[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
THE VETERANS HEALTH ADMINISTRATION'S
FISCAL YEAR 2011 BUDGET
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 23, 2010
__________
Serial No. 111-61
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
Subcommittee on Health
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida HENRY E. BROWN, Jr., South
VIC SNYDER, Arkansas Carolina, Ranking
HARRY TEAGUE, New Mexico CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas JERRY MORAN, Kansas
JOE DONNELLY, Indiana JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
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C O N T E N T S
__________
February 23, 2010
Page
The Veterans Health Administration's Fiscal Year 2011 Budget..... 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 27
Hon. Henry E. Brown, Jr., Ranking Republican Member, prepared
statement of................................................... 27
WITNESSES
U.S. Department of Veterans Affairs, Hon. Robert A. Petzel, M.D.,
Under Secretary for Health, Veterans Health Administration..... 2
Prepared statement of Dr. Petzel............................. 28
______
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission.......................... 20
Prepared statement of Mr. Wilson............................. 46
The Independent Budget:
Blake C. Ortner, Senior Associate Legislative Director,
Paralyzed Veterans of America.............................. 17
Prepared statement of Mr. Ortner......................... 32
Eric A. Hilleman, Director, National Legislative Service,
Veterans of Foreign Wars of the United States.............. 19
Prepared statement of Mr. Hilleman....................... 37
SUBMISSION FOR THE RECORD
National Association for Veterans' Research and Education
Foundations, Barbara F. West, Executive Director............... 48
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Hon. Eric K. Shinseki,
Secretary, U.S. Depart-
ment of Veterans Affairs, letter dated March 9, 2010, and VA
responses................................................. 53
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Blake C. Ortner, Senior
Associate Legislative Director, Paralyzed Veterans of
America, letter dated March 9, 2010, and response letter
and attachment, dated April 1, 2010........................ 65
THE VETERANS HEALTH ADMINISTRATION'S
FISCAL YEAR 2011 BUDGET
----------
TUESDAY, FEBRUARY 23, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 1:05 p.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Snyder, Teague, Donnelly,
Halvorson, Brown of South Carolina, Boozman, and Buchanan.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. We may as well get started. Mr. Brown is on
the floor giving a 1 minute speech, and I know Mr. Teague is on
his way over here, so we may as well get started now.
I would like to thank everyone for coming out this
afternoon. The purpose of today's hearing is to examine the
fiscal year 2011 President's budget request for the Veterans
Health Administration (VHA) of the U.S. Department of Veterans
Affairs (VA). The ``Veterans Health Care Budget Reform and
Transparency Act of 2009'' provides for advanced appropriation
for the VA medical care accounts and was enacted into law on
October 22nd, 2009. In accordance with this Act, the
President's budget requests fiscal year 2011 and 2012 funding
for the VA medical care accounts.
The Administration requests $48.2 billion for VA medical
care for fiscal year 2011, which includes the medical services,
medical support, and compliance, and medical facility accounts
of the VA. When medical care collections are included, the
Administration's request is $51.5 billion for VA medical care,
which is $4 billion or 8.6 percent above the 2010 enacted
level.
In fiscal year 2012, the Administration requests $54.3
billion for VA medical care, which is about $3 billion or 5.3
percent above the 2011 request.
The fiscal year 2011 budget request addresses many of the
shared priorities of this Subcommittee such as rural health,
mental health, and homeless veterans.
The President's budget request for VA is a robust budget in
the tradition of the significant funding increase that the VA
will receive or has received in the past several years.
Through today's hearing we will examine the President's
2011 budget request for VHA, which includes a funding
recommendation, as well as policy and legislative proposals for
the medical care accounts of VHA.
In addition, we will examine the information technology
(IT) and the construction resources for VHA, and we will
explore whether the budget request for the VA health care
system provides significant resources to meet the needs of our
returning servicemembers, including those who deployed as part
of the troop surge in Afghanistan.
Today we will hear from the VA's Under Secretary for
Health, as well as Paralyzed Veterans of America (PVA), and the
Veterans of Foreign Wars (VFW), who are co-authors of The
Independent Budget (IB). We will also hear from the American
Legion. I look forward to hearing testimonies.
[The prepared statement of Chairman Michaud appears on p. 27
.]
Mr. Michaud. I would like to recognize Mr. Boozman for any
opening statement he might have? Mr. Teague or Mr. Donnelly, do
either of you have an opening statement?
Mr. Teague. No, and for the sake of time I will defer to
the questions.
Mr. Michaud. Thank you very much. Without any further ado,
I would like to recognize our first panel, Dr. Robert Petzel
who is the Under Secretary for Health. He is accompanied by
Paul Kearns, Robert Neary, and Brandi Fate. I want to thank all
of you for coming today. I want to congratulate you, Doctor,
for your appointment as Under Secretary of Health. I will look
forward to working with you as we try to take care of the needs
of the brave men and women who serve this Nation of ours. I
have heard a lot about you, and look forward to your testimony
today.
So without any further ado, Doctor.
STATEMENT OF HON. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR
HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ACCOMPANIED BY PAUL KEARNS III, FACHE, FHFMA,
CPA, CHIEF FINANCIAL OFFICER, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ROBERT L. NEARY, ACTING
DIRECTOR, OFFICE OF CONSTRUCTION AND FACILITIES MANAGEMENT,
U.S. DEPARTMENT OF VETERANS AFFAIRS; AND BRANDI FATE, DIRECTOR,
CAPITAL ASSET MANAGEMENT AND PLANNING SERVICE, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Petzel. Chairman Michaud, Ranking Member Brown, and
distinguished Members of the Subcommittee, thank you for this
opportunity to present the President's fiscal year 2011 budget
and fiscal year 2012 advanced appropriation requests for the
Veterans Health Administration.
Our budget provides resources necessary to continue our
aggressive pursuit of the President's two overarching goals, to
transform VA into a 21st century organization and to ensure
that we provide the highest quality of health care to our
deserving veterans.
Before I begin, I would like to thank all of you and your
colleagues in the Senate for your support as I take on the
responsibility of managing the Nation's largest and best
integrated health care system as the new Under Secretary for
Health. There are many challenges and opportunities ahead, and
I look forward to working closely with you to improve the
health and well-being of America's veterans. I also look
forward to developing strong relationships with the veterans
service organizations (VSOs), including those who appear today
in support of The Independent Budget, and I thank them for
their efforts on behalf to improve the lives of veterans.
During my confirmation, I pledged to the Senate that I
would focus on three areas. Articulating a vision of our health
care system and what it needs to become, more patient centered,
providing more team care, and continuously improving itself.
Number two, aligning the organization to achieve that vision.
And number three, reducing the variation in our organizations,
structures, business practices, and medical care.
I believe our budget supports these three strategic goals
as well as the six high priority performance goals mentioned in
my written statement.
VA's budget provides $51.5 billion for medical care in
2011, an increase of $4 billion over the previous year, or
about an 8.5-percent increase. This level will allow us to
continue providing timely, high-quality care to all enrolled
veterans.
During 2011, we expect to treat 6.1 million unique
patients, a 2.9-percent increase over the previous year. Among
this total will be 439,000 veterans who have served in Iraq or
Iran, an increase--in Afghanistan rather--an increase of nearly
15 percent from 2010. Our budget request provides $2.6 billion
to meet the health care needs of this population, a 20-percent
increase from the previous year, 2010. This estimate reflects
also the surge of troops that we expect in Afghanistan.
The treatment of this newest generation of veterans has
provided stimulation to us to improve the treatment for
conditions such as post traumatic stress disorder and traumatic
brain injury. We are increasing resources for an aging veteran
population with chronic illness by increasing the funding for
long-term care by 14 percent, and providing an almost 23-
percent increase in money for non-institutional long-term care.
We will also strengthen access to health care for rural
veterans through our new outreach and delivery initiatives, as
well as expanding home-based primary care, telemental health,
and telehealth services.
We will further expand health care eligibility for Priority
8 veterans in 2011. We estimate that approximately 100,000 new
veterans will enroll because of this effort.
The 2011 budget provides $217.6 million to meet the gender
specific health care needs of women veterans, an increase of
more than 9 percent over the 2010 level. We will be delivering
better primary care for women veterans, and this remains one of
the Department's highest priorities.
This budget provides the resources required to enhance
access in our health care system by activating new and improved
facilities, expanding health care eligibility, and making
greater investments in telehealth.
We are requesting a substantial investment for our homeless
program as part of our plan to ultimately eliminate veteran
homelessness through an aggressive approach that includes
housing, education, jobs, and health care.
VA will be successful in resolving these concerns by
maintaining a clear focus on developing innovative business
practices and delivery systems that will not only serve
veterans and their families for many years to come, but will
also dramatically improve the efficiency of our operations. By
making appropriate investments today, we can ensure that higher
value and better outcomes will endure for our veterans.
VA must provide timely, high-quality health care in a
medical infrastructure, which is on average 60 years old. In
2011, we are requesting $1.6 billion to invest in our major and
minor construction programs to accomplish projects that are
crucial to right sizing and modernizing VA's health care
infrastructure, providing greater access to benefits and
services for more veterans closer to where they live, and
adequately addressing patient safety and other critical
facility deficiencies.
The 2011 budget request for VA major construction is $1.15
billion. The $467 million request for 2011 for minor
construction is an integral component of our overall capital
program.
Minor construction permits VA to realign critical services,
make seismic corrections, improve patient safety, enhance
access to health care, increase capacity for dental care,
enhance patient privacy, improve treatment of special emphasis
programs, and expand our research capability.
Further, minor construction resources will be used to
comply with energy efficiency and sustainability design
requirements.
VA's 298,000 employees are committed to providing the
quality of service needed to serve our veterans and their
families. They are our most valuable resource. VA is fortunate
to have public servants that are not only creative thinkers,
but also able to put good ideas into practice.
With such a workforce and the continuing support of
Congress, I am confident we can achieve our shared goal of
accessible, high-quality, timely care and benefits for our
Nation's veterans.
Thank you again for this opportunity to appear, and my
colleagues and I are prepared to answer your questions.
[The prepared statement of Dr. Petzel appears on p. 28.]
Mr. Michaud. Thank you very much Doctor, we really
appreciate your testimony. As I stated in my opening remarks, I
am looking forward to working with you.
I now recognize Mr. Teague for any questions he may have.
Mr. Teague. Good afternoon, thanks for coming to all of you
and thanks for participating in this hearing. And Mr. Chairman,
Ranking Member, thank you for allowing me to ask a couple of
questions here.
A couple a weeks ago when the Secretary said that after the
26.4 percent medical care budget increase since 2009 we are
going to be working on reducing the rate of increase in the
cost of the provision of health care by focusing on areas
better leveraging acquisitions and contracting. Could you
expand on that a little bit more?
Dr. Petzel. Yes, thank you Congressman Teague.
Just to give you an example, I come from Minneapolis
Network 23 where I was the network director, and in that
network we consolidated our imaging or radiology services and
consolidated our purchasing for the radiology services, to wit,
we saved in the purchasing of seven new CAT scanners, about $3
million. This sort of consolidated purchasing across the entire
system I think is going to provide us with substantial,
substantial cost reductions. I also think that by standardizing
our services, in again many of our networks, we are going to be
able to realize substantial savings.
Just one more example, the Prosthetics Service several
years ago began a process of standardizing some of their
prosthetic equipment, and one of the things that they
standardized was hips. We had about 35 different brands and
varieties of artificial hips that we used when we did a hip
replacement in patients. And we have consolidated that down to
I believe about five different prosthetics that meet
everybody's needs at a substantial savings. I think that doing
this across the system is going to entail substantial savings.
Mr. Teague. Coming from a rural district, and I mean a
really rural district where we have a lot of people that have
to travel 300 miles to get to a hospital, and knowing that
there was an additional $30 million in the medical facilities
account so that we could have more community based outpatient
clinics (CBOCs) and everything open up, I was just wondering
how many of those have we added, and how many do we intend to
continue adding in the 2011 budget? And if so, how many?
Dr. Petzel. By the end of 2010, and it is actually going to
be spilling into 2011, because we are not going to be able to
activate all of the CBOCs that we had planned for 2010, but by
the end of that period we expect to have 862, I believe,
community based outpatient clinics, and that is an increase, I
think, of almost 100 over what we had in 2009. Fifty-one of
these, Mr. Kearns is pointing out, are in rural areas. So there
is going to be a substantial investment in 2010 extending into
2011 in rural CBOCs.
Mr. Teague. Okay. Is there a list somewhere where we can
see where they are projected to be? I mean, because as I say,
with people traveling the distances that they do, it is pretty
relevant in our district.
Dr. Petzel. Post hearing we can provide you with a list I
am quite certain, yes.
[The VA provided the answer in response to Question #2 of
the Post-Hearing Questions and Responses for the Record, which
appears on p. 55.]
Mr. Teague. Very good, thank you, and thank you for
attending today and for your answers. I yield back.
Mr. Michaud. Thank you. Mr. Donnelly.
Mr. Donnelly. Thank you, Mr. Chairman.
Dr. Petzel, in regard to the major construction funding,
additional locations were put on the list to a total of 61 now
and two were funded. What is your long-term plan?
Dr. Petzel. The $1.1 billion in 2011, Congressman, is for
five projects. Two of them--three of them rather--were ongoing.
Mr. Donnelly. I am sorry, I should say two new places were
funded.
Dr. Petzel. And there were two new places, that is correct.
Alameda and Omaha.
I will ask Mr. Neary in a minute to comment on the list and
how we deal with that list, but there is a substantial list of
major projects, and this makes I think a substantial dent in
the monetary amount at least, but there still are, as you point
out, a large number of projects on the list, and I would ask
Mr. Neary if he could comment on the size of that list and how
we move through it.
Mr. Neary. Thank you, Doctor. Congressman Donnelly, as Dr.
Petzel indicated, I think the major construction proposal for
fiscal year 2011 is a very robust proposal, but we do have----
Mr. Donnelly. But it only includes two, two new places.
Mr. Neary. It only includes two new starts. We have been
fortunate with the support of the Congress to receive funding
levels in the approximately $1 billion range for the last 3
years, substantially higher than the past, so we are headed in
the right direction, I think. We evaluate all the projects that
are proposed and prioritize them to the extent that we believe
the most important projects rise to the top of the list. We are
working down that list, but it will take some time to go
through the list that is displayed in the 5-year plan.
Mr. Donnelly. So those 61 are included in a 5-year plan?
Mr. Neary. In the volume that submits the construction
budget and the last half of that volume is the VA's 5-year
capital plan, and it identifies the projects that we have
prioritized, yes.
Mr. Donnelly. So is it your expectation that those 61 will
all be started within a 5-year period?
Mr. Neary. It is unlikely that they will all be started
within 5 years. I believe that the value of that list is
approximately $13 billion, and obviously the budgets that we
are seeing are while good will take a little longer than 5
years to work through them.
Mr. Donnelly. Thank you very much.
Mr. Michaud. Mrs. Halvorson.
Mrs. Halvorson. Thank you, Mr. Chairman, and
congratulations, Dr. Petzel, on your confirmation, and I know I
just wanted to let you know that I worked very closely with Dr.
Cross on a medical facility in my district that I am hoping to
bring to Joliet, Silver Cross Hospital, I am sure your
wonderful staff has kept you up to date, or if not, I am sure
they will, and I just didn't know if there was any light that
you would like to shed--shed any light on this for me maybe or
any updates that maybe you want to know, or if there is any
questions that you have for me.
Dr. Petzel. Well, Congresswoman Halvorson, that is
incredibly timely. I was just told not 5 minutes ago that we
just finished a site visit.
Mrs. Halvorson. Yes.
Dr. Petzel. And the word that came back is that this is an
excellent facility.
Mrs. Halvorson. It is.
Dr. Petzel. So we are very optimistic that the Silver Cross
Medical Facility is going to meet our needs and it is going to
work very well into our system.
Mrs. Halvorson. Great, because it is something that is so
very important to any district. And I know we had the district
work period last week, and everywhere I went people wanted an
update, and this is something that we are expecting to come to
fruition, and I just wanted to make sure that it was always on
the forefront of your memory and on your radar screen. So very,
very important to us.
Dr. Petzel. And it is very important to us.
Mrs. Halvorson. Because I think the more that--and I know
Chairman Filner has been out there and I know Secretary
Shinseki is coming out, and we haven't quite found the date
yet, but--and you had another site visit, so I just wanted to
reiterate our concern and how important it is to us.
We have also seen substantial increases in the past few
years in my district in terms of the veterans that rely on the
VA care, so I certainly have concerns. I think that the minor
construction budget doesn't really reflect the increases in the
need for veterans care, so I am really concerned about that.
And maybe you can shed a little more light on why these budget
slashes and why for the funds for the minor construction
projects, especially in Illinois and in my area.
Dr. Petzel. Thank you, Congresswoman. Again, I will let Mr.
Neary comment in a minute.
Just to make a statement. The minor construction budget, as
I understand it, is the second highest request that has been
made for minor construction in the history of the VA. It is a
large amount of money relative to what we have been seeing
before, but as you point out, and I think as Mr. Neary will
point out, it is not going to completely address our list of
minor projects.
Mr. Neary. Certainly correct. Similar to the major
construction appropriation, in the last few years minor
construction has been at an all time high in terms of funding
levels. And as Dr. Petzel said, this is the second largest
request that has been made for minor construction. The first
largest being in fiscal year 2010, but it is less than fiscal
year 2010, and we will be looking to ensure that those funds
are used most judiciously to bring the most value to our
facilities programs.
Mrs. Halvorson. So just so you know we are just really
concerned that it doesn't meet the needs. As the needs are
going up, the last thing we need to do is cut those projects
that we want to keep on track.
So you know, I appreciate you all being here, but my staff
and I will be constantly letting you know what is going on in
my district. So thank you all for being here. It is good to see
you.
Mr. Michaud. Thank you. Mr. Brown.
Mr. Brown of South Carolina. Thank you, Mr. Chairman, and
thank you to the witnesses who came, and particularly Dr.
Petzel, glad to have you on board, congratulations for this new
level of service that you and all the other support folks in
the VA.
I think we have a good health care budget in this cycle,
and I am certainly pleased to support it.
I am a little disappointed in one project that we have been
trying to move forward since 2006, what we always refer to as
the Charleston model. This was a combination of services
between the VA and the Medical University of South Charleston,
and we actually put I think it was like $36.8 million in the
Reauthorization Bill, I guess Benefits and Health Care
Information Technology Act of 2006, but nothing has actually
moved on it since then. And I noticed in this particular budget
there is no funding available and it hasn't been addressed.
And since we have all of you here in one room, if you all
could kind of help me go through this and kind of give me an
idea, you know, of exactly what might be going to take place,
and if there is a timeline that you are working with that you
might share it with me.
Dr. Petzel. Thank you Congressman Brown. I am in a general
sense familiar with the history of the project in Charleston,
but not with the specifics, and I think I would ask Mr. Neary
if he could--or Ms. Fate if she could comment on that, please.
Ms. Fate. Thank you, sir. Based on the assessment of the
workload increases as well as the space deficiencies as well as
the facility condition assessments of the Charleston VA, it was
assessed that a new hospital wasn't the most advantageous for
the Charleston VA Medical Center, but instead an expansion to
decompress the facility, more in an outpatient setting.
So the request that has come forward is to acquire the
Naval Hospital, and through their Base Realignment and Closure
(BRAC) process--through the Navy's BRAC process. And so that
project was submitted for consideration in the fiscal year 2011
process and was ranked 51 out of 61 priorities, and so it
wasn't--and at the same time we are also waiting on the Navy to
decide which facility is going to get the facility based on
their BRAC process.
Mr. Brown of South Carolina. I know I talked about that
with the Secretary and I know that he was concerned about
funding, and I know that if it is going to be part of the BRAC
process, it looks like it could be some kind of lateral
transfer without any dollars involved. That is generally the
way that the BRAC process works. I know that when they closed
Joel's shipyard, most of that property actually deeded over to
the City of North Charleston, and so I mean certainly if you
are going to move it into a government entity, you certainly
ought to be able to do that within the confines of the Federal
Government.
But what concerns me about the Charleston model, and if you
are familiar with the area--in fact we tried to get some money
and we did get a few dollars in the stimulus where the flooding
is such a major problem. The roads adjoining to the VA hospital
are under water if the right rains come and the tide is at the
right place, so we got $10 million in this last stimulus payout
back in--last Wednesday, so that--what concerns me is right
after Katrina hit New Orleans, we actually went down and saw
some of the facilities, and we recognize that the VA hospital
there in New Orleans was not damaged, but because of the
flooding and because of the lack of power we assumed that
building was not going to be used. Are you all tearing that
down is what the--what are you--are you reusing the old VA
hospital in New Orleans, or are you going to relocate it?
Dr. Petzel. I will let Mr. Neary comment on that,
Congressman.
Mr. Brown of South Carolina. Okay.
Mr. Neary. Certainly. Presently the bulk of the former
hospital is closed. We are operating an outpatient clinic in
the facility, but we are in design for a new VA hospital that
will be located a mile or two away, and we have funding. We
have partially funded in previous budgets. We have the final
incriminate of funding in the fiscal year 2011 budget. We
expect to beginning the first, all be it a small phase of
construction in the next 2, 3 months, and then in fiscal year--
later in this fiscal year and through 2011 we will be awarding
further contracts to construct a new facility.
Mr. Brown of South Carolina. And I might bobtail a little
bit on that. That is exactly my idea of the Charleston model,
is we are basically in that same zone. The VA hospital is
actually in a lower location than say some parts of Medical
University.
We were hoping that by being more proactive we could be
able to address the issue before another Hugo would come in,
and we had Hugo back in 1989, which was I guess the same
intensity as the storm that hit New Orleans back in I guess
2006, or 2005, when it was. But so we were hoping by putting
that money in that Reauthorization Bill, it would give some
initiative to actually jump start that project, and I was
hoping that somehow or another we would be able to be moving.
The Medical University is actually in a rebuilding mode
now. They are going to probably replace most of their
facilities, and by doing so, we thought it would give us a good
opportunity to be able to bring the VA and the Medical
University closer together. Some 95 percent of the doctors that
actually treat those patients at the VA hospital have
affiliation with the Medical University, so it would seem like
it would just be a proper thing to be able to bring them in a
more closer proximity.
I know the VA hospital itself is in pretty good shape, but
I am telling you the location we have is going to be at risk if
we have another major storm that hits.
So, Dr. Petzel, I hate to just give it to you on the first
day that you testify before us, but it is a major concern of
ours. Like I said, we have been working with it since 2006. It
seems like we are the only one that has the vision, and I am
just trying to share that with other people, maybe somebody
else might be able to sense the same problem that we find. But
I am telling you it was pretty obvious to me when I went to
that fine facility in New Orleans and recognized that it is not
going to be able to--although it withstood the winds, the mold
is going to actually take it down.
Dr. Petzel. Well, Congressman Brown, I will review the
circumstances in Charleston with our construction facilities
management people, see where that stands right now, and become
acquainted with the details.
Mr. Brown of South Carolina. I appreciate it. Thank you
very much.
I apologize, my southern hospitality just slipped me for a
minute. We would be happy to accommodate you any time you want
to come.
Dr. Petzel. Congressman, thank you very much.
Mr. Brown of South Carolina. Thank you.
Mr. Michaud. Thank you, Mr. Brown.
Medical IT, as you know, is an integral part of the VHA
health care delivery system. My concern is whether VHA and the
IT system are working collaboratively in a way that will help
expedite the process of getting a facility online. If the
fiscal year 2011 budget request includes about $930 million in
medical IT support, which is a decrease of about $150 million
from the 2010 levels, what is the rationale for that decrease?
[The VA subsequently provided the following information:]
Facility activations are a top priority for Office of
Information and Technology (OI&T). All field Information Technology
(IT) managers are empowered to meet IT activation requirements in
concert with the activation timelines established by VA facility
leadership. OI&T Field Operations staff are members of the facility
project planning teams that develop, schedule and activate new
facilities, services and programs.
In response to the question regarding the rationale for budget
decrease of medical IT, we offer the following:
There are numerous one time or unique fiscal year activities
that occur in FY 2010 that are not occurring in FY 2011 or are
recurring at a different funding level.
For example:
Life Cycle Management decreased by $28.939 million;
Wireless decreased by $47.967 million;
Engineering Support Contractor Service was reduced by $15
million to $0;
Enterprise backup solution was reduced by $16.5 million to $0;
and
The National Archive Project was reduced by $12 million to $0.
Activations costs in FY 2010 are a one-time investment that will
change in FY 2011 based on the nature, scope, and completion of ongoing
construction work across the VA system. This includes major
construction, minor construction, nonrecurring maintenance (NRM), and
bringing online new Community Based Outpatient Clinics (CBOCs). The
drop in funding from the FY 2010 Current Estimate to the FY 2011
President's Submission is the result of the a thorough review of the FY
2010 Medical IT Support needs (licensing and maintenance agreements),
having taken place during the execution review for FY 2010. No such
review has yet taken place for FY 2011. During the summer of 2010,
OI&T, working with its VA business partners, will conduct a similar
review of FY 2011 execution needs and necessary adjustments will be
made to this and other programs prior to the start of FY 2011.
Mr. Michaud. My second question is, some folks within the
VA system nationwide have been concerned that there has been a
lag between VHA and IT that seems to be delaying some of the
projects that are needed out there. So those are my two
questions relating to IT.
Dr. Petzel. Thank you, Mr. Chairman. I want to make just a
general statement about VHA and IT. I have been working in the
Central Office as the Acting Principal Deputy Under Secretary
for the last 9 months, and I have been impressed with the
change in tenor, if you will, that has occurred with the
ascendance of Roger Baker as the Assistant Secretary for IT.
There is really a very, very new wind blowing through that
organization, and the level of cooperation is probably much
better than it had been before. And I am encouraged that we are
going to be able to eventually be on the same path and get our
needs met in an expeditious manner, but I think it is going to
take some time.
Having said that, I don't know what the change in the IT
medical budget is. We would have to get back to you after I
talk with Mr. Baker.
[The VA subsequently provided the following information:]
Veterans Health Administration (VHA) and VA's OI&T are working
very closely together throughout the entire lifecycle of project and
program development. Staff, managers and leadership in both VHA and
OI&T are demonstrating a strong and consistent commitment to completing
projects on-time and on-cost.
VA, however, has experienced IT project delays. A review of
these projects led to the development of the Program Management and
Accountability System (PMAS), an IT project management framework that
uses the best practices from various management and accountability
methods.
All programs and projects are now developed and managed under
PMAS. This level of standardization in project management and
development is a fundamental change in the way VA develops programs and
conducts oversight and accountability. Key attributes of PMAS include:
building in 6-month increments, frequent customer involvement,
adherence to milestones with frequent milestone reviews, customer
acceptance of functionality, and a practice of allowing only three
strikes (missed milestones) before the project is halted or terminated.
In the event of a halted or terminated project, the entire project,
along with its managers, will come under intense scrutiny, which
facilitates a culture of personal accountability. PMAS is already
demonstrating its value in improving adherence to scheduled milestones
and project delivery dates.
VA senior leadership continues its efforts to improve
communication and coordination between VHA and OI&T, which is evidenced
by the Deputy Secretary's personal involvement in monthly Operational
Management Reviews of VHA/OI&T programs and projects. This commitment
when combined with the recent implementation of PMAS accountability and
reporting standards, has significantly enhanced VA's ability to quickly
and efficiently produce and deploy systems to support the services that
VA provides to our Nation's veterans.
Mr. Michaud. Thank you. I also know the VA has been working
collaboratively with the U.S. Department of Defense (DoD) on
the Virtual Lifetime Electronic Records (VLER). How is that
project moving forward? Has it been fully developed? Are there
any delays or any changes that need to be made?
Dr. Petzel. Well thank you, Congressman. This is an
incredibly interesting project. Virtual Lifetime Electronic
Record is the beginning of the attempt to create a completely
inter-operative medical record across the Nation. The first
pilot was set up in San Diego between the VA, Kaiser Permanente
and the DoD. It began modestly with just a very few elements
being shared using the national health information network. The
pilot tested very successfully. There are approximately 1,500
patients from both sides that are enrolled in this and for
which we are sharing information.
As we speak, the amount of information that is available is
being expanded, and we are also beginning to develop the second
pilot site, which I believe is going to be in Hampton,
Virginia. In our view, it has been a very successful pilot. It
is going to require several years of development until it is
fully implemented, but we believe that this is going to be the
demonstration of how the Nation can be sharing its medical
records not only within the government but across the private
sector, and I am very encouraged.
Mr. Michaud. Thank you. Moving on to a different topic;
grants to States for extended care facilities. There has been a
reduction of about $15 million in that count. What is the
rationale for this reduction? What I have heard from a lot of
the State veterans nursing homes is that there is actually a
backlog of about $405 million where the States have already
committed dollars for construction.
Dr. Petzel. I will ask Mr. Kearns to comment on that in a
minute, but my understanding is that a significant amount of
American Recovery Reinvestment Act (ARRA) money was used in the
State homes grant program, and I think if you compare 2011 to
2010 and take out that stimulus money that went in, we see a
rather substantial increase.
But Mr. Kearns, could you comment more specifically?
Mr. Kearns. Yes, sir. Basically in stimulus funding we had
$150 million for the grants, and that is progressing very
nicely. And then it has to be matched with the States. We have
another $85 million in this budget for fiscal year 2011. So we
feel that we are going to be able to continue very good
progress in that area.
Mr. Michaud. But where the States are already ready to go,
why wouldn't you want to increase that amount so they can get
those projects up and running?
Mr. Kearns. I think we would need to get back with you on
the specifics, sir. I do know that in a couple of the instances
when we had the high priority items in the stimulus money, some
of the States could not match with their funding--the timing
didn't fit and they couldn't match so we had to slip that and
put them into the next year.
So I think it varies State by State as to what their
specific condition is as to whether they are ready to match at
any given time, largely because of the current economic
conditions. But we can get you the specifics back.
[The VA subsequently provided the following information:]
The backlog of approximately $405 million has been reduced to
two projects with an estimated cost to the Department of Veterans
Affairs of approximately $43 million. This was accomplished as a result
of the FY 2010 regular appropriation of $175 million for the State Home
Construction Grant Program, the additional American Recovery and
Reconstruction Act appropriation of $150 million, and the withdrawal or
deferral of certain projects at the request of the States. Currently,
there is no Priority Group 1 backlog of renovation projects (including
renovations to protect the lives and safety of veterans) or of new
construction projects in States with a great need for new nursing home
beds. Priority Group 1 projects are those for which the States have
committed matching funds. VA is confident that the budget request of
$85 million for FY 2011 will be sufficient to fund all new Priority
Group 1 Life Safety and other renovation projects and all new
construction projects in States with a great need for new beds.
Mr. Michaud. Thank you. And there has been actually an
increase in mental health, about $410 million from fiscal year
2010 to fiscal year 2011. Are there any new mental health
programs that you plan on implementing with the additional
funding, or does that just reflect an ongoing need?
Dr. Petzel. Excellent question, Chairman, and that
basically is the ongoing needs. We do not have any specific new
programs in mental health. We want to consolidate and make as
vibrant the things that we have.
As you know through both our own actions and Congress's
actions over the last 3 or 4 years there is been a huge
increase in our mental health. We have added since 2005, 5,000
mental health workers, and just in this last year we added
almost 2,000 new mental health workers. So we think we have the
programs that we need, we think we have the people that we
need, and it is a matter of making sure these programs work
during this year.
Mr. Michaud. Also, in the previous budget we increased
funding so we can start reenrolling Priority 8 veterans. What
have you done specifically to increase reenrollment of Priority
8 veterans? Have you met your initial goal?
Dr. Petzel. Thank you, Congressman. The goal was
approximately 200,000 new enrollees in 2010. As you know we
increased the threshold in the means test by approximately 10
percent, and made eligible I think over 300,000 new enrollees
theoretically, and we expected to see about 200,000 of those
come.
There has been an extensive outreach program with the
county veteran service officers. We have mailed letters to
everybody that had been denied enrollment previously, but we
have not met our goal. We have enrolled a substantial number of
new Priority 8's and we have enrolled a larger number of
Priorities 5 and 7 than previously. We think that some of these
Priority 8's, because of the economic conditions, have moved
into categories 5 and 7. And we look at those people as being
people who would have otherwise been in our new Priority 8.
But I would ask Mr. Kearns if you can add anymore specifics
to that.
Mr. Kearns. No, sir, that is all. We are in the fiscal year
2011 budget raising that threshold from 10 percent to 15
percent, and we are aggressively marketing through different
media sources to get to those potentially eligible veterans.
Mr. Michaud. Thank you. My last question relates to some of
the earlier questions from Mr. Donnelly and others dealing with
access to health care in rural areas. The Capital Asset
Realignment for Enhanced Services (CARES) process identified
several different access points. If you look at some of those
access points it would probably be fair to say that a lot of
them are probably at places where we also have a federally
qualified health care facility.
Have you looked at the CARES process and determined whether
or not the access points that were recommended under CARES are
still valid? And if so, are you looking at working with the
U.S. Department of Health and Human Services (HHS) to see
whether or not there might be a qualified health care clinic in
that area that might overlap? Can you collaborate with HHS to
try to get more of these access points up and running sooner
rather than later so we can start taking care of veterans in
the really rural areas?
Dr. Petzel. Thank you, Mr. Chairman. Each year, starting at
the facility level, moving up through the network level, and
finally coming to Washington we ask for an evaluation of access
that includes a review of pending access points as well as new.
I think, as you realize, not only have we almost completed
activation of all of the CBOCs that were identified in the
CARES process, there have been many, many other CBOCs that have
been added. I think since CARES began it would be numbered in
the hundreds that we have added in terms of community based
outpatient clinics.
So I think the process of making sure that the CARES, CBOCs
are taken care of is well in hand.
The question whether we are maximizing the possibilities
with the community health centers remains open, and I think
that we need to have a renewed effort at looking at how we can
interact with the community health centers. I am not familiar
with what kind of efforts have been made in the past, but it is
something I am interested in pursuing. They are another Federal
agency and we should be in the process of cooperating with
another Federal agency to see if we can maximize the benefit of
the Federal dollars we had. So we will be examining that.
Mr. Michaud. Thank you, thank you, Doctor.
Mr. Boozman.
Mr. Boozman. Thank you, Mr. Chairman. I guess I would like
to follow up a little bit. I know that you have touched on this
a little bit.
In regard to the mileage reimbursement, my question is
where is the money coming from? Does that come from the
Veterans Integrated Services Network (VISN) or does that come
from the Central Office? Are we accounting for the fact of our
rural districts, our rural hospitals? I would like to know all
of the different factors that go to work in regard to the
payment of that. I know that it has been discussed and we have
a tremendous increase. Where is the money coming from that pays
for that?
Dr. Petzel. Thank you, Congressman. We have had extensive
discussions about this. There is a 23-percent increase in the
money in our budget for patient travel. I think the figure now
is $798 million. That is part of our budget. It is distributed
as part of, and correct me if I am wrong, Mr. Kearns, it is
part of the veterans equitable resource allocation (VERA)
distribution. So based on the workload that each one of the
networks has they would be getting a portion of that money.
Then it is the responsibility of the networks to ensure that
money gets distributed to the place where it is needed.
Mr. Boozman. But would there be some allocation based on
the fact that maybe if you had a rural hospital that didn't
have as much tertiary care and things, is it distributed that
way also if there is more travel involved?
Dr. Petzel. Congressman, I will ask Mr. Kearns in a minute
to comment on that more specifically.
Let me give you my experience from the network that I used
to direct in Minneapolis, which is quite rural. We would
distribute the money for patient travel based upon previous
years' experience. So we know that the Fargo VA medical center
as an example----
Mr. Boozman. Right.
Dr. Petzel [continuing]. Has a disproportionately high need
for money because they bring people from as far as 400 miles to
the Fargo hospital from far western North Dakota. So our
distribution would have been based upon previous use and
current need. Whereas the Minneapolis VA medical center, which
serves primarily an urban area, would not need proportionately
as much travel money.
So the travel money wouldn't go out just based on the
workload, it would go out with some cognizance of the ruralness
or urbanness of the facility and its need.
Now, Mr. Kearns, you want to make a comment?
Mr. Kearns. No, sir, that is correct. We do not separately
allocate the travel money, it is part of the basic allocation
to the networks, and the networks make that decision.
However, we do have a large increase in the budgeted fiscal
year 2010 because the rate of 41.5 cents went up last year. We
feel we will have the largest experience this year and that
money is out in the system not specifically targeted to travel,
so at specific locations if they experience more than they had,
we would expect them to fund that, if they experience less they
wouldn't have as much requirement in that area.
In this current budget, we are funding in fiscal year 2011
and 2012 average increases above that, but we are not planning
in the budget to increase that rate of 41.5 cents.
Mr. Boozman. Okay, very good. In regard to the extra cost
for the fee-based services in New Orleans, where does that come
from? Does that come from Central Office or is that coming from
VISN 16? Is that a nationwide sacrifice or is that a sacrifice
of that particular VISN?
Dr. Petzel. Congressman, that money would be expected to
come out of the budget from VISN 16. And that has been taken
into account in terms of the total amount of money that VISN 16
would get, and then they would again distribute that money
based upon the need.
So there is nobody else that is not getting care because we
have an excessive fee basis need in New Orleans right now.
Mr. Boozman. Okay. And the hospitals that are growing, in
other words, that have the significant percentage of increase,
9, 10 percent increases, whatever it may be, do you account for
that in your budgeting also?
Dr. Petzel. Yes, Congressman, we do, and I will again let
Mr. Kearns explain in a minute, I will just make a general
statement.
The VERA model puts the money where the work is. That is
the real salient feature of VERA. So if there is a facility
that is growing more rapidly than another facility or a network
that is growing, they are going to get more money than that
facility that isn't growing as rapidly. Would you like to make
a comment?
Mr. Kearns. That is correct, sir. And then in addition to
that, many times in those facilities that are growing some of
those veterans also have health insurance so the collections
will also grow, and those collections stay with the facility
where the veterans are treated.
Mr. Boozman. Okay. Thank you, Mr. Chairman. Again we
appreciate your hard work. I know this is difficult, but like I
said, we appreciate your service for veterans. Thank you.
Mr. Michaud. Mr. Snyder.
Mr. Snyder. I am sorry I wasn't here for the earlier part
of the meeting.
Dr. Petzel, what is status of funding for physicians? Do
you have all physician slots filled that you want with adequate
funding, or do you have slots that you would like to have
filled and don't have adequate funding for?
Dr. Petzel. Congressman, thank you for the question. I am
going to have a little soliloquy about physician reimbursement
for just a second if you don't mind.
First of all, we have enough money to purchase the services
of all the physicians that we need. And fortunately with the
relatively new physician pay bill that Congress is responsible
for, we are able to pay in a general sense salaries that
attract the physicians that we need. We do have occasions in
some remote areas, some difficult-to-recruit areas even for the
private sector, where we sometimes have difficulties
recruiting. But, we have been able to meet the needs of our
system for physician services.
Mr. Snyder. So if somebody tells me that there is some
empty physician slots some place and they are told the reason
they are not being filled is there is not adequate funding that
is inaccurate?
Dr. Petzel. It would be inaccurate in my experience. I am
not aware, and I have not been told about, any place that is
not able to recruit its physicians because it doesn't have
adequate budget.
Mr. Snyder. Great, thank you.
Dr. Petzel. And I would like to know about that.
Specifically, if there is a place, let's talk to you about
that. Please talk to us.
Mr. Snyder. All right. Thank you.
Mr. Michaud. That is something we actually talked about
beforehand, and that is a concern that I have, because I have
heard the same thing about hiring freezes due to a lack of
funding.
This Subcommittee will be looking in more detail at the
VERA model. Getting back to Mr. Boozman's question about
mileage reimbursement, I will use Togus as an example.
Dr. Petzel, you mentioned the VERA model puts the money
where the work is, and that might be the cause of some of the
problems that we are seeing in really rural areas. For
instance, in Boston a lot of the medical care involves tertiary
care and you have veterans who have to travel 9, 10, 12 hours
to travel to Boston whereas they could actually get that care
locally. But it is to the advantage of the VISN 1 office to
have them come to Boston because that is where the money goes,
rather than to really rural areas.
We will follow up with additional questions on a more
detailed break out on how the VERA funding is distributed. We
have also asked for specific detail on this information for
VISN 1. I only want one VISN to really focus on, but we haven't
received that information yet and we have followed up with
further questions to try to get that break out so that we can
really try to follow the money and assess what is happening out
there and determine whether or not the VERA model is a good
model. It could be a good model, but we are hearing concerns
back in our respective States about how resources are being
distributed and whether it might hamper the ability of some
areas to put forward a new CBOC or access point, because that
comes out of the operating money, and if you have the Central--
VISN office--trying to control their budget then they might not
be willing to move forward as aggressively as if they had money
allocated for the creation of a new CBOC.
So these are some of the issues that we definitely would
want to work with you on, Dr. Petzel. And hopefully, can try to
take care of some of the concerns that we are hearing out there
as well.
If there are no further questions I want to thank you, Dr.
Petzel, and the panel for coming forward today, and I look
forward to working with you. We will have some followup
questions in writing as well. So thank you.
Dr. Petzel. Thank you, Mr. Chairman, and thank you to the
Subcommittee.
Mr. Michaud. I would like to now invite panel two to come
forward. We have Mr. Blake Ortner from the Paralyzed Veterans
of America, Mr. Eric Hilleman from the Veterans of Foreign
Wars, and Mr. Joe Wilson from the American Legion.
I want to thank all three of you for coming forward today.
I look forward to your testimony, and I also look forward to
working with you as we move forward in dealing with issues
important to veterans that serve this great Nation of ours.
So without any further ado, we will start out with Mr.
Ortner.
STATEMENTS OF BLAKE C. ORTNER, SENIOR ASSOCIATE LEGISLATIVE
DIRECTOR, PARALYZED VETERANS OF AMERICA, ON BEHALF OF THE
INDEPENDENT BUDGET; ERIC A. HILLEMAN, DIRECTOR, NATIONAL
LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED
STATES, ON BEHALF OF THE INDEPENDENT BUDGET; AND JOSEPH L.
WILSON, DEPUTY DIRECTOR, VETERANS AFFAIRS AND REHABILITATION
COMMISSION, AMERICAN LEGION
STATEMENT OF BLAKE C. ORTNER
Mr. Ortner. Thank you, Mr. Chairman, Members of the
Subcommittee. Paralyzed Veterans of America is pleased to
present our views on the Veterans Health Administration's
fiscal year 2011 budget in particular as it relates to
construction.
PVA previously testified on the 2011 budget and it is
addressed in my written testimony, so I would like to focus my
oral comments on two key issues that PVA is concerned with
regarding VA construction. That is VA research infrastructure
funding shortfalls and maintaining critical VA health
infrastructure.
In recent years, funding for VA maintenance and
construction appropriations has failed to provide the resources
needed to maintain, upgrade, and replace its aging research
facilities. Consequently, many facilities have run out of
adequate research space while ventilation, electrical supply,
roofs, and plumbing deficiencies appear frequently on lists of
urgently needed upgrades along with significant space
reconfiguration.
In the 2003 CARES plan, VA listed over $468 million
designated for new laboratory construction, renovation of
existing space, and build-out costs for leased facilities, but
then omitted these projects from the Secretary's final report.
In House Report 109-95, accompanying the 2006 VA
Appropriations Act, the Appropriations Committee expressed
concern that equipment and facilities to support the research
program may be lacking and that some mechanism is necessary to
ensure the Department's research facilities remain competitive,
directing VA to conduct a comprehensive review of its research
facilities and report to the Congress.
Of three sites inspected, all scored poor with the total
correction cost of over $26 million. By the end of fiscal year
2009, a total of 53 sites with 47 research programs were
surveyed. Approximately 20 sites remain to be assessed in
fiscal year 2010, but to date the combined total estimated cost
for improvements exceeds $570 million. About 44 percent of the
estimated correction costs constitute priority one deficiencies
with an immediate need for correction. Five buildings that
rated poor were main hospitals housing laboratories.
A significant cause of the VA research infrastructure's
neglect is that there is no direct funding line nor any
budgetary request made for VA research facilities, nor does the
VA medical and prosthetic research appropriation contain
funding for construction, renovation, or maintenance of VA
research facilities. VA researchers must rely on local facility
management to repair, upgrade, and replace research facilities
and capital equipment. As a result, VA research competes with
medical facilities direct patient care infrastructure needs.
PVA recommends the Administration and Congress establish a
new appropriations account to independently define and separate
VA research infrastructure funding and recommends an
appropriation in fiscal year 2011 of $300 million dedicated
exclusively to renovating existing research facilities.
Regarding critical VA health infrastructure, over the past
year, VA has begun to discuss its desire to address its health
infrastructure needs in a new way and acknowledged its
challenges with aging infrastructure, changing health care
delivery needs, limited funding for construction, and the
timeliness of construction projects.
VA has noted, and we concur, that a decade or more is
required from initial proposal until the doors actually open
for veterans to receive care in a major medical facility.
Given these significant challenges, VA has developed a new
model for health care delivery, the Health Care Center Facility
Leasing Program, or HCCF. Under this proposal VA would obtain
by long-term lease a number of large outpatient clinics built
to VA's specifications. These large clinics would provide a
broad range of outpatient services, including primary and
specialty care, as well as outpatient mental health services
and ambulatory surgery.
VA noted that in addition to the new HCCF facilities it
would maintain its VA medical centers, larger independent
outpatient clinics, community based outpatient and rural
outreach clinics.
VA has argued that adopting this model would allow VA to
quickly establish new facilities that would provide 95 percent
of the care and services veterans need in their areas.
We concur that the HCCF model seems to offer a number of
benefits in addressing capital infrastructure problems,
including more modern facilities that meet current life safety
codes. But while it offers some obvious advantages, the model
could face significant challenges.
PVA is particularly concerned about the overall impact on
the future of VA's system of care, including the potential
unintended consequences on continuity of high-quality care and
maintenance of its specialized medical programs for spinal cord
injury, blindness, amputations, and other health challenges of
seriously disabled veterans.
In conclusion, PVA agrees with VA's assertion that it needs
a balanced capital assets program, but VA should not replace
the majority or even a large fraction of medical centers with
HCCFs; this would concern us. But we see this challenge as only
a small part of the overall picture.
The emerging HCCF plan does not address the fate of 153
medical centers located throughout the Nation that are on
average 55 years of age or older. It does not address long-term
care needs of the aging veterans population, inpatient
treatment of the chronically and seriously mentally ill, the
unresolved rural health access issues, or the lingering
questions on improving VA's research infrastructure.
The major question is, what will VA's 21st century health
infrastructure look like and how will it be managed and
sustained?
Congress and the Administration must work together to
secure VA's future to design a VA of the 21st century.
This concludes my testimony and I would be happy to answer
any questions.
[The prepared statement of Mr. Ortner appears on p. 32.]
Mr. Michaud. Thank you very much. Mr. Hilleman.
STATEMENT OF ERIC A. HILLEMAN
Mr. Hilleman. Thank you, Chairman Michaud, Members of the
Subcommittee.
On behalf of the 2.1 million men and women of the Veterans
of Foreign Wars and our auxiliaries, it is my pleasure to
testify before you today.
The VFW works side by side with AMVETS, the Disabled
Veterans of America, Paralyzed Veterans of America to produce a
policy budget recommendation document known as The Independent
Budget. The VFW is responsible for the construction portion of
the budget, so I will limit my remarks to that portion.
VA's infrastructure, particularly within its health care
system, is at a crossroads. The system is facing many
challenges, including the average age of buildings at 60 years
or more, significant funding needs for routine maintenance,
upgrades, modernization and construction.
VA is beginning a patient-centered information reformation
in the way it delivers care and manages infrastructure to meet
the needs of the sick and disabled veterans of the 21st
century.
Regardless of what the VA health care system of the future
looks like, our focus must remain on the lasting and accessible
VA health care system that is dedicated to the unique needs of
veterans.
VA manages a wide portfolio of capital assets throughout
the Nation. According to its latest asset plan, VA is
responsible for 5,500 buildings and almost 34,000 acres of
land. This vast network of facilities requires significant time
and attention from the capital asset management planners.
CARES, a VA data-driven assessment of the current future
construction needs gave VA a long-term roadmap that has helped
guide its capital asset planning process over the past fiscal
years. CARES showed a large number of significant construction
priorities that would be necessary to fill the needs of VA in
the future. And Congress has made significant end roads into
these priorities. It has been a huge but necessary undertaking,
and VA has made slow and steady progress in these critical
areas.
The challenge for VA in the post-CARES era is that there
are still numerous projects that need to be carried out, and
the current backlog of partially funded projects that CARES has
identified as large, this means that VA is going to continue to
require significant appropriations for major and minor
construction accounts to live up to the promise of CARES.
VA's most recent asset management plan provides an update
of the status of CARES projects, including those in the
planning and acquisition process. The top 10 major construction
projects in queue require $3.25 billion in appropriations. This
is just the tip of the iceberg. There are 82 additional ongoing
or partially funded projects that demonstrate the construction
need for VA to upgrade and repair its aging infrastructure and
that continuous funding is necessary to address this backlog of
projects.
A November 17th, 2008, letter to the Senate Veterans'
Affairs Committee by Secretary Peake stated that the Department
estimates that a total funding requirement for major medical
facility projects over the next 5 years would be in excess of
$6.5 billion.
It is clear that the VA needs a significant infusion of
cash for its construction priorities. VA's own words and
studies state this. The total major construction request that
the IB estimates is $1.295 billion. The minor request is $785
million.
The IB recognizes that the money was provided for military
and veterans construction in the American Recovery Reinvestment
Act of 2009, and the Administration has requested lower than
what the IB requested in this fiscal year.
We ask this Committee to examine VA's construction request
with the money that was given in the American Recovery and
Investment Act and weigh that against the growing list of
construction, both major and minor projects that are
outstanding.
We thank you for this opportunity to testify, Mr. Chairman,
and we look forward to your questions.
[The prepared statement of Mr. Hilleman appears on p. 37.]
Mr. Michaud. Thank you. Mr. Wilson.
STATEMENT OF JOSEPH L. WILSON
Mr. Wilson. Mr. Chairman and Members of the Subcommittee,
thank you for this opportunity to present the American Legion's
views on VA's Veterans Health Administration's fiscal year 2011
budget request.
The following chart reflects the President's 2011 budgetary
recommendations as well as those of the American Legion. Due to
time constraint, we ask that you please review that at your
leisure.
For the improvement of mental health care, VA's budget
provides approximately $5.2 billion for mental health, or 8.5
percent over the 2010 enacted level. VA says this will expand
inpatient residential and outpatient mental health programs
with an emphasis on integrating mental health services with
primary and specialty care. The American Legion supports this
increase in funding.
In addition to improving mental health care, VA reported
that the 2011 budget request will provide $217.6 million to
meet the gender-specific health care needs of women veterans.
The number of women veterans, currently 1.8 million, is growing
rapidly, and women are increasingly relying on VA for their
health care. The American Legion believes this provision of
funding for women veterans will minimize many issues facing
them and their families to include post traumatic stress
disorder, depression, substance abuse, and other disorders.
According to VA, the 2011 budget request provides $51.5
billion for medical care, an increase of $4 billion, or 8.5
percent over the 2010 level.
In addition, this level will allow VA to continue to
provide timely, high-quality care to all enrolled veterans. The
American Legion agrees with the VA's 2011 budget request on the
deliverance of medical care to adequately accommodate Operation
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) and Vietnam
veterans, as well as veterans from all other eras.
The 2011 budget contains $6.8 billion for long-term care.
VA also reported that $250 million has been allotted to
continual strengthening access to health care for 3.2 million
enrolled veterans who reside in rural and highly rural areas.
The delivery of health care includes a variety of avenues
to include new rural health outreach and delivery initiatives
and expanded use of home-based primary care, mental health, and
telemental health services. The American Legion supports VA's
actions in providing access to care with the construction of
new facilities as well as technologies. However, due to the
vast number of rural venues, we urge that oversight be provided
to ensure adequate funding is supplied to those areas.
In 2009, VA opened enrollment to Priority Group 8 veterans
whose incomes exceed last year's geographic and VA means test
thresholds by no more than 10 percent. The most recent estimate
is that 193,000 more veterans will enroll for care by the end
of 2010 due to this policy change.
In fiscal year 2011, VA will further expand health care
eligibility for Priority Group 8 veterans to those whose
incomes exceed the geographic and VA means thresholds by no
more than 15 percent compared to the levels in effect to
expanding enrollment in 2009. The American Legion again
proposes this proper oversight by Congress to ensure adequate
funding is in place to meet these enrollees as they arrive to
receive health care.
For 2011, VA has allotted $163 million in home telehealth.
In total, the VA home telehealth program cares for
approximately 35,000 veteran patients. The American Legion
concurs with the allotment of funding for the home telehealth
program because it will serve to provide more access to care
for veterans residing in rural and highly rural areas and
reduce travel for health care.
According to VA more than 150,000 active and reserve
component servicemembers leave active duty annually. This
transition relies on the transfer of paper-based administrative
and medical records from the Department of Defense to the
veteran, the VA, or other non-VA health providers. VA agrees
this paper-based transfer carries risk of errors or oversights
and delays the claim process. The American Legion agrees with
the establishment of the VLER.
The capital assessment realignment and enhancement
services, or CARES initiative, identified approximately 100
major construction projects throughout the VA medical center
system. Approximately 5 years have passed since the CARES
initiative. During that time to present, more women and men
servicemembers are transitioning from active duty to VA and
presenting with multiple illnesses such as post traumatic
stress disorder and mild traumatic brain injury. Meanwhile the
average age of VA's facilities is approximately 60 years.
In addition, the American Legion's 2009 ``A System Worth
Saving'' publication reports space is one of the major overall
challenges, which is due in part to many VA medical facilities
being landlocked. The American Legion hereby urges Congress to
assess the above-mentioned areas being funded in 2011 as well
as the number of servicemembers and current veterans they
anticipate will visit a VA medical facility to receive medical
care. We contend this action may shed light on the actual need
of each VA facility in their sincere effort to accommodate
America's veterans.
Mr. Chairman and Members of the Subcommittee, thank you for
allowing me the opportunity to present the views of the
American Legion to you today. Thank you.
[The prepared statement of Mr. Wilson appears on p. 46.]
Mr. Michaud. Thank you very much, Mr. Wilson, and I want to
thank the entire panel.
Did you mention, Mr. Wilson, the backlog is $785 million
for minor construction?
Mr. Wilson. Did I mention the backlog? I didn't mention the
backlog, no, sir.
Mr. Michaud. Well, the total cost of the 5-year plan is
$6.5 billion for major construction.
And for minor construction, as far as the work that is
needed? My point is, if you look at the major construction and
you look at minor construction, clearly the total cost for
minor construction is less than major construction. Have you
done an analysis on the total number of veterans that might be
affected by both major versus minor construction?
Mr. Wilson. Well, Mr. Chairman, if I can reserve that
response for a later date to give you the full consensus of the
American Legion. We are in the midst of conducting site visits
for 2010, and during our research, as I have said, we are
gathering numbers and we will have a full assessment--we should
have a full assessment by the end of our traveling season which
will be around July.
Mr. Michaud. After your full assessment and a look at the
areas where a larger portion of the veteran's population can be
affected in a positive way, would you encourage the Committee
to put a real emphasis on minor construction, and on trying to
get those facilities and CBOCs up and running sooner, rather
than later, versus spending hundreds of millions of dollars for
a major hospital when you can actually construct several other
CBOCs and access points for the same cost?
Mr. Wilson. Again, that question when you are talking about
minor construction and CBOCs and then a full VA medical
facility, I would say that was two different conversations
there.
When you are talking about a full facility, for example
like Orlando, you are talking about approximately 400,000. They
are going up from maybe under 100,000 to 400,000 veterans. So
it is a big difference when you are talking about a full VA
facility as opposed to CBOCs which are located in rural areas.
And I can't generally say it is hit or miss, because however,
this will be a hit because there will be an influx of veterans
coming in from theater, they may also migrate into rural areas,
which affects CBOCs.
So that is again, I would reserve that to our giving a full
assessment; probably by July we will have this full assessment
so we can respond appropriately.
Mr. Michaud. Okay, thank you. Mr. Hilleman, I believe I
read in your testimony that you identified some shortfall of
the design build construction process. What do you believe is
the best method to deal with the design build type of
construction? If that is not a good process what would be a
good process?
Mr. Hilleman. Mr. Chairman, if I might answer this for the
record I would appreciate that. I don't know that the VFW has
an ideal model for the design build process or an ideal
solution. We feel that the best solution would be one where the
VA is collaborating with the Congress and the veterans service
organizations to try and work something out that addresses all
of our concerns. But I would be happy to get back to you for
the record on that question.
Mr. Michaud. Okay. As you know Congress has appropriated
additional funding to expand access to health care for Priority
8 veterans. What do your three organizations feel the VA has
done to reenroll Priority 8 veterans? Do you think they have
done a good job? And if not, what do you think that they could
do differently to encourage the Priority 8 veterans to sign up
for VA health care?
Mr. Hilleman. If I could lead off, Mr. Chairman.
The VFW has seen a number of Priority Group 8 veterans in
the dark. Something that could be done to improve this is
marketing. VA has had greater success as of late with its
mental health marketing and some of its marketing to female
veterans, and we would urge VA to do marketing, but we
understand that it is a 5-year plan and VA plans to bring in
125,000 every year over the next 4 years. But in select
marketing they may be able to increase Category 8 enrollments.
Mr. Michaud. What is your organization doing as well? Are
you doing anything special to help Priority 8 veterans sign up?
Mr. Hilleman. We have been encouraging veterans to enroll
that have contacted us about health care. We have made them
aware of the passage in law authorizing dollars for Priority
Group 8's. I believe there has been announcements in our
magazine publicizing the open enrollment for specific Category
8's.
Mr. Wilson. Mr. Chairman, since 2003, the demographics have
changed significantly now that women veterans are coming into
the system at a high rate. Economics have changed and we
question whether or not that was considered. I think
approximately 260,000 were supposed to be enrolled by July of
this year, and as you heard previously, that hadn't been
accomplished. In addition, they were supposed to be on track to
enroll 500,000 by 2013, however they are not on track.
So we think they are lagging behind. However, I compliment
VA on inviting VSOs to Central Office to assist in this process
to include getting the word out to veterans. The American
Legion has also placed it on our Web site, and after hearing
that today it encourages me to go back to my office and the
drawing board and pretty much analyze a few notes and assess/
ascertain what has happened from that point, as far as
progress.
Mr. Michaud. What else are you doing other than putting it
on your Web site? Because you could have some veterans out
there that are not members of the American Legion and might not
think to go there. So what are you doing as an organization to
really encourage veterans to sign up for VA health care?
I appreciate and have always encouraged the VA to do their
part, but I think it is also important for the VSOs to be out
there aggressively educating the public. It is part of your
responsibility. I think when you consider the importance of
trying to provide adequate health care benefits, for us to do
our job to make sure veterans are taken care of, we have to get
veterans enrolled. That is a concern that I have; yes, we are
going to increase funding to reenroll Priority 8 veterans, but
VA hasn't met their goal for the Priority 8 veterans, which I
know all the VSOs think we need to do. If VA hasn't met the
goal, then I think we all have a responsibility to do it.
For example, if you look at what is happening in the
economy today, I have seen a lot of veterans who have never
signed up for the VA because they had health care provided
through their employer. Then they lose their job and they no
longer have health care provided.
So has your organization met with other organizations, such
as labor or other entities to really encourage them to get
their members who are veterans to sign up? It is going to take
a collaborative effort.
Mr. Wilson. Mr. Chairman, I will give you an example. Back
in November the American Legion collaborated with other VSOs
and the Washington Redskins to help veterans. The event was
entitled, ``Time Out for Veterans.'' We collectively informed
veterans of reopening of priority groups in 2009. We also
provided them information to contact us, as well as information
to contact our Web site and the VA's Web site.
We partner with VA as well as other VSOs to place that
assessment on our Web site, along with the means test and a
link that led to VA's Web site.
To reiterate, we have conducted outreach in events such as
``Time Out for Veterans'' at FedEx Field.
Mr. Michaud. Okay, thank you. And PVA?
Mr. Ortner. Yes, sir, I will hit the last part first there
about what we are doing.
Obviously PVA is a smaller organization focusing on the
catastrophically disabled. However, we use a lot of methods to
do the outreach. Again, similar to the other organizations, we
use our magazines. We have both sports magazines as well as our
paraplegic news, which reaches a larger membership than just
PVA. So there is outreach in that.
I think one of the key things that we have as well as some
of the other organizations like DAV is our service officers.
Service officers, the contact that they have with not only
members of the organization, but members of, you know, regular
veterans as well, getting the word out through that does help a
lot.
Then also, of course, we have our chapters throughout the
Nation that provide information primarily again to those
individuals that may be members, but the word gets out to
others as well.
Going back to what the VA is doing, echoing again my
colleagues, I think the VA has done a good job of getting
information out there, but I think it is an issue of who they
are contacting. As an OEF/OIF veteran myself I have had a whole
lot of stuff come to me talking to me as an OIF or an OEF
veteran, but that is everything I have been seeing. I haven't
seen anything else on, you know, just being a regular veteran
or a, you know, a Gulf War veteran or anything like that.
So I think that is probably where VA could improve is just,
you know, maybe cast a wider net. Now whether they are doing
that because they are trying to limit the number coming in,
which is understandable, you know, they have a plan to increase
the numbers, but again, as was mentioned also, you know,
information going out to the women veterans.
So I think it would be possible for the VA to cast a wider
net, but nowadays there seems to be the greatest interest in
OIF and OEF veterans, and I think some of those others may be
left out a bit.
And your comment about the effects of the economy now I
think that makes it even more important for the VA to reach out
to those others to get those individuals that may not be aware
of it due to the health care losses.
Mr. Michaud. Thank you. Mr. Boozman.
Mr. Boozman. Thank you, Mr. Chairman. I really don't have
any questions. We as always appreciate you guys coming over and
offering us good advice and commenting about your concerns. We
really do appreciate your help.
I want to thank you, Mr. Chairman and Mr. Brown for, in
such a timely fashion, getting Dr. Petzel over and his team to
visit with us.
I want to congratulate you on your appointment. I know that
you are going to do a great job and we really do look forward
to working with you, and then all of us together, the
Committee, or VSOs that do such a tremendous job, to continue
to push forward for veterans and providing veterans
opportunities. So thank you very much.
Mr. Michaud. Thank you, Mr. Boozman.
Once again I would like to thank this panel for your
testimony today. I look forward to working with your
organizations to do what we can to make sure that veterans get
the health care that they need and deserve. And I think it is
important for all of us to recognize that it is not just the
VA's responsibility to try to get veterans into the system. I
think it is all of our responsibility to do that.
I am reminded of a round table discussion we had with Judge
Russell from New York who was instrumental in getting the
Veterans Court established. He made very clear when he was
talking to groups that when he asked them how many in the room
were veterans he had so many put their hands up. Then, when he
rephrased the question to ask how many served in the services,
more hands went up. There are veterans out there who do not
feel that they are veterans because they did not serve in World
War II or were not on active duty, and I think it is an
educational process that all of us have to undertake, and
hopefully we will be able to do what we can to get the word out
there to those veterans who should be in the system to
ultimately get them into the system, because it will benefit
all of us in the long run, and it will definitely help the VA
as well.
Once again, I want to thank this panel as well as the
previous panel. I look forward to working with each of you as
we move forward. Thank you.
No other comments. The hearing is adjourned.
[Whereupon, at 2:28 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
The Subcommittee on Health will now come to order. I thank everyone
for attending this hearing. The purpose of today's hearing is to
examine the fiscal year 2011 President's budget request for the
Veterans Health Administration (VHA) of the Department of Veterans
Affairs (VA).
The ``Veterans Health Care Budget Reform and Transparency Act of
2009'' provides for advance appropriations for the VA medical care
accounts and was enacted into law on October 22, 2009. In accordance
with this Act, the President's budget requests fiscal year 2011 and
2012 funding for the VA medical care accounts.
The Administration requests $48.2 million for VA medical care in FY
2011, which includes the medical services, medical support and
compliance, and medical facilities accounts of the VA. When medical
care collections are included, the Administration requests $51.5
billion for VA medical care, which is $4 billion or 8.6 percent above
the 2010 enacted level. In fiscal year 2012, the Administration
requests $54.3 billion for VA medical care, which is about $3 billion
or 5.3 percent above the 2011 request.
The fiscal year 2011 budget request addresses many of the shared
priorities of this Subcommittee, such as rural health, mental health,
and homeless veterans. The President's budget request for the VA is a
robust budget in the tradition of the significant funding increases
that the VA has received in the past several years.
Through today's hearing, we will examine the President's 2011
budget request for VHA, which includes the funding recommendations as
well as policy and legislative proposals for the medical care accounts
of VHA. In addition, we will examine the IT and construction resources
for VHA and will explore whether the budget request for the VA health
care system provides sufficient resources to meet the needs of our
returning servicemembers, including those who deployed as part of the
troop surge to Afghanistan.
Today, we will hear from the VA's Under Secretary for Health, as
well as Paralyzed Veterans of America and Veterans of Foreign Wars who
are the co-authors of The Independent Budget. We will also hear from
the American Legion. I look forward to hearing their testimonies.
Prepared Statement of Hon. Henry E. Brown, Jr.,
Ranking Republican Member, Subcommittee on Health
Thank you, Mr. Chairman, for holding this hearing today and I'm
especially thankful that the weather has finally cooperated enough to
allow us to meet and discuss the Veterans Health Administration's
fiscal year 2011 budget. I think one thing we can all agree on is the
immense pride we feel in the brave men and women who have served our
Nation so honorably in uniform and our commitment to ensuring that they
are adequately cared for when they return home from battle. Proper
funding of VHA is vital to achieving this goal.
This year, the Administration is requesting funding for health care
in the amount of $51.5 billion, an increase of $4 billion from last
year's request. Among the many worthy goals included in this budget are
initiatives to improve mental health care, to better meet the unique
needs of female veterans, to expand health care eligibility to Priority
8 veterans, and to improve access to care for veterans in rural areas.
I look forward to working with my esteemed colleagues in both parties
on these important issues in the coming months.
However, while I support this budget request overall, I do want to
express my disappointment that funding has still not been appropriated
for the ``Charleston Model''--a joint venture between the Ralph H.
Johnson VA Medical Center and the Medical University of South Carolina
to design, construct, and operate a co-located, joint-use medical
facility in Charleston, South Carolina. It has been 5 years since
Congress authorized $36.8 million for this project in the Veterans
Benefits, Health Care, and Informational Technology Act of 2006. If
properly funded, this partnership would not only ensure high-quality
care for veterans in the Charleston area, but could also be used to
improve access and quality of care in areas across the United States.
Such an endeavor is too important for this Committee to overlook and I
strongly encourage we allow this enterprise to go unfunded no longer.
I'd also like to take a brief moment to congratulate Dr. Petzel,
who recently took the oath of office to become the new VA Under
Secretary for Health. Dr. Petzel has been with us as Acting Under
Secretary since last May and before that served veterans as Director of
the Midwest Health Care Network and Chief of Staff for the Minneapolis
VA Medical Center. Dr. Petzel, I'm glad to have you with us officially
and I look forward to working with you.
Once again, thank you, Mr. Chairman and all of our witnesses for
appearing here this afternoon. I look forward to a fruitful discussion
and I yield back the balance of my time.
Prepared Statement of Hon. Robert A. Petzel, M.D.,
Under Secretary for Health, Veterans Health Administration,
U.S. Department of Veterans Affairs
Chairman Michaud, Ranking Member Brown, and distinguished Members
of the Subcommittee. Thank you for this opportunity to present the
President's fiscal year 2011 budget and fiscal year 2012 advance
appropriations request for the Veterans Health Administration. Our
budget provides the resources necessary to continue our aggressive
pursuit of the President's two overarching goals for the Department--to
transform VA into a 21st century organization and to ensure that we
provide the highest quality health care to our veterans.
We will remain focused on producing the outcomes veterans expect
and have earned through their service to our country. To support VA's
efforts, the President's budget provides $125 billion in 2011--almost
$60.3 billion in discretionary resources and nearly $64.7 billion in
mandatory funding. Our discretionary budget request represents an
increase of $4.3 billion, or 7.6 percent, over the 2010 enacted level.
Delivering World-Class Medical Care
The budget provides $51.5 billion for medical care in 2011, an
increase of $4 billion, or 8.5 percent, over the 2010 level. This level
will allow us to continue providing timely, high-quality care to all
enrolled veterans. Our total medical care level is comprised of funding
for medical services ($37.1 billion), medical support and compliance
($5.3 billion), medical facilities ($5.7 billion), and resources from
medical care collections ($3.4 billion). In addition to reducing the
number of homeless veterans and expanding access to mental health care,
our 2011 budget will also achieve numerous other outcomes that improve
veterans' quality of life, including:
Providing extended care and rural health services in
clinically appropriate settings;
Expanding the use of home telehealth;
Enhancing access to health care services by offering
enrollment to more Priority Group 8 veterans and activating new
facilities; and
Meeting the medical needs of women veterans.
During 2011, we expect to treat nearly 6.1 million unique patients,
a 2.9-percent increase over 2010. Among this total are over 439,000
veterans who served in Operation Enduring Freedom and Operation Iraqi
Freedom, an increase of almost 57,000 (or 14.8 percent) above the
number of veterans from these two campaigns that we anticipate will
come to VA for health care in 2010.
In 2011, the budget provides $2.6 billion to meet the health care
needs of veterans who served in Iraq and Afghanistan. This is an
increase of $597 million (or 30.2 percent) over our medical resource
requirements to care for these veterans in 2010. This increase also
reflects the impact of the recent decision to increase troop size in
Afghanistan. The treatment of this newest generation of veterans has
allowed us to focus on, and improve treatment for, PTSD as well as TBI,
including new programs to reach veterans at the earliest stages of
these conditions.
The FY 2011 budget also includes funding for new patients resulting
from the recent decision to add Parkinson's disease, ischemic heart
disease, and B-cell leukemias to the list of presumptive conditions for
veterans with service in Vietnam.
Extended Care and Rural Health
VA's budget for 2011 contains $6.8 billion for long-term care, an
increase of $858.8 million (or 14.4 percent) over the 2010 level. In
addition, $1.5 billion is included for non-institutional long-term
care, an increase of $276 million (or 22.9 percent) over 2010. By
enhancing veterans' access to non-institutional long-term care, VA can
provide extended care services to veterans in a more clinically
appropriate setting, closer to where they live, and in the comfort and
familiar settings of their homes.
VA's 2011 budget also includes $250 million to continue
strengthening access to health care for 3.2 million enrolled veterans
living in rural and highly rural areas through a variety of avenues.
These include new rural health outreach and delivery initiatives and
expanded use of home-based primary care, mental health, and telehealth
services. VA intends to expand use of cutting edge telehealth
technology to broaden access to care while at the same time improve the
quality of our health care services.
Home Telehealth
Our increasing reliance on non-institutional long-term care
includes an investment in 2011 of $163 million in home telehealth.
Taking greater advantage of the latest technological advancements in
health care delivery will allow us to more closely monitor the health
status of veterans and will greatly improve access to care for veterans
in rural and highly rural areas. Telehealth will place specialized
health care professionals in direct contact with patients using modern
IT tools. VA's home telehealth program cares for 35,000 patients and is
the largest of its kind in the world. A recent study found patients
enrolled in home telehealth programs experienced a 25-percent reduction
in the average number of days hospitalized and a 19-percent reduction
in hospitalizations. Telehealth and telemedicine improve health care by
increasing access, eliminating travel, reducing costs, and producing
better patient outcomes.
Expanding Access to Health Care
In 2009, VA opened enrollment to Priority 8 veterans whose incomes
exceed last year's geographic and VA means test thresholds by no more
than 10 percent. Our most recent estimate is that 193,000 more veterans
will enroll for care by the end of 2010 due to this policy change.
In 2011, VA will further expand health care eligibility for
Priority 8 veterans to those whose incomes exceed the geographic and VA
means test thresholds by no more than 15 percent compared to the levels
in effect prior to expanding enrollment in 2009. This additional
expansion of eligibility for care will result in an estimated 99,000
more enrollees in 2011 alone, bringing the total number of new
enrollees from 2009 to the end of 2011 to 292,000.
Meeting the Medical Needs of Women Veterans
The 2011 budget provides $217.6 million to meet the gender-specific
health care needs of women veterans, an increase of $18.6 million (or
9.4 percent) over the 2010 level. The delivery of enhanced primary care
for women veterans remains one of the Department's top priorities. The
number of women veterans is growing rapidly and women are increasingly
reliant upon VA for their health care.
Our investment in health care for women veterans will lead to
higher quality of care, increased coordination of care, enhanced
privacy and dignity, and a greater sense of security among our women
patients. We will accomplish this through expanding health care
services provided in our Vet Centers, increasing training for our
health care providers to advance their knowledge and understanding of
women's health issues, and implementing a peer call center and social
networking site for women combat veterans. This call center will be
open 24 hours a day, 7 days a week.
VA's 2011 health care budget also focuses on two concerns that are
of critical importance to our veterans--easier access to benefits and
services, and ending the downward spiral that results in veterans'
homelessness.
This budget provides the resources required to enhance access in
our health care system. We will expand access to health care through
the activations of new or improved facilities, by expanding health care
eligibility to more veterans, and by making greater investments in
telehealth. We are also requesting a substantial investment for our
homelessness programs as part of our plan to ultimately eliminate
veterans' homelessness through an aggressive approach that includes
housing, education, jobs, and health care.
VA will be successful in resolving these concerns by maintaining a
clear focus on developing innovative business processes and delivery
systems that will not only serve veterans and their families for many
years to come, but will also dramatically improve the efficiency of our
operations by better controlling long-term costs. By making appropriate
investments today, we can ensure higher value and better outcomes for
our veterans. The 2011 budget also supports many key investments in
VA's six high-priority performance goals. I will address several of
these goals related to health care now.
Eliminating Veteran Homelessness
Our Nation's veterans experience higher than average rates of
homelessness, depression, substance abuse, and suicides; many also
suffer from joblessness. On any given night, there are about 131,000
veterans who live on the streets, representing every war and
generation, including those who served in Iraq and Afghanistan. VA's
major homeless-specific programs constitute the largest integrated
network of homeless treatment and assistance services in the country.
These programs provide a continuum of care for homeless veterans,
providing treatment, rehabilitation, and supportive services that
assist homeless veterans in addressing health, mental health and
psychosocial issues. VA also offers a full range of support necessary
to end the cycle of homelessness by providing education, jobs, and
health care, in addition to safe housing. We will increase the number
and variety of housing options available to homeless veterans and those
at risk of homelessness with permanent, transitional, contracted,
community-operated, HUD-VASH provided, and VA-operated housing.
Homelessness is primarily a health care issue, heavily burdened
with depression and substance abuse. VA's budget includes $4.2 billion
in 2011 to prevent and reduce homelessness among veterans--over $3.4
billion for core medical services and $799 million for specific
homeless programs and expanded medical programs. Our budget includes an
additional investment of $294 million in programs and new initiatives
to reduce the cycle of homelessness, which is almost 55 percent higher
than the resources provided for homelessness programs in 2010.
VA's health care costs for homeless veterans can drop in the future
as the Department emphasizes education, jobs, and prevention and
treatment programs that can result in greater residential stability,
gainful employment, and improved health status.
Improving Mental Health Care
The 2011 budget continues the Department's keen focus on improving
the quality, access, and value of mental health care provided to
veterans. VA's budget provides over $5.2 billion for mental health, an
increase of $410 million, or 8.5 percent, over the 2010 enacted level.
We will expand inpatient, residential, and outpatient mental health
programs with an emphasis on integrating mental health services with
primary and specialty care.
Post traumatic stress disorder (PTSD) is the mental health
condition most commonly associated with combat, and treating veterans
who suffer from this debilitating disorder is central to VA's mission.
Screening for PTSD is the first and most essential step. It is crucial
that VA be proactive in identifying PTSD and intervening early in order
to prevent chronic problems that could lead to more complex disorders
and functional problems.
VA will also expand its screening program for other mental health
conditions, most notably traumatic brain injury (TBI), depression, and
substance use disorders. We will enhance our suicide prevention
advertising campaign to raise awareness among veterans and their
families of the services available to them.
More than one-fifth of the veterans seen last year had a mental
health diagnosis. In order to address this challenge, VA has
significantly invested in our mental health workforce, hiring more than
6,000 new workers since 2005.
In October 2009, VA and DoD held a mental health summit with mental
health experts from both Departments, and representatives from Congress
and more than 57 non-government organizations. We convened the summit
to discuss an innovative, wide-ranging public health model for
enhancing mental health for returning servicemembers, veterans, and
their families. VA will use the results to devise new innovative
strategies for improving the health and quality of life for veterans
suffering from mental health problems.
Advance Appropriations for Medical Care in 2012
VA is requesting advance appropriations in 2012 of $50.6 billion
for the three medical care appropriations to support the health care
needs of 6.2 million patients. The total is comprised of $39.6 billion
for Medical Services, $5.5 billion for Medical Support and Compliance,
and $5.4 billion for Medical Facilities. In addition, $3.7 billion is
estimated in medical care collections, resulting in a total resource
level of $54.3 billion. It does not include additional resources for
any new initiatives that would begin in 2012.
Our 2012 advance appropriations request is based largely on our
actuarial model using 2008 data as the base year. The request continues
funding for programs that we will continue in 2012 but which are not
accounted for in the actuarial model. These initiatives address
homelessness and expanded access to non-institutional long-term care
and rural health care services through telehealth. In addition, the
2012 advance appropriations request includes resources for several
programs not captured by the actuarial model, including long-term care,
the Civilian Health and Medical Program of the Department of Veterans
Affairs, Vet Centers, and the State home per diem program. Overall, the
2012 requested level, based on the information available at this point
in time, is sufficient to enable us to provide timely and high-quality
care for the estimated patient population. We will continue to monitor
cost and workload data throughout the year and, if needed, we will
revise our request during the normal 2012 budget cycle.
After a cumulative increase of 26.4 percent in the medical care
budget since 2009, we will be working to reduce the rate of increase in
the cost of the provision of health care by focusing on areas such as
better leveraging acquisitions and contracting, enhancing use of
referral agreements, strengthening DoD/VA joint ventures, and expanding
applications of medical technology (e.g. telehome health).
Investments in Medical Research
VA's budget request for 2011 includes $590 million for medical and
prosthetic research, an increase of $9 million over the 2010 level.
These research funds will help VA sustain its long track record of
success in conducting research projects that lead to clinically useful
interventions that improve the health and quality of life for veterans
as well as the general population.
This budget contains funds to continue our aggressive research
program aimed at improving the lives of veterans returning from service
in Iraq and Afghanistan. This focuses on prevention, treatment, and
rehabilitation research, including TBI and polytrauma, burn injury
research, pain research, and post-deployment mental health research.
Capital Infrastructure
VA must provide timely, high-quality health care in medical
infrastructure which is, on average, over 60 years old. In the 2011
budget, we are requesting $1.6 billion to invest in our major and minor
construction programs to accomplish projects that are crucial to right
sizing and modernizing VA's health care infrastructure, providing
greater access to benefits and services for more veterans, closer to
where they live, and adequately addressing patient safety and other
critical facility deficiencies.
Major Construction
The 2011 budget request for VA major construction is $1.151
billion. This includes funding for five medical facility projects in
New Orleans, Louisiana; Denver, Colorado; Palo Alto and Alameda,
California; and Omaha, Nebraska.
VA's major construction request also includes $24 million for
resident engineers that support medical facility projects. This
represents a new source of funding for the resident engineer program,
which was previously funded under General Operating Expenses.
Minor Construction
The $467.7 million request for 2011 for minor construction is an
integral component of our overall capital program. In support of the
medical care and medical research programs, minor construction funds
permit VA to realign critical services; make seismic corrections;
improve patient safety; enhance access to health care; increase
capacity for dental care; enhance patient privacy; improve treatment of
special emphasis programs; and expand our research capability. Further,
minor construction resources will be used to comply with energy
efficiency and sustainability design requirements.
Summary
Our job at VA is to serve veterans by increasing their access to VA
benefits and services, to provide them the highest quality of health
care available, and to control costs to the best of our ability. Doing
so will make VA a model of good governance. The resources provided in
the 2011 President's budget will permit us to fulfill our obligation to
those who have bravely served our country.
The 298,000 employees of VA are committed to providing the quality
of service needed to serve our veterans and their families. They are
our most valuable resource. VA is fortunate to have public servants
that are not only creative thinkers, but also able to put good ideas
into practice. With such a workforce, and the continuing support of
Congress, I am confident we can achieve our shared goal of accessible,
high-quality and timely care and benefits for veterans.
Prepared Statement of Blake C. Ortner,
Senior Associate Legislative Director, Paralyzed Veterans of America,
on Behalf of The Independent Budget
Chairman Michaud, Ranking Member Brown, and Members of the
Subcommittee, Paralyzed Veterans of America (PVA) is pleased to present
our views on the Department of Veterans Affairs (VA) Veterans Health
Administration's (VHA) fiscal year 2011 budget, in particular as it
relates to construction. As one of the four co-authors of The
Independent Budget (IB), much of our testimony will directly correspond
to testimony last week on the views of The Independent Budget regarding
the funding requirements for the VA health care system for FY 2011.
When looking back on 2009, it is fair to say that the 111th
Congress took a historic step toward providing sufficient, timely, and
predictable funding, and yet it still failed to complete its
appropriations work prior to the start of the new fiscal year on
October 1. The actions of Congress last year generally reflected a
commitment to maintain a viable VA health care system. More important,
Congress showed real interest in reforming the budget process to ensure
that the VA knows exactly how much funding it will receive in advance
of the start of the new fiscal year. This is particularly critical to
VHA. With the President's signature on P.L. 111-81, the ``Veterans
Health Care Budget Reform and Transparency Act,'' and the enactment of
advance appropriations, the VA can properly plan to meet the health
care needs of the men and women who have served this Nation in uniform.
In February 2009, the President released a preliminary budget
submission for the Department of Veterans Affairs for FY 2010. This
submission only projected funding levels for the overall VA budget. The
Administration recommended an overall funding authority of $55.9
billion for the VA, approximately $5.8 billion above the FY 2009
appropriated level and nearly $1.3 billion more than The Independent
Budget had recommended.
In May, the Administration released its detailed budget blueprint
that included approximately $47.4 billion for medical care programs, an
increase of $4.4 billion over the FY 2009 appropriated level and
approximately $800 million more than the recommendations of The
Independent Budget. The budget also included $580 million in funding
for Medical and Prosthetic Research, an increase of $70 million over
the FY 2009 appropriated level. By the end of the year, Congress
enacted P.L. 111-117, the ``Consolidated Appropriations Act for FY
2010,'' that provided funding for the VA to virtually match the
recommendations of the Administration. While the importance of these
historic funding levels coupled with the enactment of advance
appropriations legislation cannot be overstated, it is important for
Congress and the Administration to continue this commitment to the men
and women who have served and sacrificed for this country.
Funding for FY 2011
Included in P.L. 111-117 was advance appropriations for FY 2011.
Congress provided approximately $48.2 billion in discretionary funding
for VA medical care. When combined with the $3.3 billion Administration
projection for medical care collections in 2010, the total available
operating budget provided by the appropriations bill is approximately
$51.5 billion. Accordingly for FY 2011, The Independent Budget
recommends approximately $52.0 billion for total medical care, an
increase of $4.5 billion over the FY 2010 operating budget level
established by P.L. 111-117. We believe that this estimation validates
the advance projections that the Administration developed last year and
has carried forward into this year. Furthermore, we remain confident
that the Administration is headed in a positive direction that will
ultimately benefit veterans who rely on the VA health care system to
receive their care.
However, PVA continues to be seriously concerned about reports of
VA's continued inappropriate billing of service connected veterans for
service connected injuries as well as non-service connected veterans
being billed multiple times for the same treatment. Inappropriate
charges for VA medical services places unnecessary financial stress on
individual veterans and their families. These inaccurate charges are
not easily remedied and their occurrence places the burden for
correction directly on the veteran, their families or caregivers. PVA
believes that many veterans are not aware of these mistakes and simply
submit full payment to VA when a billing statement arrives at their
home. If Congress and the Administration are going to continue to rely
on massive collections estimates and dollars actually collected to
support the VA health care budget, then serious examination of how the
VA is achieving these numbers is necessary.
The medical care appropriation includes three separate accounts--
Medical Services, Medical Support and Compliance, and Medical
Facilities--that comprise the total VA health care funding level. For
FY 2011, The Independent Budget recommends approximately $40.9 billion
for Medical Services. Our Medical Services recommendation includes the
following recommendations:
------------------------------------------------------------------------
Current Services Estimate $38,988,080,000
------------------------------------------------------------------------
Increase in Patient Workload $ 1,302,874,000
------------------------------------------------------------------------
Policy Initiatives $ 650,000,000
------------------------------------------------------------------------
Total FY 2011 Medical Services $40,940,954,000
------------------------------------------------------------------------
Our growth in patient workload is based on a projected increase of
approximately 117,000 new unique patients--Priority Group 1-8 veterans
and covered non-veterans. We estimate the cost of these new unique
patients to be approximately $926 million. The increase in patient
workload also includes a projected increase of 75,000 new Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans at a
cost of approximately $252 million.
Finally, our increase in workload includes the projected enrollment
of new Priority Group 8 veterans who will use the VA health care system
as a result of the Administration's plan to incrementally increase the
enrollment of Priority Group 8 veterans by 500,000 enrollments by FY
2013. We estimate that as a result of this policy decision, the number
of new Priority Group 8 veterans who will enroll in the VA will
increase by 125,000 in each of the next 4 years. Based on the Priority
Group 8 empirical utilization rate of 25 percent, we estimate that
approximately 31,250 of these new enrollees will become users of the
system. This translates to a cost of approximately $125 million.
As we have emphasized in the past, the VA must have a clear plan
for incrementally increasing this enrollment. Otherwise, the VA risks
being overwhelmed by significant new workload. The Independent Budget
is committed to working with the VA and Congress to implement a
workable solution to allow all eligible Priority Group 8 veterans who
desire to do so to begin enrolling in the system.
Our policy initiatives have been streamlined to include immediately
actionable items with direct funding needs. Specifically, we have
limited our policy initiatives recommendations to restoring long-term
care capacity (for which a reasonable cost estimate can be determined
based on the actual capacity shortfall of the VA) and centralized
prosthetics funding (based on actual expenditures and projections from
the VA's prosthetics service). In order to restore the VA's long-term
care average daily census (ADC) to the level mandated by P.L. 106-117,
the ``Veterans Millennium Health Care Act,'' we recommend $375 million.
Finally, to meet the increase in demand for prosthetics, the IB
recommends an additional $275 million. This increase in prosthetics
funding reflects the significant increase in expenditures from FY 2009
to FY 2010 and the expected continued growth in expenditures for FY
2011. The funding for prosthetics is particularly important because it
reflects current services and represents a demonstrated need now;
whereas, our funding recommendations for long-term care reflect our
desire to see this capacity expanded beyond the current services level.
For Medical Support and Compliance, The Independent Budget
recommends approximately $5.3 billion. Finally, for Medical Facilities,
The Independent Budget recommends approximately $5.7 billion. Our
recommendation once again includes an additional $250 million for
nonrecurring maintenance (NRM) provided under the Medical Facilities
account. This would bring our overall NRM recommendation to
approximately $1.26 billion for FY 2011. While we appreciate the
significant increases in the NRM baseline over the last couple of
years, total NRM funding still lags behind the recommended 2 to 4
percent of plant replacement value. Based on that logic, the VA should
actually be receiving at least $1.7 billion annually for NRM.
For Medical and Prosthetic Research, The Independent Budget
recommends $700 million. This represents a $119 million increase over
the FY 2010 appropriated level, and approximately $110 million above
the Administration's request. We are particularly pleased that Congress
has recognized the critical need for funding in the Medical and
Prosthetic Research account in the last couple of years. Research is a
vital part of veterans' health care, and an essential mission for our
national health care system. We are extremely disappointed in the
Administration's decision to virtually flat line the research budget.
VA research has been grossly underfunded in contrast to the growth rate
of other Federal research initiatives. At a time of war, the government
should be investing more, not less, in veterans' biomedical research
programs.
As explained in The Independent Budget, there is a significant
backlog of major and minor construction projects awaiting action by the
VA and funding from Congress. We have been disappointed that there has
been inadequate followthrough on issues identified by the Capital Asset
Realignment for Enhanced Services (CARES) process. In fact, we believe
it may be time to revisit the CARES process altogether. For FY 2011,
The Independent Budget recommends approximately $1.295 billion for
Major Construction and $785 million for Minor Construction. The Major
Construction recommendation includes approximately $100 million for
research infrastructure and the Minor Construction recommendation
includes approximately $200 million for research facility construction
needs.
We note that the budget request reduces funding for Major
Construction and slashes funding for Minor Construction. Despite
additional funding that has been provided in recent years to address
the construction backlog and maintenance needs facing VA, a great deal
remains to be done. We cannot comprehend what policy decisions could
justify such a steep decrease in funding for Minor Construction.
Specifically, there are two areas where PVA is significantly concerned.
VA Research Infrastructure Funding Shortfalls
In recent years, funding for the VA maintenance and construction
appropriations has failed to provide the resources needed by VA to
maintain, upgrade, and replace its aging research facilities.
Consequently many VA facilities have run out of adequate research
space. Also, ventilation, electrical supply, roofs and plumbing
deficiencies appear frequently on lists of urgently needed upgrades
along with significant space reconfiguration. In the 2003 Draft
National Capital Asset Realignment for Enhanced Services (CARES) Plan,
VA listed $468.6 million designated for new laboratory construction,
renovation of existing research space, and build-out costs for leased
research facilities. However, these capital improvement projects were
omitted from the Secretary's final report on capital planning
consequential to the CARES effort.
In House Report 109-95 accompanying the ``FY 2006 VA Appropriations
Act,'' the House Appropriations Committee expressed concern that
``equipment and facilities to support the research program may be
lacking and that some mechanism is necessary to ensure the Department's
research facilities remain competitive.'' In the same report, the
Committee directed VA to conduct ``a comprehensive review of its
research facilities and report to the Congress on the deficiencies
found and suggestions for correction of the identified deficiencies.''
VA piloted the evaluation instrument and methodology in FY 2006 at
three sites--Central Arkansas Veterans Health System, Little Rock; VAMC
Salt Lake City; and VA New York Harbor Health Care System (Manhattan
and Brooklyn campuses). All three sites scored within the ``poor''
range (D on an A to F scale) with a total correction cost of over $26
million.
In FY 2008, the VA Office of Research and Development (ORD)
followed up with an as yet incomplete examination of all VA research
infrastructure, for physical condition, capacity for current research,
as well as needed program growth and sustainability of VA space to
conduct research. According to an October 26, 2009, ORD report to the
VA National Research Advisory Committee, surveys to date support the
pilot findings: ``There is a clear need for research infrastructure
improvements throughout the system, including many that impact on life
safety.''
By the end of FY 2009, a total of 53 sites within 47 research
programs will have been surveyed. Approximately 20 sites remain to be
assessed in FY 2010. To date, the combined total estimated cost for
improvements exceeds $570 million. About 44 percent of the estimated
correction costs constitute ``priority 1'' deficiencies--those with an
immediate need for correction to return components to normal service or
operation; stop accelerated deterioration; replace items that are at or
beyond their useful life; and correct life-safety hazards. Furthermore,
only six buildings (of 38 buildings surveyed) at five sites were rated
above the ``poor'' range. Three of the seven buildings rated above
``poor'' were structures housing the main hospital. Five buildings that
rated ``poor'' were main hospitals housing laboratories.
A significant cause of the VA research infrastructure's neglect is
that there is no direct funding line, nor any budgetary request made,
for VA research facilities. Nor does the VA Medical and Prosthetic
Research appropriation contain funding for construction, renovation, or
maintenance of VA research facilities. VA researchers must rely on
local facility management to repair, upgrade, and replace research
facilities and capital equipment associated with VA's research
laboratories. As a result, VA research competes with medical
facilities' direct patient care infrastructure needs (such as elevator
replacement, heating and air conditioning upgrades, operating room
equipment and space upgrades, outpatient clinic space construction or
renovations, and capital equipment upgrades and replacements such as X-
ray machines and MRIs) for funds provided under either the VA Medical
Facility appropriation account or the VA Major and Minor Construction
appropriations accounts. VA investigators' success in obtaining funding
from non-VA sources exacerbates VA's research infrastructure problems
because non-VA grantors typically provide no funding to cover the costs
to VA medical centers of housing extramurally funded projects.
We anticipate VA's ongoing research facilities assessment will
identify a need for research infrastructure funding significantly
greater than the 2003 Draft National CARES report. As VA moves forward
with its research facilities assessment, we urge Congress to require VA
to submit the resulting report to the House and Senate Committees on
Appropriations and Veterans' Affairs by June 1, 2010. Surfacing this
key report will ensure that the Administration and Congress are well
informed of the deteriorating condition of VA's research infrastructure
and of its funding needs so these may be fully considered in the budget
formulation process.
In accordance with the recommendations of The Independent Budget,
to address the VA research infrastructure's defective funding
mechanism, PVA recommends the Administration and Congress establish a
new appropriations account to independently define and separate VA
research infrastructure funding needs from capital and maintenance
funding for direct VA medical care. The account should be sub-divided
for major and minor construction, and for maintenance and repair needs.
This revision in appropriations accounts will empower VA to address
research facility needs without interfering with direct health care
infrastructure. We believe correction of the known infrastructure
deficiencies should not be further delayed and consistent with the
recommendations of The Independent Budget, we recommend an
appropriation in FY 2011 of $300 million dedicated exclusively to
renovating existing research facilities to address the current and
well-documented shortfalls in research infrastructure.
Maintain Critical VA Health Infrastructure
Over the past year, VA has begun to discuss its desire to address
its health infrastructure needs in a new way. VA has acknowledged its
challenges with aging infrastructure; changing health care delivery
needs, including reduced demand for inpatient beds and increasing
demand for outpatient care and medical specialty services; limited
funding available for construction of new facilities, that are growing
prohibitively expensive; frequent delays in constructing and renovating
space needed to increase access, and particularly the timeliness of
construction projects. VA has noted, and we concur, that a decade or
more is required from the time VA initially proposes a major medical
facility construction project, until the doors actually open for
veterans to receive care in that facility.
Given these significant challenges, VA has developed a new model
for health care delivery, the Health Care Center Facility (HCCF)
leasing program. Under the HCCF proposal, in lieu of the traditional
approach to major medical facility construction, VA would obtain by
long-term lease, a number of large outpatient clinics built to VA
specifications. These large clinics would provide a broad range of
outpatient services, including primary and specialty care as well as
outpatient mental health services and ambulatory surgery. Inpatient
needs at such sites would probably be managed through contracts with
affiliates or local private medical centers, although today we are
unclear on how such arrangements would be managed.
VA noted that, in addition to its new HCCF facilities, it would
maintain its VA medical centers (VAMCs), larger independent outpatient
clinics, community based outpatient clinics (CBOCs) and rural outreach
clinics. VA has argued that adopting the HCCF model would allow VA to
quickly establish new facilities that would provide 95 percent of the
care and services veterans need in their catchment areas, specifically
primary care, and a variety of specialty services, mental health,
diagnostic testing and same-day ambulatory surgery.
We concur with VA that the HCCF model seems to offer a number of
benefits in addressing its capital infrastructure problems including
more modern facilities that meet current life-safety codes; better
geographic placements; increased patient safety; reductions in
veterans' travel costs and increased convenience; flexibility to
respond to changes in patient loads and technologies; potential savings
in operating costs and in facility maintenance; and, reduced overhead
in maintaining outdated medical centers.
While it offers some obvious advantages, the HCCF model could face
significant challenges. PVA is particularly concerned about the overall
impact on the future of VA's system of care, including the potential
unintended consequences on continuity of high-quality care; maintenance
of its specialized medical programs for spinal cord injury, blindness,
amputations and other health challenges of seriously disabled veterans;
delivery of comprehensive services; its recognized biomedical research
and development programs; and the impact on VA's renowned graduate
medical education and health professions training programs, in
conjunction with longstanding affiliations with nearly every health
professions university in the Nation.
Moreover, we believe the HCCF model could well challenge VA's
ability to provide alternatives to maintaining directly its existing
130 nursing home care units, homelessness programs, domiciliaries,
compensated work therapy programs, hospice and respite, adult day
health care units, the Health Services Research and Development
Program. Additionally, the unique nature of highly specialized services
could be compromised including 24 spinal cord injury centers, 10 blind
rehabilitation centers, a variety of unique ``centers of excellence''
(in geriatrics, gerontology, mental illness, Parkinson's, and multiple
sclerosis), and critical care programs for veterans with serious and
chronic mental illnesses.
In general, the HCCF proposal could be a positive development, with
good potential. Leasing has the advantage of avoiding long and costly
in-house construction delays and can be adaptable, especially when
compared to costs for renovating existing VA major medical facilities.
Leasing options have been particularly valuable for VA as evidenced by
the success of the leased space arrangements for many VA community
based outpatient clinics and Vet Centers. However, VA says it will
contract for these essential inpatient services with VA affiliates or
community hospitals if needed. First and foremost, VA must provide
assurances that this approach will not negatively impact safety,
quality and continuity of care, and permanently privatize many services
we believe VA should continue to provide. We have testified on this
topic and have expressed objections in the Contract Care Coordination
and Community Based Outpatient Clinics sections of The Independent
Budget.
We agree with VA's assertion that it needs a balanced capital
assets program, of both owned and leased buildings, to ensure demands
are met under current projections. Likewise, we agree with VA that the
HCCF concept could provide modern health care facilities relatively
quickly that might not otherwise be available due to the predictable
constraints of VA's major construction program. On the other hand, if
VA plans to replace the majority or even a large fraction of all VAMCs
with HCCFs, such a radical shift would pose a number of concerns for
us. But we see this challenge as only a small part of the overall
picture related to VA health infrastructure needs in the 21st century.
The emerging HCCF plan does not address the fate of VA's 153 medical
centers located throughout the Nation that are on average 55 years of
age or older. It does not address long-term care needs of the aging
veteran population, inpatient treatment of the chronically and
seriously mentally ill, the unresolved rural health access issues, or
the lingering questions on improving VA's research infrastructure. The
major question is what will VA's 21st century health infrastructure
look like and how it will be managed and sustained? Fully addressing
these and related questions is extremely important and will impact
generations of sick and disabled veterans.
Congress and the Administration must work together to secure VA's
future to design a VA of the 21st century. It will take the joint
cooperation of Congress, veterans' advocates, and the Administration to
support this reform, while setting aside resistance to change, even
dramatic change, when change is demanded and supported by valid data.
Accordingly, we urge the Administration and Congress to live up to the
President's words by making a steady, stable investment in VA's capital
infrastructure to bring the system up to match the 21st century needs
of veterans.
Finally, one of our community's frustrations with respect to VA's
infrastructure plans is lack of consistent and periodic updates,
specific information about project plans, and even elementary
communications. We ask VA to improve the quality and quantity of
communication with the VSOs, enrolled veterans, concerned labor
organizations and VA's own employees, affiliates and other
stakeholders, as the VA capital and strategic planning process moves
forward. We believe that all of these groups must be made to understand
VA's strategic plan and how it may affect them, positively and
negatively. Talking openly and discussing potential changes will help
resolve the understandable angst about these complex and important
questions of VA health care infrastructure. While we agree that VA is
not the sum of its buildings, and that a veteran patient's welfare must
remain at the center of VA's concern, VA must be able to maintain an
adequate infrastructure around which to build and sustain ``the best
care anywhere.'' If VA keeps faith with these principles, we are
prepared to aid VA in accomplishing this important goal.
This concludes my testimony. I will be happy to answer any
questions you may have.
Prepared Statement of Eric A. Hilleman, Director,
National Legislative Service, Veterans of Foreign Wars of the United
States,
on Behalf of The Independent Budget
MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE:
On behalf of the 2.1 million men and women of the Veterans of
Foreign Wars of the U.S. (VFW) and our Auxiliaries, I would like to
thank you for the opportunity to testify today. The VFW works alongside
the other members of The Independent Budget (IB)--AMVETS, Disabled
American Veterans and Paralyzed Veterans of America--to produce a set
of policy and budget recommendations that reflect what we believe would
meet the needs of America's veterans. The VFW is responsible for the
construction portion of the IB, so I will limit my remarks to that
portion of the budget.
VA's infrastructure--particularly within its health care system--is
at a crossroads. The system is facing many challenges, including the
average age of buildings (60 years) and significant funding needs for
routine maintenance, upgrades, modernization and construction. VA is
beginning a patient-centered reformation and transformation of the way
it delivers care and new ways of managing its infrastructure plan based
on needs of sick and disabled veterans in the 21st century. Regardless
of what the VA health care system of the future looks like, our focus
must remain on a lasting and accessible VA health care system that is
dedicated to their unique needs and one that can provide high-quality,
timely care when and where they need it.
VA manages a wide portfolio of capital assets throughout the
Nation. According to its latest Capital Asset Plan, VA is responsible
for 5,500 buildings and almost 34,000 acres of land. It is a vast
network of facilities that requires significant time and attention from
VA's capital asset managers.
CARES--VA's data-driven assessment of their current and future
construction needs--gave VA a long-term roadmap and has helped guide
its capital planning process over the past few fiscal years. CARES
showed a large number of significant construction priorities that would
be necessary for VA to fulfill its obligation to this Nation's veterans
and over the last several fiscal years, the Administration and Congress
have made significant inroads in funding these priorities. Since FY
2004, $4.9 billion has been allocated for these projects. Of these
CARES-identified projects, VA has completed 5 and another 27 are
currently under construction. It has been a huge, but necessary
undertaking and VA has made slow, but steady progress on these critical
projects.
The challenge for VA in the post-CARES era is that there are still
numerous projects that need to be carried out, and the current backlog
of partially funded projects that CARES has identified is large, too.
This means that VA is going to continue to require significant
appropriations for the major and minor construction accounts to live up
to the promise of CARES. VA's most recent Asset Management Plan
provides an update of the state of CARES projects--including those only
in the planning or acquisition process. Table 4-5: (page 7.4-49) shows
a need of future appropriations to complete these projects of $3.25
billion.
------------------------------------------------------------------------
Future Funding Needed ($ in
Project Thousands)
------------------------------------------------------------------------
Denver $ 492,700
------------------------------------------------------------------------
San Juan $ 122,920
------------------------------------------------------------------------
New Orleans $ 370,000
------------------------------------------------------------------------
St. Louis $ 364,700
------------------------------------------------------------------------
Palo Alto $ 478,023
------------------------------------------------------------------------
Bay Pines $ 80,170
------------------------------------------------------------------------
Seattle $ 38,700
------------------------------------------------------------------------
Seattle $ 193,830
------------------------------------------------------------------------
Dallas $ 80,100
------------------------------------------------------------------------
* Louisville $1,100,000
------------------------------------------------------------------------
TOTAL $3,246,143
------------------------------------------------------------------------
This amount represents just the backlog of current construction
projects. It does reflect the Administration's FY 2011 proposed
appropriation toward Denver, New Orleans, and Palo Alto.
* Louisville's cost estimate is found in table 5-6, on page 7.5-93.
Meanwhile, VA continues to identify and re-prioritize potential
major construction projects. These priorities, which are assessed using
the rigorous methodology that guided the CARES decisions, are released
in the Department's annual Five Year Capital Asset Plan, which is
included in the Department's budget submission. The most recent one was
included in Volume IV and is available on VA's Web site: http://
www4.va.gov / budget / docs / summary / Fy2011 _ Volume _ 4-
Construction _ and _ 5_ Year_Cap_Plan.pdf.
Table 4-5 shows a long list of partially funded major construction
projects. These 82 ongoing projects demonstrate the continued need for
VA to upgrade and repair its aging infrastructure, and that continuous
funding is necessary for not just the backlog of projects, but to keep
VA viable for today's and future veterans.
In a November 17, 2008 letter to the Senate Veterans Affairs
Committee, Secretary Peake said that ``the Department estimates that
the total funding requirement for major medical facility projects over
the next 5 years would be in excess of $6.5 billion.''
It is clear that VA needs a significant infusion of cash for its
construction priorities. VA's own words and studies show this.
------------------------------------------------------------------------
Major Construction Account Recommendations
-------------------------------------------------------------------------
Recommendation ($ in
Category Thousands)
------------------------------------------------------------------------
VHA Facility Construction $1,000,000
------------------------------------------------------------------------
NCA Construction $ 60,000
------------------------------------------------------------------------
Advance Planning $ 40,000
------------------------------------------------------------------------
Master Planning $ 15,000
------------------------------------------------------------------------
Historic Preservation $ 20,000
------------------------------------------------------------------------
Medical Research Infrastructure $ 100,000
------------------------------------------------------------------------
Miscellaneous Accounts $ 58,000
------------------------------------------------------------------------
TOTAL $1,295,000
------------------------------------------------------------------------
VHA Facility Construction--this amount would allow VA to
continue digging into the $3.25 billion backlog of partially funded
construction projects. Depending on the stages and ability to complete
portions of the projects, any additional money could be used to fund
new projects identified by VA as part of its prioritization methodology
in the Five-Year Capital Plan.
NCA Construction's Five-Year Capital Plan details
numerous potential major construction projects for the National
Cemetery Association throughout the country. This level of funding
would allow VA to begin construction on at least three of its scored
priority projects.
Advance Planning--helps develop the scope of the major
construction projects as well as identifying proper requirements for
their construction. It allows VA to conduct necessary studies and
research similar to planning processes in the private sector.
Master Planning--a description of our request follows
later in the text.
Historic Preservation--a description of our request
follows later in the text.
Miscellaneous Accounts--these include the individual line
items for accounts such as asbestos abatement, the judgment fund, and
hazardous waste disposal. Our recommendation is based upon the historic
level for each of these accounts.
------------------------------------------------------------------------
Minor Construction Account Recommendations
-------------------------------------------------------------------------
Funding ($ in
Category Thousands)
------------------------------------------------------------------------
Veterans Health Administration $450,000
------------------------------------------------------------------------
Medical Research Infrastructure $200,000
------------------------------------------------------------------------
National Cemetery Administration $100,000
------------------------------------------------------------------------
Veterans Benefits Administration $ 20,000
------------------------------------------------------------------------
Staff Offices $ 15,000
------------------------------------------------------------------------
TOTAL $785,000
------------------------------------------------------------------------
Veterans Health Administration--Page 7.8-138 of VA's
Capital Plan reveals hundreds of already identified minor construction
projects. These projects update and modernize VA's aging physical
plant, ensuring the health and safety of veterans and VA employees.
Additionally, a great number of minor construction projects address
FCA-identified maintenance deficiencies; the backlog of 216 projects in
FY 2010 with over $1 billion that has yet to be funded.
Medical Research Infrastructure--a description of our
request follows later in the text.
National Cemetery Administration of the Capital Plan
identifies numerous minor construction projects throughout the country
including the construction of several columbaria, installation of
crypts and landscaping and maintenance improvements. Some of these
projects could be combined with VA's new NCA nonrecurring maintenance
efforts.
Veterans Benefits Administration--Page 7.6-106 of the
Capital Plan lists several minor construction projects in addition to
the leasing requirements VBA needs.
Staff Offices--Page 7.8-134 lists numerous potential
minor construction projects related to staff offices.
Increase Spending on Nonrecurring Maintenance
The deterioration of many VA properties requires increased spending on
nonrecurring maintenance
For years, the Independent Budget Veteran Service Organizations
(IBVSOs) have highlighted the need for increased funding for the
nonrecurring maintenance (NRM) account. NRM consists of small projects
that are essential to the proper maintenance and preservation of the
lifespan of VA's facilities. NRM projects are one-time repairs such as
maintenance to roofs, repair and replacement of windows, and flooring
or minor upgrades to the mechanical or electrical systems. They are a
necessary component of the care and stewardship of a facility.
These projects are so essential because if left unrepaired, they
can really take their toll on a facility, leading to more costly
repairs in the future, and the potential of a need for a minor
construction project. Beyond the fiscal aspects, facilities that fall
into disrepair can create access difficulties and impair patient and
staff health and safety. If things do develop into a larger
construction projection because early repairs were not done, it creates
an even larger inconvenience for veterans and staff.
The industry standard for medical facilities is for managers to
spend from 2 percent-4 percent of plant replacement value (PRV) on
upkeep and maintenance. The 1998 PriceWaterhouseCoopers study of VA's
facilities management practices argued for this level of funding and
previous versions of VA's own Asset Management Plan have agreed that
this level of funding would be adequate.
The most recent estimate of VA's PRV is from the FY 08 Asset
Management Plan. Using the standards of the Federal Government's
Federal Real Property Council (FRPC), VA's PRV is just over $85 billion
(page 26).
Accordingly, to fully maintain its facilities, VA needs a NRM
budget of at least $1.7 billion. This number would represent a doubling
of VA's budget request from FY 2009, but is in line with the total NRM
budget when factoring in the increases Congress gave in the
appropriations bill and the targeted funding included in the
supplemental appropriations bills.
Increased funding is required not just to fill current maintenance
needs and levels, but also to dip into the extensive backlog of
maintenance requirements VA has. VA monitors the condition of its
structures and systems through the Facility Condition Assessment (FCA)
reports. VA surveys each medical center periodically, giving each
building a thorough assessment of all essential systems. Systems are
assigned a letter grade based upon the age and condition of various
systems, and VA gives each component a cost for repair or replacement.
The bulk of these repairs and replacements are conducted through
the NRM program, although the large increases in minor construction
over the last few years have helped VA to address some of these
deficiencies.
VA's 5-Year Capital Plan discusses FCAs and acknowledges the
significant backlog of the number of high-priority deficiencies--those
with ratings of D or F--that had replacement and repair costs of over
$9.4 billion, found on page 7.1-18. VA estimates that 52 percent of NRM
dollars are obligated toward this cost.
VA uses the FCA reports as part of its Federal Real Property
Council (FRPC) metrics. The Department calculates a Facility Condition
Index, which is the ratio of the cost of FCA repairs to the cost of
replacement. According to the FY 08 Asset Management Plan, this metric
has gone backward from 82 percent in 2006 to just 68 percent in 2008.
VA's strategic goal is 87 percent, and for it to meet that, it would
require a sizeable investment in NRM and minor construction.
Given the low level of funding the NRM account has historically
received, the IBVSOs are not surprised at the metrics or the dollar
cost of the FCA deficiencies. The 2007 ``National Roll Up of
Environment of Care Report,'' which was conducted in light of the
shameful maintenance deficiencies at Walter Reed, further prove the
need for increased spending on this account. Maintenance has been
neglected for far too long, and for VA to provide safe, high-quality
health care in its aging facilities, it is essential that more money be
allocated for this account.
We also have concerns with how NRM funding is actually apportioned.
Since it falls under the Medical Care account, NRM funding has
traditionally been apportioned using the Veterans Equitable Resource
Allocation (VERA) formula. This model works when divvying up health
care dollars, targeting money to those areas with the greatest demand
for health care. When dealing with maintenance needs, though, this same
formula may actually intensify the problem by moving money away from
older hospitals, such as in the northeast, to newer facilities where
patient demand is greater, even if the maintenance needs are not as
high. We were happy to see that the conference reports to the VA
appropriations bills required NRM funding to be apportioned outside the
VERA formula, and we would hope that this continues into the future.
Another issue related to apportionment of funding came to light in
a May 2007 Government Accountability Office (GAO) report. They found
that the bulk of NRM funding is not actually apportioned until
September, the final month of the fiscal year. In September 2006, GAO
found that VA allocated 60 percent of that year's NRM funding. This is
a shortsighted policy that impairs VA's ability to properly address its
maintenance needs, and since NRM funding is year-to-year, it means that
it could lead to wasteful or unnecessary spending as hospital managers
rushed in a flurry to spend their apportionment before forfeiting it
back. We cannot expect VA to perform a year's worth of maintenance in a
month. It is clearly poor policy and not in the best interest of
veterans. The IBVSOs believe that Congress should consider allowing
some NRM money to be carried over from one fiscal year to another.
While we would hope that this would not resort to hospital managers
hoarding money, it could result in more efficient spending and better
planning, rather than the current situation where hospital managers
sometimes have to spend through a large portion of maintenance funding
before losing it at the end of the fiscal year.
Recommendations
VA must dramatically increase funding for nonrecurring maintenance
in line with the 2 percent-4 percent total that is the industry
standard so as to maintain clean, safe and efficient facilities. VA
also requires additional maintenance funding to allow the Department to
begin addressing the substantial maintenance backlog of FCA-identified
projects.
Portions of the NRM account should be continued to be funded
outside of the VERA formula so that funding is allocated to the
facilities that actually have the greatest maintenance needs.
Congress should consider the strengths of allowing VA to carry over
some maintenance funding from one fiscal year to another so as to
reduce the temptation some VA hospital managers have of inefficiently
spending their NRM money at the end of a fiscal year for fear of losing
it.
Inadequate Funding and Declining Capital Asset Value
VA must protect against deterioration of its infrastructure and a
declining capital asset value
The last decade of underfunded construction budgets has meant that
VA has not adequately recapitalized its facilities. Recapitalization is
necessary to protect the value of VA's capital assets through the
renewal of the physical infrastructure. This ensures safe and fully
functional facilities long into the future. VA's facilities have an
average age approaching 60 years, and it is essential that funding be
increased to renovate, repair, and replace these aging structures and
physical systems.
As in past years, the IBVSOs cite the Final Report of the
President's Task Force to Improve Health Care Delivery for Our Nation's
Veterans (PTF). It found that from 1996-2001, VA's recapitalization
rate was just 0.64 percent. At this rate, VA's structures would have an
assumed life of 155 years.
The PTF cited a PriceWaterhouseCoopers study of VA's facilities
management programs that found that to keep up with industry standards
in the private sector and to maintain patient and employee safety and
optimal health care delivery, VA should spend a minimum of 5 to 8
percent of plant replacement value (PRV) on its total capital budget.
The FY08 VA Asset Management Plan provides the most recent estimate
of VA's PRV. Using the guidance of the Federal Government's Federal
Real Property Council (FRPC), VA's PRV is just over $85 billion (page
26).
Accordingly, using that 5 to 8 percent standard, VA's capital
budget should be between $4.25 and $6.8 billion per year in order to
maintain its infrastructure.
VA's capital budget request for FY 2009--which includes major and
minor construction, maintenance, leases and equipment--was just $3.6
billion. We greatly appreciate that Congress increased funding above
that level with an increase over the Administration request of $750
million in major and minor construction alone. That increased amount
brought the total capital budget in line with industry standards, and
we strongly urge that these targets continue to be met and we would
hope that future VA requests use these guidelines as a starting point
without requiring Congress to push them past the target.
Recommendation
Congress and the Administration must ensure that there are adequate
funds for VA's capital budget so that VA can properly invest in its
physical assets to protect their value and to ensure that the
Department can continue to provide health care in safe and functional
facilities long into the future.
Maintain VA's Critical Infrastructure
The IBVSOs are concerned with VA's recent attempts to back away
from the capital infrastructure blueprint laid out by CARES and we are
worried that its plan to begin widespread leasing and contracting for
inpatient services might not meet the needs of veterans.
VA acknowledges three main challenges with its capital
infrastructure projects. First, they are costly. According to a March
2008 briefing given to the VSO community, over the next 5 years, VA
would need $2 billion per year for its capital budget. Second, there is
a large backlog of partially funded construction projects. That same
briefing claimed that the difference in major construction requests
given to OMB was $8.6 billion from FY 03 through FY 09, and that they
have received slightly less than half that total. Additionally, there
is a $2 billion funding backlog for projects that are partially but not
completely funded. Third, VA is concerned about the timeliness of
construction projects, noting that it can take the better part of a
decade from the time VA initially proposes a project until the doors
actually open for veterans.
Given these challenges, VA has floated the idea of a new model for
health care delivery, the Health Care Center Facility (HCCF) leasing
program. Under the HCCF, VA would begin leasing large outpatient
clinics in lieu of major construction. These large clinics would
provide a broad range of outpatient services including primary and
specialty care as well as outpatient mental health services and
ambulatory surgery.
On the face of it, this sounds like a good initiative. Leasing has
the advantage of being able to be completed quickly, as well as being
adaptable, especially when compared to the major construction process.
Leasing has been particularly valuable for VA as evidenced by the
success of the Community Based Outpatient Clinics (CBOCs) and Vet
Centers.
Our concern rests, however, with VA's plan for inpatient services.
VA aims to contract for these essential services with affiliates or
community hospitals. This program would privatize many services that
the IBVSOs believe VA should continue to provide. We lay out our
objections to privatization and widespread contracting for care
elsewhere in The Independent Budget.
Beyond those objections, though, is the example of Grand Island,
Nebraska. In 1997, the Grand Island VA Medical Center closed its
inpatient facilities, contracting out with a local hospital for those
services. Recently, the contract between the local facility and VA was
canceled, meaning veterans in that area can no longer receive inpatient
services locally. They must travel great distances to other VA
facilities such as the Omaha VA Medical Center. In some cases, when
Omaha is unable to provide specialized care, VA is flying patients at
its expense to faraway VA medical centers, including those in St. Louis
and Minneapolis.
Further, with the canceling of that contract, St. Francis no longer
provides the same level of emergency services that a full VA Medical
Center would provide. With VA's restrictions on paying for emergency
services in non-VA facilities, especially for those who may have some
form of private insurance, this amounts to a cut in essential services
to veterans. Given the expenses of air travel and medevac services, the
current arrangement in Grand Island has likely not resulted in any cost
savings for VA. Ferrying sick and disabled veterans great distances for
inpatient care also raises patient safety and quality concerns.
The HCCF program raises many concerns for the IBVSOs that VA must
address before we can support the program. Among these questions, we
wonder how VA would handle governance, especially with respect to the
large numbers of non-VA employees who would be treating veterans. How
would the non-VA facility deal with VA directives and rule changes that
govern health care delivery and that ensure safety and uniformity of
the quality of care? Will VA apply its space planning criteria and
design guides to non-VA facilities? How will VA's critical research
activities, most of which improve the lives of all Americans and not
only veterans, be affected if they are being conducted in shared
facilities, and not a traditional part of VA's first-class research
programs? What would this change mean for VA's electronic health
record, which many have rightly lauded as the standard that other
health care systems should aim to achieve? Without the electronic
health record, how would VA maintain continuity of care for a veteran
who moves to another area?
But most importantly, CARES required years to complete and consumed
thousands of hours of effort and millions of dollars of study. We
believe it to be a comprehensive and fully justified roadmap for VA's
infrastructure as well as a model that VA can apply periodically to
assess and adjust those priorities. Given the strengths of the CARES
process and the lessons VA learned and has applied from it, why is the
HCCF model, which to our knowledge has not been based on any sort of
model or study of the long-term needs of veterans, the superior one? We
have yet to see evidence that it is and until we see more convincing
evidence that it will truly serve the best needs of veterans, the
IBVSOs will have a difficult time supporting it.
Recommendation
VA must resist implementing the HCCF model without fully addressing
the many questions the IBVSOs have and VA must explain how the program
would meet the needs of veterans, particularly as compared to the
roadmap CARES has laid out.
Research Infrastructure Funding
The Department of Veterans Affairs must have increased funding for
its research infrastructure to provide a state-of-the-art research and
laboratory environment for its excellent programs, but also to ensure
that VA hires and retains the top scientists and researchers
VA Research Is a National Asset
Research conducted in the Department of Veterans Affairs has led to
such innovations and advances as the cardiac pacemaker, nuclear
scanning technologies, radioisotope diagnostic techniques, liver and
other organ transplantation, the nicotine patch, and vast improvements
in a variety of prosthetic and sensory aids. A state-of-the-art
physical environment for conducting VA research promotes excellence in
health professions education and VA patient care as well as the
advancement of biomedical science. Adequate and up-to-date research
facilities also help VA recruit and retain the best and brightest
clinician scientists to care for enrolled veterans.
VA Research Infrastructure Funding Shortfalls
In recent years, funding for the VA Medical and Prosthetics
Research Program has failed to provide the resources needed to
maintain, upgrade, and replace VA's aging research facilities. Many VA
facilities have exhausted their available research space. Along with
space reconfiguration, ventilation, electrical supply, and plumbing
appear frequently on lists of needed upgrades in VA's academic health
centers. In the 2003 Draft National Capital Asset Realignment for
Enhanced Services (CARES) plan, VA included $142 million designated for
renovation of existing research space and build-out costs for leased
researched facilities. However, these capital improvement costs were
omitted from the Secretary's final report. Over the past decade, only
$50 million has been spent on VA research construction or renovation
nationwide, and only 24 of the 97 major VA research sites across the
Nation have benefited.
In House Report 109-95 accompanying the FY 2006 VA appropriations,
the House Appropriations Committee directed VA to conduct ``a
comprehensive review of its research facilities and report to the
Congress on the deficiencies found and suggestions for correction of
the identified deficiencies.'' In FY 2008, the VA Office of Research
and Development initiated a multi-year examination of all VA research
infrastructures for physical condition and capacity for current
research, as well as program growth and sustainability of the space
needed to conduct research.
Lack of a Mechanism to Ensure VA's Research Facilities Remain Competitiv
e
In House Report 109-95 accompanying the FY 2006 VA appropriations,
the House Appropriations Committee expressed concern that ``equipment
and facilities to support the research program may be lacking and that
some mechanism is necessary to ensure the Department's research
facilities remain competitive.'' A significant cause of research
infrastructure's neglect is that there is no direct funding line for
research facilities.
The VA Medical and Prosthetic Research appropriation does not
include funding for construction, renovation, or maintenance of
research facilities. VA researchers must rely on their local facility
managements to repair, upgrade, and replace research facilities and
capital equipment associated with VA's research laboratories. As a
result, VA research competes with other medical facilities' direct
patient care needs--such as medical services infrastructure, capital
equipment upgrades and replacements, and other maintenance needs--for
funds provided under either the VA Medical Facilities appropriation
account or the VA Major or Minor Medical Construction appropriations
accounts.
Recommendations
The Independent Budget veteran's service organizations anticipate
VA's analysis will find a need for funding significantly greater than
VA had identified in the 2004 Capital Asset Realignment for Enhanced
Services report. As VA moves forward with its research facilities
assessment, the IBVSOs urge Congress to require the VA to submit the
resulting report to the House and Senate Committees on Veterans'
Affairs no later than October 1, 2010. This report will ensure that the
Administration and Congress are well informed of VA's funding needs for
research infrastructure so they may be fully considered at each stage
of the FY 2011 budget process.
To address the current shortfalls, the IBVSOs recommend an
appropriation in FY 2010 of $142 million, dedicated to renovating
existing VA research facilities in line with the 2004 CARES findings.
To address the VA research infrastructure's defective funding
mechanism, the IBVSOs encourage the Administration and Congress to
support a new appropriations account in FY 2010 and thereafter to
independently define and separate VA research infrastructure funding
needs from those related to direct VA medical care. This division of
appropriations accounts will empower VA to address research facility
needs without interfering with the renovation and construction of VA
direct health care infrastructure.
Program for Architectural Master Plans
Each VA medical facility must develop a detailed master plan.
The delivery models for quality health care are in a constant state
of change. This is due to many factors including advances in research,
changing patient demographics, and new technology.
The VA must design their facilities with a high level of
flexibility in order to accommodate these new methods of patient care.
The Department must be able to plan for change to accommodate new
patient care strategies in a logical manner with as little effect as
possible on other existing patient care programs. VA must also provide
for growth in already existing programs.
A facility master plan is a comprehensive tool to look at potential
new patient care programs and how they might affect the existing health
care facility. It also provides insight with respect to possible
growth, current space deficiencies, and other facility needs for
existing programs and how VA might accommodate these in the future.
In some cases in the past, VA has planned construction in a
reactive manner. After funding, VA would place projects in the facility
in the most expedient manner--often not considering other projects and
facility needs. This would result in shortsighted construction that
restricts, rather than expands, options for the future.
The IBVSOs believe that each VA Medical Center should develop a
comprehensive facility master plan to serve as a blueprint for
development, construction, and future growth of the facility. Short-
and long-term CARES objectives should be the basis of the master plan.
Four critical programs were not included in the CARES initiative.
They are long-term care, severe mental illness, domiciliary care, and
polytrauma. VA must develop a comprehensive plan addressing these needs
and its facility master plans must account for these services.
VA has undertaken master planning for several VA facilities; most
recently Tampa, Florida. This is a good start, but VA must ensure that
all facilities develop a master plan strategy to validate strategic
planning decisions, prepare accurate budgets, and implement efficient
construction that minimizes wasted expenses and disruption to patient
care.
Recommendation
Congress must appropriate $20 million to provide funding for each
medical facility to develop a master plan.
Each facility master plan should include the areas left out of
CARES; long-term care, severe mental illness, domiciliary care, and
polytrauma programs as it relates to the particular facility.
VACO must develop a standard format for these master plans to
ensure consistency throughout the VA health care system.
Empty or Underutilized Space
VA must not use empty space inappropriately and must continue
disposing of unnecessary property where appropriate. Studies have
suggested that the VA medical system has extensive amounts of empty
space that the Department can reuse for medical services. Others have
suggested that unused space at one medical center may help address a
deficiency that exists at another location. Although the space
inventories are accurate, the assumption regarding the feasibility of
using this space is not.
Medical facility planning is complex. It requires intricate design
relationships for function, but also because of the demanding
requirements of certain types of medical equipment. Because of this,
medical facility space is rarely interchangeable, and if it is, it is
usually at a prohibitive cost. For example, VA cannot use unoccupied
rooms on the eighth floor to offset a deficiency of space in the second
floor surgery ward. Medical space has a very critical need for inter-
and intra-departmental adjacencies that must be maintained for
efficient and hygienic patient care.
When a department expands or moves, these demands create a domino
effect of everything around it. These secondary impacts greatly
increase construction expense, and they can disrupt patient care.
Some features of a medical facility are permanent. Floor-to-floor
heights, column spacing, light, and structural floor loading cannot be
altered. Different aspects of medical care have different requirements
based upon these permanent characteristics. Laboratory or clinical
spacing cannot be interchanged with ward space because of the needs of
different column spacing and perimeter configuration. Patient wards
require access to natural light and column grids that are compatible
with room-style layouts. Labs should have long structural bays and
function best without windows. When renovating empty space, if the area
is not suited to its planned purpose, it will create unnecessary
expenses and be much less efficient.
Renovating old space rather than constructing new space creates
only a marginal cost savings. Renovations of a specific space typically
cost 85 percent of what a similar, new space would. When you factor in
the aforementioned domino or secondary costs, the renovation can end up
costing more and produce a less satisfactory result. Renovations are
sometimes appropriate to achieve those critical functional adjacencies,
but it is rarely economical.
Many older VA Medical Centers that were rapidly built in the 1940s
and 1950s to treat a growing veteran population are simply unable to be
renovated for modern needs. Most of these Bradley-style buildings were
designed before the widespread use of air conditioning and the floor-
to-floor heights are very low. Accordingly, it is impossible to
retrofit them for modern mechanical systems. They also have long,
narrow wings radiating from a small central core, which is an
inefficient way of laying out rooms for modern use. This central core,
too, has only a few small elevator shafts, complicating the vertical
distribution of modern services.
Another important problem with this unused space is its location.
Much of it is not located in a prime location; otherwise, VA would have
previously renovated or demolished this space for new construction.
This space is typically located in outlying buildings or on upper floor
levels, and is unsuitable for modern use.
VA Space Planning Criteria/Design Guides
VA must continue to maintain and update the Space Planning Criteria
and Design Guides to reflect state-of-the-art methods of health care
delivery.
VA has developed space-planning criteria it uses to allocate space
for all VA health care projects. These criteria are organized into 60
chapters; one for each health care service provided by VA as well as
their associated support services. VA updates these criteria to reflect
current methods of health care delivery.
In addition to updating these criteria, VA has utilized a computer
program called VA SEPS (Space and Equipment Planning System) it uses as
a tool to develop space and equipment allocation for all VA health care
projects. This tool is operational and VA currently uses it on all VA
health care projects.
The third component used in the design of VA health care projects
is the design guides. Each of the 60 space-planning criteria chapters
has an associated design guide. These design guides go beyond the
allocation of physical space and outline how this space is organized
within each individual department, as well as how the department
relates to the entire medical facility.
VA has updated several of the design guides to reflect current
patient delivery models. These include those guides that cover Spinal
Cord Injury/Disorders Center, Imaging, Polytrauma Centers, as well as
several other services.
Recommendation
The VA must continue to maintain and update the Space Planning
Criteria and the VA SEPS space-planning tool. It also must continue the
process of updating the Design Guides to reflect current delivery
models for patient care. VA must regularly review and update all of
these space-planning tools as needed, to reflect the highest level of
patient care delivery.
Design-build Construction Delivery System
The VA must evaluate use of the design-build construction delivery
system.
For the past 10 years, VA has embraced the design-build
construction delivery system as a method of project delivery for many
health care projects. Design-build attempts to combine the design and
construction schedules in order to streamline the traditional design-
bid-build method of project delivery. The goal is to minimize the risk
to the owner and reduce the project delivery schedule. Design-build, as
used by VA, places the contractor as the design builder.
Under the contractor-led design-build process, VA gives the
contractor a great deal of control over how he or she designs and
completes the project. In this method, the contractor hires the
architect and design professionals. With the architect as a
subordinate, a contractor may sacrifice the quality of material and
systems in order to add to his own profits at the expense of the owner.
Use of design-build has several inherent problems. A short-cut
design process reduces the time available to provide a complete design.
This provides those responsible for project oversight inadequate time
to review completed plans and specifications. In addition, the
construction documents may not provide adequate scope for the project,
leaving out important details regarding the workmanship and/or other
desired attributes of the project. This makes it difficult to hold the
builder accountable for the desired level of quality. As a result, a
project is often designed as it is being built, which often compromises
VA's design standards.
Design-build forces the owner to rely on the contractor to properly
design a facility that meets the owner's needs. In the event that the
finished project is not satisfactory to the owner, the owner may have
no means to insist on correction of work done improperly unless the
contractor agrees with the owner's assessment. This may force the owner
to go to some form of formal dispute resolution such as litigation or
arbitration.
Recommendation
VA must evaluate the use of design-build as a method of
construction delivery to determine if design-build is an appropriate
method of project delivery for VA health care projects.
The VA must institute a program of ``lessons learned.'' This would
involve revisiting past projects and determining what worked, what
could be improved, and what did not work. VA should compile and use
this information as a guide to future projects. VA must regularly
update this document to include projects as they are completed.
Preservation of VA's Historic Structures
The VA must further develop a comprehensive program to preserve and
protect its inventory of historic properties.
The VA has an extensive inventory of historic structures that
highlight America's long tradition of providing care to veterans. These
buildings and facilities enhance our understanding of the lives of
those who have worn the uniform, and who helped to develop this great
Nation. Of the approximately 2,000 historic structures, many are
neglected and deteriorate year after year because of a lack of funding.
These structures should be stabilized, protected and preserved because
they are an integral part our Nation's history.
Most of these historic facilities are not suitable for modern
patient care. As a result, a preservation strategy was not included in
the CARES process. For the past 6 years, the IBVSOs have recommended
that VA conduct an inventory of these properties; classifying their
physical condition and their potential for adaptive reuse. VA has been
moving in that direction and historic properties are identified on
their Web site. VA has placed many of these buildings in an ``Oldest
and Most Historic'' list and these buildings require immediate
attention.
At least one project has received funding. The VA has invested over
$100,000 in the last year to address structural issues at a unique
round structure in Hampton, VA. Built in 1860, it was originally a
latrine and the funding is allowing VA to convert it into office space.
The cost for saving some of these buildings is not very high
considering that they represent a part of history that enriches the
texture of our landscape that once gone cannot be recaptured. For
example, VA can restore the Greek Revival Mansion in Perry Point, MD,
which was built in the 1750's, to use as a training space for about
$1.2 million. VA could restore the 1881 Milwaukee Ward Memorial Theater
for use as a multi-purpose facility at a cost of $6 million. This is
much less than the cost of a new facility.
As part of its adaptive reuse program, VA must ensure that the
facilities that it leases or sells are maintained properly. VA's legal
responsibilities could, for example, be addressed through easements on
property elements, such as building exteriors or grounds.
We encourage the use of P.L. 108-422, the Veterans Health Programs
Improvement Act, which authorized historic preservation as one of the
uses of a new capital assets fund that receives funding from the sale
or lease of VA property.
Recommendation
VA must further develop a comprehensive program to preserve and
protect its inventory of historic properties.
Mr. Chairman, this concludes my statement. I would be happy to
answer any questions that you or the Members of the Committee may have.
Prepared Statement of Joseph L. Wilson, Deputy Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on the Department of Veterans Affairs (VA) Veterans Health
Administration's (VHA) fiscal year (FY) 2011 budget request. To date,
the VHA provides integrated health care services to eligible veterans
through 153 medical centers, 755 Outpatient Clinics, and 232 Vet
Centers in all 50 States, including the District of Columbia, Guam,
Puerto Rico, and the U.S. Virgin Islands. In 2009, Congress enacted
Public Law 111-81, the ``Veterans Health Care Budget Reform and
Transparency Act'' which requires VA to submit this request for advance
appropriations with its President's budget submission each year.
The American Legion proposes the following budgetary
recommendations for selected programs within the VA Veterans Health
Administration for FY 2011:
----------------------------------------------------------------------------------------------------------------
President's
Program FY 10 Funding Request Legion's Request
----------------------------------------------------------------------------------------------------------------
Medical Services $37.7 billion $40.5 billion
----------------------------------------------------------------------------------------------------------------
Medical Support and Compliance $4.9 billion $5.3 billion
----------------------------------------------------------------------------------------------------------------
Medical Facilities $4.9 billion $5.7 billion
----------------------------------------------------------------------------------------------------------------
Medical Care Total $48.1 billion $51.5 billion $48 billion
(includes
medical and
prosthetics
research)
----------------------------------------------------------------------------------------------------------------
Major Construction $1.2 billion $1.2 billion $2 billion
----------------------------------------------------------------------------------------------------------------
Minor Construction $703 million $467.7 million $1.5 billion
----------------------------------------------------------------------------------------------------------------
Medical and Prosthetics Research $581 million $590 million $700 million
----------------------------------------------------------------------------------------------------------------
Medical Care Recovery Fund ($3 billion) ($3.4 billion) *
----------------------------------------------------------------------------------------------------------------
* Third-party reimbursements should supplement rather than offset discretionary funding.
Improving Mental Health Care
VA recently stated that the 2011 budget request will continue to
improve the quality, access, and value of mental health care provided
to veterans. VA's budget provides approximately $5.2 billion for mental
health, an increase of $410 million, or 8.5 percent, over the 2010
enacted level. In addition, VA says this will expand inpatient,
residential, and outpatient mental health programs with an emphasis on
integrating mental health services with primary and specialty care.
The American Legion supports this increase in funding and contends
that appropriate increases in mental health should be frequently
evaluated due to the influx of men and women servicemembers diagnosed
with Post Traumatic Stress Disorder (PTSD) and traumatic brain injury
(TBI), depression, and substance use disorders.
Meeting the Medical Needs of Women Veterans
VA reported that the 2011 budget request will provide $217.6
million to meet the gender-specific health care needs of women
veterans. The delivery of enhanced primary care for women veterans
remains one of the Department's top priorities. The number of women
veterans is growing rapidly and women are increasingly reliant upon VA
for their health care.
The American Legion believes the provision of funding to ensure
women veterans receive complete, comprehensive care will minimize many
issues facing them and their families, to include PTSD, depression,
substance abuse, and other disorders.
Delivery of Medical Care
According to VA, the 2011 budget request provides $51.5 billion for
medical care, an increase of $4 billion, or 8.5 percent, over the 2010
level. VA says this level will allow them to continue providing timely,
high-quality care to all enrolled veterans.
VA states their total medical care level is comprised of funding
for medical services ($40.5 billion), medical support and compliance
($5.3 billion), medical facilities ($5.7 billion), and resources from
medical care collections ($3.4 billion). VA also stated that the 2011
budget will reduce the number of homeless veterans and expand access to
mental health care, as well as accomplish other outcomes that improve
veterans' quality of life, including:
Providing extended care and rural health services in
clinically appropriate settings;
Expanding the use of home telehealth;
Enhancing access to health care services by offering
enrollment to more Priority Group 8 veterans and activating new
facilities; and
Meeting the medical needs of women veterans.
During FY 2011, VA anticipates treating nearly 6.1 million unique
patients, a 2.9-percent increase over 2010. Among the total to be
treated are over 439,000 veterans who served in Operation Enduring
Freedom and Operation Iraqi Freedom.
The American Legion agrees with the VA's 2011 budget request on the
deliverance of medical care. We also applaud Congress on the approval
of funding to adequately accommodate OEF/OIF and Vietnam veterans as
well as veterans from other areas.
Extended Care and Rural Health
VA's budget request for FY 2011 contains $6.8 billion for long-term
care. VA also reported that $250 million has been allotted to continue
strengthening access to health care for 3.2 million enrolled veterans
living in rural and highly rural areas through a variety of avenues,
including new rural health outreach and delivery initiatives and
expanded use of home-based primary care, mental health, and telehealth
services. VA intends to expand use of cutting edge telehealth
technology to broaden access to care while at the same time improve the
quality of our health care services.
The American Legion supports VA's actions in providing access to
care with new facilities as well as technologies. However, due to the
vast number of rural venues, we urge that oversight be provided to
ensure funding reaches these areas.
Expanding Access to Health Care
In 2009, VA opened enrollment to Priority Group 8 veterans whose
incomes exceed last year's geographic and VA means test thresholds by
no more than 10 percent. Our most recent estimate is that 193,000 more
veterans will enroll for care by the end of 2010 due to this policy
change.
In FY 2011, VA will further expand health care eligibility for
Priority Group 8 veterans to those whose incomes exceed the geographic
and VA means test thresholds by no more than 15 percent compared to the
levels in effect prior to expanding enrollment in 2009. This additional
expansion of eligibility for care will result in an estimated 99,000
more enrollees in 2011 alone, bringing the total number of new
enrollees from 2009 to the end of 2011, to 292,000.
Home Telehealth
For FY 2011, VA has also allotted $163 million in home telehealth.
The Secretary says they are taking greater advantage of the latest
technological advancements in health care delivery which will allow VA
to closely monitor the health status of veterans and improve access to
care for veterans in rural and highly rural areas. In total, the VA
home telehealth program cares for approximately 35,000 veteran
patients.
The American Legion concurs with the allotment of funding for the
Home Telehealth program because it will serve to provide more access to
care for veterans residing in rural and highly rural areas and reduce
travel for health care.
Establishing a Virtual Lifetime Electronic Record
According to VA more than 150,000 active and Reserve component
servicemembers leave active duty annually. This transition relies on
the transfer of paper-based administrative and medical records from the
Department of Defense (DoD) to the veteran, the VA or other non-VA
health care providers. VA agrees this paper-based transfer carries
risks of errors or oversights and delays the claim process.
The VA is currently building a fully interoperable electronic
records system that will provide every member of our armed forces a
Virtual Lifetime Electronic Record (VLER), which will enhance the
timely delivery of high-quality benefits and services by capturing key
information from the day they put on the uniform, through their time as
veterans, until the day they are laid to rest. The Secretary of VA also
stated VA has $52 million in IT funds in 2011 to continue the
development and implementation of this Presidential priority.
The American Legion agrees with the establishment of the VLER. As
with many programs, we remain adamant that proper oversight be placed
on the implementation of this record. The storing of such records is
extremely vital to the health and welfare of each and every veteran.
The Capital Asset Realignment for Enhanced Services (CARES)
initiative identified approximately 100 major construction projects
throughout the VAMC system, DC, and Puerto Rico. Approximately 5 years
have passed since the CARES initiative. In addition, more women and men
servicemembers are transitioning from active duty to VA and presenting
with multiple illnesses, such as PTSD and mild TBI. Meanwhile, the
average age of VA's facilities is approximately 45 years. The American
Legion's 2009 ``A System Worth Saving'' publication reports ``space
availability'' as one of the major overall challenges.
The American Legion hereby urges Congress to assess the
abovementioned areas they funded for FY 2011, as well as the number of
servicemembers and current veterans they anticipate to visit a VA
medical facility to receive medical care. We contend this action will
shed light on the actual need of each VA facility in their sincere
effort to accommodate America's veterans.
Conclusion
Mr. Chairman and Members of the Subcommittee, The American Legion
appreciates the commitment of this Subcommittee, and remains fully
committed to working with you to ensure all of this Nation's veterans
are provided with timely access to the quality health care they
deserve, are entitled to receive. It is imperative we remain vigilant
in our efforts to adequately accommodate them as they continue to
adjust to the civilian community.
Thank you for allowing me the opportunity to present the views of
The American Legion to you today.
Statement of Barbara F. West, Executive Director,
National Association for Veterans' Research and Education Foundations
The National Association of Veterans' Research and Education
Foundations (NAVREF) appreciates the opportunity to submit a statement
for the record of the February 23, 2010, hearing of the Health
Subcommittee of the House Committee on Veterans Affairs.
NAVREF is proud to be the voluntary membership association of the
more than 80 nonprofit research and education corporations (NPCs)
established by Department of Veterans Affairs (VA) medical centers and
operated in accordance with 38 USC Sec. Sec. 7361-7366. Last year, NPCs
administered over $250 million in private sector and non-VA Federal
funding on behalf of VA investigators and educators conducting
approximately 4,000 research studies and education activities at VA
facilities across the Nation.
The purpose of this statement is to convey NAVREF's views on VA's
request for legislative authority to establish a ``Central Nonprofit
Corporation for VA Research.'' VA's proposal is described in Volume II,
Medical Programs and Information Technology Programs of the
Department's FY 2011 Funding and FY 2012 Advance Appropriations
Request, pages 1I-20 and 1I-21.
Despite careful consideration, NAVREF is unable to support VA's
proposal for a central nonprofit because:
VA fails to make a compelling case for what a central VA
nonprofit could accomplish that the existing NPCs cannot;
The proposal contains so little detail about how VA and a
central VA nonprofit would interact that NAVREF is forced to consider
potentially problematic possibilities; and
Absent from VA's justification is how a central VA
nonprofit would further VA's research mission which is to ``discover
knowledge, develop VA researchers and health care leaders, and create
innovations that advance health care for our veterans and the Nation.''
NAVREF and its member NPCs fully appreciate the advantages of
public/private nonprofit partnerships. As ``flexible funding
mechanism[s] for the conduct of VA research'' [38 USC Sec. 7361(a)],
NPCs confer substantial advantages on VA medical centers. Through
careful stewardship of funds entrusted to them by private sector
grants, cooperative research and development agreements (CRADAs) for
industry-sponsored studies and non-VA Federal awards, NPCs have
provided innumerable benefits to the VA facility research programs and
VA investigators. Over the 22 years since they were first authorized by
Congress, NPCs have helped to foster vibrant VA research enterprises at
VA medical centers across the country through contributions of research
personnel; equipment; supplies; facility improvements; compliance
training; grant writing, submission and management services; travel
support and much more. Because VA already has more than 80 nonprofits,
we feel that it is incumbent on VA to make a more convincing case for
authority to establish a new and untested form of VA nonprofit. Toward
that end, we recommend that in order for a central VA nonprofit to
warrant consideration:
1. VA should provide compelling justification for a central VA
nonprofit that clearly articulates what the proposed central VA
nonprofit could accomplish that the existing NPCs cannot.
In our view, some NPCs are already accomplishing the stated
objectives of the central VA nonprofit, and more could do so if given
the opportunity, particularly under the updated NPC authority that is
presently close to final enactment in H.R. 2770 and title VIII of S.
1963.
VA's justification for a central VA nonprofit hinges in part on its
desire to ``carry out national medical research and education
projects.'' However, VA has a long history of successfully managing
complex, multi-site studies involving thousands of subjects through its
Cooperative Studies Program (CSP) and its Health Services Research and
Development (HSR&D) program. As a result, we are uncertain of the need
for a central VA nonprofit to accomplish what has long been a major
strength of the VA research program.
Also, while the updated NPC authority awaiting enactment will
clarify that NPCs may administer multi-site studies, they have been
doing so for years [see Multi-Center Studies, OGC Opinion 023 (11/4/
99)]. Further, NPCs have increasingly partnered with VA to administer
non-VA funds for CSP studies since the longstanding relationship
between the Office of Research and Development (ORD) and the Friends
Research Institute (FRI) had to be terminated in 2004 when misuse of
non-VA funds directed to FRI for CSP studies came to light. [See OIG
administrative investigation Report No. 03-03053-115; March 22, 2004].
(Please note that FRI is not one of the more than 80 VA NPCs. ORD's
relationship with FRI pre-dated authorization of the NPCs in 1988 but
continued until 2004.)
Since termination of the FRI relationship, NPCs associated with
medical centers where VA has CSP Coordinating Centers (CSPCCs)--Hines,
Illinois; Palo Alto, California; West Haven, Connecticut; and Perry
Point near Baltimore, Maryland--have worked closely with CSPCC
personnel to set up efficient systems and MOUs that allow accountable
management of non-VA Federal funding, and private sector funds
contributed by industry partners, for CSP and other centrally directed
VA studies. Recent examples include NPC facilitation of the ACCORD
(diabetes) and ALLHAT (hypertension) studies and the shingles vaccine
trials. Additionally, an NPC not associated with a CSPCC currently
administers over $15 million annually in NIH funding for multi-site
studies led by a single VA principal investigator.
Another justification that VA uses in support of a central VA
nonprofit is found in the statement, ``While current NPCs work well
with their current authority to manage studies in their specific
jurisdictions, few of the individual NPCs have all the skill sets
needed to coordinate more complex efforts.'' Although some NPCs may
lack all the ``skill sets'' needed to coordinate more complex efforts,
we believe that more could readily acquire those skills--or hire new
personnel with the necessary skills--if given greater opportunity for
responsibility for multi-site studies. It should be noted that many
NPCs--even some of those associated with relatively large VA research
programs--have not reached their full potential because so much non-VA
funding for research performed in VA facilities is administered by
entities other than VA or NPCs, primarily universities and university-
affiliated nonprofits.
2. VA should establish that centralized administration of research
is an appropriate model for VA.
First, it should be noted that the purposes of the central VA
nonprofit stated in the proposal are strikingly similar to the
statutory authority given to the Department of Defense (DoD) to
establish the Henry M. Jackson Foundation (HJF) for the Advancement of
Military Medicine (10 USC Sec. 178) in 1985. HJF has one primary
university affiliation (Uniformed Services University of the Health
Sciences), has relationships with more than 160 military medical and
other organizations worldwide, and employs 1,800 personnel providing a
broad array of research and clinical services.
We are uncertain how well the HJF model would suit VA even though
we understand that VA does not intend for the central VA nonprofit to
supplant medical center-based NPCs, except possibly where the research
programs are very small. The centralized HJF model was considered when
legislation proposing the NPCs was the subject of congressional
hearings (H. Rept. 100-373). It is our understanding that after review,
the centralized model was rejected in favor of a decentralized approach
more suitable for VA which has affiliations with 107 medical schools
and more than 5,000 affiliation agreements with some 1,200 other health
professional colleges and universities.
For over 20 years, VA's decentralized approach using local NPCs has
demonstrated effective support of the VA research and education
missions through on-site (most NPC offices are located in VA facilities
or very nearby) research support services for VA investigators while
working closely with the medical center personnel responsible for the
conduct and oversight of research at each facility. Indeed, for a short
time VA had centralized research support offices--the Eastern and
Western Research and Development Offices (ERDO and WRDO). These offices
administered VA-appropriated funds for sites with just a few projects,
but they were closed after a few years.
We agree that it makes little sense for facilities with very few
research projects to incur the effort, expense and responsibility of
maintaining their own NPC. However, legislation already passed by the
House and Senate in H.R. 2770 and title VIII of S. 1963 respectively,
and presently awaiting final resolution of their minor differences,
offers a means for these facilities to access the benefits of NPCs
through voluntarily sharing one NPC among two or more VAMCs. By pooling
funds, consolidating management and avoiding duplication, such as
having one audit instead of three, or one executive director instead of
three, ``multi-medical center research corporations'' (MMRCs) will
preserve the advantages of the close relationship NPCs have with the
facilities and investigators they serve while reducing overhead. These
MMRCs will offer smaller research programs a locally accountable option
which is likely to be nearby, if not onsite, for management of their
research projects and education activities. We see no need for the
option of remote, possibly Washington-based, services a central VA
nonprofit would offer.
3. To preserve the integrity of the intramural nature of the VA
research program, VA should clarify that the central VA nonprofit would
accept only non-VA Federal and private sector funds.
We further question the suitability of an HJF-like authority for VA
because, unlike DoD and NIH, which have authority to conduct research
both intra- and extramurally, a core tenet of the VA Research and
Development program is that it is solely an intramural research
program. If--and that is a big ``if'' because the proposal contains so
few details--authority for the central VA nonprofit would encompass
reciprocal contracting or the ability to pass VA-appropriated funds
through to VA or non-VA entities (as HJF does for some DoD funds), we
believe that would compromise the long held intramural nature of the VA
research program. Ultimately, this would reduce its effectiveness as a
recruitment and retention tool for high-quality clinician-investigators
who in turn focus their research on conditions prevalent among veterans
and who provide optimum care for veterans. We may be reading too much
into the proposal, but we feel it is important to state that NAVREF
would be opposed to any measures that could have the unintended
consequence of altering the intramural nature of VA research.
4. VA should describe what legal mechanisms available to VA would
be used to engage with a central VA nonprofit.
Although we are unable to discern from the proposal how VA and the
central VA nonprofit would interact to each other (what are
``cooperative arrangements''?), it appears that justification for the
central VA nonprofit may entail plans for VA to use VA-appropriated
funds to contract with the central VA nonprofit for services. We
regularly hear that VA hiring mechanisms are ill-suited for research
projects because these require prompt hiring to meet time-limited
funder deadlines and the ability to terminate employees when their
services are no longer needed. These problems may be an underlying
reason for seeking a central VA nonprofit authority which perhaps would
function as a private sector contractor to meet VA's fluctuating
research staffing needs. However, in our view contracting with a
central VA nonprofit may be problematic from the perspective of
compliance with Federal hiring and contracting statutes and
regulations. As a result, we encourage the Subcommittee to determine
how VA and the central VA nonprofit would engage with each other.
It should be noted that to the extent allowed by law, NPCs already
routinely help VA research facilities meet their temporary staffing
needs using the Intergovernmental Personnel Act (IPA) authority (5 USC
Sec. Sec. 3371-3375 and 5 CFR part 334). This allows VAMCs to work with
NPCs to acquire the services of skilled research personnel, who are
considered to be VA employees for most purposes except pay and
benefits, quickly and only for the time their services are needed.
5. Compliance with Federal ethics statutes applicable to Federal
employees regarding conflicts of interest as well as membership on the
board of directors and staffing by VA or non-VA personnel should be
addressed satisfactorily before congressional approval is given.
It has taken over 20 years of regular consultation with VA
policymakers, attorneys, and overseers; two modifications of the
original NPC authority; and most recently, a thorough updating and
clarification of the NPC authority, to resolve the many ambiguities
inherent in the public/private partnership embodied in the NPCs. To
avoid similar protracted uncertainty, a number of matters not addressed
in the proposal should be resolved before the Subcommittee considers
approving an authority for a central VA nonprofit.
For example, would VA personnel serve on the board of the central
VA nonprofit? How much influence would VA personnel have over funding,
management and expenditures of the central VA nonprofit? Also, how
would potential conflicts of interest be addressed? It took VA and
NAVREF many years to grasp the implications of the Federal ethics
statutes, particularly those found at 18 USC Sec. 208 and Sec. 209,
when applied to VA personnel associated with NPCs, and to manage
potential conflicts. In our view, these questions should be fully
answered in advance to avoid putting VA employees who may interact with
the central VA nonprofit at risk of unwittingly violating Federal
ethics statutes.
6. Congress should ensure that funds that could be appropriately
managed by local mechanisms may not be directed to the central VA
nonprofit.
As noted above, we firmly believe in the advantages of local
administration and local accountability for VA research. Also, it is
important to note that ultimately, every research project requires a PI
and a site where the research is actually conducted. As a result, and
assuming the central VA nonprofit would not have its own laboratories
or patients, we are concerned that the central VA nonprofit may add an
unnecessary layer of bureaucracy and administrative expense to VA
research. Consequently, we feel there must be a compelling reason for a
central VA nonprofit to administer a project as opposed to longstanding
local mechanisms such as NPCs.
Additionally, we are having difficulty envisioning what ``national
medical research and education projects'' VA would engage in that NPCs
could not administer. VA's genomic research initiative has been cited
as an example, but we have not yet fully grasped why a designated NPC
could not accept non-VA Federal or private sector funds made available
for this initiative. Nor have we been able to discern how a central
nonprofit would fulfill the regulatory requirements for local oversight
of human subjects research.
Further, we encourage the Subcommittee to ask VA how the central VA
nonprofit would allow VA to ``compete for non-VA funding at a national
level.'' NPCs and VA-affiliated universities have historically
supported VA PIs in their applications for non-VA funding whatever the
source, scope or amount. We are uncertain what funding ``at a national
level'' means or what types of non-VA funding a central VA nonprofit
could apply for that excludes applications submitted by VA PIs through
NPCs or VA-affiliated universities. That said, if a central VA
nonprofit were to compete for the same non-VA Federal and private
sector research funding opportunities as PIs supported by NPCs, the
result may be a reduction in NPCs' ability to provide much needed
research infrastructure support at the facility level.
7. There must be sufficient justification for the substantial
investment of funds and effort establishing a central VA nonprofit
would require.
While we assume that statutory approval to establish a central VA
nonprofit would also authorize startup funding from the R&D
appropriation, we are concerned about the use of R&D appropriated funds
for two reasons. First, allocating $200,000 for startup of a central VA
nonprofit would take funds away from ongoing VA research. Second, the
proposed budget of $200,000 for each of the first 2 years appears far
too low, particularly if this nonprofit would be incorporated and
managed in the Washington, DC area. Even if VA relied on VA attorneys
and accountants to assist with incorporation and filing for exemption
from Federal taxes, and VA provided office space, utilities and other
government resources, a central VA nonprofit would require an executive
director experienced in nonprofit establishment and management as well
as skilled in research administration. Additionally, it is likely that
a central VA nonprofit would require a bookkeeper experienced in
nonprofit accounting and administrative staff. Annual salaries alone
are likely to add up to far more than $200,000 during the first few
years.
Also, 2 years seems to be a very short timeframe for the central VA
nonprofit to become self-sustaining. It would have to charge funders
for its administrative services as well as those of any organizations
to which it passes through funds. VA should anticipate that some
funders would pay little or no indirect costs and as a nonprofit
affiliated with a Federal agency, its Federal indirect cost rate is
likely to be relatively low because Federal agencies will not fund
facility costs of another Federal agency. These factors clearly portend
a much higher cost to the Federal budget than the unrealistic startup
estimate noted in the proposed budget and continuing for a longer time
period. In our view $400,000 for each of the first 3 years would be a
more realistic estimate.
Conclusion
Strikingly missing from the central VA nonprofit's purposes is any
discussion of how a central VA nonprofit would benefit veterans or
further VA's research mission. We do not view serving as a ``focus for
interdisciplinary interchange and dialogue'' among VA personnel and
researchers from other Federal and non-Federal entities as appropriate
justification for a central VA nonprofit. Rather, the ultimate test
should be whether it would foster advances in treatments for conditions
prevalent among veterans and high-quality care for the veteran
population VA serves.
Again, NAVREF is unable to take a position in support of VA's
proposal for a central nonprofit. If VA pursues such an authority, we
hope that the above discussion offers the Subcommittee a framework for
determining why such an authority is needed when there are already so
many VA-affiliated nonprofits providing a wide variety of services in
support of VA research and education.
Thank you for considering our views. Questions or comment may be
directed to Barbara West, Executive Director, NAVREF, at
[email protected] or 301-656-5005.
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
March 9, 2010
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20240
Dear Secretary Shinseki:
Thank you for the testimony of Dr. Robert A. Petzel, Under
Secretary for Health, at the U.S. House of Representatives Committee on
Veterans' Affairs Subcommittee on Health oversight hearing on ``The
Veterans Health Administration's Fiscal Year 2011 Budget'' that took
place on February 23, 2010.
Please provide answers to the following questions by April 20,
2010, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. VA requests $250 million in fiscal year 2011 for the Office of
Rural Health. In 2009, there was $190 million in carryover funds which
are available to be spent in 2010. Why is VA having difficulty spending
this money? What steps has VA taken to ensure that resources are spent
in a timely manner in the fiscal year that the funds were appropriated?
2. As you know, for fiscal year 2010, Congress provided an
additional $30 million for the Medical Facilities account so that VA
can open new CBOCs in rural areas. Does the fiscal year 2011 budget
continue and expand on this effort? Also, please identify the total
number of new CBOCs, be they new constructions or leases, that are
supported by the fiscal year 2011 budget request.
3. It is my understanding that VA has implemented a systemwide
screening for returning OEF/OIF veterans for depression, PTSD, TBI, and
problem drinking. How much funding is requested in the fiscal year 2011
budget to continue this screening? To date, what are some key findings
of this screening? For example, how many are screened positive and
receive treatment?
4. How much funding is requested in the fiscal year 2011 budget to
continue VA's suicide prevention hotline? How does this compare to what
VA spent in 2009 and will spend in 2010? Also, what are the latest
program data on the hotline?
5. In a June 2009 press release, VA committed to expanding the
enrollment of Priority Group 8 veterans into the VA system by more than
500,000 by fiscal year 2013. How much additional funding is needed to
fulfill this commitment in the outyears? Finally, what steps is VA
taking to ensure that the expanded enrollment is implemented in a
responsible manner so that it does not overwhelm the current VA health
care system?
6. The President has committed to deploying an additional 30,000
U.S. troops to Afghanistan. Does VA have a clear sense of the numbers
of deploying and returning servicemembers so that VA can plan properly
for the VA health care system to meet the increasing health care needs?
Please describe the nature and the extent of the coordination and
communication between VA and DoD.
7. VA expects to provide over $4 billion to help homeless veterans
in fiscal year 2011. Of this, $3.4 billion is for medical services and
nearly $800 million is for specific homeless programs. Of the $800
million, a relatively small portion of funds is dedicated to prevention
efforts. Please explain how prevention fits into VA's overall strategy
to end homelessness among our veterans.
8. VA informs that investments in homeless initiatives in fiscal
year 2011 will emphasize education, jobs, prevention and treatment
programs. Please explain the details of the education and jobs
investments.
9. The fiscal year 2011 budget includes several legislative
proposals to help caregivers of veterans. This includes health coverage
through CHAMPVA, travel expenses, and education and training. As you
know, both the House and Senate passed caregiver bills. What specific
population of eligible veterans and caregivers do the fiscal year 2011
legislative proposals intend to target?
10. With the funds requested in the fiscal year 2011 budget, VA
expects to spend about $218 million for women veterans. This includes a
new peer call center and social networking site. Please expand on the
details of the call center and social networking site proposals.
11. What is VA's long-term strategy to improve the care provided
to women veterans and how does the fiscal year 2011 budget request for
women veterans fit into this long-term strategy?
12. During the past year, the Committee has become concerned over
reports that there are problems in the implementation of the NDAA
fiscal year 2008 and NDAA fiscal year 2009 sections regarding the joint
establishment of the Defense and VA Centers of Excellence for Vision,
Hearing, and Limb Extremity `orthopedic injury.' We would like to know
what VA staff has been appointed to these three centers, the budget for
this year as well as fiscal year 2011-2012, and locations of these
joint centers.
13. The Committee has been told that strong concerns over the
organizational structure of these three Centers of Excellence have
resulted in numerous meetings and delays in implementation. Where do
the Directors and Deputy Directors report to, in both DoD and within
VHA?
14. The 2011 budget provided $590 million for medical and
prosthetic research, which is $9 million above the 2010 enacted level.
However, this increase does not keep pace with the estimated inflation
for biomedical research and development. Does this mean that VA will
have to decrease staff and/or award fewer grants?
15. The 2011 budget includes a legislative proposal to create a
central nonprofit corporation for VA research. It is my understanding
that the VA already has more than 80 research and education nonprofit
corporations, or NPCs. What could a central VA nonprofit do that the
existing NPCs cannot? Please be specific in your response.
16. In an effort to better understand the need for the legislative
proposal to create a central nonprofit corporation, I would like to
know if there are opportunities for non-VA support for research that VA
is unable to accommodate through its own authorities, through the NPCs
or through VA-affiliated universities. If yes, please give specific
examples.
17. Also related to the legislative proposal to create a central
nonprofit corporation, I would like to know whether under the current
law, regulations, or policies, there are specific impediments to VA
research that central nonprofit is intended to overcome.
18. Of the $48.2 billion requested in fiscal year 2011 for the
medical care accounts, about 80 percent of the funds are distributed to
the 21 VISNs using the VERA General Purpose Fund and 20 percent is
distributed to select VISNs for special programs and initiative using
the VERA Specific Purpose Fund. In the fiscal year 2012 budget request,
the projected funding distribution using the VERA Specific Purpose Fund
decreases to about $290 million compared to the fiscal year 2011
request. It is my understanding that the VERA Specific Purpose Fund
provides resources for special programs such as mental health and
homeless grants. As these are priority initiatives, what is the
rationale for decreasing the funding set-aside for the VERA Specific
Purpose Fund?
19. After years of no major hospital construction, there are now a
few projects in the pipeline scheduled for completion. I believe the
first one is scheduled to open in 2012. At what point are budgetary
arrangements going to be made to ensure activation or to bring them
online? For example, if a facility is opening in 2012, would activation
funds be included in the fiscal year 2011 budget?
20. Of the budget request for medical facilities, how much is for
facility activation? How does VA develop the budget request for
facility activation and how do you disseminate the facility activation
funding? In other words, must localities apply for this funding or are
the funds set aside for a defined list of facilities?
21. In 2010, resident engineers were funded from the GOE account.
The 2011 budget requests $24 million to fund 140 resident engineers in
the major constructions account, but these funds would be used to
reimburse the GOE account. What is the rationale for requesting funding
for resident engineers under the major construction account only to
reimburse the GOE account? Why not keep the funding for the resident
engineers in the GOE account? Also, how many resident engineers were
funded in 2010 and please justify whether 140 resident engineers in
2011 is sufficient to oversee the major construction projects of VA.
22. The budget proposes $468 million for minor construction
programs in 2011, of which $387 million is for VHA. This represents a
decrease of $235 million from 2010. Please explain the proposed
decrease in funding when VA facilities are aging and minor construction
demands continue to grow.
23. VA requests about $1.3 billion for medical IT investments to
develop the next generation health care system known as HealtheVet to
enhance and supplement the current legacy system, VistA. This is a
decrease of about $150 million from the 2010 level. In light of this
focus on HealtheVet, what is the rationale for the decrease in funding
in 2011?
24. Please provide an update on VA's collaboration with DoD to
create Virtual Lifetime Electronic Records (VLER). How much is
requested in the fiscal year 2011 budget for the VLER initiative and
what is the full project cost in the out-years in fiscal year 2012 and
beyond to fully develop and implement VLER?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by April 20, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
Submitted by Chairman Michaud
U.S. House of Representatives Committee on Veterans' Affairs
Subcommittee on Health
February 23, 2010
The Veterans Health Administration's (VHA) Fiscal Year 2011 Budget
Question 1: VA requests $250 million in fiscal year 2011 for the
Office of Rural Health. In 2009, there was $190 million in carryover
funds which are available to be spent in 2010. Why is VA having
difficulty spending this money? What steps has VA taken to ensure that
resources are spent in a timely manner in the fiscal year that the
funds were appropriated?
Response: Congress provided the Veterans Health Administration
(VHA) Office of Rural Health (ORH) with $250 million in 2 year funds
(fiscal year 2009/2010) for rural health care initiatives. Since
December 2008, $213 million have been distributed to the Veterans
Integrated Service Networks (VISNs) and VHA program offices. Of the
$213 million allocated, $212 million has either already been obligated
or is specifically identified for obligation before the end of Fiscal
Year (FY) 2010.
There are several reasons why rural health care dollars have been
delayed in obligation, which fall into three broad categories. First,
the pool of qualified bidders willing to contract with Department of
Veterans Affairs (VA) to provide health care in rural communities is
limited. Second, identifying qualified employees in highly rural areas
has proven difficult, and finding health care workers willing to move
to isolated areas has also been a challenge. Third, identifying
appropriate physical space for clinical activities in rural areas that
meet privacy standards has been a challenge, as well. Frequently, the
space has required significant alteration, thus causing delays in
construction and obligating dollars for completion of these projects.
Please be assured, however, that additional project enhancements
and/or new projects are currently under consideration, which will
result in obligating the remaining $38 million before the end of FY
2010.
Question 2: As you know, for fiscal year 2010, Congress provided an
additional $30 million for the Medical Facilities account so that VA
can open new CBOCs in rural areas. Does the fiscal year 2011 budget
continue and expand on this effort? Also, please identify the total
number of new CBOCs, be they new constructions or leases that are
supported by the fiscal year 2011 budget request.
Response: VA is committed to enhancing access to health care for
veterans residing in rural and highly rural areas. On March 30, 2010, a
Report to Congress was provided to the Committee on Appropriations of
both Houses of Congress to detail an expenditure plan for the $30
million funding for community based outpatient clinics (CBOCs) in rural
areas. VA has invested a total of $62.1 million ($30 million as
directed and $32.1 million from rural health funding) in FY 2010 and is
planning to invest $87.8 million in FY 2011 rural health funding for 51
of the FY 2010 activated CBOCs located in rural counties (see attached
list of CBOCs and funding plan) for a total 2-year investment of $149.9
million. This investment will sustain the 51 CBOCs in 11 VISNs for the
first 2 years of operation. The FY 2011 budget will continue the
operation of the rural CBOCs, which were opened in FY 2010 and funded
with the $30M. At this time, plans for any additional CBOCs in FY 2011
are part of an ongoing evaluation and assessment process to address the
health care needs of our veterans.
Question 3: It is my understanding that VA has implemented a
systemwide screening for returning OEF/OIF veterans for depression,
PTSD, TBI, and problem drinking. How much funding is requested in the
fiscal year 2011 budget to continue this screening? To date, what are
some key findings of this screening? For example, how many are screened
positive and receive treatment?
Response: No additional funding will be required as the screening
activity is built into the existing budget. Cumulatively from the first
quarter of FY 2002 through the fourth quarter of FY 2009 (the most
recent complete data available) among Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) veterans who have been treated at VA
medical centers and clinics, 129,654 have been seen for at least a
provisional diagnosis of post traumatic stress disorder (PTSD), 90,936
for depression, and 24,454 for alcohol dependence. These numbers
represent veterans who have received a diagnosis from at least one
provider during at least one clinical encounter. They should be
considered to be provisional diagnoses that may have changed during
subsequent encounters when more information became available.
An FY 2008 records review of a small representative sample of
veterans from all service eras has data to address the question of
veterans screened and referred for treatment. Of that sample, 7,231
veterans screened positive for the possibility of PTSD, and of that
population 1,724 (23.8 percent) were documented as being positive for
PTSD and referred for further intervention/treatment. The number of
OEF/OIF veterans in the study sample was too small to be effectively
broken out. The question of OEF/OIF veterans screened and followed up
for treatment will continue to be explored using VA databases.
From April 2007 through December 2009, VA has screened 383,054 OEF/
OIF veterans for possible mild traumatic brain injury (TBI). Of these,
71,158 screened positive for potential mild TBI and were referred for
comprehensive followup evaluations. To date, 27,287 have received a
confirmed diagnosis of having suffered a mild TBI; all are referred for
ongoing treatment as necessary for their medical condition. Over 90
percent of all veterans who screen positive have been determined not to
have suffered a TBI, but all who are screened and report current
symptoms are evaluated and treated as appropriate for their condition
and symptoms.
In FY 09, VA screened over 96 percent of eligible veterans for
alcohol misuse with a validated screening measure and screening remains
at 97 percent in FY 10 to date. Data on alcohol misuse screening
prevalence and followup are available for 737 OEF/OIF veterans included
in a FY 2007 national sample of VA outpatients randomly selected for
standardized medical record review for quality monitoring. Age adjusted
prevalence of alcohol misuse was higher in OEF/OIF men than non-OEF/OIF
men (21.8 percent vs. 10.5 percent), but did not differ reliably within
the smaller sample of OEF/OIF and non-OEF/OIF women (4.7 percent vs.
2.9 percent). Age adjusted rates of documented advice or feedback (31.6
percent vs. 34.6 percent) and referral (24.1 percent vs. 28.9 percent)
were not significantly different between OEF/OIF and non-OEF/OIF men
who screened positive for alcohol misuse. Overall, OEF/OIF men were
more likely to screen positive for alcohol misuse than non-OEF/OIF men
and approximately half of all those with alcohol misuse had documented
counseling and/or referral to alcohol treatment.
Question 4: How much funding is requested in the fiscal year 2011
budget to continue VA's suicide prevention hotline? How does this
compare to what VA spent in 2009 and will spend in 2010? Also, what are
the latest program data on the hotline?
Response: Suicide Hotline budget for FY 2009 and FY 2010 are as
follows:
FY 2009: $11,177,433
FY 2010: $15,068,350 (projected)
The increase from 2010 reflects both increased utilization of the
program and enhancements to its activities, including growth of the
online Internet chat service, and increases in services for active duty
personnel. In general, staffing and costs for the hotline are based on
projections of the demand for its services.
Question 5: In a June 2009 press release, VA committed to expanding
the enrollment of Priority Group 8 veterans into the VA system by more
than 500,000 by fiscal year 2013. How much additional funding is needed
to fulfill this commitment in the outyears? Finally, what steps is VA
taking to ensure that the expanded enrollment is implemented in a
responsible manner so that it does not overwhelm the current VA health
care system?
Response: VA's base budget request already includes funding for the
expanded enrollment commitment. VA is closely monitoring observed
demand for enrollment and patient access, and proposes expansion of
enrollment based on the availability of resources to meet current and
projected demand through subsequent relaxations of enrollment
restrictions.
Question 6: The President has committed to deploying an additional
30,000 U.S. troops to Afghanistan. Does VA have a clear sense of the
numbers of deploying and returning servicemembers so that VA can plan
properly for the VA health care system to meet the increasing health
care needs? Please describe the nature and the extent of the
coordination and communication between VA and DoD.
Response: Due to operational readiness issues and sensitivity
surrounding actual plans for military deployments, VA utilizes data
from the Congressional Budget Office (CBO) to project the overall
number of servicemembers that may seek care at VA in any given year.
The VA enrollee health care projection model projects separate OEF/OIF
veteran enrollment and utilization. The model is updated annually to
reflect VA's most recent experience among the OEF/OIF veteran
population. The overall FY 2011 and FY 2012 funding levels for medical
care takes into account the impact of publically announced increases in
troop deployment levels.
Question 7: VA expects to provide over $4 billion to help homeless
veterans in fiscal year 2011. Of this, $3.4 billion is for medical
services and nearly $800 million is for specific homeless programs. Of
the $800 million, a relatively small portion of the funds is dedicated
to prevention efforts. Please explain how prevention fits into VA's
overall strategy to end homelessness among our veterans.
Response: Prevention is one of VA's six strategic pillars of
intervention and services to end homelessness among veterans. VA will
enhance prevention by offering grants to assist vulnerable veterans and
their families; enhance health care and benefits to veterans involved
with the criminal justice system; enhance street outreach and provide
additional contracts with community providers who will help get
veterans off the streets and engage them with appropriate services to
end their homelessness. Below are four of VA's initiatives to prevent
homelessness:
Supportive Services for Low-Income Veteran Families
Under the 2011 proposed budget VA will enhance prevention by
offering more than $50 million for Supportive Service Grants for Low-
Income Veterans and Families at 50 percent or less of area median
income. This initiative will establish and provide grants and technical
assistance to community nonprofit organizations to provide case
management and supportive services for eligible veterans and their
families to maintain their current housing and in cases where the
veteran lacks financial capability to secure deposits, get them into
permanent housing. This will include financial assistance to prevent
veterans falling into homelessness. We expect to award funding in 2011
that will provide services for 22,500 veterans and families.
HUD-VA Homeless Prevention Pilot
Housing and Urban Development (HUD) and VA are initiating a
prevention initiative which is a multi-site 3-year pilot project
designed to provide early intervention to recently discharged veterans
and their families to prevent homelessness. This collaborative effort
will provide comprehensive community services for veterans and families
and intensive case management by VA to provide needed health care and
benefit assistance to eligible veterans. VA expects to spend $5 million
to provide services to 200-300 veterans and families in 2011.
Programs for Justice-Involved Veterans
The prevention of homelessness requires a wide variety of efforts,
including working with veterans who are being seen in the criminal
justice system. The Health Care to Re-Entry (HCR) program aims to
prevent homelessness by engaging veterans discharging from prisons and
by providing linkage to VA services. VA also has a Veterans Justice
Outreach program that provides direct linkage to veterans in drug,
mental health, and veterans courts to offer appropriate health care
services designed to get the veteran needed treatment that will prevent
them from becoming homeless. VA expects to spend $12.6 million to
provide direct services to more than 7,500 veterans in 2011.
Health Care for Homeless Veterans Contract Residential Care
VA's Health Care for Homeless Veterans (HCHV) program provides
outreach services to more than 40,000 homeless veterans each year. HCHV
is increasing resources and capacity at each VA medical center to
realize the commitment to ``no wrong door'' by contracting with
community partners who will provide comprehensive residential care for
veterans who seek safe places to stay where immediate admission to a VA
operated program is not available. VA expects to spend nearly $116
million and provide services to 12,000 veterans in 2011.
Question 8: VA informs that investments in homeless initiatives in
fiscal year 2011 will emphasize education, jobs, prevention and
treatment programs. Please explain the details of the education and
jobs investments.
Response: Education and employment is another of VA's six strategic
pillars in the continuum of interventions and services to end
homelessness among veterans. VA is constantly striving to provide more
supportive services through partnerships to prevent homelessness,
improve employability, and increase independent living for veterans. We
will do this by enhancing Compensated Work Therapy/Supported Employment
(CWT/SE), Homeless Veterans Reintegration (HVRP) and the Vocational
Rehabilitation and Employment (VR&E) Vet Success programs. Below are
descriptions of these programs:
Compensated Work Therapy/Supported Employment (CWT/SE)
Program
One of the key needs for many veterans is to return to gainful
employment. Many veterans who have been homeless have years without
productive employment. Many suffer with physical and mental issues that
require them to participate in a therapeutic rehabilitative effort in
order to once again be able to return to a position where they can
become employment ready. The CWT/SE program is a therapeutic employment
program targeted at veterans with significant health problems.
VA currently offers CWT services at VA Medical Centers. Under our
2011 budget VA plans to expand CWT/SE services into the community by
offering community-based staff that will target supportive employment
opportunities for veterans with significant health problems. The
availability of these services in community settings will increase
employment opportunities available for veterans. VA plans to spend more
than $29 million and provide community based CWT/SE services for 8,150
veterans in 2011.
Homeless Veteran Reintegration Program (HVRP)
The Department of Labor's (DoL) HVRP program is a key partnership
with VA at the Federal level. DoL's Veterans Employment and Training
Service (VETS) offers funding to community groups to get veterans back
into gainful employment. VA aids this effort and works closely with DoL
and its grantees to coordinate that needed health care and benefits
assistance is provided. This close working relationship is beneficial
to the veterans we mutually serve since employment opportunities,
without addressing underlying health care and benefits, may produce
gains that are not maintained over time.
VA continues to partner with DoL and looks forward to working with
them as they fund women-only HVRP programs and offer funding for
Incarcerated Veteran Transition programs.
VBA Benefits
The Vocational Rehabilitation and Employment (VR&E)
VetSuccess Program
This program is authorized by Congress under Title 38, Code of
Federal Regulations, Chapter 31. The VetSuccess program assists
veterans with service connected disabilities: to prepare for, find, and
keep suitable jobs. For veterans with disabilities so severe that they
cannot immediately consider work; VetSuccess offers services to improve
their ability to live as independently as possible. Homeless veteran
and those at risk of becoming homeless apply for benefits through VBA's
Vocational Rehabilitation and Employment program.
Question 9: The fiscal year 2011 budget includes several
legislative proposals to help caregivers of veterans. This includes
health coverage through CHAMPVA, travel expenses, and education and
training. As you know, both the House and Senate passed caregiver
bills. What specific population of eligible veterans and caregivers do
the fiscal year 2011 legislative proposals intend to target?
Response: With the passage of P.L. 111-163 ``Caregivers and
Veterans Omnibus Health Services Act of 2010'' on May 5, 2010, VA is
currently analyzing the legislation and determining the population of
eligible veterans.
Those proposals include:
One proposal provides the Civilian Health and Medical Program of
the Department of Veterans Affairs (CHAMPVA) benefits to caregivers
without entitlement to other health insurance or coverage. This benefit
would apply to one caregiver for each eligible veteran, provided that
the caregiver meets all other CHAMPVA criteria.
The second proposal would provide travel benefits to the
caregivers of veterans in a manner similar to that currently available
to family caregivers of active duty servicemembers when the
servicemember or veteran is receiving care for service related
conditions. This proposal would only apply to the caregivers of
eligible veterans with service after September 11, 2001.
The third proposal would provide caregiver education
materials for caregivers and individuals who support caregivers. The
proposal assumes one caregiver per veteran would qualify.
The final proposal would provide that VA conduct a caregiver
survey every 3 years to determine the number of caregivers, the types
of services they provide and information about the caregiver.
Question 10: With the funds requested in the fiscal year 2011
budget, VA expects to spend about $218 million for women veterans. This
includes a new peer call center and social networking site. Please
expand on the details of the call center and social networking site
proposals.
Response: The $218 million listed in the budget on page 1K-32,
Volume 2 of 4, is for Gender Specific Health Care Services for
approximately 186,000 unique patients. These services would include
mammography and breast care, reproductive health care, including
maternity services, and treatment for all female-specific diagnostic
conditions and disorders. However, it does not include a proposal for a
specific women veteran call center or social networking site. This will
be addressed through a VA transformation initiative. Every VA medical
center has a women veterans program manager designated to assist women
veterans. In addition, VA currently uses Facebook, Twitter, Flicker,
and YouTube to improve communication with all veterans, including women
veterans, to help them access health care and benefits.
Question 11: What is VA's long-term strategy to improve the care
provided to women veterans and how does the fiscal year 2011 budget
request for women veterans fit into this long-term strategy?
Response: VA has continued long term strategic plans to enhance the
provision of health care services to women veterans. The following
elements from the plan are outlined as they relate to the FY 2011
budget request:
Fully Implement Comprehensive Primary Care for Women Veterans
Staffing: Providers proficient in women's health.
Staffing: Support staff for care coordination within
medical home care in women's health.
Facility Resources: Construction enhancements focusing on
dignity, privacy and safety.
Equipment and Supplies: Necessary clinical enhancements to
deliver primary care.
Training: Retrain providers to care for women veterans.
Communication: Effective internal and external
communication about the care needs of women veterans.
Beginning with FY 2010, the VHA's New Model of Care
Initiative supports the addition of primary care support staff,
training, and some space configuration for women's health. In the FY
2011 budget request, general medical services dollars will continue to
support the overall medical care provision for women veterans. In
addition, the FY 2011 budget line item request for women veterans
specifically increases the amount needed for gender-specific care, such
as cervical and breast cancer screenings.
Develop a High-Quality Continuum of Health Care for Women
Veterans
The strategic goal is to fully integrate specialty care services
for women veterans at the facility level. In FY 2011, the requested
budget will support Comprehensive Care Services for women veterans that
includes:
Mental Health
Specialty Care
Emergency Care
Diagnostic Services
Tele-Health
Geriatric and extended care services
Women's health and wellness screening and prevention
programs
Rehabilitation health (catastrophically injured women)
Question 12: During the past year, the Committee has become
concerned over reports that there are problems in the implementation of
the NDAA fiscal year 2008 and NDAA fiscal year 2009 sections regarding
the joint establishment of the Defense and VA Centers of Excellence for
Vision, Hearing, and Limb Extremity `orthopedic injury.' We would like
to know what VA staff has been appointed to these three centers, the
budget for this year as well as fiscal year 2011-2012, and locations of
these joint centers.
Response: National Defense Authorization Act (NDAA) of 2008 and
2009 establishes each of these as Department of Defense (DoD) Centers
of Excellence. The legislation mandates collaboration from DoD ``to the
maximum extent practicable with the Secretary of Veterans Affairs'' for
the Hearing Loss and Auditory Injuries Center, and Vision Center. The
legislation mandates that DoD and VA ``jointly'' establish the Center
for Extremity Injuries and Amputation. VA has been steadily involved
and working with DoD representatives to develop plans for these
centers, and the registries associated with them.
The Vision Center of Excellence currently occupies temporary DoD
space within the Washington, DC area. A congressional supplemental
appropriation for DoD ($4.052 million) was approved for a permanent
location at the Walter Reed National Military Medical Center in
Bethesda, Maryland, with expected occupancy in fourth quarter FY 2011.
VA has committed a total of six staff members for the Vision Center.
The positions are currently supported for Deputy Director (detailed
effective April 12, 2010), Chief of Staff (position filled), and a
Blind Rehabilitation Specialist (detailed). A permanently hired Deputy
Director and a Blind Rehabilitation Specialist have been selected, and
are expected to begin third quarter FY 2010. VA is recruiting for the
low vision research specialist (optometrist), administrative assistant,
and biostatistician. Originally, the biostatistician position was going
to be filled via DoD under a contract; however, VA just recently agreed
to take responsibility for this recruitment and is in the process of
developing a position description. Of the funding provided by Congress
in FY 2009, VA allocated $6.9 million in the Medical Services
appropriation for FY 2010 through 2014 and the funding for FY 2010
through 2012 is presented below. Cost for support of the Registry for
FY 2010 is $1.7 million.
------------------------------------------------------------------------
Budget FY10 FY11 FY12
------------------------------------------------------------------------
O&M $1.1M $1.1M $1.5M
------------------------------------------------------------------------
IT (Registry) $1.7M
------------------------------------------------------------------------
Plans for the Hearing Loss and Auditory Injuries Center, and the
Center for Extremity Injuries and Amputation, are still under
development by DoD and have not yet been submitted to VA for review.
Consequently, the level of support from VA will be determined when the
plans are finalized.
Question 13: The Committee has been told that strong concerns over
the organizational structure of these three Centers of Excellence have
resulted in numerous meetings and delays in implementation. Where do
the Directors and Deputy Directors report to, in both DoD and within
VHA?
Response: For the Vision Center, VA staff report organizationally
to the VHA Chief Patient Care Services Officer, through the VA National
Program Directors for their respective disciplines; i.e., the VA
National Program Directors for Ophthalmology, for Optometry, and for
Blind Rehabilitation Service. VA staff functionally report to the DoD
Executive Director for the Center. The DoD Executive Director currently
reports to the Director of the TRICARE Management Activity, Under
Assistant Secretary of Defense for Health Affairs.
Plans for the Hearing Loss and Auditory Injuries Center and the
Center for Extremity Injuries and Amputation are still under
development by DoD. VA continues to be involved in working groups with
DoD representatives to assist in developing concepts of operations and
plans for these centers and the level of support from VA with regard to
budget and staff will be determined when the plans are finalized.
Question 14: The 2011 budget provided $590 million for medical and
prosthetic research, which is $9 million above the 2010 enacted level.
This increase does not keep pace with the estimated inflation for
biomedical research and development. Does this mean that VA will have
to decrease staff and/or award fewer grants?
Response: The increase in appropriations from FY 2009 ($510
million) to FY 2011 ($590 million) is 16 percent. The Office of
Research and Development will be able to execute their mission without
any adverse impacts.
Question 15: The 2011 budget includes a legislative proposal to
create a central nonprofit corporation for VA research. It is my
understanding that the VA already has more than 80 research and
education nonprofit corporations, or NPCs. What could a central VA
nonprofit do that the existing NPCs cannot? Please be specific in your
response.
Response: This legislative proposal remedies several deficiencies
associated with the use of local nonprofit corporations (NPC) in
support of national research initiatives. It does so by minor
modifications of the current law that strengthen accountability for
national program operation by making the Chief Research and Development
Officer and Chief Academic Affiliations Officer statutory members of
the Board of the National Nonprofit, and assures that other members of
the board serve under the same ethical and financial restrictions that
govern board members for local NPCs. The Central NPC will not
``compete'' with local NPC's, nor operate in a manner similar to that
of the Henry M. Jackson Foundation. Had that been the intent of the
legislative initiative, a plan for disestablishing the local NPCs would
have been proposed. It is expected that the Central NPC will often work
cooperatively with the local NPCs, administering national research
while each of them administers the particular part of the national
study that is accomplished at its VAMC.
The nature of research has changed since 1988, with an increasing
emphasis on interdisciplinary, large multi-site research. The VA is
uniquely able to conduct this type of research because clinical care
and research are under the same roof. Current NPCs work well with its
current authority to manage studies in its specific jurisdictions, but
the decentralized system does not allow VA to efficiently and
effectively coordinate non-VA funded large multi-site research at a
systemwide level, or to compete for non-VA funding at a national level.
A central NPC will be integral to the future of VA's Genomic
Medicine initiative to develop a genomic database that links patient
genetic information with longitudinal health outcomes using VA's
electronic health record. Few areas hold as much promise for changing
everyday practice of health care delivery. This initiative includes the
Million Veteran Program to collect samples and health information, with
longitudinal followup, on a million veterans--an effort that will be
unparalleled anywhere in the world. It also includes nationwide studies
to examine the genetic bases of mental health issues such as
schizophrenia and bipolar disease. This initiative requires
partnerships with other Federal and non-Federal research entities, for
which a central NPC will be an essential enabler. VA's Genomic Medicine
initiative is a national program whose activities will not be managed
in a specific VAMC, so a central NPC without ties to a specific VAMC,
as is required by current statutory authority, is crucial to the future
of this program. Likewise, when VA Cooperative Studies leverage funding
by partnering with industry partners, a central NPC would facilitate
the dissemination of funding to the multiple coordinating centers and
sites. While it is true that the Cooperative Studies Program has been
able to operate within the current framework of local NPCs, its concern
has been overwhelmingly with only intramural research funded fully
through VA's research appropriation. Such funds are wholly managed
within VA without assistance from the NPCs. When outside funds are
needed or appropriated for national or multi-site research, the Central
NPC will provide VA with a mechanism for obtaining, administering and
overseeing such funds. Indeed, since the Chief Research and Development
Officer and Chief Academic Affiliations Officer of VA will serve on the
Board of the proposed Central NPC, the new arrangement will give VA, at
the national level, the same level of oversight and accountability for
NPC operations in support of national programs that local facility
Directors now have for local NPCs.
The purpose of the Central NPC will be to: (1) act as a flexible
funding mechanism for the conduct of national medical research and
education projects under cooperative arrangements with VA, (2) serve as
a focus for interdisciplinary interchange and dialogue between VA
medical research personnel and researchers from other Federal and non-
Federal entities and (3) encourage the participation of the medical,
dental, nursing, veterinary and other biomedical scientists at VA in
research at the national level that will be facilitated by the Central
NPC for the mutual benefit of VA and non-VA medicine, veterans and the
public.
The establishment of a central NPC also creates synergies with
other efforts currently underway in VA to improve the health and well-
being of veterans. This includes VA's development of a central
Institutional Review Board (IRB) to streamline the IRB review process
for large multi-site studies. This type of study, especially when
supported by outside funding, is the type that a central NPC will
better enable VA to conduct. The existence and authorities of the local
NPCs would be unaffected.
Question 16: In an effort to better understand the need for the
legislative proposal to create a central nonprofit corporation, I would
like to know if there are opportunities for non-VA support for research
that VA is unable to accommodate through its own authorities, through
the NPCs or through VA-affiliated universities. If yes, please give
specific examples.
Response: A central NPC can leverage VA funding by negotiating with
non-VA funding agencies, such as National Institutes of Health (NIH),
to support studies associated with large VA projects such as the
Genomic Medicine initiative. It would be neither feasible, nor
appropriate for a local NPC to take on this role on behalf of the
entire VA research enterprise. A central NPC will increase VA's ability
to compete nationally for funding from other Federal, industry and
nonprofit research sponsors, by making VA's research program a more
attractive collaborator. The central NPC will provide VA a more
straightforward mechanism to work with other Federal and non-Federal
research sponsors. It will further give VA more flexibility and
leverage to execute interagency agreements with other Federal research
sponsors, and to assure that VA's responsibilities under these
agreements are appropriately executed with high-level program
accountability. A central NPC will also provide VA with more
flexibility and weight for collaborations with industry and nonprofit
research sponsors. This is particularly relevant for large multi-site
clinical trials where industry and nonprofit research sponsors must
currently negotiate with several separate local VA-affiliated NPCs,
which may result in the sponsors turning to other organizations to
conduct the research.
The Central NPC should be in a more robust financial position than
smaller local NPCs and would be able to enter into research agreements
under the Federal Acquisition Regulation (FAR). Currently, smaller
local NPCs are unable to afford to meet some of the requirements for
subcontractors under the FAR, making research with the DoD through the
Henry M. Jackson Foundation that now requires use of FAR contracts
instead of grants, problematic for the smaller NPCs. Through economies
of scale the Central NPC, after meeting the FAR requirements, would
enter into one larger agreement on behalf of the affected VA sites and
would fully administer the funds for any site where the local NPC was
not able to meet the FAR requirements.
Additionally, the Central NPC will be VA's facilitator for
collaborative research between VA and outside public and/or private
entities which contain centers for excellence or leaders in various
fields. Through the Central NPC, needed funds can be sought and raised
for projects such as this which are of national scope and importance,
in which VA might otherwise be unable to participate.
Question 17: Also related to the legislative proposal to create a
central nonprofit corporation, I would like to know whether under the
current law, regulations, or policies, there are specific impediments
to VA research that central nonprofit is intended to overcome.
Response: By statute, local VA-affiliated NPCs cannot administer
funds for large studies involving a number of VA sites and multiple
VAMCs. They are limited to facilitating research and education at the
one VA medical center (VAMC) at which they were created. The proposal
will, first and foremost, permit the establishment of an NPC that is
not affiliated with a particular VAMC, but which may operate in any or
all VAMCs, including those in which there is a local NPC. This is the
major change accomplished by the proposed legislation. It will allow VA
research that is of national scale to be conceived of, facilitated,
funded and administered on that scale and could usher in a new age for
VA research. The proposed legislation will, in addition, grant VA
limited new authorities not available under the current NPC statute and
clarify others, by allowing: (1) VA to enter into Intergovernmental
Personnel Act agreements with the proposed central NPC; (2) VA and the
Central NPC to enter into Cooperative Agreements with one another to
conduct cooperative enterprises with non-appropriated funds; and (3) VA
to provide appropriated funds and resources to establish the NPC.
Although the Board of Directors of the Central NPC will include VA
Central Office staff, the majority of Directors will not be government
employees. Finally, the Central NPC will be explicitly defined as not
an entity of the U.S. Government.
A central NPC will increase VA's flexibility in using non-VA
funding. It will allow VA to adapt more quickly to changes in science
by shifting the focus on non-VA funding and changing the scope of
agreements with non-VA sponsors more easily. It will also increase VA's
ability to carry over non-VA funds between fiscal years.
A central NPC will increase ability and flexibility to hire
personnel. A central NPC will provide VA a quick and flexible hiring
mechanism for professional, technical and/or clerical personnel as part
of the cooperative agreements with the Central NPC. This will allow VA
to quickly fill gaps in personnel that may be necessary to address
rapidly emerging needs.
Question 18: Of the $48.2 billion requested in fiscal year 2011 for
the medical care accounts, about 80 percent of the funds are
distributed to the 21 VISNs using the VERA General Purpose Fund and 20
percent is distributed to select VISNs for special programs and
initiative using the VERA Specific Purpose Fund. In the fiscal year
2012 budget request, the projected funding distribution using the VERA
Specific Purpose Fund decreases to about $290 million compared to the
fiscal year 2011 request. It is my understanding that the VERA Specific
Purpose Fund provides resources for special programs such as mental
health and homeless grants. As these are priority initiatives, what is
the rationale for decreasing the funding set-aside for the VERA
Specific Purpose Fund?
Response: When comparing FY 2009 and FY 2010 Specific Purpose
funding one needs to consider the one-time congressional funding of
nearly $1.5 billion. Specific Purpose funds actually increased over $1
billion when accounting for the one-time congressional add-ons in FY
2009 (see table below). From FY 2011 to FY 2012, Specific Purpose
funding increases nearly $288 million.
------------------------------------------------------------------------
Description 2009 2010 Inc./Dec.
------------------------------------------------------------------------
VERA Specific Purpose $9,380,011 $9,092,279 ($287,732)
Allocation to VISNs &
Prgs
------------------------------------------------------------------------
Less: Congressional Add-Ons ($1,497,400) ($186,000) $1,311,400
(Non-Recurring)
------------------------------------------------------------------------
Total $7,884,620 $8,908,289 $1,023,669
------------------------------------------------------------------------
2011 2012 Inc./Dec.
------------------------------------------------------------------------
VERA Specific Purpose $9,592,354 $9,880,125 $287,771
Allocation to VISNs &
Prgs
------------------------------------------------------------------------
Question 19: After years of no major hospital construction, there
are now a few projects in the pipeline scheduled for completion. I
believe the first one is scheduled to open in 2012. At what point are
budgetary arrangements going to be made to ensure activation or to
bring them online? For example, if a facility is opening in 2012, would
activation funds be included in the fiscal year 2011 budget?
Response: Funds for estimated activation requirements are included
in each year's budget request. VA budgets an amount estimated to be
sufficient to meet the needs of the VISNs that will be activating
facilities and will have funding requirements in that year. This amount
is based on projected major construction and major leases with
occupancy dates for the current and following years.
Question 20: Of the budget request for medical facilities, how much
is for facility activation? How does VA develop the budget request for
facility activation and how do you disseminate the facility activation
funding? In other words, must localities apply for this funding or are
the funds set aside for a defined list of facilities?
Response: The budget request estimates $268 million for
activations. The activation request is based on anticipated facility
activations. While the funds are set aside for a defined list of
activations, VISNs request these funds to ensure budget execution is
synchronized with actual beneficial occupancy dates of the specific
facilities.
Question 21: In 2010, resident engineers were funded from the GOE
account. The 2011 budget requests $24 million to fund 140 resident
engineers in the major constructions account, but these funds would be
used to reimburse the GOE account. What is the rationale for requesting
funding for resident engineers under the major construction account
only to reimburse the GOE account? Why not keep the funding for the
resident engineers in the GOE account? Also, how many resident
engineers were funded in 2010 and please justify whether 140 resident
engineers in 2011 is sufficient to oversee the major construction
projects of VA.
What is the rationale for requesting funding for resident engineers
under the major construction account? Why not keep the funding for the
resident engineers in the GOE account?
Response: In 2011, resident engineer costs will be moved from the
General Administration (GOE) appropriation to the Major Construction
appropriation in order to directly link the funding for staffing
requirements for major construction to the funding for the projects
themselves.
The Major Construction appropriation will provide funding for on-
site supervision, including resident engineers and other project
administrative staff for VHA and National Cemetery Administration (NCA)
major construction projects located throughout the country.
The Office of Acquisition, Logistics, and Construction (OALC) will
use its GOE appropriation to transform itself into a 21st century
enterprise facilities management system. Under this transformation
initiative, OALC will provide increased local and regional on-site
supervision and support for construction and leasing projects. Because
the costs of resident engineers will be reimbursed from the Major
Construction and Medical Facilities appropriations, OALC will use GOE
funding to hire additional planning staff, project managers,
contracting officers, real property officers and sustainment personnel.
This transformation effort will allow OALC to:
Integrate facilities management functions to maximize
life-cycle performance.
Implement corporate-level management with a decentralized
system of project execution.
Assess and meet facility needs while reducing overall
costs.
Leverage core mission expertise for minor design,
construction and leasing.
Increase technical support for local facilities
engineers.
Increase return on facility investment.
How many resident engineers were funded in 2010?
The GOE appropriation provides funding for 129 full-time
equivalents (FTE) in 2010, including on-site supervision and support.
The Medical Facilities appropriation provides funding for 36 FTE in
2010.
In 2011, funding from the Major Construction appropriation is
requested for 140 FTE, including on-site supervision and support.
Funding from the Medical Facilities appropriation is requested for 62
FTE, an increase of 26 from the 2010 level.
Justify whether 140 resident engineers in 2011 is sufficient to
oversee the major construction projects of VA.
The 2011 Major Construction budget request identifies 5 major
construction projects with funding for construction. There will also be
39 projects under construction in 2011 using prior year funding. An
analysis of the size and scope of the major projects requested and
ongoing major projects indicate that 140 FTE are required to provide
sufficient oversight. This is an average of only 3 to 4 people per site
and includes administrative support necessary to effectively manage
these projects. The number of staff required to adequately provide
oversight varies based on the complexity and scope of the project. More
staff are needed with increased complexity of the work, multiple shifts
and multiple contractors. VA currently has several projects costing
over $100 million, which require at least 5 resident engineers to
oversee various aspects of construction--foundations, electrical,
mechanical, plumbing, dry wall, etc. Insufficient staff can lead to
poor quality work, untimely responses to requests for information from
the contractor, which cause delays in completion and beneficial
occupancy for veterans and increased claims. Inadequate staff can also
slow the close out of contracts since staff must move to a new job
before being able to fully finish the prior job.
Question 22: The budget proposes $468 million for minor
construction programs in 2011, of which $387 million is for VHA. This
represents a decrease of $235 million from 2010. Please explain the
proposed decrease in funding when VA facilities are aging and minor
construction demands continue to grow.
Response: The 2011 minor construction request is the second largest
amount the Department has requested for the minor construction program.
(The largest minor construction budget requested was the President's
2010 budget at $600 million.) Historically, VA has requested $390
million for minor construction (2008-2010). This request is
approximately 20 percent above this historical request level. In
addition, the 2011 request includes $1.1 billion in the medical
facilities account for nonrecurring maintenance (NRM). This is the
largest request VA has ever made for the VHA NRM account. A significant
portion of the VHA NRM account is used to address the repair and
maintenance needs at VA medical facilities.
Question 23: VA requests about $1.3 billion for medical IT
investments to develop the next generation health care system known as
HealtheVet to enhance and supplement the current legacy system, VistA.
This is a decrease of about $150 million from the 2010 level. In light
of this focus on HealtheVet, what is the rationale for the decrease in
funding in 2011?
Response: The $1.3 billion for medical IT investments includes not
only development of HealtheVet; it also includes the sustainment of
VistA Legacy and operational sustainment of medical center IT systems.
The 2011 budget request provides development funding that is comparable
to 2010; the estimated $150 million decrease is represented in the
Operations and Maintenance portion of the budget request and should not
affect the development efforts underway.
Question 24: Please provide an update on VA's collaboration with
DoD to create Virtual Lifetime Electronic Records (VLER). How much is
requested in the fiscal year 2011 budget for the VLER initiative and
what is the full project cost in the out-years in fiscal year 2012 and
beyond to fully develop and implement VLER?
Response: VA is collaborating daily with DoD on various aspects of
the Virtual Lifetime Electronic Record (VLER). A number of lessons
learned from the go-live January 31st date for the VLER Health
Communities exchange of health information between DoD, VA, and Kaiser
Permanente in San Diego, CA are being applied toward the planning of
the next pilot deployment site in the Tidewater, Virginia, area. VA is
working with DoD to determine the next several sites yet to be
announced. Determining the next health data sets, collaborating on
similar functionalities, and establishing a joint integrated master
schedule through the Interagency Program Office are all activities
underway.
There is $52 million in the FY 2011 President's Budget for VLER.
This money will continue deployment and productization of the software
solution created for the VLER Health Communities throughout the VA. It
will also begin to address the overall enterprise architecture and
systems integration required for the long-term strategy for VLER. Work
is commencing in the VLER Enterprise Program Management Office (EPMO)
to develop a multi-year funding profile for VLER that will identify and
incorporate the initiatives required to meet the President's vision of
VLER. It should be noted that the two Departments are not creating a
new system, but leveraging existing initiatives that create the
seamless integration of the information required for all service
providers.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
March 9, 2010
Mr. Blake C. Ortner
Senior Associate Legislative Director
Paralyzed Veterans of America
801 18th Street, NW
Washington, D.C. 20006
Dear Mr. Ortner:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health oversight hearing
on ``The Veterans Health Administration's Fiscal Year 2011 Budget''
that took place on February 23, 2010.
Please provide answers to the following questions by April 20,
2010, to Jeff Burdette, Legislative Assistant to the Subcommittee on
Health.
1. The Independent Budget estimates that it will cost about $252
million to care for an additional 75,000 new OEF/OIF veterans in fiscal
year 2011. However, VA's 2011 budget submission projects spending about
$600 million to care for an additional 57,000 OEF/OIF veterans. This
means that the IB projects a faster growth in OEF/OIF veterans but
estimates that it will cost less to treat these additional individuals.
Please provide an explanation of the basis for The Independent Budget's
projections.
2. The Independent Budget highlights two key policy initiatives
for long-term care and prosthetics. There appears to be a disconnect
between the critical issues that The Independent Budget identified for
fiscal year 2011 in that neither long-term care nor prosthetics were
mentioned in The Independent Budget's critical issues document. Please
explain this disconnect.
3. The Independent Budget recommends $700 million for medical and
prosthetic research in 2011. This is $119 million above the fiscal year
2010 enacted level and $100 million above the Administration's request.
We recognize the importance of research and would like to better
understand the basis for The Independent Budget's funding
recommendation for medical and prosthetic research. In addition, are
there particular research areas that you believe VA should target with
your recommended increase in funding?
4. You recommend $300 million to address the research
infrastructure deficiencies in fiscal year 2011. To clarify, is this
request reflected in the $52 billion that The Independent Budget
requests for the medical care accounts in 2011? Do you have alternate
recommendations for addressing the research infrastructure deficiencies
without creating a new appropriations account?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by April 20, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Paralyzed Veterans of America
Washington, DC.
April 1, 2010
Honorable Michael Michaud
Chairman
House Committee on Veterans' Affairs
Subcommittee on Health
338 Cannon House Office Building
Washington, D.C. 20515
Dear Chairman Michaud:
On behalf of Paralyzed Veterans of America, I would like to thank
you for the opportunity to present our views on the FY 2011 budget for
the Veterans Health Administration (VHA). We appreciate the Committee
recommending a substantial budget for the VA in its recently submitted
Views and Estimates. We also look forward to working with the Committee
to ensure that the Government Accountability Office (GAO) follows
through on its responsibility as a part of the advance appropriations
process. Only through cooperation between the veterans' service
organizations and the Members of the Committee can we hope to attain a
sufficient, timely, and predictable budget for the VA.
We have included with our letter a response to each of the
questions that you presented following the hearing on February 23,
2010. Thank you very much.
Sincerely,
Blake C. Ortner
Senior Associate Legislative Director
__________
Question 1: The Independent Budget estimates that it will cost
about $252 million to care for an additional 75,000 new OEF/OIF
veterans in fiscal year 2011. However, VA's 2011 budget submission
projects spending about $600 million to care for an additional 57,000
OEF/OIF veterans. This means that the IB projects a faster growth in
OEF/OIF veterans but estimates that it will cost less to treat these
additional individuals. Please provide an explanation of the basis for
The Independent Budget's projections.
Answer: Before providing an explanation of The Independent Budget's
projections, we believe that it is first necessary to analyze the
Administration's proposal. While the Administration recommends
approximately $600 million to provide for 56,784 new OEF/OIF uniques,
we do not fully understand how they came up with this recommendation.
Examining the Administration budget submission in more detail, we
note that the Administration projects $2.575 billion in total
expenditures for FY 2011 to address the needs of 439,271 total
cumulative OEF/OIF unique users. This computes to approximately $5,862
per individual unique OEF/OIF user. However, taking the
Administration's $600 million estimation and applying it to the 56,784
new OEF/OIF uniques suggests a cost per individual unique OEF/OIF user
of $10,566. This seems to suggest a real discrepancy in their budget
recommendations. Calculating a cost for new OEF/OIF unique users based
on the actual cost per unique ($5,862) yields a real cost of
approximately $333 million.
However, it is fair to conclude that they may have additional
factors built into the budget recommendation. For instance, the cost
per unique OEF/OIF user may also factor in things like prosthetics
utilization, access to new mental health programs, or similar programs.
Unfortunately, the Administration budget submission does not really
provide detailed justification for its budget recommendations, and it
certainly does not explain the difference between the apparent cost per
unique ($5,862) and the cost for new unique users in FY 2011 ($10,566).
As for The Independent Budget, part of the reason our budget
estimate is less than the Administration's recommendation is because we
project an even lower cost per unique OEF/OIF user. That value is
approximately $3,360. Our projection of 75,000 new uniques is based on
the historical trend that year-to-year increases in new users have gone
up over time, not leveled out or declined. In recent years, we believe
the Administration has actually underestimated the year-to-year
increases in new users. Our cost estimate of $252 million is based on
this projection of new OEF/OIF unique users multiplied by our projected
cost per user. Were we to use the apparent actual cost of unique OEF/
OIF users ($5,862) according to the VA, the recommendation would
actually be approximately $440 million.
Question 2: The Independent Budget highlights two key policy
initiatives for long-term care and prosthetics. There appears to be a
disconnect between the critical issues that The Independent Budget
identified for fiscal year 2011 in that neither long-term care nor
prosthetics were mentioned in The Independent Budget's critical issues
document. Please explain this disconnect.
Answer: First, we believe there is no particular disconnect between
the Critical Issues Report published last fall and the recently
released Independent Budget. It is important to realize that the
Critical Issues Report is meant to address broad, sweeping policy
issues facing the VA. While overall funding for the VA, and the VA
health care system in particular, is of critical importance, the
individual components of the funding recommendations do not generally
receive that level of attention in the Critical Issues Report.
Additionally, as explained in the introduction of the Critical
Issues Report, that document is designed to alert the Administration,
Members of Congress, VA, and the public to the issues concerning VA
health care, benefits, and benefit delivery that we believe deserve
special scrutiny and attention. The Report does not offer specific
funding recommendations, but instead serves as a guide to policymakers
so they can prepare for the coming budget debate in February and
beyond. Through these efforts we believe VA is better positioned to
successfully meet the challenges of the future. The Critical Issues
Report also provides direction and guidance for the Administration and
Members of Congress.
Question 3: The Independent Budget recommends $700 million for
medical and prosthetic research in 2011. This is $119 million above the
fiscal year 2010 enacted level and $100 million above the
Administration's request. We recognize the importance of research and
would like to better understand the basis for The Independent Budget's
funding recommendation for medical and prosthetic research. In
addition, are there particular research areas that you believe VA
should target with your recommended increase in funding?
Answer: For over 60 years, the VA research program has been
improving veterans' lives through innovation and discovery that has led
to advances in health care for veterans and all Americans. VA
researchers conducted the first large scale clinical trial that led to
effective tuberculosis therapies and played key roles in developing the
cardiac pacemaker, the CT scan, and radioimmunoassay. The first liver
transplant in the world was performed by a VA surgeon-researcher. VA
clinical trials established the effectiveness of new treatments for
schizophrenia, high blood pressure, and other heart diseases. The
``Seattle Foot'' and subsequent improvements in prosthetics developed
in VA have allowed people with amputations to run and jump. The ``DEKA
Arm,'' a collaborative invention involving VA and Department of Defense
(DoD) scientists and private entrepreneurs, holds major promise for
upper extremity amputees to regain normative activity.
To keep VA research funding at current-services levels, the program
needs at least $20 million (a 3.3-percent increase over FY 2010) to
account for inflation. Beyond anticipated inflation, additional VA
research funding is needed to: (1) take advantage of burgeoning
opportunities to improve the quality of life for our Nation's veterans
through ``personalized medicine;'' (2) address the critical needs of
returning Operations Enduring Freedom and Iraqi Freedom (OEF/OIF)
veterans and others who were deployed to combat zones in the past; and
(3) maximize use of VA's expertise in research conducted to evaluate
the clinical effectiveness, risks and benefits of medical treatments.
Thus, the IBVSOs believe an additional $100 million in FY 2011, beyond
inflationary coverage, is necessary for sustained support of new VA
research initiatives.
In fiscal year (FY) 2009, VA awarded more than 2,200 new grants to
VA-based investigators designed to enhance the health care VA provides
to veterans. Among other initiatives, VA researchers are currently:
Developing new assistive devices for the visually
impaired, including an artificial retina to restore vision.
Working on ways to ease the physical and psychological
pain of veterans now returning from two current overseas wars.
Gaining new knowledge of the biological and behavioral
roots of post traumatic stress disorder (PTSD) and developing and
evaluating effective PTSD treatments.
Developing powerful new approaches to assess, manage, and
treat chronic pain to help veterans with burns and other injuries.
Learning how to deliver low-level, computer-controlled
electrical currents to weakened or paralyzed muscles to allow people
with incomplete spinal cord injury to once again walk and perform other
everyday activities.
Studying new drug therapies and ways to enhance primary
care models of mental health care.
Identifying genes associated with Alzheimer's disease,
diabetes, and other conditions.
Studying ways to prevent, diagnose, and treat hearing
loss.
Pioneering new home dialysis techniques.
Developing a system that decodes brain waves and
translates them into computer commands to allow quadriplegics to
perform routine daily tasks such as using e-mail.
Exploring organization of care, delivery methods, patient
outcomes, and treatment effectiveness to further improve access to
health care for veterans.
As for specific areas to direct funding, the IBVSOs would like to
see added focus in two research areas. First, additional funding is
needed to expand research on strategies for overcoming the devastating
injuries suffered by veterans of OEF/OIF. Urgent needs are apparent for
improvements in prosthetics technologies and rehabilitation methods, as
well as more effective treatments for polytrauma, traumatic brain
injury, injury to the eye (highly significant in this population, with
thousands of potential injuries), significant body burns, PTSD and
other mental health consequences of war, including depression and
suicide risk.
Second, through genomic medicine VA is uniquely positioned to
revamp modern health care and to provide progressive and cutting-edge
care for veterans. VA is the obvious choice to lead advances in genomic
medicine. It is the largest integrated health system in the world,
employs an industry-leading electronic health record, and has an
enrolled treatment population of millions of veterans to sustain
important research. Innovations in genomic medicine will allow the VA
to:
reduce drug trial failure by identifying genetic
disqualifiers and allowable treatment of eligible populations;
track genetic susceptibility for disease and develop
preventative measures;
predict responses to medications; and
modify drugs and treatments to match an individual's
unique genetic structure.
In 2006, VA launched the Genomic Medicine Program to examine the
potential of emerging genomic technologies, optimize medical care for
veterans, and enhance the development of tests and treatments for
relevant diseases. One of the main objectives of the Genomic Medicine
Program is to create an expanded DNA sample bio-bank of veteran donors,
which will be made available for carefully designed research that leads
to improved treatment while protecting veteran privacy and safety. The
Independent Budget believes that at least $25 million should be
directed toward this initiative in FY 2011 to move this program
forward.
Question 4: You recommend $300 million to address the research
infrastructure deficiencies in fiscal year 2011. To clarify, is this
request reflected in the $52 billion that The Independent Budget
requests for the medical care accounts in 2011? Do you have alternate
recommendations for addressing the research infrastructure deficiencies
without creating a new appropriations account?
Answer: The research infrastructure recommendation is not included
in the funding recommendations for the medical care accounts for FY
2011. The Major Construction account includes a $100 million
recommendation to address the backlog of research infrastructure needs.
Additionally, the Minor Construction account includes $200 million for
research infrastructure needs. As explained in The Independent Budget
for FY 2011, in recent years, funding for the VA maintenance and
construction appropriations has failed to provide the resources needed
by VA to maintain, upgrade, and replace its aging research facilities.
Consequently many VA facilities have run out of adequate research
space.
In the 2003 Draft National Capital Asset Realignment for Enhanced
Services (CARES) Plan, VA listed $468.6 million designated for new
laboratory construction, renovation of existing research space, and
build-out costs for leased research facilities. However, these capital
improvement projects were omitted from the Secretary's final report on
capital planning consequential to the CARES effort.
In FY 2008, the VA Office of Research and Development (ORD) began
an as yet incomplete examination of all VA research infrastructure, for
physical condition, capacity for current research, as well as needed
program growth and sustainability of VA space to conduct research.
According to an October 26, 2009, VA ORD report to the VA National
Research Advisory Committee, surveys to date support the pilot
findings: ``There is a clear need for research infrastructure
improvements throughout the system, including many that impact on life
safety.''
By the end of FY 2009, a total of 53 sites within 47 research
programs will have been surveyed. Approximately 20 sites remain to be
assessed in FY 2010. To date, the combined total estimated cost for
improvements exceeds $570 million. About 44 percent of the estimated
correction costs constitute ``priority 1'' deficiencies--those with an
immediate need for correction to return components to normal service or
operation; stop accelerated deterioration; replace items that are at or
beyond their useful life; and correct life-safety hazards. Furthermore,
only six buildings (of 38 buildings surveyed) at five sites were rated
above the ``poor'' range. Three of the seven buildings rated above
``poor'' were structures housing the main hospital. Five buildings that
rated ``poor'' were main hospitals housing laboratories. It is time
that dedicated resources are provided for research infrastructure
upgrades to overcome these challenges.
A significant cause of the VA research infrastructure's neglect is
that there is no direct funding line, nor any budgetary request made,
for VA research facilities. The VA Medical and Prosthetic Research
appropriation also does not contain funding for construction,
renovation, or maintenance of VA research facilities. If the VA and
Congress are unwilling to provide dedicated funding in a separate
account for VA research infrastructure needs, then the Congress must
ensure that adequate funding is appropriated through the current
account structure, with particular emphasis on directing that funding
to research needs.