[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 183; H.R. 2527;
H.R. 2661; H.R. 2974; H.R. 3180; H.R. 3387; H.R.
3831; H.R. 4198; AND, DRAFT LEGISLATION TO
AUTHORIZE MAJOR MEDICAL FACILITY
PROJECTS FOR THE DEPARTMENT OF VET-
ERANS AFFAIRS FOR FISCAL YEAR 2014 AND
FOR OTHER PURPOSES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, MARCH 27, 2014
__________
Serial No. 113-61
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman CORRINE BROWN, Florida
DAVID P. ROE, Tennessee MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
JEFF DENHAM, California DINA TITUS, Nevada
JON RUNYAN, New Jersey ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan RAUL RUIZ, California
TIM HUELSKAMP, Kansas GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
Jon Towers, Staff Director
Nancy Dolan, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
DAVID P. ROE, Tennessee JULIA BROWNLEY, California,
JEFF DENHAM, California Ranking Minority Member
TIM HUELSKAMP, Kansas CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio GLORIA NEGRETE McLEOD, California
ANN M. KUSTER, New Hampshire
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Thursday, March 27, 2014
Page
Legislative Hearing on H.R. 183; H.R. 2527; H.R. 2661; H.R. 2974;
H.R. 3180; H.R. 3387; H.R. 3831; H.R. 4198; and, Draft
Legislation to Authorize Major Medical Facility Projects for
the Department of Veterans Affairs for Fiscal Year 2014 and for
Other Purposes................................................. 1
OPENING STATEMENTS
Hon. Dan Benishek, Chairman, Subcommittee on Health.............. 1
Prepared Statement........................................... 30
Hon. Julia Brownley, Ranking Member.............................. 3
WITNESSES
Hon. Michael Grimm, U.S. House of Representatives................ 3
Prepared Statement........................................... 31
Hon. Dina Titus, U.S. House of Representatives................... 10
Prepared Statement........................................... 31
Hon. Jackie Walorski, U.S. House of Representatives.............. 4
Prepared Statement........................................... 32
Hon. Sean Duffy, U.S. House of Representatives................... 7
Prepared Statement........................................... 33
Hon. Marcy Kaptur, U.S. House of Representatives
Prepared Statement........................................... 34
Hon. Kyrsten Sinema, U.S. House of Representatives............... 9
Prepared Statement........................................... 34
Hon. David P. Roe, U.S. House of Representatives................. 11
Prepared Statement........................................... 36
Hon. Jeff Denham, U.S. House of Representatives.................. 22
Prepared Statement........................................... 36
Joy J. Ilem, Deputy National Legislative, Director, Disabled
America Veterans............................................... 14
Prepared Statement........................................... 37
Alethea Predeous, Associate Director of Health Analysis,
Paralyzed Veterans of America.................................. 15
Prepared Statement........................................... 46
Aleksandr Morosky, Senior Legislative Associate, National
Legislative Service, Veterans of Foreign Wars.................. 17
Prepared Statement........................................... 50
Madhulka Agarwal M.D., M.P.H., Deputy Under Secretary for Health
for Policy and Services, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 23
Prepared Statement........................................... 54
Accompanied by:
Philip Matkovsky, Assistant Deputy Under Secretary for
Health for Operations and Management, Veterans Health
Administration, U.S. Department of Veterans Affairs
Renee L. Szybala, Acting Assistant General Counsel, U.S.
Department of Veterans Affairs
STATEMENT FOR THE RECORD
Hon. Kevin McCarthy, U.S. House of Representatives, 23rd
District, California........................................... 59
American Academy of Otolaryngology-Head and Neck Surgery......... 60
Department of Veterans Affairs Office of the Inspector General... 62
International Hearing Society.................................... 63
Iraq and Afghanistan Veterans of America......................... 66
National Association of State Veterans Homes..................... 68
Servicewomen's Action Network.................................... 70
The American Speech-Language-Hearing Association................. 72
Warrior Canine Connection........................................ 74
Wounded Warrior Project.......................................... 76
VetsFirst........................................................ 80
Questions For The Record......................................... 82
LEGISLATIVE HEARING ON H.R. 183; H.R. 2527; H.R. 2661; H.R. 2974; H.R.
3180; H.R. 3387; H.R. 3831; H.R. 4198; AND, DRAFT LEGISLATION TO
AUTHORIZE MAJOR MEDICAL FACILITY PROJECTS FOR THE DEPARTMENT OF
VETERANS AFFAIRS FOR FISCAL YEAR 2014 AND FOR OTHER PURPOSES
Thursday, March 27, 2014
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The subcommittee met, pursuant to notice, at 9:03 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[chairman of the subcommittee] presiding.
Present: Representatives Benishek, Roe, Denham, Walorski,
Brownley, Negrete-McLeod, Kuster, and Titus.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Mr. Benishek. The subcommittee will come to order. Before
we begin I would like to ask unanimous consent from my friends
and colleagues and members of the full committee to sit on the
dais and participate in today's proceedings. Without objection,
so ordered.
Good morning. And thank you all for joining us today to
discuss pending legislation regarding the health care benefits
and services provided to our nation's veterans through the
Department of Veterans Affairs. The ten bills we will discuss
today are H.R. 183, the Veterans Dog Training Therapy Act; H.R.
2527, to provide veterans with counseling and treatment for
sexual trauma that occurred during inactive duty training; H.R.
2661, the Veterans Access to Timely Medical Appointments Act;
H.R. 2974, to provide beneficiary travel eligibility for
veterans seeking treatment or care for military sexual trauma;
H.R. 3387, the Classified Veterans Access to Care Act; H.R.
3508, to clarify the qualifications of VA hearing aid
specialists; H.R. 3180, to provide an exception to the
requirement that the federal government recover a portion of
the value or certain projects; H.R. 3881, the Veterans Dialysis
Pilot Program Review Act; H.R. 4198, the Appropriate Care for
Disabled Veterans Act; and draft legislation to authorize VA
major medical facility projects for fiscal year 2014.
By and large these ten bills aim to address two of this
subcommittee's highest priorities: ensuring that our veterans
have access to the care that they need, and two, ensuring that
VA is held accountable when that care fails to meet the high
standards that it should. Some of these bills, such as H.R.
2527 and H.R. 2974, which aim to resolve gaps in care for
veterans who have experienced military sexual trauma, address
issues that have been raised through subcommittee oversight.
Others, such as H.R. 2661, H.R. 2508, and H.R. 3831, which
concern lengthy patient waiting times, access to care for
hearing impaired veterans, and ongoing issues with the
provision of dialysis care, address issues that were raised
through external stakeholder reviews by the VA Inspector
General and the Government Accountability Office. Still others,
such as H.R. 183 and H.R. 4198, which concern the need for
innovative treatment options for veterans with Post Traumatic
Stress Disorder and the need to ensure that VA maintains
adequate capacity to provide for the unique health care needs
of disabled veterans, address issues that were raised by our
veteran constituents and veterans service organizations. One
other, the draft legislation to authorize VA major medical
facility projects for fiscal year 2014 and of note authorize
the construction of a new bed tower at the James A. Haley
Veterans' Hospital in Tampa, Florida, is the department's own
legislative request.
I would note that VA's fiscal year 2015 budget submission
includes five additional lease authorization requests that are
not included in the draft bill we will discuss this morning.
While I recognize the value of those five lease authorization
requests, which would certainly be included in future VA major
medical facility lease authorization packages moving through
the committee, I thought it was important to thoroughly analyze
and receive stakeholder views on the department's fiscal year
2014 request.
As you may know, last Fall the House passed H.R. 3521, the
Department of Veterans Affairs Major Medical Facility Lease
Authorization Act of 2013, which would authorize 27 VA major
medical facility leases requested by the department in the
fiscal year 2014 budget submission. It is my sincere hope that
H.R. 3521 will be passed through the Senate and quickly signed
into law.
I would like to express my gratitude to my colleagues who
have sponsored the legislation on our agenda today and who are
joining us this morning to discuss their proposals. I would
also like to thank our witnesses from the Disabled Veterans of
America, the Paralyzed Veterans of America, and the Veterans of
Foreign Wars, as well as the witness from VA for their
leadership and advocacy on behalf of our veterans and for being
here today to offer their views.
It is critical that we have thorough understanding of the
benefits and consequences of each of these bills before moving
forward in the legislative process. And as such I look forward
to a detailed and comprehensive conversation. With that, I now
yield to Ranking Member Brownley for any opening statement she
may have.
[The prepared statement of Dan Benishek appears in the
Appendix]
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman. As you said the
purpose of today's hearing will be to explore the policy
implications of nine bills and one draft piece of legislation
before us today which covers a wide range of topics that would
expand and enhance VA's health ca reprograms and services.
I am glad this committee is considering Representative
Walorski's legislation, H.R. 2974, which I have proudly
cosponsored. I believe there is a lot of work to be done for
our veterans that are victims of military sexual trauma and
providing travel benefits to those veterans is a good start. I
look forward to hearing the views from our panelists and
appreciate the hard work that I know their testimony will
demonstrate. While I am disappointed in the department for not
furnishing views on three of the bills I do understand that
sometimes there are extenuating circumstances that preclude
them from submitting their views in a timely manner. I hope the
VA will be able to at least comment on some of the provisions.
As you know, Mr. Chairman, we hold these legislative hearings
to ensure that the committee is as fully informed as possible
and we rely on this input to make intelligent and well-educated
decisions on whether to advance a bill from this subcommittee.
I look forward to a frank and open discussion on the very
topics that are presented before us today. And thank you again,
Mr. Chairman. And I yield back.
Mr. Benishek. Thank you, Ms. Brownley. Joining us on the
first panel today, and hopefully a few more members will show,
are Representative Michael Grimm from New York; Representative
and committee member Dina Titus from Nevada; Representative and
committee member Jackie Walorski from Indiana; Representative
Sean Duffy from Wisconsin; Representative Marcy Kaptur from
Ohio; Representative Kyrsten Sinema from Arizona;
Representative and committee member David Roe from Tennessee;
and Representative and committee member Jeff Denham from
California.
It is an honor to have you all here this morning. I look
forward to hearing your testimony. Mr. Grimm, may we begin with
you?
Mr. Grimm. Yes, Chairman.
Mr. Benishek. Please proceed with your testimony.
STATEMENT OF HON. MICHAEL GRIMM
Mr. Grimm. Thank you very much, Chairman. I appreciate it.
Both Chairman Benishek and Ranking Member Brownley, thank you
for allowing me to testify today on H.R. 183, the Veterans Dog
Training Therapy Act. This is a bill I introduced along with my
friend the ranking member of the House Veterans' Affairs
Committee, Congressman Michaud, in the last Congress and again
this Congress.
As a Marine combat veteran, it is a unique honor for me to
address this committee. Having seen firsthand both the physical
and mental wounds of War that the members of our nation's
military are faced with I have a very special appreciation for
the important work this committee does every single day. Today
millions of Iraq and Afghanistan veterans have returned home to
the challenge of a stagnant economy, high unemployment, and for
many the long road to recovery for the mental and physical
wounds sustained during their service. During my time in
Congress I have had the honor to meet with a number of our
nation's veterans who are now faced with the challenges of
coping with PTSD and physical disabilities resulting from their
service in combat. Their stories are not for the weak of heart
and are truly moving.
It was these personal accounts of recover, both physical
and mental, and the important role therapy and service dogs
played in that process, that inspired this legislation. The
Veterans Dog Training Therapy Act would require the Department
of Veterans Affairs to conduct a five-year pilot program in at
least three, but not more than five, VA medical centers
assessing the effectiveness of addressing post-deployment
mental health and PTSD through the therapeutic medium of
training service dogs for veterans with disabilities. These
trained service dogs are then given to physically disabled
veterans to help them with their daily activities. Simply put,
this program treats veterans suffering from PTSD while at the
same time aiding those suffering from physical disabilities.
When I originally introduced this legislation in the 112th
Congress both the House Veterans' Affairs Committee and the
full House of Representatives passed it with overwhelming
bipartisan support. Additionally, with high veteran suicide
rats and more servicemen and women returning from deployment
being diagnosed with PTSD, this bill meets a crucial need for
additional treatment methods. I believe that by caring for our
nation's veterans suffering from the hidden wounds of PTSD
while at the same time providing assistance dogs for those with
physical disabilities we create a win-win for everyone which I
believe is a goal we can all be proud to accomplish.
Working in conjunction with a number of veterans service
organizations I have drafted updated language which mirrors
changes made to this legislation in the 112th Congress. And I
hope to work with the committee during mark up of H.R. 183 to
ensure this program provides our nation's veterans with the
highest quality care for both PTSD and physical disabilities
while maintaining my commitment to fiscal responsibility.
Again, I would like to thank the committee for holding
today's hearing and I look forward to working with you to
ensure that this program is included in your continuing efforts
to guarantee that our nation's heroes have the best possible
programs for treating PTSD and providing disability assistance.
Thank you, and I yield back.
[The prepared statement of Michael Grimm appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony, Mr.
Grimm. Let me yield five minutes to Ms. Walorski for her
statement. Thank you.
STATEMENT OF HON. JACKIE WALORSKI
Mrs. Walorski. Good morning. Chairman Benishek, thank you,
Ranking Member Brownley, and members of the committee, thank
you for the opportunity to discuss H.R. 2974, a bill making
victims of military sexual trauma eligible for Department of
Veterans Affairs beneficiary travel benefits. According to the
VA, one in five women and one in 100 men screen positive for
military sexual trauma, or MST.
The VA provides counseling, care, and services to veterans
and certain other servicemembers who may not have veteran
status but who experienced MST while serving on active duty or
active duty for training. VHA policy states, ``veterans and
eligible individuals who report experiences of MST but were
deemed ineligible for other VA health care benefits or
enrollment may be provided MST-related care only. This benefit
extends to Reservists and members of the National Guard who
were activated to full-time duty status in the armed forces.
Veterans and eligible individuals who received an other than
honorable discharge may be able to receive free MST-related
care with Veterans Benefits Administration regional office
approval.''
Every VA medical center offers evidence-based therapy for
conditions related to MST and has providers who know how to
treat the downstream effects of MST. Nationwide there are
almost two dozen programs that offer specialized treatment in
both residential and in patient settings. All health care for
treatment for mental and physical health conditions related to
MST, including medications, is provided free of charge. Fee
basis is available when it is not appropriate to provide
counseling in a VA facility, when VA facilities are
geographically inaccessible or when VA facilities are unable to
provide care in a timely manner.
Overall while VA has taken the appropriate steps to provide
counseling services for victims of MST, these services need to
be more accessible. MST-related care must be provided in a
setting that is therapeutically appropriate and takes into
account the circumstances related in the need for such care. A
supportive environment is essential for recovery. VA policy
states that any veteran with MST must receive clinically
appropriate care regardless of the location.
Veterans being treated for conditions associated with MST
are often admitted to programs outside their Veteran Integrated
Service Network. VA health care in general, especially for
women, has been characterized as fragmented. Patients with
special needs who are unable to access the services they need
from their local providers are referred elsewhere and
oftentimes have to travel long distances to receive such
services. According to a 2012 VA Inspector General report,
obtaining authorization for travel funding was frequently cited
as a major problem for both patients and staff.
The beneficiary travel policy indicates that only certain
categories of veterans are eligible for travel benefits and
payment is only authorized to the closest facility providing a
comparable service. The current beneficiary travel policy
contradicts VA's MST policy, which states that patients with
MST should be referred to programs that are clinically
indicated regardless of geographic location. A veteran should
never have to choose to skip treatment for conditions related
to MST due to distance or lack of transportation.
I applaud VA's commitment to an effective program that
provides counseling and treatment to men and women in need of
help in overcoming the physical and psychological stress
associated with MST. However, VA is not doing enough to help
veterans access these important resources and services.
Survivors of MST should not feel re-traumatized and helpless
because of geographic barriers to treatment. Representative
Kuster and I introduced H.R. 2974 to make victims of MST
eligible for VA beneficiary travel benefits. By better aligning
the beneficiary travel policy with VA's current policy for
responding to veterans who have experienced MST, H.R. 2974
ensures appropriate services are more readily available to meet
the treatment needs of our nation's veterans.
I am grateful to work with Representative Kuster and the
committee in addressing this critical issue for the survivors
of military sexual trauma and I again thank you for this
opportunity to speak today.
[The prepared statement of Jackie Walorski appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony and
for the legislation. Dr. Roe, are you ready? Well, some members
may be late in joining us. But I think as long as we are all
here I would ask a couple of questions of the people that are
here with us this morning. So I will yield myself five minutes
to begin that.
Mr. Grimm, there is a statement from VA in their written
testimony I would like you to respond to. It says, ``The VA
does not support the specific provisions of H.R. 183 because
the bill focuses on the training of the dog as opposed to what
we believe is the goal of the legislation, which is finding
better ways to improve the health of this veteran population.''
Can you respond to that?
Mr. Grimm. Certainly. Thank you, Chairman. Simply put, they
completely miss the mark. It is actually the veteran that may
have Post Traumatic Stress that is actually training the dog.
It is the actual training that is the therapy itself. Often
veterans come back and they have had so much responsibility,
literally life and death responsibility for multiple tours,
years at a time. And they come back and they feel very
minimized. They do not have that sense of responsibility. Many
of them cannot find work. They are having trouble fitting in.
And they feel that everyone is looking at them differently. And
for, and I cannot tell you how it happens because it is almost
magical. It seems almost as if it is miraculous. But what we
have noticed is when these veterans tend to this animal, to
this dog, to train them, one it gives them that sense of
responsibility back again, that they are doing something that
is important. And the way these animals just seem to know how
to act around these veterans is simply amazing.
So it gives them a sense of purpose. And when they know
that the dog, if they succeed and the dog is fully trained that
then that dog is going to be given to a fellow veterans with
physical disabilities, it is a veteran helping another veteran.
That is what is happening here. So it is, whether the dog
actually gets trained fully or not is almost irrelevant. If the
dog gets fully trained, great. We pass that dog on, it gets
certified, and goes to another veteran. But if not what we are
finding is many times the veteran, just that sense of being
needed is a big step in the process of being healed. And
sometimes they even just want to take the dog home and it
becomes a pet. Either way, and that is why the actual training
of the dog is very secondary. It is that sense of purpose given
to that veteran. That is the actual therapy itself. So I think
the Veterans Administration in this case is just completely
missing the mark. I yield back.
Mr. Benishek. Well I certainly know that we just did a
field hearing in California. And that, they have veterans who
are working with horses. I am not a horse person. But, they
found the same thing, in that either the animal seems to be
able to provide a measure of confidence to patients with Post
Traumatic Stress Disorder. And I think, there is a lot of
opportunity for this sort of alternative methods of treatment.
Because we should be really casting a wide net to try to find
what can help many of our veterans. So I applaud your efforts
here.
Let me--oh, are you waiting to talk now? Oh, okay. Well one
other question for you, Mr. Grimm. Would you be willing to
consider amendments to H.R. 183 that would allow VA to be
flexible in the housing and training off campus, as the VFW
suggested?
Mr. Grimm. Chairman, absolutely. In fact I have proactively
been working in conjunction with several VSOs on this issue and
intend to suggest modified language to the committee based on a
number of recommendations that we have already received. So
there are VSOs that are doing this in Palo Alto and other
places that have gotten it pretty much down to a science and we
are willing to incorporate all of those things. So we think
that absolutely.
Mr. Benishek. Thank you. I will yield to Ms. Brownley for
questions.
Ms. Brownley. Thank you, Mr. Chairman. I am not sure that I
have a question but I did want to make a remark with regards to
Ms. Sinema's bill and thank you for bringing this bill forward.
And suicide and suicide prevention is one of the number one
goals of this committee. And as you know and the committee
knows and the audience knows that, you know, 22 suicides a day
in our country by our veterans and that is completely
unacceptable. And I know that your legislation unfortunately
will not save Daniel's life but hopefully it will save someone
else's life. And I know today even on the Mall the Iraq and
Afghanistan Veterans of America, whose number one priority is
suicide prevention, is having a big occasion out on the Mall
and will be raising flags, thousands of flags in honor of our
veterans who have committed suicide and who have served our
country so honorably. So I just wanted to thank you for
bringing this legislation forward and this seems like a very,
very simple fix that is part of the VA's policy in some sense
and a very simple fix to potentially save future lives. So
thank you very much for bringing it forward.
Mr. Benishek. Thank you very much. Mr. Duffy.
STATEMENT OF HON. SEAN DUFFY
Mr. Duffy. Good morning and thank you, Chairman Benishek
and Ranking Member Brownley for holding today's very important
hearing and for allowing me to testify on my bill 3508. I
worked on this along with Congressman Tim Walz from Minnesota
and I appreciate all his work and efforts to make sure this is
a bipartisan proposal. This is a proposal that will address the
times and backlogs that our veterans have to receive services
from the VA.
Currently you have the VA that hires doctors of audiology,
which is wonderful. When our veterans receive services the
services are wonderful. The problem is there is long wait times
and backlogs before they are actually able to get in and see
the doctors. Oftentimes a veteran who needs an initial exam or
a hearing test will wait two weeks to one year for that initial
appointment with the audiologist. And then their hearing aids
are ordered, it is two weeks to one year before they actually
get the hearing aid itself. And then once they get the hearing
aid they have to go back to the VA where it is an appointment
time of six weeks to six months before they get that
appointment. And then if you have to have your hearing aid
tweaked or adjusted, it is another wait time of six weeks to
six months.
This is unacceptable. When you have our younger veterans
who are coming home from War and our aging veterans who have
had hearing loss issues, you cannot hear. And they are waiting
weeks if not months before they can get into the VA. It is
creating real problems and I think a disservice to our
veterans.
This came to my attention, one of my constituents, Roger,
he is a Vietnam Vet. He is 70 years old. He had a hearing aid,
the hearing aid went out on him. And so he called the VA to get
an appointment to go get a new hearing aid and they told him it
would take six months before he got an appointment. Six months!
He cannot hear. This is unacceptable. So he went to his local
hearing aid specialist, bought a new hearing aid out of pocket
and paid $5,000 for it. Now Roger could afford that. It was a
significant dent to him. But a lot of our veterans cannot
afford to pay $5,000 to get service on their own when they
actually could get service from the VA.
So what we are doing in this bill is asking that we allow
the VA to hire hearing aid specialists. For the complex issues
of hearing loss and hearing issues we still have the
audiologists. But we will have hearing aid specialists who can
do some of the more minor functions in regard to hearing loss
like dispensing, repairing, adjusting, and fitting the aids. So
we can eliminate that backlog and get our veterans seen right
away. So not only will the VA be allowed to hire hearing aid
specialists, not required, not mandated, but allowed if they
see fit to hire hearing aid specialists, we will also allow the
VA to contract with hearing aid specialists around our rural
communities.
I know, Chairman Benishek, you and I share district lines.
We do not come from the most populated districts in the
country. We live in rural America. And you hear stories about
our veterans and the length of travel time they have to go to
the VA clinics. If we allow the VA to actually contract with
hearing aid specialists in their community, far less disruption
for our veterans to just have the simple pleasure of hearing
provided to them and services provided to them from the VA. So
I hope the committee will consider our bipartisan proposal and
I think it goes a long way to making sure we are doing justice
by way of the men and women who have so honorably served our
country. I yield back.
[The prepared statement of Sean Duffy appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Duffy. Now I will
call on Representative Sinema.
STATEMENT OF HON. KYRSTEN SINEMA
Ms. Sinema. Thank you, Chairman Benishek and Ranking Member
Brownley, for holding today's hearing, and thank you to my
colleagues who have introduced important bills that improve the
quality of care available to veterans, especially Congresswoman
Walorski's legislation to make travel assistance available for
veterans seeking care for military sexual trauma.
I am here to discuss H.R. 3387, the Classified Veterans
Access to Care Act, and thank you, Chairman Benishek, for
cosponsoring this bill. The Classified Veterans Access to Care
Act ensures that veterans with classified experiences can
access appropriate mental health services at the Department of
Veterans Affairs.
I am working on this issue because last year a veteran in
my district, Daniel Somers, failed to receive the mental health
care he needed and tragically committed suicide. No veteran or
family should have to go through the tragedy that the Somers
family experienced. Daniel Somers was an Army veteran of two
tours in Iraq. He served on Task Force Lightning, an
intelligence unit. He ran over 400 combat missions as a machine
gunner in the turret of a HUMVEE. Part of his role required him
to interrogate dozens of terror suspects and his work was
deemed classified.
Like many veterans, Daniel was haunted by the War when he
returned home. He suffered from flashbacks, nightmares,
depression, and additional symptoms of Post Traumatic Stress
Disorder made worse by a Traumatic Brain Injury. Daniel needed
help and he and his family asked for help. Unfortunately the VA
enrolled Daniel in group therapy sessions, which Daniel could
not attend for fear of disclosing classified information.
Despite requests for individuals counseling, or some other
reasonable accommodation to allow Daniel to receive appropriate
care for his PTSD, the VA delayed providing Daniel with
appropriate support and care. Like many, Daniel's isolation got
worse when he returned to civilian life. He tried to provide
for his family but he was unable to work due to his disability.
He struggled with the VA bureaucracy. His disability appeal had
been pending for over two years in the system without
resolution and he did not get the help he needed in time.
On June 10, 2013, Daniel wrote a letter to his family. It
begins, ``I am sorry that it has come to this. The fact is for
as long as I can remember my motivation for getting up everyday
has been so that you would not have to bury me. As things have
continued to get worse it has become clear that this alone is
not a sufficient reason to carry on. The fact is, I am not
getting better. I am not going to get better. And I will most
certainly deteriorate further as time goes on. From a logical
standpoint it is better to simply end things quickly and let
any repercussions from that play out in the short term than to
drag things out in the long term.''
He goes on to say, ``I am left with basically nothing. Too
trapped in a War to be at peace, too damaged to be at War.
Abandoned by those who would take the easy route, and a
liability to those who stick it out and thus deserve better. So
you see, not only am I better dead but the world is better off
without me in it. This is what brought me to my actual final
mission.''
Daniel's parents, Howard and Jean, were devastated by the
loss of their son. But they bravely shared Daniel's story and
created a mission of their own. Their mission is to ensure that
Daniel's story brings to light America's deadliest War: the 22
veterans that we lose everyday to suicide. My office worked
with Howard and Jean to develop this Act so that veterans can
seek and receive comprehensive mental health care from the VA
regardless of the classified nature of their military
experiences. Our bill directs the Secretary of the VA to
establish standards and procedures to ensure that a veteran who
participated in a classified mission or served in a sensitive
unit may access mental health care in a manner that fully
accommodates the veteran's obligation to not improperly
disclose classified information. It also directs the Secretary
to disseminate guidance to employees of the Veterans Health
Administration, including mental health professionals, on such
standards and procedures on how to best engage veterans during
the course of mental health treatment with respect to
classified information. And finally, the bill directs the
Secretary to allow veterans with classified experiences to
self-identify so they can quickly receive care in an
appropriate setting.
Our legislation is supported by the Retired Enlisted
Association, the Association of the United States Navy, and the
Iraq and Afghanistan Veterans of America. As the IAVA states in
its letter of support, these reforms to mental health treatment
are necessary to provide safe and inclusive care for all
veterans. I look forward to continuing to work with the
committee to ensure that no veteran feels trapped, like my
constituent Daniel did, and that all veterans have access to
appropriate mental health care.
Again, thank you, Chairman Benishek and Ranking Member
Brownley, for including the Classified Veterans Access to Care
Act in today's hearing. Thank you.
[The prepared statement of Kyrsten Sinema appears in the
Appendix]
Mr. Benishek. Thank you very much for your compelling
testimony. Ms. Titus. Are you ready to go ahead?
STATEMENT OF HON. DINA TITUS
Ms. Titus. I am, Mr. Chairman. Thank you for your
indulgence. I apologize. I am introducing H.R. 2527. I
certainly appreciate your and the ranking member's including
this in the hearing today.
This is bipartisan legislation that addresses an
unacceptable gap in current law that effectively leaves certain
victims of sexual assault without support and treatment that
they need and deserve. Members of the National Guard and other
Reserve components of the armed services who have fought
bravely for our country, and many have completed multiple tours
in Iraq and Afghanistan, certainly that is true of the National
Guard in Nevada. Since September 11th, more than 50,000
Guardsmen and Guardswomen have been called to service both at
home and abroad.
Now we all recognize the great importance of the National
Guard and other Reserve components and we thank them for their
incredible service. Members of the National Guard and other
Reserve components who are unfortunate victims of sexual
assault while they are on active duty are like members of other
armed forces. They are provided with all the services and
resources they need to recover and heal physically and
emotionally. This treatment is provided by the VA for free for
as long as it is needed and this is the very least that we can
do. These benefits, however, are not offered to members of the
National Guard or other Reserve components who experience
sexual assault while they are on active training missions. For
example, members of the Guard are required to participate in
training missions one weekend a month and two weeks a year.
This oversight is simply unacceptable and it leaves many who
have served our country so well without any assistance or
support during a very devastating time if they are such
victims.
The National Guard Military Sexual Trauma Parity Act would
fix this omission and clarify that all victims of sexual trauma
in the National Guard or the other Reserve components would
have access to the resources and services they need whether
they are on active duty or they are in a required training
mission. We should make it a priority to change the culture of
the military and put an end to the acts of sexual trauma that
exist within our military and that we have heard so much about
lately. But until we do that, however, we have to provide
victims of this kind of trauma with the care that they need.
And certainly that would include not just the active military
but also our National Guard in these other times.
So I want to thank many of the VSO organizations for their
support, the VA is supportive of this, and I thank the
subcommittee for including this important legislation. And I
yield back.
[The prepared statement of Dina Titus appears in the
Appendix]
Mr. Benishek. I yield five minutes to Dr. Roe to present
his testimony.
STATEMENT OF HON. DAVID P. ROE
Dr. Roe. Thank you, Mr. Chairman. And it is my pleasure to
present H.R. 3831, the Veterans Dialysis Pilot Program Review
Act, to my colleagues on the subcommittee. This bill would
prevent the Veterans Health Administration from rolling out a
new in house dialysis centers until an independent review of
the VHA dialysis pilot program has been completed.
In 2009 the Secretary of Veterans Affairs launched a VHA
dialysis pilot program creating four test sites at outpatient
VA clinics to see if quality dialysis treatment could be
delivered to veterans in house at a lower cost than contracting
the care out to commercial dialysis treatment centers. In 2012
a GAO report, which I ask to be inserted into the record----
Mr. Benishek. So ordered.
Dr. Roe. Thank you. Shows that early implementation of the
dialysis pilot program has shown many weakness, including
erroneous cost estimation practices and cost savings
calculations. The Department of Veterans Affairs, however, is
moving to expand the in house dialysis program nationally
before review of the pilot program has been performed. In fact,
VA is still contracting for an independent analysis of how well
it is working.
H.R. 3831 would simply direct the Secretary of Veterans
Affairs to halt the establishment of any new VA dialysis
clinics until each of the four original pilot sites has been
operating for two years, an independent analysis of the sites
is conducted, and a full report has been submitted to Congress.
The intent of this bill is to ensure that we have found out if
this pilot program is in the best interests of veterans and
taxpayers before the VA rolls out the program nationally.
And let me say this briefly. This does not prevent the four
senators from continuing exactly what they are doing, and it
does nothing to veterans receiving care that they are now from
the private sector. It is just to see if the program works
before we roll out another program at the VA. How many times
have we seen this? We do not, we start a program, do not even
analyze it, and then we are explaining and trying to figure out
why it does not work. That is all we are doing, is just asking
to do exactly what the VA said it would do which is to analyze
the program before they expand it. That is all this is.
And anecdotally, Mr. Grimm, I completely agree with what
you are doing and I wholeheartedly support. I have seen
veterans at home, I have met veterans and talked to them, it is
really amazing to see what these animals can do. So I am very
supportive of your bill. I yield back.
Mr. Benishek. Thank you. Ms. Walorski, do you have any
questions you would like to ask?
Mrs. Walorski. Thank you, Mr. Chairman. I just have a
couple of comments. To Representative Grimm, I applaud your
efforts as well. I was just at Walter Reed's Research and
Development Facility just a couple of weeks ago and saw a whole
new program they are laying out with actually a whole breed of
labs that they are using for pet therapy. And they have even
taken it a step farther, which I think is phenomenal, because
the therapy is for the veteran. And they are actually now
allowing the veteran to name their therapy dog the name of
their buddy that was left behind that was killed. And it is
powerful. And pet therapy is a powerful tool. And just seeing
the families there and the veterans that were involved in the
training was incredible, and we have seen it in our district as
well.
And then also to Representative Sinema, I just, I applaud
your efforts on that bill. I think, I am appalled by what we
hear sometimes what seems to be everyday in this committee
about how our veterans are treated. And this issue of suicide,
I would agree with Ranking Member Brownley, is one of our top
issues on this committee and this subcommittee. And I had a
situation in my district where we had a Vietnam Vet that was
not dealing with a classified issue necessarily but was
certainly dealing with extreme depression, mental health issues
based on chronic pain from the effects of Agent Orange. And we
did everything we could and then some and it just was not
enough. And they sent him home over Christmas and we got a call
from his wife that he committed suicide. And it was one of the
most distressing things I have dealt with being in Congress. It
just, it is a sad, sad reality. And we have to do better. We
just have to completely do better for the sake of our veterans
in this country. And I yield back the rest of my time. Thank
you, Mr. Chairman.
[The prepared statement of David Roe appears in the
Appendix]
Mr. Benishek. Thanks, Ms. Walorski. Ms. Kuster.
Ms. Kuster. Thank you, Chairman Benishek, and thank you
Ranking Member Brownley. And I just want to speak on a couple
of bills but I want to make a comment about our members, our
colleagues coming forward with these bills and this committee
being one of the few places that we can make bipartisan
progress. So I just want to speak to the bill that I had the
opportunity to be original cosponsor with Representative
Walorski, and commend your work on military sexual trauma
generally and specifically making sure that our veterans, both
men and women, get the treatment that they need and have the
funds for travel that they need.
I also want to comment my colleague Representative Sinema
for giving Daniel's live a legacy and meaning. And I think for
all of us we each have our individual stories in our districts,
but I have had the opportunity to meet Daniel's family with you
and just to know that he, his life will have a purpose if we
can do everything that we can on this committee and convince
our colleagues that this is a priority issue for our country.
And lastly to my colleague Representative Titus, I do a lot
with the National Guard in New Hampshire and we have also had a
very high level of participation in these conflicts, and I
think it is critically important to include the National Guard.
I have been having a series of round tables with our veterans
and our VSOs and our National Guard on the issue of military
sexual assault. And I completely agree with you that we need to
eradicate this problem from our military, but in the meantime
we need to be doing everything we can on this committee to make
sure that people get the treatment that they need in a timely
way.
So I have no questions, just comments. Just thank you for
your leadership and thank you, Representative Brownley, for
your leadership on this committee. Thank you.
Mr. Benishek. Thank you, Ms. Kuster. Ms. Negrete-McLeod? Do
you have any questions? Ms. Titus, do you have any questions?
Well I think we can excuse the first panel. Thank you very
much for your testimony today and for taking the effort to put
through these good efforts to improve services to our veterans.
Thank you very much for your time.
We will proceed with the next panel. Mr. Denham may still
arrive to present his bill and if he does we will give him some
time to present his case.
Will now welcome the second panel to the witness table.
Joining us on the second panel is Ms. Joy Ilem, Deputy National
Legislative Director from the Disabled American Veterans; Ms.
Alethea Predeoux, the Associate Director of Health Analysis for
the Paralyzed Veterans of America; and Aleksandr Morosky, the
Senior Legislative Associate for the Veterans of Foreign Wars.
Thank you for being here this morning and for your hard work
and advocacy on behalf of our veterans. I appreciate your being
here to present your views and we will begin with Ms. Ilem.
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you, Mr. Chairman and members of the
subcommittee. We appreciate your inviting DAV to testify at
this legislative hearing. My comments will be focused primarily
on the bills DAV supports but DAV's written testimony submitted
for the record discusses our position on each measure in
detail.
H.R. 2527 seeks to expand eligibility for counseling and
treatment for conditions related to military sexual trauma, or
MST. Current law authorizes VA to provide such services for
those who served on active duty, or active duty for training.
H.R. 2527 would amend the statute to include veterans in the
Reserve components of the armed forces during inactive duty for
training as well so that they too will become eligible for this
type of care. Based on DAV Resolution No. 125 we are pleased to
support this measure and urge its enactment.
H.R. 2974 seeks to provide eligibility for beneficiary
travel reimbursement to veterans receiving care in one VA
facility but based on a clinical determination they need to
access a specialized MST program or treatment only available at
another VA facility. According to the Inspector General, as
noted, patients and VA mental health staff have indicated they
are often challenged to obtain authorization for VA funded
patient transportation to these specialized centers. DAV
Resolution No. 125 calls on VA to ensure all MST survivors have
access to the specialized treatment programs and services they
need to fully recover. Therefore DAV supports this legislation
but we also recommend the subcommittee review the VA's
beneficiary travel policy as it relates to other groups of
veterans' access to VA specialized care as well.
H.R. 2661, the Veterans Access to Timely Medical
Appointments Act, would direct VA to establish a national
standardized scheduling policy to improve timely access to
care. While the intent of this bill is laudable and we
appreciate the sponsors' efforts, DAV believes the overriding
component to solve many of VA's access challenges is a lack of
an effective automated scheduling system. While the bill seeks
to rectify many of the existing problems identified by GAO,
enactment of this bill would not address what we consider the
core issue. Specifically the implementation of a modernized
scheduling system so that VA could begin to be based on
reliable data, begin to assess demand versus capacity as well
as determine associated staffing needs and resources more
accurately. While DAV supports the intent of the legislation
based on our Resolution No. 204, we urge the subcommittee to
work with the bill's sponsor and VA to fully address the
underlying issues related to this problem and determine how the
intent of this measure could be best achieved.
H.R. 3387 seeks to ensure that standards and procedures are
in place for VA clinicians to provide mental health treatment
to veterans who served in a classified military mission. We
agree that guidance on how to best engage such veterans during
the course of mental health treatment is critical to ensuring
the veteran is able to access appropriate care and services
without having to disclose sensitive information. DAV
Resolution No. 193 supports program improvement and enhanced
resources for VA mental health programs and we believe this
bill is consistent with the purposes of our resolution.
Therefore DAV offers its support of this measure.
H.R. 4198 seeks to reinstate the requirement for an annual
report to Congress on the capacity of VA to provide specialized
treatment and rehabilitative needs of disabled veterans.
Although we have no specific resolution calling to reinstate
the report we do acknowledge the importance of having data that
accurately reflects available capacity for these important
services. However, due to the changes in health care delivery
since the requirement of the original report we recommend
amendments to the bill that would track capacity in discrete
bed intensive units along the lines of the intent of the bill
yet also obtain relevant information on VA program capacities
that are no longer bed intensive, such as specialty outpatient
mental health services, substance use disorder treatment
services, and long term services and supports, among others.
DAV asks the committee to consider approving the bill in its
current form with the understanding that at a future
legislative meeting of the committee an amendment would be
offered by the bill's sponsor incorporating the changes we hope
to achieve cooperatively.
My final comments are related to the draft bill to
authorize major VA medical facility projects for fiscal year
2014. DAV strongly supports this draft measure on the basis of
DAV Resolutions No. 28 and 188.
Mr. Chairman and members of the subcommittee, thank you for
considering the views of DAV today and I am happy to respond to
any questions you may have related to these proposals or in any
of DAV's testimony. Thank you.
[The prepared statement of Joy Ilem appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony. Ms.
Predeoux, you may begin.
STATEMENT OF ALETHEA PREDEOUX
Ms. Predeoux. Thank you. Chairman Benishek, Ranking Member
Brownley, and members of the subcommittee, Paralyzed Veterans
of America, PVA, would like to thank you for the opportunity to
present our views on the health care legislation being
considered by the subcommittee. These important bills will help
ensure that veterans have access to quality and timely health
care services through the Department of Veterans Affairs.
We are particularly pleased that H.R. 4198, which is a
legislative priority for PVA, is among the legislation being
reviewed today. My remarks will focus on only a few bills as
PVA's full statement as been submitted to the subcommittee.
H.R. 2661, the Veterans Access to Timely Medical
Appointments Act, proposes to establish a standardized
scheduling policy for veterans enrolled in VA health care. This
scheduling policy would mandate that VA schedule all primary
care appointments within seven days of the date requested by
the veteran or the health care provider on behalf of the
veteran, and require specialty care medical appointments to be
scheduled within 14 days of the date requested by the veteran
or physician. Timely access to quality care is vital to VA's
core mission of providing primary care and specialized services
to veterans. PVA is concerned with how to determine the best
standardized policy for scheduling primary and speciality care
appointments. Measuring patient access and demand is an
extremely complex tasks. Despite VA's stated goals of providing
primary care appointments within seven days of a veteran's
requested date and 14 days for specialty care, wait times
continue to exist. Legislating these goals as standardized
policy for scheduling VA medical appointments has the potential
to lead to unintended outcomes that could force VA into
contracting for care with private providers too frequently. We
encourage the VA and Congress to determine if VA has adequate
resources to develop, implement, and support a patient
scheduling system that will address issues involving wait time
measures, sufficient staffing levels, and patient demand.
PVA supports H.R. 2974, a bill to amend Title 38 to provide
for eligibility for beneficiary travel for veterans seeking
treatment or care for military sexual trauma in specialized
outpatient and residential programs. Recognizing that the
burden of cost associated with travel for health care services
can lead to veterans foregoing much needed medical attention
for many years, PVA has advocated for expanding beneficiary
travel eligibility for specialized groups of veterans such as
catastrophically disabled and severely injured ill and wounded
veterans. PVA believes that veterans seeking treatment for MST
should be eligible for beneficiary travel and sufficient
resources should be provided for the costs associated with
expanding this program.
Lastly, PVA strongly supports H.R. 4198, the Appropriate
Care for Disabled Veterans Act. This legislation proposes to
amend Title 38 to reinstate the requirement for an annual
report on the capacity of the VA to provide specialized
treatment and rehabilitative needs for disabled veterans. Many
of the VA's specialized systems of care and rehabilitative
programs have established policies on the staffing requirements
and number of beds that must be available to maintain capacity
and provide high quality care. When VA facilities do not adhere
to these staffing policies and requirements veterans suffer
with prolonged wait times for medical appointments, or in the
case of PVA members having to limit their care to an SCI clinic
despite the need to receive more comprehensive care from an SCI
hospital. Requiring the VA to provide Congress with an annual
capacity report to be audited by the Office of the Inspector
General would give VA leadership and Congress an accurate
depiction of VA's ability to provide quality care and services
to disabled veterans. This is particularly important for
measuring access and bed capacity of VA's specialized services
for blinded veterans, veterans with spinal cord injury or
disorder, and veterans who have sustained severe traumatic
brain injury. PVA also urges the subcommittee to not only
reinstate the reporting requirement but also update the
language in Title 38 to most accurately reflect specialized
services within VA for VA long term care, mental health, and
substance use disorders.
We thank the subcommittee for recognizing VA's capacity to
provide specialized services as a priority in VA health care
deliver and look forward to working with our VSO partners and
this subcommittee to update this report so that it reflects
useful information that will improve care delivery for all
veterans receiving services through VA's specialized programs.
Again, I thank you for the opportunity to submit our views
on the bills being reviewed today and I am happy to answer any
questions.
[The prepared statement of Alethea Predeoux appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony. Mr.
Morosky, could you proceed?
STATEMENT OF ALEKSANDR MOROSKY
Mr. Morosky. Chairman Benishek, Ranking Member Brownley,
and members of the subcommittee, on behalf of the Veterans of
Foreign Wars of the United States and our auxiliaries I want to
thank you for the opportunity to present VFW's stance on
legislation pending before this subcommittee. The bills we are
discussing today are aimed at improving the quality of veterans
health care and we thank you for bringing them forward.
(The Veterans Dog Training Therapy Act)--The VFW recognizes
the potential value of canine therapy and would not be opposed
to a pilot program to treat veterans with PTSD by teaching them
to train service dogs. We do however have two suggestions that
we believe would strengthen this bill. First, we suggest the
bill be amended to allow VA to carry out the pilot program in
partnership with existing community resources. Second, we
recommend the bill be amended to allow VA the flexibility to
house the dogs at off site locations when necessary. With these
changes, VFW fully supports this bill.
(H.R. 2527)--The VFW supports this legislation which would
authorize VA to provide counseling and treatment to
servicemembers who experience MST during inactive duty
training. The VFW strongly believes that members of the Reserve
component who experience MST during weekend drills or other
inactive duty deserve the same MST related services as those
who experience sexual trauma while activated.
(The Veterans Access to Timely Medical Appointments Act)--
Although the VFW strongly supports the intent of this
legislation to reduce appointment wait times for veterans we do
not support the statutory mandate of VA's seven-day primary
care and 14-day specialty care appointment wait time goals. The
VFW is primarily concerned that this legislation would force VA
to overutilize purchased care. VA's new purchase care model,
PC3, is still being implemented. Its effectiveness is still
unknown and it may not be the best option for many veterans.
The VFW wants to see PC3 as a secondary option to direct care,
as it was intended. To solve this problem of long wait times VA
must implement its plans for appointment scheduling, physician
staffing, and purchased care, and VFW urges continued
congressional oversight to ensure that those things happen.
(H.R. 2974)--The VFW strongly supports this legislation.
Under current VA policy all MST victims are eligible for
residential rehab treatment programs and facilities that do not
have those programs have been directed to refer veterans to
those that do. Not all MST victims, however, meet the current
criteria for beneficiary travel reimbursement. This legislation
would fix that problem, fully aligning VA travel policy with
MST treatment policy.
(H.R. 3508)--This legislation would authorize VA to hire
hearing specialists as full-time employees at department
facilities to provide hearing health services alongside
audiologists and hearing health technicians. Although we
appreciate this bill's intent to increase hearing health
access, the VFW believes that VA has the ability to address
that issue under its current hiring authority. We strongly
believe that VA must improve timeliness in issuing and
repairing hearing aids. But adding a new class of provider
whose scope of practice overlaps that of existing employees
does not get to the root of the problem. To fully address the
issue VA must determine proper staffing levels of audiologists
and hearing health technicians necessary to provide timely care
and increase the number of those employees accordingly.
(H.R. 3180)--The VFW supports this legislation which would
allow state veterans homes that receive residential care
contracts or grants from VA to also contract with VA under the
health care for Homeless Veterans Supported Housing Program. As
long as there are homeless veterans who need them, beds in
state veterans homes should not remain empty simply due to the
unintended consequences of a federal regulation.
(Classified Veterans Access to Care Act)--The VFW supports
this legislation which would require VA to develop standards to
provide care for veterans who participate in sensitive missions
in a way that does not require them to improperly disclose
classified information. The VFW believes that this requirement
is reasonable and would ensure that veterans feel that they can
access the mental health services they need without violating
any non-disclosure responsibilities they may have.
(The Veterans Dialysis Pilot Program Review Act)--The VFW
supports this legislation. A May, 2012 GAO report found that VA
was planning to expand the dialysis pilot despite not having
developed adequate performance measures to evaluate the
existing locations. The purpose of any pilot program should be
to assess its strengths and weaknesses on a small scale before
deciding whether or not it should be expanded.
(The Appropriate Care for Disabled Veterans Act)--The VFW
supports this legislation which would reinstate the requirement
for VA to submit an annual report to Congress on its capacity
to provide for the specialized treatment and rehabilitative
needs of disabled veterans. The VFW believes that current
accurate data on VA capacity will greatly assist Congress in
conducting oversight on veterans access to care.
(The draft bill to authorize major medical facility
projects)--It is critical that VA is provided with the
authority to enter into the 27 major medical leases. Many of
these leases have been awaiting authorization for nearly two
years. These facilities provide direct medical care in the
community where veterans live and VA must enter into these new
leases to serve their needs. The VFW supports the provision
expanding VA's enhanced use lease authority, but VA must make
every effort to lease these unused or underutilized properties
for projects that directly support veterans and their families
before considering other leasing projects.
Mr. Chairman, this concludes my testimony and I look
forward to any questions you or other members of the committee
may have.
[The prepared statement of Aleksandr Morosky appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Morosky, for your
testimony. I will begin by yielding myself five minutes for
some questions. The question I had was about the appointment
schedule there or the timely access. Are there any provisions
of that legislation that you do support? I think, Mr. Morosky,
you were the most critical of that legislation.
Ms. Ilem. I think for DAV, I mean, we support the intent,
wanting to have timely access. I think we did have some concern
about legislating the seven-day and the 14-day requirements.
But I think for DAV the biggest thing was that to really
achieve these goals we felt that the core of the problem is the
scheduling package that is 30 years old and VA has testified on
that a number of times. So to achieve that things and correct
the deficiencies that I think they really want to get at, I
think that is the most important thing for us, that would be
included. But, you know, there are, I think the overall intent,
to improve access, we do not have a problem with.
Mr. Benishek. All right, great. Go ahead, Mr. Predeoux, do
you have a response?
Ms. Predeoux. Just to piggyback off what Ms. Ilem just
said. We agree with the intent. Our concern would just be
making sure that the VA has adequate tools to ensure that the
standards that are set are standards that are reasonable and
positively impact patient care deliver within the VA.
Mr. Benishek. Mr. Morosky, do you have any?
Mr. Morosky. And Mr. Chairman, we also support the intent.
It is mainly the seven- and 14-day requirement that we do not
support. You know, wait times result is another way of saying
access. And VA's plan for access right now is to develop its
appointment scheduling policy so that the wait times are
accurate and representative. They are not accurate and
representative right now. So to put a day number on it when
they are not accurately reporting what the wait times are may
be a bit too soon. It is also their physician staffing plans
that they are instituting across specialty care, that is part
of access. It is hard to have access if you do not have enough
providers. And third, they are just finishing rolling out their
PC3 program. And so all those things put together are going to
equal access and we certainly support the greatest level of
access. And we support the intent of this bill, which is to
provide that.
Mr. Benishek. Right. Right. Well we brought up this PC3
program, I have my own particular concerns about how that is
going to work. Because I am not sure what the level of payment
they are going to provide to providers and if people are
actually going to sign up now. Talking to the VA myself on
several occasions, they seem to think that it is all going to
go hunky-dory. But I do not know if that is actually going to
be the case, you know what I mean? Because I have not seen any
actual numbers of how many people have actually signed up. So I
am just so hesitant. And I understand your concern about
mandating in statute, a date and a time. But I do not see, all
the time that I have talked to VA and they say, ``well, we are
going to have it done.'' And then it never actually happens.
And we keep, bypassing deadlines and that. It is very
frustrating to me.
Let me switch topics a little bit. There was some concern
about H.R. 183, the Veterans Dog Training Therapy Act. The
statement for the record from the Wounded Warrior Project
equated H.R. 183 with a directed research program and states
that decisions to fund research initiatives, however appealing
as they may appear, should be based on peer review evaluation
process. Do you agree that the pilot program that would be
mandated by H.R. 183 amounts to directed research? Does anyone
have a comment on that?
Ms. Predeoux. I was not able to read the statement from the
Wounded Warriors. But as far as research, I can only imagine
that they are likening it to the fact that the VA, this is not
a traditional program in the area of mental health. And along
the lines of the comments that you made earlier from the first
panel, PVA supports this as an alternative, non-traditional
method for mental health care and dog therapy training. I am
not sure, we will definitely have benefits from it and it could
be considered research in some respects. But I am not sure I
agree with the statement that it is directed research.
Mr. Benishek. Mr. Morosky, I think the Veterans of Foreign
Wars in their written statement expressed concerns regarding
the potential use of, or kenneling service dogs at a VA medical
center could lead to some problems. Would you be supportive of
an amendments to H.R. 183 that would allow VA flexibility to
house and train service dogs off campus?
Mr. Morosky. Yes, we would. That along with allowing them
to go into community partnerships, like the Palo Alto VA
Medical Facility does with I believe it is called the Bergen
Canine Institute. We feel that has been very beneficial. It has
led to positive patient and provider responses. So with those
two things we would be supportive of this legislation.
Mr. Benishek. I think you heard that Mr. Grimm was, willing
to do that sort of thing. So I hope that you all can get
together and figure that out.
Mr. Morosky. Yes, sir. We will.
Mr. Benishek. I am out of time, thank you. Ms. Walorski, do
you have any questions for the panel? Or Ms. Brownley, sorry.
Ms. Brownley. Thank you, Mr. Chairman. You have asked a lot
of the questions that I was going to ask. But I think I will go
back again to H.R. 2661, and I concur that I agree with the
intent of the bill. I think I just wanted to ask, I hear what
the concerns are with regards to, you know, strict standards
and possibly encouraging some data manipulation and we would
not get the, you know, the accurate data that we all are
looking for which is a very small wait time and not a long one.
Do you think that that is still happening, that we have not
done enough oversight to correct it? I think that we do need an
automated system. We are not there yet. But I mean, do you see
this happening across the country in terms of not providing
accurate information?
Ms. Ilem. I think there has been, you know, continued
concern because of the limitations of the current IT system
that is in place, of what VA can actually do. I think the parts
of the bill that talk about making sure people are trained
properly and know the procedures and the policies is critical,
I mean, that is absolute. But without a system that is nuanced
for what they are really trying to capture today, I think
everybody, at the end of the day everybody wants to just be
sure we know are people waiting? They want to be sensitive in
certain areas if there is a backlog in a certain area for
certain procedures so that they can then transfer resources
into that area and the proper amount of staff. We do not want
to see VA just having to, you know, send people out of the
system unless it is absolutely necessary because they cannot
get a timely appointment. But to be more sensitive through
this, you know, through that type of a scheduling package that
they can really see do we have a wait list? Do we have a, and
we have not seen that. I mean, it has just been very, you know,
they have goals, they want to see people as quickly as
possible. And you know, but if you cannot meet those goals then
what happens? So I think, you know, the goal is to see is it a
lack of resources? Is it a lack of management issues? You know,
what is the problem in this particular area that we cannot get
people seen in a timely manner?
Ms. Brownley. Thank you. Anybody else have a comment on
that? Or I think----
Mr. Morosky. We mentioned the past sort of data
misrepresentation in our testimony as well. We hope that the VA
is not still doing that. We feel like they are trying to be
more open and honest and transparent about it. But we would not
want to impose such a strict standard on them that it sort of
almost encourages not necessarily data manipulation but as we
all know there are different ways to present data and you can
present data in a way that is more favorable to yourself or
that is maybe more apples to apples that everybody can
understand. We just want to make sure that they are being as
transparent as possible without the undue constraints of
unreasonable standards.
Ms. Brownley. Thank you. I did not have a chance to tell
Representative Grimm how much I support his bill. The VA will
state that, you know, training of dogs is sort of outside of
their purview. I am just wondering from your perspective
whether you agree, disagree with the VA's perspective on it?
Ms. Ilem. I would just note that, you know, VA seems to
have been more open in the past couple of years to the
complementary and alternative medicine and treatment options
for veterans and certainly that is what we are hearing. I mean,
especially with service animals. You know, we have heard such
great feedback from so many veterans saying, you know, this
helped me get off, you know, so much medication. I really, you
know, I have this connection with my service animal. It has
allowed me to get out and do things that, you know, I was not
able to do. So and we have also heard about, you know, the
therapeutic training, aspects of training an animal. So I mean,
if they are going to do it it would be nice to see if they can
see what, you know, some outcomes of that would be for
veterans. I mean, certainly we are hearing positive feedback
based on the program up in Palo Alto. So we would hope that,
and I see the problems that VA would, or challenges they would
face with having, as the bill is currently written. But I think
the amendments that have been suggested would be appropriate.
Ms. Brownley. Thank you. And just, well, I might have run
out of time but I will yield back.
Mr. Benishek. Thank you. Ms. Negrete-McLeod, do you have
any questions? In that case, we will excuse the second panel.
Thank you very much for your input. We may have some written
questions which we hope you will answer for us. So thank you
very much for your testimony.
At this time I will recognize the gentleman from California
Mr. Denham to present his legislation.
STATEMENT OF HON. JEFF DENHAM
Mr. Denham. Thank you, Chairman Benishek, Ranking Member
Brownley, and thank you to the panel as supporters of H.R.
4198, the Appropriate Care for Disabled Veterans Act. This
legislation has the support of the Paralyzed Veterans of
America, Veterans of Foreign Wars, and the Disabled American
Veterans, and I look forward to working with each of those
groups as this bill moves forward.
Mr. Chairman, as you know the number of disabled veterans
has been increasing at an alarming rate. The number of severely
disabled veterans is increasing even at a quicker rate. These
severely disabled veterans are suffering from a range of issues
from spinal cord injury, dysfunction, blindness, Traumatic
Brain Injury, or mental health disorders. Many require
prosthetic or orthotic and sensory aids and all need
specialized care in their communities.
It is the responsibility of this committee to ensure that
the VA is meeting the mission requirement. To ensure that the
veterans had the care they needed Congress mandated in the
beginning of 1996 that the VA maintain its capacity for the
specialized treatment and rehabilitative needs of disabled
veterans based on a number of specific measurements. For spinal
cord injuries in particular this capacity was to be measured by
the number of staffed beds and the number of full-time
employees available to provide care. The VA was also required
to report this information to Congress after it was reviewed by
the VA's Office of the Inspector General. Unfortunately this
report requirement has lapsed and consequently so has the VA's
adherence to the capacity standards required by Congress. As an
example, Paralyzed Veterans of America's testimony explains how
issues involving VA's capacity such as staffing directly
impacts daily bed censuses and thus creates access issues for
veterans who need comprehensive care.
With this bill we have the opportunity to restore and
modernize that reporting requirement so that this committee and
our partners in the VSO community maintain a thorough
understanding of the VA's ability to provide specialized care
across the Veterans Health Administration system. To that end I
welcome the testimony that we just heard. The American people
have provided extraordinary resources to the Department of
Veterans Affairs. It is our job to provide oversight of those
resources. We cannot provide the oversight necessary without
accurate information.
Mr. Chairman, thank you for letting me speak out of order.
[The prepared statement of Jeff Denham appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Denham. At this
point I will call up the third panel then. Joining us from the
Department of Veterans Affairs is Dr. Madhulka Agarwal, Deputy
Under Secretary for Health for Policy and Services. She is
accompanied by Mr. Philip Matkovsky, the Assistant Deputy Under
Secretary for Health for Operations and Management, and Renee
Szybala, the Acting Assistant General Counsel. Thank you all
for being here this morning. Dr. Agarwal, please proceed.
STATEMENT OF MADHULKA AGARWAL, M.D., M.P.H., DEPUTY UNDER
SECRETARY FOR HEALTH FOR POLICY AND SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY PHILIP MATKOVSKY, ASSISTANT DEPUTY UNDER
SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND
RENEE L. SZYBALA, ACTING ASSISTANT GENERAL COUNSEL, U.S.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF MADHULKA AGARWAL
Dr. Agarwal. Good morning, Chairman Benishek, Ranking
Member Brownley, and members of the subcommittee. We appreciate
your continued efforts to support and improve veterans health
care. Thank you for the opportunity to address the bills on
today's agenda and to discuss the impact of these bills on
VHA's health care operations. Joining me today are Mr. Philip
Matkovsky, Assistant Deputy Under Secretary for Health for
Operations and Management, and Ms. Renee Szybala, Acting
Assistant General Counsel.
I want to thank the subcommittee for the opportunity to
testify concerning the bills we support, starting with H.R.
2527. We fully support affording the same crucial benefits to
our National Guard and Reservists as others who have suffered
the indignity of military sexual trauma. VA is poised to begin
delivering services to the population as soon as this bill is
enacted.
Let me also assure the subcommittee that while we do not
yet have prepared views on H.R. 2974, our evaluation of the
bill is being done within the context of recognizing the
importance of this issue for these veterans. Likewise although
in draft form the major medical facilities projects bill would
authorize critically needed operations and we support it as
well.
With respect to the other bills on the agenda I want to
state at the outset that we support the intent behind many of
the provisions in these bills but have valid concerns that have
been highlighted in our testimony, and we ask the subcommittee
to reconsider them.
H.R. 183 requires a five-year pilot to evaluate using
service dog training programs to address post-deployment mental
health and PTSD symptoms and produce specially trained service
dogs for veterans. VA is fully committed to effective and
proven treatment modalities as well as to alternative
therapies, especially for veterans suffering from mental health
disorders including PTSD. However, VA does not support H.R. 183
as written. This Bill contains a high number of requirements
related to selection and training of the proposed service dogs.
The bill requires a specialized and rigorous training
methodology for these service dogs which exceeds the competence
and expertise in VHA.
We have concerns about H.R. 2661. This bill seeks to
identify specific standards with respect to appointment
scheduling and access to VA services. VA is fully supportive of
systems and organizational processes that promote a culture of
excellence and accountability. However, H.R. 2661 does not
provide the critical flexibility that is needed to manage
clinical acuity, resources, and patient preferences for
appointment scheduling. VA looks forward to continuing our
ongoing and active engagement with the subcommittee and other
members in this very important area.
Another bill which we cannot support as written is H.R.
3508. This bill seeks to clarify qualifications for hearing aid
specialists within the department. We believe the clinical
expertise that is already provided in the department by our
audiology health technicians working under the supervision of
our professional audiologists can provide the necessary
services that this bill seeks to require. Should VA need to
leverage the capabilities of hearing aid specialists the
Secretary already has the legal authority to appoint such
individuals.
H.R. 3831 would prohibit VA from expanding the free
standing dialysis pilot programs and prohibit the creation of
any new dialysis capability provided by VA. VA plans to brief
our congressional committees on the results of the dialysis
pilot program before establishing any new free standing
dialysis center. However, restricting our ability to create
needed capacity in our super CBOCs or in our replacement
hospitals, or the new medical centers that are planned to be
activated soon would negatively impact our ability to deliver
services to veterans who need dialysis at these sites.
Finally we do not believe that H.R. 3180 as drafted has
application in the current contracting environment for state
homes. We also have concerns about the potential impact on our
residential settings.
In the time allotted to prepare for this hearing we were
not able to complete our views and testimony on the remaining
two bills. Thank you for the opportunity testify before you
today. My colleagues and I will be pleased to respond to
questions that you have, or other members may have for us.
Thank you.
[The prepared statement of Madhulka Agarwal appears in the
Appendix]
Mr. Benishek. Thank you for your testimony, Dr. Agarwal. I
will yield myself five minutes for questions. I hope that you
will submit answers or some comments on the other legislation
that you say you have not had time to do that----
Dr. Agarwal. Yes sir, we will.
Mr. Benishek [continuing]. In the near future. So I would
appreciate that. I understand Mr. Duffy's reason for his
legislation about the audiology component. Have you done any
studies about, his concern with waiting, waiting 6 months to
get care and the timeline? Are you trying to hire more
audiologists? What is the story with that whole problem?
Dr. Agarwal. So thank you again for an opportunity to
clarify certain issues related to the wait times, both for the
hearing aids that would be delivered to our veteran patients as
well as to be able to see an audiologist in the clinic. We have
taken actions on both fronts. So let me just describe what had
happened about the hearing aid delivery to our veteran patients
that had gone in for repairs. There had been vacancies in the
Denver Acquisition Logistics Center for a long period of time,
which has been rectified. And the delivery times for those
repairs are back to our standards.
As for the hearing services wait times in the audiology
clinics, various actions have been taken. First of all the
number of audiologists and support staff have been increased.
The number of sites of care where we provide audiology services
has also been increased. We are increasingly providing
teleaudiology services, the sites, if I can recall correctly,
are going up from 25 sites to up to 71 sites by the end of this
year largely in the rural communities. We are also looking to
provide these hearing services with non-VA services, the fee
care contracts, as well as we are looking at the overall
systems we design of the hearing services, to see how we can
manage our demand and capacity better.
Mr. Benishek. It is my understanding that hearing loss and
tinnitus is one of the largest claims for medical disability
among returning veterans now. It definitely needs a ramp up. I
appreciate what you said here. I did not quite analyze it in my
brain as fast as you said it, the implications of all that. We
would like to look at that a little bit better but I appreciate
that.
My other question is about the dialysis pilot program that
Dr. Roe's talked about. I still do not understand. He, as I
understand it, he thinks that we should analyze the results of
the pilot program before moving along to, building more
centers. I am sort of familiar with dialysis and that most
dialysis in the country now is done through, local dialysis
centers. And it just seems to me that supporting that access is
better than VA having another access point in the same
community, as there already may be services. So I am just a
little concerned about that duplication there. Am I incorrect
in that assumption? Because people who are getting dialysis now
are getting dialysis now, it is just they are getting paid by
different sources. I was in a situation where in my local area
there were two dialysis centers, one at VA and one at the other
community hospital. So that did not make much sense having two
different dialysis centers. And I just seem to think that, VA
supporting a local dialysis center person makes a little more
sense than having another one in VA. Can you give me your
thoughts on that?
Dr. Agarwal. Sure. So sir, currently VA overall provides
dialysis to 17,000 veteran patients. Of that, only 20 percent
of it is done in house in our medical centers.
Mr. Benishek. Right.
Dr. Agarwal. We have 65 facilities that offer dialysis
service in the, as you probably have noted, in our medical
centers. Not everyone provides it.
Mr. Benishek. Right.
Dr. Agarwal. The other 80 percent is of course non-VA care
through different contracts.
Mr. Benishek. Right.
Dr. Agarwal. The pilot that we were referencing earlier was
started in 2010 and the intention here is to look at four
aspects. First of all is the quality of care, the access to
care, veteran satisfaction, as well if they are cost effective.
So that component of the pilot, sir, we will be completing that
evaluation because there was a certain delay in two of those
centers, in the next couple of years and we will submit the
evaluation to Congress before we will proceed with expanding
any free standing units.
However, we have certain medical centers that are going to
be activated this year, Orlando being one example. And they
have ten regular dialysis stations and one isolation. There is
a super CBOC in Green Bay, Wisconsin that also has, it has been
planned to have several regular dialysis stations there as well
as a couple of replacement hospitals. So with this bill it
would restrict our ability to expand on what has been planned
for quite some time during the construction phase.
Mr. Benishek. All right, thank you. I am out of time. Ms.
Brownley, do you have any questions for the panel?
Ms. Brownley. Just quickly, thank you, Mr. Chair. I wanted
the panel to just if they could briefly comment on H.R. 3387,
which is Representative Sinema's bill on Classified Veterans
Access to Care Act. And I do not think that you commented on it
in your testimony. And just if you could share your sort of
initial response or feelings towards the bill? And do you
recognize it as a problem? I would imagine hopefully there are
not too many cases across the country where suicide was the
ultimate outcome, but I would imagine that there are quite a
few people who were in classified positions who may not have
access to the appropriate mental health care. So if you could
just comment I would appreciate it.
Dr. Agarwal. So Ranking Member Brownley, thank you for that
question. It was a very compelling testimony and I have heard
of this case of Mr. Somers before. And I will sort of
personally say that, you know, the fact that we need to provide
services in the context of what information the veterans can
provide to us. So that is the first goal. Our strategic goal,
which is to be proactive to offer personalized and patient
drive services I think also is in line with this legislation.
But it has got to be done, within that context, that if someone
is not ready for group therapy, then we need to offer the kind
of services that sort of fit their needs and no one else's. So
I do not know if I am on the right track. But clearly I think
the intent is going to be well supported. And if we need to
provide more education and guidance to our clinicians, we will
do so.
Ms. Brownley. Thank you. And I also wanted to ask briefly
on your draft bill, I think part of the bill, the draft
legislation to authorize the major medical facilities projects
includes in Section 4 amendments that modify the definition of
the medical facility. If you could comment on that? And if you
could also explain how some of these amendments will assist the
VA in their construction of medical facilities and why the need
for the transfer authority that you have requested.
Dr. Agarwal. I am going to ask my colleague Philip
Matkovsky to answer that.
Ms. Brownley. Thank you.
Mr. Matkovsky. Some of them are sort of technical
adjustments in Section 4, and then there is an element which
allows us to use certain funds in design. In the current
practice we have been, you know, seeking appropriation of funds
off a prospectus and the Secretary has instituted something
that is called the Construction Review Council. Mr. Hagstrom is
our, sort of presides over our construction portfolio. And we
have adjusted the practice so that we are going to a 35 percent
design which gives us a much more accurate picture of the scope
of the project prior to requesting appropriation of funds. But
in order to accomplish that we need to be able to sort of
redirect certain funds to get to the 35 percent design.
I think it is a good idea. It is a little bit hard to have
a perfectly accurate estimate on something that is a few-page
prospectus. Having 35 percent designs gives us a much more
valid estimate to bring to this committee for authorization of
funds.
Ms. Brownley. Can you comment on some of the technical
adjustments?
Mr. Matkovsky. In a couple of cases here we are looking at
definition for a major medical facility lease as it relates to
some of the lease issues that we have had. But some of them I
will have to take for the record as I am not terribly
proficient on them. Sorry.
Ms. Brownley. Thank you. I will yield back.
Mr. Benishek. Thanks, Ms. Brownley. Mr. Denham, five
minutes for questions.
Mr. Denham. Thank you, Mr. Chair. Dr. Agarwal, do you
support the legislation that I proposed here, H.R. 4198?
Dr. Agarwal. This is 3180, sir.
Mr. Denham. 4198.
Dr. Agarwal. 4198. Okay. This is the capacity?
Mr. Denham. Reporting requirements.
Dr. Agarwal. So we have to provide you the formal views of
the department. But as a concept I will tell you that the
capacity report as I have seen it from 2008 provided detailed
information on the availability of beds, as well as services
for many of our program areas, spinal cord injury
rehabilitation, mental health, and so on. So in general I think
it is very important to know what the capacity is. So in that
of course we agree that, you know, it should be supported.
However, health care delivery has also evolved over time and
there are many services that were provided way back in 1996
have sort of changed their scope. So I think it is going to be
important to make sure that the metrics for each of these
programs is appropriate.
Mr. Denham. So is that an excuse on why the reporting is
not being done today? Because they have changed?
Dr. Agarwal. Sir, I would not say that this----
Mr. Denham. So how long does it take you to support a bill?
To get authorization back from the agency?
Dr. Agarwal. Sir, I am going to defer it to my right.
Ms. Szybala. We just got too many bills.
Mr. Denham. Too many bills? Yes, we have too many committee
hearings, too fast.
Ms. Szybala. I understand.
Mr. Denham. And even though we only get your testimony the
night before we still find time to prepare questions and be
prepared for the committee hearing. This bill has been in print
for over two weeks. So we would expect a response, I think,
that our disabled veterans would expect a response. How do you
respond to the testimony of the PVA which states that staffing
vacancies are creating access issues for severely disabled
veterans?
Dr. Agarwal. Sir, that is something that we take very
seriously. We have regular meetings with PVA on those reports
and PVA also does oversight of our facilities very closely.
Mr. Denham. So do you think the VA is meeting its
requirement, its capacity requirements for the specialized
care?
Dr. Agarwal. So generically I believe that we are. But if
there are certainly instances where we are not then we would
love to find those out and we will be having those discussions
with PVA.
Mr. Denham. Well, that is fantastic. We would love to find
that out, too, which is why we want that 1996 reporting
requirement back to Congress. That is an important reporting
requirement that we feel that Congress not only should mandate
but we ought to actually get that information so we know
whether you are doing your job.
Dr. Agarwal. Sir, as I previously stated we certainly
support the intent. But I think we need to also have the
appropriate metrics.
Mr. Denham. And when can you provide what those metrics
would be back to this committee?
Ms. Szybala. I do not know----
Mr. Denham. I do not know is not a good answer for us to
take back to our constituents.
Ms. Szybala. I do understand that. But health care has
evolved so that beds is not a metric now for everything. We do
telehealth. We have CBOCs----
Mr. Denham. I understand. But the question here is there is
a reporting requirement. Congress is going to continue to
mandate that reporting requirement. If you are telling us that
there needs to be new metrics in place, we would ask what do
you think those metrics should be? And I do not know is not a
good answer.
Ms. Szybala. Well, I understand. I mean I think we provide
technical assistance when asked to feed into that----
Mr. Denham. Okay. So if you are telling us that new metrics
needs to be in place, how long will it take you to come back to
this committee with what those new metrics are?
Ms. Szybala. I cannot give you a date. I cannot.
Mr. Denham. Can you give us an estimation?
Ms. Szybala. I really, I think that is ill-advised. It is
too many facets of VA get involved. And it is hard to control.
So all I can say----
Mr. Denham. Telling a disabled veteran that has come back
from serving in our military that they may have to wait because
we do not know is not an acceptable answer. So this committee
will be providing a list of questions so that we can get back
those answers in writing on what those metrics should, what the
timeline would be, and what the reporting requirements will be.
Ms. Szybala. And we will get it all to you as fast as we
can.
Mr. Denham. Thank you. I yield back.
Mr. Benishek. Dr. Agarwal, the subcommittee will be
submitting additional questions for the record. I would
appreciate your assistance in ensuring an expedient response to
these inquiries. If there are no further questions, then the
third panel is excused. I ask unanimous consent that all
members have five legislative days to revise and extend their
remarks and include extraneous material. Without objection, so
ordered.
I would like to thank again all of our witnesses and the
audience members for joining us this morning. The hearing is
now adjourned.
[Whereupon, at 10:34 a.m., the subcommittee was adjourned.]
APPENDIX
Prepared Statement of Chairman Dan Benishek
Good morning and thank you all for joining us today to discuss
pending legislation regarding the health care benefits and services
provided to our nation's veterans through the Department of Veterans
Affairs (VA).
The ten bills we will discuss this morning are:
H.R. 183, the Veterans Dog Training Therapy Act;
H.R. 2527, to provide veterans with counseling and treatment for
sexual trauma that occurred during inactive duty training;
H.R. 2661, the Veterans Access to Timely Medical Appointments Act;
H.R. 2974, to provide beneficiary travel eligibility for veterans
seeking treatment or care for military sexual trauma;
H.R. 3387, the Classified Veterans Access to Care Act;
H.R. 3508, to clarify the qualifications of VA hearing aid
specialists;
H.R. 3180, to provide an exception to the requirement that the
Federal Government recover a portion of the value of certain projects;
H.R. 3831, the Veterans Dialysis Pilot Program Review Act;
H.R. 4198, the Appropriate Care for Disabled Veterans Act; and,
Draft legislation, to authorize VA major medical facility projects
for fiscal year 2014.
By and large, these ten bills aim to address two of this
Subcommittee's highest priorities: (1) Ensuring that our veterans have
access to the care that they need; and, (2) ensuring that VA is held
accountable when that care fails to meet the high standards that it
should.
Some of these bills--such as H.R. 2527 and H.R. 2974, which aim to
resolve gaps in care for veterans who have experienced military sexual
trauma--address issues that have been raised through Subcommittee
oversight.
Others--such as H.R. 2661, H.R. 3508, and H.R. 3831, which concern
lengthy patient waiting times, access to care for hearing-impaired
veterans, and ongoing issues with the provision of dialysis care--
address issues that were raised through external stakeholder reviews by
the VA Inspector General and the Government Accountability Office.
Still others--such as H.R. 183 and H.R. 4198, which concern the
need for innovative treatment options for veterans with post-traumatic
stress disorder and the need to ensure that VA maintains adequate
capacity to provide for the unique health care needs of disabled
veterans--address issues that were raised by our veteran constituents
and veterans service organizations.
One other--the draft legislation to authorize VA major medical
facility projects for fiscal year (FY) 2014 and, of note, authorize the
construction of a new bed tower at the James A. Haley Veterans'
Hospital in Tampa, Florida--is the Department's own legislative
request.
I would note that VA's FY 2015 budget submission includes five
additional lease authorization requests that are not included in the
draft bill we will discuss this morning.
While I recognize the value of those five lease authorization
requests--which would certainly be included in future VA major medical
facility lease authorization packages moving through the Committee--I
felt it was important to thoroughly analyze and receive stakeholder
views on the Department's FY 2014 request.
As you may know, last fall the House passed H.R. 3521, the
Department of Veterans Affairs Major Medical Facility Lease
Authorization Act of 2013, which would authorize 27 VA major medical
facility leases requested by the Department in the FY 2014 budget
submission.
It is my sincere hope that H.R. 3521 will be passed through the
Senate and quickly signed into law.
I would like to express my gratitude to my colleagues who have
sponsored the legislation on our agenda today and who are joining us
this morning to discuss their proposals.
I would also like to thank our witnesses from the Disabled Veterans
of America, the Paralyzed Veterans of America, and the Veterans of
Foreign Wars, as well as the witnesses from the VA for their leadership
and advocacy on behalf of our veterans and for being here today to
offer their views.
It is critical that we have a thorough understanding of the
benefits and consequences of each of these bills before moving forward
in the legislative process and, as such, I look forward to a detailed
and comprehensive conversation.
Prepared Statement of Hon. Michael G. Grimm
Chairman Benishek, Ranking Member Brownley, thank you for allowing
me to testify today on H.R. 183, the ``Veterans Dog Training Therapy
Act,'' a bill I introduced along with my friend the Ranking Member of
the House Veterans Affairs Committee, Congressman Michaud. As a Marine
Combat Veteran of Operation Desert Storm it is a unique honor for me to
address this committee. Having seen firsthand both the physical and
mental wounds of war that the members of our nation's military are
faced with, I have a special appreciation for the important work this
committee does every day.
Today, millions of Iraq and Afghanistan Veterans have returned home
to the challenge of a stagnant economy, high unemployment rate, and,
for many, the long road to recovery from the mental and physical wounds
sustained during their service.
During my time in Congress I have had the honor to meet with a
number of our nation's veterans who are now faced with the challenges
of coping with PTSD and physical disabilities resulting from their
service in Iraq and Afghanistan. Their stories are not for the weak of
heart and are truly moving. It was these personal accounts of recovery,
both physical and mental, and the important role therapy and service
dogs played in that process, that inspired this legislation.
The Veterans Dog Training Therapy Act would require the Department
of Veterans Affairs to conduct a five-year pilot program in at least
three but not more than five VA medical centers assessing the
effectiveness of addressing post-deployment mental health and PTSD
through the therapeutic medium of training service dogs for veterans
with disabilities. These trained service dogs are then given to
physically disabled veterans to help them with their daily activities.
Simply put, this program treats veterans suffering from PTSD while at
the same time aiding those suffering from physical disabilities. When I
originally introduced this legislation in the 112th Congress both the
House Veterans Affairs Committee and the full House of Representatives
passed it with overwhelming bipartisan support.
Additionally, with high veteran suicide rates and more servicemen
and women returning from deployment being diagnosed with PTSD, this
bill meets a crucial need for additional treatment methods. I believe
that by caring for our nation's veterans suffering from the hidden
wounds of PTSD while at the same time providing assistance dogs to
those with physical disabilities we create a win-win for everyone,
which I believe is a goal we can all be proud to accomplish.
Working in conjunction with a number of Veteran Service
Organizations, I have drafted updated language which mirrors changes
made to this legislation in the 112th Congress, and I hope to work with
the committee during markup of H.R. 183 to ensure this program provides
our nations veterans with the highest quality care for both PTSD and
physical disabilities, while maintaining my commitment to fiscal
responsibility.
Again, I would like to thank the committee for holding today's
hearing and I look forward to working with you to ensure that this
program is included in your continuing efforts to guarantee that our
nation's heroes have the best possible programs for treating PTSD and
providing disability assistance.
Prepared Statement of Hon. Dina Titus
Chairman Benishek, Ranking Member Brownley, fellow members of the
Committee.
Thank you for including my bill H.R. 2527, the National Guard
Military Sexual Trauma Parity Act on today's agenda. This bipartisan
legislation addresses an unacceptable gap in current law that
effectively leaves certain victims of sexual assault without the
support and treatment that they need.
Members of the National Guard and other reserve components of the
armed services have fought bravely for our country, many completing
multiple tours of duty in Iraq and Afghanistan. Since September 11th,
more than 50,000 Guardsmen and Guardswomen have been called to service,
both at home and abroad.
We recognize the great importance of the National Guard and other
reserve components, and thank them for their service. Members of the
National Guard or other reserve components who are the unfortunate
victims of sexual assault while on active duty are, like members of the
other armed forces, provided all the resources and services they need
to recover and heal, physically and emotionally. This treatment is
provided by the VA for free for as long as is needed. This is the very
least that we can do.
These benefits, however, are not offered to members of the National
Guard or other reserve components who experience sexual assault while
on inactive training missions. For example, Members of the Guard are
required to participate in training missions one weekend a month and
two weeks a year. This oversight is simply unacceptable, and leaves so
many who have served our country without assistance or support during a
devastating time.
The National Guard Military Sexual Trauma Parity Act would fix this
omission and clarify that all victims of sexual trauma in the National
Guard or other reserve components have access to the resources and
services they need whether they are on active duty or on a required
training mission.
We must make it a priority to change the culture of the military
and put an end to acts of sexual trauma within our armed services.
Until we do, however, we must provide victims with the care that they
need and deserve.
I want to thank many of the Veteran Service Organizations for their
support and appreciate that this subcommittee will consider this
important legislation creating parity for the brave men and women in
the National Guard and other reserve components.
Prepared Statement of Hon. Jackie Walorski
Good morning, Chairman Benishek, Ranking Member Brownley, and
members of the Committee. Thank you for the opportunity to discuss H.R.
2974, a bill making victims of military sexual trauma (MST) eligible
for Department of Veterans Affairs (VA) beneficiary travel benefits.
According to the Department of Veterans Affairs, 1 in 5 women, and
1 in 100 men screen positive for military sexual trauma (MST).\1\ The
VA provides counseling, care, and services to veterans and certain
other servicemembers who may not have veteran status, but who
experienced MST while serving on active duty or active duty for
training.\2\ VHA policy \3\ states that ``veterans and eligible
individuals who report experiences of MST, but who are deemed
ineligible for other VA health care benefits or enrollment, may be
provided MST-related care only. This benefit extends to Reservists and
members of the National Guard who were activated to full-time duty
status in the Armed Forces. Veterans and eligible individuals who
received an `other than honorable' discharge may be able to receive
free MST-related care with the Veterans Benefits Administration
Regional Office approval''.
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\1\ Department of Veterans Affairs, National Center for PTSD,
Military Sexual Trauma Fact Sheet, September 2013 http://
www.mentalhealth.va.gov/docs/mst-general-factsheet.pdf.
\2\ U.S. Code, Title 38, Section 1720D, 1992.
\3\ VHA Directive 2010-033, Military Sexual Trauma (MST)
Programming, July 14, 2010.
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Every VA Medical Center (VAMC) offers evidence-based therapy for
conditions related to MST, and has providers knowledgeable about
treatment for the aftereffects of MST.\4\ Nationwide there are almost
two dozen programs that offer specialized treatment in residential or
inpatient settings. All health care for treatment of mental and
physical health conditions related to MST, including medications, is
provided free of charge. Fee basis is available when it is clinically
inadvisable to provide counseling in a VA facility, when VA facilities
are geographically inaccessible, or when VA facilities are unable to
provide care in a timely manner.\5\ Overall, while VA has taken the
appropriate steps to provide counseling services for victims of MST,
these services need to be more accessible.
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\4\ McCutcheon, SJ and Pavao, J; Military Sexual Trauma Support
Team, VA Office of Mental Health Services, National Training Summit on
WomenVeterans; ``Resources for Military Sexual Trauma (MST)
Survivors,'' PowerPoint, 2011.
\5\ Department of Veterans Affairs Office of Inspector General.
health care Inspection Report No. 12-03399-54, Inpatient and
Residential Programs For Female Veterans with Mental Health Conditions
Related to Military Sexual Trauma, December 5, 2012. Retrieved from
http://www.va.gov/oig/pubs/VAOIG-12-03399-54.pdf.
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MST-related care must be provided in a setting that is
therapeutically appropriate, taking into account the circumstances that
resulted in the need for such care. A supportive environment is
essential for recovery. Thus, VA policy states that any veteran with
MST must receive clinically appropriate care regardless of location.
Veterans being treated for conditions associated with MST are often
admitted to programs outside their Veterans Integrated Service Network.
VA health care in general, especially for women, has been characterized
as fragmented.\6\ Patients with special \7\ needs who are unable to
access the services they need from their local providers are referred
elsewhere, and oftentimes have to travel long distances to receive such
services. According to a 2012 VA Inspector General report, obtaining
authorization for travel funding was frequently cited as a major
problem for both patients and staff. \8\ The beneficiary travel policy
indicates that only certain categories of veterans are eligible for
travel benefits, and payment is only authorized to the closest facility
providing a comparable service. \9\
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\6\ Washington DL, Yano, EM, Simon B, and Sun S. 2006. To Use or
Not to Use: What Influences Why Women Veterans Choose VA Health Care. J
Gen Intern Med, 21(Suppl 3): S11-S18.
\7\ Bean-Mayberry B, Chang CC, McNeil M, Hayes P, Scholle SH. 2004.
Comprehensive care for women veterans: indicators of dual use of VA and
non-VA providers. J Am Med Womens Assoc, 59(3): 192-7.
\8\ Department of Veterans Affairs Office of Inspector General.
health care Inspection Report No. 12-03399-54, Inpatient and
Residential Programs For Female Veterans with Mental Health Conditions
Related to Military Sexual Trauma, December 5, 2012. Retrieved from
http://www.va.gov/oig/pubs/VAOIG-12-03399-54.pdf.
\9\ VHA Handbook 1601B.05, Beneficiary Travel, July 23, 2010.
---------------------------------------------------------------------------
The current beneficiary travel policy contradicts VA's MST policy,
which states that patients with MST should be referred to programs that
are clinically indicated regardless of geographic location. A veteran
should never have to choose to skip treatment for conditions related to
MST due to distance or a lack of transportation.
I applaud VA's commitment to an effective program that provides
counseling and treatment to men and women in need of help in overcoming
the physical and psychological stress associated with MST. However, VA
is not doing enough to help veterans access these important resources
and services. Survivors of MST should not feel re-traumatized and
helpless because of geographic barriers to treatment.
Representative Kuster and I introduced H.R. 2974 to make victims of
MST eligible for VA beneficiary travel benefits. By better aligning the
beneficiary travel policy with VA's current policy for responding to
veterans who have experienced MST, H.R. 2974 ensures appropriate
services are more readily available to meet the treatment needs of our
nation's veterans. I am grateful to work with Representative Kuster and
the committee in addressing this critical issue for the survivors of
military sexual trauma. I thank you again for this opportunity to speak
today.
Prepared Statement of Hon. Sean Duffy
Good morning. Thank you, Chairman Benishek and Ranking Member
Brownley for holding this hearing today. I appreciate the opportunity
to testify on behalf of H.R. 3508, legislation I introduced to help
address the long wait times and lack of access our Veterans are facing
in regard to hearing health.
Our aging and younger veterans returning from the battlefield are
seeking help from the VA for hearing loss more than any other
disability facing them today. The demand for audiology services is
growing at nearly 10% per year. Because of this increased demand, the
VA can't keep up.
Veterans across the US are being forced to wait weeks or even
months for an appointment, Veterans like my constituent Roger from
Marshfield. Roger is 70 years old and a Veteran of the Vietnam War. He
suffers from hearing loss, and when he sought help from the VA, he was
told he could not get an appointment for six months. Unfortunately,
Roger couldn't wait that long, so he went to his local hearing aid
specialist--and he was seen that day. Roger was willing to pay out of
pocket for his hearing aids because six months was just too long to
wait.
This situation is because today the VA is only allowed to use
Doctors of Audiology to provide hearing services to Veterans. While
audiology doctors are a great resource for the VA and provide adequate
service for Veterans, there are not enough to keep up with the demand
and needs of people like Roger.
Hearing aid specialists have gone through a 1-2 year apprenticeship
training period, have completed a comprehensive written exam, and are
certified by the state to fit and sell hearing aids. They are very
qualified to support the specialized services of Audiology doctors by
fitting, adjusting, and making minor repairs to hearing aids, helping
to relieve the current burden Audiologists have of performing all
hearing services for the VA. With the provisions of my bill in place,
VA Audiologists can turn their attention to specialized cases and
complex conditions, and people like Roger won't be waiting six months
for hearing aids.
A recent Office of Inspector General report supported these
findings: 42 percent of Veterans waited more than 30 days from the time
the medical facility received the hearing aids to the time they were
mailed back to the Veteran and blames the delay in repairs on staff
vacancies and an increase in workload. My bill would also allow the VA
to fill those staff vacancies with specialists certified for adjusting
and repairing hearing aids.
H.R. 3508 has the support of the Iraq and Afghanistan Veterans of
America, the International Hearing Society, VetsFirst, Blinded Veterans
Association, and American Veterans.
As Americans, we can never repay our debt to Veterans like Roger,
but Congress can pass common-sense measures like H.R. 3508 to help make
their lives back home a little easier. I urge the Committee to pass my
legislation quickly and appreciate your support today.
I yield back the balance of my time.
Prepared Statement of Hon. Marcy Kaptur
Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee, I appreciate the Subcommittee's consideration today of
H.R. 3180, and thank you for the opportunity to submit testimony on
this important legislation.
This bill takes a critical step to address a most unfortunate
epidemic of homelessness among our veterans. The U.S. Department of
Housing and Urban Development estimates that nearly 60,000 veterans are
homeless on any given night, including more than 12,000 veterans of our
most recent military involvements. Moreover, about 1.4 million veterans
are considered at risk of homelessness.
In a prosperous nation such as ours, this is simply unacceptable.
These men and women who did so much in service to our nation deserve
better. The U.S. Department of Veterans Affairs does provide critical
services for our homeless veterans and indeed, all who served. Still,
many slip through the cracks.
H.R. 3180 would provide help to ensure that number is lower. This
legislation is intended to remove the barriers faced by State Veterans
Homes in running homeless veterans programs. Many State Homes operate
with continued vacancies--beds that could be filled by homeless
veterans. Unfortunately, federal requirements can hinder these efforts.
By providing an exemption for State Homes that receive a contract
or grant from VA for residential care programs, including homeless
veterans programs, we remove disincentives to State Homes to offer
homelessness services.
This provision places no requirements on VA to award special
treatment in grants and contracts. Nor does it take away from the base
services of State Homes in favor of homelessness programs. It simply
puts State Homes on a level playing field with other groups providing
homeless veterans programs.
As we wind down our military involvements overseas, we face a
renewed need to provide the services our veterans have earned. We
should be doing everything we can to ensure these services are provided
efficiently and effectively. Especially in the tight fiscal constraints
we currently face, we must ensure that we are not wasting precious
resources. H.R. 3180 takes an important step in that direction and I
urge continued favorable consideration of the bill.
Thank you again Mr. Chairman and Members of the Subcommittee.
Prepared Statement of Hon. Kyrsten Sinema
Thank you Chairman Benishek and Ranking Member Brownley for holding
this legislative hearing.
Thank you to my colleagues who introduced important bills to
improve the quality of care available to veterans, especially
Congresswoman Walorski's legislation, H.R. 2974, to make travel
assistance available for veterans seeking care for military sexual
trauma.
I am here to discuss H.R. 3387, the Classified Veterans Access to
Care Act--thank you Chairman Benishek for helping me to introduce this
bipartisan bill.
The Classified Veterans Access to Care Act ensures that veterans
with classified experiences can access appropriate mental health
services at the Department of Veterans Affairs.
I am working on this issue because last year a military family in
my district--the family of Daniel Somers--was devastated when Daniel
failed to receive the care he needed and committed suicide.
No veteran or family should go through the same tragedy that the
Somers family experienced.
Daniel Somers was an Army veteran of two tours in Iraq. He served
on Task Force Lightning, an intelligence unit. He ran over 400 combat
missions as a machine gunner in the turret of a Humvee. Part of his
role required him to interrogate dozens of terrorist suspects, and his
work was deemed classified.
Like many veterans, Daniel was haunted by the war when he returned.
He suffered from flashbacks, nightmares, depression, and additional
symptoms of Post-Traumatic Stress Disorder, made worse by a traumatic
brain injury. Daniel needed help. He and his family asked for help the
best way they knew how.
Unfortunately, the VA enrolled Daniel in group therapy sessions,
which Daniel would not attend for fear of disclosing classified
information. Despite requests for individualized counseling, or some
other reasonable accommodation to allow Daniel to fully share what gave
him nightmares, VA delayed providing Daniel with appropriate support
and care.
Like many, Daniel's isolation got worse when he transitioned to
civilian life. He tried to provide for his family, but he was unable to
work due to his disability. Daniel struggled with the VA bureaucracy;
his disability appeal had been pending for over two years in the system
without any resolution. Daniel didn't get the help he needed in time.
On June 10, 2013, Daniel wrote a letter to his family. It begins:
I am sorry that it has come to this.
The fact is, for as long as I can remember my motivation for
getting up every day has been so that you would not have to bury me. As
things have continued to get worse, it has become clear that this alone
is not a sufficient reason to carry on. The fact is, I am not getting
better, I am not going to get better, and I will most certainly
deteriorate further as time goes on. From a logical standpoint, it is
better to simply end things quickly and let any repercussions from that
play out in the short term than to drag things out into the long term.
He goes on to say:
I am left with basically nothing. Too trapped in a war to be at
peace, too damaged to be at war. Abandoned by those who would take the
easy route, and a liability to those who stick it out--and thus deserve
better. So you see, not only am I better off dead, but the world is
better without me in it.
This is what brought me to my actual final mission.
Daniel's parents, Howard and Jean, were devastated by the loss of
their son, but they bravely shared Daniel's story and created a mission
of their own. Their mission is to ensure that Daniel's story brings to
light America's deadliest war--the 22 veterans that we lose every day
to suicide.
My office worked closely with Howard and Jean to develop the
Classified Veterans Access to Care Act so that veterans know they can
seek and receive comprehensive mental health care from the VA,
regardless of the classified nature of their military experiences.
Our bill directs the Secretary of the VA to establish standards and
procedures to ensure that a veteran who participated in a classified
mission or served in a sensitive unit may access mental health care in
a manner that fully accommodates the veteran's obligation to not
improperly disclose classified information.
It also directs the Secretary to disseminate guidance to employees
of the Veterans Health Administration, including mental health
professionals, on such standards and procedures and on how to best
engage such veterans during the course of mental health treatment with
respect to classified information.
Finally, the bill directs the Secretary to allow veterans with
classified experiences to self-identify so they can quickly receive
care in an appropriate setting.
Our legislation is supported by the Retired Enlisted Association,
the Association of the United States Navy, and the Iraq and Afghanistan
Veterans of America.
As the Iraq and Afghanistan Veterans of America states in its
letter of support, ``these reforms to mental health treatment are
necessary to provide safe and inclusive care for all veterans.''
I look forward to continuing to work with the Committee to ensure
that no veteran feels trapped like Daniel and that all our veterans
have access to the necessary mental health care they need and deserve.
By working together, and using the strength that the Somers family
shows every day, we can end the scourge of veteran suicide, and ensure
that veterans and their families have the care they need and deserve.
Again, thank you Chairman Benishek and Ranking Member Brownley for
including H.R. 3387, the Classified Veterans Access to Care Act in
today's hearing. I welcome any questions you may have.
Prepared Statement of Hon. Phil Roe, MD
Mr. Chairman, it is my pleasure to present H.R. 3831, the Veterans
Dialysis Pilot Program Review Act, to my colleagues on this
subcommittee. This bill would prevent the Veterans Health
Administration (VHA) from rolling out new in-house dialyses centers
until an independent review of the VHA Dialysis Pilot Program has been
completed.
In 2009, the Secretary of Veterans Affairs launched the VHA
Dialysis Pilot Program, creating four test sites at outpatient VA
clinics to see if quality dialysis treatment could be delivered to
veterans in house at a lower cost than contracting care out to
commercial dialysis treatment centers. A 2012 GAO report, which I ask
to be inserted into the record, shows that the early implementation of
the Dialysis Pilot Program has shown many weaknesses, including
erroneous cost estimation practices and cost savings calculations. The
Department of Veterans Affairs (VA), however, is moving to expand the
in-house dialysis program nationally--before a review of the pilot has
been performed. In fact, VA is still contracting for an independent
analysis of how well it is working.
H.R. 3831 would simply direct the Secretary of Veterans Affairs to
halt the establishment of any new VA dialysis clinics until each of the
four original pilot sites has been operating for two years, an
independent analysis of the sites is conducted, and a full report has
been submitted to Congress. The intent of this bill is to ensure that
we find out if this pilot program is in the best interest of veterans
and taxpayers before the VA rolls out the program nationally.
I would like to thank the witnesses for coming before us today and
I look forward to their testimony.
Prepared Statement of Hon. Jeff Denham
Chairman Benishek, Ranking Member Brownley,
Thank you for the opportunity to testify today on behalf of my
legislation, H.R. 4198, the Appropriate Care for Disabled Veterans Act.
I am pleased that this legislation has the support of the Paralyzed
Veterans of America, Veterans of Foreign Wars and Disabled American
Veterans and look forward to working with these groups further as we
move this important bill through the legislative process.
Mr. Chairman, as you know, the number of disabled veterans has been
increasing at an alarming rate. The number of severely disabled
veterans is increasing even more quickly. These severely disabled
veterans are suffering from a range of issues--spinal cord injury/
dysfunction (SCI/D); blindness; traumatic brain injury (TBI); or mental
health disorders. Many require prosthetic, orthotic and sensory aids,
and all need specialized care in their communities. It is the
responsibility of this committee to ensure that the VA is meeting that
mission requirement.
To ensure that veterans had the care they needed, Congress
mandated, beginning in 1996, that the VA maintain its capacity for the
specialized treatment and rehabilitative needs of disabled veterans
based on a number of specific measurements. For spinal cord injuries in
particular, this capacity was to be measured by the number of staffed
beds and the number of full-time employee equivalents available to
provide care. The VA was also required to report this information to
Congress after it was reviewed by the VA's Office of the Inspector
General.
Unfortunately this reporting requirement has lapsed and
consequently so has the VA's adherence to the capacity standards
required by Congress. As an example, Paralyzed Veterans of America's
testimony explains how issues involving VA's capacity such as staffing
directly impacts daily bed censuses and thus, creates access issues for
veterans who need comprehensive care.
With this bill, we have the opportunity to restore and modernize
that reporting requirement so that this committee and our partners in
the VSO community maintain a thorough understanding of the VA's ability
to provide specialized care across the Veterans Health Administration
system.
To that end I welcome the testimony provided today by Disabled
American Veterans which points out how substantial changes in the way
the VA provides care in such areas as substance abuse disorders, long-
term nursing care and prosthetics require new capacity measurements not
based on standards set in 1996.
The American people have provided extraordinary resources to the
Department of Veterans Affairs. It is our job to provide oversight of
those resources. We cannot provide the oversight necessary without
accurate information.
Chairman Benishek, Ranking Member Brownley, thank you again for the
opportunity to speak on behalf of this legislation.
Prepared Statement of Joy J. Ilem
Chairman Benishek, Ranking Member Brownley and Members of the
Subcommittee:
On behalf of the DAV and our 1.2 million members, all of whom are
wartime wounded, injured and ill veterans, I am pleased to present our
views on legislative measures that are the focus of the Subcommittee
today, and of DAV and our members.
H.R. 183, the Veterans Dog Training Therapy Act
This bill would require the Secretary of Veterans Affairs to
conduct a 5-year pilot program to assess the effectiveness of a
therapeutic medium of service dog training and handling in addressing
post-deployment mental health and post-traumatic stress disorder (PTSD)
symptoms in veterans.
The pilot program would be carried out in three to five Department
of Veterans Affairs (VA) medical centers with available resources to
educate veterans with certain mental health conditions, in the art and
science of service dog training and handling. The bill would require a
facility to offer wheelchair accessibility, dedicated indoor space for
grooming and training dogs; a classroom or lecture space for education;
office space for staff; storage for training equipment; periodic use of
other areas to train the dogs with wheelchair users; outdoor exercise
and toileting space; and, transportation for weekly field trips to
train the dogs in other environments.
The pilot program would be administered through VA's Recreation
Therapy Service led by a certified recreation therapist with sufficient
experience to administer and oversee the pilot program. The measure
also would require that, when the selection of dogs was made, a
deference would be given to dogs from animal shelters or foster homes
with compatible temperaments to serve as service dogs, and with health
clearances. Each service dog in training would live at the pilot
program site or in a volunteer foster home in close proximity to the
training site during the period of training.
Veterans with post-deployment mental health conditions, including
PTSD, would be able to volunteer to participate in the pilot if the
Secretary determined adequate resources were available and those
selected could participate in conjunction with VA's compensated work
therapy program. Under the bill, the Secretary would also give veterans
preference in the hiring of certified service dog trainers to those who
had successfully completed therapy for PTSD or other residential
treatment.
The goal of the pilot would be to maximize the therapeutic benefits
to veterans participating in the program and to ultimately provide
well-trained service dogs to veterans with certain disabilities. The
stated purpose of the pilot program would be to determine how
effectively trained dogs would assist veterans in reducing mental
health stigma; improve emotional stability and patience; reintegrate
into civilian society; and, make other positive changes that aid
veterans' quality of life and recovery. The bill would require VA to
study and document such efficacy, and to provide a series of reports to
Congress.
Although DAV has no specific resolution approved by our membership
relating to service dogs that would authorize DAV to formally support
this measure, we recognize that trained service animals can play an
important role in maintaining functionality and promoting veterans'
recovery, maximum independence and improved quality of life. We
recognize this pilot program could be of benefit to veterans suffering
from post-deployment mental health struggles, including PTSD. We
understand a similar program that operates at the Palo Alto VA Medical
Center has been beneficial for veterans--and specifically in improving
symptoms associated with post-deployment mental health problems,
including PTSD. DAV is supportive of non-traditional therapies and
expanded treatment options for veterans. For these reasons we have no
objection to this bill.
H.R. 2527, To Provide Veterans With Counseling and Treatment for Sexual
Trauma That Occurred During Inactive Duty Training
Unfortunately, the sexual assault and harassment scourge continues
in the active military services, and often results in lingering
emotional or chronic psychological symptoms or conditions in victims of
these attacks. Currently, Title 38, United States Code, section 1720D
authorizes VA to provide priority counseling and specialized treatment
for eligible veterans who have experienced military sexual trauma
(MST), but this eligibility is limited to only those who served on
active duty or active duty for training.
This measure would amend Section 1720D to include veterans serving
in the reserve components of the armed forces during inactive duty for
training so that they, too, will be eligible for VA counseling services
for conditions related to sexual trauma that occurred during their
training.
DAV Resolution 125 calls on VA to ensure that all military sexual
trauma survivors gain access to the VA specialized treatment programs
and services they need to fully recover from sexual trauma that
occurred during their military service. Therefore, DAV is pleased to
support H.R. 2527 and urges its enactment.
H.R. 2661, the Veterans Access to Timely Medical Appointments Act
This bill would direct the Secretary of Veterans Affairs to
establish a standardized scheduling policy for veterans enrolled in the
VA health care system. This measure would propose to improve veterans'
timely access to health care in the VA based on an external finding of
unreliable waiting time data, lack of local adherence to national
scheduling policy, and ineffective oversight by VA on the scheduling
process itself.
If enacted, the bill would require VA to implement recent
Government Accountability Office (GAO) recommendations (GAO-13-130,
http://www.gao.gov/assets/660/651076.pdf) to improve the reliability
and accuracy of appointment waiting time measures; ensure VA medical
centers (VAMC) consistently observe and adhere to official VA
scheduling policy; require VAMCs to allocate staffing resources based
on actual scheduling needs; and, ensure that VAMCs provide oversight
of, and implement best practices to improve, veterans' telephone access
to care. The bill would also require VA to make a series of reports to
Congress on its efforts to improve scheduling under the mandates of
this bill.
DAV has testified on numerous occasions before this Committee on
the topic of timely access in general, and of a variety of individual
VA health care scheduling challenges, such as those in outpatient
primary care, in mental health, in prosthetics and sensory aids and in
other specialized services. While policies made at VA's Central Office
seek to standardize a set of goals and actions across all VA facilities
and programs, such as for timely access, or access-to-care standards,
the mechanisms by which these policies are implemented locally may vary
over time for a variety of reasons.
We also note that VA's national waiting time policies have been
changed over the years, and were re-defined and re-interpreted as they
encountered conflicts with realities on the ground. For example, about
20 years ago, to respond to criticisms about long waiting times,
particularly for specialty services, VA established its ``30/30/20''
goal. For outpatient care, patients were to receive initial, non-urgent
appointments with their primary care or other appropriate providers
within 30 days of requesting visits; receive specialty care
appointments within 30 days when referred by primary care providers;
and, be seen by providers within 20 minutes of scheduled appointments.
In 2000, to replace paper waiting lists, changes were made to VHA's
automated scheduling module, measuring actual waiting times versus VA's
30-day standard. Over time, VA has used several different waiting time
measures defining and refining which patients would be included in
waiting time analysis, which outpatient and specialty clinic services
would be counted in waiting time calculations, and when waiting times
started and ended. VA's access goals changed again in 2010 when VA
began measuring performance for all outpatients based on a new 14-day
waiting time benchmark. All these shifts and amendments have
encountered challenges when they were implemented locally.
While the intent of the bill is laudable and we appreciate the
sponsor's interest in this ongoing challenge at VA, DAV believes the
overriding critical component to solving many of VA's access
challenges, unaddressed and lingering for several years now, is lack of
an effective, sensitive and contemporary automated VA health care
scheduling system.
VA's outpatient clinic scheduling module is a core component of the
Veterans Health Information Systems and Technology Architecture
(VistA), a landmark multi-functional computerized patient records
system, first deployed 30 years ago. The system has been modified many
times since, and now performs multiple interrelated functions affecting
patients, clinicians and other VA resources. The VistA scheduling
module captures data which enables VA to measure, manage and improve
access, quality and efficiency of care, and monitors operating and
capital resources used in providing care. However, as has been
continually reported and observed by GAO, ``the VistA scheduling system
is outdated and inefficient, which hinders the timely scheduling of
medical appointments.'' (See GAO-13-130, page 24.) We believe when a
new scheduling system is eventually installed, VA could reasonably
begin to assess demand versus capacity, as well as determine associated
staffing needs and resources more accurately for management and
oversight purposes.
Measuring capacity, patient access and demand is a complex issue.
DAV believes that progress toward successful implementation of VA's
timely access policy must be assessed to ascertain what is or is not
being achieved and why. Valid and reliable information is crucial
because it helps shape decisions and actions at various levels to
ensure compliance with policy directives, reaching intermediate
performance indicators or benchmarks, and achieving long-term policy
goals and objectives. Many of these important objectives are hampered
because of weaknesses and failures of VA's current IT scheduling
infrastructure. Furthermore, trying to standardize waiting times may
result in VA having to contract for services if staffing levels and
appropriate resources are not identified to resolve excessive waiting
times.
While DAV supports the intent of this legislation based on our
Resolution No. 204, which calls on VA and Congress to ensure timely
access to quality VA services, to identify and correct the related
underlying data, scheduling and reporting problems that exist, and to
provide sufficient resources and staff to achieve this goal, we believe
this bill may bring an opposite effect. Despite its good intentions,
enactment of this bill would not address these issues, and may only
further complicate VA's ongoing quest to meet its own national access
standards. Like the author of this bill, we want veterans to gain and
keep access to timely care in VA. Therefore, we urge the Subcommittee
to work with VA to fully address the core issues to determine how the
intent of this measure could be best achieved.
H.R. 2974, To Provide for the Eligibility for Beneficiary Travel for
Veterans Seeking Treatment or Care For Military Sexual Trauma in
Specialized Outpatient or Residential Programs at Facilities of the
Department of Veterans Affairs
This bill would amend Title 38, United States Code, section 111, to
provide veterans new eligibility for VA beneficiary travel
reimbursement if they need to travel to specialized outpatient or
residential programs at VA facilities for treatment of mental health
conditions related to sexual trauma that occurred during their military
service.
The Sexual Assault Prevention and Response Office (SAPRO) in the
Department of Defense (DoD) reports that over 3,000 sexual assaults are
acknowledged each year across the military branches. However, SAPRO
estimates 87 percent of these assaults actually go unreported--meaning
that as many as 26,000 sexual assaults are likely to occur in DoD each
year. The VA provides specialized residential and outpatient counseling
programs and evidence-based treatments to military sexual trauma (MST)
survivors, and notes that nearly 800,000 MST-related patient encounters
take place annually.
According to VA's Office of the Inspector General (VAOIG) Report
No. 12-03399-54, Inpatient and Residential Programs for Female Veterans
with Mental Health Conditions Related to Military Sexual Trauma, VA
facility and mental health services staff interviewed by the VAOIG
consistently indicated difficulties obtaining VA authorization for
patient transportation funding to VA's specialized centers for MST. We
believe these difficulties arise from conflicting VA authorities and
policies. Specifically, VHA Directive 2010-033, Military Sexual Trauma
(MST) Programming, establishes policy that veterans and eligible
individuals must have access to VA residential or inpatient programs
able to provide specialized MST-related mental health care. However,
access to such care is affected for veterans eligible and not eligible
for beneficiary travel benefits.
In the case of a veteran who is eligible for beneficiary travel
benefits under current statutory authority, \1\ applying VHA Directive
2010-033 requires clearer guidance on inter-facility referrals for
care, consistent implementation of current policy, and oversight.
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\1\ Traveling for treatment or care: 1) for a service-connected
disability; 2) for any disability of a veteran rated 30 percent or more
for a service-connected disability; 3) for a scheduled compensation and
pension examination; 4) of a veteran receiving pension under 38 U.S.C.
Sec. 1521, and; 5) a veteran whose annual income (as determined under
38 U.S.C. Sec. 1503) does not exceed the maximum annual rate of pension
under 38 U.S.C. Sec. 1521 (as adjusted under 38 U.S.C. Sec. 5312) if
the veteran was eligible for pension.
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Clearer guidance to VA facilities from VA Central Office is needed
to help determine which VA facility would be responsible for paying
beneficiary travel benefits when more than one VA facility is involved
in a veteran's care, or when treating VA facilities are located in
different Veterans Integrated Service Networks (VISN). This lack of
guidance for beneficiary travel affects all types of care including for
MST-related conditions. Ostensibly, the memorandum of understanding on
inter-facility referrals required in VHA Directive 2010-033, should
address this problem.
Consistent implementation and oversight is required when mileage
reimbursement is calculated to the nearest VA facility. The VAOIG
report indicates that reimbursement is only authorized to the VA
facility ``where the care or services could be provided.'' This
interpretation is not wholly accurate.
Title 38, Code of Federal Regulations, section 70.30(b)(1) and VHA
Handbook 1601B.05 state that reimbursement for beneficiary travel to an
eligible beneficiary ``[i]s limited to travel from a beneficiary's
residence to the nearest VA facility where the care or services could
be provided and from such VA facility to the beneficiary's residence.''
However, the Handbook also indicates that the nearest appropriate VA
facility is subject to a clinician's determination. The ``nearest
appropriate VA facility'' means the particular VA facility that a VA
provider determines is capable of providing the treatment or service
required. Thus, if a VA clinician indicates a veteran who is eligible
for beneficiary travel requires specialized treatment for MST at a VA
facility located in a different VISN, current policy states the amount
of beneficiary travel payment or reimbursement shall be calculated from
the veteran's residence to the distant facility, not the home VA
facility.
In the case of a veteran who is not eligible for beneficiary travel
under current statutory authority, we believe successfully achieving
the intentions of VHA Directive 2010-033 regarding access to
specialized MST-related residential or inpatient MST-related care would
require enactment of H.R. 2974.
As you may be aware, DAV called for enactment of a similar measure
in testifying before the Senate Veterans' Affairs Committee on October
30, 2013, regarding a draft bill, the Survivors of Military Sexual
Assault and Domestic Abuse Act of 2013. Thus, in accordance with DAV
Resolution No. 125, which calls for supporting legislation to change
beneficiary travel policies to meet the specialized clinical needs of
veterans receiving MST-related treatment, DAV supports H.R. 2974.
However, DAV also testified on May 21, 2013, before this Subcommittee
on a related bill that proposed to amend Section 111 by expanding
eligibility for beneficiary travel reimbursement benefits to another
select group of veterans. That bill, H.R. 1284, would have given new
eligibility for VA beneficiary travel reimbursement to veterans needing
specialized care for vision impairment, for spinal cord injury or
disorder, or for double or other multiple amputations. In that
testimony, we urged this Subcommittee, as we do now, to consider a more
equitable approach to beneficiary travel eligibility.
Specifically, in addition to a handful of specialized MST
residential programs targeted by H.R. 2974, VA operates 24 spinal cord
injury/dysfunction rehabilitation centers, 13 blind rehabilitation
centers, 7 geriatric research, education and clinical centers, 7 mental
illness research, education and clinical centers, 3 war-related illness
and injury study centers, and a number of other clinical centers of
excellence. Access to these centers is important for veterans with
conditions connected to the expertise of these centers.
In DAV's view, the developing care delivery model for MST-related
specialized treatment is similar to the concentrations of other
specialized VA clinical services that often require patients to travel
long distances to gain access to these services. Without VA's support
for their transportation costs to reach these centers, some veterans
encounter challenging barriers to care and do not benefit from the
higher quality care and outcomes intended by VA and Congress in
establishing and operating these centers of excellence. This problem
should be addressed through the legislative process.
H.R. 3180, To Include Contracts and Grants for Residential Care for
Veterans in the Exception to the Requirement That the Federal
Government Recover a Portion of the Value of Certain Projects
H.R. 3180 was introduced with the intention of allowing some state
veterans homes to compete for existing grants to support the operation
of homeless veterans programs using a portion of excess bed capacity in
state home domiciliaries. The bill would amend Title 38, United States
Code, to authorize a state veterans home to receive contracts or grants
from VA for any residential care program, including a homeless veterans
program, without being subjected to required federal recapture of prior
VA construction grants to the home for the building of those beds.
Under current statute, state veterans homes receive federal support,
including both per diem payments for veterans' care and construction
grants, to operate only three authorized programs: skilled nursing
care, adult day health care, and domiciliary care. Under current law,
were a state home to use facilities previously granted by VA to operate
any other type of program, the federal government would seek to
recapture a proportionate value of the construction grant funds that
had been provided over the prior 20 years.
The legislation as currently drafted, however, does not
specifically reference either domiciliaries or homeless veterans
programs, nor would it assure the intended outcome. The bill's current
language would create a broad exception to the recapture provision that
could be applied to any residential care program for veterans, and its
enactment could raise the potential for other unintended consequences.
Based on DAV Resolution 165, DAV supports the intention of H.R. 3180--
to use existing excess capacity to help homeless veterans--but
recommends that the Subcommittee work with VA, state homes and veterans
service organizations to craft more targeted and effective legislative
language to achieve the goal of this bill.
H.R. 3387, the Classified Veterans Access to Care Act
This bill would seek to amend Title 38, United States Code, to
improve mental health treatment provided by the VA to veterans who
served in classified military missions. If enacted, this bill would
provide accommodation to certain veterans in VA mental health care
treatment to not improperly disclose classified information in cases in
which they served in ``sensitive military assignments'' or ``sensitive
units.'' The bill would define both of these terms, as well as the term
``classified information.'' The bill would require VA to establish
standards and procedures to carry out its purposes.
Given the unique nature of this relatively small group of veterans
who have been deployed in classified missions or worked in sensitive
units while serving, we would hope VA already acknowledges, especially
in its mental health treatment programs, the need to be respectful of
these veterans' particular circumstances and personal military
histories.
Many of VA's treatment programs are provided in group therapy
settings. A veteran who served in a classified mission may well not be
comfortable discussing that personal history in the presence of a
group, and we hope that VA already has established procedures in place
to make arrangements for individual counseling or therapy sessions in
such cases. We understand this to already be the case in VA's
readjustment counseling Vet Centers. We also understand that service
members with security clearances receive training about disclosure and
restrictions on classified information.
We understand from VA that generally, active duty personnel are
able to discuss their experiences without revealing classified
information to counselors and therapists, and should be able to engage
in treatment irrespective of whether their health care providers
possess comparable levels (or any) security clearance. In our review of
this issue, we have discovered that even in prolonged exposure-based
therapy for PTSD, it is not the case that every detail of an event or
experience must be shared by a veteran with a provider in order for
treatment to be effective. It is reasonable to believe that VA mental
health providers and Vet Center counselors respect and work within the
limits of the information that veterans can share and within the
confines of any confidentiality requirements and security clearance
levels that may be involved.
A reasonable approach would be to inform active duty personnel (and
certain veterans) seeking mental health services in VA about all the
limits of confidentiality, to include the fact that the care provider
may not possess a security clearance. We note that mental health
providers working in the DoD routinely inform their patients about the
limits of confidentiality, but not security clearance limitations.
Nevertheless, VA mental health practitioners and counselors could be at
times impeded in aiding particular individuals because they may believe
they are effectively ``gagged,'' and thus unable to describe in therapy
certain military events or activities sheltered from disclosure that
might be, or could become, keys to improved treatment. For example, in
prolonged exposure therapy, reliving a traumatic event or incident
repetitively has proven to be an effective treatment to reduce or
control symptoms of post-traumatic stress disorder. In these cases, a
talented, experienced practitioner should be able to use other
techniques, such as cognitive behavioral therapy, to enable a service
member or veteran to deal with his or her individual challenges,
without disclosing classified information.
While it may be technically unnecessary, enactment of this bill
could reinforce a sense that these particular veterans' prior military
duties should not become a bar to their receiving effective VA mental
health services following their discharges, or be a reason to avoid
seeking treatment. Thus, we believe enactment could make a positive
contribution to care, or help persuade some veterans to actually seek
VA mental health services who had not previously done so because of the
nature or duties of their prior sensitive or classified military
assignments.
While DAV has not received a resolution from our membership
concerning mental health services for veterans who once worked in
classified or sensitive military activities, we did receive Resolution
No. 193, at our most recent national convention, that supports
``enhanced [VA] resources for VA mental health programs to achieve
readjustment of new war veterans and continued effective mental health
care for all enrolled veterans needing such services.'' We believe this
bill is consistent with the purposes of our resolution; therefore, DAV
offers its support of this measure.
H.R. 3508, To Clarify the Qualifications of Hearing Aid Specialists of
the Veterans Health Administration of the Department of Veterans
Affairs
If enacted, this bill would authorize the appointment of hearing
aid specialists in the Veterans Health Administration (VHA). The bill
would specify that such individuals hold associate degrees in hearing
instrument sciences, or the equivalent, from colleges or universities
approved by the Secretary, or have successfully completed approved
hearing aid specialist apprenticeship programs. Individuals eligible
for appointment would need to be licensed by a state as a hearing aid
specialist, or its equivalent.
The Secretary would also be required to submit an annual report on
timely access to hearing health services to include staffing levels and
average waiting times for patients seeking appointments, a description
of how the Secretary measured performance related to appointments and
care in hearing health, and information on contracting policies with
respect to providing hearing health services in non-VA facilities. Not
later than 180 days after enactment of this bill, the Secretary would
be required to update and reissue the VHA handbook, ``VHA Audiology and
Speech-Language Pathology Services,'' to reflect these new
requirements.
On February 20, 2014, the VA's Office of the Inspector General
(VAOIG) issued a report and findings of its audit of VA hearing aid
services (VAOIG 12-02910-80). The purpose of the audit was to evaluate
the effectiveness of VA's administration of hearing aid orders.
According to the report, VA is not issuing hearing aids to veterans in
a timely manner or meeting its own five-day goal to complete repair
services of hearing aids issued previously. Specifically, VHA issued 30
percent of its hearing aids to veterans more than 30 days from the
estimated date the facility received hearing aids from vendors.
Audiology staff attributed the delays to inadequate staffing levels and
the large number of veterans requiring compensation and pension
examinations, which they reported take priority over other types of
clinic appointments. The VAOIG further noted that with the veteran
population aging, demand for hearing aid services has increased from
596,000 in FY 2011 to over 665,000 in FY 2012. Also, the VAOIG
estimated that about 19,500 sealed packages of hearing aids were
awaiting repairs at VA's Denver Acquisition and Logistics Center and
that 17-24 days were being consumed by the center to complete the
repair services, exceeding VA's five-day timeliness standard for such
services.
The VAOIG recommended VA develop a plan to implement productivity
standards and staffing plans for audiology clinics as well as to
determine appropriate staffing levels for its repair laboratory, and to
establish controls to track and monitor received hearing aids pending
repair. The VA Under Secretary for Health concurred with the audit
recommendations and submitted corrective action plans. We understand
these actions have been initiated and look forward to VA's report.
DAV has no specific resolution from our membership related to the
employment of hearing aid specialists within VA. However, the findings
of the VAOIG report cited demonstrate that VA is now struggling to meet
timely access for the delivery of hearing aids and for completing
necessary repairs on malfunctioning ones. Because hearing loss
(including tinnitus) is the most prevalent service-connected disability
for veterans, and the demand for audiology services and hearing aid
repairs and adjustments continues to rise, having qualified hearing aid
specialists available for basic services (within their scope of
practice, for necessary repairs and cleaning) may significantly reduce
the waiting times found by VAOIG. We do, however, defer to VA to ensure
that hearing aid specialists would meet VA's quality standards, through
their certified scope of practice, and could contribute in reducing the
backlog of hearing aid repairs and delivery of hearing aids to
veterans. If this can be verified by VA we have no objection to passage
of this measure.
H.R. 3831, the Veterans Dialysis Pilot Program Review Act of 2014
This measure would require the Secretary to undertake an
independent analysis of the existing dialysis program implemented by
the VA and provide a report to Congress on the review prior to
expanding the existing dialysis pilot program at VAMCs in Durham and
Fayetteville, North Carolina; Philadelphia, Pennsylvania; and
Cleveland, Ohio, or creating any new dialysis capability.
VA estimates show that in FY 2011, approximately 35,000 veterans
enrolled in the VA health care system were diagnosed with end-stage
renal disease (ESRD), reflecting a higher prevalence of this condition
in the VA population than in the general U.S. population. (Comparison
of outcomes for veterans receiving dialysis care from VA and non-VA
providers, Wang et al., BMC Health Services Research 2013, 13:26.) VA
initiated several studies of this population based on the rapidly
rising cost of VA-financed hemodialysis treatment in non-VA facilities
and the high rates of morbidity and mortality of veteran patients with
ESRD. (Comparing VA and private sector health care costs for end-stage
renal disease, Hynes et al., Medical care 2012, 50(2):161-170.)
ESRD patients are one of the most resource-intensive population
cohorts in the VA health care system. The reality of hemodialysis is
often overwhelming to these patients. Kidney failure is a life-altering
disease that has a significant impact on a veteran's overall physical
and mental health, lifestyle, and livelihood. A veteran diagnosed with
ESRD who needs dialysis typically requires three outpatient treatments
per week, each requiring about four hours, to be repeated for the
remainder of his or her life, absent kidney transplant.
In a May 2012 report, the GAO evaluated VA's dialysis pilot. GAO
reported VA had not fully developed performance measures for assessing
the dialysis pilot locations, even though the Department had already
begun planning an expansion of the pilot to additional sites. Further,
GAO concluded that such an expansion ``should not occur until after VA
has defined clear performance measures for the existing pilot locations
and evaluated their success.''
DAV has no approved, specific resolution on this issue, and
therefore takes no formal position on this bill. We do, however, offer
some concerns that we ask the Subcommittee to consider.
While Congress has been focused on the accuracy of VA's data,
analysis, and plan of action to address the growing demand for dialysis
therapies depicted in recent Committee reports (House Appropriations
Report 112-094, page 41, May 31, 2011 and House Appropriations Reports
112-491, pages 39-40, May 23, 2012), DAV is concerned that enactment of
this measure would, at least through July 2015, restrict VA's capacity
to provide life-sustaining dialysis treatment through fee-basis
dialysis, except for those under sharing or other negotiated
agreements.
We note for the Subcommittee that VA testified on October 30, 2013,
before the Senate Veterans' Affairs Committee, and indicated that
requiring continuation of the four initial pilot sites without change
beyond these activities for at least the next two years would prohibit
activation of any additional free-standing VA dialysis centers until at
least 2015. The VA also testified that a restriction of this type had
the potential to ``. . . adversely impact VA's efforts to optimize
Veterans' dialysis care.'' Given the brittle nature of these veterans'
health problems and their very high morbidity and mortality rates due
to this fatal disease, in our judgment new projects that the VA is
currently working to activate should continue without interruption or
further delay, and certainly should go forward without regard to the
fate of these four pilot programs. Further, DAV would be deeply
concerned if this bill were to halt or restrict VA from continuing to
provide dialysis care to veterans within the system itself, or through
private providers under contract.
Discussions surrounding the dialysis pilot of the Department's
purchased and provided dialysis therapy appear generally to be centered
on cost. We find insufficient emphasis on the veteran patient;
therefore, we appreciate this legislation's inclusion of non-cost
factors such as access to care, quality of care, and veteran
satisfaction in the bill's provisions related to independent analysis
of the VA dialysis pilot program.
As one of four Independent Budget veterans service organizations
(IBVSOs), we note that coordinating care among the veteran, dialysis
clinic, VA nephrologists, and VA facilities and physicians, is
essential to improving clinical outcomes and reducing the total costs
of care. The benefits of an integrated, collaborative approach for this
population have been proven in several Centers for Medicare and
Medicaid Services demonstration projects and within private-sector
programs sponsored by health plans and the dialysis community. Such
programs implement specific interventions that are known to avoid
unnecessary hospitalizations, which, when they occur for these
patients, frequently cost more than the total cost of dialysis
treatments. These interventions include a focus on behavioral
modification and various motivational techniques. The potential return
on investment in better clinical outcomes, higher quality of life, and
lower costs could be substantial for VA and veteran patients if
integrated care coordination were emphasized.
We understand that some community dialysis providers are piloting
the integrated care management concept among their veteran population
cohorts. The IBVSOs believe that VA should also provide integrated care
management in this pilot program that can test and demonstrate the
value of such an approach to VA and the veterans it serves.
H.R. 4198, the Appropriate Care for Disabled Veterans Act
H.R. 4198 would amend Title 38, United States Code, to reinstate
the requirement for an annual report to Congress on the capacity of the
VA to provide for specialized treatment and rehabilitative needs of
disabled veterans. The renewed report would emphasize a special--but
not exclusive--focus on maintenance of programs of care for spinal cord
injury/dysfunction (SCI/D); blindness; traumatic brain injury (TBI);
prosthetic, orthotic and sensory aids; and mental health.
We have received no national resolution approved by our membership
to support reinstatement of this previous reporting requirement;
however, we wish to offer some thoughts to the Subcommittee for its
consideration in determining how to manage this proposal.
Section 1706, Title 38, United States Code, was formulated by the
Committee in the mid-1990's and was first authorized in Public Law 104-
262. The section was subsequently revised in three additional acts, the
last of which was Public Law 109-461, an act that extended the
reporting requirement through 2008. The capacity report has been
suspended since that time, but other provisions of section 1706 are
still applicable to VA.
Several elements in the report that H.R. 4198 would reauthorize
rely on the year 1996 (the year of enactment of Public Law 104-262) as
the benchmark year for VA capacity comparisons and reporting going
forward. Given changes in the veteran patient population, their health
care needs, and the manner in which health care is delivered today, we
believe reinstating the existing comparison year of 1996 for a number
of important programs would not produce information useful for
Congressional oversight, for review by members of our community of
veterans service organizations, and for others with interest in VA
capacity.
Due to the nature and severity of veterans' contemporary war
injuries from Iraq and Afghanistan, and the consequent massive
investment in new and innovative prosthetics made by both VA and the
Department of Defense since 2002, VA's prosthetic and sensory aids
program is now more innovative, extensive and expensive today than in
1996. Thus, 1996 would not be an appropriate benchmark in our view. In
this light a more effective date for comparative reporting purposes in
the prosthetics program might be 2001 or, perhaps even 2010, so that
Congress could more closely gauge how VA capacity to provide these
specialized services may be changing annually during a more meaningful
interval.
Importantly, in no small part because of this Committee's advocacy
and the benevolence of Congressional appropriators, VA mental health
programs including those for substance-use disorder, have been
reformed, revised and expanded to such an extent that they barely
resemble those of nearly twenty years ago. In staffing alone, since
2002, VA has added over 20,000 mental health personnel to its
employment rolls. VA already reports to Congress in its annual budget
submissions estimated total expenditures on mental health, but
reporting of detailed subsets is not currently required. We believe
more detail on mental health program capacity should be made available.
As an example of the need for public reporting, we note that
substance-use disorder bed units were prevalent in VA and elsewhere in
1996 when the expired reporting requirement was first established, but
they are much rarer now. In fact over the past decade and more, VA has
severely curtailed inpatient residential substance-use disorder
programs. Most of these programs are now conducted on an outpatient
basis. The expired language of section 1706 assumes inpatient
substance-use programs are still prevalent today. Also, VA maintains a
number of detoxification beds for acute substance-use disorder intake
cases, but we have experienced challenges in determining the number and
location of these beds since no publicly available inventory of them is
maintained by VA.
In another evolution in VA, traditional long-term, skilled nursing
care (historically a bed-intensive program) has given way to VA's
establishment of an array of institutional and non-institutional long-
term services and supports. The expired language is silent on VA long-
term services and supports capacity, but as an important and growing
component of VA's clinical care mission, we believe it should be
included. DAV is supportive of the VA's initiative to rebalance its
long-term services and supports portfolio to care for veterans closer
to where they live by increasing access to and creating new and
innovative home and community-based services. However, variation in
availability and accessibility of VA long-term services and supports
across the 21 VA health care networks has been critiqued in multiple
reports by the GAO. These reports collectively could offer insights
into how a capacity report might be structured.
In certain discrete bed units (such as VA SCI/D centers, designated
TBI rehabilitation units, and residential blind rehabilitation centers,
for example), year-to-year comparative bed capacities by unit, and
full-time employee equivalents assigned to each such unit (as well as
the distribution of those staff by health profession, compared to VA's
``objective standards of job performance,'' as also prescribed by
section 1706), could provide a meaningful yardstick to ascertain VA's
true capacity to care for and rehabilitate veterans in these particular
specialized bed-based units. Given the bill sponsor's coordination with
Paralyzed Veterans of America in crafting this bill, DAV would support
amendments to this bill that would require VA to report to Congress on
discrete bed-intensive rehabilitation programs along the parameters of
the expired section. As described in this testimony, for other VA
specialized health care programs we believe a more nuanced report to
gauge capacity taking into account the changes that have occurred in
these programs would be more beneficial for oversight and monitoring
purposes.
Representatives of DAV and other veterans organizations recently
have discussed these concerns and needs with the bill's sponsor, and
have offered our assistance in crafting a possible substitute amendment
that would accomplish our goal of reinstating a capacity-reporting
statute that would track capacity resources in discrete bed-intensive
units along the lines of the intent of this bill, yet also would
provide Congress information on VA capacities that are not bed-
intensive or bed-relevant as described above.
Taking into account these concerns, DAV asks the Subcommittee to
consider approving the bill in its current form, with the understanding
that at a future legislative meeting of the Committee an amendment in
the nature of a substitute will be offered by the bill's sponsor,
incorporating the agreed-on changes that we hope to achieve in a
collaborative fashion.
Draft Bill, To Authorize Major Medical Facility Projects for the
Department of Veterans Affairs for Fiscal Year 2014
Sections 1, 2, and 3 of this bill would authorize, or amend a prior
authorization of, 27 major medical facility leases, primarily
outpatient clinic facilities, in fiscal year 2014, and would authorize
appropriations of $236.6 million, an amount sufficient for VA to
execute these leases. These are the same leases that are included in
H.R. 3521, a bill passed by the House in 2013, and that are also
embedded in S. 1982, now pending before the Senate.
DAV strongly supports these sections on the basis that these new or
expanded community-based clinics and other leased facilities would
improve access to convenient VA primary and specialty outpatient care,
and provide other positive health outcomes that support veterans,
consistent with DAV Resolution No. 028. We urge the Committee to
advance these provisions, and to deal as well with the ongoing
stalemate between the Office of Management and Budget and the
Congressional Budget Office on an acceptable method of treating the
long-term costs of these facilities under the Budget Control and
Impoundment Act of 1974, as amended.
Section 4 of the bill would broaden the statutory definition of VA
``medical facility'' in Title 38, United States Code, section 8101(3),
by adding the term ``or as otherwise authorized by law'' that conveys
jurisdiction of a capital entity to the VA Secretary. This section of
the bill also would amend the definition of ``major medical facility
project'' to exclude shared federal facilities constructed, altered or
acquired, so long as the cost of VA's share did not exceed $10 million;
the section would apply this same logic to federally shared major
medical facility leases when VA's share did not exceed $1 million in
annual rental costs. We have no objection to this change in definition
that would provide VA additional flexibility to establish VA health
care facilities in the future with other federal health partners.
This section of the bill would create a new section 8111A in Title
38, United States Code, to authorize the Secretary to enter into
agreements with other federal agencies to plan, design and construct
shared federal medical facilities for the stated purpose of improving
access, quality and cost effectiveness of health care provided by VA to
veterans, and by other federal agencies to their respective
beneficiaries. The authorization would also empower the Secretary to
transfer funds to another federal agency for these purposes, so long as
such transfer did not exceed the applicable existing thresholds in
Title 38, United States Code, for major medical facilities or major
medical facility leases ($10 million, and $1 million, respectively).
The Secretary would also be authorized to receive funds from other
federal agencies for these same purposes, for VA construction or leases
of shared federal facilities.
We understand that VA has been stymied in the past in cooperating
with the DoD on shared facilities projects due to lack of clear
statutory authority within VA to do so. This language, if enacted,
would provide VA this specific authority. Our only concern is that this
policy be applied to shared VA-DoD facilities and not become the basis
for shared activities with numerous other potential federal health
agencies with missions unrelated to the care of veterans and military
beneficiaries. With that understanding DAV offers no objection to this
language.
Section 5 of the bill would amend VA's existing authority for
enhanced-use leases by liberalizing the purposes of such leases to two
clear options: enhance the use of the property concerned; or, provide
supported housing for homeless veterans. Because the enhanced-use lease
authority has been moribund since Congress last amended it, now adding
general language that would enhance the use of unneeded VA structures,
in a complementary manner, in addition to their use for homeless
veterans (the only approved use under current law) might stimulate new
lease activity. VA anticipates this more flexible language will
generate receipt of new funds from leaseholders of unused VA structures
producing no income now. On that basis, DAV would not object to
enactment of this section.
Sections 6 and 7 of the bill would modify a prior act of Congress
that authorized a major medical facility construction project at the
Tampa, Florida VAMC, in effect authorizing a new bed tower at that
facility in the amount of $231.5 million, in lieu of upgrades of the
existing tower previously authorized by law in 2008. It is our
understanding from VA that a determination has been made that
constructing a new tower in lieu of renovating the existing one would
be a more cost-effective use of these funds. Section 7 also would
restrict the use of certain funds in carrying out the Tampa project.
DAV takes no position on this section, but makes no objection to this
proposed change.
In summary, we would offer no objection to the Committee's approval
of this bill in its current form.
Mr. Chairman and Members of the Subcommittee, thank you for
inviting DAV to testify before the Subcommittee on these legislative
proposals. I stand ready to respond to any questions you wish to ask
that are related to these proposals, DAV's positions on them, or other
matters related to this testimony.
Prepared Statement of Alethea Predeoux
Chairman Benishek, Ranking Member Brownley, and members of the
Subcommittee, Paralyzed Veterans of American (PVA) would like to thank
you for the opportunity to present our views on the health care
legislation being considered by the Subcommittee. These important bills
will help ensure that veterans have access to quality and timely health
care services through the Department of Veterans Affairs (VA). We are
particularly pleased that H.R. 4198, which is a legislative priority of
PVA, is among the legislation being reviewed today.
H.R. 183, the ``Veterans Dog Training Therapy Act''
PVA does not have an official position on H.R. 183, the ``Veterans
Dog Training Therapy Act.'' If enacted, this legislation would direct
the VA to conduct a pilot program on dog training therapy for veterans.
PVA recognizes that dog training has been successfully used as a
beneficial form of therapy for veterans dealing with Post-Traumatic
Stress Disorder (PTSD) and other mental health issues. A model program
for this service was created in 2008 at the Palo Alto VA Medical Center
in conjunction with the Assistance Dog Program. This program,
maintained by the Recreational Therapy Service at the Palo Alto VA
medical center, was designed to create a therapeutic environment for
veterans with post-deployment mental health issues and symptoms of PTSD
to address their mental health needs.
In these programs, veterans training service dogs is believed to
help address symptoms associated with post-deployment mental health
issues and PTSD in a number of ways. Specifically, veterans
participating in these programs demonstrated improved emotional
regulation, sleep patterns, and a sense of personal safety. They also
experienced reduced levels of anxiety and social isolation. Further,
veterans' participation in these programs has enabled them to actively
instill or re-establish a sense of purpose and meaning while providing
an opportunity to help fellow veterans reintegrate back into the
community. PVA does not oppose dog training therapy as a non-
traditional form of mental health care. However, if this legislation is
enacted as written, it would differ from the existing program at the
Palo Alto VA medical center in that the VA would be fully responsible
for all aspects of caring for the dogs and the training program. PVA
does not believe that VA has the resources needed for such an
undertaking.
H.R. 2527
PVA strongly supports H.R. 2527, which proposes to amend Title 38
United States Code to provide veterans with counseling and treatment
for military sexual trauma (MST) that occurred during inactive duty
training. As discussed in the FY 2015 Independent Budget, currently
members of the National Guard or Reserves who experienced sexual trauma
during drill training do not have access to VA counseling and treatment
for sexual trauma. If a veteran is injured while in drill status,
including transit to or from drill training, all such injuries are
considered service-connected. The unfortunate instance of sexual trauma
should not be treated differently. To deny veterans who serve in the
reserve components of the military VA MST-related care for sexual
trauma experienced during inactive duty training is not only
inequitable, but detrimental to veterans' health and well-being.
H.R. 2661, the ``Veterans Access to Timely Medical Appointments Act''
The ``Veterans Access to Timely Medical Appointments Act,''
proposes to establish a standardized scheduling policy for veterans
enrolled in the VA health care system. This scheduling policy would
mandate that VA schedule all primary care appointments within seven
days of the date requested by the veteran or the health care provider
on behalf of the veteran, and require specialty care medical
appointments to be scheduled within 14 days of the date requested by
the veteran or physician.
Timely access to quality care is vital to VA's core mission of
providing primary care and specialized services to veterans. Therefore,
PVA believes that the VA must develop reasonable standards for
scheduling medical appointments, and have a system that allows VA
leadership to assess and evaluate scheduling practices as well as
veterans' access to care. It is for this reason that we are pleased
that H.R. 2661 addresses the Government Accountability Office's four
main recommendations from its March 14, 2013, testimony before the
Subcommittee on Oversight and Investigations, ``VA Health Care:
Appointment Scheduling Oversight and Wait Time Measures Need
Improvement.'' The four recommendations were as follows:
Improve the reliability of [VA] medical appointment
wait time measures.
Ensure VA medical centers consistently implement VHA's
scheduling policy.
Require VA medical centers to allocate staffing
resources based on scheduling needs.
Ensure VA medical centers provide oversight of
telephone access and implement best practices to improve
telephone access for clinical care.
Nonetheless, PVA is concerned with how to determine the best
standardized policy for scheduling primary and specialty care
appointments. Measuring patient access and demand is an extremely
complex task. Despite the VA's stated goals of providing primary care
appointments within seven days of a veterans' requested date, and 14
days for primary care, wait times continue to exist and fall outside of
these seven and 14 day goals, and the definition of a veterans
``desired'' or requested appointment date varies across VA's national
system of care.
Legislating these goals as standardized policy for scheduling VA
medical appointments has the potential to lead to unintended outcomes
that could force VA into contracting for care with private providers
too frequently. PVA urges the Subcommittee to work with VA leadership
to make access to VA care timelier. We encourage the VA and Congress to
determine if VA has adequate resources to develop, implement, and
support a patient scheduling system that will address issues involving
wait time measures, sufficient staffing levels, and patient demand.
H.R. 2974
PVA supports H.R. 2974, a bill to amend Title 38 United States Code
to provide for eligibility for beneficiary travel for veterans seeking
treatment or care for MST in specialized outpatient or residential
programs at VA facilities. For many years, PVA has advocated for
expanding beneficiary travel eligibility to specialized groups of
veterans, such as catastrophically disabled, and severely injured, ill,
and wounded veterans, recognizing that the burden of costs associated
with travel for health care services can lead to veterans forgoing much
needed medical attention. In fact, PVA testified before the
Subcommittee last year in support of H.R. 1284, legislation to expand
VA beneficiary travel benefits to catastrophically disabled veterans.
It is for these reasons PVA believes that VA should extend the
beneficiary travel benefit to veterans seeking treatment for MST, and
Congress must ensure that sufficient resources will be provided for the
costs associated with expanding eligibility of the beneficiary travel
program.
Additionally, it is often the case that veterans who have
experienced sexual trauma related to their military service receive
care from specialized programs such as specialized outpatient or
residential programs outside of their nearest VA medical center or
their Veteran Integrated Service Networks. When this is the case, the
veteran is not eligible for beneficiary travel because current policy
only allows for travel reimbursement benefits from the veteran's home
to the nearest VA facility providing the services rendered. The VA's
policy for beneficiary travel benefits should coincide with VA MST
policy that veterans who have experienced MST should be referred to
treatment that is clinically indicated regardless of geographic
location. \1\
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\1\ ``The FY 2015 Independent Budget,'' www.independentbudget.org.
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H.R. 3508
PVA does not have an official position on H.R. 3508, legislation
that proposes to amend Title 38 United States Code to clarify the
qualifications of hearing aid specialists of the Veterans Health
Administration of the VA.
H.R. 3180
PVA does not have an official position on H.R. 3180, legislation
that proposes to amend Title 38 United States Code to include contracts
and grants for residential care for veterans as an exception to the
requirement that the federal government recover a portion of the value
of certain projects.
H.R. 3387, the ``Classified Veterans Access to Care Act''
PVA supports H.R. 3387, the ``Classified Veterans Access to Care
Act,'' which proposes to improve the mental health treatment provided
by the VA to veterans who served on a classified mission. It is PVA's
position that all VA mental health care should meet the specific,
individual need of the veteran seeking medical services on a consistent
basis. The VA should also ensure that veterans seeking mental health
services have access to care options provided in appropriate settings.
This is particularly important for veterans who served on classified
missions. This particular cohort of veterans should not be compromised
by inappropriate care settings that force them to choose between their
duty not to improperly disclose classified information and their need
to get much needed help. If this legislation is enacted, the VA should
make a concerted effort to inform veterans of the option to self
identify as a ``covered'' veteran to help provide immediate mental
health care, and alleviate any concerns regarding veterans' military
service records not indicating that they participated on classified
missions.
H.R. 3831, the ``Veterans Dialysis Pilot Program Review Act of 2014''
PVA generally supports H.R. 3831, the ``Veterans Dialysis Pilot
Program Review Act of 2014.'' If enacted this legislation would require
VA to review the dialysis pilot program and submit a report to Congress
before expanding the program. Gathering and analyzing data to make the
most informed decisions is always best when such choices involve
veterans' health care. For this reason, PVA supports the provisions of
this bill that require independent analysis of the pilot and a VA
report that includes cost comparisons and non-cost factors such as
access to care and quality of care provided to veterans. PVA believes
that the dialysis pilot should be completed and comprehensive analysis
should be conducted to determine the best, most cost-efficient, way to
provide veterans with timely, quality access to dialysis care.
On October 30, 2013, the VA testified at the Senate Committee on
Veterans Affairs' hearing on health and benefits legislation that
requiring implementation of each of the four initial pilot sites for at
least two years would prohibit activation of any free-standing dialysis
centers until 2015. The VA further testified that such a restriction
has the potential to `` . . . adversely impact VA's efforts to optimize
Veterans' dialysis care.'' Keeping the well-being and health care needs
of veterans first, projects involving dialysis centers that the VA is
currently working to activate should continue to completion without
interruption. Additionally, PVA does not support provisions of this
bill that would prevent VA from continuing, establishing, or providing
dialysis care for veterans within the VA or with outside providers.
H.R. 4198, the ``Appropriate Care for Disabled Veterans Act''
PVA strongly supports H.R. 4198, a bill to amend Title 38 United
States Code, to reinstate the requirement for an annual report on the
capacity of the VA to provide for specialized treatment and
rehabilitative needs of disabled veterans. Since 1996, the VA has been
required to collect and maintain specific information and data that is
a reflection of its capacity to provide for the specialized treatment
and rehabilitative needs of disabled veterans. Initially, the VA was
also required to compile this data into a report for Congress on an
annual basis. Unfortunately, this reporting requirement expired in
April of 2008.
H.R. 4198 would reinstate the annual reporting requirement,
mandating that the VA provide an annual report to Congress that
includes information such as utilization rates, staffing, and facility
bed censuses. Requiring the VA to compile such data into the form of a
report to share with Congress annually will lead to more accountability
within the VA, help ensure more efficient allocation of VA resources,
particularly in the area of staffing, and improve veterans' access to
care in VA's specialized systems of care. Ultimately, the VA's capacity
to provide specialized care and rehabilitative treatment for disabled
veterans is directly correlated to its ability to provide veterans with
timely, quality health care services.
Within the VA's Spinal Cord Injury and Dysfunction (SCI/D) system
of care, access to timely care is critical to the health and well-being
of this population of veterans. Many of the VA's specialized systems of
care and rehabilitative programs have established policies on the
staffing requirements and number of beds that must be available to
maintain capacity and provide high quality care. When VA facilities do
not adhere to these staffing policies and requirements, veterans suffer
with prolonged wait times for medical appointments, or in the case of
PVA members, having to limit their care to an SCI/D clinic, despite the
need to receive more comprehensive care from an SCI/D hospital. There
have been instances within VA's SCI/D system of care when staffing
positions have gone vacant for long periods at a time, and as a result,
the facility's bed capacity is decreased, decreasing veterans' access
to care. Requiring the VA to provide Congress with an annual capacity
report, to be audited by the VA Office of Inspector General, will allow
VA leadership and Congress to have an accurate depiction of VA's
ability to provide quality care and services to disabled veterans--
blinded veterans, veterans with spinal cord injury/disorder, and
veterans who have sustained a traumatic brain injury--as it relates to
access and bed capacity of VA specialized services and rehabilitative
programs.
Recognizing that not all VA specialized services and rehabilitative
programs for disabled veterans require inpatient care, the current
language of Title 38 United States Code, Section 1706, does not fully
allow for accurate evaluation of VA's current capacity to provide many
specialized and rehabilitative health care services that cannot be
sufficiently measured using a bed census. PVA urges the Subcommittee to
not only reinstate the reporting requirement, but also update the
language in Title 38 to most accurately reflect the current specialized
services within the VA, especially in the areas of VA long-term care,
mental health care and substance use disorders.
We thank the Subcommittee for recognizing VA's capacity to provide
specialized services as a priority in VA health care delivery and look
forward to working with our VSO partners and the Subcommittee to update
this report so that it reflects useful information that will improve
care delivery for all veterans receiving services through VA
specialized systems of care.
Draft Legislation to Authorize Major Medical Facility Projects for the
Department of Veterans Affairs for Fiscal Year 2014 and for Other
Purposes
PVA generally supports the draft legislation to authorize major
medical facility projects for the VA for fiscal year 2014. PVA fully
supports provisions of this bill that authorize fiscal year 2014 major
medical facility leases. Authorization of funding for these facilities
is critical to the VA maintaining its ability to provide health care
services. We urge Congress to continue to work towards the most viable
solution for dealing with the long-term costs of VA facilities given
the Congressional Budget Office's current scoring methodology for
facility leases.
Of particular importance to PVA is section 4 of this legislation
which includes amendments to modify the definition of a medical
facility and to authorize VA to plan, design, construct, or lease joint
VA and federal use medical facilities. PVA is aware that while there
are not many instances where VA shares federal medical facilities, such
arrangements do exist. However, we have concerns regarding shared
federal medical facility projects and leases as it has the potential to
result in situations that diminish VA's unique mission of providing
solely for veterans' medical health care needs. Sharing medical
facilities with federal agencies has the potential to dilute not only
VA's mission but the quality of care delivered to veterans. This is
particularly the case when considering shared facilities with federal
agencies that are not accustomed to building health care services
around patients that are veterans and military service members like VA
and the Department of Defense.
This concludes my statement. PVA would like to thank the
Subcommittee for allowing us to testify on these important issues
involving veterans' health care services from the VA. We look forward
to working with both the Subcommittee and the VA to improve veterans'
access to care and the quality of services provided through the VA.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2013
National Council on Disability--Contract for Services--$35,000.
Fiscal Year 2012
No federal grants or contracts received.
Fiscal Year 2011
Court of Appeals for Veterans Claims, Administered by the Legal
Services Corporation--National Veterans Legal Services Program--
$262,787.
Alethea Predeoux, Senior Associate Director for Health Legislation,
PVA
Alethea joined Paralyzed Veterans of America in 2007 and works in
PVA's national office in Washington, DC. As a member of PVA's
Government Relations staff, Alethea is responsible for monitoring and
analyzing policy within the Department of Veterans Affairs (VA) to
determine how such policies impact the health care of disabled
veterans, particularly veterans with Spinal Cord Injury/Dysfunction
(SCI). Alethea also covers issues involving women veterans, VA human
resources, prosthetics, and mental health. Alethea's professional
experience is in the area of legislative affairs and government policy.
In addition to her policy work, Alethea also manages the production
of The Independent Budget, a comprehensive budget and policy document
produced by veterans for veterans.
Alethea earned a Master's Degree in Public Policy from George Mason
University and completed her undergraduate studies in Political Science
at Spelman College.
Prepared Statement of Aleks Morosky
Chairman Benishek, Ranking Member Brownley and members of the
Subcommittee, on behalf of the men and women of the Veterans of Foreign
Wars of the United States (VFW) and our Auxiliaries, I want to thank
you for the opportunity to present the VFW's stance on legislation
pending before this Subcommittee. Your hard work and dedication to
improving the quality of veterans' health care positively impacts the
lives of all those who have served in our nation's military. The bills
we are discussing today are aimed at continuing that progress and we
thank the Committee for bringing them forward.
H.R. 183, Veterans Dog Training Therapy Act
This legislation would require the Department of Veterans Affairs
(VA) to establish a pilot program at three to five facilities to assess
the effectiveness of treating veterans for post-traumatic stress
disorder (PTSD) by instructing them in the art of service dog training.
The Palo Alto VA Medical Center (VAMC) has been operating a similar
program since 2008 in partnership with the Bergin University of Canine
Studies, known as Paws for Purple Hearts, which resulted in positive
feedback from veterans and staff.
The VFW recognizes the potential value of canine therapy and would
not be opposed to a limited pilot program for the purpose of collecting
data to determine its effectiveness in treating veterans for PTSD. We
do, however, have suggestions that we believe would strengthen H.R.
183, which we hope the subcommittee would consider, should this bill be
advanced to markup.
VA has been directed by Executive Order to establish community
mental health partnerships, and numerous organizations around the
country have expertise in the field of service dog training. We believe
that the collaboration with the Bergin University of Canine Studies has
benefitted the Paws for Purple Hearts program, and similar
relationships should be encouraged going forward. For this reason, we
suggest that the bill be amended to allow VA to carry out the pilot
program at the selected sites in partnership with existing community
resources.
We also believe that it may not always be appropriate to kennel
dogs on the grounds of VA medical facilities. The VFW is concerned that
noise, sanitation, and available space could present problems for VA
facilities tasked with the primary mission of delivering health care to
veterans. We recommend the bill be amended to allow VA the flexibility
to house and train the dogs at off-site locations when necessary. With
the above changes, the VFW would fully support this legislation.
H.R. 2527, To Amend Title 38, United States Code to Provide Veterans
With Counseling and Treatment for Sexual Trauma That Occurred During
Inactive Duty Training
The VFW supports this legislation which would authorize VA to
provide counseling and treatment to service members who experience
military sexual trauma (MST) during inactive duty training. VA policy
states that veterans are entitled to treatment for all physical and
mental health conditions determined by a VA provider to be related to
MST, without the need for service connection or other enrollment
qualifications. Current law, however, narrowly defines MST as having
occurred while the service member was on active duty or active duty for
training status. This means that many veterans who experienced MST on
inactive duty but while still in uniform, cannot receive the care they
need.
VA is aware of this loophole and included proposals to expand
eligibility for MST treatment to those who experienced MST during
inactive duty in their FY 2014 and FY 2015 budget requests. The VFW
agrees that members of the Reserve Component who experience sexual
trauma during weekend drills or other inactive duty should be entitled
to the same MST-related services as those who experience sexual trauma
while activated, and we encourage the subcommittee to move quickly on
this critical legislation.
H.R. 2661, Veterans Access to Timely Medical Appointments Act
This legislation would codify the 2012 VA goal of completing all
primary care appointments within seven days of the desired date and all
specialty care appointments within fourteen days of the desired date.
Additionally, it would require VA to comply with several
recommendations of a March 2012 Government Accountability Office (GAO)
report including: eliminating scheduler error, providing reliable
appointment wait time data, standardizing the scheduling policy across
all Veterans Integrated Service Networks (VISNs) and VAMCs, restricting
the scheduling system to those who have been properly trained,
improving veterans' phone access, and routine assessments. Although the
VFW strongly supports the recommendations of GAO and the intent of this
legislation to reduce appointment wait times for veterans, we do not
support a statutory mandate of VA's appointment wait time goals at this
time.
In the past, VA has tried to enforce scheduling policies and wait
time standards without proper training of staff and using flawed
tracking programs. GAO found that this often led to data manipulation
by staff in an effort to falsely create the appearance of short wait
times. We are concerned that codifying the VA wait time goals would
apply so much pressure that it would encourage further data
manipulation in order to comply with the law. Transparency and honest
self-assessment will be necessary to truly reduce the wait times
experienced by veterans.
Complicating the well-known deficiencies in VA appointment
scheduling is the fact that VA is still in the process of establishing
productivity standards to determine appropriate physician staffing
levels at its facilities. Simply put, it is impossible to achieve the
greatest level of access if too few providers are available to meet the
demand for care. Accurate appointment scheduling and proper physician
staffing must both be achieved in order to solve the problem of long
appointment wait times.
The VFW is also concerned that this legislation would force VA to
over-utilize purchased care in order to meet its mandates. VA's new
purchased care model, Patient-Centered Community Care (PC3), is still
being implemented. Its effectiveness is still unknown, and it may not
be the best option for many veterans. The VFW wants to see PC3 succeed,
but as a secondary option to direct care, as it was intended, not as
VA's only option to comply with the law. Suddenly sending large numbers
of veterans out of VA for care would not solve the appointment wait
time problem at VA facilities, only camouflaging it.
VA should be given the opportunity to implement its plans for
appointment scheduling, physician staffing, and purchased care before
its self-imposed wait time goals are written into law. Furthermore, VA
should not be discouraged from setting ambitious goals in the future
out of fear that their announcement will be quickly followed by
statutory mandates. In order to solve the problem of long appointment
wait times, the VFW urges continued congressional oversight to ensure
that VA complies with GAO and VA Office of the Inspector General (OIG)
recommendations.
H.R. 2794, To Amend Title 38, United States Code to Provide for the
Eligibility for Beneficiary Travel for Veterans Seeking Treatment or
Care for Military Sexual Trauma in Specialized Outpatient or
Residential Programs at Facilities of the Department of Veterans
Affairs, and for Other Purposes
The VFW supports this legislation which would extend beneficiary
travel benefits to veterans seeking care at VA facilities for
conditions associated with MST. VA currently provides care for all
physical and mental health conditions determined by a VA provider to be
related to MST, without the need for service connection. This care is
provided with no copay charges and without any income eligibility
requirements. Qualifying veterans are eligible for residential
rehabilitation treatment programs, and facilities that do not have
those programs have been directed to refer veterans to those that do in
order to guarantee access. This means that some veterans have to travel
significant distances to receive MST care.
VA travel benefits are currently available to veterans who have a
service-connected (SC) rating of 30 percent or more, are traveling for
treatment of a SC condition, are eligible for pension, or are traveling
for a scheduled compensation and pension examination. Not all veterans
eligible for MST care are included in one of those categories. As a
result, many MST victims may have to forgo the care they need and
deserve, simply because they cannot afford the costs of traveling to
facilities that are able to provide that care.
OIG identified this as a problem in a December 2012 report, stating
that VHA beneficiary travel policies are not properly aligned with MST
policy. They recommended that the travel policy be reviewed. As of now
the travel policy has not changed. This legislation would fix the
problem by adding veterans who are receiving MST treatment to the list
of eligible travel beneficiaries.
H.R. 3508, To Amend Title 38, United States Code, to Clarify the
Qualifications of Hearing Aid Specialists of the Veterans Health
Administration of the Department of Veterans Affairs, and for Other
Purposes
This legislation would authorize VA to hire hearing aid specialists
as full time employees at department facilities to provide hearing
health services alongside audiologists and hearing health technicians.
Hearing aid specialists would assume the responsibilities of performing
in-house repairs, currently performed by technicians, and fitting and
dispensing hearing aids, currently performed by audiologists. Although
we appreciate this bill's intent to increase hearing health access and
reduce wait times for hearing aids and repairs, the VFW believes that
VA has the ability to address these issues under its current hiring
authority.
The VFW strongly believes that VA must improve timeliness in
issuing and repairing hearing aids. A February 20, 2014 OIG report
revealed that 30 percent of veterans are waiting longer than 30 days to
receive new hearing aids, and repairs take an average of 17 to 24 days
to complete, far exceeding the VA 5-day timeliness goal for those
services. According to the report, the long wait times can be
attributed to a steadily increasing work load, which will likely
continue to increase as the veteran population grows older. This
problem is compounded by the fact that many audiology clinics are not
fully staffed. Additionally, OIG found that the Denver Acquisition and
Logistics Center (DALC), which performs major hearing aid repairs for
VAMCs nationwide, lacks an adequate tracking system for the devices it
receives.
To address these problems, OIG recommended that VA develop and
implement productivity standards to determine proper staffing levels in
audiology clinics and establish tracking controls for the hearing aids
received by the DALC. VA concurred with these recommendations and will
include audiology in its implementation plan for productivity
standards. In our opinion, this is the correct course of action. The
VFW believes that adding a new class of provider whose scope of
practice overlaps that of existing employees does not get to the root
of the problem. To fully address the issue, VA must determine the
proper staffing levels of audiologists and hearing health technicians
necessary to meet timeliness standards and increase the number of those
employees accordingly.
H.R. 3180, To Amend Title 38, United States Code, to Include Contracts
and Grants for Residential Care for Veterans in the Exception to the
Requirement That the Federal Government Recover a Portion of the Value
of Certain Projects
The VFW supports this legislation which would allow state veterans
homes that receive residential care contracts or grants from VA to also
contract with VA under the Health Care for Homeless Veterans (HCHV)
supported housing program. Since state veterans homes receive VA
funding for other programs, the recapture clause of section 8136 of
Title 38 prohibits them from receiving HCHV funds. Only those state
veterans homes that also run outpatient VA clinics are currently
exempted from the recapture clause. This means that many state veterans
homes with empty beds are unable to offer them to homeless veterans in
their communities. Similarly exempting them from the recapture clause
would solve this problem.
The Secretary's ambitious five-year plan to end homelessness among
veterans includes six strategic pillars. The sixth pillar is community
partnerships, which certainly must include state veterans homes. The
VFW strongly supports the Secretary's five-year plan and believes that
state veterans homes should be utilized to the fullest extent possible
to ensure its success. As long as there are homeless veterans who need
them, beds in state veterans homes should not remain empty simply due
to the unintended consequences of a federal regulation.
H.R. 3387, Classified Veterans Access to Care Act
The VFW supports this legislation which would require VA to develop
standards and disseminate guidance to ensure that veterans who
participated in sensitive missions or were assigned to sensitive units
are able to access mental health services in a way that does not
require them to improperly disclose classified information.
We are aware that this legislation was inspired by the case of
Daniel Somers, a veteran of sensitive missions in Iraq, who felt that
he was unable to participate in the group therapy sessions offered to
him at the Phoenix VAMC, believing that he would be required to share
classified information with other group members. Tragically, Daniel
Somers took his own life last year. The VFW has been in contact with
his parents, who strongly believe that had their son been offered
individual therapy from the beginning due to the nature of his service,
his suicide may have been prevented. The VFW believes that requiring VA
to develop standards for those who served on sensitive missions is
reasonable and would ensure that veterans feel that they can access the
services they need without violating any nondisclosure responsibilities
they may have.
H.R. 3831, Veterans Dialysis Pilot Program Review Act of 2014
The VFW supports this legislation which would prohibit VA from
expanding the dialysis pilot program until the program has operated at
each initial facility for at least two years, an independent analysis
has been conducted at each facility, and a report is submitted to
Congress.
A May 2012 GAO report found that VA was planning to expand the
pilot, despite not having developed adequate performance measures to
evaluate the existing locations. While the GAO report focused primarily
on cost, the VFW is pleased that the report required by this
legislation would also examine non-cost factors such as access, quality
of care, and veteran satisfaction.
The purpose of any pilot program should be to assess its strengths
and weaknesses on a small scale in order to decide whether or not it
should be expanded. If and when it is instituted on a large scale, it
should be done based on a detailed analysis and lessons learned from
the pilot. Therefore, we believe it is both reasonable and prudent to
require VA to submit a detailed report on the dialysis pilot program
before it is allowed to expand.
H.R. 4198, Appropriate Care for Disabled Veterans Act
The VFW supports this legislation which would reinstate the
requirement for VA to submit an annual report to Congress on its
capacity to provide for the specialized treatment and rehabilitative
needs of disabled veterans. This requirement expired in 2008 and since
that time, it has become apparent that the capacity of VA specialty
care has been inadequate to meet veteran demand. The VFW believes that
current accurate data on VA capacity will greatly assist Congress in
conducting oversight on veterans' access to care.
Since the report was first mandated in 1996, many changes have been
made in the way VA provides specialty care. We look forward to working
with the subcommittee and our Independent Budget Veterans Service
Organization (IBVSO) partners to identify any necessary updates to the
original reporting requirements to ensure future reports are relevant
and actionable.
Draft Bill, To Authorize Major Medical Facility Projects for the
Department of Veterans Affairs for Fiscal Year 2014
This legislation provides VA the authority to enter into 27 major
facility leases, allows VA to construct or lease joint VA/Federal use
medical facilities, expands VA's Enhanced-Use Lease (EUL) authority,
and modifies the authority to build a major medical facility project in
Tampa, Florida.
Sections 1, 2 and 3 provide authorization for VA major facility
leases. It is critical that VA is provided the authority to enter into
the 27 major medical leases. Many of these leases have been awaiting
authorization for nearly two years. Most of these facilities are
Community-Based Outpatient Clinics (CBOC) that have provided direct
medical care in the communities where veterans live. However, since the
current leases have expired and there is a need to expand capacity or
change the physical location of the CBOCs to better serve the needs of
veterans, VA must enter into new leases.
Congress had failed to authorize these leases because of the
Congressional Budget Office's revised scoring model, which now requires
VA to account for the full lease amount in the first year of the lease.
Congress must find a workable solution to allow VA to continue its
major capital leasing projects. Failing to pass this authorization into
law will create greater access and timeliness issues for veterans and
in the end cost VA more as they begin reimbursing veterans for travel
to distant medical centers or pay for fee-based care in the community.
The VFW fully supports these provisions and their quick passage.
Section 4 amends VA's current medical facility construction and
leasing authority to allow VA to enter into joint acquisitions and
leases with other Federal agencies. Currently, when VA sees the value
in co-locating a medical or research facility with another agency,
either VA or the other agency must already own the property and grant
the other agency a portion of the property through an acquisition by
exchange. By amending the current authority, VA will be able to reduce
construction and/or lease costs by acquiring, planning and building
facilities jointly. The VFW sees the value in this authority and we
fully support this provision.
Section 5 amends VA's authority to enter into EULs. In 2012, VA was
forced to modify its EUL authority, greatly reducing its ability to
lease out its unused or underutilized properties. This authority will
greatly widen VA's lease options, thereby producing revenue and
reducing the number of unused or underutilized properties in VA's
inventory. The VFW understands that when VA property is unused or
underutilized, VA still incurs significant costs to maintain it,
ultimately squandering resources that could be better used serving
veterans. This is why the VFW supports the idea of expanding VA's
leasing authority, but we must also point out that VA must make every
effort to lease these unused or underutilized properties for projects
that directly support veterans and their families before considering
other leasing projects.
Sections 6 and 7 authorize modification and the appropriations for
the major medical project in Tampa, Florida. VA has requested that a
previously authorized upgrade to the medical facility bed tower be
reauthorized as a new bed tower at the Tampa, Florida medical center.
The VFW supports this modification.
Mr. Chairman, this concludes my testimony and I look forward to any
questions you and the members of this Subcommittee may have.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, VFW
has not received any federal grants in Fiscal Year 2013, nor has it
received any federal grants in the two previous Fiscal Years.
Prepared Statement of Madhulika Agarwal, M.D., M.P.H.
Good Morning Chairman Benishek, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for inviting me here today to
present our views on ten bills that would affect Department of Veterans
Affairs (VA) health programs and services. Joining me today is Mr.
Philip Matkovsky, Assistant Deputy Under Secretary for Health for
Operations and Management and Ms. Reneee L. Szybala, Acting Assistant
General Counsel.
We do not yet have cleared views on H.R. 3387, H.R. 4198, and H.R.
2974. Also, we do not yet have estimated costs associated with
implementing several of the bills. We will forward these views and any
estimated costs to you as soon as they are available.
H.R. 183, Veterans Dog Training Therapy Act
H.R. 183 would require the Secretary, within 120 days of enactment,
to commence a pilot program for a 5-year period to assess the
effectiveness of using service dog training programs to address post-
deployment mental health and post-traumatic stress disorder (PTSD)
symptoms and produce specially-trained service dogs for Veterans. The
bill would require the Secretary to conduct the pilot program at a
minimum of three and not more than five VA medical centers.
The bill also includes provisions concerning the service dogs
themselves and the personnel assigned to the program. The bill requires
VA to ensure that each service dog in training have adequate
temperament and health clearances. Dogs in animal shelters or foster
homes are not to be overlooked as candidates. The Secretary must also
ensure that each service dog in training is taught all essential
commands and behaviors required of service dogs. The bill would require
each pilot program site to have certified service dog training
instructors with preference given to Veterans who have graduated from a
residential treatment program and are adequately certified in service
dog training.
VA supports the identification of effective treatment modalities to
address PTSD and other post-deployment mental health symptoms; however,
VA does not support the specific provisions in H.R. 183 because the
bill focuses on the training of the dog as opposed to what we believe
is the goal of this legislation, which is finding better ways to
improve the health of this Veteran population by exploring the efficacy
and effectiveness of certain treatments, specifically Animal Assisted
Therapy or Animal Facilitated Therapy, that will prepare dogs to become
service dogs for Veterans.
The restrictions that would be imposed by H.R. 183 regarding the
criteria for the selection of dogs and the qualifications required of
the trainers pose significant challenges to the goal of this
legislation. Provisions requiring medical centers to ensure appropriate
areas for the ``art and science'' of service dog training are focused
on ensuring the quality of the rigorous training regimen required to
produce well-trained service dogs as opposed to the therapeutic
activities that Animal Assisted Therapy or Animal Facilitated Therapy
may provide if appropriately administered as a component of a
comprehensive mental health treatment program. This specialized and
rigorous training regimen for the service dogs falls outside the
purview and mission of VA health care and well beyond the scope of
corporate expertise. These same concerns are extended to provisions
related to the design of the pilot, such as the acceptance of animals
from shelters, educating participants about service dog training
methodologies, practical hands-on training and grooming of service
dogs, ensuring mastery of all essential commands, and residency
requirements for dogs.
The VA Palo Alto Health Care System (Menlo Park Division), in
collaboration with Bergin University of Canine Studies, established the
Palo Alto Service Dog Training Program in July 2008. The Palo Alto
program is not an example of VA independently and internally training
or producing service dogs for Veterans. The dogs involved in the Palo
Alto program were trained to become service dogs by an external
organization, accredited by Assistance Dogs International, over an
extended period of time and subject to standards as adopted and applied
by that organization. The Palo Alto program, using VA facilities for
the therapy portion but relying completely on the external
organization's dog training program, focuses on basic obedience (e.g.,
commands such as ``sit,'' ``stay,'' and ``heel'') and public access
skills (sensitizing dogs to different environments) to prepare the dogs
to become service dogs for disabled persons because VA does not have
the expertise, experience, or resources to develop independent training
criteria or otherwise train or produce safe, high-quality service dogs
for Veterans. Such training is highly specialized and includes the
training of the Veteran who is to receive the service dog.
Cost estimates for this bill were not available at the time of the
hearing.
H.R. 2527, To Provide Veterans With Counseling and Treatment for Sexual
Trauma That Occurred During Inactive Duty Training
H.R. 2527 would amend 38 United States Code (U.S.C.) 1720D to
extend VA's counseling and care benefits for treatment of sexual trauma
to Veterans who experienced sexual trauma while serving on inactive
duty for training. Current authority covers only sexual trauma that a
Veteran experienced while serving on active duty or active duty for
training.
H.R. 2527 would also define the term ``Veteran,'' with respect to
inactive duty training described in section 1720D(a)(1), as amended by
the bill, to include an individual who is not eligible for VA health
care benefits (under 38 U.S.C. chapter 17), and who, while serving in
the reserve components of the Armed Forces, performed such inactive
duty training but did not serve on active duty.
VA supports this bill as it would close a gap in eligibility for
military sexual trauma-related counseling and care. The current gap in
eligibility arises when sexual trauma occurs during weekend drill
trainings for members of the National Guard or Reserves. Weekend drill
trainings are inactive duty training. Unless a Veteran who experienced
sexual trauma while serving on inactive duty for training is eligible
to enroll in VA's health care system and receive needed care under VA's
medical benefits package, VA lacks current authority to treat the
Veteran for conditions resulting from that trauma.
VA anticipates this bill will require minimal additional funding.
H.R. 2661, The Veterans Access to Timely Medical Appointments Act
H.R. 2661 would require the Secretary, not later than 180 days
after enactment, to implement a standardized policy to ensure that
enrolled Veterans are able to schedule primary care appointments within
7 days, and specialty care appointments within 14 days, of the date
such appointment is requested by the Veteran or the Veteran's provider.
In addition, the Secretary would be required to ensure the policy is
not subject to interpretation or prone to scheduling errors and is able
to provide the Secretary with reliable data regarding the length of
time Veterans wait for appointments. The bill would also require VHA,
in carrying out the policy, to use uniform procedures and to issue
detailed guidance to Directors of Veterans Integrated Service Networks
(VISN) to ensure consistent implementation at each VA medical center
(VAMC) and other related VA facilities. The Secretary would be required
to ensure that only VA employees, who have completed required training,
are allowed to schedule medical appointments and that annual
performance reports of each VISN's performance under the policy are
made public.
H.R. 2661 would also require the Secretary, not later than 180 days
after enactment and each 180-day period thereafter, to assess the
resources of each VISN to determine the ability of the VISN to meet its
scheduling requirements. To ensure that each VISN meets the scheduling
requirements of its enrollees, the Secretary would be authorized to
reprogram funds and to allocate or transfer staff and other resources
within VHA and the VISN; however, Congress would need to be notified of
any such reprogramming.
The bill would further require the Secretary to direct each VAMC to
provide oversight of telephone access and to implement the best
practices outlined in VHA's Telephone Improvement Guide including, at a
minimum, practices to ensure calls are answered in a timely manner and
that patients' messages are returned with a call within 24 hours. Each
VAMC's call center would also need to be properly staffed to meet the
demands of its patient-population.
Finally, H.R. 2661 would require VA's Office of Inspector General,
in consultation with Veterans Service Organizations, to submit a
detailed annual report to Congress on VA's progress in implementing the
requirements of the bill.
VA does not support H.R. 2661. VA continues to make progress in the
reliability of measuring and reporting waiting times. This process is
heavily dependent on the software, technology and business processes
available at the time. Mandating the timeframe within which a patient
must receive an appointment is ill-advised because the process of
scheduling is multi-factorial, and flexibility is required to ensure
that scheduling occurs in a manner that is in line with clinical
operating standards, which can evolve over time. This also extends to
clinical contacts made by telephone. We also are uncertain of the basis
for the inflexible timetables that would be mandated by H.R. 2661. We
would be interested in discussing this issue with the Committee,
including the need for flexibility while ensuring Veterans receive
access to high-quality health care.
VA believes the telephone-related elements of the bill state
valuable principles but could conflict with our ongoing efforts. The
practices outlined in the Telephone Improvement Guide are currently
being tested at both the VISN and facility level. In addition, three
VISNs are investigating the use of specific communication models to
assess the most effective approach by which to provide Veterans with
responsive, available telephone service. It may be that these models
will prove more efficient and preferable to what is used now or even to
what would be required by H.R. 2661. Similar to scheduling procedures
and other clinical operational matters, we believe codifying in law the
details of how VA communicates with our patients is ill-advised. Once
in statute, such terms could well end up preventing VA from identifying
and using newer and more effective mechanisms and procedures that
better align with clinical operational and clinical practice standards.
VA is unable to estimate the cost of this bill.
H.R. 2974, To Provide Beneficiary Travel Eligibility for Veterans
Seeking Treatment or Care for Military Sexual Trauma
H.R. 2974 would amend 38 U.S.C. 111(b)(1) to ensure beneficiary
travel eligibility for Veterans whose travel to a specialized
outpatient or residential program at a VA facility for treatment or
care for military sexual trauma. The bill would define the term
``military sexual trauma'' in 38 U.S.C. 111 to mean ``psychological
trauma, which in the judgment of a Department mental health
professional, resulted from a physical assault of a sexual nature,
battery of a sexual nature, or sexual harassment which occurred while
the Veteran was serving on active duty or active duty for training;''
and the bill would define the term ``sexual harassment'' to mean
``repeated, unsolicited verbal or physical contact of a sexual nature
which is threatening in character.'' The amendments made by this
legislation would apply with respect to travel occurring after
enactment.
VA is currently reviewing this bill and will provide a position
upon completion of this review. As a technical matter, we note that the
bill purports to add a new subsection (g) to section 111 of Title 38
U.S.C. We believe the drafters intended to add a new subsection (h) to
section 111 instead, as the bill makes no mention of striking the
current subsection (g) in section 111.
Cost estimates for this bill were not available at the time of the
hearing.
H.R. 3180, To Provide an Exception to the Requirement That the Federal
Government Recover a Portion of the Value of Certain Projects
H.R. 3180 would authorize VA to contract with, or award a grant to,
a state for residential care for Veterans in a state home without
triggering the recapture of the state home construction grants
previously awarded to the state for that home. The term ``residential
care'' is not defined in Title 38 U.S.C. For purposes of the community
residential care program, the term ``community residential care'' is
defined in 38 CFR Sec. 17.62 to mean ``the monitoring, supervision,
and assistance, in accordance with a statement of needed care, of the
daily living activities of referred Veterans in an approved home in the
community by the facility's provider.'' However, VA cannot provide
grants or contracts for such care under that program. See 38 U.S.C.
Sec. 1730(b)(3). Nevertheless, under another authority, 38 U.S.C.
Sec. 1720(g), VA may contract with appropriate entities to provide
specialized residential care and rehabilitation services to an
Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF)
Veteran, who VA determines suffers from a traumatic brain injury, has
an accumulation of deficits in activities of daily living and
instrumental activities of daily living, and because of these deficits,
would otherwise require admission to a nursing home even though such
care would generally exceed the Veteran's nursing needs. If H.R. 3180
is enacted, VA could contract with states to provide residential care
in a state home under section 1720(g) without triggering the recapture
of a grant.
VA does not support enactment of this bill because it would
authorize VA to contract with state homes without triggering the
recapture of the state home construction grants previously awarded to
the state for that home for care for which they currently receive VA
per diem payments under the VA State Home Grant Program. State Veterans
homes can provide any combination of three levels of care: nursing
home, domiciliary, and adult day health care without being subject to
the recapture of any VA construction grant. Domiciliary care is
essentially specialized residential care that VA may contract for under
38 U.S.C. Sec. 1720(g). State Veterans homes that provide domiciliary
care should thus be capable of providing specialized residential care
and rehabilitation services for OEF/OIF Veterans who suffer from a
traumatic brain injury.
There are no current requests from states for state Veterans homes
to provide residential care under VA contract or grant. Thus, VA cannot
predict future costs that would be associated with this bill.
H.R. 3508, To Clarify the Qualifications of VA Hearing Aid Specialists
H.R. 3508 would amend 38 U.S.C. 7401(3) to include hearing aid
specialists among personnel who may be appointed by VA as the Secretary
may find necessary for the health care of Veterans. The bill would also
amend 38 U.S.C. 7402(b) to specify qualifications for hearing aid
specialists, including requiring the individual ``hold an associate's
degree in hearing instrument sciences, or its equivalent, from a
college or university approved by the Secretary, or have successfully
completed a hearing aid specialist apprenticeship program approved by
the Secretary,'' and ``be licensed as a hearing aid specialist, or its
equivalent, in a State.'' Hearing aid specialists who do not meet these
requirements would still be eligible for appointment to a hearing aid
specialist position if, during the 2 years prior to enactment of the
bill, the individual ``held an unrevoked, unsuspended hearing aid
license, or its equivalent, in a State,'' and ``worked as a licensed
hearing aid specialist in a State.''
In addition, H.R. 3508 would require VA, no later than 1 year after
enactment and each year thereafter, to report to Congress on timely
access to hearing health services and contracting policies with respect
to providing hearing health services in non-VA facilities. VA would be
required to include in the report VHA staffing levels of audiologists,
health technicians in audiology, and hearing aid specialists; a
description of performance measures with respect to appointments and
care related to hearing health; average wait times for specified
appointments; percentages of patients whose wait times fell within
specified time frames; the number of patients referred to non-VA
audiologists for initial hearing health diagnosis appointments and to
non-VA hearing aid specialists for follow-up hearing health care; and
VHA policies regarding referral to non-VA hearing aid specialists and
how such policies will be applied under the Patient-Centered Community
Care initiative.
Finally, H.R. 3508 would require VA, no later than 180 days after
enactment, to update and reissue VHA Handbook 1170.02, VHA Audiology
and Speech-Language Pathology Services, to reflect the requirements of
this bill.
VA values the current contribution being made by hearing aid or
instrument specialists to hearing loss treatment and evaluation
services, however, VA does not believe this bill is necessary as the
Secretary already has existing authority under 38 U.S.C. Sec. 7401(3)
to appoint such specialists if deemed necessary to support the
recruitment and retention needs of the Department. In addition, the
Secretary already has authority under 38 U.S.C. Sec. 7402(b) to
establish qualification standards for health care occupations,
including establishing technical qualifications for hearing aid
specialists. VA believes this bill's language unduly restricts the
Secretary's latitude to establish qualification standards under this
authority, and that existing procedures for establishing qualifications
standards under title 5 series 640 or hybrid Title 38 are sufficient.
Also, VA is concerned that the lack of standardized educational or
professional health licensure requirements could fragment hearing
health care services and limit delivery of comprehensive hearing health
care under the language in H.R. 3508.
A highly trained workforce is required to deliver comprehensive
services and coordinate care in the VA health care system, given VA's
mission to provide comprehensive patient-centered health care.
Utilizing occupations that are limited in training and scope for
comprehensive hearing health services under the proposed legislation
would fragment the current high-quality health care delivery system,
especially because Veterans frequently exhibit hearing loss in
combination with other co-morbidities.
VA audiologists are doctoral-level professionals trained to
diagnose and treat hearing loss, acoustic trauma and ear injuries,
tinnitus, auditory processing disorders, and patients with vestibular
complaints. VA provides comprehensive hearing health care services and
employs both audiologists and audiology health care technicians who
deliver care coordinated within the Patient Aligned Care Team (PACT).
VA can appoint hearing aid specialists as audiology health technicians
in job series 640 (health technicians) under title 5. VA currently
employs 318 audiology health technicians (also commonly known as
audiology assistants) who function under the supervision of
audiologists. Some of these audiology health technicians are licensed
as hearing aid specialists, although they are hired as health
technicians whether or not they are licensed as hearing aid
specialists.
Audiology health technicians, currently employed in audiology
clinics as valued members of the audiology team and working under the
direction of audiologists, have a broader scope of practice than the
typical hearing aid specialist. VA developed this job series and
associated core competencies for health technicians to provide
efficient support services and assist audiologists in the provision of
comprehensive hearing care. Examples of the scope of services include
cerumen management, aural rehabilitation, hearing conservation and
prevention of noise-induced hearing loss, tinnitus management, hearing
aids and other amplification technologies including implantable
auditory devices, and management of Veterans' hearing health care with
other health care disciplines in the context of their overarching
patient-centered needs.
The VA audiology health technician has duties and responsibilities
beyond those allowed by state law for hearing aid specialists. The
hearing instrument specialist occupation has no consistent professional
education requirements and no standardized internships resulting in
highly-variable skill sets. In 33 states, only a high school education
is required for hearing instrument specialist licensure. Nine states
have no educational requirement and eight states require an associate's
degree. As a result, based on hybrid Title 38 grade-related education
requirements, hearing instrument specialists are likely to be hired at
low grades making less money working for VA than they would earn
working in the retail business community where they are licensed to
sell hearing aids. Hearing instrument specialists are licensed to sell
hearing aids and are regulated primarily for their hearing aid sales
roles. The license does not require professional education, clinical
training, or experiential health care apprenticeships, and the
licensure qualifications have not changed in many years. They are not
part of any health care teams in the military, the academic or medical/
professional school environment, or the hospital environment.
Substituting the VA audiology health technician with a hearing
instrument specialist would fragment hearing health care services and
limit delivery of comprehensive hearing health care.
Finally, with respect to the treatment of ``certain current
specialists'' in section 1(b) of the bill, we note that VHA does not
appoint hearing aid specialists, and none are actively practicing in
VHA as hearing aid specialists. Some audiology assistants (health
technicians) are licensed as hearing aid specialists and may use these
skills in performing their duties, but they were hired as health
technicians and function under the scope of practice defined in their
position description.
Cost estimates for this bill were not available at the time of the
hearing.
H.R. 3831, The Veterans Dialysis Pilot Program Review Act
If enacted, H.R. 3831 would prohibit VA from expanding VA's
dialysis pilot program or creating any new dialysis capability provided
by VA in any facility other than the four participating free-standing
dialysis facilities until three requirements have been met: VA has
implemented the pilot program at each facility for at least 2 years; VA
has provided for an independent analysis of the pilot program at each
facility; and VA has submitted a report to Congress. The required
report must include the results of the independent analysis and a
comparison of both cost and non-cost factors (such as access to care,
quality of care, and Veteran satisfaction) concerning the dialysis
pilot program, and must address any recommendations from the Government
Accountability Office with respect to the pilot. The bill would also
require the Secretary to fully utilize VA dialysis resources in
existence at the time this bill is enacted, including utilization of
any community dialysis provider with whom the Secretary has entered
into a contract or agreement for the provision of such care.
VA fully supports using the results of our ongoing dialysis pilot
program to inform the expansion of dialysis care by VA. However, VA is
concerned that enactment of this bill in its current form would delay
activating additional VA free-standing dialysis centers, which could
adversely impact VA's efforts to optimize Veterans' dialysis care. This
bill would have the effect of preventing VA from creating any new
dialysis capacity until July 2015 because one of the pilot facilities
(Cleveland, Ohio) did not activate until July 2013. Delaying expansion
would also adversely impact VA's ability to realize potential cost
savings associated with free-standing dialysis centers.
VA has already developed an evaluation plan to assess performance
of each pilot. Additionally, VA has contracted with the University of
Michigan-Kidney Epidemiology and Cost Center (UM-KECC) to conduct an
independent analysis of the pilot facilities. In fiscal year 2013, UM-
KECC produced five clinical quality and four cost reports analyzing the
performance of the Raleigh and Fayetteville, North Carolina pilots. UM-
KECC will be producing these reports for all four pilot sites in fiscal
year 2014.
VA is ready to work with the Committee to ensure the Committee is
briefed on the results of the pilot program before establishing any new
free-standing dialysis centers.
Cost estimates for this bill were not available at the time of the
hearing.
Draft Bill To Authorize Major Medical Facility Projects for the
Department of Veterans Affairs for Fiscal Year 2014 and for Other
Purposes
The draft bill represents the Administration's request for its
fiscal year 2014 construction program and includes other measures
useful for VA. It authorizes numerous individual medical leases
proposed by VA, including those proposed in its fiscal year 2013
budget, and includes provisions aimed at facilitating more streamlined
planning, construction, and leasing for joint VA/Federal-use medical
facilities. The bill would also enhance VA's Enhanced-Use Lease
authority and authorize major construction funds for VHA facilities in
Tampa, Florida. Mr. Chairman, we appreciate your inclusion of this
Administration request on the agenda today.
Conclusion
Mr. Chairman, this concludes my statement. Thank you for the
opportunity to appear before you today. I am ready to respond to
questions you or the other Members of the Subcommittee may have.
FOR THE RECORD
House Committee on Veterans' Affairs, Subcommittee on Health
Hearing on Pending Health Care Legislation
March 27, 2014
Rep. Kevin McCarthy
Chairman Benishek, Ranking Member Brownley and Members of the
Subcommittee
Thank you for allowing me to testify on legislation I introduced,
H.R. 2661, the Veterans Access to Timely Medical Appointments Act. This
bill is based on the Government Accountability Office (GAO) audit on
the Veterans Health Administration's (VHA) scheduling of timely medical
appointments, as well as a Veterans Affairs Oversight and Investigation
Subcommittee hearing on the audit's findings. After disappointing
responses from leadership at the Department of Veterans Affairs (VA), I
decided to take legislative action to implement the GAO's
recommendations to improve the wait times our veterans face to receive
care.
Chairman Miller and I led 28 other members in requesting the GAO to
conduct this audit on the VHA regarding its scheduling of medical
appointments because I was receiving numerous complaints from veterans
in my district who were waiting months for crucial medical appointments
at either the local VA clinic in Bakersfield or at the VA Medical
Center in Los Angeles. This audit was released over a year ago and to
this day, the complaints of poor service from the VA to schedule timely
medical appointments is still one of the most frequent by veterans in
my district. I would also note that according to the GAO's website,
none of its recommendations have yet to be implemented by the VA.
H.R. 2661 would legislatively implement the GAO's recommendations
and aid the VA in developing a better scheduling policy so veterans can
have timely access to needed care. Specifically, it addresses the GAO-
identified factors contributing to unreliability of appointment wait
times by mandating the VA to improve their
medical appointment scheduling policy within 180 days of the bill's
enactment. The bill requires the VA to schedule primary care
appointments within seven days and specialty care appointments within
fourteen days--goals used internally by VA supervisors and identified
within the GAO report. It also addresses the allocation of scheduling
resources to meet the demands of veterans, and to ensure timely medical
appointments by improving the VA's telephone access and responsiveness.
GAO found that the VA's positive wait time reports are far greater than
veterans actually experience. This is due to a number of reasons,
including unreliable data input by VA employees, the VA not requiring
stricter adherence to scheduling policy, and a lack of over sight on
the scheduling process as a whole.
The VA's 2015 Budget request does not sufficiently address the wait
times new veterans face when scheduling medical appointments and
receiving care. It only marginally decrease times and provides no
accountability measures. We have tens of thousands of new veterans who
served in Iraq and Afghanistan who can't get appointments in a timely
fashion. The VA's recent Performance Accountability Report says that
41% of new primary care appointments are scheduled within 14 days of
the creation date, and 40% of new specialty care appointments are
within 14 days of the creation date. This means that over 60% of these
veterans aren't getting appointments within two weeks. It concerns me
that the budget submission only marginally increases scheduling goals
to 51% and 45% respectively, and reveals a lack of urgency within the
VA to ensure funding reduces wait times. Why should veterans and
Congress tolerate such low targets?
There have also been recent news stories on a supposed
whistleblower who alleges that the VA's Greater Los Angeles Medical
Center, which serves the health care needs of my constituents,
``administratively closed'' about 40,000 appointments in order to
reduce the medical appointment backlog to make its numbers look better.
According to Dr. Petzel--who spoke briefly about this issue during a
Subcommittee on Health Oversight Hearing last month--no patients were
denied care and there was no attempt to destroy records in this
instance. With an ongoing investigation, I was surprised by this
testimony. That is why Chairman Benishek and I requested an independent
investigation of these allegations, for which we are still waiting on
the results. Regardless, it is still not clear to me that the needs of
these 40,000 veterans were adequately met by the Department. This
highlights the troubled scheduling system within the VA and that it is
not meeting the needs of our nation's veterans.
I am confident that H.R. 2661 will help the VA better meet the
needs of the veterans it serves with timely access to medical
appointments by creating a cohesive and unified scheduling policy that
is both reliable and predictable. After a decade of war, it is our
responsibility as Members of Congress to ensure that the department
created to serve the men and women returning home and discharged of
their military service have access to the care they need. I look
forward to continuing to work with Chairman Miller, this committee, the
Veterans Service Organizations, and my constituents to see that we
solve the problems within the VA and help create a better system to
serve our veterans.
American Academy of Otolaryngology--Head and Neck Surgery
The American Academy of Otolaryngology--Head and Neck Surgery (AAO-
HNS) thanks the Subcommittee for the opportunity to submit a statement
for the record regarding H.R. 3508, a bill to amend Title 38, United
States Code, to clarify the qualifications of hearing aid specialists
of the Veterans Health Administration of the Department of Veterans
Affairs, and for other purposes.
The AAO-HNS, with approximately 12,000 members nationwide, is the
medical specialty society for physicians dedicated to the care of
patients with disorders of the ears, nose, throat (ENT), and related
structures of the head and neck. Our members are specifically trained
to provide hearing-impaired patients with a full medical evaluation,
diagnosis, and treatment for their hearing disorders. Given the
specialization of our members, the AAO-HNS closely monitors various
pieces of legislation pertaining to the delivery of hearing health care
services, including H.R. 3508.
The AAO-HNS strongly supports the development and utilization of VA
programs designed to broaden veterans' access to quality hearing health
care services, and recognizes that in some areas, current VA programs
are failing to meet the needs of the veteran population. However, while
the AAO-HNS does not officially oppose H.R. 3508 at this point in the
legislative process, we believe current Congressional action to advance
the bill is premature and may represent an unnecessary legislative
approach to address process failures within the VA.
It is our understanding that the purpose of H.R. 3508 is to
mitigate an ongoing issue within the VA regarding long wait times for
hearing aids and hearing health care services for veterans in general.
While this is a laudable goal, we are concerned that the bill,
spearheaded by the national association representing hearing aid
dispensers, would have unintended consequences. We find it necessary to
register our concerns for the record so the members of this
Subcommittee are fully advised of its potential impact.
Timing of Legislation
Hearing-related issues, including hearing loss and tinnitus, are
among the most common injuries within our nation's population of active
and retired service men and women. The proliferation of these types of
injuries among veterans presents a serious challenge for the VA. In
fact, the AAO-HNS believes that the VA should explore all appropriate
means necessary to ensure the delivery of high-quality hearing health
care services.
However, efforts to expand access to care must be balanced and
include assurances that veterans are being cared for by the most
qualified and appropriate hearing health care professionals. Hearing
loss and tinnitus, particularly within the veteran population, are
complex health issues, and therefore require a more comprehensive
approach in regards to treatment.
While the AAO-HNS contends that the underlying intent of H.R. 3508
to ensure robust hearing-health related services are available to
veterans is commendable, we are concerned that the course of action
outlined in the bill attempts to legislatively correct what should, at
least initially, be viewed as a ``process'' issue within the VA.
Following a February 2014 audit of the VA's hearing health
services, the VA Office of Inspector General (OIG) released a report
outlining existing problem areas within the VA system. Specifically,
the report recognized that inadequate staffing, coupled with
inefficient operations/processes, at a major VA hearing aid center in
Denver, CO (where a large percentage of hearing aids are repaired),
accounted for much of the issue relating to long wait times. Based on
the report's findings, the OIG recommended that the VA focus its
immediate efforts on developing a plan for implementing more
consistent/cohesive standards for audiology and hearing care centers in
general.
Given the OIG report and its recommendations for improving existing
processes within the VA, the AAO-HNS contends that it is premature to
pursue a legislative remedy for issues that may potentially be resolved
via internal process changes.
Inclusion of Hearing Aid Specialists in OIG Report
As stated, the AAO-HNS believes the VA should have the opportunity
to conduct and implement a plan related to the productivity standards
and staffing for audiology clinics, as recommended by the recent OIG
audit, prior to passage of any legislation related to the provision of
hearing health care services by the VA. We maintain that one of the
main tenets of H.R. 3508--to allow hearing aid specialists the ability
to directly contract with the VA--is duplicative to the current
statutory authority of the VA. In fact, 38 U.S.C. 7401 allows the
Secretary to appoint ``such other classes of health care occupations as
the Secretary considers necessary for the recruitment and retention
needs of the Department.'' Given that hearing aid specialists in some
locations are already being contracted with by the VA to provide
limited hearing health services, the Secretary should take hearing aid
specialists in consideration when developing care plans and remedies as
it implements the recommendations set forth in the OIG report.
Additional Considerations/Concerns Relating to H.R. 3508
If after the implementation of the OIG's recommendations,
legislation is still deemed necessary, the AAO-HNS looks forward to
working with the bill's sponsors and this Subcommittee to address the
below concerns with the current draft of H.R. 3508.
Inclusion of hearing aid specialists in 38 USC 7402(b) as a
new paragraph (14) rather than inclusion in the existing ``catch-all''
paragraph (14) with other health care professionals with comparable
training [see Section (1)(a)(2)].
Inclusion in Section (1)(c)(3)(B) of the bill the provisions
of certain services by hearing aid specialists as described in Section
(1)(c)(2)(C). Most notably, disability rating evaluations, primary
hearing aid evaluations, and ordering of hearing aids are beyond the
existing state laws governing the appropriate scope of practice of
hearing aid dispensers.
Inclusion of Section (1)(d) requiring the Secretary to
``update and re-issue'' the handbook entitled ``VHA Audiology and
Speech Language Pathology'' based upon the findings of the bill's
required report. The AAO-HNS is concerned with this particular
provision, especially without a requirement for stakeholder and
Congressional input, given the VA's unilateral revisions set forth in a
recently updated version of its nursing handbook.
In conclusion, the AAO-HNS appreciates the opportunity to comment
on this critical issue and to work with all interested (and impacted)
parties to ensure our nation's veterans have timely access to and
receive the highest quality hearing health care services. However, for
the reasons set forth above, we respectfully urge the Subcommittee to
not advance H.R. 3508 at this time and await the implementation of the
OIG's recommendations.
Thank you for your consideration. To receive additional
information, please contact Megan Marcinko, AAO-HNS Senior Manager for
Congressional & Political Affairs, at [email protected] or 703-535-
3796.
Department of Veterans Affairs Office of the Inspector General
March 25, 2014
The Hon. Dan Benishek, MD, Chairman
Subcommittee on Health, Committee on Veterans' Affairs,
United States House of Representatives,
Washington, DC 20515
Dear Mr. Chairman:
This is in response to your March 20, 2014, request for the views
of the Office of Inspector General on legislation the Subcommittee will
be considering on March 27, 2014. Specifically, we are concerned about
the requirements for the Office of Inspector General (OIG) contained in
Section 3(d) of H.R. 2661, The Veterans Access to Timely Medical
Appointments Act, which would require the OIG to submit an annual
report on the Secretary's progress in implementing the requirements
contained in the bill. We are concerned about the following issues:
Consultation with veteran service organizations (VSOs)--The
bill requires the OIG to consult with Veteran Service Organizations
(VSOs) as we prepare the report. The OIG's independence is key to
producing reports that are a fair and balanced review of VA programs
and operations. We believe that a statutory requirement to consult with
and ostensibly gain the consensus of VSOs, or any other stakeholders,
in the course of an OIG review can impinge on our independent authority
to plan the scope and methodology of our work, and sets a troubling
precedent.
Annual Report--The OIG has a finite capacity to conduct and
complete timely and relevant assessments of VA programs and operations.
With an already substantial number of mandatory audits such as FISMA
and the Consolidated Financial Statements, the addition of another
annual reporting requirement on waiting times limits our flexibility to
plan other oversight projects on current or emerging areas of concern
on VA programs. Since 2001, the OIG has issued eight reports \1\
dealing with inaccurate waiting times. While we fully expect to follow
up on this important issue as the need arises in the future, we do not
believe an annual requirement in statute is necessary. Furthermore, an
annual reporting requirement may not allow sufficient time to measure
the effectiveness of actions taken by VA to implement recommended
corrective actions from the OIG's prior year reports.
\1\ Review of Veterans' Access to Mental Health Care (April 23,
2012); Veterans Health Administration Review of Alleged Use of
Unauthorized Wait Lists at the Portland VA Medical Center (August 17,
2010); Review of Alleged Manipulation of Waiting Times, North Florida/
South Georgia Veterans Health System (December 4, 2008); Audit of
Veterans Health Administration's Efforts to Reduce Unused Outpatient
Appointments (December 4, 2008); Audit of Alleged Manipulation of
Waiting Times in Veterans Integrated Service Network 3 (May 19, 2008);
Audit of the Veterans Health Administration's Outpatient Waiting Times
(September 10, 2007); Audit of the Veterans Health Administration's
Outpatient Scheduling Procedures (July 7, 2005); Audit of the
Availability of health care Services in the Florida/Puerto Rico
Veterans Integrated Service Network (VISN) 8 (August 13, 2001).
---------------------------------------------------------------------------
We would also like to comment on H.R. 2974, ``To amend Title 38,
United States Code, to provide for the eligibility for beneficiary
travel for veterans seeking treatment or care for military sexual
trauma in specialized outpatient or residential programs at facilities
of the Department of Veterans Affairs, and for other purposes,'' which
would address a recommendation we made in our report, health care
Inspection--Inpatient and Residential Programs for Female Veterans with
Mental Health Conditions Related to Military Sexual Trauma. This
legislation would allow VA to pay for travel for veterans being treated
for mental health issues related to military sexual trauma at any VA
facility regardless of the location. We support this legislation.
Thank you for your interest in the Department of Veterans Affairs.
Sincerely,
Richard J. Griffin, Acting Inspector General
International Hearing Society
Chairman Benishek, Ranking Member Brownley, and esteemed Members of
the Subcommittee:
International Hearing Society thanks you for the opportunity to
comment on H.R. 3508. IHS stands in full support of the bill, which
would create a new provider class for hearing aid specialists within
the Department of Veterans Affairs (VA), thereby enabling the VA to
hire hearing aid specialists to help deliver hearing aid services to
Veterans. The bill would also require the VA to report annually to
Congress on appointment wait times and the utilization of providers for
hearing-related services, which would make the VA's efforts to address
the backlog more transparent and provide much needed data to inform
Congress about Veterans' experiences in accessing hearing aid services
through the VA.
The International Hearing Society, founded in 1951, is a
professional membership organization that represents hearing aid
specialists, dispensing audiologists, and dispensing physicians,
including the approximately 9,000 hearing aid specialists who practice
in the United States. IHS promotes and maintains the highest possible
standards for its members in the best interests of the hearing-impaired
population they serve by conducting programs in competency
accreditation, testing, education and training, and encourages
continued growth and education for its members through advanced
certification programs.
The VA has seen a dramatic rise in the demand for audiology
services in the last five years. According to the VA there were
1,617,377 outpatient audiology visits \1\ in 2012, up 36% from 2009.\2\
The number of hearing aids ordered per year has also dramatically
increased with more than 665,000 ordered over the 12-month period
ending in September 2012,\3\ up from 475,945 in FY 2009,\4\ or an
increase of 39% in four years. With tinnitus and hearing loss being the
two most prevalent service-connected disabilities for veterans
receiving federal compensation, the demand will continue to rise. And
despite audiologist-hiring following a similar growth track with a 34%
increase in staffing between 2009 and 2013, the high demand and
subsequent backlog continue to affect the VA's ability to deliver
timely and high-quality hearing health care.
---------------------------------------------------------------------------
\1\ 2013 Presentation to the Joint Defense Veterans Audiology
Conference, ``Update on the VA Audiology Program'', Lucille B. Beck,
PhD
\2\ 2010 Presentation to the Joint Defense Veterans Audiology
Conference, ``21st Century Approach to VA Audiology Care'', Lucille B.
Beck, PhD
\3\ VA Office of Inspector General report ``Audit of VA's Hearing
Aid Services,'' February 20, 2014
\4\ 2010 Presentation to the Joint Defense Veterans Audiology
Conference, ``21st Century Approach to VA Audiology Care'', Lucille B.
Beck, PhD
---------------------------------------------------------------------------
IHS and its membership have a great deal of respect for VA
audiologists. They provide a wide variety of critical services to our
Veterans, including compensation and pension exams (over 157,247
performed in 2012 for 151,934 Veterans), programming and providing
support for cochlear implant implantation and use, vestibular (balance)
disorder services, tinnitus services, hearing conservation, hearing aid
services, and advanced hearing testing. VA audiologists are also
responsible for training and supervising audiology health technicians.
The high demands on VA audiologists' time and expertise means that
the VA is not currently able to meet all Veterans' needs for hearing
health care services. To that point, in February 2014, the VA Inspector
General released a report, ``Audit of VA Hearing Aid Services'' that
found that ``during the 6-month period ending September 2012, VHA
issued 30 percent of its hearing aids to veterans more than 30 days
from the estimated date the facility received the hearing aids from its
vendors.'' The audit also found that deliveries of repaired hearing
aids to Veterans were subject to delay partially due to ``inadequate
staffing to meet an increased workload, due in part to the large number
of veterans requiring C&P audiology examinations.''
In a practical sense, as a result of the backlog and delays, many
Veterans are experiencing long wait times for appointments, shortened
appointments, and limited follow-up care and counseling. And hearing
aid specialists are observing an increase in the number of Veterans who
seek care in their private offices as well. These Veterans request
hearing aid specialists' help with hearing aid adjustments and repairs,
oftentimes because they do not want to wait for the next available VA
appointment, which may be months away, or because the distance to the
closest VA facility that offers audiology services is too far to
travel. We also have many Veterans who choose to purchase hearing aids
at their own expense through a private hearing aid specialist, rather
than using the benefits they've earned and are entitled to, because
they want to work with someone local who they trust.
Considering the safety risks involved as well as the impact
untreated hearing loss can have on one's personal relationships and
mental well-being, the VA needs an immediate solution to deal with the
backlog and get Veterans the help they need. We also know that our
working-age Veterans are anxious to contribute to society through
employment, and properly fit and adjusted hearing aids are necessary
for their success in obtaining and maintaining a job.
H.R. 3508 provides the VA a much needed solution by creating a new
provider class for hearing aid specialists to work within the VA.
Hearing aid specialists can help the VA hearing health care team by
providing hearing aid evaluations; hearing aid fittings and
orientation; hearing aid verification and clinical outcome
measurements; customary after care services, including repairs,
reprogramming and modification; and the making of ear impressions for
ear molds--just as they are currently authorized to do in the VA's fee-
for-service contract network.
By adding hearing aid specialists to the audiology-led team to
perform these specialized hearing aid services independently,
audiologists will be able to focus on Veterans with complex medical and
audiological conditions, as well as perform the disability evaluations,
testing, and treatment services for which audiologists are uniquely
qualified to provide--thereby creating efficiencies within the system
and supporting the team-based approach. Adoption of the hearing aid
specialist job classification at this juncture will also be
advantageous given the fact that VA Audiology and Speech Pathology
Service management will be developing staff and productivity standards
as a result of the Inspector General's audit and recommendations,\5\
and would be able to consider the use of hearing aid specialists as
they develop their model.
---------------------------------------------------------------------------
\5\ VA Office of Inspector General report ``Audit of VA's Hearing
Aid Services,'' February 20, 2014
---------------------------------------------------------------------------
Also, by virtue of the report language in H.R. 3508, which would
shine a light on the VA's utilization of hearing aid specialists in its
contract network, it is our hope that the VA would take better
advantage of this willing and able provider type to help address the
need for hearing aid services.
Hearing Aid Specialist Qualifications
Hearing aid specialists are regulated professionals in all 50
states and in the non-VA market, hearing aid specialists perform
hearing tests and dispense 50% of hearing aids to the public. They are
licensed/registered to perform hearing evaluations, screen for the Food
and Drug Administration (FDA) ``Red Flags'' indicating a possible
medical condition requiring physician intervention, determine candidacy
for hearing aids, provide hearing aid recommendation and selection,
perform hearing aid fittings and adjustments, perform fitting
verification and hearing aid repairs, take ear impressions for ear
molds, and provide counseling and aural rehabilitation.
Training for the profession is predominantly done through an
apprenticeship model, which works very well given the hands-on and
technical skill involved. And while licensure requirements vary from
state to state, in addition to the apprenticeship experience,
candidates generally must hold a minimum of a high school diploma, or
they must hold an associates degree in hearing instrument sciences.
Based on an industry study, we know that the actual level of schooling
of a hearing aid specialist on average is an associates degree or
higher. In nearly every state, candidates must pass both written and
practical examinations, and in many states a distance learning course
in hearing instrument sciences is required or recommended.
Hearing aid specialists are already recognized by several Federal
agencies to perform hearing health care services. The Standard
Occupational Classification (SOC) identifies hearing aid specialists
within the health care Practitioners and Technical Occupations category
(29-2092), and the Federal Employee Health Benefit program and Office
of Policy and Management support the use of hearing aid specialists for
hearing aid and related services. And while Medicare does not cover
hearing testing for the purpose of recommending hearing aids (a policy
that applies to all dispensing practitioners), hearing aid specialists
provide hearing testing, hearing aids, and related services for state
Medicaid programs around the country. Further, many insurance companies
contract with hearing aid specialists to provide hearing tests and
hearing aid services for their beneficiaries.
Finally, evidence shows that there is no comparable difference in
the quality and outcomes of hearing aid services based on site of
service or type of provider. A well-respected industry study found that
instead the best determinant of patient satisfaction is whether the
provider used best practices like fit verification, making adjustments
beyond the manufacturer's initial settings, providing counseling, and
selecting the appropriate device for one's loss and manual
dexterity.\6\
---------------------------------------------------------------------------
\6\ MarkeTrak VIII: The Impact of the Hearing Health Care
Professional on Hearing Aid User Success, The Hearing Review, Vol 17
(No.4), April 2010, pp. 12-34.
---------------------------------------------------------------------------
VA Strategies To Address Demand
To address the demand for audiology and hearing aid services, the
VA has been relying on the use of teleaudiology, audiology health
technicians, and contract audiologists outside the VA setting. While
IHS applauds the VA for its efforts to better serve the needs of
Veterans, each of these strategies has its limitations. Though
teleaudiology can make audiological services more available in remote
settings, the cost of staffing and facilities are needlessly high,
especially given that hearing aid specialists have fully-equipped
offices, oftentimes operate in rural settings, and perform home and
nursing home visits. Audiology health technicians have a very limited
scope of duties, which does not include hearing aid tests or the
fitting and dispensing of hearing aids, and must be supervised by
audiologists. Finally, increased reliance solely on contract
audiologists may also limit access as there are not enough audiologists
to fill the current and future need for hearing care services. In order
to fill the need, the field needs an additional 23,000 audiologists by
2030; however only about 600 are entering the profession annually.\7\
---------------------------------------------------------------------------
\7\ Demand for Audiology Services: 30-Year Projections and Impact
on Academic Programs, Journal of the American Academy of Audiology, Ian
A. Windmill and Barry A. Freeman, 24:407-416, 2013
---------------------------------------------------------------------------
As the federal government seeks to become more efficient and cost-
effective, we urge the Subcommittee to pass H.R. 3508, which will round
out the VA hearing health care team to mirror the private-market model,
and increase Veterans' access to care, improve overall quality, and
reduce cost. Now is the time to embrace hearing aid specialists to help
meet the hearing health care needs of our Veterans, which will only
continue to rise in the coming years.
Thank you for your consideration and for your service to our
Veterans. With questions, please contact government affairs director
Alissa Parady at 571-212-8596 or [email protected].
International Hearing Society, 6880 Middlebelt Rd., Ste. 4 Livonia,
MI 48154, Phone: (734) 522-7200 Fax: (734) 522-0200, Web site:
www.ihsinfo.org
Statement of Iraq & Afghanistan Veterans of America
Statement of Iraq & Afghanistan Veterans of America on Pending Health Care Legislation
----------------------------------------------------------------------------------------------------------------
Bill # Bill Name Sponsor Position
----------------------------------------------------------------------------------------------------------------
H.R. 183 Veterans Dog Training Rep. Grimm Support
Therapy Act
----------------------------------------------------------------------------------------------------------------
H.R. 2527 A bill to provide Rep. Titus Support
counseling and
treatment for MST that
occurred during
inactive duty training.
----------------------------------------------------------------------------------------------------------------
H.R. 2661 Veterans Access to Rep. McCarthy Support
Timely Medical
Appointments Act.
----------------------------------------------------------------------------------------------------------------
H.R. 2974 A bill to provide for Rep. Walorski Support
the eligibility for
beneficiary travel for
veterans seeking
treatment or care for
military sexual trauma
in specialized
outpatient or
residential programs
at facilities of the
VA.
----------------------------------------------------------------------------------------------------------------
H.R. 3508 A bill to clarify the Rep. Duffy Support
qualifications of
hearing aid
specialists within VHA.
----------------------------------------------------------------------------------------------------------------
H.R. 3180 A bill to include Rep. Kaptur Support
contracts & grants for
residential care for
veterans in the
exception to the
requirement that the
government recover a
portion of the value
of certain projects.
----------------------------------------------------------------------------------------------------------------
H.R. 3387 Classified Veterans Rep. Sinema Support
Access to Care Act.
----------------------------------------------------------------------------------------------------------------
H.R. 3831 A bill to review the Rep. Roe No Position
dialysis pilot program
implemented by the VA
and submit a report to
Congress before
expanding that program.
----------------------------------------------------------------------------------------------------------------
H.R. 4198 A bill to reinstate an Rep. Denham Support
annual report on the
capacity of the VA to
provide for
specialized treatment
and rehabilitative
needs of disabled
veterans.
----------------------------------------------------------------------------------------------------------------
Draft A bill to authorize Rep. Benishek No Position
major VA medical
facility leases for
Fiscal Year 2014.
----------------------------------------------------------------------------------------------------------------
Chairman Benishek, Ranking Member Brownley, and Distinguished
Members of the Subcommittee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA), we
would like to extend our gratitude for being given the opportunity to
share with you our views and recommendations regarding this important
legislation that will impact the lives of IAVA's members and all of
America's troops and veterans.
As the nation's first and largest nonprofit, nonpartisan
organization for veterans of the wars in Iraq and Afghanistan, IAVA's
mission is critically important but simple--to improve the lives of
Iraq and Afghanistan veterans and their families. With a steadily
growing base of nearly 270,000 members and supporters, we aim to help
create a society that honors and supports veterans of all generations.
In partnership with other military and veteran service and advocacy
organizations, IAVA has worked tirelessly to see that our members'
needs are appropriately addressed by the Department of Veterans Affairs
(VA) and by Congress. IAVA appreciates the efforts put forth by this
Subcommittee to address the challenges facing our nation's veterans and
their families, and we are proud to offer our support for the
legislation that is the subject of this hearing today.
H.R. 183
IAVA supports H.R. 183, the Veterans Dog Training Therapy Act,
which would direct the VA to establish a pilot program to allow
veterans receiving post-deployment mental health care to train service
dogs for disabled veterans.
The use of dog training as a therapy for post-traumatic stress
disorder is a forward-thinking and unique option for veterans seeking
care. Most importantly, there is a strong body of evidence supporting
the therapeutic value of dogs, and growing evidence supporting their
therapeutic value specifically for servicemembers and veterans with
PTSD. Using animals as therapy or as service dogs has been a successful
model of care already supported by the DoD and VA. This particular
program goes a step further, to equip veterans with vocational skills.
Such skills and abilities are instrumental in helping veterans develop
new career opportunities.
Additionally, the proposed program would train service dogs for
other veterans. The use of occupational therapy to train new service
dogs serves two populations of veterans and promotes innovative care to
address the unique needs of every veteran.
H.R. 2527
IAVA supports H.R. 2527, which would provide veterans with
counseling and treatment for military sexual trauma that occurred
during inactive training.
The VA has a responsibility to provide the best counseling and
treatment available to survivors of military sexual trauma. However,
the men and women who courageously served in the National Guard or
other reserve components of the armed services are not eligible for
such counseling and treatment if the MST occurred during inactive
training. IAVA supports enabling and facilitating this type of training
in order to ensure that all survivors of MST are afforded prompt VA
care and treatment.
H.R. 2661
IAVA supports H.R. 2661, the Veterans Access to Timely Medical
Appointments Act, which would require the VA to implement a
standardized policy to ensure veterans enrolled in VA health care are
able to schedule primary care appointments and specialty appointments
within a certain amount of time after requesting an appointment.
The lack of standardized appointment policies and inefficient data
on adherence to appointment policies has been a routine issue among
veterans seeking care at the VA. This legislation is directly
reflective of Government Accountability Office recommendations, which
were based on an audit stemming from veteran concerns. IAVA strongly
supports increased access to medical care and encourages Congress and
the VA to continue addressing ways in which increased access to care
can be achieved.
H.R. 2974
IAVA supports H.R. 2974, which would authorize beneficiary travel
for veterans seeking treatment or care for military sexual trauma at
specialized outpatient or residential programs at VA facilities.
A 2012 survey released Pentagon report estimated nearly 26,000
servicemembers experienced unwanted sexual contact in 2012, with just
3,374 cases ultimately reported. Recent incidents continue to highlight
the appalling presence of sexual assault in the U.S. military and the
urgent need to ensure that servicemembers and veterans can access the
appropriate assistance available to them.
Currently, the VA is required to operate a program that provides
counseling and the necessary care to veterans that need help in
overcoming the physical and psychological stress of sexual assault and
harassment. By ensuring that the travel expenses of veterans seeking
MST-related treatment are covered, this bill would serve as a natural
extension of the care required by the VA for survivors of military
sexual trauma.
H.R. 3508
IAVA supports H.R. 3508, which would clarify the qualifications of
hearing aid specialists at the VA.
When veterans seek VA-provided hearing aid services at a VA medical
facility, too often they encounter facilities that are overloaded with
appointments and/or are forced to endure long wait times, substantial
distances to travel, and limited follow-up care. This seems to indicate
that the number of veterans in need of adequate hearing-related
services is quickly surpassing VA's ability to sufficiently respond.
Since hearing impairment is one of the most common injuries faced
by our newest generation of veterans, ensuring that these men and women
receive the care they are entitled to is critical. IAVA supports this
legislation because it seeks to ensure that qualified hearing aid
specialists can work alongside the hearing professionals of the VA in
order to better serve this nation's veterans and reduce the wait times
and stress associated with seeking care at a VA facility.
H.R. 3180
IAVA supports H.R. 3180, which would exempt contracts and grants
for residential care for veterans from the requirement that the
government recover a portion of the value of certain projects.
The VA is authorized to provide grant money to state-run facilities
that provide domiciliary care, medical care, or nursing home care to
veterans. If the facility ceases to be run by the state within a
certain amount of time, the VA is authorized to recapture up to 65
percent of the value of the project, but not more than the original
grant amount. This legislation would exempt residential care facilities
from these recapture requirements. IAVA supports the VA exempting
residential care facilities from these recapture requirements so long
as the facilities continue to maintain high levels of care for
veterans.
H.R. 3387
IAVA supports H.R. 3387, the Classified Veterans Access to Care
Act, which would improve access to mental health care for veterans who
conducted classified missions or served in classified units.
Currently, the VA utilizes group therapy sessions as a form of
mental health treatment. However, these group therapy sessions do not
consider the security clearance of the veteran, often putting veterans
in a position to choose between compromising classified information and
utilizing this helpful form of mental health support. However, a
veteran should never be forced to opt out of mental health treatment
due to a lack of feasible treatment options. The mental health needs of
each veteran are unique, as is the nature of many military occupational
specialties and their associated missions. Likewise, the full range of
mental health care treatments available from the VA should reflect the
full range of unique needs and special circumstances of military
service.
H.R. 3831
At this point in time, IAVA has no position on H.R. 3831, which
would require VA to ensure that it's dialysis pilot program is not
expanded until it has been implemented at its initial facilities, an
independent analysis of the program has been conducted, and VA has
provided a report to Congress detailing progress of the program.
H.R. 4198
IAVA supports H.R. 4198, which would require the VA to reinstate an
annual report on the capacity of the VA to provide for specialized
treatment and rehabilitative needs of disabled veterans. This report
has provided invaluable data on the capabilities of the VA to meet the
needs of disabled veterans, and this bill makes a common sense change
to require the VA to reinstate these reports.
Draft 1
At this time, IAVA is still reviewing the draft bill to authorize
major VA medical facility leases for Fiscal Year 2014. IAVA strongly
encourages Congress and the VA to continue to invest in facilities to
support the medical needs of veterans, and we therefore look forward to
having the opportunity to evaluate this new draft legislation.
Mr. Chairman, we at IAVA again appreciate the opportunity to offer
our views on these important pieces of legislation, and we look forward
to continuing to work with each of you, your staff, and this
Subcommittee to improve the lives of veterans and their families.
Thank you for your time and attention.
Statement on Receipt of Federal Grant or Contract Funds
Iraq and Afghanistan Veterans of America has not received federal
grant or contract funds relevant to the subject matter of this
testimony during the current or two previous fiscal years.
National Association of State Veterans Homes
Testimony of Brad Slagle, President
Chairman Benishek, Ranking Member Brownley and Members of the
Subcommittee:
Thank you for the opportunity to submit testimony on behalf the
National Association of State Veterans Homes (NASVH) in support of H.R.
3180, legislation introduced by Congresswoman Marcy Kaptur of Ohio.
H.R. 3180 was drafted to remove existing legal and financial barriers
that effectively prevent State Veterans Homes from operating certain
homeless veterans programs. We applaud Congresswoman Kaptur for her
lifelong commitment to supporting veterans, including homeless
veterans, and for her leadership in introducing this legislation. If
properly implemented, this legislation could have the effect of
utilizing excess existing capacity in some State Home domiciliaries to
support new homeless veterans programs. Although there may need to be
some language changes made to H.R. 3180 to strengthen the bill, we hope
that the Subcommittee will work with the bill's sponsor, VA and NASVH
to move this important, innovative and commonsense legislation.
Mr. Chairman, as you know, NASVH is an all-volunteer, non-profit
organization whose primary mission is to ensure that each and every
eligible U.S. veteran receives the benefits, services, long term health
care and respect which they have earned by their service and sacrifice.
NASVH also ensures that no veteran is in need or distress and that the
level of care and services provided by State Veterans Homes meets or
exceeds the highest standards available. The membership of NASVH
consists of the administrators and senior staffs at 146 State Veterans
Homes in all 50 States and the Commonwealth of Puerto Rico.
Mr. Chairman, the State Veterans Homes system is a mutually
beneficial partnership between the States and the federal government
that dates back more than 100 years. Today, State Homes provide over
30,000 nursing home and domiciliary beds for veterans and their
spouses, and for the gold-star parents of veterans. Our nursing homes
assist the VA by providing long-term care services for approximately 53
percent of the VA's long-term care workload at the very reasonable cost
of only about 12 percent of the VA's long-term care budget. VA's basic
per diem payment for skilled nursing care in State Homes is
approximately $100, which covers about 30 percent of the cost of care,
with States responsible for the balance, utilizing State funding and
other sources. On average, the daily cost of care of a veteran at a
State Home is less than 50 percent of the cost of care at a VA long-
term care facility. The VA per diem for adult day health care is
approximately $75 and the domiciliary care rate is approximately $43
per day.
The bill before the Committee, H.R. 3180, is intended to address a
problem in Title 38 that effectively prevents State Homes from
operating certain homeless veterans programs, even when a domiciliary
has excess capacity that could be used in other ways to help fight the
pernicious problem of homelessness amongst veterans. According to the
Department of Housing and Urban Development, on any given night there
are almost 60,000 homeless veterans, and more than twice that many
experience homelessness at some point each year. This shameful fact led
VA Secretary Shinseki to make ending homelessness amongst veterans by
2015 one of his highest priorities and enactment of H.R. 3180, properly
crafted and implemented, could add State Veterans Homes to his arsenal
of tools in that effort.
Mr. Chairman, some State Homes currently have unused bed capacity
in their domiciliary programs that could be used to operate specialized
homeless veterans programs. For example, the Ohio Veterans Home in
Sandusky, Ohio has both a 427 bed nursing home program and a separate
300 bed domiciliary program. While the nursing home program has a 98
percent or higher occupancy rate, the domiciliary is currently
operating at less than 60 percent occupancy, leaving more than 125 beds
available at any given time. The administrators at Sandusky have been
exploring ways to use a small number of their unused domiciliary beds
to help homeless veterans.
However, eligibility requirements for admission to the Ohio
Veterans Home domiciliary program limit or restrict admission for most
homeless veterans. To be admitted to the domiciliary, a veteran must
provide a current medical history and physical completed by a
physician, along with detailed financial documentation demonstrating
need for this assistance, as well as other information. Often homeless
veterans lack the resources to obtain such information required for
possible admission so the Ohio Veterans Home has been looking for other
ways to use their facility to support homeless veterans.
Learning about VA's Health Care for Homeless Veterans (HCHV)
program, which provides grants to community homeless programs, the
Sandusky Home drew up plans for a small homeless program using HCHV
funding as a source of support. Under this proposed program, they would
be able to admit homeless veterans without the tighter domiciliary
requirements, allowing them immediate access to food, shelter, primary
care, social services and other services. There are also a number of
recently deployed veterans that may need a stable transition facility
for post-acute care but who don't fall into the admissions criteria
outlined in the VA domiciliary care program regulations. Because
homeless veterans generally need more intense services initially to
help them to stabilize and adjust, the Home also developed plans to
work collaboratively with the VA Homeless Coordinators in an effort to
help the veteran with any specific needs they may have, which could
include education, job training and long term housing.
After approaching VA with this proposal, the Sandusky Home was told
that under Title 38 regulations, State Homes are only authorized to use
their federally-supported homes to operate three programs: skilled
nursing care, adult day health care and domiciliary care. According to
VA's Office of General Counsel, if a State Veterans Home applied for
and received a grant to operate a homeless veterans program, VA would
have to recapture a portion of the construction grant funding
previously awarded to the State Home over the past twenty years. This
recapture of federal funds would be such a severe financial penalty
that it would effectively prevent any State Veterans Home from even
considering new homeless veterans programs, even though domiciliaries
were built to provide housing for veterans without homes.
In order to remove this obstacle, H.R. 3180 was drafted to amend
the recapture provisions (38 USC Sec. 8136) by providing an exemption
for State Homes that receive a contract or grant from VA for
residential care programs, including homeless veterans programs through
HCHV. This legislation would not require VA to award grants or
contracts to State Homes; VA would retain the authority and discretion
to determine when and where it might make sense for a State Home to use
a portion of its empty beds to help homeless veterans. Nor would it
open the door to State Homes converting domiciliary beds into new
homeless program beds on their own; only VA's decision to provide
funding through a grant or contract, such as HCHV, would exempt them
from the recapture provisions. This innovative and practical proposal
would not increase federal spending, rather it would simply allow State
Veterans Homes to compete for existing VA grants just as private
community organizations presently do.
However, in further exploring how this legislation could be
interpreted and implemented, we have become aware that the language may
not be specific enough in terms of either the intended facilities or
the intended programs. The broad exception in the current draft of the
bill providing the Secretary the ability to award grants and contracts
for resident care without triggering the recapture provision could
theoretically be used for any number of residential programs, not just
at domiciliaries, but at skilled nursing facilities as well. Moreover,
there are some concerns that even though the Secretary would have broad
new authority to award grants and contracts for additional residential
programs, there is no guarantee VA would actually use this authority to
support new homeless veterans programs in domiciliaries through HCHV.
Mr. Chairman, although H.R. 3180 as currently drafted could achieve
its intended purpose, we would recommend that the Subcommittee work
with the bill's sponsor, VA and NASVH to tighten and strengthen the
language in the bill. We are confident that working together we can
refine this legislation to create new opportunities for State Homes
with underutilized bed capacity in their domiciliary programs to help
VA end the scourge of homelessness amongst veterans using existing
programs, such as HCHV.
Servicewomen's Action Network
Chairman Benishek, Ranking Member Brownley, and distinguished
members of the Subcommittee:
On behalf of the Service Women's Action Network, thank you for the
opportunity to submit written testimony for the record and thank you
for your continued leadership on veterans' issues and for convening
this hearing.
The Service Women's Action Network (SWAN) is a non-profit, non-
partisan veterans led civil rights organization. SWAN's mission is to
transform military culture by securing equal opportunity and freedom to
serve without discrimination, harassment or assault; and to reform
veterans' services to ensure high quality health care and benefits for
women veterans and their families.
We challenge institutions and cultural norms that deny equal
opportunities, equal protections, and equal benefits to service members
and veterans. SWAN is not a membership organization, instead we utilize
direct services to provide outreach and assistance to service members
and veterans and our policy agenda is directly informed by those
relationships and that interaction. SWAN extends opportunities to and
promotes the voices and agency of service women and women veterans
without regard to sex, gender, sexual orientation or gender identity or
the context, era, or type of service.
SWAN welcomes the opportunity to share our views on two of the
bills before the Subcommittee today, H.R. 2527 and H.R. 2974.
H.R. 2527
The National Guard is unique among components of the Department of
Defense in that it has the dual state and federal mission. For example,
while serving operationally on Title 10 active-duty status in Operation
Iraqi Freedom or Operation Enduring Freedom, National Guard units are
under the command and control of the president. However, upon release
from active duty, members of the National Guard return to their states
as serving members of the reserve component but under the command and
control of their governors.
A reservist can complete a full Guard or Reserve career but never
have served on Title 10 active duty for other than training purposes.
Drill training, annual training and Title 32 service responding to
domestic natural disasters and defending our nation's airspace, borders
and coastlines do not qualify for veteran status and thus any of these
service members if sexually assaulted have the potential to fall
through the cracks, not receiving counseling and treatment for their
assault if that assault happened during inactive duty training.
Compounding this conflict is the risk of becoming a victim of sexual
violence is just as great for these service members as it is for active
duty troops. In fact, according to the Department of Defense, nearly
80% of reported sexual assaults occur CONUS, or stateside, in garrison-
type installations. The remainder happen at overseas installations and
still an even smaller percentage happen in ``combat areas of
interest.'' \1\ Serving in your community stateside does not ensure a
service member's safety when it comes to sexual assault.
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\1\ http://www.sapr.mil/public/docs/reports/FY12-DoD-SAPRO-Annual-
Report-on-Sexual-Assault-VOLUME-ONE.pdf
---------------------------------------------------------------------------
Eliminating this gap in protection for our service members is why
the Senate unanimously passed the Victims Protection Act of 2014. Sec.
107 of the bill requires the Department of Defense to provide for the
availability of Sexual Assault Response Coordinators for members of the
National Guard and the Reserve regardless of their training status. It
only makes sense, then, that the VA close the similar gap in
protections to veterans who need counseling and treatment for sexual
trauma that occurred during inactive duty training. SWAN fully supports
passage of H.R. 2527.
H.R. 2974
As DoD continues to makes changes to policy and programming for
sexual assault survivors, it is imperative that the VA do likewise and
provide the men and women veterans who suffer from the invisible wounds
of sexual assault the full range of treatment, services and disability
benefits available to veterans who are suffering from the visible
wounds of war.
Since 2008, SWAN has been monitoring VA's treatment of veterans who
carry these invisible wounds of sexual violence due to rape, sexual
assault or sexual harassment. We have been encouraged by the progress
that the Veterans Health Administration continues to show in the
screening and treatment of Military Sexual Trauma and its related
diagnoses; however, the Veterans Benefit Administration continues to
process and award disability claims for Military Sexual Trauma
diagnoses, specifically PTSD, inconsistently and unfairly. In spite of
repeated requests by a chorus of military and veterans' organizations,
individual survivors and Members of this committee, the VA continues to
refuse to amend the language in their regulations to make evidentiary
standards and the processing of a MST PTSD claims as consistent and
fair as it is for the other particularized PTSD claims found in the
regulation. \2\ Data obtained by SWAN through litigation under the
Freedom of Information Act demonstrates that since 2010, VA approval
rate for MST PTSD claims have lagged behind the approval rates of all
other PTSD claims, and male survivors--who constitute the majority of
sexual assault victims--continued to be discriminated against in the
awarding of claims. \3\ VA's response to this has been to ignore the
data and falsely claim that the gap between awarded MST PTSD and other
PTSD claims is closing and their training efforts have worked.
Unfortunately, this Jedi Mind Trick is betrayed by the facts. In 2013,
the VA Appropriations bill included reporting language that required VA
to submit to Congress data on MST claims. \4\ The 2013 data in this
report shows that the VA's efforts have not worked and both the claims
gap continues to exist and male survivors continue to face
discrimination in the awarding of their claims. It is clear that until
VA changes the language in the regulations so that the evidentiary
burden for MST PTSD claims matches that of other particularized claims,
the disability benefits process will remain broken and continue to be
another betrayal that serves to compound the trauma of a survivor's
initial sexual assault.
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\2\ 38 C.F.R. Sec. 3.304(f).
\3\ See enclosure 1: ``The Battle for Benefits''.
\4\ See enclosure 2: Military Sexual Trauma: FY2014 Congressional
Report to the House and Senate Appropriations Committees
www.servicewomen.org
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As SWAN and members of both the House and Senate continue to work
for this needed regulatory reform, it is imperative that VA provide
whatever it can to our men and women who have suffered from the impact
of sexual violence while serving in the military. This includes common-
sense logistical support to survivors, like the support found in H.R.
2974. This bill requires VA to provide for the eligibility for
beneficiary travel for Military Sexual Trauma survivors seeking
treatment in specialized outpatient or residential programs at VA
facilities. This is a simple, common-sense benefit. The fact that today
an MST survivor would be unable to make required appointments,
participate in prescribed treatment programs or attend a beneficial
resident treatment program simply because he or she cannot afford to
travel to the facility is beyond outrageous. It is inexcusable that
transportation costs should be a detour on a survivor's road to
recovery. SWAN wholeheartedly supports the passage of H.R. 2974.
Again, we appreciate the opportunity to offer our views on these
important bills and we look forward to continuing our work together to
improve the lives of veterans and their families. Any questions can be
directed to Greg Jacob, Policy Director at 646-569-5216 or by mail at
Service Women's Action Network, 1225 I St, NW., Ste 307, Washington,
DC, 20005.
Non-Governmental Witness Declaration
Neither the Service Women's Action Network nor I have received
during the current or previous two fiscal years any Federal grant or
contract relevant to the subject matter of this testimony.
The American Speech-Language-Hearing Association
To the House of Representatives Committee on Veterans Affairs
Health Subcommittee Regarding H.R. 3508
Allowing for the Appointment of Hearing Aid Specialists to the Veterans
Health Administration
The American Speech-Language-Hearing Association (ASHA) appreciates
the opportunity to submit a statement for the record regarding H.R.
3508, legislation that would allow for the appointment of hearing aid
specialists to the Veterans Health Administration. While we understand
the desire of Congress to ensure appropriate access to hearing health
services, we believe that this legislation will not address the
problems associated with long wait times for hearing aids and hearing
health care services. Additionally we believe that the legislation
could lead to fragmented care. For these reasons, ASHA opposes the
legislation as currently written. ASHA is the national professional,
scientific, and credentialing association for more than 173,070
audiologists, speech-language pathologists, speech, language, and
hearing scientists, audiology and speech-language pathology support
personnel, and students.
Unfortunately, as currently written the legislation may not have
the desired outcome of decreasing wait times for veterans either
seeking to obtain hearing aids or repairs. Hearing health care is more
than fitting a veteran with a device. An audiologist must do a full
diagnostic hearing evaluation and take into consideration health
factors, such as tinnitus and brain injury, when determining
appropriate amplification and audiologic rehabilitation for the
patient.
Hearing loss and tinnitus are two of the top service-related
disabilities of our nation's veterans, and these disabilities require
more complex and comprehensive treatment. Although we acknowledge that
hearing aid specialists have the knowledge and skills to dispense
hearing aids, many of our veterans, especially those with traumatic
brain injury or tinnitus, require the specialized care of an
audiologist.
The VA Office of Inspector General (OIG) recently released the
finding of an audit of the VA's hearing health services. The audit
found that inadequate staffing to meet increased workloads as well as
operations and processes at the Denver Acquisition and Logistics Center
(where hearing aids are repaired) attributed to long wait times.
The OIG recommended that the VA develop a plan to implement
productivity standards and staffing plans for audiology clinics. They
also recommended that the repair center determine appropriate staffing
levels for its rehab lab to establish controls to timely track and
monitor hearing aid repairs.
The VA should have the ability to review its current policies and
develop productivity standards and staffing plans as recommended by the
OIG prior to the adoption of any legislation that would require changes
to the provision of hearing health care services in the VA.
Additionally, in order to enhance hearing health care services to
our veterans ASHA makes the following recommendations to the committee.
Work with the VA to identify areas of the country
where veterans have difficulty accessing hearing health
services, and authorize additional funding to hire more
audiologists and/or contract to private audiologists to meet
the needs of the veterans in those areas.
Request the VA to review data on wait times and access
to hearing health care services and identify best practices by
those facilities that have implemented ways to reduce wait
times for services and devices and provide this information to
lower performing facilities as a means to improve.
Amend the Non-VA Purchased Care provisions of Title
38 to include audiologists.
Grant the VA the authority to hire more audiologists.
Legislation Redundant Of Current VA Practices
The VA has the authority to hire hearing aid specialists as
technicians that work under the direction of an audiologist. According
to the VHA handbook 1170.02, the job description of the health
technicians for audiology is to, among other things, increase
productivity by reducing wait times and enhancing patient satisfaction;
and reducing costs by enabling health technicians to perform tasks that
do not require the professional skills of a licensed audiologist. The
role of these technicians includes performing checks on hearing aids
and other amplification devices, performing troubleshooting and minor
repairs to hearing aids, ear molds, and other amplification devices,
and performing electroacoustic analysis of hearing aids, among other
things. These responsibilities, which are already provided in the VA,
are what hearing aid specialists are requesting to be recognized for
under H.R. 3508.
Additionally, Appendix A of the VA handbook specifically addresses
the use of hearing aid specialists and allows for referrals to these
individuals when timely referrals to private audiologists and/or other
VHA facilities are not feasible or when the medical status of the
veteran prevents travel to a VHA facility or a private audiologist.
Given that hearing aid specialists are already permitted to be
hired by the VA, we believe that H.R. 3508 adds an unnecessary mandate
on the agency to specifically recognize hearing aid specialists for
appointment by the Secretary.
Training and Education
Given the complex nature of a veteran's hearing health care needs,
veterans should have timely access to an audiologist. Audiologists are
the primary licensed health care professionals who evaluate, diagnose,
treat, and manage hearing loss and balance disorders. Audiologists hold
a doctoral degree in audiology from a program accredited by the Council
on Academic Accreditation in Audiology and Speech-Language Pathology of
the American Speech-Language Hearing Association. Under the scope of
practice for audiology, these individuals serve the veteran through a
broad range of professional activities including evaluating,
diagnosing, managing, and treating disorders of hearing, balance,
tinnitus, and other disorders associated with the practice of
audiology. This includes determining the appropriateness of
amplification devices and systems as well as selecting, evaluating,
fitting and programming hearing aids.
Hearing aid specialists are trained in the interpretation of
hearing assessment instrumentation, hearing aid electronics,
specifications, analysis, modifications, and programming of hearing
aids. While some states have gone to a college-level associate degree
as a minimum education requirement for hearing aid dispensers, many
states still require only a high school diploma or equivalent. There
are no national standards or dedicated curriculum that outlines the
core competencies of a hearing aid specialist. For example, in addition
to the high school diploma or equivalent requirement, in the state of
Wisconsin an individual must be 18, while in Minnesota they must be 21.
Both licensure requirements require a test for proficiency. For more
information and an analysis of each state's hearing aid specialist
(dispenser) requirements for licensure, see www.asha.org/advocacy/
state/.
Additionally, we are unaware of any nationally recognized
accreditation body for hearing aid specialists. We are aware of the
International Institute for Hearing Instruments Studies. This
organization is not on the list of recognized accrediting agencies by
the U.S. Department of Education or the Council for Higher Education
Accreditation (CHEA). This organization is also not listed as a member
agency of the Association of Specialized and Professional Accreditors
(ASPA). It appears the accreditation body is limited to continuing
education courses and programs.
We appreciate the opportunity to express our concerns. ASHA remains
committed to working with the Committee to address access to timely
hearing health care services, but does not believe that H.R. 3508 is
the solution. For additional information please contact Ingrida Lusis,
ASHA's director of federal and political advocacy, at [email protected]
or 202-624-5951.
Warrior Canine Connection,
Rick A. Yount, Executive Director
Mr. Chairman and Members of the Subcommittee, as the Executive
Director of Warrior Canine Connection, I would like to thank you for
your invitation to submit a statement for the record in support of H.R.
183, the Veterans Dog Training Therapy Act. I am pleased to have the
opportunity to bring Members of the Subcommittee up to date on this
promising therapy for symptoms of Post Traumatic Stress Disorder (PTSD)
and Traumatic Brain Injuries (TBI) in combat Veterans, and to address
the need for this legislation.
Warrior Canine Connection (WCC) is a 501(c) 3 nonprofit
organization dedicated to empowering returning combat Veterans who have
sustained physical and psychological wounds while in service to our
country. Based on the concept of Warriors helping Warriors, WCC's
therapeutic service dog training program is designed to mitigate
symptoms of PTSD and TBI, while giving injured combat Veterans a sense
of purpose, help in reintegrating back into their families and
communities, and a potential career path as a service dog trainer. WCC
currently provides its program to recovering Warriors at Walter Reed
National Military Medical Center (WRNMMC), the National Intrepid Center
of Excellence (NICoE), Palo Alto VA Medical Center (Menlo Park), Ft.
Belvoir Warrior Transition Brigade, the NeuroRestorative Residential
Treatment Center in Germantown, MD, and at WCC's ``Healing Quarters''
in Brookeville, MD.
Based on my experience as a licensed social worker and certified
service dog instructor, I developed the concept of using the training
of service dogs for fellow Warriors as a therapeutic intervention for
the symptoms of combat trauma experienced by hundreds of thousands of
returning Veterans. The program I designed specifically addresses the
three symptom clusters associated with PTSD; re-experiencing, avoidance
and numbing, and arousal. Working with Golden and Labrador Retrievers
specially bred for health and temperament, Warrior Trainers must train
the dogs to be comfortable and confident in all environments. In
teaching the dogs that the world is a safe place, the Warrior Trainers
challenge their symptoms of combat stress. By focusing on preparing the
dogs for service as the partners of disabled Veterans, they are
motivated and able to visit places they usually avoid, like stores,
restaurants, and crowded public transportation stations. The program
also emphasizes positive reinforcement, emotional affect, consistency,
and patience--tools that make Warrior Trainers better parents and
improve their family relationships.
Since launching the first therapeutic service dog training program
as a privately funded pilot at the Palo Alto VA Trauma Recovery Program
at Menlo Park in July 2008, I have seen significant improvement in
symptoms of PTSD and TBI in participating Veterans. In some cases, this
safe, non-pharmaceutical intervention has benefitted patients who were
not responding to any other treatments being offered by their medical
providers. Based on positive feedback from wounded Warriors and their
clinical providers, the program has expanded to several new sites and
is being sought by other treatment facilities caring for injured combat
Veterans. In response to these encouraging patient outcomes, the House
Armed Services Committee included the following language in its report
accompanying the 2014 National Defense Authorization Act:
The committee is aware that recovering service members in treatment
at the National Intrepid Center of Excellence (NICoE) and Walter Reed
National Military Medical Center are reporting improvement in their
symptoms of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain
Injury (TBI) when participating in the service dog training programs
currently operating in those facilities. In addition, clinical
observations support the benefits of this animal-assisted therapy
modality to psychologically injured service members, including:
decreased depressive symptoms, improved emotional regulation, improved
sleep patterns, a greater sense of purpose, better reintegration into
their communities, pain reduction, and improved parenting skills. The
committee urges the Secretary of Defense to consider making this
promising new therapeutic intervention more available to service
members suffering from the invisible wounds of PTSD and TBI. Therefore,
the committee directs the Secretary of Defense to conduct such studies
as may be necessary to evaluate the efficacy of service dog training as
an adjunctive treatment for PTSD and TBI and to maximize the
therapeutic benefits to recovering members who participate in the
programs. The committee further directs the Secretary to provide a
report not later than March 1, 2015 to update the congressional defense
committees.
WCC is currently collaborating with NICoE, WRNMMC, the Uniform
Services University of the Health Sciences (USUHS), and civilian
academic experts, to conduct research on the therapeutic service dog
training programs at WRNMMC and NICoE. I look forward to obtaining the
necessary scientific data to establish service dog training as an
evidence-based treatment for the invisible wounds of war.
Despite anecdotal evidence of the benefits of service dog training
therapy on the psychological injuries of wounded Warriors, and almost
daily news reports of Veterans who say that dogs have helped them to
deal with symptoms of combat stress, the Department of Veterans Affairs
(VA) presently does not support the provision of service dogs for
psychological injuries. It is my understanding that the VA is waiting
for the results of the VA research study mandated by the 2010 National
Defense Authorization Act before officials will consider revising VA
policy with regard to service dogs for psychological disabilities.
Unfortunately, as Subcommittee Members are aware, the VA research study
has been significantly delayed and wrought with problems. Last month,
the VA published a solicitation for service dogs to be used in the
study. As a clinician and a member of the Assistance Dogs International
(ADI) Subcommittee charged with recommending tasks to be carried out by
service dogs for psychiatric disabilities, I was alarmed to read
through the tasks the VA is requiring the dogs to perform for the
study. They included blocking (standing in front of the Veteran to give
them space), sweeping rooms for intruders, barking at intruders, and
standing behind the Veteran to give them space. In my view, these tasks
support symptoms of PTSD by reinforcing cognitive distortions, rather
than mitigate them and will distract Veterans from addressing their
challenges to fully reintegrate into their communities and families.
Clearly there is a need for mental health experts, government policy
makers, and service dog industry representatives to come together to
develop standards and best practices for service dogs that will support
our Nation's Veterans with psychiatric disabilities.
Results from the VA research study will not be available for
several years. Meanwhile, hundreds of thousands of returning Service
Members and Veterans with psychological injuries and their families are
struggling to find treatments that will help heal the invisible wounds
of war. Service dog training therapy programs at VA and DOD medical
facilities offer combat Veterans a continuing mission to help their
disabled brothers and sisters, as well as an innovative Animal Assisted
Therapy for their invisible wounds. Each dog participating in the
program touches the lives of approximately 60 wounded Warriors during
training. The Warrior Trainers benefit from the close interactions with
the dogs without the responsibilities of ownership. They also learn
about the use, care, and training of service dogs. In some cases,
Warriors may experience significant improvement in their symptoms,
lessening their need for a service dog. When and if Warrior Trainers
eventually decide to apply for a service dog to assist them with their
disabilities, their experience working with service dogs in training
sets them up for success with their new canine partners.
Veterans seeking industry standard service dogs often wait years on
the waiting lists of the nonprofit organizations that provide them. The
need for well-trained service dogs to support Veterans from the recent
conflicts will remain for many decades to come. Creating additional
program sites will enable more recovering Warriors to benefit from this
Animal Assisted Therapy modality, while increasing the number of
service dogs available to be placed with disabled Veterans. In my
testimony to the Subcommittee on similar legislation in July 2011, I
stated that when it comes to training dogs for Veterans, no one takes
that task more seriously than those who served by their sides in
conflict. After working alongside wounded Warriors these past six
years, I am more convinced of that than ever.
Several Veterans who have participated in the training program have
gone on to become professional service dog trainers and will continue
to serve the needs of their fellow Warriors and other persons with
disabilities.
Collaborative opportunities between VA and DoD
Warrior Canine Connection is currently operating the therapeutic
service dog training program at both VA and DoD treatment centers. Both
Departments are individually engaged in funding and carrying out
research studies to fully understand the efficacy of using dogs to help
Veterans and Service Members with PTSD. Collaboration between the VA
and DoD would enhance their individual efforts as well as offer cost
sharing opportunities. The Bob Woodruff Foundation recently sponsored a
convening at the National Intrepid Center of Excellence to focus on the
use of service dogs and Animal Assisted Therapy in helping Veterans
with the invisible wounds of war. The convening included VA and DoD
policy makers, mental health providers, researchers and service dog
SME's. The convening was a great first step in fostering discussion and
future collaboration related to using dogs to support the recovery of
returning Veterans. The therapeutic service dog training concept
resonated with almost all who attended the convening as an innovative
Complementary Alternative Medicine (CAM) modality.
H.R. 183
As you are aware, legislation to create a VA pilot program on
service dog training therapy has been approved by the U.S. House of
Representatives in the past two Congresses. While VA officials have
recognized the therapeutic value of the program at VA Menlo Park, and
indicated that the Secretary does not need Congressional authorization
to create a VA pilot program on service dog training therapy, the WCC
program at VA Menlo Park continues to be supported exclusively by
private donations.
The provisions of H.R. 183 are based on the original program
launched in 2008 at VA Menlo Park through the Recreation Therapy
Department. Since that time, service dog training therapy has been
incorporated into additional programs at that facility. Consequently,
it may be more appropriate at this point to provide the Secretary with
more discretion to tailor the pilot program on this CAM modality to the
needs of the Veterans at individual pilot sites.
In the past, all matters associated with service dogs have been
delegated to the VA's Dept. of Prosthetics and Sensory Aid Services
(PSAS). As reflected in the Congressionally mandated VA Inspector
General's report on the VA Guide and ServiceDog Program, PSAS officials
have been very slow to implement the VA's authority to provide service
dogs to disabled Veterans and to provide related education and outreach
to VA medical providers and Veterans. Since the pilot program
established by the Veterans Dog Training Therapy Act is clearly first
and foremost a mental health intervention and CAM modality, I would ask
that the VA's Office of Patient Centered Care and Cultural
Transformation be considered to take the lead on this effort, working
closely with VA Mental Health consultants to maximize the therapeutic
benefits to Veterans.
I appreciate this opportunity to provide my views on this
legislation to create a VA pilot program on service dog training
therapy. Based on my experience working with wounded Warriors, I know
that making this CAM modality more widely available will contribute
significantly to the psychological healing of returning Veterans.
Financial disclosure associated with the statement for the record
of Rick A. Yount, Executive Director, Warrior Canine Connection
Rick Yount serves as an individual contractor providing service dog
training therapy and education to patients and their family members at
the National Intrepid Center of Excellence (NICoE) in Bethesda, MD.
Funding for his services at NICoE and associated expenses are being
provided through a NICoE (DoD) subcontract under which he received
$121,240 annually in calendar years 2012 and 2013.
WOUNDED WARRIOR PROJECT
Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee: Thank you for inviting Wounded Warrior Project (WWP) to
offer views today on legislation under consideration by the
Subcommittee. Working closely with warriors who have sustained wounds,
injuries, and illnesses in service since 9/11, WWP brings an important
perspective to your deliberations regarding the VA health care system
and the statutory framework under which it operates. Several bills on
your agenda address issues of importance to our warriors, though we
also want to alert the Subcommittee to concerns raised by other
measures. For the record, however, we are concerned that today's agenda
does not include either legislation or draft legislation to extend the
VA's Assisted Living Pilot Program. That program has been an important
resource for warriors who have sustained traumatic brain injuries and
have required specialized residential rehabilitation. With veterans who
need this level of care now ``locked out'' of the program and others at
risk of being discharged prematurely, we renew our request that this
Subcommittee move legislation at the earliest opportunity to lift the
program's ``sunset.''
Expanding Access to Care for MST-Related Conditions
WWP welcomes the Subcommittee's consideration of legislation to
remove barriers to care and treatment for MST-related conditions. The
importance of early access to counseling and treatment as well as
assuring the quality and effectiveness of treatments for health
problems associated with MST cannot be overstated. Researchers report
that MST is an even stronger predictor of PTSD than combat \1\ and
victims' reluctance to report these traumatic incidents can also result
in delaying treatment for conditions relating to that experience.\2\
In-service sexual assaults have long-term health implications,
including PTSD, increased suicide risk, major depression and alcohol or
drug abuse and without outreach to engage victims of MST on needed
care, the long-term impact may be intensified.\3\ With the VA reporting
that some 1 in 5 women and 1 in 100 men seen in its medical system
responded ``yes'' when screened for MST4 and the Department of Defense
reporting that 26,000 active duty service members experienced a sexual
assault in 2012,\4\ it is clear that there is a great need for
resources, support, and effective treatment for those who are coping
with health issues as a result of an in-service assault. While
researchers cite the importance of screening for MST \5\ and associated
referral for mental health care, many victims do not currently seek VA
care. Indeed, researchers have noted frequent lack of knowledge on the
part of women veterans regarding eligibility for and access to VA care,
with many mistakenly believing eligibility is linked to establishing
service-connection for a condition.\6\ A recent survey of WWP Alumni
further demonstrates the great challenges in getting needed treatment
for warriors affected by MST. Almost half of the respondents indicated
accessing care through VA for MST related conditions was `Very
difficult'. And of those who did not seek VA care, 41% did not know
they were eligible for such care. In our view, there is still a lot of
work to do to improve care and treatment for veterans with MST related
conditions.
---------------------------------------------------------------------------
\1\ D. Yaeger, et al.'' DSM-IV Diagnosed Posttraumatic Stress
Disorder in Women Veterans With and Without Military Sexual Trauma,''
21(S3) J Gen Internal Medicine S65-S69 (2006).
\2\ Rachel Kimerling, et al., ``Military-Related Sexual Trauma
Among Veterans Health Administration Patients Returning From
Afghanistan and Iraq,'' 100(8) Am. J. Public Health, 1409-1412 (2010).
\3\ M. Murdoch, et al., ``Women and War: What Physicians Should
Know,'' 21(S3) J. of Gen. Internal Medicine S5-S10 (2006).
\4\ U.S. Dept. of Veterans' Affairs and the National Center for
PTSD Fact Sheet, ``Military Sexual Trauma,'' available at http://
www.ptsd.va.gov/public/pages/military-sexual-trauma-general.asp.
\5\ http://www.defense.gov/transcripts/
transcript.aspx?transcriptid=5233
\6\ See Donna Washington, et al., ``Women Veterans' Perceptions and
Decision-Making about Veterans Affairs Health Care,'' 172(8) Military
Medicine 812-817 (2007).
---------------------------------------------------------------------------
With these challenges in mind, WWP offers our strong support for
H.R. 2527 and H.R. 2974, which, respectively, would expand eligibility
to counseling and treatment for MST-related conditions for veterans
whose sexual trauma occurred during inactive duty training and provide
eligibility for beneficiary travel for veterans seeking treatment or
care for MST through VA. As the Subcommittee's important oversight work
has documented, however, the scope of the problem is not limited to
access to care. Testimony at a recent Subcommittee hearing provided
strong evidence that both the Department of Defense and the VA are
failing to provide adequate mental health services for veterans who had
been assaulted by fellow service members. Veterans at that hearing
detailed troubling, yet similar experiences relating not only to access
to VA care, but to inadequate screening, providers who were either
insensitive or lacked needed expertise, and facilities ill-equipped to
appropriately care for MST survivors. \7\
---------------------------------------------------------------------------
\7\ http://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=101095
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We commend the VA for taking significant steps (described at the
Subcommittee's February 26th oversight hearing) to improve veterans'
screening and care for MST-related conditions. To date, however, too
many warriors still have not received timely, effective treatment. In
short, wide gaps remain between well-intentioned policies and on-the-
ground practice. With those concerns, we urge the Committee to continue
to pursue these issues through oversight, to include conducting a
searching inquiry as to whether VA has yet achieved the level of mental
health staffing needed to meet the mental health needs of our veterans.
Further, we urge that such oversight focus on improving access to MST-
related care and training providers, as needed, to provide effective
screening and appropriate, sensitive care for those seeking treatment
for MST-related conditions.
Legislation to Address Operational Challenges: H.R. 2661 and H.R. 4198
We are unable to support two other bills, in particular, H.R. 2661
and H.R. 4198, that propose to address operational challenges inherent
in the administration of a health care system. H.R. 2661 would direct
VA to implement a policy ``to ensure'' that a veteran enrolled in VA's
health care system is able to schedule an appointment, within seven
days in the case of primary care and within 14 days in the case of
specialty care, of the date that the veteran or provider requests. The
bill sets additional expectations VA is to achieve to further that
policy.
In testifying before the Subcommittee in the past at hearings
examining VA mental health care, WWP expressed deep concerns with the
long waits warriors have encountered at many facilities with regard to
both initial and follow-up mental health care visits. Those concerns
have not vanished. But while there are certainly systemic problems with
VA scheduling practices and with the reliability of VA's mechanisms for
reporting wait times, scheduling cannot be altogether divorced from an
array of other, often complex issues. To focus solely on implementation
of a scheduling policy, as proposed in H.R. 2661, is to fall short of
remedying deeper problems and to risk compounding those that already
exist.
Repairing flaws in how VA accomplishes appointment-scheduling is
unlikely by itself to ensure that veterans actually receive timely,
needed treatment. To illustrate, sustained congressional oversight into
severe timeliness problems in VA's provision of mental health care
finally led to the Secretary's acknowledging in April 2012 a need for
1900 additional mental health staff. Just as it is important to take
account of the link between adequate staffing and timeliness, we urge
the Subcommittee to work toward ensuring that VA care is not only
timely, but effective. The establishment of rigid standards of
timeliness (not goals, but requirements)--without regard to staffing
levels or other limitations--can create (and has in recent experience
in VHA led to) perverse incentives to ``game'' the system and even to
institute practices that compromise care quality. Well-intentioned VA
performance requirements too often lead to inappropriate practices. We
offer the following relatively recent examples arising from VA efforts
to set policy for mental health care:
A VA facility at which practitioners were directed not
to ask veterans about their mental health problems lest it
become necessary to provide them treatment (as required by
performance measures) for which there was not adequate staff;
VA facilities that have shifted staff to ensure that
veterans are ``seen'' within 14 days (to meet a metric) but
that, as a result, cannot begin real treatment until many weeks
later;
A VA facility that has instructed staff to substitute
a diagnosis other than PTSD in instances where PTSD is a
patient's primary diagnosis to avoid having to meet performance
requirements relating to provision of evidence-based treatments
for PTSD.
VA facilities that have prematurely placed veterans
who need individual therapy into group therapy that is being
``counted'' inappropriately as meeting a performance metric.
While we certainly acknowledge the importance of improving both
VA's timeliness and systems for effective scheduling of appointments,
we have real concern with setting rigid requirements that ignore not
only patient acuity and differences between elective and necessary
care, but overarching fiscal and other resource constraints. We do not
in any way seek to minimize the importance of the issues raised by the
Government Accountability Office in its report on the Reliability of
Reported Outpatient Medical Appointment Wait Times and Scheduling
Oversight. But we believe the well-intentioned prescription set in H.R.
2661 is not the ``best medicine'' to cure the problem, and do not
support its enactment.
H.R. 4198 proposes to reinstitute a statutory reporting requirement
established in 1996 that was aimed at preventing downsizing or even
termination of certain specialized programs dedicated to the
specialized needs of veterans with particular disabilities. A careful
review of the impact of that well-intentioned law, and subsequent
amendments to it, would likely call its effectiveness into question.
The law employed 1996 as a baseline against which to gauge whether VA
``maintained'' then-existing programs. While this bill does implicitly
raise highly important issues, there has been too much change in the VA
health care system to employ a 17-year old benchmark as the framework
for judging whether VA programs and services are meeting some of our
veterans' most critical needs. We are more than sympathetic to the
concerns underlying the bill, but urge the Subcommittee to avoid
missing this important mark by simply reinstating a reporting
requirement that for a number of the programs it aims to protect is
substantially outdated.
Mental Health Care
H.R. 3387, the Classified Veterans Access to Care Act, would direct
VA to establish standards and procedures to accommodate veterans'
access to care without ``improperly disclos[ing] classified
information.'' It is our understanding that this legislation was
developed as a response to a disturbing instance of a patient (with
knowledge of classified information) being prematurely placed in group
therapy. We share a concern that veterans needing mental health care
should be afforded that care in an appropriate and timely manner and,
particularly, without being made to attend group therapy before they
are offered needed individual treatment. That concern is not limited to
situations where a patient feels unable to discuss mental health
problems in a group setting because of an obligation not to disclose
classified information. Congressional testimony that many VA medical
centers have routinely placed patients in group-therapy settings rather
than provide needed individual therapy \8\ highlights a broader problem
than the bill addresses. As such, we recommend that the Subcommittee
consider a more comprehensive solution than H.R. 3387 proposes.
Providing effective care requires building a relationship of trust
between provider and patient--a bond that is not necessarily easily
established \9\ and setting the foundation for such trust should
generally begin in individual treatment. We also urge more focus on the
soundness and effectiveness of the VA's mental health performance
measures, which currently track adherence to process requirements, but
fail to assess whether veterans are actually improving.\10\
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\8\ VA Mental Health Care: Evaluating Access and Assessing Care:
Hearing Before the S. Comm. on Veterans' Affairs, 112th Cong. (Apr. 25,
2012) (Testimony of Nicholas Tolentino, OIF Veteran and former VA
medical center administrative officer).
\9\ VA Mental Health Care Staffing: Ensuring Quality and Quantity:
Hearing Before the Subcommittee on Health of the H. Committee on
Veterans' Affairs, 112th Cong. (May 8, 2012) (Testimony of Nicole
Sawyer, PsyD, Licensed Clinical Psychologist).
\10\ VA Mental Health Care Staffing: Ensuring Quality and Quantity:
Hearing Before the Subcommittee on Health of the H. Comm. on Veterans'
Affairs, 112th Cong. (2012) (Testimony of Ralph Ibson), supra note 21.
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A second measure, H.R. 183, would direct VA to carry out a five-
year pilot program to assess training service dogs as a therapeutic
medium to treat mental health and posttraumatic stress disorder
symptoms. In our work with Wounded Warriors, we hear from many
individuals who have benefitted greatly from the use of a service dog
for a mental health condition. We are also aware of reports suggesting
incarcerated inmates have derived benefits from participating in
programs in which they train service dogs. WWP is not able to assess
the strength or existence of evidence that might suggest that training
dogs offers promise as a mode of therapy for veterans with mental
health conditions. More importantly, however, H.R. 183 is in the nature
of a directed research program. Given many other competing claims on
VA's budget, we believe that decisions to fund research initiatives,
however appealing they may appear, should be based on a peer-review
evaluation process. However meritorious this proposal may be, we would
urge the Subcommittee to discourage the direction of VA research. While
we do not support H.R. 183, WWP is certainly not opposed to innovation.
To the contrary, we are supportive of finding innovative ways to engage
more veterans in needed mental health care. In that regard, we have
specifically supported approaches that would integrate complementary
medicine into traditional practices as well as using complementary
practices as a gateway to evidence-based services to engage veterans
who, for example, might otherwise be reluctant to seek or accept mental
health treatment.
Hearing-Related Issues
With WWP's most recent annual survey of our wounded warriors
showing that nearly 18% of our survey respondents report having severe
hearing loss, evaluation, care and services for hearing-impaired
veterans is certainly a concern. As such, we welcome the Subcommittee's
consideration of hearing-related issues. In that regard, H.R. 3508
would set standards for, and authorize appointment under Title 38 to,
hearing aid specialists, and require VA to report annually on timely
access to hearing health services and contracting policies with respect
to providing those services.
As discussed above, wait times for treatment and needed VA services
is an overarching issue. And as discussed above, and in a recent IG
audit report on VA's Hearing Aid Services,\11\ the adequacy of VA
staffing is an important dimension of providing timely service.
---------------------------------------------------------------------------
\11\ VA Office of Inspector General, ``Audit of VA's Hearing Aid
Services,'' 12-02910-80 (Feb. 20, 2014).
---------------------------------------------------------------------------
As with other VA services, there appears to be variability in the
timeliness of VA hearing-related services. WWP field staff who reported
very recently on their experience in several regions of the country
advised that ``warriors still have general complaints with wait times
for appointments, [but] not any more so for hearing assistance than any
other service,'' and even that ``many [WWP staff and warriors] reported
that hearing evaluations and administering of services (aids, battery
replacements, etc.) are one of the more expedited facets of the VAMC.''
Another, however, cited ``lag[s in service] universally around my
region.'' Such delays could certainly continue to grow as earlier
generations of veterans age, and hearing impairments worsen.
While WWP has no position on H.R. 3508, we do believe VA has much
more work to do--across a broad range of health care services--to
address the adequacy of health care staffing and the timeliness (as
well as the effectiveness) of its provision of services. We would
encourage the Subcommittee to continue to press VA on these important
issues.
Finally, we applaud the Subcommittee's efforts to resolve the
longstanding difficulty associated with authorizing major medical
facility leases, and welcome the draft authorization bill being
considered today.
Thank you for your consideration of our views.
VetsFirst
Chairman Benishek, Ranking Member Brownley, and other distinguished
members of the subcommittee, thank you for the opportunity to share
VetsFirst's views on four of the bills under consideration today.
VetsFirst, a program of United Spinal Association, represents the
culmination of over 65 years of service to veterans and their families.
We advocate for the programs, services, and disability rights that help
all generations of veterans with disabilities remain independent. This
includes access to Department of Veterans Affairs (VA) financial and
health care benefits, housing, transportation, and employment services
and opportunities. Today, we are not only a VA-recognized national
veterans service organization, but also a leader in advocacy for all
people with disabilities.
H.R. 3508, To Amend Title 38, United States Code, To Clarify the
Qualifications of Hearing Aid Specialists of the Veterans Health
Administration of the Department of Veterans Affairs, and for Other
Purposes
VetsFirst believes veterans should have timely access to
professional hearing care services to ensure a higher quality of life.
The VA's Office of Inspector General's February 2014 audit of
hearing aid services found that VA was not timely in issuing new
hearing aids to veterans and meeting its 5 day timeliness goal. The
report indicated that VA audiology staff attributed the hearing service
delays to inadequate staffing.\1\ In addition to providing hearing aid
services, these staff members are also required to conduct compensation
and pension examinations.
---------------------------------------------------------------------------
\1\ U.S. Department of Veterans Affairs, Office of Audits and
Evaluations, Audit of VA's Hearing Aid Services, February 20, 2014.
---------------------------------------------------------------------------
Tinnitus and hearing loss were the most prevalent service-connected
disabilities in FY 2012 for veterans receiving disability
compensation.\2\ It is concerning that VA has not adequately
anticipated the demand for hearing services, and in turn created a
staffing model to meet the challenge. I, like many veterans of all
eras, have experienced acoustic trauma due to my military service.
---------------------------------------------------------------------------
\2\ Ibid.
---------------------------------------------------------------------------
With the prevalence of explosions from artillery, and the sound of
rifle-fire in training operations and combat operations, it is not
surprising that many veterans have hearing loss. Audiology staff having
to divide their time between compensation and pension exams is
understandable. However, not adjusting current staff workloads
appropriately to meet the timeliness delay is not acceptable.
This legislation would allow VA to appoint hearing aid specialists
to assist veterans in receiving quicker access to needed services.
These professionals are licensed in their respective states and can
provide robust services that include: hearing testing; determining
necessity for hearing assistive devices; performing hearing aid
adjustments; taking impressions for ear molds, and providing counseling
and aural rehabilitation. These hearing aid specialists have received
extensive training and hundreds of professionals are currently entering
the industry. The legislation's reporting requirements related to wait
times and contract referrals will also help identify remaining gaps in
hearing care services.
VetsFirst strongly supports H.R. 3508.
H.R. 183 Veterans Dog Training Therapy Act
Service animals promote independence for people with disabilities
and break down societal barriers; thus, promoting community
reintegration. Consequently, VetsFirst supports efforts to ensure that
properly trained service animals are available to veterans who can
benefit from their assistance.
This legislation would require VA to establish a pilot program to
allow veterans with mental health needs to train service dogs for
fellow veterans with disabilities. Specifically, this legislation
addresses two critical needs by providing service dogs to veterans who
are seeking the assistance of a service dog and giving veterans with
post-deployment mental health concerns or post-traumatic stress
disorder the opportunity to benefit from training these dogs. The dual
nature of this approach will assist a wide range of veterans.
Veterans who assist with training the service dogs will be required
to follow a structured training process to ensure that the animals are
properly trained. The legislation also requires VA to collect data
regarding the effectiveness of the program. Lastly, veterans
participating may even be able to use the skills they acquired as a
trainer to successfully pursue a career in the service animal field.
VetsFirst strongly supports H.R. 183.
H.R. 2527 To Amend Title 38, United States Code, To Provide Veterans
With Counseling and Treatment For Sexual Trauma That Occurred During
Inactive Duty Training
VetsFirst knows that access to VA health care is a lifeline for
many veterans who seek assistance for mental health conditions that may
result from military sexual trauma (MST).
Reservist and Guard personnel who are serving their weekend duty
requirements are not considered to be on Active Duty under the law.
Instead, these personnel are on Inactive Duty for Training (IADT)
status. Title 38 currently excludes these service members from
accessing needed VA counseling and treatment due to MST.
This legislation would provide Reservist and Guard personnel who
suffer an MST while on IADT status with access to related health care
services at VA. MST assaults occurring during military service can have
a devastating impact on a service member's mental health and well-
being. Timely access to quality VA health care is critical in assisting
these service members with the counseling and treatment they need. This
bill would expand those services to a greater number of our brave men
and women.
VetsFirst strongly supports H.R. 2527.
H.R. 2974 To Amend Title 38, United States Code, To Provide for the
Eligibility for Beneficiary Travel for Veterans Seeking Treatment or
Care for Military Sexual Trauma in Specialized Outpatient or
Residential Programs at Facilities of the Department of Veterans
Affairs, and for Other Purposes
VetsFirst strongly supports access to beneficiary travel for
veterans requiring treatment at VA health care facilities.
This legislation would expand beneficiary travel to veterans who
need specialized outpatient or residential VA health care due to MST.
We strongly believe that expanding access to beneficiary travel to
include MST survivors sends a message that encourages veterans to
pursue the treatments currently available for these conditions. By
receiving the care they need, we hope that veterans who have
experienced MST will be able to more fully reintegrate into their
community.
VetsFirst strongly supports H.R. 2974.
Thank you for the opportunity to present our supportive views on
these important pieces of legislation. We believe that passage of these
bills will be of great value to veterans with disabilities. This
concludes my statement.
Information Required by Clause 2(g) of Rule XI of the House of
Representatives
Written testimony submitted by Christopher Neiweem, Director of
Veterans Policy, VetsFirst, a program of United Spinal Association;
1660 L Street, NW, Suite 504; Washington, DC 20036. (202) 556-2076,
ext. 7702.
This testimony is being submitted on behalf of VetsFirst, a program
of United Spinal Association.
In fiscal year 2012, United Spinal Association served as a
subcontractor to Easter Seals for an amount not to exceed $5000 through
funding Easter Seals received from the U.S. Department of
Transportation. This is the only federal contract or grant, other than
the routine use of office space and associated resources in VA Regional
Offices for Veterans Service Officers that United Spinal Association
has received in the current or previous two fiscal years.
Christopher J. Neiweem is the Director of Veterans Policy at
VetsFirst, which is a program of United Spinal Association.
Mr. Neiweem began his tenure with the organization in September
2013. His responsibilities include promoting the policy priorities of
VetsFirst to the U.S. Congress, White House, federal agencies, and
veteran service organization community.
He has been advocating for veterans at the federal level since
2011. After spending 6 years in the U.S. Army Reserve, which included a
deployment to Iraq in 2003 to detain prisoners and support base
security as a military police soldier, he attended college in his home
state of Illinois. Chris completed a Bachelor's Degree in Political
Science at Northern Illinois University, which included a summer
internship in the Washington, DC office of Congressman Donald Manzullo.
He went on to graduate school utilizing the Post 9-11 G.I. Bill and
completed a Master's Degree in Political Affairs, at the University of
Illinois at Springfield. During graduate school he completed 2
internships. The first at Springfield-based consulting firm Cook Witter
Inc., and the other for the U.S. Senate campaign of now Senator Mark
Kirk.
Since graduation Chris relocated to the Washington, DC area where
he uses his experience in policy and military affairs to impact the
federal benefits and services of our nation's veterans at VetsFirst.
QUESTION FOR THE RECORD
Context of Inquiry: On February 26, 2014, Dr. Robert Petzel, Dr.
Robert Jesse, Dr. Rajiv Jain, Dr. Madhulika Agarwal and Mr. Phillip
Matkovsky testified before the HVAC-Health committee at a hearing
titled: ``VA Accountability: Assessing Actions Taken in Response to
Subcommittee Oversight''. There were seven deliverables from the
hearing.
Question 1: Please provide the complete list of specialty care
services that have not yet implemented productivity standards.
Response: Specialties scheduled for implementation during the 3rd
and 4th quarters this year:
Cardiology
Pulmonary/Critical Care
General Surgery
Physical Medicine and Rehab
Anesthesiology
Emergency Medicine
Laboratory/Pathology
Geriatrics
Question 2: Please provide an examination of the need for and
potential incorporation of whistleblower protections for Veterans
reporting military sexual trauma.
Response: As noted by Committee Member Kuster, the Department of
Defense is currently reforming policies regarding Servicemembers'
protection against retaliation after reporting experiences of military
sexual assault. VHA cannot conceive of a scenario where a parallel set
of policies in VHA would be necessary.
Disclosures of MST to a VA staff member would be
considered protected health information and thus subject to the
provisions of the Health Insurance Portability and
Accountability Act (HIPAA). Penalties for unauthorized use of
medical record information are already covered under HIPAA and
do not need to be duplicated by VA MST-specific whistleblower
protections.
VA does provide care for some active duty
Servicemembers or Reservists who later return to active duty.
In these cases, VA medical record information may be shared
with the Department of Defense. If a disclosure of MST noted in
a Servicemember's medical record subsequently led to
retaliation against the Servicemember, the transgression would
presumably be covered under the Department of Defense's
whistleblower protections. Again, there is no need for a
parallel set of VA policies.
Eligibility for VA care is independent of any
Department of Defense disciplinary or other proceedings, unless
the Veteran was to ultimately receive an Other Than Honorable
or Dishonorable discharge. If this discharge were the result of
retaliation, this would also presumably be covered by the
Department of Defense's whistleblower protections.
Question 3: The Circumstances surrounding the six members of the
SES who had ``serious disciplinary actions'' taken against them over
the last two years.
Response: The Department is currently working to provide the
circumstances surrounding the six members of the SES who has
disciplinary actions taken and will provide this information as soon as
possible.
Question 4: Provide a report on MST anonymous callers (Mystery
Shopper).
Response: The MST anonymous caller initiative targets a potential
barrier to accessing MST-related care: difficulty contacting the MST
Coordinator at a VHA health care facility. The initiative was first
authorized in June 2010, and four rounds of review have been conducted
since at an approximately yearly interval.
During each round, two members of the MHS national MST Support
Team--one female and one male--placed calls to the primary switchboard
phone number of each facility during normal business hours. Following a
standard script, callers asked for assistance in reaching the facility
MST Coordinator. Calls were rated based on the ability of operators and
other frontline staff (e.g., clinic clerks) to identify the MST
Coordinator, the seamlessness of the transfer, and staff members'
courtesy and sensitivity to callers' privacy concerns. Each facility
was rated as Satisfactory, Marginal, or Unsatisfactory based on results
from both calls. All facilities with a Marginal or Unsatisfactory
rating received detailed feedback on the calls, and, to date, have
submitted action plans to VA Central Office to address the identified
issues negatively impacting MST Coordinator accessibility.
The MST Support Team has taken several steps to assist facilities
with preparing for the calls and with writing action plans. These
include hosting a webinar presentation on the initiative, disseminating
tip sheets of strategies on increasing and maintaining accessibility,
and consulting with MST Coordinators to problem solve identified
barriers.
The initiative has been successful in improving nationwide MST
Coordinator accessibility. In Round 4 (Aug-Sep 2013), 83.6% of
facilities were judged to have Satisfactory accessibility, 13.6%
Marginal, and 2.9% Unsatisfactory. These results represent a nearly 30
percentage point improvement in Satisfactory accessibility and 16
percentage point drop in Unsatisfactory accessibility since Round 1
(Jul-Aug 2010).
Question 5: Provide the FY 2013 Office of Productivity and
Efficiency's staffing standard report for MST (measuring the number of
MST patients that VA facilities are treating and the staff resources
available to treat them).
Response: The Annual Report on Counseling and Treatment for
Military Sexual Trauma (MST) for Fiscal Year (FY) 2013 is currently
being reviewed and we will provide the report to you as soon as it is
available.
Question 5a: Please also provide information paper on the (2) FTE
for MST.
Response: Please see below for the methods and results regarding
decision to have (2) FTE for MST.
Methods
The VA MHS MST Support Team completes an annual report
to determine the number of trained full time equivalent
employees (FTEEs) required to meet the mental health needs of
Veterans who have experienced MST, to fulfill the requirements
of 38 United States Code, Section 1720D(e). Because MST is
associated with a variety of mental health conditions and is
treated across multiple outpatient treatment settings, we could
not rely solely on the number of providers in a given mental
health service line or clinic. Therefore, we relied on methods
developed by the VA Office of Productivity, Efficiency, and
Staffing (OPES) to quantify workload associated with MST-
related mental health care and calculate the effective number
of FTEEs associated with this care at each VA Health Care
System (HCS). From this we created a metric so that staffing
levels could be compared across facilities.
Each VA HCS varies in the number of Veterans that it
serves who have experienced MST and therefore varies in the
demand for MST-related mental health care. To enable
comparisons across facilities, we calculated a ratio of
provider staffing against population size: the total FTEEs
providing MST-related mental health care for every 100 Veterans
with positive MST screens. It is important to note that not all
Veterans with a positive MST screen will want treatment and
among those that do request care, the amount of MST-related
care required by each Veteran will vary due to the range of
mental health conditions associated with MST. But in general, a
larger staffing ratio indicates greater staffing and
availability of MST-related mental health services.
We examined the amount of MST-related mental health
care that each VA HCS provided and ranked facilities on two
indicators: (1) The proportion of Veterans with a positive MST
screen who received any MST-related mental health care; and (2)
the median number of visits among patients who received MST-
related mental health care. We identified health care systems
that ranked in the top 25% for both indicators. We then used
staffing ratio data from these ``high volume'' VA health care
systems to establish the benchmark.
The benchmark of 0.2 FTEE per 100 Veterans (or 2 FTEE
per 1,000 Veterans) who experienced MST is based on a
comparison with these ``high volume'' VA health care systems.
This benchmark is within two standard deviations of the average
staffing ratio at high volume health care systems. Even
staffing levels that are only a portion of a single FTEE
represent portions of workload from several different providers
due to the wide range of mental health conditions and clinic
settings associated with MST-related mental health care.
Results
Knowledgeable in the treatment of MST-related mental
health conditions. In the most recent analysis, 99 percent of
VA health care systems were at or above the established
benchmark for MST-related mental health staffing capacity. Over
64,000 Veterans received MST-related mental health care from a
VA health care facility. These Veterans received a total of
over 693,000 MST-related mental health care visits from over
17,950 individual providers. Not all of those 17,950 individual
providers, however, spent all of their clinical hours
delivering MST-related mental health care. The care delivered
by those providers was equivalent to 580 FTEEs.
Question 6: Provide the committee with information about the VA
employees that were held accountable for patient deaths at the Augusta
VAMC and the Atlanta VAMC.
Response: Disciplinary actions for Atlanta and Augusta are below:
Disciplinary Actions
Atlanta VAMC
Chief of Staff--Reprimand
Associate Director--Reprimand
Associate Director/Nursing and Patient Care Services--
Reprimand
Chief, Mental Health Service Line--Reassigned
Mental Health Inpatient Nurse Manager--Reprimand
Associate Nurse Executive/Mental Health and
Geriatrics--Reprimand
Mental Health Inpatient Unit Medical Director--
Admonishment
Former Medical Center Director--Retired
Veterans Integrated Service Network (VISN) Chief of
Mental Health Services--Retired
Augusta VAMC
Chief of Staff--Received Performance Counseling
(Voluntarily resigned from position)
Question 7: Please provide the timeline for VHA to contribute to
the State Prescription Drug Monitoring Program.
Response: VA participation with State Prescription Drug Monitoring
Program is estimated to begin August 2014. This is predicated on a
contract award by May 5, 2014, with a contract start shortly after
award. The timeline includes achieving Milestone 2 (development enters
implementation phase) by May 30, with code changes to other patches and
Medication Order Checking Application (MOCHA 2.0) completed,
documentation updated, and identification of additional test sites by
the end of June. It is expected that this work would enter the national
release process near the middle of July with testing and deployment
leading to a mid-August completion. The State Drug Monitoring Program
patch is dependent on MOCHA 2.0 which will deploy in waves between
March 24, 2014 and June 16, 2014, as well as a titration management
patch that will start simultaneously with the State Drug Monitoring
Program patch. There are potential risks of delays to the August 2014
start date that could arise from dependencies that include contract
start date and unforeseen technical issues with states that are not
part of the test site process. The VA Office of Information and
Technology is responsible for oversight and management of software
development and deployment for this program.
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