[Senate Hearing 111-]
[From the U.S. Government Publishing Office]



 
   MILITARY CONSTRUCTION AND VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2011

                              ----------                              


                        THURSDAY, APRIL 15, 2010

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 2:04 p.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Tim Johnson (chairman) presiding.
    Present: Senators Johnson, Murray, Nelson, Pryor, 
Hutchison, Brownback, Collins, and Murkowski.

                     DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF HON. ERIC K. SHINSEKI, SECRETARY
ACCOMPANIED BY:
        HON. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR HEALTH, 
            VETERANS HEALTH ADMINISTRATION
        MICHAEL WALCOFF, ACTING UNDER SECRETARY FOR BENEFITS, VETERANS 
            BENEFITS ADMINISTRATION
        STEVE L. MURO, ACTING UNDER SECRETARY FOR MEMORIAL AFFAIRS, 
            NATIONAL CEMETERY ADMINISTRATION
        W. TODD GRAMS, ACTING ASSISTANT SECRETARY FOR MANAGEMENT AND 
            CHIEF FINANCIAL OFFICER
        HON. ROGER W. BAKER, ASSISTANT SECRETARY FOR INFORMATION AND 
            TECHNOLOGY, OFFICE OF INFORMATION AND TECHNOLOGY

                OPENING STATEMENT OF SENATOR TIM JOHNSON

    Senator Johnson. This hearing will come to order.
    We meet today to review the fiscal year 2011 budget request 
and the fiscal year 2012 advance appropriations request for the 
Department of Veterans Affairs.
    Secretary Shinseki, I welcome you and your colleagues and I 
thank you for appearing before our subcommittee.
    I will remind my colleagues that in order to reserve time 
for questions, our procedure is to have opening statements by 
the chairman and ranking member, followed by an opening 
statement from the Secretary. We will limit the first round of 
questions to 6 minutes per member, but we can have additional 
rounds should we need them.
    The fiscal year 2011 discretionary budget request for the 
VA totals $56.9 billion, an increase of 7.4 percent over the 
fiscal year 2010 enacted level. Additionally, the request 
includes $50.6 billion in fiscal year 2012 advance 
appropriations for medical care.
    The budget submission also includes a separate supplemental 
request of $13.4 billion to expand Agent Orange benefits.
    I am especially pleased to see that the request includes an 
increase of $460 million over fiscal year 2010 for the Veterans 
Benefits Administration (VBA) to hire additional claims 
processors. Delays in claims processing are probably the most 
common complaint I hear from South Dakota vets.
    Mr. Secretary, I have read your testimony and I am happy to 
see that reducing the current claims backlog is your highest 
priority. It is my highest priority as well, and I will 
continue to work to provide the sufficient resources to the 
Department to increase the number of claims processors and to 
streamline and expedite the process.
    Before I turn to my ranking member, I want to commend you, 
Mr. Secretary, for your passion and commitment to ending 
homelessness among the vets population.
    I am also pleased to see a continued commitment in the 
budget to improve mental healthcare among vets and to 
strengthen and expand rural healthcare.
    Mr. Secretary, I look forward to hearing your opening 
statement, but before you begin, Senator Hutchison, would you 
care to make an opening statement?

               STATEMENT OF SENATOR KAY BAILEY HUTCHISON

    Senator Hutchison. Thank you, Mr. Chairman. I will be 
brief. Let me just make a couple of points. I think the 
chairman has stated the facts.
    I want to say that I commend the Department for the 
decision on the Agent Orange diseases, and I think that is the 
right thing to do. I also commend you for putting into the 
rulemaking process gulf war syndrome and the diseases that have 
come from that that have heretofore not been acknowledged, and 
I think that is a step in the right direction.
    However, I will say that I also agree with the chairman 
that it means that you are going to have more claims and claims 
processing has been an issue, and I know you know that. But 
certainly the Agent Orange ones will come first and 150,000 are 
expected. That is information that I know you have and I know 
that you will make that a high priority. But it is the right 
decision for our veterans, and I commend you for it.
    The only other thing that I will mention in the big 
picture--and I will have a question or two--is also the 
emphasis on mental health services. As we have all discussed, 
post traumatic stress disorder, substance abuse problems, 
suicides, and illnesses that have increased in our active duty 
population, which also moves into our veterans population and 
retirees--I think that the increase in the budget proposed, 
$5.2 billion for mental health treatment, is an increase from 
last year that is very warranted. I think that we have begun in 
the last few years to acknowledge more the mental health issues 
and I think the treatment that is to follow coming from that is 
the right thing.
    With that, Mr. Chairman, I will submit the rest of my 
statement for the record and look forward to asking a few 
questions.
    [The statement follows:]
           Prepared Statement of Senator Kay Bailey Hutchison
    Thank you, Mr. Chairman. I am pleased to welcome Secretary Shinseki 
and our other witnesses and guests to discuss the President's 2011 
budget request.
    Mr. Chairman, the Department of Veterans Affairs has one of the 
most important missions in our government, and this subcommittee has 
always worked hard to provide the Department with the resources it 
needs to give our veterans the very best care this Nation can provide. 
In my home State of Texas, I am proud to say the VA operates 11 major 
medical centers, more than 40 outpatient clinics, 14 vet centers, and 6 
national cemeteries to care for our State's 1.7 million veterans.
    Today we will examine the budget request that provides for our 
veterans nationwide, including their benefits and healthcare. The VA's 
2011 budget request proposes an $11.4 billion increase above last 
year's level--a robust 10 percent increase for our veterans. In 
addition to the $121 billion requested in 2011, the Department has 
recommended $13.4 billion in the 2010 supplemental appropriations bill 
for new Agent Orange-related presumptions, and $50.6 billion in advance 
appropriations to fund veterans' healthcare in 2012. That is a total of 
$185 billion in VA spending before us today--a tremendous amount of 
funds--and I want us all to work together to ensure this money is spent 
is the most fiscally efficient way possible.
    In addition to its 2011 request, the Department is requesting $13.4 
billion in the 2010 supplemental appropriations bill to fund the VA's 
recent decision to add ischemic heart disease, Parkinson's disease, and 
B cell leukemia to its list of automatic service-connected disabilities 
for Vietnam veterans exposed to Agent Orange. This presents a 
considerable challenge to the VA's claims processing system, which 
already has an unacceptably large disability claims backlog. The 
Department anticipates the total number of disability claims it 
receives to increase by 30 percent in 2010, with approximately 150,000 
of these claims Agent Orange-related. I am pleased to see that this 
budget adds another 2,100 claims processors to the VA's current staff 
level, because I am concerned that our veterans already wait too long 
for their disability claims to be processed. Mr. Secretary, you have a 
significant challenge in front of you on how to handle a 30 percent 
increase in your claims workload, in addition to such a large influx 
into your workforce that will require specialized training, without 
causing a major disruption to other veterans' disability claims. I look 
forward to your comments on how we can assist you in this matter.
    Mr. Secretary, the Army and the VA currently share a joint facility 
in El Paso, Texas. The Army has requested a significant amount of money 
in its 2011 budget request to begin design of a new facility in June of 
this year. As I understand it, the VA will need to commit funds towards 
a joint design by June, or the Army will award a contract based only on 
its own requirements. I look forward to discussing your plans on how to 
match the Army's accelerated timetable for this facility during the 
question and answer portion of our hearing today.
    In its 2011 budget request, the VA recommends $1.15 billion for 
major construction projects, slightly below last year's level of $1.2 
billion. A significant portion of this funding shows an effort to 
accelerate the schedules for two of the VA's longest-running projects--
hospitals in New Orleans and Denver that have been partially funded for 
several years.
    However, I am concerned that we are not obligating construction 
funds as quickly and efficiently as we could, and that the VA does not 
have a prioritized long-range capital plan to present to Congress. As 
you know, Mr. Secretary, for military construction projects we 
appropriate funds that have to be spent within 5 years to ensure 
efficient planning and execution. And, we also receive a Future-Year 
Defense Program (FYDP) from each service to understand and budget for 
long-range capital needs. As a former Army Chief of Staff, I am 
interested to hear your thoughts on whether you think having the VA 
construction program abide by some of these parameters, such as 5-year 
funding and a prioritized Five-Year Capital Plan, would be beneficial 
to the process.
    Mr. Secretary, nearly all the efforts to modernize the VA hinge 
upon the Department's ability to leverage information technology to 
improve services to our veterans. Some of the projects we've funded in 
past budgets include a paperless solution to the disability claims 
backlog, a new electronic medical record, and a lifetime service record 
to follow service members through the Departments of Defense and 
Veterans Affairs. However, government agencies have a poor track record 
developing and implementing costly IT programs, and an internal audit 
by the VA last year resulted in 45 of the Department's 282 ongoing 
projects being halted because they were either significantly behind 
schedule or over budget. I want to be sure we are spending our taxpayer 
dollars efficiently, and I look forward to hearing your thoughts on 
what steps we can take to ensure more efficiency and transparency for 
these projects.
    I am pleased to see the emphasis that the Medical Services request 
places on mental health and rehabilitation, especially for our soldiers 
returning with delayed Post-Traumatic Stress Disorder and substance 
abuse problems. The VA's budget proposes $5.2 billion for mental health 
treatment, a $410 million increase above last year. The VA now has PTSD 
specialists or treatment teams in all of its medical centers.
    As our men and women return from war, we want to be certain they 
receive the very best medical care our Nation can provide. Your budget 
request keeps us on that track. I know it is difficult to anticipate 
every need, but this subcommittee will certainly make every effort to 
provide you the resources you need.
    Mr. Secretary, I am extremely pleased with the VA's decision to 
build its fifth polytrauma center in San Antonio. I can't wait to see 
this project complete and operational, and I'm thrilled that contracts 
have been awarded and construction has begun. This new center will care 
for our most severely injured veterans and will be a great complement 
to the other medical facilities in the San Antonio area, where cutting-
edge technology will be shared between the VA and the military 
services.
    The VA manages the only nationwide network to care for polytrauma 
patients and has become the world's leader in traumatic brain injury 
rehabilitation. As more of our soldiers return home with multiple 
traumatic injuries, I am confident we can leverage the VA's experiences 
at the other four Level 1 polytrauma centers to make this new facility 
the VA's flagship for our Nation's most seriously wounded veterans.
    Mr. Secretary, this subcommittee has always put our Nation's 
veterans first, and I can say with great assurance that we will do 
whatever it takes, in a bipartisan manner, to work with you to make 
sure the VA has all of the necessary resources to take care of our 
Nation's veterans. At the same time, it is our joint responsibility to 
ensure these funds are spent in the most fiscally responsible and 
efficient manner possible. I look forward to working with you on these 
and other issues in the coming months.
    Thank you, Mr. Chairman.

    Senator Johnson. Thank you, Senator Hutchison.
    Mr. Secretary, again I welcome you to the subcommittee. I 
understand that yours will be the only opening statement. Your 
full statement will be included in the record. So please feel 
free to summarize your remarks. Mr. Secretary.
    Secretary Shinseki. Thank you very much, Chairman Johnson. 
To you and Ranking Member Hutchison, other distinguished 
members of this subcommittee, thanks. I always say that 
sincerely. Thank you for this opportunity to present the 
President's 2011 budget and the 2012 advance appropriations 
request for VA.
    I am able to report a good start in 2009, and I would just 
take a moment to remind that the 2009 budget was a 
congressionally enhanced budget. So there was a great 
foundation for this Secretary upon arrival to put in place a 
good foundation for the year that we are now having with the 
2010 budget. VA had a good start in 2009 with a tremendous 
opportunity this year in 2010. We are happy to talk about what 
we are doing, and the President's continued strong support for 
veterans and veterans needs into the 2011 budget request, which 
is before Congress, with the 2012 advance appropriations.
    I appreciate the generosity of time shared by members of 
this subcommittee with me as I made my rounds. I regret that I 
was not able to call on everyone, but I thank the members that 
I was able to meet. Those opportunities are always invaluable 
to me in getting insights.
    I would like to acknowledge in our audience today 
representatives from some of our veterans service 
organizations. Their insights have been helpful to me in 
understanding our obligation and how to frame our actions to 
better meet the needs of veterans.
    By way of introduction, Mr. Chairman, let me introduce the 
members of my team from my left here. Mike Walcoff is the 
Acting Under Secretary for Benefits. Todd Grams is our new 
Principal Deputy and Acting Assistant Secretary for Management. 
Dr. Randy Petzel to my right, recently confirmed Under 
Secretary for Health. Steve Muro, Acting Under Secretary for 
Memorial Affairs. And on my extreme right, Roger Baker, our 
Assistant Secretary for Information and Technology, who also 
serves as our Chief Information Officer.
    This subcommittee's longstanding commitment to our Nation's 
veterans has always been unequivocal and unwavering, and such 
commitment and the President's own steadfast support of 
veterans resulted in a 2010 budget that provides this 
Department the resources to begin renewing itself in 
fundamental and comprehensive ways, not in spots but as an 
entire organization, fundamental and comprehensive ways.
    We are well launched on that effort and determined to 
continue that transformation into 2011 with this budget and 
2012.
    For over a year now, we have promoted a new strategic 
framework organized around three governing principles, and I 
have mentioned them before in prior testimonies, and I will 
just repeat them again. It is about transforming VA into being 
more people-centric, results-oriented or results-driven, and 
forward-looking. And in our effort, our strategic goals are 
several: improve the quality of, and increase access to, care 
and benefits while optimizing value; heighten readiness to 
protect our people, clients as well as our workforce, and our 
resources each day, as well in times of crisis; enhance veteran 
satisfaction with our health, education, training, counseling, 
financial, and burial benefits and services; and finally, 
invest in our human capital both in their well-being, our 
workforce, and in their development as leaders so that over 
time we have this irreversible drive toward excellence in 
everything we do, from management, to IT systems, to support 
services.
    This last goal is vital to mission performance if we are to 
attain being a model of governance in the next 4 years, which 
is our goal. These goals will guide our people daily and focus 
them on producing the outcomes veterans expect and have earned 
through their service to the Nation. We will advocate for 
veterans we serve.
    To support our pursuit of these goals, the President's 
budget provides $125 billion in 2011, $60.3 billion in 
discretionary resources and $64.7 billion in mandatory funding. 
Our discretionary budget request represents an increase of $4.2 
billion over the President's 2010 enacted budget.
    VA's 2011 budget focuses primarily on three critical 
concerns that are of significant importance to veterans, and I 
get this in feedback as I travel and I am sure members of the 
subcommittee do as well. First, increase access to benefits and 
services now. Eliminate the disability claims backlog by 2015. 
And finally, end veteran homelessness in the next 5 years. The 
three goals we have set for ourselves.
    Access. This budget provides the resources required to 
increase access to our healthcare system and our national 
cemeteries. We will expand access to healthcare by activating 
new and improved facilities, by honoring the President's 
commitment to veterans who were exposed to Agent Orange 40 
years ago, by delivering on President Obama's promise to 
provide healthcare eligibility to more priority group 8 
veterans, by making greater investments in telehealth and 
extending our delivery of care into the most remote rural 
communities and, where warranted, even into veterans' homes. 
And finally, we will increase access to our national shrines by 
establishing five new national cemeteries.
    The backlog. We are requesting an unprecedented 27 percent 
increase in funding for our Veterans Benefits Administration, 
primarily for staffing to address the growing increase in 
disability claims receipts, even as we continue to reengineer 
our processes and develop a paperless system integrated with 
VLER, the Virtual Lifetime Electronic Record. That is the joint 
project between DOD and VA.
    Our goal in processing: no claim that is longer than 125 
days. So it is not an average. No claim longer than 125 days, 
and a processing accuracy of 98 percent. Today we are at the 84 
percent mark. So this is a stretch goal.
    Ending homelessness. We are requesting substantial 
investment in our homelessness program as part of our plan to 
eliminate homelessness in 5 years. Ending the downward spiral 
that often enough leads to veterans' homelessness mandates that 
we aggressively and simultaneously address housing, education, 
jobs, and healthcare.
    In this effort, we partner with other Departments. The 
Department of Housing and Urban Development is probably our 
closest collaborator, but we collaborate as well with Labor, 
Education, Health and Human Services, Small Business 
Administration, among others.
    Now, taken together, these initiatives are intended to meet 
veterans' expectations in each of these three mission-focused 
areas. I mentioned them earlier. Increasing their access, 
eliminating the backlog, ending homelessness. We will achieve 
these objectives by developing innovative business processes, 
some of them already underway, and delivery systems that not 
only better serve veterans and families' needs for many years 
to come, but which also dramatically improve our efficiency and 
control our costs.
    While our budget and advance appropriations request provide 
the resources to continue our pursuit of the President's two 
overarching goals for this Department--transform this 
Department and ensure veteran access--we still have much work 
to accomplish.
    We appreciate the chairman's and ranking member's 
leadership and the support of all the members of the 
subcommittee especially in some of the areas that we have given 
attention to, areas like rural health and healthcare for women 
veterans. We are determined to build on the progress you have 
enabled, especially with the provision of a significant first-
year funding for rural initiatives. So our efforts are well 
begun, but there is more work to be done in meeting our 
obligations here.

                           PREPARED STATEMENT

    Again, Mr. Chairman, members of the subcommittee, thanks 
for this opportunity to appear here today. I look forward to 
your questions.
    [The statement follows:]
              Prepared Statement of Hon. Eric K. Shinseki
    Chairman Johnson, Ranking Member Hutchison, Distinguished Members 
of the Senate Appropriations Committee, Subcommittee on Military 
Construction, Veterans Affairs, and Related Agencies:
    Thank you for this opportunity to present the President's Fiscal 
Year 2011 Budget and Fiscal Year 2012 Advance Appropriations request 
for the Department of Veterans Affairs (VA). 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 timely 
access to benefits and high quality care to our Veterans over their 
lifetimes, from the day they first take their oaths of allegiance until 
the day they are laid to rest.
    We recently completed development of a new strategic framework that 
is people-centric, results-driven, and forward-looking. The path we 
will follow to achieve the President's vision for VA will be presented 
in our new strategic plan, which is currently in the final stages of 
review. The strategic goals we have established in our plan are 
designed to produce better outcomes for all generations of Veterans:
  --Improve the quality and accessibility of healthcare, benefits, and 
        memorial services while optimizing value;
  --Increase Veteran client satisfaction with health, education, 
        training, counseling, financial, and burial benefits and 
        services;
  --Protect people and assets continuously and in time of crisis; and,
  --Improve internal customer satisfaction with management systems and 
        support services to achieve mission performance and make VA an 
        employer of choice by investing in human capital.
    The strategies in our plan will guide our workforce to ensure we 
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.
    VA's 2011 budget also focuses on three concerns that are of 
critical importance to our Veterans--easier access to benefits and 
services; reducing the disability claims backlog and the time Veterans 
wait before receiving earned benefits; and ending the downward spiral 
that results in Veterans' homelessness.
    This budget provides the resources required to enhance access in 
our healthcare system and our national cemeteries. We will expand 
access to healthcare through the activations of new or improved 
facilities, by expanding healthcare eligibility to more Veterans, and 
by making greater investments in telehealth. Access to our national 
cemeteries will be increased through the implementation of new policy 
for the establishment of additional facilities.
    We are requesting an unprecedented increase for staffing in the 
Veterans Benefits Administration (VBA) to address the dramatic increase 
in disability claim receipts while continuing our process-reengineering 
efforts, our development of a paperless claims processing system, and 
the creation of a Virtual Lifetime Electronic Record.
    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 healthcare.
    VA will be successful in resolving these three 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 (HPPGs).
                  hppg i: reducing the claims backlog
    The volume of compensation and pension rating-related claims has 
been steadily increasing. In 2009, for the first time, we received over 
1 million claims during the course of a single year. The volume of 
claims received has increased from 578,773 in 2000 to 1,013,712 in 2009 
(a 75 percent increase). Original disability compensation claims with 
eight or more claimed issues have increased from 22,776 in 2001 to 
67,175 in 2009 (nearly a 200 percent increase). Not only is VA 
receiving substantially more claims, but the claims have also increased 
in complexity. We expect this level of growth in the number of claims 
received to continue in 2010 and 2011 (increases of 13 percent and 11 
percent were projected respectively even without claims expected under 
new presumptions related to Agent Orange exposure), which is driven by 
improved access to benefits through initiatives such as the Benefits 
Delivery at Discharge Program, increased demand as a result of nearly 
10 years of war, and the impact of a difficult economy prompting 
America's Veterans to pursue access to the benefits they earned during 
their military service.
    While the volume and complexity of claims has increased, so too has 
the productivity of our claims processing workforce. In 2009, the 
number of claims processed was 977,219, an increase of 8.6 percent over 
the 2008 level of 899,863. The average time to process a rating-related 
claim fell from 179 to 161 days in 2009, an improvement of 11 percent.
    The progress made in 2009 is a step in the right direction, but it 
is not nearly enough. My goal is to process claims so no Veteran has to 
wait more than 125 days. Reaching this goal will become even more 
challenging because of additional claims we expect to receive related 
to Veterans' exposure to Agent Orange. Adding Parkinson's disease, 
ischemic heart disease, and B-cell leukemias to the list of presumptive 
disabilities is projected to significantly increase claims inventories 
in the near term, even while we make fundamental improvements to the 
way we process disability compensation claims.
    We expect the number of compensation and pension claims received to 
increase from 1,013,712 in 2009 to 1,318,753 in 2011 (a 30 percent 
increase). Without the significant investment requested for staffing in 
this budget, the inventory of claims pending would grow from 416,335 to 
1,018,343 and the average time to process a claim would increase from 
161 to 250 days. If Congress provides the funding requested in our 
budget, these increases are projected to be 804,460 claims pending with 
an average processing time of 190 days. Through 2011, we expect over 
228,000 claims related to the new presumptions and are dedicated to 
processing this near-term surge in claims as efficiently as possible.
    This budget is based on our plan to improve claims processing by 
using a three-pronged approach involving improved business processes, 
expanded technology, and hiring staff to bridge the gap until we fully 
implement our long-range plan. We will explore process and policy 
simplification and contracted service support in addition to the 
traditional approach of hiring new employees to address this spike in 
demand. We expect these transformational approaches to begin yielding 
significant performance improvements in fiscal year 2012 and beyond; 
however, it is important to mitigate the impact of the increased 
workload until that time.
    The largest increase in our 2011 budget request, in percentage 
terms, is directed to the Veterans Benefits Administration as part of 
our mitigation of the increased workload. The President's 2011 budget 
request for VBA is $2.149 billion, an increase of $460 million, or 27 
percent, over the 2010 enacted level of $1.689 billion. The 2011 budget 
supports an increase of 4,048 FTEs, including maintaining temporary FTE 
funded through ARRA. In addition, the budget also includes $145.3 
million in information technology (IT) funds in 2011 to support the 
ongoing development of a paperless claims processing system.
               hppg ii: 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 107,000 
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 
healthcare, 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 healthcare 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 healthcare 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.
            hppg iii: automating the gi bill benefits system
    The Post 9/11 GI Bill creates a robust enhancement of VA's 
education benefits, evoking the World War II Era GI Bill. Because of 
the significant opportunities the Act provides to Veterans in 
recognition of their service, and the value of the program in the 
current economic environment, we must deliver the benefits in this Act 
effectively and efficiently, and with a client-centered approach. In 
August 2009, the new Post-9/11 GI Bill program was launched. We 
received more than 496,000 original applications, 578,000 enrollment 
certifications, and 237,000 changes to enrollment certifications since 
the inception of this program.
    The 2011 budget provides $44.1 million to complete the automated 
solution for processing Post-9/11 GI Bill claims and to begin the 
development and implementation of electronic systems to process claims 
associated with other education programs. The automated solution for 
the Post 9/11 GI Bill education program will be implemented by December 
2010.
    In 2011, we expect the total number of all types of education 
claims to grow by 32.3 percent over 2009, from 1.70 million to 2.25 
million. To meet this increasing workload and complete education claims 
in a timely manner, VA has established a comprehensive strategy to 
develop an end-to-end solution that utilizes rules-based, industry-
standard technologies to modernize the delivery of education benefits.
       hppg iv: establishing a virtual lifetime electronic record
    Each year, more than 150,000 active and reserve component service 
members leave the military. Currently, this transition is heavily 
reliant 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 healthcare providers. A paper-based transfer carries risks 
of errors or oversights and delays the claim process.
    In April 2009, the President charged me and Defense Secretary Gates 
with building a fully interoperable electronic records system that will 
provide each member of our armed forces a Virtual Lifetime Electronic 
Record (VLER). This virtual record 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 VLER is the centerpiece of our 
strategy to better coordinate the user-friendly transition of service 
members from their service component into VA, and to produce better, 
more timely outcomes for Veterans in providing their benefits and 
services.
    In December 2009, VA successfully exchanged electronic health 
record (EHR) information in a pilot program between the VA Medical 
Center in San Diego and a local Kaiser Permanente hospital. We 
exchanged EHR information using the Nationwide Health Information 
Network (NHIN) created by the Department of Health and Human Services. 
Interoperability is key to sharing critical health information. 
Utilizing the NHIN standards allows VA to partner with private sector 
healthcare providers and other Federal agencies to promote better, 
faster, and safer care for Veterans. During the second quarter of 2010, 
the DOD will join this pilot and we will announce additional VLER 
health community sites.
    VA has $52 million in IT funds in 2011 to continue the development 
and implementation of this Presidential priority.
                  hppg v: improving mental health care
    The 2011 budget continues the Department's keen focus on improving 
the quality, access, and value of mental healthcare 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 service members, 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.
      hppg vi: deploying a veterans relationship management system
    A key component of VA's transformation is to employ technology to 
dramatically improve service and outreach to Veterans by adopting a 
comprehensive Veterans' Relationship Management System to serve as the 
primary interface between Veterans and the Department. This system will 
include a framework that provides Veterans with the ability to:
  --Access VA through multiple methods;
  --Uniformly find information about VA's benefits and services;
  --Complete multiple business processes within VA without having to 
        re-enter identifying information; and
  --Seamlessly access VA across multiple lines of business.
    This system will allow Veterans to access comprehensive online 
information anytime and anywhere via a single consistent entry point. 
Our goal is to deploy the Veterans Relationship Management System in 
2011. Our budget provides $51.6 million for this project.
    In addition to resources supporting these high-priority performance 
goals, the President's budget enhances and improves services across the 
full spectrum of the Department. The following highlights funding 
requirements for selected programs along with the outcomes we will 
achieve for Veterans and their families.
                  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 healthcare, 
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 healthcare 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 healthcare in 2010.
    In 2011, the budget provides $2.6 billion to meet the healthcare 
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 fiscal year 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 healthcare 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 healthcare 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 
healthcare 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 
healthcare 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 healthcare 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 healthcare 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 
healthcare 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 healthcare.
    Our investment in healthcare 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 healthcare services provided in 
our Vet Centers, increasing training for our healthcare 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.
            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 healthcare 
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 healthcare 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 healthcare 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.
          sustaining high quality burial and memorial programs
    VA remains steadfastly committed to providing access to a dignified 
and respectful burial for Veterans choosing to be buried in a VA 
national cemetery. This promise to Veterans and their families also 
requires that we maintain national cemeteries as shrines dedicated to 
the memory of those who honorably served this Nation in uniform. This 
budget implements new policy to expand access by lowering the Veteran 
population threshold for establishing new national cemeteries and 
developing additional columbaria to better serve large urban areas.
    VA expects to perform 114,300 interments in 2011 or 3.8 percent 
more than in 2010. The number of developed acres (8,441) that must be 
maintained in 2011 is 4.6 percent greater than the 2010 estimate, while 
the number of gravesites (3,147,000) that will be maintained is 2.6 
percent higher. VA will also process more than 617,000 Presidential 
Memorial Certificates in recognition of Veterans' honorable military 
service.
    Our 2011 budget request includes $251 million in operations and 
maintenance funding for the National Cemetery Administration. The 2011 
budget request provides $36.9 million for national shrine projects to 
raise, realign, and clean an estimated 668,000 headstones and markers, 
and repair 100,000 sunken graves. This is critical to maintaining our 
extremely high client satisfaction scores that set the national 
standard of excellence in government and private sector services as 
measured by the American Customer Satisfaction Index. The share of our 
clients who rate the quality of the memorial services we provide as 
excellent will rise to 98 percent in 2011. The proportion of clients 
who rate the appearance of our national cemeteries as excellent will 
grow to 99 percent. And we will mark 95 percent of graves within 60 
days of interment.
    The 2011 budget includes $3 million for solar and wind power 
projects at three cemeteries to make greater use of renewable energy 
and to improve the efficiency of our program operations. It also 
provides $1.25 million to conduct independent Facility Condition 
Assessments at national cemeteries and $2 million for projects to 
correct safety and other deficiencies identified in those assessments.
                   leveraging information technology
    We cannot achieve the transformation of VA into a 21st century 
organization capable of meeting Veterans' needs today and in the years 
to come without leveraging the power of IT. The Department's IT program 
is absolutely integral to everything we do, and it is vital we continue 
the development of IT systems that will meet new service delivery 
demands and modernize or replace increasingly fragile systems that are 
no longer adequate in today's healthcare and benefits delivery 
environment. Simply put, IT is indispensable to achieving VA's mission.
    The Department's IT operations and maintenance program supports 
334,000 users, including VA employees, contractors, volunteers, and 
researchers situated in 1,400 healthcare facilities, 57 regional 
offices, and 158 national cemeteries around the country. Our IT program 
protects and maintains 8.5 million vital health and benefits records 
for Veterans with the level of privacy and security mandated by both 
statutes and directives.
    VA's 2011 budget provides $3.3 billion for IT, the same level of 
funding provided in 2010. We have prioritized potential IT projects to 
ensure that the most mission-critical projects for improving service to 
Veterans are funded. For example, the resources we are requesting will 
fund the development and implementation of an automated solution for 
processing education claims ($44.1 million), the Financial and 
Logistics Integrated Technology Enterprise project to replace our 
outdated, non-compliant core accounting system ($120.2 million), 
development and deployment of the paperless claims processing system 
($145.3 million), and continued development of HealtheVet, VA's 
electronic health record system ($346.2 million). In addition, the 2011 
budget request includes $52 million for the advancement of the Virtual 
Lifetime Electronic Record, a Presidential priority that involves our 
close collaboration with DOD.
                enhancing our management infrastructure
    A critical component of our transformation is to create a reliable 
management infrastructure that expands or enhances corporate 
transparency at VA, centralizes leadership and decentralizes execution, 
and invests in leadership training. This includes increasing investment 
in training and career development for our career civil service and 
employing a suitable financial management system to track expenditures. 
The Department's 2011 budget provides $463 million in General 
Administration to support these vital corporate management activities. 
This includes $23.6 million in support of the President's initiative to 
strengthen the acquisition workforce.
    We will place particular emphasis on increasing our investment in 
training and career development--helping to ensure that VA's workforce 
remain leaders and standard-setters in their fields, skilled, 
motivated, and client-oriented. Training and development (including a 
leadership development program), communications and team building, and 
continuous learning will all be components of reaching this objective.
                         capital infrastructure
    VA must provide timely, high-quality healthcare 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 healthcare 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.
    This request provides $106.9 million to support the Department's 
burial program, including gravesite expansion and cemetery improvement 
projects at three national cemeteries--Indiantown Gap, Pennsylvania; 
Los Angeles, California; and Tahoma, Washington.
    Our major construction request includes $51.4 million to begin 
implementation of a new policy to expand and improve access to burial 
in a national cemetery. Most significantly, this new policy lowers the 
Veteran population threshold to build a new national cemetery from 
170,000 to 80,000 Veterans living within 75 miles of a cemetery. This 
will provide access to about 500,000 additional Veterans. Moreover, it 
will increase our strategic target for the percent of Veterans served 
by a burial option in a national or state Veterans cemetery within 75 
miles of their residence from 90 percent to 94 percent.
    VA's major construction request also includes $24 million for 
resident engineers that support medical facility and national cemetery 
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 healthcare; increase capacity 
for dental care; enhance patient privacy; improve treatment of special 
emphasis programs; and expand our research capability. Minor 
construction funds are also used to improve the appearance of our 
national cemeteries. Further, minor construction resources will be used 
to comply with energy efficiency and sustainability design 
requirements.
                                summary
    Our job at the VA is to serve Veterans by increasing their access 
to VA benefits and services, to provide them the highest quality of 
healthcare 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 the VA are committed to providing the 
quality of service needed to serve our Veterans and their families. 
They are our most valuable resource. I am especially proud of several 
VA employees that have been singled out for special recognition this 
year.
    First, let me recognize Dr. Janet Kemp, who received the ``2009 
Federal Employee of the Year'' award from the Partnership for Public 
Service. Under Dr. Kemp's leadership, VA created the Veterans National 
Suicide Prevention Hotline to help Veterans in crisis. To date, the 
Hotline has received almost 256,000 calls and rescued about 8,100 
people judged to be at imminent risk of suicide since its inception.
    Second, we are also very proud of Nancy Fichtner, an employee at 
the Grand Junction Colorado Medical Center, for being the winner of the 
President's first-ever SAVE (Securing Americans Value and Efficiency) 
award. Ms. Fichtner's winning idea is for Veterans leaving VA hospitals 
to be able to take medication they have been using home with them 
instead of it being discarded upon discharge.
    And third, we are proud of the VA employees at our Albuquerque, New 
Mexico Clinical Research Pharmacy Coordinating Center, including the 
Center Director, Mike R. Sather, for excellence in supporting clinical 
trials targeting current Veteran health issues. Their exceptional and 
important work garnered the center's recognition as the 2009 Malcolm 
Baldrige National Quality Award Recipient in the nonprofit category.
    The 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.

                             CLAIMS BACKLOG

    Senator Johnson. Thank you, Secretary Shinseki.
    In the 4 years that I have chaired this subcommittee, we 
have provided a total of $427 million above what the VA 
requested to hire additional claims processors to reduce the 
claims backlog. I am pleased to see that this year's budget 
request reflects a significant increase over last year to hire 
claims processors. However, the average claims time still 
hovers around 161 days and is expected to increase, given the 
new decision regarding Agent Orange.
    I know that the task of transforming the VA is daunting, 
but the level of frustration that vets expressed to me is 
growing.
    When can we expect to see some tangible results from the 
investments that we are making into the VBA claims process?
    Secretary Shinseki. Mr. Chairman, if there is frustration 
to go around, I share a good bit of it.
    I wanted to put a little more of my attention into the 
claims backlog last year. I got diverted a little bit. I spent 
some time making sure that the 9/11 G.I. bill was up and 
running properly, and now that it is, this year for me and for 
VA is about breaking the back in the backlog, getting to the 
root causes of what creates this as a never-ending challenge. 
Last year, we produced 977,000 decisions on claims, and then we 
got a million new claims in return. So this is a big numbers 
issue.
    Today we have probably 11,400 claims adjudicators, and this 
number of workforce, good people who come to work every day, 
takes a while to get them trained up. They provide us the 
ability to take that average processing time from, at one 
point, 190 days, and we have worked our way down to about 160 
days now, headed toward that 125 goal as an average.
    With this budget for 2011, we have increased VBA's budget 
by 27 percent. A good portion of that resources initiatives 
underway, but also adds 4,000 people to the workforce. And 
right now, if we want to go faster, the solution is to hire 
more people because we lack the automation tools that should 
have helped us break the code some time ago. We are working on 
developing those tools, and I will turn to Secretary Baker in a 
second to give you an assessment of where we are.
    I will also tell you that we created four pilots to take 
this process apart and look at those pieces individually and we 
intend to put them back together in a way that makes greater 
sense, simpler, less complex, and then try to get momentum here 
at the same time we are developing these tools.
    This year, 2010, I am happy to report that we have the 
resources in the right place, and we have the leadership 
focused on how to do this correctly.
    So let me turn to Secretary Baker and then I will turn to 
Mike Walcoff here for any other comments he might like to 
provide.
    Mr. Baker. Thank you, Mr. Secretary. Just quickly recapping 
where we are on the paperless system, the Veterans Benefits 
Management System. There are a number of pilots in place right 
now looking at different processes and different technologies 
to move VBA forward, one in Baltimore that we are particularly 
proud of, the Virtual Regional Office, that ties together 
process changes with technology to demonstrate what can be done 
inside of VBA. We will be letting contracts in the spring and 
the summer to get that fully implemented into pilots during 
2011 at VBA regional offices and then full rollout starting in 
late 2011 and 2012 of the paperless system across the entire 
VBA enterprise.
    Now, the paperless system does two things for us. One 
clearly is moving the system away from being paper-bound and 
into electronic. But the second is making it much more flexible 
for the VBA to look at their processes and make changes in 
their processes that will speed the way the work is done on top 
of the electronic system. So we are making good progress in 
that area at this point, primarily driven by our Chief 
Technology Officer, Peter Levin, and I think we have 
substantial progress to this point and you will see substantial 
progress through the rest of 2010 and 2011.
    Mr. Walcoff. Thank you, Mr. Secretary.
    Just a couple of things that I want to add. The Secretary 
mentioned that we are going to be hiring more people. Secretary 
Baker talked about the technology. And we also mentioned the 
pilots that we are doing that are looking at the business 
process itself to determine what can we do to improve the 
process so that when we have the new tools, it will not be just 
adding the tools to the old process.
    In addition to that, we recently brought all of our 
leadership together about a month ago and laid out for them 
what the challenge was. The Secretary has set some very, very 
ambitious goals for us. We always used to talk about time 
limits in terms of average. So when we said our goal was 125 
days, it was that the average case would take 125 days. This 
goal is a lot more ambitious where he is saying that he is 
eliminating any cases over 125 days and, at the same time, 
doing it with a 98 percent accuracy rate. That is really 
putting the challenge to us and saying we have to change the 
basic way we do business in order to accomplish that.
    We talked with our directors. We got a lot of really good 
ideas. We have some things that we are going to implement 
immediately. Just to give you an example, we are looking at 
doing what we call interim ratings where, for instance, on 
Agent Orange, if a veteran applies, is able to establish 
Vietnam service, has a diagnosis of, say, ischemic heart 
disease, but we do not have an exam to determine how disabling 
is the condition, we would pay him immediately at a minimum 
rate so he at least starts getting benefits and starts getting 
entitlement to things like voc rehab and treatment at VA 
hospitals while we go and do the exam to determine what his 
permanent rating would be. Those are the kinds of things that 
we believe we need to do to improve the service that we are 
providing to veterans.
    Senator Johnson. My time has expired.
    Senator Hutchison.

                          PRESUMPTIVE DISEASES

    Senator Hutchison. Thank you very much, Mr. Chairman.
    On the gulf war illness issue, your task force recommended 
nine new conditions to be automatic presumptions, and I am very 
pleased because these young men and women have been really in 
never-never land for a long time. I think that hitting it now 
rather than waiting so long, as was done in Agent Orange, it is 
still late, but I am glad we are doing it.
    This is my question. What is the timetable that you have 
after you have your rulemaking and you go through all of the 
required processes, that you think you will make the final 
determination on the gulf war syndrome presumptions? And then 
after learning the timetable, then I am wondering on the budget 
what you will expect, if it is going to be able to be covered 
this year, or will you have to accommodate that next year.
    Secretary Shinseki. I am going to turn to Dr. Petzel on 
this.
    Dr. Petzel. Thank you, Mr. Secretary.
    The process by which presumption is established is that 
there is a gulf war task force that will look at information 
such as the IOM report that recently came out regarding the 
gulf war. They will then make a recommendation to the Secretary 
as to illnesses that ought to be considered presumptive. The 
decision then is his as to what illnesses will be presumptive 
and what illnesses will not. And then there is a rulemaking 
process that occurs after the Secretary's decision has been 
made. As an example, I believe that the decision and the rules 
regarding Agent Orange, where the decision was made this early 
spring/late winter, will be finished, Michael, sometime----
    Mr. Walcoff. Early July.
    Dr. Petzel. In the late summer.
    Mr. Walcoff. Correct.
    Dr. Petzel. So, Senator, that would be the process by which 
we establish presumption.
    Senator Hutchison. So give me a guesstimate then. Is it 9 
months you are talking about after you get the recommendation 
and then there is the rulemaking and then the publication? I am 
just getting just a general idea. I am not asking for some 
blood oath, but just a general idea of what are we looking at 
in a timetable?
    Secretary Shinseki. I believe we will begin and will have 
the rulemaking done this summer, and then we will begin 
processing claims. It will be late summer timeframe.

                      FORT BLISS JOINT FACILITIES

    Senator Hutchison. Okay. That is what I needed. Thank you.
    So we will probably need--I know it is not in this year's 
budget. So we will probably need to address that at some point 
in the future.
    The other question that I have--General, you and I have 
talked about this, but the VA and the Army currently share 
joint facilities at Fort Bliss, and as we all know, Fort Bliss 
is in the process of being plused-up by about 30,000 troops. 
And that is going to affect the retiree population as well. 
Once the Army leaves the facility, the VA is going to be in a 
problem situation if the VA does not move with the Army.
    This is my question. The funding for the new hospital that 
is, at this stage, planned to be a joint facility, Army and VA, 
is in the Army's 2011 budget request and in the 2009 stimulus 
and then the 2009 war supplemental. The Army is ready to move 
and it is not in your budget this year because you were 
planning for all of this to be 1 year out.
    My question is, what are your plans? A, are you committed 
to the joint facility with the Army at Fort Bliss? And B, what 
are you thinking in updating your timetable to go along with 
the Army?
    Secretary Shinseki. Senator, we are committed to an 
integrated effort with the Army. We are a bit mid-stride right 
now because we planned on and were programmed for a 2012 start. 
So this acceleration to 2011 leaves us in a position where we 
do not have the resources to do that. We are looking at what 
options might be available to us. It also requires about a $20 
million design investment this year, 2010. So we are looking at 
that as well.
    And while we may be successful in being able to find those 
dollars, 2011 still remains an issue. I do not have the 
resources for it right now. It is not in my budget, and there 
are a number of longstanding projects that are on execution for 
us, and I would prefer to keep that priority because there have 
been veterans waiting for those assets to be provided. But we 
are interested in staying abreast of the Army's move here. We 
think it is important for it to be an integrated facility, and 
so we are looking at this hard.
    Senator Hutchison. You believe that you can have the $20 
million that would work with the Army to start the planning 
process in June. Is that correct?
    Secretary Shinseki. We are locating those dollars. I think 
there is a good chance we will do that, but I am hesitant to 
put $20 million up without understanding how we take care of 
2011, and right now I do not have resources.
    Senator Hutchison. Well, I will look forward to having you 
come to us with your suggestions, and then we certainly will be 
helpful because it would not make sense not to be joint and it 
would leave a big void if the Army moved and you did not. And 
it also would not be a wise use of taxpayer dollars when a 
joint effort would be so much more efficient. So I will look 
forward to hearing from you and helping as well. Thank you.
    Secretary Shinseki. Thank you.
    Senator Johnson. Senator Nelson.

                               OMAHA VAMC

    Senator Nelson. Thank you, Mr. Chairman.
    Thank you, Secretary Shinseki for testifying today. I am 
particularly pleased with your budget this year. I know the 
increases are there and there will be those who ask questions 
about why during these difficult times are we having increases. 
But the various causes that you are addressing in your budget 
are the kinds of things that I think, in spite of difficult 
times, we still have to identify and help.
    And I was especially pleased to see in your fiscal year 
2011 budget request that it addresses the needs of the Omaha VA 
Hospital. As we have discussed, this institution provides very 
good care for veterans, and I know Dr. Petzel knows that. But 
the physical facility is stuck back in the 20th century. Built 
back in the 1950s, upgrades to the facility and its equipment 
have served well, but now it is in need of a major overhaul. 
And working with your predecessor, Secretary Peake, and you, we 
have pushed to see that the hospital shortcomings are being 
addressed. You personally are well aware of these shortcomings, 
but for the record, I think they bear noting.
    A study by the VA, released last summer, found a number of 
critical functional deficiencies. I will not name all of them, 
but I will address a few. Significant space deficiencies. 
Forty-two out of 52 departments will need additional space. 
Surgical capacity is based on 1948 design. Present space does 
not meet room size, privacy requirements. A deteriorating 
building envelope, including problems with windows, walls, and 
the roof. Air handling and HVAC system beyond useful life, and 
overall refrigeration systems rated an F.
    In addition, the hospital has a unitary heating and cooling 
system and health officials have shared serious concerns about 
a virus such as the recent H1N1 virus being spread by this HVAC 
throughout the entire hospital, providing less than adequate 
health safety for the patients.
    So for these reasons, I am very pleased to see that your 
2011 budget calls for $56 million for planning and design 
toward substantial modernization of this hospital. It is a 
necessary first step toward what we expect will be a 21st 
century healthcare facility. And, Secretary Shinseki, this 
commitment is extremely good news for the thousands of veterans 
both in Nebraska and western Iowa.
    I have often said that I hope we some day become--and I 
think you are in the process of doing that--as good at taking 
care of our veterans as we are creating them. And your 
commitment to improving the Omaha VA Hospital is just one more 
example that caring for American veterans remains one of the 
Nation's highest priorities and clearly is one of yours.
    So, Mr. Secretary, from your perspective, perhaps you could 
give us your idea why this is a high priority for the Veterans 
Administration to see an improved facility in Nebraska.
    Secretary Shinseki. There is a great tradition in the VA, 
Senator. When we have problems, we do not blame our 
predecessors. When something comes out right, we give credit to 
them as well. Jim Peake is an old friend. He and I soldiered 
together for many years. In fact, I selected him to be the 
Surgeon General when I was on my last service in uniform. He 
was my predecessor in 2008, I think. Because he was apprised of 
some shortfalls in the service, primarily the safety aspects of 
the hospital in Omaha, he initiated an independent study, not a 
VA study, but an independent study, to go in and make their own 
assessment to provide him some idea of what the conditions 
were. As things turned out, I inherited that study which came 
in the spring of last year, as I recall. We put it into our 
annual scoring process. I think the Omaha hospital at one point 
was 15 or 16 on a priority list. Seven of the projects in that 
list were funded in the previous year's budget. So it moved up, 
and so all of the projects moved up, at least moved up 
accordingly. One project was removed from the list, as I 
recall, for some reason, but then with this new independent 
study, the rescoring just put Omaha within the range to get the 
ranking it did.
    I think it came out well. It came out right. It was the 
right thing to do for veterans in that part of the country. But 
understand, Omaha is just the location of the hospital. It 
serves Iowa. It serves lots of adjacent States. So veterans in 
many locations are serviced by this hospital. Location is only 
one issue.
    So that is my take on it, Senator.

                           VETERANS CEMETERY

    Senator Nelson. Well, I appreciate that.
    I also want to commend you for the VA budget having design 
funds for a new national veterans cemetery in Sarpy County, 
Nebraska, also eastern Nebraska adjacent to the Omaha area, 
which will serve a number of veterans from a region. The 
location of that cemetery, as the location of the hospital, 
will catch not only some South Dakota residents, veterans, but 
Iowa and northern Missouri, as well as perhaps some of Kansas' 
as well. So we appreciate your focus on it. You are doing an 
outstanding job, and we appreciate the opportunity to work with 
you.
    And we want to compliment former Secretary Peake for his 
wisdom in stepping in and seeing that we get an independent 
study so that it is some outside thoughts, as well as our 
inside thoughts.
    Thank you very much.
    Thank you, Mr. Chairman.
    Senator Johnson. Senator Murkowski.

                              RURAL ACCESS

    Senator Murkowski. Mr. Chairman, thank you.
    Secretary Shinseki, good to see you. Thank you for our 
conversation earlier in the week. Not only did we have a chance 
earlier this week to discuss the issue of access to care to so 
many of our veterans who live in very rural parts of the 
country, we talked about it last year and the challenges that 
particularly our Alaska Native veterans face in accessing their 
earned healthcare benefits when they come back to their 
villages and they are hundreds of miles from the nearest VA 
facility, the challenges that they face. And we have talked a 
little bit about the effort that has gone into the rural Alaska 
pilot project and the need to make sure that we make that pilot 
function a little more efficiently.
    I understand--and I thank you for your offer to visit with 
the folks over at Indian Health Service (IHS) to see how we 
cannot iron out some of those issues, but again, find an easier 
path for those veterans who are in some of our most rural 
communities and have access to an IHS facility, that we might 
be able to partner with some of that care. But we know that 
that is just one part of the problem in Alaska.
    The other dimension of access to our veterans in my State 
is we have got concerns that those that actually have access to 
the VA facilities there cannot access the facilities with their 
particular healthcare conditions. Sometimes demand exceeds the 
capacity. Sometimes our veterans are told that they have to 
travel to Seattle because the procedures are not available in 
Alaska, just not available within the facilities that we have. 
It is our understanding that these veterans are told, well, the 
regulations require us to send you outside to Seattle rather 
than purchase care within the community. I had asked whether or 
not you felt that the VA was being a little overly rigid in 
interpreting these regulations.
    But essentially what I am looking for and what I am hoping 
that we can work with you on is how we ensure that the 
commitment made to these Alaskans is kept without having to 
send them outside to care, a 2,000-mile trip, for some even 
more than 2,000 miles, to access care when it could be made 
available through purchased care within the State.
    Secretary Shinseki. Well, Senator, I appreciate those 
insights. I am reminded that in our geographical descriptions 
of our system, we have urban, rural, highly rural. So two-
thirds of our definitions have the word ``rural'' in it, and 
then I am told that even highly rural may not describe some 
parts of the country and Alaska is one of them.
    We are going to look at very closely why we would send a 
veteran on a 2,000-mile journey if there is competent, safe 
healthcare available close by. We will take a look at that.
    This also behooves us to have a better working 
relationship, although we have already started this with the 
Indian Health Service, but a better relationship of sharing 
assets and capabilities so that we reach out into these areas. 
Even as hard as we are working at it, it is not still good 
enough. Telehealth is another capability we have invested in 
heavily. If there is any place we ought to be demonstrating the 
power of a microprocessor it would be in places like remote 
tribal lands in Alaska.
    Let me just turn to our senior medical officer, Dr. Petzel, 
and ask him for his insights here.
    Dr. Petzel. Thank you, Mr. Secretary.
    Senator Murkowski, I share your concern about the distance 
that some of these people have had to travel. We looked back 
and 685 veterans were asked to travel from Alaska down to a 
medical center in the Lower 48, usually Seattle, but it may 
have been other places. The question that I have when I heard 
that is what sorts of things are they being referred for. It is 
one thing to come down for open heart surgery, which may be a 
super-special kind of thing to do. But, on the other hand, 
routine surgery that we could be performing in Anchorage on a 
contract or on a fee basis probably ought to be looked at. So 
it is my intention to look at why those cases were sent, what 
kinds of cases were sent, and see if we can find out some sort 
of an arrangement that provides better, more community-level 
access for those veterans.
    Senator Murkowski. Well, Dr. Petzel, I appreciate that. In 
speaking with constituents that are expressing their concerns 
and their frustrations, what we are hearing is that a 6-week 
chemotherapy treatment--an individual lives in Fairbanks, our 
second-largest community, fine medical facilities, and yet they 
are being sent outside down to Seattle for treatment. I would 
like to think that that is one of those that should absolutely 
not be necessary for something as routine as chemotherapy 
treatment. So we would like to work with you on that. I would 
certainly like a better understanding myself. So much of what 
we know is anecdotal, but when we hear these anecdotes, this is 
something that for these families that have to make these 
transitions and spend 6 weeks down in a hotel in Seattle with 
no family members, the expense that is involved, but also the 
separation is something that is not the kind of care that I 
think our veterans certainly deserve and that we owe to them. 
So we want to work with you on this.
    Dr. Petzel. We would share your concern, Senator.
    Senator Murkowski. Thank you, Mr. Chairman.
    Senator Johnson. Senator Murray.

                          VETERANS EMPLOYMENT

    Senator Murray. Thank you very much, Mr. Chairman. And I 
would tell my colleague from Alaska that we would happily take 
care of your veterans in Seattle. But I think most people do 
not realize it is a 3\1/2\ hour flight from Alaska to Seattle. 
It is a long way for those people to go. So I appreciate your 
concern.
    Mr. Secretary, thank you for you and your team being here 
today.
    I wanted to talk with you about an issue that is really 
weighing heavily on our veterans today and that is that they 
are coming home from serving us so honorably overseas and 
cannot find a job. The unemployment rate for our young veterans 
returning from Iraq and Afghanistan is now over 21 percent.
    When I was out in my State for the last 2 weeks, I sat down 
with a number of young veterans to talk to them about what was 
keeping them from finding work when they came home. And 
frankly, it was really shocking what a lot of them said to me. 
Some of them told me that they actually leave off the fact on 
their resume, when they are giving it to an employer, that they 
are a veteran. And I asked them why and they said it was 
because it went to the bottom of the stack. They did not know 
if it was because of the stigma of the invisible wounds of war, 
but they were finding that from many employers.
    Many of them told me that the Pentagon and VA transition 
programs do not work for the jobs and types of opportunities 
that could be available today.
    Many of them told me that they completely struggle to get 
civilian employers to understand what their experience was in 
the military that translates to what a civilian employer might 
need.
    They basically told me that their peer group either chose 
to get a job and had good experience or went to college or some 
kind of apprenticeship school and had that experience. They 
chose to go to the military and their experience does not count 
when they come home to get a job.
    I just find that completely unacceptable. I found that it 
often triggers a lot of mental and emotional issues that we are 
seeing among our veterans today as well. These people serve our 
country honorably. They are great workers. They are skilled. 
They come to work on time. They should not be facing these kind 
of barriers when they come home.
    So I wanted to ask you today, while you are here, if you 
are hearing the same kinds of concerns from our returning 
veterans and if there is anything the VA is doing today to try 
and make the transition work better.
    Secretary Shinseki. Thank you, Senator.
    I hear some of the same things, perhaps not the same 
anecdotes, but it feeds a couple of images I carry around and I 
tend to refer to them in speeches. This will take a few 
minutes, so I hope I do not take up too much time here.
    The first image is the one we are most familiar with. Every 
year about 60 percent of high school graduates go on to 
universities or some higher institution of learning. The 
remaining 40 percent go to vocational training or right into 
the workforce, and as you indicate, a very small percentage 
join the less than 1 percent of Americans serving in uniform 
doing the Nation's bidding. Good folks. They go through the 
train of experience, prepare for life with discipline and 
accountability. When they arrive in their first unit, good 
leadership puts them on missions that are complex, dangerous, 
sometimes near impossible. And yet, they outperform all our 
expectations. Great youngsters.
    The second image is a smaller population, but it says 
veterans are a disproportionate share of the Nation's homeless, 
jobless, mental health, depressed patients, substance abusers, 
and suicides.
    So the issue is what happened here. They are the same kids 
in both images. Something happened, and that is what we are 
about, is to try to figure this out, how to keep the kids in 
image one going on to do great things and then reach into image 
two and get those youngsters the help they need. That is what 
we are about.
    Senator, I would tell you that in all of our Departments of 
the Federal Government we have a goal of hiring veterans as 
part of the workforce. Right now, VA is at about 30 percent. It 
may be a point or two less. We intend to raise that. I am happy 
to serve as the Vice Chair to Secretary Solis who chairs the 
interagency task force on hiring veterans in the Federal 
Government. All of us are working toward this to try to 
increase the opportunities for them.
    At the VA, we have a Veterans First project which is better 
known. Small businesses are given the opportunity to compete 
for our contracts, and if competent, we level the playing field 
and they have a good shot at that.
    An example of this is last year in the stimulus funding, we 
were given $1 billion, lots of money for VA, and we competed 98 
percent of those dollars. As a result, our contracts came in 
lower than usual, and so we were able to have 20 percent more 
buying power.
    So just by the way we run these things, we feel good about 
the processes we have in place. In that process, 82 percent of 
our contracts went to veteran-owned small businesses, important 
for us because veterans hire other veterans. So that creates 
the churn of jobs, and we are looking for any opportunity we 
might have to repeat that.
    But I do share your concern. The G.I. bill is important 
because it gives some opportunity for youngsters to have 
constructive work for the next 4 years, but 4 years from now, 
they will be looking for jobs, and we need to have in place----
    Senator Murray. Well, I very much appreciate that response. 
I think there are a number of things we need to do. The TAPS 
program, National Guard, their skills and the way we treat them 
today cannot be the way we treated them 20 years ago.
    I am going to be introducing actually legislation next week 
on a veterans' employment legislation. I would love to have 
anybody join me on that that is interested. But looking at how 
we can help them transition their skills better so that 
civilian employees actually hear the skills that they have, 
opening up opportunities for apprenticeship programs that they 
currently do not have under the G.I. bill in an online school 
which often works for them, and helping them actually establish 
small businesses, not just have veterans on preference, but 
actually helping them do that. I think there are a number of 
things we have really got to aggressively work on so that as we 
are recruiting today and telling young people to come into the 
military, it is great experience, it is actually an experience 
that will help them get a job some day and they do not feel 
left behind.
    So, Mr. Chairman, I thank you for the extra time here.
    Mr. Secretary, I hope I get your help and support on my 
legislation as well. Thank you.
    Senator Johnson. Senator Collins.

                            VETERAN SUICIDES

    Senator Collins. Thank you, Mr. Chairman.
    Mr. Secretary, welcome. I was pleased to have an 
opportunity to talk with you recently in my office and to thank 
you for coming to the great State of Maine to tour our veterans 
hospital, which I would inform my colleagues is the oldest in 
the Nation, the very first veterans hospital.
    A recent article in Time magazine noted that between 2001 
and the summer of 2009, our military lost 761 soldiers in 
combat in Afghanistan. During that exact same period, the 
military lost more soldiers to suicide, 817 of our men and 
women in uniform. Last year, 160 active duty soldiers took 
their lives, and just this week the Army announced that in the 
first 3 months of this year, 71 more soldiers took their own 
lives.
    I know that this news is heartbreaking to you personally, 
as it is to all of the members of this subcommittee. I have 
talked with the active duty leaders in our military about what 
the Pentagon is doing to address the mental health needs of the 
active duty force, but I would like to know from you whether 
you feel the VA's budget is adequate to address the same kind 
of needs for mental health services and counseling that face so 
many of our returning veterans.
    Secretary Shinseki. Well, Senator, thank you very much for 
that question.
    We have resourced this properly, but there is so much more 
to be done in this area. First of all, none of us are experts 
in how to deal with the phenomena that results in great young 
people who do such wonderful things for us ending up feeling 
that there is no other choice but to have to take this step and 
hurt themselves.
    We have, in the last 4 years, hired probably an additional 
5,000 to 6,000 mental health staff to bolster our capabilities 
here in dealing with this issue. We probably number 20,000 or 
19,000 mental health staff today. We have made mental health 
part of our primary care facilities so that having someone 
think about having to go to the mental health clinic and the 
stigma associated with that is eliminated, especially amongst 
20-year-olds. We are trying to help them not have to deal with 
that. So we provide mental healthcare inside the primary care 
facility.
    We have created a suicide hotline that is well recognized 
nationally out of Canandaigua, New York. They handle probably 
10,000 calls each month and each day something on the order of 
10 rescues online of individuals who are under such great 
duress that they are thinking about hurting themselves. Over 
the several years since we have started this, we have had 
probably 3,000 intercessions that stop the act of self-
destruction in progress while the phone call is being made. 
When the phone is picked up, it is a mental health professional 
on the line. It is not just an operator. There are two of them. 
They work in a pair, one of them speaking to the individual and 
getting as much information and the other is helping to try to 
locate the individual so we can get help there. So these are 
actual online rescues that are occurring.
    We advertise this hotline in most of the major cities in 
the country so that people have some understanding of this, at 
bus stops, on buses, on the metro.
    More work needs to be done in terms of research, and so we 
are putting some energy there as well.
    Let me turn to the Chief Medical Officer here, Dr. Petzel, 
and see if he has got anything to add to this.
    Dr. Petzel. Thank you, Mr. Secretary. That was really quite 
thorough. Just a couple of things, Senator, that I would add.
    One is that we have a suicide prevention team at every one 
of our facilities. These teams include experts in PTSD, 
substance abuse, and those other mental illnesses that are 
often associated with suicide.
    In addition to that, all of the veterans returning from 
combat who seek care with us are screened for traumatic brain 
injury, substance abuse, PTSD, and depression: again, those 
things which we often have associated with suicide. Any suicide 
death is a tragedy. Any suicide death is a tragedy.
    I think that we have the resources, as the Secretary 
pointed out, and the programs to have an impact on veterans' 
suicide. I would not want to say we can eliminate this, but I 
think we will be able to see the fact that we are having an 
impact.
    The Secretary mentioned at the end of his remarks, 
research. One of the things that we need, that the Nation needs 
to do is a better job of, is being able to identify those 
people who are really at risk. I mean, there is a suicide 
assessment that could be done, but it does not really hone in 
on those people who are very seriously at risk and I think we 
need to be at the forefront of doing that kind of research.
    Secretary Shinseki. May I just provide just some data here 
to answer your question, Senator? The 2011 budget request 
includes an 8.5 percent increase, or $400 million, over the 
2010 budget for mental healthcare, and then in terms of mental 
health research, the 2011 budget request is a 15 percent 
increase above the 2009. Eighty-three million dollars is the 
research number.

                               G.I. BILL

    Senator Collins. Thank you. That is very encouraging.
    Mr. Chairman, I have another question that I would like to 
just submit for the record. It has to do--and the Secretary was 
the one who brought this to my attention, the fact that when we 
updated the G.I. bill to help provide more educational 
assistance, we narrowed the kind of training program that is 
available, and we left out a lot of vocational, community 
college kinds of programs. And that is something I think we 
need to take a second look at. So I have a couple of questions 
on that that, with your consent, I would like to submit for the 
record. Thank you, Mr. Chairman.
    Senator Johnson. It will be received.
    Senator Pryor.

                              RURAL ACCESS

    Senator Pryor. Thank you, Mr. Chairman, and thank you, Mr. 
Secretary, for being here.
    I do want to echo Senator Collins' concerns about the 
suicide rates. I agree with what you have said, that any 
suicide is a tragedy. I know you are working on it. You are 
very attentive to it, and I would just encourage you to 
continue on that track and even put more resources there if 
that is what you need to do. But it is very important.
    Let me ask a question. I do not want this to sound like a 
parochial question because I am going to talk about Arkansas 
here for just a minute. I am sure every other State in the 
Union has these same type of concerns because even the most 
urban States have some type of rural area in them.
    But in our rural areas of my State, I hear from a lot of 
our veterans about the difficulties they have in accessing 
medical care that meets their needs. The VA outreach 
initiatives have been good in a lot of ways and there have been 
good attempts and steps in the right direction. I know you have 
the community-based outpatient clinic program. But have you 
done any sort of top-down review of the community-based 
outpatient programs and looking for ways that they can provide 
greater oversight and guidance so that the best possible care 
and access is available to these veterans who live in these 
rural areas? I know you mentioned some of the most rural areas 
in the country, Alaska, but our State has a lot of hard-to-
access areas with not much healthcare in there.
    Secretary Shinseki. I am going to turn to Dr. Petzel in a 
second.
    Again, Senator, this is a great reminder. Several years 
ago, very bright people, well before my time, decided that 
having 153 premier flagship medical centers was not good 
enough, that there is so much expanse to our country that we 
had to find a different solution in delivering healthcare, not 
just welcoming people to come get it but delivering healthcare. 
So we created a community-based outpatient clinic system, which 
you have asked me whether or not we are taking a look at. 
Outreach clinics in places that do not have a veteran 
population to support a full-time clinic will go lease a piece 
of real estate, stand a clinic up for 3 days, shut it down, and 
move it, mobile, on wheels, and do the same thing.
    Telehealth, telemedicine. Right now, we have 40,000 
veterans who are receiving telehealth monitoring because they 
are chronically ill in their own homes. They do not have to go 
anywhere. The technology is there. So this is part of the 
structure.
    Yes, we are looking down to make sure that we have the 
right capabilities, the right services to meet the needs out 
there, and that is a constant look. There are looks underway 
right now. In fact, I would just offer to everyone that this is 
a look and we are trying to ensure that we have a good 
understanding where the needs are.
    With that, let me turn to Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    Senator Pryor, I heard two questions or two concerns. Let 
me just add a little bit to the first one to what the Secretary 
had to say.
    Each year we assess the needs for community-based 
outpatient clinics. It starts at the medical center level, 
moves up through the network, and eventually we come to a 
national understanding of what the needs are for additional 
community-based outpatient clinics. We will be opening a number 
of new ones during 2010. We hope to have about 862 clinics 
opened with the completion of fiscal year 2010.
    But as the Secretary mentioned, there are much more mobile, 
if you will, modalities that we can use. Home-based primary 
care where we send visitors into the home. Telehome health 
where we actually have tools for monitoring in the home. A case 
manager, from the veterans' perspective, is probably the most 
desirable way to provide care in the rural community. They do 
not have to travel very frequently to a clinic or to a medical 
center. And then we have telemedicine where we can provide in 
the community telemedicine access to specialists at various 
places.
    I think we are going to be doing a better job in these next 
2 years of reaching rural America. I think the Secretary 
mentioned there are 40,000 patients on telehome health. I think 
that the number who need that modality is probably hundreds of 
thousands, and we are moving aggressively to increase the 
number using telehome health.
    The second question, though, that I thought I heard in what 
you said was, what about the quality of the care that we 
receive in our community-based outpatient clinics. And we do 
hold them to the same standards and do assess them in the same 
ways for the quality of care that they are receiving, and that 
is whether it is a clinic that we staff ourselves or whether it 
is a clinic where we contract for care.

                        ELECTRONIC HEALTH RECORD

    Senator Pryor. Great. I appreciate that and I appreciate 
your attention to that. It is important to pretty much every 
Senator in the Senate because we all have some rural areas and 
some challenges out in those rural areas.
    Mr. Secretary, I would like to ask you about the joint 
lifetime electronic record. I know that this is something that 
the DOD and the VA have been working on together. I think it is 
very important that we do it and do it right. Could you give us 
a very brief status report on that?
    Secretary Shinseki. Let me turn to the expert, Senator. Let 
me turn to Roger Baker here who handles that for us.
    Mr. Baker. Thank you, Mr. Secretary. I will give you a 
quick update. We have a lot of detail on this one.
    As you know, we have probably the best interoperability 
right now with the Department of Defense, exchanging 
information between our electronic health records. As we moved 
to expand that, we have moved to a national standard for 
information exchange so that we can bring the private sector 
into that electronic health record. Roughly 50 percent of the 
care provided to veterans is done by the private sector, and in 
the past we have not shared those health records. So we are 
moving that forward.
    We have had a pilot live in San Diego with Kaiser 
Permanente on that project for several months. We have 
announced that we will be doing another pilot in the Hampton 
Roads area and moving forward with pilots there toward a 2012 
general availability of that for private sector folks to hook 
in with.
    On the benefits side, we have also made substantial 
progress in achieving what the Secretary terms the ``seamless 
transition'' and doing things along the lines of putting all of 
our benefits information and the DOD's benefit information on a 
common Web site so that a service member goes to the e-benefits 
portal while they are in the service and sees what their 
benefits are. They have the same log-in, exactly the same Web 
site, when they move to VA so all the information is the same 
there.
    We really have moved a long ways forward in a global 
approach to sharing that information. It is a long process. 
There are a lot of systems involved and a lot of information 
involved, but we feel very good about the progress.
    Senator Pryor. Good.
    Thank you, Mr. Chairman.
    Senator Johnson. Senator Brownback.

                             JOINT VENTURES

    Senator Brownback. Thank you, Mr. Chairman.
    Mr. Secretary, welcome, and gentlemen, good to have you 
here.
    I want to raise two quick issues with you. One is the joint 
VA/DOD ventures that you have around the country, Mr. 
Secretary. I understand you have eight joint ventures between 
DOD and the Veterans Administration as far as healthcare 
facilities that serve both active duty members and veterans.
    I just want to put out for you that at Leavenworth one of 
the things that I have been talking about with the local base 
and the Veterans Administration in Leavenworth is that as they 
look to move forward, I think there are some real synergies and 
possibilities of a joint facility in Leavenworth. You have a 
small VA hospital that is there. You have got a major Army 
base. We have the disciplinary barracks from the DOD also 
there. And then the Bureau of Prisons (BOP) has a major 
facility. And yet, no hospital healthcare facility for the 
entire complex.
    It is expensive care that is taking place now. The Bureau 
of Prisons is building a kidney care center for dialysis just 
for older people that are in prison. To get dialysis, they are 
going to move all their prisoners from around the country to 
Leavenworth to get dialysis care. Probably a good idea, but I 
am looking at this and thinking you have a VA, a major military 
base, disciplinary barracks, and BOP, and it is all the same 
Government and we are short of taxpayer money.
    I think this is a prime place to look at something of that 
nature, and I would just urge your folks to take a look at 
that. I know the base commander at Leavenworth would be 
interested in doing this because he does not have a healthcare 
facility at all, and it is a substantial base. I think it is 
the largest base in the country without a healthcare facility, 
and it would be nice to do this in the most economical way we 
could.
    A second issue I just want to raise with you--and Senator 
Collins raised it. It was on Senator Pryor's mind as well--is 
on the suicide, PTSD, traumatic brain injury issue. I think we 
are doing a lot better job this time around on this than after 
the Vietnam era. When I first came into Congress, I would see a 
number of Vietnam veterans come into our office that just had 
not--there was not any recognition that there was a PTSD 
syndrome at the time, and then they did not get any care and it 
just got worse for neglect. I think you are doing a better job 
this time around.
    One issue I would offer to you on that and I hope you do is 
to engage more of the private sector community on it, 
particularly the not-for-profit, faith-based community that 
would really like to engage because in my experience, these 
guys have difficulties that in many cases they are not willing 
to express or talk about or it is not tough if I do, and yet 
the longer it goes on, the worse it is going to dig in. And 
they need to really just build relationships. They need 
somebody that just sits there and says I care about you. Look, 
we have a problem and let us go get it taken care of.
    And I have seen some interesting models around the country 
of where the private sector is stepping in. There is a group 
that just came into my office--I think they are from Kentucky--
that is working doing this--and this seemed to me to be really 
classically built for a private, faith-based community 
engagement because really what you need is somebody to build a 
relationship that can see the signs coming on this. And many of 
these guys either do not have that level of relationship or 
have already blown through their relationships, their close 
ones, because of PTSD or traumatic brain injury and then the 
steps on down the road are drugs or alcohol or suicide at the 
worst case. This one seemed to me to be really made for that 
sort of issue because you are going to need a lot of hands on 
deck to pick these sort of problems up as they come along.
    I would urge you to look at that and I would hope you could 
look at this possible joint facility at Leavenworth.
    Secretary Shinseki. Senator, I am going to turn to the 
Chief Medical Officer here for his insights.
    But I would tell you we look for any opportunity to 
partner, especially with DOD. Very little of what we do in VA 
originates here. We are joined by the one key link between us 
and that is the individual who wears a uniform one day and 
takes the uniform off the next. And the VA then has 
responsibility to care for them for a long period of time.
    You may be interested to know that today we still have two 
children of Civil War veterans on our rolls as beneficiaries.
    Senator Brownback. Is that right?
    Secretary Shinseki. One hundred and fifty-one Spanish-
American War beneficiaries. So our responsibilities go on for a 
long time, and this effort to partner with DOD makes good 
sense, makes good business sense, and it takes great care of 
these youngsters.
    Let me just turn to Dr. Petzel here for a few seconds.
    Dr. Petzel. Just to elaborate a bit on the Secretary's 
comment--thank you, Mr. Secretary. In Kansas, we are actually 
engaged already with Leavenworth. The VHA leadership has been 
in discussions with the Leavenworth military community about 
how we can cooperate.
    Senator Brownback. Good.
    Dr. Petzel. I think that is an excellent suggestion, 
Senator.
    Senator Brownback. I have been pushing them to do this. It 
really makes a lot of sense to do it.
    Dr. Petzel. We are actually also looking at another place 
in Kansas, in Wichita at McConnell Air Force Base. We have 
engaged McConnell in discussions about how we can share 
jointly. We are one Federal Government and there ought to be 
ways that we can share our expenses.
    Senator Brownback. This would be unusual, but if you could 
even think about involving the disciplinary barracks which is 
part of the military that is in Leavenworth and the BOP. I know 
that is really outside of the box, and we may be pushing it to 
get two stovepipes together, and three or four may be just a 
bridge too far. But they are all within 3 miles of each other--
4. And you would impress a lot of people if you are able to get 
that many stovepipes in the same chimney.
    Dr. Petzel. We will certainly look into that.
    Senator Brownback. Thank you.
    Secretary Shinseki. Senator, I will just add to this. Forty 
thousand veterans come out of prisons every year, and so out of 
our medical care system--out of VA for both benefits and 
healthcare, we have already been in touch with prisons. I think 
there are something on the order of 1,300 Federal prisons. We 
have visited maybe 800 of them and made contact with about 
15,000 prisoners in the effort to prepare them so they leave to 
be on track with a good phase in the next phase of their lives. 
Much of that has to do with treatment to begin with and then 
stability in jobs and other things. But already there is this 
requirement to work together with the Bureau of Prisons.
    Senator Brownback. Good.
    Thank you, Chairman.
    Senator Johnson. Thank you, Senator Brownback.
    I would like to thank the Secretary and those accompanying 
him for appearing before this subcommittee. I look forward to 
working with you this year.

                     ADDITIONAL COMMITTEE QUESTIONS

    For the information of members, questions for the record 
should be submitted to the subcommittee staff by close of 
business on April 21.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
               Questions Submitted by Senator Tim Johnson
    Question. Mr. Secretary, on March 18, the VA published a Proposed 
Rule in the Federal Register that would establish a presumption of 
service connection for nine diseases for veterans who served in the 
Persian Gulf and Afghanistan. I am pleased that the VA is taking steps 
to recognize diseases that afflict vets that served in the Gulf. As the 
VA moves to implement this proposed rule, have you developed any budget 
estimates, both for compensation payments and healthcare costs, for the 
cost of implementing this new policy?
    Answer. The compensation benefit costs associated with this 
proposed rule are estimated to be $1.5 million during the first year, 
$11.5 million for 5 years, and $36.4 million over 10 years. This 
proposal would amend section 3.317 of title 38 C.F.R. to establish a 
presumption of service connection for the nine diseases (brucellosis 
infection, campylobacter jejuni infection, coxiella burnetti infection, 
malaria infection, mycobacterium tuberculosis infection, nontyphoid 
salmonella infection, shigella infection, viseceral leishmaniasis and 
west nile virus infection). However, the costs associated with this 
regulation are based only on compensation for tuberculosis due to 
insufficient data available on the other rare diseases. Because of the 
small number of veterans and survivors affected by this rule annually, 
the additional caseload and cost of implementing this new rule will be 
absorbed in existing resources.
    Question. Collaboration between the VA and the Indian Health 
Service needs to improve. Many Native Americans who are veterans often 
get conflicting information regarding benefits that they are entitled 
to. What plans does the VA have to improve the coordination of benefits 
between the two Departments?
    Answer. VA has a robust program with the Indian Health Service 
(IHS) as is reflected in Attachment A, which provides details regarding 
specific Native American/Alaska Native veteran outreach and healthcare 
activities.
    In addition, on May 24, 2010, VA Secretary Shinseki met with Dr. 
Yvette Roubideaux, Director of Indian Health Service. During this 
meeting, it was agreed the Memorandum of Understanding between VA/IHS 
would be updated by September 30, 2010, to reflect the expansion of 
collaborative activities, as well as the enhancement of communications. 
Both organizations agreed that working together in partnership will 
enhance the delivery of benefits to our Native American and Alaska 
Native veterans.
    Question. Mr. Secretary, the budget includes a supplemental request 
to implement the Agent Orange decision. The entire request is for VBA 
disability claims. However, this decision is likely to have an 
important impact on demand for VHA medical care as well. Has VHA 
projected the likely effects on its medical expenditures?
    Answer. VHA projects Agent Orange expenditures of $165 million and 
$171 million in fiscal year 2011 and 2012, respectively. These costs 
are included in the budget request.
    Question. The denial of On-the-Job Training (OJT) benefits under 
the GI Bill for the State workers who work in State Veterans Affairs' 
State Approving Agencies (SAA) is inconsistent with the policy 
regarding Federal VA workers and OJT. There have been several incidents 
where the VA has denied OJT programs with the South Dakota SAA. The VA 
has deemed employees to be ``fully qualified'' due to the fact that 
they were hired to their positions, but being fully qualified is not 
the same as being fully trained. VA employees, such as a VA Veterans 
Claims Representative, or an Education Liaison Representative can use 
their GI Bill benefits for an OJT program with the VA, but those in 
State Approving Agencies are denied approval to use their GI Bill 
benefits for OJT Programs. The VA's argument for denying the claims of 
SAA employees is that they don't need training because they are already 
qualified, and yet, the VA employees who are in positions of authority 
over the SAA employees are generally approved to use OJT benefits.
    Why does the VA deny the use of the GI Bill for OJT programs for 
SAA employees while approving them for the education liaison 
representatives (and others) who would generally be considered more 
qualified, trained, and knowledgeable?
    Answer. SAAs are charged with approving education courses in 
accordance with the provisions of chapters 33, 34, 35 and 36 of title 
38 U.S.C. Under contracts with VA, SAAs ensure that education and 
training programs meet Federal VA standards through a variety of 
approval activities, such as evaluating course quality, assessing 
school financial stability, and monitoring student progress. SAAs also 
promote the development of apprenticeship and on-the-job training 
programs and approve tests used for licensing and certification. The 
Federal Acquisition Regulations (FAR) require SAAs to be qualified to 
perform the required duties before they can be awarded a contract. 
Therefore, VA has denied the requests of current SAA employees for on-
the-job training programs.
    VA's General Counsel is currently reviewing the law and regulation 
as it applies to this matter and will issue a formal opinion by mid-
July 2010.
    The Veterans Benefits Administration does hire employees in entry-
level trainee positions. Work completed by trainees is reviewed and 
approved by experienced supervisors. These supervisors are required to 
have the necessary knowledge and skills to perform the duties of the 
job prior to being selected for the position, much like the 
requirements for SAAs. Therefore, they would not be approved for an on-
the-job training program.
                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye
    Question. Mr. Secretary, it is my understanding that the Department 
of Veterans Affairs has done an extremely good job when it comes to 
both hiring veterans, and utilizing service-disabled veterans small 
businesses to execute contracts. Would you please elaborate on some of 
the goals that VA would like to meet with regard to both hiring and 
small businesses in fiscal year 2011?
    Answer. The average employment of veterans across the Federal 
workforce is 25.8 percent according to OPM, as of September 30, 2009. 
Today, approximately 30 percent of the Department of Veterans Affairs 
workforce (over 90,000 of 300,000 employees) is comprised of veterans. 
We've set a strategic target of 35 percent veteran employment. Our 
target for fiscal year 2011 is to obtain 31 percent veteran employment.
    VA is proud to lead the Federal Government in small business 
contracts to service-disabled and other veteran-owned small businesses. 
Preliminary VA data for fiscal year 2009 indicate that service-disabled 
and other veteran-owned small business interests respectively received 
16.3 percent and 19.3 percent of VA's total procurement dollars. We are 
on a similar performance track to exceed our goals in fiscal year 2010. 
Our employees worked especially hard to exceed these ambitious goals 
for implementing ARRA funds. Of the over $1 billion in ARRA funding for 
VA approximately 80 percent have so far been awarded to Veteran Owned 
Small Businesses (VOSB). Our goal for fiscal year 2011 for service-
disabled VSOB is 10 percent, and for VSOB is 12 percent.
    Question. Mr. Secretary, there are many pressing issues that face 
our veterans, and the fiscal year 2011 VA budget was crafted to seek 
the greatest degree of balance. The VA is the agency charged with 
caring for the needs of our veterans for the long-term. As you looking 
forward and anticipate the greater demands that will fall upon VA, in 
terms of healthcare and benefits, what actions are you taking to 
prepare the Department for the expected influx? Given the constraints 
we are all facing during these economically difficult times, how do you 
see the Department meeting the requirements this preparation requires?
    Answer. We recently completed development of a new strategic 
framework that is people-centric, results-driven, and forward-looking. 
The path we will follow to achieve the President's vision for VA will 
be presented in our new strategic plan, which is currently in the final 
stages of review. The strategic goals we have established in our plan 
are designed to produce better outcomes for all generations of 
veterans:
  --Improve the quality and accessibility of healthcare, benefits, and 
        memorial services while optimizing value;
  --Increase veteran client satisfaction with health, education, 
        training, counseling, financial, and burial benefits and 
        services;
  --Protect people and assets continuously and in time of crisis; and
  --Improve internal customer satisfaction with management systems and 
        support services to achieve mission performance and make VA an 
        employer of choice by investing in human capital.
    VA's 2011 budget focuses on three concerns that are of critical 
importance to our veterans--easier access to benefits and services; 
reducing the disability claims backlog and the time veterans wait 
before receiving earned benefits; and ending the downward spiral that 
results in veterans' homelessness.
    This budget provides the resources required to enhance access in 
our healthcare system and our national cemeteries. We will expand 
access to healthcare through the activations of new or improved 
facilities, by expanding healthcare eligibility to more veterans, and 
by making greater investments in telehealth. Access to our national 
cemeteries will be increased through new burial policies that lower the 
veteran population threshold required to build a national cemetery from 
170,000 to 80,000 within a 75-mile radius and that allow for the 
establishment of urban satellite cemeteries.
    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 healthcare.
    The Veterans Benefits Administration now employs more than 11,600 
full-time claims processors and plans to add 3,000 additional 
decisionmakers in fiscal year 2011. However, continuing to increase the 
size of our workforce is neither a long-term nor scalable solution; we 
need to do a much better job of leveraging network automation and 
software productivity tools to more effectively manage our workload and 
serve our clients. Bold and comprehensive changes are needed to 
transform VA into a high-performing 21st century organization that 
provides high quality services to our Nation's veterans and their 
families.
    VA's transformation strategy leverages the power of 21st century 
technologies applied to redesigned business processes. Pilot programs 
are underway at four of our regional offices to support our business 
transformation plan to reduce the claims backlog, improve service 
delivery, and increase efficiencies. Each pilot functions as a building 
block to the development of an efficient and flexible paperless claims 
process. The results of all four pilots will be incorporated into the 
nationwide deployment of the Veterans Benefits Management System (VBMS) 
in 2012. VBMS will be built upon a service-oriented architecture, 
enabling electronic claims processing by providing a shared set of 
service components derived from business functions. Initially, VBMS 
will focus on scanned documents to facilitate the transition to a 
paperless process. Ultimately, it will provide end-to-end electronic 
claims workflow and data storage.
    VA is also seeking contractor support to develop a system to 
support evidentiary assembly and case development of the new Agent 
Orange presumptive claims. The system will enable veterans to 
proactively assist in the development of their claims through a series 
of guided questions and will automate many development functions such 
as Veterans Claims Assistance Act notification and follow up.
    In addition to an electronic claims processing system, VA is 
committed to improving the speed, accuracy, and efficiency with which 
information is exchanged between veterans and VA, regardless of the 
communications method. The Veterans Relationship Management Program 
(VRM) will provide the capabilities to achieve on-demand access to 
comprehensive VA services and benefits in a consistent, user-centric 
manner to enhance veterans', their families' and their agents' self-
service experience.
    In summary, VA will be successful in resolving these three 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.
    Question. Mr. Secretary, would you please discuss some of VA's 
long-term plans to meet the healthcare needs of our veterans that live 
in remote areas? For example, the State of Hawaii is home to many brave 
men and women that have served this country in uniform. Remote and 
rural areas in the State as well as the territories in the Pacific 
create unique demands on the VA's system. There has been discussion of 
allowing existing Federal healthcare providers in the area to provide 
care for veterans. Could you please elaborate on the plans to address 
these unique needs through partnerships, telehealth, or other 
initiatives, and how these goals may be met through the VA's budget?
    Answer. It is VA's intention to continue aggressively pursuing a 
strategy designed to reach veterans in remote areas, no matter where 
they live. Veterans Integrated Service Network (VISN) and local 
facility leadership are also exploring opportunities to extend the 
reach of VA's benefits into more remote areas. As a result, a 
comprehensive strategy for addressing the needs of rural and highly 
rural veterans, including those in the Hawaiian and other Pacific 
Islands, is based on the establishment of community-based outpatient 
clinics, rural health outreach clinics, telehealth and telemental 
health initiatives, as well as partnering with other Federal, State and 
local healthcare providers.
    In Hawaii, VA closely partners with the Department of Defense and 
is exploring opportunities to partner with Papa Ola Lokahi, a non-
profit organization which addresses native Hawaiian healthcare needs, 
and other healthcare systems and practitioners located in the Islands. 
This partnership is seeking to improve the availability of and access 
to VA enrollment materials for Native Hawaiian veterans, and is 
considering the potential use of Native Hawaiian Clinics where veterans 
can access traditional and complementary medical care, where feasible.
                                 ______
                                 
            Questions Submitted by Senator Mary L. Landrieu
    Question. General Shinseki, as you are aware, VA is in the process 
of improving its human capital capabilities through the Human Capital 
Investment Plan and Human Resources Lines of Business initiative. These 
are important efforts and I applaud VA's efforts to both improve its 
efficiency and look after its people. With respect to the HR Line of 
Business initiative, there are a number of Federal shared service 
centers capable of providing these services, one of which is located in 
East New Orleans at USDA's National Finance Center. In February, I 
wrote you asking that you consider the merits of utilizing NFC for your 
department's line-of-business needs. Utilizing a Federal agency like 
the National Finance Center would allow VA to avoid a lengthy and 
costly procurement process--and there are certainly other benefits.
    I would be interested to know where VA is in the process of 
selecting a line-of-business provider, and whether your staff has met 
with NFC personnel to discuss this matter.
    Answer. VA has been working with the Office of Personnel Management 
and other Executive Branch Departments and agencies on the overall 
Human Resources Line of Business Initiative. Using our current 
selection process guidelines, VA will consider NFC as our human 
resources services provider along with all interested and approved 
providers.
    NFC will be afforded the full opportunity to demonstrate to key 
members of my staff the full range of products and services they desire 
to provide VA in this regard, and we will look forward to that process.
    Question. I would also like to ask about an issue that I am sure is 
very much on your mind--the implementation of the Post 9/11 GI Bill. 
There has been a great deal of effort to make sure this goes as 
smoothly as possible--a difficult task under the best of circumstances, 
but made all the more difficult given the complexity of the law and the 
short amount of time to get the system up and running. And indeed, 
there have been delays and backlogs that have frustrated veterans, but 
I know the VA is moving aggressively to address these issues.
    A significant amount of the work to develop the long term solution 
for the Post 9/11 GI Bill is being done by SPAWAR in New Orleans. It 
seems to me that given the concentration of subject matter expertise in 
both the implementation of the law and development of the supporting IT 
system, VA would be wise to examine an ongoing relationship between VA 
and SPAWAR with respect to GI Bill benefits.
    Once the planned releases of the Long Term Solution (LTS) system 
are complete, what are VA's plans with respect to the LTS system?
    Answer. As of today, VA intends to continue to house the Long Term 
Solution at the Terremark Data Center in Culpepper, Virginia. No 
decision has been made to date on whether or when to transition LTS 
back into a VA data center.
    Question. It is my understanding correct that the system will be 
housed at a VA data center and that claims will be processed in 
regional centers? Given the complexity of this undertaking, would it 
not be wise to examine a centralized processing center to handle claims 
and eliminate any existing backlog?
    Answer. All VA education benefit claims are currently processed at 
one of four Regional Processing Offices (RPOs) nationwide using systems 
housed in various locations throughout the country. VA has substantial 
experience in processing claims through off-site systems and is 
prepared to continue this procedure for the Long Term Solution (LTS). 
The creation of a centralized processing center would add complexity to 
the process by requiring that VA build out a centralized location, 
transition all relevant IT systems to this center, and relocate the 
trained claims processing staff currently spread throughout the four 
RPOs. VA has developed staffing and IT strategies to address any 
backlog of education claims that may occur and is confident that these 
strategies will be sufficient to achieve timely processing and payment 
of claims.
    Lastly, the LTS will both reduce the number of people needed to 
process claims and allow VA to move work electronically to available 
resources. Therefore, once VA gains experience with the new claims 
processing system, a review of the best model for claims processing 
locations will routinely occur as we maintain the best efficiency in 
our system while accounting for workload and available resources.
    Question. Will VA consider a Project Labor Agreement for the 
construction of the New Orleans VA Hospital?
    Answer. The Executive Order which relates to Project Labor 
Agreements encourages Federal agencies to consider the use of a PLA on 
construction projects valued at greater than $25 million. The final 
change to the Federal Acquisition Regulation was recently issued. The 
Department is finalizing an acquisition instruction letter that will 
establish policy on evaluating the use of PLAs for projects over $25 
million, including New Orleans. This will include evaluating factors 
such as the positive or negative impacts of a PLA on project cost, 
schedule, labor availability, competition, and labor unrest. The 
developed business cases and final decisions will become part of the 
contract file.
    Question. Where is VA in its decision for VA/DOD centers of 
excellence for blind veterans?
    Answer. VA is assisting the Department of Defense (DOD) in 
establishing the Vision Center of Excellence (VCE). VA is responsible 
for providing staff support for the VCE based on a Joint DOD/VA 
Memorandum of Understanding signed on October 16, 2009. VA has 
successfully recruited a Deputy Director, Chief of Staff, and Vision 
Rehabilitation Specialist. A Research Optometrist and Administrative 
Assistant are in the selection process and the Biostatistician position 
will be released for recruitment before the end of the 3rd Quarter of 
fiscal year 2010. VA personnel are currently occupying DOD space in 
Falls Church, VA.
    DOD has the lead on developing the Joint Defense and Veterans Eye 
Injury and Vision Registry (DVEIVR) to provide capability for analyzing 
longitudinal outcomes, assessing intervention strategies, enhancing 
performance improvement, and developing a common user/provider 
interface across DOD and VA. VA provided $1.7 million for use in 
developing a data store to capture information to populate the DVEIVR. 
Initial testing for VA's data store was completed in March 2010. VA 
estimates that by the end of the first quarter of fiscal year 2011, it 
will begin data abstraction efforts for the VA functional data store. 
Data abstractors will take clinical information from medical records 
and enter it into a computable database for analysis to improve medical 
care and conduct research. Development of the DVEIVR is projected to 
begin in the first quarter of fiscal year 2011.
                                 ______
                                 
             Questions Submitted by Senator Robert C. Byrd
    Question. Secretary Shinseki, Congress has continued to fund 
Department of Defense and the Department of Veterans Affairs' efforts 
to integrate record keeping for over two and a half decades. As a 
result of departmental failures in both agencies, wounded soldiers 
often languish between the systems and receive inadequate care. Last 
April, President Obama joined you and Secretary Gates in announcing a 
combined DOD-VA electronic health record system development effort. 
Since that announcement over a year ago, what concrete progress has 
been made towards making the system a reality? What role have you 
played in accomplishing this goal? What are the milestones and 
timelines for completion of this effort? What will the system look like 
when completed? Will it be one seamless system, an integrated system, 
or an interoperable system?
    Answer. The Department is fully committed to meeting the needs of 
our service members and veterans, especially those who have given so 
much for their country. The Virtual Lifetime Electronic Record (VLER) 
is one of VA's highest priorities. VA's dedicated VLER team quickly 
explored new opportunities for exchanges of health information between 
not only VA and the Department of Defense (DOD), but also with private 
healthcare providers who also care for our veterans. The information 
obtained from this group is critical to the Department's efforts to 
ensure a complete treatment record is available. VA and DOD capitalized 
on the work being done by the Department of Health and Human Services 
to create the Nationwide Health Information Network (NHIN). VA 
conducted a proof of concept in September 2009 by exchanging very 
limited information over the NHIN on two patients who consented to be a 
part of this exchange. The test was conducted in San Diego, California, 
with two veterans who were seen by both the VA Medical Center and by 
Kaiser Permanente (KP). After the test, VA completed more work to be 
able to begin exchanging a limited set of health data for approximately 
400 veterans who have consented to be part of a production pilot in San 
Diego between the VA and KP. That effort commenced mid-December 2009 
and continues today. VA plans a second pilot in the Virginia Tidewater 
area that is expected to go into production during the summer of this 
year. Following the guidelines of the Chief Information Officer's 
Program Manager Accountability System (PMAS), development and 
deployment of additional health data elements and additional 
functionalities will occur in 6-month phases.
    However, as VLER builds upon this health data exchange, the VA's 
Enterprise Program Management Office (EPMO), which was established to 
oversee the efforts of both the health and benefits lines of business 
teams and coordinate those requirements with the information technology 
development teams, will begin exploring additional means of creating 
the framework for information interoperability necessary for all of 
VA's service providers to seamlessly have secure access to the 
information needed. This data liquidity will significantly reduce the 
burden on service members and veterans to repeatedly provide 
information that should and will be made available to our service 
providers.
    The next step in this approach will be to engage in discussions 
throughout VA and with the Social Security Administration (SSA) to 
identify those health data elements required for a disability claim 
that can be exchanged via the NHIN, and to determine the remaining data 
elements and design the framework for those exchanges. This approach 
will build on the lessons learned from the NHIN work and rely on HHS 
standards and protocols where applicable for health data exchanges.
    The approach VA is taking leverages the work being done by HHS and 
allows exchange of health data information over the NHIN. Utilizing the 
NHIN by creating an adapter from each Electronic Health Record (EHR) to 
the NHIN gateway allows each Department to modernize on their own 
schedule and meet their individual needs but still share health 
information.
    The VA's approach to VLER will accomplish the following:
  --Create the data liquidity required for service providers to access 
        and use the information needed;
  --Reduce the burden on the service member and veteran of repeatedly 
        providing information;
  --Deliver new functionalities and capabilities every 6 months, to the 
        NIHN adapter for information interoperability; and
  --Position the Department to have laid the framework for the lifetime 
        electronic record by 2012.
    Question. Secretary Shinseki, many wounded, disabled, and homeless 
veterans live in rural areas. Conversely, Department of Veterans' 
Affairs facilities tend to be aggregated in more densely populated 
areas to achieve maximum efficiencies. Southern West Virginia disabled 
veterans often have to travel to facilities as far away as Richmond, 
Virginia, to receive certain types of medical care. For some services, 
these veterans may have to travel 6-8 hours each way in order to 
receive care. For homeless veterans living in these areas, services are 
often completely unavailable. Last year, I asked what could be done to 
accommodate some of these services closer to home. What new initiatives 
have been undertaken since then, in West Virginia and nationwide, to 
accommodate some of these services closer to rural veterans?
    Answer. A significant number of initiatives have been developed and 
are providing services to veterans in remote areas, including West 
Virginia. Partnering with local community providers, community and 
outreach clinics, and telehealth initiatives are all methods VA is 
utilizing to provide care closer to the veterans' home. Attachment B 
provides details on a variety of programs that benefit all veterans who 
reside in the Appalachian region.
    Question. Secretary Shinseki, many VA community-based treatment 
centers are being collocated with large VA hospitals. These hospitals, 
in turn, are near large community or general hospitals. In part, this 
is because collocation affords cost-savings and staff-sharing 
relationships. Unfortunately, community-based centers are most needed 
in underserved areas where VA hospitals are far away. What are some of 
your thoughts on how we can best serve veterans living in these rural 
areas and what have you done to accomplish this in the last year?
    Answer. VA has long recognized that veterans who reside in more 
remote communities or geographic areas require the same level of 
services and healthcare as those living in more accessible areas. 
Providing care away from a VA medical center is a concept that VA began 
using in the early 1990s. Initially, community-based outpatient clinics 
(CBOCs) were located in areas with large concentrations of veterans and 
were reasonably accessible to a VA medical center or community 
hospital. As the number of CBOCs has increased and technology has 
improved, VA has recognized that veterans who reside in more remote 
communities or geographic areas require the same level of services and 
healthcare as those living in more accessible areas. As a result, in 
fiscal year 2008, the Office of Rural Health (ORH) funded the 
establishment of 10 part-time outreach clinics and 4 rural mobile 
healthcare clinics to target areas where there is not sufficient demand 
(or it is not feasible) to establish a full-time CBOC. These clinics 
extend access to primary care, case management and mental health 
services to rural veterans.
    Building upon these initiatives, an additional 30 rural outreach 
clinics and 51 CBOCs were approved in fiscal year 2009 and fiscal year 
2010, respectively. The primary requirement in determining the location 
of the outreach clinics was based on drive time and percentage of rural 
and highly rural veterans who receive care.
    In addition to the establishment of CBOCs and outreach clinics, a 
number of telehealth and Home-Based Primary Care (HBPC) teams have been 
activated.
    In fiscal year 2009, VA allocated $80 million for telehealth, 
augmented by an additional $67 million in fiscal year 2010 for a total 
of $147 million. Telehealth care is now provided from 144 VA medical 
centers to 500 other sites of care and supports care to more than 
260,000 veterans.
    The outcomes of this funding through the end of September 2009, 
when compared to the September 2008 baseline, has shown an 18 percent 
growth in the average daily census of rural and highly rural veteran 
patients receiving care in their homes via care coordination home 
telehealth (CCHT); a 41 percent growth in the number of clinical video 
telehealth (CTV) visits provided to rural and highly rural veteran 
patients; and a 77 percent increase in the number of care coordination 
store-and-forward telehealth (CCSF) visits provided to rural and highly 
rural veteran patients.
    The fiscal year 2010 initiatives are also showing positive growth 
over the prior year achievements by increasing access to care for 
veterans who reside in rural/highly rural area and who use telehealth 
care.
    Question. Secretary Shinseki, with an aging Vietnam veteran 
population, my office is receiving an increasing number of complaints 
about the lack of adequate VA nursing home and extended care facilities 
for veterans in West Virginia. Many facilities scheduled for 
construction years ago have experienced repeated delays. Last year, I 
asked you to look into this and get back to me on what we can do to 
accelerate and increase the construction of these facilities. Has 
anything been done to accelerate the construction of nursing home 
facilities during the last year and when can we expect to see 
additional Administration efforts in this area?
    Answer. The Beckley VA medical center submitted a 90-bed Community 
Living Center (CLC) Major Construction project application that ranked 
50 out of 61 in the fiscal year 2011 budget consideration. Projects 
ranking higher in priority focused on several sub-criteria, such as 
special emphasis, safety or seismic deficiencies. However, this project 
only supported the access sub-criteria; therefore, it ranked in the 
lower echelon.
    VA CLCs offer modern nursing home care units focusing on a home-
like environment to foster healing. These are primarily constructed in 
pods of 10-12 home-like units. Due to this new concept, the current CLC 
design offers a unique opportunity to construct pods within the Minor 
Construction threshold. In the fiscal year 2010 Minor Construction 
program, for example, VA started approximately $261.3 million worth of 
design or construction projects across the country. VA will analyze the 
opportunities for Beckley's CLC to use an approach that considers Minor 
Construction while continuing to evaluate the project under Major 
Construction.
    Question. The Conference Report associated with the fiscal year 
2010 Military Construction, VA and Related Agencies Appropriations Act 
encouraged the VA to expand its partnership with accredited nonprofit 
service dog organizations where veterans with PTSD help to train 
service dogs. What is the current status of this effort, and to what 
degree has the Department of Veterans Affairs expanded its partnership 
with accredited nonprofit service dog organizations where veterans with 
PTSD help to train service dogs?
    Answer. VA has developed an excellent working relationship with 
nationally recognized organizations in the service dog community. VA 
has provided information to these organizations to assist with veteran 
education about the benefits of service dogs, and the veterans they 
interact with are provided an invitation to contact VA with questions. 
VA is partnering with the certification agency, Assistance Dogs 
International, Inc., for assistance with the development of educational 
materials for our veterans and clinicians, including a brochure and a 
video.
    VA Rehabilitation Service has a pilot program at the Palo Alto 
Veterans Healthcare System (Menlo Park Division) called the ``Paws for 
Purple Hearts Service Dog Training Program,'' which began in July 2008. 
VA has found that patients with PTSD assigned to the Men and Women's 
Trauma Recovery Program have benefited from this program. These 
patients are training dogs to become service dogs for persons with 
mobility impairments. Under this program, the service dogs are the 
property of the Assistance Dog Institute, with the Bergin University of 
Canine Studies, and return there for placement after the dogs are 
trained. The program has made the following clinical observations, 
finding that participants who train service dogs for mobility 
impairment have, on average:
  --Increased patience, impulse control, and emotional regulation;
  --Improved ability to display affection with less emotional numbness;
  --Increased positive social interactions and reduced isolation;
  --Improved sleep patterns and decreased use of pain medication;
  --Decreased number of startled responses and lowered stress levels; 
        and
  --Improved parenting skills and family dynamics.
    The pilot program is ongoing. Its outcomes and the demand for its 
services will continue to be assessed to determine if expansion of the 
program to other VA medical centers is warranted.
    Question. Secretary Shinseki, the Department of Veterans Affairs 
receives funding for research. Historically, this funding has been 
restricted by the Department to research performed by, or in 
conjunction with, VA researchers. This practice has sometimes resulted 
in policy-based rather than science-based research. The VA's own Gulf 
War Veterans Illness Research Advisory Committee has been forced to 
approach Congress directly, year after year, to get funding for 
independent peer-reviewed scientific research. Last year, we had some 
indications that the Administration would request this independent 
research funding in the fiscal year 2011 budget request; however, it 
did not. This research has been funded through the Department of 
Defense, and again in fiscal year 2011, Congress will have to directly 
provide these funds. Some of this research has been groundbreaking and 
very productive. Last year, I asked you what could be done to bring 
this type of research back into the VA budget process. What has been 
done in this regard since our last meeting, and when will the VA's own 
Gulf War Research Advisory Committee be able to say that they no longer 
need Congressional assistance to fund the best and brightest proposals 
and scientists to conduct research into the causes and treatments for 
gulf war related illnesses?
    Answer. VA's plans for its gulf war research portfolio include a 
multi-pronged approach that balances the urgency of understanding and 
finding new diagnostic tests and treatments for ill veterans of the 
1990-1991 gulf war (short-term) with the need to do new studies on a 
national group of gulf war veterans (long-term). VA's goal is to 
maintain funding levels for gulf war research as close as possible to 
$15 million per year.
    VA's Office of Research and Development (ORD) issued three new 
requests for applications (RFA) specific to gulf war veterans research 
on November 10, 2009. RFA CX-09-013 is specifically aimed at 
identifying potential new treatments (clinical trials, including 
complementary medicine approaches) for ill gulf war veterans. RFA CX-
09-014 and BX-09-014 are aimed at increasing our understanding of gulf 
war veterans' illnesses and identifying new diagnostic markers of 
disease and potential therapeutic targets to develop new therapies. The 
lists of topics of interest in CX-09-014 and BX-09-014 incorporate over 
80 percent of the research recommendations contained in the 2008 report 
from the VA Research Advisory Committee on Gulf War Veterans' Illnesses 
(RAC) and direct RAC input to ORD. The three RFAs described above will 
be re-issued twice a year to regularly request submission of new 
proposals and revisions of previously reviewed, but unfunded, 
applications.
    ORD's long-term plans include the design and implementation of a 
new study of a national group of gulf war veterans under the auspices 
of the VA Cooperative Studies Program, which has extensive experience 
in developing multi-site VA clinical trials and clinical studies. The 
design of this new study will include a Genome Wide Association Study 
(GWAS) and other elements, based on evaluating the existing body of 
scientific and clinical knowledge about the illnesses affecting gulf 
war veterans and recommendations received from the RAC. VA has targeted 
September 2010 for completion of the study design and implementation. 
This study was discussed with the RAC at their November 2-3, 2009, 
meeting to gather input on what additional elements could be included 
in the study. A planning committee has been established to define the 
elements to be included in the final study.
    The expiring authority found at 38 U.S.C.  1117(c)(2) will not 
result in the loss of compensation benefits or medical care for gulf 
war veterans currently receiving benefits for disabilities that are 
categorized as ``undiagnosed illnesses'' and for which service 
connection has been properly decided. Those veterans will continue to 
receive benefits after the date of the expiring authority on September 
30, 2011.
    Question. Secretary Shinseki, the Persian Gulf War Veterans Act of 
1998, passed as part of the fiscal year 1999 Omnibus Appropriations Act 
(Public Law 105-277), is scheduled to expire this year, 10 years after 
the last day of the fiscal year in which the National Academy of 
Sciences submitted its first report. Will any veterans lose priority 
care or benefits as a result of the expiration of the law, such as 
those who remain classified as having an ``undiagnosed illness,'' and 
will Congress have to pass additional legislation to ensure that these 
veterans will continue to receive priority healthcare, disability 
payments and other benefits? If so, what efforts are you aware of 
within your department or the Congress to draft this legislation?
    Answer. No veterans will lose priority care or benefits as a result 
of expiration of Public Law 105-277. Section 513 of the recently 
enacted Public Law 111-163, the ``Caregivers and Veterans Omnibus 
Health Services Act of 2010,'' gives both certain Vietnam-era veterans 
exposed to herbicides, as well as veterans of the gulf war, special 
priority care for treatment.
    Benefit determinations and payments initiated under Public Law 105-
277 will continue to be made. For future reference, 2 of the 3 expiring 
sections of Public Law 105-277, including the one affecting benefit 
decisions, actually expired on the first day of fiscal year 2010 per 
Public Law 105-277, 122 STAT 2681-744 and 745.
    Question. Secretary Shinseki, given the importance of the care we 
give to veterans, and knowing that not all needs can be adequately 
reflected in a budget document, what do you feel are critical or 
important needs at the Department of Veterans Affairs that are not well 
reflected in the fiscal year 2011 budget request?
    Answer. The 2011 VA budget continues the strong commitment of the 
President with an increase in discretionary funding of almost 20 
percent since 2009. The budget reflects a balanced and prioritized 
program that addresses the most critical and important needs of the 
Department. It allows VA to improve services for veterans and continue 
transformation of the VA. VA's 2011 budget focuses on three concerns 
that are of critical importance to our veterans--easier access to 
benefits and services; reducing the disability claims backlog and the 
time veterans wait before receiving earned benefits; and ending the 
downward spiral that results in veterans' homelessness. The budget 
includes $799 million in specific programs to eliminate homelessness 
and $250 million for Rural Health Initiatives. It also provides a $42 
million increase in telehealth funding in VHA and an unprecedented 
increase of 27 percent in funding for VBA to address the disability 
claims backlog. Funding is also provided to continue improving the 
condition of VA's capital infrastructure.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray
    Question. Secretary Shinseki, I was deeply disturbed by the news 
reports in January stating the VA's preliminary data show a dramatic 
increase in veterans suicide between 2005 and 2007. The fact that our 
veterans have sacrificed for our Nation only to spiral into depression 
and suicide is appalling. The preliminary data did suggest that access 
to VA services makes a difference in suicide prevention. The VA needs a 
more comprehensive effort and these numbers show that the duty of 
providing mental health services and outreach to our returning veterans 
is still a challenge.
    Answer. VA shares your concern regarding veteran suicide. Each is a 
tragedy for the veteran, his family, the community and the Nation. The 
rates of suicide among veterans in the 16 States monitored by the 
Center for Disease Control and Prevention's (CDC) National Violent 
Death Reporting System increased from 2005 to 2007. The increases were 
greatest among those veterans aged 18-29, with only a slight increase 
among those aged 30-64, and a slight decrease among those 65 and older. 
However, among those aged 18-29, suicide rates decreased significantly 
in those veterans who came to VA for services. VA interprets these 
findings as an early indication that VA's mental health enhancements 
and its suicide prevention programs are working for those who come to 
us for care. As a result of these statistics, as well as other factors, 
VA is transforming its mental health system to follow a public health 
model, providing more programs and resources to veterans in the 
community and the Nation as a whole, as well as to those seen in our 
medical centers, clinics, and Vet Centers. These efforts will focus on 
outreach and education to returning service members and veterans, and 
to veterans of all eras in their communities. The goal is to encourage 
as many eligible veterans as possible to seek care within VA, and to 
support help-seeking for all veterans when they need it. Specific plans 
are being developed as components of VA's Operating Plan for Mental 
Health for 2011-2013, and the Department of Defense (DOD)-VA Integrated 
Strategy for Mental Health.
    Additionally, VA created the Veterans National Suicide Prevention 
Hotline in June 2007 to help veterans in crisis. To date, the hotline 
has received almost 256,000 calls and rescued about 8,100 people judged 
to be at imminent risk of suicide since its inception. The center's 
newest feature is a chat line for those who prefer computer-oriented 
communication, especially young veterans. Both the hotline and chat 
line are available 24 hours a day, 7 days a week.
    Question. It has been 9 years since our service members have been 
going to war, often for multiple deployments. What have we done to 
improve the mental health efforts of those returning veterans?
    Answer. VA has made enormous efforts to expand access to care, 
continuity of care, and quality of care regarding mental health 
concerns of returning veterans. Those efforts particularly began in 
2005, with the implementation of the VA Comprehensive Mental Health 
Strategic Plan. In each fiscal year from 2005 through 2008, VA funded 
elements of the Strategic Plan for implementation, with broad national 
development of innovative programs and overall enhanced staffing of 
mental health services. In fiscal year 2008, the results of 
implementation helped VA organize a national model of what mental 
health services must be made available to all eligible, enrolled 
veterans seeking VA healthcare. The resulting document, VHA Handbook 
1160.01, ``Uniform Mental Health Services in VA Medical Centers and 
Clinics,'' became VA policy at the start of fiscal year 2009 and is 
being fully implemented throughout the system nationally, with regular 
monitoring of implementation showing excellent progress. As of the end 
of December 2009, VA medical centers and community-based outpatient 
clinics (CBOC) reported an implementation rate of 98 percent for the 
more than 200 requirements in the Uniform Mental Health Services 
Handbook.
    We have reported previously on VA mental health efforts--some of 
the successes include (but are not limited to) the following: 
increasing mental health staff by over one-third, from 14,000 to over 
20,000 nationally and decreasing time to a first appointment for new 
mental health referrals with a standard of evaluation within 24 hours. 
This is then followed by urgent care, if needed, or development and 
implementation of a treatment plan within the next 14 days (with 96 
percent success in meeting this standard). VA has also developed the 
Suicide Prevention Hotline and teams of Suicide Preventions 
Coordinators at every VA facility. VA integrated mental health into 
primary care clinics and mandated screening for mental health problems 
to include: PTSD, depression, problem drinking, military sexual trauma, 
and suicide risk assessment if PTSD or depression screens are positive. 
Finally, VA expanded substance use disorder treatment and treatment of 
co-occurring substance use and PTSD problems.
    All of these efforts improved the full system of care for all 
veterans, but there also have been elements specifically designed to 
serve returning Operation Enduring Freedom and Operation Iraqi Freedom 
(OEF/OIF) veterans. These include:
  --Development of special mental health staff specifically reaching 
        out to returning veterans, in the system, to ensure mental 
        health issues are fully addressed.
  --Integration of these staff into the Post-Deployment OEF/OIF special 
        primary care clinics.
  --Collaboration with the case management system for OEF/OIF veterans 
        to ensure mental health needs are always considered.
  --Placement of mental health staff in specialty polytrauma care 
        settings for severely wounded returning veterans.
  --Training of over 3,000 VA mental health staff in evidence-based 
        psychotherapies for PTSD, depression, family distress, and 
        other mental health disorders that have been shown in research 
        and clinical practice to have the greatest likelihood of 
        resulting in significant improvement in these mental health 
        conditions. Training has been provided with guidance to ensure 
        that initial implementation of these therapies should target 
        OEF/OIF veterans, to provide early intervention as much as 
        possible.
  --Expansion of mental health services for women veterans. Female OEF/
        OIF veterans are more likely to seek VA care than male OEF/OIF 
        veterans, and their increasing numbers require VA to expand 
        services. Specific requirements for serving female veterans are 
        included in the VA Uniform Mental Health Services Handbook 
        mentioned above.
  --Collaboration with the Defense Centers of Excellence (DCOE) for 
        Psychological Health and Traumatic Brain Injury, to coordinate 
        efforts.
  --Implementation and planning of a joint VA/DOD Mental Health Summit 
        with DCOE and other health components of DOD. This has led to 
        development of an integrated Mental Health Strategic Plan to 
        increase coordination and continuity of care as service members 
        obtain care in DOD, then separate and come to VA for care.
    In summary, VA has transformed its overall mental health services 
in the last 5 years, and that transformation has included focused 
efforts to ensure enhanced care for currently returning OEF/OIF 
veterans. These efforts will continue to receive priority.
    Question. Why do we still not have the trained mental health 
professionals in all of our VA facilities?
    Answer. VA does have a greatly increased number of mental health 
staff throughout the system, with mental health professionals in all VA 
medical facilities. Community living centers, residential 
rehabilitation treatment programs and domiciliaries have access to 
mental health resources because they are co-located with other 
facilities (hospitals or outpatient centers) that have mental health 
professionals. All large community-based outpatient clinics (CBOC) and 
all vet centers also have mental health staff who provide outpatient 
mental health services. Smaller CBOCs must provide mental healthcare 
through telemental health connections or by contract or fee basis. In 
addition, all medical facilities have mental health professionals who 
have been trained in providing various evidence-based psychotherapies 
and connections to staff with such training are available via 
telemental health in most CBOCs. VA strongly believes in ensuring that 
VA mental health staff members have appropriate, high quality training 
to promote the delivery of high quality, evidence-based and recovery-
oriented services. VA qualification standards for employment in mental 
health positions require that mental health professionals have 
established levels of education necessary to provide clinical care, 
with specific competencies required for specific clinical activities 
and responsibilities.
    VA develops and provides extensive training to mental health staff 
throughout its healthcare system on a broad array of mental health 
topic areas to ensure that mental health staff can deliver high quality 
care that is consistent with current clinical science. As part of its 
commitment to training and high quality patient care, VA has developed 
national staff training programs in state-of-the-art, evidence-based 
psychotherapies (EBPs), including cognitive processing therapy and 
prolonged exposure therapy for posttraumatic stress disorder (PTSD), 
cognitive behavioral therapy and acceptance and commitment therapy for 
depression, and social skills training and family psychoeducation for 
serious mental illness. Training in these programs consists of two key 
components: (1) participation in an in-person, experientially based 
workshop of 2-4 days in length, followed by (2) active participation in 
weekly consultation with an expert in the specific psychotherapy for 
approximately 6 months. To date, VA has provided training to over 3,000 
mental health staff in evidence-based psychotherapy, including 
providing evidence-based psychotherapy training to staff at all VA 
medical centers.
    In addition, VA annually provides national and regional training to 
mental health staff on a wide variety of mental health topics through 
VA's Employee Education System. These trainings are provided through 
in-person conferences, videoconferences, Web-based trainings, and DVD 
video trainings. In addition to training provided through these 
national mechanisms, local VA facilities provide a wide variety of 
mental health trainings to mental health staff on specific mental 
health topics.
    Question. What can Congress do to assist you? Do you need 
additional hiring authorities or incentives?
    Answer. VA's fiscal year 2011 budget provides for more than $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. Recent VA 
research has demonstrated that the more returning veterans feel 
supported by their communities and by the Nation as a whole, the less 
likely they are to develop PTSD and depression. Congress has helped our 
troops and veterans by continuing to support mental health programs.
    VA has significantly invested in our mental health workforce, 
hiring more than 6,000 new workers since 2005. VA has estimated that 
the current level of staffing is sufficient to meet the needs of 
veterans who use VHA for their mental healthcare. There are still a 
small number of unfilled positions at various VA medical facilities 
that are supported with mental health enhancement funds. Direction has 
been sent to all Veterans Integrated Service Networks (VISNs) to use 
the enhancement funds to fill these positions. In addition, it is 
essential that this level of staffing be sustained, e.g., positions 
that are vacated through retirement or other departures are filled in 
timely fashion.
    VA has not experienced widespread difficulties in hiring and 
retaining mental health professionals. However, it has been VA's 
experience that in certain localities, particularly highly rural 
regions, there may be a limited number of mental health professionals, 
especially psychiatrists. Specific incentives have been developed and 
used in such situations. In addition to opportunities for education 
debt reduction, VHA has established opportunities for facilities to 
engage in local advertising and recruitment activities, and to cover 
interview-related costs, relocation expenses, and provide hiring 
bonuses for certain applicants. Flexibility is provided to hire 
providers of other appropriate disciplines or to utilize fee-basis or 
contract care, when indicated, so that veterans have continuous access 
to the full continuum of mental health services.
    Question. In Washington we are bringing in residents to assist with 
the manning shortfall. Do we need to expand the program?
    Answer. Recognizing the importance of mental health services in the 
overall care of veterans, VA has expanded training positions in the 
core mental health disciplines of Psychology, Psychiatry, and Social 
Work. Within Graduate Medical Education (GME), VA launched the GME 
Enhancement Initiative in 2006 to expand physician residents in areas 
of need to attain greater geographic balance in resident allocations, 
and to foster innovation in the models of training physician residents. 
The GME Enhancement Initiative created an additional 1,221 physician 
residents positions, with 123 in psychiatry, and 169 in all mental 
health related specialties.
    In addition, over the last several years, VA has pursued an 
initiative to increase the number of non-physician mental health 
practitioners, especially psychologists and social workers. These 
efforts have been highly successful. Psychology has expanded its 
national trainee complement by 251 positions, to a total of 683 
nationally. Moreover, social work training positions have increased 
from 588 to 732 for the coming year.
    The impact of these initiatives for the State of Washington is 
shown in the chart below. The overall increase in VA mental health 
training positions (psychiatry, psychology, and social work) from 2005 
to the present is 48 percent.




    These data suggest that Washington has benefited greatly from 
recent expansions in trainee positions. In addition, because of the 
rural nature of practice in some parts of Washington, it is anticipated 
that the State will continue to have a high priority for future trainee 
expansions.
    Question. Secretary Shinseki, as you know, women are the fastest 
growing subsection of veterans and increasingly in need of services 
from our VA system. Unfortunately the VA has been slow to modernize to 
meet their unique physical and mental health needs. I recognize the VA 
is trying to make changes at their facilities to make them more female-
friendly, but there appears to lack a coherent, nationwide plan to 
review and assess the capabilities of all facilities and create a 
capital plan to start addressing shortfalls in high demand areas.
    What is the status of a VA-wide capital plan to evaluate each 
facility in the VA system and target those that service greater 
populations of female veterans and veterans with children?
    Answer. VA has undertaken an ongoing assessment and improvement 
process to ensure that VHA facilities meet the healthcare needs of 
women veterans in a friendly and safe environment that respects their 
unique needs, dignity, and privacy.
    Elements relevant to structural, environmental, and psychosocial 
patient safety and privacy issues have been incorporated into VHA's 
monthly environment of care rounds checklist. VA is obtaining monthly 
assessments from each medical center in order to follow actions taken 
to address identified issues in the privacy and security of all 
veterans. Women Veteran Program Managers at each medical center are 
included in the review process.
    In addition, an annual review of structural, environmental, and 
psychosocial patient safety and privacy issues in VHA patient care 
settings will be conducted by the Director, Environmental Program 
Service and incorporated into monthly environment of care rounds.
    The Women Veteran's Health Strategic Health Care Group is in the 
process of performing a comprehensive assessment of facilities' current 
capacity for providing optimal care of women veterans. The assessment 
includes site visits and tours of six medical centers in fiscal year 
2010 with ongoing assessments in fiscal year 2011. During tours, the 
site assessment team will review available space, environmental 
considerations (e.g., signage, privacy), patient and provider flow, and 
availability of equipment and supplies. The assessment team will also 
conduct brief interviews with staff in each of these areas. Results of 
the assessment will be used to address deficiencies and drive future 
budget allocation requests.
    VA's design and construction standards are being enhanced to 
address the physical and mental healthcare needs of women veterans. 
Space planning criteria are being adjusted for specific functions to be 
performed (mammography spaces, outpatient clinics, radiation therapy, 
etc.).
    The national capital plan to address women's healthcare is 
incorporated into the new Strategic Capital Investment Planning (SCIP) 
process. With this process, every medical center will identify how it 
will mitigate service delivery gaps over a 10-year window, including 
women's privacy deficiencies. As part of the SCIP process, we will 
create corporate data to support women's privacy needs to ensure a more 
focused effort is dedicated to mitigating the deficiencies.
                                 ______
                                 
          Questions Submitted by Senator Kay Bailey Hutchison
    Question. The VA has established a new policy to presume veterans 
with ischemic heart disease, Parkinson's disease, and B cell leukemia 
and who served in Vietnam are entitled to compensation benefits as a 
result of their exposure to Agent Orange. The Department estimates this 
new policy will result in approximately 150,000 new claims generated in 
2010, and for the total number of disability claims to increase from 1 
million in 2009 to 1.3 million in 2010. The claims process already 
takes too long to make decisions on a veteran's disability claim, and I 
am highly concerned that this new policy will further complicate the 
already large claims backlog.
    I understand that there are funds for 1,800 new claims processing 
staff in the 2011 budget (excluding term-hire positions included in 
last year's stimulus bill), and I applaud the effort to handle this 
influx in claims. But since 2007, this subcommittee has appropriated 
funding to add nearly 7,000 new positions to the VA's claims processing 
staff, and there has been no significant decrease in claims processing 
time. This does not seem to be purely a problem of understaffing.
    Does the Department have any estimates on how the 30 percent 
increase in claims receipts will affect the processing time, and what 
can we do to help you tackle this problem?
    Can you tell me whether the Department is looking at new ways to 
change the way in which it handles disability claims and what impact 
the paperless claims IT project will have on both the claims backlog 
and the average claims processing time?
    Answer. Currently, the average time to process a disability 
compensation claim is about 160 days. Based on the continued growth in 
claims receipts and the anticipated influx of claims related to the new 
Agent Orange presumptions VA anticipates our inventory will rise to 
over 700,000 claims in 2011, and the average time to process claims is 
expected to increase as a result.
    The Veterans Benefits Administration now employs more than 11,600 
full-time claims processors and plans to add 3,000 more in fiscal year 
2011. However, continuing to increase the size of our workforce is 
neither a long-term nor scalable solution; we need to do a much better 
job of leveraging network automation and software productivity tools to 
more effectively manage our workload and serve our clients. Bold and 
comprehensive changes are needed to transform VA into a high-performing 
21st century organization that provides high quality services to our 
Nation's veterans and their families.
    VA's transformation strategy leverages the power of 21st century 
technologies applied to redesigned business processes. Pilot programs 
are underway at four of our regional offices to support our business 
transformation plan to reduce the claims backlog, improve service 
delivery, and increase efficiencies. Each pilot functions as a building 
block to the development of an efficient and flexible paperless claims 
process. The results of all four pilots will be incorporated into the 
nationwide deployment of the Veterans Benefits Management System (VBMS) 
in 2012. VBMS will be built upon a service-oriented architecture, 
enabling electronic claims processing by providing a shared set of 
service components derived from business functions. Initially, VBMS 
will focus on scanned documents to facilitate the transition to a 
paperless process. Ultimately, it will provide end-to-end electronic 
claims workflow and data storage.
    VA is also seeking contractor support in development of a system to 
support evidentiary assembly and case development of the new Agent 
Orange presumptive claims. The system will enable veterans to 
proactively assist in the development of their claims through a series 
of guided questions and will automate many development functions such 
as Veterans Claims Assistance Act notification and follow up.
    In addition to an electronic claims processing system, VA is 
committed to improving the speed, accuracy, and efficiency with which 
information is exchanged between veterans and VA, regardless of the 
communications method. The Veterans Relationship Management (VRM) 
transformational initiative will provide the capabilities to achieve 
on-demand access to comprehensive VA services and benefits in a 
consistent, user-centric manner to enhance veterans', their families' 
and their agents' self-service experience.
    Question. It is everyone's goal to leverage information technology 
to improve services to our veterans and to have them seamlessly 
transition from DOD to the VA. A paperless solution to the disability 
claims backlog, a lifetime electronic service record that follows a 
soldier through DOD and VA, a new electronic health record, and a 
financial management system that provides greater accountability of 
government resources all have potential to transform the VA. However, 
the Department has a poor track record in its ability to develop and 
implement these costly programs. An internal audit by the VA last year 
temporarily halted 45 of the VA's 282 ongoing IT projects because they 
were either significantly over budget or behind schedule, and the 
Department's 2011 budget proposes $3.3 billion for IT, which is 
identical to the 2010 appropriation, not including the nearly $700 
million that was unspent from the 2010 appropriation. I am concerned 
that this may not be the most efficient use of taxpayer dollars in 2011 
without proper oversight and transparency. These projects are of great 
importance to our veterans, and I want to be sure they succeed.
    Mr. Secretary, have you found the certification requirements 
included in last year's bill to be helpful in your efforts to improve 
management over IT projects and programs?
    Answer. In 2010, VA has fully implemented its Project Management 
Accountability System (PMAS). This system has put in place the 
necessary program review and rigor to examine an IT project's chances 
for success on an ongoing basis. PMAS has been successful in 
identifying what projects VA should terminate and what projects should 
continue. Now that the PMAS process is in place, all IT projects must 
be certified by the Chief Information Officer in order to receive 
funding and approval to proceed. With PMAS in place, we believe bill 
language requiring certification may no longer be necessary. The 
Department is committed to keeping the Committee informed on the PMAS 
process and the status of IT projects.
    Question. Mr. Secretary, we believe there is the potential for more 
budgetary steps to be taken to improve accountability over IT projects, 
such as separating the 1-year costs of staff salaries and expenses, and 
operations and maintenance costs, from the longer-term costs of 
developing new IT programs. Do you have any thoughts on that idea?
    Answer. The Department appreciates the flexibility Congress has 
provided by making funds appropriated to the Information Technology 
Systems account available for a 2-year period. This flexibility was a 
key factor and management tool in VA's successful consolidation of all 
IT funding into one account over a 3-year period.
    The Department would like to retain this management flexibility for 
administering its IT program. VA continues to refine its accounting for 
IT costs; this includes better defining which projects are purely new 
development projects as opposed to operations and maintenance projects. 
The distinction is not always simple to discern, and there would be 
some risk in segregating the availability of these funds either by time 
period or by establishing separate accounts. In addition, the 
availability of 2-year funding for salaries and administrative costs 
will enable IT managers to effectively plan for the hiring of 
additional staff and to adjust to unanticipated changes impacting the 
workforce.
    Currently, VA identifies development, operations and maintenance, 
and salary/administrative costs separately as part of the annual budget 
submission and the IT project reprogramming baseline. We will continue 
to do so to meet the information needs of the Congress.
    Question. Can you tell us how many of your project managers are 
``Project Management'' certified by an outside organization (such as 
Project Management Institute, etc.)?
    Answer. Trained project management leaders are critical to ensuring 
IT project success. As an important part of workforce management, all 
project managers are involved in ongoing project training, training 
that can be applied towards Project Management certification 
requirements. At present, 70 percent of IT development project and 
program managers maintain credentials in Program Management, either 
through organizations such as the Project Management Institute or VA's 
rigorous Project Management training programs.
    Question. Mr. Secretary, the 2011 budget recommends nearly $2 
billion for the VA construction program, including $864 million in 
site-specific funding for new or replacement hospitals. However, I was 
concerned to see that there was $2.56 billion in unobligated funds from 
2009 into 2010, more than the last 2 years of major construction 
appropriations, for projects that should be obligated within the fiscal 
year. I am concerned that our major construction program is not 
spending its appropriations in a timely and efficient manner, and I 
want to work with you to resolve this challenge. As I'm sure you know, 
this is an issue for military construction projects, and we combat it 
by making projects subject to 5-year funding and by having the services 
publish a Future Years Defense Program (FYDP) that outlines each 
service's expected construction needs in the immediate future. This 
helps us to ensure efficient budgetary planning and that only those 
projects that are shovel-ready receive funding.
    Mr. Secretary, as a former Army Chief of Staff, do you have any 
thoughts on making new VA construction projects subject to some of 
these rules? Would you be willing to submit a prioritized ``FYDP'' for 
VA construction projects in order to ensure they are shovel-ready and 
to help us be more fiscally responsible to our veterans and to the 
taxpayer?
    Answer. VA does not support restricting the availability of major 
construction funding to 5 years. Construction funds should remain as no 
year money. Once funding is received for a major project, it is 
obligated over a period of several years for design, construction, 
contingencies, completion items and contract closeout. VA monitors the 
progress closely to ensure contracts remain on time and within budget. 
There are several reasons that project funding remains unobligated 
including:
  --When VA awards a construction contract, a contingency is set aside, 
        5 percent on new construction and 7.5 percent on renovation. 
        The contingency set-aside is available to address unforeseen 
        conditions. These funds are not obligated until needed and 
        contribute to the unobligated amounts.
  --Some projects are phased. Funds required for future phases cannot 
        be awarded until the preceding phase is completed. There are 10 
        projects with funding of $698.6 million that have future 
        phases. These projects have phases that are currently under 
        construction that must be completed prior to awarding the 
        subsequent phase. Some of these phases will be awarded later 
        this fiscal year. Some of the high visibility projects in this 
        category are polytrauma centers at Palo Alto and Tampa
  --When contract claims have been filed or are anticipated, funding is 
        held after completion in case it is needed when a claim is 
        adjudicated.
    There are 4 projects with funding of $713.3 million that are 
currently in design and VA anticipates a construction award later this 
fiscal year. Some of the high visibility projects in this category are 
new medical facilities at New Orleans and Denver. Projects like these 
would be halted until funding could be obtained if funding is 
restricted. The major challenge for VA has been in the planning phase 
for these projects. The current process selects projects for initial 
budget submission without the benefit of early design. Projects at this 
stage often have significant unknowns such as constructability issues, 
incomplete scope definition and the need to complete environmental, 
historic preservation and often real estate due diligence. The 
resolution of these issues contributes to delay in making significant 
obligations on the projects.
    VA submits a 5-year Capital Plan annually with the President's 
budget submission. The current 5-year plan lists approximately 92 major 
projects. These projects may vary from year to year due to re-
prioritization each year--new projects are added, while others are 
removed as alternative investment strategies (e.g., leases or enhanced-
use leases) are utilized to provide the services. Currently the 
Department is embarking on a Strategic Capital Investment Planning 
(SCIP) process that will provide a 10-year plan for all capital 
investments. This plan will help to address where facilities are needed 
throughout the Department based on demographics, changes in the 
delivery of care, and the type of care to be provided. The SCIP process 
will result in a consolidated prioritized list for all capital 
investments (major/minor construction, non-recurring maintenance, and 
leases) for 2012-2021. This multiyear planning effort will thus 
obligate project funding sooner after an appropriation from Congress is 
received.
    Question. Mr. Secretary, I understand that the VA has conducted a 
comprehensive review of the VA's approach and practices to treat 
veterans of the 1990-1991 gulf war. This Gulf War Illness Task Force 
recently released its report and recommended adding nine new conditions 
as automatic presumptions for service-connected injuries. I applaud 
your efforts to improve the lives of those veterans suffering from 
undiagnosed illnesses during this conflict and hope we remain committed 
to treating those affected and finding a cure. However, as I understand 
it, this new policy was not in effect when the Department's 2011 budget 
was formulated.
    Assuming these new presumptions go into effect, has the Department 
made any cost estimates for adding these nine new presumptive 
conditions for gulf war veterans?
    How does the VA expect to pay for these new presumptions if they 
are not in the Department's 2011 budget request?
    Answer. The compensation benefit costs associated with this 
proposed rule are estimated to be $1.5 million during the first year, 
$11.5 million for 5 years, and $36.4 million over 10 years. VBA will 
provide updated fiscal year 2011 projections in the annual Mid Session 
Review budget submission. This budget submission will include changes 
in economic assumptions, changing trends based on FYTD experience, and 
technical adjustments including estimated effects of proposed rules.
    The decision to create nine new presumptives based on exposure to 
infectious agents in the Gulf resulted from the IOM report on Gulf War 
and Health, Volume 5, Infectious Agents. The Secretary's decision to 
establish these presumptions was made prior to the formation of the 
Gulf War Illness Task Force.
                                 ______
                                 
             Questions Submitted by Senator Mitch McConnell
    Question. Telemedicine is a tool that would seem to have potential 
to provide improved access to healthcare services for rural veterans, 
allowing them to get the medical advice they need without undertaking 
the time and expense of driving to a major VA facility. What measures, 
if any, are being taken by the VA to expand the use of this technology 
to help rural veterans?
    Answer. VA's 2011 President's budget includes an investment of $163 
million in home telehealth. Taking greater advantage of the latest 
technological advancements in healthcare 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 is one of the ways in which VA is actively increasing 
access for veteran patients to healthcare services in rural and remote 
locations. In fiscal year 2009, 118,000 veterans received healthcare 
services from VA in rural and remote locations via telehealth. This 
number represented a 20 percent increase over fiscal year 2008 levels 
and included 16,000 veterans receiving care in their own homes via home 
telehealth, 67,000 veterans receiving teleretinal screening and 
teledermatology services via ``store-and-forward'' telehealth 
technologies and 35,000 veterans participating in specialist 
consultations between community-based outpatient clinics and VA medical 
centers, predominantly to meet mental health needs. By the end of 
fiscal year 2010, VA anticipates a further 20 percent increase in 
telehealth-based care to veteran patients in rural/remote locations. 
This will reduce avoidable time and expenses involved in veterans 
travel to a major VA facility. Telehealth, therefore, continues to be 
an important capability that VA is utilizing to meet the healthcare 
needs of veterans we serve in rural and remote locations.
    Question. In 2006, there was an alleged homicide that occurred at 
the Lexington, Kentucky VA Medical Center where the patient died due to 
an overdose of morphine. In 2009, the nurse involved in the case was 
arrested and charged with homicide.
    Consistent with any restrictions governing the release of 
information linked to ongoing criminal investigations, what further 
developments have occurred in this investigation? What actions have 
been taken by the VA to prevent events like these from happening in the 
future?
    Answer. The investigation was turned over to the VA Office of the 
Inspector General (OIG) and Federal investigators. A trial for this 
case is before the U.S. District Court, Eastern District of Kentucky, 
Central Division at Lexington, KY, and it has been re-set for October 
12, 2010. To prevent events like this from happening in the future, VA 
purchased new intravenous (IV) pumps with additional safety features. 
These features help prevent the pumps from being set over the maximum 
dosage or below therapeutic levels. VA used at the time of the event, 
and continues to use today, tubing sets that prevent the free flow of 
medication as another safety precaution. VA continues to review monthly 
dispensing practices to monitor the narcotic administration practices 
of individual staff.
    Question. Of the contract-run Community Based Outpatient Centers in 
Kentucky, what is the level of patient satisfaction with their care?
    Answer. There are two contracted CBOCs in Kentucky. The Bowling 
Green CBOC received an outpatient score of 62.7 which exceeds the VISN 
nine goal and makes it the highest satisfaction score for any Tennessee 
Valley Healthcare System CBOC. The Hopkinsville CBOC does not have a 
sufficiently large response population for a patient satisfaction 
score.
    Question. What is the VA doing to enhance efforts to locate 
homeless veterans and to provide resources and programs to help them?
    Answer. VA is taking decisive action toward its goal of ending 
homelessness among our Nation's veterans in 5 years. VA has continued 
to use and expand its Healthcare for Homeless Veterans (HCHV) efforts, 
which involve staff making direct searches of environments where 
homeless veterans are likely to be found and making every effort to 
gain their trust and bring them in for services. The National Call 
Center for Homeless Veterans (NCCHV) is a recent initiative in VA's 5-
year plan to end homelessness. It can provide homeless veterans with 
timely and coordinated access to VA and community services, and 
disseminate information to concerned family members and non-VA 
providers about all the programs and services available to assist these 
veterans. There have been callers who have not been previously 
identified and can now be connected with VA and other services. Callers 
seeking more details about VA Homeless programs or services can also be 
referred to the VA Homeless Web site and appropriate VA medical center 
points of contact for further intervention, referral, or information. 
As information about the Call Center is more broadly disseminated by 
local VA facilities and the Homeless Coordinators in all VISNs, more 
calls are expected. This new outreach effort already is proving very 
valuable.
    In order to better track veterans located through these and other 
efforts, VA is developing a homeless veterans registry that will track 
and monitor the expansion of homeless and prevention initiatives and 
the treatment outcomes for homeless veterans. The registry will be a 
comprehensive veteran-centric registry (data warehouse) of information 
about homeless veterans who receive services provided by VA 
administered programs, as well as services provided by external Federal 
agencies, and other private and public entities. Additionally, the 
registry will also be used to identify and collect information about 
veterans who are at-risk for homelessness. This system will allow VA to 
analyze mobility among homeless veterans.
    Question. What is the VA doing to enhance the privacy of and to 
increase the resources and programs available for female veterans?
    Answer. Following recommendations by a VA workgroup on Veteran 
Privacy, Security and Dignity, a review of structural, environmental, 
and psychosocial patient safety and privacy issues has been conducted 
in VHA outpatient care settings and incorporated into monthly 
environment of care action plans. The initial review was completed in 
August 2009 and VA has been conducting monthly status updates since 
that time. The Women Veteran Program Manager participates as a member 
of the environment of care team. Each facility must engage in an on-
going, continual process to assess and correct physical deficiencies 
and environmental barriers to care for all veterans, particularly women 
veterans. In addition, Women Veterans Program Managers and Deputy Field 
Directors are conducting on-site visits to monitor compliance with 
correction of privacy deficiencies. Findings are communicated to local 
leadership. Other strategies to ensure compliance include unannounced 
site visits by VISN Environment of Care Teams, random site visits, and 
records reviews by VHA's Office of Environmental Programs Service, as 
well as System-wide Ongoing Assessment and Review Strategy (SOARS) site 
visits. Action plans will be maintained and tracked by the VHA 
Environmental Programs Service to ensure compliance and assist with 
construction planning to renovate facilities.
    Current initiatives to increase resources and programs available to 
women veterans include:
  --Redesigning Primary Care for Women.--Specifically, VHA is 
        redesigning comprehensive women's healthcare delivery within 
        three models of care, which co-locate commonly used services 
        and specialties into one care delivery process, ensuring that 
        women can receive all of their primary healthcare (prevention, 
        medical, and routine gynecologic care) by a single primary care 
        provider. Our goal is to decrease fragmentation of care and 
        improve continuity of care.
  --A Full-Time Women Veteran Program Manager at Each Site.--As of June 
        28, 2010, 132 of the 144 facilities with a Women Veterans 
        Program Manager has a full-time employee in place; seven other 
        facilities have an acting or interim Women Veterans Program 
        Manager, and four of the remaining five will fill the position 
        by August 2010.
  --National Training Programs for Women's Healthcare Providers.--
        Improving primary care clinicians' proficiency, knowledge, and 
        cultural sensitivity in women's health and VA resources 
        available to women veterans through the implementation of mini-
        residency programs.
  --Evaluation of Primary Care for Women.--Assessing VA women's health 
        programs through the creation of an assessment tool to identify 
        highly developed women's health programs, their best practices, 
        and better understand successful pathways to implementing 
        comprehensive women's health.
  --Women Veteran Outreach Campaigns.--Educating women veterans through 
        age and culturally informed communication and outreach 
        initiatives. For example, modifying their cardiovascular risk 
        factors and maintaining their health status in order to delay 
        the onset of complex chronic conditions.
    Question. The percentage of female veterans who do not show up for 
their medical appointments is in many cases greater than the percentage 
of male veterans that do not show up for theirs. What is the VA doing 
to better understand why this occurs, and what is being done to reduce 
this higher percentage?
    Answer. Addressing barriers to access for women veterans is a 
priority. VHA is preparing a report, ``Assessment of the Health Care 
Needs and Barriers to VA Use Experienced by Women Veterans: Findings 
from the National Survey of Women Veterans.'' One of the aims of the 
National Survey of Women Veterans (NSWV) was to determine how 
healthcare needs and barriers to VA healthcare use differ among women 
veterans of different periods of military service and assess women 
veterans' healthcare preferences in order to address VA barriers and 
healthcare needs. The interim report on barriers to care will be 
complete by mid-July 2010 with the final report anticipated to be 
published in 2011.
    In addition, several current initiatives will directly improve 
access to care for women veterans.
  --Redesigning Primary Care for Women.--Our goal is to decrease 
        fragmentation of care and improve continuity of care. By 
        providing all of a woman veteran's care from one provider, no-
        show rates will be improved by decreasing the number of 
        appointments a women veteran will have to keep.
  --Patient Centered Medical Home (PCMH).--VHA recognizes the unique 
        needs of women veterans, specifically the need for after hours 
        care, women's health providers at community based outpatient 
        centers (CBOC) and flexibility in how appointments are 
        scheduled due to demands as the primary caregivers of their 
        families which often include other veterans and inflexible work 
        schedules. The PCMH improves access to care by providing 
        flexibility in when and how women veterans schedule appointment 
        time so complicated schedules can be accommodated. Access to 
        women's health providers in a CBOC means fewer miles traveled 
        to see a provider who can meet women veterans' needs.
    In addition, PCMH improves access through direct contact with case 
managers who will assist veterans with care coordination, facilitates 
veteran participation with their healthcare with the use of self-
management health tools and improves veteran satisfaction by allowing 
for greater communication with a provider and the veteran through 
alternative forms of communications such as the Internet through secure 
messaging.
    Question. Following the Wounded Warrior legislation and the Dole-
Shalala Commission's recommendations, improvements were to be made to 
the coordination mechanisms between DOD and VA facilities to better 
care for our injured troops who are transitioning between the two 
healthcare systems. What steps have already taken place to improve 
coordination between the two Departments? What steps remain? Are these 
provisions sufficient to provide a seamless transition for wounded 
warriors from the DOD to the VA system? Does DOD or the VA need further 
legislative authority to improve matters? If so, what?
    Answer. To ensure a smooth transition from the Department of 
Defense (DOD), VA has stationed 33 healthcare liaisons at 18 military 
treatment facilities to facilitate the transfer of care to VA 
facilities. This program grew during 2009 with six additional liaisons 
at five new sites. Altogether these liaisons have assisted more than 
20,000 service members in transitioning from DOD to VA since 2004. We 
continue to work with DOD to identify additional sites that have 
increasing numbers of wounded warriors who may benefit from these 
services. VA works closely with DOD to support high quality integrated 
care for severely injured service members and veterans. The two 
Departments recently developed revisions to clinical codes to improve 
identification and tracking of traumatic brain injury (TBI). In 2009, a 
5-year pilot project to provide assisted living services for veterans 
with severe TBI was initiated in collaboration with the Defense and 
Veterans Brain Injury Center (DVBIC). We have placed three veterans in 
Virginia, Florida and Wisconsin, and enrollment is pending for two 
veterans in Texas and Kentucky.
    Pursuant to the Dole-Shalala Commission's recommendation, VA and 
DOD collaborated on development of the eBenefits portal to provide a 
single and transparent access point to online benefits for wounded, 
ill, and injured service members, veterans, and their family members 
and care providers. The eBenefits portal has expanded beyond its 
original scope and is now intended to be an interactive Web portal for 
all veterans, service members, and their families. In April 2010, 
eBenefits launched version 2.3 that provides on-line capability to 
check the status of disability claims, review payment histories, obtain 
home loan certificates of eligibility, and obtain military documents.
    In November 2007, DOD launched the Disability Evaluation System 
(DES) Pilot to modernize the process by which potentially unfit 
wounded, ill, and injured service members are evaluated for retirement, 
separation, or placement on the temporary disability retirement list. A 
single medical examination is used by both DOD and VA in determining 
entitlements. The pilot program began in November 2007 in the National 
Capitol Region (Walter Reed Army Medical Center, National Naval Medical 
Center (NNMC) at Bethesda, and Malcolm Grow Air Force Hospital) and has 
since expanded to 24 additional military installations. Of those 
separating with a medical disability, approximately 47 percent 
participate currently in the DES pilot process. VA and DOD are 
developing a plan to deploy and transform the DES pilot into the 
integrated DES process worldwide by the end of fiscal year 2011.
    VA believes current legislative authority is sufficient to ensure a 
smooth transition of our injured troops from DOD. VA will work closely 
with the Committee if further legislative authority is needed in the 
future.
    Question. The Western Kentucky Veterans Center expansion in Hanson, 
Kentucky is listed as priority #47 in the Fiscal Year 2010 Priority 
List of Pending State Home Construction Grant Applications subject to 
38 CFR part 59. (It involves increasing the number of beds by 40). It 
is my understanding that an updated priority list for fiscal year 2011 
will be submitted sometime in the fall. Although Kentucky is classified 
as a ``limited needs'' State by the VA, I want to ensure that expansion 
of the Hanson facility takes place in the near future and is not 
permitted to slide down the list of priorities. How can we ensure that 
even ``limited needs'' States such as Kentucky are properly looked 
after in the State Home Construction Grant Application process?
    Answer. The Department of Veterans Affairs (VA) may have sufficient 
funds to participate in a grant for the construction of a 36-bed 
expansion project at the State Veterans Home in Hanson, Kentucky during 
fiscal year 2010. A letter was sent to the Honorable Ken Lucas, 
Commissioner Kentucky Department of Veterans Affairs on May 18, 2010, 
stating VA participation in the project is contingent upon the State of 
Kentucky's compliance with the remaining Federal requirements listed in 
title 38, Code of Federal Regulations, part 59. All projects on the 
priority list are strictly ranked following the guidelines in the 
regulation which places life safety projects at the top of the list.
                                 ______
                                 
              Question Submitted by Senator Susan Collins
    Question. Many of the employees at VA Togus focus specifically on 
disability claims processing. I was recently was told that the Veterans 
Benefits Administration at Togus is in the process of hiring 40 new 
employees that will process disability claims for 8,000 cases related 
to new Agent Orange and Agent Purple claims. I understand that another 
20 employees may be added at Togus to continue to help reduce the 
disability claims backlogs. Because of the age of some of the buildings 
and recent storms, as well as the increasing number of claims 
processing employees, the facility may require additional space and 
administrative offices. Has the Department reviewed the space 
requirements at the VBA facility at Togus or can you commit to 
performing such a review in the near future?
    Answer. The Togus Regional Office (RO) received authority to hire 
61 additional full-time employees. The RO is actively recruiting, and 
32 employees are already on the rolls. The RO plans to use 40 new 
employees to process Agent Orange claims with the remaining new 
employees focused on processing the regular disability claims workload. 
To fully utilize the space at the RO facility, the majority of the new 
employees will work during a second shift. The RO is on the campus of 
the Togus VA Medical Center. Although an older building, significant 
investments were made over the last 2 years to improve the physical 
space. The improvements include new windows, a new roof, and a new 
heating, ventilation and cooling system.

                          SUBCOMMITTEE RECESS

    Senator Johnson. This hearing is recessed.
    [Whereupon, at 3:17 p.m., Thursday, April 15, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]
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