[House Hearing, 106 Congress]
[From the U.S. Government Publishing Office]
DEPARTMENTS OF VETERANS AFFAIRS AND HOUSING AND URBAN DEVELOPMENT,
AND
INDEPENDENT AGENCIES APPROPRIATIONS FOR 2001
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTH CONGRESS
SECOND SESSION
________
SUBCOMMITTEE ON VA, HUD, AND INDEPENDENT AGENCIES
JAMES T. WALSH, New York, Chairman
TOM DeLAY, Texas ALAN B. MOLLOHAN, West Virginia
DAVID L. HOBSON, Ohio MARCY KAPTUR, Ohio
JOE KNOLLENBERG, Michigan CARRIE P. MEEK, Florida
RODNEY P. FRELINGHUYSEN, New Jersey DAVID E. PRICE, North Carolina
ANNE M. NORTHUP, Kentucky ROBERT E. ``BUD'' CRAMER, Jr.,
JOHN E. SUNUNU, New Hampshire Alabama
VIRGIL H. GOODE, Jr., Virginia
NOTE: Under Committee Rules, Mr. Young, as Chairman of the Full
Committee, and Mr. Obey, as Ranking Minority Member of the Full
Committee, are authorized to sit as Members of all Subcommittees.
Frank M. Cushing, Timothy L. Peterson, Valerie L. Baldwin,
Dena L. Baron, and Jennifer Whitson, Staff Assistants
________
PART 5
DEPARTMENT OF VETERANS AFFAIRS
________
Printed for the use of the Committee on Appropriations
________
U.S. GOVERNMENT PRINTING OFFICE
64-315 WASHINGTON : 2000
COMMITTEE ON APPROPRIATIONS
C. W. BILL YOUNG, Florida, Chairman
RALPH REGULA, Ohio DAVID R. OBEY, Wisconsin
JERRY LEWIS, California JOHN P. MURTHA, Pennsylvania
JOHN EDWARD PORTER, Illinois NORMAN D. DICKS, Washington
HAROLD ROGERS, Kentucky MARTIN OLAV SABO, Minnesota
JOE SKEEN, New Mexico JULIAN C. DIXON, California
FRANK R. WOLF, Virginia STENY H. HOYER, Maryland
TOM DeLAY, Texas ALAN B. MOLLOHAN, West Virginia
JIM KOLBE, Arizona MARCY KAPTUR, Ohio
RON PACKARD, California NANCY PELOSI, California
SONNY CALLAHAN, Alabama PETER J. VISCLOSKY, Indiana
JAMES T. WALSH, New York NITA M. LOWEY, New York
CHARLES H. TAYLOR, North Carolina JOSE E. SERRANO, New York
DAVID L. HOBSON, Ohio ROSA L. DeLAURO, Connecticut
ERNEST J. ISTOOK, Jr., Oklahoma JAMES P. MORAN, Virginia
HENRY BONILLA, Texas JOHN W. OLVER, Massachusetts
JOE KNOLLENBERG, Michigan ED PASTOR, Arizona
DAN MILLER, Florida CARRIE P. MEEK, Florida
JAY DICKEY, Arkansas DAVID E. PRICE, North Carolina
JACK KINGSTON, Georgia MICHAEL P. FORBES, New York
RODNEY P. FRELINGHUYSEN, New Jersey CHET EDWARDS, Texas
ROGER F. WICKER, Mississippi ROBERT E. ``BUD'' CRAMER, Jr.,
GEORGE R. NETHERCUTT, Jr., Alabama
Washington MAURICE D. HINCHEY, New York
RANDY ``DUKE'' CUNNINGHAM, LUCILLE ROYBAL-ALLARD, California
California SAM FARR, California
TODD TIAHRT, Kansas JESSE L. JACKSON, Jr., Illinois
ZACH WAMP, Tennessee CAROLYN C. KILPATRICK, Michigan
TOM LATHAM, Iowa ALLEN BOYD, Florida
ANNE M. NORTHUP, Kentucky
ROBERT B. ADERHOLT, Alabama
JO ANN EMERSON, Missouri
JOHN E. SUNUNU, New Hampshire
KAY GRANGER, Texas
JOHN E. PETERSON, Pennsylvania
VIRGIL H. GOODE, Jr., Virginia
James W. Dyer, Clerk and Staff Director
(ii)
DEPARTMENTS OF VETERANS AFFAIRS AND HOUSING AND URBAN DEVELOPMENT, AND
INDEPENDENT AGENCIES APPROPRIATIONS FOR 2001
----------
Wednesday, March 22, 2000.
DEPARTMENT OF VETERANS AFFAIRS
WITNESSES
TOGO D. WEST, JR., SECRETARY
ACCOMPANIED BY:
THOMAS L. GARTHWAITE, M.D., DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS
HEALTH ADMINISTRATION; JOSEPH THOMPSON, UNDER SECRETARY FOR
BENEFITS, VETERANS BENEFITS ADMINISTRATION; MICHAEL WALKER, ACTING
UNDER SECRETARY FOR MEMORIAL AFFAIRS, NATIONAL CEMETERY
ADMINISTRATION; D. MARK CATLETT, DEPUTY ASSISTANT SECRETARY FOR
BUDGET; DEPARTMENTAL ADMINISTRATION
Chairman's Opening Remarks
Mr. Walsh. Good morning. The hearing will come to order.
Today is the first day of budget oversight hearings for the
Department of Veterans Affairs and the President's budget for
fiscal year 2001. I would like to welcome the Secretary, his
assistants and the staff and members of the Veterans Affairs
Department. We are glad to have you back.
This year it seems the Administration finally got the
message that we have a responsibility to our Nation's veterans
and need to provide enough resources to care for them. The
Department's budget increases $1.5 billion in fiscal year 2001
and includes an additional $1.355 billion for medical care,
$109 million for claims and processing and $13 million for
cemeteries, yet popular programs that produce positive results,
like medical research programs and grants for State homes are
flat-lined or reduced.
Despite these increases, the Committee is wary that the
additional resources in areas like claims processing, medical
care and appeals are not translating to improved performance in
these areas. We will be watching the performance plans and
targets closely in the next few years to see if these
investments are paying off because the veterans community
deserves better treatment than they have received in the past.
We will be sharing our concerns and expectations with you
in the course of our hearings. We are concerned with the VA's
ability to implement the Millennium Health Care Act while
improving the level of basic care to our veterans in hospitals
at outpatient clinics. We are concerned with the
Administration's plan to return $350 million to the Treasury
from medical care collections. We are going to be looking to
the Department to produce real results when it comes to
processing benefits. We are looking to the Department to
provide a plan for addressing cemetery needs, as we lose more
of our Nation's heroes.
We are depending on the inspector general to catch waste,
fraud and abuse by those inside and outside of the Department,
and we are depending on the Department to provide a solid plan
and sensible plan for providing medical care in all parts of
the country for veterans, including a plan for merging capital
assets.
I will address many of my questions and concerns to the
respective assistant and under secretaries at our April 5th
hearing and look forward to your testimony today.
I would, at this time, yield to my colleague and friend,
Mr. Mollohan, for any opening remarks that he may have.
Ranking Member's Opening Remarks
Mr. Mollohan. Thank you, Mr. Chairman, just a few remarks
welcoming the Secretary. I, along with the Chairman, look
forward to his testimony.
Mr. Secretary, I was pleased when I received your budget
submission, it demonstrated that the administration recognizes
the medical care funding needs of our veterans and is
attempting to meet them. The $1.5 billion requested increase is
the largest discretionary dollar increase ever proposed for
veterans' programs, and you are to be commended.
That being said, it must be noted that the VA continues to
face significant challenges in meeting the obligations that our
Nation has to veterans. Access to medical care must be achieved
in a more timely manner, appeals of benefits decisions need to
be heard and decided in a more timely manner and the VA needs
to make a better effort to ensure that veterans are aware of
the benefits to which they are entitled.
Finally, one of the biggest challenges facing the VA today
involves the aging veteran population. The VA must be prepared
to provide long-term care and to increase home health care to
meet the needs of these veterans. The Millennium Health Care
Act of 1999 provides some authority to begin to meet these
needs, and I am interested to learn how this law is being
implemented and what needs are still unmet.
I look forward to your testimony, Mr. Secretary.
Thank you, Mr. Chairman.
Mr. Walsh. Thank you.
Secretary West's Opening Remarks
Mr. Secretary, please make your statement. It will be
included in the record in its entirety.
Secretary West. Thank you, Mr. Chairman, for including the
full statement in the record. I will just make some brief
opening comments.
Mr. Chairman, Ranking Member Mollohan, members of the
committee, good morning. It is a pleasure, and thank you for
inviting me and my colleagues to join you once again with this
opportunity to present the President's Veterans budget for
fiscal year 2001.
The President's overall budget for 2001 is the fiscally
responsible approach to balancing the budget. It puts our
Nation on a path to eliminate the national debt in the year
2013, making our Nation debt free the first time since 1835.
This budget recognizes, as well, another debt; that of this
Nation to her veterans. The President's request for Department
of Veterans Affairs reflects his and this Nation's continuing
commitment to those who have served our country with valor and
with honor.
Our budget proposes significant increases for each of the
Department's, three administrations, whose under secretaries
are here before you with me, and for all of our staff functions
represented by the assistant secretaries behind me. These
resources will allow us to continue to improve our ability to
provide the highest quality service to our Nation's veterans.
The VA fiscal year 2001 budget request is for approximately
$48 billion, which includes $22 billion for discretionary
programs and $26 billion for entitlement. As you, Mr. Chairman,
and the ranking member have noted, that is a discretionary
increase of $1.5 billion above last year's appropriated funding
level, the highest increase requested by any President. That
request, along with the additional resources agreed to by the
Congress, at the insistence of this subcommittee and by the
administration in 2000, reflects a 2-year discretionary total
increase of more than $3.1 billion or 16.4 percent.
Mr. Chairman, our veterans are, as we often say, entitled
to the best health care America can provide. It is our
determination to provide that. The past few years at the
Department, we have transformed the hospitals, medical centers,
outpatient clinics run by the Department to provide greater
access to better care for more veterans. And with the funding
in this year's fiscal year 2001 budget, we will continue this
improvement.
Within the VA budget, we are requesting $20.3 billion to
provide health care for veterans. This represents an increase
of $1,355 billion over last year's authorized and appropriated
level. Added to that approximate amount is an additional $608
million we anticipate in medical collections. With these health
care funds, the Department will treat 3.9 million veterans,
100,000 more patients in 2001, than in 2000. We will open 63
new outpatient clinics, which when added to the clinics opening
in 2000, will bring us well above the 600-outpatient clinic
level.
We will redirect 1,500 full-time equivalent employees to
increase access to VA care and to improve our service to
veterans. We will spend an additional $145 million to treat
veterans with Hepatitis C for a total funding level in the
fiscal year 2001 budget of $340 million. In addition, we will
fully fund the implementation of the Veterans' Millennium
Health Care Act passed by this Congress late last year at $548
million. As you recall, the act deals with specialized mental
health services, emergency care and extended care services.
We will increase our funding for long-term care initiatives
by $350 million. This will enhance home and community-based
care programs for older veterans and will cover the
implementation of emergency care programs.
Once again, we will set aside $321 million for high-
priority research projects, some 1,942 of them.
Mr. Chairman and members of the committee, recently,
medical journals and other media have carried reports that as
many as 180,000 deaths occur in the United States each year due
to errors in medical care, many of which are preventable. It
will take dramatic action from all health care providers in the
United States, not just VA, to improve in this area.
To enhance VA's leadership in patient safety management,
however, we plan to spend $137 million to monitor and oversee
safety issues and to comprehensively train all VHA staff on a
recurring basis on patient safety issues. VA has not only
recognized the problem, but we have recognized a basic fact;
this is one of the greatest opportunities we will have and have
had in a long time to make dramatic improvements in the way
health care is provided in this country. At VA, we have
insisted that it is impossible to correct or prevent errors
without first acknowledging that they occur.
We have launched the National Patient Safety Partnership,
an organization that has brought together Federal and private
sector experts to join forces to address the patient safety
problem. We recognize that change will require team effort at
every level in our organization, and we will make those
changes.
We have led the Nation in identifying problems that result
in medical errors. This budget will enable us to continue that
leadership. We will engage in comprehensive monitoring at the
national and local levels with respect to patient safety. We
will be redirecting an additional 190 FTE towards patient
safety enhancements, which means a total of 500 FTE dedicated
to this effort in fiscal year 2001. Significant training,
highlighted by VA's National Center for Patient Safety, the
Quality Scholars Program and 20 hours of biannial training for
all full-time staff, will keep this Department in the forefront
of this important area to our veterans, to their families, to
the Nation.
VA's benefit programs are a tangible expression of this
Nation's determination to meet its obligations to our veterans.
For fiscal year 2001, we are requesting $22.9 billion to
support compensation payments to 2.3 million veterans, 301,000
survivors of veterans, and 864 children of Vietnam veterans
born with spinal bifida. This amount will also support pension
payments to some 363,000 veterans and 253,000 survivors.
We propose a cost-of-living adjustment at 2.5 percent, to
be effective on the 1st of December 2000. If this body, if
Congress approves, we will pay full disability compensation to
veterans and survivors of Filipino forces who served with U.S.
forces in World War II and are now living in the United States.
They currently receive benefits at half the level of the U.S.
veterans beside whom they fought.
In this budget, we are requesting $1.6 billion for
readjustment benefits, to provide education opportunities to
veterans and eligible dependents and for special assistance
programs for disabled veterans. Educational benefits will be
provided to about 480,000 veterans and dependents in 2001,
including 309,000 who will be receiving training under the
Montgomery GI bill.
We will emphasize faster, more accurate claims decisions, a
priority of ours for some years now, along with a high level of
customer service and satisfaction. In the discretionary budget
for the Veterans Benefits Administration, for administration
and claims processing, we provide $999 million and 11,824 FTE.
That request reflects an increase of $109 million in the
discretionary budget for VBA and an increase of 287 FTE over
the 2000 level. This will enable us to direct 586 new FTE into
compensation processing. They will help process disability
claims in a more timely fashion and to continue with quality-
enhancing initiatives.
You will recall that we added 440 FTE into adjudication in
fiscal yer 2000, which will give us an increase in FTE devoted
to processing claims in excess of 1,000 personnel for fiscal
years 2000 and 2001. This is not our only undertaking to
improve the timeliness, effectiveness and accuracy of our
claims processing. Also included in this budget is yet another
payment on our effort to go to a totally computerized claims
processing environment. That, of course, is a process which
will take several years.
Last year, 561,000 veterans died--an average of about 1,500
per day. For the operation of the National Cemetery
Administration, this budget requests $110 million, a $13-
million increase over the fiscal year 2000-enacted level. This
includes funding and FTE to address an increasing interment and
maintenance workload at our national cemeteries. It also
includes the high rate of interments during the first years of
operation at four new national cemeteries being opened in
fiscal year 1999 and being opened in fiscal year 2000; two in
1999 in Sarasota and outside of Chicago, and two in 2000 at
Dallas-Fort Worth and Cleveland.
We have in the budget planning funds for four additional
cemeteries in Atlanta, Miami, Detroit and Sacramento. And we
proceed, as well, with plans under legislation in the fiscal
year 2000 for cemeteries in Oklahoma and Pittsburgh.
Mr. Chairman and members of the committee, one of the
initiatives reflected in this budget for the national cemetery
system is what we have identified as the national shrine
commitment. It assumes that our cemeteries are not just places
where our veterans rest in honored glory, as they are, but also
national shrines: shrines to patriotism, shrines to service and
sacrifice for our Nation, shrines for the eternal verities of
this Nation--faithfulness, integrity and belief in our country
and in her people.
To carry out this commitment, we will need to take care of
backlogs of maintenance that have not been accomplished over
the years--gravestones, grave markers that have sunk in some
parts of cemeteries, roads that need repair, activities that
are not funded out of our daily regular operating budget for
the cemetery system. That amount, $5 million, is only a down
payment, and to make a real investment, real progress, will
need to be replicated each year.
For those of you who have had the opportunity to visit
American cemeteries abroad, not maintained by this Department,
they are a fine statement and an effective representation of
our devotion to our veterans and our dead abroad. American
families do not get to visit them as much as they do our
cemeteries here. So we can do something to improve the
appearance of those parts of our cemeteries that have begun to
suffer from decay.
For 224 years, America's veterans and our men and women who
currently serve on active duty in uniform have brought a record
of security and peace to the North American continent and the
American people who live here. With this bill, we say to our
veterans, ``Well done. The Nation values your gift of service
and patriotism and will honor her commitment to you.''
Mr. Chairman, I thank the members of your staff and the
members of this committee for your continued interest to the
Department's needs, the needs of our veterans. We look forward
to working with you. We thank, as well, the VSOs, the veterans
service organizations, for their vigorous advocacy during last
year's authorization appropriation process doing this year's
budget cycle. We look forward to working with them as well.
Seated here with me to my far right, the Acting Under
Secretary for Memorial Affairs, Mike Walker; the Deputy Under
Secretary for Health, Tom Garthwaite; the director of our
budget, the Deputy Assistant Secretary for Budget, Mark
Catlett; and the Under Secretary for Benefits, Joe Thompson.
Mr. Chairman, we are fully identified. I have completed my
remarks. We are prepared for your questions.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
veterans claims--well-grounded claims
Mr. Walsh. Thank you very much for those remarks and for
your service to the Veterans Administration and to the veterans
of this country.
I would like to ask some questions beginning with veterans
claims, the new veterans agency, policy, and well-grounded
claims.
I think it is safe to say that many of us have heard from
various veterans service organizations regarding the Agency's
pending rule on well-grounded claims. We have been hearing that
this rule will further clog the already choked C&P process by
adding another level of decision making, and it puts a larger
burden of proof on the veteran. I do not think the claims
process can stand another delay. Please tell us the VA's vision
for how the rule changes claim processing and how you perceive
this change will be a benefit to the veteran and to the
Department.
Secretary West. Mr. Chairman, you have asked specifically
about the rule, so I will let Joe Thompson, our Under
Secretary, go directly to the specifics of our proposed rule.
Mr. Thompson. Mr. Chairman, last summer the Court of
Appeals for Veterans Claims issued a decision in a case known
as the Morton case. This case limited our duty to assist
veterans in pursuing their claims. I have to say up front that
we take very seriously our obligation to help veterans in the
pursuit of their claims. We believe it is part of our core
mission to do that. But as a result of the court's decision, we
put out an interim policy statement late last summer basically
telling regional offices that they have to comply with the
court's decision. Shortly thereafter, we also issued a proposed
regulation that would, in effect, liberalize the court's
decision. We are in the middle of that rulemaking process right
now.
Our view of how the proposed regulation would work is this:
Number one, a well-grounded claim is simply a plausible claim.
We believe it to have a low threshold of proof, one that is
very consistent with most claims processes in the Federal
Government. We do not believe it will put a significant burden
on claimants.
What we will do, under our proposed regulation, is this: we
will presume the credibility and truthfulness of the evidence
presented to us, and we will request and review all service
medical records and all VA treatment records that VA possesses
before we make decisions. In no case will we go back to the
veteran and simply deny his or her claim. What we will say is,
``You are missing this piece of evidence that will allow us to
go further with your claim.'' So we give them 30 days to
provide us with that evidence.
And then we have allowed for exceptions in the regulations,
which may change based on the public comments we receive. But
veterans who do not have the financial means to pursue a claim,
veterans who have psychiatric problems, veterans suffering from
post-traumatic stress disorder, and anyone discharged within
one year, of this filing, all of them would be presumed to have
well-grounded claims.
I also have to point out that veterans have an extensive
network of help throughout the United States. There are
approximately 3,700 people who do not work for VA, but who are
charged primarily with the responsibility to help veterans
pursue their claims at the State level, at the county level and
at the national service organization level. They are there to
help veterans with these issues.
Right now we are meeting with the stakeholders in this
process: the NSOs, members of the congressional committees
staffs. We are looking at the 22 comments we received on our
proposed regulation. We do not believe a change of law is
required. We think it will cost more and we do not believe it
will help veterans. In fact, implausible claims that come into
us overwhelmingly end up denied no matter the efforts we go to.
And we think it could create unforeseen obligations for the
Federal Government that are hard to predict at this point in
time. So we believe that our regulation will get the job done
and will meet veterans' needs. Veterans with plausible claims
that ultimately can be proved will prevail in this process.
That is our position.
Secretary West. I would like to add one point, Mr.
Chairman, and that is this: I would not want the fact that we
are pursuing this rulemaking effort to confuse a larger
overarching point, and that is the question of where this
Department stands on its duty to assist veterans who file a
claim. We believe that, unlike other agencies, we have a duty
to assist; that we have a duty to lean forward in our chair
when veterans come in and to be as helpful to them as we can.
The court decision cut back on that. This regulation is an
attempt to carve out the ways in which we can preserve that in
a balanced fashion.
reactions to well-grounded claims ruling
Mr. Walsh. Clearly you are putting the burden of proof onto
the veteran. While they do have lots of support from the
veterans service organizations, you are talking about an
individual taking on an agency, and there is a lot of concern
out there about, ``Wait a minute. This is our agency. They are
protecting our benefits and the promises the country has made
to us. Why are we the bad guy? Now we have to prove these
things?'' There should be a presumption here on the part of the
Agency.
Secretary West. Of course, we did not put that burden on
it, the court did in Morton v. West.
Mr. Walsh. I understand that.
Secretary West. What we are trying to do is carve out ways
in which to live with the ruling and show our willingness to
reach across in specific cases and be even more helpful to
veterans.
Mr. Walsh. Is it the intention of the Agency that anyone
who files a claim must have now all of their military and
service records before they file?
Mr. Thompson. Not at all. We will secure the evidence 100
percent of the time. We will get their service records. If
there are VA treatment records, we will secure those as well.
We think the threshold is not high. It is simply putting forth
a claim that we believe has a chance of being approved. It does
not mean proving it yourself. We will assume the responsibility
of going in and digging into the evidence, but we do not think
the threshold we are establishing is very high.
Mr. Walsh. Could you explain the Agency's view of the
veteran's claim prior to this ruling as opposed to after this
ruling.
Mr. Thompson. The Agency had a rule that said we would
develop the evidence in all cases. The Court of Appeals for
Veterans' Claims said before the Agency has an obligation to
assist veterans in developing their claims, it is the
responsibility of the veterans to present a plausible claim to
us. So they reversed the process. In the past, we would have
developed all issues. Under the Morton decision, the court
said, in order for you to invoke those Government resources to
developing issues, the veteran needs to put forth a plausible
claim.
By studying the claims that were coming in to see whether
they met a well-grounded threshold or not, we found that,
overwhelmingly, if we cannot get the veterans to meet that
threshold, their claims ultimately are denied. And the irony is
that we will spend more resources pursuing evidence which
oftentimes does not exist or does not exist in a form to
support their claim versus using those resources for veterans
who do have plausible claims before us.
veterans service records
Mr. Walsh. When I asked if the veteran has to have all of
his military and service records prior to filing, you said,
``No, we will get their service records.'' What is the
difference between the prior standard and the current, in terms
of your support for getting the data for that claim.
Mr. Thompson. In the case of the military records, service
medical records or VA records, there is no difference. We would
have done it in the past and we will do it under our proposed
regulations.
Mr. Walsh. What does the veteran have to provide now that
is different from before?
Mr. Thompson. The court imposed a three-part test.
Basically, they said that first, you need to have some evidence
within your service records that there was a disability
incurred; second, you need to have a current disability; and
third you need to have a nexus to show that there is some
relationship between those two things. That is the test. As far
as securing the service records and VA treatment records, we
have done that historically and we will continue to do so.
impact of new ruling on claims processing
Mr. Walsh. The practical application of this, other than
the burden-of-proof issue on the veteran, is the processing
time. How will this new ruling affect processing?
Mr. Thompson. We know it takes, on average 60 days longer
when the claim is not well grounded to make a final decision on
the claims. And I think the difference is somewhere between 130
and 199 days. This is the impact. They slow you down because
you have to pursue more evidence and oftentimes you have to
pursue it multiple times before concluding that it does not
exist. If a plausible claim comes in, not only are they easier
and faster to do, they almost certainly have a higher chance at
being granted than cases where that plausibility test is not
met.
Mr. Walsh. You mentioned that the veterans service
organizations are there to help the veteran process easier and
to help make their case. What is their reaction to this
rulemaking?
Mr. Thompson. Most of them do not like it. We have
extensive comments to our regulation. They think the regulation
needs to be seriously changed. A number of them support
legislation to codify the duty to assist in the law before a
well-grounded claim is filed.
Mr. Walsh. If a statute were passed that shifted the burden
back to the Agency, for example, that would be something the
veterans service organizations would support?
Mr. Thompson. I do not want to speak for all of them, but
for some of them, yes. The ones we have been dealing with, I
would say that is probably more the sentiment than otherwise.
Secretary West. I would say something slightly different,
Mr. Chairman. I would say we have not finished our rulemaking
process and that the important part of it right now is to try
and take into account and to accommodate those very concerns
and comments they have raised. The test will be whether we come
up with a rule that they think they can live with. If not, the
answer is yes to your question; that is, they would probably
like legislation. But if we come up with a rule that they can
live with, they may prefer that. We need to see how that works,
and that is not going to take forever. It is going to take a
little bit longer because we are going to be very careful--22
comments and lengthy comments at that. We are going to take
time. We are going to talk with them and work through it, but
we will know better once we finish the process, and we should
know in a reasonable time.
Mr. Walsh. What is the time frame for a decision on the
rule.
Secretary West. The general counsel thinks approximately
two to three months.
Mr. Walsh. From this day.
Secretary West. From today, yes.
Mr. Walsh. I would like to ask you just a few more
questions, now on the Board of Appeals.
Secretary West. Can I say one other thing about this?
Mr. Walsh. Sure.
Secretary West. It is not, Mr. Chairman, as if the court
has acted in this case and VA has sort of happily joined hands
and skipped off to say, ``Great. A burden has been lifted from
us.'' On the contrary. VA persisted in our practice of
developing all of the evidence, despite the fact that the court
had sent several warnings to us in earlier decisions. In some
respects, this thunderbolt is not really a thunderbolt. We
could have seen it coming because we persisted in developing
the evidence for veterans.
Now that we are faced with it, we are making a good-faith
effort in working with the VSOs and others to try to deal with
this in a regulatory fashion. If we failed, then it would
certainly be appropriate for whatever legislative remedy you
would consider.
Mr. Thompson. Mr. Chairman, if I could mention that we have
been meeting particularly with the NSOs on this issue, and we
have another meeting scheduled for early next month. We are
going to sit down, and if there is any middle ground where we
can craft the regulation to address their concerns, their valid
concerns, we will certainly do so. So we will pursue that.
Mr. Walsh. I have used up enough time for now. I think I
will go to Mr. Mollohan for questions.
veterans millennium health care and benefits act
Mr. Mollohan. Thank you, Mr. Chairman.
Mr. Secretary, your budget includes $548 million to
implement the new Veterans' Millennium Health Care and Benefits
Act. That law makes substantial changes in your programs for
veterans. I would like to hear you talk about what you feel it
will mean to the individual veteran and the individual
veteran's families.
Secretary West. All right. I will make a couple of
comments, and Dr. Garthwaite, deputy under secretary of health
will want to fill in some details. But one thing I would like
to focus on specifically, a couple of things actually. This is
a great step forward in trying to help us deal with the problem
that both VA and the Nation are wrestling with, long-term care
for veterans.
As our veterans population continues to age, I think now
the number is approximately 63 percent of all of our veterans
are over 65. Thus, long term care is of immediate importance to
veterans. The act and our implementation of it depended on us
specifically to look at long-term care alternatives to
institutional care such as community-based and home-based
initiatives. That is going to be very important. It will make a
difference to every veteran and veteran's family for whom long-
term care is a factor.
Similarly, we have had for a long time the issue of
emergency care for veterans, emergency care, especially when
they are out of system. The act also advances that. And it
makes an effort to lay out some things that we will be
undertaking over the next several years. That is why we have
chosen to fully fund it with an appropriation of $548 million.
Let me let, if I might----
funding the millennium act
Mr. Mollohan. Let me ask you just on that point, when you
say ``fully funded,'' do you mean it is fully funded up to the
authorization or it is fully funded to meet all of the needs
that could be met under its provisions?
Secretary West. Without sounding presumptuous, it is just
the latter; that is, we tried to fully fund everything we can
see that would flow from it. And I may have not----
Mr. Mollohan. What is the authorization funding level for
the provisions of that Act?
Secretary West. There is none specified. The only----
Mr. Mollohan. It is not specified.
Secretary West. The only measure I have is that built into
it is an effort to offset some of that funding with increased
authorization for copays and the like. That does not come to
that. That comes to only $350 million; whereas, we are
suggesting an appropriation of $548 million.
Mr. Mollohan. All right. Well, I want to get to that as
well.
What is your request with regard to funding? As I
understand it, the act anticipates an appropriation
supplemented with fee collections. But as you have structured
your budget request, you are asking for a full appropriation
and a return of whatever fees are generated to the general
revenue. Is that the authorization scheme?
Secretary West. No, it is not a scheme. Every year since I
have been here, I have come before you, Mr. Mollohan, this
subcommittee and others have said to me: Can we trust your
projections on third-party collections? Are you really going to
meet that number?
At the same time, when I go before the VSOs, they say: Why
are you using that money for operations? You are supposed to
get appropriations for authorizations. And this money that
comes from collections is supposed to be available to center
directors to fill in, as it were, to meet the needs
essentially, unanticipated and the like.
Now, whether they are correct about that or not, this year
we are going to try to, especially in the case of the
Millennium Act, do something that perhaps offers greater
certainty. The one thing that is for certain is that if that
appropriation is there----
Mr. Mollohan. You are asking for an appropriation and you
want the authorization you are operating under, which provides
that fees be used to offset benefit costs, to be changed.
Secretary West. Only the amount attributable to the
Millennium Act, however, one half of the first $700 million of
all collections would go to Treasury.
Mr. Mollohan. I understand. Are you requesting that
authority from this committee or from the authorizing
Committee?
Secretary West. I think we are trying to structure it where
it is appropriate. And so we are requesting it from you.
Mr. Mollohan. Have you talked with the Authorization
Committee about this request?
Secretary West. Yes, sir. I testified before them three
weeks ago and presented it.
Mr. Mollohan. Do they like that request? Do they want this
committee to deal with that issue?
Secretary West. Well, they did not express themselves on
the issue of which committee should deal with it. Obviously,
the opinions as to whether having the $350 million in
collections go into the Treasury rather than be retained were
divided between different points of view.
Mr. Mollohan. It was discussed, though.
Secretary West. Yes, sir. I think they are well aware of
our proposal.
Mr. Mollohan. Did you request of them that they fix this in
authorization? As a part of your presentation to that
committee, did you request that they be responsive to the way
you want to handle collected fees and the way you want the
Millennium Act funded through the general appropriation?
Secretary West. Well, we certainly presented it to them.
Mr. Mollohan. You made that request of them?
Secretary West. Yes, sir. And said this is our legislative
program.
Mr. Mollohan. So that is an action item for the authorizing
committee?
Secretary West. We think it is an action item for the
Appropriations Committee, sir.
Mr. Mollohan. So you are asking this Committee to allow
that funding structure and not asking the Authorizing Committee
to do so?
Secretary West. We are presenting it to both, but asking
you to do it.
Mr. Mollohan. Okay. All right.
Did you want to elaborate on that?
Dr. Garthwaite. I think it has been answered. [Laughter.]
Secretary West. No, this was on the Millennium Act.
Mr. Mollohan. So just to be clear, the $548 million that
you are presenting here as fully funded, you think it is fully
funded to meet all of the needs that could flow from the
Millennium bill to veterans?
Secretary West. For fiscal year 2001.
Mr. Mollohan. I am going to submit the Medicare subvention
issues for the record.
drug addiction
Mr. Mollohan. Let me ask you does the VA see drug addiction
among veterans to be a significant problem?
Secretary West. Well, we certainly treated it as one, sir.
It has always been one of our high priorities. Substance abuse
issues, especially among homeless veterans, for example, have
always had a high priority with us. So, yes.
If you look at it from the attention we paid to it, we
certainly do.
Mr. Mollohan. How is that expressed in your budget request?
Secretary West. For example, how much of our request can we
identify as flowing to treatment, to substance abuse treatment?
Mr. Mollohan. That would be a good way of answering it.
Well, you can answer for the record if you or you can talk
about it.
Secretary West. My budget director is saying it is in the
range of $300 to $400 million, but we will give you the exact
figures for the record.
Mr. Mollohan. Would you do that?
Secretary West. Yes, sir.
insert for the record
Mr. Mollohan. In addition to supplying the information for
the record, would you send it over to me?
[The information follows:]
Specialized Substance Abuse Treatment
VA specialized Substance Abuse Treatment Programs provide
for the care and treatment of eligible veterans with alcohol
and drug use disorders. They are estimated to cost $391 million
in FY 2001.
Secretary West. Dr. Garthwaite might have some numbers for
you.
medical research funding
Mr. Mollohan. Why not just submit it for the record.
What is your request for research generally?
Secretary West. $321 million.
Mr. Mollohan. That is a flat request; is it not?
Secretary West. Yes, sir, it is. It is the same as last
year.
Mr. Mollohan. Sir, why are you not asking for additional
money for VA research, medical research?
Secretary West. Two basic reasons, maybe more, but one is
the straightforward fact that we have to assign our priorities
somewhere, and our priorities in health care this year have
been in clinical efforts. The increase that we got for research
last year for $321 million was significant. We think we can do
a lot with it. There is also the other fact that that is not
the only source of our research budget. I think we have another
$343 million in Federal grants, $154 million in other grants,
$331 million support from Medical Care, for a total of almost a
billion dollars.
Mr. Mollohan. You are giving me history now?
Secretary West. No, sir. This is what we have proposed to
spend in fiscal year 2001.
Mr. Mollohan. Does that represent an increase?
Secretary West. About $7 million.
Mr. Mollohan. In a really generous budget request, that
seems like a small increase request.
Secretary West. I think it is a small increase, but it is a
large amount that we are spending. We are spending in the
neighborhood of a billion dollars on research in fiscal year
2001. That is to say that we will spend every cent we get.
Mr. Mollohan. Did you request more in this area from OMB?
Secretary West. I am not sure. We will find out.
Mr. Mollohan. Somebody here is sure. Please ask them, will
you? I would like you to respond to that question.
What was your first request to OMB or your highest request
to OMB in this area?
Secretary West. It was for about $65 million more.
[Clerk's note.--On page 32, line 754, Mr. Mollohan asked
``What was your first request to OMB or your highest request to
OMB in this area?'' He was requesting information on VA's
Medical and Prosthetic Research request. Secretary West
answered $65 million more than the FY 2000 enacted level. The
additional $65 million was for initiatives only. The OMB
request included an additional $11 million for current services
or uncontrollable adjustments and $65 million for initiatives,
for a total of $76 million above the enacted level. On the next
two pages of the testimony, the reference to $65 million is
correct when referencing the additional funding for research
program initiatives.
Secretary West's testimony (line 756) is edited then as
follows (edits in italic):
Secretary West. It was for about $76 million more than the
FY 2000 enacted level, $11 million for current services
adjustments and $65 million more for program initiatives.]
Mr. Mollohan. So it was OMB that pushed it back. In what
research areas were you requesting an increase that OMB did not
approve?
Secretary West. Which areas within our research?
Mr. Mollohan. Yes, sir.
Secretary West. I am not sure we have that breakdown. This
was just a discussion, unless I am wrong, of the macro number,
the total number.
Mr. Mollohan. You had to have a basis for requesting $65
more than you requested the year before, and I am asking you
what was the basis for----
Secretary West. I will try to tell you, but I do not think
I have that here.
Mr. Mollohan. Excuse me. I have not finished my question
yet.
Secretary West. I am sorry.
Mr. Mollohan. There must have been a basis for that
requested increase. I mean, that $65 million request was for a
purpose, and what I am asking is what was that purpose?
Dr. Garthwaite. We can break that out. I believe there were
some increases in health services research.
Secretary West. While he is doing that, can I say that OMB
did not specifically deny some specific elements of our
research. That is the answer I was trying to give. But go ahead
and finish your----
Dr. Garthwaite. We can break out what other programs----
Mr. Mollohan. I am interested in knowing where you wanted
to increase your research activities and where this $65 million
would have allowed you to do that.
Dr. Garthwaite. I believe in addition to inflationary
increases, we added to health services research. I think there
was more for Gulf War, but we can get you the specifics.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Mollohan. Do you have any increase provided for in your
research request for drug addiction, drug treatment?
Dr. Garthwaite. I will have to get you that information for
the record.
Mr. Mollohan. Sure. That is fine. Thank you, Mr. Secretary.
Thank you.
[The information follows:]
Research for Drug Addiction
Presently, spending for Drug Addiction/Substance Abuse VA Research
is $29.9 million per year.
Mr. Walsh. Thank you. Mr. Knollenberg?
bio-artificial kidney implant research
Mr. Knollenberg. Mr. Chairman, thank you very much and
welcome, Mr. Secretary, and your group this morning. I want to
thank you for coming to my office the other day to discuss a
number of issues, and one in particular that I want to thank
you on, too, for having put in the persuasion or whatever it
was that allowed us to get a letter in regard to this issue
that you are very familiar with now, and I am sure your staff
and the officials that are here with you are becoming familiar
with it.
It is on the issue of the bio artificial kidney implant.
And I am a little bit confused, and again bear with me on this
because you and I talked about this. We did receive a letter
from Dr. Garthwaite, I believe it is. I know that this is a
position that you have held for some time now, but it has not
been forever. So perhaps some of--there is a lot of work that
you have to do and catch up on.
But what I am confused about, and I wanted to bring this up
kind of in the order of the sequence of the communications
first from me and then Dr. Humes. And let me just briefly state
that Dr. Humes is a researcher in Ann Arbor. Incidentally, on
this research issue, I noticed that you mentioned that that is
pretty flat. I noticed that you also mentioned that a lot of
your research is done with NIH but that has been, as a
component of your total research budget, pretty flat, too. So,
it is not really increasing as I can see in either category.
But what I wanted to talk about, to get a better
understanding because this research that Dr. Humes is involved
in is cutting edge. You know, there is a Phase I, there is a
Phase II. Phase I, obviously, is the one that was overlooked in
the process. I don't exactly understand why but let me get to
that.
Phase I really was the device worn outside the body. Phase
II was the implantation of the device in the body. And what we
have received is what looks like a go-ahead, a green light for
Phase II, which is the second, but there has been an
overlooking of Phase I. This is sort of like putting the cart
in front of the horse. Phase I should have been looked at
because Phase II can't really take off until Phase I is in
place, unless somebody can explain that to me.
correspondence on bio-artificial kidney implant
I know that you know the background on this. We originally
had it in the House bill last year. It was tempered in the
conference with the Senate. Because they didn't want earmarking
we got in some language that was pretty specific and, in fact,
you quoted that language, I think Doctor, in your response to
me. But my problem with this is simply the sequence. It took
the conversation with the Secretary to get a response from you
regarding our request which goes back to the 14th of January.
On the 10th of January Dr. Humes sent his request in for the
grant and both Phases came in the same letter, two different
documents, but Phase II, we finally received some response on,
the 7th of March.
And incidentally, in my letter that went out on the 14th of
January, just after Dr. Humes' letter, we requested an
expedited procedure, something quick, because we felt this was
something we should get to. Your response of the 7th ignored
anything to do with Phase I. It talked about Phase II. That is
one question I have for you. I don't understand why.
Then the response that we got last night at 5 o'clock, I
believe, at the urging of the Secretary, indicates that you
have stepped up somehow, the dog didn't eat that first letter;
you found it on Phase I and your response is what I want to
talk about as well. Because the response, it seems to me,
indicates that certain conditions must be met. I am going to
refer to those so that there is no mistaking what is taking
place here.
Your letter of the 7th of March says that--it took almost
two months, by the way--that there were two issues, two
conditions that had to be considered. And one was documentation
from the FDA that the device has been evaluated and determined
to be safe for initial clinical testing in humans. And, number
two, evidence from Phase I studies that the device is safe with
an acceptable rate of adverse effects for human research
participants.
My understanding is that the VA--and tell me if this is not
true--commonly, very commonly approves grants, pending FDA
approval, and I am particularly perplexed that that was not an
option that was provided at least in your letter. Maybe that is
forthcoming. But we want to work with you on this. We need to
have a more expedient return or response to our request for
information so we can, in fact, do something about this in
fiscal year 00. That was the whole design of that language that
is in the conference report, to do it this year.
And, so, my concern is that you are perplexed about, I am
perplexed about your concerns and about your assurances that
the device is safe. So, tell me in a few words, if you can,
very briefly, what are your concerns about this on this Phase I
device? And explain for me, too, how you move on Phase II
without even considering Phase I? It almost seems like you are
coming at yourself. And if you can be fairly brief about that
because we do want to work with you, but we have to know what
you are thinking and I don't know right now.
Dr. Garthwaite. First, let me apologize for any delay in
any correspondence. I did not become aware of this until early
March and have had several conversations----
delay in response to correspondence
Mr. Knollenberg. Do you know why? Can you tell me why?
Dr. Garthwaite. I can't. I have to trace it back. I mean we
had a lot of correspondence and it is routed through various
offices and we have come down from 800 to 500 FTE over the last
several years so it is hard to get all the papers through. But
we will redouble our efforts and certainly there should be no
delay to any Congressional member.
Secondly, you know, part of the confusion may lie in the
cooperative studies program aspects in which we have large
multi-center trials of projects that have gone through a Phase
I trial. And we are going to have to get Dr. Humes and our head
of research together to talk about the timing of the Phase II
versus Phase I.
We believe we got the Phase II in January and that was
responded to on January 20th. Now for Phase I whether it was
sent originally and we somehow lost it or whether we didn't get
it until later, and we could trace that back, the bottom line
is that once we received that piece I believe we did respond in
a timely fashion to that as well.
Mr. Knollenberg. They were sent at the same time. They came
in the same envelope. And I related to that in my letter of the
14th, four days later. So, I don't know what happened but that
is what we want to get to the bottom of, what did happen? Where
did it go?
Dr. Garthwaite. I think the smart thing here is for perhaps
a member of your staff and a member of our research staff to
sit down and with either Dr. Humes or with him on the phone and
work through the issues.
Mr. Knollenberg. And I would be happy to do that because I
don't want to confront you and confront you and confront you
but to say that we are perplexed, we are confused.
Dr. Garthwaite. And we want to be as responsive as we can.
merit review of research proposal
Mr. Knollenberg. Let me just--and Mr. Secretary, you know
that we are halfway, almost halfway through this fiscal year,
so, with the months in mind here, it looks like even if we do a
rapid turn-around it may be getting dangerously close to the
end of the fiscal year--we will be talking about 02 or 01, I am
sorry. So, I want, if I could, to ask you to do whatever you
can as well to provide any kind of coordination on this so that
we do bring that about. And we would like very much to have
your assurance that we can get together on that, as the Doctor
suggests.
Secretary West. You have that assurance, Congressman, with
one note. I saw this morning a letter that you should have
received late yesterday. I am concerned that if there is a
proposal that we bypass merit review processes in this that we
are careful because we have learned over time, I think at VA,
that when we bypass those kind of review processes we may have
to pay the piper later.
So, with that----
Mr. Knollenberg. Are you suggesting anything from that that
I should know that would indicate that there is a delay or a
denial?
Secretary West. I know far less about this than you and I
am certainly not withholding any knowledge from you that I
have. I know what I read in that letter and it caught my
attention that included in here is a merit review process. That
concerns me because when we have found research efforts that
have avoided merit review, peer review, other kinds of
protections that we suffer from that later.
Mr. Knollenberg. Well, I am very comfortable with that. I
think those are the things that should be applied in every
case.
Secretary West. Fair enough.
Mr. Knollenberg. But I just want to know if there is
something else out there that we should be----
Secretary West. No. I am not withholding any--I am not
saying that with any knowledge that I have. I am saying it,
simply having read the letter.
Mr. Knollenberg. Expedited review was a thing that I
requested here. I didn't get that on Phase II, either. It did
not happen. So, expedited review is something that I would like
to have a lot of persuasive ability provided to bring it to
reality because I think we deserve a little better response and
certainly you don't need this kind of approach from me as to
what these questions raise but I think that with your assurance
that we can move forward and get into those conversations that
that would be very helpful.
Secretary West. As long as expedited review does not mean
no review.
Mr. Knollenberg. Absolutely. I am not suggesting that there
shouldn't be a review. Mr. Chairman, how is my time?
Mr. Walsh. The gentleman's time has expired.
Mr. Knollenberg. Then I relinquish my time to the Chairman,
thank you.
Mr. Walsh. We should have time for a second round.
Mr. Cramer.
Mr. Cramer. Thank you very much.
veterans benefits administration funding
Mr. Secretary, Mr. Under Secretary, welcome to the
Committee and you have already--I wasn't here for your
statement, though I do have your statement in front of me. But
some questions have been asked already about the claims
process. And I know you know that this is one of the most
frustrating processes that our veterans have go to through. And
my colleagues and I, our casework largely pivots around
frustration over the claims process. And it is not just a
matter of no assistance with the filing of claims and that
issue that is not necessarily under our control, but it is the
long lines, too few staff, the delays in processing, the loss
of documents, the inability to understand what needs to be
submitted for there to be a timely ruling, and the constant
interaction that we face with veterans that are trying to
survive, literally, survive that process.
What would you say about this budget and the way this
budget will impact those issues?
Secretary West. I would add one other thing to your list of
bad things that have happened. That is the constant assurances
that by day certain we are going to meet targets, which I think
is a fine thing to do, we should set goals for ourselves, and
then remediate our failure to meet them.
In the budget, we do two things. There is a $109 million
increase in the VBA processing budget. It has a two-pronged
purpose. The first is to try to deal with a long-range,
reliable solution to the timely and accurate processing of
claims. I think, in my view and that of the VBA Under Secretary
Thompson, that has to go with getting rid of the bulky paper
files, misplaced files, the necessity to get them from one
place to another, access to them by veterans, their
representatives, national service officers and the like and by
our people. That would be a computerized processing, an
entirely computerized processing environment.
That will take several years to get to. I think VBA is only
in their second year of pilot programs, a study contract. There
is money for that in this $109 million increase.
Secondly, though, because that is like saying be patient
with us. Some day out there in the future you will see an
improvement. We have to have some improvement now. We started
last year by adding 440 additional FTE bodies and minds into
the claims processing process. Now, the bodies and minds also
have to be trained. So, they are still struggling with getting
the training done. But in this budget----
Mr. Cramer. So, you think we haven't seen the impact of
that yet?
Secretary West. Not yet. And in addition, in this budget we
have a provision for an additional 586, for a total of 1,000.
We haven't seen the impact yet. I think we should hear from
Under Secretary Thompson about when we will see the impact. But
those are the two things in this budget that will address that.
Mr. Cramer. Be brief, if you would, I wish I had more time.
Mr. Thompson. Mr. Congressman, let me say up front, this is
the most complex disability evaluation process in the Federal
Government, perhaps, in the United States. Our pages just for
calculating an effective date for the benefits runs to 35 pages
of matrixes. We are acutely aware of the veterans' concerns.
Mr. Cramer. It would be difficult to design a system that
is more difficult or more frustrating than this.
Mr. Thompson. Believe me, it is frustrating for veterans
and it is frustrating for the people that have to administer
it. It is way more complex, I believe, than it needs to be. One
of the things we are doing that I think will have an immediate
impact is moving away from an assembly-line type process, where
you send the paper in and somewhere along the line somebody
will contact you and let you know what is going on. We are
moving towards a case-managed environment.
This means that when a veteran files a claim with a
regional office, they will know precisely who is responsible
for making the decision and keeping them apprised of what is
going on. The case managers have a responsibility, not just to
wait for the veteran to come in and to ask the questions, but
to go out and make sure that the veterans are kept informed not
only about the issue in front of them, but about everything
else that they may be entitled to.
We piloted case management in six regional offices last
year. We piloted that. We added nine more this month. By the
end of this year, we will have 41 of 57 regional offices using
case management. This move will have an immediate impact. We
know that because we are surveying veterans----
Mr. Cramer. You have tracked it. You are tracking it and
already seeing in those demonstration projects----
Mr. Thompson. Absolutely. We tracked it----
Mr. Cramer [continuing]. Success?
Mr. Thompson. We track customer satisfaction. We asked the
veterans questions about whether they are kept informed,
whether they are satisfied, whether they felt they were treated
fairly, a host of issues. We know that the six prototype sites
have significantly better performance in this respect than do
the traditional organizations.
medical care access and service
Mr. Cramer. Thank you. As well, it has been frustrating for
veterans' access to just the facilities, the doctors, the waits
and that process have been very difficult, to say the least.
Your budget reflects you plan to open 63 new outpatient
clinics. You will see 100,000 more patients in 2001 than in
2000. What about new doctors?
Secretary West. That is the way to deal with access with
the waiting times and the like: To put more docs, more nurses,
more technicians into the process of dealing with them in
clinics.
What we contemplate is redirecting 1,500 health care
personnel into that clinical process as part of this budget.
Mr. Cramer. You are talking about----
Secretary West. And contracting for additional ones.
Mr. Cramer [continuing]. Newly established service
standards and access goals, including patients will be seen
within 20 minutes of their scheduled appointment?
Secretary West. Yes, sir.
Mr. Cramer. Is that what you have already implemented or
what you will implement?
Secretary West. That is a process we have underway. We
haven't gotten there yet. We are measuring ourselves against
it, but that is our goal. That is what this 1,500 is for and
that is that no patient, no veteran should have to wait more
than 30 days for his or her first appointment with a primary
care provider. That thereafter no veteran should have to wait
more than 30 days--and, frankly, we would like it to be less
than 30 days, obviously--more than 30 days for the appointment
with a specialist for specialized care. And once there, once in
the waiting room, no veteran would have to wait more than 20
minutes.
Mr. Cramer. Well, it is going to be difficult to accomplish
that but, please, stay on that.
Secretary West. Yes.
disability benefits
Mr. Cramer. I want to talk about veterans' benefits offsets
quickly. The disabled veterans have their disability benefits
reduced if they are receiving other types of Government
benefits. Has the VA done any studies to examine the
practicality and the cost of exempting those disability
benefits, certain groups, such as combat-wounded veterans from
the offset rule?
Mr. Thompson. Their benefits are offset only against
military retired pay. If the veteran is receiving other types
of benefits, we don't reduce their compensation based on that.
It would only be offset against military retired pay. In other
words, if you are entitled to a $1,000 a month in military
retired pay and $500 a month for VA, we would offset that.
There is a tax advantage for veterans to do that, that is why
they opt for our payments. For other programs there is no means
test for compensation other than this one exception.
hepatitis c funding
Mr. Cramer. And in this budget you are requesting an
increase of $145 million to treat veterans with hepatitis C;
more power to you there, thank you, Mr. Chairman.
Secretary West. For a total of $340 million.
Mr. Cramer. Is that the total?
Secretary West. Yes.
Mr. Cramer. Thank you.
Mr. Walsh. Mr. Frelinghuysen?
medical services for veterans
Mr. Frelinghuysen. Thank you, Mr. Chairman.
My apologies for being late, Mr. Secretary and gentlemen. I
know last year I provided, I think, a high degree of discomfort
because I was on the attack and several people have suggested I
ought to be somewhat more restrained today in your waning hours
as the head of the operation.
While I personally like you and you certainly have a lot to
be proud of in terms of your career, I do get a feeling as I
visit with veterans in New Jersey and have contacts now, as a
Member of Congress, with veterans around the country, that
there is not a sense of urgency at the VA, and that we are not
concentrating enough resources in meeting the needs of these
individuals.
And I am dismayed at times, I am angry at times, but I
don't get the feeling that there is a sense of urgency. I think
Members of Congress on both sides of the aisle feel there is
some urgent needs out there. When we embraced the Veterans
Millennium Health Care Act, I think we wanted it to be more
inclusive and more expansive and, hopefully, we sent a message
to you and your colleagues that you need to reinvigorate
yourself.
I get the feeling--and maybe this is an unfair
characterization--that somehow we are sort of treading water
and we shouldn't be treading water. If the men and women
veterans of World War II are dying at a rate of 30,000 a month
we ought to be escalating our efforts and reaching out. Many
veterans have already voted with their feet as to where they
want to get their health care--let's be blunt. Some have the
luxury of using other hospital systems in their States but some
are wholly dependent on the VA system. They love it. They
protect it. They are stakeholders.
And there are a lot of men and women who actively support
your endeavors and make our hospitals, given their meager
resources, work remarkably well. And I particularly would like
to commend all those veterans groups who work with the VA
system for their volunteer efforts. It is, indeed, remarkable.
And I am sure if you were to measure it in dollars and cents
that it would be pretty difficult. It is an incredible gift to
the nation.
That is why even with your increase for medical care--and I
salute you for that, although a little late in coming--I still
get a concern here that there is not a sense of urgency. The
statistics cry out for us to do more. And I think actually the
issues that relate to veterans are resonating in the American
public. It may have as much to do with ``Saving Private Ryan''
as anything or maybe the recent involvement of Senator McCain
in his bid to be President. Regardless, veterans are waking up
and I think many of us here would like to be more responsive
and I am here today to ask you, specifically, to be more
responsive.
I literally, Mr. Chairman, have dozens of questions. So,
let me begin but let me just say again that I think that the VA
needs to be far more proactive and I don't get the feeling,
even with the new money, that there is the degree of advocacy
that there should be and has traditionally been.
I would like to know, relative to the National Reserve
Account--I represent VISN 3, New York and New Jersey, for those
of you not familiar with that VISN and, yes, we make a hell of
a lot of noise on behalf of our veterans, Republicans and
Democrats, in that part of metropolitan New York and New
Jersey--how much money was in the National Reserve Account in
the start of fiscal year 2000?
national reserve account
We have been able to tap in it, thank God, because we have
lobbied, and I think effectively, we have made a case. But I
would like to just know for the record, how much money was in
the National Reserve Account at the start of the fiscal year
2000?
Dr. Garthwaite. We started with $150 million in that
account.
Mr. Frelinghuysen. How much has been spent to date and
could you provide me, very briefly, with a breakdown of the
expenditures?
Well, if you can't provide----
Dr. Garthwaite. About $70 million.
Mr. Frelinghuysen. What?
Dr. Garthwaite. We have spent about $70 million.
nursing home care
Mr. Frelinghuysen. That is $70 million. So there is $70
million in that account. Last week, I visited Lyons VA Hospital
in northern New Jersey and learned that 60 beds in that nursing
home at Lyons are empty, as well as 60 beds of the East Orange
Nursing Home--Mr. Chairman, another VA hospital in New Jersey--
and I was told that there is no waiting list for veterans to
get into the homes.
Personally, I find that hard to believe given, obviously,
the death statistics that I mentioned. There are obviously a
lot of people that are near death, incapacitated, for one
reason or the other, certainly old age being the primary cause.
We have the second oldest veterans population in the nation,
behind Florida. I am told, in fact, by the New Jersey
Department of Military and Veterans Affairs that there are over
250 veterans waiting for a bed in one of the three State-run
veterans homes. We are proud of what we do on the State level.
And, so, I am very surprised that none of these veterans
would qualify for a bed at the two facilities in New Jersey.
Can you tell me why?
Well, let me fill the gap. I hear the rumor that veterans
are not admitted to the VA nursing home beds if they cannot be
moved to another facility within 45 days. Is there a VA
regulation that prevents veterans from taking those beds if
they can't be moved to a State veterans home or other facility
after 45 days?
Dr. Garthwaite. There is no regulation. Certainly I think
over time that we have emphasized the rehabilitative nature of
our nursing homes. We used to get a lot of complaints that
there was no turnover in our nursing homes, that the same
veterans were there forever and that there was a long line of
veterans trying to get in.
We have also seen that a major part of what we provide
especially well is rehabilitation in nursing home beds and
transition after acute care.
Mr. Frelinghuysen. But we have nobody in our beds in these
two hospitals.
Dr. Garthwaite. Right. And----
Mr. Frelinghuysen. And obviously, we have got a lot of
older veterans that are waiting for the State facility. There
seems to be some disconnect here and I would like to know--
there has to be more to it than just the continual push of the
VA to adopt even more of a managed care model than we have now.
I mean we are literally supposed to be serving veterans but we
have designed a system where we have the potential for 120
veterans to be in these two hospitals between them and there is
nobody in these beds.
Dr. Garthwaite. We will take a hard look at what exactly
the issue is with those.
Mr. Frelinghuysen. Well, I would suggest that a hard look
may be the kindest way. I mean you have an obligation. Why do
we have a Department of Veterans Affairs, why are we providing
nursing home care if we don't have anybody in those beds?
How much, on average, does the VA pay for every veteran
placed in a State nursing home? And how does that compare with
the cost of treating that same veteran in a VA nursing home?
Dr. Garthwaite. The cost is significantly less than the
State veterans home cost and we can get you that information. I
think it is about a third as much in a State veterans home as
in the VA. I think our costs are comparable or slightly less
than the private sector.
[The information follows:]
Nursing Home Care in New Jersey
The total number of Nursing Home Care Unit beds at Lyons Campus is
240 beds. The 60 beds at East Orange Campus were not closed. The
patients were moved to the Lyons Campus and staff was redistributed to
other patient care units. Currently there is no waiting list for VA
Nursing Home Care beds at the VA New Jersey Healthcare System (VA NJ
HCS). As recently as of March 24, 2000, the total number of eligible
individuals on the waiting list for the NJ State Homes was reported to
be 100. This number includes spouses or widows of veterans who are not
eligible for admission to VA Nursing Home beds. In addition the VA NJ
HCS may already be serving some of the veterans on the waiting list
through a variety of Extended Care programs. The VA New Jersey Health
Care System would be happy to meet with congressional staff and discuss
specific cases.
There is no regulation that prevents veterans from being admitted
to VA Nursing Home beds if they are not admitted to a State Veteran
home within 45 days. VA Nursing Home admission criteria, clinical
assessment results and veteran eligibility are the determining factors
in VA Nursing Home admission.
In FY 2001 average cost per patient day in a VA Nursing Home is
estimated to be $346. The average cost per patient day in State Home
Nursing is estimated to be $154 of which VA pays $55 (which includes
administrative support).
respite care
Mr. Frelinghuysen. Are there any plans to allow or even
require the VA nursing homes to take empty beds and use them
for respite care, for families who are caring for veterans at
home but perhaps need a week or two break from the demands of
caring for their elderly or sick veteran?
Dr. Garthwaite. We do have respite care beds in VA nursing
homes. We have other alternatives to nursing care home programs
including home health care. Our hospital-based primary care
programs actually send providers out into the community which
is quite distinct from what you see in home health care in the
private sector, which is much more therapy oriented, ours are
assessment oriented as well. But we do have respite care beds
in VA nursing homes.
Mr. Frelinghuysen. But, getting back, why aren't these
nursing home beds being used? I think it is wonderful to look
at respite care and provide respite to those that need it but
why aren't these beds being filled?
Secretary West. Congressman----
Mr. Frelinghuysen. Is it my imagination or are we having a
problem here communicating?
Secretary West. No.
Mr. Frelinghuysen. This is what I am talking about.
Secretary West. I was wondering if we have any indication
that we are somehow turning people away who would qualify for
those beds? Is that the suggestion here?
Mr. Frelinghuysen. Yes. I get the feeling from talking to
my veterans that some sort of strategy has been devised here
that you are wholly dependent now on the three State veterans
homes. Why do we have a veterans facility at all if we are not
using the nursing home beds that we have in these two
hospitals? And what I am saying, largely, Mr. Chairman, is this
symptomatic of what we see around the nation? And if it is, to
this layperson, that is totally unacceptable.
Secretary West. I would say it is not symptomatic. And I
have been listening to this line of questioning because I was
wondering if the point here is that we are suspected there of
having a policy that leaves beds empty of people who are
qualified for them. I would assume that the same rules apply
there as everywhere else.
Certainly we have not been unresponsive to the needs of
that Network. You asked about----
Mr. Frelinghuysen. Oh, I understand that we have received
money and we lobbied for it, but we have nursing homes with the
second oldest veteran population in the nation, and a waiting
list of 250 people for State nursing home beds. The VA ought to
be opening those beds to those veterans.
Secretary West. Well, we will look to find out what the
story is there for you.
Mr. Frelinghuysen. Thank you.
Secretary West. But I would be very disturbed to find out
that we had some affirmative policy of trying to keep those
beds empty. We are there to serve the veterans.
Mr. Frelinghuysen. In the days of managed care, which the
VA has embraced and Dr. Kizer is--I won't say long gone--but
not soon forgotten, things have occurred that I think are very
unhealthy.
The whole nature here is that we are supposed to be
embracing and looking after our veterans. In some ways, it
appears that we are turning them away.
Thank you, Mr. Chairman.
Mr. Walsh. Mrs. Meek.
women veteran initiatives
Mrs. Meek. Mr. Chairman, and I would like to apologize to
the Chairman. I am on two committees at the same time and I had
to makeup the absence of someone else. But I want to thank the
Secretary and his staff today for a job that you work very hard
at doing. We gave you a pretty good hosing down the last time
you were here and it appears that you have rebounded in a very
good fashion.
And I am very happy that the President showed some
affirmation by providing, suggesting more money to be added to
the veterans budget. You are our most honored resource in this
country.
And I hear from all kinds of veterans, of all age groups
and I also visit the Veterans Hospital in my area, and it just
looks like we are doing our very best and, of course, we could
never do enough in this particular area, it is never enough
that you can do for veterans.
I wasn't here when you spoke about some of the questions. I
understand you answered quite a few of the questions that I had
an inquiry about. So, I won't repeat it. But I just wanted to
commend you on your performance and to ask you to continue the
advocacy that some members of the Committee have challenged you
on today because that is extremely necessary and it is
something that we will look very closely at, how well you
advocate for the people you serve.
I understand that the VA Advisory Committee on Women
Veterans is meeting here in Washington this week. I am not sure
that I saw any information in your updates about the
participation of women and initiatives that you have for women.
Would you mind addressing that quickly as to the participation
of women, any concerns they have which I am not privy to?
Secretary West. Well, thank you for your comments. And,
yes, the Advisory Committee chartered by the Congress is
meeting here this week for three days. I had the opportunity to
speak to them yesterday. Dr. Garthwaite may want to talk a bit
about our extensive commitment to health care for our women
veterans.
As you know, by statute we have a Center for Women Veterans
Office in the Department. It is required by law to report
directly to the Secretary. Our director of that office, Joan
Furey, may or may not be present but she is an important part
of the staff and is probably meeting with them now and is not
here.
They have voiced several concerns to me. One of them is
their concern that we have established specific clinics or
centers across the nation to deal with the specific health care
problems of women veterans because they have some unique issues
around their health care requirements. At the same time, their
numbers of participation in the system have been so small--that
is the small representation of women veterans in our system,
that the effort to make sure that medical personnel in training
get an opportunity to be exposed to those issues--has caused
some of the centers to assign health care to other parts of the
system. This is needed by, I guess, our accreditation people.
That has caused a concern. It means that the centers may be
in danger of disbanding. We do not intend to disband them but
the Committee has raised that issue with them.
They have also raised the fact that in dealing with benefit
concerns of women veterans on issues such as breast cancer
women veterans are rated in the same way without any regard to
the particular impact, for example, of a mastectomy. That is an
issue they have raised with Under Secretary Thompson that we
are still looking at because right now that is precisely the
way that the rating process occurs. That is a concern of the
Advisory Committee and I think we can all understand why it is.
They have several other issues that they have raised. Our
concern has been that we be as in touch with them, as
responsive to them as possible. Women veterans are still not
using our facilities, not engaged in the system in numbers that
represent their presence in the veterans community. That means
we have still not done our job in terms of outreach, in terms
of going to them, making them aware and also, perhaps in
creating a receptive atmosphere for them. So, we have a lot of
work to do there. I don't know if Dr. Garthwaite wants to say
anything more on the health care area.
Mrs. Meek. Okay. I just needed to have that question
addressed. If there is any additional information, would you
please send it to me, Doctor.
Dr. Garthwaite. All right.
medical programs for women veterans
Mrs. Meek. In that I am interested in the medical research
and the medical programs for women. Many of the diseases are
distinctly higher in incidence among women veterans than others
and I would appreciate that.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
rehabilitation for blinded veterans
Mrs. Meek. Several veterans visited my office and one took
quite a strong interest in the blinded veterans. They are
concerned about the rehab centers. You have a good rehab center
according to their report but many times it sort of impinges on
their mobility to be able to reach those centers. And they
figured it would be much easier if they did not have to travel,
you know, they are more concerned about being near a home and
the rehab centers are quite some distance from where they are.
Now, have you had any success with your clinic programs
relative to meeting the needs of these blinded veterans?
Secretary West. I think our clinics--I see Dr. Garthwaite
reaching for his microphone, he probably wants to answer. Let
me just say a word. I think our clinics have actually been
quite successful. I think they are very popular with blinded
veterans and the association keeps a watchful eye on the
centers, how we staff them, how we resource them.
I think one of the keys though for effective provision of
specialized services to our blinded veterans is something
called the Blinded Vet Coordinator. This is the person in our
medical centers and other facilities whose job is to connect
the blinded veteran and blinded veteran population with the
center or with a resource so they can get the care.
Blinded veterans have expressed to me on several occasions
that if we let those coordinators get, perhaps, caught up in
ancillary duties, not able to devote themselves to it, then the
key link between the services we provide and the blinded
veterans who need them will be lost. And they have seen some of
that occurring.
I know Dr. Garthwaite is looking to answer.
Mrs. Meek. Now, Doctor, it appears that most of your
facilities for blinded veterans are located in large central
cities or is that assumption incorrect? I say that because many
of them mentioned to me that they have to travel to central
cities for this kind of service. So, is there any way we could
bring some of those services closer to those veterans?
Dr. Garthwaite. Well, I appreciate that. We have several
large inpatient facilities for week-long rehabilitation
programs for veterans where there are specially trained staff,
specially trained experiences of the inpatient nature which is
a critical part of their rehabilitation.
We have other models of outpatient rehabilitation that we
are disseminating and, because many blinded veterans today lose
their sight more gradually, we are introducing training that
would be helpful if their sight further deteriorates earlier in
the disease process.
So, we have a series of things going on including a very
extensive report and a Gold Ribbon Panel reviewing blind
rehabilitation and vision preservation. And we have a new
advisory committee I think will add to this which includes
representatives of blinded veterans. So, there has been a fair
amount of activity over the last year in attempting to engage
in dialogue.
We also have performance measures for blinded veterans in
terms of the quality of service they are given and their
satisfaction with it that we will be holding our managers
accountable to. So, I anticipate some good news by next year on
blinded veterans.
Mrs. Meek. I have quite a few other questions, but I will
make this my last one and I will submit the others for the
record.
I am a World War II person of the greatest generation and I
am not planning to leave right now. I want to say that to my
colleagues.
Mr. Frelinghuysen. Thank God. [Laughter.]
long-term care
Mrs. Meek. Mr. Frelinghuysen and I are good friends. So, I
just wanted to let you know there are a lot of people my age
around. I want to know from the Department here just what are
you doing in terms of long-term care? These people are still
living. They are not dead. So, what are you doing in your
system to make aging a process that is good for the elderly?
Dr. Garthwaite. Well, you may be aware that the VA has been
a leader in the field of geriatrics. In fact, the VA almost
invented the term, geriatrics----
Mrs. Meek. True.
Dr. Garthwaite [continuing]. With the geriatric
rehabilitation and education centers that we have introduced.
We funded a couple more of them during the past year. You know,
although a critical piece, it isn't just about the effects of
aging. There are simply more health issues when you get older.
And there are specific diseases, some of which are very much
more treatable today and some of which are preventable.
For instance, our immunization rates have gone from a
relatively low number to the high 80s to 90 percent in the
Medicare population. It is about 75 percent for pneumococcal
pneumonia.
That, in and of itself, saves significant numbers of lives
and it keeps people out of the hospital. It is cost saving and
life saving that will assure these systems are in place.
Mr. Walsh. Excuse me, Doctor, I am going to have to
interrupt.
You can finish up your response when we return, if you
would.
Thank you.
[Recess.]
Mr. Walsh. If everyone would take your seats, we will get
right back at it.
Dr. Garthwaite was just finishing his response to Mrs.
Meek's last question.
Dr. Garthwaite. Yes. I was just trying to make the point
that we do a lot of geriatrics and we do a lot in geriatrics
research and we also believe that there are a lot of medical
problems that are more common as we age and we put a lot of
emphasis on that, as well.
Mr. Walsh. Thank you.
Yes?
Mrs. Meek. Mr. Chairman, I will submit the rest.
Mr. Walsh. Thank you very much. Mrs. Northup.
medical services in kentucky
Mrs. Northup. Thank you, Mr. Chairman.
I just have a couple of questions. Primarily, I want to
pursue a question that I raised last year. I will tell you I
have met with the head of the VISN that we are in which is
Nashville and I have a lot of faith in the answers I got from
that gentleman and reassurances. But I am not sure that the
people in my district do in Louisville. There is a continuing
concern and a lot of rumors that services in Louisville were
the largest percentage of the veterans live that are in
Kentucky, not only because we are the largest city but also
because of the proximity to Ft. Knox, people tend to retire
near that area.
There is considerable concern that when you are targeting
tertiary care and high specialist care that there is a strong
pull to put that in Lexington. And I have to tell you I think
it is more than just people being fearful. I think there is
some evidence of that.
You may know that Louisville, out of all of the locations,
has the second most efficient rating of all the facilities. It
is considerably better than Lexington. And I asked you last
year to provide me with some sort of list of how you make the
allocations and you said there was a 10, I think, 10 principles
or goals. The goals are very vague. They are very vague. They
would in no way sort of decide how you would appropriate
resources and what locations you would put facilities.
And it seems that to me that those 10 principles need to be
visited in much more measurable, mathematical terms. For
example, where the largest number of veterans to be served
exist? What are the precise services they need and are
requesting? And your strategic plan should reflect 10
principles that are measurable and much more specific.
Secretary West. You are talking about the fairness of the
distribution within a Network as between different medical
centers.
Mrs. Northup. Right.
Dr. Garthwaite. The only thing I would say is that we are
not 100 percent sure how you distribute dollars without putting
the wrong incentives in medicine. I think managed care has not
been successful. Capitated contracting hasn't been terribly
successful. Fee-for-service has a separate set of problems
associated with it and it tends to induce volume of services.
But we are dedicated to try and do that and we have a group
looking at that. I actually think you are right on target that
we have to look at the needs of veterans and adapt the systems
to them. We are dealt a historical set of buildings that makes
it a lot more challenging and a historical set of relationships
and teaching programs and research programs and others. I agree
with you.
medical services at Louisville VAMC
Mrs. Northup. Well, I think that there is more than just
those challenges involved here. Let me, again, for example, we
are the second out of seven of the medical centers. The next
nearest one, the average cost per admission is $4,100 compared
to ours which is $3,100. And both locations have a medical
school. They have excellent outcomes. I am concerned that there
is, as I was last year, that there is a political draw to more
specialized care in the future heading towards the one in
Lexington.
And I would be--I don't mind telling you--I would be
appalled if that happened. I think that if there are concerns
with--you know, I think one of the problems is that there
aren't precise measurements, there isn't clear discussions
about just what the criteria are going to be, how many veterans
are going to be served, what are the specialized services, what
is going to be the measurement of where it ought to be? And,
so, it leaves people in my district with a very uncertain idea
of how it is going to be judged, and how they reassure or
compete for the location to provide these services.
And, of course, if it is something that is political it
would be no wonder you would be very unsure about that.
Secretary West. Would you like us to revisit that in some
way, again, in the specific context of those medical centers
there, with you, with the veterans, with the----
Mrs. Northup. What I want to make sure doesn't happen is
that anybody intervenes because of the close relationship or
past working relationship to pull services out of Louisville
and send where you have a much smaller proportion of veterans
that are to be served. That there would be intervention that
would wait, that would cause that to happen.
At this point I do have confidence in the head of that
VISN. He is located in Lexington. He and I have talked, and I
feel somewhat reassured. But it does occur to me that if he
doesn't have the final authority or somebody decides to make
that decision from Washington, it doesn't matter what the
reassurances are.
Mr. West. I think our model is to put a great deal of
responsibility on the shoulders of the network director to make
those calls.
Dr. Garthwaite. Absolutely.
Mrs. Northrup. Well, I think that is usually the way,
although if one of your high-ranking past veterans medical
people happen to become an official at the University of
Kentucky, they might have a direct line and be able to persuade
somebody to go in a different direction. That is the concern in
Louisville.
third-party overpayments
Let me just ask you about one other concern, and that is
the question of third-party payments. I read in the GAO that
you all estimate that there were--I am really concerned about
over payments, and what the level of those are. The GAO report
said that there are some people that estimate that the over
payments that have been made to you, not to mention the money
that has not been collected, but the money that has been
collected, that there is possibly $600 million of that that was
made incorrectly in over payments that would have to refunded.
Where are we on asserting exactly what that amount will be, and
what is the process by which those over payments would be made,
especially the ones since 1997 where it would not be returned
from the Treasury, but from the VA.
Dr. Garthwaite. As you are probably aware, that billing in
all of medicine is not as accurate as it should be. There have
been considerable issues in billing in the private sector and
since we have become billers late in the game, we have
significant issues in the quality of documentation that
supports the bill that is rendered. We became aware of that
when the AARP challenged some of our bills and we ended up
having to pay them back. And then we commissioned our study
from Price Waterhouse to get a handle on that, and found that
indeed, as bad as it is in the private sector, we were worse.
And it probably is not unrealistic to expect that that would
have happened, given the fact that billing was not a part of
our nature and wasn't built into our culture from the day we
opened the hospitals.
Having said all of that, we have had a very aggressive
approach at improving our compliance, and given the squawks I
have heard from deans of medical schools and other physicians
about how much trouble this is to make sure that documentation
is placed in there, they thought we were the reprieve from the
private hospitals where they are constantly being harangued
about documentation. I know that this is happening. I have
visited several medical centers and seen it in progress. I do
not know if we will ever have a completely accurate assessment
of what our overall liability is. We can do sampling techniques
and then try to guess. And a lot will depend on if they come
back to us and challenge all the bills. The other thing though
is if they come back and challenge all the bills, as we open
those up, there may be other billing that we have missed. So we
may find some other billings that we can make as opposed to
just what we owe.
The bottom line is we are going to need to get back to you
on the record if we can give you an estimate of the total
dollar amount, but I do feel pretty confident that we have made
dramatic strides in the past year and even in the past few
months at getting it under control.
Mrs. Northrup. Well, I think it is important, Mr. Chairman,
for us to know what that liability might be and what we might
be facing in terms of a payout. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Walsh. Thank you. Ms. Kaptur.
nobel prizes awarded to va
Ms. Kaptur. Yes. Welcome, Mr. Secretary and representatives
of the Department of Veterans Affairs. Thank you for the fine
job you do in caring for our veterans across this country and
for managing this system of benefits that we hope to improve
over the years.
I have several questions. Some require only very short
answers. One is: historically, it is my understanding, that the
VA has received Nobel Prizes for the development of the cardiac
pacemaker and magnetic resonance imaging. Does the Secretary
have a list of other technologies that the VA may have received
Nobel Prizes for other than those two?
Mr. West. Or that are otherwise worth noting?
Ms. Kaptur. Yes.
Mr. West. We do. Would you like us to recite some of it or
furnish it to you?
Ms. Kaptur. Yes, I would very much appreciate that for the
record.
Mr. West. We have a whole list of ``did-you-knows'', and we
would be happy to pass them along to you.
Ms. Kaptur. All right. I think that is very important for
us to enter in the record and remind the newer members of
Congress and the American public how important this department
is and all of the people who work for it.
mental illness research
I wanted to ask you how do we get Nobel Prizes out of the
VA in the area of neuropsychiatry and the development of
pharmaceuticals to treat serious mental illness? How do we help
the world through the VA?
Mr. West. Fair enough question. Do you want to----
Dr. Garthwaite. Well, I think----
Mr. West. One thing I would say is you recruit the very
best people, and you support them, and you attract them with
research, something we have been challenged on already, but let
me let him continue. Go ahead.
Ms. Kaptur. While he is doing that, maybe I could ask of
any of the staff from the VA would have the percent of veterans
treated annually, either as inpatients or in outpatient
facilities; of all of your visits that would present with
serious mental illness, what percent of your population? I know
some have dual diagnoses, but where that would be one of the
diagnoses that bring them to a facility. Is it a significant
percent.
Dr. Garthwaite. It is very much a significant percentage.
With regards to how do we improve the discoveries in
neuroscience, I would just say I used to do research in
neuroendocrinology and have a great personal interest in this.
And I would say that we have done some things already that are
putting us on that path. In our medical research we have
targeted mental illness through the years, and you may be aware
that one of our researchers discovered a gene for schizophrenia
in the last year to year and a half, which is profoundly
important both in the understanding of a critically important
disease, but also the recognition that there is a genetic basis
for mental illness. The stronger that evidence becomes, and the
more that those not in the area understand that, the more I
think we can destigmatize mental illness as a problem.
Secondly, we have started what are called MIRECCs, Mental
Illness Research and Education Centers. These are modeled after
our successful GRECC program in geriatrics.
Ms. Kaptur. You only have about, what, 8 of those?
Dr. Garthwaite. 8 of those.
Ms. Kaptur. At about $1.5 or $1.6 million per site?
Dr. Garthwaite. Correct.
Ms. Kaptur. So that is less than $10 million.
Dr. Garthwaite. But what it does is it provides a fertile
soil for researchers and the critical mass of researchers to go
out and attract other money from the NIH, which has been
getting some increases in their funding, and from our own merit
review and other studies. So I think all of those pieces are
critically important.
I can tell you that for all VA patients, 23 percent of
outpatient visits are mental health visits, and 20 percent of
all of our outpatients use mental health services. Now, how
that breaks out in terms of seriousness I think would be a much
harder number to come up with.
Ms. Kaptur. Well, I think that the veterans of this country
are going to help us find an answer for the rest of the nation
and the world. I really do.
Dr. Garthwaite. We hope to be part of that.
Ms. Kaptur. And I was going to ask you, the materials that
have been provided, Mr. Secretary, for my perusal--and I will
read every word, I guarantee you that--in this area of
psychiatric illness, have been very helpful. What is hard to
decipher on first reading, and I would ask you, who at the VA
we work with on this. I want to distinguish between basic
research, applied research, actual care, therapeutic care, so I
can see how the VA compares to other instrumentalities of this
government.
mirecc in the midwest
Another question I have, which is sort of a politically
loaded one because I am from the Midwest. If I look at where
these MIRECCs are located, Philadelphia, I think Seattle, Palo
Alto, Boston. There is one in Connecticut. There is not a
single one in the Midwest. So being very parochial, could I ask
you, did no one apply? Were their applications insufficient?
What happened there?
Dr. Garthwaite. I would have to go back and check who
applied. There was a process, a request for applications, so
the applications were reviewed by the best scientists in the
area we could find, and then there was a site visit team that
visited all the top applicants to gauge their feeling about the
success of the endeavor and the commitment of the institutions
to making it work. So we can provide those who got screened
out, but I don't have those in the top of my head.
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Ms. Kaptur. All right. I am going to ask a question for the
record, and then I will take my final question.
respite care
Mr. Frelinghuysen had talked about respite care. And for
the record, I would like to ask you, Mr. Secretary, to tell me
whether under existing authority that the VA has or under
authority that we would have to provide, how could we begin
working with the VA at some of the nursing home sites, some of
the long-term care sites, where you have spouses that are
permanently going to be housed, and their wives or husbands are
driving miles across the countryside to visit these people--
many of them are elderly--how do we embark upon some type of a
program that would provide a bed on site, maybe kitchen access
or something, so these people would not be split from perhaps
their only living relative in the last few years of their
lives?
I am really interested in looking at that issue, maybe
starting experimentally with some of our state homes or maybe
some of the nursing homes around the country. There must be a
way that we can deal with this.
Somebody said to me--I think, Mr. Secretary, you said there
was a McDonald's house on one of the----
Mr. West. Fisher Houses.
Ms. Kaptur. Fisher Houses on one of the bases or something.
But you know, it just seems to me we ought to be thinking about
a way. I think a lot of our local veterans organizations would
support this in terms of publicizing it and so forth. So many
of these local homes are understaffed and we can just be more
family friendly.
Mr. West. We will furnish it for the record. There may be
some authority on the Millennium Act that helps us, but we will
furnish it for you.
Ms. Kaptur. All right. I would love to work with you on
that.
[The information follows:]
Respite Care
VA has no legislative authority to provide housing services
to veterans and/or family members. VA expects that such
services might best be developed through some form of public/
private partnership or sharing agreement.
training physicians and nurses
Ms. Kaptur. And, finally, I want to ask something about
nursing care and physician care. Historically--and if you do
not have this information now, please provide it for the
record--what are the most consequential education and training
programs that the VA has embarked upon for the training of
physicians and nurses? Right now I know--for instance, in the
area of psychiatry I know nationally we have a problem.
Dr. Garthwaite. We probably should go back and look at this
more carefully, but I know that we have used an opportunity we
have to create special fellowships in particular areas. One
that comes to mind immediately is the one we created a few
years ago in health quality scholars, because we believe that
not enough physicians have been trained to think systematically
about how to improve the quality of a system of care. We have
been pretty good about pointing the finger and saying, ``You
are at fault'', but we have not been very good at making the
system work better, and we think that is an important need.
Through the years we have been very active in producing
subspecialists in medicine in a number of psychiatric residency
programs. But I think your questions are great ones, and we
look forward to working with you with those.
Ms. Kaptur. Well, you know, there is not a community in
this country that hasn't been riveted by changes in the health
system. And the VA, as the largest health care system in the
United States and probably the world, has a whole lot of role
modeling to do. And with the kind of people that I have met at
the VA and with the dedication that I have seen, if we do our
job here and you do your job as professionals, we can make a
big difference across this country if we can think outside the
box a little bit. So we really appreciate your testimony this
morning.
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Thank you very much.
Mr. Walsh. Thank you. Mr. Goode.
Mr. Goode. Thank you, Mr. Chairman, and thank you to the
Department of Veterans.
satellite clinic at danville, va
Thank you. In Danville, Virginia a satellite clinic was
recently opened, and we are certainly thankful of that, and
that is under the Salem Veterans Hospital's jurisdiction. That
clinic treats only service-connected veterans. And my first
question is: is that typical of your clinics nationwide, or do
they treat both non-service-connected and service-connected in
most of your clinics? And this is a private contract clinic.
You have it I think with the Sandy River Medical Center which
is in Danville. Is that typical or----
Dr. Garthwaite. No, they should be seeing all veterans, and
we will need to look into why that might be the case, if it is
a volume issue or just because they had started up that way,
but we need to take a look. They should be treating all
veterans, all enrolled veterans.
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Mr. Goode. All right. Danville is located between Durham
and Salem, and some of the veterans had been to the Durham
hospital, but they have been told that since they are under the
jurisdiction of Salem at this satellite clinic, that if they
have to go to the hospital, they have to go Salem and not
Durham, and I just wondered if that is standard procedure?
Dr. Garthwaite. No, I think they--clearly, our preference
is that they go where they feel most comfortable getting care.
There may be special programs in a particular place where it is
to their advantage to go there, but generally they should be
able to go where they choose, where they like.
Mr. Goode. That is not the case, at least with the couple
that I----
Dr. Garthwaite. I would just say that VISN 6 has not jelled
as a team-base network between the medical centers as quickly
as possible. We had some turnover early on with the network
director, and we have had some real challenges in recruiting,
in that we have had to go through two cycles of interviewing
and so forth, even though I think Jerry Husson's done an
admirable job in an interim basis, to get at some of these root
issues of cooperation among medical centers we really need some
strong leadership.
Mr. West. Let me add one other thing. We will specifically
follow up on both of these.
federal employees health benefits plan
Mr. Goode. All right. Thank you. A more general question--
well, I want to say I am glad in the budget that you have
gotten increased funding for veterans health care. You are
familiar with the bill sponsored by--I believe it is
Congressman Norwood and Congressman Shays, to say all veterans
can get in--Medicare-eligible veterans can participate in the
Federal Employees Health Benefits Plan.
Mr. West. Is this retirees, Congressman?
Mr. Goode. Yes.
Mr. West. This is military retirees?
Mr. Goode. Right. And I have seen different estimates on
the cost. Do you all have a cost guess on that? I think it was
like $10 billion on that.
Mr. West. I don't think so, no, sir. I don't think we have
a cost estimate on that.
Mr. Goode. All right. Your total for health care in the
last fiscal year, what was it for retirees?
Mr. West. For retirees?
Mr. Goode. Yes. You all have a figure on that?
Mr. West. We can look to see if we can separate that out.
Of course----
Mr. Goode. I don't want you to go to--if you don't have
something readily available.
Do you think you will have it?
Mr. West. I would think it would be a small number.
Retirees, of course, are provided by and large by DOD hospitals
until 65, and then the whole point of the bill is that they are
thrown into, as it were, out on the economy. To the extent they
come through our system, it will be as any other veteran,
service-connected disability or the like. But we can certainly
go try to see if we have some sort of an ability to segregate
those numbers. I think it would be small though.
Dr. Garthwaite. I remember reading, I think last night,
that there is somewhere an estimate of around 600,000 military
retirees enrolled in the VA health care system. I think we have
that.
Mr. Goode. That is retirees?
Dr. Garthwaite. Yes. So I think we have enrollment data but
I do not think we have ever run the cost of care for that
particular group, and the cost might be quite different than
another group of veterans. I would suspect it might be a little
less.
empty hospital beds
Mr. Goode. This is an observation about the Salem Hospital.
It takes a long time to get in, and it is just like the
Congressman from New Jersey was commenting about the hospitals
in his area there, empty beds there and empty spaces, and a
typical veteran looks at that and says, ``Well, if you could
see me quicker, and I could be in the hospital if you would
just utilize this other wing.'' And I know that is not always
the best avenue from a cost effective viewpoint, but it is
still--the perception to the veteran is that you are not
providing me with as quick a care as you could if you would
utilize more of your facilities.
The director at the Salem Hospital I think is working hard
and doing a good job and no reflection there. I think it is a
perception that exists in New Jersey, Virginia, and in a number
of points across the country.
Mr. West. Let me, if I might, Congressman, say something
before Dr. Garthwaite does. We will look into that. That is
always the first point. But the possible existence of beds
other than long-term care beds that are empty is a little more
understandable to me. As the system over the past, what five or
six years, has gone from a residential care inpatient base to
outpatient. Remember that the number of veterans we are serving
is going up, not down. We are not declining in care we provide
for veterans. We are increasing. We are going to treat 100,000
more in 2001 than we are treating in 2000. Now, the question of
timing, how long they wait, is of vital concern to us, and I
described earlier that we are looking to get the waiting times
down for that first appointment for referrals and even for the
time waiting in the doctor's office. And that will allow us to
care for more people. But in terms of beds, residential beds,
we actually expect them to be emptier, because we are doing
more of our treatment in those 600 plus outpatient clinics, the
benefit being that they get us closer to the veterans.
Mr. Goode. My last point is I certainly like what you said
in your statement about 30 days max. Just keep going in that
direction and get it back.
Thank you, Mr. Chairman.
Mr. Walsh. Mr. Price.
claims decision waiting times
Mr. Price. Thank you, Mr. Chairman.
Mr. Secretary, I want to welcome you and your colleagues
back before us, and welcome Dr. Garthwaite for the first time
to this hearing.
And I would like to follow-up on a discussion that we had
last year concerning the claim waiting times, the initial claim
waiting times for veterans seeking disability rating reviews.
But the first thing I want to say is that we have gotten
excellent cooperation from your people in Winston-Salem. The
staff there has been very helpful to us. They have always been
timely.
Mr. West. The regional office?
Mr. Price. Yes.
Mr. West. Under Secretary Thompson.
Mr. Price. All right. Well, they have been very responsive
working with my staff. Director Montgomery spent time very
recently with two of my staff members, answering questions,
giving full access to rating and training staff, which was very
helpful I think in our understanding of how the disability
claims process works. And of course in our office, we are
trying to work on this on two levels, first in dealing with
individuals who need help in getting their claims processed,
and then coming back here to the committee and trying to make
good funding decision that will help us improve the process.
I know this has come up many times today. I understand the
question about the claims decision waiting times has been
raised by the Chairman, Mr. Mollohan, and Mr. Cramer. I am
particularly interested in the situation, of course, with the
regional office there in Winston-Salem. At last year's hearing,
the amount of time that a veteran had to wait to get an initial
disability compensation determination had increased to 238 days
or nearly eight months. The year before that the waiting time
had been 175 days. I am aware of the various problems that led
to this, particularly staffing problems, experienced staff, the
loss of some experienced staff, and the need to bring people on
and train them so that we have not only better turnaround
times, but also acceptable rates of accuracy.
update on claims processing at winston-salem var
I wonder if you or Mr. Thompson could give me an update on
the situation in Winston-Salem, Mr. Secretary. How long are
those initial disability review waiting times now? And while
you are at it, could you give me an indication of how we are
doing on the accuracy front? It is not just speed we are
looking at. Have the remand rates dropped? And how do these
numbers, both on speed and accuracy, compare to the rest of the
country, and what kind of rate of improvement can we expect in
the future?
Mr. West. Fair enough. And I think Under Secretary Thompson
will give you those figures. I will just say a brief couple
words.
I know that you want me to keep these answers short and I
may be going on too long. First of all, with regard to Winston-
Salem I am particularly aware of it. Let me put it that way.
Mr. Price. For very good personal reasons, I am aware of
that.
Mr. West. Secondly, Under Secretary Thompson, two years ago
told me and this committee and other committees, something that
has turned out to be true. He said the waiting times will get
worse before they get better, because he was instituting a
program that requires our people in our regional offices to
follow steps that make them essentially more honest in the way
they deal with the claims, not that anybody has been dishonest,
the tendency is to complete the easier claims, in order to
complete the easier claims, in order to improve the numbers
quickly. He has put in programs that require more honesty.
Secondly, as he attempts to divert more people into the
processing, there is a training problem to be dealt with as he
reorganizes the offices.
That is just an overview to say to you, as distressed as
every one of us is, me personally, our veterans, our
organizations, and the members of this subcommittee, over the
waiting times, they are not a surprise. We knew this was going
to happen before the numbers got better. Now we believe that
things are being put in place that will make them better. Go
ahead.
Mr. Thompson. Thank you, Mr. Secretary.
I do agree with what the Secretary said. I will speak to
Winston-Salem in particular. I believe we have turned the
corner down there. For February the original rating actions are
taking approximately 180 days.
Mr. Price. And that is the--the point of comparison there
is to the 238-day?
Mr. Thompson. No. The national average, actually, is 183,
so they are just slightly better than the national average.
That is just for the month of February. It is the most recent
data we have. If you look at 12-month trends, those numbers
would be higher because they are inching down.
Mr. Price. Okay. But in terms of Winston-Salem's
performance, the point of comparison is the 238?
Mr. Thompson. Last year.
Mr. Price. That we had last year.
Mr. Thompson. Correct. Winston is an interesting case. They
have a middle to large veteran population in the State of North
Carolina. But the military bases add 112,000 potential
claimants to our workload down there. Winston-Salem actually
comes out to be about the fourth largest compensation and
pension workload office.
I will say in advance that VBA is a Vietnam-era
organization. By that I mean that most of our senior officials
and most of our senior decision makers came to work for this
agency during the Vietnam War years. With a 30-year full
retirement in the federal government, if you do the math, you
realize that many of our most senior and experienced people
either have retired, are going to retire, or will shortly be
eligible for retirement. In Winston-Salem, 56 percent of people
in the first line of decision makers are in a training status.
The percentage of rating specialists in a training status is 50
percent and that is the most critical decision-making job. Of
the remaining rating specialists, 70 percent will be eligible
to retire in 3 years.
What you are seeing in VBA is an enormous transition from
one generation to the next as the work continues to come in. We
scramble to try to bring on new employees and to train them in
what, by any measure, is an extraordinarily difficult process.
Nationwide 40 percent of our decision makers are in training.
rating specialists eligible for retirement
Mr. Price. And the number eligible for retirement, do you
know what that figure is, the rating specialists and appeals
specialists who are eligible for retirement say in the next 5
years?
Mr. Thompson. In Winston-Salem, about 70 percent will be
eligible in the next 3 years, of the ones that are not in
training. We have about half of them who are in training. Of
the remainder, it is about 70 percent of them. Nationwide, I
can get you the specific numbers, but the average age for a
disability rating specialist is up around 50. For other jobs it
is higher than that.
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Mr. Price. Well, I would appreciate that. That certainly
does underscore the nature of the problem you face in replacing
these personnel and getting them trained.
processing times and remand rates
I do want to go back just briefly if I might to the
turnaround times. You gave me a February figure. I want to
understand exactly what I am getting there and how accurate
that number is--or how representative it is of what we are
really getting done month by month over in Winston.
Mr. Thompson. That is a point in time. We also measure by a
12-month rolling average. I don't have that right in front of
me. I will be glad to get that for you for the record.
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Mr. Thompson. I can answer your remand question. Winston-
Salem has dropped the remand rate from 48 percent to 38
percent. The national average right now is 29, so they are not
doing as well as the national average, although they have made
good improvements. I think a lot of that has to do with the
percent of trainees they have in this process.
Mr. Price. All right. We will pick up again after the vote.
Thank you.
Mr. Walsh. Thank you. We will return.
Mr. Knollenberg. Mr. Chairman, just before you drop the
gavel, is there any chance of getting in a minute?
Mr. Walsh. You are welcome to stay and ask questions.
Mr. Knollenberg [presiding].
allen park health care needs study
Mr. Secretary, very quickly, Allen Park is a community in
my area, and the Detroit Metropolitan area. There was to have
been a study which would include a projection of current and
future health care needs of this facility. As you know, it was
vacated when the new Dingell Center was brought into play in
1996. I would like to know if you are prepared to submit this
report to the House. We have inquired about this, I think it
was last year and maybe the year before, and we want to know if
there is a report coming. I don't have to have the details, but
is there something that we can anticipate seeing?
Mr. West. I think there was a report received at VHA. I
have not seen it, and I think they are not ready to forward it
to me because they have some questions about the report.
Mr. Knollenberg. So it is still in the process? We may want
to follow up on that with you, because it has been a while
since that request was made.
The other thing that I should tell you about, there is a
lingering problem. As you know, that facility was granted to
the VA back in the '30s by Ford. Ford may want it back. They
are talking in some earnest about--because that was a part of
the provision, that once it was----
Mr. West. A reverter?
Mr. Knollenberg. It was a reverter type clause that allows
it to come back. And I am sure that you are aware there is a
38-acre campus there, so there is some concern about the use.
So I would like to make sure that we hear what is being
proposed, what is the situation, and then finally with the
Dingell Veteran Center, I want to know if there is any way that
we can utilize some of the space in there? That is a facility
that is not entirely being used. Could it be possible--I am
just asking--if Wayne State University and my office could work
with you in some fashion to determine if any of that unused
space could be available for some other research or whatever. I
am not clear on what we could do, but if it is not being used,
could we use it for something?
Mr. West. Let us take a look.
Mr. Price. And so that is the focus of my intent. So I will
be glad to----
Dr. Garthwaite. My understanding is we are currently
examining whether that would be useful for the benefits office
for co-location, but we have other examples where we have used
space, so we would be happy to----
Mr. Knollenberg. We would be interested in all that, and I
guess I am the only one that has access to the gavel, so with
that, I will call for a recess. Thank you very much.
[The information follows:]
Allen Park Study
The medical center has met with representatives of Wayne
State University on more than one occasion to discuss the
possibility of utilizing VAMC space. These discussions have
centered on the use of research space in light of the fact that
the John D. Dingell VAMC and the Wayne State University School
of Medicine are educational affiliates. These discussions have
resulted in Wayne State University and the VAMC entering a
contractual arrangement whereby the University uses VA research
space and the VAMC is provided educational tuition credits at
Wayne State University. This agreement is in the final review
process at Wayne State University.
Mr. West. All right, sir.
[Recess.]
processing remand cases
Mr. Walsh [presiding]. My opportunity right now to ask
questions.
I have some concerns about the way the department handles
remand cases, as most of the members here have expressed today.
The VA budget justification states remands represent a rework
phase of the appellate cycle, and typically add two years to
the processing time for an appeal. Two years is a long time.
I can say from my experience with my regional office in
Buffalo, there are 163 remanded cases as of January 18th that
are more than two years old. The length of time is in addition
to the time it took the Department to initially adjudicate
those cases. And I might add, this is a tremendous workload on
my office too, because my veterans issues and claims expert is
handling the same cases over and over and over. So obviously,
it is difficult for me. Imagine the veteran that has waited
two, sometimes three years to have their claim adjudicated.
What is the Department doing to clear these cases,
specifically Buffalo, but obviously Winston-Salem has some
problems, and others do too.
Mr. Thompson. Mr. Chairman, I will put this in a little
better perspective. The same people that process claims handle
the remands in a regional office. In the middle of the last
decade, as this agency focused on trying to get original claims
decision done more quickly, we put a lot of the other types of
work aside, including appellate work and remands. We did not
focus on them because we simply did not have the resources.
I can tell you that over the last 18 months to two years we
have required regional offices to put increasing attention on
remands. That has contributed some to the original decisions
taking more time. But the good news is that the pending remands
in regional offices are down 14 percent over the last year. The
oldest ones, the ones over two years and the ones over four
years, which are also there, have declined significantly, by
more than half. We have the rate at which the appeals are
remanded from the Board of Veterans Appeals (BVA). In 1997, 45
percent of the claims we sent to them were remanded back to
regional offices. That number right now is at 29 percent, which
we think is a significant decline.
VBA and BVA meet biweekly to make sure we are on the same
page. We have joint training. Probably one of the most
significant things we did was last year was to develop a joint
evaluation system. We have one computer system now that tracks
the process from the regional office through BVA and any
iterations of that. This is the first time that has ever
happened. Traditionally, VBA had its system, BVA had its
system, and never the twain did meet.
I am not satisfied with how we are doing with remands, but
I think we are on the right track. With continued effort, I
think we will get the numbers down to where we are much more
comfortable.
appeal process
Mr. Walsh. One of the really frustrating aspects to this,
certainly for my office, and for veterans in general, is that
in so many of these cases the first action that the veteran
sees after waiting for months and months and months is to get a
referral back from the appeals or from the agency that says,
``You are missing certain forms'', or ``Something is not
signed'' or some ``i'' isn't dotted or some ``t'' isn't
crossed. And to wait for months and months and months to get an
answer back, and then to get that sort of response back makes
people angry. What are you doing about that? There has to be a
way to clear those out, clean them up first.
Mr. Thompson. It makes me angry as well. At a minimum,
veterans who file claims with us need to know quickly and
accurately what the status of their claim is, and to be kept
apprised of that. Frankly, if they have waited months, and are
then told they are missing a document or didn't sign something,
that is just a flat-out mistake. There is really no excuse for
that. Again, part of that has to do with claims backlogs and
people not having the opportunity to look at these things as
they are coming in the door. They often sit for extended
periods of time before anyone can consider them.
I think the long-range solution to this is to have a
relationship with the veterans that currently does not exist in
most VA regional offices. Currently, it is a machine-like
process. You send your paper in, and when we get to it, when we
can, we will let you know what is going on when we think we
should. What I mentioned in response to Congressman Cramer's
question, we are going to a case management system. You will
have individuals in regional offices that the veterans know;
they know their phone number; they know how to get hold of
them; they know these people that are the veteran's advocate in
the regional office. I think moving to that system will do more
than almost any other single thing I can think of to make
veterans satisfied with the process and make them feel not only
that we make fair and accurate decisions, but that we have
their best interests in mind at all times.
reduction in backlogs
Mr. Walsh. The skeptic, or even worse, the cynic, might
suggest that these reductions in backlogs are more of a result
of the statistic that Mr. Frelinghuysen mentioned earlier, a
thousand veterans a day dying. How would you refute that?
Mr. Thompson. I think the facts speak otherwise. The older
veterans, the World War II generation, don't constitute a
significant part of our work right now. For the most part they
have had settled issues with us oftentimes for many decades.
Our largest single workload area are Vietnam-era veterans,
followed by Gulf War veterans and peacetime-era veterans. World
War II and Korea constitute a small fraction of what we do. If
you are using age as a measure of the likelihood of death, I
think that it won't significantly impact the claims process,
because most of our claimants are somewhat younger than World
War II and Korea.
additional funding for medical care
Mr. Walsh. Lastly, we provided an additional $1.7 billion
last year to the Agency for medical care. The President has
requested in the neighborhood of $1.3 billion. That is $3
billion. It is a substantial increase. How are you going to
spend that money? What are your priorities for spending it?
What can we, as representatives, and what can the veterans
expect from the Department of Veterans Affairs with that
substantial increase in expenditure?
Mr. West. A half a billion of it is in implementing the
Millennium Act, $548 million. That is very significant because
of how it will help us in terms of real solutions to the long-
term care problem. I mentioned community, home-based and the
like, and to the emergency care, will have an effect on
veterans. I think the other big portion--I will give Dr.
Garthwaite, who is our health person, a chance to talk briefly
on access to health care and service. And that is the
outpatient clinics opening up, the 63 additional ones to go
with the 77 opened this year, which takes it out to more
points. Then is the FTE that we are able to redirect nurses and
doctors into the clinical health care provision. And quite
frankly, that is also the ability in most of our networks now,
who are passed the impact, except I think for one, the
significant impact that was driving down the amount that they
were getting there to begin to build their programs again.
We will do a lot of health care with that, just as we will
with all of the $1.7 in fiscal year 2000. The $1.355 will help
fund improvements in service and increased access, Millennium
Act and of course, the cost of hepatitis C. The procedure is
expensive. We started from a small cost just a few years ago
now, to $340 million. So those will be part of it, as well as
the ongoing activities. Research is staying the same, at $321
million, but that is still a big amount of money.
What else would you say are our priorities within that?
Dr. Garthwaite. Clearly, the hepatitis C piece, the
increase in drug costs. We have noticed a continuing increase
in drug costs over time. It was 6 percent of our budget in 1994
and now last year over 10 percent of our budget. So as new
therapeutic drugs come out that are effective, we have invested
more and more in getting those appropriately to veterans. We
have committed to homeless veteran initiatives, and some
additional dollars there. Clearly, one of the big pushes is to
improve our waits and delays, and we have not waited to start.
We have a huge initiative ongoing with the Institute for Health
Care Improvement on the processes that underlie some of the
waits and delays. Some are resource issues. Some are
recruitment of doctors and nurses. Some of them are just the
dumb old way we have always done business that needs to change,
and we have dramatically changed some of those.
Health care inflation is not an insignificant part of all
this, and it would be wrong, I think, not to point out that my
health care premiums have been going up by 8, 9, 10 percent the
last couple years. That reflects the increased cost of
pharmaceuticals. It reflects the increased cost for personnel
that we have to recruit against the private sector. It reflects
a whole series of things that are underlying that health care
inflation piece. That is a big part.
Secretary West. Speaking of drug costs, that is, obviously,
not inconsiderable. Over two years that will be another half a
billion. So, that in 2001, you might assume half of it or
approximately half is a significant part of the increase, as
well.
Mr. Walsh. It certainly is.
Thank you. Mr. Mollohan?
Mr. Mollohan. Thank you, Mr. Chairman.
access and service
Mr. Secretary, you have been asked some access and service
improvement questions. I just want to go over them a little
bit. The VA medical system has had chronic problems with
managing outpatient care schedules. Veterans have complained to
all of us over the years that it takes forever to get an
appointment and that the wait once they arrive at the facility
can be hours. I get this all the time from veterans in North
Central West Virginia that have to go to Pittsburgh. They have
a real dilemma once they get there. The bus they go on, except
on one day of the week, returns at 2:30. They will have an
appointment in the morning and they don't get served until they
are bumping up against the time that the bus has to leave. Many
of them have to choose between staying past the time the bus
leaves or making another appointment.
The President's budget request includes $400 million
targeted to improving access in service. This includes meeting
the goal of an appointment within 30 days and patients being
served within 20 minutes, as you have testified here today.
Can you put this goal into perspective? Tell us where we
started in terms of scheduling problems? What progress has been
made to date? I do know that you have been working on it. When
do you expect to achieve the goals that you are setting forth?
Dr. Garthwaite. We have a little better data, I think, on
seeing you within 20 minutes. We said, please come in for a 2
o'clock appointment, when did we actually take you into the
room? In 1997, we believe we did that 55 of the time; in 1998,
66 percent; in 1999, 69 percent of the time. Our goal by 2003
is to do that 90 percent of the time. We would love to exceed
that goal if that is at all possible and we are going to split
the difference in what we demand of our managers in that we
will ask them to make a third of that progress during each of
the next three years.
Now, the other issue is when can you get in and when is the
next available clinic waiting time? We temporarily used the
next third available appointment. It is a computer term that
will give us a better handle on how soon until the next
appointment.
And we don't have good system-wide data yet, but we have
been using clinic data to feedback to teams that are involved
in trying to improve that process. And we have made some
dramatic improvements. And all 162 medical centers have
improved some and at least their most problematic clinic that
they chose to work on during this initiative and we are rolling
out that data. And as soon as I have it, I will get you a copy.
Because I think it is going to be very impressive.
Our goal, however, is to get to that 30-day. Again, I will
say our data isn't the best as a baseline. We thought we were
about 60 percent on the 30 days for primary care. A lot
depended on the type of specialty, whether we were close. Our
baseline data estimates vary by specialty. They are probably
the worst in ophthalmology, where we dispensed almost a half a
million eye glasses last year, and orthopedics and urology
which affects a lot of older veterans.
So, I think we have made significant progress but we are in
the midst of change and I think we have now the fix in our
computer systems that allows us to track it. Every time you
ask, we will be able to give you that running average of how
long until the next appointment and I think that will
dramatically change.
waiting times
Mr. Mollohan. I think the questions on this subject assume
that a veteran who is waiting actually gets seen. But in the
situation that I described for you, that veteran would not be
seen that day because the bus was leaving at 2:30 from
Pittsburgh and they had to go back to West Virginia.
In your statistics, do you track the veterans who, because
they have had to wait so long, don't get seen?
Dr. Garthwaite. I am not aware that that is the focus of
what we have done. It is obviously an inexcusable situation and
whenever it occurs, we would like to know about it. We have a
lot of systems set up to try to help people who are having
trouble, patient reps that are easily available to a veteran
who is concerned about that and should intervene.
Mr. Mollohan. But is this a problem that you know about,
veterans leaving because they have had to wait so long for
their appointment?
Dr. Garthwaite. My guess is that it probably happens
occasionally and, that because it happens occasionally and
should never happen, that it is well-remembered and----
Mr. Mollohan. No, no. Excuse me.
Dr. Garthwaite. But I don't believe it happens a lot.
Mr. Mollohan. Okay. My question was do you track that? Do
you know?
Dr. Garthwaite. Not that I am aware of.
Mr. Mollohan. I would like to get some sense of to what
extent that is a problem. I know that just last week I had
veterans bring this to my attention. I don't know how unique it
is that veterans have to get on a bus to go some distance, but
that leads me into another question.
Veterans tell me that when they are seeking eye exams or
some sort of specialty examinations, they call into a system to
get an appointment. They may get an appointment, but at a
number of different institutions which may be some distance
from their home. Is that the way it happens? I know that it
does in some situations because I was on the phone with a
veteran waiting to get an appointment. The veteran was
complaining it took so long to get an appointment and it would
be so far from home. It was like the VA was booked up and had a
central operator that has the schedule for all the different
clinics in the Washington area.
The veteran was complaining about doing this time and time
again and not getting an appointment. However, when I was on
the phone they were routed to Aberdeen and got an appointment
in about two weeks.
So, the veteran was disappointed in this case that they got
an appointment because he wanted to impress the Congressman
that they couldn't get one. But, they had been trying for some
time to get an appointment. Is this a part of the process that
you are looking at?
Dr. Garthwaite. Well, the system is, I believe, designed to
work a fair amount better than that. If it is your first visit
to the system, brand new, we have set up a fair number of
mechanisms where you can call in, who you talk to, and we have
tried to expedite that process where you can do a lot of the
registration over the phone. There is even one medical center
that allows you to do it over the Internet. You can fill out
the forms before you get there, come in and try to expedite
your first visit.
Now, if you are in the system you should have a primary
care provider. Veterans answer to that question, well over 80
percent of the time, they knew who is in charge of their care
and who is coordinating their care.
So, if you are seeing us fairly often, someone who is your
primary care provider or team should be referring you for
specialty care. And they should be making those appointments or
calls for you.
Each medical center has a call-in number to straighten out
prescription issues, appointment issues, and so forth, as well.
va medical performance compared to private sector
Mr. Mollohan. How does the current performance compare to
the private sector, say, the largest HMOs or managed care
plans?
Dr. Garthwaite. We have a lot of trouble finding that
information. I think that in a sense if it is exceptional they
are already bragging about it and trying to get business and if
it is not so good they don't really want to brag about it
because it would deter business. And, so, no one really
publishes that.
We have been looking for waiting times in the private
sector to benchmark against but we have not been terribly
successful to date.
Secretary West. Was your question also, do we have any
suspicions or--I mean----
Mr. Mollohan. Well, I don't know that suspicions are
helpful. But if you have anything a little better than
suspicions, I would like that.
Dr. Garthwaite. One anecdote that I am not terribly in
favor of----
Mr. Mollohan. Well, tell me, what are your suspicions?
[Laughter.]
Get those on the record and then maybe you can follow-up
them up with something.
[The information follows:]
Waiting Time Performance
In developing the customer service standard of 30 days to
obtain a speciality appointment and 30 days to obtain an
initial primary care appointment, information was obtained from
some non-VA health care systems (Air Force and Group Health of
Puget Sound). The 30-day period appears to reflect community
standards, but no comparable data is available for HMOs in
general. We are also not aware of any industry information on
waiting times for a scheduled appointment that could be used as
a benchmark.
Since 1995, our overall customer service scores for access
have improved from a problem rank of 24% to a problem rate of
11%. On the 1999 customer service survey, only 17.6% of
respondents said they were not able to get an appointment in a
timely fashion.
Secretary West. It may be good news.
Dr. Garthwaite. I am not a proponent of anecdotes but we
have one anecdote where we tried to contract for eye exams
where we weren't going to provide them, we were trying to set
up a contract for them. And because we asked--and we put in the
contract-to meet a 30-day recommendation, a 30-day time frame.
They told us that they can't do that for all their other
patients, so it will cost you more. The particular area was, I
believe, Colorado or Wyoming.
So, that is an anecdote which is worth just that. But there
will be places around the country where an appointment within
30 days will exceed what the community standard is. We think
overall health care could induce fewer waits than it does, VA,
non-VA.
Mr. Mollohan. Thank you, Secretary, for helping me
understand.
[The information follows:]
Additional Money
If additional monies were made available, priorities would
include accelerating the investment in timeliness and access to
care and reducing waiting times for Medical Care and increasing
Health Services Research, the delivery of health care research
as being of particular importance to VA's large health care
delivery mission.
tobacco litigation
Mr. Walsh. This issue of the tobacco suit. The Federal
Government, the Justice Department, I think, was fairly
strongly instructed by the Congress not to enter this suit. We
did not provide any funds to DOJ to pursue the suit. And yet
you have decided to provide $2.5 million of veterans' health
care money for this lawsuit.
Why did you do that?
Secretary West. Mr. Chairman, we took a very careful look
at this and it turns out that the Justice Department has
statutory authority to ask us to contribute to this suit.
Mr. Walsh. You believe you have statutory authority to
provide the money?
Secretary West. Yes we do.
Mr. Walsh. There is absolutely no question about that?
Secretary West. Our lawyers are pretty clear on that.
Because I asked it several times and I am a former agency
general counsel two times over and was concerned about that
very point. And, thirdly, it is true that we are one of the
departments that will benefit significantly from any recovery
from that suit. It does not go into the general fund of the
Treasury. It will go into our health care budget.
Mr. Walsh. How much might you get in return?
Secretary West. We won't get all of it but we will get a
share of it.
Mr. Walsh. What is the anticipated opportunity here?
Secretary West. You mean how much do we think we will get?
I am not real clear on that. I don't know if we have a good
feel for it. This is the general counsel, Leigh Bradley.
Ms. Bradley. We don't have a good idea at this time about
what our recovery will be because there are still some legal
issues to determine which of our veterans would, in fact, fall
within the class. Can you hear me okay?
I don't know that I have anything to add to that. The
Justice Department has been working very closely with us to
determine the class of veterans that, in fact, will be subject
to the lawsuit. So, I can't give you a good idea about what we
think the estimated recovery will be. I can tell you, to
reinforce what the Secretary said, that we have taken a very
careful look at our authority to support the litigation with
our appropriated dollars and we feel very confident that we
can.
Mr. Walsh. Why did these dollars come out of medical care
as opposed to administrative costs?
Ms. Bradley. Because of the authority that Congress gave us
under the Medical Care Recovery Act to use the Medical Care
Collections Fund to pay expenses incurred in collecting VA
health-care costs. Since it is money that we are going to put
back into the MCCF it is appropriate for us to use that fund to
pay for the litigation.
Mr. Walsh. If you lose the suit, are you going to put $2.5
million back in?
Ms. Bradley. It is a good question. We don't anticipate
losing the suit. [Laughter.]
Mr. Walsh. I will leave it there. Thank you.
[Recess.]
reduction in force
Mr. Frelinghuysen [presiding]. I would like to call the
hearing to order. Mr. Secretary, last year we talked quite
extensively about reductions in force, 1,100 of those, which
you approved, including 320 RIFs at Lyons and East Orange VA
Hospitals in New Jersey and other reductions in force in the
New York area.
How many RIFs, in total, did you approve last year and
perhaps, more importantly, do you anticipate any additional
RIFs in fiscal year 2000?
Secretary West. This is a total throughout VHA, throughout
the system.
Mr. Frelinghuysen. Yes.
Secretary West. We sent out 1,349 notices of RIFs to
employees in fiscal year 1999. Of those, 55 were actually
separated under the RIF procedures. And did you also ask about
anticipations for this year, as well?
Mr. Frelinghuysen. Yes.
Secretary West. So far in fiscal year 2000 we have sent out
already 137 notices, of which 8 have actually led to
separations. And I don't know that we have any anticipated RIFs
on board except for one package that has been previously
discussed in Network 1. Is that right?
But those are on hold. We have had an acting or interim
Network director in there. Dr. Garthwaite has just recommended
and I have just approved, I don't know if we actually got her
in the position yet, a new Network director, who is going to
review that whole question.
Mr. Frelinghuysen. That is, obviously, in anybody's vision
demoralizing. Certainly people work hard but those are the
statistics?
Secretary West. Yes, sir.
patient health status evaluation
Mr. Frelinghuysen. Your fiscal year 2001 budget states that
the VA has undertaken a study of how high cost, sicker patients
are distributed among the 22 VISNs, giving the perception that
these patients are not evenly allocated among VISNs. A final
report is supposed to be provided to the VA last month. Has
that report been submitted?
Secretary West. Let me ask Dr. Garthwaite to answer that.
Dr. Garthwaite. I have not seen the complete report. It has
come in to our financial people and to our VERA work group and
they are reviewing its implications. The verbal report that I
have, to the best of my memory, was that the major issue still
remaining has to do with age and whether there should be an
adjustment for age. And I have asked them to pursue that
vigorously and carefully but quickly.
Mr. Frelinghuysen. So, that is just the short review? There
will be a more comprehensive version?
Dr. Garthwaite. People that we have who know the most about
all of this are just going to provide their comments so we have
that full vetting when we take a look at it. But I anticipate
that that would be around shortly.
Mr. Frelinghuysen. So, Congress may anticipate the report
at what point?
Dr. Garthwaite. I will look at it but I would think that it
is not far away, hopefully a month or a month and a half. Maybe
sooner.
Hepatitis
Mr. Frelinghuysen. Some reference was made earlier in the
discussion about the receipt of letters and the New York and
New Jersey members of Congress have written to you, Mr.
Secretary, quite a few pieces of correspondence. There seems to
be some lack of response, most particularly, in the are of
questions relating to the funding of Hepatitis C in VISN 3. I
have sent a couple of letters to you, Dr. Garthwaite, the most
recent being March but I think we initiated the letter-writing
process regarding Hepatitis C back in October of last year.
When will our delegations get the response we have been
looking for?
Dr. Garthwaite. I will check on the specific response. I
have now a recommendation that is about a week old to me about
the cost of hepatitis C and whether that should be included in
the model, in the VERA model. And, so, I do have some data and
I am in the process, personally, of looking at that data.
This year it is not a huge issue in terms of the total
numbers. There are some differences and they are in the order
of magnitude of a million dollars or so. And I think on
principle that it may be something that we want to get into the
model fairly quickly because we anticipate it will grow because
our testing is now going up and then a significant number of
veterans test positive for hepatitis.
Mr. Frelinghuysen. By all evidence that we have seen, the
hepatitis C situation is a growing problem, as has been stated
earlier, largely among Vietnam Era veterans.
In my neck of the woods, VISN 3, alone, during March of
last year, in a random one-day hepatitis screening about 12
percent of those tested, tested positive for the virus. All of
us here are pleased that there is an increase of $145 million
in funding for hepatitis C. It is a huge problem. I am not sure
if it is on everybody's radar screens in the general public.
However, I do have some questions about Hepatitis C funding
and you have somewhat indicated that you are reviewing this. I
and other members from my area would like to know how this
money will be distributed? Based on need or on the VERA
formula? We can say more and I will say more about VERA,
generally, later, but what do you anticipate basing your
distribution on?
Dr. Garthwaite. Where we can find differences by region
that need to be accounted for in VERA, we have tried to account
for those. We, for instance, provide some increase in the VISN
3 budget because it is more expensive, the cost of living in
that area is higher and there are other adjustments that we
make in terms of building and research and education.
Given the fact that these patients are not distributed
equally and given the fact that they don't fall into the
special categories, like AIDS patients do, I think it is going
to be wise for us to account for that, even though I think it
is a small percentage today.
Mr. Frelinghuysen. There is actually quite a correlation
between the number of AIDS patients and the number of HIV.
Dr. Garthwaite. That is correct.
Mr. Frelinghuysen. Drug users.
Dr. Garthwaite. That is correct. I mean just, for example,
last fiscal year we were able to document the VISN 3
expenditures, which were about $3 million, which is .31 percent
of their total VERA allocation. That ranges across the United
States all the way down to VISN 2, which is in the same State,
of .09 percent of their budget or $384,000. New York and New
Jersey had 1,700 patients with hepatitis C, versus Albany VISN
which had 451.
Mr. Frelinghuysen. We are always appreciative whenever you
can tinker with VERA, without repealing the law--of course,
many of us would like you go to back to the drawing board. And
not all people that have hepatitis C go through the VA system,
obviously, to seek a remedy and assistance. Some do and I think
you actively recruit as many veterans as you can to participate
in the overall system and that is an ongoing effort. And,
obviously, some people get so damn sick and need such immediate
attention they go to the nearest emergency room and that may be
a university of medicine and dentistry hospital perhaps before
one of our VA hospitals.
Hepatitis C Treatment and Funding
How will that money be spent? How much for treatment? How
much do you anticipate for testing and will it be spent for any
other purposes?
Dr. Garthwaite. That is actually what was spent and I don't
have the detail with me. About 10 to 13 percent of patients who
have hep C are currently being treated. And that seems like a
relatively low number to me and I think maybe to many others.
But there are significant side effects and contraindications to
the medications. And, so, I was in VISN 3 last week and they
were telling me that the real problem is getting concomitant
treatment with psychiatry because the drugs can worsen
depression and there is preexisting depression in many of the
patients.
But they are working through those processes. But it is
important. What we made very clear is that no veteran must be
denied access to the drugs for other than a medical reason.
Financial reasons are not adequate as an excuse simply because
the drugs are relatively expensive. So, we have reinforced
that.
Mr. Frelinghuysen. It has come to my attention that the VA
may not be spending the entire amount appropriated for
hepatitis C in fiscal year 2000 on treatment and testing. Is
this true? And if so, where else would that money be spent if
it isn't being spent where we think it should be?
Dr. Garthwaite. I think our original numbers for 1999
suggest that we are a little less than we had originally
predicted. I think we projected $46 million and we believe we
have spent around $27 million that we can directly attribute in
our data bases to treatment for veterans with hepatitis C.
Mr. Frelinghuysen. Where does the money go if it isn't
spent on treatment or testing? I am sure you have an answer at
the ready there.
Dr. Garthwaite. Well, there are always plenty of other
demands for all the resources in the medical care budget. You
know, these estimates that we put forward are our best estimate
based on the number of veterans we have seen and, often not too
much real world experience. As we gain real world experience,
we try to go back and change that.
Obviously, any dollars that we have are plowed back into
treating veterans, whether they----
Mr. Frelinghuysen. I understand things are fungible but if,
in fact, this is a crisis and one of the biggest financial
obligations you are faced with, I think the assumption here is
that we would be putting the money into treatment or to
testing.
Dr. Garthwaite. Correct. But to my knowledge, we are
treating and testing every veteran who presents. We are
actively screening and asking the questions whether you are at
risk or not for hepatitis C of all the veterans that we serve.
We are working with the American Liver Foundation, the Vietnam
Veterans to get the word out to veterans on the street that
they should come in and get tested.
We have worked with other public figures to get that word
out.
Secretary West. Congressman, can I say a word here about
that?
Mr. Frelinghuysen. Jump in.
Secretary West. And I want to give Dr. Garthwaite a chance
to correct me if I am wrong. But I think the money----
Mr. Frelinghuysen. I am sure he would not think of it,
would he? [Laughter.]
Secretary West. He does it all the time. I think the money
gets distributed under VERA. So, that if you are hearing that
we are not using all of say the $199 million that was
appropriated in 2000 for hepatitis C, it would be because we
are not seeing that incidence of patients that add up to that
much money, essentially.
I think our number of $340 million for testing and
treatment is our estimate of the incidence that we will see, an
estimate of the number that will come in for testing and then
the incidence we will find after that that will require
treatment of this expensive amount. But it gets distributed
under VERA and that is why your conversation with him, that
says, hey, we need to tweak this to look at the Networks in
which there is likely to be a higher incidence is so pertinent
to the discussion.
Mr. Frelinghuysen. Well, as long as that happens and the
money isn't spent on other things, since members of Congress
think that you are going to be spending it on hepatitis C.
Secretary West. Which we will to the extent that it is
needed.
Hepatitis C Funding
Mr. Frelinghuysen. Just for the record, how much do you
anticipate spending on hepatitis C in fiscal year 2001 on
testing and treatment?
Secretary West. That is the number we have requested.
Mr. Frelinghuysen. What number?
Secretary West. Oh, the $340 million.
Mr. Frelinghuysen. The $340 million that was mentioned?
Secretary West. Yes, sir.
Mr. Frelinghuysen. That is the total sum?
Secretary West. That appropriation is for testing and
treatment.
Mr. Frelinghuysen. Okay. I understand that veterans are not
automatically tested for hepatitis C and from what I can gather
it is pretty expensive and there is certain identifiable
characteristics in the individuals you are working with that
perhaps would automatically exclude a few people from that
process.
Dr. Garthwaite. Correct.
Mr. Frelinghuysen. But are they tested if they meet several
risk factors and what are those risk factors?
Dr. Garthwaite. Well, the major ones would be transfusion
blood products, drug use with unclean needles, and there may--
--
Mr. Frelinghuysen. And this is not a pleasant test. So,
people may be in a state of denial.
Dr. Garthwaite. Right.
Mr. Frelinghuysen. But it may be obvious to the
professionals in the VA that there are some primary candidates
for testing?
Dr. Garthwaite. Right. We have a meeting going on in this
area tomorrow and Friday with our practitioners and experts in
this area in our continued effort of bringing ourselves up to
date and then proposing new actions that will be more effective
at getting more people to get tested.
Just for the record, we tested in fiscal year 1998 95,000
veterans; in 1999 we tested 177,000 veterans, and I anticipate
it will be higher this year.
Mr. Frelinghuysen. So, it would be fair to say that you are
doing everything with the resources you can to make sure that
all at-risk veterans are screened for hepatitis C?
Dr. Garthwaite. Yes. I don't know what everything is but I
feel we feel an urgency to this problem. We feel that testing
needs to happen and we feel that the patients who can tolerate
the treatment and who will benefit ought to be on the drugs as
soon as possible.
Mr. Frelinghuysen. Thank you, Mr. Chairman.
I know Mr. Hobson has been waiting.
Mr. Walsh. Thank you.
Mr. Hobson?
Mr. Hobson. Thank you, Mr. Chairman.
Nice to see you, sir, all of you.
Community Based Outpatient Clinics
I have three questions I would like to talk about. First of
all, I would like to commend you on the community based
outpatient clinics. Those seem to be working very well in my
district and across my State. Laura Miller seems to have done a
good job in locating those in our State.
The veterans in Lancaster are very excited. The veterans in
Springfield are very excited. They just had--I didn't get to
it--but they just had a big open house in Springfield, I think,
last weekend. I think these have been a tremendous success
elsewhere in getting convenient access for patients.
Can you tell me how many of these have been opened
nationwide and how is this affecting your medical care budget
allocations? And are you saving money by doing these? Certainly
from a wellness standpoint, I think these are good. Do you have
any results yet?
Secretary West. Well, I am sure that Dr. Garthwaite and our
financial people can talk a bit about whether we are saving
money. We are certainly getting health care closer to veterans.
I mean they are like Americans, they live where they choose to
live, not necessarily where there are medical centers. And this
has been an effort to get the health care closer to them. We
have over 530 now.
We are still on target for 77 in this fiscal year 2000. So,
we have 63 more in the 2001 budget, the one we are discussing.
I think they are working. They are quite popular. But whether
we are saving on them I don't know. I don't know that that was
necessarily our intent. I think our intent was a better model
of health care delivery.
Dr. Garthwaite. I don't know that I know any data about
whether we save money or not. What is very clear, though, if we
give primary care and we can get to a disease earlier, in
general, that is believed in the medical model to save more
money. I mentioned earlier that I think that immunizations save
money.
If we take elderly, 65 and older, people with lung disease
and immunize them for pneumonia, we save $294 every time we
give a shot because we avoid hospitalization and we avoid other
illnesses that require medications and antibiotics and they
live longer and feel better.
Mr. Hobson. The point is that people will go and get those
in these community centers when they wouldn't drive to Dayton
or to Chillicothe or Columbus to do it.
Dr. Garthwaite. Exactly.
enhanced use leasing
Mr. Hobson. Let me ask another question. As you know I have
got one medical center in my district in Chillicothe and
another just outside of my district in Dayton, which is in Tony
Hall's district. In the past year both centers have had to make
touch decisions concerning deteriorating buildings on their
campuses. However, in both cases the buildings are quite
significant to the campus and the surrounding communities.
In Dayton, Tony and I put together a group that both
financially and physically to turn a building that was
constructed by Civil War veterans into a national museum
without using any medical center funding.
Chillicothe is also looking at several alternatives to fill
empty buildings which the VA recently decided it no longer
needed. Obviously, the top priority for your medical centers is
to provide quality medical centers for veterans. However, I
suspect that older medical centers across the country are
experiencing similar situations with their campuses like the
ones that are occurring in Chillicothe and Dayton.
I guess my question to you is, what are you doing to assist
medical centers and communities in finding viable alternative
uses for buildings no longer needed by the VA? And I think you
need to share these options with the various directors.
I can tell you this is not an unusual problem. I am
chairman of Military Construction and I can tell you in bases
across the country there is going to be a whole bunch of
buildings in the Army and the Navy and the Air Force that all
go on the historical register and we can't afford all those.
You have got similar type problems and how are you looking at
these issues?
Secretary West. The Congress has been very helpful to us
and given us special statutory authority. We have the enhanced
use authority to make leases, which allows us to be able to use
money other than just appropriated money, to be able to take
buildings and to lease them and use them for purposes and we
can invite people in to do that.
I think that has been a big help to our medical center
directors. I am not sure how many cases we have used it. But we
have made fairly good use out of it and it is one of our
mainstays.
chillicothe facility
Mr. Hobson. Well, let me tell you what I find, and I would
like to see--I think sometimes the people who run these things
are a little afraid to be creative because I am not sure it is
in their job description.
For example, at Chillicothe, they have got a building that
I wanted to turn into a State facility for the veterans in
Ohio, a nursing home. Now I think that we might give some
thought to some outside group coming in from the community, and
leasing that facility and making it into a nursing home,
because the State has decided not to take you up on the State
Nursing home plan.
But I think somehow you need to send messages to the
Regional Offices to think outside the box a little bit on how
we use some of these facilities. You have got big campuses, and
I think we need to get you some revenue from some of these
things, and you need to encourage them to come up with creative
plans.
For example, in both instances they were a little afraid to
ask for money maybe even out of cycle or pushing things forward
because of all this--you know what I am talking about.
Secretary West. It probably varies. We have got some
medical center directors and some network directors who are
actually quite aggressive, so much so that every now and then
we have to go back and make sure we, in thinking outside the
box, have not thought outside the rules.
I meant to mention we are also, trying to colocate as much
as possible the Under Secretary for Benefits regional offices
on these campuses so that veterans can have one-stop shopping
in terms of their benefits and their health care.
Dr. Garthwaite has what he calls the CARES Initiative,
which we are trying to share with you and your staff, to look
at how we are using all of our facilities.
Do you want to add anything?
Dr. Garthwaite. We have briefed with directors with the
people who are expert in the enhanced use leasing fairly
recently to re-emphasize how to go about that process to
expedite it. In Indianapolis, we were able to actually turn
over a building to the State, and we have an account that bears
interest that is put to veterans' use out of all that.
So we have 16 examples of enhanced use leases, and we are
exploring a variety of other options. We are currently working
with VSOs to allow a rehabilitation contractor to use an extra
floor in Reno where they would not interfere with the VA care
but the space which is excess to our needs might be used.
So we encourage this. We try to support it as much as
possible.
claims processing
Mr. Hobson. I know we have got the baseball stadium that
has been leased. Now it has been so successful they want to
build a stadium in downtown Chillicothe. I don't know whether
that is going to fly or not.
Let me ask one other question here, and this has been
beaten around a little bit here, and I am going to give you an
editorial out of the Lancaster Eagle Gazette which says,
``Veterans not getting what they deserve.'' And you can take a
look at it. It is kind of a theme that has gone throughout
today, and a couple of other people--I haven't been here for it
all, but they tell me that Mr. Cramer asked, and when I was
here, the gentleman from North Carolina asked about it. I think
Mr. Mollohan may have asked also.
They published an editorial stating that the VA takes
longer to process disability claims than it did a decade ago,
despite spending more than $200 million to upgrade the VA's
computer system. The numbers I have indicated--and I was
listening to the numbers--that it takes an average of 205 days
to complete an original disability claim today compared to 164
days--and you answered some of this. I want you to explain a
little bit more about that. You have got a budget request for
$10.9 million to continue the expansion of a pilot program. I
guess this is going to be for computer use, and I just want to
talk about that for a minute.
I guess Mr. Cramer talked about the complexity of the
claims filing. The VA stated they have the most complex filing
process in the Federal Government and are trying to move in a
more case-based system, which would be less bureaucratic.
What else can you do to cut the red tape? Because this is
very frustrating to the veterans. It is very frustrating to
staff, also, who works on these cases when they are working
with the veteran and the families. You are dealing generally
with older people.
I wonder how are you going to deal with this better? And I
wonder if you could get some of the people out of Washington
out into some of these districts?
Secretary West. Well, I agree with you. I will say several
things, and then I know the Under Secretary for Benefits wants
to comment again.
First of all, you are absolutely right. We should get
people out there in the field to have that experience. We
haven't done it. What we did do is we took one of them and
brought them in here who already had the experience and made
him the Under Secretary for Benefits. Joe Thompson worked for
years in the New York office, became its Director, won the
Hammer Award for turning around its performance----
Mr. Hobson. We have a Hammer guy, too. We have a guy in our
leadership they call ``The Hammer,'' too. That is interesting.
[Laughter.]
Secretary West. And he is a hammer. And, secondly, you are
right, if there is one common thing that veterans say to me
wherever I go, it is, well, you know, I have this claim and let
me tell you how long I have been waiting and let me tell you
what has happened on it. It hits them where they live and where
they hope to live, and we have a duty to improve.
We have got things in the budget to seek to do that, yes,
in terms of the computerized--in the effort to computerize, but
also in terms of the additional people we are building into it.
Joe, why don't you comment?
Mr. Thompson. A couple of points I think----
claims processing
Mr. Hobson. Joe, the Hammer?
Mr. Thompson. Yes, sir.
Secretary West. Joe Thompson is the Hammer for benefits.
Mr. Thompson. Two things are really important to keep in
mind. One, which I mentioned before, is that this agency is
turning over a generation. We are moving from a retiring
Vietnam era generation to newer employees. That brings enormous
requirements for training. Approximately 40 percent of our
decisionmakers nationwide are in training today. When you
train, you can't also do the work, so there is a conflict
there.
The claims themselves are considerably more complicated and
have more issues embedded in them. In other words, veterans are
filing for more issues today than they ever have before.
I will note, by way of passing, more veterans are receiving
disability compensation today than at any time in this Nation's
history, despite the fact that the veterans population has been
in decline for 21 years.
As an illustration of the complexity of the work, in 1989,
one rating specialist would have been expected to make 1,700
decisions a year. Today that number is around 750. They didn't
get lazy, they didn't get stupid, and they didn't get
unmotivated. It is a simple fact that to make the decision with
issues that are much more subtle--for example, undiagnosed
illnesses from the Gulf War and things like that--it is much
more complex, and trying not only to change a generation but
also to train them on systems and disability evaluations that
are frankly very new to us, is really a complicating factor in
all this.
There are three keys, as far as we are concerned, to
reversing this situation. The most critical one is we have to
hire new staff. We have to bring in the generation that will
run VBA in this century. Secondly, we have to build training
systems. I can tell you, a little over 2 years ago when I took
this job we had no national program for training people who
made disability claims. We are working furiously and spending
every dollar we can to build those training systems.
The third key, which you mentioned, is getting our computer
systems up-to-date. We still are a paper process. We house tens
of millions of cubic feet of records. Getting your hands on
them and getting them to the right person at the right time to
make a speedy decision is an enormously complex process.
So we have long-range issues, which we are trending in the
right direction now. Our backlogs are down. A lot of our
appellate work is down. We are seeing our busy signals on the
phones down by 90 percent. The remands from the Board of
Veterans Appeals are way down.
So we are trending in the right direction. I wish I could
tell you that we are moving as fast as veterans would like us
to be. We are not. We have a lot of work to do and we are
committed to doing it.
Secretary West. What we can say is that we are pretty good
at it, a lot better than most people think. For example, some
time back someone wrote a report--was it the GAO?--that
contrasted our performance with another agency, Social
Security. And they said, boy, why isn't VA as fast at
processing its claims as Social Security?
So the Under Secretary's people went to check on it, and
when you compare what we do that is like what they do, our
pension processing, we are just as fast. Indeed, we are faster.
It is the complicated compensation processing which nobody else
does that we do that continues to be the source that we are
continually trying to improve.
electronic transfer of data
Mr. Hobson. I don't want to go too long. The chairman is
gone and is coming back. My State had the same problem with
disability. They used to have to go to shoe boxes to find the
claims.
But I think what is frustrating to us is when we see $200
million out there as being spent. You know, you are going to
say, well, when is this going to get there, and you are saying,
well, we have got to train all these people to get there. But
how many more hundreds of millions of dollars is it going to
take to get this system to where you are comfortable with it
and we are comfortable with it is still out there.
The other thing I would just like to say, I hope you keep
the commitment up to keep working on this. It is not an easy
problem. It is a difficult problem. But we can get there with
computerization and electronic transfer of data. And I had a
bill that a lot of people shot at me about, the electronic
transfer of data, especially in health care and things. But it
can be done and it is being done in the private sector, and I
think you need to look at some of the things that are going on
in the private sector in the electronic transfer of data and
you can save a lot of money, because when the Congressman from
Chicago was here, he thought at one time we could pay for all
of health care, universal health care, by getting to electronic
transfer of data. But there are tremendous savings in the
electronic transfer of not only dollars but in giving good
health care.
So I would just leave you with that. Thank you very much.
Secretary West. Thank you.
Mr. Frelinghuysen. Thank you, Mr. Hobson.
Mr. Mollohan?
Mr. Mollohan. I have some questions for the record, but
thank you, and I already thanked the Secretary for his
appearance.
medical care request
Mr. Frelinghuysen. I know the hour is late. I just have a
couple more questions, Mr. Secretary. How much of the $1.3
billion increase for veterans' medical care is from actual
appropriations? Maybe I should repeat it. How much of the $1.3
billion increase for veterans' medical care is from actual
appropriations as opposed to other anticipated revenue streams
such as the medical care collections fund and things of that
nature?
Secretary West. It is all from actual appropriations. The
whole $1,355,000,000 is an appropriation that we request of
this committee.
It is true that the equivalent of the $350 million of
collections we intend--that would come from the Millennium Act
authority will go into the general fund of the Treasury, but we
are not including in any of that $1.3 billion the collections.
We are anticipating an additional $608 million in collections
that would be collections. But I think what your question is
dealing with is this. The Millennium Act will provide us
authority with copays and the like for an additional $350
million collections in addition to the $608 million we would
normally have collected in the fund. One half of the first $700
million collected, or $350 million which is that additional
amount, equivalent to we are proposing to pay directly into the
Treasury rather than as part of our collections. And we have
asked the Congress instead, have asked you instead to
appropriate as part of our $1.355 billion that amount. So it is
all appropriations.
Mr. Frelinghuysen. The $608 million from the medical care
collections fund is for fiscal year 2001.
Secretary West. Yes, sir.
tricare
Mr. Frelinghuysen. I understand that some of that amount is
expected from the Department of Defense, from DOD. I serve on
that Defense Appropriations Committee, and if you want an
invitation to confusion, you serve on that committee and you
talk with Dr. Sue Bailey, and you try to understand the TRICARE
system.
The TRICARE system owes the VA money. Isn't that correct?
Secretary West. Yes, sir.
Mr. Frelinghuysen. Well, for the life of me, nobody at DOD
knows how much it is. How much are you owed in your estimation?
Secretary West. Well, I don't know what that number is,
but----
Mr. Frelinghuysen. Well, actually, I think it is important
for us to know because if your budget is going to be as----
Secretary West. We may be able to----
Mr. Frelinghuysen [continuing]. Whole as we anticipate it
will be----
Secretary West. Here is the way I understand it will work,
sir. We are requesting an appropriation of $1,355,000,000 for
health care, and that is all appropriations. On the other side
of collections, we anticipate some $900-plus million in
collections. That is a total of $608, which is the amount we
would normally be collecting. It is the fiscal year 2001
component of the collections we collected in 2000.
medical care collections fund
Mr. Frelinghuysen. Before you go too much farther, using
your own budget documents, fiscal year 2001, fiscal year 2000,
and fiscal year 1999, your estimates for the medical care
collections fund in fiscal year 1999 were $637 million. Your
actual receipts were $573 million. For fiscal year 2000, your
estimates of collection were $761 million. Your actual receipts
were $600 million. And God only knows what your actual receipts
will be that relate to the $608 million.
You need to tell me a little more directly: If DOD owes you
money----
Secretary West. It won't be part of that. It will be part
of the Millennium Act collections, the extra amount, the $355
million.
Mr. Frelinghuysen. But does the DOD owe you money, and how
much do they owe you?
Secretary West. I think our estimate is--I don't even
think--do we have the agreement in place yet?
Mr. Frelinghuysen. In the way of background----
Secretary West. We are scheduled not to have the agreement
in place until I think August or so.
Dr. Garthwaite. I think there are a couple of things being
mixed together. I think under current TRICARE agreements, their
payments have lagged for a more technical reason that we are
working through.
Mr. Frelinghuysen. Well, actually, the technical reasons
involve substantial sums of money. Isn't that correct?
Secretary West. I don't think those do add up to
substantial sums. In fiscal year 2001, in the Millennium Act,
there will be a substantial sum, but the ones you are talking
about I don't believe are substantial.
Dr. Garthwaite. My understanding is we weren't doing that
much TRICARE business, even though we have a lot of agreements.
And my folks say we are trying to get our hands on that number.
But I don't believe that is a huge number.
Mr. Frelinghuysen. What worries me, whether it is DOD or
any other third party money that we can claim out there that is
due the system, does somebody have a handle on it? And how much
are we talking about? If it isn't received on a timely basis--
and I understand there is a lag in collections, because TRICARE
is getting a super black eye, generally speaking, from most of
the people in that system. The committee would want to know
whether your budget in some way is going to be impaired,
because while we celebrate this increase in medical care
dollars here, we want to make sure there is real substance that
in the final analysis, you are really going to have as much
money for medical care as you originally anticipated, and
which, Congress and the veterans' community are expecting you
to spend.
Secretary West. If we receive our appropriation request, we
will get all of that, $1.355 billion. The question then will be
whether the $608 million is less reliable or more reliable than
past estimates, and we will try to get you better information
on that.
national drug formulary
Mr. Frelinghuysen. And for the record, I would particularly
want to speed up your report on the national drug formulary.
Secretary West. Yes, sir.
Mr. Frelinghuysen. The report is still being formed. It has
been quite a period of time since the committee asked that that
research and those statistics be gathered. I hope we can
expedite that before we are all old and gray.
Secretary West. All right.
Mr. Frelinghuysen. We ought to have that study of the VA's
formulary. I do understand from at least the local people in
our area that every effort is made to give veterans who need
the latest drugs and technology access to them, which is
reassuring. There had been considerable evidence at some point
in time that VA had the most restrictive drug formulary. So the
sooner we have information that relates to that subject, I
think it will be reassuring to us.
Dr. Garthwaite.
Dr. Garthwaite. I will just mention, as you are aware, this
is an Institute of Medicine study, and as of last week when we
talked to them, they believe they will beat the July 2000 due
date for the study. So they are progressing reasonably well.
Mr. Frelinghuysen. The 2000----
Dr. Garthwaite. July.
Mr. Frelinghuysen. July 2000.
Dr. Garthwaite. The July 2000 date. That is when the
Institute of Medicine projected finishing the study.
Mr. Frelinghuysen. Okay. Mr. Mollohan, anything else?
Mr. Mollohan. No, thank you.
Mr. Frelinghuysen. Well, thank you very much. I guess we
will see some of your colleagues back here on April 5th. We
stand adjourned.
Secretary West. Thank you, sir. Thank you, Mr. Mollohan.
Wednesday, April 5, 2000.
VETERANS HEALTH ADMINISTRATION DEPARTMENTAL ADMINISTRATION
WITNESSES
THOMAS L. GARTHWAITE, MD, DEPUTY UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION
ACCOMPANIED BY:
MELINDA L. MURPHY, CHIEF OF STAFF; KENNETH J. CLARK, CHIEF NETWORK
DIRECTOR; JOHN R. FEUSSNER, MD, CHIEF RESEARCH AND DEVELOPMENT
OFFICER; JOHN E. OGDEN, CHIEF CONSULTANT, PHARMACY BENEFITS
MANAGEMENT STRATEGIC HEALTH GROUP; JIMMY A. NORRIS, ACTING CHIEF
FINANCIAL OFFICER; C.V. YARBROUGH, ACTING CHIEF INFORMATION OFFICER
AND CHIEF FACILITIES MANAGEMENT OFFICER; AND ART KLEIN, ACTING
DIRECTOR RESOURCE FORMULATION
RICHARD J. GRIFFIN, INSPECTOR GENERAL, DEPARTMENT OF VETERANS
AFFAIRS
ACCOMPANIED BY:
LEIGH A. BRADLEY, GENERAL COUNSEL; JOHN H. THOMPSON, DEPUTY GENERAL
COUNSEL; E.D. CLARK, CHAIRMAN, BOARD OF VETERANS' APPEALS; GUY H.
McMICHAEL III, CHAIRMAN, BOARD OF CONTRACT APPEALS; EDWARD A.
POWELL, JR., ASSISTANT SECRETARY FOR FINANCIAL MANAGEMENT; DENNIS
M. DUFFY, ASSISTANT SECRETARY FOR PLANNING AND ANALYSIS; EUGENE A.
BRICKHOUSE, ASSISTANT SECRETARY FOR HUMAN RESOURCES AND
ADMINISTRATION; JOHN HANSON, ASSISTANT SECRETARY FOR PUBLIC AND
INTERGOVERNMENTAL AFFAIRS; HAROLD F. GRACEY, JR., PRINCIPAL DEPUTY
ASSISTANT SECRETARY FOR INFORMATION AND TECHNOLOGY; D. MARK
CATLETT, DEPUTY ASSISTANT SECRETARY FOR BUDGET; PHIL RIGGIN, DEPUTY
ASSISTANT SECRETARY FOR CONGRESSIONAL OPERATIONS
Opening Remarks
Mr. Walsh. The subcommittee hearing will come to order.
Good morning. Today we welcome, again, the Department of
Veterans Affairs as we meet with Under and Assistant
Secretaries. This morning we are going to discuss the medical
aspect of the VA. This afternoon, when we reconvene at 1:30,
the committee will hear from the Under and Assistant
Secretaries representing the Benefits Administration, Cemetery
Administration, Office of Financial Management, Information and
Technology Office, Human Resources, Public and Congressional
Affairs, Planning and Policy, General Counsel and Inspector
General.
At this time, I would ask my colleague Mr. Mollohan if he
has any opening remarks?
Mr. Mollohan. None, Mr. Chairman.
tricare payments
Mr. Walsh. We will get right to it. These questions would
be regarding collections. The budget assumes collections of
$958 million; $608 million in standard MCCF collections and
$350 million in new copays is authorized by the Millennium
Health Care Act.
Mr. Frelinghuysen touched a little on this issue in the
last hearing, but now that the Budget Committees are coming
forward with their estimates, I think we need to take a closer
look. One source of these collections is TRICARE payments from
the Department of Defense. The President's budget assumes that
the VA will collect almost $190 million in 2001 from TRICARE
agreements with DOD.
Checking with our colleagues on the Defense Subcommittee,
we have learned that these new agreements are not a priority.
Could you please tell us how the VA is going to collect almost
$200 million from DOD without their cooperation?
Dr. Garthwaite. Mr. Chairman, I believe the Millennium Act
provides for a period up to September for us to negotiate
between the two Secretaries a cooperative agreement. And if
that cannot be negotiated, to come back.
We have identified the key players on both sides of for VA
and on DOD, who are the key program individuals. And I have had
personal conversations with Dr. Sue Bailey and will be taking
this up again in another week or so when we get together in our
executive council to look at the cooperation between the VA and
DOD. I don't know whether to be optimistic or pessimistic in
terms of whether or not an agreement can be reached. We do know
that at least during the early phases of discussions about this
issue, that DOD was somewhat reticent in terms of the overall
legislation debated in the Millennium bill before its
enactment.
Mr. Walsh. Is this an all-or-nothing proposition? Either
you get $190 million or you won't get any?
Dr. Garthwaite. I think the agreement is that we would get
the amount of money based on the amount of work we did. So
presumably if we do not have an agreement, at least some of
that workload wouldn't be coming to us. I think we currently
provide an estimated $59 million of care to TRICARE-eligible
beneficiaries.
va services to dod
Mr. Walsh. What services do you provide for DOD?
Dr. Garthwaite. We provide services in a variety of ways.
We have some shared medical centers and we provide services
under very specific contracts in those such as in Albuquerque,
Las Vegas and Anchorage. We also provide some services under
TRICARE but we negotiate directly with the TRICARE providers'
intermediaries, and then we get reimbursed by them at their
vary rates. Some of it is mental health, some is of it primary
care. We also have some centers of excellence where they can
refer patients for specific things, like in San Francisco where
they would refer open heart surgery to a center of excellence.
Mr. Walsh. Are military retirees eligible for services in
both the VA and the military system?
Dr. Garthwaite. Yes, in general, yes.
Mr. Walsh. So they can enroll and receive care in both
systems?
Dr. Garthwaite. Right.
Mr. Walsh. Does that create any problems?
Dr. Garthwaite. I think it does. I think that in addition,
I hesitate to make this more complex, but in fact there is a
considerable amount of confusion in coordination of Federal
benefits not only within VA and DOD with retired military, but
also if you loop in Medicare. I think that overall, this whole
coordination of Federal benefits is an issue to be addressed
more in a global sense as to how--as to what benefits any given
veteran has, because in truth military retirees are veterans,
and then how to coordinate the care and the financing so as to
not set up perverse incentives for moving between the systems
to try to get some nuance of reimbursement for a particular
service.
Mr. Walsh. Who is the referee here? If the patient can move
between the systems, does anybody say no, you cannot have that
service? Or do you just shop it until you get care that you are
looking for?
Dr. Garthwaite. I think, regrettably, today veterans can
shop between different systems. I am not aware of any computer
matches with the DOD health care system in that regard, but
that would be a good topic to take on.
We are very close to an agreement or have already signed an
agreement with HCFA to merge our databases so that we can have
a better handle on the combined uses between Medicare and VA.
But I am not aware of any in DOD. Others might be.
Mr. Walsh. So you are negotiating with DOD regarding the
collection of these fees? Is this joint health care that you
are providing to military retirees, is that also part of the
negotiation or not?
Dr. Garthwaite. Yes, very clearly, understanding the
current level of effort with about $59 million and the impact
of any new use of VA facilities, and how that reimbursement
would occur would be obviously the key part of the negotiation.
In fact, the other key part is whether or not we set up
incentives for one system versus the other, and what is the
incentive to use a VA facility in place of a military treatment
facility in place of a priority hospital. I think it is all
related to the incentives and a lot of it will probably come
down to drug benefit and copays.
scoring the millenium act
Mr. Walsh. When the Millennium Health Care Act was under
discussion, CBO scored the legislation as being very expensive.
What role did the VA play in scoring that legislation?
Dr. Garthwaite. In scoring the legislation?
Mr. Walsh. Obviously not a major role.
The additional services that would be provided under the
Millennium Health Care Act, did you estimate the cost of those
for CBO? Somebody in the VA must have determined what those
services would cost.
Dr. Garthwaite. Yes, I think our involvement, especially
related to the long-term care provisions, included working
carefully with and testifying in the House Veterans Affairs
Committee and in working very closely with OMB on their
estimates for the Millennium bill.
Mr. Walsh. Mr. Powell?
Mr. Powell. Yes, we did work with OMB. We had an OMB
meeting with DOD, where there was an agreement by the
representatives of DOD on the $180 million dollar reimbursable
figure.
Mr. Walsh. So they committed to collect that money?
Mr. Powell. At the meeting that Tom and I had with OMB,
they did.
Mr. Walsh. Do you have any doubt that that commitment will
be kept?
Mr. Powell. I think there is reason to believe they will
try within the context of it. But I cannot give you an absolute
assurance, no.
Mr. Walsh. Then how do you make up that shortfall?
Mr. Powell. I think Tom's answer was appropriate. A lot of
it would be depending on the amount of care that we provide.
Collection methodologies should be followed to the same extent
we do for any other reimbursable source.
Mr. Walsh. Did the VA tell the authorizers VA would most
definitely have the ability to recoup the costs associated with
Millennium Health Care Act? Would the copays play a major role
in recouping those costs?
Dr. Garthwaite. I am trying to recollect that hearing. It
seems to me, that what I remember testifying to with regards to
the Millennium Act, is whether or not there would be
significant incentives for an onrush of veterans to use the
long-term care provisions, especially. And whether or not that
copay would offset our costs and/or provide at least a neutral
playing ground so that if people were happy in the situation
they had, they wouldn't have a clear incentive to move to the
VA and overwhelm the system.
And I think that is probably true. As we speak, in
Leesburg, Virginia, we have about 90 experts working on the
policy and provisions of the Millennium Act and getting
regulations ready. And that is clearly a significant part of
that debate.
Mr. Walsh. When will that be completed?
Dr. Garthwaite. April 14th we plan to have everything
ready, including draft regulations. Obviously we have to
publish and get public comment and so forth. That is our goal.
infrastructure--maintenance of buildings
Mr. Walsh. I would like to ask now a couple of questions
regarding infrastructure. Looking at another of GAO's reports
issued last year, what is the VA doing about the reported $1
million per day lost from medical care for the maintenance of
buildings?
Dr. Garthwaite. We have a series of initiatives to try to
deal with our capital infrastructure globally. First of all, I
will say that we do not know whether that million dollar figure
is accurate. We do know that we have a lot of buildings in
excess of our needs given the way we provide health care today
compared to when the buildings were built.
Probably the key piece in the future will be the CARES
initiative, the Capital Asset Realignment for Enhanced
Services, which will take on major markets this year and will
look at the relationship of current assets to our current need
and put forward some plans for aligning those assets to the
best needs of veterans' care in these facilities.
In addition to that, we are obviously doing things that we
think make sense, especially with enhanced use leases. For
instance, if we have vacant buildings that can be used by the
community and can be rented out, we have done that. If we have
excess land, where it can be put to good use and can generate
rent, we do that.
We have taken on the issue of Fort Lyon, Colorado, and are
working with the State, with the possibility if we can work
through the legalities of turning that facility over to the
State, and developing other arrangements for the veterans of
southern Colorado, which is a critical piece. We continue to
integrate the centers in Boston. We are integrating the two
largest medical centers that had about 90 percent redundance of
programs and were only 6 miles apart. And we are well into the
process of integrating those facilities and trying to put them
into the right place and that has a profound effect on the
kinds of infrastructure needs we would have.
occupancy rate in boston area
Mr. Walsh. On that point, because there are a number of
communities around the country, especially in the larger cities
that have multiple facilities, Boston, for example, what is the
occupancy rate of those two hospitals?
Dr. Garthwaite. I would have to get you that for the
record. All of our hospitals have significantly decreased their
acute care hospital beds. The occupancy rate is somewhat
adjusted by how many beds you keep open. So if we close beds,
the occupancy rates will stay about 80 percent, but the total
number of beds that we operate are significantly fewer. So in
most of our centers we have decreased the total number of beds
and kept the occupancy at 80 percent, but it leaves us space
where those beds were for ambulatory care.
[The information follows:]
Occupancy Rate for Multiple Facilities in Boston
As of March 2000, the Occupancy Rate for multiple facilities in
Boston, Massachusetts is as follows:
----------------------------------------------------------------------------------------------------------------
Average Occupancy
Station Bed section Operating daily rate
beds census (percentage)
----------------------------------------------------------------------------------------------------------------
Boston, MA................................... Hospital....................... 218 166.0 76.2
West Roxbury, MA............................. Hospital....................... 118 90.9 77.0
Brockton, MA................................. Hospital....................... 187 168.8 90.3
Brockton, MA................................. Nursing home care unit......... 120 105.9 88.3
Brockton, MA................................. Domiciliary.................... 70 62.7 89.6
----------------------------------------------------------------------------------------------------------------
Mr. Walsh. When you have hospitals that are 6 miles apart,
you have what percent of redundancy?
Dr. Garthwaite. At the time we started the integration in
the program it was about 90 percent.
Mr. Walsh. Obviously you are under pressure to make a
decision. We are under pressure to retain both of those
facilities, or in the case of Chicago, all three or in the case
of New York City, all five. Would it not make some sense to
look at closing one of those facilities and consolidating those
services? For example, if I am a veteran and I need X-rays I
can get them in one hospital but if I need a medical response
to those X-rays I have to go to another hospital?
Dr. Garthwaite. In some cases it makes sense to close
facilities. In most--given that we have major facilities in 172
places, probably, most of those places we continue to need a
presence. Even if it is not an acute hospital, we still need to
have a clinic or we still need to have a nursing home or we
still need to have a drug treatment program or something else.
So that actually walking away from the site, padlocking it,
walking away and realizing large savings on that infrastructure
closure is relatively problematic for us because we almost
always have a significant program and service delivery need at
that site.
We have closed acute care in about, I believe it is 10 to
12 places, depending on how you define that. But we have closed
acute care in a significant number of facilities and we now
have maybe a nursing home and outpatient care presence. But the
problem we have then is the vacant buildings that are often
old, relatively little use to anyone, often ridden with
asbestos, and we face a significant investment in terms of
closing those down totally.
Medical Services
Mr. Walsh. Obviously, there are a lot of politics in this.
There are a lot of additional decisions, such as shutdown costs
that come into play. But if you have two facilities 6 miles
apart--I don't know Boston that well. I know New York City. You
have one in the Bronx, two in Brooklyn, one in Manhattan. Do
these hospitals all have different services that they provide?
Or are they basically the same services?
Dr. Garthwaite. Well, in terms of Boston, a lot of the
integrations have already occurred, a single medical service,
single cardiovascular surgery, cardiac cath, and open heart
surgery program.
Mr. Walsh. So physicians might work at both of those
hospitals, perform operations and see patients?
Dr. Garthwaite. Correct, correct. Ken Clark who runs our
operations, may want to provide additional detail on that.
Mr. Kenneth Clark. In many metropolitan areas, it is true
that services are duplicated. Much of that is for historical
reasons. As technology continues to advance and as our
inpatient programs are reduced in size it does provide
opportunities for consolidation, further consolidation. And I
think the question of whether that will ultimately lead to
closures or certainly to a substantial change in mission is
really at the heart of the CARES program, which is in fact a
comprehensive capital asset assessment and management program.
So out of that process over the next several years we will
be doing comprehensive studies of our infrastructure, trying to
match that to our service delivery needs and determining what
additional infrastructure or changed infrastructure we will
need. And if we have excess in that infrastructure, it will
identify that and suggest ways that we can better use that
infrastructure.
Vacant Space in Medical Centers
Mr. Walsh. Well, Boston, for example, you have gone to this
integrated approach. At this point in its implementation, what
percent of those buildings are now vacant or otherwise not
producing or providing medical services?
Mr. Kenneth Clark. I think in the instance in Boston, none
of the buildings, because there are actually relatively few
buildings on both of those sites, none of the buildings are
actually vacant.
Mr. Walsh. What percent of the available square footage of
office space, what percent of that is empty now?
Mr. Kenneth Clark. I couldn't give you a precise answer. I
would be happy to give you that after the hearing. I don't know
what that is in those particular facilities.
[The information follows:]
Vacant Structure--Infrastructure
The integration of the Boston Healthcare System allowed for
realignment of functional units and has not created additional
vacant space. The downsizing of our major outpatient clinic at
Causeway Street, Boston, has reduced our ability to capture
vacant space at the Jamaica Plain campus. Currently there is
approximately 0.6% vacant space between West Roxbury and the
Jamaica Plain Campuses. If you include Brockton the percentage
increases to 6.2%, however this is space that has been vacant
and unused for a substantial amount of time.
The percentage of office space between the Jamaica Plain
and West Roxbury campuses of the Boston Healthcare System is
6.3%. If you include the Brockton campus the figure increases
to 8.1% of the total space. The vacancy rate for offices falls
within the overall rate, 0.6% for the Jamaica Plain and West
Roxbury campuses. Considering the Brockton campus in the mix it
is 6.2%.
Mr. Walsh. Do you know what it would be in any of the major
urban centers, Chicago, New York?
Mr. Kenneth Clark. It would vary dramatically according to
the mission of the medical centers. In many of the medical
centers, many of the urban areas, particularly where there has
been a concentration of long-term psychiatry and has probably
realized the most dramatic decrease in inpatient use, there
would be substantial portions of facilities that are no longer
needed.
Mr. Walsh. For example?
Mr. Kenneth Clark. In Los Angeles, California, where a
major portion of that facility which was dedicated to long-term
psychiatry by and large over the last 10 years probably as many
as 3- or 400 beds have been taken out of service and
consolidated into a single acute care building.
Mr. Walsh. 300 or 400 beds out of how many?
Mr. Kenneth Clark. Out of 1,300.
Mr. Walsh. So it is a reduction of 30 percent, 40 percent?
Mr. Kenneth Clark. Yes, I would estimate as just a rough
estimate on my part. In that particular facility, and I don't
know that it is that unusual we probably have floor space,
gross space needs, that are 30 percent less than what they were
just a few years ago. And, again, it is the capital asset
planning initiative that Dr. Garthwaite referred to which will
help us identify precisely what that reduction in need is,
given our anticipated program and service delivery needs into
the foreseeable future.
Facilities Closures
Mr. Walsh. Is there any instance in any of these
consolidations or integrations where you have 50 percent of
those buildings empty?
Mr. Kenneth Clark. I couldn't answer that question
precisely.
Mr. Walsh. Is it possible?
Mr. Kenneth Clark. It is possible.
Mr. Walsh. The gentleman makes an important point. This is
important. For some of you, this is your responsibility.
Dr. Garthwaite. If I could just make a comment, we have a
significant number of ancillary buildings which are often older
which could be closed, and we have many square feet of vacant
space in many of the ancillary buildings. When you talk about
the main bed towers and the main clinical delivery sites of
care, I think in fact we often put clinic space into places
where we have closed other beds. And that is not 100 percent,
but it is predominantly what we have used.
If you remember, in closing half of our acute care hospital
beds, we have increased the number of outpatient visits by 10
million. Those have to occur somewhere.
Mr. Walsh. Right, and I think that is a move that we all
agree with. But why are we maintaining dozens and dozens of
empty or half empty buildings? If we are wasting, as GAO put
it, a million dollars a day, that money either should be
returned to the taxpayer or put into medical care. We raised
medical care last year by $1.7 billion. The President requested
we do it by another $1.3 billion this year. That is a $3
billion increase. What are we doing with it? Are we maintaining
old empty buildings? Are we providing medical care?
Dr. Garthwaite. We agree totally that we need to look at
closing some buildings. And that is really what the CARES
effort is really about.
Mr. Walsh. Thank you. Mr. Mollohan.
Implementing the Millennium Health Care and Benefits Act
Mr. Mollohan. Thank you, Mr. Chairman. Mr. Garthwaite, we
discussed with the Secretary 2 weeks ago the efforts to
implement the Millennium Health Care and Benefits Act. Your
budget includes $548 million to finance the expanded benefits
envisioned by the act. Please review for the committee again
what these benefits are, the steps you have taken to make this
law a reality for veterans and how will it impact the average
veteran?
Dr. Garthwaite. Sure. Pleased to. One of the main
provisions is being the payer for emergency care. Although we
are the payer of last resort for emergency care, there are many
veterans who have avoided going to the closest emergency room
for needed care because of the fear of incurring a large bill
or have driven too far when they are really sick, and we think
that is an important benefit for veterans. That is about $138
million.
A significant part of this has to do with long-term care,
especially alternatives to nursing home care. These things
would be things like hospital-based primary care where we send
clinicians to the home to keep people out of the nursing home.
And this is a significant part of this $365 million.
That comprise is the bulk of it, although there are a few
other minor provisions.
Mr. Mollohan. In the long-term care area, which accounts
for two-thirds of the $548 million, will that be provided by VA
staff or by private contracting?
Dr. Garthwaite. We have envisioned a mix. Again the group
that is looking at this week will ferret out most of the final
policy, but we have envisioned it will be a combination of VA
and contract. In some cases it is efficient and effective for
us to bring up a program, but in other cases we do not have the
volume or transportation issues impede us from doing it.
Mr. Mollohan. How does break down? What is the purpose of
your Leesburg meeting?
Dr. Garthwaite. We have a group of our policy and field
representatives pulling together the policy decisions and
writing regulations for the Millennium Act.
Mr. Mollohan. Is that VA staff or contractors?
Dr. Garthwaite. No, virtually all VA staff.
Mr. Mollohan. With regard to how it is breaking down
between providing these long-term services under the Millennium
Act, how do you anticipate it breaking down, after your
Leesburg meeting, between private contractors and VA staff
providing those services?
Dr. Garthwaite. I don't know for sure. I know in terms of
the 70 percent and above service connected veterans who are
eligible for nursing home care, we have envisioned that a
significant amount of their care will be under contract. For
extended care service other than nursing home, I do not have an
estimate for you but I think we will be able to provide you one
probably by early next week. I do believe that much of this can
be contracted care.
[The information follows:]
Implementing Long-Term Care
Final decisions regarding the use of VA-provided or contract long-
term care services will be determined by such factors as medical need
and availability of services inside and outside the VA. The extent to
which VA provides long-term care directly or by contract will be
tracked as we implement the Millennium Act at the facility level. Over
FY 2000 and 2001, $365 million in additional spending for VA long-term
care services is estimated/proposed. Of that amount, 51% is estimated
to be used for contract care and 49% for VA-provided services.
Mr. Mollohan. I can imagine quality control will be a real
issue in the provision of long-term care outside of VA
facilities. Are you looking at that?
Dr. Garthwaite. Yes, we are. In addition to what we have
done traditionally through the program office, within the
Office of the Medical Inspector, we have established an
additional group of professionals to review on an ongoing basis
care delivered in a nursing home.
In addition, any contract that we let will have a
demonstration of quality as part of the conditions of meeting
the contract.
Mr. Mollohan. I recall the Secretary's testimony was that
the requested amount was to--would fully fund the needs out
there. Do you agree with that statement? And exactly what does
it mean?
Dr. Garthwaite. In terms of long-term care?
Mr. Mollohan. No, in terms of providing all the services
under the Millennium Act, that the $548 million, as I
understood it, was a request that would sufficiently fund all
of the needs and all of the benefits provided for under the
Millennium Act.
Dr. Garthwaite. Yes, I believe that is true.
funding the millennium act
Mr. Mollohan. Okay. Would you review for the committee the
financing scheme under the Millennium Act for this first year--
and then I am also interested in how you project it for future
years. You are proposing to not forward fund, but to fund by an
appropriation a certain amount of the resource needed to
implement the Millennium Act, and then to come back around and
fee-fund the rest of it. And I just want to hear you talk about
what you anticipate. First of all, your proposal for this first
year and then how you anticipate it working in future years.
Dr. Garthwaite. I think the legislation anticipated
copayments and fees as part of the ongoing funding for
especially the extended care provisions.
Mr. Mollohan. Part of or all of? What does the legislation
anticipate?
Dr. Garthwaite. Well, I think it depends on how we
implement the copays.
Mr. Mollohan. How does the authorizing legislation, which I
understand is not how you intend to implement, anticipate you
funding the Millennium Act?
Mr. Catlett. What I understand of it, Mr. Mollohan, is it
would be a partial recovery of the cost. The copayments would
be based on the market rates in the community and that is what
Dr. Garthwaite is indicating now is being examined.
Mr. Mollohan. Does the authorizing legislation anticipate
that the Millennium Act would be fully funded by fee
collections and copays?
Mr. Catlett. No, no.
Mr. Mollohan. What does the authorizing legislation say,
with regard to funding?
Mr. Catlett. I don't believe it is clear. It does not
specify a portion of it to be done by fee or collection. It
just tells us to expand the copays but there is no direct----
Mr. Mollohan. Will you look at that more carefully and give
us a definitive response, because I sense a bit of uncertainty
of how you interpret it.
Dr. Garthwaite. The setting up of the copays is the
critical piece because based on what those copays are, it will
either draw or repel patients from the VA health care system
and coverage. And, laying out those responsibilities is a lot
of what the policy group is working on.
Mr. Mollohan. Here is the question for this committee, you
are asking for appropriation funding, then you are anticipating
additional funding from copay and from other fees.
What do you expect in the future after this first year, to
fund this program with fee collections or do you expect to fund
with appropriations? Do you expect to fund it with a
combination of both? When you look at your fee collections,
what do you expect to do with them? If you collect fees that
are in excess of those anticipated, and they exceed the amount
of the cost of the Millennium Act, what do you expect to happen
to those fees? How are you looking at this and what are you
going to be asking this committee for, not only this year but
in the future with regard to funding the Millennium Act?
Dr. Garthwaite. We certainly think it is a going to be a
combination and given that we have no experience in this area,
that experience----
copay collections
Mr. Mollohan. Well, you do have experience collecting fees,
although not terrific experience collecting them.
Dr. Garthwaite. Understood. Yes, but we do not have
experience collecting them in extended care. We will be in a
much better position to estimate those within the next month or
so. And then once we get the regulations out and get comments,
I think we will be in a better position yet, to at least
estimate the copay collections.
And I believe the act anticipated that the copays for
extended care would be plowed back into extended care. However,
our budget proposal does not make that distinction.
Mr. Mollohan. Well, let's take this year's request to the
committee. Do you look at that as an advance to be repaid? Or
do you look at it as an appropriation which----
Dr. Garthwaite. We anticipate receipts of $350 million in
this budget.
Mr. Mollohan. From the Appropriations Committee?
Dr. Garthwaite. No. Receipts.
Mr. Mollohan. Fee receipts, not appropriation money? Okay.
And the rest of it from appropriation? Would you expect the
fees to go back to the Treasury?
Dr. Garthwaite. Well, our budget proposes that $350 million
in fees would go back and we would get an additional $350
million this year.
Mr. Mollohan. Would go back to the Treasury?
Dr. Garthwaite. Correct. I mean, I may have been confusing
on this and I apologize.
Mr. Mollohan. I think you said that wrong.
Dr. Garthwaite. Basically we would expect $350 million in
fees. The administration proposed $350 million in
appropriations with $350 million in fees going back into the
Treasury to offset that.
Which does a couple of things. One, it kind of guarantees
that the act gets implemented and is not slowed down by the
trouble of collecting fees but also keeps the incentive on us
aggressively pursue collection of all fees.
Mr. Mollohan. Well, will you put that policy in writing for
the Committee? And submit it to us?
Dr. Garthwaite. Be happy to.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
medical research request
Mr. Mollohan. I would like to return this morning to what I
consider a disappointing request in research. Despite an
overall increase in the budget of more than $1.4 billion for
medical care, your request for research is flat at $321
million. You have been praised repeatedly for the high caliber
research you do, and for its relevance. Do you disagree with
that evaluation of the quality of the research that VA does?
Dr. Garthwaite. I believe we do have very high quality and
relevant research.
Mr. Mollohan. You appear to have a unique advantage as a
research system because of the large patient pool and the
records you keep and how you can track patient care. Do you
think that the research establishment has adequately used this
aspect of VA?
Dr. Garthwaite. Well, if your question is are our
researchers using every dollar that we give them to do as much
research of high quality as they can, I think they are. So, we
work very hard to spend every dollar wisely and to get the
maximum return on investment. I think Dr. Feussner has added a
new energy to the research service and a new accountability,
and we are very proud of the progress they have been making.
Mr. Mollohan. Well, I guess what I am saying is you have
this unique built-in advantage for a research system. You have
got a large patient pool, a captive audience if you will. You
track records well, and my question is have you maximized this
advantage?
Dr. Garthwaite. If your question is----
Mr. Mollohan. My question is exactly as I asked it. So if
you do not understand, tell me you do not understand it and I
will ask it again. Do you understand it?
Dr. Garthwaite. I believe so.
Mr. Mollohan. No, you do not. Let me repeat it. If you
don't understand the question, then I will ask it again, maybe
I haven't been articulate enough.
Dr. Garthwaite. I believe if we had additional dollars, we
could determine additional important scientific findings using
our health care system, which I think is a unique resource to
study how health care is delivered in the United States.
Mr. Mollohan. Dr. Feussner, can you respond to that,
please?
Dr. Feussner. Yes, sir, my understanding of the question is
are we really using the health system that is available to us
to maximize our research potential, and I think the answer to
that is categorically yes. Our research enterprise is different
from other federally supported research enterprises in two
important ways. Almost 75 percent of our total research
appropriation goes to support clinical research. That is
research done on our patients or human materials. And unlike
the rest of the research enterprise in the United States,
almost 80 percent of our funded investigators are clinician
investigators. Roughly 70, 72 percent physician investigators
and then the other 8 percent are nonphysician clinicians.
In the context of large scale studies, like treatment
studies or large scale population-based epidemiological
studies, I think we do an excellent job of leveraging the
health care system to facilitate the research and to make the
research less expensive.
Mr. Mollohan. So quality is high.
Dr. Feussner. Yes, sir.
Mr. Mollohan. Are your research activities a very important
to attract good providers.
Dr. Feussner. Yes, sir.
Mr. Mollohan. And you have no increase in your budget, a
very generous budget request, for research, why is that?
Let Dr. Feussner answer. You haven't asked for an increase
in your research budget. Why is that? There is a reason for it.
Did you request an increase? Did your views lose out in the
competition for scarce resources or did OMB knock it down? Why
do not we have a request for an increase in research?
Dr. Feussner. Well, we did make a request for an increase
in research, and that request was substantial.
Mr. Mollohan. We, who?
Dr. Feussner. VHA.
Mr. Mollohan. To OMB?
Dr. Feussner. Yes, sir.
omb request for medical research
Mr. Mollohan. What was your request?
Dr. Feussner. The request was for an increase from the
current appropriation of $321 million to an appropriation of
$397 million, or an increase of $76 million. We estimated that
approximately $11 million of that would be for current services
so in a sense, the net research increase requested is----
Mr. Mollohan. Just to keep current services?
Dr. Feussner. Yes, sir, and as the Secretary alluded to at
the last hearing, and additional $65 million in research
initiatives. And then I think it is fair to say that in the
process other priorities competed more successfully for
appropriations.
Mr. Mollohan. That is obvious, but were you supported
within VA for an increase in your research budget.
Dr. Feussner. Yes, sir.
Mr. Mollohan. What did you request up through VA as an
increase?
Dr. Feussner. What I just told you.
Mr. Mollohan. So they took your request and passed it up to
OMB.
Dr. Feussner. That is correct.
Mr. Mollohan. What research areas would you have used those
additional resources?
Dr. Feussner. Well, there are four major areas that I would
list in the following groups: major new treatment studies in
areas such as Parkinson's disease, end-stage renal disease,
diabetes, PTSD, and so forth. Major initiatives in quality
improvement of VA has initiated what is called a quality
enhancement research initiative. Approximately half of that
initiative is severely underfunded in specific areas such as
mental health, spinal cord injury, stroke, cerebral vascular
disease, and AIDS.
The third area would be in brain disease and that is more
basic, looking at regeneration of nerves that would have
applicability to spinal cord injury. Brain remodeling. We
believe that the brain, after stroke or traumatic injury, can
actually recover more effectively. And then in the specific
area, that is an overlapping area between basic and
rehabilitation research and specific rehabilitation research
area, we would like to make a better investment in upper
extremity prosthesis development.
And then finally in pure bioscience, we believe that our
research efforts in schizophrenia are underfunded. We are
reducing our commitment to our centers of excellence by half
this fiscal year.
Mr. Mollohan. In those areas, are you talking about
underfunding? You have all of those research activities going
on but they are underfunded? Or are you talking about research
activities that you are not even undertaken because you do not
have the money?
Dr. Feussner. Mostly the latter, about two-thirds the
latter and one-third underfunded.
Mr. Mollohan. Are there research projects that you know of
but are unable to fund?
Dr. Feussner. That is correct.
mental health research
Mr. Mollohan. In the mental health area, what comes under
that? Are you doing addiction research?
Dr. Feussner. Yes, we have a substantial investment in
substance abuse research that is broad based, both drug abuse
such as street drugs, alcohol abuse, and tobacco abuse. We also
have extended that substance abuse research portfolio with a
major collaboration with the National Institute of Drug Abuse.
We have a formal MOU with NIDA that we have sustained over the
past several years.
In mental health research what we are specifically dealing
with, where we would like to expand the research portfolio is
in schizophrenia and depression.
Mr. Mollohan. Thank you. We will follow up. Thank you, Mr.
Chairman.
Mr. Walsh. Thank you. Mr. Frelinghuysen.
research collaboration with national science foundation
Mr. Frelinghuysen. Thank you, Mr. Chairman. Good morning,
gentlemen. Just to follow up on the mental health aspect, this
committee spent about 3\1/2\ hours yesterday with Rita
Caldwell, Director of the National Science Foundation. What are
the VA's research relationships specifically with mental
health, with the National Science Foundation? I did not get a
feeling from the questions I asked Dr. Caldwell that there is a
great deal of collaboration. Is there a collaboration?
Dr. Feussner. There are not significant collaborations with
the National Science Foundation. There are collaborations with
the National Institutes of Health.
Mr. Frelinghuysen. Yes, I understand that. I just think it
would be reassuring to the committee, since we have the
Veterans Administration under our jurisdiction, that there be
some relationship between your good work and the work of the
National Science Foundation. I find it hard to believe that
good people are not comparing notes. And I assume that they
mentioned some project at Emory that they are very active in,
and I was just wondering whether you were aware of some of the
things they are working on there.
Dr. Feussner. Is this the--well, there is a lot of work at
Emory that is being done by NIH----
Mr. Frelinghuysen. I am talking about the National Science
Foundation specifically.
Dr. Feussner. No, I am not.
Mr. Frelinghuysen. As one person on this committee, I would
like to encourage you to work with Dr. Rita Caldwell and see
what she is doing. We assume that information passes between
Federal agencies. Maybe that is too much to assume.
occupancy rate reductions
I want to get back to a few of the questions that the
chairman asked. Were there specific hospitals in Los Angeles or
were there several hospitals where the patient count had been
reduced by 30 percent?
Mr. Kenneth Clark. I was referring to my own experience,
and that would be with regard to what was formerly known as the
West Los Angeles VA Medical Center, now known as the Greater
Los Angeles Health Care System, as it involves three campuses.
Mr. Frelinghuysen. And there were 400 beds that were there
that are there no longer?
Mr. Kenneth Clark. No longer in use, approximately, yes.
Mr. Frelinghuysen. Where do the patients go?
Mr. Kenneth Clark. Many of those patients, as I said, were
long-term mental health patients. As we have developed
additional community-based programs, adult day health care
programs, those patients no longer require institutional care.
Mr. Frelinghuysen. Unless they are deceased they are all
present and accounted for in somebody's jurisdiction?
Mr. Kenneth Clark. Most are but they are receiving
treatment in a different way than they did in the past; in
other words, on an ambulatory basis rather than in a VA
institution.
Mr. Frelinghuysen. And I am intrigued. We have a lot of
empty buildings? Do you have any idea how many square feet of
VA buildings are unoccupied or vacant systemwide? Does that
figure exist?
Mr. Kenneth Clark. That figure exists. And could we paint a
picture that in many cases, maybe this is the right thing to
do, that there have been consolidations, there have been BOCA
code issues, fire safety issues, technology issues that have
driven you as a system to put people together in smart new
technologically fire safe buildings?
Mr. Frelinghuysen. But is there--can one get the picture
that there is a lot of vacant space out there that is costing
the system a lot of money to maintain and to protect? And could
you, for the committee give us a general idea of what the
carrying cost of all of this upkeep and maintenance might be?
Mr. Kenneth Clark. We could provide you with those
estimates and, yes, you are correct, I would not deny at all
that there are a number of buildings where the substantial
gross square feet of space that is no longer being needed for
the purpose that was originally intended.
inpatient census rates
Mr. Frelinghuysen. And could you give me just a general
view, what would have been the inpatient population in our VA
system 5 years ago versus today? I know we are working all
sorts of outpatient clinics and we are doing outreach and we
are doing consolidations. Can somebody just give me an
overview? Many veterans ask.
Dr. Garthwaite. Five years ago we admitted 900,000 patients
a year to the hospital. Last year, I think the number was about
600,000. Five years ago, we did 25 million outpatient visits.
Last year we did about 37 million outpatient visits. So
patients are getting treated and seen. In fact, the number of
surgeries has risen mildly. The number of patients seen overall
has gone up by 24 percent but a significant number of patients
who had been admitted to the hospital no longer are.
Mr. Frelinghuysen. Some of those patients are obviously
seeking treatment in non-VA facilities? You do not necessarily
win them over forever once you sign them up.
Dr. Garthwaite. Correct, even within the 24 percent.
Mr. Frelinghuysen. Some may have a choice by virtue of
their means.
Dr. Garthwaite. Correct.
Mr. Frelinghuysen. And medical needs, and others may not
because of their limited means.
Dr. Garthwaite. There are some veterans coming in and some
who we are not seeing in any given year, some coming in and
going out. We have done some surveys on percent usage and we
can provide for the record, I do not remember the percent
reliance on VA for health care as part of our eligibility
reform analysis. An actuary has done some estimates of the
percent reliance of those who use our system or who enroll in
our system, to project their percent reliance on VA.
[The information follows:]
Reliance on VA for Health Care
In the Spring of 1999, a survey was conducted of enrollees in the
Department of Veterans Affairs (VA) health care system to determine
their reliance on VA for health care. The information from this survey
was used by the actuary VA contracted with to project utilization and
expenditures. For inpatients, the average (Mean) reliance for all
enrollees having at least one inpatient stay (either in VA or
elsewhere) during 1998 was 54.6%. The average (mean) outpatient
reliance for all enrollees having at least one outpatient visit in
either VA or elsewhere in 1998 was 79.9%.
nursing home care in new jersey
Mr. Frelinghuysen. I know you are promoting and are out
there actively recruiting and that is not in and of itself a
bad idea. I would like to ask some questions relative to
nursing homes. At the hearing with, Secretary West on March
23rd, I asked why there are over 100 empty nursing home beds in
New Jersey's two VA hospitals, while there are over 250
veterans waiting for beds in the State of New Jersey's three
veterans' homes. At that time I was not provided with an
answer. And as I look at your list of nursing home units in
your budget document here, under New Jersey, you list East
Orange and Lyons. For all intents and purposes there is no
nursing home at East Orange because there are no patients. The
physician unit, I assume, is still there, some of us would like
to fill it up, but for all intents and purposes this listing
here is not entirely accurate or maybe we just list it because
it is available for future use.
Would you tell me whether we have--I asked the question
because each of us likes to think we have some facility with
the nursing homes in our district, but is this symptomatic of
the situation nationwide where you have 134 nursing home units,
how many of them are vacant? We know in New Jersey there is one
which is empty, but you can reply to the New Jersey question
and then perhaps the general question nationally.
Dr. Garthwaite. Sure. The Lyons campus has 240 beds. On
paper, at least, the East Orange has 60 beds. They may not all
be in operation because the number of veterans who are
appropriate for placement at this time, and requests for
placement have been down somewhat. Given the combination East
Orange seems to be meeting the needs of the population. It is
our understanding there are about 100 people on the waiting
list, or at least when we checked following the hearing, about
100 people on the waiting list now for state veterans homes,
some of whom are wives and widows of veterans and who,
therefore, would not be eligible for placement in our nursing
homes.
In addition----
Mr. Frelinghuysen. You are aware that three of the veterans
on the state's waiting list are 100 percent service connected
and were you aware, Dr. Garthwaite, that an additional 40 of
those veterans do have service connected disabilities ranging
from 10 percent to 70 percent? I assume that knowing that we
were having this hearing you did your homework and I give you a
pat on the back, but some of these people who are waiting for
state facilities could well be in our facilities.
Dr. Garthwaite. Certainly, given the information you just
provided we would be happy to look at those individuals to
determine if they are interested for placement in our
facilities, especially the 100 percenters who clearly are our
first obligation. And we obviously would provide them care
under the Millennium Act, regardless of where they would want
to be.
There are different criteria for admission in our nursing
homes. They are largely rehabilitative although we have some
that are long-term, but we often contract for the long term
care in nursing homes.
I think overall, our nursing homes are well used and the
average occupancy rate is in the high nineties.
va's collaboration with state nursing homes
Mr. Frelinghuysen. Here again, we talk about collaboration,
the VA does not work in a vacuum, or maybe it does, but I
assume you work with the state nursing homes. If the state
nursing homes have a huge backup and there are a number of
people who would qualify for our units, why can there not be
some sort of a temporary placement into our facility while
these veterans are on the waiting list?
Dr. Garthwaite. I don't know if that question has been
asked but it is a good question.
Mr. Frelinghuysen. I shouldn't have to ask it. We do not
manage your operation on a day-to-day basis nor do we manage
our own state nursing homes on a day-to-day basis, but I would
assume that the entities talk, and if perhaps this hearing
results in better communication, then----
Dr. Garthwaite. I do believe we talk, but I do not know if
that specific issue has been addressed and we should make sure
that we have that conversation.
Mr. Frelinghuysen. Having brought it up on March 22nd, and
bringing it up today, maybe we can reactivate and reinvigorate
the process so we can get the parties talking to one another
again.
hepatitis c treatment and funding
Hepatitis C. We talked about the growing problem of the
hepatitis C virus and the veterans population at the last
hearing and I asked several questions about how much money was
actually being spent on testing and treatment. At that last
hearing I noted that 6 percent of the veterans population
nationally tested positive for hepatitis C virus in a one-day
random screening test in March 1999, and that over 12 percent
of veterans in my VISN, New York and New Jersey, tested
positive for the virus on that day.
Since then I have received some additional details about
the March 1999 random hepatitis C test compared against the 6.6
percent national average. A breakdown of VISN 3 shows that in
New Jersey, Lyons, East Orange, 12.5 percent of veterans tested
positive; in the Bronx, 15.8 percent tested positive; New York-
Manhattan, 18.3 percent; Hudson Valley, Castle Point and
Montrose, 9.5 percent.
Further, I understand that from the VA's own figures that
VISN 8, Florida, Mrs. Meek's VISN, tested at about the national
average of 6 percent. When we discussed this last month, I was
told by Secretary West that the hepatitis C money in the fiscal
year 2001 budget will be distributed under the VERA model, not
based on need. Is that still the case, given the sobering and
exceedingly high infection rate in our area of New York and New
Jersey?
Dr. Garthwaite. The policy board recommended to me, based
on the numbers up to this point on the amount expended on
hepatitis C, that this is not a significant amount. However, my
own personal leaning at this moment is that we should
distribute money based on the occurrence of hepatitis C.
Mr. Frelinghuysen. On the need?
Dr. Garthwaite. The need, because I believe--even though
today it is not a large amount of money, and we believe that
the VERA allocations actually cover the entire expense, the
fact is that the treatment and testing are fairly expensive. I
think we need to make sure that we are very aggressive in
detecting and treating this disorder. I think that funding is
going to be an important piece.
There is another significant piece of----
Mr. Frelinghuysen. It is an important piece, our VISN had
to ask, as you know, for $22 million extra because it has a
higher incidence of hepatitis C than other VISNs in the
country. That should have been pretty much a warning shot
across your bow.
Dr. Garthwaite. For instance, with patients with HIV who
also occur more commonly in VISN 3 and several other VISNs, we
place them into the high reimbursement rate, especially if
those patients are on the modern drugs for HIV, which clearly
reimburses those VISNs with a higher percentage of patients at
a higher rate. So the principle has been there that we do
attempt to account for very expensive patients who are not
distributed equally across the United States and therefore put
the money where the need is. And that is the principle we will
follow with hepatitis C. Right now we are working very hard to
get all the numbers correct.
One of the ways we look at the numbers is to look at the
codes that are in our encounter forms. Whenever we see a
patient we fill out what they were in for. But we have some
concern that when we look at the laboratory tests, there are
more patients' test being positive than turn up in the
treatment codes. And so we are now trying to resolve that
difference. We will have that fairly soon.
Mr. Frelinghuysen. Well, I assume you have the computer
capacity to do this pretty much instantaneously, or am I
assuming too much?
Dr. Garthwaite. Well, it is not usually the computer
capacity that slows things down, it is the human beings
entering information into the computers that is the challenge.
Mr. Frelinghuysen. Do you have the authority to use
hepatitis C funding to hire additional gastroenterologists and
other medical personnel needed to administer and interpret
these tests, the physicians----
Dr. Garthwaite. Absolutely.
Mr. Frelinghuysen [continuing]. That you need. Thank you,
Mr. Chairman.
Mr. Walsh. Mrs. Meek.
antibiotic resistance
Mrs. Meek. Thank you, Mr. Chairman. And welcome. My
questions are directed to Dr. Feussner and they pretty much
have to do with your area of research and development. I am
sure you are aware it was, as a doctor, of the fact that we are
losing the battle against many of these infectious diseases
because of the antibiotics that we have, many of them at first
were very, very good and viable, but as time when on they
became less viable. And I have just a series of questions I
want to ask you about that. I would like to know if the VA
health care system tracks the antibiotic use, the use of
antibiotics in VA hospitals and your clinics? Do you track
that?
Dr. Feussner. Well, in a research mode, we don't
specifically track the use of antibiotics in hospitals. But
with the national pharmacy, antibiotics are tracked in those
two sites, yes.
Mrs. Meek. Do you track the antibiotic resistance rates
because of these highly--maybe Dr. Garthwaite.
Dr. Garthwaite. I just wanted to add that several years ago
we set up a national surveillance system across the United
States, so at each VA, our computers automatically roll up any
new and emerging infections, any new and emerging bacteria with
antibiotic resistance which we haven't seen before. And that is
all fed into Dr. Rozelle, head of infectious disease in
Cincinnati. We would be more than happy to get you a summary of
how that program works, but it is one of the more novel and
creative things that the VA does. So if there is a beginning of
emergence of bacterial resistance to the antibiotics somewhere
in the VA health care system, if they acquire it in the
community, we should be able to detect that.
Dr. Feussner. We are working with the Center for Disease
Control to exchange that information.
Mrs. Meek. So it is pretty much that you have sort of a
model of showcase model of what has happened with the
antibiotics as the VA has done in several other areas.
streptococcus pneumonia virus vaccine
My second question has to do with the streptococcus
pneumonia virus in the bloodstream, the bacteria at least. That
has been very prevalent with elderly people and they have
become many times compromised. And I would like to know if, for
veterans whom the vaccine is indicated, are they offered the
pneumococcus vaccine?
Dr. Garthwaite. Absolutely. In fact, our immunization rates
have continued to improve. One of our performance measures is
the rate of immunizations as part of the preventation index. So
we track that very aggressively. I think last year it was 76
percent of all veterans received the pneumococcal, who were
appropriate to receive it. It continues to improve over time.
That number may not be exactly accurate, I don't know. But the
point is that we have now exceeded, for both influenza
immunization and pneumococcal and pneumonia immunization, all
published rates for any other health care system and the
Healthy People 2010 goals. We feel we have come a long way and
we won't rest until every appropriate veteran gets the vaccine.
But I think as a health care system, we aren't aware of any
data that have shown any other health care system has done
better.
Mrs. Meek. So if any of them have become resistant, you are
also utilizing any other vaccines that might fight the
streptopneumococcus vaccine?
Dr. Feussner. There is----
Mrs. Meek. There's one that afflicts elderly people.
Dr. Feussner. There currently is one vaccine that protects
against multiple strains of the bacteria, and that is the one
that we use. In addition to what Dr. Garthwaite said, 2 years
ago we started an initiative, a joint initiative with VA and
DOD looking at issues of emerging infections that is a research
parallel to the emerging pathogens or germs. That initiative is
coordinated in Cincinnati. And then VA did some of the major
initial studies to demonstrate the risk groups, the elderly
you've identified being one of them, that would benefit from
the pneumococcal vaccine.
mental health care delivery
Mrs. Meek. My third question has to do with your mental
health, and the Secretary answered some of this, I think, Dr.
Garthwaite, when you were here too before. I would like to know
what is the status of the VA in terms of restructuring your
delivery system regarding delivering mental health services to
veterans?
Dr. Garthwaite. We believe that the VA offers a unique
resource to veterans in that we treat mental illness the same
as physical illness. There is no lifelong benefit of number of
days for the treatment that you might have for mental illnesses
as many insurance policies have. In fact, as long as you need
our help, we are able to provide it. I think that is a very
positive thing. We actually believe that we have data that show
that patients get more mental health treatment in the VA than
comparable other systems. We have moved from an inpatient model
to more of an outpatient model, especially in substance abuse.
We believe that is, overall, a good thing. And I think we have
evolved outpatient care in very intensive outpatient expenses
and programs which substitute for the inpatient care and give
us similar results. I think in the beginning there was a move
to move patients out a little too quickly, but I talked to Dr.
Lehmann, the head of our mental health, as recently as
yesterday, and he said that in the last year plus, there have
been no systems that have moved from inpatient to outpatient
without the appropriate outpatient programs.
I think overall we have really an impressive program. In
addition, we built off of our experience in geriatrics where we
have geriatric research education and clinical centers, GRECCs,
which have been very important in advancing the cause of
geriatrics in the United States, and we have now founded
MIRECCS, mental illness, research education clinical centers.
These now form a nucleus where we can bring in clinicians,
clinical programs, educational programs and important research
programs together, and then they go out and compete for
additional dollars, both inside the VA and outside the VA to
further our understanding of mental disease.
So that is part of our program. I don't remember all the
pieces, but it is a really impressive program. I think the
important part to remember is that we treat mental health quite
differently than it is often treated elsewhere. We treat it as
a medical illness and provide the services that are needed.
Mrs. Meek. Doctor, a snapshot of my district, most large
urban areas show veterans in a pitiful condition mentally in
terms, and I know you do have outpatient clinics that provide
those services, but it does bother me to see them many times,
and most of them are in need of psychiatric treatment.
So I understand that you are cutting your work force in
terms of your serving these veterans in most of your outpatient
clinic. How do you plan with that work force so dismally cut to
take care of these veterans, which are obviously in need of
psychiatric care?
Dr. Garthwaite. There are probably some decreases overall
as we have moved from inpatient to outpatient. Once you do
that, you don't necessarily need nursing staff and other staff
associated with the inpatient program such as dietetics staff
and housekeeping staff; when the treatments are given in
outpatient settings rather than inpatient. So although the
total number of staff associated with a given program may
decrease as we move from inpatient to outpatient, that doesn't
necessarily mean the intense interactions with the patients
change.
I have visited a program in one of my tours to the field
where when they moved from inpatient to outpatient, the amount
of time a professional spent with the patients actually went
up. They were actually able to move some of the FTE from the
inpatient to have more counselors, so when patients came in,
they got more one-on-one time with counselors. Your issue about
veterans on the street with mental illness is a significant
concern of ours, and I am sure you're aware a significant
number of homeless people in America are veterans. We continue
to be the largest hands-on provider of care to the homeless and
continue to fund growing number of initiatives, especially
community-based initiatives in homeless care.
community-based outreach clinics
Mrs. Meek. So you feel that the community-based outreach
clinics which you propose for the year 2001 will be adequately
staffed and be able to provide the services which you have
listed here today?
Dr. Garthwaite. Yes, I do believe that. In addition to
that, as another check on that, there is an advisory committee
on the care of the chronically and seriously mentally ill that
meets on a regular basis, and includes providers, veteran
advocates, advocates for the mentally ill. I meet with them to
hear specifically their complaints. There are no filters
whatsoever. I meet personally with them.
So I think we have some checks and balances built in if
there are focal areas, or local areas where we are not meeting
that demand, or if we see additional demand that needs
additional attention.
Mrs. Meek. I understand you have a strong case management
system in these outpatient clinics. And are you happy--not
happy. Are you comfortable with the follow-up on the cases that
you work with there?
Dr. Garthwaite. Yes. I think case management in medicine
overall, is an evolving discipline. I think it is an important
part. We use primary care in our medical system and the
providers serve largely to help guide and coordinate the care.
I think it is critically important in the mentally ill, because
often family members that serve in that coordinating function
need a professional to make sure things get coordinated. And to
the extent that that can help, we are dedicated to maintaining
the gains we have and enhancing those coordination functions as
we move forward.
claims process
Mrs. Meek. Thank you. On the other major concern I have in
my district is the claim situation. I am sure that will never
be perfect. Because they appeal and they appeal. And I have
been to court with some of them. I had the nerve to follow some
of them to your courts. They are pretty tough. Give me some
idea of what is going on now in the claims adjuster. We have
asked these questions consistently regarding veterans, because
I feel it is extremely important that the claims process be one
that is the best.
Dr. Garthwaite. I'll turn this over to Judge Clark.
Mrs. Meek. He might be one of the tough ones that I faced
when I came to court.
Dr. Garthwaite. He sees the appeals.
Mr. E.D. Clark. The Board of Veterans Appeals only gets the
claims after they have been adjudicated at the various regional
offices. So perhaps the one to more appropriately address this
issue is someone who uses the regional offices and who is
familiar with the process at that level, which would probably
be the Under Secretary for Benefits. Is someone available to
deal with that?
Mrs. Meek. Thank you.
Dr. Garthwaite. I think they are coming this afternoon.
Mrs. Meek. I will ask the question. Thank you very much and
thank you, Mr. Chairman.
Mr. Walsh. Thank you, Mrs. Meek.
Mr. Hobson, by the way, I am going to have to leave for
about a half an hour. Mr. Frelinghuysen is going to take the
chair. I really appreciate him doing that. I will be back as
quick as I can. And actually we are giving members about 15
minutes each to develop into these questions. I haven't heard
any objection to that. It really does give you a chance to go
in depth. So we appreciate your responses. If you could make
them quickly we can get to ask more questions that way. Thank
you.
departmental management
Mr. Hobson. I want to ask some questions of this end of the
table down here if I might. I want to get into some--I am going
to ask seven questions here. I will read them to you, and you
guys can come back and answer me if anybody else wants to jump
in or stay quiet, they can. Are all of the VA hospitals using
the same software and hardware for information and financial
management? Secondly, who makes those decisions? Thirdly, how
does the VA or VHA as a whole keep track of medical care
expenditures and patient information? Why doesn't the
department require the VHA to update and improve their systems?
That is for the CFO, the CIO and maybe even the IG. And is this
lack of central information and management contributing to the
VA's problems?
And Mr. Duffy, as Assistant Secretary for Planning, what
help do you give to the VHA for their budget and resource
allocation processes? I personally sense some real problems on
the whole--well, frankly, HUD generally and VA with the
computer technology coming into the real world. I happen to
have been chairman of Health and Human Services in the Ohio
State Senate. I want to know how you are going to grapple with
this problem for the future. So you want to start with the
first one about the software.
information technology
Mr. Gracey. Yes, the software and hardware that is used in
the VA medical centers across the system is essentially
standard and the same. In fact, it was developed within VHA. It
is now called the Vista system. It was originally the
Decentralized Hospital Computer System. It is probably the
premiere health care delivery support system in the world, very
well attuned to direct support of clinicians and support of
patient care. And it is being improved constantly, because it
is a system that is in use by clinicians who have, as their
driving need, the need to know as much information about the
patient as they can. And I am very comfortable with that.
The way the decision is made in VHA is their CIO, although
vacant right now, in Veterans Health Administration, who
oversees through the VISN structure, the decision-making with
about the expenditures on information technology. It is around
the standard framework of the VISN system that most of the
process revolves.
The larger challenge, sir, is the integration of
information across the department. And we have, as a major
initiative this year, a real attack on that through something
called One VA Access to Information. We had four One VA
conferences that Mr. Duffy organized and supported, which
brought together people from the field and the headquarters.
The number one concern we heard was that which you expressed in
your series of questions, how can we have access to information
across the organization benefits information, cemetery
administration information as well as health care information.
We put together a departmentwide task force, delivered a plan
to begin doing that this year with a very small first step, but
clearly that is the model from here on out as we make further
investments in technology.
Would you like to re-pose any questions I might have
skipped. I feel like I didn't take good notes.
Mr. Hobson. Who does the budgeting and the allocations on
this particular part of your operation?
Mr. Gracey. There is a formal process on large
acquisitions, which is the capital investment process, where
anything of significant value and for VHA, that is any
expenditure over $10 million, comes from a process which is
first reviewed at the staff level, then a formal review by an
information technology board, then if it passes those two
reviews, a review by the Department's capital investment board
which is headed by the deputy secretary and includes most of us
here at the table. If it passes all those tests, it is then put
in the budget. It is a very rigorous test that is based on a
number of criteria, including improvement of services to
veterans, interoperability with other systems in the department
and return on investment.
updating financial and information systems
Mr. Hobson. Are there any requirements to update these
systems? And secondly, how do you know from region to region, I
think this is one of the things you pointed out what your
spending for certain types of patient care, whether you are in
line, say, with what that same care would cost in the private
sector, whether you are better, whether you are worse, and how
do you keep updating that information in your systems is what I
am worried about.
Mr. Gracey. There is a system called a decision support
system that Dr. Garthwaite probably knows the inner workings of
better than I do, but it is designed to do exactly what you
just described so that there is comparability between the
VISNs.
Mr. Hobson. I think it would be important for this
committee, from time to time, to be able to see that kind of
information. So you know one we can support you when we think
you are doing right and we understand what you are doing.
Because I found when I sat on the hospital board that was one
of the most difficult things to get out of them is how they
compared elsewhere. Because they don't want to tell you. They
don't want to tell what their outcomes were. They don't want to
tell what their costs are. They just want to show you the
bottom line at the end. But I think we need to know that. So I
would encourage you, some way, to get some system in place that
we can interact with you on that.
Mr. Powell. If I may address that. We do have a major
effort underway to revamp our entire financial information
management systems. We call this core FLS, which is the
financial logistics system. We are in the process of
redesigning how we accumulate our financial information to move
to a new system. Our current FLS schedule is a Cobol-base
system which was implemented some years ago.
Mr. Hobson. You have to go back and try to find people who
can understand that system today because they are all retired.
Mr. Powell. That is one of our real problems. We are in the
process now of conducting a VA wide effort with study groups;
firms we have hired to help us through that process are KPMG
Peat Marwick and Booz Allen Hamilton. We hope to be acquiring a
new system towards the beginning of next fiscal year, maybe
early October and November. Our goal is to provide a much more
seamless financial management system. We currently have some 48
different systems that integrate into our core system, about 30
percent of the time of my staff is spent strictly on
reconciling, and our goal is to eliminate that effort.
Mr. Hobson. That was the point of my first question.
Mr. Powell. Our current system is also an appropriations-
based system that is really just an expenditures system. It was
not intended to be a cost-driven system. The new effort will be
much more aligned with providing the types of national
information that you are talking about. We also in partnership,
Harold and I, are setting up an oversight board within VA. The
CIO and CFO are the chair and the board will include the senior
operating managers from each of the program offices. This is to
insure IT projects stay on time and on budget. They will have
direct oversight from the senior executives and hopefully this
will bring more discipline to their implementation.
Mr. Hobson. I think that is good. I hope you will also
include the veterans health care in that system. Because the
total management of your operation has got to be integrated
today. It looks to me like you're moving to a more private
sector-type of view from your financial management.
Mr. Powell. Absolutely. VHA is a critical piece of that
effort.
Dr. Garthwaite. If I could briefly add that the decision
support system, or DSS, is a private sector system used by
several large academic health systems and other health centers.
We have implemented that universally across the VA. This year's
DSS data will be used to drive the budget allocations. So the
interest in making sure those numbers are correct, used and
understood by our managers. As a result is going to be very
intense this year and into the future. So I think that will
help get us the kind of information you are really talking
about. Because we agree with you that we need that information
to manage.
policy change regarding nursing qualifications
Mr. Hobson. Hope you'll keep the chairman involved in that.
I have one other question I would like to ask. I had some
people come to me extremely concerned about a policy change
regarding nursing qualifications. As I understand it, 2 years
ago you ruled that the VA nurses would have bachelor degrees
and even designated 50 million in assistance for nurses to
obtain BA degrees. And I agree that our veterans deserve the
best care possible, however I think in not hiring or promoting
registered nurses with associates degrees will have a negative
effect on nursing supply and ultimately our veterans. I would
like you to talk a little bit about the policy, because in a
number of our districts, we have nursing shortages.
We have these community colleges and I have a hospital that
I was on the board of that has the nursing school; it is a 2-
year program. I think it is important that we encourage the
degrees and we do things to assist that, but I am concerned
about the practice of--I have had people come and say they
won't hire our people. Now, I know everybody shakes their head
and says that is not true. But the perception is reality in
some cases, and maybe people have taken it a step further and
said we are not going to do this because then we got to pay for
these people to get the other 2 years in promoting it.
And I would just like to support the idea, and I would like
you to respond to the perception that, or the reality that you
are only hiring people with 4-year degrees, and you know I have
got what, Dayton, Chillicothe, Cincinnati and Columbus Center
in my district. So--not in my district, but around it and in
it. Can you respond to that. They came in extremely concerned.
Dr. Garthwaite. Pleased to respond. I am somewhat
apologetic that a good news story has been so misinterpreted.
The goal that we set out was to achieve, was to, enhance the
knowledge of our nursing personnel and staff so that it could
be applied to the care of veterans. Simultaneously it would
advance the careers of our nursing staff and personnel, so that
they would be more employable and at a higher level, both
within the VA and if they like, other parts of the health care
sector. The policy is relatively simple. In the past you could
be hired at an associate degree level after two-year training
program, and then work your way up through a series of waivers
to nurse level 3, a potentially higher level.
And that is still true. You can be hired at associate
degree level and work your way up. Now, the easiest way to work
your way up is to go ahead and get your bachelors degree which
raises your overall salary, but also allows you a great deal
more flexibility in terms of your employability across health
care systems. In addition, we maintained waiver provision; that
is to say, if you can demonstrate that you can meet levels of
competence and some clearly defined appropriate measures for
nurses, you can move up under a waiver process.
So it is not really that different. The concern, I think,
has been the misinterpretation that we are not hiring these
two-year nurses. We are just making it easier to move up with
an educational credential and probably a little harder to move
up with a waiver process. And we have put $50 million aside to
fund the continuing education of these nurses. So, in fact, it
should stimulate----
Mr. Hobson. Got the news letter.
Dr. Garthwaite. Should stimulate nurses who have an
associate degree or who could see that as a way to get that
education join the VA, begin to get a salary and have the VA
help them get all the way through the full four years.
Mr. Hobson. Can I suggest one thing to you. You need to go
back and talk to these community colleges and these hospitals,
somebody needs directly to talk to them and say hey, this is
our program because I think there is some miscommunication. I
think your intentions are correct. The message got out the
wrong way to some of these people.
Dr. Garthwaite. We have met a couple times and set up a
liaison, but we will reintensify our efforts and see if we can
help.
nursing home care
Mr. Hobson. Around my district it still needs some help.
Two comments. One, I really like the emphasis on the outpatient
clinics. I think those have been well received in my district
and in some of the surrounding districts where we have done
them. And I don't know that the veterans really appreciate
that. And I know it has some difficulty. The other thing I
would like to comment about are the State initiatives that we
are doing. And I didn't object to this one.
But I think you all need to look at some oversight. Just
because a State says they are willing to put up half the money
doesn't necessarily mean--and they want to put it in a certain
place. I think you should have more input into is it the right
place when you do it for the nursing homes. For the reason that
just because some State is willing to put up half the money
doesn't mean it is the most cost effective way to use that
money. It may be politically expedient to do, but it costs you
resources to do that, and continuing resources to do that. And
I have an instance in my state where they took, I don't know,
$8 million, and another $8 million; they are going to have $16
million, and they have reinvented the wheel in a particular
spot that I think your region would say it is not necessarily
the spot that they would prefer, certainly wasn't where I
preferred, because I thought there was a more cost-effective
way to get 100-bed nursing home open in a current VA facility
where you don't have to reinvent all the ancillary stuff.
So I don't know what the overall make of it is but it
looked to me like that the VA was just willing to say well, if
the State is willing to come up with half the money we are
going to put up the other half. I don't think that's really the
way it ought to be done. We ought to look at the veterans and
the veterans service stuff. So that is just the comment.
Dr. Garthwaite. Your comments are exceptionally timely. We
are in the process of redoing the criteria, which basically
sets the prioritization of funding of State veterans homes. So
we have noted your concerns and we will try to incorporate them
into the process.
Mr. Hobson. Just to reminisce for a second when I was in
the legislature I was on the review panel that went up and
looked at the one in Sandusky many years ago and we had
problems there. And I think it is a lot better today. But I
think we need to watch how we are spending our money along with
the State.
Thank you, Mr. Chairman.
Mr. Frelinghuysen [presiding]. Thank you very much.
Mr. Mollohan.
federal research grants funding
Mr. Mollohan. Thank you, Mr. Chairman. I want to thank
Congresswoman Kaptur for allowing me to jump in here for a few
minutes. I will just be a few.
Dr. Feussner, I would like to ask a couple questions about
research funding. I am going to be, I hope, fast. I notice that
page 3(b)12 of your budget submission reflects Federal grants,
1999, 2000, 2001 projections, which stay pretty constant at
about $340 million. Does that reflect accurately the VA's
participation in Federal grants? I assume most of that is NIH
funding? I am on 3(b)12 in the summary. Your budget submission,
summary volume 5.
Dr. Feussner. I understand the question. And the way the
data are displayed on the budget page is correct. And yes, you
are also correct, most of the funding is NIH funding. If we
were to present these data back a little further, sir, and
start with a base year of 95 or 96 and what it would show is
that we have essentially plateaued. Using the 95, 96 numbers as
a base and for every dollar that the VA appropriation and
research has gone up, the external dollars have gone up about
two and a half to three fold.
Mr. Mollohan. Say that again I am sorry.
Dr. Feussner. What the current number shows is this is
relatively stable.
Mr. Mollohan. Actually it is a decrease in inflation-
adjusted dollars.
Dr. Feussner. Yes that is correct. These data only go back
to 1999. If you use a base year that was 95 or 96 and looked at
the same numbers in 95 and then went forward through time, what
you would see is that the VA appropriation over that period of
time, say would go up $70 million, the external grants that VA
competes for would go up approximately three times that. Okay.
So what has happened is we have had a brisk step up in the
acquisition or in the competition for external non appropriated
dollars until very recently and that number has now stabilized.
In terms of real dollars it has decreased.
Mr. Mollohan. So the external source of funds for research
has also plateaued.
Dr. Feussner. That is correct.
Mr. Mollohan. And your internal dollars have gone down.
Dr. Feussner. Well, in real dollars yes. I mean inflation
adjusted dollars over the period of time you are correct.
Mr. Mollohan. NIH funding has increased by more than $4
billion in the last 2 years. That is about a 33 percent
increase. Your budget document, as I understand it, and as I
understand your explanation of it, does not reflect VA
researchers benefiting from this increase.
Dr. Feussner. That is correct.
Mr. Mollohan. So my question is why?
Dr. Feussner. Well, what I haven't clearly explained yet,
is that I think that the number of investigators in the VA is
flat, and that the overwhelming majority of the NIH dollars
that comes to VA comes through individual investigators located
in the field. And that number is flat.
research personnel
Mr. Mollohan. Your research infrastructure is capped out in
terms of personnel, so you can't accommodate any more research
activity?
Dr. Feussner. I think that, in a sense, yes, that the
individual investigators that are currently there are maximumed
out.
Mr. Mollohan. Okay. If you want to increase your research
activity, you would need additional investigators or additional
research infrastructure?
Dr. Feussner. Yes, sir. And what we have done over the past
4 years, as we have started along that pathway, our new career
development awardees have increased from a low of about 90 to
what is currently about 170 in just the last 3 years. So we are
building the personnel research infrastructure that should make
us be able to be more competitive for more external dollars
down the line.
Mr. Mollohan. Let me ask, in research organizations I am
familiar with, they fund their researchers with direct dollars.
Do you do that in the VA?
Dr. Feussner. Not as clearly. The money to do the research
comes out of the appropriation for research. The investigator
time to do the research comes out of the medical care
appropriation and is classified as VERA dollars in support of
research. The research appropriation is $321 million, the VERA
amount is approximately $331 million.
Mr. Mollohan. You don't pay your researchers with direct
dollars from a research grant you get from NIH?
Dr. Feussner. Okay. The dollars for the NIH research grant
do not come to headquarters. That would go either through the
affiliated university or be managed by a VA nonprofit
foundation, and would go directly from NIH to the investigator.
Mr. Mollohan. Research facilities capabilities are often
built up with indirect dollars. Do you get the advantage of
indirect dollars in these grants?
Dr. Feussner. No, at the moment we do not. We have been in
negotiations with NIH now for the past two years to work out an
arrangement such that for NIH grants that are done
predominantly at VA facilities, that the NIH would support the
infrastructure costs.
Mr. Mollohan. I have, I think, exhausted the patience and
graciousness of Ms. Kaptur here. I very much appreciate it. I
would like to follow up outside the context of the hearing with
regard to understanding how this works.
Thank you, Mr. Chairman.
Mr. Walsh [presiding]. Thank you, Mr. Mollohan.
Ms. Kaptur.
psychiatric care
Ms. Kaptur. I want to compliment Mr. Mollohan on his
questions. It leads me into some of mine. I want to welcome you
all here today. I feel like we are looking at the front line. I
know this is the front line of the largest hospital system in
the world, and Dr. Garthwaite, I wanted to ask you how many
years have you been there now?
Dr. Garthwaite. I have been at headquarters for 5 years,
been in the VA health care system for 26.
Ms. Kaptur. How does it feel to be at the head of the
largest hospital system in the world?
Dr. Garthwaite. It is challenging. I enjoy it. I think it
is great opportunity to try to do the things I went into
medicine to try to accomplish, which is to provide quality care
to as many people as possible, and to help them out with
problems that they are having. It is very challenging in terms
of its complexity and the number of issues. It is a great job.
Ms. Kaptur. I wanted to thank the department for sending me
a lot of very detailed information on psychiatric care, which
is something I am deeply, deeply interested in. And it is going
to take me a long time to understand it, but I see all these
experts here on information and technology, planning and
analysis, there is somebody in finance. Financial officer,
chief financial--associate, financial management.
One of the questions I have, and I just want an answer on
one page, because I have to pour through when I get an answer
that fills a file drawer, then I worry. Because I ask myself
where is the focus? And in this area of psychiatric care, what
I want to ask you is the budget that you submitted to Congress
for 2001 indicates the number of inpatient episodes that you
cared for in 1999, 412,000 acute area, 15,000 rehabilitation,
86,000 that are listed as psychiatric care, 99,000 nursing home
care, 59,000 subacute care, 50,000 residential care and 41
million outpatient visits.
One of my questions is how would you go about using the
data that you have to tell me in each of those categories, and
then in totality how much of your dollars for care, putting
research aside for the moment, goes into treating people whose
primary diagnosis is some type of serious psychotic illness
that may be complicated by alcohol and drug use? How can you
pull that data out for me?
[The information follows:]
Psychiatric Care for Substance Abuse
The estimated cost to treat patients with dual diagnoses
(substance abuse and psychiatric disorders) in FY 1999 was
$703.9 million. There were 46,827 inpatient and 35,324
outpatient visits in FY 1999.
Dr. Garthwaite. We appreciate the opportunity to try to get
that onto one page and to provide that information. I think the
picture, or the concept that I would try to convey is that it
is not always the number of dollars for a given individual or
group of individuals, it is really whether they are spent
effectively and if we have improved the outcomes for those
individuals as well. Dollars can clearly be an important
indicator of that, and in many cases are, but it is not the
sole driving force. In our country, we spend many dollars doing
operations that in the end we found not only didn't help
patients, but in some cases hurt patients. So I think we want
to make sure that we are focused, in addition, on the outcomes
of the patient.
So I would agree with you that the dollars we spent in
mental health probably do bear a significant relationship to
the quality of care, and there is a tendency in the country at
large to avoid spending dollars on mental health. So we will
get you the information on how we can do that as quickly as
possible.
Mental Illness
Ms. Kaptur. Well, I tell you what, I will tell you a story.
Maybe you heard this story already, but it stays with me
forever, when I was out at Hines and I was over in the
emergency room, this is when I was back on the Veterans
Authorizing Committee, and I watched admissions. And I was
there, just happened that the Chicago Police brought in a
veteran, it was his 19th admission. And they said we will clean
him up, we will send him back out on the streets of Chicago and
he will be back a year later because he won't take his
medication.
This is a pattern that is repeated in the private health
care system of this country. I am out for a Nobel prize out of
the VA in the area of serious mental illness. You are going to
solve this problem for the world. I just got to get you
organized to do that. I haven't been able to figure that out.
It is now 18 years that I have been trying to figure this out,
so I am not a very good student, I guess, because I am not
getting the answers I want out of the VA, every time you push
here something happens here. You can't quite figure out how to
get a hold of this thing.
But yes, the VA does a better job of receiving people who
have these conditions, but I am not sure that it behaves any
differently than the private sector in terms of solving the
problem. That person probably needed transitional housing. Now
we have had Secretary Cisneros and Secretary Cuomo, we have got
more transitional housing, some of the psychiatric counseling
programs that the VA has permitted certain veterans to be able
to be housed in group situations where their meds are
monitored. And we are further today than we were 18 years ago,
but we are still not where we need to be in terms of the answer
in terms of medication and of brain analysis, so that we
understand what is really going on here.
And I am--I really would like to know the percent, I mean,
the percent that are operational within the VA at the health
care level, in a given hospital, Ann Arbor VA, for example, how
much time in dollars are spent there dealing with problems of
psychiatric related illnesses? I would really--I sometimes read
these studies, well, 10 percent. I think it is more than that
if you really look at the dollars of the admission offices, of
the nurses' dollars. And I am trying to get a sense of how
significant this is in your population. And you have got an
interesting population because many individuals who came into
the military do so at an age where those illnesses onset, so my
theory would be that you have a higher proportion that might
present with those illnesses simply because of when they were
inducted or when they enlisted than the general population that
uses other hospitals in our country.
So I guess I am looking to you for leadership here and I
don't always sense it out of the VA. Now, I found out something
yesterday. We were over on the National Science Foundation
hearing and I asked the question of the director and of the
head of the sciences board in some of the staff about why we
can't come up with answers on mental illness or the country,
the diagnosis, the treatment, understanding how the brain
works. The answer I was given was that well, we don't
understand the way the brain works. So therefore, we don't have
the answer medically.
And I said, is there any kind of interagency effort to work
together, Congressman Mollohan was asking about NIH, and so
forth. Oh, yes, yes there is an interagency effort and it
involves NIH and NIMH and NSF. I said that is interesting. Is
the VA involved? Oh, no the VA is not involved. I said oh, why
is that. Everyone looked at one another. And it is the same
reply I got from the vice president's officer when his wife did
that mental illness workshop a year ago, and we were or
whenever it was last year, and I was sitting there, I said why
isn't the VA around the table. Where are they? Everybody looked
at one another. The VA? Oh, no one even thought about it.
Somehow you are not a player. Maybe you don't want to be a
player. And I would hope that isn't the case. But you are
always missing in action. And why is that?
Dr. Garthwaite. That is a good question. I think we have
made some significant strides in terms of quality measurement
and in terms of patient safety to the point where we were
consulted and were a significant part of the administration's
response to the OIM report on safety. I know we did have people
attend the seminar on mental illness. Whether we were a big
enough player, a prominent enough player, certainly you could
argue. I don't know. I didn't personally get to go. But I would
say that we like your goal of getting a Nobel Prize for
treatment of mental illness and we look forward to some
significant new initiatives in mental illness over the next
year or two.
Psychiatric Counseling for Homeless Vets
Ms. Kaptur. Let me ask you, in the area of psychiatric
counseling in your budget is a program Dr. Errera started years
ago. What has happened with that program? Where did I find it
in your budget? What is it doing? I can't remember the exact
title of the program, but this is dealing with homeless,
mentally ill veterans around our country. That is it, for the
chronically mentally ill. Could you give me, or one of the
staff there, give me a sense of when did that program start,
where is it today and how does it relate to your MIRECC
initiative?
Mr. Frelinghuysen. We have 14 panelists. You want to bring
up another one?
Dr. Garthwaite. We do have on page 2-114 we do have a
break-out of homeless program budgeting for this year, up to
$150 million proposed in 2001. That includes homeless grant per
diems, and health care for homeless vets. So it is a
multifaceted program.
Ms. Kaptur. So the program for the chronically--is
contained in one of those line items? Homeless, chronically
mentally ill?
Dr. Garthwaite. We are going to have to find that out for
the record in terms of that specific program, is included it
there or under our general medical expenses where I think it
probably is.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Kaptur. May I ask over the years what has happened--can
someone talk about this program? What has happened to it since
it began? Where is it today? What have we learned what are we
doing?
Mr. Frelinghuysen. This is an issue that you should be
familiar with because I believe Ms. Kaptur and others have
raised it in previous hearings.
Dr. Garthwaite. Well, I can tell you a few things, I guess.
In 1998, Health Care for Homeless Veterans Program assisted
40,335 veterans. And in 1999, 38,023. We believe that is a
significant number of homeless veterans who do receive services
and up to two-thirds do receive services of a specific program.
And one of our issues is that to collect all homeless
counseling that goes on, we have to look across many programs,
but the ones specifically in this particular program are in
that ballpark, about 40,000 veterans.
Mental Illness Treatment
Ms. Kaptur. Doctor, may I just say I think you are a
wonderful man and you are trying very hard, but I am shocked
that there isn't another person on the panel that, knowing we
have asked these questions year after year after year that is
trying to help you answer. And let me ask this question. I want
to know who at the VA is in charge of the treatment, diagnosis
and treatment of those who are mentally ill? Then I want to
know who is in charge of the program dealing with them? Which
individual do we hold accountable?
Dr. Garthwaite. For research, Jack is in charge of the
overall research program, which includes emphasis on the
mentally ill. Dr. Lehman has recently been appointed as our
head of mental health. He has been working there in another
capacity for a long period of time.
Ms. Kaptur. May I ask what his title is, Doctor?
Dr. Garthwaite. Associate chief medical director for mental
health and mental behavioral health. I think that is right.
Ms. Kaptur. He reports to you?
Dr. Garthwaite. Reports to the chief patient care service
officer who reports to me, so indirectly.
You know, I think what you are asking very specifically is
for this program, where we are today, and I apologize that we
didn't ask those individuals to be present here. I am sure they
can easily answer this question for you. And we would be happy
to get you the answer in writing or set up a meeting.
Mental Illness Research
Ms. Kaptur. Well, I can't speak for other members on this
panel, and but I have got to have confidence that there is some
focus, and there is some sense of mission within the VA in this
serious area. I have got to figure out how to help you do that.
I am a bit at a loss this morning. I will pore over the
material that has been sent to me. I know Congressman
Frelinghuysen has an interest in this. I know Congresswoman
Meek has an interest. I would guess there are some other
members of this panel that have an interest.
Dr. Feussner. May I comment on the research component?
Ms. Kaptur. I would love it.
Dr. Feussner. I think that Congressman Frelinghuysen has
addressed the issue of our lack of cooperation with NSF and
that is a fair criticism. We have a brisk collaboration with
NIH, and if there is a logical explanation for the fact that we
have a brisk collaboration with groups, say, like NIH and DOD
and not one with NSF I think, to some degree, our focus is more
clinical research and basic research. So that may have been why
we have not gone to NSF.
In terms of the research portfolio in mental illness, it is
quite substantial. If we, as we categorize our research
portfolio, almost 17 percent as the data we sent you indicate,
17 percent of our research portfolio is vested in issues of
mental illness. We have done the definitive work establishing
the basic treatment for schizophrenia, being antipsychotic
agents.
We have done the lead work establishing the effectiveness
of Clozapine in the treatment of refractory schizophrenia. We
are doing the largest study in the country to date on
Clozapine, a family of antipsychotic agents that have a better
adverse effect profile than do other agents. In terms of basic
research, that is where one gets Nobel Prizes. There are no
Nobel Prizes for applications of research funding. And boy, I
would love to get there.
Ms. Kaptur. The cardiac pacemaker.
Dr. Feussner. We got no prize for the cardiac pacemaker. We
received no prizes for the CT scans. We have gotten the Nobel
Prize for discovering how brain hormones control the rest of
the body. We have gotten the Nobel Prize for discovering the
radio amino acid which allows us to measure a lot of body
chemicals, and recently we received the Nobel Prize for studies
of nitrous oxide which really relates to blood vessel
functioning. But we have never gotten the Nobel Prize for those
applications. In terms of current, in part, because of the
question you asked earlier, and in part, because of something
we are writing about in our clinical trials program, we were
able to go back 30 years and look at these trials, and the
major two national treatment groups that we have funded since
1972 is heart disease first and mental illness second.
So the research portfolio in mental illness is very brisk,
especially in psychoses, schizophrenia and bipolar disorder.
And that research portfolio spans the basics of schizophrenia,
the discovery that we have made, all the way through
implementation and assessment of, say, the schizophrenia
guidelines in routine clinical care.
Ms. Kaptur. I know that my time has expired here. I would
ask for the next round, if you could be thinking about the
number of neuropsychiatrists, the number of travel researchers
that you include on your peer review groups when you select and
when you determine and select research projects to fund or to
seek. At one point it was about 4 percent back in mid-1980s, I
would like to know whether that has gone up or not.
Dr. Feussner. Okay. I will get you that. The mental illness
research is reviewed exclusively by experts in psychiatry,
psychology, et cetera, so all the research, we have organized
in the peer review process is so that if you have a research
project on brain disease such as mental illness, that would go
to the panel of psychiatrists, psychologists, experts. If it is
on gut disease, it would go to gastroenterologists. So off the
top of my head, what I would say is that there are nine such
panels and about one-ninth of those would be in the area of
mental health, even though one-fifth of the research portfolio
is in the area of mental health.
Ms. Kaptur. Thank you. Thank you very much.
Mr. Walsh. Mr. Knollenberg, it is your turn, thank you for
your patience, and take the time you need.
bioartificial kidney
Mr. Knollenberg. Thank you, Mr. Chairman. Thank you very
much. Panel, welcome, Dr. Garthwaite and all. This is probably
the most intimidating group of people that we get in front of
us in terms of numbers and also in terms of maturity, and I
presume wisdom and some other things but we will stop there and
let you decide if that is totally true.
What I want to do, first of all, is thank you, Dr.
Garthwaite and Dr. Feussner, for your appearance in my office
regarding the matter of the bioartificial kidney and the
research that goes on there. And I know that you are well aware
of my interest in that, and certainly both of you have been
kind enough to come over and spend some time, and I think we
have ground out a framework here that we can proceed with. I
appreciate--your response came through just, I believe,
yesterday. So I think that is the kind of interaction that we
need to bring about some successes, hopefully, that we all want
to see happen.
And so I want to also thank Secretary West for his
involvement to bring it about. And hopefully we can bring this
to a closure that is successful for everybody.
allen park, mi, facility
Let me go to a couple of issues. These are local issues to
my district in Michigan. One is Allen Park, which is the
facility that has been vacated by the VA. And we brought this
question up and the other question has to do by the way with
the new center, the Dingell Center, I believe appropriately
named for the Dean of the House, in Detroit. But we have asked
for a study, I think, in last year's report language, I believe
there was a request for a comprehensive long-term study of
veterans and their needs, their care, in southeast Michigan.
Almost half the population of the State is kind of centered
in that southeastern corner. And the reason for the study was
to project current and future health care needs of veterans in
the Detroit metropolitan area.
It is my understanding, and you can correct me if I am
wrong, that the report has been completed by the VA officials.
The so-called VISN 11 report. And I would like to know, first,
are you prepared to submit this report at this time? Or is it
coming soon? What is the status of that?
Dr. Garthwaite. I think we have just received it. I did
peruse a final draft or near-final draft, and so it is very
short. The fundamental conclusion address this question if
there's a need for Allen Park and long-term care beds in Allen
Park? And I think the fundamental conclusion is that the study
did not demonstrate a need. So then the real question becomes
what to do with it. It reverts back to, I think, the Ford Land
Development Company.
Mr. Knollenberg. I have a couple of questions on that, too.
Relative to the new Dingell Center, there have been
conversations going on about how, if possible, that some of the
space of that center could be used by a private entity or a
separate entity. And maybe a good question would be, can you
even do that? Can you contract with, let's say, a university to
provide space within the Dingell Center? Is that possible?
Dr. Garthwaite. Yes, it certainly is. One of the creative
pieces of legislation the Congress gave to the VA many years
ago and even improved in the Millennium Act, is enhanced use
leasing authority. This allows us to take underutilized space
and work out contracts with private sector entities to develop
and use that space for mutual benefit. And we have good
examples of where we have done that.
Mr. Knollenberg. So it does work?
Dr. Garthwaite. Yes, the only thing I am aware of in the
Dingell building that might be competing is that we also have
an effort ongoing to try to collocate veterans benefit offices
in vacant VA space, colocations are another thing we are trying
to do to is utilize the space we have to the maximum benefit.
Mr. Knollenberg. Okay. Back to the point of the original
mandate, or gift made by Ford Motor back in, I think, the
1930s. In that deed that was made at that time, there was a
reverter clause which suggested that upon completion of use by
the VA, that Ford would be interested. My understanding is that
they are interested. Now, the dilemma, of course, comes up to
the point of what do you do with all of those great big
buildings that may or may not be made for anything that we can
deal with in the 21st century? And there is the implication of
cost.
I noticed in the budget that there is absolutely--we talked
about flat funding in the research end of it, but there is a
$31 million reduction in the construction end of it. So when it
comes to preparing that property for reversion to Ford, I don't
know where the discussions are, who is going to tear down or
what, but I would like some enlightenment on that.
Dr. Garthwaite. I don't know all the specifics. I know that
there have been at least some preliminary talks.
Ms. Bradley. Thank you. You are probably aware that there
is no common law right to simply abandon the property. There
have been discussions that have been ongoing since 1997 between
the Department of Veterans Affairs and Ford. It is not the Ford
family per se, but it is an organization called the Ford Motor
Land Development Company. And no formal proposals have been
exchanged. My understanding from my lawyers in Detroit is that
the Fords will not assent to the VA using the land for any
commercial purposes, nor will they be willing to pay for the
demolition costs or the environmental costs that will be
required in order to give the property back to the Ford family
in the event that we choose to use the reverter clause of the
deed. And you are right, the Fords conveyed this property to us
in 1937.
dingell building space
Mr. Knollenberg. By the way, just jumping around here a
little bit. What percentage of the Dingell building space is
nonutilized?
Dr. Garthwaite. We have two of the wards that are not
utilized. About 5 percent of the total space.
Mr. Knollenberg. Okay. Do you expect to utilize that in the
future for your own needs?
Dr. Garthwaite. I think it is adequate for current needs as
we envision the system based on current utilization and current
eligibility.
Mr. Knollenberg. There is a diminishing population of
veterans. I don't know what the matter would be or the number
would be in terms of veterans needing services. Presumably some
of those might be attracted from a region beyond the
southeastern Michigan area for treatment there. So it might
swell that number.
There are guidelines that govern the--when this projection
is made finally, there will be guidelines within that
projection, presumably that will telescope into the future as
to what your needs might be in the future along the line of
veterans services, and I presume that will come out in this
report; is that right?
Dr. Garthwaite. Yes.
Mr. Knollenberg. I know this report has been ordered. I
don't know what kind of a deadline.
Dr. Garthwaite. I believe at least a significant part of it
tries to project long-term care beds across the network for the
future, and compares both VA and community resources that might
be available for that.
medical errors
Mr. Knollenberg. Let me go to medical errors. I know that
you have been getting some press, not necessarily the greatest
press, when it comes to medical errors. A recent report
indicated that some 98,000 people--this is not just VA, this is
countrywide--die every year as a result of medical mistakes by
physicians, by pharmacists, by other medical personnel. I have
been told that more Americans die from medical mistakes than
die from cancer, highway accidents and AIDS. I don't know the
magic of that trio, but that begins to loom as a pretty large
number.
And like your counterparts in the private sector, the VA
hospitals are not immune from medical errors either, and the
study conducted back in 1997, and I think through 1998 in which
the VA staff was required to report any indication of a medical
error documents, nearly some 3,000 mistakes or 3,000 cases of
medical mistakes. I guess the most disturbing figure of that is
that 700 patients died while hospitalized or shortly
thereafter. That could be a mirror of what goes on in the
private sector. I don't know. You can respond to that but
before you do, what is apparently true also is that about a
third of those patients that were suffering from depression or
mental illness, and I know that was a subject that was just
brought up, committed suicide. That too may mirror the private
sector, I don't know.
But in terms of the Gulf War syndrome, and in terms of the
posttraumatic stress syndrome so-called of the Vietnam era, I
am wondering if any of those patients committed suicide or were
a part of those numbers that come from those two categories. If
you could respond to that as well.
Dr. Garthwaite. Yes, if I could start way back at the
beginning and talk a little bit about medical errors and the
VA's response to medical errors.
patient safety
Mr. Knollenberg. I will say this. I think you did a good
job about being forthcoming. And that is appreciated. My
understanding is that was something that you opened the door
to, so I would applaud you for that.
Dr. Garthwaite. Right. Right. We recognized in 1997 that
there was a problem, whereas in much of American medicine woke
up later when the Institute of Medicine released its report
last December. In 1997, we began a very aggressive initiative,
which included formation of the National Patient Safety
Partnership, (with other large health care organizations)
establishment of a center for patient safety within the VA
which reports directly to the Under Secretary for Health,
establishment of centers of inquiry for patient safety, and the
institution of a reporting mechanism that is mandatory. The
reporting system is one which we did not really have a lot of
experience with, and which is the subject of the medical
inspector's report.
Based on the medical inspector's report, we did some
additional things such that now we believe we have a much
better reporting system, including root cause analysis of the
problems. This system is being piloted in 8 networks in Florida
and 22 in Southern California.
Just a comment on the medical inspector review of the first
approximately 3,000 adverse events. These were not defined as
medical mistakes; these were defined as adverse events. By
``adverse event,'' we meant things that we felt were not part
of the predicted outcome in relationship to a hospitalization
or the time immediately following a hospitalization.
With today's knowledge, suicide within 30 days of
hospitalization is not known to be preventable in all cases. We
felt, however, that we ought to be looking to see if there were
things that we could learn from the fact that someone has
committed suicide shortly after a hospitalization or could we
get better at predicting who was going to commit suicide, and
therefore intervene in a different way. In fact, we have
learned that if you are single, you have recently had a
diagnosis such as cancer, and you own a handgun, you are much
more likely to commit suicide than someone who does not have
those characteristics. That allows us to look for those
characteristics and also allows us the opportunity to intervene
and hopefully prevent the problem.
In addition, a number of those deaths and adverse events
were falls, and today when you operate 130 nursing homes and
are the largest integrated health care system in the world, you
are not likely to get all the sick people in beds and keep them
from falling unless you tie them in bed, which we also cannot
do. So I don't think that we can eliminate all falls, but I do
believe that if we think about it not as something that we are
stuck with but rather that there are new technologies, new
opportunities to assist. We could think more systematically,
have you engineered beds properly? Have you engineered
guardrails properly? Are we staffed appropriately? All of those
sorts of things are questions that we ought to be asking, and
we think we should.
Overall, the issue of patient safety is, as you have
suggested, not a good story for American medicine. But the good
news is we have recognized it and the VA recognized it several
years in advance, and we are hard at work at trying to fix the
problems. And almost all of the problems are system problems.
People do not get up in the morning going in to work to harm a
patient. They go in trying to do the right thing. But I think
what we have done, we have been guilty of thinking that human
beings will become perfect if we train them hard enough. And
the reality is, all of us are going to make a few mistakes, so
we need to accept that and try to engineer systems that
compensate for the fact that people are in them and people are
imperfect.
And so we either eliminate the mistake, like we are doing
with bar coding in medication administration, or at least
minimize any impact it would have.
Mr. Knollenberg. Let me just ask, does an employee come
under any criticism for reporting an adverse event?
Dr. Garthwaite. In our system, they should not.
Mr. Knollenberg. Do they?
Dr. Garthwaite. Have they in the past? In most systems they
might. We have worked very hard at changing that culture. I
think that is an important aspect of this. If you turn yourself
in, how are you treated? Are you treated fairly? Are you
admired for improving the system so that the next person is not
still in jeopardy?
There was a plane crash west of here where all the United
pilots knew that there were some altitude issues which they
told each other. But there was a mandatory punishment if they
violated altitudes, so they did not tell the FAA and another
airliner crashed. That sort of thing.
Mr. Knollenberg. And I know our time is running out, Mr.
Chairman. I do want to get back to the Gulf War syndrome, and
also the posttraumatic stress syndrome. Among these fatalities,
and if you don't know, now you can submit that obviously in
writing, but I would like to actually ask for some reassurance
from you, Dr. Garthwaite that you will respond to those
questions relative to Allen Park to the Dingell facility, to
how quickly--and also the request in the report language of
last year's bill relative to the projection for the
southeastern part of Michigan as to what can we expect.
Quickly on the Gulf War Syndrome.
Dr. Garthwaite. We will have to get you the breakout by
specific diagnosis if we can do that easily. Overall, veterans
commit suicide at a slightly lower rate than the general
population. But we are very interested specifically which
veterans, which diagnoses and how to intervene to prevent all
suicides.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Knollenberg. If you would respond with that, I would
appreciate it.
[Recess.]
capital asset planning
Mr. Frelinghuysen [presiding]. I think we might as well
begin. When Mr. Goode comes in, we will recognize him. I know
we are going to have a full day, so we might as well keep the
machinery moving here.
I suppose this question goes to Dr. Garthwaite. Today,
before the VA Health Subcommittee, the GAO testified during a
hearing on the VA capital asset planning, and released at that
time new information to last year's GAO report that pointed out
that the VA is wasting a million dollars a day on underutilized
buildings. And I note from that report last year, and I quote
from page 7 of the March 1999 report, ``The VHA uses fewer than
1,200 buildings, one-fourth of their overall buildings,'' which
I believe are 4,700, ``to deliver health care services to
veterans. The rest are used primarily to support health care
activities, although many have tenants or are vacant. Of note,
the VA has over 5 million square feet of vacant space which can
cost as much as $35 million a year to maintain.''
I assume those figures are out there. No one would argue
that those figures are there. The findings that the GAO
presented to the committee this morning show that despite the
passage of a year, the VA has been unable to design a capital
realignment plan. And further that, in their own words,
``Senior managers,'' quote, unquote, ``have not been proactive
enough in the process, delegating in many instances work to
stakeholders and others that, at least in the case of the
Chicago hospitals,'' which I guess is one of those, situations
which you have been wrestling with for some time, ``has led to
delays and sent the process back to the drawing board.''
Dr. Garthwaite, what role have you taken in developing the
VA's capital asset management plan? And have you worked with
Secretary West on developing a framework that you can share
with the committee?
Dr. Garthwaite. The data that you point out that we have
too many buildings we do not argue with, and we do believe that
we have been working at getting a policy that can be acceptable
to both veterans who look to VA to be there when they need
them, and the symbolism is often the building that the VA has
built as a part of that symbolism, that can get them
comfortable; and our other stakeholders such as academic
affiliations and others comfortable with how we realign our
assets to maximally and efficiently care for veterans.
Specifically what I have done is to meet with Secretary
West, and he has significant concerns about the process under
which we use to make these assessments. We have a draft policy
that we sought input from stakeholders on. That is now back and
should be available very shortly. We will have to get that
approved by the Secretary, but we have had significant amount
of input, and I think it is a much improved document.
Simultaneous to that, we are writing the statement of work
for contracts under this provision so that as we get the policy
approved by the Department, we will simultaneously be able to
let contracts to do the first 10 analyses of 10 geographic
markets identified by the General Accounting Office as having
perhaps excess infrastructure, but at least having several
facilities in a small geographic area.
Specifically about Chicago, I think the Chicago process has
been too long and it has been something that we have used in
part as a learning experience. We have taken several messages
away from that experience. The first message is that not all
contractors are the same. When we contracted in northern
California, we did not rebuild Martinez and put in a northern
California system of clinics. The data we got was very helpful
in making a decision. We had hoped to have that same experience
be repeated in Chicago, but we are disappointed that we had a
lot of trouble early on getting the data generated from the
contract.
That required us to bring in some additional VA folks to
oversee the process and to help work on that data. And I think
that----
status of study on capital assets
Mr. Frelinghuysen. Aren't the VA folks involved in that
already?
Dr. Garthwaite. Yes, they were. But their role became much
more prominent when the data that they were getting presented
to them and analyzed from the contractor did not seem to come
fast enough or in meaningful enough manner.
So I think that was a significant delay. We did get a
proposal in the fall in which we then sent out for stakeholder
comment and got significantly more comments than probably we
would have anticipated. I think it was 4,000. Almost 5,000
letters. It took us a while to read, categorize, try to
understand and make sure that we utilized that input.
The committee, with some additional members to it, then
reconvened to consider those and to change any of the
recommendations of the original proposal for Chicago. And the
piece of paper that I got, or the report that I got about a
week and a half ago, I felt was not driven enough by data. And
I sent it back to make sure that the data was the first thing
you saw, not the vote of the members on the committee.
I don't think this is really an opinion issue, although
expert opinions will be important. I do think this has to be
driven by data that is important to patients.
As a way of example, the driving force for the northern
California study was the driving time and distance for
veterans. There was an analysis done looking at the veteran
population where they lived and the possible alternative
solutions that were seen that absolutely made any other
conclusion than the one we did very hard to make. And it was
data driven and it was veteran-related, and convenience-related
and it really drove the decision. And I think in the Chicago
study, we got away from that, or the committee evolved itself
away from that. I think they did the analysis in the beginning
but then did not use data-driven criteria to make their final
recommendations to analyze each option that way. So it may be
there.
Mr. Frelinghuysen. So to answer my question, you have
learned some specific lessons from Chicago process, one of
those being that accurate data is absolutely essential?
Dr. Garthwaite. I think it is that the committee must be
charged with and all the future committees must be charged with
very accurate criteria that is data driven for which to assess
the various options. I talked to the GAO about their testimony
the day before yesterday and I think we are in complete
agreement. They believe the same thing. I am not saying that
this group did not use the criteria, but it is not evident in
their report in how they selected the options, which is the
difference. They did seek the data.
Mr. Frelinghuysen. Page 2 from the April 5th--that is
today--report, to a layperson is pretty damning. ``Our
assessment of the VA's process as currently designed raises
concerns about whether the right people are involved at the
right times in the right ways. Specifically, senior managers at
headquarters may not be proactively involved in the leadership
role at key decision points.''
And I assume that this is the situation that you will be
working to rectify since you appear to be in agreement with
most of the GAO's conclusions?
Dr. Garthwaite. I am very much in agreement with that.
Where this should lie and how it should be done, I think, can
be debated and we should get on with that and get it done and
make sure that someone is pushing to make the right decisions.
Mr. Frelinghuysen. We are hoping that you will be one of
those people. Mr. Goode, thank you for your patience.
adult day care
Mr. Goode. I have got a question about adult day care. How
many of your hospitals have outside adult day care? Like I am
in a rural area, and persons in the center of my district, they
are either going to go to Richmond, Virginia; Durham, North
Carolina; or Salem, Virginia. Nationwide, how many of your
hospitals have contracts with outlying communities to provide
adult day care? Many or very few? You do not have to give me--
--
Dr. Garthwaite. 83 VA medical centers have contracts for
adult day care and 14 VA medical centers operate in-house
programs.
Mr. Goode. Okay. Maguire at Richmond, do they do any in-
house?
Dr. Garthwaite. I don't know specifically. We can easily
find out.
Mr. Goode. And 83 have--you contract with outside entities?
Dr. Garthwaite. Correct.
standards for purple heart
Mr. Goode. All right. Let me ask you, or maybe this would
not be you, doctor, can somebody just--anyone with the VA
familiar with the standards for Purple Heart? I am not sure
that you would be the right ones to ask.
Dr. Garthwaite. I don't know if anyone wants to take that
on. I don't know.
Mr. Goode. I know you have to be wounded, but my question
is if you had a morning report saying that you were wounded,
but it was not on the DD-214.
Dr. Garthwaite. That is determined in the Department of
Defense, so I don't know.
service connected veterans
Mr. Goode. To jump to another thing, on service connected
veterans, if you gave every service connected veteran a
Medicaid card and just let them be in Medicaid, I am not saying
that all would like it, but some might like it better than
going to a VA hospital because of length. Would that be
cheaper?
Dr. Garthwaite. It is a very difficult study to do. I know
previous administrations have tried to study whether or not
vouchering out health care for veterans would be economically
feasible, having concluded it would not.
I think the thing that I always say to people who raise
that as an issue is that it would be relatively easy to voucher
out certain things. Cataract surgery, general internal medicine
for noncomplex conditions, hip replacements, knee replacements.
The kind of things that there is a fair amount of profit,
relatively simple to treat, and where there is a lot of
capacity in the private sector.
The line of people would be short to treat our patients
with AIDS, and having 25 percent of our patients having
hepatitis or a significant number of our patients having
hepatitis C, or treating people with mental illness.
aids treatment
Mr. Goode. What number of veterans treated by the VA
percentagewise are AIDS patients? What percentage?
Dr. Garthwaite. I don't know. I know we are the largest
provider of care to patients with HIV, but I don't know the
percentage.
Mr. Goode. I mean, just you do not even have a ballpark on
it? You are going to use that as an argument against a
voucher----
Dr. Garthwaite. I am just saying the alternative. To try to
find alternative sources for that health care would be
difficult. In other words, if you just gave them a voucher and
said go find the same quality of care, the same coordination of
care in the private sector for this amount of money that is
included in your voucher. Are there systems out there designed
and able to deliver that same kind of service? I think it would
be difficult. We have treated 46,000 patients so far with HIV.
Mr. Goode. Okay. Over what period of time?
Dr. Garthwaite. I think that is since the epidemic began,
essentially.
Mr. Goode. How many did you treat last year.
Dr. Garthwaite. 18,000.
Mr. Goode. 18,000 in 1999? And how many patients did you
say treat totally? You probably have got it right there.
Dr. Garthwaite. Total number of patients in 1999, 3.6
million.
Mr. Goode. You treated 3.6 million and 18,000 of them with
AIDS. That is not a big percentage. Look at your numbers. Is
that correct? You treated 3.6 million different persons even on
an inpatient or an outpatient basis just to see the doctor in
the VA system, and 18,000 of 3.6 million had AIDS. That does
not sound right to me. Is that what your figures show?
Dr. Garthwaite. Yes.
Mr. Goode. That is a very small percentage.
Dr. Garthwaite. A percentage for other illnesses for which
there is not excess capacity in the private sector are things
like mental illness. It is one thing to say we will give
general medical care for this voucher, but it is another thing
to say what is the cost of a voucher for someone who has been
hospitalized for schizophrenia for 5 years or requires long-
term care, aggressive care, or treatments for homeless. Where
do you find spinal cord injury units of the quality and makeup
of the VA?
We have done a study, had a contractor do a study and
looked for private sector equivalent.
spinal cord injury units
Mr. Goode. Where are your spinal cord units now in the
United States? Where are yours now? How many spinal cord units
do you have? You do not have a whole lot.
Dr. Garthwaite. We have 23 Spinal Cord Injury Centers.
Mr. Goode. If I had Medicaid and I could go to the
University of Virginia versus a VA, I think I would take the
University of VA, not disparaging the VA system.
Dr. Garthwaite. For spinal cord injury? It may be, but the
Paralyzed Veterans of America believe that there are few places
where you can get equivalent care, but by and large, you cannot
find that equivalent care around the United States that offers
the same services. I refer you to the patients on those.
Mr. Goode. Because, I mean, I have got constituents that
say both things. I have some constituents that like very much
their treatment at the Salem VA hospital, but then I have
others that tell me I would rather just be able to go anywhere
I wanted to and just know that it was covered. I am going over
to VA because the medicine is free or very cheap. And I am
going to the VA because the doctor is free. You know, that is
what a lot of them say. But I know they are not all one way or
the other on it. But I would have thought you would have had
more AIDS patients than 18,000 if that is----
Dr. Garthwaite. Treated in the last year. Yes.
Mr. Goode. That is all I have, Mr. Chairman.
veteran population
Mr. Walsh [presiding]. A couple of general questions, Mr.
Duffy, could you tell me generally or exactly how many veterans
there are now in the country? I think you are the right person
to address that question to.
Mr. Duffy. At the present time there are just over 24
million veterans who qualify in some way or another for VA
services.
Mr. Walsh. And how many new veterans come on every year?
Mr. Duffy. If you would bear with me a moment, I can give
you that number.
Mr. Walsh. Sure.
Mr. Duffy. There are approximately 200,000 to 210,000
separations per annum from military service.
Mr. Walsh. And how many veterans do we lose a year?
Mr. Duffy. At the present time the rate is about 574,000
per annum. That will increase to 618,000 per annum by the year
2010.
Mr. Walsh. Do you have a projection for how many veterans
will be in the system in that year?
Mr. Duffy. I do.
Mr. Walsh. We could do the math, I am sure.
Mr. Duffy. I have got it here if you will just bear with me
a moment.
Mr. Walsh. Sure. This is 10 years out.
Mr. Duffy. 10 and 20 years out.
Mr. Walsh. Assuming, hopefully, no major conflict.
Mr. Duffy. Yes. In 1990, we had 27.32 million veterans.
This year 2000 the estimate is 24.4 million. 2010, the
projection is 20 million. 2020, the projection is 16.159
million.
medical research funding
Mr. Walsh. Thank you. Okay. Back to research for a minute.
I know Mr. Mollohan addressed this, but I wanted to delve a
little bit more deeply. Last year the Congress provided a $5
million increase for the research account. This year, there is
no increase in the budget request. Other research accounts in
our bills like NASA, NSF and EPA all have increases requested.
Why did the VA research not also seek an increase?
Dr. Feussner?
Dr. Feussner. I think that to elaborate on the question
that Congressman Mollohan had asked earlier, the VA research
sought an increase in the appropriation, but I think the
competing priorities of patient care, et cetera, overwhelmed
the research request.
Mr. Walsh. What was the request for?
Dr. Feussner. The request was to go from a budget of $321
million, which is current, to approximately $397 million, which
is about a $76 million increase. We estimated that about $11
million of that is current services dollars. So that would have
resulted in $65 million of new money, which is the figure that
the Secretary quoted in the last hearing.
Mr. Walsh. So that $397 million was it?
Dr. Feussner. Yes, sir.
Mr. Walsh. Where did that number appear in this process of
budget making?
Dr. Feussner. The number appeared in the research budget
request that went to VHA, and then left VHA and went to the
Secretary's office. And left the Secretary's office to go to
Office of Management and Budget intact.
Mr. Walsh. All right. So when it left the Secretary's
office it was still at $397 million?
Dr. Feussner. Yes, sir, that is correct.
Mr. Walsh. And when OMB submitted, after consultation with
you, the budget request, it was $321 million?
Mr. Catlett?
Mr. Catlett. Mr. Chairman, the decision about the research
level is a VA decision, not an OMB decision. They gave us the
target for total discretion any funding.
Mr. Walsh. OMB does impact on some of these budgetary
decisions.
Mr. Catlett. Yes, sir, that changes year to year. This year
in this budget we had no direction specifically to reduce
research. VA was given a total amount money and having to make
those priorities and decisions about how we spread the money.
Mr. Walsh. Did they suggest to you this might be a place to
look to find those funds?
Mr. Catlett. I don't recall that this year. Generally, the
OMB's attitude has been that the research focus at the VA
should be subsumed within the broader government efforts. But
there was no direct reference to that in this budget cycle as I
recall.
Mr. Walsh. Well, when the President's request came in for
$1.355 billion increase for VA medical care, did they suggest
line items?
But did they suggest a specific number for research?
Mr. Catlett. No, sir, they did not.
Mr. Walsh. So even though when the Secretary sent it over
with $397 million level, he got the sense that that was not a
realistic number from OMB?
Mr. Catlett. The amount that we received in total was
obviously less than we had requested across the board. The
decision was made to focus on direct health care, on
improvement of benefits delivery, and on expanding the efforts
in the cemetery operations. So it was a decision that we focus
primarily on direct benefits delivered across the system versus
research. So research was secondary to that in our decision-
making.
medical care omb request
Mr. Walsh. Let me ask you, what was the request for medical
care? From the Secretary going over to OMB? Do you know?
Mr. Catlett. It was approximately a billion dollars more,
and we will provide that for the record, but a billion more
than we requested.
Mr. Walsh. So you requested $2.3 billion?
Mr. Catlett. Actually more than that, but I will provide
that for the record.
[The information follows:]
Medical Care OMB Request for 2001
The Department requested $21,184,613,000 for the Medical
Care account, an increase of $2.3 billion above the 2000
enacted level.
medical research funding
Mr. Walsh. So while we are talking about a flat line
budget, in effect, the way you deal with research is to reduce
FTEs because otherwise they would--those positions would
absorb--in order to maintain the level of research, you had to
cut people. Is that, in effect, what you are saying?
Dr. Feussner. No, sir. The way we have dealt with the
current year budget in 2000 is that we reduced across the board
the funding level for all projects by 5 percent. And in that
way, accommodated this current year budget. What we would do
next year, in developing plans now for the $321 million
appropriation, we will likely reduce the pay line drastically.
Mr. Walsh. Employees?
Dr. Feussner. I am sorry, I am sorry, the number of
investigators supported by our appropriation will diminish.
That does not necessarily translate into an FTE reduction. It
depends on whether those investigators get money from other
sources, get research money from other sources or do other
things such as clinical care.
Mr. Walsh. Okay. Do either Mr. Frelinghuysen or Mr. Goode
have additional questions they would like to ask in this round?
Mr. Frelinghuysen. Yes, I actually do, Mr. Chairman.
Mr. Walsh. Go ahead. We will let Mr. Frelinghuysen
conclude, then. Thank you.
adult day care regulations
Mr. Frelinghuysen. I understand that when our State opened
the Menlo Park Veterans Nursing Home last year, it included an
adult day care facility which would provide daily assistance to
at least 30 veterans. However, the State has informed me that
the day care facility cannot open until the VA finishes
developing the regulations for adult day care programs, a
process State officials tell me has been ongoing for 5 years.
For the record, when will the final regulations be issued
and why has the process taken so long? When I meet with
veterans they say they are going to go ahead and try to do this
themselves, but they need a sign-off from you. What is going
on? And I assume we are not the only State that has sort of a
panoply of services that would help veterans.
Dr. Garthwaite. You are talking about can we fund an adult
day care program and place it in the veterans nursing home?
Mr. Frelinghuysen. No, we have an adult day care facility
ready to go, but we need your blessing. There are some
regulations that you put out for adult day care programs that
relate to veterans.
Dr. Garthwaite. I really do not know what the hangup is,
but we will find that out and provide you a record quickly.
[The information follows:]
Adult Day Care Regulations
The State Adult Day Health Care proposed regulation was
approved by the Secretary and transmitted to Office of
Management and Budget (OMB) for approval on November 9, 1999.
OMB provided no feedback or approval related to these
regulations until late February 2000. VA requested written
comments and has not received them to date. VA General Counsel
has contacted OMB several times concerning the approval or
written comments related to the proposed regulations. On April
7, 2000, VA General Counsel received comments by telephone. On
that date VA provided the material that was requested. The
approval of the State Adult Day Health Care regulations is
pending OMB approval. VA is trying to resolve any concerns that
OMB may have about these regulations.
asset realignment process
Mr. Frelinghuysen. If you would, please. Several of the
concluding observations, and I would like your reaction to
them, to today's testimony from the GAO statement from Steven
P. Bachus, director of Veterans Affairs and military health
care issues, health education human services division, and I
quote, among his concluding observations: ``we are concerned
that the VHA's slow progress in establishing an asset
realignment process needlessly delays critical decisions and
the opportunity to reinvest resources to enhance veterans'
future care.''
And it goes on and I continue to quote the last paragraph,
``Because the VHA is struggling to reach a sound realignment
decision in Chicago and complete the design of a systemwide
realignment process, and because the VA's capital investment
board has a model that could address many of the VHA's
weaknesses, it seems appropriate the VA consider transferring
the asset plan responsibility to the board. The daily cost of
delayed decisions is unacceptably high.''
Would you react to that suggestion or proposal or
recommendation?
Dr. Garthwaite. I don't think that the delays are
necessarily in the planning areas. I think really the delays
all relate to the very challenging issue of moving care from
where it traditionally has been, the relationships we have with
our service organizations and their understanding of what that
means to their own personal care. Also, how far they would have
to travel, and the relationships to our affiliates who are
working hard with us to try to educate smarter health care
providers and do research. Those are where the real contentious
issues are. We are willing to look on any----
Mr. Frelinghuysen. We recognize that there are stakeholders
at the table, but the GAO is suggesting that perhaps there is a
state of semiparalysis here that could be moved forward by
embracing this model. And I just wondered whether that is
within the realm of possibility.
Dr. Garthwaite. Absolutely within the realm of possibility.
We will look at anything to help expedite it. I do think we are
making some progress.
Mr. Frelinghuysen. You made reference a few minutes ago
when I came back from a vote, Dr. Garthwaite, as to 10 analyses
that are moving ahead relative to regional capital assets.
Dr. Garthwaite. Right.
Mr. Frelinghuysen. Could you expand on that a little bit
and how much these analyses are going to cost?
Dr. Garthwaite. We anticipate to spend about $10 million
the first year to do the top eight to 10 regions identified by
the General Accounting Office as those in which we have a
significant number of assets per unit of geography. And we are
working on a statement of work, a criteria-based statement of
work that we would anticipate letting the contract by July, I
believe.
status of last year's cno memo
Mr. Frelinghuysen. Two other areas. I know Mr. Clark is
here, the chief network director. Last year, there was a memo
attributed to you and I am not quite sure whatever happened to
the Clark memo and some of the recommendations that discussed
the potential closure of VA hospitals. Obviously, I assume this
is part and parcel of the whole issue of asset realignment.
Where do we stand would you say relative to your memo, is it
still out there or has it been somewhat legitimized by the new
push for asset realignment?
Mr. Kenneth Clark. I hesitate to say it has legitimized. It
has certainly been overtaken by events. The memo that you are
referring to was really a precursor in some ways to the CARES
program initiative. It raised the question of what criteria we
use to make decisions about realigning our assets and that
really is at the core of the CARES initiative. It is a process
that would lead us to some intelligent decisions about what
assets we need, which assets we no longer need and what will we
do with the ones that we no longer need.
So to answer your question specifically, no, that memo is
no longer in effect. It has been taken over by the CARES
initiative.
access to care
Mr. Frelinghuysen. Thank you. Lastly, an issue that relates
to access to care. After last year's hearing some 450,000
veterans nationally received letters in the mail telling them
that they might no longer be eligible to receive treatment at
VA medical centers after September 30th of last year. The
veterans were enrolled with the VA but were considered to be
priority 7, or category C veterans who have no service-
connected disability and who had an annual income over $9,000.
Some of these veterans have been receiving their medical care
from VA hospitals, as you are aware, for over a decade. As a
result, I did add language to last year's report preventing you
from denying these veterans access to care at VA medical
facilities.
Is the VA planning on sending out any similar letters this
year?
Dr. Garthwaite. The initial letter we sent out, although
technically correct in terms of eligibility reform legislation,
contained the language that was too alarming compared to
reality, and so the new mailings have all had a much different
letter and an information packet explaining it, I think, in a
much better way. And we have not heard any feedback in a
negative way on those. Mr. Clark has signed these letters as
well.
Mr. Frelinghuysen. Are you the prophet of doom?
Dr. Garthwaite. I think he just--ended up signing them and
ended up getting all the responses back from people who were
concerned. And in retrospect, I think the original language did
confuse veterans, and I think we made a concerted effort to
make it a little more clear, and we haven't heard the negative
feedback this year.
Mr. Frelinghuysen. Thank you very much, Mr. Chairman.
Mr. Walsh. You are welcome. We anticipated concluding at
12:30. Ms. Kaptur has returned, I assume you would like to ask
some more questions.
Ms. Kaptur. I have one more round.
Mr. Walsh. I have a 12:30 appointment. I would like to ask
if either Mr. Frelinghuysen or Mr. Goode could sit in for the
next 10 minutes. Ms. Kaptur you can proceed. Thank you very
much for this morning.
seriously mentally ill
Ms. Kaptur. Thank you, Mr. Chairman. Could I ask you, Dr.
Garthwaite, in the six volumes you have presented for your 2000
budget submission, where are the MIRECCs, Mental Illness
Research Education Centers? What page is that on, please?
Dr. Garthwaite. They are included in the medical care
appropriation overall. We take that money off the top and fund
the MIRECCs specifically, so that is part of our administrative
funding. It would----
Ms. Kaptur. So it is not separately broken out?
Dr. Garthwaite. I don't think so.
Ms. Kaptur. Could I ask you this Dr. Lehmann that you
mentioned, how long has that position existed? Mental
behavioral health specialist or associate chief?
Dr. Garthwaite. Or equivalent. A long time. Dr. Errera
occupied that position for many years.
Ms. Kaptur. Does this person have responsibility for
overall coordination? Because I will tell you next year--
frankly, actually, I would like it for 2001. I would like you
to give me the budget of the VA for the seriously mentally ill
and those with psychiatric disorders and present it in a way
that is not disorganized. Is that possible?
Dr. Garthwaite. Sure. I hope so. We will do that.
Ms. Kaptur. And I would hope that in the letter that I
received from your department, which I appreciate, it tends to
be a letter that lists the law that was passed and quotes from
the law, and then says how much money has been apportioned to
that account. I would hope that when this is submitted, one
could have a more policy-oriented focus to the way in which the
dollars and the responsibilities are respondent so that we
could see that it has been internalized within the agency and
there is actually a mission in this area.
I am having trouble deciphering that from the materials
that were sent to me and also the six volumes that have been
sent to the committee. And we would be happy to respond to what
is sent to us, and it would be very helpful in looking at the
treatment, at the research, in trying to understand where this
is in terms of total dollars and total need.
It is almost impossible--it is impossible to decipher from
what has been submitted to us thus far.
homeless programs
I want to ask another question. Hopefully--who in VA
coordinates all the homeless programs? The medical side as well
as the benefits and all agency services in this area, does that
have a chief coordinator?
Dr. Garthwaite. There is both a VHA point person and a
departmental homeless veteran advocate. Go ahead.
Mr. Hanson. Ms. Kaptur, the departmental coordinator is
Pete Dougherty, who works in the Office of Intergovernmental
Affairs. He has a staff of three. And he works with VHA to
coordinate. Pete's office coordinates the presentation or the
disbursement of the homeless grants per diem programs that we
have every year and we are in the middle of that round for this
year.
va medical facilities
Ms. Kaptur. All right. Thank you very much. Dr. Garthwaite,
let me ask you a question. Just state for the record again, how
many hospitals there are within the VA system, how many
outpatient clinics there are, and for the outpatient clinics, I
understand they can have an A, B, or C affiliation with a
hospital. I want to understand the structure you are operating
under now. I know there have been several reorganizations at VA
over the last several years, and what does one have to do to be
a class A affiliate of one of these hospitals a class B or
class C. What are the determining features of this?
Dr. Garthwaite. We have 172 medical centers, which are
sites that have two major missions. We have 134 nursing homes.
We have, let's take the year 2000, 596 community-based
outpatient clinics; 162 hospital clinics; four mobile clinics.
Ms. Kaptur. When you say ``hospital clinics,'' are those a
part of the medical centers?
Dr. Garthwaite. Right. They would be at a medical center.
Four mobile clinics and four independent outpatient clinics
that are just clinics. They are fairly larger operations that
are just clinics.
relationships of clinics to medical centers
Ms. Kaptur. Now do all of those clinics or outpatient
facilities have a relationship to a hospital?
Dr. Garthwaite. 162 are actually in the hospital. All the
others would have some relationship. They would have a base
hospital, yes. Right.
Ms. Kaptur. Now, what types of relationships do they have?
How do you decide which hospital which clinic belongs to if
they belong to any?
Dr. Garthwaite. Our clinics all, except for the independent
ones, would have that relationship----
Ms. Kaptur. Are those the four?
Dr. Garthwaite. That is the distinction. They are
independent. The others, mostly because they were started at
the impetus of the administration and leadership and funding of
the base medical center. Give you an example. I was chief of
staff in Milwaukee, we realized in the Fox River Valley, which
is near Appleton, Fond du Lac, Oshkosh, that there was no
available care for veterans in that area other than drive down
to Milwaukee. Or you could, I suppose, go north to Iron
Mountain, Michigan. We established a clinic, a Fox Valley
clinic. It was established out of the budget of Milwaukee VA by
internal mechanisms, and the budgeting was through the
Milwaukee VA and most of the referral mechanisms for tertiary
care and specialty care was through the Milwaukee VA.
Ms. Kaptur. The clinics that exist, do they all have the
same type of relationship to the medical centers?
Dr. Garthwaite. To my knowledge, most have very similar
mechanisms.
Ms. Kaptur. This thing I am talking about, A, B, C, that
does not exist? A clinic would not have a type A relationship
or type B?
Dr. Garthwaite. I am not familiar with that terminology
myself. That is not something I have used or that I am aware
of. They all report, and their data systems also are integrated
together with a parent facility referral mechanisms. A lot of
times they share the same human resources, the same
administrative oversight, quality management is shared between
them. Those sort of things.
Ms. Kaptur. Does any clinic have a relationship with more
than one hospital?
Dr. Garthwaite. Not that I am aware of, nor is Mr. Clark.
There are other relationships in terms of academic affiliations
that may have something to do with this kind of----
Ms. Kaptur. Would someone else want to comment on that
please?
Mr. Kenneth Clark. I know that historically we did have
what we referred to as A and B affiliation agreements. But that
is not in the context that you are describing. That has nothing
to do with the relationship of our clinics to the host medical
centers. But it sounds like the terminology you are referring
to is old terminology with regard to academic affiliations.
academic affiliations
Ms. Kaptur. These 172 medical centers, do they all have
academic affiliations or do some stand on their own?
Mr. Kenneth Clark. Not all of them. Most of them would have
some sort of affiliation or another. 125 VA medical facilities
are affiliated with medical schools.
Ms. Kaptur. What are the rest? Freestanding?
Mr. Kenneth Clark. Well, they may have affiliation
agreements with other than medical schools. Nursing schools or
universities of a variety of sorts, so there would be different
kinds of affiliation agreements. Most of our hospitals (medical
centers) in one way or another have some affiliation but not
all. But again that is not related to the relationship between
a clinic and a host medical center.
Ms. Kaptur. How do you decide which medical centers can
become a part of your academic affiliations?
Mr. Kenneth Clark. A medical center that wishes to initiate
an affiliation arrangement would submit that to headquarters
for review.
Ms. Kaptur. All right. And is there an application they
have to fill out?
Mr. Kenneth Clark. I don't know--it is not my immediate
area. I am not aware of the precise procedures but yes, there
is a format for an affiliation agreement.
Ms. Kaptur. Doctor, you mentioned in Fox Valley, and you
had worked in Milwaukee, and so the clinic was in the same
State as the hospital that the center it was affiliated with.
How many clinics do you have around the country that are not
located in the State in which the medical center or the
university-affiliated hospital is located? Out of the 596
outpatient clinics that you manage?
Dr. Garthwaite. I am not sure we have ever done that count.
There are a fair number of situations where there are border
issues where the closest VA facility and the closest medical
school lies across a State boundary. And when we set up the
network structure, we tried to follow the natural way veterans
tended to go for their care to make it maximally convenient for
them. That was the driving force, where they had actually
traveled previously.
Ms. Kaptur. Of the medical school affiliations, the 125
that you do have, how many of them are recent as opposed to
historic, existing for over 20 years?
Dr. Garthwaite. Most of them are long-term. Medical schools
have been around a while, and most of the VA affiliation
agreements started in 1947, so many of them go back. We have
added some in the last 20, 30 years, but many of them are
historic.
Ms. Kaptur. Doctor, I would really appreciate a listing
from the VA of the medical school affiliations and the year in
which those were established and the locations of those.
Dr. Garthwaite. Be happy to do that, sure.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Kaptur. I would also appreciate a list of outpatient
clinics that exist in our country that are affiliated with
institutions that are not within the same State as those
outpatient clinics exist in.
Dr. Garthwaite. We can do that easily.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
residency and training programs
Ms. Kaptur. Finally, for the record, could you provide--and
this will be my last question--historically, has the VA ever
been involved in a physician or nurse's training and residency
program that provided a way for American citizens to gain their
educations as well as serve the VA, and what were the nature of
those programs and what exists today with regard to that? And I
want you to talk to us in the answer a little bit about how
many people were accommodated, what were the terms of those
educational programs, what has happened over the years?
I am very interested in how the VA--at one point, probably
20 years ago, the VA had been responsible for residencies for
over half the physicians in this country. I don't know what is
true with nurses, whether there were residency or some type of
training programs within the VA but I am very interested in
that. And what kind of information you could give us
historically what the VA has done to help on the medical
education side of the equation, and what the costs of those
were and how many sort of input, output, how many people were
assisted, how many people ended up going into the health
professions.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Kaptur. And then currently, does the VA have any type
of relationship that exists in the country or relationships
where there are shared personnel, let's say, at the local level
between these medical centers, their nursing personnel, for
example, in hospice or your nursing homes that you run where
nurses are shared. Are there any types of sharing agreements
that exist out in the country today?
I would be very interested in understanding what those
might look like, and if that is something the VA is embarking
upon in trying to satisfy its own needs for personnel as well
as sharing the people it has trained with broader community
health needs.
[The information follows:]
Shared Personnel
Enhanced Sharing legislation does not permit shared
staffing with the private sector. Department of Veterans
Affairs and Department of Defense have twelve shared staffing
agreements involving physicians and nurses at nine sites. The
sites are Columbia, South Carolina; Albuquerque, New Mexico;
Anchorage, Alaska; Honolulu, Hawaii; Northern California
(including Travis Air Force Base); Miami, Florida, Richmond,
Virginia; Dublin, Georgia; and, Cheyenne, Wyoming.
treatment of non-veterans
Ms. Kaptur. Finally, are you aware of the authorizing
committee doing anything relative to the treatment of
nonveterans at veterans facilities, either outpatient clinics
in urban or rural areas or the medical centers or universities
associated with the VA? I understand there is some change of
thinking at the authorizing committee level. Could you share
with us now or in writing what that change of thinking might
be?
Dr. Garthwaite. The only thing I am aware of, off the top
of my head, is that during the debate over last year and the
Millennium Act, there was a provision, I think, pressed by
American Legion, which would pilot families of veterans being
able to buy in to the VA health care system and utilize the
system. They would have to pay either an insurance premium or
bring other insurance, but there was at The GI bill of rights,
I think they call it. The legion has pushed this and there was
some provision for a pilot program in the Millennium Act that
did not make it through, I believe.
family lodging on campus of state nursing homes
Ms. Kaptur. I thank my colleagues for allowing me to ask
these questions. I thank the Chairman very much. And also I
would just say in ending for the State programs, and several of
our members asked about those, if you have examples in the
country of where State nursing home programs are allowing
spouses to reside on that campus where the husband or the wife
might be elderly and incapacitated, I would very much
appreciate knowing where those are. It is something I am quite
interested in and I have not been able to find examples within
the VA system of that occurring.
Mr. Hansen. We will find that out for you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Kaptur. Thank you all for being here today, and I thank
my colleagues again for their indulgence.
closing comments on medical programs
Mr. Frelinghuysen [presiding]. Thank you, Ms. Kaptur. In
wrapping up hours late, a lot of Ms. Kaptur's questions
relating to psychiatry, psychiatric help and mental illness, I
think we need to get a clearer picture of exactly what you are
doing. We obviously have inpatient, outpatient, we have medical
research, but somebody ought to have a handle on the
homelessness issue, and I am not sure that question was
adequately responded to. I assume that with our various
outreach centers and clinics, that there is some sort of
psychiatric component.
This is not all done within a hospital setting. I think we
need to get a clearer picture as to exactly what we are doing.
And whether in fact we have social workers that are actively
involved and prepared and whether we do things relative to job
referrals. I am not familiar with the per diem program, but in
reality, I assume there is a degree of comprehensiveness, or
maybe I am just wishing it exists.
Dr. Garthwaite. Most of the deficit is in my ability to
explain it, sir.
Mr. Frelinghuysen. For the record, I would like a copy of
whatever you may have sent the committee. I would like to see
the veterans relative to their eligibility and access issues
that you referred to earlier.
ig investigation on bocchino death
And lastly, to the Inspector General, it has been 2 years,
almost, since you and others began investigating the Bocchino
death at Lyons. I am not going to put you on the spot other
than this. But we need to reach some sort of a conclusion. I
have read all of the materials over. It seems that we are more
interested in due process for the living than we are due
process for this veteran who died. And I do not know where we
stand on that, but if you would provide the committee with an
update on that and we need to bring this to some sort of a
satisfactory conclusion sooner rather than later.
[The information follows:]
VAMC Lyons
The Office of Inspector General (OIG) final report was
issued June 4, 1999. The report identified several material
weaknesses related to patient supervision and accounting for
patients' whereabouts. The report also addressed concerns
regarding findings and related personnel actions resulting from
a VHA Administrative Board of Investigation into the
circumstances surrounding the death of Mr. Bocchino. Because
the VHA VISN 3 Director did not concur with several of the
OIG's recommendations, the report was issued to the Under
Secretary for Health for resolution. To address the disputed
issues, on June 28, 1999, the Under Secretary for Health asked
a review team, led by the VHA Office of Medical Inspector (OMI)
to review the OIG report. The OMI report, dated August 5, 1999,
generally agreed with the OIG. In a September 20, 1999 letter
to the Inspector General, the Acting Under Secretary for Health
stated that they had reached an agreement to concur in the OIG
report recommendations. For the next several months, VHA worked
to develop acceptable implementation plans for agreed upon
recommendations. The OIG received a final status report from
VHA, dated April 7, 2000, which outlines actions taken by the
VISN 3 Director and the New Jersey Healthcare System Director
to complete implementation of the OIG recommendations. With the
corrective actions in place to improve patient supervision and
accounting for patients' whereabouts, and after resolution of
several personnel actions, the OIG considers the matter closed.
Mr. Frelinghuysen. Anything else, Mr. Goode? Ms. Kaptur?
Thank you very much we will see you, I think, at 1:30 or
thereabouts.
[Recess 12:49 p.m.]
Wednesday, April 5, 2000.
VETERANS BENEFITS ADMINISTRATION
NATIONAL CEMETERY ADMINISTRATION
DEPARTMENTAL ADMINISTRATION
WITNESSES
JOSEPH THOMPSON, UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS
ADMINISTRATION
ACCOMPANIED BY:
NORA E. EGAN, DEPUTY UNDER SECRETARY FOR MANAGEMENT; JAMES W. BOHMBACH,
CHIEF FINANCIAL OFFICER, AND JIMMY L. WARDLE, ACTING DEPUTY CHIEF
FINANCIAL OFFICER
MICHAEL WALKER, ACTING UNDER SECRETARY FOR MEMORIAL AFFAIRS,
NATIONAL CEMETERY ADMINISTRATION
ACCOMPANIED BY:
ROGER R. RAPP, DEPUTY UNDER SECRETARY FOR OPERATIONS; VINCENT L.
BARILE, DEPUTY UNDER SECRETARY FOR MANAGEMENT; AND DANIEL TUCKER,
DIRECTOR, BUDGET AND PLANNING SERVICE
RICHARD J. GRIFFIN, INSPECTOR GENERAL, DEPARTMENT OF VETERANS
AFFAIRS
ACCOMPANIED BY:
LEIGH A. BRADLEY, GENERAL COUNSEL; JOHN H. THOMPSON, DEPUTY GENERAL
COUNSEL; E.D. CLARK, CHAIRMAN, BOARD OF VETERANS' APPEALS; EDWARD
A. POWELL, JR., ASSISTANT SECRETARY FOR FINANCIAL MANAGEMENT;
DENNIS M. DUFFY, ASSISTANT SECRETARY FOR PLANNING AND ANALYSIS;
EUGENE A. BRICKHOUSE, ASSISTANT SECRETARY FOR HUMAN RESOURCES AND
ADMINISTRATION; JOHN HANSON, ASSISTANT SECRETARY FOR PUBLIC AND
INTERGOVERNMENTAL AFFAIRS; HAROLD F. GRACEY, JR., PRINCIPAL DEPUTY
ASSISTANT SECRETARY FOR INFORMATION AND TECHNOLOGY; D. MARK
CATLETT, DEPUTY ASSISTANT SECRETARY FOR BUDGET
Opening Remarks
Mr. Walsh. The subcommittee will come to order.
This morning we heard from the Veterans Health
Administration regarding the fiscal year 2001 budget request.
This afternoon, we are joined by the rest of the deputies to
discuss the other appropriations under Veterans Affairs.
We changed the format of the hearing this year so that the
Committee could cover all topics surrounding the VA. Last year,
we spent a great deal of time focusing on the medical issues of
the VA, especially in light of the President's flat budget
request and the crisis that would have caused if the Congress
had not provided the additional $1.7 billion.
While the President's budget includes an adequate increase
for medical care, the budget justification also includes some
significant increases for just about every other office in the
VA. Because the budget resolution calls for some cuts in
discretionary programs, we need to examine all of the VA's
programs to see what expenditures are necessary to ensure a
better quality of service for our Nation's veterans and how we
can help the VA spend that money wisely.
Do any of you have an opening statement that you would like
to share at this point?
Mr. Joseph Thompson. I do have an opening statement.
Under Secretary for Benefits Opening Remarks
Mr. Walsh. Please go ahead.
Mr. Joseph Thompson. Okay.
Mr. Chairman, there should be a package in front of you
that we are about to discuss about VBA and what it is we are
trying to do. I will try to keep my remarks brief.
VBA administers a wide array of programs, perhaps the
broadest array of programs in the Federal Government. I know,
typically, most of the interest revolves around the
compensation and pension program. But we do a number of other
things that I think are important and I would like to share
them with the committee today.
We know that the benefits we provide are of critical
importance to veterans. When they come to us, they are sick,
they are disabled, often homeless. They may be buying a home,
may be going to school under the GI bill, a whole host of
things that are really key events in a person's life. So we
know that what we do affects their lives in important ways.
In one form or another we have been doing this for 211
years; it is one of the first programs in the Federal
Government signed right after the Constitution was enacted.
There are several points I want to make today, if I could.
I will talk about what we do in terms of volume both in the
number of veterans we help and the amount of money we spend, of
the challenges we face; our plans and accomplishments, and what
lies ahead for VBA.
The second page of the handout shows the number of folks
that came to us in fiscal year 1999 that we were able to help.
I won't go through each of them, but you can see both the array
of programs that we administer, as well as the numbers of
veterans' family members that come to us. The total helped is
over 6 million.
I should add that we sat down and counseled veterans more
than a million times last year. We also spoke to them on the
telephone more than 16 million times. We have a lot of
interactions with veterans. I like to think in a very positive
way each year.
The next page talks about how the monies are spent. Of
course, it does mention that compensation often gets most of
the attention. You can see by the size of the dollars spent
that it is probably well-deserved attention. In sum we spend
$24 billion or so every year trying to help veterans. This is
the largest part of VA, in terms of outlays.
The next page talks about the challenges in VBA and some of
the things that we think are of central importance and need to
be addressed in order to make this agency what it was intended
to be, which is an organization that keeps our Nation's
commitment to veterans. We talk about culture, but I want to
capsulize what we mean by that. The VBA that we want to change
is inwardly focused, overly bureaucratic and very reactive. We
want to get away from that scenario.
The second bullet is succession planning. We are a Vietnam-
era agency. Most of the key decision-makers, senior officials
in this agency came to work for the VA during the Vietnam era.
They will be leaving soon. We have not been hiring since about
1992. So we have a crisis, if you will, in terms of
demographics in this agency. We have a lot of key jobs where
the average age is in the 50s. We know these folks, at age 55,
will have a fully vested retirement. So we need to get on with
changing generations.
Training is important to us. In 1997 when I came into this
job, we had no centrally directed training program. Everything
was ad hoc and done at the regional office level. It leads to
very inconsistent, if not inaccurate, types of decisions.
Program evaluations. Under the Government Performance and
Results Act, we have to evaluate each of our programs to make
sure they are doing what the Congress intended when they passed
the laws. We are in the process of doing that.
Strategic Planning. VBA has been broadly criticized for not
having very good strategic planning, if any planning at all.
The organizational structure had not changed since the early
1950s. In essence, somewhere between World War II and Korea was
the last time we really reorganized, particularly in the field.
Information Technology. Again, well documented by many
parties that we have been unable to deliver new technology very
successfully.
Quality. Our quality was poor in the area of decision-
making, and that it is something that is at the heart of what
we needed to change.
Data Integrity. Much of the information we reported was not
accurate for many reasons, and that was a major concern.
Rules and Regulations. We are often times tied in knots, as
an organization, by both the regulations and the rules we
impose on ourselves. As I mentioned in the first hearing, when
we tried to simply quantify or list out all of the ways in
which a veterans claims examiner would calculate the effective
date of benefits, we not only had to look in a host of
different manuals and citations, but when we got through
listing all the combinations and permutations, we had 35 pages
of matrices on how to calculate just one effective date.
Workload Management. I will say again that we were reactive
on this. We reacted to the things that came to us instead of
trying to manage it.
In terms of what we tried to do, on the next page, I
mentioned what the strategies were in terms of our business
processes themselves, how we were going to measure performance,
what we would do in terms of training and developing our
employees, how we would capitalize on technology, and how we
would communicate all of this, both with veterans and with all
the interested stakeholders in our business.
The next page, if you will, the multicolored one, lists
some of the initiatives that we have. I will not go through
these. We have plenty of information to provide the committee
if you are interested in any particular area. Just let me say,
this is only a sample of the initiatives we have underway to
address those major strategies. We actually have more than 80
major initiatives underway right now. So we have a significant
amount of work to do. We recognize that.
The next page talks about some of the things that we think
are going right for us now in terms of undoing or changing some
of those past practices. Again, I won't mention all of these
things; I will just touch on a few.
We did get a clean financial opinion on our accounting
systems the first time since 1997.
Case management is where we provide veterans very specific
one-on-one service, replacing the old assembly-line process. We
have seen the veterans are happier with case management
service. In the Voc-Rehab program, we are finding that we can
get more veterans jobs. The number of remands from the Board of
Veterans' Appeals has gone down significantly. We think this is
going to be a very successful program.
I won't go down through this entire list, but when we look
at our macro trends they are going in the right direction. We
have a number of challenges still facing us.
Many of the things that require fixing in VBA will take the
better part of a generation, in my view. There are no easy
fixes. There is nothing that can happen overnight. Most of what
we are doing requires years of effort and building of
fundamental, basic structures. That will take some time.
But I have to say something for VBA employees, many of whom
are veterans. We care deeply about our mission and are
enormously proud of what we do. We know we make a difference in
veterans' lives. As Federal employees, we are also enormously
frustrated by the fact that we don't do as good a job as we
should and that we are often times hamstrung in our ability to
help veterans.
I promise you and all the members of this committee that
the management of VBA and, I know, the rank-and-file employees
as well, will do everything in our power to change the system,
to make it one that we are all proud of.
Thank you for hearing me today.
[The information follows:]
Succession Planning in VBA
Mr. Walsh. Thank you. Thank you, Mr. Thompson.
If I could just comment briefly on Mr. Thompson's
statement. I found it very thoughtful and well organized. And
you were moving right along until you said you will have all
these problems worked out by the next generation, and I almost
fell off my chair.
Could you imagine anyone in any other surrounding reporting
to whoever the oversight responsibility for that department,
business or governmental entity--can you imagine that being
said anywhere else on Earth?
You didn't mean that, right?
Mr. Joseph Thompson. If you are looking at a generation as
20 years, I didn't mean that.
Mr. Walsh. That is 20 years.
Mr. Joseph Thompson. No, that was not my intention. When I
am talking about ``generation,'' it gets back to the earlier
point I made. We have, at heart, a demographic issue that will
take years in transition.
Mr. Walsh. How many? I understand this is something that
the Library of Congress brought to us when I was over on the
legislative branch. We said, we had all these people we hired
after World War II and we have got to move them out, we have to
move new people in. They asked us for hundreds of millions of
dollars to train people and have someone sit with somebody else
for 5 years. I mean, it is a wonderful approach, but it is
unrealistic.
Mr. Joseph Thompson. Our estimate is that, over the next 7
years, we will lose most of our key decision-makers. Most are
in the center, around 3 to 4 years, we are going to lose our
rating specialists, directors, and senior managers. That
transition is going to take time. In fact, I wouldn't want it
to go any faster than that, because it is easier for us the
longer it gets spread out.
There are other things in terms of technology, changing
rules and a host of other things that we will do this year and
next year. But I would think that for the Agency as we know it
to be changed completely, 7 years is a fair range.
Mr. Walsh. Okay.
Mr. Walker.
Acting Under Secretary for Memorial Affairs Opening Remarks
Mr. Walker. Thank you, Mr. Chairman.
On the attrition issue, if I might say, this is the third
executive branch agency I have served in this administration--
the Department of Defense, FEMA, and now the Department of
Veterans Affairs. There is concern all over the Federal
Government that attrition is a significant problem. We are
going to have a real talent drain. And all of us in our agency
are very concerned about succession planning. That is a very
important issue. And you asked a very important question.
Mr. Chairman, I would like to thank you and the
subcommittee for the strong support that you have given the
National Cemetery Administration and National Cemetery System
over the years. The President's budget request before the
committee is the largest single budget increase that we have
had in the history of NCA.
We need that increase, Mr. Chairman, because, as you know,
we are facing the real challenge of a rapidly aging veterans
population. Interments will increase from 78,000 in 1999 to
108,000 by the year 2008. That is a 39 percent increase in just
10 years, and the number of interments are not going to go
below the 1999 figure for decades to come. The workload of the
National Cemetery Administration is going to be very high for a
long time.
As you know, we try to provide veterans with a burial
option at either a national or a State cemetery within 75 miles
of their home. Last year, only 67 percent of veterans were
provided with such an option, and the budget that is before the
committee provides for programs that will bring that percentage
up to 82 percent by the year 2005. We are going to achieve that
by building new national cemeteries, by extending the service
life of existing cemeteries and also by continuing our
partnership with the States through the State cemetery grant
program.
Last year, as you know, we opened the new Saratoga National
Cemetery in New York. We also opened Abraham Lincoln National
Cemetery in Illinois. And I am pleased to report that on May
12th we will be opening and dedicating a new national cemetery
in Dallas. In June, we will begin burials in the new national
cemetery near Cleveland, Ohio.
With regard to future cemeteries last month we awarded a
contract for master planning for a new cemetery at Ft. Sill,
Oklahoma. We are also aggressively proceeding with the site
selection process for cemeteries in Atlanta, Detroit, Miami,
Sacramento, and the Pittsburgh area. In addition to that, the
Millennium Act has directed us to look at future needs beyond
those next 6, out to the year 2020. We welcome that opportunity
and will soon be awarding a contract to fulfill that
requirement.
And if I might just mention one other element of the budget
request. I think we all agree that our veterans cemeteries are
our national shrines and that we should maintain them in a
manner and appearance that is befitting our veterans and gives
lasting meaning to what our veterans did for all of us.
Over the years, quite frankly, as the workload has grown,
as the number of veterans' deaths increased, we had to divert
funds from routine maintenance and repair just in order to keep
up with the workload. And as a result, we have far too many
sunken grave sites and far too many misaligned or damaged
markers. And quite frankly, our men and women who served in
uniform deserve more than that.
This year we are requesting $5 million for a new
initiative, what we call the National Shrine Commitment. It is
a modest amount that will permit us to begin a program to bring
our national cemeteries up to the standard that veterans
deserve. So I urge the committee to support the National Shrine
Commitment.
Mr. Chairman, with the committee's support, we have made a
great deal of progress in the last 10 years. We are going to
continue to need your help as we look at the future and as we
try to expand our service to veterans. We thank you for that.
Well-Grounded Claims
Mr. Walsh. Thank you, sir, for your comments. I am sure
there will be some questions regarding this cemetery proposal.
I would like to begin in the area of well-grounded claims,
an issue that we are all hearing so much about.
Mr. Thompson, we spoke briefly at the last hearing about
this. I just wanted to delve into it a little bit more. What
exactly does a veteran need to include in an initial claim to
establish well-groundedness that he or she did not have to
include before?
Mr. Joseph Thompson. There is a three-part test, Mr.
Chairman. The veteran needs to show that he or she has a
current disability.
Mr. Walsh. Just what is different from before this ruling?
Mr. Joseph Thompson. If I could, there is a three-part
test. You need to show a current disability; there needs to be
evidence in your service records that the disability or some
related disability existed during service; and there needs to
be a nexus or connection between these two events.
The nexus is the key. The nexus is something the Court of
Appeals for Veterans Claims said is required in order to well-
ground a claim. If I can go back and give you a little bit of
history. If you go back before the court was established in
1989, the nexus rule was applied by the people making the
claims decisions.
The ratings specialist would look at it and say there is no
connection. The veteran hurt his knee in the service in 1940
and its now 1985, but there is no medical treatment in between
those dates. Even though you might have another knee condition,
there is no nexus. The decisionmakers would apply the rules
informally.
When the court came in, they formalized that process. They
said you need a much more stringent application of the rules.
You can't allow individuals to make these decisions informally.
They said you will formally and specifically apply these rules.
There are two principles at play here. One is that a
veteran must file a claim that is well grounded, which means
plausible on its face or that looks like something that can be
proved. The second part is that VA has a duty to assist
veterans when they come to us filing claims. The Court's
decision said that the well-grounded issue precedes the duty to
assist a veteran. Before VA can expend resources assisting a
veteran, the veteran needs to give VA enough information to say
they have a well-grounded claim.
Mr. Walsh. So in the prior construct of this claims
process, the VA helped the veteran to establish this nexus; is
that a proper characterization?
Mr. Joseph Thompson. I will bring up one more issue in
this. The Court has been ruling on the well-grounded issue for
a number of years, becoming increasingly stronger in its
opinions. They first issued well-grounded guidelines, if you
will, years ago. And one of the things that was happening was
that, in some regional offices, they helped veterans every time
with every claim, even ones that were totally implausible. In
other regional offices, they were applying the rules that the
Court had given out.
One of the reasons for the Court's reaction the last time
was ``you can't do that.'' You can't apply Federal programs
differently depending on the State you happen to live in. And
so the Court said, you need to come out with stringent rules.
So the answer is, it was done both ways. In some regional
offices the help was given 100 percent of the time, in other
regional offices they were more selective.
court Ruling on Veterans Claims
Mr. Walsh. In your view, the intent of the court ruling,
was it to reduce the number of claims or was it to ensure that
these laws were interpreted evenly across the country in the
system?
Mr. Joseph Thompson. Well, I don't know that it was to
reduce the number of claims at all. I don't think that was the
intent.
I think making them consistent was important. I think the
Court's interpretation of the law was to ensure there would be
no obligation for the government to expend resources until the
veteran has furnished a plausible claim. And the claims the
Court were looking at should never have risen to this level.
This veteran never filed a plausible claim. Why is it ending up
with all this work and litigation? You don't have a good issue
here; this is one that can never be proved.
Mr. Walsh. These decisions are subjective though. Even this
idea of the nexus is subjective.
Mr. Joseph Thompson. I think there is some subjectivity in
it, but I don't think that it is a subjective call. The
informal rule is one I am actually familiar with, because I
used to be a claims examiner many years ago. Does it look like
there is any chance of ever granting this benefit? The reason
we are trying to get a regulation is that we could end up
chasing a lot of things that don't exist when we recognize the
claim is never going to be proven and we are never going to
grant the benefit. Veterans who have plausible will claims have
to wait while we chase this other evidence.
We know that, on average, if a veteran submits what we call
a well-grounded claim today, we can process them 2 months
faster than the other claims. And the other claims are
ultimately denied anyway, but may take us 2 months longer just
to reach that point.
The General Counsel is here. Where is Leigh? She is right
here. I would suggest they have a more legal view on this.
Mr. Walsh. Why don't you give us your view General Counsel,
if you would, of the court's ruling and its impact on claims.
Ms. Bradley. Jack Thompson, the Deputy General Counsel, is
here. As a matter of fact, he spent all day yesterday with a
group of Hill staffers and VSOs, so I think I will pass it over
to him.
Mr. Walsh. Good move.
Mr. John Thompson. The stage was set back in 1988 when
Congress enacted the Judicial Review Act, which created the
Court of Veterans Appeals. And what happened was, in that act,
Congress stuck together in statute two regulations that had
existed at VA for years. One of the regulations said, the
veteran is responsible for presenting a well-grounded claim;
the other regulation said that VA has a duty to assist
claimants.
Mr. Walsh. Who said that?
Mr. John Thompson. The one regulation said that; Congress
then codified that in the statute. Congress tacked on language
from another VA regulation that said VA has a duty to assist
claimants. That is the way this new statute was assembled.
Mr. Walsh. Is that a conflict?
Mr. John Thompson. No, I don't believe so.
The Court then interpreted this new statute, because of the
way it was assembled, in such a way that it said the veteran
must first present a well-grounded claim before VA's duty to
assist arises.
well-grounded claim regulations
Mr. Walsh. The court determined that?
Mr. John Thompson. The Court determined it in interpreting
the statute.
More recently----
Mr. Walsh. No responsibility to that claimant until what?
Mr. John Thompson. Until it is a well-grounded claim, a
plausible claim that meets the three-pronged test that the
Under Secretary described.
Mr. Walsh. So if a veteran calls the claims office, or
assume he didn't deal with the VSO, and they say, ``I am sorry,
we can't help you; you don't have a well-grounded claim.'' Is
that the response they are going to get?
Mr. Joseph Thompson. No. Number one, we do request service
medical records VA or any other records in the government's
possession. In essence, we will get them. If we find the
veteran is missing any part, the nexus, the in-service event or
the current disability we go back to him or her and say, ``this
is what you are missing.'' They have 30 days to come back with
that information or contact us and tell us what is going on
with this.
So if they say, I hurt my knee in service and I have a bad
knee now, we will say there is no evidence of anything
transpiring in the 20 years since you were in the military; do
you have any medical records?
Now, what is different? In the past, we would have gone out
and asked for those private medical records ourselves. Under
this regulation, we ask the veteran to secure the records and
send them to us.
Mr. Walsh. Okay. Did you want to go further?
Mr. John Thompson. I would then add that this
interpretation occurred a few years ago, and while we
understood the court to say that VA has no statutory obligation
to assist veterans until they file well-grounded claims, we did
not believe we were forbidden from offering some additional
assistance. And we had various instructions out during this
interim that suggested we really ought to do a little bit more
than the bare minimum required by the statute.
This past summer, in July of 1999, the Court went further
to say, no, has no authority to assist these claimants until
they present well-grounded claims. That has really forced the
issue and gotten the veteran community understandably upset.
We have proposed a regulation that we think would go
partially toward where the veterans service organizations would
like us to be. The question is whether, under the current
interpretation of the statute, we can by rule making go far
enough and arrive at a position that the veteran community
would be comfortable with.
Mr. Walsh. So by virtue of your initial understanding or
interpretation of the court's ruling on this, you were at odds
with their decision, were you not?
Mr. Joseph Thompson. Yes. Our instructions were at odds
with their decision.
pending legislation regarding well-grounded claims
Mr. Walsh. So, if the VA is at odds with this decision,
presumably--the remedy is a statutory remedy, is that right?
Mr. Joseph Thompson. We thought we could handle it through
regulation. We thought we could craft a regulation that would
carve out the exceptions where we thought veterans needed
special protection, needed more help than the average.
Again, as Jack mentioned, the VSOs disagree with us on
that. They believe, and perhaps Congress does as well, that
legislation is required, since either our regulations could be
undone or they won't be able to go far enough.
Mr. Walsh. Have you seen the pending authorizing
legislation regarding well-grounded claims?
Mr. Joseph Thompson. Yes.
Mr. Walsh. Would you care to comment, either of you?
Mr. John Thompson. We do not yet have a formal, cleared
position on it. As the General Counsel mentioned, we had a 3-
hour meeting yesterday on these issues with representatives of
the major veterans service organizations. We also had
authorizing committee staff there. We had a very good, lengthy
discussion of the issues.
I think that there is enough common ground upon which to
build. And I believe, based upon that, we will be able to
develop a departmental position fairly rapidly.
Mr. Walsh. Any further comment? Then I will yield to Mr.
Frelinghuysen.
Mr. Joseph Thompson. I agree. I think the key to what Mr.
Thompson said is, there is middle ground, that when we sit down
and talk specifics, we recognize that we have a duty to help
veterans. That has never been in question. I think most VSOs
recognize that we get claims that really aren't worthy of
further pursuit, and how do you separate one from the other and
make sure you protect the interests of those who do have valid
issues? I think there is a middle ground. I am hopeful we can
craft something.
Mr. Walsh. I would hope that you could do that. There has
always been a predisposition for the veteran on the part of the
VA, certainly the Congress has always felt that way. If we have
to make that law, then I think we probably will.
Mr. Frelinghuysen.
Mr. Frelinghuysen. Thank you, Mr. Chairman. Just for the
record, we lost Dr. Garthwaite, but there are 13 people left.
How many of you are veterans?
Got a good crowd here. That is just a few exceptions. Thank
you very much.
I have a number of questions. Mr. Secretary, is this your
sheet here?
Mr. Joseph Thompson. Yes, it is.
VBA Challenges
Mr. Frelinghuysen. Educate me here for a few minutes on the
VBA challenges, accomplishing a balanced approach. Would you
comment briefly on the culture issue?
Mr. Joseph Thompson. Certainly.
Mr. Frelinghuysen. I think I know what you are talking
about, but I would like to hear it in your own words.
Mr. Joseph Thompson. I mentioned that we were a 211-year-
old organization with all the blessings and curses that come
with great age. The organization, as I saw it at least, was
overly inward-focused, not focused on veterans, bureaucratic to
a fault, and very reactive--waiting for things to happen and
then reacting to them versus going out and trying to take your
fate into your own hands.
At heart, one of the things we have to change in the
organization is the culture, the underlying assumptions. Why
are you in business? Are you in business to move paper across
your desk, or are you in business to help your fellow human
beings?
Mr. Frelinghuysen. We can assume most of the people in your
employ are veterans?
Mr. Joseph Thompson. No, it is not most.
Mr. Frelinghuysen. What would be the percentage?
Mr. Joseph Thompson. About 36 percent is the number that
sticks in my mind right now.
Mr. Frelinghuysen. I am sure, whether they are veteran or
nonveteran, you have remotivated them all.
Mr. Joseph Thompson. We are trying desperately to do that,
sir. I think we are having some success.
vba employment
Mr. Frelinghuysen. What is the average length of
employment? I have to tell you, I had a call from Secretary
Cuomo relative to HUD, making a plea on behalf of his agency.
He bemoaned the fact that he was dealing with career employees,
the average length of service was 17 years, he said, and he
made a case that he needed X, Y and Z to overcome this huge
employment barrier; and I somewhat sympathized with him.
What is the average length of employment in your agency?
Mr. Joseph Thompson. I don't know that off the top of my
head. I can tell you that the average age, assuming there is
some corollary there, is in the late 40s for most of our key
jobs. So most of them are career. I don't necessarily see that
as a bad thing.
I think some bad habits develop over time, and maybe it is
more difficult to motivate a long-term employee, but I think
that our folks are, on balance, pretty focused.
customer satisfaction
Mr. Frelinghuysen. Briefly, trending in the right
direction, case management, how do you--literally, if you can
give a brief response--measure customer satisfaction?
Mr. Joseph Thompson. We go out and ask veterans. We have a
contract to survey veterans. We ask, I think it is 83
questions. We run a statistically valid sample every year.
In our traditional assembly line process you drop paper
into it, it comes out the other end at some point with a
decision on it. In case management, veterans know who the human
being is they can talk to, and who will keep them apprised of
what is going on. Customer satisfaction is significantly higher
for case-managed work, regardless of the decision.
claims filed with vba
Mr. Frelinghuysen. A few questions. In fiscal year 1999,
the Veterans Board of Appeals rejected approximately 14,000 or
15,000 of the claims that were filed with the VBA.
How many total claims were filed in fiscal year 1999?
Mr. Joseph Thompson. Total claims filed with the VBA? It is
more than a million, but I don't have the specific number in
front of me. I can provide it for the committee.
[The information follows:]
Claims
VBA received a total of 1,915,846 compensation and pension
claims in fiscal year 1999.
Mr. Frelinghuysen. It is my understanding, of the 15,000
claims rejected, only 2,300 or 2,400 were appealed to the U.S.
Court of Veterans' Appeals? Does anyone want to confirm that
figure?
Mr. John Thompson. That is very close to the numbers I
have.
remand rate
Mr. Frelinghuysen. There has been a decline over the past 3
years in the number of claims denied by the VBA, but an
increase in the number of appeals brought before the Court of
Veterans' Appeals. How many of VBA's decisions are being
overturned by the appeals court?
Mr. Joseph Thompson. I think you are looking at the Board
of Veterans' Appeals decisions being reversed. Maybe Judge
Clark has some information on that.
Mr. Frelinghuysen. Your Honor, you are on.
Mr. Clark. I don't have those figures immediately before
me. We could provide them to you at some later date. But I can
assure you that the rate of remand has been constantly
declining. And both the rate of remands from the Board back to
the regional office and from the Court to the Board. But I will
have to provide those specific figures to you at some later
time.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Frelinghuysen. I don't know whether this is your
jurisdiction or department, but I understand a number of
concerns have been raised with the way the Department handles
remand cases. According to the VA's budget justification, and I
quote, ``Remand represents a rework phase of the appellate
cycle, and it typically adds 2 years to the processing time for
appeal,'' end of quotation.
For many of these veterans, 2 years is an awfully long
time, since this 2-year remand period is in addition, as I
understand it, to the time it took the VA to initially
adjudicate these cases.
Mr. Clark. I am not sure I understand what your question
is. Is it in reference to the length of time itself?
Mr. Frelinghuysen. Yes.
Mr. Clark. The cases are remanded for further development.
This request involves many different things--possibly a
physical examination, possibly going out finding medical
service records, and there is just a great variety of things
that can be involved in further developing the case. This is
why the time is so lengthy, because of what is involved in
trying to actually help the veteran develop a case which
otherwise probably would not be granted.
Mr. Frelinghuysen. So everybody is working mightily to
clear these cases out of the system, given these types of
roadblocks?
Mr. Clark. We hope that everyone is working mightily.
And also, when cases are sent back for remand, it is
required that they be handled expeditiously.
Mr. Frelinghuysen. The budget justification also states,
and I quote, ``Many appeals that do go to the court''--and this
is of appeals for veterans' claims--``are returned because of
due process or other deficiencies found during the review,''
end of quotation.
What can be done now to reduce the number of cases remanded
back to VA? Is this a problem with claims processing or with
the Board's decisions?
Mr. Clark. It is probably a combination of the two, plus
additional matters as well. Because the fact that a case is
remanded from the Court to the Board does not necessarily mean
that there has been anything that was done inappropriately at
the time that that claim was decided. It might be, in some
cases, the result of changes in the law in either statutes or
court decisions. And of course, that doesn't rule out the
possibility that there were some improper claims procedures
involved. But it is not necessarily the deciding factor.
Mr. Frelinghuysen. Some of them must relate, I suppose, to
what was in the actual budget document due to due process
issues and other deficiencies.
Mr. Clark. That is correct, sir.
funding increases to reduce backlog of cases
Mr. Frelinghuysen. Over the past 4 years, this committee
has provided significant funding increases to the VA's Office
of General Counsel and the Board of Veterans' Appeals, as well
as to the Court of Appeals for Veterans Claims to reduce the
huge backlog of cases.
When can we expect to see the results from these--that
would come from these types of funding increases?
Mr. Clark. We are constantly working on reducing----
Mr. Frelinghuysen. Will you comment on the whole issue of
older claims versus, shall we say, more current contemporary
claims?
Mr. Clark. Well, we are constantly trying to reduce the
backlog. And I don't have the exact figures of what the backlog
is now, but you know, we have to handle all the cases in exact
docket order except for some exceptions which involve advances
on the docket, something of that nature.
But I am not aware of any distinction between the way the
older claims are handled as compared to the newer claims.
Mr. Frelinghuysen. Is there a distinction between
disability claims and other types of claims, and how they are
handled?
Mr. Clark. I understand that all of the claims are handled
primarily in the same manner.
Mr. Frelinghuysen. They are. But is there not, in fact,
some sort of a record as to the number of claims that have been
in the system that are outstanding, for many years? Is that
figure available?
Mr. Clark. We do keep those figures. I don't have them
available right now, but I will get them to you.
[The information follows:]
Backlog of Claims
Currently, there are about 44,000 claims on which an appeal has
been filed. However, only about 21,000 of those are ready for BVA
review. The remainder are in various stages of development by VA
regional offices. Of the 21,000 ready for review about 4,800 are
awaiting the scheduling of a travel board or video hearing. Appeals are
forwarded to the Board as soon as they are ready for review and
reviewed by the Board in docket number order. The Board is currently
assigning cases with December 1998 docket numbers.
In addition to new appeals, around 26,000 cases are currently in
remand status. About 9,100 of these were remanded prior to FY 1999 with
the oldest having been remanded in 1992. As of now, the average time
for those cases in remand status is about 16 months.
Mr. Frelinghuysen. I think it would be interesting to know
how many might be a part of the older claims; if there is a
backlog, to what extent older claims might represent a certain
portion of that backlog. Thank you very much.
Thank you, Mr. Chairman.
Mr. John Thompson. If I could add, Congressman, that--the
chairman spoke with respect to the backlog at the Board of
Veterans Appeals. At the Court of Appeals for Veterans Claims
the pending case load there has remained relatively constant
over the last 12 months or so. However, the number of cases
filed has increased, and VA Office of General Counsel has had
to devote additional resources to this work in order to keep
relatively current with the work there.
And also, because the trend continues for additional
filings in the court cases, the case--new cases are growing at
a rate of about 300 per year, new cases filed. In order to keep
on top of that case load and to keep current, we have requested
some additional resources for fiscal year 2001.
forecasting compensation and pension caseloads
Mr. Frelinghuysen. And in the area of compensation, if I
can reclaim my time a little bit here, I understand there is an
ongoing assessment of the current methodology used to forecast
compensation and pension case loads and related obligations.
Who is up to speed on that? And where do we stand in terms
of getting some recommendations?
Mr. Joseph Thompson. Congressman, I will take it as far as
I can. Nora Egan here can probably fill in some of the gaps. We
contracted with the Institute for Defense Analyses to develop a
forecasting model for compensation and pension claims, and they
have delivered the first phase of that. We expect to have the
last phase by later this spring.
Mr. Frelinghuysen. What had existed before you had that
contract?
Mr. Joseph Thompson. It was pretty rough. It looked at
historical trends made the best guesstimate as to what it would
be.
We think this will be a much more predictive model of what
we are likely to see, bringing in a lot more variables. We are
very hopeful we can provide better information to the Congress,
when we come up with a budget request, about how many veterans
are likely to file claims with us.
Mr. Frelinghuysen. What are you budgeting for this?
Mr. Joseph Thompson. The study itself, I think that was
$600,000 total.
Mr. Frelinghuysen. Thank you, Mr. Chairman.
Mr. Walsh. We have two votes in succession. And unless any
other members arrive, I am not sure--I have some additional
questions, I will ask now and then submit for the record, but--
Rodney, how much?
Mr. Frelinghuysen. Record, as well.
backfilling claims decision-makers
Mr. Walsh. Just a thought on this backfilling problem where
you are losing all these people, is there some opportunity
there, too, that if part of the idea is to speed up this claims
process and better manage these cases; and I understand the
problem as we change laws here, having you go back and review
each case and make sure it is in line with the current law.
Isn't there an opportunity here with new information
technology and new training programs and bringing in large
groups of people to really change the culture of this claims
process and improve it?
Mr. Joseph Thompson. Absolutely. It is definitely a two-
sided coin. You lose the brain power, the people who spend the
better part of their adult lives remembering the rules and the
laws. But, on the up side, you also lose a lot of ingrained
attitudes that maybe aren't as productive as you would like.
The other key for us is that the people coming out of
college today are very, very comfortable with where we are
headed in terms of technology. They don't care that you don't
have paper in front of you to read. They are very comfortable
downloading data on a 25-inch computer screen and reading and
making decisions on that. I think it is an advantage.
Our big challenge, however, is to get them up to speed on
what I described in the last hearing as the most complex
disability claims process in the Federal Government.
Mr. Walsh. Well, it would seem that it may be
oversimplifying, but if we change the law, rather than having a
human being go through and check every one of these cases to
make sure that its activity date is changed, it could be done
by software.
Mr. Joseph Thompson. Absolutely. The capabilities in expert
systems are ones that we hope to take full advantage of. Some
of them are nuanced in the law, and no matter what the
technology does, you still have over 700 disability evaluations
that we can grant under. You have, literally hundreds of pages
of regulations.
Part of the earlier discussion on taking as long as I think
it will take to make some of these changes, actually has to do
with rewriting the underlying principles we use to make
decisions on claims.
We really do have to work with the authorizing committees
on things that need to be changed to simplify our lives and
make better and faster decisions for veterans.
Mr. Walsh. Did you want to respond, Ms. Egan?
Ms. Egan. If I can do this without upsetting everything.
Sometimes it is easier to listen to the question than answer
it.
Mr. Walsh. You will get your new technology; maybe we will
get some too.
Ms. Egan. Just to enhance what the Under Secretary said,
one of the things that we have worked very hard on in the last
several years is to develop expert systems to help train the
people. We are investing a fair amount of money in computer
based training that will not only be an expert system to help
our folks work through the simplest to the most complex cases,
but it will be team based too, so that they will learn
together, and that will reflect the case management approach
that they will take in the regional office.
In addition as we get more and more new folks in, although
our last two recruitment classes have been about 40 percent
veterans, there are fewer and fewer veterans and we want to
make sure they understand our mission. Part of that culture
change will be reflected in the way we orient them. Every new
employee will spend at least 2 weeks learning what the VA is
about, our mission and our culture. This computer training not
only enables us to build in an expert system, which employees
will continue to use as they become more expert in developing
claims, but also when there are changes, such as those that you
mentioned, we can make a change in that software and it will be
reflected in the training packages relatively quickly. So, we
don't have a lot of catchup to do. Those changes would also be
used by our more senior folks so that skills are maintained at
an expert level.
Mr. Walsh. Rodney?
Mr. Frelinghuysen. I just wanted to put my oar in the water
here. Looking at the distribution compensation case load by
period in service, I think sometimes we need to recognize that
the Vietnam era veterans are at the top of the list followed by
peacetime. But as some of you heard me say at the hearing with
Secretary West, you have 30,000 World War II veterans dying
every month. I would assume that a lot of those people cannot
wait for action on their claim.
And I would like for the record to know, in the overall
scheme of things, how those cases would be distributed among
those period of service areas categories, if possible.
Mr. Joseph Thompson. We can get you the exact statistics
but you had it right. Vietnam is one, peacetime, Gulf War,
World War II decorated.
Mr. Frelinghuysen. I am all for new technology, bright
energetic people seizing control of the agency and this and
that, but in reality some things need to be done with a little
more rapidity.
Thank you.
closing remarks
Mr. Walsh. I have a series of questions that I would like
to ask about cemetery administration. I do not have the time,
but I will submit some for the record. I think one of the
things that we as Subcommittee members hear a lot about from
our colleagues and from the folks back home, is we need to
address this issue in a serious way. There is tremendous demand
out there. And again, if we are going to keep our promises we
really need to step up to the plate, and I am not sure we have
done that yet. I am sure we haven't done that yet.
And so, we welcome your comments and if you could respond
back constructively, maybe we could be able to address this
issue in a more thorough way.
Thank you. Thank you all very much for coming in today.
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W I T N E S S E S
----------
Page
Barile, V.L...................................................... 171
Bohmbach, J.W.................................................... 171
Bradley, L.A....................................................93, 171
Brickhouse, E.A.................................................93, 171
Catlett, D.M.................................................1, 93, 171
Clark, E.D......................................................93, 171
Clark, K.J....................................................... 93
Duffy, D.M......................................................93, 171
Egan, N.E........................................................ 171
Feussner, J.R.................................................... 93
Garthwaite, T.L.................................................. 1, 93
Gracey, H.F., Jr................................................93, 171
Griffin, R.J....................................................93, 171
Hanson, John....................................................93, 171
Klein, Art....................................................... 93
McMichael, G.H., III............................................. 93
Murphy, M.L...................................................... 93
Norris, J.A...................................................... 93
Ogden, J.E....................................................... 93
Powell, E.A., Jr................................................93, 171
Rapp, R.R........................................................ 171
Riggin, Phil..................................................... 93
Thompson, J.H...................................................93, 171
Thompson, Joseph.................................................1, 171
Tucker, Daniel................................................... 171
Walker, Michael..................................................1, 171
Wardle, J.L...................................................... 171
West, Hon. T.D., Jr.............................................. 1
Yarbrough, C.V................................................... 93
I N D E X
----------
Department of Veterans Affairs
Page
Academic Affiliations............................................ 147
Access to Care................................................... 144
Additional Funding for Medical Care.............................. 74
Adult Day Care................................................... 137
Adult Day Care Regulations....................................... 142
AIDS Treatment................................................... 138
Allen Park Health Care Needs Study............................... 71
Allen Park, MI, Facility......................................... 129
Antibiotic Resistance............................................ 112
Appeal Process................................................... 73
Asset Realignment Process........................................ 142
Backfilling Claims Decision-Makers............................... 195
Backlog of Claims................................................ 194
Bio-Artificial Kidney............................................ 129
Bio-Artificial Kidney Implant Research........................... 31
Budget Justification Volume 1 Benefit Programs................... 261
Budget Justification Volume 2 Medical Programs................... 431
Budget Justification Volume 3 Construction Programs.............. 649
Budget Justification Volume 4 General Operating Expenses......... 783
Budget Justification Volume 5 Summary............................ 1270
Budget Justification Volume 6 Departmental Performance Plan...... 1504
Capital Asset Planning........................................... 135
Chillicothe Facility............................................. 85
Claims Decision Waiting Times.................................... 63
Claims Filed With VBA............................................ 191
Claims Processing...............................................86, 115
Closing Comments on Medical Programs............................. 169
Closing Remarks.................................................. 197
Community-Based Outpatient Clinics..............................84, 115
Copay Collections................................................ 103
Court Ruling on Veterans Claims.................................. 187
Customer Satisfaction............................................ 190
Departmental Management.......................................... 116
Dingell Building Space........................................... 131
Disability Benefits.............................................. 36
Drug Addiction................................................... 27
Electronic Transfer of Data...................................... 89
Empty Hospital Beds.............................................. 63
Enhanced Use Leasing............................................. 85
Facilities Closures.............................................. 100
Family Lodging on Campus of State Nursing Homes.................. 167
Federal Employees Health Benefits Plan........................... 62
Federal Research Grants Funding.................................. 121
Forecasting Compensation and Pension Caseloads................... 194
Funding the Millennium Act....................................... 102
Hepatitis C...................................................... 80
Hepatitis C Funding.............................................. 37
Hepatitis C Treatment and Funding...............................82, 111
Homeless Programs................................................ 145
IG Investigation on Bocchino Death............................... 169
Impact of New Ruling on Claims Processing........................ 23
Implementing the Millennium Health Care and Benefits Act......... 100
Information Technology........................................... 116
Infrastructure--Maintenance of Buildings......................... 96
Impatient Census Rates........................................... 109
Long-Term Care................................................... 47
Medical Care Access and Service..................................36, 75
Medical Care Collections Fund.................................... 90
Medical Care OMB Request......................................... 141
Medical Care Request............................................. 89
Medical Errors................................................... 131
Medical Programs for Women Veterans.............................. 42
Medical Research Funding...................................27, 140, 141
Medical Research Request......................................... 105
Medical Services.................................................37, 98
Medical Services at Louisville VAMC.............................. 48
Medical Services in Kentucky..................................... 47
Mental Health Care Delivery...................................... 113
Mental Health Research.....................................54, 127, 107
Mental Illness................................................... 124
Mental Illness Treatment......................................... 127
Merit Review of Research Proposal................................ 33
MIRECC in the Midwest............................................ 55
National Cemetery Administration................................. 184
National Drug Formulary.......................................... 91
National Reserve Account......................................... 38
Nursing Home Care...............................................38, 120
Nursing Home Care in New Jersey.................................. 109
Occupancy Rate in Boston Area.................................... 97
Occupancy Rate Reductions........................................ 108
OMB Request For Medical Research................................. 106
Opening Remarks..............................................1, 93, 171
Patient Health Status Evaluation................................. 80
Patient Safety................................................... 132
Pending Legislation Regarding Well-Grounded Claims............... 189
Policy Change Regarding Nursing Qualifications................... 118
Processing Remand Cases.......................................... 72
Processing Times and Remand Rates................................ 69
Psychiatric Care................................................. 122
Psychiatric Care for Substance Abuse............................. 123
Psychiatric Counseling for Homeless Vets......................... 125
Questions for the Record......................................... 198
Rating Specialists Eligible for Retirement....................... 66
Reduction in Backlogs............................................ 73
Reduction in Force............................................... 79
Relationships of Clinics to Medical Centers...................... 146
Remand Rate...................................................... 191
Research Collaboration with National Science Foundation.......... 107
Research Personnel............................................... 122
Residency and Training Programs.................................. 164
Respite Care.....................................................40, 57
Satellite Clinic at Danville, VA................................. 60
Scoring the Millennium Act....................................... 95
Seriously Mentally Ill........................................... 144
Service Connected Veterans....................................... 138
Spinal Cord Injury Units......................................... 139
Standards for Purple Heart....................................... 137
Status of Last Year's CNO Memo................................... 143
Status of Study on Capital Assets................................ 136
Streptococcus Pneumonia Virus Vaccine............................ 113
Succession Planning in VBA....................................... 184
Third-Party Overpayments......................................... 49
Tobacco Litigation............................................... 78
Training Physicians and Nurses................................... 57
Treatment of Non-Veterans........................................ 167
Tricare.......................................................... 90
Tricare Payments................................................. 94
Update on Claims Processing at Winston-Salem VAR................. 64
Updating Financial and Information Systems....................... 117
VA Medical Facilities............................................ 145
VA Medical Performance Compared to Private Sector................ 77
VA Services to DOD............................................... 94
VA's Collaboration with State Nursing Homes...................... 110
Vacant Space in Medical Centers.................................. 99
VBA Challenges................................................... 190
VBA Employment................................................... 190
Veterans Benefits Administration................................34, 172
Veterans Claims--Well-Grounded Claims............................ 21
Veterans Millennium Health Care and Benefits Act................. 25
Veterans Population.............................................. 139
Veterans Service Records......................................... 23
Waiting Times.................................................... 76
Well-Grounded Claim Regulations.................................. 188
Well-Grounded Claims............................................. 186
Women Veteran Initiatives........................................ 41
Written Statement................................................ 7