[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 
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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.

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    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.


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    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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