[Senate Hearing 110-132]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-132
 
                     HEARING ON THE NOMINATION OF 
MICHAEL J. KUSSMAN, M.D., TO BE UNDER SECRETARY FOR HEALTH, DEPARTMENT 
                          OF VETERANS AFFAIRS 

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 16, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                                 senate


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Larry E. Craig, Idaho, Ranking 
    Virginia                             Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Kay Bailey Hutchison, Texas
Jon Tester, Montana                  John Ensign, Nevada
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director



























                            C O N T E N T S

                              ----------                              

                              May 16, 2007
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
    Prepared statement...........................................     2
Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho....    19
    Prepared statement...........................................    20
Tester, Hon. Jon, U.S. Senator from Montana......................    21
Murray, Hon. Patty, U.S. Senator from Washington.................    21
Burr, Hon. Richard, U.S. Senator from North Carolina.............    74

                               WITNESSES

Kirch, Darrell G., M.D., President and Chief Executive Officer, 
  Association of American Medical Colleges.......................     2
    Prepared statement...........................................     4
Frese, Frederick J., III, Ph.D., Member, National Board of 
  Directors, National Alliance on Mental Illness.................     6
    Prepared statement...........................................     8
Mitchell, Douglas H., Jr., MSW, LCSW, ACSW, President, 
  Association of VA Social Workers...............................    12
    Prepared statement...........................................    14
Wallace, Robert E., Executive Director, Washington Office, 
  Veterans of Foreign Wars of the United States..................    15
    Prepared statement...........................................    17
Kussman, Michael J., M.D., Nominee to be Under Secretary for 
  Health, Department of Veterans Affairs.........................    24
    Prepared statement...........................................    26
    Response to pre-hearing questions submitted by Hon. Daniel K. 
      Akaka......................................................    28
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................    42
      Hon. John D. Rockefeller IV................................    51
      Hon. Patty Murray..........................................    55
      Hon. Sherrod Brown.........................................    56
    Questionnaire for Presidential nominee.......................    57
    United States Office of Government Ethics, letter............    66

                                APPENDIX

Sanders, Hon. Bernard, U.S. Senator from Vermont, prepared 
  statement......................................................    81
Inouye, Hon. Daniel K., U.S. Senator from Hawaii, letter of 
  support........................................................    82


                     HEARING ON THE NOMINATION OF 
                 MICHAEL J. KUSSMAN, M.D., TO BE UNDER 
         SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS' AFFAIRS

                              ----------                              


                        WEDNESDAY, MAY 16, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in Room 
562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Tester, Webb, Craig, and 
Burr.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. The hearing of the U.S. Senate Veterans' 
Affairs Committee will come to order.
    I note that we have a series of votes scheduled for 10:30. 
My hope is that we can withhold all opening statements, and 
move directly to the testimony of the first panel as we 
consider the nomination of Dr. Michael Kussman to serve as 
Under Secretary for Health of the Department of Veterans 
Affairs. When we return from votes, we can proceed with opening 
statements and hear from our nominee, Dr. Kussman. But in the 
meantime, we will proceed with the panel.
    But before we do that, I want to make a special 
introduction and that is of Dr. Kussman's wife, Ginny. Ginny, 
it is good to have you here, also Josh, who is here, as well as 
Josh and Deana's significant others, as well, here with us 
today for this very, very special hearing.
    I welcome our first panel of witnesses. We have invited 
each of you to hear your perspective on Dr. Kussman's 
qualifications to be Under Secretary for Health for the 
Department of Veterans Affairs.
    First, I welcome Dr. Darrell Kirch, President of the 
Association of American Medical Colleges since July of 2006. 
Dr. Kirch, thank you so much for being here today. I look 
forward to hearing your views on Dr. Kussman from the 
perspective of VA's medical school affiliations.
    Dr. Fred Frese is a respected clinician and is here on 
behalf of the National Alliance on Mental Illness.
    I also welcome Douglas Mitchell of the Association of VA 
Social Workers. It is important to have VA employees 
represented at this hearing, and I am glad that you could make 
it here to provide us with your perspective.
    Finally, I have asked Robert Wallace of the Veterans of 
Foreign Wars to speak for his organization regarding Dr. 
Kussman. Mr. Wallace, as a representative of those who rely on 
VA health care and the health care system, your opinion is 
particularly important.
    Again, I want to thank all of you for being here today.
    Your full statements will appear in the record of the 
Committee.
    [The prepared statement of Hon. Daniel K. Akaka follows:]
         Prepared Statement of Hon. Daniel K. Akaka, Chairman, 
                        U.S. Senator from Hawaii
    This hearing is to consider the nomination of Michael J. Kussman, 
M.D., to be VA's Under Secretary for Health.
    Dr. Kussman, your nomination comes before the Senate at a difficult 
and challenging time for VA. The terrible conditions at Walter Reed put 
a spotlight on VA health care. With each passing day, more and more 
servicemembers are returning with serious traumas and injuries, which 
for some will mean a lifetime of care from VA. As servicemembers reach 
out to VA, inevitably we hear tragic stories of those who did not get 
the care they needed.
    There is no doubt that mental health issues will also be a 
challenge for VA. A truth of the war is that the toll will be felt by 
servicemembers and their families for years to come. I am talking about 
invisible wounds--wounds which cannot be seen but are every bit as 
devastating as physical wounds.
    VA's Under Secretary for Health is one of the most important public 
servants. The next Under Secretary will guide the VA medical system at 
a time when so many new veterans will be turning to VA. From my vantage 
point, VA was not prepared to deal with the types of injuries stemming 
from this war. Capacity must be rebuilt. And the next Under Secretary 
will have this challenge.
    I urge you, Dr. Kussman: if you are confirmed, to first and 
foremost serve as an advocate for veterans. I am quite cognizant of the 
constraints placed upon you by the White House and OMB. I promise you 
my full cooperation and assistance, but I tell you now, that I will not 
be satisfied unless you work to uphold the promises made to all our 
troops.

    May I call first on Dr. Kirch.

        STATEMENT OF DARRELL G. KIRCH, M.D., PRESIDENT, 
            ASSOCIATION OF AMERICAN MEDICAL COLLEGES

    Dr. Kirch. Mr. Chairman, Members of the Committee, I very 
much appreciate the opportunity to testify in support of Dr. 
Kussman today. As you said, I am Darrell Kirch and I serve as 
the President of the Association of American Medical Colleges. 
We represent the 125 medical schools in the United States and 
107 of those schools are closely affiliated with the VA. We 
also represent over 400 major teaching hospitals, and that 
includes 68 VA medical centers.
    It has been more than six decades that America's medical 
schools and the VA have had this remarkable partnership around 
research, education, and patient care. I have to say that 
relationship means a great deal to me personally. The majority 
of my clinical experiences as a medical student, as a resident 
in training, happened in VA medical centers. The physicians, 
the staff of the VA, but most of all, the patients of the VA 
were among the finest teachers I had in my career. 
Additionally, my first exposure to the excitement of medical 
research and the beginning of my career as a medical scientist 
came seeing studies conducted at the VA to improve 
patient care.
    It is really clear to me from the work of the Joint VA-AAMC 
Deans Liaison Committee we have that Dr. Kussman takes a great 
deal of pride in this special relationship and partnership, and 
it is also clear to me from his distinguished career that his 
first priority is ensuring first-class health care for the 
Nation's veterans.
    Before I speak specifically to why I think he is so well-
suited to carry forward our joint mission, I do want to mention 
two items that are in my written testimony that I think are 
critically important to our Nation going forward. The VA plan 
to increase support for graduate medical education by adding 
2,000 residency positions over the next 5 years is absolutely 
vital at this time to our Nation. It is increasingly clear with 
the growth and aging of our population we face a severe 
physician shortage and this will help us dramatically with 
that.
    The second point I wanted to underscore is the urgent need 
to increase funding for the VA Medical and Prosthetic Research 
Program. This attracts high-caliber clinicians, scientists, to 
deliver care, conduct research at the VA facilities, and it is 
my hope that Dr. Kussman, the Administration, and this Congress 
can work to provide more funding for that program.
    But turning my attention to Dr. Kussman and the VA Deans 
Liaison Committee, I can highlight four things that I have seen 
under his stewardship where we are making great progress.
    First, we have worked with Dr. Kussman and the VA staff to 
ensure that the Blue Ribbon Panel on Medical School 
Affiliations will have measurable outcomes. We want this panel 
to help us establish specific criteria so that we can look at 
each affiliation and evaluate its health as a partnership.
    Second, to prevent conflicts of interest, the VA has very 
appropriately determined that we have to have limits on 
remuneration from affiliated institutions for VA employees who 
serve at the level of chief of staff or above. We have been 
pleased, though, to work with Dr. Kussman and the VA to ensure 
that while these arrangements scrupulously avoid conflicts of 
interest, they also address concerns that prohibiting certain 
kinds of academic compensation could hinder the VA's ability to 
recruit the best staff from its 
affiliates.
    The third thing we have worked on under Dr. Kussman's 
leadership has been a pilot of the new hours bank concept for 
the way part-time physicians can work at the VA.
    Medical work is very complex and the hours bank will allow 
medical faculty who also have appointments at the VA to work 
more efficiently to negotiate pay schedules and get the job 
done for patients.
    And then last, we have worked with Dr. Kussman to ensure 
that the changes required by the Veterans' Health Care 
Eligibility Reform Act of 1996 would not adversely affect the 
affiliations, and we are very pleased that recognizing the 
benefit of the affiliated training programs, the VA has 
concluded that contract awards that overlap with medical 
education have to be weighed by additional factors beyond just 
the pure contract cost.
    I thank you for the opportunity to testify today. I 
congratulate Dr. Kussman on his nomination and I personally 
very much look forward to working with him and continuing what 
is a truly remarkable partnership for America. I will be happy 
to answer any questions you have at any point.
    [The prepared statement of Dr. Kirch follows:]
   Prepared Statement of Darrell G. Kirch, M.D., President and Chief 
      Executive Officer, Association of American Medical Colleges
    Good morning. Mr. Chairman, Members of the Committee, I would like 
to thank you for the opportunity to testify in support of Dr. Michael 
J. Kussman's nomination as Under Secretary for Health at the Veterans 
Health Administration (VHA) of the U.S. Department of Veterans Affairs 
(VA).
    My name is Dr. Darrell G. Kirch and I am President and Chief 
Executive Officer of the Association of American Medical Colleges 
(AAMC). The AAMC is a nonprofit association representing all 125 
accredited U.S. medical schools; nearly 400 major teaching hospitals 
and health systems, including 68 Department of Veterans Affairs medical 
centers; and 94 academic and scientific societies. Through these 
institutions and organizations, the AAMC represents 109,000 faculty 
members, 67,000 medical students, and 104,000 resident physicians.
    For more than 60 years, academic medicine and the VA have enjoyed a 
remarkable partnership in our joint missions of medical education, 
research, and patient care. This relationship is especially meaningful 
to me because the majority of my own clinical experience as a medical 
student and resident occurred in VA medical centers. The physicians and 
staff, and especially the patients, of the VA were among my finest 
teachers. Additionally, my first exposure to the excitement of 
biomedical research, leading to my own career in science, came through 
studies being conducted at the VA to improve patient care.
    Dr. Kussman understands that the first priority is the patient. And 
throughout his distinguished military career, he has dedicated himself 
to ensuring world-class health care for our Nation's military 
servicemen and women. Dr. Kussman also understands that veteran care 
can be improved by the partnerships the VA has built with medical 
schools and teaching hospitals.
    In my comments today, I would like to tell you more about the 
relationship between the VA and academic medicine--and why I believe 
Dr. Kussman's leadership will be pivotal in carrying forward our joint 
missions of education, research, and patient care, with the goal of 
ensuring the best care for our Nation's veterans.
                  history of va--academic affiliations
    Our longstanding association with the VA began shortly after World 
War II when the VA faced the challenge of an unprecedented number of 
veterans who would need medical care and a shortage of qualified VA 
physicians to provide these services. At the same time, medical schools 
had been looking for ways to expand graduate medical education 
opportunities to accommodate all physicians who had entered the armed 
services without completing specialty training.
    Responding to these pressing needs, President Truman signed Public 
Law 79-293, providing the legal basis for the VA to affiliate with 
schools of medicine and establishing the VA Department of Medicine and 
Surgery, the predecessor of the VHA. Less than a month after this law 
went into effect, the VA published Policy Memorandum No. 2, the 
``Policy on Association of Veterans' Hospitals with Medical Schools.'' 
This memorandum officially launched our partnership with the VA, 
enabling medical schools to staff VA hospitals with top-notch medical 
school faculty physicians, residents, and interns. The affiliated VA 
facilities, in turn, would provide medical schools with new venues in 
which to conduct research and educate young physicians.
                     va graduate medical education
    Today, the VA manages the largest graduate medical education 
training program in the United States, with 107 of the Nation's 125 
accredited allopathic medical schools now affiliated with VA medical 
centers. The VA system accounts for approximately 10 percent of all 
graduate medical education in the country, supporting more than 9,000 
full-time medical residency training positions. More than half the 
Nation's physicians receive some part of their medical training in VA 
hospitals, as over 31,000 medical residents and 16,000 medical students 
rotate through the VA health system each year.
    As our Nation once again faces a critical shortage of physicians, 
the VA has been the first to respond. Under Dr. Kussman's leadership, 
the VA plans to increase its support for graduate medical education, 
adding an additional 2,000 positions for residency training over the 
next 5 years. The expansion will begin in July 2007 when the VA adds 
341 new positions. These training positions will address the VA's 
critical needs and provide skilled health care professionals for the 
entire Nation. The additional residency positions also will encourage 
innovation in education that will improve patient care, enable 
physicians in different disciplines to work together, and incorporate 
state-of-the-art models of clinical care--including VA's renowned 
quality and patient safety programs and electronic medical record 
system.
                   va medical and prosthetic research
    The VA research program is another important element of the 
affiliations that Dr. Kussman is charged to oversee. The VA Medical and 
Prosthetic Research program is one of the Nation's premier research 
endeavors and attracts high-caliber clinicians to deliver care and 
conduct research in VA medical facilities. The program is supported by 
a dedicated source of funding available only to physicians with full- 
or part-time VA appointments. As a result, our Nation's medical schools 
use VA research as a recruiting tool to attract top-quality physicians. 
The VA currently supports over 3,800 researchers, of whom nearly 83 
percent are practicing clinicians who provide direct patient care to 
veteran patients. As a result, the VHA has a unique ability to 
translate progress in medical science directly to improvements in 
clinical care.
    As we move forward, it is imperative that the Administration work 
with this Congress to reverse the recent flat-funding for VA Medical 
and Prosthetic Research. The VA needs significant growth in its annual 
research and development appropriation to develop solutions for new 
conditions prevalent among our most recent veterans, as well as 
continuing the groundbreaking research that has benefited veterans of 
previous wars--and certainly our Nation as a whole.
    Of course, state-of-the-art research requires state-of-the-art 
technology, equipment, and facilities. In coordination with increases 
in the research budget, the Administration must also ensure a steady 
stream of resources dedicated to renovating existing research 
facilities. An environment that promotes excellence in teaching and 
patient care as well as research will help VA recruit and retain the 
best and brightest clinician scientists.
                    va--aamc deans liaison committee
    Finally, I would like to talk briefly about the VA--AAMC Deans 
Liaison Committee--a standing committee of medical school deans and VA 
officials, including the Chief Academic Affiliations Officer, the VA 
Chief Research and Development Officer, and three Veterans Integrated 
Service Network (VISN) directors. Dr. Kussman and I meet regularly with 
this committee to maintain an open dialogue between the VA and academic 
medical centers and provide advice on how to better manage their joint 
affiliations. The agendas usually cover a variety of issues raised by 
both parties and range from ensuring information technology security to 
the integrity of sole-source contracting directives.
    At its most recent meeting last February, the VA-Deans Liaison 
Committee reviewed the remarkable progress being made on several VA 
initiatives under the stewardship of Dr. Kussman in his capacity as VA 
Acting Under Secretary for Health. These include:
     Establishment of the Blue-Ribbon Panel on Veterans Affairs 
Medical School Affiliations--This panel will provide advice and 
consultation on matters related to the VA's strategic planning 
initiative to assure equitable, harmonious, and synergistic academic 
affiliations. During the panel's deliberations, those affiliations will 
be broadly assessed in light of changes in medical education, research 
priorities, and the health care needs of veterans. The AAMC has worked 
with Dr. Kussman and VA staff to ensure that this will be an 
operational commission with measurable outcomes. Similarly, we have 
discussed the aspiration that the panel would facilitate putting in 
place criteria for evaluating the ``health'' of individual affiliation 
relationships.
     Development of VA Handbook on VHA Chief of Staff Academic 
Appointments--To prevent conflicts of interest or the appearance 
thereof, the VA has determined that limits on receiving remuneration 
from affiliated institutions are necessary for VHA employees at levels 
higher than chief of staff. While it is important to ensure that 
remuneration agreements do not create bias in the actions of VHA staff, 
prohibition of certain compensation from previous academic appointments 
(e.g., honoraria, tuition waivers, and contributions to retirement 
funds) could significantly hinder the VA's ability to recruit staff 
from their academic affiliates. The AAMC has worked with Dr. Kussman 
and VA staff to develop a mutually amicable agreement that considers 
this balance.
     Piloting the VA physician time and attendance/hours bank--
Monitoring physician time and attendance for the many medical faculty 
holding joint appointments with VA medical centers has been complicated 
and inefficient. The VHA has accepted the ``hours bank'' concept to 
improve the tracking of part-time physician attendance. Under the hours 
bank, participating physicians will be paid a level amount over a time 
period agreed to in a signed Memorandum of Service Level Expectations 
(MSLE). This agreement will allow the supervisor and participating 
physician to negotiate and develop a schedule for the upcoming pay 
period. A subsidiary record will track the number of hours actually 
worked, and a reconciliation will be performed at the end of the MLSE 
period to adjust for any discrepancies. A pilot for this program has 
been successfully completed under Dr. Kussman's leadership.
     Implementing health care resource contracting for 
veterans' care--VA Directive 1663 implements provisions of the 
``Veterans Health Care Eligibility Reform Act of 1996'' (Public Law 
104-262), which expands VA's health care resources sharing authority. 
Dr. Kussman and VA staff have worked with the AAMC to ensure that these 
changes would not adversely affect the VA's academic affiliations. As a 
result, the VA determined that sole-source contract awards with 
affiliates must be considered the preferred option whenever education 
and supervision of graduate medical trainees is required. Similarly, 
the decision to compete contracts for services overlapping programs in 
which the facility has graduate medical education training in place 
must be weighted by additional factors beyond the contract costs. The 
decision must consider all implications to the business, including the 
impact to the facility's training program, which is a direct 
contributor to the facility's productivity and may provide beneficial 
offsets.
    Mr. Chairman and Members of the Committee, I hope my testimony 
today has provided a better understanding of the extraordinary 
partnership between academic medicine and the VA, and in particular, 
the strong leadership Dr. Kussman has provided in many of our joint 
endeavors. I am confident that as Under Secretary for Health, Dr. 
Kussman's outstanding track record in public service as well as in 
putting patients first will combine to strengthen what has become the 
Nation's largest integrated health system.
    Once again, I would like to thank the Committee for this 
opportunity to appear here today and to congratulate Dr. Kussman on his 
nomination. Over the last 60 years, we have made great strides toward 
preserving the success of our affiliations. I look forward to working 
with Dr. Kussman in the future to strengthen these model partnerships 
between the Federal Government and nonfederal institutions. I am happy 
to answer any questions the Committee may have now or at a later date. 
Thank you.

    Chairman Akaka. Thank you very much.
    Dr. Frese?

      STATEMENT OF FREDERICK J. FRESE III, PH.D., MEMBER, 
   NATIONAL BOARD OF DIRECTORS, NATIONAL ALLIANCE ON MENTAL 
                            ILLNESS

    Mr. Frese. Chairman Akaka, Ranking Member Craig, Senator 
Murray, Senator Tester, and the other Members of the Veterans' 
Affairs Committee, thank you very much for inviting me. I am 
Fred Frese. I am here to give voice for the National Alliance 
on Mental Illness, NAMI, on the nomination of Michael Kussman, 
M.D., to be Under Secretary for Health of the Department of 
Veterans Affairs.
    My formal statement was submitted earlier and I ask that 
that be included in the record. The statement provides the 
Committee background on myself and background on NAMI, on whose 
national Board of Directors I have been serving for most of the 
last 12 years. With over 200,000 members and 1,200 chapters in 
every State, NAMI is the Nation's largest membership 
organization that advocates for the mentally ill.
    At the outset, lest there be any doubt, the Committee and 
Dr. Kussman should know that NAMI supports his nomination to be 
Under Secretary for Health, albeit with some reservations, 
which I would like to discuss.
    Mr. Chairman, I have a personal connection with these 
issues. In addition to being a psychologist and medical school 
faculty member, I am also a service-connected disabled veteran. 
In 1966, while serving in the Marine Corps, I was diagnosed 
with schizophrenia. I have been treated for this condition 
mostly by the Veterans' Administration, both in hospitals, and 
I have been in ten times, and as an outpatient. I believe I am 
an example of someone with a serious mental illness who can 
still contribute positively to American society. I am providing 
this Committee with my history to validate that mentally ill 
veterans such as myself can, in fact, serve in useful 
capacities and need not be shunted away or locked away in 
institutions. This, indeed, is the heart of NAMI's message, as 
well.
    We at NAMI are deeply involved in the care of veterans and 
the veterans' mental health programs nationwide because many of 
our family members and many of us are veterans. On the ground 
every day, we see the effects of national veterans service 
organizations that have been reported in the Independent Budget 
for years, every year for 21 years now, regarding the chronic 
underfunding of veterans' health care. Funding shortages have 
caused deterioration in many VA programs, including those about 
which we are most 
concerned.
    As veteran consumers and monitors, we know the VA programs 
that treat mentally ill veterans certainly need more funding 
for staff, administrative help, program development, 
technology, equipment, furnishings, et cetera. Our veterans, 
whether new ones from the current wars or previous military 
service, depend on the good will of key officials, such as Dr. 
Kussman, to meet the needs of those of us with these 
disabilities.
    In that regard, we are particularly pleased that the VA's 
National Mental Health Strategic Plan has been put together to 
reform its mental health program, taking from the President's 
New Freedom Commission's recommendations on mental health. It 
has been designed and is beginning to be implemented very well 
and we are very pleased about that.
    However, the Government Accountability Office documented 
recently the VA's failure to spend millions of available 
dollars for important initiatives that would continue these VA 
reforms. We ask the Committee to closely monitor the VA's 
investments and programs in mental health to guarantee funding 
that will remain available and will be used for the purposes 
which you would want them used.
    NAMI desires a closer relationship with Dr. Kussman and 
those who work on mental health policy. A number of obstacles 
have emerged recently that become somewhat problematic.
    NAMI is represented on the Consumer Affairs Council of the 
VA's Committee on Care of the Seriously and Chronically 
Mentally Ill Veterans, also known as the SMI Committee, 
authorized under Section 7321, Title 38 of the U.S. Code.
    Historically, the SMI Committee was an independent voice 
evaluating the VA. Recently, however, the activities of this 
Committee have been cut back and those of us both with the VSOs 
and consumer organizations have not had the input into this 
Committee that we have had in the past.
    Mr. Chairman, thousands of our troops have been exposed to 
massive explosions in Iraq and Afghanistan and come away 
apparently unharmed. We believe that these explosions have been 
called the signature injury of this war. Both Congress and NAMI 
will need to depend on Dr. Kussman's judgment to ensure needs 
of these veterans, as well as veterans from other wars, need to 
be addressed.
    Mr. Chairman, NAMI appreciates your invitation to testify 
and I will be pleased to answer any questions you may have for 
me on any of these issues. Thank you very much.
    [The prepared statement of Mr. Frese follows:]
 Prepared Statement of Frederick J. Frese III, Ph.D., Member, National 
        Board of Directors, National Alliance on Mental Illness
    Chairman Akaka, Ranking Member Craig, and Members of the Senate 
Committee on Veterans' Affairs:
    The National Alliance on Mental Illness (NAMI) appreciates your 
invitation to provide testimony regarding the President's nomination of 
Michael J. Kussman, M.D., to be Under Secretary for Health of the 
Department of Veterans Affairs (VA). My statement today constitutes a 
joint effort by our NAMI Veterans Council, ably chaired by Mrs. Mary 
Gibson of Waco, Texas, as well as our full national NAMI Board of 
Directors, on which I serve as a member and also as Chairman of its 
Veterans Subcommittee.
    At the outset, lest there be any doubt, I want the Committee and 
Dr. Kussman to know that NAMI supports his nomination to be Under 
Secretary for Health, albeit with some reservations that I will discuss 
in more detail in this statement.
    With 210,000 members, NAMI is the Nation's largest organization 
representing and advocating on behalf of persons with serious brain 
disorders that manifest in chronic mental health challenges. Through 
our 1,200 chapters and affiliates in all 50 states, NAMI supports 
education, outreach, advocacy and biomedical research on behalf of 
persons with serious brain disorders such as schizophrenia, manic 
depressive illness, bipolar disorder, major depression, severe anxiety 
disorders and other major mental illnesses affecting children and 
adults.
    In addition to serving on the NAMI Board, I have a very personal 
connection to these issues. I am a veteran. In 1966 while serving in 
the U.S. Marine Corps, I was selected for promotion to the rank of 
Captain. During that period I was first diagnosed as having the brain 
disorder schizophrenia--perhaps the most severe and disabling mental 
illness diagnosis. Over the years since my original diagnosis, I have 
been treated within the VA health care system, both as an inpatient at 
the VA hospital in Chillicothe, Ohio, and as an outpatient. I believe I 
am an example of someone with a serious mental illness who can still 
contribute positively to American society. During the past three 
decades I have functioned as a clinical psychologist and an 
administrator, served as Director of Psychology at Western Reserve 
Psychiatric Hospital for a 15-year period, and coordinated the Summit 
County Recovery Project to assist persons in recovery from mental 
illness to integrate into the vocational and social framework of 
greater Akron.
    I hold degrees from Tulane University, the American Graduate School 
of International Management, and masters and doctoral degrees in 
psychology from Ohio University. I am currently an Assistant Professor 
of Psychology in Clinical Psychiatry in the psychiatry departments at 
both Case Western Reserve University and the Northeastern Ohio 
Universities College of Medicine. At the latter facility, I lecture 
psychology interns and third year medical students, as well as third 
and fourth year psychiatry residents. Additionally during the past 
several years I have been invited to deliver annual lectures at the 
Uniformed Services University of the Health Sciences and the George 
Mason University Law School. I am providing the Committee this personal 
history not to boast, but to validate that mentally ill citizens like 
me can still serve in useful capacities and need not be shunted aside 
or locked in institutions.
    Mr. Chairman, our veteran members established the NAMI Veterans 
Council and Veterans Subcommittee to assure that closer attention is 
paid to mental health issues in the Department of Veterans Affairs 
(VA), not only at the national level, but also within each Veterans 
Integrated Service Network (VISN). The NAMI Veterans Council includes 
members from each of VA's 21 VISNs, and in that capacity we advocate 
for an improved VA continuum of care for veterans with severe and 
persistent mental illnesses. The council is composed of persons with 
mental illnesses, relatives of persons with mental illnesses, or 
friends with mental illnesses who have an involvement and interest in 
issues affecting veterans who suffer from severe and persistent mental 
illness. Some of the roles that Veterans Council members play include 
serving in liaison to VISNs; providing outreach to national veterans 
service organizations; educating Congress on the special circumstances 
and challenges of severe mental illness in the veteran population; and, 
working closely with NAMI state and affiliate offices on issues 
affecting veterans. Also our Veterans Council Executive Committee holds 
regular monthly conference calls where featured speakers present new 
information on developments in treatment, research, service delivery 
and service initiatives for veterans and active military servicemembers 
or dependents with severe and persistent mental illness. We also use 
these opportunities to stay informed of national developments in 
Congress and the executive branch that affect veterans struggling to 
recover from mental illnesses.
    Much has been reported in the news in the past few months about 
conditions at the Walter Reed Army Medical Center. Our organization--
dedicated to advancing health care, research and improving social 
understanding on matters that deal with dysfunction of the human mind--
was deeply disturbed as were you at hearing how combat veterans 
recovering from serious disabilities, including mental and emotional 
problems, were being maltreated and mistreated by the system then in 
place at Walter Reed. Adjusting to and recovering from, disability, 
whether it is physical or mental, is a challenge in itself that can 
rival the crossing of a mighty river against the current. But when that 
challenge is made more difficult by a layering of mindless but 
``official'' bureaucracy, delay, confusion, lost records, intimidation, 
threats, hazing and other inexcusable behaviors displayed in multiple 
reports of the media, this is doubly disturbing to us. These veterans 
should be treated more decently, with compassion and with care, assured 
that their needs are going to be met by a grateful government, not one 
that is bent on minimizing the cost of war by reducing or hiding the 
liability for their injuries and illnesses. One of the bittersweet 
lessons that may be learned from this war is that the ultimate cost to 
the human beings who had to actually fight it cannot be hidden from 
public view. We hope that this shameful episode in the facility's 
history has been laid to rest with renewed intentions and actions to 
improve our care of American military heroes. No veteran should be 
treated this way.
    NAMI members are deeply involved in the care of veterans in VA's 
mental health programs nationwide because many are family members of 
those veterans. Some of us are those veterans. On the ground every day 
we see the effects of what the national veterans service organizations 
have reported through the Independent Budget for years: chronic 
underfunding of veterans' health care. Funding shortages and emergency 
supplemental appropriations, combined with the regular employment of 
Continuing Resolutions as stopgap measures to provide financial 
resources for VA health care, have caused deterioration in many VA 
programs, including those about which we are concerned.
    We are particularly concerned that VA's ``National Mental Health 
Strategic Plan'' to reform its mental health programs, has been stalled 
by VA's over-arching financial problems. The General Accountability 
Office (GAO) issued a startling report last year to your House 
counterpart Committee documenting VA's failure to spend several 
millions of available dollars in pursuit of important initiatives that 
would continue moving VA in the right direction to reform its mental 
health programs. The Veterans Council Executive Committee met a few 
months ago with Dr. Ira Katz, Deputy Chief Patient Care Services 
Officer for Mental Health, to discuss his plans to improve the 
allocation of funds dedicated to the initiatives under the new 
strategic plan. We hope Congress will closely monitor VA's 
implementation of the new strategic plan to ensure it meets that 
promise.
    Mr. Chairman, we ask today: Is Michael Kussman qualified to be 
Under Secretary for Health? Speaking for NAMI, I must say that, while 
we have observed his presence in VA health care for several years, and 
are generally aware of his distinguished military career, it is fair to 
say that we at NAMI really do not know Dr. Kussman as well as we desire 
to know him. While serving as Chief Patient Care Services Officer, Dr. 
Kussman supervised the mental health programs of the Department. In 
that capacity and also during his term as Deputy Under Secretary, Dr. 
Kussman contributed positively to VA's corporate decision to engage and 
adopt concepts from the President's New Freedom Commission on Mental 
Health. He is to be commended for this stance. More recently as Acting 
Under Secretary, Dr. Kussman distinguished himself by making a number 
of comments in the media concerning the state of mental health of our 
fighting force in Iraq and Afghanistan. This statement is illustrative:

    ``Readjustment and reintegration issues are very common among 
servicemen returning from any combat. A large portion of people have 
this temporary reaction. These are normal reactions to abnormal 
situations and are not considered mental illnesses.'' (Washington Post, 
March 1, 2006)

    NAMI commends Dr. Kussman's view that we should not stigmatize 
veterans who need care for adjustment disorders that may be temporary 
in nature following a period of combat exposure. We strongly believe no 
one with a mental illness should be stigmatized, whatever the cause. 
However, some veterans of war come home with serious problems, 
including deep-seated mental health problems. We trust Dr. Kussman 
believes these veterans' needs must be addressed by a caring VA.
    As an organization concerned about the mental health of hundreds of 
thousands of Dr. Kussman's patients, NAMI desires to have a closer 
relationship with Dr. Kussman and those who work with him in mental 
health policy in Washington. A number of issues have emerged to make 
those relationships problematic, but should you confirm him we hope to 
work with Dr. Kussman to relieve them. Let me give you some pertinent 
examples.
    NAMI is represented on the consumer affairs council associated with 
VA's Committee on Care of Severely and Chronically Mentally Ill 
Veterans, also known as the ``SMI Committee,'' authorized in Section 
7321, Title 38, United States Code. This independent committee has 
played an active and vital role in determining policy and shaping 
programs in VA mental health care. I am privileged to have been a 
regular participant on this consumer affairs council. The SMI Committee 
was a driving force in VA's shift toward the ``New Freedom'' 
philosophy. To paraphrase the law, the Committee has a clear mandate to 
assess, and carry out a continuing assessment of, the capability of the 
VA to meet effectively the treatment and rehabilitation needs of 
mentally ill veterans whose mental illness is severe and chronic. The 
law requires the Committee to identify system-wide problems in caring 
for such veterans; identify specific facilities at which program 
enrichment is needed to improve treatment and rehabilitation; and 
identify model programs that should be implemented more widely in or 
through facilities of the VA. The Committee is required to advise the 
Under Secretary regarding the development of policies for the care and 
rehabilitation of severely chronically mentally ill veterans, and to 
make recommendations to the Under Secretary for improving programs of 
care of such veterans; for establishing special programs of education 
and training relevant to their care; regarding research needs and 
priorities relevant to the care of such veterans; and regarding the 
appropriate allocation of resources for all such activities. The 
Secretary is required by law to submit a variety of reports to Congress 
on the work of the SMI Committee and VA's responses to the Committee's 
recommendations.
    Historically the SMI Committee met four times each year to carry 
out its responsibilities, held regular conference call meetings, 
reported at regular intervals, and provided VA and Congress an 
important and independent voice in evaluating VA's mental health 
programs, especially those that deal with veterans with psychoses and 
other very serious problems. Several years ago, VA Central Office 
(VACO) determined the SMI Committee would be afforded only two meetings 
annually. VA re-chartered the Committee in 2006 and populated it with 
new membership, some of whom were unfamiliar with the Committee's 
history or role. The Consumer Affairs Council's participation since 
that time has been severely restricted. The SMI Committee now seems 
moribund. To NAMI and other participating organizations, this is a very 
large matter in terms of muffling a source that has provided VA and 
Congress an independent means of evaluating a very important VA 
program. We hope your Committee will determine whether VA's 
justification for restricting and suspending the activities of this key 
committee was warranted, and to examine Dr. Kussman's role and reasons 
for those decisions.
    Another issue of concern to NAMI bears discussion today. In the 
past several fiscal years, VA's expenditures in mental health have 
unquestionably risen, and we deeply appreciate this Committee's 
insistence that VA mental health spending be maintained. Nevertheless, 
in the final compromise on Public Law 110-5, the ``Revised Continuing 
Appropriations Resolution, 2007,'' Congress removed a recurring 
requirement that VA spend at least $2.2 billion in programs of mental 
health care this year. The following text carried out that decision:
    ``Sec. 20810. Notwithstanding any other provision of this division, 
the following provisions included in the Military Quality of Life, 
Military Construction, and Veterans Affairs Appropriations Act, 2006 
(Public Law 109-114) shall not apply to funds appropriated by this 
division: the first, second, and last provisos, and the set-aside of 
$2,200,000,000, under the heading `Veterans Health Administration, 
Medical Services'; the set-aside of $15,000,000 under the heading 
`Veterans Health Administration, Medical and Prosthetic Research'; the 
set-aside of $532,010,000 under the heading `Departmental 
Administration, Construction, Major Projects'; and the set-aside of 
$155,000,000 under the heading `Departmental Administration, 
Construction, Minor Projects'.'' (emphasis added)
    While we appreciate the need to give the VA flexibility in its 
spending decisions under the Medical Services account, NAMI comes from 
a perspective of observing, and hopefully protecting, a number of 
programs important to our members and to the veterans under VA care 
about whom we are most concerned. The set-asides in prior 
appropriations acts gave us assurance of dependability of funding 
sources for VA programs that provide our loved ones the care they need. 
Without that protection, some in VA may believe they are free to shift 
resources from these programs to the detriment of veterans with serious 
mental illnesses. We ask that your Committee closely examine Dr. 
Kussman's commitment to spend appropriate sums on mental health 
programs to ensure this commitment is kept.
    Mr. Chairman, the current overseas wars in Iraq and Afghanistan are 
producing a very heavy burden in follow-on mental health treatment and 
counseling requirements. While we very much want to agree with the 
sentiments of Dr. Kussman, that the vast majority of our soldiers, 
sailors, marines, airmen and Coast Guardsmen are repatriating whole and 
healthy, with temporary adjustment problems, some reports are not 
encouraging. About two of every ten serving members are experiencing 
problems of a magnitude about which we all should be concerned. About 
70,000 individuals have so far touched VA with some kind of mental or 
emotional challenge in post-service life. The military departments are 
rotating active, reserve and Guard forces through these wars in 
multiple deployments of individuals and units. The press has reported a 
number of cases of individuals having been deployed who may not be in 
ready condition to serve, some with worrisome mental states. Given the 
drag of this war, it is not surprising that military recruiters are 
beginning to fail to meet their quotas or are meeting them by enlisting 
marginal candidates whose mental status might be of serious concern to 
domestic employers. Another outcome of these wars is the unknown degree 
to which ``mild'' and ``moderate'' traumatic brain injury (TBI) is 
going to manifest into behavioral, medical and psychosocial problems 
later. Thousands of our troops have been exposed to massive explosions 
in Iraq and Afghanistan but have come away apparently ``unharmed'' 
according to our current technology to measure harm. We believe the 
complete story of those exposures is yet to be told.
    Dr. Charles Hoge of the Walter Reed Army Institute of Research 
reported the following findings last year in a study he published in 
the New England Journal of Medicine:

    ``This study has shown that overall 15-17 percent of Soldiers from 
combat units screen positive for PTSD when surveyed 3-12 months after 
returning from deployment to Iraq. When we added one additional 
question related to functional impairment at the end of the 17 question 
PTSD scale, we found that 10 percent of Soldiers surveyed 12 months 
after deployment reported that PTSD symptoms have made it very 
difficult to do their work, take care of things at home, or get along 
with other people. The inclusion of screens for major depression and 
generalized anxiety raise the rates of screening positive to 
approximately 20 percent; 16 percent of Soldiers surveyed 12 months 
after returning from Iraq screened positive for PTSD, depression, or 
anxiety and reported that there was functional impairment at the `very 
difficult' level.''

    Mr. Chairman, while many say that TBI is the ``signature injury'' 
of these wars, we believe the picture is more mixed, with a large 
burden of the war legacy expressing itself in mental and emotional 
damage from both TBI, post-traumatic stress disorder (PTSD), 
depression, substance abuse and other problems. We hope the Committee 
as well as the VA will remain vigilant and sensitive to the needs of 
this new generation as time goes by, because their needs are going to 
exist long after cessation of deployment of our forces into Southwest 
Asia. In this instance both Congress and NAMI need to depend on Dr. 
Kussman's judgment to ensure these needs are addressed with sensitivity 
and care.
    The Secretary of Veterans Affairs James Nicholson has testified on 
VA's intentions with respect to funding mental health services in 
Fiscal Year 2008. On February 8, 2007, and again on February 13, 2007, 
he stated ``The President's request includes nearly $3 billion to 
continue our effort to improve access to mental health services across 
the country. These funds will help ensure VA provides standardized and 
equitable access throughout the Nation to a full continuum of care for 
veterans with mental health disorders. The resources will support both 
inpatient and outpatient psychiatric treatment programs as well as 
psychiatric residential rehabilitation treatment services. We estimate 
that about 80 percent of the funding for mental health will be for the 
treatment of seriously mentally ill veterans, including those suffering 
from post-traumatic stress disorder (PTSD). An example of our firm 
commitment to provide the best treatment available to help veterans 
recover from these mental health conditions is our ongoing outreach to 
veterans of Operation Iraqi Freedom and Operation Enduring Freedom, as 
well as increased readjustment and PTSD services.'' (emphasis added)
    Without guidance from your Committee, Mr. Chairman, and strong 
oversight by other committees of jurisdiction, it is challenging at 
best for NAMI to measure whether, indeed, Secretary Nicholson's 
commitment, and presumably one to which Dr. Kussman agrees, will be 
fulfilled next year. As consumers and monitors, we know the VA programs 
that treat mentally ill veterans certainly need more funding--for 
professional and support staff, administrative help, program 
development, technology, equipment, furnishings, infrastructure, family 
caregiver respite and other supports. Our veterans in need of care for 
serious mental health conditions, whether new veterans from current 
wars or veterans from previous military service periods, depend on the 
good will of such promises. We ask your Committee to monitor VA's 
investments and programs in mental health care to guarantee funding 
will remain available and will be used for the purpose for which it is 
intended.
    In summary, holding in abeyance our stated reservations and looking 
optimistically to the future, NAMI believes Dr. Kussman is fully 
qualified to serve as VA Under Secretary for Health. We recommend you 
report this nomination and that the Senate confirm him to serve as 
Under Secretary for Health. Should the Senate in its wisdom confirm him 
for this position, we hope to gain a better working relationship with 
Under Secretary Kussman as time goes along. NAMI wants to be a partner 
with VA as the New Freedom reforms are put into place, and as more 
veterans of the current wars come to VA for aid. We want to work with 
Dr. Kussman, Dr. Katz and other key VA officials in Washington and 
across the VA system to ensure VA meets its responsibilities for the 
care of veterans with serious and chronic mental illnesses, whether 
from this war or previous military engagements.
    Chairman Akaka, Ranking Member Craig and other distinguished 
Members of the Committee, NAMI appreciates your invitation to testify, 
and we thank you for giving consideration to our views.

    Chairman Akaka. Thank you very much, Dr. Frese.
    Mr. Mitchell?

 STATEMENT OF DOUGLAS H. MITCHELL, JR., ACSW/LCSW, PRESIDENT, 
                ASSOCIATION OF VA SOCIAL WORKERS

    Mr. Mitchell. Mr. Chairman and Members of the Committee, 
good morning. I am here today representing the Association of 
VA Social Workers, all of whom are employed obviously by the 
Veterans Health Administration. I myself am a veteran of the 
United States Army. I served from February 1966 to September 
1973. I also received health care in the private sector and I 
currently have elected to receive my own health care within the 
Department of Veterans Affairs. I can tell you, it is my firm 
belief that the health care available in the Department of 
Veterans Affairs is second to none.
    During the 22 years I have been employed by the Department 
of Veterans Affairs, I have been through several 
reorganizations and several changes in functioning. Most 
recently, I would like to talk about the changes that have been 
enacted by Dr. Kussman. Specifically, I believe that he is 
committed for each of our veterans to make the transition from 
active duty to veteran status as seamless as possible. Dr. 
Kussman was responsible for placing a liaison social worker at 
Walter Reed Army Medical Center to help ease this transition. 
Within a few months, a second social worker was added, and now 
we have 14 social workers at military treatment facilities, all 
designed to assist with easing the transition from veteran 
status into VA care.
    Dr. Kussman is, of course, seriously interested in those 
most severely injured, the polytrauma veterans. The second 
phase of seamless transition included a case management program 
to ensure that no veteran falls through the cracks. Each VA 
medical center has a nurse or a social worker, a case manager 
who follows their patients wherever they go, either inpatient, 
outpatient, or back to the community.
    Although the VA has had a system of four Traumatic Brain 
Injury Centers for years, Dr. Kussman, through his concern for 
OIF/OEF veterans, required more comprehensive care. He 
converted those TBI centers to polytrauma centers to ensure 
that veterans received concurrent care for all of their 
injuries, including TBI, amputation, spinal cord injury, visual 
impairment, hearing loss, combat stress, and PTSD, in one 
location. More recently he expanded this with the polytrauma 
system of care, which includes the four polytrauma TBI centers 
and 17 additional network polytrauma sites.
    When the Secretary announced that he wanted to hire 100 new 
patient advocates, Dr. Kussman had a vision for how these new 
employees could help the most severely injured OIF veterans 
with their transition. The new transition patient advocates are 
being assigned to active duty patients while they are still on 
active duty. They go to the military treatment facility, 
establish contact, establish a relationship, and act as an 
ombudsman for those severely injured veterans as they return 
both to the VA and to their 
community.
    Dr. Kussman understands that our patients and families are 
people who are experiencing multiple life crises and he fully 
supports the team effort to help patients and families cope 
with all of these challenges they are facing, which includes 
medical, social, psychological, and spiritual. He recognizes 
that we are as we go reinventing the health care system to 
serve a new generation of veterans and he supports this effort.
    At Dr. Kussman's direction, a committed team of VA staff 
developed a template that automatically screens for medical 
conditions endemic to the Gulf area as well as TBI. This 
template, again, automatically triggers specialty consults for 
further evaluation. This multi-disciplinary team consists of 
physicians, nurse practitioners, physician assistants, 
information management, social work, nursing, speech pathology, 
and mental health practitioners. It is truly an effort to treat 
the whole veteran.
    Equally extraordinary, if I may, is the relationship that 
has developed in Phoenix between the Veterans Health 
Administration and the VBA regional office. Lower-level 
workers, myself included, established relationships with their 
lower level workers and together we developed a working 
relationship that resulted in a memo of understanding with the 
U.S. Army Reserves and the Army National Guard that we would 
attend every demobilization, every sort of activity we could in 
order to make these new veterans aware, or these potential 
veterans aware of benefits that were available to them.
    Finally, and personally, very personally, most important to 
me, is that I believe that Dr. Kussman has empowered each of us 
at the facility level to do the right thing for the veteran. 
Thank you.
    [The prepared statement of Mr. Mitchell follows:]
   Prepared Statement of Douglas H. Mitchell, Jr., MSW, LCSW, ACSW, 
              President, Association of VA Social Workers
    Mr. Chairman and Members of the Committee, good morning. I am here 
today representing the membership of the Association of VA Social 
Workers employed by the Veterans Health Administration.
    First of all, I am a veteran of the United States Army. I proudly 
served my country from February 22, 1966 to September 4, 1973.
    I also receive my medical care through the Department of Veterans 
Affairs. I am equally proud to do so. Having received care both outside 
VA and inside, I feel qualified to state unequivocally that there is no 
comparison; the VA is second to none.
    I have been employed by VA for 22 years. For the past 13 years, I 
have been assigned to the Carl T. Hayden VA Medical Center in Phoenix, 
AZ as the Assistant Chief of Social Work and for the last 10 years as 
the Chair of the Social Work Department.
    During my tenure in Phoenix, I have observed the VA health care 
system evolve from a rigid, facility centered hospital system with 
virtually little regard for resource availability to a vibrant, 
patient-centered system determined to deliver the best quality care in 
the most efficient manner closer to home. I would like to highlight 
some specifics concerning experience in the field based upon decisions 
Dr. Kussman has made.
    I believe Dr. Kussman is committed to making the transition from 
active duty military to veteran status and community life as seamless 
as possible. In August 2003, Dr. Kussman started the seamless 
transition program. He placed a VA social worker at the Walter Reed 
Army Medical Center to help transfer active duty patients to VA medical 
centers. Within a few months, a second social worker was added. Today, 
we have 14 social worker liaisons at 10 military hospitals. Dr. Kussman 
supports the liaisons and knows them by name. In Phoenix, our case 
managers interact often with these individuals.
     Dr. Kussman is committed to the best quality care possible 
for all veterans. But he is particularly concerned with the severely 
injured OEF/OIF veterans. The second phase of seamless transition 
included a case management program to ensure that no veteran falls 
through the cracks. Every VA medical center has nurse or social worker 
case managers who follow their patients wherever they go--inpatient to 
outpatient to the community.
     Although VA has had a system of 4 Traumatic Brain Injury 
(TBI) Centers since the early 1990s, Dr. Kussman believed that the 
severity of the injuries of OEF/OIF veterans required that we provide 
more comprehensive care. He converted the TBI centers to Polytrauma 
Centers to ensure that veterans could receive concurrent treatment for 
all of their injuries including TBI, amputation, spinal cord injuries, 
visual impairment, hearing loss, combat stress and PTSD in one 
location. Further, he developed the Polytrauma System of Care, which 
includes the 4 Polytrauma/TBI Centers and 17 Network sites.
     When the Secretary announced that he wanted to hire 100 
patient advocates, Dr. Kussman had a vision for how these new employees 
could help the most severely injured OEF/OIF veterans with their 
transitions. The new transition patient advocates (TPAs) are being 
assigned to active duty patients while they are still at the military 
hospital to meet the patient and family and serve as an ombudsman to 
help them with any problems or concerns and assist them in navigating 
in both the DOD and VA systems.
     Under Dr. Kussman's guidance, VA developed a computerized 
veterans tracking system to (a) notify the gaining facility of the 
patient's pending discharge, (b) document the patient's status and, c) 
notify staff as to both the clinical and logistical status.
     Dr. Kussman is a physician who understands and promotes 
interdisciplinary care. Under his leadership, all clinical team members 
work together with patients and families on treatment plans and 
treatment decisions.
     Dr. Kussman also understands the importance of families 
and supportive services for them. He has been a staunch supporter of 
the VA Fisher House Program and has ensured that VA medical centers, 
particularly the Polytrauma/TBI Centers, address family needs. He 
understand that our patients and families are people experiencing 
multiple life crises and he fully supports a team effort to help 
patients and families cope with all of the challenges they are facing 
which include medical, social, psychological and spiritual.
    In summation, I strongly believe that:
    Dr. Kussman is a hands-on leader in terms of supporting the staff 
and the patients.
    He recognizes that we are re-inventing a health care system to 
serve a new generation of veterans and his enthusiastic support for 
innovative ideas has resulted in unprecedented levels of case 
management and high quality care for a veteran population transitioning 
from active duty to civilian life.
    An immediate local example in Phoenix is that, for more than two 
years, we have known of the need to evaluate all veterans who have been 
exposed to blasts, incidents or accidents that could conceivably result 
in neuropsychological impairment. At Dr. Kussman's direction, a 
committed team of VA clinical staff developed a CPRS template that 
screens for medical conditions endemic to the Gulf area as well as TBI. 
This template automatically triggers specialty consults for further 
evaluation. This multidisciplinary team consists of Physicians, Nurse 
Practitioners, Physician Assistants, Information Management, Social 
Work, Nursing, Speech Pathology, and Mental Health practitioners. It is 
truly an effort to treat the whole veteran.
    Perhaps even more extraordinary is the relationship that has 
developed between the VBA Regional Office and the VA Medical Center due 
to Dr. Kussman's leadership. The Phoenix VARO sends personnel to 
evening groups at our medical center to explain veteran's benefits, 
initiate claims for service connected disability compensation and to 
provide access to the complete array of services available through VBA. 
In previous years, ``One VA'' was a slogan. In Phoenix, it has become 
the practice.
    Finally, and most important to me, Dr. Kussman empowers each of us 
in VA to do the right thing for our patients.

    Chairman Akaka. Thank you very much, Mr. Mitchell.
    Mr. Wallace?

      STATEMENT OF ROBERT E. WALLACE, EXECUTIVE DIRECTOR, 
   WASHINGTON OFFICE, VETERANS OF FOREIGN WARS OF THE UNITED 
                             STATES

    Mr. Wallace. Thank you, Mr. Chairman, Senator Craig, and 
Members of the Committee. I am pleased to appear before you 
today representing the 2.4 million men and women of the 
Veterans of Foreign Wars of the United States and our 
Auxiliaries. I am here to discuss the nomination of Brigadier 
General Michael J. Kussman, M.D., United States Army, Retired, 
to be the Under Secretary for Health for the Veterans Health 
Administration of the United States Department of Veterans 
Affairs.
    It is my privilege to offer the strong support of the 
Veterans of Foreign Wars of the United States for Dr. Kussman, 
a man we believe is clearly qualified for this vital position 
and whom we feel sincerely and honestly cares about veterans 
and the issues they confront. He will be an excellent Under 
Secretary for Health.
    I am also pleased to note for the record that my colleagues 
from the AMVETS, Disabled American Veterans, Paralyzed Veterans 
of America, and Vietnam Veterans of America join with the VFW 
in supporting Dr. Kussman's nomination.
    I come before you today not just as a veteran's advocate, 
but as a VA shareholder. I earned my stock when I wore the 
uniform of this great Nation, like millions of other veterans 
have. As a shareholder of a corporation, I want the best 
leadership for the company that I have invested in. Veterans 
demand effective and efficient leadership in a Department in 
which they have also so much invested.
    We have all witnessed over the years problems that VHA has 
encountered. So many times, the issues could have been 
prevented if there were true leadership, management, and 
accountability at all levels of the system. Dr. Kussman's 
experience demonstrates that he possesses these and many other 
qualities that make him the right person for the position.
    His years of service in the United States Army, rising to 
the rank of Brigadier General of the Medical Corps, shows he is 
a leader, knows how to work with others, knows how to manage 
people, hold them accountable, and at the same time knows how 
to motivate people. Dr. Kussman was selected as the top 
candidate for this position by an independent search Committee, 
a requirement of Congress. You made this a requirement, I 
believe, to ensure that the highest quality and most 
professional candidate would be recommended for this position 
and that no undue influence would play into the process.
    The American Legion, due to their constitution, is unable 
to publicly support or oppose any nominees. However, based on 
the need for a permanent Under Secretary for Health of VHA and 
the fact that Dr. Kussman was recommended by the search 
committee, they also agree that his nomination should move 
forward.
    I did not serve on the search committee. However, I have 
served on other search committees in the past and can attest to 
the fact that they are fiercely independent. The VFW's support 
of Dr. Kussman is not just based on the search committee's 
recommendation. Our beliefs are based on our personal 
experience interacting with him on health care issues faced by 
our Nation's veterans.
    Dr. Kussman cares deeply about veterans and the issues 
confronting their health care and well-being. He is highly 
responsive to their needs. In conversations, you can tell his 
sincerity. When we differ on policy issues or have policy-
related questions, he does not hesitate to give us a fair 
hearing and is open to ideas, whether he ultimately agrees with 
us or not. That is all that we as VA shareholders can ask for 
from the head of the Veterans Health Administration.
    But that truly is his strength. He cares passionately about 
VA's mission to help veterans and their dependents and he takes 
criticism of the system personally, leading him to strive for 
excellence and in doing so to motivate others. He is not a 
person who is full of excuses when mistakes are made and we 
have found that he takes a personal approach to solving 
problems, ensuring that the best care is provided to our 
Nation's veterans by the VA.
    Dr. Kussman can rightly pride himself on the high quality 
of veterans' health care. Since 2000, he has been a part of 
VHA, a period in which VHA has rightfully been lauded for the 
high quality of its health care. Many articles in major 
publications have said VHA delivers the best care anywhere. His 
personal philosophy is to continue to improve on these facts 
and the quality of care delivered and to never allow the care 
given to our Nation's veterans to diminish, just improve.
    Certainly, the system is not perfect. Access, especially 
for specialty care, continues to be a challenge, although we 
would argue that this is a function of a lack of dedicated and 
on-time resources, not one of administration. Once in the 
system, veterans are very pleased and typically receive the 
best care. There have been some high-profile examples yesterday 
where this has not been the case, and I do not want to make 
light of them, but I am confident and the VFW is confident that 
Dr. Kussman's leadership and his strong desire and dedication 
to improving VA health care will do much to fix these 
situations.
    Dr. Kussman has demonstrated a deep concern about the 
health issues facing all veterans, especially those with 
specialized needs and those serving today. He wants to have VA 
learn more about traumatic brain injuries as well as improve on 
the delivery of mental health care.
    One of the major challenges he will face is finding 
qualified clinicians who fully understand the new challenges 
brought on by the war and to help the thousands of returning 
servicemembers who need first-rate mental health care and 
specialized services. We are confident that he is up to the 
challenge.
    We feel that his years of experience managing health care 
facilities and systems give him the knowledge and experience to 
understand the business side of VHA and how to best use 
taxpayers' money in an efficient way while still delivering 
high-quality health care. Those years of experience demonstrate 
that he is more than qualified to lead the thousands of 
hardworking and dedicated employees within VHA.
    We believe he is a man who will not be afraid to butt heads 
with the Office of Management and Budget, you the Congress, or 
the Department of Defense. Many of the issues and challenges 
VHA faces today will be helped by Dr. Kussman's military 
experience. All of us in Washington have been talking about a 
true system where DOD and VA create a seamless transition for 
military personnel to veteran status. We believe that if anyone 
can make it happen, it is Dr. Kussman because he understands 
both systems.
    The VFW sincerely believes Dr. Michael Kussman is the right 
person to lead the Veterans Health Administration and we cast 
our unanimous votes, our shares, for his immediate 
confirmation. We urge the Committee to favorably report his 
nomination to the full Senate and we ask your colleagues to 
confirm him as the Under Secretary for Health without delay.
    I thank you for the opportunity to testify today. I would 
be more than happy to answer any questions you may have.
    [The prepared statement of Mr. Wallace follows:]
     Prepared Statement of Robert E. Wallace, Executive Director, 
    Washington Office, Veterans of Foreign Wars of the United States
    Mr. Chairman and Members of the Committee:
    I am pleased to appear before you today representing the 2.4 
million men and women of the Veterans of Foreign Wars of the U.S. (VFW) 
and our Auxiliaries. I am here to discuss the nomination of Brigadier 
General Michael J. Kussman, M.D. (United States Army Ret.) to be the 
Under Secretary for Health for the Veterans Health Administration 
(VHA), United States Department of Veterans Affairs (VA).
    It is my privilege to offer the strong support of the Veterans of 
Foreign Wars of the United States for Dr. Kussman, a man we believe is 
clearly qualified for this vital position, and whom we feel sincerely 
and honestly cares about veterans and the issues that confront them. He 
will be an excellent Under Secretary for Health.
    I am also pleased to note for the record that my colleagues of the 
AMVETS, Disabled American Veterans, Paralyzed Veterans of America and 
the Vietnam Veterans of America join with the VFW in supporting Dr. 
Kussman's nomination.
    I come before you today, not just as a veterans advocate, but as a 
VA shareholder. I earned my stock when I wore the uniform of this great 
Nation, like millions of other veterans have. Just as a shareholder of 
a corporation wants the best leadership for the company they have 
invested in, veterans demand strong, effective and efficient leadership 
of the Department in which we all have so much invested.
    We have all witnessed over the years problems that VHA has 
encountered. So many times the issues could have been prevented if 
there were true leadership, management and accountability at all levels 
of the system. Dr. Kussman's experience demonstrates that he possesses 
these and many other qualities that make him the right person for the 
position. His years of service in the United States Army rising to the 
rank of Brigadier General of the Medical Corps shows he is a leader, 
knows how to work with others, and knows how to manage people, holding 
them accountable and motivating them.
    Dr. Kussman was selected as the top candidate for this position by 
an independent search committee, a requirement of Congress. You made 
this a requirement, I believe, to ensure the highest quality and most 
professional candidates would be recommended for this position, and 
that no undue influence would play into the process.
    I did not serve on this search committee; however, I have served on 
search committees in the past, and can attest to the fierce 
independence of the process. Dr. Kussman's selection as the top 
candidate of the three recommended to the Secretary is a strong 
indication that his credentials and interview impressed the committee--
many of whom are not involved in the day-to-day operation of VHA. It 
further demonstrates that they too felt he would be a capable, 
independent and effective leader.
    The VFW's support for Dr. Kussman is not just based on the search 
committee's recommendation. That just reaffirmed our beliefs that he is 
the right person for the position. Our beliefs are based on our 
personal experiences interacting with him on health care issues faced 
by our Nation's veterans.
    Dr. Kussman cares deeply about veterans and the issues confronting 
their health care and well-being. He is highly responsive to their 
needs. In conversations, you can tell his sincerity. When we differ on 
policy issues or have policy-related questions, he does not hesitate to 
give us a fair hearing, and is open to ideas whether he ultimately 
agrees with us or not.
    That is all we--VA's shareholders--can ask for from the head of the 
Veterans Health Administration.
    That truly is his strength. He cares passionately about VA's 
mission to help veterans and their dependents. And he takes criticism 
of the system personally, leading him to strive for excellence, and in 
doing so to motivate others. He is not full of excuses when mistakes 
are made, and we have found that he takes a personal approach to 
solving problems, ensuring that the best care is provided to veterans 
in VA.
    Dr. Kussman can rightfully pride himself on the high quality of 
veterans' health care. Since 2000, he has been part of VHA, a period in 
which VHA has rightfully been lauded for the high quality of its health 
care. Many articles in major publications have said VHA delivers the 
best care anywhere.

     A 2004 RAND study found that VA hospitals outperformed 
private facilities in over 294 categories of care.
     The 2006 American Customer Satisfaction Index found that 
veterans had a 10 percent higher satisfaction rate with VA health care 
than the general public has with private hospitals.
     VA is at the forefront of advances in medical records 
technology, and their electronic medical records system is the envy of 
the medical care field.
     VA health care is significantly cheaper per patient than 
private health care and efficiency of service has kept the increase in 
per patient costs far below the overall costs of medical inflation.

    His personal philosophy is to continue to improve on these facts 
and the quality of care delivered, and to never allow the care given to 
our Nation's veterans to diminish, just improve.
    Certainly the system is not perfect. Access, especially for 
specialty care, continues to be a challenge; although we would argue 
that this is a function of a lack of dedicated and on-time resources, 
not one of administration. Once in the system, veterans are very 
pleased and typically receive the best of care. There have been some 
high profile examples recently where this has not been the case, and I 
do not want to make light of them, but we are confident that Dr. 
Kussman's leadership, and his strong desire and dedication to improving 
VA health care will do much to fix these situations. Dr. Kussman has 
demonstrated a deep concern about the health issues facing all 
veterans, especially those with specialized needs, and those serving 
today. He wants to have VA learn more about traumatic brain injuries as 
well as improve on the delivery of mental health care.
    One of the challenges he will face is finding qualified clinicians 
who fully understand the new challenges brought on by the war, and to 
help the thousands of returning servicemembers who need first-rate 
mental health care and specialized services. We are confident that he 
is up to the challenge.
    We feel that his years of experience managing health care 
facilities and systems give him the knowledge and experience to 
understand the business side of VHA and how to best use taxpayer's 
money in an efficient way while still delivering high-quality health 
care. Those years of experience demonstrate that he is more than 
qualified to lead the thousands of hardworking and dedicated employees 
within VHA.
    Further, we believe he is a man who will not be afraid to butt 
heads with the Office of Management and Budget for proper funding, the 
Congress or the Department of Defense (DOD).
    Many of the issues and challenges VHA faces today will be helped by 
Dr. Kussman's military experience. All of us in Washington have been 
talking about a true system where DOD and VA create a seamless 
transition for military personnel to veterans' status. We believe that 
if anyone can make that happen, it is Dr. Kussman, because he 
understands both systems and knows the necessity of creating such a 
system for the care and treatment of our wounded warriors, ensuring 
that they receive the benefits they have rightly earned by their 
honorable service to our Nation.
    The VFW sincerely believes Dr. Michael Kussman is the right person 
to lead the Veterans Health Administration and we cast our unanimous 
votes--our shares--for his immediate confirmation.
    Mr. Chairman, as I mentioned earlier, the VFW is joined by the 
AMVETS, Disabled American Veterans, the Paralyzed Veterans of America, 
and the Vietnam Veterans of America in strongly supporting the 
nomination of Dr. Michael Kussman for the position of Under Secretary 
for Health, Veterans Health Administration, Department of Veterans 
Affairs.
    We urge this Committee to favorably report his nomination to the 
full Senate, and we would ask your colleagues to confirm him as the 
Under Secretary of Health without delay.
    I thank you for the opportunity to testify today, and I would be 
happy to answer any questions you may have.

    Chairman Akaka. Thank you very much, Mr. Wallace.
    I want to thank all of you for your thoughtful and 
comprehensive testimony. I believe you have given the Committee 
a good understanding of where your organizations stand on Dr. 
Kussman's nomination, and I want you to know that I appreciate 
your taking the time to appear here today.
    As I said at the outset, because of time, we would go 
directly to this first panel and therefore did not offer an 
opening statement. At this time, I would like to include my 
full statement in the record and ask other Members for any 
statement or questions they may have for this panel.
    Chairman Akaka. May I call first on Senator Craig?

       STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER, 
                    U.S. SENATOR FROM IDAHO

    Senator Craig. Mr. Chairman, thank you for holding this 
hearing and doing a confirmation hearing in a way that, I 
think, adds the dimension and the reality of the personality as 
much as the experience and the qualifications of the 
personality that comes before us. So I thank you for that.
    I do have a full statement I will enter into the record. 
But I do want to say in entering that statement into the record 
that in my conversations with Dr. Kussman, recognizing almost 
40 years now of the kind of experience that he brings to this 
position, recognizing that we have been without a person in 
this capacity for an extended period of time, the thing that I 
was most impressed about, because the credentials are evident, 
as you know--there is the resume, look at it, a phenomenal list 
of experiences--but my conversations with Mike Kussman left me 
appreciating something that sometimes you don't hear from 
nominees and that was an open and obvious passion for the job 
and a sincerity and concern about veterans that really stood 
out.
    We recognize the new challenges, and I think Mr. Mitchell 
put it well. You keep reinventing this health care system to 
fit the new veteran, and we have got to do that. It has got to 
be a dynamic system, and sometimes we are not as quick to catch 
up, but we do catch up. When you have somebody in the capacity 
that the President has asked Dr. Kussman to serve in, you need 
that kind of talent, and I think it is obvious within the man. 
It is obviously clearly to me within the passion of the person 
that we have got before us, and so I am pleased. I hope we can 
move him and move him expeditiously.
    And let me thank this panel for their openness and their 
directness about this particular gentleman. It is a 
phenomenally important position for veterans because it will 
sustain and, I hope, enhance one of the best health care 
delivery systems in the country today, if not the best, and 
that is what we are all about here.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Craig follows:]
      Prepared Statement of Hon. Larry E. Craig, Ranking Member, 
                        U.S. Senator from Idaho
    Good morning, Mr. Chairman. I want to thank you very much for 
calling this hearing to review the qualifications of Dr. Michael 
Kussman to head the VA health care system. I also want to thank all of 
the witnesses on the first panel for coming here this morning to voice 
their views on this man.
    Mr. Chairman, I'd like to say at the outset of this hearing that 
based on a review of his record and having spent some time with him 
personally, I believe Dr. Kussman is very qualified for this job. And I 
strongly support his nomination.
    Mike Kussman, a physician for almost 40 years, is a veteran of the 
United States Army, who retired as a Brigadier General after serving 
this Nation on active duty for over 20 years. . . . He has published 
numerous papers; served on countless boards and Committees inside and 
outside of government; and managed some of the military's largest 
medical installations.
    In short, he is a highly educated and dedicated, Army veteran, with 
management experience who understands both the military and VA health 
care systems inside and out.
    But Mr. Chairman, I'd also like to suggest to the Committee that 
perhaps Dr. Kussman is more than simply qualified for the job. After 
all qualifications are largely just objective facts about a person. 
They are a person's education and experience. While I hope I'm not 
offending him by saying this. Candidly, I'm sure there are a few other 
people along with Dr. Kussman who are technically qualified to lead 
VA's health care system.
    But, when you add Mike's qualifications together with the enormous 
passion for the job he displayed during my interview with him. And then 
you wrap that passion around the integrity and character of this 
gentleman, I find someone with more than just qualifications. I find 
the right man for the job.
    Mr. Chairman, I know you and I share this view of Dr. Kussman. So, 
I hope we are able to work with our colleagues to move quickly on his 
confirmation. The VA health care system needs strong, confirmed 
leadership at the helm to care for our veterans. We have spent nearly 9 
months seeking out the person to fill the position left vacant by Dr. 
Perlin's departure last year.
    I believe we have found that person. He enjoys the strong support 
of our veterans' service organizations, the professional medical 
community, many of his former colleagues in the military, and even his 
current employees. I think that speaks volumes about this nominee. I 
hope our colleagues will join us in supporting Dr. Kussman.
    Thank you, again, Mr. Chairman, for holding this hearing. I look 
forward to hearing from all of our witnesses.

    Chairman Akaka. Thank you very much, Senator Craig.
    I would like to call on Senator Tester and Senator Murray 
for any comments, statements, or questions they may have. 
Senator Tester?

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman, Ranking Member 
Craig. I want to thank the panel also for being here and taking 
time out and giving us your perspective on Dr. Kussman. I 
appreciate that.
    I had an opportunity to visit with Dr. Kussman last week. I 
appreciate your frankness and that discussion. I think the 
biggest issue that I have is not the quality of care, once 
again, as we talked about, but it is access to that care and 
how we are going to cut down on those access times to make sure 
that those folks who made the commitment to this country and 
the military get the kind of care they deserve and don't have 
to wait an extended period of time for that care.
    It is important to reiterate, though, that the VA is going 
to have increased challenges like they have never seen before 
with what has transpired in Iraq and Afghanistan and it is 
very, very important that as we go through with this, and I 
will hold my questions until the end, Mr. Chairman, that as we 
go through with this process of confirmation, that you 
understand that you have got a hard job ahead of you once 
confirmed because our military is coming back with some 
injuries that in previous wars probably wouldn't have survived.
    So I look forward to the questions and answers and I look 
forward to working with you once you are confirmed because I 
think you will be. Thank you.
    Chairman Akaka. Senator Murray?

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Mr. Chairman, thank you so much for holding 
this hearing, and I want to thank all of our panelists for 
their testimony.
    Certainly, we do a lot of nominations here and to me this 
is an extremely important one for a number of reasons.
    Dr. Kussman obviously has an excellent resume and I had a 
chance to meet with him and appreciate his honesty and his 
trying to confront the many challenges that the VA has.
    But we all know there are 1.5 million men and women who 
have gone to Iraq and to fight terrorists around the globe who 
are coming home who need care that we have not thought about 
before, from traumatic brain injury to post-traumatic stress 
syndrome to loss of limb, that are fighting to get their 
benefits, that are fighting to get the right care.
    The issue of transition is enormous. We know that there are 
an increasing number of veterans from previous wars, 
particularly the Vietnam War, that are now accessing our VA and 
are finding it very difficult to get in. We have talked about a 
lot of these issues and we need somebody at the helm at the VA 
today that can really address those, not just to deal with the 
crisis of today but to look out further ahead and determine 
what our VA is going to look like in the future. That is why 
this position is important.
    But even more importantly to me, Mr. Chairman, is the 
concerns that we have seen consistently come from the VA over 
the last several years. We need a new level of frankness from 
the Veterans' Administration. We have seen them minimize the 
costs of this war, both in money and in lives, to the detriment 
of the men and women who we have asked to serve us. We haven't 
been able to get straight answers or real numbers, to the 
detriment of our servicemen and women over the past several 
years.
    Our own experience has been that the VA came to us with 
information that was inaccurate, underestimating the amount of 
money that we needed, and we had to come up with additional 
billions of dollars late in the game to address the needs of 
the VA in the past few years. The GAO has found in report after 
report that the VA has misled the Congress, concealed their 
funding problems, and based its projections on inaccurate 
models. And very troubling to me, Mr. Chairman, is a report 
that we got from McClatchy News that the VA has repeatedly 
exaggerated the past successes of the VA medical systems, 
exactly at a time when we need honesty from the VA so that we 
can provide the resources and the policies to make sure that no 
one falls through the cracks today.
    I have been very upset most recently about inaccurate 
responses to questions that we have asked of VA. I have 
witnessed the VA transform itself into an agency that guards 
information like a mother bear hugging her cub. We need that 
information and that honesty and frankness in order to be able 
to do the right things on this Committee.
    It is troubling to me that we have watched the VA undermine 
our confidence in its leadership over the last few years, from 
the troubling issues with the budget, to the records that were 
lost and not told to us in a timely manner for the VA employees 
themselves, to backlogs for benefits, and the list goes on. 
Just yesterday, the Associated Press reported that nearly two 
dozen officials who received hefty performance bonuses last 
year at the Veterans Affairs Department also sat on the boards 
charged with recommending the payments. These are the kinds of 
things that repeatedly and repeatedly and repeatedly undermine 
our confidence in what the VA is telling us.
    So, Mr. Chairman, this nomination and this appointment to 
me takes on a very huge significance in the scheme of things. 
We need a culture of change at the VA. We need someone who will 
come in front of us and be honest and frank and tell us the 
truth. We need someone who can provide the leadership to 
address the real challenges of today and tomorrow. I will be 
looking forward to hearing Dr. Kussman's response to the many 
questions that we have here.
    I appreciate all of your support of the nomination, but I 
hope that this Committee bears in mind how important this 
nomination is, because again, to me, it is about the real need 
for a culture of change at the VA and a new direction in 
honesty and frankness so that we, as Members of this Committee 
and the U.S. Senate, can have the information we need to do the 
right thing for the men and women who have served us so 
honorably.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Murray.
    Dr. Kussman, your nomination comes before the Senate at a 
difficult and challenging time for VA. The terrible conditions 
in Walter Reed put a spotlight on VA health care. With each 
passing day, more and more servicemembers are returning with 
serious traumas and injuries, as was mentioned by Senator 
Murray, which will cause many veterans to rely on lifetime of 
care from VA. As servicemembers reach out to VA, inevitably, we 
hear tragic stories of those who did not get the care they 
needed.
    There is no doubt that mental health issues will also be a 
challenge for VA. The truth of the war is that the toll will be 
felt by servicemembers and their families for years to come. I 
am talking about invisible wounds, wounds which cannot be seen 
but are every bit as devastating as physical wounds.
    VA's Under Secretary for Health is one of the most 
important public servants. The next Under Secretary will guide 
the VA medical system at a time when so many new veterans will 
be turning to VA. From my vantage point, VA was not prepared to 
deal with the types of injuries stemming from this war. 
Capacity must be rebuilt and the next Under Secretary will have 
this huge 
challenge.
    So I urge you, Dr. Kussman, if you are confirmed, to first 
and foremost serve as an advocate for veterans. I am quite 
cognizant of the constraints placed upon you by the White House 
and by OMB, as well, and I promise you my full cooperation and 
assistance. But I tell you now that I will not be satisfied 
unless you work to uphold the promises made to all of our 
troops. I know you have--and this is why I think you are so 
well suited for this position--that you have been working on 
seamless transition. This is another huge problem and challenge 
that we have ahead of us, and thankfully we are not starting 
from zero with you. Hopefully, we can move to bring a truly 
seamless transition from active duty to civilian life.
    We are expecting, as I told you, a series of votes that was 
supposed to begin at 10:30, but it is due here any minute. I 
just received word that we are down to three votes, a series of 
three votes, and that will happen soon. So I would like to 
thank our panel for being here, for contributing to the record 
of Dr. Kussman's hearing. Again, thank you for being here.
    With that, I ask the Committee now stand in recess for the 
series of votes and then we will come back and take Dr. 
Kussman's statement and also have questions for you, Dr. 
Kussman. Thank you very much, and we stand in recess.
    [Recess.]
    Chairman Akaka. The Committee will again come to order.
    I would like to introduce the nominee, Dr. Michael Kussman. 
I have known Dr. Kussman for many years, since he first served 
in Hawaii in the early 1980s. His service in Hawaii included 
several senior positions at Tripler Army Medical Center and 
later as Division Surgeon for the Hawaii-based 25th Infantry 
Division. He joined VA in September of 2000 after retiring from 
a long career of military service at the rank of Brigadier 
General. He has served as Acting Under Secretary for Health 
since August of last year, when Dr. Perlin resigned.
    If I have the time line correct, by the time the Kussman 
family left Hawaii, their daughter, Deana, had spent half of 
her life in the islands. Deana, I hope that by now you and the 
rest of the family have found it in your hearts to forgive your 
dad for moving the family from the beautiful State to continue 
his service elsewhere. Maybe you can work on him to find his 
way back to paradise.
    Thank you for coming before this Committee today, Dr. 
Kussman, and to the entire Kussman family, as we say in Hawaii, 
E Komo mai, or welcome to our hearing.
    Dr. Kussman?

        STATEMENT OF MICHAEL J. KUSSMAN, M.D., NOMINEE 
        TO BE UNDER SECRETARY FOR HEALTH, DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Kussman. I think it is still morning, sir. Good 
morning, Mr. Chairman. Aloha to you.
    Chairman Akaka. Aloha.
    Dr. Kussman. I appreciate your comments. Before I begin my 
statement, may I mention that my wife, Ginny, whom you 
acknowledged, my son Josh and his fiance Laura, my daughter 
Deana and her husband Steve, are all with me today, sitting 
right behind me next to the Deputy Secretary. Their love and 
support, especially Ginny's--I love you, dear--have made it 
possible for me to serve my country faithfully and well through 
my career. Without their help, I could not possibly have 
qualified for the office for which I have the honor of being 
considered.
    Mr. Chairman, I began my career with the United States Army 
back in 1970. Like many at the time, I was drafted and served 
my 2-year tour honorably before leaving the Service. I finished 
my medical training, went into private practice for a few 
years, and then volunteered to return to the Army in 1979. I 
came back because I realize as a physician and a healer, that 
being an Army doctor allowed me to practice my profession while 
being of service to our Nation's greatest heroes, our 
servicemembers. I am proud of my military service and 
privileged to have worked my way through the ranks to be 
selected as a general officer.
    When I transitioned from the military, I wanted to continue 
to serve. The Veterans Health Administration offered me that 
opportunity in 2000 and I could have not been more grateful. 
Although I am not still wearing a uniform, I consider myself to 
be still serving. I appreciate the VHA for giving me that 
opportunity.
    When I joined the VHA, the agency was in the process of 
successfully redefining itself as the standard of care by which 
all other health care providers must be measured. Just last 
month, for example, a new book was published. It is entitled, 
The Best Care Anywhere: Why VA Health Care is Better Than 
Yours. I am truly fortunately to have been chosen to carry the 
standard for this great organization.
    From my perspective, VHA not only offers the best health 
care anywhere, but we have the best people anywhere, as well. 
With the proper resources and the support we receive from the 
Senate, the House, the President, and the veterans service 
organizations, we can continue to set the benchmark for quality 
care for the Nation and the world.
    Mr. Chairman, soon after I came to VA, our Nation went to 
war. We have been at war for more than 4 years now. Our losses, 
while they may not be as numerous as those in past wars, have 
nonetheless affected the lives of thousands of America's heroes 
and their families.
    Our Department has no more important mission than to 
restore those who have been injured or made ill as a result of 
their service in this war to their highest possible level of 
functioning. Personally and professionally, I accept the 
responsibility for VHA's readiness to provide these heroes with 
the level of care they have earned through their service and 
the sacrifices they have made in defense of our freedom. That 
is why I am here and that is my passion.
    Our care for OIF/OEF veterans has not been perfect by any 
means. We continue to learn what world class care means to this 
new generation of servicemembers, veterans, and their families. 
Their expectations have raised the bar for our success and we 
continue to improve in order to meet their expectations. When 
things have not gone well for individual veterans, I have 
listened intently and then done whatever I could to ensure that 
whatever mistakes we made will never happen again.
    It is true we made some errors, but we have accepted 
responsibility for those errors and we will fix them properly, 
whatever the cost may be. We have learned and we will continue 
to learn from what we have done wrong. If you confirm me as 
Under Secretary, that is how we will do business throughout my 
tenure.
    Make no mistake, however. I believe VHA has done an 
exceptional job of meeting the needs of our newest generation 
of veterans and we have received remarkable support from the 
President and Congress. But we still face many challenges. 
Among them are to improve our level of cooperation and 
collaboration with our partners at the Department of Defense; 
to enhance our ability to treat veterans with severe traumatic 
brain injuries and to detect mild to moderate TBI where brain 
injuries are not immediately apparent; to continue our search 
for the most effective therapies for post-traumatic stress 
disorder and ensure those therapies are quickly distributed 
throughout our system and elsewhere; to improve access of all 
enrolled veterans to our world-class care, from our newest 
veterans to our oldest; and to meet the goal of the President's 
New Freedom Commission on Mental Health, to emphasize recovery, 
not stabilization, for every mentally ill veteran.
    As Acting Under Secretary, I have established four 
priorities for improvement in our system to help us meet 
today's challenges and tomorrow's. First, I have made 
leadership, responsible, accountable, demonstrated leadership, 
the key to the VHA's future success. We have many fine leaders 
in our organization, but the men and women who are willing to 
accept positions of leadership in our organization must also 
understand the responsibilities they are asked to accept as 
leaders. I am committed to getting the right people in the 
right positions for the good of the entire organization.
    Second, I believe that of the VA's four missions--patient 
care, education, research, and emergency management--patient 
care is by far the most important. To meet the needs of the 
veterans it is our privilege to serve, we must bring the 
quality of our care and our ability to provide that care to a 
higher level. We are now focusing on some basic questions. Are 
our waiting times and our wait time measures appropriate? Are 
our customers satisfied with our service? And are employees 
satisfied with their work? I believe, and I know Members of 
Congress believe, we can do better in those areas.
    Third, I do not believe that the quality of our business 
processes matches the quality of our health care we provide. 
Among other things, we must be able to properly handle the 
sensitive personal information our veterans entrust to us. 
Every VA employee, especially our managers and supervisors, has 
a duty and responsibility to protect sensitive and confidential 
information. I have worked with Secretary Nicholson and others 
to ensure that the VHA is in the first rank of those who are 
helping to make our Department the gold standard in information 
security.
    And finally, I want to be sure that in measuring 
performance, we are measuring the right things. Our performance 
measures system is the best in health care, but we must 
continue to be vigilant in this area, especially where lives 
are at stake.
    Mr. Chairman, Members of the Committee, let me close by 
thanking you, Secretary Nicholson, and the President for the 
privilege that I have been given to continue to serve America's 
heroes at the Department of Veterans Affairs. I am deeply 
humbled by the search committee that chose me from among many 
qualified candidates and by the President's willingness to 
nominate me to lead the finest health care system in America. 
If I am confirmed as Under Secretary, I promise to work with 
you and all Members of the Congress to build a health care 
system that will meet the needs of all veterans and their 
families, the men and women it is VHA's privilege and honor to 
serve.
    [The prepared statement of Dr. Kussman follows:]
        Prepared Statement of Michael J. Kussman, M.D., Nominee 
    to be Under Secretary for Health, Department of Veterans Affairs
    Chairman Akaka, Ranking Member Craig, Members of the Committee and 
its staff. Good morning.
    Before I begin my statement, may I mention that my wife Ginny; my 
son Josh and his fiance, Laura; and my daughter Deana and her husband 
Steve are all here with me today. Their love and support--especially 
Ginny's--have made it possible for me to serve my country faithfully 
and well throughout my career. Without their help, I could not possibly 
have qualified for the office for which I have the honor of being 
considered.
    Mr. Chairman, I began my career with the United States Army back in 
1970. Like many at that time, I was drafted and served my 2-year tour 
honorably before leaving the service. I finished my medical training, 
went into private practice for a few years, and then volunteered to 
return to the Army in 1979. I came back because I realized, as a 
physician and a healer, that being an Army doctor allowed me to 
practice my profession while being of service to our Nation's greatest 
heroes--our servicemembers.
    I am proud of my military service; and privileged to have worked my 
way through the ranks to be selected as a General Officer. When I 
transitioned from the military, I wanted to continue to serve. The 
Veterans Health Administration offered me that opportunity in 2000, and 
I could not have been more grateful.
    When I joined VHA, the agency was in the process of successfully 
redefining itself as the standard of care by which all other health 
care providers must be measured. Just last month, for example, a new 
book was published. It is titled ``The Best Care Anywhere: why VA 
health care is better than yours.'' I am truly fortunate to have been 
chosen to carry the standard for this great organization.
    From my perspective, VHA not only offers the best health care 
anywhere, but we have the best people anywhere as well. With the proper 
resources, and the support we receive from the Senate, the House, the 
President, and the Veterans Service Organizations, we can continue to 
set the benchmark for quality care for the Nation and the world.
    Mr. Chairman, soon after I came to VA, our Nation went to war. We 
have been at war for more than 4 years now. Our losses--while they may 
not be as numerous as those of past wars--have nonetheless affected the 
lives of thousands of America's heroes and their families.
    Our Department has no more important mission than to restore those 
who have been injured or made ill as a result of their service in this 
war to their highest possible level of functioning. Personally and 
professionally, I accept responsibility for VHA's readiness to provide 
these heroes with the level of care they have earned through their 
service and the sacrifices they have made in defense of our freedom. 
That is why I am here.
    Our care for OIF/OEF veterans has not been perfect by any means. We 
continue to learn what world-class care means to this new generation of 
servicemembers and veterans--and to their families. Their expectations 
have raised the bar for our success, and we must continue to improve in 
order to meet those expectations.
    When things have not gone well for individual veterans, I have 
listened intently--and then done whatever I could to insure that 
whatever mistakes we made will never happen again. It's true we've made 
some errors, but we have accepted responsibility for those errors, and 
we will fix them properly, whatever the cost may be. We have learned--
and we will continue to learn--from what we have done wrong. If you 
confirm me as Under Secretary, that is how we will do business 
throughout my tenure.
    Make no mistake, however--I believe VHA has done an exceptional job 
of meeting the needs of our newest generation of veterans, and we have 
received remarkable support from the President and from Congress. But 
we still face many challenges. Among them are:

    To improve our level of collaboration with our partners at the 
Department of Defense;
    To enhance our ability to treat veterans with severe traumatic 
brain injuries, and to detect mild to moderate TBI where brain injuries 
are not immediately apparent;
    To continue our search for the most effective therapies for Post-
Traumatic Stress Disorder, and ensure those therapies are quickly 
distributed throughout our system and elsewhere;
    To improve access for all enrolled veterans to our world-class 
care, from our newest veterans to our oldest; and
    To meet the goal of the President's New Freedom Commission on 
Mental Health to emphasize recovery, not stabilization, for every 
mentally ill veteran.

    As Acting Under Secretary, I have established four priorities for 
improvement to our system, to help us meet today's challenges--and 
tomorrow's.
    First, I have made leadership--responsible, accountable, 
demonstrated leadership--the key to VHA's future success. We have many 
fine leaders in our organization; but the men and women who are willing 
to accept positions of leadership in our organization must also 
understand the responsibilities they are asked to accept as leaders. I 
am committed to getting the right people in the right positions for the 
good of our entire organization.
    Second, I believe that of VA's four missions: patient care, 
education, research, and emergency management--patient care is by far 
the most important. To meet the needs of the veterans it is our 
privilege to serve, we must bring the quality of our care, and our 
ability to provide that care, to a higher level.
    We are now focusing on some basic questions: are our waiting times, 
and our wait time measures, appropriate; are customers satisfied with 
their service; and are employees satisfied with their work. I believe, 
and I know Members of Congress believe, we can do better in these 
areas.
    Third, I do not believe that the quality of our business processes 
matches the quality of the health care we provide. Among other things, 
we must be able to properly handle the sensitive personal information 
our veterans entrust to us.
    Every VA employee, especially our managers and supervisors, has a 
duty and responsibility to protect sensitive and confidential 
information. I have worked with Secretary Nicholson and others to 
ensure that VHA is in the first rank of those who are helping to make 
our Department the gold standard in information security.
    And finally, I want to be sure that in measuring performance, we 
are measuring the right things. Our performance measurement system is 
the best in health care--but we must continue to be vigilant in this 
area, especially where lives are at stake.
    Mr. Chairman, Members of the Committee, let me close by thanking 
you, Secretary Nicholson, and the President, for the privilege I have 
been given to continue to serve America's heroes at the Department of 
Veterans Affairs. I am deeply humbled that the search committee chose 
me from among many qualified candidates, and by the President's 
willingness to nominate me to lead the finest health care system in 
America.
    If I am confirmed as Under Secretary, I promise to work with you 
and all Members of Congress to build a health care system that will 
meet the needs of all veterans and their families--the men and women it 
is VHA's privilege, and our honor, to serve.
                                 ______
                                 
  Response to Pre-hearing Questions Submitted by Hon. Daniel K. Akaka 
to Michael J. Kussman, M.D., Nominee to be Under Secretary for Health, 
                     Department of Veterans Affairs
    Question 1: The VHA leads the private health sector in many areas, 
such as electronic medical records, overall patient satisfaction, and 
negotiations with pharmaceutical companies. In what areas do you 
believe VA still lags behind? In what fields could VHA learn from the 
private sector or benefit from the implementation of methods used in 
the private sector, and what are your plans to make the necessary 
improvements?
    Response: I agree that the Veterans Health Administration (VHA) 
leads the private health care sector in the areas of electronic medical 
records, overall patient satisfaction, and effective negotiations with 
pharmaceutical companies. However, the Department of Veterans Affairs 
(VA) has room to improve regarding best practices from the private 
sector. VA is learning to leverage private sector business practices to 
increase our productivity.
    VA has implemented a private sector-based business model pilot 
known as the Consolidated Patient Account Center (CPAC) tailored for 
our revenue operations. This private sector-based business model will 
enable VA to increase collections and improve our operational 
performance. CPAC is addressing all operational areas contributing to 
the establishment and management of patient accounts and related 
billing and collections processes. CPAC currently serves revenue 
operations for medical centers and clinics in one of our Veterans 
Integrated Service Networks (VISN) but this program will be expanded to 
serve other networks.

    Question 2: I consider VHA's university affiliations, and related 
programs such as internships, medical residencies, and joint research, 
as among VHA's greatest strengths. Aside from existing initiatives, 
what original plans or ideas would you propose in order to maintain the 
long-term strength of these programs?
    Response: Our university affiliations are a cornerstone of our 
delivery of care and the quality of our delivery system. This symbiotic 
relationship has been going on for over 60 years and remains strong 
today. As part of this relationship, VA works with affiliates to 
address concerns. For example, we are examining how VA can use its 
clinical learning environment to maximize the training of physicians 
for the realities of practice in the modern health care environment. VA 
has one of the best, if not the best, patient safety program in the 
Nation. The question then becomes, how can we best use this resource in 
our health professional training programs? We have had continuous and 
ongoing dialogue with the Association of American Medical Colleges to 
assess these and other issues. The outgrowth of dialogue such as this 
was the establishment of a Blue Ribbon Task Force to look at where we 
are and where we need to go.
    Acting on Task Force recommendations to improve and strengthen 
VHA's university affiliations, I have directed VHA's Office of Academic 
Affiliations to work with our medical school and academic medical 
center partners to explore new and potentially transformative 
approaches to medical education. The centerpiece of this approach is 
the emerging realization by medical educators that educational reform 
without concurrent redesign of the care delivery environment is 
unlikely to be successful and that clinical redesign has profound 
implications on the process and content of education as well. For 
example, one has only to consider the importance of continuity of care 
in forming the attitudes of young physicians and provider continuity in 
managing patients with chronic disease to appreciate the essential 
unity of education and care delivery. Indeed, learning and care are 
inseparable.
    But physicians alone will be insufficient in the team-based care 
delivery system of the future, and VA must increase its attention to 
other health professions. At my direction, the Office of Academic 
Affiliations is expanding inter-professional training opportunities 
and, in partnership with VHA's Office of Nursing Services, has just 
launched a major initiative in nursing education, the VA Nursing 
Academy.
    The central intent of the Nursing Academy is to work hand in hand 
with the Nation's nursing schools in addressing the major problem 
underlying the present nursing shortage--insufficient numbers of 
teaching faculty. A 5-year pilot project is already underway to 
identify VA facility-nursing school partnerships willing and able to 
invest in nursing faculty while at the same time admitting additional 
numbers of qualified students.
    VA nurses will be given faculty appointments and VA will provide 
additional funding for nursing school faculty. Innovative ways of 
enhancing the learning environment and nursing curriculum will be 
explored and the scholarly and research development of nursing faculty 
will be enhanced.
    As is evident from the initiatives summarized above, new, more 
collaborative management models are appropriate for the current 
relationship between VA and its affiliates. One potential model that I 
would like to see explored in more depth is ``educational consortia''--
in which VA works much more closely with its academic affiliates to 
jointly manage educational programs while still retaining sole control 
of its health care delivery operations.
    In summary, I believe VA's academic affiliations provide 
significant opportunities for improving health care for veterans while 
strengthening academic institutions throughout the country. We should, 
and we will, work hard to keep these relationships vibrant by 
continuously exploring new approaches to collaboration and securing the 
resources necessary to ensure excellence in our statutory educational 
mission.

    Question 3: What is your overall direction for the VA research 
program?
    Response: The VA research program is a jewel in the crown of the 
Nation's research capability. Over the years it has done magnificent 
research, and VA researchers have received two Nobel Prizes and six 
Lasker Awards. Our goal is that the research we conduct needs to have 
direct transferability to veteran care. Over the last 3 years we have 
shifted the direction of our research program to increase emphasis on 
research related to Operation Enduring Freedom and Operation Iraqi 
Freedom (OEF/OIF) veterans, including traumatic brain injury (TBI) and 
other neurotrauma, combat-related mental health, prosthetics and 
amputation health care, polytrauma, and other related issues.
    VA's research is performed in house with funding coming from direct 
appropriation, other government entities and the private industry. We 
have increased our percentage of research dollars directly related to 
OEF/OIF issues to 58 percent. We are also continuing to focus on 
chronic disease research and our research in this area is expanding to 
incorporate genomics research. In addition, we are increasing our focus 
on research related to reducing health disparities, including minority 
and rural health disparities, and are beginning interventional studies 
in this important area.

    Question 4: Anecdotal evidence suggests that waiting times for 
medical appointments--including non-specialist appointments--often 
reach several months, and occasionally exceed six months. In addition, 
it is my understanding that VA is not tracking the time it takes 
specialty medical procedures and surgeries to be scheduled once they 
are recommended. Finally, the IG has reported manipulation of the 
electronic waiting list and other procedures used to track waiting 
times. If confirmed, what would you do to ensure that waiting times are 
accurate and, more importantly, that veterans are not waiting excessive 
times for care, including medical procedures and surgeries?
    Response: The most important issue is making sure veterans see a 
provider as quickly as possible. Delaying the provision of care beyond 
reasonable periods of time is not acceptable.
    At present, 95 percent of all appointments are made within 30 days 
of the desired date and 98 percent within 60 days of the desired date. 
We have been tracking the number of new veterans to the system that 
have had to wait more than 30 days from the desired date to get an 
appointment. This number has declined from 22,000 in May 2006 to 1,300 
in March 2007.
    To ensure the accuracy of waiting times, VA has undertaken various 
measures to improve the performance of schedulers who initiate 
appointments. For example, we have made a concerted effort to identify 
schedulers that are making mistakes. To improve performance, VA 
developed and implemented a comprehensive policy on the proper way to 
schedule and record appointments.
    As part of the implementation process, training is mandated for all 
employees working on scheduling appointments. VHA has conducted 
training for schedulers to help them determine and document these 
desired appointment dates. Our efforts have been successful at reducing 
the wait times for veterans across the country.
    With respect to waiting for medical procedures and surgeries, this 
is not yet being tracked. One of my top priorities is to develop 
tertiary care performance standards to do just this.

    Question 5: VISNs were implemented a dozen years ago. Since that 
time the total number of personnel assigned to each VISN has grown from 
the originally envisioned 8-10 employees to, in some cases, hundreds. 
Please share your views about what are the advantages and disadvantages 
of the current structure.
    Response: VHA is among the largest health care systems in the 
country. The VISN structure supports the integration of service 
delivery within a network. VISNs can provide their population of 
veterans with the full range of health care services from primary care, 
available at locations throughout the network, to highly specialized 
treatment, which may be available at only one location. Since the VISN 
system was established, the role of VISNs has grown significantly as 
they take advantage of myriad efficiencies. They have taken on a 
significant work load that could no longer be done in Central Office.
    VHA recently held a Summit Meeting in Baltimore to assess where we 
have come in the past 10 years from enrollment reform and the 
establishment of the VISNs and where we would like to go. One of the 
issues is the role of the VISNs vis-a-vis Central Office. Most agree 
that health care is local, so the development of regions has its 
advantages, but there still needs to be consistency and standardization 
of delivery of care. Although the balance between centralization and 
decentralization will always be debated, there is no absolute. It is my 
opinion the pendulum probably has swung a little too far in the 
direction of decentralization and needs to come back toward the center 
in order to ensure appropriate consistency and standardization.

    Question 6: Are you comfortable with the amount of oversight that 
VA Headquarters program managers are able to conduct? In your view, is 
budgetary authority a requisite for such oversight?
    Response: I am comfortable with the amount of oversight VHA program 
managers have and I do not believe any additional budgetary oversight 
is required. Central Office program managers are responsible for 
establishing policies and procedures and setting standards. They work 
closely with the Chief Financial Officer to ensure program funds are 
appropriately planned, allocated, and used. They are not operators. 
Program managers advise VA leadership on what should be done. If they 
believe existing policies and procedures are not being followed, they 
have opportunities to raise their concerns before the National 
Leadership Board and, using the chain of command, to bring these issues 
to my attention. Our managers are evaluated based upon objective 
performance measurement criteria, so they have a direct interest in 
maintaining oversight and accountability. I do not believe budgetary 
authority is a requisite for oversight and direction.

    Question 7: What would you do as Under Secretary for Health--beyond 
increasing funding for the existing EDRP and scholarship programs--to 
enable VA managers to recruit and retain health professionals, 
especially in the area of nursing?
    Response: VA places a high priority on hiring and retaining nurses. 
We are fortunate our retention rate seems to be higher than civilian 
markets. Our nurses believe in our mission and enjoy the work 
environment we create as well as our mission. We are in the process of 
establishing a VA Nurse Academy we hope will lead to better visibility 
of the VA in Nursing Schools and increased hiring.
    I would like to highlight the programs for recruitment and 
retention of health care professionals noted in your question. The 
Education Debt Reduction Program (EDRP) receives $15 million each year. 
This program has authorized over 5,200 awards since its inception in 
2002 for health care employees with outstanding student educational 
loans. There is a current total obligation through Fiscal Year (FY) 
2012 of $89 million. The impact on retention is significant. A study in 
2005 revealed the resignation rate for EDRP nurses, physicians, and 
pharmacists was less than half that of non-EDRP staff (for nurses, 13.7 
percent versus 28 percent; physicians 15.9 percent versus 34.8 percent; 
pharmacists 13.4 percent versus 27.6 percent).
    In addition to continuing and enhancing the Education Debt 
Reduction Program, VHA manages one of the largest employee scholarship 
programs in the Federal Government, the Employee Incentive Scholarship 
Program. Over 6,300 academic scholarships have been awarded to VHA 
employees seeking degrees in health care occupations or advancing their 
education in the nursing professions.

    Question 8: In your view, what can be done to enhance compensation 
for senior non-medical personnel? How do you perceive the discrepancy 
between compensation in VA and in the field of private hospital 
management, given the similar nature of the work?
    Response: Proper and equitable compensation for our most 
experienced executive personnel is a challenge. The government pay 
system prevents us from paying non-medical personnel comparable 
competitive salaries.
    Growing pay disparities both within and outside VHA make it 
increasingly likely that many executives will be lured away by more 
lucrative private sector opportunities or will choose retirement, 
leaving a void in the ranks of senior leadership positions needed to 
ensure VHA's continued pre-eminent position in health care. In a study 
published in 2000, the Hay Group affirmed the scope of responsibilities 
of VHA health care executives was, overall, comparable to that of 
private sector executives.
    Recent trends in VHA senior executive positions provide evidence of 
a growing problem, since turnover in medical center director positions 
increased from 6.8 percent in 2005 to 21.7 percent in 2006. VHA is 
engaged in rigorous succession planning, using such models as the High 
Performance Development Plan and the Leadership Development Plan, to 
identify, train, and retain promising managers. VA, like other Federal 
agencies, is taking advantage of Office of Personnel Management (OPM) 
programs designed to develop the next generation of leaders.

    Question 9: Are you confident that current VHA authorities and 
procedures allow for sufficiently expeditious hiring of medical 
personnel? Please describe any recommendations that you may have for 
changes to the current hiring system.
    Response: No, I am not confident that our Human Resources policies 
and procedures allow for expeditious hiring in all areas. In fact, I 
believe that there have been instances where we lost the opportunity to 
hire good people because our process took too long for our clinical 
professionals. We have appointing authority under title 38 for 
physicians, dentists, and registered nurses, and similar authority 
under our hybrid title 38 appointment for pharmacists, physical 
therapists, social workers, psychologists, medical instrument 
technicians, and others, which allows for quicker hiring for these 
positions, However, other allied health areas do not fall under this 
same authority and are subject to prolonged hiring processes. Like most 
of the rest of the Federal Government, we do not have this authority 
for other professionals and technical staff, but we are working 
internally to identify obstacles and develop solutions to speed up the 
process.

    Question 10: In my view, Physician Assistants play a vital and 
growing role in the delivery of health care. You have already indicated 
your dedication to expanding the role of the PA Advisor. What new 
efforts would you undertake as Under Secretary for Health to ensure 
full participation of the PA Advisor in health care planning and to 
provide adequate resources for the position?
    Response: I agree that physician assistants (PA) are valuable and 
essential to the delivery of care in the VA. VHA increasingly relies on 
PAs for critical contributions to providing quality and timely health 
care to our Nation's veterans. The PA Advisor is now required to travel 
to Central Office on a regular basis to enhance his full participation 
in the position's expanded responsibilities. I have made the decision 
that, with the next iteration of consultant for PAs, the position will 
be full time and will be located in Central Office. I am requesting the 
PA Advisor provide periodic briefings identifying barriers and 
recommended changes to expand the scope of responsibilities in order to 
fully use PAs in VA.

    Question 11: The Veterans Benefits, Health Care, and Information 
Technology Act of 2006 enacted by Congress last year added Marriage and 
Family Therapists and Licensed Professional Mental Health Counselors to 
the list of health professionals that VA may employ. Please outline 
your plan for how this law will be implemented, specifically with 
regard to how these professionals will be fully integrated into VA 
mental health care.
    Response: To assist with implementation of Public Law (P.L.) 109-
461, VHA is currently evaluating the graduate training requirements for 
Marriage and Family Therapists and Licensed Professional Mental Health 
Counselors. Specifically, we are looking at the post-graduate clinical 
experience and supervision required for licensure, the scopes of 
practice developed within the states, and the evidence-base for the 
effectiveness of care provided. It is necessary to take these steps to 
define the combinations of credentials and experience, as well as the 
scope of practice, required to ensure the professionals will enhance 
VHA's ability to deliver high quality mental health care services to 
veterans in need.

    Question 12: Marriage and Family Therapists and Licensed 
Professional Mental Health Counselors have similar or comparable 
qualifications with social workers, who have been eligible to work with 
VA for years. If confirmed, how will you utilize these health 
professionals?
    Response: The education of professionals in each discipline is 
defined by conceptual models specific to each discipline and an 
understanding of the clinical needs of the population served. Under my 
direction, the Offices of Mental Health Services and Management Support 
are reviewing the knowledge-base, supervision, and experience that 
define training, as well as the scope of practice in other settings to 
develop plans using these professions to an optimal degree. These 
evaluations will inform the strategies for utilization.

    Question 13: Last month, you issued a policy that introduced 
anesthesiologist assistant (AAs) to the VA health system. Please 
explain the basis for this new policy, including how you expect it to 
enhance the quality of VA health care.
    Response: In some markets, VA has difficulty recruiting nurse 
anesthetists. Allowing facilities to use anesthesiologist assistants 
(AAs) to provide care offers us another option in providing veterans 
timely and quality access to needed health care. The use of AAs in VA 
has been an issue even before the December 22, 2006 Human Resources 
Management Letter (HRML) No. 05-06-12 allowing human resources offices 
to establish these positions. Anesthesiologist assistants practiced in 
VA before this decision as contractors, and some physician assistants 
performed this role as well.
    This is a relatively new field that could potentially expand the 
ability of the VA to provide anesthesiology services to veterans. These 
professionals must work under the supervision of an anesthesiologist 
and more than 10 States currently offer licenses to practice. There has 
been some concern from the Certified Registered Nurse Anesthetist 
(CRNA) community about this approach. It is our opinion that in the 
right setting and with appropriate oversight, the use of anesthesiology 
assistants will expand our capability and in no way diminish quality. 
It is my understanding that the VA CRNA organization is not opposed to 
the use of AAs in VA, but they have some concerns about the specifics 
outlined in the recently published directive. VA leadership agrees with 
the VA CRNA organization that further discussion will take place to 
ensure their concerns are addressed. If needed, we would issue a new 
directive.

    Question 14: What is the standard by which you would approve or 
reject enhanced use lease applications for use of VA facilities?
    Response: The Enhanced-Use Lease (EUL) legislation (i.e., 38 U.S.C. 
Sec.  8161-8169) allows VA to enter into an enhanced-use lease if: (1) 
at least part of the property under the lease will provide appropriate 
space for an activity related to VA's mission; the lease will not be 
inconsistent with nor adversely affect VA's mission; and the lease will 
either enhance the use of the property; or (2) the lease would provide 
consideration to be used to improve the health care for veterans in the 
affected community.
    Essentially, there are three levels of strategic review--one at the 
initial stage when the EUL requests (concept papers) are submitted 
through VISNs to VHA's Capital Assessment and Management and Planning 
Services (CAMPS) office; another when VHA submits the concept papers to 
VA's Office of Management (OM); and then finally when OM submits the 
request to the Secretary. At any of these levels, if it is identified 
that the legislative criteria is not met, the concept paper is 
disapproved and returned to the VISNs and medical centers.

    Question 15: Much has been promised about ensuring that there is a 
smooth transition between DOD and VA for separating servicemembers. I 
understand you have been directly involved in many of VAs initiatives 
to improve this process. What is the state of progress in this area, 
and what more needs to be done?
    Response: Seamless Transition has been a goal of VA and the 
Department of Defense (DOD) for many years, but our success has been 
measured and has, in some instances, fallen short of what our veterans 
deserve. In August 2003, I was asked by Secretary Principi to co-chair 
a Task Force to look at specific issues related to the new group of 
severely injured OEF/OIF servicemembers. I served in this capacity 
until January 2005, when VA established a permanent Office of Seamless 
Transition, composed of representatives from VHA and the Veterans 
Benefits Administration (VBA), as well as an active duty Marine Corps 
Officer and an Army Officer. Unprecedented efforts were taken by both 
DOD and VA to put VA personnel full time in 10 DOD military treatment 
facilities (MTF) and to place full time military personnel in VA 
facilities. Our four traumatic brain injury (TBI) centers were 
converted to polytrauma rehabilitation centers to deal with the complex 
injuries of some of our recently injured servicemembers. VA began 
employing a system of clinical case management to assist in the 
movement of servicemembers from DOD to VA. We recognized the challenges 
faced by previous generations, and we wanted to simplify the process 
for servicemembers and their families, especially those dealing with 
medical issues. If servicemembers are not going to a Polytrauma Center, 
our case managers coordinated with the nearest VA facility as selected 
by the veteran. Veterans are scheduled to be enrolled in VA prior to 
leaving the MTF and social workers are tasked with coordinating 
appointments with VA, while case managers will handle clinical issues 
and Transition Patient Advocates (TPAs) address logistical issues for 
our most seriously wounded veterans and servicemembers.
    In March 2007, Secretary Nicholson announced VA would be hiring 100 
patient advocates to serve as ombudsmen for severely injured OEF/OIF 
veterans. These new TPAs will assist seriously injured veterans and 
their families with issues and concerns and help them navigate the VA 
system. In March 2007, VHA published a policy document outlining the 
responsibilities of the TPAs, which include traveling to military 
hospitals to meet severely injured patients and their families and 
following those patients into the VA health care system. Also in March 
2007, VHA began recruiting to fill the positions. As of this date, VA 
medical centers have hired 46 TPAs and are interviewing to select the 
remaining 54. Each medical center with vacant TPA positions has 
detailed employees to perform the functions while recruitment is 
underway. I believe that the TPAs will help us assure that no severely 
injured OEF/OIF veteran falls through the cracks.
    We are improving our coordination in joint-case management 
situations with more communication. Veteran Tracking Application, VA's 
adaptation of the Joint Patient Tracking Application system will help 
track and provide clinically important information. VA has also started 
using ombudsmen for each severely injured veteran or servicemember to 
ensure one person will follow him or her across the continuum of care; 
we are filling these positions now. We need to do better with less 
severely injured servicemembers who do not enter the Polytrauma System 
of Care. Our improved case management system will help them as well.
    Seamless transition for all separating servicemembers is also very 
important and, to a large degree, is handled through the Benefits 
Delivery at Discharge process. We must continue to improve our 
Compensation & Pension process to ensure effective, standardized and 
timely examinations so veterans receive the care and benefits they 
earned.
    With those limits and needs acknowledged, VA has done a great deal 
for our servicemembers. VHA staff has coordinated over 7,000 transfers 
of OEF/OIF servicemembers and veterans from an MTF to a VA medical 
facility. Active duty Army Liaison Officers are assigned to each of the 
four VA polytrauma rehabilitation centers and assist servicemembers and 
their families from all branches of Service on a wide variety of 
issues. VA established an OEF/OIF Polytrauma call center to assist our 
most seriously injured veterans and their families with clinical, 
administrative, and benefit inquiries. VA has implemented an automated 
tracking system to track servicemembers and veterans transitioning from 
MTFs to VA facilities. During the period October 2006 through March 31, 
2007, over 150 severely ill/injured patients were transferred from MTFs 
to VA medical centers (VAMC). VA is participating in DOD's Post 
Deployment Health Reassessment (PDHRA) program for returning deployed 
servicemembers, and between 5 November 2005 and 30 April 2007, over 
85,000 Reserve and Guard members were screened, generating more than 
20,000 referrals to VAMCs and over 10,500 referrals to Vet Centers.
    In addition, VA signed a memorandum of agreement (MOA) with the 
National Guard in May 2005 to form state coalitions in 54 States and 
territories. A similar MOA is being developed with the U.S. Army 
Reserve Command and the U.S. Marine Corps at the national level. VA and 
the National Guard Bureau teamed up to train 54 National Guard 
transition assistance advisors who assist VA in advising Guard members 
and their families about VA benefits and services. We are currently 
reviewing the recommendations of the President's Task Force on 
Returning Global War on Terror Heroes. Some of these recommendations 
are already being developed and implemented, such as the call to 
develop a system of co-management and case management between DOD and 
VA and providing full support to DOD for PDHRA for Guard and Reserve 
members, as an extension of the outreach described above.

    Question 16: In an attempt to respond to the demand for care from 
servicemembers from the operations in Iraq and Afghanistan, the 
Administration has chosen to prioritize the care of veterans who served 
in these operations. Do you believe it is appropriate for older 
veterans to wait behind new veterans for care? Would you advocate for 
increase funding to obviate the need for this type of prioritization?
    Response: We certainly do not want to create a situation that pits 
one group of veterans against another. Specific clinical needs should 
be the final arbiter of priority access. If there is no clinical 
difference, it is administrative policy to expedite appointments for 
new veterans, including OEF/OIF veterans. Our goal is to have all 
veterans seen within 30 days of their requested appointment date, or 
within 30 days of their request in the case of new enrollees. If we 
achieve that, there is no need to prioritize one group of veterans over 
another. Almost all facilities currently comply with this 30-day 
standard 90 percent or more of the time. We believe our current level 
of funding will allow us to meet that goal. The expansion of non-
institutional services targeted for Fiscal Year 2008 is the most rapid 
expansion that can realistically be achieved in a single year in 
services for our veterans.

    Question 17: Criticism of VA's prosthetics, TBI, and mental health 
programs has raised the issue of VA contracting with private and/or 
community entities to make up for either perceived or real shortcomings 
in these programs. What are your thoughts about this? Is it not 
possible for VA to reach the pinnacle of care in these areas? Would you 
consider the need for contracting out for care in these areas? Can a 
viable VA health care system exist if its role is relegated to solely 
that of a payer versus a provider in these clinical areas?
    Response: Let me first say that our Nation's veterans deserve the 
best care possible and we continually work to improve our care and 
services that we provide. VA achieves a gold standard according to 
external and internal measures of quality for our prosthetic, TBI, and 
mental health care. VA performs over 5,000 amputations each year and 
provides state-of-the-art care to all. Our research, academic 
affiliations, and clinical programs uniquely place VA as a national 
leader in the treatment of TBI, a position we have held since 1992 when 
we developed our four Lead TBI centers. Mental health care is one of 
our most important areas of concern, and we have led the country in the 
treatment of severe mental illness and substance abuse. In fact, our 
National Center for Post Traumatic Stress Disorder (PTSD) is a 
recognized international leader in the field.
    While no program is perfect, I do not feel the criticism about our 
prosthetic program raised by some is accurate. I will concede that 
early on in the war, VA was not adequately prepared for this new group 
of veterans. We dealt primarily with geriatric amputees, many with 
diabetes, making them less than ideal candidates for new technologies 
like myoelectric upper extremity prosthetics and computer-driven lower 
extremities. But, we have redirected our attention and our prosthetists 
and physical therapists have learned from the great work being done at 
Walter Reed Army Medical Center (Walter Reed) and other DOD sites.
    As far as TBI, I believe we have world class care. Again, we must 
provide the best care possible. To reassure our patients and their 
families, I have instructed our facilities to seek a second opinion 
from reputable civilian experts when servicemembers or families are 
concerned about our level of care or our diagnosis. When we have done 
this, these experts have usually concurred with our work and the 
services provided. The Commission on Accreditation Rehabilitation 
Facilities certifies each Polytrauma Rehabilitation Center, home to our 
TBI Lead centers. We are in the process of requesting a civilian review 
of our care.
    As far as mental health services, I am very proud of what we 
provide. We spend approximately 10 percent of our budget directly on 
mental health services and are the largest provider of mental health 
services in the country. Obviously there are geographic challenges, and 
VA appreciates the need to overcome these obstacles, which is why we 
initiated a very aggressive hiring campaign for mental health workers. 
If there are insufficient services available in an area for us to 
provide needed care, we will to consider fee-basing the care; however, 
in many under-served areas, there are few providers, if any, who would 
meet our quality standards for care.
    VA, as a provider of specialty care, is able to exercise direct 
supervision and oversight on the care and health care policies 
associated with our veterans. Contracting out this functionality 
entirely will lead to fragmentation of care and an adverse effect on 
the continuity of care needed to ensure quality of care, patient 
safety, and efficiency.
    We take our commitment to providing care to our Nation's heroes and 
will continually strive to achieve the highest quality of care and 
services which they deserve.

    Question 18: When asked by AP about a VA report stating that 30,000 
or 16 percent of the 184,000 OEF/OIF veterans who had sought VA care as 
of late 2006 had symptoms of PTSD, you called this a ``gross 
overestimation'' of actual mental health disorders. However, I note 
that the 16 percent figure is consistent with Colonel Charles Hoge's 
testimony at the September 28, 2006, hearing of the House Committee on 
Veterans' Affairs. According to Colonel Hoge' s research, ``16 percent 
of soldiers surveyed 12 months after returning from Iraq screened 
positive for PTSD, depression, or anxiety and reported that there was 
functional impairment at the `very difficult' level.'' Do you still 
believe the reports of PTSD are grossly overestimated?
    Response: Let me clarify what we know about mental health 
disorders. As of the end of Fiscal Year 2006, over 205,000 OEF/OIF 
servicemembers have come to VA; 72,000 had symptoms of some kind of 
mental health disorder. That does not mean that they came for a mental 
health problem or that they actually had a mental health disorder. Our 
screening process identifies many symptoms that would not have been 
elicited without asking. Of the 72,000, 34,000 have symptoms consistent 
with PTSD. It is not clear exactly how many of these are finally 
diagnosed with PTSD, but several small studies show that 75 percent to 
90 percent of those with symptoms will have some degree of PTSD. In 
Colonel Hoge's first report, he states 16 percent of servicemembers 
were diagnosed with PTSD, depression, or anxiety, but 9 percent of all 
servicemembers had that diagnosis prior to their deployment, meaning 
only 7 percent of servicemembers diagnosed with PTSD as the result of 
combat experience.
    With regard to your question, it is possible that many of our 
returning servicemembers have readjustment issues that are not due to 
mental illness but are normal reactions to abnormal situations. If so, 
it would be unfair and inaccurate to label them as having mental 
illness. I can tell you that VA is very concerned about cases of PTSD 
and we are doing everything we can to identify and provide treatment to 
those in need. The actual prevalence of PTSD among recent combat troops 
can only be determined by well-designed, large-scale epidemiological 
studies that rely on clinically confirmed diagnoses of PTSD. Multiple 
deployments to hazardous theaters of military operations can increase 
the risk of developing PTSD and other mental health problems and PTSD 
often develops over many years. The level of PTSD among OEF/OIF troops 
will not be completely known until well after the end of current 
hostilities and deployments to Southwest Asia.
    To better understand the long-term health concerns of OEF/OIF 
veterans, I'm pleased to report I approved funding for VA's Office of 
Public Health and Environmental Hazards to conduct a longitudinal 
health surveillance of OEF/OIF veterans to track the illnesses and 
diagnoses they have after their deployment.

    Question 19: As I have shared on many occasions, I am concerned 
about VHA's ability to manage the mental health needs of servicemembers 
if deployments continue indefinitely. With current levels of staffing 
and resources, how will VHA continue to meet the mental health needs of 
both long-time and new veterans three or four years from now?
    Response: Most of our increase in PTSD patients has not been 
because of veterans returning from Iraq or Afghanistan, but from 
veterans of previous wars experiencing a resurgence of their symptoms. 
On the basis of projected need for all veterans, VHA is increasing the 
estimated budget for mental health services in both our medical 
facilities and our Vet Centers. We have placed a clear emphasis on 
mental health and combat related experiences, with almost $3 billion 
allocated to mental health following an increase of $545 million from 
2006 to 2008. We believe this should be adequate to meet our needs. VHA 
anticipates continued growth in funding for mental health programs, 
both through Veterans Equitable Resource Allocation and the Mental 
Health Initiative, beyond 2008.
    We are aggressively expanding our staffing wherever possible, but I 
do not think we are yet where we need to be. The Office of Mental 
Health Services is working with Management Support to augment our 
current strategies for recruiting mental health professionals into our 
system. We are actively involved in research on mental health and 
clinical neuroscience where findings can be translated into improved 
care within a few years, and other, more basic studies, that may 
translate into more dramatic advances over longer time frames. 
Similarly, VA is educating and training our existing staff to ensure 
they have the knowledge and skills needed to provide the most up-to-
date forms of evidence-based care in a safe, effective, efficient, and 
compassionate manner. If we cannot meet the clinical needs of these 
veterans with the appropriate type of care, then we need to leverage 
the civilian community. We will monitor this very closely and adjust 
resources as needed.

    Question 20: Early diagnosis and referral can limit the development 
and effects of mental health problems, particularly PTSD. As such, VA 
and DOD must cooperate closely on an effective screening and referral 
system. What specific steps will you take to improve this cooperative 
system, and to make it comprehensive, reliable and ultimately, 
successful?
    Response: I agree that early diagnosis is very important. When this 
occurs, we have the opportunity to prevent or ameliorate the long term 
consequences of PTSD. It is clear that the immediate post-deployment 
screen is only of marginal value. Recognizing this, VA and DOD 
generated the PDHRA process. This occurs at 90 and 180 days after 
deployment. Research shows this is an optimal time to screen for PTSD. 
We screen all OEF/OIF servicemembers that come to us for care, 
regardless of the initial diagnosis. Many people will not come and 
express a need for psychiatric assistance. Our goal is to ensure all 
servicemembers and their families are aware of the available help and 
to make it as easy as possible for them to access care.
    For veterans and servicemembers with severe injuries who have 
required medical evacuation from combat areas, VA and DOD conduct a 
comprehensive and formal system of seamless transition including 
monitoring any signs or symptoms of mental health conditions.
    For those with planned returns from deployment, veterans and 
servicemembers requiring help can be identified through PDHRA and 
collaborative PDHRAs 3 to 6 months after their return.
    There are currently 83 Returning Veterans Outreach, Education and 
Care (RVOEC) teams in VAMCs across the Nation. By the end of Fiscal 
Year 2007 there will be 90 such teams in operation. The goal of these 
teams is to provide early assessment and care to returning OEF/OIF 
veterans designed to address psychosocial problems before they 
deteriorate into actual mental disorders. If existing mental disorders 
such as PTSD are identified clinical services are provided by the team 
or by referral to other mental health programs including PTSD clinical 
teams. Outreach activities are carried out in coordination with Vet 
Centers. Education on clinical conditions and coping skills training 
are basic approaches to controlling emotional/behavioral problems in a 
manner that promotes coping skills yet can avoid the potential stigma 
of the term ``treatment.'' RVOEC teams also serve veterans in primary 
care settings, as do other mental health providers using evidence based 
collaborative and coordinated care approaches. A survey of the 38 teams 
established in Fiscal Year 2005 indicated that over 7,700 OEF/OIF 
veterans were seen for problems including PTSD, depression, substance 
use disorders and employment problems. VA is already working closely 
with community health providers to educate them on the signs and 
symptoms of PTSD. At the urging of the President's Task Force on 
Returning Global War on Terror Heroes, VA is reinforcing and expanding 
this outreach.

    Question 21: In this era of extensive Reserve component call-ups, 
do you foresee a need for additional Vet Centers beyond the current 
modest expansion?
    Response: The Vet Centers are extremely effective in providing a 
venue for help with readjustment issues. Through 2008 we will have 
increased our number of locations by 23 for a total of 232 while also 
augmenting the staff at 61 existing Vet Centers with 150 additional 
positions. In addition to the 100 OEF/OIF outreach workers hired in 
2004 and 2005, VA has added 269 positions since before 2004.
    VA's internal budget for the Vet Center program in Fiscal Year 2008 
will be $125 million dollars, which is a 25 percent increase over the 
program's Fiscal Year 2006 $100 million budget. Although we anticipate 
that these additional resources will be of great value to VA's efforts 
to intervene early and serve the OEF/OIF troops returning from combat, 
we are aware of the increasing number of returning combat veterans and 
will evaluate the need for additional resources on an ongoing basis.

    Question 22: What is your view on maintaining the continued 
independence of Readjustment Counseling Service and its Vet Centers 
from the medical operations under VHA?
    Response: The Vet Centers have my full and total support in their 
mission of providing early intervention and quality readjustment 
services to our Nation's war veterans and their families. These 
community-based centers provide a unique combination of outreach and 
effective readjustment counseling services aimed to assist veterans and 
family members in making a successful transition from military 
deployment to civilian life. Vet Center services have enabled VA to 
better serve the newer generation of veterans returning from OEF/OIF. 
It is my view that the optimal way to ensure their continued success is 
to maintain their current status within the health care structure.

    Question 23: VA currently has the authority to involve families 
only in a limited course of treatment. It is now apparent that 
increased attention to family members, outside of specific courses of 
treatment, would directly benefit veterans at risk of mental health 
problems. What changes, legislative or otherwise, would you pursue to 
increase attention to veterans' families and to encourage their 
participation in the veteran's recovery process?
    Response: Family involvement is essential to the care of the 
veteran. In fact, we have adapted our policies to encourage the maximum 
level of family support, consistent with the clinical or rehabilitative 
needs of the veteran, particularly in TBI cases.
    In VA medical centers and clinics, families are involved in 
treatment when this is covered in a treatment plan developed to benefit 
the veteran. This has allowed the dissemination and implementation of 
family psycho-education, an evidence-based intervention with a focus on 
families of veterans with serious mental illness, and outcomes that 
include decreased rates of hospitalization for the veteran. We have 
heard of a number of cases in which families are aware of mental health 
symptoms, but where veterans are reluctant to come for care. In these 
cases, there can be a real need for families to know that they can come 
to the VA to talk with mental health professionals about their loved 
one and to learn how to manage symptoms and potentially dangerous 
behaviors. This type of care is already available through Vet Centers, 
but we lack the authority to allow it in medical centers and clinics.
    As you are aware, Vet Centers have been authorized to provide 
bereavement counseling for family members of deceased servicemembers. 
Counseling after return from deployment often focuses on the veteran's 
readjustment to the family as well as to the job, school, and 
community.

    Question 24: Women make up a growing portion of the military and 
veteran population and are serving in theaters of combat in increasing 
numbers. This growing group of veterans will continue to require new 
services from VA. What steps would you take to keep pace with the 
demands of women veterans? What is your view on what VHA could be doing 
to improve services for women veterans?
    Response: Providing gender-specific, age-appropriate health care is 
our most important responsibility to women veterans. Since Fiscal Year 
2002, 37.2 percent of separated women OEF/OIF veterans have sought VA 
health care services. This means we will be dealing with women veterans 
of child-bearing age. To properly address this situation, we created 
the Women Veterans Health Strategic Healthcare Group (SHG). I have 
given my full support to this SHG in planning and implementing the 
highest quality care to women veterans.
    VA has designed services and programs to be responsive to the 
gender-specific needs of women veterans. VA offers comprehensive health 
care services for women including: all aspects of primary care, gender-
related health care, counseling for sexual trauma, pregnancy and 
infertility care. In addition, VA has Women Veterans Program Managers 
at every VA medical center. VA sets the benchmark for care in the 
United States in such areas as breast and cervical cancer screening.
    More and more research is being done to assess the special needs of 
women in the military, including Military Sexual Trauma (MST), and the 
differences in how women respond to stress, especially PTSD. We have a 
special inpatient women's PTSD center in Cincinnati named Chrysalis and 
we will consider opening more of the same as the need is identified. 
Similarly, the Women's Mental Health Center in Palo Alto was opened in 
October 2002 to provide treatment and support for sexual trauma. VHA's 
Office of Mental Health Services recently established a MST support 
team to monitor MST screening and treatment, coordinate MST-related 
education and training, and to promote best practices in the field. New 
cognitive-processing therapy and behavioral therapy have proven highly 
effective, and these lessons are being disseminated to other locations.
    VA is pursuing improved care on multiple levels. We are:

     Providing enhanced training for primary care providers in 
the complexity of women's health medicine;
     Adding a nationally renowned female surgeon to work in our 
Office of the Medical Inspector;
     Establishing a ``provider registry'' so VHA providers can 
access ``real-time''interaction on gender-related medical issues; and
      Improving the physical environment of care, with 
particular attention given to the need for private, welcoming space for 
women veterans.

    With regard to what else can be done, I think it would be 
appropriate to have additional research in the areas of general women's 
health, such as cardiac disease, breast cancer, and cervical cancer 
rates for veterans and in issues related to military service, such as 
MST. We are particularly interested in collaborating with DOD in 
efforts to understand how to best respond early after sexual trauma 
exposure and to assist veterans to achieve recovery from traumatic 
events.

    Question 25: You have testified that currently when wounded service 
personnel enter the VA health system that there is a detailed procedure 
to minimize the infection and spread of the acinetobacter infection. 
What type of testing is currently being used to screen patients?
    Response: When patients are admitted to VA facilities, the standard 
of care is to assess all wounds or open sores. This assessment would 
include a review of all available previous culture and susceptibility 
data from any other facility. Additional culture and susceptibility 
testing would be dictated by the clinical presentation and assessment. 
Acinetobacter baumanii is an organism that grows on usual media in VA 
microbiology laboratories and where routine susceptibility testing is 
available to allow appropriate antibiotic decisionmaking.
    VA has provided a great deal of information to our veterans and 
staff on this bacterium and we have coordinated with DOD to be sure our 
providers are aware of the potential of this bacterium. Acinetobacter 
baumanii was reported to be the most common gram-negative bacillus 
recovered from traumatic injuries to extremities during the Vietnam 
War. It also occurs in other non-veterans who suffer traumatic injuries 
suggesting environmental contamination of wounds as a potential source.
    A staff physician in Infectious Diseases at the National Naval 
Medical Center Bethesda (Bethesda Naval) first informed VA about multi-
drug resistant gram-negative rods on the USNS Comfort and at Walter 
Reed. This occurred in a memorandum to the National Director for 
Infectious Diseases on April 22, 2004. Because some of these patients 
potentially could have been transferred to a VA Medical Center, VA 
prepared and released a Colleague's Letter the next day alerting VA 
staff to this possibility. This letter also noted the general 
susceptibility pattern, made general therapeutic recommendations, and 
covered overall infection protocol from Bethesda Naval. Additional 
information was sent to the field on November 19, 2004 that provided 
more information on isolates, susceptibility testing, and military 
protocols for isolation precautions.

    Question 26: Witnesses from the Committee's recent hearing on 
seamless transition health issues testified that there needs to be 
improved screening and testing of wounded service personnel for 
conditions such as TBI (traumatic brain injury) and infection (such as 
acinetobacter) as they are transferred to the VA system. Do you intend 
to have VA work with DOD to gain information about an existing testing 
mechanism for such infections currently being used at Fort Sam Houston?
    Response: We have been working closely with DOD and have developed 
a screening mechanism for TBI that was implemented VA wide as of 1 
April 2007. VA is now screening all returning servicemembers for mild 
to moderate TBI. VA, in coordination with DOD developed a tool for 
effective early screening of TBI. This tool stands ready for use, as 
directed by the President's Task Force on Returning Global War on 
Terror Heroes. While screening for mild to moderate TBI is a challenge, 
we have set up a registry to ensure follow-up for people who come up 
positive on the screen.
    VA is also working with DOD through the VA-DOD Deployment Health 
Workgroup to obtain more information about acinetobacter among recent 
combat veterans. At Fort Sam Houston, wounded patients are screened for 
this and other infectious diseases. Information about this screening 
and any follow-up health care is provided to VA in the patient record 
when these patients transition to VA for health care.

    Question 27: Do you anticipate a continued need for annual 
increases, significantly above the rate of inflation, to VHA's budget 
for the foreseeable future? In rough numbers, what is VHA's budget 
projection through the next five fiscal years, and how does it relate 
to projected patient load?
    Response: The Administration determines the details of its 
appropriations request one year at a time. That said, our budget 
increases have historically been over inflation. An increase in the 
size of the budget equal to the rate of inflation would be practical 
only if no new veterans came into the system, veterans' health remained 
unchanged, and there were no increased changes in the delivery of care 
from year to year. We have a very rigorous and accurate actuarial model 
we are continuously improving each year that projects our need through 
a budget year. In addition, VA and OMB together monitor performance and 
resources monthly to ensure no issues arise. We do not have a budget 
projection for the next 5 years.

    Question 28: As stated in the proposed Fiscal Year 2008 budget, the 
Administration intends to continue its ban on so-called ``middle-
income'' or Priority 8 veterans. What are your views on explicitly 
excluding certain veterans from the VA health care system?
    Response: The Enrollment Act of 1996 required VA to establish 
priority levels of veteran care to ensure that those with the greatest 
needs receive timely and high quality care. The law requires the 
Secretary on a yearly basis to determine what priorities he believes VA 
can support. In January, 2003, then-Secretary Principi made a decision 
precluding new priority 8s from enrolling. This was predicated on an 
unprecedented influx of enrollees and growing wait times. Over 80 
percent of this group had other forms of health insurance and care 
available, so this group was not put in a situation where they had no 
access to any kind of care. Secretary Nicholson has continued that 
policy. VA estimates that if Priority 8 veterans were again allowed to 
enroll, 1.6 million veterans would do so in the first year at a cost of 
$1.7 billion. Our 5-year estimate places the cost at $4.8 billion, and 
our 10-year projection estimates a cost of $33 billion.
    Any change in this determination would require several years of 
preparation. We would require new, larger facilities and additional 
staff to handle the added workload. Simply opening the door for 
Priority 8 veterans now, without taking these steps, would prove 
disastrous for the quality and timeliness of care VA provides.
    I will note, however, that VA has the authority to enroll combat-
theater veterans returning from OEF/OIF in VA's health care system, 
regardless of income level, making them eligible to receive any needed 
medical care or services.

    Question 29: In your view, what are the merits of a predictable and 
viable funding mechanism for VA, such as mandatory or guaranteed 
funding?
    Response: While I am not familiar with the details of how mandatory 
or guaranteed funding would work, we believe it could have serious, 
unintended effects. VA has greatly benefited from a receptive Congress 
and Administration and has actually done better in our budget than 
would have been the case with mandatory funding. A strict financial 
formula would not be able to capture the complexity and dynamism 
required by a health care system for a population as diverse as our 
veterans. Potentially, rapid advances in medical science, prescription 
drugs, and treatment modalities would be stymied.
    A mandatory funding system also does not appear to allow Congress 
to exercise the oversight it now does in the budgetary process. This 
could result in inadequate funding by the Congress and the President 
for America's veterans.

    Question 30: What are the practical effects of running a health 
care system under the constraints of a Continuing Resolution? Are those 
constraints any different than those included in a budget request which 
essentially flat-lines medical care funding?
    Response: The process of a Continuing Resolution places a great 
strain on VA. We cannot move forward on new initiatives and leadership 
is unable to make new plans or significant changes in our delivery 
process. It is in effect a flat line budget which if continued could 
significantly impact our ability to provide needed care for our 
veterans.

    Question 31: The theft or loss of computer equipment containing 
sensitive personal information on private citizens or agency employees 
is becoming a routine feature of our government. However, I am 
concerned that hastily issued security directives could lead to 
unforeseen difficulties and negatively impact agency operations. What 
will you do to ensure that VHA mitigates the loss of any more laptops 
or memory devices, while not harming essential functions?
    Response: Protecting Personally Identifiable Information (PII) is 
critically important to this agency. We owe that to our veterans. VHA 
is reducing the risk of future breaches through better physical 
security and better business practices. We are working closely with 
Office of Information & Technology (OI&T) to deploy data protection 
solutions, including encrypted laptops and encrypted removable storage 
media. We are also working with OI&T's Information Protection Office to 
develop business requirements, validation processes, and classification 
requirements.
    As we have developed initiatives to protect data, we have always 
operated under the admonishment to do no harm. We are constantly 
dialoging with VA Ol&T about issues concerning patient care and the 
delivery of care. When we have had concerns, I personally have brought 
those up to VA leadership; they have, and are, being addressed.

    Question 32: VA and DOD have allegedly been working for over a 
decade to develop an interoperable and bidirectional electronic health 
record that would facilitate the smooth transfer of medical information 
between DOD and VA. Please give your assessment of the state of 
development of the electronic health record, and what steps are needed 
to reach the goal.
    Response: There have been real and significant advances in the 
transfer of medical information from DOD to the VA. VA and DOD have 
achieved a significant level of success and are currently using 
standards-based interoperable electronic health records to share 
clinical data bidirectionally.
    DOD provides as much electronic data as possible using their 
current system. At present, DOD does not have a mature in-patient 
electronic health record that could be transmitted to VA. VA and DOD 
have agreed to work expeditiously toward the development of a 
compatible inpatient electronic health record that would leverage the 
strengths of the Armed Forces Health Longitudinal Technology 
Application (AHLTA) as well as our CPRS/VISTA.
    On January 24, 2007, the Secretaries of VA and DOD agreed to study 
the feasibility of a new common inpatient electronic health record 
system. During the initial phase of this work, expected to last between 
6 and 12 months, VA and DOD are working to identify the requirements 
that will define the common VA/DOD inpatient electronic health record. 
The Departments are working to conduct the joint study and report 
findings as expeditiously as possible. At the conclusion of the study, 
we will begin developing a common solution.
    For now, VA receives available electronic data through secure and 
successful one-way and bidirectional data exchange systems. These 
interfaces, known as the Federal Health Information Exchange or 
``FHIE'' and the Bidirectional Health Information Exchange or ``BHIE'', 
ensure that DOD provides VA as much of the health record as possible 
electronically. FHIE supports the care of separated and retired Service 
members and supports the transfer of pre- and post-deployment health 
assessment and reassessment data on separated Service members and 
demobilized National Guard and Reserve patients. Through FHIE, DOD has 
transferred electronic health data on almost 3.8 million unique 
separated servicemembers. VA has provided care or benefits to more than 
2.2 million of these veterans.
    BHIE supports the care of and active duty patients and dependants 
using both systems pursuant to sharing agreements or other 
arrangements. BHIE is now available at all VA sites of care and is 
currently installed at 25 DOD host locations. These 25 locations 
consist of 15 DOD medical centers, 18 DOD hospitals and over 190 DOD 
outpatient clinics. By June 2007, VA will be able to access data from 
all DOD sites.
    VA and DOD are implementing several pilot projects to expand our 
cooperation and the transfer of records that will potentially be 
expanded enterprise wide. In El Paso, Texas, VA and DOD are using BHIE 
to share radiology images, while in the Puget Sound area (and at 
several other locations, including Hawaii, San Antonio, and San Diego), 
VA and DOD can share inpatient discharge summaries and other narrative 
documents.
    VA and DOD also developed transferable, computable allergy and 
pharmacy data between next-generation systems and data repositories. 
This interface, known as CHDR, permits VA and DOD systems to conduct 
automatic drug-drug and drug-allergy interaction checks using data from 
both Departments to improve patient safety of those active dual 
consumers of VA and DOD, just as CPRS already does within the VA 
system.
    VA is now able to access DOD medical digital images and 
electronically scanned inpatient health records. We successfully 
piloted this program, at least in one direction (from DOD to VA), 
between Walter Reed and three of the four VA Polytrauma Rehabilitation 
Centers, located in Tampa, Richmond, and Palo Alto. VA clinicians can 
immediately access critical components of the veteran or 
servicemember's inpatient record from DOD military treatment 
facilities. Bethesda Naval is also sending digital images to Tampa and 
Minneapolis. Expansion of this capability to Brooke Army Medical Center 
is planned for this summer.

    Question 33: Prior to the Secretary's directive to centralize all 
Information Technology (IT) operations under VA's Chief Information 
Officer, VHA was responsible for its own IT functions. What has been 
the impact of this reorganization on VHA? What problems, if any, have 
resulted from the reorganization?
    Response: The VA Chief Officer (CIO) assumed authority over the 
Information Technology (IT) staff and their responsibilities on April 
1, 2007, approximately 6 weeks ago. VA is still in the early phases of 
constructing an IT governance framework, a critically important task. 
When the governance structure is established, VHA's will shift toward 
being a ``customer'' requiring products and services from its new IT 
provider, the VA CIO. Anytime you make as dramatic a shift as we have, 
there will be challenges. Thousands of personnel have been moved from 
the administration to VA OI&T. I believe that this has gone amazingly 
well given the magnitude of the project. I believe we have worked 
together in a cooperative spirit to continue providing IT services for 
clinical activities and to ensure quality care for our veterans. The VA 
CIO, the Secretary, and I share the view that VHA will set the business 
requirements to ensure our internationally recognized electronic health 
record system continues to provide the highest quality of health care 
to veterans.
    Some of the challenges we have encountered involve ensuring 
everyone understands the new procedures and maintaining communication 
at all levels.

    Question: 34: Do you believe that the Inspector General can 
continue the oversight of VA operations, if budget cuts are once again 
required of the OIG?
    Response: While I cannot speak directly to the adequacy of the 
Office of Inspector General's (OIG) budget, I can say that I will 
provide any and all assistance or consultation the OIG requires to make 
the most effective use of its resources in providing oversight of VHA 
programs. Such consultation will assist OIG in prioritizing areas for 
review and in addressing critical concerns of the Department while 
maximizing available resources.

    Question 35: Given the surge and complexity of claims that VA is 
receiving as a result of ongoing operations abroad, does VHA have the 
capacity to provide timely and accurate medical examinations on behalf 
of VBA? What would you do, as Under Secretary for Health, to ensure 
that these exams are expedited?
    Response: VHA has been working closely with VBA to ensure that OEF/
OIF veterans get the evaluations that they require and deserve in a 
timely fashion. VHA compensation and pension (C&P) initial exams have a 
timeliness of 34 days, which is within the standard established in the 
VHA/VBA memorandum of understanding. We will put in the necessary 
resources to meet whatever goal is established.
    VA's Compensation and Pension Examination Program Office (CPEP) 
recently compared workload for the first 6 months of Fiscal Year 2007 
with the first 6 months of Fiscal Year 2006. While there was an 11 
percent increase in completed requests and an almost 20 percent 
increase in completed exams, we also saw a 5 point jump (to 86 percent) 
for ``A'' quality C&P exams, those that meet more than 90 percent of 
our quality indicators. Essentially, our quality and our timeliness 
have improved in spite of the increased workload.
    VA anticipates an increase in C&P claims from approximately 800,000 
in Fiscal Year 2007 to approximately 815,000 in Fiscal Year 2008. As 
the Under Secretary for Health, I will ensure that VHA continues to 
identify and commit the resources needed to manage the anticipated C&P 
examination workload increase.

    Question 36: Do VHA and VBA facility directors work together to 
reduce the percentage of incomplete examinations in order to improve 
the timeliness and accuracy of medical examinations? Please cite 
examples.
    Response: Yes, VHA and VBA facility directors and staff at all 
levels are expected to work together to improve C&P exam processes.
    Veterans Service Center officials at each regional office (RO) are 
required, at a minimum, to meet with their VHA medical center 
counterparts at least once per year to address C&P exam related issues. 
However, in a recent survey of communication practices between VBA ROs 
and VHA examining sites, CPEP found the majority of respondents met 
more frequently than once a year to address C&P issues, and 
approximately 30 percent conducted monthly meetings. In addition to VHA 
facility directors, these meetings are attended by RO service center 
managers, VAMC chiefs of staff, associate directors, and other 
staffers. These meetings often cover exam requests and report on 
quality, timeliness, cancellations, workload projections, staffing, and 
other issues.
    But even more can be done to enhance effective communication. VBA 
and VHA jointly conducted a national conference on improving 
communication between ROs and VAMCs concerning C&P exams in April 2007. 
VBA and VHA were both well represented (about 150 attendees each). VBA/
VHA teams jointly developed concrete action plans for improving 
communications at this meeting. Appropriate experts are currently 
reviewing these action plans in an ongoing progress for improved 
service and support.
    Florida (VISN 8) and Southern California (VISN 22) provide two 
examples of our best practices for VBA/VHA coordination. In Florida, 
the VISN 8 Network Director and Health Systems Specialist have worked 
with the St. Petersburg RO Director and Service Center Manager to 
establish working collaborations resulting in VISN 8 being one of the 
Nation's leading performers in C&P exam quality. In VISN 22, VISN 
Network Director and Network Strategic Management Officer have worked 
with the VBA Western Area Director and San Diego RO Assistant Director 
to identify problems, establish working groups to apply systems 
improvement principles, and develop service agreements to serve as a 
tool for change. VISN 6 is another example where leadership has 
established ongoing processes for collaborative ownership of C&P exam 
processing issues. The Director of the Salisbury VA Medical Center has 
taken the lead for the VISN 6 Network Director and worked with RO 
Directors in Huntington, WV, Roanoke, VA, and Winston-Salem, NC. VISN 6 
is a high performer in both quality and timeliness of exams.

    Question 37: Do medical facilities reschedule examinations, when a 
first examination has been missed, without a Regional Office having to 
resubmit an examination request? Please provide any direction that has 
been given to the field regarding this matter.
    Response: The Chief Business Office (CBO) VHA Procedure Guide 
1601E, C&P Examinations, states that a veteran's C&P exam will be 
rescheduled by the medical facility on a one-time basis if the veteran 
requested the exam be postponed for a valid reason. If the veteran 
failed to report for the exam and provides no justifiable reason for 
missing the exam, the exam request is returned to the regional office.
    Web links to the CBO procedure guide are embedded in the electronic 
posting of VHA Handbook 1601E.01, Compensation and Pension 
Examinations, which is available on the VHA Intranet. The Handbook was 
distributed to VHA by email on 4/5/2006. In addition, CBO provided 
training via conference calls and ``live meetings'' to VHA facilities 
on these procedure guidelines and the Web based educational materials.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Daniel Akaka to 
  Michael J. Kussman, M.D., Nominee to be Under Secretary for Health, 
                     Department of Veterans Affairs
    Question 1: Recent news stories have noted that American Samoan 
servicemembers have extremely high per capita casualty rates in our 
current conflicts in Iraq and Afghanistan--more than 13 times higher 
than the national average. While American Samoans are overrepresented 
in uniform, those who return home after their service have difficulty 
receiving health care. Currently, there are no VA hospitals in American 
Samoa. In fact, there is only one hospital in all of American Samoa, 
which does not provide certain types of care. Frequently, American 
Samoan veterans must fly to Hawaii to receive care, which can be a 
difficult process.
    I was pleased to learn that a new VA clinic is scheduled to be 
dedicated in American Samoa this July. Please provide me an update on 
the clinic, including progress on staff recruitment and linking to 
computer systems in Hawaii. Also, please describe VA's plans over the 
next 5 years to better meet the needs of American Samoan veterans.
    Response: The Department of Veterans Affairs (VA) Pacific Islands 
Health Care System (VAPIHCS) will open its community-based outpatient 
clinic (CBOC) in American Samoa on June 25, 2007, and dedicate the CBOC 
on Saturday July 21, 2007. The CBOC will be staffed with six 
employees--internal medicine physician, psychiatrist, social worker, 
nurse, medical assistant and clerk. All employees have been selected 
and accepted VA offers (three currently reside in American Samoa). 
However, the primary care provider will join the staff several weeks 
after the clinic opens. The CBOC will provide care to approximately 
1,000 eligible veterans and support up to another 600 Army Reserve and 
TRICARE beneficiaries.
    The CBOC will use the VA computerized patient record system (CPRS). 
Initially, to link to electronic systems in Hawaii, CPRS will run on a 
``site to site virtual provider network'' connection to an internal VA 
gateway. VAPIHCS and VA Office of Information and Technology (OI&T) are 
currently negotiating with several vendors for a permanent solution 
that will offer additional speed and bandwidth. VAPIHCS and OI&T are 
optimistic they will be able to successfully establish a ``T1 line'' 
via satellite. This additional speed and bandwidth will be necessary to 
support planned telehealth activities. Currently, there is no high-
speed information technology cable to American Samoa and this is not 
expected to be rectified soon.
    Over the next 5 years, VA plans to establish an active telehealth 
program. Telehealth capabilities in cardiology, endocrinology, 
ophthalmology, orthopedics and rheumatology are currently being 
evaluated. The establishment and maturation of the American Samoa CBOC 
will be the linchpin to meeting the health care needs of veterans on 
American Samoa. Veterans will continue to use LBJ Tropical Medical 
Center for specialty care i.e., non-primary care and non-mental health 
services. Also, veterans will obtain needed care from VA providers 
traveling to American Samoa (e.g., currently a VA orthopedist travels 
to American Samoa quarterly) and referrals to VA facilities in Hawaii 
or U.S. mainland.

    Question 2: On February 23, 2003, the VHA and the Indian Health 
Service signed a Memorandum of Understanding to encourage cooperation 
and resource sharing between the two parties, for the benefit of 
American Indian and Alaska Native veterans. The MOU included agreement 
on five mutual goals and on nine different items regarding health care 
for American Indian and Alaska Native veterans.
    Please provide a status report on VHA and IHS's progress regarding 
each of the goals and agreed-to items. Also, please provide all reports 
published by the interagency work group proposed in the MOU.
    Response: The Department of Veterans Affairs (VA) and the 
Department of Health and Human Services (HHS), Indian Health Service 
(IHS) have partnered on a number of national projects to implement the 
goals and agreed-to items in the February 23, 2003, Memorandum of 
Understanding (MOU). In addition, local VHA facilities and Tribes have 
established programs and agreements to implement the goals and 
objectives at the local level.
    To accomplish the goals of improving beneficiary's access to 
quality health care and services and to improve health promotion and 
disease prevention services to AI/AN, VA and IHS identified five 
objectives: facilitating collaboration on effective health care 
delivery, promoting activities to improve health and quality of life 
for AI/AN veterans, identifying needs and gaps to ensure optimal health 
care for the AI/AN population, creating an interagency workgroup to 
oversee national initiatives, and developing a common methodology to 
track VA and IHS activities. VA and IHS created a Shared Health Care 
Workgroup, which drafted an Inter-Departmental Coordinated Care Policy 
to optimize the quality, appropriateness, and efficacy of health care 
services and to improve patient satisfaction. Fifteen VISNs are engaged 
in various access-related outreach activities, four VISNs have 
incorporated disease-specific or prevention services, and seven 
Networks are planning and negotiating new access initiatives. The 
Office of Rural Health will play an important role in coordinating with 
IHS to meet the needs of AI/AN veterans in rural areas. VA and IHS 
conduct monthly meetings to oversee proposed national initiatives and 
both agencies have an agreed upon framework for documenting and 
tracking these discussions.
    VA and IHS identified two other goals: IHS facilitating improved 
communication between VA and AI/AN veterans and tribal governments, and 
encouraging partnerships and sharing agreements. Four objectives 
support these goals: collaborating in the exchange of program 
communications and other information; cosponsoring and providing 
reciprocal support for Continuing Medical Education, training, and 
certification of IHS and VA health care staff; developing and 
implementing strategies for information sharing and data exchange; and 
developing national agreements on sharing related to electronic medical 
records systems, telemedicine, prescriptions, bar code medication, 
national credentialing programs, and other technologies. VA is 
providing training programs to IHS staff and the Tribal community 
through its Employee Education Service and supporting internships and 
residencies in three VHA intensive care units (Phoenix, Minneapolis, 
and Houston). VA and IHS are currently test piloting the use of VetPro, 
VHA's electronic credentialing system, in the Phoenix area, and the 
Tribal Veterans Representative (TVR) Resource Guide and the TVR 
Facilitator Guide were completed and distributed in November 2006. VA 
and IHS are collaborating on several IT projects, including medical 
record and data-sharing, pharmacy benefits, potential integration into 
IHS Integrated Behavioral Health package, and other forms of 
connectivity. Telemedicine has proven to be extremely effective in 
treating PTSD in AN communities.
    The final goal is to ensure appropriate resources are available to 
support programs for AI/AN veterans. An Interagency Working Group of 
senior leaders from VA and IHS conducts a monthly conference call to 
discuss programs and associated resource needs. VHA has also initiated 
a performance measurement to track progress. A progress report is 
issued quarterly detailing the group's work and to ensure programs are 
implemented as planned. Two published documents are available--the 
first, a cumulative report from Fiscal Year 2005, and the second, a 
White Paper prepared and submitted to the White House in October 2006. 
These documents and the MOU are attached.
    [FY 2005 issue update, VHA and IHS collaboration report, and VA and 
HHS Memorandum of Understanding follow:]

                   Issue Update for Fiscal Year 2005
     VHA and IHS Support for American Indian Alaska Native Veterans
                                 issue
    Over the last two years, Indian Health Service (IHS) and Veterans 
Health Administration (VHA) have implemented a memorandum of 
understanding (MOU) to promote greater cooperation and sharing between 
the two health services to enhance the health of American Indian and 
Alaska Native veterans. This brief summarizes the progress made under 
the MOU to date and highlights a few of the more than 150 activities 
and programs undertaken in FY2005.
                               background
    American Indians and Alaska Natives (AI/AN) have a distinguished 
history of exemplary military service to the United States. They have 
served in high numbers and were often assigned to forward combat areas. 
As a result, they have a wide range of combat related health care 
needs. AI/AN veterans may be eligible for health care from VHA or from 
IHS or both. Despite this dual eligibility, Indian veterans report the 
highest rate of unmet health care needs among veterans and exhibit high 
rates of disease risk factors.
                            program summary
    The MOU between the Departments of Health and Human Services and 
Veterans Affairs, specifies five objectives to enhance the health of 
AI/AN veterans: (1) improving communication, (2) encouraging 
partnership and sharing, (3) expanding access to health services for 
Indian veterans, (4) ensuring organizational support, and (5) improving 
health promotion and disease prevention services.
National Activities
    The Office of the Deputy Under Secretary for Health for Health 
Policy Coordination (DUSH/HPC), 1OH, is the principal office 
responsible for coordinating implementation of the MOU within VHA. The 
office works with the leadership and staff of VHA and IHS to identify 
priority actions and ensure they are carried out. The office fosters 
progress on national initiatives and supports local implementation 
activities through the annual VHA strategic planning process and 
quarterly VISN monitoring system.
    Communication: The Headquarters Advisory group meets monthly, the 
Steering Committee meets three times each year and the Area and Network 
Directors have twice been convened to discuss priorities and coordinate 
activities. A FAQ sheet about the collaborations has been developed, an 
annual report was produced in August 2004, and an implementation guide 
highlighting best practices was completed in January 2005. A Web site 
is under development. VHA has initiated connections to tribal and 
national AI/AN organizations such as the National Indian Health Board 
and National American Indian Veterans, Inc. Briefings and presentations 
about the partnerships have been made at more than a dozen events 
around the country.
    Sharing and Collaboration: VHA Employee Education Service (EES) and 
the Nashville Area of IHS signed an operational agreement in April 2005 
to implement a sharing demonstration of VHA educational resources with 
IHS and tribes in the region. A password protected Web site has been 
established to provide IHS staff with electronic educational materials 
and to provide and track continuing education credits. Twenty programs 
were made available to IHS staff in 2005.
    VHA and IHS have a long partnership of sharing in software 
development, and new activities are underway to enhance this 
partnership. The VHA/IHS Information Technology Collaboration has 
developed a five-point work plan and has established a shared Web site 
to facilitate joint project management. An Interconnection Security 
Agreement that paves the way for direct network-to-network electronic 
communication has been signed. A project agreement for IHS use of VISTA 
imaging has been drafted and is under review. IHS and VHA staff are 
regularly attending the planning, development and training meetings of 
the other agency.
    Expanding Access: Access is focused at the local level. However, 
the national telehealth collaboration supports the use of telehealth to 
provide remote access to health services for AI/AN veterans. In April 
2005, eighteen IHS staff attended the annual VHA telehealth 
coordination meeting for the first time. During the meeting, VHA agreed 
that IHS and tribal representatives will join each VHA VISN-level 
telehealth coordination workgroup and two test sites for joint network 
development were identified: the Billings Area IHS and the Utah 
telehealth network (which includes tribes).
    Organizational Support: VHA has developed an implementation guide 
that shares best practices with the field. Both VHA and IHS require 
progress reports from the field on collaboration and the expansion of 
services to AI/AN veterans. VHA sharing is an element of the IHS Area 
Directors performance contract with the Director of IHS. Starting in 
2005, VHA requires that each facility provide access to American Indian 
spiritual practices equivalent to that provided for other religious 
affiliations. EES is developing a national Tribal Veteran 
Representative training curriculum.
    Health Promotion/Disease Prevention: IHS/VHA workgroups in Diabetes 
Prevention and Behavioral Health were established. On the 
recommendation of the Diabetes Prevention workgroup, three diabetes 
prevention partnerships were funded in Albuquerque, Los Angeles and San 
Diego. The programs incorporate primary prevention measures, including 
diet modification and physical activity, into activities targeted to 
AI/AN veterans.
    The Behavioral Health workgroup developed a framework for AI/AN 
communities to assist the 3,668 returning Operations Iraqi Freedom and 
Enduring Freedom (OIF/OEF) AI/AN servicemembers and veterans 
reintegrate with their families and communities and readjust to 
civilian life. The objective is to promote a community health model 
that gives tools to Tribal communities and families to help returning 
veterans address emerging adjustment reactions, traumatic stress, and 
Post Traumatic Stress Disorder (PTSD), emphasizing recovery as the 
goal. Outreach and informational materials have been developed and, to 
date, have been shared directly with four Tribes for local 
customization and adaptation. The program also includes education for 
local VHA, IHS and Tribal clinical staff on special health care 
concerns that arise following combat exposure; and training for VHA 
staff on cultural and spiritual needs of AI/AN veteran patients.
    Three projects have been funded to pilot-test evidence-based mental 
health treatment resource kits for use with veteran and AI/AN veteran 
populations.
IHS Area and VHA Network Activities (Examples, Attachment 1)
    Communication: In FY2005, VISNs reported more than 120 contacts 
with IHS, Tribal leaders or AI/AN veteran groups. Nearly two-thirds of 
these discussions occurred directly with Tribes.
    Sharing and Collaboration: The Networks reported more than 25 
agreements to promote sharing and collaboration in FY2005. Projects 
included the sharing of space, information technology expertise, 
educational programming, joint purchasing, and contracting for 
laboratory or diagnostic services.
    Access: By the end of FY2005, VISNs reported more than 20 programs 
that expand access to services for AI/AN veterans. For example, Network 
19 reported nearly 300 telepsychiatry patient contacts, 84 veteran 
participants in traditional ceremonies or native healer consults, and 
the completion of a residential substance abuse treatment program by 10 
patients. Other programs around the country include a dedicated AI 
coordinator to assist with nursing home placements, Tribal/reservation 
based CBOCs, telehealth home health care, telecardiology services, 
emergency room care agreements and reservation based housing for 
homeless AI/AN veterans. Network 18 reported an overall 17 percent 
increase in the number of AI/AN patients served in FY2005.
    Organizational Support: At the local level, organizational support 
frequently manifests as VHA sponsored health fairs, pow wow or homeless 
stand downs for AI/AN veterans, often held on or near a reservation. 
VISNs reported holding or participating in more than 70 such events in 
FY2005.
    Health Promotion/Disease Prevention: Three Networks reported 
prevention oriented programs: OIF/OEF readjustment outreach in VISN 18 
and 20 and health promotion programs in VISN 18 and 22.
Two Year Review
    The Steering Committee (SC) met in April 2005 to review progress 
under the MOU, hear from veterans and Tribal leaders, and determine if 
changes were needed to the agreement. The SC recommended that the MOU 
and the programs under it continue unchanged. However, the SC expects 
to see a greater emphasis on communication, outreach and the sharing of 
program and benefit information with veterans and Tribes including 
information on housing programs and support for homeless AI/AN 
veterans. In addition, the leadership of each organization has been 
asked to develop a joint policy for the coordination of health care for 
dual use veterans. Finally, the development of a new home health care 
demonstration for long term care elderly patients is expected.

                              ATTACHMENT 1

        Examples of IHS/VHA Sharing and Collaboration Activities
                                 FY2005
------------------------------------------------------------------------
      PROGRAM EXAMPLES              LOCATION               COMMENT
------------------------------------------------------------------------
Access:
1. Telecardiology Services..  SC, IHS at Rockhill.  12 clients served to
                                                     date.
2. Patient diet counseling..  NM, IHS Gallup......  IHS provided
                                                     counseling for VA.
3. Home based care..........  AZ, LA..............  Telehealth enabled.
4. Tribal staffed CBOC......  OK, Choctaw Nation..  1,000 vets; save 130
                                                     mile drive.
5. ER diagnostic/treatment..  OK, Choctaw Nation..  Saves 2 hour
                                                     emergency trip.
6. Health fair prevent        LA, Jena Band         Enrolled vets w/
 screen.                       Choctaw.              presumptive Dx.
7. Mental Health Therapy....  AZ, reservation       2 group; 63 indiv
                               based WY.             consults Q2.
8. Telepsychiatry...........  WY..................  @ 100 patient
                                                     contacts, Q2.
9. Residential SA treatment.  UT..................  Eight patients
                                                     completed.
10. Co-management w/ CPRS...  SD/ND; Pine Ridge,    IHS staff can view
                               Ft. Yates, Eagle      VA records for all
                               Butte.                shared patients.
11. Homeless Housing........  SD, Pine Ridge......  Building dedicated
                                                     Nov 2005.
12. Vet Centers.............  AZ, SD, OK, AK......  Hopi, Navajo, Pine
                                                     Ridge, Rosebud,
                                                     Tahlequah, AK
                                                     Native Villages.
13. Shared FTE veteran coord  NC, Cherokee          108 clients served
                               Hospital.             FY2005.

Sharing & Collaboration:
1. Radiology and Pathology..  KS, Haskell Nation..  100-200 reads/month.
2. Space Lease..............  WI, Ho-Chunk Nation.  5,661 sq ft space
                                                     leased.
3. Tribal College             OK, Cherokee Nation.  Training for student
 affiliation.                                        RN, opt, rad.
4. Laboratory contract......  TX..................  $3,361 revenue
                                                     generated Q2.
5. PTSD education training..  AK..................  Prepare IHS for OIF/
                                                     OEF vets.

Organizational Support:
1. Veteran Tours of VAMC....  NC, Cherokee          Tours introduce AI
                               Hospital.             vets to VA.
2. Credentialing Tribal       NC, Cherokee          Smooth referral,
 staff.                        Hospital.             access CPRS.
3. Share patient edu          VISN 12, Bemidji IHS
 material.
4. Tribal veteran rep         VISN 23, 19, 18, 12.
 training.
5. Weekly talking circle....  AZ..................  PTSD patients
                                                     enrolled.
6. Full Time AI Coordinator.  AZ..................  Assist nursing home
                                                     placement.
------------------------------------------------------------------------


Veterans Health Administration and Indian Health Service Collaboration 
               for American Indian/Alaska Natives (AI/AN)
    On February 25, 2003, the Department of Health and Human Services 
(HHS) and the Department of Veterans Affairs (VA) entered into a 
Memorandum of Understanding (MOU) to encourage cooperation and resource 
sharing between the Indian Health Service (IHS) and the Veterans Health 
Administration (VHA). The goal of the MOU is to use the strengths and 
expertise of both organizations to deliver quality health care services 
and enhance the health status of American Indian and Alaska Native 
veterans. Through the Headquarters Advisory Group, numerous national 
programs have been initiated to serve AI/AN veterans. In addition, 
local activities take place between the Veterans Integrated Service 
Networks (VISN), VA medical facilities, and the tribes themselves.
    Outreach. At the national level, outreach activities have consisted 
of increased communications between VHA and IHS through the 
Headquarters Advisory Group and the Steering Committee, briefings such 
as the VA briefing on VA Seamless Transition Activities to IHS 
leadership, IHS participation in the VHA Symposium on ``Caring for 
Veterans Returning from Recent Conflicts,'' and the pending revision of 
the joint IHS/VA Web site. The Tribal Veterans Representative (TVR) 
Resource Guide and the TVR Facilitator Guide have been completed and 
will be distributed in November 2006. A video broadcast of the 
materials is also scheduled for release in November. At the local 
level, thirteen networks are engaged in a variety of outreach 
activities, including meetings and conferences with IHS program and 
tribal representatives, VA membership in the Native American Healthcare 
Network, VA participation in traditional Native American ceremonies, 
transportation support to AI/AN, etc.
    Education. VHA Employee Education Service (EES) is providing 
training programs to IHS staff and the tribal community. A password 
protected Web site has been established to provide IHS staff with 
electronic educational materials and to provide and track continuing 
education credits. In 2006, VHA delivered 145 training programs, of 
which 90 were made available using satellite technology and 55 using 
web based technology. These educational programs will be continued in 
2007, and VHA will also provide selected IHS staff an opportunity to 
attend regional EES workshops on buprenorphine.
    Behavioral Health. The Behavioral Health workgroup developed a 
framework for AI/AN communities to assist returning Operations Iraqi 
Freedom and Enduring Freedom (OIF/OEF) AI/AN servicemembers and 
veterans reintegrate with their families and communities and readjust 
to civilian life. The objective is to promote a community health model 
that gives tools to Tribal communities and families to help returning 
veterans address emerging adjustment reactions, traumatic stress, and 
Post Traumatic Stress Disorder (PTSD), emphasizing recovery as the 
goal. The joint committee has developed a slide presentation to be used 
by outreach teams when addressing various Tribal veterans. There have 
been briefings using the slide presentation in Montana, with 
approximately 30 veterans now receiving services from VA.
    Expanded Health Care Services. At the local level, ten VHA networks 
are engaged in targeted initiatives aimed at providing a full continuum 
of healthcare services, such as health fairs, VA/IHS Advisories, Use of 
Health Buddy, and education and/or shared services in substance abuse, 
domestic violence programs, cardiac rehabilitation, dietetics, 
behavioral medicine, etc.
    Information Technology. VHA and IHS are collaborating on numerous 
information technology projects, including Medical record and data-
sharing policy, a Bar Code Medication Administration (BCMA) project, 
Centralized Mail Out Pharmacy (CMOP) support, potential integration 
into IHS Integrated Behavioral Health package, potential use of VA 
information technology systems for some IHS sites, data networking and 
communication--exploring VA network operations for alternate 
connectivity for non-clinical applications (i.e. electronic lab 
services) and collaboration on hardware whereby approximately 100 CPUs 
will be sent to the Aberdeen Area.
    Patient Safety Program. The VHA National Center for Patient Safety 
(NCPS) has trained the newly appointed IHS patient safety manager in 
Root Cause Analyses and Healthcare Failure Mode and Effects Analysis 
and has provided a small library of core patient safety literature and 
various NCPS tools.
    Care Coordination. The VHA-IHS Shared Health Care Workgroup has 
drafted an Inter-Departmental Coordinated Care Policy, the goal of 
which is to optimize the quality, appropriateness and efficacy of the 
health care services provided to eligible American Indian and Alaska 
Native (AI/AN) veterans receiving care from both VHA and IHS or Tribes; 
and to improve the patient's satisfaction with the coordination of care 
between the two Departments.
    Diabetes Prevention Programs. Three Diabetes Prevention programs 
have been initiated in San Diego, Greater Los Angeles, and Albuquergue. 
The goal of the program is to assist AI/AN veterans integrate healthy 
lifestyles, and therefore to prevent healthcare problems related to 
diabetes. Various components of the program include training Diabetes 
Prevention Program (DPP) lifestyle coaches, producing deliverable DVDs 
of the training sessions and distributing them to each AI site; 
providing sites with related equipment, including TVs, TV carts and 
DVD/VCR players and other related educational materials.
    Telemedicine. Another VA program that is very effective and popular 
with Indian and Alaskan Native Veterans is Telemedicine. It is proving 
to be extremely effective in the treatment of PTSD in Alaskan Native 
villages. VA and IHS are working to spread the use of telemedicine 
services by AI/AN veterans, which will allow VA to bring physical and 
mental health care to the tribes, especially those in remote areas of 
the country.
    Credentialing Program. VA and IHS are currently in a pilot test of 
the use of VetPro, VHA's electronic credentialing system by the Phoenix 
Area Indian Health Service. The intent of this pilot is to demonstrate 
the value of sharing Federal information technology used for the 
credentialing of health care providers. The pilot began in May 2006. To 
date, 61 Licensed Independent Practitioners have been enrolled by the 
two IHS facilities and IHS appears enthusiastic about the VetPro 
process.
    Research. The Los Angeles VA Geriatric Research Education and 
Clinical Center has been funded for a research study entitled ``VHA and 
IHS: Access for American Indian Veterans.'' The study will describe 
dual utilization of VA and IHS services, including fragmentation or 
potential overlap of services, identify organizational and individual 
factors that impede or facilitate access to care, and generate 
recommendations on how VA and IHS can work together to improve access 
to health care.
    Traditional Healing. Some VHA facilities and Vet Centers have 
incorporated Traditional Healing Ceremonies along with modern methods 
of treatment and counseling. As a national initiative, VA has sent over 
500 letters to tribal leaders to ask them to provide information on 
appropriate providers of Traditional Practices so that they may be 
called upon for religious/spiritual care of AI/AN veterans.

                    Department of Veterans Affairs,
                            Veterans Health Administration,
                                     Washington, DC, June 24, 2003.
    Dear Colleagues in Veterans and Indian Health: On February 25, 
2003, the Department of Health and Human Services (HHS) and the 
Department of Veterans Affairs (VA) entered into a Memorandum of 
Understanding (MOU) to provide optimal health care for the more than 
165,000 American Indian and Alaska Native veterans in the Nation. This 
MOU, signed by the Deputy Secretaries of VA and HHS on behalf of 
Secretary Anthony J. Principi and Secretary Tommy G. Thompson, offers 
many opportunities to enhance access to health services and improve the 
quality of health care for Indian veterans. The purpose of our letter 
is to provide guidance on the intent and potential applications of the 
MOU. We have enclosed a copy of the MOU for your reference.
    The MOU is designed to improve communication between the agencies 
and Tribal governments and to create opportunities to develop 
strategies for sharing information, services, and information 
technology. The technology sharing includes the VA's electronic medical 
record system, bar code medication administration, and telemedicine. 
Also, VA and the Indian Health Service (IHS) will co-sponsor continuing 
medical training for their health care staffs. Significantly, the MOU 
encourages VA, Tribal, Urban, and IHS programs to collaborate in 
numerous ways at the local level. We expect that the most progress will 
be made where effective local partnerships are formed among the IHS, 
VA, and Tribal governments to identify local needs and develop local 
solutions. You are encouraged to establish a means for routine and 
periodic communication between local elements of VA and the IHS. At a 
minimum, such communication would serve to clarify and share 
information on which services are provided by each organization and to 
whom at each location. At its most effective, the communication would 
include a broader discussion of joint program initiatives in clinical 
service delivery, community-based care, health promotion, and disease 
prevention. The management and prevention of chronic disease is a 
challenge that confronts both Departments; creative solutions in case 
management, home and community-based care, and primary prevention 
activities will improve the health of those we serve.
    Collaborations already exist in many locations but the intent of 
the MOU is to expand these activities where they are and extend them to 
more communities and facilities. Examples of shared service 
arrangements already in place include the following: In some locations, 
specialists from VA provide cost-effective consultation to Indian 
health facilities; at others; telemedicine capabilities are shared to 
enhance access to otherwise unattainable services; and continuing 
education through access to veterans' programs is another shared 
capability that has been developed in some areas. Other collaborative 
efforts remain to be developed and might include primary care for non-
Indian veterans in exchange for hospital care for non-veteran Indians. 
The creation of joint community-based care and prevention is another 
area of collaboration where few models currently exist.
    Another principle embodied in the MOU is that collaboration and 
more creative and effective use of resources will meet the President's 
management objectives. President Bush has clearly stated his management 
agenda to improve the efficacy and efficiency of Federal Government 
activities. Where there are opportunities to fill gaps or eliminate the 
duplication of effort, collaboration can help with the planning and 
deployment of resources in the most cost-effective and highest-quality 
manner. The MOU encourages the development of resource-sharing, within 
our current legal authority, to enhance the services provided to meet 
the missions of both Departments. It does not mean that each Department 
will begin to bill the other for services provided to the other's 
beneficiaries, except where it is agreed to by both entities. It may 
mean, however, the development of responsible sharing of services to 
meet the needs of patients and communities.
    At the national level, the two Departments will continue their very 
productive collaboration in developing more effective information 
technologies. Collaboration has led to many advancements in electronic 
health record systems and quality improvement tools. The MOU should 
facilitate the engagement of local entities in both Departments that 
are able to influence national program development in these areas.
    In summary, the MOU expresses the commitment of both Departments to 
expand our common efforts to improve the quality and efficiency of our 
programs. It provides policy support to local planning and 
collaboration, and it charges local leadership to be more innovative 
and engaged in discharging our responsibilities. It is clear that the 
goal of the MOU is to improve both the quality and quantity of services 
provided to the populations we serve. Ultimately, it is a tool to 
elevate the health of our patients, communities, and the Nation.
            Sincerely yours,
                                   Robert H. Roswell, M.D.,
                                        Under Secretary for Health.
                         Charles W. Grim, D.D.S., M.H.S.A.,
                                         Assistant Surgeon General,
                           Interim Director, Indian Health Service.
                                 ______
                                 
      Memorandum of Understanding Between the VA/Veterans Health 
              Administration and HHS/Indian Health Service
                               i. purpose
    The purpose of this Memorandum of Understanding (MOU) is to 
encourage cooperation and resource sharing between the Veterans Health 
Administration (VHA) and Indian Health Service (IHS). The goal of the 
MOU is to use the strengths and expertise of our organizations to 
deliver quality health care services and enhance the health of American 
Indian and Alaska Native veterans. This MOU establishes joint goals and 
objectives for ongoing collaboration between VHA and IHS in support of 
their respective missions.
                             ii. background
    The mission of the Indian Health Service is to raise the physical, 
mental and spiritual health of American Indians and Alaska Natives to 
the highest level. The IHS goal is to assure that comprehensive, 
culturally acceptable personal and public health services are available 
and accessible to American Indian and Alaska Native people.
    The mission of the Department of Veterans Affairs is to ``care for 
him who shall have borne the battle and his widow and orphan.'' Those 
words were spoken by Abraham Lincoln during his second inaugural 
address and reflect the philosophy and principles that guide VA in 
everything it does. The Veterans Health Administration six strategic 
goals are: put quality first until we are first in quality; provide 
easy access to medical knowledge, expertise and care; enhance, 
preserve, and restore patient function; exceed patient's expectations; 
maximize resource use to benefit veterans; and build healthy 
communities.
    The IHS and the VA enter into this MOU to further their respective 
missions. It is our belief, that through appropriate cooperation and 
resource sharing both organizations can achieve greater success in 
reaching our organizational goals.
                              iii. actions
    A. This MOU sets forth 5 mutual goals:
    1. Improve beneficiary's access to quality healthcare and services.
    2. Improve communication among the VA, American Indian and Alaska 
Native veterans and Tribal governments with assistance from the IHS.
    3. Encourage partnerships and sharing agreements among VHA 
headquarters and facilities, IHS headquarters and facilities, and 
Tribal governments in support of American Indian and Alaska Native 
veterans.
    4. Ensure that appropriate resources are available to support 
programs for American Indian and Alaska Native veterans.
    5. Improve health-promotion and disease-prevention services to 
American Indians and Alaska Natives.

    B. To further the goals of this MOU, VA and IHS agree to:
    1. Facilitate collaboration on effective healthcare delivery for 
American Indian and Alaska Native veterans and shared responsibility 
for implementation of appropriate health promotion and disease 
prevention efforts. Ensure that IHS and VA facilities develop and 
provide effective linkages between facilities to support health 
promotion for American Indian and Alaska Native veterans that benefit 
their communities.
    2. Identify needs and gaps between the VA and the IHS to develop 
and implement strategies to ensure optimal health for the American 
Indian and Alaska Native veteran population.
    3. Promote activities and programs designed to improve the health 
and quality of life for American Indian and Alaska Native veterans.
    4. Develop and implement strategies for information sharing and 
data exchange.
    5. Collaborate in the exchange of relevant programmatic 
communications and other information related to American Indian and 
Alaska Native veterans.
    6. Cosponsor and provide reciprocal support for Continuing Medical 
Education, training and certification for IHS and VA healthcare staff.
    7. Develop national sharing agreements, as appropriate, in 
healthcare information technology to include electronic medical records 
systems, provider order entry of prescriptions, bar code medication, 
telemedicine, and other medical technologies, and national 
credentialing programs.
    8. Create an interagency work group to oversee proposed national 
initiatives.
    9. Develop a common methodology to track VA and IHS interagency 
activities and report progress.
                        iv. other considerations
    A. All VA Medical facilities and the IHS will comply with all 
applicable Federal laws and regulations regarding the confidentiality 
of health information. Medical records of IHS and VA patients are 
Federal records and are subject to some or all of the following laws: 
the Privacy Act, 5 U.S.C. 552a; the Freedom of Information Act, 5 
U.S.C. 552; the Drug Abuse Prevention, Treatment, and Rehabilitation 
Act, 21 U.S.C. 1101, the Comprehensive Alcohol Abuse and Alcoholism 
Prevention, Treatment and Rehabilitation Act, 42 U.S.C. 4541, the 
Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. 
1301, VA's Confidentiality of Certain Medical Records, 38 U.S.C. 7332; 
Confidential Nature of Claims, 38 U.S.C. 5701; Medical Quality 
Assurance Records Confidentiality, 38 U.S.C. 5705, and Federal 
Regulations promulgated to implement those Acts.
    B. Care rendered under this MOU will not be part of a study, 
research grant, or other test without the written consent of both the 
IHS and the VA facility and will be subject to all appropriate HHS and 
VA research protocols.
    C. The VA and the IHS will abide by Federal Regulations concerning 
the release of infonnation to the public--and will obtain advance 
approval from either VA or IHS before publication of technical papers 
in professional and scientific journals--for articles derived from 
information covered by this MOU. The VA and the IHS agree to cooperate 
fully with each other in any investigations, negotiations, settlements 
or defense in the event of a notice of claim, complaint, or suit 
relating to care rendered under this VA/IHS MOU.
    D. No services under this MOU will result in any reduction in the 
range of services, quality of care or established priorities for care 
provided to the veteran population or the IHS service population.
    E. The VA may provide IHS employees with access to VA automated 
patient records maintained on VA computer systems to the extent 
permitted by applicable Federal confidentiality and security law. 
Additionally, the IHS will likewise provide VA employees access to 
Veteran IHS records to the same extent permitted by applicable Federal 
confidentiality and security law.
    F. Both parties to this MOU are Federal agencies and their 
employees are covered by the Federal Tort Claims Act, 28 U.S.C 1346(b), 
2671-2680, in the event of an allegation of negligence. It is agreed 
that any and all claims of negligence attributable to actions taken 
pursuant to this MOU will be submitted to legal counsel for both 
parties for investigation and resolution.
                             v. termination
    This MOU can be terminated by either party upon issuance of written 
notice to the other party not less than 30 days before the proposed 
termination date. The 30 days notice may be waived by mutual written 
consent of both parties involved in the MOU.
                          vi. effective period
    The VA and the IHS will review the MOU annually to determine 
whether tenns and provisions are appropriate and current.

                                        Leo S. MacKay, Jr.,
                              Deputy Secretary of Veterans Affairs,
                                    Department of Veterans Affairs.
                                           Claude A. Allen,
                     Deputy Secretary of Health and Human Services,
                           Department of Health and Human Services.
    Date: February 25, 2003.

    Question 3: I understand from representatives of the Disabled 
American Veterans, based on a recent briefing at the Walter Reed Army 
Medical Center (WRAMC), that the average number of prosthetic limbs 
issued to amputees treated at WRAMC is six. These sophisticated 
artificial limbs enable severely wounded service personnel to run, 
climb, swim, lump and do other physical exercises and sports that were 
impossible for earlier generations of amputees. I understand that VA's 
average prosthetics issue is three prostheses for a veteran amputee 
under your care.
    Question 3(a): Does VA have plans to modernize its prosthetic and 
orthotic programs in a similar way to that of WRAMC, and if so, what 
are those plans?
    Response: Yes, VA has begun a modernization process to upgrade 
existing computer aided design-computer aided manufacture (CAD-CAM) 
equipment in the 58 prosthetics labs. In the personnel area, VA has 
mandated and has achieved full accreditation for all 58 of its 
Prosthetic and Orthotic Labs. Each lab has been mandated to have at 
least one Certified Prosthetist, Orthotist or an individual certified 
in both specialties. VA has also established training programs with 
private industry to learn more about the latest technology and fitting 
techniques.
    VA has established two national contracts to provide state-of-the-
art upper extremity prostheses. To ensure convenience to the veteran 
amputee and access to the state-of-the-art prosthetic appliances, VA 
contracts out to private industry 95 to 98 percent of the total limbs 
fabricated for all veterans. In addition, VA has established a rotation 
system with Walter Reed Army Medical Center and Brooke Army Medical 
Center to send VA Prosthetists, Physical and Occupational Therapists to 
their amputee centers to ensure continuity of care between VA and 
Department of Defense (DOD).

    Question 3(b): If a veteran comes to VA today for newly invented 
prosthetic appliances or limbs, such as the ``C-Leg,'' or a prosthetic 
arm that would allow him to play golf or tennis, what is VA's policy 
for providing those limbs and the necessary training to use them?
    Response: When a veteran comes to VA for a prosthetic appliance, VA 
provides the newest versions available and trains the veteran in its 
proper use. Prosthetists, physical or occupational therapists, and 
other rehabilitation specialists provide training relevant to the 
veteran's specific needs as part of the rehabilitation process. If the 
patient has a lower extremity amputation and requires a C-leg, for 
example, VA offers training on how to walk on various surfaces, how to 
negotiate stairs, how to get back up after falling, how to care for the 
appliance, and how to don the device. For veterans with an upper 
extremity amputation requiring a myoelectric arm, for example, VA 
trains the veteran in how to don and care for the appliance, how to 
manipulate the hand, wrist, and elbow, and how to employ independent 
living techniques to care for themselves. This training is available 
whenever VA provides a prosthetic, whether the veteran is a new patient 
or not.

    Question 3(C): How will VA respond when veterans who have been 
issued these high level appliances come to the Department's Prosthetics 
and Sensory Aids Program for repairs and replacements?
    Response: When a veteran comes to VA for a repair or replacement of 
an appliance they received from DOD, they are provided repairs for that 
appliance or a replacement of equal or greater technology and provided 
the necessary training for use and maintenance.

    Question 4: I am concerned that there are a great number of 
enrolled veterans who are at risk of Obstructive Sleep Apnea (OSA) who 
today are not being tested and diagnosed. I understand that the current 
backlog of sleep studies is quite high. While I understand that VA 
considers adding a large number of sleep study beds and contracting 
with community facilities as options to meet the current demand, what 
other innovative approaches for diagnosing OSA is the Department 
evaluating?
    Response. A number of VA sleep centers including, Houston and Los 
Angeles, are working to integrate a combination of in-laboratory and 
at-home testing into a comprehensive program. These programs are 
designed so we can continue to meet the national standards of practice 
for OSA diagnosis set forth by the American Academy of Sleep Medicine. 
VA will continue to evaluate the need for additional sleep centers and 
will expand to other facilities as the need arises. A description of 
the program, its operating procedures, guidelines, and implementation 
are currently being produced in the new volume of sleep clinics.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
to Michael J. Kussman, M.D., Nominee to be Under Secretary for Health, 
                     Department of Veterans Affairs
    Question 1: Over 1 million active duty soldiers and over 400,000 
Guard and Reservists have served in Iraq and Afghanistan, including 
8,000 West Virginia service personnel and over 4,000 Guard and 
Reservists. Policymakers believe at least one-third or more soldiers 
will need mental health care at some point, and having met with many 
West Virginia soldiers, you believe this number could be even higher. 
The Vet Centers, created after the Vietnam War, are independent centers 
and provide quality counseling and care with the least bureaucracy in 
the VA system. Rumors suggest that VA is considering changing Vet 
Center so that each would report to a VA Medical Center, but this is a 
terrible idea, in my judgment. Dr. Kussman, I meet with returning West 
Virginia veterans privately, and they are strong advocates for the Vet 
Centers, and the independence of such centers.
    Question 1(a): What is your view of the Centers, and what will VA 
do to support the Centers and increase the staff and support necessary 
to fully care for the more than 1.4 million veterans who may need 
mental health care?
    Response: I believe Vet Centers play a unique role in VA's services 
to returning combat veterans and I fully support maintaining them as a 
separate section within VHA. VA continues to expand into more 
communities with our Vet Centers, thus bringing our services closer to 
the veterans who need them and to help combat veterans successfully 
readjust to life at home.
    Since the beginning of Fiscal Year (FY) 2005, VA has created 26 new 
Vet Centers and added 72 staff, not including the 100 Global War on 
Terrorism (GWOT) outreach specialists authorized and now in place since 
Fiscal Year 2004 and Fiscal Year 2005. This represents a 26 percent 
increase in Vet Center staffing and a 13 percent increase in the number 
of Vet Centers.

    Question 1(b): What special arrangements are underway to prepare to 
serve the unique needs of female veterans, especially on the sensitive 
issue of military sexual trauma?
    Response: VA offers special training on women's health care issues 
to the 100,000 medical trainees who rotate through VA every year. We 
also provide 13 fellowships in health issues of women veterans, and a 
number of our clinical scholars pursue research projects on women 
veterans. VA recently created the Women Veterans Strategic Health Care 
Group (WVSHG). The WVSHG is closely examining the access to, and 
environment of care in, inpatient areas to recommend enhancements 
necessary to ensure adequate security and privacy on inpatient areas 
and comfort in outpatient waiting rooms and counseling centers. This 
will be accomplished in part through the annual plan of care/clinical 
inventory Web based survey sponsored by the WVSHG. In the past 3 years, 
this survey has shown significant improvements in the environment of 
care, specifically in the area of privacy.
    VA has made great strides in caring for women veterans over the 
past several years. We offer a number of programs specifically for 
women through the Center for Women Veterans. VA offers special 
counseling options for women recovering from trauma through the 
National Women's Trauma Recovery Program. It should be noted that women 
receive better care on average in the VA system than from Medicare or 
from the best non-governmental provider. In fact, VA scores nearly 10 
points better in breast cancer and cervical cancer screening than 
Medicare or the private sector according to the American Journal of 
Managed Care, thanks to our award-winning electronic health record 
system.
    VA screens all veterans for military sexual trauma (MST). If a 
veteran reports military sexual assault or harassment, he or she is 
eligible for copay exempt health and mental health services for 
treatment of problems related to those experiences. Unless specifically 
established for women, programs serve both genders. There are, in 
absolute numbers, as many men as women who have experienced MST.
    Every VA facility has designated a MST coordinator, and Vet Centers 
also have specially trained sexual trauma counselors. Thirteen programs 
offer sexual-trauma specific treatment in a residential or inpatient 
setting, and at least two more are under development. In Fiscal Year 
2007, VA established a Military Sexual Trauma Support Team to ensure VA 
is in compliance with mandated MST screening and treatment. This team 
also helps coordinate and expand education and training efforts related 
to MST and to promote best practices in the field.

    Question 1(c): Do you think that VA should consider mandatory 
screening for mental health care as recommended by the Iraq and 
Afghanistan Veterans of America (IAVA)?
    Response: The post-deployment health assessment is conducted by DOD 
and includes some screening for mental health concerns, but we defer to 
DOD on those issues. VA participates in the post-deployment health 
reassessment (PDHRA) and conducts mental health evaluations. Returning 
Operation Enduring Freedom/ Operation Iraqi Freedom (OEF/OIF) veterans 
are screened for post traumatic stress disorder (PTSD) when they are 
first seen in VHA, at least annually thereafter for 5 years, and at 
least every 5 years after that. Like all veterans seen in VA medical 
centers and clinics, returning veterans are also screened for 
depression and substance abuse on at least an annual basis. VHA policy 
requires physicians to conduct follow-up care for all positive screens, 
and provides treatment for all veterans found positive for indicators 
of PTSD, depression, substance use disorders, or other mental health 
conditions. These measures are taken to provide preventative care for 
patients and identify those in need of treatment.

    Question 2: Under current law, Guard and Reservists who serve in 
combat have access to VA health care for 2 years after deployment and 
lifetime care if they can prove it is service-connected which is easier 
for physical injuries than mental health care. Combat veterans who 
apply for enrollment in VA health care before their two-year post 
discharge period ends, remain enrolled and are eligible for hospital 
care, medical services and nursing home care. However, their priority 
group assignment and copay responsibilities will be based on the 
eligibility factors applicable at that period of time.

    Question 2(a): Dr. Kussman, what is VA doing to improve the 
transition and outreach for Guard and Reservists, particularly on the 
mental health care issues?
    Response: National Guard members and reservists who served in 
combat, who meet the minimum active duty length of service requirement, 
and who are discharged or released under conditions other than 
dishonorable are treated the same as other combat-theater veterans. 
They are enrolled in Category 6 for 2 years and then placed in 
whichever enrollment category is appropriate, based on their particular 
situation. Like other combat-theater veterans, they may be subject to 
copayment requirements if placed in Category 7 or 8. But, importantly 
they still remain eligible for VA care and the medical care package. 
They are enrolled as Category 6 veterans when they present to VA during 
the 2-year period after their discharge or separation and are not dis-
enrolled.
    To ensure Guard members and Reservists are aware of these 
opportunities, VA uses its Vet Centers to facilitate transition and 
outreach for veterans, particularly for mental health issues. Vet 
Centers have provided outreach to 173,277 OEF/OIF veterans since 
October 2001 through the end of the second quarter Fiscal Year 2007. VA 
has hired 100 OEF/OIF combat veterans to provide outreach services to 
their fellow returning OEF/OIF veterans. Our Vet Centers have provided 
readjustment counseling to 54,451 OEF/OIF veterans in Vet Centers and 
have engaged in outreach to active duty, National Guard, and Reserve 
units demobilizing upon their return from combat. Vet Centers have 
participated in all 595 PDHRA screening events, including the pilot 
project and Vet Center staff members have facilitated 10,578 referrals 
for readjustment counseling through the end of the second quarter 
Fiscal Year 2007.

    Question 2(b): I strongly support legislation by Chairman Akaka to 
expand access for Guard and Reservists from 2 years to 5 years which 
will give them more time to seek care for mental health; will you work 
with us to implement such a policy?
    Response: VA would support an extension of the enrollment period 
from 2 to 5 years. When OEF/OIF veterans seek care from VA they are 
placed in priority Category 6 and make no copayments for covered 
conditions. When the special treatment authority for combat-theater 
veterans was originally enacted, it was generally assumed that 2 years 
was sufficient. However, experience has shown that is not always the 
case. In caring for OEF/OIF veterans we have discovered the onset of 
symptoms and adverse health effects related to PTSD, and even traumatic 
brain injury (TBI), are often delayed, or do not manifest clinically, 
for more than 2 years after a veteran has left active service. As a 
result, many OEF/OIF veterans do not seek VA health care benefits until 
after their 2-year window of eligibility has closed. Without 
eligibility for enrollment in priority Category 6, many, i.e., those 
with higher incomes and non-service connected conditions, would not be 
eligible to enroll because they would be in priority Category 8.
    In addition, many OEF/OIF veterans are non-career military members 
who are unfamiliar with veterans' benefits and the procedures for 
obtaining them. For that reason many fail to enroll in a timely 
fashion. Providing combat-theater veterans with an additional 3 years 
within which they can access VA's health care system would help ensure 
none of them are penalized because of reasons beyond their control or 
because they have been unable to navigate VA's claims system in time.

    Question 3: Traumatic Brain Injury (TBI) seems to be a growing 
concern for many of our soldiers returning from combating. At previous 
hearings, witnesses have testified about the challenges in getting an 
accurate diagnosis, due to problems with hearing and vision issues.
    Question 3(a): What screening is being done now, and what plans are 
underway to expand such screening?
    Response: VA has implemented mandatory TBI screening of all OEF/OlF 
veterans receiving medical care within VA. Those who screen positive 
for TBI are offered further evaluation and treatment by clinicians with 
expertise in TBI.
    Patients with Polytrauma and TBI receive vision evaluations as part 
of their comprehensive rehabilitation management evaluation. Blind 
rehabilitation outpatient specialists serve as members of 
interdisciplinary polytrauma teams and provide thorough functional 
assessment of polytrauma veteran's vision to ensure that functional 
vision problems are diagnosed and treated.
    Veterans receive basic eye examinations by ophthalmologists and/or 
optometrists in VA medical center eye clinics. Veterans documented with 
vision loss are referred to VA medical center low vision clinics or 
blind rehabilitation centers, where they receive clinical visual 
rehabilitation examinations by optometrists or ophthalmologists.
    VA does not routinely screen returning veterans for hearing loss; 
however active duty servicemembers receive a post-deployment health 
survey that addresses hearing-related concerns. Audiology services are 
routinely provided for veterans injured on active duty and undergoing 
physical evaluation boards within military treatment facilities. 
Injured veterans transferred to the VA system of care are typically 
screened for hearing loss by an audiologist and more comprehensive 
evaluation and treatment is completed by an audiologist as warranted.

    Question 3(b): What research is in development to care for TBI 
among our returning soldiers?
    Response: To advance the treatment and rehabilitation of soldiers 
returning with traumatic brain injury (TBI) and related neurotrauma, VA 
has issued a request for research proposals that focus on TBI; cervical 
spinal cord injury; co-morbid conditions such as PTSD and trauma to 
extremities; screening and diagnostic tools related to mild TBI, 
especially field-based; and continuity of care between DOD and VA. 
Applicants are asked to pay special attention to cooperative projects 
with DOD.
    Some exciting research projects currently underway include: (1) 
studying neural repair after brain injury to build a theoretical 
understanding of cognitive rehabilitation and creating targets for 
practical treatments to enhance quality of life; (2) exploring 
community re-integration for servicemembers with TBI (to promote 
seamless transition between servicemembers currently being treated, or 
who will one day be treated, in both DOD and VA medical facilities); 
and, (3) assessing whether there are differences in the cost patterns 
for rehabilitation among soldiers returning from OEF/OIF with combat-
related TBI compared to those with non-combat-related TBI. 
Investigators are also examining how PTSD impacts future outcomes and 
costs associated with combat-related TBI.
    In addition, VA has established a Polytrauma and Blast-Related 
Injury Quality Enhancement Research Initiative (PT/BRI QUERI) 
coordinating center to promote the successful rehabilitation, 
psychological adjustment, and community reintegration of veterans. We 
have identified two priorities: (1) TBI with polytrauma, and (2) 
traumatic amputation with polytrauma. The primary target is OEF/OIF 
patients in VA, many of whom remain on active duty during their initial 
course of treatment. However, its activities will benefit all VA 
patients with complex injuries, regardless of service era and mechanism 
of injury. Finally, VA recently issued a special solicitation for 
research projects on the long-term care and management of veterans with 
polytrauma, blast-related injuries, or TBl.
    Question 4: Having candid communications is a priority for me, and 
I have been frustrated during recent hearing with standard testimony 
noting that VA appointments are quick and almost all veterans are seen 
in a timely manner. I meet regularly with returning West Virginia 
veterans, and this is not the story I hear. Dr. Kussman, how can we get 
direct, candid information about the true funding needs for VA health 
care?
    Response: VA's actuarial model developed approximately 84 percent 
of the Fiscal Year 2008 VA medical care budget and VA has made every 
effort to account for the needs of veterans. The Model has had several 
key methodological improvements including development of separate 
enrollment, morbidity, and reliance assumptions for OEF/OIF veterans 
based on their actual enrollment and usage patterns. However, many 
unknowns can impact the number and types of services that VA will need 
to provide OEF/OIF veterans, including the duration of the conflict, 
when OEF/OlF veterans are demobilized, and the impact of our enhanced 
outreach efforts. VA is well-positioned to provide assistance to 
veterans returning from Iraq and Afghanistan. As a physician and a 
veteran myself, if there is ever a situation where patient care is in 
jeopardy due to inadequate funding, I will be sure to raise those 
concerns within the Administration.

    Question 5: In 2005, when VA acknowledged a shortfall in the health 
care budget, the Secretary noted that part of the problem was a wrong 
estimate of the costs of care for the returning soldiers of $273 
million. But an even larger amount of the shortfall was the 
miscalculation of the long-term care costs for our older veterans--VA 
testified long-term care costs were $446 million short.
    Question 5(a): It is easiest to understand how the estimate could 
be off on the needs of the returning soldiers, but why was VA off by 
almost half a billion dollars on long-term care?
    Response: This was due to unrealistic assumptions in developing the 
budget estimates for VA long-term care nursing home care. The Fiscal 
Year 2005 supplemental budget request and the Fiscal Year 2005 budget 
amendment request corrected these errors. VA's subsequent budget 
requests demonstrate an improved model of forecasting accuracy.

    Question 5(b): How has the budget process been improved and what 
action is VA taking to ensure quality long term care for our aging 
veteran population?
    Response: The Fiscal Year 2007 and Fiscal Year 2008 budget requests 
included accurate estimates of VA's long-term care costs and did not 
repeat the unrealistic assumptions and computational errors. VA 
continues to provide patient-centered long-term care services in the 
most independent setting suitable for a veteran's medical condition and 
personal circumstances, especially in locations close to the veteran's 
home and community-based settings.
    VA facilities may establish an enhanced use lease agreement in 
which VA leases space for a privately owned assisted living (AL) 
facility in return for affordable AL for veterans. This public-private 
partnership provides for supervised housing at an affordable rate 
structured to address the needs of the community, as well as the 
specific needs of veterans. VHA helps support veterans in assisted 
living settings through community residential care, medical foster 
homes, and home based primary care. Medical foster homes combine the 
adult foster home concept with VA home based primary care (HBPC), where 
VA finds people in the community willing to take veterans into their 
home and provide personal assistance and continuous supervision. 
Veterans pay for these services using their aid and attendance benefits 
from the Veterans Benefit Administration (VBA). The home based primary 
care team continues to provide health care, adaptive equipment, 
caregiver education, and oversight. We are operating medical foster 
homes in Little Rock, Tampa, and San Juan, and we are ready to expand 
to 20 additional sites.

    Question 5(c): Will VA make long term care and nursing home care a 
priority for its construction projects?
    Response: VA will continue to make long term and nursing home care 
a priority for all veterans for whom such care is mandated by statute, 
and who need such care and seek it from VA. The current budget request 
will support continued expansion of veterans' access to VA's spectrum 
of non-institutional home and community based long-term care services 
while sustaining capacity in VA's own nursing home care units and the 
community nursing home program and continuing to support modest growth 
in capacity in the State veterans home program.
    VA expects to meet a substantial part of the growing need for long-
term care through such innovative services as care coordination/home 
telehealth. Care coordination in VA involves the use of health 
informatics; telehealth and disease management technologies to enhance 
and extend existing care; and case management activities. Home 
telehealth enables delivery of VA health care to veterans living 
remotely from VA medical facilities, including those in rural areas.
                                 ______
                                 
      Response to Written Question Submitted by Hon. Patty Murray 
to Michael J. Kussman, M.D., Nominee to be Under Secretary for Health, 
                     Department of Veterans Affairs
    Question. Are there any external reviewers involved in the 
decisionmaking process for VA bonuses?
    Response: The Department of Veterans Affairs (VA) has four separate 
Performance Review Boards (PRBs)--one for VA personnel (employees who 
report to an Assistant Secretary, General Counsel, and other key staff 
and offices, usually in Central Office), one for the Veterans Benefits 
Administration (VBA), one for the Veterans Health Administration, and 
one for the Office of Inspector General (OIG). The first three are all 
composed entirely of VA employees, while the fourth is composed of 
three non-VA members (one from Housing and Urban Development, one from 
the Department of Labor, and one from NASA). This composition for an 
OIG PRB is common across government, since Offices of Inspector General 
are tasked with conducting an independent oversight role of their 
Department and tying their performance assessments to the Department 
could present a conflict of interest for personnel.
    Each agency is required to publish its PRB membership in the 
Federal Register. VA reviewed this listing for seven Cabinet-level 
Departments (Defense, Education, Health and Human Services, Homeland 
Security, Interior, Justice, and Treasury) and several agencies and 
administrations (Environmental Protection Agency, Government Services 
Administration, Small Business Administration, and the Nuclear 
Regulatory Commission) and found it is very rare for PRBs to include 
external members. For example, the Office of Personnel Management 
(OPM), which sets the rules for the bonus process, does not have an 
external member on its board. The only agencies VA could find that did 
include an external member for their PRB were relatively small--the 
Equal Employment Opportunity Commission, the Office of Government 
Ethics, and the National Transportation Safety Board. It should be 
noted that each of these agencies provides an oversight role similar to 
an OIG.
    VHA's PRB includes the chair of each of the six national committees 
for VHA's National Leadership Board, the chairs of the Performance 
Management Work Group, the Deputy Under Secretary for Health for 
Operations and Management, the Principal Deputy Under Secretary for 
Health, and the Chief of Staff. All of the committee members are VHA 
employees. The PRB determines the ratings of subordinate executives, 
SES pay adjustments, year-end performance bonuses, and priority 
rankings for rank awards for subordinate executives. Subsequently, a 
senior management committee composed of the Deputy Under Secretary for 
Health for Operations and Management, the Principal Deputy Under 
Secretary for Health, and the Chief of Staff, makes recommendations on 
all other executives' ratings, SES pay adjustments, year-end 
performance bonuses, and the priority rankings for rank awards for 
subordinate executives, but they do not determine their own. The Under 
Secretary for Health makes recommendations on the Deputy Under 
Secretary for Health for Operations and Management, the Principal 
Deputy Under Secretary for Health, and the Chief of Staff. All 
recommendations go to the VA PRB for review and recommendation to the 
Secretary. No member of VA's PRB acts on his or her own rating, bonus, 
or pay adjustment.
                                 ______
                                 
    Response to Written Question Submitted by Hon. Sherrod Brown to 
     Michael J. Kussman, Nominee to be Under Secretary for Health, 
                     Department of Veterans Affairs
    Question: Our vets returning from the Iraq and Afghanistan theaters 
of battle have faced enemies who have in many ways, fought in a manner 
different than any other we have faced in the past. I know that many 
other nations, particularly the Israelis, have reached out to the VA 
and that the VA has sent delegations and held meetings with foreign 
officials in the recent past. I would hope that you would keep those 
lines of communication open and to the extent that you can, expand on 
this relationship especially in the fields of brain trauma and stress 
disorders. Please comment on how you see the relationships developing, 
and what resources, if any, you might need to take advantage of such an 
opportunity.
    Response: Between January 15 and 19, 2007, a delegation from VA 
visited the Department of Rehabilitation, Ministry of Defense in Tel 
Aviv, Israel. The primary purpose of the visit was to examine how 
Israel deals with PTSD. VA also visited a TBI center and a Veterans' 
Organization. VA observed that Israeli and U.S. clinicians take similar 
approaches to PTSD and TBI.
    VA welcomes continued discussions with the Israeli Ministry of 
Defense and is willing to consider funding collaborative, peer-reviewed 
research projects involving VA and Israeli investigators. We believe 
this cooperation will yield scientifically rich and highly relevant 
data to provide even better care to our Nation's veteran population.

    [Michael J. Kussman's response to Questionnaire for Presidential 
Nominees follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                 United States Office of Government Ethics,
                                    Washington, DC, April 23, 2007.
Hon. Daniel K. Akaka,
Chairman, Committee on Veterans' Affairs,
U.S. Senate,
Washington, DC.
    Dear Mr. Chairman: In accordance with the Ethics in Government Act 
of 1978, I enclose a copy of the financial disclosure report filed by 
Dr. Michael J. Kussman, who has been nominated by President Bush for 
the position of Under Secretary for Health, Department of Veterans 
Affairs.
    We have reviewed the report and have also obtained advice from the 
Department of Veterans Affairs concerning any possible conflict in 
light of its functions and the nominee's proposed duties. Also enclosed 
is a letter dated April 11, 2007, from the agency's ethics official, 
outlining the steps Dr. Kussman will take to avoid conflicts of 
interest. In addition to the steps indicated in the enclosed letter, 
Dr. Kussman informed the ethics official that he will divest General 
Electric and Pfizer in the immediate future.
    Based thereon, we believe that Dr. Kussman is in compliance with 
applicable laws and regulations governing conflicts of interest.
            Sincerely,
                                          Robert I. Cusick,
                                                          Director.
    Enclosures.

                            Department of Veterans Affairs,
                             Office of the General Counsel,
                                    April 11, 2007, Washington, DC.
Mr. Robert I. Cusick,
 Director, Office of Government Ethics,
Washington, DC.
    Dear Mr. Cusick: In accordance with section 2634.605(c) of title 5, 
Code of Federal Regulations, I am forwarding the enclosed Public 
Financial Disclosure Report (SF-278) of Dr. Michael Kussman. President 
Bush has nominated Dr. Kussman to serve in the position of Under 
Secretary for Health of the Department of Veterans Affairs (VA). It is 
my opinion that Dr. Kussman's report is complete and discloses no 
unresolved conflicts of interest under applicable law or regulation.
    Dr. Kussman has agreed pursuant to 18 U.S.C. Sec.  208(a) that he 
will not participate personally and substantially in any particular 
matter that has a direct and predictable effect on his financial 
interests or those of any other person whose interests are imputed to 
him, unless he first obtains a written waiver under section 208(b)(1), 
or qualifies for a regulatory exemption under section 208(b)(2) and 5 
CFR Sec. Sec.  2640.201-2640.203. Dr. Kussman understands that the 
interests of the following persons and entities are imputed to him: his 
wife; minor children; general partner; any organization in which he 
serves as an officer, director, trustee, general partner or employee; 
and any person or organization with which he is negotiating, or has an 
arrangement concerning, prospective employment.
    Dr. Kussman currently holds stock in General Electric and Pfizer. 
Dr. Kussman has agreed that he will divest himself of these stock 
interests within 90 days of his confirmation. Further, pending his 
divestiture of these assets, Dr. Kussman has agreed not to participate 
personally and substantially in any particular matters that will have a 
direct and predictable effect on the financial interests of either of 
these companies.
    Dr. Kussman also holds stock in Hewlett Packard. We have determined 
that it is not necessary at this time for him to divest this interest. 
However, Dr. Kussman has agreed that he will not participate personally 
and substantially in any particular matter that will have a direct and 
predictable effect on the financial interests of Hewlett Packard unless 
he first obtains a written waiver, pursuant to section 208(b)(1), or 
qualifies for a regulatory exemption, pursuant to section 208(b)(2).
    These assurances resolve any concern about real or apparent 
conflicts of interest that may arise from Dr. Kussman's report. 
Therefore, I have certified and dated the report.
            Sincerely yours,
                                            Walter A. Hall,
                                          Assistant General Counsel
                             and Designated Agency Ethics Official.

    Chairman Akaka. Thank you very much, Dr. Kussman.
    Let me note that the nominee has completed the Committee 
questionnaire for Presidential nominees and responded to my 
pre-hearing questions, all of which will appear in the hearing 
record. Also included will be a letter from the Office of 
Government Ethics acknowledging that he is in compliance with 
laws and regulations governing conflicts of interest.
    Before we go further here, there is a requirement that I 
swear in the nominee, and so, Dr. Kussman, I ask that you stand 
and raise your right hand.
    Do you solemnly swear that the testimony you are about to 
give the Veterans' Committee is the truth, the whole truth, and 
nothing but the truth, so help you, God?
    Dr. Kussman. Yes, sir.
    Chairman Akaka. Thank you very much.
    At this time, I would like to ask our Committee Members for 
any comments or statements they would like to make before we 
ask questions. We will go to questions, Dr. Kussman.
    Let me say that as I spoke of this in my opening statement, 
about being an advocate for veterans in light of OMB control, I 
urge you to ensure that the best interests of veterans is 
behind each and every decision you make. How will you advocate 
for that approach as VA deals with pressure from OMB to limit 
spending on health care?
    Dr. Kussman. Mr. Chairman, thank you for the question.
    As you know, I am a veteran and a retiree and that is what 
I am here to do. I represent veterans. When Mr. Nicholson asked 
me to be the Acting Under Secretary and we talked, and I was 
very flattered that he did so, I told him that--and he knew 
this already--that I tell the people I work for what I think is 
correct, not what they want to hear, and he told me very 
clearly he wouldn't have it any other way.
    And so my passion is to fight for veterans, to tell the 
leadership, including OMB, what I think needs to be done in 
support of veterans. Those people who know me know that I 
already have done that in my capacity in the VA and I assure 
you that is what I will continue to do.
    Chairman Akaka. I want you to address criticisms leveled at 
you that you have not actively worked to improve things as 
veterans move from Walter Reed to VA. Please describe your 
involvement with Walter Reed, including the specific allegation 
that you knew about the problems at Walter Reed through focus 
groups carried out in 2004.
    Dr. Kussman. Yes, Mr. Chairman. Thank you for the question. 
I worked at Walter Reed, as you know, from 1996 to 1998. At 
that time, I was the Commander of the Walter Reed Health Care 
System, the hospital, not the installation. So even when I was 
there, I wouldn't have had anything to do with Building 18 or 
the other residential areas around the post.
    I am very proud of my service at Walter Reed in 1996 to 
1998. Walter Reed got the highest score it ever got on the 
Joint Commission survey when I was there and was recognized in 
DOD as the large military hospital that had the best patient 
satisfaction during those two years that I was there. Any 
issues that have occurred more recently in Walter Reed didn't 
exist back in 1996 to 1998, the specific issue related to the 
focus group in 2004.
    In 2003, then-Secretary Principi asked me to co-chair with 
an individual from VBA a Seamless Transition Task Force to look 
at what the VHA and VBA were doing or not doing in support of 
servicemembers when they were transitioning. The first thing we 
did, and I was responsible for that, I think it was noted in 
the first panel, is call the commanders of the major 
installations, both Army and Navy, and was successful in 
getting VBA benefits counselors and social workers full-time in 
there to assist. That was unprecedented, having full-time VA 
people working within military facilities.
    About 9 months after we had started this, then-Chief of 
Staff Nora Egan for Mr. Principi asked whether or not we were 
doing our job, whether the servicemembers at Walter Reed, their 
families, knew who the VBA/VHA people who were there. A group 
was put together--I was really not part of that group--to do a 
sensing session that took place on one day. There were six 
servicemembers that were there and, I believe, six family 
members. The issues that they discussed were really related to 
the VBA and VHA service. There was very little discussion of 
what was going on nor were we asked about what was going on in 
relationship to Walter Reed.
    I am a big critic of myself, the biggest critic I know, and 
I have gone back and read this report several times. I have 
talked to the people who did the report and there really wasn't 
anything there that could have been presumed to have been 
related to the issues that came up several years later. In 
fact, those conditions did not exist at Walter Reed in 2004.
    Chairman Akaka. Thank you very much for that. We will have 
a second round here.
    Let me call on Senator Craig for his questions and 
comments.
    Senator Craig. Thank you very much, Mr. Chairman.
    Dr. Kussman, you have now spent many years at the highest 
levels of the VA health care system. Of course, prior to 
joining VA, you operated in the world of military medicine. VA 
and DOD, in spite of working under one President, have 
struggled over the years to work effectively together. From the 
perspective of the military, why has that relationship been so 
difficult to foster? That would be my first question.
    And then from your perspective as the potential head of the 
VA system, how do you think you can continue to improve 
cooperation of these two systems?
    Dr. Kussman. Thank you, sir. The first part of the question 
was my perception why DOD----
    Senator Craig. Why has it been difficult to foster a better 
relationship between the two?
    Dr. Kussman. I think that on a personal basis, there are a 
lot of good relationships with DOD, but I believe that the 
perceived mission of the two organizations are different. One 
fights a war, one is a more specific health care system, and 
there have been challenges in that cooperation.
    With this Administration, we have moved far along with the 
partnering at multiple levels. There is Health Executive 
Committee chaired by myself and now Dr. Ward Cassells who took 
over for Dr. Winkenwerder. There is a Joint Executive Committee 
co-chaired by Dr. Chu and Deputy Secretary Mansfield. There is 
a Benefits Executive Committee co-chaired by Mr. Domingous, I 
believe, and Admiral Cooper, the Under Secretary for Benefits. 
We are together working common issues. We have developed a DOD-
VA strategic plan and we are holding people's feet to the fire 
to meet those requirements. So I think we are trying to break 
through the cultures that have existed and are moving along 
with that.
    As far as the second part of the question, what the VA can 
do, we are committed to doing that and I believe one of the 
things that I bring to the table is the knowledge of both 
sides, and when I go talk to people, and sometimes I am in 
danger of losing my guild card for DOD, but I bleed VA now as 
much as I bleed any green leftover from the Army, and when 
people come and ask me about things, I say frequently, stop. 
Remember who you are talking to. I understand your system. We 
move on from there.
    So I believe that with the Secretary's leadership and the 
Deputy Secretary, I believe Secretary Gates is committed, 
Deputy Secretary England, we are going to move very rapidly to 
continue and improve the relationship between the two entities.
    Senator Craig. Thank you, Dr. Kussman.
    Every war produces, from a health care standpoint, a 
different kind of veteran. Can you talk a little bit about your 
views on the care and treatment we are providing the severely 
injured veteran and where you believe changes might need to be 
made in our approaches and our delivery system, if you are 
confirmed to lead the VA health care system?
    Dr. Kussman. Yes, sir. You are absolutely correct, sir, 
that every war has its sentinel injuries. I believe there are 
three signature injuries. I believe that there are three 
actually in this war. One is PTSD, particularly related to the 
National Guard and Reserve, not to minimize the active 
component, but we have in this war, really in an unprecedented 
manner since World War II, have used and relied upon the 
National Guard and Reserve. So we have a great obligation to 
them.
    Second is TBI, and we can talk about that in just a second, 
for major, minor, and moderate TBI.
    The third thing that I look at is what we have described 
and put into the lexicon, polytrauma, or multiple trauma. This 
war has brought to us unprecedented quality of combat medicine. 
With the body armor and the far-forward delivery of care, with 
the forward surgical teams doing unprecedented surgery right on 
the streets of Baghdad, the survival of severely injured people 
have come back and they have really challenged the system. 
These issues are not arithmatic, they are geometric in their 
complications and we consider people with severe illness to 
have TBI, spinal cord, mental illness, blindness, and 
amputations, and sometimes some of these poor kids have had all 
of them. So how do we approach that multi-disciplinary need?
    We have had our four TBI centers that were established in 
1991 in Palo Alto, Minneapolis, Richmond, and Tampa, in 
conjunction with the Defense and Veterans Brain Injury Study 
and Center at Walter Reed. That is partly why they were 
established, because we were in partnership with DOD, and they 
have been at the forefront of the delivery of TBI care in the 
country. They are staffed by the same people who staff all the 
civilian agencies, trained in the same places and using the 
same techniques.
    When the war got going, we realized that we needed to put 
together facilities that had a multi-disciplinary approach so 
it could take care of the full gamut of the injuries as I 
described, and what we did is build on our TBI centers. 
Unfortunately, people forget that they were originally TBI 
centers. They weren't built as polytrauma centers, but they 
were expanded. We believe that we can provide the full depth 
and breadth of services.
    As related to TBI, we have known and DOD together do very 
well with severe traumatic brain injury as far as that 
evacuation. Those people get into the evacuation chain and come 
through Landstuhl, come to the Bethesda and Walter Reed and 
then come to us, and I think we are doing a very good job in 
treating them.
    The bigger challenge right now is mild to moderate TBI that 
is not diagnosed because the individual doesn't know they had 
it. The scenario that I describe is that there is an IED that 
went off. There may be carnage around, people severely injured. 
A servicemember may have lost consciousness or banged their 
head or had lost consciousness for a second or two. The 
sergeant yells, ``Is everybody all right?'' and the kid says, 
``Yes, Sarge, I am fine.'' It may happen more than once. It 
could happen three or four times. It could happen in multiple 
deployments. But they never surface in the medical evacuation 
chain. Nobody knows that they have TBI.
    They come back, and the question is the literature doesn't 
tell us what to do with mild to moderate TBI. The literature 
that exists in the medical community is very anemic when it 
comes to this and is generally based on relatively mild head 
bumps related to football Friday night. I played basketball 
when I was a kid and I, not so much joking, but I am not too 
agile and I would get an elbow in the side of the head and see 
stars for a couple of seconds. The coach would say, ``You OK?'' 
I never left the game. I never played too well, either, but I 
never left the game. That probably is mild TBI.
    There is a lot of that that goes on, but it may very well 
be that the mild to moderate TBI that occurs in the blast 
injury that is one of the ways that the enemy has fought us 
causing the TBI may be different. There may be molecular 
changes that are different from a blast than a more common head 
bump, if you will. We are initiating research, both in the 
civilian community and also with DOD, to try to determine that, 
try to determine if there are tests and things that can be done 
to identify mild to moderate TBI.
    However, we are not waiting for that to happen. As you 
know, we have put in place a screen for every OIF/OEF person 
that comes to us, regardless of what the initiating diagnosis 
is, just like we have done with PTSD, military sexual trauma, 
substance abuse, and depression. We screen everybody for all 
those. We have been doing that for a long time. Now we have 
added a screen for TBI. If those questions are positive, we 
then refer the patient according to a clinical guidance process 
to neuro-cognitive testing. Frequently, there is no one test 
that can be done, but just treat the symptoms.
    It appears from the civilian literature that I described as 
anemic that anywhere from 70 to 90 percent of people will get 
better within 18 to 24 months, but that may be a different 
illness compared to the illness that we are talking about with 
the TBI that we are seeing because of the blast injuries and we 
are putting together a registry so we can then identify the 
people and follow them longitudinally to see what happens over 
1 year, 5 years, 10 years, and to be sure that we are giving 
them all the things that we can do. So I believe that we are 
addressing the multiple levels of the TBI.
    From a PTSD perspective, the VA was a prime mover in the 
diagnosis and the description of PTSD. As you probably know, it 
wasn't in the medical lexicon until 1980. We have led the 
country in the treatment of PTSD and have our major center for 
TBI in White River Junction and is seen as a national, if not 
international, center of excellence for PTSD.
    So we are constantly looking at how we treat people. We are 
expanding our capability with mental health. We spend almost $3 
billion, a lot of it on this. It was mentioned earlier about 
the money. As you know, there was an issue of $100 million that 
didn't get spent last year and that was because we have 
challenges hiring people to do that and getting them to go to 
areas in the country that we would need the assistance. Having 
said that, we have hired in the last couple of years over 1,000 
new mental health personnel, to include psychiatrists, 
psychologists, and social 
workers.
    Senator Craig. My time is way over, so I will stop.
    One--two comments. I just pinned a Purple Heart on a young 
man the other night out at Walter Reed whose life was saved and 
may well live a full life because of that street capability in 
Baghdad today that we are delivering to our men and women in 
uniform.
    Secondarily, I understand that we are, at least in the 
private sector, working on a device that might go on each 
individual soldier's uniform to detect and measure impact or 
concussion, the volume of impact that a person might receive 
during one of those events. Are you aware of that, and does 
that have potential to at least begin to measure the amount of 
impact that might relate to this kind of trauma?
    Dr. Kussman. Yes, sir. I have heard about it, but I really 
don't know enough to comment. But clearly, that is an important 
thing, because what we really need to do is identify the people 
who have experienced a blast and then identify them so we can 
track them when they come and there would be an identifier with 
that to make sure that they get special attention than just the 
average person we are screening for.
    Senator Craig. Thank you, Dr. Kussman. Thank you, Mr. 
Chairman.
    Chairman Akaka. Thank you, Senator Craig.
    Senator Murray?
    Senator Murray. Yes. Thank you. Dr. Kussman, I wanted to 
start by raising an issue that affects every single thing we do 
in the Senate for veterans. Many Members of Congress, myself 
included, are extremely wary today of the information that the 
VA provides to us. As you know, the VA has a track record of 
being less than honest with Congress. I know you remember well 
back in 2005 when the VA told us consistently they had all the 
money they needed, blocked an amendment three times on the 
floor that Senator Akaka and I worked on to provide VA with 
money, and learned later, of course, that the VA was indeed 
short $3 billion.
    Well, as I mentioned a few minutes ago when we were here, I 
was astonished by an article written by Chris Adams of the 
McClatchy newspaper, and I want to quote it, ``the VA has 
habitually exaggerated the record of its medical system, 
inflating its achievements in ways that make it appear more 
successful than it is.'' In the context of the information we 
receive from the VA that we are all very wary of, that raises a 
lot of red flags for me and I wanted to know if you had read 
that report and if you had a comment on it.
    Dr. Kussman. Yes, Senator Murray. As you and I talked about 
when I had the privilege of talking to you in your office, I 
agree that we have to work very hard on getting our information 
clear, concise. One of my goals is to look at our access 
standards, look at our appointment schedules, and correct 
anything that is in there that is not accurate.
    As far as the McClatchy report, I appreciate that report 
because I take any criticism or corrections very seriously to 
look at what we are doing. I am very forthright and honest 
about what I do and so I was actually--there were comments in 
there by the reporter that were very positive, as well, that 
the VA has transformed itself, is identified as a leader in 
health care. I think that there were correct issues that he 
raised of things that need to be articulated better and we are 
committed to do that.
    Senator Murray. I hope that part of your commitment is to 
give us a picture of reality, not of one that you just want to 
have us.
    Dr. Kussman. I don't believe in fantasies and I guarantee 
you that I will give you the best information that I know.
    Senator Murray. OK. I wanted to ask you also about this 
issue of bonuses. I am sure you are well aware of the issue. 
When you were acting VHA head, millions of dollars in bonuses 
were granted to senior managers, particularly those based here 
in Washington, DC. I know there are good reasons to do bonuses, 
but I was also perturbed yesterday to read a report by the 
Associated Press that says that 21 of 32 VA officials who sat 
on the board responsible for performance reviews and bonuses 
received more than half-a-
million dollars in payments themselves. Would you comment on 
that?
    Dr. Kussman. I don't know specifically what the 21 were or 
which ones that the reporter is alluding to. I can just tell 
you, Senator, that to the best of my knowledge, our bonus 
process that is based on performance is consistent with what 
OMB's policies are. I believe that the Secretary, because of 
this latest situation, has asked--I said OMB, I meant OPM--has 
asked OPM to come and look at our process to assure that we are 
doing the right things.
    Senator Murray. Does the VA's Performance Review Board 
include any outside observers today?
    Dr. Kussman. Outside the VA? I would have to go back and 
look. I don't think so.
    Senator Murray. OK. Do you think that it should?
    Dr. Kussman. I would have to look at that.
    Senator Murray. If you could get a response back to me, I 
would appreciate that.
    I also wanted to ask you about the VA budget shortfall that 
occurred back in 2005 because, as you know, the VA relied on 
2002 data to forecast medical expenditures and wound up $3 
billion short. I was met by opposition from the VA every step 
of the way as we worked to try and deal with what we knew from 
the ground out there was a shortfall, and in fact, Secretary 
Nicholson wrote a letter to Senator Hutchison that denied at 
the time that VA needed any more money, right before they came 
back around and said they were indeed $3 billion short.
    You were VA's number two medical leader at the time. Can 
you describe to this Committee any involvement that you had in 
that budget shortfall?
    Dr. Kussman. I wasn't directly involved in the development 
of the budget. Clearly, there were things that happened that 
were mistakes. We have tried to learn from that. As you know 
when we talked, I am now directly involved in the budget. The 
recommendation for 2008 was the first year that I had spent a 
lot of time and was directly involved in the development. I 
believe it is a good budget. It has things that are not in it 
that potentially were in there before. I believe that we have 
worked----
    Senator Murray. Your VA request or what the Senate actually 
has included, which is about----
    Dr. Kussman. No, the VA request for 2008.
    Senator Murray. Well, I assume that you believe that the 
budget that the Senate passed with $3.5 billion would better 
serve the needs of the veterans than the request.
    Dr. Kussman. We are very appreciative of dollars and we are 
a large agency and we will spend it on the best care of 
veterans.
    Senator Murray. Well, let me ask you a more specific 
question. Were you involved in any way with the writing of the 
letter by Secretary Nicholson that was sent to Senator 
Hutchison in April of 2005?
    Dr. Kussman. Not that I recall.
    Senator Murray. Let me ask you one other question. The 
Washington Post recently reported about high-level political 
meetings between White House officials and senior agency 
officials across the Federal Government, including the VA, and 
at one of those hearings, the Administrator of GSA asked how 
she could ``help our candidates.'' Those meetings raised a lot 
of serious concerns about possible violations of Hatch Act, 
which prohibit the use, as you know, of Federal funds for 
partisan political purposes, and they call into question the 
possibility of undue political influence at the VA, as well. 
Have you, Dr. Kussman, or anyone you know at the VA ever 
received a briefing or briefings from the White House that were 
political in nature?
    Dr. Kussman. No, ma'am.
    Senator Murray. None?
    Dr. Kussman. Not--I haven't, or I don't know of anybody who 
has.
    Senator Murray. And never heard of them, never been in a 
meeting--
    Dr. Kussman. I am not aware of that happening.
    Senator Murray. All right. As you heard me talk about in my 
opening statement, we are all pretty cautious about information 
we receive from the VA and I am really looking to find somebody 
in this position that we can trust, that will bring about a 
culture of change, that won't just paint the happy-dappy 
picture but will actually tell us the reality, because we have 
a responsibility to make sure that those men and women who 
serve us have what they need. And if we are not getting 
accurate information, if we are being told a happy picture and 
not getting the reality, then we are not doing our jobs 
accurately, either, and it reflects on the performance of every 
one of us. How can you assure us that your going into this 
position will change that culture and really bring about a 
better, trustworthy, more honest information to this Committee 
so we can do the job we need to do?
    Dr. Kussman. I am not sure how I can convince you other 
than to tell you that that is not my character. That is what I 
do. You and I have talked about this before. I am committed to 
working with you to correct any deficiencies or inaccuracies 
that we have. That is what I do. That is my passion.
    Senator Murray. Thank you, Dr. Kussman.
    Chairman Akaka. Senator Burr?

                STATEMENT OF HON. RICHARD BURR, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Mr. Chairman. I am at a distinct 
disadvantage because I don't read newspapers as widely as 
others. My fear is that if I read the articles about myself, it 
would probably lead me into the bathroom to slit my wrist if I 
believed everything that is in it.
    Mr. Chairman, I want to thank the Administration because 
they have, in my estimation, sent us a man that is incredibly 
qualified, unbelievably experienced, to take on, I think, one 
of the most difficult tasks that we could ask a nominee to do, 
not only to go into an agency that has a challenged background 
and shown tremendous progress, but one that is getting ready to 
go through a decade of significant challenges that I think most 
of us can predict exactly what those challenges will be like.
    I want to thank you, Dr. Kussman, for your willingness to 
do this. I want to thank the groups who were willing to 
publicly come in and support this nomination.
    Mr. Chairman, Dr. Kussman have had an opportunity to sit 
down and we have talked about every issue that I thought was 
relevant to hear from a nominee. We have explored the 
outpatient challenges of antiquated facilities with the full 
understanding that I have and that he has is that we can't go 
out and build new hospitals everywhere we have got veterans. If 
we could do that, the delivery of care would be seamless. We 
wouldn't have the physical challenges of somebody having to go 
from an outpatient entry point to a third-floor back room where 
we are now doing endoscopies because that is the only spot we 
have got. The reality is that we consistently make changes 
based upon the available funds. I want to thank you for working 
with the limitations, but also for giving me hope that we have 
got a vision of where we need to get from a standpoint of our 
VA facility.
    I have talked to him about the challenges of PTSD and 
polytrauma and how that is the makeup of the service personnel 
that we are going to see. It is significantly different from 
what we have seen.
    Mr. Chairman, I believe every nominee deserves to have a 
champion on the Hill. Maybe by default, I will be Dr. 
Kussman's, and I want to explain to you why. It is because 
after I got through meeting with him, I left the room believing 
he gets it. He understands what this job is all about. For a 
Member that is involved about 60 percent of my time in health 
care on the private sector side, and just because of the nature 
of this Committee pulled into it from a committee jurisdiction, 
there are a lot of people in health care today that don't get 
it.
    And not only does he get the health care piece, he gets the 
veterans' piece. He gets the fact that these, in some cases 
kids, in some cases parents, in some cases friends, made a hell 
of a commitment for us and that we have an obligation to 
provide the best level and delivery of care that we can 
possibly do and that we can't be shaded by the challenges that 
it presents to us, we can't complain that every one of them is 
different. We have got to learn how to deal with it and to do 
it successfully.
    So I look at some of the issues that have been raised about 
this nomination. They have expressed that the VA is a bad 
system. Well, you know, we have beat that horse, and it is not 
perfect, but you know, when Business Week magazine did an 
article last summer on it, they said, you know, this is the 
best performing hospital system in the country. It far exceeds 
the two that I have got in Winston-Salem or the multiple 
systems that I have got in North Carolina, and most believe 
that our State has one of the best delivery systems in the 
country.
    The second belief was that Dr. Kussman's service as co-
chair of the DOD Seamless Transition Task Force, that in those 
focus groups, maybe somehow you should have known that Walter 
Reed had problems, since they were held at Walter Reed. As a 
matter of fact, the article was done by salon.com. Now, I am 
not--I don't read salon.com, but I don't necessary look to them 
for the cutting-edge news that happens day to day. And I am 
sure that it sells magazines to come to conclusions that people 
want to find something that is in the realm of ``gotcha'' 
because this is a town of ``gotcha,'' but the reality is that 
if you should have known because you did it, Congress should 
have known.
    So if we are blaming you, we should be blaming ourselves 
and we probably should have blamed ourselves before we blamed 
anybody else, even the folks that were in charge of Walter Reed 
because this type of thing shouldn't happen, and ultimately, 
when we are involved with sign-offs of our leadership, we put a 
tremendous amount of responsibility on them, but that also 
requires us to do a degree of oversight. I want you to know, we 
are going to do our oversight. I think you expect us to do our 
oversight and we are going to continue to do that.
    We discussed the seamless transition from DOD to the 
veterans. I think that what is important with Dr. Kussman is he 
has, one, acknowledged the problem. Two, he has a desire to 
change. Three, he has a plan to transition.
    Now, DOD has to play a very, very important role in this 
and a commitment to technology and a commitment to the sharing 
of records. I can only speak from my conversation with Dr. 
Kussman, Mr. Chairman. He is more than willing to pick up the 
VA's side of that transition. Unfortunately, we don't have the 
jurisdiction over DOD about their willingness, but I am 
personally going to stay on the appropriate Committee Members 
to make sure that DOD, in fact, is a willing partner, but a 
willing partner at the level of commitment that I think Dr. 
Kussman and the VA is.
    Lastly, I want to end where I started. Dr. Kussman gets it. 
His focus is on veterans. It is on our children, our parents, 
our friends, and making sure that the commitment that we all 
made as a country to our veterans is to provide them with the 
best possible delivery of care for the rest of their lives. I, 
for one, believe that this is the man for whatever number of 
years he might be there can do an exemplary job at representing 
our best choice as the Medical Director at the VA.
    So I have no questions, Mr. Chairman, but I look forward to 
a speedy conclusion to his nomination. I thank the Chair.
    Chairman Akaka. Thank you very much, Senator Burr, and I 
thank you so much for your comments about our nominee and look 
forward with you in trying to move it as quickly as we can.
    Dr. Kussman, if you are confirmed, the mental health needs 
of the returning servicemembers will rightly dominate so much 
of your agenda. Dr. Frese previously testified that the outside 
advisory body on mental health, which has been so vibrant, now 
seems dormant. As we know, the demand for care for invisible 
wounds continues to grow, and you have mentioned that. I note 
that if the supplemental is enacted, funding should not be a 
problem. What do you plan to do to improve mental health care?
    Dr. Kussman. Mr. Chairman, if it is dormant, it won't be 
dormant for long, so we will certainly go back and look at the 
comments that were made.
    Mental health--we are the largest provider of mental health 
service in the country. As I mentioned, we spend close to $3 
billion a year and we will spend more now with your help. That 
does not include the Vet Centers, the readjustment counseling. 
That is a separate funding line. We are increasing that. That 
is critically important to us, led by Al Batres, who is one of 
my heroes. And we are increasing now--by next year, we will 
have 232 Vet Centers around the country. We are putting PTSD 
treatment teams in all our facilities and other groups of 
people even out into the CBOCs to be sure that mental health is 
available.
    What we need to do is looking--and I will extrapolate a 
little bit with my comments--besides PTSD is the issue of 
suicide and other things that are relevant to this age group. 
We have educated all our people about suicide. We have put 
suicide counselors in every facility. We are putting together a 
24-hour suicide hotline. And working together, we want people 
who have a mental health issue to be seen right away, not have 
to wait any period of time, and the goal is that we will try to 
get people in within 24 hours to be assessed if they come for a 
mental health issue.
    We have some challenges of getting the resources where they 
need to be, but those are challenges that actually exist in the 
civilian community, as well, because there aren't any resources 
out there. But I am committed to providing the world-class 
mental health care, PTSD and otherwise, for all our veterans. 
We will 
either do it inside or we will buy it.
    Chairman Akaka. Well, I have also heard, Dr. Kussman, 
concerns but have seen nothing official about changes to the 
readjustment counseling service. Are there plans to merge 
readjustment counseling service with VA health care?
    Dr. Kussman. No.
    Chairman Akaka. The law is that if a Vet Center is to be 
moved, the Veterans' Affairs Committees must receive official 
notification of that fact, and I mention this because I 
understand that a Vet Center in Chicago may be moved. Please 
make sure that we have the appropriate notice.
    Dr. Kussman, in your response to my pre-hearing questions, 
you expressed your view that the VA health care system has 
become too decentralized as a result of its division into 
regional networks. You also indicated that this 
decentralization is a detriment to ensuring appropriate 
consistency and standardization. Will you please explain what 
your plans are for improving standardization of care through 
increased centralization?
    Dr. Kussman. I believe any organization, particularly one 
that went through the tectonic shifts of the mid-1990s when we 
developed the VISN structure, has to continue to assess itself. 
Just parenthetically, we recently had a summit meeting last 
month to look at the 10-year evolvement of the VA from the mid-
1996 and the millennium changes that took place and one of the 
things that we were talking about is as the pendulum shifts, 
there has always been in health care delivery or other agencies 
this constant balancing of centralization and 
peripheralization, establishing policies, procedures, and 
standards and then allowing people to implement those policies 
and standards. Health care is local.
    So I believe that--my personal opinion is that potentially 
the pendulum has swung a little too far. It needs to be looked 
at and brought back toward the center, and I think that will 
help standardization and consistency. That is part of my second 
issue of leadership, that we need consistence and standard. A 
veteran should have the same care and the same advantages 
whether they are in Maine or Manila and that at times, when you 
go around the system, sometimes you don't find that. So that is 
one of the things that is a very important issue for me.
    Chairman Akaka. VA TBI care, mental health care, and 
prosthetics have each been criticized in recent months for not 
being the best. My goal is to ensure that VA care of all kinds, 
especially care for war traumas, should be the best. How do you 
answer those who wish to contract out most VA care?
    Dr. Kussman. First of all, Mr. Chairman, let me say that I 
have the same passion you do. It has got to be the best. Shame 
on us if we don't do that. I believe that with our TBI care, it 
is the best. Sometimes it may not appear that way to some 
patients. What I have initiated is a process where anybody who 
is unhappy or is concerned about the quality of care, we 
automatically get a second opinion from a reputable civilian 
agency to come in and look at it.
    I want that done for two reasons. One is if, God forbid, we 
are not doing the right thing, then we need to know about it 
and fix it. If we are doing the right thing, at least we owe it 
to the veteran and their families to tell them. But if they 
still want to go someplace else because they think that the 
care would be better, there are options to do that.
    I think in mental health, we are doing the same thing, and 
as I mentioned earlier, our outreach and money put against 
mental health. I will be the first one to acknowledge, when you 
mentioned prosthetics, early on in the war, we had some 
challenges. We do a lot of prosthetic work, as you know, and we 
probably do more amputations than any other health care system 
in the country. It is over 5,000 a year. But they tend to be 
more vascular and geriatrics, not anywhere near what this new 
generation of veterans needs. They want to go rock climbing and 
kayaking and play hockey and things. Being asked whether you 
can get off the floor is seen as an insult. There were 
instances like that early on.
    We have changed. We have sent our prosthetists and our 
people to Walter Reed and Bethesda and Brooke to train them and 
get them up to the same level. So we will buy anything for 
anybody for whatever they need. One of the issues is that 
sometimes there is experimental stuff with prosthetics going on 
at Walter Reed and that is the only place you can get it. We 
would obviously encourage people to go back there.
    But as far as outsourcing the care in the generality of 
things, I would be concerned. I think that we need to partner 
with the civilian community to get care as appropriate and we 
are looking at that. But one of the strengths that we have by 
keeping people in our system is to assure the quality, the 
integration, and the continuity of care with our electronic 
health record and things. So I think that we do need to partner 
with the civilian community, but to make it a common practice 
that would be of concern to me.
    Chairman Akaka. Well, we also hear that the Brooke Army 
Medical Center is a premier rehabilitation facility for war 
injuries, and I am so glad you did mention about prosthetics 
and how far we have advanced on that and continue to do that. I 
look forward to see what you can do in keeping this operating.
    I really appreciate your responses, Dr. Kussman, and also 
your patience and your family's, as well, and all those who are 
here.
    So in closing, I again thank all of our witnesses for being 
here today. We could not have had a truly informed hearing 
without your insight and your perspectives. I also want to 
again thank Dr. Kussman's family for their presence here today.
    As you all know, every organization needs an unquestioned 
leader. It is not optimal for the Veterans Health 
Administration to have an acting leader for an indefinite 
period of time. With this in mind, I will work, I want to tell 
you, I will work to move Dr. Kussman's nomination prior to our 
adjournment for Memorial Day recess, but we will see.
    I want to again say mahalo, thank you, and aloha to all of 
you. This hearing is adjourned.
    Dr. Kussman. Mahalo, Mr. Chairman. Thank you.
    [Whereupon, at 12:38 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              

              Prepared Statement of Hon. Bernard Sanders, 
                       U.S. Senator from Vermont
    Thank you Mr. Chairman and thank you for holding this important 
hearing. I want to welcome Dr. Kussman and his family as well as the 
other witnesses we have with us today. Thank you for being here to 
share your views.
    Mr. Chairman, I don't have to tell you that today's VA faces 
enormous challenges.
    We have a backlog of over 400,000 claims waiting to be processed.
    We have the VA reportedly paying $3.8 million in bonuses to its 
employees while veterans are on waiting lists all across this country 
and Category 8 veterans are not allowed in at all. Some of those 
receiving bonuses are the very same people that were responsible for 
the over $3 billion VA budget short fall in 2005 as well as gaming the 
VA claims system so that it looked like claims were being processed 
faster than they were.
    We have the Institute of Medicine and National Research Council 
reporting on May 8th of this year that ``[a] surge in the number of 
disability claims for PTSD has revealed inconsistencies in compensation 
levels awarded across the country, raising questions about the 
effectiveness of the VA's current ways of assessing and rating this 
condition, and whether some veterans are getting payments that are too 
low, too high, or unmerited . . . It urged the VA to base compensation 
decisions on how greatly PTSD affects all aspects of a veteran's daily 
life, not just his or her ability to be gainfully employed.''
    Reuters reports that ``the Department of Veterans Affairs estimates 
12 percent to 20 percent of those who served in Iraq suffer from PTSD. 
A 2004 Army study found 16.6 percent of those returning from combat 
tested positive for the disorder.''
    We have USA Today reporting on May 3 that ``from 125,000 to 150,000 
U.S. troops may have suffered mild, moderate or severe brain injuries 
in Iraq and Afghanistan.'' As many note, that is a number far higher 
than what the official casualty figures of 26,000 tell us.
    The Associated Press reports that the Defense Department's Task 
Force on Mental Health tells us in its study that it ``found 38 percent 
of Soldiers and 31 percent of Marines report psychological concerns 
such as traumatic brain injury and post-traumatic stress disorder after 
returning from deployment . . . Among members of the National Guard, 
the figure is much higher--49 percent--with numbers expected to grow 
because of repeated deployments.''
    Army Times tells us ``Suicides are up among combat vets, mental 
health issues are worse among those who deploy often and for longer 
periods, . . . ''
    For example the Army Times explained that Marine Commandant General 
James Conway of the military's Mental Health Advisory Team recently 
reported:
    ``Soldiers and Marines who have faced the most combat situations, 
deployed for longer periods of time, and deployed more than once face 
more mental health issues, according to a survey of 1,320 soldiers and 
447 Marines. Of those on a second, third or fourth deployment, 27 
percent screened positive for mental health issues, compared to 17 
percent of first-time deployers. And 22 percent of those in-theater for 
6 months or more screened positive for mental health issues, compared 
to 15 percent of those who had been there fewer than 6 months.''
    The list goes on and on, Mr. Chairman.
    My question today is does the VA, does Dr. Kussman recognize the 
challenges that the VA is up against? Will they stop all the 
stonewalling and the games with requesting low amounts of funding for 
the VA and work with the Congress to provide the services and benefits 
that our veterans need in a timely manner? We need a partner that will 
work us, not tell us that ``we have it all taken care of.''
    The VA is filled with wonderful and dedicated employees, there is 
no doubt about that and they give great care to many veterans once they 
get into the system.
    But for too many the VA is a bureaucratic organization where red 
tape is the norm. As many have said, the VA needs to be an advocate for 
the veteran not an adversary.
    We have a lot of work to do, Mr. Chairman, and I look forward to 
hearing from our witnesses today about Dr. Kussman's ability to meet 
these challenges.
    Thank you, Mr. Chairman.
                                 ______
                                 
                                               U.S. Senate,
                                      Washington, DC, May 14, 2007.
Hon. Daniel K. Akaka,
Chairman, Committee on Veterans' Affairs,
U.S. Senate Washington, DC.
    Dear Mr. Chairman: It is my understanding the nomination of Dr. 
Michael Kussman to become the Under Secretary for Health in Department 
of Veterans Affairs is scheduled for May 16, 2007. Dr. Kussman is also 
a retired Brigadier General, U.S. Army (Ret.). He has an extremely 
impressive 10 page Curriculum Vitae which I have attached. In my view, 
he will make an outstanding Under Secretary for this vital function. I 
urge your support for his nomination.
            Aloha,
                                          Daniel K. Inouye,
                                             United States Senator.

  

                                  
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