[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
VBA AND VHA INTERACTIONS: ORDERING
AND CONDUCTING MEDICAL EXAMINATIONS
=======================================================================
HEARING
before the
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
Wednesday June 25, 2014
__________
Serial No. 113-77
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Vice- 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
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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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
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C O N T E N T S
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Page
Thursday June 12, 2014
VBA And VHA Interactions: Ordering And Conducting Medical
Examinations 1
OPENING STATEMENT
Hon. Jeff Miller, Chairman
Statement.................................................... 1
Prepared Statement........................................... 3
Hon. Mike Michaud, Ranking Minority Member
Statement.................................................... 4
Prepared Statement........................................... 5
Hon. Ann Kirkpatrick
Prepared Statement........................................... 7
WITNESSES
Mr. Thomas Murphy, Director Compensation Service, Veterans
Benefits Administration, U.S. Department of Veterans Affairs
Oral Statement............................................... 7
Statement.................................................... 10
Accompanied by:
Ms. Beth McCoy, Acting Deputy Under Secretary for Field
Operations, Veterans Benefits Administration, U.S. Department
of Veterans Affairs
Dr. Gerald M. Cross, Chief Officer Office of Disability and
Medical Assessment, Veterans Health Administration, U.S.
Department of Veterans Affairs
Ms. Patricia D. Murray, Director Clinical Programs and
Administrative Operations, Veterans Benefits Administration,
U.S. Department of Veterans Affairs
Mr. George C. Turek
Oral Statement............................................... 17
Statement.................................................... 19
Exhibit 1.................................................... 25
Exhibit 2.................................................... 27
Exhibit 3.................................................... 28
Executive Summary............................................ 29
APPENDIX
STATEMENT FOR THE RECORD............................. 59
Statement of Jeff Scarpiello 59
VA Responses to Pre-Hearing Questions 62
Mr. Turek's Supplemental Testimony 70
VBA AND VHA INTERACTIONS: ORDERING AND CONDUCTING MEDICAL
----------
Wednesday, June 25, 2014
U.S. House of Representatives
Committee on Veterans' Affairs
Washington, D.C.
The committee met, pursuant to notice, at 9:15 a.m., in
Room 334, Cannon House Office Building, Hon. Jeff Miller
[chairman of the committee] presiding.
OPENING STATEMENT OF CHAIRMAN JEFF MILLER
The committee met, pursuant to notice, at 10:03 a.m., in
Room 334, Cannon House Office Building, Hon. Jeff Miller
[chairman of the House Committee on Veterans' Affairs]
presiding.
Present:Representatives Miller, Lamborn, Bilirakis, Roe,
Flores, Denham, Runyan, Benishek, Huelskamp, Coffman, Wenstrup,
Walorski, Michaud, Brown, Takano, Brownley, Titus, Ruiz,
Negrete McLeod, Kuster, O'Rourke, and Walz.
The *Chairman.* Good morning, everybody. During this
morning's full committee hearing entitled VBA and VHA
Interactions: Ordering and Conducting Medical Examinations, we
are going to examine the relationship that exists between VHA
and VBA as to their respective efforts to conduct medical
examinations on veterans' claims for disability benefits known
as C&P exams. There will be several reasons that we are going
to focus on today and the reason that we are focusing on it is
medical but non-treatment related VA functions that they
perform.
The first is based on that fact that VHA has failed. It has
failed in its paramount mission and I quote, ``to honor
America's veterans by providing exceptional healthcare that
improves their health and their well-being.'' The rampant
corruption, dishonesty, and cowardice that has been brought to
light by this committee shocks the very conscience of everyone
in this room and certainly of the United States of America.
This week's newest whistleblower allegation regarding the
falsification of deceased veteran records yet again underscores
the bureaucratic arrogance that exists within this department.
The consequences of VA's failures did not fall on the
unscrupulous or the willfully ignorant facility leadership.
Instead the consequences fell squarely on the shoulders of
those individuals who stood up and swore commitments to this
nation. Commitments that center on fidelity, on honor, and on
duty. And veterans have died.
Over the course of recent weeks this committee has held
many hearing, targeted to address comprehensive VA reform and
there are going to be more hearings to come. I still believe
that the majority of VA's workforce, the doctors, the nurses,
the claims processes, and the veterans service representatives
truly do endeavor to provide quality service to our veterans.
But VA's epidemic lack of accountability, and mission focus
requires a wholesale, systematic reform of the Department. A
massive, massive cultural shift is in fact necessary.
I have listened to VA's responses to this committee's
questions in recent weeks and what I hear are frequently
institution-centered answers, not veteran-centered responses.
In setting the tone for this hearing and future hearings, let
me begin by cautioning that any equivocation, any excuse
provided by VA that seeks to protect the establishment to the
detriment of the veteran is going to fall on deaf ears. The
time for excuses has long passed.
Today's hearing will explore the current division of labor
between VBA and VHA on provision of C&P exams for disability
adjudications, as well as the various contract tools that each
administration uses. Given the recent VHA failures and issues
raised by VHA to include space limitations and staff shortages,
I want to hear your thoughts on whether the thousands of VHA
employees assigned to performing C&P exams could be better used
to treat veterans. VHA currently has nearly 8,200 registered
and certified C&P examiners, which include physicians, nurse
practitioners, physician assistants, and psychologists, as well
as additional administrative support staff necessary to
administer this function, many of whom work with VBA solely to
perform C&P disability exams. Transferring some or all of the
VHA C&P staff to treatment jobs would significantly increase
the number of appointments available to veterans.
I am aware that VHA has voiced some initial resistance to
this concept and has objected on the basis that many C&P exam
providers at VHA have either not maintained the necessary
credentials to transition into patient treatment roles or that
some prefer to work on a part-time schedule and thus must
remain with a C&P examiner capacity at VHA.
I would point out that this is a prime opportunity to
demonstrate that culture shift that I have spoken about. The
mission is to provide quality and timely healthcare to
veterans, not to accommodate the status quo. And in any event,
I am curious as to why VA does not require more than their
healthcare providers to maintain their qualifications. Based on
the high level of satisfaction with the contractors who perform
medical disability examinations for purposes of adjudicating
disability claims, VA has supported expansion of its contract
authority in the past. However, we are also aware that VBA and
VHA do not award or administer contracts uniformly. The
ordering processes are different, the scheduling systems are
different, the work flow processes are different, and the
billing and collection processes are different. Accordingly,
today we are going to take a detailed look at the big picture.
We will look for sensible solutions and best practices to
achieve both the most effective access to medical treatment as
well as assurance of timely, high quality C&P exams for
disability adjudication.
STATEMENT OF JEFF MILLIER, Chairman
During this morning's full committee hearing entitled,
``VBA and VHA interactions: ordering and conducting medical
examinations'' we will examine the relationship that exists
between VHA and VBA as to their respective efforts to conduct
medical examinations on veterans' claims for disability
benefits, known as ``C&P exams.''
And there are several reasons that we will focus on this
specific medical, but non-treatment related, VA function.
The first is based upon the fact that VHA has failed . . .
it has failed its paramount mission, I quote, ``to honor
America's veterans by providing exceptional health care that
improves their health and well-being.''
The rampant corruption, dishonesty, and cowardice brought
to light by this committee shocks the conscience of everyone in
this room, and of this Nation.
This week's newest whistle-blower allegation, regarding the
falsification of deceased veterans' records, yet again
underscores the bureaucratic arrogance that subsists within
this department.
The consequences of VA's failures did not fall on the
unscrupulous manager, or the willfully ignorant facility
leadership; instead, the consequences fell squarely on the
shoulders of those individuals who stood up and swore
commitments to this nation . . . commitments that center on
fidelity, honor, and duty.
And, veterans died.
Over the course of recent weeks, this committee has held
many hearings targeted to address comprehensive VA reform, and
there will be more hearings to come.
I still believe that the majority of VA's workforce - the
doctors, nurses, claims processors, and veteran service
representatives - truly do endeavor to provide quality service
to veterans. But, VA's epidemic lack of accountability --- lack
of mission focus--- requires a wholesale systematic reform of
the department . . . a massive, massive, cultural shift is
necessary.
I have listened to VA's responses to this committee's
questions in recent weeks . . . and what I hear are frequently
institution-centered, not veteran-centered, responses. And so,
in setting the tone for this hearing, and future hearings, let
me begin by cautioning that any equivocation --- any excuse ---
provided by VA that seeks to protect the establishment, to the
detriment of the veteran, will fall on deaf ears. The time for
excuses is long past.
Today's hearing will explore the current division of labor
between VBA and VHA on provision of C&P exams for disability
adjudications, as well as the various contract tools that each
administration maintains.
Given the recent VHA failures, and issues raised by VHA to
include space limitations, and staff shortages, I would like to
hear your thoughts on whether the thousands of VHA employees
assigned to performing C&P examinations could be better used to
treat veterans.
VHA currently has nearly eight thousand two hundred
registered and certified C&P examiners, which include
physicians, nurse practitioners, physician assistants, and
psychologists, as well as additional administrative support
staff necessary to administer this function, many who work
closely with VBA solely to perform C&P disability examinations.
Transferring some or all of the VHA C&P staff to treatment
jobs would significantly increase the number of appointments
available to veterans.
Now, I am aware that VA has voiced some initial resistance
to this concept, and has objected on the basis that many C&P
exam providers at VHA have either not maintained the necessary
credentials to transition into patient treatment roles, or that
some prefer to work on a part-time schedule, and thus must
remain within a C&P examiner capacity at VHA. I would point out
that this is a prime opportunity to demonstrate that culture
shift I spoke about:
The mission is to provide quality and timely healthcare to
veterans, not to accommodate the status- quo. And, in any
event, I am curious why VA does not require more of their
healthcare providers to maintain their qualifications.
Based on the high level of satisfaction with the
contractors who perform medical disability examinations for
purposes of adjudicating disability claims, VA has supported
expansion of its contract authority in the past.
However, we are also aware that VBA and VHA do not award or
administer contracts uniformly; the ordering processes are
different, the scheduling systems are different, the workflow
processes are different, and the billing and collection
processes are different.
Accordingly, today we are going to take a detailed look at
the big picture.
We will look for sensible solutions, and best practices, to
achieve both the most effective access to medical treatment, as
well as assurance of timely, high-quality C&P exams for
disability adjudication.
With that, I want to recognize the Ranking Member Mr.
Michaud for his opening statement.
OPENING STATEMENT OF MIKE MICHAUD, RANKING MEMBER
Mr. Michaud. Thank you very much, Mr. Chairman, for holding
this hearing today on behalf of our nation's veterans. Mr.
Chairman, I appreciate your taking the time during our
extensive oversight of the VA to focus on something that the VA
is improving upon, processing claims.
As of today the VA has reduced the backlog by more than 50
percent from the highest point in March of 2013. We are not
even close to the finish line but we are starting to see
increase in productivity as a result of VBA's long overdue
shift from paper to an electronic processing system. All 56
offices have moved into this electronic processing system and
into a new organizational model that appears to be showing
positive results. Some of our high performing regional offices
are nearing the point at which the backlog will be eliminated.
While we have heard of the scheduling challenges that the
veterans face in receiving clinical appointments, I am happy to
hear that VA has been providing timely medical examinations to
determine a veteran's entitlement for VA benefits. Currently
VA's national average for medical examinations for benefits
purposes is 24 days, which is six days better than their goal
of 30 days. VA seems to believe that they have a solid handle
on their mix of contract versus non-contract examination. We
have heard VA suggest that in an ideal world they would prefer
non-contract examinations over contract examinations because
they believe it will provide a better continuum of care for our
veterans. We have generally heard the same things from
veterans, who suggest that when they have access VA quality of
care is second to none.
However, with regards to contract examination it seems that
the logical way forward continues to be a mix based on clear
standards as to when and where they should or should not be
used. That said, I have some overarching concerns with VBA's
transformation efforts. Foremost, the all in focus on the
backlog is starting to come at the cost of increased delays
from other benefits. Management by crisis is not a long term
viable solution. We cannot afford to solve one critical issue
by taking our attention off another.
I urge VA to reallocate resources to process non-rating
claims and appeals in a timely fashion. Appeals in non-rating
claims are also part of the backlog and deserve to be
adequately resourced to provide timely and accurate decisions
to our veterans.
There will be no victory laps until VBA has eliminated
their entire overdue inventory. If we have learned anything
from this healthcare debacle it should be that serving
veterans, not performing metrics, is a way to do business.
Along these lines I would encourage VBA to ask itself are we
oriented towards a specific set of performance metrics at the
expense of identifying how to best serve our veterans? These
are the types of questions we must answer as we move forward
and I hope to hear them discussed in today's hearing in more
detail.
I want to thank all of you for coming here today, joining
us, and look forward to the hearing, your testimony, as well.
With that, Mr. Chairman, I yield back.
STATEMENT OF MIKE MICHAUD, Ranking Member
Thank you, Mr. Chairman for holding this hearing today on
behalf of our nation's veterans.
Mr. Chairman, I appreciate you taking the time during our
extensive oversight of the VA to focus on something that the VA
is improving upon: processing claims.
As of today, the VA has reduced the backlog by more than 50
percent from its highest point in March of 2013.
We are not even close to the finish line, but we are
starting to see increases in productivity as a result of VBA's
long overdue shift from paper to an electronic processing
system.
All 56 offices have moved into this electronic processing
system and into a new organizational model that appears to be
showing positive results.
Some of our high-performing regional offices are nearing
the point at which the backlog will be eliminated.
While we have heard of the scheduling challenges that
veterans face in receiving clinical appointments, I am happy to
hear that VA has been providing timely medical examinations to
determine a veteran's entitlement for VA benefits.
Currently VA's national average for medical examinations
for benefits purposes is 24 days, which is six days better than
their goal of 30 days.
VA seems to believe that they have a solid handle on their
mix of contract versus non-contract examinations.
We have heard VA suggest that in an ideal world they would
prefer non-contract examinations over contract examinations
because they believe it provides a better continuum of care for
veterans.
We have generally heard the same thing from veterans, who
suggest that when they have access, VA quality of care is
second to none.
However, with regards to contract examinations, it seems
that the logical way forward continues to be a mix based on
clear standards as to when and where they should or should not
be used.
That said, I have some overarching concerns with VBA's
transformation efforts.
Foremost, the ``all-in'' focus on the backlog is starting
to come at the cost of increased delays for other benefits.
Management-by-crisis is not a long-term viable solution -
We cannot afford to solve one critical issue by taking our
attention off another.
I urge VA to reallocate resources to process non-rating
claims and appeals in a timely fashion.
Appeals and non-rating claims are also part of the backlog
and deserve to be adequately resourced to provide timely and
accurate decisions to our veterans.
There will be no victory laps here until VBA has eliminated
their entire overdue inventory.
If we have learned anything from this healthcare debacle,
it should be that serving veterans, not performance metrics, is
the way to do business.
Along these lines, I would encourage VBA to ask itself, are
we oriented toward a specific set of performance metrics at the
expense of identifying how to best serve our veterans?
These are the types of questions we must answer as we move
forward, and I hope to hear them discussed in today's hearing
in a bit more detail.
The *Chairman.* Thank you very much, Mr. Michaud. And if
you have a telephone on in this room, turn it off. Thank you
very much. I would ask all members to waive their opening
statement as per the Committee's custom. Thank you for
appearing before us today as witnesses. We are going to hear
from Mr. Tom Murphy, Director of Compensation, Veterans
Benefits Administration, Department of Veterans Affairs. He is
accompanied by Ms. Beth McCoy, Acting Deputy Under Secretary
for Field Operations, Veterans Benefits Administration,
Department of Veterans Affairs; Dr. Gerald Cross, Chief of the
Office of Disability and Medical Assessment, Veterans Health
Administration, Department of Veterans Affairs; and Ms.
Patricia D. Murray, Director of Clinical Programs and
Administrative Operations, Veterans Health Administration,
Department of Veterans Affairs. And we also will hear from Mr.
George Turek, Founder, Owner, Chairman, and Chief Executive
Officer for Veterans Evaluation Services. I ask all the
witnesses now if you would please rise and raise your right
hand?
STATEMENT OF THE HON. ANN KIRKPATRICK
Veterans are waiting too long--for medical appointments and
for their disability claims to be processed. This week, the VA
claims backlog stands at 562,968. This number only reflects the
number of claims that have been filed and have been pending for
longer than 125 days. If veterans are waiting just to get that
examination to file a claim, this adds to the wait time.
Appointment scheduling and wait time data for compensation
and pension examinations should be carefully scrutinized in
light of report after report of VA medical facilities covering
up long patient wait times. Any additional reviews of
appointment scheduling should include an examination of patient
wait times for these exams as well. It is imperative that
accurate data be reported so that the VA is able to serve the
growing number of veterans that are seeking care.
Major reforms in the VA are sorely needed. The VA and
Congress must work together to strip away the layers of
bureaucracy and cut through the red tape so that the VA is able
to efficiently meet the needs of our veterans. While
contracting out compensation and pension examinations gives VA
primary care doctors more time to see patients, we cannot
sacrifice quality for efficiency. We have received several
reports of compensation and pension exams being performed by
contract doctors that do not have the licenses or credentials
to perform these exams--which can lead to wrongfully denied
claims, and the growing backlog of appealed claims.
[Witnesses sworn.]
The *Chairman.* Thank you very much. Please be seated. Each
of your written statements will be entered into the record and
Mr. Murphy, you are now recognized for five minutes.
STATEMENT OF THOMAS MURPHY
Mr. Murphy. Chairman Miller, Ranking Member Michaud, and
committee members, thank you for providing me the opportunity
to discuss the VA's C&P examination process.
The Department of Veterans Affairs is committed to
providing timely, high quality healthcare and other benefits
that veterans deserve and have earned through their service. An
important part of accurately determining those healthcare and
other benefits for which a veteran is eligible is through a C&P
examination. For this reason it is important that C&P exams are
performed under stringent clinical requirements and
credentialing criteria for both the elements of the exam as
well as the clinicians who perform them.
These requirements are the same whether the exam is
conducted by a VA provider or a VA contracted community health
provider. A case has been identified where 51 veterans were
previously examined by a VA contractor need to be reexamined by
VA to ensure the required standard was upheld. These 51
veterans are being contacted individually and their
appointments scheduled at their earliest convenience. VA
benefits staff members are standing by to expedite processing
of these C&P exams and inform veterans of their benefits for
which they may be eligible.
VA is working with the contractor to rectify the current
situation and prevent any recurrences. In addition, VA
contacted all DEM vendors and reviewed requirements for
training and certifying providers that conduct C&P exams. VA
required that all DEM vendors verify they are following these
requirements.
VHA conducts disability exams at the request of VBA. A
medical exam or opinion is required in claims when, after the
development of all other relevant evidence, there is not
sufficient medical evidence to make a rating decision on the
claim. To trigger the requirement for the examination there
must be evidence of a current disability, evidence of an event,
injury, or disease in service, and a nexus between the two.
VBA and VHA have instituted several initiatives to improve
the timeliness and accuracy of claims processing based on
medical evidence. For example, DBQs are designed to efficiently
gather medical evidence by capturing all information needed to
rate a claim for a specific condition. A total of 81 DBQs are
available for VHA clinicians, including 71 DBQs that can be
completed by private doctors. Similarly, in the ACE VHA
initiative, clinicians review existing medical evidence and
determine whether that evidence can be used to complete a DBQ.
For many veterans this means they no longer need to travel and
take time off to complete an examination.
VHA is providing certified C&P clinicians at all 56 VBA
regional offices and two DRAS sites. The clinicians provide
medical opinions, answer staff questions, correct insufficient
examinations, and serve as a key communication link between VBA
and VHA. No examinations are conducted at the regional offices.
VHA and VBA joint analytics team work closely together to
track C&P examination metrics as well as to analyze data to be
able to identify trends, strengths, and weaknesses and project
future workload.
VHA's DMA is a national office that facilitates the
disability examination process to support field C&P clinics.
Nearly 8,200 VHA registered and certified V&P examiners, which
included full-time and part-time VHA employees, residents, fee
for service examiners, VHA contract vendors, locum tenens, and
specialty providers.
In 2011 VHA established a nationwide medical examination
contract with additional overseas capability. The contract is
held by four vendors who provide their services to meet VHA
standards.
In addition to DEM contract services, VHA provided VA
medical centers a number of tools. Examples of these tools
include hiring staff, fee basis support, the locum tenens
program, and additional funding.
The national standard for completing C&P disability exams
is 30 days, or 45 days for IDES. This is measured from the day
VBA electronically submits an exam request to the day VHA
electronically returns the report. For fiscal year 2014 the
average time was 24 days and 32 days for IDES. The total number
of disability exams and medical opinions completed by VHA and
its contractors was 1.85 million for fiscal year 2012, 2.17
million in fiscal year 2013, and 1.58 million in fiscal year
2014 to date.
In addition to examinations completed by VHA, VBA contracts
with three vendors. They provide examinations to 18 regional
offices. VBA is able to conduct contract examinations using
both mandatory and discretionary funds. VA's authority to use
discretionary funds for contract exams expires this December
and VA supports extension of this authority. VBA's authority to
use mandatory funds for contract exams is limited to ten
regional offices. The authority to contract disability exams is
essential to VBA's goal to eliminate the claims backlog.
In fiscal year 2013 VBA contractors completed over 225,000
examinations in addition to the 2 million exams conducted by
VHA and its contractors. In fiscal year 2014 exams conducted
using mandatory appropriations were completed on an average of
29 days and exams conducted using the discretionary funding
were completed in an average of 17 days.
VBA and VHA have worked to expand capacity for disability
examinations provided internally and through contract
resources. This collaboration has helped improve the timeliness
and accuracy of examinations and ultimately improved the
delivery of benefits to disabled veterans.
This concludes my testimony, Mr. Chairman. I would be happy
to address any questions you or other members of the committee
may have.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The *Chairman.* Thank you very much, Mr. Murphy. Mr. Turek,
you are recognized for five minutes.
STATEMENT OF GEORGE C. TUREK
Mr. Turek. Thank you, Mr. Chairman, Mr. Ranking Member, and
the committee members for providing me the opportunity to
testify today. My name is George Turek. I am a veteran. My wife
and I and four dogs and five cats, all rescue, live in Houston,
Texas.
I have been in the independent medical evaluation business
for 36 years, having established the first fee standing IME
facility in the U.S. in Detroit, Michigan in 1978. We formed
Veterans Evaluation Services in 2007 to provide outsourced
medical disability examinations, or MDEs, to the VA. We became
involved because we are highly committed to our veterans.
Currently VES has two contracts with the VA for outsourced
MDEs, one with the VBA and the other with the VHA. Our VBA
contract is a single source discretionary funded contract and
we serve in seven and a half regions. Our VHA contract is
indefinite quantity for overflow cases from VAMCs across the
world and we compete with compete with four other contractors
on this contract. We thoroughly enjoy working with both the VBA
and the VHA and their respective staffs are top notch.
There are challenges, however, adhering to each agency's
divergent processing and work flow requirements. The
differences in work flow processes between the VBA and VHA are
notable. One, VBA outsourced MDE allotments are controlled by
senior staff in Washington, D.C., while the allotments of MDEs
from the VHA are determined by each individual VAMC. Number
two, although they use the same computer system to process
MDEs, VBA and VHA use totally different scheduling systems. The
VBA uses CAATS, which is highly automated and efficient, while
VHA uses DemTRAN, which essentially consists of encrypted
emails that have to be manually entered into our system each
and every referral. And number three, the VBA and VHA have two
entirely different work flow processes for the same exact MDE.
An MDE referred from the VHA requires over twice as many steps
to process as the same one referred from the VBA. Number four,
monthly billing is a one-step process with the VBA while it is
a 12-step process with the VHA. With the VBA we simply prepare
one bulk bill for all the MDEs performed in the past month. But
with the VHA each MDE is billed separately and sent to each
referring VAMC. Based on our experience of working with both
agencies, it is our opinion that the VBA method of outsourcing
MDEs is far more time efficient and cost effective.
Now I would like to comment on two pressing issues. This
committee, the Senate Veterans' Affairs Committee, and the VA
have been struggling for years with the backlog of veterans
disability claims. Now in addition you are forced to deal with
the backlog of veterans seeking timely treatment appointments
at VAMCs. I am convinced that we have at least a partial
solution for both frustrating problems. Our recommendation is
that VAMC medical providers perform medical treatment only, no
MDEs, allowing them to focus 100 percent of their time on
treating veterans. With 80 percent of all MDEs currently
conducted by VAMC medical providers, this would free up
hundreds of thousands of man hours for VAMC medical providers
and their support staff to treat veterans. Concurrently, the VA
should outsource all MDEs to community based medical providers.
Private contractors have access to trained and experienced
medical providers as well as the necessary support staff to
allow them to timely and cost effectively process all MDEs.
The simple, reallocation of existing assets would go a long
way to resolve the backlog of both treatment cases and C&P
claims. This can be done quickly, much more quickly than
building new hospitals and clinics and then hiring and training
staff. This method of handling MDEs is consistent with how
independent medical examinations, the commercial equivalent of
MDEs, are processed in all other delivery systems, where they
are part of the claims management process, not the healthcare
delivery system. This is a crucial point and one which the
members of this committee who are themselves physicians should
well understand. This protocol is tried and true and has worked
extremely well in the commercial world for years. We believe
that it would likewise work well for the VA. We are simply
suggesting that with regard to MDEs, the VA should adopt the
commercial market method for processing claims.
The mission of the VHA should be to treat veterans, period.
On the other hand, the VBA should function as the claims
administrator for MDEs by ordering and scheduling them with
independent community based medical providers as part of the
C&P benefits delivery process.
Lastly, with regard to pending legislation, House Bill 2189
and Senate Bill 2091 are commendable but we believe they do not
go far enough. All VA regional offices should be allowed to
outsource MDEs under mandatory funded contracts with private
contractors. This would dramatically increase the resources
available to the VA to reduce the backlog of C&P claims as well
as reduce the treatment backlog at VAMCs.
Mr. Chairman, that concludes my statement. I would be
pleased to answer any questions that committee members may
have.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
EXECUTIVE SUMMARY
The VA and this Committee are confronted today with two
significant issues affecting our nation's veterans:
1. Veterans are waiting too long to receive medical
treatment at VAMC's; and
2. Veterans are waiting too long to receive C&P benefits
because of the backlog of MDEs waiting to be performed.
A simple, straightforward and easily implemented solution
would be to outsource all C&P MDEs to community-based medical
providers, thereby allowing VAMC-employed medical providers to
focus 100% of their time on providing treatment to our
veterans. The VA's mantra should be: all hands on deck for
treatment and C&P benefits for our veterans.
Private contractors such as VES already successfully
facilitate approximately 20% of all MDEs, with quality ratings
equal to or surpassing those of VAMC-employed medical
providers. Private contractors have access to trained and
experienced community-based medical providers, as well as the
support staff, facilities and other resources necessary to
process all MDEs.
Outsourcing MDEs is consistent with the long-standing and
proven practice in the commercial insurance claims industry of
ordering IMEs from independent community-based medical
providers. Doing so maintains the integrity of the medical
opinion by removing any internal or institutional bias, and
allows for a truly independent and objective medical opinion.
There is every reason to believe that the VA would experience
similar results with MDEs if it adopted the insurance
industry's approach to IMEs.
Both the VBA and the VHA currently utilize private
contractors to perform MDEs, although the process for ordering
and conducting MDEs is divergent depending on which agency is
involved: the ordering process is different, the scheduling
systems are different, the workflow processes are different and
the billing and collection processes are different. The VBA's
process, we believe, is more time-efficient, cost-effective and
less prone to mistakes than that of the VHA.
Another difference in outsourced MDEs is the type of
contractual funding: discretionary vs. mandatory.
Discretionary-funded contracts, with inconsistent monthly
referral volume, make it difficult for contractors to develop
and maintain fully credentialed and readily available medical
provider networks, let alone to plan, budget and staff
accordingly for the work. At least until the backlog is
eradicated, all outsourced MDE contracts should be mandatory-
funded.
H.R. 2189 and S. 2091 are commendable, but all VA regional
offices should be allowed to outsource MDEs (not just 15)
through the open RFP and competitive bidding process. This
would dramatically increase the resources available to reduce
the backlog of C&P claims.
All hands on deck for treatment and C&P benefits for our
veterans!
The *Chairman.* Thank you very much, Mr. Turek. We
appreciate all of you being here today. And I am going to start
with kind of a lengthy set up to a question, but I think it
goes right to the heart of some of the problems that this
committee is having with the Department.
To the VA witnesses, you have noted that you have a joint
analytics team in place that tracks C&P exam performance
metrics. I am curious as to which one of you oversees the
office because in preparation for this hearing VA provided
three separate documents to this committee, each of which
contains different numbers listed in the column total
examinations completed by VHA clinicians for fiscal years 2012
and 2013. In June 2014, correspondence between OCLA staff and
my staff stated that in fiscal year 2012 never mind 1,789,470
examinations were completed and in 2013 1,996,148 examinations
were completed by VHA clinicians. In the answers to the pre-
hearing questions that were submitted for today's hearing, the
table contained in the answer to pre-hearing questions, number
seven, located on page five of eight in the document states
that fiscal year 2012, 1,791,192 were completed by VHA
clinicians, and in 2013 1,998,886 examinations were completed.
And finally, in VA's written testimony today, which was
provided at the same time and in the correspondence as the
answers to the pre-hearing question, it states that in fiscal
year 1,850,386 examinations were completed by VHA clinicians
and in 2013 2,176,651 examinations were completed.
As you are all aware VA, and VHA in particular, has been
recently exposed for manipulating performance metrics and data.
How can we take any of the numbers reported here at face value
when you reported three separate numbers for the same metric
including two sets of differing numbers that were reported to
the committee on the same day?
Dr. Cross. Sir, I am happy to respond. The Ph.D. level
statisticians that helped prepare this report for the VHA
component of the numbers are in Florida. I went over with them
with the same numbers in preparation for this committee
hearing. I said, why are the numbers different? In every case,
they had a good answer. For instance, when you look at the
numbers on total examinations, in one chart they included
medical opinions and in the other chart they did not. Other
differences related to the exact point in time when the
measurement was started and the measurement was ended. We can
go through these with you. I know my staff will go through
every one of them with you if you are----
The *Chairman.* If you would deliver it for the record. But
it makes it very difficult when you provide conflicting numbers
like that to the committee and expect us to be able to decipher
how those numbers were arrived at.
Mr. Murphy, why does VBA only award contracts to single,
nationwide vendors who can bid on the entire contract, rather
than soliciting a regional contract provider in particular
geographic areas?
Mr. Murphy. Mr. Chairman, in years past prior to the
contracts that we have in existence today, that was the
practice. However, since I have been in the Compensation
Service Director position, the three contracts that we do, have
awarded have been recompeted. The larger contract on the
mandatory funds, we broke the area of the country down into
four areas and then we awarded those four areas to the best
contractor, the best bid in that process. So in years past in
prior contracts it was one which would cover the entire nation.
We have modified that under the existing contract and we are
taking a hard look at that for a recompete which is going to be
necessary because we are going to be out of option years at the
end of 2015.
The *Chairman.* Dr. Cross, do you use a regional method
instead of the nationwide? Is that an appropriate way to look
at it?
Dr. Cross. Our contract is nationwide, Sir, with additional
contractors. We have four at the moment. We used to have five.
And we are happy with that arrangement.
The *Chairman.* And very quickly, and this may take a
little more than 30 seconds, but in response to pre-hearing
question number nine, I note that despite providing two full
paragraphs in response to the question, the answer was not
given. So I am going to ask it again. Yes or no, does VHA pay
for local C&P exam programs by using money from its general
purpose fund?
Dr. Cross. Funding for the program comes from VERA, which
is the overall mechanism that we have for distributing funds to
the VISNs.
The *Chairman.* So that does or does not come from the
general purpose fund?
Dr. Cross. That is correct, yes.
The *Chairman.* Okay. Yes or no, is this the same fund from
which VA pays for its primary care?
Dr. Cross. Yes.
The *Chairman.* Yes or no, VHA is suffering from a dearth
of providers and long appointment wait times in primary care?
Dr. Cross. Yes, sir.
The *Chairman.* Yes or no, there is no separate line item
in the budget specifically allocated to the C&P examination
process alone?
Dr. Cross. Yes, sir. For Fy 15 there is no separate tie one
item for C&P. And may I go back into your previous question----
The *Chairman.* Yes----
Dr. Cross. --in regard to the shortage of personnel, there
are other factors as well related to----
The *Chairman.* Just yes or no. Thank you.
Dr. Cross. Yes, Sir.
The *Chairman.* Given the recent issues at VHA with primary
care in particular, do you think there should be a separate
line item?
Dr. Cross. Sir, I am not sure on that. I think that is
something we would have to consider.
The *Chairman.* Okay. Thank you. Mr. Michaud?
Mr. Michaud. Thank you very much, Mr. Chairman. As I stated
in my opening statement, your efforts to reduce rating claims,
otherwise known as the backlog, has been laudable. However, we
are starting to see a new backlog of other workloads, such as
non-rating workload and appeals. When will the VA adjust their
staffing to ensure that these areas are adequately addressed
for timely outcomes on behalf of our veterans?
Ms. McCoy. Sir, I would say yes, we have made substantial
progress on serving veterans whose claims have been pending the
longest with our oldest claims initiative. Also those priority
veterans, such as homeless, terminally ill, financial hardship.
That has been our primary, first focus in reducing the rating
claims backlog. We have also continued at the same time to
process non-rating claims. Last year 2.4 million non-rating
claims, this year on track to complete 2.8 million non-rating
claims. There are dedicated staff in the regional offices for
that work, as well as the appeals work. They focus on that work
during their day hours. On overtime they are helping on the
disability rating claims. So we have taken steps to continue
working on that as well.
It is of course not going at the pace that any of us are
satisfied. We have put other measures in place. Some of those
include automation. We have a rules based processing system
that is processing dependency claims received online in as
little as one day. We also have worked with Compensation
Service to put in place a contract to more quickly address the
dependency rating claim, non-rating claims that are pending. We
have a number of efforts underway. And these have been part of
our transformation initiatives from the beginning.
Mr. Michaud. But are you seeing an increase in the backlog
in the appeals process?
Ms. McCoy. Part of producing more claims is that there are
other side claims that come up. So we have completed more than
a million claims for each of the last four years and we are on
track to complete 1.3 million claims this year. So some of the
secondary effects of that are additional non-rating claims and
additional appeals. The appeals rate has stayed steady for
about the last 20 years, at about 11 percent. So when we
complete more claims, as that appeals rate does continue to
stay steady, there is a volume that comes along with that. Last
year we did complete more than 76,000 appeals.
Mr. Michaud. I see that most of the contractors tend to
slightly lag VA in terms of examination timeliness. How do the
contractors compare to the VA in terms of quality metrics?
Mr. Murphy. Sir, are we referring specifically to the VBA
contractors on this?
Mr. Michaud. Yes.
Mr. Murphy. Okay. The VBA contractors have two different
performance standards based on what year those contracts were
awarded. One of the contractors is on a 20-day standard and
they are currently performing at 17 days. The other contractors
are on a 38-day standard and they are currently delivering in
39 days. And as we recompete these contracts and as we move
forward we have lessons learned in improvements and efficiency
and we are leveraging that and reducing those times in
contracts.
Mr. Michaud. Thank you. Mr. Turek, in your testimony you
highlight a large disparity in the number of examinations per
month and how this is a challenge. Can you explain why there
are such significant shifts in the number of medical
examinations that are requested per month?
Mr. Turek. Yes, I can. We have two different contracts. We
have the VHA contract, which is a demand contract, and then we
have the VBA contract, which is a discretionary contract and we
receive so much money per year from Mr. Murphy.
With the VBA contract if we receive X amount of money, we
will be given so many cases per month based on the amount of
money that is allocated for the year. That way we do not use it
all up in six months and fall on our face, run out of money.
With the VHA contract it is purely discretionary demand by the
VAMCs themselves. So in essence we have 151 customers with the
VHA contract. With the VBA contract we have one customer. And
we have to essentially deal with each VAMC and let them know
our services are available for overflow and they can choose to
use us or not use us. So we never know from one month to the
next how many cases we are going to get from any of those 151.
Right now we have about 75 that are actively sending us cases
around the world. And we do, I believe we are the only
contractor that does overseas work for the VHA as well.
So it is tough when you have discretionary funds and on top
of that you have another contract where you do not know what
you are going to get, you know, from month to month for
staffing purposes and dealing with just trying to run a
business. It would be much better if we had, you know, a
contract that was much more stable and we had some kind of
uniform flow coming in. That way we could service the contract
better and we could make sure that we had the right doctors in
the right places.
Mr. Michaud. Okay. Thank you. Thank you, Mr. Chairman.
The *Chairman.* Thank you very much. Mr. Runyan, you are
recognized for five minutes.
Mr. Runyan. Thank you, Mr. Chairman. And I want to
apologize for not being here on Monday but I had the
opportunity to have Acting Secretary Gibson up in our
Philadelphia health facility. And to go back to the question
you had asked Dr. Cross a second ago, it was myself and my
colleague, Pat Meehan, an opportunity to sit down with him and
talk to him about exactly how Dr. Cross answered your question
about why the numbers. And we talked about 15 minutes about
standardization, so we can get out in front of these problems
from a central office level before we end up in these crises.
So that was brought up in that hearing and I just wanted to
make you aware of that.
The *Chairman.* Thank you.
Mr. Runyan. And to all of our witnesses, I know Mr. Murphy,
you previously expressed support of H.R. 2189, which has the
language of my bill, which was H.R. 2423, which was cosponsored
by my good friend Mr. Walz, and is now sitting over in the
Senate. It includes provisions that would expand VA's mandatory
funding for contract examinations. Your testimony dated July
25, 2013 states that VA strongly supports this provision to
extend VA's authority to contract for C&P examinations. And
further stating that this authority is essential to allowing
the Veterans Health Administration to focus on providing
healthcare to veterans needing it. Given VHA's recent issues
providing healthcare to veterans in need, can you further
explain your support of this legislation?
Mr. Murphy. Mr. Runyan, we can state that, WC reinforce the
position that we do strongly support the expansion from ten to
15 regional offices, and the additional surge capacity that an
expansion brings to us to address the surges as they arise
around the country.
Mr. Runyan. And I thank you again for that support. Because
I think it is another piece of the puzzle, how we are
eventually going to solve this problem. Dr. Cross, with regard
to the substance of C&P examinations, what are the most
frequently conducted C&P exams?
Dr. Cross. Probably exams related to musculoskeletal.
Mr. Runyan. Okay.
Dr. Cross. There are about I think nine or 11 DBQs related
to that.
Mr. Runyan. How many exams are deemed inadequate for rating
for purposes by VBA requiring an additional follow up?
Dr. Cross. Let me ask Ms. Murray to answer that.
Ms. Murray. Sure. Thank you, Congressman Runyan, for your
question. VHA has monitored the sufficiency of exams for an
extended period of time. And right now we have a goal of no
more than two percent of those exams being insufficient and we
are about around one percent of running insufficient exams. And
so we are taking extraordinary measures to ensure that those
exams are corrected very quickly. We have providers in the RO
that will provide clarifications and get those exams back to
the raters to do immediate rating on. So to answer your
question, around one percent.
Mr. Runyan. Okay. Thank you.
Dr. Cross. Sir, may I add to that?
Mr. Runyan. Yes.
Dr. Cross. Any insufficiency is not a good thing from our
point of view because that means working again to do what we
had already done. Putting the clinicians from VHA at the
regional office was a huge effort and collaboration between VHA
and VBA. It serves a vital purpose in this regard. We can make
those corrections on the spot, as soon as the VBA staff point
out to us what that is instead of sending it back through the
mail or through other means to the VHA. We have cut off many
days of processing just by doing that.
Mr. Runyan. Thank you. One last question. Have any of you
seen any improvement in performance since the implementation of
DBQs?
Ms. Murray. Since the implementation of DBQs I think we
have seen more standardized medical evidence being returned to
VBA in a format that is usable and efficient for their use. So
we have seen some improvements, and particularly for our raters
to be able to more efficiently look at the medical evidence and
be able to clearly identify the ratable criteria. So it has
organized the information very clearly for the raters. And so
we are providing them that information in that format and I
think it is effective.
Mr. Runyan. All right. I yield back, Chairman.
The *Chairman.* Thank you, Mr. Runyan. Dr. Cross, I think
your answer in regards to taking physicians and surging them
out of the regional offices or into the field is a good step.
But I want to read to you an email that was sent on June 19th.
``Good afternoon, and our in house physicians are out of work.
All employees currently reviewing and processing claims should
be on the outlook for any cases that would be appropriate to
refer them to our in-house physicians for medical opinions,
consultations, and any possible ACE examinations, etcetera. We
need work for them ASAP." How would you respond to that?
Dr. Cross. One of the things that we want in our contract
support is the ability to control it so that it is supplemental
as opposed to primary. And I am not sure if that was the case,
or where the location was that was from, whether it was a VBA
contract or a VHA contract?
The *Chairman.* It is within the VA. It is not a contract.
It is in a regional office. So it is your physicians.
Dr. Cross. I would stick with my comment, sir. We prefer a
situation where we go to VHA first for the work that we have to
do.
Ms. McCoy. Mr. Chairman, if I could add, we constantly
encourage our regional office personnel to engage with the
doctors, the clinicians in the ROs. They do more than fill out
disability questionnaires. They do supplemental opinions, as
Dr. Cross alluded to. They are also available to answer
questions for the raters on medical questions----
The *Chairman.* If I could, Ms. McCoy, if I could interrupt
you. But there is a serious crisis out there today with a
backlog of people trying to see physicians. And so you have a
physician that is just sitting there with nothing to do?
Ms. McCoy. Sir, we constantly have our folks looking to
take best advantage of that resource.
The *Chairman.* But they are looking to take best
advantages within VBA and not surging them to VA. Why?
Ms. McCoy. I understand your concern. It is our concern as
well, sir. But having those folks available----
The *Chairman.* Do you think this email is a strange email?
Ms. McCoy. I do not----
The *Chairman.* Do you think it is normal?
Ms. McCoy. No, I do not think it is normal, sir.
The *Chairman.* Okay. Does it bother you at all?
Ms. McCoy. Of course it bothers me.
The *Chairman.* Okay. Ms. Brownley, you are recognized for
five minutes.
Ms. Brownley. Thank you, Mr. Chairman, and I thank the
panelists for joining us this morning. Mr. Murphy, I wanted to
ask you what your reaction is to some of Mr. Turek's testimony
with regard to what he pointed out, the differences between VHA
and VBA, and the scheduling systems, the work flow processes.
Clearly from what he stated it sounded like one is much more
superior than the other and if you could comment on that,
please?
Mr. Murphy. We have done some things recently on the VBA
side, the introduction of CAATS, for example, the scheduling
system, and upgrade our systems, leverage some of the
technology that we had, and the fact that we are moving files
back and forth electronically as opposed to the paper that we
shipped previously. And because we are dealing with a single
contractor we have been able to leverage that a little bit
faster. And it is certainly something that we are discussing
actively with VHA to roll into all of our facilities.
Dr. Cross. May I respond to that as well?
Ms. Brownley. Yes.
Dr. Cross. We really appreciate the work that our
contractors do and Mr. Turek, of course. There is an issue
here. He described in great detail the additional complexity
related to working with the local customers. And so he
identified instead of having one customer, 151. That is exactly
why we designed the contract that way. We want local folks to
be taking responsibility for this and determine how much
contract work they want to do, how much they want to do
internally, how much they want to do for fee basis. In my view,
from where I sit, that is a success.
Ms. Brownley. Thank you. And Mr. Murphy, do you track the
C&P exam wait times across regional offices?
Mr. Murphy. We track C&P examination times across regional
offices, yes. And it is measured, like I said in the testimony,
from the time that we order, complete a Form 2507, the ordering
of the examination, until the time that it is returned to us
electronically. Meaning, I now have that examination in front
of me and a rater can then take action. Yes, we track that.
Ms. Brownley. Thank you. So you can provide me with the
wait times in the Los Angeles Regional Benefit Office? And we
also have an intake site in Port Hueneme. I am from Ventura
County in California.
Mr. Murphy. Yes, we would be happy to provide you that
information.
Ms. Brownley. Thank you. And in terms of, we have been
talking about standardization, and what is the VBA doing to
ensure that all of the exams, whether they are conducted at VHA
or by a contractor, are being performed accurately, and that
the physicians performing the exams are using the same metrics
and criteria for reporting so that veterans are being treated
equitably no matter who performs the exam?
Mr. Murphy. This requires a two-part answer. I can speak
specifically to what VBA is doing with our contractors and then
there is a whole other side of this that VHA is going to need
to discuss. But we have timeliness standards in terms of how
much time you need to spend with the veteran as a standard
written into the contract. We also have a quality team that
samples, measures, monitors. With all of our contractors, they
use electronic systems to complete these DBQs and they have
built in some quality steps and measures that require the
blocks that are necessary to be completed to require the
signature, license numbers, etcetera, that the doctors need to
complete and provide an adequate DBQ for rating purposes.
In addition to that in the VBA contract there are financial
penalties in place that a contractor must meet certain quality
standards. So there is an incentive for the contractor to do
the right thing, to give an exam that is completed the first
time. And I believe VHA would like to expand on that.
Ms. Murray. Yes. Thank you, Tom. So the Office of
Disability has a quality team that randomly selects exams on a
monthly basis, which is our VHA exams as well as our contract
exams. And we apply about ten criteria to that to ensure that
the information that is being requested on the 2507 and what is
being provided by the examiners are consistent with what is
needed and to ensure that the information is ratable and it is
sufficient for rating.
We also conduct inter rater reliability between our two
organizations and we do some sampling nationwide, and we have
both of our teams looking at those. And so we ensure that we
are looking at these consistently. And when we identify any
outliers we immediately provide education and training. Our
benchmark is at 90 percent and we have been maintaining 90
percent across the nation. Our quality managers go out and do
individual education and training at our sites. And then we
also provide all of our training modules that we do for our
clinicians, we provide those also for our vendors.
Ms. Brownley. So do you find discrepancies across the
country in terms of regions performing better than others?
Ms. Murray. They are pretty consistent with ranging about
90 percent. We do have two measures that we look at that tend
to be something that we have to make sure that we stay on top
of. And that is sort of, it is not really consistent across any
one location but just reminders that we send out to be sure
that we pay attention to this. So just whenever we find that
there is an outlyer for the month we will immediately send out
some reminders, and conduct needed training.
Ms. Brownley. Thank you. And Mr. Murphy, you talked about
the VBA contractors, or the contracts that you have, and that
you have two metrics, one 20 days, one 38 days. It seems like
the 38-day one is performing less than the other. You also
talked about lessons learned when you renew these contracts.
Can you kind of share lessons learned? Am I over? Oh, I
apologize. I yield back.
The *Chairman.* There is a little clock right in front of
you. And there is a little red light that comes on. Thank you,
Ms. Brownley. Dr. Benishek, you are recognized.
Mr. Benishek. Thank you, Mr. Chairman. I guess I am not
understanding exactly the numbers that I am looking at here.
Because from what I can understand there was about 2 million
C&P exams last year. But they talk about 800,000 veterans. So
how is it that there is 2 million exams and 800,000 veterans?
Dr. Cross. Sir, that is one that is fairly easy for me to
answer. I appreciate that. The exams are multiple for veteran
quite often. The reason for instance that the standard for C&P
in general is 30 days and the standard for IDES, which is on
active duty military, is 45 days is because of the increased
complexity of those exams. So they require typically even more
exams, more----
Mr. Benishek. But I thought you said earlier that only one
percent of the exams were not complete?
Dr. Cross. I----
Mr. Benishek. I mean, did not Ms. Murray----
Ms. Murray. So----
Mr. Benishek. --did you not just say that only one percent
of your exams did not have the complete information?
Ms. Murray. So we were asked about the sufficiency for
rating, and our target is two percent.
Mr. Benishek. But there is twice as many exams as there are
patients.
Ms. Murray. And so what I would say, Congressman, is that
many of our exam requests contain anywhere from one condition
up to 60 conditions. And so depending on how many issues are
claimed, we are doing multiple exams on any given----
Mr. Benishek. But that is not the same, you are talking
about the same thing. You are telling me there more than two
exams per patient. Then you previously told me that only one
percent of the exams do not comply with all the stuff.
Dr. Cross. The percentage----
Mr. Benishek. That is inconsistent.
Dr. Cross. Sir, no, that is quite explainable. The
percentage for insufficiencies applies across the board, no
matter how many exams there are. We look at those for quality.
We have to survey the entire package. What we wanted to convey
to you is that the complexity of this is multiple DBQs, similar
to multiple exams, for many of these individual patients that
come in. We may have a patient come in and says I have a
neurological problem, another one, and at the same time an
orthopaedic problem, and other things. And so they are going to
have different exams for those conditions. They will have
different DBQs.
Mr. Benishek. But they do not, the person that does the
exam is not the same person, then?
Dr. Cross. In many cases it is the generalist. We try and
do as much as this by primary, general type medical skills as
we can. If it requires a specialist examination, such as say
for audiology, they have to go see the audiologist. If we are
going to do a new diagnosis for PTSD, we want to go find a
specialist who is highly skilled in that area to do that
assessment.
Mr. Benishek. Well I guess I can understand that. It is
just that it is kind of disconcerting when there is twice as
many exams as there are patients. It seems like you would try
to get most things done and I guess I understand that, you
know, I am not going to do an audiology study as a surgeon. But
what, you are saying that the rate of people getting, not
getting their rating, a sufficient exam is only one percent,
and that they go back for the same thing twice does not occur,
basically?
Dr. Cross. No, sir. They do not generally come back for an
exam----
Mr. Benishek. All right. Okay.
Dr. Cross. We do not correct the exam.
Mr. Benishek. I guess that answers the question. Mr.
Murphy, I am kind of concerned about this process and Dr. Cross
kind of touched on it a little bit. But, you know, Mr. Turek
seems to think that it is much more efficient to, the VBA's
method of contracting is easier than the VHA's method. And Dr.
Cross may have touched on it a little bit but I still do not
quite understand the answer, why it takes 12 steps to pay
somebody through the VHA process versus the VBA process.
Mr. Murphy. I cannot answer for the VHA in terms of the
steps that they have to go through. But one aspect of this is I
order the exam directly from that contractor, where if it is
VHA I go to VHA first, and VHA uses that as a surge or overflow
to order that examination. So there are some additional steps
in there as that examination goes from us, to VHA, to VHA's
contractor.
Mr. Benishek. I mean, it seems like the 12-step makes it a
longer timeline.
Mr. Murphy. Again, sir, I have to defer to Dr. Cross on
this one.
Dr. Cross. Sir, let me provide some more information. Those
exams are controlled by the local medical center in terms of
the volume that we want to use, how much we want to pay. That
is where we want the control, right there, so that they can
maximize the use of their internal staff. I do not want them
having emails like the chairman pointed out, ever.
Secondly we provide some value added in the course of those
steps, such as trying to enroll the individual in VA healthcare
as early as possible, and tying into the famous electronic
record that we have in the VA so that those things link up.
But to be fair, it is complex. And while it serves our
needs we would like to streamline that. So we have a program
called DEAP that our IT folks are working on which will help
replace at least a portion of the legacy program, which was
called CAPRI. So we are working on a solution to add more
efficiency. But I want to tell you that some of that is built
in legitimately.
Mr. Benishek. I am out of time.
The *Chairman.* Thank you very much. Ms. Kuster, you are
recognized for five minutes.
Ms. Kuster. Thank you very much, Mr. Chair. And thank you
to our panel for being with us today. I wanted to focus in on a
different area of concern. This is with regard to a June 20th
letter that 32 members of Congress sent to Acting Secretary Mr.
Gibson. And it relates to the GAO report on VA's disability
claims process for survivors of military sexual trauma. In the
report we found, we learned, that the current regulation for
MST claims discriminates against survivors of sexual assault
and should be simplified and improved. And it appears that it
is due to the fact that despite a change, and I believe this
was a court ordered change, in 2002, the VA changed the
regulation to allow veterans to submit circumstantial evidence,
sometimes referred to as markers, because often there is not an
official record of the assault, typically because the victim
was not in a position to report the assault that may have been
perpetrated by a commanding officer. But it seems there is wide
variation among the claims in these medical examinations and in
this process. And this GAO analysis found that granting the
claims ranged across the various states from 14 to 88 percent
in terms of whether the claims were granted. And I think you
will agree that is a pretty broad range.
What I am wondering is what is the process for training and
updating and informing these people that are making these
evaluations? And then I would also love to hear a comment on
the number of claims that were denied. This comes from a June
25th Huffington Post did a very lengthy article about the GAO
report, noting that it really was more a function of where the
evaluation was conducted rather than whether or not the assault
occurred as to whether or not the claims would be granted. And
so what has happened in terms of those that were denied, how
have we reached out due to the high rate of failure to identify
and grant these claims? So if you could address those two
points, and perhaps Mr. Murphy we will start with you and go
from there.
Mr. Murphy. Let me start with the GAO report. Over the last
18 months, year to 18 months, we have spent a significant
amount of time and effort on MST in particular. As a result of
GAO and other attention around military sexual trauma we made
the decision, and we saw the inconsistencies that you are
describing early on. So we went back in and said the way we are
going to handle this is we are going to identify specific
individuals, train them to the standard of this is how you
properly identify markers which lead to the conduct of the C&P
examination, which allows the rating. So what we did not want
to do was improperly deny somebody even the benefit of coming
in and having the C&P examination to determine if there is some
compensation due to the individual.
So we went back in and targeted in each regional office
specifically trained individuals and said those people and only
those people are the ones that will touch MST cases. And the
results of that, which are not reflected in the GAO report
because the GAO report looks at a large set of data that is
early on in that 18 months and before the process that I
described to you. So what I am saying is the process that they
describe versus the process happening right now in the regional
offices, we are seeing different results from them and it is
much better results. The rates that we are seeing on grant rate
for MST are more in line with all of the other situations
around PTSD.
Ms. Kuster. And could you ask the Acting Secretary, or in
your office could you report back to, not just the 32 members
of Congress that sent this letter, but to this committee and
others that may be interested on progress beyond the date of
the GAO report? Because these are troublesome findings.
Mr. Murphy. Yes.
Ms. Kuster. And if there is progress being made, we would
very much like, the American people would love to hear progress
being made right now at the VA.
Mr. Murphy. We would be happy to take that for the record
and provide updated information to the committee.
Ms. Kuster. Thank you so much. My time is up. Thank you.
The *Chairman.* Thank you, Ms. Kuster.
Mr. Coffman, you are recognized for five minutes.
Mr. Coffman. Thank you, Mr. Chairman.
Mr. Turek, in your testimony, you propose outsourcing all
medical disability examinations to private contractors so that
VA employed medical providers would be free to devote a hundred
percent of their time to treating veterans.
However, in a recent conversation with VA staff, staff was
informed that such a changeover was not feasible because many
C&P physicians have not treated veterans in many years and are
lacking in the proper certifications or because many of them
choose to work part time.
As anyone who works in the private sector knows, if your
organization's needs evolve and certain employees cannot evolve
to keep up with current needs, those employees are terminated.
Mr. Turek, what are your thoughts on VA's response?
Mr. Turek. Well, my response would be that if those
physicians are not credentialed, that they should get
credentialed. And if they don't want to get credentialed to
treat, that they should go back into the community or retire
and be replaced with active treaters. That is my response.
Mr. Coffman. Okay. To the VA witnesses at the panel
testifying today, please tell me why your responses are more
focused on--it seems to be more focused on protecting employees
than meeting veterans' healthcare needs.
Can you respond to that?
Dr. Cross. Exactly, sir. As my opening statement was, let's
do what is best for our veterans in this issue. So let's look
at some of this.
We looked at the number, preliminary numbers just to get a
ballpark figure. And I want to be very careful with this
because I would like to go through and look at these numbers
more closely.
So we started off with the number of 8,000 individuals.
What does that mean? That means that these individuals have
taken the course and passed the certification exam. I am one of
them. That doesn't mean I am seeing patients routinely.
Most of these individuals in that 8,000 I would expect are
already seeing patients because they see these C&P exams only
on occasion when they are referred a case such as an ENT
doctor. And that explains part of that.
I think the magnitude of this is that roughly a little bit
less than a thousand of our docs and nurse practitioners and
PAs and so forth are full time, a little bit less than a
thousand. But, again, preliminary numbers that we worked up
just this week.
About 1,100 plus, maybe 1,200, in that ballpark, are part
time. Six hundred and sixty some of them, roughly again, have
some primary care experience somewhere in their past.
But then there is something that I think we can use right
away, if we can, is about a hundred of them are currently
working in primary care and C&P. So obviously that would be the
first place we would start as a constructive response to the
situation that we are facing.
Mr. Coffman. Dr. Cross, you said that is the first place, I
think if I remember your comment, that we should start. How
about will start? Tell me what the solution is here to move
forward.
Dr. Cross. You say will we or we won't? I say there is no
choice. We are in a situation that, you know, to me it is
heartbreaking in that we have worked on this. So many of us
have worked so hard on the system.
These are veterans that we are taking care of. We have to
do better. We have to do better. And so we are going to have to
look at each of these options with our leadership and use as
many of them as we have to.
Mr. Coffman. Thank you, Dr. Cross. Really I appreciate your
response.
I think there are so many times before this committee where
it seems as if there is a defense of the status quo with no
hope to those veterans seeking treatment or in this case,
seeking some type of outcome in terms of a claim. And so I
appreciate your response.
Mr. Chairman, I yield back.
The *Chairman.* Thank you, Mr. Coffman.
Mr. O'Rourke, you are recognized for five minutes.
Mr. *O'Rourke.* Thank you, Mr. Chairman.
Mr. Chairman, I would like to begin by first of all
thanking the VA. As our ranking member, Mr. Michaud, said, we
are very focused on the access to healthcare crisis right now,
but we can't lose sight of other important issues within the VA
and our responsibilities to the veterans we serve including
those carried out by the VBA.
The director for the Waco regional office which serves the
veterans in El Paso, Mr. John Limpose, is coming out to our
veterans' town hall this Saturday. And it is really hard for us
to and veterans in El Paso to directly hold VBA accountable at
that regional office. It is a nine-hour drive from El Paso to
Waco one way.
So, you know, his coming out to El Paso, I think, helps us
to hold the VBA accountable for him to hear directly from
veterans. So I just through you want to thank VBA leadership
for this level of responsiveness and accountability.
I would like to ask a question based on a comment Dr. Cross
made about the Integrated Disability Evaluation System or IDES
which is a process by which we transition wounded active
servicemembers out.
And that process is supposed to take 295 days, but because
of delays within the VBA, in the examination and the rating
process, we were adding another 185 days to that wait. So those
servicemembers at the warrior transition unit in Fort Bliss in
El Paso were literally languishing an additional 200 plus days
in some cases before they could transition out.
Mr. Runyan held a great hearing last month where we learned
that when it comes to the benefits part of this, we are now--we
no longer have a delay as of March and that on the rating side
of this, we are supposed to end the backlog by October of this
year.
So I want to compliment you on achieving those goals, but I
want to ask you how you did it and how that might apply to the
situation that we are discussing today.
Ms. McCoy. Thank you for your question, Congressman.
Part of it was sharing resources between the DRAS sites
focusing on partnership with VHA in getting the examinations
completed.
One of the lessons learned from our oldest case initiative,
two-year-old cases focus, one-year-old case focus was the
goodness from more hands across the country touching those
oldest cases to serve those veterans with the longest pending
claims.
As we move forward toward our national work queue in VBA,
where 90 percent of our claims are electronic in the Veterans
Benefits Management System, that gives us agility that we
haven't had before. We will be able to move that work around by
priority and be able to utilize the full resources across the
country to do that work and all of our work.
So we are looking forward beginning of next calendar year
to having more agility with the national work queue.
Mr. *O'Rourke.* Yeah. If these numbers hold up under
scrutiny, that is a remarkable turnaround. I would love to see
that same initiative applied to the problems that we are
hearing today.
Dr. Cross, did you have a comment?
Dr. Cross. Yes, indeed, in terms of the numbers. IDES is
overseen by the Department of Defense, VA, VHA, VBA, many, many
different eyes looking at this along each step of the way.
So I think in terms of confidence, this is one of those
sets of numbers I have the greatest confidence in and it has
been working now for many years.
And I wanted to remind you one part of this that has been
successful for some time now is the--it is always on time for
the exam part.
Mr. *O'Rourke.* Switching gears, you know, Mr. Turek makes
a great argument and Mr. Murphy brings up some wonderful points
about where core competencies should be and how we most
effectively and efficiently serve the veterans for whom we have
a responsibility.
And I am wondering, is there to kind of resolve some of the
differences that--between the arguments that you brought up, is
there--has there been some kind of independent analysis or
accounting that looks at, you know, timeliness, cost, accuracy,
overall effectiveness for the veteran either by the GAO, a
veteran service organization, or some other outside party?
Mr. Turek, are you aware of any study to do so?
Mr. Turek. No, sir.
Mr. *O'Rourke.* Mr. Murphy, do you know?
Mr. Murphy. I am unaware of a GAO or IG report.
Mr. *O'Rourke.* Yeah. I will yield back to the chairman and
just ask that we pursue a GAO analysis if it is different so
that we have the facts to make the best policy decisions going
forward. I yield back.
The *Chairman.* There was an IG report from 2010, but it
has not, to my knowledge, been updated----
Mr. *O'Rourke.* Thank you.
The *Chairman.* --since that time.
Dr. Wenstrup, you are recognized for five minutes.
Mr. Wenstrup. Thank you, Mr. Chairman.
I am going to ask some questions just to get some clarity
for me of how the system is operating right now, especially
between DoD and VA.
I was stationed at Fort Lewis and Madigan last summer,
spent some time in IDES, the Integrated Disability Evaluation
System.
So my first question is, you know, within the VA, you have
MEB and a PEB, correct, Physical Evaluation Board, just in DoD?
Ms. Murray. That is correct, just in DoD.
Mr. Wenstrup. Okay. So when you are doing your disability
ratings, there are standards of measures that you use and, you
know, I've seen the books to determine disability, you know,
how you come up with the numbers.
And so there are standards there and the DoD, the army does
have their board. And they come up with a disability evaluation
as well.
Is that rating that is done while the soldier is in uniform
able to carry right over to the VA or do they start all over
again?
Dr. Cross. I will ask my VBA colleagues to add into this,
but we do one rating and it is based on the claimed conditions
and on the referred conditions. But the referred conditions are
those that were found unfitting, those conditions that caused
the individual to be put into the program in the first place.
Why? He would be non-deployable and so forth.
The claimed conditions are the whole person exam that we do
looking at everything else. For instance, some high blood
pressure might not make you unfit for duty, but it is still a
condition that we can help that veteran with going forward.
Can I ask my VBA folks if they would like to answer?
Mr. Murphy. Dr. Cross is spot on. From the VBA perspective,
we make a rating decision based on all claimed conditions. The
Department of Defense uses a subset of that to the conditions
which are unfitting to continue your military service.
And the decision that we make that is used to make that
decision by DoD is the one that carries forward after the
veteran leaves service.
Mr. Wenstrup. I guess what I am trying to do is cut out
redundancy here. And that is the impression I got when I spent
time in that department that they were saying as a test model,
they were bringing the VA into that component. Now, I don't
know if that is nationwide or if it is just at Madigan right
now.
So if you could help me out.
Ms. Murray. So if I could add, the IDES is the Integrated
Disability Evaluation System, meaning that we have integrated
the DoD side of the program with the VA side of the program.
And so VA for the most part is doing all of the exams so the
servicemember goes through the process one time.
Mr. Wenstrup. So we are tearing down that wall.
Now, I got the impression last year that it was just being
done sort of as a test at Madigan. Is it throughout the
military, throughout the army?
Ms. Murray. It is throughout the entire IDES system
including all services.
Mr. Wenstrup. All branches. Okay. So, in essence, it is a
one-stop shop then for the servicemember. Now, obviously
someone who has something develop later such as a result of
Agent Orange, then that is all through the VA side, correct----
Ms. Murray. Yes.
Mr. Wenstrup. --because it is so much later? Thank you.
That answers my question.
I yield back.
The *Chairman.* Thank you.
Mr. Walz, you are recognized for five minutes.
Mr. Walz. Thank you, Chairman.
And thank you, each, for coming here today.
And, Dr. Cross, you are right. I said the heartbreaking
nature of this and it is so frustrating. I am appreciative,
though, that we are trying to diagnose and then we are trying
to come up with some prescriptions on this.
The thing I would say that may be most frustrating for us,
and, again, I think the specifics of this are going to be
important, but I am going to take it back up to that 40,000
foot, this cultural issue that we keep coming back to.
And the reason I say this is is that one of the questions I
get asked by veterans and folks when I am back home is how
could what happened in Phoenix and other things, how could it
possibly happen, how could no one have understood this. And
that is unfair because I would make the argument that people
like Mr. Runyan knew it was going to happen.
And in 2012, I traveled with him when we came up with this
idea and heard from veterans and heard from providers that
there was a shortage and the C&P exams were taking people away
from seeing patients to cover that and that there was
opportunity in the private sector to make up that difference.
So what we did was work with people, crafted a bill, and
Mr. Runyan put a bill together. There is a Senate companion.
Senator Franken has a bill over there on this very issue.
And I would come back to this. It seemed to me, though,
every step of the way when we would try and ask and try and be
seen as collaborators and partners in this, I got the thing, we
got it. It is under control, we got it.
And there was no sense of urgency because I clearly
remember up in New Jersey a veteran coming and saying I am
convinced that they are spending all their time on these C&P
exams and that is why it takes me so long to get an
appointment. How prophetic was that, of coming up, of saying
that?
So, Mr. Turek, I am going to ask you on this. I have got a
gentleman out in my district that, again, over three years ago.
His name is Don Weber. He has LHI that I think does basically
what you do. And Don made this very same thing. He told me he
has 2,100 physicians, but he is always meant to feel like there
is another hoop, there is another to get to, and that his
physicians aren't as prepared.
This is a subjective question to you. Is that a fair
assessment that is seems like it is always one more thing or
that it is not an equal ability here because all I care about
for you is to provide the best care to veterans just like you
do?
And I think there are folks out there that were willing to
do it, to take away some of that pressure to make it easy as
possible. We were convinced and I am convinced here is there
was no real desire to help us move this bill. There was no real
desire to make it easier for Mr. Turek.
And I am trying to get at your take on this. Is that true?
Mr. Turek. Could you rephrase it, Congressman? I am not
sure exactly what you are asking.
Mr. Walz. What I am saying is that is there a willingness
to reach out from the VA to say we need your help, let's get
this done as easily as possible, and let's see these veterans
and move on?
Mr. Turek. Okay. I think that the VBA and we work real well
together. There is a business partner relationship. I don't
think that we have reached that level with the VHA. I will be
real frank with you. Although we try desperately to partner,
you get that feeling that there is, you know, some push back.
Okay? And I am just being as honest as I possibly can.
Mr. Walz. Oh, I am grateful for that because I am being
honest, too, as I get the same feeling. And I feel like I am
one of the offending partners to try and make this work. And I
always feel like I get resistance. And I understand there are
metrics. I understand that there has got to be standards that
are kept and all that.
But these folks we are getting there, and I didn't come to
this conclusion because I thought this was something to do. I
came to the conclusion that I thought what Mr. Runyan was
proposing and what we talked about would have made it easier. I
wanted to see you get your folks in there, get these C&P exams,
and move the process forward.
Mr. Turek. Well, there is no doubt that given the
opportunity, we can spool up very quickly and take on a lot
more work.
I mean, I had another company, a commercial IME company
which we sold three or four years ago to a New York Stock
Exchange company. I on purpose kept Veteran Evaluation Services
because I didn't want anyone to touch it other than us. And at
that time, we were doing a quarter of a million exams a year,
fully integrated.
We have been doing it for 36 years. We really know what we
are doing. We did it in all 50 states, across the world,
different benefit delivery systems that had different resources
and demands. We could spool up very, very quickly.
Mr. Walz. Well, for your time.
And, Dr. Cross, again, I come to this because here is the
thing. Perceived reality is reality. And at this point in time,
the VA gets no benefit of the doubt on anything. And I am
telling you as someone who has been around this, has worked,
has tried to do this is I feel the resistance.
Mr. Turek and others, Mr. Weber and others have felt
resistance. Use us as a resource to help. Use this committee,
use these providers. Just help us change the attitude.
Dr. Cross. Could I respond?
Mr. Walz. It is the chairman's time. I am going to have to
yield back.
The *Chairman.* Yes, you may.
Mr. Walz. Thank you.
Dr. Cross. Sir, there was a period of time in the past
months where what you said was precisely correct in my view. It
was all hands on deck. We were dealing with our colleagues in
VBA on the one-year-old claims, very large number of
individuals, tremendous desire on everyone's part including, I
think, this committee's to lower the backlog and to do
everything we could. It was hands on deck.
And to some degree, that impacted on the primary care
folks. We are past that and we work with our primary care
community to say do what you can. Some of your veteran
patients, your patients want your input into their condition,
but still you have the option of sending them to the C&P clinic
and so forth.
So many things have taken place and so many
accomplishments, but, yes, I have to admit that there was a
period of time where that was happening.
Mr. Walz. Thank you, Mr. Chairman.
The *Chairman.* Mr. Bilirakis, you are recognized for five
minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
What procedures are in place to hold these C&P examiners
accountable? Can you elaborate on that? Can you, please, to
follow-up Mr. Walz?
Dr. Cross. Perhaps Ms. Murray can help me on this, but the
oversight from the quality folks, the oversight in terms of
their performance is relayed through the entire system and
reviewed repeatedly. We look for outliers and we are very
aggressive when we find outliers. We want to go hold them
accountable, but really what that means to me in most
situations is they are working very hard. They need some help.
It may be that it is not their fault, that they have fallen
behind in some way.
So we go in, educate them, tell them how to use the fee
basis system, how to use the contract system. We sometimes even
send people in from my office to actually do exams. We
development a locum tenens program so that we can air assault
individuals directly into that program who are qualified when
we lose someone who is unexpected.
Mr. Bilirakis. Thank you.
Mr. Murphy, regarding the number of examinations by the VHA
clinicians, what are the cancellation and no-show percentages
for fiscal year 2012 and 2013?
Mr. Murphy. I don't have those numbers in front of me.
Perhaps Ms. Murray does.
Ms. Murray. Sure. The cancellation rates when our office
stood up was about 18 percent and have been holding at about 18
percent for many years. Since we have jointly began to look at
the flow of the work between the VHA and VBA, we have reduced
the cancellation rate down to 14 percent. We have revised our
policies to clarify guidance.
And any cancellation rate that peaks or is out of the norm,
we immediately contact the facility, take immediate actions.
And if anything comes to our attention through anything outside
of our data, we immediately take actions to assess what the
issue is and implement corrective actions.
Mr. Bilirakis. Is it common practice to call the veteran to
remind the veteran that an appointment will take place?
Ms. Murray. So our----
Mr. Bilirakis. Is that a common practice within the VA?
Ms. Murray. So for C&P, our process is that when the 2507
exam request is received at our medical center, there is a
requirement to contact the veteran by phone.
Mr. Bilirakis. Okay. If there is a no show or cancellation,
is that included in the veteran serve category?
Ms. Murray. Can you repeat the question, sir?
Mr. Bilirakis. Well, if there is a no show, let's say a no
show, is that included in the veteran serve category? First of
all, why don't you answer this question. What does constitute
as a veteran being served by VHA clinicians, i.e. attempted to
contact the veteran, made contact with the veteran, appointment
scheduled, appointment completed? What is the definition----
Ms. Murray. Yes.
Mr. Bilirakis. --of a veteran being served?
Ms. Murray. Sure. That represents the 2507 exam requests
that has come over from VBA and the exams completed and closed
out in the CAPRI System and returned back to VBA. That is what
that number represents, everything that has been completed.
Mr. Bilirakis. Okay. Mr. Murphy, VBA is now tracking the
difference between the electronic date stamp from when the
request is submitted by VBA and when it is returned to VBA as
complete.
Is anyone from VA using this information to track the
overall number of days from when the veteran submitted the
claim?
Mr. Murphy. Yes. VBA's clock never stops from the time I
identify there is a need until the rating is done. Our clock on
the timeliness for the exam doesn't stop. We talked about
cancellations. If there is a cancellation or a delayed
appointment or any of the other things that happen, I still
have a claim that has to be done in less than 125 days.
So in order to drive that process, we sit down with VHA
every Friday and we dig deep and sometimes the conversations
aren't so pleasant, but that is exactly how it needs to be. We,
the VA, have a mission. We have to deliver on it. And we have
candid, frank conversations based on the numbers to drive the
performance of the whole organization.
Mr. Bilirakis. So you are saying that when the veteran
submits the claim, there is tracking between when the veteran
submits the claim and when the claim is completed, not just
when it is stamped by the VA?
Mr. Murphy. Correct. In years past, there were people
involved in the process. There has been steps put in place now
where it is done by triggering events in the system. So we have
taken the ability away from the individual to date stamp and do
things. The system tracks it.
When the 2507 request for examination is completed and we
hit the enter button, that gives me the ability without the
individual's ability to influence to look at that and tell when
exactly that examination started.
On the other side, VHA completes the examinations required,
returns them to me. And when they show up back in my box, there
is another trigger that is electronic and we can go back and we
do go back and measure the spread between those two dates. That
is the 24-day number average that you are hearing.
Mr. Bilirakis. All right. Thank you.
My time is expired. I yield back.
The *Chairman.* Dr. Ruiz, you are recognized for five
minutes.
Mr. Ruiz. Thank you, Mr. Chairman. I appreciate that we
must leave no stone unturned as we identify ways the VA can
expedite quality care for our veterans.
My question is, what measurements does the VA have in place
for a compensation in pension and medical examination that
demonstrate the VA is conducting quality exams that further a
veteran-centered mission? Specifically, do you have a system in
place where a veteran can provide feedback on the quality of
the medical assessment?
Ms. Murray. So, I thank you for your question, Congressman.
For our military service members that are going through the
process, that process is in place. They are surveyed and we get
their feedback on their experience with our examiners. And on
the C&P side, it is not quite as formal but we are developing
tools to be able to put that in place more specifically for our
C&P.
Mr. Ruiz. Okay. So it is not there yet, but you are going
to do it?
Ms. Murray. That is correct.
Mr. Ruiz. And you are going to do surveys?
Ms. Murray. We have looked at having some kiosks at the
medical centers where when a veteran completes his or her
appointment, they can go to a kiosk and give us some feedback
on ----
Mr. Ruiz. In person, or on-line, or a survey? Because, you
know, as you know, being a scientist, the methodology is
everything. And you have to match the methodology with the
culture of the veterans and what they have access to. So I just
encourage you to make sure that it is something that they can
respond to in a timely manner.
My next question is, if they disagree with the medical
assessment in the ratings, what do they need to do and how long
do they have for it to be corrected?
Mr. Murphy. There is an avenue for a veteran to not agree
with what is found in the medical examination process and after
they receive their rating decision they have one year to file
an appeal and run through the appeals process.
Mr. Ruiz. Okay. How can you expedite that so that they do
not have to jump through so many loops and bureaucratic red
tapes so that at the moment that they receive it, there is a
discretion and then they can maybe have that second exam with a
different examiner.
Dr. Cross. Let me add to that, please. Sitting in the room
with the patient, in the examining room, and you are doing the
exam, what I have witnessed is the patient becomes part of that
process. And if you make a mistake as you are typing it in, you
are talking to the patient and you are talking about what you
are entering. That is the first chance right there to make a
correction or engage the patient.
There is something else that I want to tell you about.
There is a lot of stress for a veteran coming in to that
examining room, and I talked to them about this, and we want to
try and find ways to lower that stress. This is such an
important event for them. This means so much to them and to
their family potentially, and we are looking at every way that
we can to make that experience as more ----
Mr. Ruiz. That is wonderful and I want to expedite the
appeal process because they cannot get the care that they need,
the resources that they need unless they get conclusion with
that.
The other thing I want to note here is that oftentimes
certain mental health illnesses or physical disabilities do not
present themself on their exit interview from the Department of
Defense.
So to clearly delineate that a veteran does not have a
certain illness, and that becomes your gold standard. That
becomes what then in the future you might want to refer back to
and say, well, but your disability was on this when you left
the Army, so clearly you did not get this illness--this mental
health illness, because when you left your exam showed this.
We do know that Post Traumatic Stress Disorders, other
mental health illnesses that are derived from very high stress
scenarios develop over time, including pulmonary illnesses from
exposures to certain chemicals. So I think that we have to
reevaluate how definitive we make that exam when they leave the
Department of Defense and recognize that illnesses change.
Dr. Cross. One thing that we have not talked about and I
have not heard in the Committee is something that we are
starting new is separation health assessment. This is an
agreement that we have now worked out with DoD. Both sides have
signed it to do a standard examination at the time of
departure.
One of the things we will look at, of course, is hearing
and see where the baseline was at the time that the individual
was leaving the military as opposed to what it was at some
future point when a claim was made.
Mr. Ruiz. Okay. You know, these questions are once again
aimed at changing the focus and using a veteran-centered lenses
from the eyes of our veterans, and not from the eyes of the
institution. Okay?
Thank you. I yield back my time.
The *Chairman.* Thank you. Mr. Huelskamp, you are
recognized for five minutes.
Mr. Huelskamp. Thank you, Mr. Chairman. I appreciate
particularly your opening questions. I want to follow up on a
few of those, particularly the concern about different data
being submitted to the Committee about actual number of exams
actually conducted.
But first of all I wanted to hear an explanation a little
bit more on CAPRI. It is a Legacy system. How old is that
system again? Who would answer that question? How old is old?
Is it a DOS based system?
Dr. Cross. I do not know precisely how old it is.
Mr. Huelskamp. Anybody have any guess? Is it contained
wholly within the VISTA system, or is it separate? Can you
describe the architecture of how these two systems work
together, or part of the same system?
Dr. Cross. Sir, if you are asking me to start describing IT
stuff, we are in trouble, I think. So I will get you that
answer if that is what you want.
Mr. Huelskamp. I would like to see that as well, and it is
troubling to have obviously three separate sets of data
submitted. That needs to be answered, I think. You have offered
to answer that separately.
So do you have any staff here that can answer that
question, how old is this system? Because as you know that is
something that I think the American people have been most upset
about, is for years this Committee has been told things are
fine and then whistle blowers say, well, no, because somebody
was gaming the system. As of today there are 70 different
investigative teams looking into criminal allegations across
the country.
So do you have any staff available?
Dr. Cross. There are staff members watching this program on
TV, and their job is to go find the questions that I cannot
answer.
Mr. Huelskamp. Okay. All right. Well, thank you. I will
follow up with that. Are there any bonuses tied to performance
in the numbers of the exams conducted and completed?
Dr. Cross. Yes. The bonuses in this case are part of a
large package of performance measures. Certainly just one small
part of that overall package of performance that the individual
is held accountable for.
Mr. Huelskamp. And that would be for SES employees and/or
the examiners?
Ms. Murray. We could probably come back to you on that, but
we would, you know, we do roll down our measures through the
organization. So, you know, those measures are--in my
performance plan. They are probably at the VISN level and I
would venture to say that they are being held accountable at
the medical center level, as well.
Dr. Cross. For clarification, none of those are the 14 day
issue in regard to C&P, which is irrelevant to C&P. We do not
measure wait time because we do not have wait time, and as such
we have process time.
Let me explain. You have 30 days to get this job done.
Whether we get the person in on the second day of that period
or the tenth day of that period, we have still got to wrap it
up in 30 days.
Mr. Huelskamp. And what happens if you do not? Again,
remind me what happens, Doctor.
Dr. Cross. Then you are out of standard and they will
receive our personal attention.
Mr. Huelskamp. Okay. Do they lose their bonuses?
Dr. Cross. What we try and start with usually is education
and trying to figure out why they fell out of standard and help
them. But, yes, ultimately it could have negative consequences.
Mr. Huelskamp. Well, yeah, I appreciate that, Doctor. I
would like to see from you then how these bonuses are tied to
whether it is the member exams or the wait time, I would--you
have a different term. I would call it the wait time,
especially if they are waiting as long as some of my
constituents have been waiting to get through the process.
Thirty days would seem fairly miraculous to many of them based
on their situation, and can you provide that back to me, a
description of how that would ruin the bonuses?
Dr. Cross. Sir, I will do my best on that. I am happy to
show you mine.
Mr. Huelskamp. Are any of the folks here are SES level? Are
you, Doctor?
Dr. Cross. I am a physician so we fall in a different
category, but they call it SES equivalent.
Mr. Huelskamp. I though the Administration announced SES
employee bonuses for VBA had been cancelled for 2012; is that
correct or am I missing that? So they still come out. Dr.
Cross, you did get a bonus then, or not?
Dr. Cross. Last year?
Mr. Huelskamp. Yes.
Dr. Cross. Yes.
Mr. Huelskamp. Okay. How much was your bonus?
Dr. Cross. I have got here the past three years. Would you
like them all?
Mr. Huelskamp. If you provide them to the Committee,
however you would like to do that, so.
Dr. Cross. Do you want me to provide them separately?
Mr. Huelskamp. Let's just provide them separately. It would
have to make it--I am just curious about that and look forward
to a description of how that is signed together, sir. Just
understand my concern. I want to make certain that the data is
accurate and how it might be tied to bonuses, because on the VA
health side, that has been the excuse, that we had a system
that encouraged folks to do bad things, which is meet standards
and got bonuses as a result.
So with that, Mr. Chairman, I yield back.
Dr. Cross. We understand quite specifically.
The *Chairman.* Yes, as I understand bonuses for VBA were
suspended for last year and for VHA this year. And Dr. Cross,
you are with VHA, correct?
Dr. Cross. Yes, sir.
The *Chairman.* Okay. Thank you. Ms. Titus, you are
recognized for five minutes.
Ms. Titus. Thank you, Mr. Chairman. Thank you, Mr. Murphy,
for being here. As you know, as a Ranking Member of the
Disability Subcommittee, we pay a lot of attention to this
issue. Chairman Runyan and I have heard a lot about this over
the last 18 months, so these issues are not really new to us.
Maybe you could tell me how many veterans though in Nevada
have had these C&P exams from contracted positions outside of
the system. Do you all have numbers like that?
Mr. Murphy. I do not have those off the top of my head. I
have to take that one for the record.
Ms. Titus. Okay. Well, thank you if you will get that back
to me. And speaking of Nevada, I will take this opportunity to
raise some issues with you that I have done in the past. A
claim that is completed today in Reno for Las Vegas, the
District I represent where most of the veterans in the State
are, closes at 300 days. And it was the fifth worst in the
country. The average was 500 and something days. So you are
getting that down, but I would point out that half of the cases
there were brokerage somewhere else. So if you had not brokered
them, I do not think you would have been making very much
progress in the 18 months that I have been there.
Also the VA's Inspector General released a report that VERA
was very critical of the leadership of the Reno Office, called
in, in fact, a leadership vacuum. So I would ask again because
I have heard from many members of the staff that they have no
confidence in the leadership if any of the members of that
leadership team received any bonuses.
I hope that you are looking into that and that you will
make a leadership change at that Reno Office. Now you recently
doubled VBA staff in Las Vegas and I appreciate that. We
certainly needed it. But the fact remains that two-thirds of
the staff is still in Reno. The folks in Las Vegas are being
monitored over the phone by this leadership vacuum that is in
Reno. You obviously can not recruit people to Reno, but it is
very easy to recruit people to Las Vegas. That is what you told
me--it was hard to recruit people.
So I am wondering, isn't it time to move that office to Las
Vegas? I mean, you are running out of excuses so let me just
make that case one more time as I will every time I see you.
Now I would like to get to my question. I have been very
supportive of your efforts to bring down that backlog. We have
been trying to help. You have been doing a good job. I
compliment you when you do that. But that 2015 deadline is
coming. You are going to be under more scrutiny from this
Committee, from the public, from our veterans, from the media.
They are going to be looking at those metrics. There is going
to be a lot of pressure.
I am wondering, do you have any knowledge, any suspicion,
any concern that the VBA employees like we have been hearing
about the other employees at the Phoenix Hospital and other
places on the other side of this equation have falsified the
numbers to make it look like they are having more success. Is
that occurring with VBA employees? Tell us something now that
we will not hear about from some whistle blowers in the next
few months.
Do you have any sense that any of that is happening?
Mr. Murphy. I do not believe that any of that is happening.
There is--and the reason is we are not relying on the actions
of individuals to tell us when ratings happen, when notices to
veterans go out, when appeals happen. All of this is done by
triggering events in our system. So the numbers reported to you
are not done by individuals.
They are not going in and--no individual has the ability to
go in and change dates, for example. So we are unaware of any
manipulation of the system of any kind.
Now on the other side of that, that is the part that I do
not sleep at night. I do not want that thing going on, not
while I am the Compensation Service Director. It is
unacceptable at any time for that kind of thing to happen.
So we are constantly on the look at for where is the next
one where we are going to be looked at and under the microscope
to somebody say, you know, manipulating the data here. And as
we see opportunities--we automate, we lock down as much as we
can. We control it so individuals cannot go in and influence
their own performance numbers to their own gain, to their own
benefit at the detriment of the veteran and the system in
general.
Ms. Titus. And I realize that has much improved with the
electronic system because that can be electronically dated. But
when something comes in on paper and you can throw it in the
desk and wait 30 minutes before you start clocking it, those
are the kind of concerns I have.
So you feel like you have some safeguards in place to----
Mr. Murphy. You are absolutely right that something could
be locked in the desk drawer. The problem is, I still own that
from the date that it shows up, and when I record it in my
system I put it at the date that it shows up and I have to come
in here and explain to you why I have claims that are over a
certain age.
So it is in our best interest and in the veteran's best
interest to drive this the way we are driving it and record it
back to the date of claim.
Ms. McCoy. Congresswoman Titus, if I can add, that is one
of the reasons we have also launched a centralized mail
initiative so that the mail--it will not be coming to the
Regional Offices to be opened in their individual mail rooms.
It is going to be rerouted by the Post Office to the vendor and
be scanned more immediately.
So we are saving time on moving that paper around. We want
to get it into the system as soon as possible, get it under
control so that we can see it, and we plan to have that done--
that initiative by the end of this fiscal year.
Ms. Titus. Okay. Thank you. I yield back.
The *Chairman.* Mr. Takano, you are recognized for five
minutes.
Mr. Takano. Thank you, Mr. Chairman. Mr. Murphy, am I
correct that VHA performed C&P examinations may be entered
seamlessly into the veteran's electronic health record?
Mr. Murphy. I'm trying to--would you mind repeating that,
sir?
Mr. Takano. Yeah. Am I correct in my understanding that VHA
performed C&P examinations can be entered seamlessly into the
veteran's electronic health record?
Mr. Murphy. I have got to answer that in two parts, and I
will talk about it first from the VBA aspect where VBA does
directly place that into our VBMS system for the rater to have
direct access to. But there is another part of that where you
are asking about the electronic health record, and that has
implications on the VHA side that I need to defer to VHA. Yes,
Dr. Cross?
Dr. Cross. This is an important question because this is
information that although administrative at the moment, serves
a purpose down the road that is clinical.
The testing results, the X-rays, all of those kind of
things are integrated fully as I understand it into the
electronic health record. Let me make this distinction. Because
it is integrated fully, my understanding is that if there is an
abnormality, it gets flagged. If the doctor wants to do a graph
of all of the blood pressures that they have had over the past
six months, it becomes part of those graph of information.
But because it is flagged, that information--particularly
if it is abnormal, is brought right forward to the doctor. It
is not a .pdf file stuck off in the system somewhere that you
have to go looking for.
Mr. Takano. Well, Doctor, can you tell me how does the
process of this record--being able to enter, say the physical
examination results into the record, how does that work when
they are contracted out to non-VA providers?
Dr. Cross. I think this applies on the side of our VHA
contract as probably as well as our VBA contract. They do get
information back to us, but again, it is in a different fashion
than full integration as I understand it. I will ask Tom to
comment, or Beth.
Mr. Murphy. Are we talking about the exam results from a
VBA contractor?
Mr. Takano. Yes.
Mr. Murphy. Being fed back into our file. Our contractors
provide currently into----
Mr. Takano. Yeah. Into the electronic health record.
Mr. Murphy. Okay. Now they are fed into our virtual VA
system.
Mr. Takano. Okay.
Mr. Murphy. They are not fed into the electronic health
record. But examinations that are done in-house are.
Ms. Murray. That is correct.
Mr. Takano. Would it be beneficial if there was an ability
for our contractors who do the health examinations to be able
to do that directly?
Mr. Murphy. Yes. Yes, of course.
Mr. Takano. It would be extremely helpful, right? I mean,
it is--you lay out an example of why it would be important. Mr.
Turek, does VES use electronic health records and is your
system interoperable with VISTA?
Mr. Turek. I am sorry, Congressman. Could you repeat that?
Mr. Takano. Does your company use electronic health records
and is your electronic system interoperable with VISTA?
Mr. Turek. I wish I had my team IT here. Yes, we do
interact with the VBA much more electronically than we do with
the VHA, okay? We would like to see--and I am going to go off
course here a little bit, but I could see even more beneficial
things happening down the line to speed up the whole process
because what we have talked about in the past is taking the
data that is gleamed from each DBQ and feeding that into--and
turning it into XML computable data.
Mr. Takano. But currently you are not completely
interoperable in the way that VBA is with or VHA is?
Mr. Turek. We are not completely.
Mr. Takano. And that is a pretty significant difference,
because it has huge health implications for the ability of for
the integrated health system to work.
And so, in my view, it is a major problem in terms of your
argument to contract out the entire examination process.
Mr. Turek. Can you talk on that, Tom? Okay, me either. We
can do anything--we have a full computer staff. We can do
anything that the VA wants us to do as far as hooking up with
the VA.
Mr. Takano. Well, if you could give me an answer to the
question whether or not how much it would cost for you to ramp
up on whether your company can make that kind of investment?
Mr. Turek. I cannot do that.
Mr. Takano. Okay. Well, it does not have to be now. You can
get the answer to me later.
Mr. Turek. Yeah. We could.
Mr. Takano. Thank you.
Mr. Turek. Sure.
The *Chairman.* Thank you very much. Ms. Brown, you are
recognized for as much time as you need, because of that fine
coat you have on today.
Ms. Brown. Thank you, Mr. Chairman, and before I begin, let
me just thank you for your leadership and how you conduct the
Committee. I was not on the Hill Monday night and a news
flashing came on about another Committee. And the way that the
Chairman conducted himself with the witnesses was an
embarrassment to the House of Representatives.
So there are some things that you learn before you come to
the House of Representatives, and it is how you treat the
witnesses, and I want to thank you for your leadership in that
manner.
The *Chairman.* Thank you very much.
Ms. Brown. Now, after saying that, let me just say that
there is a lot of doctors on this Committee, and there is a lot
of doctors on the conference committee. And they talk a great
deal about the private system. Let us be clear. I am a part of
the private system and, in fact, I have one of the best. I am a
Mayo person. And my doctor, Dr. Willis, controls all of the
tests that I do, even when I have tests here they refer it to
them. So it is a real coordinated system.
And I am not going to sit up here and be on this Committee
and be involved in dismantling VA or privatizing VA, and you
have members, they say, well, we want a certain--I want a
system in my area and I want all of the doctors to be in my
area--all of the clinics in my area.
But the point is we build clinics based on a formula-
driven, my understanding, by the number of veterans in the
area. Can you correct me with that? Is that correct?
For example, if my clinic is in Las Vegas, which is where I
want to be, and I live in one of those little outlying areas--
based on how many veterans in that area is whether or not you
have the claims there.
And then I heard other members talking about, well, we do
not have a hospital in our area. Well, maybe you do not have
that many veterans in that area. That is why you do not have a
clinic in that area, and maybe we need to come up with some
innovative ways to get to those veterans. Clear that up for me.
Ms. Murray. So, ma'am, thank you for your question, and I
would hopefully be able to provide you more information on
that. But I think when VHA looks at setting up a clinic in a
location there are a number of criteria that they look at to do
that, and I do not know the full details of that. But I would
imagine that the number of veterans would be one of those
criteria, but I can certainly find out more information about
that.
Ms. Brown. Probably I know a little bit more than you then,
because I have been on this Committee for 22 years and my
understanding is we come up with clinics and hospitals and
cemeteries based on the number of veterans in that area. No one
has the answer?
Dr. Cross. Yes.
Ms. Brown. Is that correct?
Dr. Cross. To the best of my knowledge, that is correct.
Ms. Brown. It is a problem when I am the institutional
memory in the room. I think VA does an excellent job and the
feedback that I get is that they are satisfied, but we do have
a problem.
And so, I would like for each one of you--how do you think
is the best way to address the wait time? And one of the
things, like in the Gainesville area, I know we have a good
hospital there, and the information was not put into the system
because the computer system was outdated. Not that anybody was
trying to whatever they think that you are doing. They were
making sure that the veterans were getting the services. I know
about my area.
Dr. Cross. Would you like me----
Ms. Brown. Yes, please. I would like a response.
Dr. Cross. This is so very important. The confidence is not
there, as has been pointed out many times. I would judge the
wait time and so forth by what I experience when I go there. I
am a veteran. I go to the hospital, at the VA, of course. So I
think, you know, what you experienced is a starting point to
gain that confidence back, to make it a reality.
Ms. Brown. Well, one of the things that came up in the
conference was women veterans, which is the fastest growing
group in providing services. Well, one of the things that I get
when we did the clinic in Jacksonville was that we made sure
that the doctors--and we had the input from the veterans--so
that the women say, well, we don't want cat calls when we walk
in. How do we control cat calls? The way you control it is the
women have a separate entrance.
And so I think it is very important as we move forward that
we do not just talk to the veterans, but we talk to the VA
physicians so that they can make input as to how we can improve
the system.
Dr. Cross. An excellent idea, and I concur.
Ms. Brown. Mr. Chairman, I want to thank you so much for
your kindness in extending a couple of minutes to me. I yield
back the balance of my time.
The *Chairman.* Thank you very much, Ms. Brown. Are there
any further questions that the members may have?
I have one, Mr. Murphy. What happens if a claim is just
found somewhere within the system. Somebody has lost it. Paper
file sitting somewhere for two years. Now I am not saying that
I have one in mind, but I am interested in where the start date
begins. Does it begin when that claim arrived or does it begin
when the claim--somebody discovers that the claim was found?
Mr. Murphy. It depends on the circumstances surrounding
that case, but the majority of the time, the overwhelming
majority of the time, it goes back to the date we received that
piece of paper.
If there is a date stamp on it and we received it four
years ago and it is sitting in a desk drawer somewhere, it goes
into the system as four years old.
The *Chairman.* What if it is not date stamped?
Mr. Murphy. Then we have to figure out how it is that we
established the receipt of that. Is the envelope still there
and is a postal stamp on it?
And then we have some cases where we can identify that is a
communication that came in with a certain claim, and we give
the veteran the most liberal date that we can assign to that
case.
The *Chairman.* So the veteran does get the benefit?
Mr. Murphy. Absolutely. The veteran is entitled to the
first time we see the evidence as an effective date.
The *Chairman.* Well, the first time you see it, that is
the question. I mean, if it came in somewhere and it got
misfiled in somebody else's file and you do not discover it for
two years, when does that veteran--when does it start? When you
find it, you see it, or when the veteran says they sent it in?
Mr. Murphy. The date of claim on that goes back to the date
that we can identify that we received that piece of paper. Not
that--I said a moment ago ``found.'' It is not found. It is we
are obligated--the VA is obligated from the date that the VA
receives that evidence, and the veteran is entitled to
compensation from that date.
Ms. Brown. Mr. Chairman, on that point.
The *Chairman.* Yes, ma'am?
Ms. Brown. Mr. Chairman, I think we have to encourage our
veterans to be proactive, also. If my doctor, you know, waits
two years, I'm not going to wait for any appointment. And so it
is important that they also, and the families or the support
system, contact the system. I mean, it is going to take a team
effort. The Army motto is, ``One team, one fight,'' so we have
got to make sure that we are not just relying on the VA but the
stakeholders involved working with the VA, and the family. It
is not just the veteran, it is the family, it is the support
system.
Certainly it is the responsibility of the VA, but like you
say, two years--that is ludicrous. If they had not contacted me
in a certain amount of time, then I am going to contact them. I
am going to go to the office, or I am going to the emergency
room. And so we have got to encourage them to be proactive,
also.
The *Chairman.* Thank you, Ms. Brown, very much. Thank you
everybody for being here. We thank the witnesses. I would ask
unanimous consent that all members would have five legislative
days for which to revise and extend their remarks.
Without objection, with that, this hearing is adjourned.
(Whereupon, at 12:01 p.m. the meeting of this subcommittee
was adjourned)
APPENDIX
STATEMENT FOR THE RECORD
Statement of Jeff Scarpiello To
The House Committee on Veterans' Affairs
VBA and VHA Interactions: Ordering and Conducting Medical
Examinations
Chairman Miller, Ranking Member Michaud, and distinguished members
of the Committee, I appreciate the challenges facing you as you study
the important role that VBA and VHA have in effectively ordering and
conducting medical disability examinations (MDE) in support of benefits
that America provides in law to care for our veterans.
As background, I am a service-connected disabled veteran who has
underwent several compensation and pension (C&P) exams, so I understand
the process and can speak from a recipient's viewpoint. I have also
worked for Disabled American Veterans and Paralyzed Veterans of America
at the busiest Regional Office (RO) in the country in St. Petersburg,
FL and am familiar with the disability exam process from an advocacy
perspective. I have also worked for US Senator Bill Nelson for 8 years
handling veterans and military issues and can speak directly to the
impact of the backlog and veterans not being able to get timely
benefits and healthcare. In 2008, I went to work for the Department of
Veterans Affairs, Veterans Health Administration (VHA) as a Legislative
Health Specialist and have investigated complaints regarding the C&P
exam process at several locations throughout the country and provided
written responses with the findings back to members of Congress. In
2010-2011, I was the Deputy Director of the Disability Examination
Management Office (DEMO), now known as the Office of Disability and
Medical Assessment (DMA) led by Dr. Gerald M. Cross who is providing
testimony before you today. Among my many responsibilities running the
DEMO was to help draft, select and award the Disability Examination
Management contract to vendors and implement the contract nationally. I
have also drafted all existing policies, directives and guidance
currently in effect to govern the current VHA C&P exam process. I am
currently the Director of Business Development for Medical Support Los
Angeles (MSLA), a Medical Company. MSLA has an indefinite delivery,
indefinite quantity contract with the VHA to conduct medical disability
examinations for veterans in Region 10 (California, Nevada, Hawaii and
Guam) under the Disability Examination (DEM) contract.
I have just a few observations and recommendations to share with
you, but first, want to explain several reasons why veterans are not
getting timely access to health care from the Veteran Health
Administration that may be a result of the disability exam process. As
a result of the system-wide delays in processing rating claims Veterans
Benefits Administration implemented an initiative to eliminate the 1-
year and 2-year old claims backlog by accelerating the claims rating
process. At some locations, VHA primary care providers were asked to
augment /assist the C&P exams clinics. In addition, VBA's fully
developed claim (FDC) initiative, put additional stress on the VHA
health care system as veterans began making appointments with their
primary care/treating providers at the urging of Veterans Service
Organization's (VSO) to have Disability Benefit Questionnaire's (DBQ)
completed in support of their disability claims. The Office of
Disability and Medical Assessment (DMA) attempted to explain that by
allowing primary care providers to complete DBQ's could be problematic.
However, the VSO's urged the Secretary and Under Secretary of Health to
do more to help veterans get their DBQs completed upon request. DMA
then instituted a ``no-wrong door'' policy and VHA primary care
providers were informed they should do everything they can to complete
DBQs when requested by the veteran. Subsequently, DMA learned that
despite the urging of the Secretary and Under Secretary of Health, many
primary care providers who were not familiar with DBQs continued to
refuse to complete them.
As a result of primary care providers refusing to complete DBQs,
VHA DMA implemented DBQ referral clinic (walk-in) guidance instructing
primary care providers who could not complete DBQs to provide a ``warm-
hand off'' of the veteran to the C&P clinic for assistance. Many of the
larger C&P clinics are so busy with scheduled appointments that this
hand-off typically results in the veteran having to have an appointment
scheduled to return to the C&P clinic to have the DBQ completed.
In 1996, when Congress gave VBA the authority to contract MDE's at
10 locations and now with capability that VHA has developed with the
DEM contract; the full utilization of these contract vehicles could
free up to 7,000-10,000 C&P examiners and hundreds of administrative
support staff to provide medical care/treatment services that would
help to resolve the current health care scheduling, access and wait
time issues plaguing VA.
It is important to note, as I'm sure Ms. Murray & Dr. Cross will
attest to in their testimony that VHA's C&P program is a success. In
2010/11 when I ran the Disability Examination Management Office, C&P
exams were averaging over 40 days nationally and in some locations 90
days or longer. The implementation of the DEM contract has played a
critical role in exams now being completed in 22-26 days; besting the
30 day or less national requirement/standard for completion of exams.
However, there is no established national customer service survey that
drives performance improvement or to help identify problems from a
user/veterans perspective. There is no centralized control of the C&P
clinics within VHA, as C&P is not recognized as its own separate
service line and at each location within VHA, the C&P structure varies
which makes it difficult for VHA C&P clinics to get on-board nationally
when new initiatives are rolled-out. Most importantly, C&P facilities
do not receive separate funding and if they utilize the DEM contract
services they must pay for it the local level, unlike the centrally
funded VBA contracts.
I have identified several issues with the VBA contract that should
be of concern to the Committee:
* VBA does not manage its contract exams as completely as the VHA
DEM contract and has been reliant upon VHA to provide them with
accurate C&P data.
* VBA has no governance board and has not allowed any VHA input
into the clinical aspects of the exam process.
* The Compensation Service Director can make unilateral contract
decisions that involve hundreds of millions of dollars which can give
the appearance of impropriety if the same vendor continues to receive
the contract award.
* The fact that VBA only awards contracts to single vendors who can
bid on the entire contract vastly diminishes the ability of other
contract providers to participate in providing exam services in
geographic areas where they can compete.
* VBA allows contractors to provide their own quality assurance and
has no real mechanisms in place like VHA's quality review specialists
to monitor the quality of the exams'
* Under VBA's existing contract, exams that are reworked can be
double billed
* No additional authorization is required for additional testing or
exams.
* Payments for exams are more expensive in some cases than VHA DEM
contract, although they are listed in VBA's contract as a flat fee.
Suggestions and Recommendations:
* Establish a single office that can focus on medical disability
examination management. The current oversight is fragmented as
currently exists within VBA/VHA. The new joint office should include a
single SES responsible for the oversight of the program and include:
contract management staff, clinicians to provide quality assurance of
contract exams, administrative support, and VBA adjudicators.
* Establish one VA national medical disability examination contract
that is broken up into multiple geographical regions including overseas
exams, where multiple contract awards can be given to more than one
contract vendor in each region.
* Allowing multiple contract awards will help drive internal
competition among contract vendors that will drive performance to
provide quality and timely exams that will meet or exceed or contract
requirements.
* The DEM contract has a successful contract model in place where
the contract is divided up into ten geographic regions and multiple
vendors are awarded contracts. This would provide fairness and equity
so that smaller companies can bid in geographic areas where they are
best positioned to provide services without having to bid on a single
large contract.
* The efficiencies created by using these contracts will benefit
Veterans' immeasurably by creating more options and accessibility to
disability exam services and timely access to healthcare that veterans
deserve and need.
* Ensure consistent contract standards, pricing, and timeliness
standards within existing contracts by VHA / VBA to eliminate
confusion.
* Fast-track any IT system solutions that have been presented that
would allow this will eliminate current barriers to why VHA facilities
are not utilizing the DEM contract.
A lot of work lies before this Committee. All of us who care about
the quality of medical disability exams and the benefits we have
promised veterans and their families are hopeful that your work will
lay the foundation for reform and improvement of the medical disability
exam process that will give truth to the commitment to those who have
served this nation
Thank you for your consideration of my observations, suggestions
and recommendations for changes. Taking care of veterans - and doing it
well- is the right thing to do.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
George C. Turek
Supplemental Testimony
House Committee on Veterans' Affairs,
VBA and VHA Interactions: Ordering and Conducting Medical
Examinations
In response to the following question from Congressman Takano, I
would like to supplement my testimony as follows:
Mr. Takano: Mr. Turek, does VES use electronic health records and
is your electronic system interoperable with VISTA? Currently you are
not completely interoperable in the way VBA is with VHA. That is a
pretty significant difference because it has huge health implications
for the ability for the integrated health system to work. In my view
it's a major problem in terms of your argument to contract out the
entire examination process. Could give me an answer to the question of
how much would it cost to ramp up and whether your company could make
that kind of investment?
Mr. Turek: VES works in an electronic medical records environment.
All aspects from scheduling to delivery are done electronically. This
includes the work performed by VES medical providers who review medical
records and complete DBQs in the VES Secure Provider Portal.
With respect to the work VES does for the VBA, we have access to
certain limited components of VISTA, including CAPRI and CAATS (which
recently replaced VERIS). We also upload all completed C&P MDE reports
and the associated diagnostics directly into VBMS, as required by our
contract. VES' captive IT department built this capability at the
request of and in cooperation with the VBA. We also post the completed
reports to our VES Secure Client Portal.
With respect to the work VES does for the VHA, we do not access
VISTA, nor do we upload completed reports into VBMS. Although we have
offered to do so, the VHA has declined this offer. We currently send
completed MDE reports to the VHA via encrypted e-mail as a secure PDF
attachment. We also upload the completed reports to the VES Secure
Client Portal.
With that said, as a private contractor, VES certainly does not
have the same level of access to or interoperability with VISTA as does
the VHA or VBA. Moreover, I highly doubt that the VA would allow any
private contractor unlimited and unfettered access to a system with
such highly confidential and private information. Nevertheless, to the
extent the VA was to allow us such access, our company certainly has
the IT capability and financial resources to make the necessary
investment to become fully interoperable with VISTA. VES maintains a
robust, captive IT department, complete with a team of professional
programmers who have previously worked together with VA technical
experts on a number of IT-related projects. We are confident we can
accommodate any reasonable IT requirements established by the VA going
forward. However, absent a more detailed understanding from the VA of
the parameters of a project to establish full interoperability, we have
no basis upon which to provide you an estimate of how much that might
cost.
The point is that we do not need the same level of access to or
interoperability with VISTA in order to provide the VA timely and
quality medical disability examination services. Not having the same
level of interoperability with VISTA as the VHA does not in any way
limit or compromise VES' ability to deliver valuable services to the
VA. Moreover, it does not detract from our position that our veterans
would be better served with the VHA focusing exclusively on treatment,
and outsourcing all C&P MDEs to private contractors through the VBA.
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