utilize our relocation, recruitment, and retention awards Authority to reccoop relocation expenses authorized through fraud of malfeasance. Increased protections for whistle blowers U.S. Departmcnl VA i'~ ) ofVctc.-a ns ,\ffa i rr-; VA-19-0799-D-000390 OS 00002056 4. Improve Timeliness of Services • Access to care and wait times • Decisions on appeals • Performance on disability claims ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000391 OS 00002057 How quickly does my VA see patients? How satisfied are veterans like me with the timeliness of their care? How well does my VA's care compare to other hospitals? VA-19-0799-D-000392 OS 00002058 5- Suicide Prevention ~ G(TTING TO Z[RO ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000393 OS 00002059 Suicide Prevention , , • U ·• . . ...... Reach Vetenns and their families Expand the YA Suicide Prevention Office ···... Develop innovative prevention strategies /!!\::':. V 20 Build community engagement roundsulclde ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000394 OS 00002060 Mental Health PSA 21 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ The video will play as soon as you cue the next slide. VA-19-0799-D-000395 OS 00002061 22 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000396 OS 00002062 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/18/2017 10:13:44 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Star ratings Sent from my iPhone Begin forwarded message: From: "IP" <(b) (6) frenchangel59.com> Date: April 18, 2017 at I :58:33 PM EDT To: "'David shulkin"' Cc: "'Bruce Moskowitz'" <(b) (6) Subject: RE: Star ratings mac.com> Can we please do the top 30 right away? Thank you. -----Original Message----From: David shulkin [mailto:Drshulkin@aol.com] Sent: Tuesday, April 18, 2017 I: 52 PM To: Ike Perlmutter Cc: Bruce Moskowitz Subject: Star ratings The date that we will have comparable quality data with the private sector is July 1st. We have to rely upon Medicare to do this as its their data set. We are calling Medicare to see if they can accelerate this. David Sent from my iPhone VA-19-0799-D-000397 OS 00002063 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/18/2017 6:49:37 PM To: IP [(b) (6) frenchangel59.com] Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com] Re: Star ratings CC: BCC: Subject: The problem is that we need the data on the other hospitals from Medicare- we are pushing them to give us this faster than July 1 We are working on another way to get this soonerdeliver- but we are trying didnt want to commit to this until I know we can Sent from my iPhone > on Apr 18, 2017, at 1:58 PM, IP <(b) (6) frenchangel59.com> wrote: > > can we please do the top 30 right away? Thank you. > > > > > > > -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Tuesday, April 18, 2017 1:52 PM To: Ike Perlmutter cc: Bruce Moskowitz subject: Star ratings > > The date that we will have comparable quality data with the private sector > is July 1st. > > We have to rely upon Medicare to do this as its their data set. > calling Medicare to see if they can accelerate this. We are > > David > > Sent from my iPhone > VA-19-0799-D-000398 OS 00002064 Message From: Sent: To: CC: Subject: IP [(b) (6) frenchangel59.com] 4/18/2017 5:58:33 PM 'David shulkin' [Drshulkin@aol.com] 'Bruce Moskowitz' [(b) (6) RE: Star ratings mac.com] can we please do the top 30 right away? Thank you. -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Tuesday, April 18, 2017 1:52 PM To: Ike Perlmutter cc: Bruce Moskowitz subject: Star ratings The date that we will have comparable quality data with the private sector is July 1st. We have to rely upon Medicare to do this as its their data set. calling Medicare to see if they can accelerate this. We are David Sent from my iPhone VA-19-0799-D-000399 OS 00002065 Message David shulkin [Drshulkin@aol.com] 4/26/2017 12:01:48 PM Poonam Alaigh [(b) (6) hotmail.com] From: Sent: To: (b) (6) (b) (6) will come Sent from my iPhone VA-19-0799-D-000400 OS 00002066 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/28/2017 8:04:38 PM Poonam Alaigh [(b) (6) hotmail.com] David Shulkin [drshulkin@aol.com]; (b) (6) aol.com Re: Baltimore meeting Thank you. Sent from my iPad Bruce Moskowitz M.D. > on Apr 28, 2017, at 4:00 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Just spoke to my internal team and May 15 is confirmed on our end. We have the wheels in motion already- you can let your team know. (b) (6) will help coordinate the effort on my behalf here. The meeting will be at the Baltimore Medical Center. Details to follow- thanks a ton > > Sent from my iPhone > >> on Apr 28, 2017, at 2:25 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: >> >> our contingent needs to know if May 15 works especially the large group traveling form Kaiser. I would like to get back to them this weekend if possible. Thank you >> >> Sent from my iPad >> Bruce Moskowitz M.D. VA-19-0799-D-000401 OS 00002067 Message Poonam Alaigh [(b) (6) hotmail.com] 4/28/2017 6:34:52 PM David Shulkin [drshulkin@aol.com] Fwd: Baltimore meeting From: Sent: To: Subject: Let's discuss Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 28, 2017 at 2:25:22 PM EDT To: Poonam Alaigh <(b) (6) hotmail.com> Subject: Baltimore meeting mac.com> Our contingent needs to know if May 15 works especially the large group traveling form Kaiser. I would like to get back to them this weekend if possible. Thank you Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000402 OS 00002068 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/19/2017 11:36:07 PM (b) (6) [(b) (6) Re: Checking In gmail.com] Let's look at the organization and the size of their meetings first Sent from my iPad On Apr 19, 2017, at 7:27 PM, (b) (6) <(b) (6) gmail.com> wrote: Do you want to do this? I'll look at the date tmrw On Wed, Apr 19, 2017 at 7:26 PM David shulkin wrote: Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) msn.com> Date: April 19, 2017 at 12:44: 14 PM EDT To: David Shulkin Subject: Checking In David, I do hope you are addressing the challenges of your position with your usual energy and enthusiasm and drive to attain palpable results. Need to ask how did your meeting today with Mr. Trump go? The Hospital Planning & Marketing Society of NJ wants to present you with an award and have you deliver the key note address at their December 1 Annual Meeting in Princeton. You suggested to reach out and check in when things "settled down". Are we there yet? Hope to hear back when you have a chance to take a breath. Best regards (b) (6) Sent from Gmail Mobile VA-19-0799-D-000403 OS 00002069 Message From: (b) (6) Sent: 4/19/2017 11:27:07 PM David shulkin [Drshulkin@aol.com] Re: Checking In To: Subject: [(b) (6) gmail.com] Do you want to do this? I'll look at the date tmrw On Wed, Apr 19, 2017 at 7:26 PM David shulkin wrote: Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) msn.com> Date: April 19, 2017 at 12:44: 14 PM EDT To: David Shulkin Subject: Checking In David, I do hope you are addressing the challenges of your position with your usual energy and enthusiasm and drive to attain palpable results. Need to ask how did your meeting today with Mr. Trump go? The Hospital Planning & Marketing Society of NJ wants to present you with an award and have you deliver the key note address at their December 1 Annual Meeting in Princeton. You suggested to reach out and check in when things "settled down". Are we there yet? Hope to hear back when you have a chance to take a breath. Best regards (b) (6) Sent from Gmail Mobile VA-19-0799-D-000404 OS 00002070 Message David shulkin [Drshulkin@aol.com] 4/19/2017 11:26:16 PM (b) (6) [(b) (6) Fwd: Checking In From: Sent: To: Subject: gmail.com] Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) msn.com> Date: April 19, 2017 at 12:44: 14 PM EDT To: David Shulkin Subject: Checking In David, I do hope you are addressing the challenges of your position with your usual energy and enthusiasm and drive to attain palpable results. Need to ask how did your meeting today with Mr. Trump go? The Hospital Planning & Marketing Society of NJ wants to present you with an award and have you deliver the key note address at their December 1 Annual Meeting in Princeton. You suggested to reach out and check in when things "settled down". Are we there yet? Hope to hear back when you have a chance to take a breath. Best regards (b) (6) VA-19-0799-D-000405 OS 00002071 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/22/2017 3:47:14 PM IP [(b) (6) frenchangel59.com]; brucem(b) (6) @mac.com; mbs(b) (6) @gmail.com; David shulkin [drshulkin@aol.com] lperl(b) (6) @gmail.com Re: Remarks by President Trump at Signing of S. 544, The Veterans Choice Program Extension and Improvement Act Thanks for keeping us in the loop. We are in the meantime working with a SWAT team to make sure there are no additional vulnerabilities around patient safety related to the inventory management system especially since there has been a recent transition of the software for the system Hopefully we will meet next week and can catch up some more. Bruce is arranging for us to discuss with Hopkins best practices simultaneously. It would be great if you can send along some good leads for a Chief Logistics Officer located here in DC to be part of our team. If we meet with the Big Five this week, I will be sure to address with them too. Ike, I cant thank you enough for your guidance. David and I have been talking constantly to make sure with can assemble the right and trusted team in the VA around us. Laurie and team, looking forward to spending some quality time soon, and possibly this coming week. Also, a gentle reminder to bring me a signed copy of Ike's book. Thanks From: IP <(b) (6) frenchangel59.com> Sent: Thursday, April 20, 2017 10:53 AM To: brucem(b) (6) @mac.com; mbs(b) (6) @gmail.com; Poonam Alaigh; David shulkin Cc: lperl(b) (6) @gmail.com Subject: FW: Remarks by President Trump at Signing of S. 544, The Veterans Choice Program Extension and Improvement Act FYI From: IP [mailto:(b) (6) frenchangel59.com] Sent: Thursday, April 20, 2017 10:38 AM To: (b) (6) who.eop.gov; (b) (6) who.eop.gov; (b) (6) who.eop.gov Cc: (b) (6) gmail.com Subject: Remarks by President Trump at Signing of S. 544, The Veterans Choice Program Extension and Improvement Act Jared, (b) (6) and (b) (6) VA-19-0799-D-000406 OS 00002072 First, thank you so much for everything you have done and are doing to enhance the efforts to transform Veterans Affairs. Your contributions are so critical to its success. On December 27, 2016, a number of us had a meeting with the then President Elect and presented to him a plan to transform the VA for our deserving Veterans. Step one of that plan was to extend, and then to enhance, the Veterans Choice Program. Well, yesterday, when the President signed the extension of the Choice Act, we entered the passageway toward making that plan a reality. And, as the media noted, the bigger changes will come this fall when a "Choice 2.0" revamp of the program is unveiled to allow more outside care options. The procurement issue for the EHR contract is very closely tied to the success of the Choice Program and especially Choice 2.0. That needs to be solved without delay if we plan to climb any further up the hill. That is the very kind of impediment on which we need your laser focus and your continued and swift assistance and resolution. What are your thoughts on timing to get that solved? While yesterday's accomplishments are a pivotal achievement; in reality, we are just at the beginning of a long uphill climb. And for that climb your help and focus on the VA is more important than ever. I hope we can count on you to keep that focus and sense of urgency toward our shared goal of a transformed VA. Ike https ://m.youtube.com/watch?v=AufMXIGtr-O Trump Signs Veterans Health Choice Program Extension - Full Ceremony And Remarks m.youtube.com President Donald Trump signed a bill Wednesday to temporarily extend a program that lets some veterans seek medical care in the private sector, part of an ef... --------------------································································································································································································· http ://www.militarytimes.com/articles/trump-va-reform-veterans-affairs-choice-card VA-19-0799-D-000407 OS 00002073 Trump extends vets access to privatized health care 1 www.militarytimes.com The Choice Card program allows vets to seek medical care outside VA facilities. http ://www.washingtontimes.com/news/2017/apr/ 19/donald-trump-signs-extension-veterans-choice-healt/ http ://abcnews.go.com/Health/wireStory/trump-extends-private-sector-health-care-program-vets-46887778 Trump extends privatesector health care program for vets abcnews.go.com President Donald Trump signed a bill Wednesday to temporarily extend a program that lets some veterans seek medical care in the private sector, part of VA-19-0799-D-000408 OS 00002074 an effort by the president to deliver on a campaign promise. The extension will give Veterans Affairs Secretary David Shulkin time to ... From: White House Press Office Date: April 19, 2017 at 1 :33:08 PM EDT Subject: Remarks by President Trump at Signing of S. 544, The Veterans Choice Program Extension and Improvement Act Reply-To: THE WHITE HOUSE Office of the Press Secretary For Immediate Release April 19, 2017 REMARKS BY PRESIDENT TRUMP AT SIGNING OF S. 544, THE VETERANS CHOICE PROGRAM EXTENSION AND IMPROVEMENT ACT Roosevelt Room VA-19-0799-D-000409 OS 00002075 11 :32 AM. EDT THE PRESIDENT: Good morning. We're honored to join and be joined today by some absolutely tremendous people and great veterans. Thanks, as well -- and I have to thank them dearly -- but as well to Representative Phil Roe. Where is he? What a job you've done. And all the members of Congress who worked on the bill that we're about to sign. Such an important bill. I especially want to thank Senator John McCain and Senator Johnny Isaacson. They have been incredible in working with us. Let me also welcome my good friend, Florida Governor Rick Scott, a Navy veteran who's here with us to represent more than a million veterans from the state of Florida. We're also joined by the leaders of a number of veterans groups. I want to thank all of them for being here and all of the tremendous and important work that they do. We would not be here if it weren't for them, I can tell you that. Finally, I want to thank our Secretary of the VA, David Shulkin, who, by the way, was approved with a vote of 100 to nothing. That's shocking, right? (Laughter.) One hundred to nothing, really. Now, you wouldn't be getting 100 to nothing. (Laughter.) We met earlier today in the Oval Office, and Secretary Shulkin updated me on the massive and chronic challenge he inherited at the VA, but also the great progress that he is making. He's got a group of people that are phenomenal at the VA It's one of my most important things. I've been telling all of our friends at speeches and rallies for two years about the VA, how we're going to tum it around. And we're doing that. And, actually, next week, on Thursday at 2 o'clock, we're going to have a news conference with David and some others to tell you about all of the tremendous things that are happening at the VA and what we've done in terms of progress and achievement. The veterans have poured out their sweat and blood and tears for this country for so long, and it's time that they're recognized, and it's time that we now take care of them, and take care of them properly. That's why I'm pleased today to sign into law the Veterans Choice Program Improvement Act. So this is called the Choice Program Improvement Act. It speaks for itself. This bill will extend and improve the Veterans Choice Program so that more veterans can see the doctor of their choice -- you got it? The doctor of their choice -- and don't have to wait and travel long distances for VA care. Some people have to travel five VA-19-0799-D-000410 OS 00002076 hours, eight hours, and they'll have to do it on a weekly basis, and even worse than that. It's not going to happen anymore. This new law is a good start, but there is still much work to do. We will fight each and every day to deliver the long-awaited reforms our veterans deserve, and to protect those who have so courageously protected each and every one of us. So we've made a lot of strides for the veterans. These are, like, the most incredible people we have in our country as far as I'm concerned, and they have not been taken care of properly. I want to thank David. You've done an incredible job. And you're going to see some of that on Thursday. So thank you all very much. And we're going to sign this. And I think I'm going to have to give this pen -- the way I look at it, we should probably give it to Phil. What do you think? PARTICIPANT: I agree. THE PRESIDENT: Does everybody agree? I think Phil is -- REPRESENTATIVE ROE: I'll agree with that. (Laughter.) THE PRESIDENT: Phil agrees. But congratulations, everybody. Really fantastic. Thank you very much. (Bill is signed.) (Applause.) Phil, maybe you could say a few words, if you'd like. VA-19-0799-D-000411 OS 00002077 REPRESENTATIVE ROE: Well, Mr. President, thank you very much. And this was a very, very important bill to get started with so we can get Choice 2.0 to get to the place exactly where the President said he wanted to be. And it's a privilege to work with all of these great people up here to help make the VA better. I've spent the last week on the break going to Los Angeles and Phoenix to get a firsthand view of what's going on. And what we want to do is put the veteran in charge of these choices, not the bureaucracy. And I think Dr. Shulkin is just the person to see that happen. Mr. President, thank you so much. THE PRESIDENT: Thank you very much. It's fantastic. And David? Where's David? DR. SHULKIN: Yeah, I'm right behind you, Mr. President. THE PRESIDENT: Go ahead. I won't look back. You just talk. (Laughter.) DR. SHULKIN: Well, first of all, I want to thank everybody here as well, and thank Congress for seeing this done, and Mr. President to be signing this. This is a good day for veterans. This is a great day to celebrate not only what veterans have contributed to the country, but how we're making things better for them. And by working together, we're going to continue this progress. I think, as the President said, we're actually going to do this a week from Thursday, Mr. President -- THE PRESIDENT: Right. DR. SHULKIN: -- and talk about the tremendous accomplishments, but most importantly, about the great things that are to come to fulfill the President's commitments that he made to veterans. And so thank you all for being here today. VA-19-0799-D-000412 OS 00002078 THE PRESIDENT: Thank you. Great job. So again, next week, on Thursday, at 2 o'clock -- it may change a little bit, but about that time we're going to have a conference to talk about the progress and the achievement. I'd like to ask Rick Scott, the governor of Florida -- he's done a fantastic job as governor, by the way, and really understands his subject, and really understands a lot of subjects. Rick, do you want to say a few words? GOVERNOR SCOTT: Sure. Well, I was really proud. My father was in the 82nd Airborne, he did all the combat jumps, and I grew up listening to all his stories about the war. I had the opportunity to serve in the Navy. Unfortunately, in 2014, I had to sue the VA because we had -- our state healthcare agency couldn't go inspect their hospitals when we heard all the stories about deaths, delays, and poor conditions. And so Mr. President and I want to thank Congress for doing this to create certainty of care while we figure out how to fix the VA system. And David, I want to thank you for what you' re doing. You've got actually the right background to do this. I know President Trump has been focused on our veterans and our military before he was President, and I know he's going to continue to do a great job. We have 1.5 million veterans. I want them all to move to Florida. (Laughter.) But thank you for doing this, Mr. President. THE PRESIDENT: Thank you very much. Most importantly, thank you, thank all of the great veterans. Would you like to say something to all of these people out there? You'll become a movie star tomorrow. (Laughter.) PARTICIPANT: Well, our nation will be judged by how it treats its veterans, and I'm sure our country will allow generations -- right now, they're children, but they're going to be our future servicemen. And so we have to treat veterans well. It's about national security, it's about patriotism, and this is a great step forward to doing it. THE PRESIDENT: Thank you very much. Nobody can say it better than that, so we're going to end. But I want to just thank you all. Thank you for being here. Thank you. (Applause.) END 11:40 AM. EDT VA-19-0799-D-000413 OS 00002079 Unsubscribe The White House · 1600 Pennsylvania Avenue, NW· Washington DC 20500 · 202-456-1111 VA-19-0799-D-000414 OS 00002080 Message From: Sent: To: CC: Subject: IP [(b) (6) frenchangel59.com] 4/20/2017 2:53:24 PM brucem(b) (6) @mac.com; mbs(b) (6) @gmail.com; Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [drshulkin@aol.com] lperl(b) (6) @gmail.com FW: Remarks by President Trump at Signing of S. 544, The Veterans Choice Program Extension and Improvement Act FYI From: IP [mailto:(b) (6) frenchangel59.com] Sent: Thursday, April 20, 2017 10:38 AM (b) (6) (b) (6) To: (b) (6) who.eop.gov; (b) (6) who.eop.gov; (b) (6) who.eop.gov (b) (6) Cc: gmail.com Subject: Remarks by President Trump at Signing of S. 544, The Veterans Choice Program Extension and Improvement Act Jared, (b) (6) and (b) (6) First, thank you so much for everything you have done and are doing to enhance the efforts to transform Veterans Affairs. Your contributions are so critical to its success. On December 27, 2016, a number of us had a meeting with the then President Elect and presented to him a plan to transform the VA for our deserving Veterans. Step one of that plan was to extend, and then to enhance, the Veterans Choice Program. Well, yesterday, when the President signed the extension of the Choice Act, we entered the passageway toward making that plan a reality. And, as the media noted, the bigger changes will come this fall when a "Choice 2.0" revamp of the program is unveiled to allow more outside care options. The procurement issue for the EHR contract is very closely tied to the success of the Choice Program and especially Choice 2.0. That needs to be solved without delay if we plan to climb any further up the hill. That is the very kind of impediment on which we need your laser focus and your continued and swift assistance and resolution. What are your thoughts on timing to get that solved? While yesterday's accomplishments are a pivotal achievement; in reality, we are just at the beginning of a long uphill climb. And for that climb your help and focus on the VA is more important than ever. I hope we can count on you to keep that focus and sense of urgency toward our shared goal of a transformed VA. Ike https ://m.youtube.com/watch?v=AufMXIGtr-O http ://www.militarytimes.com/articles/trump-va-reform-veterans-affairs-choice-card http ://www.washingtontimes.com/news/2017/apr/ 19/donald-trump-signs-extension-veterans-choice-healt/ http ://abcnew s.go.com/Health/wireStory/trump-extends-private-sector-health-care-program-vets-46887778 VA-19-0799-D-000415 OS 00002081 From: White House Press Office Date: April 19, 2017 at 1:33:08 PM EDT Subject: Remarks by President Trump at Signing of S. 544, The Veterans Choice Program Extension and Improvement Act Reply-To: THE WHITE HOUSE Office of the Press Secretary For Immediate Release April 19, 2017 REMARKS BY PRESIDENT TRUMP AT SIGNING OF S. 544, THE VETERANS CHOICE PROGRAM EXTENSION AND IMPROVEMENT ACT Roosevelt Room 11:32 A.M. EDT THE PRESIDENT: Good morning. We're honored to join and be joined today by some absolutely tremendous people and great veterans. Thanks, as well -- and I have to thank them dearly -- but as well to Representative Phil Roe. Where is he? What a job you've done. And all the members of Congress who worked on the bill that we're about to sign. Such an important bill. I especially want to thank Senator John McCain and Senator Johnny Isaacson. They have been incredible in working with us. Let me also welcome my good friend, Florida Governor Rick Scott, a Navy veteran who's here with us to represent more than a million veterans from the state of Florida. We're also joined by the leaders of a number of veterans groups. I want to thank all of them for being here and all of the tremendous and important work that they do. We would not be here if it weren't for them, I can tell you that. Finally, I want to thank our Secretary of the VA, David Shulkin, who, by the way, was approved with a vote of 100 to nothing. That's shocking, right? (Laughter.) One hundred to nothing, really. Now, you wouldn't be getting 100 to nothing. (Laughter.) We met earlier today in the Oval Office, and Secretary Shulkin updated me on the massive and chronic challenge he inherited at the VA, but also the great progress that he is making. He's got a group of people that are phenomenal at the VA. It's one of my most important things. I've been telling all of our friends at speeches and rallies for two years about the VA, how we're going to turn it around. And we're doing that. VA-19-0799-D-000416 OS 00002082 And, actually, next week, on Thursday at 2 o'clock, we're going to have a news conference with David and some others to tell you about all of the tremendous things that are happening at the VA and what we've done in terms of progress and achievement. The veterans have poured out their sweat and blood and tears for this country for so long, and it's time that they're recognized, and it's time that we now take care of them, and take care of them properly. That's why I'm pleased today to sign into law the Veterans Choice Program Improvement Act. So this is called the Choice Program Improvement Act. It speaks for itself. This bill will extend and improve the Veterans Choice Program so that more veterans can see the doctor of their choice -- you got it? The doctor of their choice -- and don't have to wait and travel long distances for VA care. Some people have to travel five hours, eight hours, and they'll have to do it on a weekly basis, and even worse than that. It's not going to happen anymore. This new law is a good start, but there is still much work to do. We will fight each and every day to deliver the long-awaited reforms our veterans deserve, and to protect those who have so courageously protected each and every one of us. So we've made a lot of strides for the veterans. These are, like, the most incredible people we have in our country as far as I'm concerned, and they have not been taken care of properly. I want to thank David. You've done an incredible job. And you're going to see some of that on Thursday. So thank you all very much. And we're going to sign this. And I think I'm going to have to give this pen -- the way I look at it, we should probably give it to Phil. What do you think? PARTICIPANT: THE PRESIDENT: I agree. Does everybody agree? REPRESENTATIVE ROE: I'll agree with that. THE PRESIDENT: Phil agrees. fantastic. Thank you very much. (Bill is signed.) I think Phil is -(Laughter.) But congratulations, everybody. Really (Applause.) Phil, maybe you could say a few words, if you'd like. REPRESENTATIVE ROE: Well, Mr. President, thank you very much. And this was a very, very important bill to get started with so we can get Choice 2.0 to get to the place exactly where the President said he wanted VA-19-0799-D-000417 OS 00002083 to be. And it's a privilege to work with all of these great people up here to help make the VA better. I've spent the last week on the break going to Los Angeles and Phoenix to get a firsthand view of what's going on. And what we want to do is put the veteran in charge of these choices, not the bureaucracy. And I think Dr. Shulkin is just the person to see that happen. Mr. President, thank you so much. THE PRESIDENT: And David? Thank you very much. It's fantastic. Where's David? DR. SHULKIN: THE PRESIDENT: talk. (Laughter.) Yeah, I'm right behind you, Mr. President. Go ahead. I won't look back. You just DR. SHULKIN: Well, first of all, I want to thank everybody here as well, and thank Congress for seeing this done, and Mr. President to be signing this. This is a good day for veterans. This is a great day to celebrate not only what veterans have contributed to the country, but how we're making things better for them. And by working together, we're going to continue this progress. I think, as the President said, we're actually going to do this a week from Thursday, Mr. President -THE PRESIDENT: Right. DR. SHULKIN: -- and talk about the tremendous accomplishments, but most importantly, about the great things that are to come to fulfill the President's commitments that he made to veterans. And so thank you all for being here today. THE PRESIDENT: Thank you. Great job. So again, next week, on Thursday, at 2 o'clock -- it may change a little bit, but about that time we're going to have a conference to talk about the progress and the achievement. I'd like to ask Rick Scott, the governor of Florida -- he's done a fantastic job as governor, by the way, and really understands his subject, and really understands a lot of subjects. Rick, do you want to say a few words? GOVERNOR SCOTT: Sure. Well, I was really proud. My father was in the 82nd Airborne, he did all the combat jumps, and I grew up listening to all his stories about the war. I had the opportunity to serve in the Navy. Unfortunately, in 2014, I had to sue the VA because we had -- our state healthcare agency couldn't go inspect their hospitals when we heard all the stories about deaths, delays, and poor conditions. VA-19-0799-D-000418 OS 00002084 And so Mr. President and I want to thank Congress for doing this to create certainty of care while we figure out how to fix the VA system. And David, I want to thank you for what you're doing. You've got actually the right background to do this. I know President Trump has been focused on our veterans and our military before he was President, and I know he's going to continue to do a great job. We have 1.5 million veterans. I want them all to move to Florida. (Laughter.) But thank you for doing this, Mr. President. THE PRESIDENT: Thank you very much. Most importantly, thank you, thank all of the great veterans. Would you like to say something to all of these people out there? You'll become a movie star tomorrow. (Laughter.) PARTICIPANT: Well, our nation will be judged by how it treats its veterans, and I'm sure our country will allow generations -- right now, they're children, but they're going to be our future servicemen. And so we have to treat veterans well. It's about national security, it's about patriotism, and this is a great step forward to doing it. THE PRESIDENT: Thank you very much. Nobody can say it better than that, so we're going to end. But I want to just thank you all. Thank you for being here. Thank you. (Applause.) END 11:40 A.M. EDT Unsubscribe The White House · 1600 Pennsylvania Avenue, NW· Washington DC 20500 · 202-456-1111 VA-19-0799-D-000419 OS 00002085 Message From: Sent: To: CC: Subject: Attachments: Poonam Alaigh [(b) (6) hotmail.com] 4/28/2017 7:17:06 PM David Shulkin [drshulkin@aol.com]; David Shulkin [david.shulkin@va.gov] (b) (6) va.gov Fwd: updated datapalooza slides Datapalooza draft 3.pptx; ATT0000l.htm I used these slides today- please update your access website slides Sent from my iPhone Begin forwarded message: <(b) (6) va.gov> From: "(b) (6) To: "VHA USH Meeting Requests" Cc: "Alaigh, Poonam, M.D." , "Poonam Alaigh ((b) (6) <(b) (6) hotmail.com )" hotmail.com > Subject: updated datapalooza slides VA-19-0799-D-000420 OS 00002086 Datapalooza Presented by Dr. Poonam Alaigh, Acting Under Secretary for Health Datapalooza 4/28/2017 VAi Defining HEALTH EXCB.LENCE CARE in the 21S1: Century Veterans Health Administration 0 VA-19-0799-D-000421 OS 00002087 ,.,,; $ Greater Choice • • • VA Telehealth MyHealtheVet VA Mobile Apps ~ Modernize Systems .:E-0 • • • eHMP JLV EHR 41~~ Efficiency • MVP • • Big Data Precision Medicine ••• ••• ••• Improve Timeliness Suicide Prevention • • • Accesstocare@va.gov ReachVet Telemental Health Hubs VA-19-0799-D-000422 OS 00002088 Access and Quality in V 'I_Healthcare~ ........ 1.r.... ,_~ , - ~ ,, ,,. '" ........ , visit AccesstoCare.va.gov ~ ACC ESSTO CARE.VA.GOV 2 VA-19-0799-D-000423 OS 00002089 AVERAGE LOCAL CLINIC WAIT TIMES VETERAN SATISFACTION WITH ACCESS Average Wait Times at Individual Facilities What Veterans Say About Access to Care .._____ _, i=----· . -·------.-,...-.-------...-. . -- - - -· --..:. - --· -,.e,.,. --·----..i •-:::J .e•-· -:_c•--~ • L_ ~ Wa,t Times for 'PRIMARY CARE' Appoontments FACILITY NAME l:MSTA.NCE AVERAGE WAIT {MILES) TIME I A.LakesKte VAClnic ShrJ'#onMap :,..r- ~-- - _ ShowMore Sdays 8 Jesse Brown Oepartment or veterans AffUS Medical Center Show More Show on Map 1-4 days C Auburn Gresham VA Cin1t Show More Show on Map 0 Edward Hne$ Jurnor Hospital Show More 32 days 11 Show on Map - " ----1 ---------·.::::::.::;.-=::::..-::::=:~~~= ...- · - - - · - . - - - ~olV....'lllflo1IPQllldM..,-..~orU.U., ait..togiit.,.........,,.....,..wa'f'l-vC..(Ro..tlNY Dll'lANC1!111 ,_,lAYCAAE aaf.l ..,A.GMT~,._, (ROUTlllf) ..._._. ..... c s.. ..... s,_..,._ ~- ------------~ a~v•ca,ic se-1 - -,_ - ..--- - - - - - - - - - 1 - !C NcwhMI P!lo.-VACIM& ,Sf.w- - - - - :si.. ..... ._.,. ... ! O S - - V,1,. Clllil: ,--------------! te.,__v.i.~ is,...,- si.. . . . . . 1 3days VETERANS HEALTH ADMINISTRATION 3 VA-19-0799-D-000424 OS 00002090 Veterans can learn about timeliness in the VA system ... A.ccess .md Qua ,iy in I/A He.lllthcare~ ...1111.. - . _ • ~ Review Nati onal Data on Wa it Times How satisfied are Veterans with their care in my facility? Review National Data on Access to Specialty Care I How is the VA system doing with access nationally? ~ visit AccesstoCa re.va .gov ~ select your topic select sub-topic view t he res ults Veterans can learn about average local wait times ... How quickly can my VA facility see me? -Vf ~ How does care in my VA facility compare to other hospitals in the area? Location ... 1 Radius ... I Clinic Type ... I Visit Type .. - I How satisfied are Veterans with their care in my facility? visit A ccesstoCare.va.gov ~ Sort by... l How is the VA system doing with access nationally? Search se lect y o u r top ic ente r t ex t to pinpoint d ata ~ 4 VA-19-0799-D-000425 OS 00002091 • This is a work in progress and we are working hard to make it better for Veterans • If you have expertise in communicating complex information to broad stakeholders or user testing please reach out • Contact VHA10E2Action@va .gov with insights, feedback, or general interest VETERANS HEALTH ADMINISTRATION 5 VA-19-0799-D-000426 OS 00002092 Message From: Sent: To: Subject: Marisol Garcia [(b) (6) frenchangel59.com] 4/15/2017 10:43:56 AM L Perl [(b) (6) gmail.com]; (b) (6) hotmail.com; David shulkin [Drshulkin@aol.com]; Bruce Moskowitz (b) (6) [ mac.com]; mbs(b) (6) @gmail.com; (b) (6) frenchangel59.com; (b) (6) va.gov FRIENDLY REMINDER - VA Conference Call TODAY - Saturday, April 15th @10:00AM Saturday, April 15 th 10:00 AM -10:45 AM ESli Dial-in Information: (b) (6) US: 1-866-244- (b) (6) International: 719-457Passcode: (b) (6) Participants: Laurie Perlmutter, Poonam Alaigh, Secretary David Shulkin, Dr. Bruce Moskowitz, Marc Sherman and Ike Thank you, Marisol Garcia 212-576-(b) (6) (646) 201-(b) (6) (b) (6) (Office) (Cell) frenchangel59.com VA-19-0799-D-000428 OS 00002094 Message From: (b) (6) Sent: 4/14/2017 9:59:18 PM David Shulkin [drshulkin@aol.com] Fya article from today To: Subject: [(b) (6) gmail.com] http ://www.lehighvalleylive.com/allentown/index.ssf/2017/04/veterans affairs secretary vis.html VA-19-0799-D-000429 OS 00002095 Message David shulkin [Drshulkin@aol.com] From: Sent: 4/13/2017 4:34:18 PM To: (b) (6) [(b) (6) Fwd: [EXTERNAL] (b) (6) Subject: va.gov] Fyi Sent from my iPhone Begin forwarded message: RDML USN WHMO/WHMU" <(b) (6) From: "(b) (6) Date: April 13, 2017 at 12:20:42 PM EDT To: David shulkin Subject: RE: [EXTERNAL] (b) (6) whmo.mil> David, Meant to send this to you yesterday. Suspect you may have intended it for the other BTW, everyone loves what you are doing over there and you are making great headlines! Hope to see you soon. R/ (b) (6) From: David shulkin [mailto:Drshulkin@aol.com ] Sent: Wednesday, April 12, 2017 10:43 AM To: Bruce Moskowitz <(b) (6) mac.com > Cc: RDML USN WHMO/WHMU <(b) (6) Subject: Re: [EXTERNAL] (b) (6) (b) (6) whmo.mil > My office is working on it I have a keynote to 1000 people till 2 but then could get to a meeting We have some rearranging to do but will work on it Sent from my iPhone On Apr 12, 2017, at 8:58 AM, Bruce Moskowitz <(b) (6) Mr. (b) (6) mac.com> wrote: asked if you can attend the Bethesda meeting. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: From: "(b) (6) <(b) (6) Date: April 12, 2017 at 8:53:59 AM EDT va.gov> VA-19-0799-D-000430 OS 00002096 To: Bruce Moskowitz <(b) (6) Subject: RE: [EXTERNAL] (b) (6) Yes. Good call with (b) (6) Meeting with (b) (6) around 2 or 3pm. mac.com> Have call with (b) (6) today. et al: Friday, 28 April. Details TBD. Likely at (b) (6) 805 551 (b) (6) -----Original Message----F rom: Bruce Moskowitz [mailto:(b) (6) Sent: Wednesday, April 12, 2017 8:40 AM To: (b) (6) Subject: [EXTERNAL] (b) (6) mac.com] Spoke to him today. When is the meeting at Bethesda? Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000431 OS 00002097 Message From: (b) (6) Sent: 4/13/2017 4:20:42 PM To: David shulkin [Drshulkin@aol.com] RE: [EXTERNAL] (b) (6) Subject: RDML USN WHMO/WHMU [(b) (6) whmo.mil] David, Meant to send this to you yesterday. Suspect you may have intended it for the other BTW, everyone loves what you are doing over there and you are making great headlines! Hope to see you soon. R/ (b) (6) From: David shulkin [mailto:Drshulkin@aol.com] Sent: Wednesday, April 12, 2017 10:43 AM To: Bruce Moskowitz <(b) (6) mac.com> RDML USN WHMO/WHMU <(b) (6) Subject: Re: [EXTERNAL] (b) (6) Cc: (b) (6) whmo.mil> My office is working on it I have a keynote to 1000 people till 2 but then could get to a meeting We have some rearranging to do but will work on it Sent from my iPhone On Apr 12, 2017, at 8:58 AM, Bruce Moskowitz <(b) (6) Mr. (b) (6) mac.com> wrote: asked if you can attend the Bethesda meeting. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: From: "(b) (6) <(b) (6) Date: April 12, 2017 at 8:53:59 AM EDT To: Bruce Moskowitz <(b) (6) Subject: RE: [EXTERNAL] (b) (6) Yes. Good call with (b) (6) Meeting with (b) (6) 3pm. Have call with (b) (6) va.gov> mac.com> today. et al: Friday, 28 April. Details TBD. Likely at around 2 or (b) (6) 805 551 (b) (6) -----Original Message----VA-19-0799-D-000432 OS 00002098 From: Bruce Moskowitz [mailto:(b) (6) Sent: Wednesday, April 12, 2017 8:40 AM To: (b) (6) Subject: [EXTERNAL] (b) (6) mac.com] Spoke to him today. When is the meeting at Bethesda? Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000433 OS 00002099 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/12/2017 2:42:36 PM To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] L. RDML USN WHMO/WHMU Jackson [(b) (6) Re: [EXTERNAL] (b) (6) (b) (6) whmo.mil] My office is working on it I have a keynote to 1000 people till 2 but then could get to a meeting We have some rearranging to do but will work on it Sent from my iPhone On Apr 12, 2017, at 8:58 AM, Bruce Moskowitz <(b) (6) Mr. (b) (6) mac.com> wrote: asked if you can attend the Bethesda meeting. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: From: "(b) (6) <(b) (6) Date: April 12, 2017 at 8:53:59 AM EDT To: Bruce Moskowitz <(b) (6) Subject: RE: [EXTERNAL] (b) (6) Yes. Good call with (b) (6) Meeting with (b) (6) 3pm. va.gov> mac.com> Have call with (b) (6) today. et al: Friday, 28 April. Details TBD. Likely at around 2 or (b) (6) 805 551 (b) (6) -----Original Message----F rom: Bruce Moskowitz [mailto:(b) (6) Sent: Wednesday, April 12, 2017 8:40 AM To: (b) (6) Subject: [EXTERNAL] (b) (6) mac.com] Spoke to him today. When is the meeting at Bethesda? Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000434 OS 00002100 Message From: Bruce Moskowitz [(b) (6) Sent: 4/12/2017 12:58:20 PM To: David Shulkin [drshulkin@aol.com] Fwd: [EXTERNAL] (b) (6) Subject: Mr. (b) (6) mac.com] asked if you can attend the Bethesda meeting. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: From: "(b) (6) <(b) (6) Date: April 12, 2017 at 8:53:59 AM EDT To: Bruce Moskowitz <(b) (6) Subject: RE: [EXTERNAL] (b) (6) Yes. Good call with (b) (6) Meeting with (b) (6) va.gov> mac.com> Have call with (b) (6) today. et al: Friday, 28 April. Details TBD. Likely at around 2 or 3pm. (b) (6) 805 551 (b) (6) -----Original Message----From: Bruce Moskowitz [mailto:(b) (6) Sent: Wednesday, April 12, 2017 8:40 AM To: (b) (6) Subject: [EXTERNAL] (b) (6) mac.com] Spoke to him today. When is the meeting at Bethesda? Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000435 OS 00002101 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/15/2017 2:04:40 AM David shulkin [Drshulkin@aol.com] Re: Musical chairs I know, but still like to ask you Sent from my iPad > on Apr 14, 2017, at 6:54 AM, David shulkin wrote: > > You have my support to do what you feel is best > > Sent from my iPhone > >> on Apr 14, 2017, at 5:04 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >> >> Yes, Gerry wants to try her. Don't really trust her but spoke to her yesterday and told her that I wanted no gossip, needed to work on trust issues and no direct contact to the 10th floor now the Jen will be there. The deputy pdush role gives me some degrees of separation while being able to leverage her talent, and nobody reports to her. Agree about mike, although the is about to retire and this may incentivize him to stay longer by challenging him in a new way >> >> Sent from my iPhone >> >>> on Apr 13, 2017, at 10:53 PM, David shulkin wrote: >>> >>> I would definitely move Dort- she adds no value- does Gerry want her or should she go to the field? >>> >>> I think Ash has value- it's up to u if u trust her >>> >>> I don't know who would take over for Mike- Pharmacy is not broken so please make sure you don't break it by removing him >>> >>> Sent from my iPad >>> >>>> on Apr 13, 2017, at 10:43 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >>>> >>>> With all this happening around us-thinking of making additional moves- what do you think? >>>> >>>> 1) Ash- deputy PDUSH- she works on all the quick hit priorities like the IG reports denoting system wise issues like the inventory management >>>> >>>> 2) Mike Valentino- becomes deputy to Lu Beck >>>> >>>> 3) Deb Dort- moves to Gerry cox area >>>> >>>> Sent from my iPhone >>> > VA-19-0799-D-000436 OS 00002102 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/14/2017 10:54:06 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Musical chairs You have my support to do what you feel is best Sent from my iPhone > on Apr 14, 2017, at 5:04 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Yes, Gerry wants to try her. Don't really trust her but spoke to her yesterday and told her that I wanted no gossip, needed to work on trust issues and no direct contact to the 10th floor now the Jen will be there. The deputy pdush role gives me some degrees of separation while being able to leverage her talent, and nobody reports to her. Agree about mike, although the is about to retire and this may incentivize him to stay longer by challenging him in a new way > > Sent from my iPhone > >> on Apr 13, 2017, at 10:53 PM, David shulkin wrote: >> >> I would definitely move Dort- she adds no value- does Gerry want her or should she go to the field? >> >> I think Ash has value- it's up to u if u trust her >> >> I don't know who would take over for Mike- Pharmacy is not broken so please make sure you don't break it by removing him >> >> Sent from my iPad >> >>> on Apr 13, 2017, at 10:43 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >>> >>> With all this happening around us-thinking of making additional moves- what do you think? >>> >>> 1) Ash- deputy PDUSH- she works on all the quick hit priorities like the IG reports denoting system wise issues like the inventory management >>> »> 2) Mike Valentino- becomes deputy to Lu Beck >>> >>> 3) Deb Dort- moves to Gerry cox area >>> >>> Sent from my iPhone >> VA-19-0799-D-000437 OS 00002103 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/14/2017 9:04:55 AM David Shulkin [drshulkin@aol.com] Re: Musical chairs Yes, Gerry wants to try her. Don't really trust her but spoke to her yesterday and told her that I wanted no gossip, needed to work on trust issues and no direct contact to the 10th floor now the Jen will be there. The deputy pdush role gives me some degrees of separation while being able to leverage her talent, and nobody reports to her. Agree about mike, although the is about to retire and this may incentivize him to stay longer by challenging him in a new way Sent from my iPhone > on Apr 13, 2017, at 10:53 PM, David shulkin wrote: > > I would definitely move Dort- she adds no value- > > I think Ash has value- does Gerry want her or should she go to the field? it's up to u if u trust her > > I don't know who would take over for Mike- Pharmacy is not broken so please make sure you don't break it by removing him > > Sent from my iPad > >> on Apr 13, 2017, at 10:43 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >> >> With all this happening around us-thinking of making additional moves- what do you think? >> >> 1) Ash- deputy PDUSH- she works on all the quick hit priorities like the IG reports denoting system wise issues like the inventory management >> >> 2) Mike Valentino- becomes deputy to Lu Beck >> >> 3) Deb Dort- moves to Gerry cox area >> >> Sent from my iPhone > VA-19-0799-D-000438 OS 00002104 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/14/2017 2:53:35 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Musical chairs I would definitely move Dort- she adds no valueI think Ash has value- does Gerry want her or should she go to the field? it's up to u if u trust her I don't know who would take over for Mike- Pharmacy is not broken so please make sure you don't break it by removing him Sent from my iPad > on Apr 13, 2017, at 10:43 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > With all this happening around us-thinking of making additional moves- what do you think? > > 1) Ash- deputy PDUSH- she works on all the quick hit priorities like the IG reports denoting system wise issues like the inventory management > > 2) Mike Valentino- becomes deputy to Lu Beck > > 3) Deb Dort- moves to Gerry cox area > > Sent from my iPhone VA-19-0799-D-000439 OS 00002105 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/14/2017 2:43:37 AM David Shulkin [drshulkin@aol.com] Musical chairs With all this happening around us-thinking of making additional moves- what do you think? 1) Ash- deputy PDUSH- she works on all the quick hit priorities like the IG reports denoting system wise issues like the inventory management 2) Mike Valentino- becomes deputy to Lu Beck 3) Deb Dort- moves to Gerry cox area Sent from my iPhone VA-19-0799-D-000440 OS 00002106 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/15/2017 4:52:49 PM (b) (6) gmail.com Re: Smag yes -----Original Message----From: (b) (6) <(b) (6) To: David Shulkin Sent: Sat, Apr 15, 2017 6:27 am Subject: Smag gmail.com> Hi, We talked about smag last week, and you said you were just going to talk about the priorities. I wanted to double check to see if that was still the case. VA-19-0799-D-000441 OS 00002107 Message From: (b) (6) Sent: 4/15/2017 10:27:51 AM David Shulkin [drshulkin@aol.com] Smag To: Subject: [(b) (6) gmail.com] Hi, We talked about smag last week, and you said you were just going to talk about the priorities. I wanted to double check to see if that was still the case. VA-19-0799-D-000442 OS 00002108 Message CC: Poonam Alaigh [(b) (6) hotmail.com] 6/3/2017 10:24:16 PM David shulkin [Drshulkin@aol.com] Vivieca Wright Simpson [vivieca.Wright@va.gov] Subject: Re: From: Sent: To: Agree and I concur with his guidance - surprises it's not already in place to that effect Sent from my iPhone On Jun 3, 2017, at 4: 14 PM, David shulkin wrote: https://correa.house.gov/media/press-releases/rep-correa-sends-secretary-shulkin-letter-veteranuse-medical-mari juana Can we discuss this at report Im ok if you need sme but i think its unnecessary- i think we just need a policy clarification about his issue Thanks Sent from my iPhone VA-19-0799-D-000443 OS 00002109 Message From: Sent: To: CC: David shulkin [Drshulkin@aol.com] 6/3/2017 8:14:43 PM Poonam Alaigh [(b) (6) hotmail.com] Vivieca Wright Simpson [vivieca.Wright@va.gov] https ://correa.house.gov/media/press-rel eases/rep-correa-sends-secretary-shulkin-1 etter-veteran-use-medicalman 1uana Can we discuss this at report Im ok if you need sme but i think its unnecessary- i think we just need a policy clarification about his issue Thanks Sent from my iPhone VA-19-0799-D-000444 OS 00002110 Message To: David shulkin [Drshulkin@aol.com] 4/25/2017 12:31:00 PM IP [(b) (6) frenchangel59.com] Subject: Re: RE: From: Sent: (b) (6) Sent from my iPhone > on Apr 25, 2017, at 7:48 AM, IP <(b) (6) frenchangel59.com> wrote: > > Please email me his/her name. Thank you > > > > > > -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Tuesday, April 25, 2017 6:48 AM To: Ike Perlmutter subject: > >Ike-the DoD top person for health will come to dinner Wednesday > > Im still working on isakkson > > David > > Sent from my iPhone > VA-19-0799-D-000445 OS 00002111 Message From: IP [(b) (6) frenchangel59.com] Sent: To: 4/25/2017 11:48:31 AM 'David shulkin' [Drshulkin@aol.com] Subject: RE: Please email me his/her name. Thank you -----original Message----From: David shulkin [mailto:Drshulkin@aol .com] Sent: Tuesday, April 25, 2017 6:48 AM To: Ike Perlmutter subject: Ike- the DoD top person for health will come to dinner Wednesday Im still working on isakkson David Sent from my iPhone VA-19-0799-D-000446 OS 00002112 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/25/2017 10:48:09 AM To: Ike Perlmutter [(b) (6) frenchangel59.com] Ike- the DoD top person for health will come to dinner Wednesday Im still working on isakkson David Sent from my iPhone VA-19-0799-D-000447 OS 00002113 Message From: Poonam Alaigh [(b) (6) Sent: 4/16/2017 1:24:28 PM To: David Shulkin [drshulkin@aol.com] Re: How are things Subject: hotmail.com] I am on the Acee la 2255 train- let me know if there is anything I can do. From: David Shulkin Sent: Sunday, April 16, 2017 9:19 AM To: (b) (6) hotmail.com Subject: Re: How are things a lot going on -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: David Shulkin Sent: Sat, Apr 15, 2017 7:42 pm Subject: How are things On the home front Sent from my iPhone VA-19-0799-D-000448 OS 00002114 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/16/2017 1:19:13 PM To: (b) (6) Subject: hotmail.com Re: How are things a lot going on -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: David Shulkin Sent: Sat, Apr 15, 2017 7:42 pm Subject: How are things On the home front Sent from my iPhone VA-19-0799-D-000449 OS 00002115 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/15/2017 11:42:21 PM David Shulkin [drshulkin@aol.com] How are things on the home front Sent from my iPhone VA-19-0799-D-000450 OS 00002116 Message Marc Sherman [(b) (6) gmail.com] 4/18/2017 3:16:08 AM David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) gmail.com]; Bruce Moskowitz [(b) (6) mac.com] Re: PELOSI -- Remarks at Veterans Health Care Action Campaign Forum From: Sent: To: CC: Subject: You deserve a huge congratulations for that. Everything else she got wrong, unfortunately. On Mon, Apr 17, 2017 at 10:05 PM, David shulkin wrote: Of all people look what Nancy Pelosi said in yellow below Subject: FW: PELOSI -- Remarks at Veterans Health Care Action Campaign Forum Sir, Leader Pelosi had a Veterans event in San Francisco at the end of last week with Michael Blecker, Swords to Plowshares. Her staff forwarded her remarks, which included positive things about you that are highlighted. V/R, (b) (6) From: Democratic Leader Sent: Thursday, April 13, 2017 7:12 PM Subject: PELOSI -- Remarks at Veterans Health Care Action Campaign Forum NANCY PELOSI O E H.OCR AT I C L EADE R News FROM DEMOCRATIC LEADER NANCY PELOSI Contact: Jorge Aguilar, April 13, 2017 202-226-7616 VA-19-0799-D-000451 OS 00002117 Pelosi Remarks at Veterans Health Care Action Campaign Forum San Francisco - Democratic Leader Nancy Pelosi joined Michael Blecker, Executive Director of Swords to Plowshares, veterans and leaders qf veterans advocacy groups at the Veterans Health Care Action Campaign Forum. Below is a transcript qf the Leader's remarks: "Thank you, everyone. Thank you Michael [Blecker] for your great leadership and your kind words of welcome. Thank you Paul Cox for your leadership as well, to be here with you and Michael Blecker, of course with Suzanne Gordon, we'll all be looking forward to her speech, and Edgar Escobar thank you for your leadership. I also want to acknowledge my daughter, Christine Pelosi who is here, she is a member of the Democratic National Committee, and she was the leader in insisting they have Veterans desk at the Democratic National Committee. "Michael will tell you he wrote the dissenting view on Commission on Care. I was so very grateful. I'm so very, very proud of him, I've seen his work for decades - as Paul has mentioned he's been working with Swords to Plowshares for a long time, so I've been aware of his leadership for a long time on behalf of our vets. So, I was very honored recently to appoint him to the Commission on Care, but even earlier than that to our regular meeting with Veteran Service Organizations, going back to when I first became Leader almost a dozen years ago, and then Speaker, and then Leader again. "But Michael when he would come, I would say, 'I'd like to introduce you to a saint.' He would blush as he's blushing now, but not for long. He would soon speak up on behalf of veterans there. We had our most recent meeting just about a week or so ago before we broke for Easter and Passover, and I want to say it was as usual very informative, a very strong meeting but this time very much focused, and that is a decision by the vets. "At this meeting, we focused on women veterans and the rising list of concerns that we have for women veterans. That's a very large and growing, number as well. But we always take our agenda from what the veterans bring, going back to our first meeting. We talked about the Veteran's Disability Tax in Congress, issues the relate to Survivor Benefits. You name it, just a full array of issues, but saying to you prioritize, we'll act upon it. "When we had the Majority [in Congress], we were able to allocate the resources necessary to implement some of the policy that we were able to achieve earlier. I was very proud of all of the - I'll put up a selfserving sign - when I was introduced the Commander said what I had done as Speaker was recognized more than any other Speaker in terms of meeting the needs of veterans since the GI Bill. So we're very, very excited about that. It's a recognition of your work. VA-19-0799-D-000452 OS 00002118 "But I am here today to listen, that's definitely the most valuable thing. I learn more when I listen than when I speak. And I come here to listen to your concerns, but I want to put it in this context. "A couple days ago we had a social media call where we meet with all of the groups - VoteVets, Daily Kos, Move On, Planned Parenthood, all these groups - about how we can protect the Affordable Care Act. Well in the meantime Syria intervened, so our veterans were an even stronger voice, they're always strong, but we had more questions for them on the call. And at the end of the call they said, 'We're talking about vets, and we're talking about the VA, that's very important to us, but our veterans need to go beyond the VA' "It's about housing and how HUD is funded, it's about mental health, it's about the Affordable Care Act and other issues. It's about Medicaid, it's about Opioids which is about the Medicaid solution that we have in our legislation and so they said, 'there are so many other things that effect our well-being, as important as the VA is one of the most important things that affects us is we like to have peace, so we can get well.' [Applause] "Because as we know, and you've heard it over and over, you've said it yourself -when you're on the battle field you leave no soldier behind, and when they come home we leave no veteran behind. That is our mantra, and you have to help us make that happen. "Because as Michael said, when he was named to this Commission the issue is they're not listening to vets, they're just talking to each other. And this threat loomed large during the Presidential campaign, privatizing the VA is a real threat. We will not let them make money off of delivering health care to our veterans and that's a promise. [Applause] "We've got to move our own health care system to a more nonprofit place, rather than moving our Veterans Health Administration to a 'Let's make more off our Vets' place. "So in our meeting, a group that represents nobody but has money from somebody, Conservative Veterans of America, I don't think anyone here is part of it, but if you are I want you to hear what I have to say - the VA-19-0799-D-000453 OS 00002119 VA and Veterans Services Organizations are unified. Now, having said that, if we're going to address concerns that we have, making delivery of service better - do we recognize how that fits very much in our health care system and how we need other things - need other things. "I had one of those penchants this morning, we planted a garden to start the construction of the barrier and net at the Golden Gate Bridge. We spent a lot of time with families who have lost their loved one - taking their own lives. We know that that is an increasing problem across the board in our country, including among our veterans. So, our mental health issues are very, very important, and in fact, we're very dismayed that our colleagues across the aisle did not make addressing mental health issues - they took off of the list of things that must be done. "So, let's look up here: Veterans' Health Care Action Campaign. Veterans - it's about our veterans' health care. They're taking action and having a campaign. Understand this very clearly: nothing is more eloquent to a Member of Congress than the voice of his or her own constituents. You're my bosses, or if you're not in my district, you're somebody else's bosses. So, let your voice be known to them, as well. Your experience is the wisdom that we need to make the decisions when we have choices to make. Of all of the things President Trump has done, one thing I am happy about is his choice for Secretary of Veterans' Affairs - the secretary there. So far, so good. Wouldn't you say? So far, so good- because we thought for sure he was going to put a privatizer at the head of the VA, and that would've been very problematic. We'll see how we go from there. "A couple of other thoughts - just to say, today - this spring is the 100th anniversary since our entry into World War I, 75 years since the Bataan Death March, 14 years since the invasion oflraq. So sad. So sad. And, so many veterans are coming home. So, we are getting hundreds of thousands of servicemembers each year- becoming veterans, challenging our system. Over 70 percent of our nation's 21 million are over the age of 45, including the majority of veterans in San Francisco. As I mentioned, many more women, and we need to address [each] of those concerns - and that's why we have regular veterans service organizations' meetings, and that's why I am here to hear what you have to say, on the ongoing but as a group here today. "Again, we are very concerned about this issue of privatization. Privatization can virtually end the guarantee - end the guarantee of free health care for those who have served. Privatization would see the VA's doors closed for most of its 366,000 employees, a third of whom are veterans themselves - 100,000 of the workers in the VA are vets. While ensuring the VA can better coordinate care in a community where there are gaps, we have to be smart, we have to be cautious. Nearly one-third percent of care is already provided outside of the VA - you know that. Increasing the amount of care outside of the VA could have negative impacts on comprehensive and specialty care. There are just some things the VA knows better - combat related injuries and the rest. There are just some things they can diagnose more readily, care for with experience in having cared for others. At the VA, veterans are treated as a whole person. That is the only service-connected, comprehensive care culture that provides unparalleled, personal medical expertise. VA-19-0799-D-000454 OS 00002120 "We must lift, not load. VA privatization is not the answer. I look forward to our forum and debunking the myth of what veterans' choice really means - what that really means. We have to hold our bedrock promise. Again, just as the military leaves no one behind on the battlefield, we must leave no veteran behind when they come. That is our promise - not only that, it is our values system, it is an ethical commitment that we have to you. You make us the home of the brave and the land of the free. And while we're doing that, we have to also consider what they're doing in the budget. The budget should be a statement of our national values. What is important to us as a nation should be reflected in our budget. When veterans come from [overseas], we need the biomedical research, we need these other things that they are cutting because this is something that we all benefit from. So, as a statement of our values, our veterans are not at that place - the place that we want them to be. "So, it's pretty exciting to see right now - learn our lesson from the March on Washington, which many of you participated in, all over the world, in every continent. What was good about it was: it was spontaneous. It wasn't organized by politicians and elected officials. It was spontaneous, and different groups joined in. And what was good about it too is that when it came time, the airports and the bans and this and that- people showed up at the steps of the Supreme Court. People showed up. And when the Affordable Care Act was under a threat - under a threat with a bill that they called an 'act of mercy.' It was really an act of malice in what it did to working families in our country. The biggest transfer of weal th - the Republican bill was the biggest - I used a partisan word, please forgive me - the biggest transfer of wealth in the history of our country. Robin Hood in reverse - $600 or more, $600 billion lifted from middle income families and those who aspire to the middle class to the wealthiest people in our country. "So, as we gather here to talk about this, it comes down to budget. It comes down to budget - how we're going to allocate resources. And that's why they want to move to privatize and say 'we're going to save money.' No, we're here to save lives and to improve the quality of care in the lives, to honor the vision of our Founders: life, liberty and the pursuit of happiness. We want people to have a healthier life and the liberty to pursue their happiness. And when we do whatever we do, it has to be to honor the values of our Founders, the sacrifice of our men and women in uniform - they are right there on par with other leaders and of course, the aspirations of our children. "So, thank you for all that you have done for our country, for your leadership, for your service and for your concern, not only about you but for so many other veterans as they come back home. Thank you all very much for [giving me] the time to share some thoughts with you. I look forward to hearing what you all have to say. Thank you all very much." ### Press Release Link: VA-19-0799-D-000455 OS 00002121 http://www.democraticleader.gov/newsroom/413 l 7-3/ DemocraticLeader.gov - Twitter - YouTube - Flickr - Facebook - Instagram - Medium - The Gavel VA-19-0799-D-000456 OS 00002122 Message David shulkin [Drshulkin@aol.com] 4/18/2017 2:05:37 AM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) gmail.com]; Bruce Moskowitz [(b) (6) mac.com]; Marc Sherman [(b) (6) gmail.com] Fwd: PELOSI -- Remarks at Veterans Health Care Action Campaign Forum From: Sent: To: Subject: Of all people look what Nancy Pelosi said in yellow below Subject: FW: PELOSI -- Remarks at Veterans Health Care Action Campaign Forum Sir, Leader Pelosi had a Veterans event in San Francisco at the end of last week with Michael Blecker, Swords to Plowshares. Her staff forwarded her remarks, which included positive things about you that are highlighted. V/R, (b) (6) From: Democratic Leader Sent: Thursday, April 13, 2017 7:12 PM Subject: PELOSI -- Remarks at Veterans Health Care Action Campaign Forum News FROM DEMOCRATIC LEADER NANCY PELOSI Contact: Jorge Aguilar, April 13, 2017 202-226-7616 VA-19-0799-D-000457 OS 00002123 Pelosi Remarks at Veterans Health Care Action Campaign Forum San Francisco - Democratic Leader Nancy Pelosi joined A1ichael Blecker, Executive Director of Swords· to Plowshares, veterans and leaders of veterans advocacy groups at the Veterans Health Care Action Campaign Forum. Below is a transcript of the Leader's remarks: "Thank you, everyone. Thank you Michael [Blecker] for your great leadership and your kind words of welcome. Thank you Paul Cox for your leadership as well, to be here with you and Michael Blecker, of course with Suzanne Gordon, we'll all be looking forward to her speech, and Edgar Escobar thank you for your leadership. I also want to acknowledge my daughter, Christine Pelosi who is here, she is a member of the Democratic National Committee, and she was the leader in insisting they have Veterans desk at the Democratic National Committee. "Michael will tell you he wrote the dissenting view on Commission on Care. I was so very grateful. I'm so very, very proud of him, I've seen his work for decades - as Paul has mentioned he's been working with Swords to Plowshares for a long time, so I've been aware of his leadership for a long time on behalf of our vets. So, I was very honored recently to appoint him to the Commission on Care, but even earlier than that to our regular meeting with Veteran Service Organizations, going back to when I first became Leader almost a dozen years ago, and then Speaker, and then Leader again. "But Michael when he would come, I would say, 'I'd like to introduce you to a saint.' He would blush as he's blushing now, but not for long. He would soon speak up on behalf of veterans there. We had our most recent meeting just about a week or so ago before we broke for Easter and Passover, and I want to say it was as usual very informative, a very strong meeting but this time very much focused, and that is a decision by the vets. "At this meeting, we focused on women veterans and the rising list of concerns that we have for women veterans. That's a very large and growing, number as well. But we always take our agenda from what the veterans bring, going back to our first meeting. We talked about the Veteran's Disability Tax in Congress, issues the relate to Survivor Benefits. You name it, just a full array of issues, but saying to you prioritize, we'll act upon it. "When we had the Majority [in Congress], we were able to allocate the resources necessary to implement some of the policy that we were able to achieve earlier. I was very proud of all of the - I'll put up a selfserving sign - when I was introduced the Commander said what I had done as Speaker was recognized more than any other Speaker in terms of meeting the needs of veterans since the GI Bill. So we're very, very excited about that. It's a recognition of your work. VA-19-0799-D-000458 OS 00002124 "But I am here today to listen, that's definitely the most valuable thing. I learn more when I listen than when I speak. And I come here to listen to your concerns, but I want to put it in this context. "A couple days ago we had a social media call where we meet with all of the groups - VoteVets, Daily Kos, Move On, Planned Parenthood, all these groups - about how we can protect the Affordable Care Act. Well in the meantime Syria intervened, so our veterans were an even stronger voice, they're always strong, but we had more questions for them on the call. And at the end of the call they said, 'We're talking about vets, and we're talking about the VA, that's very important to us, but our veterans need to go beyond the VA' "It's about housing and how HUD is funded, it's about mental health, it's about the Affordable Care Act and other issues. It's about Medicaid, it's about Opioids which is about the Medicaid solution that we have in our legislation and so they said, 'there are so many other things that effect our well-being, as important as the VA is one of the most important things that affects us is we like to have peace, so we can get well.' [Applause] "Because as we know, and you've heard it over and over, you've said it yourself -when you're on the battle field you leave no soldier behind, and when they come home we leave no veteran behind. That is our mantra, and you have to help us make that happen. "Because as Michael said, when he was named to this Commission the issue is they're not listening to vets, they're just talking to each other. And this threat loomed large during the Presidential campaign, privatizing the VA is a real threat. We will not let them make money off of delivering health care to our veterans and that's a promise. [Applause] "We've got to move our own health care system to a more nonprofit place, rather than moving our Veterans Health Administration to a 'Let's make more off our Vets' place. "So in our meeting, a group that represents nobody but has money from somebody, Conservative Veterans of America, I don't think anyone here is part of it, but if you are I want you to hear what I have to say - the VA-19-0799-D-000459 OS 00002125 VA and Veterans Services Organizations are unified. Now, having said that, if we're going to address concerns that we have, making delivery of service better - do we recognize how that fits very much in our health care system and how we need other things - need other things. "I had one of those penchants this morning, we planted a garden to start the construction of the barrier and net at the Golden Gate Bridge. We spent a lot of time with families who have lost their loved one - taking their own lives. We know that that is an increasing problem across the board in our country, including among our veterans. So, our mental health issues are very, very important, and in fact, we're very dismayed that our colleagues across the aisle did not make addressing mental health issues - they took off of the list of things that must be done. "So, let's look up here: Veterans' Health Care Action Campaign. Veterans - it's about our veterans' health care. They're taking action and having a campaign. Understand this very clearly: nothing is more eloquent to a Member of Congress than the voice of his or her own constituents. You're my bosses, or if you're not in my district, you're somebody else's bosses. So, let your voice be known to them, as well. Your experience is the wisdom that we need to make the decisions when we have choices to make. Of all of the things President Trump has done, one thing I am happy about is his choice for Secretary of Veterans' Affairs - the secretary there. So far, so good. Wouldn't you say? So far, so good- because we thought for sure he was going to put a privatizer at the head of the VA, and that would've been very r.roblematic. We'll see how we go from there. "A couple of other thoughts - just to say, today - this spring is the 100th anniversary since our entry into World War I, 75 years since the Bataan Death March, 14 years since the invasion oflraq. So sad. So sad. And, so many veterans are coming home. So, we are getting hundreds of thousands of servicemembers each year- becoming veterans, challenging our system. Over 70 percent of our nation's 21 million are over the age of 45, including the majority of veterans in San Francisco. As I mentioned, many more women, and we need to address [each] of those concerns - and that's why we have regular veterans service organizations' meetings, and that's why I am here to hear what you have to say, on the ongoing but as a group here today. "Again, we are very concerned about this issue of privatization. Privatization can virtually end the guarantee - end the guarantee of free health care for those who have served. Privatization would see the VA's doors closed for most of its 366,000 employees, a third of whom are veterans themselves - 100,000 of the workers in the VA are vets. While ensuring the VA can better coordinate care in a community where there are gaps, we have to be smart, we have to be cautious. Nearly one-third percent of care is already provided outside of the VA - you know that. Increasing the amount of care outside of the VA could have negative impacts on comprehensive and specialty care. There are just some things the VA knows better - combat related injuries and the rest. There are just some things they can diagnose more readily, care for with experience in having cared for others. At the VA, veterans are treated as a whole person. That is the only service-connected, comprehensive care culture that provides unparalleled, personal medical expertise. VA-19-0799-D-000460 OS 00002126 "We must lift, not load. VA privatization is not the answer. I look forward to our forum and debunking the myth of what veterans' choice really means - what that really means. We have to hold our bedrock promise. Again, just as the military leaves no one behind on the battlefield, we must leave no veteran behind when they come. That is our promise - not only that, it is our values system, it is an ethical commitment that we have to you. You make us the home of the brave and the land of the free. And while we're doing that, we have to also consider what they're doing in the budget. The budget should be a statement of our national values. What is important to us as a nation should be reflected in our budget. When veterans come from [overseas], we need the biomedical research, we need these other things that they are cutting because this is something that we all benefit from. So, as a statement of our values, our veterans are not at that place - the place that we want them to be. "So, it's pretty exciting to see right now - learn our lesson from the March on Washington, which many of you participated in, all over the world, in every continent. What was good about it was: it was spontaneous. It wasn't organized by politicians and elected officials. It was spontaneous, and different groups joined in. And what was good about it too is that when it came time, the airports and the bans and this and that- people showed up at the steps of the Supreme Court. People showed up. And when the Affordable Care Act was under a threat - under a threat with a bill that they called an 'act of mercy.' It was really an act of malice in what it did to working families in our country. The biggest transfer of weal th - the Republican bill was the biggest - I used a partisan word, please forgive me - the biggest transfer of wealth in the history of our country. Robin Hood in reverse - $600 or more, $600 billion lifted from middle income families and those who aspire to the middle class to the wealthiest people in our country. "So, as we gather here to talk about this, it comes down to budget. It comes down to budget - how we're going to allocate resources. And that's why they want to move to privatize and say 'we're going to save money.' No, we're here to save lives and to improve the quality of care in the lives, to honor the vision of our Founders: life, liberty and the pursuit of happiness. We want people to have a healthier life and the liberty to pursue their happiness. And when we do whatever we do, it has to be to honor the values of our Founders, the sacrifice of our men and women in uniform - they are right there on par with other leaders and of course, the aspirations of our children. "So, thank you for all that you have done for our country, for your leadership, for your service and for your concern, not only about you but for so many other veterans as they come back home. Thank you all very much for [giving me] the time to share some thoughts with you. I look forward to hearing what you all have to say. Thank you all very much." ### Press Release Link: VA-19-0799-D-000461 OS 00002127 http://www.democraticleader.gov/newsroom/413 l 7-3/ DemocraticLeader.gov - Twitter - YouTube - Flickr - Facebook - Instagram - Medium - The Gavel VA-19-0799-D-000462 OS 00002128 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/14/2017 10:53:06 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Announcement I think its nice of you Sent from my iPhone On Apr 14, 2017, at 5:34 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: I sent this to Jen last night- you may not agree with what I said, but David, I cant purposely hurt anyone ever. David, my true friend, you are a blessing in my life!! Sent from my iPad Begin forwarded message: From: "Alaigh, Poonam, M.D." Date: April 14, 2017 at 5:25:01 AM EDT To: 'Poonam Alaigh' <(b) (6) hotmail.com> Subject: FW: Announcement Sent with Good (www.good.com) -----Original Message----From: Alaigh, Poonam, M.D. Sent: Thursday, April 13, 2017 09:45 PM Eastern Standard Time To: Lee, Jennifer S. (VACO) Cc: Hyduke, Barbara Subject: Announcement Jennifer, Barbara and the team will work on the announcement tomorrow. Just got off the phone with Lu Beck and she has agreed to step into the role as an acting deputy effective Monday. Jennifer, I want to thank you so much your commitment and dedication in VHA, and feel the loss already. But as you know, the boss gets what he wants. And he wants you now- more importantly, he needs you! I know you will be successful in this new role- we will talk more tomorrow. Thanks again for everything. Sent with Good (www.good.com) VA-19-0799-D-000463 OS 00002129 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) 4/14/2017 9:34:24 AM Drshulkin@aol.com Fwd: Announcement hotmail.com] I sent this to Jen last night- you may not agree with what I said, but David, I cant purposely hurt anyone ever. David, my true friend, you are a blessing in my life!! Sent from my iPad Begin forwarded message: From: "Alaigh, Poonam, M.D." Date: April 14, 2017 at 5:25:01 AM EDT To: 'Poonam Alaigh' <(b) (6) hotmail.com> Subject: FW: Announcement Sent with Good (www.good.com) -----Original Message----From: Alaigh, Poonam, M.D. Sent: Thursday, April 13, 2017 09:45 PM Eastern Standard Time To: Lee, Jennifer S. (VACO) Cc: Hyduke, Barbara Subject: Announcement Jennifer, Barbara and the team will work on the announcement tomorrow. Just got off the phone with Lu Beck and she has agreed to step into the role as an acting deputy effective Monday. Jennifer, I want to thank you so much your commitment and dedication in VHA, and feel the loss already. But as you know, the boss gets what he wants. And he wants you now- more importantly, he needs you! I know you will be successful in this new role- we will talk more tomorrow. Thanks again for everything. Sent with Good (www.good.com) VA-19-0799-D-000464 OS 00002130 Message David shulkin [Drshulkin@aol.com] 4/13/2017 2:11:56 AM Darin Selnick [(b) (6) @gmail.com] Re: draft note From: Sent: To: Subject: Your confidence in him was important to me Sent from my iPhone On Apr 12, 2017, at 9:51 PM, Darin Selnick <(b) (6) @gmail.com> wrote: I am forwarding this from Larry to you as he wanted to make sure it reached you. He is deeply honored that you gave him this opportunity and the confidence you have in him. Darin ---------- Forwarded message ---------From: Larry Connell <(b) (6) Date: Wed, Apr 12, 2017 at 5:32 PM Subject: draft note To: (b) (6) k@gmail.com gmail.com> Dr. Shulkin, Just a quick note to say thanks for this one in a lifetime opportunity. I greatly appreciate your confidence in me and my pledge to you is to ensure we regain the trust of our Veterans at the D.C. VA Medical Center. I will make you proud. Thanks, Larry Larry Connell (b) (6) gmail.com (210) 764-9530 VA-19-0799-D-000465 OS 00002131 Message From: Sent: To: Subject: Darin Selnick [(b) (6) @gmail.com] 4/13/2017 1:51:23 AM David shulkin [Drshulkin@aol.com] Fwd: draft note I am forwarding this from Larry to you as he wanted to make sure it reached you. He is deeply honored that you gave him this opportunity and the confidence you have in him. Darin ---------- Forwarded message---------From: Larry Connell <(b) (6) Date: Wed, Apr 12, 2017 at 5:32 PM Subject: draft note To: (b) (6) @gmail.com gmail.com> Dr. Shulkin, Just a quick note to say thanks for this one in a lifetime opportunity. I greatly appreciate your confidence in me and my pledge to you is to ensure we regain the trust of our Veterans at the D.C. VA Medical Center. I will make you proud. Thanks, Larry Larry Connell (b) (6) @gmail .com (210) 764-9530 VA-19-0799-D-000466 OS 00002132 Message David shulkin [Drshulkin@aol.com] 4/14/2017 11:54:17 PM Marisol Garcia [(b) (6) frenchangel59.com] Poonam Alaigh [(b) (6) hotmail.com]; (b) (6) va.gov Re: Conference call for tomorrow Saturday, April 15, 2017 From: Sent: To: CC: Subject: Yes 10 Am works Sent from my iPhone On Apr 14, 2017, at 4:43 PM, Marisol Garcia <(b) (6) frenchangel59.com > wrote: Thank you - Laurie prefers 10am --David, please let me know. From: Poonam Alaigh [ mailto:(b) (6) Sent: Friday, April 14, 2017 4:38 PM To: Marisol Garcia hotmail.com] Cc: David shulkin; (b) (6) va.gov Subject: Re: Conference call for tomorrow Saturday, April 15, 2017 I can make myself available at a time that works for everyone- preferably 9am or later. Thanks Sent from my iPhone On Apr 14, 2017, at 4:33 PM, Marisol Garcia <(b) (6) frenchangel59.com > wrote: Poonam and David, Laurie and Ike would like to have a call tomorrow morning. Please let me know as soon as possible what time works best: 10:00 AM or 11:00 AM for 45 minutes Participants: Laura Perlmutter, Poonam Alaigh, Secretary Shu/kin, Dr. Bruce Moskowitz, Marc Sherman and Ike Thank you, Marisol VA-19-0799-D-000467 OS 00002133 Message From: Sent: To: CC: Subject: Marisol Garcia [(b) (6) frenchangel59.com] 4/14/2017 8:43:19 PM 'Poonam Alaigh' [(b) (6) hotmail.com] 'David shulkin' [Drshulkin@aol.com]; (b) (6) va.gov RE: Conference call for tomorrow Saturday, April 15, 2017 Thank you - Laurie prefers 10am --David, please let me know. From: Poonam Alaigh [mailto:(b) (6) Sent: Friday, April 14, 2017 4:38 PM To: Marisol Garcia hotmail.com] Cc: David shulkin; (b) (6) va.gov Subject: Re: Conference call for tomorrow Saturday, April 15, 2017 I can make myself available at a time that works for everyone- preferably 9am or later. Thanks Sent from my iPhone On Apr 14, 2017, at 4:33 PM, Marisol Garcia <(b) (6) frenchangel59.com > wrote: Poonam and David, Laurie and Ike would like to have a call tomorrow morning. Please let me know as soon as possible what time works best: 10:00 AM or 11:00 AM for 45 minutes Participants: Laura Perlmutter, Poonam Alaigh, Secretary Shu/kin, Dr. Bruce Moskowitz, Marc Sherman and Ike Thank you, Marisol VA-19-0799-D-000468 OS 00002134 Message From: Yehia, Baligh R. [Baligh.Yehia@va.gov] Sent: 4/17/2017 2:58:08 AM To: 'David Shulkin' [drshulkin@aol.com] RE: [EXTERNAL] Fwd: draft for the choice demonstration pilots Subject: Sounds good. Will do. Sent with Good (www.good.com) -----Original Message----From: David Shulkin [drshulkin@aol.com] Sent: Sunday, April 16, 2017 11 :03 AM Eastern Standard Time To: Y ehia, Baligh R. Subject: [EXTERNAL] Fwd: draft for the choice demonstration pilots A demo as Darin defines might be good but I would like to build into the main legislation as much as we can to allow us to bill for other health insurance and to operate with the same rules as private sector hospitals and systems. Worse case is that it gets taken out. -----Original Message----From: Darin Selnick <(b) (6) @gmail.com> To: David shulkin Sent: Sat, Apr 15, 2017 11 :09 am Subject: Fwd: draft for the choice demonstration pilots FYI Baligh asked me to draft up the ideas from Monday for the pilot demonstration pilots, so I did and sent them to him and Poonam. The draft is rough but it gives the ideas form and structure and we will have the team build upon them so they can be part of the legislation. Hope you are having a good weekend with family. Darin ---------- Forwarded message ---------From: Selnick, Darin Date: Thu, Apr 13, 2017 at 10:31 PM Subject: draft for the choice demonstration pilots To: "Yehia, Baligh R." Cc: "Alaigh, Poonam, M.D.", "(b) (6) k@gmail.com" <(b) (6) @gmail.com> Hi Baligh Attached is the draft I promised on the basics for the demonstration pilots and how conceptually it would all work. I finish it on the plane today. This is just the basics to get it going and we will need to flush it out with the team. Best Darin VA-19-0799-D-000469 OS 00002135 Darin Selnick Senior Advisor to the Secretary Cell 202-390-5845 VA-19-0799-D-000470 OS_00002136 Message From: David Shulkin [drshulkin@aol.com] Sent: To: (b) (6) Subject: Attachments: 4/16/2017 3:03:35 PM gmail.com Fwd: draft for the choice demonstration pilots Community of Care and VAMC Health Care Delivery Modernization.docx please print this attachemnt -----Original Message----From: David Shulkin To: baligh.yehia Sent: Sun, Apr 16, 2017 11 :02 am Subject: Fwd: draft for the choice demonstration pilots A demo as Darin defines might be good but I would like to build into the main legislation as much as we can to allow us to bill for other health insurance and to operate with the same rules as private sector hospitals and systems. Worse case is that it gets taken out. -----Original Message----From: Darin Selnick <(b) (6) @gmail.com> To: David shulkin Sent: Sat, Apr 15, 2017 11 :09 am Subject: Fwd: draft for the choice demonstration pilots FYI Baligh asked me to draft up the ideas from Monday for the pilot demonstration pilots, so I did and sent them to him and Poonam. The draft is rough but it gives the ideas form and structure and we will have the team build upon them so they can be part of the legislation. Hope you are having a good weekend with family. Darin ---------- Forwarded message ---------From: Selnick, Darin Date: Thu, Apr 13, 2017 at 10:31 PM Subject: draft for the choice demonstration pilots To: "Yehia, Baligh R." Cc: "Alaigh, Poonam, M.D.", "(b) (6) k@gmail.com" <(b) (6) @gmail.com> Hi Baligh Attached is the draft I promised on the basics for the demonstration pilots and how conceptually it would all work. I finish it on the plane today. This is just the basics to get it going and we will need to flush it out with the team. Best Darin Darin Selnick Senior Advisor to the Secretary Cell 202-390-5845 VA-19-0799-D-000471 OS 00002137 Community of Care and VAMC Health Care Delivery Modernization Demonstration Pilots Overview of Concept The purpose of the demonstration pilots is to see if VA can operate its healthcare system more effectively both in access and in cost, using the best practices of the TRICARE and the private sector, to improve the delivery of healthcare to veterans. For the demonstration pilots, VHA would separate its payer and provider functions into two different operating units and move them from the existing HMO staff model to a HMO mixed model. A HMO mixed model is when the community care provider network is a combination of delivery systems. The VA demonstration pilots HMO mixed model will offer a wide variety of choices and broad geographic coverage to its veteran's members. Patients will have the choice of VHA and Community Care clinics, labs, pharmacies, and hospitals as their providers of care. In the VA demonstration pilots, the HMO mixed model would be a combination of a the VAMCs and CBOCs operating as a group model accountable care organization, such as the Cleveland Clinic or Kaiser Permanente, and the Community Care operating as a contracted provider network, such as United Healthcare or TRI CARE. Key Components Payer: The VA demonstration payer pilots would be operated as the Veterans Health Plan (VHP). It would have the ability to operate using the best practices from private sector health plans and from government payers. In addition to using the new VA community care RFP, it would have legislative relief from any government contracting and acquisition regulations that would impede its ability to operate and compete with private sector HMO contracted provider networks. Key operating function would include: • Cost mitigation using secondary payer: Like TRICARE, VHP would be secondary payer for all veterans who have other health insurance, including for all service connected and non-service connected services that the OHi would normally pay for as part of its benefits package. The current estimate is that 80% of veterans enrolled in VA healthcare have OHi. This would mean that VHP would pay after all OHi, including all other government and private insurance programs. VHP would be primary payer for any benefits that the veteran would be entitled to as part of the VA healthcare benefit, but is not part of their OHi benefit. • Primary coordinator of benefits: To ensure veterans are not balance billed, VHP would act as the primary coordinator of benefits to ensure veterans are not charged inappropriately by their OHi and would receive an EOB which would list the charges and VA-19-0799-D-000473 OS 00002139 • • what is owed by the veteran. VHP would ensure the veterans OHi would process the providers claim first and be responsible to settle all disputes. Balance billing: By law, VHP like TRICARE would prohibit the practice of balance billing. Balance billing requirements would apply to both network and non-network providers who treat VHP beneficiaries and noncompliance would impact their VHP and/or Medicare, Medicaid or FEHB status. Governance - Board of Directors: An overall board of directors would provide governance and operational oversite for the demonstration pilots. The board would consist of the SECVA, USH, PDUSH, DUSHs, leading healthcare experts, and veteran representation. Provider The VA demonstration provider pilots would be operated as the Veterans Clinic. As the Veterans Clinic, it would be set up and have the ability to operate on a level playing field with private sector provider healthcare organizations. It would be able to use the same best practices that private sector provider accountable care organizations such as the Cleveland Clinic, Mayo Clinic and Kaiser Permanente use It would operate as a not for profit group practice with physician leadership which would be salaried. Its governance would consist of a board of directors. Revenue would come from all payers for all services rendered to its patients, including VHP, all other government payers, and all private coverage. It would have legislative relief from any government personnel, contracting, acquisition, and any other government regulations and rules that would impede its ability to operate and compete with private sector providers. Key operating functions would include: • Governance - Board of Directors: An overall board of directors would provide governance and operational oversite for the demonstration pilots. The board would consist of the SECVA, USH, PDUSH, DUSHs, leading healthcare experts, and veteran representation. The board of director would have oversight from Congress. • Control of facilities and footprint: The board of directors would have complete authority and control over its facilities and footprint. Other governmental agencies and Congress would not be able to block lawful decisions. • Leadership: Each demonstration pilot would have a traditional private sector provider structure headed by a CEO that would report to the board of directors. They would have a 5 year contract but could be terminated by the board due to poor performance. • Revenue: The dollars would follow the patient. Each demonstration pilot would have provider contracts with all payers, including both government (Medicare, Medicaid, FEHB), private sector managed care and commercial. The Veterans Clinics would be reimbursed for all services provided the same as private provider groups. If there is excess capacity each pilot would have the option to open up to non-eligible veterans and family members who would be pay the full premium through their OHi. VA-19-0799-D-000474 OS 00002140 • • • Benefit Package: All eligible veterans would have the same existing benefit package they currently do. VHP would have to pay the gap between what the veteran OHi authorized benefit package and VHP. Non-eligible veterans and families would only be offered services that are 100% paid for by their OHi. Efficiency: All Veterans Clinic would have to operate based on the revenue provided by the payers. It would be expected that they would have to improve their operations to be more efficient to match their revenue. Accountable Care Organization functions: The Veteran Clinics would operate following the primary characteristics of an ACO to include strong primary, specialty and hospital care with effective cost control and quality of care: o Capacity to manage both the cost and quality of health care services under a range of payment systems. o Have comprehensive, valid and reliable performance measurements, make internal system improvements in care quality and externally report on its performance on cost and quality of care o Commitment to achieve quality and cost efficiencies, a physician management structure and a culture that supports and rewards continuous quality improvement. o Use of health information technology to manage patients across the continuum of care and across different institutional settings. Demonstration pilot sites • • Arizona: Senate Sponsor - Senator McCain Washington: House Sponsor- Rep McMorris Rodgers Time Frame • Demonstration pilots would be required to be set up and fully operational within one year after the legislation had been passed by congress and signed by the President. • Demonstration pilots after the one year set up period would run for five years with an automatic five year extension unless congress voted to end the extensions. VA-19-0799-D-000475 OS 00002141 Organizational Structure VHA - Mixed Model Demonstration Pilots (Payer and Provider Organization) VHA Board of Directors SECVA,USH,PDUSH Demonstration Pilots DUSHs, HC experts, Veterans Office VHA Payer Veterans Health Plan Community Care Networks VHA Provider Veteran Clinic VACO VACO , Veteran Clinic Arizona Local -Hospital and Clinics Veteran Clinic Washington Local -Hospital and Clinics Community Care Providers Arizona Washington VA-19-0799-D-000476 OS 00002142 Revenue Flow VHA Revenue (Payer and Provider) Congressional Funding ~-----~ - c:=J VHA VHA Payer Veterans Health Plan OHi Payer Contracts Gov & Private VHA Provider Veteran Clinic National Private Sector Community Care Network Pilot Sites VHA - Veteran Clinic Pilot Regional Area VHA - Veteran Clinic Pilot Local -Hospital and Clinics VA-19-0799-D-000477 OS 00002143 Revenue from Payers Veterans OHi % Mediaaid VHA Payer TBD 100% Services Medicare 51.3% 100% Services Veterans Clinic Federal ACO --------------------- TRICARE 18.5% 100% Services Board of Directors FEHB/ Others TBD% 100% Services VA-19-0799-D-000478 OS 00002144 Message From: David Shulkin [drshulkin@aol.com] Sent: To: 4/16/2017 3:02:51 PM Subject: Attachments: baligh.yehia@va.gov Fwd: draft for the choice demonstration pilots Community of Care and VAMC Health Care Delivery Modernization.docx A demo as Darin defines might be good but I would like to build into the main legislation as much as we can to allow us to bill for other health insurance and to operate with the same rules as private sector hospitals and systems. Worse case is that it gets taken out. -----Original Message----From: Darin Selnick <(b) (6) @gmail.com> To: David shulkin Sent: Sat, Apr 15, 2017 11 :09 am Subject: Fwd: draft for the choice demonstration pilots FYI Baligh asked me to draft up the ideas from Monday for the pilot demonstration pilots, so I did and sent them to him and Poonam. The draft is rough but it gives the ideas form and structure and we will have the team build upon them so they can be part of the legislation. Hope you are having a good weekend with family. Darin ---------- Forwarded message ---------From: Selnick, Darin Date: Thu, Apr 13, 2017 at 10:31 PM Subject: draft for the choice demonstration pilots To: "Yehia, Baligh R." Cc: "Alaigh, Poonam, M.D.", "(b) (6) k@gmail.com" <(b) (6) @gmail.com> Hi Baligh Attached is the draft I promised on the basics for the demonstration pilots and how conceptually it would all work. I finish it on the plane today. This is just the basics to get it going and we will need to flush it out with the team. Best Darin Darin Selnick Senior Advisor to the Secretary Cell 202-390-5845 VA-19-0799-D-000479 OS 00002145 Community of Care and VAMC Health Care Delivery Modernization Demonstration Pilots Overview of Concept The purpose of the demonstration pilots is to see if VA can operate its healthcare system more effectively both in access and in cost, using the best practices of the TRICARE and the private sector, to improve the delivery of healthcare to veterans. For the demonstration pilots, VHA would separate its payer and provider functions into two different operating units and move them from the existing HMO staff model to a HMO mixed model. A HMO mixed model is when the community care provider network is a combination of delivery systems. The VA demonstration pilots HMO mixed model will offer a wide variety of choices and broad geographic coverage to its veteran's members. Patients will have the choice of VHA and Community Care clinics, labs, pharmacies, and hospitals as their providers of care. In the VA demonstration pilots, the HMO mixed model would be a combination of a the VAMCs and CBOCs operating as a group model accountable care organization, such as the Cleveland Clinic or Kaiser Permanente, and the Community Care operating as a contracted provider network, such as United Healthcare or TRI CARE. Key Components Payer: The VA demonstration payer pilots would be operated as the Veterans Health Plan (VHP). It would have the ability to operate using the best practices from private sector health plans and from government payers. In addition to using the new VA community care RFP, it would have legislative relief from any government contracting and acquisition regulations that would impede its ability to operate and compete with private sector HMO contracted provider networks. Key operating function would include: • Cost mitigation using secondary payer: Like TRICARE, VHP would be secondary payer for all veterans who have other health insurance, including for all service connected and non-service connected services that the OHi would normally pay for as part of its benefits package. The current estimate is that 80% of veterans enrolled in VA healthcare have OHi. This would mean that VHP would pay after all OHi, including all other government and private insurance programs. VHP would be primary payer for any benefits that the veteran would be entitled to as part of the VA healthcare benefit, but is not part of their OHi benefit. • Primary coordinator of benefits: To ensure veterans are not balance billed, VHP would act as the primary coordinator of benefits to ensure veterans are not charged inappropriately by their OHi and would receive an EOB which would list the charges and VA-19-0799-D-000480 OS 00002146 • • what is owed by the veteran. VHP would ensure the veterans OHi would process the providers claim first and be responsible to settle all disputes. Balance billing: By law, VHP like TRICARE would prohibit the practice of balance billing. Balance billing requirements would apply to both network and non-network providers who treat VHP beneficiaries and noncompliance would impact their VHP and/or Medicare, Medicaid or FEHB status. Governance - Board of Directors: An overall board of directors would provide governance and operational oversite for the demonstration pilots. The board would consist of the SECVA, USH, PDUSH, DUSHs, leading healthcare experts, and veteran representation. Provider The VA demonstration provider pilots would be operated as the Veterans Clinic. As the Veterans Clinic, it would be set up and have the ability to operate on a level playing field with private sector provider healthcare organizations. It would be able to use the same best practices that private sector provider accountable care organizations such as the Cleveland Clinic, Mayo Clinic and Kaiser Permanente use It would operate as a not for profit group practice with physician leadership which would be salaried. Its governance would consist of a board of directors. Revenue would come from all payers for all services rendered to its patients, including VHP, all other government payers, and all private coverage. It would have legislative relief from any government personnel, contracting, acquisition, and any other government regulations and rules that would impede its ability to operate and compete with private sector providers. Key operating functions would include: • Governance - Board of Directors: An overall board of directors would provide governance and operational oversite for the demonstration pilots. The board would consist of the SECVA, USH, PDUSH, DUSHs, leading healthcare experts, and veteran representation. The board of director would have oversight from Congress. • Control of facilities and footprint: The board of directors would have complete authority and control over its facilities and footprint. Other governmental agencies and Congress would not be able to block lawful decisions. • Leadership: Each demonstration pilot would have a traditional private sector provider structure headed by a CEO that would report to the board of directors. They would have a 5 year contract but could be terminated by the board due to poor performance. • Revenue: The dollars would follow the patient. Each demonstration pilot would have provider contracts with all payers, including both government (Medicare, Medicaid, FEHB), private sector managed care and commercial. The Veterans Clinics would be reimbursed for all services provided the same as private provider groups. If there is excess capacity each pilot would have the option to open up to non-eligible veterans and family members who would be pay the full premium through their OHi. VA-19-0799-D-000481 OS 00002147 • • • Benefit Package: All eligible veterans would have the same existing benefit package they currently do. VHP would have to pay the gap between what the veteran OHi authorized benefit package and VHP. Non-eligible veterans and families would only be offered services that are 100% paid for by their OHi. Efficiency: All Veterans Clinic would have to operate based on the revenue provided by the payers. It would be expected that they would have to improve their operations to be more efficient to match their revenue. Accountable Care Organization functions: The Veteran Clinics would operate following the primary characteristics of an ACO to include strong primary, specialty and hospital care with effective cost control and quality of care: o Capacity to manage both the cost and quality of health care services under a range of payment systems. o Have comprehensive, valid and reliable performance measurements, make internal system improvements in care quality and externally report on its performance on cost and quality of care o Commitment to achieve quality and cost efficiencies, a physician management structure and a culture that supports and rewards continuous quality improvement. o Use of health information technology to manage patients across the continuum of care and across different institutional settings. Demonstration pilot sites • • Arizona: Senate Sponsor - Senator McCain Washington: House Sponsor- Rep McMorris Rodgers Time Frame • Demonstration pilots would be required to be set up and fully operational within one year after the legislation had been passed by congress and signed by the President. • Demonstration pilots after the one year set up period would run for five years with an automatic five year extension unless congress voted to end the extensions. VA-19-0799-D-000482 OS 00002148 Organizational Structure VHA - Mixed Model Demonstration Pilots (Payer and Provider Organization) VHA Board of Directors SECVA,USH,PDUSH Demonstration Pilots DUSHs, HC experts, Veterans Office VHA Payer Veterans Health Plan Community Care Networks VHA Provider Veteran Clinic VACO VACO , Veteran Clinic Arizona Local -Hospital and Clinics Veteran Clinic Washington Local -Hospital and Clinics Community Care Providers Arizona Washington VA-19-0799-D-000483 OS 00002149 Revenue Flow VHA Revenue (Payer and Provider) Congressional Funding ~-----~ - c:=J VHA VHA Payer Veterans Health Plan OHi Payer Contracts Gov & Private VHA Provider Veteran Clinic National Private Sector Community Care Network Pilot Sites VHA - Veteran Clinic Pilot Regional Area VHA - Veteran Clinic Pilot Local -Hospital and Clinics VA-19-0799-D-000484 OS 00002150 Revenue from Payers Veterans OHi % Mediaaid VHA Payer TBD 100% Services Medicare 51.3% 100% Services Veterans Clinic Federal ACO --------------------- TRICARE 18.5% 100% Services Board of Directors FEHB/ Others TBD% 100% Services VA-19-0799-D-000485 OS 00002151 Message From: Darin Selnick [(b) (6) Sent: To: 4/15/2017 3:09:35 PM Subject: Attachments: @gmail.com] David shulkin [Drshulkin@aol.com] Fwd: draft for the choice demonstration pilots Community of Care and VAMC Health Care Delivery Modernization.docx FYI Baligh asked me to draft up the ideas from Monday for the pilot demonstration pilots, so I did and sent them to him and Poonam. The draft is rough but it gives the ideas form and structure and we will have the team build upon them so they can be part of the legislation. Hope you are having a good weekend with family. Darin ---------- Forwarded message---------From: Selnick, Darin Date: Thu, Apr 13, 2017 at 10:31 PM Subject: draft for the choice demonstration pilots To: "Yehia, Baligh R." Cc: "Alaigh, Poonam, M.D." , "(b) (6) <(b) (6) k@gmail .com> @gmail.com" Hi Baligh Attached is the draft I promised on the basics for the demonstration pilots and how conceptually it would all work. I finish it on the plane today. This is just the basics to get it going and we will need to flush it out with the team. Best Darin Darin Selnick Senior Advisor to the Secretary Cell 202-390-5845 VA-19-0799-D-000486 OS 00002152 Community of Care and VAMC Health Care Delivery Modernization Demonstration Pilots Overview of Concept The purpose of the demonstration pilots is to see if VA can operate its healthcare system more effectively both in access and in cost, using the best practices of the TRICARE and the private sector, to improve the delivery of healthcare to veterans. For the demonstration pilots, VHA would separate its payer and provider functions into two different operating units and move them from the existing HMO staff model to a HMO mixed model. A HMO mixed model is when the community care provider network is a combination of delivery systems. The VA demonstration pilots HMO mixed model will offer a wide variety of choices and broad geographic coverage to its veteran's members. Patients will have the choice of VHA and Community Care clinics, labs, pharmacies, and hospitals as their providers of care. In the VA demonstration pilots, the HMO mixed model would be a combination of a the VAMCs and CBOCs operating as a group model accountable care organization, such as the Cleveland Clinic or Kaiser Permanente, and the Community Care operating as a contracted provider network, such as United Healthcare or TRI CARE. Key Components Payer: The VA demonstration payer pilots would be operated as the Veterans Health Plan (VHP). It would have the ability to operate using the best practices from private sector health plans and from government payers. In addition to using the new VA community care RFP, it would have legislative relief from any government contracting and acquisition regulations that would impede its ability to operate and compete with private sector HMO contracted provider networks. Key operating function would include: • Cost mitigation using secondary payer: Like TRICARE, VHP would be secondary payer for all veterans who have other health insurance, including for all service connected and non-service connected services that the OHi would normally pay for as part of its benefits package. The current estimate is that 80% of veterans enrolled in VA healthcare have OHi. This would mean that VHP would pay after all OHi, including all other government and private insurance programs. VHP would be primary payer for any benefits that the veteran would be entitled to as part of the VA healthcare benefit, but is not part of their OHi benefit. • Primary coordinator of benefits: To ensure veterans are not balance billed, VHP would act as the primary coordinator of benefits to ensure veterans are not charged inappropriately by their OHi and would receive an EOB which would list the charges and VA-19-0799-D-000488 OS 00002154 • • what is owed by the veteran. VHP would ensure the veterans OHi would process the providers claim first and be responsible to settle all disputes. Balance billing: By law, VHP like TRICARE would prohibit the practice of balance billing. Balance billing requirements would apply to both network and non-network providers who treat VHP beneficiaries and noncompliance would impact their VHP and/or Medicare, Medicaid or FEHB status. Governance - Board of Directors: An overall board of directors would provide governance and operational oversite for the demonstration pilots. The board would consist of the SECVA, USH, PDUSH, DUSHs, leading healthcare experts, and veteran representation. Provider The VA demonstration provider pilots would be operated as the Veterans Clinic. As the Veterans Clinic, it would be set up and have the ability to operate on a level playing field with private sector provider healthcare organizations. It would be able to use the same best practices that private sector provider accountable care organizations such as the Cleveland Clinic, Mayo Clinic and Kaiser Permanente use It would operate as a not for profit group practice with physician leadership which would be salaried. Its governance would consist of a board of directors. Revenue would come from all payers for all services rendered to its patients, including VHP, all other government payers, and all private coverage. It would have legislative relief from any government personnel, contracting, acquisition, and any other government regulations and rules that would impede its ability to operate and compete with private sector providers. Key operating functions would include: • Governance - Board of Directors: An overall board of directors would provide governance and operational oversite for the demonstration pilots. The board would consist of the SECVA, USH, PDUSH, DUSHs, leading healthcare experts, and veteran representation. The board of director would have oversight from Congress. • Control of facilities and footprint: The board of directors would have complete authority and control over its facilities and footprint. Other governmental agencies and Congress would not be able to block lawful decisions. • Leadership: Each demonstration pilot would have a traditional private sector provider structure headed by a CEO that would report to the board of directors. They would have a 5 year contract but could be terminated by the board due to poor performance. • Revenue: The dollars would follow the patient. Each demonstration pilot would have provider contracts with all payers, including both government (Medicare, Medicaid, FEHB), private sector managed care and commercial. The Veterans Clinics would be reimbursed for all services provided the same as private provider groups. If there is excess capacity each pilot would have the option to open up to non-eligible veterans and family members who would be pay the full premium through their OHi. VA-19-0799-D-000489 OS 00002155 • • • Benefit Package: All eligible veterans would have the same existing benefit package they currently do. VHP would have to pay the gap between what the veteran OHi authorized benefit package and VHP. Non-eligible veterans and families would only be offered services that are 100% paid for by their OHi. Efficiency: All Veterans Clinic would have to operate based on the revenue provided by the payers. It would be expected that they would have to improve their operations to be more efficient to match their revenue. Accountable Care Organization functions: The Veteran Clinics would operate following the primary characteristics of an ACO to include strong primary, specialty and hospital care with effective cost control and quality of care: o Capacity to manage both the cost and quality of health care services under a range of payment systems. o Have comprehensive, valid and reliable performance measurements, make internal system improvements in care quality and externally report on its performance on cost and quality of care o Commitment to achieve quality and cost efficiencies, a physician management structure and a culture that supports and rewards continuous quality improvement. o Use of health information technology to manage patients across the continuum of care and across different institutional settings. Demonstration pilot sites • • Arizona: Senate Sponsor - Senator McCain Washington: House Sponsor- Rep McMorris Rodgers Time Frame • Demonstration pilots would be required to be set up and fully operational within one year after the legislation had been passed by congress and signed by the President. • Demonstration pilots after the one year set up period would run for five years with an automatic five year extension unless congress voted to end the extensions. VA-19-0799-D-000490 OS 00002156 Organizational Structure VHA - Mixed Model Demonstration Pilots (Payer and Provider Organization) VHA Board of Directors SECVA,USH,PDUSH Demonstration Pilots DUSHs, HC experts, Veterans Office VHA Payer Veterans Health Plan Community Care Networks VHA Provider Veteran Clinic VACO VACO , Veteran Clinic Arizona Local -Hospital and Clinics Veteran Clinic Washington Local -Hospital and Clinics Community Care Providers Arizona Washington VA-19-0799-D-000491 OS 00002157 Revenue Flow VHA Revenue (Payer and Provider) Congressional Funding ~-----~ - c:=J VHA VHA Payer Veterans Health Plan OHi Payer Contracts Gov & Private VHA Provider Veteran Clinic National Private Sector Community Care Network Pilot Sites VHA - Veteran Clinic Pilot Regional Area VHA - Veteran Clinic Pilot Local -Hospital and Clinics VA-19-0799-D-000492 OS 00002158 Revenue from Payers Veterans OHi % Mediaaid VHA Payer TBD 100% Services Medicare 51.3% 100% Services Veterans Clinic Federal ACO --------------------- TRICARE 18.5% 100% Services Board of Directors FEHB/ Others TBD% 100% Services VA-19-0799-D-000493 OS 00002159 Message From: Sent: To: Subject: Attachments: David Shulkin [drshulkin@aol.com] 4/16/2017 1:21:17 PM (b) (6) gmail.com early draft for april 25th april25thtoppriorities.pptx There is still more to work on but so far this is what I have if we want to begin to work from this VA-19-0799-D-000494 OS 00002160 , IA V'"' I U.S. Department ofVeterans Affairs 5 Things We Need From Leadership and 5 Priorities for VA David J. Shulkin, MD Secretary of Veterans Affairs April 19, 2017 VA-19-0799-D-000495 OS 00002161 1. 38 Don't Plan for Incremental Change ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000496 OS 00002162 Events at the DC VA Acting Decisively Draft/ Pre-dec1s1onal / For Internal VA Use Only 3 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000497 OS 00002163 2- 4 Run Towards the Gun Fire ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000498 OS 00002164 Making Tough Decisions 5 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000499 OS 00002165 United's Response Ill r'::itertJayseDavid 4:51 PM ET UNITED DRAGS PASSENGER FROM OVERBOOKED FLIGHT THE LEAD Draft/ Pre-dec1s1onal / For Internal VA Use Only 6 ,1A V'"'- I ~ \ ~!,I 1 US l)ppartmcnl ofVcLcrar1s Mfa ,rs VA-19-0799-D-000500 OS 00002166 3. 7 Demonstrate Your Commitment to the Mission ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000501 OS 00002167 From: Inc. United Airlines To: Vet eran Sm ith Important update about your checked baggage Today at 9:09 AM We're sorry, but your checked bag will arrive on a later fl ight to Philadelph ia. When you arrive, please see a Baggage Service representative in Baggage Claim to arrange your choice of delivery or pickup. We apologize for this disruption to your plans today. VA-19-0799-D-000502 OS 00002168 4. Focus On Your People I,_ My VA Organizational Hicrard1y _ ~ • .._ ( ., ~ Dr D111ld Shulkln, VA Under Se wrote: David, please see below- they need me to be the project sponsor in order to move forward in the direction below. I am getting a little concerned especially if we don't have a clear path- I think the team needs to meet with you and we should meet with the WH again soon to ensure we have all synced up. Also, they need a finance person on the team now- should I get Mark Yow involved or do you want someone from Ed Murrays area? Sent from my iPad Begin forwarded message: From: "Alaigh, Poonam, M.D." Date: April 13, 2017 at 8:57:58 PM EDT To: 'Poonam Alaigh' <(b) (6) hotmail.com> Subject: FW: EHRM team. Sent with Good (www.good.com) -----Original Message----(b) (6) From: (b) (6) J., Jr. Sent: Thursday, April 13, 2017 08:54 PM Eastern Standard Time To: Alaigh, Poonam, M.D. Subject: EHRM team. All, and I met with Dr. Alaigh this evening and I was given clear marching efforts to (b) (6) quickly and quietly usher our EHR Modernization effort with the DoD forward. (b) (6) and I sat down with (b) (6) on the phone to outline our key deliverables and dates, building from the schedule (b) (6) established. This email outlines our roles and responsibilities in the near term. EHRM Project Sponsor - Dr. Alaigh Team Lead-(b) (6) Clinical - (b) (6) VA-19-0799-D-000521 OS 00002187 OI&T-TBA (Dr. Alaigh requested from OI&T 4-13) Legal - (b) (6) & (b) (6) Contracts - (b) (6) (b) (6) David, (b) (6) and (b) (6) Engineering - Digital Service Financial & Appropriation - TBD (request from Dr. Alaigh 4-13) Conununications - via existing Mitre contract and VA Front office I believe the following deliverables and dates are achievable, let's discuss on our daily call: Deliverables: Draft Due Final Due Apr 18 Apr 21 D&F - (b) (6) PWS - OI&T & (b) (6) (DS) Apr 20 Apr26 IGCE - (b) (6) Apr 20 Apr26 RTM-(b) (6) Apr 20 Apr26 Station Code (aka MTF Codes - OIT lead & (b) (6) Apr 20 Apr26 Apr 21 Action Memo - (b) (6) Apr 18 Apr26 Financial Budget & Appropriations Language Changes Apr 20 Acquisition Strategy - (b) (6) (if required) Tomorrow morning I have a meeting with DoD' s Program Executive Officer Stacy Cummings. I have asked (b) (6) and (b) (6) to dial into that call. I will send out a standing daily Team Call for our synchronization for 1PM EDT. Upcoming Key Events: D&F Signed Team Lock Down Vendor Meeting & PWS Review Site Visit - VAMC NY Site Visit - VAMC Philly Congressional Notification White House Public Announcement Apr 21 Apr 24 & 25 - TAC Apr26 Apr27 Apr28 Apr24 May 15 Please let me know if I missed anything or we need to discuss further. Finally, I came to the VA just over a year ago to work on modernizing our EHR. This vision is quickly becoming a reality. It is both an honor and privilege to be working with such an esteemed TEAM on this incredibly important project for the VA and our Veterans. Warm regards, (b) (6) Program Executive for EHR Modernization - 703-587-(b) (6) (b) (6) VA-19-0799-D-000522 OS 00002188 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) 4/14/2017 1:05:28 AM Drshulkin@aol.com Fwd: EHRM team. hotmail.com] David, please see below- they need me to be the project sponsor in order to move forward in the direction below. I am getting a little concerned especially if we don't have a clear path- I think the team needs to meet with you and we should meet with the WH again soon to ensure we have all synced up. Also, they need a finance person on the team now- should I get Mark Yow involved or do you want someone from Ed Murrays area? Sent from my iPad Begin forwarded message: From: "Alaigh, Poonam, M.D." Date: April 13, 2017 at 8:57:58 PM EDT To: 'Poonam Alaigh' <(b) (6) hotmail.com> Subject: FW: EHRM team. Sent with Good (www.good.com) -----Original Message----(b) (6) From: (b) (6) J., Jr. Sent: Thursday, April 13, 2017 08:54 PM Eastern Standard Time To: Alaigh, Poonam, M.D. Subject: EHRM team. All, and I met with Dr. Alaigh this evening and I was given clear marching efforts to quickly and quietly (b) (6) usher our EHR Modernization effort with the DoD forward. (b) (6) and I sat down with (b) (6) on the phone to outline our key deliverables and dates, building from the schedule (b) (6) established. This email outlines our roles and responsibilities in the near term. EHRM Project Sponsor - Dr. Alaigh Team Lead-(b) (6) Clinical - (b) (6) OI&T-TBA (Dr. Alaigh requested from OI&T 4-13) Legal - (b) (6) & (b) (6) Contracts - (b) (6) (b) (6) David, (b) (6) and (b) (6) Engineering - Digital Service Financial & Appropriation - TBD (request from Dr. Alaigh 4-13) Communications - via existing Mitre contract and VA Front office I believe the following deliverables and dates are achievable, let's discuss on our daily call: Deliverables: Draft Due Final Due Apr 21 D&F - (b) (6) Apr 18 PWS- OI&T & (b) (6) (DS) Apr 20 Apr 26 VA-19-0799-D-000523 OS 00002189 IGCE - (b) (6) Apr 20 Apr26 RTM-(b) (6) Apr 20 Apr26 Station Code (aka MTF Codes - OIT lead & (b) (6) Apr 20 Apr 21 Action Memo - (b) (6) Apr 18 Financial Budget & Appropriations Language Changes Apr 20 Acquisition Strategy - (b) (6) (if required) Apr26 Apr26 Tomorrow morning I have a meeting with DoD' s Program Executive Officer Stacy Cummings. I have asked and (b) (6) to dial into that call. (b) (6) I will send out a standing daily Team Call for our synchronization for 1PM EDT. Upcoming Key Events: D&F Signed Team Lock Down Vendor Meeting & PWS Review Site Visit - VAMC NY Site Visit - VAMC Philly Congressional Notification White House Public Announcement Apr21 Apr 24 & 25 - TAC Apr26 Apr27 Apr28 Apr24 May 15 Please let me know if I missed anything or we need to discuss further. Finally. I came to the VA just over a year ago to work on modernizing our EHR This vision is quickly bec01ning a reality. It is both an honor and privilege to be working with such an esteemed TEAM on this incredibly important project for the VA and our Veterans. Warm regards, (b) (6) Program Executive for EHR Modernization - 703-587-(b) (6) (b) (6) VA-19-0799-D-000524 OS 00002190 Message From: (b) (6) Sent: To: 4/13/2017 7:01:06 PM David Shulkin [drshulkin@aol.com] Fwd: Re: draft for studer group 2017 04 19-3 HURON CEO FORUM.pptx; 2017 04 19 Huron (Studer) CEO Forum Audience Analysis.docx Subject: Attachments: [(b) (6) Here is a copy of the slides to review ---------- Forwarded message---------From: "Brian Mitchell" <(b) (6) Date: Apr 13, 2017 2:52 PM Subject: Re: draft for studer group To: "(b) (6) <(b) (6) Cc: gmail.com] gmail.com> gmail .com>, "(b) (6) <(b) (6) gmail .com> (b) (6) Here are the Huron slides, 51 in all, plus an audience analysis with most of what he'll need to know (bios, guest list). I'll be out on leave for Easter tomorrow and Monday, in church and unavailable for work most of the time. Al will be in tomorrow, and Ed and (b) (6) will be back Monday. I don't expect there will be much more work for them to do. But someone will need to make the slides available to Nushin before Wednesday (possibly by posted them on our FTP) and send (b) (6) the suggested questions for the Q&A, once the Secretary OK's them. Happy Easter. Brian On Mon, Apr 10, 2017 at 5:40 PM, (b) (6) I <(b) (6) gmail.com> wrote: I Hi Brian, here is the deck the Secretary wants to use for the Studer CEO speech. The slide that says "VA is leading in Many areas", he would like to develop that slide a little bit more and get more input from the Under Secretaries and Deputy Under Secretaries. VA-19-0799-D-000525 OS 00002191 , IA V'"' I U.S. Department ofVeterans Affairs Lessons from the U.S. Department of Veterans Affairs David J. Shulkin, MD Secretary of Veterans Affairs April 19, 2017 VA-19-0799-D-000526 OS 00002192 2 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000527 DS_ 00002193 High Performing Organizations ~ y ' -,--~· ~- - '-.,.,__·~ , High - ~ ~ Performance Organization ~ ""'! Technical Competence 11 : 3 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000528 OS 00002194 Share Your Journey ~ ~• ~ , ' + ' k t~...._,,._: ..J ...,1, ~IS I ....,!'\Cd ~ c.fl-00 ··-----·- ..._., 'f" C, (S a.. ~tr.;. ' 4ood i ~,_,Ult.d- t-:M,-trh.aN ' i. .... _ ~································-············· ,OI" ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000529 OS 00002195 Living With Purpose Is More Rewarding Than Meandering Around .----------~ 5 -~er~--~- ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000530 OS 00002196 Paying Attention to Culture 'Final Salute' honors Holocaust survivor, Veteran 6 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000531 OS 00002197 Connect with Culture by Getting Out of the Office 7 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000532 OS 00002198 Learn Medicine on the Ski Slopes 8 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000533 OS 00002199 V A's Definition of Health Private Sector Peer Support 9 Ve erans Health Administration X Crisis Lines X Tra nsportation X Caregivers X Homelessness Services X Med ication Support X Behaviora l Hea lt h Integration X Aligned Incentives X Lifelong Relationships X Single EMR Pla t form X Works wit h Most Lead ing Med ica l Centers X Vocat iona l Support X ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa1r~ VA-19-0799-D-000534 OS 00002200 Leaders Ask the Right Questions Two Things Every Leader Needs to Know: • Am I pushing too hard or not hard enough? • What don't I know that is likely to damage the organization? 10 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000535 OS 00002201 600,000 11 Veterans "Waiting for Care? ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000536 OS 00002202 Focus on -What's Important 12 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000537 OS 00002203 Set Big Goals you ave a nee or primary or mental health care right away, you can have it addressed ttie same day during regular business hours. ~ //~Y.~!!;5!!~ The tools you want for the care you need! ~fMQ'~ffi -~.["15"""1 ··~ •dMffborl•eOf" "'"'"" Ulyo1r'N:l•~ KUlthTHmMlflqt('ST~fti wb11nb~ ra1t f(t y,<££ 20,710 20,000 32 119 31,505 ,.,,.-· _ 16,220 10,000 o 2010 + Total Homeless Veterans 17 2011 2012 e 2013 Sheltered Veterans 2014 2015 Unsheltered Veterans ,1A VI-I. I ~ \ ~!/ 1 ' ' ' US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000542 OS 00002208 Focus On Our People I,_ My VA Organizational Hicrard1y _ ~ • .._ ( ., ~ Dr D111ld Shulkln, VA Under Se to lhO ~ n e y room V"1 ambullnc fromtt,eVA'$ car~ . .,,10Ch d abotJ1 a fM!>fl'lll'IUte wa ftotfl lhe ER. -0•o ~ . . -.... a SOl.#iCt•~rrv 25 ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ This slide and the next two are examples of the services VA provides that the private sector often doesn't. VA-19-0799-D-000550 OS 00002216 Choose the Harder Right Over the Easier "Wrong lij;lliS:::-::;i;::;:~~ID"""""'~r.--""!:"ll..,,,, 26 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000551 OS 00002217 Walking the Talk: Practicing in NY and Oregon 27 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000552 OS 00002218 Leaders Propose Solutions Rather Than Criticize PROPOSE Tl-IE SOLUTION 28 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000553 OS 00002219 Get People To Be Part of the Solution 29 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000554 OS 00002220 Challenge the Status Quo 38 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000555 OS 00002221 To Modernize, First Understand History 31 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000556 OS 00002222 VA Innovations Nicotine Patches First Liver Transplant Barcoding of Medications Cardiac Pacemaker 3 Nobel Prizes 32 Artificial Kidney CT Scanner ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000557 OS 00002223 Center for Compassionate Innovation To enhance Veterans health and well-being by offering safe and ethical therapies after traditional treatments have not been successful The Power of U._S. Department of Veterans Affairs COMPASSION 41 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000558 OS 00002224 Making Tough Decisions 34 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000559 OS 00002225 APRNS - 37 300,000 Comments ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000560 OS 00002226 Effective Organizations Break Down Silos 36 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000561 OS 00002227 Don't Take No For An Answer 38 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000562 OS 00002228 "It takes an Act of Congress" 36 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000563 OS 00002229 ~ NOTICE 1-48 Visiting Hours - Unlimited - 39 , IA VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000564 OS 00002230 VA is Leading In Many Areas "Hospital-acquired infection is one of the country's leading causes of death, killing 75,000 people per year - more than car accidents and breast cancer combined. Yet hospitals have only started to take prevention seriously in the last decade, most in the last five years. "One hospital group, however, has done more than all others. It's not the Mayo Clinic's hospitals, nor the Cleveland Clinic's, nor Kaiser Permanente, nor Sutter, nor Geisinger. These are all hospital chains known for their quality, but another big name leaves them in the dust: the \I.A." Tina Rosenberg The New York Times 40 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000565 OS 00002231 Safety and Clinical Outcomes JAMA, February 2015 : 30-day risk-adjusted mortality rates lower than those of non-VA hospitals for acute myocardial infarction and heart failure. American Journal of Infection Control: In five years, MRSA infections declined 81% in VA Spinal Cord Injury units (AJIC May 2013) 69% in VA Acute Care facilities (AJIC Nov 2013) 36% in VA Community Living Centers (AJIC Jan 2014) The Independent Assessment: VA performed the same or significantly better than non-VA providers on 12 of 14 effectiveness measures in the inpatient setting, significantly better on 16 outpatient HEDIS measures compared with commercial HMOs, and significantly better on 15 outpatient HEDIS measures compared with Medicare HMOs. A 2015 study published in the Psychiatric Services: VA mental health care was better than private-sector care by at least 30 percent on all seven performance measures, with VA patients with depression more than twice as likely as private-sector patients to get effective long-term treatment. A 2015 UC Davis study: Outcomes for VA patients compared favorably to patients with non-VA health insurance, with VA patients more likely to receive recommended evidence-based treatment. 41 ,1A VI-I. I ~ \ ~!/ 1 US D<"partmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000566 OS 00002232 Reduction in Opioid Use Overall opioid use: Benzo co-prescribing: 420,000 395,00J High dose: ~qooo 345,00J ~qooo 295,00J nqooo £ ~ 42 E B Annual drug screening: 86% 8 8 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ Decline in Veterans on long-term opioid therapy, 40 FY 2012 to 10 FY 2017. Overall opioid use down 31% in the same period. VA-19-0799-D-000567 OS 00002233 Our Pharmacy Is Best in Class J.D. Power's Mail Order Pharmacy Overall Satisfaction Department of Veterans Affairs 871 Kaiser Perm. Mail Pharmacy Humana RightSourceRX Walgreens Mail Service 822 Mail Order Average 800 43 820 840 860 880 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000568 OS 00002234 Population-based Hepatitis C treatment 86,000 Veterans treated 77,400 cured 90% cure rate 2,000 treated each month Poised to eliminate Hep C among Veterans in 2 Years 44 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ Decline in Veterans on long-term opioid therapy, 40 FY 2012 to 10 FY 2017. Overall opioid use down 31% in the same period. VA-19-0799-D-000569 OS 00002235 Specialists in Our Foundational Services 45 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000570 OS 00002236 Veterans Crisis Line • 2.8 million calls answered since inception in 2007 • 2,000 life-changing calls answered daily • 60 dispatches for emergency services daily • 463,000 referrals made to local suicide prevention coordinators • calls rolled over to back-up centers cut from 3,000 in October to under 60 in January. • Roll-over rate since January: Less than one percent. 46 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000571 OS 00002237 Innovative Research REUTERS ,_ _,_,. II •••MUI "'· _,, ,oun,:s 1ta Together we can achieve 9reat things _,, -- =:::= - - ~ . - . ... , -,.y ==- " - ,n ,c1,-1 -.UO • l ....,,:- - D> PNC Top 25 Global Innovators - Government M12 U.S. Department of Veterans A ffa i rs USA 0 0 0 Almost 10,000 peerreviewed studies published last year: 1,800 on Access 577 on PTSD 386 on Suicide 230 on TBI x._l1n1t/" XFlNITYI' X1 Double Play • $680 million on research "Nl'Mfwl"""""'-..-IV•111a..-.........i~at1Nl.l,_ il'l""'-'IWl---"-C.-.-,b\J$ .,...,._ M""'"9&V~po-l\!'..-.;.;m_,~ - ~ - - - · - - .. -<11 ... 47 _,_.,_ICIIOlle-ocmUllno) ••---- - i _,......,v_...,,_•....,•-••-----4 ,l -{;;·· -::.:::-..:::.::="..:.-.::..··-:.":-• -- J ,._ .; --·-- -=-,.} _j~_~;__ ~ ~:- --: :: ":' ! :r' ■ 1 . - ·l'lo_._._,,_.,..,_ _ _,_..,./lo<, _ __,... ...,,.. .... _.,.., _ _ _,, •• .....,..,. ••• ~-_. .. ..,__,ci..,.._y,,,,,.,v-•-»c.. .,,..c_....,. - " - 0 • ~-r -- -,----- ~ "_:~, · ;.: -,--• -- ~ ..,.,_._.,.,, 48 ,1A VI-I. I ~ =-=:=--,,.__,,,, .-·~~~"".. _,..,_ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000573 OS 00002239 Largest Educator of Health Professionals • Over 1,800 academic and institutional partners • 120,000 healthcare workers trained each year: ~60,000 medical students and residents ~30,000 nursing students ~30,000 students in other health fields • An estimated 70% of all U.S. doctors have trained with VA. 49 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000574 OS 00002240 The Secretary's 5 Priorities 1. Greater Choice for Veterans 4. Improve Timeliness of Services Redesign the 40/30 Rule - Access to Care and Wait Times Build a High-Performing Integrated Network of Care - Decisions on Appeals Empower Veterans through transparency of information - Performance on Disability Claims 2. Modernize our Systems - Infrastructure Improvements and Streamlining - EMR Interoperability and IT Modernization 5. Suicide Prevention Getting to Zero 3. Focus Resources More Efficiently - Strengthening of Foundational Services in VA - VA/DOD/Community Coordination Deliver on Accountability and Effective Management practices 50 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000575 OS 00002241 51 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000576 OS 00002242 Huron CEO Forum Sofitel, Washington, DC April 19, 2017 Huron is a global professional services firm committed to achieving sustainable results in partnership with our clients. We bring a depth of expertise in strategy, operations, advisory services, technology and analytics to drive lasting and measurable results in the healthcare, higher education, life sciences and commercial sectors. Through focus, passion and collaboration, Huron provides guidance to support organizations as they contend with the change transforming their industries and businesses. • The audience will consist of 32 healthcare CEOs (see list below), plus a dozen or so Huron managers. • Huron Managers (b) (6) • (b) (6) • You will speak from a podium with a Lavalier mic and confidence monitor. • You have been allotted one hour (3:45 to 4:45) for remarks and Q&A with CEO, Carilion Clinic in Roanoke, VA and (b) (6) will meet you upon your arrival. Huron Managing Director, will introduce you. See bio below. (b) (6) Run of Show: 3:30-3:45 3:45-4:45 5:00 Break You speak and then answer questions Program ends VA-19-0799-D-000577 DS 00002244 (b) (6) Managing Director, Huron Consulting, has more than 26 years of experience helping large health systems, academic medical centers, children's hospitals and large physician groups to substantially improve their operational and financial performance. (b) (6) is a member of the Huron Healthcare senior executive team, providing leadership for the strategic direction and operations of the practice. His leadership role includes responsibility for strategy, marketing, and strategic relationships in addition to his role leading large, complex client engagements. (b) (6) In 1995, (b) (6) joined Stockamp & Associates, which was acquired by Huron Consulting Group in 2008, and held various leadership positions within Stockamp over his 15 years with the company. Prior to joining Stockamp, (b) (6) had a successful nine-year consulting career at Boaz Allen & Hamilton and at Accenture. Prior to leading the Strategy, Marketing and Sales operations at Stockamp, (b) (6) led the firm's Western U.S. operations. In this role he had overall responsibility for Stockamp's client engagements, client relationships, strategic sales pursuits and strategy in the western half of the United States. (b) (6) has worked with over 100 hospitals, health systems and academic medical centers, helping them to realize millions of dollars in financial benefits and implementing improvements in healthcare operations and IT-enabled solutions. He has a BS in economics from Oregon State University. (b) (6) President and CEO of Carilion Clinic, a notfor-profit healthcare organization based in Roanoke, Va., providing care close to home for nearly 1 million Virginians. (b) (6) Born at Roanoke Memorial Hospital, Ms. (b) (6) began her career in nursing in the early 1970s, serving in various management roles over the years. In 1996, she was appointed vice president and gradually assumed increasing administrative and executive leadership roles at Carilion. As Executive Vice President and Chief Operating Officer from 2001 to 2011 , Ms. (b) (6) was at the forefront of the successful initiative to reorganize Carilion into a patientcentered, physician-led clinic. She supports many professional and community activities including board positions for The American Hospital Association, The Joint Commission, Virginia Hospital and Healthcare Association, Virginia Center for Health Innovation, Roanoke Gas Company, HomeTown Bank, Virginia Tech Carilion School of Medicine, Rockingham Mutual Insurance Co. and the Taubman Museum of Art. Previously, Ms. (b) (6) served on the Radford University Board of Visitors. Ms. (b) (6) and her husband, (b) (6) have one son, (b) (6) VA-19-0799-D-000578 DS 00002245 Registered Attendees (b) (6) (b) (6) (b) (6) (b) (6) SoutheastHEAL TH Sentara Healthcare CHI St. Luke's Health VCU Health FMOL Health System Hartford HealthCare Woman's Hospital UI Health UW Medicine Benefis Health System Atlantic Health System Northwestern Memorial HealthCare Holyoke Medical Center Spartanburg Regional Healthcare System, Apella Health, and Guardian Research Network Hartford HealthCare Virginia Mason Medical Center Sentara Healthcare Mosaic Life Care Carle Health System TBD Visiting Nurse Service of New York Dignity Health UNC Hospitals NA Navicent Health Bon Secours Health System Orlando Health, Inc. Marshfield Clinic Health System, Inc. NEW VA-19-0799-D-000579 DS 00002246 Message From: Sent: To: Subject: Attachments: David Shulkin [drshulkin@aol.com] 4/8/2017 8:14:57 PM (b) (6) gmail.com draft for studer group studer2017.pptx VA-19-0799-D-000580 OS 00002247 Lessons from the US Department of Veterans Affairs David J. Shulkin MD The 9th Secretary of US Department of Veterans Affairs VA-19-0799-D-000581 OS 00002248 fly/VA FULFILLING OUR MISSION WE SERVE ALL WHO SERVED. VA 11mm ~ c.' . :-~ High-Performance Organization . High , . Performance ' Organization •••• Technical Competence - - Ii -- - - - - - - - - J - - - Purpose, Values & Principles - - - - - - - - - - - - - - I ~ VA-19-0799-D-000583 OS 00002250 Share YourJourney Living with purpose is more rewarding than meandering around Pay Attention to Culture 'i,,1/n,~ -..all"' a holl••cry fm 1/u! m~u:al•rnrgrM/j!oo~ ar ,_,,w,/1 F !l('Cfl,r the t,;,,Jy ufH,:,/o.;;m-,/ .,...,,._., .,.., ""'' Kor,,an m,, Air !•1) 1-.:,: Vi,,..,un f'.o~I A J';(l<'WICZ ..-, I;,.- -.. h.•~/~,J w rhr devaw-,· {l'h<,rcn by 1n.·~c,r&~ la) VA-19-0799-D-000586 OS 00002253 Understand Culture By Getting Out of the Office Learning Medicine on the Ski Slopes VA's Definition of Health Pnvate Sector Veterans Health Admin1strat1on Peer Support X Crisis Lines X Transportation X Caregivers X Homelessness Services X Medication Support X Behavioral Health Integration X Aligned Incentives X Lifelong Relationships X Single EMR Platform X Works with Most Leading X Medical Centers Vocational Support X VA-19-0799-D-000589 OS 00002256 Ask the Right Questions Two Things Every Leader Needs to Know • Am I pushing too hard or am I not pushing hard enough? • What don't I know that is likely to damage the organization? VA-19-0799-D-000590 OS 00002257 Asking About 600,000 Veterans Waiting for Care --, ....amw.. ~ - - -~ VETERANS WAITING FOR CARE VA-19-0799-D-000591 OS 00002258 FOCUS ON WHAT IS IMPORTANT IQI [Jim Set Big Goals you ave a need or primary or mental health care right away, you can have it addressed tile same day during regular business hours. ~ - -it&;!!<,. 1 ~ y Y.~ !~ The tools you want for the care you need! .,_ ~rwcyautti aad1tNl1ori111:« Ul)Vlr,ACT«,..,.,. KUIUITt1m-criQttS1bns «hl'inl:inNbon Ta.ct to your ,atlfflr Al1gne4 (on Team (PAGJ orrorn Metttal Health ream to l«lrn abotitfOCJt optJoM NJJl ri mHfl11rr-«f.nrnrP wlH,,n..,N fN>ffl It. VA-19-0799-D-000593 OS 00002260 .... ·- ·· MMkal Gro ■ p Will your doctor see you at 3 am? Open 24 hours a day. Every day. Beth Israel Medical Group 23rd Street and 7th Avenue VA-19-0799-D-000594 OS 00002261 Run Towards the GunFire Be Present Decline in Homelessness 80,000 ~ 037 70,000 65,455 60,579 60,000 55,61' - 50,000 40,000 _ 47,725 ~ 43,437 40,033 35,143 34,909 32,119 30,650 30,000 25,422 31,505 25,436 20,710 20,000 1-1,57 _ 16,220 10,000 2010 ♦ 17 Total Homeless Veterans 20 12 20 11 • 2013 Sheltered Veterans 20 14 • 20 15 Unsheltered Veterans ' ' ' VA-19-0799-D-000597 OS 00002264 ~ Focus on Our People My VA Organizational Hierarchy _,'.'. ll\s VAP E . , a.t>Sd>nlU•• . ~ :t~ HO ME 1.!!:) EXPLORE• CRun - 2.710puk,tl ~°"" - Dr, D1vid Stlulkin, VA Under Secretary for Health - Welcomes You to VA Pulse - ...,. MyltMli The Coll1bor1tlon Network Open to All YA Employees! VAPUViE VA (~••,: \~ c ...,_, ct C. No1lf'a1ion1 G MYVA PULS£ VA. PULSE CENTRAL SIVAPulN,101 ./,) 0'"9fwdbec:II ¢:; Helpo.k HOW CAN VA PULSE HELP MU YACAA/Cholce Aot • """"' =?c;}~ ,-.Olbl-,,. J.. Vttlrll'IIO-.Pl'oQr'lmOuic:k '""' VA-19-0799-D-000598 OS 00002265 DS 00002266 :mom.u..u.c.-n Rid Organizations of Bad Actors (Stop the Detailing) "Dealing with employee issues can be difficult, but n o t de a Ii n g with th e m can be worse." - Paul Foster, CEO and Founder, The Business Therapist, ~ Busiress· VA-19-0799-D-000600 OS 00002267 Accountability Legislation "•;. --~x~ • '~.,J·-: ✓ ,,- - ■ l, Increased flexibility to remove, demote, or suspend VA employees for poor performance or misconduct. Authority to recoup bonuses of employees for poor performance or misconduct. Authority to recoup relocation expenses authorized through fraud or malfeasance. \ Authority to reduce federal pensions for employees convicted of felonies. • Increased protections for whistleblowers. VA-19-0799-D-000601 OS 00002268 Little Stufmc Matters 97W Get Everyone's Ideas Questions Patients Need to Ask Getting Better Healthcare I Essential Information Every Patient Needs to Know Edited By David J. Shulkin, M.D. VA-19-0799-D-000603 OS 00002270 Invest in others and develop them sums may?; Iinux A Principle Based (vs. Rules Based) Organizations Alt,,u(lUCrque \tclCfilllS AH..., o(fiebls $a.d a ~~eran suf erina died Monday flf1e( wa1llllft. ber-.M~ a_, - on 20 Md 2$ nV'ltltff 10 be Ullo.Of' to lhc ~ n e y room Y"-1 ~ e from tne VA's eefe1.eoa. wttlCh d about e rrvie....,inute 111·a> ' °"" ,ne ER. VA-19-0799-D-000605 OS 00002272 Choose the Hard Right than the Easier Wrong os_00002273 Walk the Talk?Practicing in NY and Oregon Leaders Propose Solutions, not Criticize PROPOSE TJ-IE SOLUTION VA-19-0799-D-000608 OS 00002275 Getting People to Be Part of the Solution 29 On February 2, 2016, VA hosted a summit, "Preventing Veterans Suicide -A Call to Action" to bring together Veterans, families, federal agencies, community providers, subject matter experts, and other key stakeholders to enhance suicide prevention efforts. The summit generated a new framework for VA's approach to Suicide Prevention that will transform the vision and structure of suicide prevention across VA and the community. VA has elevated and expanded our Suicide Prevention Program to fulfill this vision, which includes: Meeting urgent mental health needs by providing Veterans same-day evaluations and access by the end of calendar year 2016. Building and leveraging strategic partnerships to disseminate new initiatives within VA and to reach non-VA using Veterans. Development and implementation of innovative life-saving programs, such as REACH-VET, which uses predictive modeling to identify Veterans at high risk for suicide. Continuing to partner with the Department of Defense for a seamless transition from military service to civilian life. VA-19-0799-D-000609 OS 00002276 Challenge the Status Quo 0 ?.41909? 140? no of 9-0799-D-000611 Innovations from VA :~DJ ~]:. ~~~:E::}; -:r:....= --::;:.;:~:!E ~'""'..::C.:.':: -r=-'-:..•- ...... -~=-:::.- . ...- .,.., ...:::-_-:;z_ CT Scanner First Liver Transplant Artificial Kidney Nicotine Patches Cardiac 3 Nobel Prizes Pacemaker VA-19-0799-D-000612 OS 00002279 Center for Compassionate Innovation@ VA To enhance veteran's health and well being by offering safe and ethical therapies after traditional treatments have not been successful VA-19-0799-D-000613 OS 00002280 Making Tough Decisions 9-0799-D-000614 300k comments 5 0330002232 Effective Organizations Break Down Silos • • ooo Sprin t LTE 7:23 PM Done CancerMoonshot Discus .. ~ ® ,t ~ c!J VA-19-0799-D-000616 OS 00002283 Don?t take no for an answer "It takes an Act of Congress? 8 Our Pharmacy is best in class J.D. Power's Mail Order Pharmacy Overall Satisfaction Dept. of Veterans Affairs 871 Kaiser Perm. Mail Pharmacy Humana RightSourceRX Walgreens Mail Service Mail Order Average 822 800 810 820 830 840 850 860 870 880 VA-19-0799-D-000619 OS 00002286 NOTICE 1-4B Visiting Hours - Unlimited - VA is Leading In Many Areas • Safety and Clinical Outcomes as good or Better than Private Sector • Opioid Reduction of> 30% • Population Based Hepatitis C Treatment • Largest educator of health professionals in US • Over 10,000 peer reviewed studies published last year • More than 2000 veteran crisis line calls are addressed each day VA-19-0799-D-000621 OS 00002288 The Secretary's 5 Priorities Greater Choice for Veterans -Revise the 40/30 Rule -Build an Integrated Network of Care - Empower veterans through transparency of information Modernize our System -Infrastructure Improvements and Consolidations -EMR Interoperability and Modernization Focus Resources More Efficiently -Foundational Services in VA -VA/DOD/Community Coordination -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Accessibility for Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention VA-19-0799-D-000622 OS 00002289 Thank You ·-------- ---·- --------------- ---· --·- ---- · - - - - - "THE PRICE OF FREEDOM IS VISIBLE HERE. --------- ____ ,,. -------- - ------- --· .... -··--~-· - ------ ·--~- VA-19-0799-D-000623 OS 00002290 Beth Israel Medical Group Will your doctor see you at 3am? Ours will. Open 24 hours a day. Every day. Beth Israel Medical Group 23rd Street and 7th Avenue VA-19-0799-D-000624 OS 00002292 Message From: Sent: To: Subject: Attachments: David Shulkin [drshulkin@aol.com] 4/15/2017 10:49:30 PM (b) (6) gmail.com slides for huron huronupdated.pptx VA-19-0799-D-000625 OS 00002293 , IA V'"' I U.S. Department ofVeterans Affairs Lessons from the U.S. Department of Veterans Affairs David J. Shulkin, MD Secretary of Veterans Affairs April 19, 2017 VA-19-0799-D-000626 OS 00002294 2 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000627 OS 00002295 Largest Educator of Health Professionals • Over 1,800 academic and institutional partners • 120,000 healthcare workers trained each year: ~60,000 medical students and residents ~30,000 nursing students ~30,000 students in other health fields • An estimated 70% of all U.S. doctors have trained with VA. 3 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000628 OS 00002296 VA Research Nicotine Patches First Liver Transplant Barcoding of Medications Cardiac Pacemaker 3 Nobel Prizes 4 Artificial Kidney CT Scanner ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000629 OS 00002297 Current Research REUTERS ,_ _,_,. II •••MUI "'· _,, ,oun,:s 1ta Together we can achieve 9reat things _,, -- =:::= - - ~ . - . ... , -,.y ==- " - ,n ,c1,-1 -.UO • l ....,,:- - D> PNC Top 25 Global Innovators - Government M12 U.S. Department of Veterans A ffa i rs USA 0 0 0 Almost 10,000 peerreviewed studies published last year: 1,800 on Access 577 on PTSD 386 on Suicide 230 on TBI x._l1n1t/" XFlNITYI' X1 Double Play • $680 million on research "Nl'Mfwl"""""'-..-IV•111a..-.........i~at1Nl.l,_ il'l""'-'IWl---"-C.-.-,b\J$ .,...,._ M""'"9&V~po-l\!'..-.;.;m_,~ - ~ - - - · - - .. -<11 ... 5 _,_.,_ICIIOll< 71~ ~ N7'Ai,.11Uif.T'H ; c5•~':-! 1:::,g1•!1: ~~1:'::;d"."i: :=~! ~-".:=-1:•~~':~~.:: 'BAYFINES', /'lhory C,n lRootlne) - ~l'IICl,IQS-S_,__,_ _ _,,__Atc. . _a.,.... ... ~ - - -==a!.- ee ---· ApflO'"-"lyPO SPEOAI.TVCAlri;,;.,,.;i1i,,,->O._FGf~~--- ~=. . . . C-!,...----IN: ..... ...,Xl"°t'>l"""..,-,_0_,.l>Cnnllll!~ Ill ✓ -•-- _d_""" _.._,_,_,._,,.,,_,,, .... "" .. c... .,_.,.,_,_o.,,, •:.".:;...-_.,_ ..af~ I ~ 10 - ✓ - !! !! \.:_:-_:-::_ -·· "-···""' - 17 C :!::.:;;;~- - ... ~ ~ !! _.,..., u1o, :,,":...,";"'°"'" --oe - - - -- · -- - - - - ~ ;.-;;:~:- ·- --~=.;,_,,_ .... -- -...... !!Ill' ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000642 OS 00002310 Run Towards the Gun Fire 18 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000643 OS 00002311 Being Present 19 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000644 OS 00002312 Focus On Our People I,_ My VA Organizational Hicrard1y _ ~ • .._ ( ., ~ Dr D111ld Shulkln, VA Under Se to lhO ~ n e y room V"1 ambullnc fromtt,eVA'$ car~ . .,,10Ch d abotJ1 a fM!>fl'lll'IUte wa ftotfl lhe ER. -0•o ~ . . -.... a SOl.#iCt•~rrv 22 ,1A VI-I. I ~ \ ~ !/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ This slide and the next two are examples of the services VA provides that the private sector often doesn't. VA-19-0799-D-000647 OS 00002315 Choose the Harder Right Over the Easier "Wrong lij;lliS:::-::;i;::;:~~ID"""""'~r.--""!:"ll..,,,, 23 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000648 OS 00002316 My Board 36 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000649 OS 00002317 Get People To Be Part of the Solution 25 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000650 OS 00002318 Making Tough Decisions 26 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000651 OS 00002319 APRNS - 37 300,000 Comments ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000652 OS 00002320 Challenge the Status Quo 38 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000653 OS 00002321 Center for Compassionate Innovation To enhance Veterans health and well-being by offering safe and ethical therapies after traditional treatments have not been successful The Power of U._S. Department of Veterans Affairs COMPASSION 41 ,1A V,..._ I ~ \ ~!/ 1 US l)ppartmcnl ofVctc.-an~ ,\ffa 1r~ VA-19-0799-D-000654 OS 00002322 Effective Organizations Break Down Silos 30 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000655 OS 00002323 Decline in Homelessness 80,000 ~ 087 70,000 ...............65 455 60,579 60,000 50,000 40,000 30,000 - 43 437 .. ,,, , 49,689 47 725 40,033 35,143 34,909 -. 30,650 25,436 . £>,<££ 20,710 20,000 32 119 31,505 ,.,,.-· _ 16,220 10,000 o 2010 + Total Homeless Veterans 31 2011 2012 e 2013 Sheltered Veterans 2014 2015 Unsheltered Veterans ,1A VI-I. I ~ \ ~!/ 1 ' ' ' US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000656 OS 00002324 Reduction in Opioid Use Overall opioid use: Benzo co-prescribing: 420,000 395,00J High dose: ~qooo 345,00J ~qooo 295,00J nqooo £ ~ 32 E B Annual drug screening: 86% 8 8 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ Decline in Veterans on long-term opioid therapy, 40 FY 2012 to 10 FY 2017. Overall opioid use down 31% in the same period. VA-19-0799-D-000657 OS 00002325 Population-based Hepatitis C treatment 86,000 Veterans treated 77,400 cured 90% cure rate 2,000 treated each month Poised to eliminate Hep C among Veterans in 2 Years 33 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ Decline in Veterans on long-term opioid therapy, 40 FY 2012 to 10 FY 2017. Overall opioid use down 31% in the same period. VA-19-0799-D-000658 OS 00002326 The Secretary's 5 Priorities 1. Greater Choice for Veterans 4. Improve Timeliness of Services 2. Modernize our Systems 5. Suicide Prevention 3. Focus Resources More Efficiently 34 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000659 OS 00002327 Greater Choice for Veterans • Redesign the 40/30 Rule to use clinical criteria for veteran choice • Build a high-performing, integrated network of ca re • Empower Veterans through transparency of information ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000660 OS 00002328 h. \1I. .ra Veterans Speak with their Feet VA must operate simHar to the private sector lncrementamism is not the answer to additional improvements VA and Veterans need. 37 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000662 OS 00002330 Modernize Our Systems • Infrastructure improvements and streamlining services • EMR interoperability and IT modernization ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000663 OS 00002331 Infrastructure Improvements Gas Station Minneapolis, MN 1932 Fort Thomas, KY Circa 1895 39 Palo Alto VAMC ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000664 OS 00002332 Focus Resources More Efficiently • Strengthening of foundational services in VA • VA/DOD/Community coordination • Deliver on accountability and effective management practices ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000665 OS 00002333 "World Class Foundational Services 41 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000666 OS 00002334 Accountability Legislation Increased flexibility to remove, demote,or suspend VA employees for poor performance or misconduct. Authority to recoup bonuses of employees for poor performance or misconduct. Authority to recoup relocation expenses authorized through fraud or malfeasance. Authority to reduce federal pensions for employees convicted of felonies. Increased protections for whistle blowers U.S. Departmcnl VA i'~ ) ofVctc.-a ns ,\ffa i rr-; VA-19-0799-D-000667 OS 00002335 Improve Timeliness of Services • Access to care and wait times • Decisions on appeals • Performance on disability claims ~ ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000668 OS 00002336 How quickly does my VA see patients? How satisfied are veterans like me with the timeliness of their care? How well does my VA's care compare to other hospitals? VA-19-0799-D-000669 OS 00002337 5- Suicide Prevention ~ G(TTING TO Z[RO ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Vete r-an~ ,\ffa 1r~ VA-19-0799-D-000670 OS 00002338 Priority 8- Suicide Prevention , , • U ·• . . ...... Reach Vetenns and their families Expand the YA Suicide Prevention Office ···... Develop innovative prevention strategies /!!\::':. V 46 Build community engagement roundsulclde ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000671 OS 00002339 47 ,1A VI-I. I ~ \ ~!/ 1 US l)ppartmcnl of Veter-an~ ,\ffa 1r~ VA-19-0799-D-000672 OS 00002340 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/16/2017 1:19:27 AM To: Vivieca Simpson [(b) (6) gmail.com] Vivieca- if i wanted to ask about a wolftrap show - who is best to ask? Sent from my iPhone VA-19-0799-D-000673 OS 00002342 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/13/2017 4:08:28 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Jen of course Sent from my i Phone > On Apr 13, 2017, at 11: 38 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > I want to give it to Lu Beck instead of Mike Valentino- you OK? > > Sent from my iPhone VA-19-0799-D-000674 OS 00002343 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/13/2017 3:38:08 PM David Shulkin [drshulkin@aol.com] Jen I want to give it to Lu Beck instead of Mike Valentino- you OK? Sent from my iPhone VA-19-0799-D-000675 OS 00002344 Message From: (b) (6) Sent: To: 4/19/2017 10:22:07 PM David Shulkin [drshulkin@aol.com] health data palooza options healthdatapoolza-Shulkin.pptx; LPW Healthdata Palooza.pptx; 2017 04 28-1 Health Datapalooza.pdf Subject: Attachments: [(b) (6) gmail.com] Hi, the first deck is yours. the second deck is mine -recommendations, not fully edited, just wanted to show you a story before I edited down the second deck is the deck brian created from your suggestions talk is only 15 minutes. Can edit more if you choose. VA-19-0799-D-000676 OS 00002345 Health Datapalooza David Shulkin, M.D. Secretary Department of Veterans Affairs Q\ ~ I U.S. Departme nt ofVeterans Affairs AAMC 11/6/15 VA-19-0799-D-000677 OS 00002346 lilyVA LLING OUR MISSION SERVE ALL WHO SERVED. VA u: ULm?a Great Tradition: Honoring Those Who Served 'Final Salute' honors Holocaust survivor, Veteran Smlo,i >roll ma liall•w .,,, ,M --'rml-swr1caljloorat /,,,.y/1 fl lCCjo, ,,_. t,,.,JJ<>fll.,/1,ca11Jt llrf\"IWll'-1 Kortilll Hor Air J,o,w l tlt/'11111'011I A,g'"·lc ,ok •l1ukdro 1M dn'1000 simultaneous VA and non-VA researchers by 2020 Safe/secure, CUA-compliant biorepository with back-up Establish mechanisms to return results responsibly to: Providers, EHR and Participants VETERANS HEALTH ADMINISTRATION 13 VA-19-0799-D-000689 OS 00002358 Host Facility: VA Palo Alto Health Care System Provides remote diagnostic radiology interpretations, with final reports uploaded directly into the patient electronic health record • Serves 88 VA facilities across all service networks • Operates from multiple reading centers to ensure 24/7 operation VETERANS HEALTH ADMINISTRATION 14 VA-19-0799-D-000690 OS 00002359 VHA Tele-ICU Fact Sheet VISN lO Tele-lCU program (Cincinnati) Connects rn other fa cilit ies lnt ens.ive Car e Units VETERANS HEALTH ADMINISTRATION VISN 23 Tele-I CU Program (Mi nneapo lis) Connects; t o other Facilit ies' lnt ens.ive Care Units 15 VA-19-0799-D-000691 OS 00002360 Hub in Salt Lake City: • Centralized Genomic Medicine Service started in 2012 • Reaches areas of the country where genetic services are generally unavailable • Provides direct patient counseling and support to local clinicians • Now reaches 80 VAMCs VHA Genom ic Medic ine 0 Hub • Affiliated Care delivered through CBOCs as well as VAMCs to reach Veterans in their communities VETERANS HEALTH ADMINISTRATION 16 VA-19-0799-D-000692 OS 00002361 Reductions in Utilization FY 2015 ■ Home Telehealth reduced bed days of care: 58% ■ Home Telehealth reduced hospital admissions: 32% ■ Clinical Video TeleMental health reduced acute psychiatric bed days of care: 35% Patient Satisfaction ■ Home Telehealth: 89% ■ Store-and-Forward Telehealth: 96% ■ Clinical Video Telehealth: 94% VETERANS HEALTH ADMINISTRATION 17 VA-19-0799-D-000693 OS 00002362 VA I ,',~J1l' llcr-m,cm ~ DASHBOARD ' Searrli Q {1l hik1a..11~.\lla.11, PHARMACY APPOINTI,IDff'S MESSAGES HEALTII RECORDS RESOURCT.S My HealtheVet Statistics Registrants: 3.6 million Secure Messaging users: 1.7 million Rx Refill Requests: 81 million 0 1/f.. Blue:l urui n R~c ord t-'~ ~ lth:Summ l!l ry Resources ~ Benefits Notifications .:f' Hea lt hy Living .g Me n tal Health liflt Vet era n.s. Hea Ith Libra ry Lil '2Jn.;, r c;.-0!.8 .=inoph=,.,.... -U~blc fcrRdi U :Z.Jo't?r:W!':- Hydrochlorotmn.zi de.r,•111il.a!Jl~:IMl'!.elil -.:Jf.;: r20!.6 !!im·1d!.'~ 'tin,;;.•,ail,W l~ :lol'-E! clil Hea It h ll!Llvin g -.:1.=.p r:W!E. "inop rilA'l'='bl ~for i.e!ill As:se s.sme n t '.ZL-";l r :W!E- .NWCP..:..CT:WEH : D9DOEDT VA Blue Button Downloads: 1.4 million Change in Appointment Viewers from December 2014 to December 2015: 32% increase *Statistics as of March 2016 VETERANS HEALTH ADMINISTRATION 18 VA-19-0799-D-000694 OS 00002363 Annie - a mobile messaging system that promotes self-care for Veterans. Annie sends regular, automated text message reminders to Veterans to help them track health information their VA care teams have requested. Annie can also send Veterans reminders and messages from their local VA facility. Learn More: https ://www.youtube.com/watch ?v=zke kN r6DeQY &featu re=youtu. be VETERANS HEALTH ADMINISTRATION 19 VA-19-0799-D-000695 OS 00002364 ____ - Veterans Appointment Request (VAR) Allows Veterans to directly schedule and cancel selected primary care appointments directly through the app ~ _.., Veteran Appointment Usability Study Results: • 76% satisfied with app • 95% believe it has the potential to improve access to care o°"~....,_._. ___ _.,. ...,_,.,_, """ .. _____ ~_,,.__. _ _ . 'bl ~ ---~ ? .. -·- ·-· - II ..,_ ~. • :::--- VETERANS HEALTH ADMINISTRATION R -N----- ..,,_ http://mobile.va.gov/appstore 20 VA-19-0799-D-000696 OS 00002365 Mobile Distance Hearing Aid Fitting App A distance hearing aid fitting application that runs on a smartphone and allows audiologists to perform hearing aid adjustments remotely on hearing aids • ·····•·················· ··············· AudiOlog>I r., "' '"'"""" VETERANS HEALTH ADMINISTRATION 21 VA-19-0799-D-000697 OS 00002366 https://www.youtube.com/watch?v=38pl8hc9aso&feature=youtu.be VETERANS HEALTH ADMINISTRATION 22 VA-19-0799-D-000698 OS 00002367 Thank You ·---~ __ ·- ---------- --~- - - · - - - - - - - - - - .. THE PRICE OF FREEDOM IS VISIBLE HERE .. ------ -- - - --- ......... ._ ~ -- -- .. --·--- - - - ------- ·--a.- .,.. --~ ·- ... -. - - - - - - - - - ----- . ,- - -- ·- - - - - - - - - •---- VA-19-0799-D-000699 OS 00002368 U.S. Department of Veterans Affairs Health Data Palooza David J. Shulkin, MD Secretary of Veterans Affairs April 25, 2017 VA-19-0799-D-000700 OS 00002369 ff . i·'.r "To care for him who shall have borne the · battle, and for his widow and his orphan." President Abraham Lincoln, 1865 1 Our Mission ~ ·~ To care for those "who shall have borne the battle" and for their families and their survivors. VA Today ~;,(. . / \. VA-19-0799-D-000701 OS 00002370 Important Contributions to Society VA Research Nicotine Patches First Liver Transplant Barcoding of Medications Cardiac Pacemaker 3 Nobel Prizes Artificial Kidney CT Scanner 4 VA-19-0799-D-000703 DS_00002372 v~"f Nee~ Pa~~Aers_anN~CTe• • IM,iiDI ~ """""'' - "·"""'"""""'-· [ml Rffr """' a@a1on G I r-. Cleveland Clinic 0 0 9 e >H GrantThornton accenture ~ISNEf \\' J,\arnott. Q ... Virginia Mason- T,eRm -CAA,mN" pwo ~ BCG ~ • •~ ~ ologe ri1 ~ ~ ~n ~ • STARBUCKS' ,., JOHNSHOPKI S ~----=------i•DmtH'.:'.jij Jollibee ~ KAISER PERMANENTE® I Booz Allen fjj~ I Hamilton • M ' 0 ' • ' " ' ® MU -- ~~§~ ~ c VA-19-0799-D-000704 DS_00002373 ?Out of crisis comes clarity.? Randolph O?Toole Greater Choice Modernize Systems _,:::. --.::-\;;} Improve Timeliness Focus Resources •••• •• ••• Suicide Prevention VA-19-0799-D-000706 OS 00002375 Greater Choice for Veterans • Redesign the 40/30 Rule • Build a high-performing, integrated network of care • Empower Veterans through transparency of information VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000707 OS 00002376 VA Digital Health Platform FUTURE DEVELOPMENTS c1 VA~ Providers ◄Department of Defense \ '' .,,,, .,,,, ' -'' Veterans /D Supply Chain -► ' .... 1~ 1 Decision Support Community Providers VA-19-0799-D-000708 OS 00002377 Modernize Our Systents lt lcit{one, St J D ~ · liil lB • EMR interoperability and IT modernization • Infrastructure improvements and streamlining services -., ►, h,ro W., ~~ H .""i1·~~ ~ - :.-~:•.m fll:K.l~ • llliil ~::':'~ :~ m ~ ?i .II l ...... • i ~ ~ 11 II, ~ • ... ~ ll ~ . VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000709 OS 00002378 Improve Timeliness of Services • Access to care and wait times • Decisions on appeals • Performance on disability claims VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000710 OS 00002379 Wait times at local facilities Walt Times for Appointments at VA Facillties '""" What Veterans are saying about access What Veterans Say About Access to Care at VA facilities SortR111bty s~rt~mb Sy Appo!r.l:nlnLTypt P~Cn(Rolitrel f atltyN.nt ~ "''"' ,onoo,CAA! illd~~Wil """"" COll'\\UE'IS HI.TH """""""""" Waill'tnesasofl/2 LIE'4"AL!EAI..Tk Fandliaittsllil be oo!t edaa:ll!dltl§JlOJ'O',l Percent o! IJe:erans 'MID rl!jlorted tllat llieywm Always or Usually able !Cl get 1111ppo'1tment when needed. Tht clo'1''1! Yo,o,111~ierorr.,,,Dea-trttt F11~l"OIIICt"~ nm 111 qtr:,,sb~~IWWl$lltll••~(iol; N}Q,l'l,at ... i.'t'lo;rgert..3011-,SICl.l~oilli!d•;h:: ., .. --!lVl'•U., t l : l " - ~ I D IJ>Ol o - \ ' , 1 0 . VA-19-0799-D-000711 OS 00002380 Focus Resources More Efficiently • Strengthening of foundational services in VA • VA/DOD/Community coordination • Deliver on accountability and effective management practices VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000712 OS 00002381 Delivering Care Where We Don?t Have Facilities 3 VA Telehealth Services 2.14 million episodes to 677,000 Veterans {12%} Home Telehealth 156,000 Veterans Video Telehealth 282,000 Veterans Store-and-Forward Tele health 298,000 Veterans 45% of our Telehealth services are for rural Veterans 336,000 TeleMental health visits 15 VA-19-0799-D-000714 OS 00002383 That?s Ear! 5 VISN 10 Tele-ICU program (Cincinnati) Tele-ICU Hubs Connects to other fa cilities Intensive Care Units I I Telehealth - Clinical Genomics Tele-ICU hub · ·· I •-= TeleRadiology Program .- .VHA Genomic Medicine . ....... 0 .... VA-19-0799-D-000716 DS_00002385 Taking the Lead in Healthcare Big Data • Big Data Announcement Slide VA-19-0799-D-000718 OS 00002387 Watson Health 9 D8 00002388 Predictive Analytics Oncology PTSD TBI Suicide Million Veteran Program: A Partnership with Veterans I< I I n I! 11 Re: )'lr h0SOevelopm nt VA-19-0799-D-000721 OS 00002390 VA Mobile Apps ---------1 . --. ... _ II ~ Om"-_,.., _ _ _ _ .,. ___ . 1111 _ _ , ,._... _ _ --· ..... 111 . u u ... ...,.,_,.,c....... . .. -·- ,.......,,,.,_ ~ • -----~-.. ~ [! Veteran Appointment Request (VAR) - Allows Veterans to directly schedule and cancel selected primary care appointments directly through the app Veteran Appointment Usability Study: .. □ 76% satisfied with the app □ 95% feel that it has the potential to □ htt~:l[mobile.va.gov[a~~store improve access to care VA-19-0799-D-000722 DS_00002391 Mobile Distance Hearing Aid Fitting App A distance hearing aid fitting application that runs on a smartphone and allows audiologists to perform hearing aid adjustments remotely on hearing aids . ················· .....• ··············· Audiologl,1 l'et cnl VA-19-0799-D-000723 OS 00002392 Veteran's Portal- MyHealtheVet ..\ ~-= VA I (~ l~ l1i,-.-m11"mt My HealtheVet Statistics -Q DASHBOARD PHAllMACT APJIOllfl'MElfl'S MESSAGES IIEALTil RECORDS RESOURCES - ~. Meas.ages - ~ ' H,a!th lleoord, Registrants: 3.6 million □ - _,_;:;~~- Health Management Dashboard Q Appointments □ □ □ Notifications :f Healthy Living q Menta l Hea lth Ifill Vetera"' Hee Ith Li brary t] Hee Ith a.iving Asses.sment VA Blue Button Downloads: 1.4 million Hcolth-Summ,:iry \li ewMe:!Iceiti oru. Resources Rx Refill Requests: 81 million - □ HcolthC-,:ilcndcir Secure Messaging users: 1.7 million ru-.e ~ m *S@tisticsasofMarch:2016 :2>0.=.pr:2011:, ~ . 11:nin.,:, ~..en.=.i.le.n:i~le forRei U ::.J,=.;:r1v!6 Hy,drochlorotl,i~deA·111~':Jl~im-t1.efil -.:onprw !e. sim·1f!.U!1i11A..-eil.e~l~:iorRcf.l 21 npr 101e. -V..=tp r :20! 1:- • inopril i'frl Change in Appointment Viewers from December 2014 to December 2015: 32% Increase bl~forRd:1 1 NWCflh.CT20EH:D9ClDE:>T VA-19-0799-D-000724 OS 00002393 Improve Timeliness of Services • Access to care and wait times • Decisions on appeals • Performance on disability claims VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000725 OS 00002394 Wait times at local facilities Walt Times for Appointments at VA Facillties '""" What Veterans are saying about access What Veterans Say About Access to Care at VA facilities SortR111bty s~rt~mb Sy Appo!r.l:nlnLTypt P~Cn(Rolitrel f atltyN.nt ~ "''"' ,onoo,CAA! illd~~Wil """"" COll'\\UE'IS HI.TH """""""""" Waill'tnesasofl/2 LIE'4"AL!EAI..Tk Fandliaittsllil be oo!t edaa:ll!dltl§JlOJ'O',l Percent o! IJe:erans 'MID rl!jlorted tllat llieywm Always or Usually able !Cl get 1111ppo'1tment when needed. Tht clo'1''1! Yo,o,111~ierorr.,,,Dea-trttt F11~l"OIIICt"~ nm 111 qtr:,,sb~~IWWl$lltll••~(iol; N}Q,l'l,at ... i.'t'lo;rgert..3011-,SICl.l~oilli!d•;h:: ., .. --!lVl'•U., t l : l " - ~ I D IJ>Ol o - \ ' , 1 0 . 2 VA-19-0799-D-000726 OS 00002395 Suicide Prevention • Getting to ZERO Expand the VA Reach Veterans Suicide Prevention and their families Office Develop innovative prevention strategies VAi Build col'T1munity engagement U.S. Department ofVeterans Affairs VA-19-0799-D-000727 OS 00002396 Predictive Analytics: REACH VET • Rolled out nationally • Uses data to identify Veterans at high risk for suicide • Notifies VA providers of the risk assessment VA-19-0799-D-000728 OS 00002397 Center for Compassionate Innovation To enhance Veterans health and well-being by offering safe and ethical therapies after traditional treatments have not been successful VA-19-0799-D-000729 OS 00002398 https://www.youtube.com/watch?v=38pl8hc9aso&feature=youtu.be 32 VA-19-0799-D-000731 OS 00002400 ThankYou -- ,. ,.c.-' -·· "THE PRICE OF FREEDOM IS VlSIBIF HF r · VA-19-0799-D-000732 OS 00002401 .:_--_--~:----=-:--, I A U.S. Department =~---_-:_-:_-:.-- -_-_--.:~V ~-:-_ --- ------ --.of Veterans Affairs - '• -----:-::- VA·Modernization Health Datapalooza David J. Shulkin, MD Secretary of Veterans Affairs April 28, 2017 VA-19-0799-D-000733 I 1111 q 111yVA FULFILLING OUR MISSION TO CARE FOR HIM WHO T ODAY , W E SAY TO CARE SHALL HAVE BORNE THE FOR Il::lQS.E " WHO SHALL BATTLE AND FOR HIS HAVE BORNE THE BATTLE ," WIDOW , AND H IS ORPHAN . AND FOR THEIR FAM I LIES -ABRAHAM LINCOLN. 1865 AND THEIR SURVIVORS WE SERVE ALL WHO SERVED. \ /A V l'I ,V1 --'°', \ \:i: ,. . ) "-.:_:., l'.S. Ilq>.1 rl nwnt of'\i.·1<·1-.: 111s .\!fairs / . . .'·, VA I :VA-19-0799-D-000734 _~ ~) of VNc rn ns 1\ffa rs U.S. Dcpartmcn!l. i OS 00002403 Honoring Those Who Served 'Final Salute' honors Holocaust survivor, Veteran VA-19-0799-D-000735 OS 00002404 VA Research Nicotine Patches 8 Lasker Awards First Liver Transplant Barcoding of Medications Cardiac Pacemaker 3 Nobel Prizes Artificial Kidney CT Scanner VA-19-0799-D-000736 OS 00002405 Current Research · · REUTERS , .. . .. ,. HOMC. OIJSUIC. 55 · MAIIKc:T5 • WOIILD • POUTIC S • ., ,. ·· ,,f,,, TttH • O PIJa>II • DRLAJUN GVCW S • WONCY • urc - ~ PICT URt.S • • VIDCO Top 25 Global Innovators - Government 0 0 0 #12 U.S. Department of Veterans Affairs usA +1,::2 ;;;p jij B.ld - US 5168.8 bl!lon Almost 10,000 peerreviewed studies published last year: 1,800 on Access :◄ TOP IHSTTTUTIONS l :lO'Hi RNIIICINCS 577 on PTSD 386 on Suicide 230 on TBI n,, ~fmtly XFINITY" Xl Double Play ThP~rr',Mllrl.VIP"eraMAJl'alrs(VA)ls.ac.ar11u'lft ,..v~IIH>ar.rnfflloftne U ·,:111t!lltfl~nl ~ r~ 11e,ciJ1tl'lth1otq1 ii 79 99 ·----S lt1.11 ~Clf)OI-. ~••I -•~" for US W!t!fg "Zl!l ,:.P r ::2:0.1.e iii Co mmc,"ity ~ ~ r ::roie :Zi:M i=t.;. r ~ :,ii:, tj'J Hea Ith ~ vin" As.s.e:s;5m e n t :-:1 npr ::ZO:!B :z,L n.p r ::1>) 11:1 .~ mi nop~ • !l bl.e- ful- fi.dl ll ::l r.uch loro1f·f ~ l2: .r.•.i1!11 iL!!:J l11!! '!l:Jr il.!! .s: im·.-.=s.~!in.r.,Li= ~!::il ~ fur ~.fill l.Ciiinor;i ril.n..- • •'.i:J li: for ~ 11 .NWC P .~ ::i-:i EH : a ~,~ EDT *Statistics as of March 2016 VA-19-0799-D-000754 OS 00002423 Mobile Distance Hearing Aid Fitting App A distance hearing aid fitting application that runs on a smartphone and allows audiologists to perform hearing aid adjustments remotely on hearing aids -···· .. - ························-·· ·····. VA-19-0799-D-000755 OS 00002424 MVP and PMI Summary Objectives MVP participation available to all Veterans and DoD Veterans MVP /1 Participants DoD State-of-the-art computational environment - ~ Survey Responses ~ Genomic Data Medical Records Data access leading to scientific discoveries and publications - -VA - - ~ ... Investigators Non-VA Investigators • Current enrollment 520,000 Veterans • Enroll at least 1 Million by 2020 • Expand computational capacity to serve more than 1,000 simultaneous VA and non-VA researchers by 2020 • Safe/secure, CUA-compliant biorepository with back-up • Establish mechanisms to return results responsibly to providers, EHR, and participants VA-19-0799-D-000756 OS 00002425 Predictive Analytics: REACH VET • Rolled out nationally • Uses data to identify Veterans at high risk for suicide • Notifies VA providers of the risk assessment VA-19-0799-D-000757 OS 00002426 MVP Enrollment Sites k New England Consortium Seattle White River Junction, VT Northampton, MA Bedford, MA Manchester, NH Tagus, ME Portland Minneapolis * * * Salt Lake City * • Palo Alto Denve r: 4,202 Los Angeles Loma Linda Long Beac Dallas* * * H Shreveport OJi-ton San Antonio Actively Recruiting Closed to Recruitment *' N'\}pvill\ I" b • ~ mp~is . a 1s ury * Birmingham * Little Rock * * Tuscaloosa : 4,003 • Atlanta * Temple* *• Boston : 5,517 * Albuquerque San Diego ** Madi ~ n Buffalo Alban~ •Northoort Iowa City '*i Milwaukee West Haven : 6,513 H" Pittsburgh* Manhattan ines Cleveland * • Philadelphia KansasCity : 3,390 d" D~ Baltimore:2,858 . ,j,..W h" t * • In 1anapo 11s- . ~s ing on, L Cinc1nnat1 Richmon cfk Leavenworth St. Louis Louisville Hampton * c Durham lumbia Charleston * Gainesville Tampa * Orlando Bay ines Miami [ San Juan : 193 .::. ] VA-19-0799-D-000758 OS 00002427 VA Need Partners and Technology ~ Mount S inai B eth l s ra 1 • ·'c;J ~ [Nvcl 1 HCA ~ :~ Hospital Co rporation of America- P&'Li- a!!la_J~on ~ ~fsNEf G o o g le Cl C1eve1and Clinic GrantThornton ~ ~arr,ott~ virgi n ia Mason- accenture ~ a BCG ~ .. T H E RI TZ-CARLTON ® ~?-w~HNUI& @'1 ~ ~~,,; ~ ~ w~ ~ STARBUCKS. JOH r-11 ~ D HO KI S l .C I N ~ I'-•::....1--;1---t...ji::11[.....irllllt.. ¥1- I Allen I Hamilton m IRS • Jollibee KAISER PERMANENTE ® Booz ft ~ - - - - ® GS.c'" MAYO CLINIC 1!]~13~ ~ VA-19-0799-D-000759 OS 00002428 VA US. Dupa rti?nunl :15; Affairs 28 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/26/2017 2:04:36 PM (b) (6) [(b) (6) mayo.edu] Re: Details I Thursday I totally understand (b) (6) Sent from my iPhone > on Apr 26, 2017, at 9:14 AM, (b) (6) <(b) (6) mayo.edu> wrote: > > Hi David - thank you for the kind offer of access to the Thursday, 4:30 p.m. event. unfortunately, I have commitments back here at Mayo/Rochester that require that I depart DC late morning, Thursday. > > Hope your meeting w/ your large group of leaders continues to go well -- thank you for your continued strong leadership of the VA and for our nation's veterans. > > (b) (6) > > -----original Message----> From: David shulkin [mailto:drshulkin@aol .com] > Sent: Tuesday, April 25, 2017 9:20 PM > To: IP (b) > cc: (6) > subject: Re: Details I Thursday > > Sorry just getting in and now just seeing your message > > I have my top 500 leaders in Virginia today and this was my afternoon to tell them where we need to change- I've been out of cell range. > > I'll get (b) (6) on the list for the event. 430 pm on Thursday > > We have to be in the building by 2 as per secret service > > David > > > Sent from my iPad > >> on Apr 25, 2017, at 3:51 PM, IP <(b) (6) frenchangel59.com> wrote: >> >> > > VA-19-0799-D-000761 OS 00002430 Message (b) (6) [(b) (6) mayo.edu] 4/26/2017 1:14:08 PM David Shulkin [drshulkin@aol.com] IP [(b) (6) frenchangel59.com] Details I Thursday From: Sent: To: CC: Subject: Hi David - thank you for the kind offer of access to the Thursday, 4:30 p.m. event. unfortunately, I have commitments back here at Mayo/Rochester that require that I depart DC late morning, Thursday. Hope your meeting w/ your large group of leaders continues to go well -- thank you for your continued strong leadership of the VA and for our nation's veterans. (b) (6) -----original Message----From: David shulkin [mailto:drshulkin@aol .com] Sent: Tuesday, April 25, 2017 9:20 PM To: (b) (b) (6) cc: (6) subject: Re: Details I Thursday Sorry just getting in and now just seeing your message I have my top 500 leaders in Virginia today and this was my afternoon to tell them where we need to change- I've been out of cell range. I'll get (b) (6) on the list for the event. 430 pm on Thursday We have to be in the building by 2 as per secret service David Sent from my iPad > on Apr 25, 2017, at 3:51 PM, IP <(b) (6) frenchangel59.com> wrote: > > VA-19-0799-D-000762 OS 00002431 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/26/2017 2:20:28 AM IP [(b) (6) frenchangel59.com] (b) (6) [(b) (6) mayo.edu] Re: Details I Thursday To: (b) (6) CC: Subject: Sorry just getting in and now just seeing your message I have my top 500 leaders in Virginia today and this was my afternoon to tell them where we need to change- I've been out of cell range. I'll get (b) (6) on the list for the event. 430 pm on Thursday We have to be in the building by 2 as per secret service David Sent from my iPad > on Apr 25, 2017, at 3:51 PM, IP <(b) (6) frenchangel59.com> wrote: > > VA-19-0799-D-000763 OS 00002432 Message From: IP [(b) (6) frenchangel59.com] Sent: 4/25/2017 7:51:31 PM To: David shulkin [drshulkin@aol.com] FW: Details I Thursday Subject: Please give me a call. Thank you [mailto:(b) (6) mayo.edu] From: (b) (6) Sent: Tuesday, April 25, 2017 3:32 PM To: Marisol Garcia ((b) (6) frenchangel59.com) Cc: IP ((b) (6) frenchangel59.com); Bruce Moskowitz; Marc Sherman ((b) (6) Subject: Details I Thursday gmail.com) Hi Marisol - can you send what you have in terms of details for Thursday - location/timeline of meetings - if possible before 4:45 EDT. Thanks, (b) (6) Chair I Mayo Clinic Department of Public Affairs 200 First Street S.W. I Rochester, MN 55905 cell: 507 .269.(b) (6) I office: 507 .284.(b) (6) e-mail: (b) (6) mayo. edu VA-19-0799-D-000764 OS 00002433 Message From: Sent: To: David Shulkin [drshulkin@aol.com] 4/14/2017 2:32:35 AM Poonam Alaigh [(b) (6) hotmail.com] Missals comments are overboard- very dissapointing he is playing to the press https ://www.washington post. com/1ocal/dc-politi cs/highest-I evel s-of-chaos-im pair-dc-veterans-hospi talinspector-general-finds/20 l 7/04/l 3/777bc786-203 d-lle7-ad743a742a6e93a7 story. html?utm term=.298ade90d0f2 Sent from my iPad VA-19-0799-D-000765 OS 00002434 Message To: David shulkin [Drshulkin@aol.com] 5/20/2017 12:31:14 AM Bruce Moskowitz [(b) (6) Subject: Re: From: Sent: mac.com] This would be interesting You know everyone! Sent from my iPhone On May 19, 2017, at 6:27 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: After you were off phone my next call was to (b) (6) chairman of Bristol there are enough managers in the pharmaceutical industry he believes to assist filling management positions. We think between this and the business schools we can do it. Mayo has an internship with Baylor. If you can leave Texas for Minnesota that is something!! Sent from my iPhone On May 19, 2017, at 6:09 PM, David shulkin wrote: From morningjoe show today- talking up the president http ://www.newsmax. com/t/newsmax/article/791121 ?section=Politics&keywords =david-shulkin-veterans-affairsleaders&year=2017 &month=0S&date= l 9&id=79 l 12 l&aliaspath=%2FManage% 2F Artic1es%2FTemplate-Main&oref=www.google.com Sent from my iPhone VA-19-0799-D-000766 OS 00002435 Message CC: Bruce Moskowitz [(b) (6) mac.com] 5/19/2017 10:27:17 PM David shulkin [Drshulkin@aol.com] Poonam Alaigh [(b) (6) hotmail.com] Subject: Re: From: Sent: To: chairman of Bristol there are enough managers After you were off phone my next call was to (b) (6) in the pharmaceutical industry he believes to assist filling management positions. We think between this and the business schools we can do it. Mayo has an internship with Baylor. If you can leave Texas for Minnesota that is something!! Sent from my iPhone On May 19, 2017, at 6:09 PM, David shulkin wrote: From morningjoe show today- talking up the president http ://www.newsmax. com/t/newsmax/article/791121 ?section=Politics&keywords=davidshulkin-veterans-affairsl eaders&year=2017 &month=0S&date= l 9&id=79 l 12 l&aliaspath=%2FManage%2F Articles%2F Template-Main&oref=www.google.com Sent from my iPhone VA-19-0799-D-000767 OS 00002436 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 5/19/2017 10:09:40 PM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) [(b) (6) mac.com] gmail.com]; Bruce Moskowitz From morningjoe show today- talking up the president http ://www.newsmax.com/t/newsmax/article/791121 ?section=Politics&keywords=david-shulkin-veteransaffairsleaders&year=2017 &month=OS&date= l 9&id=79 l 12 l&aliaspath=%2FManage%2F Artic1es%2FTemp1ateMain&oref=www.google.com Sent from my iPhone VA-19-0799-D-000768 OS 00002437 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/14/2017 7:05:12 PM To: Bruce Moskowitz [(b) (6) Re: Tracking inventory Subject: mac.com] I look forward to meeting him- thanks Sent from my iPhone On Apr 14, 2017, at 9:39 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: mentioned below. One of the CIO's your meeting April 17 is (b) (6) The actual application that I am most interested in applying for a device registry is to insure appropriate procurement, utilization and tracking of devices throughout the VA system. This is any device internal and external. I have enough data to show it (not in an email) what occurred the past few days is not an anomaly. This was also in the full report that (b) (6) participated in not the summary. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: From: Aaron Moskowitz <(b) (6) brefnet.org> Date: April 13, 2017 at 3 :54:30 PM EDT To: "Bruce Moskowitz M.D." <(b) (6) mac.com> Subject: VA call follow up I think the group has a good framework for the clinical applications. I was in Baltimore this morning with (b) (6) and discussed the actual problem of tracking devices throughout the medical system, not just in patients. Apparently Hopkins has been so successful at this they have a company, fully owned by Johns Hopkins, that sets up inventory management at hospitals. We brainstormed a bit on other methods to link implant information to patient records, a "smart" inventory system could help this process. VA-19-0799-D-000769 OS 00002438 Message From: Sent: To: Subject: Bruce Moskowitz [(b) (6) 4/14/2017 1:39:33 PM Poonam Alaigh [(b) (6) Tracking inventory mac.com] hotmail.com]; David Shulkin [drshulkin@aol.com] One of the CIO's your meeting April 17 is (b) (6) mentioned below. The actual application that I am most interested in applying for a device registry is to insure appropriate procurement, utilization and tracking of devices throughout the VA system. This is any device internal and external. I have enough data to show it (not in an email) what occurred the past few days is not an anomaly. This was also in the full report that (b) (6) participated in not the summary. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: From: Aaron Moskowitz <(b) (6) brefnet.org> Date: April 13, 2017 at 3 :54:30 PM EDT To: "Bruce Moskowitz M.D." <(b) (6) mac.com> Subject: VA call follow up I think the group has a good framework for the clinical applications. I was in Baltimore this morning with (b) (6) and discussed the actual problem of tracking devices throughout the medical system, not just in patients. Apparently Hopkins has been so successful at this they have a company, fully owned by Johns Hopkins, that sets up inventory management at hospitals. We brainstormed a bit on other methods to link implant information to patient records, a "smart" inventory system could help this process. VA-19-0799-D-000770 OS 00002439 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/15/2017 2:11:49 AM Charlie Wiggins [(b) (6) remedyventures.com] Re: Home - Malone Center for Engineering in Healthcare Ok great Charlie Sent from my iPhone On Apr 14, 2017, at 9:30 PM, Charlie Wiggins <(b) (6) remedyventures.com> wrote: Secretary Shulkin, Often times while building a new initiative I find it helpful to free-form brainstorm to capture ideas while cultivating vision. I've found using the open source software mindnode to be one effective way to share those ideas amongst a team, remotely. Attached and pasted below is an initial draft of a semantic tree of sorts that captures notable accomplishments from the VACI to date and provides some additional avenues to consider as we move forward. It is by no means a comprehensive document, but if you don't hate the layout it can be a way we begin to structure thought/effort as we begin working together. Looking forward to taking the next steps and walking you through some of these concepts during our next conversation. Have a great weekend, Charlie On Wed, Apr 12, 2017 at 12:47 PM, David shulkin wrote: Ok great Sent from my iPhone On Apr 12, 2017, at 3 :37 PM, Charlie Wiggins <(b) (6) remedyventures. com> wrote: The Malone center is onto some interesting work - the Galen System, microsurgical robotics platform and the Kata Studio - are two that stick out as being beneficial for patients and clinicians within the VA I have only spoke with the White House Liaison to the VA, (b) (6) yesterday and submitted all the necessary documentation here: https ://apply.ptt.gov/ (b) (6) also has a copy of the attached Bio, so I suspect he will be moving the process along. Please let me know what else I can do to be helpful to your internal process. VA-19-0799-D-000771 OS 00002440 Thanks for sharing, Charlie On Wed, Apr 12, 2017 at 1:48 PM, David shulkin wrote: More good stuff Has anyone cobtacted you from VA Sent from my iPhone Begin forwarded message: Date: April 12, 2017 at 1 :34:43 PM EDT To: drshulkin@aol.com, Poonam Alaigh <(b) (6) hotmail .com> Subject: Home - Malone Center for Engineering in Healthcare (b) (6) Dr. (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to see if we can get their innovative technology center to provide their expertise as a service to their Country and the VA https://malonecenter.jhu.edu/ Sent from my iPad Bruce Moskowitz M.D. Charles Wiggins 203 .856(b) (6) Charles Wiggins 203.856.(b) (6) VA-19-0799-D-000772 OS 00002441 Message From: Sent: To: Subject: Attachments: Charlie Wiggins [(b) (6) remedyventures.com] 4/15/2017 1:30:21 AM David shulkin [Drshulkin@aol.com] Re: Home - Malone Center for Engineering in Healthcare Veterans Administration Innovation Center.mindnode.zip Secretary Shulkin, Often times while building a new initiative I find it helpful to free-form brainstorm to capture ideas while cultivating vision. I've found using the open source software mindnode to be one effective way to share those ideas amongst a team, remotely. Attached and pasted below is an initial draft of a semantic tree of sorts that captures notable accomplishments from the VACI to date and provides some additional avenues to consider as we move forward. It is by no means a comprehensive document, but if you don't hate the layout it can be a way we begin to structure thought/effort as we begin working together. Looking forward to taking the next steps and walking you through some of these concepts during our next conversation. Have a great weekend, Charlie • □ * .!. __ ..._ - □ - --------- =--= .......,iot,odt,y_...... On Wed, Apr 12, 2017 at 12:47 PM, David shulkin wrote: Ok great Sent from my iPhone VA-19-0799-D-000773 OS 00002442 On Apr 12, 2017, at 3 :37 PM, Charlie Wiggins <(b) (6) remedyventures .com> wrote: The Malone center is onto some interesting work - the Galen System, microsurgical robotics platform and the Kata Studio - are two that stick out as being beneficial for patients and clinicians within the VA I have only spoke with the White House Liaison to the VA, (b) (6) yesterday and submitted all the necessary documentation here: https ://apply.ptt.gov/ (b) (6) also has a copy of the attached Bio, so I suspect he will be moving the process along. Please let me know what else I can do to be helpful to your internal process. Thanks for sharing, Charlie On Wed, Apr 12, 2017 at 1:48 PM, David shulkin wrote: More good stuff Has anyone cobtacted you from VA Sent from my iPhone Begin forwarded message: Date: April 12, 2017 at 1 :34:43 PM EDT To: drshulkin@aol.com, Poonam Alaigh <(b) (6) hotmail.com> Subject: Home - Malone Center for Engineering in Healthcare (b) (6) Dr. (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to see if we can get their innovative technology center to provide their expertise as a service to their Country and the VA https://malonecenter.jhu.edu/ Sent from my iPad Bruce Moskowitz M.D. Charles Wiggins 203 .856(b) (6) VA-19-0799-D-000774 OS 00002443 Charles Wiggins 203.856.- bplistOOO[typeOptionsWversion[NSPrintinfoWmindMapU _NSHorizontallyCentered[NSFirstPage_NSVerticalPagination_NSHorizonalPaginationZNSLastPa ge]NSOrientation_NSVerticallyCentered_NSScalingFactor_NSPrintAllPagesyyy#?oO)EYmainNode s crossConnectionsUcoloru],U !"#$%&' ()*+45?9@BYshapeType_borderStrokeStyleYfillColor6/0lA_({l.OOOOOO, 1.000000, 1.000000, 1.000000) ({1.000000, 1.000000, 1.000000, 1.000000}0DEFGHIYXmaxWidthYfontStyle allowToShrinkWidthTtext#@rA0JKlLMNOPQRSQUQQVitalic XfontSize]strikethroughXfontNameYalignmentYunderlineTbold#@8_({0.102000, 0.333000, 0.412000, 1.000000) HelveticaNeue-LightP $0B9F11CA-6932-4612-A9E8-02F18E51494CU !A$%& ('~f,,'QZ[layoutStyle decreasingStrokeWidth:aeCTuU !#b$%&(c QQ]isLeftAlignedud'oIU !#e$%&(fz{€Q~Q']isLeftAlignedjg0 !h$%&()jkQpuQy]isLeftAligned {-666.0234375, -695.109375}6,lmXpathType6/012n ({0.863000, 0.133000, 0.157000, 1. 000000} 6=>?qt6/0lrs#@ ( { 0. 863000, 0. 133000, 0. 157000, 1. 000000} ( { 1. 000000, 1. 000000, 1.000000, 1.000000}0DFGHw_6

Shorter time to productivity & more rational post deployment schedule than typical college model

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Education to Employment: Approach key employers with offer to have Mission U types design customized curriculum for veteran study, testing and placement. 1-2 year programs, 80-90% web-based

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Community enhancing apparel

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Entry-level = profile set up+ 3 actions

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Health box Remote monitoring system

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Advanced Level= Daily Engagement

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Engagement & Activation: Initially, broker relationship with Under Armour types to provide multi-tiered incentive rewards program for Vets to provide feedback, research and data to VA Innovation Center

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Idea#l: Track Service Journey with VA overlay

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Micro Documentary setting strategic direction and focus

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Broadcasters Fireside Chats with the Secretary on organizational innovation management

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Tom Brady

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Elon Musk

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Peter Thiel

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Lindsay Vonn

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Tony Robbins

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Eric Schmidt

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Lebron James

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Business, Celebrity & Professional figures- VA Initiative support

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Storytelling rgba(52, 72, 83, 1.000000); font: "Hel veticaNeue"; & Mission Visibility: Partner with independent documentarians, artists and culturally

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Co-invest at strategic partner to add value with VA VA-19-0799-D-000778 OS 00002447 core assets

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Prioritization to follow major VA focus areas (Amputation/PTSD etc.)

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Products & Services

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Strategic Partnerships

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Full System redesign on how we approach Innovation to adopt a Developmentally Deliberate Organization (Radical Optimism)

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Voluntary Performance Based initiatives offered to well performing VISN s, or individual providers

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VA central to define and price high volume episodes

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VA-19-0799-D-000779 OS 00002448 unclaimed episodic risk available opened for bid by accredited general contractors (Veteran owned-start up opportunity)

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Create proprietary episode definitions logic for Long-Tail Bundles spreading service and delivery risk/severity/intensity over multiple durations

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Payment Models Group initially tasked with model creation, data management, and access strategy(waivers or equiv.)

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Immersion based controlled psychedelic research

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Match vets with local families of fallen vets to encourage mentorship opportunities for kids and purpose building for isolated vets

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Offer incentives through partnership or direct veteran compensation for assisting vets with ADL support

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Vet s supporting Vets : Revolutionize community support networks by incenti vi zing recovered veterans to care for veterans in active rehabilitation ex. gig economy for meaning making activities

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Big Ideas

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Data *{- 2017.8694937100972, -600.67195916944934}0,XpathType6/0l~ ({0.992000, 0.714000, 0.051000, 1.000000)6=>? 6/0lr ({0.992000, 0.714000, 0.051000, 1.000000} ({1.000000, 1.000000, 1.000000, 1.000000}6DFGH _¾

National Footprint of Service Delivery Capacity

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Captive Workforce

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Largest Bio-Bank of Genetic Material

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VA Core Assets

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Upstream Suicide Prevention

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Destigmitize mental health and mental health engagement. 8EB5-0A63FDCC94160 !n$%&()pqvzQ~]isLeftAligned

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web- based PTSD

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Fellows Program

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4 public one page studies

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Innovators Network

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Industry Competitions

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Special Projects (no information)

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Partnerships

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2 010-Present

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Community

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Physical Health

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Wellness

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Mindfulness

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Education

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Entrepreneurship

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Transparency & Communication

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Progressive Behavioral Health

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Strategic Re-Focus Areas

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Trusts

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Wal ton Family

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Bezos

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Family Offices

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Venture & PE Community

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Models for sharing execution risk withoutside capital sources

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Capital & Access

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Veterans Administration Innovation Center

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SIX erulh , up- l(d UNITE us VA-19-0799-D-000794 OS 00002465 Got Your Six Walgreens Si ce 2013 VAC I has partnered with Got Your Six to pmse nt Storyte 11 e rs J a tti ought leadership symposium for :sharing time un ique stories of Veterans working in innovative fields and lrnaving a pmfo u nd impact on the ci vman wo rid . As a result of th is partnership_ . Veterans ow have thle option to electronically forward the iI!' immunie;ation records from Walgree s to VA] relieving them of the need to complete addimon al torms or l'\emember to provid e time information to their local VA provider;s. 1 TE -S Unite S 1 1 Te hS ~ ~ VACI has partnered with unite uS to explore 111ew approaches to ou tmach and engagement at the lo cal level1 ena.bling sm,al l VA teams to do direct.• Mal-ti me m.J trea,ch with Veterans in th sir oo mm un ities . ,:,t) TechShop [,L VAC I colIa.borated with Tech Shop to provide 2 ,ooo one-year members hips art six Tech Shop Iocatians aoross the u.S., providing Veterans w~th free access to outtin g edge training a 11d equipment to become more competitive in the job ma rrket or pursue entrepn; neu riall goals. VA-19-0799-D-000795 OS 00002466 ru<> £~, , 1; ~ ,., E"rn~y,n,;01: ¾,·,=,lit<;' ,er,,~oya,, w~t, ~ S~or1.r o,,a 10 ;,100u<:1!·1ni• t n)(;~ ,-.,al P,.'iJl dE!pl0:,,•~•1, Wiedultl lO hil,~ Yi!laSl01, IJ IYI>% - ~ , , ~'!-Jrr11zod curr1cu .-n tor wlcfan sl:ull)\ .as'lng and olaollmcnt. 1 2 = eo f,, , 9016 - 1t-.;,,1 ""'"re .. nx,~ ~ 11U, ~.:o!il'fo,'l!l,( .;u, Un<"' A1t1t0ur 1!.'~1:1 LO b u~de rnuUil)en,iid ht:t:111Li'MI ~1:1wa,tJ:3. p·Or.)'H•n tor \li'l!ts ta prm•Da 1Dodb~. l'l!~I" :u-iddl:J.t31o'JA1rnm•~kln a.cbcn; Hcallh box fiarral1t mc11rtor.n;i ~= C1mt«MO'(! ChXu-'111:11•~ :!l!ltti ,~ 9'!,a, i(:dr'~l•~'IW r~ Vstsrar.s Admiris!ra.ion lnn=lirn Oantsr -- • CoJ ,a, J"l'il~t i:Lt .s.~rat,agtc llill":nar 'li:ltoo IMth VA oorc, .z~al!.i ildj rri(;•' ~~110,, l'Ocu!I a•i:,t1a ro r~low II oj(;r VA li;;t lPTSD 1:11e ~II \r"DIJnillfy f'1cioled ,-eii8 M:11i',i,rt1tJa.bilir::t1io11 l:li'i .• !)!J ;).!:(111U1tt,· %11 tittl& 1r'liJ 1r'tlkfo!.il .ac.,Mbalii"" VA-19-0799-D-000799 OS 00002470 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/13/2017 9:59:47 AM Bruce Moskowitz [(b) (6) mac.com] drshulkin@aol.com Re: Home - Malone Center for Engineering in Healthcare sounds good Bruce- looking forward to it. Sent from my iPad > on Apr 12, 2017, at 1:35 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to > Dr. (b) (6) see if we can get their innovative technology center to provide their expertise as a service to their country and the VA. > https://malonecenter.jhu.edu/ > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000800 OS 00002471 Message David shulkin [Drshulkin@aol.com] 4/12/2017 7:47:24 PM Charlie Wiggins [(b) (6) remedyventures.com] Re: Home - Malone Center for Engineering in Healthcare From: Sent: To: Subject: Ok great Sent from my iPhone On Apr 12, 2017, at 3 :37 PM, Charlie Wiggins <(b) (6) remedyventures.com> wrote: The Malone center is onto some interesting work - the Galen System, microsurgical robotics platform and the Kata Studio - are two that stick out as being beneficial for patients and clinicians within the VA I have only spoke with the White House Liaison to the VA, (b) (6) yesterday and submitted all the necessary documentation here: https://apply.ptt.gov/ (b) (6) also has a copy of the attached Bio, so I suspect he will be moving the process along. Please let me know what else I can do to be helpful to your internal process. Thanks for sharing, Charlie On Wed, Apr 12, 2017 at 1:48 PM, David shulkin wrote: More good stuff Has anyone cobtacted you from VA Sent from my iPhone Begin forwarded message: Date: April 12, 2017 at 1 :34:43 PM EDT To: drshulkin@aol.com, Poonam Alaigh <(b) (6) hotmail.com> Subject: Home - Malone Center for Engineering in Healthcare (b) (6) Dr. (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to see if we can get their innovative technology center to provide their expertise as a service to their Country and the VA https://malonecenter.jhu.edu/ Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000801 OS 00002472 Charles Wiggins 203.856.- Bio Sheet PDF.pdf> Message From: Sent: To: Subject: Attachments: Charlie Wiggins [(b) (6) remedyventures.com] 4/12/2017 7:37:36 PM David shulkin [Drshulkin@aol.com] Re: Home - Malone Center for Engineering in Healthcare SKC_SES Bio Sheet PDF.pdf The Malone center is onto some interesting work - the Galen System, microsurgical robotics platform and the Kata Studio - are two that stick out as being beneficial for patients and clinicians within the VA I have only spoke with the White House Liaison to the VA, (b) (6) yesterday and submitted all the necessary documentation here: https://apply.ptt.gov/ (b) (6) also has a copy of the attached Bio, so I suspect he will be moving the process along. Please let me know what else I can do to be helpful to your internal process. Thanks for sharing, Charlie On Wed, Apr 12, 2017 at 1:48 PM, David shulkin wrote: More good stuff Has anyone cobtacted you from VA Sent from my iPhone Begin forwarded message: Date: April 12, 2017 at 1 :34:43 PM EDT To: drshulkin@aol.com, Poonam Alaigh <(b) (6) hotmail.com> Subject: Home - Malone Center for Engineering in Healthcare (b) (6) Dr. (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to see if we can get their innovative technology center to provide their expertise as a service to their Country and the VA https://malonecenter.jhu.edu/ Sent from my iPad Bruce Moskowitz M.D. Charles Wiggins 203.856.(b) (6) VA-19-0799-D-000803 OS 00002474 The White House Presidential Personnel Office SKC/SES BIO SHEET NOTICE: Return this form to the Presidential Personnel Office as soon as complete. This information is necessary to begin the clearance process. Return to White House Liaison when completed. I PART I: PERSONAL. INFORMATION (TO BE COMPLETED BY THE CANDIDATE) 1. FULL NAME (Last, First, Middle): 2. SOCIAL SECURITY NUMBER: (b) (6) Wiggins, Charles, Anthong b rHS (b) (6) (b) (6) D[D tyQ ity, State, ZIP Code) i ZIP Code, if different than current address) 5. PLACE OF BIRTH (City, State; if not U.S., state, country) 6. GENDER (b) (6) 8. ETHNIC HERITAGE 9. RACE 90% Scottish/Irish 10%Hungarian White 11. HOME PHONE (b) (6) 10. POLITICAL PARTY (b) (6) 12. CELL PHONE 13. WORK PHONE 2038567662 2038567662 14. PERSONAL EMAIL (b) (6) 7. DATE OF BIRTH (b) (6) Male 15. WORK EMAIL (b) (6) remedyventures.com remedyventures.com 16. CURRENT POSITION (Title, Company) 17. WORK ADDRESS (Number, Street, City, State, Zip) CEO, Second Cycle 160 14th Street, San Francisco, CA 94103 18. PLEASE L/.ST ALL SOCIAL MEDIAi ACCOUNTS 10r :;~Y, 11011!:l if you have none) https:l/www. 1nked1n.com/1n/char es-w1gg1ns-016008:.:s:.:s; 19. EDU.CATION (Degree, lnstitution Year) I 20. AWARDS BA, University of l\llaryland, 20 08 MHA, Johns Hopkins University, 2011 1st-team All-American A CC-Champion 21. MILITARY SERVICE (Rank, Branch, Years) 22. PREVIOUS PRESIDENTIAL APPOINTMENTS PART II: POSITION INFORMATION (TO BE COMPLETED BY WHITE HOUSE LIAISON) 1. POSITION TITLE 2. AGENCY 2. APPOINTMENT TYPE 3. GRADE 4. OPM NUMBER 5. WH LIAISON NAME 6. WH LIAISON PHONE 7. WH LIAISON EMAIL VA-19-0799-D-000804 OS 00002475 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/12/2017 5:48:16 PM To: Charlie Wiggins [(b) (6) remedyventures.com] Fwd: Home - Malone Center for Engineering in Healthcare Subject: More good stuff Has anyone cobtacted you from VA Sent from my iPhone Begin forwarded message: Date: April 12, 2017 at 1 :34:43 PM EDT To: drshulkin@aol.com, Poonam Alaigh <(b) (6) hotmail.com> Subject: Home - Malone Center for Engineering in Healthcare (b) (6) Dr. (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to see if we can get their innovative technology center to provide their expertise as a service to their Country and the VA. https://malonecenter.jhu.edu/ Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000805 OS 00002476 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/12/2017 5:47:35 PM Bruce Moskowitz [(b) (6) mac.com] Re: Home - Malone Center for Engineering in Healthcare Great Sent from my iPhone > on Apr 12, 2017, at 1:34 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > (b) (6) > Dr. (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to see if we can get their innovative technology center to provide their expertise as a service to their country and the VA. > https://malonecenter.jhu.edu/ > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000806 OS 00002477 Message From: Bruce Moskowitz [(b) (6) Sent: 4/12/2017 5:34:43 PM To: drshulkin@aol.com; Poonam Alaigh [(b) (6) hotmail.com] Home - Malone Center for Engineering in Healthcare Subject: mac.com] (b) (6) is Mandela Bellmore Professor of Computer science and I will have an initial call to Dr. (b) (6) see if we can get their innovative technology center to provide their expertise as a service to their country and the VA. https://malonecenter.jhu.edu/ Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000807 OS 00002478 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/19/2017 1:25:16 AM Darin Selnick [(b) (6) @gmail.com] Re: Curt Cashour Excellent I thought so Sent from my iPhone > on Apr 18, 2017, at 9:20 PM, Darin selnick <(b) (6) > > I did some checking on curt, talked to a few people and @gmail.com> wrote: (b) (6), (b) (2) > > I think you have a winner in curt. > > Darin VA-19-0799-D-000808 OS 00002479 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/9/2017 10:43:32 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: VA - EPIC Advisory Committee On Veterans Healthcare.03.9.2017.docx; Untitled attachment 05084.htm; Contact lnformation.docx; Untitled attachment 05087.htm Just between us of course Sent from my iPhone Begin forwarded message: From: "IP" <(b) (6) frenchangel59.com > Date: April 9, 2017 at 6:15:35 PM EDT To: "David shulkin" Subject: FW: VA - EPIC From: IP [mailto:(b) (6) frenchanqel59.com] Sent: Sunday, April 09, 2017 6:12 PM To: '(b) (6) who.eop.gov' Cc: (b) (6) who.eop.gov; Ivanka Kushner ((b) (6) Subject: VA - EPIC (b) (6) lperl(b) (6) @qmail.com (b) (6) It was pleasure meeting and having dinner with you last night. We very much look forward to working with you on the VA. A little more background on EPIC. The DOD recently signed a new contract to implement a new system called Cerner with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. As I mentioned last night, there is a push for the VA to choose the same Cerner system. What the VA needs is a system that can speak to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership). The top 5 Academic Medical Centers do not use Cerner and highly recommend against using it, and instead strongly favor using another system called EPIC. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. Using EPIC, therefore, as the VA platform will allow seamless integration with the platform of the majority of community and academic medical centers. As a result, when veterans access care outside the VA system (the choice extension) there will be the necessary access and integration to vital medical information. This means less cost, easier access to the doctors, patients and veterans and their medical records. In addition, the VA's doctors and doctors in training who come from the academic medical centers and who practice part time at the VA have been trained on and use EPIC. It would be VA-19-0799-D-000809 OS 00002480 impractical to expect them to learn two different systems. Also, the VA conducts medical research with academic medical centers across the nation, and using something other than EPIC would make many vital research projects more costly to integrate and collect data. The VA has confirmed that they are on same page to pursue EPIC as their EMR of choice, instead of Cerner. Cerner has claimed that its system cannot talk to EPIC if the VA chooses EPIC. We, however, believe that EPIC will allow for this cross talk. We also believe that the ability of working with the two different platforms is, in reality, an artificial barrier by Cerner that can be resolved if they choose. As I discussed yesterday, the best solution is for the DOD to change to EPIC, for the good of the DOD, the soldiers, the VA and our veterans. However, if that is not in the cards, then It is CRITICAL that Cerner be mandated to design its DOD system to talk to (be able to share medical records with) whatever system the VA chooses to install. It is very important that this is resolved quickly at the DOD/Cerner level by instructions from the White House. If you think it will be beneficial for you to talk directly to the experts at the Academic Medical Centers, you can call one of the people working on the VA effort with me, Dr. Bruce Moskowitz, and he will be happy to arrange discussions with the head IT leaders at any or all of the top 5 academic medical centers so you can hear their points of view and perspectives on this topic directly. Bruce's phone number is (561) 346-(b) (6) and his email is (b) (6) @mac.com . I have also attached my contact information. Regards, Ike VA-19-0799-D-000810 OS 00002481 ADVISORY ON VETERANS HEALTH CARE 1. Dr. David Shulkin, Secretary for Health for the Department of Veterans Affairs (b) (6) (b) (6) 2. Dr. President and CEO of the Cleveland Clinic (b) (6) 3. Dr. (b) (6) President and CEO of the Mayo Clinic (b) (6) 4. Chair Department of Public Affairs of the Mayo Clinic (b) (6) (b) (6) 5. Dr. President and CEO of Partners HealthCare (Massachusetts General and Brigham and Women's Hospitals) (b) (6) (b) (6) 6. Dr. Dean and CEO of Johns Hopkins Medicine 7. Marc. B. Sherman, Senior Partner at international business restructuring and financial consulting firm Alvarez & Marsal (b) (6) 8. (b) (6) Chairman and CEO of Kaiser Foundation Health Plan, Inc. and Hospitals - known as Kaiser Permanente, one of America's leading integrated health care providers and not-for-profit health plans. 9. Dr. Bruce Moskowitz, who has observed in frustration over his years as a noted Palm Beach physician in private practice the crucial need to overhaul our system of delivering veterans' health care. (b) (6) is the wife of injured Purple Heart Veteran, co10. founder of Hope Unseen, mother, nurse BSN, news contributor, speaker and believe that there is always joy to be uncovered. 11. Laura r'Laurie") Perlmutter, a member of the Board of Trustees of NYU Langone Medical Center and of the Board of Advisors of the Laura & Isaac Perlmutter Cancer Center at NYU Langone, which she established with her husband Isaac Perlmutter. 12. Isaac ({like") Perlmutter, a self-made and highly successful business leader and member of the Board of Trustees of NYU Langone whose support for medical research and care has included the establishment, with his wife Laura of the Perlmutter Cancer Center at NYU Langone. VA-19-0799-D-000811 OS 00002482 Our contact Information below: Laurie Perlmutter 561-585-(b) (6) (Home) 561-818-(b) (6) (Cell) Email: (b) (6) gmail.com Ike Perlmutter 561-586-(b) (6) (Home) 561-685-(b) (6) (Cell) **Please note I rarely keep the cell "ONn - If you can't reach me call Marisol - Marisol is able to find me any time. Email: (b) (6) frenchangel59.com Assistant: Marisol Garcia 212-576-(b) (6) (Office) 212-576-(b) (6) (Weekend Office) Cell: 646-668-(b) (6) (Marisol's Cell) Email: (b) (6) frenchangel59.com Please feel free to email or call us any time. VA-19-0799-D-000813 OS 00002484 Message From: Sent: To: Subject: Attachments: IP [(b) (6) frenchangel59.com] 4/9/2017 10:15:35 PM David shulkin [drshulkin@aol.com] FW: VA- EPIC Advisory Committee On Veterans Healthcare.03.9.2017.docx; Contact lnformation.docx From: IP [mailto:(b) (6) renchanqel59.com ] Sent: Sunday, April 09, 2017 6:12 PM To: '(b) (6) who.eop.gov' Cc: (b) (6) who.eop.gov; Ivanka Kushner ((b) (6) (b) (b) (6) (6) (b) (6) mail.com Subject: VA - EPIC (b) (6) It was pleasure meeting and having dinner with you last night. We very much look forward to working with you on the VA. A little more background on EPIC. The DOD recently signed a new contract to implement a new system called Cerner with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. As I mentioned last night, there is a push for the VA to choose the same Cerner system. What the VA needs is a system that can speak to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership). The top 5 Academic Medical Centers do not use Cerner and highly recommend against using it, and instead strongly favor using another system called EPIC. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. Using EPIC, therefore, as the VA platform will allow seamless integration with the platform of the majority of community and academic medical centers. As a result, when veterans access care outside the VA system (the choice extension) there will be the necessary access and integration to vital medical information. This means less cost, easier access to the doctors, patients and veterans and their medical records. In addition, the VA's doctors and doctors in training who come from the academic medical centers and who practice part time at the VA have been trained on and use EPIC. It would be impractical to expect them to learn two different systems. Also, the VA conducts medical research with academic medical centers across the nation, and using something other than EPIC would make many vital research projects more costly to integrate and collect data. The VA has confirmed that they are on same page to pursue EPIC as their EMR of choice, instead of Cerner. Cerner has claimed that its system cannot talk to EPIC if the VA chooses EPIC. We, however, believe that EPIC will allow for this cross talk. We also believe that the ability of working with the two different platforms is, in reality, an artificial barrier by Cerner that can be resolved if they choose. As I discussed yesterday, the best solution is for the DOD to change to EPIC, for the good of the DOD, the soldiers, the VA and our veterans. However, if that is not in the cards, then It is CRITICAL that Cerner be mandated to design its DOD system to talk to (be able to share medical records with) whatever system the VA VA-19-0799-D-000815 OS 00002486 chooses to install. It is very important that this is resolved quickly at the DOD/Cerner level by instructions from the White House. If you think it will be beneficial for you to talk directly to the experts at the Academic Medical Centers, you can call one of the people working on the VA effort with me, Dr. Bruce Moskowitz, and he will be happy to arrange discussions with the head IT leaders at any or all of the top 5 academic medical centers so you can hear their points of view and perspectives on this topic directly. Bruce's phone number is (561) 346-(b) (6) and his email is (b) (6) mac.com . I have also attached my contact information. Regards, Ike VA-19-0799-D-000816 OS 00002487 ADVISORY ON VETERANS HEALTH CARE 1. Dr. David Shulkin, Secretary for Health for the Department of Veterans Affairs (b) (6) 2. Dr. (b) (6) President and CEO of the Cleveland Clinic (b) (6) 3. Dr. (b) (6) President and CEO of the Mayo Clinic (b) (6) 4. Chair Department of Public Affairs of the Mayo Clinic (b) (6) (b) (6) 5. Dr. President and CEO of Partners HealthCare (Massachusetts General and Brigham and Women's Hospitals) (b) (6) (b) (6) 6. Dr. Dean and CEO of Johns Hopkins Medicine 7. Marc. B. Sherman, Senior Partner at international business restructuring and financial consulting firm Alvarez & Marsal (b) (6) 8. (b) (6) Chairman and CEO of Kaiser Foundation Health Plan, Inc. and Hospitals - known as Kaiser Permanente, one of America's leading integrated health care providers and not-for-profit health plans. 9. Dr. Bruce Moskowitz, who has observed in frustration over his years as a noted Palm Beach physician in private practice the crucial need to overhaul our system of delivering veterans' health care. (b) (6) is the wife of injured Purple Heart Veteran, co10. founder of Hope Unseen, mother, nurse BSN, news contributor, speaker and believe that there is always joy to be uncovered. 11. Laura r'Laurie") Perlmutter, a member of the Board of Trustees of NYU Langone Medical Center and of the Board of Advisors of the Laura & Isaac Perlmutter Cancer Center at NYU Langone, which she established with her husband Isaac Perlmutter. 12. Isaac ({like") Perlmutter, a self-made and highly successful business leader and member of the Board of Trustees of NYU Langone whose support for medical research and care has included the establishment, with his wife Laura of the Perlmutter Cancer Center at NYU Langone. VA-19-0799-D-000817 OS 00002488 Our contact Information below: Laurie Perlmutter 561-585-1571 (Home) 561-818-3073 (Cell) Email: (b) (6) gmail.com Ike Perlmutter 561-586-6707 (Home) 561-685-8824 (Cell) **Please note I rarely keep the cell "ONn - If you can't reach me call Marisol - Marisol is able to find me any time. Email: (b) (6) frenchangel59.com Assistant: Marisol Garcia 212-576-(b) (6) (Office) 212-576-(b) (6) (Weekend Office) Cell: 646-668-(b) (6) (Marisol's Cell) Email: (b) (6) frenchangel59.com Please feel free to email or call us any time. VA-19-0799-D-000818 OS 00002489 Message From: Sent: To: CC: David shulkin [Drshulkin@aol.com] 5/1/2017 12:34:16 AM (b) (6) [(b) (6) erwin@va.gov] (b) (6) [(b) (6) va.gov]; Poonam Alaigh [(b) (6) hotmail.com] and (b) wand see if they are able to join me and dr alaigh for a can you reach out to verna, (b) (6) (6) dinner mobday (tommorow night) at 630 pm at the source (at nuseum) to informally discuss choice - i know its no notice but its my only open evening for a while- we will go if 1,2 or all 3 are able to join Sent from my iPhone VA-19-0799-D-000819 OS 00002490 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/10/2017 10:30:11 PM To: Bruce Moskowitz [(b) (6) mac.com] Re: VA & Epic Core Competencies in Healthcare - Draft Subject: Bruce- ill call you on tuesday Happy Passover David Sent from my iPhone On Apr 10, 2017, at 12:57 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: I had an excellent call with (b) (6) and her staff. They are ready to move forward with the integration idea that we discussed on Friday. Second they are in favor of a system that allows a total open platform that any EMR can freely exchange records with. They believe that the Veteran should have the ability to have medical records sent to or sent from any EM R system. Third they will donate as a service to the Country their expertise in prevention of the opioid addiction, maternal health, mental health and a medical device registry. I would suggest you contact them to move forward. Thank you Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: <(b) (6) epic.com > From: (b) (6) Date: April 10, 2017 at 12:33:34 PM EDT To: "(b) (6) mac.com " <(b) (6) mac.com > (b) (6) (b) (6) Cc: < epic.com >, (b) (6) <(b) (6) epic.com > Subject: VA & Epic Core Competencies in Healthcare - Draft VA-19-0799-D-000820 OS 00002491 Message Bruce Moskowitz [(b) (6) mac.com] Sent: 4/10/2017 4:57:22 PM David Shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) hotmail.com] To: (b) (6) (b) (6) @epic.com]; (b) (6) (b) (6) @epic.com] CC: [(b) (6) epic.com]; (b) (6) Subject: Fwd: VA & Epic Core Competencies in Healthcare - Draft Attachments: VA & Epic - Core Competencies in Healthcare VlO.docx; Untitled attachment 05099.htm From: and her staff. They are ready to move forward with the integration idea that I had an excellent call with (b) (6) we discussed on Friday. Second they are in favor of a system that allows a total open platform that any EMR can freely exchange records with. They believe that the Veteran should have the ability to have medical records sent to or sent from any EMR system. Third they will donate as a service to the Country their expertise in prevention of the opioid addiction, maternal health, mental health and a medical device registry. I would suggest you contact them to move forward. Thank you Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: <(b) (6) epic.com > From: (b) (6) Date: April 10, 2017 at 12:33:34 PM EDT To: "(b) (6) mac.com " <(b) (6) mac.com > Cc: (b) (6) <(b) (6) epic.com >, (b) (6) <(b) (6) epic.com > Subject: VA & Epic Core Competencies in Healthcare - Draft VA-19-0799-D-000821 OS 00002492 Department of Veterans Affairs: Core Competencies in Healthcare Size and Complexity Lifetime Care The Best Care Choice Of Care Scalability and Performance The VA is the largest integrated healthcare delivery system in the U.S with over 1,700 sites of care. The VA has over 20,000 beds across 168 VA Medical Centers and completes over 100 million outpatient appointments annually. The VA serves more than 8.9 million Veterans each year. Epic Footprint The largest integrated civilian health systems in the U.S. run Epic, such as Kaiser Permanente, Sutter, Mayo Clinic, Partners, and Providence. • Kaiser Permanente serves over 11.3 million members across 38 hospitals and 661 clinics. • Over 336,000 physicians use Epic. • 57% of US population has a chart in Epic. Supporting Veterans at Every Stage The VA supports the entire continuum of care for all 22 million veterans, from the time they first see the veteran to death. VA provides services to treat all medical needs of a veteran throughout their lifetime, including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. Most VA medical centers offer specialty services including audiology, dermatology, dental, geriatrics, neurology, oncology, prosthetics, urology, and vision. Providing Quality The VA is a benchmark of excellence, value in health care and benefits by providing exemplary services that are both patientcentered and evidence-based. Veterans think highly of VA healthcare too. In 2015, the VA scored an 86 and 80 for inpatient and outpatient 1n customer service satisfaction, respectively, compared to an average of customer service satisfaction score of 74 across private sector hospitals. A Full Suite of Products EpicCare clinical systems provide a single healthcare platform to support a lifetime's worth of care for the veteran. Regardless of when or where the patient is seen at the VA, the clinician have access to the entirety of the patient chart. Modules for specialty care like Wisdom (dental), Cupid (cardiology), and Kaleidoscope (vision) are included as part of the enterprise Epic platform. Veterans and their caregivers have 24/7 access to the MyChart Patient Portal, allowing them to check lab results, message clinicians, request an appointment, and much more. The Best EHR Software Epic software helps organizations deliver the best possible care to patients. • Truven Top 100 - more hospitals use Epic than any other system. • Leapfrog Top Hospitals for Quality and Safety - more hospitals use Epic than any other vendor. • KLAS surveys - healthcare organizations rank Epic as having the #1 software suite each year for the last seven years. Retaining the Veteran Customer Base With the expansion of the Choice Act, veterans now have more options to see care outside of the VA VA retains its patient base by being the best. VA provides value in health care, superb customer service, and cutting edge care and technology to keep veterans coming back to VA for their hea Ith ca re. Patients Notice the Best Software Epic software keeps patients coming back. Customer Success: • A Kaiser Permanente study showed MyChart positively impacts patient loyalty and member satisfaction. Users are 2.6 times more likely than nonusers to remain KP members. 85% of users rate email encounters an 8 or a 9 on a 9-point scale. VA-19-0799-D-000822 OS 00002493 Suicide Prevention Mental Health Drug and Opioid Addiction Decreasing Veteran Suicides An average of 20 veterans die from suicide each day. As a leader in evidence-based care for suicide prevention, VA utilizes risk scoring data elements and screening tools for proactive and reactive suicide crisis care. For preventative care, VA uses predictive models to determine which Veterans may be at highest risk of suicide, so providers can intervene early. For those veterans in suicide crisis, the Veterans Crisis Line is available to veterans in time of need. The Veterans Crisis Line has answered over 2.3 million calls, 55,000 texts, and made over 376,000 referrals to a Suicide Prevention Coordinator. Mental Health Detection and Prevention Epic builds in preventive care and screening for depression and suicide risk, as well as associated follow-up plans, in physician, nurse and clinician workflows to ensure high visibility amongst all team members. Veterans determined at risk for a crisis event after assessment can be automatically referred to a Suicide Prevention Coordinator without any additional end user intervention. For veterans in crisis, same-day mental health or telehealth appointment slots are reserved for their care. Customer Success • Institute of Family Health reached a depression screening rate of nearly 90% through workflows in Epic. Four Principles of VA Mental Health Care Mental health is the most pervasive health issue the VA faces on a daily basis. 50% of all veterans face mental health issues, according to VA Secretary David Shulkin, with 30% of soldiers developing mental problems within 3 to 4 months of being The Right Data at the Right Time Epic support of mental health workflows ensures that whether a veteran has an acute or a chronic condition, clinicians have the tools keep the veteran healthy. Key lab, demographic and assessment data are combined in a single view for easy analysis and diagnosis. home. VA has developed core principles as a foundation to improve veteran mental health, including a 1) A Focus on Recovery, 2) Coordinator Care for the Whole Person 3) Mental Health Treatment in Primary Care and 4) Providing Veterans with a Mental Health Treatment Coordinator. Customer Success • UCLA implemented veteran mental health Managing the Epidemic Though all of the United States struggles with managing the drug and opioid crisis, the VA has a disproportionate rate of drug and opioid issues compared to the civilian population. Over 50% of veterans deal with chronic pain, compared to 30% of Americans nationwide. Veteran opioid-use disorders spiked by 55% from 2010 to 2015, and veterans are twice as likely to die from accidental opioid overdoses as nonveterans. The VA provides effective, scientifically proven drug and opioid dependency services for all veterans, no matter where they come for services. • program in partnership with Wounded Warriors for psychological health support JPS saw use of evidence-based protocols on dosing, best practices, and pitfalls increase from 6% to 95% on their Virtual Psychiatric Service. Addiction Care Planning Tools Integrated clinical and pharmacy data within Epic aids in the identification of veterans with drug addictive behavior. Opioid reporting tools built into the system allow organizations to monitor and track prescriptions. Health and history assessments drive risk scores within Epic that detect patients with possibility of drug addiction, and automatically flag them for support services. Customer Success • MetroHealth saved 500 lives with Opioid Overdose Prevention Program through risk scoring and care planning tools within Epic. VA-19-0799-D-000823 DS 00002494 Prostheses and Physical Therapy Women's Health Veteran Housing and Food Insecurity Rehab and Prosthetic Care Over 31% (2.38 million) of all Veterans treated in VHA saw a rehabilitation care provider and nearly half of all Veterans seen 1n VHA have received prosthetic and sensory aids items and services. VA's Rehabilitation and Prosthetic Services office aligns medical expertise, clinical and practice guidance, and specialized procurement resources to provide comprehensive rehabilitation, prosthetic and orthotic, services across the VHA health care system in the most, economical and timely manner. Rehab for the Clinician and Veteran All veteran information from an initial prosthetic placement or injury consults and subsequent physical therapy visits are grouped together under a single therapy episode for ease of data access. Patient Goals tools allow veterans to track and contribute to their progress without clinician intervention, such as recording minutes walked each day, via the MyChart. Raising the Bar for Women Health Services Women are the fastest growing veteran population and VA strives to be a national leader in the provision of health care for women. However, there are still barriers to women veteran care today, such as effective outreach addressing women's health, location and hours of women's services, and gender sensitivity of health care staff. The Women Veterans Health Care program aims to break down these barriers to ensure that timely, equitable, comprehensive and high-quality health care is provided in a sensitive and safe environment at VA facilities nationwide. Increase in Positive Health Outcomes for Women Epic creates standard ways to document medical histories for gender minorities, preventing clinically relevant information from being overlooked and helping clinicians provide tailored care. Epic's pregnancy tools include prenatal checklists to ensure that prenatal checkups and education classes are completed. Supporting the Homeless and Hungry Veteran care delivery goes beyond the walls of the traditional care setting. VA is serving more Veterans than ever who are homeless or at risk of homelessness. Since 2010, more than 365,000 Veterans and their family members have been permanently housed or prevented from falling into homelessness. In recent years, hunger among the more than 12 million veterans over 60 is reaching critical levels, and estimates are that over 300,000 elderly veterans are food insecure. Efforts at VA to keep veterans fed and with shelter prevent more serious health events. Epic in the Community Epic uses social determinants of health to flag veterans who may be at risk for food and shelter needs to automatically enroll them in social programs. Healthy Planet Link provides web based tools to community organizations to contribute health and social assessments into the patient chart. Customer Success: • Hospital For Special Surgery implemented scheduling acute care visits with Epic, enabling a systematic approach to care provisioning to ensure all patients are seen. Customer Success. • UPMC increased prevention of medicationinduced births by notifying physicians when they order teratogenic medications for women who could become pregnant. • Children's Hospital Colorado saw clinicians act on 99% of decision support reminders to screen mothers for postpartum depressions. Customer Success • ProMedica implemented a screening initiative to connect patients experiencing hunger or food insecurity to an on-site food pharmacy and other food resources. • OHSU utilized Epic to identify patients for a transitional care program, helping to improve quality of care for the underserved who transition from the hospital to home. VA-19-0799-D-000824 OS 00002495 Veteran Access to Care Team Based Approach to Care Dispersed Patient Population Right Access at the Right nme Provide timely access to veterans as determined by their clinical needs is the number 1 priority at VA VA has initiated a number of programs to make sure veterans receive the care they very much so deserve. The partnership between the VA and CVS in California now offers urgent care services to more than 65,000 veterans. The Stand Down initiative ensured 56,000-plus identified urgent care had been successfully resolved. Additional healthcare staff and an increase in advanced scheduling software has helped decrease veteran wait times. Faster Access to Care with Scheduling Tools Referrals provide closed-loop communication in Epic allowing staff at VA to verify that a veteran received care at an outside facility, such as CVS or Wal greens. Epic's Fast Pass automated wait list tool lets veterans receive earlier appointment slots as they open up due to cancellations. Most critical patients, such as those with mental health and life threatening illnesses, are offered earlier appointments first. Coordination Across Care Team Members A core strength at VA is its team-based, Veteran-centric model of primary care that focuses on patient-driven, proactive, and personalized care. This patient aligned care team - including primary care providers, nurses, social workers, pharmacists, nutritionists, behavioral health professionals, as well as the Veteran, family members, and caregivers - addresses not only disease management, but also disease prevention, wellness, and health promotion. Communication is Key Epic focuses on providing patient care via a multi-disciplinary approach. Treatment planning tools, screenings and risk scores, are embedded throughout all clinical workflows. Clinicians utilize a longitudinal plan of care that summarizes data across all encounters. Secure Chat allows care team members to send secure text messages through desktop and mobile devices. Access to Care Anywhere A quarter of all Veterans in US, 5.2 million, returned from active military careers to reside in rural communities, Even with VA's large footprint across the nation, veterans may often find themselves hours from the nearest VA healthcare facility, or out of reach of specialist that they can regularly see due to living in a remote or rural area. The Office of Rural Health provides enterprise-wide programs to veterans in rural areas to make sure they stay healthy. Programs include Tele-Intensive Care Units, Telemental Health Hubs, Rural Health Social workers, Rural Transportation Service, and Remote, telephone-based delivery of cardiac rehabilitation. See Your Patients Sooner Home Health tools in Epic allow home care nursing staff to stay connected. Traveling staff can communicate back to a full clinician care team while out in the field with a veteran via real time video and documentation needs. Telemonitoring tools expand veteran access to specialists regardless of where they are located. Customer Success • Kaiser Permanente saw a 50% reduction in no show appointment rates for patients who booked online using MyChart. Customer Success: • Bronson developed a multidisciplinary medication reconciliation program to decrease readmissions, reduce case manager workload, and improve clarity of patient medication instructions Customer Successes • Mercy Health's Telehealth program reduced inpatient length of stay and mortality rates declined by 40 percent, while the average cost of care significantly declined as fewer patients require a hospital stay • Telestroke tools and workf1ows in Epic allow neurologists to diagnose and treat a patient 0 exhibiting stroke symptoms at a different location using a video feed. VA-19-0799-D-000825 OS 00002496 Veteran Care Coordination with DoD and Private Sector Research Largest Safety Net in the U.S. Facilitating Data Exchange The majority of veterans use non-VA health care providers 1n addition to their VA providers. The VA has been a pioneer in healthcare IT to help connect veteran healthcare with data from both DoD private sector. VA has been a partner of eHealth Exchange, a network that connects federal agencies (including the VA, DoD, and SSA) and nonfederal organizations to improve patient care, streamline disability benefit claims, and improve public health reporting through interoperable health information exchange. VA has enhanced coordination 1n recent years with DoD through implementation of the Joint Legacy Viewer (JLV), a read-only tool that lets VA and DoD clinician see data from each system. Facilitating Research Efforts VA Research and Development plays a key role in advancing the health and care of Veterans, engaging patients and family's altruistic desires to improve health for fellow Veterans and others. VA fosters dynamic collaborations both within VHA and with external partners, such as the National Institutes of Health, academic affiliates and community partners. Research efforts in the VA such as the Million Veteran Program (MV), the largest genomic database in the world, aim to partner with Veterans receiving their care in the VA Healthcare System to study how genes affect health. The VA research partnership with IBM uses Watson to help VA doctors tailor cancer care. In 2016, VA spent $1.8 billion on research. Serving the Underserved The VA shares many of the same characteristics of large safety nets, and the VA could be considered the largest of all safety nets in the US. Health issues such as diabetes, domestic abuse, and obesity are disproportionality high within the veteran population. VA responds to the needs of the socially-disenfranchised with targeted programs, outreach, and prevention. Most Experienced in Interoperability 100% of Epic organizations are interoperable with organizations inside or outside of the Epic community. Epic is a proud member of the eHealth Exchange, as well as Carequality, a public-private, multi-stakeholder collaborative that uses a consensus-based process to enable seamless connectivity across all participating networks. Cerner/commonwell, athenahealth, eClinicalWorks, NEXTGEN, GE and surescripts are all carequality participants. • 90 billion transactions occur between Epic systems and non-Epic systems each year. • Epic's Care Everywhere is the #1 ranked Health Information Exchange (HIE). • No other EHR vendor has enabled 100% of its healthcare organizations to interoperate. Reduce Barriers to Clinical Research Epic's research module natively integrates clinical workflows and documentation with clinical trials and observational studies to help advance communication and partnership between clinicians and researchers. The Cosmos Research Network, Epic's cross-organization research collaboration, will allow participants access a database to compare therapies and outcomes, discover causes, identify side effects, determine efficacy of treatments, and study extreme outliers through a nationwide patient dataset. Customer Statistics • The Top 15 NIH research grants by amount of funding go to organizations that use Epic. • 14 of 15 U.S. News and World Report's top medical research hospitals use Epic. • The Flint, Michigan water study used Epic to discover the lead crisis at hand. More Safety Net Organization Use Epic Epic is the chosen software vendor for many of the nation's largest safety net organizations such as Contra Costa, Legacy Health, MetroHealth, and New York City Health and Hospitals. Customer Success • Legacy Health uses Community Connect for disability group homes. • Contra Costa uses Epic in detention centers. VA-19-0799-D-000826 OS 00002497 Message Bruce Moskowitz [(b) (6) mac.com] 4/27/2017 11:09:52 AM David shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) Fwd: VA mental Heath From: Sent: To: Subject: hotmail.com] Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: From: (b) (6) <(b) (6) nyspi.columbia.edu> Date: April 26, 2017 at 11 :22:47 PM EDT To: Bruce Moskowitz <(b) (6) mac.com> Subject: Re: VA mental Heath Bruce let me know if you need the statement endorsing Mccance-Katz nomination sent as a letter on my letter-head (b) (6) M.D. Lawrence C. Kolb Professor and Chairman of Psychiatry, Columbia University College of Physicians and Surgeons, Director, New York State Psychiatric Institute Psychiatrist-in-Chief, New York Presbyterian Hospital-Columbia University Medical Center 1051 Riverside Drive - Unit #4 New York, NY, 10032 Phone (646) 774-(b) (6) email: (b) (6) www.(b) (6) columbia.edu com VA-19-0799-D-000829 OS 00002500 Follow me on twitter~ @(b) (6) Watch my talk on E Q,X T1 (b) (6) From: (b) (6) <(b) (6) nyspi.columbia.edu > Date: Wednesday, April 26, 2017 at 4:32 PM To: Bruce Moskowitz <(b) (6) mac.com > Subject: Re: VA mental Heath Bruce, see comments re our discussion on the Asst Secy appointment, recommendations to Secy Shulkin on military mental health and research. Sorry for the length. Let me know if you need me to send in different format. (b) (6) I. Assistant Secretary of Mental Health I enthusiastically support (as does the APA https://www.psychiatry.org/newsroom/news-releases/apa-supportsnomination-of-dr-mccance-katz-urges-senate-to-confirm) Dr. Elinore Mccance-Katz for the Asst Secy position. She is an M.D., Ph.D. with a background in addiction research and clinical care, who is committed to and experienced in public mental health care. She moved from the Univ. of California at San Francisco where she was on the faculty in the Dept of Psychiatry, to become Medical Director of SAMHSA. After only a year she resigned from this position because she appropriately objected to the unscientific and wasteful activities of the agency and its hostility to modern medicine and evidence based mental health care. Most recently, she was the Director of Mental Health for the State of Rhode Island. She is qualified and would be an excellent choice, despite what Congressman Murphy has said. VA-19-0799-D-000830 OS 00002501 2. lmproving Military Mental Health Care The first attachment is a summary providing guidance to the Secretary of the Veterans Administration on how to improve mental health care to military personnel. Briefly, what I recommend to Secretary Shulkin is: 1. 2. 3. 3. Convene a review committee of experts in mental health care, services, systems and financing. Committee to review existing scope of VA programs and services to identify which work and are good (or could be with better staffing and oversight) and what new services need to be developed. Develop a plan for implementation including resource, workforce, training and quality control and oversight. Disruptive Research I believe that if funding is directed to the best scientists to carry out goal directed research on the most urgent military mental health, gamechanging progress can be made in PTSD, suicide, aggression and TBI. Three examples of outstanding research proposals by National Academy of Science level researchers that have never worked on military or VA issues and have been denied funding are summarized below. 1. Development of Stress Resilience-Enhancing Medications as Primary Prophylaxis against PTSD and MDD Christine Denny, Ph.D. and Rene Hen, Ph.D. Columbia University VA-19-0799-D-000831 OS 00002502 Post-traumatic stress disorder (PTSD) is a leading mental health problem that can occur after a traumatic event, such as sexual assault, war, or injury. PTSD affects approximately 8 million adult Americans, with an annual prevalence of 3.5% across the general population (Kessler et al., 2005). Soldiers and veterans, however, are at greater risk of developing PTSD. The estimated prevalence of PTSD is 13.8% in previously deployed Operation Enduring Freedom and Operation Iraqi Freedom (Afghanistan and Iraq) service members, and 10.1 % in Gulf War Veterans, and lifetime prevalence, including partial PTSD, is over 30% in American Vietnam theater veterans (Tanielian et al., 2008; Kang et al., 2003; National Vietnam Veterans Readjustment Study (NVVRS)). Department of Defense (DoD) expenditure on PTSD care for service mem hers has increased over time, reaching almost $300 million in 2012. In the same year, the Veterans Affairs (VA) spent $3 billion on PTSD care for veterans; a striking reminder of the chronic and cumulative costs of the disease (IOM, 2014). In addition to PTSD, depression affects 350 million people worldwide and has now surpassed HIV/AIDS, malaria, diabetes, and war as the leading cause of disability (Marcus et al., 2016). Estimated at $2.5 trillion in 2010, the global cost of mental illness is expected to rise to $6 trillion in the next 15 years (Bloom et al., 2011). Furthermore, rates of depression are five times higher in soldiers than in civilians (The Army Study to Assess VA-19-0799-D-000832 OS 00002503 Risk and Resilience in Servicemem bers (Army STARRS)). Stress exposure is one of the greatest risk factors for both major depressive disorder (MDD) and PTSD. Traumatic life stress causes PTSD and is the initial trigger in 80% of cases of MDD (Mazure, 2006). Traditionally, affective disorders have been treated from a symptom-suppression approach. Existing drugs aim to mitigate the impact of these chronic diseases, but do not cure or prevent the disease itself. There are no known cures. Prevention, if discussed at all, is usually thought of only in terms of behavioral interventions. However, if drugs were developed that enhance stress resilience, they could potentially be used in at-risk populations to protect against stress-induced psychiatric disorders. Describe how the proposed research project addresses one or more of the FY16 PRMRP Topic Areas. The proposed project is relevant to the FY16 PRI\!IRP Topic Area of Psychotropic ~fedications. Specifically, our research will directly address: 1) the FY16 PRMRP Area of Encouragement: research on the use of psychotropic medications to increase resilience in military units.We have discovered the first resilienceenhancing compounds that may prevent stress-related psychiatric disorders. This proposal aims to identify and develop novel lead compounds with potential resilience-enhancing and prophylactic efficacy against these disorders. This proposal also addresses: 2) the FY16 PRMRP Area of Encouragement: research to evaluate the VA-19-0799-D-000833 OS 00002504 use of psychotropic medications for mental health issues specific to women in the military. All the experiments that we have outlined will be performed in male and female mice. This is of the utmost importance as women respond differently to medications and are twice as likely to develop MDD and PTSD. The ultimate product to be developed is a psychotropic drug that enhances resilience and provides long-lasting protection against stress-induced psychiatric disorders, like PTSD and MDD, in a prophylactic (or vaccine-like) fashion. Using targeted compound screening and subsequent hit-to-lead optimization followed by lead optimization, this proposal aims to develop a suitable clinical candidate for a subsequent Investigational New Drug (IND) application. Stress resilience: One in five soldiers returns from combat with PTSD, combat-associated ~1DD, or both (Tanielian et al., 2008). Perhaps more surprising, however, is that 4 out of 5 soldiers do not develop psychopathology. This ability to adapt to stress without developing psychopathology is known as stress resilience. Until recently, research on stress resilience has been predicated on the assumption that resilience is a passive property - more or less the absence of the risk factors that make individuals susceptible to stress-induced pathology. Recent work in animal models, however, suggests that the VA-19-0799-D-000834 OS 00002505 neurobiology of stress resilience is mediated through active processes, and often distinct, parallel mechanisms to those of susceptibility (Krishnan et al., 2007; Chaudhury et al., 2013; Walsh et al., 2014). The idea that enhancing stress resilience could protect against the development of psychiatric disorders is an appealing one, but treatments to increase resilience are still in their infancy. Current interventions fall predominantly on the behavioral side, with psychotherapy, exercise, and stress inoculation-mild stress exposure to promote adaptive coping to subsequent severe stress (Levine, 1957; Lyons and Parker, 2007)being the best available tools to increase resilience clinically (l\1eredith et al., 2011). Rodent studies also suggest a role for exercise and enriched environment in stress resilience (Schloesser et al., 2010; Lehmann and Herkenham, 2011; Schoenfeld, et al., 2013). Beyond behavioral manipulations, researchers have successfully increased resilience biochemically in mice through viral and transgenic overexpression methods (Donahue et al., 2014), optogenetic activation (Chaudhury et al., 2013), and chronic blockade of stress hormones. However, none of these interventions is directly translatable to the clinic. Here, we propose to develop the first clinically applicable resilience-enhancing therapeutics for the prevention of stress-induced psychopathology. VA-19-0799-D-000835 OS 00002506 2. A Clinical Trial of Letrozole for the Treatment of Irritable Aggression in PTSD David Anderson, Ph.D. California Institute of Technology http://www.bbe.caltech.edu/content/david-j-anderson Rationale: Both military trauma exposure and posttraumatic stress disorder (PTSD) have been linked to problems with aggression. Traumarelated irritable aggression is associated with impairments in interpersonal relationships, dysfunction at work and school, intimate partner violence, and legal problems. Among male combat veterans of the conflicts in Iraq and Afghanistan, 57% reported problems controlling anger, and controlling anger was the most common post-deployment readjustment problem reported by veterans with and without probable PTSD (Sayer et al, 2010). More serious manifestations of aggression affect a smaller yet substantial subpopulation: 13% of Iraq and Afghanistan veterans reported engaging in violence towards family, while 9% reported violence towards strangers. Violent criminal offenses were found to be 2-3 times higher (6-8%) in veterans with PTSD compared to those without PTSD (3%). Irritability, anger, and aggressive behavior are often targeted for treatment in patients with PTSD. While cognitive behavioral therapy (CBT) for PTSD modestly reduces anger symptoms, response rates are less than optimal, and several studies show an association between baseline anger and CBT non-response. Further, retention of veterans in CBT for aggression can be difficult, and those terminating early demonstrate no improvement (Galovski et al., 2014). For patients unwilling to engage in CBT, or who do not respond optimally, a pharmacological option may be beneficial. However, there are no established pharmacological treatments with clear efficacy for irritable or impulsive aggression in PTSD. Specific effects on aggression of serotonin reuptake inhibitors (SSRis ), the only FDA approved medications for the treatment of PTSD, have not been investigated; in fact, increased irritability and anxiety are potential side effects of SSRis. VA-19-0799-D-000836 OS 00002507 Moreover, male combat veterans are often resistant to SSRis (e.g., Friedman et al., 2007), although ethnic differences may play a role. Although not well-investigated, anti-adrenergic medications (e.g., prazosin or doxazosin) and atypical neuroleptics may counter irritable, impulsive aggression in some veterans by antagonizing effects of stressinduced monoamine surges at noradrenergic alpha-I or serotonin (5HT)type 2 receptors in the frontal lobe or amygdala, or secondarily through effects on sleep (Pitman et al., 2012). These agents are often avoided, however, due to potential long-term side effects (e.g., tardive dyskinesia or metabolic syndrome) or undesirable drug interactions (alpha-I noradrenergic antagonists interact unsafely with drugs for erectile dysfunction). It is therefore critical to develop new, well-tolerated, and more effective pharmacotherapeutics for irritable impulsive aggression in veterans. A potential novel approach to reducing irritable aggression has arisen recently from work in rodents (Anderson, 2012, 2016). Evidence accumulated over the last 25 years indicates that conversion of testosterone (T) to estrogen (E) by the enzyme aromatase (AT) contributes to many physiological processes and behaviors in males, including aggression. In mutant mice lacking the androgen receptor, supplemental T restores male aggressive behavior. AT gene knockout reduces inter-male aggression, an effect reversed by E. AT inhibitors (Als) reduce aggression in fish, birds and rodents; thus, effects on aggression of AT gene knockout are not due simply to developmental effects of reduced E. AT is expressed in brain regions implicated in aggression, including the hypothalamus, frontal cortex and amygdala. The laboratory of our collaborator, David Anderson, Ph.D., has recently shown that neurons in the ventromedial hypothalamus (VMH) that promote aggression in mice express the E-1/alpha receptor (Esrl) (Lee et al., 2014). Knockout of the Esrl gene dramatically reduces inter-male aggression in mice, an effect that cannot be overcome by T. Similarly, RNAi-mediated knock-down of Esrl mRNA in the VMH dramatically reduces inter-male aggression (Sano et al., 2013). VA-19-0799-D-000837 OS 00002508 A shift away from E to T synthesis by AI administration, even though T and E levels may stay within the normal range (Goudrian et al., 2010), may also influence other neurobiological systems of relevance to PTSD. T increases, while E inhibits, synthesis of neuropeptide Y (NPY), which in turn modulates sympathetic system reactivity, anxiety, distress, and dissociation during stress. Baseline NPY levels and NPY responses to sympathetic system activation are markedly low in combat veterans with PTSD. In contrast, increased NPY responses to extreme stress correlate positively with military performance requiring behavioral restraint and use ofpreviously learned skills. E also upregulates 5HT 2A receptors in the frontal cortex of males and females (e.g., Frokjaer et al., 2010). Increases in frontal cortical 5HT 2A receptors have been observed in postmortem brain of violent suicide victims (Mann et al, 1989; Hrdina et al., 1993 ), and by neuroimaging in the brains of impulsively aggressive dogs (Vermeire et al., 2011) and humans (Laruelle et al., 201 0; Rosell et al., 2010). T also upregulates allopregnanolone in males (Mitev et al., 2003), whereas experimentally induced allopregnanolone deficits result in mouse-on-mouse homicidal aggression (Pinna et al., 2005). An estrogen5HT 2A or 2c receptor-aggression endophenotype is supported in the PTSD literature. Southwick et al. (1997) demonstrated that one third of Vietnam veterans with PTSD experienced acute panic and PTSD symptoms in response to meta-chlorophenylpiperazine (mCPP), a potent 5HT 2A, 5HT2B, and 5HT 2c receptor agonist. It thus should come as no surprise that a loss-of-function allele of the serotonin transporter gene that increases synaptic 5HT levels increases PTSD risk, or that SSRis are ineffective in so many male veterans. Whether this endophenotype manifests in women is less clear; however, a polymorphism of the Esensitive PACAP gene increase PTSD risk in women. These studies thus suggest that reducing T to E conversion by Als may reduce irritable aggression as well as other symptoms of PTSD. Data so far support the safety of Aisin men (Goudriaan et al., 2010; de Ronde and de Jong, 2011). Als are prescribed in males for a variety of medical disorders, including infertility, short stature, and gynecomastia. They also are used by body builders to counter the negative impact of exogenous T. Als used widely for breast cancer chemoprevention in women are associated with modest decreases in bone mineral density. VA-19-0799-D-000838 OS 00002509 However, Ais appear to have less impact on bone in males, possibly because of the high rate of T to E conversion in males. A 10-week course of anastrozole in young eugonadal males revealed no catabolic effects on protein metabolism, body composition, muscle strength, or bone calcium metabolism. Also, no significant side effects or negative effects on metabolism were observed in a 10-day trial of exemestane in males. 3. Role of Leaky Neuronal Ryanodine Receptors in Stress-Induced Cognitive Dysfunction Andrew R. Marks M.D., Ph.D. Department of Physiology and Cellular Biophysics, Clyde and Helen Wu Center for Molecular Cardiology Columbia University College of Physicians and Surgeons SUMMARY The type 2 ryanodine receptor/calcium release channel (RyR2), required for excitation-contraction coupling in the heart, is abundant in the brain. Chronic stress induces catecholamine biosynthesis and release, stimulating b-adrenergic receptors and activating cAMP signaling pathways in neurons. In a murine chronic restraint stress model, neuronal RyR2 were phosphorylated by protein kinase A(PKA), oxidized, and nitrosylated, resulting in depletion of the stabilizing subunit calstabin2 (FKBP12.6) from the channel complex and intracellular calcium leak. Stressinduced cognitive dysfunction, including VA-19-0799-D-000839 OS 00002510 deficits in learning and memory, and reduced long-term potentiation (L TP) at the hippocampal CA3-CA 1 connection were rescued by oral administration of S 107, a compound developed in our laboratory that stabilizes RyR2-calstabin2 interaction, or by genetic ablation of the RyR2 PKA phosphorylation site at serine 2808. Thus, neuronal RyR2 remodeling contributes to stress-induced cognitive dysfunction. Leaky RyR2 could be a therapeutic target for treatment of stressinduced cognitive dysfunction. (b) (6) M.D. Lawrence C. Kolb Professor and Chairman of Psychiatry, Columbia University College of Physicians and Surgeons, Director, New York State Psychiatric Institute Psychiatrist-in-Chief, New York Presbyterian Hospital-Columbia University Medical Center 1051 Riverside Drive - Unit #4 New York, NY, 10032 Phone (646) 774-(b) (6) email: (b) (6) www.(b) (6) columbia.edu com VA-19-0799-D-000840 OS 00002511 Follow me on twitter~ @(b) (6) Watch my talk on E Q,X T1 From: Bruce Moskowitz <(b) (6) mac.com > Date: Friday, April 21, 2017 at 6:48 AM (b) (6) To: (b) (6) <(b) (6) nyspi.columbia.edu> Subject: Re: VA mental Heath Anytime this weekend or next week Sent from my iPad Bruce Moskowitz M.D. On Apr 21, 2017, at 2:51 AM, (b) (6) <(b) (6) nyspi.columbia.edu> wrote: Hi Bruce, Hope all is well. I have been involved with DS re VA mental health and that interaction has gone well. Thank you for facilitating. I would like to briefly chat with you re couple of related issues. Please let me know when would be a convenient time to call you or best way to arrange. (b) (6) (b) (6) M.D. Lawrence C. Kolb Professor and Chairman of Psychiatry, VA-19-0799-D-000841 OS 00002512 Columbia University College of Physicians and Surgeons, Director, New York State Psychiatric Institute Psychiatrist-in-Chief, New York Presbyterian Hospital-Columbia University Medical Center 1051 Riverside Drive - Unit #4 New York, NY, 10032 Phone (646) 774-(b) (6) email: (b) (6) www.(b) (6) columbia.edu com Follow me on @(b) (6) Find me on Watch my talk on Watch my talk on From: Bruce Moskowitz <(b) (6) mac.com > Date: Tuesday, March 14, 2017 at 7:25 PM (b) (6) To: (b) (6) <(b) (6) nyspi.columbia.edu> Cc: David Shulkin Subject: VA mental Heath Thank you David and I will review. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000842 OS 00002513 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/11/2017 11:13:09 AM Poonam Alaigh [(b) (6) hotmail.com] Re: USH commission No Sent from my iPhone > on Apr 11, 2017, at 5:34 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Is Bruce on it > > Sent from my iPhone VA-19-0799-D-000843 OS 00002514 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/11/2017 9:34:59 AM David Shulkin [drshulkin@aol.com] USH commission Is Bruce on it Sent from my iPhone VA-19-0799-D-000844 OS 00002515 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/12/2017 11:37:11 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Thanks for this tremendous opportunity I cannot imagine a bigger platform for us to be doing together at this time- and then after this experience we can do something amazing as well Sent from my iPhone > on Apr 12, 2017, at 5:53 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > I am so emotional and probably am overreacting today, but I know you understand. > > In this moment, I truly and sincerely believe that it is because of you, David, that I have had a very very small role in a huge opportunity to make a positive impact on the care of my veterans. I just want to ingrain this moment in my memory forever. After all, this is the purpose of life- to make a positive impact in the lives of others- and you are helping me with my purpose! I don't know how long we will be working together and if there are other things we will accomplish together, but it has all been worth it my dearest friend! Thank you! > > Sent from my iPad VA-19-0799-D-000845 OS 00002516 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/12/2017 9:53:06 AM Drshulkin@aol.com Thanks for this tremendous opportunity I am so emotional and probably am overreacting today, but I know you understand. In this moment, I truly and sincerely believe that it is because of you, David, that I have had a very very small role in a huge opportunity to make a positive impact on the care of my veterans. I just want to ingrain this moment in my memory forever. After all, this is the purpose of life- to make a positive impact in the lives of others- and you are helping me with my purpose! I don't know how long we will be working together and if there are other things we will accomplish together, but it has all been worth it my dearest friend! Thank you! Sent from my iPad VA-19-0799-D-000846 OS 00002517 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/9/2017 2:09:31 PM To: (b) (6) Subject: Re: MITRE @gmail.com ok that's fine- I have had no further discussions -----Original Message----From: Darin Selnick <(b) (6) @gmail.com> To: David shulkin Sent: Sun, Apr 9, 2017 9:42 am Subject: MITRE Did MITRE get back with you after they met with Baligh and me? Baligh and I had agreed the time to engage them would be after we had solidified the future vision, which we did on Friday. I think we are ready, and I recommend we bring MITRE or some one to help us use the systems approach to flush out and develop our fully developed roadmap starting with an impact vs. feasibility assessment. This would be accomplished at the same time we are working with Congress on legislation and with stakeholders. We really need this to finalize the legislation so that it is air tight. I recommend we start this process next week. Darin VA-19-0799-D-000847 OS 00002518 Message To: Darin Selnick [(b) (6) @gmail.com] 4/9/2017 1:42:18 PM David shulkin [Drshulkin@aol.com] Subject: MITRE From: Sent: Did MITRE get back with you after they met with Baligh and me? Baligh and I had agreed the time to engage them would be after we had solidified the future vision, which we did on Friday. I think we are ready, and I recommend we bring MITRE or some one to help us use the systems approach to flush out and develop our fully developed roadmap starting with an impact vs. feasibility assessment. This would be accomplished at the same time we are working with Congress on legislation and with stakeholders. We really need this to finalize the legislation so that it is air tight. I recommend we start this process next week. Darin VA-19-0799-D-000848 OS 00002519 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/14/2017 1:07:03 AM David shulkin [Drshulkin@aol.com] Re: In the full report Just missing someone Sent from my iPad On Apr 13, 2017, at 9:05 PM, David shulkin wrote: I never saw a one word Poonam reply Must have been a tough day! Sent from my iPhone On Apr 13, 2017, at 8:53 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Thanks Sent from my iPhone On Apr 13, 2017, at 6:26 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000849 OS 00002520 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/14/2017 1:05:06 AM Poonam Alaigh [(b) (6) hotmail.com] Re: In the full report I never saw a one word Poonam reply Must have been a tough day! Sent from my iPhone On Apr 13, 2017, at 8:53 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Thanks Sent from my iPhone On Apr 13, 2017, at 6:26 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000850 OS 00002521 Message From: Poonam Alaigh [(b) (6) Sent: 4/14/2017 12:53:52 AM To: Bruce Moskowitz [(b) (6) David shulkin [drshulkin@aol.com] Re: In the full report CC: Subject: hotmail.com] mac.com] Thanks Sent from my iPhone On Apr 13, 2017, at 6:26 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000851 OS 00002522 Message From: Sent: To: Subject: IP [(b) (6) frenchangel59.com] 4/12/2017 2:35:24 PM David shulkin [drshulkin@aol.com] (b) (6) FW: (b) (6) of Kaiser Permanente - #2 Powerful man in the healthcare FYI EOP/WHO [mailto:(b) (6) From: (b) (6) Sent: Wednesday, April 12, 2017 10:31 AM To: IP Cc: (b) (6) Subject: Re: (b) (6) who.eop.gov] EOP/WHO of Kaiser Permanente - #2 Powerful man in the healthcare (b) (6) Thanks Sent from my iPhone On Apr 12, 2017, at 10:29 AM, IP <(b) (6) frenchangel59.com> wrote: Please look at the links below before our call on (b) (6) what's possible. This will help you understand https://share.kaiserpermanente.org/article/chairman-ceo-bernard-j-tyson-kaiser-permanentenam ed-n o-2-m od em-heal thcare-li st-influential -heal th-care-Ieaders/ https://www.bloomberg.com/ graphics/2015-how-did-i-get-here/bernard-tyson.html VA-19-0799-D-000852 OS 00002523 Message From: (b) (6) Sent: 4/12/2017 12:18:10 AM To: David Shulkin [drshulkin@aol.com]; Vivieca Simpson [(b) (6) Hires Subject: [(b) (6) gmail.com] gmail.com] http ://www.politico.com/story/201 7/04/donald-trump-white-house-staff-vacancies-23 7081 VA-19-0799-D-000853 OS 00002524 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 5/3/2017 2:30:32 AM Bruce Moskowitz [(b) (6) mac.com] (b) (6) [(b) (6) (b) (6) @uphs.upenn.edu]; drshulkin@aol.com Re: TinnitusMalingeringTest-bwol.docx Is there an attachment you can send (b) (6) thanks Sent from my iPhone On May 2, 2017, at 1:19 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: Thank you Sent from my iPad Bruce Moskowitz M.D. On May 2, 2017, at 1:13 PM, (b) (6) <(b) (6) (b) (6) @uphs.upenn.edu> wrote: Bruce, Please see the short summary that describes our development (in progress) of a test to see if a patient is "faking tinnitus". This is different from our parallel efforts ongoing that are focused on developing a test to confirm and potentially quantify tinnitus. This distinction is important as while we can wean out people who are faking with this concept I'm attaching in this email, we would need the other testing to substantiate the claim and extent of tinnitus that I mentioned in the previous emails and summaries. (b) (6) (b) (6) (b) (6) M.D. Gabriel Tucker Professor and Chairman Dept of Otorhinolaryngology - Head and Neck Surgery Associate Vice President, Director Physician Network Development The University of Pennsylvania Health System 3400 Spruce Philadelphia, 215-349-(b) (6) 215-615-(b) (6) 215-615-(b) (6) Street - 5 Ravdin PA 19104 (Academic Office) (Clinical Office) (Fax) VA-19-0799-D-000854 OS 00002525 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/12/2017 7:30:32 PM Poonam Alaigh [(b) (6) hotmail.com] Vivieca Wright Simpson [vivieca.Wright@va.gov] Fwd: ugh Sent from my iPhone Begin forwarded message: From: "Slack, Donovan" Date: April 12, 2017 at 3: 11 :55 PM EDT To: David shulkin Subject: ugh This is a big problem and growing (thousands and thousands ofreaders in the past hour alone). Maybe consider instituting some kind of rapid response protocol for press and medical issues in future? Not sure that's even possible in a federal agency, but throwing it out there. https://www.usatoday.com/story/news/politics/2017/04/ 12/veterans-danger-va-hospitalwashington-dc-investigation-finds/l 003 76124/ "A spokesman for the VA did not immediately respond to a message seeking comment." Donovan Slack White House and Veterans Affairs Correspondent USA TODAY (703) 854-8926 office (202) 415-9493 cell -----Original Message----From: David shulkin [mailto:Drshulkin@aol.com] Sent: Wednesday, April 12, 2017 7:19 AM To: Slack, Donovan Subject: Donovan- thanks for another fair and accurate story - i truly appreciate how you do things David Shulkin Sent from my iPhone VA-19-0799-D-000855 OS 00002526 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/15/2017 6:16:07 PM To: (b) (6) Subject: hotmail.com; vacodjsl@va.gov Events DC (b) (6) we need a statement to be developed for release on Monday as to the facts and timelines of the events at DC. We should develop the statement and then we can decide if we want to release and if so what if any of this is appropriate for release. As far as I Understand here is the timeline (VHA please confirm this as factual)- I am trying to focus on the major events and not all of the facts: The conversion of logistics systems back from the new system back to the old system at DC VA occurred on January 9th. On 1/12/17 the VISN requests VHA logistics to conduct an audit of the conversion. An audit occurs on January 24th-26th and determined there are deficiencies In February- the VISN and VHA logistics teams were notified and the Facility CLO was detailed off the service and an AIB was begun. A new Facility CLO was brought in and an action plan was sent to the VISN. Assistance from the logistics team rom the VISN continues in March At the end of March the VISN GMO rounds at the facility and identifies issues DUSHOM sends memo with new actions on 3/21/17. In this memo it notes that the VISN contacted IG and asks for guidance The VHA Patient Safety team came for a site visit on 3/22/17 IG arrives for a site visit on 3/29 IG contacts the PDSUSH on 3/30/17 On 3/30/17 a 12 person tiger team arrives to assist from Martinsburg VA An ICC is stood up in April to oversee the efforts. Rounding on units occurs 2X per day. IG shares interim report with Secretary on 4/12/17 Medical Center Director, Associate Director removed on 4/12/17 Acting Director Larry Connell Appointed on 4/12/17 USH arrives on site for personal oversight of ICC on 4/13/17 Full investigation of events being undertaken in cooperation with IG At this point in the investigation there is no evidence of harm to any patient Notification of the issues to the Secretary and USH did not occur prior to the IG interim report. VHA conducting an assessment of inventory systems across VHA. VA-19-0799-D-000856 OS 00002527 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/11/2017 8:32:59 AM David shulkin [Drshulkin@aol.com] Re:Today I will have the team check in the meantime Sent from my iPhone On Apr 10, 2017, at 6:22 PM, David shulkin wrote: Sent from my iPhone Begin forwarded message: From: "Slack, Donovan" Date: April 10, 2017 at 3 :35:48 PM EDT To: David shulkin Subject: Re: Today Ha! No worries. James hand delivered the results page to me. I still have some concerns - 8 days sounds awfully short. But we'll see I guess if data measures up when site goes public. Donovan Slack White House and Veterans Affairs Correspondent USA TODAY dslack@usatoda y.com (703) 854-8926 Office (202) 415-9493 Cell On Apr 10, 2017, at 2:22 PM, David shulkin wrote: Donovan- apparently i had not refreshed the computer as I should have - but now I see new mental health patients at the Phoenix VA is 8 days. Sorry about that- but as you can see I didn't rehearse this David [cid:ae64df80-24b4-4c48-b0ebl aed4a330e2a@prod.exchangelabs.com] VA-19-0799-D-000857 OS 00002528 Sent from my iPhone Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/10/2017 10:21:32 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Today Sent from my iPhone Begin forwarded message: From: "Slack, Donovan" Date: April 10, 2017 at 3 :35:48 PM EDT To: David shulkin Subject: Re: Today Ha! No worries. James hand delivered the results page to me. I still have some concerns - 8 days sounds awfully short. But we'll see I guess if data measures up when site goes public. Donovan Slack White House and Veterans Affairs Correspondent USA TODAY dslack@usatoday.com (703) 854-8926 Office (202) 415-9493 Cell On Apr 10, 2017, at 2:22 PM, David shulkin wrote: Donovan- apparently i had not refreshed the computer as I should have - but now I see new mental health patients at the Phoenix VA is 8 days. Sorry about thatbut as you can see I didn't rehearse this David [cid:ae64df80-24b4-4c48-b0eb-l aed4a330e2a@prod.exchangelabs.com] Sent from my iPhone VA-19-0799-D-000859 OS 00002530 Message From: (b) (6) Sent: 4/13/2017 6:11:51 PM David Shulkin [drshulkin@aol.com] Graphics slides DHP _diagram.pptx; Top5_Priorities_0417.pptx; Top5Priorities_04112017.pdf; Access_Accountability_slides.pptx To: Subject: Attachments: [(b) (6) gmail.com] so you have for future use. VA-19-0799-D-000860 OS 00002531 VA Digital Health Platform FUTURE DEVELOPMENTS c1 VA~ Providers ◄Department of Defense \ '' .,,,, .,,,, ' -'' Veterans /D Supply Chain -► ' .... 1~ 1 Decision Support Community Providers VA-19-0799-D-000861 OS 00002532 Greater Choice Modernize Systems Focus Resources _,:::. --.::-\;;} Improve Timeliness Suicide Prevention VA-19-0799-D-000862 OS 00002533 Greater Choice for Veterans • Redesign the 40/30 Rule • Build a high-performing, integrated network of care • Empower Veterans through transparency of information VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000863 OS 00002534 Modernize Our Systents • Infrastructure improvements and streamlining services • EMR interoperability and IT modernization VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000864 OS 00002535 Focus Resources More Efficiently • Strengthening of foundational services in VA • VA/DOD/Community coordination • Deliver on accountability and effective management practices VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000865 OS 00002536 lntprove Tinteliness of Services • Access to ca re and wait ti mes • Decisions on appeals • Performance on disability claims VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000866 OS 00002537 Suicide Prevention • Getting to ZERO VAi U.S. Department ofVeterans Affairs VA-19-0799-D-000867 OS 00002538 VA U.S. Department of Veterans Affairs Top 5 Priorities U.S. Department of Veterans Affairs 1. Greater Choice for Veterans Redesign the 40/30 rule Build a high -performing, integrated network of care Empower Veterans through transparency of information 2. Modernize Our Systems Infrastructure improvements and streamlining services EMR interoperability & IT modernization ~ ~ ~ -: 3. Focus Resources More Efficiently 0 Strengthening of foundational services in VA • VA/DOD/Community coordination Deliver on accountability & effective management practices 4. Improve Timeliness of Services • Access to care and wait times Decisions on appeals Performance on disability claims Suicide Prevention Getting to zero 04/11/17 www.va.gov VA-19-0799-D-000868 OS_00002539 Maintain a high-performing integrated network that includes VA, federal partners, academic affiliates, and community providers. Apply industry standards for performance, quality patient satisfaction, payment models, and health outcomes. Increase choices for all Veterans, starting with those with service connected conditions. Choice 2.0 Legislation •~ n11 f11 _ nn Ensure Veterans get the care they need, closer to home when appropriate. Optimize coordination of VA healthcare with the health insurance Veterans already have. \ l'il/ Assist in coordinating care for Veterans served by multiple providers. Maintain affordability of healthcare options for low-income Veterans. VA-19-0799-D-000869 DS_00002540 Priority #4 Accountability Legislation -.,t+)( :~:;t: / '·<·I l, Increased flexibility to remove, demote, or suspend VA employees for poor performance or misconduct. \ ~, -- ~ Authority to recoup bonuses of employees for poor performance or misconduct. Authority to recoup relocation expenses authorized through fraud or malfeasance. Authority to reduce federal pensions for employees convicted of felonies. • Increased protections for whistle blowers. VA-19-0799-D-000870 OS 00002541 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/12/2017 10:33:45 AM David Shulkin [drshulkin@aol.com] Jennifer's position I am leaning towards Mike Valentino- he has a good track record of success, has a non controversial personality, should be accepted by both the field and lOP- what do you think Sent from my iPhone VA-19-0799-D-000871 OS 00002542 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/17/2017 6:34:28 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Project Healthy Heroes update HH Project Update_2017 _04_17.pptx; Untitled attachment 05290.htm Sent from my iPhone Begin forwarded message: From: "(b) (6) [JSGUS]" <(b) (6) its.jnj .com> Date: April 17, 2017 at2:19:21 PM EDT To: Bruce Moskowitz <(b) (6) mac.com>, David Shulkin , Ike Perlmutter <(b) (6) frenchangel5 9.com> Subject: Project Healthy Heroes update VA-19-0799-D-000872 OS 00002543 Healthy Heroes Project (b) (6) & (b) (6) I April 17, 2017 6/19/2019 12:55 PM 05_ASM09_(b) (6) v32.ppt VA-19-0799-D-000873 OS 00002544 Timeline Progress to date ~ Mar1, 2017 ~ Mar10, 2017 ~ Mar17, 2017 ~ Mar 24, 2017 ~ Apr14, 2017 May 15, 2017 (b) (4) • (b) (4) • • • 6/19/2019 12:55 PM 05_ASM09_(b) (6) v32.ppt VA-19-0799-D-000874 OS 00002545 Our 10 Point Plan (b) (4) (b) (4) (b) (4) r 1 Month (b) (4) 6/19/2019 12:55 PM 05_ASM09_(b) (6) v32.ppt VA-19-0799-D-000875 OS 00002546 Sent from my iPad Message From: (b) (6) Sent: 4/17/2017 6:19:21 PM Bruce Moskowitz [(b) (6) mac.com]; David Shulkin [Drshulkin@aol.com]; Ike Perlmutter [( @frenchangel59.com] Project Healthy Heroes update b HH Project Update_2017 _04_17.pptx; ATT0000l.txt To: Subject: Attachments: [JSGUS] [(b) (6) its.jnj.com] VA-19-0799-D-000877 OS 00002548 Healthy Heroes Project (b) (6) & (b) (6) I April 17, 2017 6/19/2019 12:44 PM 05_ASM09_(b) (6) v32.ppt VA-19-0799-D-000878 OS 00002549 Timeline Progress to date ~ Mar1, 2017 ~ Mar10, 2017 ~ Mar17, 2017 ~ Mar 24, 2017 ~ Apr14, 2017 May 15, 2017 (b) (4) (b) (4) • • • • 6/19/2019 12:44 PM 05_ASM09_(b) (6) v32.ppt VA-19-0799-D-000879 OS 00002550 Our 10 Point Plan (b) (4) (b) (4) (b) (4) 1 Month (b) (4) 6/19/2019 12:44 PM 05_ASM09_(b) (6) v32.ppt VA-19-0799-D-000880 OS 00002551 Sent from my iPad Message David shulkin [Drshulkin@aol.com] 4/8/2017 8:38:15 PM (b) (6) [(b) (6) gmail.com] Fwd: American Association for Physician Leadership Honoring you as Honorary Fellow From: Sent: To: Subject: Do we know what time i need to be there this day for the event? Sent from my iPhone Begin forwarded message: <(b) (6) physicianleaders.org> Date: March 9, 2017 at 1:44:44 PM EST To: David shulkin From: (b) (6) Subject: Re: American Association for Physician Leadership Honoring you as Honorary Fellow Terrific David - thanks for considering and it will be a pleasure to have our paths cross again. All the best - Peter MD Any typos - it's the phone (b) (6) On Mar 9, 2017, at 13:42, David shulkin wrote: Thank you (b) (6) this is a true honor. My mom office will reach out to you soon David Sent from my iPhone On Mar 9, 2017, at 1:07 PM, (b) (6) <(b) (6) physicianleaders.org> wrote: Good Afternoon, Please take a moment to read the attached letter from the American Association for Physician Leadership. Sincerely - (b) (6) (b) (6) MD FRCS(C), FACS, MCCM President and Chief Operating Officer (CEO) American Association for Physician Leadership Tampa, Florida, USA 33602 Inspiring Change. Together. www .physicianleaders.org 2017 Annual Meeting I April 22-23, 2017, New York, NY VA-19-0799-D-000882 OS 00002553 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/10/2017 11:20:20 PM Poonam Alaigh [(b) (6) hotmail.com] Re: FYI: URGENT I Your Input: VA Public-facing Web site Nice Sent from my iPhone On Apr 10, 2017, at 7:02 PM, Poonam Alaigh <(b) (6) hotmail.com > wrote: Yes- thanks a ton and really appreciate you talking to us against this evening - you guys are best Sent from my iPhone On Apr 10, 2017, at 6:26 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: Excellent Sent from my iPad Bruce Moskowitz M.D. On Apr 10, 2017, at 5:59 PM, (b) (6) (b) (6) mayo.edu > wrote: Hi-fyi. ... From: (b) (6) Sent: Monday, April 10, 2017 4:59 PM (b) (6) To: (b) (6) (b) (6) (b) (6) (b) (6) ( (b) (6) ccf.org); kp.org ; (b) (6) (b) (6) (b) (6) (b) (6) ccf.org ; (b) (6) (b) (6) jhu.edu ; (b) (6) kp.org ; [RO PA]; (b) (6) (b) (6) Subject: URGENT I Your Input: VA Public-facing Web site Sensitivity: Confidential * PLEASE TREAT AS BUSINESS CONFIDENTIAL* Hi - on Wednesday, the VA will announce a web site designed for Veterans to make informed decisions about where they receive their health care. The overview of the plan and the project objectives are attached. Dr. Bruce Moskowitz routed the plan in late March to the CEO of the five academic medical center organizations, encouraging that the CEOs "express support/confidence" in the plan. Several CEOs expressed in follow-up emails that they would be willing to "voice support for the approach, that it's reflective of the direction the VA needs to move to best support the care of veterans, etc." Dr. Poonam Alaigh, VA Acting Under Secretary for Health, Dr. Moskowitz and I spoke late this afternoon - the question: as this rolls VA-19-0799-D-000884 OS 00002555 out (going public on Wednesday), would your CEO; or someone you designate in your organization (perhaps a Quality lead; or "digital care/web" lead be open to speaking w/ the news media, sharing perspective on how this reflects a step forward for veterans and reflects what patients are seeking from healthcare providers? If not someone from your organization, would you recommend an industry expert that can talk to these issues w/ news media? The timeline for this would be tomorrow (Tuesday) or Wednesday, as this news goes public. Thanks for your consideration. (b) (6) Chair I Mayo Clinic Department of Public Affairs 200 First Street S.W. I Rochester, MN 55905 cell: 507 .269.(b) (6) I office: 507 .284.(b) (6) e-mail: (b) (6) mayo.edu VA-19-0799-D-000885 OS 00002556 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/10/2017 11:02:19 PM Bruce Moskowitz [(b) (6) mac.com] (b) (6) [(b) (6) mayo.edu]; David Shulkin [drshulkin@aol.com] Re: FYI: URGENT I Your Input: VA Public-facing Web site Yes- thanks a ton and really appreciate you talking to us against this evening - you guys are best Sent from my iPhone On Apr 10, 2017, at 6:26 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: Excellent Sent from my iPad Bruce Moskowitz M.D. On Apr 10, 2017, at 5:59 PM, (b) (6) (b) (6) mayo.edu > wrote: Hi-fyi. ... From: (b) (6) Sent: Monday, April 10, 2017 4:59 PM (b) (6) (b) (6) To: (b) (6) (b) (6) (b) (6) (b) (6) ccf.org ; jhu.edu ; (b) (6) (b) (6) kp.org ; (b) (6) (b) (6) (b) (6) (b) (6) ( kp.org ; (b) (6) (b) (6) ccf.org); [RO PA]; (b) (6) Subject: URGENT I Your Input: VA Public-facing Web site Sensitivity: Confidential * PLEASE TREAT AS BUSINESS CONFIDENTIAL* Hi - on Wednesday, the VA will announce a web site designed for Veterans to make informed decisions about where they receive their health care. The overview of the plan and the project objectives are attached. Dr. Bruce Moskowitz routed the plan in late March to the CEO of the five academic medical center organizations, encouraging that the CEOs "express support/confidence" in the plan. Several CEOs expressed in follow-up emails that they would be willing to "voice support for the approach, that it's reflective of the direction the VA needs to move to best support the care of veterans, etc." Dr. Poonam Alaigh, VA Acting Under Secretary for Health, Dr. Moskowitz and I spoke late this afternoon - the question: as this rolls out (going public on Wednesday), would your CEO; or someone you designate in your organization (perhaps a Quality lead; or "digital care/web" lead be open to speaking w/ the news media, sharing perspective on how this reflects a step forward for veterans and reflects what patients are seeking from healthcare providers? If not someone from your organization, would you recommend an industry expert that can talk to these issues w/ news media? VA-19-0799-D-000886 OS 00002557 The timeline for this would be tomorrow (Tuesday) or Wednesday, as this news goes public. Thanks for your consideration. (b) (6) Chair I Mayo Clinic Department of Public Affairs 200 First Street S.W. I Rochester, MN 55905 cell: 507 .269.(b) (6) I office: 507 .284.(b) (6) e-mail: (b) (6) mayo .edu VA-19-0799-D-000887 OS 00002558 Message From: Sent: To: Subject: Attachments: IP [(b) (6) frenchangel59.com] 4/8/2017 3:08:31 PM David shulkin [drshulkin@aol.com] Document #2 - SEPARATE REMINDERS FOR JARED KUSHNER DINNER MEETING 4/8/2017 AT 7:30 PM Ike dinner w Jared 040817 v3.docx See attached. I will call you later about both attachments. MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has 2. Approximately 700 vacant and underutilized locations a. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY & ELECTRONIC MEDICAL RECORDS SYSTEM 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. 4. DOD recently signed a new contract to implement a new system (Cerner) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cerner system. 5. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) a. The Top 5 Academic Medical Centers DO NOT use Cerner and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. Using EPIC, therefore, as the VA IT platform will allow seamless integration with the platform of the majority of community and academic medical centers. As a result, when veterans access care outside the VA system (the choice extension) there can be the necessary access and integration to vital medical information. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. d. The VA has confirmed that they are on same page to pursue Epic as EMR of choice instead of Cerner. VA-19-0799-D-000888 OS 00002559 e. Cerner has established (what we think is) an artificial barrier ... claiming that Cerner cannot talk to EPIC if the VA chooses EPIC. We believe that EPIC will allow for this cross talk. We also believe that the ability of working with the two different platforms is, in reality, an artificial barrier by Cerner that can be resolved if Cerner chooses. Therefore, Cerner's DOD implementation MUST be instructed talk to whatever system the VA chooses to install. This must be resolved NOW at the DOD/Cerner level. STAFFING 6. Freeze "All Hiring" - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon the Secretary's approval. 7. Institute an early retirement employee buyout program. 8. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 9. The FY17 VA budget is over $181 Billion. We are evaluating the budget to identify waste, inefficiencies and potential surpluses. 10. The preliminary goal looks like a potential minimum reduction of $15B. 11. This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. PTSD I SUICIDE PREVENTION 12. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch problems at the outset and prevent surprises and costs upon retirement) 13. Establish a wellness prevention program. [As an example, we administer colonoscopy exams for early detection of cancer. If the disease is discovered early we can save lives and reduce costs] WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled (hospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the White House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs them available (on call) when requested. For our continuing needs, we can interface with (b) (6) which will also develop him as an operator in business as well. OTHER 15. PRESIDENT'S !NV/TA TION a. 's initiative is gathering 500 people in Washington on April 29 th at 7:00 PM. He is working with the Pastor, Dr (b) (6) . The party will take place in the Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. (b) (6) VA-19-0799-D-000889 OS 00002560 MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has 2. Approximately 700 vacant and underutilized locations a. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY & ELECTRONIC MEDICAL RECORDS SYSTEM 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. 4. DOD recently signed a new contract to implement a new system (Cerner) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cemer system. 5. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) a. The Top 5 Academic Medical Centers DO NOT use Cerner and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. Using EPIC, therefore, as the VA IT platform will allow seamless integration with the platform of the majority of community and academic medical centers. As a result, when veterans access care outside the VA system (the choice extension) there can be the necessa1y access and integration to vital medical information. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. d. The VA has confirmed that they are on same page to pursue Epic as EMR of choice instead of Cerner. e. Cerner has established (what we think is) an artificial barrier. .. claiming that Cerner cannot talk to EPIC if the VA chooses EPIC. We believe that EPIC will allow for this cross talk. We also believe that the ability of working with the two different platforms is, in reality, an artificial barrier by Cerner that can be resolved if Cerner chooses. Therefore, Cemer's DOD implementation VA-19-0799-D-000890 OS 00002561 MEMORANDUM JARED KUSHNER APRIL 8, 2017 PAGE I 2 MUST be instructed talk to whatever system the VA chooses to install. This must be resolved NOW at the DOD /Cemer level STAFFING 6. Freeze "All Hiring'' - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon the Secretary's approval. 7. Institute an early retirement employee buyout program. 8. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 9. The FYl 7 VA budget is over $181 Billion. We are evaluating the budget to identify waste, ineHiciencies and potential surpluses. 10. The preliminary goal looks like a potential minimum reduction of $15B. 11. This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. PTSD I SUICIDE PREVENTION 12. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch problems at the outset and prevent surprises and costs upon retirement) 13. Establish a wellness prevention program. [As an example, we administer co!onoscop_y exams.for detection of cancer. If the disease is disco1 ered ear!J 2ve can save ii1 es and reduce costJj 1 1 WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled (hospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the \Vhite House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs them available (on call) when requested. For our continuing needs, we can interface with A vi, which will also develop him as an operator in business as well. OTHER 15. PRESIDENTS INVITATION a. (b) (6) s initiative is gathering 500 people in Washington on April 29 th at 7:00 PM. He is working with the Pastor, Dr (b) (6) The party will take place in the Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. VA-19-0799-D-000891 OS 00002562 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/6/2017 11:32:18 AM Bruce Moskowitz [(b) (6) mac.com] Ike Perlmutter [(b) (6) frenchangel59.com] Re: VACIO Search Wow- your amazing! Sent from my iPhone On Apr 6, 2017, at 7:22 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: I should have four to interview at end of today Sent from my iPad Bruce Moskowitz M.D. On Apr 6, 2017, at 7:21 AM, David shulkin wrote: Ike- I had seen an email yesterday that Bruce was asked to try to identify some additional Names as a backup for CIO and i wondered if the below offer was useful to us or not. What do you think? David Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 6, 2017 at 5:50:36 AM EDT To: David Shulkin Subject: Re: VA CIO Search mac.com> Ike would know more than I would Sent from my iPad Bruce Moskowitz M.D. On Apr 5, 2017, at 10:08 PM, David Shulkin wrote: Bruce - we can pursue this if helpful David VA-19-0799-D-000892 OS 00002563 -----Original Message----From: (b) (6) [(b) (6) ourpublicservice.org] Sent: Wednesday, April 05, 2017 05:34 PM Eastern Standard Time To: Blackburn, Scott R. Subject: [EXTERNAL] VA CIO Search Scott: The purpose of this note is to put another important issue on your radar screen. Following up on the conversation with you and David about your talent needs, I've spoken to the CIO practice leaders at Heidrick & Struggles and they have agreed to work together on a pro bono basis to find you the best possible CIO candidates. I've connected them with Gina and the GC's office has signed off on accepting the help under your gift acceptance authority. I know you have a very full plate but I think your direct involvement with them is most likely to lead to your getting the best talent. They are truly top drawer and I don't think VA is used to having that kind of assistance. Would it help to have a very quick call on this? Best, (b) (6) VA-19-0799-D-000893 OS 00002564 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/6/2017 11:22:32 AM David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com] Re: VACIO Search I should have four to interview at end of today Sent from my iPad Bruce Moskowitz M.D. On Apr 6, 2017, at 7:21 AM, David shulkin wrote: Ike- I had seen an email yesterday that Bruce was asked to try to identify some additional Names as a backup for CIO and i wondered if the below offer was useful to us or not. What do you think? David Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 6, 2017 at 5:50:36 AM EDT To: David Shulkin Subject: Re: VA CIO Search mac.com> Ike would know more than I would Sent from my iPad Bruce Moskowitz M.D. On Apr 5, 2017, at 10:08 PM, David Shulkin wrote: Bruce - we can pursue this if helpful David -----Original Message----From: (b) (6) [(b) (6) ourpublicservice.org1 Sent: Wednesday, April 05, 2017 05:34 PM Eastern Standard Time To: Blackbum, Scott R. Subject: [EXTERNAL] VACIO Search Scott: VA-19-0799-D-000894 OS 00002565 The purpose of this note is to put another important issue on your radar screen. Following up on the conversation with you and David about your talent needs, I've spoken to the CIO practice leaders at Heidrick & Struggles and they have agreed to work together on a pro bono basis to find you the best possible CIO candidates. I've connected them with Gina and the GC's office has signed off on accepting the help under your gift acceptance authority. I know you have a very full plate but I think your direct involvement with them is most likely to lead to your getting the best talent. They are truly top drawer and I don't think VA is used to having that kind of assistance. Would it help to have a very quick call on this? Best, (b) (6) VA-19-0799-D-000895 OS 00002566 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/6/2017 11:21:28 AM To: Ike Perlmutter [(b) (6) frenchangel59.com] Bruce Moskowitz [(b) (6) mac.com] Fwd: VACIO Search CC: Subject: Ike- I had seen an email yesterday that Bruce was asked to try to identify some additional Names as a backup for CIO and i wondered if the below offer was useful to us or not. What do you think? David Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 6, 2017 at 5:50:36 AM EDT To: David Shulkin Subject: Re: VA CIO Search mac.com> Ike would know more than I would Sent from my iPad Bruce Moskowitz M.D. On Apr 5, 2017, at 10:08 PM, David Shulkin wrote: Bruce - we can pursue this if helpful David -----Original Message----From: (b) (6) [(b) (6) ourpublicservice.org1 Sent: Wednesday, April 05, 2017 05:34 PM Eastern Standard Time To: Blackburn, Scott R. Subject: [EXTERNAL] VACIO Search Scott: The purpose of this note is to put another important issue on your radar screen. Following up on the conversation with you and David about your talent needs, I've spoken to the CIO practice leaders at Heidrick & Struggles and they have agreed to work VA-19-0799-D-000896 OS 00002567 together on a pro bona basis to find you the best possible CIO candidates. I've connected them with Gina and the GC's office has signed off on accepting the help under your gift acceptance authority. I know you have a very full plate but I think your direct involvement with them is most likely to lead to your getting the best talent. They are truly top drawer and I don't think VA is used to having that kind of assistance. Would it help to have a very quick call on this? Best, (b) (6) VA-19-0799-D-000897 OS 00002568 Message From: Bruce Moskowitz [(b) (6) Sent: 4/6/2017 9:50:36 AM To: David Shulkin [drshulkin@aol.com] Re: VACIO Search Subject: mac.com] Ike would know more than I would Sent from my iPad Bruce Moskowitz M.D. On Apr 5, 2017, at 10:08 PM, David Shulkin wrote: Bruce - we can pursue this if helpful David -----Original Message----From: (b) (6) [(b) (6) ourpublicservice.org1 Sent: Wednesday, April 05, 2017 05:34 PM Eastern Standard Time To: Blackburn, Scott R. Subject: [EXTERNAL] VACIO Search Scott: I hope all is well and the leadership retreat preparation is going well from your perspective. I know my colleagues Tom, Chris and Michelle have very much enjoyed working with you and the VA team. The purpose of this note is to put another important issue on your radar screen. Following up on the conversation with you and David about your talent needs, I've spoken to the CIO practice leaders at Heidrick & Struggles and they have agreed to work together on a pro bono basis to find you the best possible CIO candidates. I've connected them with Gina and the GC's office has signed off on accepting the help under your gift acceptance authority. I know you have a very full plate but I think your direct involvement with them is most likely to lead to your getting the best talent. They are truly top drawer and I don't think VA is used to having that kind of assistance. Would it help to have a very quick call on this? VA-19-0799-D-000898 OS 00002569 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/6/2017 2:08:40 AM To: Bruce Moskowitz [(b) (6) Fwd: VACIO Search Subject: mac.com] Bruce - we can pursue this if helpful David -----Original Message----From: (b) (6) [(b) (6) ourpublicservice.org l Sent: Wednesday, April 05, 2017 05:34 PM Eastern Standard Time To: Blackburn, Scott R. Subject: [EXTERNAL] VACIO Search Scott: I hope all is well and the leadership retreat preparation is going well from your perspective. I know my colleagues Tom, Chris and Michelle have very much enjoyed working with you and the VA team. The purpose of this note is to put another important issue on your radar screen. Following up on the conversation with you and David about your talent needs, I've spoken to the CIO practice leaders at Heidrick & Struggles and they have agreed to work together on a pro bono basis to find you the best possible CIO candidates. I've connected them with Gina and the GC's office has signed off on accepting the help under your gift acceptance authority. I know you have a very full plate but I think your direct involvement with them is most likely to lead to your getting the best talent. They are truly top drawer and I don't think VA is used to having that kind of assistance. Would it help to have a very quick call on this? Best, (b) (6) VA-19-0799-D-000900 OS 00002571 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/2017 1:13:53 AM (b) (6) [(b) (6) Re: Amtrak gmail.com] Sundays 73EA12 Sent from my iPhone > on Apr 6, 2017, at 8:50 PM, (b) (6) <(b) (6) gmail.com> wrote: > > Don't forget to send VA-19-0799-D-000901 OS 00002572 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/2017 1:13:14 AM (b) (6) [(b) (6) Re: Amtrak gmail.com] Reservation 7546E9 Did we ever get the travel company to add my guest rewards to my trips in the past, including monday? Rewards (b) (6) Sent from my iPhone > on Apr 6, 2017, at 8:50 PM, (b) (6) <(b) (6) gmail.com> wrote: > > Don't forget to send VA-19-0799-D-000902 OS 00002573 Message From: (b) (6) Sent: 4/7/2017 12:50:13 AM David Shulkin [drshulkin@aol.com] Amtrak To: Subject: [(b) (6) gmail.com] Don't forget to send VA-19-0799-D-000903 OS 00002574 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/7/2017 8:05:01 PM David shulkin [Drshulkin@aol.com] Re: The Situation Report: Is the CIO Job at VA About to Lose Its Influence? Game changing bold move Sent from my iPhone On Apr 7, 2017, at 3 :46 PM, David shulkin wrote: Sent from my iPhone Begin forwarded message: From: Michael Tepper (b) (6) @yahoo.com> Date: April 7, 2017 at 12:32:02 PM EDT To: "David J. Shulkin" Subject: The Situation Report: Is the CIO Job at VA About to Lose Its Influence? Reply-To: (b) (6) @yahoo.com https ://www .meri talk. com/the-si tuati on-report-i s-the-ci o-j ob-at-va-about-to-1oseits-influence/ VA-19-0799-D-000904 OS 00002575 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/2017 7:40:32 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: The Situation Report: Is the CIO Job at VA About to Lose Its Influence? Sent from my iPhone Begin forwarded message: From: Michael Tepper <(b) (6) @yahoo.com> Date: April 7, 2017 at 12:32:02 PM EDT To: "David J. Shulkin" Subject: The Situation Report: Is the CIO Job at VA About to Lose Its Influence? @yahoo.com Reply-To: (b) (6) http s://www.meri talk. com/the-si tuati on-report-is-the-ci o-j ob-at-va-ab out-to-1 ose-i ts-influence/ VA-19-0799-D-000905 OS 00002576 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/21/2017 5:31:12 PM Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com] Re: partnership opportunities Bruce- i think she is definitely on target David Sent from my iPhone On Apr 21, 2017, at 12:26 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: Thank you I will ask the Secretary and acting undersecretary to review with me Sent from my iPad Bruce Moskowitz M.D. On Apr 20, 2017, at 8:57 AM, (b) (6) (NOLA) <(b) (6) va.gov> wrote: Good morning, Bruce Thank you again for your interest in the work that I am leading, and I look forward to identifying synergies to maximize our collective impact. As I mentioned, of the 20 Veterans who are dying by suicide every day, 14 are not engaged in VA care. While it is our responsibility to support all 22 million Veterans, the greatest need (and potential impact) is with those who are NOT engaging in VA healthcare. Pursuant to targeting these "14", I have built relationships with leaders from organizations outlined in the attached and have highlighted partnerships that could be expanded for greater impact. In addition, my team is working to partner with organizations that help us reach large concentrations of Veterans (before they are in crisis) while simultaneously developing an integrated and comprehensive public health strategy that is executed in local communities nationally. Specifically, we are interested in exploring opportunities in healthcare for the following: 1. 2. Partnerships with private sector healthcare companies to provide training in suicide risk assessment for physicians, nurse practitioners, and nurses working in Primary Care and Emergency Room settings; Partnership with professional associations such as American Academy of Family Physicians, American Nurses Association, etc. to promote training programs for community/private sector providers. I look forward to any ideas that you have and the opportunity to discuss next steps. Thank you for all that you are doing to support Veterans and VA. We must succeed. With sincere appreciation and respect, (b) (6) VA-19-0799-D-000906 OS 00002577 (b) (6) National Director, Public-Private Partnerships (Acting) Department of Veterans Affairs Office for Suicide Prevention NEW PHONE: 561-701-(b) (6) Email: (b) (6) va .gov VA-19-0799-D-000907 OS 00002578 Message Bruce Moskowitz [(b) (6) mac.com] 4/21/2017 4:26:58 PM (b) (6) (NOLA) [(b) (6) va.gov] Poonam Alaigh [(b) (6) hotmail.com]; David shulkin [drshulkin@aol.com] Re: partnership opportunities From: Sent: To: CC: Subject: Thank you I will ask the Secretary and acting undersecretary to review with me Sent from my iPad Bruce Moskowitz M.D. On Apr 20, 2017, at 8:57 AM, (b) (6) (NOLA) <(b) (6) va.gov> wrote: Good morning, Bruce Thank you again for your interest in the work that I am leading, and I look forward to identifying synergies to maximize our collective impact. As I mentioned, of the 20 Veterans who are dying by suicide every day, 14 are not engaged in VA care. While it is our responsibility to support all 22 million Veterans, the greatest need (and potential impact) is with those who are NOT engaging in VA healthcare. Pursuant to targeting these "14", I have built relationships with leaders from organizations outlined in the attached and have highlighted partnerships that could be expanded for greater impact. In addition, my team is working to partner with organizations that help us reach large concentrations of Veterans (before they are in crisis) while simultaneously developing an integrated and comprehensive public health strategy that is executed in local communities nationally. Specifically, we are interested in exploring opportunities in healthcare for the following: 1. 2. Partnerships with private sector healthcare companies to provide training in suicide risk assessment for physicians, nurse practitioners, and nurses working in Primary Care and Emergency Room settings; Partnership with professional associations such as American Academy of Family Physicians, American Nurses Association, etc. to promote training programs for community/private sector providers. I look forward to any ideas that you have and the opportunity to discuss next steps. Thank you for all that you are doing to support Veterans and VA. We must succeed. With sincere appreciation and respect, (b) (6) (b) (6) National Director, Public-Private Partnerships (Acting) Department of Veterans Affairs Office for Suicide Prevention NEW PHONE: 561-701-(b) (6) Email: (b) (6) va.gov VA-19-0799-D-000908 OS 00002579 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/7/201710:02:54 PM Va David [vacodjsl@va.gov] Fwd: Another CIO Yale Biosketch_(b) (6), _2017PMC.docx; Untitled attachment 05404.htm (b) (2) Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 3:29:07 PM EDT To: drshulkin@aol .com Cc: IP <(b) (6) frenchangel59.com> Subject: Another CIO Yale mac.com> VA-19-0799-D-000909 OS 00002580 0MB No. 0925-0001 and 0925-0002 (Rev. 11/16 Approved Through 10/31/2018) BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors. Follow this format for each person. DO NOT EXCEED FIVE PAGES. NAME: (b) (6), (b) (2) (b) (6), (b) (2) eRA COMMONS USER NAME (credential, e.g., agency login): POSITION TITLE: Professor, Yale University EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable. Add/delete rows as necessary.) INSTITUTION AND LOCATION DEGREE (if applicable) Completion Date MMNYYY FIELD OF STUDY (b) (6), (b) (2) A. Personal Statement (b) (6), (b) (2) (b) (6) . VA-19-0799-D-000910 OS 00002581 B. Positions and Honors Positions and Employment (b) (6), (b) (2) National Appointments (b) (6), (b) (2) C. Contributions to Science (b) (6), (b) (2) VA-19-0799-D-000911 OS 00002582 (b) (6), (b) (2) (b) (6) Complete List of Published Work in MyBibliography: (b) (6), (b) (2) D. Additional Information: Research Support and/or Scholastic Performance Current Research Support NIH Grants: (b) (6), (b) (2) VA-19-0799-D-000912 OS 00002583 VA Grants 3 Sent from my iPad Bmce Moskowitz MD. 5 Message From: Sent: To: CC: Subject: Attachments: Bruce Moskowitz [(b) (6) mac.com] 4/7/2017 7:29:07 PM drshulkin@aol.com IP [(b) (6) frenchangel59.com] Another CIO Yale Biosketch_(b) (6), _2017PMC.docx; Untitled attachment 05410.txt (b) (2) VA-19-0799-D-000916 OS 00002587 0MB No. 0925-0001 and 0925-0002 (Rev. 11/16 Approved Through 10/31/2018) BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors. Follow this format for each person. DO NOT EXCEED FIVE PAGES. NAME: (b) (6), (b) (2) eRA COMMONS USER NAME (credential, e.g., agency login): (b) (6), (b) (2) POSITION TITLE: Professor, Yale University EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable. Add/delete rows as necessary.) INSTITUTION AND LOCATION DEGREE (if applicable) Completion Date MMNYYY FIELD OF STUDY (b) (6), (b) (2) A. Personal Statement (b) (6), (b) (2) (b) (6) VA-19-0799-D-000917 OS 00002588 B. Positions and Honors Positions and Employment (b) (6), (b) (2) National Appointments (b) (6), (b) (2) C. Contributions to Science (b) (6), (b) (2) VA-19-0799-D-000918 OS 00002589 (b) (6), (b) (2) (b) (6) Complete List of Published Work in MyBibliography: (b) (6), (b) (2) D. Additional Information: Research Support and/or Scholastic Performance Current Research Support NIH Grants: (b) (6), (b) (2) VA-19-0799-D-000919 OS 00002590 VA Grants Sent from my iPad Bruce Moskowitz M.D. Message From: Sent: To: Subject: IP [(b) (6) frenchangel59.com] 4/12/2017 1:51:24 AM 'David shulkin' [Drshulkin@aol.com] RE: Passoverseder I love it! Thank you. From: David shulkin [mailto:Drshulkin@aol.com] Sent: Tuesday, April 11, 2017 6:38 PM To: Ike Perlmutter Subject: Fwd: Passover seder Ike- youll enjoy this Subject: Re: Passover seder http ://www.timesofisrael .com/trump-a-no-show-at-white-house-seder/ Sent via the Samsung Galaxy S® 5 ACTIVE™, an AT&T 4G LTE smartphone VA-19-0799-D-000923 OS 00002594 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/11/2017 10:37:32 PM Ike Perlmutter [(b) (6) frenchangel59.com] Fwd: Passover seder Ike- youll enjoy this Subject: Re: Passover seder http ://www.timesofisrael .com/trump-a-no-show-at-white-house-seder/ Sent via the Samsung Galaxy S® 5 ACTIVE™, an AT&T 4G LTE smartphone VA-19-0799-D-000924 OS 00002595 Message From: (b) (6) [(b) (6) Sent: To: 4/15/2017 5:07:06 PM David shulkin [Drshulkin@aol.com] Subject: Re: gmail.com] Just sent in seperate message On Apr 15, 2017 1:05 PM, "(b) (6) Yes stand by <(b) (6) gmail.com> wrote: On Apr 15, 2017 1:04 PM, "David shulkin" wrote: Do you have one of those screen shots from the access paper for the annals I can use for my studer slides? If so can you send? Sent from my iPhone VA-19-0799-D-000925 OS 00002596 Message From: (b) (6) [(b) (6) Sent: To: 4/15/2017 5:05:03 PM David shulkin [Drshulkin@aol.com] Subject: Re: gmail.com] Yes stand by On Apr 15, 2017 1:04 PM, "David shulkin" wrote: Do you have one of those screen shots from the access paper for the annals I can use for my studer slides? If so can you send? Sent from my iPhone VA-19-0799-D-000926 OS 00002597 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/15/2017 5:04:37 PM (b) (6) [(b) (6) gmail.com] Do you have one of those screen shots from the access paper for the annals I can use for my studer slides? If so can you send? Sent from my iPhone VA-19-0799-D-000927 OS 00002598 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/6/2017 3:20:29 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Call me in the morning K Sent from my iPhone > on Apr 5, 2017, at 11:19 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > on your way to work in the morning if that is the best time > > Sent from my iPhone VA-19-0799-D-000928 OS 00002599 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/6/2017 3:19:21 AM David Shulkin [drshulkin@aol.com] Call me in the morning on your way to work in the morning if that is the best time Sent from my iPhone VA-19-0799-D-000929 OS 00002600 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/7/2017 11:21:31 PM To: IP [(b) (6) frenchangel59.com] Re: Lab Soft News: Cerner/Leidos/Accenture Secure EHR Contract for a Global Military EHR Subject: Bruce and I spoke and we definitely want to pursue an Epic option through one of our partners. The Department of Defense option is worth exploring as well as Congress has been urging VA and DOD to work together on electronic records for over a decade. Sent from my iPhone On Apr 7, 2017, at 6:49 PM, IP <(b) (6) frenchangel59.com> wrote: This was posted in 2015 .... Do you think it makes sense to share this with the people I am seeing this weekend? http://labsoftnews.typepad.com/lab soft news/2015/08/cerner-dod -contract-conn.html Cerner/Leidos/Accenture Secure EHR Contract for a Global Military EHR I have waited about five days to comment about the success of Cerner and its partners with the DOD EHR contract. This has allowed me to collect my thoughts and review some of the other articles covering the news. I thought that the best analysis I have read was by Joseph Conn of Modern Healthcare (see: Cerner, Leidos and Accenture win massive Defense contract for EHR system ). Below are some quotes from his article: For the better part of a year, Epic has been buffeted by charges from its critics, competitors and various members of Congress about an alleged lack of interoperability of its system .... Chris MillerJ program executive officer of defense health management systemsJ the Defense Department office that handled the DHMSM procurementJ said the buyers were acutely aware of the data-blocking issue .... VA-19-0799-D-000930 OS 00002601 Dr. Howard Landa .... previously worked in medical informatics for Kaiser PermanenteJ including during the 2003 through 2007 period when it switched from multiple home-grown EHRs to Epic. The worry then was that Kaiser, with its 36 hospitals, would drain Epic's resources from its other customers. That largely didn't happen. Now, that monkey will be on Cerner's back.... Leidos, formerly the national security, health and engineering business of defense contractor Science Applications International Corp, was spun off from SAIC in 2013. In the late 1980s and early 1990s, SAIC, operating on a $1.1 billion Defense Department contract, created and installed the Composite Health Care System for the military health system. CHCS I; which is still in use., was based on public domain software code provided free by the VA from an early version of what is now the VA 's VistA EHR .... Todd Cozzens ..., a noted venture capital firm in the information technology industry, said interoperability is a key issue. ,,.The No. 1 focus of the DoD., the ONC and others should be., not only is this system useful., but can it interoperateH with other vendors' EH Rs., Cozzens said. "There's so little emphasis on making these systems interoperable/' Cozzens said. "'We really failed as an industry to do that.".... Perhaps in anticipation of good news from the Defense Department, Cerner stock prices jumped nearly 7.2% on the day, closing an hour before the award was announced at $73.40 a share. Miller said the military has more than 50 systems it is planning to replace with the new Cerner installation. I believe that Cerner has been preoccupied with Wall Street and its quarterly earnings since it went public. The same charge cannot be leveled against Epic which is privately held and generally uninterested in marketing or hyping its product. The company depends largely on referrals and word of mouth. This new contract is certainly good news for Cerner stockholders because the company will now be feeding at the "Uncle Sugar" trough for many years to come. This new relationship with the DOD will push Cerner further down the path of a VA-19-0799-D-000931 OS 00002602 de facto governmental contractor like its partner Leidos. I can't say that this will necessarily hurt the services and products that Cerner provides to its current hospital clients but I am sure that they are not going to get any better. As to Epic "failure" to win the contract, I suspect that there were a lot of smiles of relief in Verona when the winner was announced. I think that Epic was competing in the contest because everyone expected it to do so. The Epic culture and emphasis on client control was probably a non-starter for the military brass. Leidos/SAIC contrariwise was a known quantity for them. Epic has almost a lock on the EHR business for the larger and most prestigious U.S. hospitals and success with a DOD contract would have done little to burnish the company image. It will just keep on rolling, closing more deals in the U.S. and beefing up its international set of clients. Here's a quote from another article reinforcing this same idea (see: CIOs 'surprised' at Cerner DoD win ): In addition to partner strength ... [an EHR expert] believes Cerner likely had the upper hand in terms of sales skills. "Cerner is a selling machine and they do a very good job of selling their product," ... [he noted]. "Epic thinks they are the de facto winner all the time and they don't know how to sell because they haven't needed to sell. "But that's not how the government works. They have a whole process they go through and Epic isn't geared to deal with that. One more thing. What's the chance of Cerner/Leidos/Accenture actually succeeding in this huge, global EHR military/VA integration project? I and many informed observers put the chances of success at slim to none. Ross Koppel's quote below accurately reflects my opinion (see: Cerner is part of team that wins huge contract to revamp military's health records ): Some analysts were skeptical that any of the bidders was up to the task. In the end, the Pentagon had a choice among three finalists who offered fairly mediocre systems for the price, said Ross Koppel, a professor of sociology at the University of Pennsylvania who studies health information technology. "All the systems are stunningly clunky, VA-19-0799-D-000932 OS 00002603 the interfaces are state of the art 15 years ago, the usability is far inferior to every other system of the modern era, and the lack of interoperability makes a hash of the data," Koppel said. So, here's what's I think is going to happen? A year or two from now, Cerner/Leidos/Accenture will announce a huge victory in installing and integrating the Cerner EHR in a large Army hospital and a few freestanding clinics. Then, total "radio silence" for five or six years. Then a DOD spokesperson will announce that the military is unhappy with the EHR contractors who have not lived up to the terms of the contract in addition to being responsible for cost overruns with the cost swelling to, say, $15 billion with little to show for it. This latter news will not receive much media coverage. Posted by Bruce Friedman on August 03, 2015 at 12:42 PM in Electronic Health Record (EHR), Healthcare Business, Healthcare Delivery, Healthcare Information Technology, Pathology Informatics I Permalink • • VA-19-0799-D-000933 OS 00002604 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/7/2017 11:03:28 PM To: IP [(b) (6) frenchangel59.com] Re: Lab Soft News: Cerner/Leidos/Accenture Secure EHR Contract for a Global Military EHR Subject: Yes Sent from my iPhone On Apr 7, 2017, at 6:49 PM, IP <(b) (6) frenchangel59.com> wrote: iThis was posted in 2015 .... Do you think it makes sense to share this with the people I am seeing this weekend? http://labsoftnews.typepad.com/lab soft news/2015/08/cerner-dod -contract-conn.html Cerner/Leidos/Accenture Secure EHR Contract for a Global Military EHR I have waited about five days to comment about the success of Cerner and its partners with the DOD EHR contract. This has allowed me to collect my thoughts and review some of the other articles covering the news. I thought that the best analysis I have read was by Joseph Conn of Modern Healthcare (see: Cerner, Leidos and Accenture win massive Defense contract for EHR system ). Below are some quotes from his article: For the better part of a year, Epic has been buffeted by charges from its critics, competitors and various members of Congress about an alleged lack of interoperability of its system .... Chris MillerJ program executive officer of defense health management systemsJ the Defense Department office that handled the DHMSM procurementJ said the buyers were acutely aware of the data-blocking issue .... VA-19-0799-D-000934 OS 00002605 Dr. Howard Landa .... previously worked in medical informatics for Kaiser PermanenteJ including during the 2003 through 2007 period when it switched from multiple home-grown EHRs to Epic. The worry then was that Kaiser, with its 36 hospitals, would drain Epic's resources from its other customers. That largely didn't happen. Now, that monkey will be on Cerner's back.... Leidos, formerly the national security, health and engineering business of defense contractor Science Applications International Corp, was spun off from SAIC in 2013. In the late 1980s and early 1990s, SAIC, operating on a $1.1 billion Defense Department contract, created and installed the Composite Health Care System for the military health system. CHCS I; which is still in use., was based on public domain software code provided free by the VA from an early version of what is now the VA 's VistA EHR .... Todd Cozzens..., a noted venture capital firm in the information technology industry, said interoperability is a key issue. ,,.The No. 1 focus of the DoD., the ONC and others should be., not only is this system useful., but can it interoperateH with other vendors' EH Rs., Cozzens said. "There's so little emphasis on making these systems interoperable,'' Cozzens said. "'We really failed as an industry to do that.".... Perhaps in anticipation of good news from the Defense Department, Cerner stock prices jumped nearly 7.2% on the day, closing an hour before the award was announced at $73.40 a share. Miller said the military has more than 50 systems it is planning to replace with the new Cerner installation. I believe that Cerner has been preoccupied with Wall Street and its quarterly earnings since it went public. The same charge cannot be leveled against Epic which is privately held and generally uninterested in marketing or hyping its product. The company depends largely on referrals and word of mouth. This new contract is certainly good news for Cerner stockholders because the company will now be feeding at the "Uncle Sugar" trough for many years to come. This new relationship with the DOD will push Cerner further down the path of a VA-19-0799-D-000935 OS 00002606 de facto governmental contractor like its partner Leidos. I can't say that this will necessarily hurt the services and products that Cerner provides to its current hospital clients but I am sure that they are not going to get any better. As to Epic "failure" to win the contract, I suspect that there were a lot of smiles of relief in Verona when the winner was announced. I think that Epic was competing in the contest because everyone expected it to do so. The Epic culture and emphasis on client control was probably a non-starter for the military brass. Leidos/SAIC contrariwise was a known quantity for them. Epic has almost a lock on the EHR business for the larger and most prestigious U.S. hospitals and success with a DOD contract would have done little to burnish the company image. It will just keep on rolling, closing more deals in the U.S. and beefing up its international set of clients. Here's a quote from another article reinforcing this same idea (see: CIOs 'surprised' at Cerner DoD win ): In addition to partner strength ... [an EHR expert] believes Cerner likely had the upper hand in terms of sales skills. "Cerner is a selling machine and they do a very good job of selling their product," ... [he noted]. "Epic thinks they are the de facto winner all the time and they don't know how to sell because they haven't needed to sell. "But that's not how the government works. They have a whole process they go through and Epic isn't geared to deal with that. One more thing. What's the chance of Cerner/Leidos/Accenture actually succeeding in this huge, global EHR military/VA integration project? I and many informed observers put the chances of success at slim to none. Ross Koppel's quote below accurately reflects my opinion (see: Cerner is part of team that wins huge contract to revamp military's health records ): Some analysts were skeptical that any of the bidders was up to the task. In the end, the Pentagon had a choice among three finalists who offered fairly mediocre systems for the price, said Ross Koppel, a professor of sociology at the University of Pennsylvania who studies health information technology. "All the systems are stunningly clunky, VA-19-0799-D-000936 OS 00002607 the interfaces are state of the art 15 years ago, the usability is far inferior to every other system of the modern era, and the lack of interoperability makes a hash of the data," Koppel said. So, here's what's I think is going to happen? A year or two from now, Cerner/Leidos/Accenture will announce a huge victory in installing and integrating the Cerner EHR in a large Army hospital and a few freestanding clinics. Then, total "radio silence" for five or six years. Then a DOD spokesperson will announce that the military is unhappy with the EHR contractors who have not lived up to the terms of the contract in addition to being responsible for cost overruns with the cost swelling to, say, $15 billion with little to show for it. This latter news will not receive much media coverage. Posted by Bruce Friedman on August 03, 2015 at 12:42 PM in Electronic Health Record (EHR), Healthcare Business, Healthcare Delivery, Healthcare Information Technology, Pathology Informatics I Permalink • • VA-19-0799-D-000937 OS 00002608 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/5/2017 2:03:30 AM Bruce Moskowitz [(b) (6) mac.com] Re: Lab Soft News: Cerner/Leidos/Accenture Secure EHR Contract for a Global Military EHR Interesting Sent from my iPhone > on Apr 4, 2017, at 6:40 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > > http://labsoftnews.typepad.com/lab_soft_news/2015/08/cerner-dod-contract-conn.html > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000938 OS 00002609 Message From: Bruce Moskowitz [(b) (6) Sent: 4/4/2017 10:40:56 PM To: IP [(b) (6) frenchangel59.com]; mbs(b) (6) @gmail.com drshulkin@aol.com Lab Soft News: Cerner/Leidos/Accenture Secure EHR Contract for a Global Military EHR CC: Subject: mac.com] http://labsoftnews.typepad.com/lab_soft_news/2015/08/cerner-dod-contract-conn.html Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000939 OS 00002610 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/25/2017 5:05:13 PM Ike Perlmutter [(b) (6) frenchangel59.com]; Marisol [(b) (6) frenchangel59.com] Tom Bowman will come to dinner so the senate efforts are represented. I would have invited the number 2 republican on the committee but they all are going to the senate spouses dinner Sent from my iPhone VA-19-0799-D-000940 OS 00002611 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 5/23/2017 11:50:29 PM David shulkin [Drshulkin@aol.com] Re: Terry Fadem You will be simply great!! Sent from my iPhone On May 23, 2017, at 5:28 PM, David shulkin wrote: Ok - thats a big assumption about my state of mind tommorow Sent from my iPhone On May 23, 2017, at 4:58 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Let's talk about this tomorrow after your hearing when you have a clearer mindwe can do it hourly - spoke to Rachel Sent from my iPhone On May 23, 2017, at 7:33 AM, David shulkin wrote: Can you see if Rachels group in technology transfer has done anything about a contract with Terry Fadem- ive asked three times We have to be careful he would need to work for the technology transfer group as a consultant as Bruce cannot direct his activities since he is not a federal employee- he must work for TTp- maybe On an hourly basis We need to do this by the rules or lets not do it Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) mac.com> Date: May 23, 2017 at 6:40:45 AM EDT To: drshulkin@aol .com Cc: L Perl <(b) (6) gmail.com>, IP (b) (6) < frenchangel59.com>, mbs(b) (6) @gmail .com Subject: Terry Fadem EMCL VA-19-0799-D-000941 OS 00002612 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 5/23/2017 9:23:54 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Terry Fadem Ok - thats a big assumption about my state of mind tommorow Sent from my iPhone On May 23, 2017, at 4:58 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Let's talk about this tomorrow after your hearing when you have a clearer mind- we can do it hourly - spoke to Rachel Sent from my iPhone On May 23, 2017, at 7:33 AM, David shulkin wrote: Can you see if Rachels group in technology transfer has done anything about a contract with Terry Fadem- ive asked three times We have to be careful he would need to work for the technology transfer group as a consultant as Bruce cannot direct his activities since he is not a federal employee- he must work for TTp- maybe On an hourly basis We need to do this by the rules or lets not do it Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) mac.com> Date: May 23, 2017 at 6:40:45 AM EDT To: drshulkin@aol .com Cc: L Perl <(b) (6) gmail.com>, IP (b) (6) @gmail .com < frenchangel59.com>, mbs(b) (6) Subject: Terry Fadem EMCL VA-19-0799-D-000942 OS 00002613 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 5/23/2017 8:58:53 PM David shulkin [Drshulkin@aol.com] Re: Terry Fadem Let's talk about this tomorrow after your hearing when you have a clearer mind- we can do it hourly - spoke to Rachel Sent from my iPhone On May 23, 2017, at 7:33 AM, David shulkin wrote: Can you see if Rachels group in technology transfer has done anything about a contract with Terry Fadem- ive asked three times We have to be careful he would need to work for the technology transfer group as a consultant as Bruce cannot direct his activities since he is not a federal employee- he must work for TTp- maybe On an hourly basis We need to do this by the rules or lets not do it Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) mac.com> Date: May 23, 2017 at 6:40:45 AM EDT To: drshulkin@aol .com Cc: L Perl <(b) (6) gmail.com>, IP <(b) (6) frenchangel59.com>, (b) (6) mbs @gmail .com Subject: Terry Fadem EMCL VA-19-0799-D-000943 OS 00002614 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 5/23/2017 11:33:08 AM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Terry Fadem Can you see if Rachels group in technology transfer has done anything about a contract with Terry Fadem- 1ve asked three times We have to be careful he would need to work for the technology transfer group as a consultant as Bruce cannot direct his activities since he is not a federal employee- he must work for TTp- maybe On an hourly basis We need to do this by the rules or lets not do it Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) mac.com> Date: May 23, 2017 at 6:40:45 AM EDT To: drshulkin@aol .com Cc: L Perl <(b) (6) gmail.com>, IP <(b) (6) frenchangel59 .com>, mbs(b) (6) Subject: Terry Fadem @gmail.com EMCL VA-19-0799-D-000944 OS 00002615 Message From: David shulkin [Drshulkin@aol.com] Sent: 5/23/2017 11:26:56 AM To: Bruce Moskowitz [(b) (6) Re: Terry Fadem Subject: mac.com] of course Sent from my iPhone > on May 23, 2017, at 7:15 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > Thank you is it possible to let him know? > > Sent from my iPad > Bruce Moskowitz M.D. > >> on May 23, 2017, at 7:13 AM, David shulkin wrote: >> >> Bruce- we are working on this- i know it seems crazy but this is the toughest thing to do in government- since it deals with procurement and you need to bid things our and give preferences to disabled veteran owned businesses- but we are getting close >> >> >> >> Sent from my iPhone >> >>> on May 23, 2017, at 6:40 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>> >>> We need to know what is timeline for his approval. I can not get needed technology donated from the group without his assistance. We have the following waiting for his assistance: >>> >>> off the shelf programs for Inventory management that do not rely on EMR and can start tracking unnecessary spending immediately >>> Your internal group headed by your current CIO wants the EMCL software so Veterans can access care at reliable health care clinics and know wait times under the choice program. >>> >>> Program tracking opioid prescriptions and overprescribing. >>> >>> suicide and mental health tracking who is at risk. >>> >>> Thank you for the update. >>> Sent from my iPad >>> Bruce Moskowitz M.D. >> VA-19-0799-D-000945 OS 00002616 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 5/23/2017 11:15:19 AM David shulkin [Drshulkin@aol.com] Poonam Alaigh [(b) (6) hotmail.com]; Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter (b) (6) [ gmail.com]; Marc Sherman [(b) (6) gmail.com] Re: Terry Fadem Thank you is it possible to let him know? Sent from my iPad Bruce Moskowitz M.D. > on May 23, 2017, at 7:13 AM, David shulkin wrote: > > Bruce- we are working on this- i know it seems crazy but this is the toughest thing to do in government- since it deals with procurement and you need to bid things our and give preferences to disabled veteran owned businesses- but we are getting close > > > > Sent from my iPhone > >> on May 23, 2017, at 6:40 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >> >> We need to know what is timeline for his approval. I can not get needed technology donated from the group without his assistance. We have the following waiting for his assistance: >> >> off the shelf programs for Inventory management that do not rely on EMR and can start tracking unnecessary spending immediately >> Your internal group headed by your current CIO wants the EMCL software so Veterans can access care at reliable health care clinics and know wait times under the choice program. >> >> Program tracking opioid prescriptions and overprescribing. >> >> suicide and mental health tracking who is at risk. >> >> Thank you for the update. >> Sent from my iPad >> Bruce Moskowitz M.D. > VA-19-0799-D-000946 OS 00002617 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 5/23/2017 11:13:35 AM Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com]; Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) gmail.com]; Marc Sherman [(b) (6) gmail.com] Re: Terry Fadem Bruce- we are working on this- i know it seems crazy but this is the toughest thing to do in governmentsince it deals with procurement and you need to bid things our and give preferences to disabled veteran owned businesses- but we are getting close Sent from my iPhone > on May 23, 2017, at 6:40 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > We need to know what is timeline for his approval. I can not get needed technology donated from the group without his assistance. We have the following waiting for his assistance: > > off the shelf programs for Inventory management that do not rely on EMR and can start tracking unnecessary spending immediately > Your internal group headed by your current CIO wants the EMCL software so Veterans can access care at reliable health care clinics and know wait times under the choice program. > > Program tracking opioid prescriptions and overprescribing. > > suicide and mental health tracking who is at risk. > > Thank you for the update. > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000947 OS 00002618 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 5/23/2017 10:40:45 AM drshulkin@aol.com L Perl [(b) (6) gmail.com]; IP [(b) (6) frenchangel59.com]; (b) (6) Terry Fadem gmail.com We need to know what is timeline for his approval. I can not get needed technology donated from the group without his assistance. We have the following waiting for his assistance: off the shelf programs for Inventory management that do not rely on EMR and can start tracking unnecessary spending immediately Your internal group headed by your current CIO wants the EMCL software so Veterans can access care at reliable health care clinics and know wait times under the choice program. Program tracking opioid prescriptions and overprescribing. suicide and mental health tracking who is at risk. Thank you for the update. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000948 OS 00002619 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/8/2017 7:47:05 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Document #1 - REMINDERS FOR DINNER WITH JARED KUSHNER - Saturday, April 8th at 7:30 PM I agree - well have to think this through Sent from my iPhone On Apr 8, 2017, at 3 :37 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Lost for words- had to re-read it a few times, but the good thing is that he looped you in - we just have to find ways to meet with them face to face on a regular basis- not just the quick daily calls. They have to get to know you over time, build trust and recognize you as the ultimate authoritynot just quick phone calls Sent from my iPhone On Apr 8, 2017, at 11 :20 AM, David shulkin wrote: 0mg Sent from my iPhone Begin forwarded message: From: "IP" <(b) (6) frenchangel59 .com> Date: April 8, 2017 at 11 :02:47 AM EDT To: "David shulkin" Subject: Document #1 - REMINDERS FOR DINNER WITH JARED KUSHNER- Saturday, April 8th at 7:30 PM See attached. I will call you later today. MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has VA-19-0799-D-000949 OS 00002620 2. Approximately 700 vacant and underutilized locations a. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. STAFFING 4. Freeze "All Hiring" - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon the Secretary's approval. 5. Institute an early retirement employee buyout program. 6. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 7. The FY17 VA budget is over $181 Billion. We are evaluating the budget to identify waste, inefficiencies and potentia I surpluses. 8. The preliminary goal looks like a potential minimum reduction of $15B. 9. This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. PTSD I SUICIDE PREVENTION 10. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch VA-19-0799-D-000950 OS 00002621 problems at the outset and prevent surprises and costs upon retirement) 11. Establish a wellness prevention program. [As an example, we administer colonoscopy exams for early detection of cancer. If the disease is discovered early we can save lives and reduce costs] INFORMATION TECH I ELECTRONIC MEDICAL RECORDS SYSTEM 12. DOD recently signed a new contract to implement a new system (Cerner) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cerner system. 13. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) a. The Top 5 Academic Medical Centers DO NOT use Cerner and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. d. Cerner's DOD implementation then MUST be instructed talk to whatever system the VA chooses to install. WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled (hospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the White House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs them available (on call) when requested. For our continuing needs, we can interface with (b) (6) which will also develop him as an operator in business as well. VA-19-0799-D-000951 OS 00002622 OTHER 15. PRESIDENT'S INVITATION a. (b) (6) initiative is gathering 500 people in Washington on April 29 th at 7:00 PM. He is working with the Pastor, Dr (b) (6) . The party will take place in the Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. VA-19-0799-D-000952 OS 00002623 Message Poonam Alaigh [(b) (6) hotmail.com] 4/8/2017 7:37:10 PM David shulkin [Drshulkin@aol.com] Re: Document #1 - REMINDERS FOR DINNER WITH JARED KUSHNER - Saturday, April 8th at 7:30 PM From: Sent: To: Subject: Lost for words- had to re-read it a few times, but the good thing is that he looped you in - we just have to find ways to meet with them face to face on a regular basis- not just the quick daily calls. They have to get to know you over time, build trust and recognize you as the ultimate authority- not just quick phone calls Sent from my iPhone On Apr 8, 2017, at 11 :20 AM, David shulkin wrote: 0mg Sent from my iPhone Begin forwarded message: From: "IP" <(b) (6) frenchangel59.com> Date: April 8, 2017 at 11 :02:47 AM EDT To: "David shulkin" Subject: Document #1 - REMINDERS FOR DINNER WITH JARED KUSHNER- Saturday, April 8th at 7:30 PM See attached. I will call you later today. MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has 2. Approximately 700 vacant and underutilized locations a. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. VA-19-0799-D-000953 OS 00002624 c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. STAFFING 4. 5. 6. Freeze "All Hiring" - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon the Secretary's approval. Institute an early retirement employee buyout program. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 7. The FY17 VA budget is over $181 Billion. We are evaluating the budget to identify waste, inefficiencies and potential surpluses. 8. The preliminary goal looks like a potential minimum reduction of $15B. 9. This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. PTSD I SUICIDE PREVENTION 10. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch problems at the outset and prevent surprises and costs upon retirement) 11. Establish a wellness prevention program. [As an example, we administer colonoscopy exams for early detection of cancer. If the disease is discovered early we can save lives and reduce costs] INFORMATION TECH I ELECTRONIC MEDICAL RECORDS SYSTEM 12. DOD recently signed a new contract to implement a new system (Cerner) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cerner system. 13. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) VA-19-0799-D-000954 OS 00002625 a. The Top 5 Academic Medical Centers DO NOT use Cerner and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. d. Cerner's DOD implementation then MUST be instructed talk to whatever system the VA chooses to install. WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled (hospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the White House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs them available (on call) when requested. For our continuing needs, we can interface with (b) (6) which will also develop him as an operator in business as well. OTHER 15. PRESIDENT'S INVITATION a. (b) (6) 's initiative is gathering 500 people in Washington on April 29 at 7:00 PM. He is working with the Pastor, Dr (b) (6) . The party will take place in the Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. th VA-19-0799-D-000955 OS 00002626 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/8/2017 3:20:47 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Document #1 - REMINDERS FOR DINNER WITH JARED KUSHNER - Saturday, April 8th at 7:30 PM Ike dinner w Jared 040817.docx; Untitled attachment 05477.htm 0mg Sent from my iPhone Begin forwarded message: From: "IP" <(b) (6) frenchangel59.com > Date: April 8, 2017 at 11:02:47 AM EDT To: "David shulkin" Subject: Document #1- REMINDERS FOR DINNER WITH JARED KUSHNER- Saturday, April 8th at 7:30 PM See attached. I will call you later today. MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has 2. Approximately 700 vacant and underutilized locationsa. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans VA-19-0799-D-000956 OS 00002627 Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. STAFFING 4. Freeze "All Hiring" - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon the Secretary's approval. 5. lnstitute an early retirement employee buyout program. 6. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 7. The FY17 VA budget is over $181 Billion. We are evaluating the budget to identify waste, inefficiencies and potential surpluses. 8. The preliminary goal looks like a potential minimum reduction of $15B. 9. This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. PTSD I SUICIDE PREVENTION 10. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch problems at the outset and prevent surprises and costs upon retirement) 11. Establish a wellness prevention program. [As an example, we administer colonoscopy exams for early detection of cancer. If the disease is discovered early we can save lives and reduce costs] INFORMATION TECH I ELECTRONIC MEDICAL RECORDS SYSTEM 12. DOD recently signed a new contract to implement a new system (Cerner) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cerner system. 13. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) a. The Top 5 Academic Medical Centers DO NOT use Cerner and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. VA-19-0799-D-000957 OS 00002628 d. Cerner's DOD implementation then MUST be instructed talk to whatever system the VA chooses to install. WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled (hospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the White House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs them available (on call) when requested. For our continuing needs, we can interface with (b) (6) which will also develop him as an operator in business as well. OTHER 15. PRf5/DfNT'5 INVITATION a. (b) (6) 's initiative is gathering 500 th people in Washington on April 29 at 7:00 PM. He is working with the Pastor, Dr (b) (6) . The party will take place in the Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. VA-19-0799-D-000958 OS 00002629 MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has 2. Approximately 700 vacant and underutilized locations a. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. STAFFING 4. Freeze" All Hiring" - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon tl1e Secretary's approval. 5. Institute an early retirement employee buyout program. 6. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 7. The FYl 7 VA budget is over $181 Billion. We are evaluating the budget to identify waste, inefficiencies and potential surpluses. 8. The preliminary goal looks like a potential minimum reduction of $1 SB. 9. This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. PTSD I SUICIDE PREVENTION 10. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch problems at the outset and prevent surprises and costs upon retirement) VA-19-0799-D-000959 OS 00002630 MEMORANDUM JARED KUSHNER APRIL 8, 2017 PAGE I 2 11. Establish a wellness prevention program. fAs an example, we administer colonoscopy examsfor ear!J detection if cancer. [/the disease is discovered ear'fy we can save lives cost1J INFORMATION TECH reduce I ELECTRONIC MEDICAL RECORDS SYSTEM 12. DOD recently signed a new contract to implement a new system (Cemer) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cerner system. 13. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) a. The Top 5 Academic Medical Centers DO NOT use Cemer and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. d. Cerner's DOD implementation then MUST be instructed talk to whatever system the VA chooses to install. WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled 01ospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the \Vhite House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs tl1em available (on call) when requested. For our continuing needs, we can interface with (b) (6) which will also develop him as an operator in business as well. OTHER 15. PRESIDENTS INVITATION a. (b) (6) 's initiative is gathering 500 people in Washington on April . The party 29 th at 7 :00 PM. He is working with the Pastor, Dr (b) (6) will take place in tl1e Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. VA-19-0799-D-000960 OS 00002631 Message From: Sent: To: Subject: Attachments: IP [(b) (6) frenchangel59.com] 4/8/2017 3:02:47 PM David shulkin [drshulkin@aol.com] Document #1 - REMINDERS FOR DINNER WITH JARED KUSHNER - Saturday, April 8th at 7:30 PM Ike dinner w Jared 040817.docx See attached. I will call you later today. MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has 2. Approximately 700 vacant and underutilized locations a. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. STAFFING 4. Freeze "All Hiring" - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon the Secretary's approval. 5. Institute an early retirement employee buyout program. 6. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 7. The FY17 VA budget is over $181 Billion. We are evaluating the budget to identify waste, inefficiencies and potential surpluses. 8. The preliminary goal looks like a potential minimum reduction of $15B. VA-19-0799-D-000962 OS 00002633 9. PTSD This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. I SUICIDE PREVENTION 10. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch problems at the outset and prevent surprises and costs upon retirement) 11. Establish a wellness prevention program. [As an example, we administer colonoscopy exams for early detection of cancer. If the disease is discovered early we can save lives and reduce costs] INFORMATION TECH I ELECTRONIC MEDICAL RECORDS SYSTEM 12. DOD recently signed a new contract to implement a new system (Cerner) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cerner system. 13. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) a. The Top 5 Academic Medical Centers DO NOT use Cerner and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. d. Cerner's DOD implementation then MUST be instructed talk to whatever system the VA chooses to install. WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled (hospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the White House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs them available (on call) when requested. For our continuing needs, we can interface with (b) (6) which will also develop him as an operator in business as well. OTHER 15. PRESIDENT'S INVITATION a. initiative is gathering 500 people in Washington on April 29 th at 7:00 PM. He is working with the Pastor, Dr (b) (6) . The party will take place in the Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. (b) (6) VA-19-0799-D-000963 OS 00002634 MEMORANDUM TO: JARED KUSHNER FROM: IKE PERLMUTTER SUBJECT: TOPICS/INITIATIVES FOR DISCUSSION DATE: APRIL 8, 2017 CC: PHYSICAL INFRASTRUCTURE 1. Concentrate on the 30% good hospitals the VA currently has 2. Approximately 700 vacant and underutilized locations a. Sell right away - the VA must be permitted to utilize the cash for better use. b. Let a third party run/manage homeless shelters. They will do a better job. c. Do not use the real estate to build more Homeless shelters. INFORMATION TECHNOLOGY 3. The CIO from Mayo Clinic is overseeing (and other institutions are participating in) a search for a new CIO for the Dept. of Veterans Affairs. CIO candidates will be in DC on April 17th for interviews by the VA, Mayo's CIO and others. STAFFING 4. Freeze" All Hiring" - Not only with the Secretary of the VA but throughout all agencies and departments. Hiring should be done on a case by case basis and only upon tl1e Secretary's approval. 5. Institute an early retirement employee buyout program. 6. Transfer employees from one segment of the VA to another to balance excess workforce and shortages BUDGETING 7. The FYl 7 VA budget is over $181 Billion. We are evaluating the budget to identify waste, inefficiencies and potential surpluses. 8. The preliminary goal looks like a potential minimum reduction of $1 SB. 9. This should be achievable without adding any extra costs and, at the same time, improving quality of and access to care. PTSD I SUICIDE PREVENTION 10. Establish mandatory new enlistee psych and physical exams (from day one when entering the military to catch problems at the outset and prevent surprises and costs upon retirement) VA-19-0799-D-000964 OS 00002635 MEMORANDUM JARED KUSHNER APRIL 8, 2017 PAGE I 2 11. Establish a wellness prevention program. fAs an example, we administer colonoscopy examsfor ear!J detection if cancer. [/the disease is discovered ear'fy we can save lives cost1J INFORMATION TECH reduce I ELECTRONIC MEDICAL RECORDS SYSTEM 12. DOD recently signed a new contract to implement a new system (Cemer) with an initial cost of $4.3 billion and a total budgeted cost of $9 billion. There is a push for the VA to choose the same Cerner system. 13. What the VA needs is a system that can talk to the private hospitals' systems with which it will be partnering for Veterans medical care (interoperability among the Public-Private Partnership) a. The Top 5 Academic Medical Centers DO NOT use Cemer and highly recommend against it in favor of another system (EPIC). b. EPIC is used by 50% of the hospitals in the US and covers over 120 million patients. c. This means less cost, easier access to the doctors, patients and soldiers and their medical records. d. Cerner's DOD implementation then MUST be instructed talk to whatever system the VA chooses to install. WHITE HOUSE LIAISON 14. The VA transformation process is moving quickly and effectively by leaning on the expertise of the team I assembled 01ospital, medical and restructuring experts). The effort is more efficiently and effectively managed as a unified, singular effort. To be most efficient (and successful) the \Vhite House staff would contribute best if focused on opening doors and removing political obstacles, when requested, but not on overseeing their own initiatives. Currently, our group doesn't need to inconvenience (b) (6) (b) (6) and her group, but needs tl1em available (on call) when requested. For our continuing needs, we can interface with (b) (6) which will also develop him as an operator in business as well. OTHER 15. PRESIDENTS INVITATION a. (b) (6) initiative is gathering 500 people in Washington on April . The party 29 th at 7 :00 PM. He is working with the Pastor, Dr (b) (6) will take place in tl1e Trump Hotel in Washington. It will be televised and Fox's Hannity will attend and we would like the President to attend. VA-19-0799-D-000965 OS 00002636 Message To: Poonam Alaigh [(b) (6) hotmail.com] 4/8/2017 7:32:21 PM David Shulkin [drshulkin@aol.com] Subject: Re: From: Sent: Definitely much much better; I) is there a way of making it into only 5- with maybe combining transparency with the Greater Choice. 2) Also, there has to be a strong "accountability" priority - maybe adding it to the "efficient use of resources". 3) Does Fraud/waste/abuse message have to be explicit or is it implicit in that Priority of efficient use of resources? Sent from my iPhone On Apr 8, 2017, at 3 :02 PM, David Shulkin wrote: Do you like this any better than the 10 priorities?- I got it to 6 VA-19-0799-D-000966 OS 00002637 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/8/2017 7:02:50 PM To: (b) (6) Attachments: hotmail.com priorities.pptx Do you like this any better than the 10 priorities?- I got it to 6 VA-19-0799-D-000967 OS 00002638 The Secretary's 6 Priorities Greater Choice to Veterans -Revise the 40/30 Rule -Build an Integrated Network of Care Modernize our System -Infrastructure Improvements and Consolidations -EMR Interoperability and Modernization Focus Resources More Efficiently -Foundational Services in VA -VA/DOD/Community Coordination Suicide Prevention Improve Timeliness of Services - Wait times and Accessibility for Care - Decisions on Appeals - Performance on Disability Claims Deliver on Accountability and Transparency VA-19-0799-D-000968 OS 00002639 Message From: David Shulkin [drshulkin@aol.com] Sent: To: (b) (6) 4/18/2017 2:34:44 AM [(b) (6) gmail.com] Can we ask the librarian to get a full copy http ://annals .org/aim/article/262 l 65 l /understanding-veteran-wait-times Sent from my iPad VA-19-0799-D-000969 OS 00002640 Message From: Sent: To: Subject: Ike- sorry David shulkin [Drshulkin@aol.com] 4/6/2017 7:40:03 PM Ike Perlmutter [(b) (6) frenchangel59.com] Prep for your meetings I think i missed your call and did not reach you when I tried back just now I sent you the one executive order We did get the choice extension through the Senate and the House this week and it will be ready for the Presidents signature when he returns to DC We are working on two big things. First as you know we may be able to get VA and the Department of Defense on the same IT platform- if we did this it would both lives and money Second we are working to eliminate the 40 mile rule soon and give veterans much greater choice. In order to do this we need the Presidents help in the budget in years 2019-21 (we are ok in 2018). In 2019 we need to keep our current budget and then use savings we find in our mandatory spending to keep for greater choice for veterans. If we dont do this then we need new funds and I dont want to ask for any new money. In years 2020-21 I think we will be in better shape as we will realize savings from facility closures but it will take us 1-2 years to get these done. David Sent from my iPhone VA-19-0799-D-000970 OS 00002641 Message From: (b) (6) [(b) (6) Sent: To: 4/12/2017 9:24:23 PM David Shulkin [drshulkin@aol.com] gmail.com] https ://www.usatoday.com/story/news/politics/2017/04/12/veterans-danger-va-hospital-washington-dcinvestigation-finds/l 003 76124/ Your pictures are at the bottom. VA-19-0799-D-000971 OS 00002642 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/201710:27:50 PM Darin Selnick [(b) (6) @gmail.com] Re: Decision Memo for President Great Sent from my iPhone > on Apr 7, 2017, at 6:26 PM, Darin selnick <(b) (6) @gmail.com> wrote: > > FYI > > (b) (6) just sent me a draft decision memorandum she made up for the President to sign for the Veterans choice Improvement Act. Her ask was for me to review and edit, which I did. A couple of sentences needed to be reworked so that they would be more accurate, and I sent it back to her with the corrections. > > Hopefully this means it gets signed very soon. > > Darin > > VA-19-0799-D-000972 OS 00002643 Message From: Darin Selnick [(b) (6) Sent: 4/7/201710:26:50 PM To: David shulkin [Drshulkin@aol.com] Decision Memo for President Subject: @gmail.com] FYI (b) (6) just sent me a draft decision memorandum she made up for the President to sign for the Veterans Choice Improvement Act. Her ask was for me to review and edit, which I did. A couple of sentences needed to be reworked so that they would be more accurate, and I sent it back to her with the corrections. Hopefully this means it gets signed very soon. Darin VA-19-0799-D-000973 OS 00002644 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/25/2017 4:57:58 PM Ike Perlmutter [(b) (6) frenchangel59.com] Senator issakson cannot make the dinner since its the same night as the senate spouses dinberapologizes he Sent from my iPhone VA-19-0799-D-000974 OS 00002645 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/6/2017 11:22:33 AM To: (b) (6) Subject: Fwd: (No Subject) [(b) (6) gmail.com] Print Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) torreyapartners.com> Date: April 6, 2017 at 7:21 :09 AM EDT To: David shulkin Subject: Re: (No Subject) Some things below don't make much sense below. Don't all patients in all IRBs have the central privacy review and I assume information security review is also standard or could be added. I disagree with the lack of benefits to the vets. They get intense state of the art monitoring and the latest advances. In fact, in oncology, the FDA allows phaseless design -- the phase 1 goes right to phase 2 and phase 3. Its seamless---there is a concept that if a patient responds then its a n of one trial. The IP issue does not make sense in an industry trial. Maybe they mean who can publish? Industry owns the data but must release it. Here is my suggestion to save you the most valuable asset you have -- your time. There are 2 options. One, I learned from a ceo who bought 15 biotech companies. Ask your team---how could we set up a phase 1 unit with central IRB and one master contract. The biotech ceo would tell his team, I know all the reasons why we should not buy x, I want to hear why we should do it and how we do it. Or the second is i can take these concerns/issues orally (won't ever send an email from you or your people without your explicit approval) to jim greenwood of bio. He would appoint a group and once they have flushed out the issues and can step up then we have a meeting like we had on Monday with regeneron but there needs to be prep to get these ironed out. The win here beyond better care/options for vets is the industry does not to go to china. Someone may like that. Last point--The one call you should make is to rob califf. He knows the IRB issues and other obstacles. His big issue is the govt (Medicare and medicaid) can't pay for clinical trials--he is correct but smaller companies and the big pharma don't want to go to china/overseas and they are VA-19-0799-D-000975 OS 00002646 glad to pay here in the US. The logistics of flying over to china and other countries and monitoring overseas is a pain. On Apr 5, 2017, at 11: 18 PM, David shulkin wrote: When you get tine- let me know your thoughts Sent from my iPhone Begin forwarded message: -----Original Message----From: Ramoni, Rachel Sent: Wednesday, April 05, 2017 09:00 PM Eastern Standard Time To: DJS Cc: Alaigh, Poonam, M.D.; Lee, Jennifer S. (VACO) Subject: RE: Dear Dr. Shulkin, I met with my team at ORD today -- responses follow: - Feedback from industry is that we need a truly functional central irb -- The VA central IRB currently has 200 VA studies and 5 industry trials open. Until recently, the VA central IRB was not allowed to do industry trials. Since that restriction was lifted, 5 industry studies were approved. At present, an agreement to allow industry to reimburse the central IRB for review is awaiting Carolyn Clancy's approval -- charging industry for such review is the norm. Our central IRB includes central privacy and information security review, necessary steps that would not be offered by a commercial IRB. We would be very interested to hear the specific criticisms from industry. We should look at NCAts from NIH as a model -- I have a meeting scheduled with Chris Adams, the head ofNCATS. We should look at phase 1 units- do we have any currently? -- We can respond better if we understand the motivation for increased phase I trials. In the past, participation in such trials was discouraged because of the higher risk to Veterans and the lower potential for benefits. The current Master CRAD A templates do not offer any advantage IP-wise for phase I trials (we currently do not get any IP for phase I - IV trials under the master CRADA template). Is there already a group looking at clinical trials? Yes, we are in the process of executing an agreement with NCI to both increase the number of NCI trials available to our Veterans and to make the process more efficient. NCI is going to fund this effort. We would be very happy to have industry perspectives as we modernize our clinical trials process. Novartis has a platform they would give us called signature platform -- I will alert Mike Kelley (an oncologist at the Durham who is involved in the NCI trials project as well as the APOLLO effort) to this, as it seems like the signature platform has to do with matching patients to therapy based upon their genomic VA-19-0799-D-000976 OS 00002647 profile. Is there a point of contact at Novartis? Do you have plans undenvay? Yes -- with NCI. We'd like to add in multiple industry perspectives, including smaller industry perspectives, given the more limited marketplace for some Veteran-specific conditions. We anticipate that there will be a number of considerations as we expand industry trials at the VA, including the potential impact on access of shifting clinician time to clinical trials, so this is an effort that will touch a number of points at VHA. When will you present your strategy for research? We are having a strategic planning meeting on April 12. A first draft of our strategy will be distributed for input at the end of April. With appreciation, Rachel -----Original Message----From: DJS Sent: Wednesday, April 05, 2017 7:29 AM To: Ramoni, Rachel Cc: Alaigh, Poonam, M.D. Subject: Importance: High Rachel- as you know with our Johnson and Johnson meetings we set as a goal to increase clinical trials Feedback from industry is that we need a truly functional central irb We should look at NCAts from NIH as a model We should look at phase 1 units- do we have any currently? Is there already a group looking at clinical trials? Novartis has a platform they would give us called signature platform Do you have plans undenvay? When will you present your strategy for research? Sent with Good (www.good.com) VA-19-0799-D-000977 OS 00002648 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/6/2017 3:20:51 AM To: (b) (6) Subject: Fwd: (No Subject) [(b) (6) gmail.com] Print Sent from my iPhone Begin forwarded message: From: DJS Date: April 5, 2017 at 11: 10: 19 PM EDT To: 'Shulkin' Subject: FW: (No Subject) Sent with Good (www.good.com) -----Original Message----From: Ramoni, Rachel Sent: Wednesday, April 05, 2017 09:00 PM Eastern Standard Time To: DJS Cc: Alaigh, Poonam, M.D.; Lee, Jennifer S. (VACO) Subject: RE: Dear Dr. Shulkin, I met with my team at ORD today -- responses follow: - Feedback from industry is that we need a truly functional central irb -- The VA central IRB currently has 200 VA studies and 5 industry trials open. Until recently, the VA central IRB was not allowed to do industry trials. Since that restriction was lifted, 5 industry studies were approved. At present, an agreement to allow industry to reimburse the central IRB for review is awaiting Carolyn Clancy's approval -- charging industry for such review is the norm. Our central IRB includes central privacy and information security review, necessary steps that would not be offered by a commercial IRB. We would be very interested to hear the specific criticisms from industry. We should look at NCAts from NIH as a model -- I have a meeting scheduled with Chris Adams, the head of NCATS. We should look at phase 1 units- do we have any currently? -- We can respond better ifwe understand the motivation for increased phase I trials. In the past, participation in such trials was discouraged because of the higher risk to Veterans and the lower potential for benefits. The current Master CRAD A templates do not offer any advantage IP-wise for phase I trials (we currently do not get any IP for phase I - IV trials under the master CRADA template). Is there already a group looking at clinical trials? Yes, we are in the process of executing an agreement with NCI to both increase the number of NCI trials available to our Veterans and to make the process more efficient. NCI is going to fund this effort. We would be very happy to have industry perspectives as we modernize our clinical trials process. VA-19-0799-D-000978 OS 00002649 Novartis has a platform they would give us called signature platform -- I will alert Mike Kelley (an oncologist at the Durham who is involved in the NCI trials project as well as the APOLLO effort) to this, as it seems like the signature platform has to do with matching patients to therapy based upon their genomic profile. Is there a point of contact at Novartis? Do you have plans underway? Yes -- with NCI. We'd like to add in multiple industry perspectives, including smaller industry perspectives, given the more limited marketplace for some Veteran-specific conditions. We anticipate that there will be a number of considerations as we expand industry trials at the VA, including the potential impact on access of shifting clinician time to clinical trials, so this is an effort that will touch a number of points at VHA. When will you present your strategy for research? We are having a strategic planning meeting on April 12. A first draft of our strategy will be distributed for input at the end of April. With appreciation, Rachel -----Original Message----From: DJS Sent: Wednesday, April 05, 2017 7:29 AM To: Ramoni, Rachel Cc: Alaigh, Poonam, M.D. Subject: Importance: High Rachel- as you know with our Johnson and Johnson meetings we set as a goal to increase clinical trials Feedback from industry is that we need a truly functional central irb We should look at NCAts from NIH as a model We should look at phase 1 units- do we have any currently? Is there already a group looking at clinical trials? Novartis has a platform they would give us called signature platform Do you have plans underway? When will you present your strategy for research? Sent with Good (www.good.com) VA-19-0799-D-000979 OS 00002650 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/6/2017 11:32:48 AM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Hopkins Should we connect him to neil in telehealth? Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 6, 2017 at 7:21:34 AM EDT To: David shulkin Cc: (b) (6) hotmail .com Subject: Re: Hopkins mac.com> I am ready anytime. Sent from my iPad Bruce Moskowitz M.D. On Apr 6, 2017, at 7: 18 AM, David shulkin wrote: We can connect with our Telehealth group when you are ready Sent from my iPhone On Apr 6, 2017, at 6:53 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: I spoke to this group at Hopkins and told them I would discuss a pilot project on their nickel! Actually they have an impressive record so far. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000980 OS 00002651 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) 4/6/2017 11:21:34 AM David shulkin [Drshulkin@aol.com] (b) (6) hotmail.com Re: Hopkins mac.com] I am ready anytime. Sent from my iPad Bruce Moskowitz M.D. > on Apr 6, 2017, at 7:18 AM, David shulkin wrote: > > We can connect with our Telehealth group when you are ready > > Sent from my iPhone > >> on Apr 6, 2017, at 6:53 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >> >> I spoke to this group at Hopkins and told them I would discuss a pilot project on their nickel! Actually they have an impressive record so far. >> >> >> >> >> >> Sent from my iPad >> Bruce Moskowitz M.D. > VA-19-0799-D-000981 OS 00002652 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/6/2017 11:18:24 AM Bruce Moskowitz [(b) (6) (b) (6) hotmail.com Re: Hopkins mac.com] We can connect with our Telehealth group when you are ready Sent from my iPhone > on Apr 6, 2017, at 6:53 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > I spoke to this group at Hopkins and told them I would discuss a pilot project on their nickel! Actually they have an impressive record so far. > > > > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000982 OS 00002653 Message From: Sent: To: Subject: Attachments: Bruce Moskowitz [(b) (6) mac.com] 4/6/2017 10:53:27 AM drshulkin@aol.com; (b) (6) hotmail.com Hopkins emocha Letter to Dr Moskowitz 04052017.pdf; Untitled attachment 05592.txt I spoke to this group at Hopkins and told them they have an impressive record so far. I would discuss a pilot project on their nickel! Actually VA-19-0799-D-000983 OS 00002654 emocha® M OB I LE HEA LTH IN C. April 5, 2017 Dr. Bruce Moskowitz BY EMAIL Re: Video-based Directly Observed Therapy (DOT) for Opioid Addiction Treatment; pilot with the VA Dear Dr. Moskowitz, Many thanks for our conversation yesterday. We are a mobile technology company that spun out of Johns Hopkins School of Medicine in 2013. Our modular, HI PAA-compliant platform is specialized in securing medication adherence and keeping patients linked to care. In addition to having developed a world-class, proven product, our affiliation with Johns Hopkins University has been a key factor in our success. We have had the great fortune of developing our software with public health experts in HIV, hepatitis C, tuberculosis (TB), and opioid addiction through our close connection to academia. Our asynchronous solution is a novel and efficient form of telehealth focused on medication adherence, using a video recording rather than live stream connection to achieve adherence rates typically above 90%. The platform has been most frequently deployed to monitor TB therapy as DOT is the accepted standard of care. emocha has been implemented in more than twenty-five clinics all over the country, as well as in Australia and India. Our NIH-funded study for implementing the technology among TB patients in Maryland has demonstrated rates of medication adherence comparable to the high rates of in-person DOT, while creating significant savings for health departments. Furthermore, qualitative interviews with staff and patients showed a high level of acceptability. We have also recently deployed our video DOT solution in nine clinics nationwide for monitoring adherence to 12-week, single dose HCV regimens among injection drug using patients. We have received a Notice of Intent to Fund a SBIR grant from NIDA to support our efforts in opioid addiction. We believe that our asynchronous video-based DOT solution can provide a strong support and monitoring system for patients being treated for opioid addiction using office-based therapies such as take-home buprenorphine while serving as an automated triage tool for providers. Patients use a smartphone or tablet to report side effects or cravings, view their regimen, and video record themselves taking their medication at every dose. On a secure web portal, the provider or a case manager reviews the video to assess adherence soon after the data is submitted. Using sophisticated protocols and algorithms, the provider is guided to efficiently and selectively engage patients who need support in order to keep them on track. Our NIDA-funded work involves pilot testing at office-based buprenorphine programs run by University of Washington in Seattle and Boston University. Dr. (b) (6) , emocha Mobile Health Inc . I 1812 Ashland Avenue, Suite #100 Baltimore, MD 21205 I @emochaHealth VA-19-0799-D-000984 OS 00002655 emocha® M OB I LE HEA LTH IN C. the Director for the substance abuse program at the VA Puget Sound Health Care System, is part of the project team. Helping veterans struggling with opioid addiction is one of the highest priorities for the VA, and we propose to use emocha in a pilot with a VA clinic, potentially as part of our NIDA project. We propose implementing the technology for patients entering their buprenorphine initiation phase. Patients will receive the application from their provider who will utilize the application to monitor their adherence for the first 3-6 months after initiation of buprenorphine treatment-a period when patients are at high risk to dropout and relapse to illicit opiate use. The application can also be used at later stages if a patient is struggling to maintain abstinence or if the provider has concerns regarding diversion. The application will also include educational materials, appointment reminders, tailored, dynamic messaging to assuage cravings, and risk assessments to prioritize provider intervention. Video capture will also allow providers to visualize their patients and their environment each day. We believe this has the potential to increase adherence, provide patient-centered social support at scale, track outcomes over time, as well as serve as a powerful diversion mitigation strategy .. We believe partnering with a VA medical center would be an ideal setting to implement the technology. emocha video DOT could also be expanded to uses outside of buprenorphine. Patients with other substance abuse or mental health issues could benefit from daily support in the proper taking of their medications. In other cases, patients in remote areas with limited internet connectivity could remain engaged with their provider, and helped to achieve high levels of adherence. We would appreciate any advice you may have and we look forward to further conversations. Many thanks in advance for your support. Sincerely, (b) (6) CEO (b) (6) @emocha.com (410) 804-(b) (6) emocha Mobile Health Inc . I 1812 Ashland Avenue, Suite #100 Baltimore, MD 21205 I @emochaHealth VA-19-0799-D-000985 OS 00002656 Sent from my iPad Bruce Moskowitz M.D. Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/7/2017 9:31:02 PM David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com]; Marc Sherman [(b) (6) Re: Information systems article gmail.com] Excellent and goes right after what we want including a device registry. Sent from my iPad Bruce Moskowitz M.D. On Apr 7, 2017, at 4:27 PM, David shulkin wrote: http s://www.meri talk. com/the-si tuati on-report-is-the-ci o-j ob-at-va-ab out-to-1 ose-i ts-influence/ Sent from my iPhone VA-19-0799-D-000987 OS 00002658 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/2017 8:27:34 PM Bruce Moskowitz [(b) (6) [(b) (6) gmail.com] Information systems article mac.com]; Ike Perlmutter [(b) (6) frenchangel59.com]; Marc Sherman https ://www.meritalk.com/the-situation-report-is-the-cio-j ob-at-va-about-to-lose-its-influence/ Sent from my iPhone VA-19-0799-D-000988 OS 00002659 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/5/2017 11:35:49 AM To: Bruce Moskowitz [(b) (6) mac.com] IP [(b) (6) frenchangel59.com]; mbs(b) (6) @gmail.com Re: Pentagon revises schedule for electronic health record roll out CC: Subject: understood Sent from my iPhone > on Apr 5, 2017, at 6:42 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > As ~he Penn Professor article predicted the roll out is at one hospital system and the delays and costs will increase. > The bigger problem is that there will be no integration with the majority of community and academic centers medical records. The reason why all S of our partners chose Epic independently was discussed by Dr. (b) (6) at our first meeting with the President. I personally do not use Epic but a program designed by Quest Labs that integrates with other internal medicine practices. > http://federalnewsradio.com/defense/2016/10/pentagon-revises-schedule-electronic-health-record-rolloutincluding-several-months-delays/ > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-000989 OS 00002660 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/5/2017 10:42:18 AM drshulkin@aol.com IP [(b) (6) frenchangel59.com]; mbs(b) (6) @gmail.com Pentagon revises schedule for electronic health record roll out As the Penn Professor article predicted the roll out is at one hospital system and the delays and costs will increase. The bigger problem is that there will be no integration with the majority of community and academic centers medical records. The reason why all S of our partners chose Epic independently was discussed by Dr. (b) (6) at our first meeting with the President. I personally do not use Epic but a program designed by Quest Labs that integrates with other internal medicine practices. http://federalnewsradio.com/defense/2016/10/pentagon-revises-schedule-electronic-health-record-rolloutincluding-several-months-delays/ Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-000990 OS 00002661 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/5/2017 12:20:09 PM (b) (6) [(b) (6) gmail.com] Fwd: Proposed Article in Gladwyne Living Can you get a high resolution photo to bob below? From: Bob Norkus N2 Date: April 4, 2017 at 8:57:44 AM EDT To: (b) (6) <(b) (6) hotmail. com> Subject: Re: Proposed Article in Gladwyne Living can you source us to high resolution photos? 300dpi Bo b On Apr 4, 2017, at 7:50 AM, (b) (6) <(b) (6) h otmail . com> wrote: Bob, there are several factual errors. Ok for meto correct VA-19-0799-D-000991 OS 00002662 them and ill resend tomorr ow? Sent from my iPhone On Apr 3, 2017, at 2:01 PM, Bob Norkus N2 wrote: L 0 0 k n g f r 0 w a r d t 0 h e a r n g f r 0 VA-19-0799-D-000992 OS 00002663 m y 0 u b 0 t h 0 n 1 y r e f e r e n C e w e w s h t 0 m a k e s t h a t y 0 u a r e r e s d e VA-19-0799-D-000993 OS 00002664 n t s 0 f G 1 a d w y n e w h C h s p u b 1 C k n 0 w 1 e d g e 0 n t h e I n t e r n e t VA-19-0799-D-000994 OS 00002665 D a V d s h u 1 k n A m e r C a s D 0 C t 0 r 0 n F e b r u a r y 1 3 2 0 1 7 0 n g t VA-19-0799-D-000995 OS 00002666 m e G 1 a d w y n e r e s d e n t D r D a V d s h u 1 k n w a s a p p r 0 V e d b y t h e u n VA-19-0799-D-000996 OS 00002667 m e G 1 a d w y n e r e s d e n t D r D a V d s h u 1 k n w a s a p p r 0 V e d b y t h e u n VA-19-0799-D-000996 OS 00002667 t e d s t a t e s s e n a t e t 0 h e a d t h e D e p a r t m e n t 0 f V e t e r a n s A f f a r s VA-19-0799-D-000997 OS 00002668 t e d s t a t e s s e n a t e t 0 h e a d t h e D e p a r t m e n t 0 f V e t e r a n s A f f a r s VA-19-0799-D-000997 OS 00002668 I n t h e s e f r a C t 0 u s t m e s t h e V 0 t e t a 1 1 e s w e r e n 0 t h n g s h 0 r VA-19-0799-D-000998 OS 00002669 I n t h e s e f r a C t 0 u s t m e s t h e V 0 t e t a 1 1 e s w e r e n 0 t h n g s h 0 r VA-19-0799-D-000998 OS 00002669 t 0 f a s t 0 n s h n g 0 n e h u n d r e d n f a V 0 r t 0 z e r 0 a g a n s t F u r t h e VA-19-0799-D-000999 OS 00002670 t 0 f a s t 0 n s h n g 0 n e h u n d r e d n f a V 0 r t 0 z e r 0 a g a n s t F u r t h e VA-19-0799-D-000999 OS 00002670 r u n d e r s C 0 r n g t h e s p r t 0 f C 0 n s e n s u s s t h e f a C t t h a t t h s C a VA-19-0799-D-001000 OS 00002671 r u n d e r s C 0 r n g t h e s p r t 0 f C 0 n s e n s u s s t h e f a C t t h a t t h s C a VA-19-0799-D-001000 OS 00002671 b n e t s e 1 e C t 0 n b y p r e s d e n t D 0 n a 1 d J T r u m p e 1 e V a t e d D r s h u VA-19-0799-D-001001 OS 00002672 b n e t s e 1 e C t 0 n b y p r e s d e n t D 0 n a 1 d J T r u m p e 1 e V a t e d D r s h u 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0 s VA-19-0799-D-001005 OS 00002676 u s n g h s e 1 t e t a 1 e n t s f 0 r m e d C n e t 0 C a r e f 0 r 0 u r h e r 0 e s " T VA-19-0799-D-001006 OS 00002677 u s n g h s e 1 t e t a 1 e n t s f 0 r m e d C n e t 0 C a r e f 0 r 0 u r h e r 0 e s " T VA-19-0799-D-001006 OS 00002677 0 q u 0 t e s m 0 k e y R 0 b n s 0 n I s e C 0 n d t h a t e m 0 t 0 n a n d I C a n d 0 s 0 w VA-19-0799-D-001007 OS 00002678 0 q u 0 t e s m 0 k e y R 0 b n s 0 n I s e C 0 n d t h a t e m 0 t 0 n a n d I C a n d 0 s 0 w VA-19-0799-D-001007 OS 00002678 t h a C 0 n f d e n C e b 0 r n e 0 f e X p e r e n C e D a V d s h u 1 k n y 0 u s e e VA-19-0799-D-001008 OS 00002679 t h a C 0 n f d e n C e b 0 r n e 0 f e X p e r e n C e D a V d s h u 1 k n y 0 u s e e VA-19-0799-D-001008 OS 00002679 w a s m y p e r s 0 n a 1 p h y s C a n 0 u r d 0 C t 0 r I p a t e n t r e 1 a t 0 n s h p VA-19-0799-D-001009 OS 00002680 w a s m y p e r s 0 n a 1 p h y s C a n 0 u r d 0 C t 0 r I p a t e n t r e 1 a t 0 n s h p 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n d D 0 VA-19-0799-D-001017 OS 00002688 n a 1 d T r u m p ' s n a u g u r a t 0 n b u t n 0 t b y C h 0 C e a s w a s t h e C a s e w VA-19-0799-D-001018 OS 00002689 n a 1 d T r u m p ' s n a u g u r a t 0 n b u t n 0 t b y C h 0 C e a s w a s t h e C a s e w VA-19-0799-D-001018 OS 00002689 t h a n u m b e r 0 f 0 t h e r n 0 s h 0 w s I n f a C t h e w a s e X p r e s s 1 y e X C 1 u d VA-19-0799-D-001019 OS 00002690 t h a n u m b e r 0 f 0 t h e r n 0 s h 0 w s I n f a C t h e w a s e X p r e s s 1 y e X C 1 u d VA-19-0799-D-001019 OS 00002690 e d f r 0 m t h e e V e n t I n w h a t C a n 0 n y b e V e w e d a s a n u 1 t m a t e s h 0 w VA-19-0799-D-001020 OS 00002691 e d f r 0 m t h e e V e n t I n w h a t C a n 0 n y b e V e w e d a s a n u 1 t m a t e s h 0 w VA-19-0799-D-001020 OS 00002691 0 f C 0 n f d e n C e h e w a s n a m e d " d e s g n a t e d s u r V V 0 r " f 0 r t h a t d a VA-19-0799-D-001021 OS 00002692 0 f C 0 n f d e n C e h e w a s n a m e d " d e s g n a t e d s 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h e p h ; l a d e l p h i a I n q u VA-19-0799-D-001025 OS 00002696 i r e r p u t s t a 1 1 n C 0 n t e X t " I V e a 1 w a y s a p p r 0 a C h e d m y J 0 b f r VA-19-0799-D-001026 OS 00002697 i r e r p u t s t a 1 1 n C 0 n t e X t " I V e a 1 w a y s a p p r 0 a C h e d m y J 0 b f r VA-19-0799-D-001026 OS 00002697 s t a s a p h y s C a n I m a n a d m n s t r a t 0 r s e C 0 n d " T h 0 u g h a t t VA-19-0799-D-001027 OS 00002698 s t a s a p h y s C a n I m a n a d m n s t r a t 0 r s e C 0 n d " T h 0 u g h a t t VA-19-0799-D-001027 OS 00002698 h e t m e h e w a s t h e u n d e r s e C r e t a r y 0 f t h e d e p a r t m e n t e a C h m 0 n t VA-19-0799-D-001028 OS 00002699 h e t m e h e w a s t h e u n d e r s e C r e t a r y 0 f t h e d e p a r t m e n t e a C h m 0 n t VA-19-0799-D-001028 OS 00002699 h h e t r a V e 1 e d f r 0 m h s 0 f f C e n w a s h n g t 0 n t 0 a V A f a C t y n N VA-19-0799-D-001029 OS 00002700 h h e t r a V e 1 e d f r 0 m h s 0 f f C e n w a s h n g t 0 n t 0 a V A f a C t y n N VA-19-0799-D-001029 OS 00002700 e w y 0 r k t 0 a t t e n d p e r s 0 n a 1 1 y t 0 w a 1 k n p a t e n t s H e r e g a r d e d VA-19-0799-D-001030 OS 00002701 e w y 0 r k t 0 a t t e n d p e r s 0 n a 1 1 y t 0 w a 1 k n p a t e n t s H e r e g a r d e d VA-19-0799-D-001030 OS 00002701 t h s a s p a r t a n d p a r C e 1 0 f t h e 1 a r g e r m s s 0 n s e e n g t h a t 0 u r V VA-19-0799-D-001031 OS 00002702 t h s a s p a r t a n d p a r C e 1 0 f t h e 1 a r g e r m s s 0 n s e e n g t h a t 0 u r V VA-19-0799-D-001031 OS 00002702 e t e r a n s r e C e V e t h e t r e a t m e n t t h e y s 0 r C h 1 y d e s e r V e I t s VA-19-0799-D-001032 OS 00002703 e t e r a n s r e C e V e t h e t r e a t m e n t t h e y s 0 r C h 1 y d e s e r V e I t s VA-19-0799-D-001032 OS 00002703 e n t r e 1 y f t t n g t h e r e f 0 r e t h a t D a V d s h u 1 k n w a s b 0 r n 0 n a VA-19-0799-D-001033 OS 00002704 e n t r e 1 y f t t n g t h e r e f 0 r e t h a t D a V d s h 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VA-19-0799-D-001037 OS 00002708 e 1 d t h e r a n k 0 f C a p t a n a n d b 0 t h 0 f h s g r a n d f a t h e r s s e r V e d n t VA-19-0799-D-001038 OS 00002709 e 1 d t h e r a n k 0 f C a p t a n a n d b 0 t h 0 f h s g r a n d f a t h e r s s e r V e d n t VA-19-0799-D-001038 OS 00002709 h e F r s t w 0 r 1 d w a r 0 n e 0 f w h 0 m w e n t 0 n t 0 b e C 0 m e t h e C h e f p h a r m VA-19-0799-D-001039 OS 00002710 h e F r s t w 0 r 1 d w a r 0 n e 0 f w h 0 m w e n t 0 n t 0 b e C 0 m e t h e C h e f p h a r m VA-19-0799-D-001039 OS 00002710 a C s t a t t h e V A h 0 s p t a 1 n M a d s 0 n w s C 0 n s n D a V d r e C e V e VA-19-0799-D-001040 OS 00002711 a C s t a t t h e V A h 0 s p t a 1 n M a d s 0 n w s C 0 n s n D a V d r e C e V e VA-19-0799-D-001040 OS 00002711 d h s B A f r 0 m t h e u n V e r s t y 0 f N e w H a m p s h r e a n d h s M D f r 0 VA-19-0799-D-001041 OS 00002712 d h s B A f r 0 m t h e u n V e r s t y 0 f N e w H a m p s h r e a n d h s M D f r 0 VA-19-0799-D-001041 OS 00002712 m t h e M e d C a 1 C 0 1 1 e g e 0 f p e n n s y 1 V a n a n 0 w k n 0 w n a s t h e D r e X e 1 VA-19-0799-D-001042 OS 00002713 m t h e M e d C a 1 C 0 1 1 e g e 0 f p e n n s y 1 V a n a n 0 w k n 0 w n a s t h e D r e X e 1 VA-19-0799-D-001042 OS 00002713 C 0 1 1 e g e 0 f M e d C n e H e C 0 m p 1 e t e d h s n t e r n s h p a t t h e y a 1 e s VA-19-0799-D-001043 OS 00002714 C 0 1 1 e g e 0 f M e d C n e H e C 0 m p 1 e t e d h s n t e r n s h p a t t h e y a 1 e s VA-19-0799-D-001043 OS 00002714 C h 0 0 1 0 f M e d C n e a n d h s r e s d e n C y a t t h e u n V e r s t y 0 f p t t s VA-19-0799-D-001044 OS 00002715 C h 0 0 1 0 f M e d C n e a n d h s r e s d e n C y a t t h e u n V e r s t y 0 f p t t s VA-19-0799-D-001044 OS 00002715 b u r g h p r e s b y t e r a n M e d C a 1 C e n t e r w h e r e h e m e t h s f u t u r e w 1 f VA-19-0799-D-001045 OS 00002716 b u r g h p r e s b y t e r a n M e d C a 1 C e n t e r w h e r e h e m e t h s f u t u r e w 1 f VA-19-0799-D-001045 OS 00002716 e D r (b) (6) a d e r m a t 0 1 0 g s t w h 0 m a n t a n s a p r a C t C e h VA-19-0799-D-001046 OS 00002717 e D r (b) (6) a d e r m a t 0 1 0 g s t w h 0 m a n t a n s a p r a C t C e h VA-19-0799-D-001046 OS 00002717 e r e n G 1 a d w y n e D a V d a 1 s 0 e s t a b 1 s h e d a p r V a t e p r a C t C e n VA-19-0799-D-001047 OS 00002718 e r e n G 1 a d w y n e D a V d a 1 s 0 e s t a b 1 s h e d a p r V a t e p r a C t C e n VA-19-0799-D-001047 OS 00002718 G 1 a d w y n e a s a f a m y d 0 C t 0 r I n 2 0 0 3 a s m e n t 0 n e d a b 0 V e h e VA-19-0799-D-001048 OS 00002719 G 1 a d w y n e a s a f a m y d 0 C t 0 r I n 2 0 0 3 a s m e n t 0 n e d a b 0 V e h e VA-19-0799-D-001048 OS 00002719 b e g a n t h e a d m n s t r a t V e p 0 r t 0 n 0 f h s C a r e e r n t a t n g p VA-19-0799-D-001049 OS 00002720 b e g a n t h e a d m n s t r a t V e p 0 r t 0 n 0 f h s C a r e e r n t a t n g p VA-19-0799-D-001049 OS 00002720 r a C t C e s t h a t V a s t 1 y m p r 0 V e d s t a n d a r d s a n d q u a 1 t y 0 f C a r e a VA-19-0799-D-001050 OS 00002721 r a C t C e s t h a t V a s t 1 y m p r 0 V e d s t a n d a r d s a n d q u a 1 t y 0 f C a r e a VA-19-0799-D-001050 OS 00002721 t B e t h I s r a e 1 I n a d d t 0 n ' h e h a s s e r V e d n a n u m b e r 0 f s e n 0 r e VA-19-0799-D-001051 OS 00002722 t B e t h I s r a e 1 I n a d d t 0 n ' h e h a s s e r V e d n a n u m b e r 0 f s e n 0 r e VA-19-0799-D-001051 OS 00002722 X e C u t V e p 0 s t 0 n s a n d a s p r e s d e n t 0 f t h e M 0 r r s t 0 w n M e d C a VA-19-0799-D-001052 OS 00002723 X e C u t V e p 0 s t 0 n s a n d a s p r e s d e n t 0 f t h e M 0 r r s t 0 w n M e d C a VA-19-0799-D-001052 OS 00002723 1 C e n t e r u n d e r h s 1 e a d e r s h p t h s f a C t y w a s n a m e d " t h e s VA-19-0799-D-001053 OS 00002724 1 C e n t e r u n d e r h s 1 e a d e r s h p t h s f a C t y w a s n a m e d " t h e s VA-19-0799-D-001053 OS 00002724 a f e s t h 0 s p t a 1 n N e w J e r s e y " a n d s e 1 e C t e d b y F 0 r t u n e m a g a z n VA-19-0799-D-001054 OS 00002725 a f e s t h 0 s p t a 1 n N e w J e r s e y " a n d s e 1 e C t e d b y F 0 r t u n e m a g a z n VA-19-0799-D-001054 OS 00002725 e a s " 0 n e 0 f t h e b e s t p 1 a C e s t 0 w 0 r k n A m e r C a " D a V d h a s a 1 s VA-19-0799-D-001055 OS 00002726 e a s " 0 n e 0 f t h e b e s t p 1 a C e s t 0 w 0 r k n A m e r C a " D a V d h a s a 1 s VA-19-0799-D-001055 OS 00002726 0 b e e n t h e C h e f m e d C a 1 0 f f C e r a t t h e u n V e r s t y 0 f p e n n s y 1 V VA-19-0799-D-001056 OS 00002727 0 b e e n t h e C h e f m e d C a 1 0 f f C e r a t t h e u n V e r s t y 0 f p e n n s y 1 V VA-19-0799-D-001056 OS 00002727 a n a H e a 1 t h s y s t e m t h e H 0 s p t a 1 0 f t h e u n V e r s t y 0 f p e n n s y 1 VA-19-0799-D-001057 OS 00002728 a n a H e a 1 t h s y s t e m t h e H 0 s p t a 1 0 f t h e u n V e r s t y 0 f p e n n s y 1 VA-19-0799-D-001057 OS 00002728 V a n a T e m p 1 e u n V e r s t y a n d t h e M e d C a 1 C 0 1 1 e g e 0 f p e n n s y 1 VA-19-0799-D-001058 OS 00002729 V a n a T e m p 1 e u n V e r s t y a n d t h e M e d C a 1 C 0 1 1 e g e 0 f p e n n s y 1 VA-19-0799-D-001058 OS 00002729 V a n a H 0 s p t a 1 A C a d e m C p 0 s t 0 n s h e h a s h e 1 d n C 1 u d e C h a r VA-19-0799-D-001059 OS 00002730 V a n a H 0 s p t a 1 A C a d e m C p 0 s t 0 n s h e h a s h e 1 d n C 1 u d e C h a r VA-19-0799-D-001059 OS 00002730 m a n 0 f m e d C n e a n d V C e d e a n a t t h e D r e X e 1 C 0 1 1 e g e 0 f M e d C n e VA-19-0799-D-001060 OS 00002731 m a n 0 f m e d C n e a n d V C e d e a n a t t h e D r e X e 1 C 0 1 1 e g e 0 f M e d C n e VA-19-0799-D-001060 OS 00002731 a n d p r 0 f e s s 0 r 0 f m e d C n e a t t h e A 1 b e r t E n s t e n C 0 1 1 e g e 0 f M e VA-19-0799-D-001061 OS 00002732 a n d p r 0 f e s s 0 r 0 f m e d C n e a t t h e A 1 b e r t E n s t e n C 0 1 1 e g e 0 f M e VA-19-0799-D-001061 OS 00002732 d C n e H e h a s w r t t e n s e V e r a 1 p e e r r e V e w e d J 0 u r n a 1 a r t C 1 VA-19-0799-D-001062 OS 00002733 d C n e H e h a s w r t t e n s e V e r a 1 p e e r r e V e w e d J 0 u r n a 1 a r t C 1 VA-19-0799-D-001062 OS 00002733 e s a n d n 2 0 0 8 a b 0 0 k Q u e s t i 0 n s p a t i e fl t s N e e d t 0 A s k G e t t i VA-19-0799-D-001063 OS 00002734 e s a n d n 2 0 0 8 a b 0 0 k Q u e s t i 0 n s p a t i e fl t s N e e d t 0 A s k G e t t i VA-19-0799-D-001063 OS 00002734 n g t h e B e s t H e a l t h C a r e I f t h s w a s n t e n 0 u g h h e f 0 u n d e d 0 n e 0 f VA-19-0799-D-001064 OS 00002735 n g t h e B e s t H e a l t h C a r e I f t h s w a s n t e n 0 u g h h e f 0 u n d e d 0 n e 0 f VA-19-0799-D-001064 OS 00002735 t h e f r s t C 0 n s u m e r 0 r e n t e d n f 0 r m a t 0 n s e r V C e s D 0 C t 0 r Q VA-19-0799-D-001065 OS 00002736 t h e f r s t C 0 n s u m e r 0 r e n t e d n f 0 r m a t 0 n s e r V C e s D 0 C t 0 r Q VA-19-0799-D-001065 OS 00002736 u a 1 t y I n C L 0 0 k n g 0 V e r t h s h s t 0 r y a n d s p e a k n g I a d m t VA-19-0799-D-001066 OS 00002737 u a 1 t y I n C L 0 0 k n g 0 V e r t h s h s t 0 r y a n d s p e a k n g I a d m t VA-19-0799-D-001066 OS 00002737 a s a 1 a y m a n a p 0 n t 0 f C 0 n C e r n C 0 m e s t 0 m n d d 0 e s m y f 0 r m e r d 0 C VA-19-0799-D-001067 OS 00002738 a s a 1 a y m a n a p 0 n t 0 f C 0 n C e r n C 0 m e s t 0 m n d d 0 e s m y f 0 r m e r d 0 C VA-19-0799-D-001067 OS 00002738 t 0 r e V e r s 1 e e p ? T 0 d a y a s t h e h e a d 0 f t h e D e p a r t m e n t 0 f V e t e r a VA-19-0799-D-001068 OS 00002739 t 0 r e V e r s 1 e e p ? T 0 d a y a s t h e h e a d 0 f t h e D e p a r t m e n t 0 f V e t e r a VA-19-0799-D-001068 OS 00002739 n s A f f a r s D a V d 0 V e r s e e s a b u d g e t 0 f 1 8 2 3 b 0 n d 0 1 1 a r s VA-19-0799-D-001069 OS 00002740 n s A f f a r s D a V d 0 V e r s e e s a b u d g e t 0 f 1 8 2 3 b 0 n d 0 1 1 a r s VA-19-0799-D-001069 OS 00002740 0 V e r 3 6 6 t h 0 u s a n d e m p 1 0 y e e s a n d 2 3 3 h e a 1 t h C a r e f a C t e VA-19-0799-D-001070 OS 00002741 0 V e r 3 6 6 t h 0 u s a n d e m p 1 0 y e e s a n d 2 3 3 h e a 1 t h C a r e f a C t e VA-19-0799-D-001070 OS 00002741 s s e r V n g m 0 r e t h a n 8 9 m 0 n V e t e r a n s I n 2 0 1 5 w h e n h e f r s VA-19-0799-D-001071 OS 00002742 s s e r V n g m 0 r e t h a n 8 9 m 0 n V e t e r a n s I n 2 0 1 5 w h e n h e f r s VA-19-0799-D-001071 OS 00002742 t J 0 n e d t h e C r s s r d d e n V A a s u n d e r s e C r e t a r y h e w a s a s k e d VA-19-0799-D-001072 OS 00002743 t J 0 n e d t h e C r s s r d d e n V A a s u n d e r s e C r e t a r y h e w a s a s k e d VA-19-0799-D-001072 OS 00002743 w h y h e a g r e e d t 0 a C C e p t t h e C h a 1 1 e n g e a 1 0 n g w t h a m a s s V e C u t VA-19-0799-D-001073 OS 00002744 w h y h e a g r e e d t 0 a C C e p t t h e C h a 1 1 e n g e a 1 0 n g w t h a m a s s V e C u t VA-19-0799-D-001073 OS 00002744 n s a 1 a r y C 0 m p a r e d t 0 w h a t h e w a s e a r n n g a s a p r V a t e s e C t 0 r h 0 s VA-19-0799-D-001074 OS 00002745 n s a 1 a r y C 0 m p a r e d t 0 w h a t h e w a s e a r n n g a s a p r V a t e s e C t 0 r h 0 s VA-19-0799-D-001074 OS 00002745 p t a 1 a d m n s t r a t 0 r H s r e s p 0 n s e r e V e a 1 s e V e r y t h n g w e n e e VA-19-0799-D-001075 OS 00002746 p t a 1 a d m n s t r a t 0 r H s r e s p 0 n s e r e V e a 1 s e V e r y t h n g w e n e e VA-19-0799-D-001075 OS 00002746 d t 0 k n 0 w a b 0 u t t h e m a n s C h a r a C t e r a n d C a r e e r t r a J e C t 0 r y " H 0 VA-19-0799-D-001076 OS 00002747 d t 0 k n 0 w a b 0 u t t h e m a n s C h a r a C t e r a n d C a r e e r t r a J e C t 0 r y " H 0 VA-19-0799-D-001076 OS 00002747 w C 0 u 1 d I s a y n 0 ? " R e g a r d s B 0 b 4 8 4 3 5 4 0 2 8 7 w h a t I s N 2 p u B L VA-19-0799-D-001077 OS 00002748 w C 0 u 1 d I s a y n 0 ? " R e g a r d s B 0 b 4 8 4 3 5 4 0 2 8 7 w h a t I s N 2 p u B L VA-19-0799-D-001077 OS 00002748 I s H I N G a I I a b 0 u t ? L e a r n m 0 r e a b 0 u t u s H E R E p L E A s E V I s I T T H E s E w E B s VA-19-0799-D-001078 OS 00002749 I s H I N G a I I a b 0 u t ? L e a r n m 0 r e a b 0 u t u s H E R E p L E A s E V I s I T T H E s E w E B s VA-19-0799-D-001078 OS 00002749 I T E s D. ~ 2 u b Q Q !I! - Q Q Q D. Q r k !! ?. Q Q !I! - f _?_ Q e b Q Q ls Q Q m I g ! _?_ _g_ Y:!.. y_ D. e I Y.. D. g VA-19-0799-D-001079 OS 00002750 I T E s D. ~ 2 u b Q Q !I! - Q Q Q D. Q r k !! ?. Q Q !I! - f _?_ Q e b Q Q ls Q Q m I g ! _?_ _g_ Y:!.. y_ D. e I Y.. D. g VA-19-0799-D-001079 OS 00002750 D. ! D. e t _?_ I g ~ ! ~ d !I! _?_ r ls ~ ! D. g _Q Q !I! - i D. ?. ! _?_ g I _?_ !I! _Q Q !I! I g I a _g_ Y:!.. y_ D. e I y__ D. g VA-19-0799-D-001080 OS 00002751 D. ! D. e t _?_ I g ~ ! ~ d !I! _?_ r ls ~ ! D. g _Q Q !I! - i D. ?. ! _?_ g I _?_ !I! _Q Q !I! I g I a _g_ Y:!.. y_ D. e I y__ D. g VA-19-0799-D-001080 OS 00002751 _Q h ~ C k Q u ! Q D. ~ 0 f N 2 ~ Y.. ~ D. t _?_ n V e s t y 0 u r r e s 0 u r C e s w s e I y a n d p a r t n e r w i t h a VA-19-0799-D-001081 OS 00002752 _Q h ~ C k Q u ! Q D. ~ 0 f N 2 ~ Y.. ~ D. t _?_ n V e s t y 0 u r r e s 0 u r C e s w s e I y a n d p a r t n e r w i t h a VA-19-0799-D-001081 OS 00002752 T 0 p 2 0 p r V a t e M e d a C 0 m p a n y n t h e u s b y I N C M a g a z n e f 0 r s I X y e a r s i n a r 0 w a n d A m e VA-19-0799-D-001082 OS 00002753 T 0 p 2 0 p r V a t e M e d a C 0 m p a n y n t h e u s b y I N C M a g a z n e f 0 r s I X y e a r s i n a r 0 w a n d A m e VA-19-0799-D-001082 OS 00002753 r C a s I e a d n g p r 0 V i d e r 0 f s p e C a I t y p u b I C a t 0 n s f 0 r 0 V e r 5 0 0 e X C I u s V e C 0 m m u n VA-19-0799-D-001083 OS 00002754 r C a s I e a d n g p r 0 V i d e r 0 f s p e C a I t y p u b I C a t 0 n s f 0 r 0 V e r 5 0 0 e X C I u s V e C 0 m m u n VA-19-0799-D-001083 OS 00002754 e s a C r 0 s s t h e n a t 0 n < 3 f b 9 3 1 0 p n g > Regards, Bob 484-354-0287 What is N2 PUBLISHING all about? Learn more about us HERE ! PLEASE VISIT THESE WEB SITES www.n2pub.com www.bobnorkus.com www.facebook.com/gladw yneliving www. mainlinetargetedmar keting .com VA-19-0799-D-001084 OS 00002755 e s a C r 0 s s t h e n a t 0 n < 3 f b 9 3 1 0 p n g > Regards, Bob 484-354-0287 What is N2 PUBLISHING all about? Learn more about us HERE ! PLEASE VISIT THESE WEB SITES www.n2pub.com www.bobnorkus.com www.facebook.com/gladw yneliving www. mainlinetargetedmar keting .com VA-19-0799-D-001084 OS 00002755 www.instagram.com/gladw yneliving Check out one of N2 events ... Invest your resources wisely and partner with a Top 20 Private Media Company in the US by INC Magazine for SIX Years in a row.. and America's leading provider of specialty publications for over 500 exclusive communities across the nation. <3fb931 O.png> VA-19-0799-D-001085 OS 00002756 www.instagram.com/gladw yneliving Check out one of N2 events ... Invest your resources wisely and partner with a Top 20 Private Media Company in the US by INC Magazine for SIX Years in a row.. and America's leading provider of specialty publications for over 500 exclusive communities across the nation. <3fb931 O.png> VA-19-0799-D-001085 OS 00002756 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/5/2017 1:05:22 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: (b) (6) documents (b) (6) CV (2017).doc; Untitled attachment 05659.htm; (b) (6) (2.16.2017).docx; Untitled attachment 05662.htm; Executive Profile (b) (6) (11.28.2016).docx; Untitled attachment 05665.htm Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) Date: April 5, 2017 at 6:37:40 AM EDT To: drshulkin@aol .com Subject: (b) (6) documents gmail.com> As discussed, please see attached. Thanks again Dr. Shulkin! (b) (6) VA-19-0799-D-001086 OS 00002757 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/5/2017 1:05:22 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: (b) (6) documents (b) (6) CV (2017).doc; Untitled attachment 05659.htm; (b) (6) (2.16.2017).docx; Untitled attachment 05662.htm; Executive Profile (b) (6) (11.28.2016).docx; Untitled attachment 05665.htm Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) Date: April 5, 2017 at 6:37:40 AM EDT To: drshulkin@aol .com Subject: (b) (6) documents gmail.com> As discussed, please see attached. Thanks again Dr. Shulkin! (b) (6) VA-19-0799-D-001086 OS 00002757 (b) (6), (b) (2) (b) (6), (b) (2) (b) (6), (b) (2) (6), (b) , Pennington, NJ (b) (2) (b) (6), @verizon.net (b) (2) PROFILE (b) (6), (b) (2) . EXPERIENCE (b) (6), (b) (2) 2011-2016 (b) (6), (b) (2) . (b) (6), (b) (2) (2015-2016) (b) (6), (b) (2) (b) (6), (b) (2) (2011-2015) (b) (6), (b) (2) (b) (6), (b) (2) 2008-2011 (b) (6), (b) (2) VA-19-0799-D-001087 OS 00002758 (b) (6), (b) (2) (b) (6), (b) (2) (b) (6), (b) (2) (6), (b) , Pennington, NJ (b) (2) (b) (6), @verizon.net (b) (2) PROFILE (b) (6), (b) (2) . EXPERIENCE (b) (6), (b) (2) 2011-2016 (b) (6), (b) (2) . (b) (6), (b) (2) (2015-2016) (b) (6), (b) (2) (b) (6), (b) (2) (2011-2015) (b) (6), (b) (2) (b) (6), (b) (2) 2008-2011 (b) (6), (b) (2) VA-19-0799-D-001087 OS 00002758 (6), 609.462.(b) (b) (2) (b) (6), (b) (2) o (b) (6), (b) (2) @verizon.net Page Two (b) (6), (b) (2) (b) (6), (b) (2) 1998-2008 (b) (6), (b) (2) 1986-1998 (b) (6), (b) (2) (1991-1994) (b) (6), (b) (2) (1986-1991) (b) (6), (b) (2) . (b) (6), (b) (2) 1984-1985 (b) (6), (b) (2) 1982-1983 (b) (6), (b) (2) EDUCATION (b) (6), (b) (2) 1982 1978 PUBLIC SERVICE (b) (6), (b) (2) 1997-2008 (b) (6), (b) (2) (b) (6), (b) (2) 1999-2007 (b) (6), (b) (2) VA-19-0799-D-001088 OS 00002759 (6), 609.462.(b) (b) (2) (b) (6), (b) (2) o (b) (6), (b) (2) @verizon.net Page Two (b) (6), (b) (2) (b) (6), (b) (2) 1998-2008 (b) (6), (b) (2) 1986-1998 (b) (6), (b) (2) (1991-1994) (b) (6), (b) (2) (1986-1991) (b) (6), (b) (2) . (b) (6), (b) (2) 1984-1985 (b) (6), (b) (2) 1982-1983 (b) (6), (b) (2) EDUCATION (b) (6), (b) (2) 1982 1978 PUBLIC SERVICE (b) (6), (b) (2) 1997-2008 (b) (6), (b) (2) (b) (6), (b) (2) 1999-2007 (b) (6), (b) (2) VA-19-0799-D-001088 OS 00002759 089 089 090 090 (b) (6) (b) (6), (b) (2) (6), (b) Pennington, NJ (b) (2) (b) (6), 609.462.(b) (2) (b) (6), @verizon.net (b) (2) To Whom It May Concern: (b) (6), (b) (2) I would welcome the opportunity to discuss my professional interests with you at (6), (6), (b) your convenience. I can be reached at 609.462.(b) ( cell) or (b) @verizon.net. (b) (2) (2) Thank you, and best regards. Very truly yours, (b) (6) VA-19-0799-D-001091 OS 00002762 (b) (6) (b) (6), (b) (2) (6), (b) Pennington, NJ (b) (2) (b) (6), 609.462.(b) (2) (b) (6), @verizon.net (b) (2) To Whom It May Concern: (b) (6), (b) (2) I would welcome the opportunity to discuss my professional interests with you at (6), (6), (b) your convenience. I can be reached at 609.462.(b) ( cell) or (b) @verizon.net. (b) (2) (2) Thank you, and best regards. Very truly yours, (b) (6) VA-19-0799-D-001091 OS 00002762 092 092 (b) (6), (b) (2) (b) (6), (b) (2) (6), 609.462.(b) (b) (2) @verizon.net Profile (b) (6), (b) (2) Key Skills o (b) (6), (b) (2) r Major Accomplishments o (b) (6), (b) (2) VA-19-0799-D-001093 OS 00002764 (b) (6), (b) (2) (b) (6), (b) (2) (6), 609.462.(b) (b) (2) @verizon.net Profile (b) (6), (b) (2) Key Skills o (b) (6), (b) (2) r Major Accomplishments o (b) (6), (b) (2) VA-19-0799-D-001093 OS 00002764 094 094 Appointment From: Sent: To: Subject: Location: Marisol Garcia [(b) (6) frenchangel59.com] 4/4/2017 11:36:45 PM (b) (6) its.jnj.com; ktorokl@its.jnj.com; 'David shulkin' [Drshulkin@aol.com]; 'L Perl' [(b) (6) gmail.com]; 'Bruce Moskowitz' [(b) (6) mac.com]; mbs(b) (6) @gmail.com; (b) (6) frenchangel59.com; (b) (6) (b) (6) va.gov; (b) (6) va.gov; '(b) (6) [(b) (6) mayo.edu]; (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) [ mayo.edu]; ' [JJCUS]' [ its.jnj.com]; ' [JSGUS]' [(b) (6) its.jnj.com]; '(b) (6) [JRDUS]' [(b) (6) its.jnj.com]; (b) (6) Bruce Moskowitz,MD' [(b) (6) gmail.com]; '(b) (6) [(b) (6) va.gov] Conference Call with (b) (6) (Johnson and Johnson) and Ike Perlmutter and their teams - Monday, April 17, 2017 at 2:00 PM EST (30 minutes) Conference Call 4/17/2017 6:00:00 PM 4/17/2017 6:30:00 PM Show Time As: Tentative Start: End: Recurrence: (none) Monday, April 17th 2:00 PM -2:30 PM EST Dial-in Information: (b) (6) US: 1-866-244- (b) (6) International: 719-457Passcode: (b) (6) Participants: (b) (6) (b) (6) Chairman and CEO (Johnson & Johnson), and Dr. Secretary David Shulkin (White House), Dr. (b) (6) (b) (6) VA-19-0799-D-001095 OS 00002766 Appointment From: Sent: To: Subject: Location: Marisol Garcia [(b) (6) frenchangel59.com] 4/4/2017 11:36:45 PM (b) (6) its.jnj.com; ktorokl@its.jnj.com; 'David shulkin' [Drshulkin@aol.com]; 'L Perl' [(b) (6) gmail.com]; 'Bruce Moskowitz' [(b) (6) mac.com]; mbs(b) (6) @gmail.com; (b) (6) frenchangel59.com; (b) (6) (b) (6) va.gov; (b) (6) va.gov; '(b) (6) [(b) (6) mayo.edu]; (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) [ mayo.edu]; ' [JJCUS]' [ its.jnj.com]; ' [JSGUS]' [(b) (6) its.jnj.com]; '(b) (6) [JRDUS]' [(b) (6) its.jnj.com]; (b) (6) Bruce Moskowitz,MD' [(b) (6) gmail.com]; '(b) (6) [(b) (6) va.gov] Conference Call with (b) (6) (Johnson and Johnson) and Ike Perlmutter and their teams - Monday, April 17, 2017 at 2:00 PM EST (30 minutes) Conference Call 4/17/2017 6:00:00 PM 4/17/2017 6:30:00 PM Show Time As: Tentative Start: End: Recurrence: (none) Monday, April 17th 2:00 PM -2:30 PM EST Dial-in Information: (b) (6) US: 1-866-244- (b) (6) International: 719-457Passcode: (b) (6) Participants: (b) (6) (b) (6) Chairman and CEO (Johnson & Johnson), and Dr. Secretary David Shulkin (White House), Dr. (b) (6) (b) (6) VA-19-0799-D-001095 OS 00002766 Bruce Moskowitz, Marc Sherman, Mayo Clinic) and Ike (b) (6) (Chair, Thank you, Marisol Garcia (b) (6) (646) 201(b) (6) (Cell) frenchange1S9.com VA-19-0799-D-001096 OS 00002767 Bruce Moskowitz, Marc Sherman, Mayo Clinic) and Ike (b) (6) (Chair, Thank you, Marisol Garcia (b) (6) (646) 201(b) (6) (Cell) frenchange1S9.com VA-19-0799-D-001096 OS 00002767 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/201710:04:32 PM Bruce Moskowitz [(b) (6) Re: CIO I see two from Yale and 2 from Florida. mac.com] I dont see a hopkins one Sent from my iPhone > on Apr 7, 2017, at 5:40 PM, Bruce Moskowitz <(b) (6) > > No go ahead we have 5 now including the one from Hopkins. mac.com> wrote: All excellent I can get more > > Sent from my iPhone > >> on Apr 7, 2017, at 5:26 PM, David shulkin wrote: >> >>Bruce-thanks for the four 0/s for CIO. >> Is it okay to contact them yet or do you want yo have discussions with them first? >> >> David >> >> Sent from my iPhone >> >>> >>> >>> >>> >>> >>> >>> >>> >>> >>> >> on Apr 7, 2017, at 3:31 PM, Bruce Moskowitz <(b) (6) U mac.com> wrote: of F <(b) (6) Resume Mar 2017.docx> Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001097 OS 00002768 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/201710:04:32 PM Bruce Moskowitz [(b) (6) Re: CIO I see two from Yale and 2 from Florida. mac.com] I dont see a hopkins one Sent from my iPhone > on Apr 7, 2017, at 5:40 PM, Bruce Moskowitz <(b) (6) > > No go ahead we have 5 now including the one from Hopkins. mac.com> wrote: All excellent I can get more > > Sent from my iPhone > >> on Apr 7, 2017, at 5:26 PM, David shulkin wrote: >> >>Bruce-thanks for the four 0/s for CIO. >> Is it okay to contact them yet or do you want yo have discussions with them first? >> >> David >> >> Sent from my iPhone >> >>> >>> >>> >>> >>> >>> >>> >>> >>> >>> >> on Apr 7, 2017, at 3:31 PM, Bruce Moskowitz <(b) (6) U mac.com> wrote: of F <(b) (6) Resume Mar 2017.docx> Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001097 OS 00002768 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/7/201710:02:42 PM Va David [vacodjsl@va.gov] Fwd: CIO 2017 March 2 (b) (6) CV.docx; Untitled attachment 05680.htm Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 3:29:55 PM EDT To: drshulkin@aol .com Subject: CIO mac.com> U of Fl VA-19-0799-D-001098 OS 00002769 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/7/201710:02:42 PM Va David [vacodjsl@va.gov] Fwd: CIO 2017 March 2 (b) (6) CV.docx; Untitled attachment 05680.htm Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 3:29:55 PM EDT To: drshulkin@aol .com Subject: CIO mac.com> U of Fl VA-19-0799-D-001098 OS 00002769 CURRICULUM VITAE {PRIVATE } (b) (6) Name: (b) (6), (b) (2) Department: (b) (6), (b) (2) (b) Health (b) (6), (b) (2) (6), (b) Present Rank: (b) (6), (b) (2) (6), (b) Business Address: (b) (6), (b) (2) , Gainesville, FL (b) (2) (6), Business Telephone: 352-265-(b) (b) (2) (b) (6), (6), (b) Home Address: , Gainesville, FL (b) (b) (2) (2) EDUCATIONAL RECORD: Professional Development (b) (6), (b) (2) Fellowship: (b) (6), (b) (2) Residency: (b) (6), (b) (2) Medical School: (b) (6), (b) (2) l VA-19-0799-D-001099 OS 00002770 CURRICULUM VITAE {PRIVATE } (b) (6) Name: (b) (6), (b) (2) Department: (b) (6), (b) (2) (b) Health (b) (6), (b) (2) (6), (b) Present Rank: (b) (6), (b) (2) (6), (b) Business Address: (b) (6), (b) (2) , Gainesville, FL (b) (2) (6), Business Telephone: 352-265-(b) (b) (2) (b) (6), (6), (b) Home Address: , Gainesville, FL (b) (b) (2) (2) EDUCATIONAL RECORD: Professional Development (b) (6), (b) (2) Fellowship: (b) (6), (b) (2) Residency: (b) (6), (b) (2) Medical School: (b) (6), (b) (2) l VA-19-0799-D-001099 OS 00002770 Page 2 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6), (b) (2) Graduate: (b) (6), (b) (2) (b) (6), (b) (2) Undergraduate: (b) (6), (b) (2) 983 BOARD CERTIFICATION: (b) (6), (b) (2) LI CENSURE: State (b) (6), (b) (2) Number EMPLOYMENT: Place of Employment City Date Title or Position Status Years of Empl. (b) (6), (b) (2) (b) (6), (b) (2) HONORS AND/OR AW ARDS: . VA-19-0799-D-001100 OS 00002771 Page 2 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6), (b) (2) Graduate: (b) (6), (b) (2) (b) (6), (b) (2) Undergraduate: (b) (6), (b) (2) 983 BOARD CERTIFICATION: (b) (6), (b) (2) LI CENSURE: State (b) (6), (b) (2) Number EMPLOYMENT: Place of Employment City Date Title or Position Status Years of Empl. (b) (6), (b) (2) (b) (6), (b) (2) HONORS AND/OR AW ARDS: . VA-19-0799-D-001100 OS 00002771 Curriculum Vitae Page 3 of 15 (b) (6), (b) (2) SERVICE/PATIENT CARE LEADERSHIP: UNIVERSITY SERVICE: (b) (6), (b) (2) COLLEGE OF MEDICINE SERVICE (b) (6), (b) (2) COLLEGE OF MEDICINE, ADMISSIONS: (b) (6), (b) (2) VA-19-0799-D-001101 OS 00002772 Curriculum Vitae Page 3 of 15 (b) (6), (b) (2) SERVICE/PATIENT CARE LEADERSHIP: UNIVERSITY SERVICE: (b) (6), (b) (2) COLLEGE OF MEDICINE SERVICE (b) (6), (b) (2) COLLEGE OF MEDICINE, ADMISSIONS: (b) (6), (b) (2) VA-19-0799-D-001101 OS 00002772 Page 4 of 15 Curriculum Vitae (b) (6), (b) (2) COLLEGE OF MEDICINE, OTHER (b) (6), (b) (2) (b) COM, (6), (b) (6), (b) (2) SEARCH COMMITTEES NATIONAL SERVICE (b) (6), (b) (2) COMMUNITY HOSPITAL - PATIENT LEADERSHIP (b) (6), (b) (2) (b) (6), (b) (2) (b) (6), (b) (2) HOSPITAL-FACULTY GROUP PRACTICE- (b) (6), (b) VA-19-0799-D-001102 OS 00002773 Page 4 of 15 Curriculum Vitae (b) (6), (b) (2) COLLEGE OF MEDICINE, OTHER (b) (6), (b) (2) (b) COM, (6), (b) (6), (b) (2) SEARCH COMMITTEES NATIONAL SERVICE (b) (6), (b) (2) COMMUNITY HOSPITAL - PATIENT LEADERSHIP (b) (6), (b) (2) (b) (6), (b) (2) (b) (6), (b) (2) HOSPITAL-FACULTY GROUP PRACTICE- (b) (6), (b) VA-19-0799-D-001102 OS 00002773 Curriculum Vitae Page 5 of 15 (b) (6), (b) (2) COMMUNITY SERVICE: (b) (6), (b) (2) GRANT REVIEWS (b) (6), (b) (2) ME1\1BERSHIP IN PROFESSIONAL SOCIETIES: (b) (6), (b) (2) EDUCATIONAL ACTIVITIES: Curriculum Development (b) (6), (b) (2) Evaluation l\!Iethods/Development (b) (6), (b) (2) VA-19-0799-D-001103 OS 00002774 Curriculum Vitae Page 5 of 15 (b) (6), (b) (2) COMMUNITY SERVICE: (b) (6), (b) (2) GRANT REVIEWS (b) (6), (b) (2) ME1\1BERSHIP IN PROFESSIONAL SOCIETIES: (b) (6), (b) (2) EDUCATIONAL ACTIVITIES: Curriculum Development (b) (6), (b) (2) Evaluation l\!Iethods/Development (b) (6), (b) (2) VA-19-0799-D-001103 OS 00002774 Page 6 of 15 Curriculum Vitae (b) (6), (b) (2) Family Practice noon conferences series (some old, some still being given) (b) (6), (b) (2) Older (b) (6), (b) (2) RAST (b) (6), (b) (2) Preceptorships (b) (6), (b) (2) Other Lectures (b) (6), (b) VA-19-0799-D-001104 OS 00002775 Page 6 of 15 Curriculum Vitae (b) (6), (b) (2) Family Practice noon conferences series (some old, some still being given) (b) (6), (b) (2) Older (b) (6), (b) (2) RAST (b) (6), (b) (2) Preceptorships (b) (6), (b) (2) Other Lectures (b) (6), (b) VA-19-0799-D-001104 OS 00002775 Page 7 of 15 Curriculum Vitae (b) (6), (b) (2) Journal/Publication/Conference Submission Reviews (b) (6), (b) (2) PRESENTATIONS: Invited Presentations, lecture, poster or other, Local, National and International (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001105 OS 00002776 Page 7 of 15 Curriculum Vitae (b) (6), (b) (2) Journal/Publication/Conference Submission Reviews (b) (6), (b) (2) PRESENTATIONS: Invited Presentations, lecture, poster or other, Local, National and International (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001105 OS 00002776 Page 8 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001106 OS 00002777 Page 8 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001106 OS 00002777 Cur?culum Vitae Page 9 of 15 107 DS Cur?culum Vitae Page 9 of 15 107 DS Cur?culum Vitae Page 10 of 15 108 Cur?culum Vitae Page 10 of 15 108 Page 11 of 15 Curriculum Vitae (b) (6), (b) (2) LOCAL PRESENTATIONS (b) (6), (b) (2) CONTRACTS AND GRANTS: (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001109 OS 00002780 Page 11 of 15 Curriculum Vitae (b) (6), (b) (2) LOCAL PRESENTATIONS (b) (6), (b) (2) CONTRACTS AND GRANTS: (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001109 OS 00002780 Curriculum Vitae Page 12 of 15 MAJOR CONSULTATIONS OUTSIDE THE UNIVERSITY: (b) (6), (b) (2) PUBLICATIONS: Books --- Published: (b) (6), (b) (2) VA-19-0799-D-001110 OS 00002781 Curriculum Vitae Page 12 of 15 MAJOR CONSULTATIONS OUTSIDE THE UNIVERSITY: (b) (6), (b) (2) PUBLICATIONS: Books --- Published: (b) (6), (b) (2) VA-19-0799-D-001110 OS 00002781 Page 13 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) Refereed Journals (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) Non-refereed Publications (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001111 OS 00002782 Page 13 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) Refereed Journals (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) Non-refereed Publications (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001111 OS 00002782 Page 14 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) Electronic Publications: (These are probably aged to the point that the links no longer work) (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001112 OS 00002783 Page 14 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) Electronic Publications: (These are probably aged to the point that the links no longer work) (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001112 OS 00002783 Curriculum Vitae Page 15 of 15 (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001113 OS 00002784 Curriculum Vitae Page 15 of 15 (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001113 OS 00002784 Sent from my iPad Bmce Moskowitz MD. 1 14 Sent from my iPad Bmce Moskowitz MD. 1 14 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/7/201710:02:31 PM Va David [vacodjsl@va.gov] Fwd: CIO 2017 March 2 (b) (6) CV.docx; Untitled attachment 05685.htm Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 3:29:55 PM EDT To: drshulkin@aol .com Subject: CIO mac.com> U of Fl VA-19-0799-D-001115 OS 00002786 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/7/201710:02:31 PM Va David [vacodjsl@va.gov] Fwd: CIO 2017 March 2 (b) (6) CV.docx; Untitled attachment 05685.htm Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 3:29:55 PM EDT To: drshulkin@aol .com Subject: CIO mac.com> U of Fl VA-19-0799-D-001115 OS 00002786 CURRICULUM VITAE {PRIVATE } (b) (6) Name: (b) (6), (b) (2) Department: (b) (6), (b) (2) (b) Health (b) (6), (b) (2) (6), (b) Present Rank: (b) (6), (b) (2) (6), (b) Business Address: (b) (6), (b) (2) Gainesville, FL (b) (2) (6), Business Telephone: 352-265-(b) (b) (2) (b) (6), (6), (b) Home Address: , Gainesville, FL (b) (b) (2) (2) EDUCATIONAL RECORD: Professional Development (b) (6), (b) (2) Fellowship: (b) (6), (b) (2) Residency: (b) (6), (b) (2) Medical School: (b) (6), (b) (2) VA-19-0799-D-001116 OS 00002787 CURRICULUM VITAE {PRIVATE } (b) (6) Name: (b) (6), (b) (2) Department: (b) (6), (b) (2) (b) Health (b) (6), (b) (2) (6), (b) Present Rank: (b) (6), (b) (2) (6), (b) Business Address: (b) (6), (b) (2) Gainesville, FL (b) (2) (6), Business Telephone: 352-265-(b) (b) (2) (b) (6), (6), (b) Home Address: , Gainesville, FL (b) (b) (2) (2) EDUCATIONAL RECORD: Professional Development (b) (6), (b) (2) Fellowship: (b) (6), (b) (2) Residency: (b) (6), (b) (2) Medical School: (b) (6), (b) (2) VA-19-0799-D-001116 OS 00002787 Page 2 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6), (b) (2) Graduate: (b) (6), (b) (2) Undergraduate: (b) (6), (b) (2) BOARD CERTIFICATION: (b) (6), (b) (2) LI CENSURE: State Number Date Status (b) (6), (b) (2) EMPLOYMENT: Place of Employment City Title or Position Years of Empl. (b) (6), (b) (2) HONORS AND/OR AW ARDS: (b) (6), (b) (2) VA-19-0799-D-001117 OS 00002788 Page 2 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6), (b) (2) Graduate: (b) (6), (b) (2) Undergraduate: (b) (6), (b) (2) BOARD CERTIFICATION: (b) (6), (b) (2) LI CENSURE: State Number Date Status (b) (6), (b) (2) EMPLOYMENT: Place of Employment City Title or Position Years of Empl. (b) (6), (b) (2) HONORS AND/OR AW ARDS: (b) (6), (b) (2) VA-19-0799-D-001117 OS 00002788 Curriculum Vitae Page 3 of 15 (b) (6), (b) (2) SERVICE/PATIENT CARE LEADERSHIP: UNIVERSITY SERVICE: (b) (6), (b) (2) COLLEGE OF MEDICINE SERVICE (b) (6), (b) (2) COLLEGE OF MEDICINE, ADMISSIONS: (b) (6), (b) (2) VA-19-0799-D-001118 OS 00002789 Curriculum Vitae Page 3 of 15 (b) (6), (b) (2) SERVICE/PATIENT CARE LEADERSHIP: UNIVERSITY SERVICE: (b) (6), (b) (2) COLLEGE OF MEDICINE SERVICE (b) (6), (b) (2) COLLEGE OF MEDICINE, ADMISSIONS: (b) (6), (b) (2) VA-19-0799-D-001118 OS 00002789 Page 4 of 15 Curriculum Vitae (b) (6), (b) (2) COLLEGE OF MEDICINE, OTHER (b) (6), (b) (2) (b) COM, (6), (b) (6), (b) (2) SEARCH COMMITTEES NATIONAL SERVICE (b) (6), (b) (2) COMMUNITY HOSPITAL - PATIENT LEADERSHIP (b) (6), (b) (2) (b) (b) (6), (b) (2) (6), (b) (6), (b) (2) - (b) (6), (b) (2) HOSPITAL-FACULTY GROUP PRACTICE- (b) (6), (b) VA-19-0799-D-001119 OS 00002790 Page 4 of 15 Curriculum Vitae (b) (6), (b) (2) COLLEGE OF MEDICINE, OTHER (b) (6), (b) (2) (b) COM, (6), (b) (6), (b) (2) SEARCH COMMITTEES NATIONAL SERVICE (b) (6), (b) (2) COMMUNITY HOSPITAL - PATIENT LEADERSHIP (b) (6), (b) (2) (b) (b) (6), (b) (2) (6), (b) (6), (b) (2) - (b) (6), (b) (2) HOSPITAL-FACULTY GROUP PRACTICE- (b) (6), (b) VA-19-0799-D-001119 OS 00002790 Curriculum Vitae Page 5 of 15 (b) (6), (b) (2) COMMUNITY SERVICE: (b) (6), (b) (2) GRANT REVIEWS (b) (6), (b) (2) ME1\1BERSHIP IN PROFESSIONAL SOCIETIES: (b) (6), (b) (2) EDUCATIONAL ACTIVITIES: Curriculum Development (b) (6), (b) (2) Evaluation l\!Iethods/Development (b) (6), (b) (2) VA-19-0799-D-001120 OS 00002791 Curriculum Vitae Page 5 of 15 (b) (6), (b) (2) COMMUNITY SERVICE: (b) (6), (b) (2) GRANT REVIEWS (b) (6), (b) (2) ME1\1BERSHIP IN PROFESSIONAL SOCIETIES: (b) (6), (b) (2) EDUCATIONAL ACTIVITIES: Curriculum Development (b) (6), (b) (2) Evaluation l\!Iethods/Development (b) (6), (b) (2) VA-19-0799-D-001120 OS 00002791 Page 6 of 15 Curriculum Vitae (b) (6), (b) (2) Family Practice noon conferences series (some old, some still being given) (b) (6), (b) (2) Older (b) (6), (b) (2) RAST (Resident AS Teachers) (b) (6), (b) (2) Preceptorships (b) (6), (b) (2) Other Lectures (b) (6), (b) VA-19-0799-D-001121 OS 00002792 Page 6 of 15 Curriculum Vitae (b) (6), (b) (2) Family Practice noon conferences series (some old, some still being given) (b) (6), (b) (2) Older (b) (6), (b) (2) RAST (Resident AS Teachers) (b) (6), (b) (2) Preceptorships (b) (6), (b) (2) Other Lectures (b) (6), (b) VA-19-0799-D-001121 OS 00002792 Page 7 of 15 Curriculum Vitae (b) (6), (b) (2) Journal/Publication/Conference Submission Reviews (b) (6), (b) (2) PRESENTATIONS: Invited Presentations, lecture, poster or other, Local, National and International (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001122 OS 00002793 Page 7 of 15 Curriculum Vitae (b) (6), (b) (2) Journal/Publication/Conference Submission Reviews (b) (6), (b) (2) PRESENTATIONS: Invited Presentations, lecture, poster or other, Local, National and International (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001122 OS 00002793 Page 8 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001123 OS 00002794 Page 8 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001123 OS 00002794 Cur?culum Vitae Page 9 of 15 124 Cur?culum Vitae Page 9 of 15 124 Cur?culum Vitae Page 10 of 15 125 Cur?culum Vitae Page 10 of 15 125 Page 11 of 15 Curriculum Vitae (b) (6), (b) (2) . LOCAL PRESENTATIONS (b) (6), (b) (2) CONTRACTS AND GRANTS: (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001126 OS 00002797 Page 11 of 15 Curriculum Vitae (b) (6), (b) (2) . LOCAL PRESENTATIONS (b) (6), (b) (2) CONTRACTS AND GRANTS: (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001126 OS 00002797 Curriculum Vitae Page 12 of 15 MAJOR CONSULTATIONS OUTSIDE THE UNIVERSITY: (b) (6), (b) (2) PUBLICATIONS: Books --- Published: (b) (6), (b) (2) VA-19-0799-D-001127 OS 00002798 Curriculum Vitae Page 12 of 15 MAJOR CONSULTATIONS OUTSIDE THE UNIVERSITY: (b) (6), (b) (2) PUBLICATIONS: Books --- Published: (b) (6), (b) (2) VA-19-0799-D-001127 OS 00002798 Page 13 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) Refereed Journals (b) (6) (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001128 OS 00002799 Page 13 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) Refereed Journals (b) (6) (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001128 OS 00002799 Page 14 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) Electronic Publications: (These are probably aged to the point that the links no longer work) (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001129 OS 00002800 Page 14 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) Electronic Publications: (These are probably aged to the point that the links no longer work) (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001129 OS 00002800 Curriculum Vitae Page 15 of 15 (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001130 OS 00002801 Curriculum Vitae Page 15 of 15 (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001130 OS 00002801 Sent from my iPad Bmce Moskowitz MD. 131 Sent from my iPad Bmce Moskowitz MD. 131 Message David shulkin [Drshulkin@aol.com] Sent: 4/7/201710:02:19 PM Va David [vacodjsl@va.gov] To: Subject: Fwd: CIO Attachments: (b) (6) Resume Mar 2017.docx; Untitled attachment 05690.htm From: Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 3 :31 :30 PM EDT To: drshulkin@aol .com Cc: IP <(b) (6) frenchangel59.com> Subject: CIO mac.com> UofF VA-19-0799-D-001132 OS 00002803 Message David shulkin [Drshulkin@aol.com] Sent: 4/7/201710:02:19 PM Va David [vacodjsl@va.gov] To: Subject: Fwd: CIO Attachments: (b) (6) Resume Mar 2017.docx; Untitled attachment 05690.htm From: Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 3 :31 :30 PM EDT To: drshulkin@aol .com Cc: IP <(b) (6) frenchangel59.com> Subject: CIO mac.com> UofF VA-19-0799-D-001132 OS 00002803 (b) (6), (b) (2) (b) (6) RN, MBA (b) (6), (b) (2) (6), (b) Gainesville, Florida (b) (2) (6), Home Phone (352) 335-(b) (b) (2) (b) (6), Cell Phone (352) 214-(b) (2) (b) (6), (b) @shands.ufl.edu (2) (b) (6), (b) (2) @att.net Summary: (b) (6), (b) (2) . Professional Experience: (b) (6), (b) (2) (b) (6), (b) (2) October 2011 - present July 2009 - March 2010 1993 - 2011 (b) (6), (b) (2) VA-19-0799-D-001133 OS 00002804 (b) (6), (b) (2) (b) (6) RN, MBA (b) (6), (b) (2) (6), (b) Gainesville, Florida (b) (2) (6), Home Phone (352) 335-(b) (b) (2) (b) (6), Cell Phone (352) 214-(b) (2) (b) (6), (b) @shands.ufl.edu (2) (b) (6), (b) (2) @att.net Summary: (b) (6), (b) (2) . Professional Experience: (b) (6), (b) (2) (b) (6), (b) (2) October 2011 - present July 2009 - March 2010 1993 - 2011 (b) (6), (b) (2) VA-19-0799-D-001133 OS 00002804 (b) (6), (b) (2) (b) (6), (b) (2) 1988 -1991 1985 - 1988 1980 - 1983 Education: (b) (6), (b) (2) 2 VA-19-0799-D-001134 OS 00002805 (b) (6), (b) (2) (b) (6), (b) (2) 1988 -1991 1985 - 1988 1980 - 1983 Education: (b) (6), (b) (2) 2 VA-19-0799-D-001134 OS 00002805 Professional Licensure: (b) (6), (b) (2) Affiliations: (b) (6), (b) (2) Publications: (b) (6), (b) (2) (b) (6) 3 VA-19-0799-D-001135 OS 00002806 Professional Licensure: (b) (6), (b) (2) Affiliations: (b) (6), (b) (2) Publications: (b) (6), (b) (2) (b) (6) 3 VA-19-0799-D-001135 OS 00002806 Sent from my iPad Bmce Moskowitz MD. 136 Sent from my iPad Bmce Moskowitz MD. 136 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) 4/7/2017 9:40:41 PM David shulkin [Drshulkin@aol.com] IP [(b) (6) frenchangel59.com] Re: CIO mac.com] No go ahead we have 5 now including the one from Hopkins. All excellent I can get more Sent from my iPhone > on Apr 7, 2017, at 5:26 PM, David shulkin wrote: > >Bruce-thanks for the four 0/s for CIO. > Is it okay to contact them yet or do you want yo have discussions with them first? > > David > > Sent from my iPhone > >> on Apr 7, 2017, at 3:31 PM, Bruce Moskowitz <(b) (6) >> >> U of F >> >> <(b) (6) mac.com> wrote: Resume Mar 2017.docx> >> >> >> >> Sent from my iPad >> Bruce Moskowitz M.D. > VA-19-0799-D-001137 OS 00002808 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/7/2017 9:26:30 PM Bruce Moskowitz [(b) (6) IP [(b) (6) frenchangel59.com] Re: CIO mac.com] Bruce- thanks for the four 0/s for CIO. Is it okay to contact them yet or do you want yo have discussions with them first? David Sent from my iPhone > on Apr 7, 2017, at 3:31 PM, Bruce Moskowitz <(b) (6) > > U > mac.com> wrote: of F > <(b) (6) Resume Mar 2017.docx> > > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-001138 OS 00002809 Message From: Sent: To: CC: Subject: Attachments: U of Bruce Moskowitz [(b) (6) mac.com] 4/7/2017 7:31:30 PM drshulkin@aol.com IP [(b) (6) frenchangel59.com] CIO (b) (6) Resume Mar 2017.docx; Untitled attachment 05696.txt F VA-19-0799-D-001139 OS 00002810 (b) (6), (b) (2) (b) (6) RN, MBA (b) (6), (b) (2) Gainesville, Florida 32608 (6), Home Phone (352) 335-(b) (b) (2) (b) (6), Cell Phone (352) 214-(b) (2) (b) (6), (b) @shands.ufl.edu (2) (b) (6), (b) (2) @att.net Summary: (b) (6), (b) (2) . Professional Experience: (b) (6), (b) (2) October 2011 - present July 2009 - March 2010 1993 - 2011 (b) (6), (b) (2) VA-19-0799-D-001140 OS 00002811 (b) (6), (b) (2) (b) (6), (b) (2) 1991 -1993 (b) (6), (b) (2) 1988 -1991 1985 - 1988 1980 - 1983 Education: (b) (6), (b) (2) 2 VA-19-0799-D-001141 OS 00002812 Professional Licensure: (b) (6), (b) (2) Affiliations: (b) (6), (b) (2) Publications: (b) (6), (b) (2) (b) (6) 3 VA-19-0799-D-001142 OS 00002813 Sent from my iPad Bruce Moskowitz M.D. 143 Message From: Sent: To: Subject: Attachments: Bruce Moskowitz [(b) (6) mac.com] 4/7/2017 7:29:55 PM drshulkin@aol.com CIO 2017 March 2 (b) (6) CV.docx; Untitled attachment 05702.txt U of Fl VA-19-0799-D-001144 OS 00002815 CURRICULUM VITAE {PRIVATE } (b) (6) Name: (b) (6), (b) (2) Department: (b) (6), (b) (2) (b) Health (b) (6), (b) (2) (6), (b) Present Rank: (b) (6), (b) (2) (6), (b) Business Address: (b) (6), (b) (2) , Gainesville, FL (b) (2) (6), Business Telephone: 352-265-(b) (b) (2) (b) (6), (6), (b) Home Address: , Gainesville, FL (b) (b) (2) (2) EDUCATIONAL RECORD: Professional Development (b) (6), (b) (2) Fellowship: (b) (6), (b) (2) Residency: (b) (6), (b) (2) Medical School: (b) (6), (b) (2) VA-19-0799-D-001145 OS 00002816 Page 2 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6), (b) (2) Graduate: (b) (6), (b) (2) arship Undergraduate: (b) (6), (b) (2) BOARD CERTIFICATION: (b) (6), (b) (2) LI CENSURE: State Number Date Status (b) (6), (b) (2) EMPLOYMENT: Place of Employment City Title or Position Years of Empl. (b) (6), (b) (2) HONORS AND/OR AW ARDS: (b) (6), (b) (2) VA-19-0799-D-001146 OS 00002817 Curriculum Vitae Page 3 of 15 (b) (6), (b) (2) SERVICE/PATIENT CARE LEADERSHIP: UNIVERSITY SERVICE: (b) (6), (b) (2) COLLEGE OF MEDICINE SERVICE (b) (6), (b) (2) COLLEGE OF MEDICINE, ADMISSIONS: (b) (6), (b) (2) VA-19-0799-D-001147 OS 00002818 Page 4 of 15 Curriculum Vitae (b) (6), (b) (2) COLLEGE OF MEDICINE, OTHER (b) (6), (b) (2) (b) (b COM, (6), (b)) (6), (b) (2) SEARCH COMMITTEES NATIONAL SERVICE (b) (6), (b) (2) COMMUNITY HOSPITAL - PATIENT LEADERSHIP (b) (6), (b) (2) (b) (6), (b) (2) (b) (6), (b) (2) HOSPITAL-FACULTY GROUP PRACTICE- (b) (6), (b) VA-19-0799-D-001148 OS 00002819 Curriculum Vitae Page 5 of 15 (b) (6), (b) (2) COMMUNITY SERVICE: (b) (6), (b) (2) GRANT REVIEWS (b) (6), (b) (2) ME1\1BERSHIP IN PROFESSIONAL SOCIETIES: (b) (6), (b) (2) EDUCATIONAL ACTIVITIES: Curriculum Development (b) (6), (b) (2) Evaluation l\!Iethods/Development (b) (6), (b) (2) VA-19-0799-D-001149 OS 00002820 Page 6 of 15 Curriculum Vitae (b) (6), (b) (2) . Family Practice noon conferences series (some old, some still being given) (b) (6), (b) (2) Older (b) (6), (b) (2) RAST (Resident AS Teachers) (b) (6), (b) (2) Preceptorships (b) (6), (b) (2) Other Lectures (b) (6), (b) VA-19-0799-D-001150 OS 00002821 Page 7 of 15 Curriculum Vitae (b) (6), (b) (2) Journal/Publication/Conference Submission Reviews (b) (6), (b) (2) PRESENTATIONS: Invited Presentations, lecture, poster or other, Local, National and International (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001151 OS 00002822 Page 8 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001152 OS 00002823 Cur?culum Vitae Page 9 of 15 153 Cur?culum Vitae Page 10 of 15 154 Page 11 of 15 Curriculum Vitae (b) (6), (b) (2) . LOCAL PRESENTATIONS (b) (6), (b) (2) CONTRACTS AND GRANTS: (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001155 OS 00002826 Curriculum Vitae Page 12 of 15 MAJOR CONSULTATIONS OUTSIDE THE UNIVERSITY: (b) (6), (b) (2) PUBLICATIONS: Books --- Published: (b) (6), (b) (2) VA-19-0799-D-001156 OS 00002827 Page 13 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) Refereed Journals (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) Non-refereed Publications (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001157 OS 00002828 Page 14 of 15 Curriculum Vitae (b) (6), (b) (2) (b) (6) (b) (6) Electronic Publications: (These are probably aged to the point that the links no longer work) (b) (6), (b) (2) (b) (6) , (b) (6) ASK THE EXPERT Series http: www.medscape.com (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001158 OS 00002829 Curriculum Vitae Page 15 of 15 (b) (6), (b) (2) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) VA-19-0799-D-001159 OS 00002830 Sent from my iPad Bruce Moskowitz M.D. 160 Message From: Sent: To: Subject: Darin Selnick [(b) (6) @gmail.com] 4/7/2017 12:14:31 AM David shulkin [Drshulkin@aol.com] Re: Draft EO on accountability and whistleblower protection (b) (6) sent it to me yesterday. It is the only VA EO that I have seen. Her first question to me when she called was have you seen the EO. Then why not. Thanks for sending it, do we have some others out there waiting for WH approval. Darin On Thu, Apr 6, 2017 at 4:29 PM, David shulkin wrote: Have you seen this one? Sent from my iPhone Begin forwarded message: (b) (6) From: "(b) (6) <(b) (6) va.gov> Date: April 6, 2017 at 1:56:24 PM EDT To: 'David shulkin' Subject: Draft EO on accountability and whistleblower protection VA-19-0799-D-001161 OS 00002832 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/6/2017 11:30:15 PM Ike Perlmutter [(b) (6) frenchangel59.com] Fwd: Draft EO on accountability and whistleblower protection Untitled attachment 05720.docx Here is another EO Im home now and up until 11pm > > VA-19-0799-D-001162 OS 00002833 EXECUTIVE ORDER IMPROVING ACCOUNTABILITY AND WHISTLEBLOWER PROTECTIONS AT THE DEPARTMENT OF VETERANS AFFAIRS By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows: Section 1. Purpose. This order is intended to improve accountability and whistleblower protection at the Department of Veterans Affairs Affairs (VA) by directing the Secretary of Veterans (Secretary) to appoint a Special Assistant to serve as Executive Director of a newly-created VA Office of Accountability, Civil Rights, and Whistleblower Protection. Sec. 2. Establishing a VA Office of Accountability, Civil Rights, and Whistleblower Protection. (a) Within 45 days of the date of this order, the Secretary shall establish a new VA Office of Accountability, Civil Rights, and Whistleblower Protection (Office), and shall appoint a Special Assistant, reporting directly to the Secretary, to serve as Executive Director (Executive Director) of the Office. (b) The Executive Director shall advise and assist the Secretary in using all available authorities to discipline or terminate any VA manager or employee who has violated the public's trust and failed to carry out his or her duties on behalf of Veterans. (c) The Executive Director shall work closely with Congress to identify options for legislative change to improve the Secretary's authority to discipline or terminate any employee who has jeopardized the health, safety, or well-being of a Veteran. VA-19-0799-D-001163 OS 00002834 2 (d) The Executive Director shall work closely with the White House Veterans hotline to ensure swift and effective resolution of Veterans' complaints of wrongdoing at the VA. (e) The Executive Director will ensure adequate investigation and correction of wrongdoing throughout VA, and will ensure that honest employees who highlight wrongdoing are protected from retaliation. (f) In establishing the Office described in paragraph 2(a) above, the Secretary shall consider, in addition to any other relevant factors: (i) whether some or all of the functions of the Office are currently being performed by an existing VA office, component, or program (ii) whether certain administrative capabilities necessary for operating the Office are redundant with those of another VA office, component, or program; (iv) whether combining the Office with another VA office, component, or program may improve VA's efficiency, effectiveness, or accountability. Sec. 3. General Provisions. (a) This order shall be implemented consistent with applicable law and subject to the availability of appropriations. (b) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person. THE WHITE HOUSE, VA-19-0799-D-001164 OS 00002835 Message From: David shulkin [Drshulkin@aol.com] Sent: To: 4/6/2017 11:29:16 PM Subject: Attachments: Darin Selnick [(b) (6) @gmail.com] Fwd: Draft EO on accountability and whistleblower protection Untitled attachment 05725.docx; Untitled attachment 05728.htm Have you seen this one? Sent from my iPhone Begin forwarded message: (b) (6) From: "(b) (6) <(b) (6) va.gov> Date: April 6, 2017 at I :56:24 PM EDT To: 'David shulkin' Subject: Draft EO on accountability and whistleblower protection VA-19-0799-D-001165 OS 00002836 EXECUTIVE ORDER IMPROVING ACCOUNTABILITY AND WHISTLEBLOWER PROTECTIONS AT THE DEPARTMENT OF VETERANS AFFAIRS By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows: Section 1. Purpose. This order is intended to improve accountability and whistleblower protection at the Department of Veterans Affairs Affairs (VA) by directing the Secretary of Veterans (Secretary) to appoint a Special Assistant to serve as Executive Director of a newly-created VA Office of Accountability, Civil Rights, and Whistleblower Protection. Sec. 2. Establishing a VA Office of Accountability, Civil Rights, and Whistleblower Protection. (a) Within 45 days of the date of this order, the Secretary shall establish a new VA Office of Accountability, Civil Rights, and Whistleblower Protection (Office), and shall appoint a Special Assistant, reporting directly to the Secretary, to serve as Executive Director (Executive Director) of the Office. (b) The Executive Director shall advise and assist the Secretary in using all available authorities to discipline or terminate any VA manager or employee who has violated the public's trust and failed to carry out his or her duties on behalf of Veterans. (c) The Executive Director shall work closely with Congress to identify options for legislative change to improve the Secretary's authority to discipline or terminate any employee who has jeopardized the health, safety, or well-being of a Veteran. VA-19-0799-D-001166 OS 00002837 2 (d) The Executive Director shall work closely with the White House Veterans hotline to ensure swift and effective resolution of Veterans' complaints of wrongdoing at the VA. (e) The Executive Director will ensure adequate investigation and correction of wrongdoing throughout VA, and will ensure that honest employees who highlight wrongdoing are protected from retaliation. (f) In establishing the Office described in paragraph 2(a) above, the Secretary shall consider, in addition to any other relevant factors: (i) whether some or all of the functions of the Office are currently being performed by an existing VA office, component, or program (ii) whether certain administrative capabilities necessary for operating the Office are redundant with those of another VA office, component, or program; (iv) whether combining the Office with another VA office, component, or program may improve VA's efficiency, effectiveness, or accountability. Sec. 3. General Provisions. (a) This order shall be implemented consistent with applicable law and subject to the availability of appropriations. (b) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person. THE WHITE HOUSE, VA-19-0799-D-001167 OS 00002838 168 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/4/2017 2:32:40 PM To: (b) (6) Subject: [(b) (6) Fwd: Re: Fwd: hotmail.com] John kelly and nicki haley have no money Rick perry too Sent from my iPhone Begin forwarded message: From: Poonam Alaigh <(b) (6) hotmail .com> Date: April 4, 2017 at 9:19:12 AM EDT To: David shulkin Subject: Re: Fwd: Lol- it's just that the press simply loves you and doesn't want you to be dragged into any public controversy!! Your bubble will only get larger! Sent from my iPhone On Apr 4, 2017, at 12: 11 PM, David shulkin wrote: Its so small it was popped before it made it to the photo Sent from my iPhone On Apr 4, 2017, at 3:33 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: What happened to your bubble Sent from my iPhone On Apr 4, 2017, at 3:55 AM, David shulkin wrote: Sent from my iPhone Begin forwarded message: From: (b) (6) (b) (6) gmail .com> Date: April 3, 2017 at 10:04:41 PM EDT To: (b) (6) VA-19-0799-D-001169 OS 00002840 https://www.nytimes.com/interactive /2017/04/01 /us/politics/how-muchpeople-in-the-trump-administrationare-worth-financialdisclosure.html?smid=fbnytimes&smtyp=cur& r=l how much every cabinet secretary is worth Sent from my iPad VA-19-0799-D-001170 OS 00002841 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/4/2017 1:19:12 PM David shulkin [Drshulkin@aol.com] Re: Fwd: Lol- it's just that the press simply loves you and doesn't want you to be dragged into any public controversy!! Your bubble will only get larger! Sent from my iPhone On Apr 4, 2017, at 12: 11 PM, David shulkin wrote: Its so small it was popped before it made it to the photo Sent from my iPhone On Apr 4, 2017, at 3:33 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: What happened to your bubble Sent from my iPhone On Apr 4, 2017, at 3:55 AM, David shulkin wrote: Sent from my iPhone Begin forwarded message: (b) (6) From: (b) (6) gmail.com> Date: April 3, 2017 at 10:04:41 PM EDT To: (b) (6) https://www.nytimes.com/interactive/2017/04/0l /us /politics/how-much-people-in-the-trumpadministration-are-worth-financialdisclosure.html?smid=fbnytimes&smtyp=cur& r=l how much every cabinet secretary is worth Sent from my iPad VA-19-0799-D-001171 OS 00002842 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/4/2017 11:11:08 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Fwd: Its so small it was popped before it made it to the photo Sent from my iPhone On Apr 4, 2017, at 3:33 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: What happened to your bubble Sent from my iPhone On Apr 4, 2017, at 3 :55 AM, David shulkin wrote: Sent from my iPhone Begin forwarded message: (b) (6) From: (b) (6) (b) (6) gmail.com> Date: April 3, 2017 at 10:04:41 PM EDT To: (b) (6) https://www.nytimes.com/interactive/2017/04/01 /us/politics/howmuch-people-in-the-trump-administration-are-worth-financialdisclosure.html?smid=fb-nytimes&smtyp=cur& r=l how much every cabinet secretary is worth Sent from my iPad VA-19-0799-D-001172 OS 00002843 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/4/2017 7:33:23 AM David shulkin [Drshulkin@aol.com] Re: Fwd: What happened to your bubble Sent from my iPhone On Apr 4, 2017, at 3 :55 AM, David shulkin wrote: Sent from my iPhone Begin forwarded message: (b) (6) From: (b) (6) gmail.com> Date: April 3, 2017 at 10:04:41 PM EDT To: (b) (6) https://www.nytimes.com/interactive/2017/04/01 /us/politics/how-much-peoplein-the-trump-administration-are-worth-financial-di sclosure.html? smid=fbnytimes&smtyp=cur& r=l how much every cabinet secretary is worth Sent from my iPad VA-19-0799-D-001173 OS 00002844 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/4/2017 2:55:59 AM To: (b) (6) Subject: Fwd: [(b) (6) gmail.com] Sent from my iPhone Begin forwarded message: (b) (6) From: (b) (6) (b) (6) gmail.com> Date: April 3, 2017 at 10:04:41 PM EDT To: (b) (6) https://www.nytimes.com/interactive/2017/04/01 /us/politics/how-much-people-in-the-trumpadministration-are-worth-financial-disclosure.html? smid=fb-nytimes&smtyp=cur& r= l how much every cabinet secretary is worth Sent from my iPad VA-19-0799-D-001174 OS 00002845 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/4/2017 2:55:50 AM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Sent from my iPhone Begin forwarded message: (b) (6) From: (b) (6) gmail.com> Date: April 3, 2017 at 10:04:41 PM EDT To: (b) (6) https://www.nytimes.com/interactive/2017/04/01 /us/politics/how-much-people-in-the-trumpadministration-are-worth-financial-disclosure.html? smid=fb-nytimes&smtyp=cur& r= l how much every cabinet secretary is worth Sent from my iPad VA-19-0799-D-001175 OS 00002846 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/19/2017 11:43:18 PM (b) (6) [(b) (6) gmail.com] Re: Actual cbs clip here. Does this work? Yes - I'll want it for me to play on the 25 th Sent from my iPad On Apr 19, 2017, at 7:37 PM, (b) (6) <(b) (6) gmail.com> wrote: http ://www.cbsnews.com/videos/wounded-vet-frustrated-with-weeks-long-delays-in-localva/?ftag=CNM-OO-l 0aab4i VA-19-0799-D-001176 OS 00002847 Message From: (b) (6) Sent: 4/19/2017 11:37:47 PM David Shulkin [drshulkin@aol.com] Actual cbs clip here. Does this work? To: Subject: [(b) (6) gmail.com] http ://www.cbsnews.com/videos/wounded-vet-frustrated-with-weeks-long-delays-in-local-va/?ftag=CNM-OOl0aab4i VA-19-0799-D-001177 OS 00002848 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/9/2017 12:25:13 AM (b) (6) gmail.com Re: Documents you typed on my computer thanks -----Original Message----From: (b) (6) <(b) (6) gmail.com> To: David Shulkin Sent: Sat, Apr 8, 2017 8:24 pm Subject: Re: Fwd: Documents you typed on my computer Folders were put together yesterday for signature on Monday. I will email the letters after you sign them On Apr 8, 2017 8:23 PM, "David Shulkin" wrote: Do you know if we have sent out the invites to the Secretarys Advisory Board yet? -----Original Message----From: (b) (6) <(b) (6) gmail.com> To: David Shulkin Sent: Mon, Apr 3, 2017 5:28 pm Subject: Documents you typed on my computer ACMO is working on doc 1 under MyvA advisory committee (b) (6) ---------- Forwarded message ---------From: (b) (6) <(b) (6) Date: Thu, Mar 30, 2017 at 7:54 PM Subject: Documents from last night To: David Shulkin gmail.com> attached VA-19-0799-D-001178 OS 00002849 Message From: (b) (6) Sent: 4/9/2017 12:24:33 AM To: David Shulkin [drshulkin@aol.com] Re: Fwd: Documents you typed on my computer Subject: [(b) (6) gmail.com] Folders were put together yesterday for signature on Monday. I will email the letters after you sign them On Apr 8, 2017 8:23 PM, "David Shulkin" wrote: Do you know if we have sent out the invites to the Secretarys Advisory Board yet? -----Original Message----From: (b) (6) <(b) (6) gmail.com> To: David Shulkin Sent: Mon, Apr 3, 2017 5:28 pm Subject: Documents you typed on my computer ACMO is working on doc 1 under MyvA advisory committee (b) (6) ---------- Forwarded message ---------From: (b) (6) <(b) (6) Date: Thu, Mar 30, 2017 at 7:54 PM Subject: Documents from last night To: David Shulkin gmail.com> attached VA-19-0799-D-001179 OS 00002850 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/9/2017 12:23:24 AM To: (b) (6) Subject: Attachments: gmail.com Fwd: Documents you typed on my computer advisoryletter.docx; annals.docx Do you know if we have sent out the invites to the Secretarys Advisory Board yet? -----Original Message----From: (b) (6) <(b) (6) gmail.com> To: David Shulkin Sent: Mon, Apr 3, 2017 5:28 pm Subject: Documents you typed on my computer ACMO is working on doc 1 under MyvA advisory committee (b) (6) ---------- Forwarded message ---------From: (b) (6) <(b) (6) Date: Thu, Mar 30, 2017 at 7:54 PM Subject: Documents from last night To: David Shulkin gmail.com> attached VA-19-0799-D-001180 OS 00002851 As we work to transform the US Department of Veterans Administration, I am seeking your expertise in guiding us through these efforts. I would be honored if you would serve on our board of advisors to help us shape the future of VA. This newly formed group will be called the Secretary's Advisory Board and will be replacing the myVA Committee. As such, it will operate as a FACCA (Federal Advisory Committee) so that meetings are open to the public. The Secretrary's Advisory Board will focus on strategic directions and policy issues that facing VA and veterans. The Board will consist of approximately members and meet three times a year for one day each. Meetings will usually be held in Washington DC or on occasion in a field location. I realize that you are busy and I am appreciative of your consideration of this important work. I look forward to hearing from you. Sincrerely, David Shulkin MD VA-19-0799-D-001181 OS 00002852 Putting Veterans in Control of Their Care The 2014 access crisis at the Department of Veterans Affairs was a pivotal moment for VA. Daily media accounts, like non-stop drumbeats- reported that Veterans were on long waitlist for care and at suggested that some were dying while they. The extent of VA's access problems, like many others in US Health care, was not immediately clear. The Department had difficult to understand wait time metrics exacerbated by arbitrary scheduling goals that it could not meet. Those hard-to-meet and hard to measure goals led to allegations of secret and covert waitlists which resulted in a loss of confidence and trust in the system. In, the wake of the crisis and in response to a public outcry VA began publicly posting patient wait time data on line. Few, if any, health systems were doing this and in its' efforts to be transparent, VA forged new ground in doing so. We consulted with the National Academy Medicine and a number of other industry and thought leaders it became clear that no standards for wait times existed and VA would have to create a new set of terminology. What followed was reports on appointments from the time they were requested, created, completed, when the patient wanted the appointment, when the clinician wanted the on (using 31 different preferences to order a consult). With more than 50 million appointments a year, and descriptive statistics on appointments in a large number of different ways VA is also transitioning from a system that focused almost exclusively on data that compared its performance to others in the VA system, to comparisons with the private sector. While numerous independent assessments have found that overall VA provides care that is comparable with or superior to the private sector, we recognize that overall metrics obscure weak performance in selected facilities and furthermore that veterans seek care comparisons in their local community and not at the national level. For decades, VA has led the healthcare in reporting on comprehensive performance metrics that are not readily reported by most other healthcare organizations. We believe our measures enable high performance and include extensive ambulatory measures, behavioral healthcare metrics, and leadership and nursing turnover rates. Called Strategic Analytics for Improvement and Learning (SAIL) we invite others to adopt these metrics so our comparisons to the private sector become more robust. As part of VA's modernization efforts, focusing on veterans needs and preferences, VA has launched on line informant on wait times, veteran experience, and quality that veterans can use to make decisions about their care. As we continually improve this approach, guided by veterans feedback, we hope others in the community will join us. This will allow veterans to seek the care that is best for them and to be able to find care either in the vA, or in the community, that best fits their needs and delivers optimal outcomes. The VA of the future must be based on what veterans want and how they want to receive care. In his book, "Best Care Anywhere" author Philip Longman described the VA healthcare system as a model system of care. Ten years later, as we define our network to include both the VA system and our federal, academic, and community partners, we seek to expand Longman notion and believe that we are on the cusp on being able to deliver the best care everywhere. VA-19-0799-D-001182 OS 00002853 what resulted was tantamount to a data dump. The metrics, while comprehensive and accurate,they had little meaning to member of Congress that were holding the Department accountable, to medical reporting on VA to taxpayers who fund it, or most important to Veterans who rely on VA for care. I recall sitting in a radio interview with a reporter trying to interpret our online wait time data and it became apparent to me in do so that that we had created metrics so complex that despite my best efforts few people were likely to understand what I had said. I realized then and there that there needed to be a better way With all of our measurements, VA had never analyzed wait time by clinical urgency. In response to the 2014 wait time crisis, VA initially had focused only on those veterans waiting the longest for care and failed to differentiate between those waiting for routine care and those that were at greatest risk for potential harm. Once we shifted to reporting our data as routne or urgent we began to see the true extent of our access problems. That led us to be able to define and target solutions to geographic locations that needed the most help. VA is now reporting its' data for routine care and urgent care. It is also using a single measure of wait times- the patient indicated date. This date reflects that outcome of a discussion that the has with their clinician, as an established relationship exists. Waits are reported from the time that this patient indicated date. For new patients wait times are reported from the date the veteran requests an VA is also transitioning from a system that focused almost exclusively on data that compared its performance to others in the VA system, to comparisons with the private sector. While numerous independent assessments have found that overall VA provides care that is comparable with or superior to the private sector, we recognize that overall metrics obscure weak performance in selected facilities and furthermore that veterans seek care comparisons in their local community and not at the national level. For decades, VA has led the healthcare in reporting on comprehensive performance metrics that are not readily reported by most other healthcare organizations. We believe our measures enable high performance and include extensive ambulatory measures, behavioral healthcare metrics, and leadership and nursing turnover rates. Called Strategic Analytics for Improvement and Learning (SAIL) we invite others to adopt these metrics so our comparisons to the private sector become more robust. As part of VA's modernization efforts, focusing on veterans needs and preferences, VA has launched on line informant on wait times, veteran experience, and quality that veterans can use to make decisions about their care. As we continually improve this approach, guided by veterans feedback, we hope others in the community will join us. This will allow veterans to seek the care that is best for them and to be able to find care either in the vA, or in the community, that best fits their needs and delivers optimal outcomes. The VA of the future must be based on what veterans want and how they want to receive care. In his book, "Best Care Anywhere" author Philip Longman described the VA healthcare system as a model system of care. Ten years later, as we define our network to include both the VA system and our federal, academic, and community partners, we seek to expand Longman notion and believe that we are on the cusp on being able to deliver the best care everywhere. VA-19-0799-D-001183 OS 00002854 appointment. VA also reports on the veterans experience with access to care. Using the Clinical-Group CAHPS survey, data is reported by site. VA is also transitioning from a system that focused almost exclusively on data that compared its performance to others in the VA system, to comparisons with the private sector. While numerous independent assessments have found that overall VA provides care that is comparable with or superior to the private sector, we recognize that overall metrics obscure weak performance in selected facilities and furthermore that veterans seek care comparisons in their local community and not at the national level. For decades, VA has led the healthcare in reporting on comprehensive performance metrics that are not readily reported by most other healthcare organizations. We believe our measures enable high performance and include extensive ambulatory measures, behavioral healthcare metrics, and leadership and nursing turnover rates. Called Strategic Analytics for Improvement and Learning (SAIL) we invite others to adopt these metrics so our comparisons to the private sector become more robust. As part of VA's modernization efforts, focusing on veterans needs and preferences, VA has launched on line informant on wait times, veteran experience, and quality that veterans can use to make decisions about their care. As we continually improve this approach, guided by veterans feedback, we hope others in the community will join us. This will allow veterans to seek the care that is best for them and to be able to find care either in the vA, or in the community, that best fits their needs and delivers optimal outcomes. The VA of the future must be based on what veterans want and how they want to receive care. In his book, "Best Care Anywhere" author Philip Longman described the VA healthcare system as a model system of care. Ten years later, as we define our network to include both the VA system and our federal, academic, and community partners, we seek to expand Longman notion and believe that we are on the cusp on being able to deliver the best care everywhere. VA-19-0799-D-001184 OS 00002855 Message From: (b) (6) Sent: 4/3/2017 9:27:32 PM David Shulkin [drshulkin@aol.com] Documents you typed on my computer advisoryletter.docx; annals.docx To: Subject: Attachments: [(b) (6) gmail.com] ACMO is working on doc I under MyvA advisory committee (b) (6) ---------- Forwarded message---------From: (b) (6) <(b) (6) Date: Thu, Mar 30, 2017 at 7:54 PM Subject: Documents from last night To: David Shulkin gmail.com> attached VA-19-0799-D-001185 OS 00002856 As we work to transform the US Department of Veterans Administration, I am seeking your expertise in guiding us through these efforts. I would be honored if you would serve on our board of advisors to help us shape the future of VA. This newly formed group will be called the Secretary's Advisory Board and will be replacing the myVA Committee. As such, it will operate as a FACCA (Federal Advisory Committee) so that meetings are open to the public. The Secretrary's Advisory Board will focus on strategic directions and policy issues that facing VA and veterans. The Board will consist of approximately members and meet three times a year for one day each. Meetings will usually be held in Washington DC or on occasion in a field location. I realize that you are busy and I am appreciative of your consideration of this important work. I look forward to hearing from you. Sincrerely, David Shulkin MD VA-19-0799-D-001186 OS 00002857 Putting Veterans in Control of Their Care The 2014 access crisis at the Department of Veterans Affairs was a pivotal moment for VA. Daily media accounts, like non-stop drumbeats- reported that Veterans were on long waitlist for care and at suggested that some were dying while they. The extent of VA's access problems, like many others in US Health care, was not immediately clear. The Department had difficult to understand wait time metrics exacerbated by arbitrary scheduling goals that it could not meet. Those hard-to-meet and hard to measure goals led to allegations of secret and covert waitlists which resulted in a loss of confidence and trust in the system. In, the wake of the crisis and in response to a public outcry VA began publicly posting patient wait time data on line. Few, if any, health systems were doing this and in its' efforts to be transparent, VA forged new ground in doing so. We consulted with the National Academy Medicine and a number of other industry and thought leaders it became clear that no standards for wait times existed and VA would have to create a new set of terminology. What followed was reports on appointments from the time they were requested, created, completed, when the patient wanted the appointment, when the clinician wanted the on (using 31 different preferences to order a consult). With more than 50 million appointments a year, and descriptive statistics on appointments in a large number of different ways VA is also transitioning from a system that focused almost exclusively on data that compared its performance to others in the VA system, to comparisons with the private sector. While numerous independent assessments have found that overall VA provides care that is comparable with or superior to the private sector, we recognize that overall metrics obscure weak performance in selected facilities and furthermore that veterans seek care comparisons in their local community and not at the national level. For decades, VA has led the healthcare in reporting on comprehensive performance metrics that are not readily reported by most other healthcare organizations. We believe our measures enable high performance and include extensive ambulatory measures, behavioral healthcare metrics, and leadership and nursing turnover rates. Called Strategic Analytics for Improvement and Learning (SAIL) we invite others to adopt these metrics so our comparisons to the private sector become more robust. As part of VA's modernization efforts, focusing on veterans needs and preferences, VA has launched on line informant on wait times, veteran experience, and quality that veterans can use to make decisions about their care. As we continually improve this approach, guided by veterans feedback, we hope others in the community will join us. This will allow veterans to seek the care that is best for them and to be able to find care either in the vA, or in the community, that best fits their needs and delivers optimal outcomes. The VA of the future must be based on what veterans want and how they want to receive care. In his book, "Best Care Anywhere" author Philip Longman described the VA healthcare system as a model system of care. Ten years later, as we define our network to include both the VA system and our federal, academic, and community partners, we seek to expand Longman notion and believe that we are on the cusp on being able to deliver the best care everywhere. VA-19-0799-D-001187 OS 00002858 what resulted was tantamount to a data dump. The metrics, while comprehensive and accurate,they had little meaning to member of Congress that were holding the Department accountable, to medical reporting on VA to taxpayers who fund it, or most important to Veterans who rely on VA for care. I recall sitting in a radio interview with a reporter trying to interpret our online wait time data and it became apparent to me in do so that that we had created metrics so complex that despite my best efforts few people were likely to understand what I had said. I realized then and there that there needed to be a better way With all of our measurements, VA had never analyzed wait time by clinical urgency. In response to the 2014 wait time crisis, VA initially had focused only on those veterans waiting the longest for care and failed to differentiate between those waiting for routine care and those that were at greatest risk for potential harm. Once we shifted to reporting our data as routne or urgent we began to see the true extent of our access problems. That led us to be able to define and target solutions to geographic locations that needed the most help. VA is now reporting its' data for routine care and urgent care. It is also using a single measure of wait times- the patient indicated date. This date reflects that outcome of a discussion that the has with their clinician, as an established relationship exists. Waits are reported from the time that this patient indicated date. For new patients wait times are reported from the date the veteran requests an VA is also transitioning from a system that focused almost exclusively on data that compared its performance to others in the VA system, to comparisons with the private sector. While numerous independent assessments have found that overall VA provides care that is comparable with or superior to the private sector, we recognize that overall metrics obscure weak performance in selected facilities and furthermore that veterans seek care comparisons in their local community and not at the national level. For decades, VA has led the healthcare in reporting on comprehensive performance metrics that are not readily reported by most other healthcare organizations. We believe our measures enable high performance and include extensive ambulatory measures, behavioral healthcare metrics, and leadership and nursing turnover rates. Called Strategic Analytics for Improvement and Learning (SAIL) we invite others to adopt these metrics so our comparisons to the private sector become more robust. As part of VA's modernization efforts, focusing on veterans needs and preferences, VA has launched on line informant on wait times, veteran experience, and quality that veterans can use to make decisions about their care. As we continually improve this approach, guided by veterans feedback, we hope others in the community will join us. This will allow veterans to seek the care that is best for them and to be able to find care either in the vA, or in the community, that best fits their needs and delivers optimal outcomes. The VA of the future must be based on what veterans want and how they want to receive care. In his book, "Best Care Anywhere" author Philip Longman described the VA healthcare system as a model system of care. Ten years later, as we define our network to include both the VA system and our federal, academic, and community partners, we seek to expand Longman notion and believe that we are on the cusp on being able to deliver the best care everywhere. VA-19-0799-D-001188 OS 00002859 appointment. VA also reports on the veterans experience with access to care. Using the Clinical-Group CAHPS survey, data is reported by site. VA is also transitioning from a system that focused almost exclusively on data that compared its performance to others in the VA system, to comparisons with the private sector. While numerous independent assessments have found that overall VA provides care that is comparable with or superior to the private sector, we recognize that overall metrics obscure weak performance in selected facilities and furthermore that veterans seek care comparisons in their local community and not at the national level. For decades, VA has led the healthcare in reporting on comprehensive performance metrics that are not readily reported by most other healthcare organizations. We believe our measures enable high performance and include extensive ambulatory measures, behavioral healthcare metrics, and leadership and nursing turnover rates. Called Strategic Analytics for Improvement and Learning (SAIL) we invite others to adopt these metrics so our comparisons to the private sector become more robust. As part of VA's modernization efforts, focusing on veterans needs and preferences, VA has launched on line informant on wait times, veteran experience, and quality that veterans can use to make decisions about their care. As we continually improve this approach, guided by veterans feedback, we hope others in the community will join us. This will allow veterans to seek the care that is best for them and to be able to find care either in the vA, or in the community, that best fits their needs and delivers optimal outcomes. The VA of the future must be based on what veterans want and how they want to receive care. In his book, "Best Care Anywhere" author Philip Longman described the VA healthcare system as a model system of care. Ten years later, as we define our network to include both the VA system and our federal, academic, and community partners, we seek to expand Longman notion and believe that we are on the cusp on being able to deliver the best care everywhere. VA-19-0799-D-001189 OS 00002860 Message From: Poonam Alaigh [(b) (6) Sent: 5/4/2017 10:08:43 PM To: Bruce Moskowitz [(b) (6) David shulkin [Drshulkin@aol.com] Re: Suicide prevention CC: Subject: hotmail.com] mac.com] Thanks so much- you are such an awesome partner!! We will make a difference in suicide Prevention- that is our conviction!! Sent from my iPhone > on May 4, 2017, at 12:35 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > Very important ultimately we need their resources to have more psychologists and psychiatric services available to the VA. That is my main goal. > > Sent from my iPad > Bruce Moskowitz M.D. > >> on May 4, 2017, at 12:30 PM, David shulkin wrote: >> >> We have the most advance analytics on this- called reachvet if its helpful >> >> Sent from my iPhone >> >>> on May 4, 2017, at 12:29 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>> the President of the u of PENN has agreed to work with me to put together a consortium to >>> (b) (6) work on early detection of who is at risk and a consortium to have more resources for treatment. We need more resources for the VA to solve the problem and also this is important to decrease University suicide risk. >>> >>> Sent from my iPad >>> Bruce Moskowitz M.D. >> VA-19-0799-D-001190 OS 00002861 Message From: David shulkin [Drshulkin@aol.com] Sent: 5/4/2017 4:30:51 PM To: Bruce Moskowitz [(b) (6) Re: Suicide prevention Subject: mac.com] We have the most advance analytics on this- called reachvet if its helpful Sent from my iPhone > on May 4, 2017, at 12:29 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > (b) (6) the President of the u of PENN has agreed to work with me to put together a consortium to work on early detection of who is at risk and a consortium to have more resources for treatment. We need more resources for the VA to solve the problem and also this is important to decrease University suicide risk. > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-001191 OS 00002862 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 5/4/2017 4:29:05 PM Poonam Alaigh [(b) (6) hotmail.com] David shulkin [drshulkin@aol.com] Suicide prevention (b) (6) the President of the u of PENN has agreed to work with me to put together a consortium to work on early detection of who is at risk and a consortium to have more resources for treatment. We need more resources for the VA to solve the problem and also this is important to decrease University suicide risk. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001192 OS 00002863 Message From: (b) (6) [(b) (6) Sent: To: 4/16/2017 4:04:50 PM David shulkin [Drshulkin@aol.com] Subject: Re: gmail.com] Yes On Sun, Apr 16, 2017 at 11 :58 AM David shulkin wrote: Can we talk about telling the wsj tommorow about the WH correspondents dinner ? Sent from my iPhone Sent from Gmail Mobile VA-19-0799-D-001193 OS 00002864 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/16/2017 3:58:26 PM To: (b) (6) [(b) (6) gmail.com] can we talk about telling the wsj tommorow about the WH correspondents dinner? Sent from my iPhone VA-19-0799-D-001194 OS 00002865 Message David Shulkin [Drshulkin@aol.com] 4/6/2017 1:56:16 AM Darin Selnick [(b) (6) @gmail.com] Re: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program From: Sent: To: Subject: Ok I trust your judgement Sent from my iPad On Apr 5, 2017, at 9: 10 PM, Darin Selnick <(b) (6) @gmail.com> wrote: Yes, he is the guy who has been catching and fixing issues in OCLA despite not having any authority. We would not have ever fixed the Sen Lee hold without him, he was the guy who organized and led the quick response for the McCain and Lee staff and they are very grateful. Once in as Asst Sec, he is ready to overhaul and lead OCLA to be a well run machine. I do not know what you are hearing that would be of concern about Brooks, if you want to share them I can give you my perspective. Darin Darin On Wed, Apr 5, 2017 at 6:03 PM, David shulkin wrote: Im getting some concerns about Brooks- are you confident he is our right choice for Asst secretary? Sent from my iPhone On Apr 5, 2017, at 8:46 PM, Darin Selnick <(b) (6) @gmail.com> wrote: This was sent to me today from (b) (6) who works for Sen Moran. I think you should be aware of this, but I know (b) (6) well and she has a tendency to overreact. I do not think we should overreact as well, but use this as a learning experience for sending out these type of news releases. Neither Brooks nor I saw the VA press release before it went out and we only found out about it from (b) (6) Brooks is checking out who did see it, but we need a better process to ensure we list all the members who need to be listed based on their support. (b) (6) is right that Sen Moran should have been listed as well. I have a phone meeting with her tomorrow, and I understand from Brooks that he had Sen Moran on the list for the WH of who should be at the signing ceremony. Darin -----Original Message----From: (b) (6) (b) (6) (Moran) [(b) (6) moran.senate.gov] VA-19-0799-D-001195 OS 00002866 Sent: Wednesday, April 05, 2017 05:27 PM Eastern Standard Time To: Selnick, Darin Subject: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program This is just poor form. Moran and our office did a lot of work to get this bill moving. know McCain catches the headlines but Moran is VA's appropriator not to mention your biggest backer on Choice reforms. Sorry to vent but this yet another slap by the VA and you're the only person I really know the send a message that it's unacceptable. From: (b) (6) (Moran) Sent: Wednesday, April 5, 2017 5:23 PM (b) (6) (Moran) <(b) (6) moran.senate.gov>; (b) (6) < moran.senate.gov> Cc: (b) (6) (Moran) <(b) (6) moran.senate.gov>; (b) (6) (b) (6) (Moran) < moran.senate.gov> Subject: FW: VA Secretary Praises Congress for Extending Choice Program To: (b) (6) (b) (6) (Moran) (b) (6) Boo, VA. Boo. From: VA Congressional Notifications fmailto:VACongressionalNotifications@public.govdel ivery.com l Sent: Wednesday, April 05, 2017 5:20 PM (Moran) <(b) (6) moran.senate.gov> Subject: VA Secretary Praises Congress for Extending Choice Program To: (b) (6) U.S. Department of Veterans Affairs Office of Congressional and Legislative Affairs VA Secretary Praises Congress for Extendi1 Choice Program VA-19-0799-D-001196 OS 00002867 Calls legislation major step toward increasing access to care WASHINGTON - Today, following the U.S. Senate's passage by unanimous consent last week, the U.S. House Representatives passed legislation that extends the Veterans Choice Program (VCP) until the funding dedicated I program is exhausted. The VCP is a critical program that increases access to care for millions of Veterans. Witho legislation, the ability to use VCP funding would have ended abruptly on Aug. 7 of this year. Secretary of Veteran: Dr. David J. Shulkin released the following statement of support: "Congress has once again demonstrated that the country stands firmly united when it comes to supporting our na Veterans," Secretary Shulkin said. "The Department of Veterans Affairs truly appreciates the quick bipartisan resc Congress provided with the extension of the Veterans Choice Program. "I want to thank Chairman Johnny Isakson, Ranking Member Jon Tester, Chairman Phil Roe, Ranking Member Ti and all the members of our committees for their leadership as we continue to make improvements to increase Ve1 access to care," Secretary Shulkin continued. "I also want to thank Senator John McCain, who has championed c Veterans and whose work on this issue allowed for swift and successful resolution. "VA looks forward to continue1 bipartisan support as we partner with Congress to not only develop a long-term solution for community care, but ~ toward other critical legislation, such as accountability and appeals modernization to ensure Veterans receive the quality of care, benefits and support they have earned." ### U.S. Department of Veterans Affairs Office of Congressional and Legislative Affairs We value our Congressional partners, and that's wl have created our VA Casework Guide to help yo you assist our shared Veteran constituents. You have received this message because you have been identified as interested in Veterans issues and are subscr VA's Office of Congressional and Legislative Affairs - Congressional Distribution List. Access your Subscribers Preferences to make changes to your subscription or unsubscribe. Get this as aforward? Sign up to receive important updates from the Department of Veterans Affairs. Have questions or Problems? Please contact subscriberhelp.govdelivery.com for assistance. This email was sent to (b) (6) moran.senate.gov using GovDelivery, on behalf of: U.S. Department of Veterans Affairs, Office of Government Relations 810 Vermont Avenue, NW . Washington, DC 20420 VA-19-0799-D-001197 OS 00002868 Message David shulkin [Drshulkin@aol.com] 4/6/2017 1:03:02 AM Darin Selnick [(b) (6) @gmail.com] Re: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program From: Sent: To: Subject: Im getting some concerns about Brooks- are you confident he is our right choice for Asst secretary? Sent from my iPhone On Apr 5, 2017, at 8:46 PM, Darin Selnick <(b) (6) @gmail.com> wrote: This was sent to me today from (b) (6) who works for Sen Moran. I think you should be well and she has a tendency to overreact. I do not think we aware of this, but I know (b) (6) should overreact as well, but use this as a learning experience for sending out these type of news releases. Neither Brooks nor I saw the VA press release before it went out and we only found out about it from (b) (6) Brooks is checking out who did see it, but we need a better process to ensure we list all the members who need to be listed based on their support. (b) (6) is right that Sen Moran should have been listed as well. I have a phone meeting with her tomorrow, and I understand from Brooks that he had Sen Moran on the list for the WH of who should be at the signing ceremony. Darin -----Original Message----From: (b) (6) (b) (6) (Moran) [(b) (6) moran.senate.gov] Sent: Wednesday, April 05, 2017 05:27 PM Eastern Standard Time To: Selnick, Darin Subject: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program This is just poor form. Moran and our office did a lot of work to get this bill moving. I know McCain catches the headlines but Moran is VA's appropriator not to mention your biggest backer on Choice reforms. Sorry to vent but this yet another slap by the VA and you're the only person I really know the send a message that it's unacceptable. From: (b) (6) (Moran) Sent: Wednesday, April 5, 2017 5:23 PM To: (b) (6) (b) (6) (Moran) <(b) (6) (b) (6) < moran.senate.gov> Cc: (b) (6) (Moran) <(b) (6) moran.senate.gov>; (b) (6) moran.senate.gov>; (b) (6) (b) (6) (Moran) (Moran) VA-19-0799-D-001198 OS 00002869 <(b) (6) moran.senate.gov> Subject: FW: VA Secretary Praises Congress for Extending Choice Program Boo, VA. Boo. From: VA Congressional Notifications [mailto:VACongressionalNotifications@public.govdelivery.com ] Sent: Wednesday, April 05, 2017 5:20 PM (Moran) <(b) (6) moran.senate.gov> Subject: VA Secretary Praises Congress for Extending Choice Program To: (b) (6) U.S. Department of Veterans Affairs Office of Congressional and Legislative Affairs VA Secretary Praises Congress for Extending Choice Program Calls legislation major step toward increasing access to care WASHINGTON - Today, following the U.S. Senate's passage by unanimous consent last week, the U.S. House of Representatives passed legislation that extends the Veterans Choice Program (VCP) until the funding dedicated to the program is exhausted. The VCP is a critical program that increases access to care for millions of Veterans. Without this legislation, the ability to use VCP funding would have ended abruptly on Aug. 7 of this year. Secretary of Veterans Affairs Dr. David J. Shulkin released the following statement of support: "Congress has once again demonstrated that the country stands firmly united when it comes to supporting our nation's Veterans," Secretary Shulkin said. "The Department of Veterans Affairs truly appreciates the quick bipartisan resolution Congress provided with the extension of the Veterans Choice Program. "I want to thank Chairman Johnny Isakson, Ranking Member Jon Tester, Chairman Phil Roe, Ranking Member Tim Walz and all the members of our committees for their leadership as we continue to make improvements to increase Veterans' access to care," Secretary Shulkin continued. "I also want to thank Senator John McCain, who has championed choice for Veterans and whose work on this issue allowed for swift and successful resolution. "VA looks forward to continued bipartisan support as we partner with Congress to not only develop a long-term solution for community care, but also work toward other critical legislation, such as accountability and appeals modernization to ensure Veterans receive the highest quality of care, benefits and support they have earned." ### VA-19-0799-D-001199 OS 00002870 U.S. Department of Veterans Affai rs Office of Congressional and Legislative Affairs We value our Congressional partners, and that's why we have created our VA Casework Guide to help you as you assist our shared Veteran constituents. You have received this message because you have been identified as interested in Veterans issues and are subscribed to VA's Office of Congressional and Legislative Affairs - Congressional Distribution List. Access your Subscribers Preferences to make changes to your subscription or unsubscribe. Get this as aforward? Sign up to receive important updates from the Department of Veterans Affairs. Have questions or Problems? Please contact subscriberhelp.govdelivery.com for assistance. This email was sent to (b) (6) moran.senate .gov using GovDelivery, on behalf of: U.S. Department of Veterans Affairs, Office of Government Relations 810 Vermont Avenue, NW . Washington, DC 20420 VA-19-0799-D-001200 OS 00002871 Message David shulkin [Drshulkin@aol.com] 4/6/2017 1:01:55 AM Darin Selnick [(b) (6) @gmail.com] Re: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program From: Sent: To: Subject: Good pick up Thanks Sent from my iPhone On Apr 5, 2017, at 8:46 PM, Darin Selnick <(b) (6) @gmail.com> wrote: This was sent to me today from (b) (6) who works for Sen Moran. I think you should be (b) (6) well and she has a tendency to overreact. I do not think we aware of this, but I know should overreact as well, but use this as a learning experience for sending out these type of news releases. Neither Brooks nor I saw the VA press release before it went out and we only found out about it from (b) (6) Brooks is checking out who did see it, but we need a better process to ensure we list all the members who need to be listed based on their support. (b) (6) is right that Sen Moran should have been listed as well. I have a phone meeting with her tomorrow, and I understand from Brooks that he had Sen Moran on the list for the WH of who should be at the signing ceremony. Darin -----Original Message----From: (b) (6) (b) (6) (Moran) [(b) (6) moran.senate.gov] Sent: Wednesday, April 05, 2017 05:27 PM Eastern Standard Time To: Selnick, Darin Subject: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program This is just poor form. Moran and our office did a lot of work to get this bill moving. I know McCain catches the headlines but Moran is VA's appropriator not to mention your biggest backer on Choice reforms. Sorry to vent but this yet another slap by the VA and you're the only person I really know the send a message that it's unacceptable. From: (b) (6) (Moran) Sent: Wednesday, April 5, 2017 5:23 PM To: (b) (6) (b) (6) (Moran) <(b) (6) (b) (6) < moran.senate.gov> (b) (6) Cc: (Moran) <(b) (6) moran.senate.gov>; (b) (6) moran.senate.gov>; (b) (6) (b) (6) (Moran) (Moran) VA-19-0799-D-001201 OS 00002872 <(b) (6) moran.senate.gov> Subject: FW: VA Secretary Praises Congress for Extending Choice Program Boo, VA. Boo. From: VA Congressional Notifications [mailto:VACongressionalNotifications@public.govdelivery.com ] Sent: Wednesday, April 05, 2017 5:20 PM (Moran) <(b) (6) moran.senate.gov> Subject: VA Secretary Praises Congress for Extending Choice Program To: (b) (6) U.S. Department of Veterans Affairs Office of Congressional and Legislative Affairs VA Secretary Praises Congress for Extending Choice Program Calls legislation major step toward increasing access to care WASHINGTON - Today, following the U.S. Senate's passage by unanimous consent last week, the U.S. House of Representatives passed legislation that extends the Veterans Choice Program (VCP) until the funding dedicated to the program is exhausted. The VCP is a critical program that increases access to care for millions of Veterans. Without this legislation, the ability to use VCP funding would have ended abruptly on Aug. 7 of this year. Secretary of Veterans Affairs Dr. David J. Shulkin released the following statement of support: "Congress has once again demonstrated that the country stands firmly united when it comes to supporting our nation's Veterans," Secretary Shulkin said. "The Department of Veterans Affairs truly appreciates the quick bipartisan resolution Congress provided with the extension of the Veterans Choice Program. "I want to thank Chairman Johnny Isakson, Ranking Member Jon Tester, Chairman Phil Roe, Ranking Member Tim Walz and all the members of our committees for their leadership as we continue to make improvements to increase Veterans' access to care," Secretary Shulkin continued. "I also want to thank Senator John McCain, who has championed choice for Veterans and whose work on this issue allowed for swift and successful resolution. "VA looks forward to continued bipartisan support as we partner with Congress to not only develop a long-term solution for community care, but also work toward other critical legislation, such as accountability and appeals modernization to ensure Veterans receive the highest quality of care, benefits and support they have earned." ### VA-19-0799-D-001202 OS 00002873 U.S. Department of Veterans Affai rs Office of Congressional and Legislative Affairs We value our Congressional partners, and that's why we have created our VA Casework Guide to help you as you assist our shared Veteran constituents. You have received this message because you have been identified as interested in Veterans issues and are subscribed to VA's Office of Congressional and Legislative Affairs - Congressional Distribution List. Access your Subscribers Preferences to make changes to your subscription or unsubscribe. Get this as aforward? Sign up to receive important updates from the Department of Veterans Affairs. Have questions or Problems? Please contact subscriberhelp.govdelivery.com for assistance. This email was sent to (b) (6) moran.senate .gov using GovDelivery, on behalf of: U.S. Department of Veterans Affairs, Office of Government Relations 810 Vermont Avenue, NW . Washington, DC 20420 VA-19-0799-D-001203 OS 00002874 Message From: Sent: To: Subject: Darin Selnick [(b) (6) @gmail.com] 4/6/2017 12:46:24 AM David shulkin [Drshulkin@aol.com] Fwd: FW: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program This was sent to me today from (b) (6) who works for Sen Moran. I think you should be aware of this, but I know (b) (6) well and she has a tendency to overreact. I do not think we should overreact as well, but use this as a learning experience for sending out these type of news releases. Neither Brooks nor I saw the VA press release before it went out and we only found out about it from (b) (6) Brooks is checking out who did see it, but we need a better process to ensure we list all the members who need to be listed based on their support. (b) (6) is right that Sen Moran should have been listed as well. I have a phone meeting with her tomorrow, and I understand from Brooks that he had Sen Moran on the list for the WH of who should be at the signing ceremony. Darin -----Original Message----From: (b) (6) (b) (6) (Moran) [(b) (6) moran.senate.gov] Sent: Wednesday, April 05, 2017 05:27 PM Eastern Standard Time To: Selnick, Darin Subject: [EXTERNAL] FW: VA Secretary Praises Congress for Extending Choice Program This is just poor form. Moran and our office did a lot of work to get this bill moving. I know McCain catches the headlines but Moran is VA's appropriator not to mention your biggest backer on Choice reforms. Sorry to vent but this yet another slap by the VA and you're the only person I really know the send a message that it's unacceptable. (b) (6) (Moran) Sent: Wednesday, April 5, 2017 5:23 PM (b) (6) To: (b) (6) (b) (6) (Moran) <(b) (6) moran.senate.gov>; (b) (6) (b) (6) < moran.senate.gov> (b) (6) Cc: (Moran) <(b) (6) moran.senate.gov>; (b) (6) (b) (6) < moran.senate.gov> Subject: FW: VA Secretary Praises Congress for Extending Choice Program From: (Moran) (Moran) Boo, VA. Boo. VA-19-0799-D-001204 OS 00002875 From: VA Congressional Notifications [mailto:VACongressionalNotifications@public.govdelivery.com ] Sent: Wednesday, April 05, 2017 5:20 PM (Moran) <(b) (6) moran.senate.gov> Subject: VA Secretary Praises Congress for Extending Choice Program To: (b) (6) U.S. Department of Veterans Affairs Office of Congressional and Legislative Affairs VA Secretary Praises Congress for Extending Choice Program Calls legislation major step toward increasing access to care Today, following the U.S. Senate's passage by unanimous consent last week, the U.S. House of Representatives passed legislation that extends the Veterans Choice Program (VCP) until the funding dedicated to the program is exhausted. The VCP is a critical program that increases access to care for millions of Veterans. Without this legislation, the ability to use VCP funding would have ended abruptly on Aug. 7 of this year. Secretary of Veterans Affairs Dr. David J. Shulkin released the following statement of support: "Congress has once again demonstrated that the country stands firmly united when it comes to supporting our nation's Veterans," Secretary Shulkin said. "The Department of Veterans Affairs truly appreciates the quick bipartisan resolution Congress provided with the extension of the Veterans Choice Program. "I want to thank Chairman Johnny Isakson, Ranking Member Jon Tester, Chairman Phil Roe, Ranking Member Tim Walz and all the members of our committees for their leadership as we continue to make improvements to increase Veterans' access to care," Secretary Shulkin continued. "I also want to thank Senator John McCain, who has championed choice for Veterans and whose work on this issue allowed for swift and successful resolution. "VA looks forward to continued bipartisan support as we partner with Congress to not only develop a long-term solution for community care, but also work toward other critical legislation, such as accountability and appeals modernization to ensure Veterans receive the highest quality of care, benefits and support they have earned." ### WASHINGTON - U.S. Department of Veterans Affairs Office of Congressional and Legislative Affairs We value our Congressional partners, and that's why we have created our VA Casework Guide to help you as you assist our shared Veteran constituents. You have received this message because you have been identified as interested in Veterans issues and are subscribed to VA's Office of Congressional and Legislative Affairs - Congressional Distribution List. Access your Subscribers Preferences to make changes to your subscription or unsubscribe. VA-19-0799-D-001205 OS 00002876 Get this as a forward? Sign up to receive important updates from the Department of Veterans Affairs. Have questions or Problems? Please contact subscriberhelp.govdelivery.com for assistance. This email was sent to (b) (6) moran.senate .gov using GovDelivery, on behalf of: U.S. Department of Veterans Affairs, Office of Government Relations 810 Vermont Avenue, NW . Washington, DC 20420 VA-19-0799-D-001206 OS (b) (6) Message David shulkin [Drshulkin@aol.com] 3/31/2017 3:47:40 PM David Shulkin [drshulkin@aol.com] Marc Sherman [(b) (6) gmail.com] Re: Infrastructure From: Sent: To: CC: Subject: Marc- we can discuss more when we meet David Sent from my iPhone On Mar 31, 2017, at 11:32 AM, (b) (6) (b) (6) (b) (6) va.gov> wrote: Good Morning Marc, Dr. Shulkin asked that I share the analysis of the initial realignment proposals for our facilities ( first attachement). Additionally, please find the recommendation from our staff (powerpoint) to request congress establish a BRAC to facilitate this process. (b) (6) VA-19-0799-D-001207 OS 00002878 Message From: (b) (6) Sent: To: 3/31/2017 3:32:22 PM 'Marc Sherman' [(b) (6) gmail.com]; 'drshulkin@aol.com' [drshulkin@aol.com] Infrastructure Infrastructure Background - Facilities.pdf; SECVA Briefing Independent Review Commission for VHA Facilities and Capi .... pptx Subject: Attachments: (b) (6) [(b) (6) va.gov] Good Morning Marc, Dr. Shulkin asked that I share the analysis of the initial realignment proposals for our facilities ( first attachement). Additionally, please find the recommendation from our staff (powerpoint) to request congress establish a BRAC to facilitate this process. (b) (6) VA-19-0799-D-001208 OS 00002879 1. Background The United States (US) Department of Veterans Affairs (VA} operates one of the largest, integrated health care systems in the country. It delivers this care through over 1,600 points of care that lt either leases or owns outright. Over the decades, as the US Veteran population has migrated, VA's capital infrastructure has not been able to keep pace with those changes due to the inabi!lty to rapidly divest from its operating locations where Veterans were moving from (legacy locations) to where Veterans were moving. Additionally, as care delivery models shifted away from long inpatient stays to greater outpatient care, VA has increasingly found itself with capital infrastructure not ideally suited to current trends in health care. VA has initiated or participated in numerous studies over the past decade, or so, focused on better aligning health care facilities to more efficiently deliver health care to Veterans. This document provides results of a recent summary data call performed by the Veterans Health Administration (VHA) that requested input from VHA's operating networks as to viable options to realign facilities to more efficiently deliver care to Veterans. The summary contained in this document does not include financial impact of realignments nor does lt assess the political feasibility of such realignments. 2. initial Realignment Proposals Table 2-1 provides a listing of Veterans Integrated Service Network {V!SN) and Facility of potential realignments. These realignments result in a partial or full closure of a facility. In most all cases, the realignment would require a short term investment of resources (e.g. establishing a large Community Based Outpatient Cllnlc-CBOC, expanding services in another VA Medical Center to absorb workload, etc.). Overall, there are eighteen facilities identified where some form of realignment could be Implemented, Of these realignments, five realignments result in the outright closure of current major facilities. Eleven of the proposed realignments result in the discontinuation of inpatient services at a given facility and then align those inpatient services at another VA facility or within the private sector community. One propose~ realignment results in adjustment of certain services betwf}en already existing facilities. Table 2-1: Proposed Alignment of VA Health Care Facilities Facility Closure Involved in Facility Realignment VlSN Canandaigua !S2BA5) Partial - Canandaigua V!SN2 VISN3 Bath {528A6) Partial - Canandaigua VA Hudson Valley HCS-Cast!e Point Division !620A4l Yes - Castle Point Initial Proposal Merge facility with Bath; realign Rochester CBOC to Western New York Health Care System - HCS (Buffalo) Merge facility with Canandaigua Oom!c!Uary will fall within current Bath fac!lity Propose dosing and vacating Castle Polnt HCS and transfer care to other VISN 3 facilities VA-19-0799-D-001209 OS 00002880 Facility VJSN Facility Closure Involved in Realignment Initial Proposal Brooklyn (630A4) Partial - Brooklyn Move all Inpatient beds from Brooklyn to Manhattan campus St Albans (630A5) Partial - St. Albans VISN4 VA Pittsburgh HCS No VISN 7 Dublin (557) Partial- Dublin VISN9 Middle Tennessee Health Care System No VISN 11 Battle Creek (515) Partial - Battle Creek !!liana HCS (Danv!l!e) (550) Partial - llliana Saginaw (655) Partial - Saglnaw Vacate and develop a multloserv!ce CBOC on current slte - Inpatient and community living center care w!U be transferred to otherV!SN 3 facilities VA fully discontinued services at the Highland Drive Campus and retired its station number, VA seeks to excess the property through GSA Close Inpatient services, malntaln outpatient surgeryo refer complex cases to Augusta or Atlanta Close Nashville un!t4B (MH) and transfer work to York - close all IP medicine beds at York and transfer work to Nashville, Close Inpatient Medical/Surgical beds, retain !RR & Community Living Center Close Inpatient Medical/ Surgical and retain acute Mental Health, IRR High potential o will become a HCC Eastern Kansas HCS Leavenworth Dlvlslon (589A5j WestTexas HCS (Big Spring) (519) Partial - Leavenworth Yes - Big Spring Prescott (649} Yes - Prescott V!SN 19 Grand Junction (575) Partial -Grand Junction VlSN 20 Roseburg HCS (653} Partla! - Roseburg VISN 21 Livermore (640A4) Yes - Livermore V!SN 23 Fort Meade (568) Partial - Fort Meade Hot Springs {568A4) Yes - Hot Springs VISN 15 VISN 18 Vlable Candidateo no detal!ed plans given Close lnpatient services and move health care to Amarillo; dose Domiciliary and Community Living Center- vacate HCS Close lnpatlent-e!!minate Emergency Department; a!!gn with Phoenix; expand Community Living Center Close Inpatient beds and use community contracts Close inpatient (possible! operate as a CBOC + lRR and Community Living Center Planning to dose - move all care to Stockton and Freemont Plan to contract Inpatient to communityo retain Community Living Center Plan to dose lP services and contract with community providerso expand mult!-speclalty care d!nlc !n Rapid City The proposed realignment associated with the VISN 23 Hot Springs facility has already been initiated, and the VA is currently conducting an environmental impact analysis. The nature of cost savings in the identified realignments may be realized in the reduction of both labor costs and ln certain other fixed and variable facilities' costs. VA-19-0799-D-001210 OS 00002881 3. Further Analysis The identified facilities represent the result of a data can. Where a realignment has been proposed the VISN has developed a notional end-state vision for services to be provided to Veterans, a high-level project sequence, and very rough estimate timeframe. It is proposed that further analysis be performed by forming an integrated program of VISN teams supported by a projects coordinator within VHA's Network Operations (10N). This effort will require support from VHA's Office of Policy and Planning, and VA's Office of Management. The effort should be pursued with the assumption that the identified capital realignments will be included in FY17, 1B and 19 Budget Cycles. VA-19-0799-D-001211 OS 00002882 \ IA V l"I I ~ ~ U.S. Department ofVeterans Affairs SECVA Morning Report: Independent Review Commission for Veterans Health Administration Facilities and Capital Assets VHA Office of Policy and Planning VA-19-0799-D-001212 OS 00002883 o Background and Purpose o Recommendation o Principles o Lessons Learned o Timeline o Legislative Technical Assistance o Communications [Date Ti me] VA DRAFT DOCUMENT - For Internal Use 2 VA-19-0799-D-001213 OS 00002884 0 BACKGROUND AND PURPOSE o In February, the VHA NLC recommended establishment of a VHA facilities review commission (similar to DOD's Base Realignment and Closure (BRAC) Commission) as a top "big hairy audacious change", which stemmed in part from CARES Commission lessons learned, the Section 201 Independent Assessments (2014) and Commission on Care (2016) reports o SECVA requested a recommended path forward for the review o A tiger team was established - including Sr. Advisors to SECVA, OPP, OAEM, OCFM, OCAMES, OGC, OSI - to weigh the options: Option 1 : a Statutory VA Advisory Commission ~ recommended option Option 2 : a Discretionary VA Advisory Committee o The tiger team is now presenting its recommendation to SECVA, including - Suggested methodology/approach - Timeline - Legislative Technical Assistance - Communications strategy to accompany the initiative [Date Time] VA DRAFT DOCUMENT - For Internal Use 3 VA-19-0799-D-001214 OS 00002885 0 RECOMMENDATION o It is recommended by the tiger team that VA request Congress to pass legislation requiring VA to establish a Statutory VA Advisory Commission for the realignment of VHA facilities (i.e. Option 1) o The recommendation for a Statutory VA Advisory Commission is based on the following rationale: - Recommendations from a Statutory VA Advisory Commission would have a higher likelihood of receiving an approval/disapproval vote from Congress on the entire recommendations package, since Congress required VA to establish the Commission - Congress could appropriate funds for the Commission, to include funds for staff and Contractors (if necessary); and - Congress could provide, by statute, that the Commission is FACA-exempt [Date Time] VA DRAFT DOCUMENT - For Internal Use 4 VA-19-0799-D-001215 OS 00002886 ~ V PRINCIPLES IN DEVELOPING A NATIONAL REALIGNMENT PLAN o Several principles will guide development of the national realignment plan and subsequent decisions by the Commission. Some include: - Balance the need for equal or better access, Veteran satisfaction, state-of-theart world-class facilities, and cost-effectiveness - While addressing VNs health care mission, preserve VHNs other missions education, research and emergency preparedness - The quality of VA and community care will be examined to ensure suitable facilities and well-trained health care professionals are available to meet the needs of Veterans - Assure a high performing clinically integrated network of VA care and community care, which may include adding sites of care where population and referral patterns indicate access needs to be improved - Leverage lessons learned from CARES Commission and DOD BRAC Commission [Date Ti me] VA DRAFT DOCUMENT - For Internal Use 5 VA-19-0799-D-001216 OS 00002887 0 LESSONS LEARNED o Some lessons learned from the CARES Commission and BRAC Commission process will be incorporated in the independent review and the National Realignment Plan that VA will submit to the Commission: A number of CARES initiatives were never implemented because members of Congress and special interest groups blocked closure of facilities that the CARES Commission verified were no longer needed Avoid adding requirements after implementation begins and fully account for IT requirements in initial estimates to prevent understating costs In general, the Commission would not be able to add recommendation contingencies, but if contingencies are to be permitted, limit them to specific conditions Requirements such as environmental clean-up before transfer or re-use and historical preservation hindered full implementation BRAC analysis did not give a credible assessment of total excess capacity across DOD or the potential for achieving greater efficiencies in use of that capacity - this could be an issue with VHA as well Not considering property transfer/disposal process once the BRAC closure process completed seemed to prolong moving of the liability, which slowed realizing cost savings [Date Ti me] VA DRAFT DOCUMENT - For Internal Use 6 VA-19-0799-D-001217 OS 00002888 0 SUGGESTED TIMELINE o FY17 Develop Initiate Technical Assistance with Congress or Appropriate VA and Request for White Paper White House Office by SecVA ' ' Conduct National Market-by- National Facilities Realignment Plan Submitted to Recommendations Submitted to Congress and (1 mo} Market Assessments ("'12 mo} Commission White House ' ' I 17 I FY19 Methodology for Conducting National Market-by-Market Health System Design ' I 2017 o Ii I I 2017 I 2018 I I 2018 2019 1 White House o 1 : Approval I I I I I I ' 17 Congressional Approval o 2019 EEMNl-o.ol.}MMMt,MHIMF+---.ee++ijlNM.MtjiNo."ift! I o White Paper Completed I o Congress to Introduce legislation for, or White House to Announce, Independent Commission I I ongomg -+ o Midterm Elections o I (Nov 6, 2018) Finalize Format for National Facilities Realignment Plan (lmo) o o I Commission Approves Recommendations I Implement Approved Commission Recommendations (onc:oi nc} We are here [Date Ti me] VA DRAFT DOCUMENT - For Internal Use 7 VA-19-0799-D-001218 OS 00002889 0 LEGISLATIVE TECHNICAL ASSISTANCE o Establish a Statutory VA Advisory Commission comprised of members appointed by the WH and Congress with ex-officio expert members from VA facilities and VHA health care o Offer legislative assistance on inclusion of review criteria based on access, quality, safety and community facility standards o Congress has up or down vote on entire plan as a whole o Criteria can be used for future decisions on capital by SECVA o Empower the Commission to assess and approve VA/VHA's national realignment plan within 45 days of receipt of VHA's recommendations o Insert language to preclude members of congress from blocking implementation in their districts [Date Ti me] VA DRAFT DOCUMENT - For Internal Use 8 VA-19-0799-D-001219 OS 00002890 0 COMMUNICATIONS o Need a focused and deliberate communications strategy to accompany the work of the Commission - before and during the assessments, and during implementation o Communicate to Congress, the Commission, Veterans, VA employees, VSOs, Union partners, and other stakeholders o Requires a comprehensive multi-media strategy o Expand routine communications between the markets, VISNs and VHACO, to encourage joint resolution of common challenges, and sharing of best practices and lessons learned in managing mission changes o Continually accentuate the benefits in terms of equal or greater access, quality, satisfaction, and economic benefits [Date Time] VA DRAFT DOCUMENT - For Internal Use 9 VA-19-0799-D-001220 OS 00002891 Message From: Sent: To: Attachments: David shulkin [Drshulkin@aol.com] 6/12/2017 6:45:35 PM mac.com]; Ike Perlmutter [(b) (6) frenchangel59.com] Bruce Moskowitz [(b) (6) IMG_4068.JPG; Untitled attachment 05908.txt Roundtable list VA-19-0799-D-001221 OS 00002892 Committee on Veterans' Affairs U.S. House of Representatives 115 111 Congress "Improving Access, Quality, and Efficiency: Exploring Organizational Changes for the Veterans Health Administration" Thursday, June 15, 2017, at 8:00 a.m. 334 Cannon House Office Building I. James B. Peake M.D., LTG (Ret), Senior Vice President, CGI Federal/Former Secretary, U.S. Department of Veterans Affairs 2. Katrina Armstrong MD, Jickson Professor of Clinical Medicine, Harvard Medical \ School 3. Christine Cassel, M.D., Kaiser Permanente School of Medicine/Former President and Chief Executive Officer, National Quality Forum 4. George Halvorson, Chair and Chief Executive Officer, Institute for Intergroup Understanding/Former Chairman and Chief Executive Officer, Kaiser Permanente Accompanied by: La Verne Council, MITRE Corporation/ Former Chief Information Officer, U.S. Department of Veterans Affairs 5. Gail Wilensky, Ph.D., Senior Fellow, Project HOPE 6. David Hecht, M.D., M.B.A., Chief of Staff, Mountain Home VA Healthcare System, U.S. Department of Veterans Affairs 7. Paul Rothman, M.D., Dean and Chief Executive Officer, Johns Hopkins Medicme 8. Peter Pronovost, M.D., Senior Vice President, Patient Safety and Quality, Johns Hopkins Medicine 9. Sam Hazen, President, HCA 10. The Honorable David Shulkin, Secretary, U.S. Department of Veterans Affairs Accompanied by: Dr. Poonam Alaigh, Acting Under Secretary for Health, U.S. Department of Veterans Affairs 11. John Noseworthy, M.D., President and Chief Executive Officer, Mayo Clinic 0 (/) I 0 0 0 0 ~ (X) c.o u) VA-19-0799-D-001222 Sent from my iPhone Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/3/2017 11:30:32 AM Poonam Alaigh [(b) (6) hotmail.com]; Bruce Moskowitz [(b) (6) Fwd: [EXTERNAL] Project Hero launches PTSD device to eliminate suicide mac.com] Poonam and Bruce- this is an interesting device that we might want to look atIm not sure if yiu have seen this before. Poonam you may wish to share with out clinical team. i am seeing the developer on thursday David Subject: [EXTERNAL] Project Hero launches PTSD device to eliminate suicide PROJECT HERO ANNOUNCES PARTNERSHIP WITH TEXAS A&M UNIVERSITY TO LAUNCH INNOVATIVE PTSD DEVICE ~HGBPR0TRRH Project Hero, the groundbreaking national non-profit veterans and first responders organization, will partner with Texas A&M University to introduce the first wearable biometric monitoring device specifically designed to help veterans and first responders with PTSD, it was announced today by (b) (6) president and founder of Project Hero. The device will debut as part of Project Hero's HEROTrak program during the organization's upcoming 2017 UnitedHealthcare Texas Challenge April 3-8. The partnership features the debut and first non-clinical use of a wristwatch-sized wearable biometric monitor programmed to respond to and learn the wearer's PTSD-specific physical triggers to predict episodes and provide tools to strengthen resilience. The device uses heart rate, skin conductance and heart rate variation, not associated with athletics or normal activities, and interact with the wearer to help manage the onset of the episode and allow tools including contact peer support or assistance. VA-19-0799-D-001224 OS 00002895 The unique device and its sophisticated monitoring software have been developed by the Engineering Department of Texas A&M University. The university has been working with the Project Hero Research Institute of Mental Health to develop opportunities to test the device using highly-qualified veterans in non-clinical environments such as Project Hero events. The organization has selected veteran and first responders who have a VA mental health rating taking part in the 2017 UnitedHealthcare Texas Challenge for the inaugural study. The riders will wear the device throughout the 350+-plus mile journey through from San Antonio to Houston. "Project Hero is honored by our partnership with Texas A&M and thrilled to be the first organization serving veterans and first responders to use the HERO Trak device that will help wearers identify, manage and reduce PTSD episodes," said Wordin. "We are also planning to continue working with Texas A&M using this innovative device at our Challenge Series and other events throughout the year." Riders will wear the HERO Trak device throughout the 2017 UnitedHealthcare Challenge Series and allow data generated by the device to collected on an anonymous basis by Project Hero and Texas A&M after the Challenge has ended. Project Hero and Texas A&M are planning to use the device in the organization's upcoming 2017 Challenge and Honor Ride events to improve the predictability and accuracy. A companion App is being developed with Project Hero, the VA, and other partners. The goal is to increase resources so that more veterans can take part in the initial study phase to provide more data to perfect the relevant algorithms. We appreciate all of the veterans and partners taking part in this groundbreaking initiative and look forward to a future where all military personnel would have access to this information from the time they start their military service through their transition into the VA system to provide a more accurate and personalized continuum care path and eliminate suicide. Regards, (b) (6) President and Founder Project Hero Providing Hope Recovery & Resilience 818.888.7(b) (6) 818.710.(b) (6) Fax ProjectHero.org VA-19-0799-D-001225 OS 00002896 PFIOJECTHEFICJ Research Institute of Mental Health Hope Recovery Resilience Supporters include UnitedHealthcare, GE, United Airlines, USO, Hero Miles, Tawani Foundation, Disabled Veterans National Foundation, Scott USA, Uhaul, Bike Nashbar, Pactimo, Macy's, Shimano, Boeing, Strohman Enterprise Garmin, Camelbak, Rocktape, Parktool, Speedplay, Geico, Chamois Butt'r, Hutchinson, Kenda, Pepsi, Gatorade, Soldier Fuel, ICC, R4 Alliance and is the creator and founding partner of the Warrior Games. This message, including any attachments, is solely for the use of the intended recipient(s) and may contain confidential and/or privileged information. Any unauthorized review, use, disclosure or distribution of this communication is expressly prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy any and all copies of the original message. Thank you. VA-19-0799-D-001226 OS 00002897 Message From: Sent: To: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/4/2017 5:02:49 PM drshulkin@aol.com; Poonam Alaigh [(b) (6) hotmail.com] Congressional hearing on VA CRISIS LINE The staff did a great job under difficult circumstances. The points that stood out in my mind are the following: By the time the VA gets the patient who calls there is no prior system within the DOD to let the VA know who may be at risk and a focus of a mental wellness program. Telemedicine instant link with a patient who calls may be necessary in many locations. A focus was on women during the hearing and we should be able to come up with a women's health care initiative very quickly. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001227 OS 00002898 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/4/2017 12:12:31 AM Bruce Moskowitz [(b) (6) Re: Academic Affiliations SECVA mac.com] Ok ill respond and get back to you Sent from my iPhone On Apr 3, 2017, at 8:01 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: It would be my pleasure to take the lead if you believe it to be of benefit and indeed they make a case for the same issues we have identified. Sent from my iPad Bruce Moskowitz M.D. On Apr 3, 2017, at 7: 19 PM, David shulkin wrote: Bruce- i just wanted you to be aware - so we coordinate efforts Im ok if you take the lead David Sent from my iPhone Begin forwarded message: From: DJS Date: April 3, 2017 at6:58:15 PM EDT To: 'Shulkin' Subject: FW: Academic Affiliations SECVA Sent with Good (www.good.com) -----Original Message----(b) (6) From: (b) (6) Sent: Monday, April 03, 2017 05:23 PM Eastern Standard Time To: DJS Subject: FW: Academic Affiliations SECVA Sent to (b) (6) already VA-19-0799-D-001228 OS 00002899 From: (b) (6) [mailto:(b) (6) Sent: Monday, April 03, 2017 4:09 PM To: Shulkin, David J., MD mssm.edu ] Cc: (b) (6) Subject: [EXTERNAL] Academic Affiliations SECVA Dear Dr. Shulkin, We would like to take this opportunity to respond to your call for ideas for building academic partnership for faculty, training, and research. The Icahn School of Medicine at Mount Sinai has had a longstanding affiliation of over 30 years with the Veterans Affairs Hospital in the Bronx, New York (VA). We have shared a history of successful achievements including two Lasker Awards and a Nobel Prize in research. However in order for the VA to continue its successful 70 year partnership with academic institutions, the VA must move forward with audaciousness and a renewed energy. There is a need to streamline and expedite the hiring processes between the VA and the affiliations. A process is needed that promotes swift onboarding, functional privileges and efficient portable Heath IT access. There is a need to develop safe and secure exchange of patient and research information across the VA and affiliated institutions for shared patients and for research information and research protocols. This will require a fresh look at interoperability between IT platforms at the VA and the affiliate. It is critical that the VA strongly continues the support of research development in order to remain viable with a critical mass of research and also to continue to attract the best research talent in the community. We must maintain adequate funding of veteran centric clinical and research development, both in general veteran focused areas of care delivery and research including women's health, PTSD, and long term effects of concussion but also in the highly specialized treatment of veterans and their loved ones that the VA provides for the more rare but devastating conditions of spinal cord injury, ALS, MS, Alzheimer's Disease, along with Centers of Excellence in Suicide prevention. To more effectively task those important issues we encourage moving more resource and research decisions to local director leadership instead of centrally, because facility directors are able to make more informed decisions based on availability of local clinical and research expertise and excellence in the local community, academic affiliation, and the VA medical center. Sincerely, VA-19-0799-D-001229 OS 00002900 (b) (6) (b) (6) MD (b) (6) MD President & CEO, (b) (6) Dean, Mount Sinai Health System of Medicine at Mount Sinai (b) (6) Icahn School President for Academic Affairs, Mount Sinai Health System VA-19-0799-D-001230 OS 00002901 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/4/2017 12:01:20 AM David shulkin [Drshulkin@aol.com] Poonam Alaigh [(b) (6) hotmail.com]; Ike Perlmutter [(b) (6) frenchangel59.com] Re: Academic Affiliations SECVA It would be my pleasure to take the lead if you believe it to be of benefit and indeed they make a case for the same issues we have identified. Sent from my iPad Bruce Moskowitz M.D. On Apr 3, 2017, at 7: 19 PM, David shulkin wrote: Bruce- i just wanted you to be aware - so we coordinate efforts Im ok if you take the lead David Sent from my iPhone Begin forwarded message: From: DJS Date: April 3, 2017 at6:58:15 PM EDT To: 'Shulkin' Subject: FW: Academic Affiliations SECVA Sent with Good (www.good.com) -----Original Message----(b) (6) From: (b) (6) Sent: Monday, April 03, 2017 05:23 PM Eastern Standard Time To: DJS Subject: FW: Academic Affiliations SECVA Sent to (b) (6) already [mailto:(b) (6) From: (b) (6) Sent: Monday, April 03, 2017 4:09 PM To: Shulkin, David J., MD mssm.edu ] Cc: (b) (6) Subject: [EXTERNAL] Academic Affiliations SECVA VA-19-0799-D-001231 OS 00002902 Dear Dr. Shulkin, We would like to take this opportunity to respond to your call for ideas for building academic partnership for faculty, training, and research. The Icahn School of Medicine at Mount Sinai has had a longstanding affiliation of over 30 years with the Veterans Affairs Hospital in the Bronx, New York (VA). We have shared a history of successful achievements including two Lasker Awards and a Nobel Prize in research. However in order for the VA to continue its successful 70 year partnership with academic institutions, the VA must move forward with audaciousness and a renewed energy. There is a need to streamline and expedite the hiring processes between the VA and the affiliations. A process is needed that promotes swift onboarding, functional privileges and efficient portable Heath IT access. There is a need to develop safe and secure exchange of patient and research information across the VA and affiliated institutions for shared patients and for research information and research protocols. This will require a fresh look at interoperability between IT platforms at the VA and the affiliate. It is critical that the VA strongly continues the support of research development in order to remain viable with a critical mass of research and also to continue to attract the best research talent in the community. We must maintain adequate funding of veteran centric clinical and research development, both in general veteran focused areas of care delivery and research including women's health, PTSD, and long term effects of concussion but also in the highly specialized treatment of veterans and their loved ones that the VA provides for the more rare but devastating conditions of spinal cord injury, ALS, MS, Alzheimer's Disease, along with Centers of Excellence in Suicide prevention. To more effectively task those important issues we encourage moving more resource and research decisions to local director leadership instead of centrally, because facility directors are able to make more informed decisions based on availability of local clinical and research expertise and excellence in the local community, academic affiliation, and the VA medical center. Sincerely, (b) (6) President & CEO, Dean, MD (b) (6) MD (b) (6) VA-19-0799-D-001232 OS 00002903 Mount Sinai Health System Mount Sinai Icahn School of Medicine at President for Academic Affairs, Mount Sinai Health System VA-19-0799-D-001233 OS 00002904 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/3/2017 11:19:07 PM Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com]; Ike Perlmutter [(b) (6) frenchangel59.com] Fwd: Academic Affiliations SECVA Bruce- i just wanted you to be aware - so we coordinate efforts Im ok if you take the lead David Sent from my iPhone Begin forwarded message: From: DJS Date: April 3, 2017 at6:58:15 PM EDT To: 'Shulkin' Subject: FW: Academic Affiliations SECVA Sent with Good (www.good.com) -----Original Message----(b) (6) From: (b) (6) Sent: Monday, April 03, 2017 05:23 PM Eastern Standard Time To: DJS Subject: FW: Academic Affiliations SECVA Sent to (b) (6) already [mailto:(b) (6) From: (b) (6) Sent: Monday, April 03, 2017 4:09 PM To: Shulkin, David J., MD mssm.edu ] Cc: (b) (6) Subject: [EXTERNAL] Academic Affiliations SECVA Dear Dr. Shulkin, We would like to take this opportunity to respond to your call for ideas for building academic partnership for faculty, training, and research. VA-19-0799-D-001234 OS 00002905 The Icahn School of Medicine at Mount Sinai has had a longstanding affiliation of over 30 years with the Veterans Affairs Hospital in the Bronx, New York (VA). We have shared a history of successful achievements including two Lasker Awards and a Nobel Prize in research. However in order for the VA to continue its successful 70 year partnership with academic institutions, the VA must move forward with audaciousness and a renewed energy. There is a need to streamline and expedite the hiring processes between the VA and the affiliations. A process is needed that promotes swift onboarding, functional privileges and efficient portable Heath IT access. There is a need to develop safe and secure exchange of patient and research information across the VA and affiliated institutions for shared patients and for research information and research protocols. This will require a fresh look at interoperability between IT platforms at the VA and the affiliate. It is critical that the VA strongly continues the support of research development in order to remain viable with a critical mass of research and also to continue to attract the best research talent in the community. We must maintain adequate funding of veteran centric clinical and research development, both in general veteran focused areas of care delivery and research including women's health, PTSD, and long term effects of concussion but also in the highly specialized treatment of veterans and their loved ones that the VA provides for the more rare but devastating conditions of spinal cord injury, ALS, MS, Alzheimer's Disease, along with Centers of Excellence in Suicide prevention. To more effectively task those important issues we encourage moving more resource and research decisions to local director leadership instead of centrally, because facility directors are able to make more informed decisions based on availability of local clinical and research expertise and excellence in the local community, academic affiliation, and the VA medical center. Sincerely, (b) (6) MD President & CEO, Mount Sinai Health System (b) (6) (b) (6) MD Dean, Icahn School of Medicine at Mount Sinai President for Academic Affairs, Mount Sinai Health System VA-19-0799-D-001235 OS 00002906 Message From: Sent: To: Subject: Marc Sherman [(b) (6) gmail.com] 4/3/2017 3:15:17 PM IP [(b) (6) frenchangel59.com]; Bruce Moskowitz [(b) (6) shulkin [drshulkin@aol.com] Fwd: Thank You mac.com]; L Perl [(b) (6) gmail.com]; David FYI ---------- Message ---------Date: Mon, Apr 3, 2017 at 11 :07 AM Subject: Thank You To: "(b) (6) isakson.senate.gov" <(b) (6) isakson.senate.gov> (b) (6) I waited until today to send this email because I didn't want to disturb your weekend. Again, a special thanks to you for making our meeting happen, and with a big smile, and thanks for passing this on to the Senator. My regards to (b) (6) and, if you don't mind, can you confirm that you received this? Marc Senator Isakson Thank you very much for giving of your time last Thursday to talk about the VA and T(b) (6) I know that you fit that conversation into an otherwise packed day of a one day trip. Some conversations strain to last five minutes and others fly by. Our time flew by, for me anyway. It was one of those conversations that you hope will take place, but so often fails to deliver. This one didn't disappoint. I so hope we can meet again ... I would love to pick up the conversation- about the VA and life in general. On both fronts, there is so much to discuss. I passed our discussion onto the President, including your need to maintain the momentum that Tom has brought to you and the Senate Committee, without any impact to that effort. Your message was clear. My heartfelt wishes for a continued recovery from the surgery. Joan told me that golf is likely not in your near-term plans because of the surgery, but I belong to a top 75 golf course nearby and would enjoy nothing more than the opportunity to spend that time with you enjoying the outdoors with good conversation. Please let me know if that becomes a possibility. It is a standing invitation. VA-19-0799-D-001236 OS 00002907 With gratitude, all my best, Marc Marc B. Sherman I Managing Director Alvarez & Marsal Washington Center I 1001 G Street, NW I Suite 1100, West Tower I Washington, DC 20001 Office 202.729.(b) (6) I Mobile 202.758.(b) (6) Executive Assistant!(b) (6) 1202.729.(b) (6) I (b) (6) @alvarezandmarsal.com North America + Europe + Latin America + Middle East + Asia VA-19-0799-D-001237 OS 00002908 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 4/2/2017 11:04:01 PM Poonam Alaigh [(b) (6) hotmail.com] Re: VA And Apple Absolutely right Can we get someone to send us the commas plan on this Sent from my iPad On Apr 2, 2017, at 5:47 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Wow!! That's the precise reason we have to make sure we continue to include them regularly. You should share the comms plan around release of the Transparency Site that includes talking to congress, 60min and USA Today. I think we get (b) (6) involved with Marc and Bruce so that we can get comments from the Academic Affiliate group incorporated in our messaging. Remember what I told you- they want to give us there valuable time and support but ensure that they are respected and valued and want to be "in the loop" with constant communication. They are our biggest allies and have confidence in us- but we have to manage the relationship very very carefully and with full attention. Sent from my iPhone On Apr 2, 2017, at 8:02 PM, David Shulkin wrote: It's easy to get on the wrong side of this group Sent from my iPad Begin forwarded message: From: "IP" <(b) (6) frenchangel59 .com> Date: April 2, 2017 at 10:51:54 AM EDT To: "David shulkin" Subject: FW: VA And Apple From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Sunday, April 02, 2017 10:16 AM To: '(b) (6) EOP/WHO' Cc: 'Kushner, Jared C. EOP/WHO'; '(b) (6) Subject: RE: VA And Apple EOP/WHO' (b) (6) My email to (b) (6) on Thursday expressed my frustration and displeasure in learning about activity and decisions concerning issues at the VA in a separate and invisible parallel effort. Regrettably, your response to my email that "(b) (6) has VA-19-0799-D-001238 OS 00002909 been working but not communicating" not only fails to recognize or explain the issue, but merely highlights the very fundamental problem that is so troubling. While a lack of communication has certainly exacerbated the problem, the mere fact that there has been any activity or decision without first coordinating that activity with our team before taking any action is the problem. Simply offering to communicate better solves very little. In your and (b) (6) first meeting in the West Wing with Marc Sherman it was clear and agreed that (b) (6) would be the liaison between our expert team and the White House and provide her IT counsel to our team related to our initiatives (not as an invisible, parallel effort). In addition, the White House was to be available to assist our team with executive and legislative clout when requested (not conduct an invisible, parallel effort), a threepronged approach, if you recall. This is the program I reported to the President and the go-ahead we received. The essential problem at the VA is that 22 veterans die every day and the system of care and access to care is in need of repair. This is a medical issue and medical delivery problem. In order to fix the VA, these medical problems must first be defined and fixed. All other issues, like IT, are a function of the determined fix to the medical issues and medical delivery problems. To transform the VA into the best of class, I assembled a team that includes the best and brightest minds in the academic medical community. The restructuring efforts on which we embark are informed by the advice and participation of those great medical minds. Parallel (and invisible to us) IT efforts are not connected to what the medical minds decide are the problem or the fix and are frustrating the IT solution that deals with the medical issues. It is also spending the valuable time of volunteers and delaying the best care that our veterans deserve. Your email to me underscores this problem. You say that: "[ efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services," and "There is a call on Monday with Apple, the VA, and (b) (6) to review the ... status of the EHMP work ... [and] to confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities." However, it is not possible to design an EHMP system or integrate the system with an Apple device until you know how the medical experts are going to change the medical delivery system and how VA-19-0799-D-001239 OS 00002910 they advise a device should be utilized in the medical delivery system. The academic medical experts on our team are assisting the VA in designing a sophisticated system of community care through a public-private delivery system. They are formulating that system and its inner workings, the creation of which will dictate the Integration and interoperability of records. Neither (b) (6) nor Apple can define a scope or product use without consulting with our group on how veteran's records used in the private sector will get integrated into the portable record and back to the VA. You mention in your email telehealth. Our team of medical experts are working on a telehealth initiative and delivered a draft Executive Order to the President ... while you are working with the DEA and DOJ, without the courtesy of advising us, which could have tremendous implications on the wording or, worse yet, the prudence of an Executive Order in the first place. This parallel path as well creates the potential for embarrassment for the President and wasted invaluable time that our veterans can ill afford. Lastly, you discuss your parallel meeting on a Military Wellness program which you apparently already brought in which you believe focuses on preventative medicine. The program that you are touting however is surrounded by rumors that are less than flattering. Moreover, our team's academic medical experts are already assisting in the active development of a wellness program for the VA and their views will prevail. Those experts have already assembled the working parts of a wellness program and the seamless integration with active service members and family. There is no need to have a parallel side effort that is not integrated into the agreed program. Again, the problem is not about communication. I had an employee a few years back that meant well but thought that there was an "I" in team. His work for the company created value and profits for the company at various times, however, in spite of those benefits, I advised him that his way was not working and he should find something else that better met his style. With all this considered, I think that (b) (6) is a smart woman that could provide the VA IT experience and benefits, my way ... not as a renegade player. I am willing to work with her as a team player on our team. The expert team that I assembled and is sanctioned by the President will be proceeding with its efforts as planned. All other parallel efforts should stand down. (b) (6) can participate as part of that team, not outside of that team or its efforts or its direction. As agreed on day one, the White House can participate by providing executive and administrative assistance, when requested by our expert team. We will arrange and conduct discussions with Apple (in which (b) (6) should participate if done within the confines of the expert team). We will work with design and implementation of a wellness program and we will decide on VA-19-0799-D-001240 OS 00002911 the proper way to integrate an EMR system, with (b) (6) team participation if agreed. Any items that relate to the transformation of the VA must be funneled through and managed by the expert team and should be coordinated with Dr. Moskowitz and Marc Sherman. Let me know if you have any questions. Ike EOP/WHO From: (b) (6) [ mailto:(b) (6) who.eop.gov] Sent: Friday, March 31, 2017 6:03 PM To: IP; Kushner, Jared C. EOP/WHO Cc: (b) (6) EOP/WHO; (b) (6) Subject: RE: VA And Apple EOP/WHO As we discussed it seems like (b) (6) has been working but not communicating. Her efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services. There is a call on Monday with Apple, the VA, and (b) (6) to review the following: 1. Status of the EHMP work 2. to find a legal mechanism to allow for 3 month tour of duty from Apple engineers with the employees staying on Apple payroll. This is being investigated by USDS lawyers and the VA. 3. To work through an NDA / conflict waiver which is a necessary legal document. 4. To confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities.) I believe we should then schedule a call for mid next week with Ike, appropriate members of Ike's team, the VA, Apple and (b) (6) myself to ensure we are on same page (I can coordinate the call). I think we should allow (b) (6) an opportunity to reset and to act as a true overall project manager where we allow her to coordinate. She should communicate with Ike and his designee consistently and she should professionally coordinate the team, get everyone working together, and show us VA-19-0799-D-001241 OS 00002912 progress. I believe she will do a great job, and we will know quickly if she does not. As everyone knows huge other hot items at VA in the works right now including Accountability (legislation and EO), Choice Reform Act extension and reform; telehealth (working through the issue with DOJ and DEA; hard to just slam it through if they oppose but based on meeting today with VA/DOJ/DEA I believe we can get them there in next two weeks. Ike, I can explain in detail when we next talk but having been through this with the Opioid EO this week we should see if we can get DEA/ DOJ on board). Different subject, Ike would also like your advice on NIH and the idea (I think your idea?) to create a profit sharing program with our grants. Love this idea. Yours truly, (b) (6) P.S. I need to update you on very exciting meeting on a Military Wellness program which we brought in; focuses on preventative medicine and is working for over 20,000 vets currently. Readily scalable. (b) (6) Assistant to the President For lntragovernmental and Technology Initiatives 202.456.(b) (6) (Direct) (b) (6) who.eop.gov From: IP fmailto:(b) (6) frenchangel59.com1 Sent: Friday, March 31, 2017 12:05 AM To: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov> Cc: (b) (6) EOP/WHO <(b) (6) who.eop.gov>; EOP/WHO <(b) (6) who.eop.gov> Subject: FW: VA And Apple (b) (6) Jared, As you know lvanka introduced me to (b) (6) at Apple and (b) (6) at Johnson & Johnson. Ours Academic team and experts have has done here worked so well with them and their teams. What is really outrageous. She may be very good in social media, but this an entirely different and very complicated area. We will fix this. VA-19-0799-D-001242 DS 00002913 All my Best, Ike From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Thursday, March 30, 2017 11:56 PM To: (b) (6) omb.eop.gov Cc: (b) (6) who.eop.gov; lperl(b) (6) @qmail.com ; brucem(b) (6) @mac.com ; mbs(b) (6) @qmail.com Subject: FW: VA And Apple (b) (6) With all due respect, I am shocked and extremely disappointed with the manner in which you have engaged in individual communications with Apple - and intentionally excluded our broader team of subject matter experts. I understand that these backdoor discussions have apparently been occurring almost daily for weeks, and you have not told anyone and refuse to return phone calls and emails. When we first met on February 7th, I personally shared with you our vision and goals and explained that it is critical that everything we do must be done as a team. The very purpose of our Academic team, Dr. Moskowitz, and Marc Sherman is to ensure proper analysis, sharing of best practices, and provide a forum for discussion, debate, and ultimately the strongest collective decisions/recommendations. You agreed then, but your actions to date regarding Apple prove otherwise. When I spoke with (b) (6) on February 1st we discussed and agreed on the importance of leveraging our Academic team and experts for the end goal of creating the best system for our veterans. Further on our Apple conference call on March 3rd - which we invited you and (b) (6) to join - we again discussed and all agreed that for us to be successful and fix all the issues that our great veterans are going through on a daily basis, we must all unite and work as one team, with only one agenda and one goal. What we are seeing from you today is a blatant disregard for that commitment and clear disrespect to everyone involved. You are putting yourself, your own agenda, and your own ego ahead of our veterans. This is unacceptable. There are 22 veterans dying every day. Your decision to alone discuss IT and technology solutions with Apple for weeks without the broader team of experts and not informing me and Dr. Moskowitz is major step backwards and will only cause additional work and significant delays. As a result of your hijacking of this effort, Apple has already canceled conference calls. VA-19-0799-D-001243 OS 00002914 In fact, many of the current problems with the VA is because of this very reason - the lack of team work within. Let me be clear, I will not allow this to happen while I am involved. I want this resolved immediately. First, you must include Dr. Moskowitz and Marc Sherman on any and all calls or meetings. Additionally, I will formally ask you again to please respect me and our broader group of subject matter experts, and immediately cease individual discussions with Apple and/or any other parties related to the work we have undertaken regarding the VA. Ike -----Original Message----(b) (6) From: (b) (6) EOP/OMB fmailto:(b) (6) omb.eop.gov] Sent: Thursday, March 30, 2017 6:48 PM To: Bruce Moskowitz Cc: (b) (6) EOP/WHO; IP; (b) (6) frenchangel59.com Subject: Re: VA And Apple Hey team! We're making great progress, which I'm excited to fill you in on. Will send you more info when I get out of these back-to-back mtgs and will give you a ring back Ike! Thanks! > On Mar 30, 2017, at 6:49 AM, Bruce Moskowitz <(b) (6) mac.com > wrote: > > In the last email exchange i was supposed to receive information on your interaction with Apple so that we could rapidly obtain needed technology from our Academic Center Consortium upcoming discussion with Apple. I realize there are multiple technology issues on everyone's desk however we have medical emergencies daily at the VA that can only be solved by rapid deployment of new technology. I am available 24-7 by phone 561-3466(b) (6) Thank you > > Sent from my iPad > Bruce Moskowitz M.D. -----Original Message----From: Bruce Moskowitz fmailto:(b) (6) Sent: Tuesday, March 28, 2017 11:41 AM To: (b) (6) who.eop.gov; (b) (6) Cc: IP Subject: VA And Apple mac.com ] omb.eop.gov It would be of benefit to discuss what we can accomplish in technology with Apple for the benefit of the VA. It would be of importance to understand what discussions the Whitehouse team has already had VA-19-0799-D-001244 OS 00002915 with Apple so that we have a clear path forward and do not duplicate what has already been accomplished. Let me know a convenient time to talk. Thank you Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001245 OS 00002916 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/2/2017 9:47:59 PM David Shulkin [drshulkin@aol.com] Re: VA And Apple Wow!! That's the precise reason we have to make sure we continue to include them regularly. You should share the comms plan around release of the Transparency Site that includes talking to congress, 60min and USA Today. I think we get (b) (6) involved with Marc and Bruce so that we can get comments from the Academic Affiliate group incorporated in our messaging. Remember what I told you- they want to give us there valuable time and support but ensure that they are respected and valued and want to be "in the loop" with constant communication. They are our biggest allies and have confidence in us- but we have to manage the relationship very very carefully and with full attention. Sent from my iPhone On Apr 2, 2017, at 8:02 PM, David Shulkin wrote: It's easy to get on the wrong side of this group Sent from my iPad Begin forwarded message: From: "IP" <(b) (6) frenchangel59.com> Date: April 2, 2017 at 10:51:54 AM EDT To: "David shulkin" Subject: FW: VA And Apple From: IP [mailto:(b) (6) frenchanqel59.com] Sent: Sunday, April 02, 2017 10:16 AM To: '(b) (6) EOP/WHO' Cc: 'Kushner, Jared C. EOP/WHO'; '(b) (6) Subject: RE: VA And Apple EOP/WHO' (b) (6) My email to (b) (6) on Thursday expressed my frustration and displeasure in learning about activity and decisions concerning issues at the VA in a separate and invisible parallel effort. Regrettably, your response to my email that "(b) (6) has been working but not communicating" not only fails to recognize or explain the issue, but merely highlights the very fundamental problem that is so troubling. While a lack of communication has certainly exacerbated the problem, the mere fact that there has been any activity or decision without first coordinating that activity with our team before taking any action is the problem. Simply offering to communicate better solves very little. In your and (b) (6) first meeting in the West Wing with Marc Sherman it was clear and agreed that (b) (6) would be the liaison between our expert team and the White House and provide her IT counsel to our team related to our initiatives VA-19-0799-D-001246 OS 00002917 (not as an invisible, parallel effort). In addition, the White House was to be available to assist our team with executive and legislative clout when requested (not conduct an invisible, parallel effort), a three-pronged approach, if you recall. This is the program I reported to the President and the go-ahead we received. The essential problem at the VA is that 22 veterans die every day and the system of care and access to care is in need of repair. This is a medical issue and medical delivery problem. In order to fix the VA, these medical problems must first be defined and fixed. All other issues, like IT, are a function of the determined fix to the medical issues and medical delivery problems. To transform the VA into the best of class, I assembled a team that includes the best and brightest minds in the academic medical community. The restructuring efforts on which we embark are informed by the advice and participation of those great medical minds. Parallel (and invisible to us) IT efforts are not connected to what the medical minds decide are the problem or the fix and are frustrating the IT solution that deals with the medical issues. It is also spending the valuable time of volunteers and delaying the best care that our veterans deserve. Your email to me underscores this problem. You say that: "[ efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services," and "There is a call on Monday with Apple, the VA, and (b) (6) to review the ... status of the EHMP work ... [and] to confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities." However, it is not possible to design an EHMP system or integrate the system with an Apple device until you know how the medical experts are going to change the medical delivery system and how they advise a device should be utilized in the medical delivery system. The academic medical experts on our team are assisting the VA in designing a sophisticated system of community care through a public-private delivery system. They are formulating that system and its inner workings, the creation of which will dictate the Integration and interoperability of records. Neither (b) (6) nor Apple can define a scope or product use without consulting with our group on how veteran's records used in the private sector will get integrated into the portable record and back to the VA. You mention in your email telehealth. Our team of medical experts are working on a telehealth initiative and delivered a draft Executive Order to the President...while you are working with the DEA and DOJ, without the courtesy of advising us, which could have tremendous implications on the wording or, worse yet, the prudence of an Executive Order in the first place. This parallel path as well creates the potential for embarrassment for the President and wasted invaluable time that our veterans can ill afford. VA-19-0799-D-001247 OS 00002918 Lastly, you discuss your parallel meeting on a Military Wellness program which you apparently already brought in which you believe focuses on preventative medicine. The program that you are touting however is surrounded by rumors that are less than flattering. Moreover, our team's academic medical experts are already assisting in the active development of a wellness program for the VA and their views will prevail. Those experts have already assembled the working parts of a wellness program and the seamless integration with active service members and family. There is no need to have a parallel side effort that is not integrated into the agreed program. Again, the problem is not about communication. I had an employee a few years back that meant well but thought that there was an "I" in team. His work for the company created value and profits for the company at various times, however, in spite of those benefits, I advised him that his way was not working and he should find something else that better met his style. With all this considered, I think that (b) (6) is a smart woman that could provide the VA IT experience and benefits, my way ... not as a renegade player. I am willing to work with her as a team player on our team. The expert team that I assembled and is sanctioned by the President will be proceeding with its efforts as planned. All other parallel efforts should stand down. (b) (6) can participate as part of that team, not outside of that team or its efforts or its direction. As agreed on day one, the White House can participate by providing executive and administrative assistance, when requested by our expert team. We will arrange and conduct discussions with Apple (in which (b) (6) should participate if done within the confines of the expert team). We will work with design and implementation of a wellness program and we will decide on the proper way to integrate an EMR system, with (b) (6) team participation if agreed. Any items that relate to the transformation of the VA must be funneled through and managed by the expert team and should be coordinated with Dr. Moskowitz and Marc Sherman. Let me know if you have any questions. Ike From: (b) (6) EOP/WHO [mailto:(b) (6) Sent: Friday, March 31, 2017 6:03 PM To: IP; Kushner, Jared C. EOP/WHO Cc: (b) (6) EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO As we discussed it seems like (b) (6) has been working but not communicating. Her efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services. There is a call on Monday with Apple, the VA, and (b) (6) to review the following: 1. Status of the EHMP work VA-19-0799-D-001248 OS 00002919 2. to find a legal mechanism to allow for 3 month tour of duty from Apple engineers with the employees staying on Apple payroll. This is being investigated by USDS lawyers and the VA. 3. To work through an NDA / conflict waiver which is a necessary legal document. 4. To confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities.) I believe we should then schedule a call for mid next week with Ike, myself appropriate members of Ike's team, the VA, Apple and (b) (6) to ensure we are on same page (I can coordinate the call). I think we should allow (b) (6) an opportunity to reset and to act as a true overall project manager where we allow her to coordinate. She should communicate with Ike and his designee consistently and she should professionally coordinate the team, get everyone working together, and show us progress. I believe she will do a great job, and we will know quickly if she does not. As everyone knows huge other hot items at VA in the works right now including Accountability (legislation and EO), Choice Reform Act extension and reform; telehealth (working through the issue with DOJ and DEA; hard to just slam it through if they oppose but based on meeting today with VA/DOJ/DEA I believe we can get them there in next two weeks. Ike, I can explain in detail when we next talk but having been through this with the Opioid EO this week we should see if we can get DEA/ DOJ on board). Different subject, Ike would also like your advice on NIH and the idea (I think your idea?) to create a profit sharing program with our grants. Love this idea. Yours truly, (b) (6) P.S. I need to update you on very exciting meeting on a Military Wellness program which we brought in; focuses on preventative medicine and is working for over 20,000 vets currently. Readily scalable. (b) (6) Assistant to the President For lntragovernmental and Technology Initiatives VA-19-0799-D-001249 DS 00002920 202.456.(b) (6) (Direct) (b) (6) who.eop.gov From: IP fmailto:(b) (6) frenchangel59.com1 Sent: Friday, March 31, 2017 12:05 AM To: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov> Cc: (b) (6) EOP/WHO <(b) (6) EOP/WHO <(b) (6) who.eop.gov> Subject: FW: VA And Apple who.eop.gov>; (b) (6) Jared, As you know lvanka introduced me to (b) (6) at Apple and (b) (6) at Johnson & Johnson. Ours Academic team and experts have worked so well with them and their teams. What has done here is really outrageous. She may be very good in social media, but this an entirely different and very complicated area. We will fix this. All my Best, Ike From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Thursday, March 30, 2017 11:56 PM To: (b) (6) omb.eop.gov Cc: (b) (6) who.eop.gov; lperl(b) (6) @qmail.com ; brucem(b) (6) @mac.com ; mbs(b) (6) @qmail.com Subject: FW: VA And Apple (b) (6) With all due respect, I am shocked and extremely disappointed with the manner in which you have engaged in individual communications with Apple - and intentionally excluded our broader team of subject matter experts. I understand that these backdoor discussions have apparently been occurring almost daily for weeks, and you have not told anyone and refuse to return phone calls and emails. When we first met on February 7th, I personally shared with you our vision and goals and explained that it is critical that everything we do must be done as a team. The very purpose of our Academic team, Dr. Moskowitz, and Marc Sherman is to ensure proper analysis, sharing of best practices, and provide a forum for discussion, debate, and ultimately the strongest collective decisions/recommendations. You agreed then, but your actions to date regarding Apple prove otherwise. When I spoke with (b) (6) on February 1st we discussed and agreed on the importance of leveraging our Academic team and experts for the end goal of creating the best system for our veterans. Further on our Apple conference call on March 3rd which we invited you and (b) (6) to join - we again discussed and all agreed that for us to be successful and fix all the issues that our great veterans are going through on a daily basis, we must all unite and work as one team, with only one agenda and one goal. VA-19-0799-D-001250 OS 00002921 What we are seeing from you today is a blatant disregard for that commitment and clear disrespect to everyone involved. You are putting yourself, your own agenda, and your own ego ahead of our veterans. This is unacceptable. There are 22 veterans dying every day. Your decision to alone discuss IT and technology solutions with Apple for weeks without the broader team of experts and not informing me and Dr. Moskowitz is major step backwards and will only cause additional work and significant delays. As a result of your hijacking of this effort, Apple has already canceled conference calls. In fact, many of the current problems with the VA is because of this very reason - the lack of team work within. Let me be clear, I will not allow this to happen while I am involved. I want this resolved immediately. First, you must include Dr. Moskowitz and Marc Sherman on any and all calls or meetings. Additionally, I will formally ask you again to please respect me and our broader group of subject matter experts, and immediately cease individual discussions with Apple and/or any other parties related to the work we have undertaken regarding the VA. Ike -----Original Message----(b) (6) From: (b) (6) EOP/OMB fmailto:(b) (6) Sent: Thursday, March 30, 2017 6:48 PM To: Bruce Moskowitz Cc: (b) (6) EOP/WHO; IP; (b) (6) frenchangel59.com Subject: Re: VA And Apple omb.eop.gov] Hey team! We're making great progress, which I'm excited to fill you in on. Will send you more info when I get out of these back-to-back mtgs and will give you a ring back Ike! Thanks! > On Mar 30, 2017, at 6:49 AM, Bruce Moskowitz <(b) (6) wrote: mac.com > > > In the last email exchange i was supposed to receive information on your interaction with Apple so that we could rapidly obtain needed technology from our Academic Center Consortium upcoming discussion with Apple. I realize there are multiple technology issues on everyone's desk however we have medical emergencies daily at the VA that can only be solved by rapid deployment of new technology. I am available 24-7 by phone 561-3466(b) (6) Thank you > > Sent from my iPad > Bruce Moskowitz M.D. -----Original Message----From: Bruce Moskowitz fmailto:(b) (6) Sent: Tuesday, March 28, 2017 11:41 AM To: (b) (6) who.eop.gov; (b) (6) Cc: IP mac.com ] omb.eop.gov VA-19-0799-D-001251 OS 00002922 Subject: VA And Apple It would be of benefit to discuss what we can accomplish in technology with Apple for the benefit of the VA. It would be of importance to understand what discussions the Whitehouse team has already had with Apple so that we have a clear path forward and do not duplicate what has already been accomplished. let me know a convenient time to talk. Thank you Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001252 OS 00002923 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/2/2017 7:17:35 PM To: IP [(b) (6) frenchangel59.com] Re: VA And Apple Subject: Great Sent from my iPhone On Apr 2, 2017, at 2:57 PM, IP <(b) (6) frenchangel59.com > wrote: EOP/WHO [ mailto:(b) (6) From: (b) (6) Sent: Sunday, April 02, 2017 2:33 PM (b) To: IP; (6) EOP/WHO Cc: Kushner, Jared C. EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO Ike and I had a great conversation and are on the same-page. From: (b) (6) EOP/WHO Sent: Sunday, April 2, 2017 1:13 PM To: 'IP' <(b) (6) frenchangel59.com >; (b) (6) (b) (6) Cc: Kushner, Jared C. EOP/WHO < <(b) (6) who.eop.gov> Subject: RE: VA And Apple EOP/WHO <(b) (6) who.eop.gov>; (b) (6) who.eop.gov> EOP/WHO Call me anytime From: IP fmailto:(b) (6) frenchangel59.com1 Sent: Sunday, April 2, 2017 1:08 PM To: (b) (6) EOP/WHO <(b) (6) who.eop.gov>; (b) (6) < who.eop.gov> Cc: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov>; (b) (6) <(b) (6) who.eop.gov> Subject: RE: VA And Apple EOP/WHO (b) (6) EOP/WHO (b) (6) Thanks for your email and especially the thoughts on FACA. The good news is that we have been advised that FACA does not apply because we are not a formal group in any way. I have identified, as I mentioned, the brightest medical minds in medical system operations. Each of those people (in their individual capacity) is willing to give of their personal time for the betterment of the VA when requested by the VA. And each of these people has been willing to provide advice to the Secretary when he reaches out to any one of them. I have an understanding of their individual views and could fill you in when we speak since it isn't practical to continue debating any of this on email. VA-19-0799-D-001253 OS 00002924 Ike From: (b) (6) EOP/WHO [ mailto:(b) (6) Sent: Sunday, April 02, 2017 11:17 AM To: IP; (b) (6) EOP/WHO Cc: Kushner, Jared C. EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO Ike, you expressed concern in our call the other day that "we were just posing for pictures" in this WH but in the below you seem concerned that we are engaged. You are concerned that we are not communicating but please consider that I do not receive updates from your team. Please keep in mind that I have nothing but the utmost respect for what you are doing and that I know this is a life-and-death topic. But to do what you outlined below you will need to form a FACA group. One is being formed on Infrastructure. Please have your attorney reach out to WH Counsel (b) (6) (copied) to start that process. I have interjected a few thoughts into your email below: From: IP [mailto:(b) (6) frenchangel59.com ] Sent: Sunday, April 2, 2017 10:16 AM To: (b) (6) EOP/WHO <(b) (6) who.eop.gov> Cc: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov>; (b) (6) <(b) (6) who.eop.gov> Subject: RE: VA And Apple EOP/WHO (b) (6) My email to (b) (6) on Thursday expressed my frustration and displeasure in learning about activity and decisions concerning issues at the VA in a separate and invisible parallel effort. Regrettably, your response to my email that "(b) (6) has been working but not communicating" not only fails to recognize or explain the issue, but merely highlights the very fundamental problem that is so troubling. While a lack of communication has certainly exacerbated the problem, the mere fact that there has been any activity or decision without first coordinating that activity with our team before taking any action is the problem. Simply offering to communicate better solves very little. I AGREE, THAT WAS MY POINT, LACK OF COMMUNICATION. I WAS FOCUSED ON CHANGE MOVING FORWARD NOT GOING BACKWARD. In your and (b) (6) first meeting in the West Wing with Marc Sherman it was clear and agreed (b) (6) that would be the liaison between our expert team and the White House and provide her IT counsel to our team related to our initiatives (not as an invisible, parallel effort). In addition, the White House was to be available to assist our team with executive and legislative clout when requested (not conduct an invisible, parallel effort), a three-pronged approach, if you recall. This is the program I reported to the President and the go-ahead we received. VA-19-0799-D-001254 OS 00002925 The essential problem at the VA is that 22 veterans die every day and the system of care and access to care is in need of repair. This is a medical issue and medical delivery problem. In order to fix the VA, these medical problems must first be defined and fixed. All other issues, like IT, are a function of the determined fix to the medical issues and medical delivery problems. To transform the VA into the best of class, I assembled a team that includes the best and brightest minds in the academic medical community. The restructuring efforts on which we embark are informed by the advice and participation of those great medical minds. Parallel (and invisible to us) IT efforts are not connected to what the medical minds decide are the problem or the fix and are frustrating the IT solution that deals with the medical issues. It is also spending the valuable time of volunteers and delaying the best care that our veterans deserve. Your email to me underscores this problem. You say that: "[ efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services," and "There is a call on Monday with Apple, the VA, and (b) (6) to review the ... status of the EHMP work ... [and] to confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities." However, it is not possible to design an EHMP system or integrate the system with an Apple device until you know how the medical experts are going to change the medical delivery system and how they advise a device should be utilized in the medical delivery system. The academic medical experts on our team are assisting the VA in designing a sophisticated system of community care through a public-private delivery system. They are formulating that system and its inner workings, the creation of which will dictate the Integration and interoperability of records. Neither (b) (6) nor Apple can define a scope or product use without consulting with our group on how veteran's records used in the private sector will get integrated into the portable record and back to the VA. RIGHT NOW THERE IS NO MEDICAL DELIVERY SYSTEM THAT CAN ACCESS THE MEDICAL RECORDS. THE EHMP MUST BE COMPLETED TO ALLOW ANY SUCH PRODUCT TO EXTRAPOLATE THE DATA. You mention in your email telehealth. Our team of medical experts are working on a telehealth initiative and delivered a draft Executive Order to the President ... while you are working with the DEA and DOJ, without the courtesy of advising us, which could have tremendous implications on the wording or, worse yet, the prudence of an Executive Order in the first place. This parallel path as well creates the potential for embarrassment for the President and wasted invaluable time that our veterans can ill afford. THIS EO (WHICH IS LIKELY TO BE PART OF A LARGER VA EO) WILL 100% GO THROUGH DOJ AND DEA. IT MAY OR MAY NOT BE POSSIBLE FOR THE PRESIDENT TO SLAM THROUGH AN EO AGAINST THEIR WISHES HOWEVER IT IS FAR BETTER FOR THE PRESIDENT TO REACH CONCENSUS. KEEP IN MIND THERE ARE OVER 50,000 PEOPLE PER YEAR DYING FROM DRUG OVERDOSES MUCH OF WHICH IS LINKIED TO THE OVER-SUBSCRIBING OF OPIOIDS. DEA AND DOJ (I BELIEVE INCORRECTLY) VIEW TELEHEALTH AS A LESSENING OF CONTROL. VA-19-0799-D-001255 OS 00002926 Lastly, you discuss your parallel meeting on a Military Wellness program which you apparently already brought in which you believe focuses on preventative medicine. The program that you are touting however is surrounded by rumors that are less than flattering. Moreover, our team's academic medical experts are already assisting in the active development of a wellness program for the VA and their views will prevail. Those experts have already assembled the working parts of a wellness program and the seamless integration with active service members and family. There is no need to have a parallel side effort that is not integrated into the agreed program. Again, the problem is not about communication. THE MILITARY WELLNESS INITIATIVE HAS BEEN LAUDED IN EVERY REVIEW, AND BT THE VA, AND VSO'S. IT IS IN PLACE, THE VA CAN DECIDE TO AMPLIFY ITS EFFORTS OR NOT. IT WOULD IN NO WAY PREVENT THE VA FROM HAVING A MAJOR WELLNESS INITIATIVE OF ITS OWN; IT IS SUPPLEMENTAL. I DO NOT HAVE AN OPINION AS TO WHETHER IT SHOULD BE AMPLIFIED, IT IS SOMETHING FOR THE VA TO DETERMINE. I had an employee a few years back that meant well but thought that there was an "I" in team. His work for the company created value and profits for the company at various times, however, in spite of those benefits, I advised him that his way was not working and he should find something else that better met his style. I HAD A FEW OF THEM WITH MY 15,000 EMPLOYEES AS WELL! With all this considered, I think that (b) (6) is a smart woman that could provide the VA IT experience and benefits, my way ... not as a renegade player. I am willing to work with her as a team player on our team. The expert team that I assembled and is sanctioned by the President will be proceeding with its efforts as planned. All other parallel efforts should stand down. (b) (6) can participate as part of that team, not outside of that team or its efforts or its direction. As agreed on day one, the White House can participate by providing executive and administrative assistance, when requested by our expert team. We will arrange and conduct discussions with Apple (in which (b) (6) should participate if done within the confines of the expert team). We will work with design and implementation of a wellness program and we will decide on the proper way to integrate an EMR system, with (b) (6) team participation if agreed. Any items that relate to the transformation of the VA must be funneled through and managed by the expert team and should be coordinated with Dr. Moskowitz and Marc Sherman. SHE CANNOT REPORT TO NON-GOVERNMENT PEOPLE. Let me know if you have any questions. AS I EMAILED SOME OF THE BIGGEST ISSUES FOR THE VA RIGHT NOW ARE LEGISLATIVE. THE ACCOUNTABILITY ACT, THE EXTENSION OF THE CHOICE ACT, THE CHOICE REFORM ACT (AND THE CORRESPONDING BUDGET ISSUES RAISED BY ALLOWING CHOICE) Ike EOP/WHO [ mailto:(b) (6) From: (b) (6) Sent: Friday, March 31, 2017 6:03 PM To: IP; Kushner, Jared C. EOP/WHO Cc: (b) (6) EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO VA-19-0799-D-001256 OS 00002927 As we discussed it seems like (b) (6) has been working but not communicating. Her efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services. There is a call on Monday with Apple, the VA, and (b) (6) to review the following: 1. Status of the EHMP work 2. to find a legal mechanism to allow for 3 month tour of duty from Apple engineers with the employees staying on Apple payroll. This is being investigated by USDS lawyers and the VA. 3. To work through an NDA / conflict waiver which is a necessary legal document. 4. To confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities.) I believe we should then schedule a call for mid next week with Ike, appropriate myself to ensure we are on members of Ike's team, the VA, Apple and (b) (6) an same page (I can coordinate the call). I think we should allow (b) (6) opportunity to reset and to act as a true overall project manager where we allow her to coordinate. She should communicate with Ike and his designee consistently and she should professionally coordinate the team, get everyone working together, and show us progress. I believe she will do a great job, and we will know quickly if she does not. As everyone knows huge other hot items at VA in the works right now including Accountability (legislation and EO), Choice Reform Act extension and reform; telehealth (working through the issue with DOJ and DEA; hard to just slam it through if they oppose but based on meeting today with VA/DOJ/DEA I believe we can get them there in next two weeks. Ike, I can explain in detail when we next talk but having been through this with the Opioid EO this week we should see if we can get DEA/ DOJ on board). Different subject, Ike would also like your advice on NIH and the idea (I think your idea?) to create a profit sharing program with our grants. Love this idea. Yours truly, (b) (6) P.S. I need to update you on very exciting meeting on a Military Wellness program which we brought in; focuses on preventative medicine and is working for over 20,000 vets currently. Readily scalable. (b) (6) VA-19-0799-D-001257 DS 00002928 Assistant to the President For lntragovernmental and Technology Initiatives 202.456.(b) (6) (Direct) (b) (6) who.eop.gov From: IP fmailto:(b) (6) frenchangel59.com1 Sent: Friday, March 31, 2017 12:05 AM To: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov> Cc: (b) (6) EOP/WHO <(b) (6) who.eop.gov>; (b) (6) (b) (6) < who.eop.gov> Subject: FW: VA And Apple EOP/WHO Jared, As you know lvanka introduced me to (b) (6) at Apple and (b) (6) at Johnson & Johnson. Ours has done here Academic team and experts have worked so well with them and their teams. What is really outrageous. She may be very good in social media, but this an entirely different and very complicated area. We will fix this. All my Best, Ike From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Thursday, March 30, 2017 11:56 PM To: (b) (6) omb.eop.gov Cc: (b) (6) who.eop.gov; lperl(b) (6) @qmail.com ; brucem(b) (6) mbs(b) (6) @qmail.com Subject: FW: VA And Apple @mac.com ; (b) (6) With all due respect, I am shocked and extremely disappointed with the manner in which you have engaged in individual communications with Apple - and intentionally excluded our broader team of subject matter experts. I understand that these backdoor discussions have apparently been occurring almost daily for weeks, and you have not told anyone and refuse to return phone calls and emails. When we first met on February 7th, I personally shared with you our vision and goals and explained that it is critical that everything we do must be done as a team. The very purpose of our Academic team, Dr. Moskowitz, and Marc Sherman is to ensure proper analysis, sharing of best practices, and provide a forum for discussion, debate, and ultimately the strongest collective decisions/recommendations. You agreed then, but your actions to date regarding Apple prove otherwise. on February 1st we discussed and agreed on the importance of leveraging When I spoke with (b) (6) our Academic team and experts for the end goal of creating the best system for our veterans. Further on our Apple conference call on March 3rd - which we invited you and (b) (6) to join - we again discussed and all agreed that for us to be successful and fix all the issues that our great veterans are going through on a daily basis, we must all unite and work as one team, with only one agenda and one goal. VA-19-0799-D-001258 OS 00002929 What we are seeing from you today is a blatant disregard for that commitment and clear disrespect to everyone involved. You are putting yourself, your own agenda, and your own ego ahead of our veterans. This is unacceptable. There are 22 veterans dying every day. Your decision to alone discuss IT and technology solutions with Apple for weeks without the broader team of experts and not informing me and Dr. Moskowitz is major step backwards and will only cause additional work and significant delays. As a result of your hijacking of this effort, Apple has already canceled conference calls. In fact, many of the current problems with the VA is because of this very reason - the lack of team work within. Let me be clear, I will not allow this to happen while I am involved. I want this resolved immediately. First, you must include Dr. Moskowitz and Marc Sherman on any and all calls or meetings. Additionally, I will formally ask you again to please respect me and our broader group of subject matter experts, and immediately cease individual discussions with Apple and/or any other parties related to the work we have undertaken regarding the VA. Ike -----Original Message----(b) (6) From: (b) (6) EOP/OMB fmailto:(b) (6) Sent: Thursday, March 30, 2017 6:48 PM To: Bruce Moskowitz Cc: (b) (6) EOP/WHO; IP; (b) (6) frenchangel59.com Subject: Re: VA And Apple omb.eop.gov] Hey team! We're making great progress, which I'm excited to fill you in on. Will send you more info when I get out of these back-to-back mtgs and will give you a ring back Ike! Thanks! > On Mar 30, 2017, at 6:49 AM, Bruce Moskowitz <(b) (6) mac.com > wrote: > > In the last email exchange i was supposed to receive information on your interaction with Apple so that we could rapidly obtain needed technology from our Academic Center Consortium upcoming discussion with Apple. I realize there are multiple technology issues on everyone's desk however we have medical emergencies daily at the VA that can only be solved by rapid deployment of new technology. I am available 24-7 by phone 561-3466(b) (6) Thank you > > Sent from my iPad > Bruce Moskowitz M.D. -----Original Message----From: Bruce Moskowitz fmailto:(b) (6) Sent: Tuesday, March 28, 2017 11:41 AM To: (b) (6) who.eop.gov; (b) (6) Cc: IP Subject: VA And Apple mac.com ] omb.eop.gov It would be of benefit to discuss what we can accomplish in technology with Apple for the benefit of the VA. It would be of importance to understand what discussions the Whitehouse team has already had VA-19-0799-D-001259 OS 00002930 with Apple so that we have a clear path forward and do not duplicate what has already been accomplished. let me know a convenient time to talk. Thank you Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001260 OS 00002931 Message From: Sent: To: Subject: Attachments: David Shulkin [drshulkin@aol.com] 4/2/2017 7:02:20 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: VA And Apple Untitled Attachment; Untitled attachment 05945.htm It's easy to get on the wrong side of this group Sent from my iPad Begin forwarded message: From: "IP" <(b) (6) frenchangel59.com > Date: April 2, 2017 at 10:51:54 AM EDT To: "David shulkin" Subject: FW: VA And Apple From: IP [mailto:(b) (6) frenchanqel59.com] Sent: Sunday, April 02, 2017 10:16 AM To: '(b) (6) EOP/WHO' Cc: 'Kushner, Jared C. EOP/WHO'; '(b) (6) Subject: RE: VA And Apple EOP/WHO' (b) (6) My email to (b) (6) on Thursday expressed my frustration and displeasure in learning about activity and decisions concerning issues at the VA in a separate and invisible parallel effort. Regrettably, your response to my email that "(b) (6) has been working but not communicating" not only fails to recognize or explain the issue, but merely highlights the very fundamental problem that is so troubling. While a lack of communication has certainly exacerbated the problem, the mere fact that there has been any activity or decision without first coordinating that activity with our team before taking any action is the problem. Simply offering to communicate better solves very little. In your and (b) (6) first meeting in the West Wing with Marc Sherman it was clear and agreed (b) (6) that would be the liaison between our expert team and the White House and provide her IT counsel to our team related to our initiatives (not as an invisible, parallel effort). In addition, the White House was to be available to assist our team with executive and legislative clout when requested (not conduct an invisible, parallel effort), a three-pronged approach, if you recall. This is the program I reported to the President and the go-ahead we received. The essential problem at the VA is that 22 veterans die every day and the system of care and access to care is in need of repair. This is a medical issue and medical delivery problem. In order to fix the VA, these medical problems must first be defined and fixed. All other issues, like IT, are a function of the determined fix to the medical issues and medical delivery problems. To transform the VA into the best of class, I assembled a team that includes the best and brightest minds in the academic medical community. The restructuring efforts on which VA-19-0799-D-001261 OS 00002932 we embark are informed by the advice and participation of those great medical minds. Parallel (and invisible to us) IT efforts are not connected to what the medical minds decide are the problem or the fix and are frustrating the IT solution that deals with the medical issues. It is also spending the valuable time of volunteers and delaying the best care that our veterans deserve. Your email to me underscores this problem. You say that: "[ efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services," and "There is a call on Monday with Apple, the VA, and (b) (6) to review the ... status of the EHMP work ... [and] to confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities." However, it is not possible to design an EHMP system or integrate the system with an Apple device until you know how the medical experts are going to change the medical delivery system and how they advise a device should be utilized in the medical delivery system. The academic medical experts on our team are assisting the VA in designing a sophisticated system of community care through a public-private delivery system. They are formulating that system and its inner workings, the creation of which will dictate the Integration and interoperability of records. Neither (b) (6) nor Apple can define a scope or product use without consulting with our group on how veteran's records used in the private sector will get integrated into the portable record and back to the VA. You mention in your email telehealth. Our team of medical experts are working on a telehealth initiative and delivered a draft Executive Order to the President ... while you are working with the DEA and DOJ, without the courtesy of advising us, which could have tremendous implications on the wording or, worse yet, the prudence of an Executive Order in the first place. This parallel path as well creates the potential for embarrassment for the President and wasted invaluable time that our veterans can ill afford. Lastly, you discuss your parallel meeting on a Military Wellness program which you apparently already brought in which you believe focuses on preventative medicine. The program that you are touting however is surrounded by rumors that are less than flattering. Moreover, our team's academic medical experts are already assisting in the active development of a wellness program for the VA and their views will prevail. Those experts have already assembled the working parts of a wellness program and the seamless integration with active service members and family. There is no need to have a parallel side effort that is not integrated into the agreed program. Again, the problem is not about communication. I had an employee a few years back that meant well but thought that there was an "I" in team. His work for the company created value and profits for the company at various times, however, in spite of those benefits, I advised him that his way was not working and he should find something else that better met his style. VA-19-0799-D-001262 OS 00002933 With all this considered, I think that (b) (6) is a smart woman that could provide the VA IT experience and benefits, my way ... not as a renegade player. I am willing to work with her as a team player on our team. The expert team that I assembled and is sanctioned by the President will be proceeding with its efforts as planned. All other parallel efforts should stand down. (b) (6) can participate as part of that team, not outside of that team or its efforts or its direction. As agreed on day one, the White House can participate by providing executive and administrative assistance, when requested by our expert team. We will arrange and conduct discussions with Apple (in which (b) (6) should participate if done within the confines of the expert team). We will work with design and implementation of a wellness program and we will team participation if decide on the proper way to integrate an EMR system, with (b) (6) agreed. Any items that relate to the transformation of the VA must be funneled through and managed by the expert team and should be coordinated with Dr. Moskowitz and Marc Sherman. Let me know if you have any questions. Ike EOP/WHO [ mailto:(b) (6) From: (b) (6) Sent: Friday, March 31, 2017 6:03 PM To: IP; Kushner, Jared C. EOP/WHO Cc: (b) (6) EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO As we discussed it seems like (b) (6) has been working but not communicating. Her efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services. There is a call on Monday with Apple, the VA, and (b) (6) to review the following: 1. Status of the EHMP work 2. to find a legal mechanism to allow for 3 month tour of duty from Apple engineers with the employees staying on Apple payroll. This is being investigated by USDS lawyers and the VA. 3. To work through an NDA / conflict waiver which is a necessary legal document. 4. To confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities.) I believe we should then schedule a call for mid next week with Ike, appropriate myself to ensure we are on members of Ike's team, the VA, Apple and (b) (6) same page (I can coordinate the call). I think we should allow (b) (6) an opportunity to reset and to act as a true overall project manager where we allow her to coordinate. She should communicate with Ike and his designee VA-19-0799-D-001263 DS 00002934 consistently and she should professionally coordinate the team, get everyone working together, and show us progress. I believe she will do a great job, and we will know quickly if she does not. As everyone knows huge other hot items at VA in the works right now including Accountability (legislation and EO), Choice Reform Act extension and reform; telehealth (working through the issue with DOJ and DEA; hard to just slam it through if they oppose but based on meeting today with VA/DOJ/DEA I believe we can get them there in next two weeks. Ike, I can explain in detail when we next talk but having been through this with the Opioid EO this week we should see if we can get DEA/ DOJ on board). Different subject, Ike would also like your advice on NIH and the idea (I think your idea?) to create a profit sharing program with our grants. Love this idea. Yours truly, (b) (6) P.S. I need to update you on very exciting meeting on a Military Wellness program which we brought in; focuses on preventative medicine and is working for over 20,000 vets currently. Readily scalable. (b) (6) Assistant to the President For lntragovernmental and Technology Initiatives 202.456.(b) (6) (Direct) (b) (6) who.eop.gov From: IP fmailto:(b) (6) frenchangel59.com1 Sent: Friday, March 31, 2017 12:05 AM To: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov> Cc: (b) (6) EOP/WHO <(b) (6) (b) (6) < who.eop.gov> Subject: FW: VA And Apple who.eop.gov>; (b) (6) EOP/WHO Jared, As you know lvanka introduced me to (b) (6) at Apple and (b) (6) at Johnson & Johnson. Ours has done here Academic team and experts have worked so well with them and their teams. What is really outrageous. She may be very good in social media, but this an entirely different and very complicated area. We will fix this. All my Best, Ike VA-19-0799-D-001264 DS 00002935 From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Thursday, March 30, 2017 11:56 PM To: (b) (6) omb.eop.gov Cc: (b) (6) who.eop.gov; lperl(b) (6) @qmail.com ; brucem(b) (6) mbs(b) (6) @qmail.com Subject: FW: VA And Apple @mac.com ; (b) (6) With all due respect, I am shocked and extremely disappointed with the manner in which you have engaged in individual communications with Apple - and intentionally excluded our broader team of subject matter experts. I understand that these backdoor discussions have apparently been occurring almost daily for weeks, and you have not told anyone and refuse to return phone calls and emails. When we first met on February 7th, I personally shared with you our vision and goals and explained that it is critical that everything we do must be done as a team. The very purpose of our Academic team, Dr. Moskowitz, and Marc Sherman is to ensure proper analysis, sharing of best practices, and provide a forum for discussion, debate, and ultimately the strongest collective decisions/recommendations. You agreed then, but your actions to date regarding Apple prove otherwise. When I spoke with (b) (6) on February 1st we discussed and agreed on the importance of leveraging our Academic team and experts for the end goal of creating the best system for our veterans. Further on our Apple conference call on March 3rd - which we invited you and (b) (6) to join - we again discussed and all agreed that for us to be successful and fix all the issues that our great veterans are going through on a daily basis, we must all unite and work as one team, with only one agenda and one goal. What we are seeing from you today is a blatant disregard for that commitment and clear disrespect to everyone involved. You are putting yourself, your own agenda, and your own ego ahead of our veterans. This is unacceptable. There are 22 veterans dying every day. Your decision to alone discuss IT and technology solutions with Apple for weeks without the broader team of experts and not informing me and Dr. Moskowitz is major step backwards and will only cause additional work and significant delays. As a result of your hijacking of this effort, Apple has already canceled conference calls. In fact, many of the current problems with the VA is because of this very reason - the lack of team work within. Let me be clear, I will not allow this to happen while I am involved. I want this resolved immediately. First, you must include Dr. Moskowitz and Marc Sherman on any and all calls or meetings. Additionally, I will formally ask you again to please respect me and our broader group of subject matter experts, and immediately cease individual discussions with Apple and/or any other parties related to the work we have undertaken regarding the VA. Ike -----Original Message----(b) (6) From: (b) (6) EOP/OMB [mailto:(b) (6) Sent: Thursday, March 30, 2017 6:48 PM To: Bruce Moskowitz Cc: (b) (6) EOP/WHO; IP; (b) (6) frenchangel59.com Subject: Re: VA And Apple omb.eop.gov] VA-19-0799-D-001265 OS 00002936 Hey team! We're making great progress, which I'm excited to fill you in on. Will send you more info when I get out of these back-to-back mtgs and will give you a ring back Ike! Thanks! > On Mar 30, 2017, at 6:49 AM, Bruce Moskowitz <(b) (6) mac.com > wrote: > > In the last email exchange i was supposed to receive information on your interaction with Apple so that we could rapidly obtain needed technology from our Academic Center Consortium upcoming discussion with Apple. I realize there are multiple technology issues on everyone's desk however we have medical emergencies daily at the VA that can only be solved by rapid deployment of new technology. I am available 24-7 by phone 561-3466(b) (6) Thank you > > Sent from my iPad > Bruce Moskowitz M.D. -----Original Message----From: Bruce Moskowitz [mailto:(b) (6) Sent: Tuesday, March 28, 2017 11:41 AM To: (b) (6) who.eop.gov; (b) (6) Cc: IP Subject: VA And Apple mac.com ] omb.eop.gov It would be of benefit to discuss what we can accomplish in technology with Apple for the benefit of the VA. It would be of importance to understand what discussions the Whitehouse team has already had with Apple so that we have a clear path forward and do not duplicate what has already been accomplished. Let me know a convenient time to talk. Thank you Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001266 OS 00002937 Message From: (b) (6) EOP/WHO [(b) (6) Sent: 4/1/2017 12:40:55 PM To: Kushner, Jared C. EOP/WHO [(b) (6) who.eop.gov]; (b) (6) frenchangel59.com who.eop.gov] To follow up on my email of yesterday (and this may not need clarifying) but I am suggesting we give (b) (6) a chance to project manage the IT component only. And that we quickly ascertain if she is up to it. obvi the VA needs a great CIO. (b) (6) USDS has sourced and interviewed 4 candidates and reviewed w David., he has asked 3 to come in to meet with him. (Ike, Jared said you might have a great person from Cleveland clinic that would get on team for a period of time? That would be incredible). Two other hot items: met w shulkin and 0MB. shulkin believes he will need additional $7.5B in 2018 budget to offer the choice option (part of choice reform legislation being considered). He had some ideas how to achieve (charging Medicare) but all have issues, 0MB is going to consider and get back to us. I arranged and David is preparing for meeting w Sec Mattis and DOD senior staff on the myriad of coordination issues. Need to force it but there is ability to make huge progress there. Sent from my iPad VA-19-0799-D-001267 OS 00002938 Message From: IP [(b) (6) frenchangel59.com] Sent: 4/2/2017 5:10:25 PM To: David shulkin [drshulkin@aol.com] FW: VA And Apple Subject: From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Sunday, April 02, 2017 1:08 PM To: '(b) (6) EOP/WHO'; ' Cc: 'Kushner, Jared C. EOP/WHO'; '(b) (6) Subject: RE: VA And Apple (b) (6) EOP/WHO' EOP/WHO' (b) (6) Thanks for your email and especially the thoughts on FACA. The good news is that we have been advised that FACA does not apply because we are not a formal group in any way. I have identified, as I mentioned, the brightest medical minds in medical system operations. Each of those people (in their individual capacity) is willing to give of their personal time for the betterment of the VA when requested by the VA. And each of these people has been willing to provide advice to the Secretary when he reaches out to any one of them. I have an understanding of their individual views and could fill you in when we speak since it isn't practical to continue debating any of this on email. Ike EOP/WHO [ mailto:(b) (6) From: (b) (6) Sent: Sunday, April 02, 2017 11:17 AM (b) To: IP; (6) EOP/WHO Cc: Kushner, Jared C. EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO Ike, you expressed concern in our call the other day that "we were just posing for pictures" in this WH but in the below you seem concerned that we are engaged. You are concerned that we are not communicating but please consider that I do not receive updates from your team. Please keep in mind that I have nothing but the utmost respect for what you are doing and that I know this is a life-and-death topic. But to do what you outlined below you will need to form a FACA group. One is being formed on Infrastructure. Please have your attorney reach out to WH Counsel (b) (6) (copied) to start that process. I have interjected a few thoughts into your email below: From: IP [mailto:(b) (6) frenchangel59.com ] Sent: Sunday, April 2, 2017 10:16 AM To: (b) (6) EOP/WHO <(b) (6) who.eop.gov> Cc: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov>; (b) (6) Subject: RE: VA And Apple EOP/WHO <(b) (6) who.eop.gov> (b) (6) VA-19-0799-D-001269 OS 00002940 My email to (b) (6) on Thursday expressed my frustration and displeasure in learning about activity and decisions concerning issues at the VA in a separate and invisible parallel effort. Regrettably, your response to my email that "(b) (6) has been working but not communicating" not only fails to recognize or explain the issue, but merely highlights the very fundamental problem that is so troubling. While a lack of communication has certainly exacerbated the problem, the mere fact that there has been any activity or decision without first coordinating that activity with our team before taking any action is the problem. Simply offering to communicate better solves very little. I AGREE, THAT WAS MY POINT, LACK OF COMMUNICATION. I WAS FOCUSED ON CHANGE MOVING FORWARD NOT GOING BACKWARD. In your and (b) (6) first meeting in the West Wing with Marc Sherman it was clear and agreed that (b) (6) would be the liaison between our expert team and the White House and provide her IT counsel to our team related to our initiatives (not as an invisible, parallel effort). In addition, the White House was to be available to assist our team with executive and legislative clout when requested (not conduct an invisible, parallel effort), a three-pronged approach, if you recall. This is the program I reported to the President and the goahead we received. The essential problem at the VA is that 22 veterans die every day and the system of care and access to care is in need of repair. This is a medical issue and medical delivery problem. In order to fix the VA, these medical problems must first be defined and fixed. All other issues, like IT, are a function of the determined fix to the medical issues and medical delivery problems. To transform the VA into the best of class, I assembled a team that includes the best and brightest minds in the academic medical community. The restructuring efforts on which we embark are informed by the advice and participation of those great medical minds. Parallel (and invisible to us) IT efforts are not connected to what the medical minds decide are the problem or the fix and are frustrating the IT solution that deals with the medical issues. It is also spending the valuable time of volunteers and delaying the best care that our veterans deserve. Your email to me underscores this problem. You say that: "[ efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services," and "There is a call on Monday with Apple, the VA, and (b) (6) to review the ... status of the EHMP work ... [and] to confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities." However, it is not possible to design an EHMP system or integrate the system with an Apple device until you know how the medical experts are going to change the medical delivery system and how they advise a device should be utilized in the medical delivery system. The academic medical experts on our team are assisting the VA in designing a sophisticated system of community care through a public-private delivery system. They are formulating that system and its inner workings, the creation of which will dictate the Integration and interoperability of records. Neither (b) (6) nor Apple can define a scope or product use without consulting with our group on how veteran's records used in the private sector will get integrated into the portable record and back to the VA. RIGHT NOW THERE IS NO MEDICAL DELIVERY SYSTEM THAT CAN ACCESS THE MEDICAL RECORDS. THE EHMP MUST BE COMPLETED TO ALLOW ANY SUCH PRODUCT TO EXTRAPOLATE THE DATA. You mention in your email telehealth. Our team of medical experts are working on a telehealth initiative and delivered a draft Executive Order to the President ... while you are working with the DEA and DOJ, without the VA-19-0799-D-001270 OS 00002941 courtesy of advising us, which could have tremendous implications on the wording or, worse yet, the prudence of an Executive Order in the first place. This parallel path as well creates the potential for embarrassment for the President and wasted invaluable time that our veterans can ill afford. THIS EO (WHICH IS LIKELY TO BE PART OF A LARGER VA EO) WILL 100% GO THROUGH DOJ AND DEA. IT MAY OR MAY NOT BE POSSIBLE FOR THE PRESIDENT TO SLAM THROUGH AN EO AGAINST THEIR WISHES HOWEVER IT IS FAR BETTER FOR THE PRESIDENT TO REACH CONCENSUS. KEEP IN MIND THERE ARE OVER 50,000 PEOPLE PER YEAR DYING FROM DRUG OVERDOSES MUCH OF WHICH IS LINKIED TO THE OVER-SUBSCRIBING OF OPIOIDS. DEA AND DOJ (I BELIEVE INCORRECTLY) VIEW TELEHEALTH AS A LESSENING OF CONTROL. Lastly, you discuss your parallel meeting on a Military Wellness program which you apparently already brought in which you believe focuses on preventative medicine. The program that you are touting however is surrounded by rumors that are less than flattering. Moreover, our team's academic medical experts are already assisting in the active development of a wellness program for the VA and their views will prevail. Those experts have already assembled the working parts of a wellness program and the seamless integration with active service members and family. There is no need to have a parallel side effort that is not integrated into the agreed program. Again, the problem is not about communication. THE MILITARY WELLNESS INITIATIVE HAS BEEN LAUDED IN EVERY REVIEW, AND BT THE VA, AND VSO'S. IT IS IN PLACE, THE VA CAN DECIDE TO AMPLIFY ITS EFFORTS OR NOT. IT WOULD IN NO WAY PREVENT THE VA FROM HAVING A MAJOR WELLNESS INITIATIVE OF ITS OWN; IT IS SUPPLEMENTAL. I DO NOT HAVE AN OPINION AS TO WHETHER IT SHOULD BE AMPLIFIED, IT IS SOMETHING FOR THE VA TO DETERMINE. I had an employee a few years back that meant well but thought that there was an "I" in team. His work for the company created value and profits for the company at various times, however, in spite of those benefits, I advised him that his way was not working and he should find something else that better met his style. I HAD A FEW OF THEM WITH MY 15,000 EMPLOYEES AS WELL! With all this considered, I think that (b) (6) is a smart woman that could provide the VA IT experience and benefits, my way ... not as a renegade player. I am willing to work with her as a team player on our team. The expert team that I assembled and is sanctioned by the President will be proceeding with its efforts as planned. All other parallel efforts should stand down. (b) (6) can participate as part of that team, not outside of that team or its efforts or its direction. As agreed on day one, the White House can participate by providing executive and administrative assistance, when requested by our expert team. We will arrange and conduct discussions with Apple (in which (b) (6) should participate if done within the confines of the expert team). We will work with design and implementation of a wellness program and we will decide on the proper way to integrate an EMR system, with (b) (6) team participation if agreed. Any items that relate to the transformation of the VA must be funneled through and managed by the expert team and should be coordinated with Dr. Moskowitz and Marc Sherman. SHE CANNOT REPORT TO NON-GOVERNMENT PEOPLE. Let me know if you have any questions. AS I EMAILED SOME OF THE BIGGEST ISSUES FOR THE VA RIGHT NOW ARE LEGISLATIVE. THE ACCOUNTABILITY ACT, THE EXTENSION OF THE CHOICE ACT, THE CHOICE REFORM ACT (AND THE CORRESPONDING BUDGET ISSUES RAISED BY ALLOWING CHOICE) Ike From: (b) (6) EOP/WHO [ mailto:(b) (6) Sent: Friday, March 31, 2017 6:03 PM To: IP; Kushner, Jared C. EOP/WHO Cc: (b) (6) EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO VA-19-0799-D-001271 OS 00002942 As we discussed it seems like (b) (6) has been working but not communicating. Her efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services. There is a call on to review the following: Monday with Apple, the VA, and (b) (6) 1. Status of the EHMP work 2. to find a legal mechanism to allow for 3 month tour of duty from Apple engineers with the employees staying on Apple payroll. This is being investigated by USDS lawyers and the VA. 3. To work through an NDA / conflict waiver which is a necessary legal document. 4. To confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities.) I believe we should then schedule a call for mid next week with Ike, appropriate members of Ike's team, the VA, Apple and (b) (6) myself to ensure we are on same page (I can coordinate (b) (6) the call). I think we should allow an opportunity to reset and to act as a true overall project manager where we allow her to coordinate. She should communicate with Ike and his designee consistently and she should professionally coordinate the team, get everyone working together, and show us progress. I believe she will do a great job, and we will know quickly if she does not. As everyone knows huge other hot items at VA in the works right now including Accountability (legislation and EO), Choice Reform Act extension and reform; telehealth (working through the issue with DOJ and DEA; hard to just slam it through if they oppose but based on meeting today with VA/DOJ/DEA I believe we can get them there in next two weeks. Ike, I can explain in detail when we next talk but having been through this with the Opioid EO this week we should see if we can get DEA/ DOJ on board). Different subject, Ike would also like your advice on NIH and the idea (I think your idea?) to create a profit sharing program with our grants. Love this idea. Yours truly, (b) (6) P.S. I need to update you on very exciting meeting on a Military Wellness program which we brought in; focuses on preventative medicine and is working for over 20,000 vets currently. Readily scalable. (b) (6) Assistant to the President For lntragovernmental and Technology Initiatives 202.456.(b) (6) (Direct) (b) (6) who.eop.gov VA-19-0799-D-001272 DS 00002943 From: IP fmailto:(b) (6) frenchangel59.com1 Sent: Friday, March 31, 2017 12:05 AM To: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov> Cc: (b) (6) EOP/WHO <(b) (6) Subject: FW: VA And Apple who.eop.gov>; (b) (6) EOP/WHO <(b) (6) who.eop.gov> Jared, As you know lvanka introduced me to (b) (6) at Apple and (b) (6) at Johnson & Johnson. Ours Academic team has done here is really outrageous. She may and experts have worked so well with them and their teams. What be very good in social media, but this an entirely different and very complicated area. We will fix this. All my Best, Ike From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Thursday, March 30, 2017 11:56 PM To: (b) (6) omb.eop.gov Cc: (b) (6) who.eop.gov; lperl(b) (6) @qmail.com ; brucem(b) (6) Subject: FW: VA And Apple @mac.com ; mbs(b) (6) @qmail.com (b) (6) With all due respect, I am shocked and extremely disappointed with the manner in which you have engaged in individual communications with Apple - and intentionally excluded our broader team of subject matter experts. I understand that these backdoor discussions have apparently been occurring almost daily for weeks, and you have not told anyone and refuse to return phone calls and emails. When we first met on February 7th, I personally shared with you our vision and goals and explained that it is critical that everything we do must be done as a team. The very purpose of our Academic team, Dr. Moskowitz, and Marc Sherman is to ensure proper analysis, sharing of best practices, and provide a forum for discussion, debate, and ultimately the strongest collective decisions/recommendations. You agreed then, but your actions to date regarding Apple prove otherwise. When I spoke with (b) (6) on February 1st we discussed and agreed on the importance of leveraging our Academic team and experts for the end goal of creating the best system for our veterans. Further on our Apple conference call on March 3rd - which we invited you and (b) (6) to join - we again discussed and all agreed that for us to be successful and fix all the issues that our great veterans are going through on a daily basis, we must all unite and work as one team, with only one agenda and one goal. What we are seeing from you today is a blatant disregard for that commitment and clear disrespect to everyone involved. You are putting yourself, your own agenda, and your own ego ahead of our veterans. This is unacceptable. There are 22 veterans dying every day. Your decision to alone discuss IT and technology solutions with Apple for weeks without the broader team of experts and not informing me and Dr. Moskowitz is major step backwards and will only cause additional work and significant delays. As a result of your hijacking of this effort, Apple has already canceled conference calls. VA-19-0799-D-001273 OS 00002944 In fact, many of the current problems with the VA is because of this very reason - the lack of team work within. Let me be clear, I will not allow this to happen while I am involved. I want this resolved immediately. First, you must include Dr. Moskowitz and Marc Sherman on any and all calls or meetings. Additionally, I will formally ask you again to please respect me and our broader group of subject matter experts, and immediately cease individual discussions with Apple and/or any other parties related to the work we have undertaken regarding the VA. Ike -----Original Message----(b) (6) From: (b) (6) EOP/OMB [mailto:(b) (6) Sent: Thursday, March 30, 2017 6:48 PM To: Bruce Moskowitz Cc: (b) (6) EOP/WHO; IP; (b) (6) frenchangel59.com Subject: Re: VA And Apple omb.eop.gov] Hey team! We're making great progress, which I'm excited to fill you in on. Will send you more info when I get out of these back-to-back mtgs and will give you a ring back Ike! Thanks! > On Mar 30, 2017, at 6:49 AM, Bruce Moskowitz <(b) (6) mac.com > wrote: > > In the last email exchange i was supposed to receive information on your interaction with Apple so that we could rapidly obtain needed technology from our Academic Center Consortium upcoming discussion with Apple. I realize there are multiple technology issues on everyone's desk however we have medical emergencies daily at the VA that can only be solved by rapid deployment of new technology. I am available 24-7 by phone 561-3466(b) (6) Thank you > > Sent from my iPad > Bruce Moskowitz M.D. -----Original Message----From: Bruce Moskowitz [mailto:(b) (6) Sent: Tuesday, March 28, 2017 11:41 AM To: (b) (6) who.eop.gov; (b) (6) Cc: IP Subject: VA And Apple mac.com ] omb.eop.gov It would be of benefit to discuss what we can accomplish in technology with Apple for the benefit of the VA. It would be of importance to understand what discussions the Whitehouse team has already had with Apple so that we have a clear path forward and do not duplicate what has already been accomplished. Let me know a convenient time to talk. Thank you Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001274 OS 00002945 Message From: IP [(b) (6) frenchangel59.com] Sent: 4/2/2017 2:51:54 PM To: David shulkin [drshulkin@aol.com] FW: VA And Apple Untitled Attachment Subject: Attachments: From: IP [mailto:(b) (6) renchanqel59.com ] Sent: Sunday, April 02, 2017 10:16 AM To: '(b) (6) EOP/WHO' Cc: 'Kushner, Jared C. EOP/WHO'; '(b) (6) Subject: RE: VA And Apple EOP/WHO' (b) (6) My email to (b) (6) on Thursday expressed my frustration and displeasure in learning about activity and decisions concerning issues at the VA in a separate and invisible parallel effort. Regrettably, your response to my email that "(b) (6) has been working but not communicating" not only fails to recognize or explain the issue, but merely highlights the very fundamental problem that is so troubling. While a lack of communication has certainly exacerbated the problem, the mere fact that there has been any activity or decision without first coordinating that activity with our team before taking any action is the problem. Simply offering to communicate better solves very little. In your and (b) (6) first meeting in the West Wing with Marc Sherman it was clear and agreed that (b) (6) would be the liaison between our expert team and the White House and provide her IT counsel to our team related to our initiatives (not as an invisible, parallel effort). In addition, the White House was to be available to assist our team with executive and legislative clout when requested (not conduct an invisible, parallel effort), a three-pronged approach, if you recall. This is the program I reported to the President and the goahead we received. The essential problem at the VA is that 22 veterans die every day and the system of care and access to care is in need of repair. This is a medical issue and medical delivery problem. In order to fix the VA, these medical problems must first be defined and fixed. All other issues, like IT, are a function of the determined fix to the medical issues and medical delivery problems. To transform the VA into the best of class, I assembled a team that includes the best and brightest minds in the academic medical community. The restructuring efforts on which we embark are informed by the advice and participation of those great medical minds. Parallel (and invisible to us) IT efforts are not connected to what the medical minds decide are the problem or the fix and are frustrating the IT solution that deals with the medical issues. It is also spending the valuable time of volunteers and delaying the best care that our veterans deserve. Your email to me underscores this problem. You say that: "[ efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services," and VA-19-0799-D-001275 OS 00002946 "There is a call on Monday with Apple, the VA, and (b) (6) to review the ... status of the EHMP work ... [and] to confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities." However, it is not possible to design an EHMP system or integrate the system with an Apple device until you know how the medical experts are going to change the medical delivery system and how they advise a device should be utilized in the medical delivery system. The academic medical experts on our team are assisting the VA in designing a sophisticated system of community care through a public-private delivery system. They are formulating that system and its inner workings, the creation of which will dictate the Integration and interoperability of records. Neither (b) (6) nor Apple can define a scope or product use without consulting with our group on how veteran's records used in the private sector will get integrated into the portable record and back to the VA. You mention in your email telehealth. Our team of medical experts are working on a telehealth initiative and delivered a draft Executive Order to the President ... while you are working with the DEA and DOJ, without the courtesy of advising us, which could have tremendous implications on the wording or, worse yet, the prudence of an Executive Order in the first place. This parallel path as well creates the potential for embarrassment for the President and wasted invaluable time that our veterans can ill afford. Lastly, you discuss your parallel meeting on a Military Wellness program which you apparently already brought in which you believe focuses on preventative medicine. The program that you are touting however is surrounded by rumors that are less than flattering. Moreover, our team's academic medical experts are already assisting in the active development of a wellness program for the VA and their views will prevail. Those experts have already assembled the working parts of a wellness program and the seamless integration with active service members and family. There is no need to have a parallel side effort that is not integrated into the agreed program. Again, the problem is not about communication. I had an employee a few years back that meant well but thought that there was an "I" in team. His work for the company created value and profits for the company at various times, however, in spite of those benefits, I advised him that his way was not working and he should find something else that better met his style. With all this considered, I think that (b) (6) is a smart woman that could provide the VA IT experience and benefits, my way ... not as a renegade player. I am willing to work with her as a team player on our team. The expert team that I assembled and is sanctioned by the President will be proceeding with its efforts as planned. All other parallel efforts should stand down. (b) (6) can participate as part of that team, not outside of that team or its efforts or its direction. As agreed on day one, the White House can participate by providing executive and administrative assistance, when requested by our expert team. We will arrange and conduct discussions with Apple (in which (b) (6) should participate if done within the confines of the expert team). We will work with design and implementation of a wellness program and we will decide on the proper way to integrate an EMR system, with (b) (6) team participation if agreed. Any items that relate to the transformation of the VA must be funneled through and managed by the expert team and should be coordinated with Dr. Moskowitz and Marc Sherman. Let me know if you have any questions. Ike VA-19-0799-D-001276 OS 00002947 From: (b) (6) EOP/WHO [ mailto:(b) (6) Sent: Friday, March 31, 2017 6:03 PM To: IP; Kushner, Jared C. EOP/WHO Cc: (b) (6) EOP/WHO; (b) (6) Subject: RE: VA And Apple who.eop.gov] EOP/WHO As we discussed it seems like (b) (6) has been working but not communicating. Her efforts have been focused with the VA on ensuring that an EHMP is completed above their health records so that the medical records can be pulled into an Apple device. The EHMP work is in process and is a necessity for Apple to then come in and provide its services. There is a call on to review the following: Monday with Apple, the VA, and (b) (6) 1. Status of the EHMP work 2. to find a legal mechanism to allow for 3 month tour of duty from Apple engineers with the employees staying on Apple payroll. This is being investigated by USDS lawyers and the VA. 3. To work through an NDA / conflict waiver which is a necessary legal document. 4. To confirm Apple job scope which includes portability of health records/ data from VA to Apple products; VA technical changes to how to allow VA workers to use Apple products; (and potentially portability of health records/ data to non-VA medical facilities.) I believe we should then schedule a call for mid next week with Ike, appropriate members of Ike's team, the VA, Apple and (b) (6) myself to ensure we are on same page (I can coordinate (b) (6) the call). I think we should allow an opportunity to reset and to act as a true overall project manager where we allow her to coordinate. She should communicate with Ike and his designee consistently and she should professionally coordinate the team, get everyone working together, and show us progress. I believe she will do a great job, and we will know quickly if she does not. As everyone knows huge other hot items at VA in the works right now including Accountability (legislation and EO), Choice Reform Act extension and reform; telehealth (working through the issue with DOJ and DEA; hard to just slam it through if they oppose but based on meeting today with VA/DOJ/DEA I believe we can get them there in next two weeks. Ike, I can explain in detail when we next talk but having been through this with the Opioid EO this week we should see if we can get DEA/ DOJ on board). Different subject, Ike would also like your advice on NIH and the idea (I think your idea?) to create a profit sharing program with our grants. Love this idea. Yours truly, (b) (6) P.S. I need to update you on very exciting meeting on a Military Wellness program which we brought in; focuses on preventative medicine and is working for over 20,000 vets currently. Readily scalable. VA-19-0799-D-001277 OS 00002948 (b) (6) Assistant to the President For lntragovernmental and Technology Initiatives 202.456.(b) (6) (Direct) (b) (6) who.eop.gov From: IP fmailto:(b) (6) frenchangel59.com1 Sent: Friday, March 31, 2017 12:05 AM To: Kushner, Jared C. EOP/WHO <(b) (6) who.eop.gov> Cc: (b) (6) EOP/WHO <(b) (6) who.eop.gov>; (b) (6) Subject: FW: VA And Apple EOP/WHO <(b) (6) who.eop.gov> Jared, As you know lvanka introduced me to (b) (6) at Apple and (b) (6) at Johnson & Johnson. Ours Academic team has done here is really outrageous. She may and experts have worked so well with them and their teams. What be very good in social media, but this an entirely different and very complicated area. We will fix this. All my Best, Ike From: IP [ mailto:(b) (6) frenchanqel59.com] Sent: Thursday, March 30, 2017 11:56 PM To: (b) (6) omb.eop.gov Cc: (b) (6) who.eop.gov; lperl(b) (6) @qmail.com ; brucem(b) (6) Subject: FW: VA And Apple @mac.com ; mbs(b) (6) @qmail.com (b) (6) With all due respect, I am shocked and extremely disappointed with the manner in which you have engaged in individual communications with Apple - and intentionally excluded our broader team of subject matter experts. I understand that these backdoor discussions have apparently been occurring almost daily for weeks, and you have not told anyone and refuse to return phone calls and emails. When we first met on February 7th, I personally shared with you our vision and goals and explained that it is critical that everything we do must be done as a team. The very purpose of our Academic team, Dr. Moskowitz, and Marc Sherman is to ensure proper analysis, sharing of best practices, and provide a forum for discussion, debate, and ultimately the strongest collective decisions/recommendations. You agreed then, but your actions to date regarding Apple prove otherwise. When I spoke with (b) (6) on February 1st we discussed and agreed on the importance of leveraging our Academic team and experts for the end goal of creating the best system for our veterans. Further on our Apple conference call on March 3rd - which we invited you and (b) (6) to join - we again discussed and all agreed that for us to be successful and fix all the issues that our great veterans are going through on a daily basis, we must all unite and work as one team, with only one agenda and one goal. VA-19-0799-D-001278 OS 00002949 What we are seeing from you today is a blatant disregard for that commitment and clear disrespect to everyone involved. You are putting yourself, your own agenda, and your own ego ahead of our veterans. This is unacceptable. There are 22 veterans dying every day. Your decision to alone discuss IT and technology solutions with Apple for weeks without the broader team of experts and not informing me and Dr. Moskowitz is major step backwards and will only cause additional work and significant delays. As a result of your hijacking of this effort, Apple has already canceled conference calls. In fact, many of the current problems with the VA is because of this very reason - the lack of team work within. Let me be clear, I will not allow this to happen while I am involved. I want this resolved immediately. First, you must include Dr. Moskowitz and Marc Sherman on any and all calls or meetings. Additionally, I will formally ask you again to please respect me and our broader group of subject matter experts, and immediately cease individual discussions with Apple and/or any other parties related to the work we have undertaken regarding the VA. Ike -----Original Message----(b) (6) From: (b) (6) EOP/OMB fmailto:(b) (6) Sent: Thursday, March 30, 2017 6:48 PM To: Bruce Moskowitz Cc: (b) (6) EOP/WHO; IP; (b) (6) frenchangel59.com Subject: Re: VA And Apple omb.eop.gov] Hey team! We're making great progress, which I'm excited to fill you in on. Will send you more info when I get out of these back-to-back mtgs and will give you a ring back Ike! Thanks! > On Mar 30, 2017, at 6:49 AM, Bruce Moskowitz <(b) (6) mac.com > wrote: > > In the last email exchange i was supposed to receive information on your interaction with Apple so that we could rapidly obtain needed technology from our Academic Center Consortium upcoming discussion with Apple. I realize there are multiple technology issues on everyone's desk however we have medical emergencies daily at the VA that can only be solved by rapid deployment of new technology. I am available 24-7 by phone 561-3466(b) (6) Thank you > > Sent from my iPad > Bruce Moskowitz M.D. -----Original Message----From: Bruce Moskowitz fmailto:(b) (6) Sent: Tuesday, March 28, 2017 11:41 AM To: (b) (6) who.eop.gov; (b) (6) Cc: IP Subject: VA And Apple mac.com ] omb.eop.gov It would be of benefit to discuss what we can accomplish in technology with Apple for the benefit of the VA. It would be of importance to understand what discussions the Whitehouse team has already had with Apple so that we have a clear path forward and do not duplicate what has already been accomplished. Let me know a convenient time to talk. Thank you VA-19-0799-D-001279 OS 00002950 Bruce Moskowitz MD. Message From: (b) (6) EOP/WHO [(b) (6) Sent: 4/1/2017 12:40:55 PM To: Kushner, Jared C. EOP/WHO [(b) (6) who.eop.gov]; (b) (6) frenchangel59.com who.eop.gov] To follow up on my email of yesterday (and this may not need clarifying) but I am suggesting we give (b) (6) a chance to project manage the IT component only. And that we quickly ascertain if she is up to it. obvi the VA needs a great CIO. (b) (6) USDS has sourced and interviewed 4 candidates and reviewed w David., he has asked 3 to come in to meet with him. (Ike, Jared said you might have a great person from Cleveland clinic that would get on team for a period of time? That would be incredible). Two other hot items: met w shulkin and 0MB. shulkin believes he will need additional $7.5B in 2018 budget to offer the choice option (part of choice reform legislation being considered). He had some ideas how to achieve (charging Medicare) but all have issues, 0MB is going to consider and get back to us. I arranged and David is preparing for meeting w Sec Mattis and DOD senior staff on the myriad of coordination issues. Need to force it but there is ability to make huge progress there. Sent from my iPad VA-19-0799-D-001281 OS 00002952 Message Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/12/2017 1:39:51 AM (b) (6) [(b) (6) mayo.edu] David Shulkin [drshulkin@aol.com]; Marc Sherman [(b) (6) Fwd: FYI I Follow-up: VA Public-facing Web site Sensitivity: Company Confidential From: Sent: To: CC: gmail.com]; brucem(b) (6) @mac.com Chris- on behalf of the secretary and the VA, I want to thank you for your support. Your leadership in rallying the other academic centers and your strategic advice has been invaluable. We are really excited about tomorrow when we go-live! This is new turn for us as we embark upon our transformation journey together. Marc- good catching up today- looking forward to dinner next week Sent from my iPhone Begin forwarded message: From: "(b) (6) <(b) (6) mayo.edu > Date: April 11, 2017 at 2:44:20 PM EDT To: "Poonam Alaigh ((b) (6) hotmail.com )" <(b) (6) (b) (6) Cc: " Subject: FYI (b) (6) ( I (b) (6) gmail.com )" < hotmail.com > gmail.com > Follow-up: VA Public-facing Web site From: (b) (6) Sent: Tuesday, April 11, 2017 1:44 PM (b) (6) To: '(b) (6) va.gov (b) (6) (b) (6) Cc: (b) (6) Subject: Follow-up: VA Public-facing Web site Sensitivity: Confidential Hi - thanks (b) (6) connecting you w/ (b) (6) ((b) (6) qmail.com) at the VA. ... From: (b) (6) [ mailto:(b) (6) jhmi.edu] Sent: Tuesday, April 11, 2017 1:20 PM To: (b) (6) (b) (6) Cc: (b) (6) Subject: MORE I Your Input: VA Public-facing Web site Sensitivity: Confidential Hello, (b) (6) I spoke with (b) (6) about this and we have reached out to Dr. (b) (6) patient safety and quality and he has agreed to speak about this. senior vice president of (b) (6) (b) (6) Executive Assistant to SVP Marketing & Communications, JHM 901 S. Bond Street, Baltimore, MD 21231 P: 410-955-(b) (6) F: 410-955-(b) (6) VA-19-0799-D-001282 OS 00002953 From: (b) (6) fmailto:(b) (6) mayo.edu] Sent: Tuesday, April 11, 2017 1:34 PM To: (b) (6) <(b) (6) PARTNERS.ORG>; (b) (6) <(b) (6) (b) (6) mayo.edu>; (b) (6) mayo.edu>; (b) (6) (b) (6) (b) (6) @PARTNERS.ORG>; (b) (6) @jhmi.edu>; (b) (6) ccf.org; (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) (b) (6) ( ccf.org) < ccf.org>; < jhu.edu>; (b) (6) @PARTNERS.ORG>; (b) (6) kp.org; (b) (6) kp.org; (b) (6) (b) (6) (b) (6) @mayo.edu>; (b) (6) @mayo.edu>; (b) (6) (b) (6) @mayo.edu > Subject: MORE I Your Input: VA Public-facing Web site Sensitivity: Confidential Hi - sharing an additional update from the team at the VA: o o o o o The site will not be active outside of the VA firewall until late early tomorrow morning. However, the VA team is finalizing a video that walks people through the site. Will have that for you as soon as it is finished and online. The VA team is "most interested" in your CEO; or someone you designate in your organization (perhaps a Quality lead; or "digital care/web" lead be open to speaking w/ the news media, sharing perspective on how this reflects a step forward for veterans and reflects what patients are seeking from healthcare providers? The VA team would also welcome our organizations sharing this on our various social media platforms. Would you also consider sharing a "heads up" to your local/regional medical/health reporters encouraging coverage. The VA team would is also exploring a "day three" story about this - Dr. Shulkin had a "sit down/exclusive" w/ USA Today (story will hit tomorrow); possibilities they are exploring include an extended conversation w/ a designated reporter that would pair Dr. Shulkin w/ one of the academic partner CEOs (think National Public Radio, or another outlet); or possibly an op-ed submission. Again, focus would be on sharing perspective on how this reflects a step forward for veterans and reflects what patients are seeking from healthcare providers. Let me know of your interest in participating in the above - in follow-up, will link you directly w/ the VA Communications "point." (b) (6) Thanks, (b) (6) From: (b) (6) Sent: Monday, April 10, 2017 4:59 PM (b) (6) (b) (6) To: (b) (6) (b) (6) (b) (6) (b) (6) ccf.org ; jhu.edu ; ((b) (6) (b) (6) (b) (6) (b) (6) kp.org ; kp.org ; (b) (6) (b) (6) (b) (6) ccf.org); [RO PA]; (b) (6) (b) (6) Subject: URGENT I Your Input: VA Public-facing Web site Sensitivity: Confidential *PLEASE TREAT AS BUSINESS CONFIDENTIAL* VA-19-0799-D-001283 OS 00002954 Hi - on Wednesday, the VA will announce a web site designed for Veterans to make informed decisions about where they receive their health care. The overview of the plan and the project objectives are attached. Dr. Bruce Moskowitz routed the plan in late March to the CEO of the five academic medical center organizations, encouraging that the CEOs "express support/confidence" in the plan. Several CEOs expressed in follow-up emails that they would be willing to "voice support for the approach, that it's reflective of the direction the VA needs to move to best support the care of veterans, etc." Dr. Poonam Alaigh, VA Acting Under Secretary for Health, Dr. Moskowitz and I spoke late this afternoon - the question: as this rolls out (going public on Wednesday), would your CEO; or someone you designate in your organization (perhaps a Quality lead; or "digital care/web" lead be open to speaking w/ the news media, sharing perspective on how this reflects a step forward for veterans and reflects what patients are seeking from healthcare providers? If not someone from your organization, would you recommend an industry expert that can talk to these issues w/ news media? The timeline for this would be tomorrow (Tuesday) or Wednesday, as this news goes public. Thanks for your consideration. (b) (6) Chair I Mayo Clinic Department of Public Affairs 200 First Street S.W. I Rochester, MN 55905 cell: 507 .269.(b) (6) I office: 507 .284.(b) (6) e-mail: (b) (6) mayo. ed u VA-19-0799-D-001284 OS 00002955 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/2/2017 6:46:30 PM Va David [vacodjsl@va.gov] Fwd: Medical Student Proposal for VA system Osteopathic _Training in The VA.docx; Untitled attachment 05981.htm Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) gmail .com> Date: April 2, 2017 at 2:00:26 PM EDT To: David shulkin Subject: Fwd: Medical Student Proposal for VA system From: (b) (6) <(b) (6) gmail.com > Subject: Medical Student Proposal for VA system Date: April 2, 2017 at 1:52:30 PM EDT Cc: Poonam Alaigh <(b) (6) hotmail.com >, "(b) (6) FACOFP dist."<(b) (6) aol.com > DO, MPH, Dear David, Hope all is well with you and that you are adjusting to your new whirlwind life in D.C. Commensurate with my brief discussion to you last month I have been working with (b) (6) who will likely represent the American Osteopathic Association and their subgroups in a proposal I wanted to send to you in its raw form. I spoke to Poonam at the banquet about it briefly so I am copying her on the proposal (b) (6) and I wrote. If you want to wait for its final form you don't have to read it, but if you read it and either you or Poonam have any thoughts , any and all changes to form and content are welcome. Be Well and as always , it was great to see you in NJ Q Q) (b) (6) (b) (6) DO F ACOI,F ASVM Associate Professor Internal Medicine VA-19-0799-D-001285 DS 00002956 Medical Director Vascular Technology Training program Rutgers School of Medicine Attending Gagnon Heart Center Director Anticoagulation Service Morristown Medical Center Morristown ,NJ VA-19-0799-D-001286 OS 00002957 Osteopathic Training in The VA System Since the Advent of the Viet Nam war Osteopathic Physicians have played an increasingly important role in the Military healthcare system with Physicians Enlistees participating in a progressively disproportionate responsibility for healthcare for our serviceman and women in the United States. The Profession takes great pride in our military and the sacrifices they have made. In this, the American Osteopathic Association feels strongly we should play a role vital in the health care of the armed forces, and also with those who serve if in their times to follow. Medical students provide a hearty source of academic posture which vitalize their staff counterparts and enhance patient care and patient experience. The role of a medical student thus is thus not parasitic but symbiotic. The last decade has found American trained students in an increasingly contracted healthcare academic delivery environment. Our proposal would be to arrange an academic, contractual relationship with the VA System on a national scale which would provide high level Medical students, all of whom have completed Part I of the boards and who would engage in the VA system as a Whole. We would agree to provide students from around the United States and would be responsible for their presence, behavior, and provide a uniform platform upon which their training would commence. VA-19-0799-D-001287 OS 00002958 Given the distinction in governance of the Osteopathic profession as an organization, with regard to its relationship to their colleges of medicine, an agreement could be crafted which would provide a fixed and constant workforce minimal or no cost. We would provide a number of students of which we would agree, and they would be at their posts each month and a schedule would be applied which would include on call, the appropriate number of patients which would benefit the patient population, and enhance the workload experience of the VA personnel. We will apply established standards to mitigate against undue burdens on both sides. Our hope would be a relationship which will provide high level staffing for patients in a time of fiscal contraction. Our fervent belief is that setting will provide the students with a lifelong understanding of both the medical problems which are many times unique and the dynamic issues which Veterans face. We provide students arrange transportation in potentially all 50 states. Taken on a large scale; there could be between 1000 and 2500 OMS rotating/month at a VA institutions. Rotations could be set up in internal medicine, psychiatry and/or addiction medicine as well as others, depending upon the programs in place at the individual VA. We will need to further discuss details of housing etc. If It Is available this would greatly enhance the programing and facilitate an seamless start to the program. We should also add aside from the basic platform an elective program for students who wish to do other rotations VA-19-0799-D-001288 OS 00002959 we can ask for all VA institutions to partner with our COMs. The VA has been noted to profound need of primary care physicians. The Colleges of Osteopathic Medicine are in need of training slots for 3rd and 4th year osteopathic medical students (OMS). Those OMS are primary care oriented and could eventually feed the workforce need of the VA. This would provide a mutually synergistic aim: to provide quality healthcare to VA patients and quality rotations to OMS, and potentially seed the next generation of physicians into the VA. We would arrange for AOIA to coordinate these rotations and would take complete responsibility for their actions . The rotations would be guaranteed by all COMs participating and we will provide continuous monitoring for the VA institutions. References 1. Osteopathic physicians for military service: hearing before the Committee on Military Affairs. 65th Cong 1 2nd sess ( 1918) (testimony of George W. Riley, DO). 2 Pub L No. 65-12., 40 Stat 76. 3 Swope C. Public relations committee: selective compulsory military training and service bill. J Am Osteopath Assoc. 1941i40(1):16-17. 4 Willard A Where our students come from. J Am Osteopath Assoc. 1947;46:313. Clinical Careo In FY 2011, 70 percent of VA physicians (20,527) had a faculty appointment at a U.S. medical school.2 o In FY 2012, AAMC-member VA teaching hospitals (37 percent of all VA hospitals) accounted for 50 percent of the total admissions at all VA hospitals, 51 percent of the total inpatient days, and 49 percent of the emergency visits. They also performed 41 percent of the total surgeries at VA hospitals.3 o In FY 2007, the Veterans Health Administration reported 669 noncompetitive clinical sharing agreements (i.e., sole source contracts) with affiliated institutions, including medical schools and teaching hospitals, to provide care for veterans outside of the VA valued at $575 million.4 Research With an annual budget of nearly $590 million,5 the VA Office of Research and Development sponsors veteran-centric research VA-19-0799-D-001289 OS 00002960 on numerous topics, including post-traumatic stress disorder, traumatic brain injury, and prosthetics. VA researchers have joint appointments at VA hospitals and medical schools. Recent studies include: o Sophisticated VA-invented eye- tracking tests to determine a method that could provide physicians with a simpler and more accurate way to diagnose Parkinson's disease. o A recent VA-sponsored trial for a drug that provided relief for veterans from Operations Iraqi Freedom, Enduring Freedom, and New Dawn who were suffering from nightmares. o The Million Veteran Program, which was launched in 2011 to recruit a million veterans to collect data on genetics, lifestyle, and health. This information will help clinicians better understand how genetic factors contribute to conditions like post-traumatic stress disorder and traumatic brain injury. 1 FY2015 VA Budget Submission Volume 11 Medical Programs and Information Technology Programs, http://www.va.gov/ budget/docs/summary/Fy2015-VolumeII-MedicalProgramsAndin formationTechnology.pdf 2 Annual Report of Residency Training Programs (ARRTP) database, estimate provided by the VA Office of Academic Associations (OAA) 3 AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers 4 2008 Office of Inspector General (OIG) Audit of VHA Noncompetitive Clinical Sharing Agreements 5 Friends of VA Medical Care and Health Research Recommendations for FY2015, http://www.friendsofva.org/ resources/2014/20 l 5fovarecommendations.pdf. (b) (6) (b) (6) D.O., MPH, FACOFP D.O. FACOI, FSVM VA-19-0799-D-001290 OS 00002961 Message From: Sent: To: CC: Subject: (b) (6) David shulkin [Drshulkin@aol.com] 4/2/2017 6:46:19 PM (b) (6) [(b) (6) gmail.com] Poonam Alaigh [(b) (6) hotmail.com] Re: Medical Student Proposal for VA system - we will get out acadmic affiliations group involved- Thanks for pulling this together David Sent from my iPhone On Apr 2, 2017, at 2:00 PM, (b) (6) <(b) (6) gmail.com> wrote: From: (b) (6) <(b) (6) gmail.com > Subject: Medical Student Proposal for VA system Date: April 2, 2017 at 1:52:30 PM EDT Cc: Poonam Alaigh <(b) (6) hotmail.com >, "(b) (6) FACOFP dist."<(b) (6) aol.com > DO, MPH, Dear David, Hope all is well with you and that you are adjusting to your new whirlwind life in D.C. Commensurate with my brief discussion to you last month I have been working with (b) (6) who will likely represent the American Osteopathic Association and their subgroups in a proposal I wanted to send to you in its raw form. I spoke to Poonam at the banquet about it briefly so I am copying her on the proposal (b) (6) and I wrote. If you want to wait for its final form you don't have to read it, but if you read it and either you or Poonam have any thoughts , any and all changes to form and content are welcome. Be Well and as always, it was great to see you in NJ Q Q) (b) (6) (b) (6) DO F ACOI,F ASVM Associate Professor Internal Medicine VA-19-0799-D-001292 DS 00002963 Medical Director Vascular Technology Training program Rutgers School of Medicine Attending Gagnon Heart Center Director Anticoagulation Service Morristown Medical Center Morristown ,NJ VA-19-0799-D-001293 OS 00002964 Message (b) (6) From: Sent: To: Subject: Attachments: [(b) (6) gmail.com] 4/2/2017 6:00:26 PM David shulkin [drshulkin@aol.com] Fwd: Medical Student Proposal for VA system Osteopathic _Training in The VA.docx; Untitled attachment 05988.htm From: (b) (6) <(b) (6) gmail.com > Subject: Medical Student Proposal for VA system Date: April 2, 2017 at 1:52:30 PM EDT Cc: Poonam Alaigh <(b) (6) hotmail.com >, "(b) (6) dist."<(b) (6) aol.com > DO, MPH, FACOFP Dear David, Hope all is well with you and that you are adjusting to your new whirlwind life in D.C. Commensurate with my brief discussion to you last month I have been working with who will likely represent the American Osteopathic Association and their subgroups in a proposal I wanted to send to you in its raw form. I spoke to Poonam at the banquet about it briefly so I am copying her on the proposal (b) (6) and I wrote. If you want to wait for its final form you don't have to read it, but if you read it and either you or Poonam have any thoughts , any and all changes to form and content are welcome. (b) (6) Be Well and as always , it was great to see you in NJ Q Q) (b) (6) (b) (6) DO F ACOI,F ASVM Associate Professor Internal Medicine Medical Director Vascular Technology Training program Rutgers School of Medicine Attending Gagnon Heart Center Director Anticoagulation Service Morristown Medical Center Morristown ,NJ VA-19-0799-D-001294 DS 00002965 Osteopathic Training in The VA System Since the Advent of the Viet Nam war Osteopathic Physicians have played an increasingly important role in the Military healthcare system with Physicians Enlistees participating in a progressively disproportionate responsibility for healthcare for our serviceman and women in the United States. The Profession takes great pride in our military and the sacrifices they have made. In this, the American Osteopathic Association feels strongly we should play a role vital in the health care of the armed forces, and also with those who serve if in their times to follow. Medical students provide a hearty source of academic posture which vitalize their staff counterparts and enhance patient care and patient experience. The role of a medical student thus is thus not parasitic but symbiotic. The last decade has found American trained students in an increasingly contracted healthcare academic delivery environment. Our proposal would be to arrange an academic, contractual relationship with the VA System on a national scale which would provide high level Medical students, all of whom have completed Part I of the boards and who would engage in the VA system as a Whole. We would agree to provide students from around the United States and would be responsible for their presence, behavior, and provide a uniform platform upon which their training would commence. VA-19-0799-D-001296 OS 00002967 Given the distinction in governance of the Osteopathic profession as an organization, with regard to its relationship to their colleges of medicine, an agreement could be crafted which would provide a fixed and constant workforce minimal or no cost. We would provide a number of students of which we would agree, and they would be at their posts each month and a schedule would be applied which would include on call, the appropriate number of patients which would benefit the patient population, and enhance the workload experience of the VA personnel. We will apply established standards to mitigate against undue burdens on both sides. Our hope would be a relationship which will provide high level staffing for patients in a time of fiscal contraction. Our fervent belief is that setting will provide the students with a lifelong understanding of both the medical problems which are many times unique and the dynamic issues which Veterans face. We provide students arrange transportation in potentially all 50 states. Taken on a large scale; there could be between 1000 and 2500 OMS rotating/month at a VA institutions. Rotations could be set up in internal medicine, psychiatry and/or addiction medicine as well as others, depending upon the programs in place at the individual VA. We will need to further discuss details of housing etc. If It Is available this would greatly enhance the programing and facilitate an seamless start to the program. We should also add aside from the basic platform an elective program for students who wish to do other rotations VA-19-0799-D-001297 OS 00002968 we can ask for all VA institutions to partner with our COMs. The VA has been noted to profound need of primary care physicians. The Colleges of Osteopathic Medicine are in need of training slots for 3rd and 4th year osteopathic medical students (OMS). Those OMS are primary care oriented and could eventually feed the workforce need of the VA. This would provide a mutually synergistic aim: to provide quality healthcare to VA patients and quality rotations to OMS, and potentially seed the next generation of physicians into the VA. We would arrange for AOIA to coordinate these rotations and would take complete responsibility for their actions . The rotations would be guaranteed by all COMs participating and we will provide continuous monitoring for the VA institutions. References 1. Osteopathic physicians for military service: hearing before the Committee on Military Affairs. 65th Cong 1 2nd sess ( 1918) (testimony of George W. Riley, DO). 2 Pub L No. 65-12., 40 Stat 76. 3 Swope C. Public relations committee: selective compulsory military training and service bill. J Am Osteopath Assoc. 1941i40(1):16-17. 4 Willard A Where our students come from. J Am Osteopath Assoc. 1947;46:313. Clinical Careo In FY 2011, 70 percent of VA physicians (20,527) had a faculty appointment at a U.S. medical school.2 o In FY 2012, AAMC-member VA teaching hospitals (37 percent of all VA hospitals) accounted for 50 percent of the total admissions at all VA hospitals, 51 percent of the total inpatient days, and 49 percent of the emergency visits. They also performed 41 percent of the total surgeries at VA hospitals.3 o In FY 2007, the Veterans Health Administration reported 669 noncompetitive clinical sharing agreements (i.e., sole source contracts) with affiliated institutions, including medical schools and teaching hospitals, to provide care for veterans outside of the VA valued at $575 million.4 Research With an annual budget of nearly $590 million,5 the VA Office of Research and Development sponsors veteran-centric research VA-19-0799-D-001298 OS 00002969 on numerous topics, including post-traumatic stress disorder, traumatic brain injury, and prosthetics. VA researchers have joint appointments at VA hospitals and medical schools. Recent studies include: o Sophisticated VA-invented eye- tracking tests to determine a method that could provide physicians with a simpler and more accurate way to diagnose Parkinson's disease. o A recent VA-sponsored trial for a drug that provided relief for veterans from Operations Iraqi Freedom, Enduring Freedom, and New Dawn who were suffering from nightmares. o The Million Veteran Program, which was launched in 2011 to recruit a million veterans to collect data on genetics, lifestyle, and health. This information will help clinicians better understand how genetic factors contribute to conditions like post-traumatic stress disorder and traumatic brain injury. 1 FY2015 VA Budget Submission Volume 11 Medical Programs and Information Technology Programs, http://www.va.gov/ budget/docs/summary/Fy2015-VolumeII-MedicalProgramsAndin formationTechnology.pdf 2 Annual Report of Residency Training Programs (ARRTP) database, estimate provided by the VA Office of Academic Associations (OAA) 3 AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers 4 2008 Office of Inspector General (OIG) Audit of VHA Noncompetitive Clinical Sharing Agreements 5 Friends of VA Medical Care and Health Research Recommendations for FY2015, http://www.friendsofva.org/ resources/2014/20 l 5fovarecommendations.pdf. (b) (6) (b) (6) D.O., MPH, FACOFP D.O. FACOI, FSVM VA-19-0799-D-001299 OS 00002970 300 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/8/2017 12:24:11 PM To: Poonam Alaigh [(b) (6) Re: (b) (6) Subject: hotmail.com] Great Sent from my iPhone > on Apr 8, 2017, at 8:15 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Spoke to him last night and he has initial interest- will speak to him in more details next week > > Sent from my iPhone VA-19-0799-D-001301 OS 00002972 Message To: Poonam Alaigh [(b) (6) hotmail.com] 4/8/2017 12:15:52 PM David Shulkin [drshulkin@aol.com] Subject: (b) (6) From: Sent: Spoke to him last night and he has initial interest- will speak to him in more details next week Sent from my iPhone VA-19-0799-D-001302 OS 00002973 Message From: Sent: To: David shulkin [Drshulkin@aol.com] 4/19/2017 11:29:50 PM (b) (6) [(b) (6) gmail.com] can we ask our team to track down the clip from cbs evening news tonight that ran on VA Sent from my iPhone VA-19-0799-D-001303 OS 00002974 Message From: Sent: To: CC: Subject: bruce moskowitz [(b) (6) gmail.com] 4/1/2017 5:03:29 PM David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) Re: UPDATED VERSION gmail.com] Amazing that it takes a case Like this to get it done Sent from my iPhone On Apr 1, 2017, at 12:24 PM, David shulkin wrote: Im taking an unusual and aggressive stance to push for accountability legislation using this outrageous case. I had to fight my lawyers to do this. Already congress has released a statement of support fir my position and Fox news wants a live interview Sunday morning- see the release below VA-19-0799-D-001304 OS 00002975 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/1/2017 4:24:18 PM brucem(b) (6) @gmail.com; Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) Fwd: UPDATED VERSION Press Release - Accountability Final Draft-jeh (3).docx; Untitled attachment 06027.htm gmail.com] Im taking an unusual and aggressive stance to push for accountability legislation using this outrageous case. I had to fight my lawyers to do this. Already congress has released a statement of support fir my position and Fox news wants a live interview Sunday morning- see the release below VA-19-0799-D-001305 OS 00002976 VA News Release 0 ice Public Aff ,rs Media Rela ions W hington, DC 20 20 (202) 461-7600 .va.gov FOR IMMEDIATE RELEASE March 31, 2017 VA Forced to Delay Removing Employee Caught Watching Pornography VA Supports Congress's Effort to Change Legislation to Expedite Process WASHINGTON - After a through internal review of an employee of the Michael DeBakey Veterans Affairs Medical Center in Houston was caught watching porn while with a patient, the designated proposing official recommended removal from federal service. The VA immediately removed the Veteran in question from patient care and placed on administrative duties. Due to current law, the deciding official cannot affect a final determination for 30 days from the date the proposal for removal was made. VA is committed to ensuring every employee retains their right to due process while at the same time reducing the time it takes to remove employees who have engaged in misconduct. "This is an example of why we need accountability legislation as soon as possible," said Secretary of Veterans Affairs David J. Shulkin. "It's unacceptable that VA has to wait 30 days to act on a proposed removal." Under current law, the Department of Veterans Affairs (VA) must continue to pay employees who are in the process of being removed. During this advance notice period, at least 30 days from the date that the employee's removal has been proposed, assuming there is no evidence that the employee has committed a crime, an employee must be paid. If the employee has been assessed as a potential danger to Veterans, the employee should be placed on administrative leave with pay. If the employee does not pose an immediate threat to Veterans, they are typically placed on administrative duties, which limits their contact with Veterans and their families while ensuring that they aren't sitting at home collecting a pay check without providing any services to the government. VA is grateful that Congress has made this a priority. VA has been working with Congress to ensure any legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service. "Current legislation in Congress reduces the amount of time we have to wait before taking action," continued Secretary Shulkin. "I look forward to working with both the Senate and the House to ensure final legislation gives us the flexibility we need." VA-19-0799-D-001306 OS 00002977 307 Message From: Darin Selnick [(b) (6) Sent: 4/9/2017 8:28:02 PM To: David shulkin [Drshulkin@aol.com] Re: TEDVA Talk Subject: @gmail.com] Thanks, most people would not get it by just looking at the slides, that is why I have to walk them through it. Darin On Sun, Apr 9, 2017 at 1: 17 PM, David shulkin wrote: I didnt appreciate how this model achieved the goals- brilliant 1 Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: April 8, 2017 at 6:44:27 PM EDT To: David shulkin Subject: TEDVA Talk Hi David Attached are the two slides from my TEDVA talk. The second slide answers the questions on how the VHA providers, as a purely providers group, can get all of the OHi $ just like a Cleveland Clinic can, including the Federal (Medicare, Medicaid and TRICARE). Key is to have VHA internally fully separate the payer and provider functions and then have Congress designate the provider function as a Federal ACO. That way the$ follows the veteran patients, and the VHA provider has contracts with all OHi and VHA payer. Using this method the eligibility issue goes away since VHA providers are paid for all services from all payers, including all Federal. VHA providers have to become efficient since they have to run their operations on the same payer reimbursement payments as the private sector like Cleveland Clinic gets. For VAMCs that have extra capacity, they can take non-eligible veterans and family members since they are getting full reimbursement from their Health Insurance. Just my out of the box thinking, key is the legislation which at the same time we can ask for legislative relief on Government regulations on personnel, contracting, acquisition, and other items we identify that stop us from being competitive with the private sector. Time to level the playing field. Darin VA-19-0799-D-001308 OS 00002979 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/9/2017 8:18:58 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: TEDVA Talk VA TED Talk 2.pptx; Untitled attachment 06063.htm; VA TED Talk 2.pptx; Untitled attachment 06066.htm Tommorow on your way down look at this Its actually pretty smart We may need to tweak it- but starting a new business line might be the key to billing medicare Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: April 8, 2017 at 6:44:27 PM EDT To: David shulkin Subject: TEDVA Talk Hi David Attached are the two slides from my TEDVA talk. The second slide answers the questions on how the VHA providers, as a purely providers group, can get all of the OHi $ just like a Cleveland Clinic can, including the Federal (Medicare, Medicaid and TRICARE). Key is to have VHA internally fully separate the payer and provider functions and then have Congress designate the provider function as a Federal ACO. That way the$ follows the veteran patients, and the VHA provider has contracts with all OHi and VHA payer. Using this method the eligibility issue goes away since VHA providers are paid for all services from all payers, including all Federal. VHA providers have to become efficient since they have to run their operations on the same payer reimbursement payments as the private sector like Cleveland Clinic gets. For V AMCs that have extra capacity, they can take non-eligible veterans and family members since they are getting full reimbursement from their Health Insurance. Just my out of the box thinking, key is the legislation which at the same time we can ask for legislative relief on Government regulations on personnel, contracting, acquisition, and other items we identify that stop us from being competitive with the private sector. Time to level the playing field. Darin VA-19-0799-D-001309 OS 00002980 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001310 OS 00002981 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001311 OS 00002982 312 31 3 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001314 OS 00002985 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001315 OS 00002986 316 317 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/9/2017 8:17:31 PM David Shulkin [drshulkin@aol.com] Fwd: TEDVA Talk VA TED Talk 2.pptx; Untitled attachment 06071.htm; VA TED Talk 2.pptx; Untitled attachment 06074.htm Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: April 8, 2017 at 6:44:27 PM EDT To: David shulkin Subject: TEDVA Talk Hi David Attached are the two slides from my TEDVA talk. The second slide answers the questions on how the VHA providers, as a purely providers group, can get all of the OHi $ just like a Cleveland Clinic can, including the Federal (Medicare, Medicaid and TRICARE). Key is to have VHA internally fully separate the payer and provider functions and then have Congress designate the provider function as a Federal ACO. That way the$ follows the veteran patients, and the VHA provider has contracts with all OHi and VHA payer. Using this method the eligibility issue goes away since VHA providers are paid for all services from all payers, including all Federal. VHA providers have to become efficient since they have to run their operations on the same payer reimbursement payments as the private sector like Cleveland Clinic gets. For V AMCs that have extra capacity, they can take non-eligible veterans and family members since they are getting full reimbursement from their Health Insurance. Just my out of the box thinking, key is the legislation which at the same time we can ask for legislative relief on Government regulations on personnel, contracting, acquisition, and other items we identify that stop us from being competitive with the private sector. Time to level the playing field. Darin VA-19-0799-D-001318 OS 00002989 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001319 OS 00002990 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001320 OS 00002991 321 322 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001323 OS 00002994 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001324 OS 00002995 325 326 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/9/2017 8:17:16 PM Darin Selnick [(b) (6) @gmail.com] Fwd: TEDVA Talk VA TED Talk 2.pptx; Untitled attachment 06079.htm; VA TED Talk 2.pptx; Untitled attachment 06082.htm I didnt appreciate how this model achieved the goals- brilliant Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: April 8, 2017 at 6:44:27 PM EDT To: David shulkin Subject: TEDVA Talk Hi David Attached are the two slides from my TEDVA talk. The second slide answers the questions on how the VHA providers, as a purely providers group, can get all of the OHi $ just like a Cleveland Clinic can, including the Federal (Medicare, Medicaid and TRICARE). Key is to have VHA internally fully separate the payer and provider functions and then have Congress designate the provider function as a Federal ACO. That way the$ follows the veteran patients, and the VHA provider has contracts with all OHi and VHA payer. Using this method the eligibility issue goes away since VHA providers are paid for all services from all payers, including all Federal. VHA providers have to become efficient since they have to run their operations on the same payer reimbursement payments as the private sector like Cleveland Clinic gets. For V AMCs that have extra capacity, they can take non-eligible veterans and family members since they are getting full reimbursement from their Health Insurance. Just my out of the box thinking, key is the legislation which at the same time we can ask for legislative relief on Government regulations on personnel, contracting, acquisition, and other items we identify that stop us from being competitive with the private sector. Time to level the playing field. Darin VA-19-0799-D-001327 OS 00002998 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001328 OS 00002999 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001329 OS 00003000 330 331 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001332 OS 00003003 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001333 OS 00003004 334 335 Message From: Darin Selnick [(b) (6) Sent: 4/8/2017 10:44:27 PM To: David shulkin [Drshulkin@aol.com] TEDVA Talk VA TED Talk 2.pptx; VA TED Talk 2.pptx Subject: Attachments: @gmail.com] Hi David Attached are the two slides from my TEDVA talk. The second slide answers the questions on how the VHA providers, as a purely providers group, can get all of the OHI $ just like a Cleveland Clinic can, including the Federal (Medicare, Medicaid and TRICARE). Key is to have VHA internally fully separate the payer and provider functions and then have Congress designate the provider function as a Federal ACO. That way the$ follows the veteran patients, and the VHA provider has contracts with all OHI and VHA payer. Using this method the eligibility issue goes away since VHA providers are paid for all services from all payers, including all Federal. VHA providers have to become efficient since they have to run their operations on the same payer reimbursement payments as the private sector like Cleveland Clinic gets. For V AJ\tICs that have extra capacity, they can take non-eligible veterans and family members since they are getting full reimbursement from their Health Insurance. Just my out of the box thinking, key is the legislation which at the same time we can ask for legislative relief on Government regulations on personnel, contracting, acquisition, and other items we identify that stop us from being competitive with the private sector. Time to level the playing field. Darin VA-19-0799-D-001336 OS 00003007 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001337 OS 00003008 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001338 OS 00003009 339 t .= =-- ~- ~ VHA-Today : : -.-;,, #-~ - --=- - - _ 1r..----- Eligibility+ Facilities+ Footprint @ $ + Healthcare Model + Control $ 34% Reliance+ Staff Model + Congress Medicare 51 .3% $0 Congress 34% Reliance $65B ii? TII IAlKING DEAD Staff Model HMO SURVIVAL INSTINCT VA-19-0799-D-001340 OS 00003011 Veterans Clinic - Future Operate Like the Cleveland Clinic Eligibility+ Facilities+ Footprint = $ + Healthcare Model + Control $ Follows the Veteran + Federal ACO + Board of Directors Medicare 51 .3% 100% Services VHA Payer TBD 3/4 100% HC Services Other Services Veterans Clmic ~ Fecl~ral ACO TBD 3/4 100% Services VA-19-0799-D-001341 OS 00003012 342 Message From: (b) (6) Sent: 4/11/2017 9:10:44 PM Bruce Moskowitz [(b) (6) David Shulkin [drshulkin@aol.com] Re: Pacemaker To: CC: Subject: [(b) (6) gmail.com] mac.com] Good afternoon, Yes, there are national contracts that individual medical centers can use to order to orthopedic implantables and neuro implantables. Here are just a few names of the national contracts: Zimmer Smith & Nephew Biomet orthopedics Depuy orthopedics On Tue, Apr 11, 2017 at 4:46 PM (b) (6) Yes checking for you now <(b) (6) On Tue, Apr 11, 2017 at 4:45 PM Bruce Moskowitz <(b) (6) We are referring to orthopedic and neuro gmail.com> wrote: mac.com> wrote: Sent from my iPhone > On Apr 11, 2017, at 4:39 PM, (b) (6) <(b) (6) gmail.com> wrote: > > Hi Dr. Moskowitz, > > On behalf of Dr. Shulkin, we have a national pacemaker contract, each medical center individually orders off of that national contract. > > (b) (6) VA-19-0799-D-001343 OS 00003014 > -> Sent from Gmail Mobile Sent from Gmail Mobile Sent from Gm ail Mobile VA-19-0799-D-001344 OS 00003015 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/7/2017 8:26:39 PM To: Jennifer Lee [(b) (6) This is your idea Subject: gmail.com] https ://www.meritalk.com/the-situation-report-is-the-cio-job-at-va-about-to-lose-its-influence/ Sent from my iPhone VA-19-0799-D-001345 OS 00003016 Message From: Sent: To: Subject: IP [(b) (6) frenchangel59.com] 3/31/2017 4:16:00 AM David shulkin [drshulkin@aol.com] FW: VA And Apple From: IP [mailto:(b) (6) frenchangel59.com] Sent: Friday, March 31, 2017 12:05 AM To: (b) (6) who.eop.gov Cc: (b) (6) who.eop.gov; ' Subject: FW: VA And Apple (b ) EOP/WHO' Jared, As you know lvanka introduced me to (b) (6) at Apple and (b) (6) at Johnson & Johnson. Ours Academic team has done here is really outrageous. She may and experts have worked so well with them and their teams. What be very good in social media, but this an entirely different and very complicated area. We will fix this. All my Best, Ike From: IP [ mailto:(b) (6) frenchangel59.com] Sent: Thursday, March 30, 2017 11:56 PM To: (b) (6) omb.eop.gov Cc: (b) (6) who.eop.gov; lperl(b) (6) @qmail.com ; brucem(b) (6) Subject: FW: VA And Apple @mac.com ; mbs(b) (6) @qmail.com (b) (6) With all due respect, I am shocked and extremely disappointed with the manner in which you have engaged in individual communications with Apple - and intentionally excluded our broader team of subject matter experts. I understand that these backdoor discussions have apparently been occurring almost daily for weeks, and you have not told anyone and refuse to return phone calls and emails. When we first met on February 7th, I personally shared with you our vision and goals and explained that it is critical that everything we do must be done as a team. The very purpose of our Academic team, Dr. Moskowitz, and Marc Sherman is to ensure proper analysis, sharing of best practices, and provide a forum for discussion, debate, and ultimately the strongest collective decisions/recommendations. You agreed then, but your actions to date regarding Apple prove otherwise. on February 1st we discussed and agreed on the importance of leveraging our Academic When I spoke with (b) (6) team and experts for the end goal of creating the best system for our veterans. Further on our Apple conference call on March 3rd - which we invited you and (b) (6) to join - we again discussed and all agreed that for us to be successful and fix all the issues that our great veterans are going through on a daily basis, we must all unite and work as one team, with only one agenda and one goal. VA-19-0799-D-001346 OS 00003017 What we are seeing from you today is a blatant disregard for that commitment and clear disrespect to everyone involved. You are putting yourself, your own agenda, and your own ego ahead of our veterans. This is unacceptable. There are 22 veterans dying every day. Your decision to alone discuss IT and technology solutions with Apple for weeks without the broader team of experts and not informing me and Dr. Moskowitz is major step backwards and will only cause additional work and significant delays. As a result of your hijacking of this effort, Apple has already canceled conference calls. In fact, many of the current problems with the VA is because of this very reason - the lack of team work within. Let me be clear, I will not allow this to happen while I am involved. I want this resolved immediately. First, you must include Dr. Moskowitz and Marc Sherman on any and all calls or meetings. Additionally, I will formally ask you again to please respect me and our broader group of subject matter experts, and immediately cease individual discussions with Apple and/or any other parties related to the work we have undertaken regarding the VA. Ike -----Original Message----(b) (6) From: (b) (6) EOP/OMB fmailto:(b) (6) Sent: Thursday, March 30, 2017 6:48 PM To: Bruce Moskowitz Cc: (b) (6) EOP/WHO; IP; (b) (6) frenchangel59.com Subject: Re: VA And Apple omb.eop.gov] Hey team! We're making great progress, which I'm excited to fill you in on. Will send you more info when I get out of these back-to-back mtgs and will give you a ring back Ike! Thanks! > On Mar 30, 2017, at 6:49 AM, Bruce Moskowitz <(b) (6) mac.com > wrote: > > In the last email exchange i was supposed to receive information on your interaction with Apple so that we could rapidly obtain needed technology from our Academic Center Consortium upcoming discussion with Apple. I realize there are multiple technology issues on everyone's desk however we have medical emergencies daily at the VA that can only be solved by rapid deployment of new technology. I am available 24-7 by phone 561-3466(b) (6) Thank you > > Sent from my iPad > Bruce Moskowitz M.D. -----Original Message----From: Bruce Moskowitz fmailto:(b) (6) Sent: Tuesday, March 28, 2017 11:41 AM To: (b) (6) who.eop.gov; (b) (6) Cc: IP Subject: VA And Apple mac.com ] omb.eop.gov It would be of benefit to discuss what we can accomplish in technology with Apple for the benefit of the VA. It would be of importance to understand what discussions the Whitehouse team has already had with Apple so that we have a clear path forward and do not duplicate what has already been accomplished. Let me know a convenient time to talk. Thank you VA-19-0799-D-001347 OS 00003018 Sent from my iPad Bruce Moskowitz MD. 348 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/3/2017 12:51:49 AM To: Darin Selnick [(b) (6) @gmail.com] Re: CVA Support of your statement today Subject: Thanks Sent from my iPhone On Apr 2, 2017, at 7: 14 PM, Darin Selnick <(b) (6) @gmail.com> wrote: Good job on Fox and Friends today. I received some feedback from people who saw it who said you did well. Your effort is working on changing the narrative, as per this article from daily caller. http ://dailycaller.com/2017/04/02/va-secretary-backs-maj or-legislation-to-fire-incompetentcorrupt-employees-in-historic-move/ Besides fox and friends, I understand a lot of Republican members read the Daily Caller, so it will be interesting to see how much movement we get this week. Bottom line, public, veterans and VA staff know you are serious about accountability and that is important and a win. Darin On Sat, Apr 1, 2017 at 12:31 PM, Darin Selnick <(b) (6) Great, happy to assist. @gmail.com> wrote: On Sat, Apr 1, 2017 at 12:22 PM, David shulkin wrote: I like this idea Up until now I wasnt sure who could do this but i agree Sent from my iPhone On Apr 1, 2017, at 3:15 PM, Darin Selnick <(b) (6) @gmail.com> wrote: Just a thought, as part of being proactive with the press we could have both an internal and external surrogate program in order to drive our VA narrative. That is what we did at VA and why CVA is in the media so much. Internally we can have besides you, a few trusted senior staff to meet with the media, they can be trained. Externally we can people like Newt Gingrich. We all would have talking points so we drive our message. For example on this story, I could have gone on Fox and Friends as your surrogate. I did this all the time at CVA and was on a number of Fox shows and CNN. I can do again if you want in the future. Something to explore with your new Asst Sec OPIA and WH. VA-19-0799-D-001349 OS 00003020 Darin On Sat, Apr 1, 2017 at 6:22 AM, Darin Selnick <(b) (6) wrote: Will do @gmail.com> On Sat, Apr 1, 2017 at 5:08 AM, David shulkin wrote: This is really great to see Please thank them on behalf of all of us at the Department Sent from my iPhone On Mar 31, 2017, at 10:50 PM, Darin Selnick <(b) (6) wrote: @gmail.com> FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) @gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire PornWatching Employee, VA Secretary Demands VA-19-0799-D-001350 OS 00003021 Accountability Legislation Is Taken Up Arlington, VA - After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 201 7, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process VA-19-0799-D-001351 OS 00003022 for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsd uCrVLSqatgFsbFtqqHnuD2i86vPbmc7itP AXk5bAdJu3mdaBt 8dckgr5uUi38Kh8cYRBWyhYbBHxWNZEQ6CXY6EmzF9N QvsnV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 2220 I VA, USA VA-19-0799-D-001352 OS 00003023 Message From: Darin Selnick [(b) (6) Sent: 4/2/2017 11:14:41 PM To: David shulkin [Drshulkin@aol.com] Re: CVA Support of your statement today Subject: @gmail.com] Good job on Fox and Friends today. I received some feedback from people who saw it who said you did well. Your effort is working on changing the narrative, as per this article from daily caller. http ://dailycaller.com/2017/04/02/va-secretary-backs-major-legislation-to-fire-incompetent-corrupt-employeesin-historic-move/ Besides fox and friends, I understand a lot of Republican members read the Daily Caller, so it will be interesting to see how much movement we get this week. Bottom line, public, veterans and VA staff know you are serious about accountability and that is important and a win. Darin On Sat, Apr 1, 2017 at 12:31 PM, Darin Selnick <(b) (6) Great, happy to assist. @gmail.com> wrote: On Sat, Apr 1, 2017 at 12:22 PM, David shulkin wrote: I like this idea Up until now I wasnt sure who could do this but i agree Sent from my iPhone On Apr 1, 2017, at 3:15 PM, Darin Selnick <(b) (6) @gmail.com> wrote: Just a thought, as part of being proactive with the press we could have both an internal and external surrogate program in order to drive our VA narrative. That is what we did at VA and why CVA is in the media so much. Internally we can have besides you, a few trusted senior staff to meet with the media, they can be trained. Externally we can people like Newt Gingrich. We all would have talking points so we drive our message. For example on this story, I could have gone on Fox and Friends as your surrogate. I did this all the time at CVA and was on a number of Fox shows and CNN. I can do again if you want in the future. Something to explore with your new Asst Sec OPIA and WH. Darin On Sat, Apr 1, 2017 at 6:22 AM, Darin Selnick <(b) (6) Will do @gmail.com> wrote: On Sat, Apr 1, 2017 at 5:08 AM, David shulkin wrote: VA-19-0799-D-001353 OS 00003024 This is really great to see Please thank them on behalf of all of us at the Department Sent from my iPhone On Mar 31, 2017, at 10:50 PM, Darin Selnick <(b) (6) @gmail.com> wrote: FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) @gmail. com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire PornWatching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA - After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced VA-19-0799-D-001354 OS 00003025 to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned VA-19-0799-D-001355 OS 00003026 Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgF sbFtqqHnuD2i86vPbmc7itP AXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWy hYbBHxWNZEQ6CXY6EmzF9NQvsnV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001356 OS 00003027 Message From: Darin Selnick [(b) (6) Sent: 4/1/2017 7:31:30 PM To: David shulkin [Drshulkin@aol.com] Re: CVA Support of your statement today Subject: @gmail.com] Great, happy to assist. On Sat, Apr 1, 2017 at 12:22 PM, David shulkin wrote: I like this idea Up until now I wasnt sure who could do this but i agree Sent from my iPhone On Apr 1, 2017, at 3:15 PM, Darin Selnick <(b) (6) @gmail.com> wrote: Just a thought, as part of being proactive with the press we could have both an internal and external surrogate program in order to drive our VA narrative. That is what we did at VA and why CVA is in the media so much. Internally we can have besides you, a few trusted senior staff to meet with the media, they can be trained. Externally we can people like Newt Gingrich. We all would have talking points so we drive our message. For example on this story, I could have gone on Fox and Friends as your surrogate. I did this all the time at CVA and was on a number of Fox shows and CNN. I can do again if you want in the future. Something to explore with your new Asst Sec OPIA and WH. Darin On Sat, Apr 1, 2017 at 6:22 AM, Darin Selnick <(b) (6) Will do @gmail.com> wrote: On Sat, Apr 1, 2017 at 5:08 AM, David shulkin wrote: This is really great to see Please thank them on behalf of all of us at the Department Sent from my iPhone On Mar 31, 2017, at 10:50 PM, Darin Selnick <(b) (6) @gmail.com> wrote: FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. VA-19-0799-D-001357 OS 00003028 Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) @gmail. com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire PornWatching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA - After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that VA-19-0799-D-001358 OS 00003029 problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFs bFtqqHnuD2i86vPbmc7itP AXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWyh YbBHxWNZEQ6CXY6EmzF9NQvsnV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001359 OS 00003030 360 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/1/2017 7:22:51 PM To: Darin Selnick [(b) (6) @gmail.com] Re: CVA Support of your statement today Subject: I like this idea Up until now I wasnt sure who could do this but i agree Sent from my iPhone On Apr 1, 2017, at 3:15 PM, Darin Selnick <(b) (6) @gmail.com> wrote: Just a thought, as part of being proactive with the press we could have both an internal and external surrogate program in order to drive our VA narrative. That is what we did at VA and why CVA is in the media so much. Internally we can have besides you, a few trusted senior staff to meet with the media, they can be trained. Externally we can people like Newt Gingrich. We all would have talking points so we drive our message. For example on this story, I could have gone on Fox and Friends as your surrogate. I did this all the time at CVA and was on a number of Fox shows and CNN. I can do again if you want in the future. Something to explore with your new Asst Sec OPIA and WH. Darin On Sat, Apr 1, 2017 at 6:22 AM, Darin Selnick <(b) (6) Will do @gmail.com> wrote: On Sat, Apr 1, 2017 at 5:08 AM, David shulkin wrote: This is really great to see Please thank them on behalf of all of us at the Department Sent from my iPhone On Mar 31, 2017, at 10:50 PM, Darin Selnick <(b) (6) @gmail.com> wrote: FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press VA-19-0799-D-001361 OS 00003032 Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) @gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire PornWatching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA - After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. VA-19-0799-D-001362 OS 00003033 "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsb FtqqHnuD2i86vPbmc7itP AXk5bAdJu3mdaBt8dckgr5u Ui3 8Kh8cYRBWyh Yb BHxWNZEQ6CXY6EmzF9NQvsnV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001363 OS 00003034 Message From: Wright, Vivieca (Simpson) [Vivieca.Wright@va.gov] Sent: 4/1/2017 3:00:10 PM To: 'David shulkin' [Drshulkin@aol.com] RE: [EXTERNAL] Fwd: CVA Support of your statement today Subject: Great! -----Original Message----From: David shulkin [Drshulkin@aol.com] Sent: Saturday, April 01, 2017 10:58 AM Eastern Standard Time To: Wright, Vivieca (Simpson) Subject: Re: [EXTERNAL] Fwd: CVA Support of your statement today Yup and something we can fix Fox wants me on in the mornjng to discuss Sent from my iPhone On Apr 1, 2017, at 10:42 AM, Wright, Vivieca (Simpson) wrote: Good article. Steve has a job ahead of him. The discussion on April 25 with all leaders has to go into detail on this matter. This is the number 1 issue that is holding back the agency. -----Original Message----From: David shulkin [Drshulkin@aol.com] Sent: Saturday, April 01, 2017 08:09 AM Eastern Standard Time To: Wright, Vivieca (Simpson) Subject: [EXTERNAL] Fwd: CVA Support of your statement today Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: March 31, 2017 at 10:50: 15 PM EDT To: David shulkin Subject: CVA Support of your statement today VA-19-0799-D-001364 OS 00003035 FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) @gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire PornWatching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA-After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 201 7, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: VA-19-0799-D-001365 OS 00003036 "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsbFt qqHnuD2i86vPbmc7itPAXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWyh YbBHx WNZEQ6CXY6EmzF9NQvsn V3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001366 OS 00003037 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/1/2017 2:57:48 PM To: Wright, Vivieca (Simpson) [Vivieca.Wright@va.gov] Re: [EXTERNAL] Fwd: CVA Support of your statement today Subject: Yup and something we can fix Fox wants me on in the mornjng to discuss Sent from my iPhone On Apr 1, 2017, at 10:42 AM, Wright, Vivieca (Simpson) wrote: Good article. Steve has a job ahead of him. The discussion on April 25 with all leaders has to go into detail on this matter. This is the number 1 issue that is holding back the agency. -----Original Message----From: David shulkin [Drshulkin@aol.com] Sent: Saturday, April 01, 2017 08:09 AM Eastern Standard Time To: Wright, Vivieca (Simpson) Subject: [EXTERNAL] Fwd: CVA Support of your statement today Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: March 31, 2017 at 10:50: 15 PM EDT To: David shulkin Subject: CVA Support of your statement today FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up VA-19-0799-D-001367 OS 00003038 To: (b) (6) @gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire PornWatching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA-After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA VA-19-0799-D-001368 OS 00003039 Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsbFt qqHnuD2i86v Pbmc7itPAXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWyh YbBHx WNZEQ6CXY6EmzF9NQvsnV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001369 OS 00003040 Message From: Wright, Vivieca (Simpson) [Vivieca.Wright@va.gov] Sent: 4/1/2017 2:42:36 PM To: 'David shulkin' [Drshulkin@aol.com] RE: [EXTERNAL] Fwd: CVA Support of your statement today Subject: Good article. Steve has a job ahead of him. The discussion on April 25 with all leaders has to go into detail on this matter. This is the number 1 issue that is holding back the agency. -----Original Message----From: David shulkin [Drshulkin@aol.com] Sent: Saturday, April 01, 2017 08:09 AM Eastern Standard Time To: Wright, Vivieca (Simpson) Subject: [EXTERNAL] Fwd: CVA Support of your statement today Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: March 31, 2017 at 10:50: 15 PM EDT To: David shulkin Subject: CVA Support of your statement today FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) k@gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org VA-19-0799-D-001370 OS 00003041 CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA-After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also VA-19-0799-D-001371 OS 00003042 empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsbFtqqHnuD2i86v Pbmc7itP AXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWyh YbBHx WNZEQ6CXY6EmzF9NQv snV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001372 OS 00003043 Message From: Darin Selnick [(b) (6) Sent: 4/1/2017 1:22:22 PM To: David shulkin [Drshulkin@aol.com] Re: CVA Support of your statement today Subject: @gmail.com] Will do On Sat, Apr 1, 2017 at 5:08 AM, David shulkin wrote: This is really great to see Please thank them on behalf of all of us at the Department Sent from my iPhone On Mar 31, 2017, at 10:50 PM, Darin Selnick <(b) (6) @gmail.com> wrote: FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) k@gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up VA-19-0799-D-001373 OS 00003044 Arlington, VA-After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, VA-19-0799-D-001374 OS 00003045 please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsbFtqqHnuD2i86v Pbmc7itP AXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWyh YbBHxWNZEQ6CXY6EmzF9NQ vsn V3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001375 OS 00003046 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/1/2017 12:09:24 PM To: Vivieca Wright Simpson [vivieca.Wright@va.gov] Fwd: CVA Support of your statement today Subject: Sent from my iPhone Begin forwarded message: From: Darin Selnick <(b) (6) @gmail.com> Date: March 31, 2017 at 10:50: 15 PM EDT To: David shulkin Subject: CVA Support of your statement today FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) k@gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up VA-19-0799-D-001376 OS 00003047 Arlington, VA-After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, VA-19-0799-D-001377 OS 00003048 please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsbFtqqHnuD2i86v Pbmc7itP AXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWyh YbBHx WNZEQ6CXY6EmzF9NQv snV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001378 OS 00003049 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/1/2017 12:08:56 PM To: Darin Selnick [(b) (6) @gmail.com] Re: CVA Support of your statement today Subject: This is really great to see Please thank them on behalf of all of us at the Department Sent from my iPhone On Mar 31, 2017, at 10:50 PM, Darin Selnick <(b) (6) @gmail.com> wrote: FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message ---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) k@gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA-After the Department of Veterans Affairs (VA) failed to quickly remove an VA-19-0799-D-001379 OS 00003050 employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsbFtqqHnuD2i86v VA-19-0799-D-001380 OS 00003051 Pbmc7itP AXk5bAdJu3mdaBt8dckgr5uUi3 8Kh8cYRBWyh YbBHx WNZEQ6CXY6EmzF9NQv snV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001381 OS 00003052 Message From: Darin Selnick [(b) (6) Sent: 4/1/2017 2:50:15 AM To: David shulkin [Drshulkin@aol.com] CVA Support of your statement today Subject: @gmail.com] FYI I thought you would want to see the CVA statement supporting you. Starting Monday they will be pushing on Senate members to move the bill. Darin ---------- Forwarded message---------From: CVA - Press Date: Fri, Mar 31, 2017 at 5:35 PM Subject: Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up To: (b) (6) @gmail.com For Immediate Release: March 31, 2017 Media Contact: press@cv4a.org CONCERNED VETERANS FOR AMERICA Unable to Quickly Fire Porn-Watching Employee, VA Secretary Demands Accountability Legislation Is Taken Up Arlington, VA-After the Department of Veterans Affairs (VA) failed to quickly remove an employee caught watching pornography with a VA patient, VA Secretary David Shulkin is demanding strong VA accountability measures. "VA has been working with Congress to ensure legislation would provide VA the ability to expedite removals while still preserving an employee's right to due process. Without these legislative changes, VA will continue to be forced to delay immediate actions to remove employees from federal service," the VA wrote in a statement. The VA Secretary is referring to the VA Accountability First Act of 2017, a measure that would shorten the termination and appeals process for removing bad employees while protecting whistleblowers who speak up about wrongdoings. VA-19-0799-D-001382 OS 00003053 Concerned Veterans for America (CVA) Policy Director Dan Caldwell issued the following statement: "It is incredibly refreshing to see Dr. Shulkin emphatically calling for strong accountability measures at the VA Under the previous administration, the Secretaries spent most of their time denying that problems within the department existed. By acknowledging the need for systemic reform, Secretary Shulkin has taken a bold and courageous step in helping veterans push Congress to pass meaningful accountability legislation. "An employee caught watching pornography with a VA patient should be escorted out of the building immediately, never to return. The VA is forced to retain employees like this due to incredibly cumbersome and bureaucratic regulations. To change this, the Senate must move quickly on the VA Accountability First Act of 2017, a bill supported by the President, VA Secretary, major veteran organizations, and veterans around the country who need and deserve better care than what they're getting from the VA" CVA supports the VA Accountability First Act of 2017, which passed through the House with bipartisan support earlier this month. The Senate version of the bill, introduced by Senator Marco Rubio (R-FL), has not yet been scheduled for a vote. If passed, the 2017 VA Accountability First Act would drastically shorten the overall termination and appeals process for Department of Veterans Affairs (VA) employees who are found to have engaged in misconduct. Currently, that process can take months or even years. The bill also empowers the VA Secretary to recoup bonuses awarded in error or given to employees who were later found to have engaged in misconduct. Additionally, the bill gives the VA Secretary the ability to reduce the pensions of VA employees who are convicted of felonies that influenced their job performance. Earlier this week, it was reported that one VA hospital held a job open for its accountant while he served a prison term for killing someone and hired a convicted child molester, keeping him on VA payroll while he repeatedly reoffended. ### If you would rather not receive future communications from Concerned Veterans for America, please go to https ://optout.cision.com/en/2LlqdTrCUnjiC2jNYlbavkvLLsduCrVLSqatgFsbFtqqHnuD2i86vPbmc7itPAXk5 bAdJu3mdaBt8dckgr5uUi38Kh8cYRBWyhYbBHxWNZEQ6CXY6EmzF9NQvsnV3NcjWkfc. Concerned Veterans for America, 1310 N. Courthouse Rd, Arlington, 22201 VA, USA VA-19-0799-D-001383 OS 00003054 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/3/2017 4:29:13 PM (b) (6) [(b) (6) pcommgroup.com] (b) (6) IP [ frenchangel59.com]; Marisol Garcia [(b) (6) frenchangel59.com]; (b) (6) Simpson [(b) (6) gmail.com] Re: DRAFT: VA COMMUNICATIONS TASK FORCE [(b) (6) pcommgroup.com]; Vivieca I like the way you think Sent from my iPhone On Apr 3, 2017, at 12:02 PM, (b) (6) <(b) (6) pcommgroup.com> wrote: Thank you. Understood. We can also call it a volunteer communications advisory committee etc. On Apr 3, 2017, at 9:00 AM, David shulkin wrote: (b) (6) thanks so much . Like many things in government- its always a bit complicated. There are rules around task forces so let me get some internal guidance on the least complex way to approach this. Thanks David Shulkin Sent from my iPhone On Apr 3, 2017, at 11:21 AM, (b) (6) <(b) (6) pcommgroup.com > wrote: Thank you Dr. Shulkin. I am glad the list works, we agree it is a good start. As per below the only target I socialized the idea with was (b) (6) who heads communications for 2P1 Century Fox and the Murdochs. I think the approach is critical, from my POV it is important we outline the task force's specific goals, time commitment and if applicable the corporate approval/support/relationship that exists (i.e. Apple, Johnson & Johnson, Disney, Fox, etc). To this end, I suggest the following: 1) We will draft an outline of the Task Force's role, commitment and goals. 2) We will create an excel grid so you may input existing relationships with each associated C-Suite. The goal is to really get a commitment from the "host" company. Where you have an existing relationship, (i.e. (b) (6) the invitation VA-19-0799-D-001384 OS 00003055 letter can go to the target+ CC the C-Suite relationship (ex. (b) (6) Where there is no existing C-Suite relationship, we can navigate the best route to reach each target, in many or most cases we can provide. I assume all costs associated with travel and accommodations would be subsidized by the host company. Available to speak as needed. Best, (b) (6) David shulkin [mailto:Drshulkin@aol.com] Sent: Monday, April 3, 2017 3:59 AM (b) (6) To: <(b) (6) pcommgroup.com> (b) (6) Cc: IP < frenchangel59.com >; Marisol Garcia <(b) (6) frenchangel59.com >; (b) (6) <(b) (6) pcommgroup.com> Subject: Re: DRAFT: VA COMMUNICATIONS TASK FORCE From: (b) (6) once again thank you. This is a perfect list and you did an amazing job pulling it together. As a next step - is this a group of prospects or is this a group that has already agreed to help? Should i reach out to them to invite them to join an advisory group? Or do you have a different suggestion? David Shulkin Secretary, US Department of Veterans Affairs Sent from my iPhone On Mar 28, 2017, at 3:41 PM, (b) (6) <(b) (6) pcommgroup.com > wrote: Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 2P1 Century Fox, who is committed to the idea and involvement and shared that her VA-19-0799-D-001385 OS 00003056 leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001386 OS 00003057 Message (b) (6) [(b) (6) pcommgroup.com] 4/3/2017 4:02:27 PM David shulkin [Drshulkin@aol.com] IP [(b) (6) frenchangel59.com]; Marisol Garcia [(b) (6) frenchangel59.com]; (b) (6) Simpson [(b) (6) gmail.com] Re: DRAFT: VA COMMUNICATIONS TASK FORCE From: Sent: To: CC: Subject: [(b) (6) pcommgroup.com]; Vivieca Thank you. Understood. We can also call it a volunteer communications advisory committee etc. On Apr 3, 2017, at 9:00 AM, David shulkin wrote: (b) (6) thanks so much . Like many things in government- its always a bit complicated. There are rules around task forces so let me get some internal guidance on the least complex way to approach this. Thanks David Shulkin Sent from my iPhone On Apr 3, 2017, at 11:21 AM, (b) (6) <(b) (6) pcommgroup.com > wrote: Thank you Dr. Shulkin. I am glad the list works, we agree it is a good start. As per below the only target I socialized the idea with was (b) (6) heads communications for 2P1 Century Fox and the Murdochs. who I think the approach is critical, from my POV it is important we outline the task force's specific goals, time commitment and if applicable the corporate approval/support/relationship that exists (i.e. Apple, Johnson & Johnson, Disney, Fox, etc). To this end, I suggest the following: 1) We will draft an outline of the Task Force's role, commitment and goals. 2) We will create an excel grid so you may input existing relationships with each associated C-Suite. The goal is to really get a commitment from the "host" company. Where you have an existing the invitation letter can go to the target+ relationship, (i.e. (b) (6) CC the C-Suite relationship (ex. (b) (6) Where there is no existing C-Suite relationship, we can navigate the best route to reach each target, in many or most cases we can provide. I assume all costs associated with travel and accommodations would be subsidized by the host company. Available to speak as needed. Best, VA-19-0799-D-001387 OS 00003058 Melissa From: David shulkin [mailto :Drshulkin@aol.com ] Sent: Monday, April 3, 2017 3:59 AM <(b) (6) pcommgroup.com> Cc: IP <(b) (6) frenchangel59.com >; Marisol Garcia <(b) (6) frenchangel59.com >; <(b) (6) pcommgroup.com > Subject: Re: DRAFT: VA COMMUNICATIONS TASK FORCE To: (b) (6) (b) (6) (b) (6) once again thank you. This is a perfect list and you did an amazing job pulling it together. As a next step - is this a group of prospects or is this a group that has already agreed to help? Should i reach out to them to invite them to join an advisory group? Or do you have a different suggestion? David Shulkin Secretary, US Department of Veterans Affairs Sent from my iPhone On Mar 28, 2017, at 3:41 PM, (b) (6) <(b) (6) pcommgroup.com > wrote: Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. of Please note, the only name we approached was (b) (6) 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001388 OS 00003059 Message David shulkin [Drshulkin@aol.com] 4/3/2017 4:00:56 PM (b) (6) [(b) (6) pcommgroup.com] (b) (6) IP [ frenchangel59.com]; Marisol Garcia [(b) (6) frenchangel59.com]; (b) (6) Simpson [(b) (6) gmail.com] Re: DRAFT: VA COMMUNICATIONS TASK FORCE From: Sent: To: CC: Subject: [(b) (6) pcommgroup.com]; Vivieca (b) (6) thanks so much . Like many things in government- its always a bit complicated. There are rules around task forces so let me get some internal guidance on the least complex way to approach this. Thanks David Shulkin Sent from my iPhone On Apr 3, 2017, at 11:21 AM, (b) (6) <(b) (6) pcommgroup.com > wrote: Thank you Dr. Shulkin. I am glad the list works, we agree it is a good start. As per below the only target I socialized the idea with was (b) (6) communications for 2P1 Century Fox and the Murdochs. who heads I think the approach is critical, from my POV it is important we outline the task force's specific goals, time commitment and if applicable the corporate approval/support/relationship that exists (i.e. Apple, Johnson & Johnson, Disney, Fox, etc). To this end, I suggest the following: 1) We will draft an outline of the Task Force's role, commitment and goals. 2) We will create an excel grid so you may input existing relationships with each associated C-Suite. The goal is to really get a commitment from the "host" company. Where you have an existing relationship, (i.e. (b) (6) the invitation letter can go to the target+ CC the C-Suite relationship (ex. (b) (6) Where there is no existing C-Suite relationship, we can navigate the best route to reach each target, in many or most cases we can provide. I assume all costs associated with travel and accommodations would be subsidized by the host company. Available to speak as needed. Best, (b) (6) From: David shulkin [mailto:Drshulkin@aol.com ] Sent: Monday, April 3, 2017 3:59 AM (b) (6) <(b) (6) pcommgroup.com > To: VA-19-0799-D-001389 OS 00003060 Cc: IP <(b) (6) frenchangel59.com >; Marisol Garcia <(b) (6) frenchangel59.com >; <(b) (6) pcommgroup.com > Subject: Re: DRAFT: VA COMMUNICATIONS TASK FORCE (b) (6) (b) (6) once again thank you. This is a perfect list and you did an amazing job pulling it together. As a next step - is this a group of prospects or is this a group that has already agreed to help? Should i reach out to them to invite them to join an advisory group? Or do you have a different suggestion? David Shulkin Secretary, US Department of Veterans Affairs Sent from my iPhone On Mar 28, 2017, at 3:41 PM, (b) (6) <(b) (6) pcommgroup.com > wrote: Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001390 OS 00003061 Message (b) (6) CC: [(b) (6) pcommgroup.com] 4/3/2017 3:21:01 PM David shulkin [Drshulkin@aol.com] IP [(b) (6) frenchangel59.com]; Marisol Garcia [(b) (6) frenchangel59.com]; (b) (6) Subject: RE: DRAFT: VA COMMUNICATIONS TASK FORCE From: Sent: To: Thank you Dr. Shulkin. I am glad the list works, we agree it is a good start. As per below the only target I socialized the idea with was (b) (6) Century Fox and the Murdochs. [(b) (6) pcommgroup.com] who heads communications for 21 st I think the approach is critical, from my POV it is important we outline the task force's specific goals, time commitment and if applicable the corporate approval/support/relationship that exists (i.e. Apple, Johnson & Johnson, Disney, Fox, etc). To this end, I suggest the following: 1) We will draft an outline of the Task Force's role, commitment and goals. 2) We will create an excel grid so you may input existing relationships with each associated C-Suite. The goal is to really get a commitment from the "host" company. Where you have an existing relationship, (i.e. (b) (6) the invitation letter can go to the target+ (b) (6) CC the C-Suite relationship (ex. Where there is no existing C-Suite relationship, we can navigate the best route to reach each target, in many or most cases we can provide. I assume all costs associated with travel and accommodations would be subsidized by the host company. Available to speak as needed. Best, (b) (6) From: David shulkin [mailto:Drshulkin@aol.com] Sent: Monday, April 3, 2017 3:59 AM <(b) (6) pcommgroup.com> Cc: IP < frenchangel59.com>; Marisol Garcia <(b) (6) frenchangel59.com>; Subject: Re: DRAFT: VA COMMUNICATIONS TASK FORCE To: (b) (6) (b) (6) (b) (6) (b) (6) <(b) (6) pcommgroup.com> once again thank you. This is a perfect list and you did an amazing job pulling it together. As a next step - is this a group of prospects or is this a group that has already agreed to help? Should i reach out to them to invite them to join an advisory group? Or do you have a different suggestion? David Shulkin Secretary, US Department of Veterans Affairs Sent from my iPhone On Mar 28, 2017, at 3:41 PM, (b) (6) <(b) (6) pcommgroup.com > wrote: Dr. Shulkin: VA-19-0799-D-001391 OS 00003062 It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. of 21 st Century Fox, who is Please note, the only name we approached was (b) (6) committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001392 OS 00003063 Message David shulkin [Drshulkin@aol.com] From: Sent: 4/3/2017 10:58:39 AM To: (b) (6) [(b) (6) [(b) (6) frenchangel59.com]; pcommgroup.com] Marisol Garcia [(b) (6) frenchangel59.com]; (b) (6) CC: IP Subject: Re: DRAFT: VA COMMUNICATIONS TASK FORCE (b) (6) [(b) (6) pcommgroup.com] once again thank you. This is a perfect list and you did an amazing job pulling it together. As a next step - is this a group of prospects or is this a group that has already agreed to help? Should i reach out to them to invite them to join an advisory group? Or do you have a different suggestion? David Shulkin Secretary, US Department of Veterans Affairs Sent from my iPhone On Mar 28, 2017, at 3:41 PM, (b) (6) <(b) (6) pcommgroup.com > wrote: Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001393 OS 00003064 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/3/2017 1:47:23 AM To: Vivieca Simpson [(b) (6) Subject: Re: DRAFT: VA COMMUNICATIONS TASK FORCE gmail.com] Tommorow- im on a train from 7 am to 9 am and free again 1130- 12 est Sent from my iPhone On Apr 2, 2017, at 9: 12 PM, Vivieca Simpson <(b) (6) gmail.com> wrote: Do you want to talk tonight or tomorrow. On Mar 30, 2017 12: 19, "David shulkin" wrote: We need to discuss somewhat urgently Sent from my iPhone Begin forwarded message: From: David shulkin Date: March 28, 2017 at 3: 13: 49 PM CDT To: Vivieca Wright Simpson Subject: Fwd: DRAFT: VA COMMUNICATIONS TASK FORCE Lets discuss Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) pcommgroup.com> Date: March 28, 2017 at 3: 41: 44 PM EDT To: David shulkin , IP Cc: Marisol Garcia <(b) (6) frenchangel59 .com>, (b) (6) <(b) (6) pcommgroup.com> Subject: DRAFT: VA COMMUNICATIONS TASK FORCE Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. VA-19-0799-D-001394 OS 00003065 Please note, the only name we approached was (b) (6) of st 21 Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001395 OS 00003066 Message From: Sent: To: Subject: Vivieca Simpson [(b) (6) gmail.com] 4/3/2017 1:12:06 AM David shulkin [Drshulkin@aol.com] Re: Fwd: DRAFT: VA COMMUNICATIONS TASK FORCE Do you want to talk tonight or tomorrow. On Mar 30, 2017 12: 19, "David shulkin" wrote: We need to discuss somewhat urgently Sent from my iPhone Begin forwarded message: From: David shulkin Date: March 28, 2017 at 3: 13: 49 PM CDT To: Vivieca Wright Simpson Subject: Fwd: DRAFT: VA COMMUNICATIONS TASK FORCE Lets discuss Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) pcommgroup.com> Date: March 28, 2017 at 3: 41: 44 PM EDT To: David shulkin , IP <(b) (6) frenchangel59.com> Cc: Marisol Garcia <(b) (6) frenchangel59.com>, (b) (6) <(b) (6) pcommgroup.com> Subject: DRAFT: VA COMMUNICATIONS TASK FORCE Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. of 2P1 Century Please note, the only name we approached was (b) (6) Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. VA-19-0799-D-001396 OS 00003067 Best 7 - Paul 397 Message From: Sent: To: CC: Subject: Attachments: David shulkin [Drshulkin@aol.com] 3/30/2017 5:19:45 PM Vivieca Simpson [(b) (6) gmail.com] (b) (6) [(b) (6) gmail.com] Fwd: DRAFT: VA COMMUNICATIONS TASK FORCE VA Comms Committee Draft 1 3.28.17.docx; Untitled attachment 06181.htm We need to discuss somewhat urgently Sent from my iPhone Begin forwarded message: From: David shulkin Date: March 28, 2017 at 3:13:49 PM CDT To: Vivieca Wright Simpson Subject: Fwd: DRAFT: VA COMMUNICATIONS TASK FORCE Lets discuss Sent from my iPhone Begin forwarded message: <(b) (6) pcommgroup.com > Date: March 28, 2017 at 3:41:44 PM EDT To: David shulkin , IP <(b) (6) frenchangel59.com > Cc: Marisol Garcia <(b) (6) frenchangel59.com >, (b) (6) <(b) (6) pcommgroup.com > From: (b) (6) Subject: DRAFT: VA COMMUNICATIONS TASK FORCE Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001398 OS 00003069 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Facebook, Inc. Vice President- Communications and Public Policy at Facebook Mr. (b) (6) serves as Vice President of Global Communications, Marketing and Public Policy at Facebook, is responsible for developing and coordinating key messages about products, Inc. At Facebook, Mr. (b) (6) corporate business and partnerships. He also oversees Facebook's public policy strategy worldwide. He served as Strategic Advisor of luminate, Inc. He served as Vice President of Public Affairs and Global Communications at Google Inc. since October 2005. He served as a Board Observer of luminate, Inc. He helped broaden and coordinate Google's messaging from a focus on product PR to include all aspects of corporate, financial, policy, philanthropic and internal communications. Prior to Google, he was the Bernard l. Schwarz Senior Fellow in business and foreign policy at the New York-based Council on Foreign Relations. In his career, he served as Senior Vice President of Global Affairs at Gap Inc. and an Adjunct Professor at Columbia University and Columbia law School. He is a contributor to the Harvard Business Review and the Financial Times. Mr. (b) (6) holds a bachelor's degree from Harvard University, a master's degree in public policy from the Kennedy School of Government and a J.D. from Harvard law School. He studied at Ecole Normale Superieure. (b) (6) - NH Executive vice president of communications (b) (6) a former press secretary for President Bill Clinton, will join the NFL as the league's executive vice joins the NFL from a Washington, D.C.-based communications and president of communications. (b) (6) government affairs firm he co-founded. He was Clinton's press secretary from 1998 to 2000 and an advisor and press secretary to several presidential campaigns over two decades. Reports to NFL chief operating officer Tod leiweke (b) (6) Apple Vice president of Communications (b) (6) (b) (6) is Apple's vice president of Communications, reporting to CEO (b) (6) is responsible for Apple's worldwide media relations and communications strategy, leading the public relations team as well as employee communications and corporate events. He previously led Apple's corporate public relations team for ten years. Before joining Apple in 2003, (b) (6) worked as a broadcast journalist at CNBC, first as a writer and producer in the network's Washington, D.C. bureau. He later established CNBC's Silicon Valley bureau and holds a bachelor's degree in Political Science from served as bureau chief. A native of Massachusetts, (b) (6) the University of Minnesota (b) (6) - WME Chief Communications Officer (b) (6) is chief communications officer for WME and IMG. In his position, (b) (6) serves as the companies' chief communications strategist, handling media relations, internal communication, advertising, and events for all of WM E's divisions and offices. (b) (6) also serves as an advisor to many of the agency's clients, providing communication and marketing services to some of the world's leading artists and brands, including Hasbro, Mark Wahlberg, M. Night Shyamalan, Usher and James Frey. As a specialist in entertainment trade and has secured corporate and client profiles in such publications as the New York Times, business press, (b) (6) 1 VA-19-0799-D-001399 OS 00003070 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 Wall Street Journal, Los Angeles Times, Fast Company, Forbes, Financial Times, Fortune, Vanity Fair, The Hollywood Reporter and Variety. (b) (6) also oversees WM E's philanthropic initiatives, including the launch of an annual all-company volunteer day and the adoption of Foster Elementary School in Compton, California. WME is helping transform the school's campus, resources and overall academic performance. Named to The Hollywood Reporter's "Next Generation" list, which recognizes the top entertainment executives under 35, (b) (6) was previously the head of Corporate Communications for the William Morris Agency. At WMA, he handled all corporate press for the agency, including coverage of its 2009 merger with Endeavor which resulted worked in international in the creation of WME. Prior to joining the William Morris Agency in 2004, (b) (6) publicity and marketing at Warner Bros. Pictures, helping to launch campaigns for such films as "Harry Potter," "Matrix Reloaded," "Ocean's Eleven" and "Mystic River." (b) (6) graduated from Boston University with a Bachelor's Degree in International Relations. (b) (6) - AT&T Senior Vice President, Corporate Communications (b) (6) senior vice president of corporate communication, oversees reputation management, media relations, executive communications, financial communications, digital and social media and employee communications for AT&T Inc. He has worked more than 30 years in corporate communications, most of it in the telecommunications industry. (b) (6) provided strategic media relations and crisis communications counsel to Fortune 100 clients while working as senior vice president and senior partner at Fleishman Hillard from 1996 to 2007. Before that, he spent five years leading media relations, marketing and advertising for the Oklahoma Bankers Association. He holds a bachelor's degree in journalism and public relations from Oklahoma State University (b) (6) - McDonalds Restaurants Ltd. Senior Vice President, Chief Marketing Officer In January 2014 (b) (6) was promoted to Senior Vice President, Chief Marketing Officer, with responsibility for McDonald's UK, Ireland, Norway, Denmark, Sweden and Finland. (b) (6) also holds responsibility for the UK's Business Strategy & Insight function. (b) (6) joined McDonald's in 2007 and was promoted to Vice President, Marketing in September 2010 with responsibility for Marketing and Food Development. Since joining the Company, he has led his team and agency partners in the development of some of the highest performing campaigns in McDonald's UK history, including its award-winning consumer trust and 'Favourites' advertising campaigns. (b) (6) has a strong pedigree in retail having started his career in Store Management for both Marks went on to cover a variety of roles culminating in the & Spencer and Debenhams. At Marks & Spencer (b) (6) position of Corporate Marketing Planning Manager. He then moved to Blockbuster where he took up the role of Marketing Director before starting up and establishing Blockbuster Online, as Managing Director. (b) (6) - Nike, Inc. Chief Communications Officer (b) (6) was named Chief Communications Officer in June 2013. (b) (6) joined Nike in 1999 as communications director for the company's EMEA region. He was named head of US communications in 2002, global brand communications director in September 2004, and vice president of global communications in November 2005. 2 VA-19-0799-D-001400 OS 00003071 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Johnson & Johnson Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer (b) (6) is Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer and a member of the Corporation's Management Committee. In his role he leads the Corporation's global marketing, communication, equity and philanthropy functions. He assumed his position in January 2012. Previous to this role, Mr. (b) (6) was a Company Group Chairman for Johnson & Johnson and a member of the Medical Devices & Diagnostics Group Operating Committee, a role he assumed in January 2007. He had primary responsibility for the global vision care franchise. (b) (6) joined Johnson & Johnson in 1983 as a Marketing Assistant for Personal Products Company. He held positions of increasing responsibility in the marketing organization. In 1991 Mr. (b) (6) moved to McNeil Consumer Products as a Group Product Director and was promoted to Vice President, Worldwide Consumer Pharmaceuticals in 1995 to lead the company's growth in the Asia Pacific, Eastern relocated to Europe as Managing Director, McNeil European and Latin American regions. In 1998 (b) (6) Consumer Nutritionals Europe. He returned to the U.S. as President, McNeil Nutritionals Worldwide, in 2000. In 2002 he was named Global President, Personal Products Company. (b) (6) was promoted to Company Group Chairman and a member of the Consumer and Personal Care Group Operating Committee in 2004, with North American responsibility for the Personal Products Company, Johnson & Johnson Sales and logistics Company and Johnson & Johnson Consumer Canada. In his role he also had North American responsibility for the IT, Finance and HR organizations within the Consumer & Personal Care group. (b) (6) is a member of the board of trustees at Macalester College and a member of the Executive Committee of the Board of Directors of Family Service Association. He also serves on the Executive Committee of the Ad Council. He holds a Master's degree in business administration from the Tuck School of Business at Dartmouth College and a Bachelor of Arts' degree, cum laude, from Macalester College. (b) (6) - American Express Company Executive Vice President, Corporate Affairs & Communications (b) (6) is Executive Vice President, Corporate Affairs & Communications, American Express Company. He is a member of the Company's Operating Committee, with responsibility for Public and Shareholder Communications, International Government Affairs, Corporate Social Responsibility and Public Policy. Mr. (b) (6) joined American Express in 1991 from Shearson Lehman Brothers Inc., where he had been Senior Vice President, Corporate Affairs and Communications. Prior to joining the securities industry in 1987, is a director and former Mr. (b) (6) worked for Manufacturers Hanover Trust Company in New York. Mr. (b) (6) Chairman of the Public Relations Seminar. He has also served as Chairman of The Wisemen, an organization of senior public relations executives founded in New York in 1938. Mr. (b) (6) is a former director of Kids in a Drug Free Society and a 2005 David Rockefeller Fellow. A graduate of the State University of New York at Buffalo, Mr. (b) (6) is married and resides in New York City. (b) (6) - 21 st Century Fox Executive Vice President and Chief Communications Officer for 21st Century Fox (b) (6) is the Executive Vice President and Chief Communications Officer for 21st Century Fox. In this role, Ms. (b) (6) serves as the chief spokesperson for the Company, leading all global communications initiatives, specifically in support of corporate financial matters, mergers and acquisitions, regulatory issues and 3 VA-19-0799-D-001401 OS 00003072 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 litigation. She is also responsible for leading the Company's efforts to build and manage the 21st Century Fox corporate brand among key audiences worldwide. She has served as Chief Communications Officer since January 2012. Prior to her current post, Ms. (b) (6) was the Company's Senior Vice President of Communications and Corporate Strategy. In addition to her communications responsibilities, she was called upon to develop company-wide marketing and distribution strategies designed to drive greater value from the Company's deep portfolio of media and publishing assets. Previously, Ms. (b) (6) served as the Company's Senior Vice President Corporate Communications and Public Affairs, focusing on its West Coast businesses. She first joined the Company as Senior Vice President of Corporate Communications for Fox Interactive Media (FIM) was a Senior Vice President at MPRM Public and MySpace. Before joining the Company, Ms. (b) (6) Relations from 1994 to 2006. At MPRM, she ran the digital practice, working with companies at the intersection of media and technology. Ms. (b) (6) resides in Los Angeles with her husband and two children. (b) (6) - Walt Disney Company Executive Vice President and Chief Communications Officer (b) (6) is responsible for global communications for The Walt Disney Company, including acting as chief spokesperson and overseeing communication strategy and media relations for the company, its various business segments and its philanthropic and environmental initiatives. Her role also includes oversight of internal communications, the Walt Disney Archives and D23. Since 2002, Ms. (b) (6) has led the communications and positioning strategy for all of Disney's strategic business initiatives including the acquisitions of Pixar, Marvel and Lucasfilm; the Company's leadership in leveraging digital technology to connect consumers to creative content in new and exciting ways; and its expansion and growth in international such as the landmark opening of Disney's first theme park and resort in Mainland China, Shanghai Disney Resort. Under her direction, Disney launched D23, the first-ever official Disney fan club, with members in all 50 states and 35 countries. Since its 2009 debut, D23 has delighted Disney fans with experiences such as the bi-annual D23 Expo: The Ultimate Disney Fan Event, year-round member-only insider access events, and the award-winning quarterly magazine, Disney Twenty-three. Ms. (b) (6) originally joined the Company in 2001, as senior vice president, Communications, for the ABC Broadcast Group and the ABC Television Network. In this role, she oversaw the communication strategy and implementation of all external and internal communications. She also had oversight of public service campaigns, audience information, internal publication and the ABC Foundation. Prior to joining The Walt Disney Company, Ms. (b) (6) served as director of communications and senior policy advisor to New York State Governor George Pataki. In these roles, she counseled him on a broad range of public policy and other issues and successfully positioned him for re-election, earning a national reputation for her communication strategy and political expertise in the process. The New York Times described her role as expanded beyond communications, "to include virtually every major decision made by the Governor." Ms. (b) (6) previously served as communications director for United States Senator Alfonse D' Amato, managing his successful re-election campaigns in 1986 and 1992. She originally joined Senator D' Amata's team in 1982 as a press representative. In 2012 Ms. (b) (6) received the prestigious Matrix Award from New York Women in Communications, Inc. She has also been named one of the 100 Most Important In-House Communicators in the World by The Holmes Report, PR Week's Top 50 Industry Elite and was recognized on PR Week's Power List for 2014. 4 VA-19-0799-D-001402 OS 00003073 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 3/29/2017 12:45:36 AM (b) (6) va.gov Fwd: DRAFT: VA COMMUNICATIONS TASK FORCE VA Comms Committee Draft 1 3.28.17.docx; Untitled attachment 06186.htm Please print Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) pcommgroup.com > Date: March 28, 2017 at 3:41:44 PM EDT To: David shulkin , IP <(b) (6) frenchangel59 .com > Cc: Marisol Garcia <(b) (6) frenchangel59.com >, (b) (6) <(b) (6) pcommgroup.com > Subject: DRAFT: VA COMMUNICATIONS TASK FORCE Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001404 OS 00003075 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Facebook, Inc. Vice President- Communications and Public Policy at Facebook Mr. (b) (6) serves as Vice President of Global Communications, Marketing and Public Policy at Facebook, is responsible for developing and coordinating key messages about products, Inc. At Facebook, Mr. (b) (6) corporate business and partnerships. He also oversees Facebook's public policy strategy worldwide. He served as Strategic Advisor of luminate, Inc. He served as Vice President of Public Affairs and Global Communications at Google Inc. since October 2005. He served as a Board Observer of luminate, Inc. He helped broaden and coordinate Google's messaging from a focus on product PR to include all aspects of corporate, financial, policy, philanthropic and internal communications. Prior to Google, he was the Bernard l. Schwarz Senior Fellow in business and foreign policy at the New York-based Council on Foreign Relations. In his career, he served as Senior Vice President of Global Affairs at Gap Inc. and an Adjunct Professor at Columbia University and Columbia law School. He is a contributor to the Harvard Business Review and the Financial Times. Mr. (b) (6) holds a bachelor's degree from Harvard University, a master's degree in public policy from the Kennedy School of Government and a J.D. from Harvard law School. He studied at Ecole Normale Superieure. (b) (6) - NH Executive vice president of communications (b) (6) a former press secretary for President Bill Clinton, will join the NFL as the league's executive vice joins the NFL from a Washington, D.C.-based communications and president of communications. (b) (6) government affairs firm he co-founded. He was Clinton's press secretary from 1998 to 2000 and an advisor and press secretary to several presidential campaigns over two decades. Reports to NFL chief operating officer Tod leiweke (b) (6) Apple Vice president of Communications (b) (6) (b) (6) is Apple's vice president of Communications, reporting to CEO (b) (6) is responsible for Apple's worldwide media relations and communications strategy, leading the public relations team as well as employee communications and corporate events. He previously led Apple's corporate public relations team for ten years. Before joining Apple in 2003, (b) (6) worked as a broadcast journalist at CNBC, first as a writer and producer in the network's Washington, D.C. bureau. He later established CNBC's Silicon Valley bureau and holds a bachelor's degree in Political Science from served as bureau chief. A native of Massachusetts, (b) (6) the University of Minnesota (b) (6) - WME Chief Communications Officer (b) (6) is chief communications officer for WME and IMG. In his position, (b) (6) serves as the companies' chief communications strategist, handling media relations, internal communication, advertising, and events for all of WM E's divisions and offices. (b) (6) also serves as an advisor to many of the agency's clients, providing communication and marketing services to some of the world's leading artists and brands, including Hasbro, (b) (6) Wahlberg, M. Night Shyamalan, Usher and James Frey. As a specialist in entertainment trade and has secured corporate and client profiles in such publications as the New York Times, business press, (b) (6) 1 VA-19-0799-D-001405 OS 00003076 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 Wall Street Journal, Los Angeles Times, Fast Company, Forbes, Financial Times, Fortune, Vanity Fair, The Hollywood Reporter and Variety. (b) (6) also oversees WM E's philanthropic initiatives, including the launch of an annual all-company volunteer day and the adoption of Foster Elementary School in Compton, California. WME is helping transform the school's campus, resources and overall academic performance. Named to The Hollywood Reporter's "Next Generation" list, which recognizes the top entertainment executives under 35, (b) (6) was previously the head of Corporate Communications for the William Morris Agency. At WMA, he handled all corporate press for the agency, including coverage of its 2009 merger with Endeavor which resulted worked in international in the creation of WME. Prior to joining the William Morris Agency in 2004, (b) (6) publicity and marketing at Warner Bros. Pictures, helping to launch campaigns for such films as "Harry Potter," "Matrix Reloaded," "Ocean's Eleven" and "Mystic River." (b) (6) graduated from Boston University with a Bachelor's Degree in International Relations. (b) (6) - AT&T Senior Vice President, Corporate Communications (b) (6) senior vice president of corporate communication, oversees reputation management, media relations, executive communications, financial communications, digital and social media and employee communications for AT&T Inc. He has worked more than 30 years in corporate communications, most of it in the telecommunications industry. (b) (6) provided strategic media relations and crisis communications counsel to Fortune 100 clients while working as senior vice president and senior partner at Fleishman Hillard from 1996 to 2007. Before that, he spent five years leading media relations, marketing and advertising for the Oklahoma Bankers Association. He holds a bachelor's degree in journalism and public relations from Oklahoma State University (b) (6) - McDonalds Restaurants Ltd. Senior Vice President, Chief Marketing Officer In January 2014 (b) (6) was promoted to Senior Vice President, Chief Marketing Officer, with responsibility for McDonald's UK, Ireland, Norway, Denmark, Sweden and Finland. (b) (6) also holds responsibility for the UK's Business Strategy & Insight function. (b) (6) joined McDonald's in 2007 and was promoted to Vice President, Marketing in September 2010 with responsibility for Marketing and Food Development. Since joining the Company, he has led his team and agency partners in the development of some of the highest performing campaigns in McDonald's UK history, including its award-winning consumer trust and 'Favourites' advertising campaigns. (b) (6) has a strong pedigree in retail having started his career in Store Management for both Marks (b) (6) went on to cover a variety of roles culminating in the & (b) (6) and Debenhams. At Marks & (b) (6) position of Corporate Marketing Planning Manager. He then moved to Blockbuster where he took up the role of Marketing Director before starting up and establishing Blockbuster Online, as Managing Director. (b) (6) - Nike, Inc. Chief Communications Officer (b) (6) was named Chief Communications Officer in June 2013. (b) (6) joined Nike in 1999 as communications director for the company's EMEA region. He was named head of US communications in 2002, global brand communications director in September 2004, and vice president of global communications in November 2005. 2 VA-19-0799-D-001406 OS 00003077 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Johnson & Johnson Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer (b) (6) is Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer and a member of the Corporation's Management Committee. In his role he leads the Corporation's global marketing, communication, equity and philanthropy functions. He assumed his position in January 2012. Previous to this role, Mr. (b) (6) was a Company Group Chairman for Johnson & Johnson and a member of the Medical Devices & Diagnostics Group Operating Committee, a role he assumed in January 2007. He had primary responsibility for the global vision care franchise. (b) (6) joined Johnson & Johnson in 1983 as a Marketing Assistant for Personal Products Company. He held positions of increasing responsibility in the marketing organization. In 1991 Mr. (b) (6) moved to McNeil Consumer Products as a Group Product Director and was promoted to Vice President, Worldwide Consumer Pharmaceuticals in 1995 to lead the company's growth in the Asia Pacific, Eastern relocated to Europe as Managing Director, McNeil European and Latin American regions. In 1998 (b) (6) Consumer Nutritionals Europe. He returned to the U.S. as President, McNeil Nutritionals Worldwide, in 2000. In 2002 he was named Global President, Personal Products Company. (b) (6) was promoted to Company Group Chairman and a member of the Consumer and Personal Care Group Operating Committee in 2004, with North American responsibility for the Personal Products Company, Johnson & Johnson Sales and logistics Company and Johnson & Johnson Consumer Canada. In his role he also had North American responsibility for the IT, Finance and HR organizations within the Consumer & Personal Care group. (b) (6) is a member of the board of trustees at Macalester College and a member of the Executive Committee of the Board of Directors of Family Service Association. He also serves on the Executive Committee of the Ad Council. He holds a Master's degree in business administration from the Tuck School of Business at Dartmouth College and a Bachelor of Arts' degree, cum laude, from Macalester College. (b) (6) - American Express Company Executive Vice President, Corporate Affairs & Communications (b) (6) is Executive Vice President, Corporate Affairs & Communications, American Express Company. He is a member of the Company's Operating Committee, with responsibility for Public and Shareholder Communications, International Government Affairs, Corporate Social Responsibility and Public Policy. Mr. (b) (6) joined American Express in 1991 from Shearson Lehman Brothers Inc., where he had been Senior Vice President, Corporate Affairs and Communications. Prior to joining the securities industry in 1987, is a director and former Mr. (b) (6) worked for Manufacturers Hanover Trust Company in New York. Mr. (b) (6) Chairman of the Public Relations Seminar. He has also served as Chairman of The Wisemen, an organization of senior public relations executives founded in New York in 1938. Mr. (b) (6) is a former director of Kids in a Drug Free Society and a 2005 David Rockefeller Fellow. A graduate of the State University of New York at Buffalo, Mr. (b) (6) is married and resides in New York City. (b) (6) - 21 st Century Fox Executive Vice President and Chief Communications Officer for 21st Century Fox (b) (6) is the Executive Vice President and Chief Communications Officer for 21st Century Fox. In this role, Ms. (b) (6) serves as the chief spokesperson for the Company, leading all global communications initiatives, specifically in support of corporate financial matters, mergers and acquisitions, regulatory issues and 3 VA-19-0799-D-001407 OS 00003078 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 litigation. She is also responsible for leading the Company's efforts to build and manage the 21st Century Fox corporate brand among key audiences worldwide. She has served as Chief Communications Officer since January 2012. Prior to her current post, Ms. (b) (6) was the Company's Senior Vice President of Communications and Corporate Strategy. In addition to her communications responsibilities, she was called upon to develop company-wide marketing and distribution strategies designed to drive greater value from the Company's deep portfolio of media and publishing assets. Previously, Ms. (b) (6) served as the Company's Senior Vice President Corporate Communications and Public Affairs, focusing on its West Coast businesses. She first joined the Company as Senior Vice President of Corporate Communications for Fox Interactive Media (FIM) was a Senior Vice President at MPRM Public and MySpace. Before joining the Company, Ms. (b) (6) Relations from 1994 to 2006. At MPRM, she ran the digital practice, working with companies at the intersection of media and technology. Ms. (b) (6) resides in Los Angeles with her husband and two children. (b) (6) - Walt Disney Company Executive Vice President and Chief Communications Officer (b) (6) is responsible for global communications for The Walt Disney Company, including acting as chief spokesperson and overseeing communication strategy and media relations for the company, its various business segments and its philanthropic and environmental initiatives. Her role also includes oversight of internal communications, the Walt Disney Archives and D23. Since 2002, Ms. (b) (6) has led the communications and positioning strategy for all of Disney's strategic business initiatives including the acquisitions of Pixar, Marvel and Lucasfilm; the Company's leadership in leveraging digital technology to connect consumers to creative content in new and exciting ways; and its expansion and growth in international such as the landmark opening of Disney's first theme park and resort in Mainland China, Shanghai Disney Resort. Under her direction, Disney launched D23, the first-ever official Disney fan club, with members in all 50 states and 35 countries. Since its 2009 debut, D23 has delighted Disney fans with experiences such as the bi-annual D23 Expo: The Ultimate Disney Fan Event, year-round member-only insider access events, and the award-winning quarterly magazine, Disney Twenty-three. Ms. (b) (6) originally joined the Company in 2001, as senior vice president, Communications, for the ABC Broadcast Group and the ABC Television Network. In this role, she oversaw the communication strategy and implementation of all external and internal communications. She also had oversight of public service campaigns, audience information, internal publication and the ABC Foundation. Prior to joining The Walt Disney Company, Ms. (b) (6) served as director of communications and senior policy advisor to New York State Governor George Pataki. In these roles, she counseled him on a broad range of public policy and other issues and successfully positioned him for re-election, earning a national reputation for her communication strategy and political expertise in the process. The New York Times described her role as expanded beyond communications, "to include virtually every major decision made by the Governor." Ms. (b) (6) previously served as communications director for United States Senator Alfonse D' Amato, managing his successful re-election campaigns in 1986 and 1992. She originally joined Senator D' Amata's team in 1982 as a press representative. In 2012 Ms. (b) (6) received the prestigious Matrix Award from New York Women in Communications, Inc. She has also been named one of the 100 Most Important In-House Communicators in the World by The Holmes Report, PR Week's Top 50 Industry Elite and was recognized on PR Week's Power List for 2014. 4 VA-19-0799-D-001408 OS 00003079 Message CC: David shulkin [Drshulkin@aol.com] 3/28/2017 8:14:16 PM (b) (6) [(b) (6) pcommgroup.com] (b) (6) IP [ frenchangel59.com]; Marisol Garcia [(b) (6) frenchangel59.com]; (b) (6) Subject: Re: DRAFT: VA COMMUNICATIONS TASK FORCE From: Sent: To: Thanks so much (b) (6) [(b) (6) pcommgroup.com] and Paul Ill be in touch soon Sent from my iPhone On Mar 28, 2017, at 3:41 PM, (b) (6) <(b) (6) pcommgroup.com > wrote: Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001410 OS 00003081 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 3/28/2017 8:13:49 PM Vivieca Wright Simpson [vivieca.Wright@va.gov] Fwd: DRAFT: VA COMMUNICATIONS TASK FORCE VA Comms Committee Draft 1 3.28.17.docx; Untitled attachment 06193.htm Lets discuss Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) pcommgroup.com > Date: March 28, 2017 at 3:41:44 PM EDT To: David shulkin , IP <(b) (6) frenchangel59 .com > Cc: Marisol Garcia <(b) (6) frenchangel59.com >, (b) (6) <(b) (6) pcommgroup.com > Subject: DRAFT: VA COMMUNICATIONS TASK FORCE Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001411 OS 00003082 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Facebook, Inc. Vice President- Communications and Public Policy at Facebook Mr. (b) (6) serves as Vice President of Global Communications, Marketing and Public Policy at Facebook, is responsible for developing and coordinating key messages about products, Inc. At Facebook, Mr. (b) (6) corporate business and partnerships. He also oversees Facebook's public policy strategy worldwide. He served as Strategic Advisor of luminate, Inc. He served as Vice President of Public Affairs and Global Communications at Google Inc. since October 2005. He served as a Board Observer of luminate, Inc. He helped broaden and coordinate Google's messaging from a focus on product PR to include all aspects of corporate, financial, policy, philanthropic and internal communications. Prior to Google, he was the Bernard l. Schwarz Senior Fellow in business and foreign policy at the New York-based Council on Foreign Relations. In his career, he served as Senior Vice President of Global Affairs at Gap Inc. and an Adjunct Professor at Columbia University and Columbia law School. He is a contributor to the Harvard Business Review and the Financial Times. Mr. (b) (6) holds a bachelor's degree from Harvard University, a master's degree in public policy from the Kennedy School of Government and a J.D. from Harvard law School. He studied at Ecole Normale Superieure. (b) (6) - NH Executive vice president of communications (b) (6) a former press secretary for President Bill Clinton, will join the NFL as the league's executive vice joins the NFL from a Washington, D.C.-based communications and president of communications. (b) (6) government affairs firm he co-founded. He was Clinton's press secretary from 1998 to 2000 and an advisor and press secretary to several presidential campaigns over two decades. Reports to NFL chief operating officer Tod leiweke (b) (6) Apple Vice president of Communications (b) (6) (b) (6) is Apple's vice president of Communications, reporting to CEO (b) (6) is responsible for Apple's worldwide media relations and communications strategy, leading the public relations team as well as employee communications and corporate events. He previously led Apple's corporate public relations team for ten years. Before joining Apple in 2003, (b) (6) worked as a broadcast journalist at CNBC, first as a writer and producer in the network's Washington, D.C. bureau. He later established CNBC's Silicon Valley bureau and holds a bachelor's degree in Political Science from served as bureau chief. A native of Massachusetts, (b) (6) the University of Minnesota (b) (6) - WME Chief Communications Officer (b) (6) is chief communications officer for WME and IMG. In his position, (b) (6) serves as the companies' chief communications strategist, handling media relations, internal communication, advertising, and events for all of WM E's divisions and offices. (b) (6) also serves as an advisor to many of the agency's clients, providing communication and marketing services to some of the world's leading artists and brands, including Hasbro, (b) (6) Wahlberg, M. Night Shyamalan, Usher and James Frey. As a specialist in entertainment trade and has secured corporate and client profiles in such publications as the New York Times, business press, (b) (6) 1 VA-19-0799-D-001412 OS 00003083 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 Wall Street Journal, Los Angeles Times, Fast Company, Forbes, Financial Times, Fortune, Vanity Fair, The Hollywood Reporter and Variety. (b) (6) also oversees WM E's philanthropic initiatives, including the launch of an annual all-company volunteer day and the adoption of Foster Elementary School in Compton, California. WME is helping transform the school's campus, resources and overall academic performance. Named to The Hollywood Reporter's "Next Generation" list, which recognizes the top entertainment executives under 35, (b) (6) was previously the head of Corporate Communications for the William Morris Agency. At WMA, he handled all corporate press for the agency, including coverage of its 2009 merger with Endeavor which resulted worked in international in the creation of WME. Prior to joining the William Morris Agency in 2004, (b) (6) publicity and marketing at Warner Bros. Pictures, helping to launch campaigns for such films as "Harry Potter," "Matrix Reloaded," "Ocean's Eleven" and "Mystic River." (b) (6) graduated from Boston University with a Bachelor's Degree in International Relations. (b) (6) - AT&T Senior Vice President, Corporate Communications (b) (6) senior vice president of corporate communication, oversees reputation management, media relations, executive communications, financial communications, digital and social media and employee communications for AT&T Inc. He has worked more than 30 years in corporate communications, most of it in the telecommunications industry. (b) (6) provided strategic media relations and crisis communications counsel to Fortune 100 clients while working as senior vice president and senior partner at Fleishman Hillard from 1996 to 2007. Before that, he spent five years leading media relations, marketing and advertising for the Oklahoma Bankers Association. He holds a bachelor's degree in journalism and public relations from Oklahoma State University (b) (6) - McDonalds Restaurants Ltd. Senior Vice President, Chief Marketing Officer In January 2014 (b) (6) was promoted to Senior Vice President, Chief Marketing Officer, with responsibility for McDonald's UK, Ireland, Norway, Denmark, Sweden and Finland. (b) (6) also holds responsibility for the UK's Business Strategy & Insight function. (b) (6) joined McDonald's in 2007 and was promoted to Vice President, Marketing in September 2010 with responsibility for Marketing and Food Development. Since joining the Company, he has led his team and agency partners in the development of some of the highest performing campaigns in McDonald's UK history, including its award-winning consumer trust and 'Favourites' advertising campaigns. (b) (6) has a strong pedigree in retail having started his career in Store Management for both Marks (b) (6) went on to cover a variety of roles culminating in the & (b) (6) and Debenhams. At Marks & (b) (6) position of Corporate Marketing Planning Manager. He then moved to Blockbuster where he took up the role of Marketing Director before starting up and establishing Blockbuster Online, as Managing Director. (b) (6) - Nike, Inc. Chief Communications Officer (b) (6) was named Chief Communications Officer in June 2013. (b) (6) joined Nike in 1999 as communications director for the company's EMEA region. He was named head of US communications in 2002, global brand communications director in September 2004, and vice president of global communications in November 2005. 2 VA-19-0799-D-001413 OS 00003084 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Johnson & Johnson Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer (b) (6) is Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer and a member of the Corporation's Management Committee. In his role he leads the Corporation's global marketing, communication, equity and philanthropy functions. He assumed his position in January 2012. Previous to this role, Mr. (b) (6) was a Company Group Chairman for Johnson & Johnson and a member of the Medical Devices & Diagnostics Group Operating Committee, a role he assumed in January 2007. He had primary responsibility for the global vision care franchise. (b) (6) joined Johnson & Johnson in 1983 as a Marketing Assistant for Personal Products Company. He held positions of increasing responsibility in the marketing organization. In 1991 Mr. (b) (6) moved to McNeil Consumer Products as a Group Product Director and was promoted to Vice President, Worldwide Consumer Pharmaceuticals in 1995 to lead the company's growth in the Asia Pacific, Eastern relocated to Europe as Managing Director, McNeil European and Latin American regions. In 1998 (b) (6) Consumer Nutritionals Europe. He returned to the U.S. as President, McNeil Nutritionals Worldwide, in 2000. In 2002 he was named Global President, Personal Products Company. (b) (6) was promoted to Company Group Chairman and a member of the Consumer and Personal Care Group Operating Committee in 2004, with North American responsibility for the Personal Products Company, Johnson & Johnson Sales and logistics Company and Johnson & Johnson Consumer Canada. In his role he also had North American responsibility for the IT, Finance and HR organizations within the Consumer & Personal Care group. (b) (6) is a member of the board of trustees at Macalester College and a member of the Executive Committee of the Board of Directors of Family Service Association. He also serves on the Executive Committee of the Ad Council. He holds a Master's degree in business administration from the Tuck School of Business at Dartmouth College and a Bachelor of Arts' degree, cum laude, from Macalester College. (b) (6) - American Express Company Executive Vice President, Corporate Affairs & Communications (b) (6) is Executive Vice President, Corporate Affairs & Communications, American Express Company. He is a member of the Company's Operating Committee, with responsibility for Public and Shareholder Communications, International Government Affairs, Corporate Social Responsibility and Public Policy. Mr. (b) (6) joined American Express in 1991 from Shearson Lehman Brothers Inc., where he had been Senior Vice President, Corporate Affairs and Communications. Prior to joining the securities industry in 1987, is a director and former Mr. (b) (6) worked for Manufacturers Hanover Trust Company in New York. Mr. (b) (6) Chairman of the Public Relations Seminar. He has also served as Chairman of The Wisemen, an organization of senior public relations executives founded in New York in 1938. Mr. (b) (6) is a former director of Kids in a Drug Free Society and a 2005 David Rockefeller Fellow. A graduate of the State University of New York at Buffalo, Mr. (b) (6) is married and resides in New York City. (b) (6) - 21 st Century Fox Executive Vice President and Chief Communications Officer for 21st Century Fox (b) (6) is the Executive Vice President and Chief Communications Officer for 21st Century Fox. In this role, Ms. (b) (6) serves as the chief spokesperson for the Company, leading all global communications initiatives, specifically in support of corporate financial matters, mergers and acquisitions, regulatory issues and 3 VA-19-0799-D-001414 OS 00003085 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 litigation. She is also responsible for leading the Company's efforts to build and manage the 21st Century Fox corporate brand among key audiences worldwide. She has served as Chief Communications Officer since January 2012. Prior to her current post, Ms. (b) (6) was the Company's Senior Vice President of Communications and Corporate Strategy. In addition to her communications responsibilities, she was called upon to develop company-wide marketing and distribution strategies designed to drive greater value from the Company's deep portfolio of media and publishing assets. Previously, Ms. (b) (6) served as the Company's Senior Vice President Corporate Communications and Public Affairs, focusing on its West Coast businesses. She first joined the Company as Senior Vice President of Corporate Communications for Fox Interactive Media (FIM) was a Senior Vice President at MPRM Public and MySpace. Before joining the Company, Ms. (b) (6) Relations from 1994 to 2006. At MPRM, she ran the digital practice, working with companies at the intersection of media and technology. Ms. (b) (6) resides in Los Angeles with her husband and two children. (b) (6) - Walt Disney Company Executive Vice President and Chief Communications Officer (b) (6) is responsible for global communications for The Walt Disney Company, including acting as chief spokesperson and overseeing communication strategy and media relations for the company, its various business segments and its philanthropic and environmental initiatives. Her role also includes oversight of internal communications, the Walt Disney Archives and D23. Since 2002, Ms. (b) (6) has led the communications and positioning strategy for all of Disney's strategic business initiatives including the acquisitions of Pixar, Marvel and Lucasfilm; the Company's leadership in leveraging digital technology to connect consumers to creative content in new and exciting ways; and its expansion and growth in international such as the landmark opening of Disney's first theme park and resort in Mainland China, Shanghai Disney Resort. Under her direction, Disney launched D23, the first-ever official Disney fan club, with members in all 50 states and 35 countries. Since its 2009 debut, D23 has delighted Disney fans with experiences such as the bi-annual D23 Expo: The Ultimate Disney Fan Event, year-round member-only insider access events, and the award-winning quarterly magazine, Disney Twenty-three. Ms. (b) (6) originally joined the Company in 2001, as senior vice president, Communications, for the ABC Broadcast Group and the ABC Television Network. In this role, she oversaw the communication strategy and implementation of all external and internal communications. She also had oversight of public service campaigns, audience information, internal publication and the ABC Foundation. Prior to joining The Walt Disney Company, Ms. (b) (6) served as director of communications and senior policy advisor to New York State Governor George Pataki. In these roles, she counseled him on a broad range of public policy and other issues and successfully positioned him for re-election, earning a national reputation for her communication strategy and political expertise in the process. The New York Times described her role as expanded beyond communications, "to include virtually every major decision made by the Governor." Ms. (b) (6) previously served as communications director for United States Senator Alfonse D' Amato, managing his successful re-election campaigns in 1986 and 1992. She originally joined Senator D' Amata's team in 1982 as a press representative. In 2012 Ms. (b) (6) received the prestigious Matrix Award from New York Women in Communications, Inc. She has also been named one of the 100 Most Important In-House Communicators in the World by The Holmes Report, PR Week's Top 50 Industry Elite and was recognized on PR Week's Power List for 2014. 4 VA-19-0799-D-001415 OS 00003086 Message (b) (6) From: Sent: To: CC: Subject: Attachments: [(b) (6) pcommgroup.com] 3/28/2017 7:41:44 PM David shulkin [Drshulkin@aol.com]; IP [(b) (6) frenchangel59.com] Marisol Garcia [(b) (6) frenchangel59.com]; (b) (6) [(b) (6) pcommgroup.com] DRAFT: VA COMMUNICATIONS TASK FORCE VA Comms Committee Draft 1 3.28.17.docx Dr. Shulkin: It was a privilege to speak last week. Per our conversation, please see a DRAFT list of proposed names to target for the Communications Committee- whose responsibility it will be to identify near term and intermediate VA Communications goals, specific near term opportunities and evaluate, and if necessary staff and resource. Please note, the only name we approached was (b) (6) of 21 st Century Fox, who is committed to the idea and involvement and shared that her leadership team (the Murdoch(s)) consider the VA a priority focus. We look forward to discussing next steps and defer to Ike on positioning and final thoughts. Best, (b) (6) & Paul VA-19-0799-D-001417 OS 00003088 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Facebook, Inc. Vice President- Communications and Public Policy at Facebook Mr. (b) (6) serves as Vice President of Global Communications, Marketing and Public Policy at Facebook, is responsible for developing and coordinating key messages about products, Inc. At Facebook, Mr. (b) (6) corporate business and partnerships. He also oversees Facebook's public policy strategy worldwide. He served as Strategic Advisor of luminate, Inc. He served as Vice President of Public Affairs and Global Communications at Google Inc. since October 2005. He served as a Board Observer of luminate, Inc. He helped broaden and coordinate Google's messaging from a focus on product PR to include all aspects of corporate, financial, policy, philanthropic and internal communications. Prior to Google, he was the Bernard l. Schwarz Senior Fellow in business and foreign policy at the New York-based Council on Foreign Relations. In his career, he served as Senior Vice President of Global Affairs at Gap Inc. and an Adjunct Professor at Columbia University and Columbia law School. He is a contributor to the Harvard Business Review and the Financial Times. Mr. (b) (6) holds a bachelor's degree from Harvard University, a master's degree in public policy from the Kennedy School of Government and a J.D. from Harvard law School. He studied at Ecole Normale Superieure. (b) (6) - NH Executive vice president of communications (b) (6) a former press secretary for President Bill Clinton, will join the NFL as the league's executive vice joins the NFL from a Washington, D.C.-based communications and president of communications. (b) (6) government affairs firm he co-founded. He was Clinton's press secretary from 1998 to 2000 and an advisor and press secretary to several presidential campaigns over two decades. Reports to NFL chief operating officer Tod leiweke (b) (6) Apple Vice president of Communications (b) (6) (b) (6) is Apple's vice president of Communications, reporting to CEO (b) (6) is responsible for Apple's worldwide media relations and communications strategy, leading the public relations team as well as employee communications and corporate events. He previously led Apple's corporate public relations team for ten years. Before joining Apple in 2003, (b) (6) worked as a broadcast journalist at CNBC, first as a writer and producer in the network's Washington, D.C. bureau. He later established CNBC's Silicon Valley bureau and holds a bachelor's degree in Political Science from served as bureau chief. A native of Massachusetts, (b) (6) the University of Minnesota (b) (6) - WME Chief Communications Officer (b) (6) is chief communications officer for WME and IMG. In his position, (b) (6) serves as the companies' chief communications strategist, handling media relations, internal communication, advertising, and events for all of WM E's divisions and offices. (b) (6) also serves as an advisor to many of the agency's clients, providing communication and marketing services to some of the world's leading artists and brands, including Hasbro, (b) (6) Wahlberg, M. Night Shyamalan, Usher and James Frey. As a specialist in entertainment trade and has secured corporate and client profiles in such publications as the New York Times, business press, (b) (6) 1 VA-19-0799-D-001418 OS 00003089 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 Wall Street Journal, Los Angeles Times, Fast Company, Forbes, Financial Times, Fortune, Vanity Fair, The Hollywood Reporter and Variety. (b) (6) also oversees WM E's philanthropic initiatives, including the launch of an annual all-company volunteer day and the adoption of Foster Elementary School in Compton, California. WME is helping transform the school's campus, resources and overall academic performance. Named to The Hollywood Reporter's "Next Generation" list, which recognizes the top entertainment executives under 35, (b) (6) was previously the head of Corporate Communications for the William Morris Agency. At WMA, he handled all corporate press for the agency, including coverage of its 2009 merger with Endeavor which resulted worked in international in the creation of WME. Prior to joining the William Morris Agency in 2004, (b) (6) publicity and marketing at Warner Bros. Pictures, helping to launch campaigns for such films as "Harry Potter," "Matrix Reloaded," "Ocean's Eleven" and "Mystic River." (b) (6) graduated from Boston University with a Bachelor's Degree in International Relations. (b) (6) - AT&T Senior Vice President, Corporate Communications (b) (6) senior vice president of corporate communication, oversees reputation management, media relations, executive communications, financial communications, digital and social media and employee communications for AT&T Inc. He has worked more than 30 years in corporate communications, most of it in the telecommunications industry. (b) (6) provided strategic media relations and crisis communications counsel to Fortune 100 clients while working as senior vice president and senior partner at Fleishman Hillard from 1996 to 2007. Before that, he spent five years leading media relations, marketing and advertising for the Oklahoma Bankers Association. He holds a bachelor's degree in journalism and public relations from Oklahoma State University (b) (6) - McDonalds Restaurants Ltd. Senior Vice President, Chief Marketing Officer In January 2014 (b) (6) was promoted to Senior Vice President, Chief Marketing Officer, with responsibility for McDonald's UK, Ireland, Norway, Denmark, Sweden and Finland. (b) (6) also holds responsibility for the UK's Business Strategy & Insight function. (b) (6) joined McDonald's in 2007 and was promoted to Vice President, Marketing in September 2010 with responsibility for Marketing and Food Development. Since joining the Company, he has led his team and agency partners in the development of some of the highest performing campaigns in McDonald's UK history, including its award-winning consumer trust and 'Favourites' advertising campaigns. (b) (6) has a strong pedigree in retail having started his career in Store Management for both Marks (b) (6) went on to cover a variety of roles culminating in the & (b) (6) and Debenhams. At Marks & (b) (6) position of Corporate Marketing Planning Manager. He then moved to Blockbuster where he took up the role of Marketing Director before starting up and establishing Blockbuster Online, as Managing Director. (b) (6) - Nike, Inc. Chief Communications Officer (b) (6) was named Chief Communications Officer in June 2013. (b) (6) joined Nike in 1999 as communications director for the company's EMEA region. He was named head of US communications in 2002, global brand communications director in September 2004, and vice president of global communications in November 2005. 2 VA-19-0799-D-001419 OS 00003090 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 (b) (6) - Johnson & Johnson Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer (b) (6) is Worldwide Vice President, Global Corporate Affairs & Chief Communication Officer and a member of the Corporation's Management Committee. In his role he leads the Corporation's global marketing, communication, equity and philanthropy functions. He assumed his position in January 2012. Previous to this role, Mr. (b) (6) was a Company Group Chairman for Johnson & Johnson and a member of the Medical Devices & Diagnostics Group Operating Committee, a role he assumed in January 2007. He had primary responsibility for the global vision care franchise. (b) (6) joined Johnson & Johnson in 1983 as a Marketing Assistant for Personal Products Company. He held positions of increasing responsibility in the marketing organization. In 1991 Mr. (b) (6) moved to McNeil Consumer Products as a Group Product Director and was promoted to Vice President, Worldwide Consumer Pharmaceuticals in 1995 to lead the company's growth in the Asia Pacific, Eastern relocated to Europe as Managing Director, McNeil European and Latin American regions. In 1998 (b) (6) Consumer Nutritionals Europe. He returned to the U.S. as President, McNeil Nutritionals Worldwide, in 2000. In 2002 he was named Global President, Personal Products Company. (b) (6) was promoted to Company Group Chairman and a member of the Consumer and Personal Care Group Operating Committee in 2004, with North American responsibility for the Personal Products Company, Johnson & Johnson Sales and logistics Company and Johnson & Johnson Consumer Canada. In his role he also had North American responsibility for the IT, Finance and HR organizations within the Consumer & Personal Care group. (b) (6) is a member of the board of trustees at Macalester College and a member of the Executive Committee of the Board of Directors of Family Service Association. He also serves on the Executive Committee of the Ad Council. He holds a Master's degree in business administration from the Tuck School of Business at Dartmouth College and a Bachelor of Arts' degree, cum laude, from Macalester College. (b) (6) - American Express Company Executive Vice President, Corporate Affairs & Communications (b) (6) is Executive Vice President, Corporate Affairs & Communications, American Express Company. He is a member of the Company's Operating Committee, with responsibility for Public and Shareholder Communications, International Government Affairs, Corporate Social Responsibility and Public Policy. Mr. (b) (6) joined American Express in 1991 from Shearson Lehman Brothers Inc., where he had been Senior Vice President, Corporate Affairs and Communications. Prior to joining the securities industry in 1987, is a director and former Mr. (b) (6) worked for Manufacturers Hanover Trust Company in New York. Mr. (b) (6) Chairman of the Public Relations Seminar. He has also served as Chairman of The Wisemen, an organization of senior public relations executives founded in New York in 1938. Mr. (b) (6) is a former director of Kids in a Drug Free Society and a 2005 David Rockefeller Fellow. A graduate of the State University of New York at Buffalo, Mr. (b) (6) is married and resides in New York City. (b) (6) - 21 st Century Fox Executive Vice President and Chief Communications Officer for 21st Century Fox (b) (6) is the Executive Vice President and Chief Communications Officer for 21st Century Fox. In this role, Ms. (b) (6) serves as the chief spokesperson for the Company, leading all global communications initiatives, specifically in support of corporate financial matters, mergers and acquisitions, regulatory issues and 3 VA-19-0799-D-001420 OS 00003091 VETERANS AFFAIRS: DRAFT COMMUNICATIONS COMMITTEE TARGETS PRESENTED BY: (b) (6) OF PRINCIPAL COMMUNICATIONS GROUP DATE: 3/28/17 litigation. She is also responsible for leading the Company's efforts to build and manage the 21st Century Fox corporate brand among key audiences worldwide. She has served as Chief Communications Officer since January 2012. Prior to her current post, Ms. (b) (6) was the Company's Senior Vice President of Communications and Corporate Strategy. In addition to her communications responsibilities, she was called upon to develop company-wide marketing and distribution strategies designed to drive greater value from the Company's deep portfolio of media and publishing assets. Previously, Ms. (b) (6) served as the Company's Senior Vice President Corporate Communications and Public Affairs, focusing on its West Coast businesses. She first joined the Company as Senior Vice President of Corporate Communications for Fox Interactive Media (FIM) was a Senior Vice President at MPRM Public and MySpace. Before joining the Company, Ms. (b) (6) Relations from 1994 to 2006. At MPRM, she ran the digital practice, working with companies at the intersection of media and technology. Ms. (b) (6) resides in Los Angeles with her husband and two children. (b) (6) - Walt Disney Company Executive Vice President and Chief Communications Officer (b) (6) is responsible for global communications for The Walt Disney Company, including acting as chief spokesperson and overseeing communication strategy and media relations for the company, its various business segments and its philanthropic and environmental initiatives. Her role also includes oversight of internal communications, the Walt Disney Archives and D23. Since 2002, Ms. (b) (6) has led the communications and positioning strategy for all of Disney's strategic business initiatives including the acquisitions of Pixar, Marvel and Lucasfilm; the Company's leadership in leveraging digital technology to connect consumers to creative content in new and exciting ways; and its expansion and growth in international such as the landmark opening of Disney's first theme park and resort in Mainland China, Shanghai Disney Resort. Under her direction, Disney launched D23, the first-ever official Disney fan club, with members in all 50 states and 35 countries. Since its 2009 debut, D23 has delighted Disney fans with experiences such as the bi-annual D23 Expo: The Ultimate Disney Fan Event, year-round member-only insider access events, and the award-winning quarterly magazine, Disney Twenty-three. Ms. (b) (6) originally joined the Company in 2001, as senior vice president, Communications, for the ABC Broadcast Group and the ABC Television Network. In this role, she oversaw the communication strategy and implementation of all external and internal communications. She also had oversight of public service campaigns, audience information, internal publication and the ABC Foundation. Prior to joining The Walt Disney Company, Ms. (b) (6) served as director of communications and senior policy advisor to New York State Governor George Pataki. In these roles, she counseled him on a broad range of public policy and other issues and successfully positioned him for re-election, earning a national reputation for her communication strategy and political expertise in the process. The New York Times described her role as expanded beyond communications, "to include virtually every major decision made by the Governor." Ms. (b) (6) previously served as communications director for United States Senator Alfonse D' Amato, managing his successful re-election campaigns in 1986 and 1992. She originally joined Senator D' Amata's team in 1982 as a press representative. In 2012 Ms. (b) (6) received the prestigious Matrix Award from New York Women in Communications, Inc. She has also been named one of the 100 Most Important In-House Communicators in the World by The Holmes Report, PR Week's Top 50 Industry Elite and was recognized on PR Week's Power List for 2014. 4 VA-19-0799-D-001421 OS 00003092 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/31/2017 10:39:22 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Take care No finger pointing but people simply atnt listening and continuing old patterns Sent from my iPhone > on Mar 31, 2017, at 5:23 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > I agree that this is something you have to be involved in with me. The field is now feeling the urgency and welcome the ability for definitive action thanks to your strong messaging, but they need support in their actions at the VA level since all of this gets stalled by the legal and statutory interpretation amongst other things David, as leaders we have to stay calm and give them the support they need. This is a culture change and doesn't happen with just showing frustration. We need to also give them the tools for execution and free them of the shackles. It's a system change, even though I know how impatient we are. And that's why you have this job- remember what everyone says including POTUS- it's the hardest job in the USA. The message today is that given the current environment, how do we take the risk and bring about change in accountability. How can we make today different from the past? No finger pointing when you have the discussion today please- it will only make things difficult. Just a collaborative discussion that will result in fast and urgent sustainable change > > Sent from my iPhone > >> on Mar 31, 2017, at 2:09 AM, David shulkin wrote: >> >> The accountability stuff is out of control and killing vha >> >> Remember how everyone laughed when fox asked me about employees watching porn >> >> And we actually allow this? >> >> This was easy - employee should have been fired on the spot- instead we detailed them to A desk job and then pay them to do nothing >> >> Then i read that ridiculous email from skye that says because it was regular porn and not child porn we have to wait weeks >> >> >> >> By the way the shrevsport director is still our employee and has nit been fired and you should hear about how bad he is >> >> This is easy- really easy - and it just takes leadership to say that this stops here >> >> I will handle this >> >> Sent from my iPhone >> >>> on Mar 30, 2017, at 7:56 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >>> >>> Anything else brewing besides these accountability issues? Getting a little worried about things there now- and you. Take care of yourself- I will stay connected >>> >>> Sent from my iPhone >> VA-19-0799-D-001422 OS 00003093 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/31/2017 9:23:36 AM David shulkin [Drshulkin@aol.com] Re: Take care I agree that this is something you have to be involved in with me. The field is now feeling the urgency and welcome the ability for definitive action thanks to your strong messaging, but they need support in their actions at the VA level since all of this gets stalled by the legal and statutory interpretation amongst other things David, as leaders we have to stay calm and give them the support they need. This is a culture change and doesn't happen with just showing frustration. We need to also give them the tools for execution and free them of the shackles. It's a system change, even though I know how impatient we are. And that's why you have this job- remember what everyone says including POTUS- it's the hardest job in the USA. The message today is that given the current environment, how do we take the risk and bring about change in accountability. How can we make today different from the past? No finger pointing when you have the discussion today please- it will only make things difficult. Just a collaborative discussion that will result in fast and urgent sustainable change Sent from my iPhone > on Mar 31, 2017, at 2:09 AM, David shulkin wrote: > > The accountability stuff is out of control and killing vha > > Remember how everyone laughed when fox asked me about employees watching porn > > And we actually allow this? > > This was easy - employee should have been fired on the spot- instead we detailed them to A desk job and then pay them to do nothing > > Then i read that ridiculous email from skye that says because it was regular porn and not child porn we have to wait weeks > > > > By the way the shrevsport director is still our employee and has nit been fired and you should hear about how bad he is > > This is easy- really easy - and it just takes leadership to say that this stops here > > I will handle this > > Sent from my iPhone > >> on Mar 30, 2017, at 7:56 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >> >> Anything else brewing besides these accountability issues? Getting a little worried about things there now- and you. Take care of yourself- I will stay connected >> >> Sent from my iPhone > VA-19-0799-D-001423 OS 00003094 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/31/2017 12:59:02 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Take care The accountability stuff is out of control and killing vha Remember how everyone laughed when fox asked me about employees watching porn And we actually allow this? This was easy - employee should have been fired on the spot- instead we detailed them to A desk job and then pay them to do nothing Then i read that ridiculous email from skye that says because it was regular porn and not child porn we have to wait weeks By the way the shrevsport director is still our employee and has nit been fired and you should hear about how bad he is This is easy- really easy - and it just takes leadership to say that this stops here I will handle this Sent from my iPhone > on Mar 30, 2017, at 7:56 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Anything else brewing besides these accountability issues? Getting a little worried about things there now- and you. Take care of yourself- I will stay connected > > Sent from my iPhone VA-19-0799-D-001424 OS 00003095 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/30/2017 11:56:22 PM David Shulkin [drshulkin@aol.com] Take care Anything else brewing besides these accountability issues? Getting a little worried about things there now- and you. Take care of yourself- I will stay connected Sent from my iPhone VA-19-0799-D-001425 OS 00003096 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/3/2017 1:52:14 AM To: (b) (6) Did we send (b) (6) [(b) (6) gmail.com] the last eo thst was not cut off Sent from my iPhone VA-19-0799-D-001426 OS 00003097 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/29/2017 9:51:19 AM Bruce Moskowitz [(b) (6) mac.com] David Shulkin [drshulkin@aol.com] Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am Thanks that is great to hear and will be a part of our communications strategy From: Bruce Moskowitz <(b) (6) mac.com> Sent: Wednesday, March 29, 2017 5:42 AM To: Poonam Alaigh Cc: David Shulkin Subject: Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am All are enthusiastically standing behind this important initiative Sent from my iPad Bruce Moskowitz M.D. hotmail.com> wrote: > On Mar 28, 2017, at 10:23 PM, Poonam Alaigh <(b) (6) > >Bruce-any feedback from the Big Five? Would want to also see if they can send out a public statement after the launch on 4/12 > > Sent from my iPhone > >> On Mar 25, 2017, at 12:49 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >> >> Please see attached power point for our discussion tomorrow - thanks >> >> >> - - - - - - - - - - - - - >> From: Bruce Moskowitz <(b) (6) rnac.com> >> Sent: Saturday, March 25, 2017 8:52 AM >> To: Poonam Alaigh >> Cc: David Shulkin >> Subject: Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am >> >> Ok >> >> Sent from my iPhone >> >> On Mar 25, 2017, at 8:46 AM, Poonam Alaigh <(b) (6) >> hotmail.com> wrote: >> >> Bruce and David- confirming our conference call tomorrow at 11am. I will dial both of you in at that time. >> >> >> David, will you please send the slides to both of all of us- if you dont have them, I will try to get them today. >> >> VA-19-0799-D-001427 OS 00003098 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/29/2017 2:23:52 AM Bruce Moskowitz [(b) (6) mac.com] David Shulkin [drshulkin@aol.com] Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am Bruce- any feedback from the Big Five? Would want to also see if they can send out a public statement after the launch on 4/12 Sent from my iPhone > on Mar 25, 2017, at 12:49 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > Please see attached power point for our discussion tomorrow - thanks > > > > > > > > From: Bruce Moskowitz <(b) (6) mac.com> Sent: Saturday, March 25, 2017 8:52 AM To: Poonam Alaigh cc: David shulkin subject: Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am > > Ok > > Sent from my iPhone > > on Mar 25, 2017, at 8:46 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > > Bruce and David- confirming our conference call tomorrow at 11am. I will dial both of you in at that time. > > > David, will you please send the slides to both of all of us- if you dont have them, I will try to get them today. > > VA-19-0799-D-001428 OS 00003099 Message From: Sent: To: Subject: Attachments: Poonam Alaigh [(b) (6) hotmail.com] 3/26/2017 3:00:45 PM David Shulkin [drshulkin@aol.com] Fw: Publicly Facing Transparency Website- Confirming call tomorrow at 11am Access and Quality Metric Screenshots.pptx From: Poonam Alaigh <(b) (6) hotmail.com> Sent: Saturday, March 25, 2017 12:49 PM To: Bruce Moskowitz Cc: David Shulkin Subject: Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am Please see attached power point for our discussion tomorrow - thanks From: Bruce Moskowitz <(b) (6) Sent: Saturday, March 25, 2017 8:52 AM mac.com> To: Poonam Alaigh Cc: David Shulkin Subject: Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am Ok Sent from my iPhone On Mar 25, 2017, at 8:46 AM, Poonam Alaigh <(b) (6) hotmail.com > wrote: Bruce and David- confirming our conference call tomorrow at 11am. I will dial both of you in at that time. David, will you please send the slides to both of all of us- if you dont have them, I will try to get them today. VA-19-0799-D-001429 OS 00003100 How quickly does my VA see patients? How satisfied are veterans like me with the timeliness of their care? How well does my VA's care compare to other hospitals? VA Pre-Decisional VA-19-0799-D-001430 OS 00003101 Home > Healthcare ) Access How quickly does my local VA see patients? Click below to see how we do. My Local Care Times Same-Day Service Options How qu1ckty can my VA hospital see Does my VA hospita l or clinic have memc lmJC? same-day services? How is the VA doing overall? National Care Times How timely 1s VA care right now? Access to Specialty Care How quickly are patients seeing a specialist for care needed right away? VA Pre-Decisional VA-19-0799-D-001431 OS 00003102 Wait Times for Appointments at VA Facilities Location (zip, city/state, fu ll address) Appointment Type Radius 50N6 Establistlecl Visit SPECIALTY CARE AUDIOLOGY CARDIOLOGY COMP WOMEN'S HLTH GASTROENTEROLOGY Back to US Map Wait Times as of 3/2 0 @ Automatic o ~4~- ,-, 7"'"' Wei"tlae : Obo,tin@" [i ChJPYdon ~J A Medina, cC ? !'l ? rty VA. ClinlC 210-1,Jg..()!I~ o 2days V;:~::~-:=o>Bl.'ed1~1c..,1-, S . Lou,s S1okH Clev.t ? nd Dap ? nm - ? m 8days L !Fl.~ --.- :h::::.::~. . ShownM ? p C Panna VA. Clime 6day1 210-73~7000 Show Mor9 Show on Map Corti alt 0. M G=m,i _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, """"'" t O ~ 1ro,n,,., tow Kent AIM!nN ~ mi::;:r , > <) . ~-r"' _J c ,W ...-W,.PI o-Lo---' / Q ,..,,....,iu/ (MILES) /t- - - - - - - - - - - - - - - - -I ,'otlons times vary according to the type of appointment >-- - - - - - - - - - - - 1 required. OPTOMETRY UROLOGY CLI NIC page) For urgent problems there are same day seMtes available in search DiStance More search MENTAL HEALTH OPHTHALMOLOGY Note- Your personal waibng time may differ-these wait bmes reflect A o N o sort ResultS By Visit Type Gr Hu ____ ? Alll.-.c~ "1~ ~ Niles, 11,1 0 $,1o 440-244-3833 Salffll Youngstown New Springfield 440-3!i7-0740 I Show More = C 20l7~Corporation l days Show on Map ----------------, Neshi : ..:.~~: r;:I VA.Cltnic ( _Sh __ .,_- _ ,_ - _ ~_ - _" _ _ _ _ _ _ G . RavaNta VA.Clintc ~ ~ 33 Union 3 3 0 - ~ 1 ldays C, Q:li _ sh_- _o_o,_o _',_ _ ~_o_o_o- - - - - - - - - - 11f o~~rfi~ @ Paris 3 days ~ ~ ~: C 2017 ME:.. Showt.!ore M IC ~ Showon~lap VA Pre-Decisional VA-19-0799-D-001432 OS 00003103 Same Day Services in VA for Primary Care and Mental Health Location (zip, city/state-, full 3ddress) R3dius 501-iEJ Sort Results By I 1o(R)t.1i1a- - Search More search Back to US Map Same Day Services report as of 3/21/2017 using filters: 50 mile radius of 'Richmond' SAME DAY SERVICES IN PRIMARY CARE AND MENTAL HEALTH DEFINITION: \o\lhen you contact us we will either address your need that day or schedule appropnate follow up care, depending on the urgency We may address your health care need by PfOVld1ng a face to face v1s1t retummg a phone call arranging a telehea!th or video care visit, responding by secure email or scheduhng a future appomtmenl 0 0 o N' Automatico SAME DAY SERVICES IN PRIMARY CARE AND MENTAL HEALTH Mechaf'IICSVIUe "'""?"" ) "'"'' DISTANCE . Stanardsville SAME DAY SERVICES (MILES) Leellnd A. Huntoo Hot....iJ Mi:Gun Ho!lpq.l 804..,7~ Lexington Pa, Show More L!I Show on Map B Fredench burg 2 VAClifuc 804..,7~5000 I Rivarina Show More PolD Tappahannodc ,;;, Show on Map o Heathmlle t. "~ Lancastef' King And Queen Cout1 Hou1e 0 Gokl Hill :k,ngham Powha1on CUlTll:>erland Cu,dsville WareNeck Amc!lia Court Hous.e {Mil 'e mp 1 1orri:s. wR,... 20km e2011 u.-cro":~=9i_;e . ~ VA Pre-Decisional VA-19-0799-D-001433 OS 00003104 Home > Healthcare , Access , National Care Times How timely is VA care right now? Note: Data updated 3/1/17 Veterans currently have 8.02 mill ion appointments scheduled 9-1% (7.5 million) are scheduled to be seen no lat than 30 days after the 6% (484,603) are scheduled to be seen 30 days or greater after the requested requested date fPatient Indicated Datel. ~ < 1% (of total scheduled) are considered 'priority'*. o How is this figure calculated? .. VA Pre-Decisional VA-19-0799-D-001434 OS 00003105 Home , Healthcare i Access , Access to Specialty Care Access to Specialty Care Note: Data updated 311117 How q uickly are patients seeing a specialist fo r care needed right away7 Veterans currently have 32 549 referra ls to a special ist for care needed right away. I l 93% (30 4151 are 99% (31.190) are addressed within 30 days add ressed within 7days What do we mean by "care needed right away"" or "referrals needed right away''? VA Pre-Decisional VA-19-0799-D-001435 OS 00003106 What Veterans Say About Access to Care at VA facilities Loc3tion (zip, city/st.1te, fu ll 3ddress) r~ Appointment "fYpe Radius l X sort Results By Facility Name Primary Care (Routine) 50 Miles Searc h E3ack lo US Map - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - < Found facilities will be ordered according to your Percent of Veterans who reported that they were Always or Usually able to get an appointment when needed . The choice here 7/1/2016 - 12/31 /2016. At least 30 Veterans have responded to this question for a site to be included . The filters used W!miffirnlW.Wll!Trnfflllff"llT'_ _ _T"' 'BAY PINES', Primary Care (Routine) Note - Tne data shows what Veterans have said aoout tnelr own Access experiences over the preceding 6 months Your own experience may t>e different For urgent problems there onen are options to t>e seen sooner, such as a same...e longer than 30 days, you may request a referral to care in ttle community. o N o 00 u--- Automatico ~ able to gel an appombnenl when needed fOf 'Pnrnary Care (Routine)' Appointments "' Kin1mm1 FACILITY NAME New Port Rid,ey LandO'lak ) ~~ Zephymdts r,, A. Bradenton VA Clinie '~G """""' ~~ Clearwater ~ le ampa18,a Tamp, Boy 28 89% ',":; 85 % B C.W BillYoung Oepzutmentof v.1,t<H (JSO"I) Oowr,load Seard'! Ruults (CSV) 20 1;Micros Show More 10 milu 1!Corp ? tion Oow11load ALL Fac,~ues (CSV) Show oo Map G Sarasot.11 VA Cinie "" V VA Pre-Decisional VA-19-0799-D-001436 OS 00003107 Home , Healthcare , Health Care Quality Information and Resources How well does my VA perform compared to other hospitals? How well does my VA medical center compare to surrounding hospitals? How well does my VA medical center compare against other clinics that can treat me as an outpatient? [COMING SOON] We are posting this data here lemporarily until Medicare uploads our submitted data into "Hospital Compare" VA Pre-Decisional VA-19-0799-D-001437 OS 00003108 Horne ) Healthcare > Hospital Compa re Data Hospital Compare Data Select your hospital from the list below to compare. More hospitals COMI NG SOON (402) Togus VA Medical Center (NEW) (402) Togus VA Medical Center (501) VA New Mexico Healthcare System (508) Decatur (Atlanta) VA Medical Center (528) Upstate New York VA Healthcare System (537) Jesse Brown VA Medical Center - VA Chicago Healthcare (573A4) VA North Florida and South Georg ia Healthcare System (578) Hines VA Medical Center (580) Housto n VA Medical Center VA Pre-Decisional VA-19-0799-D-001438 OS 00003109 Hospital Compare Data x "!B lonvert ..- ~ ~elect A wound that splits open Accidental cuts and tears after surgery on the from medica l treatment abdomen or pelvis Blood stream infection after surgery Broken hip from a fall after surgery Collapsed lung due to medical treatment Deaths among with serious compl1catio surge Data date range (Preferred direction) 7113 6115 I -- 1113 6115 I mi -- 6115 I 1In 6115 I 1113 6115 I 1113 611 National Average 2.32 1.43 10.21 0.06 0.41 136.48 National Median 21 1.4 9.3 0.1 0.4 1l5.6 Portland {HRR) Average 2.4 2.2 0.1 0.5 m .2 Pon.land (HRR) Median 2.2 1.6 8.7 9.6 0.1 0.4 137.3 National Top 10 Percent 1.98 0.92 8.00 0.06 0.32 114.)5 National Top 25 Percent 2.13 1.14 9.04 0.06 O.JG 124.46 (402) Togus VA Medtcal Center BRIDGTON HOSPITAL 4.52 1.67 6.41 0.00 0.00 Not Available Not Avail.able Not Available Nol Available Not Available 0.00 NotAvaila CENTRAL MAINE MEDICAL CENTER 197 239 9 93 0 06 035 14561 FRANKIJ N MEMORIAL HOSPITAL 2.26 1.34 9.76 0.06 0.39 NotAvaila FRISBIE MEMORIAL HOSPITAL 2.19 1.48 9.45 0.06 0.36 NotAvail a INLAND HOSPITAL 227 138 9 72 0 06 039 Not Availa MAINE MEDICAL CENTER 278 333 7 30 0 06 064 12989 MAINEGENERAL MEDICAL CENTER 2.06 1.60 8.75 0.06 0.42 Not Available Not Available Not Available Not Available Not Available MERCY HOSPITAL 212 207 9 64 0 06 0 33 121 38 MID COAST HOSPITAL 2.21 1.18 Not Available 0.06 0.40 Not Availa MEMOR W. HOSPITAL. THE PENOBSCOT BAY MEDICAL CENTER RUMFORD HOSPITAL SOUTHERN MAINE HEALTH CARE ST ANDREWS HOSPITAL ST MARYS REGIONAL MEDICAL CENTER 125.1l Not Availa 2.22 1.61 9.46 0.06 0.47 Not Availa No1AvailablEUR Not Available Not Available Not Available Not Available NotAvaila 261 1.62 927 0 06 033 Not Available Not Available Not Available Not Available Not Available 144-61 Not Availa 219 220 10 82 0 06 0.46 Not Available Nol Avail.able Not Available Not Available Not Available WENTWORTH-OOUGLASS HOSPITAL 212 1.85 1031 0 06 0.46 14525 YORK HOSPITAL 217 1.04 8 76 0 06 039 14464 STEPHENS MEMORIAL HO SPITAL 12172 Not Availa VA Pre-Decisional VA-19-0799-D-001439 OS 00003110 Message Poonam Alaigh [(b) (6) hotmail.com] 3/25/2017 2:07:24 PM David shulkin [Drshulkin@aol.com] Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am From: Sent: To: Subject: I didnt get the slides From: David shulkin Sent: Saturday, March 25, 2017 10:00 AM To: Poonam Alaigh Cc: Bruce Moskowitz Subject: Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am Confirmed I sent slides Sent from my iPhone On Mar 25, 2017, at 8:46 AM, Poonam Alaigh <(b) (6) hotmail.com > wrote: Bruce and David- confirming our conference call tomorrow at 11am. I will dial both of you in at that time. David, will you please send the slides to both of all of us- if you dont have them, I will try to get them today. VA-19-0799-D-001440 OS 00003111 Message David shulkin [Drshulkin@aol.com] 3/25/2017 2:00:05 PM Poonam Alaigh [(b) (6) hotmail.com] Bruce Moskowitz [(b) (6) mac.com] Re: Publicly Facing Transparency Website- Confirming call tomorrow at 11am From: Sent: To: CC: Subject: Confirmed I sent slides Sent from my iPhone On Mar 25, 2017, at 8:46 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Bruce and David- confirming our conference call tomorrow at 11am. I will dial both of you in at that time. David, will you please send the slides to both of all of us- if you dont have them, I will try to get them today. VA-19-0799-D-001441 OS 00003112 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/25/2017 12:46:53 PM Bruce Moskowitz [(b) (6) mac.com]; David Shulkin [drshulkin@aol.com] Publicly Facing Transparency Website- Confirming call tomorrow at 11am Bruce and David- confirming our conference call tomorrow at 11am. I will dial both of you in at that time. David, will you please send the slides to both of all of us- if you dont have them, I will try to get them today. VA-19-0799-D-001442 OS 00003113 Message From: Sent: To: Subject: Attachments: David shulkin [Drshulkin@aol.com] 4/7/2017 11:22:24 PM (b) (6) R. (b) (6) [(b) (6) va.gov] Fwd: Hopkins CIO (b) (6) pdf; Untitled attachment 06221.htm Last one Sent from my iPhone Begin forwarded message: From: Bruce Moskowitz <(b) (6) Date: April 7, 2017 at 7: 19:34 PM EDT To: drshulkin@aol .com Subject: Hopkins CIO mac.com> He now is in a private venture excellent to include VA-19-0799-D-001443 OS 00003114 (b) (6) MSE, CIIP (b) (6) @ jhmi .edu (b) (6) Glen Burnie, MD (b) (6) (785) 218-(b) (6) CURRENT WORK: (b) (6) August 2011 - present o o (b) (6), (b) (2) (b) (6), (b) (2) 0 (b) (6), (b) (2) 0 (b) (6) January 2014 - present (b) (6) (b) (6) September 2011 - present (b) (6), (b) (2) (b) (6), (b) (2) December 2016 - present (b) (6), (b) (2) (b) (6), (b) (2) July 2016 - present (b) (6), (b) (2) (b) (6), (b) (2) June 2016 - present (b) (6), (b) (2) February 2016 - present VA-19-0799-D-001444 OS 00003115 PAST WORK: (b) (6), (b) (2) o July 20 l O - August 2011 (b) (6), (b) (2) (b) (6), (b) (2) o (b) (6), (b) (2) (b) (6), (b) (2) o o o o (b) (6), (b) (2) o . March 2007 - May 2008 (b) (6), (b) (2) (b) (6), (b) (2) o September 2009 - May 20 l 0 August 2009 - May 20 l 0 June 2009 - September 2009 September 2009 - December 2009 s (b) (6), (b) (2) e o o January 2008 - May 2008, January 2007 - May 2007 (b) (6), (b) (2) (b) (6), (b) (2) August 2004 - January 2005 January 2005 - May 2006 EDUCATION: (b) (6), (b) (2) SKILLS: o (b) (6), (b) (2) o o o o o o o VA-19-0799-D-001445 OS 00003116 l\1EMBERSHIPS: o (b) (6), (b) (2) o o o o ACHIEVEMENTS: (b) (6), (b) (2) o o o o o o o PUBLICATIONS: Peer-Reviewed Publications: (b) (6), (b) (2) Abstracts: (b) (6), (b) (2) (b) (6) VA-19-0799-D-001446 OS 00003117 Sent ?om my iPhone Message From: David shulkin [Drshulkin@aol.com] Sent: 4/7/2017 11:22:07 PM To: Bruce Moskowitz [(b) (6) Re: Hopkins CIO Subject: mac.com] Got it Sent from my iPhone > on Apr 7, 2017, at 7:19 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > He now is in a private venture excellent to include > > <(b) (6) pdf> > > > > Sent from my iPhone VA-19-0799-D-001448 OS 00003119 Message From: Bruce Moskowitz [(b) (6) Sent: To: 4/7/2017 11:19:34 PM Subject: Attachments: mac.com] drshulkin@aol.com Hopkins CIO (b) (6) pdf; Untitled attachment 06227.txt He now is in a private venture excellent to include VA-19-0799-D-001449 OS 00003120 (b) (6), (b) (2) MSE, CIIP (b) (6) @ jhmi .edu (b) (6), (b) (2) (6), (b) Glen Burnie, MD (b) (2) (785) 218-(b) (6) CURRENT WORK: (b) (6), (b) (2) August 2011 - present 0 (b) (6), (b) (2) 0 (b) (6), (b) (2) January 2014 - present (b) (6), (b) (2) (b) (6), (b) (2) September 2011 - present (b) (6), (b) (2) (b) (6), (b) (2) (b) (6), (b) (2) December 2016 - present ) July 2016 - present (b) (6), (b) (2) (b) (6), (b) (2) June 2016 - present (b) (6), (b) (2) February 2016 - present VA-19-0799-D-001450 OS 00003121 PAST WORK: (b) (6), (b) (2) o July 20 l O - August 2011 (b) (6), (b) (2) o o o o (b) (6), (b) (2) (b) (6), (b) (2) o September 2009 - May 20 l 0 August 2009 - May 20 l 0 June 2009 - September 2009 September 2009 - December 2009 March 2007 - May 2008 (b) (6), (b) (2) January 2008 - May 2008, January 2007 - May 2007 o (b) (6), (b) (2) August 2004 - January 2005 January 2005 - May 2006 EDUCATION: (b) (6), (b) (2) SKILLS: o (b) (6), (b) (2) o o o o o o o VA-19-0799-D-001451 OS 00003122 l\1EMBERSHIPS: o (b) (6), (b) (2) o o o o ACHIEVEMENTS: o o (b) (6), (b) (2) o o o o o PUBLICATIONS: Peer-Reviewed Publications: (b) (6), (b) (2) Abstracts: (b) (6), (b) (2) (b) (6) VA-19-0799-D-001452 OS 00003123 Sent from my iPhone Message From: David Shulkin [drshulkin@aol.com] Sent: 4/9/2017 2:06:30 PM To: (b) (6) Subject: hotmail.com Re: Tough to do on the phone But .. your version is the final draft -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: David Shulkin Sent: Sun, Apr 9, 2017 10:02 am Subject: Re: Tough to do on the phone But.. K- send me a initial final version if you can and I will forward on for a quick turn around by mid week at the latest. Trying to head home in the afternoon from the wedding stuff- if you can't get to coming up with a final draft, I will do it later. Also have scheduled a conference call in prep of the website stuff at 2pm today with the team and will give you an update accordingly Sent from my iPhone On Apr 9, 2017, at 9:36 AM, David Shulkin wrote: If you think it might be helpful- yes -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: David shulkin Sent: Sun, Apr 9, 2017 9:02 am Subject: Re: Tough to do on the phone But.. Do you want me to have Kate and her consultants do a quick review before making it official - I think we should Sent from my iPhone On Apr 8, 2017, at 7:02 PM, David shulkin wrote: Good edits Sent from my iPhone On Apr 8, 2017, at 6:50 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Almost there- my edits in italics Greater Choice for Veterans -Redesign the 40/30 Rule -Build a High Performing Integrated Network of Care - Empower veterans through transparency of information Modernize our System -Infrastructure Improvements and Streamlining -EMR Interoperability and IT Modernization oFocus Resources More Efficiently -strengthening of Foundational Services in VA -VA/DOD/Community Coordination VA-19-0799-D-001454 OS 00003125 -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides Sent from my iPhone On Apr 8, 2017, at 4:11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001455 OS 00003126 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/9/2017 2:02:46 PM David Shulkin [drshulkin@aol.com] Re: Tough to do on the phone But .. K- send me a initial final version if you can and I will forward on for a quick turn around by mid week at the latest. Trying to head home in the afternoon from the wedding stuff- if you can't get to coming up with a final draft, I will do it later. Also have scheduled a conference call in prep of the website stuff at 2pm today with the team and will give you an update accordingly Sent from my iPhone On Apr 9, 2017, at 9:36 AM, David Shulkin wrote: If you think it might be helpful- yes -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: David shulkin Sent: Sun, Apr 9, 2017 9:02 am Subject: Re: Tough to do on the phone But.. Do you want me to have Kate and her consultants do a quick review before making it official - I think we should Sent from my iPhone On Apr 8, 2017, at 7:02 PM, David shulkin wrote: Good edits Sent from my iPhone On Apr 8, 2017, at 6:50 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Almost there- my edits in italics Greater Choice for Veterans -Redesign the 40/30 Rule -Build a High Performing Integrated Network of Care - Empower veterans through transparency of information Modernize our System -Infrastructure Improvements and Streamlining -EMR Interoperability and IT Modernization oFocus Resources More Efficiently -strengthening of Foundational Services in VA -VA/DOD/Community Coordination -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides VA-19-0799-D-001456 OS 00003127 Sent from my iPhone On Apr 8, 2017, at 4:11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001457 OS 00003128 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/9/2017 1:36:29 PM To: (b) (6) Subject: hotmail.com Re: Tough to do on the phone But .. If you think it might be helpful- yes -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: David shulkin Sent: Sun, Apr 9, 2017 9:02 am Subject: Re: Tough to do on the phone But.. Do you want me to have Kate and her consultants do a quick review before making it official - I think we should Sent from my iPhone On Apr 8, 2017, at 7:02 PM, David shulkin wrote: Good edits Sent from my iPhone On Apr 8, 2017, at 6:50 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Almost there- my edits in italics Greater Choice for Veterans -Redesign the 40/30 Rule -Build a High Performing Integrated Network of Care - Empower veterans through transparency of information Modernize our System -Infrastructure Improvements and Streamlining -EMR Interoperability and IT Modernization oFocus Resources More Efficiently -strengthening of Foundational Services in VA -VA/DOD/Community Coordination -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides Sent from my iPhone On Apr 8, 2017, at 4:11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001458 OS 00003129 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/9/2017 1:02:41 PM David shulkin [Drshulkin@aol.com] Re: Tough to do on the phone But .. Do you want me to have Kate and her consultants do a quick review before making it official - I think we should Sent from my iPhone On Apr 8, 2017, at 7:02 PM, David shulkin wrote: Good edits Sent from my iPhone On Apr 8, 2017, at 6:50 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Almost there- my edits in italics o Greater Choice for Veterans o -Redesign the 40/30 Rule o -Build a High Performing Integrated Network of Care - Empower veterans through transparency of information Modernize our System o -Infrastructure Improvements and Streamlining o -EMR Interoperability and IT Modernization oFocus Resources More Efficiently o -strengthening of Foundational Services in VA o -VA/DOD/Community Coordination o -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides Sent from my iPhone On Apr 8, 2017, at 4: 11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001459 OS 00003130 Message From: (b) (6) Sent: 4/8/2017 11:03:21 PM David shulkin [Drshulkin@aol.com] Re: Tough to do on the phone But .. To: Subject: [(b) (6) gmail.com] Ok On Sat, Apr 8, 2017 at 7:02 PM David shulkin wrote: I like her edits - lets use these Sent from my iPhone Begin forwarded message: From: Poonam Alaigh <(b) (6) hotmail.com> Date: April 8, 2017 at 6:50:56 PM EDT To: David Shulkin Subject: Tough to do on the phone But.. Almost there- my edits in italics Greater Choice for Veterans VA-19-0799-D-001460 OS 00003131 o -Redesign the 40/30 Rule o -Build a High Pe1forming Integrated Network of Care o - Empower veterans through transparency of information 1\fodernize our System o -Infrastructure Improvements and Streamlining o -El\fR Interoperability and IT Modernization VA-19-0799-D-001461 OS 00003132 oFocus Resources More Efficiently o -strengthening of Foundational Services in VA o -VA/DOD/Community Coordination o -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals VA-19-0799-D-001462 OS 00003133 - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides Sent from my iPhone On Apr 8, 2017, at 4: 11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001463 OS 00003134 Sent from Gmail Mobile Message David shulkin [Drshulkin@aol.com] 4/8/2017 11:02:32 PM (b) (6) [(b) (6) Fwd: Tough to do on the phone But .. From: Sent: To: Subject: gmail.com] I like her edits - lets use these Sent from my iPhone Begin forwarded message: From: Poonam Alaigh <(b) (6) hotmail .com> Date: April 8, 2017 at 6:50:56 PM EDT To: David Shulkin Subject: Tough to do on the phone But.. Almost there- my edits in italics o Greater Choice for Veterans o -Redesign the 40/30 Rule o -Build a High Performing Integrated Network of Care - Empower veterans through transparency of information Modernize our System o -Infrastructure Improvements and Streamlining o -EMR Interoperability and IT Modernization oFocus Resources More Efficiently o -strengthening of Foundational Services in VA o -VA/DOD/Community Coordination o -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides Sent from my iPhone On Apr 8, 2017, at 4: 11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001465 OS 00003136 Message David shulkin [Drshulkin@aol.com] 4/8/2017 11:01:56 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Tough to do on the phone But .. From: Sent: To: Subject: Good edits Sent from my iPhone On Apr 8, 2017, at 6:50 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Almost there- my edits in italics o Greater Choice for Veterans o -Redesign the 40/30 Rule o -Build a High Performing Integrated Network of Care - Empower veterans through transparency of information Modernize our System o -Infrastructure Improvements and Streamlining o -EMR Interoperability and IT Modernization oFocus Resources More Efficiently o -strengthening of Foundational Services in VA o -VA/DOD/Community Coordination o -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides Sent from my iPhone On Apr 8, 2017, at 4: 11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001466 OS 00003137 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/8/2017 10:50:56 PM David Shulkin [drshulkin@aol.com] Tough to do on the phone But .. Almost there- my edits in italics o Greater Choice for Veterans o -Redesign the 40/30 Rule o -Build a High Performing Integrated Network of Care - Empower veterans through transparency of information Modernize our System o -Infrastructure Improvements and Streamlining o -EMR Interoperability and IT Modernization oFocus Resources More Efficiently o -strengthening of Foundational Services in VA o -VA/DOD/Community Coordination o -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Access to Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention Getting to Zero Suicides Sent from my iPhone On Apr 8, 2017, at 4: 11 PM, David Shulkin wrote: revised to 5 VA-19-0799-D-001467 OS 00003138 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/31/2017 12:54:21 AM Darin Selnick [(b) (6) @gmail.com] Re: Important Sen Lee Intel Got it Thats what I figured Im speaking toLee tommorow Sent from my iPhone > on Mar 30, 2017, at 8:14 PM, Darin selnick <(b) (6) @gmail.com> wrote: > > A friend of mine on the Hill talked to Sen Lee staff and just told me what the real problem is that is causing the hold on the choice Act extension. > > He was told by Sen Lee staff that some VA career staff, a Sen Moran staffer and some Sen Isakson SVAC staff are saying that choice 2.0 and all of the community care programs should have VA as primary payer. > > They also said that VA should not ever be the 2nd payer, including choice.2.0. what has Sen Lee and staff concerned is that they were also told by this same Sen staff, that they want Section 2 in the bill so that it will be a precedent and a way to have VA be primary payer for choice 2.0. Hearing that from the other Sen staff plus hearing from some VA staff that VA should be primary payer with choice 2.0. is why they have kept the hold on the legislation. They are very concerned and have mixed signals from VA. > > To release the hold Sen Lee wants reassurance from you on two things: > 1. To hear directly from you that you will not have VA be the primary payer for choice 2.0. > 2. For you to give him some written reassurances that VA will not be primary payer for choice 2.0. > > I now understand why Sen Lee and his staff changed their tune after what they heard from other Sen Staff and VA staff. > > There is nothing we can do about Sen staff other than to educate them. I am very concerned that there are VA staff still saying about primary payer what you told them not to say. > > We will never get choice 2.0 passed if we do not fix this. > > Darin > > VA-19-0799-D-001468 OS 00003139 Message From: Darin Selnick [(b) (6) Sent: 3/31/2017 12:14:05 AM To: David shulkin [Drshulkin@aol.com] Important Sen Lee Intel Subject: @gmail.com] A friend of mine on the Hill talked to Sen Lee staff and just told me what the real problem is that is causing the hold on the Choice Act extension. He was told by Sen Lee staff that some VA career staff, a Sen Moran staffer and some Sen Isakson SVAC staff are saying that Choice 2.0 and all of the community care programs should have VA as primary payer. They also said that VA should not ever be the 2nd payer, including Choice.2.0. What has Sen Lee and staff concerned is that they were also told by this same Sen staff, that they want Section 2 in the bill so that it will be a precedent and a way to have VA be primary payer for Choice 2.0. Hearing that from the other Sen staff plus hearing from some VA staff that VA should be primary payer with Choice 2.0. is why they have kept the hold on the legislation. They are very concerned and have mixed signals from VA. To release the hold Sen Lee wants reassurance from you on two things: 1. To hear directly from you that you will not have VA be the primary payer for Choice 2.0. 2. For you to give him some written reassurances that VA will not be primary payer for Choice 2.0. I now understand why Sen Lee and his staff changed their tune after what they heard from other Sen Staff and VA staff There is nothing we can do about Sen staff other than to educate them. I am very concerned that there are VA staff still saying about primary payer what you told them not to say. We will never get Choice 2.0 passed if we do not fix this. Darin VA-19-0799-D-001469 OS 00003140 Message From: David shulkin [Drshulkin@aol.com] Sent: 4/5/2017 10:35:35 PM To: Ike Perlmutter [(b) (6) frenchangel59.com] Great meeting today with Jared and the Department of Defense. Jared pushed hard and cut out what has been probably decades of red tape and we got to "yes" on finally working with DoD on electronic records. Its never been done before and if we can get this working it wi 77 be a game changer. David Sent from my iPhone VA-19-0799-D-001470 OS 00003141 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/19/2017 10:25:27 AM Poonam Alaigh [(b) (6) hotmail.com] Re: No story now 3 am? Sent from my iPhone On Apr 19, 2017, at 3:01 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: You did it!! Sent from my iPhone On Apr 18, 2017, at 10:43 PM, David Shulkin wrote: Between us Sent from my iPad Begin forwarded message: From: Donovan Slack Date: April 18, 2017 at 9:44:53 PM EDT To: David Shulkin Subject: No story now I wanted, between us as always, to make sure not to leave you in limbo. Given everything, I decided it's not fair to do a story right now about what visn/vaco officials did or didn't do in three weeks leading up to last weeks PR crisis. I would normally tell someone else this, who could relay it to you (ie: Linda), but honestly haven't found a person I feel comfortable with yet in your new orbit. I'm sure I will at some point but didn't want to leave u hanging in the meantime. VA-19-0799-D-001471 OS 00003142 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/19/2017 10:16:21 AM David Shulkin [drshulkin@aol.com] Re: No story now Maybe (b) (6) can also be the one who is on point for both you and I for these critical and high visibility relationships- don't know that there is anyone else we can trust for these sensitive situations Sent from my iPhone On Apr 18, 2017, at 10:43 PM, David Shulkin wrote: Between us Sent from my iPad Begin forwarded message: From: Donovan Slack Date: April 18, 2017 at 9:44:53 PM EDT To: David Shulkin Subject: No story now I wanted, between us as always, to make sure not to leave you in limbo. Given everything, I decided it's not fair to do a story right now about what visn/vaco officials did or didn't do in three weeks leading up to last weeks PR crisis. I would normally tell someone else this, who could relay it to you (ie: Linda), but honestly haven't found a person I feel comfortable with yet in your new orbit. I'm sure I will at some point but didn't want to leave u hanging in the meantime. VA-19-0799-D-001472 OS 00003143 Message Poonam Alaigh [(b) (6) hotmail.com] 4/19/2017 7:01:22 AM David Shulkin [drshulkin@aol.com] Re: No story now From: Sent: To: Subject: You did it!! Sent from my iPhone On Apr 18, 2017, at 10:43 PM, David Shulkin wrote: Between us Sent from my iPad Begin forwarded message: From: Donovan Slack Date: April 18, 2017 at 9:44:53 PM EDT To: David Shulkin Subject: No story now I wanted, between us as always, to make sure not to leave you in limbo. Given everything, I decided it's not fair to do a story right now about what visn/vaco officials did or didn't do in three weeks leading up to last weeks PR crisis. I would normally tell someone else this, who could relay it to you (ie: Linda), but honestly haven't found a person I feel comfortable with yet in your new orbit. I'm sure I will at some point but didn't want to leave u hanging in the meantime. VA-19-0799-D-001473 OS 00003144 Message David Shulkin [drshulkin@aol.com] 4/19/2017 2:43:00 AM Poonam Alaigh [(b) (6) hotmail.com]; Vivieca Simpson [(b) (6) Fwd: No story now From: Sent: To: Subject: gmail.com] Between us Sent from my iPad Begin forwarded message: From: Donovan Slack Date: April 18, 2017 at 9:44:53 PM EDT To: David Shulkin Subject: No story now I wanted, between us as always, to make sure not to leave you in limbo. Given everything, I decided it's not fair to do a story right now about what visn/vaco officials did or didn't do in three weeks leading up to last weeks PR crisis. I would normally tell someone else this, who could relay it to you (ie: Linda), but honestly haven't found a person I feel comfortable with yet in your new orbit. I'm sure I will at some point but didn't want to leave u hanging in the meantime. VA-19-0799-D-001474 OS 00003145 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 5/2/2017 11:56:28 AM Bruce Moskowitz [(b) (6) mac.com] drshulkin@aol.com; darin.selnick@va.gov; IP [(b) (6) frenchangel59.com]; l Perl [(b) (6) mbs(b) (6) @gmail.com; (b) (6) aol.com Re: Apple Thanks - Darin, copying point for us here at VA (b) (6) gmail.com]; my Senior Advisor, on my end so that the two of you can be on Sent from my iPhone > on May 2, 2017, at 7:37 AM, Bruce Moskowitz <(b) (6) > > I think the number one priority with Apple will be health records available to Veterans. If they choose what the evaluation and treatment is, not was or the needs important data from the VA records The 5 CEO's mac.com> wrote: to have what they are already working on, portable the choice program then we need to know in realtime cost can be prohibitive. Also the health provider have committed resources also to get this done. > > We will need their assistance to have a patient centric program for preventive medicine that can also tract progress > > Tracking mechanism for opioid prescriptions within and outside of the VA > > Organize mental health early detection and treatment strategies. currently there are too many unorganized initiatives and no feed back on effectiveness. > > Approved choice services geotagged to the Veterans location hospitals, providers walk in clinics etc. > > The CEO's want to have their teams work with Apple for strategies to reduce health care costs. This is very important and we need to take advantage of everyone's intellectual capital. > > I am available to discuss 24/7 and the academic team is ready to move now. > > > > > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-001475 OS 00003146 Message From: (b) (6) Sent: 3/29/2017 7:48:48 PM To: David [drshulkin@aol.com] Fwd: Subject: [(b) (6) hotmail.com] U c this is her entertainment that she gets to do everything u do Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) Date: March 29, 2017 at 2:59:20 PM EDT To: (b) (6) <(b) (6) hotmail.com> gmail.com> Dr. Shulkin will probably be the only cool Secretary in history. I appreciate him very much, even when he keeps us on our toes. Today was fun. We left the WH at 12:14, Reggie got us to the airport by 12:23. We made our 12:50 flight. Yes! I of course ran to the gate like a crazy person I was determined to save the flight. Not needed, we made it. By far the best crazy experience ever...well except for meeting Barack and michelle, traveling to the Greek isles, etc. But it's up there :-) VA-19-0799-D-001476 OS 00003147 Message From: David Shulkin [drshulkin@aol.com] Sent: 4/8/2017 8:11:45 PM To: (b) (6) Attachments: hotmail.com priorities.pptx revised to 5 VA-19-0799-D-001477 OS 00003148 The Secretary's 5 Priorities Greater Choice for Veterans -Revise the 40/30 Rule -Build an Integrated Network of Care - Empower veterans through transparency of information Modernize our System -Infrastructure Improvements and Consolidations -EMR Interoperability and Modernization Focus Resources More Efficiently -Foundational Services in VA -VA/DOD/Community Coordination -Deliver on Accountability and Effective Management practices Improve Timeliness of Services - Wait times and Accessibility for Care - Decisions on Appeals - Performance on Disability Claims Suicide Prevention VA-19-0799-D-001478 OS 00003149 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/30/2017 12:06:10 PM Ike Perlmutter [(b) (6) frenchangel59.com]; Laurie Perlmutter [(b) (6) gmail.com]; Bruce Moskowitz [(b) (6) mac.com] Fwd: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR This morning on national public radio VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR http ://www.npr.org/sections/health-shots/201 7/03/30/52193 7557/the-va-is-on-a-path-towardrecovery-secretary-of-veterans-affairs-says VA-19-0799-D-001479 OS 00003150 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/30/2017 12:05:04 PM (b) (6) [(b) (6) hotmail.com]; (b) (6) [(b) (6) gmail.com]; (b) (6) gmail.com Fwd: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) gmail.com> Date: March 30, 2017 at 5:29:19 AM CDT To: drshulkin@aol .com Subject: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots Health News : NPR VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR http ://www.npr.org/sections/health-shots/2017/03/30/52193 7557/the-va-is-on-a-path-towardrecovery-secretary-of-veterans-affairs-says VA-19-0799-D-001480 OS 00003151 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/30/2017 12:04:40 PM (b) (6) [(b) (6) sunnyshulkin.com]; (b) (6) [(b) (6) sunnyshulkin.com]; (b) (6) (b) (6) [ gmail.com] Fwd: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) gmail .com> Date: March 30, 2017 at 5:29:19 AM CDT To: drshulkin@aol .com Subject: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots Health News : NPR VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR http ://www.npr.org/sections/health-shots/2017/03/30/52193 7557/the-va-is-on-a-path-towardrecovery-secretary-of-veterans-affairs-says VA-19-0799-D-001481 OS 00003152 Message From: (b) (6) Sent: 3/30/2017 10:29:19 AM drshulkin@aol.com VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR To: Subject: [(b) (6) gmail.com] VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR http ://www.npr.org/sections/health-shots/201 7/03/30/52193 7557/the-va-is-on-a-path-toward-recoverysecretary-of-veterans-affairs-says VA-19-0799-D-001482 OS 00003153 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/29/2017 6:54:49 PM Bruce Moskowitz [(b) (6) Fwd: Problems at the WPB VA mac.com] Fyi- im handling Sent from my iPhone Begin forwarded message: From: DJS Date: March 29, 2017 at 11 :59:42 AM CDT To: 'Shulkin' Subject: FW: Problems at the WPB VA Sent with Good (www.good.com) -----Original Message----From: (b) (6) Sent: Wednesday, March 29, 2017 11 :51 AM Eastern Standard Time To: Shulkin, David J., MD Subject: Problems at the WPB VA Dear Dr. Shulkin, I am writing to inform you of the problems at the West Palm Beach V AMC in regard to recruiting and retaining nurse practitioners. For almost nine years I have been working as a psychiatric nurse practitioner at this facility. My duty station for the past 7 years has been in the PTSD clinic. It is an honor to care for veterans like my father whose lives were changed forever by the horrors of combat. There are two issues of concern. First, there is a problem with recruiting NP' s as the salary is not commensurate with the private sector. Second there is no mechanism to retain qualified NP' s like myself Despite having a doctoral degree and outstanding performance reviews, attempts to attain a step increase have been denied. Here lies the problem. Once a nurse is "boarded" he/she cannot be "re-boarded." In 2008, I was "boarded" in an obsolete manner. Thus, I am literally "stuck" with a very low salary. In order to VA-19-0799-D-001483 OS 00003154 get "re-boarded" I was informed by HR that I must leave the VA for one year and then return. This policy does not make sense for a facility that has been struggling to recruit psychiatric nurse practitioners. To date, I believe we have 7 unfilled NP positions. Dr. Casariego, my immediate supervisor can verify how difficult it is to recruit NP' s once they learn the salary. This shortage puts a strain on the existing staff More importantly, it affects the veteran who gets shifted from provider to provider which results in poor of continuity of care. Recently at a conference I learned that a 27 year old new graduate (who I trained) is earning $120,000 per year at a local facility. With my education and experience, nurse practitioners in the private sector are earning $150,000 - $160,000. I earn $98,107.00 after 34 years of being a nurse! It is quite disheartening that the VA devalues the contribution that NP's make in caring for our veterans. Many people ask why I remain in such a low paying job. I tell them it is because I am devoted to my patients whom I have a long standing relationship with. However, the time has come that I must start looking after my best interests. As such, I am aggressively seeking employment in other government agencies. Dr. Shulkin, we have a mutual acquaintance, Dr. Bruce Moskowitz, whom I have known for 30 years. He can vouch for my integrity. My efforts at the local level have been futile. I am hoping that during your administration you will find a way to rectify this inequitable pay scale system. Respectfully, (b) (6) DNP, ARNP, PMHNP-BC PTSD Clinic (lF-108) (561) 422-(b) (6) VA-19-0799-D-001484 OS 00003155 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/30/2017 2:53:43 AM Marc Sherman [(b) (6) gmail.com] Re: AIPAC Yes - i enjoyed meeting him Sent from my iPhone > on Mar 29, 2017, at 9:32 PM, Marc Sherman <(b) (6) > > I heard that you spent some time with my friend he was telling me. gmail.com> wrote: (b) (6) at AIPAC. We played tennis tonight and > > Marc Sherman (202) 758-(b) (6) > VA-19-0799-D-001485 OS 00003156 Message From: Sent: To: Subject: Marc Sherman [(b) (6) gmail.com] 3/30/2017 2:32:06 AM David shulkin [drshulkin@aol.com] AIPAC I heard that you spent some time with my friend (b) (6) was telling me. at AIP AC. We played tennis tonight and he Marc Sherman (202) 758-(b) (6) VA-19-0799-D-001486 OS 00003157 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/8/2017 1:35:40 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Google Alert - david shulkin These were the rogue vaco employees that did this without our knowledge When i found out i canceled it I was looking to terminate these employees who are really crooked - havnt been able to do yet Sent from my iPhone On Apr 7, 2017, at 9:25 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: How did that happen- why would we give MVP data to a start up company - maybe I don't understand everything, but looks like a close call. You will have to fill me in on this Sent from my iPhone On Apr 7, 2017, at 5:35 PM, David shulkin wrote: See first articlE Sent from my iPhone Begin forwarded message: From: Google Alerts Date: April 7, 2017 at 4:02:59 PM EDT To: drshulkin@aol .com Subject: Google Alert - david shulkin Google Alerts david shulkin Daily update o April 7, 2017 NEWS Home Ben's Blog Veterans Affairs Almost Gave Away Veteran MVP Genomic Data Russian ... DisabledVeterans.org VA-19-0799-D-001487 DS 00003158 In a letter signed by then Under Secretary for Health David Shulkin, MD, the now VA Secretary canceled an a that would have allowed an ... Flag as irrelevant The Situation Report: Is the CIO Job at VA About to Lose Its Influence? MeriTalk (blog) It is a truly stunning detail overlooked by most observers during the confirmation process of David Shulkin to I secretary of Veterans Affairs. Flag as irrelevant Trump: 'We Wouldn't Be Here If It Weren't For' Veterans [VIDEO] Daily Caller "They have not been taken care of properly. David [Shulkin], who you know is the new secretary [of Veterans going to do a fantastic job." ... Congress passes bill to save Veterans Choice Program - Beckley Register-Herald VA to Expand Mental Health Care Eligibility to Discharged Veterans - Law Firm Newswire (press release) Full Coverage Flag as irrelevant WEB David Shulkin IMDb David Shulkin. Personal Details. Biography. Other Works . Publicity Listings . Official Sites . Contact Info (IM Filmography. by Year. by Job ... @ I] CJ Flag as irrelevant See more results I Edit this alert You have received this email because you have subscribed to Google Alerts. Unsubscribe I View all your alerts l !Receive this alert as RSS feed Send Feedback VA-19-0799-D-001488 DS 00003159 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/8/2017 1:25:12 AM David shulkin [Drshulkin@aol.com] Re: Google Alert - david shulkin How did that happen- why would we give MVP data to a start up company - maybe I don't understand everything, but looks like a close call. You will have to fill me in on this Sent from my iPhone On Apr 7, 2017, at 5:35 PM, David shulkin wrote: See first articlE Sent from my iPhone Begin forwarded message: From: Google Alerts Date: April 7, 2017 at 4:02:59 PM EDT To: drshulkin@aol .com Subject: Google Alert - david shulkin Google Alerts david shulkin Daily update o April 7, 2017 NEWS Home Ben's Blog Veterans Affairs Almost Gave Away Veteran MVP Genomic Data To Russian ... DisabledVeterans.org In a letter signed by then Under Secretary for Health David Shulkin, MD, the now VA Secretary canceled an agreemen that would have allowed an ... @ 11 CJ Flag as irrelevant The Situation Report: Is the CIO Job at VA About to Lose Its Influence? MeriTalk (blog) It is a truly stunning detail overlooked by most observers during the confirmation process of David Shulkin to become secretary of Veterans Affairs. @ 11 CJ Flag as irrelevant VA-19-0799-D-001489 DS 00003160 Trump: 'We Wouldn't Be Here If It Weren't For' Veterans [VIDEO] Daily Caller "They have not been taken care of properly. David [Shulkin], who you know is the new secretary [of Veterans Affairs], i going to do a fantastic job." ... Congress passes bill to save Veterans Choice Program - Beckley Register-Herald VA to Expand Mental Health Care Eligibility to Discharged Veterans - Law Firm Newswire (press release) Full Coverage Flag as irrelevant WEB David Shulkin IMDb David Shulkin. Personal Details. Biography. Other Works. Publicity Listings. Official Sites. Contact Info (IMDbPro). Filmography. by Year. by Job ... @ I] CJ Flag as irrelevant See more results I Edit this alert You have received this email because you have subscribed to Google Alerts. Unsubscribe I View all your alerts 0 Receive this alert as RSS feed Send Feedback VA-19-0799-D-001490 DS 00003161 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/7/2017 9:24:27 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: Google Alert - david shulkin See first articlE Sent from my iPhone Begin forwarded message: From: Google Alerts Date: April 7, 2017 at 4:02:59 PM EDT To: drshulkin@aol .com Subject: Google Alert - david shulkin Google Alerts david shulkin Daily update o April 7, 2017 NEWS Home Ben's Blog Veterans Affairs Almost Gave Away Veteran MVP Genomic Data To Russian ... DisabledVeterans.org In a letter signed by then Under Secretary for Health David Shulkin, MD, the now VA Secretary canceled an agreement that would have allowed an ... @ 11 CJ Flag as irrelevant The Situation Report: Is the CIO Job at VA About to Lose Its Influence? MeriTalk (blog) It is a truly stunning detail overlooked by most observers during the confirmation process of David Shulkin to become secretary of Veterans Affairs. @ 11 CJ Flag as irrelevant Trump: 'We Wouldn't Be Here If It Weren't For' Veterans [VIDEO] Daily Caller "They have not been taken care of properly. David [Shulkin], who you know is the new secretary [of Veterans Affairs], is going to do a fantastic job." ... Congress passes bill to save Veterans Choice Program - Beckley Register-Herald VA to Expand Mental Health Care Eligibility to Discharged Veterans - Law Firm Newswire (press release) VA-19-0799-D-001491 DS 00003162 Full Coverage Flag as irrelevant WEB David Shulkin IMDb David Shulkin. Personal Details. Biography. Other Works. Publicity Listings. Official Sites. Contact Info (IMDbPro). Filmography. by Year. by Job ... @ I] CJ Flag as irrelevant See more results I Edit this alert You have received this email because you have subscribed to Google Alerts. Unsubscribe I View all your alerts m Rece ive this alert as RSS feed Send Feedback VA-19-0799-D-001492 OS 00003163 Message From: David shulkin [Drshulkin@aol.com] Sent: 3/29/2017 12:38:52 AM To: (b) (6) Subject: Re: Meds [(b) (6) gmail.com] Sent from my iPhone > on Mar 28, 2017, at 8:14 PM, (b) (6) <(b) (6) gmail.com> wrote: > > Sir, > > The agents wanted to build their emergency kit and came by to express the seriousness of the request in case something unforeseen happens. > > Do you have food allergies? No > Are you on any medications? No > Blood type? Ill check > Preferred foods to eat granola bars. I said salad, fish, poultry and vegetables. Snacks -mini pretzels, trail mix, > -- sounds good > Sent from Gmail Mobile VA-19-0799-D-001493 OS 00003164 Message From: (b) (6) Sent: 3/29/2017 12:14:29 AM To: David Shulkin [drshulkin@aol.com] Meds Subject: [(b) (6) gmail.com] Sir, The agents wanted to build their emergency kit and came by to express the seriousness of the request in case something unforeseen happens. Do you have food allergies? Are you on any medications? Blood type? Preferred foods to eat : I said salad, fish, poultry and vegetables. Snacks -mini pretzels, trail mix, granola bars. Sent from Gm ail Mobile VA-19-0799-D-001494 OS 00003165 Message From: David shulkin [Drshulkin@aol.com] Sent: 3/31/2017 1:49:28 PM To: Jennifer Lee [(b) (6) Re: Next steps Subject: Yes lets move this forward- gmail.com] agree vivieca can help with the details Sent from my iPhone > on Mar 31, 2017, at 7:14 AM, Jennifer Lee <(b) (6) gmail.com> wrote: > > Hi David > I would like to move forward with what we discussed earlier this week- I think the fastest route would be to begin as a detail? Would also allow me to keep working clinically at DC VAMC on weekends. > what do you see as next steps? should I discuss w Vivieca again? > Thank you for the opportunity > Jen > VA-19-0799-D-001495 OS 00003166 Message From: Jennifer Lee [(b) (6) Sent: 3/31/2017 11:14:36 AM To: David Shulkin [drshulkin@aol.com] Next steps Subject: gmail.com] Hi David I would like to move forward with what we discussed earlier this week- I think the fastest route would be to begin as a detail? Would also allow me to keep working clinically at DC V AMC on weekends. What do you see as next steps? Should I discuss w Vivieca again? Thank you for the opportunity Jen VA-19-0799-D-001496 OS 00003167 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/3/2017 4:46:31 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Me and ma precious baby Great picture! Sent from my iPhone > on Apr 3, 2017, at 11:21 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > > > > > > > Sent from my iPhone VA-19-0799-D-001497 OS 00003168 Message From: Sent: To: Subject: Attachments: Poonam Alaigh [(b) (6) hotmail.com] 4/3/2017 3:21:48 PM David Shulkin [drshulkin@aol.com] Me and ma precious baby IMG_0036.JPG; ATT0000l.txt VA-19-0799-D-001498 OS 00003169 .1411 . bl ICE-I1 I ail-F4? . r; - Sent from my iPhone Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/6/2017 2:01:56 AM SreyRam Kuy [(b) (6) @gmail.com] Re: Thank you! Were working on opportunities Thanks for your patience Sent from my iPhone > on Apr 3, 2017, at 11:36 AM, SreyRam Kuy <(b) (6) @gmail.com> wrote: > > Secretary shulkin, > > It was such a pleasure getting to meet you a week ago. Thank you for > chatting with me about my passion for excellence in healthcare for > veterans. > > > > > > I would love the opportunity to serve on your executive leadership team at the VA. I believe my experiences leading medical efforts in Louisiana's Medicaid, which serves 1.6 million lives in a $10.7 billion system, and my decade of experience working in the VA system can be valuable as a national VA healthcare executive leader. > > I've attached my OI, and if you would like to talk with some of my > mentors, here are their contacts: > > Dr. Harlan Krumholz > Board of Governors, PCORI > Harold H Hines Professor of Medicine, Yale school of Medicine > Phone: 203-641-2501 >Email: Harlan.Krumholz@yale.edu > > Dr. Elizabeth Bradley > President-Elect, Vassar college >Email: Elizabeth.Bradley@yale.edu (until June 30, 2017) > > Dr. Ramon Romero > chief, surgical Service, Overton Brooks VA Medical Center > Phone: 318-990-9674 >Email: Ramon.Romero@va.gov > > Dr. Quyen Chu > Charles Knight, Sr Endowed Professor of surgery > chief, surgical Oncology, Louisiana State University - Shreveport > Phone: 318-655-1358 >Email: qchu@lsuhsc.edu > > Again, thank you so much for all you do for our veterans. It inspires me. > > Respectfully, SreyRam > > SreyRam Kuy, MD, MHS, FACS > chief Medical officer, Medicaid, Lou1s1ana Department of Health > RWJ clinical scholar, Yale 2007-2009 > > > On Tue, Mar 28, 2017 at 2:15 PM, Shulkin, David J., MD > wrote: > Thanks I enjoyed our meeting and your passion for this work > >> >> >> >> >> >> >> -----original Message----From: SreyRam Kuy [mailto:(b) (6) @gmail .com] Sent: Friday, March 24, 2017 4:43 PM To: shulkin, David J., MD; David shulkin Subject: [EXTERNAL] Thank you! Secretary shulkin, >> >> It was such a pleasure talking with you today, and thank you for taking the time to meet with me. VA-19-0799-D-001501 OS 00003172 >> >> Here is the link to the "save A Spot, Give a slot to Your Battle Buddy" poster a veteran helped us design, as part of my initiative to reduce clinic no shows. Here is also the template of the letter sent to veterans. I would be honored if you utilized them. >> https://www.avasnews.com/single-post/2016/05/16/REDUCING-NO-SHOWS >> https://media.wix.com/ugd/04bfb6_bb75c2d33e714fadae596bd4a300f325.pdf >> https://media.wix.com/ugd/04bfb6_096148d38d354faba5bba809a4bfb3a0.pdf >> >> Also, here's a link to the VA article about my work to reduce surgical mortality at the VA. >> http://www.patientsafety.va.gov/features/shreveport_A_Success_Story.asp >> >> Again, it was wonderful to get to meet you and Dr. Alaigh. Thank you so much for all you do for our veterans! >> >> I'll reach out again in 1 week. Thanks, -SreyRam >> >> >> SreyRam Kuy, MD, MHS, FACS >> chief Medical officer, Medicaid >> Louisiana Department of Health >> Phone: 210-535-(b) (6) >>Email: (b) (6) @gmail.com > VA-19-0799-D-001502 OS 00003173 Message SreyRam Kuy [(b) (6) @gmail.com] Sent: 4/3/2017 3:36:50 PM To: Shulkin, David J., MD [David.Shulkin@va.gov]; David shulkin [DrShulkin@aol.com] Thank you! Subject: Attachments: Dr. SreyRam Kuy CV - VA 2017.pdf From: Secretary shulkin, It was such a pleasure getting to meet you a week ago. Thank you for chatting with me about my passion for excellence in healthcare for veterans. I would love the opportunity to serve on your executive leadership team at the VA. I believe my experiences leading medical efforts in Louisiana's Medicaid, which serves 1.6 million lives in a $10.7 billion system, and my decade of experience working in the VA system can be valuable as a national VA healthcare executive leader. I've attached my 0./, and if you would like to talk with some of my mentors, here are their contacts: Dr. Harlan Krumholz Board of Governors, PCORI Harold H Hines Professor of Medicine, Yale school of Medicine Phone: 203-641-2501 Email: Harlan.Krumholz@yale.edu Dr. Elizabeth Bradley President-Elect, Vassar college Email: Elizabeth.Bradley@yale.edu (until June 30, 2017) Dr. Ramon Romero chief, surgical Service, Overton Brooks VA Medical Center Phone: 318-990-9674 Email: Ramon.Romero@va.gov Dr. Quyen Chu Charles Knight, Sr Endowed Professor of surgery chief, surgical Oncology, Louisiana State University - Shreveport Phone: 318-655-1358 Email: qchu@lsuhsc.edu Again, thank you so much for all you do for our veterans. It inspires me. Respectfully, SreyRam SreyRam Kuy, MD, MHS, FACS chief Medical officer, Medicaid, Lou1s1ana Department of Health RWJ clinical scholar, Yale 2007-2009 On Tue, Mar 28, 2017 at 2:15 PM, Shulkin, David J., MD wrote: Thanks I enjoyed our meeting and your passion for this work > > > > > -----original Message----From: SreyRam Kuy [mailto:(b) (6) @gmail .com] Sent: Friday, March 24, 2017 4:43 PM To: shulkin, David J., MD; David shulkin Subject: [EXTERNAL] Thank you! > > Secretary shulkin, > > It was such a pleasure talking with you today, and thank you for taking the time to meet with me. > > Here is the link to the "save A Spot, Give a slot to Your Battle Buddy" poster a veteran helped us design, as part of my initiative to reduce clinic no shows. Here is also the template of the letter sent to veterans. I would be honored if you utilized them. > https://www.avasnews.com/single-post/2016/05/16/REDUCING-NO-SHOWS > https://media.wix.com/ugd/04bfb6_bb75c2d33e714fadae596bd4a300f325.pdf > https://media.wix.com/ugd/04bfb6_096148d38d354fabaSbba809a4bfb3aO.pdf VA-19-0799-D-001503 OS 00003174 > > Also, here's a link to the VA article about my work to reduce surgical mortality at the VA. > http://www.patientsafety.va.gov/features/shreveport_A_Success_Story.asp > > Again, it was wonderful to get to meet you and Dr. Alaigh. veterans! > > I'll reach out again in 1 week. Thank you so much for all you do for our Thanks, -SreyRam > > > SreyRam Kuy, MD, MHS, FACS > chief Medical officer, Medicaid > Louisiana Department of Health > Phone: 210-535-(b) (6) >Email: (b) (6) @gmail.com VA-19-0799-D-001504 OS 00003175 SreyRam Kuy, MD, MHS, FACS Medicaid Chief Medical Officer, Louisiana Department of Health Associate Professor of Surgery, Louisiana State University- New Orleans PROFILE: ? As Chief Medical Officer of Louisiana :Medicaid, I lead the state's drive to improve healthcare quality, engage healthcare providers and stakeholders in both managed care and fee for service systems, develop quality performance metrics and integrate cost effectiveness into a $10.7 billion health system which serves 1.6 million lives. ? Supervise staff members comprising the Quality Team, Pharmacy Team, Clinical Policy Team, Health Information Technology Team and Benefits & Covered Services Team. ? Advise the Secretary of Health on critical public health issues, communicate policies and vision to state legislators and the Governor and represent Medicaid to the media on issues ranging from opioids to zika and healthcare quality. ? Lead initiatives for emerging public health threats such as coordinating medical efforts at Flood Shelters, developing a Zika transmission prevention policy, and working with the Governor's office and state legislators to implement strategies tackling the opioid crisis. ? Oversee Cl\fS grant for state Health Information Technology projects; including increasing EHR adoption among providers, ED discharge data linkage to primary care physicians, advancing a Telehealth network, implementing an EHR system in the Department of Corrections, and enabling providers to achieve meaningful use HIT. ? More than a decade of experience in the VA systems in Oregon, Texas, Connecticut, Wisconsin and Louisiana as a trainee, provider and administrator. Served as Assistant Chief of the General Surgery Section, Director of the Center for Innovations in Quality, Outcomes and Patient Safety, Chair of the Systems Redesign Committee and Board Member on the Quality, Safety and Value Board at Overton Brooks VA Medical Center. Worked with the Pentad on SAIL performance reports, HEDIS and Joint Commission ORYX core measures. Led initiatives to improve veterans' access to care through a 50% reduction in surgery clinic no shows. ? Worked to successfully decrease veteran mortality and reduce patient safety adverse events at Overton Brooks VA Medical Center. Developed biweekly provider educational series, broadcast remotely to outlying VA Community Based Outpatient Clinics in Louisiana and East Texas. VA-19-0799-D-001505 OS 00003176 PERSONAL: Office Address: Mobile Telephone: Office Telephone: Email Address: Citizenship: Louisiana Medicaid, Department of Health 628 North 4th Street, Baton Rouge, LA 70802 210-53 5-(b) (6) 225-342-53 81 (b) (6) @gmail.com SreyRam.Kuy@LA. Gov United States EDUCATION: 2017 Presidential Leadership Scholars Program Nominated and selected to be a Presidential Leadership Scholar - a joint executive leadership training program by Presidents Bush and Clinton and run by the presidential centers of Lyndon B. Johnson, George H. W Bush, William J Clinton and George W Bush 2016 Healthcare Executive Leadership Program in Health Policy and Management Heller School of Policy and Management, Brandeis University 2009 M.H.S. (Master of Health Science) Yale University School ofMedicine, Robert Wood Johnson Clinical Scholar 2005 M.D. (Medical Degree) Oregon Health & Sciences University School ofMedicine 2000 B.S. (Bachelor of Science, Philosophy), magna cum laude Oregon State University 2000 B.S. (Bachelor of Science, Microbiology), magna cum laude Oregon State University POSTGRADUATE TRAINING: 2009-2012 Residency, General Surgery (PGY 3-5) Medical College of Wisconsin 2007-2009 Robert Wood Johnson Clinical Scholar Fellowship Yale University School ofMedicine 2005-2007 Residency, General Surgery (PGY 1-2) University of Texas Health Sciences Center at San Antonio VA-19-0799-D-001506 OS 00003177 APPOINTMENTS: 2016-present Chief Medical Officer, Medicaid, Louisiana Department of Health and Hospitals As ClvfO ofLouisiana lvfedicaid I lead the drive to improve healthcare quality, cost effectiveness and Health Information Technology in a $10. 7 billion health system which serves 1.6 million lives in both managed care and fee for service systems. My work includes managing the Quality Team, Pharmacy Team, Clinical Policy Team, Health Information Technology Team and a Bene.fits & Covered Services Team. In addition, I lead initiatives for emerging public health threats such as coordinating medical efforts at Flood Shelters, developing a Zika transmission prevention policy, and working with the Governor's office and legislatures to implement strategies tackling the opioid crisis. o Health Information Technology Team: lead the state's electronic health record adoption initiative and health information technology strategy, oversee CMS grant for Health Information Technology and a National Governors' Association HIT grant o Quality Team: Develop and evaluate incentivized quality performance measures for providers & health plans to improve outcomes, safety, and quality of care for the state of Louisiana. Manage a Quality Team comprised of physicians, nurses & policy analysts addressing health care quality. Creation of a "Search by Score" site that promotes quality, transparency and adoption in Louisiana healthcare. o Clinical Policy Team overseeing the evidence based approach for coverage of new benefits and services for Medicaid beneficiaries o Benefits and Covered Services Team: manage all covered services and benefits in the Louisiana Medicaid system o Pharmacy Team: overseeing Medicaid prescription coverage o Rapidly respond to emergent public health issues (such as Zika virus, Opioid epidemic, drug shortages, flooding and emergency natural disasters) and develop guidance for providers and health plans o Work with Louisiana healthcare stake holders, including Managed Care Organizations, hospital associations, healthcare providers, health facilities and institutions, patient advocacy groups to ensure high quality care for Louisiana's Medicaid population, and efficient use ofresources 2014-2016 Director, Center for Innovations in Quality, Outcomes and Patient Safety, OBVAMC o Develop and lead initiatives to meet Joint Commission ORYX core measures, SAIL performance measures, and monitor PSI occurrences. o Develop programs that lead to sustained improvement in quality, outcomes and safety in the Surgical Services at the OBVAMC. o Work on reducing mortality and adverse events profiled in the VA National Center for Patient Safety newsletter and website. Work on decreasing clinic no-shows featured in the Association of VA Surgeons newsletter and website. o Collaborate with section chiefs to assess needs for quality improvement; develop, monitor and assess quality measures and initiatives; monitor VA-19-0799-D-001507 OS 00003178 o analyze and assess surgical outcomes; integrate quality improvement tools and surgical outcome measures to create a cohesive program for the OBV AMC Surgical Services. Partner with VA clinical, policy and operational leaders to implement and evaluate different ways to make surgical healthcare safer, more effective and more affordable. 2015-2016 Assistant Chief, General Surgery Section Overton Brooks VA Medical Center (OBV AMC) o Integrate quality improvement tools and surgical outcome measures to create a cohesive program for General Surgery Section, leading to improved patient safety with a decrease in patient mortality and reduction in Critical Incident Network Tracking adverse events o Work on SAIL and Joint Commission performance measures (pressure ulcer prevention, accidental puncture monitoring, smoking cessation/flu immunization documentation) Led initiative to improve veterans access to care through decreased o surgery clinic no shows, with more than 50% reduction in clinic no shows Develop, monitor and assess quality and efficiency measures and o initiatives for the General Surgery Section o Monitor, analyze and assess surgical outcomes for the General Surgery Section o Review Quality Improvement tools and surveys o Collaborate with other section chiefs (Anesthesiology, ENT, General Surgery, ENT, Neurosurgery, Ophthalmology, Orthopedics, Podiatry, Urology, Vascular and Thoracic Surgery) to assess needs for a collaborative, comprehensive surgical care 2014-2016 Director, Surgical Services Grand Rounds Lecture Series, OBVAMC o Developed a CME accredited academic curriculum for Grand Rounds Lecture Series; recruited local and national speakers o Incorporated telecommunication to broadcast Grand Rounds Lectures remotely, available to outlying VA Community Based Outpatient Clinics (CBOCs) in Louisiana and Texas and also to employee's computer desktops to allow greater educational reach 2017-present Attending Surgeon, LSU Health - Perkins Surgery Center and Surgery Clinic 2017-present Associate Professor, Department of Surgery Louisiana State University - New Orleans 2014-2016 Assistant Professor, Department of Surgery Louisiana State University - Shreveport 2014-2016 (OBVAMC) Attending Surgeon, Overton Brooks Veterans Affairs Medical Center VA-19-0799-D-001508 OS 00003179 o o o 2014-2015 Had highest RYU' s and total number of cases in general surgery section Performed first laparoscopic assisted Low Anterior Resection at OBYAMC Developed a laparoscopic training course for residents, OR staff and surgeons; taught at OBYAMC and LSU Consultant, Parkland Center for Clinical Innovation Consultant on surgical site infection risk prediction modeling BOARD CERTIFICATION 2014 American Board of Surgery# 059382 MEDICAL LICENSURE: State of Texas# P9893 -Expiration 5/31/2017 State of Wisconsin #53724-20 -Expiration 10/3/2017 State of Tennessee #~ID00000 50960 - Expiration 3/3 l /2018 State of Louisiana #300710 -Expiration 3/31/2017 POSTGRADUATE COURSES: 10/2014 Cleveland Clinic, Advanced Laparoscopic Colorectal Master Class 11/2014 Florida Hospital, Laparoscopic General Surgery Master Class 7/2015 University of South Florida, Laparoscopic Colectomy Mini-Fellowship 9/2015 Methodist MITE, Advanced Hernia and Abdominal Wall Repair Master Class 2/2016 Life Cell, Complex Abdominal Wall Reconstruction Bioskills Lab LEADERSHIP/HEALTHCARE POLICY TRAINING & EXPERIENCE: June 12-18, 2016 American College of Surgeons Health Policy Award "Leadership Program in Health Policy and Management" Executive Education Program at Brandeis University Heller School for Social Policy and Jvfanagement. 2013 American Medical Association Campaign School Training in healthcare policy, legislation and politics in Washington, D.C. American College of Surgeons Advocacy Grant 2012 2007 -2009 Robert Wood Johnson Clinical Scholar, Yale University School of Medicine Fellowship in healthcare policy & management, public health and research. Healthcare Policy Synergy Workshop, Institute of Medicine. Washington, D.C. 2008 Healthcare policy training, development of health disparities proposal Robert Wood Johnson Foundation Cover the Uninsured Week Oregon Committee 2003 Organized symposium on the uninsured in Oregon, ::,peaker Governor Kitzhaber American Academy of Family Physicians National Congress 2000 Authored resolution on "Presentation of the AAFP Universal Health Care Coverage Task Force Report and Inclusion of Resident and Student Feedback 2000 Kaiser Family Foundation Barbara Jordan Health Policy Scholar Worked in Washington DC office of US Senator Tom Harkin. Wrote speeches on The Breast & Cervical Cancer Treatment Act and Re-authorization of the VA-19-0799-D-001509 OS 00003180 Older Americans Act, attended hearings, wrote briefs on prescription drug coverage, coveragefor experimental studies, and healthcare instrument safety. HEALTH POLICY PANELS/KEY NOTE SPEAKER/PRESENTATIONS The Louisiana Story: Tackling Preterm Birth through Collaboration and Innovation CMS Quality Conference, Baltimore, MD Achieving Viral Load Suppression through Collaboration - The Louisiana Story HIV Affinity Group National Conference, Washington DC Medicaid Expansion and Access to Healthcare: Leaming from Louisiana Louisiana Public Health Institute Bridging the Gap Between Health Care and Health Equity National Academy for State Health Policy, Pittsburgh, PA HIV Affinity -The Louisiana Story HIV Health Improvement Affinity Group National Webinar Medicaid Industry Who's Who Series, "Mostly Medicaid" State Spotlight Series: Achieving Healthcare Quality Medicaid Expansion and Improving Healthcare Quality in Louisiana American Association on Intellectual & Developmental Disabilities,Alexandria,LA Panel Member: Using National Data Sources to Understand Healthcare Quality, Access and Disparities Among Women AcademyHealth 2015 Annual Research Meeting, Minneapolis, Jvfinnesota Panel Member: Emerging Issues in Gender-Based and Women's Health. AcademyHealth 2009 Annual Research A1eeting, Chicago, Illinois. Moderator, Robert Wood Johnson Alumni Careers in Health Policy. Robert Wood Johnson Clinical Scholars National Conference, Washington, D. C. Panel Member: The Many Avenues to Pursuing a Career in Health Policy. Barbara Jordan Health Policy Scholars Conference, Washington, D.C. TOWN HALLS Town Hall Meeting Flood Recovery, Mold and Tetanus Vaccination, Mental Health Crisis Hotline Town Hall Meeting Flood Recovery, Prescription Co-Pay Waivers, Early Refills for Prescriptions Rotary Club of Shreveport Key Note Speaker: Medicaid Expansion Shreveport Medical Society Key Note Speaker: Medicaid Expansion COMMITTEE SERVICE AND ORGANIZATIONS National Quality Forum Medicaid Innovation Accelerator Committee Alliance for a Healthier Generation Obesity Prevention Task Force Opioid Commission Comparing Outcomes of Drugs and Appendectomy (CODA) National Stakeholder Advisory Board Dec 2016 Dec 2016 Dec 2016 Oct 2016 Nov 2016 Sept 2016 Sept 2016 2015 2009 2008 2007 August 2016 August 2016 July 2016 July 2016 2016-present 2016-present 2016-present 2016-present VA-19-0799-D-001510 OS 00003181 National Academy for State Health Policy Public and Population Health Advisory Group AcademyHealth State Health Research and Policy Interest Group Advisory Committee American College of Surgeons Committee on Diversity Issues Robert Wood Johnson Foundation Clinical Scholars Alumni Association Co-President Chair, Medicaid Quality Committee Louisiana Commission on HIV, AIDS and Hep C Office ofPublic Health designee, appointed by Governor Edward-., Louisiana Task Force on Telehealth Access Appointed by Secretary Executive Committee, Medicaid Evidence-based Decisions Project, Portland, OR Chair, Improving Veterans Access to Care Committee Board Member, Quality, Safety and Value Board, OBV AMC Chair, Systems Redesign Committee, OBVAMC Chair, General Surgery Faculty Recruitment Committee, OBVAMC Federation of State Medical Boards (FSMB) Appointed Representative to Accreditation Council/or Continuing Medical Education Accreditation Review Committee (revie,t' accreditation for ClvJE) National Board of Medical Examiners (NBME) NBA1E Board A1ember Appointed by American Medical Association as one of 80 Board Members governing the NBME, overseeing a $100 million annual budget that governs the USMLE, the Post-Licensure Assessment System, and works with specialty boards to protect the public health. NBME Diversity and Inclusion Task Force Tasked to improve diversity and inclusion in the executive leadership of the NBME and the USMLE exam contents. Association for Academic Surgery Membership Committee Information and Technology Committee Program Committee Association of Women Surgeons, Communications Committee, Vice-Chair Medical Society of Milwaukee County, Board of Directors American Medical Association Chair, Wisconsin Resident & Fellow Governing Council AMA Surgical Caucus, Executive Committee Wisconsin Medical Society, AN1A Resident Delegate Robert Wood Johnson Clinical Scholars National Conference, Planning Committee Oregon Health & Science University Medical School First Year, Class President Habitat for Humanity, Oregon State University Campus Chapter President Science Student Council, President Phi Eta Sigma National Honor Society, Oregon State University Chapter President Oregon State University Undergraduate Senate, Senator 2016-present 2016-present 2016-2019 2016-2018 2016-present 2016-present 2016-present 2016-present 2015 2015-2016 2015-2016 2015-2016 2015-2016 2011 - 2015 2013 - 2015 2013 - 2015 2010 - 2012 2016 - present 2012 - 2014 2012 - 2014 2011 - 2013 2010 - 2011 2010 - 2011 2008 2000 - 2001 1988-1999 1997-1998 1997-1998 1997-1998 VA-19-0799-D-001511 OS 00003182 Talons Women's Leadership & Service Honorary Society, Vice-President Medical Careers Explorer Scouts, Corvallis Chapter President 1997-1998 1995-1996 PEER-REVIEWED PUBLICATIONS l. Kuy S, Romero R. Decreasing 30 Day Surgical Mortality Utilizing the ACS NSQIP Surgial Risk Calculator. Journal of Surgical Research. In Press 2. Kuy S, Romero R. Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution through Crew Resource Management Training. American Journal of lvfedical Quality. In Press 3. Kuy S, Romero R. Improving Staff Perception of a Safety Climate with Crew Resource Management Training. Journal of Surgical Research. In Press 4. Kuy S. Rapidly Growing, Bleeding Mass on a Golfer's Back. JAMA Surgety. In Press 5. Kuy S, Romero R, Rose K, Vincent L. Perineal Pain and Malodorous Drainage in a Rectal Cancer Patient. BMJ Postgraduate Medical Journal. In Press 6. Koo D, Kuy S, Ogunleye A, Sangji N. A Tradition of Advocacy in the American College of Surgeons: Protecting our patients, advancing our profession. Bull Am Coll Surg. In Press 7. Eskander M, Neuwirth M, Kuy S, Keshava H, Meizoso J. Technology for Teaching: New Tools for 21st Century Surgeons. Bull Am Coll Surg. In Press 8. Kuy S, Dua A, Rieland J, Cronin D. Cavernous Transformation of the Portal Vein. Journal of Vascular Swgery. 2016 Feb;63(2):529. 9. Kuy S, Jenkins P, Romero R, Samra N, Kuy S. The Rising Incidence and Mortality of Clostridium Difficile Associated Megacolon. JAlvfA Surgery. 2015 Oct 7: 1-2. 10. Kuy S, Romero R, Kuy S. Gas Gangrene in a Diabetic Foot. Journal of the Louisiana State A4edical Society. 2015 Sep-Oct; 167(5):213-214. Epub 2015 Oct 15. 11. Kuy S. Carotid Body Tumor. Journal of the Louisiana State Medical Society. 2015 JulAug;l67(4):165. Epub 2015 Aug 15. 12. Busch K, Keshava H, Kuy S, Nezgoda J, Picou A Teaching in the Operating Room: New Lessons for Training Surgical Residents. Bull Am Coll Surg. 2015 Aug; 100(8):29-34. 13. Ogunleye A, Bliss L, Kuy S, Leichtle S. Political Advocacy in Surgery: The Case for Individual Engagement. Bull Am Coll Surg. 2015 Aug; 100(8):40-4. 14. Dua A, Kuy S, Desai S, Heller J, Lee C. Diagnosis and Management of a Ruptured Mycotic Popliteal Pseudoaneurysm. Vascular. 2015 Aug;23(4):419-21 15. Kuy S, Dua A Uncertainty in management of carotid stenosis in women - reply. JAMA Surgery. 2014; 149(4):402-3. 16. Kuy S, Dua A, Desai S, Chappidi Rohit, Patel B, Seabrook G, Brown K, Lewis B, Rossi P, Lee C. The Increasing Incidence of Thromboembolic Events among Hospitalized Patients with Inflammatory Bowel Disease. Vascular. 2014 Jul l.pii: l 708538114541799. 17. Kuy S, Dua A, Lee C, Patel B, Desai S, Dua A, Szabo A, Patel P. National Trends in Utilization of IVC Filters in the United States, 2000-2009. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2014 Jan;2(1): 15-20. 18. Dua A, Kuy S, Lee CJ, Upchurch G Jr, Desai S. Epidemiology of Aortic Aneurysm Repair in the United States from 2000 to 2010. Journal a/Vascular Surge1y. 2014;59(6):1512-7. 19. Dua A, McMaster J, Desai P, Desai S, Kuy S, Mata M, Cooper J. The Association between Blunt Cardiac Injury and Isolated Sternal Fracture. Journal of Cardiology Research and Practice. 2014;2014:629687 VA-19-0799-D-001512 OS 00003183 20. Dua A, Dua A, Jechow S, Desai S, Kuy S. Idiopathic Spontaneous Rupture of an Intercostal Artery. Wisconsin Medical Journal. 2014; 113(3): 116-8. 21. Dua A, Aziz A, Desai S, McMaster J, Kuy S. National Trends in the Adoption of Laparoscopic Cholecystectomy over 7 years in the United States and Impact of Laparoscopic Approaches Stratified by Age. Minimally Invasive Surgery. 2014;2014:635461. 22. Kuy S, Juern J, Weigelt J. Laparoscopic Primary Repair of Traumatic Intrapericardial Diaphragmatic Hernia. Journal o.fLaparoscopic Surgeons 2014;18(2):333-7. 23. Kuy S, Dua A, Rossi P, Seabrook G, Lewis B, Patel B, Lee C, Desai S, Brown K. Carotid Endarterectomy National Trends Over a Decade: Does gender matter? Annals of Vascular Surgery. 2013 Dec 6. pii: SO89O-5O96(13)OO641-9. 24. Dua A, Desai SS, Dua A, Charlton-Ouw K, Dongerkery SP, Patel B, Kuy S, McMaster J, Darlow M, Shapiro ML. The Impact of Co-Morbid Conditions and Insurance Status on Trauma Patient Outcomes. TRAUMA. 2013, Vol. 15 Issue 3, p239 25. Kuy S, Rossi P, Seabrook G, Brown K, Lewis B, Rilling W, Martin G, Patel B, Dua A, McMaster J, Desai S, Lee C. Endovascular Management of a Traumatic Renal-Caval Arteriovenous Fistula in a Pediatric Patient. Annals of Vascular Surgery. Dec 2013. pii: SO89O-5O96(13)OO472-X. 26. Kuy S, Dua A, Desai S, Dua A, Patel B, Tondravi N, Seabrook G, Brown K, Lewis B, Lee C, Kuy S, Subbarayan R, Rossi P. Surgical Site Infections Following Lower Extremity Revascularization Procedures Involving Groin Incisions. Annals o_f Vascular Surge1y. 2013 Nov 1. doi:pii: SO89O5O96(13)OO423-8. 27. Dua A, Dua A, Desai S, Kuy S, Sharma R, Jechow S, McMaster J, Patel B, Kuy S. Gender Based Differences in Management and Outcomes of Cholecystitis. American Journal of Surgery. 2013 Nov;2O6(5):641-6. 28. Kuy S, He C, Cronin D. Renal Mucormycosis: A Rare and Potentially Lethal Complication of Kidney Transplantation. Case Reports in Transplantation. October 2013;2013:915423 29. McMaster J, Dua A, Desai S, Kuy S. Short Term Outcomes Following Breast Cancer Surgery in Pregnant Women. Gynecologic Oncology. 2013 Sep 13. doi:pii: SOO9O-8258(13)O1 l 77-3. 30. Kulaylat AN, Zheng F, Kuy S, Bittner JG. Early Surgical Specialization: a new paradigm. Bull Am Coll Surg. 2013 Aug;98(8):43-9. 31. Baker J, Misra S, Manimala NJ, Kuy S, Gantt G. The Role of Politics in Shaping Surgical Training. Bull Am Coll Surg. 2013 Aug;98(8): 17-25 .. 32. Kuy S, Seabrook G, Rossi P, Lewis B, Dua A, Brown K. Management of Carotid Stenosis in Women. JAMA Surgery. 2013 Aug;l48(8):788-9O. Epub June 26, 2013. 33. Dua A, Patel B, Kuy S, Seabrook G, Tondravi N, Brown K, Lewis B, Rossi P. Asymptomatic 50-75% Internal Carotid Artery Stenosis in 288 Patients: Risk Factors for Disease Progression and Ipsilateral Neurological Symptoms. Perspectives in Vascular Surgery and Endovascular Therapy. 2013 Dec; 24(4): 165-70. doi: 1O. ll 77/1531OO3513491986. 34. Dua A, Patel B, Heller J, Kuy S, Dubose J, Tomasek JS, Larssen EM, Desai S. Variability in the Management of Superficial Venous Thrombophlebitis between Phlebologists and Vascular Surgeons. Perspectives in Vascular Surgery and Endovascular Therapy. 2013 Jun;25(1-2):5-1O. 35. Desai P, Dua A, McMaster J, Patel B, Dua A, Kuy S, Desai S, Krzowski-Firych J. Infectious Mononucleosis-Like Syndrome Presented in Toxoplasmosis Infection. J Surg Rad 2013:134136. 36. Kuy S, Vickery M, Dua A, Rosner G. Appendiceal endometriosis mimicking appendicitis. JAMA Surgery. 2013 May 1;148(5):481. VA-19-0799-D-001513 OS 00003184 37. Kuy S, Samberg L, Paul J, Brown N, Saving A, Codner P. Undetected Penetrating Bladder Injuries Presenting as a Spontaneously Expulsed Bullet During Voiding: A Rare Entity and Review of the Literature. Journal of Emergency Medicine. 2013 May 25: S0736-4679(13)003569. 38. Dua A, Desai S, Kuy S, Patel B, Dua A, Desai P, Darlow M, Shirqavi J, Charlton-Ouw K, Shortell C. Predicting outcomes using the national trauma data bank: Optimum management of traumatic and blunt thoracic injury. Per::,pectives in Vascular Surgery and Endovascular Therapy. Sep;24(3): 123-127, ePub: March 26, 2013. 39. Kuy S, Dua A, Desai SS, Baraniewski H, Lee C. Ruptured Mycobacterial Aneurysm of the Carotid Artery. Perspectives in Vascular Surgery and Endovascular Therapy. 2013;25(3-4):53-6. 40. Dua A, Desai S, McMaster J, Aziz A, Dua A, Kuy S. The Role of Platelets in Vascular Trauma Patients Compared to Patients with Chronic Vascular Disease. Vascular Disease Management. 2013; 10(1 l):E240-E243. 41. Kuy S, Codner P, Guralnick M, Dua A, Paul J. Combined rectovesicular injuries from low velocity penetrating trauma in an adult. Wisc A1ed J. 2013; 112(1):32-34. 42. Kuy S, Greenberg C, Gusani N, Dimick J, Kao L, Brasel K. Health services research resources for surgeons. J Surg Res. 2011; l 71(1):e69-73. 43. Kuy S, Sosa J, Desai R, Roman S, Rosenthal R. Age matters: A study of clinical and economic outcomes following cholecystectomy in elderly Americans. Am J Swg. 2011;201(6):789-796. 44. Kuy S, Roman SA, Desai R, Sosa JA. Outcomes Following Cholecystectomy in Pregnant and Non-pregnant Women. Surgery. 2009; 146(2):358-366. 45. Kuy S, Roman S, Desai R, Sosa J. Outcomes following thyroid and parathyroid surgery in pregnant women. Arch Stag. 2009;144(5):399-406. Commentary by F Moore. 46. Kuy S. Stand up for patients. Bull Am Coll Surg. 2008;93(8):23-24. 47. Franks K, Li H, Kuy S, Kong W. Photodissociation ofICN at 266 nm and BrCN at 230 nm using brute force orientation. Chemical Physics Letters. 1999;302: 151-156. EDITORIALS/TECHNICAL NOTES/NEWSLETTER ARTICLES/lvIEDICAL BLOGS l. 2. 3. 4. 5. 6. 7. Kuy S, Romero R, Cypher E. Shreveport: A Success Story. Creating a Culture of Safety at the Overton Brooks VA Medical Center. Topics in Patient Safety. Veterans Affairs National Center for Patient Safety. September 2014; 14(5): 1,4. Kuy S. Profiles in Leadership. Association of Women Surgeons Blog. September 2014. Kuy S. Health Services Research for Surgeons. Association of Women Surgeons Website. 2014. Kuy S. Women Surgeon Leaders for the 21 st Century. Association of Women Surgeons Newsletter. July 25, 2014 Kuy S. The Imperative to Improve Gallbladder Disease Treatment and Outcomes for Men. Robert Wood Johnson Foundation Human Capitol Blog. November 22, 2013. Kuy S. Society for Vascular Surgery Trainee Advocacy Award Essay. Society for Vascular Swgery website. 2012. Kuy S. Information & technology review: Online health resources for surgeons. Association for Academic Surgery Newsletter. Fall, 2010: 6-7. VA-19-0799-D-001514 OS 00003185 8. Kuy S. Stand up for patients. Los Angeles Times. February 28, 2008. BOOKS AND BOOK CHAPTERS 1. Kuy S (senior editor), Kwon R, Hochman M. 50 Studies Every Surgeon Should Know. Oxford Press. (Planned release 2017) 2. Provo B, Kuy S. Venous insufficiency ulcers. In Domino FJ (Ed.), The 5-Minute Clinical Consult 2015, Philadelphia: Lippincott Williams and Wilkins. 3. Aljoudi M, Dua A, Kuy S. Cervical Bruit. In Domino FJ (Ed.), The 5-Minute Clinical Consult 2016, Philadelphia: Lippincott Williams and Wilkins. 4. Dua A, Aljoudi M, Kuy S. Absent or Diminished Pulse. In Domino FJ (Ed.), The 5Minute Clinical Consult 2016, Philadelphia: Lippincott Williams and Wilkins. 1. Aljoudi M, McMaster J, Kuy S. Breast Cancer and Pregnancy. In Domino FJ (Ed.), The 5-Minute Clinical Consult 2016, Philadelphia: Lippincott Williams and Wilkins. 2. Dua A, Desai S, Kuy S. Inguinal Mass. In Domino FJ (Ed.), The 5-Minute Clinical Consult 2016, Philadelphia: Lippincott Williams and Wilkins. PRESENTATIONS 1. Reducing Surgery Cancellations in a Tertiary Hospital: A Three Year Review. Association of VA Surgeons 2016 Meeting; Virginia Beach, VA April 2016. 2. Why We Don't Come to Clinic: Patient Perspectives. Association of VA Surgeons 2016 Meeting; Virginia Beach, VA April 2016. 3. The Myth of Sisyphus: Is Reducing Surgery Clinic No-Shows Impossible? Association of VA Surgeons 2016 Meeting; Virginia Beach, VA April 2016. 4. It Takes a Village: Referring Providers Impact Patient No Shows. Association of VA Surgeons 2016 Meeting; Virginia Beach, VA April 2016. 5. Reducing Surgical Site Infections Utilizing a Prevention Bundle and a Multidisciplinary Approach at a Veterans Affairs Hospital. The American College of Surgeons NSQIP 2015 Meeting; Chicago, IL; July 2015. 6. Transformational Change: Creating a Culture of Safety in the Operating Room. Presented at: The American College of Surgeons NSQIP 2015 Meeting; Chicago, IL; July 2015. 7. Outlier to Leader: Designing a Risk Stratification Intervention to Decrease 30 Day Surgical Mortality in a Veterans Affairs Hospital. The American College of Surgeons NSQIP 2015 Meeting; Chicago, IL; July 2015. 8. Outlier to Leader: Designing a Risk Stratification Intervention to Decrease 30 Day Surgical Mortality in a Veterans Affairs Hospital. Presented at: The Association of VA Surgeons 2015 Meeting; Miami, FL; May 2015. 9. Transformational Change: Creating a Culture of Safety in the Operating Room. Presented at: The Association of VA Surgeons 2015 Meeting; Miami, FL; May 2015. 10. The Rising Incidence and Mortality of Clostridium Difficile Associated Megacolon. Presented at: The Association of VA Surgeons 2015 Meeting; Miami, FL; May 2015. 11. The Increasing Incidence of Thromboembolic Events Among Patients with Inflammatory Bowel Disease. Presented at: American College of Surgeons 2013 Clinical Congress; Washington DC; October 2013. VA-19-0799-D-001515 OS 00003186 12. Diagnosis and Management of a Ruptured Popliteal Mycotic Pseudoaneurysm. Presented at: Eastern Vascular Society. Sulfur Springs, West Virginia. September 21, 2013. (First Place Winner of the 2013 Resident Award) 13. Ruptured Carotid Mycotic Tuberculoid Aneurysm from Intravesical BCG. Presented at: Midwestern Vascular Surgical Society. Chicago, Illinois; September 8, 2013 14. Do women experience delays in carotid endarterectomy? Presented at: Society for Vascular Surgery Annual Meeting; San Francisco, California; May 31, 2013. (Winner of Sectional Poster Competition) 15. National trends in utilization of IVC filters over a decade in the United States, 20002009. Presented at: Society for Vascular Surgery Annual Meeting; San Francisco, California; May 31, 2013. 16. Surgical site infections and complications following vascular groin procedures. Presented at: Peripheral Vascular Surgery Society meeting; Park City, Utah; February 1, 2013. 17. Endovascular management of a traumatic renal-caval arteriovenous fistula in a pediatric patient. Presented at: International Symposium on Endovascular Therapy; Miami, Florida; January 22, 2013. 18. Carotid endarterectomy national trends over a decade: Does gender matter? Presented at: Midwestern Vascular Surgery annual meeting; Milwaukee, Wisconsin; September 6, 2012. 19. Asymptomatic 50-75% internal carotid artery stenosis in 288 patients: Risk factors for disease progression and ipsilateral neurological symptoms. Presented at: Midwestern Vascular Surgery annual meeting; Milwaukee, Wisconsin; September 6, 2012. 20. A study of clinical and economic outcomes following cholecystectomy in elderly Americans. Presented at: Department of Surgery grand rounds, Medical College of Wisconsin; Milwaukee, Wisconsin; June 10, 2010. 21. Predictors of in-hospital mortality following cholecystectomy among hospitalized patients. Presented at: 5th annual Academic Surgical Congress; San Antonio, Texas; February 3, 2010. 22. Predictors of in-hospital mortality following cholecystectomy. Presented at: American Medical Association 2010 research symposium; San Diego, California; November 5, 2010 (Honorable Mention Prize). 23. Outcomes following breast surgery in pregnant women. Presented at: 90th annual meeting of the New England Surgical Society; Newport, Rhode Island; September 13, 2009. 24. Outcomes following breast surgery in pregnant women. Presented at: Department of Surgery grand rounds, Yale University School of Medicine; New Haven, Connecticut; September 9, 2009. 25. Gender based differences in management and outcomes of cholecystitis. Presented at: AcademyHealth 2009 annual research meeting; Chicago, Illinois; June 28, 2009. 26. Gender based disparities in outcomes of cholecystitis. Presented at: New England science symposium; Boston, Massachusetts; April 3, 2009. 27. Women have better outcomes in cholecystitis. Presented at: American Medical Women's Association conference, Women's Health 2009, 17th Annual Congress; Williamsburg, Virginia; March 27-29, 2009. VA-19-0799-D-001516 OS 00003187 28. Outcomes following cholecystectomy in pregnant and non-pregnant women. Presented at: 4th Annual Academic Surgical Congress; Fort Myers, Florida; February 3-6, 2009. 29. Outcomes following thyroid and parathyroid surgery in pregnant women. Presented at: Robert Wood Johnson Clinical Scholars 2008 National Conference; Washington, D.C.; November 18-21, 2008. 30. Disparities in outcomes following thyroid and parathyroid surgery in pregnant and nonpregnant women. Presented at: Disparities in Surgical Care symposium; Boston, Massachusetts; Oct 27-28, 2008. 31. Outcomes following thyroidectomy and parathyroidectomy in pregnant women in the US, 1999-2005. Presented at: 89th annual meeting of the New England Surgical Society; Boston, Massachusetts; September 26-28, 2008. 32. Outcomes following thyroid and parathyroid surgery in pregnant women. Presented at: Department of Surgery grand rounds, Yale University School of Medicine; New Haven, Connecticut; September 24, 2008. 33. Are Drains Necessary After Craniosynostosis Surgery? American Society of Plastic Surgeons: Plastic Surgery Senior Residents Conference. Houston, Texas. March 1719, 2005. 34. The Effects of Heat Treatment on Lactoferrin Concentration in Breast Milk. International Health Medical Education Consortium Conference. Havana, Cuba. March 12-15, 2002 JOURNAL REVIEWER JAJvfA Surgery Reviewer Journal of Surgical Research Reviewer British Medical Journal Case Reports Reviewer 2016-present 2016-present 2014-present TEACHING EXPERIENCE: Louisiana State University - New Orleans, Associate Professor of Surgery Louisiana State University - Shreveport, Assistant Professor of Surgery Lecturer, Surgery Resident SCORE Curriculum Lecturer, Third Year Medical Student Curriculum Clinical Preceptor, First Year Medical Students Yale University School of Medicine Course Facilitator, Introduction to Research Oregon State University Teaching Assistant, General Microbiology Teaching Assistant, Introduction to Microbiology Teaching Assistant, Biology 2017-present 2014-2016 2016 2014-2016 2014-2016 2007-2009 1999 1998 - 1999 1997 HONORS, AW ARDS & GRANTS Early Career Achievement Award, Oregon Health & Sciences University, School of Medicine Alumni Association. Awarded to an alumnus who has made significant career contributions in improving health. 2017 2017 Presidential Leadership Scholar VA-19-0799-D-001517 OS 00003188 Executive Leadership Training led by President Bush and President Clinton, held over 6 months onsite at the George H. W Bush Presidential Center, William .J Clinton Presidential Center, George W Bush Presidential Center & Lyndon B. Johnson Presidential Center. American College of Surgeons Health Policy Scholar Award provides $8,000 grant, one of two general surgeons awarded to attend the "Leadership Program in Health Policy and Management" Executive Education Program at Brandeis University Heller School for Social Policy and Jvfanagement. 2016 Business Report's 2016 "Forty Under 40" Award Award in recognition qf leadership, community service and career accomplishments 2016 Ford Family Foundation Gerald E. Bruce Leadership & Community Service Award Award recognizing excellence in leadership & service, provides $5,000 grant which Dr. Kuy donated to a nonprofit serving veterans. 2016 Certificate of Appreciation, Overton Brooks VA Medical Center Presented by A1edical Center Director for lt'ork in promoting diversity, invited Keynote Speaker for VA 's Asian Pacific American Celebration A1onth 2015 Making a Difference Award, Overton Brooks VA Medical Center Recognition of excellence in clinical care 2014 Certificate of Appreciation, Overton Brooks VA Medical Center Presented by Jvfedical Center Director for Surgical Services' Achievement in Reducing Adverse Events and Mortality 2014 American College of Surgeons Advocacy Travel Grant 2012 American Medical Association 2010 Research Symposium Honorable Mention Prize 2010 Medical College of Wisconsin Affiliated Hospitals (MCW AH) Research Award 2010 New England Surgical Society 89th Annual Resident Research Competition Award 2008 Robert Wood Johnson Foundation Clinical Scholars Fellowship. National award providing two years of training in health services research, Yale University School of Medicine 2007 -2009 VA-19-0799-D-001518 OS 00003189 Surgery Intern of the Year Award, Department of Surgery, University of Texas Health Sciences Center at San Antonio 2006 Oregon Health & Science University ROSE Award (Recognition of Outstanding Service and Excellence) 2001 Ralph Bosworth, MD Memorial Scholarship 2000 Dr. JoAnne J. Trow Woman of Distinction Award 2000 Wal do-Cummings Outstanding Student Award 2000 Phi Kappa Phi Honor Society Tunison Award 1999 OSU Department of Microbiology Mark H. MiddleKauf Scholarship 1999 OSU Department of Microbiology Joseph E. Simmons Scholarship 1999 OSU College of Agricultural Science Jesse Hanson Scholarship 1999 OSU College of Science Heitmeyer Scholarship 1996 Presidential Scholar 1996 Laurel G. Case, MD Memorial Scholarship 1996 Robert C. Byrd Honors Scholar 1996 Valedictorian, Crescent Valley High School 1996 NEWS ARTICLES: Read about Dr. Kuy's work reducing mortality and patient safety adverse events profiled in the VA National Center for Patient Safety here: http ://www.pati entsafety.va.gov/features/Shreveport A Success Story.asp Read about Dr. Kuy's work improving veterans' access to care through clinic efficiency profiled by the Association of VA Surgeons here: http ://www.avasnews .com/singlepost/2016/05/16/REDUCING-NO-SHOWS Read about Dr. Kuy's work at Louisiana Medicaid improving healthcare quality profiled by Mostly Medicaid here: http ://www.mostlymedicaid.com/? p=l82l Read about Dr. Kuy's work with Medicaid Expansion to improve patient health profiled by Business Reports 40 Under 40 here: https://www.businessreport.com/article/forty-40-qasreyram-kuy VA-19-0799-D-001519 OS 00003190 GRANTS AWARDED: Zero to Three Grant "Text4Baby" $10,000 grant for Technical Assistance implementing Text4Baby, a program aimed at improving birth outcomes for pregnant women in Louisiana Medicaid. 2016 National Governors Association Grant "Getting the Right Information to the Right Health Care Providers, at the Right Time- How States Can Improve Data Flow" Awarded to Louisiana Medicaid's Health Information Technology Team, one of three states to receive this grant in the form of Technical Assistance 2016 Centers for Medicare & Medicaid Services Grant "Louisiana's Health Information Technology (HIT) and Health Information Exchange (HIE) Implementation Advance Planning". Support adoption and meaningful use of certified EHR technology activities, promote interoperability among EHRs, state HIEs and the Medicaid system; and provide for the design, development and implementation of the appropriate data infrastructure for FY 2017 and 2018. Total grant awarded: $25,900,382 2016 GRANT APPLICATION IN SUBMISSION Submitted to PCORI 12/2016 "Provider-Targeted Strategies to Improve Patient-Centered Care for a Medicaid-Insured Population by Reducing Opioid Over-Prescribing and Increasing Provider Knowledge of Opioid Harms and Alternative Therapies for Chronic Non-Cancer Pain" Principal Investigator: SreyRam Kuy, MD, MHS, FACS (Louisiana Department of Health) Total Project Cost: $4 million VA-19-0799-D-001520 OS 00003191 REFERENCES Dr. Harlan Krumholz Board of Governors, PCORI Harold H Hines Professor of Medicine, Yale School of Medicine Director, Yale Robert Wood Johnson Foundation Clinical Scholars Program Director, Center for Outcomes Research and Evaluation Phone: 203-641-2501 Email: Harlan.Krumhol z@yale.edu Dr. Elizabeth Bradley President-Elect, Vassar College Professor of Public Health Faculty Director of the Yale Global Health Leadership Institute Brady-Johnson Professor of Grand Strategy Master of Branford College, Yale University - School of Public Health Yale Email: Elizabeth.Bradley@yale.edu (until June 30, 2017) Vassar Email: Elizabeth.Bradley@vassar.edu (After July 1, 2017) Dr. Ramon Romero Chief, Surgical Service, Overton Brooks VA Medical Center Associate Professor, Louisiana State University - Shreveport Phone: 318-990-9674 Email: Ramon.Romero@va.gov Dr. Quyen Chu Charles Knight, Sr Endowed Professor of Surgery Chief, Surgical Oncology, Louisiana State University - Shreveport Phone: 318-655-1358 Email: qchu@lsuhsc.edu Dr. Ashley Ferraro Associate Program Director of Pulmonary & Critical Care Medicine Fellowship Overton Brooks VA Medical Center Associate Professor, Louisiana State University - Shreveport Phone: 816-591-9866 VA-19-0799-D-001521 OS 00003192 Message David shulkin [Drshulkin@aol.com] 3/29/2017 11:21:29 PM Poonam Alaigh [(b) (6) hotmail.com] Re: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? - New studies build the case - Shuren promises 'black belt' regulatory excellence From: Sent: To: Subject: Or hire (b) (6) Sent from my iPhone On Mar 29, 2017, at 6: 13 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Not at all- it's strange how (b) (6) has become our source of information about the VA- we will need to change things around here Sent from my iPhone On Mar 29, 2017, at 7: 10 PM, David shulkin wrote: Did u know? Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) nyu.edu> Date: March 29, 2017 at 4:30:29 PM CDT To: (b) (6) Subject: Fwd: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? - New studies build the case Shuren promises 'black belt' regulatory excellence VA ALLOWS RELEASE OF NEGATIVE HIV RECORDS: A recent rule from the Department of Veterans' Affairs will allow VA personnel to share veterans' negative HIV tests - and sickle cell test results - with outside providers. The rule explains that some of the stigma is gone from both diseases, and the previous regulation "causes delays and an unnecessary burden on veterans" when the VA tries to share EHR data through electronic health information exchanges. VA will continue to require a "qualifying written authorization from the veteran" prior to sharing positive HIV or sickle cell test results, per the rule. Sent from my iPhone Begin forwarded message: VA-19-0799-D-001522 OS 00003193 From: "Morning eHealth" Date: March 29, 2017 at 10:06:20 AM EDT To: <(b) (6) nyu.edu> Subject: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? - New studies build the case Shuren promises 'black belt' regulatory excellence Reply-To: "POLITICO subscriptions" VA ALLOWS RELEASE OF NEGATIVE HIV RECORDS: A recent rule from the Department of Veterans' Affairs will allow VA personnel to share veterans' negative HIV tests - and sickle cell test results - with outside providers. The rule explains that some of the stigma is gone from both diseases, and the previous regulation "causes delays and an unnecessary burden on veterans" when the VA tries to share EHR data through electronic health information exchanges. VA will continue to require a "qualifying written authorization from the veteran" prior to sharing positive HIV or sickle cell test results, per the rule. VA-19-0799-D-001523 OS 00003194 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/29/2017 11:13:21 PM David shulkin [Drshulkin@aol.com] Re: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? - New studies build the case - Shuren promises 'black belt' regulatory excellence Not at all- it's strange how (b) (6) things around here has become our source of information about the VA- we will need to change Sent from my iPhone On Mar 29, 2017, at 7: 10 PM, David shulkin wrote: Did u know? Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) nyu.edu> Date: March 29, 2017 at 4:30:29 PM CDT To: (b) (6) Subject: Fwd: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? New studies build the case - Shuren promises 'black belt' regulatory excellence VA ALLOWS RELEASE OF NEGATIVE HIV RECORDS: A recent rule from the Department of Veterans' Affairs will allow VA personnel to share veterans' negative HIV tests - and sickle cell test results - with outside providers. The rule explains that some of the stigma is gone from both diseases, and the previous regulation "causes delays and an unnecessary burden on veterans" when the VA tries to share EHR data through electronic health information exchanges. VA will continue to require a "qualifying written authorization from the veteran" prior to sharing positive HIV or sickle cell test results, per the rule. Sent from my iPhone Begin forwarded message: From: "Morning eHealth" Date: March 29, 2017 at 10:06:20 AM EDT To: <(b) (6) nyu.edu> Subject: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? - New studies build the case - Shuren promises 'black belt' regulatory excellence Reply-To: "POLITICO subscriptions"<~ VA-19-0799-D-001524 OS 00003195 fe9412747d65057d72 -630302 HTML-778973872-13763190@poli ti coemail .com> VA ALLOWS RELEASE OF NEGATIVE HIV RECORDS: A recent rule from the Department of Veterans' Affairs will allow VA personnel to share veterans' negative HIV tests - and sickle cell test results - with outside providers. The rule explains that some of the stigma is gone from both diseases, and the previous regulation "causes delays and an unnecessary burden on veterans" when the VA tries to share EHR data through electronic health information exchanges. VA will continue to require a "qualifying written authorization from the veteran" prior to sharing positive HIV or sickle cell test results, per the rule. VA-19-0799-D-001525 OS 00003196 Message David shulkin [Drshulkin@aol.com] 3/29/2017 10:59:48 PM Poonam Alaigh [(b) (6) hotmail.com] Fwd: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? - New studies build the case - Shuren promises 'black belt' regulatory excellence From: Sent: To: Subject: Did u know? Sent from my iPhone Begin forwarded message: From: (b) (6) <(b) (6) nyu.edu> Date: March 29, 2017 at 4:30:29 PM CDT To: (b) (6) Subject: Fwd: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? - New studies build the case - Shuren promises 'black belt' regulatory excellence VA ALLOWS RELEASE OF NEGATIVE HIV RECORDS: A recent rule from the Department of Veterans' Affairs will allow VA personnel to share veterans' negative HIV tests and sickle cell test results - with outside providers. The rule explains that some of the stigma is gone from both diseases, and the previous regulation "causes delays and an unnecessary burden on veterans" when the VA tries to share EHR data through electronic health information exchanges. VA will continue to require a "qualifying written authorization from the veteran" prior to sharing positive HIV or sickle cell test results, per the rule. Sent from my iPhone Begin forwarded message: From: "Morning eHealth" Date: March 29, 2017 at 10:06:20 AM EDT To: <(b) (6) nyu.edu> Subject: POLITICO's Morning eHealth, presented by the Coalition to Protect America's Health Care: A new notion for telemedicine funding? New studies build the case - Shuren promises 'black belt' regulatory excellence Reply-To: "POLITICO subscriptions" VA ALLOWS RELEASE OF NEGATIVE HIV RECORDS: A recent rule from the Department of Veterans' Affairs will allow VA personnel to share veterans' negative HIV tests - and sickle cell test results - with outside providers. The rule explains that some of the stigma is gone from both diseases, and the previous regulation "causes delays and an unnecessary burden on veterans" when the VA tries to share EHR data through electronic health information exchanges. VA-19-0799-D-001526 OS 00003197 VA will continue to require a "qualifying written authorization from the veteran" prior to sharing positive HIV or sickle cell test results, per the rule. VA-19-0799-D-001527 OS 00003198 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/29/2017 2:26:04 AM brucem(b) (6) @mac.com David Shulkin [drshulkin@aol.com] Intro to R&D Bruce - should I proceed with an introductory call with the R&D point of contact at the VA- if so will plan it in 2 weeks once I am back in the country Sent from my iPhone VA-19-0799-D-001528 OS 00003199 Message From: David shulkin [Drshulkin@aol.com] Sent: 5/5/2017 5:43:40 PM To: Bruce Moskowitz [(b) (6) Re: Va budget document Subject: We need to define the specific actionsstrong leadership yet mac.com] this comes out of our benefits part of VA that does not have Sent from my iPhone > on May 5, 2017, at 1:24 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > Who will be assigned at the VA to get this on tract? We have a call with (b) (6) Tuesday to get him working on the DOD to assign someone in preventive medicine and early detection to the VA. I was surprised that the diabetes claims are so high and we should hold the DOD accountable. It seems that the DOD has to take more interest in the tremendous 100 billion that the VA has to spend on disability claims. > > Sent from my iPad > Bruce Moskowitz M.D. > >> on May 5, 2017, at 1:13 PM, David shulkin wrote: >> >> sounds promising Bruce >> >> Sent from my iPhone >> >>> on May S, 2017, at 12:56 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>> >>> This is the document that we should use to cut the budget and at the same time improve care. >>> For instance on the call I was on today regarding the largest claim for disability which is tinnitus, over 120 million service men and women claimed this disability. We had the leading expert in the field on (b) (6) the call Dr. (b) (6) and we all agreed this does not make sense. only a small number of these claims could have been on the battlefield and exposed to a situation that could cause tinnitus. >>> Until we take a step back and find out what the DOD does in early detection and prevention coupled with what data the VA collects to find out the type of environment the claimant served in to apply for this disability we will have an even larger budget deficit next year. >>> Since (b) (6) (b) (6) can attack the problem on the prevention side and detect who actually has the disease we should be able to lower the outlay for tinnitus. We should do the same for every category of disability payments. >>> https://www.va.gov/budget/docs/summary/Fy2017-BudgetinBrief.pdf >>> >>> >>> >>> >>> >>> >>> Sent from my iPad >>> Bruce Moskowitz M.D. >> VA-19-0799-D-001529 OS 00003200 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 5/5/2017 5:24:39 PM David shulkin [Drshulkin@aol.com] mbs(b) (6) @gmail.com; IP [(b) (6) frenchangel59.com]; L Perl [(b) (6) Re: Va budget document gmail.com] Who will be assigned at the VA to get this on tract? We have a call with (b) (6) Tuesday to get him working on the DOD to assign someone in preventive medicine and early detection to the VA. I was surprised that the diabetes claims are so high and we should hold the DOD accountable. It seems that the DOD has to take more interest in the tremendous 100 billion that the VA has to spend on disability claims. Sent from my iPad Bruce Moskowitz M.D. > on May 5, 2017, at 1:13 PM, David shulkin wrote: > > sounds promising Bruce > > Sent from my iPhone > >> on May S, 2017, at 12:56 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: >> >> This is the document that we should use to cut the budget and at the same time improve care. >> For instance on the call I was on today regarding the largest claim for disability which is tinnitus, over 120 million service men and women claimed this disability. We had the leading expert in the field on (b) (6) the call Dr. (b) (6) and we all agreed this does not make sense. only a small number of these claims could have been on the battlefield and exposed to a situation that could cause tinnitus. >> Until we take a step back and find out what the DOD does in early detection and prevention coupled with what data the VA collects to find out the type of environment the claimant served in to apply for this disability we will have an even larger budget deficit next year. >> Since (b) (6) (b) (6) can attack the problem on the prevention side and detect who actually has the disease we should be able to lower the outlay for tinnitus. We should do the same for every category of disability payments. >> https://www.va.gov/budget/docs/summary/Fy2017-BudgetinBrief.pdf >> >> >> >> >> >> >> Sent from my iPad >> Bruce Moskowitz M.D. > VA-19-0799-D-001530 OS 00003201 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 5/5/2017 5:13:44 PM Bruce Moskowitz [(b) (6) Re: Va budget document mac.com] sounds promising Bruce Sent from my iPhone > on May 5, 2017, at 12:56 PM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > This is the document that we should use to cut the budget and at the same time improve care. > For instance on the call I was on today regarding the largest claim for disability which is tinnitus, over 120 million service men and women claimed this disability. We had the leading expert in the field on (b) (6) the call Dr. (b) (6) and we all agreed this does not make sense. only a small number of these claims could have been on the battlefield and exposed to a situation that could cause tinnitus. > Until we take a step back and find out what the DOD does in early detection and prevention coupled with what data the VA collects to find out the type of environment the claimant served in to apply for this disability we will have an even larger budget deficit next year. > Since (b) (6) (b) (6) can attack the problem on the prevention side and detect who actually has the disease we should be able to lower the outlay for tinnitus. We should do the same for every category of disability payments. > https://www.va.gov/budget/docs/summary/Fy2017-BudgetinBrief.pdf > > > > > > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-001531 OS 00003202 Message From: Sent: To: CC: Subject: Attachments: Bruce Moskowitz [(b) (6) mac.com] 5/5/2017 4:56:05 PM drshulkin@aol.com; Poonam Alaigh [(b) (6) hotmail.com] IP [(b) (6) frenchangel59.com]; mbs(b) (6) @gmail.com; L Perl [(b) (6) Va budget document Fy2017-BudgetlnBrief.pdf; Untitled attachment 06497.txt gmail.com] This is the document that we should use to cut the budget and at the same time improve care. For instance on the call I was on today regarding the largest claim for disability which is tinnitus, over 120 million service men and women claimed this disability. We had the leading expert in the field on (b) (6) the call Dr. (b) (6) and we all agreed this does not make sense. only a small number of these claims could have been on the battlefield and exposed to a situation that could cause tinnitus. Until we take a step back and find out what the DOD does in early detection and prevention coupled with what data the VA collects to find out the type of environment the claimant served in to apply for this disability we will have an even larger budget deficit next year. Since (b) (6) (b) (6) can attack the problem on the prevention side and detect who actually has the disease we should be able to lower the outlay for tinnitus. We should do the same for every category of disability payments. https://www.va.gov/budget/docs/summary/Fy2017-BudgetinBrief.pdf VA-19-0799-D-001532 OS 00003203 Department of Veterans Affairs - Budget In Brief Overview The 2017 Budget and 2018 Advance Appropriations (AA) requests for the Department of Veterans Affairs (VA) fulfill the President's promise to provide America's Veterans, their families, and Survivors the care and benefits they have earned through their service. The 2017 request for discretionary funding totals $78.7 billion (including collections); the mandatory funding request is $103.6 billion, of which $102.5 billion was previously provided via a 2017 Advance Appropriation. The 2017 request will support 366,544 Full-time Equivalent (FTE) employees. In addition, the 2018 AA request includes: o o $66.4 billion in discretionary funding for Medical Care; and $103.9 billion in mandatory funding for Veterans benefits programs (Compensation and Pensions, Readjustment Benefits, and Veterans Insurance and Indemnities accounts). The 2017 request will provide the necessary resources to meet VA's obligation to provide timely, quality health care and benefits to Veterans. It will allow VA to operate the largest integrated health care system in the country, delivering health care to approximately 9.2 million enrolled Veterans. Funding will provide for: o o o o o o o A disability compensation benefits program for 4.4 million Veterans and 405,000 Survivors; A pension benefits program for 297,000 Veterans and 210,000 Survivors; The nation's tenth largest life insurance program, covering both active duty Service members and enrolled Veterans; An education assistance program serving nearly 1.1 million students; Vocational rehabilitation and employment benefits for nearly 141,000 Veterans; A home mortgage program with a portfolio of over two million active loans guaranteed by VA; and The largest national cemetery system that leads the Nation as a high-performing organization, with projections to inter 132,093 Veterans and family members in 2017. Department of Veterans Affairs Discretionary and Mandatory Funding VA Discretionary Budget VA Budget: Mandatory vs. Discretionary Information Technology Benefit Construction 1.1% 5 -4 % Mandatory 56.8\1 2017 Congressional Submission BiB-1 VA-19-0799-D-001533 OS 00003204 As of September 30, 2015, there were an estimated 22 million Veterans living in the United States and its territories and other locations. In addition to these Veterans, up to 25.7 million family members and dependents may be eligible for benefits from VA The resources requested in this budget will allow VA to deliver on the Nation's promise to Veterans through investments in personnel, efficient business practices, and technology. VA will continue to work with its Federal, state, and local partners, including Veterans Service Organizations (VSO). VA Staffing Each day, more than 360,000 VA employees come to work for America's Veterans. These employees have a close connection with Veterans - over 32 percent are Veterans themselves. With this request and the resources provided by the Veterans Access, Choice, and Accountability Act of 2014 (the Choice Act), VA will see an increase of over 16,740 FTE in 2017 above the 2016 estimated level to expand access to health care and improve benefits delivery. This includes new FTE in the Veterans Benefits Administration (VBA) to improve the timeliness of non-rating claims, additional FTE in the Board of Veterans' Appeals (BVA) to address the appeals backlog, and more clinical FTE in the Veterans Health Administration (VHA), including physicians, nurses, and scheduling clerks. Department of Veterans Affairs Full-Time Equivalent Employees By Administration and Office Veterans Health Administration * Veterans Benefits Administration National Cemetery Administration Office of Information Technology General Administration Board ofVeterans' Appeals Office of the Inspector General Supply Funds Franchise Funds Total Veterans Affairs 2015 Actual 298,546 21,522 1,730 7,309 2,586 646 676 1,048 1,217 2016 Estimate 311,232 21,871 1,789 7,631 3,048 680 721 1,120 1,708 2017 Request 326,415 22,171 1,809 8,334 3,153 922 821 1,150 1,769 335,280 349,800 366,544 Note: Total VA employees include actual and planned hires under the Choice Act. * VHA FTE includes Medical Care, Medical Research, Veterans Choice Act, Canteen, Joint DoD-VA Medical Facility Demonstration Fund, and DoD-V A Health Care Sharing Incentive Fund. BiB-2 Budget in Brief VA-19-0799-D-001534 OS 00003205 Department of Veterans Affairs - Budget In Brief MyVA Transformation MyVA puts Veterans in control of how, when, and where they wish to be served. It is a catalyst to make VA a world-class service provider - a framework for modernizing VA' s culture, processes, and capabilities to put the needs, expectations, and interests of Veterans and their families first. A Veteran walking into any VA facility should have a consistent, high-quality experience. To accomplish this, the Department has developed five strategies that are fundamental to the transformation in VA: o Improving the Veterans' experience. At a minimum, every contact between Veterans and VA should be predicable, consistent, and easy. However, under MyVA, the Department is working to make each touch point exceptional. o Improving the employee experience. VA employees are the face of VA They provide the care, information, and access to benefits Veterans and their dependents have earned. They serve with distinction every day. o Achieving support services excellence will let employees and leaders focus on assisting Veterans, rather than worry about back office issues. o Establishing a culture of continuous performance improvement will apply lean strategies to help employees examine their processes in new ways and build a culture of continuous improvement. o Enhancing strategic partnerships will allow the Department to extend the reach of services available for Veterans and their families. To aid in the transforming of VA' s culture, processes and capabilities, the Veterans Experience Office (VEO) was created with the mission of building trusted, lifelong relationships with Veterans, their families and supporters. VEO will have three primary roles: o Represent the voice and perspective of Veterans and their families in VA departmental governance. o Design, implement and manage a portfolio of enterprise-level, customer-centric projects that will simplify customers' interactions with VA and help Veterans understand and access care and benefits provided by VA and their local communities. o Support VA "mission owners" - those leaders responsible for delivering, day-in and wrote: Very exciting ! Thanks so much for sending this along - I can't wait to start reading. Have a good day Poonam ! Sent from my iPhone On Mar 29, 2017, at 5: 17 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: We are the core innovative, imaginative and transformative team that will bring to reality the big dream of redesigning the VA. I am attaching a good overview of the international health care systems that we may want to learn from and tailor to our veteran needs- so that we build a new delivery system, a system that the nation has never seen. Welcome aboard (b) (6) and to you Secretary Shulkin, we will have to keep you focused! <1857 _Mossialos_intl_profiles_2015 _v7 (l).pdt> VA-19-0799-D-001577 OS 00003248 Message From: Sent: To: Subject: Attachments: Poonam Alaigh [(b) (6) hotmail.com] 3/29/2017 2:36:45 AM David Shulkin [drshulkin@aol.com]; (b) (6) Redesigning the VA system 1857_Mossialos_intl_profiles_2015_v7 (1).pdf aol.com We are the core innovative, imaginative and transformative team that will bring to reality the big dream of redesigning the VA. I am attaching a good overview of the international health care systems that we may want to learn from and tailor to our veteran needs- so that we build a whole new delivery system that the nation has never seen. Welcome aboard (b) (6) and to Secretary Shulkin, we will have to keep you focused! VA-19-0799-D-001578 OS 00003249 579 THE COMMONWEALTH FUND is a private foundation that promotes a high performance health care system providing better access, improved quality, and greater efficiency. The Fund's work focuses particularly on society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. VA-19-0799-D-001580 OS 00003251 ..-::::?:::-:-, ? International Profiles of Health Care Systems 2015 Australia, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, The Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States EDITED BY Elias Mossialos and Martin Wenzl London School of Economics and Political Science Robin Osborn and Dana Sarnak The Commonwealth Fund JANUARY 2016 Abstract: This publication presents overviews of the health care systems of Australia, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, the Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States. Each overview covers health insurance, public and private financing, health system organization and governance, health care quality and coordination, disparities, efficiency and integration, use of information technology and evidence-based practice, cost containment, and recent reforms and innovations. In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views. To learn more about new publications when they become available, visit the Fund's website and register to receive email alerts. Commonwealth Fund pub. 1857. VA-19-0799-D-001581 OS 00003252 u? 11 ?t . . Table 1. Health Care System Financing and Coverage in 18 Countries BENEFIT DESIGN HEALTH SYSTEM AND PUBLIC/PRIVATE INSURANCE ROLE Private insurance role (core benefits; cost-sharing; Government role Australia Regionally administered, joint (national & state) public hospital funding; noncovered benefits; private facilities or amenities; substitute for public insurance) Caps on cost-sharing General tax revenue; earmarked income tax ~47.3% buy complementary (e.g., private hospital and dental care, optometry) and supplementary coverage (increased choice, faster access for nonemergency services, rebates for selected services) Caps for pharmaceutical OOP expenditure only, dependent on income and total OOP expenditure in the same year Low-income and older people: Lower cost-sharing; lower pharmaceutical OOP cap and lower OOP maximum for 80% Medicare services rebatea Public system financing universal public medical insurance program (Medicare) Exemptions and low-income protection Canada Regionally administered universal public insurance program that plans and funds (mainly private) provision Provincial/federal general tax revenue ~67% buy complementary coverage for noncovered benefits (e.g., private rooms in hospitals, drugs, dental care, optometry) No There is no cost-sharing for publicly covered services; protection for low-income people from cost of prescription drugs varies by region China Supervision by health authorities (Health and Family Planning Commissions) at the national, provincial and local levels; some direct provision through public ownership of hospitals There are three main publicly financed health insurance types with local-area risk-pooling: urban employer-based (mainly payroll taxes, for formally employed urban residents), urban resident basic (mainly government funded, for urban nonemployed residents), and rural cooperative medical scheme (government-funded, for rural residents) Complementary to cover cost-sharing and gaps, as well as better health care quality and/or higher reimbursements. No data on coverage, but growth has been rapid. No Government subsidies to low-income families for insurance contributions and OOP; emergency assistance by local governments for specific diseases and unpaid emergency department or other expenses Denmark National health care system. Regulation, central planning, and funding by national government; provision by regional and municipal authorities. Earmarked income tax ~39% have complementary coverage (cost-sharing, noncovered benefits such as physiotherapy), ~26% have supplementary coverage (access to private providers) No. Decreasing copayments with higher OOP drug spending. Drug OOP cap for chronically ill (DKK3,775 [USD498]); financial assistance for low income and terminally ilia England National health service (NHS) General tax revenue (includes employment-related insurance contributions) ~11% buy supplementary coverage for more rapid and convenient access (including to elective treatment in private hospitals) No general cap, but OOP payments almost exclusively apply to prescription drugs and medical appliances only. For drugs, prepayment certificate with GBP29.10 [USD41.10] per three months or GBP104[USD147] per year ceiling for those needing a large number of prescription drugs.a Drug cost-sharing exemption for low-income, older people, children, pregnant women and new mothers, and some disabled/chronically ill; financial assistance with transport costs available to people with low income; vision tests free for young people, older people, and low-income people France Statutory health insurance system, with all SHI insurers incorporated into a single national exchange Employer/employee earmarked income and payroll tax; general tax revenue, earmarked taxes ~95% buy or receive government vouchers for complementary coverage (mainly cost-sharing, some noncovered benefits); limited supplementary insurance No. EUR50 [USD60] cap on deductibles for consultations and servicesa Exemption for low income, chronically ill and disabled, and children Germany Statutory health insurance (SHI) system, with 124 competing SHI insurers ("sickness funds" in a national exchange); high income can opt out for private coverage Employer/employee earmarked payroll tax; general tax revenue ~11% opt out from statutory insurance and buy substitutive coverage. Some complementary (minor benefit exclusions from statutory scheme, copayments) and supplementary coverage (improved amenities). Yes. 2% of household income; 1% of income for chronically ill. Children and adolescents <18 years of age are exempt India Children and adolescents <18 years of age are exempt General tax revenue Limited role (<5% of total expenditure) providing substitutive coverage for the upper class urban population No. Significant reliance on OOP payments (> 70% of total health expenditure). Various government-financed health insurance schemes for poor and vulnerable population groups to improve access to hospitalization and reduce out-of-pocket payments Israel National Health Insurance (NHI) system with four competing, nonprofit health plans. Government distributes the NHI budget among the health plans primarily through capitation. Earmarked income-related tax and general government Complementary (for benefits such as dental care, drugs, or longterm care) and supplementary coverage (for quicker access and superior service) provided by two types of voluntary insurance: VHI offered by statutory health plans (HP-VHI) (~87% of adult population coverage); commercial VHI (C-VHI) (~53% coverage); C-VHI tend to be more comprehensive and more expensive. Not overall. Caps on OOP for drugs (chronically ill only) and specialist visits (at household level). Quarterly OOP caps for drugs for the chronically ill and age-, income-, and health status-related discounts; copayment exemptions for Holocaust survivors; age-, income-, disability-, and health status-related exemptions on copayments for specialist consultations; reduced health tax (3% instead of 5%) for people with low incomes Italy National health care system. Funding and definition of minimum benefit package by national government; planning, regulation and provision by regional governments. National earmarked corporate and value-added taxes; general tax revenue and regional tax revenue ~15% buy complementary (services excluded from statutory benefits) or supplementary coverage (more amenities in hospitals, wider provider choice) No. Max EUR46.15[USD61] copayment pa- outpatient specialist consultation or diagnostic procedure; limited copayment (regional rates) on drugs.a Exemptions for low-income older people/children, pregnant women, chronic conditions/disabilities, rare diseases Japan Statutory health insurance system, with >3,400 noncompeting public, quasi-public, and employer-based insurers. National government sets provider fees, subsidizes local governments, insurers, and providers and supervises insurers and providers. General tax revenue; insurance contributions Majority of population have coverage for cash benefits in case of sickness, usually together with life insurance. Limited role of complementary and supplementary insurance offered separately from life insurance. Yes. Coinsurance reduced to, e.g., 1 % after JPY80, 100 [USD761] monthly cap, depending on enrollee age and income. Annual cap of total OOP payments at between JPY340,000 Low-income monthly OOP ceiling: JPY35,400 [USD336]; reduced cost-sharing for young children, older people, those with chronic conditions, mental illness and disabilities. Tax-funded health services for those on social assistance.a [USD3,230] aod JPY1 .26M [USD11,970] pee household, depending on income and ages of household members.a Netherlands Statutory health insurance system, with universally-mandated private !nsurance (national exchange); government regulates and subsidizes Earmarked payroll tax; community-rated insurance premiums; general tax revenue Private plans provide statutory benefits; 84% buy complementary coverage for benefits excluded from statutory package such as dental care, alternative medicine, physiotherapy, eyeglasses, contraceptives and copayments No, but annual deductible of EUR375 [USD455] covers most cost-sharinga GP care and children exempt from cost-sharing; premium subsidies for low-income New Zealand National health care system. Responsibility for planning, purchasing, and provision devolved to geographically defined District Health Boards. General tax revenue ~33% buy complementary coverage (for cost-sharing, specialist fees, and elective surgery in private hospitals) and supplementary coverage for faster access to non urgent treatment No. Reduced fees after 12 doctor visits per year/patient and no drug copayments after 20 prescriptions per year/family. No primary care consultation charges for children under age 13; subsidies for low-income, some chronic condition and high-need groups, Maori and Pacific Islanders Noiway National health care system. Some direct funding and provision roles for national government and some responsibilities devolved to Regional Health Care Authorities and municipalities. General tax revenue, national and municipal taxes ~8% holds supplementary VHI, mainly bought by employers for providing employees quicker access to publicly covered elective services and choice among private providers. Yes. Overall annual cost sharing ceiling is Exemptions for children< 16 yrs. somatic, <18yrs psychiatric, pregnant women, for some communicable diseases (including STDs), those with work-related injuries; low-income groups receive free essential drugs and nursing care Singapore Government subsidies at public health care institutions and some providers; Medisave: mandatory medical savings program for routine expenses; MediShield: catastrophic health insurance; Medifund: government endowment fund to subsidize health care for low-income and those with large bills. Government regulation of private insurance, central planning and financing of infrastructure and some direct provision through public hospitals and clinics. General tax revenue Medisave-approved Integrated Shield Plans (private insurance plans) supplement MediShield coverage to provide catastrophic health coverage for additional ward classes. Other types of private insurance are also available, including private insurance provided by employers. No. Subsidized care for low-income population, with incomeand asset-based means-test to target subsidies. Medifund as safety net to pay for low-income and people with no means to pay for their health care bills. Sweden National health care system. Regulation, supervision, and some funding by national government; responsibility for most financing and purchasing/ provision devolved to county councils. Mainly general tax revenue raised by county councils; some national tax revenue ~10% of all employed individuals ages 15-7 4 get supplementary coverage from employers for quicker access to a specialists and elective treatment Yes. SEK1, 100 [USD123] for health services and SEK 2,200 [USD246] for drugs.a Some cost-sharing exemptions for children, adolescents, pregnant women, and elderly. Switzerland Statutory health insurance system, with universally mandated private insurance (regional exchanges); some federal legislation, with cantonal (state) government responsible for provider supervision, capacity planning, and financing through subsidies Community-rated insurance premiums; general tax Private plans provide universal core benefits; some people buy complementary (services not covered by statutory insurance) and supplementary (improved amenities and access); no coverage data available Yes. CHF700[USD511] maximum after deductible.a Some copayment exemptions and CHF350 [USD255] cap for <19-year-olds; income-related premium assistance (28% receive); maternity care fully covereda United States Medicare: age 65 and older, some disabled; Medicaid: some lowincome; for those without employer coverage, state-level insurance exchanges with income-based subsidies; insurance coverage mandated, with some exemptions (10.4% of adults uninsured) Medicare: payroll tax, premiums, federal tax revenue; Medicaid: federal, state tax revenue Primary private voluntary insurance covers ~66% of population (employer-based and individual); supplementary for Medicare Yes for most private insurance plans: $6,600 yearly limit for individuals; $13,200 for families as of 2015 Yes for most private insurance plans: $6,600 yearly limit for individuals; $13,200 for families as of 2015 NOK2, 105 [USD223].' a All bracketed figures in USD were converted from local currency using the purchasing power parity conversion rate for GDP in 2014 reported by the Organisation for Economic Co-operation and Development (2015). VA-19-0799-D-001584 OS 00003255 Table 2. Selected Health Care System Indicators for 17 Countries Norway Sinqapore Sweden Switzerland United Kinqdom United States 5.080 5.3129 9.600 8.089 64.107 316.129 14.2% 15.6% 10.0%9 19.0% 17.3% 17.1% 14.1% 11.1%e 11.0% 9.4% 4.7% 9 11.5% 11.1%e 8.8% 17.1% $3,713 $5,131e $3,855 $6,170 $2,881h $5,153 $6,325e $3,364 $9,086 n/a 3.83% 1.73%e 0.82% 1.40% n/a 6.95%e 2.54%e -0.88% 1.24% $627 $666 $503' $270 $420 $855 n/a $726 $1,630 $321 $1,074 $1,423 $772 6 n/a 1,673' $1,849 n/a $2,285' n/a $1,907 $2,289 n/a $2,964 $622 $678 287 6 $572 $756' $397 n/a $437 n/a $496 $696 n/a $1,034 3.62' 3.10 4.05 3.43 3.90 2.29' n/a 2.81 4.31 1 _99.c 4.01' 4.04 2.77 2.56 5.4 4.6 6.4 9.9 n/a 6.8 12.9' 6.2 3.7' 4.2 n/a 2.9 3.9' n/a 4.oc 1.71' 4.55 2.47 3.35 5.34 1.90 2.75 6 7.92 3.32' 2.59 2.29 2.01.b 1.94 2.91 2.28 2.48' $9,529' $15,916' $2,033 $11,471 c $9,622 $5,641 $4,797 6 n/a $14,408 6 14,980' n/a $11,361c n/a n/a $13,437' n/a $20,991 c Hospital discharges per 1,000 population 173' 83' 140 172c 166 252 159 124 111 6 119' 146 175c n/a 163c 166' 129 125c Average length of stay for curative care (days) 4.8' 7.6' 8.9 n/a SP 7.7 4.3 6.8 17.2 6.4' 5.3 5.5 n/a 5.6' 5.9 5.9 5.4b Medical technology, 2013 (unless otherwise noted) Magnetic resonance imaging (MRI) machines per million population 13.4 8.8 3.2P n/a 9.4 n/a 3.1 24.6' 46.9 6 11.5 11.2 n/a 3_31.c n/a n/a 6.1 35.5 MRI exams per 1,000 population 27.6 52.8 42.7P 60.3 90.9 n/a 30.5 n/a n/a 50.0 6 n/a n/a n/a n/a n/a n/a 106.9 IT, 2015 Physicians' use of EMRs (% of primary care physicians/ 92% 73% n/a n/a 75% 84% n/a n/a n/a 98% 100% 99% n/a 99% 54% 98% 84% 12.8% 14.9% 28.1%9 17% 24.1%' 20.9% 16.2% 21.1% 19.3% 18.5% 15.5% 15.0% 13.3%k 10.7% 20.4%' 20.0%' 13.7% 28.3% 6 25.8% 11.9%9 14.2%n 14.5%'on 23.6% 15.7%n 10.3%n 3.7% 11.1%n 30.6% 10.0%'on 10.8%k.c 11.7%n 10.3%'on 24.9% 35.3%' Population, 2013 Spending, 2013 (unless otherwise noted) Physicians, 2013 (unless otherwise noted) Hospital spending, utilization, and capacity, 2013 (unless otherwise noted) Australia Canada China 0 Denmark France Germany Israel Italy Japan Netherlands New Zealand Total population (millions) 23.132 35.317 1,360.720 5.615 63.790 80.646 8.057 60.233 127.296 16.804 4.472 Percentage of population over age 65 14.4% 15.2% 9.7% 17.8% 17.7% 21.1% 10.7% 21.0% 25.1% 16.8% Percentage of GDP spent on health care 9.4%' 10.7% 5.4% 11.1% 11.6% 11.2% 7.4%6 n/a 10.2% Health care spending per capitad $4,115' $4,569 $636 $4,847 $4,361 $4,920 $2,232 6 n/a Average annual growth rate of real health care spending per capita, 2009-13 2.42% 0.22% 15.41% -0.17% 1.35% 1.95% 2.61%m Out-of-pocket health care spending per capitad $771' $623 $216 $625 $277 $649 Hospital spending per capitad $1,645' $1,338 $392 $2,070 $1,600 Spending on pharmaceuticals per capitad $590' $761 $263' $288 3.39 2.48' 2.04 7.1 7.7' 3.36' Number of practicing physicians per 1,000 population Average annual number of physician visits per capita Number of acute care hospital beds per 1,000 population Hospital spending per discharqed Health risk factors, 2013 Percentage of adults who report being daily smokers (unless otherwise noted) Obesity (BMl>30) prevalence 1 Source: OECD Health Data 2015 (November) unless otherwise noted. '2012. b 2011. C 2010. d Adjusted for differences in the cost of living. e Current spending only, and excludes spending on capital formation of health care providers. f Commonwealth 2015 Survey of Primary Care Physicians. 9 Source: World Bank, 2014. h Source: World Bank, 2014; 2005 purchasing power parity (PPP) adjustment. Source: World Bank, 2014; may include chronic care beds as well as acute care beds. J Source: World Health Organization, 2014. 1 k Source: Singapore Health Promotion Board, 2014. I 2009-12. 2009-11. n Self-reported as opposed to measured data. ? China indicators are from China Health and Family Planning Statistical Yearbook 2014 unless otherwise noted. P Calculated by using data from China Health and Family Planning Statistical Yearbook and Gu, X., D. He, X. Hu et al., Forecast analysis of MRI allocation in China. China Health Resources 2013, 16(1):41-43. _q National Health and Family Planning Commission of China, 2015. Report on Nutrition and Non-communicable Disease Status of Chinese Residents 2015. r China National Health Development Research Center. China National Health Accounts Report 2014. m Interna t io na l Profi les of 1-i ea lth Ca re Syst ems , 2015 VA-19-0799-D-001585 OS 00003256 Table 3. Selected Health System Performance Indicators for 11 Countries Australia Adults' access to care, 2013 Safety problems among sicker adults, 2014?,P Care coordination and transitions among older adults, 2014? Chronic care management among older adults, 2014?. 0 Primary care Canada France Germany Netherlands New Zealand Norway Sweden Switzerland United Kinqdom United States Able to get same-day/next-day appointment when sick 58% 41% 57% 76% 63% 72% 52% 58% n/a 52% 48% Very/somewhat easy getting care after hours 46% 38% 36% 56% 56% 54% 58% 35% 49% 69% 39% 6% Waited 2 months or more for specialist appointment' 18% 29% 18% 10% 3% 19% 26% 17% 3% 7% Waited 4 months or more for elective surgery6 10% 18% 4% 3% 1% 15% 22% 6% 4% n/a 7% Experienced access barrier because of cost in past yea re 16% 13% 18% 15% 22% 21% 10% 6% 13% 4% 37% Health professional did not review their prescriptions in past year 16% 16% 47% 19% 37% 23% 37% 48% 27% 21% 14% Experienced a coordination problem in past 2 yearsd 21% 32% 7% 41% 21% 20% 37% 24% 29% 24% 35% Experienced gaps in hospital discharge planning in past 2 yearse 41% 44% 54% 56% 59% n/a 70% 67% 56% 38% 28% Had a treatment plan they could carry out in daily life 80% 76% 62% 30% 41% 64% 53% 41% 47% 73% 83% Between visits, has health care professional they can contact to ask questions or to get advice 65% 67% 53% 43% 83% 75% 55% 75% 58% 71% 84% Routinely receives and reviews clinical outcomes data 35% 23% 43% 44% 88% 65% 32% 79% 9% 86% 52% performance feedback, 2015 Routinely receives and reviews patient satisfaction and experience data 46% 17% 3% 25% 61% 60% 9% 88% 15% 88% 63% Routinely receives data comparing performance to other practices 13% 17% 49% 29% 42% 61% 4% 55% 37% 71% 37% OECD health care quality indicators' Diabetes lower extremity amputation rates per 100,000 population, 2013 4.5 7.4 7.5 9.2 4_7k 5.91 5.7 4.1 3.1 1 3.1 n/a Breast cancer five-year survival rate, 2008-2013 (or nearest period) 88% 9 n/a 86.2% 85.8%' 85.3% 86.0% 89.8%' 89.4% n/a 81.1% 88.9%9 Mortality after admission for acute myocardial infarction per 100 admissions over age 45, 20139 4.r 6.7 7.2 8.7 7.6m,k 6.6 6.7 4_5m 7.7 7.6 5.5 2013 Mortality amenable to health careh (deaths per 100,000 population) 68k 73k 64k 88 72 89k 69 72 n/a 86 115 Prevention, 2013' Percentage of children with measles immunization 94% 95% 89% 97% 96% 92% 93% 97% 93% 95% 91% Percentage of population over age 65 with influenza immunization n/a 64% 52% 58.6%1 69% 69% 21% 46% 46% 76% 67%1 Works well, minor changes needed 48% 42% 40% 42% 51% 47% 46% 44% 54% 63% 25% Fundamental changes needed 43% 50% 49% 48% 44% 45% 42% 46% 40% 33% 48% Needs to be completely rebuilt 9% 8% 11% 10% 5% 8% 12% 10% 7% 4% 27% practices receive Avoidable deaths, Public views of health system, 2013 Sources (unless noted otherwise): 2013, 2014, and 2015 Commonwealth Fund International Health Policy Surveys. a Base: Saw or needed to see a specialist in past two years. h 6 Base: Needed elective surgery in past two years. c Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care. dTest results/medical records not available at time of appointment and/or doctors ordered medical test that had already been done; received conflicting information from different doctors; and/or specialist lacked medical history or regular doctor was not informed about specialist care. e When discharged from the hospital: you did not receive written information about what to do when you returned home and symptoms to watch for; hospital did not make sure you had arrangements for follow-up care; someone did not discuss with you the purpose of taking each medication; and/or you did not know who to contact if you had a question about your condition or treatment. Base: hospitalized overnight in the past two years. f Base: Has a regular doctor or place of care. Health Policy. 2011 Sep. ' Source: OECD Health Data 2015. I 2012. k 2011. I 2010. 9 In-hospital case-fatality rates within 30 days of admission. 1 1 Source: WHO Mortality files (number of deaths by age group) and populations (except Human Mortality Database for CAN, UK, and US). List of amenable causes: Nolte E, McKee M. Variations in amenable mortality-Trends in 16 high-income nations. Admissions resulting in a transfer are included. n Who had at least one chronic condition. m 0 Age 65 or older. P Who are taking four or more prescription medications regularly. q C 2006-11. 2006-12. The Commonwealth Fund VA-19-0799-D-001586 OS 00003257 Table 4. Provider Organization and Payment in 18 Countries Provider ownership Australia Provider payment Primary care Hospitals Primary care payment Hospital payment Private Public (~65% of beds), private (~35%) ~95% FFS, ~5% incentive payments Global budgets and case-based payment in public hospitals Primary care role Registration with GP required Gatekeeping No Yes Not generally, but yes for some capitation models Yes, mainly through financial (includes physician costs); FFS in private hospitals Private Canada Public/private mix Mostly FFS (~45o/~85%, Mostly global budgets, case-based payment in some (proportions vary by region), depending on province), but mostly not-for-profit some alternatives (e.g., capitation) for group practices provinces (does not include provinces: e.g., in most physician costs) provinces, specialists receive lower fees for patients FFS for private providers, salaries and FFS for GPs employed by hospitals Mainly FFS, with some pilot projects using case-based payments, capitation, or global budgets Not generally, with exceptions in some areas Not generally, with exceptions in some areas ~70% FFS, ~30% capitation Mainly global budgets and Yes (for 98% of population) Yes (for 98% of population) Yes Yes Mainly case-based payments (includes physician costs in public hospitals but not in private) and non-activity-based grants for education, research, etc. No, but many patients register voluntarily Voluntary but incentivized: higher cost-sharing for visits and prescriptions without a referral from the physician with which patients registered incentives varying across not referred China Denmark Private/public mix (private village doctors and clinics; public township and community hospitals providing GP services) Public (~55%)/private (~45%) Private Almost all public mix (mainly public in rural areas, public and private in urban areas) Mix capitation/FFS/P4P; salary payments for a minority (the salaried GPs are employees of private group practices, not ofthe NHS) case-based payments (includes physician costs) Mainly private, limited number of NHS-owned practices with salaried physicians Mostly public, some private France Private Mostly public (67% of capacity), some private for-profit (25%) and private not-for-profit Mix FFS/P4P/flat EUR40 [USD48] Germany Private Public (~50% of beds); private nonprofit (~33%); private for-profit (~ 17%) FFS Case-based payment (includes physician costs) No Generally no, present in specific programs by sickness funds Global budgets for public hospitals No No Yes in the largest health plan (Clalit), no in the other three Yes in two of the four health plans (including the largest, Clalit), no in the other two Subject to regional variation, mainly case-based payment (except hospitals owned by regional authorities) and global budgets (includes physician costs) Yes Yes Case-based per diem No No, but some large hospitals and academic centers charge extra fees to patients not referred England Private non- and for-profit Salary for staff at public (~63% of beds) and public providers, FFS (paid OOP) Public (~50%), Mainly capitation and some FFS to private providers, salary if owned by health plan India Mainly public, some private in urban areas Israel Nonprofit, either salaried by Health Plan or Health Plan contractors private nonprofit (including health plans, ~45%), private for-profit (~5%) Italy Private Mostly public (~80% of beds), Mostly private Japan bonus per year per patient with chronic disease and regional agreements for salaried GPsa Mainly case-based payments (60%) plus budgets for mental health, education, and research and training. All include physician costs, drug costs, etc. for private providers some private (~ 20%) Mix capitation (~ 70% of total), FFS and limited P4P (~30%) Mainly private nonprofit (~80% of beds), some public (~20%) Most FFS, some per-case daily or monthly payments payments plus FFS, or FFS only (includes physician costs) Netherlands Private Mostly private, nonprofit Mix capitation and FFS for 'core' activities (75% in total), some bundled payments and P4P negotiated with insurers Mainly case-based payment (include physician costs) No, but most patients register voluntarily Yes New Zealand Private Mostly public, some private Mix capitation (~50% of total), FFS patient payments (~ 50%) Global budgets (includes physician costs) No Yes Mainly private Almost all public, some private not-for-profit, some for-profit hospitals offering elective treatment only GPs: Capitation from municipal contracts (~35% of income), government-sponsored FFS (~35%) and user-charges (~30%) Somatic: Global budgets (~50%) plus case-based payment (~50%) (includes physician costs); Psychiatric: 100% global budgets No, but more than 95% of patients register voluntarily Yes Mainly public, 20%-30% FFS For public hospitals, combination of global budgets and case-based payments No No Mix capitation (~80% of total) and FFS/limited P4P (~20%) Global budgets (~66% oftotal) and case-based payment/limited P4P (includes ohvsician costs) Yes, in all counties except Stockholm No Case-based payments (~50% No, except in some managed care plans offered by insurers No, except in some managed care plans with gatekeeping offered by insurers No In some insurance programs Norway (95% of general practitioners) Singapore Almost all private, with some larger public clinics for lower-income population private based on activity Mixed, ~40% private Almost all public, some private for- and not-for-profit ~60% public Sweden Switzerland United States Private Private Mostly public or publicly subsidized private, some private Most FFS, some capitation in managed care plans offered by insurers oftotal) and subsidies (through Mix of nonprofit (~70% of beds), public(~ 15%), and for-profit (~15%) Most FFS, some capitation with private plans; some incentive payments Mostly per-diem and case-based payments (usually does not include physician costs) various mechanisms) from cantonal qovernment a Bracketed figure in USD was converted from local currency using the purchasing power parity conversion rate for GDP in 2014 reported by the Organisation for Economic Co-operation and Development (2015). Notes: FFS = fee-for-service; P4P = pay-for-performance; GP= general practitioner; NHS= National Health Service; OOP = out-of-pocket. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001587 OS 00003258 ~ 0000 What is the role of government? i=i Three levels of government are collectively responsible for providing universal health care: federal; state and territory; and local. The federal government mainly provides funding and indirect support to the states and health professions, subsidizing primary care providers through the Medicare Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) and providing funds for state services. It has only a limited role in direct service delivery. States have the majority responsibility for public hospitals, ambulance services, public dental care, community health services, and mental health care. They contribute their own funding in addition to that provided by federal government. Local governments play a role in the delivery of community health and preventive health programs, such as immunization and regulation of food standards (Department of the Prime Minister and Cabinet, 2015). P-ff: Who is covered and how is insurance financed? Publicly financed health insurance: Total health expenditure in 2013-2014 represented 9.8 percent of gross domestic product (GDP), an increase of 3.1 percent from 2012-2013. Two thirds of this expenditure (67.8%) came from 2012-2013 (Australian Institute of Health and Welfare [AIHW], 2015). The federal government funds Medicare, a universal public health insurance program providing free or subsidized access to care for Australian citizens, residents with a permanent visa, and New Zealand citizens following their enrollment in the program and confirmation of identity (AIHW, 2014). Restricted access is provided to citizens of certain other countries through formal agreements (Department of Human Services [DHS], 2015). Other visitors to Australia do not have access to Medicare. Government funding is raised an estimated AUD10.3 billion (USD6.7 billion) in 2013-2014 (The Commonwealth of Australia, 2013). (In July 2014, the levy was expanded to raise funds for disability care.) Private health insurance: Private health insurance (PHI) is readily available and offers more choice of providers (particularly in hospitals), faster access for nonemergency services, and rebates for selected services. Government policies encourage enrollment in PHI through a tax rebate and, above a certain income, a penalty payment for not having PHI (the Medicare Levy surcharge) (PHIO, 2015). The Lifetime Health Coverage program provides a lower premium for life if participants sign up before age 31. There is a 2 percent increase in the base premium for every year after age 30 for people who do not sign up. Consequently, take-up is highest for this age group but rapidly drops off as age increases, with a trend to opt out at age 50 and up. Nearly half of the Australian population (47%) had private hospital coverage and nearly 56 percent had general treatment coverage in 2015 (Private Health Insurance Administration Council, 2015). Insurers are a mix of for-profit and nonprofit providers. In 2013-2014, private health insurance expenditures represented 8.3 percent of all health spending (AIHW, 2015). Private health insurance can include coverage for hospital, general treatment, or ambulance services. When accessing hospital services, patients can opt to be treated as a public patient (with full fee coverage) or as a private patient (with 75% fee coverage). For private patients, insurance covers the MBS fee. If a provider charges above the MBS fee, the consumer will bear the gap cost unless they have gap coverage. The patient International Profiles of Health Care Systems, 2015 VA-19-0799-D-001589 OS 00003260 AUSTRALIA may also be charged for costs such as hospital accommodation, surgery fees (implants and theater fees), and diagnostic tests. General coverage provides insurance for dental, physiotherapy, chiropractic, podiatry, home nursing, and optometry services. Coverage may be capped by dollar amount or number of services. Private health insurance coverage varies by socioeconomic status. PHI covers just one-third of the most disadvantaged 20 percent of the population, a proportion that rises to more than 79 percent for the most advantaged population quintile. This disparity is due in part to the Medicare Levy surcharge applied to higher-income earners (Australian Bureau of Statistics [ABS], 2013). ?1 What is covered? Services: The federal government defines Medicare benefits, which include hospital care, medical services, and pharmaceuticals, to name a few. States provide further funding and are responsible for the delivery of free public hospital services, including subsidies and incentive payments in the areas of prevention, chronic disease management, and mental health care. The MBS provides for limited optometry and children's dental care. Pharmaceutical subsidies are provided through the PBS. Pharmaceuticals need to be approved for cost-effectiveness by the independent Pharmaceutical Benefits Advisory Committee (PBAC) to be listed. War veterans, the widowed, and their dependents may be eligible for the Repatriation PBS (DHS, 2015). Nearly half (49%) of federal support for mental health is for payments to people with a disability; remaining support goes to payments to states, payments and allowances for caregivers, and subsidies provided through the MBS and PBS (National Mental Health Commission, 2014). State governments are responsible for specialist and acute mental care services. Home care for the elderly and hospice care coverage are described below in the section "How is the delivery system organized and financed?" Cost-sharing and out-of-pocket spending: Out-of-pocket payments accounted for 18 percent oftotal health expenditures in 2013-2014. The largest share (38%) was for medications, followed by dental care (20%), medical services (e.g., referred and unreferred private health insurance), medical aids and equipment, and other health practitioner services (Al HW, 2015). There are no deductibles or out-of-pocket costs for public patients receiving public hospital services. General practitioner (GP) visits are subsidized at 100 percent ofthe MBS fee, and specialist visits at 85 percent. GPs and specialists can choose whether to charge above the MBS fee. About 83 percent of GP visits were provided without charge to the patient in 2014-2015. Patients who were charged paid an average of AUD31 (USD20) (DH, 2015). Out-of-pocket pharmaceutical expenditures are capped. In 2015 the maximum cost per prescription for lowincome earners was set at AUD6.10 (USD3.97) with an annual cap of AUD366 (USD238). For the general population, the cap per prescription is AUD37.70 (USD24.55) per prescription, which reverts to the low-income 1 rate cap if they incur more than AUD1 ,454 (USD947) in out-of-pocket expenditure within a year. Consumers pay the full price of medicines not listed on the PBS. Pharmaceuticals provided to inpatients in public hospitals are generally free. Safety nets: Beginning in January 2016, a new Medicare Safety Net will replace the previous Original Medicare Safety Net, the Extended Medicare Safety Net, and the Greatest Permissible Gap arrangements. Medicare will reimburse 80 percent of out-of-pocket costs (up to a cap of 150 percent ofthe MBS fee) for the remainder of the calendar year once annual thresholds are met: AUD400 (USD260) for concessional patients (including 1 Please note that, throughout this profile, all figures in USD were converted from AUD at a rate of about AUD1 .54 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for Australia. The Commonwealth Fund VA-19-0799-D-001590 OS 00003261 AUSTRALIA low-income adults, children under 16, and certain veterans); AUD700 (USD456) for parents of school children and singles; and AUD1 ,000 (USD651) for all other families. [ (R)] How is the delivery system organized and financed? Primary care: In 2013, there were 25,702 GPs, and a slightly higher number of specialists (27,279) (AIHW, 2015a). GPs are typically self-employed, with about four per practice on average (DH, 2015, and DHS, 2015). In 2012 those in nonmanagerial positions earned an average of AUD2,862 (USD1 ,864) per week. The schedule of service fees is set by the federal health minister through the MBS. Registration with a GP is not required, and patients choose their primary care doctor. GPs operate as gatekeepers, in that a referral to a specialist is needed for a patient to receive the MBS subsidy for specialist services. The fee-for-service MBS model accounts for the majority of federal expenditures on GPs, while the Practice Incentives Program (PIP) accounts for 5.5 percent (ANAO, 2010). State community health centers usually employ a multidisciplinary provider team. The federal government provides financial incentives for the accreditation of GPs, multidisciplinary care approaches, and care coordination through PIP and through funding of GP Super Clinics and Primary Health Networks (PHNs). PHNs (which replace Medicare Locals) are being implemented in 2015-2016 to support more efficient, effective, and coordinated primary care. The number of nurses working in primary care has been increasing, from 8,649 registered or enrolled nurses primarily working in a general practice setting in 2011 to 11,370 in 2014. Their role has been expanding with the support of the PIP practice nurse payment. Beyond this, nurses are funded through practice earnings. Nurses in general practice settings provide chronic disease management and care coordination, preventive health education, and oversight of patient follow-up and reminder systems (Health Workforce Australia [HWA], 2015). Outpatient specialist care: Specialists delivering outpatient care are either self-employed in a solo private practice (6,745 specialists in 2013) or employed in a group practice (5,257) (HWA, 2015). Patients are able to choose which specialist they see, but must be referred by their GP to receive MBS subsidies. Specialists are paid on a fee-for-service basis. They receive a subsidy through the MBS of 85 percent of the schedule fee and set their patients' out-of-pocket fees independently. Many specialists split their time between private and public practice. Administrative mechanisms for direct patient payments to providers: Many practices have the technology to process claims electronically so that reimbursements from public and private payers are instantaneous, and patients pay only their copayment (if the provider charges above the MBS fee). If the technology is not in place, patients pay the full fee and seek reimbursement from Medicare and/or their private insurer. After-hours care: GPs are required to ensure that after-hours care is available to patients, but are not required to provide care directly. They must demonstrate that processes are in place for patients to obtain information about after-hours care, and that patients can contact them in an emergency. After-hours walk-in services are available, and may be provided in a primary care setting or within hospitals. As there is free access to emergency departments, these also may be utilized for after-hours primary care. The federal government provides varying levels of practice incentives for after-hours care, depending on whether access is direct or provided indirectly through arrangements with other practitioners in the area. Government also funds PHNs to support and coordinate after-hours services, and there is an after-hours advice and support line. Hospitals: In 2013-2014 there were 747 public hospitals (728 acute, 19 psychiatric) with a total of 58,600 beds and 612 private hospitals (326 day hospitals and 286 other) with 31,000 beds (AIHW, 2014a; AIHW, 20146). Private hospitals are a mix of for-profit and nonprofit. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001591 OS 00003262 AUSTRALIA Public hospitals receive a majority offunding (91 %) from federal and state governments, with the remainder coming from private patients and their insurers. Most of the funding (62% of the total) is for public physician salaries. Private physicians providing public services are paid on a per-session or fee-for-service basis. Private hospitals receive most of their funding from insurers (47%), federal government's rebate on health insurance premiums (21%), and private patients (12%) (AIHW, 20146). Public hospitals are organized into Local Hospital Networks (LHNs), of which there were 138 in 2013-2014. These vary in size, depending on the population they serve and the extent to which linking services and specialties on a regional basis is beneficial. In major urban areas, a number of LHNs comprise just one hospital. State governments fund their public hospitals largely on an activity basis using diagnosis-related groups. Federal funding for public hospitals includes a base level of funding, with growth funding set at 45 percent of the "efficient price of services" of activities, determined by the Independent Hospital Pricing Authority (IHPA [http://www.ihpa.gov.au]). States are required to cover the remaining cost of services, providing an incentive to keep costs at the efficient price or lower. Small rural hospitals are funded through block grants (IHPA, 2015). Starting in July 2017, the federal government will return to block-grant funding for all hospitals. Mental health care: Mental health services are provided in many different ways, including by GPs and specialists, in community-based care, in hospitals (both in- and outpatient, public and private), and in residential care. GPs provide general care and may devise treatment plans of their own or refer patients to specialists. Specialist care and pharmaceuticals are subsidized through the MBS and PBS. State governments fund and deliver acute mental health and psychiatric care in hospitals, community-based services, and specialized residential care. Public hospital-based care is free to public patients (AIHW, 20156). The federal government has commissioned the National Mental Health Commission to undertake a review of all existing services (NMHC, 2015). Long-term care and social supports: The majority of people living in their own homes with severe or profound limitations in core activities receive informal care (92%). Thirty-eight percent receive only informal assistance and 54 percent receive a combination of informal and formal assistance. In 2009, 12 percent of Australians were informal caregivers and around 30 percent ofthose were the primary caregiver (carer). In 2011-2012, federal government provided AUD3.18 billion (USD2.07 billion) under the income-tested Carer Payment program, and AUD1 .75 billion (USD1 .14 billion) through the Carer Allowance (not income-tested, and offered as a supplement for daily care). Government also provides an annual Carer Supplement of AUD480 million (USD313 million) to help with the cost of caring. Recipients of the Carer Allowance who care for a child under the age of 16 receive an annual Child Disability Assistance Payment of AUD1 ,000 (USD651). There are also a number of respite programs providing further support for caregivers (AIHW, 2013). Home care for the elderly is provided through the Commonwealth Home Support Program in all states except Western Australia. Subsidies are income-tested and may require copayments from recipients. Services can include assistance with housework, basic care, physical activity, nursing, and allied health. The program began in July 2015 as a consolidation of home and community care, planned respite for caregivers, day therapy, and assistance with care and housing (Department of Social Services, 2015). The Western Australian Government administers and delivers its Home and Community Care Program with funding support from federal government. Aged care homes may be private nonprofit or for-profit, or run by state or local governments. Federally subsidized residential aged care positions are available for those who are approved by an Aged Care Assessment Team. Hospice care is provided by states through complementary programs funded by the Commonwealth. The Australian Government supports both permanent and respite residential aged care. Eligibility is determined through a needs assessment, and permanent care is means-tested (AIHW, 2015c). The Commonwealth Fund VA-19-0799-D-001592 OS 00003263 AUSTRALIA In 2013, the federal government, in partnership with states, implemented the pilot phase ofthe National Disability Insurance Scheme. The scheme provides more-flexible funding support (not means-tested), allowing greater tailoring of services. &h What are the key entities for health system governance? Intergovernmental collaboration and decision-making at the federal level occur through the Council of Australian Governments (COAG), with representation from the Prime Minister and first ministers of each state. The COAG focuses on the highest-priority issues, such as major funding discussions and the interchange of roles and responsibilities between governments. The COAG Health Council is responsible for more detailed policy issues and is supported by the Australian Health Ministers Advisory Council (http://www. coaghealthcouncil.gov.au/). The federal Department of Health (DH) oversees national policies and programs such as the MBS and PBS. Payments through these schemes are administered by the Department of Human Services. The PBAC provides advice to the Minister for Health on the cost-effectiveness of new pharmaceuticals (but not routinely on delisting). Several national agencies and the state governments are responsible for quality and safety of care (see below). The AIHW and the Australian Bureau of Statistics (ABS) are the major providers of health data. Regulatory oversight is provided by a number of agencies, such as the Therapeutic Goods Administration, which oversees supply, imports, exports, manufacturing, and advertisement; the Australian Health Practitioner Regulation Agency, which ensures registration and accreditation of the workforce in partnership with National Boards; and the Australian Prudential Regulation Authority, for private health insurance. The Australian Competition and Consumer Commission promotes competition among private health insurers. Beginning in July 2016, the Australian eHealth Commission will take over responsibility from the National eHealth Transition Authority for matters relating to electronic health data. State governments operate their own departments of health, and have devolved management of hospitals to the LHNs. The LHNs are responsible for working collaboratively with PHNs. There are patient-consumer organizations and groups operating at the national and state level. ~ X What are the major strategies to ensure quality of care? The overarching strategy to ensure quality of care is captured in the National Healthcare Agreement of the COAG (2012). The agreement sets out the common objective of Australian governments in providing health care-improving outcomes for all and the sustainability of the system-and the performance indicators and benchmarks on which progress is assessed. It also sets out national-priority policy directions, programs, and areas for reform, such as major chronic diseases and their risk factors. Indicators and benchmarks in the agreement address issues of quality from primary to tertiary care and include disease-specific targets of high priority, as well as general benchmarks. The Australian Commission on Safety and Quality in Health Care (ACSQH) is the main body responsible for safety and quality improvement in health care. The ACSQH has developed service standards that have been endorsed by health ministers (DH, Portfolio Budget Statement 2015-16). These include standards for conducting patient surveys, which must be met by hospitals and day surgery centers for accreditation. The ABS, the national government statistical body, also undertakes an annual patient experience survey. The Australian Council on Healthcare Standards is the (nongovernment) agency authorized to accredit provider institutions. States license and register private hospitals and the health workforce, legislate on the operation of public hospitals, and work collaboratively through a National Registration and Accreditation Scheme facilitating workforce mobility across jurisdictions while maintaining patient protections. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001593 OS 00003264 AUSTRALIA Organization of the Health System in Australia Austra lian Parliament State Parliaments 1 Prime Minister & Cabinet Counci l of Austra lian Governments (COAG) State Premiers & Cabinets Federal Health Minister COAG Health Council State Health Ministers Austra lian Health Ministers Advisory Council Key regulatory bod ies Aged Care Standards & Accreditation Agency Australian Health Practitioner Regulation Agency Community Pharmacy Agreement with Pharmacy Gui ld of Australia Primary health networks Medical and pharmaceutical benefits to patients State-run aged care services Public community health services Public hospitals (including outpatients) Public dental services (including hospitals) Australian Prudential Regulatory Authority (in Treasury portfolio with oversight of private health insurers) Australian Radiation Protection & Nuclear Safety Authority Food Standards Australia New Zealand ____. Hierarchica l (may include fund ing) . -? Negotiation ____. Funding Therapeutic Goods Administration Source: L. G love r, 2015 . The Royal Australian College of General Practitioners has responsibility for accrediting GPs. The MBS includes financial incentives such as the PIP, and approximately 85 percent of GPs are accredited. To be eligible for government subsidies, aged care services must be accredited by the government-owned Aged Care Standards and Accreditation Agency. There are a number of disease and device registries. Government-funded registries are housed in universities and nongovernmental organizations, as well as within state governments. ACSQH has developed a national framework to support consistent registries. The National Health Performance Authority reports on the comparable performance of LHNs, public and private hospitals, and other key health service providers. The reporting framework was agreed to by the COAG, and includes measures of equity, effectiveness, and efficiency. The federal government has regulatory oversight of quarantine, blood supply, pharmaceuticals, and therapeutic goods and appliances (AIHW, 2014). In addition, there are a number of national bodies who promote quality and safety of care through evidence-based clinical guidelines and best-practice advice. They include the National Health and Medical Research Council and Cancer Australia. The Commonwealth Fund VA-19-0799-D-001594 OS 00003265 AUSTRALIA t:: j What is being done to reduce disparities? The most prominent disparities in health outcomes are between the Aboriginal and Torres Strait Islander population and the rest of Australia's population; these are widely acknowledged as unacceptable. In 2008, the COAG agreed to a target date of 2031 for closing the gap in life expectancy. Its strategy goes beyond health care, seeking to address disparities in other areas such as education and housing. The Prime Minister makes an annual statement to Parliament on progress toward closing the gap. Disparities between major urban centers and rural and remote regions and across socioeconomic groups are also major challenges. The federal government provides incentives to encourage GPs and other health workers to work in rural and remote areas, where it can be very difficult to attract a sufficient number of practitioners. This challenge is also addressed to an extent through the use oftelemedicine. Since 1999, the Australian Government has funded the Public Health Information Development Unit (www.publichealth.gov.au) for the purpose of publishing small-area data showing disparities in access to health services and health outcomes on a geographic and socioeconomic basis. (R)~ What is being done to promote delivery system integration and ~ 0 care coordination? Approaches to improving integration and care coordination include the PIP, which provides a financial incentive to providers for the development of care plans for patients with certain conditions, such as asthma, diabetes, and mental health needs. The PHNs were established in July 2015 with the objective of improving coordinated care, as well as the efficiency and effectiveness of care for those at risk of poor health outcomes. These networks are funded through grants from the federal government and will work directly with primary care providers, health care specialists, and LHNs. Care also may be coordinated by Aboriginal health and community health services. ~ What is the status of electronic health records? ~ The National eHealth Transition Authority has been working to establish interoperable infrastructure to support communication across the health care system. A national e-health program based on personally controlled unique identifiers has commenced operation in Australia, and 2.5 million patients and nearly 8,000 providers have registered (DH, 2015a). The record supports prescription information, medical notes, referrals, and diagnostic imaging reports. Following a review, government is taking a number of steps to increase uptake by both patients and providers, which has been poor to date, by improving usability, clinical utility, governance, and operations. In addition, an opt-out approach will be tested to replace the current opt-in approach. The new Australian Commission for eHealth will begin oversight in July 2016, taking on thee-health roles ofthe Department of Health and the National eHealth Transition Authority. The current PIP eHealth Incentive, which aims to encourage GPs to participate, also will be reviewed for potential improvements. How are costs contained? The major drivers of cost growth are the MBS and PBS. Government regularly considers opportunities to reduce spending growth in the MBS through its annual budget process and has established an expert panel to undertake a review of the entire schedule and report by the end of 2016. Government influences the cost of the PBS in making determinations about what pharmaceuticals to list on the scheme and in negotiating the price with suppliers. Government provides funds to pharmacies for dispensing medicines subsidized through the PBS and to support professional programs and the wholesale supply of medicines. This arrangement is through the current Community Pharmacy Agreement (the Community Pharmacy Agreements were instituted in 1991 and are subject to renegotiation every five years). The Sixth Community Pharmacy Agreement, which began in July 2015, supports AUD6.6 billion (USD4.3 billion) in savings through supply chain efficiencies (Ley, 2015). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001595 OS 00003266 AUSTRALIA Hospital funding is set through policy decisions by the federal government, with states required to manage funding within their budgets. Through the 2015-2016 budget, the federal government also consolidated the back-office functions of a number of its health agencies to generate AUD106 million (USD69 million) in savings. Beyond these measures, the major control is through the capacity constraints of the health system, such as workforce supply. G ~ What major innovations and reforms have been introduced? In 2015, the federal government announced a number of reforms to primary care, including implementation of the aforementioned PHNs and the MBS Review. In addition, the government has established the Primary Health Care Advisory Group to consider innovations to funding and service delivery for people with complex and chronic illness, including mental health. Together, these three reforms seek to ensure that primary care is being delivered efficiently and effectively and that Medicare is put on a sustainable funding trajectory. The group's advice, which was submitted to the government at the end of 2015, will consider how to best utilize the PHNs. The government is also reforming care for the aging. In addition to the implementation of the Commonwealth Home Support program outlined above, a new funding model is pursued whereby allocations will be made directly to consumers based on their care needs instead of directly to service providers, affording them greater choice in providers and stimulating provider competition. This reform will take effect in February 2017. The Commonwealth Fund VA-19-0799-D-001596 OS 00003267 AUSTRALIA References Australian Bureau of Statistics, Australian Government (2013). "Cat no: 4364.0.55.002 - Australian Health Survey: Health Service Usage and Health Related Actions, 2011-12." ABS: Canberra. Australian National Audit Office (2010). Audit Report No. 5 2010-11. Performance Audit: Practice Incentives Program. Canberra: ANAO. Australian Taxation Office, Australian Government. https://www.ato.gov.au/General/New-legislation/ln-detail/Direct-taxes/ Income-tax-for-individuals/Net-medical-expenses-tax-offset-phase-out/. Accessed Nov. 16, 2015. Australia's Institute of Health and Welfare (AIHW), Australian Government (2015). "Health Expenditure Australia 2013-14." Canberra: AIHW. AIHW, Australian Government (2015a). "Medical Workforce 2013 Detailed Tables, Table 4." Accessed Aug. 12, 2015. Canberra: AIHW. AIHW, Australian Government (20156). "Mental Health Services in Australia." https://mhsa.aihw.gov.au/home/. Accessed Nov. 18, 2015. AIHW, Australian Government (2015c). http://www.aihw.gov.au/aged-care/residential-and-community-2011-12/aged-care-inaustralia/. Accessed Nov. 18, 2015. AIHW, Australian Government (2014). "Australia's Health 2014." Canberra: AIHW. AIHW, Australian Government (2014a). "Australia's Hospitals 2013-14 at a glance." Canberra: AIHW. AIHW, Australian Government (20146). "Hospital resources 2013-14: Australian hospital statistics." Canberra: AIHW. AIHW, Australian Government (2013). "Australia's Welfare." Canberra: AIHW. The Commonwealth of Australia (2013). "Budget Paper No. 1: Budget Strategy and Outlook 2013-14." The Commonwealth of Australia: Canberra. http://www.budget.gov.au/2013-14/content/bp1/download/bp1_consolidated.pdf. Accessed Dec. 9, 2015. Department of the Prime Minister and Cabinet, Australian Government (2015). "Reform of the Federation White Paper: Roles and Responsibilities in Health. Issues Paper 3." Canberra, DPMC. Department of Health, Australian Government (2015). General Practice Workforce Statistics. http://www.health.gov.au/ internet/main/publishing.nsf/content/F21 0D973E08C0193CA257BF0001 B5F1 F/$File/GP%20Workforce%20Statistics%20 2013-14%20PUBLIC%20Web%20version.pdf. Accessed Aug. 12, 2015. Department of Health, Australian Government (2015a). http://www.ehealth.gov.au/internet/ehealth/publishing.nsf/Content/ pcehr-statistics. Accessed Nov. 16, 2015. Department of Human Services, Australian Government (2015). http://www.humanservices.gov.au/. Accessed Nov. 16, 2015. Department of Human Services, Australian Government (2015). http://medicarestatistics.humanservices.gov.au/statistics/ do.jsp?_PROGRAM=%2Fstatistics%2Fdgp_report_selector&statisticF=count&reportTypeFH=report&variableF=&drillTypeFH= on&DIVISIONS=&DGPSORT =divgp&groupF=999&schemeF=PIP&reportNameFH=piprrma&reportFormatF=by+time+period &reportPeriodF=quarter&startDateF=20131 0&endDateF=201312. Accessed Aug. 12, 2015. Department of Social Services (2015). https://www.dss.gov.au/our-responsibilities/ageing-and-aged-care/aged-care-reform/ commonwealth-home-support-programme#03 . Accessed Sept. 6, 2015. Health Workforce Australia, Australian Government. http://data.hwa.gov.au/webapi/jsf/tableView/tableView.xhtml. Accessed Sept. 6, 2015. Independent Hospital Pricing Authority (2015). "National Efficient Price Determination 2015-16." IHPA: Sydney. Ley, Susan (2015). Media release by Susan Ley (Minister for Health): "Pharmaceutical Benefits Scheme to be reformed." Accessed Sept. 6 from: https://www.health.gov.au/internet/ministers/publishing.nsf/Content/FDA6A9682797EDD7CA257E52 001 F423C/$File/SL063.pdf. National Mental Health Commission, Australian Government (2014). "Contributing lives, thriving communities: Report of the National Review of Mental Health Programmes and Services." NMHC: Canberra. Private Health Insurance Administration Council, Australian Government (2015). "Statistics: Private Health Insurance Membership and Coverage, Sept. 2015." PHIAC: Sydney. Private Health Insurance Ombudsman, Australian Government. http://www.privatehealth.gov.au/healthinsurance/ whatiscovered/privatehealth.htm. Accessed Nov. 16, 2015. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001597 OS 00003268 ~ ? ~ What is the role of government? Provinces and territories in Canada have primary responsibility for organizing and delivering health services and supervising providers. Many have established regional health authorities that plan and deliver publicly funded services locally. Generally, those authorities are responsible for the funding and delivery of hospital, community, and long-term care, as well as mental and public health services. Nearly all health care providers are private. The federal government cofinances provincial and territorial programs, which must adhere to the five underlying principles of the Canada Health Act-the law that sets standards for medically necessary hospital, diagnostic, and physician services. These principles state that each provincial health care insurance plan needs to be: 1) publicly administered; 2) comprehensive in coverage; 3) universal; 4) portable across provinces; and 5) accessible (i.e., without user fees). ~ The federal government also regulates the safety and efficacy of medical devices, pharmaceuticals, and natural health products; funds health research; administers a range of services for certain populations, including First Nations, Inuit, Metis, and inmates in federal penitentiaries; and administers several public health functions. Who is covered and how is insurance financed? Publicly financed health care: Total and public health expenditures were forecast to account for an estimated 10.9 percent and 8.0 percent of GDP, respectively, in 2015; by that measure, 70.7 percent oftotal health spending comes from public sources (Canadian Institute for Health Information, 2015a). The provinces and territories administer their own universal health insurance programs, covering all provincial and territorial residents according to their own residency requirements (Health Canada, 2013a). Temporary legal visitors, undocumented immigrants (including denied refugee claimants), those who stay in Canada beyond the duration of a legal permit, and those who enter the country "illegally," are not covered by any federal or provincial program, although provinces and territories provide some limited services. The main funding sources are general provincial and territorial spending, which was forecast to constitute 93 percent of public health spending in 2015 (Canadian Institute for Health Information, 2015a). The federal government contributes cash funding to the provinces and territories on a per capita basis through the Canada Health Transfer, which totaled CAD34 billion (USD27 billion) in 2015-2016, accounting for an estimated 24 percent oftotal provincial and territorial health expenditures (Canadian Institute for Health Information, 2015a; Government of Canada, 2015a). 1 Privately financed health care: Private insurance, held by about two-thirds of Canadians, covers services excluded from public reimbursement, such as vision and dental care, prescription drugs, rehabilitation services, home care, and private rooms in hospitals. In 2013, approximately 90 percent of premiums for private health plans were paid through group contracts with employers, unions, or other organizations (Canadian Life and Health Insurance Association, 2014). In 2015, private health insurance accounted for approximately 12 percent oftotal health spending (Canadian Institute for Health Information, 2015a). The majority of insurers are for-profit. 1 Please note that, throughout this profile, all figures in USD were converted from CAD at a rate of about CAD1 .26 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for Canada. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001599 OS 00003270 CANADA ~ What is covered? Services: To qualify for federal financial contributions under the Canada Health Transfer, provincial and territorial insurance plans must provide first-dollar coverage of medically necessary physician, diagnostic, and hospital services (including inpatient prescription drugs) for all eligible residents. There is no nationally defined statutory benefits package; most public coverage decisions are made by provincial and territorial governments in conjunction with the medical profession. Provincial and territorial governments provide varying levels of additional benefits, such as outpatient prescription drugs, nonphysician mental health care, vision care, dental care, home health care, and hospice care. They also provide public health and prevention services (including immunizations) as part of their public programs. Cost-sharing and out-of-pocket spending: There is no cost-sharing for publicly insured physician, diagnostic, and hospital services. All prescription drugs provided in hospitals are covered publicly, with outpatient coverage varying by province or territory. Physicians are not allowed to charge patients prices above the negotiated fee schedule. In 2012, out-of-pocket payments represented about 14.2 percent oftotal health spending (Canadian Institute for Health Information, 2015a), going mainly toward prescription drugs (21%), nonhospital institutions (mainly long-term care homes) (22%), dental care (16%), vision care (9%), and over-the-counter medications (10%) (Canadian Institute for Health Information, 2015a). Safety net: Cost-sharing exemptions for non insured services such as prescription drugs vary among provinces and territories, and there are no caps on out-of-pocket spending. For example, the prescription drug program in Ontario exempts low-income seniors and social assistance recipients from all cost-sharing except a CAD2.00 (USD1 .60) copayment, which is often waived by pharmacies. Low income is defined as annual household income of less than CAD16,018 (about USD12,700) for single people and less than CAD24,175 (USD19,168) for couples. There are no caps on out-of-pocket spending. However, the federal Medical Expense Tax Credit supports tax credits for individuals whose medical expenses, for themselves or their dependents, are significant (above 3% of income). A disability tax credit and an attendant care expense deduction also provide relief to individuals (or their dependents) who have prolonged mental or physical impairments, and to those who incur expenses for care that is needed to allow them to work. [ (R)] How is the delivery system organized and financed? Primary care: In 2014, about half of all practicing physicians (2.24 per 1,000 population) were general practitioners, or G Ps (1.14 per 1,000 population) and ha If were specialists (1.10 per 1,000 population) (Canadian Institute for Health Information, 20156). Primary care physicians act largely as gatekeepers, and many provinces pay lower fees to specialists for nonreferred consultations. Most physicians are self-employed in private practices and paid fee-for-service, although there has been a movement toward group practice and alternative forms of payment, such as capitation. In 2013-2014, fee-for-service payments made up 45 percent of payments to GPs in Ontario, compared with 67 percent in Quebec and 84 percent in British Columbia (Canadian Institute for Health Information, 2015c). In 2014, 46 percent of GPs reported to work in a group practice, 19 percent in an interprofessional practice, and 15 percent in a solo practice (National Physician Survey, 2014). In some provinces, such as Ontario, some new primary care teams paid partly by capitation must require patients to register to receive those partial payments; otherwise, registration is not required. Clinical fee-forservice payments to primary care physicians in Canada averaged CAD249,154 (USD197,550) in 2013-2014 (Canadian Institute for Health Information, 2015c); these do not account for alternative payments and nonclinical payments. It has been estimated that the average payment, including alternative payments, for primary care physicians in Ontario is 21 percent higher than for fee-for-service alone (Henry et al., 2012). In several provinces, networks of GPs work together and share resources. For instance, Primary Care Networks in Alberta, My Health Teams in Manitoba, and Family Health Teams in Ontario support interdisciplinary health professionals (e.g., nurses, pharmacists, and dietitians). In Ontario, the minimum size of practice for physicians in alternative payment models (not fee-for-service) is three (Sweetman and Buckley, 2014). In Family Health The Commonwealth Fund VA-19-0799-D-001600 OS 00003271 CANADA Teams, the average practice size is approximately 10 physicians, and ranges from seven to 14 physicians in other models (Rudoler et al., 2015). In Ontario, team composition varies among practices, and interdisciplinary providers are generally salaried employees of the practice. Patients have free choice of primary care doctor, although in some areas choices are restricted owing to limited supply. Provincial and territorial ministries of health negotiate physician fee schedules (for primary and specialist care) with provincial and territorial medical associations. In some provinces, such as British Columbia and Ontario, payment incentives have been linked to performance, and also are used to encourage the provision of a number of services including, but not limited to, delivering "guideline-based" care for specified chronic conditions, offering preventive services, developing care plans for patients with complex needs, and registering complex or vulnerable patients. Outpatient specialist care: The majority of specialist care is provided in hospitals, although there is a trend toward providing services in private nonhospital facilities. Specialists are mostly self-employed and paid fee-forservice. Specialists in Canada received an average of CAD379,051 (USD300,545) annually in clinical fee-forservice payments in 2013-14 (Canadian Institute for Health Information, 2015c). In most provinces, specialists have the same fee schedule as primary care physicians. In 2014, 65 percent of specialists reported to work in a hospital, compared with 24 percent in a private office or clinic (National Physician Survey, 2014). Patients can choose, and have direct access to, a specialist, but it is common for GPs to refer patients to specialty care. Specialists who work in the public system are not permitted to receive payment from private patients for publicly insured services. There are few formal multispecialty clinics, although in some provinces, such as Ontario, there are informal, or virtual, networks of specialists that share patients and information (Stukel et al., 2013). Administrative mechanisms for paying primary care doctors and specialists: The majority of physicians and specialists bill provincial governments directly, although some are paid a salary by a hospital or facility. There are no direct payments from patients to physicians; there is no cost-sharing, although patients may be required to pay for services that are not medically necessary-for example, physician letters sent to employers when employees are ill. After-hours care: After-hours care is provided generally by physician-led (and mainly privately owned) walk-in clinics and hospital emergency rooms. In most provinces and regions, a free telephone service ("telehealth") is available 24 hours a day for health advice from a registered nurse. Traditionally, primary care physicians were not required to provide after-hours care, although many of the government-enabled group practice arrangements have requirements or financial incentives for providing after-hours care to registered patients. For example, in Ontario, physicians practicing in non-fee-for-service models have to provide sessions during some evenings and weekends. In some models, this amounts to a single three-hour session per week per physician in the group, up to five sessions per week (MOHLTC, 2009). These physicians are paid a 30 percent bonus for primary care services provided during evenings, weekends, and holidays (MOHLTC, 2011). Manitoba has implemented OuickCare clinics, staffed by nurses and nurse practitioners, to meet health care needs after hours (Government of Manitoba, 2015). The 2012 Commonwealth Fund International Survey of Primary Care Doctors found that only 46 percent of physician practices in Canada had arrangements for patients to see a doctor or nurse after hours, with the highest rate in Ontario, at 67 percent (Health Council of Canada, 2013). The same survey found that only 30 percent of physicians received notification of hospital emergency department visits by their patients, and only about a quarter received a full report on specialist consultations. Hospitals: Hospitals are a mix of public and private, predominantly not-for-profit, organizations, often managed locally by regional authorities or hospital boards representing the community. In provinces with regional health authorities, many hospitals are publicly owned (Marchildon, 2013), whereas in other provinces, such as Ontario, they are predominantly private nonprofit corporations. There are no data on the number of private for-profit clinics (which are mostly diagnostic and surgical). In Ontario, as of May 2014, the government was providing International Profiles of Health Care Systems, 2015 VA-19-0799-D-001601 OS 00003272 CANADA funding to 145 not-for-profit hospital corporations (with 224 different facilities and sites) and six private for-profit hospitals (Ontario Ministry of Health and Long-Term Care, 2014). Hospitals in Canada generally operate under annual global budgets, negotiated with the provincial or territorial ministry of health or regional health authority. However, several provinces have considered introducing activitybased funding for hospitals, including Ontario, Alberta, and British Columbia (Sutherland et al., 2013, 2013a). Hospital-based physicians generally are not hospital employees and are paid fee-for-service directly. Mental health care: There is universal coverage for physician-provided mental health care, alongside a fragmented system of allied services. Hospital mental health care is provided in specialty psychiatric hospitals and in general hospitals with adult mental health beds. The provinces and territories all provide a range of community mental health and addiction services including case management, community-based crisis response, and supported housing (Goering et al., 2000). Psychologists may work privately and are paid out-of-pocket or through private insurance, or under salary in publicly funded organizations. Mental health has not been formally integrated into primary care; any coordination or colocation of mental health services within primary care is unique to its particular practice. In Ontario, the government introduced an intersectoral mental health strategy in 2011 that aims to better integrate mental health care into primary care (Government of Ontario, 2011). Long-term care and social supports: Long-term care and end-of-life care provided in nonhospital facilities and in the community are not considered insured services under the Canada Health Act. All provinces and territories fund services, but coverage varies among and within them. All provinces provide some nursing home care and some combination of case management and nursing care for home care clients, but there is considerable variation when it comes to other services, including medical equipment, supplies, and home support, and many jurisdictions require client contributions (OECD, 2011). About half ofthe provinces and territories provide some home care without means-testing, but access may depend both on assessed priority and on availability within capped budgets (Health Canada, 20136). Eligibility criteria for home and institutional long-term care services vary across provinces but generally include a needs assessment based on health status and functional impairment. Some provinces have established minimum residency periods as an eligibility condition for facility admission. Spending on nonhospital institutions, of which the majority are long-term care facilities, accounted for just over 10 percent oftotal health expenditure in 2013, with financing mostly from public sources (71 %) (Canadian Institute for Health Information, 201 Sa). A mix of private for-profit (41 %), private not-for-profit (43%), and public facilities (13%) provide long-term care (Statistics Canada, 2011). Public funding of home care is provided either through provincial or territorial government contracts with agencies that deliver services (e.g., the Community Care Access Centres, in Ontario) or through government stipends to patients to purchase their own services (e.g., the "Choice in Support for Independent Living" program in British Columbia). Provinces and territories are responsible for delivering palliative and end-of-life care in hospitals, where the majority of such costs occur. But many provide some coverage for services outside those settings, such as doctors, nurses, and drug coverage in hospices, in nursing facilities, and at home. Support for informal caregivers (estimated to provide 66% to 84% of care to the elderly) varies by province and territory (Grignon and Bernier, 2012). In Ontario, for example, the Family Caregiver Leave Bill offers job protection to caregivers. There are also some federal programs, including the Family Caregiver Tax Credit and the Employment Insurance Compassionate Care Benefit (Canada Revenue Agency, 2014; Government of Canada, 2014). The Commonwealth Fund VA-19-0799-D-001602 OS 00003273 CANADA &h What are the key entities for health system governance? Because of the high level of decentralization, provinces have primary jurisdiction over administration and governance of their health systems. The federal ministry of health, Health Canada, plays a role in promoting overall health, disease surveillance and control, food and drug safety, and medical device and technology review. The Public Health Agency of Canada is responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. At the national level, several intergovernmental nonprofit organizations aim to improve governance by monitoring and reporting on health system performance; disseminating best practice in patient safety (the Canadian Patient Safety Institute); providing information to the public on health and health care and standardizing health data collection (the Canadian Institute for Health Information); and providing funding and support for provincial health information systems (Canada Health lnfoway). The Canadian Agency for Drugs and Technologies in Health oversees the national health technology assessment process, which produces information about the clinical effectiveness, cost-effectiveness, and broader impact of drugs, medical technologies, and health systems. The Agency's Common Drug Review reviews the clinical effectiveness and cost-effectiveness of drugs and provides common, nonbinding formulary recommendations to the publicly funded provincial drug plans (except in Quebec) to support greater consistency in access and evidence-based resource allocation. Nongovernmental organizations with important roles in system governance include professional organizations such as the Canadian Medical Association, provincial regulatory colleges, which are responsible for licensing professions and developing and enforcing standards of practice, and Accreditation Canada (see below). Most providers are self-governing under provincial and territorial law; they are registered with professional associations that ensure that education, training, and quality-of-care standards are met. The professional associations for physicians are also responsible for negotiating fee schedules with the provincial ministries of health. Most provinces have an ombudsperson providing patient advocacy. ~ X What are the major strategies to ensure quality of care? Since 2014, there have been no new national strategies initiated to ensure quality of care, although in the previous decade the Canada Health Accord provided for dedicated federal funding to provinces to achieve common goals in wait times, primary care, and home care. Some provinces have agencies responsible for producing health care system reports and for monitoring system performance, and many quality improvement initiatives take place at the provincial and territorial level. Examples include the Saskatchewan Health Quality Council, Health Quality Ontario, the British Columbia Patient Safety & Quality Council, and the New Brunswick Health Council. The use of financial incentives to improve quality is limited. For example, since 2010, Ontario hospitals have been required to develop and report quality improvement plans, and executive compensation has been linked to the achievement of targets set out in these plans (Government of Ontario, 2010). The federally funded Canadian Patient Safety Institute promotes best practices and develops strategies, standards, and tools. The Optimal Use Projects program, operated by the Canadian Agency for Drugs and Technologies in Health, provides recommendations (though not formal clinical guidelines) to providers and consumers in order to encourage the appropriate prescribing, purchasing, and use of medications. The Canadian Institute for Health Information produces regular reports on health system performance. There is no system of professional revalidation for physicians in Canada, but each province has its own process of ensuring that physicians engage in lifelong learning, such as a requirement that they participate in a continuing education program, and undergo peer review. There is no information available on doctors' performance. Accreditation Canada-a not-for-profit organization-provides voluntary accreditation services to about 1,200 health care organizations across Canada, including regional health authorities, hospitals, long-term care facilities, and community organizations. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001603 OS 00003274 CANADA Organization of the Health System in Canada Ca n adia n Constitution Transfer payments Provincial an d territoria l govern m ent s Regiona l health authorities -- ? - F/P/T Conferences of Ministers and Deputy Ministers of Health and Committees Ministers and Ministries or ~ Departments of Health Federal govern ment Stat ist ics Ca nada Minister of Hea lth Canadian Institut es for Health Researh I L---------------------------------------- , I Mental hea lth and public hea lth providers - Home care and long-term providers Canada Health Act. 1984 Hospital and medica l services providers ? -" Hea lth Canada Public Hea lth Agency of Canada Patented Medicine Prices Review Board '' Provincial and t e rritorial prescription drug programmes ,, L- ---------1---------~------ ---------7-------------------------,-------------------------T-------------------------r-------1 Canadian Agency for Drugs a nd Techno logies in Health (1989) '1 '' I _,'' I Canadian Institute for Health Information (1994) I I I Ca nada Health lnfoway (2001) Canadian BIood Services (1996) Canadian Patient Safety Institute (2003) Note : Solid lines represent direct relations hips of accountability whi le dotted lines indicate more indirect or arm's length relationships. Source: Adapted from G. P. Marchildon, "Canada: Health System Review," Health Systems in Transition, vol . 15, no . 1, 2013, p. 22. Few formal disease registries exist, although many provincial cancer care systems maintain some type of patient registry. Provincial cancer registries feed data to the Canadian Cancer Registry, a national administrative survey that tracks cancer incidence. There is no national patient survey, although a standardized acute-care hospital inpatient survey developed by the Canadian Institute for Health Information has been implemented in several provinces. Each province has its own strategies and programs to address chronic disease (see below). t:" j What is being done to reduce disparities? By signing the Rio Political Declaration on Social Determinants of Health, Canada committed to reducing inequalities in health (Public Health Agency of Canada, 2011). Although no single body is responsible for addressing health disparities, several provincial or territorial governments have departments and agencies devoted to addressing population health and health inequities. Aboriginal health is a concern for federal as well as provincial and territorial governments; recent federal initiatives include the Aboriginal Diabetes Initiative, the National Aboriginal Youth Suicide Prevention Strategy, and the Maternal Child Health Program. The Public Health Agency of Canada includes in its mandate reporting on health disparities, and the Canadian Institute for Health Information also reports on disparities in health care and health outcomes (Canadian Institute for Health Information, 201 Sd). However, no formal and periodic process exists to measure disparities. The Commonwealt h Fund VA-19-0799-D-001604 OS 00003275 CANADA (C)-0- What is being done to promote delivery system integration and )yf care coordination? Provinces and territories have introduced several initiatives to improve integration and coordination of care for chronically ill patients with complex needs. These include Divisions of Family Practice (British Columbia) (Divisions of Family Practice, 2014), the Regulated Health Professions Network (Nova Scotia), and Health Links (Ontario). Also, Ontario has alternative community-based and multidisciplinary primary care models that are funded by the province and serve primarily vulnerable populations; these models include Community Health Centres and Aboriginal Health Access Centres. Also in Ontario, a pilot program that bundles payments across different providers is being expanded (from one to six communities) to improve coordination of care for patients as they transition from hospital to the community (Government of Ontario, 2015). As discussed above, some provinces also have implemented incentives to encourage physicians to provide guideline-based care for chronic disease. In Ontario, for example, Diabetes Education Programs (employing teams of diabetes education nurses and registered dieticians) support individuals and primary care physicians in providing guideline-based diabetes care (Government of Ontario, 201 Sa). Each province determines its own structure for the coordination of health and social care services. In Ontario, for instance, Community Care Access Centres are also responsible for coordinating services for vulnerable populations, particularly the elderly and individuals with disabilities, including health and social care services (e.g., supportive housing and meal delivery programs). In Ontario, there is a single ministry responsible for health and long-term care, with funding devolving to the regional level. ~ What is the status of electronic health records? ~ Uptake of health information technologies has been slowly increasing in recent years. Provinces and territories are responsible for developing their electronic information systems, with support from Canada Health lnfoway; however, there is no national strategy for implementing electronic health records and no national patient identifier. According to Canada Health lnfoway, provinces have systems for collecting data electronically for the majority oftheir populations (Canada Health lnfoway, 2014). Interoperability, however, is limited (Ogilvie and Eggleton, 2012). In 2014, 42 percent of GPs reported using exclusively electronic records to enter and retrieve patient clinical notes, and 38 percent used a combination of paper and electronic charts (National Physician Survey, 2014). In the same survey, 87 percent of GPs report that their patients are not able to access their personal health record for any function, and only 6 percent reported that patients can request appointments online. How are costs contained? Costs are controlled principally through single-payer purchasing, and increases in real spending mainly reflect government investment decisions or budgetary overruns. Cost-control measures include mandatory global budgets for hospitals and regional health authorities, negotiated fee schedules for providers, drug formularies, and resource restrictions vis-a-vis physicians and nurses (e.g., provincial quotas of students admitted annually) as well as restrictions on new investment in capital and technology. The national health technology assessment process is one of the mechanisms for containing the costs of new technologies (see above). The federal Patented Medicine Prices Review Board, an independent, quasi-judicial body, regulates the introductory prices of new patented medications. This measure ensures that prices are not "excessive," on the basis of their "degree of innovation" and by comparison with prices of existing medicines in Canada and in seven other countries, including the United States and the United Kingdom. The board regulates "ex-factory" prices but does not have jurisdiction over wholesale or pharmacy prices, or over pharmacists' professional fees. However, prices of all patented drugs are reviewed regularly, and the board can intervene if price increases are deemed excessive. Since 2010, the Pan-Canadian Pricing Alliance also coordinates, across provinces, negotiations to reduce the prices of branded drugs. Jurisdiction over prices of generics and control over pricing and purchasing under public drug plans (and, in some cases, pricing under private plans) is held by provinces, leading to some interprovincial variation. "Choosing Wisely Canada" is a new publicly funded campaign that International Profiles of Health Care Systems, 2015 VA-19-0799-D-001605 OS 00003276 CANADA provides recommendations to governments, providers, and the public on reducing low-value care (Choosing Wisely Canada, 2015). What major innovations and reforms have been introduced? At the annual meeting of Canada's provincial premiers in July 2015, national health care priorities included pharmaceuticals, appropriateness of care, senior care, and dementia. There has not been a meeting between the first ministers ofthe federal and provincial governments on health care since 2009. In its 2015 election platform, the Liberal Party committed to a CAD3 billion (USD2.4 billion) investment in home care services and proposed a pan-Canadian collaboration to improve access to prescription medication (Liberal Party of Canada, 2015). In 2015, the Canadian government expanded the National Anti-Drug Strategy to include prescription drug abuse. This strategy focuses on reducing the supply of and demand for illicit drugs (Government of Canada, 20156). Also introduced in 2015 was the Protecting Canadians from Unsafe Drugs Act (Vanessa's Law), which strengthens regulation on therapeutic products to promote reporting of adverse reactions by health care institutions (Government of Canada, 2014). Provincial health system governance: Several provinces have reformed or are in the process of reforming their health system governance structures, mostly in an attempt to achieve efficiencies and reduce costs. Quebec is merging 182 Health and Social Centres, which include hospitals, clinics, and long-term care facilities, into just 28 (Assemblee Nationale Quebec, 2015). In April 2015, Nova Scotia passed legislation to consolidate 10 district health authorities into two: the Nova Scotia Health Authority and the IWK Health Centre. The two merged authorities will work together to plan and deliver primary care, community health services, and acute care across the province (Government of Nova Scotia, 2015). The 2015 Newfoundland and Labrador provincial budget announced the consolidation of administrative service for the health care system into one shared services organization. The regional health authorities will remain in place, while the shared services organization will provide them with support for human resources, information technology, telecommunications, marketing, communications, finance, and payroll (Government of Newfoundland Labrador, 2015). The government appointed an implementation team in August 2015. The authors would like to acknowledge Diane Watson as a contributing author to earlier versions of this profile. The Commonwealth Fund VA-19-0799-D-001606 OS 00003277 CANADA References Assemblee Nationale Quebec (2015). Bill No. 10: "An Act to Modify the Organization and Governance of the Health and Social Services Network, in Particular by Abolishing the Regional Agencies." http://www.assnat.qc.ca/en/travauxparlementaires/projets-loi/projet-loi-10-41-1.html. Accessed Aug. 24, 2015. Canada Health lnfoway (2014). Annual Report, 2013-2014. Ottawa: Canada Health lnfoway. https://www.infoway-inforoute. ca/index.php/resources/infoway-corporate/annual-reports. Accessed Oct. 1, 2014. Canada Revenue Agency (2014). "Family Caregiver Amount (FCA)." http://www.cra-arc.gc.ca/familycaregiver/. Accessed Oct. 1, 2014. Canadian Institute for Health Information (2015a). "National Health Expenditure Trends 1975-2015." Ottawa: Canadian Institute for Health Information. Canadian Institute for Health Information (20156). "Supply, Distribution and Migration of Canadian Physicians." Ottawa: Canadian Institute for Health Information. Canadian Institute for Health Information (2015c). "National Physician Database, 2010-2011." Ottawa: Canadian Institute for Health Information. Canadian Institute for Health Information (2015d). "Trends in Income-Related Health Inequalities in Canada." Ottawa: Canadian Institute for Health Information. Canadian Life and Health Insurance Association Inc. (2014). "Canadian Life and Health Insurance Facts." http://clhia.uberflip. com/i/369328-canadian-life-and-health-insurance-facts-2014-edition. Accessed Aug. 27, 2015. Choosing Wisely Canada (2015). "What is CWC?" http://www.choosingwiselycanada.org/about/what-is-cwd. Accessed Nov 1, 2015. Divisions of Family Practice (2014). "Welcome to the Divisions of Family Practice," https://www.divisionsbc.ca/provincial/ home. Accessed Sept. 1, 2014. Goering, P., Wasylenki, D., and Durbin, J. (2000). "Canada's Mental Health System." International Journal of Law and Psychiatry 23(3-4):345-59. Government of Canada (2014). "Protecting Canadians from Unsafe Drugs Act (Vanessa's Law): Questions/Answers." http:// www.hc-sc.gc.ca/dhp-mps/legislation/unsafedrugs-droguesdangereuses-faq-eng.php. Accessed Aug 24, 2015. Government of Canada (2015a). "Federal Support to Provinces and Territories." Ottawa: Department of Finance. http:// www. fin.gc.ca/fedprov/mtp-eng.asp . Accessed Nov. 1, 2015. Government of Canada (20156). "National Anti-Drug Strategy." http://healthycanadians.gc.ca/anti-drug-antidrogue/indexeng.php. Accessed Aug 24, 2015. Government of Ontario (2010) "Excellent Care for All Act, 2010, S.O. 2010, c. 14." http://www.ontario.ca/laws/ statute/1 0e 14. Accessed Aug. 1, 2015. Government of Ontario (2011). "Open Minds, Healthy Minds. Ontario's Comprehensive Mental Health and Addictions Strategy." http://www. hea Ith .gov.on. ca/en/ common/min istry/pu blications/reports/mental_health2011 /mental health_rep2011 . pdf. Accessed Oct. 1, 2014. Government of Ontario (2014). "Health Force Ontario. Family Practice Models." http://www.healthforceontario.ca/en/Home/ Physicians/Training_%7C_Practising_Outside_Ontario/Physician_Roles/Family_Practice_Models. Accessed Oct. 9, 2014. Government of Ontario (2015) "Ontario Funds Bundled Care Teams to Improve Patient Experience" http://news.ontario.ca/ mohltden/2015/09/ontario-funds-bundled-care-teams-to-improve-patient-experience.html. Accessed Sept. 1, 2015 Government of Ontario. (2015a). "Diabetes Education Program." https://www.ontario.ca/page/diabetes-educationprogram?_ga=1.120298504.125010404.1446227826. Accessed Oct. 30, 2015. Government of Manitoba (2015). "QuickCare Clinic." http://www.gov.mb.ca/health/primarycare/publidaccess/quickcare. html. Accessed Aug. 25, 2015. Government of Newfoundland Labrador (2015). "Innovative Approaches to Effective Health Care Delivery: Minister Announced Implementation Team for New Health Shared Services Organization." http://www.releases.gov.nl.ca/ releases/2015/health/0806n02.aspx. Accessed Aug. 24, 2015. Government of Nova Scotia (2015). "Nova Scotia Health Authority." http://novascotia.ca/dhw/about/nova-scotia-healthauthority.asp. Accessed Dec. 2, 2015. Grignon, M., and N. F. Bernier (2012). Financing Long-Term Care in Canada. Canada: Institute for Research on Public Policy (IRPP). Health Canada (2013a). Canada Health Act Annual Report 2012-2013. Ottawa: Minister of Health of Canada, http://www. hc-sc.gc.ca/hcs-sss/pubs/cha-lcs/2013-cha-lcs-ar-ra/index-eng.php. Accessed Oct. 1, 2014. Health Canada (20136). "Provincial and Territorial Home Care Programs: A Synthesis for Canada." http://www.hc-sc.gc.ca/ hcs-sss/pubs/home-domicile/1999-pt-synthes/index-eng.php. Accessed Oct. 9, 2014. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001607 OS 00003278 CANADA Health Council of Canada (2013). "How Do Canadian Primary Care Physicians Rate the Health System? Survey Results from the 2012 Commonwealth Fund International Survey of Primary Care Doctors." Toronto: Health Council of Canada. Henry, D. A., S. E. Schultz, R. H. Glazier, R. S. Bhatia, I. A. Dhalla, and A. Laupacis (2012). "Payments to Ontario Physicians from Ministry of Health and Long-Term Care Sources 1992/93 to 2009/10." Toronto: Institute for Clinical Evaluative Sciences. Liberal Party of Canada. (2015). "A New Plan for a Strong Middle Class." https://www.liberal.ca/realchange/. Accessed Oct. 30, 2015. Marchildon, G. P. (2013). Canada: Health System Review. Copenhagen: WHO Regional Office for Europe on Behalf of the European Observatory on Health Systems and Policies. National Physician Survey, 2014. The College of Family Physicians of Canada, Canadian Medical Association, The Royal College of Physicians and Surgeons of Canada. http://nationalphysiciansurvey.ca/wp-content/uploads/2014/11 /2014National-EN.pdf. Accessed Aug 1, 2015. Ogilvie, K. K., and Eggleton, A. (2012). Time for Transformative Change: A Review of the 2004 Health Accord. Ottawa, Ontario: The Standing Senate Committee on Social Affairs, Science and Technology. Ontario Ministry of Health and Long-Term Care (MOHLTC) (2011). Info Bulletin. http://www.health.gov.on.ca/en/pro/ programs/ohip/bulletins/11000/bul11020.pdfhttp://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/11000/bul11020. pdf. Access Oct. 30, 2015. Ontario Ministry of Health and Long-Term Care (MOHLTC) (2014). "Hospitals. Questions and Answers." http://www.health. gov.on.ca/ en/common/system/services/hosp/faq.aspx. Accessed Oct. 1, 2014. Ontario Ministry of Health and Long-Term Care (MOHLTC) (2009). "Guide to Physician Compensation." http://www.health. gov.on.ca/en/pro/programs/fht/docs/fht_compensation.pdf (Accessed Aug. 30, 2015). Organization for Economic Cooperation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787 /data-00285-en. Accessed July 2, 2015. Organization for Economic Cooperation and Development (OECD) (2014). "Health Data, 2014." Paris: OECD. Organization for Economic Cooperation and Development (OECD) (2011). "Long-Term Care." Paris: OECD. Public Health Agency of Canada (2011). "Reducing Health Inequalities: A Challenge for Our Times." Ottawa: Public Health Agency of Canada. Rudoler, D., A. Laporte, J. Barnsely, R. H. Glazier, and R. B. Deber (2014). "Paying for Primary Care: A Cross-Sectional Analysis of Cost and Morbidity Distributions Across Primary Care Payment Models in Ontario, Canada" (unpublished manuscript). Institute of Health Policy, Management and Evaluation, University of Toronto. Statistics Canada. (2011). "Residential Care Facilities: 2009/10." Ottawa: Statistics Canada Catalogue, no.83-237-X. http:// www.statcan.gc.ca/pub/83-237-x/83-237-x2012001-eng.pdf. Accessed Aug. 29, 2015. Stukel, T., R. H. Glazier, S. E. Schultz, J. Guan, B. M. Zagorski, P. Gozdyra, and D. A. Henry (2013). "Multispecialty Physician Networks in Ontario." Open Medicine 7:2. Sutherland, J.M., R. T. Crump, N. Repin, and E. Hellsten (2013). "Paying for Hospital Services: A Hard Look at the Options." Toronto: C. D. Howe Institute. Sutherland, J. M., N. Repin, and R. T. Crump (20136). "The Alberta Health Services Patient/Care-Based Funding Model for Long-Term Care: A Review and Analysis." British Columbia: Centre for Health Services and Policy Research. Sweetman, A., and G. Buckley (2014). "Ontario's Experiment with Primary Care Reform." The University of Calgary School of Public Policy Research Papers 7(11 ):1-37. http://www.policyschool.ucalgary.ca/sites/default/files/research/ontario-health-carereform.pdf. Accessed Oct. 10, 2014. The Commonwealth Fund VA-19-0799-D-001608 OS 00003279 ifMa ~ Pp:: What is the role of government? In China, the central government has overall responsibility for national health legislation, policy, and administration. It is guided by the principle that every citizen is entitled to receive basic health care services, with local governments-provinces, prefectures, cities, counties, and towns-responsible for providing them according to local circumstances. Health authorities include the National Health and Family Planning Commission and the local Health and Family Planning Commissions (or Bureaus of Health, if they have not been merged with local Family Planning Commissions), which have primary responsibility for organizing and delivering health care and supervising providers (mainly hospitals). Health authorities at the prefectures/city, county, and town levels have limited flexibility in carrying out provincial health policies. Who is covered and how is insurance financed? Generally, health insurance is publicly provided and financed by local governments. Publicly financed health insurance: In 2013, China spent approximately 5.6 percent of its gross domestic product (CNY3, 187B, or USD871 B) on health care, with 30 percent financed by local governments and 36 percent by publicly financed health insurance, private health insurance, or social health donations (National Health and Family Planning Commission, 2014). There were three main types of publicly financed insurance: 1) urban employment-based basic insurance (launched in 1998); 2) urban resident basic insurance (launched in 2009); and 3) the new cooperative medical scheme for rural residents (launched in 2003). Urban employment-based basic insurance is mainly financed from employee and employer payroll taxes, with minimal government funding. Participation is mandatory for employees in urban areas; the insured population was 274.2 million in 2013 (National Health and Family Planning Commission, 2014). Employees' nonemployed family members are not covered. Urban resident basic insurance, which is voluntary at the household level, covered 299 million self-employed individuals, children, students, and elderly adults in 2013. Both urban employment-based and urban resident insurance are administered by the Ministry of Human Resources and Social Security and run by local authorities. The new cooperative medical scheme, mainly administered by the National Health and Family Planning Commission and run by local authorities, is also voluntary at the household level and covered a rural population of 802 million in 2013, representing a coverage rate of 98. 7 percent. Urban resident basic insurance and the new cooperative medical scheme are mainly government financed. In regions where the economy is less developed, the central government provides the largest share of subsides, with provincial and prefectural governments providing the rest. In more-developed provinces, most government subsidies are locally provided (mainly provincial). Coverage of publicly financed health insurance is nearuniversal-exceeding 95 percent of the population since 2011 (Jiang and Ma, 2015). The few permanent foreign residents are entitled to the same coverage benefits as citizens. Undocumented immigrants (there are very few) and visitors are not covered by publicly financed health insurance. 1 Please note that, throughout this profile, all figures in USD were converted from CNY at a rate of about CNY3.66 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for China. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001609 OS 00003280 CHINA Private health insurance: Complementary private health insurance is purchased to cover deductibles, copayments, and other cost-sharing, as well as coverage gaps, in publicly financed health insurance, which serves as the primary coverage source for most people. Private coverage is provided mainly by for-profit companies. In 2014, total premiums collected amounted to CNY158.7B (USD43.4B), an increase of 45 percent compared to the prior year, and represents approximately 10 percent of total (public and private) health insurance spending (Zhao et al., 2015; Liu, 2015). ~ Purchased primarily by higher-income individuals and by employers for their workers, private insurance often enables people to receive better quality of care and higher reimbursement, as some health services are very expensive or not covered by public insurance. There are currently no statistics on the percentage of the population with private coverage, but the Chinese government is encouraging development of this market. Growth in private coverage has been rapid, with some foreign insurance companies recently entering the market. What is covered? Services: Publicly financed insurance covers primary, specialist, emergency department, hospital, and mental health care, as well as prescription drugs, and traditional medicine. A few dental services (e.g., tooth extraction, but not cleaning) and optometry services are covered, but mostly they are paid for completely out-of-pocket. Home care and hospice care are often not included either. Local health authorities define the benefits package. Preventive services such as immunization and disease screening are included in a separate public-health benefits package funded by central and local government; every citizen and migrant is entitled to these without copayments or deductibles. Coverage is person-specific; there are no family or household benefit arrangements. Cost-sharing and out-of-pocket spending: Inpatient and outpatient care, including prescription drugs, is subject to different deductibles, copayments, and reimbursement ceilings. There are no annual caps on out-of-pocket spending. In 2013, out-of-pocket spending per capita was CNY2,327 (USD636) to CNY3,234 (USD886) and CNY1 ,274 (USD348) in urban and rural areas, respectively-representing about 34 percent oftotal health expenditures (National Health and Family Planning Commission, 2014). Most out-of-pocket spending is for prescription drugs. Reimbursement ceilings are significantly lower for outpatient care than for inpatient care. For example, in 2013, ceilings were CNY3,000 (USD820) for outpatient care and CNY180,000 (USD49, 180) for inpatient care in the rural new cooperative medical scheme in Beijing. Provider networks are specific to the insurance scheme, normally at the prefecture-level for urban employmentbased basic health insurance and urban resident basic health insurance (which may share the same network, but with different benefits) and at the county-level for new cooperative medical scheme. People can use out-ofnetwork health services (even across provinces), but these have higher copayments. There are no universal cost-sharing arrangements, and each risk-pooling unit (network) has its own policies. Cost-sharing in primary care facilities (village clinics, rural township hospitals, and urban community hospitals) and secondary/tertiary hospitals is also different, with the lowest copayments in the former. Secondary and tertiary hospitals are accredited by the local health authorities based on their qualifications, and both provide primary care, outpatient specialists, and inpatient hospital care. Migrant populations face much higher cost-sharing and out-of-pocket spending, since they often use care out-of-network. Fee schedules for primary and secondary care are regulated by the local health authorities and the Bureaus of Commodity Prices, and it is unlawful to charge patients above the fee schedules. Safety net: For individuals who are not able to afford individual premiums for publicly financed health insurance or out-of-pocket spending (which is not capped), a medical financial assistance program, funded by local governments and social donations, serves as safety net in both urban and rural areas. In Beijing, the individual poverty level in 2015 was defined as CNY670 (USD183) per month in rural areas and CNY710 (USD194) in urban areas; poverty levels for other provinces may be lower than Beijing. Medical financial assistance programs prioritize inpatient care expenses. Funds are mainly used to pay for individual deductibles, copayments, and The Commonwealth Fund VA-19-0799-D-001610 OS 00003281 CHINA medical spending exceeding annual caps, as well as individual premiums for publicly financed health insurance. In 2013, 63.6 million people (approximately 5% ofthe Chinese population) received such assistance for health insurance enrollment, and 21.3 million people (1.6% of the population) received funds for direct health expenses (China National Health and Family Planning Commission, 2014). There are other financial assistance programs to help with unreimbursed emergency department expenses and other health expenses. Mostly these are funded by local governments. [ (R)] How is the delivery system organized and financed? Primary care: Primary care is delivered mainly through village doctors and health workers in rural clinics, general practitioners (GPs) in rural township and urban community hospitals, and secondary and tertiary hospitals. Village doctors, who are not licensed GPs, can work only in village clinics. In 2013, there were 1.08 million village doctors and health workers (National Health and Family Planning Commission, 2014). Although rural patients are encouraged to seek care in village clinics or township hospitals and urban patients in community hospitals-as such providers are associated with lower cost-sharing rates-residents can also see any GP in upper-level hospitals directly. Registration with a GP is not required and, except for the very few areas that use GPs as gatekeepers, referrals are generally not necessary to see outpatient specialists. In 2013, China had 194,310 licensed and assistant GPs (including preventive medicine), representing only 8.5 percent of all licensed physicians and assistant physicians (National Health and Family Planning Commission, 2014). Except for village doctors and health workers in the village clinics, GPs rarely practice solo or through partnership but instead work in a hospital with nurses and nonphysician clinicians. Village clinics in rural areas receive technical support from township hospitals. Fee schedules for primary care are regulated by local health authorities and the Bureaus of Commodity Prices. Village doctors and health workers in the village clinics receive income through reimbursement of public health services (e.g., immunizations and chronic disease screening) and clinical services, as well as through markups of prescription drugs and government subsidies. Incomes vary substantially by region. GPs at hospitals receive a base salary along with activity-based payments (e.g., patient registration fees, surgeries performed). With fee-for-service still the dominant payment mechanism for hospitals (see below), hospital-based physicians have strong financial incentives to induce demand. It is estimated that wages constitute only one-quarter of physician incomes; the rest is thought to be derived from practice activities. In 2013, 48 percent of outpatient revenues and 39 percent of inpatient revenues were from prescription drugs provided to patients in tertiary hospitals (National Health and Family Planning Commission, 2014). Care coordination is generally not incentivized. Outpatient specialist care: Outpatient specialists are employed by and usually work in hospitals, through which they obtain their practice licenses. Although practicing in multiple settings is being introduced in China, most specialists practice in one hospital only. They receive compensation in the form of base salary and activity-based payments from hospitals. Patients can usually see outpatient specialists without GP referral. Administrative mechanisms for direct patient payments to providers: Patients pay deductibles and copayments to hospitals at the point of service. Hospitals directly bill insurers the covered payment at the same time if the payment mechanism is fee-for-service or a diagnosis-related group (DRG) system. Hospitals receive annual lump-sum payments under global budgets or capitation. After-hours care: Because village doctors and health workers often live in the same community as patients, they voluntarily provide some after-hours care when needed. Rural township hospitals and urban secondary and tertiary hospitals have emergency rooms or departments (EDs) where both primary care doctors and specialists are available, minimizing need for walk-in after-hours care centers. In EDs, nurse triage is not required and there are few other restrictions, so people can simply walk in and register for care at any time. (Urban community hospitals often do not provide after-hours care, given the availability of secondary and tertiary hospitals.) ED use International Profiles of Health Care Systems, 2015 VA-19-0799-D-001611 OS 00003282 CHINA is not substantially more expensive than usual care for patients. Information on patients' emergency visits is not routinely sent to their primary care doctors. Hospitals: Hospitals can be public or private, nonprofit or for-profit. Most township hospitals and community hospitals are public, but both public and private secondary and tertiary hospitals exist in urban areas. Rural township hospitals and urban community hospitals are often regarded as primary care facilities, similar to village clinics rather than 'true' hospitals. In 2013, there were 13,396 public hospitals and 11,313 private hospitals (excluding township hospitals and community hospitals), of which 17,269 were not-for-profit and 7,440 were for-profit (National Health and Family Planning Commission, 2014). In 2013, there were 487,802 public primary care facilities and 427,566 private village clinics (National Health and Family Planning Commission, 2014). Hospitals are paid through a combination of out-of-pocket payments, health insurance compensation, and, in the case of public hospitals, government subsidies-the latter representing 13.5 percent of total revenue in 2013 (National Health and Family Planning Commission, 2014). A significant number of patients pay 100 percent out-of-pocket, because they receive out-of-network services. Although fee-for-service is dominant, DRGs, capitation, and global budgets are becoming more popular in selected areas. Local health authorities set fee schedules, and doctor salaries and other payments are included in hospital reimbursement. Mental health care: Mental health care, including disease diagnosis, treatment, and rehabilitation services, is provided in special psychiatric hospitals and psychological departments oftertiary hospitals. Patients with mild illness are often treated at home or in the community; only severe mentally ill patients are treated in psychiatric hospitals. Both outpatient and inpatient mental health services are covered by insurance, with benefits subject to lower copayment rates. In 2013, there were 28 million mental health patient visits to special psychiatric hospitals, and on average one psychiatrist treated 4.6 patients per day (National Health and Family Planning Commission, 2014). Mental health is not integrated with primary care. Long-term care and social supports: In accordance with Chinese tradition, long-term care is provided mainly by family members at home. There are very few formal long-term care providers. Family caregivers are not entitled to financial support or tax benefits, and long-term care insurance is virtually nonexistent; expenses for care in long-term care facilities are paid almost entirely out-of-pocket. Government may provide some subsidies to long-term care facilities. On average, conditions in long-term care facilities are poor, and there are long waiting lists for enrollment in high-end facilities. Formal long-term care facilities usually provide only housekeeping, meals, and basic services like transportation, but very few health care services. Some long-term care facilities may coordinate health care with local township or community hospitals, however. There were 4.94 million beds for aged and disabled people in 2013 (National Bureau of Statistics, 2014). Some hospice care is available, but it is normally not covered by health insurance (Chen, 2014). &h What are the key entities for health system governance? In 2013, the Ministry of Health and the National Population and Family Planning Commission were merged into the National Health and Family Planning Commission as the main agency for health controlled by the State Council (central government). The State Administration of Traditional Chinese Medicine is affiliated with the new Commission. The National People's Congress is responsible for health legislation. However, major health policies and reforms may be initiated by the State Council and the Central Committee of the Communist Party as well, and these are also regarded as law. The National Development and Reform Commission, which has been heavily involved in the recent health care system reform, oversees health infrastructure plans and competition among health care providers. The Ministry of Finance provides funding to government health subsidies, health insurance contributions, and health system infrastructure. The Ministry of Human Resource and Social Security runs urban employment-based basic insurance and urban resident basic insurance. The China Food and Drug Administration is responsible for drug approvals and licenses, but health technology assessment or cost-effectiveness have not played a significant role yet. The China Center for Disease Control and Prevention is administrated by the National Health and The Commonwealth Fund VA-19-0799-D-001612 OS 00003283 CHINA Family Planning Commission, though it is not a government agency. The Chinese Academy of Medical Science, under the National Health and Family Planning Commission, is the national center for health research. The National Health and Family Planning Commission directly owns some hospitals in Beijing, and national universities directly administrated by the Ministry of Education also own affiliated hospitals. Local government health agencies, usually the Bureau of Health or Health and Family Planning Commission in each province, may have a similar structure and often own provincial hospitals. Local governments (for prefectures, counties, and towns) may have departments of health and own hospitals directly. Centers for Disease Control and Prevention also exist in local areas and are administered by the local bureaus or departments of health. At the national level, the China Center for Disease Control and Prevention provides technical support to the local centers only. Both national and local Health and Family Planning Commissions have comprehensive responsibilities for health quality and safety, cost control, provider fee schedules, health information technology, and clinical guidelines. ~ What are the major strategies to ensure quality of care? The Department of Health Care Quality within the Bureau of Health Politics and Hospital Administration and overseen by the National Health and Family Planning Commission is responsible for quality of care at the national level. The National Health Service Survey is conducted every five years (the latest in 2013), and a report is published after each survey highlighting data on selected quality indicators. Hospitals must obtain licenses from local health authorities for hospital accreditation. Physicians get their practice licenses through hospitals, and they have to renew their licenses after a certain period. Several national hospital rankings are available from third parties too, but there are no financial incentives for hospitals to meet quality targets (Dong et al., 2015). Following release of the "Temporary Directing Principles of Clinical Pathway Management" by the former Ministry of Health in 2009, clinical pathways are now regulated nationally and used in a similar manner as clinical guidelines are in Western countries. Previously, pathways were created at the hospital, rather than national, level. t::" j What is being done to reduce disparities? There are still severe disparities in accessibility and quality of health care, although China has made significant improvements in the past decade. Income-related disparities in health care access were serious before the reform of the health insurance system more than 10 years ago, as most people did not have any coverage at all. Today, publicly financed insurance coverage is now nearly universal and there are safety nets for the poor (see above); as a result, income-related disparities have been reduced substantially. Remaining disparities in access are mainly because of variation in insurance benefit packages, urban and rural factors, and income inequality. Urban employment-based basic insurance offers broader benefit packages than the other two insurance schemes. To improve benefit packages and reduce disparities, central and local governments intend to consolidate insurance schemes, an effort that has already been piloted in selected areas, such as Dongying City in Shandong Province and Jinhua City in Zhejiang Province. In addition, central and local government subsidies to urban resident basic insurance and the rural newly cooperative medical scheme have increased in recent years. Most good hospitals (particularly tertiary hospitals) are located in urban areas, where there are better-qualified health professionals. Village doctors are often undertrained. To help bridge the urban-rural health care divide, the central government and local governments sponsor training for rural doctors in urban hospitals and require new medical graduates to work as residents in rural health facilities. Nevertheless, the China Health and Family Planning Statistical Yearbooks show that substantial disparities remain. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001613 OS 00003284 CHINA Organization of the Health System in China [ China People's Congress ] [ ~I Central Committee of Communist Party of China ] L State Council ,I i i i i Ministry of Human Resource and Social Security National Development and Reform Commission National Health and Family Planning Commission l r i i i China Food and Drug Administration Ministry of Finance Ministry of Education ,. ,Ir General Administration of Quality Supervision, Inspection, and Quarantine Urban Employmentbased Health Insurance and Urban Resident -lealth Insurance National Universities ,,, State Administration of Traditional Chinese Medicine ,, Provincial Governments " i i Rural Newly Cooperative Medical Scheme Hospitals Chinese Academy of Medical Science [ "' China CDC ] ,Ir ] Hospitals " Bureau of Health Politics and Hospital Administration ,, A similar government structure to that at the national level Department of Health Care Quality Source: Hai Fang, Peki ng University, 2015 . 0~ What is being done to promote delivery system integration and "-.:::,I care coordination? 0 Medical alliances are regional hospitals groups, often including one tertiary hospital and several secondary hospitals and primary care facilities, that provide access to primary care facilities for patients with minor health issues. The aim is to reduce the need for people to visit tertiary hospitals. At the same time, patients with serious health problems can be referred to tertiary hospitals easily and moved back to primary care facilities after their condition improves. It is hoped that this type of care coordination will meet demand for chronic The Commonwealt h Fund VA-19-0799-D-001614 OS 00003285 CHINA disease care, improve health care quality, and contain rising costs. Hospitals in the same medical alliance use the same electronic health record system, and results of labs, images, and diagnoses can be shared easily within the alliance. There are three main medical alliance models (Jiang et al., 2014). Hospitals in the Zhenjiang model have only one owner (usually the local bureau of health). Those in the Wuhan model do not belong to the same owner, but administration and finances are all handled by one tertiary hospital. Hospitals in the Shanghai model share management and technical skills only; ownership and financial responsibility are separate. ~ What is the status of electronic health records? Nearly every health care provider has set up its own electronic health record (EHR) system. Within hospitals, EH Rs are also linked to the health insurance systems for payment of claims with unique patient identifiers (citizenship ID). However, EHR systems vary significantly by hospital and are usually not integrated or interoperable. Patients often have to bring with them a printed health record if they would like to see doctors in different hospitals. Even if hospitals are owned by the same local bureau of health or universities in the same region, different EHR systems may be used. Patients generally do not use EHR systems for accessing information, appointment scheduling, secure messaging, prescription refills, or accessing doctors' notes. ~ How are costs contained? Health expenditures have risen significantly in recent decades as a result of health insurance reform, population aging, economic development, and health technology advances. Health expenditures increased from CNY510 (USD139) per capita in 2003 to CNY3,234 (USD884) in 2013 (China National Health and Family Planning Commission, 2014). The key cost-containment strategy is reform of provider payment. Prior to the recent introduction of DRGs, global budgets, and capitation in 2009, fee-for-service was the main provider payment mechanism and consumer- and physician-induced demand increased costs significantly. Global budgets in particular have been used in many regions, since these are relatively easy for authorities to implement. As noted above, government encourages use of community and township hospitals over more expensive care provided in tertiary hospitals. Hospitals compete on the basis of quality, level of technology, and copayment rates. In township, community, and county hospitals, a campaign of "zero markups" for prescription drugs was introduced in 2013 (see below).The National Development and Reform Commission places stringent supply constraints on new hospital buildings and hospital beds, and the National Health and Family Planning Commission controls the purchase of high-tech equipment such as MRI scanners. Q ~ What major innovations and reforms have been introduced? Sales of prescription drugs have been a major revenue source for hospitals, which are allowed a 15 percent markup, and providers have strong financial incentives to induce demand for more and expensive drugs. Prices for services, on the other hand, are rather low, in accordance with traditional health practice in China. However, as of 2015, 3,077 public county hospitals and 446 public city hospitals were participating in a governmentfinanced pilot program to eliminate markup of prescription drug prices. At the same time, 224 prefectures and cities in 21 provinces adjusted prices of health care services upward to reflect true costs. The zero-markup policy has been found to have significantly reduced total medical spending (Fu and Yang, 2013). Another important health reform was the introduction in 2015 of special health insurance for severe diseases, such as cancers, kidney disease, and acute myocardial infarction (AMI), which supplements the regular publicly financed schemes. Severe-disease health insurance provides reimbursement beyond the rather low reimbursement ceilings. It is also mostly publicly financed, particularly for urban resident basic insurance and the rural new cooperative medical scheme, and administrated by local health authorities. However, private commercial health insurance companies, given their experience in providing complementary insurance, are heavily involved as well. By 2017, severe-disease insurance is expected to be available throughout China. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001615 OS 00003286 CHINA References Chen, X. (2014). "Hospice Care: Pass Away with Warmth." China Social Protection, 12:64-65. Dong, S., S. Guo, L. He, M. Liang (2015). "Study of Present Situation and Countermeasures of China's Hospital Rankings." Chinese Hospital Management, 35(3):38-40. Fu, C., and J. Yang. (2013). "Influence of Carrying Out Zero Price Addition Policy of Drugs on Public Hospital Expenses in Shenzhen." Chinese Hospital Management, 33(2):4-6. Jiang, C., J. Ma. (2015). Analyzing the role of overall basic medical insurance in the process of universal health coverage. Chinese Health Service Management 2(320):108-10. Jiang, L., S. Song, W. Guo (2014). "Study on the Models and Development Status of Regional Longitudinal Medical Alliance in China." Medicine and Society 27(5):35-38. Liu, Y. 2015. "Development Opportunities and Challenges of Commercial Health Insurance in China." Foreign Business and Trade, 4(250):51-54. National Bureau of Statistics (2014). China Statistical Yearbook 2014. China Statistics Press, Beijing. National Health and Family Planning Commission (2014). China Health and Family Planning Statistical Yearbook 2014. China Union Medical University Press, Beijing. Organisation for Economic Co-operation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787/data-00285-en. Accessed Sept. 17, 2015. Zhao, D., S. He, R. Zhang, B. Sun, Y. Chen (2015). "Analysis on Commercial Health Insurance Among Stakeholders in China." Health Economics Research, 5(337):37-39. The Commonwealth Fund VA-19-0799-D-001616 OS 00003287 ~ ~ What is the role of government? Universal access to health care is the underlying principle inscribed in Denmark's Health Law, which sets out the government's obligation to promote population health and prevent and treat illness, suffering, and functional limitations. Other core principles include high quality; easy and equal access to care; service integration; choice; transparency; access to information; and short waiting times for care. The law also assigns responsibility to regions and municipalities for delivering health services. The national government sets the regulatory framework for health services and is in charge of general planning and supervision. Five administrative regions governed by democratically elected councils are responsible for the planning and delivery of specialized services, but also have tasks related to specialized social care and coordination. The regions own, manage, and finance hospitals and the majority of services delivered by general practitioners (GPs), office-based specialists, physiotherapists, dentists, and pharmacists. Municipalities are responsible for financing and delivering nursing home care, home nurses, health visitors, some dental services, school health services, home help, and treatment for drug and alcohol abuse. Municipalities are also responsible for general prevention and rehabilitation tasks; the regions are responsible for specialized rehabilitation. Pft: Who is covered and how is insurance financed? Publicly financed health care: Public expenditures in 2013 accounted for 84 percent of total health spending, representing 10.4 percent of GDP in 2013 (OECD, 201 Sa). It should be noted, however, that Danish cost reporting with regard to the "gray zone" of long-term care tends to include more activities (services) than reporting requirements do in many other member countries of the Organisation for Economic Co-operation and Development (OECD) (S0gaard 2014). All registered Danish residents are automatically entitled to publicly financed health care, which is largely free at the point of use. In principle, undocumented immigrants and visitors are not covered, but a voluntary, privately funded initiative by Danish doctors, supported by the Danish Red Cross and Danish Refugee Aid, provides this population with access to care. Health care is financed mainly through a national health tax, set at 8 percent of taxable income. Revenues are allocated to regions and municipalities, mostly as block grants, with amounts adjusted for demographic and social differences; these grants finance 77 percent of regional activities. A minor portion of state funding for regional and municipal services is activity-based or tied to specific priority areas, usually defined in the annual economic agreements between the national government and the municipalities or regions. The remaining 20 percent of financing for regional services comes from municipal activity-based payments, which are financed through a combination of local taxes and block grants. Private health insurance: Complementary voluntary insurance, purchased on an individual basis, covers statutory copayments-mainly for pharmaceuticals and dental care-and services not fully covered by the state (e.g., physiotherapy). Some 2.2 million Danes have such coverage, which is provided almost exclusively by the not-for-profit organization Danmark (Sygeforsikringen "Danmark," 2014). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001617 OS 00003288 DENMARK In addition, nearly 1.5 million people hold supplementary insurance to gain expanded access to private providers (CEPOS, 2014). Policies are purchased mostly from among seven for-profit insurers and are provided mainly through private employers as a fringe benefit, although some public-sector employees are also covered. Students, pensioners, the unemployed, and others outside the job market are generally not covered by supplementary insurance. Private expenditures accounted for nearly 16 percent of health care spending in 2013, and private insurance accounted for about 12 percent of total private expenditures (OECD, 2015a). ?1 What is covered? Services: Publicly financed health care covers all primary, specialist, hospital, and preventive care, as well as mental health and long-term care services. Dental services are fully covered for children under age 18. Outpatient prescription drugs, adult dental care, physiotherapy, and optometry services are subsidized. Home care and hospice care are organized and financed by the regions as described below. Decisions about levels of service and new medical treatments are made by the regions, within a framework of national laws, agreements, guidelines, and standards. Municipalities decide on the service level for most other welfare services. There is no defined benefits package, but very few restrictions exist for treatments that are evidence-based and clinically proven. Cost-sharing: There is no cost-sharing for hospital and primary care services. Cost-sharing is applied to dental care for those age 18 and older (coinsurance of 35% to 60% oftotal cost), outpatient prescriptions, and corrective lenses. Out-of-pocket payments represented 12.4 percent oftota I hea Ith expenditures in 2013 (OECD 2014), covering mostly outpatient drugs, corrective lenses, hearing aids, and doctor and dental care. Patients with outpatient drug expenses of more than 3,045 DKK (USD394) per year receive the highest reimbursement rate-85 percent. 1 Private specialists, hospitals, and dentists are free to set their own fees for patients not covered by public funding. Safety net: There are cost-sharing caps for children, and municipalities provide means-tested social assistance to older people. If personal assets are DKK77,500 (USD10,217) or less, 85 percent of all prescription drug costs are covered. Chronically ill people with high drug usage and costs can apply for full reimbursement above an annual out-of-pocket ceiling of DKK3,775 (USD498). The terminally ill also can apply for full coverage of prescriptions. Municipalities may grant financial assistance to individuals certified as otherwise unable to pay for needed medicine. [ (R)] How is the delivery system organized and financed? Primary care: Around 22 percent of all doctors work in general practice. All general practitioners (GPs) are selfemployed and paid by the regions via capitation (about 30% of income) and fee-for-service (70% of income). Rates are set through national agreements with the doctors' associations. Service-based fees are used as financial incentives to prioritize services. National fees are paid per consultation, whether for office visits, e-consults, or home visits. The average income for a GP was DKK1 .1 M (USD145,000) in 2011. The average salary for senior hospital doctors was DKK1 M (USD132,000) (Danske Regioner, 2012). The practice structure is gradually shifting from solo to group practices, typically consisting of two to four GPs and two to three nurses (Danske Regioner, 2007). The number of nurses employed has increased in the past decade; they are paid by the practice and have gradually assumed responsibility for such tasks as blood 1 Please note that throughout this profile, all figures in USD were converted from DKK at a rate of about DKK7.59 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (20156) for Denmark. The Commonwealth Fund VA-19-0799-D-001618 OS 00003289 DENMARK sampling and vaccination. Co location of various clinicians is also on the rise, with GPs, physiotherapists, and office-based specialists operating out of the same facilities but under separate management. Anyone who chooses the "group 1" coverage option (98% of the population), under which GPs act as gatekeepers for secondary care, is required to register with a GP. People can register with any available local GP. "Group 2" coverage provides free choice of GP and access to practicing specialists without referral, though a copayment is required. Under both groups, access to hospitals requires referral. Outpatient specialist care: Outpatient specialist care is delivered through hospital-based ambulatory clinics (fully integrated and funded, as are other public hospital services) or by self-employed specialists in privately owned facilities. Private self-employed specialists can be full-time or part-time; full-timers may not have other full-time jobs. Part-timers also may work in the hospital sector, subject to codes of conduct, with their activity level monitored and their incomes limited by the regions. Practices may be colocated but normally do not operate in formal multispecialty groups. Services from self-employed private providers are paid by the regions on a fee-for-service basis for referred public patients. Fees are set through negotiations with the regions and are based on regional priorities and resource assessments. Private specialists and hospitals also receive patients paying out-of-pocket or covered by voluntary insurance. As a result of legislation initially introduced in 2013 guaranteeing patients the right to diagnostic assessment within 30 days of referral, private practitioners also may receive patients referred from public-sector providers; they are paid for these services through specific agreements with the regions. Patients have a choice of private outpatient specialists upon referral (group 1) or without referral (group 2). Administrative mechanisms for direct patient payments to providers: There is no out-of-pocket payment for medical services for patients in group 1. Primary care doctors and specialists are paid directly by the regions when registering provision of services electronically. Group 2 patients make a copayment to supplement the automatic payment (Strandberg-Larsen et al., 2007). After-hours care: After-hours care is organized by the regions, mainly by agreement with GPs on a collective basis. The Copenhagen region employs staff including specialized nurses, who do the initial screening of calls. GPs can volunteer to take on more or less responsibility within this scheme, and receive a higher rate of payment for after-hours than for normal care. Capitation does not apply to after-hours care. The first line of contact is a regional telephone service, with a GP (or a nurse, in the Copenhagen region) deciding whether to refer the patient for a home visit or to an after-hours clinic, which is usually colocated with a hospital emergency department. Information on patient visits is sent routinely to GPs. There are walk-in emergency units in larger hospitals. Hospitals: Approximately 97 percent of hospital beds are publicly owned. Regions decide on budgeting mechanisms, generally using a combination of fixed-budget and activity-based funding based on diagnosisrelated groups (DRGs), where the fixed budget makes up the bulk of the funding (although significant fluctuations occur among specialties and hospitals). DRG rates are calculated by the Ministry of Health at the national level based on average costs. Activity-based funding is usually combined with target levels of activity and declining rates of payment to control expenditure. This strategy succeeded in increasing activity and productivity by an average of 5 percent annually from 2009 to 2011 and by 1.4 percent from 2011 to 2012 (Danske Regioner, 2015). Bundled payments are not yet used extensively. Hospital physicians are salaried and employed by regional hospitals, which bear the attendant costs, as are other health care professionals in hospitals and in most municipal health services. Patients can choose among public hospitals upon referral, and payment follows the patient to the receiving hospital if it is located in another region. Physicians at public hospitals are not allowed to see private patients within the hospital. Mental health care: There is no cost-sharing for inpatient psychiatric care, but there is some cost-sharing (which may be covered by voluntary health insurance) for psychologists in private practice. Some general practitioners offer specific therapeutic consultations, but their main role is early detection and referral. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001619 OS 00003290 DENMARK Social psychiatry and care are a responsibility of the municipalities, which can choose to contract with a combination of private and public service providers, but most providers are public and salaried. A right to diagnostic assessment for psychiatry within one month of referral was introduced in 2014. Treatment must be commenced within two months for less serious conditions and one month for more serious conditions. There are walk-in units for acute psychiatric care in all regions. Long-term care: Responsibility for chronic care is shared between regional hospitals, general practitioners, and providers of municipal institutional and home-based services. Hospital-based ambulatory chronic care is financed in the same way as other hospital services. Long-term care outside of hospitals is needs-based, and is organized and funded by municipalities. Most municipal long-term care is provided at home, in line with a policy initiative to allow people to remain at home as long as possible. Home nursing is fully funded after medical referral. Permanent home care is free of charge, while temporary home care can be subject to costsharing ifthe recipient's income is above DKK143,300 (USD18,890) for single individuals and DKK215,300 (USD28,380) for couples (Frederiksberg Kommune, 2015). Municipalities are obliged to organize markets with open access for both public and private providers of home care, and patients may choose between public or private providers. While this functions relatively well in most municipalities, it has been difficult to attract private providers to remote areas. A considerable number of the elderly choose private providers. Some municipalities also have contracted with private institutions for institutional care of older people, but more than 90 percent of residential care institutions (nursing homes) remain public. Providers are paid directly by municipalities, and no cash benefits are paid to patients. Public providers are employed by the municipalities. For staying in residential care institutions, patients pay according to the facility's costs plus 10 percent oftheir income (20% of income above DKK188,700, or USD24,880), as well as heating and electricity charges (Rudersdal Kommune, 2015). Relatives of seriously ill individuals may take paid leaves of absence from their jobs for up to nine months. These can be incremental and may be divided among several relatives. A similar scheme exists for relatives of terminally ill patients who no longer receive treatment. Hospices, which may be public or private, are organized by regions and are funded by regions and municipalities. There is free choice of hospice upon referral. &h What are the key entities for health system governance? The general regulation, planning, and supervision of health services, including cost control mechanisms, take place at the national level through the Ministry of Health and the Danish Health Authority, Danish Medicines Agency, and Danish Patient Safety Authority. The national authorities are responsible for general supervision of health personnel and for development of quality management in line with national clinical guidelines and standards, usually in close collaboration with representatives from medical societies. These authorities also have important roles in planning the location of specialist services, approving regional hospital plans, and making mandatory "health agreements" between regions and municipalities to coordinate service delivery. Health technology assessments are developed at the regional level, while the national authorities do comparative effectiveness (productivity) studies that are published on a regular basis, allowing regions and hospital managers to benchmark performance of individual hospital departments (Danske Regioner, 2015). Regions are in charge of defining and running hospital services and supervising and paying general practitioners and specialists. Municipalities have important roles in prevention, health promotion, and long-term care. Rates for general practitioners and practicing specialists are set through national agreements. Doctors' associations negotiate with a collective body of the regions, also including state representatives. Regions may enter into additional regional agreements for specific services. The Commonwealth Fund VA-19-0799-D-001620 OS 00003291 DENMARK A national website (sundhed.dk) supports patient choice (see below). Organized patient groups engage in policymaking at the national, regional, and municipal levels. A patient ombudsman handles patient complaints and compensation claims, collects information about errors for systematic learning, and provides information about treatment abroad. Aspects of care that are affected by regional benchmarking results, which are published online, include expenditures for administration; expenditures for support functions (washing and cleaning); organization and handling of free choice (of private provider); and psychiatry, obesity operations, selected medical treatments, knee operations, shoulder operations, heat treatment, and back operations (Danske Regioner, 2014c). ~ X What are the major strategies to ensure quality of care? The Danish Healthcare Quality Programme (DDKM), based on accreditation and a set of accreditation standards, was in operation at the hospital level through 2015 (DDKM). It is currently being replaced in hospitals with a new program featuring fewer standards and more emphasis on clinical and local dimensions (due partially to pressure from the medical profession). The DDKM continues to be rolled out in primary and municipal health care. Organization of the Health System in Denmark rl H General legislation and guidelines Annual global budget and some activity based funding Parliament (Folketing) I Ministry for Health and Prevention i i - - and follow up I Publ ic Health Medical Officers - ,,,.,,,.( Hospitals ? - / Regions (5) // -- t: -.- ----- -r -1-------------------- , GPs and practicing specialists / I I I : : : IKAS: The Danish Healthcare Quality Programme ; (::.-~_:::: ::::::: :t:= ; I agreements I Danish Health Authority, Dan ish Patient Safety Authority, Danish Medicines Agency, Danish Health Data Agency .,,.,,...,,. //I ?- Annual coordination J Home care, - Municipalities (98) ? - prevention, rehabilitation, public health 0 --------------------------------- .o ? Guidelines and reference programs Resources, economic and general performance management - ? i Qua lity and activity performance measurement Negotiated agreements with performance targets ._ - - o Genera l su rveillance of med ica l p rofessiona ls ?.o Accred itation sta ndards and indicators Source: K. Vrangbaek, University of Copenhagen, 2015. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001621 OS 00003292 DENMARK Quality data for a number of treatment areas are captured in clinical registries and published on line for institutions, but not for individual health providers at the hospital level (sundhedskvalitet.dk). General quality and efficiency data also are published regularly in national level reports as a follow-up to national budget agreements between the state and the regions (Ministry of Health, 2013). Patient experiences are collected though biannual national, regional, and local surveys. The Danish Health Authority has laid out standard treatment pathways, with priorities including chronic disease prevention and follow-up interventions. Pathways for 34 cancers have been in place since 2008, covering nearly all cancer patients. The authority monitors pathways and the speed at which patients are diagnosed and treated. DDKM standards enforce the use of pathway programs and national clinical guidelines for all major disease types. Regions develop more specific practice guidelines for hospitals and other organizations, based on general national recommendations. There are no explicit national economic incentives tied to quality, but several regions are experimenting with such schemes. In general, regions are obliged to take action in case of poor results, and may fire hospital managers or introduce other measures to support quality improvement. The Danish Health Authority can step in if entire regions fail to live up to standards. The Danish Patient Safety Authority was created in 2015 when the former Danish Health and Medicines Authority was split into separate agencies. It receives anonymized reports of accidents and near-accidents that health care professionals at all levels are obliged to submit to regional authorities, which evaluate the incidents. The information is published in an annually updated database, with the intention of fostering learning rather than sanctioning. t:" j What is being done to reduce disparities? Regular reports are published on variations in health and health care access (Sundhedsstyrelsen, 2014). These have prompted the formulation of action plans, with initiatives including: o higher taxes on tobacco o targeted interventions to promote smoking cessation o prohibition of the sale of strong alcohol to young people o establishment of anti-alcohol policies in all educational institutions o further encouragement of municipal disease prevention activities (e.g., through increased municipal cofinancing of hospitals, thus creating economic incentives for municipalities to keep citizens healthy and out of hospitals) o improved psychiatric care o a mapping of health profiles in all municipalities, to be used as a tool for targeting municipal disease prevention and health promotion activities. The introduction of pathway descriptions (see above) is reported to have increased equity. (R)-0- What is being done to promote delivery system integration and ~ care coordination? Current mandatory health agreements between municipalities and regions on coordination of care address a number of topics related to admission and discharge from hospitals, rehabilitation, prevention, psychiatric care, IT support systems, and formal progress targets. Agreements are formalized for municipal and regional councils at least once per four-year election term, generally take the form of shared standards for action in different phases of the patient journey in the system, and must be approved by the Danish Health Authority. The agreements are partially supported by IT systems with information that is shared between different The Commonwealth Fund VA-19-0799-D-001622 OS 00003293 DENMARK caregivers. The performance of regions and municipalities in reaching the goals is measured by national indicators published online (esundhed.dk). Regions and municipalities have implemented various measures to promote care integration. Examples include the use of outreach teams from hospitals doing follow-up home visits; training programs for nursing and care staff; establishment of municipal units located within hospitals to facilitate communication, particularly in regard to discharge; and the use of" general practitioner practice coordinators." Many coordination initiatives have a special emphasis on citizens with chronic care needs, multi-morbidity, or frailty due to aging or mental health conditions (0konomi og lndenrigsministeriet, 2013). Municipalities are in charge of a range of services, including social care, elder care, and employment services; most are currently working on models for integrating these services better, such as through joint administration with shared budgets and formalized communication procedures. Practices increasingly employ specialized nurses, and several municipalities and regions have provided financial support to set up multispecialty facilities, commonly called "health houses." Models vary, but often include GPs, practicing specialists, and physiotherapists, among others. GPs in medical homes are encouraged to function as coordinators of care for patients and to develop a comprehensive view of their patients' individual needs in terms of prevention and care. This principle is commonly accepted and is supported by the general nationallevel agreements between GPs and regions. GPs participate in various formal and informal network structures and are included in the health service agreements made between regions and municipalities to facilitate cooperation and improve patient pathways. All GPs use electronic information systems as a conduit for discharge letters, electronic referrals, and prescriptions. ~ What is the status of electronic health records? Information technology (IT) is used at all levels of the health system as part of a national strategy supported by the National Agency for Health IT. Each region uses its own electronic patient record system for hospitals, with adherence to national standards for compatibility. Danish general practitioners were ranked first in an assessment of overall implementation of electronic health records in 2014 (HimSS Europe, 2014). All citizens in Denmark have a unique electronic personal identifier, which is used in all public registries, including health databases. A shared medical card-accessible by all relevant health professionals-has been implemented. It contains encoded information about each patient's prescriptions and medication use. General practitioners also have access to an online medical handbook with updated information on diagnosis and treatment recommendations. Attempts to develop national clinical databases to monitor quality in primary care (DataFangst) were aborted in 2015, as they were found to violate privacy rights and to endanger the trust between GPs and their patients. Sundhed.dk is a national IT portal with differentiated access for health staff and the wider public. It provides ~ general information on health and treatment options, and access to individuals' own medical records and history. For professionals, the site serves as an entry to medical handbooks, scientific articles, treatment guidelines, hospital waiting times, treatments offered, and patients' laboratory test results. The portal also provides access to available quality-of-care data for primary care clinics, all of which use IT for electronic records and communication with regions, hospitals, and pharmacies. How are costs contained? The overall framework for controlling health care expenditures is outlined in a "budget law," which sets budgets for regions and municipalities and specifies automatic sanctions if they are exceeded. The budget law is supplemented by annual agreements between regions, municipalities, and government that coordinate policy initiatives to control expenditures. These include direct controls of supply. Block grants to regions are conditional on annual increases in productivity of 2 percent on the basis of diagnosis-related groups, and are withheld if productivity demands are not met. Even though the activity-based International Profiles of Health Care Systems, 2015 VA-19-0799-D-001623 OS 00003294 DENMARK portion is small, it makes up regions' marginal income and presents a strong incentive (Danske Regioner, 2014). Furthermore, regions are under pressure to deliver good performance, as they can be reformed if they do not deliver. At the regional level, hospital cost control includes a combination of global budgets and activity-related incentives (see above). Inpatient pharmaceutical expenditure is controlled through national guidelines and clinical monitoring combined with collective purchasing. Two specific units have been established to evaluate and coordinate the introduction of expensive pharmaceutical products-the Council for the Use of Expensive Hospital Medicines (RADS) and the Coordinating Council for the First Use of Hospital Medicines (KRIS). Policies to control outpatient pharmaceutical expenditure include generic substitution, prescribing guidelines, and assessment by the regions of deviations in prescribing behavior. Pharmaceutical companies report a monthly price list to the Danish Health Authority, and pharmacies are obliged to choose the cheapest alternative with the same active ingredient, unless a specific drug is prescribed. Patients may choose more expensive drugs, but they have to pay the difference. Collective agreements with general practitioners and specialists include various types of clauses about rate reductions if overall expenditures exceed given levels. Regions also monitor the activity level of individual practices, and may intervene if they deviate significantly from the average. Health technology assessment and cost-effectiveness information, produced nationally and regionally, is an integrated part of the decision-making process for new treatments and guidelines for professionals. Regions may enter into contracts with private providers to deliver diagnostic and curative procedures. Prices for these services are negotiated between regions and private providers and can be lower than rates in the public sector. These measures have been relatively successful in controlling expenditures and driving up activity levels. General productivity in the hospital sector increased almost 20 percent from 2008 to 2012, while maintaining high patient satisfaction and also reducing hospital standardized mortality rates (Danske Regioner, 20146 and 2014c). G ~ What major innovations and reforms have been introduced? A reorganization of the hospital infrastructure is currently under way. All five regions are in the process of closing or amalgamating small hospitals and building new hospitals, at a total cost of DKK40.0 billion (USD5.3 bilion). A central part of this process is the reorganization of acute care, with stronger prehospital services and larger specialized emergency departments with senior medical specialists at the front end. The third generation of mandatory "health agreements" for coordination between municipalities and regions came into force in 2014. These agreements cover 2015-2018, and are based on a slightly revised format that resulted from a formal evaluation published in 2011. Upscaling of municipal health services with "temporary care units" and various types of health centers is occurring, with colocation of municipal, private, and regional health providers. At the same time, municipalities are employing more nursing staff and public health specialists to provide more systematic services for population health (Rigsrevisionen, 2013). A plan for reorganization of the central governance structure was decided on by the incoming government in August 2015, and was implemented in the fall of 2015. The reorganization will split the existing Health and Medicines Agency into four separate agencies, dealing with health, medicines, patient safety, and IT/data, to provide more clarity and improve the overall surveillance and accountability structure. The Commonwealth Fund VA-19-0799-D-001624 OS 00003295 DENMARK References CEPOS (2014). Halvdelen af danskerne har nu en privat sundhedsforsikring. http://www.cepos.dk/sites/default/files/analyse_ pu bl i cati on/N otat_H alvde Ie n_af_da nske rn e_ha r_nu_e n_privat_sun d hedsfo rsi kri ng_apr1 4. pdf. Danish Healthcare Quality Programme (DDKM). http://www.ikas.dk. Danske Regioner (2007). Organisering af almen praksis. Delrapport. http://www.regioner.dk/Sundhed/Praksissektoren/ Almen+praksis/-/media/73D4270B3EDD4EAA9450599581 F4E7E3.ashx. Danske Regioner (2012). Fakta om okonomi og aktivitet i almen praksis. Notat. http://www.regioner.dk/-/media/ Mediebibliotek_2011 /Nyheder/Fakta%20om%20%C3%B8onomi%20og%20aktivitet%20i%20almen%20praksis_2012.ashx. Danske Regioner (2014). 0konomisk Vejledning 2013. http://www.regioner.dk/-/media/Filer/0konomi/Budgetvejledning/ Budgetvejledning%20for%202013/0konomisk%20vejledning%20aktivitetspuljen%20og%20baseline%202014.ashx. Danske Regioner (20146). Styr pa regionernes okonomi. http://www.regioner.dk/-/media/Filer/0konomi/Analyser/Styr%20 pa%20regionernes%20okonomi/Styr%20pa%20regionernes%20okonomi.ashx. Danske Regioner (2014c). Hoj produktivitet, oget kvalitet og tilfredse patienter. http://www.regioner.dk/-/media/Subsites/ G F1 4/Reg ion e rn es%20resu ltater/Eff ektive %20reg i oner/ho j %20prod%205. ashx. Danske Regioner (2015). L0BENDE OFFENTLIGG0RELSE AF PRODUKTIVITET I SYGEHUSSEKTOREN. 10. delrapport. http://www. region er. dk/aktuelt/nyheder/2015/jan uar/-/media/64631 EF66 EEC42 E6AAC59 A420C566124.ashx. Esundhed.dk. National website with interactive quality information. http://www.esundhed.dk/sundhedsaktivitet/ sundhedsaftaler/Sider/Sundhedsaftaler.aspx. Frederi ks berg Kommu ne (2015). http://www.frederiksberg.dk/Borger/Aeldre/Hjemmehjaelp-og-sygepleje/Hjemmeh jael p.aspx. HimSS Europe (2014). Electronic Medical Record Adoption in Denmark. http://www.regioner.dk/-/media/ Mediebibliotek_2011 /SUN DH ED/Sundheds-it/H IM MS_Denmark_2014.ashx. Ministry of Health, 2013. 0get fokus pa gode resultater pa sygehusene. http://www.sum.dk/Aktuelt/Nyheder/Tal_og_ analyser/2013/M aj/-/media/Fi Ie r%20-%20Pu bl i kati oner_i_pdf/2013/ Oeget-fokus/oeget-fokus-pa a-gode-resu ltate r-paasyge huse ne-maj-2013. ashx. 0konomi- og lndenrigsministeriet (2013). Evaluering af Strukturreformen. http://www.regioner.dk/-/media/ M ediebi bliotek_2011 /Om%20regionerne/Eval ueri ng%20af%20kommuna Ireformen%20040313 .ashx. Organisation for Economic Co-operation and Development (OECD) (2014), OECD.Stat, (database). DOI: 10.1787/data00285-en. Accessed on October 6, 2014. Organisation for Economic Co-operation and Development (OECD) Health Data, 2015a. Organisation for Economic Co-operation and Development (OECD) (20156). OECD.Stat. DOI: 10.1787/data-00285-en. Accessed July 2, 2015. Rigsrevisionen (2013). "Beretning om borgerrettet forebyggelse pa sundhedsomradet." http://www.rigsrevisionen.dk/ publikationer/2013/102012/. Accessed June 20, 2013. Rudersdal Kommu ne (2015). http://www. rudersdal. dk/Borgerservice_selvbetjeni ng/Aeldre/Boliger_for_aeldre/Plejecentre/ Udgifter_plejebolig.aspx. Sundhedsstyrelsen (2014). Den nationale sundhedsprofil. http://sundhedsstyrelsen.dk/da/nyheder/2014/ den-nationale-sundhedsprofil . Sygeforsikring "danmark" (2014). Arsrapport 2014. http://www.sygeforsikring.dk/Default.aspx?ID=23 . Sogaard, J. (2014). Hvor hoje er sundhedsudgifterne i Dan(b) (6) (How high are health expenditures in Denmark?). Report for Danish Regions. Copenhagen. http://www.regioner.dk/-/media/Mediebibliotek_2011/Nyheder/REGIO/Rapport_hvor%20 h%C3%B8je%20er%20sundhedsudgifterne%20i%20Danmark_2014.ashx. Accessed Oct. 3, 2014. Strandberg-Larsen, M., Nielsen, M.B., Vallgarda, S., Krasnik, A., Vrangbaak, K., and Mossialos, E. (2007). "Denmark: Health System Review," Health Systems in Transition 9(6):1-164. Sundhed.dk. National portal for patients and providers. https://www.sundhed.dk. Forsikring og Pension (2014). Sundhedsforsikringer - hovedtal 2003-2014. http://www.forsikringogpension.dk/presse/ Statistik_og_Analyse/statistik/forsikring/antalpolicer/Documents/Sundhedsforsikringer.pdf. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001625 OS 00003296 ~ ? = What is the role of government? Responsibility for health legislation and general policy in England rests with Parliament, the Secretary of State for Health, and the Department of Health. 1 Under the Health Act (2006), the Secretary of State has a legal duty to promote a comprehensive health service, providing services free of charge, except for those with charges already in place. Rights for those eligible for National Health Service (NHS) care are summarized in the NHS Constitution; they include access to care without discrimination and within certain timeframes for some categories, such as emergency and planned hospital care (Department of Health, 20136). The Department of Health provides stewardship for the overall health system, but day-to-day responsibility for running the NHS belongs to a separate public body, NHS England. NHS England manages the NHS budget, oversees 209 local Clinical Commissioning Groups (CCGs), and ensures that the objectives set out in an annual mandate by the Secretary of State for Health are met, including both efficiency and health goals. Budgets for public health are held by local government authorities, which are required to establish "health and well-being boards" to improve coordination of local services and reduce health disparities. o/1:' Who is covered and how is insurance financed? Publicly financed health care: In 2013, the U.K. spent 8.8 percent of GDP on health care, of which public expenditure, mainly on the NHS, accounted for 83.3 percent (Office of National Statistics, 2015). The majority of funding for the NHS comes from general taxation, and a smaller proportion from national insurance (a payroll tax). The NHS also receives income from copayments, people using NHS services as private patients, and some other minor sources. Coverage is universal. All those "ordinarily resident" in England are automatically entitled to NHS care, largely free at the point of use, as are nonresidents with a European Health Insurance Card. For other people, such as non-European visitors or illegal immigrants, only treatment in an emergency department and for certain infectious diseases is free (Department of Health, 2013a). ~ Private health insurance: In 2012, 10.9 percent ofthe UK population had private voluntary health insurance (Nuffield Trust, 2013). The bulk of it was provided through employers (3.97 million policies) versus individual policies (0.97 million). Private insurance offers more rapid and convenient access to care, especially for elective hospital procedures, but most policies exclude mental health, maternity services, emergency care, and general practice (King's Fund, 2014). Data on private insurers are not freely available, but according to the Competition and Markets Authority (2014), four insurers account for 87.5 percent ofthe market, with small providers making up the rest. What is covered? Services: The precise scope of the NHS is not defined in statute or by legislation, and there is no absolute right for patients to receive a particular treatment. However, the statutory duty of the Secretary for Health is to ensure comprehensive coverage. In practice, the NHS provides or pays for preventive services, including screening, 1 In cases where data for England are unavailable (e.g., financial or funding data), U.K. data are used instead. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001627 OS 00003298 ENGLAND immunization, and vaccination programs; inpatient and outpatient hospital care; physician services; inpatient and outpatient drugs; clinically necessary dental care; some eye care; mental health care, including some care for those with learning disabilities; palliative care; some long-term care; rehabilitation, including physiotherapy (e.g., after-stroke care); and home visits by community-based nurses. The volume and scope of these services are generally a matter for local decision-making, but the NHS Constitution also states that patients have a right to drugs or treatment approved in technology appraisals carried out by the National Institute of Health and Clinical Excellence (NICE), if recommended by their clinician (Department of Health, 20136). For drugs or treatments that have not been appraised by NICE, the NHS Constitution states that CCGs shall make rational, evidence-based decisions (Department of Health, 20136). 2 There is no routine reporting of how individual clinical commissioning groups make decisions, but a study of predecessor organizations found considerable variation (Nuffield Trust, 2011 ). There is also evidence of wide variations in access to some treatments, such as hip replacements (Royal College of Surgeons in England, 2014). Cost-sharing and out-of-pocket spending: There are limited cost-sharing arrangements for publicly covered services. Out-of-pocket payments for general practice are limited to services that fall outside the purview of the NHS, including examinations for employment or insurance purposes and the provision of certificates for travel or insurance. Outpatient prescription drugs are subject to a copayment (currently GBP8.20, or USD11.60, per prescription item in England); drugs prescribed in NHS hospitals are free. NHS dentistry services are subject to copayments of up to GBP222.50 (USD314.00) per course of treatment. 3 These charges are set nationally by the Department of Health. Out-of-pocket expenditure on health by households accounted for 11. 9 percent oftotal expenditures in the U.K. in 2013 (Office for National Statistics, 2015). In 2013, the largest portion of out-of- pocket spending (34%) was for pharmaceuticals, followed by about 20 percent on medical appliances and equipment (Office for Nationa I Statistics, 2015). 4 Safety net: People who are exempt from prescription drug copayments include children under age 16 and those 16 to 18 in school full time; people age 60 or older; people with low income; pregnant women and those who have had a baby in the past 12 months; and people with cancer, certain other long-term conditions, or certain disabilities. Patients who need large amounts of prescription drugs can buy prepayment certificates costing GBP29.10 (USD41.10) for a period ofthree months and GBP104 (USD147) for 12 months. Users incur no further charges for the duration of the certificate, regardless of how many prescriptions they need. In 2013, 90 percent of prescriptions in England were dispensed free of charge (Health and Social Care Information Centre, 2014a). Young people, students, pregnant and recently pregnant women, prisoners, and those with low incomes are not liable for dental copayments. Vision tests are free for young people, those over 60, and people with low incomes, and financial support to meet the cost of corrective lenses is available to young people and those with low incomes. Transportation costs to and from provider sites also are covered for people who qualify for the NHS Low Income Scheme. [ (R)] How is the delivery system organized and financed? Primary care: Primary care is delivered mainly through general practitioners (GPs), who act as gatekeepers for secondary care. In 2014, there were 36,920 general practitioners (full-time equivalents) in 7,875 practices, with an average of 7,171 patients per practice and 1,530 patients per GP. There were 40,443 hospital specialists and a further 53,786 hospital doctors in training (Health and Social Care Information Service, 2015a, 20156). The number of solo practices is currently 843, while there are 3,589 practices with five or more GPs (Health 2 A total of 533 appraisals were carried out between March 2000 and August 2014. 3 Please note that, throughout this profile, all figures in USD were converted from GBP at a rate of GBP0.71 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for England. 4 Including consumer spending on drugs and medical products not covered by the NHS, such as glasses, dental treatment, and spending on hospital and outpatient care. The Commonwealth Fund VA-19-0799-D-001628 OS 00003299 ENGLAND and Social Care Information Service, 2015a). General practices are normally patients' first point of contact, and people are required to register with a local practice of their choice; however, choice is effectively limited because many practices are full and do not accept new patients. In some areas, walk-in centers offer primary care services, for which registration is not required. Most GPs (66%) are private contractors, and approximately 56 percent of practices operate under the national General Medical Services contracts, negotiated between the British Medical Association (representing doctors) and government. These provide payment using a mixture of capitation to cover essential services (representing about 60% of income), optional fee-for-service payments for additional services (e.g., vaccines for at-risk populations, about 15%), and an optional performance-related scheme (about 10%) (Health and Social Care Information Centre, 2015d). Capitation is adjusted for age and gender, local levels of morbidity and mortality, the number of patients in nursing and residential homes, patient list turnover, and a market-forces factor for staff costs as compared with those of other practices. Performance bonuses mainly relate to evidence-based clinical interventions and care coordination for chronic illnesses. The proportion of income from these bonuses will fall when the new 2014-15 contract is implemented, as the number of bonus-related services is reduced and funding rerouted into capitation. The proportion of GPs employed in practices or on a salaried basis as locums (e.g., standing in when other GPs are unavailable) is increasing (currently around 20%). Most general practices employ other professionals such as nurses, who monitor patients for such things as blood pressure and provide minor treatments such as dressing wounds. The structure of general practice is changing, away from the single-handed "corner shops" and toward networked practices, including larger multipractice organizations using multidisciplinary teams of specialists, pharmacists, and social workers (King's Fund and Nuffield Trust, 2013). The average income for combined GPs (contracted and salaried) was GBP92,200 (USD130,200) before tax in 2013-2014 (Health and Social Care Information Service, 2015c). Outpatient specialist care: Nearly all specialists are salaried employees of NHS hospitals, and CCGs pay hospitals for outpatient consultations at nationally determined rates. Specialists are free to engage in private practice within specially designated wards in NHS or in private hospitals; the most recent estimates (2006) were that 55 percent of doctors performed private work, a proportion that is declining as the earnings gap between public and private practice narrows (GHK Consulting and Office of Fair Trading, 2011). Patients are able to choose which hospital to visit, and the government has introduced the right to choose a particular specialist within a hospital (not yet fully implemented). Most outpatient specialist consultations are carried out in hospitals, although consultation may take place in general practices. Some GPs "with specialist interests" also offer specialist consultations, paid on a per-session or fee-for-service basis. Administrative mechanisms for paying primary care doctors and specialists: The bulk of general practices are reimbursed monthly for the services they deliver on the basis of data extracted automatically from practices' electronic records. Some payments may require practices to enter data manually on the number of patients screened or treated for "enhanced services," which qualify for additional payments, such as diagnosis and support for patients with dementia. These data are collated and validated by NHS England. After-hours care: GPs are no longer required personally to provide after-hours care to their patients (a small minority still do), but must ensure that adequate arrangements for its provision are in place. In practice, this means that CCGs contract mainly with GP cooperatives and private companies, both of which usually pay GPs on a per-session basis. Serious emergencies are handled by hospital emergency departments. In some areas, less serious cases are seen in urgent care centers or minor-injury units, which are staffed in a variety of ways, and include nurse-led and GP-led centers. Telephone advice is available on a 24-hour basis through NHS 111 for those with an urgent but not life-threatening condition. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001629 OS 00003300 ENGLAND Hospitals: Publicly owned hospitals are organized either as NHS trusts (currently 98) directly accountable to the Department of Health or as foundation trusts (currently 147) regulated by Monitor, an economic regulator of public and private providers. Foundation trusts enjoy greater freedom from central control, have easier access to capital funding, and are able to accumulate surpluses or run (temporary) deficits. Government wants all hospitals (including those providing mental health and ambulance services) to become foundation trusts in the near future. Both trusts and foundation trust hospitals contract with local CCGs to provide services. They are reimbursed mainly at nationally determined diagnosis-related group (DRG) rates, which include medical staff costs and account for about 60 percent of income, with the remainder coming from activities not covered by DRGs, such as mental health, education, and research and training funds (Department of Health, 2013c). Responsibility for setting those rates is shared between NHS England and Monitor. In some areas, rates are not applied and payments are made for an overall service, such as emergency care. Also at the local level, fees for "years of care"-for example, for the total cost ofthe care a diabetic patient receives over 12 months-are being developed but as yet are not in widespread use. There is no cap on hospital incomes. An estimated 548 private hospitals and between 500 and 600 private clinics in the U.K. offer a range of services, including treatments either unavailable in the NHS or subject to long waiting times, such as bariatric surgery and fertility treatment, but generally do not have emergency, trauma, or intensive-care facilities (Competition and Markets Authority, 2014). Private providers must be registered with the Care Quality Commission and with Monitor, but their charges to private patients are not regulated and there are no public subsidies. Although the volume of care purchased from private providers by the NHS has increased recently in areas outside of mental health, NHS use of private hospitals remains low-3.6 percent of overall spending by commissioners on hospital services in 2012-2013 (Nuffield Trust, 2014a). Mental health care: Mental health care is an integral part of the NHS, which covers a full range of services. Less serious illnesses-mild depressive and anxiety disorders, for example-are usually treated by GPs. Those requiring more advanced treatment, including inpatient care, are treated by mental health or hospital trusts. Some of these services are provided by community-based staff. About a quarter of NHS-funded, hospital-based mental health services are provided by the private sector. Over the past decade, policy has focused on increasing access to psychological therapies for mild to moderate mental health problems, though there can still be long waiting times. Policies to improve care of more severe conditions in the community have focused on outreach and early intervention, and there is an overarching aim to ensure "parity of esteem" between mental health and other kinds of health services. A review conducted in 2012 suggested that mental health services have been underfunded compared with treatment of physical illnesses (Centre for Economic Performance, 2012). Long-term care and social supports: The NHS pays for some long-term care, such as for people with continuing medical or skilled-nursing needs, but payments in recent years have been substantially reduced. Most long-term care is provided by local authorities and the private sector. Local authorities are legally obliged to assess the needs of all people who request it, but, unlike NHS services, state-funded social care is not universal. With the exception of time-limited "reablement" services, some equipment and home modifications (in some areas), and information services, residential and home care are needs- and means-tested. Full state support for residential care, for example, is available only to those with less than GBP14,250 (USD20,123) in assets who also have high levels of need, with a sliding scale applied up to GBP23,250 (USD32,832). There is a national framework for assessing need, but local authorities are free to set eligibility thresholds for access to funds, which has become progressively more restricted (Nuffield Trust, 20146). Those eligible are liable for some copayments, with some people contributing almost all of their "assessed income," including pensions. Beneficiaries can receive personal budgets to purchase their own care but can also opt to have the local authority arrange it. Some additional allowances paid to users and carers are exempt from means testing, such as "attendance allowance," worth a maximum of GBP81.30 (USD115) a week. The Commonwealth Fund VA-19-0799-D-001630 OS 00003301 ENGLAND The 2014 Care Act aims to limit individuals' risk of catastrophic long-term care costs by imposing a cap on total out-of-pocket expenditure; however, this provision has been postponed until 2020 over cost concerns. In 2009, the private sector provided 78 percent of residential care places for older people and the physically disabled in the U.K. (Laing and Buisson, 2013). The NHS provides end-of-life palliative care at patients' homes, in hospices (usually run by charitable organizations), in care homes, or in hospitals. Separate government funding is available for working-age people with disabilities. &h What are the key entities for health system governance? The Department of Health and the Secretary of State for Health are ultimately responsible for the health system as a whole. The Health and Social Care Act 2012 transferred important functions to NHS England, including overall budgetary control, supervision of CCGs, and, along with Monitor (described below), responsibility for setting DRG rates for provision of NHS services. NHS England also commissions some specialized low-volume services, national immunization and screening programs, and primary care. It is also responsible for setting the strategic direction of health information technology, including the development of online services to book appointments, the setting of quality standards for electronic medical record-keeping and prescribing, and the IT infrastructure of the NHS. The National Institute for Health and Clinical Excellence (NICE) sets guidelines for clinically effective treatments and appraises new health technologies for their efficacy and cost-effectiveness. The CQC ensures basic standards of safety and quality through provider registration and monitors care standards achieved (described further below). It can require closure of services if serious quality concerns are identified. The 2012 Act extended Monitor's role to being the economic regulator of public and private providers, with powers to intervene if performance deteriorates significantly. Monitor licenses all providers of NHS-funded care and may investigate potential breaches of NHS cooperation and competition rules and mergers involving NHS foundation trusts. Where such mergers are found to be prima facie undesirable, they are referred to the Office of Fair Trading and the Competition Commission. Healthwatch England promotes patient interests nationally. In each community, local Healthwatches support people who make complaints about services; quality concerns may be reported to Healthwatch England, which can then recommend that the Care Quality Commission (CQC) take action. In addition, local NHS bodies, including general practices, hospital trusts, and CCGs, are expected to support their own patient engagement groups and initiatives. The Department of Health owns NHS Choices, the primary website for public information about health conditions, the location and quality of health services, and other information. The website, which also offers a platform for user feedback, received 27 million visits a month in 2012-13 (NHS Choices, 2013). ~ X What are the major strategies to ensure quality of care? The CQC has responsibility for the regulation of all health and adult social care in England. All providers, including institutions, individual partnerships, and solo practitioners, must be registered with the CQC, which monitors performance using nationally set quality standards and investigates individual providers when concerns have been raised (e.g., by patients). It rates hospitals' inspection results and can close down poorly performing services. New "fundamental standards" for all health and social care came into force in 2015 (Department of Health, 2014a). The monitoring process includes results of national patient experience surveys. NICE develops quality standards covering the most common conditions occurring in primary, secondary, and social care. National strategies have been published for a range of conditions, from cancer to trauma. There are national registries for key disease groups and procedures. Maximum waiting times have been set for cancer treatment, elective treatments, and emergency treatment. A website, NHS Evidence, provides professionals and patients with up-to-date clinical guidelines. Support is also provided by NHS Quality Improvement, part of NHS England. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001631 OS 00003302 ENGLAND Organization of the Health System in England Accountabi lity ------. Parliament ( Department of Hea lth Health Watch England Local Authorities }- ? ( r Secretary of State -----------~ ~Public Health Eng land Health and Wellbeing boards Regulates - ? Advises , .. , .... ? _______ 1 }- - - - - - - - - - - - - NHS Eng land Care Quality Commission NHS Improvement r Clinical ... Commissioning Groups National Institute for Health and Clinical Excellence (N ICE) Social Care __ se_rv_ ic_e_s _ _ + .. ... .1. .. o"""":." .:.F: ". . . Community health services GPs and other primary care contractors . . I ooo ,/ I Secondary Care Providers. NHS Trusts, Foundation Trusts Source: R. Thorlby a nd S. Arora, Nuffield Trust, 2014. Information on the quality of services at the organization, department, and (for some procedures) physician levels is published on NHS Choices. Results of inspections by the CQC are also publicly accessible. The Quality and Outcomes Framework provides general practices with financial incentives to improve quality. General practices are awarded points (determining part of their remuneration) for keeping a disease registry of patients with certain diseases or conditions and their management and treatment. For hospitals, 2.5 percent of contract value is linked to the achievement of a limited number of quality goals through the Commissioning for Quality and Innovation initiative. In addition, DRG rates for some procedures are linked to best practice. All doctors are required by law to have a license to practice from the General Medical Council. Similar requirements apply to all professions working in the health sector. A process of revalidation every five years is being introduced for doctors. Providers of hospital services also must be registered with the CQC. t-1 ~ What is being done to reduce disparities? The Secretary of State, NHS England, and CCGs have a legal duty to "have regard" for the need to reduce health disparities, although the applicable legislation does not specify what action needs to be taken. NHS England publishes an annual report on the actions and progress being made in reducing disparities in access and outcomes, by gender, disability, age, socioeconomic status, and ethnicity (NHS England, 20156). Strategies include ensuring that local areas receive adequate resources to tackle inequalities and that the outcomes for at-risk groups are routinely monitored. The Commonwealth Fund VA-19-0799-D-001632 OS 00003303 ENGLAND (C)-0- What is being done to promote delivery system integration and )yf care coordination? GPs increasingly work in multipartner practices that employ nurses and other clinical staff, who carry out much of the routine monitoring of patients with long-term conditions. These practices also have some of the features of a medical home-that is, they direct patients to specialists in hospitals or to community-based professionals, like dieticians and community nurses, and hold treatment records of their patients. GPs are responsible for care coordination as part of their overall contract; to improve coordination for older patients, the latest version of the contract (2014-15) requires practices to have a "named accountable GP" for all patients over age 75. GPs also have financial incentives to provide continuous monitoring of patients with the most common chronic conditions, such as diabetes and heart disease. The 2012 Act charged NHS England, Monitor, and CCGs with promoting integrated care-closer links between hospital- and community-based health services, including primary and social care. The health and well-being boards within local authorities are intended to promote integration between NHS and local authority services, particularly at the intersection of hospital and social care. The government announced in 2013 the selection of 14 "Pioneer" integration pilot programs, aimed at improving coordination of health and care services for patients most at risk of having to undergo unplanned or emergency treatment. The Better Care Fund provides GBP3.8 billion (USD5.4 billion), pooled from existing health and social care budgets, for integration projects by local health and social care commissioners starting in 2015-16. Health and well-being boards have submitted plans for these funds with a range of objectives, including a reduction in emergency hospital admissions by 3.5 percent (Local Government Association, 2013). What is the status of electronic health records? The NHS number assigned to every registered patient serves as a unique identifier. Most general practice patient records are computerized. Some practices use electronic systems to allow patients to make appointments or email their GP, but there is no requirement for practices to have that capability. Records are not routinely linked between providers. A move to make primary, urgent, and emergency care services paperless by 2018, and all other parts of the NHS by 2020, is being enforced by requirements that NHS organizations show progress toward that end in the intervening years; they risk having funding removed if universal digital care records are not implemented by 2020. NHS Choices will serve as a single point of access for patients to register with a GP, book appointments and order prescriptions, access apps and digital tools, speak to their doctor online or via video link, and view their full health record (Department of Health 2014c). All NHS patients have the right of access to their own health records (in some cases it is possible electronically) and can apply in writing to have a copy of their records held by their general practice, hospital, or dentist. By 2016, all patients will be able to have access to their GP electronic record in full, and by 2018 it is hoped that access will extend to data from all health and health care interactions. Electronic transfers are widely used by GPs to send prescriptions to pharmacies, and for the storage and distribution of digital scans, X-rays, and other images. NHS England has been developing a program for collecting data and for linking electronic records from general practice with those from hospitals and other care settings, for purposes of research and planning in health and social care services (NHS England, 20146). Full implementation has been delayed because of concerns about confidentiality, but piloting in 265 general practices started in 2014. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001633 OS 00003304 ENGLAND ~ How are costs contained? Rather than using patient cost-sharing or imposing direct constraints on supply, costs in the NHS are constrained by a global budget that cannot be exceeded. NHS budgets are set at the national level, usually on a three-year cycle. CCGs are allocated funds by NHS England, which closely monitors their financial performance to prevent overspending. They are expected to achieve a balanced budget each year. The current economic situation has resulted in a largely flat NHS budget against a backdrop of rising demand. Between March 2010 and March 2015, the NHS budget rose by between 0.6 percent and 0.9 percent (in real terms), versus the 5.6 percent growth between 1996-97 and 2009-10 (King's Fund, 20156). NHS England (2014a) estimated that the gap between rising demand and a continuation ofthis minimal increase in funding would be equivalent to GBP30 billion (USD42.4 billion) per year by 2020-21, assuming no additional efficiencies, but also that efficiencies equivalent to 2 percent to 3 percent of the annual budget are possible, versus a historic rate of 0.8 percent. Although some of the savings targets have been met in the past five years, the financial pressure on the NHS is being associated with some deterioration in quality of care-notably waiting time targets (Nuffield Trust and Health Foundation, 2015). ~ Cost-containment strategies to date include freezing staff pay increases, supporting increased use of generic drugs, reducing DRG payments for hospital activity, managing demand, and reducing administration costs (King's Fund, 2015a). There are a number of tools for local purchasers to maximize value by addressing unwarranted variations in utilization and clinical practice, provided by the government-funded "Rightcare" program. Local purchasers can also run competitive tenders for certain services. What major innovations and reforms have been introduced? In October 2014, NHS bodies, led by NHS England, published the Five Year Forward View, which sets out the challenges facing the NHS and a series of strategies to address them (NHS England, 2014a). These included setting up a number of pilot programs across England to test new models of care known as "vanguards." To date there are 37 vanguard sites, which focus on scaled-up primary care, enhanced health care in long-term care homes, vertically integrated hospital and community care, and networks to improve emergency care. NHS England hopes that, among other benefits, evaluations of the program will lead to better tools for identifying those at risk of becoming high-need, high-cost patients, and to the development of capitated contracts to incentivize providers to collaborate in the care of complex patients. The Five Year Forward View also sets out strategies to improve health and well-being, including a diabetes prevention initiative (NHS England, 2015a). The primary challenge facing the NHS is finding a way to redesign services and invest in prevention while at the same time generating efficiencies without compromising service quality or access. In November 2014, the National Audit Office reviewed the financial health of hospital providers in the NHS and warned that the trend of increasing financial distress was unsustainable (National Audit Office, 2014). The new Conservative government elected in May 2015 endorsed the Five Year Forward View and committed an additional GBPS billion (USD11 billion) per year. But measured against the GBP30 billion (USD42 billion) gap identified by NHS England, this additional funding equates to an annual savings target of GBP22 billion (USD31 billion). Moreover, this funding will need to cover the implementation of new pledges, made in the election manifesto, to implement full seven-day working weeks in hospitals and general practice by 2020. The authors would like to acknowledge Anthony Harrison, the author of earlier versions of this profile. The Commonwealth Fund VA-19-0799-D-001634 OS 00003305 ENGLAND References Centre for Economic Performance and London School of Economics (2012). How Mental Health Loses Out in the NHS: A Report by the Centre of Economic Performance's Mental Health Policy Group. Competition and Markets Authority (2014). "Private Healthcare Market Investigation." Department of Health (2013a). Guidance on Implementing the Overseas Visitors Hospital Charging Regulations. Department of Health (20136). The NHS Constitution for Eng/and. Department of Health (2013c). A Simple Guide to Payment by Results. Department of Health (2014a). Hard Truths-The Journey to Putting Patients First: Volume One of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry. Department of Health (2014c). Personalised Health and Care 2020-Using Data and Technology to Transform Outcomes for Patients and Citizens: A Framework for Action. Nov. 2014. https://www.gov.uk/government/uploads/system/uploads/ attachment_ data/fi le/384650/N IB_Report. pdf. GHK Consulting Ltd and Office of Fair Trading (2011). Programme of Research Exploring Issues of Private Healthcare Among Genera/ Practitioners and Medical Consultants: Population Overview Report for the Office of Fair Trading. Health and Social Care Information Centre, (2015a). "General and Personal Medical Services, England: 2004-2014.' Health and Social Care Information Centre, (20156). "NHS Hospital & Community Health Service and General Practice Workforce." Heath and Social Care Information Centre (2015c). "GP Earnings and Expenses." Health and Social Care Information Centre (2015d). "Investment in General Practice, 2010/11 to 2014/15, England, Wales, Northern Ireland and Scotland." http://www.hscic.gov.uk/catalogue/PUB18469. Health and Social Care Information Centre (2014a). "Prescriptions Dispensed in the Community, Statistics for England, 2003-13." The King's Fund (2015a). The NHS Under the Coalition Government. Part Two: NHS Performance. March 2015. http://www. kingsfund.org.uk/pu61ications/nhs-performance-under-coalition-government. The King's Fund (20156). How Is the NHS Performing? July 2015: Quarterly Monitoring Report. http://www.kingsfund.org.uk/ pu61ications/articles/how-nhs-performing-july-2015. The King's Fund (2014). The UK Private Healthcare Market. Appendix to the Commission on the Future of Health and Social Care in England: Final Report. The King's Fund and Nuffield Trust (2013). Securing the Future of General Practice: New Models of Primary Care. http://www. n uffieldtrust. org. u k/sites/fi les/nuffield/pu 61ication/130718_secu ri ng_the_futu re_su mmary_O. pdf. Laing and Buisson (2013). "Laing's Healthcare Market Review." Local Government Association (2013). "Better Care Fund: Support and Resources Pack for Integrated Care." NHS Choices (2013). Annual Report 2012/13. National Audit Office (2014). The Financial Sustainability of NHS Bodies. Nov. 2014. https://www.nao.org.uk/report/ financial-sustaina6ility-nhs-6odies-2/. NHS England (2015a). Five Year Forward View. Time to Deliver. June 2015. https://www.england.nhs.uk/2015/06/04/ time-to-deliver/. NHS England (20156). NHS England Annual Report. July 2015. NHS England (2014a). Five Year Forward View. Oct. 2014. https://www.england.nhs.uk/ourwork/futurenhs/. NHS England (20146). "The care.data Programme-Collecting Information for the Health of the Nation." http://www. england. n hs. u k/ ou rwork/tsd/ ca re-data/. Nuffield Trust (2011). Setting Priorities in Health: A Study of English Primary Care Trusts. http://www.nuffieldtrust.org.uk/ sites/fi les/n uffield/setti ng-priorities-i n-hea lth-research-report-sep 11 . pdf. N uffield Trust (2013). Public Payment and Private Provision: The Changing Landscape of Health Care in the 2000s. Nuffield Trust (2014a). Into the Red? The State of the NHS' Finances. Nuffield Trust (20146). Focus On: Social Care for Older People. http://www.nuffieldtrust.org .uk/pu6lications/ focus-social-care-older-people . Nuffield Trust and Health Foundation (2015). "Closer to Critical? OualityWatch Annual Statement 2015." http://www. qualitywatch.org.uk/annual-statement/2015-closer-critical . International Profiles of Health Care Systems, 2015 VA-19-0799-D-001635 OS 00003306 ENGLAND Organisation for Economic Cooperation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787 /data-00285-en. Accessed July 2, 2015. Office of National Statistics (ONS) (2015). "Expenditure on Healthcare in the UK, 2013." Royal College of Surgeons in England (2014). /s Access to Surgery a Postcode Lottery? https://www.rcseng.ac.uk/news/ docs/ls%20access%20to%20surgery%20a%20postcode%20/ottery.pdf. The Commonwealth Fund VA-19-0799-D-001636 OS 00003307 ~ ? ~ What is the role of government? The provision of health care in France is a national responsibility. The Ministry of Social Affairs, Health, and Women's Rights is responsible for defining national strategy (Touraine, 2014). The French system has evolved from a labor-based Bismarckian system to a mixed public-private system. Over the past two decades, however, the state has been increasingly involved in controlling health expenditures funded by statutory health insurance (SHI). Planning and regulation within health care involve negotiations among provider representatives, the state, and SHI. Outcomes of these negotiations are translated into laws passed by parliament. In addition to setting national strategy, the responsibilities ofthe central government include allocating budgeted expenditures among different sectors (hospitals, ambulatory care, mental health, and services for disabled residents) and, with respect to hospitals, among regions. ~ The Administration of Health and Social Affairs is represented by Regional Health Agencies, which are responsible for population health and health care, including prevention and care delivery, public health, and social care. Health and social care for elderly and disabled people come under the jurisdiction of the General Council, which is the governing body at the local level. Who is covered and how is insurance financed? Publicly financed health insurance: Total health expenditures constituted 11 percent of GDP in 2013, of which 76 percent was publicly financed (DREES, 2015). SHI is financed by employer and employee payroll taxes (64%); a national earmarked income tax (16%); taxes levied on tobacco and alcohol, the pharmaceutical industry, and voluntary health insurance companies (12%); state subsidies (2%); and transfers from other branches of Social Security (6%) (Assurance Maladie, 2015). Coverage is universal and compulsory, provided to all residents by noncompetitive SHI. SHI eligibility is either gained through employment or granted, as a benefit, to students, to retired persons, and to unemployed adults who were formerly employed (and their families). Citizens can opt out of SHI only in rare cases (e.g., individuals working for foreign companies). The state covers the insurance costs of residents who are not eligible for SHI, such as the long-term unemployed, and finances health services for undocumented immigrants who have applied for residence. Visitors from elsewhere in the European Union (EU) are covered by an EU insurance card. Non-EU visitors are covered for emergency care only. Private health insurance: Most voluntary health insurance (VHI) is complementary, covering mainly the copayments for usual care, balance billing, and vision and dental care (minimally covered by SHI). Complementary insurance is provided mainly by not-for-profit, employment-based mutual associations or provident institutions, which are allowed to cover only copayments for care provided under SHI; 95 percent of the population is covered either through employers or via means-tested vouchers. Private for-profit companies offer both supplementary and complementary health insurance, but only for a limited list of services. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001637 OS 00003308 FRANCE VHI finances 13.8 percent oftotal health expenditure. The extent of VHI coverage varies widely, but all VHI contracts cover the difference between the SHI reimbursement rate and the service fee according to the official fee schedule. Coverage of balance billing is also commonly offered, and most contracts cover the balance for services billed at up to 300 percent of the official fee. To reduce inequities in coverage stemming from variations in access and quality, standards for employersponsored VHI were established by law in 2013. By 2016, all employees will benefit from employer-sponsored insurance (for which they pay 50% of the cost), which would cover at least 125 percent of SHI fees for dental care and EUR100 (USD121) for vision care per year. 1 The population of beneficiaries without supplementary insurance is estimated at 4 million. Choice among insurance plans is determined by the industry in which the employer operates (DREES, 2015). ?) What is covered? Services: Lists of covered procedures, drugs, and medical devices are defined at the national level and apply to all regions of the country. The Ministry of Health, a pricing committee within the ministry, and SHI funds all play roles in setting these lists, rates of coverage, and prices. SHI covers the following: hospital care and treatment in public or private rehabilitation or physiotherapy institutions; outpatient care provided by general practitioners, specialists, dentists, and midwives; diagnostic services prescribed by doctors and carried out by laboratories and paramedical professionals; prescription drugs, medical appliances, and prostheses that have been approved for reimbursement; and prescribed health care-related transportation and home care. It also partially covers long-term hospice and mental health care, and provides only minimal coverage of outpatient vision and dental care. While preventive services in general receive limited coverage, there is full reimbursement for targeted services and populations, e.g., immunization, mammography, and colorectal cancer screening. Cost-sharing and out-of-pocket spending: Cost-sharing takes three forms: coinsurance; copayments (the portion offees not covered by SHI); and balance billing in primary and specialist care. In 2013, total out-ofpocket spending made up 8.8 percent of total health expenditures (excluding the portion covered by supplementary insurance), a lower percentage than in previous years, possibly because of the agreement signed between physicians' unions and government to limit extra billing (DREES, 2015). In exchange for a voluntary restriction on extra billing to no more than twice the official fee, this contract offers patients partial reimbursement of extra billing by SHI and reduced social charges for physicians. Most out-of-pocket spending is for dental and vision services, for which official fees are very low, not more than a few euros for glasses or hearing aids and a maximum of EUR200 (USD241) for dentures, but all ofthese are commonly balance-billed at amounts over 10 times the official fee. The share of out-of-pocket spending on dental and optical services is decreasing, however, while that on drugs is increasing, owing to increased VHI coverage of dental and optical care and increasing numbers of delisted drugs, as well as a rise in selfmedication (DREES, 2015). Coinsurance rates are applied to all health services and drugs listed in the benefit package, and vary by: o type of care (inpatient, 20%; doctor visits, 30%; and dental, 30%) o effectiveness of prescription drugs (highly effective drugs, like insulin, carry no coinsurance; rates for all other drugs are 40%-100%, based on therapeutic value) o compliance with the recently implemented gatekeeping system 1 Please note that, throughout this profile, all figures in USD were converted from EUR at a rate of about EUR0.83 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for France. The Commonwealth Fund VA-19-0799-D-001638 OS 00003309 FRANCE The table below lists nonreimbursable copayments for various services. These apply up to an annual ceiling of EUR50 (USD60). There are no deductibles. Service Copayment Euros U.S. Dollars 18 22 Doctor visit 1.00 1.20 Prescription drug 0.50 0.60 Ambulance 2.00 2.40 18 22 Inpatient hospital day Hospital Safety net: People with low incomes are entitled to free or state-sponsored VHI, free vision care, and free dental care, with the total number of such beneficiaries estimated at around 10 percent of the population (DREES, 2015). Exemptions from coinsurance apply to individuals with any of 32 specified chronic illnesses (13% of the population, with exemption limited to the treatments for those conditions); individuals who benefit from either complete state-sponsored medical coverage (3% of the population) or means-tested vouchers for complementary health insurance (6% of the population); and individuals receiving invalidity and work-injury benefits (Fonds CMU, 2014). Hospital coinsurance applies only to the first 31 days in hospital, and some surgical interventions are exempt. Children and people with low incomes are exempt from paying nonreimbursable copayments. [ (R)] How is the delivery system organized and financed? Collective agreements between representatives of the health professions and SHI, signed at the national level, apply to all but those professionals who expressly opt out. Primary care: There are roughly 102,000 primary care physicians (GPs) and 118,000 specialists in France. About 46 percent of physicians are self-employed, more GPs (59%) than specialists (36%) (INSEE 2015; CISS 2014). Forty-two percent of GPs, mostly younger doctors, are in group practices. An average practice is made up of two to three physicians. Seventy-five percent of practices are made up exclusively of physicians; the remaining practices comprise a range of allied health professionals, typically paid fee-for-service. There is a voluntary gatekeeping system for adults age 16 and older, with financial incentives offered for registering with a GP or specialist (Cour des Comptes, 2013). Self-employed GPs are paid mostly fee-for-service and can receive a yearly capitated per-person payment of EUR40 (USD48) to coordinate care for patients with a chronic condition (Assurance Maladie, 2015). In addition, up to EUR5,000 (USD6,031) annually is provided for achieving targets related to the use of computerized medical charts, electronic claims transmission, delivery of preventive services such as immunization, compliance with guidelines for diabetic and hypertensive patients, generic prescribing, and limited use of psychoactive drugs for elderly patients. Since 2013, GPs also can enter into a contractual agreement under which they are guaranteed a monthly income of EUR6,900 (USD8,322) if they set up their practice in a region with insufficient physician supply (Ministry of Health, 2014). Moreover, they can work part-time in multidisciplinary medical centers and receive a salary or capitated payment. For those who elect to work full-time in medical centers, the guaranteed salary is around EUR50,000 (USD60,300) (Ouotidien du Medecin, 2015). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001639 OS 00003310 FRANCE The average income of primary care doctors in 2011 was EUR82,020 (USD98,925), 94 percent of which came from fees (INSEE 2015) and the remainder from financial incentives and salary. Fees, set by the Ministry of Health and SHI, have been frozen since 2011 (Cour des Comptes 2013). Experimental GP networks providing chronic care coordination, psychological services, dietician services, and other care not covered by SHI are financed by earmarked funds from the Regional Health Agencies (Nolte, 2008). Outpatient specialist care: About 36 percent of outpatient specialist care providers are exclusively selfemployed and paid on a fee-for-service basis; the rest are either fully salaried by hospitals or have a mix of income. In October 2014, participation in pay-for-performance programs was extended to all self-employed physicians, including specialists, who must meet disease-specific quality targets in addition to those targets that apply to GPs. The average income derived from pay-for-performance is EUR5,480 (USD6,609) per physician (Cour des Comptes 2014); such income constitutes less than 2 percent oftotal funding for outpatient services. Patients can choose among specialists upon referral by a GP, with the exception of gynecology, ophthalmology, psychiatry, and stomatology (Assurance Maladie, 2015). Bypassing referral results in reduced SHI coverage. The specialist fee, set by SHI, is EUR28 (USD34), but specialists can balance-bill. Half of specialists are in group practices, which are increasing among specialties that require major investments, such as nuclear medicine, radiotherapy, pathology, and digestive surgery (Senat, 2014). Specialists working in public hospitals may see private-pay patients, on an outpatient or an inpatient basis, but they must pay a percentage oftheir fees to the hospital. A 2013 report to the Ministry of Health estimated that 10 percent ofthe 46,000 hospital specialists in surgery, radiology, cardiology, and obstetrics had treated private patients. The mounting discontent over excessive balance billing revealed in the press, together with the claim of unfair competition made by private clinics, has prompted several public inquiries-the latest of which resulted in recommendations to increase public control over this activity (Ministere de la Sante 2013). Administrative mechanisms for paying primary care doctors and specialists: Patients pay the full fee (reimbursable portion and balance billing, if any) and claim reimbursement covering the full sum or less, depending on coverage, minus EUR1 .00 (USD1 .20), capped at a maximum of EUR50 (USD60) per patient per year. The 2015 Health Law included a contentious item stipulating that by 2017 patients will pay directly only for balance billing, and the reimbursable fee will be paid directly by SHI. After-hours care: After-hours care is delivered by the emergency departments of public hospitals, private hospitals that have signed an agreement with their Regional Health Agency, self-employed physicians who work for emergency services, and, more recently, public facilities financed by SHI and staffed by health professionals on a voluntary basis. Primary care physicians are not mandated to provide after-hours care. Physicians are paid an hourly rate, regardless of the number of patients seen. Emergency services can be accessed via the national emergency phone number, which is staffed by trained professionals who determine the type of response needed. Feasibility of telephone or telemedicine advice is currently under assessment; it would include sharing information from the patient's electronic medical record with the patient's primary care doctor. Publicly funded multidisciplinary health centers with self-employed health professionals (physicians and nonphysicians) allow better after-hours access to care in addition to more comprehensive care; fee-for-service payment is the rule for these centers (IRDES, 2014). Hospitals: Public institutions account for about two-thirds of hospital capacity and activity, private for-profit facilities account for another 25 percent, and private nonprofit facilities, the main providers of cancer treatment, make up the remainder (DREES, 2015). Since 2008, all hospitals and clinics are reimbursed via the diagnosisrelated group (DRG) system, which applies to all inpatient and outpatient admissions and covers physicians' salaries. Bundled payment by episode of care does not exist. The Commonwealth Fund VA-19-0799-D-001640 OS 00003311 FRANCE Public hospitals are funded mainly by statutory health insurance (80%), with voluntary insurance and direct patient payment accounting for their remaining income. Public and private nonprofit hospitals also benefit from grants that compensate research and teaching (up to an additional 13% of the budget) as well as the provision of emergency services and organ harvesting and transplantation (on average, an additional 10%-11% of a hospital's budget). Private, for-profit clinics owned either by individuals or, increasingly, by large corporations have the same funding mechanism as public hospitals, but the share of respective payers differs. Doctors' fees are billed in addition to the DRG in private clinics, and DRG payment rates are lower there than they are in public or nonprofit hospitals. This disparity is justified by differences in the size of facilities, the DRG mix, and the patients' characteristics (age, comorbid conditions, and socioeconomic status) (IRDES, 2013). Rehabilitative hospitals also have a prospective payment system based on length of stay and care intensity. Mental health care: Services for mentally ill people are provided by the public and private health care sectors, with an emphasis on community-based provision. Public care is provided within geographically determined areas and includes a wide range of preventive, diagnostic, and therapeutic inpatient and outpatient services. Ambulatory centers provide primary ambulatory mental health care, including home visits. Mental health care is not formally integrated with primary care, but a large number of disorders are also treated on an outpatient basis by GPs or private psychiatrists or psychologists, some of them practicing psychotherapy and, occasionally, psychoanalysis. Statutory health insurance covers care provided by GPs and psychiatrists in private practice, public mental health care dispensaries, and private psychiatric hospitals. Copayments do not apply to persons with a diagnosed long-term mental illness. Care provided by psychotherapists or psychoanalysts is fully financed by patients or covered by VHI. Copayments and the flat-rate fee for accommodation can also be fully covered by VHI. Long-term care and social supports: Total expenditure for long-term care in 2013 was estimated to be EUR39 billion (USD47 billion), or 17 percent oftotal health expenditures (DREES, 2014). Statutory health insurance covers the medical costs of long-term care, while families are reponsible for the housing costs in hospices and other long-term facilities-on average, EUR1 ,500 (USD1 ,809) per month (Ministere de la Sante 2013(2)). End-oflife care in hospitals is fully covered. Some funding of care for the elderly and disabled comes from the National Solidarity Fund for Autonomy, which is in turn financed by SHI and the revenues from an unpaid working "solidarity" day. Local authorities, the general councils, and households also participate in financing these categories of care. Home care for the elderly is provided mainly by self-employed physicians and nurses and, to a lesser extent, by community nursing services. Long-term care in institutions is provided in retirement homes and long-term care units, totaling roughly 10,000 institutions and 720,000 beds. Ofthese, 54 percent are public, 28 percent private nonprofit, and 18 percent for-profit, although the percentage of for-profit institutions is increasing (DREES, 2014). In addition, temporary care for dependent patients and respite services for their caregivers are available without restrictions from the states or regions. Means-tested monetary allowances are provided for the frail elderly. The allowance is adjusted in relation to the individual's dependence level, living conditions, and needs, as assessed by a joint health and social care team, and may be used for any chosen service and provider. About 1.1 percent of the total population is estimated to be eligible. Informal caregivers also benefit from tax deductions. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001641 OS 00003312 FRANCE &h What are the key entities for health system governance? The Ministry of Health sets and implements government policy in the areas of public health and the organization and financing ofthe health care system, within the framework ofthe Public Health Act. It regulates roughly 75 percent of health care expenditure on the basis of the overall framework established by parliament, which includes a shared responsibility with statutory health insurers for defining the benefit package, setting prices and provider fees (including diagnosis-related group fees and copayments), and pricing drugs. The parliamentary "Alert" Committee provides a midyear assessment of health care expenditures and proposes corrective measures in case expenditures exceed the target by more than 0.75 percent. The French Health Products Safety Agency oversees the safety of health products, from manufacturing to marketing. The agency also coordinates vigilance activities relating to all relevant products. The Agency for Information on Hospital Care manages the information systematically collected from all hospital admissions and used for hospital planning and financing. The remit of the National Agency for the Quality Assessment of Health and Social Care Organizations encompasses the promotion of patient rights and the development of preventive measures to avoid mistreatment, in particular in vulnerable populations such as the elderly and disabled, children, adolescents, and Organization of the Health System in France National level Parliament Alert Committee l ......oo ........................? ________ Statutory Health Insurance High Council for the High Level Council of Public Health (National Union of Insurance Funds) o..o.,,oo/.........''.,,...'.......' _ F_~ _: _i~-n-: :- :- :-: -,:h-h-: -: ,:- -: ,-~ :-: - ...,oM _o.._i;-~~-~-r~-~-~-: -~ -th...,.~ I I I I I I I I I National Council for the Governance of Regional Hea lth Agencies (SHI, MoH, National Solidarity Fund for Autonomy) . o ::::::.::::::::: : : : o Self-employed health professionals National Health Conference Regional leve l Regional Conference on Health and Autonomy Two coordination commissions: prevention and disability (local subsidiaries of the State, General Council, local SH I funds) ---------,.. o.? Hierarchical Advisor - ? .? ........................... ~ services ? - Regional Union of Health Professionals ? .... Planning Hospital sector Regiona l Health Agency Planning Health and social care sector for elder ly and disabled Planning Ambulatory care sector services Negotiation Notes: SHI: Statut ory health insurance. MoH: Ministry of Healt h. Adapted from K. Chevre ul, I. Dura nd-Za leski, S. B. Bahram i et a l., "France: Hea lth System Review," Health Systems in Transition, vo l. 12, no . 6, 2010, pp . xxi-xxii. Source: The Commonwealth Fund VA-19-0799-D-001642 OS 00003313 FRANCE socially marginalized people. It produces practice guidelines for the health and social care sector and evaluates organizations and services. The National Health Authority (HAS) is the main health technology assessment body, with in-house expertise as well as the authority to commission assessments from external groups. The HAS remit is diverse, ranging from the assessment of drugs, medical devices, and procedures to publication of guidelines, accreditation of health care organizations, and certification of doctors. Competition is limited to VHI, whose providers are supervised by the Mutual Insurance Funds Control Authority. ~ What are the major strategies to ensure quality of care? X National plans are developed for a number of chronic conditions (e.g., cancer, Alzheimer's), rare diseases, prevention, and healthy aging, in addition to the 104 targets set by the 2004 Public Health Act. These plans establish governance (e.g., the cancer plan to coordinate research and treatment in cancer and establish guidelines for medical practice and activity thresholds), develop tools, and coordinate existing organizations. All plans emphasize the importance of supporting caregivers and ensuring patients' quality of life, in addition to enforcing compliance with guidelines and promoting evidence-based practice. The National Health Authority publishes an evidence-based basic benefit package for 32 chronic conditions. Further guidance on recommended care pathways covers chronic obstructive pulmonary disease, heart failure, Parkinson's, and end-stage renal disease (Assurance Maladie, 2015). SHI and the Ministry of Health fund "provider networks" in which participating professionals share guidelines and protocols, agree on best practice, and have access to a common patient record. Regional authorities fund telemedicine pilot programs to improve care coordination and access to care for specific conditions (e.g., stroke) or populations (e.g., newborns, the elderly, prisoners). The PAERPA (Personnes Agees en Risque de Perte d'Autonomie) program, established in 2014 in nine pilot regions, is a nationwide endeavor to improve the quality of life and coordination of interventions for the frail elderly. For self-employed physicians, certification and revalidation are organized by an independent body approved by the National Health Authority. For hospital physicians, both can be performed as part of the hospital accreditation process. To ensure the lifelong quality of their practice, doctors, midwives, nurses, and other professionals must undergo continuous learning activities, which are audited every fourth or fifth year. Optional accreditation exists for a number of high-risk medical specialties (e.g., obstetrics and gynecology, surgery, cardiology). Accredited physicians can claim a deduction on their professional insurance premiums. Hospitals must be accredited every four years; criteria and accreditation reports are publicly available on the National Health Authority website (www.has-sante.fr). CompaqH, a national program of performance indicators, also reports results on selected indicators. Quality assurance and risk management in hospitals are monitored nationally by the Ministry of Health, which publishes online technical information, data on hospital activity, and data on control of hospital-acquired infections. Currently, financial rewards or penalties are not linked to public reporting, although they remain a contested issue. Information on individual physicians is not available. t:: J What is being done to reduce disparities? There is a 6.3-year gap in life expectancy between males in the highest and males in the lowest social categories (DREES, 2015) and poorer self-reported health among those with state-sponsored or without any complementary insurance. The reduction of health inequities is a major target ofthe 2014 National Health Strategy, and the 2004 Public Health Act set targets for reducing inequities in access to care related to geographic availability of services (so far, only nurses have agreed to limit new practices in overserved areas), financial barriers (out-of-pocket payments will be limited by state-sponsored complementary insurance), and International Profiles of Health Care Systems, 2015 VA-19-0799-D-001643 OS 00003314 FRANCE inequities in prevention related to obesity, screening, and immunization. A contractual agreement allows for the use of incentives for physicians practicing in underserved areas, the extension of third-party payment, and enforced limitations on denial of care. National surveys showing regional variations in health and access to health are reported by the Ministry of Health (DREES, 2015). 00 "...:::,I What is being done to promote delivery system integration and care coordination? Various quality-related initiatives aim to improve coordination of hospital, out-of-hospital, and social care (see above). At the regional level, telemedicine pilot programs are under way to coordinate health and social care services for target populations identified by the Regional Health Agencies, such as infants, prisoners, and persons with disabilities. Funding streams are pooled and earmarked for these pilots, and assessment is planned for 2016. ~ What is the status of electronic health records? A high-level electronic health record (EHR) project is currently being implemented across the entire country. Approximately 551,000 patients, or 0.8 percent of the population, have an EHR, and an estimated 600 hospitals and 6,000 health professionals use them. Hospital-based and office-based professionals and patients have a unique electronic identifier, and any health professional can access the record and enter information subject to patient authorization. Interoperability is ensured via a chip on patients' health cards. By law, patients have full access to the information in their own records, either directly or through their GP. All "structured information" included in EH Rs must be communicated, but handwritten notes are excluded. The sharing of information between health and social care professionals is not currently permitted, but will be tested as part of the PAERPA program for hospice residents. ~ A national agency for health information systems was created for the purpose of expanding uptake and interoperability of existing systems (ASIP, 2014), and the health records are available on a government website . How are costs contained? SHI has faced large deficits over the past 20 years, but it fell from an annual EUR10B-12B (USD12.1 B-14.5B) in 2003 to EUR6.2B (USD7.5B) in 2014. This trend is the result of a range of initiatives, including a reduction in the number of acute-care hospital beds; the removal of 600 drugs from public reimbursement; an increase in generic prescribing and the use of over-the-counter drugs; a reduction in the price of generic drugs; and a reduction of the official fees for self-employed radiologists and biology labs. Other cost-containment measures include central purchasing to better negotiate costs, increasing the share of outpatient surgery, and reducing duplicate testing. Competition is not used as a cost-control mechanism. Global budgets are used only in pricevolume agreements for drugs or devices. As described above, patient cost-sharing mechanisms include increased copayments for patients who refuse generics or do not use the gatekeeping system (Assemblee Nationale, 2013). A number of initiatives to reduce "low-value" care, launched by SHI and HAS, include pay-for-performance to reduce prescription of benzodiazepines for elderly persons; reductions in avoidable hospital admissions for patients with heart failure; early discharge after orthopedic surgery and normal childbirth; information on the absence of the benefit of prostate cancer screening; using DRG payments to incentivize shifts to outpatient surgery; establishing guidelines for the number of off-work days according to disease or procedure; strengthening controls for the prescription of expensive statins and new anticoagulants; encouraging the use of Avastin over Lucentis, and other less costly biosimilar drugs; and testing the use of taxi vouchers, instead of ambulances, for chronically ill patients (Assurance Maladie, 2015). The Commonwealth Fund VA-19-0799-D-001644 OS 00003315 FRANCE What major innovations and reforms have been introduced? The new Health Law, based on the 2012 pledge by the newly elected government to reduce health inequities and on the 2014 health strategy (Touraine, 2014), was passed in April 2015 to replace the previous law, dating back to 2004. It has 57 articles, the most prominent being the deployment of direct SHI payments to selfemployed GPs and a strong commitment to public health and prevention. The direct GP payments have been strongly opposed by physicians' unions on the grounds that such payments might be delayed by software dysfunction (versus immediate payment at the end of the consultation) and that physicians would become SHI "employees," and could be pressured into giving cheap care instead of appropriate care. The timetable is to have a full deployment by 2017 (the year of the presidential election). Prevention and public health measures aim to reduce addictions, eating disorders, and obesity, and include measures to fight binge drinking and anorexia. They support the mandatory neutral cigarette pack, the ban on soda fountains, experimentation with medically supervised IV drug injecting facilities, and mandatory nutrition information on packaged foods (Parlement, 2015). References ASIP (2014). http://www.interopsante.org/offres/doc_inline_srd412/4_Fran E7 ois%2BMacary_ASIP%2BSantE9 _Les%2Btests% 2Bd5C27i nteropE9ra bi litE9%2Bpou r%2 Bia %2 Be-santE9%2 Ben %2 BFrance. pdf?bcsi_sca n_4316 791 0db6ab4d9=0&bcsi_scan_ fi lena me=4_Fra n E? ois%2 BMacary_AS IP%2BSantE9 _Les%2 Btests%2 Bd5C27i nteropE9rabi litE9%2 Bpour%2 Bla%2 Besa ntE9%2Ben %2 BFrance. pdf. Assemblees Nation ale. http://www. assemblee-nationale. fr/14/projets/pl2302. asp. Assurance Maladie (2015). Rapport charges et produits pour /'annee 2016. http://www.ameli.fr/fileadmin/user_upload/ documents/cnamts_rapport_charges_produits_2016.pdf. Assurance Maladie (2015). http://www.ameli.fr/professionnels-de-sante/medecins/gerer-votre-activite/le-medecin-traitant/ le-dispositif-du-medecin-traitant.php. Chevreul, K., I. Durand-Zaleski, S. Bahrami, C. Hernandez-Quevedo, and P. Mladovsky (2010). "France: Health System Review," Health Systems in Transition 12(6):1-291. CISS (2014). Exercice liberal des medecins. http://www.leciss.org/sites/default/files/44-Exercice%20liberal%20medecinefiche-CISS.pdf. Cour des Comptes (2013). Le medecin traitant et le parcours de soins coordonnes : une reforme inaboutie. https://www. google .fr/u rl?url=https://www.ccomptes.fr/ content/ down load/53083/1415030/version/2/fi le/2_1_3 _medeci n_traitant_ parcours_soins_coordonnes.pdf&rct=j&frm=1 &q=&esrc=s&sa=U&ved=0CD0QFjAHahUKEwit3JHY4qXHAhXpK9sKHV1 eByc &usg=AFQjCNHnPSaxT0EnmwuvCpwR37kbWQJllw. Cour des Comptes (2014). Les relations conventionnelles entre /'assurance maladie et /es professions liberates de sante. http://www. ccom ptes. fr/Actua Iites/Archives/Les-re Iati ons-co nventi on ne 11 es-e ntre-I-assu ran ce-ma Iadi e-et-I es-professionsIi be ra Ies-de-sa nte. DREES (2014). Ministere de la Sante. Comptes nationaux de la sante 2013. http://www.drees.sante.gouv.fr/lMG/pdf/ comptes_sante_2013_edition_2014.pdf. DREES (2015). Ministere de la Sante. Les depenses de sante en 2014. http://www.drees.sante.gouv.fr/lMG/pdf/rapport_ cns_2015_commission.pdf. Fonds CMU 2014. Sixieme rapport d'evaluation de la loi du 27 juillet 1999 portant creation d'une couverture maladie universe/le. http://www. emu .fr/fichier-uti lisateu r/fichiers/Rapport_Eva Iuation_VI. pdf. INSEE 2015. Medecins suivant le statut et la specialite en 2015. http://www.insee.fr/fr/themes/tableau. asp?reg_id=0&ref_id= NATTEF06102 INSEE 2015;2. Les revenus d'activite des medecins liberaux recemment installes : evolutions recentes et contrastes avec leurs ai'nes. http://www.insee.fr/fr/ffddocs_ffdREVAIND15_c_D2_sante.pdf. IRDES 2013. http://www.irdes.fr/Publications/Oes2013/0es186.pdf. IRDES 2014. http://www. i rdes. fr/recherche/ questions-d-economie-de-la-sante/201-les-formes-du-regrou pementpl uri profession nel-en-soi ns-de-premiers-recou rs. pdf. Ministere de la Sante 2013(1 ). http://www.social-sante.gouv.fr/lMG/pdf/01 _Rapport_activite_liberale_EPS-2.pdf. Ministere de la Sante 2013(2). http://www.social-sante.gouv.fr/lMG/pdf/rapport_final_annexes.pdf. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001645 OS 00003316 FRANCE Nolte, E., C. Knai, and M. McKee (2008). Managing Chronic Conditions: Experience in Eight Countries. European Observatory. Organisation for Economic Co-operation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787 /data-00285-en. Accessed July 2, 2015. Parlement (2011). Arrete du 22 septembre 2011 portant approbation de la convention nationale des medecins generalistes et specialistes. http://www. legifra nee .gouv. fr/ affich Texte .do?cidTexte=JORFTEXT000024803 7 40. Parlement (2015). La loi de sante. http://www.gouvernement.fr/action/la-loi-de-sante. Ouotidien du Medecin (2015). Remuneration des maisons de sante. http://www.lequotidiendumedecin.fr/actualites/ a rticle/2015/02/27 /la-remuneration-des-ma isons-centres-et-poles-de-sante-a u-jou rnal-officiel-_7 41936. Senat (2014). L'exercice Regroupe, Un Nouveau Mode D'organisation De L'offre De Soins. http://www.senat.fr/rap/r07-014/ r07-0142.html. Touraine, M. (2014). "Health Inequalities and France's National Health Strategy." Lancet, March 29, 2014 383(9923):1101-02. The Commonwealth Fund VA-19-0799-D-001646 OS 00003317 ]]][ What is the role of government? = ?-ff: Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by competing, not-for-profit, nongovernmental health insurance funds ("sickness funds"; there were 124 as of January 2015) in the statutory health insurance (SHI) system, or by substitutive private health insurance (PHI). States own most university hospitals, while municipalities play a role in public health activities, and own about half of hospital beds. However, the various levels of government have virtually no role in the direct financing or delivery of health care. A large degree of regulation is delegated to self-governing associations of the sickness funds and the provider associations, which together constitute the most important body, the Federal Joint Committee. Who is covered and how is insurance financed? Publicly financed health insurance: In 2013, total health expenditure was 11.5 percent of GDP, of which 73 percent was public and 58 percent was SHI spending (Federal Statistical Office, 2015). General tax-financed federal spending on "insurance-extraneous" benefits provided by SHI (e.g., coverage for children) amounted to about 4.4 percent oftotal expenditure in 2014 and 2015. Sickness funds are funded by compulsory contributions levied as a percentage of gross wages up to a ceiling. Coverage is universal for all legal residents. All employed citizens (and other groups such as pensioners) earning less than EUR54,900 (USD69,760) per year as of 2015 are mandatorily covered by SHI, and their nonearning dependents are 1 covered free of charge. Individuals whose gross wages exceed the threshold and the previously SHI-insured self-employed can remain in the publicly financed scheme on a voluntary basis (and 75% do) or purchase substitutive PHI, which also covers civil servants. About 86 percent of the population receive their primary coverage through SHI and 11 percent through substitutive PHI. The remainder (e.g., soldiers and policemen) are covered under special programs. Visitors are not covered through German SHI. Undocumented immigrants are covered by social security in case of acute illness and pain, as well as pregnancy and childbirth. As of 2015, the legally set uniform contribution rate is 14.6 percent of gross wages. Both the legal contribution rate for employees (0.9%) and the supplementary premiums set by sickness funds have been abolished and replaced by a supplementary income-dependent contribution rate determined by each sickness fund individually (Busse and Blumel, 2014). As of 2015, the supplementary contribution rate is, on average, 0.9 percent-that is, most ofthe SHI-insured pay the same as previously, but rates range between O percent and 1.3 percent (Federa I Association of Sickness Funds, 2015). This contribution also covers dependents (nonearning spouses and children). Earnings above EUR49,500 (USD63,360) per year (as of 2015) are exempt from contribution. Sickness funds' contributions are centrally pooled and then reallocated to individual sickness funds using a risk-adjusted capitation formula, taking into account age, sex, and morbidity from 80 chronic and/or serious illnesses. Private health insurance: In 2014, 8.8 million people were covered through substitutive private health insurance (Association of Private Health Insurance Companies, 2015). PHI is especially attractive for young people with a good income, as insurers may offer them contracts with more extensive ranges of services and lower premiums. 1 Please note that, throughout this profile, all figures in USD were converted from EUR at a rate of about EUR0.79 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for Germany. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001647 OS 00003318 GERMANY There were 42 substitutive PHI companies in June 2015 (of which 24 were for-profit) covering the two groups exempt from SHI (civil servants, whose health care costs are partly refunded by their employer, and the selfemployed) and those who have chosen to opt out of SHI. All of the PHI-insured pay a risk-related premium, with separate premiums for dependents; risk is assessed only upon entry, and contracts are based on lifetime underwriting. Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases. PHI also plays a mixed complementary and supplementary role, covering minor benefits not covered by SHI, access to better amenities, and some copayments (e.g., for dental care). The federal government determines provider fees in substitutive, complementary, and supplementary PHI through a specific fee schedule. There are no government subsidies for complementary and supplementary PHI. In 2013, all forms of PHI accounted for 9.2 percent oftotal health expenditure (Federal Statistical Office, 2015). ~ What is covered? Services: SHI covers preventive services, inpatient and outpatient hospital care, physician services, mental health care, dental care, optometry, physical therapy, prescription drugs, medical aids, rehabilitation, hospice and palliative care, and sick leave compensation. Home care is covered by long-term care insurance (LTCI). SHI preventive services include regular dental checkups, child checkups, basic immunizations, checkups for chronic diseases, and cancer screening at certain ages. All prescription drugs are covered unless explicitly excluded by law (mainly so-called lifestyle drugs) or disallowed following evaluation. While the broader framework of the benefits package is legally defined, specifics are decided upon by the Federal Joint Committee (see below). Long-term care services are covered separately by the LTCI scheme (see below). Cost-sharing and out-of-pocket spending: Out-of-pocket (OOP) spending accounted for 13.6 percent oftotal health spending in 2013, mostly on nursing homes, pharmaceuticals, and medical aids (Federal Statistical Office, 2015). Copayments include EUR5.00 (USD6.40) to EUR10.00 (USD12.70) per outpatient prescription, EUR10.00 per inpatient day for hospital and rehabilitation stays (for the first 28 days per year), and EUR5.00 to EUR10.00 for prescribed medical devices. Sickness funds offer selectable tariffs with a range of deductibles and no-claims bonuses. Preventive services do not count toward the deductible. SHI-contracted physicians are not allowed to charge above the fee schedule for services in the SHI benefit catalogue. However, a list of "individual health services" outside the comprehensive range of SHI coverage may be offered to patients paying OOP. Safety nets: Children under 18 years of age are exempt from cost-sharing. For adults, there is an annual cap on cost-sharing equal to 2 percent of household income; part of a household's income is excluded from this calculation for additional family members. About 0.4 million SHI insureds exceeded the 2 percent cap in 2013 and were exempted from further cost-sharing. The cap is lowered to 1 percent of annual gross income for qualifying chronically ill people; to qualify, those people have to demonstrate that they attended recommended counseling or screening procedures prior to becoming ill. Nearly 6.5 million people, or around 9 percent of all the SHI-insured, benefited from this regulation in 2013 (Federal Statistical Office, 2015). Unemployed people contribute to SHI in proportion to their unemployment entitlements. For the long-term unemployed, government contributes on their behalf. [ (R)] How is the delivery system organized and financed? Physicians: General practitioners (GPs) and specialists in ambulatory care who get reimbursed by SHI are by law mandatory members of regional associations that negotiate contracts with sickness funds. Regional associations of SHI-accredited physicians are responsible for coordinating care requirements within their region, and act as financial intermediaries to the sickness funds and the physicians in ambulatory care. However, ambulatory physicians typically work in their own private practices-around 60 percent in solo practice and 25 percent in dual practices. Most physicians employ doctors' assistants, while other nonphysicians (e.g., physiotherapists) The Commonwealth Fund VA-19-0799-D-001648 OS 00003319 GERMANY have their own premises. In 2014, ofthe roughly 109,600 self-employed SHI-accredited physicians in ambulatory care, 52,800 (48%) were practicing as family physicians (including GPs, internists, and pediatricians) and 56,800 (52%) as specialists. There were about 2,000 multispecialty clinics with more than 13,000 physicians (10% of ambulatory care physicians) in 2014. Around 11,000 physicians working in multispecialty clinics are salaried employees, while 12,000 are employed in practices of self-employed physicians. The total number of ambulatory care physicians is more than 130,000 (Federal Association of SHI Physicians, 2015). Some specialized outpatient care is provided by hospital specialists, including treatment of rare diseases and of severe progressive forms of disease, as well as highly specialized procedures. Individuals have free choice among GPs, specialists, and, if referred to inpatient care, hospitals. Registration with a family physician is not required, and GPs have no formal gatekeeping function. However, sickness funds are required to offer their members the option to enroll in a "family physician care model," which has been shown to provide better services and also often provides incentives for complying with gatekeeping rules. SHI-accredited physicians in ambulatory care (GPs and specialists) are generally reimbursed on a fee-for-service (FFS) basis according to a uniform fee schedule negotiated between sickness funds and physicians (see below). Payments are limited to predefined maximum numbers of patients per practice and reimbursement points per patient, setting thresholds on the number of patients and treatments per patient for which a physician can be reimbursed. For the treatment of private patients, GPs and specialists also get an FFS, but the private tariffs are usually higher than the tariffs in the SHI uniform fee schedule. Pay-for-performance has not been established yet. The average reimbursement of a family physician is above EUR200,000 (USD254,000) per year, covering costs for personnel, etc., but excluding income from private patients, which varies substantially (Federal Association of SHI Physicians, 2015). Financial incentives for care coordination can be part of integrated care contracts, but are not routinely implemented. The only regular financial incentive that GPs receive is a fixed annual bonus (EUR120, or USD152, in 2015) for patients enrolled in a Disease Management Program (DMP), in which physicians provide patient training and document patient data. Bundled payments are not common in primary care, but a regional initiative, "Healthy Kinzigtal" (Kinzigtal is a valley in southeast Germany), provides an example of a shared savings model offering primary care doctors and other providers financial incentives for integrating care across providers and services. Administrative mechanisms for direct patient payments to providers: SHI physicians in ambulatory care bill their regional associations according to a uniform fee schedule; the associations are in turn reimbursed by sickness funds. Copayments or payments for services not included in the benefit catalogue are paid directly to the provider. In cases of private health insurance, patients pay up front and submit claims to the insurance company for reimbursement. After-hours care: After-hours care is organized by the regional associations of SHI-accredited physicians to ensure access to ambulatory care around the clock. Physicians are obliged to provide after-hours care in their practice, with differing regional regulations. In some areas (e.g., Berlin), after-hours care has been delegated to hospitals. The patient is given a report of the visit afterwards to hand to his or her GP. There is also a tight network of emergency care providers (the responsibility of the municipalities). After-hours care assistance is also available via a nationwide telephone hotline ( 116 117-Arztlicher Bereitschaftsdienst). Payment for ambulatory after-hours care is based on the above-mentioned fee schedules, again with differences in the amount of reimbursement for SHI and PHI. Hospitals: Public hospitals make up about half of all beds, while private not-for-profits account for about a third. The number of private, for-profit hospitals has been growing in recent years (now around one-sixth of all beds). All hospitals are staffed principally by salaried doctors. Doctors in hospitals are typically not allowed to treat outpatients (similar to hospitalists in the U.S.), but exceptions are made if necessary care cannot be provided by office-based specialists. Senior doctors can treat privately insured patients on an FFS basis. Hospitals can also provide certain highly specialized services on an outpatient basis. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001649 OS 00003320 GERMANY The 16 state governments determine hospital capacity, while ambulatory care capacity is subject to rules set by the Federal Joint Committee. Inpatient care is paid per admission through a system of diagnosis-related groups (DRGs) revised annually, currently based on around 1,200 DRG categories. DRGs also cover all physician costs. Other payment systems like pay-for-performance or bundled payments have yet to be implemented in hospitals. Mental health care: Acute psychiatric inpatient care is largely provided by psychiatric wards in general (acute) hospitals, while the number of hospitals providing care only for patients with psychiatric and/or neurological illness is low. In 2014, there were a total of 32,872 office-based psychiatrists, neurologists, and psychotherapists working in the ambulatory care sector (paid FFS) (Federal Association of SHI Physicians, 2015). Qualified GPs can provide basic psychosomatic services. Ambulatory psychiatrists are also coordinators of a set of SHIfinanced benefits called "sociotherapeutic care" (which requires referral by a GP), to encourage the chronically mentally ill to use necessary care and to avoid unnecessary hospitalizations. To further promote outpatient care for psychiatric patients (particularly in rural areas with a low density of psychiatrists in ambulatory care), hospitals can be authorized to offer treatment in outpatient psychiatric departments. Long-term care and social supports: LTCI is mandatory and usually provided by the same insurer as health insurance, and therefore comprises a similar public-private insurance mix. The contribution rate of 2.35 percent of gross salary is shared between employers and employees; people without children pay an additional 0.25 percent. The contribution rate will increase further by 0.2 percentage points in early 2017. Everybody with a physical or mental illness or disability (who has contributed for at least two years) can apply for benefits, which are: 1) dependent on an evaluation of individual care needs by the SHI Medical Review Board (leading either to a denial or to a grouping into currently one of three levels of care); and 2) limited to certain maximum amounts, depending on the level of care. Beneficiaries can choose between in-kind benefits and cash payments (around a quarter of LTCI expenditure goes to these cash payments). Both home care and institutional care are provided almost exclusively by private not-for-profit and for-profit providers. As benefits usually cover approximately 50 percent of institutional care costs only, people are advised to buy supplementary private LTCI. Since 2013, family caregivers get financial support through continuing payment of up to 50 percent of care payments if they provide care. Hospice care is partly covered by LTCI if the SHI Medical Review Board has evaluated a care level. Medical services or palliative care in a hospice are covered by SHI. The number of inpatient facilities in hospice care has grown significantly over the past 15 years, to 200 hospices and 250 palliative care wards nationwide in 2014 (German Hospice and Palliative Association, 2015). Legislation has recently been discussed to improve hospice and palliative care with the aim of guaranteeing care in underserved rural areas and linking long-term care facilities more strongly to ambulatory palliative and hospice care. ffi What are the key entities for health system governance? The German health care system is notable for two essential characteristics: 1) the sharing of decision-making powers between states, federal government, and self-regulated organizations of payers and providers; and 2) the separation of SHI (including the social LTCI) and PHI (including the private LTCI). SHI and PHI (as well as the two long-term care insurance systems) use the same providers-that is, hospitals and physicians treat both statutorily and privately insured patients, unlike many other countries. Within the legal framework set by the Ministry of Health, the Federal Joint Committee has wide-ranging regulatory power to determine the services to be covered by sickness funds and to set quality measures for providers (see below). To the extent possible, coverage decisions are based on evidence from health technology assessments and comparative-effectiveness reviews. The Federal Joint Committee is supported by the Institute for Quality and Efficiency (IQWiG), a foundation legally charged with evaluating the costeffectiveness of drugs with added therapeutic benefits, and the newly formed Institute for Quality and Transparency (IQTiG). The Federal Joint Committee has had 13 voting members: five from the Federal Association of Sickness Funds, two each from the Federal Association of SHI Physicians and the German The Commonwealth Fund VA-19-0799-D-001650 OS 00003321 GERMANY Hospital Federation, one from the Federal Association of SHI Dentists, and three who are unaffiliated. Five patient representatives have an advisory role but no vote in the committee. Representatives of patient organizations have the right to participate in different decision-making bodies, e.g., the subcommittees of the Federal Joint Committee. ~ The Federal Association of Sickness Funds works with the Federal Association of SHI Physicians and the German Hospital Federation to develop the SHI ambulatory care fee schedule and the DRG catalogue, which are then adopted by bilateral joint committees. What are the major strategies to ensure quality of care? Quality of care is addressed through a range of measures broadly defined by law, and in more detail by the Federal Joint Committee. Structural quality is assured by the requirement that providers have a quality Organization of the Health System in Germany Federal state (Ministry of Health) Supervision and tax subsidies Lander (states) Supervision and (partial) financing Statutory long-term care insurance SHI-insured Social Courts a, ? Sickness funds (and their associations) Statutory long-term care funds 7J C oFederal Joint Committee ""O C CD !l) ;::;:- ::::,- ('(l !l) +-' +-' CC Q) n ::,- to .9:! CD ::::, . - +-' +-' ('(l () ('(l Q. Q.+-' C::::, ,ii" CJ) -o Long-term care insurance Federal Chamber of Physicians Ql Private health insurance "':, Private health insurance Source: Adapted from R. Busse and M . Blumel, "Germa ny: Health System Review," Health Systems in Transition, vol. 16, no. 2, 2014, p . 20. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001651 OS 00003322 GERMANY management system, by the stipulation that all physicians continue their medical education, and by health technology assessments for drugs and procedures. However, there is no revalidation requirement for physicians. Hospital accreditation is voluntary. All new diagnostic and therapeutic procedures applied in ambulatory care must be positively evaluated in terms of benefits and efficiency before they can be reimbursed by sickness funds. Volume thresholds have been introduced for a number of complex procedures (e.g., transplantations), requiring a minimum number of such procedures for hospitals to be reimbursed. Process and (partly) outcome quality are addressed through the mandatory quality reporting system for the roughly 2,000 acute-care hospitals. The recently passed Hospital Care Structure Reform Act will provide a focus on quality-related hospital accreditation and payment, beginning in 2016 (see section on reforms). Disease management programs are modeled on evidence-based treatment recommendations, with mandatory documentation and quality assurance. Nonbinding clinical guidelines are produced by the Physicians' Agency for Quality in Medicine and by professional societies. All hospitals are required to publish results on selected indicators defined by the Federal Office for Quality Assurance and, until 2015, the AQUA Institute, allowing for hospital comparisons. Many institutions and health service providers include complaint management systems as part of their quality management programs; in 2013, such systems were made obligatory for hospitals. At the state level, professional providers' organizations are urged to establish complaint systems and arbitration boards for the extrajudicial resolution of medical malpractice claims. To strengthen quality by law, in addition to the above, government commissioned the Federal Joint Committee in 2015 to establish the Institute for Quality and Transparency in Health Care, replacing the AQUA Institute. The institute is operational from January 2016, with the task of developing further indicators for quality assurance, which might provide an additional criterion for decisions on hospital planning and payment. The Robert Koch Institute, an agency subordinate to the Federal Ministry of Health and responsible for the control of infectious diseases and health reporting, has conducted national patient surveys and published epidemiological, public health, and health care data. Disease registries for specific diseases, such as certain cancers, are usually organized regionally. In August 2013, as part ofthe National Cancer Plan, the federal government passed a bill that proposes the implementation of a nationwide standardized cancer registry in 2018 to improve the quality of cancer care. t-1 ~ What is being done to reduce disparities? Strategies to reduce health disparities are delegated mainly to public health services, and the levels at which they are carried out differ between states. Health disparities are implicitly mentioned in the national health targets. A network of 53 health-related institutions (e.g., sickness funds and their associations) promotes the health ofthe socially deprived (Cooperative Alliance National Health Targets, 2015). Primary prevention is mandatory by law for sickness funds; detailed regulations are delegated to the Federal Association of Sickness Funds, which has developed guidelines regarding need, target groups, and access, as well as procedure and methods. Sickness funds support 22,000 health-related programs, e.g., in nurseries and schools (Federal Association of Sickness Funds, 2015). With the Act to Strengthen Health Promotion and Prevention, these programs will be further developed and financially supported (see below). The Health Monitor (Gesundheitsmonitor) is a national association of nonprofit organizations and sickness funds. To assess access to health care, it regularly conducts studies from the patient perspective, for example, on the level of information, experiences with health care, or evaluation of health system reforms. The Commonwealth Fund VA-19-0799-D-001652 OS 00003323 GERMANY (C)-0- What is being done to promote delivery system integration and )yf care coordination? Many efforts to improve care coordination have been implemented, e.g., sickness funds offer integrated-care contracts and disease management programs for chronic illnesses to improve care for chronically ill patients and to improve coordination among providers in the ambulatory sector. In December 2014, 9,917 registered disease management programs for six indications had enrolled about 6.5 million patients (more than 8% of all the SHIinsured). There is no pooling of funding streams between the health and social care sectors. From 2016, the Innovation Fund will promote new forms of cross-sectoral and integrated care (also for vulnerable groups) supported by annual funding of EUR300 million, or USD381 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds will be awarded through an application process overseen by an Innovation Committee based at the Federal Joint Committee. ~ What is the status of electronic health records? About 90 percent of physicians in private practice use electronic health records (EH Rs) to help with billing, documentation, tracking of laboratory data, and quality assurance. The use of online services to transmit billing information and documentation from disease management programs is obligatory. Hospitals have implemented EH Rs to varying degrees. Unique patient identifiers do not exist and interoperability is limited, as data safety concerns represent a significant obstacle. ~ As of 2015, electronic medical chip cards are used nationwide by all the SHI-insured; they encode information as to the person's name, address, date of birth, and sickness fund, along with details of insurance coverage and the person's status regarding supplementary charges (Company for Telematics Applications for the Electronic Health Card, 2015). In 2015, the Federal Cabinet proposed a bill for secure digital communication and health care applications (E-Health Act), which provides concrete deadlines for implementing infrastructure and electronic applications, and introduces incentives and sanctions if schedules are not adhered to. SHI physicians will receive additional fees for transmitting electronic medical reports (2016-17), collecting and documenting emergency records (from 2018), and managing and reviewing basic insurance claims data online. From July 2018, SHI physicians who do not participate in the online review ofthe basic insurance claims data will receive reduced remuneration. Furthermore, in order to ensure greater safety in drug therapy, patients who use at least three prescribed drugs simultaneously will receive an individualized medication plan, starting in October 2016. In the medium term, this medication plan will be included in the electronic medical record (Federal Ministry of Health, 2015). How are costs contained? All drugs, both patented and generic, are placed into groups with a reference price serving as a maximum level for reimbursement, unless they can demonstrate added medical benefit. Drug companies are required to produce scientific dossiers for all new drugs demonstrating added medical benefit, which is then evaluated by IQWiG, followed by a Federal Joint Committee decision within a six-month period. For drugs with added benefit, the Federal Association of Sickness Funds negotiates a rebate on the manufacturer's price that is applied to all patients. In addition, rebates are negotiated between individual sickness funds and pharmaceutical manufacturers to lower prices below the reference price. Recently, reliance on overall budgets for ambulatory physicians and hospitals and on collective regional prescription caps for physicians has been replaced by an emphasis on quality and efficiency. The Hospital Care Structure Reform Act aims not only to link hospital payments to good service quality, but also to reduce payments in the case of "low value." To extend competition, some purchasing powers have been handed over to the sickness funds, e.g., to contract providers selectively within an integrated care contract or to negotiate rebates with pharmaceutical companies. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001653 OS 00003324 GERMANY What major innovations and reforms have been introduced? In June 2015, parliament passed the Act to Strengthen SHI Health Care Provision. This act is based on the 2011 SHI Care Structures Act, and takes measures to further strengthen service provision structures for SHI patients, particularly in underserved rural areas. These measures include a right for municipalities to establish medical treatment centers, a ban on transferring SHI-accredited practices to successors in overserved areas, the establishment of appointment service centers that would guarantee a specialist appointment within four weeks, and the promotion of innovative forms of care, especially through the establishment of an Innovation Fund at the Federal Joint Committee endowed with EUR300 million (USD381 million) annually from 2016 to 2019 (Health Systems and Policy Monitor, 2015). The Act to Strengthen Health Promotion and Prevention passed parliament in July 2015. In an upcoming National Prevention Conference, the social security schemes, in collaboration with federal, state, and local governments, as well as the Federal Employment Agency, will agree on common goals and approaches. Furthermore, the act aims to improve prevention and health promotion by regulating vaccination policy and by expanding health checkups. Sickness funds and long-term care funds invest EUR500 million (USD635 million) annually, of which about EUR300 million is earmarked for health promotion in children's day-care facilities, schools, the work environment, and long-term care facilities (Federal Ministry of Health, 2015). The Hospital Care Structure Reform Act comes into force in January 2016. The law provides for the introduction of quality aspects in hospital planning (legally defined minimum volumes) and payment (quality-related supplements and reductions), as well as a more patient-friendly design for hospital reports. In order to strengthen nursing care of patients and to create new nursing jobs, a subsidy program will provide up to EUR660 million (USD839 million) in 2016-2018, and, starting in 2019, EUR330 million (USD419 million) per year. Hospital financing will be developed further and the reallocation pool will earmark EUR500 million to support measures to improve hospital care structures (Federal Ministry of Health, 2015). Several other bills are pending in the legislative process, e.g., the E-Health Act (see section on EHR) and the Hospice and Palliative Care Act (see section on long-term care and social supports). The authors would like to acknowledge Stephanie Stock as a contributing author to earlier versions of this profile. References Association of Private Health Insurance Companies (2015). Zahlen und Fakten. https://www.pkv.de/service/zahlen-undfakten/. Accessed Nov. 5, 2015. Busse, R., M. Blumel. (2014). "Germany: Health System Review." Health Systems in Transition, 2014 16(2):1-296. http://www. euro.who.int/_data/assets/pdf_file/0008/255932/HiT-Germany.pdf?ua=1 . Accessed July 22, 2015. Company for Telematics Applications for the Electronic Health Card (2015). Elektronische Gesundheitskarte. https://www. gematik.de. Accessed Nov. 5, 2015. Cooperative Alliance National Health Targets (2015). Gesundheitsziele.de. http://www.gesundheitsziele.de/. Accessed Nov. 5, 2015. Federal Ministry of Health (2015). Gesetze und Verordnungen. http://bmg.bund.de/. Accessed July 22, 2015. German Hospice and Palliative Association (2015). Entwicklung stationarer Hospiz- und Palliativeinrichtungen. http://www.dhpv.de/service_zahlen-fakten.html. Accessed Nov. 5, 2015. Organisation for Economic Co-operation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787/data-00285-en. Accessed July 2, 2015. Federal Association of Sickness Funds (2015). Kennzahlen der gesetzlichen Krankenversicherung. http://www.gkvspitzenverband.de. Accessed July 22, 2015. Federal Association of SHI Physicians (2015). Statistische lnformationen aus dem Bundesarztregister 2014. http://www.kbv. de. Accessed July 22, 2015. Federal Statistical Office (2015). Gesundheitsberichterstattung des Bundes. http://www.gbe-bund.de. Accessed July 22, 2015. Health Systems and Policy Monitor (2015). Germany. http://www.hspm.org/countries/germany28082014/countrypage.aspx. Accessed July 22, 2015. The Commonwealth Fund VA-19-0799-D-001654 OS 00003325 ~ fi1 ? li What is the role of government? The constitution of India considers the "right to life" to be fundamental and obliges government to ensure the "right to health" for all, without any discrimination (MOH, 2009; Thomas, 2009). More recently, the National Health Bill, introduced in 2009, views health care as a public good and health as a human right of every individual (MOH, 2009). The goal of India's national health policy is universal access to good-quality health care services without financial hardship (MOH, 2014). Under the constitution, areas of public policy are divided between the central and state governments. States are responsible for organizing and delivering health services to their population. The central government, meanwhile, plays an important role with respect to international treaties, medical education, prevention of food adulteration, quality control in drug manufacturing, national disease control, and family planning programs. It also carries out a stewardship role with respect to policymaking, developing the regulatory framework, and supporting the work of the states. At the local level, Panchayati Raj institutions (PRls)-a decentralized system of local governance formalized in 1992-and their elected representatives participate in the functioning of district and subdistrict institutions through various committees (MOH, 2014). ?-ff: Who is covered and how is insurance financed? Publicly financed health insurance: In spite of strong economic growth, total expenditures on health represent 4.1 percent of GDP (MOH, 2014). Of total health expenditures, 71.6 percent were financed by private funds and 26.7 percent by public funds, including central, state, and local government bodies and external flows (CBHI, 2013). Per capita health spending has risen from USD21 in 2000 to USD44 in 2009 (WHO, 2015). The 12th five-year plan (2012-17) aims to increase public spending to 2 percent of GDP (MOH, 2011 ). In principle, coverage of health services is universal and available to all citizens under the tax-financed public system. In the draft national policy document, it is proposed that tax-based financing remain the major source of funding for the 70 percent of the population who are poor. Free primary care provided by the public sector, supplemented by strategic purchase of secondary and tertiary care services from both the public and private sectors, would be the main financing approach (MOH, 2014). However, in practice, severe bottlenecks in accessing government health care services compel households to seek private care, often resulting in high out-of-pocket payments. In addition to public health facilities, a number of health insurance schemes currently exist in India. The central government's health services for civil servants and state-level employee insurance for formal workers are mandatory schemes. More recently, a number of social health initiatives, like Rashtriya Swasthya Bima Yojana (RSBY), have been launched to broaden health care access, mainly for the poor. These have enrolled 36 million people, expanding coverage from 5 percent to 15 percent over a six-year period (RSBY, 2015). With proposed expansion of the RSBY scheme to include rickshaw and taxi drivers, rag pickers, sanitation workers, domestic workers, street vendors, building and construction workers, and beedi (tobacco) workers, coverage under the scheme is expected to increase further (RSBY, 2015). Given these trends, a World Bank study projects that by 2015, about halfthe country's population could be covered with some form of health insurance (Forgia and Nagpal, 2012). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001655 OS 00003326 INDIA Private health insurance: The majority of private expenditures are out-of-pocket payments made mainly at the point of service, and less than 5 percent are financed by voluntary health insurance (VHI). Despite tax exemptions for insurance premiums, only upper-class urban populations are able to afford VHI, which serves as a substitute for government health services. Given India's expanding middle class, low VHI penetration is surprising. It appears that in the coming years, the private insurance industry, which is still in its infancy, has the potential to expand. ?1 What is covered? Services: Covered services, some of which require copayments (see below), include preventive and primary care, diagnostic services, and outpatient and inpatient hospital care. Medications on the essential drug list are free (if and when available), while other prescription drugs are purchased from private pharmacies. Services available through the national health programs are free to all. India has one of the world's largest publicly financed HIV drug programs, and all drugs and diagnostic services for vector-borne diseases, such as dengue fever and malaria, are free, as are insecticide-treated bed nets for malaria control. Immunizations and maternal and child health (MCH) services are free as well (MOH, 2014). Under the National Rural Health Mission, public health institutions in rural areas are being upgraded to meet the benchmarks for quality laid down by the Indian Public Health Standards (IPHS) (MOH 2013), which specify essential and desirable services that must be available in each type of health care facility. For example, at primary health centers these include outpatient services; emergency care provided mainly by nursing staff; referral and inpatient services; MCH-related services; school health and adolescent health services; care for noncommunicable diseases; basic laboratory services; linkages with secondary care providers and community health centers; basic surgical procedures; and medications on the state essential drug list and those required under national programs. The standards also cover necessary infrastructure and human resources. In practice, however, the availability of staff, equipment, and drugs varies significantly between and within states. Cost-sharing and out-of-pocket spending: Most states have some user charges for outpatient visits, hospital admission, diagnostic and prescription drugs, though there is huge variation in fee policies among the states. More than 70 percent of total health expenditures are financed through user fees, and most out-of-pocket spending is for hospital admissions. Nearly all admission, even to public hospitals, lead to catastrophic health expenditures, and over 63 million people are faced with impoverishment every year because of health care costs. In 2011-12, out-of-pocket spending on health care as a share of total monthly household spending per capita was 6.9 percent in rural areas and 5.5 percent in urban areas (MOH, 2014). Under the National Rural Health Mission, free treatment in public hospitals, as part of the Janani Suraksha Yojana, 1 was extended to maternity, newborn, and infant care and to control oftuberculosis, malaria, and HIV/ AIDS. For all other services, user fees continue to apply, especially for diagnostics and drugs excluded from the state's essentia I drug list (MOH, 2014). Safety nets: Safety nets for the poor and other vulnerable groups are provided by a number of governmentfunded health insurance schemes that have been introduced in recent years. These are intended to improve access to hospitals and reduce out-of-pocket payments. Some states finance hospital care through health insurance programs. The RSBY (see above) protects mostly those below the poverty level. 2 Evaluations of such schemes show improved utilization of hospital services (mainly private), especially among the poorest 20 percent of households (MOH, 2014). 1 Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission with the objective of reducing maternal and neonatal mortality through the promotion of institutional delivery among poor pregnant women. 2 Defined as monthly per capita consumption expenditure of INR972 (USD55) in rural areas and INR1 ,407 (USD79.50) in urban areas. Please note that, throughout this profile, all figures in USD were converted from INR at a rate of INR17.7 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for India. The poverty ratio at the all-India level is 29.5 percent (Planning Commission, 2014). The Commonwealth Fund VA-19-0799-D-001656 OS 00003327 INDIA Another program, designed to reduce maternal mortality, is Janani Shishu Suraksha Karyakarm, launched in 2011 and currently implemented all over India. It entitles all pregnant women to free delivery, including by caesarean section, in public health institutions. Women receive free food, drugs, and consumables, as well as free diagnostics. Free transportation is also provided. Similar entitlements are available for all sick infants (up to age 1) at public health facilities (MOH, 201 Sa). [ (R)j How is the delivery system organized and financed? The average number of patients seen by a registered doctor and nurse is 1,212 and 532, respectively (WHO, 2013). This implies an average of 0. 7 doctors and 1.1 nurses per 1,000 population, compared with 3.2 and 8.8, respectively, in countries within the Organisation for Economic Co-operation and Development (OECD, 2014). Although India has a much younger population than OECD countries, this acute shortage of providers is a major constraint as India moves toward universal coverage. Health care services are delivered by a complex network of public and private providers, ranging from single doctors to specialty and "super-specialty" tertiary care corporate hospitals. The government health care system is designed as a three-tier structure comprising primary, secondary, and tertiary facilities. Primary care: Facilities at the primary level include: subcenters (SCs), for a population of 3,000 to 5,000; primary health centers (PHCs), for 20,000 to 30,000 people; and community health centers (CHCs), which serve as referral centers for every four PHCs, covering 80,000 to 120,000. Primary health centers (PHCs) are the cornerstone of rural health services, serving as a first "port of call" to a qualified doctor in the public health sector and providing a range of preventive, promotive, and curative health services. On average, they have about six beds for inpatient admission. In 2012, there were 148,366 SCs, 24,049 PHCs, and 4,833 CHCs (CBHI, 2013). Availability of staff in these primary care facilities is a major concern. For example, specialist shortage at CH Cs is nearly 70 percent (CBH I, 2013). Primary care doctors working in the public sector are employed by local governments and paid salaries. No registration is required, and patients generally go to the nearest PHC located in their geographical area. There are a number of other staff at PHCs, among them auxiliary nurse-midwives, pharmacists, and lab techniciansall on salary. Normally, there is limited scope for primary care doctors to earn additional income via incentives. Although government doctors in most states are banned from private practice, officials find it is difficult to monitor and take action against offending doctors. In the private sector, an array of services is provided, in both urban and rural areas, by solo practices ranging from unregistered "quacks" to registered medical practitioners to small nursing homes and poly clinics. There are estimates that as much as 40 percent of private care is provided by unqualified providers (MOH, 2014). Patients pay out-of-pocket for the services received. There are no fee schedules. Outpatient specialist care: In government health facilities, salaried, full-time specialists are located at CHCs and district hospitals. Usually, choice is limited in rural areas. These specialists are not permitted to work in private practice in most states. In the private sector, there is a huge choice of specialists, especially in urban areas. Consultation fees vary, as there is no fixed fee schedule, and they operate from their own clinics, hospitals, or poly clinics, or from speciality hospitals. Private specialists are commonly visited by upper- and middle-class urban residents. Administrative mechanisms for direct patient payments to providers: There are no direct payments in public health facilities and most government-sponsored insurance programs. In the private sector, patients usually pay directly out-of-pocket. Only in a small percentage of cases where patients have VHI is payment made up front and claims submitted to the insurer for reimbursement. After-hours care: All PHCs are expected to provide basic emergency services (mainly by nursing staff), and all CHCs are equipped to provide emergency services around-the-clock. Primary care doctors are required to International Profiles of Health Care Systems, 2015 VA-19-0799-D-001657 OS 00003328 INDIA provide after-hour care, reimbursement for which is built into their salaries. A free medical help line is being operated by certain states in India. Hospitals: District hospitals function as the secondary tier of public providers for the rural population (MOH, 2011 ). The average population served per public bed is 1,946. Of a tota I of 628,708 government beds, 196,182 are in rural areas (CBHI, 2013). Government hospitals operate within a yearly budget allocation. There has been a major expansion of the private hospital sector recently, and government-sponsored health schemes rely on private hospitals as a part of public-private partnerships. Between 2002 and 2010, the private sector created more than 70 percent of new beds, contributing 63 percent of total hospital beds (Gudwani et al., 2012). The private sector currently provides about 80 percent of outpatient care and 60 percent of inpatient care (MOH, 2014). In addition, about 80 percent of doctors, 26 percent of nurses, and 49 percent of beds are in the private sector (Wennerholm et al., 2013). Private-sector hospitals range from small, family-run general hospitals to facilities providing super-speciality tertiary care. Until the 1980s, private-sector hospitals were mainly run by charitable trusts and registered as notfor-profit. With India's economic liberalization, a growing middle class, and the rise in medical tourism, a number of corporate hospitals have been established, and for-profit private hospitals are becoming more common. There also has been a considerable expansion in tertiary care service providers in recent years, mostly in the private sector. The need for tertiary care is growing, but the costs are growing even faster and have become prohibitive (MOH, 2014). Physician payment in the private sector varies from salary to fee-for-service. Hospitals that pay doctors a fixed salary do have incentives for attracting new patients but provide no incentives for internal referrals within the hospita I. Mental health care: Mental health is one ofthe most neglected areas of India's health system. India has less than 21 percent of the psychiatrists its population needs and less than 2 percent of clinical psychologists and social workers required (CBHI, 2013). Attempts are being made to rectify the situation. For example, the Mental Health Care Bill of 2013 makes access to mental health care a right for every person. Access at government health facilities must be affordable, of good quality, and provided without discrimination. Recently, under the National Mental Health Programme (NMHP), a mass media campaign on creating awareness and reducing stigma was undertaken. To address the gap in mental health resources and increase training capacity, 10 centers of excellence and 23 postgraduate departments in mental health specialties have been established across the country (MOH, 2011). According to the IPHS guidelines under NMHP, primary health centers should ensure early identification (diagnosis) and treatment of common mental disorders such as psychosis, depression, anxiety disorders, and epilepsy, as well as referral services. It is also essential that PHCs provide information, education, and communication on prevention, stigma removal, and early detection of mental disorders. However, given capacity constraints, it remains to be seen to what extent these steps are implemented. Long-term care and social supports: Despite the growing elderly population, there has been a lack of longterm care services. Families have mainly been responsible for providing necessary care. Recently, the central government launched the National Programme for Health Care of the Elderly to address the health-related problems of elderly people (MOH, 2015a; DGHS, 2011). This is intended to provide additional human resources and funding for home care, screening for early diagnosis, vaccinations for high-risk groups, and health education for caregivers. Examples of social welfare support provided to the elderly include old-age pensions, subsidized food and transport, lower income tax, and higher savings interest rates. Benefits under certain schemes for the elderly, such as the old-age pension scheme and the public distribution system, are available to those below the poverty level. The Commonwealth Fund VA-19-0799-D-001658 OS 00003329 INDIA Given increasing life expectancy, an expanding middle class, and technological advances, there has been growing interest in the private sector in providing home care for the elderly. ffi What are the key entities for health system governance? Public actors in the Indian health care system include the Ministry of Health and Family Welfare, state governments, and municipal and local level bodies. The ministry consists ofthe Department of Health and Family Welfare and Department of Health Research (MOH, 201 Sa). Despite the existence ofthe latter, there is very little evidence that comparative research and cost-effectiveness studies are used in policy formation. The Directorate General of Health Services, an attached office of the Department of Health and Family Welfare, provides technical advice and is involved in the implementation of health schemes. In 2014, the new Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy was formed. In addition, health care services Organization of the Health System in India Levels ------ .---- --- ----------- ------- ------- ---------------- ------- ---- -------------- ----. --------National Drug ' Regulatory and Development Authority National ,----National Health Promotion and ' National Health Regulatory and National Drug Supply Logistic Corp. Directorate of Medical Education State Di rector ate of Nursing Directorate of Public Health, Family Welfare, and Health Systems Management Directorate of Hospital Services Other Directorates 1. AYUSH 2. ESI 3. Procurement State Drug Supply Logistic Corporation State Health Promotion & Protection Trust State Health Regulatory & Development Authority State Health & Medical Facilities Accreditation Unit Health Systems Evaluation Unit Director, District Health Services District District Health Systems Manager District Public Health Officer Block Health Systems Manager Block Public Health Officer Health Systems Management Assistants PHC Medical Officer Block/PHC ----- Flow of information ----+ Line of reporting Source: Planning Commi ssion of India, 20 11 . International Profiles of Health Care Systems, 2015 VA-19-0799-D-001659 OS 00003330 INDIA are provided by other ministries and departments to their personnel (e.g., defense, railways, ports, mines, and employee state insurance schemes). Each state has its own State Directorate of Health Services and State Department of Health and Family Welfare, which is responsible for providing care to its population. District-level health services provide a link between each state and primary care services. Other agencies involved in health system governance include the Insurance Regulatory and Development Authority, which regulates the health insurance industry, and the National eHealth Authority, which is to become the nodal authority for development of an integrated health information system (MOH, 20156). There is confusion in India with respect to which entities are responsible for regulating the private sector and for ensuring quality of care, as there are multiple agencies under different ministries, with no single responsible agency. For example, the Bureau of Indian Standards and Consumer Protection Act are under the Ministry of Consumer Affairs, whereas the Quality Council of India is under the Ministry of Commerce and Industry. An attempt is being made to bring these agencies under one authority. ~ X What are the major strategies to ensure quality of care? Over the years, several regulations have been enacted and authorities created at the state and national level with the aim of protecting patients and improving quality of care. For example, at the state level, the Nursing Home Act and State Drug Controllers ensure quality of care provided by the private sector. A major impetus to establishing patient rights was the inclusion of private medical practice under the Consumer Protection Act in 1986 (Balarajan et al. 2011). To ensure quality of care and define standards for health facilities, a number of laws were introduced, including those creating a national accreditation system, the National Accreditation Board for Hospitals (NABH, 2006; Gyani, 2015), and the Indian Public Health Standards (IPHS, 1997) for primary and secondary health care services. In addition, many hospitals undergo accreditation and certification from international bodies such as the Joint Commission International (JCI) and the International Organization for Standardization (Wennerholm et al. 2013). The Health Management Information System was launched in 2008 to monitor health programs and provide key inputs for monitoring and policy formulation. Currently, about 633 of 667 districts report data by facility (MOH, 2015a). Large-scale surveys like the National Family Health Survey, the District-Level Household Survey, and the Annual Health Survey are periodically undertaken at the district, state, and national levels. In addition, the Indian Council of Medical Research (ICMR) maintains disease registries for cancer, diabetes, cardiovascular diseases, and other illnesses. The 2010 Clinical Establishments (Registration and Regulation) Act calls for prescribing minimum standards for all public and private clinical establishments in the country (MOH, 2012; MOH, 2015c). The act has already come into force in certain states (e.g., Arunachal Pradesh, Himachal Pradesh, Mizoram and Sikkim) and in all union territories (CBHI, 2013). In addition, facilities shall charge rates as determined by central government in consultation with the state. The act stipulates fines and penalties if provisions are breached by any facility. A national council for clinical establishment will oversee implementation and compliance at the national level. Similar councils at the state and district levels will be established to enforce compliance locally (MOH, 2015c). Currently, a shift to one comprehensive approach of quality assurance is envisaged to replace the existing fragmented approach. For public health care facilities, the strategy would ensure that every facility is measured and scored for quality, and certified and incentivized when it achieves a certain minimum score. Quality measures would include clinical quality as well as patient safety, comfort, and satisfaction. In the private sector, voluntary accreditation with certificates like that of National Accreditation Board for Hospitals and National Accreditation Board for Testing and Calibration Laboratories would predominate. For private facilities that are part of a public-private partnership, quality certification would be mandatory either through those boards or through the public system (MOH, 2014). The Commonwealth Fund VA-19-0799-D-001660 OS 00003331 INDIA To ensure quality of medical education, a common national entrance exam is being debated. A licentiate exam will be introduced for all medical graduates, with renewal at periodic intervals (MOH, 2014). Although there has been some progress made and new legislation introduced, progress in government regulation has been slow and implementation challenging (MOH, 2014; Gudwani et al., 2012), and there is no single government authority responsible to ensure quality of care (Wennerholm, 2013). Although the Clinical Establishments (Registration and Regulation) Act is one of the most important, far-reaching pieces of public health legislation enacted to date, its effective and uniform implementation in each state remains to be seen. t:: j What is being done to reduce disparities? Significant inequalities with respect to health care access and health outcomes exist between states, rural and urban areas, socioeconomic groups, castes, and genders. For example, the infant mortality rate is 48 per 1,000 live births in rural areas, while it is 29 in urban areas (Save the Children, 2013). With respect to access, it is estimated that the urban rich obtain 50 percent more health services than the average Indian citizen (Gudwani et al., 2012). And the number of government hospital beds per population in urban areas is more than twice the number in rural areas (Balarajan et al., 2011), and urban areas have four times more health workers per population (Planning Commission of India, 2011 ). Recognizing the lack of a comprehensive national health care system as an important factor in health inequalities, the government views universal coverage through the National Health Mission as the main strategy to address the problem, along with a strengthening of the primary health care infrastructure in both rural and urban areas. While there is no single agency responsible for ensuring that health inequalities are reduced, a number of new initiatives have been launched on behalf of low socioeconomic groups and other vulnerable populations. For example, with respect to maternal care, there is the Janani Suraksha Yojana, which provides mothers with cash incentives for institutional delivery, transportation in case of emergency, and additional incentives for accredited social health activists. Another initiative is expanding the use of information and communication technology in an attempt to increase rural Indians' access to health services. ~ Broadly, there is growing recognition about the need to address the growing burden of noncommunicable diseases, which are responsible for two-thirds of the total morbidity burden and just over half of deaths (WHO, 2015). Starting in 2013-14, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Strokes is being implemented in 35 states and union territories (MOH, 2015a). It must be emphasised, however, that the effort against these diseases is still in its initial stages. What is the status of electronic health records? The establishment of a composite health information system (HIS) is proposed in the government's 12th fiveyear plan. The HIS will be based on adoption of national electronic health record standards, linked systems at the state and national levels, issuance of a unique health card to every citizen, and creation of a national health information center (MOH, 2015a). States can develop systems to suit their needs and priorities, as long as they are consistent with standards set by the new National eHealth Authority (NeHA). NeHA will be the nodal authority responsible for development of the HIS and for enforcing the laws and regulations relating to privacy and security of patient health information and records (MOH, 20156). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001661 OS 00003332 INDIA How are costs contained? ~ There are no comprehensive policies to hold down costs. Most cost-containment strategies are limited to costsharing and use of generic drugs. There is limited evidence with respect to use of cost-effectiveness assessments, monitoring for financial performance, improvement in operational efficiency, and health technology assessments. As the public health care system is financed through taxes, costs are contained in the first instance by allocations made to the health sector, which currently amount to less than 2 percent of GDP. Most government health facilities have to operate within the yearly allocated budget. Where there are public-private partnerships, government negotiates prices with private providers and reimburses accordingly. G What major innovations and reforms have been introduced? ~ A key goal of the 12th five-year plan is to move toward universal coverage to provide universal access to equitable, affordable, and quality health care, with supplementation from the private sector (MOH, 2014 and 201 Sa). Toward this end, the National Health Mission and its two Sub-Missions-the National Rural Health Mission and the National Urban Health Mission-was approved by the Cabinet in May 2013. The main components include health system strengthening in rural and urban areas; the Reproductive, Maternal, Newborn, Child and Adolescent Health strategy; and control of communicable and noncommunicable diseases (MOH, 201 Sa). A number of initiatives are being introduced with respect to quality of care, as described in the section on quality, above. An example of health system integration reform is the RSBY scheme. This scheme, now under the Ministry of Health and Family Welfare, is helping the state and central ministry move to a tax-financed, single-payer system (MOH, 2014). Reforms also have been introduced to ensure equity in resource allocation. Allocation decisions are to take into account financial ability, developmental need, and high-priority districts, targeting specific population subgroups, geographical areas, health care services, and gender-related issues. A risk equalization formula based on health care need could be developed, with built-in financial incentives for facilities providing a certified quality of care (MOH, 2014). Other initiatives being introduced include the India Newborn Action Plan, to reduce preventable newborn deaths and stillbirths; the provision of providing free drugs and diagnostic services; the aforementioned National eHealth Authority; and a new health rights bill to ensure health as a fundamental right (MOH, 2015a). The author would like to acknowledge the input provided by Elias Mossialos and the LSE editorial team for editing the previous draft. The Commonwealth Fund VA-19-0799-D-001662 OS 00003333 INDIA References Balarajan, Y., S. Selvaraj, and S. V. Subramanian (2011 ). Health Care and Equity in India. Lancet, Feb. 5, 2011 377(97 64):505-15. CBHI (2013). National Health Profile (NHP) of India. Central Bureau of Health Intelligence. http://cbhidghs.nic.in/index2. asp?slid=1284&sublinkid=1166. Accessed Aug. 30, 2015. DGHS (2011). National Programme for the Health Care of the Elderly: Operational Guidelines. Ministry of Health and Family Welfare. http://mohfw.nic.in/index3.php?lang=1 &deptid=36 . Accessed Aug. 22, 2015. Forgia, G., and S. Nagpal (2012). Government-Sponsored Health Insurance in India: Are You Covered? World Bank. Gudwani, A., P. Mitra, A. Puri, and M. Vaidya (2012). India Health Care: Inspiring Possibilities, Challenging Journey. McKinsey and Co. Gyani, G. (2015). "India," in J. Braithwaite, Y. Matsuyama, R. Mannion, and J. Johnson (eds.), Healthcare Reform, Quality and Safety: Perspectives, Participants and Prospects in 30 Countries. Ashgate Publishing Limited, England. Ministry of Health and Family Welfare (MOH) (2009). The National Health Bill (draft). Government of India. Accessed from http://www.prsindia.org/uploads/media/Draft_National_Bill.pdf on 22nd August, 2015. MOH (2011). Annual Report to the People on Health. Government of India. MOH (2012). Notification Clinical Establishment Act. Government of India. http://clinicalestablishments.nic.in/ WriteReadData/386.pdf. Accessed Aug. 22, 2015. MOH (2013). National Health Mission. Government of India. http://nrhm.gov.in/nhm/nrhm/guidelines/indian-public-healthstandards.html. Accessed Nov. 21, 2015. MOH (2014). "National Health Policy 2015" (draft). Government of India. MOH (2015a). Annual Report of Department of Health and Family Welfare for the Year of 2014-15. Government of India. MOH (20156 act). The Clinical Establishment Act, 2010. http://clinicalestablishments.nic.in/cms/Home.aspx. Accessed Aug. 22, 2015. MOH (2015c NeHA). National eHealth Authority (NeHA) (Concept Note). Government of India. http://mohfw.nic.in/showfile. php?lid=3099. Accessed Aug. 25, 2015. NABH (2006). NABH's hospital accreditation programme. http://nabh.co/shco-standard.aspx. Accessed Nov. 21, 2015. Organisation for Economic Co-operation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787/data-00285-en. Accessed Sept. 17, 2015. OECD (2014). OECD Health Statistics 2014. "How Does India Compare?" http://www.oecd.org/els/health-systems/BriefingNote-lNDIA-2014.pdf. Accessed Aug. 30, 2015. Planning Commission of India (2011). High Level Expert Group Report on Universal Health Coverage in India. Government of India. Planning Commission (2014). Report of the Expert Group to Review the Methodology for Measurement of Poverty. Government of India. Rashtriya Swathya Bima Yojna (2015). Rashtriya Swathya Bima Yojna Ministry of Labour and Employment. http://www.rsby. gov.in/about_rsby.aspx. Accessed Aug. 22, 2015. Save the Children (2013). Reducing Inequality: Learning Lessons for the Post-2015 Agenda-India Case Study. New Delhi. Thomas, V. (2009). "The National Health Bill 2009 and Afterwards." Annals of Indian Academy of Neurolology, April-June 2009 12(2): 79. Wennerholm, P., A. M. Scheutz, Y. Zaveri-Roy, and M. Wikstrom (2013). India's Healthcare System-Overview and Quality Improvements. Swedish Agency for Growth Policy Analysis. World Health Organization (WHO) (2013). India Country Profile: Human Resources for Health Observatory. SERO, WHO. http://www.searo.who.int/entity/human_resources/data/india-2013.pdf?ua=1 . Accessed Aug. 30, 2015. WHO (2015). Country Cooperation Strategy at a Glance: India. WHO. http://www.who.int/countryfocus/cooperation_ strategy/ccsbrief_ind_en.pdf. Accessed Aug. 16, 2015. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001663 OS 00003334 ~ ~ ? What is the role of government? Government, through the Ministry of Health, is responsible for population health and the overall functioning of the health care system. It also owns and operates a large network of maternal and child health centers, about half of the nation's acute care bed capacity, and about 80 percent of its psychiatric bed capacity (Rosen, Waitzberg and Merkur, forthcoming). In 1995, Israel passed a national health insurance (NHI) law, which provides for universal coverage. In addition to financing insurance, government also provides financing for the public health service, and is active in areas such as control of communicable diseases, screening, health promotion and education, and environmental health, as well as providing various other services provided directly by the government. It is also actively involved in financial and quality regulation of key health system actors, including health plans, hospitals, health care professionals, and others. o/,:f:' Who is covered and how is insurance financed? In 2013, national health expenditures accounted for 7.6 percent of GDP, of which about 60 percent are publicly financed. Publicly financed health insurance: Israel's NHI system automatically covers all citizens and permanent residents. It is funded primarily through a combination of a special income-related health tax and general government revenues, which in turn are funded primarily through progressive income-related sources such as income tax. Employers are required to enroll any foreign workers (whether documented or undocumented) in private insurance programs, whose range of benefits is similar to that of NHI. Private insurance is also available, on an optional basis, for tourists and business travelers. Nevertheless, there are people living in Israel who do not have health insurance, including undocumented migrants who are not working. Several services are made available to all individuals irrespective of their legal or insured status. These include emergency care, preventive mother and child health services, and treatment oftuberculosis, HIV/AIDS, and other sexually transmitted infections. Within the NHI framework, residents can choose among four competing, nonprofit health plans. Government distributes the NHI budget among the plans primarily through a capitation formula that takes into account sex, age, and geographic distribution. The health plans are then responsible for ensuring that their members have access to the NHI benefits package, as determined by government. Private health insurance: Private voluntary health insurance (VHI) includes health plan VHI (HP-VHI), offered by each health plan to its members, and commercial VHI (C-VHI), offered by for-profit insurance companies to individuals or groups. In 2014, 87 percent of Israel's adult population had HP-VHI, and 53 percent had C-VHI (Brammli-Greenberg and Medina-Artom, 2015). C-VHI packages tend to be more comprehensive and more expensive than the HP-VHI packages. While C-VHI coverage is found among all population groups, coverage rates are highly correlated with income. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001665 OS 00003336 ISRAEL Together, these two types of private VHI financed 14 percent of national health expenditures in 2012, a figure that has been increasing steadily. The Ministry of Health regulates HP-VHI programs, while the Commissioner of Insurance, who is part of the Ministry of Finance, regulates C-VHI programs. The focus of C-VHI regulation is actuarial solvency, with secondary attention to consumer protection more generally; in HP-VHI regulation, there is more attention to equity considerations and potential impacts on the health care system (Brammli-Greenberg, Waitzberg and Gross, 2015). Reasons for purchasing VHI include securing coverage of services not covered by NHI (e.g. dental care, certain life-saving medications, institutional long-term care, and treatments abroad), care in private hospitals, or a premium level of service for services covered by NHI (e.g., choice of surgeon and reduction of waiting times). VHI coverage is also purchased as a result of a general lack of confidence in the NHI system's capacity to fully fund and deliver all services needed in cases of severe illnesses. ~ What is covered? The mandated benefits package includes hospital, primary, and specialty care, prescription drugs, certain preventive services, mental health care, dental care for children, and other services. Dental care for adults, optometry, and home care are generally excluded, although the National Insurance Institute does provide some funding for home care, dependent on need. Limited palliative and hospice services are included in the NHI benefits package as well (Bentur et al., 2012). Israel has a well-developed system for prioritizing coverage of new technologies within an annual overall budget set by the Cabinet (which includes Parliament members from the ruling parties) (Greenberg et al., 2009). Proposals for additions are solicited and received from pharmaceutical companies, medical specialty societies, and others. The Ministry of Health then assesses costs and benefits ofthe proposed additions, and a public commission combines the technical input with broader considerations to prepare a set of recommendations. These are usually adopted by the Minister of Health and subsequently by the Cabinet. Cost-sharing and out-of-pocket spending: In 2012, out-of-pocket spending accounted for 26 percent of national health expenditures. Some of this was for services not included in the NHI benefits package, including dental care for adults, optical care, institutional long-term care (for those not eligible for means-tested assistance), certain medications, and medical equipment. The other major component was copayments for NHI services, such as pharmaceuticals, visits to specialists, and certain diagnostic tests. Dental care and pharmaceuticals are the two largest out-of-pocket components. There are no copayments for primary care visits or for hospital admissions. There are also no quarterly or annual deductibles with NHI coverage. Within the NHI system, physicians are not allowed to balance-bill. Safety net: There are a variety of safety-net mechanisms in place. For pharmaceuticals there is a quarterly ceiling for the chronically ill, and discounts for the elderly based on age, income, and health status. Holocaust survivors are exempt from copayments for pharmaceuticals. With regard to specialist visits, there are exemptions for elderly welfare recipients, children receiving disability payments, and people afflicted with certain severe diseases. There is a quarterly ceiling on total copayments for these visits at the household level, which is 50 percent lower for elderly people. In addition, people earning less than 60 percent of average wages pay a reduced health tax of 3 percent of income, instead of 5 percent. [ (R)] How is the delivery system organized and financed? Primary care: Nearly all Israeli primary care physicians (referred to as general practitioners (GPs) in this profile, although they also include board-certified family physicians) provide care through only one ofthe four competing nonprofit health plans, which vary markedly in how they organize care. The Commonwealth Fund VA-19-0799-D-001666 OS 00003337 ISRAEL In Clalit, the largest health plan, most primary care is provided in clinics owned and operated by the plan, and GPs are salaried employees. The typical clinic has three to six GPs, several nurses, pharmacists, and other professionals. Clalit also contracts with independent physicians; although these doctors tend to work in solo practices with limited on-site support from nonphysicians, they have access to various administrative and nursing services at Clalit district clinics. The other three health plans also use of a mix of clinics and independent physicians in primary care, with the mix varying across plans. In Maccabi (the second-largest plan) and Meuhedet, almost all of the primary care is provided by independent physicians, while in Leumit the clinic model predominates (though not to the same extent as in Clalit). Members of all plans can generally choose their GP from among those on the plan's list and can switch freely. In practice, nearly all patients remain with the same GP for extended periods. In Clalit, each patient is registered with a GP who has responsibility for coordinating care and acts as gatekeeper, except for access to five common specialties. In Leumit, patients are registered with a clinic rather than a GP, while there is no registration in the other two plans. However, in all plans there is movement under way to associate each member with a physician for purposes of quality assurance and accountability. Clalit is the only plan with referral requirements to secondary care. Independent physicians in all plans are paid on a capitation basis, with Clalit and Leumit using "passive capitation" (a quarterly, per member payment made irrespective of whether the member visited the GP in the relevant quarter) and Maccabi and Meuhedet using "active capitation" (where the payment is made only for members who visited their GP at least once during the quarter). Independent physicians also receive limited fee-for-service payments for certain procedures. Plans monitor the care provided by their GPs and work closely with them to improve quality (Rosen et al., 2011). However, quality-related financial incentives are generally not used. The salaries of Clalit clinic physicians are set via a collective bargaining agreement with the Israel Medical Association. The capitation rates of independent physicians, in all the health plans, are set by the plans in consultation with their physicians' associations. It is estimated that of Israel's 24,000 physicians employed in 2011, approximately 7,000 worked with or for the health plans as GPs. Outpatient specialty care: Outpatient specialty care is provided predominantly in community settings, either health plan clinics (the dominant mode in Clalit) or physician's offices (the dominant mode in the other health plans). The former tend to be integrated multispecialty clinics, while the latter tend to be single-specialty. Most specialists are paid on an active capitation basis, plus fee-for-service for certain procedures. Rates are set by the health plans and, within the NHI system, specialists may not balance-bill; patients pay the quarterly copayment only. Patients can choose from a list of specialists provided by their health plans. Specialists who work for the plans may also see private patients. Administrative mechanisms for direct patient payments to providers: As noted above, the only direct payments to NHI providers are copayments. Patients can usually use their health plan membership cards instead of making cash payments; the provider receives the full fee from the health plans, which then collect the copayments from enrollees. After-hours care: After-hours care is available via hospital emergency departments (EDs), freestanding walk-in "emergi-centers," and companies that provide physician home visits. Physicians providing care in EDs and emergi-centers come from a range of disciplines, including primary care, internal medicine, general surgery, orthopedics and, increasingly, emergency medicine. Nurses play a significant role in triage. They are typically salaried, while physicians working for home-visit companies are typically paid per visit. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001667 OS 00003338 ISRAEL Primary care physicians are not required to provide after-hours care. They receive reports from the after-hours providers, and increasingly this information is conveyed electronically. All the health plans operate national telephone advice lines for their members, which are nurse-staffed with physician backup. Hospitals: Acute-care bed capacity is divided approximately as follows: government, 50 percent; Clalit, 30 percent; other nonprofits, 15 percent; for-profits, 5 percent (Haklai et al., 2014). However, the for-profits account for a much larger share of admissions and an even large share of surgical operations (BrammliGreenberg and Artom, 2015). Hospital outpatient care is reimbursed on a fee-for-service basis, and inpatient care is reimbursed using a mix of per diem and DRG arrangements, with approximately two-thirds of revenue coming from per diem payments (Brammli-Greenberg et al., forthcoming). Maximum rates are set by government, but health plans negotiate discounts. There are also revenue caps set by government, which limit the extent to which each hospital's total revenues can grow from year to year. Generally speaking, hospital payments include the cost of the physicians working for the hospitals. In government and nonprofit hospitals, physicians are predominantly salaried employees, with limited arrangements for supplemental fee-for-service in some hospitals. Fee-for-service is the predominant payment mode in private hospitals. Mental health care: Responsibility for the provision of mental health care was transferred in mid-2015 from the Ministry of Health to the health plans, which provide care through a mix of salaried professionals, contracted independent professionals, and services purchased from organizations (including the Ministry's mental health clinics). The benefits package is broad and includes psychotherapy, medications, and inpatient and outpatient care. Integration with primary care is currently limited, but this is expected to improve because of the transfer of responsibility to the health plans. Long-term care and social supports: Financing of institutional long-term care is considered a responsibility of patients and their families, to the extent that they can afford it. An extensive system of needs-based, graduated subsidies is available from the Ministry of Health. These are generally paid directly to providers, although recently a change was made to the law to make it easier for families to receive cash subsides to be used in paying providers. The health plans are responsible for medical care of the disabled elderly living in the community. In recent years, they have increased access to clinicians (particularly for the homebound) via home-care teams and telemedicine. The National Insurance Institute finances personal care and housekeeping services for community-dwelling disabled elderly (Asiskovitch, 2013). Additional supports include an extensive network of day-care centers and a growing network of supportive neighborhoods. For nursing homes, home medical care, and home aids, eligibility is based on inability to carry out activities of daily living. In addition, there are means tests for government assistance for nursing home and home aids, but not for medical home care provided by the health plans, or for any services provided through private insurance. Private, for-profit providers deliver about two-thirds of nursing home care, virtually no medical home care (which is delivered by the private, nonprofit health plans), and nearly all home aids. Although the government maintains that hospice care is included in the NHI benefits package that the health plans are supposed to provide, the plans dispute this. Some hospice care is available (particularly home hospice), though much less than is needed. Approximately half of the adult population has private long-term care insurance. There is no direct financial support for informal or family caregivers. The Commonwealth Fund VA-19-0799-D-001668 OS 00003339 ISRAEL &h What are the key entities for health system governance? Parliament (the Knesset) adopts and amends legislation related to the health system. The Cabinet, comprising a selection of Knesset members from the ruling parties, has executive responsibility for the government as a whole, including the Ministry of Health (MoH). The MoH has overall responsibility for population health and the effective functioning of the health care system. It includes: o The Minister, an elected member of the Knesset and typically also a member of the Cabinet. The Minister has full authority and responsibility for the functioning of the MoH. o The Director-General, the MoH's top professional, who is appointed by the Minister to run the operations ofthe MoH. o A large number of departments, including those responsible for quality and safety, assessing costeffectiveness, fee-setting, public information, and health IT. o Various advisory bodies, including the National Health Council, a public advisory; the benefits package committee, which advises on prioritization of new technologies for inclusion in the NHI benefits package; and national councils in such areas as trauma care, mental health, and women's health. The Ministry of Health has an ombudsman's office to help citizens realize their rights under the NHI law. In addition, there are various nongovernmental patient advocacy organizations, many of which focus on particular diseases. The Budget Division of the Ministry of Finance prepares the budgets of all ministries, including the MoH, for consideration by the Cabinet and then the Knesset. It also plays a major role in promoting and shaping major structural reforms to the health system and partners with the MoH on interministerial committees, such as those that set maximum hospital prices and the capitation formula. The Ministry of Finance Insurance and Capital Markets Division regulates commercial health insurers. The government also has an antitrust unit responsible for promoting competition, but it is not very active in the health area. The Scientific Council of the Israel Medical Association is responsible for the specialty certification programs and examinations, in coordination with the MoH. The Council for Higher Education is responsible for the authorization, certification, and funding of all university degree programs, including those for training health care professionals. ~ X What are the major strategies to ensure quality of care? For over a decade, Israel has had a well-developed system for monitoring the quality of primary care. Comparative quality data for individual health plans has been made public since 2014 (Jaffe, 2012). While the published data relate to the health plans as a whole, the plans have internal data by region, clinic, and individual physician. The plans and their clinicians have made intensive use of this data to bring about substantial improvements in quality (Rosen et al., 2011; Balicer et al., 2015). The MoH publishes comparative data on the quality of hospital care. This system is much newer than the system for primary care quality and is currently limited to a handful of indicators. However, it is expected to develop rapidly over the coming years. The MoH is in the process of launching a national initiative to reduce waiting times for surgical procedures, and there are several initiatives focused on the care of particular diseases, such as dementia. The health plans are increasingly active in implementing programs for the chronically ill, including disease management. Hospitals and clinics require a license from the MoH, granted only when basic quality standards are met. Hospitals are also increasingly seeking, and securing, accreditation from Joint Commission International. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001669 OS 00003340 ISRAEL Organization of the Health System in Israel Health plans .. .. .. ..-----.... . ........ ...... -------------- ,----.----~ ___ ........ ........................ ........................... .....::,;;;....- The public Parliament Prime Minister and cabinet Ministry of Health Hospitals Health care professiona Is , ,, ,, ,, ,, Ministry of Finance _C_o_m_m_e_r_c-ia_l_ / / / insurers Source: B. Rosen, Myers-JDC-Brookdale Institute, 2015 . There are biannual surveys of the general population regarding the service level provided by the health plans. The MoH recently launched an annual survey of hospitalized patients. Results are published by institution. There are currently no explicit financial incentives for hospitals and health plans to improve quality. However, due to the competitive environment, public dissemination of quality data may be providing an indirect incentive. Consideration is being given to introducing a limited number of pay-for-performance incentives in the years ahead. National registries are maintained by the MoH for certain expensive medical devices and for a broad range of diseases and conditions, including: cancer, low birth weight, trauma, and occupational diseases. ~ To receive a medical license from the MoH, persons who studied in an Israeli medical school must also successfully complete a one-year internship. Those who studied abroad are usually also required to pass an examination. Specialty recognition requires specialty training in an accredited program and passing an exam. The there are no re-licensure exams for physicians. What is being done to reduce disparities? The MoH is leading a major national effort to reduce disparities, in cooperation with the health plans and hospitals. Key initiatives include: o Reducing financial barriers to care, particularly for low-income persons and other vulnerable populations. Most prominently, mental health care and dental care for children has been added to the NHI benefits package, thereby reducing the substantial financial barriers that existed when these services were provided privately (Rosen, 2012). o Enhancing the availability of services and professionals in peripheral regions, by increasing the supply of beds and advanced equipment in the periphery and providing financial incentives for physicians to work in the periphery. The Commonwealth Fund VA-19-0799-D-001670 OS 00003341 ISRAEL o Addressing the unique needs of cultural and linguistic minorities, through adoption of cultural responsiveness requirements for all providers, establishment of a national translation call center, and targeted interventions for the Bedouin and other high-risk groups. o lntersectoral efforts to address the social determinants of health and promote healthy lifestyles. o Creation, analysis, and public dissemination of information about health care disparities, including periodic reporting of variations in health and health care access. (R)-0- What is being done to promote delivery system integration and "-..:::,I care coordination? The health plans, which are both insurers and providers, are essentially the sole source of primary care and the main source of specialty care. This structural integration of services provides the foundation for provision of relatively seamless care for all the insured, including complex and chronically ill patients. The plans' health information systems link primary and specialty care providers, and a new national health information exchange is linking the health plans and the hospitals. Increasingly these provide access to electronic medical information at the point of care. In addition, the health plans have put forth several targeted management programs that aim to provide comprehensive integrated care for complex patients with chronic conditions. These make extensive use of the plans' sophisticated information systems, videoconferencing, and other innovative techniques (Intel, 2015). Generally speaking, integration is still limited among the various components of the long-term care system and between long-term care and other components of the health care system. However, this may change in the future if long-term care becomes a responsibility of the health plans (see below). What is the status of electronic health records? All health plans have electronic health record (EHR) systems that link all community-based providers-primary care physicians, specialists, laboratories, and pharmacies. All GPs work with an EHR. Hospitals are also computerized but are not fully integrated with health plan EH Rs. The MoH leads a major national health information exchange project to create a system for sharing relevant information across all hospitals and health plans. Each citizen has a unique identification number, which functions as a unique patient ID. Patients have the right to get copies of their medical records from hospitals and health plans, and patients can access some ~ components of their EHR on line, but the full records are not generally available. Efforts are under way to set up secure messaging systems linking patients and their GPs. How are costs contained? Israel is one of the most successful high-income countries in containing costs, with health expenditures remaining below 8 percent of GDP. Strategies include: o Channeling the bulk of funding through a single, tightly controlled, government source o Maintaining tight controls on key supply factors, such as hospital beds and expensive medical equipment o Requiring the health plans-which function as the building blocks of the health system-to provide care competitively, within budgets that are largely determined prospectively o Maintaining a well-developed system of community-based services, which reduces reliance on high-cost hospital care International Profiles of Health Care Systems, 2015 VA-19-0799-D-001671 OS 00003342 ISRAEL o Using electronic health records effectively, particularly in the community o Purchasing pharmaceuticals in bulk and relying heavily on generics o Setting maximum hospital reimbursement rates (government), negotiating discounts (health plans), and instituting hospital global revenue caps o Explicitly prioritizing public funding for new technologies included in the NHI benefits package o Aligning organizational and financial incentives between clinicians and the hospitals or health plans for whom they work (see below). Although clinicians are rarely given explicit financial incentives to contain costs, reliance on salary and capitation (rather than fee-for-service) may reduce incentives to over-treat. Moreover, the health plans have various internal processes to discourage care that provides poor value. Of recent concern to some experts, however, is the recent growth of private medical care and private financing, which is seen as potentially jeopardizing Israel's success in containing cost growth. G ? What major innovations and reforms have been introduced? Mental health: In July 2015, mental health care was added to the set of services that the health plans must provide within the NHI framework, making access a legally guaranteed right rather than a government-supplied service whose availability is subject to budget constraints. Because of this new mandatory package of mental health services, government funding for health plans has been increased substantially to cover the additional costs. The main objectives of the reform are to improve the linkage between physical and mental care, increase the availability of mental health services, and increase efficiency. An external evaluation will ascertain the extent to which the objectives are achieved and whether various concerns are realized (Rosen et al., 2008). Comparative data on hospital performance: In 2015, the MoH began publishing comparative data on hospital quality, and there are plans to rapidly expand the indicator set in the years ahead. In 2014, the Ministry published the results of a nationwide survey of hospitalized patients regarding their care experience. It is also assembling a database of waiting times for surgical operations, with the intention of publishing comparative data in 2016. The objectives of all these efforts are to provide hospitals with information to help identify problem areas, enhance consumer choice of hospitals, and provide hospitals with incentives to improve performance. Reducing surgical waiting times: Long waiting times are perceived as one of the major causes of the recent growth in private financing and care provision. Motivated by a desire to improve public confidence in the publicly financed health care system as well as quality of care, the MoH is planning a major initiative to reduce surgical waiting times. This will involve additional funding to expand hours of operation for surgical theaters as well as a series of organizational changes to improve efficiency. Improving service levels in hospital EDs: As part of a broader effort to improve patient-centered care and service levels, the MoH is launching a major effort to reduce waiting times between patient arrival and the first contact with a health care professional. Strategies are to include enhanced physician, nurse, and physician assistant staffing, as well as engaging operations management experts to improve workflow. Long-term care insurance: Israel's long-term care system is seriously fragmented, with service gaps, duplication of care, inefficient incentives, and inadequate investment in prevention and rehabilitation. The government is working on a plan to add institutional long-term care to the set of NHI benefits for which the health plans are responsible, with the plans also serving as the budget holders for institutional LTC. The Commonwealth Fund VA-19-0799-D-001672 OS 00003343 ISRAEL This profile draws on the forthcoming Healthcare in Transition-Israel, by Bruce Rosen, Ruth Waitzberg, and Sherry Merkur, due to be published in early 2016 by the European Observatory on Health Systems and Policies. The profile also benefited from valuable input from Martin Wenzl of the London School of Economics and Political Science. References Asiskovitch, S. "The Long-Term Care Insurance Program in Israel: Solidarity with the Elderly in a Changing Society." Israel Journal of Health Policy Research, Jan. 23, 2013 2(1 ):3. Balicer, R. D., M. Hoshen, C. Cohen-Stavi, S. Shohat-Spitzer, C. Kay, H. Bitterman, N. Lieberman, 0. Jacobson, E. Shadmi (2015). "Sustained Reduction in Health Disparities Achieved Through Targeted Quality Improvement: One-Year Follow-Up on a Three-Year Intervention." Health Services Research, March 19, 2015. E-pub ahead of print. Bentur, N., L. L. Emanuel, N. Cherney. "Progress in Palliative Care in Israel: Comparative Mapping and Next Steps." Israel Journal of Health Policy Research, Feb. 20, 2012 1 (1 ):9. Brammli-Greenberg, S., T. Medina-Artom (2015). Public Opinion on the Level of Service and Performance of the Healthcare System in 2014. Jerusalem: Myers-JDC-Brookdale Institute. Brammli-Greenberg, S., R. Waitzberg, V. Perman, R. Gamzu (forthcoming). "How Israel Reimburses Hospitals Based on Activity: The Procedure-Related Group (PRG) Incremental Reform." OECD Publishing. Brammli-Greenberg, S., R. Waitzberg, R. Gross (2015). "Integrating Private Insurance into the Israeli Health System: An Attempt to Reconcile Conflicting Values." In S. Thomson, E. Mossialos (eds.), Private Health Insurance and Medical Savings Accounts: History, Politics, Performance. Cambridge, England: Cambridge University Press. Greenberg, D., M. I. Siebzehner, J. S. Pliskin (2009). "The Process of Updating the National List of Health Services in Israel: Is It Legitimate? Is It Fair?" International Journal of Technology Assessment in Health Care, July 2009 25(3):255-61. Haklai, Z. (2014). Inpatient Institutions and Day Care Units in lsrael-2013. Jerusalem, Ministry of Health. Intel (2015). "Improving Health Outcomes and Reducing Costs with Video Conferencing Technology." Jaffe, D. H., A. Shmueli, A. Ben-Yehuda, 0. Paltiel, R. Calderon, A. D. Cohen, E. Matz, J. K. Rosenblum, R. Wilf-Miron, 0. Manor (2012). "Community Healthcare in Israel: Quality Indicators 2007-2009." Israel Journal of Health Policy Research 1 (1):3. Rosen, B., N. Niral, R. Gross, S. Bramali, N. Ecker (2008). "The Israeli Mental Health Insurance Reform." Journal of Mental Health Policy and Economics, Dec. 2008 11 (4):201--08. Rosen, B., L. G. Pawlson, R. Nissenholtz, J. Benbassat, A. Porath, M. R. Chassin, B. E. Landon (2011). "What the United States Could Learn from Israel About Improving the Quality of Health Care." Health Affairs, April 2011 30(4):764-72. Rosen, B., R. Waitzbeg, S. Merkur (forthcoming). "Israel: Health System Review." Health Systems in Transition. Rosen, B. (2012). "Inclusion of Dental Care for Children in NHI." Health Systems and Policies Platform. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001673 OS 00003344 ~ ? = What is the role of government? The Italian National Health Service (Servizio Sanitario Nazionale) is regionally based and organized at the national, regional, and local levels. Under the Italian constitution, responsibility for health care is shared by the national government and the 19 regions and 2 autonomous provinces. The central government controls the distribution of tax revenue for publicly financed health care and defines a national statutory benefits package to be offered to all residents in every region-the "essential levels of care" (live/Ii essenziali di assistenza). The 19 regions and two autonomous provinces have responsibility for the organization and delivery of health services through local health units. Regions enjoy significant autonomy in determining the macro structure of their health systems. Local health units are managed by a general manager appointed by the governor of the region, and deliver primary care, hospital care, outpatient specialist care, public health care, and health care related to social care. o/f:' Who is covered and how is insurance financed? Publicly financed health care: The National Health Service covers all citizens and legal foreign residents. Coverage is automatic and universal. Since 1998, undocumented immigrants have access to urgent and essential services. Temporary visitors can receive health services by paying for the costs of treatment. Public financing accounted for 78 percent oftotal health spending in 2013, with total expenditure standing at 9.1 percent of GDP (OECD, 2014). The public system is financed primarily through a corporate tax (approximately 35.6% ofthe overall funding in 2012) pooled nationally and allocated back to regions, typically the source region (there are large interregional gaps in the corporate tax base, leading to financing inequalities), and a fixed proportion of national value-added tax revenue (approximately 47.3% ofthe total in 2012) collected by the central government and redistributed to regions unable to raise sufficient resources to provide the essential levels of care (Ministero dell'Economia e delle Finanze, 2012). Regions are allowed to generate their own additional revenue, leading to further interregional financing differences. Every year the Standing Conference on Relations between the State, Regions, and Autonomous Provinces (with the presidents of the regions and representatives from central government as its members) sets the criteria (usually population size and age demographics) to allocate funding to regions. Local health units are funded mainly through capitated budgets. The 2008 financial law established that regions would be financed through standard rates set on the basis of actual costs in the regions considered to be the most efficient. Established in legislation, this policy is not yet operating. Since the National Health Service does not allow members to opt out of the system and seek only private care, substitutive insurance does not exist. At the same time, complementary and supplementary private health insurance is available (see below). Privately financed health care: Private health insurance plays a limited role in the health system, accounting for roughly 1 percent oftotal spending in 2009. Approximately 15 percent ofthe population has some form of private insurance, which generally covers services excluded under the LEA, to offer a higher standard of comfort and privacy in hospital facilities, and wider choice among public and private providers. Some private health insurance policies also cover copayments for privately provided services, or a daily rate of compensation International Profiles of Health Care Systems, 2015 VA-19-0799-D-001675 OS 00003346 ITALY during hospitalization (Thomson et al., 2009). Tax benefits favor complementary over supplementary voluntary insurance. There are two types of private health insurance: corporate, where companies cover employees and sometimes their families; and noncorporate, with individuals buying insurance for themselves or for their family. Policies, either collective or individual, are supplied by for-profit and nonprofit organizations. The market is characterized by the presence of three types of nonprofit organizations: voluntary mutual insurance organizations, and corporate and collective funds organized by employers/professional categories for their employees/members. Approximately 74 percent of policies are purchased by individuals, while the remaining 26 percent are purchased by groups. ?1 What is covered? Services: Primary and inpatient care are free at the point of use. Positive and negative lists are defined using criteria related to medical necessity, effectiveness, human dignity, appropriateness, and efficiency in delivery. Positive lists identify services (e.g., pharmaceuticals, inpatient care, preventive medicine, outpatient specialist care, home care, primary care) offered to all residents. Outpatient optometrist visits are covered, while corrective lenses are not. Negative lists, on the other hand, identify services not offered to patients (e.g., cosmetic surgery), services covered only on a case-by-case basis (e.g., orthodontics and laser eye surgery) and services for which hospital admissions are likely to be inappropriate (e.g., cataract surgery). Regions can choose to offer services not included in the essential levels of care but must finance them themselves. Essential levels of care do not include a specific list of mental health, preventive, public health, or long-term care services. Rather, national legislation defines an organizational framework for mental health services, with local health authorities obliged to define the diagnostic, curative, and rehabilitative services available. Essential levels of care also outline general community and individual levels of preventive services to be covered by the National Health Service, including hygiene and public health, immunization, and early diagnosis tools. They broadly state that rehabilitative and long-term inpatient care are to be delivered as part of a standard, inpatient curative care program. Prescription drugs are divided into three tiers according to clinical effectiveness and, in part, cost-effectiveness. The first tier is covered in all cases; the second, only in hospitals; and the third tier is not covered. For some categories of drugs, therapeutic plans are mandated, and prescriptions must follow clinical guidelines. Dental care is included in the essential levels of care for specific populations such as children (up to 16 years old), vulnerable people (the disabled, people with HIV, those with rare diseases), people in economic need, and individuals with urgent/emergency need. For others, dental care is generally not covered and is paid for out-of-pocket. Cost-sharing and out-of-pocket spending: Procedures and specialist visits can be prescribed either by a general practitioner (GP) or by a specialist. While there are no user charges for GP consultations and hospital admission stays, patients pay a copayment for procedures and specialist visits up to a ceiling determined by law-currently, at EUR36.15 (USD48) per prescription. 1 Therefore, a patient who receives two separate prescriptions (e.g., an MRI scan and a laboratory test) after a visit pays EUR36.15 (USD48) for each prescription. To address rising public debt, in July 2011 the government introduced, along with other economic initiatives, an additional EUR10 (USD13) copayment for each prescription. Copayments have also been applied to outpatient drugs at the regional level, and a EUR25 (USD33) copayment has been introduced for "inappropriate" use of emergency services (although some regions have not enforced this copayment). No other forms of deductibles 1 Please note that, throughout this profile, all figures in USD were converted from EUR at a rate of about EUR0.76 per USD, the purchasing power parity conversion rate for GDP in 2013 reported by OECD (20146) for Italy. The Commonwealth Fund VA-19-0799-D-001676 OS 00003347 ITALY exist. Public and private providers under a contractual agreement with the National Health Service are not allowed to charge above the scheduled fees. All individuals with out-of-pocket payments over EUR129 (USD170) in a given year are eligible for a tax credit equal to roughly one-fifth of their spending, but there are no caps. In 2013, 18 percent oftotal health spending was paid out-of-pocket, mainly for drugs not covered by the public system and for dental care (OECD, 2014). Out-of-pocket payments can be used to access specialist care and, to a lesser extent, inpatient care delivered in private and public facilities to paying patients. Safety net: Exemptions from cost-sharing are applied to people over age 65 and under age 6 who live in households with a gross income below a nationally defined threshold (approximately EUR36,000 [USD47,360]); people with severe disabilities, as well as prisoners, are exempt from any cost-sharing. People with chronic or rare diseases, people who are HIV-positive, and pregnant women are exempt from cost-sharing for treatment related to their condition. Most screening services are provided free of charge. [ (R)] How is the delivery system organized and financed? Primary care: Primary care is provided by self-employed and independent physicians, general practitioners (GP) and pediatricians, under contract and paid a capitation fee based on the number of people on their list (Lo Scalzo et al., 2009). Local health units also can pay additional allowances for the delivery of planned care to specific patients (e.g., home care for chronically ill patients), for reaching performance targets (e.g., to reward effective cost containment on pharmaceuticals, laboratory tests, and therapeutic treatments prescribed), or for delivering additional treatments (e.g., medications, flu vaccinations). Capitation is adjusted for age and accounts for approximately 70 percent of the overall payment. The variable portion comprises fee- for-service payment for specific treatments, including minor surgery, home care, preventive activities, and taking care of chronically ill patients. Payment levels, duties, and responsibilities of GPs are determined in a collective agreement signed every three years by consultation between central government and the GPs' trade unions. In addition regions and local health units can sign contracts covering additional services. In 2011, there were approximately 53,800 GPs and pediatricians (33.5%) and 106,800 hospital clinicians (66.5%) (Ministero della Salute, 2014). Patients are required to register with a gatekeeping GP, who has incentives to prescribe and refer only as appropriate: in most cases incentives are awarded only to those GPs and pediatricians who achieve a predetermined spending or consumption target (e.g., per capita spending on drugs or diagnostic imaging). People may choose any physician whose list has not reached the maximum number of patients allowed (1,500 for GPs and 800 for pediatricians) and may switch at any time. In recent years the solo practice model has been progressively modified toward group practice, particularly in the northern part of the country. Legislation encourages GPs and pediatricians to work in three ways: base group practice, where GPs from different offices share clinical experiences, develop guidelines, and participate in workshops that assess performance; network group practice, which functions like base group practice but allows GPs/pediatricians to access the same patient electronic health record system; and advanced group practice, where GPs/pediatricians share the same office and patient health record system, and are able to provide care to patients beyond individual catchment areas. In 2010, approximately 67 percent of GPs and 60 percent of pediatricians were working in a team (Ministero della Salute, 2014). Group practices typically range from three to eight GPs. General practitioners working in base group practices receive an additional EUR2.58 (USD3.4) per patient, while GPs in a network practice receive EUR4.7 (USD6.2) (the payment for pediatricians is EUR8 [USD11]). Lastly, GPs working in a group practice receive EUR7 (USD9) (EUR9 [USD12] for pediatricians). General practitioners or pediatricians employing a nurse or secretary receive an additional payment of EUR4 (USD5.3) for nurses and EUR3.5 (USD4.6) for a secretary. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001677 OS 00003348 ITALY Some regions are promoting care coordination by asking their GPs to work in groups involving specialists, nurses, and social workers. The aim is for each group to be in charge of all the health needs of its assigned population. This is encouraged by additional payments to GPs (e.g., paying each GP EUR1.3 (USD1 .7) per patient in Emilia-Romagna) and supplying teams with personnel, in most cases nurses and social workers. Outpatient specialist care: Outpatient specialist care is generally provided by local health units or by public and private accredited hospitals under contract with them. Once referred, patients are given choice of any public or private accredited hospital, but are not allowed to choose a specific specialist. Outpatient specialist visits are generally provided by self-employed specialists working under contract with the National Health Service. They are paid an hourly fee contracted nationally between the government and the trade unions; the current rate is approximately EUR32 (USD42). Outpatient specialists can see private patients without any limitations, whereas specialists employed by local health units and public hospitals cannot. Multispecialty groups are more common in northern regions of the country. Administrative mechanisms for paying primary care doctors and specialists: Patient copayment is limited to outpatient specialist visits and diagnostic testing, while primary care visits are provided free of charge. Copayments are usually paid by the patient before receiving the visit/test. After-hours care: After-hours centers are generally located in local health unit-owned premises and staffed only by doctors employed on an hourly basis by the local health unit. The hourly rate, negotiated between the GP trade unions and government, is approximately equal to EUR25 (USD33). Following examination and initial treatment, the doctor can prescribe medications, issue employees' medical certificates, and recommend hospital admission. Guardia medica is a free telephone health service for emergency cases. It normally operates at night and on weekends, and the doctor on duty usually provides advice, in addition to home visits if needed. Information on a patient's visit is not routinely sent to the patient's GP. To improve accessibility, government and GP associations are trying to promote a model where GPs, specialists, and nurses coordinate to ensure 24-hour access and avoid unnecessary use of hospital emergency departments. Implementation is uneven across regions. Hospitals: Depending on the region, public funds are allocated by local health units to public and accredited private hospitals. In 2011 there were approximately 194,000 beds in public hospitals and 47,500 in private accredited hospitals (Ministero della Salute, 2014). Public hospitals either are managed directly by the local health units or operate as semi-independent public enterprises. A diagnosis-related group-based prospective payment system operates across the country and accounts for most hospital revenue but is generally not applied to hospitals run directly by local health units, where global budgets are common. Rates include all hospital costs, including those of physicians. Teaching hospitals receive additional payments (typically 8% to 10% of overall revenue) to cover extra costs related to teaching. There are considerable interregional variations in the prospective payment system, such as how the fees are set, which services are excluded, and what tools are employed to influence patterns of care. However, all regions have mechanisms for cutting fees once a spending threshold is reached, to contain costs and incentives to increase admissions. In all regions, a portion of funding is administered outside the prospective payment system (e.g., funding of specific functions such as emergency departments and teaching programs). Hospital-based physicians are salaried employees. Public hospital physicians are prohibited from treating patients in private hospitals; all public physicians who see private patients in public hospitals pay a portion of their extra income to the hospital. Mental health care: Mental health care is provided by the National Health Service in a variety of communitybased, publicly funded settings, including community mental health centers, community psychiatric diagnostic centers, general hospital inpatient wards, and residential and semiresidential facilities. In 2010 there were 1,737 residential facilities and 784 semiresidential facilities providing care to approximately 60,000 patients. Promotion and coordination of mental illness prevention, care, and rehabilitation are the responsibility of The Commonwealth Fund VA-19-0799-D-001678 OS 00003349 ITALY specific mental health departments in local health units. These are based on a multidisciplinary team, including psychiatrists, psychologists, nurses, social workers, educators, occupational therapists, people with training in psychosocial rehabilitation, and secretarial staff. In most cases primary care does not play a role in provision of mental health care; a few regions have experimented with assigning the responsibility of low-complexity cases (mild depression) to general practitioners (Lo Scalzo et al., 2009). Long-term care and social supports: Patients are generally treated in residential (approximately 221,000 beds in 2011) or semiresidential (50,000 beds) facilities, or in community home care (approximately 606,000 cases). Residential and semiresidential services provide nurses, physicians, specialist care, rehabilitation services, medical therapies, and devices. Patients must be referred in order to receive residential care. Cost-sharing for residential services varies widely according to region, but is generally determined by patient income. Community home care is funded publicly, whereas residential facilities are managed by a mixture of public and private, for-profit and nonprofit organizations. Community home care is not designed to provide physical or mental care services but to provide additional assistance during a treatment or therapy. In spite of government provision of residential and home care services, long-term care in Italy has traditionally been characterized by a low degree of public financing and provision as compared with other European countries. Financial assistance for patients can take two forms: o Accompanying allowance: Awarded by the National Pension Institute to all Italian citizens who need continuous assistance. The allowance, which is related to need but not to income or age, amounts to approximately EUR500 (USD658) per month. o Care voucher. Awarded by municipalities on the basis of income, need, and clinical severity only to residents of those municipalities offering the service. The amount ranges between EUR300 and EUR600 (USD395 to USD789) per month. Voluntary organizations still play a crucial role in the delivery of palliative care. A national policy on palliative care has been in place since the end of the 1990s and has contributed to an increase in services such as hospices, day care centers, and palliative care units within hospitals. In 2011 there were 158 hospices, with approximately 1,700 beds. But much still needs to be done to ensure the diffusion of palliative care services and disparities persist: northern regions cared, on average, for 51 patients per 100,000 residents, while in central and southern regions the rate fell to 25 patients. What are the key entities for health system governance? The Ministry of Health is currently structured into 12 directorates that oversee specific areas of health care (health care planning; essential levels of care and health system ethics; human resources and health professionals; information systems; pharmaceuticals and medical devices) or supervise the main institutions related to the Ministry of Health (e.g., National Health Council, National Institute of Health). Key nongovernmental entities supporting the Ministry of Health include the National Health Council (which provides support for national health planning, hygiene and public health, pharmacology and pharmacoepidemiology, continuing medical education for health care professionals, and information systems) and the National Institute of Public Health (which provides recommendations and control in the area of public health). The National Committee for Medical Devices develops cost-benefit analyses and determines reference prices for medical devices. The Agency for Regional Health Services is the sole institution responsible for conducting comparative effectiveness analysis and is accountable to the regions and the Ministry of Health. The National Pharmaceutical Agency is responsible for all matters related to the pharmaceutical industry, including prescription drug pricing and reimbursement policies. It is accountable to the Ministry of Health and the Ministry of Economy and Finance (Lo Scalzo et al., 2009). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001679 OS 00003350 ITALY Organization of the Health System in Italy ( Parliament ( Government ) + d,rnral departmeo How are costs contained? Containing health costs is a core concern of central government, as Italy's public debt is among the highest in industrialized nations. Fiscal capacity varies greatly across regions. To meet cost containment objectives, the central government can impose recovery plans on regions with health care expenditure deficits. These identify tools and measures needed to achieve economic balance: revision of hospital and diagnostic fees, reduction of the number of beds, increased copayments for pharmaceuticals, and reduction of human resources through limited turnover. The Agency for Regional Health Services, in collaboration with the Ministry of Health, has authority to conduct health technology assessments and implement its findings at the regional level, but these are not yet formalized or undertaken systematically. Few regional health technology assessment agencies currently exist, and their primary function is to evaluate individual technologies. Assessments are not mandatory for new or referred The Commonwealth Fund VA-19-0799-D-001682 OS 00003353 ITALY procedures and devices. However, reference prices for medical devices and pharmaceuticals are set according to cost-effectiveness studies carried out by the National Committee for Medical Devices and the National Drugs Agency. Furthermore, the National Pharmaceutical Formulary bases coverage decisions in part on clinical effectiveness and cost-effectiveness. Prices for reimbursable drugs are set in negotiations between government and the manufacturer according to the following criteria: cost-effectiveness where no effective alternative therapies exist; comparison of prices of alternative therapies for the same condition; costs per day compared with those of products of the same effectiveness; financial impact on the health system; estimated market share of the new drug; and average prices and consumption data from other European countries. Prices for nonreimbursable drugs are set by the market. G ? What major innovations and reforms have been introduced? Because of the regionalization of the health system, most innovations in the delivery of care take place at the regional rather than the national level, with some regions viewed as leaders in innovation. Significant innovations can be found in: o Pharmaceuticals: Both the National Drugs Agency and the regions are particularly active in coordinating guidelines and rules to promote appropriate and cost-effective prescribing. o Hospital care: Various innovations have been introduced concerning the overall organization, management of operations (e.g., planning of surgical theaters and delivery of drugs), and health information technology (e.g., electronic medical records, automation of administrative and clinical activities). In August 2012 the parliament passed a law aimed at curbing and rationalizing public expenditure (the so-called spending review). The law promoted the prescription of generic drugs, cut the hospital bed ratio from 4 per 1,000 people to 3.7, and reduced public financing ofthe National Health Service by between EUR900M (USD1 .2B) and EUR2.1 B (USD2.8B) annually between 2012 and 2015. Many ofthe requirements ofthe law are still in the process of being implemented and effects have not yet been evaluated. In 2012, the government approved a decree (named after Renato Balduzzi, who was health minister at that time) to reorganize health care at the regional level, with the introduction of teams of primary health care professionals to ensure 24-hour coverage; to update health care fees; to restructure governance of hospitals and local health units; to revise the list of reimbursable pharmaceuticals; and to introduce health technology assessment as a tool for renegotiating the price of less effective medicines. Evaluations of the impact of both laws are not yet available as their implementation is still under way. The July 2014 Pact for Health defines funding (between EUR109B [USD143.4B] and EUR11 SB [USD151.3B] annually) for the years 2014 to 2016. In return, regions make explicit commitments to: o Reduce hospitalizations through appropriate use of hospitals, with progress toward home care and the creation of community hospitals offering subacute care. o Reorganize primary care: All regions will have to establish primary care complex units (Unita Complesse di Cure Primarie) (as described in the section on care integration) to replace all other forms of general practice networks (base group practice, network group practice, and advanced group practice). o Revise hospital and specialist care fees in line with health inflation and with the underlying structure of health care costs. o Revise copayments for outpatient specialist care to promote more equitable access. Copayments currently represent a barrier for disadvantaged sectors of the population. o Strengthen the electronic records system. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001683 OS 00003354 ITALY The author would like to acknowledge Sarah Jane earlier versions of this profile. (b) (6) and David Squires as contributing authors to References France, G. (1997). "Cross-Border Flows of Italian Patients Within the European Union: An International Trade Approach." European Journal of Public Health, 7(3 Suppl.):18-25. France, G., F. Taroni, and A. Donatini (2005). "The Italian Health-Care System." Health Economics, 14:S187-S202. Lo Scalzo, A., A. Donatini, L. Orzella, A. Cicchetti, S. Profili, and A. Maresso (2009). "Italy: Health System Review." Health Systems in Transition, 11 (6):1-216. Ministero dell'Economia e delle Finanze (2012). Relazione Generale Sulla Situazione Economica Del Paese 2012, Roma. http://www.mef.gov.it/doc-finanza-pubblica/rgse/2012/documenti/RGE_2012_-_on_line_PROTETTO.pdf. Ministero della Salute (2014). Annuario statistico del Servizio Sanitario Nazionale-Roma. http://www.salute.gov.it/imgs/C_17 _ pubblicazioni_2160_allegato.pdf. Organisation for Economic Co-operation and Development (OECD) (2014). Health Data. Organisation for Economic Co-operation and Development (OECD) (20146). OECD.Stat (database). DOI: 10.1787/data00285-en. Accessed Oct. 6, 2014. Thomson, S., and E. Mossialos (eds.) (2009). Private Health Insurance in the European Union. London: London School of Economics and Political Science. Toth, F. (2014). "How Health Care Regionalization in Italy is Widening the North-South Gap." Health Economics, Policy and Law, 9:231-49. doi:10.1017/S1744133114000012. Van Doorslaer, E., and X. Koolman (2004). "Explaining the Differences in Income Related Health Inequalities Across European Countries." Health Economics, 13(7):609-28. The Commonwealth Fund VA-19-0799-D-001684 OS 00003355 ~ ~ ? What is the role of government? Government regulates nearly all aspects of the universal public health insurance system (PHIS). The national and local governments are required by law to ensure a system that efficiently provides good-quality and well-suited medical care to the nation. National government sets the fee schedule and gives subsidies to local governments, insurers, and providers. It also establishes and enforces detailed regulations for insurers and providers. Japan's 47 prefectures (regions) implement those regulations and develop regional health care delivery with funds allocated by the national government. More than 1,700 municipalities operate components of the PHIS and long-term care insurance and organize health promotion activities for their residents (Tatara and Okamoto, 2009). o/,:f:' Who is covered and how is insurance financed? Publicly financed health insurance: The PHIS, comprising more than 3,400 insurers, provides universal primary coverage (National Institute of Population and Social Security Research, 2014). In 2013, estimated total health expenditure amounted to approximately 10 percent of GDP, 83 percent of which was publicly financed, mainly through the PHIS (OECD, 2015). Within the PHIS, premiums, tax-financed subsidies, and user charges accounted for about 49 percent, 38 percent, and 12 percent of the sum of health expenditures, respectively (MHLW, 20146). Citizens are mandated to enroll in one of the PHIS plans based on employment status and/or place of residence, as are resident noncitizens; undocumented immigrants and visitors are not covered. Insurance premiums and the basis upon which they are charged vary between types of insurance funds and municipalities. Government employees are covered by their own insurers (known as Mutual Aid Societies), as are some groups of professionals (e.g., doctors in private practice). Those who fail to keep up their enrollment must pay up to two years' worth of premiums when they reenter the system. Means-tested public assistance covers health care for its recipients. Citizens and resident noncitizens enrolled in the PHIS age 40 and over are mandatorily enrolled in long-term care insurance. Private health insurance: Although the majority of the population holds some form of medical insurance, private insurance plays only a minor supplementary or complementary role. It developed historically as a supplement to life insurance and provides additional income in case of sickness, mainly in the form of lump-sum payments when insured persons are hospitalized or diagnosed with cancer or another specified chronic disease, or through payment of daily amounts during hospitalization over a defined period. Since the early 2000s, the number of standalone medical insurance policies has increased (Japan Institute of Life Insurance, 2013; Life Insurance Association of Japan, 2014). Part of an individual's life insurance premium (up to JPY40,000, or USD380) can be deducted from taxable income. Small discounts can be applied to those employees whose employers have collective contracts with insurance companies. Both for-profit and nonprofit organizations operate private health insurance. The provision of privately funded health care has been limited to services such as dental orthodontics, expensive artificial teeth, and treatment of traffic accident injuries (although treatment of these injuries is usually paid for by compulsory or voluntary automobile insurance.) International Profiles of Health Care Systems, 2015 VA-19-0799-D-001685 OS 00003356 JAPAN ~ What is covered? Services: All PHIS plans provide the same benefits package, which is determined by the national government, usually following a decision by the Central Social Insurance Medical Council, a governmental body. The package covers hospital, primary, and specialist ambulatory and mental health care, approved prescription drugs, home care services by medical institutions, hospice care, physiotherapy, and most dental care. It does not cover corrective lenses unless recommended by physicians for children under age 9, or optometry services provided by nonphysicians. Home care services by nonmedical institutions are covered by long-term care insurance. Preventive measures, including screening, health education, and counseling, are covered by health insurance plans, while cancer screenings are delivered by municipalities. Cost-sharing and out-of-pocket spending: All enrollees have to pay a 30 percent coinsurance rate for services and goods received, except for children under age 3 (20%), adults between 70 and 74 with lower incomes (20%), and those 75 and over with lower incomes (10%). There are no deductibles. Annual expenditures on health services and goods, including copayments and payments for balance billing and over-the-counter drugs, between JPY100,000 (USD 950) and JPY2 million (USD19 ,000) can be deducted from taxable income. 1 In 2012, out-of-pocket payments for cost-sharing accounted for 14 percent oftotal health expenditures (OECD, 2015). Some employer-based health insurance plans offer reduced cost-sharing. Providers are prohibited from charging extra fees except for some services specified by the Ministry of Health, Labor and Welfare, including amenity beds, experimental treatments, the outpatient services of large multispecialty hospitals, after-hours services, and hospitalizations of 180 days or more. Safety net: Catastrophic coverage stipulates a monthly out-of-pocket threshold, which varies according to enrollee age and income-for example, JPY80,100 (USD761) for people under age 70 with an average income; above this threshold, 1 percent coinsurance applies. There is a ceiling for low-income people, who do not pay more than JPY35,400 (USD336) a month. Subsidies (mostly restricted to low-income households) reduce the burden of cost-sharing for people with disabilities, mental illness, and specified chronic conditions. There is an annual household health and long-term care out-of-pocket payments ceiling, which varies between JPY340,000 (USD3,230) and JPY1 .26 million (USD11,970) per enrollee according to income and age, above which such payments can be reimbursed. Enrollees with employer-based insurance who are on parental leave are exempt from payment of premiums. Enrollees in Citizens Health Insurance (for the unemployed, self-employed, and retired, and those others under 75) with low income and those with moderate income who face sharp, unexpected income reductions are eligible for reduced premium payments. Reduced coinsurance rates apply to patients with 306 designated long-term diseases, varying by income, when using designated health care providers. [ (R)] How is the delivery system organized and financed? Primary care: Primary care is provided at most clinics and some hospital outpatient departments. Primary care and specialist care are not regarded as distinct disciplines, although it has been argued that they should be. Approximately one-third of physicians are salaried employees of clinics, and virtually all others are selfemployed. Clinics are often owned by physicians or by medical corporations (special legal entities for health care management, usually controlled by physicians, that own hospitals as well as clinics), but sometimes by local governments or public agencies. Primary care practices typically include teams with a physician and a few employed nurses. In 2011, the average clinic had 7.2 full-time-equivalent workers, including 1.2 physicians, 1.8 nurses, and 2.1 clerks. 2 Clinics can dispense medication (which doctors can provide directly to patients). Use of pharmacists, however, has been growing; 67 percent of prescriptions were filled at pharmacies in 2013 (Japan Pharmaceutical Association, 2014). Patients are not required to register with a practice, and there is no strict gatekeeping, although government encourages patients to choose their family doctors, and there are patient disincentives for 1 Please note that, throughout this profile, all figures in USD were converted from JPY at a rate of about JPY105 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (20156) for Japan. 2 The figures are calculated from statistics of the Ministry of Health, Labor and Welfare (2012a). The Commonwealth Fund VA-19-0799-D-001686 OS 00003357 JAPAN self-referral including extra charges for initial consultations at some large hospitals with many specialties. Patients can choose and drop in at any clinic, except those requiring reservations. An entity managing many clinics can share their resources, but there is no cross-entity resource sharing. Payments for primary care are based principally on a complex national fee-for-service schedule, which includes financial incentives for coordinating the care of patients with chronic diseases, and for team ambulatory and home care. The schedule, set by the government (explained below), includes both primary and specialist services, which have common prices for defined services such as consultations, examinations, laboratory tests, imaging tests, and defined chronic disease management. Per-case payments can be chosen by providers in select cases, such as daily payments for pediatrics care and monthly payments for treating patients with diabetes. Bundled payments are not used. Balance billing is prohibited, but providers can charge for designated services. Outpatient specialist care: Most outpatient specialist care is provided in hospital outpatient departments, but some is also available at clinics, where patients can visit without referral. Fees are determined by the same schedule that applies to primary care, as they do not usually vary by provider type, although some services must be provided by specialists in order to be covered by the PHIS. There are no collective regulations on payments for specialists. At hospitals, specialists are usually salaried, with additional payments such as night duty allowance. Those working at public hospitals can work at other health care institutions and privately with the approval of their hospitals, but in such cases they usually provide services covered by the public system. The employment status of specialists at clinics varies similarly to that of primary care physicians. Administrative mechanisms for paying primary care doctors and specialists: There are no direct payments to primary care doctors and specialists in the PHIS. Although in principle patients are liable for copayments at point of service, practically all fee transactions are mediated by statutory bodies. Self-employed clinic-based primary care physicians and specialists receive all payments for services through the fee schedule, pay for employees and other inputs, allocate funds for investments, and retain surpluses. Legal entities managing clinics and hospitals send insurance claims, mostly online, to insurers in the PHIS. After-hours care: After-hours care is provided by hospital outpatient departments, where on-call physicians are available, and by some regular clinics and after-hours care clinics owned by local governments and staffed by physicians and nurses that local medical societies provide. Hospitals and clinics are paid "top-up" fees for afterhours care, including fees for telephone consultations. There is no strict formal requirement for clinics to provide such services, although physicians have a general obligation to consult with patients when requested. Patients can walk in at hospitals and clinics. National government grants subsidies to local governments for these clinics. Patient information from after-hours clinics is provided to family physicians if necessary (necessary information is often handed to patients to show to family physicians). There is a national pediatric medical advice telephone line available after hours. Hospitals: As of 2013, 14 percent of hospitals are owned by national or local governments or closely related agencies (MHLW, 2014c); most ofthe rest are private and not-for-profit, some of which receive subsidies because they are designated as having partly public roles. More than 20 percent of beds are in public hospitals; the rest are in not-for-profit hospitals. The entry of private for-profit companies in the hospital sector is now prohibited, while existing hospitals established by for-profit companies for their employees (e.g., Toyota) are allowed to continue. Payments to hospitals from the PHIS include costs for physicians' salaries. Consultation fees for large hospitals and academic medical centers are lower than those for small hospitals and clinics. More than half of all acute-care hospital beds are paid for by the Diagnosis Procedure Combination (DPC) modification, a case-mix classification similar to diagnosis-related groups (DRGs) (Matsuda, et. al., 2008), and the rest are paid for solely on a fee-for-service basis. Hospitals choose whether to receive the DPC payments or to remain under fee-for-service. The DPC payment consists of a fee-for-service and a DPC component in the form of a per diem payment determined by the DPC grouping, which includes basic hospital services and less expensive treatments; the fee-for-service component includes surgical procedures, rehabilitative services, and other specified expensive services (OECD, 2009). DPC rates are multiplied by a hospital-specific coefficient that keeps them relatively in line with fee-for-service payments; it may also limit International Profiles of Health Care Systems, 2015 VA-19-0799-D-001687 OS 00003358 JAPAN incentives for providers to contain cost, although the correlation has not yet been formally evaluated. Episodebased payments are not used. Mental health care: Mental health care is provided in outpatient, inpatient, and home care settings, with patients charged the standard 30 percent coinsurance (although there is reduced cost-sharing and other financial protections for patients in the community). Covered services include psychological tests and therapies, pharmaceuticals, and rehabilitative activities. Specialized mental clinics and hospitals exist, but services for depression, dementia, and other common conditions are integrated with primary care. Most psychiatric beds are in private hospitals owned by medical corporations (MHLW, 2014c). Long-term care and social supports: National compulsory long-term care insurance (LTCI), administered by the municipalities, covers those age 65 and older and some disabled people ages 40 to 64. It covers home care, respite care, domiciliary care, disability equipment, assistive devices, and home modification. Medical services are covered by the PHIS, as are palliative care and hospice care in hospitals and medical services provided in home palliative care, while nursing services are covered by LTCI. Long-term home care services can be considered a part of home hospice services as dying patients become eligible. Roughly half of long-term care financing comes through taxation and half through premiums. Citizens age 40 and over pay income-related premiums along with PHIS premiums. Employers pay the same premium as that of their employees. Premiums for those age 65 and older, also income-based (including pensions), and set by municipalities based on estimated expenditures, are paid only by the beneficiaries. A 10 percent coinsurance rate applies to all covered services, up to an income-related ceiling. There is additional copayment for bed and board in institutional care, but it is waived or reduced for those with low income (all costs for those with meanstested social assistance are paid from local and national tax revenue). Eligible people are entitled to use long-term services up to needs-based ceilings (called "care levels") set by local LTCI boards, according to assessment of physical and mental conditions. People are not allowed to buy unlisted services or services from non-LTCI providers with the budget provided, but they can purchase such services with their own money. Care management-covered by LTCI and offered by public, not-for-profit, and for-profit providers-is available to help people arrange long-term care services. The majority of home care providers are private; 64 percent were for-profit, 35 percent not-for-profit, and 0.4 percent public in 2013 (MHLW, 2014a). While for-profits are not allowed to provide institutional care under LTCI, there are private nursing homes for which residents pay full costs (MHLW, 2013). Family care leave benefits (part of employment insurance) are paid for up to three months when employees take leave to care for their families. Additionally, more than half of the municipalities have established marginal financial supports, mostly limited to those with lower incomes, with their own financial capacities and legislations (Kwon, 2014). &h What are the key entities for health system governance? The Social Security Council, a statutory body within the Ministry of Health, Labor and Welfare, is in charge of developing national strategies on quality, safety, and cost control, and sets guidelines for determining provider fees. Within the Ministry, the Central Social Insurance Medical Council defines the benefit package and fee schedule. National government and prefectures devise cost-control plans (described below). The Japan Council for Quality Health Care, a nonprofit organization, works to improve quality throughout the health system and develops clinical guidelines, although it does not have any regulatory power to penalize poorly performing providers. Specialist societies themselves also produce clinical guidelines. Technology assessment of pharmaceuticals and medical devices is conducted by the Pharmaceutical and Medical Devices Agency, a governmental regulatory agency. It also sets the Public Health Insurance Drug Price List, which is a list of pharmaceuticals and their prices covered by the PHIS (English Regulatory Information Task The Commonwealth Fund VA-19-0799-D-001688 OS 00003359 JAPAN Force: Japan Pharmaceutical Manufacturers Association 2012). The criteria for coverage include clinical effectiveness but not economic appraisal. Since 2012, the agency has been discussing the possible application of comparative cost-effectiveness studies in its decision-making (described below). Nonprofit organizations work toward public engagement and patient advocacy, and every prefecture establishes a health care council to discuss the local health care plan. Under the Medical Care Law, these councils must have members representing patients. The Japan Fair Trade Commission, an independent governmental administrative commission, promotes fair competition in health care as well as other sectors. ~ X What are the major strategies to ensure quality of care? By law, prefectures are responsible for making health care delivery "visions," which include detailed plans on cancer, stroke, acute myocardial infarction, diabetes mellitus, psychiatric disease, pediatric, and home care, as well as emergency, prenatal, rural, and disaster medicine. These plans include structural, process, and outcome indicators, as well as strategies for effective and high-quality delivery. Prefectures promote collaboration between providers to achieve them, with or without subsidies as financial incentives. Waiting times are generally not monitored by government, although there is cause for concern in some clinical areas, such as palliative care. Although there are structural health care delivery regulations, relatively few apply to process and outcomes. Prefectures are in charge of the annual inspection of hospitals. Sanctions include reduced reimbursement rates if staffing per bed falls below a certain ratio. Hospital accreditation, on the other hand, is voluntary and undertaken largely as an improvement exercise; roughly one-third of hospitals are accredited by the Japan Council for Quality Health Care. However, there is no disclosure of names of hospitals that fail the accreditation process. The Ministry of Health, Labor and Welfare organizes and financially supports a voluntary benchmarking project, in which hospitals report quality indicators on their websites. In order to practice, physicians are required to obtain a license by passing a national exam, but they are not subject to revalidation. However, specialist societies have introduced revalidation for qualified specialists. Clinical audits are voluntary. Public reporting on performance has been discussed but is not yet implemented. Every prefecture has a medical safety support center for handling complaints and promoting safety. Since 2004, advanced academic and public hospitals have been required to report adverse events to the Japan Council for Quality Health Care. Disease and medical device registries have been developed on a voluntary basis, possibly to be used for quality improvement in the future. Surveys of hospital patients' experiences are conducted every three years. it-I ~ What is being done to reduce disparities? Reducing health disparities between population groups has been a general goal since 2012. The two explicit targets are a reduction of disparities in healthy life expectancies between prefectures and an increase in the number of local government entities that make efforts to solve health disparity issues (MHLW, 20126). There is another plan to reduce disparities among prefectures in cancer treatment delivery, with each prefecture setting treatment targets. Health variations between regions are regularly reported by government. Health variations between socioeconomic groups and variations in health care access are occasionally measured and reported by researchers, some of them funded by the Ministry of Health, Labor and Welfare. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001689 OS 00003360 JAPAN Organization of the Health System in Japan Legal Frameworks Medical Care Act, Health Insurance Act, National Health Insurance Act, and other relevant acts National Government [ The Cabinet [ Minister of Finance Minister of Health, Welfare and Labour Japan Council for Quality Health care Social Security Council General health care policies Health Science Council Public health policies Central Social Insurance Medical Council Payment rules (fee schedule) Pharmaceutical and Medical Devices Agency ~ - - - - - - - - - - . Establishment of Regulations Funds for developing health care delivery [ Hospitals Prefectures -------------------~ . tc ~::'-,, Health Care Council Implementation of Regulations ---- ..... Planning and developing health care delivery , ,-' Municipalities ] Clinics ,.. Institutional long-term care providers Implementation of fair competition policy on providers ' ------ ---------Also, serving as statutory [;:================:::::: 1f Japan Fair Trade Commission ,--' ,...,"'........ (_____ - ---,. ~====~ Home care providers National Insurance Bodies Checking invoices from providers health insurers Notes: This chart illustrates a very simplified structure of the complex health care governance in Japan. Source: R. Matsuda, College of Social Sciences, Ritsume ika n University, 2015 . (R)-0- What is being done to promote delivery system integration and "-.:::,I care coordination? The national government prioritizes the general coordination of care, including coordination in mental health care, and has introduced financial incentives for hospitals and clinics, particularly in cancer, stroke, cardiac, and palliative care. Hospitals admitting stroke victims or patients with hip fractures can receive additional fees if they use post-discharge protocols and have contracts with clinic physicians to provide effective follow-up after discharge, for which those physicians also receive additional fees. The government also provides subsidies to leading providers in the community to facilitate care coordination. There are more than 4,000 "community comprehensive support centers" to coordinate services, particularly for those with long-term conditions. Funded by LTCI, they employ care managers, social workers, and long-term care support specialists. No pooled funding of the PHIS and LTCI exists. Regional and large-city governments are required to establish councils to promote integration of care and support for patients with 306 designated long-term diseases. What is the status of electronic health records? Electronic health record networks have been developed only as experiments in selected areas. Interoperability between providers has not been generally established. Currently, experiments are under way to make personal health information available to patients and providers via cloud computing. The Social Security and Tax Number The Commonwealth Fund VA-19-0799-D-001690 OS 00003361 JAPAN System (SSTNS), a system of unique identifiers, will begin in 2016. It will be used for social security from its inception, and for health services, possibly including medical records, starting in 2018. ~ How are costs contained? Price regulation for all services under the PHIS is a critical cost-containment mechanism (lkegami and Anderson, 2012). The fee schedule is revised every two years by the government, following informal stakeholder negotiations, and is based on the estimated overall rate of change in public health care expenditures and expenditures in different health care sectors. For medical, dental, and pharmacy services, the Central Social Insurance Medical Council revises fees on an item-by-item basis in order to meet overall spending targets set by the cabinet. Highly profitable categories see larger reductions. The revisions of prices of pharmaceuticals and devices are determined based on a market survey of actual current prices (which are often less than the listed prices). Drug prices can be revised downward for new drugs selling in greater volume than expected and for brand-name drugs when generic equivalents hit the market. Prices of medical devices in other countries are also considered in the revision. Negotiations between stakeholders take place only for the purpose of revising the fee schedule and the rule for deciding pharmaceutical prices. Whether cost-sharing and the existing competition between providers contain costs is unclear. The number of hospital beds is regulated by prefectures in accordance with national guidelines. The national medical student capacity, which is increasing since 2007 owing to physician shortages, is also regulated by the government. The government's Cost-Containment Plan for Health Care is intended to promote healthy behavior, shorten hospital stays through care coordination and home care development, and increase generic substitution. Each prefecture makes cost-control plans in accordance with the plan. Both financial incentives in the fee schedule and other incentives, including education and training, are used. Peer review committees in each prefecture also monitor claims and may deny payment for services deemed inappropriate. ~ Currently, some pharmaceuticals whose medical effectiveness is considered uncertain are not covered by the PHIS. A trial cost-effectiveness evaluation for coverage of selected pharmaceuticals and medical devices is scheduled for fiscal year 2016. What major innovations and reforms have been introduced? Community-based health insurance plans in the PHIS, operated by municipalities, usually insure residents who are sicker and less well-off than those covered by employment-based insurance plans. The plans vary significantly in the number they insure, from fewer than 100 to more than half a million. To mitigate financial risk in small plans, the national government has gradually expanded cross-subsidies between community-based plans while keeping its and local governments' subsidies. With increasing financial pressures and the development of region-based governance, plans are being restructured under the 2015 Health Care Reform Act: from 2018, regions will take overall administrative responsibility for community-based plans and work together with municipalities, which will still be insurers of their residents, to set premium rates and to collect premiums. Meanwhile, subsidies from the national government to the regions are to be slightly increased to help plans, and those with low incomes, with excessive financial burdens. A plan to strengthen the financial incentive for patients to use family physicians is intended to decrease demand on hospital outpatient departments. Although hospitals with 200 beds or more are currently allowed to charge additional fees to patients who have no referral for outpatient consultations, fewer than half of such hospitals have opted for this extra charge. Under the Health Care Reform Act of 2015, highly specialized large-scale hospitals with 500 beds or more will have an obligation to promote care coordination between providers in the community, as well as to charge additiona I fees to such patients. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001691 OS 00003362 JAPAN The author would like to acknowledge David Squires as a contributing author to earlier versions of this profile. References English Regulatory Information Task Force: Japan Pharmaceutical Manufacturers Association (2012). Pharmaceutical Administration and Regulations in Japan. http://www.jpma.or.jp/english/parj/pdf/2012.pdf. Accessed Aug. 20, 2013. Life Insurance Association of Japan (2014). Life Insurance Fact Book 2014, http://www.seiho.or.jp/english/statistics/trend/ pdf/2014.pdf. lkegami, N., and Anderson, G. F. (2012). "In Japan, All-Payer Rate Setting Under Tight Government Control Has Proved to Be an Effective Approach to Containing Costs." Health Affairs 31(5):1049-1056. Japan Institute of Life Insurance (2013). FY2013 Survey on Life Protection. FY2013 Survey on Life Protection (Quick Report Version. http://www.jili.or.jp/research/report/pdf/FY2013_Survey_on_Life_ Protection_(Quick_Report_Version). pdf. Japan Pharmaceutical Association (2014). Annual report of JPA. http://www.nichiyaku.or.jp/e/data/anuual_report2014e.pdf. Kwon, S. (2014). Research on income security of in-home caregivers. Unpublished thesis (in Japanese). Matsuda, S., K. B. Ishikawa, K. Kuwabara et al., (2008). "Development and use of the Japanese case-mix system." Eurohealth 14(3):25-30. Ministry of Health, Labor and Welfare (MHLW) (2012a). Survey of Medical Institutions, 2012. Ministry of Health, Labor and Welfare (20126). "A basic direction for comprehensive implementation of national health promotion" (Ministerial notification no. 430 of the Ministry of Health, Labor and Welfare) (tentative English translation) (http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000047330.pdf, accessed Oct. 15, 2014). Ministry of Health, Labor and Welfare (2013). "The current situation and future direction of the Long-Term Care Insurance System in Japan, with a focus on housing for the elderly." http://www.mhlw.go.jp/english/policy/care-welfare/care-welfareelderly/dl/ri_130311-01.pdf. Accessed Aug. 20, 2014. Ministry of Health, Labor and Welfare (2014a). 2012 Survey of Long-Term Care Providers, 2012. Ministry of Health, Labor and Welfare (20146). Estimates of National Medical Care Expenditure, Summary of Results for FY2012. Ministry of Health, Labor and Welfare (2014c). Survey of Medical Institutions, 2013 Summary. National Institute of Population and Social Security Research (2014). Socia/ Security in Japan 2014. http://www.ipss.go.jp/sinfo/e/ssj2014/index.asp. Accessed Aug. 20, 2014. OECD (2009). Health-care reform in Japan: Controlling costs, improving quality and ensuring equity. OECD Economic Surveys: Japan 2009. OECD Publishing. OECD (2015). OECD Health Data 2015. Organisation for Economic Co-operation and Development (20156). OECD.Stat (database). DOI: 10.1787/data-00285-en. Accessed July 2, 2015. Tatara, K., and Okamoto, E. (2009). "Japan: Health system review." Health systems in Transition 11 (5). The Commonwealth Fund VA-19-0799-D-001692 OS 00003363 Joost Wammes, Patrick Jeurissen, and Gert Westert ~ ? = P-ff: What is the role of government? In the Netherlands, the national government has overall responsibility for setting health care priorities, introducing legislative changes when necessary, and monitoring access, quality, and costs. It also partly finances social health insurance for the basic benefit package (through subsidies from general taxation and reallocation of payroll levies among insurers through a risk adjustment system) and the compulsory social health insurance system for long-term care. Prevention and social support are not part of social health insurance but are financed through general taxation. The 2015 national reforms to long-term care made municipalities and health insurers responsible for most outpatient long-term services and all youth care under a provision-based approach (with a great level of freedom at the local level). Who is covered and how is insurance financed? Publicly financed health insurance: In 2013, the Netherlands spent 12 percent of GDP on health care, and 78 percent of curative health care services were publicly financed. All residents (and nonresidents who pay Dutch income tax) are mandated to purchase statutory health insurance from private insurers. People who conscientiously object to insurance, as well as active members of the armed forces (who are covered by the Ministry of Defense), are exempt. Insurers are required to accept all applicants, and enrollees have the right to change their insurer each year. Apart from acute care, long-term care, and obstetric care, undocumented immigrants have to pay for most health care themselves (they cannot take out health insurance). However, some mechanisms are in place to reimburse costs that undocumented immigrants are unable to pay. For asylum seekers, a separate set of policies has been developed. Permanent residents (for more than 3 months) are obliged to purchase private insurance coverage. Visitors are required to purchase insurance for the duration of their visit if they are not covered through their home country. Statutory health insurance is financed under the Health Insurance Act, through a nationally defined, incomerelated contribution, a government grant for the insured below age 18, and community-rated premiums set by each insurer (everyone with the same insurer pays the same premium, regardless of age or health status). Contributions are collected centrally and issued among insurers in accordance with a risk-adjusted capitation formula that considers age, gender, labor force status, region, and health risk (based mostly on past drug and hospital utilization). Insurers are expected to engage in strategic purchasing, and contracted providers are expected to compete on both quality and cost. The insurance market is dominated by the four largest insurer conglomerates, which account for 90 percent of all enrollees. Currently, there is a ban on the distribution of profits to shareholders. Private (voluntary) health insurance: In addition to statutory coverage, most of the population (84%) purchases a mixture of complementary voluntary insurance covering benefits such as dental care, alternative medicine, physiotherapy, spectacles and lenses, contraceptives, and the full cost of copayments for medicines (excess costs above the limit for equivalent drugs-an incentive for using generics). Premiums for voluntary insurance are not regulated; insurers are allowed to screen applicants based on risk factors and offer both statutory and voluntary benefits. Nearly all of the insured purchase their voluntary benefits from the same (mostly nonprofit) insurer that provides their statutory health insurance. People with voluntary coverage do not International Profiles of Health Care Systems, 2015 VA-19-0799-D-001693 OS 00003364 THE NETHERLANDS receive faster access to any type of care, nor do they have increased choice of specialist or hospital. In 2013, voluntary insurance accounted for 7.6 percent of total health spending. ?1 What is covered? Services: In defining the statutory benefits package, government relies on advice from the National Health Care Institute. Health insurers are legally required to provide a standard benefits package including, among other things, care provided by general practitioners (GPs), hospitals, and specialists; dental care through age 18 (coverage after that age is confined to specialist dental care and dentures); prescription drugs; physiotherapy through age 18; basic ambulatory mental health care for mild-to-moderate mental disorders, including a maximum of five sessions with a primary care psychologist; and specialized outpatient and inpatient mental care for complicated and severe mental disorders. In case the duration exceeds three years, the last of these is financed under the Long-term Care Act (see below). Some treatments, such as general physiotherapy and pelvic physiotherapy for urinary incontinence, are only partially covered for some people with specific chronic conditions, as are the first three attempts at in vitro fertilization. Some elective procedures, such as cosmetic plastic surgery without a medical indication, dental care above age 18, and optometry, are excluded. A limited number of effective health improvement programs (e.g., smoking cessation) are covered, and weight management advice is limited to three hours per year. As of 2015, home care is a shared responsibility of the national government, municipalities (day care, household services), and insurers (nursing care at home), and is financed through the Health Insurance Act. Hospice care is financed through the Long-term Care Act. Prevention is not covered by social health insurance, but falls under the responsibility of municipalities. Cost-sharing and out-of-pocket spending: As of 2015, every insured person over age 18 must pay an annual deductible of EUR375 (USD455) for health care costs, including costs of hospital admission and prescription 1 drugs but excluding some services, such as GP visits. Apart from the overall deductible, patients are required to share some of the costs of selected services, such as medical transportation or medical devices, via copayments, coinsurance, or direct payments for goods or services that are reimbursed up to a limit, such as drugs in equivalent-drug groups. Providers are not allowed to balance-bill above the fee schedule. Patients with an in-kind insurance policy may be required to share costs of care from a provider that is not contracted by the insurance company. Out-of-pocket expenses represented 13.8 percent (45% through deductible) of health care spending in 2013 (author's calculation). Safety net: GP care and children's health care are exempt from cost-sharing. Government also pays for children's coverage up to the age of 18 and provides subsidies (health care allowances), subject to asset testing and income ceilings, to cover community-rated premiums for low-income families (singles with annual income of less than EUR26,316 [USD31,896] and households with income less than EUR32,655 [USD39,580]). Approximately 5.4 million people receive allowances set on a sliding scale, ranging from EUR5.00 (USD6.10) to EUR78.00 (USD95.00) per month for singles and from EUR9.00 (USD11.00) to EUR 149.00 (USD181.00) for households, depending on income. [ (R)] How is the delivery system organized and financed? Primary care: There were more than 11,300 practicing primary care doctors (GPs) in 2014 and more than 20,400 specialists in 2013. Nearly 33 percent of practicing GPs worked in group practices ofthree to seven, 39 percent worked in two-person practices, and just over 28 percent worked solo. Most GPs work independently or in a self-employed partnership; only 11 percent are employed in a practice owned by another GP. 1 Please note that, throughout this profile, all figures in USD were converted from EUR at a rate of about EUR0.83 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for the Netherlands. The Commonwealth Fund VA-19-0799-D-001694 OS 00003365 THE NETHERLANDS The GP is the central figure in Dutch primary care. Although registration with a GP is not formally required, most citizens are registered with one they have chosen, and patients can switch GPs without formal restriction. Referrals from a GP are required for hospital and specialist care. Many GPs employ nurses and primary care psychologists on salary. Reimbursement for the nurse is received by the GP, so any productivity gains that result from substituting a nurse for a doctor accrue to the GP. Care groups are legal entities (mostly GP networks) that assume clinical and financial responsibility for the chronic disease patients who are enrolled; the groups purchase services from multiple providers. To incentivize care coordination, bundled payments are provided for certain chronic diseases-diabetes, cardiovascular conditions, and chronic obstructive pulmonary disease (COPD)-and efforts are under way to implement them for chronic heart failure and depression. In 2015, the government introduced a new GP funding model comprising three segments. Segment 1 (representing 75% of spending) funds core primary care services and consists of a capitation fee per registered patient, a consultation fee for GPs (including phone consultation), and consultation fees for ambulatory mental health care at the GP practice. The Dutch Health Care Authority (Nederlandse Zorgautoriteit) determines national provider fees for this segment. Segment 2 (15% of spending) consists of funding for programmatic multidisciplinary care for diabetes, asthma, and COPD, as well as for cardiovascular risk management; prices are negotiated with insurers. Segment 3 (10% of spending) provides GPs and insurers with the opportunity to negotiate additional contracts-including prices and volumes-for pay-for-performance and innovation. Selfemployed GPs earned average gross annual income of EUR97,500 (USD117 ,000) in 2012, while salaried GPs earned EUR80,000 (USD96,000). Outpatient specialist care: Nearly all specialists are hospital-based and either in group practice (in 2012, 54% of full-time-equivalent specialists, paid under fee-for-service) or on salary (46%, mostly in university clinics). As of 2015, specialist fees are freely negotiable as a part of hospital payment. This so-called "integral funding" dramatically changed the relationship between medical specialists and hospitals. Hospitals now have the responsibility of allocating their financial resources among their specialists. There is a nascent trend toward working outside of hospitals-for example, in growing numbers of (mostly multidisciplinary) ambulatory centers-but this shift is marginal, and most ambulatory centers remain tied to hospitals. Specialists in ambulatory centers tend to work most of the time in academic or general hospitals. Only a small minority of doctors working in hospitals choose to work in ambulatory centers for part of their time. Ambulatory care center specialists are paid fee-for-service, and the fee schedule is negotiated with insurers. Medical specialists are not allowed to charge above the fee schedule. Patients are free to choose their provider (following referral), but insurers may set different conditions (e.g., cost-sharing) for different choices within their policies (Schafer et a I., 2010). Administrative mechanisms for paying primary care doctors and specialists: The annual deductible (see above) is paid to the insurer. The insured have the option of paying the deductible before or after receiving health care and may choose to pay all at once or in installments. Other copayments-those for drugs or transportation, for example-have to be paid directly to the provider. After-hours care: After-hours care is organized at the municipal level in GP "posts," which are centers, typically run by a nearby hospital, that provide primary care between 5 p.m. and 8 a.m. Specially trained assistants answer the phone and perform triage; GPs decide whether patients need to be referred to hospital. The GP post sends the information regarding a patient's visit to his or her regular GP. There is no national medical telephone hotline. Hospitals: In July 2014, there were 131 hospitals and 112 outpatient specialty clinics spread among 85 organizations, including eight university medical centers. Practically all organizations were private and nonprofit. In 2013, there were also more than 260 independent private and nonprofit treatment centers whose services were limited to same-day admissions for nonacute, elective care (e.g., eye clinics, orthopedic surgery centers) covered by statutory insurance. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001695 OS 00003366 THE NETHERLANDS Hospital payment rates (including doctor fees) are determined through negotiations between each insurer and each hospital over price, quality, and volume. The great majority of payments take place through the casebased diagnosis treatment combination system, and the rates for approximately 70 percent of hospital services are freely negotiable; the remaining 30 percent are set nationally. The number of diagnosis treatment combinations was reduced from 30,000 to 4,400 in 2012. Diagnosis treatment combinations cover both outpatient and inpatient as well as specialist costs, strengthening the integration of specialist care within the hospital organization. Mental health care: Mental health care is provided in basic ambulatory care settings, such as GP offices, for mild to moderate mental disorders. In cases of complicated and severe mental disorders, GPs will often refer patients to a psychologist, an independent psychotherapist, or a specialized mental health care institution. The delivery of preventive mental health care is the responsibility of municipalities and is governed by the Social Support Act. A policy offurther integration of general practice and mental health was agreed on in 2012, with the goals of ensuring that patients receive timely care from the right source and reducing the need for specialized care. For several years, policymakers have been aiming to substitute outpatient care for inpatient care, reflected in the steady increase in the number of GPs that employ primary care psychologists. Long-term care and social supports: A substantial proportion of long-term care is financed through the Longterm Care Act (Wet langdurige zorg), a statutory social insurance scheme for long-term care and uninsurable medical risks and cost that cannot be reasonably borne by individuals. It operates nationally, and taxpayers pay a contribution based on taxable income. The remainder of services are financed through the Social Support Act, from general sources. Long-term care encompasses residential care; personal care, supervision, and nursing; medical aids; medical treatment; and transport services. Cost-sharing depends on size of household, annual income, indication, assets, age, and duration of care. In 2014, copayments covered 7 percent oftotal spending in the compulsory long-term care (LTC) scheme. With funding provided through a block grant from the national government, municipalities are responsible for household services, medical aids, home modifications, services for informal caregivers, preventive mental health care, transport facilities, and other assistance, in accordance with the Social Support Act (Wet Maatschappelijke Ondersteuning). Municipalities have a great deal of freedom in how they organize services, including needs assessments, and in how they support caregivers (e.g., through the provision of respite care or a small allowance). Lont-term care is mostly provided by private, nonprofit organizations, including home care organizations, residential homes, and nursing homes. Most palliative care is integrated into the health system and delivered by general practitioners, home care providers, nursing homes, specialists, and volunteer workers. Under both the Social Support Act and the Long-term Care Act, personal budgets are provided for patients to buy and organize their own long-term care, and under the Long-term Care Act are set at 66 percent of rates paid for in-kind services. &h What are the key entities for health system governance? Since 2006, the Ministry of Health's role has been to safeguard health care from a distance rather than managing it directly. It is responsible for the preconditions pertaining to access, quality, and cost of the health system, has overall responsibility for setting priorities, and may, when necessary, introduce legislation to set strategic priorities. A number of arm's-length agencies are responsible for setting operational priorities. At the national level, the Health Council advises government on evidence-based medicine, health care, public health, and environmental protection. The National Health Care Institute advises government on the components of the statutory benefits package and has various tasks relating to quality of care, professions and training, and the insurance system (e.g., risk adjustment). The Medicines Evaluation Board oversees the efficacy, safety, and quality of medicines. The Commonwealth Fund VA-19-0799-D-001696 OS 00003367 THE NETHERLANDS Decisions about the benefits package rest with the health minister. The Dutch Health Care Authority (Nederlandse Zorgautoriteit) has primary responsibility for ensuring that the health insurance, health care purchasing, and care delivery markets all function appropriately (e.g., by setting the prices for 30 percent of diagnosis treatment combinations). Meanwhile, the Dutch Competition Authority (Autoriteit Consument en Markt) enforces antitrust laws among both insurers and providers. The Health Care Inspectorate (IGZ) supervises quality, safety, and accessibility of care. Self-regulation by medical doctors is also an important aspect of the Dutch system (Smith et al., 2012). Private insurers are tasked with increasing health system efficiency and cost control through prudent purchasing of health services. The patient movement consists of a wide range of organizations, some for specific diseases and some functioning as umbrella organizations. The patient umbrella organization Nederlandse Patienten Consumenten Federatie conducts a range of activities to promote transparency. Health Information Technology is not centralized in one body. The Union of Providers for Health Care Communication (De Vereniging van Zorgaanbieders voor Zorgcommunicatie) is responsible for exchange of data via an IT infrastructure. ~ What are the major strategies to ensure quality of care? At the system level, quality is ensured through legislation governing professional performance, quality in health care institutions, patient rights, and health technologies. In 2014, the National Health Care Institute was established to further accelerate the process of quality improvement and evidence-based practice. The Dutch Health Care Inspectorate is responsible for monitoring quality and safety. Most quality assurance is carried out by providers, sometimes in close cooperation with patient and consumer organizations and insurers. There are ongoing experiments with disease management and integrated care programs for the chronically ill. In the past few years, many parties have been working on quality registries. Most prominent among these are several cancer registries and surgical and orthopedic (implant) registries. Mechanisms to ensure the quality of care provided by individual professionals include reregistration of specialists contingent upon compulsory continuous medical education; regular on-site peer assessments by professional bodies; and professional clinical guidelines, indicators, and peer review. The main methods used to ensure quality in institutions include accreditation and certification; compulsory and voluntary performance assessment based on indicators; and national quality improvement programs. Furthermore, quality of care is supposed to be enhanced by selective contracting (e.g., volume standards for breast cancer treatment). In 2014, a few pay-for-performance pilot programs featuring quality targets were initiated but, as yet, specifics about the programs and effects are unknown. Moreover, in the new GP funding model, part of the old budget is preserved for pay-for-performance projects. Patient experiences are also systematically assessed and, since 2007, a national center has been working with validated measurement instruments in an approach comparable to that of the Consumer Assessment of Healthcare Providers and Systems, in the United States. Although progress has been made, public reporting on quality of care and provider performance is still in its infancy in the Netherlands. To stimulate the transparency movement, the Ministry of Health called 2015 the "year of transparency." t: j What is being done to reduce disparities? Health disparities are considerable in the Netherlands, with up to seven years of difference in life expectancy between the highest and lowest socioeconomic groups. Smoking is still a leading cause of untimely death. The current government does not have a specific policy to overcome health disparities. In 2013, government decided to include diet advice and smoking cessation programs in the statutory benefits package. Every four years, health access variations are measured and published in the Dutch Health Care Performance Reports. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001697 OS 00003368 THE NETHERLANDS Organization of the Health System in the Netherlands Ministry of Health (Regulation and supervision) Advisory bodies ~ [ Insurers I j...-- National health care institute -------/ Health care insurance market / Insured/patients j NZa Health care purchasing market Health care provision market Providers Source: J. Wammes, P. J eur issen, an d G. Westert , Radboud Univers ity Medi cal Center, 201 4. 0~ What is being done to promote delivery system integration and ~ care coordination? ~ A bundled-payment approach to integrated chronic care is applied nationwide for diabetes, COPD, and cardiovascular risk management. Under this system, insurers pay a single fee to a principal contracting entitythe care group (see above)-to cover a full range of chronic disease services for a fixed period. The bundledpayment approach supersedes traditional health care purchasing for the condition and divides the market into two segments-one in which health insurers contract care from care groups, the other in which care groups contract services from individual providers, each with freely negotiable fees (Struijs & Baan, 2011 ). To head off potential additional coordination problems and better reach vulnerable populations, the role of district nurses is currently being strengthened. What is the status of electronic health records? Authorities are working to establish a central health information technology network to enable providers to exchange information. All Dutch patients have a unique identification number (burgerservicenummer). Virtually all general practitioners have a degree of electronic information capacity-for example, they use an electronic health record and can order prescriptions and receive lab results electronically. At present, all hospitals have an electronic health record. Electronic records for the most part are not nationally standardized or interoperable between domains of care. In 2011, hospitals, pharmacies, after-hours general practice cooperatives, and organizations representing general practitioners set up the Union of Providers for Health Care Communication (De Vereniging van Zorgaanbieders voor Zorgcommunicatie), responsible for the exchange of data via an IT infrastructure named AORTA; data are not stored centrally. Patients must approve their participation in this exchange and have the right to withdraw; access to their own files is granted by providers upon request. The Commonwealth Fund VA-19-0799-D-001698 OS 00003369 THE NETHERLANDS ~ How are costs contained? The main approach to controlling costs relies on market forces while regulating competition and improving efficiency of care. In addition, provider payment reforms, including a shift from a budget-oriented reimbursement system to a performance- and outcome-driven approach, have been implemented. Cost containment was one of the most significant subjects of public debate surrounding the 2012 elections. The most recent figures indicate that expenditure growth has fallen significantly, to 1.8 percent in 2014. The pharmaceutical sector is generally considered to have contributed significantly to the decrease in spending growth. Average prices for prescription drugs declined in 2014, although less than in previous years. Reimbursement caps for the lowest-price generic have contributed to the decrease in average price. Reimbursement for expensive drugs has to be negotiated between hospital and insurer. There is some concern that this and other factors may limit access to expensive drugs in the near future. The annual deductible, which accounts for the majority of patient cost-sharing, more than doubled between 2008 and 2015, from EUR170 (USD206) to EUR375 (USD454). There are some worries that this increase has led to greater numbers of people abstaining from or postponing needed medical care. Health technology assessment is gaining in importance and is used mainly for decisions concerning the benefit package and the appropriate use of medical devices. In 2013, an agreement signed by the Minister of Health, all health care providers, and insurers set a voluntary ceiling for the annual growth of spending on hospital and mental care. When overall costs exceed that limit, the government has the ability to control spending via generic budget cuts. The agreement included an extra 1 percent spending growth allowance for primary care practices in 2014 and 1.5 percent in 2015-17, provided they demonstrate that their services are a substitute for hospital care. ~ Cost containment is most severe in long-term care. People with lower care needs are no longer entitled to residential care. In addition, the devolution of services to the municipalities was accompanied by substantial cuts to the available budgets (on average almost 10%). What major innovations and reforms have been introduced? After years of rapid spending growth, long-term care as of January 2015 is fundamentally reformed. The reform program's main goals were to guarantee fiscal sustainability and universal access in the future and to stimulate greater individual and social responsibility. The new structure seems to be up and running, but its effects as yet are unknown, and future amendments may be needed. In curative health care, market reform and regulated competition remain somewhat controversial. The government, determined to continue stimulating competition between insurers and providers, undertook some measures to that effect, such as requiring insurers and providers to assume greater financial risk. In December 2014, however, the Dutch Senate rejected a new policy proposal restricting free provider choice in specific insurance policies. The accessibility of expensive drugs has rapidly become a prominent issue in 2015. As of the date of this report, the Health Insurance Act has undergone two evaluations. The latest evaluation pointed to an imbalance of power, with providers having an advantage over insurers. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001699 OS 00003370 THE NETHERLANDS References Organisation for Economic Co-operation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787 /data-00285-en. Accessed July 2, 2015. Schafer, W., M. Krone man, W. Boerma et al. (2010). "The Netherlands: Health System Review." Health Systems in Transition 12(1 ):1-229. Smith, P. C., A. Anell, R. Busse, L. Crivelli, J. Healy, A. K. Lindahl, and T. Kene. (2012). "Leadership and Governance in Seven Developed Health Systems." Health Policy 106(1):37-49. DOI: 10.1016/j.healthpol.2011.12.009. Struijs, J.N., and C. A. Baan. "Integrating Care Through Bundled Payments-Lessons from the Netherlands." New England Journal of Medicine, March 17, 2011 364(11):990-91. The Commonwealth Fund VA-19-0799-D-001700 OS 00003371 ~ ? = What is the role of government? Beginning with passage ofthe Social Security Act in 1938, a consensus has developed in New Zealand that government has a fundamental role in providing for the population's health care needs. At the same time, there is continued public support for a private sector role as well. Government plays a central role in setting the policy agenda and service requirements for the health system and in setting the annual publicly funded health budget. Responsibility for planning, purchasing, and providing health services and disability support for those over age 65 lies with 20 geographically defined district health boards (DHBs), each of which comprises seven locally elected members and up to four members appointed by the Minister of Health. These boards pursue government objectives, targets, and service requirements while operating government-owned hospitals and health centers, providing community services, and purchasing services from nongovernment and private providers. o/1:' Who is covered and how is insurance financed? Publicly financed health care: All permanent residents have access to a broad range of services, which are largely publicly financed through general taxes. Nonresidents, such as tourists and illegal immigrants, are charged the full cost of services by public health care providers, unless treatment is related to an accident, in which case they are covered by a no-fault accident compensation scheme. Total health spending was 9.5 percent of GDP in 2013 (OECD, 2015). Public spending, generated through general taxes, accounted for 79.8 percent of total spending. Privately financed health care: Private health insurance is offered by a variety of organizations, from nonprofits and "Friendly Societies" to for-profit companies, and accounts for about 5 percent of total health expenditure. It is used mostly to cover cost-sharing requirements, elective surgery in private hospitals, and private outpatient specialist consultations; private coverage also often affords faster access to nonurgent treatment. About onethird of the population has some form of private insurance, purchased predominantly by individuals. ?1 What is covered? Services: The publicly funded system covers preventive care; inpatient and outpatient hospital services; primary care via private providers (excluding services such as optometry, adult dental services, orthodontics, and physiotherapy); inpatient and outpatient prescription drugs included in the national formulary (see below); mental health care; dental care for schoolchildren; long-term care; home help; hospice care; and disability support services. Government sets an annual overall budget and benefits package, based largely on political priorities. It also sets national requirements for publicly funded services, to be implemented by the 20 DHBs. Rationing and prioritization are applied largely to nonurgent services, and vary by DHB. Cost-sharing and out-of-pocket spending: Out-of-pocket payments, including both cost-sharing and other costs paid directly by private households, accounted for approximately 12.6 percent of total health expenditures in 2014 (OECD, 2015), with the largest portion going to outpatient services. There are no deductibles in the public sector, although copayments are required for general practitioner (GP) services and many nursing services International Profiles of Health Care Systems, 2015 VA-19-0799-D-001701 OS 00003372 NEW ZEALAND provided in GP clinics. The average copayment for a GP consultation for an adult ranges from NZD15 to NZD45 (USD10-USD31), but copayments vary significantly, as there are no limits to these set by GPs. An exception applies to the one-third of New Zealanders residing in low-income areas, where a higher annual per-patient capitation rate is paid and, in return, patient copayments are capped at NZD17.50 (USD12.00) per visit.1 GP copayments fell during the period 2002-2008, when there were significant increases in government funding for primary care, but copayments have been increasing since then. Copayments are also required for drugs prescribed by GPs and private specialists (NZDS.00 [USD3.40] per item); after copayments are made for 20 prescriptions per family per year, they are free. There are no charges for residents treated in public hospitals, although there are some user charges, such as those for crutches and other aids supplied upon discharge. There are various means-tested subsidies, resulting in some copayments for long-term care, as discussed in the relevant section below. Safety net: Primary care is mostly free for children age 13 and under, and is subsidized for the 98 percent of the population enrolled in the networks of self-employed providers known as primary health organizations (PHOs). PHOs include general practitioners (GPs), practice nurses, and allied practitioners. Additional PHO funding and services are available for treating people with chronic conditions and for improving access to care for groups with greater health needs. A "high-use health card" is also available, upon application, to patients who have had more than 12 GP visits in a year. Subsequent capitation payments for those patients are set at a higher level to reflect this high-utilization pattern, although patients continue to make copayments. [ (R)] How is the delivery system organized and financed? Primary care: The ratio of GPs to specialists is about 2:3. GPs act as gatekeepers to specialist care. They are usually independent, self-employed providers compensated by a capitated government-determined subsidy, paid through PHOs and accounting for about half their income; patient copayments, set by individual GPs, provide the rest. An average of 3.48 GPs work together in each practice, assisted by practice nurses. Nurses are salaried and paid by GPs, and have a significant role in the management of long-term conditions (e.g., diabetes), incentivized by specific government funding for chronic care management. Patient registration is not mandatory, but GPs and PHOs must have a formally registered patient list to be eligible for government subsidies. Patients enroll with a GP of their choice; in smaller communities, choice is often limited. PHOs receive additional per-capita funding to improve access, especially for people who can least afford primary care, and to aid in promoting health, coordinating care, and providing additional services for people with chronic conditions. In some cases, this support has led to the development of multidisciplinary care teams that may include specialists, such as nutritionists or podiatrists; this trend is being further driven by new alliance arrangements (outlined below). PHOs also receive up to 3 percent additional funding that is handed on to GPs if they reach targets for cancer, diabetes, and cardiovascular disease screening and follow-up, and also goes toward vaccinations. Most GPs belong to an organized network that provides management and other clinical support services. The larger networks represent several hundred GPs each. Outpatient specialist care: Most specialists are employed by DHBs and salaried for working in a public hospital. However, they are also able to work privately in their own clinics or treat patients in private hospitals, where they are paid on a fee-for-service basis. The impact ofthis "dual practice" on the public sector remains under-researched and under-debated (Gauld, 2013). Many specialists are based in multispecialty clinics but work independently, renting their office from the clinic. Private specialists are concentrated in larger urban centers and set their own fees, which vary considerably; insurance companies have little, if any, control over those fees, although insurers will pay only up to a maximum amount, meaning that patients pay any difference. In public hospitals, patients generally have limited choice of specialists. 1 Please note that, throughout this profile, all figures in USD were converted from NZD at a rate of about 1.47 NZD per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (20156) for New Zealand. The Commonwealth Fund VA-19-0799-D-001702 OS 00003373 NEW ZEALAND Administrative mechanisms for paying primary care doctors and specialists: As noted above, GPs' income is derived from government subsidies, which include payments from the Accident Compensation Corporation (ACC), and from patient copayments. Some patients subscribing to private insurance may be eligible to claim for the copayment. Patients pay the full cost of private specialist visits up front, unless the service is funded by ACC or by private insurance. In the latter case, patients may seek reimbursement from their insurer, or there may be no direct patient charge if a specialist or private hospital holds a contract with the insurer. After-hours care: GPs are required in their funding contracts to provide after-hours care or to arrange for its provision, and receive a separate government subsidy for doing so, which is higher per patient than the general capitation rate. In rural areas and small towns, GPs work on call; in some of these areas, a nurse practitioner with prescribing rights may provide first-contact care. In cities, GPs tend to provide after-hours service on a roster at purpose-built, privately owned clinics in which they are shareholders. These facilities employ their own support staff such as nurses, but patients usually see a GP in the first instance. Patient charges at these clinics are higher than those for services during the day (although 95% of children under age 13 can have access to free GP after-hours services). Consequently, some patients will visit a hospital emergency department instead, or avoid after-hours service altogether. A patient's usual GP routinely receives information on after-hours encounters. The public also has access to the 24-hour, seven-day-a-week phone-based "Healthline," staffed by nurses who provide advice in response to general health questions. "Plunketline" provides a similar service for child and parenting problems. Hospitals: New Zealand has a mix of public and private hospitals, but public hospitals constitute the majority, providing all emergency and intensive care. Public hospitals receive a budget from their owners, the DHBs, based on historic utilization patterns, population needs projections, and government goals in areas such as elective surgery. The budget includes the costs of health professionals and other staff, who are all salaried. Within a DHB hospital, the budget tends to be allocated to the various inpatient services using a case-mix funding system. A proportion of DHB funding for elective surgery is held by the Ministry of Health, and payments are made upon delivery of surgery. Certain areas of funding, such as mental health, are "ringfenced"-the DHB must spend the money on a specified range of inputs. Private-hospital patients with complications are often admitted to public hospitals, in which case the costs are absorbed by the public sector. Public-hospital services are provided largely by consultant specialists, specialist registrars, and house surgeons. Mental health care: Most people get access to mental health care through primary mental health services in the community, often through their GP, who will then coordinate any referred services, but also through school-based health services and community services provided by nongovernment agencies, which are all publicly funded. DHBs deliver a range of mental health services (including secondary services), such as forensic, acute inpatient, and community-based services, and provide support to primary care providers; they also fund nongovernment providers of community-based services. Private provision is limited. Long-term care and social supports: DHBs fund long-term care for patients on the basis of needs assessment, age, and a means test. They fund services for those over age 65 and those "close in age and interest" (e.g., people with early-onset dementia or a severe age-related physical disability). Those eligible receive comprehensive services including medical care; many older or disabled people receive home care. Some younger disabled recipients opt for individual budgets to arrange their own home care. Respite care is available to relieve informal or family caregivers, and in some circumstances there is ongoing financial support. Residential facilities, mostly private, provide long-term care. DHBs also provide hospital- and community-based palliative care. A network of hospices provides end-of-life care, with approximately 70 percent of funding coming from DHBs and the remainder through fundraising. Palliative care is also provided in the community. Long-term care subsidies for older people are means-tested. Residents with assets over a given national threshold pay the cost of their care up to a maximum contribution. Residents with assets under the allowable threshold contribute all their income, except for a small personal allowance. DHBs cover the difference between the resident's payments and the contract price for residential care. For people in their own homes, household International Profiles of Health Care Systems, 2015 VA-19-0799-D-001703 OS 00003374 NEW ZEALAND management (e.g., cleaning), which accounts for less than one-third of home support funding, is income-tested. Personal care (e.g., showering) is provided free of charge. Home care services are all provided by nongovernment agencies. &h What are the key entities for health system governance? As the health system is primarily public, government-funded and -appointed entities dominate governance structures. Some, like the health and disability commissioner (whose function is to champion consumers' rights in the health sector), sit at arm's length from the central government. Others are "crown entities," with their own boards, and are required to follow government policy through letters of expectation. Key national arrangements, all of which have a role in providing information to, and engaging with, the public, are: o the Ministry of Health, which has overall responsibility for the health and disability system. The ministry acts as the Minister of Health's principal advisor on health policy and maintains a role as funder, monitor, purchaser, and regulator of health and disability services. While it sets capitation rates paid to GPs, it has no role in regulating patient copayments. o the National Health Board (NHB), which aims to improve the quality, safety, and sustainability of health care by actively engaging with clinicians and the wider health sector. The NHB provides advice to the health minister and the director-general of health on all of the aforementioned matters. It has two subcommittees: the Capital Investment Committee, which provides advice on matters relating to capital investment and infrastructure in the public health sector, in line with the government's service planning direction; and the National Health IT Board, which provides advice on the implementation and use of IT systems across the sector. o NZ Health Partnerships, established in July 2015 to support DHBs in delivering shared services and reduce costs by identifying opportunities for savings in administrative, support, and procurement. o the Pharmaceutical Management Agency of New Zealand, which assesses the effectiveness of drugs, distributes prescribing guidelines, and determines inclusion of drugs on the national formulary (with relative cost-effectiveness being one of nine criteria for inclusion). In addition, certain medical devices have been added to its schedule (Gauld, 2014). As of late 2015, a new set of "factors for consideration" will be used to underpin decisions: need; health benefit; costs and savings; and suitability. o the Health Quality and Safety Commission, which ensures that New Zealanders receive the best health and disability care possible given available resources. It is also working toward what is known as the New Zealand "triple aim"-improved quality, safety, and experience of care; improved health and equity for all populations; and better value for public health system resources. ~ o the National Health Committee (NHC), which advises government on priorities for new and existing health technologies. All new diagnostic and nonpharmaceutical treatment services and significant expansions of existing services are referred to the NHC for evaluation and advice. The committee also provides advice on what technologies are obsolete or no longer provide value for money. What are the major strategies to ensure quality of care? The aforementioned health and disability commissioner investigates patient complaints, reports directly to Parliament, and has been active in promoting quality and patient safety. DHBs are held formally accountable to government for delivering efficient, high-quality care in hospitals, as measured by the achievement of targets across a range of indicators. These include six "health targets," published quarterly, that aim to stimulate competition among DHBs and are enforced by financial sanctions if not met. In addition, DHB performance with regard to waiting times, access to primary care, and mental health outcomes is publicly disclosed. Also publicly reported are data comparing the performance of PHOs, The Commonwealth Fund VA-19-0799-D-001704 OS 00003375 NEW ZEALAND Organization of the Health System in New Zealand ACC levies I ' Ownership and formal accountabilit Accident Compensation Corporation (ACC) Tax payments Central Government Funding for nonearners Formal accountabilit Minister of Health National Health Board 14-- ---1 -----,--"""'T'---Annual Reporting Purchase Agreement Board Health Workforce New Zealand Board Contracts Health Benefits Ltd National Health Committee Prioritization of new technologies and services Ministry of Health Provides shared support and administration and procurement services Health Quality and Safety Commission NZ Improves quality and safety Policy ? Regulation National Health Board business unit ? National services, DHB funding and performance management, and capacity planning of services Other Health Crown entities Various relationships with other . . - - - - - - ---t ? entities Service agreements for some services - ? Other Ministerial Advisory Committees Reporting for monitoring Health Workforce New Zealand ? Workforce issues .. . . Negotiation of accountability documents 20 District Health Boards (DHBs) Reporting for monitoring Private and NGO providers ? Pharmcist, laboratories, radiology clinics ? PHOs, GPs, midwives, independent nursing practices ? Voluntary providers ? Private health Comunity agreements DHB provider arms Predominantly hospital services, and some community services, public health services, and assessment, treatment and rehabilitation services Private ? Maori ? Disablty trusts ? hospitals and Pacific providers support services Some fees/ co payments insurance ........ Source: New Zea land Ministry of Hea lth, 2015. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001705 OS 00003376 NEW ZEALAND including such information as screening rates for chronic diseases. Data on individual doctors' performance, however, are not routinely made available. As noted above, PHOs and GPs receive performance payments for achieving various targets. DHBs and individual GP clinics and networks run various chronic disease management programs. There are national registries for some diseases, including diabetes, cardiovascular disease, and cancers. Since 2014, public hospitals have been required to conduct a nationally standardized survey of a random sample of patients and to submit data to the Health Quality and Safety Commission, which publicizes the findings. Certification by the Ministry of Health is mandatory for hospitals, nursing homes, and assisted-living facilities, which must meet published and defined health and disability standards. All practicing health professionals must be certified annually by the relevant registration authority (e.g., for doctors, the Medical Council of New Zealand), which has ongoing responsibility for ensuring professional standards and providing accreditation. Registration authorities supervise individual professionals where appropriate. The Health Quality and Safety Commission is intended to increase the focus on quality and coordinate the varied approaches to quality improvement across DHBs, such as those aimed at improving the patient journey, ensuring safer medication management, reducing rates of health care-associated infection, and standardizing national incident reporting. Other initiatives include the ongoing development of the Atlas of Healthcare Variation (an on line tool aimed at highlighting variations in the provision and use of services by geographic area); a series of standard quality and safety indicators for DHBs based on routinely collected data; a program for consumer involvement in service design; and advice for DHBs on how to prepare annual "Quality Accounts," required since 2012-2013. Much like a financial account, Quality Accounts report on how the DHB has approached quality improvement, including descriptions of key initiatives and their results. In 2013, the commission launched a national patient safety campaign, Open for Better Care , focused on reducing the negative consequences associated with falls, surgery, health care-associated infections, and medications. The National Health Board is also working on quality improvement in DHBs, with particular emphasis on management systems, clinical services, and patient pathways. "Clinical governance" has been implemented in most DHBs, meaning that management and health professionals are assuming joint accountability for quality, patient safety, and financial performance. t-1 ~ What is being done to reduce disparities? Disparities in health are a central concern in New Zealand, as Maori and people of Pacific Island origin have shorter life expectancies than other New Zealanders (by seven and six years, respectively), and reducing disparities is a policy priority (Ministry of Health, 2013). Maori and Pacific people are also known to experience greater difficulty in gaining access to health services, and data describing disparities are routinely collected and publicly reported. Through much of the 2000s, a multisector policy approach saw investments in housing, education, and health, as DHBs and primary health organizations were required to develop strategies for reducing disparities. Many PHOs were created especially to serve Maori or Pacific populations. The post-2008 government has focused on specific initiatives such as Whanau Ora, a policy designed to integrate health and social services for disadvantaged Maori. The aim has been to develop coordinated, multiagency approaches to service provision and foster joint responsibility for outcomes. 0~ What is being done to promote delivery system integration and ~ care coordination? Larger Integrated Family Health Centers (IFHCs) are developed in line with the "Better, Sooner, More Convenient" government policy, which aims to improve access to integrated care provided by DHBs and PHOs The Commonwealth Fund VA-19-0799-D-001706 OS 00003377 NEW ZEALAND by establishing more convenient locations for patients (outside of hospital settings) and by emphasizing chronic disease management (Ryall, 2008; Ministerial Review Group, 2009). These centers provide comprehensive primary care and care coordination, after-hours services, and some minor elective procedures for an enrolled population. New facilities will see services and providers colocated, or coordination of services improved, with funding from both primary care budgets and DHBs. Patients enrolled in PHOs have a medical home, but PHOs vary widely in size, performance, and activities. The highest-performing among them provide a model that, if nationally emulated, would result in all enrollees having a fully functional, multidisciplinary medical home, although institutional barriers to integrating primary and hospital care would remain. The New Zealand government is accelerating the drive for clinical integration to create a more patient-centered health system. It is also ensuring that all DHBs' annual plans include proposals for integration. These directions have been propelled by a new PHO contract in place since mid-2013 that requires PHO-DHB alliances modeled after Integrated Family Health Center pilot programs. There is considerable scope for these alliances to integrate health and social services (see below), and there is a gradual move toward pooled funding streams. Some specialized providers contracted by the government that focus on vulnerable populations, such as Maori and Pacific people, work to coordinate health and social services (e.g., Whanau Ora, described above). ~ What is the status of electronic health records? New Zealand has one of the world's highest rates of information technology (IT) use among primary care physicians, with almost 100 percent uptake (Schoen et al., 2012). The government's goal is universal electronic access to a core set of residents' personal health information by 2014. However, despite some progress, that goal is unlikely to be met, owing to the complexity of implementing a national patient portal. Clinicians and vendors are working together on numerous projects: there is a larger emphasis on supporting and enabling integrated care, and a shift toward regional investment decisions and solutions. However, challenges with legacy systems remain. Increasingly, primary care IT systems provide services such as structured electronic transfer of patient records, electronic referrals, decision support tools with patient safety features, and patient access to health information in a secure environment. In the near future, there will be more emphasis on facilitating secure sharing of patient information among community, hospital, and specialist settings, including common clinical information; providing all consumers with an on line view of their information; and supporting the development of shared-care plans (in which a number of health professionals are involved in a person's care). However, current levels of interoperability are limited. ~ The National Health IT Board works with a number of sector groups and receives advice from, among others, clinicians, consumers, and vendors. The Health Information Standards Organisation supports and promotes the development and use of standards to ensure interoperability between systems. Every person who uses health and disability support services has a unique national health number, facilitating the process of building interoperable systems. How are costs contained? The financial sustainability of publicly funded health care is a top government priority. To support this goal, government has implemented a range of measures, including four-year planning to align expenditure with priorities over a longer period and improving regional collaboration to drive efficiencies. All new proposals must be integral to a four-year plan and demonstrate their fit with the strategic direction of the health sector. Cost control in DHBs has been closely monitored by the Ministry of Health, with a significant reduction in deficits over the last five years, from NZD154.8 million (USD105.4 million) in 2008-2009 to NZD7.4 million (USDS.0 million) in 2013-2014 (personal communication, Ministry of Health). These reductions are achieved International Profiles of Health Care Systems, 2015 VA-19-0799-D-001707 OS 00003378 NEW ZEALAND largely through efficiency gains and cuts in spending on staff, services, and equipment. As public hospitals are essentially free of charge, there is no mechanism to shift costs to patients. There have been experiments with shared-savings arrangements in the past, with contracted providers such as GP networks. The National Health Committee prioritizes health technologies and provides advice as to which technologies no longer offer value for money, increasingly using comparative-effectiveness research in evaluation. ~ The Pharmaceutical Management Agency uses mechanisms such as reference pricing and tendering to set prices for publicly subsidized drugs dispensed through community pharmacies and hospitals (Gauld, 2014). If patients prefer unsubsidized medicines (and if there are no clinical indications that these would be more effective), they pay the full cost. Such strategies have helped to drive down pharmaceutical costs and to keep drug expenditure per capita the fourth-lowest in the OECD in 2012 (OECD, 2014). What major innovations and reforms have been introduced? Reforms over the past two years have been mostly adjustments to existing arrangements, with one standout. In mid-2013, a new national Primary Health Organisation contract was issued, with new minimum PHO standards and a requirement that DHBs and PHOs enter into alliances. The rationale for the requirement was to link together the parts of the health system-GPs and public hospitals in particular-that operate largely separately but with common populations in a region. The impetus for forming these alliances is the government's increasing concern over chronic disease and care for complex patients, and its desire to better support patients and their providers in primary care settings. These alliances reflect an important shift in the governance model and structures for designing and delivering health services in New Zealand. Each alliance must take a whole-system approach, bringing together clinical leaders, managers, and community representatives from across the local health system to consider health services from a patient perspective. An alliance's focus is primarily integration, with the alliance setting service priorities, generating consensus on how those priorities will be met, and then sharing financial and other resources to facilitate implementation. Many alliances are creating further clinically led "service level alliances" targeting different areas of care design; many also govern health pathway development, which is rapidly expanding across New Zealand (Gauld, 20146). The author would like to acknowledge the New Zealand Ministry of Health for its comments and for providing updated information for this profile. The Commonwealth Fund VA-19-0799-D-001708 OS 00003379 NEW ZEALAND References Gauld, R. (2013). "Questions About New Zealand's Health System in 2013, Its 75th Anniversary Year." New Zealand Medical Journal 126(1380): 1-7. Gauld, R. (2014). "Ahead of Its Time? Reflecting on New Zealand's PHARMAC Following Its 20th Anniversary." Pharmacoeconomics 32:937-42. Gauld, R. (20146). "What Should Governance for Integrated Care Look Like? New Zealand's Alliances Provide Some Pointers." Medical Journal of Australia 201 (3):s67-s68. Ministerial Review Group (2009). "Meeting the Challenge: Enhancing Sustainability and the Patient and Consumer Experience within the Current Legislative Framework for Health and Disability Services in New Zealand." Wellington: Ministry of Health. Ministry of Health (2013). Annual Report for the Year Ended 30 June 2013, Including the Director-General of Health's Annual Report on the State of Public Health. Wellington: Ministry of Health. Organisation for Economic Co-operation and Development (OECD) (2015). OECD Health Statistics 2015. Organisation for Economic Co-operation and Development (OECD) (20156). OECD.Stat. DOI: 10.1787/data-00285-en. Accessed July 2, 2015. Organisation for Economic Co-operation and Development (OECD) (2014). OECD Health Statistics 2014. Ryall, T. (2008). "Better, Sooner, More Convenient: Health Discussion Paper by Hon. Tony Ryall MP." Wellington: National Party. Schoen, C. et al. (2012). " A Survey of Primary Care Doctors in Ten Countries Shows Progress in Use of Health Information Technology, Less in Other Areas." Health Affairs 31 (12):2805-16. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001709 OS 00003380 a ~ What is the role of government? Government is responsible for providing health care to the population. Norway's 428 municipalities are responsible for providing primary health and social care, with the Ministry of Health playing an indirect role, mainly through legislation and funding mechanisms. The ministry plays a direct role, however, in specialist care, through its ownership of hospitals and provision of directives to the boards of regional health care authorities (RHAs), as well as through legislation and funding. ~ Who is covered and how is insurance financed? Publicly financed health care: Total health expenditure represented 9.2 percent of GDP in 2014, which is about the average for countries in the Organisation for Economic Co-operation and Development (OECD). But Norway ranks among the highest in the OECD in terms of absolute expenditure per capita (NOK56,400, or USD5,965) in 2014) (Statistics Norway, 2015). 1 The nationally managed and financed health system, providing more than 95 percent of all health care, is built on universal coverage and on the principle of equal access for all regardless of socioeconomic status, ethnicity, and area of residence. It is financed through national and municipal taxes. Social security contributions finance public retirement funds, sick leave payment, and reimbursement of extra health care costs for some patient groups. For acute hospitalization, there is no private alternative. Through common agreements, European Union residents and other legal residents have the same access to health services as Norwegians. Other visitors are charged in full. Undocumented adult immigrants have access only to emergency acute care, while undocumented children receive the same care as citizens. Private health insurance: Private health insurance is provided by for-profit insurers and purchased for quicker access to examinations and care but also for choice among private providers. Private health insurance accounts for less than 5 percent of planned services. About 8 percent of the population (or nearly 15% of the workforce) have some kind of private insurance. About 92 percent of policies are paid for by an employer (Finans, Norge 2014). ?) What is covered? Services: Parliament determines what is covered, although there is no defined benefits package except for new and costly treatments and technologies (see below). In practice, national health care covers planned and acute primary, hospital, and ambulatory care, rehabilitation, and outpatient prescription drugs on the formulary (the "blue list"). It also covers dental care services for children up to 18 years of age and other prioritized groups, such as people with rare diseases or chronic diseases that increase the risk of dental problems, patients with chronic mental disabilities, and patients in permanent nursing homes. Dental care for 19-to-20-year-olds and dental orthopedics (braces) for children are partially covered. Nonmedical eye care, aesthetic surgery, and complementary medicine are not covered. 1 Please note that, throughout this profile, all figures in USD were converted from NOK at a rate of about NOK9.45 per USD, the 2014 purchasing power parity for GDP reported by OECD (2015) for Norway. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001711 OS 00003382 NORWAY Primary, preventive, and nursing care are organized at the local level by municipalities. The municipality, often in cooperation with the county, decides on public health initiatives or campaigns to promote a healthy lifestyle and reduce social health disparities. Preventive services for mental health are directed toward children and adolescents through the school system. Psychological care for children under the age of 18 is fully covered. Primary care for mental health is provided by general practitioners (GPs) and municipal psychologists. Longterm care, including palliative end-of-life care, is provided on the basis of need, either at home or in nursing homes. There are few designated hospice facilities. The substantial government funding for municipalities is generally not earmarked, and budgets are set locally, but provision of some services is statutory, particularly those related to pediatric and long-term care. Cost-sharing: GP and specialist visits, including outpatient hospital care and same-day surgery, require copayments (NOK141 [USD15] and NOK320 [USD34] per visit in 2015, respectively), as do physiotherapy visits (in varying amounts), covered prescription drugs (up to NOK520 [USD55] per prescription), and radiology and laboratory tests (NOK227 [USD24] and NOK50 [USD5]). Public providers cannot charge patients more than these amounts, except for bandages and other supplies. Consultations for antenatal and postnatal follow-up, for prevention and treatment of transmittable diseases for particularly vulnerable individuals, and treatment of sexually transmitted diseases are also exempt from copayments. Hospital admissions and inpatient treatment are free. Out-of-pocket payments finance about 14 percent oftotal expenditure. Home-based and institutional care for older or disabled people require high cost-sharing (up to 85% of personal income), but are means-tested. Safety net: The major safety net mechanisms are annual caps for out-of-pocket expenditure set by Parliament, above which fees are waived. For 2015, the cost-sharing ceiling for most services is NOK2, 105 (USD223). A second ceiling is set at NOK2,675 (USD283) for services such as physiotherapy and certain dental services. Long-term care and prescription drugs outside the "blue list" do not apply toward these ceilings. Children under the age of 16 receive free treatment and access to essential drugs on the blue list. Pregnant women receive free medical examinations during and after pregnancy. Residents eligible for minimum retirement pension or disability pensions, which amount to about NOK162,000 (USD17, 134) per year, receive free essential drugs and nursing care. Individuals with specified communicable diseases, including HIV/AIDS, and patients with work-related injuries receive free medical treatment and medication. Taxpayers with high expenses (above NOK5,880, or USD622) as a result of permanent illness receive a tax deduction. "Basic benefits" (NOK653-NOK2,264, or USD69-USD239 per month) may be provided, upon application, to patients who regularly incur additional expenses due to permanent illness, injury, or disability. [ (R)j How is the delivery system organized and financed? Primary care: Municipalities provide primary care in accordance with current legislation, government directives, and quality requirements set by the Directorate for Health. The "regular GP scheme," whereby people register with one general practitioner (GP), covers 99.4 percent ofthe population. There were an average of 1,132 patients per GP in 2014. Patients may change their GP twice a year. GPs function as gatekeepers, as referral to specialist treatment by a GP is required for coverage. There are 2.4 specialists in hospitals or ambulatory care for every practicing primary care physician (Den norske legeforening, 2015). Financial incentives encourage physicians to certify as a specialized GP and to see many patients per day. Municipalities contract with individual GPs, who receive a combination of capitation from the municipalities (35% of income), fee-for-service from the Norwegian Health Economics Administration (Helfo) (35%), and out-of-pocket payments from patients (30%). GP financing is determined nationally by negotiation between the Ministry of Health and the Norwegian Medical Association. In the fee-for-service scheme, there are fees provided for taking part in coordination of care and individual planning, but they are relatively low. There The Commonwealth Fund VA-19-0799-D-001712 OS 00003383 NORWAY is also a financial incentive for medication reconciliation. Most GPs are self-employed, and 10 percent are salaried municipal employees (Helsedirektoratet, 2014). The average salary is estimated to be NOK750,000 (USD79,325), but may be substantially higher for full-time practitioners. GP practices typically comprise two to six physicians and employ nurses, lab technicians, and secretaries. Many municipalities have multidisciplinary outreach teams for mental health, staffed by health care workers employed by the municipalities. Specialist care: The four RHAs, which are state-owned corporations that report to the Ministry of Health, are responsible for supervising specialist inpatient somatic and psychiatric care, as well as treatment for alcohol and substance abuse. The ministry provides RHAs' budgets, and issues an annual document instructing the RHAs as to aims and priorities. Outpatient specialist care is provided both by hospitals and by self-employed specialists. Hospital-based specialists are salaried. Privately practicing specialists contracted by an RHA are paid a combination of annual lump sums, based on the type of practice and number of patients on the list (about 35%); fee-for-service payments (about 35%); and patients' copayments (about 30%). The annual lump sum and the out-of-pocket fees are set by government, and the fee-for-service payment scheme is negotiated between government and the Norwegian Medical Association. In principle, patients have a choice of specialist, although in practice specialist availability varies by geographic location. In the more densely populated areas, clinics with multidisciplinary specialists have emerged during the last few years and seem to be increasing in number. Hospital-employed specialists cannot see private patients at the hospital, but may practice privately after hours, on their own time. Specialists with an RHA contract can charge patients only the specified out-of-pocket fee. Those who do not receive public financing are neither regulated nor subject to the out-of-pocket expenditure caps. Patient out-of-pocket payments: Patients pay their out-of-pocket fee directly to the provider. If they reach the first safety net ceiling, it is automatically registered and copayments are made directly to the provider by Helfo. For the second ceiling, patients need to submit an application with proof of payment of the out-of-pocket costs. Once it is approved, patients receive a certificate and are not charged further copayments. After-hours care: After-hours emergency primary care services are the responsibility of the municipalities, whose contracts with GPs include after-hours emergency services on rotation. The municipalities provide offices, equipment, and assistance, and pay the GPs a small fee. Other payments are provided by the national fee-forservice system and out-of-pocket payments from patients. The organization of after-hours services varies according to the size of the municipality. The more densely populated municipalities have walk-in centers where nurses triage patients and answer calls, and several doctors see patients all through the day and night. In smaller municipalities, patients call an after-hours phone number and speak with a nurse, who calls the GP if the patient needs to be seen. As of September 2015, a common national phone number was launched for all of these public primary care after-hours services (legevakt). In larger cities, as a supplement to the public services, there are a few privately owned and run after-hours clinics where patients pay in full. There is variation as to whether information from emergency visits is shared with patients' regular GPs. There is an emergency phone number patients can call for urgent ambulance services, but no national medical advice line. Patient cost-sharing and provider fees are slightly higher for after-hours emergency services. Acute-care hospital services are the responsibility of RHAs. Patients need an acute-care referral to these services by a primary care physician or may, in particular cases (accidents, suspected heart attack, stroke, etc.) have access directly via ambulance. Hospitals: Public hospital trusts are state-owned, formally registered as legal entities with an executive board (approved and partly appointed by the Ministry of Health), and governed as publicly owned corporations. A few are privately owned, mostly by nonprofit humanitarian organizations, and mostly provide publicly funded services as part of RHA plans for providing acute care. The for-profit hospital sector is small, providing less than 1 percent of specialist services in 2013 (Samdata, 2013). For-profit hospitals do not provide the full range of services, and do not offer acute services. A part of their services may be publicly funded, but the proportion varies, from almost none to 85 percent in 2013. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001713 OS 00003384 NORWAY Patients are free to choose a hospital for elective services but not for emergency care. Public hospitals are financed through RHAs-for somatic services with a block grant (50%), and with an activity-based portion (50%, based on diagnosis-related group, or DRG). The RHAs are free to decide how the hospitals are paid, but all four have chosen the same funding mechanism for somatic services; 50 percent as block grant and 50 percent based on DRG. All health personnel are salaried, including doctors, and all payments, public and private, include all services. Mental health: Mental health care is provided by GPs and by other providers (psychologists, psychiatric nurses, social care workers) in municipalities. For specialized care, GPs refer patients to private psychologists or psychiatrists, or to a low-threshold hospital (district psychiatric center). These hospitals are dispersed throughout the country. They often include psychiatric outreach teams. More advanced specialized services are organized in the inpatient psychiatric wards of general hospitals or in mental health hospitals. Hospital treatment is provided free of charge, and outpatient services are subject to the same cost-sharing as described above. Hospitals and district psychiatric centers are funded by government block grants through RHAs. The role of private mental hospital care is very small, and includes services for eating disorders, nursing home care for older psychiatric patients, and some psychiatrist and psychologist outpatient practices, mostly contracted by RHAs. The role of private treatment centers for addiction (mainly drugs and alcohol) is more prominent, and funded mostly through contracts with RHAs. Long-term care: The municipalities are responsible for providing long-term care, and contract also to some extent with private providers. Cost-sharing for institutionalized care is income-based, and is set at 75-85 percent of patients' income, depending on means tests. Home nursing is also provided, if needed. The levels of care at home or in a nursing home are determined by the municipality. Only about 3 percent of nursing homes are private, and for home nursing care, the proportion is even lower. There are a few private providers of home nursing care and other services, which are purchased by patients most often as a supplement to services by public home care. In some densely populated areas, patients can have a choice of home care provider or nursing home, but rarely arrange for services themselves. Very few patients pay individually for full-time private nursing home care. End-of-life care for terminal patients is often provided in particular wards within dedicated nursing homes. There is a system in place for informal carers to apply for financial support from the municipalities. &h What are the key entities for health system governance? The Ministry of Health and Care Services is politically led by the Minister of Health, who ensures that political decisions are translated into practice. This is done through legislation, economic measures, and documents instructing the RHAs and the Directorate for Health and other underlying agencies regarding activities and priorities. The political values conveyed by the annual national budget and the instructions in the annual letter of allocation from the ministry are determinative, and specify provider fees, out-of-pocket payments, and ceilings. The Directorate for Health is an executive agency and authority subordinate to the ministry. It issues clinical guidelines, maintains the National System for the Introduction of New Health Technologies, coordinates 18 patient ombudsmen, and provides public information on health and health care through the website www.helsenorge.no. The Directorate for Health is not responsible for producing systematic reviews or health technology assessments (HTAs) but rather applies them to decision-making pertaining to the system for new technologies, to guidelines, and to policymaking. From 2014 to 2018, the directorate is also in charge ofthe secretariat for the National Patient Safety Program. It is responsible overall for setting standards and leading the development and application of health information technology in health care. The Directorate for Health is responsible for fee-setting in the DRG system, and also for the five-year project on quality-based financing. There is no single authority overseeing fee-setting for providers other than hospitals. The Medicines Agency determines which medications to reimburse. For new drugs, the agency determines whether a prescription drug should be covered (on the blue list) by evaluating its cost-effectiveness in comparison with that of existing treatments; a "green" scheme encourages providers to prescribe lifestyle and The Commonwealth Fund VA-19-0799-D-001714 OS 00003385 NORWAY nutrition programs as a first alternative to more expensive preventive medicine. The agency also decides on the maximum price of specific drugs. The Norwegian Knowledge Center for Health Services, financed by government, produces comparative effectiveness studies (systematic reviews and HTAs) and works with quality and patient safety, quality indicators, and national patient experience surveys. Its HTAs are used by the Norwegian Council for Priority Setting in Health Care and the National System for the Introduction of New Health Technologies. The center also runs the national Reporting and Learning System for adverse events in hospitals. The Board of Health Supervision is a national public institution organized under the Ministry of Health. The board audits the different areas of the health care system, either systematically on a national basis or individually. An alert system ensures that hospitals alert the board to serious adverse events, and the board may then decide to investigate particular incidents. The board can issue fines to institutions and warnings to health personnel, and can revoke authorization for health care personnel who engage in misconduct. The Norwegian Institute of Public Health is a center for research on and surveillance of the health status of the population. It provides the Ministry of Health with advice on public health. It is the main authority regarding infection control and infectious disease surveillance. It provides community health profiles regarding prevalence of disease and holds several of the large health registers, including the prescription registry. The institute also assists the prosecuting authorities and the judiciary regarding forensic medicine. Organization of the Health System in Norway Parliament The Government The Ministry of Health and Care Services .-----------------------------------. ,--------- .-. ' .-------------------------, : The municipalities : 'l ...f:;~~.~.:~:l:h Board of Health Supervision : County : The Institute of Public Health ca,e .........'.:::::;... ., The Medicines Agency : Care services and rehabilitation : : Social services : '--------------------------------------. ---------------- The Radiation Protection Agency ~ : Dental care ' , _________________ Public health ,j i System of Patient Injury Compensation Biotechnology Advisory Board Directorate for Health SAK NOKC Regional Health Authorities Hospital Trust POBO Hospitals SAK: Norwegian registration authority for health personnel NOKC: Norwegian Knowledge Centre for the Health Services POBO: Health and care services ombudsmen Source: A. K. Lindahl , Norweg ian Knowledge Cent re for Healt h Services, 20 15. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001715 OS 00003386 NORWAY ~ What are the major strategies to ensure quality of care? The national strategy for quality improvement (2005-15) focuses on efficacy, safety, efficiency, patient-centered care, care coordination, and continuity and equality in access to health care (Directorate for Health, 2005). National evidence-based guidelines are being developed for a number of diseases. For cancer, there is a disease management program, introducing defined "packages" to be delivered to patients. To improve patient safety, there is a five-year national program (2014-18), as well as a national reporting and learning system for adverse events. There are 47 national clinical registries for specific diseases, as well as 15 national health registries. There is no registry for technical devices, but a statutory duty for hospitals to report adverse events, including those involving technical equipment. The Directorate for Health is in charge of the national program for health care quality indicators. The program includes results from national patient experience surveys. No information is gathered or disseminated regarding results or quality of individual health care professionals' performance. The Registration Authority for Health Personnel licenses and authorizes all health care professionals and can grant full and permanent approval to those meeting educational and professional criteria. There is no system for reevaluation or reauthorization. The authority issues certificates of specialization to medical doctors, in accordance with specific and transparent requirements. Only the specialization for GPs requires recertification. The Norwegian Board of Health carries out audits of all levels of the health system, including the health care workforce. RHAs, hospitals, municipal providers and private practitioners are responsible for ensuring the quality of their services. There is no requirement for accreditation or re-accreditation, although some hospitals or hospital departments are accredited. A five-year developmental period (2013-17) is under way for quality-based financing of RHAs, based on performance and improvement on a set of indicators-29 indicators in 2014, increased to 33 indicators in 2015-of which patient experiences constitute about 30 percent of the reporting. Quality-based financing constitutes only about 0.5 percent ofthe total ofthe RHAs' budgets. The Norwegian Institute of Public Health uses the Norwegian Prescription Database to produce annual reports on prescribing trends, giving national health authorities a statistical base for planning and monitoring the prescribing and use of drugs. Personal information held by the registry is anonymized. it-I ~ What is being done to reduce disparities? Eliminating socioeconomic inequalities in health is a priority ofthe Directorate for Health. A national strategy for addressing inequalities in health and health care includes various ways of increasing knowledge and awareness (Ministry of Health and Care Services 2007). There have been some initiatives for children, including vaccination programs, kindergarten and education; initiatives for people with disabilities to be included in the workplace; price and tax policies; initiatives for care integration; general information campaigns regarding smoking cessation, alcohol and diets; and specific initiatives for populations at risk. There is increasing focus on immigrants' health and underutilization of health care. Research on pregnancy has been informative, as there are significantly more complications for newborns and mothers among immigrants than among Norwegians (Ahlberg and Vangen, 2005). The need for adequate information to be provided in immigrants' native languages has been emphasized. Health outcomes vary geographically, not only because of differences in the prevalence of diseases but also as a result of variations in the availability and quality of health care. Recruitment of health personnel, notably doctors and specialized nurses, is more difficult in rural areas. The Commonwealth Fund VA-19-0799-D-001716 OS 00003387 NORWAY (C)-0- What is being done to promote delivery system integration and )yf care coordination? Care coordination has been pointed out as a weakness in the health care system. The coordination reform of 2012 put more emphasis on municipalities' responsibility for 24-hour and post-discharge care, including individual treatment plans for patients with chronic diseases, but not for hospital treatment. Hospitals and municipalities must establish formal agreements on the care of patients with complex needs (Ministry of Health and Care Services 2009 and 2011 ). The number of integrated primary care practices is experiencing moderate growth, with GPs establishing common practices with physiotherapists and specialists in orthopedics, gynecology, ophthalmology, dentistry, and pediatrics. For hospitals, incentives for care coordination are provided by mandatory agreements with municipalities. Financing is still fragmented between the hospitals (state-funded) and primary care (municipality-funded), but the municipalities pay substantial fines per day to hospitals if they are not able to accommodate patients ready for discharge. What is the status of electronic health records? A national strategy for health information technology (HIT) is the responsibility ofthe Directorate for Health, with implementation by a departmental steering committee. Every resident is allotted a unique personal identification number, which is used in primary care and for hospitals' medical records. Secure messaging is not a part of that system, but several GPs use such messaging systems, for instance to request prescriptions. Some GP and specialist outpatient offices have electronic booking, while most hospitals do not. All patients have the right to see or get a copy of their complete record, including doctors' notes, but there is not yet an electronic solution for doing so. An ongoing project on patient access currently gives 2.3 million inhabitants access to their core medical record, also allowing for correction of personal information. The National Health Network is charged with providing efficient and secure electronic exchange of patient information between all relevant parties within the health and social services sector. It provides secure telecommunication for GPs, hospitals, nursing homes, pharmacists, dentists, and others. HIT in primary care is fragmented, and some areas of service lack resources and equipment for its implementation. Still, virtually all GPs use electronic patient records and transmit prescriptions electronically to pharmacies. HIT is also used for referrals, communication with laboratories and radiology services, and sick leave. Most GPs receive electronic discharge letters from hospitals. Where after-hours emergency care is organized within the same patient record network, patient histories remain available and primary care providers are able to access information regarding emergency visits. All hospitals use electronic records. ~ The lack of structured electronic records in primary and secondary care precludes automatic data extraction; hence, there is still insufficient data for quality improvement at local and national levels. How are costs contained? Central government sets an overall health budget annually, and municipalities and RHAs are responsible for maintaining their budgets. The drug pricing scheme aims to encourage use of generic drugs. Cost-effectiveness is a criterion to get on the "blue list" of drugs eligible for reimbursement, and there is a defined maximum price for drugs, linked to reference prices set at the average of the three lowest market prices for the drug in a defined group of Scandinavian and Western European countries. The Drug Procurement Cooperation (LIS) has been effective in negotiating drug purchases and delivery jointly for the four RHAs. Costs are contained through GP gatekeeping for specialized services. There is very little competition regarding pricing within the health services. A minute proportion of specialized care is offered to the private sector by RHAs and contracted through tenders, for which price is one of several criteria. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001717 OS 00003388 NORWAY The National System for the Introduction of New Health Technologies, established in 2014, bases its decisions on whether to approve new, costly drugs or treatment mainly on Health Technology Assessments, which address cost-effectiveness. Norway has a low number of hospital beds (four per 1,000 inhabitants in 2012) compared with the OECD-Europe mean of five (OECD, 2014). The low number is part of a policy to drive services toward outpatient and daycare settings, and to make municipalities accountable for patients not needing specialized hospital care. There is an ongoing debate about overdiagnosing and use of procedures that are not evidence-based. Clinical guidelines and a published atlas of variation in frequency of some daytime surgical procedures (www.helseatlas.no) are the only measures taken to date to reduce "low value" care. Although the Council on Priorities in Health Care has debated, for instance, levels of end-of-life care and use of intensive care beds, no focused initiatives have resulted from the debates. G What major innovations and reforms have been introduced? ~ Municipality cofinancing of hospital care was abolished in 2015, as it was concluded that it did not have the intended effect of keeping patients out of the hospital. Availability of single occupancy for patients in nursing homes for those preferring it has been a goal for many years. The realization that the goal had not been met led the government to introduce reduced payments by patients for occupancy in double rooms as a financial incentive (or penalty) for the municipalities effective from January 2015. No plan is in place for evaluation of the effect. A new Agency for Hospital Construction (Sykehusbygg HF) was established in November 2014. Owned by the RHAs, the agency will serve as a national center of competence for hospital planning and construction for all hospital trusts. There is no plan for evaluation. The author would like to acknowledge David Squires and Anen Ringard as contributing authors to earlier versions of this profile. The Commonwealth Fund VA-19-0799-D-001718 OS 00003389 NORWAY References Ahlberg, N., and S. Vangen (2005). "Pregnancy and Birth in Multicultural Norway." Tidskr Nor Legefor 125(5):586-88. Den norske legeforening (2015). Legestatistikk, http://legeforeningen.no/Emner/Andre-emner/Legestatistikk/. Accessed Nov. 19, 2015. Directorate for Health (2005). National Strategy for Quality Improvement for the Health and Care Services, 2005-2015. IS 1162. https://helsedi rektoratet. no/publi kasjoner/ og-bedre-skal-det-bli-nasjona 1-strategi-for-kva litetsforbedri ng-i-sosia l-oghelsetjenesten-20052015. Accessed Nov. 19, 2015. Fina ns Norge (2014). https://www.fno.no/statisti kk/skadeforsi kri ng/Arlige-pu bli kasjoner/Beha ndli ngsforsi kri ng---kritisksykdomog-ba rneforsi kri ng/. Acessed Nov. 19, 2015. Helsedi rektoratet (2014). Fastlegestatisti kk. https://helsedi rektoratet. no/statisti kk-og-a nalyse/fastlegestatisti kk. Accessed Nov. 19, 2015. Ministry of Health and Care Services (2007). National Strategy to Reduce Social Inequalities in Health, Report No. 20 (Oslo: Ministry of Health and Care Services). Ministry of Health and Care Services (2009). The Coordination Reform: Proper Treatment at the Right Place and Time, Report No. 47 (Oslo: Ministry of Health and Care Services). Ministry of Health and Care Services (2011). Helse-og omsorgstjenesteloven (The New Law for Health and Care Services). Organisation for Economic Co-operation and Development (OECD) (2014). Health at a Glance Europe 2014. http://www. oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2014_health_glance_eur-2014-en. Accessed Nov. 19, 2015. Organisation for Economic Co-operation and Development (OECD) (2015). OECDStat. DOI: 10.1787 /data-00285-en. Accessed July 2, 2015. Samdata (2013). Spesialisthelsetjenesten Helsedirektoratet 2014. https://helsedirektoratet.no/publikasjoner/samdataspesialisthelsetjenesten . Accessed Nov. 19, 2015. Statistics Norway (2015). Health Accounts. http://www.ssb.no/en/nasjonalregnskap-og-konjunkturer/statistikker/helsesat. Accessed Nov. 19, 2015. Ringard, A., A. Sagan, I. S. Saunes, A. K. Lindahl. Norway: "Health System Review." Health Systems in Transition 2013 15(8):1-162. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001719 OS 00003390 ~ ~ What is the role of government? The government of Singapore planned, built, and continues to develop and maintain the nation's public health care system. It also regulates both public and private health insurance in the country. The health care system is administered by the Ministry of Health, which has responsibility for assessing health needs and for planning and delivering services through networks of health and hospital facilities, day care centers, and nursing homes. The ministry manages, plans for, and maintains staffing throughout the system and is also responsible for financing policies and governance of the entire public health care system. Because Singapore is a very small nation-state, there is little regional- or local-level funding or regulation; the national government takes on full responsibility for the health system. Singapore offers universal health care coverage to citizens, with a financing system anchored in the twin philosophies of individual responsibility and affordable health care for all. Pft: Who is covered and how is insurance financed? Publicly financed health care: The Singapore health care system is funded directly by the national government through its Ministry of Health. The ministry's budget for fiscal year 2013 was SGDS.9 billion (USD6.7 billion), or 1.6 percent of GDP. The funds come from general revenue, and they are used for subsidies, campaigns to promote good health practices, manpower development and training, and infrastructure expenses. Most of the budget is devoted to subsidies for patients receiving medical care at public hospitals, polyclinics, community hospitals, and certain institutions providing intermediate and long-term care. Other budget allocations are for initiatives addressing obesity prevention, tobacco control, childhood preventive health services, chronic disease management, and public education (Ministry of Health, 2013). Singapore offers its citizens universal health care coverage, funded through a combination of government subsidies, multilayered financing schemes, and private individual savings, all administered at the national level. The first tier of protection is provided by government subsidies of up to 80 percent of the total bill in public hospitals and primary care polyclinics. There are also subsidies of up to 80 percent in the government-funded intermediate and long-term care institutions. This is supported by a system of savings and insurance programs to help individuals and families pay for their care-known as the "3Ms," for the Medisave, MediShield, and Medifund programs. Together, these play a critical role in maintaining Singaporeans' health and welfare. Medisave is a mandatory medical savings program that requires workers to contribute a percentage of their wages to a personal account, with a matching contribution from employers. Individual contributions to and withdrawals from the accounts are tax-exempt. Account funds are used, under strict guidelines, to pay for health services such as hospitalization, day surgery, and certain outpatient expenses, as well as health insurance for the account holder and family members. MediShield is a low-cost catastrophic health insurance scheme to help policyholders meet medical expenses for major or prolonged illnesses that their Medisave balance would not be sufficient to cover. All permanent residents are automatically enrolled in the program; undocumented immigrants and visitors are not covered. MediShield operates on a copayment and deductible system, with premiums payable by the insured through Medisave. A universal health insurance scheme will replace MediShield at the end of 2015 (see below). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001721 OS 00003392 SINGAPORE Medifund is the government endowment fund set up to aid the indigent. The fund covers Singapore citizens who have received treatment from a Medifund-approved institution and have difficulties paying their medical bills despite government subsidies, Medisave, and MediShield coverage. Privately financed health care: According to the World Health Organization (2013), in 2010, private expenditure amounted to 69 percent of the nation's total expenditure on care, 10.1 percent coming from private prepaid plans. Private insurance is available from a number of for-profit companies, usually in the form of Medisave-approved Integrated Shield Plans. These plans serve as a supplement to MediShield, providing, for example, additional benefits and coverage when a patient opts for Class A and Class B1 wards in public hospitals or private hospitalization. Individuals can use funds from their Medisave accounts to pay the premiums for Integrated Shield Plans. ~ Employers also may offer private insurance to their employees as a staff benefit. Typically, employer-sponsored insurance cover primary care and other outpatient visits, in addition to hospitalization. What is covered? Services: Subsidies are available for care provided by public hospitals and polyclinics, as well as by government-funded intermediate and long-term care providers. MediShield, the second of the "3Ms," provides low-cost insurance coverage for treatments in the subsidized wards of public hospitals and outpatient care for certain conditions, including kidney dialysis and cancer treatments. As a catastrophic insurance program, MediShield generally does not cover primary care, prescription drugs, preventive services, mental health care, dental care, or optometry. MediShield is operated by the Central Provident Fund Board. Cost-sharing and out-of-pocket spending: The government of Singapore contributes to building and maintaining the system and subsidizing a portion of the cost of patient care, based on the individual's ability to pay. Copayments after subsidy can be covered by MediShield insurance or paid for through Medisave savings. For MediShield, an annual deductible against claims must be met before coverage can begin. Coinsurance for inpatient bills ranges from 20 percent to 10 percent as the bill increases. Therefore, after government subsidies, MediShield pays between 80 percent and 90 percent of the claimable amount that exceeds the deductible for selected outpatient treatment charges claimable under MediShield (e.g., kidney dialysis, chemotherapy for cancer, and erythropoietin for chronic kidney failure). Other outpatient services are fully paid from private funds or, in some cases, employer benefits. Deductibles do not apply to outpatient treatments. Instead, a 20 percent coinsurance is imposed. There is no annual cap on out-of-pocket spending. The health care system requires individuals to be ultimately responsible for their own health and to share in the cost of the services they use. Consequently, patients approach their health care choices knowing that they will pay a portion of the bill. In the Singapore system, patients are responsible for copayments and deductibles that are often higher than in other nations. According to the World Health Organization (2013), private spending amounts to 69 percent of total health care expenditure, of which 88 percent is out-of-pocket, including costs that are covered and reimbursed by employer medical benefits. Safety net: Medifund, the third of the Singapore system's "3Ms," is an endowment program funded by the government as a health care safety net. It was established in 1993, and its mission is to help the poor pay for their care. Money from the fund is disbursed each year to approved institutions, and a committee at each institution evaluates and approves financial assistance to patients. Government-funded providers (whether public or private institutions, or voluntary welfare organizations) are able to tap Medifund assistance for their patients. Medifund generally covers necessary medical treatment, including drugs, services, and tests. Medical social workers are in place to assist patients with the application process required before aid is granted. The amount of aid granted is determined by the patient's and the family's income, the social circumstances of the patient, The Commonwealth Fund VA-19-0799-D-001722 OS 00003393 SINGAPORE the medical condition, and treatment costs. More than 90 percent of patients whose applications are approved receive assistance amounting to 100 percent of the outstanding portion of subsidized bills that they are unable to pay. The ElderCare Fund is another government-established endowment fund established by the government. The endowment, which stands at SGD3 billion (USD3.4 billion), provides grants to intermediate and long-term care facilities to subsidize the care of low- and middle-income patients (Ministry of Health, 2013). 1 [ (R)] How is the delivery system organized and financed? Primary care: Primary care is mostly administered by the 1,400 private clinics offering such care (Ministry of Health, 2013). In addition, there are 18 public, multi-doctor polyclinics that provide subsidized outpatient care, immunization, health screening, and pharmacy services, with some offering dental care as well. These clinics, however, generally serve lower-income populations; the bulk of primary care is delivered by private general practitioner clinics. Patients can choose their primary care doctor, and registration is not required. Private primary care doctors make referrals but generally do not function as gatekeepers. They are usually paid on a fee-for-service basis. The Singapore system is strengthening its ties to private general practitioner networks. The Community Health Assist Scheme was introduced in 2012 to provide portable subsidies to Singaporeans from lower- to middleincome households. The scheme subsidizes visits to a participating private clinic for acute conditions, specified chronic illnesses, specified dental procedures, and recommended health screening. There are about 720 participating medical clinics and about 460 dental clinics. Outpatient specialist care: A number of centers focus on medical specialties, including cancer, oral care, cardiovascular disease, diseases of the nervous system, and skin diseases. The National Heart Centre, for example, offers a full range of treatment, from prevention to rehabilitation and is the national and regional referral center for any cardiovascular complications. Research, teaching, and training are also conducted there. Specialists who work in the public system are salaried; they may also see nonsubsidized patients. Administrative mechanisms for paying primary care doctors and specialists: The government pays subsidies directly to provider institutions, reimbursing them for a portion of treatment costs. Patients receive the subsidy benefits for outpatient care in both public clinics and public hospitals; for emergency care at public hospitals; for intermediate- and long-term care at facilities managed by voluntary welfare organizations; and, through means-testing, for care in private nursing homes. Eligible lower- to middle-income patients may also receive subsidies for outpatient treatment for chronic or acute conditions, and also certain dental procedures, at private primary care providers. After-hours care: Numerous public and private hospitals offer 24-hour emergency care. There are approximately 30 24-hour clinics throughout the country, and many other clinics have late-night hours; lists of those clinics are available on line. There is also a 24-hour emergency hotline that can be used for contacting ambulances operated by the Singapore Civil Defence Force. A mobile 24-hour house-call medical service is also available. Information on patient visits is not sent routinely to primary care doctors. Hospitals: General care is delivered at regional hospitals. General hospitals offer acute inpatient services and specialist outpatient services, and have 24-hour emergency departments. In 2010, there were more than 11,000 beds (public and private sector) in 30 hospitals (15 public and 15 private, including specialty centers, community hospitals, and chronic care hospitals). In that same year, there were 4 million outpatient visits at public hospitals, two-thirds of them subsidized (Affordable Excellence, 2013). 1 1 Please note that, throughout this profile, all figures in USD were converted from SGD at a rate of about SGD0.88 per USD, the purchasing power parity conversion rate for GDP in 2013 reported by the World Bank (2014) for Singapore. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001723 OS 00003394 SINGAPORE Public hospital funding is derived from a block budget. Part of the budget is based on Casemix, which classifies medical conditions based on diagnosis-related groups. Hospitals can reallocate savings from the block budget to develop other aspects of public health care services. The block budgets are reviewed every three to five years to ensure that subvention models keep up with changes in models of care and hospital operations. In addition to the block grants, government funds are available for manpower training and research. Wards in Singapore's public hospitals are tiered in four main classes, according to level of amenities. Patients in the highest-class wards are treated as private patients and therefore not subsidized. Patients in the other classes receive varying subsidies depending on the choice of ward and means-testing levels. The private sector provides about 20 percent of secondary and tertiary care services. Raffles Medical Group and Parkway Health are two of the main private hospital groups; they generally offer faster service and more amenities, and are also more involved in medical tourism, than public facilities do. The public sector has begun renting private hospitals' spare capacity to treat subsidized patients, as private hospitals currently have more beds available. Mental health care: Health care and social service agencies involved in mental health care are guided by the National Mental Health Blueprint of 2007, and provide integrated services such as education and prevention, early detection, and treatment for at-risk individuals or people facing emotional difficulties. The blueprint laid the groundwork for a network of care and support systems that will enable integrated community living. The Institute of Mental Health is Singapore's only acute tertiary psychiatric hospital. It provides psychiatric, rehabilitative, and counseling services for children, adolescents, adults, and the elderly, as well as long-term care and forensic services. Patients with addictions can be treated in the lnstitute's National Addictions Management Services unit. General and specialized treatment services for eating, sleep, and addictions disorders, and for geriatric psychiatry, are also offered at a number of public hospitals. To cope with projected increase in demand for mental health care and to improve accessibility, the National Mental Health Blueprint calls for more community-based mental health services, led mainly by tertiary facilities. Components of the program include multidisciplinary shared-care teams operating in service networks in the community; support for caregivers; community safety networks for people with dementia and depression and their caregivers; and general practitioner training and support for the care and management of people with mental illnesses. There are also community-based mental health programs targeting youth, adults, and the elderly. Most cases requiring residential care or a transition period, with close supervision provided by the Institute of Mental Health and by two voluntary welfare organizations (Singapore Association for Mental Health and Singapore Anglican Community Services). Long-term care and social supports: Management of long-term care services for the elderly is provided by voluntary welfare organizations and private operators. Services are financed in a number of ways, including direct payment by individuals and families, direct government subsidy to patients through providers, and capital and recurrent funding for intermediate and long-term care providers to provide means-tested, subsidized care. ElderShield, a long-term care insurance program regulated by the government but run through designated private insurers, is also available. ElderShield makes monthly direct cash payouts to those who can no longer take care of themselves. These payouts are intended to be setting-neutral, so that families and seniors can choose the type of care that best suits their needs. Eligible care includes nursing home, facility-based, and home-based health care, including hospice care. Financial support is available for informal and family caregivers. The Agency for Integrated Care administers the Caregivers Training Grant that provides an annual SGD200 (USD228) subsidy to attend approved training courses in caring for elderly or persons with disability. The grant is allocated per care recipient, not per caregiver. Care recipients must be Singaporeans or permanent residents age 65 or older or with disability. The Foreign Domestic Worker Grant, a monthly grant of SGD120 (USD137) for hiring a foreign domestic worker to care for the frail elderly or for an individual with at least moderate disability, is also available through the Agency for Integrated Care. Eligibility requires a maximum household monthly income of SGD2,600 (USD2,965) (Ministry of Health, 2013). The Commonwealth Fund VA-19-0799-D-001724 OS 00003395 SINGAPORE &h What are the key entities for health system governance? Organization and planning: Singapore's Ministry of Health has overall responsibility for health care, setting policy direction and managing the public health care system. Its responsibilities include needs assessment, services planning, manpower planning, system governance and financing, provider fee-setting, cost control, and health information technology, with an overall goal of ensuring quality of care and responsiveness to Singaporeans' needs. Regulation: The Ministry of Health regulates the health system through legislation and enforcement. Among the its core regulatory functions are licensing health care institutions under the Private Hospitals and Medical Clinics Act and conducting regular inspections and audits. Advertising is subject to monitoring and analysis to identify potential problems, which can lead to compliance audits and prosecutions in some cases. Marketing by licensed facilities is also regulated in order to safeguard the public against false or unsubstantiated claims and to prevent inducements to using nonessential services, such as aesthetic medicine. Professional bodies, including the Singapore Medical Council, Singapore Dental Council, Singapore Nursing Board, and Singapore Pharmacy Board, regulate professionals through practice guidelines and codes of ethics and conduct. The Ministry of Health also engages these bodies to explain policy rationale and to garner support for various initiatives. The Health Sciences Authority regulates the manufacture, import, supply, presentation, and advertisement of health products, including conventional medicines, complementary medicines (traditional medicine and health supplements), cosmetic products, medical devices, tobacco products, and medicinal therapies for clinical trials. Its mission is to ensure that all these products meet internationally benchmarked standards of safety, quality, and efficacy. The insurance industry is regulated by the Monetary Authority of Singapore as part of its financial regulatory role. Organization of the Health System in Singapore The Ministry of Health '' '' :,#----------------------------~ Statutory Boards :' ~-------------------- ______ , f Healthcare o.... Institutions] --------------------- __, Singapore Medical Council Singapore Dental Council f MOH Singapore Nursing Board :. ............ J__.---........ - Singapore Pharmacy Council Holdings Pte Ltd : Public Hospital Clusters j j Ioooooooooooooooooooooooooooo-' l Private Hospitals J #. ------------------- : and Providers ,_ : --------------------. Traditional Chinese Medicine Practitioners Board Health Sciences Authority Optometrists and Opticians Board Allied Health Professions Council Source: Adapted from Singapore Ministry of Health website. International Profiles of Health Care Syst ems, 2015 VA-19-0799-D-001725 OS 00003396 SINGAPORE Public consultation: The government takes the views of patients and other stakeholders into account through various means, including the "Our Singapore Conversation" sessions and an online survey. Public consultation occurs before policies are enacted to ensure that public sentiment, concerns, and feedback are added to the discussion; that diverse views are heard and ideas are tested and refined; and that public understanding and support are cultivated to facilitate implementation. As an example, after public consultation, Medisave was expanded to include a variety of preventive and treatment services, such as mammograms and colonoscopies, treatment of some mental health disorders and chronic diseases, and palliative care. ~ X What are the major strategies to ensure quality of care? Singapore's Ministry of Health conducts an annual survey to gauge patient satisfaction and expectations regarding public health care institutions. The survey measures satisfaction with waiting times, facilities, and care coordination, among other health system attributes. Results ofthe 2012 survey show that 77 percent of respondents were satisfied, and that 78 percent of patients would "strongly recommend" or "likely recommend" institutions to others based on their own experience (Ministry of Health, 2013). Public and private hospitals, clinics, laboratories, and nursing homes are required to submit applications to the health ministry for operating licenses. Physicians wishing to practice in Singapore must secure a position with a health care institution and register with the Singapore Medical Council, which maintains the official Register of Medical Practitioners. Physicians are required to fulfill continuing medical education requirements administered by the Medical Council. For institutions, prelicensing inspections are conducted to ensure standards. Singapore uses a performance measurement and management process to help health care providers assess and benchmark their performance against peers. The National Health System Scorecard uses internationally established performance indicators to compare performance. The Public Acute Hospital Scorecard is used to measure institution-level performance. Its indicators cover clinical quality and patient perspectives. Similar scorecards for providers are being rolled out in primary care facilities and in community hospitals. The scorecards define standards of service and key deliverables required of public health care institutions, and institutions are monitored to ensure compliance. The scorecards incorporate internationally accepted indicators and definitions where possible, such as the U.S. Center for Medicare and Medicaid Services' Joint Commissionaligned measures for acute myocardial infarction and stroke. In 2008, Singapore introduced national standards for health care to set priorities for improvement efforts and alignment with planning initiatives. These standards focus on key areas of concern and are intended to promote a culture of continuous quality improvement. The national standards are implemented through the network of Healthcare Performance Offices, each chaired by a senior clinical leader who reports directly to the institution's chief executive officer or medical board chairman. Resulting quality improvement outputs can then be incorporated into the National Health System Scorecard and the Public Acute Hospital Scorecard for performance analysis and monitoring. t:" j What is being done to reduce disparities? Community Health Assist Scheme: The Community Health Assist Scheme subsidizes treatment for lower- and middle-income Singaporeans at private primary care sites. The subsidies cover acute conditions, 15 chronic conditions, and a range of dental procedures. Subsidies are also available for recommended screenings for obesity, diabetes, hypertension, lipid disorders, colorectal cancer, and cervical cancer. Revised Central Provident Fund contribution rates: The Central Provident Fund is the umbrella account under which Singaporeans save for retirement, housing costs, and medical care (through the "3Ms"). There have been periodic increases in both employee and employer matching contribution rates in recent years, with another increase in the employer contribution rate to Medisave slated for January 2015. These increases are The Commonwealth Fund VA-19-0799-D-001726 OS 00003397 SINGAPORE intended to encourage low-wage workers to save more for their retirement and medical needs and to have better access to care. (R)-0- What is being done to promote delivery system integration and "-..:::,I care coordination? Singapore's Agency for Integrated Care was created in 2009 to bring about a patient-focused integration of primary and intermediate- and long-term care. The agency, which operates at the patient, provider, and system levels, works to encourage health care providers to coordinate their efforts on behalf of the patient. The agency also advises patients and families about appropriate health care services and helps them navigate the system. A primary example of the issues it addresses is follow-up treatment for chronic-disease patients discharged from the hospital. Another major initiative seeks to expand and improve health care capabilities at the community level. To achieve better integration of all care services, all six public hospital clusters in Singapore are undergoing a systemwide transformation to a regional health care system model. Hospitals will work in close partnership with other providers in their region, such as community hospitals, nursing homes, general practitioners, and home care providers. Another significant role for the agency is to ensure integration of health and social care services for elderly and disabled populations. The agency coordinates and facilitates the placement of sick elderly people with nursing homes, community providers, day rehabilitation centers, and long-term care facilities, and manages referrals to home care services. The agency also actively helps the elderly and people with disability apply for available financial assistance. ~ What is the status of electronic health records? Singapore is building a sophisticated national electronic health record system. The system collects, reports, and analyzes information to aid in formulating policy, monitoring implementation, and sharing patient records. The long-term goal is to allow medical professionals to access clinical data on patient treatment and safety. System capabilities include: a master index that matches patient records from a variety of sources and includes a unique identifier as well as other patient identity information; a summary care record for each patient that offers an overview of recent medical activity; access to overviews of specific events, such as hospital admissions; and access to health data in Singapore's registries for immunization, medical alerts, and allergies. ~ When fully developed, the system will allow data to be accessed and viewed in appropriate formats by medical professionals, patients, and researchers. Data sources will include the electronic medical record systems of public hospitals and polyclinics. There are plans to enable patients to view and possibly contribute to their personal health records. How are costs contained? Singapore spends just 4.7 percent of its GDP on health care (World Bank Health Data, 2014). Cost is controlled in a number of ways, perhaps foremost by the manner in which the government both fosters and controls competition-intervening when the market fails to keep costs down. Public and private hospitals exist side by side, with the public sector having the advantage of patient incentives and subsidies. Because it regulates prices for public hospital services and regulates the number of public hospitals and beds, the government is able to shape the marketplace. Within this environment, the private sector must be careful not to price itself out of the market. At the same time, the government sets subsidy and cost-recovery targets for each hospital ward class, thereby indirectly keeping public sector hospitals from producing excess profits. Hospitals are also given annual budgets for patient subsidies, so they know in advance the levels of reimbursement they will receive for patient care. Within their budgets, hospitals are required to break even. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001727 OS 00003398 SINGAPORE To keep demand for services in check, the government possesses numerous tools, including copayments, deductibles, and restrictions on the use of Medisave and MediShield for consultations, treatments, and procedures. These controls discourage unnecessary doctor visits, tests, and treatments, resulting in more careful use of health system resources. Price transparency: Another factor in controlling costs is price and outcome transparency. On its website, the Ministry of Health makes available hospital bills for common illnesses, treatments, and ward classes. Patients can look up costs for specific surgeries and tests, the number of cases treated in each hospital, and more. Data for public sector hospitals are complete; since private hospitals supply data voluntarily, the information may not offer the same level of detail. Armed with pricing information, consumers are able to shop better for the services they require. Pooling of funds and purchasing: The Group Purchasing Office consolidates drug purchases at the national ~ level. One goal of this system is to keep drug prices affordable by containing the costs of pharmaceuticalrelated expenditure. The Group Purchasing Office also purchases medical supplies, equipment, and IT services for the health care system. What major innovations and reforms have been introduced? Government spending: Since 2012, Singapore has been conducting a major review ofthe health care financing framework. In the 2012 health care budget, the Minister of Finance announced the government would increase its annual share of expenditure on health care from SGD4 billion (USD4.6 billion) to SGD8 billion (USD9.1 billion) over four years (Ministry of Health, 2012). The contribution by the government will soon rise from onethird to approximately 40 percent of the total, with the prospect of future increases. Outpatient subsidies: To maintain affordability of health care, subsidies to lower- and middle-income patients at Specialised Outpatient Clinics in public hospitals were increased starting in September 2014. Subsidies for standard drugs will also be increased these patients beginning in January 2015. Increases are means-tested. Medisave: Medisave use has been expanded gradually to cover chronic conditions and health screening and vaccinations for selected groups. In early 2015, Medisave will also cover outpatient scans needed for diagnosis and treatment. MediShield Life: Changes to MediShield are being implemented to address the growing need for chronic disease care and long-term care. Coverage has become universal and compulsory, and now includes individuals with preexisting conditions. Previously ending at age 90, coverage is now for life. The lifetime cap on benefits has been removed, and the annual limit increased to SGD100,000 (USD114,000). Another recent change provides better protection from large hospital bills by reducing coinsurance payments below 10 percent, for the portion ofthe bill exceeding SGD5,000 (USD5,702) (Ministry of Health, 2014). Medifund: In 2013, the government added SGD1 billion (USD1 .1 billion) to Medifund's capital fund, which now totals SGD4 billion (USD4.6 billion). This increase will support the implementation of Medifund Junior, which will target assistance to needy children. It also allows for the extension of Medifund coverage in 2013 to primary care, dental services, prenatal care, and delivery. In the same year, annual assistance increased by almost 30 percent, to SGD130 million (USD148 million) (Ministry of Health, 2013). Community Health Assist Scheme: Previously set at 40 years, the minimum age qualification for the program was removed in 2014. The household income ceiling for eligibility increased from SGD1 ,500 (USD1 ,711) to SGD1 ,800 (USD2,053) per capita per month. More chronic diseases were added, and subsidies for recommended health screening were introduced. These enhancements have enabled more lower- and middle income Singaporeans to benefit from the portable subsidies available at more than 1,000 medical and dental clinics (Ministry of Health, 2014). The Commonwealth Fund VA-19-0799-D-001728 OS 00003399 SINGAPORE References Accenture. "Singapore's Journey to Build a National Electronic Health Record System." http://www.accenture.com/ Site Col Iecti on Documents/PDF/Accenture-Si nga pore-Journey-to- Bui Id-Nati on a I- Electronic- Hea Ith-Record-System. pdf#zoom=S0. Department of Statistics, Singapore (2013). Haseltine, W. A. (2013). Affordable Excellence: The Singapore Healthcare Story. Ministry of Health, Singapore (2013). "Expenditure Overview." World Bank (2014). World Data Bank. http://databank.worldbank.org. Accessed Oct. 14, 2014. World Health Organization (2013). World Health Statistics 2013, Part Ill, "Global Health Indicators," 138-39. http://www. who.int/gho/publications/world_health_statistics/2013/en/. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001729 OS 00003400 ~ ? = What is the role of government? All three levels of Swedish government are involved in the health care system. At the national level, the Ministry of Health and Social Affairs is responsible for overall health and health care policy, working in concert with eight national government agencies. At the regional level, 12 county councils and nine regional bodies (regions) are responsible for financing and delivering health services to their citizens. At the local level, 290 municipalities are responsible care of the elderly and the disabled. The local and regional authorities are represented by the Swedish Association of Local Authorities and Regions (SALAR). Three basic principles apply to all health care in Sweden: 1. Human dignity: All human beings have an equal entitlement to dignity and have the same rights regardless of their status in the community. 2. Need and solidarity: Those in greatest need take precedence in being treated. 3. Cost-effectiveness: When a choice has to be made, there should be a reasonable balance between the costs ~ and the benefits of health care, measuring cost in relationship to improved health and quality of life. Who is covered and how is insurance financed? Publicly financed health care: Health expenditures represented 11 percent of GDP in 2013. About 84 percent of this spending was publicly financed, with county councils' expenditures amounting to 57 percent, municipalities' to 25 percent, and the central government's to almost 2 percent (Statistics Sweden, 2015a). The county councils and the municipalities levy proportional income taxes on their populations to help cover health care services. In 2013, 68 percent of county councils' total revenues came from local taxes and 18 percent from subsidies and national government grants financed by national income taxes and indirect taxes (SALAR, 2014). General government grants are designed to reallocate some resources among municipalities and county councils. Targeted government grants finance specific initiatives, such as reducing waiting times. In 2013, about 90 percent of county councils' total spending was on health care (SALAR, 2014). Coverage is universal and automatic. The 1982 Health and Medical Services Act states that the health system must cover all legal residents. Emergency coverage is provided to all patients from European Union/ European Economic Area countries and to patients from nine other countries with which Sweden has bilateral agreements. Asylum-seeking and undocumented children have the right to health care services, as do children who are permanent residents. Adult asylum seekers have the right to receive care that cannot be deferred (e.g., maternity care). Undocumented adults have the right to receive nonsubsidized immediate care. Private health insurance: Private health insurance, in the form of supplementary coverage, accounts for less than 1 percent of expenditures. Associated mainly with occupational health services, it is purchased primarily to ensure quick access to an ambulatory care specialist and to avoid waiting lists for elective treatment. Insurers are for-profit. In 2015, 614,000 individuals had private insurance, accounting for roughly 10 percent of all employed individuals aged 15 to 74 years (Swedish Insurance Federation, 2015). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001731 OS 00003402 ~ SWEDEN What is covered? Services: There is no defined benefits package. The publicly financed health system covers public health and preventive services; primary care; inpatient and outpatient specialized care; emergency care; inpatient and outpatient prescription drugs; mental health care; rehabilitation services; disability support services; patient transport support services; home care and long-term care, including nursing home care and hospice care; dental care and optometry for children and young people; and, with limited subsidies, adult dental care. As the responsibility for organizing and financing health care rests with the county councils and municipalities, services vary throughout the country. Cost-sharing and out-of-pocket spending: In 2013, about 16 percent of all expenditures on health were private, and ofthese 93 percent were out-of-pocket (Statistics Sweden, 2015a). The majority of out-of-pocket spending is for drugs. The county councils set copayment rates per health care visit and per bed-day, leading to variation across the country. Providers cannot charge above the scheduled fee. The table below shows fee ranges for 2014. Service Fee Range (2014) Swedish Kroner U.S. Dollars Primary care physician visit 100-300 11-34 Hospital physician consultation 200-350 22-39 80-100 9-11 Hospitalization per day Source: SALAR, 2015. Nationally, annual out-of-pocket payments for health care visits are capped at SEK1, 100 (USD123) per individual. In all county councils, people under age 18-and in most county councils, people under 20-are exempt from user charges for visits. Dental care: Dental and pharmaceutical benefits are determined at the national level. People under 20 have free access to all dental care. People 20 or older receive a fixed annual subsidy of SEK150-SEK300 (USD17USD34), depending on age, for preventive dental care. For other dental services, within a 12-month period patients 20 or older pay the full cost of services up to SEK3,000 (USD335), 50 percent of the cost for services between SEK3,000 and SEK15,000 (USD1 ,676), and 15 percent of costs above SEK15,000. There is no cap on user charges for dental care. Prescription drugs: Individuals pay the full cost of prescribed medications up to SEK1, 100 (USD123) annually, after which the subsidy gradually increases to 100 percent. The annual ceiling for out-of-pocket payments for prescriptions is SEK2,200 (USD246) for adults. A separate annual out-of-pocket maximum of SEK2,200 applies collectively to all children belonging to the same family. For certain prescription drugs not on the National Drug Benefits Scheme and not subject to reimbursement, patients must pay the full price. Safety net: Because the Swedish health care system is designed to be socially responsible and equity-driven, all social groups are entitled to the same benefits. The ceilings on out-of-pocket spending apply to everyone, and the overall cap on user charges is not adjusted for income. Children, adolescents, pregnant women, and the elderly are generally targeted groups, exempted from user charges or granted subsidies for certain services such as maternity care or vaccination programs. * Please note that, throughout this profile, all figures in USD were converted from SEK at a rate of about SEK8.95 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for Sweden. The Commonwealth Fund VA-19-0799-D-001732 OS 00003403 SWEDEN [ (R)j How is the delivery system organized and financed? The health system is highly integrated. An important policy initiative driving structural changes since the 1990s has been the shifting of inpatient care to outpatient and primary care, and the concentration of highly specialized care in academic medical centers. All provider fees are set by county councils, leading to variation across the country. Public and private physicians (including hospital specialists), nurses, and other categories of health care staff at all levels of care are predominantly salaried employees. The average monthly salary for a physician with a specialist degree (including specialists in general medicine) was SEK73,000 (USD8, 157) in 2014 (Statistics Sweden, 20156). There is no regulation prohibiting physicians (including specialists) and other staff who work in public hospitals or primary care practices from also seeing private patients outside the public hospital or primary care practice. Employers of health care professionals, however, may establish such rules for their employees. Primary care: Primary care accounts for about 20 percent of all expenditures on health, and about 16 percent of all physicians work in this setting (Swedish Medical Association, 2013, 2014). Primary care has no formal gatekeeping function. Team-based primary care, with general practitioners, nurses, midwives, physiotherapists, psychologists, and gynecologists, is the main form of practice. There are, on average, four general practitioners in a primary care practice. General practitioners or district nurses are usually the first point of contact for patients. District nurses employed by municipalities also participate in home care and regularly make home visits, especially to the elderly; they have limited prescribing authority. People may register with any public or private provider accredited by the local county council, with most individuals registering with a practice instead of a physician. Registration is not required to visit a practice. There are more than 1,100 primary care practices, of which 40 percent are privately owned. Providers (public and private) are paid a combination of fixed payment for their registered individuals (about 80% of total capitated payment), fee-for-service (17%-18%), and performance-related payment (2%-3%) for achieving quality targets in such areas as patient satisfaction, enrollment in national registers, compliance with guidelines based on evidence-based medicine, and recommendations from county council drug formulary committees. Outpatient specialist care: Outpatient specialist care is provided at university and county council hospitals and in private clinics. Patients have a choice of specialist. Public and private providers are paid through the same fixed, prospective, per-case payments (based on diagnosis-related groups), complemented by price or volume ceilings and quality components. Administrative mechanisms for direct patient payments to providers: Patients normally pay the provider fee up front for primary care and other outpatient visits. In most cases, it is also possible for patients to pay later. After-hours care: Primary care providers are required to provide after-hours care in accordance with the conditions for accreditation in each county council. Practices in proximity to each other (normally three to five practices) collaborate on after-hours arrangements. Through their websites and phone services, providers advise their registered patients where to go for care. Staff providing after-hours primary care services normally include general practitioners as well as nurses. There is no special arrangement for provider payment, and the same copayments apply as those during regular hours (see above, "Cost-sharing and out-of-pocket spending"). Information regarding after-hours patient visits is routinely sent to the practice where the patient is registered. In addition, seven university hospitals and about 50 county council hospitals provide full emergency services 24 hours a day. All county councils and regional bodies provide information on how and where to seek care through their websites and a national phone line, with medical staff available all day to give treatment advice. Moreover, all county councils and their regional counterparts collaborate to provide online information about pharmaceuticals, medical conditions, and pathways for seeking care. A similar private collaboration exists as well. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001733 OS 00003404 SWEDEN Hospitals: There are seven university hospitals, and about 70 hospitals at the county council level. Six of them are private, and three of those are not-for-profit. The rest are public. Counties are grouped into six health care regions to facilitate cooperation and to maintain a high level of advanced medical care. Highly specialized care, often requiring the most advanced technical equipment, is concentrated in university hospitals to achieve higher quality and greater efficiency and to create opportunities for development and research. Acute care hospitals (seven university hospitals and two-thirds of the 70 county council hospitals) provide full emergency services. Global budgets or a mix of global budgets, diagnosis-related groups, and performance-based methods are used to reimburse hospitals. Two-thirds or more of total payment is usually in the form of budgets, and about 30 percent is based on DRGs. Performance-based payment related to attainment of quality targets constitutes less than 5 percent oftotal payment. The payments are traditionally based on historical (full) costs. Mental health care: Mental health care is an integrated part ofthe health care system and is subject to the same legislation and user fees as other health care services. People with minor mental health problems are usually attended to in primary care settings, either by a general practitioner or by a psychologist or psychotherapist; patients with severe mental health problems are referred to specialized psychiatric care in hospitals. Specialized inpatient and outpatient psychiatric care, include that related to substance use disorders, is available to adults, children, and adolescents. Long-term care and social supports: Responsibility for the financing and organization of long-term care for the elderly and for the support of people with disabilities lies with the municipalities, but the county councils are responsible for those patients' routine health care. Older adults and disabled people incur a separate maximum copayment for services commissioned by the municipalities (SEK1 ,780 [USD199] per month in 2015). The Social Services Act specifies that older adults have the right to receive public services and assistance at all later stages of life, e.g., home care aids, home help, and meal deliveries. Also included is end-of-life care, either in the individual's home or in a nursing home or hospice. The Health and Medical Services Act and the Social Services Act regulate how the county councils and the municipalities manage palliative care. The organization and quality of palliative care vary widely both between and within county councils. Palliative care units are located in hospitals and hospices. An alternative to palliative care in a hospital or hospice is advanced palliative home care. There are both public and private nursing homes and home care providers. About 14 percent of all nursing home and home care was privately provided in 2012 (Statistics Sweden, 201 Sa), although the percentage varies significantly among municipalities. Payment to private providers is usually contract-based, following a public tendering process. Eligibility for nursing home care is based on need, which is determined collaboratively by the client and staff from the municipality; often a relative participates as well. There is a national policy to promote home assistance and home care over institutionalized care, and that policy entitles older people to live in their homes for as long as possible. Municipalities can also reimburse informal caregivers either directly ("relative-care benefits") or by employing the informal caregiver ("relative-care employment"). &h What are the key entities for health system governance? The Health and Medical Services Act specifies that responsibility for ensuring that everyone living in Sweden has access to quality health care lies with the county councils and municipalities. The county councils are responsible for the funding and provision of health services, while the municipalities are responsible for meeting the care and housing needs of older adults and people with disabilities. In primary care, there is competition among providers (public and private) to register patients, although they cannot compete through pricing, since the county councils set fees. County councils control the establishment of new private practices by regulating conditions for accreditation and payment. Those conditions pertain primarily to opening hours and to the minimum number of clinical competencies at the practice. The right to establish a practice and be publicly reimbursed applies to all public and private providers fulfilling the conditions for accreditation. The Commonwealth Fund VA-19-0799-D-001734 OS 00003405 SWEDEN The central government, through the Ministry of Health and Social Affairs, is responsible for overall health care policies. There are eight government agencies directly involved in the areas of medical care and public health. The National Board of Health and Welfare supervises all health care personnel, disseminates information, develops norms and standards for medical care, and, through data collection and analysis, ensures that those norms and standards are met. The agency is the licensing authority for health care staff. (Health care personnel are not required to reapply for their license.) The National Board of Health and Welfare also maintains health data registries and official statistics. The Swedish eHealth Agency, established in 2014, focuses on promoting public involvement and providing support for professionals and decision-makers. The agency stores and transfers electronic prescriptions issued in Sweden and is responsible for transferring electronic prescriptions abroad. The agency is also responsible for Sweden's national drug statistics and for statistics on pharmaceutical sales. The Health and Social Care Inspectorate is responsible for supervising health care, social services, and activities concerning support and services for persons with certain functional impairments. It is also responsible for issuing permits in those areas. The Swedish Agency for Health and Care Services Analysis analyzes and evaluates health policy, as well as the availability of health care information to citizens and patients. The results of such analyses are published. The Public Health Agency provides the national government, government agencies, municipalities, and county councils with new knowledge, based on scientific evidence, in the area of infectious disease control and public health, including health technology assessment. The Swedish Council on Technology Assessment in Health Organization of the Health System in Sweden SALAR ______ ,,,. .---------- I Ministry of Health and Social Affairs National Board of Health and Welfare ----------290 municipalities 21 county councils 7 university hospitals in 6 medical care regions Health and Social Care Inspectorate Public and private services (special housing and home care) for elderly and disabled Approximately 70 county council-driven hospitals and 6 private hospitals Swedish Agency for Health and Care Services Analysis [ Public Health Agency ) [ Medical Products Agency ) Approximately 1,100 public and private primary care facilities Swedish Council on Technology Assessment in Health Care Dental and Pharmaceutical Benefits Agency Public and private dentists [ ) Swedish eHealth Agency International Profiles of Health Care Systems, 2015 VA-19-0799-D-001735 OS 00003406 SWEDEN Care, which promotes use of cost-effective health care technologies, has a mandate to review and evaluate new treatments from medical, economic, ethical, and social points of view. Information from the council's reviews is disseminated to central and local government officials and medical staff to provide basic data for decisionmaking purposes. The principal agency for assessing pharmaceuticals is the Dental and Pharmaceutical Benefits Agency. Since 2002, it has had a mandate to decide whether particular drugs should be included in the National Drug Benefit Scheme; prescription drugs are priced in part on the basis of their value. The agency's mandate also includes dental care. The Medical Products Agency, meanwhile, is the Swedish national authority responsible for the regulation and surveillance of the development, manufacture, and sale of drugs and other medicinal products. 't' 0 x'- What are the major strategies to ensure quality of care? County councils are responsible for accrediting health care providers and following up on conditions for accreditation. These activities include assessing whether quality targets-those associated with a pay-forperformance scheme or tied to requirements for continued accreditation-have been achieved. Providers are evaluated based on information from patient registries and national quality registries, surveys related to patient satisfaction, and clinical audits. Concern for patient safety has increased during the past decade, and patient safety indicators are compared regionally (see below). Eight priority target areas for preventing adverse events have been specified: health care-associated urinary tract infections; central line infections; surgical site infections; falls and fall injuries; pressure ulcers; malnutrition; medication errors in health care transitions; and drug-related problems (SALAR, 2011). The National Board of Health and Social Welfare, together with the National Institute for Public Health and the Dental and Pharmaceutical Benefits Agency, conducts systematic reviews of evidence and develops guidance for establishing priorities in support of disease management programs developed at the county council level. International guidelines and specialists are also central to the development of these local programs. There is a tendency to develop regional guidelines to inform the setting of priorities in order to avoid unnecessary variation in clinical practice. For example, the National Cancer Strategy was established in 2009, and six Regional Cancer Centers (RCCs) were formed in 2011. The RCCs' role is to contribute to more equitable, safe, and effective cancer care through regional and national collaboration. The 90 or so national quality registries are used for monitoring and evaluating quality among providers and for assessing treatment options and clinical practice. Registries contain individualized data on diagnosis, treatment, and treatment outcomes. They are monitored annually by an executive committee, funded by the central government and by county councils, and managed by specialist organizations. Since 2006, the government has published annual performance comparisons and rankings of the county councils' health care services, using data from the national quality registers, the National Health Care Barometer Survey, the National Waiting Time Survey, and the National Patient Surveys. The 2012 publication included 169 indicators, organized into various categories such as prevention, patient satisfaction, waiting times, trust, access, surgical treatment, and drug treatment. Some 50 indicators are shown also for hospitals, but without rankings. Statistics on patient experiences and waiting times in primary care are also made available through the Internet (www.skl.se) to help guide people in their choice of provider. The Commonwealth Fund VA-19-0799-D-001736 OS 00003407 SWEDEN t-1 ~ What is being done to reduce disparities? The 1982 Health and Medical Services Act emphasizes equal access to services on the basis of need, and a vision of equal health for all. International comparisons indicate that health disparities are relatively low in Sweden. The National Board of Health and Welfare and the Public Health Agency compile and disseminate comparative information about indicators on public health. Approaches to reducing disparities include programs to support behavioral changes, and the targeting of outpatient services to vulnerable groups in order to prevent diseases at an early stage. To prevent providers from avoiding patients with extensive needs, most county councils allocate funds to primary care providers based on a formula that takes into account both overall illness (based on diagnoses) and registered individuals' socioeconomic conditions. 0~ What is being done to promote delivery system integration and ~ care coordination? ~ The division of responsibilities between county councils (for medical treatment) and municipalities (for nursing and rehabilitation) requires coordination. Efforts to improve collaboration and develop more integrated services include the development of national action plans supported by targeted government grants. In 2005, Sweden introduced a "guarantee" to improve access to care and to ensure the equality of that access across the country. The guarantee is based on the "0-7-90-90 rule": instant contact (zero delay) with the health system for advice; seeing a general practitioner within seven days; seeing a specialist within 90 days; and waiting no more than 90 days to receive treatment after being diagnosed. For county councils to be eligible for the grant targeted at accessibility, 70 percent of all patients must receive care within the stipulated time frames. At the county council level, providers are eligible for grants linked partly to the fulfillment of goals related to coordination and collaboration in care provided to the elderly with multiple diagnoses. What is the status of electronic health records? Generally, both the quality of IT systems and their level of use are high in hospitals and in primary care; more than 90 percent of primary care providers used electronic patient records for diagnostic data in 2009 (Health Consumer Powerhouse, 2009). Nearly all Swedish prescriptions are e-prescriptions. Patients increasingly have access to their electronic medical record for the purposes of scheduling appointments or viewing their personal health data, but there is variation in this regard between county councils. The Swedish eHealth Agency (eHalsomyndigheten) was formed in 2014 to strengthen the national e-health infrastructure. Its activities focus on promoting public involvement and providing support for professionals and decision makers (see governance section , above). How are costs contained? County councils and municipalities are required by law to set and balance annual budgets for their activities. For prescription drugs, the central government and the county councils form agreements, lasting a period of years, on the levels of subsidy paid by the government to the councils. The Dental and Pharmaceutical Benefits Agency also employs value-based pricing for prescription drugs, determining reimbursement based on an assessment of health needs and cost-effectiveness. In some county councils, there are also local models for value-based pricing for specialized care such as knee replacements. Because county councils and municipalities own or finance most health care providers, they are able to undertake a variety of cost-control measures. For example, contracts between county councils and private specialists are usually based on a tendering process in which costs constitute one variable used to evaluate different providers. The financing of health services through global budgets, volume caps, capitation formulas, and contracts, as well as salary-based pay for staff, also contributes to cost control, as providers retain responsibility for meeting costs with funds received through those prospective payment mechanisms. In several counties, providers are also financially responsible for prescription costs. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001737 OS 00003408 SWEDEN G '?i What major innovations and reforms have been introduced? Important policy areas that have been under scrutiny at both the local and the national level during the last two years include the quality and equity of care, coordination of care, and patients' rights. Studies following Sweden's 2010 market reform in primary care show that objectives related to accessibility have been achieved. Its effects on quality, equity, and efficiency, however, are unclear. Accurate reporting and monitoring to measure these criteria remain important challenges in Swedish primary care and are a concern for policymakers. In the area of specialized care, there have been recent efforts to foster greater equity. The government has committed to providing SEK500 million (USD55.87 million) per year in cancer care and to reduce regional disparities. This effort is to be the framework of the National Cancer Strategy and the six Regional a commission on equitable health, established in 2015, is to submit containing proposals for reducing health inequalities in society. from 2015 to 2018 to reduce waiting times built on work previously undertaken within Cancer Centers (RCCs). In addition, a report (due by the end of May 2017) To improve continuity and coordination of care, in 2014 the government launched a four-year national initiative for people with chronic diseases. Its three areas of focus are patient-centered care, evidence-based care, and prevention and early detection of disease. In 2015, a new law addressing patients' rights went into effect, with the purpose of strengthening the rights of patients and enhancing patient integrity, influence, and shared decision-making. The law clarifies and expands providers' responsibility in conveying information to their patients, patients' right to a second opinion, and patients' choice of provider in outpatient specialist care throughout the country. The government has commissioned the Swedish Agency for Health and Care Services Analysis to monitor and follow up on implementation of the new law until 2017. References Anell, A., A. H. Glenngard, S. Merkur (2012). "Sweden: Health System Review." Health Systems in Transition 14(5):1-161. Health Consumer Powerhouse (2009). Euro Health Consumer Index 2009 Report. Danderyd: Health Consumer Powerhouse. Organisation for Economic Co-operation and Development (OECD) (2015). OE CD.Stat (database). DOI: 10.1787 /data00285-en. Accessed July 2, 2015. Statistics Sweden (2015a). Systems of Health Accounts (SHA) 2001-2013. Statistics Sweden (20156). Lonestrukturstatistik, landstingskommunal sector 2014. SALAR (2011). National Initiative for Improved Patient Safety. Stockholm: Swedish Association of Local Authorities and Regions. SALAR (2014). Statistik inom ha/so- och sjukvard samt regional utveckling. Verksamhet och ekonomi i landsting och regioner 2013. Stockholm: Swedish Association of Local Authorities and Regions. SALAR (2015). Patientavgifter i ha/so- och sjukvarden 2015. Stockholm: Swedish Association of Local Authorities and Regions. Swedish Insurance Federation (2015). http://www.svenskforsakring.se. Accessed June 18, 2015. Swedish Medical Association (2013). Lakarforbundets undersokning av primarvardens lakarbemanning. Stockholm: Sveriges lakarforbund. Swedish Medical Association (2014). Kostnader och produktion i primarvardens vardval. Stockholm: Sveriges lakarforbund. The Commonwealth Fund VA-19-0799-D-001738 OS 00003409 ~ What is the role of government? ~ ~ Duties and responsibilities in the Swiss health care system are divided among the federal, cantonal, and communal levels of government. The system can be considered highly decentralized, as the cantons are given a critical role. The 26 cantons (including six half-cantons) are responsible for licensing providers, coordinating hospital services, and subsidizing institutions and organizations. Cantons are like U.S. states in that they are sovereign in all matters, including health care, that are not specifically designated as the responsibility of the Swiss Confederation by the federal constitution. Each canton and half-canton has its own constitution articulating a comprehensive body of legislation. Who is covered and how is insurance financed? Publicly financed health insurance: There are three streams of public funding: 1. Direct financing for health care providers through tax-financed budgets for the Swiss Confederation, cantons, and municipalities. The largest portion ofthis spending is given as cantonal subsidies to hospitals providing inpatient acute care. 2. Mandatory statutory health insurance (SHI) premiums. 3. Social insurance contributions from health-related coverage of accident insurance, old-age insurance, disability insurance, and military insurance. All government expenditures are financed by general taxation. In 2013, direct spending by government accounted for 20.2 percent oftotal health expenditures (CHF69.2 billion, or USD50.5 billion), while income-based 1 SHI subsidies accounted for an additional 5.8 percent. Including SHI premiums (30.9% oftotal health expenditure, excluding statutory subsidies), other social insurance schemes (6.5%), and old age and disability benefits (4.4%), publicly financed health care accounted for 67.9 percent of all spending (SFOS, 2015a). Mandatory SHI coverage is universal. Residents are legally required to purchase SHI within three months of arrival in Switzerland, which then applies retroactively to the arrival date. Policies typically apply to the individual, are not sponsored by employers, and must be purchased separately for dependents. There are virtually no uninsured residents. Temporary nonresident visitors pay for care up front, and must claim expenses from any coverage they may hold in their home country. Missing SHI for undocumented immigrants remains an unsolved problem acknowledged by the Swiss Federal Council (SFC), the highest governing and executive authority. SHI is offered by competing nonprofit insurers supervised by the Federal Office of Public Health (FOPH), which sets floors for premiums offered to cover past, current, and estimated future costs for insured individuals in a given region. Cantonal average annual premiums in 2015 for adults range from CHF3,836 (USD2,800) to CHF6,398 (USD4,670) (Appenzell lnnerrhoden; Basel-Stadt). Funds are redistributed among insurers by a central fund, in accordance with a risk equalization scheme adjusted for canton, age, gender, and hospital or nursing home stays of more than three days in the previous year. 1 Please note that, throughout this profile, all figures in USD were converted from CHF at a rate of about CHF1 .37 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for Switzerland. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001739 OS 00003410 SWITZERLAND Insurers offer premiums for defined geographical "premium regions" limited to three per canton. Within every region, the criteria for variation in premiums are limited to age group, level of deductible, and alternative insurance plans (so-called managed care plans with the main characteristic of giving up free choice of first medical contact), but variations in premiums among insurers can be significant. In 2013, 60.6 percent of residents opted for basic coverage with a health maintenance organization, an independent practice association, or a fee-for-service plan with gatekeeping provisions (FOPH, 2014). Private health insurance: Private expenditure accounted for 32.1 percent oftotal health expenditure in 2013 (SFOS, 2015a), which is high by comparison with other OECD countries (OECD, 2011). There is complementary voluntary health insurance (VHI, 7.3% of total expenditure) for services not covered in the basic basket of SHI, and supplementary coverage for free choice of hospital doctor or for a higher level of hospital accommodation. No data are available on the number of people covered. VHI is regulated by the Swiss Financial Market Supervisory Authority. Insurers can vary benefit baskets and premiums and can refuse applicants based on medical history. Service prices are usually negotiated directly between insurers and providers. Unlike statutory insurers, voluntary insurers are for-profit; an insurer will often have a nonprofit branch offering SHI and a for-profit branch offering VHI. It is illegal for voluntary insurers to base voluntary insurance subscription decisions on health information obtained via basic health coverage, but this rule is not easily enforced. What is covered? Services: The Federal Department of Home Affairs (FDHA) defines the SHI benefits basket by evaluating whether services are effective, appropriate, and cost-effective. It is supported in this task by the FOPH and by Swissmedic, the agency for authorization and supervision of therapeutic products. SHI covers most general practitioner (GP) and specialist services, as well as an extensive list of pharmaceuticals, medical devices, home health care (called Spitex), physiotherapy (if prescribed), and some preventive measures, including the costs of selected vaccinations, selected general health examinations, and screenings for early detection of disease among certain risk groups (e.g., one mammogram per year for women with a family history of breast cancer). Hospital services are also covered by SHI, but highly subsidized by cantons (see below). Care for mental illness is covered if provided by certified physicians. The services of nonmedical professionals (e.g., psychotherapy by psychologists) are covered only if prescribed by a qualified medical doctor and provided in his or her practice. SHI covers only "medically necessary" services in long-term care. The FOPH and Swiss Conference of Cantonal Health Ministers aim to eliminate the gaps in financing of hospice care. Dental care is largely excluded from SHI, as are glasses and contact lenses for adults (unless medically necessary), but these are covered for children. Cost-sharing and out-of-pocket spending: Insurers are required to offer minimum annual deductibles of CHF300 (about USD219) for adults under SHI, although insured persons may opt for a higher deductible (up to CHF2,500 [USD1 ,825]) and a lower premium. In 2013, 23.5 percent of all insured persons opted for the standard CHF300 deductible; the other 76.5 percent chose a higher deductible or another model with a gatekeeping element. Insured persons pay 10 percent coinsurance above deductibles for all services (including GP consultations), but is capped at CHF700 (USD511) for adults and at CHF350 (USD255) for minors (under age 19) in a given year. There is also a 20 percent charge for brand-name drugs with a generic alternative. For treatment in acute-care hospitals, there is a CHF15 (USD11) copayment per inpatient day. Cost-sharing in SHI and VHI accounted for 5.6 percent and 0.1 percent oftota I hea Ith expenditure in 2013. The Commonwealth Fund VA-19-0799-D-001740 OS 00003411 SWITZERLAND Moreover, out-of-pocket payments for services not covered by insurance (and in addition to cost-sharing) accounted for 18.1 percent of total health expenditure. Most of these direct out-of-pocket payments were spent on dentistry and long-term care. Providers are not allowed to charge prices higher than SHI will reimburse. Safety net: Maternity care and some preventive services are fully covered and thus exempt from deductibles, coinsurance, and copayments. Minors do not pay deductibles or copayments for inpatient care. Federal government and cantons provide income-based subsidies to individuals or households to cover SHI premiums; income thresholds vary widely by canton (Swiss Conference of Cantonal Health Ministers, 2015a). Overall, 28 percent of residents (in 2013) benefit from individual premium subsidies. Municipalities or cantons cover the health insurance expenses of social assistance beneficiaries and recipients of supplementary old age and disability benefits. [ (R)I How is the delivery system organized and financed? Primary care: As registering with a GP is not required, people not enrolled in managed care plans generally have free choice among self-employed GPs. In 2014, 38.5 percent of doctors in the outpatient sector were classified as GPs. Apart from scale-of-charge measures (see below), there are no specific financial incentives for GPs to take care of chronically ill patients, and no concrete reforming efforts are underway to engage GPs in "bundled payments" for chronic patients (e.g., diabetics). Primary (and specialist) care tends to be physiciancentered, with nurses and other health professionals playing a relatively small role. In 2014, 57.2 percent of physicians were in solo practice (Hostettler and Kraft, 2015). Apart from some managed care plans in which physician groups are paid through capitation, ambulatory physicians (including GPs and specialists) are paid according to a national fee-for-service scale (TARMED). While billing above the fee schedule is not permitted, TARMED offers some incentives for less resource-intensive forms of care. These incentives, however, are criticized by GPs as insufficient to render attractive such services as home visits, after-hours care, and coordinating and communicating with chronically ill patients. In response, the SFC decided to slightly increase remuneration for consultations in primary care as of October 2014, while remuneration for some more technical services (such as computer tomography) has been slightly reduced. The median income of primary care doctors was CHF197,500 (USD144, 151) in 2009 (Kunzi and Strub, 2012). Outpatient specialist care: In the outpatient sector, 61.5 percent of doctors were classified as specialists in 2014 (Hostettler and Kraft, 2015). Residents have free access (without referral) to specialists unless enrolled in a gatekeeping managed care plan. Specialist practices tend to be concentrated in urban areas and within proximity of acute-care hospitals. Mostly self-employed specialists can schedule appointments in public hospitals with both SHI and private patients. Administrative mechanisms for direct patient payments to providers: SHI allows different methods of payment among insurers, patients, and providers. Providers can invoice the patient, who pays up front and claims reimbursement from the insurer, or the patient can forward the invoice to the insurer for payment. Alternatively, providers can directly bill the insurer, who makes payment and bills any balance to the patient. After-hours care: Cantons are responsible for after-hours care. They delegate those services (fees set by TARMED) to cantonal doctors' associations, which organize care networks in collaboration with their affiliated doctors. The networks can include ambulance and rescue services, hospital emergency services, and walk-in clinics and telephone advice lines run or contracted by insurers. There is no institutionalized exchange of information between these services and GPs' offices (as people are not required to register). International Profiles of Health Care Systems, 2015 VA-19-0799-D-001741 OS 00003412 SWITZERLAND Hospitals: About 70 percent of the 293 acute inpatient hospitals (in 2013) are public or publicly subsidized private hospitals (SFOS, 20156). For services covered by SHI and billed through a national diagnosis-related 2 group (DRG) payment system, hospitals receive around half (45%-55%) of their funding from insurers (Swiss Conference of Cantonal Health Ministers, 20156). The other half is covered by cantons and communes, or, in case of additional services, by private health insurance. There are no arrangements for bundled payments to include entire episodes of care are not used. Cantons are responsible for hospital planning and funding, and are legally bound to coordinate plans with other cantons. The introduction in 2012 of free movement of patients between cantons under the DRG system has reduced cantonal fragmentation. Remuneration mechanisms depend on insurance contracts; as a consequence, fee-for-service is still possible for inpatient services not covered under SHI. Hospital-based physicians are normally paid a salary, and public-hospital physicians can receive extra payments for seeing privately insured patients. Mental health care: Psychiatric practices are generally private, and psychiatric clinics and hospital departments are a mix of public, private with state subsidies, and fully private. There is also a wide range of socio-psychiatric facilities and daycare institutions that are mainly state-run and -funded. Psychiatric hospitals or clinics normally provide a full range of medical services like psychiatric diagnostics and treatment, psychotherapy, pharmaceutical treatment, and forensic services. Often, the socio-psychiatric facilities and daycare institutions offer the same medical services as the clinics, but normally treat patients with less acute illnesses or symptoms. The main field of activity of psychiatric practices is psychotherapy that can be supplemented by pharmaceutical treatment. The provision of psychiatric care is not systematically integrated into primary care. Prices for outpatient psychiatric services are calculated using TARMED, while psychiatric inpatient care prices are usually calculated as a daily rate. Long-term care and social supports: Services are provided for inpatient care (in nursing homes and institutions for disabled and chronically ill persons) and for outpatient care through Spitex. In some cases admission is possible only through a hospital or by approval from an admission authority. Palliative care provided in hospitals, in nursing homes, in hospices, or at home is not regulated separately in SHI, so coverage of services is similar to acute services in the respective provider setting. There is no provision of individual or personal budgets for patients to organize their own services. Inpatient long-term somatic and mental services are covered by SHI, but are highly subsidized by cantons. For services in nursing homes and institutions for disabled and chronically ill persons, SHI pays a fixed contribution to cover care-related inpatient long-term care costs; the patient pays at most 20 percent of care-related costs that are not covered, and the remaining care-related costs are financed by the canton or the commune. Longterm inpatient care costs totaled CHF12.0 billion (USD8.8 billion) in 2013, representing 17.4 percent oftotal health expenditures. Around one-third of these costs (32.0%) were paid by private households, one-quarter (24.1%) by old age and disability benefits, 18.4 percent by SHI and other social insurances, and the rest by government subsidies (25.5%). Of the 1,580 nursing homes (as of 2013), 29.6 percent are state-operated and -funded, 29.6 percent are privately operated with public subsidies, and 40.8 percent are exclusively private (SFOS, 2015c). Almost half of total Spitex expenditure of CHF2.0 billion (USD1 .4 billion), as of 2013 (SFOS, 2015d), is financed by government subsidies (47.5%). SHI and the other social insurances covering the cost of medically necessary health care at home made up roughly one-third (30.0%). The rest (22.6%), devoted mainly to support and household services, was paid out-of-pocket, by old age and disability benefits, by VHI, and by other private funds (SFOS, 2015a). There is no legal basis for financial support for informal help or family caregivers. Most Spitex organizations are subsidized nonprofit organizations (85% of personnel), while the remaining 15 percent are nonsubsidized for-profit organizations (SFOS, 2015d). 2 This includes private hospitals that receive public subsidies if the cantonal governments have need of their services to guarantee a sufficient supply for Sweden. The Commonwealth Fund VA-19-0799-D-001742 OS 00003413 SWITZERLAND &h What are the key entities for health system governance? Since health care is largely decentralized, the key entities for health system governance exist mainly at the cantonal level. Each of the 26 cantons has its own elected minister of public health. Supported by their respective cantonal offices of public health, ministers are responsible for licensing providers, coordinating hospital services, subsidizing institutions, and promoting health through disease prevention. Their common political body, the Swiss Conference of the Cantonal Ministers of Public Health, plays an important coordinating role. At the cantonal and the national level, market pressure, i.e., from competition, is felt most by hospitals and by health insurers (OECD, 2011). The main national player is the FOPH, which, among other tasks, supervises the legal application of mandatory SHI, authorizes insurance premiums offered by statutory insurers, and governs statutory coverage (including health technology assessment) and the prices of pharmaceuticals. Other cost-control measures are shared with cantonal and communal governments. The FDHA legally defines the SHI benefits basket. Professional selfregulation has been the traditional approach to quality improvement. Prices for outpatient services are set in the fee-for-service scale TARMED, which defines the relative cost weights of all services covered by SHI on the national level and is authorized by the Swiss Federal Council. TARMED values can vary among cantons and service groups (physicians, outpatient hospital services) as negotiated annually between the health insurers' associations and cantonal provider associations, or are set by cantonal government if the parties cannot agree. For inpatient care, the Swiss national DRG system has been in use since 2012. The nonprofit corporation SwissDRG AG is responsible for defining, developing, and adapting the national system of relative cost weights per case. ~ In addition to the responsibilities of the FOPH and cantonal governments, Health Promotion Switzerland, a nonprofit organization financed by SHI, is legally charged with disease prevention and health promotion programs and provides public information on health. A national ombudsman for health insurance and the Association of Swiss Patients engage in patient advocacy. What are the major strategies to ensure quality of care? Providers must be licensed in order to practice medicine, and are required to meet educational and regulatory standards; continuing medical education for doctors is compulsory. Local quality initiatives, often at the provider level, include the development of clinical pathways, medical peer groups, and consensus guidelines. However, there are no explicit financial incentives for providers to meet quality targets. The Quality Strategy, approved by the SFC at 2009, takes a broad conceptual approach with different fields of action, including the implementation of a national pilot program by the Swiss Foundation for Patient Security on medication safety in acute-care hospitals, a pilot program to reduce hospital infections, and the publication of quality indicators for acute-care hospitals. Quality-control mechanisms usually do not involve information from registries or patient surveys. Registries are organized by private initiatives or cantons, such as the cantonal cancer registries. At the end of 2013, the SFC mandated a task force led by the cantons and the Swiss Confederation (the Dialogue on National Health Policy) to work out a national strategy for the prevention of noncommunicable diseases (NCDs) by 2016. The strategy aims to improve the health competence ofthe population and promote healthy living conditions. The National Health Report (Obsan, 2015) discusses the growing number of case management programs for chronic illnesses. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001743 OS 00003414 SWITZERLAND Organization of the Health System in Switzerland Swiss Federa l Council ---------- i-----------Federa l Department of Home Affairs I I I Federal Office of Public Health FOPH Swiss Agency for Therapeutic Products swissmedic I --- I ! I I Vo luntary Health Insurance ' Corporation SwissDRG AG Institution: National Service Scale TARM EDsuisse I I - -- --- --,- --- --- I Swiss Association of Homes and Institutions 1-- - - - - - - - 1--- - - - - - - Cantona l Associations of Private Hospitals Cantona l Nursing Home Private Hospita ls I Public and Publicly Subsidized Nursing Homes I I I I I Private Nursing Homes I I - .-.-o---L-- -.I -. ---o- .-. I I I Swiss Medical Association FMH Swiss Spitex Association - --- -- -- I - -- -- -- . - T-------- : - - - - - - - r - - - - 1 r--- Private Practitioners ublic and Publicly Subsidized Spitex Organizations I I I I I I I I Other Outpatient Providers 1--------- Cantonal Associations of Other Providers 1-- - - - - - - - Cantonal Spitex Associations I --------- I Swiss Pharmacies Association 1-- - - - - - - - Cantonal Medical Associations Associations I i ! I I I I' ------- ;------------- ' . - . -I -- -_,_I . - . - -- -- . - . - . - . I I I I I i I I : ------- 1-------------7 I' Swiss Private Hospitals Association I I i ' --------- ? -.1 I Public and Publicly Subs idized Hospitals i I 1--------- I Centra l Secretariat Hea lth Insurance Companies Statutory Health Insurance Association of Swiss Hospitals H+ Cantonal Hospita l Associations ------------ --------,-------- Cantona l or Regiona l Associations ~-tio Swiss Conference of Cantona l Health Ministers I ' -----------+------------------- --- --- - --- - I I Swiss Financial Market Supervisory Author ity FINMA I Nationa l Associations of Swiss Health Insurance Companies Communal Departments of Public Health ' I I I Communa l Governments --------------- Cantonal Ministries of Public Hea lth: Health Services, Hea lth Safety, Hea lth Prevention and Promotion Federal Department of Financial Affairs , __ Cantonal Governments ----------------- Cantona l Pharm. Associations I Private Spitex Organizations I ! ! I I Pharmacies and Retailers for Medical Devices I I Physiotherapy, Psychotherapy, Laboratory, etc. I I I I I Source: P. Camenzi nd, Swiss Health Observatory, 20 15 . it-I ~ What is being done to reduce disparities? There are several reasons why health disparities have not attracted as much political and professional interest at the national level as elsewhere: Health inequalities are not considered to be very significant in comparison to other OECD countries; it is difficult to obtain detailed statistical information about the epidemiology of health outcomes; and health inequalities are seen more as the responsibility of cantons, making them less visible at the national level. The Swiss Federal Council's national Health2020 agenda (FDHA, 2013) includes the explicit objective of improving the health opportunities of the most vulnerable population groups, such as children and the young, those on low incomes or with a poor educational background, the elderly, and immigrants. The aim is to prevent vulnerable population groups from being unable to make appropriate use of necessary health care services. Health and health access variations are measured and reported publicly by the Swiss Health Survey (SFOS, 2014) every five years. What is being done to promote delivery system integration and care coordination? Care coordination is an issue, particularly in light of a projected lack of providers in the future and the need to improve efficiency to increase capacity. The task force Dialogue on National Health Policy discusses existing and The Commonwealth Fund VA-19-0799-D-001744 OS 00003415 SWITZERLAND new approaches to care. The national Health2020 agenda includes a comprehensive projection of the priorities of health care policy until the year 2020. The agenda also addresses care coordination, stating that integrated health care models need to be supported in all areas. The FOPH works on concrete measures to confront these challenges. Strategies and networks tackling emerging areas of importance, like palliative care, dementia, and mental health, have been created to improve coordination. They start on a conceptual level, aiming at the practical level to encourage different types of health professionals to work together. A growing number of such programs are in the works, as shown in the National Health Report (Obsan, 2015), but pooled funding streams do not exist yet. It is also worth noting the efforts in the area of e-health (see below), which should considerably improve coordination as well. ~ What is the status of electronic health records? A national e-health service called eHealth Suisse (an administrative unit of the FOPH) is coordinated by the federal and cantonal governments and has three sets of responsibilities. First, all providers in Switzerland should be able to collect and store information on their patients' treatment electronically. Second, health-related websites and online services will be required to undergo quality certification and a national health website will be constructed. Third, necessary legal changes will be made to realize these measures. A key element of eHealth Suisse is the SHI subscription card, which encodes a personal identification number and all necessary administrative data. If allowed by the insured person, information about allergies, illnesses, and medication can be recorded on the card. The insured person also decides who is allowed access to this information (all, selected, or no providers). GP e-health is still at an early stage (Vilpert, 2012), and there are ongoing discussions about incentives for physicians to adopt new technologies. ~ Hospitals are generally more advanced; some have merged their internal clinical systems in recent years and hold interdisciplinary patient files. However, the extent of this integration varies greatly among hospitals and among cantons, despite efforts by eHealth Suisse to convince providers of the benefits of electronic health records for medical practice. An interoperable national patient record is not a priority for eHealth Suisse, since the principles of decentralization, privacy, and data protection are regarded as very important. How are costs contained? Switzerland's health care costs are among the highest in the world. "Regulated competition" (Enthoven, 1993) among nonprofit health insurers and among service providers is aimed at containing costs and guaranteeing high-quality health care, and establishing solidarity among the insured. While most of its objectives are considered successfully achieved, academic analyses (OECD, 2011) and public perception have been critical of competition's ability to control health care costs. A global budget, however, has never been regarded as a possible remedy for this problem. Failures are ascribed largely to inadequate risk equalization, the dual funding of hospitals, and pressure on insurers to contract with all certified providers (OECD, 2011). The costs of providing mandatory benefits in the health system could be reduced by up to 20 percent (FDHA, 2013). An overview of possible cost-reducing measures-in coordination of care, compensating systems, and highly specialized medicine-is part ofthe Health2020 agenda. The agenda outlines a need for increasing flat-rate remuneration mechanisms and revising existing fee schedules to limit incentives for service providers. Also mentioned is the need for greater concentration in sites of highly specialized medicine to eliminate inefficiency and duplication in infrastructure systems and to increase the quality of health care provision. SwissDRG AG was introduced to contain hospital costs. Inpatient capacity is subject to cantonal planning requirements, and there is a "necessity clause for outpatient providers." See also the section on cost-sharing for patient cost-sharing mechanisms. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001745 OS 00003416 SWITZERLAND To control pharmaceutical costs, coverage decisions on all new medicines are subject to evaluation of their effectiveness (by Swissmedic) and cost (by the FOPH). Efforts are being made to reassess more frequently the prices of older drugs. Depending on national market volume, generics must be sold for 20 to 50 percent less than the original brand. In addition to the aforementioned 20 percent coinsurance for brand-name drugs, ~ pharmacists are paid flat amounts for prescriptions, so they have no financial incentive to dispense more expensive drugs. What major innovations and reforms have been introduced? As discussed throughout this profile, the Health2020 agenda outlines important national topics, objectives, and measures for improving quality of life, promoting equal opportunity and self-responsibility, ensuring and enhancing quality of care, and creating more transparency, better governance, and more coordination. In concrete terms, the SFC realized the following nine priorities in 2014 (SFC, 2015): o Adoption of the message (i.e., official explaining text of SFC) concerning the federal law of cancer registries (implementation date of law: not before 2018; o Submission for public consultation of the preliminary draft of a federal law concerning a national health quality institute in SHI (new proposal made by the Swiss Federal Council, with open date for implementation); o Submission for public consultation of a partial revision of the federal law on SHI concerning better control of the outpatient sector, more control of health care cost, and better assurance of health care quality (implementation date of law: mid-2016); o Submission for public consultation of the preliminary draft of a federal law concerning non-ionizing radiation and sound waves (implementation date of law: open); o Submission for public consultation of the preliminary draft of a federal law concerning tobacco products (implementation date of law: open); o Adoption of regulation on the adjustments oftariff structures in SHI (regulation introduced: October 2014); o Adoption of the results of a public consultation on the federal law concerning health professionals (implementation date of law: open); o Adoption of the results of a report on the current state of and need for action to support caring relatives; o Recognition of the results of the new constitutional article concerning primary health care and plans to enact it (implementation date: open). The Swiss Health Observatory (Obsan) is currently creating an indicator system to evaluate the effects of all measures proposed by the Health2020 agenda. The author would like to acknowledge David Squires as a contributing author to earlier versions of this profile. The Commonwealth Fund VA-19-0799-D-001746 OS 00003417 SWITZERLAND References Enthoven, A.C. (1993). "The History and Principles of Managed Competition." Health Affairs, 12, no.suppl 1 (1993):24-48. DOI: 10.1377 /hlthaff.12.suppl_ 1.24. Kunzi, K., and S. Strub. (2012). "Einkommen der Arzteschaft in freier Praxis: Auswertung der Medisuisse-Daten 2009." Schweizerische Arztezeitung, 93: 38:1371-75. Hostettler, S., and E. Kraf. (2015). FMH-Arztestatistik 2014: "Frauen- und Auslanderanteil nehmen kontinuierlich zu." Schweizerische Arztezeitung 96(13):462-69. Organisation for Economic Co-operation and Development (2015). OECD.Stat. DOI: 10.1787 /data-00285-en. Accessed July 2, 2015. Organisation for Economic Co-operation and Development. OECD (2011 ). Reviews of Health Systems: Switzerland. Paris: OECD. Swiss Conference of Cantonal Health Ministers (2015a). Online publication: http://www.gdk-cds.ch/fileadmin/docs/publid gdk/themen/krankenversicherung/praemienverbilligung/ipv_2015_df_def.pdf. Swiss Conference of Cantonal Health Ministers (20156). Online publication. http://www.gdk-cds.ch/index.php?id=942. Swiss Federal Council. SFC (2015). "Gesundheit2020: zehn prioritaten fur 2015." Pressemitteilung vom 25.03.2015, Bern. Swiss Federal Department of Home Affairs FDHA (2013). The Federal Council's Health-Policy Priorities. Online publication: http://www.bag.admin.ch/gesundheit2020/index.html?lang=en . Swiss Federal Office of Public Health (FOPH) (2014). Statistik der obligatorischen Krankenversicherung 2013. Bern: BAG, Sektion Datenmanagement und Statistik. Swiss Federal Office of Statistics (SFOS) (2014). Schweizerische Gesundheitsbefragung 2012-Standardtabellen 2012. Swiss Federal Office of Statistics (SFOS) (2015a). Statistik der Kosten und Finanzierung des Gesundheitswesens 2013. Swiss Federal Office of Statistics (SFOS) (20156). Krankenhausstatistik 2013-Standardtabellen 2013. Swiss Federal Office of Statistics (SFOS) (2015c). Statistik der sozialmedizinischen lnstitutionen 2013-Standardtabellen 2013. Swiss Federal Office of Statistics (SFOS) (2015d). Statistik der Hilfe und Pflege zu Hause 2013-Spitex-Statistik 2013. Swiss Health Observatory (Obsan) (2015). National Health Report 2015. Hogrefe Verlag, Bern. Vilpert, S. (2012). Medecins de premier recours-Situation en Suisse et comparaison internationale. Obsan Dossier 22, Schweizerisches Gesundheitsobservatorium, Neuchatel. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001747 OS 00003418 ~ ~ What is the role of government? The Affordable Care Act (ACA), enacted in 2010, established "shared responsibility" between the government, employers, and individuals for ensuring that all Americans have access to affordable and good-quality health insurance. However, health coverage remains fragmented, with numerous private and public sources as well as wide gaps in insured rates across the U.S. population. The Centers for Medicare and Medicaid Services (CMS) administers Medicare, a federal program for adults age 65 and older and people with disabilities, and works in partnership with state governments to administer both Medicaid and the Children's Health Insurance Program, a conglomeration offederal-state programs for certain low-income populations. Private insurance is regulated mostly at the state level. In 2014, state- and federally administered health insurance marketplaces were established to provide additional access to private insurance coverage, with income-based premium subsidies for low- and middle-income people. In addition, states were given the option of participating in a federally subsidized expansion of Medicaid eligibility. P;t: Who is covered and how is insurance financed? In 2014, about 66 percent of U.S. residents received health insurance coverage from private voluntary health insurance (VHI): 55.4 percent received employer-provided insurance, and 14.6 percent acquired coverage directly. 1 Public programs covered roughly 36.5 percent of residents: Medicare covered 16 percent, Medicaid 19.5 percent, and military health care insurance 4.5 percent (U.S. Census Bureau, 2014). In 2014, 33 million individuals were uninsured, representing 10.4 percent ofthe population (U.S. Census Bureau, 2014). The implementation ofthe AC,t,:.s major coverage expansions in January 2014, however, has increased the share of the population with insurance. These reforms include: the requirement that most Americans procure health insurance; the opening of the health insurance marketplaces, or exchanges, which offer premium subsidies to lower- and middle-income individuals; and the expansion of Medicaid in many states, which increased coverage for low-income adults. According to one survey, the rate of uninsurance among working-age adults fell by 7 percentage points between March 2015 and September 2013 (Collins et al., 2015); another survey found that 17.6 million previously uninsured people have acquired health insurance coverage (ASPE, 2015a). It is projected that the ACA will reduce the number of uninsured by 24 million by 2018 (CBO, 2015). Public programs provide coverage to various, often overlapping populations. In 2011, nearly 10 million Americans were eligible for both Medicare and Medicaid (the "dual eligibles") (Henry J. Kaiser Family Foundation, 2015a). The Children's Health Insurance Program (CHIP), which in some states is an extension of Medicaid and in others a separate program, covered more than 8.1 million children in low-income families in 2014 (Medicaid.gov, 2014). Undocumented immigrants are generally ineligible for public coverage, and nearly two-thirds are uninsured. Hospitals that accept Medicare funds (which are the vast majority) must provide care to stabilize any patient with an emergency medical condition, and several states allow undocumented immigrants to qualify for emergency Medicaid coverage beyond "stabilization" care. Some state and local governments provide additional coverage, such as coverage for undocumented children or pregnant women. 1 Estimates by type of coverage are not mutually exclusive; people can be covered by more than one type of health insurance during the year. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001749 OS 00003420 UNITED STATES What is covered? Services: The ACA requires all health plans offered in the individual insurance market and small-group market (for firms with 50 or fewer employees) to cover services in 10 essential health benefit categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health services and substance use disorder treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including dental and vision care. Each state determines the range and extent of specific services covered under each category by selecting a benchmark plan that covers all 10 categories; most states choose one ofthe largest small-group plans as the benchmark. Specific covered services vary somewhat by state. Private insurance plans sometimes use narrow networks of providers, with limited or no coverage if patients receive out-of-network care. Private coverage for dental care and optometry is also available-sometimes through separate policies-as is long-term care insurance. Private health insurance is required to cover certain preventive services (with no cost-sharing if provided in network). Medicare provides coverage for hospitalization, physician services, and, through a voluntary supplementary program, prescription drug coverage. The program also has eliminated cost-sharing for a number of preventive services. Medicare offers a choice between "traditional" Medicare, which is open-network and pays predominately on a fee-for-service basis, and Medicare Advantage, under which the federal government pays a private insurer for a network-based plan. Medicare covers postacute care but not long-term care, while Medicaid offers more extensive long-term care coverage (see below). In addition, Medicaid covers a broad range of core services, including hospitalization and physician services, with certain optional benefits varying by state. Cost-sharing and out-of-pocket spending: Cost-sharing provisions in private health insurance plans vary widely, with most requiring copayments for physician visits, hospital services, and prescription drugs. Highdeductible health plans-those with a minimum annual deductible of $1,250 per individual or $2,500 per family-can be paired with tax-advantaged health savings accounts (i.e., deposited funds are not subject to federal income tax). The ACA includes cost-sharing subsidies for the purchase of plans through the insurance exchanges, with the largest subsidies aimed at people with incomes below 250 percent of the federal poverty level (FPL) (the FPL is $20,090 for a family ofthree, as of 2015) (ASPE, 20156). Medicare requires deductibles for hospital stays and ambulatory care and copayments for physician visits and other services, while Medicaid requires minimal cost-sharing. Most public and private insurers prohibit providers from balance billing-charging patients more than the copayment required by their insurance plan-if they have an agreement with the payer to accept their set or negotiated payment amounts. Out-of-pocket spending accounts for 12 percent oftotal health expenditures in the U.S. (OECD, 2015). The ACA caps cost-sharing for most private insurance plans at $6,600 for individuals and $13,200 for families per year in 2015 (Healthcare.gov, 2015). Safety nets: A variable and patchwork mix of organizations and programs deliver care for uninsured, lowincome, and vulnerable patients in the United States, including public hospitals, local health departments, free clinics, Medicaid, and CHIP. Under the ACA, 30 states and the District of Columbia have expanded Medicaid coverage to cover individuals with incomes up to 138 percent of FPL (Commonwealth Fund, 2015), and premium and cost-sharing subsidies are now available to low- and middle-income individuals through the insurance exchanges (plan premium subsidies for incomes of 133%-400% of FPL; cost-sharing subsidies for incomes of 100%-250% of FPL). Hospitals that provide care to a high percentage of low-income and uninsured patients receive disproportionate share hospital (DSH) payments from Medicare and Medicaid to partially offset their uncompensated care; however, these payments are being substantially reduced as the ACA reduces the number of the uninsured. The federal government also funds community health centers, which provide a major source of primary care for underserved and uninsured populations. In addition, private providers are a significant source of charity and uncompensated care. The Commonwealth Fund VA-19-0799-D-001750 OS 00003421 UNITED STATES [ (R)] How is the delivery system organized and financed? Publicly financed health care: In 2013, public spending accounted for about 48 percent of total health care spending, although this figure is expected to increase post-ACA (OECD, 2015). Medicare is financed through a combination of payroll taxes, premiums, and federal general revenues. Medicaid is tax-funded and administered by the states, which operate the program within broad federal guidelines. States receive matching funds from the federal government for Medicaid at rates that vary based on their per-capita income-in 2014, federal matching ranged from 50 percent to 73 percent of states' Medicaid expenditures (ASPE, 2014). The expansion of Medicaid under the ACA is fully funded by the federal government through 2017, after which the government's funding share will be phased down to 90 percent by 2020. Federal premium subsidies on the exchanges are offered as tax credits. Privately financed health care: In 2013, private health insurance spending accounted for about 33 percent oftotal health care spending (CMS, 2015a). Private insurers, which can be for-profit or nonprofit, are regulated by state insurance commissioners and subject to varying state (and federal) regulations. Private health insurance can be purchased by individuals but is usually funded by voluntary, tax-exempt premiums, the cost of which is shared by employers and workers on an employer-specific basis, sometimes varying by type of employee. The employer tax exemption is the government's third-largest health care expenditure (after Medicare and Medicaid), reducing tax revenues by $260 billion per year (NBER, 2014). Some individuals are covered by both public and private health insurance. For example, many Medicare beneficiaries purchase private supplemental Medigap policies to cover additional services and cost-sharing. Private insurers, in general, pay providers at rates higher than those paid by public programs, particularly Medicaid. This disparity leads to wide variations in provider payment rates and revenues, which depend to a large extent on payer mix and market power. Medicare's payment rates are typically determined according to a fee schedule, with various adjustments based on cost of living and other local and provider characteristics. Medicaid rates vary by state. Private health insurers typically negotiate payment rates with providers. Primary care: Primary care physicians account for roughly one-third of all U.S. doctors. The majority operate in small self- or group-owned practices with fewer than five full-time-equivalent physicians, although larger practices are becoming increasingly common. Practices-particularly large ones-often include nurses and other clinical staff, who are usually paid a salary by the practice. Patients generally have free choice of doctor, at least among in-network providers, and are usually not required to register with a primary care practice, depending on their insurance plan. Primary care doctors have no formal gatekeeping function, except within some managed care plans. Physicians are paid through a combination of methods, including negotiated fees (private insurance), capitation (private insurance), and administratively set fees (public insurance). Physicians also can receive financial incentives, made available by some private insurers and public programs like Medicare, based on various quality and cost performance criteria. Insured patients are generally directly responsible for some portion of physician payment, and uninsured patients are nominally responsible for all or part of physicians' charges, although those charges can be reduced or waived. Outpatient specialist care: Specialists can work in both private practice and hospitals. Some insurance plans (such as health maintenance organizations, or HMOs) require a referral by a primary care doctor to see a specialist, and limit patients' choice of specialist, while other plans (such as preferred provider organizations, or PPOs) allow patients broader and direct access. Access to specialists can be particularly difficult for Medicaid beneficiaries and the uninsured, as some specialists refuse to accept Medicaid patients owing to low reimbursement rates, and because safety-net programs for specialist care are limited. Like primary care physicians, specialists are paid through negotiated fees, capitation, and administratively set fees, and are typically not allowed to bill above the fee schedule for services offered in-network. Multispecialty and singlespecialty groups are increasingly common. Specialists can see patients with either public or private insurance. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001751 OS 00003422 UNITED STATES Administrative mechanisms for paying primary care doctors and specialists: Copayments for doctor visits are typically paid at the time of service or are billed to the patient afterward. Some insurance plans and products (including health savings accounts) require patients to submit claims to receive reimbursement. Providers bill insurers by coding the services rendered; this process can be very time-consuming, as there are thousands of codes. After-hours care: After-hours access to primary care is limited (39% of primary care doctors in 2015 reported having after-hours care arrangements) (Osborn et al., 2015), with such care often being provided by hospital emergency departments. As of 2007, there were between 12,000 and 20,000 urgent-care centers in the U.S. providing walk-in after-hours care. Most urgent-care centers are independently owned by physicians, while about 25 percent are owned by hospitals (Rice et al., 2013). Some insurance companies make after-hours telephone advice lines available. Hospitals: Hospitals can be nonprofit (approximately 70% of beds nationally), for-profit (15% of beds), or public (15% of beds). Public hospitals can serve private patients. Hospitals are paid through a combination of methods, including per-service or per-diem charges, per-case payments, and bundled payment, in which case the hospital may be financially accountable for readmissions and services rendered by other providers. Some hospital-based physicians are salaried hospital employees, but most are paid on some form of fee-for-service basis-physician payment is not included in Medicare's diagnosis-related group (DRG) payments. Hospitalists are increasingly common and now present in a majority of hospitals. Mental health care: Mental health care is provided by a mix of for-profit and nonprofit providers and professionals-including psychiatrists, psychologists, social workers, and nurses-and paid for through a variety of methods that vary by provider type and payer. Most insurance plans cover inpatient hospitalization, outpatient treatment, emergency care, and prescription drugs; other benefits may include case management and peer support services. The Affordable Care Act aimed to improve access to mental health care by establishing it as an essential health benefit (see above), applying federal parity rules to ensure that coverage is comparable, and increasing access to health insurance more generally. Long-term care and social supports: Long-term care is provided by a mix of for-profit and nonprofit providers, and paid for through a variety of methods that vary by provider type and payer. Medicaid, but not Medicare, offers the most extensive coverage of long-term care, although it varies from state to state (within federal eligibility and coverage requirements). Since Medicaid is a means-tested program, patients must often "spend down" their assets to qualify for long-term care assistance. However, hospice care is included as a Medicare benefit, as are skilled short-term nursing services and nursing home stays of up to 100 days. Long-term care insurance that offers comprehensive care is available but rare. Most certified nursing facilities are for-profit (69%), while 24 percent are nonprofit and 6 percent are government-owned (Henry J. Kaiser Family Foundation, 20156). Caregiver support programs and personal health budgets-such as cash and counseling programs in Medicaid-are available in some states to support caregivers and recipients of home-based care. Some of these programs allow recipients to employ family members. However, most informal and family caregivers do not receive payment or benefits for their work. &h What are the key entities for health system governance? The Department of Health and Human Services (HHS) is the federal government's principal agency involved with health care services. Organizations that fall within HHS include the: o Centers for Medicare and Medicaid Services: o Centers for Disease Control and Prevention, which conducts research and programs to protect public health and safety; The Commonwealth Fund VA-19-0799-D-001752 OS 00003423 UNITED STATES o National Institutes of Health, which is responsible for biomedical and health-related research; o Health Resources and Services Administration, which supports efforts to improve health care access for people who are uninsured, isolated, or medically vulnerable; o Agency for Healthcare Research and Quality, which conducts evidence-based research on practices, outcomes, effectiveness, clinical guidelines, safety, patient experience, health information technology, and health disparities; o Food and Drug Administration, which is responsible for promoting public health through the regulation of food, tobacco products, pharmaceutical drugs, medical devices, and vaccines, among other products; o Center for Medicare and Medicaid Innovation, an agency within CMS that was created by the Affordable Care Act to test and disseminate promising payment and service delivery models designed to reduce spending while preserving or improving quality; and o Patient-Centered Outcomes Research Institute, also created by the ACA, which is tasked with setting national clinical comparative-effectiveness research priorities and managing research on a broad array of topics related to illness and injury. Organization of the Health System in the United States Public Financing Federal government State government I I I_______________________________ Private Financing Privately insured individuals --------------------------------- ------ 1 I I I I I I I I I I Department of Health & Human Services (HHS) Selected other HHS agencies: o-' Employers o CDC o NIH o--- Marketplaces o HRSA Centers for Medicare & Medicaid Services o AHRQ o FDA Other government insurance programs o----~ Private insurance Medicare I I I I I I I I I o Providers (e.g. hospitals, physicians, long term care institutions, mental health institutions, pharmacies) o o Nongovernmental scientific and professional organizations (IOM, AMA, PCORI, etc.) Provider regulatory organizations (Joint Commission, etc.) I I I I - - Hierarchial - - Contracts -? Regulation Source: Adapted from T. Rice, P. Rosenau, L. Y Unruh et a l., "Un ited States of Ameri ca: Health Syst em Review," Health Systems in Transition, vol. 15, no. 3, 2013, p. 27 . International Profiles of Health Care Systems, 2015 VA-19-0799-D-001753 OS 00003424 UNITED STATES The Institute of Medicine (IOM), an independent nonprofit organization that works outside of government, acts as an adviser to policymakers and the private sector on improving the nation's health. Stakeholder associations (e.g., the American Medical Association) comment on and lobby for policies affecting the health system. The independent, nonprofit Joint Commission accredits more than 20,000 health care organizations across the country, primarily hospitals, long-term care facilities, and laboratories, using criteria that include patient treatment, governance, culture, performance, and quality improvement. The National Committee for Quality Assurance, the primary accreditor of private health plans, is responsible for accrediting the plans participating ~ in the newly created health insurance marketplaces. The nonprofit National Quality Forum builds consensus on national performance priorities and on standards for performance measurement and public reporting. The American Board of Medical Specialties and the American Board of Internal Medicine provide certification to physicians who meet specified standards of quality. What are the major strategies to ensure quality of care? In 2011, the Department of Health and Human Services released the National Quality Strategy, a component of the ACA that lays out national aims and priorities to guide local, state, and national quality improvement efforts, supported by an array of partnerships with public and private stakeholders. Current initiatives include efforts to reduce hospital-acquired infections and preventable readmissions (see below). CMS has moved toward increased public reporting of provider performance data in an effort to promote improvement. One such initiative is Hospital Compare, a service that reports on measures of care processes, care outcomes, and patient experience at more than 4,000 hospitals. In additional, with support from the ACA and such groups as the Open Government Partnership, CMS is making Medicare data available to "qualified entities," such as health improvement organizations, which are beginning to release data on payments made by Medicare to individual physicians and amounts paid to physicians and hospitals by pharmaceutical and device companies. Release of such information is intended to both increase transparency and improve quality. States have developed additional public reporting systems and measures, including some that address ambulatory care. Consumer-led groups, such as Consumers Union and the Leapfrog Group, also report on quality and safety. Incentives to reduce avoidable hospital readmissions among Medicare patients were introduced in October 2012, by way of financial penalties. Since the program's initiation, 20-day readmission rates nationally have declined from 19 percent to less than 18 percent (Blumenthal et al., 2015). Incentives to reduce hospitalacquired conditions, by reducing Medicare payments to the lowest-performing hospitals by 1 percent, were also introduced. Recent data show the first-ever decline in rates of hospital-acquired conditions nationally (Blumenthal et al., 2015). Finally, Medicare, and the majority of private insurance providers, is implementing a variety of pay-for-value programs. Starting in 2013, 1 percent of Medicare payments are redistributed to the highest performers on a composite of cost and quality measures. The program was introduced to physicians in 2015 on a voluntary basis and is expected to become mandatory by 2017. As yet, results are too preliminary to draw conclusions (Blumenthal et al., 2015). The Commonwealth Fund VA-19-0799-D-001754 OS 00003425 UNITED STATES t:] What is being done to reduce disparities? There are wide disparities in the accessibility and quality of health care in the U.S. Since 2003, the annual National Healthcare Disparities Report, released by the Agency for Healthcare Research and Quality, has documented disparities among racial, ethnic, income, and other demographic groups and highlighted priority areas requiring action. Federally qualified health centers (FQHCs), which are eligible for certain types of public reimbursement, provide comprehensive primary and preventive care regardless of their patients' ability to pay. Initially created to provide health care to underserved and vulnerable populations, FQHCs largely provide safety-net services to the uninsured. Medicaid and CHIP provide public health insurance coverage for certain low-income populations. In addition, the ACA contains a number of provisions aimed at reducing disparities: subsidies to enable low-income Americans to purchase insurance through the exchanges; efforts to achieve parity for mental health care and substance abuse services; and additional funding to community health centers located in underserved communities. There are also a multitude of public and private initiatives at the local and state levels. (R)-0- What is being done to promote delivery system integration and "-.:::,I care coordination? Both the government and private insurance companies are leading efforts to move away from the currently specialist-focused health system to a system founded on primary care. In particular, the "patient-centered medical home" model, with its emphasis on care continuity and coordination, has aroused interest among U.S. experts and policymakers as a means of strengthening primary care and linking medical services more closely to community services and supports. Another trend is the proliferation of accountable care organizations (ACOs), networks of providers that assume contractual responsibility for providing a defined population with care that meets quality targets. Providers in ACOs share in the savings that constitute the difference between forecasted and actual health care spending. More than 700 ACOs have been launched by public programs and private insurers, and more than 23.5 million Americans are enrolled in one (Muhlestein, 2015). Two Medicare-driven ACO programs have been rolled outthe Medicare Shared Savings Program (MSSP) and the Pioneer ACO Program, which together encompass more than 420 ACOs servicing 14 percent ofthe Medicare population, or 7.8 million Americans (Muhlestein, 2015; CMS, 20156). Patients have reported better care experiences, quality measures have generally improved for the tracked indicators, and modest savings have been achieved (Blumenthal et al., 2015). Medicare, Medicaid, and private purchasers, including employer groups, are also experimenting with new payment incentives that reward higher-quality, more efficient care. One strategy is "bundled payments," where a single payment is made for all the services delivered by multiple providers for a single episode of care. About 7,000 hospitals, physician organizations, and postacute care providers participate in bundled payment initiatives (Blumenthal et al., 2015). ~ In addition, CMS has supported the development of local programs that aim to better integrate health and social services. Among these is Massachusetts General Hospital's Care Management Program, where nurse case managers work closely with Medicare patients who have serious chronic conditions to help coordinate their medical and social care. Medicaid ACOs also are implementing programs to integrate primary care and behavioral health services. Some ACOs are not only trying to integrate clinical and social services but also exploring innovative financing models, such as cross-sectoral shared-savings models. What is the status of electronic health records? The 2009 American Recovery and Reinvestment Act led to significant investment (more than $30 billion) in health information technology. The legislation established financial incentives for physicians and hospitals to adopt electronic health record (EHR) systems, under what is known as the Meaningful Use Incentive Program. As of 2014, 83 percent of physicians used some form of EHR system, and three of four (76%) hospitals had International Profiles of Health Care Systems, 2015 VA-19-0799-D-001755 OS 00003426 UNITED STATES adopted at least a basic EHR system, representing an eightfold increase since 2008 (Heisey-Grove and Patel, 2015; Charles et al., 2015). The Meaningful Use Incentive Program is designed to gradually raise the threshold for EHR functionality above which providers receive incentives and avoid penalties. The current focus is on information exchange. ~ How are costs contained? Annual per capita health expenditures in the United States are the highest in the world ($9,086 in 2013), despite a recent slowdown in spending (OECD, 2015). Payers have attempted to control cost growth through a combination of selective provider contracting, price negotiations and controls, utilization control practices, risksharing payment methods, and managed care. Recently, both public and private payers have focused more attention on value-based purchasing and other models that reward effective and efficient health care delivery. A movement toward favoring generic drugs over brand-name drugs, meanwhile, has led to a slowdown in pharmaceutical spending in recent years, although growth rebounded in 2014. Another growing trend is the increase in private insurance plans with high deductibles. A number of reforms included in the ACA attempt to develop payment methods in the Medicare and Medicaid programs that reward high-quality, efficient care. Some of these use pay-for-performance mechanisms, whereas others rely on bundled payments, shared savings, or global budgets to incentivize integration and coordination among health care providers. Despite a recent slowdown in health care spending, the latest data, through August 2015, show that spending grew 5. 7 percent in the past year (Alta rum Institute, 2015). G '?i What major innovations and reforms have been introduced? The Affordable Care Act, which ushered in a sweeping series of insurance and health system reforms aimed at achieving near-universal coverage, improved affordability, higher quality, greater efficiency, lower costs, strengthened primary and preventive care, and expanded community resources, has survived. There have been modifications to the law, however, as a result of several Supreme Court decisions since 2010. Perhaps most notable was the 2012 ruling that made the expansion of Medicaid optional for states: because of that decision, only 30 of 50 states (in addition to the District of Columbia) have pursued expansion as of late 2015. Still, since implementation of the ACA in 2013, the number of uninsured adults has declined by historic proportions (Collins et al., 2015). Groups that have been long been at greatest risk of being uninsured-young adults, Hispanics, blacks, and those with low income-have made the greatest coverage gains (Blumenthal et al., 2015). In 2015, the Department of Health and Human Services announced a goal to move 50 percent of Medicare payments to alternative payment models, including ACO-based arrangements, by 2018 (Blumenthal et al., 2015; Muhlestein, 2015). Medicare also has begun paying for doctors to coordinate the care of patients with chronic conditions. To be eligible for an extra $40 per patient, doctors must draft and help carry out a comprehensive plan of care for each patient who signs up for one. Under federal rules, those patients have access to doctors or other health care providers on a doctor's staff 24 hours a day, seven days a week, to deal with "urgent chronic care needs" (Edwards and Landon, 2014). In April 2015, the Senate passed the Medicare "doc fix," averting an imminent cut in Medicare physician fees that was scheduled to occur under the now-repealed sustainable growth rate (SGR) formula. While the SGR was designed to counter the tendency toward spending growth inherent in the fee-for-service model, it was a flawed model. It was replaced by an approach focusing on rewarding high-performing providers and supporting alternative payment models (Guterman, 2015). The Commonwealth Fund VA-19-0799-D-001756 OS 00003427 UNITED STATES References Altarum Institute (2015). "Health Sector Economic Indicators-Insights from Monthly National Health Spending Data Through August 2015," Oct. 2015. http://altarum.org/sites/default/files/uploaded-related-files/CSHS-Spending-Brief_ October_2015_0.pdf. Assistant Secretary for Planning and Evaluation (ASPE) (2014). ASPE Federal Medical Assistance Percentages (FMAP) 2014 Re port, https:// aspe. h hs. gov/basic-re port/fy2014-federa 1-medi ca 1-assista nce-pe rce ntages. Assistant Secretary for Planning and Evaluation (ASPE) (2015a). Health Insurance Coverage and the Affordable Care Act. Assistant Secretary for Planning and Evaluation (ASPE) (20156). U.S. Federal Poverty Guidelines Used to Determine Financial Eligibility for Certain Federal Programs. http://aspe.hhs.gov/2015-poverty-guidelines. Blumenthal, D., M. K. Abrams, R. Nuzum (2015). "The Affordable Care Act at Five Years." New England Journal of Medicine, Online First, May 6, 2015, http://www.commonwealthfund.org/publications/in-brief/2015/may/affordable-care-act-at-five. Centers for Medicare and Medicaid Services (CMS) (2015a). National Health Expenditure Data, https://www.cms.gov/ research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html. Centers for Medicare and Medicaid Services (CMS) (20156). https://www.cms.gov/Newsroom/MediaReleaseDatabase/Pressreleases/2015-Press-releases-items/2015-08-25.html. Charles, D., Gabriel, M., Searcy, T. "Adoption of Electronic Health Record Systems among U.S. NonFederal Acute Care Hospitals: 2008-2014," ONC Data Brief No. 23, April 2015, https://www.healthit.gov/sites/default/files/data-brief/2014Hospi talAdoptionDataBrief.pdf. Collins, S. R., P. W. Rasmussen, M. M. Doty, S. Beutel (2015). Americans' Experiences with Marketplace and Medicaid Coverage-Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March-May 2015. New York: The Commonwealth Fund. Commonwealth Fund (2015). Medicaid Expansion Map. http://www.commonwealthfund.org/interactives-and-data/mapsand-data/medicaid-expansion-map. Congressional Budget Office (CBO) (2015). Insurance Coverage Provisions of the Affordable Care Act-CBO's March 2015 Baseline, https://www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2015-03-ACAtables.pdf. Edwards, S. T., B. E. Landon (2014). "Medicare's Chronic Care Management Payment-Payment Reform for Primary Care." New England Journal of Medicine 371 (22):2049-51. http://www.nejm.org/doi/full/10.1056/NEJMp1410790. Guterman, S. (2015). "With SGR Repeal, Now We Can Proceed with Medicare Payment Reform. Commonwealth Fund Blog, April 15, 2015. http://www.commonwealthfund.org/publications/blog/2015/apr/repealing-the-sgr. Healthcare.gov (2015). Out-of-pocket maximum/limit. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/. Heisey-Grove, D., Patel, V. "Any, Certified and Basic: Quantifying Physician HER Adoption Through 2014," ONC Data Brief No. 28, Sept. 2015. https://www.healthit.gov/sites/default/files/briefs/oncdatabrief28_certified_vs_basic.pdf. Henry J. Kaiser Family Foundation (2015a). Number of Dual Eligible Beneficiaries, http://kff.org/medicare/state-indicator/ dual-eligible-beneficiaries/. Henry J. Kaiser Family Foundation (20156). Distribution of Certified Nursing Facilities by Ownership Type, http://kff.org/ other/state-indicator/nursing-facilities-by-ownership-type/. Medicaid.gov (2014). FY 2014 Unduplicated Number of Children Ever Enrolled in Medicaid and CHIP. http://medicaid.gov/ chip/downloads/fy-2014-childrens-enrollment-report.pdf. Muhlestein, D. (2015). "Growth and Dispersion of Accountable Care Organizations in 2015." Health Affairs Blog, March 31, 2015. http://hea lthaffa irs.org/blog/2015/03/31 / growth-a nd-dispersion-of-accou nta ble-ca re-organ izations-i n-2015-2/. National Bureau of Economic Research (NBER) (2014). Tax Breaks for Employer-Sponsored Health Insurance. Organisation for Economic Co-operation and Development (OECD) (2015). Health Data. Osborn, R., D. Moulds, E. C. Schneider, M. M. Doty, D. Squires, D. 0. Sarnak (2015). "Primary Care Physicians in Ten Countries Report Challenges Caring for Patients with Complex Health Needs." Health Affairs 34(12):2104-2112. Rice, T., P., Rosenau, L. Y., Unruh et al. "United States of America: Health System Review," Health Systems in Transition, 2013 15(3):1-431. U.S. Census Bureau (2014). Health Insurance Coverage in the United States: 2014 -Current Population Reports. http://www. census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf. International Profiles of Health Care Systems, 2015 VA-19-0799-D-001757 OS 00003428 The COMMONWEALTH FUND 1 East 75th Street New York, NY 10021 Tel: 212 .606.3800 1150 17th Street NW Suite 600 Washington, DC 20036 Tel: 202.292.6700 VA-19-0799-D-001758 DS_00003429 Message From: Sent: To: Subject: Ok- David shulkin [Drshulkin@aol.com] 3/28/2017 6:06:24 PM Darin Selnick [(b) (6) @gmail.com] Re: WH Detail it is funny to me that she is so desperate Sent from my iPhone > on Mar 28, 2017, at 1:24 PM, Darin selnick <(b) (6) > > I @gmail.com> wrote: received a call last night from (b) (6) she was shocked that I did not want to go work at the I said yes, Dr. shulkin was correct that I did not want to do a detail at the WH and wanted to know why. WH. > (b) (6) told me that she talked to you on Monday, and although reluctant was now ok with me doing a 1 year detail at WH DPC to be in charge of all veterans policy. > > Although I was reluctant to discuss it, I agreed to meet with her later this week to talk about it. told her I would not make a decision until after I talked to you about it and that I have big reservations about leaving VA, even for this detail. I > an email requesting a 1 on 1 with you either Friday or next Monday, after I have a chance > I sent (b) (6) to hear their whole pitch. she seemed desperate, but there is a lot of important work going on here. > > Darin VA-19-0799-D-001759 OS 00003430 Message From: Darin Selnick [(b) (6) Sent: 3/28/2017 5:24:59 PM To: David shulkin [Drshulkin@aol.com] WH Detail Subject: @gmail.com] I received a call last night from (b) (6) She was shocked that I did not want to go work at the WH and wanted to know why. I said yes, Dr. Shulkin was correct that I did not want to do a detail at the WH. (b) (6) told me that she talked to you on Monday, and although reluctant was now ok with me doing a 1 year detail at WH DPC to be in charge of all veterans policy. Although I was reluctant to discuss it, I agreed to meet with her later this week to talk about it. I told her I would not make a decision until after I talked to you about it and that I have big reservations about leaving VA, even for this detail. I sent (b) (6) an email requesting a 1 on 1 with you either Friday or next Monday, after I have a chance to hear their whole pitch. She seemed desperate, but there is a lot of important work going on here. Darin VA-19-0799-D-001760 OS 00003431 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/6/2017 5:17:45 PM Poonam Alaigh [(b) (6) hotmail.com] Re: can you pass this on? Funny Sent from my iPhone On Apr 6, 2017, at 12:58 PM, Poonam Alaigh <(b) (6) hotmail.com > wrote: How the tide as turned!! Boomerang!! Sent from my iPad Begin forwarded message: From: (b) (6) <(b) (6) evergreenpr.com > Date: April 6, 2017 at 12:53:32 PM EDT To: Poonam Alaigh <(b) (6) hotmail.com > Subject: can you pass this on? Can you let David know the NY Times is doing a profile of him and interviewed me? If he wants details, happy to share (b) (6) Follow Me on Twitter! @(b) (6) 51 Mt. Bethel Road Warren, NJ 07059 Tel: 908-322-(b) (6) www.evergreenpr.com VA-19-0799-D-001761 OS 00003432 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/6/2017 4:58:08 PM Drshulkin@aol.com Fwd: can you pass this on? How the tide as turned!! Boomerang!! Sent from my iPad Begin forwarded message: From: (b) (6) <(b) (6) evergreenpr.com > Date: April 6, 2017 at 12:53:32 PM EDT To: Poonam Alaigh <(b) (6) hotmail.com > Subject: can you pass this on? Can you let David know the NY Times is doing a profile of him and interviewed me? If he wants details, happy to share (b) (6) Follow Me on Twitter! @(b) (6) 51 Mt. Bethel Road Warren, NJ 07059 Tel: 908-322-(b) (6) rgr n Partn In . VA-19-0799-D-001762 OS 00003433 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/5/2017 9:53:21 AM David shulkin [Drshulkin@aol.com] Re: Possible Prob with choice Reauthorization That's an interesting development- CVA is supporting you. I agree that it still passes though didn't have an attachment in your email Sent from my iPad On Apr 4, 2017, at 10:03 PM, David shulkin wrote: Wow - always interesting Lets see how the vote goes- i still think it passes - but we will see Please let Dan know I truly appreciate his support David Sent from my iPhone On Apr 4, 2017, at 9:29 PM, Darin Selnick <(b) (6) @gmail.com> wrote: I thought you should see this development that Dan from CVA sent me. It is being circulated by the House budget committee chairwomen legislative director. CVA is supporting you and opposing this letter. Darin ---------- Forwarded message ---------From: Dan Caldwell Date: Tue, Apr 4, 2017 at 6:03 PM Subject: Possible Prob with choice Reauthorization @gmail.com> To: Darin Selnick <(b) (6) This document is being circulated by the budget committee chairwoman legislative director. As you can see, there are a lot of incorrect facts in it. However this is getting sent around far and wide and may cause issues tomorrow. VA-19-0799-D-001763 OS 00003434 Message David shulkin [Drshulkin@aol.com] 4/5/2017 2:17:41 AM Darin Selnick [(b) (6) @gmail.com] Re: Possible Prob with choice Reauthorization From: Sent: To: Subject: Agree lets do this Sent from my iPhone On Apr 4, 2017, at 10: 11 PM, Darin Selnick <(b) (6) @gmail.com> wrote: Agree it will pass. Red flag for me for Choice 2.0., we should consider talking with Chairwomen Diane Black, after the vote, as the budget committee could be a big problem with sconng. However, I know a staffer on the committee who tells me that the Chairwomen can get a CBO scoring waiver if they determine that CBO is wrong on the way they do the scoring. That could be important, either way I would want her on our side. Darin On Tue, Apr 4, 2017 at 7:03 PM, David shulkin wrote: Wow - always interesting Lets see how the vote goes- i still think it passes - but we will see Please let Dan know I truly appreciate his support David Sent from my iPhone On Apr 4, 2017, at 9:29 PM, Darin Selnick <(b) (6) @gmail.com> wrote: I thought you should see this development that Dan from CVA sent me. It is being circulated by the House budget committee chairwomen legislative director. CVA is supporting you and opposing this letter. Darin ---------- Forwarded message ---------From: Dan Caldwell Date: Tue, Apr 4, 2017 at 6:03 PM Subject: Possible Prob with choice Reauthorization To: Darin Selnick <(b) (6) @gmail.com> This document is being circulated by the budget committee chairwoman legislative director. As you can see, there are a lot of incorrect facts in it. VA-19-0799-D-001764 OS 00003435 However this is getting sent around far and wide and may cause issues tomorrow. VA-19-0799-D-001765 OS 00003436 Message From: Darin Selnick [(b) (6) Sent: 4/5/2017 2:11:19 AM To: David shulkin [Drshulkin@aol.com] Re: Possible Prob with choice Reauthorization Subject: @gmail.com] Agree it will pass. Red flag for me for Choice 2.0., we should consider talking with Chairwomen Diane Black, after the vote, as the budget committee could be a big problem with scoring. However, I know a staffer on the committee who tells me that the Chairwomen can get a CBO scoring waiver if they determine that CBO is wrong on the way they do the scoring. That could be important, either way I would want her on our side. Darin On Tue, Apr 4, 2017 at 7:03 PM, David shulkin wrote: Wow - always interesting Lets see how the vote goes- i still think it passes - but we will see Please let Dan know I truly appreciate his support David Sent from my iPhone On Apr 4, 2017, at 9:29 PM, Darin Selnick <(b) (6) @gmail.com> wrote: I thought you should see this development that Dan from CVA sent me. It is being circulated by the House budget committee chairwomen legislative director. CVA is supporting you and opposing this letter. Darin ---------- Forwarded message ---------From: Dan Caldwell Date: Tue, Apr 4, 2017 at 6:03 PM Subject: Possible Prob with choice Reauthorization To: Darin Selnick <(b) (6) @gmail.com> This document is being circulated by the budget committee chairwoman legislative director. As you can see, there are a lot of incorrect facts in it. However this is getting sent around far and wide and may cause issues tomorrow. VA-19-0799-D-001766 OS 00003437 Message David shulkin [Drshulkin@aol.com] 4/5/2017 2:03:10 AM Darin Selnick [(b) (6) @gmail.com] Poonam Alaigh [(b) (6) hotmail.com] Re: Possible Prob with choice Reauthorization From: Sent: To: BCC: Subject: Wow - always interesting Lets see how the vote goes- i still think it passes - but we will see Please let Dan know I truly appreciate his support David Sent from my iPhone On Apr 4, 2017, at 9:29 PM, Darin Selnick <(b) (6) @gmail.com> wrote: I thought you should see this development that Dan from CVA sent me. It is being circulated by the House budget committee chairwomen legislative director. CVA is supporting you and opposing this letter. Darin ---------- Forwarded message ---------From: Dan Caldwell Date: Tue, Apr 4, 2017 at 6:03 PM Subject: Possible Prob with choice Reauthorization To: Darin Selnick <(b) (6) @gmail.com> This document is being circulated by the budget committee chairwoman legislative director. As you can see, there are a lot of incorrect facts in it. However this is getting sent around far and wide and may cause issues tomorrow. VA-19-0799-D-001767 OS 00003438 Message From: Darin Selnick [(b) (6) Sent: 4/5/2017 1:29:29 AM To: David shulkin [Drshulkin@aol.com] Fwd: Possible Prob with choice Reauthorization Veterans Choice Suspension Summary.pdf Subject: Attachments: @gmail.com] I thought you should see this development that Dan from CVA sent me. It is being circulated by the House budget committee chairwomen legislative director. CVA is supporting you and opposing this letter. Darin ---------- Forwarded message---------From: Dan Caldwell Date: Tue, Apr 4, 2017 at 6:03 PM Subject: Possible Prob with choice Reauthorization To: Darin Selnick <(b) (6) @gmail.com> This document is being circulated by the budget committee chairwoman legislative director. As you can see, there are a lot of incorrect facts in it. However this is getting sent around far and wide and may cause issues tomorrow. VA-19-0799-D-001768 OS 00003439 H.R. 369 will be on the Floor tomorrow, April 4th under suspension, with brief debate and no opportunity for amendment. Debate is scheduled to begin around 2 pm, with a passage vote scheduled for 4 pm. According to the law's own congressional Commission on Care, "Both the design and implementation of the law have proven to be flawed." The report notes that the program has not solved problems, but instead "aggravated wait times and frustrated veterans, private-sector health care providers participating in networks, and VHA alike." The Commission recommends ending the program, which was supposed to be temporary, and instead focusing on improving existing VA health services. Sen. John McCain was the chief architect of the Veterans Choice Program, and has further legislation to expand it to cover every veteran, not just those who live far from VA facilities or have been waiting overlong for appointments. This would dramatically increase the cost of this new mandatory entitlement program. Proponents of the bill argue that there are already 1 million veterans receiving benefits under this costly new entitlement program, and so it should be made permanent and expanded. This reasoning locks the federal government into a never-ending, evergrowing cycle of mandatory spending. The legislation makes permanent the Veterans Choice Program, which pays for 100% of service-connected healthcare at private providers in response to the VA backlog scandal in 2014. CBO initially estimated a 10-year cost of $44 billion. Some Members have raised concerns that the Veterans Committee's proposed plan to make reforms to the program have fallen to the wayside. They note that this bill makes none of the promised reforms and substantially expands the scope of the program and is suddenly on the Floor with no opportunity to fix problems identified by the law's own Independent Assessment Report. The bill should be amended to address these concerns and ensure congress is not writing a blank check on yet another new entitlement program the government can't afford. It should not be jammed through as a suspension where it is politically toxic to raise process concerns or suggest the bill isn't ready in its current form. Members say they don't have cover to make this case. There was little notice to work on the issue, and time is running out to pause and fix this problem. VA-19-0799-D-001769 DS 00003440 Message David shulkin [Drshulkin@aol.com] 4/5/2017 11:31:35 AM IP [(b) (6) frenchangel59.com] Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel From: Sent: To: Subject: Thanks for updating me Sent from my iPhone On Apr 5, 2017, at 7:21 AM, IP <(b) (6) frenchangel59.com> wrote: FYI ---------- Forwarded message ---------(b) (6) <(b) (6) @icsgroupdc.com> From: (b) (6) Date: Tue, Apr 4, 2017 at 3:54 PM Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel To: L Perl <(b) (6) gmail.com> Mr. Perlmutter, Good afternoon. Thank you again for your response and continued consideration. I certainly understand. Thank you. We very much look forward to reaching out again and getting together at a future date. I commit to reaching out again when we have new dates for travel in either Palm Beach or New York. Thank you again for your time and help. We are grateful for the consideration. I look forward to talking again shortly .Have a wonderful day and rest of the week. (b) (6) (b) (6) Integrated Campaign Solutions, LLC (703) 867-(b) (6) Mobile (517) 813-(b) (6) Fax (b) (6) @icsgroupdc.com From: Isaac and laura Perlmutter <(b) (6) gmail.com > Date: Tuesday, April 4, 2017 at 3:35 PM To: (b) (6) <(b) (6) @icsgroupdc.com > Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel VA-19-0799-D-001770 OS 00003441 (b) (6) Thank you for your thoughtful response and insight. We really appreciate this explanation and detail. That said, Laurie and I still believe that it is premature to meet with the Senator at this time. We do look forward to a future opportunity to have dinner and develop a relationship with the Senator. Perhaps we can begin to look for new dates in the back half of the year. All my Best, Ike On Mon, Apr 3, 2017 at 11:17 PM, (b) (6) (b) (6) <(b) (6) @icsgroupdc.com> wrote: Mr. Perlmutter, Good evening. Thank you for your time and consideration. I certainly understand your concern and hesitation in engaging this early in fundraising. While it is true that we have begun to focus our efforts in maintaining our US Senate Majority in this upcoming mid-term election and help ensure President Trump's legislative success---- the purpose of our dinner was NOT to ask for any specific contribution. The purpose of the dinner was to spend a bit of time with you and Mrs. Perlmutter, to develop a relationship and discuss the upcoming legislative/political landscape. If you were willing to still have dinner with the Leader on his upcoming visit, I commit to you that no specific request for resources will be made during our visit. I understand that you and Mrs. Perlmutter are extremely busy. I very much respect and understand and your hesitation. Again, no request will be made next week. I hope we still have the opportunity to visit. Thank you again for your continued time and consideration. I look forward to talking again shortly. Have a wonderful night! (b) (6) (b) (6) Mobile: (703) 867-(b) (6) Fax: (517) 813-(b) (6) VA-19-0799-D-001771 OS 00003442 On Apr 3, 2017, at 9:46 PM, L Perl <(b) (6) gmail.com> wrote: (b) (6) Unfortunately, Laurie and I are going to have to postpone our dinner with you and Senator McConnell. We were not aware that the purpose and focus of our dinner was fundraising. It is premature for us to engage on this topic at this time. We look forward to rescheduling our dinner and this discussion to a later date. Please pass along our regrets and best wishes to the Senator. All my Best, Ike On Sun, Apr 2, 2017 at 7:41 PM, (b) (6) <(b) (6) @icsgroupdc.com> wrote: (b) (6) Mrs. Perlmutter, Good evening. Perfect. Sounds terrific. Thanks again for your time and help. We are grateful for your consideration. Look forward to seeing you shortly. Have a wonderful night! (b) (6) (b) (6) Mobile: (703) 867-(b) (6) Fax: (517) 813-(b) (6) Sent from my iPhone On Mar 31, 2017, at 5:36 PM, L Perl <(b) (6) gmail.com> wrote: We are looking forward to meeting the Senator. Yes-- we are still planning VA-19-0799-D-001772 OS 00003443 on dinner at Mar-a-Lago at 7; 15. If the weather is nice, which it should be--- dinner will be outside on the terrace. If raining, then we will be in the main dining room. Have a nice weekend .... Best.. .. LP On Fri, Mar 31, 2017 at 8:33 AM, (b) (6) <(b) (6) @icsgroupdc.com> wrote: (b) (6) Mrs. Perlmutter, Good morning. I hope that you are having a wonderful week. I wanted to circle back on our upcoming dinner in Palm Beach on Wednesday, April 12, 2017. Is your preference still Mar-a-Lago at 7:lSpm? Also, will the dinner take place at the Main Dining Room? I understand that you are incredibly busy, but if you could please reconfirm the time and location for our dinner, I would be immensely grateful. Thank you again for everything. I look forward to talking again shortly. Have a wonderful day and weekend! (b) (6) (b) (6) Integrated Campaign Solutions, LLC VA-19-0799-D-001773 OS 00003444 (703) 867-(b) (6) Mobile (517) 813-(b) (6) Fax (b) (6) @icsgroupdc.com gmail.com > From: Isaac and laura Perlmutter <(b) (6) Date: Thursday, March 2, 2017 at 6:08 PM To: (b) (6) <(b) (6) @icsgroupdc.com > Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel We will probably plan dinner at Mar-a-Lago-- around 7: 15 that evemng. Will confirm this as we get closer to the date .... Best...LP On Thu, Mar 2, 2017 at 5:01 PM, (b) (6) <(b) (6) @icsgroupdc.com> wrote: (b) (6) Mrs. Perlmutter, Good afternoon. Perfect. I will confirm our dinner. Thank you for your continued time and help! Two final questions: Would you like to have dinner at your home? If so, could you please reconfirm the address? Also, US Capital police always advances the Leader's travel. Is there a security contact that I can pass along to US Capitol Police? Thank you again for your time and help. I look forward to talking again shortly! Have a wonderful evening! (b) (6) From: Isaac and laura Perlmutter <(b) (6) gmail.com> Date: Thursday, March 2, 2017 at 4:24 PM To: (b) (6) <(b) (6) @icsgroupdc.com > Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel VA-19-0799-D-001774 OS 00003445 Dinner on Wednesday 4/12 is fine ... we look forward to it... Thanks ..LP VA-19-0799-D-001775 OS 00003446 Message From: Sent: To: Subject: IP [(b) (6) frenchangel59.com] 4/5/2017 11:21:20 AM David shulkin [drshulkin@aol.com] FW: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel FYI ---------- Forwarded message---------(b) (6) From: (b) (6) <(b) (6) @icsgroupdc.com> Date: Tue, Apr 4, 2017 at 3:54 PM Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel To: L Perl <(b) (6) gmail.com> Mr. Perlmutter, Good afternoon. Thank you again for your response and continued consideration. I certainly understand. Thank you. We very much look forward to reaching out again and getting together at a future date. I commit to reaching out again when we have new dates for travel in either Palm Beach or New York. Thank you again for your time and help. We are grateful for the consideration. I look forward to talking again shortly .Have a wonderful day and rest of the week. (b) (6) (b) (6) Integrated Campaign Solutions, LLC (703) 867-(b) (6) Mobile (517) 813-(b) (6) Fax (b) (6) @icsgroupdc.com gmail.com > From: Isaac and laura Perlmutter <(b) (6) Date: Tuesday, April 4, 2017 at 3:35 PM To: (b) (6) <(b) (6) @icsgroupdc.com > Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel (b) (6) Thank you for your thoughtful response and insight. We really appreciate this explanation and detail. That said, Laurie and I still believe that it is premature to meet with the Senator at this time. We do look forward to a future opportunity to have dinner and develop a relationship with the Senator. Perhaps we can begin to look for new dates in the back half of the year. VA-19-0799-D-001776 OS 00003447 All my Best, Ike On Mon, Apr 3, 2017 at 11: 17 PM, (b) (6) (b) (6) <(b) (6) @icsgroupdc.com> wrote: Mr. Perlmutter, Good evening. Thank you for your time and consideration. I certainly understand your concern and hesitation in engaging this early in fundraising. While it is true that we have begun to focus our efforts in maintaining our US Senate Majority in this upcoming mid-term election and help ensure President Trump's legislative success---- the purpose of our dinner was NOT to ask for any specific contribution. The purpose of the dinner was to spend a bit of time with you and Mrs. Perlmutter, to develop a relationship and discuss the upcoming legislative/political landscape. If you were willing to still have dinner with the Leader on his upcoming visit, I commit to you that no specific request for resources will be made during our visit. I understand that you and Mrs. Perlmutter are extremely busy. I very much respect and understand and your hesitation. Again, no request will be made next week. I hope we still have the opportunity to visit. Thank you again for your continued time and consideration. I look forward to talking again shortly. Have a wonderful night! (b) (6) (b) (6) Mobile: (703) 867-(b) (6) Fax: (517) 813-(b) (6) On Apr 3, 2017, at 9:46 PM, L Perl <(b) (6) gmail.com> wrote: (b) (6) Unfortunately, Laurie and I are going to have to postpone our dinner with you and Senator McConnell. We were not aware that the purpose and focus of our dinner was fundraising. It is premature for us to engage on this topic at this time. We look forward to rescheduling our dinner and this discussion to a later date. Please pass along our regrets and best wishes to the Senator. All my Best, VA-19-0799-D-001777 OS 00003448 Ike On Sun, Apr 2, 2017 at 7:41 PM, (b) (6) (b) (6) <(b) (6) @icsgroupdc.com> wrote: Mrs. Perlmutter, Good evening. Perfect. Sounds terrific. Thanks again for your time and help. We are grateful for your consideration. Look forward to seeing you shortly. Have a wonderful night! (b) (6) (b) (6) Mobile: (703) 867-(b) (6) Fax: (517) 813 -(b) (6) Sent from my iPhone On Mar 31, 2017, at 5:36 PM, L Perl <(b) (6) gmail.com> wrote: We are looking forward to meeting the Senator. Yes-- we are still planning on dinner at Mar-a-Lago at 7; 15. If the weather is nice, which it should be--- dinner will be outside on the terrace. If raining, then we will be in the main dining room. Have a nice weekend .... Best.. .. LP On Fri, Mar 31, 2017 at 8:33 AM, (b) (6) <(b) (6) @icsgroupdc.com> wrote: (b) (6) Mrs. Perlmutter, VA-19-0799-D-001778 OS 00003449 Good morning. I hope that you are having a wonderful week. I wanted to circle back on our upcoming dinner in Palm Beach on Wednesday, April 12, 2017. Is your preference still Mar-a-Lago at 7:lSpm? Also, will the dinner take place at the Main Dining Room? I understand that you are incredibly busy, but if you could please reconfirm the time and location for our dinner, I would be immensely grateful. Thank you again for everything. I look forward to talking again shortly. Have a wonderful day and weekend! (b) (6) (b) (6) Integrated Campaign Solutions, LLC (703) 867 -(b) (6) Mobile (517) 813 -(b) (6) Fax (b) (6) @icsgroupdc.com gmail.com > From: Isaac and laura Perlmutter <(b) (6) Date: Thursday, March 2, 2017 at 6:08 PM To: (b) (6) <(b) (6) @icsgroupdc.com > Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel We will probably plan dinner at Mar-a-Lago-- around 7: 15 that evening. VA-19-0799-D-001779 OS 00003450 Will confirm this as we get closer to the date .... Best.. .LP On Thu, Mar 2, 2017 at 5 :0 I PM, (b) (6) <(b) (6) @icsgroupdc.com> wrote: (b) (6) Mrs. Perlmutter, Good afternoon. Perfect. I will confirm our dinner. Thank you for your continued time and help! Two final questions: Would you like to have dinner at your home? If so, could you please reconfirm the address? Also, US Capital police always advances the Leader's travel. Is there a security contact that I can pass along to US Capitol Police? Thank you again for your time and help. I look forward to talking again shortly! Have a wonderful evening! (b) (6) gmail.com > From: Isaac and laura Perlmutter <(b) (6) Date: Thursday, March 2, 2017 at 4:24 PM To: (b) (6) <(b) (6) @icsgroupdc.com > Subject: Re: Senate Majority Leader Mitch McConnell: New York and Palm Beach County April Travel Dinner on Wednesday 4/12 is fine ... we look forward to it... Thanks ..LP VA-19-0799-D-001780 OS 00003451 Message David shulkin [Drshulkin@aol.com] 3/31/2017 10:43:32 PM (b) (6) [(b) (6) Re: Delaware Presentation. From: Sent: To: Subject: gmail.com] Agreed Sent from my iPhone On Mar 31, 2017, at 4:41 PM, (b) (6) (b) (6) <(b) (6) gmail.com> wrote: hasn't taken my advice yet for moaa, so we don't have anything to share yet. I think they may not like me today but I don't care. On Mar 31, 2017 4:08 PM, "(b) (6) Thanks sir. <(b) (6) gmail.com> wrote: On Mar 31, 2017 4:07 PM, "David shulkin" wrote: I like it! Very good Sent from my iPhone > On Mar 31, 2017, at 3:37 PM, (b) (6) <(b) (6) gmail.com> wrote: > > let me know what you think of this version. > <2017 04 03 -3 DELAWARE VETERANS SUMMIT without video. pptx> VA-19-0799-D-001781 OS 00003452 Message From: (b) (6) Sent: 3/31/2017 8:41:17 PM David shulkin [Drshulkin@aol.com] Re: Delaware Presentation. To: Subject: (b) (6) [(b) (6) gmail.com] hasn't taken my advice yet for moaa, so we don't have anything to share yet. I think they may not like me today but I don't care. On Mar 31, 2017 4:08 PM, "(b) (6) Thanks sir. <(b) (6) gmail.com> wrote: On Mar 31, 2017 4:07 PM, "David shulkin" wrote: I like it! Very good Sent from my iPhone > On Mar 31, 2017, at 3:37 PM, (b) (6) <(b) (6) gmail.com> wrote: > > let me know what you think of this version. > <2017 04 03 -3 DELAWARE VETERANS SUMMIT without video. pptx> VA-19-0799-D-001782 OS 00003453 Message From: David shulkin [Drshulkin@aol.com] Sent: 3/31/2017 8:07:47 PM To: (b) (6) Subject: I like it! [(b) (6) Re: Delaware Presentation. gmail.com] Very good Sent from my iPhone > on Mar 31, 2017, at 3:37 PM, (b) (6) <(b) (6) gmail.com> wrote: > > let me know what you think of this version. > <2017 04 03 -3 DELAWARE VETERANS SUMMIT without video.pptx> VA-19-0799-D-001783 OS 00003454 Message From: (b) (6) Sent: To: 3/31/2017 7:37:19 PM David Shulkin [drshulkin@aol.com] Delaware Presentation. 2017 04 03 -3 DELAWARE VETERANS SUMMIT without video.pptx Subject: Attachments: [(b) (6) gmail.com] let me know what you think of this version. VA-19-0799-D-001784 OS 00003455 U.S. Department of Veterans Affairs Secretary's 10 Priorities Delaware Veterans Summit David J. Shulkin, M.D. Secretary of Veterans Affairs April 3, 2017 VA-19-0799-D-001785 OS 00003456 . t' . (1 "EUR ~4 ~ Our Mission "To care for him who shall have borne the . j battle, and for his . 1 .\ widow and his orphan." President Abraham Lincoln, 1865 To care for those "who shall have borne the battle" and for their families and their survivors. VA Today ,{, / .f. '-~Jfl .,I . \IA VI'\ ~~ .~ ... - I 1~ '-1 1~ o U.S. Department ofVetcransMfairs VA-19-0799-D-001786 OS 00003457 Ending Homelessness for Veterans * D ELAWARE JOINING FORC ES o 3 States o 42 Communities .---., VA I~ ',.__ ,> ' 1 '. 1 U.S. Department ofVetcransMfairs VA-19-0799-D-001787 OS 00003458 Partnerships Create Change I Paralyzed Veterans of America - TEAM ~ ~R_.UBICON ? GOT YOUR SIX TEAM o ~1SSION CONTINUES RW13 THE HOUSE COMM ITTEE ON ***** VETER.A S' AFFAIR.S - UNITED - STATES ~----- SEN A T .E - - - -- - J COMMITTEE on VETERANS' AFFAIRS PRO UDLY SERVING \ \1ERfCAS VETERANS Stakeholders are critical to V A's success --,, VA I~ , . , 4 ' ~ y 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001788 OS 00003459 Priority 1: Extend the Choice Deadline INTERNAL VA VS. COMMUNITY CARE COMPLETED APPOINTMENTS (FY14-16) GROWTH IN COMMUNITY CARE COMPLETED APPOINTMENTS (FY14-16) - FY14 FYlS FY16 o o o FY14 FYlS FY16 o o Community Care Appointments Internal VA Facility Based Appointments *Data as of November 17, 2016 --,, VA I~ , . , 5 ' ~ y 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001789 OS 00003460 Choice 2.0 Legislation 1. Maintain a high-performing integrated network that includes VA, federal partners, academic affiliates, and community providers 2. Increase choice for all Veterans, starting with those with serviceconnected conditions 3. Ensure Veterans get the care they need, closer to home when appropriate 4. Optimize coordination of VA healthcare with the health insurance Veterans already have 5. Maintain affordability of healthcare options for low-income Veterans 6. Assist in coordinating care for Veterans served by multiple providers 7. Apply industry standards for performance, quality, patient satisfaction, payment models, and health outcomes --,, VA I~ , . , 6 ' ~ y 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001790 OS 00003461 How quickly does my VA see patients? How satisfied are veterans like me with the timeliness of their care? 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The filters used 'BAY PINES ', Primary Care (Routine) 1-o-,..,,,..,,.........,.U"l'IITTO"-r.r,llU!'1l'I- - - - . - - ! Note - The data shows What Veterans have said about their own Access experiences over the preceding 6 months Your own experience may be different For urgent problems, there often are optiOns to be seen sooner such as a same-day clime . If your ,,..,an will be longer than 30 days, you may request a referral to Care in the Community. C, -- - Automatie o ._,.,. ""''"",. .-.m, Percent of Veterans wno reported that lhey were Alwavs or Usually "' able to gel an appoo1tmenl when needed for 'Pnrnary Care (Routine)' Appointments DISTANCE IN PRIMARY CARE 1Cissimm1 FACILITY MAME MILES ~ ShowMore Palm Harbor (ROUTI NE) Show011Map 6 CW 6ilYOU1'1!10ePIIJtmenlof Veterans AfflQ Medieal Cefller 85% 727-398-6661 Show Mon, -. C James A.. Show 011 Map (b) Show More Veterans. Show 011 Map 863-701-2470 Wauchul.1 Show More Show 011 Map E. New Port Richey VA enc l..lkeP F PalmHertJorVAClinic 727-734-5276 Arudia b, bing Download Seard, RHUb (JSON) IOmiles _ _ _,_, _om Show More Show 011 Map S 2017M,croso!ICo,potot>On 0 - All F . . . - {JSON ) Oow,,toad S.orcll RHulD (CSV) Oow,mad AU Foalollff (CS\/) --,, VA I~ , . , 9 ' ~ y 1 " U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001793 OS 00003464 Priority #3: Enhancing Foundational Services --,, VA I~ , . , 10 ' --- _"/ 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001794 OS 00003465 Priority #4: Accountability Legislation 1. Increased flexibility to remove, demote, or suspend VA employees for poor performance or misconduct 2. Authority to recoup bonuses of employees for poor performance or misconduct 3. Authority to recoup relocation expenses authorized through fraud or malfeasance 4. Authority to reduce federal pensions for employees convicted of felonies 5. Increased protections for whistleblowers --,, VA I~ , . , 11 ' --- _"/ 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001795 OS 00003466 Priority #5: Infrastructure Improvements Gas Station Minneapolis, MN 1932 Palo Alto VAMC Circa 1895 --,, VA I~ , . , 12 ' --- _"/ 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001796 OS 00003467 Priority #6: VA/DoD/Federal Coordination VA and DoD Hospitals -- [Al ~ ~ [3 --,, VA I~ , . , 13 ' --- _"/ 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001797 OS 00003468 Priority #7: EMR Interoperability & Modernization VistA Scheduling Enhancement PCT( B)-DR!tt!TH Feb2015 TI--,---,---,--,----,---,----,---,----'\ # # # ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~ ~ ~ ~~~################# --,, VA I~ , . , 18 ' --- _"/ 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001802 OS 00003473 Veterans Speak with Their Feet VA is Able to Compete and Grow lncrementalism is not the answer to additional improvements VA and Veterans need~ \IA 19 VI'\ I ,'~ \ '1 ~!I . US Ocpartmcnl of Vctcra ns Affa I rs VA-19-0799-D-001803 OS 00003474 BEST CARE ANYWHERE PHILLIP LONGMAN Best Practices EVERYWHERE DAVID SHULKIN One single high-performance1 clinically integrated network --,, VA I~ , . , w ' ~ y 1 U.S. Department ofVetcransMfa 1rs VA-19-0799-D-001804 OS 00003475 Message To: David shulkin [Drshulkin@aol.com] 4/3/2017 11:57:09 PM (b) (6) [(b) (6) Subject: Re: From: Sent: gmail.com] What did they do? Sent from my iPhone On Apr 3, 2017, at 6:58 PM, (b) (6) <(b) (6) gmail.com> wrote: Darin and Mike L. On Apr 3, 2017 6:50 PM, "David shulkin" wrote: Who are we talking about? Sent from my iPhone On Apr 3, 2017, at 6:22 PM, (b) (6) <(b) (6) gmail.com> wrote: Sorry these* people. On Apr 3, 2017 6:21 PM, "(b) (6) <(b) (6) gmail .com> wrote: This people are such snakes. VA-19-0799-D-001805 OS 00003482 Message From: (b) (6) [(b) (6) Sent: To: 4/3/2017 10:58:58 PM David shulkin [Drshulkin@aol.com] Subject: Re: gmail.com] Darin and Mike L. On Apr 3, 2017 6:50 PM, "David shulkin" wrote: Who are we talking about? Sent from my iPhone On Apr 3, 2017, at 6:22 PM, (b) (6) <(b) (6) gmail.com> wrote: Sorry these* people. On Apr 3, 2017 6:21 PM, "(b) (6) This people are such snakes. <(b) (6) gmail.com> wrote: VA-19-0799-D-001806 OS 00003483 Message To: David shulkin [Drshulkin@aol.com] 4/3/2017 10:50:16 PM (b) (6) [(b) (6) Subject: Re: From: Sent: gmail.com] Who are we talking about? Sent from my iPhone On Apr 3, 2017, at 6:22 PM, (b) (6) <(b) (6) gmail.com> wrote: Sorry these* people. On Apr 3, 2017 6:21 PM, "(b) (6) This people are such snakes. <(b) (6) gmail.com> wrote: VA-19-0799-D-001807 OS 00003484 Message From: (b) (6) [(b) (6) Sent: To: 4/3/2017 10:22:13 PM David Shulkin [drshulkin@aol.com] Subject: Re: gmail.com] Sorry these* people. On Apr 3, 2017 6:21 PM, "(b) (6) This people are such snakes. <(b) (6) gmail.com> wrote: VA-19-0799-D-001808 OS 00003485 Message From: (b) (6) Sent: To: 4/3/2017 10:21:55 PM [(b) (6) gmail.com] David Shulkin [drshulkin@aol.com] This people are such snakes. VA-19-0799-D-001809 OS 00003486 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/2/2017 9:52:29 PM bruce moskowitz [(b) (6) gmail.com] drshulkin@aol.com Re: Philadelphia VA letter from Dr. (b) (6) This is awesome- we have a call scheduled this week once I am back- let's discuss both R&D and the residency/training opportunity. David, Bruce and I have a call on Thursday and will fill you in on it. Sent from my iPhone On Apr 1, 2017, at 1:23 AM, bruce moskowitz <(b) (6) gmail.com> wrote: The best part of this is it requires no funding for each position! I found a donor source. Sent from my iPhone On Mar 31, 2017, at 6:27 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Bruce - we are looking for different approaches to increasing our residencies and medical school training while creating new models of collaboration with our academic affiliates- real situations like you have identified below are going to be an important part of our discussion. Thanks so much for sending this along. Sent from my iPhone On Mar 31, 2017, at 5:20 PM, Bruce Moskowitz <(b) (6) gmail .com> wrote: There is an estimated 700 medical students like this without residency positions. The VA in Philadelphia would like to have this resident but I am not sure how to make it happen. Thanks for rev1ewmg. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (6) From: "(b) (6) <(b) (6) va.gov> Date: March 31, 2017 at 11 :57:33 AM EDT To: "Brucem(b) (6) @gmail.com " Cc: "(b) (6) <(b) (6) uphs.upenn.edu> (b) (6) Subject: Reference for VA-19-0799-D-001810 OS 00003487 Dear Dr. Moskowitz, My name is (b) (6) and I am the Section Chief of Hospital Medicine at the Corporal Michael J. Crescenz VAMC (Philadelphia VAMC). I have worked with (b) (6) extensively on the wards during her sub-internship in medical school and she asked me to reach out to you as a reference. I have attached the letter of recommendation I wrote in support of her candidacy for residency. To summarize that letter, (b) (6) is one of the most exceptional medical students I have worked with from the Perelman School of Medicine at the University of Pennsylvania. She is exceedingly intelligent, dedicated and passionate in her work, an absolutely exceptional colleague and was a vital member of our care team. I am not alone in saying that we would support her interest in doing a prelim year at a VAMC and that she would be an outstanding addition to any residency program. I have cc'd this email to the University of Pennsylvania's Site Lead for Undergraduate Medical Education here at CMCVAMC, Dr. (b) (6) who concurs with this assessment and can vouch for the type of high quality academic, clinical and personal qualities (b) (6) demonstrates. Please let us know if and how we can help, we are happy to assist. Sincerely, (b) (6) MD Section Chief of Hospital Medicine Corporal Michael J. Crescenz VAMC Philadelphia, VA 215-823-(b) (6) (Office) 703-217-(b) (6) (Cell) Clinical Assistant Professor of Medicine Division of General Internal Medicine Perelman School of Medicine University of Pennsylvania VA-19-0799-D-001811 OS 00003488 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 4/1/2017 12:09:48 PM bruce moskowitz [(b) (6) gmail.com] Re: Philadelphia VA letter from Dr. (b) (6) You are amazing! Sent from my iPhone On Mar 31, 2017, at 8:23 PM, bruce moskowitz <(b) (6) gmail.com> wrote: The best part of this is it requires no funding for each position! I found a donor source. Sent from my iPhone On Mar 31, 2017, at 6:27 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Bruce - we are looking for different approaches to increasing our residencies and medical school training while creating new models of collaboration with our academic affiliates- real situations like you have identified below are going to be an important part of our discussion. Thanks so much for sending this along. Sent from my iPhone On Mar 31, 2017, at 5:20 PM, Bruce Moskowitz <(b) (6) gmail .com> wrote: There is an estimated 700 medical students like this without residency positions. The VA in Philadelphia would like to have this resident but I am not sure how to make it happen. Thanks for rev1ewmg. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (6) From: "(b) (6) (b) (6) < va.gov> Date: March 31, 2017 at 11 :57:33 AM EDT To: "(b) (6) gmail.com " <(b) (6) gmail.com> Cc: "(b) (6) <(b) (6) uphs.upenn.edu> Subject: Reference for (b) (6) Dear Dr. Moskowitz, My name is (b) (6) and I am the Section Chief of Hospital Medicine at the Corporal Michael J. Crescenz VA-19-0799-D-001812 OS 00003489 VAMC (Philadelphia VAMC). I have worked with extensively on the wards during her sub-internship in medical school and she asked me to reach out to you as a reference. I have attached the letter of recommendation I wrote in support of her candidacy for residency. To summarize that letter, (b) (6) is one of the most exceptional medical students I have worked with from the Perelman School of Medicine at the University of Pennsylvania. She is exceedingly intelligent, dedicated and passionate in her work, an absolutely exceptional colleague and was a vital member of our care team. (b) (6) I am not alone in saying that we would support her interest in doing a prelim year at a VAMC and that she would be an outstanding addition to any residency program. I have cc'd this email to the University of Pennsylvania's Site Lead for Undergraduate Medical Education here at CMCVAMC, Dr. (b) (6) who concurs with this assessment and can vouch for the type of high quality academic, clinical and personal qualities (b) (6) demonstrates. Please let us know if and how we can help, we are happy to assist. Sincerely, (b) (6) MD Section Chief of Hospital Medicine Corporal Michael J. Crescenz VAMC Philadelphia, VA 215-823-(b) (6) (Office) 703-217-(b) (6) (Cell) Clinical Assistant Professor of Medicine Division of General Internal Medicine Perelman School of Medicine University of Pennsylvania VA-19-0799-D-001813 OS 00003490 Message From: Sent: To: CC: Subject: bruce moskowitz [(b) (6) gmail.com] 4/1/2017 12:23:52 AM Poonam Alaigh [(b) (6) hotmail.com] drshulkin@aol.com Re: Philadelphia VA letter from Dr. (b) (6) The best part of this is it requires no funding for each position! I found a donor source. Sent from my iPhone On Mar 31, 2017, at 6:27 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Bruce - we are looking for different approaches to increasing our residencies and medical school training while creating new models of collaboration with our academic affiliates- real situations like you have identified below are going to be an important part of our discussion. Thanks so much for sending this along. Sent from my iPhone On Mar 31, 2017, at 5:20 PM, Bruce Moskowitz <(b) (6) gmail.com> wrote: There is an estimated 700 medical students like this without residency positions. The VA in Philadelphia would like to have this resident but I am not sure how to make it happen. Thanks for reviewing. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (6) From: "(b) <(b) (6) va.gov> (6) Date: March 31, 2017 at 11 :57:33 AM EDT To: "(b) (6) gmail.com " <(b) (6) gmail.com> Cc: "(b) (6) <(b) (6) uphs.upenn.edu> (b) (6) Subject: Reference for Dear Dr. Moskowitz, My name is (b) (6) and I am the Section Chief of Hospital Medicine at the Corporal Michael J. Crescenz VAMC (Philadelphia extensively on the VAMC). I have worked with (b) (6) wards during her sub-internship in medical school and she asked me to reach out to you as a reference. I have attached the letter of recommendation I wrote in support of her candidacy for residency. To summarize that letter, (b) (6) is one of the most exceptional medical students I have worked with from the Perelman School of Medicine at the University of Pennsylvania. She is exceedingly intelligent, dedicated VA-19-0799-D-001814 OS 00003491 and passionate in her work, an absolutely exceptional colleague and was a vital member of our care team. I am not alone in saying that we would support her interest in doing a prelim year at a VAMC and that she would be an outstanding addition to any residency program. I have cc'd this email to the University of Pennsylvania's Site Lead for Undergraduate Medical Education here at CMCVAMC, Dr. (b) (6) who concurs with this assessment and can vouch for the type of high quality academic, clinical and personal qualities (b) (6) demonstrates. Please let us know if and how we can help, we are happy to assist. Sincerely, (b) (6) MD Section Chief of Hospital Medicine Corporal Michael J. Crescenz VAMC Philadelphia, VA 215-823-(b) (6) (Office) 703-217-(b) (6) (Cell) Clinical Assistant Professor of Medicine Division of General Internal Medicine Perelman School of Medicine University of Pennsylvania VA-19-0799-D-001815 OS 00003492 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/31/2017 10:27:42 PM Bruce Moskowitz [(b) (6) gmail.com] drshulkin@aol.com Re: Philadelphia VA letter from Dr. (b) (6) Bruce - we are looking for different approaches to increasing our residencies and medical school training while creating new models of collaboration with our academic affiliates- real situations like you have identified below are going to be an important part of our discussion. Thanks so much for sending this along. Sent from my iPhone On Mar 31, 2017, at 5:20 PM, Bruce Moskowitz <(b) (6) gmail.com> wrote: There is an estimated 700 medical students like this without residency positions. The VA in Philadelphia would like to have this resident but I am not sure how to make it happen. Thanks for reviewing. Sent from my iPad Bruce Moskowitz M.D. Begin forwarded message: (6) From: "(b) <(b) (6) va.gov> (6) Date: March 31, 2017 at 11 :57:33 AM EDT To: "(b) (6) gmail.com" <(b) (6) Cc: "(b) (6) <(b) (6) (b) (6) Subject: Reference for gmail.com> uphs.upenn.edu> Dear Dr. Moskowitz, My name is (b) (6) and I am the Section Chief of Hospital Medicine at the Corporal Michael J. Crescenz VAMC (Philadelphia VAMC). I have worked with (b) (6) extensively on the wards during her sub-internship in medical school and she asked me to reach out to you as a reference. I have attached the letter of recommendation I wrote in support of her candidacy for residency. To summarize that letter, (b) (6) is one of the most exceptional medical students I have worked with from the Perelman School of Medicine at the University of Pennsylvania. She is exceedingly intelligent, dedicated and passionate in her work, an absolutely exceptional colleague and was a vital member of our care team. I am not alone in saying that we would support her interest in doing a prelim year at a VAMC and that she would be an outstanding addition to any residency program. I have cc'd this email to the University of Pennsylvania's Site Lead for Undergraduate Medical Education here at CMCVAMC, Dr. (b) (6) who concurs with this assessment and can vouch for the type of high quality academic, clinical and personal qualities (b) (6) demonstrates. Please let us know if and how we can help, we are happy to assist. VA-19-0799-D-001816 OS 00003493 Sincerely, (b) (6) MD Section Chief of Hospital Medicine Corporal Michael J. Crescenz VAMC Philadelphia, VA 215-823-(b) (6) (Office) 703-217-(b) (6) (Cell) Clinical Assistant Professor of Medicine Division of General Internal Medicine Perelman School of Medicine University of Pennsylvania VA-19-0799-D-001817 OS 00003494 Message From: Sent: To: Subject: Attachments: David Shulkin [drshulkin@aol.com] 3/27/2017 2:14:32 AM (b) (6) gmail.com Fwd: slides ache2017.pptx I will use the ACHE presentation for the chief medical officer and nurse executive lecture this week as well VA-19-0799-D-001818 OS 00003495 Lessons from 810 Vermont and Beyond David J. Shulkin MD The 9th Secretary of US Department of Veterans Affairs VA-19-0799-D-001819 OS 00003496 To care for him I {or her] who - ?a shali have borne the battle (widow, and his orphan. - Abraham Linco1n, 1365 820 Share YourJourney Paving Attention to Culture ."11/~nait'" a /vJlbo.,r,o"" rh, ,mi,r,,/o.,,rg/<<,l,d 10 tM ,i<,,.,w,, 11''"'1o, by lrr =&ffl It. VA-19-0799-D-001831 OS 00003508 .... .- .. MMkal Gro ? p Will your doctor see you at 3 am? Open 24 hours a day. Every day. Beth Israel Medical Group 23rd Street and 7th Avenue VA-19-0799-D-001832 OS 00003509 Run Towards the GunFire Be Present 1 Decline in Homelessness 80,000 ~ 037 70,000 65,455 60,579 60,000 55,61' - 50,000 40,000 _ 47,725 ~ 43,437 40,033 35,143 34,909 32,119 30,650 30,000 25,422 31,505 25,436 20,710 20,000 1-1,57 _ 16,220 10,000 2010 ? 17 Total Homeless Veterans 20 12 20 11 o 2013 Sheltered Veterans 20 14 o 20 15 Unsheltered Veterans ' ' ' VA-19-0799-D-001835 OS 00003512 Focus on Our People '-.., My VA Organizational Hierarchy _ --,iii~~~~~~------ .-----.-------o-oll'lo-lO ~ =~ 1. :=::."::::.::C":::;.-:-1 ' :"_,...dlN~-d-""" ~ -------~ -.-.... _...-_ ' oo? o-""'-o~ o-..- ""'-----. .12 -.- VA-19-0799-D-001836 OS 00003513 3., g. Rid Organizations of Bad Actors (Stop the Detailing) "Dealing with employee issues can be difficult, but n o t de a Ii n g with th e m can be worse." - Paul Foster, CEO and Founder, The Business Therapist, ~ Busiress. VA-19-0799-D-001838 OS 00003515 Little Stufmc Matters 97W 839 Get Everyone's Ideas Questions Patients Need to Ask Getting Better Healthcare I Essential Information Every Patient Needs to Know Edited By David J. Shulkin, M.D. VA-19-0799-D-001840 OS 00003517 Invest in others and develop them sums may?; Iinux A Principle Based (vs. Rules Based) Organizations Alt,,u(lUCrque \tclCfilllS AH..., o(fiebls $a.d a ~~eran suf erina died Monday flf1e( wa1llllft. ber-.M~ a_, - on 20 Md 2$ nV'ltltff 10 be Ullo.Of' to lhc ~ n e y room Y"-1 ~ e from tne VA's eefe1.eoa. wttlCh d about e rrvie....,inute 111.a> ' ?"" ,ne ER. VA-19-0799-D-001842 OS 00003519 Choose the Hard Right than the Easier Wrong os_00003520 Walk the Talk?Practicing in NY and Oregon Leaders Propose Solutions, not Criticize PROPOSE TJ-IE SOLUTION VA-19-0799-D-001845 OS 00003522 Getting People to Be Part of the Solution 28 On February 2, 2016, VA hosted a summit, "Preventing Veterans Suicide -A Call to Action" to bring together Veterans, families, federal agencies, community providers, subject matter experts, and other key stakeholders to enhance suicide prevention efforts. The summit generated a new framework for VA's approach to Suicide Prevention that will transform the vision and structure of suicide prevention across VA and the community. VA has elevated and expanded our Suicide Prevention Program to fulfill this vision, which includes: Meeting urgent mental health needs by providing Veterans same-day evaluations and access by the end of calendar year 2016. Building and leveraging strategic partnerships to disseminate new initiatives within VA and to reach non-VA using Veterans. Development and implementation of innovative life-saving programs, such as REACH-VET, which uses predictive modeling to identify Veterans at high risk for suicide. Continuing to partner with the Department of Defense for a seamless transition from military service to civilian life. VA-19-0799-D-001846 OS 00003523 Making Tough Decisions "It takes an Act of Congress? 848 300k comments Challenge the Status Quo Innovations from VA :~DJ ~]:. ~~~:E::}; -:r:....= --::;:.;:~:!E ~'""'..::C.:.':: -r=-'-:..o- ...... -~=-:::.- . ...- .,.., ...:::-_-:;z_ CT Scanner First Liver Transplant Artificial Kidney Nicotine Patches Cardiac 3 Nobel Prizes Pacemaker VA-19-0799-D-001851 OS 00003528 Center for Compassionate Innovation@ VA To enhance veteran's health and well being by offering safe and ethical therapies after traditional treatments have not been successful VA-19-0799-D-001852 OS 00003529 ?.41909? 140? no of Effective Organizations Break Down Silos o o ooo Sprin t LTE 7:23 PM Done CancerMoonshot Discus .. ~ (R) ,t ~ c!J VA-19-0799-D-001854 OS 00003531 Don?t take no for an answer 855 Decline in Opioid Use Since 2012 Opioid use: o 31% to 471,340 Veterans on opioid Long-term opioid use: o 36% to 281,029 Veterans on LOT Benzo co-prescribing: o 56% to 53,485 Veterans High dose (>100 mg MEDD*): o 44% to 33,149 Veterans Annual drug screening: o From 37% to 86% *MEDO= Morphine Equivalent Daily Dosage 38 Decline in opioid use, 40 FY 2012 to 10 FY 2017. VA-19-0799-D-001856 OS 00003533 Have a Work Life Balance Family Time Have Fun Veterans Speak with their Feet VA is Able to Compete and Grow lncrementatism is not the answer to additional improvements VA and Veterans need. VA-19-0799-D-001859 OS 00003536 The Secretary's 10 Priorities o Extend Choice beyond August 2017 o Choice 2.0 Legislation: Eliminate the 40/30 Rule o Infrastructure Improvements and Consolidations o Enhance Foundational Services in VA o VA/DOD/Federal Coordination o EMR Interoperability and Modernization o Breakthrough in Suicide Prevention o Appeals Modernization o Accelerating VBA Performance on Claims o Accountability Legislation VA-19-0799-D-001860 OS 00003537 Beth Israel Medical Group Will your doctor see you at 3am? Ours will. Open 24 hours a day. Every day. Beth Israel Medical Group 23rd Street and 7th Avenue VA-19-0799-D-001861 OS 00003538 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/30/2017 12:10:37 PM (b) (6) sunnyshulkin.com Re: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR Did you click the link and then the listen button to hear the interview? Sent from my iPhone On Mar 30, 2017, at 7:07 AM, <(b) (6) Great news! Love, sunnyshulkin.com> <(b) (6) sunnyshulkin.com> wrote: (b) (6) -------- Original Message-------Subject: Fwd: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says : Shots - Health News : NPR From: David shulkin < Drshulkin@aol.com > Date: Thu, March 30, 2017 8:04 am To: (b) (6) < (b) (6) sunnyshulkin.com >, (b) (6) (b) (6) < @sunnyshu Ikin .com >, (b) (6) n@g ma i I .com > Sent from my iPhone Begin forwarded message: From: (b) (6) < (b) (6) gmail.com > Date: March 30, 2017 at 5:29: 19 AM CDT To: drshulkin@aol.com Subject: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says : Shots - Health News : NPR VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says : Shots - Health News : NPR http: //www.npr.org / sections/ health-shots/ 2017 / 03/ 30/ 521937557 / the-vais-on-a-path-towa rd-recovery-secreta ry-of-vetera ns-affa i rs-says VA-19-0799-D-001862 OS 00003540 Message From: Sent: To: Subject: (b) (6) sunnyshulkin.com [(b) (6) sunnyshulkin.com] 3/30/2017 12:07:28 PM David shulkin [Drshulkin@aol.com] RE: Fwd: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News: NPR Great news! Love, (b) (6) -------- Original Message-------Subject: Fwd: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says : Shots - Health News : NPR From: David shulkin < Drshulkin @aol.com > Date: Thu, March 30, 2017 8:04 am To: (b) (6) < (b) (6) sunnyshulkin.com >, (b) (6) < ma rk @sunnys hu Ikin .com >, Ned rA < ned rafetterma n@g ma i I .com > Sent from my iPhone Begin forwarded message: From: (b) (6) < (b) (6) gmail.com > Date: March 30, 2017 at 5:29: 19 AM CDT To: drshulkin @aol.com Subject: VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says: Shots - Health News : NPR VA Is On A Path Toward Recovery, Secretary Of Veterans Affairs Says : Shots - Health News: NPR http: //www.npr.org / sections/ health-shots/ 2017 / 03/ 30/ 521937557 / the-va-is-on-a-pathtowa rd-recovery-secreta ry-of-vetera ns-affa i rs-says VA-19-0799-D-001863 OS 00003541 Message From: Jared Kushner [(b) (6) Sent: 3/30/2017 2:59:22 AM To: David shulkin [Drshulkin@aol.com] Re: Notes Subject: I am very (b) (6) (b) (5) on 3/29/17, 3:00 PM, "David shulkin" wrote: Ike- below are notes from the meeting today as recorded by our team- Jared was great and just pushed hard to get things done- that was a big help. We made good progress. David > > > 1. Tel ehea l th EO (Shaul d be a done deal , will need to work with (b) (6) and (b) (6) on timing but think that it will happen quickly) > 2. Heard that there would be an EO close hold coming out in the next week to exempt technology from the hiring freeze which includes USDS. Will also say there is a need for a national technology council that reports to the president. VA Secretary will be apart of that council. > 3. our approach with Apple should be 3 prongs )1. Enable veterans to download their health records anywhere, work off blue button initiative 2.) incorporate health data from fit bits, watches etc into the health record 3.) make sure clinicians have appropriate access to the technology. The next step is for (b) (6) to convene the va group and apple group together. > 4. Secretary was shown 4 CIO resumes, he liked 3. The WH recruiting team will be doing a technical and background review on all the 3 and see who be best to come in for an interview( here are the names (b) (6) Chris Ross -CIO Mayo, (b) (6) Vet went to West Point and (b) (6) > 5. DOD and VA meeting went well. Next step is for the two teams to look at analysis if VA can piggy back on the contract and how much would that cost, is it feasible. Follow up meeting should be next week in preparation for the DOD Mattis meeting on 4/12. Looking for least amount of money and quickest win. > 6. shared the EO for Accountability and Whistleblower, need to send electronic copy to (b) (6) > > VA-19-0799-D-001864 OS 00003542 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 3/29/2017 7:40:01 PM David shulkin [Drshulkin@aol.com] Ike Perlmutter [(b) (6) frenchangel59.com] Re: Notes Thank you great progress. There is a lot of technology out there that would be free and assist with the positive interaction between the DOD and the VA when it comes to tracking military health prior to coming into VA system. Sent from my iPad Bruce Moskowitz M.D. > on Mar 29, 2017, at 3:00 PM, David shulkin wrote: > > > >Ike-below are notes from the meeting today as recorded by our team- Jared was great and just pushed hard to get things done- that was a big help. We made good progress. > > David >> >> >> 1. Telehealth EO (Should be a done deal, will need to work with (b) (6) and (b) (6) on timing but think that it will happen quickly) >> 2. Heard that there would be an EO close hold coming out in the next week to exempt technology from the hiring freeze which includes USDS. Will also say there is a need for a national technology council that reports to the president. VA Secretary will be apart of that council. >> 3. our approach with Apple should be 3 prongs )1. Enable veterans to download their health records anywhere, work off blue button initiative 2.) incorporate health data from fit bits, watches etc into the health record 3.) make sure clinicians have appropriate access to the technology. The next step is for (b) (6) to convene the va group and apple group together. >> 4. Secretary was shown 4 CIO resumes, he liked 3. The WH recruiting team will be doing a technical and background review on all the 3 and see who be best to come in for an interview( here are the names (b) (6) Chris Ross -CIO Mayo, (b) (6) Vet went to West Point and (b) (6) >> 5. DOD and VA meeting went well. Next step is for the two teams to look at analysis if VA can piggy back on the contract and how much would that cost, is it feasible. Follow up meeting should be next week in preparation for the DOD Mattis meeting on 4/12. Looking for least amount of money and quickest win. >> 6. shared the EO for Accountability and Whistleblower, need to send electronic copy to (b) (6) >> >> > VA-19-0799-D-001865 OS 00003543 Message From: Sent: To: CC: BCC: Subject: David shulkin [Drshulkin@aol.com] 3/29/2017 7:00:49 PM Ike Perlmutter [(b) (6) frenchangel59.com] Bruce Moskowitz [(b) (6) mac.com] Jared Kushner [(b) (6) (b) (6) Fwd: Notes Ike- below are notes from the meeting today as recorded by our team- Jared was great and just pushed hard to get things done- that was a big help. We made good progress. David > > > 1. Telehealth EO (Should be a done deal, will need to work with (b) (6) and (b) (6) on timing but think that it will happen quickly) > 2. Heard that there would be an EO close hold coming out in the next week to exempt technology from the hiring freeze which includes USDS. Will also say there is a need for a national technology council that reports to the president. VA Secretary will be apart of that council. > 3. our approach with Apple should be 3 prongs )1. Enable veterans to download their health records anywhere, work off blue button initiative 2.) incorporate health data from fit bits, watches etc into the health record 3.) make sure clinicians have appropriate access to the technology. The next step is for (b) (6) to convene the va group and apple group together. > 4. Secretary was shown 4 CIO resumes, he liked 3. The WH recruiting team will be doing a technical and background review on all the 3 and see who be best to come in for an interview( here are the names (b) (6) Chris Ross -CIO Mayo, (b) (6) Vet went to West Point and (b) (6) > 5. DOD and VA meeting went well. Next step is for the two teams to look at analysis if VA can piggy back on the contract and how much would that cost, is it feasible. Follow up meeting should be next week in preparation for the DOD Mattis meeting on 4/12. Looking for least amount of money and quickest win. > 6. shared the EO for Accountability and Whistleblower, need to send electronic copy to (b) (6) > > VA-19-0799-D-001866 OS 00003544 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/31/2017 1:33:06 AM (b) (6) [(b) (6) Fwd: VA Video gmail.com] Please send to tom murphyCan we discuss at report in the am? You may want to look at this in case it gets picked up https ://www.youtu be. com/watch ?v= FQ4bd Pnf7YI Only vice news has reported on it so far VA-19-0799-D-001867 OS 00003545 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/30/2017 9:06:44 PM David Shulkin [drshulkin@aol.com] Fwd: VA Video Between our boys we are sure of stuff hitting us- you maybe aware of this but a heads up Sent from my iPhone Begin forwarded message: From: <(b) (6) yahoo.com > Date: March 30, 2017 at 9:52:28 PM GMT +1 To: Poonam Alaigh <(b) (6) hotmail.com > Subject: VA Video You may want to look at this in case it gets picked up https ://www. youtu be. com/watch ?v= FQ4bd Pnf7YI Only vice news has reported on it so far VA-19-0799-D-001868 OS 00003546 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/5/2017 3:04:41 PM Bruce Moskowitz [(b) (6) mac.com] Poonam Alaigh [(b) (6) hotmail.com]; IP [(b) (6) frenchangel59.com]; L Perl [(b) (6) mbs(b) (6) @gmail.com Re: VA families gmail.com]; Perfect Sent from my iPhone > on Apr 5, 2017, at 10:36 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > I have a meeting with the Hopkins group that developed emocha at noon. Some of their solutions may help with the opioid addiction problem. My colleagues at the medical centers have been extraordinarily generous in pointing me to technology even though it may be from another competing center unrelated to the group of five. If I feel the technology is of importance I will pass it on and then perhaps if you also believe it advances health care we should go forward since you are in the best position to determine if it has merit to your mission. > > Sent from my iPad > Bruce Moskowitz M.D. > >> on Apr 5, 2017, at 10:01 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: >> >> sounds good- lets add this to the agenda for our discussion tomorrow. Please feel free to add anything additional that I may have missed >> >> Agenda >> >> 1) R&D and licensing opportunity- will introduce you to Dr (b) (6) >> >> 2) expanding/funding for VA focused residency slots >> >> 3) follow up on the VCL hearing >> >> 4) transparency website and our Academic Affiliate group >> >> Sent from my iPhone >> >>> on Apr S, 2017, at 9:16 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>> >>> I can coordinate I probably should talk with one of your group which was at the committee hearing >>> >>> Sent from my iPhone >>> >>>> on Apr 5, 2017, at 9:01 AM, David shulkin wrote: >>>> >>>> That would be great Bruce- do you need us to do anything at this point? >>>> >>>> Sent from my iPhone >>>> >>>>> on Apr S, 2017, at 7:51 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>>>> >>>>> After the Congressional testimony yesterday by a female Veteran I believe we can show the congressional committee and Veterans the partnership with the Academic Centers can advance care at the time the issue is raised. In order to do this we should have a mechanism of defining the issue and then asking which of the partners has a platform to solve the issue. In the case raised yesterday it would be two of our partners, Mayo clinic and Brigham and Women's. The ability to "pull things off the shelf" immediately shows the value of a partnership arrangement. >>>>> >>>>> Sent from my iPad >>>>> Bruce Moskowitz M.D. >>>> VA-19-0799-D-001869 OS 00003547 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/5/2017 2:36:33 PM David Shulkin [drshulkin@aol.com]; Poonam Alaigh [(b) (6) hotmail.com] IP [(b) (6) frenchangel59.com]; l Perl [(b) (6) gmail.com]; (b) (6) gmail.com Re: VA families I have a meeting with the Hopkins group that developed emocha at noon. Some of their solutions may help with the opioid addiction problem. My colleagues at the medical centers have been extraordinarily generous in pointing me to technology even though it may be from another competing center unrelated to the group of five. If I feel the technology is of importance I will pass it on and then perhaps if you also believe it advances health care we should go forward since you are in the best position to determine if it has merit to your mission. Sent from my iPad Bruce Moskowitz M.D. > on Apr S, 2017, at 10:01 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > sounds good- lets add this to the agenda for our discussion tomorrow. Please feel free to add anything additional that I may have missed > > Agenda > > 1) R&D and licensing opportunity- will introduce you to Dr > > 2) expanding/funding for (b) (6) VA focused residency slots > > 3) follow up on the VCL hearing > > 4) transparency website and our Academic Affiliate group > > Sent from my iPhone > >> on Apr S, 2017, at 9:16 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >> >> I can coordinate I probably should talk with one of your group which was at the committee hearing >> >> Sent from my iPhone >> >>> on Apr 5, 2017, at 9:01 AM, David shulkin wrote: >>> >>> That would be great Bruce- do you need us to do anything at this point? >>> >>> Sent from my iPhone >>> >>>> on Apr 5, 2017, at 7:51 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>>> >>>> After the Congressional testimony yesterday by a female Veteran I believe we can show the congressional committee and Veterans the partnership with the Academic Centers can advance care at the time the issue is raised. In order to do this we should have a mechanism of defining the issue and then asking which of the partners has a platform to solve the issue. In the case raised yesterday it would be two of our partners, Mayo clinic and Brigham and Women's. The ability to "pull things off the shelf" immediately shows the value of a partnership arrangement. >>>> >>>> Sent from my iPad >>>> Bruce Moskowitz M.D. >>> VA-19-0799-D-001870 OS 00003548 Message From: Sent: To: CC: Subject: Poonam Alaigh [(b) (6) hotmail.com] 4/5/2017 2:01:49 PM Bruce Moskowitz [(b) (6) mac.com] David shulkin [Drshulkin@aol.com]; L Perl [(b) (6) (b) (6) gmail.com Re: VA families gmail.com]; IP [(b) (6) frenchangel59.com]; sounds good- lets add this to the agenda for our discussion tomorrow. Please feel free to add anything additional that I may have missed Agenda 1) R&D and licensing opportunity- will introduce you to Dr 2) expanding/funding for (b) (6) VA focused residency slots 3) follow up on the VCL hearing 4) transparency website and our Academic Affiliate group Sent from my iPhone > on Apr 5, 2017, at 9:16 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > I can coordinate I probably should talk with one of your group which was at the committee hearing > > Sent from my iPhone > >> on Apr 5, 2017, at 9:01 AM, David shulkin wrote: >> >> That would be great Bruce- do you need us to do anything at this point? >> >> Sent from my iPhone >> >>> on Apr 5, 2017, at 7:51 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: >>> >>> After the Congressional testimony yesterday by a female Veteran I believe we can show the congressional committee and Veterans the partnership with the Academic Centers can advance care at the time the issue is raised. In order to do this we should have a mechanism of defining the issue and then asking which of the partners has a platform to solve the issue. In the case raised yesterday it would be two of our partners, Mayo clinic and Brigham and Women's. The ability to "pull things off the shelf" immediately shows the value of a partnership arrangement. >>> >>> Sent from my iPad >>> Bruce Moskowitz M.D. >> VA-19-0799-D-001871 OS 00003549 Message From: Sent: To: CC: Subject: David shulkin [Drshulkin@aol.com] 4/5/2017 1:01:03 PM Bruce Moskowitz [(b) (6) mac.com] hotmail.com]; L Perl [(b) (6) Poonam Alaigh [(b) (6) mbs(b) (6) @gmail.com Re: VA families That would be great Bruce- gmail.com]; IP [(b) (6) frenchangel59.com]; do you need us to do anything at this point? Sent from my iPhone > on Apr 5, 2017, at 7:51 AM, Bruce Moskowitz <(b) (6) mac.com> wrote: > > After the Congressional testimony yesterday by a female Veteran I believe we can show the congressional committee and Veterans the partnership with the Academic Centers can advance care at the time the issue is raised. In order to do this we should have a mechanism of defining the issue and then asking which of the partners has a platform to solve the issue. In the case raised yesterday it would be two of our partners, Mayo clinic and Brigham and Women's. The ability to "pull things off the shelf" immediately shows the value of a partnership arrangement. > > Sent from my iPad > Bruce Moskowitz M.D. VA-19-0799-D-001872 OS 00003550 Message From: Sent: To: CC: Subject: Bruce Moskowitz [(b) (6) mac.com] 4/5/2017 11:51:09 AM drshulkin@aol.com; Poonam Alaigh [(b) (6) hotmail.com] L Perl [(b) (6) gmail.com]; IP [(b) (6) frenchangel59.com]; mbs(b) (6) VA families @gmail.com After the Congressional testimony yesterday by a female Veteran I believe we can show the congressional committee and Veterans the partnership with the Academic Centers can advance care at the time the issue is raised. In order to do this we should have a mechanism of defining the issue and then asking which of the partners has a platform to solve the issue. In the case raised yesterday it would be two of our partners, Mayo clinic and Brigham and Women's. The ability to "pull things off the shelf" immediately shows the value of a partnership arrangement. Sent from my iPad Bruce Moskowitz M.D. VA-19-0799-D-001873 OS 00003551 Message From: Sent: To: Subject: Attachments: Poonam Alaigh [(b) (6) hotmail.com] 3/26/2017 3:08:02 PM David Shulkin [drshulkin@aol.com] Fw: J&J VHA Recommendations 24Mar17 JnJ VHA Recommendataions 24MAR17 _final-2.pdf see attached J&J presentation <(b) (6) va.gov> Sent: Friday, March 24, 2017 1:37 PM (b) (6) (b) (6) To: '(b) (6) its.jnj.com'; '(b) (6) [JRDUS]'; (b) (6) Rachel; Valentino, Michael (VACO); (b) (6) (NOLA); Carroll, David (VACO); (b) (6) (Portland); (b) (6) DURVAMC; (b) (6) (b) (6) (b) (6) Lisa M.; Lynch, Thomas (VHA); [JJCUS]; '(b) (6) '(b) (6) its.jnj.com'; '(b) (6) ITS.JNJ.com'; '(b) (6) ITS.JNJ.com'; (b) (6) Poonam Alaigh Subject: FW: J&J VHA Recommendations 24Mar17 From: (b) (6) (b) (6) (b) (6) Ramoni, (b) (6) (PBM); (b) (6) ITS.JNJ.com'; MD, MPH; (b) (6) Pape, Attached is the presentation for this afternoon (b) (6) Staff Assistant Office of the Under Secretary for Health Veterans Health Administration 202-461-(b) (6) (Office) 202-823-(b) (6) (Mobile) Meeting requests : VHAUSHMeetingRequests@va.gov From: (b) (6) [DPYUS] [mailto:(b) (6) ITS.JNJ.com] Sent: Friday, March 24, 2017 1:30 PM (b) (6) To: Alaigh, Poonam, M.D.; (b) (6) Subject: [EXTERNAL] J&J VHA Recommendations 24Mar17 VA-19-0799-D-001874 OS 00003552 Please see attached presentation. Thanks, 875 Healthy Heroes Project Recommendations for VHA Leadership March 24, 2017 VA-19-0799-D-001876 OS 00003554 The concepts in this presentation represent an accelerated set of ideas and proposals developed for discussion, feedback, and alignment. They are the result of an early stage of a process of envisioning a new working relationship between the pharmaceutical industry, academic affiliates and the Veterans Health Administration. It is not to be construed as a final proposal or a memorandum of understanding. VA-19-0799-D-001877 OS 00003555 . I Jolilnson ~ Johnson and the Veterans Health Administration partner ro engage the nation to reduce veteran suicides to zero. We are aligni ~g on high im(la60 initi~tives which accelerate improved outcomes with a focus on precH;~on medicine, a direct to consumer imtegrated marketing campaigri, and clinical trials and research studies. - , I I I VA-19-0799-D-001878 OS 00003556 The Framework Precision Clinical Trials Integrated Marketing Medicine Research Studies Campaign sail/?a. 9 Months Our 10 Point Plan (b) (4), (b) (5) 6 Months (b) (4), (b) (5) 3 Months (b) (4), (b) (5) 1 Month (b) (4), (b) (5) VA-19-0799-D-001880 DS_00003558 881 Precision Medicine Bottom Line Up Front (b) (4), (b) (5) The goals will be to: (b) (4), (b) (5) o o These advances will require: o (b) (4), (b) (5) o o VA-19-0799-D-001882 OS 00003560 Precision Medicine Scepe: Scalable Predictive Platform: Key Considerations (b) (4), (b) (5) o o o o o o o VA-19-0799-D-001884 OS 00003562 that we each bring to the table Veterans Health Administration WW Precision Medicine: Quick Wins (-- 9 months) predictive platform v1: 'Focus on extant data and 'THE WHO" (b) (4), (b) (5) o o o o o VA-19-0799-D-001886 OS 00003564 Precision Medicine: Phase I(_, 20 months) predictive platform v2: 'Focus on new data and THE WHEN' (b) (4), (b) (5) VA-19-0799-D-001887 OS 00003565 Precision Medicine Phase II (-- 42 Months and beyond) (b) (4), (b) (5) o o o o o VA-19-0799-D-001888 OS 00003566 rmExecutive Summary Bottom Line Up Front (b) (4), (b) (5) o o o o o VA-19-0799-D-001890 OS 00003568 Summary of Proposals 891 Summary of Proposals (cont) 892 Next Steps 893 . Zero: Veteran Suicide is Responsibility myykaTING CAMPAIGN I 894 Integrated Marketing Campaign Bottom Line Up Front Goal Insight Strategic Approach Outcome (b) (4), (b) (5) VA-19-0799-D-001895 OS 00003573 The Situation (b) (4), (b) (5) 20 veterans a day die by suicide T 14 are not engaged in VA healthcare at the time of death (b) (4), (b) (5) VA-19-0799-D-001896 OS 00003574 897 Strategic Approach Connecting communities to veterans and veterans to care o oa ,.,. o . . (b) (4), (b) (5) // : ......,_ o o VA-19-0799-D-001898 OS 00003576 Focus Influence and Reach of Leading Organizations Around Single Strategic Mission (b) (4), (b) (5) VA-19-0799-D-001899 OS 00003577 900 08330003578 Unprecedented Connections WM 26 Next Steps Today March/April May/June July/August --------------------------------------. (b) (4), (b) (5) VA-19-0799-D-001902 OS 00003580 ' ~1'~ { ' ')' l .\ . ... ,... ~ \ ' Veterans Health Administration & VA-19-0799-D-001903 OS 00003581 Backup Human Performance Institute Immersion Training & Train the Trainer Programs RFO T I U T ? (b) (4), (b) (5) VA-19-0799-D-001905 OS 00003583 Human Performance Institute Digital Coaching: Skills for Life RFO T I U T ? (b) (4), (b) (5) o o o VA-19-0799-D-001906 OS 00003584 Digital Health: My Study Reporter Digital Health: My Study Reporter Di ital Health: SIBAT Adopt SPOC center at the central research office for all VHA clinical trials (b) (4), (b) (5) o o o o o o o VA-19-0799-D-001910 OS 00003588 1-J .., .... ...., . ~ ~ o I....J - Y ~ ~ ~ J - - I .J o "' "'Id \.., .... o }/j.I} To: David Shulkin Sent: Sun, Mar 26, 2017 8:03 am Subject: Commission Any update on that? The 4 corners were asking about it and I told them that I did not know the status. Also, heard that the nominated person could not be in an acting role based on a recent ruling Sent from my iPhone VA-19-0799-D-001919 OS 00003597 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/26/2017 12:03:22 PM David Shulkin [drshulkin@aol.com] Commission Any update on that? The 4 corners were asking about it and I told them that I did not know the status. Also, heard that the nominated person could not be in an acting role based on a recent ruling Sent from my iPhone VA-19-0799-D-001920 OS 00003598 Message David Shulkin [drshulkin@aol.com] From: Sent: 3/26/2017 12:43:53 PM To: (b) (6) hotmail.com Re: Document - FROM VA - Donna Katen-Bahensky Subject: ok thanks -----Original Message----From: Poonam Alaigh <(b) (6) hotmail.com> To: David shulkin Sent: Sun, Mar 26, 2017 8:39 am Subject: Re: Document - FROM VA - Donna Katen-Bahensky It's not the content that I am concerned about but her action- will fill you in more about my concerns though harmless right now, we need to manage Sent from my iPhone On Mar 26, 2017, at 8:36 AM, David shulkin wrote: I think she made her content harmless We can discuss more monday Sent from my iPhone On Mar 26, 2017, at 7:53 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Not good judgement on Donna's part- with all her experience in the private sector, and apparently a "seasoned executive", she should've known better Sent from my iPhone On Mar 25, 2017, at 10:51 PM, David Shulkin wrote: Ike sent to me Sent from my iPad On Mar 25, 2017, at 10:05 PM, Poonam Alaigh <(b) (6) wrote: hotmail.com> How did you get this - did she include you in her correspondence with Ike Sent from my iPhone On Mar 25, 2017, at 8:20 PM, David Shulkin wrote: This is what the west palm beach medical center director sent to Ike. Nothing too surprising but wanted you to see. I told her she was free to respond to his inquiries. VA-19-0799-D-001921 OS 00003599 Dear Marisol Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va.gov VA-19-0799-D-001922 OS 00003600 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/26/2017 12:39:55 PM David shulkin [Drshulkin@aol.com] Re: Document - FROM VA - Donna Katen-Bahensky It's not the content that I am concerned about but her action- will fill you in more about my concerns though harmless right now, we need to manage Sent from my iPhone On Mar 26, 2017, at 8:36 AM, David shulkin wrote: I think she made her content harmless We can discuss more monday Sent from my iPhone On Mar 26, 2017, at 7:53 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Not good judgement on Donna's part- with all her experience in the private sector, and apparently a "seasoned executive", she should've known better Sent from my iPhone On Mar 25, 2017, at 10:51 PM, David Shulkin wrote: Ike sent to me Sent from my iPad On Mar 25, 2017, at 10:05 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: How did you get this - did she include you in her correspondence with Ike Sent from my iPhone On Mar 25, 2017, at 8:20 PM, David Shulkin wrote: This is what the west palm beach medical center director sent to Ike. Nothing too surprising but wanted you to see. I told her she was free to respond to his inquiries. Dear Marisol VA-19-0799-D-001923 OS 00003601 Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va .gov VA-19-0799-D-001924 OS 00003602 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/26/2017 12:36:14 PM Poonam Alaigh [(b) (6) hotmail.com] Re: Document - FROM VA - Donna Katen-Bahensky I think she made her content harmless We can discuss more monday Sent from my iPhone On Mar 26, 2017, at 7:53 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: Not good judgement on Donna's part- with all her experience in the private sector, and apparently a "seasoned executive", she should've known better Sent from my iPhone On Mar 25, 2017, at 10:51 PM, David Shulkin wrote: Ike sent to me Sent from my iPad On Mar 25, 2017, at 10:05 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: How did you get this - did she include you in her correspondence with Ike Sent from my iPhone On Mar 25, 2017, at 8:20 PM, David Shulkin wrote: This is what the west palm beach medical center director sent to Ike. Nothing too surprising but wanted you to see. I told her she was free to respond to his inquiries. Dear Marisol Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va.gov VA-19-0799-D-001925 OS 00003603 926 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/26/2017 11:53:14 AM David Shulkin [drshulkin@aol.com] Re: Document - FROM VA - Donna Katen-Bahensky Not good judgement on Donna's part- with all her experience in the private sector, and apparently a "seasoned executive", she should've known better Sent from my iPhone On Mar 25, 2017, at 10:51 PM, David Shulkin wrote: Ike sent to me Sent from my iPad On Mar 25, 2017, at 10:05 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: How did you get this - did she include you in her correspondence with Ike Sent from my iPhone On Mar 25, 2017, at 8:20 PM, David Shulkin wrote: This is what the west palm beach medical center director sent to Ike. Nothing too surprising but wanted you to see. I told her she was free to respond to his inquiries. Dear Marisol Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va.gov VA-19-0799-D-001927 OS 00003605 Message From: Sent: To: Subject: David Shulkin [drshulkin@aol.com] 3/26/2017 2:51:16 AM Poonam Alaigh [(b) (6) hotmail.com] Re: Document - FROM VA - Donna Katen-Bahensky Ike sent to me Sent from my iPad On Mar 25, 2017, at 10:05 PM, Poonam Alaigh <(b) (6) hotmail.com> wrote: How did you get this - did she include you in her correspondence with Ike Sent from my iPhone On Mar 25, 2017, at 8:20 PM, David Shulkin wrote: This is what the west palm beach medical center director sent to Ike. Nothing too surprising but wanted you to see. I told her she was free to respond to his inquiries. Dear Marisol Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va.gov VA-19-0799-D-001928 OS 00003606 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/26/2017 2:05:02 AM David Shulkin [drshulkin@aol.com] Re: Document - FROM VA - Donna Katen-Bahensky How did you get this - did she include you in her correspondence with Ike Sent from my iPhone On Mar 25, 2017, at 8:20 PM, David Shulkin wrote: This is what the west palm beach medical center director sent to Ike. Nothing too surprising but wanted you to see. I told her she was free to respond to his inquiries. Dear Marisol Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va .gov VA-19-0799-D-001929 OS 00003607 Message From: Sent: To: Subject: Attachments: David Shulkin [drshulkin@aol.com] 3/26/2017 12:20:16 AM (b) (6) hotmail.com Fwd: Document- FROM VA- Donna Katen-Bahensky Veteran Centric VA.docx This is what the west palm beach medical center director sent to Ike. Nothing too surprising but wanted you to see. I told her she was free to respond to his inquiries. Dear Marisol Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va.gov VA-19-0799-D-001930 OS 00003608 Let's Make the VA more Veteran-Centric When asked what could be done to make the VA system more Veteran-Centric, we realized it is impossible to consider only one priority. There are multiple factors and several can be found in the Commission on Care report-this report was developed by some of the most reputable leaders in health care across the United States. "The most public and glaring deficiency was access problems". Much work has been done and improvements have bene made but access remains a high priority. The Commission went further in writing the following, " ... the long term viability of VHA care is threatened by problems with staffing, facilities, capital needs, information systems, health care disparities, and procurement." We at West Palm Beach VA believe the Veteran experience of care is most influential attribute that will determine the future relevance of VHA. With the report's recommendations and observation at the West Palm Beach VA, we have developed the following set of priorities under four themes: 1) Recruitment, retention, compensation and talent management remain concerns for VHA. Dated standards and rigid hiring practices result in substantial delays and restrict the ability to incorporate cultural fit and customer service as critical metrics in the hiring process. This oftentimes leads to investment in staff that does not possess core values that align with VA mission. The current compensation and talent management systems do not support local growth, hindering the development of a stable leadership team. As stated in the Commission on Care Report, a system that allows for pay advancement based on professional expertise, training, and demonstrated performance (not time-in-grade); promotes flexibility in organizational structure to allow positions and staff to grow as the needs of the organization change and the success of each individual merits; and establishes simplified job documentation that is consistent across job categories and describes a clear path for staff professional development and career trajectories for advancement, would create a foundation for strength in leadership and management at all levels. Conversely, having the ability to discipline and remove those who do not possess ICARE core values, is integral to maintaining and managing a highly functional workforce. Start with the Right Staff with the Right Attitude and Focus on Accountability. 2) Providing the Right Environment and the Right Technology Tools. Modernization of physical and technological infrastructure. Investment in capital-asset needs and information technology is required to operate efficiently and effectively. In order to meet the needs of Veterans, access to state-of-the-art healthcare is required. Location of services in spaces accessible and convenient for Veterans. As an example, forward thinking initiatives using available technology, such as iPads for delivery of care to Veterans and easy-to-use applications for scheduling appointments have been delayed due to stringent security policies that hinder the ability to meet the needs and preferences of patients. VA-19-0799-D-001931 OS 00003609 3) Strengthening Community Partnerships. Strengthening community partnerships to provide an integrated and holistic approach for Veteran well-being; establishment of networks to provide access to community support for at-risk Veterans 24/7; cultivation of resources for Veterans who struggle with housing challenges, substance abuse and employment; and tangible benefits for organizations who hire Veterans. 4) Creating Integrated Networks. Harnessing the expertise of community healthcare organizations to develop the ultimate healthcare delivery system for Veterans, comprised of recognized programs with high-quality results. The newest generation Veterans are eager to receive alternative therapies and treatment options to address both physical and psychological conditions-collaborative research programs and partnerships with highly regarded institutions will help to ensure the cutting edge care Veterans deserve. VA-19-0799-D-001932 OS 00003610 Message From: IP [(b) (6) frenchangel59.com] Sent: 3/25/2017 10:09:02 PM To: David shulkin [drshulkin@aol.com] FW: Document - FROM VA- Donna Katen-Bahensky Veteran Centric VA.docx Subject: Attachments: FYI From: Katen-Bahensky, Donna [ mailto:Donna.Katen-Bahensky@va.gov] Sent: Tuesday, March 21, 2017 10:57 PM To: (b) @frenchanqel59.com (6) Subject: Document Dear Marisol Thank you for the call today. I have attached the draft document and can certainly provide more detail if you or Mr. P would like more information. Looking forward to improving the Veteran's care with the two of you Sincerely Donna Katen-Bahensky donna.katen-bahensky@va.gov VA-19-0799-D-001933 OS 00003611 Let's Make the VA more Veteran-Centric When asked what could be done to make the VA system more Veteran-Centric, we realized it is impossible to consider only one priority. There are multiple factors and several can be found in the Commission on Care report-this report was developed by some of the most reputable leaders in health care across the United States. "The most public and glaring deficiency was access problems". Much work has been done and improvements have bene made but access remains a high priority. The Commission went further in writing the following, " ... the long term viability of VHA care is threatened by problems with staffing, facilities, capital needs, information systems, health care disparities, and procurement." We at West Palm Beach VA believe the Veteran experience of care is most influential attribute that will determine the future relevance of VHA. With the report's recommendations and observation at the West Palm Beach VA, we have developed the following set of priorities under four themes: 1) Recruitment, retention, compensation and talent management remain concerns for VHA. Dated standards and rigid hiring practices result in substantial delays and restrict the ability to incorporate cultural fit and customer service as critical metrics in the hiring process. This oftentimes leads to investment in staff that does not possess core values that align with VA mission. The current compensation and talent management systems do not support local growth, hindering the development of a stable leadership team. As stated in the Commission on Care Report, a system that allows for pay advancement based on professional expertise, training, and demonstrated performance (not time-in-grade); promotes flexibility in organizational structure to allow positions and staff to grow as the needs of the organization change and the success of each individual merits; and establishes simplified job documentation that is consistent across job categories and describes a clear path for staff professional development and career trajectories for advancement, would create a foundation for strength in leadership and management at all levels. Conversely, having the ability to discipline and remove those who do not possess ICARE core values, is integral to maintaining and managing a highly functional workforce. Start with the Right Staff with the Right Attitude and Focus on Accountability. 2) Providing the Right Environment and the Right Technology Tools. Modernization of physical and technological infrastructure. Investment in capital-asset needs and information technology is required to operate efficiently and effectively. In order to meet the needs of Veterans, access to state-of-the-art healthcare is required. Location of services in spaces accessible and convenient for Veterans. As an example, forward thinking initiatives using available technology, such as iPads for delivery of care to Veterans and easy-to-use applications for scheduling appointments have been delayed due to stringent security policies that hinder the ability to meet the needs and preferences of patients. VA-19-0799-D-001934 OS 00003612 3) Strengthening Community Partnerships. Strengthening community partnerships to provide an integrated and holistic approach for Veteran well-being; establishment of networks to provide access to community support for at-risk Veterans 24/7; cultivation of resources for Veterans who struggle with housing challenges, substance abuse and employment; and tangible benefits for organizations who hire Veterans. 4) Creating Integrated Networks. Harnessing the expertise of community healthcare organizations to develop the ultimate healthcare delivery system for Veterans, comprised of recognized programs with high-quality results. The newest generation Veterans are eager to receive alternative therapies and treatment options to address both physical and psychological conditions-collaborative research programs and partnerships with highly regarded institutions will help to ensure the cutting edge care Veterans deserve. VA-19-0799-D-001935 OS 00003613 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/26/2017 12:03:23 AM (b) (6) [(b) (6) Re: 10 Priorities Slides gmail.com] No Sent from my iPhone On Mar 25, 2017, at 7:56 PM, (b) (6) <(b) (6) gmail.com> wrote: For AAMC, Baligh is in Montana and (b) (6) is in leesburg. Do you want (b) (6) attend with you -she's one of the new doctors on Baligh's team working in this area. 's to On Mar 25, 2017 3 :46 PM, "David shulkin" wrote: Thanks Sent from my iPhone > On Mar 25, 2017, at 3:41 PM, (b) (6) > > Pulled out the 10 priorities slides > (b) (6) > <10 priorities slides.pptx> <(b) (6) gmail.com> wrote: VA-19-0799-D-001936 OS 00003614 Message From: (b) (6) Sent: 3/25/2017 11:56:08 PM David shulkin [Drshulkin@aol.com] Re: 10 Priorities Slides To: Subject: [(b) (6) gmail.com] For AAMC, Baligh is in Montana and (b) (6) is in leesburg. Do you want Kameron Matthew's to attend with you -she's one of the new doctors on Baligh's team working in this area. On Mar 25, 2017 3 :46 PM, "David shulkin" wrote: Thanks Sent from my iPhone > On Mar 25, 2017, at 3:41 PM, (b) (6) > > Pulled out the 10 priorities slides > (b) (6) > <10 priorities slides.pptx> <(b) (6) gmail.com> wrote: VA-19-0799-D-001937 OS 00003615 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/25/2017 7:46:34 PM (b) (6) [(b) (6) Re: 10 Priorities Slides gmail.com] Thanks Sent from my iPhone > on Mar 25, 2017, at 3:41 PM, (b) (6) <(b) (6) gmail.com> wrote: > > Pulled out the 10 priorities slides > (b) (6) > <10 priorities slides.pptx> VA-19-0799-D-001938 OS 00003616 Message From: (b) (6) Sent: 3/25/2017 7:41:42 PM David Shulkin [drshulkin@aol.com] 10 Priorities Slides 10 priorities slides.pptx To: Subject: Attachments: [(b) (6) gmail.com] Pulled out the 10 priorities slides (b) (6) VA-19-0799-D-001939 OS 00003617 940 10 Priorities for Sec VA Accountability Legislation Extend the Choice Deadline Past August Choice 2.0 Legislation Infrastructure Improvements & Consolidations Enhance Foundational Services in VA VA/DOD/Federal Coordination EMR Interoperability and Modernization Breakthrough in Suicide Prevention Appeals Modernization Accelerating VBA Performance on Claims 2 You might want to just read the list and then go on. VA-19-0799-D-001941 DS 00003619 Accountability Legislation 1. Increased flexibility to remove, demote, or suspend VA employees for poor performance or misconduct 2. Authority to recoup bonuses of employees for poor performance or misconduct 3. Authority to recoup relocation expenses authorized through fraud or malfeasance 4. Authority to reduce federal pensions for employees convicted of felonies 5. Increased protections for whistleblowers 3 These bullet points are based on Chairman Roe's "VA Accountability First Act," introduced Feb. 28, 2017. VA-19-0799-D-001942 OS 00003620 Extend the Choice Deadline INTERNAL VA VS. COMMUNITY CARE COMPLETED APPOINTMENTS (FY14-16) GROWTH IN COMMUNITY CARE COMPLETED APPOINTMENTS (FY14-16) ? FY14 FY14 FYlS FYlS FY16 FY16 ? ? Community Care Appointments Internal VA Facility Based Appointments -- *Data as of November 17, 2016 4 VA-19-0799-D-001943 OS 00003621 Choice 2.0 Legislation 1. Maintain a high-performing integrated network that includes VA, federal partners, academic affiliates, and community providers 2. Increase choice for all Veterans, starting with those with service-connected conditions 3. Ensure Veterans get the care they need, closer to home when appropriate 4. Optimize coordination of VA healthcare with the health insurance Veterans already have 5. Maintain affordability of healthcare options for low-income Veterans 6. Assist in coordinating care for Veterans served by multiple providers 7. Apply industry standards for performance, quality, patient satisfaction, payment models, and health outcomes 5 These are based on your recent HVAC testimony. VA-19-0799-D-001944 OS 00003622 Infrastructure Improvements Gas Station Minneapolis, MN 1932 Palo Alto VAMC Circa 1895 6 VA-19-0799-D-001945 OS 00003623 Enhancing Foundational Services Million Veteran Program: APartnership with Veterans llcse:irch~Dc,clopmcn1 SCI 7 VA-19-0799-D-001946 OS 00003624 VA/DoD /Federal Coordination UArrny VA and DoD Hospitals II N"')' =i usAF H N;itl M.I IAedCen 0 .0nt V.nlJ!l! .. M O- ~ ,- ' ''''" . . . ' ~ ~ \\lashi,gbnO.C 8 VA-19-0799-D-001947 OS 00003625 EMR Interoperability & Modernization - @te;t1J~ll'l!d.'AiJOV. ~ !':001b1U"1 !n.:l Optn',MS fii lifi ( ~ n lri141 1A~m \JPYnXll/ fklp Jo~-~ 11 ~1u o* i, , IE!J~ i!H':1 111 VistA Scheduling Enhancement ~ ~-~------.--=====""'=""'~ l!!il,a: IIMljil, iO'lll!llt ICTIB l.OR il1ITH W!illll~ .... .. o11.Q'llf l,t.al ll! TIME IB 19 DATE I rn~ M 013 TU14 ME15 TH16 FR 17 M 001 TU OJ ME 04 TH 05 mos M OOB TU ii Ill I 111111111111101 I 111111111 111111111111111 I I Ill 111111111111111 111111111111111 111111111 111111111111111 I I I Ill 111111111111111 111111111111111 I 111111111 111111111111111 Ill 111 I I I I I I I Har 2015 I I I I I I I !a II I 11 13 14 I I I ~ w.- 111111111111111111 111111111111111111 I 111111111111 111111111111111111 I 111111111111 11111111111111 1 111 lll'la ._ ... ) o. :: 'II:.. Ila M' oo--.11o 111111111111111111 I 111111111111 111111111111111111 I 111111111111 11111111111111 1 111 111111111111111111 I 111111111111 8elect Appoint1ent Henu Option: I t int I Oic !Ila oPiQS.l(JR!M. Feb201 5 .. . . .... lil;M.. oau>> 11.A)iMJ 'll.mi!Gl:111 ----=-------,::== ..... ...,-- fit'iM; S.. ii. Ill 1111 o II SI I J l l I 1 1o 1 ~- - - - - - - - - - - - ----1 ! I l l I !I l ~ m ~ U ll ~ U J II ~ n 11 1 .II ir ,. , , I I [!] ll al ~ I I [ -- 717,Ll I~ l~7 -- tS.N;JS!Ln.id1.l!l('l'liiSKU1l ~ O'}ll:~ 11.rn l l . VistA Legacy Scheduling 9 The point here is VistA was outdated (left), so we've made some improvements (right), but what we really need is a new system that's fully interoperable with what our partnering providers are already using. VA-19-0799-D-001948 OS 00003626 Suicide Prevention I ..,.. . , o.. .. .. .. Reach Veterans and their families Expand the VA Suicide Prevention Office Develop innovative prevention strategies . 'o. Q Changethe conversation around suicide .o Build community engagement 10 VA-19-0799-D-001949 OS 00003627 Mental Health PSA 11 The video will play as soon as you cue the next slide. VA-19-0799-D-001950 OS 00003628 Appeals Modernization 700,000 Forecast Data Historical Data 651,300 600,000 500,000 459,810 400,000 300,000 200,000 100,000 0#-----------------------------# # ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~ ~ ~ ~~~################# 12 VA-19-0799-D-001951 OS 00003629 Accelerating Performance on Claims VA Disabilify Claims Backlo~ \l1Mt0~0!Cl1im1~ndi1jCl!l1150m 1111 Decision Ready Claims (DRC) ~ 1111 o Actively engage Veterans in the claims process. o Enhance access & capabilities of VSOs in the submission of DRC. o Expand partnership with VSOs to assist in the acceleration and performance of disability claims. o Successful participation in the DRC program will result in a claim decision within 30 days of submission. ~ 13 The bullets explain how the Decision Ready Claims program will improve performance, accelerate claims decisions, and further reduce the 125-day backlog. The program is slated to begin in May. VA-19-0799-D-001952 OS 00003630 Message From: Sent: To: Subject: David shulkin [Drshulkin@aol.com] 3/31/2017 10:38:13 AM Poonam Alaigh [(b) (6) hotmail.com] Re: John ullyot Medi a and PR Sent from my iPhone > on Mar 31, 2017, at 5:33 AM, Poonam Alaigh <(b) (6) hotmail.com> wrote: > > what position is he getting - Asst secretary of what? > > Sent from my iPhone VA-19-0799-D-001953 OS 00003637 Message From: Sent: To: Subject: Poonam Alaigh [(b) (6) hotmail.com] 3/31/2017 9:33:50 AM David Shulkin [drshulkin@aol.com] John ullyot what position is he getting - Asst secretary of what? Sent from my iPhone VA-19-0799-D-001954 OS 00003638