[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 2460; H.R. 3956; H.R. 3974; H.R. 3989;
DRAFT LEGISLATION TO ENSURE THAT EACH VA MEDICAL FACILITY COMPLIES WITH
REQUIREMENTS RELATING TO SCHEDULING VETERANS FOR HEALTH CARE
APPOINTMENTS AND TO IMPROVE THE UNIFORM APPLICATION OF DIRECTIVES; AND
DRAFT LEGISLATION TO DIRECT VA TO ESTABLISH A LIST OF DRUGS THAT
REQUIRE AN INCREASED LEVEL OF INFORMED CONSENT
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, APRIL 20, 2016
__________
Serial No. 114-66
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
25-155 PDF WASHINGTON : 2017
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
GUS M. BILIRAKIS, Florida JULIA BROWNLEY, California,
DAVID P. ROE, Tennessee Ranking Member
TIM HUELSKAMP, Kansas MARK TAKANO, California
MIKE COFFMAN, Colorado RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana BETO O'ROURKE, Texas
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Wednesday, April 20, 2016
Page
Legislative Hearing On H.R. 2460; H.R. 3956; H.R. 3974; H.R.
3989; Draft Legislation To Ensure That Each VA Medical Facility
Complies With Requirements Relating To Scheduling Veterans For
Health Care Appointments And To Improve The Uniform Application
Of Directives; And Draft Legislation To Direct VA To Establish
A List Of Drugs That Require An Increased Level Of Informed
Consent........................................................ 1
OPENING STATEMENTS
Honorable Dan Benishek, Chairman................................. 1
Honorable Julia Brownley, Ranking Member......................... 2
WITNESSES
Honorable Elise Stefanik, U.S. Hous of Representatives, 21st
Congressional District; New York............................... 4
Prepared Statement........................................... 32
Honorable Mike Bost, U.S. House of Representatives, 12th
Congressional District; Illinois............................... 5
Prepared Statement........................................... 33
Honorable Ann Kuster, U.S. House of Representatives, 2nd
Congressional District; New Hampshire.......................... 6
Prepared Statement........................................... 34
Honorable Jackie Walorski, U.S. House of Representatives, 2nd
Congressional District; Indiana................................ 8
Prepared Statement........................................... 35
Honorable Lee Zeldin, U.S. House of Representatives, 1st
Congressional District; New York............................... 9
Prepared Statement........................................... 36
Diane M. Zumatto, National Legislative Director, AMVETS.......... 12
Prepared Statement........................................... 37
Shurhonda Y. Love, Assistant National Legislative Director,
Disabled American Veterans..................................... 14
Prepared Statement........................................... 40
Fred S. Sganga, Legislative Officer, National Association of
State Veteran Homes............................................ 15
Prepared Statement........................................... 43
Maureen McCarthy, M.D., Assistant Deputy Under Secretary for
Health for Patient Care Services, Veterans Health
Administration, U.S. Department of Veterans Affairs............ 23
Prepared Statement........................................... 45
Accompanied by:
Susan Blauert, Chief Counsel, Health Care Law Group, Office
of General Counsel, U.S. Department of Veterans Affairs
STATEMENTS FOR THE RECORD
The American Legion.............................................. 51
American Psychiatric Association................................. 54
Easter Seals..................................................... 56
National Association of Mental Illness........................... 58
Veterans Affairs Physician Assistant Association................. 59
Veterans of Foreign Wars of the United States.................... 63
LEGISLATIVE HEARING ON H.R. 2460; H.R. 3956; H.R. 3974; H.R. 3989;
DRAFT LEGISLATION TO ENSURE THAT EACH VA MEDICAL FACILITY COMPLIES WITH
REQUIREMENTS RELATING TO SCHEDULING VETERANS FOR HEALTH CARE
APPOINTMENTS AND TO IMPROVE THE UNIFORM APPLICATION OF DIRECTIVES; AND
DRAFT LEGISLATION TO DIRECT VA TO ESTABLISH A LIST OF DRUGS THAT
REQUIRE AN INCREASED LEVEL OF INFORMED CONSENT
----------
Wednesday, April 20, 2016
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:01 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek, Roe, Coffman, Wenstrup,
Abraham, Brownley, Takano, Ruiz, Kuster, and O'Rourke.
Also Present: Representatives Bost, Walorski, and Zeldin,
and Kuster.
OPENING STATEMENT OF DAN BENISHEK, CHAIRMAN
Mr. Benishek. The Subcommittee will come to order, and
before we begin, I would like to ask unanimous consent for our
colleagues and fellow Committee Members, Representative Zeldin
from New York, Representative Bost from Illinois,
Representative Kuster from New Hampshire, and Representative
Walorski from Indiana, to sit on the dais and participate in
today's proceedings. So without objection, so ordered.
Good morning, and thank you all for joining us for today's
legislative hearing. Our agenda this morning includes six
bills. The bills are H.R. 2460, to improve the provision of
adult day health care services for veterans; H.R. 3956, the VA
Health Center Management Stability and Improvement Act; H.R.
3974, the Grow Our Own Directive: Physician Assistant
Employment and Education Act of 2015; H.R. 3989, the Support
Our Military Caregivers Act; and draft legislation to ensure
that each VA medical facility complies with the requirements
related to scheduling veterans for health care appointments,
and to improve the uniform application of directives; and draft
legislation to direct the VA to establish a list of drugs that
require an increased level of informed consent.
These pieces of legislation cover a wide range of topics
facing our veterans and their families. One bill on our agenda
that I look forward to discussing is H.R. 3956, the VA Health
Center Management Stability and Improvement Act. This bill,
which is sponsored by Representative Bost, would require the VA
to develop and implement a plan to hire directors at VA medical
facilities, prioritizing those that have been without permanent
leaders for the longest time. The number of VA medical
facilities that have gone without stable, consistent, long-term
leadership is alarming. We have to encourage the VA to take
every possible action to bring high-quality leaders to the
helm.
Another bill I look forward to discussing is H.R. 2460, a
bill sponsored by Lee Zeldin that would authorize the VA to
cover costs for adult day health care at State veterans' homes
for certain veterans. It is critical that we increase long-term
care options for our veterans, particularly for those who can
and want to live at home for as long possible, but need
additional assistance during the day.
I am also here to discuss H.R. 3989, a bill sponsored by
Representative Stefanik, to address the growing application
backlog in the Family Caregiver Program, and draft legislation
sponsored by Representative Walorski to ensure that VA medical
facilities comply with scheduling directives.
I am grateful to all my colleagues for introducing the
bills on our agenda this morning and thank them for being here
today to discuss them with us. I am also grateful to the
representatives from our veterans service organizations and to
the Department of Veterans Affairs for being here this morning
as well, and I will now yield to the Ranking Member, Ms.
Brownley, for any opening statement she may have.
OPENING STATEMENT OF JULIE BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman, and thank you for
holding this hearing today. Among the many bills being
considered today is my draft legislation on increased informed
consent. Over the past few years the Committee on Veterans
Affairs has heard testimony from veterans using opioids for
long-term pain management and the severe side effects that are
often associated with that treatment. Time and time again we
have heard from veterans who were not fully aware of the
potential side effects of these medications or that alternative
treatments to prescription medications were, indeed, available.
My draft legislation is designed to open up a meaningful
dialogue between the veteran and the physician by raising the
standard for informed consent for certain drugs prescribed by
doctors at the Department of Veterans Affairs. It would also
require the Veterans Health Administration to form a clinician
panel that would establish and maintain a list of drugs which
may only be furnished to a patient with increased informed
consent. In the past few years, the VA has worked to address
the prescription drug crisis. While I appreciate the
Department's work to prevent prescription drug abuse and
overdoses, I still feel their efforts have not gone far enough.
The goal for the draft legislation is to encourage a real
conversation between the veteran and doctor at the point when a
treatment plan is presented to the veteran and a conversation
that goes beyond the VA's existing standardized form, which was
last updated in 2014. Under the discussion draft, if a drug
identified by the clinician panel, is prescribed by a VA
doctor, that provider would prepare and present a written,
improved consent form to the patient.
For drugs with improved informed consent, the veteran's
doctor would provide written information and discuss with the
veteran the risk of dependency, known interactions between the
drug and other drugs or substances including alcohol, if the
drug has an FDA black box warning, and if any alternative
treatments are available and might be helpful. This form would
not require the patient to commit to that treatment plan. It
would also give the patient the opportunity to review the
information provided regarding the recommended treatment and
any other possible treatments. Additionally, the patient would
have the opportunity to speak to a VA pharmacist if the patient
has additional questions about the drug being described. I
recognize that veterans, their families, or, indeed, some
Members of this Committee, like me, are not experts in medical
care. The intent of this legislation is to not tell doctors how
to treat their patients, but to ensure that veterans are
confident they have the information they need to make an
informed decision about what would be best for their long-term
health. Before they pick up that first prescription, the
veteran deserves to have all of their options laid out.
Since the discussion draft was released, I have received
support on the principles behind the draft from many veteran
groups and constructive comments from health care providers
regarding the scope of the language. I look forward to working
with all interested parties to improve on the proposal and
bring some level of control and decision back to the veteran
when the treatment of his or her injury or illness is being
addressed.
I thank the VA for their testimony this morning as well as
their willingness to meet with my staff to address the concerns
raised in the draft language. We can all agree that including
the veteran in the decision-making process in a meaningful way
is the right way to go when it comes to the veteran's health
care. This language is my attempt to bring that about.
Thank you for this opportunity, Mr. Chairman, and I yield
back the balance of my time.
Mr. Benishek. Thank you, Ms. Brownley. I am honored to be
joined this morning by several of my colleagues to speak in
support of their legislation. I think Mr. Zeldin will be
joining us. We do have the Honorable Mike Bost from Illinois,
the Honorable Ann Kuster from New Hampshire, the Honorable
Elise Stefanik from New York, and the Honorable Jackie Walorski
from Indiana. Thank you all for being here today.
I am going to yield first to Representative Stefanik and
then Mr. Bost because I understand they both have markups to
attend in other Committees this morning.
So Representative Stefanik, please proceed with your
testimony.
STATEMENT OF ELISE M. STEFANIK
Ms. Stefanik. Chairman Benishek, Ranking Member Brownley,
thank you for the invitation to testify on this important
legislation. I truly appreciate the opportunity to appear
before you and look forward to discussing this key issue. As a
Member of the House Armed Services Committee with a critical
Army base and Navy nuclear training facility located in my
district, I am dedicated to providing support to
servicemembers, veterans, and their families.
Since September 11, 2001, the Army's 10th Mountain Division
at Fort Drum has been the most actively forward deployed
division in the global war on terror. Over the last 15 years of
war, our servicemembers have bravely served our Nation, and
their families have sacrificed an immeasurable amount. So it is
vital that we ensure they receive the best possible care. This
is especially true for our military caregivers, loved ones of
our servicemembers who selflessly care for our heroes behind
the scenes. These men and women are often left out when
discussing veterans' issues. Military caregivers are essential
component of the communal and family support system for our
disabled veterans. They are usually spouses and other family
members who spend their days transporting and caring for
disabled veterans in order to provide an environment that
enhances their everyday lives.
In 2010, Congress passed a law implementing the Family
Caregiver Program. This was an important piece of legislation
that made veterans who sustained injuries in the line of duty
eligible for a package of benefits that includes access to a
primary caregiver. These benefits would ensure that the family
members who dedicate their lives as caregivers, receives access
to health care, caregiver training, and stipends for additional
costs associated with their disabled veteran. Unfortunately,
the Department of Veterans Affairs has had a difficult time
managing the high demand of family caregiver enrollees, which
is much larger than originally accounted for during
implementation.
According to the Government Accountability Office, VA
officials estimated they would receive 4,000 enrollees and
staffed the program based on this estimate. However, in the
first few months of implementation, there were over 15,000
enrollees to the Family Caregiver Program. VA medical centers
lack sufficient caregiver support coordinators and the
necessary clinical staff to carry out medical assessments for
eligibility for this program. These implementation issues have
led to a delay in both the application and the appeals process.
Application deadlines are not being met by their own internal
standards, and the staff is still shorthanded.
These issues are not only unacceptable, but I believe they
are preventable, and after meeting with a constituent who is a
caregiver facing the burden of the VA backlog, I introduced
H.R. 3989, the Support Our Military Caregivers Act. This bill
would use preexisting funds already appropriated for the
current review and appeals process to then allow for an
objective, independent party to conduct external clinical
reviews. This bill would ensure that new, or modified processes
are veteran-centric, outcome-based, and continually improved
through the use of best practices. We can accomplish this by
permitting a third party to work within the VA to streamline
claims and reduce the caregiver backlog through a more clinical
analysis, rather than benefits adjudication. The VA would
maintain this third party until appeals are streamlined, and
the backlog is down to an acceptable rate and addresses the
issues highlighted by the GAO.
Military caregivers are truly the silent heroes in our
communities and deserve the respect and benefits proportionate
to their significant contributions. I would also like to
highlight that this legislation is supported both by the
Elizabeth Dole Foundation and American Veterans. I look forward
to discussing this issue further in order to implement a
solution and get our military caregivers the benefits they
deserve. Thank you.
[The prepared statement of Elise Stefanik appears in the
Appendix]
Mr. Benishek. Thank you very much, Ms. Stefanik. Mr. Bost,
you are now recognized.
STATEMENT OF MIKE BOST
Mr. Bost. Thank you, Mr. Chairman, Chairman Benishek,
Ranking Member Brownley. Thank you for allowing me to testify
on this bill today. We must be very, very careful in
consideration of how to reform the Department of Veterans
Affairs and ensure access to quality health care our veterans
deserve. As a Marine and the father of a Marine, I recognize
the sacrifices that so many Americans have made in defense of
our freedom. There is no doubt that we must fight for the brave
men and women who have fought for us. I know my colleagues on
both sides of the aisle feel the same way. But we need steady
leadership and long-term vision. No organization can operate
under a revolving door of interim leadership, and certainly not
one that is given the task of caring for our American heroes.
Yet, this revolving door is occurring at VA medical centers
across this country. This undermines the quality and speed of
the care that our veterans receive. That is unacceptable. That
is why I introduced House Resolution 3956, the VA Health Center
Management Stability and Improvement Act. The bipartisan
legislation requires the VA Secretary to create a plan for
hiring a permanent and qualified director at every VA Medical
Center. My bill is endorsed by the American Legion, Vietnam
Veterans of America, Paralyzed Veterans of America, AMVETS,
Disabled American Veterans, and the Association of the United
States Navy.
The issue first came to my attention in my own back yard.
Many southern Illinois veterans receive treatment from the St.
Louis VA Medical Center. The St. Louis VAMC provides health
care for 45,000 veterans annually, all under the cloud of
temporary leadership. I remain very concerned about the lack of
stability and how it impacts system operations.
Over the last several years, the St. Louis VA has been
managed by more than seven different acting directors. After I
began looking into the local issue at the St. Louis VA Medical
Center, it came to my attention that this isn't a problem that
just exists in that area. Upon further investigation, I found
dozens of VA medical centers that have lacked a permanent
director for quite some time.
The problem is due to the OPM requirements, which stipulate
that the temporary directors can serve no more than 120 days
with a 240-day maximum total if their tenure is extended. The
lack of stability and permanent leadership is no doubt one of
the reasons the Department of Veterans Affairs has been
struggling to provide appropriate health care to those it
serves. House Resolution 3956 seeks to fix the problem and fix
it now. Specifically, it requires the VA Secretary to, one,
report the status of any unfilled vacancy to the House and
Senate Veterans' Affairs Committee; two, identify possible
issues leading to the lack of staffing for these unfilled
permanent positions, directors' vacancies; three, assess the
possibility of promoting and training qualified candidates from
within the VA for promotion to these leadership positions;
four, develop a plan to hire highly qualified medical directors
for each VA Medical Center which lacks a permanent director;
and, five, submit this plan to Congress within 120 days of
enactment of the bill.
I have reached out to my local congressional colleagues and
sent letters to the department regarding the lack of leadership
at the St. Louis VAMC. Last week, I received a reply from the
VA Under Secretary of Health giving me an update on the issue.
According to his timeline, the St. Louis position has been
vacant since July 14, 2013. That is 33 months. I have enclosed
a copy of the St. Louis VA Medical Center Director timeline
with a formal statement to illustrate just how long this gap
has been.
This problem doesn't end in St. Louis. Unfortunately,
similar scenarios can be found in the Department of Veterans
Affairs Medical Centers across the country. According to the VA
Health Under Secretary Shulkin yesterday, in his testimony
before this Committee, there are currently 34 VAMCs without
permanent directors. House Resolution 3956 would help improve
the leadership at the VA medical centers and so many of our
Nation's veterans rely on.
I thank the Subcommittee for considering House Resolution
3956, and I look forward to working with you in a bipartisan
way to advance this legislation, and thank you. And I yield
back.
[The prepared statement of Mike Bost appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Bost. Ms. Kuster,
you are now recognized.
STATEMENT OF ANN M. KUSTER
Ms. Kuster. Thank you very much, Chairman Benishek, and
Ranking Member Brownley, and the Members of the Subcommittee,
for the opportunity to discuss H.R. 3974, the Grow Our Own
Directive: Physician Assistance Employment and Education Act of
2015. Our full Committee has worked hard to improve veteran
access to health care and to create opportunities for veteran
education and employment. This legislation will allow us to
merge those efforts and allow veterans to continue serving
their country while in service to their fellow veterans.
In the 14-1/2 years since September 11, and the 13 years
since the invasion of Iraq, the men and women of the United
States military have repeatedly demonstrated their skill, valor
and professionalism. They have repeatedly placed their lives on
the line, been separated from their families, and deferred
their own personal life goals in order to serve our country. As
many in this room recognize, that service on our behalf creates
an obligation on our part to ensure that our veterans have the
opportunity to succeed, and have access to the medical care
they may require.
Veterans today often leave the service with an incredible
skill set. Our corpsmen and medics have proven medical
experience in high-pressure training and real-world
environments. They have also demonstrated an interest in public
service by volunteering to serve in the military, and many hope
to continue in service to the public after they leave active
duty. Meanwhile, as this Subcommittee in particular knows well,
veterans often face challenges in accessing care. As we
discussed last week, sometimes this is due to IT and scheduling
changes, but at other times, it is due to a lack of medical
providers available.
In a time of shortage for primary care providers both in
the private sector and in the VA, with the Office of Inspector
General listing physicians assistants as one of the VA's top
five occupations with the largest staffing shortages, creating
a pathway of opportunity for our veterans to fill that gap, and
continue to serve their country seems to me to be like an
excellent opportunity. H.R. 3974 would accomplish that
objective by creating a pilot program to provide educational
assistance to qualifying veterans for education and training as
VA physician assistants.
A veteran would qualify for this program who has medical or
military health experience gained while serving in the Armed
Forces, has received a certificate, Associate's degree,
Baccalaureate degree, Master's degree, or post-baccalaureate
training in a science related to health care, has participated
in the delivery of health care services or related medical
services, and does not have a doctorate in medicine,
osteopathy, or dentistry.
Eligible veterans would be able to apply during the 5-year
pilot program to receive one of 35 scholarships available each
year to cover the cost of obtaining a Master's degree in
physician assistant studies or a similar Master's degree.
Selection would be prioritized for those veterans that
participated in an earlier veteran recruitment program known as
the Intermediate Care Technician Pilot Program, and those
veterans agreeing to be employed by the VHA in a community that
is medically underserved and in a State with a significant
veteran population.
Those veterans that use the program would then owe the VHA
a period of obligated service, based either on the scholarship
program used or 3 years. To ensure that veterans are prepared
to succeed, participants will be paired with a mentor at their
facility, and the VA will partner with institutions of higher
learning to guarantee physician assistant educational seats.
As it is currently written, the bill would also establish
standards to improve the education and hiring of VA physician
assistants, and enhance retention and recruitment through
competitive pay standards. As this bill moves through the House
and the Senate, there have already been several discussions to
find ways to improve the bill to increase its chances of
passage and to create this opportunity for our veterans. I am
happy to continue those conversations in the coming weeks and
days, and based on feedback from this hearing and from my
colleagues.
Mr. Chairman, this concludes my statement, and I would be
happy to answer any questions. Thank you.
[The prepared statement of Ann Kuster appears in the
Appendix]
Mr. Benishek. Thank you very much, Ms. Kuster. Ms.
Walorski, you are now recognized.
STATEMENT OF JACKIE WALORSKI
Mrs. Walorski. Thank you, Mr. Chairman. Good morning, and
good morning, Ranking Member Brownley and my fellow colleagues.
I appreciate the opportunity to discuss House Resolution 4977,
the VA Scheduling Accountability Act.
In 2014, news reports uncovering gross mismanagement and
schedule manipulation at a Department of Veterans Affairs
hospital in Phoenix shook us all to the core. Through hearings
held in this Committee and investigations by the VA, OIG, and
GAO, we, together, substantiated many of the allegations of
manipulated schedules and falsified wait times data at the
Phoenix facility. The manipulation of appointment schedules and
data in Phoenix led to at least 40 veterans dying while they
were waiting for care. However, as we all took a closer look,
we discovered that, sadly, this was not an issue unique to
Phoenix. It was systemic.
Here we sit 2 years later, digging deeper into some of the
root causes to ensure that no veteran ever dies again waiting
for care. So I introduced legislation this week, the VA
Scheduling Accountability Act, that gets at one of the key
drivers of the wait-time manipulation, a 2010 VA directive in
VA's implementation processes and procedures policy for
scheduling at their facilities, and contains 19 different items
on the checklist. The directive requires the annual
certification of full compliance with all items on the list.
For instance, facilities are required to ensure completion
using VISN-approved processes and procedures of a standardized
yearly schedule or audit of the timeliness and appropriateness
of scheduling actions and of the accuracy of desired dates.
They are also required to ensure that deficiencies in
competency or performance are identified by the annual schedule
or audit are effectively addressed. An August 2014 OIG report
uncovered that in May of 2013, the then-Deputy Under Secretary
for Health For Operations Management waived that fiscal year
2013 annual requirement for facility directors to certify
compliance with the VHA scheduling directive, allowing
facilities to only self-certify reduced oversight, over wait
time, data integrity, and compliance with appropriate
scheduling practices. This, in turn, allowed VA's data to be
easily manipulated, contributing to the wait-time scandal.
There was a noticeable substantial improvement in VHA's
appointment scheduling after VA waived the directive, but as we
all know now, that improvement was an illusion.
Although VA has reinstated the certification requirement,
there is nothing stopping them from waiving it again. The VA
Scheduling Accountability Act would simply require each
facility's director to annually certify compliance with a
scheduling directive or any successor directive that replaces
it, and it prohibits any waivers in the future.
Should a director be unable to certify compliance, either
because the facility is not in compliance, or the director
refuses to sign the certification for some other reason, the
director must submit a report directly to the Secretary
explaining why the facility is out of compliance. The Secretary
will then have to report yearly to the House and Senate VA
Committees with a list of facilities in compliance and those
that are not with an accompanying explanation as to why they
were not in compliance. This will provide more oversight of the
Department and ensure Congress is aware when VA is waiving
these policies.
Waiving compliance requirements was a key driver in the
wait-time scandal, which continues to be an issue at the
Department. This legislation will begin to end that reckless
practice once and for all, while increasing accountability and
transparency at the VA, as we work on ways and continue to work
on ways to ensure that those who risk their lives for their
country receive the prompt quality care that they have earned.
I look forward to working with the Members of this
Committee, veterans service organizations, and the VA,
addressing this critical issue, and I, again, thank you for
allowing me the opportunity to speak today. And I yield back.
[The prepared statement of The Honorable Jackie Walorski
appears in the Appendix]
Mr. Benishek. Thank you, Ms. Walorski. Mr. Zeldin, you are
recognized.
STATEMENT OF LEE M. ZELDIN
Mr. Zeldin. Good morning, Chairman, and thank you for the
opportunity to testify on behalf of my bill, H.R. 2460, which
provides no-cost medical model adult day health care services
for our 70 percent or more service-connected disabled veterans.
It must always be a top priority of Congress to ensure that all
veterans receive the proper treatment and care they deserve
after fighting for our country. While overseas, these brave men
and women are exposed to hardships and trauma, and when they
come home, many return with the physical and mental wounds of
war. Despite various care options for veterans, their choices
are often limited and can come at a great expense.
Servicemembers who are 70 percent or more disabled from a
service-connected injury often require significant assistance
from others in order to carry out basic everyday tasks. In many
instances, veterans must rely on family members for assistance,
creating many financial and emotional hardships. Alternatively,
some veterans, without the proper support system, may even be
forced to rely on the assistance of trained medical
professionals and reside in an institutionalized facility for
daily assistance. Veterans in these facilities often spend
significant sums of money each day just to be enrolled, and
these expenses can be expected to span the remainder of the
veteran's life in many cases.
While alternative options currently exist, accessing these
services, however, can often be very difficult. One such
program that is currently available is adult day health care, a
daily program for disabled veterans who need extra assistance
and special attention in their day-to-day lives. Adult day
health care programs provide disabled veterans and their
families with a high-quality alternative to nursing care,
providing quality outpatient services for those suffering from
debilitating illnesses or disabilities.
These programs provide a range of services from daily
activities such as bathing, to full medical services like
physical therapy. Adult day health care is only offered
currently at three facilities in the United States. Long
Island, where I represent, is fortunate to be the home of one
of these three locations, which offer adult day health care,
the Long Island State Veterans Home in Stony Brook, New York.
But this program could easily be offered at any of the 153
State veterans homes across the country. However, the
Department of Veterans Affairs does not currently cover the
cost of participation in this program at State veteran homes,
and the expense of the program is put directly on the veteran
and their family, which significantly limits the number of
veterans who can enroll.
In an effort to address this and expand access to care for
our heroes, I introduced bipartisan legislation, H.R. 2460,
which would ensure that 70 percent or more service-connected
disabled veterans are able to receive adult day health care at
no cost to the veteran and their family by defining the program
as a reimbursable treatment option through the VA. My bill
would guarantee that all severely disabled veterans are able to
access adult day health care.
By providing disabled veterans with access to adult day
health care programs, we can assure that all veterans receive
the best and most efficient outpatient services to provide them
with the assistance and special attention that they need in
their day-to-day lives, while still allowing them to maintain
their independence.
Adult day health care also helps keep families together and
strong. With the inclusion of adult day health care services as
a covered VA expense, family members and caregivers can rest
easier knowing that their loved ones are receiving topnotch
care during the day, while being treated with the same respect
and dignity that they would receive at home.
Not only does the adult day health care model care for the
medical needs of a veteran, but it also addresses their social
and emotional needs as well. Adult day health care allows
veterans to interact and socialize with their peers and other
individuals enrolled in the program. Rather than sitting home
alone all day, participants in the adult day health care
program receive one-on-one attention from medical and support
staff, while also maintaining an active social schedule through
planned events and activities. Family members and caregivers
can go about their day without the worry that their loved ones
are unattended, and the veterans can continue to remain as
active members of their community.
It should be noted that treatment at adult day health care
is $40 to $50 less on average than nursing care would cost.
It is a top priority of mine to ensure that all veterans on
Long Island and across the country receive the proper treatment
and care they deserve, which is why I fully support the adult
day health care program. Thank you, Chairman, and I yield back
the balance of my time.
[The statement of The Honorable Lee Zeldin appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Zeldin. Do any of the Members
here have questions for these Members that have proposed
legislation before us? Dr. Roe.
Mr. Roe. I do. I think one of Ms. Brownley's legislation,
I, at least from a practicing-physician standpoint, it makes it
extremely difficult as it is. I would like to work with you on
that, but this is virtually impossible to do as it is currently
written. There is not enough time in a day to go through all
the possibilities that you have laid out.
And I pulled up fluoxetine, which is Prozac, and just went
through the list of side effects of that drug. It would take
you a day to go through all that the way it is listed. I think,
certainly, the intent is to inform people about the possibility
of addiction to opioids. That, everybody at this dais agrees
on. The question is just how to do it. I know as I read this, I
thought I don't see how I could do this the way it is currently
written and see patients the rest of the day. I would like to
hear some of my other colleagues step up, Dr. Ruiz or others. I
will yield to Ms. Brownley.
Ms. Brownley. Thank you, Dr. Roe, and I appreciate the
comments and would like very much to work with you. I think,
you know, part of the bill says we are going to set up a panel
of clinicians to decide those, in my layman terms, most
dangerous drugs to have this interaction with. So it wouldn't
be--Prozac probably wouldn't be on the list. It would just be
those opioids and other kinds of high-level drugs that we see
as sometimes can have the wrong effect.
So, I think, you know, this is draft legislation right now.
That means it still needs to be worked on, but I wanted to
introduce it to the Committee to get people's feedback so that
we can get to a bill that everyone can support, so I appreciate
the feedback.
Mr. Roe. I would like to work on it. And just to give you
an example here of one particular drug, if you have stiff
muscles, high fever, sweating, fast or uneven heartbeat,
tremors, overreactive reflexes, nausea, vomiting, diarrhea,
loss of appetite, feeling unsteady, loss of coordination,
headache, trouble concentrating, memory problems, weakness,
confusion, hallucinations, fainting, seizures, shallow
breathing, breathing that stops--I would certainly think that
would be a problem--skin reactions, fever, sore throat,
swelling on your face or tongue, burning on your skin--I could
go on for another 15 minutes.
So this is why I think we have to back up and really narrow
this down so that we--people understand, look, if I am
progressively increasing more and more narcotic, I have a high-
risk. That is something fairly reasonable. I would love to work
with you on it. I know the intent, but the application of this
could be very difficult, I think.
Ms. Brownley. Very good. Thank you.
Mr. Benishek. Any other questions? Well, I thank--I guess
most of the people on that panel are gone. Ms. Kuster, thank
you for participating this morning. I appreciate you being
here. So the first panel is excused.
I now welcome our second panel to the witness table.
Joining us on the second panel is Diane Zumatto, the National
Legislative Director from AMVETS; Shurhonda Love, the Assistant
National Legislative for the Disabled American Veterans; and
Fred Sganga, the Legislative Officer for the National
Association of State Veteran Homes. I would like to thank you
all for being here and for your hard work and advocacy on
behalf of our veterans, so I look forward to hearing the views
of your Members.
And, Ms. Zumatto, you may begin when you are ready.
STATEMENT OF DIANE M. ZUMATTO
Ms. Zumatto. Thank you, Mr. Chairman. I am happy to be here
today on behalf of AMVETS. Before I begin my specific remarks,
I just want to ask that this Committee remembers that the
health care obligations imposed by the sacrifices of our
veterans are met in a timely, professional, and compassionate
manner. I would also urge you to reject any plan to eliminate
the VA from hands-on care of our veterans.
As far as H.R. 2460, AMVETS supports this legislation,
which seems like the best of both worlds in that it provides
the appropriate and necessary care for veterans in a more cost-
effective manner, while also providing an improved quality of
life. The legislation directs the Secretary of the VA to enter
into an agreement or contract with each State home to pay for
adult day health care for a veteran eligible for but not
receiving nursing home care.
H.R. 3956, AMVETS supports this legislation, which seems to
be a bit of a no-brainer to us. Medical centers without
directors will most likely not perform as well or as
consistently as those that do.
H.R. 3974, AMVETS supports the legislation which builds
upon and leverages the training and experience of former
military members. This bill directs the VA to carry out the
Grow Our Own Directive Pilot Program to provide educational
assistance to certain former members of the Armed Forces for
education and training as VA PAs.
3989, AMVETS is very supportive of this bill, which permits
an individual to elect to have an independent contractor
perform an external clinical review related to their caregiver
or their caregiver benefits. This is important because things
change over time. The needs of both the veteran and the
caregiver are likely to change, including but not limited to,
the amount of care the veteran requires, could increase or
decrease the amount of time the caregiver has available to
assist that veteran, could increase or decrease.
The caregiver might prove to be unable to perform the
necessary duties. The caregiver also might prove to be
unethical or irresponsible, and their level of expertise will
change. So we just feel that this will provide a much-needed
way out of a possibly unsuitable situation.
The draft legislation to ensure that VA medical facilities
comply with requirements related to appointment scheduling and
to improve the uniform application of directives, AMVETS feels
strongly that there needs to be continuity across the VA health
care system, and this bill should help to make that
recommendation a reality.
Finally, draft legislation on informed consent. This is a
top issue for AMVETS, and we wholeheartedly support this
legislation, because we believe that the health and welfare of
our veterans needs to come first. This means that their
interests come before any VA employees, including physicians.
AMVETS believes that having the veterans buy-in and clear
understanding of any proposed risky medications will not only
provide much-needed peace of mind for the veteran and their
family, but will be instrumental in the overall healing
process. An informed patient is much more likely to fully
comply with their doctor's instructions, and much less likely
to complain or be dissatisfied with their treatment.
Let me be clear that our intention in supporting this
legislation is not to burden or disrespect VA doctors, but to
provide veterans the opportunity to be more actively involved
in their health care treatments. In order to minimize the
burden on physicians, AMVETS suggests utilizing nationally
standardized medical educational materials which could be
adopted by the VA and made available, either digitally or in a
preprinted format, such as a medication guide.
All of the medications which would require informed consent
would either be available in a database, whereby each
medication with its additional information could be printed for
each specific covered medication and provided to the patient.
If utilizing the preprinted medication guide, each covered
medication would be included with all of the same additional
information as the database option, which is in the written
testimony, so I am not repeating that. The physician would then
merely have to check off the recommended medications and hand
that information to the patient. In both cases, a consent form
would be provided to the patient for his or her signature in
either an electronic or paper format.
The patient's signature, at this point, merely indicates
that they have been provided with the information regarding any
covered medications and should not yet be understood as an
acceptance of the proposed treatment plan. At this point, the
patient should be given the opportunity to ask any immediate
questions of the physician, or the veteran could be referred to
a pharmacist for further information. The patient then would be
given 3 full business days from the issuance of the initial
recommended prescription to either consider and internalize the
information provided by the doctor, conduct any additional
research, seek a second opinion, discuss with family, or get a
legal opinion. At the end of the three-day period, the patient
would then convey their approval or disapproval of a suggested
medication or medications by a secure messaging, phone, email,
or fax, directly to the prescribing physician or his or her
office. The veteran's signature, along with the follow-up,
whether it is oral or written at the end of the 3 days would
jointly fulfill the informed consent signature requirement, so
there would be no further reason for the veteran to return to
the doctor's office on this matter, unless there were
extenuating circumstances.
It appears that I have gone over time, so I am going to
leave it at that, and I would be happy to answer any questions.
Thank you.
[The prepared statement of Diane Zumatto appears in the
Appendix]
Mr. Benishek. Thank you very much. Ms. Love, you are
recognized.
STATEMENT OF SHURHONDA Y. LOVE
Ms. Love. Mr. Chairman, and Members of the Subcommittee,
thank you for inviting DAV, Disabled American Veterans to
testify at this legislative hearing. As you know, DAV is a
nonprofit veterans service organization comprised of 1.3
million service-disabled wartime veterans.
I will provide comment on three of the bills before the
Subcommittee. My written statement covers all bills and drafts
relative to this hearing. DAV is pleased to support the intent
of the discussion draft for increased informed consent.
However, we recommend VA include pharmacy personnel on all PACT
teams to lessen the burden on physicians.
H.R. 2460, if enacted, would authorize the Secretary to
enter into agreements with State veteran homes to provide adult
day health care for veterans who are eligible for but not
receiving skilled nursing home care. Eligible veterans are
those who require such care due to service-connected
disabilities, or who have a disability rating of 70 percent or
more disabling, and are in need of such care. The payment to
the State home under this program would be at the rate of 65
percent of the amount that would be payable to the State home
if the veteran were an inpatient receiving nursing care.
Payment by the VA would then be considered payment in full.
The adult day health care program is a program for veterans
who need assistance with activities of daily living, nursing
services, and case management. It is also beneficial for those
veterans with caregivers who may be experiencing isolation from
their own lives, and are in need of respite from the constant
care of their loved ones. During the time spent at the adult
day health care program, veterans receive the health care
services they need in addition to peer support, companionship,
recreation, and social activities. The health care services
received would be based on their personal needs, and could
range from a full or half day, two to three times per week.
Veterans want to be independent for as long as they can
without being burdensome to their families. In addition, they
still want to remain an active part of the family unit. Adult
day health care helps to accomplish this goal by allowing the
caregiver respite to take care of their personal needs while
the veteran has an opportunity to interact with their peers
while obtaining the health services that they need.
DAV is pleased to support H.R. 2460, which is in line with
DAV Resolution No. 101 adopted at our most recent national
convention calling for the support of State veteran home
programs, recognizing State home care as the most cost-
effective care available for sick and disabled veterans with
long-time health care needs outside of the VA health care
system.
H.R. 3989, if enacted, would establish an external review
process in cases in which the VA has denied caregiver benefits,
approved a level of benefits considered inadequate to the
needs, or revoked benefits. A decision on this review, once
requested by the caregiver, would be required by the bill to be
completed within 120 days. DAV has continued to express the
need for an independent mechanism through which a caregiver can
appeal the clinical team's decision. That decision can be
reviewed de novo, and an unwarranted decision can be reversed,
altered, or sent back to the clinical team with instructions to
reassess or consider additional factors.
H.R. 3989 offers a review of VA decisions. However, it is
unclear if the review will be binding on VA, or whether the
recommendations from the contractor would be cause for VA to
issue a new decision based on the review findings. For
caregivers who feel they are unduly denied benefits, VA must
establish a systematic recourse and provide a publicly
accessible program handbook, or directive, outlining mandatory
program policies, procedures, and operational requirements,
which would serve to inform and educate those enrolled and
seeking enrollment into the program.
DAV is pleased to support H.R. 3989, as it is in line with
DAV Resolution No. 106 calling for legislation to provide
comprehensive support and services to caregivers of all
veterans severely injured, and ill, from military service.
DAV has no objection to the passage of the remainder of
bills before the Subcommittee.
Mr. Chairman, DAV appreciates the opportunity to provide
testimony. I will be pleased to address any questions you or
the Subcommittee Members may have on these bills.
[The prepared statement of Shurhonda Love appears in the
Appendix]
Mr. Benishek. Thank you, Ms. Love. Mr. Sganga, you are
recognized.
STATEMENT OF FRED S. SGANGA
Mr. Sganga. Mr. Chairman, and Members of the Subcommittee,
thank you for this opportunity to testify in support of H.R.
2460, introduced by Congressman Lee Zeldin of New York, to
provide severely disabled veterans with an enhanced option to
receive adult day health care services from a State veterans
home. I am Fred Sganga, the legislative officer and past
president of the National Association of State Veterans Homes.
I also have the high honor of serving as the executive director
of the Long Island State Veterans Home at Stony Brook
University, a 350-bed State veterans home that also operates a
40-slot medical model adult day health care program.
Mr. Chairman, a decade ago, Congress passed legislation to
assist our most disabled veterans by allowing them to receive
skilled nursing care in State veterans home under a new program
where VA paid the full cost of care to the State veterans home
with no cost charged to the veteran. Unfortunately, the law did
not cover alternatives to traditional institutional care, such
as medical model adult day health care, which is currently
being provided at three State veterans homes in Stony Brook,
New York; Minneapolis, Minnesota; and Hilo, Hawaii.
H.R. 2460 would fix that. Adult day health care is designed
to promote wellness, health maintenance, socialization,
stimulation, and maximize the participant's independence while
enhancing their quality of life. A medical model adult day
health care program also provides comprehensive medical,
nursing, and personal care services.
As a licensed nursing home administrator, I would like to
thank Congressman Zeldin for recognizing the need to offer
noninstitutional alternatives to our veterans. The legislation
would also be especially important to veterans like Jim
Saladino and his wife, Noreen.
Fifty years ago Jim answered the call of his country and
served in the United States Army during the Vietnam War. Today
Jim suffers from the ravages of Agent Orange exposure,
including diabetes and Parkinson's disease. He also recently
suffered a stroke. The Saladino family could have easily
decided to put Jim into my nursing home because he is a 100
percent service-connected veteran, and his nursing home care
would have been fully paid for by the VA, but this is not their
choice.
They would like their loved one to continue enjoying the
comforts of his own home for as long as he can, and our medical
model adult day health care program does just that. Three days
a week, we pick up Jim and bring him to our home. Working
closely with his personal physician, we provide services to
help maintain his wellness and keep him out of the emergency
room, and even avoid unnecessary hospitalizations. During his
6-hour day with us, Jim receives a nutritious breakfast and
lunch. He receives comprehensive nursing care. He also receives
physical therapy, occupational theory, and speech theory. He
can get his eyes checked by an optometrist, his teeth cleaned
and examined by our dentist, his hearing checked by our
audiologist. If required and his physician orders it, we can
get him a blood test, or even an X-ray. We can have his vital
signs monitored, and we can even bathe and groom him while he
is on site. For Jim's wife, Noreen, his primary caregiver, this
program gives her peace of mind knowing that he is in a safe
and comfortable environment, and allowing her to get a break.
However, because of the way the law is currently
structured, despite Jim's eligibility for no-cost skilled
nursing care, the Saladinos are required to pay out of pocket
for a portion of Jim's adult day health care. Mr. Chairman,
H.R. 2460 will fix this disparity by authorizing the VA to
enter into agreements with State veterans homes to provide
adult day health care for veterans who are eligible for but do
not receive skilled nursing home care under the current full
cost of care program. The payment to the State veterans home
under this program would be at a rate of 65 percent of the full
amount paid for skilled nursing care, the full cost of care
program. This will save the VA money while keeping veterans
like Jim Saladino in their own home.
For the Saladino family, receiving no cost medical model
adult day care would relieve a huge financial burden they
currently incur. Even though Jim's service ended 50 years ago,
he is still paying the price for his valor related to his
service in Vietnam.
Passing H.R. 2460 would send a strong message to all those
who have worn the uniform to protect our freedoms that they
will never be forgotten. H.R. 2460 has bipartisan support in
the House, and has also been supported by the DAV, VFW,
American Legion, AMVETS. I would also ask that the Legion's
letter of support be made part of the record.
On behalf of the National Association of State Veterans
Homes, I urge you to approve H.R. 2460 for Jim and Noreen
Saladino and for thousands of others across the country just
like them.
Mr. Chairman, that concludes my testimony, and I would be
happy to answer any questions you or Members of the
Subcommittee may have, and thank you again for this
opportunity.
[The prepared statement of Fred S. Sganga appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Sganga. I am going to yield
myself 5 minutes for questioning. I just have a couple
questions that relate to the bill of Mr. Zeldin.
Mr. Sganga, the VA is going to testify because of the level
of services for adult day care and nursing home care are
different, and the period of time in which services are
furnished are different, they believe that the payment rate
proposed for 2460 was inappropriate.
So, would you please respond to that assertion and explain
what, if any, the monetary benefit is available to veterans or
to State veterans homes through the VA through adult day health
care, and why the provisions and the rate in H.R. 2460 are
appropriate and necessary in your opinion?
Mr. Sganga. Well, in my opinion, back in 2006 when Congress
had said any veteran who is 70 percent or more service-
connected disabled is entitled to skilled nursing care, it
didn't include adult day health care. Currently in my home, I
am being paid $489 a day to care for that veteran who falls
into that category. At 65 percent of that rate, I would be paid
about $318 a day. That includes, Chairman Benishek,
transportation to and from the home. Clearly $318 a day is less
than $489 a day and it would allow the veteran to live in the
comfort of his or her own home.
I think what we used as a model was recognized by CMS. In
the State of New York, if you receive nursing home care, the
State of New York will reimburse that same nursing home who
provides adult day health care at a rate of about 65 percent.
So that 65 percent number is a highly recognized number within
CMS.
Mr. Benishek. So the services that you described in your
testimony, the veteran gets a bed then for the day, and then he
may get his bath--
Mr. Sganga. That is a great question. Let me give you an
example. We had an 85-year old Marine who was going to be
admitted into the home. His wife could feed him. She could put
his clothes on. She could even assist him with toileting. But
what puts people in nursing homes is their ability to deal with
their activities of daily living. For this spouse, she couldn't
bathe this gentleman, and for that reason, he qualified for the
nursing home. We provided her with the alternative of adult day
health care, and now he comes to program 3 days a week, and now
when he comes to the program, we bathe him in the program, put
him in a clean set of clothes, and send him home at the end of
the day. This couple got to enjoy their 65th wedding
anniversary in their own home living together. So it is those
kinds of stories that we want to help our vets with.
Mr. Benishek. Let me get this straight now. So these are
veterans that are actually eligible for nursing home care?
Mr. Sganga. Yes. And the VA pays for it.
Mr. Benishek. So this would keep somebody out of a nursing
home--
Mr. Sganga. Correct. At lesser cost.
Mr. Benishek [continued].--and cost the VA less than if
they had applied to go to a nursing home?
Mr. Sganga. That is correct.
Mr. Benishek. That makes a lot of sense then. I will yield
back. Ms. Brownley, do you have any questions?
Ms. Brownley. Yes, just briefly. And first, I wanted to
thank Ms. Zumatto for helping and working with our staff in
terms of drafting the legislation in my draft bill, so thank
you very much for that.
I think I just wanted to ask all three of you, really, you
know, I think the goal of this bill is to really kind of reach
a level of excellence in terms of, you know, the appropriate
communication between the doctor and the patient, particularly
when a drug may be prescribed that could have serious side
effects, like addiction and other kinds of things, because that
is what we have heard so much about in this Committee.
So I guess, you know, if you could all comment in terms of,
you know, feedback from your veterans on how well the current
system is working and, you know, why you believe, you know,
that this bill, taking it to kind of another level, to a level,
in my opinion, of excellence, is important. Ms. Zumatto.
Ms. Zumatto. Thank you for the question, Ms. Brownley.
There are so many veterans that their quality of life has been
compromised because of some of these medications. And many
times--I mean, since most of us are not doctors, if a doctor
tells us, you need to take this, or you need to do this, we
often don't question them because we don't feel qualified. And
so we just tend to do whatever the doctor says, which may be
the appropriate thing to do. But what we would like to do is
ensure that the veteran understands any of the risks that are
going to be involved, or if there may be perhaps a less
invasive procedure, medication, that could be tried, before
perhaps moving to this more dangerous medication.
And to your question, Dr. Roe, or your comment about not
having the time as a physician, we do appreciate the short
amount of time that doctors have, although I would say that VA
doctors have a much lower panel of patients that they are
expected to see on a daily basis than non-VA physicians. But I
think by having this automated in a system, or in a piece of
material that can be preprinted and just handed to the patient,
and then it is up to the patient at that point to do any
further research or read whatever is in there. We don't expect
the doctor to spend 30 minutes or more talking about a list of
medications and its side effects. We are expecting them to
provide the information that is already created by the VA or
whomever, and then the onus is on the patient and his family to
do the research if they want to.
Ms. Brownley. And I think, you know, that just leads into
the current system in terms of the informed consent form. I
don't think, and I am looking for confirmation from you, that
the current system is not really generating that sort of more
robust conversation between a doctor and patient so that they
can go home. They want to talk to a pharmacist, they can do
that; they can discuss it with their family members; they can
do the research that they need to do. And I am just concerned,
and I am looking for confirmation from you that you feel the
same, is that, yes, they are going through and checking off and
getting the patient to sign to say, you know, I have given you
this information, you might not have read it, but I have given
you the information, that that is not getting to where we want
to get to in terms of having a more robust conversation.
Ms. Zumatto. I would definitely agree. There are very few
medications right now that require a signed form within the VA.
They do require it for certain things, but generally,
medications are not included.
And I just had surgery last week at the VA, and when they
gave me prescriptions to send me home, nobody told me anything
about it, and one of them is an opioid. So that is the type of
thing that we are trying to prevent.
Ms. Brownley. Thank you. And my time is up, so I yield
back.
Mr. Benishek. Dr. Roe, you are recognized.
Mr. Roe. I would like to comment. Look, handing somebody a
piece of paper is not health care in the same degree. You have
to have a doctor and patient or a nurse practitioner or a nurse
sit down and discuss the medication, what its risks and
benefits and side effects. I did that for 30 years. And signing
a piece of paper that is just checking a box is not going to
accomplish what we want to accomplish.
I think what Ms. Brownley wants to accomplish, we all on
this Committee want to accomplish. We have an opioid epidemic
in the United States. We have, in the State of Tennessee, more
people dying of overdose of prescription drugs than car wrecks.
So it is a huge--and it is not just Tennessee. It is a huge
problem.
And so I think one way to do it, and obviously, it is
training the medical personnel better, training patients
better, but I don't want to put another barrier. We are
complaining now about not enough access for care for our
veterans, and I think we are adding another layer of
bureaucracy here that may not get the benefit that you desire
and I desire, and that is the adequate use of prescription that
is written. I think that is what you really want at the end of
the day.
So those are my comments, and, certainly, we can work on
this. I would like to. But I would say in its current form, I
can't support it like it is.
The other thing I didn't--not with this panel, but that
Mrs. Walorski brought up that I didn't bring up a minute ago
was on the scheduling issue, I think it is fine to do these
things. But once again, there is no teeth, there is no penalty
if you don't do it. That is what I was listening to her
legislation.
In other words, we are going to--I have been sitting here
now for 7-1/2 years, and we find the VA doesn't comply or do
something, there are no teeth in it, there is no penalty that
if you don't comply. Okay, so they didn't comply.
I think we have got to look and have some teeth in this
bill that she has, and I would like to work with her on that.
She is not here right now, but I think we need to do that.
I have seen that over and over and over again here. I yield
back.
Mr. Benishek. Thank you, Dr. Roe.
Mr. Takano, do you have any questions?
Mr. Takano. Yeah. Thank you, Mr. Chairman.
My question relates to H.R. 3956, the VA Health Center
Management Stability and Improvement Act. And you are in
medical centers every day. How important is it to have a full-
time medical center director in the facility and making day-to-
day decisions and strategic decisions about care for veterans?
Ms. Love. Mr. Takano, DAV has not received a resolution to
the hiring of VA medical center directors. However, we
recognize the importance of VA being fully staffed with enough
personnel to take care of veterans. Leadership would be part of
that process.
Mr. Takano. Can you comment on how having the leadership,
having a permanent full-time director instead of acting
directors, what effect that has on the morale of VA employees
who go to work every day in a particular facility?
Ms. Love. Not from an organization standpoint, but from a
veteran standpoint, being an employee and having my leader
present to direct the operations of the establishment would
always be a plus.
Mr. Takano. And related to H.R. 2460, Adult daycare in
State Veterans' Homes, what concerns do you have for the VA to
contract some of its services to the State veteran home?
Mr. Sganga. Well, unfortunately, back in 2006, when
Congress passed a bill to provide no cost skilled nursing care,
it took the VA to implement that. It took about 3 years to
implement the reimbursement process. It was very painful to a
lot of veterans who truly deserved the care, and they did work
with us to go retrospective--retroactive, I mean, to get the
care paid for.
What I am concerned about now is the fact that a lot of
Members of this Committee understand that the VA is going to
establish new regulations for adult day health care and for
domiciliary care. Back in 2008, 8 years ago, I was part of a
team that worked on Vermont Avenue with the VA to try to update
the adult day health care regulations, which hadn't been done
for years; and it is now 8 years later, and we are still
waiting for that regulation.
My nursing home on Long Island in Stony Brook serves as a
model for adult day health care. I think it is a wonderful
program. We have had visits from about 16 different States over
the past 3 years, and I can tell you assuredly that there are
many State veterans' homes that want to get into the game.
Two things have to happen: We need the new regulations
published. We have been told for 8 years that any minute now,
they are coming out. And secondly, this bill for us, 70 percent
population will help, with the proper funding, to keep those
veterans out of the nursing home side and back into their
communities while accessing the services they truly deserve.
Mr. Takano. Thank you. Thank you for your response. On H.R.
3989, the Support our Military Veterans' Caregivers Act, have
you heard any concerns with the caregiver program as currently
managed by the VA?
Ms. Love. Some of the--Representative Takano, some of the
concerns that we have is that the--there is not clear guidance
with the current directive that VA has. Some of the issues will
be a medical determination versus a clinical determination.
These things are not clear for veterans to understand and
decipher through.
Another issue that we have would be, should a VISN director
decide to request an external review, the key word there is
``should,'' so that process should be automatic if the veteran
is requesting a review.
Mr. Takano. Well, is it necessary to set up an independent
appeals process?
Ms. Love. Can you rephrase that question?
Mr. Takano. Well, is it necessary to set up an independent
appeals process that is conceived in this bill?
Ms. Love. Absolutely. It is necessary to set up some
process in which the veteran has an opportunity to have a
decision reviewed, and it should be a clear process to where
all steps in the process are known to the veteran throughout
the entire process.
Mr. Takano. Well, what I am trying to get is, are there
changes that could be implemented instead to improve the
existing appeals process we have of VA, instead of setting up
an entirely new separate independent process?
Ms. Love. Well, the process needs to be made clear. It is
not clear at all. It is not clear in the steps that the veteran
is to take. It's not clear as far as the language that is used
in the terminology of the directive that is currently before
us.
Mr. Takano. Okay. Well, Mr. Chairman, I think, you know,
this has been a long problem for us, and it is a subject of
much further examination, but anyway, I yield back.
Mr. Benishek. I agree with you, Mr. Takano.
Dr. Wenstrup.
Mr. Wenstrup. Thank you, Mr. Chairman. Thank you all for
being here today.
You know, I think on Mr. Zeldin's bill, you know, as a
practicing physician, the more you can do on an outpatient
basis, keep people in their home, in their own home is
typically better, or, at least, as an option for them. And it
is otherwise helpful for the patient overall towards their
quality of life. For some, it may be better to not be in their
own home. And so, to me, that seems like a very viable option,
as long as the care that is necessary is rendered.
As far as the opioids, you know, I always felt an
obligation, and still do, when I prescribe, to make sure that I
am informing patients of side effects. I make sure that I am
not doing something that is contraindicated with their other
medications. I make sure that they don't have any allergies to
medications that I am prescribing. These are the things that
doctors normally do.
Now, we know there is a problem not only in the VA, but
outside the VA where people were overprescribing, and so, to
me, a lot of that onus falls on the physician and patient
relationship. But there was also always the double-check, if
you will, from the pharmacy. And you get a prescription today,
and you do get handed that information, and you have got
stickers all over your prescription that are giving you the
warning.
So I think we really need to look at what really needs to
be done to be effective to make sure that patients are aware of
the risk, and in this case, of dependency and addiction, and
maybe make sure that we are doing that.
But I agree with Dr. Roe, some of it can be too time
consuming, and the doctors here would probably agree that
sometimes one of the worst things the patient could have is
access to too much information because they find out that 1 in
10 million has some side effect that suddenly they are paranoid
about and they don't want to take the antibiotic that is
supposed to help them and will help them.
So, we have to be a little careful about how we do that,
but I think there is an obligation, obviously, to make sure
that you are doing the right thing informing patients properly,
so I would like to work with you on that.
I yield back. Thank you.
Mr. Benishek. All right. Dr. Abraham.
Mr. Abraham. Thank you, Mr. Chairman. A couple of comments
on Mr. Zeldin's bill, 2460 and Mr. Sganga. They have certainly
a civilian side of that also, and being a family practice doc,
it does work. So I am much in support of that. The thing that
nursing homes do, I think, as good a job as they can with the
patient load that they have, but if that patient is in an adult
daycare 6 hours a day, you are providing OTPT, you are moving
the patient, you are grooming the patient. That patient is
being mobile as much as possible, and I understand the
significant impairment that some of those patients
unfortunately have.
But that increases joint mobility, it increases tissue
oxygenation, just a better outcome for the patient. And if you
look at objective data, which certainly I think most of us on
the panel here have done so, either ones that are physicians,
facilities such as yours at Stony Brook, compared to 24-hour,
around-the-clock in a nursing home, less infection rate, less
resistance to antibiotics, such as the MRSA epidemic that we
are having now. So you know, I think it is a great thing, and
hopefully, we can get this done.
In response to Ms. Brownley's bill, again, you know, again,
I, like Dr. Wenstrup, we certainly, hopefully, provide the
patient with information that he or she can make an informed
decision, but it is like Dr. Roe said, opioid, the epidemic is
not only in Tennessee, Dr. Roe, it is--there are more patients
dying from opioid dependence all over the Nation than car
accidents. So it is a huge problem. We have got to figure this
out
So I think it is great. I mean, we can tweak this, and we
can certainly work with Ms. Brownley and make this--and we, you
know, we, I think, smart enough to figure this out, but just
the mere fact that we are having the discussion, I think, is
important and we keep moving this legislation forward in some
form or fashion.
And like my colleagues here, Dr. Roe and Dr. Wenstrup, you
know, we want to make this work, and we are happy to work with
you to find the right solution.
And I yield back, Mr. Chairman.
Mr. Benishek. I thank you, Dr. Abraham.
Well, I want to thank the Members of the panel for being
here today, and I encourage you to continue to keep us informed
as to changes that occur with you, we want to get your input on
all the pieces of legislation that have been put forth today.
So thank you very much for being here. You are now excused.
At this point, I welcome the third and final panel to the
witness table. Joining us from the Department of Veterans
Affairs is Dr. Maureen McCarthy, the Assistant Deputy Under
Secretary for Health for Patient Care Services. And she is
accompanied by Susan Blauert, the Chief Counsel for the Health
Care Law Group of the Office of General Counsel.
Dr. McCarthy, you may begin your testimony when you are
ready.
STATEMENT OF MAUREEN MCCARTHY M.D.
Dr. McCarthy. Thank you, sir. Good after---good morning,
rather, Chairman Benishek, Ranking Member Brownley, and Members
of the Committee. Thank you for the opportunity to be here
today to present our views on several bills that would affect
VA health care programs and services. Joining me today is Susan
Blauert, Chief Counsel for General Counsel's Health Care Law
Group.
First, I want to convey my gratitude and appreciation for
the commitment of the Members of the Committee who seek to
improve and provide these authorities to the VA. Though the
Department, in writing, opposed a majority of the bills, we do
so for purposes of resources, operations, and, in some cases,
duplication of existing programs. We look forward to continued
collaboration with the Committee and its Members to ensure we
are providing the services and care our veterans deserve.
Regarding H.R. 4977. VA policies already require directors
to certify compliance with the scheduling directors and explain
gaps in compliance based on data collected at the facility. We
also know veterans aren't required to schedule hospital care.
They can walk into the emergency department or be admitted
directly by primary care.
VA needs the flexibility to set scheduling standards that
are clinically appropriate, and that can adapt to changes in
the way veterans access health care, and I will be happy to
explain some of the structures we have in place at this point
to monitor that.
Regarding H.R. 2460, VA supports growing adult day health
care programs, because we definitely want to rebalance how we
use home- and community-based services versus institutional
services.
Veterans and their families are supportive of initiatives
that permit them to age in place and avoid nursing home care.
However, H.R. 2460 would base payment rates for these programs
on nursing home care rates, which are much higher, given the
needed level of care.
Whereas nursing home residents live at the facility and
receive 24-hour nursing home care, these adult day health care
participants live at home, and they use the program for say 6
to 8 hours. Thus, this bill would require VA to pay two-thirds
of the rate that VA pays for a higher level of care for
furnishing a lower level of care for about a third of the time.
Additionally, VA believes that shifting payments from a
grant to a contract mechanism would place additional
requirements on State homes that have been proven burdensome
and difficult to implement.
With regard to H.R. 3989, VA believes that the current
process regarding review of eligibility determinations for the
comprehensive program of support to caregivers effectively
furthers VHA's policy to provide access to fair and impartial
review of disputes.
Currently, when an individual appeals the treatment
decision of the care team about eligibility for participation,
decisions are made by VHA leadership who have direct oversight
of the clinical team that has been more intimately involved in
the veteran's care. In contrast, the proposed external clinical
review would be provided to an independent contractor who, in
turn, would employ a panel of health care professionals not
necessarily familiar with the case. We also emphasize that our
caregiver program was designed by Congress to be a clinical
treatment program and not a benefit program.
Next, VA agrees that employment of physician assistants, a
top five mission critical position within VA should be
prioritized. Thus, VA supports the pilot program in section 2
of H.R. 3974. The pilot program is a win-win for VA and the
scholarship recipients as VA will reduce future recruitment
costs while scholarship recipients fulfill their service
agreements. That being said, VA recommends removing certain
prerequisites described in the bill, and also a relook at the
timeline of the expected numbers of participants.
VA also supports section 4, including the PA occupation
being included in the locality pay system in VA. We feel that
would be an important element in addressing recruitment and
retention difficulties associated with the pay disparity
between private sector market pay and VA pay schedules.
While VA supports sections 2 and 4, VA believes that
section 3 would not be the best tool to address the current PA
shortage. As some facilities do not report issues recruiting
PAs, requiring all facilities to advertise education debt
reduction program for PA positions would deny some facilities
the ability and flexibility to make these awards for other
critical positions for them.
Next, VA is appreciative of your efforts to address
challenges with recruiting and filling VA medical center
director positions with H.R. 3956. VA has taken several steps
to reduce the number of vacant positions. For example, VA
anticipates having nominees identified for about 20 of the 34
vacancies by the end of April.
In addition, VA submitted a legislative proposal requesting
the ability to transition all medical center directors from
title 5 to title 38, which will provide additional compensation
and staffing flexibilities, thereby relieving some of the
current challenges with attracting highly qualified candidates
to serve in these leadership roles. VA seeks your support of
that proposal to ensure the resolution of the medical center
director staffing challenges.
With regard to the draft bill to establish a list of drugs
requiring an increased level of informed consent, VA believes
that we have met these terms in what we have going at this
point. I am happy to share a list of medications for which VA
already requires informed consent. VA feels the draft bill
would burden veterans and their care providers by introducing
some unnecessary steps and delays in what is standard informed
consent process for high risk medications. We list several
other concerns in the written statement.
That being said, we were, at the time, unaware of the
problem the legislation was supposed to remedy, but acknowledge
indeed, Ranking Member Brownley's statement about the opioids
and the purpose of this to address that. So we request an
opportunity to meet with the Committee to ascertain the
Members' concerns and work together.
Thank you, Mr. Chairman and Ranking Member, for the
opportunity to testify before you today. My colleague and I
would be pleased to respond to questions that you or other
Members may have at this time. Thank you.
[The prepared statement of Dr. Maureen McCarthy appears in
the Appendix]
Mr. Benishek. Thank you, Dr. McCarthy, for your testimony.
I will yield myself 5 minutes for some questions.
So you think this medical center thing, this director
program is primarily the fact that they don't pay them enough?
Is that what we are getting at, you are changing the section to
section 38? I don't remember the numbers.
Dr. McCarthy. I think the pay is part of the problem. A
typical VA medical center director compared to someone running
a similar hospital in the private sector makes a fraction of
what the private sector person makes. Some of the challenges
are where our medical centers are located and people's ability
to move to those locations, but salaries are a big piece of it.
You may have noticed we have had some negative media
attention over the last few years, and in particular, the sense
of people who may, in the past, have considered becoming a
director are feeling a lack of personal safety in assuming the
role with the increased number of requirements placed on them.
So I think it is multifactorial, but I do think salary would
help.
I also think a greater sense of appreciation for what they
are doing and the challenges they face would help. And I have
personally reached out to numbers of individuals that might be
in acting roles and talked with them about why they are not
stepping up to apply, and a number of them are talking about
really the challenges and the pressures that are on our medical
center directors right now with the intense level of oversight.
That said, that is not to say that we shouldn't have oversight,
but it is very, very challenging for all of them right now.
Mr. Benishek. Thank you for that. I don't know if you are
familiar, but I worked at a VA for 20 years as a physician, one
of the challenges we had there was that the VA directors turned
over every 2 years in many cases, and even with that 2-year
tenure, things didn't get done. And with a 120-day tenure, you
realize that these folks are not making the critical decisions
that need to be made because they are worried about
consequences of any decision they make as a temporary person.
I am willing to work to make this happen, and are there
changes in the law that need to be done to get the medical
director to get this changed to this other section? Do we need
to change the law to do that?
Dr. McCarthy. Sir, there was a proposed--a legislative
proposal VA submitted on changing it, those positions from
title 5 to title 38, which would give more salary flexibility.
Mr. Benishek. All right. Okay. I might want to go on to
this, the stay-at-home home issue. You heard the testimony that
these veterans that we are talking about, they are eligible for
nursing home care now. So an effort to cut the cost of that and
still provide them with the care they need seems like a no-
brainer to me. Why do you object to that?
Dr. McCarthy. Sir, we definitely support veterans and their
families as they make these decisions to age in place and want
to do what we can to help them. We have a number of services in
place already to support that.
Our concern is--
Mr. Benishek. We are not talking about people that aren't
eligible for nursing home, we are talking about these are
people that are eligible for nursing home care.
Dr. McCarthy. Right.
Mr. Benishek. And, either they go to a nursing home or they
get this. You are saving money, aren't you? Or you want to
provide the care a different way? I am not sure that that is
actually happening, though.
Dr. McCarthy. So as we move, shifting that balance I was
talking about between institutionalization and the care- and
community-based services that help people stay in their home,
we definitely are trying to shift that balance for sure. Our
concern was with the actual dollar number and was it, indeed, a
fair calculation to pay two-thirds of the cost of a nursing
home for them to be there for 6 to 8 hours. We have--
Mr. Benishek. I think, to tell you the truth, if you had to
pay somebody to go to the home for 6 to 8 hours, it would cost
you more than $300. And Dr. McCarthy, you understand what I am
talking about? To get a nurse to go to the home for 6 to 8
hours and to do what they are going to do, you can't get one
nurse to do that. They can't cut the hair more than one person
needs to be doing it in the patient's home.
So I have a little bit of trouble trying to figure out that
argument.
Dr. McCarthy. So just so you know, we have been working
with the State Veterans Homes and have talked with them about
two kinds of adult day health care models. One, which is a
medical model, I think the classic example would be a post-
stroke patient, for instance, that needs a lot of direct
nursing care and a comprehensive health care team, and the
other is the social model.
Mr. Benishek. I understand. I understand where you are
going. I am just telling you this is not like respite care
where you are just babysitting the patient and then the
alternative is full care. You are talking about apples and
oranges here. So to me, this--do you want to deny--you mean, it
is cheaper to deny the patient the care, that is for sure.
Dr. McCarthy. Not in the long run, I don't think.
Mr. Benishek. Nobody--I don't think you are talking about
that, but it kind of gives me the idea that that might be
happening.
Dr. McCarthy. So if I could--could I just--
Mr. Benishek. It is definitely cheaper to deny the care.
Dr. McCarthy. Right.
Mr. Benishek. So I just want to--
Dr. McCarthy. I agree with you. I was about to say that
there are two models, and one is a more medical model, and one
is a more social model, and so the way it is written is that
this would apply to both models, and what we feel is that if it
were a more social model, then the compensation wouldn't be
justified. So we do have a regulation that was out for comment,
and we are addressing the comments at this point, but it is
really to look at two different models and--
Mr. Benishek. I think we are talking about two different
patient sets, though. We are talking about a patient set that
the patient is 70 percent disabled and eligible for nursing
home placement, as I understand it. So that is a different--
that is different than what you are talking about.
Dr. McCarthy. Actually, that 70--
Mr. Benishek. I am out of time, though. I appreciate it,
but I would like to have you follow-up so I understand this
better.
Dr. McCarthy. I would be happy to do that.
Mr. Benishek. Mr. Takano, do you have any questions?
Mr. Takano. Yes, Mr. Chairman.
You know, regarding draft scheduling compliance. This
Committee heard just yesterday about the continued challenges
veterans face when scheduling access to care, and part of the
inconsistency stems from the fact that schedulers are working
under an interim scheduling directive. Once a comprehensive
scheduling directive is finalized, it would seem to me that
ensuring greater compliance will help improve wait times and
get veterans the care they need.
Does the VAMC director currently have to comply with VA
regulations and law?
Dr. McCarthy. Yes. We believe so, yes. There is an
expectation, if we could talk about scheduling, in particular,
that the medical center director and the network director would
visit the frontline staff that are involved in scheduling
periodically. And in addition, there has been a tool developed
to look at scheduling and the process, to look for any kind of
irregularities. It looks at a total of five measures of
compliance and practice to help figure out if anybody is
manipulating data in any particular way.
And if that is apparent, it will be apparent to the medical
center, it will be apparent to the VISN, it would be apparent
to leadership in VA central office. So there is a tool that
people are using to help and verify, in addition to the
expectations of the visits and the certifications.
Mr. Takano. And how does the central office verify the
compliance?
Dr. McCarthy. So what is used as a database, and I have had
this explained to me, what--what they use is a measure of five
things. They look at the average new patient wait time, the
cancel-by-patient rate, the established patient zero-day wait,
and then in terms of practice, what is going on with the
electronic wait list and the established patient measures, and
based on outlier status on any of those, it is a warning sign
that things may not be accurately followed in terms of the
scheduling directive and the scheduling processes in place.
That is the warning sign. And then there is a review that
happens that is triggered by those kinds of events.
But in addition, people are following all the time the wait
lists, and in particular, the need for urgent care and so
forth.
Mr. Takano. Well, do you think that this--that effective
compliance, verification of compliance through the central
office, would this lead to enhanced veterans' access to care?
Dr. McCarthy. So compliance and access are likely related,
yes. But I think, in my mind, some of that is separate. I think
we are all about improving access, and compliance is more
asking are we doing it right and are we doing the right thing?
But obviously, if we are compliant, we would get access. I just
think about those in two parallel spheres. I am sorry.
Mr. Takano. Okay. I want to move on to the H.R. 3989,
Support Our Military Caregivers Act. Can you quick--briefly
explain the current process to determine if a family is
eligible for caregiver assistance, and what recourse does a
family have if they disagree with the decision?
Dr. McCarthy. So the way Congress wrote this for VA is
different how it is written for DoD. For DoD, it is a benefit.
For VA, it is part of the treatment plan. So the treatment team
makes a recommendation for a veteran to have the caregiver
based on the current needs of the veteran at the time the
assessment is made.
There includes a series of events, including home visits
and so forth. Typically, it is a 90-day process of evaluation,
and so all of the kinds of things that are determined are if
the veteran needs this care, what kind of level is needed, and
then an assessment of how best to accomplish this and the
support that the family member would need, there is training
that goes in to what the family member gets. So there is a tier
assigned for the level which corresponds to the compensation
level that the family member receives.
Mr. Takano. If I could interrupt or add onto that. If the
servicemember's health situation changes, will the family have
to begin the process all over again of, you know, evaluating
the caregiver assistance?
Dr. McCarthy. Yes, because it is considered a treatment and
not a benefit, and I think that is where there is a lot of
misunderstanding. So when someone is assigned a benefit, it is
an ongoing payment; whereas, as part of the treatment plan, the
veteran may or may not need the ongoing support of a caregiver.
And initially, say after transitioning from a polytrauma
facility, they may need a lot more support, but as time goes
on, they may not need the assistance at the same level, the
same tier, or they may even not need the assistance of the
caregiver, which is a clinical decision.
Mr. Takano. All right. Thank you very much.
Thank you, Mr. Chairman.
Mr. Benishek. Dr. Roe.
Mr. Roe. Just a couple of brief questions. You know,
yesterday, the VA has 32,000 schedulers for their VA system,
and that is half the population of the city I live in, which is
the largest city in the 1st Congressional District of
Tennessee. So there are only about three or four towns in the
whole district that are bigger than the number of schedulers
the VA has.
And you know, yesterday, we were sitting in this same room,
and we heard two very different stories about scheduling. And I
think that it is important for us to get that straight. And I
would support her bill, and the reason is because we can't get
information that we can understand up here about wait times. We
hear the Secretary say it is 4 days, you go home, and you hear
everybody you talk about it, nobody is getting in in 4 days. So
I think that is a problem we have here is it is a definition.
And I know yesterday, when I went over it, it is like when
a veteran calls in and they say, Well, we don't have an
appointment for 6 weeks; would that be okay? When they would
really like to be seen in about 2 weeks. And then that is
considered the day that they actually agreed to, so there is no
wait time, even though in reality there is a month's wait time
or maybe longer than that.
So I think we do need to look at that and be--and first of
all, I told the Secretary yesterday--I mean, the Under
Secretary of Health, Dr. Shulkin, yesterday. We need just to
define what that is, and whatever it is, it is, so we are all,
you know, singing off the same song page.
The second thing. Dr. Benishek was drilling down this, and
I just did some numbers. I can't understand your VA estimated
cost on Mr. Zeldin's bill. And you look here and you say that
the estimated cost is 1.7 million in the first year. I just did
some simple arithmetic. If somebody goes 5 days a week to the
adult daycare center we just heard about at $318, that is
$76,000 a year. That means for 1.7 million, you can take care
of 25 people. So how did you come up with that number?
And then it says, 2.1 million in the second year. It makes
no sense to me. If you multiply 318 times 5 and multiply it
times however many weeks, 52 weeks a year, how many you go,
that is a--and if you--at $450, it is--at his institution, it
is $164,000 into Dr. Benishek's point. That is a lot cheaper,
almost $100,000 a year less expensive. And I agree with you
that you should look at medical and social because all patients
are not the same.
Dr. McCarthy. Right.
Mr. Roe. That is totally correct on that.
Dr. McCarthy. Right. So sir, I would be happy to kind of do
a breakdown of the cost, but I believe part of the issue is
that many of the people that go to the adult day health care
centers go 3 days a week and not 5.
Mr. Roe. Well, it is still--then it is 50,000 a year.
Dr. McCarthy. Okay.
Mr. Roe. I can do that math in my head pretty quick.
Dr. McCarthy. All right. If you wouldn't mind, I would like
to get back with you with the description of the numbers.
Mr. Roe. You see where I am concerned, though. 1.7 million
is 50,000, and 30 people is a 1.5 million a year, so I don't
know how in the world the VA came up with that small of a
number.
Dr. McCarthy. All right. I will rework that, and I promise
we will get back to you.
Mr. Roe. Okay. Thanks. I yield back.
Mr. Benishek. Dr. Abraham.
Mr. Abraham. Thank you, Mr. Chairman. Just a couple of
things on Dr. Benishek's and Dr. Roe's, just comments on the
adult daycare living. I think I can arguably make the argument
that with adult daycare, the way it is now, and the way it is
perceived in Mr. Zeldin's bill, that you need both the social
and medical input there. So yeah, I think you are getting more
bang for your buck than certainly, you know, in the nursing
home situation.
I mean, I have known both. I have treated outpatients in
both, and you know, they both do a great job. And I think when
you are talking just strictly dollars with the adult daycare, I
mean, you are certainly getting a little more bang for your
buck, and the patient, more importantly, is getting maybe some
improved therapy on joint mobility and that type of deal.
The other issue on the--you said you have got a list of
drugs there that require--and I will just ask you if you will
give me a copy to my office, I would appreciate it. But I am
assuming that one of those already are the opioids. Is that a
correct statement?
Dr. McCarthy. The long-term opioid.
Mr. Abraham. Right. Okay. And you know, like Dr. Roe said,
and the docs up here know, you know, it is burdensome, but Ms.
Zumatto had some good alternatives as to how we get that
patient to, I guess, become more informed.
So again, I think it is a good conversation, but I guess,
again, let's go back to the objective data. We have already got
informed consent for the long-term opioids, but we still have
an increasing opioid epidemic. So the question bodes, well, is
the informed consent model working as it is.
Evidently not. And again, my previous statement, I think we
are smart enough to work with Ms. Brownley and to figure this
out and get it right with Ms. Zumatto and the VSOs to get their
input where we can hopefully get the right combination of what
it does take to start chipping away at this opioid addiction
stuff.
The question I have for you. You made the comment in your
statement that in the bill of the PAs, that you--that the VA
was somewhat opposed to some of the prerequisites required. Can
you list those prerequisites that--I mean, I heard Ms. Kuster.
I was listening very acutely to what the prerequisites are.
Which ones are the VA opposed to knocking out of the box?
Dr. McCarthy. So it is just a few. There is a requirement
for hiring executive director of one program and another
position, and it requires that the person be currently employed
by VA at the time of the passage of the legislation and that
the person be a veteran. And there--that limits who would be
eligible to apply for those positions.
Mr. Abraham. Would the VA be okay with or be in favor of
giving the veteran the priority of that slot of the PA slot? I
mean, we all know we need more health care providers in the
system, and if we have got a combat veteran, either he or she,
that has been on the frontline serving as a medic or in some
health care job already, they are far ahead of the game as to
as far as somebody coming off the street literally and just
starting the program anew. So they bring so much knowledge base
already, and that is what it requires in a PA and an NP
position to have that knowledge base, and they have already got
that.
So the question is, is VA okay with the VA getting
preference or the--
Dr. McCarthy. The veteran preference--
Mr. Abraham. Yeah.
Dr. McCarthy [continued].--would--just changing that would
help, that exact wording.
Mr. Abraham. All right. Thank you, Mr. Chairman. I yield
back.
Mr. Benishek. Thank you, Dr. Abraham.
Does anyone have any further questions?
Mr. Takano. Could you submit a list of the medications or
drugs for the record?
Dr. McCarthy. I would be happy to do that, and I brought
some copies with me.
Mr. Takano. Thank you. That is what I wanted. That is it.
Dr. McCarthy. And just so you know, this was derived from
our list of informed consents, so it lists particular drugs,
and you will see a lot of chemotherapy drugs and so forth. But
in addition, it talks about, like, the spinal injections and so
forth for anesthesia, but it does have--it certainly has all
the other drugs. And under anesthesia and pain management,
about the 10th one down is consent for long-term opioid therapy
for pain. Okay.
Mr. Takano. All right. Thank you, Dr. McCarthy. Thank you.
Mr. Benishek. Thank you.
Mr. Takano. I yield back.
Mr. Benishek. There are no further questions. The third
panel is now excused.
Dr. McCarthy. Thank you very much.
Mr. Benishek. I ask unanimous consent that all Members have
5 legislative days to revise and extend their remarks and
include extraneous material.
Without objection, so ordered.
I would like to once again thank all our witnesses and
audience members today for joining us this morning. The hearing
is now adjourned.
[Whereupon, at 11:43 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Honorable Elise Stefanik
Chairman Benishek, Ranking Member Brownley - thank you for the
invitation to testify on this important legislation. I look forward to
discussing this key issue moving forward.
As a member of the House Armed Services Committee with a critical
Army base in my district, I am dedicated to providing support to
servicemembers, veterans and their families. Since September 11th,
2001, the Army's 10th Mountain Division at Fort Drum has been the most
actively forward deployed division in the Global War on Terror.
We have asked our servicemembers and their families to sacrifice an
immeasurable amount over the last 14 years, so it is vital that we do
not leave them behind - this is especially true for our military
caregivers, the selfless group that cares for our heroes behind the
scenes. These men and women are often left out when discussing
veterans' issues.
Military caregivers are an essential component of the communal and
family support system for our disabled veterans. Military caregivers
are usually spouses and other family members who spend their days
taking care of disabled veterans in order to provide an environment
that enhances their everyday lives.
In 2010, Congress passed a law implementing the Family Caregiver
Program. This was an important piece of legislation that made veterans
who sustained injuries in the line of duty eligible for a package of
benefits that includes access to a primary caregiver. These benefits
would ensure that the family members who dedicate their lives as
caregivers receive access to health care, caregiver training, and
stipends for additional costs associated with their disabled veteran.
Unfortunately, the Department of Veterans Affairs (VA) has had a
difficult time managing the high demand of Family Caregiver enrollees,
which is much larger than originally accounted for during
implementation. According to the Government Accountability Office
(GAO), VA officials estimated that they would receive 4,000 enrollees
and staffed the program based on this estimate. However, in the first
few months of implementation there were over 15,000 enrollees to the
Family Caregiver Program. VA medical centers lack sufficient caregiver
support coordinators and the necessary clinical staff to carry out
medical assessments for eligibility. \1\
---------------------------------------------------------------------------
\1\ Government Accountability Office (GAO). 2014. Actions Needed to
Address Higher-Than-Expected Demand for the Family Caregiver Program.
Informational, Washington, D.C. : GAO.
---------------------------------------------------------------------------
These implementation issues have led to a delay in both the
application and the appeals process. Application deadlines are not
being met by their own internal standards and the staff is still
shorthanded. These issues are not only unacceptable, but I believe they
are preventable.
This is why I introduced H.R. 3989, Support Our Military Caregivers
Act after meeting with a constituent who is a caregiver facing the
burden of the VA backlog.
This bill would use pre-existing funds currently appropriated for
the review and appeals process for an objective, independent party to
conduct external, clinical reviews. This bill would ensure that new or
modified processes are veteran-centric, outcomes-based and continually
improved through the use of best practices. We can accomplish this by
permitting a third party to work within the Department of Veterans
Affairs to streamline claims and reduce the caregiver backlog through a
more clinical analysis rather than benefits adjudication. The VA would
maintain the third party until the overage of appeals is streamlined
and the backlog is down to an acceptable rate in accordance with
recommendations from the Government Accountability Office.
Military caregivers are silent heroes in our communities and
deserve the respect and benefits proportionate to their significant
contributions. I look forward to discussing this issue further in order
to implement a solution and get our military caregivers the benefits
they have earned.
--------
Prepared Statement of Honorable Mike Bost
Chairman Benishek and Ranking Member Brownley, thank you for
holding this hearing on pending legislation which is critical to better
oversight of the Department of Veterans' Affairs. Careful consideration
of how the VA should be reformed is needed to ensure better health care
access and medical treatment for our nation's veterans.
As a Marine and the father of a Marine, I recognize the selfless
sacrifice that so many Americans have made in defense of our freedoms.
There is no doubt that we must fight for the brave men and women who
have fought for us. I know my colleagues on both sides of the aisle
feel the same way.
Winning any battle requires steadfast and capable leadership. No
organization can operate under a revolving door of interim leaders -and
certainly not one tasked with caring for America's heroes.
Unfortunately, that revolving door of leadership is exactly what is
occurring at VA medical facilities across the country. This situation
is simply unacceptable, as it may undermine the quality, consistency,
and speed of care that our veterans receive.
Our nation's warfighters deserve better, and that is why I
introduced H.R. 3956, the VA Health Center Management Stability and
Improvement Act. This common sense bipartisan bill requires the
Secretary of the Department of Veterans Affairs to submit a plan to
Congress within 120 days of passage for finding and hiring a permanent,
highly-qualified director at each VA Medical Center (VAMC) that is
currently under temporary leadership. This legislation is endorsed by
the American Legion, Vietnam Veterans of America, Paralyzed Veterans of
America, AMVETS, Disabled Veterans of America, and the Association of
the United States Navy.
The ``interim leadership'' problem happening at Department of
Veterans Affairs Medical Centers across the country first came to my
attention in my own backyard. I am proud to represent the Twelfth
Congressional District of Illinois in Congress, and many Southern
Illinois veterans access health care through the St. Louis Department
of Veterans Affairs Health Care System. The St. Louis VA Medical Center
provides health care to over 45,000 veterans annually, and I remain
very concerned about the lack of stability in leadership there and how
it may impact system operations.
Over the last several years, the St. Louis VA has been managed by
more than seven different acting directors. According to the VA's
hiring policies, there is no time limit for Senior Executive Service or
Medical Center Directors to serve on a detail in an acting capacity,
yet these details must be approved in increments not to exceed 120
days, with a possible extension to 240 days.
Consequently, the St. Louis VAMC has experienced a revolving door
of interim directors. This short term leadership negatively impacts the
ability to engage in long-term planning and other functions necessary
to provide and improve health care for the veterans it serves.
After I began looking into the local issue at the St. Louis VA
Medical Center, it came to my attention that this problem isn't just a
problem in our area. Upon further investigation, I found that a large
number of VA Medical Centers have lacked a permanent director for quite
some time. This problem is due to Office of Personnel Management (OPM)
requirements which stipulate that temporary directors can serve for no
more than 120 days, with a 240 day maximum total if their tenure is
extended. The lack of stable, permanent leadership is no doubt one of
the reasons the Department of Veterans Affairs has struggled to provide
appropriate health care to those it serves.
H.R. 3956 seeks to fix this problem by requiring the VA Secretary
to develop and implement a plan to fill these vacancies.
Specifically, my bill requires the Secretary of the Department of
Veterans' Affairs to:
Report to the House and Senate Committees on Veterans'
Affairs the status of any unfilled vacancies.
To develop and submit to Congress a plan hire highly
qualified medical directors for each VA Medical Center which lacks a
permanent director. This plan must be submitted within 120 days after
enactment of the bill.
Identify possible impediments to staffing VA Medical
Centers with permanent directors.
Assess the possibility of promoting and training
qualified candidates from within the Department of Veterans' Affairs
for promotion to these Senior Executive Service (SES) positions.
I have reached out to my local Congressional colleagues on the
issue and sent letters to the Department regarding the lack of
leadership at the St. Louis VAMC. Last week, I received a reply from
the Department of Veterans Affairs Under Secretary of Health, Dr. David
Shulkin, giving me an update on the issue. According to the timeline
chart he provided, the St. Louis position has been vacant since July
14, 2013 and is still vacant thirty-three months later. I have enclosed
a copy of the St. Louis VA Medical Center director timeline with my
formal statement to illustrate just how long this process has been and
how long this critical leadership position has been vacant.
This problem doesn't end in St. Louis. Unfortunately, similar
scenarios can be found at Department of Veterans Affairs Medical
Centers across the county. As of July 2015, the VA reported that over
39 VAMCs were without a permanent director. H.R. 3956 would help
correct this lack of permanent leadership at the health care centers
that so many of our nation's veterans rely on.
I thank the Chairman, Ranking Member, and this Subcommittee for
consideration of H.R. 3956 and look forward to working with my
colleagues and the Committee to further this legislation. Thank you and
I yield back the balance of my time.
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Prepared Statement of Honorable Ann Kuster
Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee, thank you for the opportunity to discuss H.R. 3974, the
Grow Our Own Directive: Physician Assistant Employment and Education
Act of 2015. Our full committee has worked hard to improve veteran
access to health care, and to create opportunities for veteran
education and employment. This legislation would allow us to merge
those efforts and allow veterans to continue serving their country
while in service to their fellow veterans.
In the 14 and a half years since September 11th, and the 13 years
since the invasion of Iraq, the men and women of the United States
military have repeatedly demonstrated their skill, valor, and
professionalism. They have repeatedly placed their lives on the line,
been separated from their families, and deferred their own personal
life goals in order to serve this country.
As many in this room recognize, that service on our behalf creates
an obligation on our part to ensure veterans have the opportunity to
succeed and have access to the medical care they may require.
Veterans today often leave the service with an incredible skill
set. Our corpsmen and medics have proven medical experience in high
pressure training and real world environments. They have also
demonstrated an interest in public service by volunteering to serve in
the military, and many hope to continue in service to the public after
they leave active duty. Meanwhile, as this subcommittee in particular
knows all too well, veterans often face many challenges in accessing
care. As we discussed last week, sometimes this is due to IT and
scheduling challenges. Other times it is due to the lack of providers
available.
In a time of shortages for primary care providers both in the
private sector and in the VA, and with the Office of Inspector General
listing physician assistants as one of the VA's top five occupations
with the largest staffing shortages, creating a pathway of opportunity
for our veterans to fill that gap and continue to serve their country
seems to me like an excellent opportunity.
H.R. 3974 would accomplish that objective by creating a pilot
program to provide educational assistance to qualifying veterans for
education and training as VA physician assistants. A veteran would
qualify for this program who has medical or military health experience
gained while serving in the Armed Forces; has received a certificate,
associate degree, baccalaureate degree, master's degree, or post-
baccalaureate training in a science relating to health care; has
participated in the delivery of health care services or related medical
services; and does not have a doctorate in medicine, osteopathy, or
dentistry.
Eligible veterans would be able to apply during the five year pilot
program to receive one of 35 scholarships available each year to cover
the costs of obtaining a master's degree in physician assistant studies
or a similar master's degree.
Selection would be prioritized for those veterans that participated
in an earlier veteran recruitment program known as the Intermediate
Care Technician Pilot Program and those veterans agreeing to be
employed by the VHA in a community that is medically underserved and in
a state with a significant veteran population.
Those veterans that use the program would then owe the VHA a period
of obligated service based either on the scholarship program used, or
three years.
To ensure that veterans are prepared to succeed, participants will
be paired with a mentor at their facility, and the VA shall partner
with institutions of higher learning to guarantee physician assistant
educational seats.
As it is currently written, the bill would also establish standards
to improve the education and hiring of VA physician assistants and
enhance retention and recruitment through competitive pay standards.
As this bill moves through the House and the Senate, there have
already been several discussions to find ways to improve the bill,
increase its chances at passage, and create this opportunity for our
veterans. I am happy to continue those conversations in the coming days
and weeks based on feedback from this hearing.
Mr. Chairman, this concludes my statement. I would be happy to
answer any questions you or our fellow members of the Subcommittee may
have.
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Prepared Statement of Honorable Jackie Walorski
Good morning Chairman Benishek, Ranking Member Brownley and members
of the Committee. I appreciate being given the opportunity to discuss
the VA Scheduling Accountability Act.
First, I would like to thank Chairman Benishek and Ranking Member
Brownley for holding this hearing and allowing me to testify on this
important legislation. In 2014, news reports uncovering gross
mismanagement and scheduling manipulation at a Department of Veterans
Affairs (VA) hospital in Phoenix shook us to the core. Through hearings
held in this committee and investigations by the VA Office of Inspector
General (OIG) and Government Accountability Office (GAO), we
substantiated many of the allegations of manipulated schedules and
falsified wait-time data at the Phoenix facility. The manipulation of
appointment schedules and data in Phoenix led to at least 40 veterans
dying while they were waiting for care. However, as we took a closer
look, we discovered that, sadly, this was not an issue unique to
Phoenix. It was systemic. Here we sit two years later, digging deeper
still into some of the root causes to ensure that no veteran ever dies
again waiting for care. I introduced legislation this week, the VA
Scheduling Accountability Act, that gets at one of the key drivers of
wait time manipulation.
VA Directive 2010-027 is VA's implementation processes and
procedures policy for scheduling at their facilities and contains 19
different items on the checklist. The directive requires an annual
certification of full compliance with all items on the list. For
instance, facilities are required to ensure completion, using Veterans
Integrated Service Network (VISN)-approved processes and procedures, of
a standardized yearly scheduler audit of the timeliness and
appropriateness of scheduling actions and of the accuracy of desired
dates. They are also required to ensure that deficiencies in competency
or performance that are identified by the annual scheduler audit are
effectively addressed.
An August 2014 OIG report uncovered that in May 2013, the then-
Deputy Under Secretary for Health for Operations Management waived the
FY 2013 annual requirement for facility directors to certify compliance
with the VHA scheduling directive. Allowing facilities to only self-
certify reduced oversight over wait time data integrity and compliance
with appropriate scheduling practices. This, in turn, allowed VA's data
to be easily manipulated, contributing to the wait time scandal. There
was a noticeable, substantial improvement in VHA's appointment
scheduling after VA waived the directive, but as we now know, that
improvement was an illusion. While the VA has reinstated the
certification requirement, there is nothing stopping them from waiving
it again.
The VA Scheduling Accountability Act would require each facility
director to annually certify compliance with the scheduling directive,
or any successor directive that replaces it, and prohibits any waivers
in the future. Should a director be unable to certify compliance,
either because the facility is not in compliance or the director
refuses to sign the certification for some other reason, the director
must submit a report to the Secretary explaining why the facility is
out of compliance. The Secretary will then report yearly to the House
and Senate VA Committees with a list of facilities in compliance and
those that are not, with an accompanying explanation as to why they
were not in compliance. Lastly, the legislation requires that anytime
VA waives or allows noncompliance with requirements in any other
directive or policy beyond scheduling, VA must provide a written
explanation for the decision to the House and Senate Veterans' Affairs
Committees. This will provide more oversight of the Department and
ensure Congress is aware when VA is waiving these policies.
Waiving compliance requirements was a key driver in the wait time
scandal, which continues to be an issue at the Department. This
legislation will end this reckless practice once and for all, while
increasing accountability and transparency at the VA as we work on ways
to ensure that those who risked their lives for their country receive
the prompt, quality care they have earned. I look forward to working
with the members of this Committee, Veteran Services Organizations, and
the VA in addressing this critical issue. I thank you again for this
opportunity to speak today.
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Prepared Statement of Honorable Lee Zeldin
Good Morning Chairman Benishek, and thank you for the opportunity
to testify on behalf of my bill, H.R. 2460, which provides no-cost
medical model adult day health care services for our 70% or more
service connected disabled veterans.
It must always be a top priority of Congress to ensure that all
veterans receive the proper treatment and care they deserve after
fighting for our country. While overseas, these brave men and women are
exposed to significant hardships and trauma, and when they come home,
many return with the physical and mental wounds of war. Despite various
care options for veterans, their choices are often limited, and can
come at a great expense. Service members who are 70% or more disabled
from a service connected injury often require significant assistance
from others in order to carry out basic everyday tasks. In many
instances, veterans must rely on family members for assistance,
creating many financial and emotional hardships for both the veteran
and his or her family. Alternatively, some veterans, without the proper
support system, may even be forced to rely on the assistance of trained
medical professionals and reside in institutionalized facilities for
daily assistance. Veterans in these facilities often spend significant
sums of money each day just to be enrolled, and these expenses can be
expected to span the remainder of the veteran's life in many cases.
While alternative options currently exist, accessing these
services, however, can often be very difficult. One such program that
is currently available is Medical Model Adult Day Health Care; a daily
program for disabled veterans who need extra assistance and special
attention in their day to day lives. Adult Day Health Care programs
provide disabled veterans and their families with a high quality
alternative to nursing home care, providing quality outpatient services
for those suffering from debilitating illnesses or disabilities. These
programs provide a range of services from daily activities, such as
bathing, to full medical services, like physical therapy. Adult Day
Health Care, however, is only offered currently at three facilities in
the United States. Long Island is fortunate to be one of the three
locations, with a facility right in the heart of my district in Stony
Brook, New York, the Long Island State Veterans Home. There are
however, 152 other State Veterans Homes across the country, and this
program could easily be offered at any of the 153 total State Veterans
Homes. Unfortunately, however, the Department of Veterans Affairs does
not currently cover the cost of participation in this program at state
veteran homes and the expense of the program is put directly on the
veteran and their family, which significantly limits the number of
veterans who can enroll.
In order to address this issue and expand access to care for our
heroes, I introduced bipartisan legislation in Congress, H.R. 2460,
which would ensure that 70% or more service connected disabled veterans
are able to receive Adult Day Health Care at no cost to the veteran and
their family by defining the program as a reimbursable treatment option
through the VA. My bill would guarantee that all severely disabled
veterans are able to access Adult Day Health Care. By providing
disabled veterans with access to Adult Day Health Care programs, we can
ensure that all veterans receive the best and most efficient outpatient
services to provide them with the assistance and special attention that
they need in their day to day lives, while still allowing them to
maintain their independence.
Adult Day Health Care also helps keep families together and strong.
With the inclusion of Adult Day Health Care services as a covered VA
expense, family members and caregivers can rest easier knowing that
their loves ones are receiving top notch care during the day, while
being treated with the same respect and dignity that they would receive
at home. Not only does the Adult day Health Care model care for the
medical needs of a veteran, but it also addresses their social and
emotional needs as well. Adult Day Health Care allows veterans to
interact and socialize with their peers and other individuals enrolled
in the program. Rather than sitting home alone all day, participants in
the adult day health care program receive one-on-one attention from
medical and support staff while also maintaining an active social
schedule through planned events and activities. Family members and
caregivers can go about their day without the worry that their loved
ones are unattended, and the veteran can continue to remain as active
members of their community.
It is a top priority of mine to ensure that all veterans on Long
Island and across the country receive the proper treatment and care
they deserve, which is why I fully support the adult day health care
program. I will continue working every day to spread awareness of this
bill, so that we pass this bill as soon as possible to expand Adult Day
Health Care for our disabled veterans, and I thank you for considering
this essential piece of legislation.
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Prepared Statement of Diane M. Zumatto
Distinguished members of the Subcommittee on Health, it is my
pleasure, on behalf of AMVETS, to offer this testimony concerning the
following pending legislation:
HR 2460, to improve the provision of adult day health
care services for veterans;
HR 3956, the VA Health Center Management Stability and
Improvement act;
HR 3974, the Grow Our Own Directive: Physician Assistant
Employment & Education Act of 2015;
HR 3989, the Support our Military Caregivers Act of 2015;
Draft legislation regarding informed consent; and
Draft legislation regarding the scheduling of veteran
appointments & to improve the uniform application of VA directives
Though I plan to focus the bulk of my remarks on Representative
Brownley's ``Informed Consent'' bill, I would like to begin today's
statement with the following introductory remarks prior to turning to
each specific piece of legislation. I ask that this committee ensures
that the health care obligations imposed by the sacrifices of our
veterans are met in a timely, professional and compassionate manner and
I urge you to reject any plan to eliminate the VA from the hands-on
care of our veterans.
I know that each of you is aware of, and appreciates the numerous
issues of importance facing our military members, veterans and
retirees; therefore this testimony will be, following these
introductory remarks limited to the specific pending health care
legislation being considered today.
I would also like to highlight several general issues that AMVETS
would like the committee to monitor and enforce as it goes about its
work, followed by specific recommendations related to the VA.
General Recommendations:
ensure that the VA provides a continuity of health care
for all individuals who were wounded or injured in the line of duty
including those who were exposed to toxic chemicals;
ensure that all eligible veterans not only have adequate
access, but timely and appropriate treatment, for all of their physical
and mental healthcare needs;
continue the strictest oversight to ensure the safety,
physical and mental health and confidentiality of victims of military
sexual trauma;
ensure that the VA continues to provide competent,
compassionate, high quality health care to all eligible veterans; and
ensure that the VA continues to receive sufficient,
timely and predictable funding.
Specific Recommendations:
Ensure that both advanced appropriations and
discretionary funding for VA keeps pace with medical care inflation and
healthcare demand so that all veterans healthcare needs can be
adequately met;
Maximize the use of non-physician medical personnel, when
appropriate, as a way to mitigate physician shortages and reduce
patient wait times especially while utilization of the VA system
continues to rise;
Ensure that VA makes more realistic third-party medical
care collection estimates so that Congress doesn't end up under-
appropriating funds based on false expectations which in turn
negatively impact veteran care. Additionally, VA needs to redouble its
efforts to increase its medical care collections efforts, because taken
together, the cumulative effects of overestimating and under-collecting
only degrade the care available to our veterans. Furthermore, VA needs
to establish both first- and third-party copayment accuracy performance
measures which would help minimize wasted collection efforts and
veteran dissatisfaction;
VA needs to incorporate civilian healthcare management
best practices and include a pathway to VA hospital/clinic management
for civilians as part of their succession plan requirements, so that VA
will be able to attract the best and the brightest healthcare managers
in the industry;
VA could immediately increase its doctor/patient (d/p)
ratio to a more realistic and productive levels in order to cut wait
times for veterans needing treatment and/or referrals. While the
current VA (d/p) ratio is only 1:1200, the (d/p) ratio for non-VA
physicians is close to 1:4200. Instituting this one change would
drastically improve our veterans access to needed healthcare;
VA needs to improve its patient management system so that
veterans have more appointment setting options available to them, which
could reduce staffing errors and requirements. VA should also consider
utilizing a hybrid system whereby half the day might consist of
scheduled appointment and the other half would be for walk in or same-
day appointment. The elimination of the need for non-specialty
appointments would allow veterans quicker access to their primary care
providers;
The current VA healthcare system appears to be top-heavy
with administrative staff and short-handed when it comes to patient-
focused clinical staff. This imbalance can only lead to noticeable
veteran wait times;
The VA needs to thoroughly review its entire
organizational structure in order to take advantage of system
efficiencies and to maximize both human and financial resources, while
also minimizing waste and redundancies;
VA must immediately improve its recruitment, hiring and
retention policies to ensure the timely delivery of high quality
healthcare to our veterans. VA currently utilizes a cumbersome and
overly-lengthy hiring process which reduces its ability to deliver
critical services. VA need to consider adopting a more expedient
hiring/approval process which could include some form of provisional
employment;
VA needs to have, and utilize, the option to terminate
non-performing employees at all levels of the organization so that only
dedicated, accurate, motivated employees will remain in service to our
veterans; and
Finally, VA needs to reform their incentive programs so
that only high-performing employees receive appropriate bonuses for
their excellence in serving our veterans.
Pending Health Care Legislation
HR 2460, to improve the provision of adult day health care services
for veterans - AMVETS supports this legislation, which seems like the
best of both worlds, in that it provides the appropriate and necessary
care for veterans, in a more cost effective manner while also providing
an improved quality of life. This legislation directs the Secretary of
Veterans Affairs to enter into an agreement or a contract with each
state home to pay for adult day health care for a veteran eligible for,
but not receiving, nursing home care.
The veteran must need such care either specifically for a service-
connected disability or the veteran must have a service-connected
disability rated 70% or more.
Payment under each agreement or contract between the Secretary and
a state home must equal 65% of the payment that the Secretary would
otherwise pay to the state home if the veteran were receiving nursing
home care.
HR 3956, the VA Health Center Management Stability & Improvement
Act - AMVETS supports this legislation which seems to be a bit of a no-
brainer. Medical centers without directors will most likely not perform
as well as or as consistently as, those that do. Specifically, the bill
directs the VA to develop and implement a plan to hire a director for
each VA medical center without a permanent director, giving the highest
priority to medical centers that have not had a permanent director for
the longest periods.
HR 3974, the Grow Our Own Directive: Physician Assistant Employment
& Education Act of 2015 - AMVETS supports this legislation which builds
upon and leverages the training and experience of former military
members. This bill directs the VA to carry out the Grow Our Own
Directive or G.O.O.D. pilot program to provide educational assistance
to certain former members of the Armed Forces for education and
training as VA physician assistants.
An individual is eligible to participate in the program if the
individual:
has medical or military health experience gained while
serving in the Armed Forces;
has received a certificate, associate degree,
baccalaureate degree, master's degree, or post baccalaureate training
in a science relating to health care;
has participated in the delivery of health care services
or related medical services; and
does not have a degree of doctor of medicine, doctor of
osteopathy, or doctor of dentistry.
The VA shall:
provide educational assistance to program participants
for the costs of obtaining a master's degree in physician assistant
studies or a similar master's degree;
ensure that mentors are available for program
participants at each VA facility at which a participant is employed;
seek to partner with specified government programs and
with appropriate educational institutions that offer degrees in
physician assistant studies;
establish specified standards to improve the education
and hiring of VA physician assistants, and
implement a national plan for the retention and
recruitment of VA physician assistants that includes the adoption of
competitive pay standards.
HR 3989, the Support Our Military Caregivers Act - AMVETS is very
supportive of this bill which permits an individual to elect to have an
independent contractor perform an external clinical review of any of
the following:
a VA denial of an individual's application to be a
caregiver or family caregiver eligible for VA benefits;
with respect to an approved application, a VA
determination of the level or amount of personal care services that a
veteran requires;
a request by a caregiver or family caregiver for a
reconsideration of the level or amount of personal care services that a
veteran requires based on post-application changes; and
a revocation of benefits by the VA.
The VA shall ensure that each external clinical review is completed
and the individual is notified in writing of the results within 120
days of the election.
Draft Legislation, to ensure that VA medical facilities comply with
requirements related to appointment scheduling for veterans and to
improve the uniform application of directives - AMVETS feels strongly
that there needs to be continuity across the VA healthcare system and
this bill should help to make that recommendation a reality.
Draft Legislation, to establish a list of drugs that require an
increased level of informed consent - this is a top issue for AMVETS
and we whole-heartedly support this legislation because we believe that
the health and welfare of veterans needs to come first. This means
their interests come before any VA employees, including physicians.
AMVETS believes that having the veteran's `buy-in' and clear
understanding of any proposed risky medications, will not only provide
much needed `peace of mind' for the veteran and their family, but will
be instrumental in the overall healing process. An informed patient is
much more likely to fully comply with their doctor's instructions and
much less likely to complain or be dissatisfied with their treatment.
Let me be clear that our intention in supporting this legislation
is not to `burden' or disrespect VA doctors, but to provide veterans
the opportunity to be more actively involved in their health care
treatments.
In order to minimize the burden on physicians, AMVETS suggests
utilizing nationally standardized medical educational material which
could be adopted by the VA and made available either digitally or in a
preprinted format (medication guide). All of the medications which
would require informed consent would either be available in a database
whereby each medication, with its additional information including, but
not limited to:
all the names of any drugs being offered to the patient,
including any other trade or generic name for such drug;
side effects, if any, including dependency;
any alternative methods of treatment or therapy not
involving a covered drug;
whether the drug is being offered for a non-Food & Drug
Administration (FDA) approved use;
whether the drug is being given in a dosage that exceeds
the dosages approved or tested by the FDA;
any potential dangers of mixing drugs and dosages in
sizes and combinations that have not been approved or tested by the
FDA;
any known interactions between a covered drug and other
drugs or substances, including alcohol;
any and all other appropriate warnings or information
that a patient in similar circumstances would reasonably want to know
could be printed for each specific covered medication and provided
to the patient.
If utilizing the pre-printed medication guide, the format of which
is yet to be determined, each covered medication would be included with
all of the same additional information as the database option, the
physician would then merely `check off' the recommended medications and
hand the information to the patient. In both cases a `consent form'
would be provided to the patient for his/her signature, in either an
electronic or paper format.
The patient's signature, at this point, merely indicates that they
have been provided with the information regarding any covered
medications and should not yet be understood as an acceptance of the
proposed treatment plan. At this point the patient should be given the
opportunity to ask any immediate questions of the physician or the
veteran could be referred to a pharmacist for further information.
The patient would then be given three full business days from the
initial prescription recommendation to:
consider and internalize the information provided by the
clinician;
conduct any additional research;
seek a second opinion, discuss with family or get a legal
opinion
At the end of the three day period, the patient would then convey
their approval/disapproval of the suggested medication(s) via secure
messaging (My HealtheVet), phone, email or fax directly to the
prescribing physician or his/her office.
The veteran's signature along with the follow up (oral or written)
at the end of the three days would jointly fulfill the informed consent
signature requirement, so there would be no further reason for the
veteran to return to the doctor's office on this matter unless there
were extenuating circumstances. (This process could be even further
streamlined by not requiring the veteran to do any follow up, unless
they disagree with the proposed treatment plan. In which case, their
previous signature plus their lack of disagreement with the proposed
treatment plan could be taken as their complicit consent.)
An additional point of clarification I would like to make is that
the VHA Handbook already mandates that side effects and alternative
treatments be explained to a veteran prior to deciding on a treatment
plan. This proposed legislation then is not asking for something
entirely alien to the VA, it is merely asking for an increased
`Informed Consent' requirement.
Remember this added requirement would only be utilized when a
physician prescribes a medication from the limited list of covered
medications which carry `black-box' warnings, have substantial risks or
undesirable side effects, etc.
This type of information is especially critical for veterans who
may have additional physical and/or mental health concerns and may
already be taking or require a number of dangerous medications.
The need for this type of medical disclosure is also a concern in
the non-veteran health care community as evidenced by the FDA's recent
announcement that immediate-release opioid painkillers such as
oxycodone will now have to carry a ``black box'' warning about the risk
of abuse, addiction, overdose and death. (``Black box'' warnings are
the FDA's strongest, and they're meant to help educate doctors as
they're prescribing medications to patients. See article below)
This completes my statement at this time and I thank you again for
the opportunity to offer our comments on pending legislation. I will be
happy to answer any questions the committee may have.
Additional Information:
VHA Handbook on Informed Consent - sent as a separate attachment
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Prepared Statement of Shurhonda Y. Love
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the Subcommittee on Health. As you know,
DAV is a non-profit veterans service organization comprised of 1.3
million wartime service-disabled veterans that is dedicated to a single
purpose: empowering veterans to lead high-quality lives with respect
and dignity.
DAV is pleased to be here to present our views on the bills under
consideration by the Subcommittee, and we appreciate your invitation.
H.R. 2460
H.R. 2460, if enacted, would authorize the Secretary to enter into
agreements with state veterans homes to provide adult day health care
for veterans who are eligible for, but do not receive, skilled nursing
home care under section 1745(a) of title 38, United States Code.
Eligible veterans are those who require such care due to a service-
connected disability, or who have a VA disability rating of 70 percent
or greater and are in need of such care. The payment to a state home
under this program would be at the rate of 65 percent of the amount
payable to the state home if the veteran were an inpatient for skilled
nursing care and payment by VA would be considered payment in full to
the state home.
Adult day health care is an alternative to traditional skilled
nursing care that can allow some veterans requiring long-term service
and supports to remain in their homes near family and friends, rather
than be institutionalized in nursing homes. This program is designed to
promote socialization, stimulation, and maximize independence while
enhancing quality of life as well as providing comprehensive medical,
nursing, and personal care services for veterans.
DAV is pleased to support H.R. 2460, which is in line with DAV
Resolution No. 101, adopted at our most recent National Convention,
calling for support for the state veteran home program, recognizing
state home care as the most cost-effective care available for sick and
disabled veterans with long-term care needs outside the VA health care
system.
H.R. 3956, the VA Health Center Management Stability and Improvement
Act
If enacted, this bill would require VA to develop and implement a
plan to hire a director for each VA medical center without a permanent
director at the time of enactment. It would place the priority for
hiring at facilities that have gone without a director for the greatest
length of time. In the Secretary's plan, a deadline for hiring would be
set at the Secretary's discretion.
This bill would also direct the Secretary to identify impediments
to the hiring of directors, and identify candidates from within VA who
could be promoted to fill these key positions. At the 120th day after
enactment of this bill, it would require the Secretary to submit a
report to Congress. Every 180 days after, the Secretary would be
required to submit a report to Congress on facilities still lacking
permanent directors.
Currently, 23 medical centers are without permanent directors.
Prior to VA's adopting this more assertive approach, 35 vacancies were
reported. We understand that VA is taking steps to hire medical center
directors by posting national vacancy announcements in multiple
locations across the system, and by leveraging social media outlets and
other venues to increase public awareness of these leadership
opportunities.
DAV has not received a resolution specific to the hiring of VA
medical center directors, but DAV Resolution No. 126 calls for the
support of modernization of VA's human resources management system to
enable VA to compete for, recruit and retain the types and quality of
VA employees needed to provide comprehensive health care services to
sick and disabled veterans. Directors of VA medical centers are key
officials in this respect; therefore, DAV would not object to the
enactment of this bill.
H.R. 3974, the Grow Our Own Directive: Physician Assistant Employment
and Education Act of 2015
If enacted, this bill would direct VA to carry out a pilot program
to provide educational assistance to certain veterans with the goal of
employment as VA physician assistants.
Under this bill, the pilot program would target veterans with
experience gained in medical or military health care while serving, and
who had received a certificate, associate degree, baccalaureate degree,
master's degree, or post-baccalaureate training in a science related to
health care, and had participated in the delivery of health care
services or related medical services.
The bill would require VA to provide educational assistance,
including scholarships, to no fewer than 250 participants, 35 of whom
would be employed each year of the pilot program. VA would be required
to reimburse their costs of obtaining master's degrees in physician
assistant studies or similar master's degrees, consistent with VA's
existing health professions scholarship program authorized in Chapter
76 of title 38, United States Code. The bill would require VA to make
available mentors for participants at each VA facility and would
require VA to establish partnerships with other government programs and
with a specific number of educational institutions that offer degrees
in physician assistant studies. It would also require selectees to
agree to an obligated work period in VA facilities in specified
geographic areas, including areas of medically underserved populations,
but also in states with per capita veteran populations of more than
nine percent.
The bill also would require VA to establish standards to improve
the education and hiring of VA physician assistants, and implement a
national plan for the retention and recruitment of VA physician
assistants.
The bill would establish a series of new, mandatory positions in
VA's national Office of Physician Assistant Services in VA Central
Office, including a Deputy Director for Education and Career
Development, a Deputy Director for Recruitment and Retention, a
designated recruiter of physician assistants, and an administrative
assistant to support these functions. The bill would outline their
major duties.
The bill would re-designate not less than $8 million in funds
appropriated prior to the passage of this bill to carry out its
purposes. The bill is silent on sources of additional funding that
might be needed to meet its mandates.
Finally, the bill would align VA physician assistant pay grades
equivalent to the pay grades of VA registered nurses.
DAV has not received a resolution from our membership dealing with
VA recruitment, training or employment of physician assistants as a
single employment category, but we recognize the value of this bill in
improving health manpower in the VA, and especially in addressing
shortages being observed today in VA's primary care provider workforce.
On this basis DAV would not object to enactment of this bill.
H.R. 3989, the Support Our Military Caregivers Act
This bill would establish an external review process in cases in
which VA denied caregiver benefits for veterans, approved a level of
benefits that was considered inadequate to a veteran's needs, or
revoked these benefits. A decision on this review, once requested by a
caregiver, would be required by the bill to be completed within 120
days.
Our concerns regarding the VA Comprehensive Caregiver Support
Program continue to include the apparent lack of due process and
transparency in the decision and appeal process for veteran and
caregiver program applicants. DAV identified early on the need for an
independent mechanism through which (1) a caregiver can appeal a
clinical team's decision; (2) that decision can be carefully reviewed
``de novo;'' and (3) an unwarranted decision can be reversed, altered,
or sent back to the clinical team with instructions to reassess or
consider additional factors. Accordingly, DAV is pleased to support
H.R. 3989 because it is in line with DAV Resolution No. 106, which
calls for legislation to provide comprehensive support and services to
caregivers of all veterans severely injured, wounded or ill from
military service.
We note the intent of this bill would be to offer program
applicants a review of VHA decisions; however, it is not clear if the
external clinical review would be binding on VA, and whether the
recommendations of the contractor would be cause for VHA to issue a new
decision based on the findings of the review. We also bring to the
Subcommittee's attention there is still no publicly accessible program
handbook or directive outlining mandatory program policies, procedures
and operational requirements, which would serve to inform and educate
those enrolled or those seeking enrollment in the program.
Moreover, we believe VA's Caregiver Support Program office should
have ready access to the types of data that would allow it to monitor
and manage the program's workload due to the limited capabilities of
VA's data system, which was designed to manage a much smaller workload.
Veterans Integrated Service Network (VISN) officials and VA medical
centers officials have reported that there are too few Care Support
Coordinators (CSC) to handle the program's workload effectively.
Specifically, at some medical centers, CSCs have been unable to perform
all of the routine administrative tasks associated with their approved
caregivers. Irrespective of inadequate staffing for the caregiver
support program from VA Central Office, or not possessing the right
tools or sufficient resources or support to properly manage, evaluate
and improve the program, caregivers of, and injured veterans
themselves, are being adversely affected and are not receiving the full
benefits intended by Congress. In addition to passage of this bill, we
urge VA and Congress to address these problems.
Discussion Draft, requirement of increased informed consent for certain
drugs
If enacted, this bill would require VA to establish a panel of
specialists that would reside within the Office of Specialty Care
Services of VHA to establish and maintain a list of drugs to include
psychotropic drugs that would require an increased level of informed
consent. Under the bill, such drugs would only be prescribed to an
enrolled veteran with written, informed consent of the veteran or
appropriate representative of the veteran.
We understand that VA maintains an oral informed consent process
covering the types of drugs contemplated by this bill. According to VA,
at the point that a VA physician prescribes psychotropic medications to
patients, an automatic process commences to gain a patient's informed
consent. In addition, some medical centers have assigned pharmacists to
Patient Aligned Care Teams (PACT), where the use of certain drugs is
explained and patients gain the opportunity to speak directly with
pharmacy staff about possible side effects and contraindications.
Finally, prescribed medications are received with accompanying
information sheets, and some medications are issued with both drug
information sheets as well as FDA medication guidelines. However, we
understand VA has not implemented a nationwide directive requiring the
presence of pharmacy counselors within PACTs. To ensure VA physicians
can continue to provide timely care it may be beneficial to require VA
to include pharmacy personnel on all PACT teams systems to ensure
patients have adequate time to gain a meaningful understanding of the
medications prescribed and alternative treatments available.
DAV is pleased to support this draft measure which is consistent
with DAV Resolution No. 126, and urges VA to promote and ensure health
care quality and value, and to protect veterans' safety in the VA
health care system.
Draft Bill, to ensure VHA medical facilities are uniformly in
compliance with VHA appointment scheduling directives and policies
This bill would require that each VHA medical center certify that
it is in compliance with current VHA directives and policies applicable
to scheduling veterans' appointments for health care. In the event the
facility was not in compliance, the facility director would be required
to provide an explanation of why the facility was not in compliance,
and what steps were being taken to achieve compliance. The Secretary
would be required to submit an annual report to Congress regarding the
status of medical centers in meeting this requirement. In addition, the
Secretary would be required to ensure all facilities are uniformly in
compliance with VHA directives and policies on scheduling. In the event
of a medical center's having been waived from uniform compliance, the
Secretary would be required to notify Congress of such waiver, and
provide explanation.
DAV has received no specific resolution from our membership
addressing the issue of VA certification of appointment scheduling, but
we would not oppose passage of this bill.
Mr. Chairman, DAV appreciates the opportunity to provide testimony.
I would be pleased to address any questions you, or members of the
Subcommittee may have on the topics covered in this statement.
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Prepared Statement of Fred S. Sganga
Mr. Chairman and Members of the Subcommittee, thank you for this
opportunity to provide testimony regarding H.R. 2460, legislation
introduced by Congressman Lee Zeldin of New York, to provide severely
disabled veterans with an enhanced option to receive adult day health
care services from State Veterans Homes.
I am Fred Sganga, the Legislative Officer of the National
Association of State Veterans Homes (NASVH). I also have the high honor
of serving as the Executive Director of the Long Island State Veterans
Home (LISVH) at Stony Brook University, a 350 bed State Veterans Home
that also operates a 40 slot medical model Adult Day Health Care (ADHC)
program.
The State Veterans Home program was established by a Congressional
Act on August 27, 1888, and for more than 125 years State Homes have
been in a partnership with the federal government to provide long term
care services to honorably discharged veterans; in some states, widows
and spouses as well as Gold Star Parents are also eligible for
admission. There are currently 153 State Veterans Homes located in all
50 states and the Commonwealth of Puerto Rico.
The National Association of State Veterans Homes (NASVH) was
conceived at a New England organizational meeting in 1952 because of
the mutual need of State Homes to promote strong federal policies and
to share experience and knowledge among State Home administrators to
address common problems. NASVH is committed to caring for our nation's
heroes with the dignity and respect they deserve.
With over 30,000 beds, the State Veterans Home program is the
largest provider of long term care for our nation's veterans. Current
services provided by State Homes include skilled nursing care,
domiciliary care and adult day health care. The Department of Veterans
Affairs (VA) provides State Homes with construction grants to build,
renovate and maintain the Homes, with States required to provide at
least 35 percent of the cost for such projects in matching funds. State
Veterans Homes also receive per diem payments for basic skilled nursing
home care, domiciliary care and ADHC from the federal government which
covers about one third of the daily cost of care.
Mr. Chairman, a decade ago, NASVH led the effort on Capitol Hill to
assist our most disabled veterans by allowing them to receive skilled
nursing care in State Veterans Homes under a new program that would
provide the ``full cost of care'' to the State Home and thereby expand
the options available to these deserving veterans at no cost to them.
In 2006, Congress passed and the President signed Public Law 109-461
which guaranteed ``no cost'' skilled nursing care to any honorably
discharged veteran who has a 70% or higher service connected disabled
rating. Unfortunately, the bill did not extend the same ``no cost''
program to cover alternatives to traditional institutional care, such
as the medical model Adult Day Health Care currently provided at three
State Veterans Homes in Stony Brook, New York, Minneapolis, Minnesota
and Hilo, Hawaii. H.R. 2460 would fix that.
Adult Day Health Care at the LISVH is designed to promote wellness,
health maintenance, socialization, stimulation and maximize the
participant's independence while enhancing quality of life. A medical
model Adult Day Health Care program provides comprehensive medical,
nursing and personal care services combined with engaging social
activities for physically or cognitively impaired adults. These
programs are staffed by a caring and compassionate team of multi-
disciplinary healthcare professionals who evaluate each participant and
customize an individualized plan of care specific to their health and
social needs.
As a licensed nursing home administrator, I would like to thank
Congressman Zeldin for recognizing the need to offer non-institutional
alternatives to our veterans. Giving our veterans and families choices
in how they can receive care is just the right thing to do. Making sure
that there are no financial barriers to care is important to our most
medically compromised veterans.
It would be especially important to veterans like Jim Saladino and
his wife Noreen. Fifty years ago, Jim answered the call of his country
and served in the United States Army during the Vietnam War. Today, he
suffers from the ravages of Agent Orange exposure. Specifically, he
suffers from chronic illnesses including diabetes and Parkinson's
disease and he also recently suffered a stroke.
Although the Saladino family could have decided to put Jim into our
State Veterans Home because he is a 100% service connected veteran so
it would have been fully paid for by VA, but that is not their choice.
They would like their loved one to continue enjoying the comforts of
his own home - for as long as he can. By providing him the benefits of
our medical model Adult Day Health Care program, Jim is able to keep
living at home.
Jim's wife, Noreen, serves as his primary caregiver. She has
publicly stated that the medical model Adult Day Health Care Program
has been a true blessing for her. Jim comes to the ADHC program three
days a week and we work closely with his personal physician to provide
services that will maintain his wellness and keep him out of the
emergency room. During his six hour day with us, Jim receives a
nutritious breakfast and lunch. He receives comprehensive nursing care.
He also receives physical therapy, occupational therapy and speech
therapy. He can get his eyes checked by an optometrist, his teeth
cleaned and examined by our dentist, and his hearing checked by an
audiologist. If required, he can get a blood test or an x-ray, have his
vital signs monitored and receive bathing and grooming services while
on site.
For Jim's wife, having him come to our program allows her the peace
of mind knowing that he is in a safe and comfortable environment. She
can then get a break as caregiver and tend to those issues that allow
her to run her household. However, because of the way the law is
currently structured, despite Jim's eligibility for ``no cost'' skilled
nursing care, they are required to pay out of pocket for a portion of
his Adult Day Health Care.
Mr. Chairman, H.R. 2460 will fix this disparity that prevents some
of the most deserving and severely disabled veterans from taking
advantage of this valuable program to help keep living in their own
homes. This legislation would authorize VA to enter into agreements
with State Veterans Homes to provide Adult Day Health Care for veterans
who are eligible for, but do not receive, skilled nursing home care
under section 1745(a) of Title 38, the ``full cost of care'' program.
Veterans who have a VA disability rating of 70 percent or greater or
who require ADHC services due to a service-connected disability would
be eligible for this program. The payment to a State Home under this
program would be at the rate of 65 percent of the amount that would be
payable for skilled nursing home care under the same ``full cost of
care'' program. This legislation would not only offer a lower cost
alternative (ADHC) for severely disabled veterans who might otherwise
require full time skilled nursing care, but it would also allow them to
continue living in their own homes.
The VA has been stressing the need to provide essential long-term
care services in non-institutional settings for our most frail, elderly
disabled veterans. Medical model Adult Day Health Care is a tremendous
solution to this challenge being faced by the VA, one that can keep
veterans living in their homes while allowing them to receive skilled
nursing services and supports. There are a number of State Homes across
the country interested in providing medical model ADHC services,
however the current basic ADHC per diem is not nearly sufficient for
most State Homes to be cover the costs of this program. Enactment of
H.R. 2460 would provide a higher ADHC per diem rate for severely
disabled veterans in medical model ADHC programs and thereby allow
additional State Homes across the country to offer this service.
For the Saladino family, receiving ``no cost'' medical model Adult
Day Health Care for their loved one would relieve a huge financial
burden that they currently incur. Even though Jim's service ended 50
years ago, he is still paying a price for his valor related to his
service in Vietnam. Passing H.R. 2460 would send a strong message to
all those who have worn the uniform to protect our freedoms that they
will never be forgotten.
H.R. 2460 has bipartisan support in the House and has also been
supported by a number of veterans service organizations, including The
American Legion and the Veterans of Foreign Wars. I would ask that The
American Legion's letter of support for this legislation be made a part
of the record.
On behalf of the National Association of State Veterans Homes, I
urge you to favorably consider and pass H.R. 2460 for Jim and Noreen
Saladino, and for thousands of others across the country just like
them. Mr. Chairman, that concludes my testimony and I would be happy to
answer any questions you and members of the Subcommittee may have.
Thank you.
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Prepared Statement of Maureen Mccarthy
Good morning Chairman Benishek, Ranking Member Brownley, and
Members of the Committee. Thank you for inviting us here today to
present our views on several bills that would affect VA health programs
and services. Joining me today is Susan Blauert, Chief Counsel for
General Counsel's Health Care Law Group.
Draft Bill: To ensure that each VA medical facility complies with
requirements relating to scheduling veterans for health care
appointments and to improve the uniform application of VA directives
The proposed draft bill would require each VA medical facility to
comply with requirements relating to scheduling Veterans for health
care appointments and to ensure the uniform application of VA
directives.
Section 1 would require the director of each VA medical facility to
annually certify to the Secretary that the medical facility is in full
compliance with all provisions of law, regulations, and VA directives
relating to scheduling appointments for Veterans to receive hospital
care and medical services. VA does not support section 1 of this bill
because it is unnecessary. Existing policies already require directors
to certify compliance with the scheduling directive and explain gaps in
compliance based on scheduling data collected at the facility level.
This bill would not increase the amount or quality of information
available regarding scheduling or meaningfully improve existing
processes for certifying compliance.
The bill also over-prioritizes scheduling to a great extent.
Scheduling, while important, is not the only way Veterans access care
in VA. As a technical matter, we note this bill would provide that each
VA medical facility Director must certify compliance with all laws and
regulations relating to ``scheduling appointments for Veterans to
receive hospital care.'' Veterans are not required to be scheduled for
hospital care; they can walk in the door and be admitted through the
emergency room, if clinically appropriate, or their primary care
provider may admit them directly. Within VA, the term ``scheduling''
typically is used in the context of outpatient care.
The bill also prohibits the Secretary from waiving any provision of
law or regulation relating to scheduling. This provision would not
benefit Veterans. VA is actively working with Members of Congress on a
consolidated care in the community program and other efforts to improve
access to health care. In this dynamic environment, particularly with
the increased use of community care, VA needs the flexibility to set
scheduling standards that are clinically appropriate and can change and
improve over time in step with other changes in the way Veterans access
health care.
Section 2 of the bill would require VA to ensure that its policies
apply uniformly to each office or facility of the Department. VA does
not support section 2 of the bill because it is unnecessary and, if
interpreted broadly, unduly rigid. VA national policies already apply
uniformly across the Department. At the same time, these policies
provide some flexibility so that facilities can develop and pilot
innovative ideas, or implement policies and procedures that are
specific to the needs of the local Veteran community and consistent
with the principles and procedures established in national policy.
Section 2 could potentially limit VA facilities' ability to implement
policies and procedures needed to tackle local challenges and address
Veterans' needs.
We do not have costs for this bill at this time.
H.R. 2460: To Improve the provision of adult day health care services
for veterans
H.R. 2460 would amend 38 United States Code (U.S.C.) Sec. 1745 to
require the Secretary to enter into an agreement under 38 U.S.C. Sec.
1720(c)(1) or a contract with each State home for payment by VA for
adult day health care (ADHC) provided to an eligible Veteran. Payments
would be made at a rate that is 65 percent of the payment VA would make
if the Veteran received nursing home care, and payment by VA would
constitute payment in full for such care. Currently, under a grant
mechanism, VA pays States not more than half the cost of care of
providing ADHC. States may currently obtain reimbursement for this care
from other sources in addition to VA's per diem payments.
VA does not support this bill for the following reasons.
Substantively, we note that the bill would base payment rates for ADHC
on nursing home care rates, even though these are two distinctly
different levels of care and are furnished for different periods of
time. VA pays per diem for three levels of care at State Veterans Homes
(SVH): nursing home care, domiciliary care, and adult day health care.
The prevailing nursing home rate is calculated based on the cost of
providing nursing home care. Nursing home residents live at the
facility and receive 24-hour skilled nursing care. ADHC, however, is a
much lower level of care where participants live at home and only use
ADHC services for a portion of time during the day, normally about 8
hours, or one third of the length of time that skilled care is
provided. A per diem payment is made only if the participant is under
the care of the facility for at least 6 hours. Because the level of
services for ADHC and nursing home care are different, and the period
of time in which services are furnished are different, we believe the
payment rate proposed in the bill is inappropriate. The bill, in
essence, would pay two thirds of the rate that VA pays for a higher
level of care for furnishing a lesser level of care for only one third
of the time.
VA also has logistical concerns with the legislation. First, we
note that the language in the bill directing VA to ``enter into an
agreement under Sec. 1720(c)(1) of this title or a contract'' with
each State home is inadequate. VA does not have independent agreement
authority under Sec. 1720, and all agreements reached under this
provision are contracts. The fact that these agreements are contracts
places additional requirements on State homes that have proved
burdensome and difficult to implement. To address this and similar
situations, VA has requested congressional action to enact the
Purchased Health Care Streamlining and Modernization Act that we
submitted to Congress last year. This legislation would allow VA to
enter into agreements that are not subject to certain provisions of law
governing Federal contracts with providers on an individual basis in
the community. Already, we have seen certain private nursing homes not
renew their contracts, requiring Veterans to find new facilities for
residence. We recommend Congress enact this new authority before
requiring VA to transition payments to States for some ADHC
participants from a grant to a contract mechanism.
Additionally, in June 2015, VA published a proposed rule, ``Per
Diem Paid to States for Care of Eligible Veterans in State Homes,'' RIN
2900-AO88, along with a clarifying and correcting rule one week later.
VA proposed these amendments to its regulations regarding payments for
ADHC care in SVHs so that States may establish diverse programs that
better meet participants' needs for socialization and maximize their
independence. Currently, VA requires States to operate these programs
using a medical supervision model exclusively. We expect that the
proposed changes to our regulations will offer a socialized model that
would result in an increase in the number of States that have ADHC
programs. Currently, the SVH ADHC program is underutilized, as only
three SVHs operate ADHC programs. We do not know at this time how many
SVHs will adopt this new model, nor how the new model's use will affect
costs. Until we have such information, we recommend against codifying a
payment rate, as such a limitation could result in VA overpaying or
underpaying States in the future.
VA has other technical comments and recommendations we would be
happy to provide at your request.
VA supports growing ADHC programs in general because they are a
part of VA's home and community-based programs included in the medical
benefits package available to enrolled Veterans. VA operates ADHC
programs, pays for ADHC in the community, and pays per diem to SVHs for
ADHC. Those who are able to utilize the ADHC program are able to avoid
nursing home care, maximizing their independence to support their
choices, while reducing costs to VA. Projections for the Long-Term
Services and Supports Model demonstrate that VA utilization for ADHC in
the community will increase. VA recommends forbearing any action at
this time until we have clear authority to enter into agreements other
than contracts for such services and until VA is able to finalize
changes to its regulations allowing for the new social model of care.
VA estimates H.R. 2460 would cost $1.7 million in the first year,
$2.1 million in the second year, and $12.6 million over five years.
H.R. 3989: Support Our Military Caregivers Act
H.R. 3989 would add a new subsection (d) to 38 U.S.C. Sec. 1720G
that would set forth a process for external clinical reviews of certain
determinations under VA's Program of Comprehensive Assistance for
Family Caregivers (PCAFC) and Program of General Caregiver Support
Services, as established in Public Law (P.L.) 111-163. Under the new
subsection (d), ``an individual may elect to have an independent
contractor . . . perform an external clinical review'' of: a denial of
a caregiver's application for benefits under Sec. 1720G, a
determination or reconsideration of ``the level or amount of personal
care services that a veteran requires,'' or a revocation of benefits
pursuant to Sec. 1720G. The bill specifies that such reviews would be
performed by an ``independent contractor'' as described in the bill,
``[u]sing amounts otherwise appropriated'' to carry out Sec. 1720G.''
VA does not support this bill because VA already has an existing
mechanism in place to review eligibility determinations under Sec.
1720G, including, where appropriate, consideration of recommendations
from an external clinical review.
VA implemented Caregiver Support Programs under Sec. 1720G in May
2011. Since then, more than 30,000 caregivers have received services
and support through PCAFC. These additional services and support are
essential aspects of a Veteran's treatment plan as VA provides Veteran-
centered and family-centered care to Veterans.
As provided in 38 U.S.C. Sec. 1720G(c), all decisions by the
Secretary under Sec. 1720G affecting the furnishing of assistance or
support shall be considered medical determinations. Accordingly, when
there are disagreements with or clinical disputes over a decision under
Sec. 1720G that are not resolved at the clinical team level, VHA
follows the VHA Clinical Appeals policy and procedures that govern the
appeals process for all VHA clinical programming (VHA Directive 2006-
057, VHA Clinical Appeals). This policy sets forth the mechanism in VHA
for both internal and external clinical appeals. As provided in VHA
Directive 2006-057, ``[i]t is VHA policy that patients or their
representatives must have access to a fair and impartial review of
disputes regarding clinical determinations or services that are not
resolved at the facility level.''
Providing a separate process for external clinical reviews, as set
forth in H.R. 3989, would significantly impact the current process for
reviewing eligibility determinations under PCAFC, in particular, as the
program is currently operated. For example, when a Veteran (or eligible
Servicemember) applies for the PCAFC, the individual's primary care
team makes a series of clinical eligibility determinations. Once
approved, the primary care team continues to remain involved by
maintaining the individual's treatment plan and collaborating with
clinical staff making home visits to monitor the individual's well-
being, supporting both the Veteran (or eligible Servicemember) and
family caregiver(s). The existing VHA Clinical Appeals policy ensures
that, in the event of an appeal, decisions are made by VHA leadership
with direct oversight of the clinical team involved with the
individual's care.
In contrast, the external clinical review under H.R. 3989 would be
conducted by an independent contractor who ``employs a panel of
physicians or other appropriate health care professionals'' and who
does not provide health care to the individual. The independent
contractor would need to be educated about PCAFC, applicable
eligibility requirements, existing assessment and revocation
procedures, as well as required assessment tools. This new process
would require management and quality assurance oversight and Veteran-
facing customer service and satisfaction supports that would require
additional staffing or contract support.
Moreover, using an ``independent contractor'' to perform external
clinical reviews, as provided in H.R. 3989, could not be achieved with
existing funding. Additional funding for this new requirement would be
necessary, to include funding for education and customer service and
satisfaction supports.
VA is unable to provide a cost estimate on this bill as data
required to construct costing is not readily available.
H.R. 3974: The Grow Our Own Directive: Physician Assistant Employment
and Education Act of 2015
VA supports section 2 of H.R. 3974, subject to the availability of
funds, which would require VA to carry out a pilot program to provide
educational assistance to certain former members of the Armed Forces
for education and training as physician assistants (PA). Having a pilot
program will help alleviate the health care workforce shortages in VA
by requiring scholarship recipients to complete a service obligation at
a VA health care facility after graduation and licensure/certification.
Additionally, scholarships will enable students to gain academic
credentials without additional debt burdens from student loans. Future
benefits are gained in reduced recruitment costs as scholarship
recipients will have obligated service agreements to fulfill. These
service agreement obligations secure the graduates' services for up to
3 years, which reduces turnover, and costs typically associated with
the first 2 years of employment.
While VA supports H.R. 3947, we believe that the Congress should
provide more flexibility in implementation. The bill is very specific,
including in areas such as directing new pay levels, and the exact
criteria for participant eligibility. VA should be afforded the
flexibility to implement such a program in a manner that can minimize
any unintended consequences, such as consistency across Title 38
programs in other Federal agencies.
While VA supports section 2, we recommend removing language in
paragraph (j) that would require these positions to be filled by a
Veteran and a current employee. While requiring a position be filled by
a Veteran could be challenging, requiring that the individual be
``employed by [VA] as of the date of enactment of the Act'' would be
legally problematic. In addition, the limitation of filling the
proposed Deputy Director positions with Veterans only (as opposed to
employing Veteran preference) would significantly limit the pool of
applicants with the necessary experience and skill sets necessary to
successfully carry out the responsibilities of the positions.
The total cost of section 2 of the Health Professional Scholarship
Program (HPSP) with HPSP Stipend cost for 250 awards over 5 years would
be $19,812,531. This amount includes $11,700,000 for scholarship
assistance, $7,652,584 for stipend costs, as well as additional costs
for administration, information technology, and travel.
Section 3 would establish standards for the Department for using
educational assistance programs to educate and hire PAs. VA does not
support this section because Educational Debt Reduction Program (EDRP)
assistance is targeted for specific positions that are designated as
difficult to recruit and retain. In order to meet local Veteran
population needs, local medical centers have the flexibility to
determine the positions that have the most critical need for EDRP
awards and advertise accordingly. Loan repayment awards are an
attractive tool; however, EDRP is a limited resource and offering EDRP
to an entire occupational series is contrary to the statutory mission
of the program and sets a precedent for other occupations to seek
similar authority.
The PA occupation is recognized as a top 5 mission-critical
occupation within VA, ranking fourth and tied with physical therapy,
according to the January 2015 VA Office of Inspector General (OIG)
report after medical officer (physician), nurse, and psychologist.
Over the last several fiscal years (FY), the number of new PA hires
has fluctuated between 250-350 annually. The number of EDRP awards made
for newly hired PAs has gradually increased from 26 to 45 (62 percent
increase) from FY 2014 to FY 2015, and currently comprises 13 percent
of all new PA hires. In the FY 2015 EDRP award cycle, the average EDRP
award for PAs was $63,000. Current projections estimate similar awards
for the PA occupation based on qualifying student loan debt. Overall,
the OIG top 5 occupations represented 82 percent of all EDRP awards
made in FY 2015.
EDRP awards are typically 5-year awards. If EDRP was offered to
every new PA hire, nearly $4.6M would be needed each year for new
awards, and additional funding would be required to sustain current
participants. Furthermore, it can be expected that PAs currently
employed within the VA network not receiving EDRP would expect to
receive a similar award, or consider moving to a position elsewhere
that authorized EDRP. Since EDRP may be awarded as a retention tool,
additional funding would be required for current PAs as well.
Including EDRP in all announcements would also give interested
candidates for hire the impression that EDRP would be available. EDRP
awards are not made until after qualifying student loan debt can be
confirmed with education institutions and lenders, which can take
several months and occurs after employees are onboard. Without
significantly increasing EDRP funding, including EDRP in all PA vacancy
announcements will prevent facilities from offering the award to other
positions that are more difficult for recruitment and retention
locally. Advertising EDRP in all PA announcements, without
significantly increasing funding, is misleading and likely to
disenfranchise new employees early in their VA career.
Advertising EDRP for an entire occupation sets a precedent that
will likely encourage other occupations to seek the same. Such costs
are not only unsustainable, but in conflict with the statutory mission.
PAs are nationally ranked as a mission-critical occupation; however,
certain facilities report no issues recruiting PAs (i.e., Michael E
DeBakey VA Medical Center in Houston, TX, has a strong PA program with
academic affiliates and reports no issues hiring PAs). Requiring all
facilities to advertise EDRP for positions would deny the facility the
ability to make awards for positions that are the most critical.
Alternative approaches may be better suited for strengthening the
PA occupation within VA. If compensation of PAs is the primary driver,
rather than include EDRP in all vacancy announcements, VA supports the
legislation in Section 4, which seeks to eliminate the pay disparity
between VA and the private sector.
The cost to include EDRP in all PA vacancy announcements for 5,350
new awards over 5 years would be $45,500,000. Salary costs and
development costs are estimated at an additional $659,037, bringing the
total cost of this proposal to $46,159,037.
The PA occupation has been a difficult to recruit and retain
occupation for several years. A major barrier to recruitment and
retention of PAs is the significant pay disparity between private
sector market pay and VA pay schedules for PAs. Special Pay rate
authority exists at the medical center level to address these
disparities. Salary surveys performed during FY 2015 by several VA
medical facilities have resulted in establishment or adjustment in
local special salary rates for the PA occupation resulting in
significant increases in salaries. This is an indication of the
existing salary disparity overall. Including the PA occupation as a
covered occupation under the nurse locality pay system in VA would be
an important element in addressing recruitment and retention
difficulties.
The total cost associated with this proposed legislation over 5
years would be $135,149,625. This amount includes $19,812,531 in
Scholarship Support Costs, $2,580,541 in Program Administration Costs,
$220,016 in Operational Costs, and $112,536,537 associated with
competitive pay for physician assistants.
H.R. 3956: The VA Health Center Management Stability and Improvement
Act
Although the bill addresses the Department's challenges with
recruiting and filling Medical Center Director positions, it does not
offer any substantive solutions to address the challenges. Instead, it
proposes legislation to develop and implement a hiring plan within 120
days of the legislation going into effect. By the time this draft
language might become legislation, VA anticipates having significantly
reduced the number of vacant Medical Center Director positions, such
that the legislation would no longer be needed, but would impose
another congressional reporting requirement on VA. Therefore, we do not
support this bill. As an alternative to creating new reporting
requirements, the Congress should consider options that would allow VA
to achieve the same result through existing reports, such as the
Agency's human capital plan. In fact, many of the topics under
consideration should already be covered in the succession management
and recruitment sections of the existing human capital plan.
Since the beginning of FY 2016, VA has been working hard to shorten
the time to hire for these executive positions. In October 2015, we
began using nationwide announcements to identify and secure larger
pools of qualified candidates, both internal and external to VA. This
enterprise approach allows us to best match the candidate's skills and
abilities with one of the vacant positions and do so in close to 120
days. Based on current recruitment efforts, we anticipate having
nominees identified for approximately 20 of the more than 30 vacancies
by the end of April 2016.
In addition, VA recently submitted a legislative proposal
requesting the ability to transition all Medical Center Directors from
Title 5 to Title 38, which will provide additional compensation and
staffing flexibilities, thereby relieving some of the current
challenges with attracting highly qualified candidates to serve in
these leadership roles. Support of this proposal would be more
beneficial to VA and ultimate resolution of the current staffing
challenges rather than what is proposed in H.R. 3956.
Draft Bill: To direct the Secretary of Veterans Affairs to
establish a list of drugs that require an increased level of informed
consent
The draft bill would add new section 7335 to Title 38, U.S.C., to
require VA to establish, within VHA's Office of Specialty Care
Services, a panel to create and maintain a list of drugs (including
psychotropic drugs) that may only be furnished with the ``increased
informed consent'' of the patient or, in appropriate cases, a
representative thereof. Such term would refer to full and informed
consent that provides the patient with a meaningful understanding of
the treatment to be provided based on such consent, an opportunity to
ask questions and receive information regarding such treatment, and is
acknowledged in written form.
The Secretary would be responsible for determining the composition,
membership, and functions of the panel. VA medical professionals who
then prescribe any drug on this list would need to prepare and present
to the patient (or patient representative) a written form that meets a
number of detailed criteria specified in the bill, (e.g., the names of
any drugs being offered to the patient) including any other trade or
the generic name for such drug, each side effect, alternative methods
of treatment or therapy not involving that drug, etc. Before such form
is used, however, the provider, except in emergency situations, would
first need to: (1) ensure that the patient signs an initial form
acknowledging that the patient has received information regarding the
recommended treatment and any other possible treatments; (2) refer the
patient to an appropriate pharmacy of the Department if the patient has
additional questions about the drug in question; and (3) provide the
patient with the opportunity to review the information.
Thereafter, the patient would have the opportunity to sign the form
reflecting the mandated requirements, to call or email the medical
professional to provide consent, or to schedule a follow-up appointment
with the medical professional to discuss the recommended treatment
during the 3-day period beginning on the date on which the patient
requests the appointment. The form would also need to provide for
acknowledgement by the patient that he or she has received the required
information, as described in brief above, and has had adequate time to
understand the information and consider alternative treatments,
including, as appropriate, the opportunity to leave the medical
facility.
VA does not support the draft bill. The terms of 38 U.S.C. Sec.
7331, as implemented by 38 CFR Sec. 17.32, VHA Handbook 1004.01,
Informed Consent for Clinical Treatments and Procedures; VHA Handbook
1004.05, iMedConsent; and VHA Directive 1005, Informed Consent for
Long-Term Opioid Therapy for Pain, already meet the objectives of the
proposed measure and are aligned with professional best practice
standards.
No medical treatment or procedure can be provided in VHA to any
patient without the patient's full and informed consent first having
been obtained and documented. Providers are required to appropriately
document the informed consent in the patients' electronic health
records. In addition, through its implementing regulations and
policies, VA has already identified classes of treatment and procedures
that, because of their inherent risk for significant pain, discomfort,
complication, or morbidity, require signed informed consent, that is, a
patient's (or surrogate's) and practitioner's signature on a VA-
authorized consent form. These forms are developed by an established
clinical expert process to include information about the treatment's
risks, benefits, and alternatives at the appropriate reading level for
the VA population. VA also provides written information about
prescribed drugs each time the drug is dispensed to the patient. VA
care is Veteran-centered, and the discussions described in the bill are
already available to our patients.
Experts in law, ethics, and clinical implementation of informed
consent in VA have also implemented appropriate means for seeking and
documenting informed consent by patients and surrogates, including
situations where the individual providing consent on behalf of the
patient is not physically present, for example mechanisms for
asynchronous signature. However, VA does not allow signed consent forms
to be transmitted through commercial e-mail services. Until secure
email is available, this prohibition in policy helps to ensure patient
privacy and the security of patient information, and it also ensures
the authenticity of the signed informed consent form confirming the
identity of the sender.
The steps described in the proposed measure could significantly
impede VA's ability to provide prompt care. The proposed legislation
would add an undue time burden on Veterans and their care providers, by
introducing unnecessary steps and delays in what is standard informed
consent practice for high-risk medications. Of particular concern, the
bill would apply the ``increased informed consent'' requirements to
involuntarily committed inpatients in need of psychotropic drugs
(because they have been found by the appropriate officials to be a
danger to themselves or others). VA regulation and policy currently
afford due process protections in these situations, while balancing the
need for prompt medical intervention as defined by generally accepted
standards of medical practice. Waiting on the completion of all the
actions required by ``increased informed consent'' could well result in
these clinical cases becoming exacerbated, with greater safety risks
being posed, as a result, to the patients themselves, their surrogates,
other patients, and/or VA staff.
Finally, it is unclear what problem this draft legislation purports
to correct or remedy. For this reason, we request the Committee forbear
in its consideration of this draft bill until we have a chance to meet
with the Committee to ascertain the Members' concerns and together
consider less formal and more flexible ways of satisfactorily
addressing them.
Mr. Chairman, this concludes my statement. Thank you for the
opportunity to appear before you today. We would be pleased to respond
to questions you or other Members may have.
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Statements For The Record
THE AMERICAN LEGION
Chairman Benishek, Ranking Member Brownley, and distinguished
members of the Subcommittee on Health, on behalf of National Commander
Dale Barnett and The American Legion; the country's largest patriotic
wartime service organization for veterans, comprising over 2 million
members and serving every man and woman who has worn the uniform for
this country; we thank you for the opportunity to testify regarding The
American Legion's position on the pending and draft legislation.
H.R.2460
To amend title 38, United States Code, to improve the provision of
adult day health care services for veterans.
State Veterans Homes are facilities that provide nursing home and
domiciliary care. They are owned, operated and managed by state
governments. They date back to the post-Civil War era when many states
created them to provide shelter to homeless and disabled veterans.
Currently, there are only two Adult Day Health Care programs at State
Veterans Homes in the United States. Both are located on Long Island,
New York. However, these programs could easily be offered at the other
151 State Veterans Homes located throughout the country.
H.R. 2460 would provide no cost medical model Adult Day Health Care
at State Veterans Homes who are 70% or more service-connected. This
bill is an extension of Public Law (P.L.) 109-461, Veterans Benefits
Health Care, and Information Technology Act of 2006, which currently
provides no cost nursing home care at any State Veterans Home to
veterans who are 70% or more for their service-connected disability and
who require significant assistance from others to carry out daily
tasks.
VA pays State Veterans Homes a per diem that covers merely one-
third of the cost of providing this service. This bill will expand
disabled veterans' access to services such as Adult Day Health Care; a
daily program for disabled veterans who need extra assistance and
special attention in their day to day lives.
Resolution Number 21 entitled State Veteran Home Per Diem
Reimbursement supports an increase in the per-diem rates for veterans
in need of such care that State Veterans Homes provide. \1\
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\1\ American legion Resolution No. 21 (Aug 2014): State Veteran
Home Per Diem Reimbursement
The American Legion Supports H.R. 2460.
H.R. 3956: VA Health Center Management Stability and Improvement Act
To direct the Secretary of Veterans Affairs to develop and
implement a plan to hire directors of the medical centers of the
Department of Veterans Affairs.
For years, The American Legion has consistently been concerned with
the Department of Veterans Affairs (VA) leadership, physicians, and
medical specialist staffing shortages within the Veterans Health
Administration. Since, the inception of The American Legion's System
Worth Saving (SWS) Program in 2003, we have tracked and reported
staffing shortages at every VA medical facility across the country. The
American Legion's SWS 2014 executive summary found that several VA
medical centers continue to struggle to fill critical leadership
positions across multiple departments resulting in communication
breakdowns between medical center leadership and staff that work at the
medical center.
This bill would address the growing problems of VA medical centers
operating without permanent directors creating an instability that puts
the care of those who have served at risk. The VA Health Center
Management Stability and Improvement Act would require the Secretary of
VA to develop and implement a plan to hire directors of the medical
centers of the VA who are under temporary leadership. No later than 120
days after the date of the enactment of this Act, the Secretary of VA
shall develop and implement a plan to hire highly qualified directors
for each medical center of the VA that lacks a permanent director. The
Secretary shall prioritize the hiring of such directors for the medical
centers that have not had a permanent director for the longest periods
of time.
The American Legion supports legislation addressing the recruitment
and retention challenges faced by the Department of Veterans Affairs
(VA) and encourage VHA to develop and implement staffing models for
critical need occupations. \2\
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\2\ American Legion Resolution No. 101 (Sept. 2015): Department of
Veterans Affairs Recruitment & Retention
The American Legion supports H.R. 3956.
H.R. 3974: Grow Our Own Directive: Physician Assistant Employment and
Education Act of 2015
To require the Secretary of Veterans Affairs to carry out a pilot
program to provide educational assistance to certain former members of
the Armed Forces for education and training as physician assistants of
the Department of Veterans Affairs, to establish pay grades and require
competitive pay for physician assistants of the Department, and for
other purposes.
This bill directs the Department of Veterans Affairs (VA) to carry
out the Grow Our Own Directive (G.O.O.D.) pilot program that is
designed to create a pathway for veterans who want to go to school to
become a physician assistant in exchange for a three-year commitment to
work within the VA healthcare system. H.R. 3974 proposes to reduce wait
times at VA medical centers, while increasing the supply of physician's
assistants within the VA healthcare system for the purpose of treating
veterans.
The American Legion endorses the Grow Our Own Directive (GOOD):
Physician Assistant Employment and Education Act of 2015 for the
following reasons:
Enhances opportunities for veterans seeking employment
within the healthcare field - these are Careers, not jobs, which equal
quality pay and benefits, along with mobility;
Addresses employment issues for underserved areas. VA has
been in dire need of these type of positions for rural and other
underserved areas;
Assists veterans who have experience in the healthcare
field with education costs, which reduces debt and other financial
barriers for gainful employment within this high growth industry; and
Ultimately, this pilot program gives the VA a chance to
properly fill these positions in order to fully maximize the veteran's
experience, while providing excellent care at the Veterans Affairs
Medical Centers (VAMCs) or other VA healthcare facilities.
The American Legion supports legislative and administrative
measures that seek to encourage and recognize organizations that hire
veterans, particular the Department of Veterans Affairs. \3\
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\3\ American Legion Resolution No. 95 (Sept. 2015): Support
Employment of Veterans in the Public and Private Workforce
The American Legion supports H.R. 3974.
H.R. 3989: Support Our Military Caregivers Act
To amend title 38, United States Code, to improve the process for
determining the eligibility of caregivers of veterans to certain
benefits administered by the Secretary of Veterans Affairs.
A caregiver is an unpaid or paid person who helps another
individual with an impairment with his or her activities of daily
living. Any person with a health impairment might use caregiving
services to address their difficulties. A military caregiver is a
family member, friend, or acquaintance who provides a broad range of
care and assistance for, or manages the care of, a current or former
military servicemember with a disabling physical or mental injury or
illness.
Typical duties of a caregiver might include taking care of someone
who has a chronic illness or disease; managing medications or talking
to doctors and nurses on someone's behalf; helping to bathe or dress
someone who is frail or disabled; or taking care of household chores,
meals, or bills for someone who cannot do these things alone.
The Support Our Military Caregivers Act, would reform the current
VA's Caregiver Program to help better assist family members who are
caring for seriously wounded veterans. The VA's Caregiver Program is
currently experiencing delays in the approval process for family
members to receive this benefit. This bill would establish an external
clinical review process that would allow for the review of the veterans
applications or when the application for caregiver benefits is denied,
allowing for an independent contractor to review the case.
The American Legion does not have an official position on H.R.
3989, and are unable to comment at this time.
Discussion Draft
To direct the Secretary of Veterans Affairs to ensure that each
medical facility of the Department of Veterans Affairs complies with
requirements relating to scheduling veterans for health care
appointments, to improve the uniform application of directives of the
Department, and for other purposes.
This draft legislation as written, requires that the director of
each VA health care facility annually certifies to the Secretary that
their medical facility is in full compliance with all provisions of the
law and regulations relating to scheduling appointments for veterans to
receive hospital care and medical services that are listed under
Veterans Health Administration Directive 2010-027, entitled VHA
Outpatient Scheduling Processes and Procedures, or any successor
directive.
The Secretary of VA on a yearly basis will report to both the House
Veterans Affairs' Committee (HVAC) and the Senate Veterans' Affairs
Committee (SVAC) with a list of medical centers that have certified
compliance and a list of facilities that are not in compliance and to
provide an explanation of why those facilities did not meet the
requirements set forth within the VHA Outpatient Scheduling Processes
and Procedures directive.
Requiring VA to adhere to the law, regulations and VA policies
governing scheduling is common sense. However, this bill fails to spell
out any consequences if VA medical center directors fail to comply with
the proposed legislation.
The American Legion would only support this draft legislation if it
includes an accountability statement holding medical center and
Veterans Integrated Service Network (VISN) directors accountable when
they have failed to comply with the intent of the discussion draft.
Discussion Draft
To amend title 38, United States Code, to direct the Secretary of
Veterans Affairs to establish a list of drugs that require an increased
level of informed consent.
Informed consent is a process for getting permission before
conducting a healthcare intervention on a person. A health care
provider may ask a patient to consent to receive therapy before
providing it, or a clinical researcher may ask a research participant
before enrolling that person into a clinical trial.
This discussion draft, as written, directs the Secretary of VA to
establish a list of drugs that require an increased level of informed
consent. This bill would require the Secretary of VA to establish
within the Office of Specialty Care Service of the Veterans Health
Administration a panel to establish and maintain a list of drugs,
including psychotropic drugs that may only be furnished under this
title to a patient with increased informed consent of the patient or,
in appropriate cases, a representative thereof.
Informed Consent has either become non-existent or hurried by
health care providers. It is standard medical procedure to ensure that
our veterans are fully informed of the side effects and other
liabilities of drugs they are administered prior to their
administration. As part of the Informed Consent process, doctors should
be required to provide a list of alternative treatments and therapies
to the veterans they serve. When providers utilize informed consent,
veterans and their families can make informed decisions of what is in
their best interest. Finally, this process needs to be a deliberative
process, where the understanding of the veteran is consulted and is
assured.
The American Legion calls for Congress to exercise oversight over
DOD/VA to ensure servicemembers and veterans are only prescribed
evidence-based treatments for TBI/PTSD and not prescribed off-label and
non-Federal Drug Administration approved medications or treatments for
TBI/PTSD. \4\
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\4\ The American Legion Resolution 292 (Aug. 2014): Traumatic Brain
and Post Traumatic Stress Disorder Programs
The American Legion supports the discussion draft.
Conclusion
As always, The American Legion thanks this subcommittee for the
opportunity to explain the position of the over 2 million veteran
members of this organization. Questions concerning this testimony can
be directed to Warren J. Goldstein in The American Legion's Legislative
Division at (202) 861-2700 or [email protected].
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AMERICAN PSYCHIATRIC ASSOCIATION
The American Psychiatric Association (APA), the national medical
specialty society representing over 36,500 psychiatric physicians and
their patients, is pleased to submit this statement for the
Subcommittee's hearing that includes legislation designed to establish
an informed consent protocol within the Department of Veterans Affairs
(VA), as part of an effort to improve the overall clinical care of our
nation's veterans.
Nearly two years after the incident surrounding delayed access to
mental health services at the Veterans Health Administration (VHA), the
matter of ensuring that veterans receive quality and timely care has
been a priority for our nation. These issues are receiving considerable
attention from Congress, and the APA is hopeful that attention will be
translated into action. Towards that end, APA thanks Subcommittee
Chairman Benishek and Ranking Member Brownley for holding this hearing.
United States veterans are a multifaceted population requiring a
culturally competent approach to medical treatment and care. Veterans
experience mental health disorders, substance use disorders, post-
traumatic stress, and traumatic brain injury at disproportionate rates
compared to their civilian counterparts. Often in combination with
military-related diseases, many veterans develop substance use
disorders and a large number ultimately complete suicide. Approximately
1.9 million OEF/OIF/OND veterans have become eligible for VHA health
care services since 2002. \1\ While a relatively small percentage of
veterans utilize the health care services offered, the VHA has seen a
63 percent increase in the number of veterans receiving mental health
care between 2005 and 2013. As of March 2015, 57.6% (685,540) of the
veterans seeking care at VHA facilities received at least one
provisional mental health diagnosis, with the most common conditions
being post-traumatic stress disorder, depressive disorders, and other
anxiety disorders. \2\ Through the expansion of the Choice Program
under the Veterans Access, Choice, and Accountability Act of 2014, the
VA anticipates the number of veterans seeking mental health services to
rise.
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\1\ U.S. Department of Veterans Affairs. VHA Office of Public
Health. Analysis of VA Health Care Utilization among Operation Enduring
Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn
(OND) Veterans. Sept. 2015.
\2\ U.S. Department of Veterans Affairs. Office of Informatics &
Analytics. VA Mental Health Services Public Report. Nov. 2014.
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The VHA operates the nation's largest integrated health care
delivery system, providing care to nearly 6 million veteran patients,
and employing more than 270,000 full-time staff. In 2015 the Government
Accountability Office audited the VHA, and identified two key barriers
to accessing quality and timely care: 1) the lack of scheduled medical
appointment slots, and; 2) the acute shortage of physicians. Health
care professionals play a central role in ensuring the well-being of
our nation's veterans. The providers working with the veteran
population must be able to address the patient's particular physical
and mental health demands. Physicians, in particular, play a critical
role to this distinct population in providing quality care by engaging
the patient, being aware of the patients' military history, and
recognizing risk factors.
With respect to the vital function of medical professionals at VHA,
APA would like to convey a number of items that inadvertently create
barriers to accessing mental health services and ensuring high quality
care. The APA stands ready to assist the Subcommittee in advancing
legislation that improves the overall care our veterans receive, and we
ask that the Subcommittee take the following items under close
consideration.
The APA believes that any legislative initiative should not
segregate mental health from other medical care, such as segregating
psychotropic medications as posing certain risks. Psychotropic
medications are in a class of pharmaceuticals along with other classes
of medications that contain potential adverse effects, including
cardiac, hematologic, oncologic, rheumatologic, steroids, as well as
most commonly prescribed antibiotics. The APA believes that all
providers should have an open dialogue and participate in shared
decision making with patients about any pharmacological treatment that
may have potential adverse effects to their lifestyle.
The APA understands that the Subcommittee is entertaining the
possibility of requiring a physician-patient dialogue concerning the
warnings associated with psychotropic medications. The vast increase in
the number of new psychopharmacologic agents over the last 20 years has
made more therapeutic options available, but has also made treating
patients more complicated. Prescribing practices, inclusive of the
concurrent administration of a variety of psychotropic medications,
have made the awareness of pharmaceutical interactions key for meeting
the treatment needs of each individual patients. To date, the Food and
Drug Administration has few indications on combination use with
psychotropic drugs. To engage in a physician-patient discussion as
entertained by the Subcommittee, the APA believes that the FDA must
provide comprehensive data that would allow for informed decisions on
complex treatment.
Frequently, veterans will utilize primary care office visits to
seek care for mental disorders. In these incidents, antidepressants are
more often prescribed by primary care providers than psychiatric
physicians. Any additional steps for increased informed consent may
unintentionally reduce a primary care provider's receptivity to
prescribe psychotropic drugs. Regrettably, the patient will likely not
receive the medical treatment needed to aid in their mental wellness.
The APA understands that the Subcommittee is entertaining a new way
of measuring standards of care for informed consent for psychotropic
drugs. Providers who do not comply with completing the required steps
of increased inform consent would be vulnerable to a claim of
negligence against them. The APA recommends establishing guidelines
that would safeguard providers.
The military culture promotes inner strength and self-reliance,
contributing heavily to a stigma associated with mental disorders and
to seeking treatment. Where stigma creates barriers to care, the
additional measures required may generate unintended consequence of
over emphasizing risks to an extent that some patients would view
psychotropic drugs as more dangerous and decide not to take them.
The Veterans Health Administration has multiple clinical practice
guidelines and evidence-based tools to assist clinicians in identifying
risk factors and measures to improve health outcomes. Physician and
patient dialogue is a significant element in a patient's treatment,
providing a platform for an informed discussion. The practice of
medicine is a serious responsibility that encompasses providing a
comprehensive understanding of treatment to the patient. The APA
concurs a physician-patient dialogue may positively impact the decision
of the patient's treatment. The APA asks that all classes of
medications that pose adverse effects be included in the process of
increased informed consent. This would eliminate an inherently
discriminatory approach to mental health treatment, and further
encourage a stigma associated behavior towards mental health services.
Thank you again for the opportunity to offer our expertise on the
consideration of establishing an increased level of informed consent
for the record. We look forward to continuing our work with members of
the Subcommittee. If you have any questions, or if we can be of further
assistance, please contact Jeffrey P. Regan, Chief of Department of
Government Relations at [email protected].
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EASTER SEALS
WRITTEN STATEMENT OF KATY NEAS, EXUCUTIVE VICE PRESIDENT FOR PUBLIC
AFFAIRS
Dear Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee:
Thank you for holding this hearing on proposed legislation to
improve Veterans' access to health care and other benefits administered
by the U.S. Department of Veterans Affairs (VA). Easter Seals
especially applauds the Subcommittee's focus on adult day health care
(ADHC) and how this community-based service can improve a Veteran's
health and well-being while also meeting the Veteran's goal of
remaining at home and in their community.
Easter Seals is changing the way the world defines and views
disabilities by making profound, positive differences in people's lives
every day. Through a network of 74-community-based affiliates, Easter
Seals is a leading nonprofit provider that assists Veterans, military
families, and others to reach their potential and succeed in their
communities by providing and connecting them to local services and
supports. Founded in 1919, Easter Seals began serving Veterans after
World War II to help address the unmet needs of service members
returning home with service-connected disabilities. Through our
national network and Easter Seals Dixon Center for Military and
Veterans Services, Easter Seals continues to fill the gap between the
services Veterans need and the services currently available through
government or other entities. Adult day health care is one of the
community-based services that Easter Seals offers through more than 50
programs in 14 states. Through the program, Easter Seals affiliates
offer a menu of person-directed care and social and recreational
activities to older adults, including Veterans, and individuals with
disabilities. Easter Seals partners with the VA at the local level and
nationally as the contractor to develop and administer the National
Veteran Caregiver Training Program, which falls under the jurisdiction
of this Subcommittee. Easter Seals is proud of its record and service
for and on behalf of America's Veterans and their families.
It is because of our long-term care expertise and Veterans'
experience that we lend our support for the twin goals behind H.R.
2460: to expand local adult day health care options for eligible
Veterans and to ensure the VA's reimbursement rate better reflects the
true cost and Veteran need of skilled adult day health care.
Expansion of Local Adult Day Health Care Options:
The VA described ADHC as ``a key component in the continuum of
long-term care'' that helps Veterans remain in their homes and provides
needed care in the ``least restrictive environment that is safe for
Veterans.'' \1\ The VA also noted that non-institutional extended care
programs, such as adult day health care, have resulted in substantial
reductions in nursing home placement, facilitates greater independence,
and promotes enhanced quality of life for Veterans receiving the
service. \2\ With the passage of the Veterans Millennium Healthcare and
Benefits Act of 1999 (P.L. 106-117), Congress recognized the importance
of adult day services for Veterans and authorized the VA to furnish
ADHC to Veterans who would otherwise require nursing home care. The VA
can provide ADHS directly or by contracting with State Veterans Homes
or community organizations ``through non-VA care mechanisms such as
sharing agreements, national or local contracts, and individual
authorizations to the extent that the Veteran is eligible.'' Some
Easter Seals affiliates currently contract with the VA to provide ADHC
for Veterans living in their communities.
---------------------------------------------------------------------------
\1\ Adult Day Health Care, VHA Handbook 1141.03, September 29,
2009, http://www.va.gov/vhapublications/ViewPublication.asp?pub--
ID=2086
\2\ Uniform Geriatrics and Extended Care Services in VA Medical
Centers and Clinics, VHA Handbook 1140.11, November 4, 2015, http://
www.va.gov/vhapublications/ViewPublication.asp?pub--ID=2086
---------------------------------------------------------------------------
H.R. 2460 would expand community-based options by directing the VA
Secretary to partner with State Veteran Homes in each state to pay for
adult day health care for a Veteran eligible for, but not receiving,
nursing home care. While the VA is currently authorized to pay for ADHC
at State Veterans Homes (SVH), only two of the 153 SVH currently offer
ADHC at its facilities. \3\ Easter Seals supports efforts to expand
long-term care options, including adult day health care, for eligible
Veterans. Easter Seals believes the most effective approach in meeting
the needs of eligible Veterans is to utilize the existing national
network of more than 5,000 community-based adult day centers, \4\ which
can include new and existing State Veteran Homes. This recommendation
also recognizes the limited coverage of the 153 State Veteran Homes.
Fourteen states, including large geographic states such as North Dakota
and Alaska, are served by a single SVH. \5\ Expansion of ADHC in State
Veteran Homes alone would not meet the needs of all eligible Veterans
in a state. For example, there is a SVH in Marquette, Michigan, which
is located in the Chairman's 1st Congressional District. However, the
Marquette SVH is more than 4 hours from Alpena, Michigan, also in the
Chairman's District. Michigan's only other SVH is located in Grand
Rapids, also several hours away from Alpena. So while SVH expansion
would benefit some Veterans it would not make sense for all eligible
Veterans looking for ADHC.
---------------------------------------------------------------------------
\3\ Caring for our Disabled Veterans Op-ed, Congressman Lee Zeldin,
April 4, 2016, https://zeldin.house.gov/media-center/press-releases/
caring-our-disabled-veterans-fight-expand-adult-day-care
\4\ National Adult Day Services Association, Research, http://
www.nadsa.org/research/
\5\ National Association of State Veteran Homes, Directory of State
Homes, http://www.nasvh.org/StateHomes/statedir.cfm
Easter Seals Recommendation: As H.R. 2460 advances, Easter Seals
encourages the Subcommittee to add ``or eligible non-Department
extended care providers'' after every ``State home'' reference in the
bill to ensure that other non-VA providers are included in the bill's
---------------------------------------------------------------------------
other improvements.
Support for Adult Day Health Care Reimbursement That Reflects Costs:
Easter Seals fully supports H.R. 2460's effort to ensure that the
VA's reimbursement rate for ADHC better reflects the true costs
associated with providing this highly skilled service. Specialized
adult day health care available through community providers could cost
approximately $90 per day or more, which is significantly less than the
estimated $250 per day associated with nursing home care. Current VA
reimbursement for ADHC is under $75 per day, which does not meet
current costs.
H.R. 2460 would tie the VA's adult day health care reimbursement
rate to 65 percent of the payment the VA pays for State home nursing
home care, a provision that Easter Seals strongly supports. In
addition, the VA typically only authorizes up to two days of adult day
health care despite the fact that some Veterans require additional
care. For example, Easter Seals Serving DC, MD, VA provides adult day
health care for about 30 Veterans through its Baltimore program. Some
of the Baltimore-area Veterans that are covered through the VA's ADHC
program require more than the two days that the VA currently covers.
These Veterans are paying out-of-pocket for the remaining days.
Easter Seals Recommendation: Easter Seals applauds efforts to more
accurately reflect the cost of adult day health care and urges the
Subcommittee to maintain the 65 percent rate provision. In addition,
Easter Seals asks the Subcommittee to include report language urging
the VA to increase the number of days a Veteran can receive VA-
reimbursed ADHC, as long as the Veteran requires the additional care
and is already eligible for the more comprehensive nursing home care.
Adult day health care is a critical long-term, extended care
support that should be available to all eligible Veterans, no matter
where they live. H.R. 2460 makes significant improvements to the
provision of ADHC service at the VA. Easter Seals urges the
Subcommittee to advance this important legislation with our recommended
changes to ensure Veterans can maintain their health and independence
by staying in their home and community through adult day health care.
Thank you for the opportunity to share Easter Seals' views with the
Subcommittee.
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NATIONAL ASSOCIATION OF MENTAL ILLNESS
STATEMENT OF MARY GILIBERTI, CHIEF EXECUTIVE OFFICER
Chairman Benishek and members of the Subcommittee, I am Mary
Giliberti, Chief Executive Officer of NAMI (the National Alliance on
Mental Illness). I am pleased to offer NAMI's views on the draft bill
before the Subcommittee directing the Secretary to establish a list of
drugs that would require a new set of informed consent protocols.
NAMI is the nation's largest grassroots advocacy organization
dedicated to building better lives for the millions of Americans
affected by mental illness. NAMI State Organizations and over 900 NAMI
Affiliates across the country raise awareness and provide support,
education and advocacy on behalf of people living with mental health
conditions and their families.
Through our NAMI Veterans and Military Council, our state and local
NAMI organizations are engaged with VA Medical Centers in working with
veterans and their families. The VA recently renewed a Memorandum of
Understanding (MOU) with NAMI that allows us to continue to offer
NAMI's ``Family-to-Family'' and ``Homefront'' classes to veterans and
their families.
NAMI would like to thank the Subcommittee on the important
bipartisan work it has done in recent years to improve treatment and
services for veterans living with mental health conditions. While
enormous challenges still confront the VA in lowering wait times and
expanding access to evidence-based practices such as Assertive
Community Treatment (ACT) and crisis intervention, progress has been
made in reaching veterans earlier. We encourage the Subcommittee to
build on these accomplishments by continuing its oversight activities
and supporting investments in evidence-based practices for treatment
and services for mental illness.
NAMI, however, would like to raise a number of concerns regarding
the draft bill before the Subcommittee.
1)The proposal unfairly singles out mental health conditions and
the medications used to treat them as part of a new mandatory protocol
that stigmatizes both these disorders and their treatment - NAMI
believes that this proposal sets forth a dangerous precedent by
singling out a category of medications, ``psychotropic drugs''
(referenced in Section 7335), as part of a separate informed consent
protocol. While NAMI supports the goal of improving clinical care in
the VA through appropriate informed consent, any new requirement
designed to achieve this laudable goal should apply across all
therapeutic areas: orthopedics, endocrinology, pulmonary medicine,
neurology, nephrology, etc. Mental health medications should NOT be
singled out in federal policy for different or separate treatment
protocols.
2)The proposed mandatory informed consent requirement has enormous
potential to limit access to psychiatric treatment in the VA - NAMI is
extremely concerned that this mandatory, inflexible informed consent
protocol would serve as a significant barrier to veterans engaging in
needed mental health treatment. Forcing clinicians to go through a
multi-step mandatory checklist which, as currently drafted in this
legislation, informs a veteran only about negative risks is exactly the
wrong way to engage individuals in treatment. Effective practice
dictates that engagement in mental health treatment needs to be done
carefully and on the patient's terms. Imposing a government-mandated
protocol would be enormously disruptive to the process of engagement.
3)The proposed requirements in the draft legislation for disclosure
contain a number of inaccurate statements regarding the FDA market
approval process and authority over labeling of products - Page 5, line
4 of the draft legislation requires prescribers to state that ``the FDA
has not approved any psychiatric drugs to be used in combination with
other psychiatric drugs.'' In fact, the FDA never approves medications
to be used in combination with other therapies. Instead, in the pre-
market approval process, the FDA reviews data from randomized
controlled trials submitted by sponsors to ensure safety and efficacy
of individual products. Further, page 4, line 15 of the current draft
sets forth a requirement for the disclosure of ``unknown dangers of
mixing drugs and dosages in sizes and combinations that have not been
approved or tested by the FDA.'' NAMI is concerned about any
requirement dictating that prescribing physicians talk to their
patients about ``unknown dangers.'' Instead, NAMI feels strongly that
physicians should be guided by evidence-based practice and peer
reviewed treatment guidelines to tailor treatment and services to the
unique person they are working with.
4)Use of the term ``psychotropic'' medications in the draft
legislation lacks precision - It is unclear from the text of the
legislation what the term ``psychotropic medications'' actually means.
In fact, there are a broad range of therapeutic classes that are
utilized for on-label treatment for mental health conditions. These
include antipsychotics, antidepressants, anticonvulsants,
benzodiazepines and others. Within these therapeutic classes, there are
many other conditions for which there are FDA on-label indications.
Does the legislation intend to apply these new disclosure mandates on
this broad range of disorders and indications?
5)Discussion of alternative treatment should be grounded in
evidence-based services - NAMI supports physicians discussing with
their patients the broad range of available therapies and options
throughout the course of treatment. This is especially important with
mental health conditions where individuals often experience periodic
acute episodes of symptoms such as mania, psychosis or suicidal
ideation. However, in discussing therapeutic interventions and
alternative therapies, it is critical that the options being discussed
be limited to and grounded in evidence-based practice. Physicians in
the VA, and any other health care setting, should not be forced to
disclose treatment options for which there is no scientific basis for
safety and efficacy.
Better Education and Training of Prescribing Physicians in the VA Will
Improve Care
NAMI supports the goal of this draft legislation in promoting
enhanced communication to veterans about diagnosis, treatment, outcomes
and alternatives. A mandatory, inflexible informed consent protocol
will not achieve this common goal. In order to achieve the goal of
better-informed and engaged patients in the VA, Congress should require
the VHA to develop training and consultation programs that promote
communication and engagement with individual patients. Such a training
program should apply across all areas of clinical practice in the VA,
not just the prescribing of medications to treat mental health
conditions.
As an organization that embraces veterans living with mental
illness, NAMI is eager to assist the VA in developing a program of best
practices for patient engagement. This would include developing a
curriculum for primary care physicians and specialists in internal
medicine as these clinicians write the majority of prescriptions for
psychotropic medications in the VA.
Despite the progress that has been made in recent decades, there is
still stigma associated with mental health conditions. Particularly
among veterans, there is often reluctance to acknowledge symptoms such
as depression, anxiety, mania and delusional thoughts associated with
conditions such as schizophrenia, bipolar disorder, depression and
PTSD. Engaging veterans in treatment is a careful and nuanced process,
one that can only occur effectively on the individual veteran's terms.
A mandatory, inflexible informed consent protocol will not achieve this
goal. Education and training of prescribing physicians is the answer.
This Subcommittee has made significant progress in expanding access
to mental health care in the VA. This record of accomplishment can be
improved through training and education, not new government-mandated
protocols that interfere with engagement and treatment.
Thank you for the opportunity to offer NAMI's views on this
legislation.
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VETERANS AFFAIRS PHYSICIAN ASSISTANT ASSOCIATION
President VAPAA
Rubina DaSilva PA-C
Chairman Benishek, Ranking member Brownley, and other members of
the House Veterans Affairs Subcommittee on Health, on behalf of the
entire membership of the Veterans Affairs Physician Assistant
Association (VAPAA) we appreciate the invitation to submit this
testimony for the record. We thank members of this committee for
critical, bipartisan legislation on Physician Assistant (PA) Workforce
issues in the VA.We are very appreciative of H.R. 3974, The `Grow Our
Own Directive: Physician Assistant Employment and Education Act of
2015,'' ) and we thank Congresswoman Ann Kuster for her leadership on
this bill.
As committee members are aware, Public Law 113-146, the Veterans
Access, Choice, and Accountability Act of 2014, directs the Secretary,
under the VA's Health Professionals Education Assistance program, to
give scholarship priority to applicants pursing education or training
towards a career in a health care occupation that represents one of the
five largest staffing shortages. However, despite the PA profession
being ranked on 1/2015 and 9/2015 as 3rd and 4th on the OIG
Determination of Veterans Health Administration's Occupational Staffing
Shortages, the VHA has not created a dedicated PA scholarship program
for any prospective students wishing to become a PA.
When congressional leaders ask VHA about the availability of
scholarship money for PA scholarships; Healthcare Talent Management
(HTM) will state that scholarship money for PA students is available
through the Employee Incentive Scholarship Program (EISP).
Unfortunately, despite this assertion, the VAPAA has found that these
programs are not applied for PA recruiting scholarships or educational
support.'
For Example:
Congressional Question: What is the amount of scholarship monies
that is currently available for Intermediate Care Technicians (ICT)?
VHA Response: The annual budgets for the following two Health
Talent Management programs for which all VA staff including Physician
Assistants (PA) and ICTs can apply are the following:
The Employee Incentive Scholarship Program (EISP) -
$2,000,000 (Provides educational funding, i.e., tuition, books, fees)
The VA National Education for Employees Program (VANEEP)
- $14,573,000 (Provides educational funding and replacement salary
A report from the Government Accountability Office in September
2015, shows that EISP has allocated from FY 2010 through FY 2014 -
$128,832,503.00 in funding for nursing and $11,842,919.00 in support of
NPs and NP programs, with only $319,074.00 for PAs. Only 6 employees
received scholarships to become PAs and 40 PAs who were mastered
prepared but received a bachelor's degree, completed additional course
work to earn their Master's degree from University of Nebraska bridge
program.
As of April 20, 2016, it appears that VHA is in violation of Public
Law 113-146 as VHA has not created a scholarship program or given
scholarship priority to PAs pursing education or training towards a
career in a health care occupation that represents one of the five
largest staffing shortages.
In fact, the Health Professional Scholarship Program (HPSP) is a
subcomponent of the Health Professionals Educational Assistance Program
(HPEAP). The original authorization for HPSP expired in 1998. On May
10, 2010, Public Law 111-163, Section 603 of The Caregivers and
Veterans Omnibus Health Services Act of 2010, eliminated the 1998
sunset date and re-authorized the use of HPSP through December 14,
2014. The final rule for reinstatement of HPSP was published in the
Federal Register and became effective on September 19, 2013. This
timeframe allowed approximately one year during which the scholarship
program would be operative. On August 7, 2014, as a result of Section
302 of Public Law 113-146, VACAA extended the authorization for HPSP
through December 31, 2019. In accordance with Section 301 of VACAA,
annual HPSP awards will be based on the top five healthcare occupations
for which there are the largest staffing shortages throughout VA.
However, the (Office of Nursing Services) ONS and the Office of
Academic Affiliation (OAA) included HPSP to fund VA Nursing Academic
Partnerships - Graduate Education. 1.2 million dollars in funding
earmarked for this program to pay for Acute Care Nurse Practitioner,
Adult-Gerontology Nurse Practitioner, or Psychiatric Mental Health
Nurse Practitioner. In addition HPSP funding will be used for
appointments to the affiliated School of Nursing to pay for non-VA
staff instead of providing support for our veterans.
To maintain a PA workforce, the VA must invest in its PA workforce.
By FY 2022 48.7% of PAs will be eligible to retire. PAs have a Total
Loss Rate of 10.92% (1.) which is the second highest total loss rate of
any of the Mission Critical Occupation 2015. PAs have 1 year quit rate
of 9.6% and a 5yr quit rate of 32.3%. PAs current vacancy rate is 23%
which is well above the overall VHA vacancy rate of 16%. Despite being
on the Workforce Succession Planning MCO for several years, and being
on the OIG top 5, PAs only netted a mere 129 new PAs for FY 2015.
The PA profession has a unique relationship with veterans. The very
first classes of physician assistants to graduate from PA educational
programs were all former Navy corpsmen and army medics who served in
the Vietnam War and wanted to apply their knowledge and experience in a
civilian role in 1967. Today, there are 210 accredited PA educational
university programs across the United States and approximately 2,020
PAs are employed by the Department of Veterans Affairs (VA), making the
VA the largest single federal employer of PAs. These PAs provide high
quality, cost effective quality health care working in hundreds of VA
medical centers and outpatient clinics, providing medical care to
thousands of veterans each year in their clinics. PAs work in both
ambulatory care clinics, emergency medicine, CBOC's in rural health,
and in wide variety of other medical, mental health, and surgical
subspecialties. \1\ In the VA system about a quarter of all primary
care patients treated are seen by a PA. Approximately 32% of PAs today
employed by VHA are veterans, retired military, or currently serving in
the National Guard and Reserves.
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\1\ Total loss rate Workforce Succession Planning 2016 reported
10.3, however, Workforce Analysis Dashboard 4.11.2016 shows PA total
loss rate at 10.92%
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The Veterans Affairs Physician Assistant Association (VAPAA)
maintains that Physician Assistants are a critical component of
improving VA health-care delivery, and have consistently recommended
that VHA include them in all health-care national strategy staffing
policy plans. However, since January 1993 when VA added the Title 38
GS-13, Chief Grade more than 22 years ago, little else has been done
for this critical workforce and hope that as these committees review
changes to improve access to care for veterans and oversight on VHA
strategy for its healthcare workforce that changes will be included to
address these PA problems.
Continued Delays in Hiring PA Employees
VAPAA has found since last May's HVAC hearing that whenever a PA
employee leaves the VA, VA acknowledges that it can take still six
months to a year to fill one vacant position-assuming a viable pool of
candidates is interested and available. When the VA seeks to replace
health care professionals, VA cannot compete with nimble private health
care systems. The lengthy process VA requires for candidates to receive
employment commitments and boarding continues to hinder the VA ability
to recruit and officially appoint new employees.
Private health care systems can easily fill PA vacancies in a
matter of days or weeks. While PA applicants may have noble intentions
of working for VA and serving veterans, many will forgo what could be a
4 to 6 month long waiting period and pursue timely employment
opportunities elsewhere. For these reasons, we ask Congress to
carefully review VA appointment authorities, internal credentialing
processes, and common human-resources practices to identify ways to
streamline the hiring process. If VA takes months to fill its health
care vacancies with top talent, VA will continue to fail the delivery
of timely, quality care to our nations' veterans.
Members of HVAC and SVAC both introduced bipartisan legislation
last October, providing for specific plans for Grow Our Own, asking
that VA utilizing VHA provisions (Titles III and VIII of the newly
enacted Veterans Access, Choice, and Accountability Act of 2014) to
include the national VHA plans for expanding recruiting for new FTEE PA
positions and for retaining an optimal PA workforce utilizing our
recommendations below.
Department of Veterans Affairs ``Independent Care Technician''
(ICT) Program, One Solution to Support Transitioning Medics and
Corpsmen OIF OEF OND into ``Grow Our Own'' to Physician Assistant
Occupation
VAPAA points to another solution for meeting the healthcare
workforce challenges in a recent pilot program. On October 26, 2011,
the Administration announced its commitment to providing support to
unemployed Post 9/11 combat veterans and it highlighted the PA
profession as a prominent targeted career path for new returning
veterans who had served as medics and corpsmen with combat medical
skills similar to the history of returning Vietnam War veterans with
these skills within the ICT pilot VA program at 19 VA sites. Medics and
corpsmen receive extensive and valuable health care training while on
active duty. They represent a large workforce - 74,000 medics and
corpsmen, including Guard/Reserve, with 10,400 separating (FY 2011).
According to a 2011 Army HR report, more than 20,000 medics were
unemployed. Combat medics were the third largest military specialty
drawing unemployment funds in 2011 from the Army.
Under this initiative, the Administration promoted incentives to
create training, education, and certifications of medic and corpsmen in
need of transitioning of their military medical skills, being hired to
work inside VA emergency departments, and has expanded into primary
care, mental health, and surgery clinic positions.
The VA has an excellent opportunity to facilitate and coordinate
``Grow Our Own'' combat medics, Corpsmen, or Air Force paramedics to
transition to the physician assistant occupation. However the (ICT's)
currently in the Grow Our Own VA program are being frustrated by
statements they should not expect scholarships from VA, and there is
lack of VHA policy language directing VAMC's to ensure educational
support of these combat veteran PA program candidates, assisting them
in admission to accredited PA university Masters programs with targeted
scholarships for PA Education. Ten former OIF OEF combat veterans
already enrolled in University PA program in Tennessee are told they
will not be eligible for scholarships.
VAPAA is concerned over this ICT program that started in 2012 as it
is being reported to be expanding to more full time ICTs. The continued
lack of use of recruitment educational incentives within VHA and having
it left at the discretion of the local hiring facility is setting up
further frustration across the VA system with the lack of VHA
scholarships for the critical PA occupation. The Office of VA
Healthcare Retention and Recruitment and the VAMC's participating in
the pilot ICT program have no dedicated VHA support to transition them
into PAs The barriers to PA recruitment and retention will continue
unless congressional members provide oversight, VHA must ensure that
employee incentive programs, such as the EISP and the VA Employee Debt
Reduction Program are made consistently available to all critical
healthcare workforce PA vacancy announcements and utilized in ICT the
program. VISN and VA medical center directors they must be held
accountable for the failure to utilize these recruiting tools.
The ICT Program establishment and expansion was authorized by the
Under Secretary of the VA in March 2015. The program expansion will
increase ICTs in the VA from the original 45 by hiring 234 more ICTs.
Hiring the additional 234 ICTs has been left to the discretion of the
Facility Directors of individual VAMC's.
Between March 2015 when the ICT expansion was approved and March
2016, less than 6 of the additional 234 ICTs have actually been hired
by the VA. So VHA was supposed to develop a national VA veteran
employment program targeting OIF OEF combat medics and corpsmen but it
is being managed by local VAMCs with little oversight from VHA or VISN
Directors.
Critical Workforce Occupations:
VA's mission statement for human resources is to recruit, develop,
and retain a competent, committed, and diverse workforce that provides
high quality service to veterans and their families. VA identifies
specific occupations as ``critical occupations'' based on the degree of
need and the difficulty in recruitment and retention. There are 3 types
of primary care clinical providers within the VA that provide direct
patient care - Physicians, Physician Assistants and Nurse
Practitioners. Physicians have mandated yearly market pay survey. Nurse
Practitioners, by virtue of being a nurse, are under the mandated
yearly RN LPS.
PAs in a few facilities fall under Special Salary Rates; however,
this is NOT mandated yearly. Some facilities have not performed a
special salary survey for 11 years, resulting in the reporting in the
VISN 2014-15 Workforce Succession Plan - 12 out of the 21 VISNs (88 VA
main facilities) reported the reason that their VISN cannot hire PA's
is because they cannot compete with the private sector pay. VA has
refused to pursue steps to solve the current retention problems for
PA's.
Recommendations: We ask that both committees recognize the need to
invest in the Recruitment and Retention of the PA Workforce in the VA
System by supporting enactment and supported by the veteran service
organizations at the November 18, 2015 hearing on S. 2134 and call
attention the VHA witness Dr. Carolyn McCarthy testified in favor of
this legislation `Grow Our Own Directive: Physician Assistant
Employment and Education Act of 2015.'' (H.R. 3974). Additionally, we
recommend the following--
A.Restructure VHA Handbook 1020 - Employee Incentive Scholarship
Program (EISP).
B.Include PAs at all facility level to reflect Workforce Succession
Planning and the OIG Top 5 as a hard to recruit occupation as this is
the qualifying factor for EISP funding.
C.Include Education Debt Reduction Plan in all PA job postings.
D.Include targeted scholarships for the ICT program OIF OEF Grow
Our Own returning veterans, and mandate VHA shall appoint PA ICT
National director to coordinate the educational assistance necessary
and be liaison with PA university programs.
E.H.R. 3974 would direct new Physician Assistant director position
to work within the National Healthcare Recruiter, Workforce Management
& Consulting VHA Healthcare Recruitment & Marketing Office.
a.This position then can develop targeted recruiting plans with 187
PA programs, working in a way that the local Human Resource Officer
(HRO) often will not; due to lack of staffing.
F.The VA employed PA national Healthcare Recruiter would develop
improvements in finding qualified candidate in a matter of days not
months.
G.VHA must incorporate new PA consultant manager into this National
Healthcare Workforce program office.
H.Health Professional Scholarship Program.-The Health Professional
Scholarship Program (HPSP) provides scholarships to students receiving
education or training in a direct or indirect health care services
discipline. Awards are offered on a competitive basis and are exempt
from Federal taxation. In exchange for the award, scholarship program
participants agree to a service obligation in a VA health care
facility. The Committee continues to support this program and is
concerned that VA is limiting HPSP awards to only nursing students in
fiscal year 2016. The Committee believes strongly that ample resources
exist within the Department to ensure that hard to fill Top 5 OIG
occupations are not excluded from participation. The Committee directs
the VA to report to the Committee on Appropriations of both Houses of
Congress no later than October 30, 2016, each profession that is
eligible to receive the scholarship and any limitation that the
Department is placing on awards
I. Establish PA Pay Grades I-V, to continue be competitive with the
civilian job market
Conclusion:
Chairman Benishek, Ranking member Brownley, and other members of
the HVAC Subcommittee on Health; as you strive to ensure that all
veterans receive timely access to quality healthcare and as you build
increased capacity for delivery of accessible high quality health care,
and demand more accountability into the VA health care system, I
strongly urge the full Committee to review the important critical role
of the PA profession and to ensure legislatively that VHA takes
immediate steps to address these longstanding problems and continue to
work with us in supporting our Nation's veterans.
DISCLOSURE OF FEDERAL GRANTS OR CONTRACTS
Veterans Affairs Physician Assistant Association
The Veterans Affairs Physician Assistant Association (VAPAA) does
not currently receive any money from a federal contract or grants.
During the past six years, VAPAA has not entered into any federal
contracts or grants for any federal services or governmental programs.
VAPAA is a 501c (3) nonprofit membership organization.
--------
VETERANS OF FOREIGN WARS OF THE UNITED STATES
STATEMENT OF CARLOS FUENTES, SENIOR LEGISLATIVE ASSOCIATE
NATIONAL LEGISLATIVE SERVICE
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the men and women of the Veterans of Foreign Wars of
the United States (VFW) and our Auxiliaries, thank you for the
opportunity to offer our thoughts on today's pending legislation.
H.R. 2460, To improve the provision of adult day care services for
veterans
The VFW supports this legislation, which would expand adult day
health care for veterans.
Currently, veterans who are at least 70 percent service connected
are eligible to receive cost free nursing home or domiciliary care at
any of the more than 150 state veterans homes throughout the country.
While nursing home care is a necessity for veterans who can no longer
live in the comfort of their home, the VFW strongly believes veterans
should remain in their homes as long as possible before turning to
inpatient, long term care options. Adult day care is vital to ensuring
such veterans are able to remain in their homes as long as possible.
However, veterans who are eligible for cost-free nursing home care
at state veterans homes are largely denied the option to receive cost-
free adult day care services at these facilities. Due to VA's delay in
publishing regulations for adult day care, only three state veterans
homes currently provide adult day care services. This legislation would
rightfully ensure VA and state veterans homes have the authority to
provide nursing home eligible veterans the ability to delay
institutional care and remain in their homes with their loved ones.
H.R. 3956, VA Health Center Management Stability and Improvement Act
This legislation would require VA to develop and implement a plan
to hire highly qualified directors for each VA medical center (VAMC).
The VFW agrees with the intent of this legislation and has
recommendations to improve it.
The VFW agrees that VA must urgently address the high volume of
interim and acting directors throughout the VA health care system.
According to recent VA data, more than 20 percent of VAMC and Veterans
Integrated System Network (VISN) director positions are currently
vacant. It is critical for VA to install permanent leadership at its
medical centers to ensure it addresses the access crisis and is able to
restore veterans' faith and confidence in their health care system.
However, the VFW does not believe a plan to hire permanent
directors would be successful if VA is not given the authority to
properly compensate VAMC and VISN directors. Director positions are
difficult to fill because they are responsible for overseeing hundreds
of employees, who deliver care and services to thousands of veterans.
That is why the VFW recommends the Subcommittee authorize market-based
compensation for VA medical directors.
VA must also have the leeway to quickly hire a qualified candidate
when one is identified. The best qualified person for a medical center
position may not be searching for a job on USA Jobs, and if VA
identifies a qualified candidate it should not be required to have that
candidate apply for an opening through USA Jobs. That is why the VFW
urges the Subcommittee to authorize VA to directly hire VAMC and VISN
directors.
Furthermore, VA will not be able to quickly fill vacancies amongst
VAMC and VISN directors if it lacks the human resources staff needed to
identify qualified candidates and process their employment
applications. Recent VA data shows VA has 633 vacancies in human
resources throughout the Department. The VFW urges the Subcommittee to
work with VA to ensure it has the authority to recruit, employ and
retain the human resources employees it needs to quickly fill vacancies
and develop succession planning processes to prevent high vacancy
rates.
H.R. 3974, Grow Our Own Directive: Physician Employment and Education
Act of 2015
This legislation would build on the success of the Intermediate
Care Technician (ICT) Pilot Program. Launched in December 2012, the ICT
pilot program recruited transitioning veterans who served as medics or
corpsmen in the military to work in VA emergency departments as
intermediate care technicians. The ICT program offered transitioning
medics and corpsmen, who have extensive combat medicine experience and
training, the opportunity to provide clinical support for VA health
care providers without requiring them to undergo additional academic
preparation.
This legislation would go a step further by affording transitioning
medics and corpsmen the opportunity to become physician assistants.
With the end of the wars in Iraq and Afghanistan, and the continued
drawdown of military personnel, more medics and corpsmen will be
leaving military service and transitioning into the civilian workforce.
The VFW strongly supports efforts to leverage their medical knowledge
and experience to meet the health care needs of our nation's veterans.
H.R. 3989, Supporting Our Military Caregivers Act
This legislation would require VA to contract with an independent
entity to review appeals regarding eligibility determinations for the
program of Comprehensive Assistance for Family Caregivers, commonly
known as the Caregivers Program. While the VFW agrees with the intent
of this legislation, we cannot support it as written.
The VFW has heard too many instances of inconsistent implementation
of the Caregivers Program. This is largely due to the fact that
Caregivers Program eligibility is determined at the local VAMC level by
a veteran's treatment team without proper guidance on how to make such
a determination. The VFW has urged VA to establish a handbook for VA
physicians to use as a reference when making a determination on whether
a veteran is able to live independently without the assistance of
others.
VA physicians must also have the proper guidance on how to conduct
a clinical evaluation to determine the degree to which a veteran is
unable to perform activities of daily living and how many hours of care
a veteran requires per week. To this date, VA has failed to provide
such guidance to the field and has allowed VAMC personnel to continue
to make inconsistent eligibility determinations. VA has informed the
VFW it is working diligently on a directive to address inconsistent
implementation of this important program. The VFW looks forward to such
directive and will monitor progress to ensure VA medical facilities
comply with the directive.
The most common concern we hear from veterans regarding the
Caregivers Program is that they were considered to be in the highest
tier (requiring at least 40 hours of care per week), but were
downgraded or discontinued from the program when they relocated to a
different VAMC or VISN. The VFW has found that this is caused by an
automatic re-evaluation that is triggered when a veteran moves from one
VISN or VAMC to another.
For example, a veteran who is service connected for numerous severe
mental health conditions from Tennessee, where he was determined to
require at least 40 hours a week of caregiver support, moved to
Colorado. When the veteran received a re-evaluation at his new VAMC, it
was determined the veteran no longer needed the assistance of a
caregiver and was discontinued from the program, despite needing the
aid of his wife to perform activities of daily living. Furthermore, the
determination to discontinue the veteran from the program was made
without a VA health care professional from his new VAMC conducting a
site visit.
The VFW strongly believes veterans who are determined to be
eligible for the Caregivers Program should not be required to undergo a
re-evaluation simply because they move to a different state or VISN
catchment area. That is why we have urged VA to end such practice and
ensure a qualified health care professional conduct a site visit to
review a veteran's level of dependency before such veteran is
discontinued from this important program.
Veterans who disagree with a clinical determination made by their
treatment team are not given appropriate recourse for appealing such
decisions. This legislation seeks to correct this issue by authorizing
veterans to seek a second opinion from an independent entity. While the
VFW strongly believes veterans who disagree with a decision made by
their treatment team must be afforded a fair and expedient opportunity
to appeal such decision, we do not believe an independent contractor
would have the experience in diagnosing and treating the unique health
care conditions veterans face. Furthermore, this legislation fails to
address the larger issue that limits a veteran's ability to appeal an
eligibility decision regarding the Caregivers Program - VA's inadequate
clinical appeals process.
VA's current clinical appeals process does not afford veterans the
ability to have their decision reviewed beyond the VISN level. Veterans
who disagree with a clinical review conducted by the VAMC chief medical
officer are given the opportunity to have the decision reviewed by the
VISN director, who rarely overturns the VAMC decision. Moreover, the
VISN level appeal is final, unless a veteran appeals to the Board of
Veterans Appeal, which is not a viable option for veterans who require
time sensitive medical treatments. That is why the VFW strongly urges
this Subcommittee to review and reform the VA clinical appeals process.
Draft legislation to ensure each medical facility of the Department of
Veterans Affairs complies with requirements relating to scheduling
veterans for health care appointments
The VFW supports the intent of this legislation, which would
require all VA medical facilities to certify compliance with scheduling
laws and directives. However, the VFW does not believe this legislation
would resolve the underlying issue with scheduling at VA medical
facilities.
In the VFW's two reports on the Veterans Choice Program, which can
be found at www.vfw.org/vawatch, we found VA's wait time metric is
flawed and susceptible to data manipulation. For example, VA's
preferred date metric does not properly measure how long a veteran
waits for an appointment. A recent Government Accountability Office
(GAO) report entitled ``Actions Needed to Improve Newly Enrolled
Veterans' Access to Primary Care'' also highlights how a veteran who
waited 20 days to see a primary care provider from the time he
requested an appointment is recorded into the scheduling system as
waiting 4 days for his appointment.
The VFW recognizes that using the request date as the starting
point is also flawed because VA has established an arbitrary wait time
goal of 30 days for all appointments, which does not represent how the
health care industry measures wait times. In a recent report, the RAND
Corporation found the best practices in the private sector for
measuring timeliness of appointments are generally based on the
clinical need of the health care requested and in consultation with the
patient and their family. That is why the VFW has urged VA and Congress
to move away from using arbitrary standards to measure whether an
appointment was delivered in a timely manner and adopt industry best
practices by basing the timeliness of appointment scheduling on a
clinical decision made by health care providers and their patients.
The VFW does not believe this legislation can be successful if VA's
wait time metric remains flawed and susceptible to data manipulation.
Compliance with flawed metrics does not lead to better health care
outcomes for veterans.
Discussion draft to direct the Secretary of Veterans Affairs to
establish a list of drugs that require increased level of informed
consent
This discussion legislation would ensure veterans are properly
informed of the possible side effects and dangers of certain
prescription drugs before beginning a treatment regimen. The VFW
supports this draft legislation and has several recommendations to
improve it.
The VFW has heard from veterans time and time again that they want
to be incorporated in decisions regarding their health care. In
particular, veterans who have been prescribed high dose medications to
treat their health conditions would like to know whether they have
alternatives to pharmacotherapy that are effective and lead to similar
or better health care outcomes. This draft legislation would rightfully
require increased informed consent before VA health care professionals
prescribe potentially harmful drugs.
While informed consent is important to ensure veterans are
incorporated in decisions regarding their health care, such consent
cannot be used to waive a VA provider's liability if veterans are
adversely impacted by such medications. The VFW recommends the
Subcommittee include a provision to ensure informed consent, as
detailed in this legislation, does not release VA from liability if an
adverse action were to occur as the result of such treatment.
This legislation would also require VA to inform veterans of the
potential danger of mixing drugs and dosages in sizes and combinations
that have not been approved by the Food and Drug Administration. While
general information on drug interactions is important, the VFW believes
it would be more beneficial to give veterans an explanation of how the
suggested prescription drug would affect the patient in accordance with
all of the patients currently prescribed pharmaceuticals. By doing this
veterans will be able make a personalized informed decision.
Information Required by Rule XI2(g)(4) of the House of Representatives
Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW
has not received any federal grants in Fiscal Year 2016, nor has it
received any federal grants in the two previous Fiscal Years.
The VFW has not received payments or contracts from any foreign
governments in the current year or preceding two calendar years.
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