[Senate Hearing 113-]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION AND VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2014
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THURSDAY, APRIL 18, 2013
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 2:43 p.m., in room SD-124, Dirksen
Senate Office Building, Hon. Tim Johnson (chairman) presiding.
Present: Senators Johnson, Reed, Udall, Begich, Mikulski,
Kirk, Collins, Murkowski, and Hoeven.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF HON. ERIC K. SHINSEKI, SECRETARY OF
VETERANS AFFAIRS
ACCOMPANIED BY:
HON. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR HEALTH
HON. ALLISON HICKEY, UNDER SECRETARY FOR BENEFITS
W. TODD GRAMS, EXECUTIVE IN CHARGE, OFFICE OF MANAGEMENT AND
CHIEF FINANCIAL OFFICER
HON. STEVE L. MURO, UNDER SECRETARY FOR MEMORIAL AFFAIRS
STEPHEN WARREN, ACTING ASSISTANT SECRETARY FOR INFORMATION AND
TECHNOLOGY
opening statement of senator tim johnson
Senator Johnson. Good afternoon. This hearing will come to
order. We meet today to review the President's fiscal year 2014
budget request for the Department of Veterans Affairs (VA).
Secretary Shinseki, I welcome you and your colleagues, and
I thank you for your appearance before this subcommittee.
I'm also very pleased to welcome back my colleague and
ranking member, Senator Mark Kirk. Senator Kirk has made great
progress in his recovery due, I'm sure, as much to his sheer
grit and determination as to his medical team. Senator Kirk has
been a strong supporter and partner on this subcommittee, and I
look forward to continuing our work on behalf of the Nation's
vets.
Mr. Secretary, I'm pleased to see that eliminating the
backlog in claims processing is among your top priorities. We
must fix this problem once and for all. After fighting for our
Nation on the battlefield, our vets simply cannot be subject to
months, if not years, of fighting redtape to secure the
benefits they have earned.
This subcommittee has provided every time the VA has
requested to improve claims processing. I understand the
challenges posed by the growing number and complexity of
claims.
I understand the challenges of recruiting and training
additional claims processors. But despite the VA's best
efforts, the situation has grown worse, not better.
Mr. Secretary, I know you share my frustration. I look
forward to hearing the VA's way forward to solve this problem
sooner rather than later.
I'm also concerned with progress of efforts to integrate
the Department of Defense (DOD) and VA health records. It is
imperative that the DOD and VA develop an electronic health
record system that will allow the seamless exchange of vets'
medical records between the two agencies.
The original plan was to develop a single integrated system
to serve both agencies. Recently, the agencies changed course
and are now pursuing separate systems that can essentially talk
to each other.
I certainly support a faster, cheaper way to allow DOD and
the VA to share vets' health records, but I'm wary of any
change in strategy that might result in the quick surface
improvements, but not capture the full range of a patient's
health history; in other words, settling for an executive
summary instead of a full report.
Mr. Secretary, I look forward to your testimony, and I now
ask my ranking member for any opening remarks he cares to make.
Senator Kirk.
statement of senator mark kirk
Senator Kirk. I'm mad at you for announcing your
retirement. You have been an honorary member of my medical
recovery team, with your wife and her support to my girlfriend.
That has been really something.
Constantly through my medical recovery, I was asking,
``What can Tim do?'' and meet that area. It was always great to
think about you back here rocking and rolling.
I will say, Mr. Secretary, very good to see you here today.
I want to thank you. And I've thanked you over and over again
for shepherding the Stryker vehicle through the U.S. Army. As a
reservist in Afghanistan, I had an opportunity to use it. I
will say, in the small time that I had in the vehicle, we did
have a little problem with the coffeemaker. The espresso
setting wasn't quite fully functional.
Let me just continue slightly. I want to continue on the
unified record issue. Our vision is to have someone join the
Navy and then retire, and the record all passes straight into
the VA. That is what we were hoping. My understanding is we
have a choice between two software systems--one in the VA
called VistA, which handles the VA systems.
And the one thing I want to commend you on, Mr. Secretary,
is you have released the code to what you own, is what I
understand. My hope is that someday we would go with, for lack
of a better term, we would have an android-kind of culture, an
explosion of apps that the private sector can develop on the
VistA or AHLTA backbone now that it's open source, and we have
an explosion of innovation in health records management of
advantage to veterans and sailors everywhere.
prepared statement
Just a last thing to say, I have been in touch with
Chairman Culberson to eventually bring an end to this
combination process. I think at some date prior to the big
markup of this subcommittee, that we should pick either VistA
or AHLTA as the backbone, so just VA or DOD wins and so the
taxpayer only pays for one software management system.
[The statement follows:]
Prepared Statement of Senator Mark Kirk
Thank you, Mr. Chairman. I'm pleased to be back here today as
ranking member of this subcommittee. I would like to join you in
welcoming Secretary Shinseki and our other witnesses and guests to
discuss the President's 2014 budget request for the Department of
Veterans Affairs (VA).
overview
The 2014 request for the Department of Veterans Affairs proposes
$149.6 billion, which consists of $63.5 billion in discretionary
funding, which is 4 percent above the 2013 enacted level, and $86.1
billion in mandatory funding, which is 18 percent above the 2013
enacted level. In addition, the Department is requesting $55.6 billion
in advance appropriations for the medical care accounts in 2015. That
is a total of $205 billion before us today--a tremendous amount of
money--and in a time of record-high deficits and debt, my priority and
the priority of this subcommittee is not only to give our veterans the
very best care this Nation can provide, but also to analyze this budget
to ensure we are spending our taxpayers' dollars wisely, without excess
or redundancy.
Mr. Chairman, the VA under the leadership of Secretary Shinseki is
doing a great job taking care of our Nation's veterans and I would like
to thank him for his hard work and dedication. There are many issues we
need to discuss today but I want to focus on two issues that will play
a significant role in the lives of all veterans: electronic health
record and claims processing.
integrated electronic health record (iehr)
Earlier this year, we learned the VA and DOD's decision to create a
single, common, joint, integrated Electronic Health Record (iEHR) has
changed, and now the two Departments are no longer planning to operate
on one core system--instead, the VA will stay with a modernized VISTA
system while the Department of Defense will select another system. This
was due, we were told, to the exorbitant cost creep associated with the
creation of a truly joint record. Secretary Shinseki, I hope to hear
details today about your discussions with the new Secretary of Defense,
and the plan you have to move forward on a joint, open-architecture,
non-proprietary designed electronic health record system. Our men and
women in uniform need to trust their health record will follow them
seamlessly from the day they raise their right hand through their time
as a proud veteran of this Nation and we will work with you and your
Department to make this a reality.
claims processing
Mr. Secretary, you have stated numerous times one of your highest
priorities was to eliminate the disability claims backlog by 2015. You
also stated the Veterans Benefits Management System and the Veterans
Relationship Management initiative would help your Department make
significant headway in reducing the backlog, yet today, 70 percent of
claims are older than 125 days and the average wait time is nearly a
year. In Chicago, the average wait time actually increased by 141 days
in 2012 to an astonishing 431 day wait. I look forward to hearing
details from you today on how the Department will meet or beat the
deadline you set for a reduction in the backlog. I know you are working
hard on this process, but we desperately need results.
closing
Mr. Chairman, this subcommittee has always worked hard together to
provide the Department with the all the resources it needs. I look
forward to working with you to make sure we give our veterans all they
have earned.
Thank you, Mr. Chairman.
Senator Johnson. Thank you, Senator Kirk.
Again, Mr. Secretary, welcome and thank you for appearing
before this subcommittee. I understand that yours will be the
only opening statement. Your full statement will be included in
the record, so please feel free to summarize your remarks.
Please proceed.
SUMMARY STATEMENT OF HON. ERIC K. SHINSEKI
Secretary Shinseki. Well, thank you very much, Chairman
Johnson, Ranking Member Kirk--I understand Chairwoman Mikulski
will be attending at some point; I acknowledge that--other
distinguished members of the subcommittee.
Thank you for this opportunity to present the President's
2014 budget and 2015 advanced appropriations request for VA. We
deeply value your partnership and support in providing the
resources needed to ensure quality care and services for
veterans. That's been true for the 4 years that I've served in
this capacity.
Let me also acknowledge other partners who are here today,
our veterans service organizations whose insights and support
make us much better at our mission of caring for veterans,
their families, and survivors.
Mr. Chairman, if I could just take a few seconds here to
introduce the other members of my panel. Seated to my far left
and to your right, Steph Warren is our Acting Assistant
Secretary for Information and Technology. To my left is Todd
Grams, our Chief Financial Officer. To my right is Dr. Randy
Petzel, Under Secretary for Health, and then Allison Hickey,
Under Secretary for Benefits. On the far right is Mr. Steve
Muro, our Under Secretary for Memorial Affairs.
Mr. Chairman, thank you for accepting my written record.
Let me just say very quickly, the 2014 budget and the 2015
advanced appropriations requests demonstrate the President's
steadfast commitment to our Nation's veterans. I thank the
members for your resolute commitment to veterans as well and
seek your support for these requests.
The latest generation of veterans is enrolling in VA at a
higher rate than previous generations; 62 percent of those who
deployed in support of operations in Iraq and Afghanistan have
used at least one VA benefit or service.
VA's requirements are expected to continue growing for
years to come. Our plans and resourcing must be robust enough
to care for them all. What you'll see in our plan is that look
to the future.
The President's 2014 budget for VA requests $152.7 billion,
with $66.5 billion in discretionary funding, and $86.1 billion
in mandatory funding. An increase of $2.7 billion in
discretionary funding equates to about a 4.3-percent increase
above the 2013 level.
This is a strong budget, which enables us to continue
building momentum for delivering the three major goals we set
for ourselves 4 years ago. One, to increase veterans' access to
VA's benefits and services, and we have done that. Two,
eliminate the disability claims backlog in 2015, and we've put
together a robust plan that's funded in order to accomplish
that. Finally three, end veterans' homelessness in 2015 as
well.
These were bold and ambitious goals 4 years ago, and they
remain bold and ambitious goals today, because veterans deserve
a VA that advocates for them and then puts the resources behind
the promises it has made.
When it comes to access, of the roughly 22 million living
veterans in the country today, more than 11 million now receive
at least one benefit or service from VA, and that's an increase
of over 1 million veterans in the last 4 years. We have
achieved this by opening new facilities, renovating others,
increasing investments in telehealth and telemedicine, sending
mobile clinics and vet centers to remote areas where veterans
live, and then using every means available, including social
media, to connect more veterans to VA. Increasing access has
been a success story for us and our numbers show it.
Backlog--too many veterans wait too long to receive the
benefits they've earned and they deserve. We know this is
unacceptable and no one wants to turn this around anymore than
I do or Secretary Hickey, or the workers at the Veterans
Benefits Administration (VBA); 52 percent of whom are veterans
themselves. We are resolved to eliminate the claims backlog in
2015 when claims will be processed in 125 days or less at a 98
percent accuracy level.
Our efforts mandate investments in VBA's people, processes,
and technology.
As far as people are concerned, more than 2,300 claims
processors have completed training to improve the quality and
productivity of their decisions. More are being trained today,
and VBA's new employees now complete more claims per day than
their predecessors.
In terms of processes, we use a disability benefits
questionnaire--we call it a DBQ--an online form for submitting
medical evidence. And that has dropped the average processing
times of medical exams and increased accuracy.
There are now three lanes for processing claims: an express
lane for those that will predictably take less time; a special
operations lane, if you will, for unusual cases or those
requiring special handling; and a core lane for probably the
majority of claims that will be handled.
Technology is critical to this discussion. It is critical
to ending the backlog. Our paperless processing system, and it
is called Veterans Benefits Management System (VBMS) will be
faster, improve access, drive automation, and reduce variance.
Thirty-six regional offices out of our 56 regional offices
all now have VBMS, 36 of 56. We had planned to have this
fielding completed by the end of this year, December. We're
going to beat that milestone. We're pulling fielding to the
left as far as we can. Those are all the adjustments that are
underway.
In terms of homelessness, the last of our three priorities
is to end veterans homelessness in 2015. Since 2009, we've
reduced the estimated number of homeless veterans by 17
percent. The latest available estimate from January 2012 is
62,600 veterans remain homeless on the streets. There's more
work to be done here, but we've mobilized a national program
that reaches into communities all across this country.
The rescue phase of this is intended to end in 2015.
Continuing long beyond that, we expect that we're going to have
a prevention of veterans homelessness program that will be the
follow-on main effort, preventing veterans from ending up on
the streets.
PREPARED STATEMENT
Mr. Chairman, we're committed to the responsible use of the
resources Congress provides. Again, thank you for this
opportunity to appear here today, and for your support of
veterans. We look forward to your questions.
[The statement follows:]
Prepared Statement of Hon. Eric K. Shinseki
Chairman Johnson, Ranking Member Kirk, distinguished members of the
Senate Appropriations Committee, Subcommittee on Military Construction,
Veterans Affairs and Related Agencies: Thank you for the opportunity to
present the President's 2014 budget and 2015 advance appropriations
requests for the Department of Veterans Affairs (VA). This budget
continues the President's historic initiatives and strong budgetary
support and will have a positive impact on the lives of Veterans, their
families, and survivors. We value the unwavering support of the
Congress in providing the resources and legislative authorities needed
to care for our Veterans and recognize the sacrifices they have made
for our Nation.
The current generation of Veterans will help to grow our middle
class and provide a return on the country's investments in them. The
President believes in Veterans and their families, believes in
providing them the care and benefits they've earned, and knows that by
their service, they and their families add strength to our Nation.
Twenty-two million living Americans today have distinguished
themselves by their service in uniform. After a decade of war, many
Servicemembers are returning and making the transition to Veterans
status. The President's 2014 budget for VA requests $152.7 billion--
comprised of $66.5 billion in discretionary funds, including medical
care collections, and $86.1 billion in mandatory funds. The
discretionary request reflects an increase of $2.7 billion, 4.3 percent
above the 2013 level. Our 2014 budget will allow VA to operate the
largest integrated healthcare system in the country, with more than 9.0
million Veterans enrolled to receive healthcare; the ninth largest life
insurance provider, covering both Active Duty members as well as
enrolled Veterans; an education assistance program serving over 1
million students; a home mortgage service that guarantees over 1.5
million Veterans' home loans with the lowest foreclosure rate in the
Nation; and the largest National Cemetery System that leads the Nation
as a high-performing organization, with projections to inter about
121,000 Veterans and family members in 2014.
priority goals
Over the next few years, more than 1 million Veterans will leave
military service and transition to civilian life. VA must be ready to
care for them and their families. Our data shows that the newest of our
country's Veterans are relying on VA at unprecedented levels. Through
January 31, 2012, of the approximately 1.58 million Veterans who
returned from Operations Enduring Freedom, Iraqi Freedom, and New Dawn,
at least 62 percent have used some VA benefit or service.
VA's top three priorities--increase access to VA benefits and
services; eliminate the disability compensation claims backlog in in
2015; and end Veterans homelessness, also in 2015--anticipate these
changes and identify the performance levels required to meet emerging
needs. These ambitious goals will take steady focus and determination
to see them through. As we enter the critical funding year for VA's
priority goals, this 2014 budget builds upon our multiyear effort to
position the Department through effective, efficient, and accountable
programming and budget execution for delivering claims and homeless
priority goals.
stewardship of resources
Safeguarding the resources--people, money, time--entrusted to us by
the Congress, managing them effectively, and deploying them
judiciously, is a fundamental duty. Effective stewardship requires an
unflagging commitment to use resources efficiently with clear
accounting rules and procedures, to safeguard, train, motivate, and
hold our workforce accountable, and to assure the effective use of time
in serving Veterans on behalf of the American people. Striving for
excellence in stewardship of resources is a daily priority. At VA, we
are ever attentive to areas in which we need to improve our operations,
and are committed to taking swift corrective action to eliminate any
financial management practice that does not deliver value for Veterans.
VA's stewardship of resources begins at headquarters. Recognizing
the very difficult fiscal constraints facing our country, the 2014
request includes a 5.0 percent reduction in the departmental
administration budget from the 2013 enacted level. This reduction
follows a headquarters freeze in the 2013 President's budget--a 2-year
commitment.
Recent audits of the Department's financial statements have
certified VA's success in remediating all three of our remaining
material weaknesses in financial management, which had been carried
forward for over a decade. In terms of internal controls and fiscal
integrity, this was a major accomplishment. In the past 4 years, we
have also dramatically reduced the number of significant financial
deficiencies from 16-to-1.
At VA, we believe that part of being responsible stewards is
shutting down Information Technology (IT) projects that are no longer
performing. Developed by our Office of Information and Technology, the
Project Management Accountability System (PMAS) requires IT projects to
establish milestones to deliver new functionality to its customers
every 6 months. Now entering its third year, PMAS continues to instill
accountability and discipline in our IT organization. Through PMAS, the
cumulative, on-time delivery of IT functionality since its inception is
82 percent, a rate unheard of in the industry where, by contrast, the
average is 42 percent. By implementing PMAS, we have achieved at least
$200 million in cost avoidance by shutting down or improving the
management of 15 projects.
Through the effective management of our acquisition resources, VA
has achieved savings of over $200 million by participating in Federal
strategic sourcing programs and establishing innovative IT acquisition
contracts. In 2012, VA led the civilian agencies in contracting with
Service-Disabled Veteran-Owned Small Businesses, which, at $3.4
billion, accounted for 19.3 percent of all VA procurement awards. In
addition, we have reduced interest penalties for late payments by 19
percent (from $47 to $38 per million) over the past 4 years.
Finally, VA's stewardship achieved savings in several other areas
across the Department. The National Cemetery Administration (NCA)
assumed responsibility in 2009 for processing First Notices of Death to
terminate compensation benefits to deceased Veterans. Since taking on
this responsibility, NCA has advised families of the burial benefits
available to them, assisted in averting overpayments of some $142
million in benefit payments and, thereby, helped survivors avoid
possible collections. In addition, we implemented the use of Medicare
pricing methodologies at the Veterans Health Administration (VHA) to
pay for fee-basis services, resulting in savings of over $528 million
since 2012 without negatively impacting Veteran care and with improved
consistency in billing and payment.
technology
To serve Veterans as well as they have served us, we are working on
delivering a 21st century VA that provides medical care, benefits, and
services through a digital infrastructure. Technology is integrated
with everything we do for Veterans. Our hospitals use information
technology to properly and accurately distribute and deliver
prescriptions/medications to patients, track lab tests, process MRI and
X-ray imaging, coordinate consults, and store medical records. VA IT
systems supported over 1,300 VA points of healthcare in 2012: 152
medical centers, 107 domiciliary rehabilitation treatment programs, 821
community-based outpatient clinics, 300 Vet Centers, 6 independent
outpatient clinics, 11 mobile outpatient clinics, and 70 mobile Vet
Centers. Technology supports Veterans' education and disability claims
processing, claims payments, home loans, insurance, and memorial
services. Our IT infrastructure consists of telephone lines, data
networks, servers, workstations, printers, cell phones, and mobile
applications.
No Veteran should have to wait months or years for the benefits
that they have earned. We will eliminate the disability claims backlog
in 2015; technology is the critical component for achieving our goal.
VA is deploying technology solutions to improve access, drive
automation, reduce variance, and enable faster and more efficient
operations. Building on the resources Congress has provided in recent
years to expand our claims processing capacity, the 2014 budget
requests $291 million for technology to eliminate the claims backlog--
$155 million in Veterans Benefits Management System (VBMS) for our new
paperless processing system, and $136 million in the Veterans Benefits
Administration (VBA) to support a Veterans Claims Intake Program, our
new online application system that will allow for the conversion of
paper to digital images for our new paperless processing system, the
Veterans Benefits Management System (VBMS). Without these resources, VA
will be unable to meet its goal to eliminate the disability claims
backlog in 2015.
Information Technology
At VA, advances in technology--and the adoption of and reliance on
IT in our daily commercial life--have been dramatic. Technology is
integral to providing high-quality healthcare and benefits. The 2014
budget requests $3.683 billion for IT, an increase of $359 million from
the President's 2013 budget, reflecting the critical role technology
plays in VA's daily work in serving and caring for Veterans and their
families. Of the total request, $2.2 billion will support the operation
and maintenance of our digital infrastructure and $495 million is for
IT development modernization and enhancement projects.
The 2014 budget includes $32.8 million for development of VBMS, our
new paperless processing system that enables VA to move from its
current paper-based process to a digital operating environment that
improves access, drives automation, reduces variance, and enables
faster, more efficient operations. As we increase claims examiners' use
of VBMS version 4.2 to process rating disability claims, our major
focus is on system performance, as we tune the system to be responsive
and effective. VA will complete the rollout of VBMS in June 2013.
In addition, the 2014 budget includes $120 million for development
of the Veterans Relationship Management (VRM) initiative, which
enhances Veterans' access to comprehensive VA services and benefits,
especially in the delivery of compensation and pension claims
processing. The program gives Veterans secure, personalized access to
benefits and information and allows a timely response to their
inquiries. Recently, VRM released Veterans Online Application Direct
Connect (VDC), which enables Veterans to apply for VBA benefits by
answering guided interview questions through the security of the
eBenefits portal. Claims filed through eBenefits use VDC to load
information and data directly into VBMS.
The Virtual Lifetime Electronic Record (VLER) is an overarching
program which aims to share health, benefits, and administrative
information, including personnel records and military history records,
among DOD, VA, SSA, private healthcare providers, and other Federal,
State, and local government partners. eBenefits is already reaching 2
million Veterans and Servicemembers and 1 million active users with
BlueButton. The 2014 budget requests $15.4 million for VLER to develop
and support these functions as well as the Warrior Support Veterans
Tracking Application; the Disability Benefits Questionnaires; a VA-DOD
joint health information sharing project known as Bidirectional Health
Information Exchange; and a storage interface known as Clinical Data
Repository/Health Data Repository. All of these efforts are designed to
enable the sharing of health, military personnel and personal
information among VA, other Federal agencies, Veteran Service
Organizations and private healthcare providers to expedite the award
and processing of disability claims and other services such as
education, training and job placement.
eliminating the claims backlog
Too many Veterans wait too long to receive benefits they have
earned. This is unacceptable. Today's claims backlog is the result of
several factors, including: increased demand; over a decade of war with
many Veterans returning with more severe, complex injuries; decisions
on agent orange, gulf war, and combat PTSD presumptions; and,
successful outreach to Veterans informing them of their benefits. These
facts, in no way, diminish the urgency that we all feel at VA to fix
this problem which has been decades in the making. VA remains focused
on eliminating the disability claims backlog in 2015 and processing all
claims within 125 days at a 98-percent accuracy level.
To deliver this goal, the Veterans Benefits Administration (VBA) is
implementing a comprehensive transformation plan based on more than 40
targeted initiatives to boost productivity by over the next several
years. However, as VBA transforms its people, processes, and
technologies, its claims demand is expected to exceed on million
annually. From 2010 through 2012, for the first time in its history,
VBA processed more than 1 million claims in three consecutive years. In
2013, VBA expects to receive another million claims and similar levels
of demand are anticipated in 2014. This is driven by successful
outreach, claims growth not previously captured in VBA's baseline, and
new requirements. Included are mandatory Servicemember participation in
VOW/VEI benefits briefings and an expected increase upon successful
completion of a transition assistance program, revamped by the
President as Transition: Goals, Plan, Success (GPS). As more than 1
million troops leave service over the next 5 years, we expect our
claims workload to continue to rise. In addition, VBA is experiencing
an unprecedented workload growth arising from the number and complexity
of medical conditions in Veterans' compensation claims. The average
number of claimed conditions for our recently separated Servicemembers
is now in the 12 to 16 range--roughly five times the number of
disabilities claimed by Veterans of earlier eras. While the increase in
compensation applications presents challenges, it is also an indication
that we are being successful in our efforts to expand access to VA
benefits.
Investments in transformation of our people, processes, and
technologies are already paying off in terms of improved performance.
For example:
--People.--More than 2,100 claims processors have completed Challenge
Training, which improves the quality and productivity of VBA
compensation claims decision makers. As a result of Challenge
Training, VBA's new employees complete more claims per day than
their predecessors--with a 30-percent increase in accuracy.
VBA's new standardized organizational model incorporates a case-
management approach to claims processing that organizes its
workforce into cross-functional teams that work together on one
of three segmented lanes: express, special operations, or core.
Claims that predictably can take less time will flow through an
express lane (30 percent); those taking more time or requiring
special handling will flow through a special operations lane
(10 percent); and the rest of the claims flow through the core
lane (60 percent). Initially planned for deployment throughout
2013, VBA accelerated the implementation of the new
organizational model by 9 months due to early indications of
its positive impact on performance.
VBA instituted Quality Review Teams (QRTs) in 2012 to improve
employee training and accuracy while decreasing rework time.
QRTs focus on improving performance on the most common sources
of error in the claims processing cycle. Today, for example,
QRTs are focused on the process by which proper physical
examinations are ordered; incorrect or insufficient exams
previously accounted for 30 percent of VBA's error rate. As a
result of this focus, VBA has seen a 23-percent improvement in
this area.
--Process.--Disability Benefits Questionnaires (DBQs) are online
forms used by non-VA physicians to submit medical evidence. Use
of DBQs has improved timeliness and accuracy of VHA-provided
exams--average processing time improved by 6 days from June
2011 to October 2012 (from 32 to 26 days).
Fully developed claims (FDCs) are critical to reducing ``wait
time'' and ``rework.'' FDCs include all DOD service medical and
personnel records, including entrance and exit exams,
applicable DBQs, any private medical records, and a fully
completed claim form. Today, VBA receives 4.5 percent of claims
in fully developed form and completes them in 117 days, while a
regular claim takes 262 days to process. Fulfilling the
Veterans Claims Assistance Act, to search for potential
evidence, is the greatest portion of the current 262-day
process. The Veterans Benefit Act of 2003 allows Veterans up to
365 days, from the date of VA notice for additional information
or evidence, to provide documentation. Of the 262 days to
complete a regular claim, approximately 145 days are spent
waiting for potential evidence to qualify the application as a
fully developed claim.
VBA built new decision-support tools to make our employees more
efficient and their decisions more consistent and accurate.
Rules-based calculators provide suggested evaluations for
certain conditions using objective data and rules-based
functionality. The Evaluation Builder uses a series of check
boxes that are associated with the Veteran's symptoms to help
determine the proper diagnostic code of over 800 codes, as well
as the appropriate level of compensation based on the Veteran's
symptoms.
--Technology.--The centerpiece of VBA's transformation plan is VBMS--
a new paperless electronic claims processing system that
employs rules-based technology to improve decision speed and
accuracy. For our Veterans, VBMS will mean faster, higher
quality, and more consistent decisions on claims. Our strategy
includes active stakeholder participation (Veterans Service
Officers, State Departments of Veterans Affairs, County
Veterans Service Officers, and Department of Defense) to
provide digital electronic files and claims pre-scanned through
online claims submission via the eBenefits Web portal.
VBA recently established the Veterans Claims Intake Program (VCIP).
This program will streamline processes for receiving records
and data into VBMS and other VBA systems. Scanning operations
and the transfer of Veteran data into VBMS are primary intake
capabilities that are managed by VCIP. As VBMS is deployed to
additional regional offices, document scanning becomes
increasingly important as the main mechanism for transitioning
from paper-based claim folders to the new electronic
environment.
There are other ways that VA is working to eliminate the claims
backlog. VHA has implemented multiple initiatives to expedite timely
and efficient delivery of medical evidence needed to process a
disability claim by VBA. As a result, timeliness improved by nearly
one-third, from an average of 38 days in January 2011 to 26 days in
October 2012. Recently, VA launched Acceptable Clinical Evidence (ACE),
an initiative that allows clinicians to review existing medical
evidence and determine whether they can use that evidence to complete a
DBQ without requiring the Veteran to report for an in-person
examination. This initiative was developed by both VHA and VBA in a
joint effort to provide a Veteran-centric approach for disability
examinations. Use of the ACE process opens the possibility of doing
assessments without an in-person examination when there is sufficient
information in the record.
Another way to eliminate the claims backlog is by working closely
with the DOD. The Integrated Disability Evaluation System (IDES) is a
collaborative system to make disability evaluations seamless, simple,
fast and fair. If the Servicemember is found medically unfit for duty,
the IDES gives them a proposed VA disability rating before they leave
the service. These ratings are normally based on VA examinations that
are conducted using required IDES examination templates. In fiscal year
2012, IDES participants were notified of VA benefit entitlement in an
average of 54 days after discharge. This reflects an improvement from
67 days in May 2012 to 49 days in September 2012.
The Benefits Delivery at Discharge (BDD) and Quick Start programs
are two other collaborations for Servicemembers to file claims for
service-connected disabilities. This can be done from 180 to 60 days
prior to separation or retirement. BDD claims are accepted at every VA
Regional Office and at intake sites on military installations in the
United States, and at two intake site locations overseas. In 2012, BDD
received more than 30,300 claims and completed 24,944--a 14-percent
increase over 2011's productivity (21,657). During this same period of
time Quick Start decreased their rating inventory by over 44 percent.
expanding access to benefits and services
VA remains committed to ensuring that Veterans are not only aware
of the benefits and services that they are entitled to, but that they
are able to access them. We are improving access to VA services by
opening new or improved facilities closer to where Veterans live. Since
2009, we have added 57 community-based outpatient clinics (CBOCs), for
a total of 840 CBOCs through 2013, and increased the number of mobile
outpatient clinics and mobile Vet Centers, serving rural Veterans, to
81. Last August, we opened a state-of-the-art medical center in Las
Vegas, the first new VAMC in 17 years. The 2014 medical care budget
request includes $799 million to open new and renovated healthcare
facilities and includes the authorization request for 28 new and
replacement medical leases to increase Veteran access to services.
Today, access is much more than the ability to walk into a VA
medical facility; it also includes technology, and programs, as well
as, facilities. Expanding access includes taking the facility to the
Veteran--be it virtually through telehealth, by sending Mobile Vet
Centers to rural areas where services are scarce, or by using social
media sites like Facebook, Twitter, and YouTube to connect Veterans to
VA benefits and facilities. Telehealth is a major breakthrough in
healthcare delivery in 21st century medicine, and is particularly
important for Veterans who live in rural and remote areas. The 2014
budget requests $460 million for telehealth, an increase of $388
million, or 542 percent, since 2009.
As more Veterans access our healthcare services, we recognize their
unique needs and the needs of their families--many have been affected
by multiple, lengthy deployments. VA provides a comprehensive system of
high-quality mental health treatment and services to Veterans. We are
using many tools to recruit and retain our large mental healthcare
workforce to better serve Veterans by providing enhanced services,
expanded access, longer clinic hours, and increased telemental health
capabilities. In response to increased demand over the last 4 years, VA
has enhanced its capacity to deliver needed mental health services and
to improve the system of care so that Veterans can more readily access
them. Since 2006, the number of Veterans receiving specialized mental
health treatment has risen each year, from over 927,000 to more than
1.3 million in 2012, partly due to proactive screening. Outpatient
visits have increased from 14 million in 2009 to over 17 million in
2012. VA believes that mental healthcare must constantly evolve and
improve as new knowledge becomes available through research.
The 2014 budget includes $168.5 million for the Veterans
Relationship Management (VRM) initiative, which is fundamentally
transforming Veterans' access to VA benefits and services by empowering
VA clients with new self-service tools. VA has already made major
strides under this initiative. Most recently, in November 2012, VRM
added new features to eBenefits, a Web application that allows Veterans
to access their VA benefits and submit some claims online. Veterans can
now enroll in and manage their insurance policies, select reserve
retirement benefits, and browse the Veterans Benefits Handbook from the
eBenefits Web site. With the help of Google mapping services, the
update also enables Veterans to find VA representatives in their area
and where they are located. Since its inception in 2009, eBenefits has
added more than 45 features allowing Veterans easier, quicker, and more
convenient access to their VA benefits and personal information.
VBA has aggressively promoted eBenefits and the ease of enrolling
into the system. We currently have over 2.5 million registered
eBenefits users. Users can check the status of claims or appeals,
review VA payment history, obtain military documents, and perform
numerous other benefit actions through eBenefits. The Stakeholder
Enterprise Portal (SEP) is a secure Web-based access point for VA's
business partners. This electronic portal provides the ability for VSOs
and other external VA business partners to represent Veterans quickly
and efficiently.
VA also continues to increase access to burial services for
Veterans and their families through the largest expansion of its
National Cemetery System since the Civil War. At present, approximately
90 percent of the Veteran population--about 20 million Veterans--has
access to a burial option in a national, State, or tribal Veterans
cemetery within 75 miles of their homes. In 2004, only 75 percent of
Veterans had such access. This dramatic increase is the result of a
comprehensive strategic planning process that results in the most
efficient use of resources to reach the greatest number of Veterans.
ending veteran homelessness
The last of our three priority goals is to end homelessness among
Veterans in 2015. Since 2009, we have reduced the estimated number of
homeless Veterans by more than 17 percent. The January 2012 Point-In-
Time estimate, the latest available, is 62,619. We have also created a
National Homeless Veterans Registry to track our known homeless and at-
risk populations closely to ensure resources end up where they are
needed. In 2012, over 240,000 homeless or at-risk Veterans accessed
benefits or services through VA and 96,681 homeless or at-risk Veterans
were assessed by VHA's homeless programs. Over 31,000 homeless and at-
risk Veterans and their families obtained permanent housing through VA
specialized homeless programs.
In the 2014 budget, VA is requesting $1.393 billion for programs to
assist homeless Veterans, through programs such as Department of
Housing and Urban Development-VA Supportive Housing (HUD-VASH), Grant
and Per Diem, Homeless Registry, and Health Care for Homeless Veterans.
This represents an increase of $41 million, or 3 percent over the 2013
enacted level. This budget will support our long-range plan to end
Veteran homelessness by emphasizing rescue and prevention--rescue for
those who are homeless today, and prevention for those at risk of
homelessness.
Our prevention strategy includes close partnerships with some 150
community nonprofits through the Supportive Services for Veteran
Families (SSVF) program; SSVF grants promote housing stability among
homeless and at-risk Veterans and their families. The grants can have
an immediate impact, helping lift Veterans out of homelessness or
providing aid in emergency situations that put Veterans and their
families at risk of homelessness. In 2012, we awarded $100 million in
Supportive Service grants to help Veterans and families avoid life on
the streets. We are currently reviewing proposals for the $300 million
in grants we will distribute later this year. In 2012, SSVF resources
directly helped approximately 21,000 Veterans and over 35,000 household
members, including nearly 9,000 children. This year's grants will help
up to 70,000 Veterans and family members avoid homelessness. The 2014
budget includes $300 million for SSVF.
To increase homeless Veterans' access to benefits, care, and
services, VA established the National Call Center for Homeless Veterans
(NCCHV). The NCCHV provides homeless Veterans and Veterans at-risk for
homelessness free, 24/7 access to trained counselors. The call center
is intended to assist homeless Veterans and their families, VA medical
centers, Federal, State, and local partners, community agencies,
service providers, and others in the community. Family members and non-
VA providers who call on behalf of homeless Veterans are provided with
information on VA homeless programs and services. In 2012, the National
Call Center for Homeless Veterans received 80,558 calls (123-percent
increase) and the center made 50,608 referrals to VA medical centers
(133-percent increase).
VA's Homeless Patient Aligned Care Teams (H-PACTs) program provides
a coordinated ``medical home'' specifically tailored to the needs of
homeless Veterans. The program integrates clinical care with delivery
of social services and enhanced access and community coordination.
Implementation of this model is expected to address health disparity
and equity issues facing the homeless population. Expected program
outcomes include reduced emergency department use and hospitalizations,
improved chronic disease management, and improved ``housing readiness''
with fewer Veterans returning to homelessness once housed.
During 2012, 119,878 unique homeless Veterans were served by the
Health Care for Homeless Veterans Program (HCHV), an increase of more
than 21 percent from 2011. At more than 135 sites, HCHV offers
outreach, exams, treatment, referrals, and case management to Veterans
who are homeless and dealing with mental health issues, including
substance use. Initially serving as a mechanism to contract with
providers for community-based residential treatment for homeless
Veterans, many HCHV programs now serve as the hub for myriad housing
and other services that provide VA with a way to outreach and assist
homeless Veterans by offering them entry to VA medical care.
VA's Homeless Veterans Apprenticeship Program was established in
2012--a 1-year paid employment training program for Veterans who are
homeless or at risk of homelessness. This program created paid
employment positions as Cemetery Caretakers at 5 of our 131 National
Cemeteries. The initial class of 21 homeless Veterans is simultaneously
enrolled in VHA's Homeless Veterans Supported Employment program.
Apprentices who successfully complete 12 months of competency-based
training will be offered permanent full-time employment at a National
Cemetery. Successful participants will receive a Certificate of
Competency which can also be used to support employment applications in
the private sector.
Another avenue of assistance is through Veterans Treatment Courts,
which were developed to avoid unnecessary incarceration of Veterans who
have developed mental health problems. The goal of Veterans Treatment
Courts is to divert those with mental health issues and homelessness
from the traditional justice system and to give them treatment and
tools for rehabilitation and readjustment. While each Veterans
Treatment Court is part of the local community's justice system, they
form close working partnerships with VA and Veterans' organizations. As
of early 2012 there are 88 Courts.
The Veterans Justice Outreach (VJO) program exists to connect these
justice-involved Veterans with the treatment and other services that
can help prevent homelessness and facilitate recovery, whether or not
they live in a community that has a Veterans Treatment Court. Each VA
Medical Center has at least one designated justice outreach specialist
who functions as a link between VA, Veterans, and the local justice
system. Although VA cannot treat Veterans while they are incarcerated,
these specialists provide outreach, assessment and linkage to VA and
community treatment, and other services to both incarcerated Veterans
and justice-involved Veterans who have not been incarcerated.
multiyear plan for medical care budget
Under the Veterans Health Care Budget Reform and Transparency Act
of 2009, which we are grateful to Congress for passing; VA submits its
medical care budget that includes an advance appropriations request in
each budget submission. The legislation requires VA to plan its medical
care budget using a multiyear approach. This policy ensures that VA
requirements are reviewed and updated based on the most recent data
available and actual program experience.
The 2014 budget request for VA medical care appropriations is $54.6
billion, an increase of 3.7 percent over the 2013 enacted level of
$52.7 billion. The request is an increase of $157.5 million above the
enacted 2014 advance appropriations level. Based on updated 2014
estimates largely derived from the Enrollee Health Care Projection
Model, the requested amount would allow VA to increase funding in
programs to eliminate Veteran homelessness; continue implementation of
the Caregivers and Veterans Omnibus Health Services Act; fulfill
multiple responsibilities under the Affordable Care Act; provide for
activation requirements for new or replacement medical facilities; and
invest in strategic initiatives to improve the quality and
accessibility of VA healthcare programs. Our multiyear budget plan
assumes that VHA will carry over negligible unobligated balances from
2013 into 2014--consistent with the 2013 budget submitted to Congress.
The 2015 request for medical care advance appropriations is $55.6
billion, an increase of $1.1 billion, or 1.9 percent, over the 2014
budget request. Medical care funding levels for 2015, including funding
for activations, non-recurring maintenance, and initiatives, will be
revisited during the 2015 budget process, and could be revised to
reflect updated information on known funding requirements and
unobligated balances.
medical care program
The 2014 budget of $57.7 billion, including collections, provides
for healthcare services to treat over 6.5 million unique patients, an
increase of 1.3 percent over the 2013 estimate. Of those unique
patients, 4.5 million Veterans are in Priority Groups 1-6, an increase
of more than 71,000 or 1.6 percent. Additionally, VA anticipates
treating over 674,000 Veterans from the conflicts in Iraq and
Afghanistan, an increase of over 67,000 patients, or 11.1 percent, over
the 2013 level. VA also provides medical care to non-Veterans through
programs such the Civilian Health and Medical Program of the Department
of Veterans Affairs (CHAMPVA) and the Spina Bifida Health Care Program;
this population is expected to increase by over 17,000 patients, 2.6
percent, during the same time period.
The 2014 budget proposes to extend the Administration's current
policy to freeze Veterans' pharmacy co-payments at the 2012 rates,
until January 2015. Under this policy, which will be implemented in a
future rulemaking, co-payments will continue at $8 for Veterans in
Priority Groups 2 through 6 and at $9 for Priority Groups 7 through 8.
The 2014 budget requests $47 million to provide healthcare for
Veterans who were potentially exposed to contaminated drinking water at
Camp Lejeune as required by the Honoring America's Veterans and Caring
for Camp Lejeune Families Act of 2012, enacted last August. Since VA
began implementation of the law and in January 2013, 1,400 Veterans
have contacted us concerning Camp Lejeune. Of these, roughly 1,100 were
already enrolled in VA healthcare. Veterans who are eligible for care
under the Camp Lejeune authority, regardless of current enrollment
status with VA, will not be charged a co-payment for healthcare related
to the 15 illnesses or conditions recognized, nor will a third-party
insurance company be billed for these services. In 2015, VA expects to
start treating family members as authorized under the law and has
included $25 million for this purpose within the 2015 advance
appropriations request. VA continues a robust outreach campaign to
these Veterans and family members while we press forward with
implementing this complex new law.
Mental Healthcare and Suicide Prevention
At VA, we have the opportunity and the responsibility to anticipate
the needs of returning Veterans. Mental healthcare at VA is a system of
comprehensive treatments and services to meet the individual mental
health needs of Veterans. VA is expanding mental health programs and is
integrating mental health services with primary and specialty care to
provide better coordinated care for our Veteran patients. Our 2014
budget provides nearly $7.0 billion for mental healthcare, an increase
of $469 million, or 7.2 percent, over 2013. Since 2009, VA has
increased funding for mental health services by 56.9 percent. VA
provided mental health services to 1,391,523 patients in 2012, 58,000
more than in 2011.
To serve the growing number of Veterans seeking mental healthcare,
VA has deployed significant resources and is increasing the number of
staff in support of mental health services. Consistent with the
President's August 31, 2012, Executive order, VHA is on target to
complete the goal of hiring 1,600 additional mental health clinical
providers and 300 administrative support staff by June 30, 2013, to
meet the growing demand for mental health services. In addition, as
part of VA's efforts to implement the Caregivers and Veterans Omnibus
Health Services Act of 2010, VA has hired over 100 Peer Specialists in
recent months, and is hiring and training nearly 700 more.
Additionally, VA has awarded a contract to the Depression and Bipolar
Support Alliance to provide certification training for Peer
Specialists. This peer staff is expected to be hired by December 31,
2013, and will work as members of mental health teams.
In addition to hiring more mental health workers, VA is developing
electronic tools to help VA clinicians manage the mental health needs
of their patients. Clinical Reminders give clinicians timely
information about patient health maintenance schedules, and the High-
Risk Mental Health National Reminder and Flag system allows VA
clinicians to flag patients who are at-risk for suicide. When an at-
risk patient does not keep an appointment, Clinical Reminders prompt
the clinician to follow-up with the Veteran.
Since its inception in 2007, the Veterans Crisis Line in
Canandaigua, New York, has answered over 725,000 calls and responded to
more than 80,000 chats and 5,000 texts from Veterans in need. In the
most serious calls, approximately 26,000 men and women have been
rescued from a suicide in progress because of our intervention--the
equivalent of two Army divisions.
We recently completed a 2012 VA suicide data report, a result of
the most comprehensive review of Veteran suicide rates ever undertaken
by VA. We are working hard to understand this issue--and VA and DOD
have jointly funded a $100 million suicide research project. We will be
better informed about suicides, but while research is ongoing, we are
taking immediate action and are not waiting 10 years for final study
outcomes. These actions include Veterans Chat on the Veterans Crisis
Line, local Suicide Prevention Coordinators' for counseling and
services, and availability of VA-DOD Suicide Outreach resources.
The Affordable Care Act
The Affordable Care Act (ACA) expands access to coverage, reins in
healthcare costs, and improves the Nation's healthcare delivery system.
The Act has important implications for VA. Beginning in 2014, many
uninsured Americans, including Veterans, will have access to quality,
affordable health insurance choices through Health Insurance
Marketplaces, also known as Exchanges, and may be eligible for premium
tax credits and cost-sharing reductions to make coverage more
affordable. The 2014 budget requests $85 million within the Medical
Care request and $3.4 million within the Information Technology request
to fulfill multiple responsibilities as a provider of Minimum Essential
Coverage under the Affordable Care Act, including: (1) providing
outreach and communication on ACA to Veterans related to VA healthcare;
(2) reporting to Treasury on individuals who are enrolled in the VA
healthcare system; and (3) providing a written statement to each
enrolled Veteran about their coverage by January 2015.
Medical Care in Rural Areas
VA remains committed to the delivery of medical care in rural areas
of our country. For that reason, in 2012, we obligated $248 million to
support the efforts of the Office of Rural Health to improve access and
quality of care for enrolled Veterans who live in rural areas. Some 3.4
million Veterans enrolled in the VA healthcare system live in rural or
highly rural areas of the country; this represents about 41 percent of
all enrolled Veterans. For that reason, VA will continue to emphasize
rural health in our budget planning, including addressing the needs of
American Indian and Alaska Native (AI/AN) Veterans.
VA is committed to expanding access to the full range of VA
programs to eligible AI/AN Veterans. Last year, VA signed a Memorandum
of Agreement with the Indian Health Service (IHS), through which VA
will reimburse IHS for direct care services provided to eligible
American Indian and Alaska Native Veterans. While the national
agreement applies only to VA and IHS, it will inform agreements
negotiated between the VA and tribal health programs.
This follows the agreement already in place between VA and IHS
whereby nearly 250,000 patients served by IHS have utilized a
prescription program that allows IHS pharmacies to use VA's
Consolidated Mail Outpatient Pharmacy (CMOP) to process and mail
prescription refills for IHS patients. By accessing the service, IHS
patients can now have their prescriptions mailed to them, in many cases
eliminating the need to pick them up at an IHS pharmacy.
Women Veterans Medical Care
Changing demographics are also driving change at VA. Today, we have
over 2.2 million women Veterans in our country; they are the fastest
growing segment of our Veterans' population. Since 2009, the number of
women Veterans enrolled in VA healthcare increased by almost 22
percent, to 591,500. However, by 2022--less than a decade from now--
their number is projected to spike to almost 2.5 million, and an
estimated 900,000 will be enrolled in VA healthcare.
The 2014 budget requests $422 million, an increase of 134 percent
since 2009, for gender-specific medical care for women Veterans. Since
2009, we have invested $25.5 million in improvements to women Veterans'
clinics and opened 19 new ones. Today, nearly 50 percent of our
facilities have comprehensive women's clinics, and every VA healthcare
system has designated women's health primary care providers, and has a
women Veteran's program manager on staff.
In 2012, VA awarded 32 grants totaling $2 million to VA facilities
for projects that will improve emergency healthcare services for women
Veterans, expand women's health education programs for VA staff, and
offer telehealth programs to female Veterans in rural areas. These new
projects will improve access and quality of critical healthcare
services for women. This is the largest number of 1-year grants VA has
ever awarded for enhancing women's health services.
medical research
Medical Research is being supported with $586 million in direct
appropriations in 2014, with an additional $1.3 billion in funding
support from VA's medical care program and through Federal and non-
Federal grants. VA Research and Development will support 2,224 projects
during 2014.
Projects funded in 2014 will be focused on supporting development
of New Models of Care, identifying or developing new treatments for
Gulf War Veterans, improving social reintegration following traumatic
brain injury, reducing suicide, evaluating the effectiveness of
complementary and alternative medicine, developing blood tests to
assist in the diagnosis of post-traumatic stress disorder and mild
traumatic brain injury, and advancing genomic medicine.
The 2014 budget continues support for the Million Veteran Program
(MVP), an unprecedented research program that advances the promises of
genomic science. The MVP will establish a database, used only by
authorized researchers in a secure manner, to conduct health and
wellness studies to determine which genetic variations are associated
with particular health issues--potentially helping the health of
America's Veterans and the general public. MVP recently enrolled its
100,000th volunteer research participant, and by the end of 2013, the
goal is to enroll at least 150,000 participants in the program.
veterans benefits administration (vba)
The 2014 budget request of $2.455 billion for VBA, an increase of
$294 million in discretionary funds from the 2013 enacted level, is
vital to the transformation strategy that drives our performance
improvements focused most squarely on the backlog.
Virtually all 860,000 claims in the VBA inventory, including the
600,000 claims that have been at VA for over 125 days and are
considered backlogged, exist only in paper. Our transition to VBMS and
electronic claims processing is a massive and crucial phase in VBA
transformation. VA awarded two VCIP contracts in 2012 to provide
document conversion services that will populate the electronic claims
folder, or eFolder, in VBMS with images and data extracted from paper
and other source material. Without VCIP, we cannot populate the eFolder
on which the VBMS system relies. The 2014 request for $136 million for
our scanning services contracts will ensure that we remain on track to
reach this key goal. In addition, the budget request includes $4.9
million for help desk support for Veterans using the Veterans On-Line
Application/eBenefits system.
VBA projects a beneficiary caseload of 4.6 million in 2014, with
more than $70 billion in compensation and pension benefits obligations.
We expect to process 1.2 million compensation claims in 2014, and we
are pursuing improvements that will enable us to meet the emerging
needs of Veterans and their families.
Veterans Employment
Under the leadership of President Obama, VA, DOD, the Department of
Labor, and the entire Federal Government have made Veterans employment
one of their highest priorities. In August 2011, the President
announced his comprehensive plan to address this issue and to ensure
that all of America's Veterans have the support they need and deserve
when they leave the military, look for a job, and enter the civilian
workforce. He created a new DOD-VA Employment Initiative Task Force
that would develop a new training and services delivery model to help
strengthen the transition of our Veteran Servicemembers from military
to civilian life. VA has worked closely with other partners in the Task
Force to identify its responsibilities and ensure delivery of the
President's vision. On November 21, 2012, the effective date of the VOW
Act, VA began deployment of the enhanced VA benefits briefings under
the revised Transition Assistance Program (TAP), called Transition GPS
(Goals, Plans, Success). VA will also provide training for the optional
Technical Training Track Curriculum and participate in the Capstone
event, which will ensure that separating Servicemembers have the
opportunity to verify that they have met Career Readiness Standards and
are steered to the resources and benefits available to them as
Veterans. Accordingly, the 2014 budget requests $104 million to support
the implementation of Transition GPS and meet VA's responsibilities
under the VOW Act and the President's Veterans Employment Initiative.
Veterans Job Corps
In his State of the Union address in 2012, President Obama called
for a new Veterans Job Corps initiative to help our returning Veterans
find pathways to civilian employment. The 2014 budget includes $1
billion in mandatory funding to develop a Veterans Job Corps
conservation program that will put up to 20,000 Veterans back to work
over the next 5 years protecting and rebuilding America. Jobs will
include park maintenance projects, patrolling public lands,
rehabilitating natural and recreational areas, and administrative,
technical, and law enforcement-related activities. Additionally,
Veterans will help make a significant dent in the deferred maintenance
of our Federal, State, local, and tribal lands including jobs that will
repair and rehabilitate trails, roads, levees, recreation facilities
and other assets. The program will serve all Veterans, but will have a
particular focus on Post-9/11 Veterans.
Post-9/11 and Other Education Programs
Since 2009, VA has provided over $25 billion in Post-9/11 GI Bill
benefits to cover the education and training of more than 893,000
Servicemembers, Veterans, family members, and survivors. We are now
working with Student Veterans of America to track graduation and
training completion rates.
The Post-9/11 GI Bill continues to be a focus of VBA transformation
as it implements the Long-Term Solution (LTS). At the end of February
we had approximately 60,000 education claims pending, 70 percent lower
than the total claims pending the same time last year. The average days
to process Post-9/11 GI Bill supplemental claims has decreased by 17
days, from 23 days in September 2012 to 6 days in February 2013. The
average time to process initial Post-9/11 GI Bill original education
benefit claims in February was 24 days.
national cemetery administration (nca)
The 2014 budget includes $250 million in operations and maintenance
funding for the National Cemetery Administration (NCA). As we move
forward into the next fiscal year, NCA projects our workload numbers
will continue to increase. For 2014, we anticipate conducting
approximately 121,000 interments of Veterans or their family members,
maintaining and providing perpetual care for approximately 3.4 million
gravesites. NCA will also maintain 9,000 developed acres and process
approximately 345,000 headstone and marker applications.
Review of National Cemeteries
For the first time in the 150-year history of National Cemeteries,
NCA has completed a self-initiated, comprehensive review of the entire
inventory of 3.2 million headstones and markers within the 131 National
Cemeteries and 33 Soldiers' Lots it maintains. The information gained
was invaluable in validating current operations and ensuring a
sustainment plan is in place to enhance our management practices. The
review was part of NCA's ongoing effort to ensure the full and accurate
accounting of remains interred in VA National Cemeteries. Families of
those buried in our national shrines can be assured their loved ones
will continue to be cared for into perpetuity.
Veterans Employment
NCA continues to maintain its commitment to hiring Veterans.
Currently, Veterans comprise over 74 percent of its workforce. Since
2009, NCA has hired over 400 returning Iraq and Afghanistan Veterans.
In addition, 82 percent of contracts in 2012 were awarded to Veteran-
owned and service-disabled Veteran-owned small businesses. NCA's
committed, Veteran-centric workforce is the main reason it is able to
provide a world-class level of customer service. NCA received the
highest score--94 out of 100 possible--in the 2010 American Customer
Satisfaction Index (ACSI) sponsored by the University of Michigan. This
was the fourth time NCA participated and the fourth time it received
the top rating in the Nation.
Partnerships
NCA continues to leverage its partnerships to increase service for
Veterans and their families. As a complement to the National Cemetery
System, NCA administers the Veterans Cemetery Grant Service (VCGS).
There are currently 88 operational State and tribal cemeteries in 43
States, Guam, and Saipan, with 6 more under construction. Since 1978,
VCGS has awarded grants totaling more than $500 million to establish,
expand, or improve Veterans' cemeteries. In 2012, these cemeteries
conducted over 31,000 burials for Veterans and family members.
NCA works closely with funeral directors and private cemeteries,
two significant stakeholder groups, who assist with the coordination of
committal services and interments. Funeral directors may also help
families in applying for headstones, markers, and other memorial
benefits. NCA partners with private cemeteries by furnishing headstones
and markers for Veterans' gravesites in these private cemeteries. In
January of this year, NCA announced the availability of a new online
funeral directors resource kit that may be used by funeral directors
nationwide when helping Veterans and their families make burial
arrangements in VA National Cemeteries.
capital infrastructure
A total of $1.1 billion is requested in 2014 for VA's major and
minor construction programs. The capital asset budget reflects VA's
commitment to provide safe, secure, sustainable, and accessible
facilities for Veterans. The request also reflects the current fiscal
climate and the great challenges VA faces in order to close the gap
between our current status and the needs identified in our Strategic
Capital Investment Planning (SCIP) process.
Major Construction
The major construction request in 2014 is $342 million for one
medical facility project and three National Cemeteries. The request
will fund the completion of a mental health building in Seattle,
Washington, to replace the existing, seismically deficient building. It
will also increase access to Veteran burial services by providing a
National Cemetery in Central East Florida; Omaha, Nebraska; and
Tallahassee, Florida.
The 2014 budget includes $5 million for NCA for advance planning
activities. VA is in the process of establishing two additional
National Cemeteries in Western New York and Southern Colorado,
according to the burial access policies included in the 2011 budget.
These two new cemeteries, along with the three requested in 2014, will
increase access to 550,000 Veterans. NCA has obligated approximately
$16 million to acquire land in 2012 and 2013 for the planned new
National Cemeteries in Central East Florida; Tallahassee, Florida; and
Omaha, Nebraska.
Minor Construction
In 2014, the minor construction request is $715 million, an
increase of 17.8 percent from the 2013 enacted level. It would provide
for constructing, renovating, expanding and improving VA facilities,
including planning, assessment of needs, gravesite expansions, site
acquisition, and disposition. VA is placing a funding priority on minor
construction projects in 2014 for two reasons. First, our aging
infrastructure requires a focus on maintenance and repair of existing
facilities. Second, the minor construction program can be implemented
more quickly than the long-term major construction program to enhance
Veterans' services.
In light of the difficult fiscal outlook for our Nation, it's time
to carefully consider VA's footprint and our real property portfolio.
In 2012, VA spent approximately $23 million to maintain unneeded
buildings. Achieving significant reduction in unneeded space is a
priority for the Administration and VA. To support this priority, the
President has proposed a Civilian Property Realignment Act (CPRA),
which would allow agencies like VA to address the competing stakeholder
interests, funding issues, and red tape that slows down or prevents the
Federal Government from disposing of real estate. If enacted by
Congress, this process would give VA more flexibility to dispose of
property and improve the management of its inventory.
legislation
Besides presenting VA's resource requirements to meet our
commitment to the Nation's Veterans, the President's budget also
requests legislative action that we believe will benefit Veterans.
There are many worthwhile proposals for your consideration, but let me
highlight a few. For improvements to Veterans healthcare, our budget
includes a measure to allow VA to provide Veterans with alternatives to
long-stay nursing homes, and enhance VA's ability to provide
transportation services to assist Veterans with accessing VA healthcare
services. Our legislative proposal also request that Congress make
numerous improvements to VA's critical homelessness programs, including
allowing an increased focus on homeless Veterans with special needs,
including women, those with minor dependents, the chronically mentally
ill, and the terminally ill.
We also are putting forward proposals aimed squarely at the
disability claims backlog--such as establishing standard claims
application forms--that are reasonable and thoughtful changes that go
hand-in-hand with the ongoing transformation and modernization of our
disability claims system. We are offering reforms to our Specially
Adaptive Housing program that will remove rules that in some
circumstances can arbitrarily limit the benefit. The budget's
legislative proposals also include ideas for expanding and improving
services in our National Cemeteries.
Finally, this budget includes provisions that will benefit Veterans
and taxpayers by allowing for efficiencies and cost savings in VA's
operations--for example, we are forwarding a proposal that would
require that private health plans treat VA as a ``participating
provider''--preventing those plans from limiting payments or excluding
coverage for Veterans' non-service-connected conditions. VA merits
having this status, and the additional revenue will fund medical care
for Veterans. We are also requesting spending flexibility so that we
can more effectively partner with other Federal agencies, including
DOD, in pursuit of collaborations that will benefit Veterans and
Servicemembers and deliver healthcare more efficiently.
summary
Veterans stand ready to help rebuild the American middle class and
return every dollar invested in them by strengthening our Nation. And
we, at VA, will continue to implement the President's vision of a 21st
century VA, worthy of those who, by their service and sacrifice, have
kept our Nation free. Thanks to the President's leadership and the
solid support of Congress, we have made huge strides in our journey to
provide all generations of Veterans the best possible care and benefits
through improved technology that they earned through their selfless
service. We are committed to continue that journey, even as the numbers
of Veterans using VA services increase in the coming years, through the
responsible use of the resources provided in the 2014 budget and 2015
advance appropriations requests. Again, thank you for the opportunity
to appear before you today and for your steadfast support of our
Nation's Veterans.
Senator Johnson. Thank you.
For the information of my colleagues, we will limit
questions to 6-minute rounds to ensure that everyone has a
chance to be heard. If needed, we will have a second round.
BLACK HILLS
Secretary Shinseki, I was surprised to find that the fiscal
year 2014 budget request includes a request for an
authorization for a new residential rehab treatment facility
and multispecialty outpatient clinic in Rapid City, South
Dakota. This goes against your repeated assurances to me and
other members of the South Dakota delegation, and our
constituents, that a final decision has not been made regarding
the VA's proposed realignment of Black Hills' healthcare
systems.
How can we believe that you are honestly still considering
other alternatives when the budget sets the VA's proposal in
motion?
Secretary Shinseki. Chairman Johnson, let me apologize for
the language that appears in the budget submission on Black
Hills. It wasn't appropriate, and it's an oversight on our
part.
As you and I have agreed, this is a dialogue that's
underway. I assure you I have not made a decision, and this is
also proof that I don't read every line in the budget. It
shouldn't have been there, and next time I'll be more thorough.
Senator Johnson. Do you intend to notify the authorization
committees that this was a mistake?
Secretary Shinseki. I will do that.
VETERANS BENEFITS MANAGEMENT SYSTEM (VBMS)
Senator Johnson. One of the key elements in the VA's
strategy to break the claims backlog is the successful
deployment of the VBMS, or paperless claims processing system.
I noted from your testimony that the Department plans to have
this system deployed by 2013. However, I'm concerned about
reports of the system's performance failures.
Will VBMS be deployed on time? Will it work? And when can
we expect tangible results from its implementation? In other
words, when will this system speed up the process for vets?
Secretary Shinseki. Mr. Chairman, let me assure you that
VBMS works. As I indicated, we had set in our plan by December
2013 to have it fully fielded. We began fielding in September
2012 and here we are, 6 months later, in 36 of our 56 regional
offices. We intend to complete fielding to the remaining 20 as
soon as we can. I am confident that it's not going to take us
until December.
I believe the reference to the problem that you're hearing
about is the last issuance of VBMS. We started with VBMS 1.0,
and then 2.0, and 3.0. We just fielded 4.2, which has probably
100 patches associated with it. One of them wasn't functioning
properly. Everything else went.
We held this off because it wasn't performing the way we
wanted and it was creating some concern. We held it off for a
week and retested it. It is finally now updated with 4.2. We're
on schedule, and it's functioning.
ACCESS TO VA
Senator Johnson. Mr. Secretary, the budget request includes
an additional $158 million for medical services in fiscal year
2014, of which $85 million is projected to impact the
Affordable Care Act (ACA) on the VA healthcare system. Is this
funding intended to implement any aspect of the ACA?
As I said, the ACA is expected to bring more eligible vets
into the VHA healthcare system, more specifically, vets who do
not currently have health insurance. Will this help VA's goal
to give more eligible vets access to VA healthcare?
Secretary Shinseki. Mr. Chairman, I'm going to call on Dr.
Petzel here in a second to provide some details, but I'd like
to be very clear up front.
VA will continue to provide eligible veterans with high-
quality care, comprehensive healthcare, and benefits they have
earned. That will not change.
We do modeling whenever we think there's going to be a
major change in the delivery of a service. Through our
modeling, it was suggested that we might have a modest
increase. The $85 million is put in there to be prepared in
case this is realized.
I will assure you that the veterans who are currently using
VA will see no degradation in the quality or the timeliness of
the service they receive.
Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary.
Mr. Chairman, as the Secretary relayed, the Affordable Care
Act will not affect the care that we deliver to veterans. As he
said, there is a modest increase that may occur as a result of
the implementation of it.
There are two aspects to the Affordable Care Act, just very
briefly: First is the mandate that one have insurance; the VA
healthcare system does provide the minimum essential coverage,
as does our CHAMPVA program. Second is the effects that it may
have on Medicare.
When we looked at those two aspects of the Affordable Care
Act and evaluated the potential impact on VA, as the Secretary
has mentioned, the indications were that there may be some net
increase in the number of people moving to the VA. Thus, the
$85 million is to cover the cost of that increased care.
Senator Johnson. Senator Kirk.
Senator Kirk. Let me do a drill down here since the ACA
might be somewhat controversial.
You guys are basically saying, for an Illinois veteran who
has signed up to the Illinois exchange, it's more likely they
seek care in the VA, is what you're estimating?
Secretary Shinseki. I wouldn't say we have specifically
focused on Illinois. I think it has to do with whether States
make decisions regarding Medicaid, or not.
Senator Kirk. I am going to interrupt you one second.
Usually, my questions kind of tend to the State of Illinois.
Secretary Shinseki. Yes, I know. I'm not familiar with
where Illinois stands on its decision.
It was based on those decisions by States that, we thought
there might be an influx, a slight influx of veterans.
CLAIMS BACKLOG
Senator Kirk. I will massively suck up to my chairwoman and
ask about Baltimore, where, I understand, Madam Chair, I
understand that we're up to 380 days for adjudication of VA
disability in Baltimore. I think you're extremely concerned
about Baltimore veterans.
Senator Mikulski. I'm hot about it. But, please, go ahead.
Senator Johnson. Go ahead.
Senator Kirk. Thank you, Mr. Chairman.
I just want to say one thing. I understand that in Chicago,
it is at 431 days, and we would want to shorten it, as you have
laid out.
Secretary Shinseki. Senator Kirk, I'll just say that this
is something we've been working on for a number of years now.
We were, 4 years ago, a paper process. And it's a huge
paper juggernaut. We get paper from DOD. We process paper. We
get claims submitted in paper. That's traditionally the way
things are done.
After over a decade of war now, requirements have gone up.
There's greater complexity. If we're going to end the backlog,
we have to do something different than just to continue to
process the way we have been.
What we have done is approach DOD and ask for electrons.
They have agreed that, by the end of this year, they're going
to begin sending us their records in electrons. Also veterans
need an online capability to submit claims electronically. We
are now providing that.
We have about 800,000-plus claims today already in our
inventory. We're taking the ones that it's smart to do and
putting them through a scanning process, creating electrons to
be stored into our electronic tool as we stand the system up.
There are some that are already started in paper. It makes
sense to just finish them in paper. So we're just going to suck
it up and keep driving on.
But at the same time, now we need a catcher's mitt to
gather all these electrons, and that's what VBMS is about. It's
taken us about 2 years to develop. Six months ago, we started
fielding it. As I said before, here we are 6 months later,
we're at 36 out of 56.
This comes together this year. It's what we've been
planning. The increase in the number of claims in the inventory
is a set of decisions we made in 2010 that was intended to
clean up some unfinished business.
This was Vietnam veterans, and agent orange with three
diseases were added to the workload. These were new adds, not
anything that VA had been resourced to deal with. Desert Storm
1 had nine diseases associated with gulf war illness that were
added to the workload; more paper workload.
Finally, for combat veterans, post-traumatic stress
disorder (PTSD) is as old as combat. What we have done is to
just say, if you have verifiable PTSD and you've been in
combat, then whatever other reasons there may be, this is good
enough. Let's go ahead and take care of our responsibilities
here.
Those three decisions have added to the inventory.
Three years ago, when we made the decision, in testimony we
said, ``Look, this is going to grow the inventory, but we're
going to build an automation tool that in time will take this
down.'' I think we even predicted that the number of waiting
days was going to go up fairly high.
It has. All of that's borne out. It doesn't excuse the fact
that veterans are waiting too long for decisions. I am
committed to ending the backlog and correcting all of this.
That's why this year's budget, it increases VBA, our
benefits administration, by 13.6 percent, and increases the
information technology tool, VBMS, among others. Increasing the
information technology (IT) budget by 10.8 percent is critical
for us to make this crossover from what has been a paper
process to a digitized one.
Senator Johnson. The chairwoman of the full committee has
joined us. At this point, I want to welcome her, and call upon
her for any statement or questions she may have.
Chairwoman Mikulski.
Senator Mikulski. Thank you very much, Senator Johnson. And
thank you for the great job you've been doing.
And, Senator Kirk, it's so good to see you back at the
table.
I used to chair the VA in the old VA-HUD days, so it's deja
vu to rejoin you at the table.
And I wanted to come and just, first of all, affirm my
support for both of you. And I note that the President has
submitted a Department of Veterans Affairs appropriations
request of $152.7 billion.
This is the number three subcommittee under the entire full
committee. Number one is Defense at $600 billion. Then there's
HHS-Labor, which is really three agencies. And then the
Department of Veterans Affairs itself at $152.7 billion.
$86 billion of that is in mandatory. $63 billion of that is
in discretionary. And then there's $3 billion in third-party
collections.
So there's a tremendous amount of money and resources that
we need to ponder in what is the most effective way to work
with the executive branch to serve our veterans.
I want you to know, we intend to follow regular order. We
hope to mark up at a topline of the $1.05 trillion, which is
mandated by the Budget Control Act. The House Budget Act number
is $966 billion, so there are some resolutions that need to
occur.
But we're going to work together on this and work with you
on how you want to do this.
BALTIMORE REGIONAL OFFICE
So I wanted to come to affirm our support for working
together. But like you, I'm ballistic about this backlog, and I
was mortified over the fact that Baltimore was one of the top
worst claims areas in the entire Nation.
Senator Kirk, you already gave some of the numbers. But we
were in the top three of a very embarrassing list.
Now, General Shinseki, you came to Baltimore, and I
appreciated that, with your team. And then you made certain
promises, which are being followed through.
But what happened is, that as you said now, the entire
Baltimore office is being shut down for training. Are you aware
of that?
Secretary Shinseki. I'm not aware they've been shut down.
My understanding is they're continuing to process claims.
Training has been integrated into their day-to-day work.
Senator Mikulski. Well, sir, that's not the way it is on
boots on the ground.
The entire Baltimore office is now in training. There is
one person answering the phone--one person answering the phone.
Now, there were 10 people on the phone to answer our
questions, 10 people from there. We can't have this, that we're
going to shut down a whole office so they're more fit for duty,
which we like the training, which you said you would do, and
we're excited about that. But we can't shut it down. Or if we
can, we need you to send temporary claims processors to
Baltimore to take in the cases and begin the methodology that's
established while this 4-week training is going on.
Secretary Shinseki. I understand we have help teams that
have been added to Baltimore. Let me ask Secretary Hickey for
some details.
Ms. Hickey. Chairwoman Mikulski, my apologies to you. There
was some miscommunication, I believe, to you about the nature
of what was happening in Baltimore. So I will accept
responsibility for that miscommunication.
There are 4 hours a day where they are literally still
working claims. The other 4 hours, they are in a class, but
while they're in that class, but they're working live claims
that belong to the Baltimore regional office.
That's the way the training is designed. It's designed so
they actually work claims, and they go through a training
process while that happens.
In the meantime, I know about your concern, and I'm very
sensitive to that concern. We are continuing to get the support
of three other regional offices, as I committed to you, to
ensure that the Baltimore backlog is coming down. They continue
to do those claims and are still working them.
We are also looking to see if we can bring one more team in
while they're working in the training environment to supplement
the additional support during the training period.
I will share with you that we have already seen production
increases in Baltimore since we visited with you. I appreciate
your taking time out of your schedule to visit Baltimore.
Not only increases in production have been seen, but also
increases in the quality, as a result of bringing in some of
those help teams, with subject-matter experts who come in and
help coach, and facilitate some improvements in Baltimore.
Senator Mikulski. Well, I think we need to talk about it. I
don't want to take the time of the subcommittee.
There has been a breakdown in communication. And there's a
breakdown in communication even in the way the director of that
office talks with us. He was silent on the phone.
When we asked, ``Where would these records go?'' we heard
they were in the cloud. Nobody could tell us where these
records were going. We're not happy.
But rather than go on and turn this into a discussion on
Baltimore, what I fear is that this is the problem everywhere,
and not only a backlog, but then the lack of communication.
Yes, they do work in the afternoon, but we hear it's a very few
set of coaches with a very few set of cases with coaches.
So let's really talk and get this straight, and let's not
take the time.
COLLABORATIONS
I'd like to go nationally, and if I could, General
Shinseki, did I hear you right--and it goes to what we're all
raising--we understand that in order for VA to do their job,
they need the cooperation of four other agencies, plus the
National Guard. They need the cooperation of VA, the Social
Security Administration (SSA) to send you records, and, to a
certain extent, the Internal Revenue Service (IRS). Is that
correct?
Now, in the hearing, does VA really cooperate with you? Or
you don't want to say, because you're a good guy, and used to
be in the chain of command, and hoorah, hoorah?
Secretary Shinseki. No. Madam Chairman, I would tell you
that I spent 38 years in uniform, as you know. In all that
time, I knew there was a VA, but there was almost no
interaction between my duties in uniform and the Department.
And so when I became Secretary of this Department, I
realized how little education I had received. One of the first
things that Secretary Bob Gates and I did was to agree, with a
handshake as we were standing in line waiting to be sworn in to
our respective duties, to bring our departments together.
And so it began with Bob Gates. It continued with Leon
Panetta. It continues now with Secretary Hagel.
The whole point is that our departments culturally look in
two different directions. That's not good enough. We are
working to bring our departments into greater synergy.
Part of that has to do with this seamless transition that
we talk about, which includes getting electronic records from
DOD, and allowing us to match up.
Senator Mikulski. Well, is that happening?
Secretary Shinseki. In terms of information that arrives
for us to be able to use, with personnel records, we have an
agreement with DOD that by December of this year, 2013, we will
begin to receive electronic records.
We're working on--and this is probably the more critical
one--a single, common, joint, integrated electronic health
record that is open in architecture and nonproprietary in
design. All those terms are code word to force us to come up
with a single system that applies to both departments.
ROUNDTABLE
Senator Mikulski. Thank you.
Mr. Chairman, Senator Kirk, colleagues, I'm going to
suggest this, as the full committee chair, the subcommittee
does their business, and they've been doing a great job on
this. But as the full committee chair, I thought I would
convene a roundtable of the four agencies that have to serve
our veterans, and actually get Hagel in the room with Shinseki,
and their assistant deputy coordinator of the health records,
and techno-micro-chips. Does this sound like a good idea?
Senator Kirk. That sounds like an awesome idea. We get both
secretaries in here to explain why we haven't combined the two
systems.
And I would give you a little partisan edge on that, a
partisan edge. By that I mean, in VA versus DOD, and just say
that I don't understand why the taxpayer has to pay for two
totally separate systems.
And I want DOD to insist on why they need to have a
separate system, that I think we should go date-certain with
just VistA, which is the VA system, and force DOD to say why we
have to slow down and have a separate system.
Senator Mikulski. Well, this subcommittee has been the
driving force. I thought we could get DOD, bring Social
Security and IRS in. And I'd really love for Appropriations to
be the committee that cracks the code on the VA backlog. It
would be a great tribute to you as a veteran.
Senator Johnson. Madam Chairwoman, that is an excellent
idea. The details need to be figured out, but I'll take charge
of that.
Senator Mikulski. Yes. And we look forward to working with
you to do that. Thank you.
Senator Johnson. Senator Reed.
Senator Reed. By order of appearance, or if it's back and
forth, I'd be happy to yield to one of my colleagues.
Senator Johnson. Senator Kirk had the last comments. I'll
turn to Senator Reed.
Senator Reed. Thank you, Mr. Chairman.
Thank you, Mr. Secretary.
TRANSITION ASSISTANCE
I have a series of simple questions, which might actually
be pretty dumb questions. But is entry into the VA automatic
upon discharge from the service? Or does a discharged military
person have to formally apply to VA?
Secretary Shinseki. Today, it is not automatic. But this is
what the Secretary of Defense and Secretary of VA are working
on.
As you know, the Department of Defense has a transition
assistance program. That is their transition program.
We have included ourselves in that process before the
uniform comes off. Whatever claims that need to be addressed,
we want to start that early.
Senator Reed. It just seems to me, Mr. Secretary, and, you
know, you said you spent 38 years in Active Duty. The day you
raise your hand as an E-1, or whatever, you're probably going
to be a veteran with perhaps 1 percent, 2 percent deviation
there.
Have we missed the focus? Shouldn't we be looking not at
the transition point from active service to another service,
but actually the point of induction, or basic training?
Secretary Shinseki. We agree. That's what we've been
working on. Today, we at VA, have created an eBenefits
automation tool. As young men and women are being inducted into
the military, they have access to that tool.
As you know, they participate in some of our education
programs, and mortgage programs. For the military, with
servicemembers group life insurance, we are their insurer.
So this ought not to be a decision to be made when the
uniform comes off. It ought to be seamless. It ought to be
mandated. Making that commitment is all about what the
electronic health record is designed to do.
Senator Reed. Does that require any further legislation, or
that's within your authority today to enroll? Pick an obvious
point, completion of basic training, you're enrolled in the VA
system. You get information, you're eligible for some programs,
but not all programs. Can you do that?
Secretary Shinseki. I would say there's a certain
definition, a time of service, before a requirement for
veterans status is rendered. Then, as you know, depending on
the character of discharge, that status could change.
Senator Reed. Right, but that's----
Secretary Shinseki. I'm not expert enough on it for an
answer today. Let me give you an answer for the record. I think
what we're getting at here is, let's make this truly seamless
between the departments, and I think we can work on that.
[The information follows:]
VA strives to reach out to all separating servicemembers to ensure
they are aware of and can access VA benefits, healthcare and other
services. As an example, VA sends a personalized letter to all recently
discharged veterans reminding them of these benefits.
In August 2011, the President called on the Department of Defense
(DOD) and Veterans Affairs (VA) to lead a task force with the White
House economic and domestic policy teams and other agencies, including
the Department of Labor (DOL), to develop proposals to maximize the
career readiness of all servicemembers. This DODVA Veterans Employment
Initiative Task Force is one element of the plan to reduce veteran
unemployment and to ensure that all of America's veterans have the
support they need and deserve when they leave the military, look for a
job, and enter the civilian workforce.
To meet the President's call for a ``career-ready military,'' the
DOD-VA Veterans Employment Initiative Task Force developed a new
training and services delivery model to help strengthen the transition
of our servicemembers from military to civilian life as they become
veterans. This revamped TAP curriculum, named Transition Goals,
Planning, Success (Transition GPS), is meant to provide servicemembers
with a set of value-added, individually tailored training programs and
services to equip them with the set of tools they need to pursue post-
military goals successfully. This model represents an improved DOD/VA/
DOL Transition Assistance Program (TAP). The new model was implemented
in November, 2012 and is consistent with Public Law 112-56, the VOW to
Hire Heroes Act of 2012 (VOW Act) which requires mandatory TAP
participation of members of the Armed Forces. This has significantly
increased VA healthcare benefits awareness and application
opportunities for all separating servicemembers. Long before these
changes, VA has had a long standing effort in place to assist veterans
with enrollment into VA healthcare system through participation in
various DOD demobilization events. An application for healthcare
benefits, named the 10-10EZ, must be completed by all veterans to
enroll in VA healthcare. As part of the outreach activities, VA works
directly with transitioning servicemembers to complete this form. It
can also be completed via the Internet and over the phone.
In addition, we now enroll every new servicemember in eBenefits as
part of the mandatory TAP enrollment. eBenefits is the highly
successful VA and DOD online Web site/portal providing a central
location for veterans, servicemembers, and their families to research,
find, access, and manage a growing list of benefits and personal
information such as certificates of eligibility for VA home loans,
Post-9/11 GI Bill enrollment information, and service verification (DD
214).
The below Federal Register notice regarding ``Duty Periods for
Establishing Eligibility for Health Care'' below shows the complexity
of the question/response.
https://www.federalregister.gov/articles/2013/05/09/2013-11051/duty-
periods-for-
establishing-eligibility-for-health-
care?utm_campaign=subscription+mailing+list
&utm_medium=email&utm_source=federalregister.gov
The Virtual Lifetime Electronic Record (VLER) project being worked
on by VA and DOD will allow VA, DOD, and others to easily share
information on servicemembers and veterans and enable VA to provide
proactive care and benefits to veterans that they have earned and
deserve. The end goal of VLER is to share health, benefits, and
administrative information, including personnel records and military
history records, among DOD, VA, HHS, SSA, private healthcare providers,
and other Federal, State, and local governmental partners; and enable
caregivers, clinicians, and benefits providers to view all relevant
information about a veteran securely, regardless of where it was
documented, in a secure, electronic record.
Senator Reed. Well, again, I think the sooner you do it,
not the discharge point but the point where that young man or
woman is going to be presumably on Active Duty for 3 years,
then become a veteran, gives you more time and actually
acclimates them to the system.
INTEGRATED DISABILITY EVALUATION SYSTEM (IDES)
Let me shift gears, basically. The Integrated Disability
Evaluation System (IDES), which you're working on, ideally--
unfortunately, we had two systems.
We had a DOD evaluation of your disability, and then we had
a separate VA system, and that was regulatory arbitrage, et
cetera. And it didn't help the veterans. Now you're trying to
make an integrated system. That's the goal.
I'll just ask another sort of dumb question. If you have
that integrated disability system, if you have actually
assessed that individual, before they leave the service, why
would they technically have to make a claim? Couldn't you
automatically make the benefits available to them based upon
their evaluation?
Secretary Shinseki. I would agree that I think that sort of
approach makes sense, but I think we have a requirement to make
sure we do a complete investigation and consult with the
individual on their disability.
There may be things that are not in the record. I'm
thinking of the kinds of things some youngsters may prefer not
to be in the record. Just looking at the record alone may not
be complete enough.
We want to give veterans an opportunity to lay out the
things that they may have masked for----
Senator Reed. Well, you have as much sensitivity to how
soldiers, sailors, marines, and airmen think and act than
anyone in this room.
But it seems to me that if the goal is to have one
evaluation complete of their health, psychological, physical,
et cetera, it might not be fully complete because of lack of
disclosure, but at least that's a starting point for automatic
benefits.
CLAIMS EXAM
Now, subsequently, and it could be 5 years later, if
someone discovers that they have a condition they weren't aware
of, well, that is the time for a claim. But I would think that
would speed up the process and be more rational.
What I observed and what you observed, too, is it was sort
of people were trying to get the highest possible DOD
disability evaluation before they left so that they were--you
know, they wanted to leave but they didn't want to leave. They
were in that situation. Then they had to go through a whole
separate process at the VA.
It just doesn't seem to be efficient nor helpful for
veterans.
Secretary Shinseki. Well, Senator, we have moved to the
single exam, a separation exam, and tried to reduce as much
overlap on these things.
There was a little difference when we conducted two
separate exams. The youngster who wants to remain in uniform
wants the lowest percentage adjudication. The youngster who's
getting out wants the better one. And so I can understand why
there may be a different approach in DOD.
Once the decision is made that the youngster is not going
to be able to be retained for whatever medical reason, then the
single exam, which is the way we've gone, by VA, will govern
both decisions, both their departure and then their arrival to
us.
Senator Reed. Again, thank you, Mr. Secretary. My time has
expired. Thank you for your service. Thank you, ladies and
gentlemen.
Senator Johnson. Senator Hoeven.
Senator Hoeven. Thank you, Mr. Chairman.
And, Secretary Shinseki, thanks for being here. Thanks for
the meeting in your office recently with Senator Collins and
Senator Murkowski. I thought it was very helpful and appreciate
you taking time to do that, as well as your commitment to our
veterans, your service and your commitment to our veterans.
Also, I appreciate very much that you've come out to the VA
Health Center in Fargo, which serves a lot of North Dakota and
Minnesota as well, and I think does a phenomenal job.
LEASE
One of the things that's been really important for us is
getting another outpatient clinic in Devil's Lake, North
Dakota, and I've talked to you about this before.
And I believe, as a follow-up, your staff indicated to me
that they're planning to have a lease in place for that
facility in August of this year, and then have it open by
December.
I want your commitment that we're going to get it open this
year. We've been working to get that for some time and maybe
just comment on the length of time it takes, because last year
we talked about getting it, which, again, we appreciate very
much and that they're very much looking forward to in Devil's
Lake, but just your comments on the length of time or what's
required to set it up and, hopefully, a commitment that we'll
have it in place this year.
Secretary Shinseki. Let me call on Dr. Petzel for the
opening.
Dr. Petzel. Thank you, Mr. Secretary.
Senator Hoeven, we've been talking about the clinic at
Devil's Lake since I was a Network Director in Minneapolis,
which goes back a couple of years. There have been difficulties
in coming to an agreement about the kind of clinic, et cetera.
That's on track now, and we expect to make an award for
space in August 2013. The planned occupancy is December 2013.
I will keep track of that, and we will provide feedback to
your staff periodically about how we're doing with that
timeline.
Senator Hoeven. Thank you, I appreciate it. We're very much
looking forward to that facility. It'll make a real difference
for our veterans. And so, if you will stay in touch with us on
it, I'd appreciate it very much.
SUICIDE PREVENTION
The other thing, Mr. Secretary, I'd like to just touch on
again, two of the things that we've been working on I know
you're very dedicated to as well, on behalf of our veterans,
are both suicide prevention and also dealing with PTSD.
Would you talk about how in this budget we're doing more to
make sure that we're addressing these very serious challenges
on behalf of veterans, both the suicide prevention and
addressing their needs in regard to PTSD?
Secretary Shinseki. Senator, let me start and then let me
ask the good doctor, Dr. Petzel, to comment on our approach to
suicides.
I would just say up front, one suicide is a tragedy and
it's one suicide too many.
We go at this with a lot of energy and, as you know, we
have put in place a national crisis line for veterans in
Canandaigua, New York. In the last 5 or so years, there have
been over 740,000 phone calls.
I think important in that number is that more than 26,000
of them were suicides in progress. They were intervened and
people were taken care of.
We've watched the numbers of calls continue to go up but
the number of crisis calls have begun to taper off a bit. What
we interpret here is that calls are coming in earlier as
opposed to in crisis. People are being referred to treatment.
The treatment they're receiving works.
We're watching our suicide numbers, which are still high at
22, that is a rate of 22 a day, staying flat and not
necessarily spiking, as we have seen elsewhere.
We believe we have a good set of treatments and the
opportunity to medicate folks properly.
Let me call on Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary.
Again, Senator Hoeven, suicide is a national tragedy, and
suicide amongst veterans, I think, is even a deeper tragedy.
This, PTSD, and depression are the results of their service
experience and are sort of the unseen wounds of war.
I think we have a tremendous obligation in the VA to find
ways to deal effectively with these things.
Just briefly, our mental health budget is $7 billion. We're
going to be spending almost $500 million more this year in 2014
rather than we have spent this last year.
In terms of PTSD, there are about 500,000 veterans with
that diagnosis, 119,000 of them come out of this present
conflict. We'll be devoting, again, about $500 million to those
veterans and their treatment.
We, in addition to that, have a research budget of almost
$49 million in PTSD research within VA itself, and then a
cooperative effort with DOD that takes $50 million from the VA
and $50 million from DOD over a period of 5 years and combines
into two research projects on PTSD and traumatic brain injury
(TBI).
OUTREACH
Just a few words about suicide, the VA has a highly
integrated approach to suicide, and we're fortunate that we
have this national system that allows us to do this level of
integration that you can't necessarily do in other venues. For
veterans, we have the crisis hotline and, as the Secretary
mentioned, it has been very effective. Almost 800,000 calls and
26,000 rescues; people prevented from harming themselves who
were in danger of harming themselves.
We have suicide prevention coordinators at every single one
of our medical centers and a team of both outreach and case
management mental health professionals for people that are
deemed to be at high risk for suicide.
Then we have a public service campaign that we're involved
in, in combination with the Department of Defense, to, pardon
the expression, destigmatize suicide and destigmatize mental
health. It's called, ``Make the Connection,'' and it's
vignettes by people who have suffered from mental illness or
have attempted suicide, urging people to make that connection
with the VA, telling them that this is not something that they
should view with trepidation, et cetera.
It's been a very effective campaign, and I think it has
been responsible for the fact that we've seen about an 88,000
veteran increase in the number of people we're treating for
mental health.
Senator Hoeven. Doctor, thank you.
And, Secretary, this absolutely has to be an area of
emphasis, along with your emphasis on homelessness. I encourage
you to involve the veterans groups. I think they're tremendous,
can be a big help for you in this area. And, of course, share
my concern on the disabilities claims, and I know you're
working on that very diligently and know how important it is.
But this area of suicide prevention, PTSD, as well as
homelessness, has to be an area of emphasis. And hopefully,
you'll reach out to the veterans groups and get them to help,
too. I think it's a tremendous network.
Secretary Shinseki. We will do that outreach, Senator. Just
to underscore how important we think it is, I think Dr. Petzel
said very quickly that, in mental health this year, our budget
is over $7 billion for mental health alone. If we were to look
back from 2009 to the 2014 timeframe, our investments in mental
health have gone up nearly 57 percent.
So this is an area of importance to us, and we will
continue to emphasize that care.
Senator Hoeven. Thank you.
Senator Johnson. Senator Udall.
Senator Udall. Thank you, Chairman Johnson.
And thank you, Secretary Shinseki, for being here today and
bringing your very able team to appear before us.
And let me say, from my perspective, I very much appreciate
your many years of service both in and out of uniform. And I
also appreciate the time you took to spend with me talking
through New Mexico veterans issues and veterans around the
country.
New Mexico is a very rural State. And as you're aware from
our discussions, in rural New Mexico, as well as rural areas
throughout the country, it can be very difficult to recruit
doctors and nurses and staff to serve in rural clinics,
including VA clinics.
RURAL VA CLINICS
What is the VA currently doing, and how will this budget
support the recruiting and retention of qualified personnel to
serve at rural VA clinics?
Secretary Shinseki. Let me call on Dr. Petzel about the
recruiting and retention efforts.
Dr. Petzel. Thank you, Mr. Secretary.
Senator Udall, you put your finger on an issue that is
important to us, and that is being able to provide medical care
in rural America. Forty percent of our veteran population lives
in rural or highly rural areas. There's a cascade of things
that we do. Let me just quickly go through them.
Number one, we have community-based outpatient clinics, 121
of those clinics around the country. We have the vet centers,
which are scattered into some very rural areas, and the mobile
vet centers, 70 of them that can go out to other areas.
The largest growing way that we do this is telehealth. And
I am getting at the recruitment. We are the largest purveyor of
telehealth in the country, and we are now setting up separate
individual telehealth clinics where we have a clinical
professional, perhaps not a physician, at a site where patients
can come in and be connected to their provider via telehealth.
It would be a primary care or specialty care.
It began in Colorado, and now it has spread across the
country. It's one of the things that we're going to be using in
New Mexico to help us supplement the care that we're delivering
in rural America.
In terms of recruitment----
Senator Udall. Dr. Petzel, let me stop you there. So, even
for primary care, you're using telehealth?
Dr. Petzel. We can. Yes, sir.
Senator Udall. And when you do that, have you taken a
reading of satisfaction of vets with doing telehealth for
primary care? I mean, I'm wondering from a perspective of
seeing that most people like to meet with their doctor in
person. And I can understand, and I think everybody can, the
telehealth for specialists and things like that.
But as you do that, I think it's very important that you
try to take the temperature of veterans in terms of how they
feel about not ever seeing an actual doctor in person.
And that's the thrust of this question of mine, because
when you see the clinics, at least in New Mexico and I bet this
is across the country, what happens is you'll have big gaps.
They'll lose a doc, and then it will be 18 months or 2 years
before you're able to get another doctor.
And so if you can fill it with telehealth, that's fine, and
have a good satisfaction level, but the thrust of my question
is really going to the recruitment of docs into these areas.
And maybe the mobile option you're talking about is a good
one, too. The reality is many of these doctors and other
professionals don't want to live in these rural areas, and so
it's very hard to get them there.
And you may want to try to team up with the medical
schools. I mean, we have a big problem in New Mexico because
our medical school on the day of graduation--we invest in all
this; the State of New Mexico puts in money--75 percent of our
graduates leave the State on that day of graduation. And so
we're trying to work with them to see how do we keep the people
there, and then how do we also get them in rural areas.
Please, go ahead.
Dr. Petzel. Senator, just a quick word about the telehealth
clinics. The patients love it. They like it because, number
one, there is a clinician there. There's a clinical person,
usually an R.N., but they don't have to drive 80 miles or 100
miles to see their doctor. They can see this person face-to-
face.
Many of the things that you would do in a visit face-to-
face are done. Blood pressure is transmitted electronically, an
EKG, et cetera. So the satisfaction levels are higher than we
see in our clinics.
Now just briefly about recruitment, salary is an important
thing. We have tremendous flexibility in terms of salary.
Providing the support around that physician is important, and
we can do that.
We don't have any more difficulty, generally, recruiting
into highly rural areas than the communities do. It's just a
very difficult task to get people who haven't lived in a small
town to come to a small town, and their wives have some
influence on doing that, too.
We are looking at scholarships to individuals where we
select people that come from rural communities, provide them
with support while they go through medical school, and they
have an obligation then to us for a period of 3 or 4 years,
depending on how long we've been providing them a scholarship,
to go back to a rural community. I think that's going to be
very effective.
Your medical school in New Mexico, I think, is doing some
of those similar things.
Senator Udall. Yes, they are. They are.
TRANSPORTATION
Just quickly, my second question was about the travel that
veterans--you know, many times in New Mexico they have to
travel 5 and 6 hours to get to the VA center in Albuquerque,
sometimes spend the night, and then come back. And it takes a
person from the family or others to take time to drive them
when they're older.
I assume telehealth is some of the answer there, but part
of my question is to ask about what this budget does to
increase transportation options for vets, in terms of trying to
travel up to get specialized care in these centers.
Dr. Petzel. Thank you. That is an excellent question.
The budget has in it money for the Veterans Transportation
Network, which is a network that the VA is setting up to
provide transportation services in these rural areas.
In addition to that, there's a second element, and that is
grants to other organizations, usually service organizations,
to provide transportation for veterans.
So there's a substantial--I would have to get back to you
with the exact amount--there's a substantial amount of money in
there to provide transportation services in these rural areas.
[The information follows:]
The budget provides money for the Veterans Transportation System
(VTS), a network that VA is setting up to provide beneficiaries not
otherwise eligible for VA travel benefits and with access issues,
including those in rural areas, a way to transport to VA healthcare.
Transporting veterans to specialized care is enabled through the use of
American Disability Act vehicles supplied by VTS. Such vehicles have
the capability to transport veterans requiring wheelchair, scooter or
needing boarding assistance: all vehicles are equipped with passenger
lift ramps. VA currently funds VTS staff and vehicles at 44 facilities
with an additional 20 facilities scheduled to begin implementation this
fiscal year. VA hopes to have VTS system-wide by 2015. VA has included
this initiative in the fiscal year 2014 President's budget request. In
2012, Congress authorized this program for 1 year. In the fiscal year
2014 budget, VA has requested that Congress extend this authorization.
Without the proposed extension, it is possible that VTS will need to be
significantly reduced or curtailed in January 2014, particularly in
rural areas of the country. S. 455 and H.R. 1702 in the House have been
proposed to resolve this issue.
In addition, the Grants for Transportation of Veterans in Highly
Rural Areas program, created in response to a congressional mandate in
section 307 of Public Law 111-163, will provide grants to eligible
entities to assist veterans in highly rural areas through innovative
transportation services to travel to VA medical centers, and to
otherwise assist in providing transportation services in connection
with the provision of VA medical care to these veterans. VA recently
published required program regulations and will be soliciting grant
applications shortly. More information can be found here: https://
www.Federalregister.gov/articles/2013/04/02/2013-07636/grants-for-
transportation-of-veterans-in-highly-rural-areas. VA has included this
initiative in the fiscal year 2014 President's budget request.
Senator Udall. Good. I hope you'll do that. Thank you very
much.
And sorry for running over, Mr. Chairman.
Senator Johnson. Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
This is a very important discussion to be having,
particularly as to how we care for our veterans in these highly
rural areas.
And you mentioned the transportation fund. In far too many
of Alaska's communities, we're simply not connected by road; 80
percent of the communities in the State of Alaska are not
accessible by road, so we've got to fly. So the expense is
considerable.
And then, of course, when you're in town, you have taxi,
you have to rent a car, you have overnight accommodations.
And so how we provide for those who are--we call them off
the road system in Alaska--is a huge issue for us.
One of the things that I thank you for your leadership,
Secretary Shinseki, in Alaska, we have an agreement between the
VA and the native health system, where the veterans can go to
the Indian Health Service (IHS) facilities for that level of
care. So it's within their region.
It might not necessarily be in their village, but it's
within their region so they don't have to fly to the major
cities for this level of care.
And it was something that Senator Stevens and I had worked
on. We think that it can be an opportunity, particularly in
very rural areas, whether it's South Dakota or New Mexico. It
was a great idea, and we want it to work. And the VA has really
led on this as they have led with telehealth.
HEALTHCARE
One of the things that I'm hearing anecdotally is from one
of the larger and better health systems in the State. They're
saying that they're not seeing the patient loads that they had
expected. We're trying to drill down into this and find out, is
it lack of publicity that the program is available? Is it lack
of unfunded travel that's prohibiting them from accessing it?
We're trying to understand how we can make it better,
because we recognize we're never going to be able to get the
providers out into these remote areas. So if we can work within
existing systems, we've got more of an opportunity.
So, Secretary, if you can address that. I know Dr. Petzel
has been working on this, of course, for years diligently with
us. But we want to try to make this work. We think it has great
promise.
Secretary Shinseki. That's certainly our intent. I was not
aware that we haven't seen the response in the local clinics,
and we'll certainly get on that.
For this discussion about delivering healthcare across the
country, our commitment is a veteran living in a rural area or
a remote area has the same entitlement to access and to care.
That's what we're committed to.
There isn't a cookie-cutter approach to this. It affects
everything from recruitment and retention bonuses to having an
affiliation with a local medical school and bringing together
VA's resources with what's already there. We have a memorandum
of understanding (MOU) with the Indian Health Service to
provide services that veterans can get access to, and we
reimburse for those services. We're not trying to deliver
something that's already available. Telehealth and telemedicine
give access wherever the veteran is able to enter the VA
system.
So it's sort of ``all the above.'' There is no cookie
cutter that says, since this worked in New Mexico, it'll work
in Alaska. We tune these tools up as the situation needs.
And certainly, as Dr. Petzel says, a challenge is
recruiting folks to go to some of the rural areas. The
scholarship program here in small numbers is intended to get a
youngster, a promising youngster, out of those communities,
help with their education, and then go home and working for the
VA. That's a work in progress and the next initiative we're
trying to seed.
Senator Murkowski. Well, if we can work with you to
identify how we might be more effective in reaching our
veterans in these highly rural areas, we would like to do that
with you.
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
I'd like to ask about what is going on within the VA system
as it relates to amyotrophic lateral sclerosis (ALS)?
And, Mr. Secretary, you and I have had this conversation
before about Lou Gehrig's disease, the fact that VA has granted
ALS the presumption of service connection, as we know that
those who serve in the military are twice as likely to develop
ALS as those who have not served.
We recognize that there are certain technologies that are
out there that allow for the individual who is afflicted with
this disease to just live an easier quality of life as they
deal with this very degenerative and very debilitating process.
But there are certain procedures that the VA has not
accepted. One, for instance, is this diaphragm pacing system. I
mentioned it at the breakfast that we had visited at, Mr.
Secretary.
And this is a process that allows the diaphragm to keep
moving when it begins to fail from ALS. The pacer was granted
humanitarian status under the Food and Drug Administration
(FDA). Insurance covers it as it does for Medicare.
But apparently, these life-extending measures are not
recognized within the VA system. And we've had to work within
the VA to try to push to provide a level of assistance.
It would seem to me that given that the VA has granted ALS
the presumption of service-connection disability, there ought
to be some consistency in the standards, so that these
individuals that are faced with this horrid disease don't have
to fight the VA to get some assistance with some life-extending
therapies.
So I don't know if you have an answer for me today, but I
feel like I must raise it on behalf of the people who are
afflicted with this. Their life should not be made that much
more difficult towards the end, when they have to take on the
system.
Secretary Shinseki. Senator, I agree. We discussed the
diaphragm pacing system during our visit together. Let me give
you a better answer for the record. We're still investigating
this.
But I agree with you, that if we've recognized ALS as a
service-connected condition, we ought to provide all the care
and benefits that go along with caring for our veterans.
[The information follows:]
VA has used the diaphragm pacing system (DPS) for veterans with
amyotrophic lateral sclerosis (ALS) or Lou Gehrig's disease since 2008.
DPS is considered when the Veteran with ALS has threatened respiratory
insufficiency that is not better managed by other means that are not
agreeable to the Veteran. Other means include a pressure supported
bilevel positive airway pressure, or BiPAP. The BiPAP supports both
inhalation and also exhalation by lowering the positive airway pressure
to facilitate exhalation.
Senator Murkowski. Well, I appreciate that, and I know that
those that are afflicted and their families care a great deal
as well.
Secretary Shinseki. Thank you.
Senator Johnson. Senator Collins.
Senator Collins. Thank you very much, Mr. Chairman.
Mr. Secretary, it's good to see you again. I want to add my
thanks to those of my colleagues for your briefing us in your
office and introducing the new members of this subcommittee to
the important work and your priorities.
Doctor, I want to follow up on questions that Senator
Hoeven asked you about suicides in the military and among our
veterans. And I'm very concerned about the epidemic of
suicides.
I know that a 2012 VA report on suicide data that was based
on information from 21 States found that an estimated 22
veterans lose their lives to suicide each day. And we know in
addition that, last year, there were approximately 350 military
suicides as well.
Obviously, these data are alarming and tragic. I listened
very carefully as you went through the list of what the VA is
doing. And I commend you for the focus.
OVERMEDICATION
But the fact is, there is substantial evidence that
prescription-drug abuse is a major contributing factor in both
military Active Duty and veterans' suicides.
And it is for that reason that in July of last year, I
wrote to the Attorney General and asked that he use the
authority that Congress had provided him by the Secure and
Responsible Drug Disposal Act of 2010 to allow military and VA
treatment facilities to conduct controlled-substance take-back
programs. These have occurred in my State with considerable
success.
It's my understanding that the Drug Enforcement
Administration, the DEA, recently proposed new regulations to
expand the options available to collect controlled substances.
And by this, I'm talking about unused prescriptions, for
example. That's probably the most common example.
But the regulations, much to my dismay, failed to authorize
VA and DOD pharmacies, medical facilities, or medical
personnel, to take part in appropriate drug take-back programs.
So I'm introducing a bipartisan bill that will require the
Attorney General to work with the VA, with Secretary Shinseki,
and with the Secretary of Defense, to implement drug take-back
programs.
I'm interested in your assessment, whether you would
support the VA being involved, and able to directly take back
these drugs, and thus mitigate the possibility of abuse of them
ending up on the black market, or being given to another
veteran who has mental-health problems, and perhaps leading to
very tragic results.
Secretary Shinseki. Senator, I tell you, I'm in great
agreement with you here on drug abuse. Even within the VA, I've
asked a question of ourselves, do we overmedicate people, and
then, so what happens with the drugs?
We are now part of the State monitoring system for
prescription writing. I think this take-back policy you're
describing just makes sense with everything else we're doing.
I think prescription drugs continue to show up as a part of
the problem when we deal with lots of other issues. So we're
happy to work with you on this.
Senator Collins. Thank you. I think this is absolutely
critical and really could make a difference. And I'm
particularly concerned when our Active Duty military leave and
go back home, and they may have these very powerful
prescriptions, and very little follow-up, which brings me to
another issue.
One of you mentioned the fact that 41 percent of total
enrolled veterans reside in either rural or highly rural areas
of our country. And of course, that certainly describes much of
the State of Maine.
PROJECT ARCH
And we know that providing access to care is one of the
VA's top priority objectives, and that you're especially
focusing on those 3.4 million rural veterans who are enrolled
in the VA system. There is a 3-year VA pilot project that is
known as Project ARCH.
One of the sites happens to be in my hometown of Caribou,
Maine. It has been an extraordinary success. The veterans that
use that program absolutely give it very high approval ratings.
They can get the care they need without traveling far to
get it. The one VA hospital in Maine, for example, is 4 hours
away from my hometown of Caribou.
And I believe that in your budget, you cited this pilot
project, the Project ARCH program, as one of your
accomplishments, and rightly so, based on what I've seen.
So this allows veterans in rural and highly rural areas to
receive specialty care closer to home from community healthcare
providers, which also helps with that continuity problem that
we were discussing earlier with the turnover at VA facilities,
instead of being forced to drive hundreds of miles to the
nearest VA hospital, for example.
So my question is, given the success of Project ARCH, do
you intend to extend this program beyond fiscal year 2014?
Dr. Petzel. Well, Senator Collins, thank you very much for
the kind words. We have also been very pleased with it,
particularly the way it has worked in Maine. The arrangements
with the Cary Medical Center really have been excellent.
We're in the third year of Project ARCH. It's a 5-year
pilot study being done at five sites. I think that we would
probably hold our cards for a bit yet to see what the
evaluation, once we're deeply into the pilot, is of the four
sites around the country.
Certainly, if it proves to be a successful concept, we
would want to extend this beyond those five pilot sites. But I
think the evaluation needs to be done. We've got at least
another year or two before we do that.
Senator Collins. Well, I would say that I think the
preliminary indications are that you've got a real winner. And
I would invite any of you to come to the program in northern
Maine at any time, if you want to see it.
It is an extremely successful program. And Maine has a very
high rate of veterans in its population, and I feel so good
about the fact that in the middle of the winter, we're not
forcing these veterans to have to travel long distances to get
the specialty care that they need. They can get it right at the
local hospital.
So it's been a great program, and it saves travel time and
money as well. So I hope they're all as successful as the one
at Cary Memorial Hospital in Caribou, Maine.
Thank you.
Senator Johnson. Secretary Shinseki, I again thank you and
your colleagues for appearing before this subcommittee, and I
look forward to working with you this year.
We will convene panel two momentarily.
Mr. Griffin, please come forward.
Office of Inspector General
STATEMENT OF RICHARD J. GRIFFIN, DEPUTY INSPECTOR
GENERAL
ACCOMPANIED BY:
JOHN DAVID DAIGH, JR., M.D., ASSISTANT INSPECTOR GENERAL FOR
HEALTHCARE INSPECTIONS
LINDA HALLIDAY, ASSISTANT INSPECTOR GENERAL FOR AUDITS AND
EVALUATIONS
Senator Johnson. Mr. Griffin, I welcome you to this
hearing. This is the first time we have had the VA Inspector
General's Office (OIG) testify on the budget. And I thank
Chairwoman Mikulski for suggesting it.
In an agency as large and complex as the VA, your office
plays a unique and crucial role in ensuring that the VA
delivers the quality care and service that our vets depend on,
and that the agency's resources are properly managed and
accounted for.
In reviewing the fiscal year 2014 budget submission, I see
that quality of care, management of regional office operations,
disability claims workloads, and effective oversight of
information technology programs and projects, are listed among
your major management challenges.
I'm also concerned about a report your office issued
earlier this week regarding mismanagement of the contract
mental health program at the Atlanta VA Medical Center.
According to the report, the lack of effective patient care
management and program oversight by the facility contributed to
problems with access to mental healthcare and contributed to
patients falling through the cracks.
As you know, this is not an abstract problem. Of the three
cases cited in the report, two vets committed suicide and one
was incarcerated due to the facility's failure to ensure
continuity of care.
Due to the surge in mental health issues among recent vets
and the efforts at increased funding that this subcommittee has
supported to improve access to mental healthcare, I worry that
this is not an isolated incident.
Allowing vets with mental conditions to fall through the
cracks is not acceptable. I'm interested in your thoughts on
how contract mental health programs can be improved throughout
the VA.
Thank you, Mr. Griffin. You may proceed. Please feel free
to summarize your remarks. Your full statement will be included
in the record.
SUMMARY STATEMENT OF RICHARD J. GRIFFIN
Mr. Griffin. Thank you, Mr. Chairman, and thank you for the
opportunity to discuss VA Office of Inspector General
priorities in fiscal year 2014.
I'm accompanied by Ms. Linda Halliday, Assistant Inspector
General for Audits and Evaluations, and Dr. John David Daigh,
Assistant Inspector General for Healthcare Inspections.
In fiscal year 2012, the OIG issued 299 reports, and our
oversight produced a 36-to-1 return on investment. This return
is realized in terms of program savings, cost avoidance,
questioned costs, and actual dollars recovered.
One of VA's core missions is to provide compensation
benefits for those injured during their service in the
military. The delivery of these benefits is a major challenge
for VA and our work indicates that much work continues to be
needed in both technology initiatives and better training for
staff to reduce the growing backlog of claims.
In February 2013, we issued a report on a Veterans Benefits
Management System known as VBMS. We reported that even though
VA had not fully tested VBMS, they continued to deploy it to
the VA regional offices. The system had not been fully
developed to the extent that its capability to process claims
from initial application through review, rating, award, and,
finally, to benefits delivery could be sufficiently evaluated.
We note that the partial VBMS capability deployed to date has
experienced system performance issues.
In addition, as of the VBMS report date, VBA did not have a
detailed plan for scanning and digitization of veterans'
claims, nor an analysis of requirements. In our recent
inspections in January, March, and April of this year of the
regional offices in Houston, Milwaukee, and Newark, 25
employees provided us a users' perspective of VBMS.
Generally, staff expressed frustration with the system
because of spontaneous system shutdowns; latency issues related
to slow times to download documents, such as medical evidence
for review; longer times to review the electronic evidence;
mislabeled electronic evidence; and mixing evidence from one
veteran's electronic file to another veteran's file.
Given the incremental system development approach used and
the complexity of the automation initiative, VA will continue
to face extremely difficult challenges in meeting its goal of
eliminating the backlog of disability claims processed by 2015.
As you referenced, in our full statement we have reported
on a number of challenges confronting the Veterans Health
Administration. Topics addressed include waiting times; access
to mental healthcare; non-VA fee care, including fiscal
controls; staffing standards; the VISN management structure;
and women's health issues.
In reality, these are overlapping issues. Without accurate
waiting times and productivity standards, it is difficult or
impossible to know how many specialists you need for timely
access to mental healthcare and women's healthcare. If there's
more demand for VA care than VA providers can handle, you need
proper management structure and focus at the VISNs and medical
centers to direct the quality of care, as well as the fiscal
oversight of the non-VA fee-basis programs.
At a time of unprecedented demand for VA benefits and
service, the OIG has directed its oversight efforts on VA's
most formidable challenges. We are committed to these efforts
because it is both good Government and because it honors our
Nation's commitment to those who served.
With increased attention to the areas outlined in our
statement, we believe we can help ensure that veterans get the
care, support, and recognition they've earned in service to our
country.
PREPARED STATEMENT
Mr. Chairman, thank you for the opportunity to discuss the
oversight work of the OIG, and we appreciate the continued,
steadfast support and interest you and the subcommittee have
demonstrated for our mission. We welcome any questions that you
may have for us this afternoon.
[The statement follows:]
Prepared Statement of Richard J. Griffin
introduction
Mr. Chairman and members of the subcommittee, thank you for the
opportunity to discuss the Department of Veterans Affairs (VA) Office
of Inspector General (OIG) priorities in fiscal year 2014. I will focus
on recent OIG work in claims processing and access to healthcare
because they continue to be challenges for VA. In addition, I will
briefly cover OIG work in VA's other programs and operations. I am
accompanied by Ms. Linda Halliday, Assistant Inspector General for
Audits and Evaluations, and Dr. John D. Daigh, Jr., Assistant Inspector
General for Healthcare Inspections.
In fiscal year 2012, the OIG issued 299 reports and our oversight
produced a $36 to $1 return on investment;\1\ as of March 31, 2013, we
have issued 164 reports and realized a $33 to $1 return on investment.
This return is realized by VA in terms of program savings, cost
avoidance, questioned costs, and actual dollars recovered. The OIG's
Office of Healthcare Inspections, whose mission results in improving
the healthcare provided to veterans rather than saving dollars, is not
included in the return on investment calculation.
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\1\ Office of Inspector General Department of Veterans Affairs
Semiannual Report to Congress April 1, 2012--September 30, 2012.
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veterans benefits administration (vba)
One of VA's core missions is to provide compensation benefits for
those injured during their service in the military. The delivery of
these benefits is a major challenge for VA and our reports indicate
that much work continues to be needed in both technology initiatives
and better training for staff to reduce the growing backlog of claims.
veterans benefits management system development
In February 2013, we issued a report on the Veterans Benefits
Management System (VBMS) \2\ that found VA had not fully tested VBMS
yet continued to deploy it to VA regional offices. Due to the
incremental development approach VA chose, the system had not been
fully developed to the extent that its capability to process claims
from initial application through review, rating, award, to benefits
delivery could be sufficiently evaluated. However, we determined the
partial VBMS capability deployed to date has experienced system
performance issues. For example, on April 8, 2013, VBA performed an
update to the portion of the VBMS system related to rating claims. As a
result, the system was unexpectedly unavailable nationwide for 2 days.
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\2\ Review of VBA's Transition to a Paperless Claims Processing
Environment (February 4, 2013).
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As of the VBMS report date, VBA did not have a detailed plan for
scanning and digitization of veterans' claims nor an analysis of
requirements. We identified issues hindering VBA's efforts to convert
hard-copy claims to electronic format for processing within VBMS,
including disorganized electronic claims folders and inadequate
management of hard-copy claims. As one of VBA's main transformation
initiatives, the Under Secretary for Benefits indicated VBMS is
designed to assist VA in eliminating the claims backlog. At the end of
fiscal year 2010, VBA's inventory of pending claims was just over
530,000 that took an average of 166 days to complete; as of March 2013,
VBA's inventory of pending claims had grown to over 850,000 and is now
taking an average 292 days to complete.
In our more recent inspections of the VA regional offices (VAROs)
in Houston, Texas; Newark, New Jersey; and Milwaukee, Wisconsin; 25
staff provided us a user's perspective of VBMS. Generally, staff
expressed frustration with the system in part because of spontaneous
system shutdowns, latency issues related to slow times to download
documents such as medical evidence for review, longer times to review
the electronic evidence, mislabeled electronic evidence, and mixing
evidence from one veteran's electronic file to another veteran's file.
Further, as outlined in our April 2013 report \3\ we found that
claims processing inaccuracy at the Baltimore, Maryland, VARO had more
than doubled for the types of medical disability claims we reviewed
since our first inspection in June 2009. The error rates changed from
28 percent inaccurate to 68 percent inaccurate for the claims we
reviewed. VBA's Systematic Technical Accuracy Review (STAR) \4\ of a
cross section of all claims found the Baltimore VARO went from 76.8
percent accuracy in 2009, down to 74.4 percent in 2013. The inventory
of pending claims grew significantly from 7,000 in 2009 and about
19,000 in 2013, while the staffing level only increased slightly from
134 staff to 143 staff respectively. The average days to complete
disability claims went from 210 days in 2009 to 342 days in 2013.
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\3\ Inspection of VA Regional Office Baltimore, Maryland (April 11,
2013).
\4\ STAR is a key mechanism for evaluating regional office
performance in processing accurate benefit claims for veterans and
beneficiaries. The STAR process provides a comprehensive review and
analysis of compensation rating processing associated with specific
claims or issues.
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Given the incremental system development approach used and the
complexity of the automation initiative, VA will continue to face
challenges in meeting its goal of eliminating the backlog of disability
claims processing by 2015. We are continuing our oversight of VA's
ongoing VBMS system development efforts assessing the system's
functionality, costs, and ability to establish and meet schedule
milestones.
temporary 100 disability evaluations
Our January 2011 report, Audit of 100 Percent Disability
Evaluations, identified veterans receiving long-term payments to which
they were not entitled. We projected that since January 1993 regional
office staff overpaid veterans a net amount of about $943 million.
Without timely corrective action, we conservatively projected that VBA
would overpay veterans $1.1 billion over the period of calendar year
2011 through calendar year 2015. Over the last 3 years our VARO
Inspections Program repeatedly reported systemic problems are
continuing in VBA's processing of temporary 100 percent disability
ratings. None of the 57 VAROs inspected fully followed VBA policy,
which resulted in VARO staff not adequately processing temporary 100
percent ratings for approximately 66 percent of cases reviewed. These
errors resulted in just under $17,000,000 in overpayments and almost
$311,000 in underpayments.
In our inspections of three California VAROs,\5\ we reported high
errors rates, ranging from 53 to 97 percent, in processing temporary
100 percent disability evaluations. The magnitude of these and other
claims processing errors caused VBA to temporarily cease operations at
the Oakland and Los Angeles VAROs in order to provide training to
staff.
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\5\ Inspection of the VA Regional Office Los Angeles, California
(May 10, 2012); Inspection of the VA Regional Office Oakland,
California (May 10, 2012); Inspection of the VA Regional Office San
Diego, California (May 10, 2012).
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In June 2011, and again in August 2012, VBA officials modified the
electronic system to ensure suspense diary dates for medical re-
examinations would automatically populate and remain in the system
without manual entry. Currently, it appears these system corrections
are working as we have observed that the diary dates remain in the
system after being automatically populated. Although VBA has taken
action to modify their electronic systems, these system fixes have not
fully addressed the staff errors we frequently find. For example,
during our fiscal year 2012 inspection cycle and through March 2013,
where we reviewed 29 VAROs, 524 (62 percent) of the total 848 temporary
100 percent disability evaluations contained processing errors. Within
this group of 524 errors, 338 (approximately 65 percent) were
attributed to human error. These errors include staff not scheduling
medical reexaminations after receiving reminder notifications to do so,
or staff not following up to reduce the temporary evaluations after
notifying veterans of their intent to do so.
medical examinations and disability benefits questionnaires
Our VARO inspections continue to find claims processing errors
associated with the use of medical examinations that do not contain the
required information to render sound disability determinations.
Further, we identified 30 of the 365 disability benefits questionnaires
(DBQs) that did not contain adequate information to make accurate
disability determinations.
Our February 2012 report, Audit of VA's Internal Controls Over the
Use of Disability Benefits Questionnaires, reported VA began using DBQs
in October 2010 as an initiative to help reduce the claims backlog.
DBQs are condition-specific forms designed to capture medical
information relevant to veterans' disability benefits claims. We
reported that VA needed to strengthen internal controls over the use of
DBQs in order to better prevent, detect, and minimize the risk of fraud
and provide reasonable assurance that medical documentation used in the
rating process is authentic and unaltered. Specifically, VBA had not
developed adequate internal controls to ensure DBQs completed by
private physicians were authentic and unaltered.
veterans health administration (vha)
For many years, the Veterans Health Administration (VHA) has been a
national leader in the quality of care provided to patients when
compared with other major U.S. healthcare providers. VHA's use of the
electronic medical record, its National Patient Safety Program, and its
commitment to use data to improve the quality of care has sustained
VHA's quality of care performance. However, VHA faces particular
challenges in managing its healthcare activities. The effectiveness of
clinical care, budgeting, planning, and resource allocation are
negatively affected due to the continued yearly uncertainty of the
number of patients who will seek care from VA.
access to mental health services
The OIG conducted a review \6\ at the request of the VA Secretary,
Chairmen and Ranking Members of the U.S. Senate and U.S. House
Committees on Veterans' Affairs, and the Chairman and Ranking Member of
the House Veterans' Affairs Committee's Subcommittee on Health, after
they expressed concerns that veterans may not be able to access the
mental healthcare they need in a timely manner. In response, OIG
reported VHA does not have a reliable and accurate method of
determining whether they are providing patients timely access to mental
healthcare services.
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\6\ Review of Veterans' Access to Mental Health Care (April 23,
2012).
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VHA did not provide first-time patients with timely mental health
evaluations, and existing patients often waited more than 14 days past
their desired date of care for their treatment appointments. In fiscal
year 2011, VHA had reported 95 percent of first-time patients received
a full mental health evaluation within 14 days. Using the same data VHA
used to calculate the 95 percent success rate, we selected a
statistical sample of completed evaluations to review which supported
only 49 percent of these evaluations occurred within 14 days. In fact,
on average, for the remaining patients, it took VHA about 50 days to
provide them with their full evaluations. Further, we reported
approximately 1.2 million or 12 percent of patient follow-up
appointments exceeded 14 days. We concluded that a series of timeliness
and treatment engagement measures could provide decisionmakers with a
more comprehensive view of the ability with which new patients can
access mental health treatment. We offered recommendations to the Under
Secretary for Health to revise the full mental health evaluation
measure to ensure the measurement is calculated to reflect a veterans'
actual wait time experience.
This week we released two reports on the mental healthcare program
at the Atlanta VA Medical Center in Decatur, Georgia. The first \7\ was
focused on allegations of an inpatient's death due to mental health
service leadership's negligence and mismanagement of unit policies,
patient monitoring, staffing, and lack of caring about patients. We did
not substantiate the allegations of inadequate staffing, inappropriate
staff assignments, or that leadership did not care about patients.
However, we substantiated that the facility did not have adequate
policies or practices for patient monitoring, contraband, visitation,
and urine drug screening. We found inadequate program oversight
including a lack of timely follow-up actions by leadership in response
to patient incidents.
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\7\ Healthcare Inspection--Mismanagement of Inpatient Mental Health
Care, Atlanta VA Medical Center, Decatur, Georgia (April 17, 2013).
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We recommended that the Under Secretary for Health ensure that VHA
develops national policies to address contraband, visitation, urine
drug screening, and escort services for inpatient mental health units.
We also recommended that the Veterans Integrated Service Network (VISN)
and facility directors ensure that the inpatient mental health unit
develops these policies; strengthen program oversight and follow-up;
improve communication with staff; and ensure functional and well-
maintained life support equipment.
The second report \8\ assessed the allegations of mismanagement and
lack of oversight of a mental health contract. We substantiated
mismanagement in the administration of the contract, and also
substantiated additional allegations that there was inadequate
coordination, monitoring, and staffing for oversight of contracted
mental health patient care. Facility managers did not provide adequate
staff, training, resources, support, and guidance for effective
oversight of the contracted mental health program. Mental health
service line managers and staff voiced numerous concerns including
challenges in program oversight, inadequate clinical monitoring, staff
burnout, and compromised patient safety.
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\8\ Healthcare Inspection--Patient Care Issues and Contract Mental
Health Program Mismanagement, Atlanta VA Medical Center, Decatur,
Georgia (April 17, 2013).
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The facility referred patients to the Community Service Boards
(CSBs) for several years before they started to track the patients
referred. The facility estimated that they referred between 4,000 and
5,000 patients since 2010, but did not know the status of those
patients. The facility managers were aware that a large number of
patients were, in the words of employees, ``falling through the
cracks'' and estimated that the Mental Health Assessment Team continued
to refer up to 60 new patients each week to the CSBs.
We reviewed 85 electronic health records from a list received from
the facility of CSB-referred patients. We found that 21 percent of our
random sample of CSB-referred patients were never provided care by the
CSBs, with no follow up provided by the facility. VHA requires that an
initial mental health appointment be scheduled within 14 days of
referral. The contract did not have a time requirement, but only stated
that the expectation was patients would be seen as soon as possible. We
found that patients waited an average of 19 days for their initial
assessment (range from 1 to 80 days). Seventy-four percent of CSB-
referred patients had wait times greater than 14 days, with a wait time
average of 92 days and a median range of 56 days (range from 5 to 432
days).
We recommended that the Under Secretary for Health rectify the
deficiencies described in this report with respect to the provision of
quality mental healthcare and contract management, with the goal that
veterans receive the highest quality medical care from either the VA or
its partners. The Under Secretary for Health and the VISN and facility
directors concurred with our recommendations and provided an acceptable
action plan. We will follow up on the planned actions until they are
completed.
These reports are particularly troublesome because in July 2011, we
reported \9\ on problems with the management of the electronic wait
list for several mental health clinics at the same facility. Among the
findings of that report, we substantiated that several mental health
clinics had significantly high numbers of patients on their electronic
wait lists over a period of months in fiscal year 2010, and we
substantiated that facility managers were aware of the wait lists but
were slow in taking actions to address the condition. Large mental
health electronic wait lists are inherently problematic as they
represent impaired access to critically needed care.
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\9\ Healthcare Inspection--Electronic Waiting List Management for
Mental Health Clinics Atlanta VA Medical Center Atlanta, Georgia (July
12, 2011).
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These new findings stand in contrast to our findings \10\ in March
2009 regarding mental healthcare for veterans in Montana. In that
report, we found that VA leverages community resources, VA resources,
and fee care to provide mental healthcare for rural veterans.
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\10\ Healthcare Inspection--Access to VA Mental Health Care for
Montana Veterans (March 31, 2009).
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non-va fee care programs
The OIG has reported that VHA faced significant challenges to
address serious nationwide weaknesses in its Non-VA Inpatient and
Outpatient Fee Care Programs.\11\ Specifically, our audits disclosed
serious weaknesses in the pre-authorization of fee service. The cost of
fee care rose from $1.6 billion in fiscal year 2005 to almost $4.3
billion in 2013. As early as 2009, we reported that VHA improperly paid
37 percent of outpatient fee claims resulting in $225 million in
overpayments and $52 million in underpayments. We estimated $1.1
billion in overpayments and $260 million in underpayments over the next
5-year period if VHA did not strengthen its processes for authorizing
fee care services. In fiscal year 2010, we reported that VHA improperly
paid 28 percent of inpatient fee claims resulting in net overpayments
of $120 million and estimated $600 million in improper payments could
be processed over the next 5-year period. Weak authorization procedures
resulted in VA healthcare facilities not having reasonable assurance
that requests for services are medically necessary.
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\11\ Audit of Veterans Health Administration's Non-VA Outpatient
Fee Care Program (August 3, 2009); Audit of Non-VA Inpatient Fee Care
Program (August 18, 2010); Review of Veterans Health Administration's
Fraud Management for the Non-VA Fee Care Program (June 8, 2010); Review
of Alleged Mismanagement of Non-VA Fee Care Funds at the Phoenix VA
Health Care System (November 8, 2011); Administrative Investigation--
Improper Contracts, Conflict of Interest, Failure to Follow Policy, and
Lack of Candor, Health Administration Center, Denver, Colorado (April
12, 2012); and Review of Enterprise Technology Solutions, LLC,
Compliance with Service-Disabled Veteran-Owned Small Business Program
Subcontracting Limitations (August 20, 2012).
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Approximately 5 years have passed since we issued our first report
on the fee care program, yet we continue to have concerns that the
authorization of fee care services is still too weak to ensure
sufficient funds for these services are available to pay for the
services veterans receive. In January 2013, our review \12\ of the
South Texas Veterans Healthcare Systems' management of fee care funds
substantiated an allegation that the healthcare system authorized $29
million in fee care without sufficient funds to pay for the services
received by veterans. We found management at the South Texas Healthcare
System and the VISN lacked effective oversight mechanisms to ensure the
financial management and stewardship of these funds.
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\12\ Review of VHA's South Texas Veterans Health Care System's
Management of Fee Care Funds (January 10, 2013).
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In response to our August 2010 audit of Non-VA Inpatient Fee Care
Program, VHA and OIG agreed there will be general cost-savings and
efficiencies realized with consolidating the fee program's claims
processing system to achieve better economies of scale. Although
specific cost-savings depend on the actual consolidated strategy VA
selects and on how well VA implements the chosen strategy, we
conservatively estimated that current program inefficiencies cost VHA
about $26.8 million in fiscal year 2009, and could cost about $134
million over the next 5 years. We recommended the Under Secretary for
Health evaluate alternative payment processing options to identify
mechanisms to improve payment processing costs and timeliness. Today,
we do not see VHA moving forward with an actual consolidation strategy
for payment processing in the fee care program.
physician staffing standards for specialty care services
In December 2012, we issued a report on VHA's Physician Staffing
Levels for Specialty Care Services. We found VHA did not have an
effective staffing methodology to ensure appropriate staffing levels
for specialty care services. The need for VHA to develop a staffing
methodology is not a recent issue. As early as 1981, we recommended
that VHA develop a methodology to measure physician productivity. VHA
has not established productivity standards for 31 of 33 specialty care
services we reviewed, and VA medical facility management did not
develop adequate staffing plans. VHA's lack of productivity standards
and staffing plans limit the ability of medical facility officials to
make informed business decisions on the appropriate number of specialty
physicians to meet patient care needs.
To determine an approximate measure of current physician specialty
productivity, we established a rudimentary standard by identifying
VHA's relative value unit median for each specialty care service. The
national median is the middle value among each specialty care service.
Using that median, we analyzed the collective group of specialty
physicians at all medical facilities and determined that 12 percent of
physician full-time equivalents did not perform to the standard, and
represented $221 million in physician salaries during fiscal year 2011.
Although we did not analyze the productivity of individual physicians,
our results support the need for an in-depth evaluation of staffing.
The primary message of this report is that VHA needs to implement
productivity standards to measure and compare the collective
productivity of physicians within a specialty care service at VA
medical facilities. This information is necessary and fundamental to
planning and building appropriate budgets to meet veteran's needs and
ensuring timely access to care.
women's health issues
VA must provide care to a growing number of women veterans,
currently 10 percent of the veteran population. In fiscal year 2009, VA
spent $180 million on gender-specific medical care. In fiscal year
2014, the President's budget plans on spending $422 million, a change
of approximately 134 percent from fiscal year 2009.
In December 2012,\13\ we issued a report on VHA services available
to women veterans who have experienced military sexual trauma (MST). We
conducted the review at the request of the Senate Committee on
Veterans' Affairs. VHA policy states that veterans and eligible
individuals who report experiences of MST, but who are deemed
ineligible for other VA healthcare benefits or enrollment, may be
provided MST-related care only. VHA also requires that veterans and
eligible individuals must have access to residential or inpatient
programs able to provide specialized MST-related mental healthcare,
when clinically needed, for conditions resulting from MST. VHA requires
that all facilities screen veterans for MST.
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\13\ Healthcare Inspection--Inpatient and Residential Programs for
Female Veterans with Mental Health Conditions Related to Military
Sexual Trauma (December 5, 2012).
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We reviewed inpatient and residential programs identified by VHA as
resources for female veterans who have experienced military sexual
trauma. We conducted site visits and reviewed the electronic health
records of female veterans with MST discharged from these programs
between October 1, 2011, and March 31, 2012. We found:
--Nearly all the women in our review had more than one mental health
diagnosis. Ninety-six percent were diagnosed with PTSD. Major
depression and substance use disorders were also common. Almost
90 percent of the women in the review were receiving outpatient
mental health services in the 3 months prior to admission to
the inpatient or residential program.
--Gender-specific care and same gender therapists were available.
Treatments utilized varied by site, but all programs employed
one or more evidence-based psychotherapies.
--Women were often admitted to programs outside their VISN. Some of
these veterans travel across the country to VA residential
programs that consider themselves national resources. Obtaining
authorization for travel funding was frequently cited as a
problem for patients and staff. The Beneficiary Travel policy
indicates that only selected categories of veterans are
eligible for travel benefits and payment is only authorized to
the closest facility providing a comparable service. This is
not aligned with the MST policy, which states that patients
with MST should be referred to programs that are clinically
indicated regardless of geographic location.
--We recommended that the Under Secretary for Health review existing
VHA policy pertaining to authorization of travel for veterans
seeking MST-related mental health treatment at specialized
inpatient/residential programs outside of the facilities where
they are enrolled.
In a report \14\ from December 2010 on VA healthcare and
compensation benefits for combat stress in women veterans, we found:
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\14\ Review of Combat Stress in Women Veterans Receiving VA Health
Care and Disability Benefits (December 16, 2010).
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--Female veterans generally were more likely to transition to and
continue to use VA healthcare services.
--Higher proportions of female veterans generally were diagnosed with
mental health conditions by VA after separation, but lower
proportions were diagnosed with post-traumatic stress disorder
(PTSD) or traumatic brain injury (TBI).
--Higher proportions of female veterans generally were receiving
disability benefits for mental health conditions, but a lower
proportion for PTSD and TBI.
--Gender-based biases were not identified in VBA's adjudication of
male and female disability claims, but data limitations affect
a full assessment of some outcomes.
--VBA has guidance and training for evaluating MST claims, but
sensitivity training is needed for claims processors and women
veterans coordinators.
--VBA has not assessed the feasibility of requiring MST-specific
training and testing.
prosthetics management
As a result of our oversight reports,\15\ VHA acknowledged that
improvements in prosthetics inventory management are necessary. In
March 2012, we reported VHA needs to strengthen VA Medical Center
(VAMC) management of prosthetic supply inventories to avoid spending
funds on excess supplies and to minimize risks related to supply
shortages. We estimated during April through October 2011 that VAMCs
maintained inventories of approximately 93,000 specific prosthetic
items worth about $70 million. Further, we estimated that VAMC
inventories exceeded current needs for almost 43,500 items (47 percent)
and were too low for nearly 10,000 items (11 percent).
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\15\ Audit of VHA Acquisition and Management of Prosthetic Limbs
(March 8, 2012); Audit of VHA's Prosthetics Supply Inventory Management
(March 30, 2012).
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VHA cannot accurately account for these inventories and because
inventory management practices are weak, inventory losses associated
with diversion can go undetected at VAMCs. To avoid spending taxpayer
dollars on excess prosthetic supply inventories and risking the
disruption of patient care by experiencing supply shortages, VHA must
ensure VAMCs properly manage prosthetic inventories. By strengthening
VAMC management of prosthetic supply inventories and using supplies
stocked in excess inventories instead of purchasing additional
supplies, VHA can reduce prosthetic supply costs by approximately $35.5
million. VA cannot afford to use valuable financial resources to
purchase, maintain, and store more prosthetic supplies than necessary.
In response to our work, VHA now has a plan to replace its inventory
systems with a comprehensive inventory management system. Completion of
the new system is projected for fiscal year 2015, pending the
availability of funds.
In addition to the management of prosthetics, we conducted a review
\16\ to evaluate VA's capacity to deliver prosthetic care. We assessed
VA credentialing requirements for prosthetists and orthotists; the
demand for healthcare services; and psychosocial adjustments and
activity limitations of Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn (OEF/OIF/OND) veterans with amputations and
their satisfaction with VA prosthetic services. We found:
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\16\ Healthcare Inspection--Prosthetic Limb Care in VA Facilities
(March 8, 2012).
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--All required prosthetist and orthotist staff in VA regional
amputation centers and polytrauma amputation network sites and
all their prosthetic laboratories were certified.
--Veterans with amputations are a complex population with a variety
of medical conditions and are significant users of VA
healthcare services and not just prosthetic services.
--OEF/OIF/OND veterans with amputations were generally adapting to
living with their amputations. While some veterans reported
receiving excellent care at VA facilities, many veterans
indicated that VA needed to improve care. Concerns with VA
prosthetic services were centered on the VA approval process
for fee basis or VA contract care, prosthetic expertise, and
difficulty with accessing VA services.
veterans integrated service network (visn) management
In March 2012,\17\ OIG assessed Veterans Integrated Service Network
(VISN) office management controls and fiscal operations to determine if
funds and resources, accountability and transparency, effective
oversight of VHA healthcare facilities, were in compliance with VA
policies. Since their establishment 16 years ago, the VISN
organizational office expenses had increased over 500 percent above the
original estimates. OIG reported VISN offices lacked adequate financial
controls and accurate information for areas such as travel, leased
office space, and performance awards. The growth in operational costs
and the fiscal issues identified supported that VHA needed to
strengthen VISN office financial management and fiscal controls. VHA
lacked fundamental management controls and quality data needed to
ensure that VISN offices effectively and efficiently use staffing
resources that might otherwise be used for direct patient care.
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\17\ Audit of VHA's Management Control Structures for Veterans
Integrated Service Network Offices (March 27, 2012); Audit of VHA's
Financial Management and Fiscal Controls for Veterans Integrated
Service Network Offices (March 27, 2012).
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The Under Secretary for Health agreed with the findings and
recommendations and put plans in place to establish a more uniform
organizational structure. VHA established work teams to analyze the
VISN office operations and to address the VISN offices' lack of a clear
consistent definition of purpose that links to a standard structure and
function capability. VHA now has agreement on a clear plan to
streamline and standardize VISN organizational structure and staffing
and is in the process of implementing this plan for more effective
oversight of its healthcare facilities and related community-based
outpatient clinics, nursing homes, and veterans' centers.
veterans integrated service network procurement practices
Since fiscal year 2000, the OIG has identified procurement
practices as a major management challenge. VA made major changes
intended to strengthen its procurement process including establishing
an integrated oversight process that replaced traditional, technical,
and legal reviews. In a review of VISN contracts,\18\ the OIG assessed
whether VHA implemented the new controls effectively and provided the
oversight and resources needed to ensure VISN contracting officers
award and manage contracts in accordance with acquisition laws,
regulations, and VA policy. We reported that required integrated
oversight reviews were not conducted on about 68 percent of contracts,
when required. In fact, we estimated almost 3,000 contracts valued at
just under $1.6 billion were at risk because systemic contracting
deficiencies associated with acquisition planning, contract award, and
administration were not effectively addressed.
---------------------------------------------------------------------------
\18\ Audit of VHA's Veterans Integrated System Network Contracts
(December 1, 2011).
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veteran homelessness
In November 2009, the VA Secretary announced a goal to end
homelessness among veterans by 2015. OIG performed an audit \19\ to
determine whether community agencies receiving funds from the Grant and
Per Diem Program are providing services to homeless veterans as agreed
upon in their grant agreements in fiscal year 2012. Further, we
examined whether program funding was effectively aligned with program
priorities. This program provides transitional housing for homeless
veterans through partnerships with nonprofit and local government
agencies. Serious female veterans' housing, safety, security, and
privacy issues were discovered during the course of our audit that
required immediate management attention by VHA.
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\19\ Audit of VHA's Homeless Providers Grant and Per Diem Program
(March 12, 2012); VHA's Safety, Security, and Privacy for Female
Veterans at a Chicago, Illinois, Homeless Grant Provider Facility
(September 6, 2011).
---------------------------------------------------------------------------
We reported the placement of homeless females in a male-only
approved provider facility. The seriousness of the issues supported a
need for VHA to perform a nationwide assessment to identify other
inappropriate housing situations placing veterans at risk under the
grant program. VHA officials took immediate action to conduct an
inventory to ascertain the gender-mix identified in each funded grant
proposal and the appropriateness of the services available relative to
the veterans currently served. Housing situations were assessed to
better ensure the privacy, safety and security of homeless veterans. We
also reported VHA lacked an effective mechanism to assess and measure
bed capacity, procedures to monitor the liability of reported
information, and sufficient training on program eligibility. A weak
grant application process created uncertainties on the abilities of
some providers to deliver the supportive services described in their
grant proposals. To minimize the risks to homeless veterans in this
program, VHA agreed to implement standards to ensure providers have the
capability and mechanisms to deliver proposed services to homeless
veterans prior to awarding grant funds.
va conferences
In September 2012,\20\ OIG reported that VA processes and oversight
were too weak, ineffective, and in some instances non-existent, to
ensure conference costs were accurate, appropriate, necessary, and
reasonably priced. Simply put, accountability and controls were
inadequate to ensure effective management and reporting of dollars
spent for two human resources conferences. We questioned about $762,000
as unauthorized, unnecessary, and/or wasteful expenses. More than a
year after the conferences, VA was unable to provide an accurate and
complete accounting of costs associated with two of its conferences.
Further, significant expenditures were authorized by VA staff lacking
authority to make the purchases, resulting in unauthorized commitments.
Transparency was lacking for what services VA purchased and paid for.
Sound conference management processes and practices were needed to gain
assurance that future business could be conducted in an economical
manner in order to ensure proper fiscal stewardship of taxpayer funds.
This work is important since VA conference spending had reached almost
$100 million annually.
---------------------------------------------------------------------------
\20\ Administrative Investigation of the fiscal year 2011 Human
Resources Conferences in Orlando, Florida (September 30, 2012).
---------------------------------------------------------------------------
office of inspector general (oig) investigative work
From April 1, 2012, through March 31, 2013, the Office of
Investigations opened 1,028 and closed 1,046 investigations, arrested
493 individuals for a wide variety of criminal offenses, and completed
judicial actions resulting in more than $1.8 billion in fines,
penalties, restitutions, and civil judgments.
service-disabled veteran-owned small business program
We arrested 13 individuals who defrauded VA's Service-Disabled
Veteran-Owned Small Business Program. Those sentenced during this
timeframe received 142 months' imprisonment and were ordered to pay
$8.7 million in fines, restitution, and forfeiture. Additionally, the
13 individuals and companies involved have been referred to the VA
committee for suspension and debarment. During this timeframe, seven
individuals and four companies were suspended, and four individuals and
one company were debarred from contracting with other Federal agencies.
fiduciary fraud
We arrested 19 individuals who stole money from VA beneficiaries
who were not competent to handle their financial affairs. In addition
to the 266 months' imprisonment imposed this past year, restitution
ordered exceeded $3.5 million.
threats and assaults
The OIG received 561 threat referrals, resulting in 57 full
investigations. We open a referral on every threat allegation that is
reported by VA, VA police service, or others. The vast majority involve
preliminary investigations that normally include an interview of the
subject and results in the subject admitting that they were not serious
about the threat and were only trying to get VA to act on their
particular issue. Full investigative cases are opened for cases that
involve the arrest, involuntary committal, or result in a substantial
amount of investigative work. These full investigations resulted in 36
arrests. Although many threat referrals do not result in judicial
action, we take all threats against VA employees and VA property
seriously.
We also conducted 35 non-sexual assault investigations resulting in
27 arrests, and 25 sexual assault investigations resulting in 11
arrests. These involved veteran assaults on VA employees, VA employee
assaults on veterans, employee on employee assaults, and veteran on
veteran assaults.
beneficiary travel fraud
We recently prioritized the deterrence of fraud associated with
VA's beneficiary travel reimbursement program, which was funded at
approximately $861 million in fiscal year 2012. Typically, this type of
fraud involves veterans grossly inflating the number of miles driven to
and from VA facilities by providing a false home address on the claim
form. During the last 12 months, we conducted 201 of these
investigations, resulting in the arrest of 63 individuals. In each of
these prosecutions, we encouraged prosecutors to issue press releases
to deter this type of fraud. In addition to developing our own data
analytic tool to proactively identify potential fraud, we have worked
closely with VHA program officials to significantly enhance their data
mining efforts and design new warning posters to be placed where
veterans file claims.
new oig initiatives
We are currently performing an audit to assess whether VHA is
effectively managing purchased home care services to ensure veterans
receive appropriate services.
OIG's current work in VHA includes examining the management of
hearing aids, as hearing loss is the most common service-connected
disability. We are also assessing whether VHA is effectively managing
the allocation of Home Telehealth Program funds to improve access to
care and to reduce patient treatment. Work in VBA includes projects
that are examining the accuracy and timeliness of GI Bill payments and
assessing the effectiveness of VBA's processing of Quick Start Claims.
While it is too early to report results on the GI Bill project, our
preliminary results support that the processing of Quick Start Program
claims is taking longer to process than the average time for all
disability claims. In addition, our preliminary results are that VBA
needs to improve the Quick Start claims-processing accuracy rate.
As President Obama's administration has placed emphasis on reducing
spending on management support service contracts, we are examining if
VHA ensured support service contract requirements were justified, and
assessing how well contract performance is monitored. As we continue to
focus our efforts to help VA improve the weaknesses in contract awards
and administration, we have teams examining whether the Technology
Acquisition Center (TAC) is effectively awarding and administering
information technology service contracts. From October 2010 to June
2012, the TAC awarded almost 4,475 contracts valued at $8.8 billion. We
also have two active projects reviewing purchase card activity. One
project is identifying opportunities for VHA to realize savings
annually by leveraging purchase card use while the other project is
examining the extent that VA personnel are making unauthorized
commitments using purchase cards. Lastly, we plan follow-up work to
assess the effectiveness of VA's controls over conference management
expenditures, to determine whether VA is demonstrating effective
controls in spending.
conclusion
At a time of unprecedented demand for VA benefits and service, the
OIG has directed its oversight efforts on VA's most formidable
challenges, including disability claims processing and mental
healthcare. We will continue to provide VA with recommendations on how
to improve benefits and services to veterans, and the information
technology, financial, and acquisition systems that support VBA and
VHA's delivery of these services. We are committed to these efforts
both because it is good government and because it honors our Nation's
commitment to those who served. With increased attention to the areas
outlined in this statement, we believe that VA can improve performance,
achieve savings, and reduce risks.
Mr. Chairman, thank you for the opportunity to discuss the results
of the work of the OIG. We appreciate the continued steadfast support
and interest you and the subcommittee have demonstrated for our
mission. We welcome any questions that you or other members of the
subcommittee may have.
BACKLOG OF CLAIMS
Senator Johnson. Mr. Griffin, the VA's strategy to breaking
the claims logjam is pinned on successfully developing and
deploying VBMS. Deployment of this paperless system to all
regional offices is scheduled for June 2013.
In February, the inspector general issued a report on VBMS
and found that the VA had not fully tested the system. However,
the Department continued with the deployment.
Moreover, I've been told that as recently as last week, the
system was experiencing performance problems. This is very
concerning, to say the least.
What has the inspector general found in its investigations?
And are you planning any follow-up reports on this issue?
Mr. Griffin. I would say that the deployment of VBMS at the
regional offices that it has been sent to is not necessarily an
indication that the system is 100 percent operable and ready to
perform. I know that VBA would tell you the same thing, that
there are multiple new initiatives that are being rolled out
simultaneously, and it's being done at a time when they're
facing massive new claims from post-9/11 veterans, from
veterans who are aging, veterans who qualified for newly
identified agent orange diagnoses and benefits, et cetera.
So they do have a steep climb, but there's not one silver
bullet that's going to make this thing right. There are a whole
series of different initiatives that are being rolled out all
at once, and it's going to be a tough task to try and have
everything work just perfectly in order to meet the 2015 goal.
Now as far as this follow up work, if I may, Linda
Halliday, who oversees our audit staff, as I mentioned, has a
team that is going to continue to monitor VBMS deployment. And
she has another team that is doing inspections of all the
regional offices on a 3-year cycle. So I would ask her if she
would like to add anything.
Senator Johnson. Please.
Ms. Halliday. We are looking at the system, the functional
requirements that are being developed, to see if there is any
gap in those, looking at the viability of the project schedule,
looking at things like the expected transaction volume response
time and whether the system really can produce accurate
results.
Right now, VBMS has really processed about 4,000 claims.
Not all of those claims were processed through the VBM system
completely, because some went through as the pilots and the
staff doing some of the claims toggled back and relied on
legacy systems when they had some system performance issues.
But VBA is moving forward, and we will look at both the
production and the system viability and the risks in that
scheduled deployment. We will also look at the accuracy of
claims.
Senator Johnson. Mr. Griffin or Ms. Halliday, does your
office believe that the 2015 goal is achievable?
Mr. Griffin. Mr. Chairman, everyone who has attended this
hearing today would love for that to be an accurate prediction.
But is that January 2015? Or is that December 2015?
Senator Johnson. That the VA can----
Mr. Griffin. That's a year apart. So I think it's a stretch
goal in the face of the number of different initiatives that
are being brought to bear simultaneously.
And as Madam Chairman indicated, there's a certain amount
of training that's going to be required in order to make the
switch from the old legacy systems to VBMS.
And as expected, what we have found is that it's causing
the process to be slower now. That was acknowledged up front,
but that's the reality.
So 2015 would take a great coming together of a number of
issues, and I think it's really a stretch goal.
Senator Johnson. Mr. Griffin, as I mentioned in my
statement, I'm concerned that shortfalls in monitoring mental
healthcare patients being treated by outside contractors could
be more widespread than just one facility.
Does the inspector general's office plan to conduct spot
audits of any other VA medical centers, particularly those in
densely populated urban areas, to assess whether the problems
found at the Atlanta Medical Center are potentially widespread?
ACCESS TO VA MEDICAL CARE
Mr. Griffin. I will give you a preliminary response, and I
want to ask Dr. Daigh to also weigh in on this issue. We did do
an audit on wait times in mental health about 1 year ago. We
found that the methodology that was being utilized to determine
wait times was not one that we found to meet VA's own standard.
We issued a report about that, and we received comments back
from the Department.
We get about 30,000 hotline contacts a year in our
organization. It covers the full range of activities. A lot of
them involve claims. A lot of them will involve access.
Frankly, the point that Senator Collins brought up about
excessive medications and the resulting outcomes, which we've
witnessed in the form of sexual assault and regular assault,
and threats on VA employees, veteran-on-veteran threats and
veteran-on-employee threats, are a byproduct of that same
issue. So it is a very important issue.
Dr. Daigh's people go to every medical center in the
country on a 3-year cycle. They identify what we think to be
the most critical areas to look at, and certainly mental health
is on their radar. So I would ask Dr. Daigh if he would expound
upon that.
Senator Johnson. Dr. Daigh.
Dr. Daigh. Yes, sir.
I would say that the breakdown that we found in Atlanta was
probably best described as an inability to coordinate and
monitor the care of veterans. Because VA Atlanta was
overwhelmed with mental healthcare demand, they had to send to
outside providers for treatment.
So it's fairly common for me to find, through usually
hotline work, that VA has a very difficult time managing care
that they procure either through what they call their fee-basis
program or, in this case, where they had contracts with these
community mental health providers.
I should say that in a prior report looking at Montana, we
found the actual opposite result. We found that in Montana
several years ago, VA had a very good alliance with local
mental healthcare providers, to a great impact in a positive
way on delivery of mental healthcare services to veterans.
I think that VA needs to say to themselves that we're
responsible for all the veterans, not just those who are
enrolled at our facility. And if you start with that mindset,
then when you think about the veterans who are in your region,
and you realize that travel time is an issue, it forces you to
look at the provision of care locally, like Project ARCH, which
I'm only minimally familiar with. But ARCH works well reflects
the kind of coordination that I think VA needs to work on more.
So there is a system of community mental health providers
and clinics that vary State-to-State and sometimes county-to-
county. But in order to be effective, VA has to have a way to
pay efficiently and pay a reasonable price for the care. They
have to have a way to get the medical record the VA has
electronically into the hands of the provider they'd like to
see this patient. And they have to wait then to receive
information on the care provided.
So if you simply say, here's a chit for fee basis, go get
care, that doesn't work very well.
And in Atlanta, again, the failure for the business
practices of the contract, and then the clinical practices of
ensuring that the proper information went with the veteran to a
provider, and that information was received, was really totally
broken.
So we've seen it work, and, unfortunately, I've seen it
fail more than I've seen it work.
Senator Johnson. Senator Begich.
Senator Begich. Mr. Chairman, thank you very much. I just
have a couple questions.
Thank you all for being here.
ANCHORAGE VA REGIONAL OFFICE INSPECTION
You all did an inspector general report for Alaska. VA
showed an error rate, and I'm just curious if you could expand
on that, and what you saw was maybe a significant issue there,
or was it multiple issues?
Could you help me there on the error rate disability
claims? As you probably saw in the authorizing committee a few
weeks ago, I got a little animated on this issue, because it
was somewhat amazing to me.
And for such a--I want to say a closed environment--and
Alaska's not complicated. We're not having people leave State,
come back to States. You know, they're there. It's not a
complicated thing.
And so, first, I want to say, thank you for doing the
report, because without your report, I'm not sure we would have
known the depth of this issue, and the impact it's having on
Alaskans. And it's also a little piece of the bigger issue of
disability claims.
Can you just give me a sense of where those problems are?
And then, do you feel that they are moving forward at a decent
rate of correcting these errors or these issues?
And I'll give you one comment here, and that is, as a
former mayor, we had an internal auditor. I always liked when
our Department said, after the audit, they all said, ``We agree
with their conclusions,'' and blah, blah, blah. And then a year
later, I find out my department hasn't done one damn thing.
So can you give me the assurance I need that they're
actually doing and following up on the issues you've brought
forward?
I didn't mean to give you a lot there, but this one is a
big issue, as you know.
Ms. Halliday. Well, we did our first benefits inspections
in 2009. And at that time, we went in and we looked at four
different medical type ratings. The Anchorage VARO had an error
rate at that point of 29 percent for that group of claims.
TEMPORARY 100 PERCENT RATINGS
The second time, in January 2013, we went in and looked at
temporary 100 percent disability evaluations and traumatic
brain injury, and just those two areas, because we were clearly
focusing on some of the financial risks associated with
inaccuracies there.
Senator Begich. Very good.
Ms. Halliday. The error rate had gone up to 47 percent. We
were concerned that----
Senator Begich. Can I pause you there for a second?
In your 2009 report, did you not have not only notification
of the problem, but suggestions or recommendations, or at least
areas of concern that they should focus on?
Ms. Halliday. Yes, we did.
Senator Begich. Is that a fair statement?
Ms. Halliday. Yes.
Senator Begich. Did they not do that?
Now, remember, you're the inspector general. You get to say
what we need you to say to make sure we're trying to figure
this out. Because it sounds like--I mean, that's 4 years--for 3
years. Let's say 3, because 2013 isn't completed.
Help me understand. You give them a list, and tell them 29,
or whatever the percent is. Three years later, you take two of
the subsets. And they, I don't want to say double, but pretty
sizable increase in errors. So something didn't happen, or
maybe not as aggressively as it could have. Help me here.
Mr. Griffin. Let me step back a little bit on the process
that we use, because VBA has their own process, called STAR,
wherein they evaluate accuracy in their claims processing.
That's the number that when they're saying in 2015 they'd like
to get to 98----
Senator Begich. Percent fulfillment and so forth.
Mr. Griffin. Right. Accuracy.
Senator Begich. Right.
Mr. Griffin. When we, with the resources we have available,
go into a regional office to look at the claims that were done
there, if someone is a double amputee, that's one of those
express lane type cases, there's no--I mean, that's a slam-
dunk. This is 100 percent, and you're done with it.
Senator Begich. Right.
Mr. Griffin. We change from one cycle to the next what we
think we need to look at. So in 2009, the types of claims we
looked at, we gave them specific recommendations, and they
agreed to fix those.
When we went back----
Senator Begich. But did they?
Mr. Griffin [continuing]. We had different ones.
Senator Begich. So do you not then, on those that they
agreed to fix, how do you know----
Mr. Griffin. We will check. We do follow-up. We have a
separate unit that when we put recommendations out----
Senator Begich. Okay, but it's 3 years.
Mr. Griffin [continuing]. They say we will fix this by a
date certain.
Senator Begich. Did they give you dates that are now past
due?
Mr. Griffin. Yes, that's in our report. In the 2009 report,
when they concur, they will say, completion date of x.
Senator Begich. Okay, understood. I don't have 2009 sitting
in front of me.
Mr. Griffin. Right. I know, but just from a process
perspective.
Senator Begich. Sure. Okay.
Mr. Griffin. We will keep that report open until we're
satisfied that the issue has been fixed.
Senator Begich. Is that report still open?
Mr. Griffin. I don't have it in front of me, either.
Senator Begich. Okay.
Mr. Griffin. We will let you know about that and the
subsequent report.
[The information follows:]
The 2009 report on the Inspection of the VA Regional Office
Anchorage, Alaska, contained 12 recommendations. We closed our report
on June 17, 2010, which means that the VA Regional Office provided
information on actions they implemented that we believed would address
all of our recommendations. The most recent inspection report released
in January 2013, contains six recommendations and all remain open as of
the date of the hearing.
Mr. Griffin. So you have to realize, when we review these
temporary 100 percent claims, after 18 months, when you're a
temporary 100 percent claim, there has to be a follow-up
medical exam to see if you still deserve 100 percent.
Senator Begich. Understood.
Mr. Griffin. So if that medical exam doesn't happen, and
there are a number of reasons why it wasn't happening, one
being that in some instances there was a problem in the
software, and even if it was put in, it was dropping out of the
system.
Senator Begich. Understood. Okay.
Mr. Griffin. But we've looked at the universe of all of
them, in an audit from January 2011, and we concluded after
that audit that over 5 years, if this wasn't fixed, it was
going to cost $1.1 billion.
Senator Begich. In this office?
Mr. Griffin. No, nationwide.
Ms. Halliday. Nationwide.
Senator Begich. Nationwide, okay. You almost gave me a
heart attack there.
Mr. Griffin. And we did the Baltimore office weeks ago. We
issued that report. They had an 83 percent error rate in the
temporary 100 percenters.
So if it's $200 million a year, we're 2 years and 3 months
past the date of that national audit.
And now the computer glitch is supposed to have been
addressed, but that just deals with future cases. The ones that
we identified as needing to be reviewed to make sure that if it
had fallen out, that it's reinserted, we're still waiting for
proof that that's all been done.
Senator Begich. Let me ask this, and then I'll ask, Mr.
Chairman, if it's okay, I do have a couple other questions, but
I'll submit those for the record.
But here's what I want to be able to know and be able to
understand, because this is very frustrating to me, because
being on the appropriations side and being on the authorizing
side, it's kind of an interesting story, you might say.
So you do the audits. You make recommendations. You follow
that up through a separate office. You keep the audit open
until those items are satisfied, I mean those things they said
were going to be done, are done.
And then you take another step to make sure what they said
they were going do is done, and producing the results, in
theory, right, to lower the error rate. Would that be the
theory? What you recommend should lower the error rate. Is that
right?
Mr. Griffin. Yes.
Senator Begich. Okay. But do you take that last and final
step and give maybe here or to the authorizing committee,
because here's my biggest frustration around this place here.
It's almost like, 3 years from now, we'll have the same
discussion, because everyone does their reports and everyone
says that you bet, we will concur. And then they kind of
concur, but maybe not as robust as we said, and then they'll
tell us we didn't have enough money to do it. And then you do
another audit. And then we say, why don't you do some more?
So is there a process that we see actually you go and you
audit. They say they do this. You say they've completed it.
And, oh, by the way, now there are results, because the result
you just give me, it's going the wrong way, even though it's a
subset. I recognize that. They are apples and oranges, to a
degree.
But if they're having problems in this, I would put money
on it, they're having problems elsewhere. I'm just doing an
educated guess, not a data-driven.
Is that a fair statement or am I way off here?
Mr. Griffin. It is fair, but what is not fair is the apples
and oranges part.
The 2009 review looked at different areas. As I said, it
would make no sense for us to invest time and resources to look
at something that is a slam-dunk. And you're not going to get
it----
Senator Begich. I agree.
Mr. Griffin. TBI is tough.
Senator Begich. I agree.
Mr. Griffin. PTSD is tough.
Senator Begich. Right.
Mr. Griffin. Gee, is this, 100 percent, 50 percent, 20
percent or none? And it's a very difficult process.
The physical injuries are a slam-dunk, and those should be
expedited. TBI is tough. This temporary 100 percenter has just
been something that, you know, has taken too long to get fixed.
In further answer to your question, when her team goes back
in 2012 to look at what's going on now, they will have looked
at the 2009 report. They will see, yes, they said they'd fix
these things. And while they're there, they will satisfy
themselves that they did.
The same thing with Dr. Daigh's personnel that are going to
the medical centers on a 3-year cycle. If they were in the
medical center in Chicago at Hines 3 years ago and gave them 10
things or 5 things that they thought needed to be addressed, we
would track those through follow-up.
It would be too intensive to go back every time. So show me
your policy, show me how you did it.
But then when his people go back 3 years later, they will
make sure of it.
Senator Begich. Look at the outcome. Very good. Thank you.
Thank you, Mr. Chairman. I didn't mean to go on there, but
I think disability claims is a common thread among us all here,
and to understand this process is, I think, helpful for all of
us.
Thank you very much.
Senator Johnson. Thank you for your testimony, Mr. Griffin
and colleagues. And thank you for your work on behalf of the VA
and the Nation's vets.
ADDITIONAL COMMITTEE QUESTIONS
For the information of members, questions for the record
should be submitted by the close of business on April 26.
[The following questions were not asked at the hearing, but
were submitted to the Department for response subsequent to the
hearing:]
Questions Submitted to Hon. Eric K. Shinseki
Questions Submitted by Senator Tim Johnson
integrated electronic health record (iehr)
Question. Secretary Shinseki, the budget includes $344 million for
the integrated Electronic Health Record. The subcommittee has been very
supportive of this joint VA-DOD effort. However, there are questions
about the future and direction of this program.
Can you please explain to us what has changed since last year and
what direction the iEHR is taking in 2013?
Answer. To be clear, VA and the Department of Defense (DOD) are not
moving away from the goal of a single, joint, integrated Electronic
Health Record--both Secretary Shinseki and Secretary Panetta reaffirmed
the Departments' commitment to this in public statements on February
5th. What has changed is the strategy that we will use to accomplish
that goal. The revised program strategy includes a shift in focus to
``quick win'' interoperability accelerators and a shift in strategy
from ``buy, adopt, create'' to ``adopt, buy, create,'' which will
reduce risk and cost, while also accelerating the delivery of
capability to users. As part of this strategy to get the compatibility
sooner, the Departments will define a ``core'' set of integrated
Electronic Health Record (iEHR) capabilities that will allow us to
evaluate the selection of existing Electronic Health Record (EHR)
products to reduce program risks and costs while accelerating
implementation. VA has committed to deploying an iEHR core based on
VistA. DOD is currently in the process of evaluating options, including
both VistA and commercially available products, for its core system.
All of these efforts are focused on meeting the key dates of Initial
Operating Capability (IOC) in 2014 and Full Operating Capability (FOC)
in 2017.
As well as renewing our commitment to IOC and FOC, VA, and DOD
added a focus this year on accelerators. First, VA and DOD clinical
health data will be made available in near real-time using translation
mechanisms such as the Health Data Dictionary and DOD's adoption of
Blue Button. This data interoperability work will be completed by
January 2014. Second, the Secretaries approved deployment of the
presentation software called JANUS Graphical User Interface (GUI) to
five VA polytrauma rehabilitation centers and two associated Military
Treatment Facilities by July 31, 2013. JANUS is the tool clinicians use
to view VA and DOD health data simultaneously. Third, the Departments
will create a VA-DOD Medical Community of Interest network and security
infrastructure to enable the creation of a logical ``single medical
enclave'' that meets both Departments' security requirements, provides
equal access to iEHR services by both Departments, leverages existing
DOD and VA existing infrastructure, and provides connectivity between
DOD and VA medical networks. This is scheduled to be accomplished by
November 2013. Fourth, the Departments will rapidly adopt an identity
management solution to establish consistent methods for identifying and
retrieving persons across the two organizations. This is scheduled to
be completed by December 31, 2013.
Question. And, what will this change mean in terms of the overall
cost of the program and timeline for deployment?
Answer. While the original budget estimate in 2011 projected a
development and deployment budget of $4-$6 billion, this estimate was
conducted using analogous work based on the requirements and
architecture known at that early stage. The Interagency Program Office
(IPO) developed a bottom-up Life Cycle Cost Estimate (LCCE) in
September 2012. This LCCE was nearly double the budget estimate that
was made when the program was just beginning. The development of LCCE
was required as part of the Milestone B approval process, a part of
DOD's acquisition process and the process adopted across the broader
iEHR Program. While VA agrees with the methodology used to develop the
new LCCE, VA is still working with IPO to adjust LCCE to reflect the
significantly lower costs seen by VA as a result of fully embracing the
Program Management Accountability System.
We believe costs will be driven down by the decision to accelerate
data interoperability capabilities, the shift in strategy to select a
minimal core set of capabilities from an existing EHR system as the
foundation of iEHR, the adjustment of the business rule to ``adopt,
buy, create,'' and institutionalizing the delivery of customer-facing
software in increments of 6-months or less.
The timeline for deployment has not changed. The Departments are
committed to meeting IOC in 2014 and FOC in 2017.
board of veterans appeals
Question. Mr. Secretary, the average time to resolve an appeal
before the Board of Veterans Appeals is currently approaching 2 years,
and the backlog of claims is growing, from more than 39,000 claims in
2012 to a projected level of more than 65,000 claims in 2013--close to
double. At the same time, staffing at the BVA has been steadily
decreasing. At my direction, the fiscal year 2013 MILCON-VA bill
included an additional $8 million above the budget request for
additional personnel at the BVA.
What is the current staffing plan for the BVA, and what steps is
the VA taking to address this unacceptable backlog of claims before the
BVA?
Answer. As noted in the chairman's annual report, in fiscal year
2012 the average time to resolve an appeal before the Board of
Veterans' Appeals (BVA or Board) from physical receipt of the case at
BVA to issuance of a BVA decision was 251 days. This includes the
Board's cycle time of 117 days. Cycle time measures the time from when
an appeal is physically received at the Board until a decision is
reached, excluding the time the case is with a Veterans Service
Organization (VSO) representative for preparation of the written
argument. Notably, the appeals process is bifurcated with most of the
appeals processing steps taking place at the VA Regional Office (RO)
level and the final appeals adjudication taking place at the Board
level. Specifically, when the RO issues a decision with which the
veteran disagrees, the veteran can initiate an appeal at the RO by
filing a Notice of Disagreement (NOD). After that point, the RO issues
a second decision known as a Statement of the Case (SOC). In fiscal
year 2012, the average number of days between the RO's receipt of an
NOD and the issuance of an SOC was 270 days. Following the SOC, if a
veteran wishes to formalize the appeal, the veteran must file a
substantive appeal (VA form 9). After that point, the RO can certify
and send the appeal to the Board for a final decision.
BVA has commenced an aggressive hiring plan to execute the $8
million additional funding provided in the Consolidated and Further
Continuing Appropriations Act of 2013. In order to complete this hiring
effort, BVA has obtained the necessary Human Resources (HR) support by
signing a memorandum of understanding with the Veterans Health
Administration's HR staff. The Board has also assessed its critical
needs by position type and has updated its Spend Plan accordingly.
Additionally, the Board is in the process of surveying existing office
space, equipment and training needs to accommodate the increase in Full
Time Employees (FTE). Finally, in order to recruit the requisite staff,
BVA has ongoing job announcements open.
As a result of these efforts, BVA expects to on-board approximately
25 attorneys in the next month. The Board is reviewing and interviewing
additional applicants on an ongoing basis, and will continue to hire
attorney staff for the remaining 4 months of fiscal year 2013 to
execute the additional funding. There is a direct and proportional
correlation between the number of BVA employees and the number of
decisions produced per year, with an average of 90 decisions produced
per FTE. With the $8 million increase, BVA will be able to hire
approximately 55 FTE (all attorneys), thus resulting in an additional
4,950 decisions produced per fiscal year once they are fully trained.
In addition to pursuing this aggressive hiring plan, to address
BVA's growing pending inventory of appeals, the Board is also actively
engaged in efforts to increase efficiencies in the appeals process. In
particular, BVA has increased Video Teleconference (VTC) hearings,
which allows BVA judges to reduce travel for hearings, and, thus,
remain in the office and leverage the down time to work cases when an
appellant fails to appear for a hearing. VBA and BVA have also
partnered on a Joint Training Initiative to reduce remands to the field
and the resulting rework that is required when BVA remands to VBA.
Additionally, BVA is pursuing a Lean Six Sigma study of the BVA
decision-writing process to find efficiencies to increase decision
output. BVA is also leveraging technology to further streamline
operations, to include use of a virtual docket that allows for
efficient electronic management of BVA hearings, and virtualization of
hearing transcripts and mail processes, thereby eliminating delay
caused by adding paper copies to claims folders. Finally, BVA has set
forth a number of legislative proposals that seek to streamline the
adjudicatory process. These include: (1) allowing BVA more flexibility
in scheduling VTC hearings in order to minimize travel time and
expenses related to conducting in-person hearings in the field; (2)
reducing the time period to initiate an appeal with an NOD from 1 year
to 180 days; (3) clarifying that a timely filed Substantive Appeal (VA
form 9) is a jurisdictional requirement for BVA review; (4) simplifying
the content requirements of BVA decisions, making them more
understandable to veterans; and (5) changing Equal Access to Justice
Act (EAJA) fee requirements to better focus attorney energy at the
Court of Appeals for Veterans Claims (CAVC) on achieving improved
results for veterans.
leases
Question. Mr. Secretary, as you are aware, the Congressional Budget
Office has changed the way in which it scores VA medical facility
leases. This change has effectively made leasing medical facilities
nearly impossible because of Government accounting rules. This inside
the beltway accounting practice has already prevented 15 new medical
facilities from opening.
What contingency plans will the Department be instituting to ensure
that VA clinics are accessible to vets should these scoring practices
continue?
Answer. If the leases requiring authorization do not receive
authorization, VHA will need to execute multiple, smaller leases to
meet the projected demand for the existing services. This will ensure
patients do not face increased wait times, deficient parking, and
cramped space to accommodate the anticipated increases in workload.
Unfortunately, this will create inefficiency with duplication of staff
and logistics at multiple sites, a lack of continuum of care for
veterans in having different facilities providing various services, and
increased costs to contract care to ensure services are provided closer
to the veteran.
Question. And are current leased facilities in danger of closing
when the lease is up for renewal?
Answer. Eight leased facilities are in danger of closing, including
five clinical and three research and administrative. They currently
require authorization to renew their current size.
mental health inspector general report and continuity of care
Question. Mr. Secretary, the VA inspector general's office recently
released a report regarding mismanagement of the contract mental
healthcare program at the Atlanta VA Medical Center. Alarming as that
report was, I am concerned that the problem may not be limited to only
one facility. Increasing access to mental healthcare has been a
priority of this subcommittee as we have seen the staggering statistics
on PTSD, Traumatic Brain Injury (TBI), substance abuse and other mental
health conditions among the Iraq and Afghanistan vets. And most
troubling, as we have seen a spike in suicides among veterans of these
wars.
The inspector general reported that a lack of program oversight and
patient care management allowed thousands of patients to ``fall through
the cracks.'' Sadly, some of those patients committed suicide. A lack
of adequate funding and staffing were cited as contributing to the
problems at the Atlanta hospital.
What is the VA doing nationwide to ensure that mental healthcare
patients are receiving the continuity of care they need, and that
contract mental health programs are being effectively monitored?
Answer. VA has developed a quality improvement process to confirm
that facilities are implementing the required services and programs for
mental health to ensure veterans receive high-quality mental
healthcare. In fiscal year 2012, VA conducted site visits at all 140 VA
Health Care Systems to review implementation status of the required
mental health programs. Mental health site visitors, trained in the
standardized site visit protocol, were experienced field-based mental
health leaders and staff and mental health subject matter experts from
the Office of Mental Health Operations, Mental Health Services, Veteran
Integrated Service Network (VISN) leadership, and Office of Homeless
Programs. Site visitors spoke not only with facility leadership but
also frontline mental health staff, veterans, and families. The site
visitors served as consultants to support facilities to improve areas
that were noted to be challenging. Following the visit, the facilities
were also asked to develop and submit action plans for ongoing
improvement in areas needing improved quality, including improvements
in continuity of care. VA is working with the facilities to monitor
these improvement efforts and to make additional changes if required.
In fiscal year 2013, the Veterans Health Administration (VHA)
Mental Health began identifying VA medical centers interested in
initiating community contracts to address local mental health access
problems. VHA Mental Health and medical centers involved in this
workgroup are collectively developing examples of effective quality of
care requirements and processes in contracting for mental health
services. The products will be made available for all VA facilities or
VISNs who are seeking community contracts.
black hills health care system (bhhcs)
Question. Federal law requires the VA to protect, use, and preserve
its historic resources; consider multiple alternatives to proposed
undertakings; solicit and consider public input; and take into account
the effects of the VA's proposed changes to National Historic
Landmarks. Can you describe how the VA has fulfilled each of these
requirements in relation to any potential changes in services that may
be proposed at the Hot Springs, South Dakota, facility?
Answer. In May 2012, as required by the National Historic
Preservation Act of 1966 (NHPA), VA initiated formal consultation with
the South Dakota State Historic Preservation Office, the National Park
Service, and other consulting parties, regarding proposals to
reconfigure the VA Black Hills Health Care System (VA BHHCS). VA
continues to identify and evaluate a range of alternatives for
providing veterans with safe, quality healthcare services, while also
assessing, in collaboration with other stakeholders, potential effects
to historic properties these alternatives may have. Any recommended
reconfiguration of VA BHHCS services that has the potential to
adversely affect the Hot Springs campus or other historic properties
will continue to be the subject of NHPA consultation, as well as
National Environmental Policy Act analyses, to address such effects
through avoidance, reduction, or mitigation. Stakeholder input
collected by VA will be evaluated as part of the ongoing processes in
accordance with Federal law.
Question. VA's performance and accountability report for 2012
states that the agency is using the space it owns or directly leases by
116 percent (page II-83); in other words, it is in an overutilization
condition. As a result, the agency's leased space costs have risen to
$608 million in 2012 (page III-52). Yet the agency stewards an
inventory of at least 850 buildings and structures that are unused or
underutilized, some of which are in Hot Springs. How are these assets
accounted for in the VA's space utilization consideration and
performance reporting? Are they removed from the equation and, if so,
why?
Answer. VA's capital inventory includes all buildings at all
facilities nationwide, including the ``underutilized'' buildings at Hot
Springs. While it is true that VA is in an ``overutilization'' state by
16 percent nationally, the demographics and utilization figures have
wide variance related to specific market conditions, veteran
demographics, and service needs. The Hot Springs campus currently
indicates an excess of space because of the decreasing workload at that
facility caused by the declining veteran population. This has resulted
in the underutilized buildings at the Hot Springs campus.
______
Questions Submitted by Senator Mark L. Pryor
mental healthcare professionals
Question. In August 2012, the President issued an Executive order
on ``Improving Access to Mental Health Service for Veterans,
Servicemembers, and Military Families.'' One of the President's
directives was to expand the Department of Veterans Affairs mental
health services staff. Specifically, the VA was directed to hire 1,600
mental health professionals by June 30, 2013, and to hire and train 800
peer to peer counselors.
In late March, it was reported that 1,089 mental health
professionals had been hired and that the Department was confident it
would reach its target by the end of June.
Please comment on the specific qualifications of these mental
healthcare professionals. For example, do they range from certified
counselors and therapists, to psychologists with a master's or higher
degree?
Answer. Basic requirements for all mental health positions include
U.S. citizenship (however, non-citizens may be appointed when it is not
possible to recruit qualified citizens) and the following requirements:
--Licensed Professional Mental Health Counselor.--Hold a master's
degree in mental health counseling, or a related field, from a
program accredited by the Council on Accreditation of
Counseling and Related Educational Programs and hold a full,
current, and unrestricted license to independently practice
mental health counseling, which includes diagnosis and
treatment.
--Marriage and Family Therapist (MFT)--Education.--Hold a master's
degree in marriage and family therapy from a program approved
by the Commission on Accreditation for Marriage and Family
Therapy Education or have graduated from a nationally
accredited program conferring a comparable mental health degree
as specified in the qualification standards of those
disciplines (social work, psychiatric nursing, psychology, and
psychiatry). All additional course work taken to be accepted
for MFT licensure must come from a nationally accredited
program in one of the above areas and hold a full, current, and
unrestricted license to independently practice marriage and
family therapy in a State.
--Social Worker--Education.--Hold a master's degree in social work
from a school of social work fully accredited by the Council on
Social Work Education. Graduates of schools of social work that
are in candidacy status do not meet this requirement until the
school of social work is fully accredited. A doctoral degree in
social work may not be substituted for the master's degree in
social work. Furthermore, applicants must hold a current, full,
active, and unrestricted license or certification by a State to
independently practice social work at the master's degree
level.
--Nurse (Registered Nurse)--Education.--Graduate of a school of
professional nursing approved by the appropriate State agency
and accredited by one of the following accrediting bodies at
the time the program was completed by the applicant: The
National League for Nursing Accrediting Commission or The
Commission on Collegiate Nursing Education, an accrediting arm
of the American Association of Colleges of Nursing. Applicants
must hold a current, full, active and unrestricted registration
as a graduate professional nurse in a State, territory, or
Commonwealth of the United States (e.g., Puerto Rico), or the
District of Columbia.
--Psychologist--Education.--Hold doctoral degree in psychology from a
graduate program in psychology accredited by the American
Psychological Association (APA). Successfully completed a
professional psychology internship training program that has
been accredited by APA and hold a full, current, and
unrestricted license to practice psychology at the doctoral
level in a State, territory, Commonwealth of the United States
(e.g., Puerto Rico), or the District of Columbia.
--Physician--Education.--Degree of doctor of medicine or an
equivalent degree resulting from a course of education in
medicine or osteopathic medicine. The degree must have been
obtained from one of the schools approved by the Secretary of
Veterans Affairs for the year in which the course of study was
completed. Approved schools are: (1) schools of medicine
holding regular institutional membership in the Association of
American Medical Colleges for the year in which the degree was
granted; (2) schools of osteopathic medicine approved by the
American Osteopathic Association for the year in which the
degree was granted; and (3) schools (including foreign schools)
accepted by the licensing body of a State, territory, or
Commonwealth (e.g., Puerto Rico), or the District of Columbia
as qualifying for full or unrestricted licensure and hold a
current, full, and unrestricted license to practice medicine or
surgery in a State, territory, Commonwealth of the United
States, or the District of Columbia.
Question. What method does the VA use to determine how many mental
healthcare professionals are needed to service the veteran population?
Is there a ratio of providers to veterans?
Answer. VA has developed staffing guidance for general outpatient
mental health teams based on identifying staffing requirements per
1,000 veterans. VA is currently developing similar guidance for
specialty outpatient mental health teams. The factors considered in
developing these models include:
--veteran population in the service area;
--mental health needs of veterans in that population; and
--range and complexity of mental health services provided in the
service area.
This guidance is still being evaluated based on access, veteran and
provider satisfaction, quality of care, and provider productivity to
ensure the staffing guidance ensures access to high-quality veterans'
care.
Question. How is the VA identifying the rural veteran population,
and ensuring they have access to the same level of care?
Answer. VA has the same staffing requirements for rural veterans as
it does for urban veterans. However, VA has multiple innovative
strategies for ensuring staffing requirements for rural veteran are met
including the use of contract care, the use of telemental health, and
specialized healthcare delivery and transportation programs
specifically designed to meet the unique access needs of rural
veterans. The VA Office of Rural Health (ORH) addresses mental health
needs of rural veterans by funding targeted projects submitted by field
personnel and other related program offices in response to a request
for proposals that is announced each year. Mental health, homelessness,
provider training on mental health issues, and rural clinic mental
health staffing support are always high priorities for ORH. Each
application submitted is peer-reviewed for how well the proposed
intervention or program addresses the identified need. Local needs
assessments are conducted as part of the proposal preparation process.
Typically, the proposals will include information as to the number of
rural veterans potentially impacted, the prevalence of mental health
disorders in the local population, and a geographic gap analysis of
services. In fiscal year 2013, ORH funded 61 projects across 20 VISNs
totaling $21.8 million that included support for the following mental
health related projects.
FISCAL YEAR 2013 ORH MENTAL HEALTH FUNDED PROJECTS
------------------------------------------------------------------------
VISN Project name Funding
------------------------------------------------------------------------
V01 Chronic Pain Treatment Project $226,011
V01 Mental Health Rural Pilots 400,000
V01, V03, V06, Rural Health Training and Education 1,112,077
V21, V23 Initiative
V02 Behavioral Health Expansion in the 250,000
Tompkins/Cortland County Rural Areas
V02 Depression Medication Monitor Case- 213,328
Finding Outreach Program for Rural
Veterans
V02 Equine Therapy for Rural Veterans 20,000
V02 Veteran Rural Health Medical and 515,278
Psychological Resource and Services
Center
V05 Enhance Rural Access Network for 366,473
Growth Enhancement (E-RANGE) for
Eastern PShore
V05 Women's Health, Education and Training 476,791
in Rural Areas, Mental Behavioral
Health
V06 Albemarle Primary Outpatient Clinic 1,761,697
Includes Mental Health
V06 Building Communities: Planning for a 106,599
National Roll-Out of Rural Clergy
Training
V06 Emporia CBOC Includes Mental Health 1,660,000
Services
V06 Greenbrier County CBOC Includes Mental 1,687,304
Health Services
V06 Robeson County Mental Health Community 28,441
Outreach Program
V06 Staunton CBOC, Wytheville CBOC, and 299,450
Lynchburg CBOC Telemental Health
Include Mental Health Services
V06 Tazewell Telemental Health 146,888
V06 Educating Rural Clergy 180,707
V07 Public Psychiatry Fellowship 20,000
V07 Telephone Assisted Dementia Outreach 175,693
V07 Substance Use Disorders (SUD) and Post 710,815
Traumatic Stress Disorder P(PTSD)
Services at CBOCs
V07 Supported Employment for Rural 235,088
Veterans with Post Traumatic Stress
Disorder (PTSD)
V08 Mental Health Intensive Case 287,057
Management
V10 Expansion of Non-Drug Chronic Pain 41,000
Treatment
V10 Mental Health Intensive Case 176,346
Management Team
V10 Telemental Health Services 197,000
V12 Hancock CBOC Enhance Rural Access 344,000
Network for Growth Enhancement Team
P(E-RANGE)
V12 Integrated Primary Care Mental Health 860,671
Program for Rural Community Based
Outpatient Clinics
V12 Rhinelander CBOC Enhance Rural Access 195,000
Network for Growth Enhancement Team
P(E-RANGE) Team
V16 Enhance Rural Access Network Growth 303,957
Enhancement (E-RANGE)
V16 Relaxation Training and Self- 81,240
Management of Pain
V16 South Central Mental Illness Research 458,291
Education & Clinical Center (SC
MIRECC) Clergy-Mental Health
Partnership to Improve Care for Rural
Veterans
V17 Central TX Telemental Health Expansion 120,000
Domiciliary
V17 Harlingen Outpatient Clinic Enhance 360,000
Rural Access Network for Growth
Enhancement Team (E-RANGE) Team
Program
V17 Telemental Health Virtual Care Clinic 289,790
V17 Telepsychiatry within Central Texas 494,000
Veterans Health Care System Project
Expansion
V17 VISN-Wide Telemental Health Clinic for 150,000
Underserved Rural Veterans
V18 CBOC Show Low/Globe Includes Mental 804,441
Health Services
V18 Enhance Mental Health Services and 164,700
Post Traumatic Stress Disorder
Outreach for Rural Veterans on the
Navajo/Hopi Nation
V18 Enhance Mental Health Services for 260,000
Rural Veterans at the Northern
Arizona VA Health Care System CBOCs
V18 Post-Traumatic Stress Disorder (PTSD) 40,000
Awareness Training/Collaboration with
Indian Health Services
V19 Mental Health Rural Pilots 271,339
V19 Telepain Treatment 305,909
V19 Sheridan VA Medical Center Challenge 5,800
Course Enhancement
V19 Rural Native Veteran Telehealth 102,433
Collaborative Education &
Consultation
V2 Depression Medication Monitor Case- 213,328
Finding Outreach Program for Rural
Veterans
V20 Alaska Rural Native Telebehavioral 131,500
Health Development
V20 Oregon Rural Mental Health Initiative 1,804,620
V20 Mental Health Rural Pilots 200,000
V20 Sustainment of Mountain Home Outreach 485,800
Clinic
V20 Veteran Cycling for Health & Wellness 134,128
V21 Extension of Kauai CBOC Mental Health 207,187
Services to North/West Kauai
V21 Extension of Kona CBOC Primary Care 197,800
and Mental Health Services to North
and South Areas of the Big Island
V21 Home-Based Telemental Health (HBTMH) 282,382
for Pacific Region Rural Veterans
Requiring Post Traumatic Stress
Disorder Follow-up
V21 Treatment for Veterans and Family 106,766
Members
V23 Fargo Mental Health Intensive Case 336,000
Management (MHICM)
V23 Mental Health Rural Outreach--Max J. 89,982
Beilke (Alexandria) CBOC
V23 Telemental Health Connectivity with 134,000
Good Samaritan Hospital
V23 Rural Mental Health and Social Work 151,200
Services
V23 Telemental Health Care of Operation 132,278
Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn (OEF/OIF/
OND) Veterans at Western Illinois
University--Macomb Campus
V23 Addressing Rural Veteran Barriers to 176,884
Mental Health Care Using Web-based
Screening, Tailored Education, and
Direct Outreach
V23 Evaluation of a Permanent Housing 104,788
Model for Homeless Rural Veterans:
The Lodge Project Phase 2
---------------------------------------------------------
TOTAL 21,794,257
------------------------------------------------------------------------
Question. Please describe and discuss the peer to peer counselor
initiative and any current results from the program, or expected impact
once fully implemented.
Answer. Pursuant to Public Law 110-387, Public Law 111-163, and the
August 31, 2012, Executive order titled ``Improving Access to Mental
Health Service for Veterans, Service Members, and Military Families,''
VHA's Office of Mental Health Services is implementing and expanding
peer support services nationwide. By the end of December 2013, VHA
expects to have 800 peer specialists and peer apprentices deployed
among each VA medical center and each very large community-based
outpatient clinic (CBOC). As a condition of employment, peers working
in VHA must be certified to provide peer support services. VA has
contracted with a not-for-profit community agency to provide the peer
certification training at no cost to the peer. Peer specialists provide
services adjunctive to the services provided by degreed professionals
and are placed in a variety of mental health programs. Peer specialists
promote recovery by sharing their own recovery stories, providing
encouragement, instilling a sense of hope, and teaching skills to
veterans.
It is too early in the expansion of peer support to provide
clinical outcomes from the program. However, there have been studies of
peer support from non-VA settings as well as from the early, initial
implementation of peer support in VHA. The VA studies show that peers
influenced veterans' involvement in their own care and increased
veterans' social relationships. Other studies have shown several
benefits from peer support, including a decrease in the use of
inpatient mental health facilities, greater satisfaction and quality of
life, greater hopefulness, better treatment engagement, and better
social functioning. We expect similar results from the implementation
of peer support services nationwide.
2012 suicide data report
Question. This February the VA released a comprehensive report on
veterans who die by suicide.
In Mr. Petzel's response to the 2012 Suicide Data Report he
outlined four immediate actions the Department must take. Action No. 1
stipulated that he receive a full report with ``risk identification
strategies and patient-centered focused care options'' no later than
March 1, 2013. Has this report been created, and can you speak to its
findings?
Answer. A task group was chartered to address how to move mental
healthcare to a more patient-centered care approach for the five
highest risk groups including veterans with post-traumatic stress
disorder (PTSD), sleep disorders, chronic pain, substance use
disorders, and depression. A plan for addressing this issue was
submitted to Robert Petzel, M.D., Under Secretary for Health, who
approved moving ahead with the implementation strategy. Templates for
care for these groups are being developed as well as a communication
plan to assist in the culture shifts that will be required to fully
implement this strategy within mental health.
Question. Regarding Action No. 4, can you please discuss the VA-DOD
Joint Suicide Repository in terms of what data is included, and how
that data will enable the VA's suicide intervention strategy?
Answer. The suicide data repository will hold death and suicide
attempt information from both the Department of Defense (DOD) and VA.
Joint data purchases have been made from the Centers for Disease
Control and Prevention to obtain any death records available for anyone
who has served in the military since 1979. Also included in the
repository will be internal VA and DOD databases that include current
suicide attempt and completion data. Looking at this data from a
combined, broad perspective will allow us to identify more specific
risk factors about military and post-military individuals including,
but not limited to, risk information related to: discharge timeframes,
job categories, deployments, service branch and job categories, medical
diagnosis, medication use, etc. Knowing which and when veterans are at
risk will allow targeted education and outreach strategies as well as
enhanced care at critical periods.
Question. In addition to the Joint Suicide Repository, how are the
VA and DOD working together to address suicide prevention techniques?
Answer. VA and DOD have a long history of working together in
suicide prevention. Annual joint educational conferences are held to
share current research findings and care-related strategies. The
Veterans Crisis Line/Chat/and Text Service connects veterans in crisis
and their families and friends with qualified, caring VA responders
through a confidential toll-free hotline, online chat, or text. It also
serves as the Military Crisis Line and provides all the same services
to Active Duty servicemembers both in country and abroad. There are
toll-free options to call from Europe, Korea, and the Middle East. The
VA-DOD Joint Clinical Practice Guidelines have been developed and are
in the review process. Education and awareness programs and materials
are freely shared between the two departments. VA is also an active
member of the DOD Suicide Prevention and Risk Reduction Committee.
veterans homelessness
Question. In 2012 it is estimated that there were 62,619 homeless
veterans on a single night in the United States (Annual Homeless
Assessment Report (AHAR) prepared by HUD). While this is a significant
decline since 2009, veteran homelessness remains a significant issue,
one that my home State of Arkansas is working hard to address.
The President's budget request commits $1.4 billion towards
programs which prevent or reduce veteran homelessness.
Can you comment on the types of community-based organizations the
VA provides grants to, and measures of effectiveness that requires
continued and increased funding?
Answer. VA's partnerships with community-based organizations
provide the backbone to VA's efforts to end veteran homelessness. VA
provides grants to consumer cooperatives, public, and nonprofit private
community providers through the Grant and Per Diem (GPD) Program and
the Supportive Services for Veteran Families (SSVF) Program. VA also
partners with community-based organizations through its Health Care for
Homeless Veterans (HCHV) Contract Residential Treatment Program.
grant and per diem (gpd) program
Question. The GPD Program provides funding through grants to public
(State and local governments and Indian tribal governments) and
nonprofit private organizations to develop and operate transitional
housing and supportive services for homeless veterans. The GPD Program
currently has over 15,000 operational transitional housing beds in
every State, the District of Columbia, Puerto Rico, and Guam. During
fiscal year 2012, over 41,000 unique veterans received services from
the GPD Program. This included over 2,800 women. Over 12,000 veterans
exited the program to permanent housing in fiscal year 2012.
Answer. There is one 40-bed transitional housing GPD project in the
State of Arkansas. The GPD Program in Arkansas provided services to 192
unique veterans in fiscal year 2012, including 20 women veterans, with
102 veterans exiting the program to permanent housing during that year.
For the past 20 years, the GPD Program has been a mainstay of VA's
continuum of homeless programs. The GPD Program currently measures its
success through a performance metric which has a target of 60 percent
of homeless veterans exiting to an independent housing arrangement.
Through April 2013, the GPD Program is at 64.55 percent for this
performance measure, currently exceeding the target.
supportive services for veteran families program
Question. The SSVF Program provides supportive services grants to
private nonprofit organizations and consumer cooperatives to coordinate
or provide supportive services for very low-income veteran families.
The SSVF Program is designed to rapidly re-house homeless veteran
families and prevent homelessness for those at imminent risk of
homelessness due to a housing crisis. In fiscal year 2012, SSVF awarded
$100 million in funding to 151 community-based organizations serving
veterans families in 49 States, the District of Columbia, and Puerto
Rico. In 2013, the SSVF Program is expected to award nearly $300
million in supportive services grants.
Answer. St. Francis House based in Little Rock, Arkansas, is
currently the one SSVF grantee in Arkansas. Through March 2013, St.
Francis House has served 94 participants. Of the 94 participants, 76
participants have been discharged from SSVF with 73 participants (96
percent) being placed in permanent housing.
VA tracks performance of SSVF grantees through data collected in
the Homeless Management Information System and VA's Homeless Registry.
In fiscal year 2012, the first year of SSVF Program operations,
community-based grantees assisted over 35,000 homeless and at-risk
veteran families participating in the SSVF Program. This participation
rate significantly exceeded VA's projected expectation to serve 22,000
in the first year of operation. In fiscal year 2012, the SSVF Program
achieved significant success, with 86 percent of those exiting SSVF
services either being placed or being able to maintain permanent
housing.
health care for homeless veterans contract residential treatment
program
Question. HCHV Contract Residential Treatment Program provides a
gateway to VA and community supportive services for eligible veterans
who are homeless. This includes ensuring that chronically homeless
veterans and/or those with serious mental health diagnoses can be
placed in community-based programs which provide quality housing and
services that meet the needs of these special populations. Although
VA's HCHV Contract Residential Treatment Program is not technically a
grant program, local VA facilities offer competitive contract
solicitations to community-based providers to provide contract
residential treatment services and housing. Dedicated community
partners are essential to the success of this program. During fiscal
year 2012, HCHV provided funding for 3,287 beds through 299 contracted
community providers in all 50 States, the District of Columbia, and
Puerto Rico.
Answer. During fiscal year 2012, over 11,500 unique veterans
received residential services from the HCHV Contract Residential
Treatment Program. Over 3,800 veterans exited the program to permanent
housing in fiscal year 2012. In Arkansas alone during fiscal year 2012,
the HCHV Contract Residential Treatment Program provided residential
services to 281 unique veterans and 112 veterans exited the program to
permanent housing. There are currently 139 operational HCHV beds via
six contracted community providers in the State of Arkansas.
veteran education benefits
Question. Since implementation of the Post-9/11 GI Bill, the VA has
also implemented the Yellow Ribbon Program. The Yellow Ribbon program
allows universities (public or private) to supplement this VA benefit,
by covering 50 percent of the difference between that universities
tuition and the highest public in-State tuition rate. The other 50
percent is covered by the VA.
How has the Yellow Ribbon program improved veteran access to degree
granting institutions?
Answer. The Yellow Ribbon Program allows veterans to attend and
obtain degrees from private institutions of higher learning or to
attend and obtain degrees from out-of-State public institutions of
higher learning at no cost or with reduced out-of-pocket expenses at
participating schools. There are 1,862 schools, representing 3,269
locations, participating in the Yellow Ribbon Program for the 2013-2014
academic year.
Question. Since implementation, how many veterans, on average,
participate in the Yellow Ribbon Program annually?
Answer. VA has not yet collected the data that would allow us to
determine the average number of Yellow Ribbon participants.
Opportunities to participate in the Yellow Ribbon Program were offered
at 1,181 schools in 2009-2010; 1,109 schools in 2010-2011; 2,323
schools in 2011-2012; and 1,859 schools in 2012-2013.
Question. How long does the VA propose to fund this program?
Answer. The Yellow Ribbon Program is a permanent part of the Post-
9/11 GI Bill, and as such, is a mandatory expense which is funded
through the ``Readjustment Benefits'' account.
______
Questions Submitted by Senator Tom Udall
Question. As you know I worked to help pass the bipartisan burn
pits registry act last year. I believe that the VA should do more to
inform veterans about the possible threats to their health from
exposure to open burn pits in Iraq and Afghanistan.
What plans does VA have to inform veterans about the possible
threats to their health and how will this budget support those efforts?
Answer. VA is committed to the implementation of the burn pit
registry and to a strong communications effort with veterans. VA has
many ongoing programs to inform veterans of the potential health
effects of military service. VA provides a summary of the current
scientific assessment of the long-term health consequences of potential
exposure to open burn pits and other airborne hazards on its public
health Web site . In
addition to this robust Web site, VA subject matter experts (SMEs)
present at various scientific conferences where veterans groups have
been in attendance. SMEs also brief Veterans Service Organizations
periodically, provide information through VA social media such as
Facebook and Twitter, and provide exposure information to veterans
subscribed to the GovDelivery listserv. VA intends to leverage these
programs within its existing budget and is developing a comprehensive
communications plan focused on the burn pits registry. VA has
recognized the need for health risk communication and outreach and has
included this as an element of its joint VA-DOD Airborne Hazards Action
Plan developed in collaboration with DOD. Existing products include a
Web site focused on military exposures developed with veteran feedback,
a Federal Register notice summarizing VA's response to the October 2011
Institute of Medicine study on the Long Term Health Consequences of
Exposure to Burn Pits in Iraq and Afghanistan, periodic briefings to
Veterans Service Organizations (VSO), and educational products to
assist VA staff in communicating health risk from potential exposure to
burn pits and other airborne hazards to veterans.
Planned communications will continue to emphasize that open burn
pit emissions during deployment to Iraq and Afghanistan are one of the
many exposures of which veterans need to be aware. VA is conducting
epidemiologic studies on health effects associated with deployment to
include potential exposure to burn pits and working to establish the
Airborne Hazards and Open Burn Pit Registry by January 10, 2014, as
required by law. VA's communications plan for the registry has four
main objectives:
--Increase awareness of VA's burn pit registry;
--Increase participation in the burn pit registry;
--Increase care of symptomatic veterans and consultations with
concerned veterans as appropriate; and
--Foster understanding of VA's commitment and efforts to characterize
health effects.
Our primary target for our communication is veterans who served in
Iraq, Afghanistan, or the 1990-1991 gulf war. Other audiences will be
targeted to enable and encourage them to increase participation in the
registry. These audiences include VSOs and other advocacy groups, as
well as VA staff, including environmental health coordinators,
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn
Program managers and advocates, women's health coordinators, vet center
counselors, Transition Assistance Program coordinators, and public
affairs officers.
Question. Last year the VA and the Indian Health Service announced
an agreement in which VA would reimburse IHS for direct healthcare
services provided to American Indian and Alaska Native veterans.
What is the status of this partnership, and does the budget provide
enough funds to continue expansion of this program to improve access to
Native veterans?
Answer. The partnership between VA and Indian Health Service (IHS)
continues to grow. For IHS, VA has one signed VA-IHS National
Reimbursement Agreement, with 10 signed Local Implementation Plans for
Phase 1. This was completed ahead of the VA-IHS Reimbursement Agreement
6-month timeline. VA and IHS are coordinating Phase 2 implementation of
all remaining IHS sites. With regard to Tribal Health Program (THP)
reimbursements, VA continues to work closely with individual THPs to
finalize more VA-THP Reimbursement Agreements. There are currently 29
signed THP Reimbursement Agreements.
Adequate funding is available in the fiscal year 2013 and fiscal
year 2014 budgets to continue implementation of the VA-IHS National
Reimbursement Agreement and THP agreements.
Question. Like my fellow Senators, the VA Claims backlog is an
issue that I am also concerned about and I am committed to working with
the VA to reduce these claims and support the shift to a paperless and
more efficient system. The current claims process is unacceptable and
our veterans deserve better. That being said, I'd like to shift to one
of the related challenges of your solution to the backlog--a shift to a
paperless system--which creates a significant cybersecurity challenge.
What precautions is the VA taking to protect veterans information
in personal records from intrusion, and has the VA worked with other
agencies working to reduce the cyber threat such as the military and
the national labs through NNSA?
Answer. VA is committed to protecting the information we hold on
millions of veterans, their beneficiaries and more than 300,000 VA
employees, and protecting the data VA holds on our Nation's veterans is
one of our highest priorities. VA is responsible for providing the
tools, services and systems that are necessary to protect veteran
information at 151 hospitals, 827 community-based outpatient clinics,
57 benefits processing offices, and over 160 cemeteries or memorial
sites. Our network supports over 400,000 users, and 750,000 individual
devices.
IT security threats continue to evolve. To that end, we have
implemented the continuous monitoring program, which constantly checks
IT systems and monitors the devices attached to the VA's network.
VA launched the Continuous Readiness in Information Security
Program (CRISP) in 2012 to proactively address process and policy
deficiencies as well as architecture and configuration issues, and to
change the culture of VA's workforce to ensure that veteran information
security is ``baked into'' their daily routine. As part of the CRISP
effort, VA conducts rigorous vulnerability scanning, continuous
monitoring and patching and software inventory, implementing port
security, anti-virus services, and encryption of non-medical IT
desktops and laptops. The Department has worked to train staff on the
importance of protecting veteran data; as of June 1, over 98 percent of
VA's employees have taken mandatory information security training.
In addition, through Web Application Security Assessments, VA is
able to identify critical vulnerabilities and potential exploits in VA
systems. VA protects the network infrastructure by identifying all
networks assets, critical database stores, all external connections, as
well as providing the Trusted Internet Connection Gateways services.
VA works with the Department of Homeland Security and other Federal
entities to protect VA systems and data.
Question. Last Congress I introduced the Southern New Mexico and El
Paso, Texas Veterans Traumatic Brain Injury Care Improvement Act with
the hope of bringing attention to the need to create a center where
veterans in the region can receive treatment at a polytrauma center or
network site. The polytrauma system of care of the Department includes
four polytrauma rehabilitation centers and 21 polytrauma network sites,
none of which are located within 300 miles driving distance of Fort
Bliss, White Sands Missile Range, or Holloman Air Force Base, all areas
where many veterans have chosen to reside.
What is VA doing to address the lack of a polytrauma center in the
region and will the VA consider locating a center in the area in the
future and providing sufficient funding for a polytrauma center?
Answer. VA agrees with the proposal to enhance services for
polytrauma and traumatic brain injury (TBI) in the Southern New Mexico
and El Paso region by establishing a Polytrauma Support Clinic Team at
the El Paso VA Health Care System. This Polytrauma Support Clinic Team,
with an enhanced telehealth component at the El Paso VA Health Care
System, would meet the needs and the workload volume of veterans with
mild to moderate TBI residing in the catchment area and concurrently
facilitate access to TBI rehabilitation care for other veterans from
rural Texas, Arizona, and New Mexico, through telehealth. In fiscal
year 2012, 549 veterans received rehabilitation care related to TBI or
polytrauma at the El Paso VA Health Care System. This workload is
comparable to that of other Polytrauma Support Clinic Teams and
indicates the need for the development of similar capacity at El Paso.
The VA Polytrauma/TBI System of Care consists of four levels of
facilities, including: 5 Polytrauma Rehabilitation Centers (PRC), 23
Polytrauma Network Sites (PNS), 87 Polytrauma Support Clinic Teams, and
41 Polytrauma Points of Contact. This integrated, tiered system of
specialized care offers comprehensive clinical rehabilitative services
including: treatment by interdisciplinary teams of rehabilitation
specialists; specialty care management; patient and family education
and training; psychosocial support; and advanced rehabilitation and
prosthetic technologies.
Veterans recovering from TBI and polytrauma in southern New Mexico
and El Paso, Texas, are currently served by the PRC in San Antonio,
Texas; the PNS in Tucson, Arizona, Dallas, Texas, and San Antonio,
Texas; the Polytrauma Support Clinic Teams in Albuquerque, New Mexico,
and Phoenix, Arizona; and the Polytrauma Points of Contact in Amarillo,
Texas; Big Spring, Texas; Prescott, Arizona; and El Paso, Texas. These
facilities participate in regular educational and training activities
focusing on TBI and polytrauma care. Telehealth technologies are used
successfully to complement face-to-face clinical encounters and to
facilitate access to care for veterans residing at a distance from
medical facilities. Services provided via telehealth include
rehabilitation assessment and treatment, mental health, and other
clinical services.
Question. My office has heard concerns and requested help for many
veteran-owned business attempting to work through the Center for
Veterans Enterprise verification process. I understand the need to
ensure that a business which is claiming veteran-owned status is
actually veteran-owned. Businesses that are not veteran-owned should
not be receiving the benefits intended for veterans. However, I am
concerned about the pace of the process, especially since some
businesses in New Mexico have reported having to wait up to a year or
longer for their certification.
Does the VA need more resources to help process these claims and
what are your proposals to help veteran-owned businesses, such as those
in New Mexico get through the process faster?
Answer. The Center for Veterans Enterprise (CVE) has received the
resources needed through the VA Supply Fund to process verification
applications. A solicitation for the development of a new case
management system, called the Veterans Enterprise Management System
(VEMS), is expected to be released in May 2013, with initial
capabilities expected in October 2013. This new system will automate
many labor-intensive parts of the process, producing increased
consistency and efficiency of the program.
By regulation, 38 CFR part 74, CVE has 60 days, when practicable,
to process a new verification application once it has been deemed
complete. CVE is currently processing new applications in fewer than 40
days. This is down from 73 days at the end of October 2012. VA
attributes this to a number of reasons. First, the Verification
Assistance Program was created. This program has four parts, where a
veteran can take advantage of one or all of the parts. The four parts
include: (1) Verification Assistance Briefs that explain common issues
that lead to denial in layman's terms; (2) the Verification Self-
Assessment Tool that walks the veteran through the regulation and their
documentation to determine if the documentation is in compliance with
the criteria contained in the regulation; (3) Verification Assistance
Partners that offer CVE-trained counselors to assist veterans with
their applications; and (4) the Pre-Application Workshop that helps
veterans understand what must be included in the application and what
to expect from the process. The second factor, introduced in March
2013, is the elimination of certain transfer restrictions, including
the right of first refusal, as a basis for denial. The third factor is
the new Pre-Determination Findings (PDF) program that was launched May
1, 2013. The PDF program issues a findings letter to every business
that would have initially been denied on the basis of the documentation
submitted. Those businesses, whose compliance issues are confined to a
list of certain easily corrected issues, are allowed to clarify their
issues and/or make adjustments to their documentation within a
specified time period with the intent to avoid denial. Those businesses
with more complicated compliance issues, or who do not wish to make the
changes required for compliance are given the opportunity to withdraw
their application prior to receiving a denial letter. By withdrawing,
they can take the time they need to address the issues and resubmit the
application at any time, rather than having to wait in the queue for a
request for reconsideration or the 6-month wait period required by
regulation before submitting a new application once denied.
Although it is too early to have significant data on the
elimination of transfer restrictions and the pre-determination
findings, the combined factors have driven the approval percentage on
initial applications from 58 percent at the end of fiscal year 2012 to
84 percent at the end of April 2013.
VA believes that those veterans reporting having to wait up to a
year or longer for their verification are businesses whose
documentation submitted with their initial application was not
compliant with the eligibility criteria in the regulation and were
subsequently denied. The queue for the request for reconsideration, a
process where a firm that was found ineligible can address the issues
found and submit the updated documentation, was taking an average of
146 days to process at the end of December 2012. The average processing
time for requests for reconsideration fell to 92 days in April 2013.
The higher approval percentage of initial applications has driven down
the number of businesses entering the request for reconsideration
queue, thus reducing the overall queuing time for these businesses. VA
expects this trend to continue going forward.
______
Questions Submitted by Senator Mark Begich
tribal veteran representatives
Question. I am glad to see you have identified rural veterans--$250
million is included for rural health initiatives such as mobile
clinics, fee-basis care, and telemedicine. Of particular interest, this
funding will also support ``exploring collaborations with other Federal
and community providers.
You know I have been supportive of expanding services to veterans
to community providers, and my push for a Hero Card, has resulted in
the successful VA/tribal agreements, I would like to know what
``exploring collaborations'' with community and Federal providers
encompasses?
Answer. VA is committed to increasing access to care closer to home
for rural veterans. This includes collaborating with other Federal
agencies and community providers to provide care and maintain high-
quality standards. For example, under the auspices of the 2010
Memorandum of Understanding (MOU) between VA and IHS, VA increased the
number of online clinical trainings available to IHS providers who
treat veterans by more than 200 new courses. Another VA-IHS
collaborative team established a Bar Code Medication Administration
pilot and related training plan for IHS inpatient facilities. Sharing
agreements have been established or are being developed between VA and
IHS to cover the collaborative use of space, providers, and telehealth
equipment.
VA and the Department of Health and Human Services (HHS) recently
signed a new MOU that will promote the secure exchange of health
information between VA and community healthcare providers and increase
the knowledge and expertise of the Health Information Technology (IT)
Workforce. This MOU supports the mutual goals of both agencies to have
a highly educated health IT workforce that can support the meaningful
use of electronic health record technology in rural communities. The
MOU also ensures the interoperability and compatibility of VA and
community health IT systems that will ensure better coordination of
care for rural veterans who are dual users of both VA and non-VA
healthcare systems. These non-VA systems may include providers in
private practice, at federally qualified healthcare centers, critical
access hospitals, and other rural healthcare facilities. Projects
created as a result of this MOU include joint VHA Office of Rural
Health (ORH) and HHS Office of the National Coordinator for Health
Information Technology (ONCHIT) innovative new patient-centered Health
Information Exchange pilots that will empower veteran patients to
electronically forward information from their VHA Electronic Health
Records (EHRs) to non-VA community providers. The goals of this multi-
State project are to enhance care coordination, improve medication
reconciliation, decrease duplicative lab testing, and increase patient
safety. VHA and the Health Resources and Services Administration (HRSA)
of HHS are also collaborating and participating in existing rural
health provider training initiatives at pilot sites across the country.
Also under the auspices of the VA/HHS MOU, VA is collaborating with
the HHS-funded Northeast Telehealth Resource Center to develop a
telehealth training curriculum for Certified Nursing Assistants (CNA).
The CNA Telemedicine Curriculum will be offered to graduates of the CNA
course currently conducted by the Augusta Maine Adult Education program
in collaboration with the Togus Maine VA Medical Center. Many rural
veterans served by VA supplement their VA care with non-VA healthcare
services in their communities. CNAs are widely used in community home
healthcare and nursing home settings where utilization of telehealth
technologies, especially in rural areas, is projected to grow.
Question. My question is in regard to the Tribal Veteran
Representatives (TVRs), this volunteer program trains workers in
settings like our tribal health facilities to reach out and sign up
veterans in rural areas in VA. I know you have had trainings in Alaska.
These individuals serve as points of contact for veterans in their
community and as liaisons between the veteran and the VA. They learn
about VA healthcare benefits, VA disability, pension, and vocational
rehabilitation benefits, and burial and memorial affairs benefits.
Can you tell me what the budget is for these important trainings, I
hear there are some funding issues with our Tribal Veteran
Representative (TVR) classes that are held in Alaska? The impact of
canceling one class is huge and could cost us the momentum we have
gained to date. We currently have 109 trained TVRs and one day our
dream is to have TVRs in every community. One other item of note is
they help us reach people in the communities while on outreach that no
one else could. The return on investment is the huge increase in claims
and medical coverage in the State. What do you need from us to keep
these trainings viable?
Answer. Outreach to American Indian and Native Alaskan veterans to
inform them of the benefits and services they may be entitled to is a
priority for VA. While there is no established budget for TVR
trainings, adequate funding is available to implement this program. VA,
like all Federal agencies, is working to increase its efficiency and
accountability within programs requiring travel and training, including
the TVR program. In addition, VHA is exploring ways to provide this
training via video conferencing and other virtual modalities. The most
recent TVR training, completed this month in Farwell, Michigan, cost
approximately $100,000 for 60 attendees.
veterans retraining assistance program
Question. The increase in FTEs is due to the need for more claims
processors as a result of VRAP (Veterans Retraining Assistance Program,
be a 35-60 years old veteran, unemployed, 12-month training program in
degree or certificate accredited program).
VRAP has had a rough start in Alaska, and thank you for helping
with the University of Alaska eligibility, what do you need from us to
expand the dates, since some of the rural schools had a late start? Can
you give me some numbers on participants in the program and successes?
Answer. There are currently two bills pending in Congress that
would extend the end date of the Veterans Retraining Assistance Program
(VRAP). S. 6, Putting Our Veterans Back to Work Act of 2013, proposes
to extend VRAP through March 31, 2016, as well as add an additional
100,000 slots for veterans to begin training after March 31, 2014. H.R.
562 proposes to extend VRAP for 3 months, making the end date of the
program June 30, 2014, instead of March 31, 2014. As of July 19, 2013,
57,409 veterans have used VRAP since the program began in July 2012.
Of the 240 veterans who have been approved for VRAP in the State of
Alaska, 64 veterans have been awarded benefits.
security
Question. My question is about VA police and security. We have
received reports of CBOCs and regional offices that have no police
coverage or have only contracted security guards. You have been
responsive after inquiries from my office in placing a security guard
in the Kenai and Wasilla offices. While the main clinic in Anchorage
has VA police officers, they are so under staffed that none of the
clinics or leased properties have VA police officers. Due to a suicide
in the parking lot of our Mat-Su CBOC, we have a contracted, un-armed
security guard who leaves the property prior to staff on many
occasions, and the Kenai clinic with contracted security, both I
understand are not trained in working with veterans, I suggest they
take mental health first aid training.
VA/Alaska also leases space at the Northway Mall in Anchorage. They
have at least 30 employees working there to include all of C&P staff.
It seems as though pocket areas across the country, specifically rural,
have less VA police on staff. Perhaps lower staffing numbers may be
correlated to an assessment by facilities in communities of low risk;
and on the other hand strengthening presence in high crime communities.
I am very concerned about the recruitment/retention. Even before
the downgrades started 3 years ago, VA police are underpaid compared to
DOD police. What are your plans to beef up security and pay the VA
police wages that will retain them?
Answer. In response to growing concern for the safety of our
patients and staff at the VA Alaska Healthcare System's four CBOCs, the
following measures were incorporated:
--May/June 2012--cameras were brought online which are monitored by
VA police during business hours for our most at-risk
facilities: Mat-Su and Kenai.
--May 2012--contract security was brought on board for the Mat-Su and
Kenai CBOCs.
--VA police physically report to any CBOC for a law enforcement
presence when requested or needed.
The CBOCs located in Fairbanks and Juneau have excellent local
support and are located in fairly secure areas. Fairbanks is located
within the Fort Wainwright military base and perimeter providing on
site security and a very speedy response to requests for service. The
Juneau CBOC is located within a Federal building inside a perimeter
that is protected by a metal detector, 100-percent ID check, and full-
time on-site security staff contracted by Federal Protective Service.
Since the incorporation of contract security at Mat-Su and Kenai,
there have been no documented reports of concerns or incidents.
In regards to training, a training sergeant provides veteran-
specific training to each contract security officer that comes on
board. This includes, at minimum:
--security general orientation;
--completion of VA security law enforcement forms and report;
--handling disturbances;
--package examination procedures;
--VA police standard operating procedures;
--response to bomb threats and other disturbances; and
--VA general orientation.
All contract security officers also attend new employee
orientation.
Security officers arrive at 0800, when the clinics open, and leave
at approximately 1600, which is when the clinics close. Although some
staff remain on-site after hours, the clinics are secured at the time
of closing.
Question.
$300 Million for Supportive Services for Veteran Families.--The
Supportive Services for Veterans Families (SSVF) is one of the first
programs the VA has that supports families, and I commend you on your
efforts to prevent family homelessness. I know the Catholic Social
Services in Alaska has shown some good results in keeping veteran
families in their homes, what are your plans for the $300 million in
this budget, are you expanding the program?
(HUD-VASH) Case Management; and $250 Million for the Grant and Per
Diem Program.--Approximately 75 percent of the increase of the 2013
enacted level is to fund case management for additional HUD-VASH
vouchers that VA anticipates will be allocated in fiscal year 2014.
HUD-VASH and grant per diem both important to your goal of ending
veterans homelessness. I do have concerns about the case management
piece. I want you to tell me about VA effort to expand the case
management to the community, I don't see why you have to hire VA
employees, when there are qualified case managers in the communities,
for example, in rural areas, there may not be a CBOC, so chances are
the veterans would not be able to access HUD-VASH vouchers. Tell me
your plans to look at community case managers (outside of the VA
employees).
Answer. The HUD-VASH Program remains a crucial component of VA's
Plan to End Homelessness Among Veterans. The HUD-VASH Program is
focused on ensuring the most in-need and vulnerable veterans are
accessing the valuable resources of the program. To this end, VA
closely monitors case loads to ensure they include primarily those who
are chronically homeless and in need of intensive case management to
navigate the system and sustain long-term housing stability.
Partnerships with community agencies are a key strategy in advancing
this goal. In addition to actively partnering with communities to
outreach and identify chronically homeless veterans, VA recognizes the
potential for community agencies to provide contracted case management
services in lieu of VA. VA has encouraged medical centers to consider
this approach in the past 2 years. To assist VAMCs in their contracting
efforts, VA Central Office recently convened an Integrated Product Team
(IPT) with the charge of reviewing VA's contracting efforts in the HUD-
VASH Program and to determine how best to facilitate contracting as an
option for providing case management services. This IPT produced
standardized contracting solicitations as well as a new national
Statement of Work for VAMC use in pursuing contracting in the future.
The IPT standardized products should facilitate a quicker and more
efficient contracting process for those VAMCs that choose to contract
for case management services.
Unfortunately, many VAMCs attempting to contract for case
management services have experienced challenges identifying community
agencies with sufficient capacity, experience, and training that can
provide the requisite case management services in a cost-effective
manner. In fact, VAMCs in both Washington and Alaska attempted to
contract for case management services in fiscal year 2012 and
ultimately determined contracting would be cost prohibitive. In
contracting for case management services, VA must also ensure
compliance with all regulatory contracting requirements, a process that
can be time intensive. Additionally, some communities have found it
difficult to identify agencies willing or able to provide equivalent
case management to the standard provided within VA programs. Despite
these challenges, VA continues to evaluate and encourage the
development of capacity for community case management and is open to
suggestions and mechanisms that would allow further engagement with
community partners.
leases
Question. Can you tell me about the challenge the CBO has created
by changing the scoring on medical leases? What impact could this have
on veterans if it is not resolved?
Answer. [A response was not provided at press time.]
______
Questions Submitted by Senator Mark Kirk
integrated electronic health record (iehr)
Question. The VA agreed in March 2011, along with the Department of
Defense, to develop an integrated Electronic Health Record (iEHR) for
use by both Departments. Earlier this year, the project took a very
different turn the decision was made not to create a truly joint
record, but instead develop an ``interoperable'' record.
VistA must be modernized in order to meet the demands of the iEHR.
How much will it cost to modernize VistA, and what is the timeline for
modernization? Does the VA have enough information on the end-product
to begin work modernizing VistA?
Answer. VistA represents a longstanding and overwhelmingly
successful investment on the part of VA that remains viable with a
strategic modernization investment. VA is managing VistA modernization
via an ``open source'' strategy. This will allow VA to meet its
commitment to keeping the code open source and more rapidly develop and
deploy enhanced versions. Our open source model ensures that veteran
and clinician needs are met without a slow feedback loop between
establishing requirements and development. The availability of VistA as
an open source solution provides opportunities for both small and large
businesses to offer implementation support as well as value-added
enhancements and modernization. In fact, there is already a large VistA
developer community that participates in new code development.
VA is managing its open source modernization of VistA through the
Open Source Electronic Health Record Agent (OSEHRA), which was
established in August 2011 as an essential element of VA's health
record modernization initiative. OSEHRA, which we sometimes refer to as
a custodial agent, is a code repository with community-structured
design, implementation, access, and licensure mechanisms. With over
2,200 members representing 100 companies, OSEHRA already provides a
transparent and cost-effective means to incorporate new features and
capabilities into the VistA source code.
VistA was made to be adaptable and extendable. Although VistA has
been around for some time, the functionality and technology continue to
evolve. Major releases and enhancements in the last few years include
Bed Management System, Pharmacy Reengineering Emergency Department
Information Software, Surgery Quality Workflow Manager, and others.
Continuous improvements include over 2,211 changes deployed in
incremental patches over the last 3 years. The fact that VA was able to
deploy the changes mentioned above emphasizes the ease of change and
version control to VistA.
Question. Can it be assured a modernized VistA will be compatible
with the new core system the DOD will select so the result is an actual
interoperable health record?
Answer. At the joint meeting in early 2013, both Secretary Panetta
and Secretary Shinseki codified that both Departments' ``cores'' must
conform to previously agreed upon standards (data, interfaces,
enterprise service bus, and user interface) to ensure interoperability.
The Secretaries agreed that the DOD core will be seamlessly
interoperable.
Question. Has the VA given any consideration to utilizing another
core option, like a current commercial off the shelf system or the
development of an entirely new system (much like DOD is currently
doing)? Why is the VA satisfied with utilizing VistA? Is there a need
to review other options?
Answer. Please see the attached ``Why VistA?'' white paper.
[The referenced white paper was not available at press time.]
Question. How will the end-user (the veterans, the doctors) be
affected by the VA and DOD decision to utilize different core systems
rather than one joint system?
Answer. If all of the agreed to standards and secretarial
commitments are met, the end-user should not be negatively impacted.
Question. Would it be overall less expensive for the two
Departments to utilize the same core system (e.g., both use VistA or
both use the core DOD selects)?
Answer. It is possible that if both Departments bought and deployed
the same core, economies of scale would be achieved and the cost would
be less.
Question. The President's fiscal year 2014 request asks for $252
million in development funding for the Interagency Program Office
(IPO). That is more than half of the entire IT development request.
What will the IPO produce in fiscal year 2014 with this development
funding? Outline specific expected deliverables in fiscal year 2014.
Answer. The President's fiscal year 2014 request for iEHR includes
funds that will be obligated by both VA and IPO to deliver key
functionality of the iEHR program. This includes the modernization of
VistA and delivery of key products needed in order to make the 2014 IOC
delivery date. The funds include money for the Virtual Lifetime
Electronic Record-Health, patient scheduling, systems integration,
pharmacy, laboratory, order services, and development of the enterprise
service bus, among other key deliverables.
Question. How will the iEHR Initial Operating Capability (IOC)
``play a critical role in resolving the major pharmacy challenges that
are currently being experienced at the James A. Lovell Federal Health
Care Center?'' (Page 5A-47 volume 2.)
Answer. IOC will not play a critical role in resolving the pharmacy
challenges. IOC is about delivering on the commitment to deploying a
single, joint, common, iEHR system that is based on an open
architecture and non-proprietary in design. In addition, VA is
committed to fixing the pharmacy issue at the James A. Lovell Federal
Health Care Center in North Chicago through the Data Management Service
and other initiatives specific to North Chicago.
claims processing
Question. Mr. Secretary, the VA has received a lot of press
lately--none of it complementary--regarding an issue that we have long
followed here on this subcommittee, claims processing. In spite of
Congress's appropriation of additional funds to address personnel and
technological issues, the backlog continues to grow and has now reached
unbelievable levels, especially in Chicago.
When will we know if your efforts to reduce the backlog are
working?
Answer. Right now, too many veterans wait too long to receive
benefits they deserve. This has never been acceptable to the Department
of Veterans Affairs (VA) or to the dedicated employees of VBA--52
percent of who are veterans themselves. VBA is aggressively
implementing its Transformation Plan, a series of people, process, and
technology initiatives designed to eliminate the claims backlog and
achieve our goal of processing all claims within 125 days with 98-
percent accuracy in 2015. VBA is retraining, reorganizing, streamlining
business processes, and building and implementing technology solutions
based on the newly redesigned processes in order to improve benefits
delivery.
Initially planned for deployment throughout fiscal year 2013, VBA
accelerated the implementation of the new organizational model by 9
months, beginning in fiscal year 2012, due to early indications of its
positive impact on performance. Given the magnitude of this change,
each office transitioned to the new organizational model individually.
Significant support and training were critical throughout this
transition. As of March 2013, the new organizational model was fully
operational at all 56 regional offices. As is anticipated with any
change of this magnitude, there was some short-term impact on
performance as we ensured that the training, communications, and other
essential change management activities were conducted to appropriately
prepare the workforce.
At the same time we also began the nationwide deployment of our new
paperless electronic claims processing system, the Veterans Benefits
Management System (VBMS). Generation One of VBMS began in 2010 with the
conceptualization, piloting, development, and deployment of baseline
system functionality with improved quality (required actions and
automation) and efficiency (no paper). VBA began deployment of VBMS
Generation One in September 2012, concluding the calendar year with 18
stations on the system. It is important to note that early adopters of
first generation technology participated heavily in the development and
refinement of efficiencies and functionality of the system, which had a
direct impact on productivity as a result of the live test environment.
These stations paved the way for the accelerated deployment of VBMS,
which will enable VBA to track and measure productivity outcomes in a
consistent and accurate manner once all regional offices are operating
with the new technology and after a period of stabilization. The first
18 stations enabled VBA to also test business processes and
functionality for the establishment of eFolders in VBMS and the model
for tracking and shipping of paper-based claims with two scanning
vendors. Generation One of VBMS concluded with the successful
implementation of Release 4.1 in January 2013. This generation
culminated in a foundational Web-based, electronic claims processing
solution. Under our accelerated deployment schedule, all 56 regional
offices and our Appeals Management Center are now using VBMS. Each VBMS
site deployment is also supported by organizational change management
practices (including extensive training) to ensure employees are able
to adapt to and adopt the new technologies and solutions. We will also
continue to enhance the automated functionalities and build additional
system capabilities in three future generations of VBMS to be deployed
over the next 2 years. As we move into future generations of VBMS, our
focus is on leveraging more complex automation features and more
extensive data exchange and system integration capabilities so that our
employees will be able to process claims electronically from receipt to
payment.
VBA is tracking execution of its transformation initiatives against
our key measures of performance, including pending and completed
ratings, timeliness, accuracy, and the impact on the backlog. The
quality of the transformation initiatives is measured through a 3-month
rolling average accuracy metric that is reported on VA's ASPIRE Web
site which can be found at http://www.vba.va.gov/reports/aspiremap.asp.
VA projected that the backlog (claims pending over 125 days) would be
approximately 595,000 claims at the end of fiscal year 2013. We are
currently significantly below that projection. As of May 14, 2013,
there are 566,802 claims in the backlog (67.3 percent of the
inventory). This is down from a peak of 611,073 claims on March 25,
2013--a reduction of 44,271 backlogged claims in less than 2 months.
Question. When will we begin seeing a turnaround at regional
offices like Chicago?
Answer. On April 19, 2013, VA announced a new initiative to
expedite compensation claims decisions for veterans who have waited 1
year or longer. Under this initiative, VA expects to have all claims
pending over 1 year eliminated from the current claims backlog within 6
months. As of June 15, 2013, over 2,700 Illinois veterans received a
decision on their pending claims. On June 20, 2013, VBA shifted its
focus to claims that have been pending over 1 year. Many veterans
served at the Chicago Regional Office (RO) will be provided decisions
on their claims as a result of this initiative. VA claims raters are
making provisional decisions on the oldest claims in inventory, which
will allow veterans to begin collecting compensation benefits more
quickly, if eligible. Veterans will be able to submit additional
evidence for consideration a full year after the provisional rating,
before the VA issues a final decision. Provisional decisions will be
based on all evidence provided to date by the veteran or obtained on
their behalf by VA. If a VA medical examination is needed to decide the
claim, it will be ordered and expedited.
It is important to understand that as a result of this initiative,
metrics used to track benefits claims will experience significant
fluctuations. The focus on processing the oldest claims will cause the
overall measure of the average length of time to complete a claim--
currently 314 days nationally--to skew, rising significantly in the
near term because of the number of old claims that will be completed.
Over time, as the backlog of oldest claims is cleared and more of the
incoming claims are processed electronically through VA's new paperless
processing system, VA's average time to complete claims will
significantly improve. In addition, the average days pending metric--or
the average age of a claim in the inventory--will decrease, since the
oldest claims will no longer be part of the inventory.
Question. By the end of 2013, what type of backlog should we expect
to see at regional offices around the country?
Answer. VA projected that the backlog (claims pending over 125
days) would be approximately 595,000 claims at the end of fiscal year
2013. We are currently significantly below that projection. As of May
14, 2013, there are 566,802 claims in the backlog (67.3 percent of the
inventory). This is down from a peak of 611,073 claims on March 25,
2013--a reduction of 44,271 backlogged claims in less than 2 months.
Question. What constitutes an accurate claim? How is accuracy
determined?
Answer. VBA's Quality Assurance Program currently measures accuracy
of disability compensation claims on two different levels. The first
assessment is based on review of the claim as a whole (claim-level)
with all claimed disabilities or issues associated with a work credit
known as an end product (EP). Audit-style case reviews are conducted
after completion of all required processing actions on a claim. The
review represents a measure of accuracy of all adjudicative actions to
include addressing all issues, completing all required evidence
gathering actions, appropriately granting or denying benefits,
assigning correct evaluations and effective dates, and paying the
correct amount of benefits. Accuracy of the claim is determined if all
of these adjudicative actions are processed correctly. If there is
deficiency in any of these elements that would ultimately impact the
outcome of the decision, the entire claim or EP is considered
inaccurate. This process is considered an ``outcome-based'' accuracy
review.
In addition to the claim-level accuracy measurement, VBA began
recording the accuracy of decisions at the issue-level on October 1,
2012. The premise of the issue-level review is generally the same;
however, each claimed disability or issue is independently determined
as correct or incorrect regardless of its impact on the other
decisions. This measurement of accuracy provides a more detailed and
accurate assessment of the work completed by field stations. The data
collected at this level allows for more focused training and will drive
behaviors that will ultimately improve the quality of decisions.
Question. When will electronic claims filing be available to all
veterans?
Answer. Currently, all veterans are able to file certain claims
electronically. Veterans can file electronic claims for disability
compensation including fully developed claims, additions and changes to
dependents, and claims for approval of school attendance. Veterans can
also request the appointment of a Veterans Service Organization (VSO)
as the claimant's representative and authorize and consent to release
information to VA electronically.
Additional electronic claims capabilities expected to be available
to all veterans and VSOs later in 2013 will include:
--Applications for increased compensation based on unemployability;
--Statements in support of claim for service connection for Post-
traumatic Stress Disorder (PTSD) and PTSD secondary to personal
assault; and
--Applications for burial benefits.
Through its Veterans Relationship Management initiative, VA has
made it easy to file claims electronically by providing two entry
portals:
--eBenefits is available for veterans who want to file a claim on
their own. This is a joint VA/Department of Defense (DOD) Web
portal that provides resources and self-service capabilities to
veterans, servicemembers, and their families to research,
access, and manage their VA benefits, military benefits, and
personal information. eBenefits allows veterans, using a free
premium account, to submit claims and upload supporting
documentation.
--The Stakeholder Enterprise Portal (SEP) will expand access to our
external business partners, such as VSOs, education providers,
physicians, attorneys, loan appraisers, other benefits
providers who will be able to electronically access
information, submit claims, and perform other actions on behalf
of veterans. SEP currently allows members of accredited VSOs to
electronically complete the same types of claims that are
available for veterans to submit, upload supporting documents,
view the status of claims, view payment history and details,
and accept or reject power of attorney applications.
Our veterans deserve a timely and positive experience each time
they contact VA. We are committed to making dramatic improvements, and
will continue our aggressive efforts to ensure we are providing
accurate and comprehensive information and assistance to our veterans
and their families in a professional and compassionate manner.
Question. How many veterans currently receive VA benefits after
going through the Integrated Disability Evaluation System (IDES)? If
such figures were included in the total number of pending and completed
claims, how would it affect the backlog figures?
Answer. In fiscal year 2012, 14,192 veterans completed VA benefit
claims through IDES. In fiscal year 2013 (as of May 13, 2013), 12,737
veterans have completed VA claims through IDES. All completed IDES
claims are counted in VA's total number of completed claims. Once VA is
notified that an IDES participant has been medically separated from the
military, the IDES claim becomes part of VA's pending disability claims
workload. It would not be appropriate to consider IDES claims from
servicemembers whose fitness for continued service has not yet been
adjudicated by the military as part of VA's pending workload.
Question. It has recently been noted that a ``veteran's claim sits
stagnant for up to 175 days as VA awaits transfer of complete STR
(service treatment records) from DOD.'' How can Congress assist the VA
in coordinating with the Department of Defense to improve this wait
time?
Answer. VBA continues to regularly and diligently work with DOD to
obtain complete service treatment records (STR) faster and more
efficiently. As such, no congressional action is needed.
One of the largest endeavors VA and DOD are working towards jointly
is the electronic transfer of STRs to VA. On December 6, 2012, VBA
reached an agreement with DOD requiring the military services to
certify a servicemember's STRs as complete as possible at the point of
transfer to VA. Effective January 1, 2013, all five military services
began full implementation of STR certification.
VA asked for and received two accounts for each VBA regional office
into DOD's Armed Forces Health Longitudinal Technology Application
(AHLTA) system, which enables VBA to review any DOD records that VBA
does not already possess in order to complete claims. The AHLTA print-
to-portable document format (PDF) pilot is scheduled to begin in
September 2013 to provide VA electronic data (PDF) of information
contained in AHLTA.
DOD will also deploy the Healthcare Artifact and Image Management
Solution (HAIMS) to provide a mechanism for scanning and uploading
paper documents to make them readily available to VA. Additionally, the
technology could also be used to scan and upload paper medical record
items received from private-sector providers. DOD has initiated an
accelerated deployment schedule for HAIMS with a goal of stopping the
flow of paper STRs to VA by December 2013.
Further, VBA has an agreement with DOD to provide 100-percent-
complete service treatment and personnel records in an integrated
Electronic Health Record (iEHR) for the 300,000 Active Duty, National
Guard, and Reserve servicemembers departing annually. This will
increase the number of fully developed claims submitted. In the short
term HAIMS and in the long term iEHR are both critical efforts to
reduce the time for VA to receive STRs from DOD significantly.
mandatory funding
Question. Mr. Secretary, you stated in your budget request $86.1
billion is needed to satisfy entitlement spending for VA's mandatory
programs in fiscal year 2014. This is an 18-percent increase over the
fiscal year 2013 enacted level. The fiscal year 2013 request was also a
17-percent increase over the previous fiscal year 2012 enacted level.
Do you foresee a trend where the VA's mandatory spending will
continue to increase each year by upwards of 20 percent? Should we
continue to expect such large mandatory increases each year?
Answer. While the budget authority for VA's mandatory programs
increased by these amounts, overall mandatory obligations are not
increasing upwards of 20 percent. Of the $86.1 billion appropriation
requested for VA's mandatory programs in fiscal year 2014, $71.2
billion, or 83 percent, is for the Compensation and Pension (C&P)
account and $13.1 billion, or 15 percent, is for the Readjustment
Benefits (RB) account. Total obligations for these accounts grew 7.3
percent and 3.8 percent, respectively.
The fiscal year 2014 budget authority for the C&P account increased
16 percent over the fiscal year 2013 level; however, total obligations
increased just 7.3 percent over the fiscal year 2013 level. The larger
increase in budget authority is due to an unobligated balance of $5.0
billion at the end of fiscal year 2012 which was carried into fiscal
year 2013. Funds appropriated to the C&P and RB accounts are authorized
to obligate until expended. Therefore, the $5.0 billion unobligated
balance at the end of fiscal year 2012 reduced the amount of new budget
authority required for fiscal year 2013. The fiscal year 2013 budget
authority also reflects a request for a transfer from the RB account to
the C&P account to fully fund fiscal year 2013 obligations. This
request is consistent with the administrative provision section 201,
and when coupled with the $5 billion in previously authorized funding
available for obligation in fiscal year 2013 and $60.6 billion
appropriation, supports anticipated obligations of $66.4 billion.
In addition, the fiscal year 2014 appropriation request for C&P
does not anticipate an unobligated balance carried forward from fiscal
year 2013; therefore, budget authority equals obligations in fiscal
year 2014. Obligations for the C&P account are expected to continue to
increase at historical levels of around 7 percent annually. Please see
the following chart for additional detail.
----------------------------------------------------------------------------------------------------------------
Compensation and pension funding (dollars in Percent Change
thousands) -------------------------------
------------------------------------------------ Fiscal year Fiscal year
2012 to 2013 to
Fiscal year Fiscal year Fiscal year fiscal year fiscal year
2012 2013 2014 2013 2014
----------------------------------------------------------------------------------------------------------------
Appropriation................... $51,237,567 $60,599,855 $71,248,171 18.3% 17.6%
Transfer from RB................ .............. 824,838 .............. N/A N/A
Appropriation Adjusted.......... 51,237,567 61,424,693 71,248,171 19.9 16.0
Unobligated Balance SOY......... 12,930,390 5,000,894 .............. N/A N/A
-------------------------------------------------------------------------------
Total Funding Available... 64,167,957 66,425,587 71,248,171 3.5 7.3
===============================================================================
Obligations..................... 59,167,063 66,425,587 71,248,171 12.3 7.3
----------------------------------------------------------------------------------------------------------------
Similarly for the RB account, while the fiscal year 2014
appropriation request was 17.3 percent over the fiscal year 2013 level,
fiscal year 2014 obligations are expected to increase just 3.8 percent
over fiscal year 2013 levels. This is primarily due to an unobligated
balance of nearly $2.6 billion that was carried into fiscal year 2013
which, in addition to the new budget authority of $11.2 billion and
$321.6 million in collections from DOD, is available to fund benefits.
Please see the following chart for additional detail.
----------------------------------------------------------------------------------------------------------------
Readjustment benefits funding (dollars in Percent Change
thousands) -------------------------------
------------------------------------------------ Fiscal year Fiscal year
2012 to 2013 to
Fiscal year Fiscal year Fiscal year fiscal year fiscal year
2012 2013 2014 2013 2014
----------------------------------------------------------------------------------------------------------------
Appropriation................... $12,108,488 $12,023,458 $13,135,898 -0.7% 9.3%
Transfer to C&P................. .............. -824,838 .............. N/A N/A
Appropriation Adjusted.......... 12,108,488 11,198,620 13,135,898 -7.5 17.3
Unobligated Balance SOY......... 1,221,327 2,554,542 577,047 N/A N/A
Collections from DOD............ 365,193 321,581 303,698 -11.9 -5.6
-------------------------------------------------------------------------------
Total Funding Available... 13,695,008 14,074,742 14,016,644 2.8 -0.4
===============================================================================
Obligations..................... 11,140,466 13,497,695 14,016,644 21.2 3.8
----------------------------------------------------------------------------------------------------------------
Question. Will you explain the major factors contributing to this
large yearly increase in mandatory entitlement spending?
Answer. Please see the response to question 1. In addition, while
the budget authority for VA's mandatory programs increased by these
amounts, overall mandatory obligations are not increasing upwards of 20
percent. Obligations for the C&P and RB accounts, which make 98 percent
of the mandatory request for fiscal year 2014, increase by a combined
6.6 percent, from $79.9 billion in fiscal year 2013 to $85.2 billion in
fiscal year 2014. Mandatory obligations are expected to increase
consistently with historical annual increases of around 7 percent.
Increases in obligations are consistent with net increases in caseload,
an upward trend in veterans' average degree of disability, increases in
the cost of education, and cost-of-living adjustments to monthly
payments.
Question. Is there anything Congress can do to help the VA reduce
its mandatory spending?
Answer. Mandatory spending provides entitlement benefit payments to
eligible veterans, their survivors, and dependents. VA is legally
obligated to make payments or provide aid to eligible veterans. VA is
committed to uphold President Lincoln's promise, ``To care for him who
shall have borne the battle, and for his widow, and his orphan.'' VA
welcomes discussion to determine best practices to meet the needs of
the Nation's veterans and families.
construction
Question. Mr. Secretary, the fiscal year 2014 budget requests $342
million for major construction. This continues the reduction we have
seen over the past few years in the account. Yet, your Department's
estimated cost for fully funding all major construction infrastructure
is nearly $23 billion.
In light of these funding cuts to major construction and this
downward trend, does the Department need to reassess its capital asset
program? Is there a plan to reconcile the major construction backlog
with future funding needs?
Answer. The fiscal year 2014 budget request and fiscal year 2014
advanced appropriations provide the necessary resources to care for our
Nation's veterans. The VA's 2014 budget request would provide resources
to allocate funding between a mix of operating and capital accounts, to
deliver the best mix of services for veterans. In addition to expanding
access to VA services through the construction and renovation of
facilities, VA provides access to veterans through non-capital
solutions such as: fee care, telehealth, beneficiary travel, veteran
transportation services, etc.
In fiscal year 2014, the budget request funds the completion of the
mental health building in Seattle, Washington, which is the highest
priority partially funded project from the list of outstanding projects
that previously received congressionally appropriated funds.
mental health
Question. Mr. Secretary, last year the VA initiated a hiring
process to bring on board 1,900 mental health professionals and support
staff. This is supposed to be completed by June 30, 2013.
Will you explain the hiring status to date of these 300
administrative staff and the 1,600 mental health professionals?
Answer. The VA Mental Health Hiring Initiative has improved the
Veterans Health Administration's (VHA) ability to expand access to
mental health services to our Nation's veterans. As of June 3, 2013,
VHA has hired 1,607 clinical staff to fill the 1,600 new mental health
positions in accordance with the President's Executive order issued on
August 31, 2012. Additionally, VHA has hired 297 of the 300 new non-
clinical positions.
Question. The VA stated it planned to hire 800 peer-to-peer
counselors. Will you elaborate on that plan?
Have all 800 counselors been hired to date?
Answer. As of June 4, 2013, 335 peer-to-peer counselors have been
hired in support of the goal to hire 800 by December 31, 2013.
What is the role of a peer-to-peer counselor?
Answer. Peer-to-peer counselors perform a variety of therapeutic
and supportive tasks including:
--assisting their peers in articulating their goals for recovery;
--helping their peers to learn and practice new skills;
--helping their peers monitor their progress;
--assisting them in their treatment;
--modeling effective coping techniques and self-help strategies based
on the counselor's own recovery experience; and
--supporting their peers in advocating for themselves to obtain
effective services.
Where will these counselors be located?
Answer. Peer-to-peer counselors will be geographically dispersed
across all of the VISNs to ensure veterans have access to the required
staffing levels. VA implemented staffing model guidance with the list
of skilled procedures and the number of providers that must be
available to every 1,000 veterans seeking services for mental health.
By the end of fiscal year 2013, there should be at least three
counselors at each medical center and at least two counselors at each
very large CBOC.
Question. When would a veteran see a peer-to-peer counselor instead
of a mental health professional or do the two work in concert with one
another on a veteran's particular case?
Answer. Peer-to-peer counselors function as part of an
interdisciplinary team. They do not provide services that replace the
services provided by degreed mental health professionals. Their work is
adjunctive to the work of degreed professionals. peer-to-peer
counselors are full members of the treatment team and provide a unique
perspective and set of services. By virtue of the fact that peer-to-
peer counselors are veterans who have been or are currently in recovery
from a mental health condition, they are role models who serve as an
example that recovery is attainable. They facilitate peer support
groups, assist with the development of treatment plans, provide crisis
support, and act as advocates for the veterans. These services work
hand-in-hand with the services provided by the other members of the
treatment team (e.g., medications, psychotherapy, placement services)
to provide a comprehensive, holistic, and recovery-oriented approach to
mental health treatment.
______
Questions Submitted by Senator Mitch McConnell
Question. Please provide an updated timeline for the design and
construction phases for the new Robley Rex VA Medical Center in
Louisville, Kentucky.
Answer. The following timeline is as of May 2013. Projected dates
are based on current status and assumptions, and are subject to change:
--Design commenced in March 2013, and VA received the design concept
submission in late April 2013 which is being revised by the
architect-engineer.
--VA anticipates receipt of a revised concept submission and
selection of preferred concept for design in spring 2013. VA
anticipates starting Schematic Design at this time with
completion by late winter 2014.
--Design development can commence in early 2014 and can complete in
the fall of 2014.
--Construction documents can commence the fall of 2014 and can be
complete in the summer of 2015.
--The construction schedule is to be determined based on when funding
is received.
Question. What specific steps has the VA taken to successfully plan
for the large influx of currently Active Duty military personnel that
will enter the VA system over the coming years?
Answer. For several years, the Department of Veterans Affairs (VA)
has worked with the Department of Defense (DOD) to ensure Active Duty
personnel are informed of VA programs and to help them transition to VA
benefits and services. As enrollment increased, additional programs
have been put in place and existing programs improved.
transition assistance
In August 2011, the President called on DOD and VA to lead a task
force with the White House economic and domestic policy teams and other
agencies, including the Department of Labor (DOL), to develop proposals
to maximize the career readiness of all servicemembers. This DOD-
Veterans Employment Initiative Task Force is one element of the plan to
reduce veteran unemployment and to ensure that all of America's
veterans have the support they need and deserve when they leave the
military, look for a job, and enter the civilian workforce.
To meet the President's call for a ``career-ready military,'' the
DOD-VA Veterans Employment Initiative Task Force developed a new
training and services delivery model to help strengthen the transition
of our servicemembers from military to civilian life as they become
veterans. This model represents an improved DOD/VA/DOL Transition
Assistance Program (TAP), called Transition Goals, Plans, and Success
(GPS). The new model was implemented in November 2012 as part of the
2012 VOW to Hire Heroes Act (VOW Act) and includes four parts:
--Pre-Separation Counseling.--Servicemembers will conduct individual
assessments and one-on-one counseling with military service
representatives.
--Employment Workshop.--DOL will assist servicemembers with
translating military skills, searching for jobs, writing
resumes, and interviewing.
--Enhanced VA Benefit Briefings.--Veterans, servicemembers, their
families, and survivors will attend comprehensive workshops
covering the entire spectrum of VA benefits.
--Individual Transition Plan.--A customized roadmap to tailor
individual needs for success will be completed for every
transitioning servicemember. Servicemembers will also have the
option of attending one or more of the following 2-day
Transition GPS Tracks:
--Education Track.--Servicemembers pursuing college education will
receive guidance to prepare for the college application
process.
--Career Technical Training Track.--Servicemembers pursuing further
technical training will receive guidance and help in
selecting schools and technical fields.
--Entrepreneurship Track.--Servicemembers pursuing self-employment
in the private or nonprofit sector will learn about the
challenges faced by entrepreneurs, the benefits and
realities of entrepreneurship, and the steps toward
business ownership.
Based upon VA's analysis of projected military service separation
data, it has developed models for the optimal delivery and support of
the VOW Act and Transition GPS. This support utilizes a regional hub-
and-spoke model. VA will deliver enhanced VA benefits briefings within
the framework of Transition GPS and is responsible for providing the
Transition Technical Training Track. VA will fully participate in the
Capstone event, a final review of the transitioning servicemember's
completion of the workshops and tracks, and ensure representatives are
available to receive and coordinate a ``warm handover'' for
servicemembers requiring additional support from VA regarding benefits,
services, and other programs.
healthcare
VA has taken a number of actions in collaboration with DOD to
identify and track servicemembers who are transitioning to civilian
life and to ensure that those in need of care are properly identified.
VA and DOD transition assets and capabilities include:
--liaison and care coordination staff to facilitate a seamless
transition process;
--enhanced health information sharing and numerous interagency
initiatives that support shared standards of care; and
--interoperable processes for care delivery that facilitates
transition between the systems.
For example, VA has 43 VA liaisons for healthcare stationed at 21
Military Treatment Facilities (MTF). VA liaisons for healthcare, either
licensed social workers or registered nurses, are co-located in MTFs,
under DOD's Care Management and Social Work Service, Office of Patient
Care Services, with concentrations of recovering servicemembers
returning from Iraq and Afghanistan. VA liaisons coordinate healthcare
as servicemembers transition from MTFs to a VA healthcare facility
closest to their homes or most appropriately located for the
specialized services their medical condition requires. VA liaisons
connect with VA's Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) program manager to coordinate this
initial care and to have a VA case manager assigned with the
expectation that the servicemember will leave the MTF registered for VA
healthcare with a scheduled VA appointment.
VA has also coordinated with DOD's inTransition program to develop
and provide joint training for staff to promote referrals from VA and
DOD providers to the inTransition program. inTransition is a DOD
program to assist servicemembers requiring behavioral health treatment
and who are transitioning between healthcare systems, status, or
location. inTransition's mission is to support continuity of care for
the servicemember during transition.
additional healthcare efforts
There are several efforts by VA to reach out to departing military
personnel, which allows VHA to gauge the number of members turning to
VA in order to adjust programs for future demand.
Individual Ready Reserve (IRR) Muster Events.--DOD provides VA with
dates and locations of the ``live'' Musters for the Marines and the
Army Reserve. VHA OEF/OIF staff conducts the 20-minute VHA briefing to
the attendees and the enrollment procedures. Many of these events are
held at VAMCs. Since 2009 the field has recorded that over 42,000 IRR
members have attended these VA briefings with over 13,000 enrolling
into VA healthcare. Since January 2013, the Marines and Air Force will
continue ``live'' Musters. The Navy and Army are developing ``virtual
musters''. Outreach staff is developing ``electronic'' VA outreach
materials in order to partner with the services in sending out
electronic materials to this population.
DOD's Yellow Ribbon Reintegration Program.--This program was
established in 2008 and was implemented for all Reserve component
servicemembers and their families: VA is a major support partner at
VAMCs, regional offices and vet centers for these events and provides
``boots on the ground'' assistance and offers enrolment and referrals
for needed services. Specialized briefings are offered by VA staff on
suicide prevention, PTSD, TBI etc. The DOD Post Deployment Health
Reassessment (PDHRA) is a healthcare screening, required for all
National Guard and Reserve servicemembers 90-180 days post-deployment.
As part of the Yellow Ribbon Program at the 60-90 day event, all
members are given the opportunity to complete this screening
evaluation. The PDHRA results in referrals to VA facilities, such as VA
medical centers, VA community clinics, and vet centers. Local VAMC and
vet center staff provide outreach, education, enrollment, and as
needed, referral for clinical services. Referred veterans have a choice
to receive care at a local VAMC, vet center, MTF, or through TRICARE.
For servicemembers who request a VHA appointment during on-site PDHRA,
VA personnel are able to schedule appointments for them at their local
VAMC.
National Guard Partnership.--In order to ensure that OEF/OIF/OND
combat veterans receive access to high-quality healthcare and
coordinated VA services and benefits, VA and the National Guard (NG)
developed a creative partnership. The NG hired 54 (now 64) National
Guard Transition Assistance Advisors (TAA) to serve as VA/NG liaisons
in the field at the State level to assist NG servicemembers and their
families with questions and assistance to access VA benefits and
services. VA staff conducted the training to enhance the outreach
skills of the TAAs. The TAAs have been the critical link in
facilitating access to VA by NG/Reserves returning combat troops in
each of the 50 States and 4 territories of Puerto Rico, Virgin Islands,
Guam, and the District of Columbia. TAAs have provided outreach to over
275,000 NG members and families. Since 2008, TAAs have facilitated VHA
enrollment or referrals for over 130,000 veterans and over 113,000 to
VBA and over 55,000 to vet centers.
Question. With an already high unemployment rate, what is the VA
doing to help ensure that servicemembers are able to find jobs when
they return to civilian life?
Answer. VA is helping to confront the issue of veteran unemployment
by first giving our veterans a strong foundation of education and
training on which to build their careers. The Post-9/11 GI Bill
provides financial support to veterans to pursue undergraduate and
professional degrees, vocational and technical training, licenses, and
certifications, and training in entrepreneurship.
In addition, the Veterans Retraining Assistance Program (VRAP)
helps retrain those veterans hit hardest by unemployment. VRAP is
available to unemployed veterans between the ages of 35 and 60. VA has
provided over $318.6 million in program benefits to the more than
51,784 veterans enrolled in a training program.
In addition to giving veterans a strong foundation of knowledge and
training, VA has long offered employment services through the
Vocational Rehabilitation and Employment (VR&E) program. More than 800
Vocational Rehabilitation Counselors (VRC) and over 90 Employment
Coordinators (EC) assist veterans with service-connected disabilities
prepare for, find, and keep suitable jobs. VRCs help veterans evaluate
their interests, aptitudes, and capabilities to determine a career
path. ECs leverage relationships with civilian employers to help match
each veteran with an appropriate work place.
Over the last 2 years, VA significantly improved veterans' access
to online employment resources. VA's VetSuccess.gov Web site integrates
the tools and information veterans need to find employment and advance
their careers. The joint VA-DOD eBenefits portal assists transitioning
servicemembers and veterans in their job search by including a
searchable online personnel file where veterans can access important
service records and a ``Career Center'' with tools to help veterans
complete self-assessments, translate their military skills to civilian
occupations, and build their resumes.
VA is leading the Federal Government in hiring veterans through our
VA For Vets Program. Part of the Veterans Employment Services Office,
the VA For Vets Program is fully dedicated to aiding veterans in
finding Federal employment and preparing job-seeking veterans for
careers at VA. The program assists veterans in translating their
military skills and training into civilian careers, and teaches human
resource professionals and supervisors how to recruit and retain
veterans. In its first year, VA For Vets offered career coaching to
19,000 veterans and helped produce over 28,000 veteran resumes.
VA has partnered with the U.S. Chamber of Commerce to support the
Chamber's ``Hiring Our Heroes'' job fairs. Per a memorandum of
understanding between our two organizations, VA participates in Chamber
of Commerce job fairs across the country to advertise and educate
veterans on VA benefits and services.
VA has also partnered with the First Lady's and Dr. Jill Biden's
Joining Forces Initiative dedicated to connecting our servicemembers,
veterans and military spouses with the resources they need to find jobs
at home.
VBA is also working with partner agencies to collaboratively
address veterans employment, including participating in a White House
forum on credentialing. The forum seeks to bring together stakeholders
from both State and Federal Government, as well as the private sector,
to discuss how veterans can more easily obtain licenses and
certifications based on their military experience and obtain academic
credit for their military duty.
In addition, VHA has developed a pilot program to hire medics and
corpsmen as emergency response technicians. This program enables
transitioning medics and corpsmen to obtain ready employment in the VA,
help meet VA workforce needs, enable them to serve other veterans, and
obtain advanced training and licensure (as nurses, physician
assistants, etc.) creating a pipeline for needed VA employees.
Question. Numerous Kentucky veterans have expressed their concerns
about the massive backlog in claims at the VA--which has increased and
now totals over 860,000 pending claims. Why has the VA not reduced this
backlog in claims?
Answer. Right now, too many veterans wait too long to receive
benefits they deserve. This has never been acceptable to VA or to the
dedicated employees of VBA--52 percent of whom are veterans themselves.
VBA is implementing its Transformation Plan, a series of people,
process, and technology initiatives designed to eliminate the claims
backlog and achieve our goal of processing all claims within 125 days
with 98-percent accuracy in 2015. VBA is retraining, reorganizing,
streamlining business processes, and building and implementing
technology solutions based on the newly redesigned processes in order
to improve benefits delivery. It is important to note that the VA
Strategic Plan to Eliminate the Compensation Claims Backlog sent to
Congress in January of 2013 (http://benefits.va.gov/transformation/
docs/va_strategic_plan_to_eliminate_the_compensation_claims_
backlog.pdf) indicates that the inventory of claims would continue to
increase for the near term before declining.
Initially planned for deployment throughout fiscal year 2013, VBA
accelerated the implementation of the new organizational model by 9
months, beginning in fiscal year 2012, due to early indications of its
positive impact on performance. Given the magnitude of this change,
each office transitioned to the new organizational model individually.
Significant support and training were critical throughout this
transition. As of March 2013, the new organizational model was fully
operational at all 56 regional offices. As is anticipated with any
change of this magnitude, there was some short-term impact on
performance as we ensured that the training, communications, and other
essential change management activities were conducted to appropriately
prepare the workforce.
At the same time we also began the nationwide deployment of our new
paperless electronic claims processing system, the Veterans Benefits
Management System (VBMS). Generation One of VBMS began in 2010 with the
conceptualization, piloting, development, and deployment of baseline
system functionality with improved quality (required actions and
automation) and efficiency (no paper). VBA began deployment of VBMS
Generation One in September 2012, concluding the calendar year with 18
stations on the system. It is important to note that early adopters of
first generation technology participated heavily in the development and
refinement of efficiencies and functionality of the system, which had a
direct impact on productivity as a result of the live test environment.
These stations paved the way for the accelerated deployment of VBMS,
which will enable VBA to track and measure productivity outcomes in a
consistent and accurate manner once all regional offices are operating
with the new technology and after a period of stabilization. The first
18 stations enabled VBA to also test business processes and
functionality for the establishment of eFolders in VBMS and the model
for tracking and shipping of paper-based claims with two scanning
vendors. Generation One of VBMS concluded with the successful
implementation of Release 4.1 in January 2013. This generation
culminated in a foundational Web-based, electronic claims processing
solution. Under our accelerated deployment schedule, all 56 regional
offices and our Appeals Management Center are now using VBMS. Each VBMS
site deployment is also supported by organizational change management
practices (including extensive training) to ensure employees are able
to adapt to and adopt the new technologies and solutions. We will also
continue to enhance the automated functionalities and build additional
system capabilities in three future generations of VBMS to be deployed
over the next 2 years. As we move into future generations of VBMS, our
focus is on leveraging more complex automation features and more
extensive data exchange and system integration capabilities so that our
employees will be able to process claims electronically from receipt to
payment.
VBA is tracking execution of its transformation initiatives against
our key measures of performance, including pending and completed
rating, timeliness, accuracy, and the impact on the backlog. The
quality of the transformation initiatives is measured through a 3-month
rolling average accuracy metric that is reported on VA's ASPIRE Web
site which can be found at http://www.vba.va.gov/reports/aspiremap.asp.
A major factor impacting all areas of VA's disability claims
workload was the addition of three new agent orange presumptive
disabilities. In 2009, Secretary Shinseki made the decision to add the
three presumptive conditions (Parkinson's disease, ischemic heart
disease, and B-cell leukemias) for veterans who served in the Republic
of Vietnam or were otherwise exposed to the herbicide agent orange. Due
to this policy change, the number of compensation and pension claims
received increased from 1 million in 2009 to 1.3 million in 2011 (a 30-
percent increase). In addition, beginning in October 2010, VBA
identified these claims for special handling to ensure compliance with
the provisions in the Nehmer court decision that requires VA to
readjudicate claims for these three conditions that were previously
denied. VBA dedicated over 2,300 claims staff to readjudicating these
claims. Nehmer claims for all live veterans were completed as of April
2012 and Nehmer survivor claims were completed in October 2012. The
claims staff is now working on reducing the backlog. Our focus on
processing these complex claims contributed to a larger claims backlog,
but it remains the right thing to do for our Vietnam veterans, many of
whom waited a long time for these benefits. Secretary Shinseki also
made an important decision to simplify the process to file claims for
combat PTSD. These decisions expanded access to benefits for thousands
of veterans and brought significantly more claims into the system.
Several other factors have contributed to this growth in the volume
of incoming claims: extensive outreach; increased demand as a result of
10 years of war; improved access to benefits through the joint VA and
DOD Pre-Discharge Programs; and new regulations for processing claims
related to gulf war service and traumatic brain injuries.
In addition, the average claim in VA's workload is getting more
complex. The number of medical conditions (issues) per original claim
for our returning Iraq and Afghanistan veterans increased dramatically,
from 6.4 at the beginning of fiscal year 2007 to 11.5 at the end of
fiscal year 2012. The total number of issues processed increased 180
percent, from 1.7 million in fiscal year 2009 to 4.8 million in fiscal
year 2012.
VBA's goal is to process all claims within 125 days with 98-percent
accuracy in 2015, and we are confident that we will meet this goal as
we continue to implement our Transformation Plan.
Question. As I understand it, VA Dependents Indemnity Compensation
(DIC) claims previously were decided at the local and State level, but
are now, in the case of Kentucky, decided in Milwaukee, Wisconsin. This
has reportedly resulted in longer wait times for veterans' spouses and
dependents to receive their claims. What caused the initial decision to
relocate this particular DIC claims processing office and what steps is
the VA taking to reduce the time it takes to make final DIC claims
decisions?
Answer. In fiscal year 2003, VBA completed the consolidation of
pension maintenance work to three regional Pension Management Centers
(PMC): Philadelphia, Pennsylvania; St. Paul, Minnesota; Milwaukee,
Wisconsin. In fiscal year 2009, VBA subsequently consolidated the
processing of pension, DIC, and burial benefit claims at the PMCs. The
consolidation provides greater processing efficiency and specialization
for these claims and focuses attention and resources on the needs of
survivors and wartime veterans who require supplemental income.
Fiscal-year-to-date through the end of April, the average days to
complete (ADC) DIC claims was 156 days. By way of comparison, for
fiscal year 2007, ADC for DIC claims was 132 days. Although ADC for DIC
claims has increased since consolidation (18.2 percent), ADC for all
types of compensation and pension claims has increased nationwide over
this period due to the dramatic growth in the volume of incoming
claims.
VBA's Pension and Fiduciary (P&F) Service, which administers the
DIC program, recently reviewed the policies and procedures applicable
to the adjudication of DIC claims, to identify obstacles to timely
processing. It determined that VBA could quickly grant many DIC claims
with little or no additional development, and that certain claims
processing steps are redundant and appropriate for elimination.
As a result of these efforts, on March 22, 2013, P&F Service issued
Fast Letter 13-04 (FL 13-04), Simplified Processing of Dependency and
Indemnity Compensation (DIC) Claims, which instructs VBA field staff on
the procedures to follow when processing claims. Among other things,
the new procedures require screening of claims at the intake point and
limited or no development of additional evidence when information in
VBA systems supports granting benefits. It also clarifies that VBA
grants DIC under 38 U.S.C. section 1318 based upon total service-
connected disability for a prescribed period before death in the same
manner as if the death were service connected. Accordingly, in these
cases, our field staff will grant service-connected burial benefits and
presume the permanence of total disability for purposes of establishing
the survivor's entitlement to VA education and healthcare benefits.
These new procedures will allow us to grant DIC benefits faster and
without unnecessary development.
Question. What is the VA doing to enhance efforts to locate
homeless veterans and to provide resources and programs to help them?
Answer. One of the key pillars of VA's Plan to End Homelessness
Among Veterans is to provide effective outreach to homeless and
veterans at risk of homelessness. Without effective outreach efforts
locating homeless and at-risk veterans, VA has little chance of ending
veteran homelessness. Although many VA homeless programs conduct
outreach, the HCHV Contract Residential Treatment Program is VA's
premier homeless outreach program. The foundation of the program is to
provide targeted outreach to veterans who are homeless or at risk of
homelessness and not currently receiving VA services. These outreach
efforts are an essential component of VA's plan to eliminate
homelessness among veterans and provide opportunities for critical
medical and psychiatric care and referrals. Once identified and
effectively engaged within their own communities, homeless veterans can
then be provided with both immediate and permanent stable housing
solutions and supportive services.
In fiscal year 2012, HCHV staff conducted outreach and provided
outpatient services to over 119,660 veterans and offered more than
11,500 episodes of contract residential community-based treatment.
Outreach has proven to be a successful link, as overall data findings
suggest that more than 90 percent of the veterans engaged with HCHV
received VA mental health services (including direct services provided
by the HCHV Contract Residential Treatment Program) in the 6 months
following outreach.
The HCHV Contract Residential Treatment Program works in
collaboration with other VA programs through a combination of outreach,
case management, housing, and supportive services. The program
collaborates with a multitude of VA homeless programs including, the
Housing and Urban Development--VA Supportive Housing (HUD-VASH)
Program, GPD Program, Veterans Justice Outreach (VJO) Program, Health
Care for Reentry Veterans (HCRV) Program, Homeless Veteran Supported
Employment Program, Homeless Patient Aligned Care Teams (HPACT) as well
as community outreach providers (e.g., 100,000 Homes Campaign, Projects
for Assistance in Transition from Homelessness (PATH) Program, and
local homeless Continuums of Care (CoC)).
In addition to the HCHV Contract Residential Treatment Program, a
number of VA homeless programs contribute to extensive and effective
outreach. For example, each year VA programs and staff actively
participate in stand downs for homeless veterans. Stand downs are
collaborative events, coordinated between local VA facilities, assorted
Government agencies, and community agencies that serve the homeless.
The original stand down for homeless veterans was modeled after the
stand down concept used during the Vietnam war to provide a safe
retreat for units returning from combat operations. Stand downs provide
services to homeless veterans such as food, shelter, clothing, health
screenings, VA and Social Security benefits counseling, and referrals
to a variety of other necessary services, such as housing, employment,
and substance abuse treatment. In 2012, VA-sponsored 205 stand downs
nationally, serving over 50,000 veterans.
VA's outreach efforts also include the National Call Center for
Homeless Veterans (NCCHV), a program dedicated to providing homeless
veterans with referrals to VA and community services, as well as
disseminating information to concerned family members and non-VA
providers about all the programs and services available to assist these
veterans. Calls to the NCCHV number (1-877-4AID VET; 1-877-424-3838)
are answered 24 hours a day, 7 days a week, with a brief screening by
responders to determine the severity of need. Responders at the NCCHV
then link those callers needing referral to their nearest VA medical
center (VAMC) anywhere in the country. VAMC homeless programs have
designated points of contact responsible for assisting veterans
referred to their facility, furthering assessment of need, providing
linkages to services within VA and the community, and developing a plan
of care appropriate for each veteran. In fiscal year 2012, there were
80,558 total calls to the NCCHV. Of these calls, there were 50,608
referrals to a VAMC homeless program point of contact.
VA's Veterans Justice Programs (the HCRV and VJO Programs) also
provide extensive and crucial outreach to veterans involved with the
justice system to prevent veteran homelessness. The HCRV Program staff
conducts outreach to veterans who are preparing to reenter the
community from State and Federal prisons. The goal of this clinical
outreach is to connect veterans at risk of homelessness with
appropriate VA services, especially homeless, mental health, and
substance use services. In fiscal year 2012, the HCRV prison outreach
clinicians contacted and conducted re-entry planning with 10,572
veterans in 1,000 of 1,254 (80 percent) total State and Federal
prisons. Similarly, VJO program specialists provide outreach to
justice-involved veterans in jails and court systems and serve as
liaisons between VA and the local criminal justice system, including
law enforcement. Every VAMC has at least one full-time VJO specialist.
In fiscal year 2012, 27,251 veterans were seen by VJO Program staff.
VA uses all available resources to locate and identify the need for
homeless services in each State and community. VA and HUD continue to
collaborate, develop, and publish HUD's AHAR. These reports, which
advance the Federal effort to end homelessness among veterans through
the collection and analysis of timely data, are intended to provide
policymakers, practitioners, and the general public with information
about the extent and nature of veteran homelessness. In addition to the
snapshot and annual estimates of veteran homelessness, the document
also describes the demographic characteristics of homeless veterans,
including race, ethnicity, gender, age, and disability status.
Finally, VA continues to develop innovative ways to locate and
engage veterans at-risk of homelessness, including developing a more
proactive approach to identifying those who are homeless or at risk of
becoming homeless. In 2012, VA developed a universal screen of
homelessness risk for veterans in the VA healthcare system. The
Homelessness Screening Clinical Reminder serves veterans by identifying
those who may need housing-related assistance but had not accessed or
are not currently being served in a VA homeless program. It also
provides additional information about the profile of veterans who are
at risk of homelessness, the types of services they need and receive,
and how veteran homelessness can be better addressed throughout VA's
system. To date, over 2.7 million veterans have been screened using
this clinical reminder. Of those screened, 25,881 (0.95 percent)
screened positive for housing instability and 30,707 (1.12 percent)
screened positive for being at risk for homelessness. A total of 17,309
veterans agreed to referrals for social work services who provided
veterans with benefits assistance, counseling, and, where appropriate,
referral to homeless programs. Through this process, 14,895 veterans
were referred to homeless programs.
Question. Veterans suffer from many health problems due to their
brave service and sacrifice. I have heard from Kentucky veterans that
do not live near VA hospitals or full medical centers that access to
certain healthcare services remains a concern for many. What criteria
are involved in determining which VA clinics provide specialty care,
such as access to mental health resources, podiatry, ophthalmology, and
dentistry?
Answer. A VA medical center's process for determining sites of care
for services, including specialty care, begins with the annual
completion of the VA Health Care Planning Model. On a regular basis, a
review of the number of days it takes to provide specialty services to
all veterans is performed, with an emphasis on those in remote or rural
areas. VA medical centers also review the frequency with which it
refers veterans outside VA's system for services not currently
available and the distance from a veteran's home he/she may have to
travel to determine potential service additions at their CBOCs.
Finally, VA medical centers utilize community providers to augment its
healthcare system when it cannot provide those services in-house or
within a specified timeframe. Generally, specialty services such as
podiatry, ophthalmology, or dentistry services are not provided at
CBOCs due to their small size (less than 10,000 unique patients).
Specialty mental health services for PTSD, military sexual trauma, and
substance abuse are available in CBOCs and by telemental health to a
clinic closest to the veteran's home.
Question. Many veterans face difficulty beginning families when
they return from service, particularly those who have sustained
injuries such as spinal cord injury or disorder (SCI/D). Is
reproductive assistance a standard VA medical service provided to
veterans with service-connected injuries? What is the VA doing to
address the needs of veterans seeking reproductive assistance? Does the
VA need additional legislative authority to provide reproductive
services?
Answer. As part of the medical benefits package, VA provides
infertility services to include patient counseling, infertility
assessment, and infertility treatment. When medically indicated, VHA
will provide the following infertility services:
------------------------------------------------------------------------
Infertility services for
Infertility services for female veterans male veterans
---------------------------------------------------------------------
--Infertility counseling --Infertility counseling
--Laboratory blood testing (e.g., --Laboratory blood testing
follicle-stimulating hormone, (e.g., serum
luteinizing hormone) testosterone)
--Genetic counseling and testing --Semen analysis
--Pelvic and/or transvaginal ultrasound --Evaluation and treatment
--Hysterosalpingogram of erectile dysfunction
--Saline infused sonohysterogram (e.g., in spinal cord
--Endometrial biopsy (e.g., rule out a injury)
luteal phase defect) --Surgical correction of
--Post coital test structural pathology
--Diagnostic laparoscopy or hysteroscopy --Vasectomy reversal \1\
--Surgical correction of structural --Hormonal therapies
pathology consistent with standard of --Sperm cryopreservation
care including operative laparoscopy \1\
and operative hysteroscopy --Genetic counseling and
--Reversal of tubal ligation (Tubal testing
Reanastomosis) \1\ --Sperm retrieval
--Hormonal therapies (Controlled ovarian techniques
hyper-stimulation) --Post-ejaculatory
--Oral medication for ovulation urinalysis
induction (i.e., Clomid/Serophene) --Transrectal and/or
(maximum of 4 ovulatory cycles) scrotal ultrasonography
--Injectable Gonadotropin
Medications for ovulation induction
--Additional hormonal therapies
approved for use for this purpose by
Pharmacy Benefits Management
--Intrauterine insemination (maximum of
4 cycles)
--Oocyte cryopreservation
------------------------------------------------------------------------
\1\ For medically indicated conditions.
The provision of In Vitro Fertilization (IVF) is excluded from VA's
medical benefits package. Also, infertility diagnosis and management is
a condition of couples. VA has limited authority to provide services to
non-veterans; however, in accordance with title 38, Code of Federal
Regulation (CFR) 17.272(a)(28), IVF is specifically excluded for
coverage under Civilian Health and Medical Program of VA.
Most male veterans with spinal cord injuries or disorders (SCI/D)
have erectile dysfunction and infertility directly related to spinal
cord dysfunction. Available options for the evaluation and treatment of
infertility in veterans with SCI/D are limited. A full diagnostic
evaluation is provided. Treatment that is available in VA includes
approaches such as surgical correction of structural pathology,
hormonal therapies, sperm retrieval and cryopreservation, and
intrauterine insemination. In the vast majority of men with SCI/D, VA
treatments that are provided do not result in successful pregnancies.
Infertility services, including IVF and other Assisted Reproductive
Technologies (ART), restore or enhance the ability to procreate, but
successful treatment requires the provision of ART services to both the
ill/injured veteran and his or her spouse/partner. Currently and in the
past, VA has worked with DOD and community partners to identify
resources that are available for veterans with SCI/D.
______
Questions Submitted by Senator Susan M. Collins
Question. Secretary Shinseki, I spoke with you last August about my
disappointment with the wasteful conference spending and improper
behavior by Department of Veterans Affairs (VA) employees related to
two VA conferences held in Orlando, Florida, in 2011. More than $6.1
million was spent on these two conferences, and the VA Office of
Inspector General (OIG) found that as much as $762,000 was
unauthorized, unnecessary or wasteful spending.
I share your belief that effective training of VA personnel--the
purpose for the conferences--is necessary. Despite the legitimate
purpose of training, there can be no excuse for excessive or wasteful
spending of VA resources. I know that you share my concerns about
wasteful spending, especially in these challenging fiscal times, and
that you agree that at a time when so many veterans are in need of care
and assistance, the VA must make every effort to spend each dollar in
support of its important mission.
What steps has the VA taken to prevent similar waste and abuse of
Government resources in the future?
Answer. VA employs over 320,000 employees who provide high-quality
healthcare, benefits, and services to veterans every day. VA is the
Nation's largest integrated healthcare system with nearly 1,300 centers
of care serving 8.6 million veterans across the country. A large number
of VA doctors, nurses, claims processors, and other employees directly
benefit from training events every year. Continuous workforce training
and development is essential to delivering timely and quality VA care
and services our veterans have earned and deserve. VA holds centralized
training forums to enhance the delivery of healthcare, benefits, and
memorial services unique to veterans. This includes employee
development through critical training to improve customer service and
the timely delivery of benefits and services; clinical training, which
includes post-deployment care, treatment of chronic conditions, mental
health, suicide prevention; and strategies to eliminate veteran
homelessness. Our training events are designed to achieve our goals--
better access, eliminate the backlog, and end veteran homelessness--by
training and developing our employees and empowering them to provide
the best care and services possible for our Nation's servicemembers and
veterans.
VA has implemented a comprehensive action plan to revise and
strengthen policies and controls on the planning and execution of
training conferences and events. These actions are consistent with the
recommendations in the September 30, 2012, inspector general report and
are reflected in VA policy issued on September 26, 2012.
Stringent internal controls for training conferences are in place
and oversight is provided by the senior executives in the Department.
Further, the newly established Training Support Office ensures
consistency and clear guidance regarding needed steps for adherence
with all appropriate regulations and requirements as the Department
balances critical training requirements to ensure achievement of stated
goals and objectives while minimizing costs.
Automating data collection is essential to provide accurate and
timely information for senior leaders so they can execute their
responsibilities and respond to queries for training related events
from congressional and other Federal oversight bodies. VA is currently
engaged in developing and delivering an automated data collection tool
to increase accountability, control conference spending, and produce
congressionally required reports.
VA's conference oversight memorandum dated September 26, 2012,
supersedes all previously issued conference guidance:
--the approval authorities:
--a senior executive must approve any conference under $20,000.
--two senior executives, the Conference Certifying Official (CCO)
and the Responsible Conference Executive (RCE), are
appointed when a conference exceeds $20,000 to ensure
adherence to all applicable statutes, regulations, and
policies when planning and executing the approved
conference.
--an Under Secretary or Assistant Secretary must approve any
conference within the threshold $20,000 to $100,000.
--the Deputy Secretary is responsible for approving conferences
exceeding $100,000 to $500,000.
--conferences exceeding $500,000 require a waiver by the Secretary.
--a quarterly conference planning and execution briefing is now
required at least 120 days prior to the quarter of execution.
This briefing outlines all the conferences planned for the
targeted quarter to include cost, attendees, location, purpose,
and outcomes.
The VA conference process has four phases: concept, development,
execution, and reporting.
--The concept phase is a disciplined conference authorization
process. In October 2012, VA began our quarterly concept
authorization briefing as part of the quarterly conference
planning and execution briefing cycle where senior officials
review all events to ensure the best value prior to being
authorized to enter the development phase.
--The development phase builds the business case for the event;
provides the guidance for the planning and execution of the
potential conferences; appoints a senior executive as the CCO
and a senior executive as the RCE. The CCO certifies the event
details are in compliance with all directives. The event plan
is then submitted through the appropriate channels to the
approving official for approval, disapproval or modification of
the planned event.
--The execution phase covers the period after the conference plan has
been approved and the responsible organization begins to
execute the approved plan. The RCE is responsible for executing
the approved plan in accordance with laws, regulations, and
policy. Additionally, the RCE oversees the spending and
contract execution, approving any changes to contract
agreements or increases in spending.
--The reporting phase covers the period after the execution of the
conference. The RCE submits an After Action Review (AAR)
reflecting how the event was conducted; providing conference
attendance and details on how the spending was tracked and
reported in accordance with Public Law 112-154 and OMB M-12-12.
The administrations and staff offices leadership review the AAR
to verify that the event was executed in accordance with the
plan and all applicable policies and regulations.
______
Questions Submitted by Senator Daniel Coats
claims processing
Question. The President's fiscal year 2014 budget calls for an 8.5-
percent increase in funding for the Department of Veterans Affairs from
fiscal year 2012. The administration justifies this increase in funding
in order to reach a target goal to ``process all claims within 125 days
with 98-percent accuracy in 2015.'' The average wait time in
Indianapolis is 600 days.
With even more servicemembers entering the VA system in the next
year, as we drawdown from Afghanistan, how feasible is this goal?
Answer. Right now, too many veterans wait too long to receive
benefits they deserve. This has never been acceptable to VA or to the
dedicated employees of VBA--52 percent of whom are veterans themselves.
In January 2013, VA delivered its Strategic Plan to Eliminate the
Compensation Claims Backlog to Congress (http://benefits.va.gov/
transformation/docs/va_strategic_plan_to_eliminate_the_
compensation_claims_backlog.pdf). We are confident that we will meet
our 2015 goal as we continue to implement our Transformation Plan.
While the troop drawdown may result in an influx of new claims, VBA has
anticipated this workload and considered its impact on VBA's ability to
reach the 2015 goals. It is important to note that the timeline for
eliminating the backlog could be affected if policymakers establish new
presumptive conditions, courts make new precedential decisions, or
legislators make laws that establish new entitlements. VBA continues to
monitor the performance impact of transformation, as well as other
external factors that could potentially have an impact.
Question. What specific actions has the Department of Veterans
Affairs taken to reach this goal?
Answer. VBA has developed and is implementing a comprehensive
Transformation Plan designed to eliminate the claims backlog and
achieve our goal of processing all claims within 125 days at a 98-
percent accuracy level in 2015. This major transformation in claims
processing includes a series of people, process, and technology
initiatives that are being implemented according to a carefully
developed multiyear timeline. The transformational initiatives are
being rolled out in a progressive, deliberate sequence that enables
efficiency gains while minimizing risks to performance.
VBA reorganized its workforce into cross-functional teams that
enable employee visibility of the end-to-end case management approach
of the entire processing cycle of a veteran's claim. These cross-
functional teams work together on one of three segmented lanes:
express, special operations, or core. VBA instituted Challenge Training
in 2011 and Quality Review Teams (QRT) in 2012 to improve employee
training and quality while decreasing rework time. Challenge Training
is focused on overall skills and readiness of the workforce, and QRTs
focus on improving performance on the most common sources of error in
the claims processing cycle; data on VBA's largest sources of error are
captured and analyzed by its National Accuracy Team. VBA tracks the
impact of these initiatives on quality through a 3-month rolling
average accuracy metric that is reported on VA's ASPIRE Web site and
can be found online at http://www.vba.va.gov/reports/aspiremap.asp.
VBA actively solicited innovative ideas for process improvement
from veterans, employees, and industry stakeholders through a variety
of structured mechanisms. Literally thousands of ideas were received
and culled down to those with the largest potential to attack the
backlog. For example, automated Disability Benefits Questionnaires
(DBQ) (discussed below)--arguably one of the most highly leveraged
changes--came from one of the VBA employee idea competitions.
Additionally, VBA has also conducted Lean Six Sigma and Kaizen events
on these selected targets of opportunity, all focused on five major
areas of focus: wait time, rework, productivity, digital intake, and
variance.
VBA also implemented the simplified notification letter initiative.
This initiative has reduced key strokes and automated production
language in the decision letter for the veteran, thus improving rating
decision productivity and quality. VBA implemented this initiative on
March 1, 2012.
Electronic DBQs are forms that physicians complete during an exam
that contain explicit medical information needed to decide a disability
compensation claim. The single largest category for rework that results
in delays in rating decisions are exams that contain insufficient data.
Fully and properly complete DBQs eliminate these errors. The DBQs, now
deployed to all 56 regional offices, can increase production and reduce
the amount of time spent on each claim by organizing key information.
Seventy-one DBQs are now available to private physicians as well. VBA
continues to work with DOD regarding the use of DBQs in exit exams.
Key to VBA's transformation is ending its reliance on outmoded and
paper-intensive processes. VBA is developing technology solutions that
improve access, drive automation, reduce variance, and enable faster
and more efficient operations. The deployment of the VBMS, VBA's new
digital, paperless processing system, is occurring across four distinct
phases or generations of development. Generation One of VBMS concluded
with the successful implementation of Release 4.1 in January 2013. This
generation culminated in a foundational Web-based, electronic claims
processing solution. Under our accelerated deployment schedule, all 56
regional offices and our Appeals Management Center are now using VBMS.
We will also continue to enhance the automated functionalities and
build additional system capabilities in three future generations of
VBMS to be deployed over the next 2 years. As we move into future
generations of VBMS, our focus is on leveraging more complex automation
features and more extensive data exchange and system integration
capabilities so that our employees will be able to process claims
electronically from receipt to payment.
Question. What actions will be taken in the future to make sure our
brave men and women are not waiting nearly 2 years to get a reply from
the VA?
Answer. VA's goal of processing claims within 125 days with 98-
percent accuracy is a permanent goal. Our Transformation Plan, which
incorporates people, process, and technology initiatives, will ensure
that the backlog is resolved and that the results are sustained and
continuously improved upon.
VBA's new organizational model, which incorporates a case-
management approach to claims processing, has been implemented at all
56 regional offices. VBA projects that the segmented lanes initiative,
part of this new organizational model, will accelerate simpler claims,
predictably taking less time through the express lane, with the
remainder of claims flowing through either a special operations lane
(claims requiring special handling) or core lane. This segmented, case-
management approach to claims processing is creating efficiencies
within our workforce.
Under our accelerated deployment schedule, all 56 regional offices
and our Appeals Management Center are now using VBMS. Once fully
developed, VBMS is projected to provide a 20-percent increase in
productivity, or an estimated increase in production of over 200,000
claims in fiscal year 2015.
Future generations of VBMS will focus on continuing to improve
electronic claims processing by providing increased system
functionality and more complex automation capabilities for all VBMS
end-users. VBA, in collaboration with the Office of Information and
Technology, is building new decision-support tools to make our
employees more efficient and their decisions more consistent and
accurate. We have already developed rules-based calculators for
disability claims decisionmakers to provide suggested evaluations. For
example, the hearing loss calculator automates decisions using
objective audiology data and rules-based functionality to provide the
decisionmaker with a suggested decision.
VBA's partnership with Veterans Service Organizations (VSOs) is
also crucial to our transformation. Today, only about 5 percent of
claims received by VA come with the documentation necessary for a
decision. As a result, VBA reviewers commit countless hours attempting
to locate medical and service records, and arranging physical
examinations needed to support veterans' claims. VBA is greatly
expanding education and collaboration efforts with VSOs that result in
the submission of more ``fully developed'' claims (FDC) (http://
benefits.va.gov/transformation/fastclaims/)--claims that come to VA
ready for final review and decision.
VBA is also completing the integration with other Federal
departments that enables inter-departmental data review and exchange to
support pension and disability claims processing. This includes the
Social Security Administration, Internal Revenue Service (income
verification), and the Department of Defense (military personnel and
medical records). Currently, claims take an average of 314 days to
process, and approximately 239 of those days are taken up in the
process of gathering information from other sources.
patient centered community care (pccc) program
Question. There are concerns from local healthcare providers that
the VA is not properly communicating the new Patient Centered Community
Care (PCCC) Program. For example, last September, the public was given
only 2 weeks to provide comments/suggestions to the VA's request for
proposal for the PCCC Program--this was not nearly enough time to
assess the impact of the implementation of PCCC nor was it enough time
for the 5,000-page program to be understood by the healthcare providers
who serve our veterans.
Do you think there should have been a larger window for that
comment period to improve transparency?
Answer. While we realize that not everyone in the community
responded with questions and comments, we believe ample time was
provided. We began our market research in 2011 with a Request for
Information (RFI) posted to Federal Business Opportunities (FedBizOps),
which allowed anyone in industry to respond to questions designed to
help guide the program's development. We also conducted Industry Day
events in Portland, Oregon, Minneapolis, Minnesota, and Atlanta,
Georgia, in November and December 2011 to allow anyone in the community
to attend and hear our plans, ask questions, and have one-on-one time
with the program team and contracting officers.
A draft Request for Proposals (RFP) was released in September 2012
that allowed time for community/industry providers and companies to see
the actual requirements we planned to release and to provide comments
or ask questions. The final RFP was released in December 2012. Through
extensions, the RFP comment and question period was prolonged to March
6, 2013. From the time of the original RFI in November 2011 to the
extended RFP comment period, March 6, 2013, the program team, through
the contracting officer, was open for discussion and comments and also
held multiple briefings with U.S. House of Representatives and U.S.
Senate congressional staff.
One of the attachments to the 114-page RFP added a number of pages
to the overall solicitation, but this data is intended to show the
types and volumes of care we have purchased historically. This
information was requested by industry so they could get a sense of care
purchased in the past and assist them in planning network development.
We assume the reference to 5,000 pages includes a printed version of
the fiscal year 2010-2012 data spreadsheet.
Question. Second, what are your opinions on requiring a minimum
length for an open comment period for a proposal of this significance?
Answer. Federal Acquisition Regulations (FAR) requires the agency
to establish a response time for commercial item acquisition that will
afford offerors a reasonable opportunity to respond. For non-commercial
item acquisitions, a minimum of 30 days is required by FAR. The time
allotted for offerors to respond with a proposal to the PCCC RFP
exceeded 30 days. With each amendment and extension of the proposal
submission timeline, open periods for comments and questions were
allowed. The final date range from initial RFP release to receipt of
proposals, after all amendments, is December 21, 2012, to May 28, 2013.
There appear to be many concerns from healthcare providers about
the Patient Centered Community Care Program (PCCC). For example,
healthcare providers are worried their existing contracts will be
allowed to expire and replaced and the VA will prohibit contracting
with long-term care hospitals and hospice. Furthermore, some are under
the impression PCCC will require veterans in rural areas needing
hospital level care to travel up to four hours or more to receive care
even if care is available in the veteran's community but it is not a
PCCC hospital.
Question. What specific communications strategies has the VA
implemented to address these questions from the public and better
inform them on these complex provisions stemming from PCCC.
Answer. Through the draft RFP and final RFP comment and question
process, we responded to any questions asked about local contracts and
provided these answers in amendments posted to the RFP on FedBizOps.
This follows normal acquisition procedures. Furthermore, we provided a
fact sheet to congressional staff and followed up with briefings and
open general sessions, including:
--holding a Four Corners briefing with the House and Senate Veterans'
Affairs Committees in January;
--responding to an inquiry from the Senate Budget Committee;
--holding general session Non-VA Medical Care Contracting 101
briefings for House and Senate staff;
--briefing, in February and April 2013, the Senate Appropriations
Committee; and
--briefing, in May 2013, the House Appropriations Committee.
VA is not restricting local VA medical centers from contracting
through the Federal acquisition process. Those community providers
wishing to support or continue supporting veterans through PCCC can
participate in an awarded contractor's network. Please note long-term
care and Hospice are not included in PCCC; therefore, these existing
contracts are not impacted in any way.
Through contracts awarded as a result of PCCC procurement, we will
be able to partner with networks of community providers that already
have existing facilities in rural and highly rural areas that will be
available to our veterans when VA determines they should receive the
needed care in their communities. If the contracted partner does not
have a facility within reasonable range of the veteran's home,
individual authorizations are available to allow VA to furnish the care
from community providers not under the PCCC contract.
The Patient Centered Community Care Program (PCCC) does not utilize
the most current quality outcome measurement tools, such as value based
purchasing used by Medicare. Instead, the RFP creates three quality
review committees looking at publicly available data instead of
requiring an outcome measurement system.
Question. Why doesn't the VA include state-of-the-art patient
outcome measurement requirements of its contractors?
Answer. The PCCC RFP includes quality requirements established by
VA clinical providers and management. A key principle in the PCCC
process is to get medical diagnostic and treatment information back to
VA care teams so that a veteran's care is managed and less fragmented
than can often occur outside VA. Requirements developed include:
timeliness for the return of medical documentation, credentialing,
privileging, licensure, board certification, medical documentation, and
safety reporting. The RFP also includes performance measurement
requirements specifically around surgical outcomes and cardio-thoracic
procedures that are not publicly available.
The requirement for Peer Review and Quality Oversight Committees is
a positive lesson learned from VA's Project HERO pilot in which our
partners had these committees as standard network operations.
Operationally, medical staff review patient/episodic quality cases to
ensure patients are protected and receiving high-quality levels of
care. The Peer Review Committee is responsible for reviewing provider
standards of practice while the Quality Oversight Committee reviews
access, patient satisfaction, and performance standards. Most
commercial networks have existing medical officers and quality
committees to provide oversight of their networks. It is in the best
interest of VA to follow these community practices and benefit from
quality activities already in place in the business community. The
requirement for VA to be allowed to participate in these committees
enhances our assurances of the provision of quality care so we are not
delegating or abdicating quality oversight to the contracting networks.
Publicly reported data will be sent to VA after acceptance by the
requesting organizations; VA will receive and evaluate that data versus
asking the contracted partner to have a subcommittee to accomplish that
activity. Our desire is to create partnerships that will leverage
existing valid quality management programs to enhance patient quality,
safety, and access to care. Additionally, as the Centers for Medicare
and Medicaid Services move toward full implementation of pay for
performance initiatives, VA will seek ways to collaborate and apply
these pay for performance initiatives to the care purchased for
veterans. The development of healthcare networks is a dynamic process;
as hospitals and healthcare providers are recognized as exceptional
performers, VHA can request potential recruitment of said performers
into the existing provider network.
______
Questions Submitted to Richard J. Griffin
Question Submitted by Senator Tim Johnson
va-dod cooperation
Question. In the VA budget submission, information technology
oversight was listed as one of the major program challenges for the
inspector general. The VA-DOD integrated Electronic Health Record, or
iEHR, is certainly a major IT initiative. Being a joint agency project
no doubt presents oversight challenges. But it is top priority of both
the VA and DOD Secretaries, and essential to the seamless transition of
health records for veterans.
I am very concerned about the direction of this initiative given
recent indications that the two agencies may drop plans for a joint
system in favor of separate systems with file-sharing capabilities. It
appears that soaring costs and time considerations played a major role
in this change of course.
What is the VA inspector general planning to do to monitor the
cost, development timeline, and likelihood to meet program goals of the
iEHR?
Answer. The status of the integrated Electronic Health Record
(iEHR) is currently in a state of uncertainty; as a result, we consider
it premature for the VA Office of Inspector General (VA OIG) to
undertake an assessment of the initiative at this time. We understand
that the Government Accountability Office is currently reviewing this
issue.
VA continues with efforts to modernize the Veterans Health
Information Systems and Technology Architecture--its ``core'' system
for the iEHR initiative. The VA OIG will continue to monitor decisions
made regarding the iEHR so that we can review this system development
initiative when the timing is right. We will then initiate an audit
focusing on the VA perspective as the VA OIG's oversight authority does
not cross departmental lines.
______
Question Submitted by Senator Mark Begich
mental health care in rural areas
Question. Mental health continues to be a concern in rural areas,
access, wait times, etc. Can you tell me in your inspections, if
contract mental health is being utilized to the full extent and what
are your recommendations to expand?
Answer. Our inspections indicate that VA struggles to provide
access to mental health services to veterans across the United States.
VA has the ability to utilize non-VA care (also known as fee basis) and
contract programs to provide healthcare to supplement the care VA is
able to provide through its own facilities. VA needs to institute
contract and fee basis agreements to permit timely and coordinated
mental healthcare for veterans who would benefit from these services.
Better coordination with State and local government mental health
officials, who often support community mental health services, and with
private mental health providers has the potential to dramatically
improve the access to mental health services by veterans.
SUBCOMMITTEE RECESS
Senator Johnson. This hearing is recessed.
[Whereupon, at 4:31 p.m., Thursday April 18, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]