[Senate Hearing 114-609]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2016
----------
TUESDAY, APRIL 21, 2015
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 2:31 p.m., in room SD-124, Dirksen
Senate Office Building, Hon. Mark Kirk (chairman) presiding.
Present: Senators Kirk, Murkowski, Hoeven, Collins,
Boozman, Capito, Cassidy, Tester, Murray, Reed, Udall, Schatz,
Baldwin, Murphy, and Mikulski.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF HON. ROBERT A. McDONALD, SECRETARY
ACCOMPANIED BY:
STEPHEN WARREN, CIO, OFFICE OF INFORMATION AND TECHNOLOGY
DR. CAROLYN M. CLANCY, INTERIM UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION
DANNY PUMMILL, PRINCIPAL DEPUTY UNDER SECRETARY FOR BENEFITS,
VETERANS BENEFITS ADMINISTRATION
OPENING STATEMENT OF SENATOR MARK KIRK
Senator Kirk. Let's begin.
Tom Fuller, who you know about, was a Vietnam veteran in
the Marines, and presented himself to the Hines VA with chest
pains, went to see Dr. Dieter, who was the head of cardiology
at Hines, and Dieter did not want him to be in his win/loss
record, referred him to the floor, and there Tom expired of a
heart attack.
I want to make sure that kind of thing never happens to our
veterans, that we have confident, strong, administration of our
people. Mr. Secretary, I have raised this issue with you
multiple times.
Behind that is the story of Lisa Nee, who is a
cardiologist, as she witnessed this whole thing and thought it
was an outright malpractice happening in this case.
I know you have a 10 minute opener, Mr. Secretary.
Senator Kirk. Senator Tester.
STATEMENT OF SENATOR JON TESTER
Senator Tester. Thank you, Mr. Chairman. I have a pretty
brief opening statement, and then we will get after it. I just
want to thank Chairman Kirk for his leadership on this
subcommittee, and I want to welcome Secretary McDonald, Dr.
Clancy, and Mr. Pummill, and thank you for your work as you
appear before this subcommittee, and your commitment to this
Nation's veterans.
Mr. Secretary, it is good to see you again. Thank you for
coming to Montana. It was a great trip, very informative, and I
hope you feel the same way.
Moving forward, I hope that we can work closely together to
address some of the concerns and issues raised during our trip,
and some of the issues that will be raised today.
I have been impressed by your leadership, Mr. Secretary,
your candor, your willingness to accept accountability and
confront tough issues. I do not have to tell you, the
Department of Veterans Affairs (VA) is an agency that is under
siege every day. You experience that every day. We have seen
several scandals that have shaken the confidence of the VA,
have created mistrust for some of our veterans, and have
created mistrust with some of our public.
Restoring that trust is one of your chief tasks, and I know
you know that, but a lot of that responsibility also falls on
our shoulders. It is critical that we provide you with the
tools you need to get the job done.
I firmly believe that we need to hold accountable those who
have abused their authority for personal gain, but also I
believe that we need to appropriately recognize and applaud the
dedication of the vast majority of VA employees who come to
work every single day with the singular goal of helping every
veteran whose lives they touch.
Dedicating all our time to pummeling--no pun intended--the
VA for past failures is not a recipe for reform or success, and
our veterans deserve more than that. At the end of the day, we
are in this together, and by law and fully supported by
Congress, American veterans are entitled to a healthcare system
and benefits program that is far superior to any comparable
government or private sector benefits, and for very good
reason.
The VA model of providing direct healthcare and benefits to
our Nation's veterans is something our veterans have come to
rely on. It is something that Congress has enshrined in law.
We each have a responsibility here to sustain this model of
service. The VA must reform and improve its delivery of
services to veterans, and Congress needs to step up and fulfill
the responsibility to fully fund the VA's model of service that
veterans have come to expect and demand.
I want to thank you again, Mr. Secretary, Dr. Clancy, Mr.
Pummill, for being before this subcommittee. I look forward to
your testimony. Thank you, Mr. Chairman.
SUMMARY STATEMENT OF HON. ROBERT A. MCDONALD
Secretary McDonald. Chairman Kirk, Ranking Member Tester,
and members of the subcommittee, thanks for the opportunity to
discuss VA's 2016 and 2017 advance appropriations requests and
budget.
We appreciate your steadfast support for veterans and the
assistance of veteran service organizations (VSOs).
As VA moves from a serious crisis, we have a critical
opportunity. We intend to take full advantage of it, to make VA
a model agency and customer experience comparable to the best
private sector businesses.
Currently, 11 million of 22 million veterans are
registered, enrolled, or use at least one VA benefit or
service. The cost of fulfilling our obligations grows over time
because veterans' demands for services and benefits continue to
increase.
In 2014, 40 years after the war ended, 22 percent of
Vietnam veterans were receiving service connected disability
benefits. We expect that percentage to continue to increase.
From 1960 to the year 2000, the percentage of veterans
receiving VA compensation was about 8.5 percent, but in the
last 14 years, that has more than doubled, to 19 percent.
In 2009, the Veterans Benefits Administration (VBA)
completed about 987,000 claims. In fiscal year 2017, we project
we will complete over 1.4 million claims, a 47-percent
increase.
There has been a huge growth in the number of medical
issues in claims, 2.7 million in 2009, and a projected 5.9
million in 2017. That is a 115-percent increase over just 8
years.
From 1950 to 1995, the average degree of disability amongst
veterans was 30 percent. Since 2000, the average degree of
disability has risen to 47.7 percent. While the total number of
veterans is declining, the number of those seeking care and
benefits is increasing due to more than a decade of war, agent
orange related claims, an unlimited claims appeal process,
increased claims issues, far greater survival rates of the
wounded, and more sophisticated medical treatments.
It is important to understand why. The most important
consideration is an aging veteran population. Forty years ago,
2.2 million veterans were 65 years old or older. That is 7.5
percent of the population. In 2017, we expect 9.8 million will
be 65 years or older. That is 46 percent. We now serve an older
population with a greater demand for care, more chronic
conditions, and less able to afford private sector care.
As veterans see positive changes at VA and as the military
downsizes, those choosing VA will continue to rise. We are
listening hard to what veterans, Congress, employees, and VSOs
tell us, driving us to a historic Department-wide
transformation, changing VA's culture, making veterans the
center of everything we do.
We call it MyVA. MyVA focuses on five objectives to
revolutionize culture and focus on veterans' outcomes rather
than internal metrics.
First, improving the veteran experience so that every
veteran has a seamless, integrated and responsive customer
service experience every single time.
Second, improving employee experience by eliminating
barriers to customer service and focusing on our people and our
culture to better serve veterans.
Third, improving our internal support services.
Fourth, establishing a culture of continuous improvement to
identify and correct problems and replicate solutions at all
facilities.
Last, fifth, enhancing strategic partnerships. We cannot do
this by ourselves. Strategic partnerships become critical.
Reorganizing the Department geographically is a first step
in achieving this goal. In the past, VA had nine disjointed
geographic organization structures. Our new organization
framework has one national structure with five districts
aligning VA's organizational boundaries. Veterans will see one
VA rather than multiple disconnected organizations.
Last, MyVA is about ensuring sound stewardship of taxpayer
dollars, will integrate management improvement systems to
ensure operational efficiency. We need congressional help. VA
cannot be a sound steward of resources with our current
portfolio of assets. No business would carry such a portfolio.
It is time to close old substandard and under utilized
facilities, 900 VA facilities are over 90 years old. More than
1,300 are over 70 years old. VA currently has 336 buildings
vacant or less than 50 percent occupied. That is 10.5 million
square feet of empty space costing about $24 million annually.
We could use these funds to hire roughly 200 registered
nurses for a year, pay for 144,000 primary care visits of
veterans, or support 41,900 days of nursing home care for
veterans. Please help us do the right thing.
MyVA reforms will take time, but in the long term, they
will enable us to better provide veterans earned benefits and
earned services.
Our 2016 VA budget request allows us to continue
transforming under MyVA. It requests $168.8 billion, $73.5
billion in discretionary funds, and $95.3 billion in mandatory
funds, a discretionary request increase of $5.2 billion above
the 2015 enacted level, to continue serving the growing number
of veterans seeking care and benefits.
The resources required in the 2016 budget request are in
addition to those Congress provided in the Veterans Choice Act.
We do not know how many veterans will ultimately use the act
for non-VA care, what we call community care, or how much it
will cost, our estimates range from $4 billion on the low end
to $13 billion on the high end.
We do know that our recent decision to change the
definition of the 40 mile provision of the act from straight
line to road distance will approximately double the number of
veterans eligible for care under the act.
As Deputy Secretary Sloan Gibson testified last week, we
proposed funding the increased cost of our new Denver Hospital
by requesting funds from the Choice Act. The Denver project has
a long history. While poor VA project and contract management
contributed to problems, decisions made years ago brought us to
this point.
In my opinion, the significant increase in the cost of the
Denver project results from four factors: first, not locking
down design early in the process. Second, some design aspects
that added costs. Third, increases to construction costs in the
Denver market while we had not effectively negotiated a firm
target price, and fourth, premiums paid to contractors for
perceived risk due to problems with the project.
We have learned from these past mistakes and are taking
meaningful corrective actions to improve performance. Among
those actions are requiring major medical construction projects
to achieve at least 35 percent design prior to publishing costs
and schedule information or requesting funds.
Second, implementing a deliberate requirements control
process, any significant changes in project scope or costs will
be approved by me prior to submission to Congress.
Third, institutionalizing a project review board similar to
what the Corps of Engineers District Offices use.
Fourth, conducting pre-construction reviews of major
projects, and fifth, integrating medical equipment planners
into the construction project teams from concept through
activation.
Those measures will help us in the future but they will not
finish Denver. After analysis by the Corps of Engineers, we
informed the subcommittee that the total estimated cost of the
facility will be $1.73 billion, an authorization increase of
$930 million, and additional funding of $830 million.
We believe requesting funds from the Choice Act is the best
approach among the difficult choices before us. Now we must
work with this subcommittee and others to secure the funding.
Last, if the President's budget request is cut by the $1.4
billion proposed by your colleagues in the House, those
reductions would have these effects: it would cut veterans'
medical care by $690 million, the equivalent of over 70,000
fewer veterans receiving VA medical care compared to the
President's request.
It would eliminate the funding for four major construction
projects. This cut would reduce VA's ability to provide
additional outpatient services and will impact the following
projects: the planned rehab therapy building in St. Louis,
Missouri; the initial phase of the Alameda, California
outpatient clinic; construction of the long sought after French
Camp, California community-based outpatient clinic (CBOC); the
replacement 155-bed community living center in Perry Point,
Maryland.
It would also eliminate funding for cemetery expansion
projects in St. Louis, Portland, Riverside, and Pensacola, and
a new columbarium in Alameda, reducing our ability to provide
burial honors for as many as 18,000 veterans and eligible
family members annually.
The impact of these cuts to veterans' care and benefits is
unacceptable to me, and I know it is unacceptable to members of
Congress.
Mr. Chairman, ranking member, members of the subcommittee,
thanks again for your support for veterans and for working on
these budget requests. We look forward to your questions. Thank
you, Chairman.
[The statement follows:]
Prepared Statement of Hon. Robert A. McDonald
Chairman Kirk, Ranking Member Tester, Distinguished Members of the
Senate Appropriations Subcommittee on Military Construction and
Veterans Affairs:
Thank you for the opportunity to present the President's 2016
budget and 2017 advance appropriations (AA) requests for the Department
of Veterans Affairs (VA). This budget continues the President's
staunch, unwavering support for veterans, their families, and
survivors. We value the support to VA that Congress has demonstrated in
providing the resources and legislative authorities needed to honor our
Nation's veterans.
This is a critical moment for VA. We are emerging from one of the
most serious crises the Department has ever experienced. But with this
crisis, VA also has before it perhaps the greatest opportunity in its
history to enhance care for veterans and build a more efficient and
effective system. We are listening hard to what veterans, Congress,
employees, Veterans Service Organizations (VSOs), and other
stakeholders are telling us. Since my nomination on June 30, 2014, I
have made more than 100 visits to VA field sites--including 31 visits
to VA Medical Centers, nine visits to VA Community-Based Outpatient
Clinics and 10 visits to Homeless Veteran program sites. I participated
in the Los Angeles Point-in-Time Homeless Veterans count. I've made six
visits to VA Regional Offices and six visits to VA cemeteries. I have
witnessed first-hand the operations at VA polytrauma centers, a
veterans community living center, a hospice, an insurance center, and a
domiciliary. I have attended 29 veteran engagements through
partnerships and 25 stakeholder events. I have also visited 16 medical
schools and universities to recruit newly minted clinical professionals
for VA's healthcare system. All of these visits are influencing the way
VA is moving forward. We are implementing an historic department-wide
transformation, changing VA's culture, and making the veteran the
center of everything we do. We aspire to make the VA a model agency
that is held up as an example for other Government agencies to follow
with respect to customer experience and stewardship of the taxpayer's
resources. We strive to be comparable to the very best private sector
businesses, with efficient and effective operations.
The President's 2016 budget will allow VA to operate the largest
integrated healthcare system in the country, including over 1,900 VA
points of healthcare and approximately 9.4 million veterans enrolled to
receive care; the tenth largest life insurance provider, covering both
active duty servicemembers and enrolled veterans; a compensation and
pension benefits program serving over 5.2 million veterans and
survivors; an education assistance program serving 1.2 million
students; a home mortgage program with a portfolio of over 2 million
active loans guaranteed by VA; and the largest national cemetery system
that leads the Nation as a high-performing organization, with
projections to inter 129,200 veterans and family members in 2016. VA's
2016 budget request is essential to begin to address the resource
requirements necessary to move VA into the future, address the crisis
we are in, and meet our obligation to provide timely, quality
healthcare and services to veterans.
The 2016 budget for VA requests $168.8 billion--$73.5 billion in
discretionary funds, including medical care collections, and $95.3
billion in mandatory funds for veterans benefits programs. The
discretionary request reflects an increase of $5.2 billion (7.5
percent) above the 2015 enacted level. The budget also requests a 2017
AA for Medical Care of $63.3 billion and a first-time AA request of
$104.0 billion for three mandatory accounts that support veterans'
benefit payments (i.e., Compensation and Pensions, Readjustment
Benefits, and Insurance and Indemnities). These investments, together
with the 2016 budget, will provide authorities, funding, and other
tools to enhance service to veterans in the short term while
strengthening the underlying VA system to better serve veterans in the
future. However, more resources in certain areas will be required to
ensure that the VA system can provide timely, high-quality healthcare
into the future. In the coming months, the administration will submit
legislation to allow the VA Secretary to reallocate a portion of
Veterans Choice Program funding to best meet veteran's needs. This will
allow the Secretary to make essential investments in VA system
priorities in a fiscally responsible, budget-neutral manner.
myva--driving reforms and improving efficiency
In order to transform VA into an organization of which veterans,
employees, and Americans can be proud, we are beginning with a
commitment to critically assess ourselves. Transformation must start
with organizational reforms to better unify the Department's efforts on
behalf of veterans. These reforms will take time, but will center
around the ICARE values and provide veterans the services and benefits
they have earned and deserve.
The goal of MyVA is to reorient the Department around the needs of
veterans. MyVA will create a VA that eliminates barriers to putting
customers first; measures success by the outcomes to veterans as
opposed to our internal processes; and integrates across programs and
organizations to optimize productivity and efficiency. MyVA focuses on
five major themes:
--Improving the veteran experience
--Improving the employee experience, and achieving ``people
excellence'' so we can better serve veterans
--Establishing a culture of continuous improvement
--Improving our internal support services
--Enhancing strategic partnerships
The overarching principle is our focus on the veteran experience.
We want every veteran to have a seamless, integrated, and responsive
customer service experience every time. We are taking the first step
towards better integration of the Department by moving from nine
separate regional maps to one. This realignment will align VA's
disparate organizational boundaries into a single framework, easing
internal coordination and collaboration between business lines, and
allowing VA to provide customer service training and capabilities
across the agency. This will make the department more seamless to
veterans, who will begin to perceive their interactions with one VA,
rather than individual organizations. The new organizational framework
will have five geographically-named districts, which we worked with
Veteran Service Organizations to name: North Atlantic, Southeast,
Midwest, Continental, and Pacific.
MyVA will empower employees with the tools they need to better
serve veterans, and will revolutionize VA's culture by emphasizing
continuous improvement, setting conditions at the local level for
issues to be raised, addressed, and solutions replicated across as many
facilities as needed to achieve enterprise level results.
MyVA is also about ensuring that VA is a sound steward of the
taxpayer dollar. By improving our internal support services, we will
ensure that our processes support VA employees serving veterans and
that we effectively balance exceptional veteran-centric service with
operational efficiency. We are using a business lens to assess all
aspects of VA operations and will pursue changes to allow VA to deliver
care and services more efficiently and effectively while delivering the
highest value to veterans and taxpayers. By exploring opportunities to
enhance Strategic Partnerships, we will ensure the best and most
effective organizations--public, private, non-profits, and volunteer--
work with VA to best serve veterans.
In addition, we are creating a new Digital Services Team, comprised
of the country's best developers, designers, and digital product
managers, who will work across VA to design and deploy world-class
digital services for America's veterans. Our digital services experts
will help the Department achieve the MyVA vision through improved
electronic access to VA services that works across veterans' computers,
tablets, kiosks, and mobile devices.
We anticipate this will be the largest department-wide
transformation in VA's history. It will be the product of ideas and
insights shared by veterans, employees, members of Congress, VSOs, and
other stakeholders.
Before: VA's Nine Organizational Maps
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
After: A Single, Coordinated Framework
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
closing unsustainable facilities
VA cannot be a sound steward of the taxpayer's resources with the
asset portfolio it is carrying. No business would carry such a
portfolio--and our veterans deserve better. It is time to close VA's
old, substandard, and underutilized facilities. Of 5,565 VA medical
facilities--which include hospitals, clinics, warehouses, and other
assets that support medical operations--more than 900 facilities are
over 90 years old, and more than 1,300 facilities are over 70 years
old. Overall, 60 percent of VA facilities are more than 50 years old.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We need to move forward with closing locations that are not
economically sustainable and old, outdated buildings that are
challenging to maintain and provide little or no value to our
customers. VA currently has 336 buildings that are vacant or less than
50 percent occupied, which are excess to our needs. This means we have
to maintain over 10.5 million square feet of unneeded space--taking
funding from needed veteran services. For example, we estimate that it
costs VA $24 million annually to maintain and operate vacant and
underutilized buildings. These funds could be better used to hire
roughly 200 Registered Nurses for 1 year; pay for 144,000 veteran
primary care visits; provide veterans 13,500 bed days of inpatient
care; or support 41,900 days of nursing home care for veterans in
Community Living Centers. The President's 2016 budget includes two
legislative proposals that would aid VA in disposing of these
unnecessary assets. The first is the Government-wide Civilian Property
Realignment Act, which would enable Federal agencies to pursue
consolidation and disposals in a streamlined way. The second proposal
would authorize VA to pursue Enhanced-Use Lease (EUL) agreements beyond
the currently authorized purpose of creating ``supportive housing'' as
defined in 38 U.S.C. Sec. 8161(3). Our existing EUL authority does not
allow VA to enter into a wide range of innovative agreements that could
benefit veterans.
VA faces many obstacles to rightsizing our capital asset portfolio.
For example, under an Enhanced Use Lease project, VA's selected third-
party developer sought to demolish the vacant building shown below in
order to provide land for the development of housing for homeless
veterans. The state historic preservation office did not support the
developer's plan to demolish the building, so in the interest of time
and funding, the developer decided to forego demolishing the building.
This action forced VA to incur the costs to mothball and maintain this
unneeded building and limited the amount of land that was available to
redevelop to provide housing for veterans. I have met with National
Historic Building advocates to discuss repurposing the buildings we
close, and look forward to a spirited, positive dialogue on this issue.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Photo: Minneapolis, Minnesota vacant building, quartermaster gas
station, built in 1932.
As the veteran population has migrated, VA's capital infrastructure
has not kept pace. We continue to operate medical facilities in legacy
locations, in places where the veteran population is small or
shrinking. We do this at the expense of creating new access and right-
sized capacity for larger numbers of veterans in the locations where
the veteran population is growing. For example, in one hospital with an
operating capacity of ten medical beds, the average daily patient
census is five patients or less. At this facility, VA is required to
maintain adequate infrastructure such as lab, x-ray, and other support
in place continuously, regardless of the facility's low utilization
rate. The cost per patient to maintain a small operation such as this
one is higher than the cost in some of our large, highly complex
facilities. Additionally, the patient volume and complexity of care
make it difficult, if not impossible, for physicians and nurses to
maintain clinical skills and competencies. This example is not an
anomaly--there are many others in VA.
VA needs to better align its healthcare facilities to meet today's
healthcare delivery models, which are shifting away from long inpatient
stays to greater outpatient care. We also need to modernize our
facilities to ensure they provide ready access to women, who now
comprise 11 percent of all veterans and 20 percent of our military.
Where hospitals no longer make sense, due to a declining veteran
population or demographic shifts, VA must look for ways to partner with
local hospitals and healthcare systems to serve veterans. Much of
healthcare today is about creating partnerships and interdependencies
to better serve patients and to contain costs. VA must be part of that.
We know that it is difficult for Members of Congress to contemplate
the closing of a facility in their own district, even when that
facility is underutilized and wasteful. Yet, given the current and
future demands on the VA system, we cannot afford to waste scarce
resources on an inefficient system. We would like to work with Members
of Congress to do the harder right, rather than the easier wrong. We
ask for your help to realign our medical facilities to best serve our
veterans and shed facilities that are not economically viable and no
longer provide value.
veterans' demand for services and benefits
We know that veterans' demand for services and benefits continues
to rise for decades after conflicts end. And we know that the veteran
population is aging. In 2017, 9.8 million, or 46 percent of the 21.1
million veteran population will be age 65 or older. This compares with
2.2 million, or 7.5 percent, in 1975. veterans' care often occurs many
years after they served in uniform, so this is a long-term issue for
VA. Just since 2002, the number of veterans receiving outpatient
services has grown by more than 76 percent.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Fueled by more than a decade of war, Agent Orange-related
disability compensation claims, a complex, non-linear claims appeal
process, demographic shifts, increased medical claims issues, and other
factors, veterans' demand for services and benefits has exceeded VA's
capacity to meet it. VA has worked with the Ad Council on a pro bono
advertising campaign to encourage more veterans to sign up for their
benefits, but we are reluctant to launch the campaign at a time when
our capacity is stretched to its limit.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We must ensure that demand for services and benefits does not
outstrip our capacity to provide them. VA must build the capacity now
to meet future demand. We look forward to working with you to identify
and prioritize spending to best serve the interests of veterans and our
Nation.
the veterans access, choice, and accountability act of 2014
The funding provided in the Veterans Access, Choice, and
Accountability Act of 2014 (Veterans Choice Act) was an important step
in moving VA on the path to improved access to care for veterans. VA
greatly appreciates these additional resources provided by the
Congress--$15 billion to allow veterans additional access to healthcare
within the community and address current access and capacity shortfalls
that are inherent within VA. While it is clear that purchased care
plays an important role, it should not be seen as a replacement for a
strong and vital veterans' healthcare system.
The emergency resources provided in the Veterans Choice Act are not
permanent, but are being used to address the current access crisis, but
do not fully address VA's longstanding capital infrastructure
requirements. Because VA has limited experience with the new Veterans
Choice Program, it is difficult to predict veterans' use of the
program, or its interaction with the medical care base budget. Our
current estimates of the total healthcare costs for the Choice Program
range from a low of $3.8 billion to a maximum of $20.4 billion over the
3-year program.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Data source: VA Office of the General Counsel, Economic Impact Analysis
for RIN 2900-AP24, ``Expanded Access to Non-VA Care through the
Veterans Choice Program''
The variance is the result of significant uncertainty surrounding
eligible veterans' participation and utilization of non-VA medical
services. Two categories of veterans are eligible to participate--those
living outside the Act's 40-mile distance, which as of April 24, 2015
will be refined to reflect driving distance (fastest) from the nearest
VA facility including CBOCs, or when we cannot provide care within 30
days of the clinically indicated date or preferred date of the veteran.
Each eligible veteran must make his or her own decision about care in
the community. For example, a veteran may prefer to be seen at the VA
by his or her regular doctor, even though there is a waiting period,
rather than see a new private sector physician in a shorter time
period. Also, wait times may be high in the community for specialty
appointments, and veterans may elect to receive their specialty care
from VA.
ensuring veterans access to care
Veterans are demanding more services from VA than ever before. The
number of veterans who are seeking VA medical care continues to grow
steadily. Compared to fiscal year 2009, the number of patients is
projected to increase by 20 percent by fiscal year 2016. We now serve a
population that is older, with more chronic conditions, and less able
to afford care in the private sector. And, as veterans see the results
of the positive changes we are making, we are confident that the number
of veterans utilizing VA services will rise. Currently, 11 million of
the 22 million veterans in this country are registered, enrolled, or
use at least one VA benefit or service. Our 2016 budget requests the
necessary resources to allow us to serve the growing number of veterans
who selflessly served our Nation.
In 2016, the number of veterans enrolled in VA medical care will be
nearly 9.4 million, an increase of 1.6 percent from 2015. Also, VA
expects to provide more than 101 million outpatient visits in 2016, an
increase of 2.8 million visits from 2015. Workload will continue to
rise as the military downsizes and veterans regain trust in the VA. In
addition, survival rates among Americans who served in conflicts have
increased, and more sophisticated methods for identifying and treating
veteran medical issues continue to become available.
The 2016 budget requests $60.0 billion for medical care, an
increase of $4.2 billion (7.4 percent) over the 2015 enacted level. The
increase in 2016 is driven by veterans' demand for VA healthcare as a
result of demographic factors, and economic assumptions, investments in
access; and high priority investments for Caregivers, new Hepatitis C
treatments, and support for Veterans Health Information Systems and
Technology Architecture (VistA) Evolution. The 2016 request supports
programs to end veteran homelessness; continue implementation of the
Caregivers and Veterans Omnibus Health Services Act; provide for
activation requirements for new or replacement medical facilities; and
invest in strategic initiatives to improve the quality and
accessibility of VA healthcare programs. The 2016 appropriations
request includes an additional $1.3 billion above the enacted 2016 AA
for veterans medical care. This is the first year VA will be seeking
additional funding in all three medical care accounts that are funded
by advance appropriations. The request includes approximately $3.3
billion annually in medical collections in 2016 and 2017.
For the 2017 advance appropriations for medical care, the current
request is $63.3 billion. This request reflects great uncertainty
surrounding the impact of the Veterans Choice Act on VA operations in
2017. This estimate will be revised as VA gains greater experience with
implementation of the Veterans Choice Act.
ending veteran homelessness
As President Obama has said, too many of those who once wore our
Nation's uniform now sleep in our Nation's streets. The administration
has made the elimination of veteran homelessness a national priority.
In 2009, we set an ambitious plan to end veteran homelessness by the
end of 2015. We have made substantial progress toward this goal--as of
January 2014, overall veteran homelessness is down 33 percent since
2010, and we have achieved a 42 percent decrease in unsheltered veteran
homelessness. Through unprecedented partnerships with Federal and local
partners, we have greatly increased access to permanent housing, a full
range of healthcare including primary care, specialty care, and mental
healthcare; employment; and benefits for homeless and at risk for
homeless veterans and their families. As a result of these investments,
in fiscal year 2014, more than 260,000 homeless or at-risk veterans
(including formerly homeless veterans) received VA specialized
services.
In 2016, VA will continue to focus on prevention and treatment
services. The budget requests $1.4 billion for VA homeless-related
programs, including case management support for the HUD-VASH voucher
program, the Grant and Per Diem Program, the Supportive Services for
Veteran Families program, and VA justice programs. The 2016 budget
supports VA's plan to help end veteran homelessness by emphasizing
rescue for those who are homeless today, and prevention for those at
risk of homelessness.
medical and prosthetic research
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
VA has a legacy of innovation and cutting-edge research that is as
broad and historically significant as it is profound--and often
unrecognized. Few are aware that VA research developed the cardiac
pacemaker, the first successful liver transplant, the nicotine patch,
and the world's most advanced prosthetics--including VA's revolutionary
``Braingate'' breakthrough that makes it possible for totally paralyzed
patients to control robotic arms using only their thoughts.
VA research also has led to major breakthroughs and advances in
medical science and care--Post-traumatic Stress Disorder, or PTSD, and
Traumatic Brain Injury, or TBI, being only two of many. In 2016,
Medical Research will be supported through a $621.8 million direct
appropriation, and an additional $1.2 billion from VA's medical care
program and grants. Total funding for Medical and Prosthetic Research
will be over $1.8 billion in 2016.
The 2016 budget includes a $10.2 million strategic initiative to
support improvements in VA medical care through research focused on a
``Learning Health Care System.'' A learning healthcare system is one
that is responsive to new information, adapts to implement more
effective clinical practices, and is committed to an ongoing mission of
excellence, supported by a culture of self-reflection and continuing
education. Through five interlocking research streams--measurement
science, operations research, point-of-care research, provider
behavior, and randomized program implementation--this initiative
proposes to broaden existing research by systematically capturing,
assessing, and translating the lessons from each care experience into
improved methods of delivering care to veterans.
continuing the transformation of the veterans benefits administration
Improving quality and reducing the length of time it takes to
process disability compensation claims is integral to our mission of
providing the care and benefits that veterans have earned and deserve
in a timely, accurate, and compassionate manner. The disability rating
claims workload continues to increase, due to the reduction in military
forces, servicemembers returning from wars, and the aging of the
veteran population. Also, the complexity of the workload continues to
grow because veterans are claiming greater numbers of disabling
conditions and the nature of disabilities--such as PTSD, combat
injuries, diabetes and related conditions, and environmental diseases--
is becoming increasingly complex.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Despite these challenges, VBA has decreased the disability claims
backlog by more than 70 percent as of April 15, 2015 , since its peak
in March 2013 (from 611,000 to 182,000), and we are on track to meet
the President's goal to eliminate the disability claims backlog by
processing all claims in 125 days by the end of 2015. VBA's success in
reducing the backlog has occurred, in part, because of its strong
reliance on mandatory overtime by claims processors. However, this
strategy is unsustainable. It strains employee-management relations and
is inconsistent with our goal to improve the employee experience so
they can be empowered to better serve veterans. We must right size
VBA's workforce and more effectively manage the use of management
practices such as the use of mandatory overtime and continue progress
toward eliminating the disability claims backlog.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We are taking the lessons learned in eliminating the disability
claims backlog and applying them to transform business processes
supporting the fiduciary program, the delivery of non-rating benefits,
and the appellate workload.
For 2016, VA requests $2.7 billion for VBA for general operating
expenses, an increase of $165.8 million (6.6 percent) over the 2015
enacted level. These resources will support 21,871 Full-Time Equivalent
(FTE) employees and allow VA to administer disability compensation and
pension benefits totaling $83.1 billion to over 5.2 million veterans
and survivors; education benefits and vocational rehabilitation and
employment benefits and services to nearly 1.3 million participants; VA
guaranty of more than 431,000 new home loans; and life insurance
coverage to 1.1 million veterans, 2.3 million servicemembers, and 3.1
million family members.
As VBA continues to receive and complete more disability rating
claims, the volume of appeals, non-rating claims, and fiduciary field
examinations increases correspondingly.
--Appeals. Over the last 20 years, appeal rates have continued to
hold steady at between 11 and 12 percent of completed claims.
As VBA continues to receive and complete record-breaking
numbers of disability rating claims in recent years (1.3
million claims completed in 2014), the volume of appeals
increases concomitantly. VBA currently has approximately
290,000 pending appeals.
--Non-rating claims. VBA's success in completing rating decisions has
driven an increase in non-rating claims. In 2015, VBA expects
to receive 2.9 million non-rating claims and review actions, an
increase of 7.4 percent over 2014 (2.7 million) and 12.5
percent over 2013 (2.4 million).
--Fiduciary program. In 2014, VA's fiduciary program protected more
than 173,000 beneficiaries, which is a 42 percent increase in
the number of beneficiaries from 2011 (122,000). Primary
drivers of the growth in this program are the increase in the
total number of beneficiaries receiving VA benefits and an
aging beneficiary population. In 2014, fiduciary personnel
conducted over 86,000 field examinations, and VBA anticipates
field examination requirements to exceed 117,000 in 2016.
To ensure all aspects of the claims process are improved for
veterans, VBA is requesting additional claims processors and field
examiners. VBA is requesting $85 million to fund 200 appeals
processors, 320 non-rating claims processors, 85 fiduciary field
examiners, and 165 support personnel (including 13 FTE for the National
Work Queue (NWQ), for a total of 770 additional FTE. VBA employees--
over 50 percent of whom are veterans--are leading advocates for
veterans, servicemembers, their families, and survivors and are key to
our success. With the additional 770 employees, VA will provide
veterans with more timely decisions on their appeals and non-rating
claims, and conduct thousands more vital fiduciary home visits.
VBA is able to accommodate additional staff within existing space
requirements by efforts underway to digitalize veterans claims folders,
building on success to date. One example is the VBA office in Winston-
Salem, North Carolina, which is shown below before and after VBA
digitized veterans' paper records.
Winston-Salem Regional Office: Before and After Transformation
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Spring 2012
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Fall 2013
The VBA request includes $140.8 million for continued investment in
the Veterans Claims Intake Program (VCIP), which converts paper claims
into an electronic format and enables the electronic transfer of
medical and personnel records. This electronic transfer is critical to
creating the necessary digital environment that supports end-to-end
electronic claims processing for each stage of the claims lifecycle. As
of December 2014, over 28,000 users of the Veterans Benefits Management
System (VBMS) could access over one billion electronic images converted
from paper.
The Budget request for the 2017 advance appropriations for the
Compensation and Pensions appropriation is $87.1 billion; the
Readjustment Benefits advance appropriation request is $16.7 billion;
and the Veterans Insurance and Indemnities advance appropriation is
$91.9 million. These amounts reflect the current estimates for the
resources that would be necessary to continue these benefit programs in
2017, and will be revised as necessary in the mid-session review of the
2016 Budget, as VA monitors workload and monthly expenditures.
enhanced focus on information technology solutions
Funding for IT infrastructure and services is at the heart of VA's
mission, because IT affects every aspect of VA's ability to serve
veterans by providing easily accessible, quality healthcare and
benefits. To offer a view of the scope of VA's IT dependency, VA IT
systems support operations at every VA location, with over a million
devices on the network. VA's current challenges present a unique
opportunity to employ innovative Information Technology (IT) solutions
to accelerate changes that will better serve veterans. Veterans and
their families of all ages are increasingly more comfortable using
leading-edge technology to communicate and access healthcare and
benefits. Our IT challenge is to safely and securely deliver veterans
that leading-edge experience--fluid mobile solutions, creative apps,
and user-friendly websites that rival the best in technology outside
VA.
The $4.1 billion request represents an increase of $230 million (6
percent) above the 2015 enacted level. The request consists of $505
million for development of new IT products; $2.5 billion for
sustainment, $892 million for more than 7,615 staff and administrative
support, and $223 million for related support services. The request
will sustain our infrastructure while making necessary investments in
IT support for critical business processes, such as streamlining
benefits processing, enhancing and modernizing VA's electronic health
record, enhancing data security, and achieving health data
interoperability with the Department of Defense.
The 2016 request funds key development projects for veterans'
access ($192 million), disability claims backlog elimination ($105
million), and VistA Evolution ($82 million). The request of $2.5
billion for IT sustainment will fund the replacement of the oldest
hardware that has fallen beyond its useful lifespan; the development of
registries to track homeless veterans; communications systems,
wireless, and mobile solutions; software license procurement; and
information security.
investing in va's infrastructure
The 2016 budget requests $1.6 billion for VA's major and minor
construction programs, an increase of $493 million (47 percent) above
the 2015 enacted level. Providing access to care and ensuring that
veterans are safe when they are in a VA facility, drive our capital
requirements. The capital asset budget demonstrates VA's commitment to
address critical major construction projects that directly affect
patient safety and seismic issues, and reflects VA's promise to provide
safe, secure, sustainable, and accessible facilities for veterans. The
request enables VA to invest in our facilities to fulfill VA's mission
to deliver timely and high quality care and services to our veterans.
The request also reflects the current fiscal climate and the great
challenges VA faces in order to close the gaps identified in our
Strategic Capital Investment Planning (SCIP) process.
Major Construction
VA acknowledges the challenges we have experienced in building the
Denver Replacement Medical Center facility in Aurora, Colorado. We are
committed to doing what is right for the veterans in Denver and
completing this major construction project without further delay. VA is
dedicated to getting the project back on track in the most effective
and cost efficient manner possible.
The 2016 budget requests $1.144 billion for major construction, an
increase of $582 million from the 2015 enacted level. The request
provides funding for nine on-going VHA major medical facility projects.
Correction of seismic deficiencies is a primary focus of our 2016 Major
construction request. The request includes funds to address seismic
problems in facilities in America Lake, Washington; and in San
Francisco, West Los Angeles, and Long Beach, California. These projects
will correct critical safety and seismic deficiencies that pose a risk
to veterans, VA staff, and the public. The photograph below shows a
known seismic deficiency at the San Francisco Medical Center--built in
1933--wherein the rebar does not extend into the ``pile cap.''
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We must prevent the devastation and potential loss of life that
occurs because our facilities are vulnerable to earthquakes--such as
occurred in 1971 in San Fernando, California. As shown below, a 6.5-
magnitude earthquake caused two buildings in the San Fernando Medical
Center to collapse and 46 patients and staff to lose their lives.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Major construction request also includes funds for medical
facility improvements and cemetery expansion project in St. Louis,
Missouri (Jefferson Barracks); new medical facility project in
Louisville, Kentucky; construction of a new outpatient clinic and a
columbarium in Alameda, California; realignment and closure of the
Livermore Campus in Livermore, California; and construction of a
replacement Community Living Center in Perry Point, Maryland. New,
replacement, and renovated medical space will provide additional
capacity to treat veterans through more efficient configurations, with
the implementation of Patient-Aligned Care Teams, and the establishment
of multi-exam rooms per provider--similar to the private sector. Once
the projects are completed, veterans will be served in modern and safe
facilities.
The major request also includes funding for four cemetery gravesite
expansion projects at: Puerto Rico National Cemetery; Willamette
National Cemetery in Portland, Oregon; Riverside National Cemetery in
Riverside, California; and Barrancas National Cemetery in Pensacola,
Florida. These projects offer VA the ability to provide access to
burial services through new and expanded cemeteries and prevent the
closure to new interments in existing cemeteries.
Minor Construction
In 2016, the minor construction request is $406.2 million. The
requested amount would provide funding for ongoing and newly identified
projects that renovate, expand and improve VA facilities, while
increasing access for our veterans. VA continues to focus on a balance
between continuing to fund minor construction projects that can be
implemented quickly to maintain and repair our aging infrastructure,
while using major construction funding to address life-threatening
safety and seismic issues that currently exist at multiple VA medical
facilities.
Leasing
The 2016 budget includes a request to authorize 18 major medical
facility leases under VA's authority at 38 U.S.C. Sec. Sec. 8103 and
8104, to provide access to veterans and enhance our research
capabilities nationwide. The proposed major medical facility lease
projects are to replace, expand, or create new outpatient clinics and
research facilities. The request includes resubmission of five leases
that were originally submitted in 2015, but have not yet been
authorized.
Additionally, since the inception of the EUL program codified at 38
U.S.C. Sec. Sec. 8161-8169, VA has entered into approximately 100 EUL
projects, leveraging approximately 5.8 million square feet and over
1,000 acres of excess property to repurpose in support of veterans, VA,
and local communities across the country. VA needs the support of
Congress for our proposed amendments to expand our current EUL
authority beyond supportive housing projects so we can better leverage
our excess space for veterans. In addition, this proposed enhancement
would allow VA to monetize unneeded assets to raise capital to address
needed investments in VA's system.
legislation
In addition to presenting VA's resource requirements, the 2016
President's budget proposes legislative action that will benefit
veterans. VA's most critical legislative request is for a significant
update to VA's authorities for purchase of non-VA healthcare. The
administration is proposing a streamlined process for purchasing
healthcare needed for veterans in those circumstances where it cannot
be purchased through existing contracts or sharing agreements. The
proposal takes care to preserve important features and protections
found in traditional contract vehicles. Current law is simply not
adequate to support the continued level of access to healthcare we need
to secure for our veterans. We look forward to detailed engagement with
the subcommittee and your staff.
Other important proposals include adjustment for VHA personnel
authorities, one of which will greatly help in having employee
scheduling flexibility that will both make hospital operations more
efficient, and help attract the most qualified medical professionals to
work for VA, especially for critical round-the-clock operations. VA in
this budget also again proposes changes in disability claims processes,
an area where reform is greatly needed, for the benefit of all veterans
who are frustrated with the time it takes to resolve claims and
appeals. We are open to all ideas from the subcommittee and from VSO's
to modernize this process, and make it work for veterans. Our increased
manpower and great strides in automation are helping, but these cannot
replace statutory changes to modernize the process.
As mentioned earlier, VA will propose a measure that would allow a
portion of the Veterans Choice Act funds to be used for essential
operational requirements. In addition, the legislative proposals would
allow for better coordination of care when a veteran also receives
other care at a non-VA hospital, by streamlining the exchange of
patient information. Additionally, we propose allowing the CHAMPVA to
cover children up to age 26, to make that program consistent with
benefits conferred under the Affordable Care Act.
To continue our priority to end veteran homelessness, VA proposes
increased flexibility in the Grant and Per Diem program to focus on the
transition to permanent housing. Also among our proposals is a measure
that would allow VA to speed payment of Dependency and Indemnity
Compensation and other benefits to surviving spouses by eliminating the
need for a formal claim when there already is sufficient evidence for
VA to act. We are proposing legislation to eliminate the requirement
for quarterly conference reporting. This requirement has impacted
essential VA training and has taken a massive staff effort to produce
the mandated reports. Since the beginning of fiscal year 2013, VA has
spent $2.4 million to prepare these reports. These resources are better
spent providing healthcare and benefits to veterans. We greatly
appreciate consideration of these and other legislative proposals
included in the 2016 budget and look forward to working with the
Congress to enact them.
closing
Veterans are VA's sole reason for existence and our number one
priority. In today's challenging fiscal and economic environment, we
must be diligent stewards of every dollar and apply them wisely to
ensure that veterans--our clients--receive timely access to the highest
quality benefits and services we can provide and which they earned
through their sacrifice and service to our Nation.
We also acknowledge the responsibility, accountability, and
importance of showing measurable returns on that investment. You have
my pledge that VA will do everything possible to ensure that the funds
Congress appropriates to VA will be used to improve both the quality of
life for veterans and the efficiency of our operations. We are proud to
be part of this VA team and feel privileged to be here serving veterans
at this key time in history. The work we do continues and grows for
decades after the end of America's conflicts. Thank you for the
opportunity to appear before you today and for your steadfast support
of veterans.
DENVER MAJOR CONSTRUCTION PROJECT
Senator Kirk. Thank you, Mr. Secretary. On Denver, I would
ask unanimous consent if I can put in a statement that Cory
Gardner gave us on this issue.
[The statement follows:]
Prepared Statement of Senator Cory Gardner
Chairman Kirk and Ranking Member Tester, I'd like to thank you for
holding this hearing and for giving me the opportunity to express my
concern over the U.S. Department of Veterans Affairs (VA) management of
the Denver Replacement hospital. In addition, I'd like to state my full
support for the completion of the hospital, which will serve hundreds
of thousands of veterans in Colorado and the Rocky Mountain Region. To
that end, I urge the subcommittee to include funding for the
construction of the Denver Replacement hospital in the upcoming
appropriations legislation.
The VA has a history of failing Colorado veterans, and this
mismanagement of the construction of the Denver Replacement hospital is
just the latest unfortunate example. The VA's failed management of the
construction of the Denver Replacement hospital has resulted in the
facility being nearly $1 billion over budget and months behind
schedule. For this reason, I've joined with Congressman Mike Coffman to
introduce the ``VA Construction, Accountability, and Reform Act'' in
the House and the Senate.
The purpose of this legislation is to complete the Denver
Replacement hospital and hold those officials responsible for its delay
accountable. Three key provisions in the legislation will accomplish
these goals.
First, the legislation transfers management of all medical
construction projects from the VA to the Army Corps of Engineers. Since
the Corps has experience with major construction projects, this
provision ensures that the Denver Replacement hospital will be
completed without further delays and cost overruns. And going forward,
removing the VA from the construction business will help ensure future
VA hospitals avoid similar mismanagement.
Second, the legislation seeks to offset the existing cost overruns
of the facility by stopping staff bonuses at the VA and using the money
saved to cover the additional cost of the Denver Replacement hospital.
Thirdly, the legislation requires the Comptroller General of the
United States to review the Secretary of the VA's management of the
replacement hospital and determine if misconduct or criminal activity
by VA employees may have contributed to the significant cost overruns
of the replacement facility. This review would establish when senior
officials at the VA should have known the replacement facility was
likely to incur cost overruns, and what the justification was for the
Secretary of the VA to withhold information relating to such
significant cost overruns from Congress.
Through these provisions, I believe this legislation will provide
accountability of taxpayer dollars, complete the construction of the
Denver Replacement hospital, and ensure that our veterans never again
have to wait for care while the VA fails to complete a construction
project.
Senator Kirk. With that $1.73 billion, Denver Hospital will
take up so much money, funding for MILCON for our missile
defense for 7.9 years, it would also take up 4 years of MILCON
for Special Operations. That is an awful big hit.
I would add to your list of things that were done wrong in
Denver is you did not have the Army Corps of Engineers
overseeing the construction of the facility. I want to make
sure that by June 1 you have already done that.
Secretary McDonald. Mr. Chairman, we have already done that
as of today. The Corps of Engineers is active on the ground, we
are working with them in concert, and we continue to want to
use the Corps of Engineers on other major projects.
May I make a statement, Mr. Chairman? This is not really a
hospital. This is a medical complex. This is what the complex
looks like, and as you can see, it is many buildings. It is not
just one building. It is very close to University of Colorado
Medical School, who is a partner of ours.
This is a major undertaking of many buildings, just not one
hospital. I just wanted to be clear on that, sir.
Senator Kirk. I would say that your proposal has been to
take $1 billion from the Choice Act to sink into this thing,
and that would eliminate about 20 percent of the Care Act
money. The promise we have already made to America's veterans,
we do not want to welsh on that promise because of the
mismanagement of the Denver facility. We need to have the
people involved with this fired and no longer a part of the
payroll.
Secretary McDonald. The gentleman that was in charge of
construction at VA is no longer with us. We conducted an
administrative investigation----
Senator Kirk. By ``no longer with us,'' it means you let
him quietly retire, he is still collecting from the taxpayer.
Secretary McDonald. He retired. He chose to retire the day
after the interview that he had, and to the best of my
knowledge, both in the private sector and in the public sector,
it is impossible to call back a retirement unless malfeasance
is proven, and the investigation is ongoing.
Senator Kirk. We had evidence of a whistleblower who sent
an e-mail very early on and said this project is likely to go
$500 million over budget, and that whistleblower was fired by
VA because of that e-mail.
I want to make sure this continued process of nailing
whistleblowers is wiped out in the VA. How would we have that
happen?
Secretary McDonald. I am not familiar with the situation
you are describing, but I would love to be able to get more
information on that and follow up.
We have been working with the Office of Special Counsel to
make sure that all of the whistleblowers who have been
retaliated against----
Senator Kirk. Let me just get it for the record, the person
that you were talking about was Glenn Haggstrom?
Secretary McDonald. Yes, sir.
Senator Kirk. The person who sent the e-mail saying we
would go $500 million over budget was a Adelino R. Gorospe, and
that person was let go, and turned out to be exactly correct on
all the warnings to VA on that subject.
Secretary McDonald. As I said, we have said within the
organization it is unacceptable to retaliate against anyone who
is criticizing our operation. In fact, we believe that we want
employees to help us improve our operation, and the only way
that can happen is if they are critical.
We have worked with the Special Counsel to get certified in
our activities around whistleblowers. We have reinstituted
several whistleblowers to new jobs. We celebrated with a
national award some of our whistleblowers, one in particular
from Phoenix, and we are committed to make sure whistleblowers
are not retaliated against. It is just unacceptable.
Senator Kirk. I want to make sure we do not wipe out the
Choice Act money for the overrun in Denver, that we stand by
our veterans there.
Secretary McDonald. We just do not know how much of the
Care money will be used, the Choice money will be used, and how
quickly.
Senator Kirk. Mr. Secretary, I understand if we just wrap
up the Denver situation, it would cost $3 million a month to
maintain that. Do you understand that to be true?
Secretary McDonald. I am not familiar with that figure. We
do not have that figure, but we will check on it.
Senator Kirk. Let me go to Mr. Tester.
Senator Tester. Thank you, Mr. Chairman. It goes without
saying the chairman, myself, and everybody on this subcommittee
knows how important this subcommittee is to our veterans in the
country and how we need to do a job together.
HOUSE COMMITTEE MARK
With that being said, I would note that the House
subcommittee mark came in about $1.4 billion, as you pointed
out, below your request. They achieved this largely by freezing
the major construction level, fiscal year 2015 levels,
including a number of other funding cuts.
In the past, there have been a lot of folks on this side of
the dais that have criticized the VA for not being frank about
what you need for money. A lot of criticism was warranted and
it led to funding shortfalls and subsequently had to be
addressed through numerous legislation, such as the Choice Act.
Now, a lot of the folks who demanded more results from you
are the same folks who refused to give you the flexibility and
the resources you needed to achieve the results that our
veterans need when they come to see you.
Is it fair to say that the House subcommittee mark is
inadequate?
Secretary McDonald. It is inadequate. It will cost veterans
to suffer.
As I said in the House subcommittee hearing on the budget,
we put in this budget knowing that it was going to be very
tight versus the demand that we faced, and in addition to the
budget itself, we wanted flexibility to be able to move money
from line item to line item because as I said to the chairman,
we cannot predict whether veterans are going to go for
community care with the Choice Act or whether they are going to
go with VA care.
Because of the way the budget is formed, I do not have the
flexibility to move money where the veteran goes.
Senator Tester. Is it also fair to say that due to Vietnam
veterans getting older, you are getting a lot more demand on
your facilities, and if that is true, can you tell me what that
$1.4 billion spending cut would mean to the veterans and to
their families?
Secretary McDonald. The $1.4 billion spending cut basically
means less veterans are going to get care. The medical care has
been cut by $690 million, which is the equivalent of 70,000
fewer veterans receiving VA medical care.
Senator Tester. As you see demand go up, you are not going
to be able to come close to----
Secretary McDonald. We will not have the money to care for
them.
VA RECRUITMENT EFFORT
Senator Tester. Okay. Hiring. We have discussed this
several times. We have given some increased funding and
enhanced mechanisms to address workforce shortage in the VA. It
looks as if it is static at best. We could be losing ground. It
seems we are battling on two fronts, not only attracting new
physicians and medical personnel, but keeping the ones we
already have.
The VA needs the authority and resources to hire good,
competent personnel and let them do their jobs, and then hold
them accountable for the outcomes.
I am worried that the cascading negative press about the
VA, its personnel, and the care it provides is crushing the
Department's ability to address workforce needs that we have in
Montana and I assume elsewhere in this country.
This is not to excuse any of the wrongdoing or to dismiss
any of the legitimate allegations of misconduct, but a lot of
folks around here are quick to go after a headline at the
expense of hard-working men and women who actually are doing
their jobs, working with the veterans, even if it means less
pay and longer hours.
My question to you as the head man, to what extent has this
impacted your ability to recruit to the VA?
Secretary McDonald. Senator Tester, as you know, I have
been to over a dozen medical schools and I have talked to
candidates to become nurses and doctors at the VA. The constant
haranguing on things that have gone wrong months ago, years
ago, has affected the public perception of the VA, and it makes
our recruiting job that more difficult.
We have increased the salary bands of our doctors. We are
looking at competitive pay of other providers within our
system. We have hired more doctors. We currently have hired
over 800 more doctors, over 2,000 more nurses, and we have
opened new facilities. We open about 17 new facilities a year.
But the demand, as you have suggested, has increased. We
have gone from roughly 4 million outpatient patients to nearly
6 million. That demand is going to increase as we continue to
improve the system and improve our customer service.
We have not even seen the full effect of the Iraq and
Afghanistan wars yet and the veterans who have fought in those
wars. We have to build the capability today to be ready for 5
years, 10 years, 20 years from now. That is what our plan does.
Senator Tester. We will talk more about those capabilities
next round.
Senator Kirk. Let me add on to that, I understand that
Glenn Haggstrom, who you said was responsible for the debacle
in Denver, got a $60,000 bonus according to Senator Gardner. I
would say if we are giving totally incompetent people big
bonuses like that, how can we ever take care of our veterans.
Secretary McDonald. I believe that bonus was for 2013 or
before, and not recently. As I said, we have the administrative
investigation going on, and as we get to the bottom of this, we
will figure out what the appropriate action is.
Senator Kirk. Mr. Boozman.
Senator Boozman. Thank you, Mr. Chairman. I agree with the
Senator from Montana, the vast majority of the VA personnel are
doing a great job and working very, very hard.
I think the thing that really shows that is how few have
actually accessed the program that we are trying to stand up so
they do not have to travel. Many of them are traveling even
though they can stay home.
It is hard, and I understand the argument, and certainly I
am going to bring up an issue that was before your time, and
yet it is hard in the sense that people are losing faith,
Congress is losing faith.
LITTLE ROCK, ARKANSAS SOLAR PANEL SYSTEM PROJECT
We have an issue in Little Rock. Congressman Hill has been
looking into this very vigorously, where we had a situation in
February 2012, the VA received an $8 million grant to build an
1.8 megawatt solar panel system at the Veterans Hospital. In
August 2012, the VA approved a parking deck project, which was
located at the same place as the solar panels. In January 2013,
construction on the solar panels began on the same location as
the planned parking garage.
VA officials were aware of the conflict at the time. In
August 2013, the solar panel construction was completed. In
April 2015, the VA dismantled some to build the parking lot,
and it is still not clear as to how much it is going to cost to
put them back, and whether or not they were able to function in
the grid to begin with.
I guess what I would like, we have these things going on,
what are the safeguards that we have? How are you dealing with
this kind of stuff?
Secretary McDonald. I mentioned some of the changes we have
made to the process of construction in my comments. I also
mentioned that we have changed the leader. We have a new leader
named Greg Giddens. He has experience across many sectors of
government and has done this before. I also happen to be an
engineer. My certification is in engineering training. I
studied engineering at West Point. Our Deputy Secretary is a
former CFO of a bank, very bright, intelligent guy.
We are digging into this in the strongest possible way, and
I would just simply say that this is not going to happen. That
happened in 2012. I appreciate you bringing it up. This is not
going to happen in the future. It just is not going to happen.
What we are doing is we are having design committees, we
are having outside people review our processes. We are using
the Corps of Engineers. We are using the best practices that
are available in industry today in order to make our system
better.
Senator Boozman. I think one thing that we have to be very
careful of, that process started then, and yet I do not know
how forthcoming VA was in admitting that the process was there.
Even now, when you ask how much is it going to cost to
reinstall, we get terms like procurement-sensitive, something
like that. That is not appropriate.
Secretary McDonald. I agree. We are trying to be more
transparent and more communicative than ever before. I would
hope that since I became Secretary, you have seen an increase
in my presence.
Senator Boozman. Yes, and I appreciate that.
Secretary McDonald. And an increase in our transparency as
a Department. I still every day do catch instances where I wish
we were more transparent and better about customer service.
PROVIDER REIMBURSEMENT
Senator Boozman. The other thing I would like to mention,
and I want to compliment you in this regard, we had a group get
together in Little Rock to discuss reimbursement to providers
that have provided outside care. You will have situations that
arise in the VA where because of emergencies or now with this
40-mile rule, the VA owes money.
It appears that the VA owes lots of people in Arkansas a
lot of money and has not been very forthcoming in paying those
bills. That is a real concern really for a couple of reasons in
the sense that it is another thing that makes it a trust issue
that we talk about.
The other problem is if you do not pay your bills, they are
going to quit dealing with you. That is the greatest thing, and
that really is going to affect quality of care.
Can you quickly mention that?
Secretary McDonald. I will, and maybe ask Carolyn to
comment. I talked about our five strategies from MyVA. One of
them I talked about was improving our internal support
services, and going to a shared services model, where we
centralize the bill paying so that is all that people do, and
that is something we are in the process of doing. We are not
done yet. We still have more work to do. That will dramatically
improve the rates at which people get paid. Carolyn.
Dr. Clancy. Yes. I would just add that we are tracking this
rates of payments and hold old the claims on a weekly basis. I
am pleased to say VISN 16, which had been struggling for a
while, and that is what Arkansas is a part of, is actually
improving faster than other networks, but we will keep a very
close eye on it.
As you said, Senator, if you do not pay your bills, people
are going to say gee, I would love to help you but I have to
pay, and that is not going to work.
Senator Boozman. Again, your people were very helpful and
did a good job in Arkansas. Thank you, Mr. Chairman.
Secretary McDonald. Thank you, sir.
Senator Kirk. Mr. Udall.
Senator Udall. Thank you very much, Mr. Chairman. Let me
along with the rest of the members echo your new aggressive
leadership and what you are doing in terms of veterans. I
really respect the team that you brought in, and this more
business like approach to what is an incredibly important issue
for veterans in my State and across the country.
Let me thank you, too, for the constructive dialogue we
have been able to have moving the VA forward as you near the
end of your first year as Secretary.
As we discussed during last week's visit, New Mexico's key
issues can be narrowed down to ensuring veterans have access to
care. Too often veterans are prevented from receiving the care
they deserve because of barriers to access. Starting with
disability claims, many veterans are not able to have their
claim adjudicated in a timely manner.
NEW MEXICO CLAIMS BACKLOG
In New Mexico, progress to reduce the backlog has
stagnated, and that is the chart I have behind me here. I think
I have showed you that before, where we have come down
dramatically, we have made good progress, but it is stagnated.
I am hopeful we can get the resources to make progress in
reducing the backlog once again, and where it is stagnated,
started in a downward turn.
ACCESS TO CARE
With regard to scheduling and the scheduling issue, last
summer showed we had a lot of work to do to ensure that
veterans are seen on time and the scheduling system was not
being utilized in a fraudulent manner.
As I mentioned, I asked the VA OIG to look into this
matter, and I am awaiting their findings. Furthermore, for
rural veterans in New Mexico and across the country, we need to
do more to find creative solutions to the recruitment and
retention problem facing the medical community in rural
clinics. This is not something that is solely a VA problem, but
I believe it is an area that VA can take a leadership role to
address.
Based on the budget requirements and the VHA's experience,
which would be the best way--this has been mentioned by several
questioners here and in some of your answers--which would be
the best way to improve access to quality care, an expanded fee
for service program, or a program which aims to recruit and
retain rural physicians and nurses at rural CBOCs and which
helps to expand telehealth? Which would be the most cost
effective way for the American taxpayer? I know you have given
this a lot of thought.
Secretary McDonald. Sir, I think we need to do both. We
envision a system in the future which is a combination of VA
care and community care working together in a network to make
sure our veterans get the care they want.
I would like to briefly comment on your chart.
Senator Udall. Please.
CLAIMS BACKLOG
Secretary McDonald. I think if you backed the time period
up, you will see a more dramatic decline in the claims backlog,
and also go back a couple of years.
I also think the reason it leveled out was we had 660
additional head count in the Choice Act for Veterans Benefits
Administration because we had been working mandatory overtime
in the Veterans Benefits Administration to drive this backlog
down to zero.
As I was going around doing town halls amongst the people
in Veterans Benefits Administration, I was seeing, not
surprisingly, increasing conflict between labor and management.
Mandatory overtime is not the way to run a business. That 660
people were stripped out of the Choice Act before it was
passed. You did not give us, ``you'' Congress, did not give us
those people.
We took off mandatory overtime hoping we could continue to
drive it down. That straight line is when we took off mandatory
overtime. It did not work. We had to put it back on. We are
still doing mandatory overtime, which we have been doing now
for several years, which is not a good idea.
We have more people in the 2016 budget that we need in
order to get the backlog down. We are going to get to zero by
the end of the year, but we need those people.
Also, I think there are a couple of months that are not on
your chart. Danny, could you update us on that?
Mr. Pummill. Yes. First of all, great charts, your numbers
are dead on. You did a really good job on it, or your staff.
Secretary McDonald. We should say we publish our numbers
every two weeks, so we want to be transparent and we want you
to know what our numbers are.
Senator Udall. We appreciate that.
Mr. Pummill. As we went back into mandatory overtime, we
started pushing again. You see these dark oranges, that is your
number pending. That has now come down.
Because that has come down, as of right now in April, you
are down to 47 percent on the backlog, 3,500 claims pending,
and 1,500 of those claims in the backlog, you will see the
continued downward slope that you saw earlier in your chart for
the next 3 months at a huge drop off this summer, because
pretty soon every claim we are going to be working is going to
be in the backlog, but that will not be just for your State,
that will be for the entire Nation. We should have zero backlog
this year.
TELEHEALTH
Secretary McDonald. Maybe I can ask Carolyn to comment on
telehealth, because this is a really important strategy for us.
Senator Udall. I have run out of time, if you could very
briefly, Carolyn.
Dr. Clancy. I would just simply say that New Mexico is
really a model with Dr. Arroyo at the University of New Mexico
working closely with us.
This is a matter of if the veteran cannot come to the
medical center, then we can use telehealth to bring that
expertise to the clinicians working out in the rural
communities. It has worked phenomenally and we are actually
using it in other parts of the system as well.
Senator Udall. Thank you very much. Dr. Arroyo, he is
pretty amazing. Thank you. Thank you, Mr. Chairman. Thank you
for your courtesy.
Senator Kirk. Mrs. Capito.
Senator Capito. Thank you, Mr. Chairman. I want to thank
the Secretary and others for being here today. It is nice to
see you again.
GREENBRIER OUTPATIENT CLINIC
I would really like to thank you and the VA for the
flexibility and the willingness to work on the 40-mile rule. We
talked about it. As you know, in a State like mine, West
Virginia, 40 miles as the crow flies could be hours in a car
sometimes. Making this change really helps veterans across the
country, and certainly in my State. Thank you.
I know you are aware of this issue. I think we talked about
it. It is in Greenbrier County. There is an outpatient clinic
there. It has been closed three times for, I believe, mold in
the facility, some unhealthy conditions in the facility because
of air quality. I think I read that the Bluefield Mobile Unit
is going to be serving the 2,400 veterans in that area.
I was wondering if you had--I know this is very specific--
if you had any other alternatives, are you going to replace
that facility, what your plans are for that.
Secretary McDonald. I would like Carolyn to comment about
the specifics. I would simply like to reiterate what I said.
Our facilities are too old. HVAC systems need to be replaced
about every 25 years. I talked to you about facilities that are
over 100 years old, 90 years old. This is unacceptable. We have
to decide which facilities to close. I talked about that. Which
facilities to refurbish so we do not have these chronic
problems.
We cannot do that with a budget that has been marked down
$1.4 billion by the House and the major construction part has
been gutted by almost half.
Dr. Clancy. I would say that we are hopeful for the moment
that we may actually be able to resolve these air quality
issues. I also want to point out that in terms of 40 miles from
that CBOC is not part of the calculation any more, so that
should offer more flexibility to the extent there are community
providers.
The mobile unit, those are the plans we have right now.
This will remain high on our agenda.
CIVILIAN BRAC PROPOSAL
Senator Capito. Thank you. It is definitely a problem. I
would just briefly ask you, and this was my last question, in
case I run out of time, since you were on it, on the facilities
you mentioned excess properties, 336 buildings are empty. You
said you need help with that.
How do we help you with that? It is not just budgetary. Is
it statutory?
Secretary McDonald. The President has put forward what I
would call a ``civilian BRAC.'' In other words, the idea to
take our facilities and have an up or down vote across the
Federal Government. I just think that is a brilliant idea. We
have to become more efficient.
I would suggest that it be passed and that we go at it.
MYVA REGIONS
Senator Capito. Okay. Let me ask you this. You mentioned
these are the MyVA regions. Dr. Clancy mentioned VISNs. This is
VA 101 for me. Are the VISNs gone?
Secretary McDonald. What we have done is we have started a
process where we are aligning the VISNs with those regions, and
in doing that, we are taking a new look at the VISNs and seeing
if there is an opportunity to reduce the number of VISNs.
The issue that we have right now, and this is a huge issue
that reflects the actions we are taking in accountability, 91
percent of our medical centers have either a new medical center
director or a new leadership team member.
We are really weak on leadership right now. We have new
leaders in place. What I do not want to do is increase the
spans of control so much that we take immature leaders or
leaders with less experience and put them under more pressure.
What we are looking at right now is a modest reduction in
the VISNs and an attempt to more align the VISNs to State
boundaries.
Senator Capito. I noticed in our State of West Virginia, we
are in the same MyVA. We are in three different VISNs, which
makes no sense----
Secretary McDonald. That is one of the things we want to
fix.
CLARKSBURG VA FACILITY
Senator Capito. For a small State like ours. Again, the
leadership issue. At the Clarksburg VA in Clarksburg, West
Virginia, it has unfortunately lagged behind as one of the top
people who have had the biggest wait times, and it just had a
leadership change at that VA. Are you seeing anything yet? Too
early to tell? Do you have anything to report there from
Clarksburg?
Dr. Clancy. I would be happy to follow up with you on that.
I want to make a point for you and all of your colleagues, that
we are tracking the excess and quality issues on an almost
daily basis. I would be delighted to follow up, Senator.
[The requested information was not available.]
Senator Capito. Thank you for that.
Secretary McDonald. In fact, we would be happy to invite
any of you to come to our daily stand up that we do, where
every morning we review the data and take action.
Senator Capito. All right. Thanks so much. Thank you.
Senator Kirk. Mr. Schatz.
VA/DOD ELECTRONIC HEALTH RECORDS INTEROPERABILITY
Senator Schatz. Thank you, Mr. Chairman. I know VA is
working with the Department of Defense (DOD) so that the two
can share servicemembers' medical records electronically, but
progress, as you know, has been slow. The Government
Accountability Office (GAO) specifically cited the lack of
progress as an issue when it added VA to its 2015 high risk
list.
According to GAO, ``The two departments have engaged in a
series of initiatives intended to achieve electronic health
record interoperability but accomplishment of this goal has
been continuously delayed and has yet to be realized. The
ongoing lack of electronic health records' interoperability
limits VA clinicians' ability to readily access information
from DOD records,'' and so on.
What kind of progress are you going to be making and when
can we expect for you to be off the GAO high risk list?
Secretary McDonald. First of all, when I met with the head
of GAO, I asked to be put on that list. We run the largest
healthcare system in the country, and with the crises that have
occurred, I thought it was appropriate that we are on the list.
I think the transparency and visibility is important to
improvement.
Second, we have made a lot of progress on the electronic
health record. Also, I would like to offer to members of the
subcommittee that we would be happy to come to your offices and
demonstrate the interoperability of the DOD and VA record. I
think once you see it, you will become much more conversant in
the progress that has been made. Steph.
Mr. Warren. Thank you, Mr. Secretary.
Senator Schatz. Very briefly, if you do not mind.
Mr. Warren. Yes, sir. From an interoperability standpoint,
we have been hitting on three levels. The first one is moving
the data within the existing systems, and we share more data
than any healthcare system in the Nation or in the world.
Our future is how do we get all the data in a single view,
and that is the demonstration that the Secretary offered, where
today you now can see all the VA data for any medical center
and DOD data as well as third party provider data in the same
screen. The data has been normalized, the providers can look at
it and they can actually make decisions based upon a continuum
of time in terms of that data.
Senator Schatz. What remains to be done?
Mr. Warren. The two next things that need to happen is the
viewer that chose that data is just for viewing, we are not
able to actually go in and change the data. That is the next
generation.
Senator Schatz. Is that a big technological or database
breakthrough?
Mr. Warren. It is two part. The first part is making sure
there are common standards. Working with ONC, the Office of
National Coordinator, to come up with national standards where
there are no national standards. We work with DOD to put those
standards in place.
Senator Schatz. Clinical standards or database?
Mr. Warren. Data standards, so we actually have
interoperability, we are using the same units, the same
definitions. A lot of effort over the next couple of years to
make sure the right standards are in place, and then we need to
go through and convert the data to meet the standards, and then
the second piece is to make sure the tools are there that shows
the data at the same time, and we can start changing the data
at either end.
Senator Schatz. What is the timeframe for all this?
Mr. Warren. The enterprise health management platform, we
are----
Senator Kirk. Let me step in here and deliver a threat that
I have been saying to DOD, if they insist on having different
standards, we will go with just the VA standards, that will
force the two bureaucracies to agree on a common standard, and
it will be a VA standard.
Secretary McDonald. Thank you.
Mr. Warren. Thank you for that, sir. A lot of strong work.
If I can bring a third party in, the Office of National
Coordinator does the standards for third party and private
providers, and with the Access to Care Act, with more care
going outside, it is not just the VA and DOD sharing, but how
do we get the private providers in the same standard so their
data can come in and be part of that continuum of care.
Senator Schatz. Start to finish--obviously, you will be
able to use some of this work as you are moving along, but what
is your total to completion?
Mr. Warren. The enterprise health management platform will
be at 33 sites by the end of the calendar year as a demo,
again, next generation, and then we will be adding capability
on over the next 3 years until we phase out what we have today.
ALOHA VET CENTER, HAWAII
Senator Schatz. Thank you. Mr. Secretary, I want to ask
very quickly about the ALOHA Vet Center on the Island of Oahu.
Oahu has 70 percent of the State's population. I have talked to
you a couple of times about it. This will double the
availability of clinical services for about 1.2 million people
and tens of thousands of veterans in the City and County of
Honolulu. Can you give me an update?
Dr. Clancy. This is going through the planning process
right now. We expect it will be advertised late fall of this
calendar year, and then the award will probably happen in the
first quarter of fiscal year 2018. It is going to take time,
but we are very, very excited about the access opportunities.
Senator Schatz. You said it would advertise this year and
the award will go out in 2018? Did you mean to say 2016?
Dr. Clancy. No. The actual final award and construction
will happen in the first quarter of fiscal year 2018, and the
construction will be complete in the last part of 2020.
Senator Schatz. Okay. My time has expired. I would like to
understand why you go 2 years from advertising of the award to
construction. Thank you, Mr. Chairman.
40-MILE DRIVING DISTANCE
Senator Kirk. My favorite Senator from Maine.
Senator Collins. Thank you very much, Mr. Chairman. Mr.
Secretary, I, too, want to thank you for working with many of
us on the 40-mile rule to change it from as the crow flies to
actual driving distance. Like Senator Capito, I represent a
State where as the crow flies and the driving distance are two
very different things.
The VA still does not consider whether or not the type of
care that the veteran needs is available at a VA facility that
is within that 40-mile limit.
For example, in Western Maine, there is a VA Mobile Unit in
Bingham, Maine that operates only 2 days a week. We are glad to
have it. Obviously, it is nowhere near a full-fledged facility
that can provide and meet the needs of our veterans.
That means veterans in Jackman, Maine could go to a
hospital, a local hospital that is 35 miles away, still a
distance, but much, much closer than going to the VA Hospital
for care, or they could go to the local community health center
right there in Jackman to get care, if the 40 miles were
considered to be measured in terms of whether the service is
actually available.
The service obviously is not available at a 2 day a week
mobile clinic. It is available at the community health center
and at a hospital that is 35 miles away.
These are not options available to our veterans in this
area due to the interpretation of the 40-mile rule. Are you
giving any thought to being more flexible in that area as well?
Secretary McDonald. We are in the process of analyzing it
and working with Members of Congress on what we discover. First
of all, the idea that whether or not you can get care from your
local facility is actually written into the law, so it is not
an interpretation. That was the way the law was written. If you
would like it changed, you need to change the law.
Secondly, our initial calculation suggests that if we were
to make that change, the minimum increase would be about $10
billion a year, not over the 3-year period of the Choice Act,
but a year, and it could be as high as $40 billion a year, if
we opened up that capability or that aperture for veterans.
We are in the process of looking at this, and what we want
to do is come back to you with the boundaries on what we
discovered and what our assumptions were, and have the
discussion if that is a law change you would like to make.
Senator Collins. There may be some sort of middle ground
here because in the case I gave you where the facility is not
even a CBOC, it is a mobile unit that is open only 2 days a
week, it just does not seem like a reasonable interpretation.
Secretary McDonald. There is a middle ground point that we
can take which is to in a sense change the geographic burden to
give the Secretary more flexibility to allow people with a
geographic burden of some kind to use the community care, and
we are also working on that, and we will come back to you with
the definition of that and how many people that will affect.
PROVIDER REIMBURSEMENT
Senator Collins. Thank you. I also want to associate myself
with the comments of the Senator from Arkansas about slow
payment to physicians and hospitals. This is a problem in my
State as well.
The problem is that if the VA ultimately denies the claim,
the hospital has missed the deadline for filing a claim for
reimbursement to a secondary insurer such as Medicare. What
happens is the healthcare provider ends up not getting paid at
all.
I really hope that some energy will be put on this problem.
Secretary McDonald. As I said, it is one of our most
important strategies. We simply have to get it right.
ADULT DAY CARE
Senator Collins. Thank you. Finally, in the 10 seconds I
have left, the VA in consultation with the National Association
of State Veterans Homes began working on regulations that would
govern adult day care, so there could be respite care for our
veterans who are living at home but may be suffering from
Alzheimer's or other dementias. That has been in process since
October of 2008, far precedes you.
That is more than 6 years ago. For the record, since I am
now out of time, I would ask you to give me an update. This
would make such a difference to so many of our veterans and
their family members, and it also would reduce nursing home
costs and costs of the State veterans homes.
I really think this is something that should be finalized
and should not have taken 6 years and still be pending.
Secretary McDonald. We agree, and we will get back to you.
[The requested information was not available.]
Senator Collins. Thank you very much, Mr. Secretary.
Senator Kirk. Senator Baldwin.
TOMAH VA MEDICAL FACILITY
Senator Baldwin. Thank you, Mr. Chairman, and ranking
member for this hearing today. Secretary McDonald, you noted in
your testimony that the VA is really at a crossroads, and you
struggle with significant challenges, including internal
management controls, as well as the delivery of safe,
appropriate care.
We have talked a number of times as I have with Dr. Clancy
about how these two failures have had really tragic results at
a particular medical hospital in Wisconsin, the Tomah VA
medical facility.
I look forward to working with the members of this
subcommittee on a number of steps we can take, including
legislation and programmatic initiatives to correct these
failures, to improve the quality of care that our veterans have
earned.
Dr. Clancy, your clinical investigation into the Tomah VA,
you have initial interim findings, and I know it is ongoing,
but with regard to opioids prescribing, you found that Tomah
was almost double the national average when it comes to rates
of prescribing opioids and benzodiazepines concurrently, which
is an unsafe practice that the VA's own clinical practice
guidelines for opioid therapy warns against.
Jason Simcakoski is a Marine who was one of the patients
prescribed both of these drugs and tragically passed away at
the Tomah VA.
I want to start with asking you if you believe the VA has
adequately managed the implementation of the clinical practice
guidelines for opioid therapy at local VA medical centers.
Dr. Clancy. I would say we made a good start and we have
far more to go and that is what we are doing right now. The
initial approach which predates both of us was to start at the
network level and then go down to the facility, and as we have
had a chance to brief you and your colleagues, this is now
getting down to the individual clinician level, because we can
do a much, much better job.
The irony, of course, is at that facility, Tomah, veterans
are less likely to be on narcotics than in the network or the
national average, but if they are on them, they are getting
very high doses, and far more likely to be on benzodiazepines.
We are also looking at how we can start to bring this down
to the individual patient level, and I think of that in two
ways. One is that as you would expect, the initial efforts to
reduce the use of opioids probably were most successful with
those veterans struggling the least, and what we have now is a
group of veterans with the most challenges with chronic pain
and other complications.
The second is I think we desperately need to figure out
what is the risk point at which someone transitions from taking
narcotics sometimes, say for low back pain as an example. Is it
a month, is it a couple of months? Where is that point where
the risk level goes way up. I think that is where pain
management intervention is most likely to be successful.
We are going to have to start to customize this much
further, which is the whole point of the academic detailing
initiative that has now been mandated and will be required for
full implementation by the end of June.
Senator Baldwin. I want to follow up on two points you just
raised. One of the real problems at Tomah was obvious dangerous
prescribing practices were considered within the bounds of
acceptable care.
Question one is do you believe the current VA prescribing
guidelines, which were last updated in 2010, are due for an
update, and the second question, and it may have to wait until
a second round, relates to driving these down to the patient
level and involving patients and their families more actively
in treatment protocols.
Dr. Clancy. Two quick responses, given time, and I am happy
to follow up with more. First, the guideline which was
developed jointly by the Department of Defense and VA will be
updated this year. They are going to be starting that process
this fall. We know on average practice guidelines need to be
updated about every 5 years, absent some kind of new
breakthrough evidence. That is the first thing.
The second thing is we actually now require that all
patients on narcotics actually sign an informed consent, and
that is part of their medical record every year.
I would say that is a down payment on the kind of
conversation you just referenced, and again, I am happy to
follow up further.
[The requested information was not available.]
Senator Baldwin. Thank you.
Senator Kirk. I would like to recognize our august vice
chairwoman, Senator Mikulski.
Senator Mikulski. Thank you for calling me august. I feel
like I have come in like a gust of air.
First of all, Mr. Chairman and Senator Tester, I would
really like to congratulate you on the work you have been doing
in VA MILCON, as you have been proceeding with due diligence,
you have had the usual sense of bipartisan that has been
characteristic of this subcommittee, and both of you have been
fighting like hell for our veterans. As the vice chair of the
full committee, I really want to thank you for the job, and
will do what I can to get you a juicy allocation.
I would like to first of all say hello to Secretary
McDonald and to his team here. I am going to engage in a bit of
a Maryland question. First of all, Mr. McDonald, thank you for
the job you have been doing, but you have a big job, and I
think you are finding that under every rock is another rock.
IG REPORT ON VA HEALTHCARE IN MARYLAND
We found the same thing in Maryland. I asked the Inspector
General of the VA to investigate claims that have come to my
attention in my constituent area program, allegations that
somebody had mouth cancer and was not properly tube fed,
somebody who did not get mental health appointments and later
committed suicide.
It was not me to finger point but to pinpoint, and the
Inspector General came back with findings. Some are deeply
troubling, that the facilities in Maryland did not follow the
outpatient feeding policy, that they needed to comply with
policies related to basic protocols on mental health services.
What the Inspector General did was come out with nine
specific recommendations. Rather than taking the time of the
subcommittee to read them, you know them, I have the report
here now, could you comment on it, and could I have your
commitment that you will do everything you can to follow up on
the Inspector General's recommendations?
Secretary McDonald. Yes, ma'am. I am a big fan of the
Inspector General and the work the Inspector General does. When
I was confirmed, I had about 100 IG investigations pending. I
think we are down to something less than 70 now. They are still
coming out, and most of them date to a year to 2 years ago. We
take them very seriously because they are an opportunity to
improve, and we remediate every single finding they come up
with, and we will certainly do that in the case of those in
Maryland.
Senator Mikulski. Did you want to say something, Dr.
Clancy?
Dr. Clancy. No, I would just add to exactly what the
Secretary said, we will follow up on this very closely.
Senator Mikulski. Are you familiar with this?
Dr. Clancy. Yes.
Senator Mikulski. Some of it is kind of surprising. First
of all, I really do appreciate it and look forward to staying
in touch on the follow up of the recommendations. They are not
only for Maryland, but they are also for the rest of the
country, like home feeding tube protocols, mental health
response time protocols.
PERRY POINT MARYLAND COMMUNITY LIVING CENTER
The other is the question related to Choice and the
implementation of Choice, and I have been an advocate of that.
Have you all covered that in the questions?
Secretary McDonald. Yes, ma'am, but go ahead and ask and we
will fire away as quickly as we can. We also covered the
replacement of a 155-bed community living center in Perry
Point, Maryland, that has been stripped out of the House
budget.
Senator Mikulski. You are replacing Perry Point?
Secretary McDonald. Yes, ma'am. We had in our 2016 budget
money to replace the 155-bed community living center in Perry
Point, and that was stripped out of the House markup.
Senator Mikulski. Mr. Chairman, Mr. Vice Chair, I would
like to talk with you about this. This is a facility that is
really oriented to mental health, and it takes care of veterans
with significant mental health challenges as well as
Alzheimer's. Some parts of that building are pre-World War I. I
would ask the subcommittee to come up, if the staff would, just
to validate the need and necessity for the MILCON request. I
think it is a compelling need, and we will talk about it.
Secretary McDonald. We do, too.
CHOICE IMPLEMENTATION
Senator Mikulski. On the Choice card, I understand--it is a
program I supported to shrink the waiting list. I understand of
the 8.5 million veterans that have been issued Choice cards,
less than 1 percent have been authorized care at non-VA
facilities. Could you give us the status of the Choice program?
Is it working the way we hoped? If it is not, is it
bureaucratic delay? What is the issue here?
This was meant to be an opportunity for veterans. My
Mountain County veterans, they are far away. The Eastern Shore,
nine counties.
Secretary McDonald. First, let me start, Senator, with the
thought that community care is important to the future of VA.
Currently today, even before the Choice Act, about 20 percent
of our appointments are community care, meaning outside the VA.
This is very important to us.
In the Choice Act, it has not yet worked the way we thought
it would. We have not had the number of veterans go outside the
VA system and use community care. What we have done is
redefined the 40 miles, how you measure the 40 miles, it is
driving distance now. We think that will double the number of
veterans using the Choice card. We think that is a big
improvement.
We are also looking at other improvements. We are doing
marketing. We are doing websites. We have a public service ad.
We are writing letters to veterans, making sure they understand
the system because many of the cards went out over the
holidays, and admittedly, a lot of people do not look at their
mail over the holidays. Marketing was necessary.
We are looking at everything we can to maximize the impact
of the Choice Act.
Senator Mikulski. Thank you. My time is up. I would just
say to my colleagues the Choice Act does offer an opportunity,
and perhaps you could use the 535 members of Congress
throughout town halls and so on, newsletters, to help
facilitate that. We hear the complaints. We would like to be
able to at least share with them an opportunity.
Secretary McDonald. That is a great idea.
Senator Mikulski. Not political, nothing political, but
really about this opportunity, particularly for the primary
care that this could provide.
Secretary McDonald. We would love to join you in writing
letters. We would also love to put a link on your website to
the Choice Care website, anything we can do to increase
communication. We would love to work with you on that.
Senator Mikulski. I think that would be fantastic.
Secretary McDonald. All members.
Senator Mikulski. Thank you very much, Mr. Chairman, for
letting me come in.
Senator Kirk. Dr. Cassidy.
HEPATITIS C TREATMENT
Senator Cassidy. Dr. Clancy, Mr. McDonald. A friend of
mine--I am a liver doctor. A friend of mine tells me that in
the VA, the budget for treating Hepatitis C has already been
exhausted, that currently the only folks that can access the
medicine used to clear Hep C are those with cirrhosis.
I suppose if you have cirrhosis, that is great. Really, you
want to catch it before it gets to cirrhosis because once you
have cirrhosis, you have a lifetime risk of cancer, that sort
of thing.
First, any comments on that, and then I have a follow up.
Secretary McDonald. As you are aware, Dr. Cassidy, Senator
Cassidy, the treatment for Hepatitis C is very expensive, in
the private sector it is roughly $1,000.
Senator Cassidy. A pill?
Secretary McDonald. A pill. We get it for about $650 a
pill, so our treatment is cheaper, and arguably, we have the
best protocols of any medical system. We do want to use it, but
it has become a huge proportion of our budget.
As a result of that, we have asked for incremental money in
the supplemental appropriation for Hepatitis C specifically,
because I think it is a moral and ethical issue that we have
the treatment, we know what to do, and we have patients that
need it, because our population disproportionately has
Hepatitis C, and we cannot use it.
Carolyn.
Dr. Clancy. We are doing a far better job than the private
sector in terms of screening and identifying veterans who have
Hepatitis C and actually getting them identified and so forth.
We have cure rates that is almost twice as high as the private
sector.
Senator Cassidy. It cannot be twice as high because it is
about 90 percent in the private sector.
Dr. Clancy. I mean the proportion of eligible veterans that
have been cured. Sorry, I used the wrong terminology.
Senator Cassidy. Let me ask just a follow up because I am
going to learn here. The fellow told me listen, what we are
told is send someone out to get the prescription from an
outside provider, which would trigger the Choice Act fund of
money, once they have the Rx, they can get their follow up in
the VA.
I guess you alluded to this in an earlier part of your
testimony. If the pot of money for the Choice Act is not being
used for pharmaceuticals, we cannot say listen, no one is
treating Hepatitis C in this community except the VA doc's and
they have room in their slot, so let them access the
pharmaceutical portion of the money. Is that correct? I am
asking. I do not know.
Secretary McDonald. Your point is correct, the
inflexibility of moving money causes us to try to do different
things with different pots of money. By sending someone out, we
can use the Choice Care money and get them treated, whereas if
they were internal, given our budget issues in pharmacy, we may
not be able to treat them.
Senator Cassidy. The pharmaceutical portion of the
patient's care is also under the Choice Act, it is not just the
doctor's visit, the surgery, whatever, it is also the
pharmaceuticals?
Dr. Clancy. What we are thinking through, and no final
decisions have been made, although our doctors have very, very
strong opinions because they have built up a tremendous
capacity and expertise, is we would refer eligible veterans to
a community provider but they would come back and get the
medications from us, which we think would be best for veterans
and the taxpayers. It would be what we pay.
Senator Cassidy. Getting back to your protocol, if you have
a good protocol on whom to treat and whom not to treat, as a
doc, I would not like that kind of discoordinated, well, we are
going to send you out here because that is how we access this
pool of money, but you are going to be followed up here because
we have the better protocol for management.
Really, the decision regarding management is critical at
its outset, if you will. Should we treat this person. Is there
no way around that?
Dr. Clancy. What we are trying to do is actually get as
many veterans access to this life saving curative treatment as
possible. This probably would not be the ideal design.
It would have some payoff, I think, of expanding the
capacity in the private sector to take care of other patients
with Hepatitis C, but it would require a lot of very close
coordination back and forth between VA doc's and doc's in the
community, and it would not work everywhere.
Senator Cassidy. There is no way for the VA doc to access
that Choice account for pharmaceuticals. It almost seems like
we are trying to really Gerry rig----
Dr. Clancy. Right now, that is not the case, and it gets
back to the Secretary's point about inflexibility of budgets.
Senator Cassidy. I have another question but I am out of
time. I yield back.
Senator Kirk. Let me add on, with the drug, we would not
need a liver transplant. As I have heard, it is about $1,000 a
pill. A liver transplant is about 300 grand. If we can avoid
300 grand by curing a veteran, then we are going to have much
better outcomes.
Secretary McDonald. Mr. Chairman, we agree.
Senator Cassidy. If I may say, speaking now as a liver
doctor, there are four stages with cirrhosis, the stage before,
transplant is the fourth stage. You really want to catch it in
that third stage. The third stage slides into the fourth.
If there is any way to expand coverage, and I am going
over, and I thank you for your indulgence.
Senator Mikulski. Mr. Chairman, speaking as vice chair
here----
Senator Kirk. Yes.
Senator Mikulski. First of all, there is a medical reason
of staying with one place. In other words, the VA is your
medical home. It seems sending them out is because of your
inability to have flexibility and money.
Here is what I am suggesting to my leadership here. I would
like to hear what is it that you need from us to give you the
flexibility to do that, and number two, what are the
impediments to do that? Do we have to go to authorizing, could
we do language here, could we do something?
You are in a medical home, you actually get these pills at
a cheaper price because you can buy in bulk.
Secretary McDonald. Correct.
Senator Mikulski. Now there seems to be just bureaucratic
rigidity maybe based on our law or something. With your
capacity and with the concurrence of Senator Cochran, I would
like to talk with you about this. I think, Dr. Cassidy, you
have identified an excellent point here.
Senator Kirk. Mr. Secretary, you look like you----
Secretary McDonald. This is an important issue for Hep C
because we are putting our doctors in the position of making
decisions about somebody's life or death, whether they go to
community care or our care.
This is an important issue for the subcommittee in general
because once we decided the Choice program, we are allowing the
veteran to choose where they go. I do not have the ability to
move money from VA care to Choice care or from Choice care to
VA care, yet we have introduced the invisible hand of Adam
Smith, allowing the veteran to choose, and I do not have the
ability to move money to care for him.
My biggest nightmare is that somebody goes for care and I
have the money in the wrong pocket. You would not run a
business this way.
Senator Mikulski. Can you help us?
Secretary McDonald. Yes, ma'am. I would love to.
Senator Mikulski. I would like you to communicate with the
chair and the ranking member who will then work with the
leadership.
Secretary McDonald. We have talked with both of them and
they are both supportive.
Senator Tester. I think Senator Cassidy brought up a great
point and you have hit it right on the head. I think the
challenge is going to be we are the problem. Congress is the
problem on this. The challenge is going to be Congress pointing
fingers at the Secretary saying you did not promote the Choice
Act enough, and unless we keep that money in there, you will
not promote that.
The truth is I think he needs the flexibility to transfer
in both directions, depending on where the veteran demand is.
Senator Kirk. Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman. Thank
you to all of you for taking so much time with us today.
We have probably exhausted the subject of the
implementation of the Choice program, but let me just add
another wrinkle for you from our experience in Connecticut for
you to ponder as you are thinking about how to implement this
in a way that works.
I agree with Senator Tester, I may have a question on this.
You certainly are going to have to prove that you have extended
the reach of the Choice program to everyone that deserves to be
under its umbrella before you are going to get the ability to
transfer money.
40-MILE DRIVE RULE
Let me add another way in which that may happen to your
laundry list. When the rule was 40 miles as the crow flies, it
was largely meaningless in the State of Connecticut, small
State, one VA.
When it moved to 40 miles by way of car travel, that
helped, but it ignored one reality in Connecticut, which is
probably not exclusive to Connecticut, I would bet it plays out
in places like Chicago and Los Angeles, which is that often the
40-mile car ride brings you into New York City, which is a
route that veterans from many parts of Connecticut are not
going to make and frankly should not make.
Because they are technically 40 miles away from a New York
VA facility, they do not get access to VA Choice in their home
town because they technically could get in their car and wait
in traffic for 3 hours to try to get into Manhattan, Queens, or
the Bronx.
I know this is tough to solve, because what you are
essentially trying to figure out is adding the ways in which
people commute to the very basic numbers that you have assigned
based on mileage.
Is this something you are thinking about in terms of how
you make sure that you are bringing as many people into the
program as possible?
Secretary McDonald. Yes, Senator Murphy. We are looking at
something called the ``geographic burden statement'' in the
Choice Act, and allowing the Secretary to have the flexibility
to determine that geographic burden. That would solve the
problem that you are describing.
We are working with the interpretation that currently
exists. We are looking to reinterpret it, and we are going to
work with you on that.
Senator Murphy. Okay, good. Thank you very much. West
Haven, our facility, first of all, it has been a really great
facility for veterans in Connecticut, notwithstanding the wait
times, backlogs, accounting scandals in other VAs. We have been
able to get veterans in pretty much on time to West Haven. They
have done a really phenomenal job there.
It is an old facility. It has an HVAC system that badly
needs to be replaced. It still has ward style bedding in many
parts of the hospital, absolutely no parking, which is a big
deal in Connecticut.
Secretary McDonald. It is a big deal everywhere.
CHOICE FUNDING FOR NON-RECURRING MAINTENANCE
Senator Murphy. Big deal everywhere. If you do not get the
ability to transfer dollars to the extent they are not used in
VA Choice, where else do you go for these kinds of capital
dollars? You are just going to have projects that simply are
not going to get done, and dollars that are going to go unused,
potentially, if you do not get this transfer authority.
Secretary McDonald. That is exactly right. We have about
70-plus line items that money is not moveable from one to the
other. As we talked about the House markup on the construction
bill, virtually cut in half, eliminating many of the projects
that are very important to us.
We do not have an alternative. It is ironic to me that
Congress passes the laws telling us what benefits we need to
execute to give the veterans. We are all for that, but if we do
not get the money to do it, I cannot make the two match.
When I look back at what happened in 2014 to the VA, before
I became Secretary, I would say it was a total mismatch of
demand versus supply. You would not run a business that way.
The way the agency has been run is working to a budget, not
working to requirements, not working on what customer needs
are. I am going to change the Department. I am going to get us
much more focused on veteran needs, but I need the wherewithal
to do that. I cannot print the money myself.
There is a choice for Congress. The choice is decide some
different benefit profile for the veteran or provide the money
that is needed for the benefit profile you have already
approved.
Senator Murphy. Hallelujah. A long question, I will save it
for the second round or for the record. Thank you, Mr.
Chairman.
Senator Kirk. Senator Tester.
Senator Tester. Just very quickly because I have to go. I
have several questions for the record on billing, partnerships
for mental health, and for Missoula CBOC. The whole committee
does not need to hear this, but I thank you for your service,
and we will look forward to the response to those. Thank you.
Senator Kirk. The Senator for all of King's Cove.
CHOICE FULLY INTEGRATED REIMBURSEMENT SYSTEM
Senator Murkowski. Thank you, Mr. Chairman. Secretary,
welcome to the subcommittee, Dr. Clancy. I appreciated the
opportunity that we had to visit last week as you kind of
walked us through some of the changes.
I was so appreciative that you took the time to visit with
Katherine Gottlieb, who not only is an Alaska leader, but truly
a national leader in innovation and working between systems,
Federal systems, whether it is IHS and VA, but to really
provide for an innovative level of care.
I am excited about this proposal. Mr. Chairman, ranking
member, and to our august vice chair--she did not hear that--I
do think at some point in time it would be wonderfully
instructive for this subcommittee and those of us who are
focused on the VA healthcare benefits for our veterans around
the country to understand the very, very innovative models that
we are utilizing in Alaska, where given large spaces and
limited facilities, we are figuring out a partnering through
systems, working through the IHS, working through our community
health centers.
It is providing a level of service to our veterans that is
immediate. We are breaking down some silos, and working with
the Secretary here.
I think we can look to some models that may work in rural
parts of our country that will provide the benefits that our
veterans have so honorably earned, but in a way that is good
care, good care. We call it ``care closer to home.''
I do not know about you, but when I am on the road, I am
always sicker when I am away from home. If I can get back home
where you have family and with our Native people and their
Native foods being in a place that is comfortable.
It is something I would like to talk to the subcommittee
about further and let you know what we are doing.
In that vein, Secretary, and Dr. Clancy, you can also jump
in on this, we do have this partnering that is going on. I
think the range of choices is good, but I also recognize that
we are still offering range of choices within systems that
still have their structure. I worry about moving of records and
sharing of data, and really making sure that these separate
rules within these differing programs do not cause more
confusion, and thus limit our veterans in terms of their
abilities to access these.
Either Dr. Clancy or Secretary McDonald, can you give me
any greater assurance as to how we are coming along with a more
fully integrated system with this very unique model that we are
seeing playing out in Alaska?
Secretary McDonald. We have a lot of work to do together to
get a single model that is integrated. Let me give you one
example. We have five different ways that a veteran can get
care in the community. Of those five different ways, each one
has a different reimbursement profile.
When Senator Tester and I were in Montana and he organized
a town hall meeting of providers, doctors, hospital systems,
and so forth, everybody there wanted ARCH. They loved ARCH as a
system. Well, ARCH pays Medicare Plus. Choice, PC3 paid
Medicare, Medicare Minus. Everybody loves ARCH but they do not
love the others.
To get to the right integrated system, we need to get all
the providers on board. To get all the providers on board, we
need to go to one integrated reimbursement system, one
integrated system, and we are going to put that together and
come to you, and hopefully get that passed, so that we can have
no question to get the providers on board and the veterans have
a place to go outside VA.
Senator Murkowski. The sooner that can be done, I think it
is to the veteran's benefit.
Secretary McDonald. Absolutely.
Dr. Clancy. The one point I would just add, it is working
well, our sharing arrangements with the Tribal Health Services.
Alaska is probably the most enthusiastic proponent and user of
those agreements. We are thrilled about that, about $10 million
from VA has gone to those services.
MYVA REGIONAL REALIGNMENT
Senator Murkowski. I appreciate that. Know that we want to
work with you. I will just make one comment. We had an
opportunity to sit down and talk about this regional
realignment. I have to tell you, I am concerned. As I look at
these divisions, it seems that we are getting bigger.
It looks like the territory that Alaska is in is almost
identical to what the 9th Circuit U.S. Court of Appeals looks
like. We have been fighting to break that up for a long time.
I am just sending the head's up to you that I am concerned
that when you have one region that is covering thousands of
miles, three different time zones, the concern that the
regional offices will be able to provide for that level of care
that our veterans expect, I am sending out the signals.
I have several different questions that I would like to
ask. We have talked a little bit about how we are focusing on
reducing the backlog, and I know it is always about numbers,
but at the end of the day for the veteran, they want to know
have you heard me, have you sat with me, what kind of care have
you provided me.
I know my case workers in my offices back in Alaska work
hard, and we are not pushing them to close out constituent
cases, boom, boom, boom, and we are assessing you on that
level.
Sometimes it is hard, but when we have one great success
with our veterans, it makes our staff feel better, like they
have really provided a service. I am concerned as we focus on
we have to reduce the numbers, we are forgetting the customer
service.
As we forget the customer service, we are forgetting not
only the satisfaction to the veteran, but the satisfaction to
the VA employee, who gets great personal satisfaction in
knowing that they have provided a level of care. They fixed a
vet's problem today.
If they cannot feel they are doing that, if they feel they
are just processing numbers, the difficulty in recruiting and
retention is going to continue, which means our backlog is
going to continue.
You are nodding because I know you agree.
Secretary McDonald. We agree with you entirely. This is why
we are all doing this. It is not because of the stock options
you get from the Government. We are doing this because of the
inspirational mission that we have of caring for those who have
protected us.
Senator Murkowski. We cannot lose sight of that.
Secretary McDonald. We cannot lose sight of that. It is
more than numbers. It is the picture of the gentleman behind
you. It is exactly the reason I gave out my cell phone number
during the first national press conference in September, and I
take calls every single day from veterans, and I listen to
them. You have to keep that visceral empathy of what we are
trying to do. It is all very personal.
Senator Murkowski. Thank you for your dedication. Thank
you, Mr. Chairman.
Senator Kirk. Senator Hoeven.
VETERANS ACCESS TO EXTENDED CARE LEGISLATION
Senator Hoeven. Thank you, Mr. Chairman. Also, Secretary,
thank you for being here today, appreciate it. I have visited
with you before about legislation that I put forward, the
Veterans Access to Extended Care.
It is all about making sure that we can encourage nursing
homes to take VA reimbursement for veterans by eliminating the
small business contracting requirements they are currently
under when they take VA reimbursement, but they do not have to
deal with when they take Medicare reimbursement.
That is a burden that really makes no sense for them, and
they even have to undergo separate inspections, so there is a
lot of red tape, a lot of compliance issues. Many nursing homes
will not take that reimbursement.
I would just ask you to comment if you would on how you can
help advance that legislation so we can get it put in place.
Secretary McDonald. We are very much in favor of it, so we
would like to talk to everyone who is going to vote and make
sure they vote in favor. We think that is the way to go.
We have to focus on veteran outcomes, veteran customer
experiences, and there is just so much red tape that is getting
in the way of it. In a sense, our people are trying to work in
a system where they are prisoners of the system rather than
working on meeting veterans' needs. We are very much in favor
of the legislation you have described and we want to work with
you on it.
Senator Hoeven. Thank you, Mr. Secretary. That is very
helpful. In fact, recently at a roundtable in my State, many
nursing homes were represented there, and they said if we could
get this passed, they would then look at taking VA
reimbursement. I think it would be very helpful. I appreciate
your willingness to help.
VETERANS ACCESS TO COMMUNITY CARE LEGISLATION
The second question I have for you is it is similar but it
goes to the healthcare/medical care from local providers. You
have touched on it here in a number of your responses.
I am a co-sponsor and others on the bill, it is similar, it
is the Veterans Access to Community Care, and you have touched
on that and some of the cost factors, but essentially the idea
is to get veterans' care closer to home, when they have to go a
long distance to a health center. They may have a CBOC.
For example, in my State, we have one VA health center. It
is a very good health center. It covers North Dakota and most
of Western Minnesota. They do a good job. It is a long way,
800-mile round trip from places like Williston, which I think
is the fastest growing community under 50,000 in the country
now, maybe over 50,000. I do not know. When they cannot get
that service at a CBOC, we have real geographical issues here.
Your thoughts on what we can do to address it in a way that
serves our veterans and then makes sense in terms of dollars
and sense, to affordability.
Secretary McDonald. I think job one is to really execute
the redefinition of the 40-mile limit, and do that as quickly
as possible so we can really determine how many people will
want to use community care.
We really do not know today how many people want to use
community care. We know the redefinition of the 40-mile limit
will virtually double the number of veterans who will take
advantage of it. That is what we think. We need to find that
out.
Second, I want to redefine or reinterpret the geographic
burden so that we have more flexibility, I have more
flexibility to provide the ability for people to call it a
geographic burden and go to community care.
The third thing we are looking at, which we talked about
earlier, is whether or not we look at whether we define it as a
VA facility that provide that service or a VA facility that
does not. Opening up that aperture could potentially be
extremely costly, as I said earlier. It could be $10 billion a
year to $40 billion a year. Of course, the whole Choice Act,
this part of it was $10 billion over 3 years.
That is a conversation we will have to have. We need the
numbers. We need some experience to be able to develop that
algorithm.
Senator Hoeven. I think that is really an important area,
to figure out how to do this. Again, if they are within 40
miles of a VA health center, then that 40-mile rule works
pretty well. If you have these really long geographic distances
where they have a CBOC, it is a real problem because there is a
big difference. If they have to have open heart surgery, sure,
maybe that trip, I understand, and so do they.
There are a lot of situations where there are these
services in between what a CBOC can provide and what a VA
health center can provide, where it actually would be cost
effective for the VA, too, because that veteran may have to
travel one day, get the service the second day, travel the
third day, and you are going to pay for both the travel and the
accommodations as well as the service.
In the case of a very senior person, think about the burden
of the travel. For a younger person who is working, they are
not taking 3 days off work. It is not only about figuring out
how to do this for the veteran, but I think it can be cost-
effective for the VA, too, if we do it as you say, figure out
the numbers and figure out how to do it. There is a difference
between carte blanche and doing it in a way that makes sense.
Thanks for your help in this, and I look forward to working
with you on it.
Senator Kirk. Senator Murray.
Senator Murray. Thank you very much, Mr. Chairman. Mr.
Secretary, good to see you again. Last year, I introduced
legislation to expand the caregiver support services the VA
offers and to make the full program available to veterans of
all eras.
I am going to be reintroducing that legislation tomorrow.
Senator Collins is my co-sponsor on that, and I want to work
with you to make sure we strengthen the program and make sure
it has the resources it needs to take on an additional
workload.
I really was happy to see the Department requested a
significant increase in funding for that program, and I have
also asked for additional resources for the Department to hire
more caregiver support coordinators.
I wanted to ask you today, do you know how many more
caregiver support coordinators you think you will need over the
next 2 years to support the current needs, and to take care of
new veteran eras coming into this program.
Secretary McDonald. Senator Murray, I do not know exactly,
but I do know we are very supportive of the legislation you
have written. We think pre-9/11 caregivers should get the same
benefits post-9/11 get.
I have spent a lot of time with caregivers myself. They are
the unsung heroes of our Nation. Many of them have to give up
their jobs, and many of them have to purposely not take on work
and not take on income because then they would fall out of the
program.
It is a real conundrum for them, and it is life changing
for families. We have to do this. We are eager to take it on
and we are eager to hire the people we need.
I have been to several college campuses. There are people
who want to join the VA to do this job. They are really eager
to join.
Senator Murray. Good. If you could let us know what you
think you are going to need over the next 2 years, that would
be really helpful.
Secretary McDonald. We will.
SPOKANE, WASHINGTON VA MEDICAL CENTER
Senator Murray. I think it is absolutely vital, so thank
you. I also wanted to ask you about the Spokane VA Medical
Center. As you are very aware, the emergency room at the
Spokane Medical Center has dramatically cut back its operations
because of staffing problems.
The medical center has repeatedly pushed back the date to
resume full time operations, and now I am being told it is not
going to be until next fall.
The Spokane VA has also recently asked for its surgical
complexity rating to be downgraded, and I am really concerned
about that request and the potential impact on the access to
care for our veterans in that region.
Last year, I asked Secretary Shinseki and Under Secretary
Petzel whether there were any plans to reduce programs and
services at the Spokane Medical Center, and they assured me
there were not. Yet, we now see this facility being downgraded.
The medical center is not getting the job done, so I want
to know what you are going to do to restore emergency services
and surgical care for the veterans that rely on the Spokane VA.
Dr. Clancy. One of the big challenges that we have had,
Senator, and we have discussed this previously, is actually
recruiting top-notch----
Senator Murray. I have been hearing that for 10 years.
Dr. Clancy. Yes. I am meeting with the College of Emergency
Physicians either next week or the week after that, and the
American Legion also has some ideas about how we might work
with some of the hospitals, and we have also raised the
available salaries that can be paid to people there.
Ultimately, if we cannot recruit top-notch talent, I think we
are going to need to explore some kind of partnership between
the Spokane facility and local hospitals vis-a-vis emergency
care.
Senator Murray. This has been ongoing forever and it is not
being resolved, and it is a huge issue for our Spokane
veterans. I want to talk with you again, Mr. Secretary. We have
to get this resolved however we do it.
Secretary McDonald. While I know it has been going on
forever, and we accept full responsibility for it, I have been
to over a dozen medical schools recruiting doctors. I have been
to the osteopathic convention recruiting doctors.
We are the canary in the coal mine. We are seeing the
problem that exists in American medicine. We need more primary
care doctors. We need more doctors who will live in rural
areas. We need more mental health professionals. We are working
extremely hard to do that, to find them, identify them, and
convince them, and give them a monetary incentive to locate
there.
We are going to continue to work very hard until we get
that Spokane facility up and running.
WOMEN VETERANS ACCESS TO QUALITY CARE ACT
Senator Murray. I really appreciate it. One other question,
I just have a few seconds left. Right now, the Veterans Affairs
Committee is holding a hearing on VA services for women
veterans. I want to stress how critically important it is for
the VA to prepare now to meet the needs of a growing population
of women veterans.
I was really pleased to work with Senator Heller to
introduce the Women Veterans Access to Quality Care Act this
year. That legislation is going to go a long way to helping the
VA provide safe, private healthcare for women.
VA already has a serious backlog in construction, but as
the number of women veterans increase and as they age, there is
going to be a need for more space dedicated to gender specific
care.
I wanted to ask you what the VA is going to do to meet the
treatment space for women veterans over the next 10 years.
Secretary McDonald. Some of our budget that was cut
dramatically in the House markup was slated for women's
clinics. We are installing women's clinics in our facilities.
We are hiring the gynecologists and other specialties that we
need in order to staff those clinics.
To us, this is critically important. Eleven percent of
veterans today are women. It is going to go up to 20 percent by
2017 or so. We have to get this done.
Many of our buildings, as I said earlier, are over 70 years
old, some of them----
Senator Murray. They do not have private space for women.
Secretary McDonald. And they have single gender bathrooms.
We have to get this fixed. That is why our construction budget
was as high as it was.
Senator Murray. Mr. Chairman, I am out of time. I will
submit the rest of my questions, but I really appreciate that
and I want to keep working with you on this.
Senator Kirk. Without objection.
DENVER MAJOR CONSTRUCTION PROJECT
Mr. Secretary, let me talk about the hippopotamus in the
room, about Denver. You guys asked for $5 billion to come from
the Choice Act to help fix Denver. Where do we go from there in
your view?
Secretary McDonald. Where do we go in terms of?
Senator Kirk. What is your instinct for Denver?
Secretary McDonald. Our instinct for Denver is to finish
constructing the medical complex. We would use----
Senator Kirk. I would say finish constructing the medical
complex under the supervision of the Army Corps of Engineers.
Secretary McDonald. Yes, they are already on the project.
They would complete the project with us. We plan to use the
Army Corps of Engineers in the future for major construction
projects.
Senator Kirk. I will make it simple for you, my position is
Cory Gardner's position, to make sure that you work very
closely with Senator Gardner. Thank you.
Secretary McDonald. We agree.
Senator Kirk. Thank you.
Secretary McDonald. In fact, the Deputy Secretary was out
in Denver yesterday and has been there, I think, seven times
since he has come into position.
Senator Kirk. Senator Baldwin.
Senator Baldwin. Thank you, Mr. Chairman. Hopefully, three
questions I can get in for this second round. I should follow
up for the record also.
TOMAH, WISCONSIN FIELD HEARING
Dr. Clancy, you were at the field hearing in Tomah,
Wisconsin, on March 30. I am a member of the Senate Homeland
Security Committee that jointly held that with the House
Veterans Affairs Committee.
We heard incredibly powerful testimony from family members
of veterans who had lost their lives at the Tomah facility or
after care there, as well as whistleblowers.
Now several months into this investigation, even at that
hearing where we were hearing of more deaths that were
unexplained that we had not heard before: in fact, I sent you
another letter today, not based on testimony at that hearing
but somebody who came up to me after the hearing and said, ``my
husband was treated there'' and I have concerns related to all
those that you have been hearing testimony about.
I just want to stress how important it is to have the
investigation be sufficiently expanded to review those deaths,
and I want your assurances that to the degree we can follow up
on everyone that has been reported during the conduct of your
investigation, that you will follow the evidence where it
leads.
Dr. Clancy. You have my full commitment; absolutely.
Senator Baldwin. I appreciate that.
Senator Kirk. If the Senator would yield, let me just add I
would associate my comments with Senator Baldwin, because a lot
of Illinois veterans would use the Tomah facility. We want to
make sure we fix the candy store, it was called.
Senator Baldwin. Candyland.
Senator Kirk. Candyland; yes.
Senator Baldwin. On the issue of proper treatment for pain,
Secretary McDonald, not only do we have to crack down on
inappropriate use of opioids and benzodiazepines, we have to
increase the alternatives to narcotics for pain management.
Veterans are calling for alternatives and complementary
medicines, and treatments, pain treatment.
We are here in the appropriations committee. I want to ask
you how the VA budget request supports the expansion of
complementary and alternative medicine and wellness programs
that would help veterans dealing with acute and chronic pain.
ALTERNATIVE MEDICINE AND WELLNESS PROGRAMS
Secretary McDonald. As we look at VA opioid use, which as
Dr. Clancy said, we track quite closely, it is moving down. The
reason it is moving down is I think we are the largest user of
alternative approaches in the country.
We have had tremendous success with acupuncture, with yoga,
with electronic stimulation, and we want to continue that.
Anything we can do to provide a different approach than opioid
use, we want to do.
As I have been touring all of our facilities, I think I
have visited about 125 so far, I am always inspired by those
people who are teaching yoga. In one location not too long ago,
there was an art instructor that was helping use art as a way
to allow people to become themselves again without opioid use.
Equine therapy, we now use equine therapy in places like
New Bedford, Massachusetts. These have been proven to be
successful. Any data-based way we can prove a successful
program, we want to do.
Dr. Clancy. I would just add, Senator, that we are doing a
lot of research in this area, trying again to understand which
veterans and what characteristics will predict a better
response to alternatives to narcotics, because that is very,
very critical.
I think it gets back to the notion of an informed
conversation between a clinician and a veteran, family, and so
forth.
Senator Baldwin. One final question. We were just talking
about the health workforce at the VA. One of the things that I
have certainly observed in rural medicine, for example, is if
you received your training there, perhaps if you were born and
raised in a rural environment, you are likely to make a
commitment in your career to remaining there.
GRADUATE MEDICAL EDUCATION RESIDENCE POSITIONS
I think the same is very much true with regard to the VA.
In the VA reform law that was passed last year, I authored a
provision that was ultimately included that would increase by
1,500 over 5 years the number of GME residency positions.
It is my understanding that in this first year of
implementation, 204 new resident positions were added. I would
like briefly for you to give me a status update on the
program's implementation.
Dr. Clancy. Senator, first, thank you for those additional
residency slots, because I think that is something that will
keep paying dividends in terms of capacity. We did not actually
think we could start residency positions until a year from this
July because of the slow ramp-up. However, what we did was go
to our existing partners and ask whether you have additional
spaces, and that is where we got the 204 slots.
We do not know what the uptake has been, so for example,
every year for the national match, it is kind of like the
Dating Game, right, primary care slots tend to go unused, so we
can get you a report on the 204. Match day was just a few weeks
ago.
One of the other areas, to get back to your point about
rural care, that we are working on, is trying to figure out how
we work with facilities and communities, who would desperately
like to do what you just described, but may not have the
infrastructure, how do we do that to make sure we can get them
the faculty support they need so the residents who are trained
there get the proper education and so forth.
It is a very exciting opportunity, so thank you for that.
Secretary McDonald. We are also pursuing osteopathic
doctors, DOs. Osteopathic doctors tend to be more family or
primary care physicians. They also tend to locate in rural
areas because that is where the medical school is.
Today, less than 1 percent of our doctors in VA are DOs, so
we are seeing if there is a way we can get more DOs. I spoke at
their convention in order to get more people to locate in rural
areas.
ADDITIONAL COMMITTEE QUESTIONS
Senator Kirk. I think we have pretty much beat this to
death now. Let me call us to a close, and we will keep the
record open until Tuesday, April 28, so members may have a
chance to put in questions for the record.
[The following questions were not asked at the hearing but
were submitted to the Department for response subsequent to the
hearing:]
Question Submitted to Hon. Robert A. McDonald
Question Submitted by Senator Mark Kirk
choice act
Question. Your budget request included an interesting statement
``VA is hearing directly from veterans and their representatives that
they would prefer to get their care in VA facilities from the medical
professionals they know and with whom they have relationships.'' You
also claimed the Choice Act will likely be underutilized and want to
transfer money out of the program for other VA needs, which we find
curious given the program is just getting started.
What data and facts are you using as the basis for these
statements?
Answer. As of April 11, 2015, there were 43,971 authorizations for
choice and 37,648 appointments scheduled. The Department of Veterans
Affairs recognizes that early utilization of the Choice Program has not
been as robust as expected. Based on input from all of our
stakeholders--from veterans, Veterans Service Organizations, our
employees, and Congress, we know that many veterans are frustrated with
the Choice Program and these frustrations and confusion are leading to
lower use of Choice. However, we have been eagerly seeking feedback on
the program from these stakeholders and we are working diligently to
address any challenges that may be contributing to the low utilization.
______
Questions Submitted by Senator Jon Tester
building capacity
Question. In this budget, the VA assumes a cost shift of $452
million next fiscal year from the discretionary VHA program for non-VA
care to the new Choice Act program. However, it's becoming clear that
the utilization of the Choice Program isn't as high as expected, at
least not at this point. Meanwhile, VA's traditional non-VA care
programs are seeing higher utilization rates than at this same time
last year. With no flexibility to move Choice Act funds and given the
VA's assumptions in this proposed budget, are we setting up the VHA for
a shortfall should the current utilization rates hold?
Answer. We continue to closely monitor usage of the Choice Program
and non-VA care and will provide additional information when we submit
our letter on the sufficiency of funds in the three medical care
advance appropriations for fiscal year 2016, as required by the
Veterans Health Care Budget Reform and Transparency Act of 2009.
agency collaborations
Question. I know that a number of VSOs have urged the VA to work
more closely with other agencies in the delivery of care. One example
is stronger partnerships with the Department of Health and Human
Services to expand mental health services through community mental
health centers. Can you speak more to this concept and how it could
expand the reach of mental health services for veterans and their
families?
Answer. Through the Interagency Task Force (ITF) on Service Member
and Veterans Mental Health and several specific initiatives such as the
Cross-Agency Priority Goal on Service Members and Veterans Mental
Health (CAP Goal), VA has worked closely with the Department of Health
and Human Services as well as the Department of Defense on a number of
mental health efforts over the past several years. For example, VA
mental health experts have participated in Policy Academies conducted
by the Substance Abuse and Mental Health Services Administration, at
which State-level plans are developed for community mental health
programs to improve services for veterans and their families. VA and
DOD also jointly developed a comprehensive curriculum on military
cultural competence that is available online and provides free
continuing education credits to healthcare providers across the
Government and in the community (i.e. to non-government providers who
may serve servicemembers, veterans and family members as a portion of
their patient population). Efforts are underway to more broadly
disseminate this course and other resources to community mental health
providers.
vet centers
Question. What is the VA's long-term strategy for mobile vet
centers?
Answer. VHA's Readjustment Counseling Service (RCS) is currently
authorized a fleet of 80 Mobile Vet Centers (MVC) that are designed to
extend the reach of Vet Center services by bringing focused outreach,
direct service provision, and referral services to communities that do
not meet the requirements for a ``brick and mortar'' Vet Center, but
where there are veterans, servicemembers, and families in need of
services. In many instances, these communities are distant from
existing services and are considered rural or highly rural.
Each MVC includes confidential counseling space for direct service
provision as well as a state-of-the-art satellite communications
package that includes fully encrypted tele-conferencing equipment,
access to all VA systems, and connectivity to emergency response
systems. Vet Center staff members regularly collaborate with VA
partners to create a single VA Footprint at events to ensure access to
all available VA services and benefits. The placement of these vehicles
is designed to cover a national network of designated Veterans Service
Areas (VSA) that collectively covers every county in the continental
United States, Hawaii, and Puerto Rico.
MVC staff, in collaboration with local and Regional RCS Leadership,
will develop and implement a focused access plan to ensure veterans,
servicemembers, and their families within their VSA have access to Vet
Center and other VA services.
Each access plan will be considered a living document to be
reviewed and updated on a biannual basis to ensure it is consistent
with the needs of the veteran and servicemember population within the
VSA. These plans will take into account the RCS goal of increasing MVC
participation in events by 15 percent over the previous fiscal year.
______
Questions Submitted by Senator Tom Udall
general accountability
Question. New Mexico's VA Hospital is within the same region as
Phoenix, and experienced some of the same scheduling abuses. I want to
make sure that headquarters does not forget about the issues in New
Mexico as well. I have worked closely with the Inspector General's
office to refer many very serious complaints and support his
investigation. Given the unacceptable nature of recent VA problems, I'm
glad we have new leadership at the VA, both in Washington and in New
Mexico. Will you give me your commitment to work to restore a culture
of high standards and accountability at the VA including in New Mexico?
Answer. Yes. VA's goal continues to be strengthening its culture of
accountability and putting renewed focus on employee-led, veteran-
centric change. Improvements in workforce culture, with a focus on
ICARE values (integrity, commitment, advocacy, respect, and
excellence), will allow VA to address issues as they arise, rather than
necessitating employee termination following repeated and/or pervasive
poor behavior.
polytrauma and travel
Question. The VHA's budget mentions that TBI and polytrauma are
major concerns for veterans who served in Iraq and Afghanistan. I
couldn't agree more. However, I am concerned about the large distances
many veterans, especially those in the west, have to travel to visit a
polytrauma rehabilitation center or a polytrauma network site. These
facilities offer advance care for our veterans, and unfortunately, for
New Mexicans, the closest sites are far away in neighboring States. Can
you tell me what the VHA's plan are for expanding access to polytrauma
care, and what it would cost to increase the coverage in the western
United States?
Answer. To improve access to specialized rehabilitation care for
Veterans with TBI and Polytrauma who live in the western United States,
VHA has expanded the Polytrauma System of Care, increased utilization
of telehealth, and engaged community providers to partner in healthcare
delivery for veterans. VHA deployed a network of 2 Polytrauma
Rehabilitation Centers, 5 Polytrauma Network Sites, and 12 Polytrauma
Support Clinic Teams to provide comprehensive TBI rehabilitation
services in the western United States. Additionally, 18 Polytrauma
Points of Contact sites offer a more limited range of TBI services with
specialized providers.
In fiscal year 2014, VA facilities in Veterans Integrated Service
Networks (VISN) 18 22 provided care for 12,721 veterans with TBI and
completed 40,895 visits. This represents approximately 24 percent of
the TBI rehabilitation workload reported nationally. Overall, the TBI
rehabilitation workload reported in VISNs 18 22 is in line with the
distribution of programming assets through the Polytrauma System of
Care.
At the same time, VA pursues new opportunities to improve access to
specialized rehabilitation care for veterans with TBI and Polytrauma.
These include:
--Expanding medical rehabilitation services: VA added two Polytrauma
Support Clinic Teams in Nevada and Montana and hired new staff
to augment existing programs. For example, the El Paso VA added
three new providers with dedicated time in polytrauma/TBI care.
Overall, the number of rehabilitation specialists working in
VISNs 18--22 grew by 7.5 percent in fiscal year 2014 from
fiscal year 2013.
While deploying additional rehabilitation assets continues to be
one of the avenues for improving coverage, VA has to balance this with
the rather low demand for services across large geographical areas.
Leveraging technology, specifically telehealth: This provides an
effective means of reaching more patients in remote areas. TBI and
Polytrauma telehealth services reached 57 percent more patients in
fiscal year 2014 than in fiscal year 2013. VA is working to bypass some
of the existing difficulties with the quality of broadband in rural
areas by leveraging new technologies such as the newly released ``CVT
Patient Tablet,'' which facilitates broadband videoconferencing between
the veteran's home and the provider, who may be located in a different
State or VISN.
Partnering with community providers to deliver healthcare services:
While VA has used fee-based care successfully in the past, the new
processes developed as a result of the Choice Act provide clarity and
facility to these partnerships. VA is also reaching out to community
partners to provide education and training using VA-developed materials
with the goal of supporting continuity of services. The cost of
expanding medical rehabilitation services in VISNs 18-22 could include
increased staffing at the 18 Polytrauma Point of Contact sites that do
not have fully staffed TBI/Polytrauma teams. To fund additional TBI/
Polytrauma teams at these sites would cost approximately $550,000 per
year (salary dollars for 3.5 staff per site), for a total of $9,900,000
annually. The cost of increasing telehealth services and community
partnerships is more difficult to calculate at this time as technology
evolves and community partnerships mature.
VA continues to work to increase access to specialized TBI and
Polytrauma care by leveraging assets, technology, and community
partners and balancing those with veterans' needs in communities across
the western United States.
choice act
Question. One concern I have heard about the veterans choice act is
that the VHA cannot guarantee that the veteran will receive the same
quality of care that they would at a veterans hospital or clinic. How
is the VHA working to ensure that veterans receive quality care when
they make use of outside medical care as authorized in the veteran's
choice act?
Answer. VHA works to maintain quality oversight of all purchased
care from the community related to certain standards, including, but
not limited to, credentialing, access to care/timeliness, patient
safety, and patient satisfaction. For example, to increase governance
and oversight of quality and patient safety in the field for VA Care in
the Community, the Choice Program has adopted a multi-committee
structure focusing on Quality Oversight and Safety and Patient Quality
and Safety.
rural health
Question. Based on the budget requirements and the VHA's
experience, which would be the best way to improve access to quality
care. An expanded fee for service program, or a program which aims to
recruit and retain rural physicians and nurses at rural CBOCs and which
helps to expand telehealth And which would be most cost-effective for
the American taxpayer?
Answer. VA is committed to delivering timely and high quality
healthcare to our Nation's veterans, and the ultimate goal is to align
our capacity with the veterans' needs and preferences. Therefore, the
most valuable measures we use to understand an individual's ability to
access our system are the perceptions and opinions of our veteran
patients. This requires balancing our fee for service program,
recruiting and retaining the best medical professionals, and using
innovative technologies such as telehealth to increase access to care
for veterans.
federal it reform
Question. Describe the role of the Veterans Health Administration's
Chief Information Officer (CIO) in the development and oversight of the
IT budget for the Veterans Health Administration. How is the CIO
involved in the decision to make an IT investment, determine its scope,
oversee its contract, and oversee continued operation and maintenance?
Answer. The VHA CIO prepares annual IT resources budget requests
that are approved by the Undersecretary for Health and then through the
Information Technology Leadership Board (ITLB), before being presented
to the Secretary. The VA ITLB is the body that recommends the annual
budget request to the Secretary. As such, with advice from staff, the
VA CIO works with VHA IT personnel to determine project scope and
subsequent contractual efforts needed to undertake development efforts
to provide needed technological solutions to our business partners in
the Department (VHA, the other Administrations, and Staff Offices). The
VA CIO plays a key role in developing the annual budget submission, as
well as being the single point of authority for IT in VA, is the sole
individual for overseeing continued operation and maintenance of
deployed IT capability in the Department.
Question. Describe the existing authorities, organizational
structure, and reporting relationship of the Chief Information Officer.
Note and explain any variance from that prescribed in the newly-enacted
Federal Information Technology and Acquisition Reform Act of 2014
(FITARA, Public Law 113-291) for the above.
Answer. There is no variance between the requirements set forth in
the Act and the activities that the VA CIO has been performing,
subsequent to 2009's consolidation of IT into a centralized account.
The VA CIO is the sole authority for all matters related to IT in VA
and reports directly to the Secretary for Veterans Affairs (SecVA).
VA's CIO:
--Approves agency's IT budget requests
--Certifies that IT investments adequately implement incremental
development
--Confirms that all requested IT positions meet ongoing requirements
--Reviews and approves VA's contracts and funds reprogramming
requests for IT
--Directs IT capital planning and investment review process and
certifies the accuracy and risks associated with the
investments
--Administers the development of an integrated IT infrastructure
--Promotes efficient and effective design and operation of
information resource management processes
Question. According to the Office of Personnel Management, 46
percent of the more than 80,000 Federal IT workers are 50 years of age
or older, and more than 10 percent are 60 or older. Just 4 percent of
the Federal IT workforce is under 30 years of age. Does the Veterans
Health Administration have such demographic imbalances? How is it
addressing them?
Answer. The Office of Information and Technology (OI&T) within the
Department of Veterans Affairs (VA) reflects similar percentages. The
attached table displays the following statistics. OI&T has a total
employee population of 7,916, which includes all IT workers and those
that provide support to the IT workforce. OI&T has 145 (1.8 percent of
the total) employees under age 30; 1,290 (16.3 percent) employees
between ages 30 and 39; 2,314 (29.2 percent) employees between ages 40
and 49; 3,087 (39.0 percent) employees between ages 50 and 59; and
1,080 (13.6 percent) employees over age 60. Percentages for IT
employees (those with occupational specialty 2210) are very similar and
near identical to the entire population of OI&T.
We are refreshing our existing Human Capital Management (HCM)
Strategic Plan to specifically address this topic. We are analyzing
existing trends within industry as well as the rest of the Federal
Government. We are leveraging our existing contracted consultants to
gain insight on how the entire Federal Government is going to address
this changing workforce. For example, OI&T is examining phased
retirement, an initiative that for which the Office of Personnel
Management (OPM) issued a final rule last year. If implemented,
employees who are eligible for retirement would continue to work part
time while drawing a portion of their retirement. This program could
aid OI&T succession planning efforts.
TABLE
--------------------------------------------------------------------------------------------------------------------------------------------------------
IT Employees in occupational specialty
Age Demographic Total OI&T Workforce: 7,916 2210 (Computer Specialist): 6,661
--------------------------------------------------------------------------------------------------------------------------------------------------------
Under 30.......................................................... 145 ( 1.8 percent) 118 ( 1.8 percent)
30-39............................................................. 1290 (16.3 percent) 1107 (16.7 percent)
40-49............................................................. 2314 (29.2 percent) 1962 (29.5 percent)
50-59............................................................. 3087 (39.0 percent) 2571 (38.6 percent)
Over 60........................................................... 1080 (13.6 percent) 903 (13.6 percent)
--------------------------------------------------------------------------------------------------------------------------------------------------------
[For further information, see the VA document ``Office of
Information and Technology: Human Capital Strategic Plan 2014-2022.'']
Question. How much of the Veterans Health Administration's budget
goes to Demonstration, Modernization, and Enhancement of IT systems as
opposed to supporting existing and ongoing programs and infrastructure?
How has this changed in the last 5 years?
Answer. As mentioned in the opening remarks, all VHA IT
expenditures are funded by the central IT Appropriation, which is
administered by the Office of Information Technology (OIT). The Office
of Information Technology Development, Modernization, and Enhancement
(DME) and Operation and Maintenance (OM) budget for the 5 years from
fiscal year 2012 through fiscal year 2016 is in the table below:
TABLE
----------------------------------------------------------------------------------------------------------------
Fiscal Year
(Dollars in Million) Fiscal Year Fiscal Year Fiscal Year Fiscal Year 2016
2012 2013 2014 2015 Request
----------------------------------------------------------------------------------------------------------------
Total DME...................................... $580.358 $517.921 $495.291 $548.335 $504.743
Total OM....................................... $1,616.018 $1,834.523 $2,181.653 $2,316.009 $2,512.863
----------------------------------------------------------------------------------------------------------------
Question. What are the 10 highest priority IT investment projects
that are under development in the Veterans Health Administration? Of
these, which ones are being developed using an ``agile'' or incremental
approach, such as delivering working functionality in smaller
increments and completing initial deployment to end-users in short, 6-
month timeframes?
Answer. VA develops hundreds of IT projects under several
categories (such as Access to Health Care, Eliminating the Backlog,
Eliminating Veteran Homelessness, and Information Security, to name a
few). Each Administration and business function within VA has its
respective priorities in support of the overall VA mission. The list
provided below represents VA's priorities in IT development across a
broad range of Department goals.
Health: Vista Evolution (including Pharmacy, Laboratory, Medical
Appointment Scheduling System, and Enterprise Health Management
Platform (eHMP)), Mental Health, Surgery, Bar Code, Enrollment Customer
Enhancements, Purchased Care, Medical Care Collection Funds, Genomic
Informatics System for Integrative Science (GenISIS), Virtual Lifetime
Electronic Record (VLER), Mobile Applications
Benefits: VBMS, eBenefits, Customer Relationship Management
Memorial and Corporate Products: HRIS/HR Smart, PIV Enhancements,
VATAS Enhancements, Memorial and Benefits Management System (MBMS)
Over the past several years, VA has become a leader among
Government agencies in implementing agile development. In fact, the
U.S. Government Accountability Office (GAO) Report 14-361 indicated
that VA was the only agency to implement agile development methodology
fully. PMAS is the disciplined, data-driven approach VA utilizes to
support on-time delivery of IT capabilities. VA is developing each of
the projects in this list using an agile development approach.
Question. To ensure that steady state investments continue to meet
agency needs, OMB has a longstanding policy for agencies to annually
review, evaluate, and report on their legacy IT infrastructure through
Operational Assessments. What Operational Assessments have you
conducted and what were the results?
Answer. VA's OIT Service Delivery and Engineering (SDE) office has
conducted an annual Operational Analysis (OA) based on OMB criteria for
its major steady-state investments, which are Medical IT Support,
Benefits IT Support, and Enterprise IT Support. These investments have
performed within acceptable variances, or higher than performance
metric thresholds. Notably, the average availability of major systems
has consistently been above 99 percent.
Question. What are the 10 oldest IT systems or infrastructures in
the Veterans Health Administration? How old are they? Would it be cost-
effective to replace them with newer IT investments?
Answer. The table below describes 18 VA systems that leverage
legacy technology (i.e., common business-oriented language (COBOL)
software or mainframe hardware) and are potential candidates for
replacement. While the VA does not track the exact deployment date for
legacy systems, many of the listed systems have been active for 25
years or more. Over the last year, VA has been developing a
comprehensive divesture process that will be utilized to assess system
value based on a variety of technical and business criteria to
determine if legacy systems should be divested or maintained.
Implementation of this process is anticipated to begin in fiscal year
2016.
Veterans Health Information Systems and Technology Architecture
(VistA) is a system containing over 100 individual component
applications (Pharmacy, Lab, Imagining, etc.) with unique instances at
data centers across the Nation. VistA includes the Computerized Patient
Records System (CPRS). VA is placing special emphasis on developing and
deploying a modern version (VistA Evolution) to replace and upgrade
VistA.
Table
----------------------------------------------------------------------------------------------------------------
Parent
VASI Id System Acronym System Name Organization Organization
----------------------------------------------------------------------------------------------------------------
1277............................ FMS............... Financial OM................ Office of Finance
Management System.
1174............................ DSS............... Decision Support OM................ Office of Finance
System.
1423............................ MPCR.............. Monthly Program OM................ Office of Finance
Cost Report.
1160............................ CCS............... Credit Card System OM................ Office of Finance
1712............................ VETSNET........... Veteran Service VBA............... Veterans Benefits
Network. Administration
1352............................ IPS............... Insurance Payment VBA............... Veterans Benefits
System. Administration
1053............................ BIRLS............. Beneficiary VBA............... Office of the
Identification Deputy Under
Record Locator Secretary for
System. Disability
Assistance
1094............................ CH 1606........... Chapter 1606-- VBA............... Veterans Benefits
Montgomery GI Administration
Bill Selected
Reserve--Benefits
Payment System.
1196............................ ESS............... Enterprise Self VBA............... Veterans Benefits
Service. Administration
1145............................ COVERS............ Control of VBA............... Veterans Benefits
Veterans Records Administration
System.
1099............................ CH 30............. Chapter 30-- VBA............... Veterans Benefits
Montgomery GI Administration
Bill Active Duty
Benefits.
1102............................ CH 31............. Chapter 31-- VBA............... Veterans Benefits
Vocational Administration
Rehabilitation
and Counsel.
1973............................ VistA............. Veterans Health VHA............... Veterans Health
Information Administration
Systems and
Technology
Architecture.
1830............................ PAID.............. VistA--Personnel VHA............... VHA Office of the
and Accounting Principal Deputy
Integrated Data. Under Secretary
for Health
1126............................ CNH............... Community Nursing VHA............... VHA Office Patient
Home. Care Services
1085............................ FEE............... Central Fee System VHA............... VHA Chief Business
Office
1909............................ DM2............... Debt Management VHA............... Veterans Health
System. Administration
1056............................ BDN............... Benefits Delivery VBA............... Office of the
Network. Deputy Under
Secretary for
Disability
Assistance
----------------------------------------------------------------------------------------------------------------
Question. How does the Veterans Health Administration's IT
governance process allow for the Veterans Health Administration to
terminate or ``off ramp'' IT investments that are critically over
budget, over schedule, or failing to meet performance goals? Similarly,
how does the Veterans Health Administration's IT governance process
allow for the Veterans Health Administration to replace or ``on-ramp''
new solutions after terminating a failing IT investment?
Answer. Although IT governance is led by the Office of Information
and Technology (OI&T), VHA recognizes the need for complementary VHA IT
governance to inform OI&T and to allow for proper investment oversight
by the customer/consumer. As such, VHA has recently revamped the VHA IT
decisionmaking process in support of VHA governance. It was recognized
that a high level of management, structure, and compliance is necessary
to carry out a successful business and/or IT program. Because better
management, awareness, and decision-making required a portfolio/
capability construct that is comprehensive, decisionmaking is now based
on a comparative review of IT investment alignments against VHA's
strategy and objectives--such as those endorsed in VHA's Blueprint for
Excellence.
Likewise to support this governance approach, VHA established an
investment review board whose responsibilities include regular program
reviews with a focus on performance and business outcomes.
Additionally, the governance process empowers capability management
boards (CMB), comprised of key VHA leaders and field clinicians, to
prioritize programs, using business criteria, for IT investment
funding. These boards also provide a business council to review funded
IT programs and make sure they are meeting their requirements,
executing properly, and doing so within the approved schedule. Finally,
the VHA IT governance process provides the forum for discussion to
occur with OI&T and VHA for ceasing poorly performing projects and
replacing them with other ``in the queue'' VHA IT priority needs.
OIT has implemented the Program Management Accountability System,
or PMAS, to monitor the progress of projects. Project efforts are
divided into increments, each of which delivers specified functionality
to OIT's business partners in 6 months or less. PMAS ensures the
readiness of increments to be successful through its milestone review
process and the performance of increments to deliver on time and on
budget through its risk management process. If a project misses three
on-time increment deliveries it must submit to a Closure Review
ensuring that if projects fail, they do ``fail fast,'' reducing the
drain on IT resources. If a project is closed out, resources then
become available to reassign. VA OIT prioritizes requirements that do
not otherwise have funding (``unfunded requirements,'' or UFRs). The
prioritization is conducted within the context of the IT governance
process--that is, the prioritization that is developed is approved
through the IT Leadership Board and the Deputy Secretary for VA.
Resources that become available are assigned to UFRs in order of their
prioritization, which will ``on ramp'' new projects. One of the
requirements for an effort to be considered in the UFR prioritization
process is that it is ready to execute if funding becomes available.
Question. What IT projects has the Veterans Health Administration
decommissioned in the last year? What are the Veterans Health
Administration's plans to decommission IT projects this year?
Answer. VA is developing a divestiture process that will be used to
formally guide divesture decisions and actions moving forward and is
continuing to strengthen governance in place to be effective. Systems
recently decommissioned are listed below.
During fiscal year 2015/2016 the following systems/applications are
being considered for retirement.
1. Titus Toolbar
2. Existing AV system
3. Region 1 Remedy Help Desk system
4. Region 3 Remedy Help Desk system
5. Region 4 Serena Help Desk system
6. Tuscaloosa Remedy Help Desk system
7. NCA Remedy
8. FSC System Center Service Manager
Table
----------------------------------------------------------------------------------------------------------------
Parent
VASI Id System Acronym System Name Organization Organization
----------------------------------------------------------------------------------------------------------------
1141............................ CMIS.............. Construction OALC.............. Office of
Management Construction and
Information Facilities
System. Management
1959............................ VBRS.............. Veterans Benefits VBA............... Veterans Benefits
Reference System. Administration
1362............................ INP............... International VBA............... Veterans Benefits
Payments. Administration
1708............................ VCC............... Veteran Call VBA............... Veterans Benefits
Center. Administration
1389............................ LACAS............. License and VBA............... Veterans Benefits
Certification Administration
Approval System.
.............................. SMART............. SMART OI&T.............. Office of
Certification and Information and
Accreditation Technology
Tool.
1104............................ FET............... Chapter 33--Front VBA............... Veterans Benefits
End Tool. Administration
1130............................ CAPRI............. Compensation and VHA............... Veterans Health
Pension Record Administration
Interchange.
1605............................ SCIDO............. Spinal Cord Injury VHA............... Veterans Health
and Discorders Administration
Outcomes.
----------------------------------------------------------------------------------------------------------------
Question. The newly-enacted Federal Information Technology and
Acquisition Reform Act of 2014 (FITARA, Public Law 113-291) directs
CIOs to conduct annual reviews of their IT portfolio. Please describe
the Veterans Health Administration's efforts to identify and reduce
wasteful, low-value or duplicative information technology (IT)
investments as part of these portfolio reviews.
Answer. Each year, OIT conducts a zero-based build of its IT
portfolio as it builds the IT budget request. By its nature, by
building from the ``bottom up'' each year, all items in the IT
portfolio are assessed regarding their support of OITs requirement to
provide VA business elements with the technological tools needed for
their success. Demand for IT solutions exceeds the resources available,
so OIT's budget build necessarily (a) focuses on the highest priority
items first, and (b) works to maximize the efficiency of all elements
in the IT portfolio. Put another way, maximizing the efficiency means
working to eliminate redundant, wasteful, and low value efforts so that
the IT portfolio, as a whole, provides the best utilization of scarce
resources. This ``zero-based'' build is reviewed through the IT
governance process where all of OIT's VA stakeholders (VHA, VBA, NCA,
and staff offices) are represented and can weigh in on the budget
build. The VA CIO chairs the IT Leadership Board that runs the IT
governance process that reviews the IT budget. As VA is unique in the
Federal Government in having a separate appropriation that funds all of
OIT, the IT governance process allows the CIO to review the entire IT
portfolio annually as a result of building the IT budget request. Once
an appropriation is received, review of execution occurs. While this
isn't an annual process but rather an ongoing one, it nonetheless also
works to identify development efforts that are not performing as
intended. Those resources are recaptured and then applied to other
projects within the constraints of enacted appropriation law.
Question. In 2011, the Office of Management and Budget (OMB) issued
a ``Cloud First'' policy that required agency Chief Information
Officers to implement a cloud-based service whenever there was a
secure, reliable, and cost-effective option. How many of the Veterans
Health Administration's IT investments are cloud-based services
(Infrastructure as a Service, Platform as a Service, Software as a
Service, etc.)? What percentage of the Veterans Health Administration's
overall IT investments are cloud-based services? How has this changed
since 2011?
Answer. Every hosting decision considered cloud computing as an
option for deployment. It is estimated that 15 of over 200 Veterans
Health Administration's IT investments involve some proportion of
cloud-based services (Infrastructure as a Service, Platform as a
Service, Software as a Service, etc.). About 5 percent of the Veterans
Health Administration's overall IT investments involve some cloud-based
services. The percentage has roughly tripled since 2011.
Question. VA CIO Stephen Warren testified to Congress in November
2014 that the VA was directing an additional $60 million to its
information security efforts in fiscal year 2015. How is the Veterans
Health Administration leveraging its internal information security
resources to protect against breaches or leaks that could disclose
sensitive and personally identifiable information? Does the Veterans
Health Administration currently use digital rights management or other
content-concentric tools to protect such information?
Answer. VA's Continuous Readiness in Information Security Program
(CRISP) is the Department's guiding initiative designed to foster a
security-conscious culture and establishing a stronger information
security posture across the enterprise. As has been recognized by the
Office of Inspector General (OIG), VA has used CRISP to make
significant progress towards addressing findings of material weakness
in recent years. VA recently established a dedicated CRISP Program
Management Office, which allows VA to allocate full-time staff members
to maintaining an effective risk-based security program and preparing
for annual OIG audits.
CRISP represents a cultural change that is necessary for VA to
achieve adequate protection of veteran and other sensitive information.
Thus, its success is largely determined by the entire community of VA
employees, business partners, and contractors adhering to security
policies to preserve the trusted relationship that VA has with
veterans. CRISP program success includes, among others, the following:
--Annual mandatory information security training is VA-wide for all
employees and contractors and is strictly monitored and
enforced.
--VA is performing onsite information security compliance validation
across the enterprise.
--VA has initiated a project to identify unauthorized software on the
VA network and remove, update, or replace the software as
appropriate.
--Scanning of all known devices for outdated software patches,
removal of software strictly prohibited by VA is being enforced
with additional resources that were allocated to the CRISP
Program.
In addition, VA utilizes a ``defense in depth'' approach to
protecting its information from internal and external risks. This
approach includes administrative, technical, and physical security
controls, which are implemented throughout VA systems. If one control
fails, others are designed to provide protection so that VA data is not
placed at risk. VA has also implemented a continuous monitoring
capability that allows VA to automatically monitor its systems for
threats and vulnerabilities.
VA has implemented rights management software (RMS) to protect
veteran information. VA also provides users with the capability to use
their PIV cards to sign and encrypt emails and documents.
VA does not use digital rights management or other content-
concentric tools. However, VA has implemented rights management
software (RMS) which allows information and documents to be protected
and controlled, including an inability to be forwarded, printed, or
saved. VA also provides users with the capability to digitally control
content through the use of PIV cards to sign and encrypt emails and
documents.
SUBCOMMITTEE RECESS
Senator Kirk. I call it adjourned.
[Whereupon, at 4:20 p.m., Tuesday, April 21, the
subcommittee was recessed, to reconvene at a time subject to
the call of the Chair.]