[Senate Hearing 114-]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2017
----------
THURSDAY, MARCH 10, 2016
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 11:05 a.m., in room SD-124, Dirksen
Senate Office Building, Hon. Mark Kirk (chairman) presiding.
Present: Senators Kirk, Murkowski, Hoeven, Collins,
Boozman, Capito, Cassidy, Tester, Udall, Schatz, and Baldwin.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF HON. ROBERT A. MCDONALD, SECRETARY
ACCOMPANIED BY:
HON. DAVID J. SHULKIN, M.D., UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION
DANNY G.I. PUMMILL, ACTING UNDER SECRETARY FOR BENEFITS,
VETERANS BENEFITS ADMINISTRATION
OPENING STATEMENT OF SENATOR MARK KIRK
Senator Kirk. The subcommittee will come to order. Good
morning. This is the subcommittee's second hearing on the
fiscal year 2017 and fiscal year 2018 advance budget request.
The President has requested over $78 billion in
discretionary funding for the Department of Veterans Affairs
(VA), an increase of 4.9 percent. This year, there was a
request for $104 billion in advance mandatory benefits funding.
This subcommittee of this Congress has given you everything
you wanted, and more. The answer to every VA problem is not
``give us more money, give us more flexibility.'' We need to
fix the VA's corrupt culture and all too often poor
performance.
We also need to talk about accountability and veterans
first and not bureaucrats.
Mr. Secretary, I understand that you will be visiting
Illinois next week while in Chicago. I hope you will notice the
difference in the culture at a facility that combines the
military's healthcare standards with veterans' care.
I want to recognize my friend, the Senator from the Big
Sandy metroplex in Montana, Mr. Tester.
STATEMENT OF SENATOR JON TESTER
Senator Tester. Thank you, Chairman Kirk. Thank you for
holding this hearing on the VA's budget.
Secretary McDonald, it is great to have you here today,
with your team. Thank you for your service to the veterans of
this country.
Last week, we heard testimony from Dr. Shulkin and Mr.
Pummill about VA and the Veterans Benefits Administration's
(VBA) budget request. I look forward to continuing that
discussion today.
As you know, one of my top concerns continues to be the
long wait times for veterans trying to get the healthcare
through the Choice program. You and I, Mr. Secretary, have had
numerous discussions about the failures of the Choice program
in my home State. Some of the fault lies with the VA, some lies
with Congress. As I said last week, a lot of lies with the
third-party administrator in Montana. What they have done and
what they are doing is completely unacceptable.
I know time is tight today, so I am not going to rehash the
litany of complaints that I receive on a daily basis from
frustrated veterans. I know these issues are not isolated to
Montana. They are in other States, including Senator Collins'
State of Maine.
I do not have to tell you the frustrations are growing up
here. I know you hear them. I know you share them. The bottom
line is the Choice program is broken. We need to fix it, and we
need to fix it as soon as possible.
That is why I introduced legislation last week that will
fix the issues we are having with Choice. Moving forward, it
will put in place a less complex and confusing framework for
Care in the Community. That will reduce administrative burdens
both for community providers and for the VA, and connect
veterans to the care they need in a more timely manner, and
more streamlined.
Earlier this week, I met with Chairman Isakson, who is
chairman of the Senate Veterans' Affairs Committee on this
issue. We share the same goals and we share the same concerns.
We are now committed to finding a bipartisan solution to
address these problems in a comprehensive manner.
Mr. Secretary, I hope we can enlist your effort in that
regard. When all is said and done, we have to get it right. Our
veterans deserve nothing less.
With regard to your budget request, as I see it, there are
some very good things in it, but there are also some things
that need further explanation.
Failure to account for sustained costs of doctors and
nurses that we have hired with Choice Act funds is one. The
overall reduction in capital budget is yet another.
I look forward to addressing these issues and other issues
with you today and in the weeks ahead. Again, I want to thank
you for your service. Thank you for being here today.
Thank you, Mr. Chairman.
Senator Kirk. Thank you.
I want to welcome our witnesses. Secretary McDonald is a
graduate of West Point and the Secretary of Veterans Affairs.
He is accompanied by Dr. David Shulkin, the Under Secretary for
Health, and Mr. Danny Pummill, the Acting Under Secretary for
Benefits. I welcome you both back to the subcommittee. Welcome,
gentlemen.
SUMMARY STATEMENT OF HON. ROBERT A. MCDONALD
Secretary McDonald. Chairman Kirk, Ranking Member Tester,
members of the subcommittee, thanks for the opportunity to
present the President's 2017 budget and 2018 advance
appropriations request for the Department of Veterans Affairs.
I have submitted a written statement for the record.
The President's 2017 budget proposal is another tangible
sign of his devotion to veterans and their families. It
proposes $182.3 billion for the department in fiscal year 2017,
which includes $78.7 billion in discretionary funding, a 4.9-
percent increase above the 2016 enacted level, largely for
healthcare. It includes $65 billion for medical care, a 6.3-
percent increase of $3.9 billion over 2016's enacted level. It
includes $12.2 billion for Care in the Community and the new
Medical Community Care budget account to increase transparency
on VA spending for non-VA care, as required in the VA budget
and Choice Improvement Act. It provides $66.4 billion in
advance appropriations for VA medical care programs in 2018, a
2.1 percent increase above the 2017 request. It provides $7.8
billion for mental health. It funds veteran contact centers,
and it funds veteran crisis line modernization.
This proposal provides $1.5 billion for effective hepatitis
C treatments for at least 35,000 veterans, but perhaps
significantly more depending upon the pricing of the drugs.
It provides $1.2 billion for telehealth access, $725
million for veteran caregivers, and $515 million for health
programs for women veterans.
The proposal includes $103.6 billion in mandatory funding
for veteran benefit programs in 2017 and $103.9 billion in
advance appropriations for our three major mandatory Veteran
Benefits Accounts.
It requests $2.8 billion for the Veterans Benefits
Administration, including support for an additional 300 staff
to reduce the nonrating claim inventory and provide veterans
with more timely decisions on nonrating claims.
And it includes $156.1 million for the Board of Veterans
Appeals, an increase of 42 percent over the 2016 level. This is
a down payment on a long-term, sustainable plan to eliminate
the appeals backlog.
The budget supports the VA's four agency priority goals. It
supports our five MyVA transformational objectives to improve
the veteran experience, to improve the employee experience, to
improve internal support services, to establish a culture of
continuous improvement, and to expand strategic partnerships.
It provides $2.6 million for the MyVA program office to
help integrate MyVA initiatives across the enterprise, and
$72.6 million for the Veterans Experience Office, so we can
continue establishing high customer service standards.
And it supports our 12 breakthrough priorities for 2016 and
fiscal year 2017. These are critical investments, if we are
serious about transforming VA into the high-performing
organization veterans deserve and taxpayers expect.
Over 3 decades in the private sector, I learned first-hand
what it takes to be a high-performance organization, and that
goal is within our reach. We already have a clear purpose and
strong values and strong strategies. We have a growing team of
talented business and healthcare professionals making
innovative changes. Ten of our top 16 executives are new since
I became Secretary, and we are building responsive systems and
processes shaped by design to meet veterans' needs.
For veterans, that means they have 24/7 access to VA
systems and know where to get answers. Veterans calling or
visiting primary care facilities at a medical center have
clinical needs addressed the same day. Veterans engaged in
mental healthcare needing urgent attention speak to a provider
the same day. And veterans calling for a new mental health
appointment receive suicide risk assessments and immediate
care, if needed.
For employees serving veterans, it means training on
advanced business techniques that drive responsive and
innovative change. It means clear performance expectations,
continuous feedback, and performance management systems that
encourage continuous improvement and excellence.
It means that executive performance ratings and bonuses
reflect actual performance and relevant inputs like veteran
outcomes, employee surveys, and 360-degree feedback. And it
means modern, automated systems in place of antiquated and
costly paper processes.
We are advancing along all of these lines and many others.
Growing a high-performing culture is what our Leaders
Developing Leaders (LDL) program is all about. Leaders
Developing Leaders is a continuous, enterprise-wide process to
instill lasting change.
We launched LDL last November with 450 senior field
leaders, and we have trained more than 5,000 leaders so far. We
met again last week to build on growing momentum and share best
practices that we will leverage across the VA. By year's end,
we will have over 12,000 senior leaders empowering more and
more teams to dramatically improve care and service delivery to
veterans.
Private sector experts are teaching cutting-edge business
skills like Lean Six Sigma and Human Centered Design. Human
Centered Design and Lean are helping leaders reshape the
compensation and pension exam that veterans find burdensome.
We are planning to automate performance management to
streamline the process and improve rating accuracy. And we are
finding new ways to provide higher quality care and benefits
more efficiently.
Our pharmacy benefits management program avoided $4.2
billion in unnecessary drug expenditures last year. We have
saved over $500 million in travel spending since 2013,
exceeding goals of the President's campaign to cut waste.
We have reduced employee award spending $150 million, and
Senior Executive Service (SES) bonuses 64 percent between 2011
and 2015 by rigorously linking awards to performance.
Since 2011, we have saved $16.6 million using more
efficient training and meeting methods. We have already saved
$10 million a year under the MyVA five district structure that
we announced in January 2015.
We saved approximately $5.5 million from 2011 to 2015 by
strengthening controls over permanent change of station moves.
And we will save millions each year in paper storage since we
implemented electronic claims processing.
So we are committed to doing everything we can for veterans
with everything we are given.
But more than 100 legislative proposals for meaningful
change require congressional action. Over 40 are new this year,
some absolutely critical to maintaining our ability to purchase
non-VA care.
To best serve veterans, we need your help streamlining VA's
Care in the Community systems and programs. We have to
modernize and clarify VA's purchase care authorities to
preserve the veterans' access to timely community care
everywhere in the country.
Above all, this needs to be done in this Congress. I have
consistently identified it as a top legislative priority. We
provided detailed legislation addressing this challenge over 9
months ago. Members of this Committee and others in Congress
have introduced legislation to address these issues. Now we
look forward to working with you to ensure we get this right.
The budget proposes a simplified, streamlined, and fair
appeals process, so that in 5 years, veterans could have
appeals resolved within 1 year of filing. The statutory appeals
process is archaic and unresponsive, not serving veterans well.
Last year, the board was still adjudicating an appeal that
originated 25 years ago and had been decided more than 27
times.
Legislating a simplified process can save over $139 million
annually beginning in 2022.
We compete with the private sector for talent, especially
in healthcare, so we are proposing flexibility on the 80-hour
pay period maximum for certain medical professionals and
critical compensation reforms for network and hospital
directors.
Likewise, we are looking at how we can treat our career
executives more like their private sector counterparts, and we
are working with our stakeholders to shape a plan that best
serves veterans.
The budget proposes appropriations language for general
transfer authority that allows me some measured spending
flexibility to respond to veterans' emerging needs.
We need congressional authorization for 18 leases submitted
in the VA's 2015 fiscal year and 2016 budget request. We need
authorization for eight major construction projects included in
VA's 2016 fiscal year request. And we need support for the six
additional replacement major medical facility leases in the
2017 budget. And passing special legislation for VA's West Los
Angeles campus will get positive results for veterans there who
are most in need.
This Congress with today's VA leadership team can make
these changes and more. And it is all for veterans. Then we can
look back on this year as the year that we turned the corner.
I appreciate this opportunity and the support you have
shown veterans, the department, and the MyVA transformation,
and I look forward to answering your questions.
Thank you, Mr. Chairman.
[The statement follows:]
Prepared Statement of Hon. Robert A. McDonald
Good morning, Chairman Kirk, Ranking Member Tester, and
distinguished members of the Senate Appropriations Subcommittee on
Military Construction and Veterans Affairs. Thank you for the
opportunity to present the President's 2017 budget and 2018 advance
appropriations (AA) requests for the Department of Veterans Affairs
(VA). This budget continues the President's faithful support of
veterans and their families and survivors, and it sustains VA's
historic transformation. It will provide the funding needed to enhance
services to veterans in the short term, while strengthening the
transformation of VA that will better serve veterans in the future.
a vision for the future
VA's vision for the future is to be the No. 1 customer-service
agency in the Federal Government. The American Customer Satisfaction
Index already rates our National Cemetery Administration No. 1 with
respect to customer service. In addition, for the sixth year in a row,
VA's Consolidated Mail Outpatient Pharmacy received J.D. Power's
highest customer satisfaction score among the Nation's public and
private mail-order pharmacies. These are compelling examples of
excellence. We aim to make that so for all of VA.
We are transforming the entire Department, not just making
incremental changes to parts of it. We began in July 2014 by
immediately reinforcing the importance of our inspiring mission--caring
for those ``who shall have borne the battle,'' their families, and
their survivors. Then, we re-emphasized our commitment to our
exceptional I-CARE Values--Integrity, Commitment, Advocacy, Respect,
and Excellence. To provide timely quality care and benefits for
veterans, everything we are doing is built, and must be built, on the
rock-solid foundation of mission and values.
MyVA is the catalyst making VA a world-class service provider. It
is a framework for modernizing VA's culture, processes, and
capabilities so we put the needs, expectations, and interests of
veterans and their families first, and put veterans in control of how,
when, and where they wish to be served.
Listening to others' perspectives and insights has been, and
remains, instrumental in shaping our transformation. We have taken
advantage of an unprecedented level of outreach to the field and our
stakeholders. In my first months as Secretary, I assessed VA and
recognized that we would need to change fundamental aspects of every
part of VA in order to rise to excellence. I shared my assessment's
results with President Obama and received his guidance. I discussed my
findings with you and other Members of Congress--privately and during
hearings. And I consulted with literally thousands of veterans, VA
clinicians, VA employees, and Veteran Service Organizations (VSOs) and
other stakeholders in dozens of meetings.
Since my July 29, 2014, confirmation, I have made 277 visits to VA
field sites in more than 100 cities, including 47 visits to VA Medical
Centers, 30 visits to homeless veterans program sites, 16 visits to
Community Based Outpatient Clinics, 15 Regional Offices, and 9
Cemeteries. I have attended 61 veteran engagements through public and
private partnerships and 60 stakeholder events to hear firsthand the
problems and concerns impacting our veterans. To recruit individuals to
work for VA as medical professionals and in other critical fields, I
have visited 50 medical schools, universities, and other educational
institutions. This kind of outreach, partnership, and collaboration
underpins our department-wide transformation to change VA's culture and
make the veteran the center of everything we do.
Progress
Transforming an organization of VA's size is an enormous
undertaking. It will not happen overnight. But we are now running the
Government's second largest Department like a $166 billion Fortune 6
organization should be run. That is, balancing near term performance
improvements while rebuilding VA's long-term organizational health.
Effective change often requires new leadership, and we have made
broad changes. Of our top 16 executives, 10 are new to their positions
since I became Secretary. Our team today includes extensive executive
expertise from the private sector: a former banking industry Chief
Financial Officer and President of the USO; the former Chief Executive
Officer of Beth Israel Medical Center in New York City and Morristown
Medical Center in New Jersey; a former Chief Executive of Jollibee
Foods and President of McDonald's Europe; a former Chief Information
Officer of Johnson & Johnson and Dell Inc.; a former partner in
McKinsey & Company's Transformational Change and Operations
Transformation Practices; a retired partner in Accenture's Federal
Services Practice; a former Chief Customer Officer for the City of
Philadelphia who previously spent 10 years at United Services
Association of America (USAA), one of the best and foremost customer-
service organizations in the country; a former entrepreneur and CEO of
multiple technology companies; and a retired Disney executive who spent
2010-2011 at Walter Reed National Military Medical Center enhancing the
patient experience.
Most members of the executive leadership team are veterans
themselves. They have served from Vietnam to Iraq and Afghanistan, and
each is here because he or she demonstrates a personal commitment to
our mission. These fresh, diverse perspectives, combined with our more
experienced government and healthcare executives, will continue to
catalyze innovation and change.
Thanks to the continuing support of Congress, VSOs, union leaders,
our dedicated employees, states, and private industry partners, we have
made tremendous headway over the past 18 months. In 2015, we made
notable progress building the momentum that will begin delivering
transformational changes that VA needs.
Congress has passed key legislation--such as the Veterans Access,
Choice, and Accountability Act and the Clay Hunt Suicide Prevention for
American Veterans Act--that gives VA more flexibility to improve our
culture and ability to execute effectively.
Consistent with the culture of a High Performance Organization that
serves veterans and their families, we have turned VA's structural
pyramid upside down. Veterans and their families are at the top. The
Office of the Secretary is at the bottom, supporting subordinate
leaders and the workforce who are serving veterans. This method of
thinking and operating is a reminder to all employees and stakeholders
that we are here to support our veterans, not our bosses.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
While reinforcing our I-CARE Values, we are transitioning from a
rules-based culture that may neglect the human dimension of service to
a principles-based culture grounded in values, sound judgment, and the
courage and opportunity ``to choose the harder right instead of the
easier wrong. . . .''
We formed a MyVA Advisory Committee (MVAC) to advise us on our
transformation. The MVAC is comprised of a diverse group of business
leaders, medical professionals, experienced government executives, and
veteran advocates. The Chairman is retired Major General Joe Robles,
former Chairman and CEO of USAA. The Vice Chairman is Dr. J. Michael
Haynie, Air Force veteran, Vice Chancellor of Syracuse University and
founder of the Institute for Veteran and Military Families (IVMF). The
MVAC includes executives with deep customer service and transformation
expertise from organizations such as Amazon, The Cleveland Clinic,
McKinsey & Company, Johns Hopkins, Mayo Clinic, as well as a former
Surgeon General, a former White House doctor for three US Presidents, a
university president who was a Rhodes Scholar from the Air Force
Academy who currently serves as a reserve Air Force Lieutenant Colonel,
and advocates for both the traditional VSOs and post-9/11 veterans'
organizations.
Private sector leadership experts are bringing cutting-edge
business skills and developing VA teams in new ways. We are training
critical pockets of our workforce on advanced techniques like Lean and
Human Centered Design. For example, working with the University of
Michigan, we have already trained more than 5,000 senior leaders across
the Nation in our ``Leaders Developing Leaders.'' The Veterans Benefits
Administration (VBA), Veterans Health Administration (VHA), and our
Veterans Experience team collaborated using Human Centered Design and
Lean techniques to redesign the Compensation and Pension Examination
(C&P Exam) process because we received consistent feedback that the
process--often, a veteran's first impression of the VA when separating
from service--can be a confusing and uncomfortable experience.
Across VA, we are encouraging different perspectives and listening
to all of our key stakeholders, even those who are critical of VA. To
benchmark and capture ideas and best practices along our transformation
journey, we have been working collaboratively with world-class
institutions like Procter & Gamble, USAA, Cleveland Clinic, Wegmans,
Starbucks, Disney, Marriott and Ritz-Carlton, NASA, Kaiser Permanente,
Hospital Corporation of America, Virginia Mason, DOD, and GSA, among
others.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
VA named the Department's first Chief Veteran Experience Officer
and began staffing the office that will work with the field to
establish customer service standards, spread best practices, and train
our employees on advanced business skills.
Rather than asking veterans to navigate our complicated internal
structure, we are redesigning functions and processes to fit veteran
needs in the spirit of General Omar Bradley's 1947 proposition that
``We are dealing with veterans, not procedures; with their problems,
not ours.''
We are realigning VA to facilitate internal coordination and
collaboration among business lines--from nine disjointed, disparate
organizational boundaries and organizational structures to a single
framework. That means down-sizing from 21 service networks to 18 that
are aligned in five districts and defined by State boundaries, except
in California. This realignment means opportunities for local level
integration, and it promotes consistently effective customer service.
Veterans from Florida to California, Puerto Rico to Maine, Alaska and
Guam, and all parts in between, will see one VA.
We have developed a multi-year plan for creating a world-class
Information Technology organization, and on November 11, Veterans Day,
we launched the Vets.gov initial capability. Developed with support
from the U.S. Digital Services Team and informed by extensive feedback
from veterans, Vets.gov is a modern, mobile-first, cloud-based website
that will replace numerous other websites and website logins with a
single, easy to navigate location. The website puts veteran needs and
wishes first, and we will continue to add the capability that's
required to improve its accessibility and usefulness. As Vets.gov
evolves, it will simplify the veteran experience by re-using and making
consistent veteran information, including mailing address and phone
number, across the agency.
At VA, we know that serving veterans is a collaborative exercise,
so we will not function in a vacuum. We are operating as part of a
community of care, forming strategic partnerships with external
organizations to leverage the goodwill, resources, and expertise of
valuable partners to better serve our Nation's veterans and help
address a wide variety of veteran needs, including employment,
homelessness, wellness, and mental health. Partners include respected
organizations like the YMCA, the Elks, the PenFed Foundation, LinkedIn,
Coursera, Google, Walgreens, academic institutions, other Federal
agencies, and many more. These partnerships reflect our commitment to
re-thinking how VA does business so we can leverage the strengths of
others who also care for veterans.
We have enabled 39 Community Veterans Engagement Boards, a national
network designed to leverage all community assets, not just VA assets,
to meet local veteran needs. Sixteen more communities are in
development right now.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We have renewed and redefined working relationships with our union
partners, and union leaders are part of the team, and have had
significant input into MyVA. We continue to work with them to address
issues and make sure our employees are involved often and early in
every major decision.
We are continuing to develop a robust provider network while we
streamline business processes and re-imagine how we obtain services
such as billing, reimbursement credentialing, and information sharing.
We continue to listen, learn, and grow.
va's agency priority goals
In 2015, we were guided by and made notable progress toward
reaching our three Agency Priority Goals (APGs)--(1) Improve Veteran
Access to VA Benefits and Services, (2) End Veteran Homelessness, and
(3) Eliminate the Disability Claims Backlog. These accomplishments
toward achieving our APGs demonstrate VA's commitment to using our
resources effectively to improve care and benefits for veterans.
Access
We expanded capacity by focusing on staffing, space, productivity,
and VA Community Care.
Since discovering the access challenges in Phoenix, Arizona, we
have aggressively improved access to care, not just in Phoenix but
across VA as a whole. For instance, in the first 12 months after
discovering the Phoenix appointment problem, from June 2014 to June
2015, we completed 7 million more appointments than during the same
period the year prior: 2.5 million of those appointments were at VA;
4.5 million appointments were in the community. Altogether in fiscal
year 2015, we completed 56.7 million appointments, nearly 2 million
more than in fiscal year 2014. More than 97 percent (55 million) of
those 56.7 million appointments were completed within 30 days of the
clinically indicated or veteran's preferred date, an increase of 1.4
million over the fiscal year 2014 numbers.
Veteran access is one of the five critical priorities supporting VA
healthcare transformation with far-reaching impact across VA that Under
Secretary for Health, Dr. David J. Shulkin announced in September 2015.
With the Access Stand Downs, VHA is empowering each facility to focus
on the needs of its specific population and refocusing people, tools,
and systems on a journey of continuous improvement towards same-day
access for primary care and urgent specialty care. The immediate goal
is that no patients with urgent appointment requests in VA clinics with
the most critical clinical needs, such as cardiology, urology, and
mental health, are waiting more than 30 days.
From November 9, through November 13, 2015, VHA conducted a
complete review of all veterans waiting for appointments--with a focus
on those veterans waiting for clinically important and acute services--
to ensure that the wait was clinically appropriate as determined by the
veteran's treatment team. This process culminated with the VHA's first-
ever Access Stand Down on November 14. The Stand Down was a nationwide
effort to ensure veterans get the right care at the right time.
In the first Access Stand Down, VHA reviewed nearly 55,800 of the
more than 56,000 urgent consults that remained open more than 30 days
(as of November 6, 2015), a herculean effort. Of those 55,800 urgent
open consults reviewed, 82 percent (45,849) were scheduled or closed by
the end of that first Stand Down.
Building on the November 14th Access Stand Down momentum and
success, VHA continued to maximize accessibility to outpatient services
with the February 27th, 2016 Access Stand Down. The February Stand Down
provided an opportunity to make another significant leap in
dramatically enhancing veterans' access to care. Clinical operations
will meet customer demand through resource-neutral, continuous
improvement at the facility-level and scaling-up excellence across the
enterprise.
VetLink data is another way we are listening to veterans. Since
September 2015, VHA has analyzed preliminary data from VetLink, our
kiosk-based software that allows us to collect real-time customer
satisfaction information. In all three separate VetLink surveys to
date--related to nearly half-a-million appointments--veterans told us
that about 90 percent of the time, they are either ``completely
satisfied'' or ``satisfied'' with getting the appointment when they
wanted it. However, about 3 percent of veterans who participated in the
survey were either ``dissatisfied'' or ``completely dissatisfied,'' so
we have more work to do.
Staffing. We increased net VHA staffing. In fiscal year 2015, VHA
hired 41,113 employees, for a net increase of 13,940 healthcare staff,
a 4.7 percent increase overall. That increase included 1,337 physicians
and 3,612 nurses, and we filled several critical leadership positions,
including the Under Secretary of Health.
Space. We activated an additional 2.2 million square feet of
clinical space in fiscal year 2015, adding to the more than 1.7 million
square feet of clinical space activated in fiscal year 2014.
Productivity. We increased physician work Relative Value Units
(RVUs) by 9 percent from fiscal year 2014 to fiscal year 2015. VA
completed more than 1.4 million extended hour completed encounters in
primary care, mental health and specialty care in fiscal year 2014 and
more than 1.5 million in fiscal year 2015, an increase of 5.7 percent
in extended hour encounters.
Care in the Community
In 2015, VA obligated $10.5 billion for Veterans Care in the
Community, including resources provided through the Veterans Choice
Act--an increase of $2.3 billion (28 percent) over the 2014 level--
which resulted in nearly 2.4 million authorizations for veterans to
receive Care in the Community from December 3, 2014 through December 2,
2015. Programmatically, this included care in the community for
veterans' dialysis, state home programs, community nursing care,
veterans home programs, emergency care, private medical facilities
care, and care delivered at Indian health clinics. It also includes
care under VA's CHAMPVA program for certain dependents entitled to that
care.
Homelessness
Veteran homelessness has continued to decline, thanks in large part
to unprecedented partnerships and vital networks of collaborative
relationships across the Federal Government, across State and local
government, and with both non-profit and for-profit organizations.
Ending and preventing veteran homelessness is now becoming a reality in
many communities, including: the Commonwealth of Virginia; the State of
Connecticut; New Orleans, Louisiana; Houston, Texas; Las Vegas, Nevada;
Philadelphia, Pennsylvania; Syracuse, New York; Winston-Salem, North
Carolina; and Las Cruces, New Mexico. In collaboration with our 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.
In fiscal year 2015 alone, VA provided services to more than
365,000 homeless or at-risk veterans in VHA's homeless programs. Nearly
65,000 veterans obtained permanent housing through VHA Homeless
Programs interventions, and more than 36,000 veterans and their family
members, including 6,555 children, were prevented from becoming
homeless.
Overall veteran homelessness dropped by 36 percent between 2010 and
2015, based on data collected during the annual Point-in-Time (PIT)
Count conducted on a single night in January 2015. We saw a nearly 50
percent drop in unsheltered veteran homelessness. Since 2010, more than
360,000 veterans and their family members have been permanently housed,
rapidly rehoused, or prevented from falling into homelessness.
Disability Claims Backlog
VA transitioned disability compensation claims processing from a
paper-intensive process to a fully electronic processing system; as a
result, 5,000 tons of paper per year were eliminated.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In fiscal year 2015, VA decided a record-breaking 1.4 million
disability compensation and pension (rating) claims for veterans and
their survivors--the highest in VA history for a single year. As of
December 31, 2015, VA had driven down the disability claims backlog to
75,480, from a peak of over 611,000 in March 2013.
2016-2017 VA's Agency Priority Goals
In a collaborative, analytical process, VA has established our four
new Agency Priority Goals (APGs). In fiscal years 2016 and 2017, our
four APGs build upon and preserve progress we made in 2015. The new
APGs will help accelerate the MyVA transformation and advance our
framework for allocating resources to improve veteran outcomes. Our new
APGs are to (1) Improve Veterans Experience with VA, (2) Improve VA
Employee Experience, (3) Improve Access to Health Care as Experienced
by the veteran, and (4) Improve Dependency Claims Processing. While no
longer APGs, VA will continue to build upon the progress it has already
made related to increasing access to care and services, ending
Veterans' Homelessness and eliminating the compensation rating claims
backlog.
fiscal year 2017 budget request
Our 2017 budget requests the necessary resources to allow us to
serve the growing number of veterans who selflessly served our Nation.
The 2017 budget requests $182.3 billion for VA--$78.7 billion in
discretionary funding (including medical care collections) and $103.6
billion in mandatory funding for veterans benefit programs. The
discretionary request reflects an increase of $3.6 billion (4.9
percent) over the 2016 enacted level. The budget also requests 2018
advance appropriations (AAs) of $66.4 billion for Medical Care and
$103.9 billion for three mandatory accounts that support veterans
benefit payments (i.e., Compensation and Pensions, Readjustment
Benefits, and Insurance and Indemnities).
We value the support that Congress has demonstrated in providing
the resources needed to honor our Nation's veterans. We are seeking
your support for legislative proposals contained in the 2017 budget--
including many already awaiting congressional action--to enhance our
ability to provide veterans the benefits and services they have earned
through their service. The budget also proposes appropriations language
to provide a new General Transfer Authority that would allow VA to move
discretionary funds across line items. Flexible budget authority would
give VA greater ability to avoid artificial restrictions that impede
our delivery of care and benefits to veterans.
rising demand for va care and benefits
Veterans are demanding more services from VA than ever before. As
VA becomes more productive, the demand for benefits and services from
veterans of all eras continues to increase, and veterans' demand for
benefits has exceeded VA's capacity to meet it.
In 2014, when the Phoenix access difficulties came to light, VA had
300,000 appointments that could not be completed within 30 days of the
date the veteran needed or wanted to be seen. To meet that demand, VA
rallied to add capacity to complete 300,000 more appointments each
month, or about 3.5 million additional appointments annually.
Despite these extraordinary measures to increase capacity, VA was
unable to absorb veterans' increasing demand for healthcare. The number
of veterans waiting for appointments more than 30 days rose by about 50
percent, to roughly 450,000 between 2014 and 2015, so we are
aggressively working on innovative ways to address that challenge, and
VHA's new Access Stand Downs are central to VHA's healthcare
transformation efforts and addressing that challenge.
The trend of a growing demand for VA healthcare is fueled by more
than a decade of war, Agent Orange-related disability claims, an
unlimited claim appeal process, demographic shifts, increased medical
issues claimed, and other factors. Additionally, 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. And, VA now serves a population
that is older, has more chronic conditions, and is less able to afford
care in the private sector. Workload will continue to increase as the
military downsizes and veterans regain trust in VA.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In 2017, the number of veterans receiving medical care at VA will
be over 6 million. VA expects to provide more than 115 million
outpatient visits in 2017, an increase of 8.4 million visits over 2016,
through both VA and Care in the Community.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Compared to fiscal year 2009, the number of patients is projected
to increase by 22 percent by fiscal year 2017. And, as veterans see the
results of VA's transformation, we are confident that the number of
veterans utilizing VA services will continue to rise. Currently, 11
million of the 22 million veterans in this country are registered,
enrolled, or use at least one VA benefit or service.
Veterans' healthcare and benefit requirements continue to increase
decades after conflicts end, and this fact is a fundamental, long-term
challenge for VA. Forty years after the Vietnam war ended, the number
of Vietnam era veterans receiving disability compensation has not yet
peaked. VA anticipates a similar trend for Gulf war era veterans, only
26 percent of whom have been awarded disability compensation.
Today, there are an estimated 22 million veterans. The number of
veterans is projected to decline to around 15 million by 2040. However,
while the absolute number may decline, an aging veteran population
requires greater care, services, and benefits. In 2017, 46 percent (or
9.8 million) of the 22 million veteran population will be 65 years old
or older, a dramatic increase since 1975, when only 7.5 percent (or 2.2
million) of the veteran population was 65 years old or older.
While the percent of the veteran population receiving compensation
was nearly constant at 8.5 percent for more than 40 years, over the
past 15 years there has been a striking increase to 20 percent. The
total number of service-connected disabilities for veterans receiving
compensation grew from 11.8 million in 2009 to 19.7 million in 2015, an
increase of more than 67 percent in just 6 years. This dramatic growth,
combined with estimates based on historic trends, predicts an even
greater increase in claims for more benefits as veterans age and
disabilities become more acute.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The increase in veterans receiving compensation is accompanied by a
significant increase in the average degree of disability granted to
veterans for disability compensation. For 45 years, from 1950 to 1995,
the average degree of disability held steady at 30 percent. But, since
2000, the average degree of disability has risen to 49 percent. VBA's
mandatory request for 2017 is $103.6 billion, twice the amount spent in
fiscal year 2009.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
As VA continues to improve access and quality of care, more
veterans will come to VA for more of their care. Veterans today often
choose VA for care either because of personal preference or because of
VA's economic edge. Some 78 percent of enrolled veterans at VA have
other choices like Medicare, Medicaid, Tricare, or private insurance.
Out-of-pocket cost for veterans at VA is often lower, and cost
considerations are a key factor in veterans' demand for VA healthcare.
In 2014, veteran enrollees received only 34 percent of their total
healthcare through VA, accounting for about $53 billion in 2014 costs.
Just a 1 percent increase in veteran reliance on VA healthcare will
increase costs by $1.4 billion.
productivity improvements and stewardship
The MyVA transformation will ensure VA is a sound steward of the
taxpayer dollar. We are instituting operational efficiencies, cost
savings, productivity improvements, and service innovations to support
this and future budget requests. We are assessing all aspects of VA
operations using a business lens and pursuing changes so VA will
deliver care and services more efficiently and effectively at the
highest value to veterans and taxpayers. For instance, few realize that
when it comes to the general operating expense of distributing over a
hundred-billion dollars in benefits to over 5.3 million veterans and
survivors, VBA spends only about 3 cents on the dollar. By any measure,
that's an excellent return on investment. Our Reports, Approvals,
Meetings, Measurements, and Policies (RAMMPs) process identifies
practices to streamline or, in some cases, eliminate entirely. To free
capacity and empower employees to identify counter-productive or
wasteful activities that management can eliminate, VA leaders at all
levels of the organization are using RAMMP to address opportunities for
improvement that employees have identified.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
To boost efficiency and employee productivity, VA is quickly moving
to paperless claims processing from its historically manual, paper-
intensive process. Modernizing to an electronic claims processing
system has helped VBA increase claim productivity per claims processor
by 25 percent since 2011 and medical issue productivity by 82 percent
per claims processor since 2009. This significant productivity increase
helped mitigate the effects of the 131 percent increase in workload
between 2009 and 2015, when the number of medical issues rose from 2.7
million to 6.4 million. VA's shift to electronic claims processing has
meant converting paper files to eFolders. Between 2012 and 2015, the
Veterans Claims Intake Program (VCIP) scanned nearly 6 million claims
files into veterans' eFolders in the Veterans Benefits Management
System (VBMS). VBA has removed more than 7,000 tons of claims-related
papers formerly undermining efficiency, hampering productivity, and
cluttering workspace.
In fiscal year 2015, VBA deployed its innovative Centralized Mail
Initiative to 56 regional offices (ROs) and one pension management
center (PMC). Centralized Mail reroutes inbound compensation and
pension claims-related mail directly to Claims and Evidence Intake
Centers at document conversion services vendor sites, an innovation
that improves productivity and enabled digital analysis of more than
four million mail packets. Through Centralized Mail, VBA can more
efficiently manage the claims workload, and prioritize and distribute
claims electronically across the entire RO network, maximizing
resources and improving processing timeliness.
To strengthen financial management and stewardship, in fiscal year
2015 VA launched its multi-year effort to replace VA's antiquated, 30-
year-old core Financial Management System (FMS) with a 21st century
system that will vastly improve VA financial management accuracy and
transparency. The modernization effort requires robust enterprise-wide
support across the Department. In fiscal year 2015, VA committed to
using a shared service solution and engaged the Department of
Treasury's Office of Financial Innovation and Transformation (FIT) to
pursue a Federal Shared Service Provider that leverages existing,
successful investments and infrastructure across the government and
meets our financial management system needs while supporting VA's
mission of serving veterans. VA also stood up a Program Management
Office, initially staffed with 5 FTE from existing resources to lead
and manage the effort, and identified an OIT Project Manager. VA has
worked to compile lessons-learned from other agencies engaged in this
effort and from VA's previous attempts to modernize the FMS, to ensure
the effort is successful. Tasks ahead include strategies, roadmaps, and
project plans, business process re-engineering, and engaging in
significant change management activities.
Recent challenges managing non-VA care program finances have
demonstrated the great risks and immense burden of the FMS legacy
system. FMS failure would severely impede the Department's ability to
execute its budget, pay vendors and veterans, and produce accurate
financial statements.
closing unsustainable facilities
It is well-past time to close VA's old, substandard, and
underutilized facilities. VA's 2016 budget testimony last year
explained that VA cannot be a sound steward of taxpayer resources with
the asset portfolio it carries, and each year of delay makes the
situation more costly and untenable. No sound business would carry such
a portfolio, and veterans and taxpayers deserve better.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
VA currently has 370 buildings that are fully vacant or less than
50 percent occupied, which are in excess to our needs. These vacant
buildings account for over 5.2 million square feet of unneeded space.
In addition, we have 770 buildings that are underutilized, accounting
for more than 6.3 million square feet that are candidates to be
consolidated to improve utilization and lower costs. This means we have
to maintain over 1,100 buildings and 11.5 million square feet of space
that is unneeded or underutilized--taking funding from needed veteran
services. We estimate that it costs VA $26 million annually to maintain
and operate these vacant and underutilized buildings. For example, when
attempting to demolish the vacant storage facility in Bedford,
Massachusetts, VA encountered environmental issues that prevented the
demolition, forcing VA to either pay costly remediation costs to
demolish a building we no longer need or maintain facilities such as
this across the system.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
As the veteran population has migrated, VA's capital infrastructure
has not kept pace. We continue to operate medical facilities where the
veteran population is small or shrinking. Our smallest hospitals often
do not have sufficient patient volume and complexity of care
requirements to maintain the clinical skills and competencies of
physicians and nurses.
ensuring veterans access to care
The President's 2017 budget will allow VA to operate the largest
integrated healthcare system in the country, including nearly 1,300 VA
sites of healthcare and approximately 6 million veterans receiving
care; the eleventh largest life insurance provider, covering both
active duty servicemembers and enrolled veterans; compensation and
pension benefit programs serving more than 5.3 million veterans and
survivors; education benefits to more than one million students;
vocational rehabilitation and employment benefits to more than 140,000
disabled veterans; a home mortgage program that will guarantee more
than 429,000 new home loans; and the largest national cemetery system
that leads the industry as a high-performing organization, with
projections to inter more than 132,000 veterans and family members in
2017.
The 2017 budget requests $65 billion for medical care, an increase
of $3.9 billion (6.3 percent) over the 2016 enacted level. The increase
in 2017 is driven by veterans' demand for VA healthcare as a result of
demographic factors, economic assumptions, investments in access, and
high priority investments for caregivers, new Hepatitis C treatments,
and support for Veterans Care in the Community. The 2017 request
supports programs to end and prevent veteran homelessness, invests in
strategic initiatives to improve the quality and accessibility of VA
healthcare programs, continues implementation of the Caregivers and
Veterans Omnibus Health Services Act, and provides for activation
requirements for new or replacement medical facilities. The 2017
appropriations request includes an additional $1.7 billion above the
enacted 2017 AA for veterans medical care. The request assumes
approximately $3.6 billion annually in medical collections in 2017 and
2018. For the 2018 Advance Appropriations for medical care, the current
request is $66.4 billion.
Hepatitis C Treatment
Although the Hepatitis C virus infection (HCV) takes years to
progress, it is the main cause of advanced liver disease in the United
States. Treatment of this disease remains a high priority because its
cure dramatically lowers patients' risk of liver failure, liver cancer,
and death.
VA is the largest single provider of care in the Nation for chronic
HCV, and over the next 5 years, VA will strive to provide treatment to
all veterans with HCV who are treatment candidates. For fiscal year
2017, VA is requesting $1.5 billion for the cost of Hepatitis C drugs
and clinical resources. With a budget of $1.5 billion in fiscal year
2017, VA expects to treat at least 35,000 patients with HCV; the actual
number of patients treated will depend on the cost to VA of Hepatitis C
drugs. At the beginning of fiscal year 2016, almost 120,000 veterans in
VA care were awaiting HCV treatment, of whom approximately 30,000 have
advanced liver disease.
VA successfully negotiated extremely favorable pricing for both of
the new treatments available--Harvoni and Viekira--from two different
drug manufacturers by stressing VA's proven ability to deliver market
share, VA's large HCV population, and the long-term impact that VA's
physician residency programs can have on post-residency prescribing
practices.
During fiscal year 2015, VA medical facilities treated more than
30,000 veterans for HCV with these new drugs with remarkable success,
achieving cure rates of 90 percent, similar to those seen in clinical
trials.
VA clinicians have rapidly adopted new, more effective therapies
for HCV as they have become available. New therapies are costly and
require well-trained clinical providers and support staff, presenting
resource challenges for the Department. VA will focus resources on the
sickest patients and most complex cases and continue to build capacity
for treatment through clinician training and use of telehealth
platforms. Patients with less advanced disease are being offered
treatment through the Veterans Choice program in partnership with
community HCV providers.
Care in the Community
VA is committed to providing veterans access to timely, high-
quality healthcare. The 2017 budget includes $12.2 billion for Care in
the Community and includes a new Medical Community Care budget account,
consistent with the VA Budget and Choice Improvement Act (Public Law
114-41). Of the total that will be spent on non-VA care in fiscal year
2017, $7.5 billion will be provided through a transfer of the 2017
enacted AA from the Medical Services account to the new budget account,
and $4.7 billion will be provided through the resources provided in the
Veterans Choice Act for implementation of the Veterans Choice Program.
The Choice Act increased VA's in-house capacity by funding medical
personnel growth in VA facilities and expanded eligibility for Care in
the Community to ensure access to care within 30 days and to provide
care closer to home for enrollees residing more than 40 miles from a VA
facility (the 40-mile group).
This additional capacity facilitated an increase in enrollees'
reliance on VA healthcare by more than half a percent over the level
expected in fiscal year 2015. This growth was the result of enrollees
increasing their use of VA funded healthcare versus their use of other
healthcare options (Medicare, Medicaid, commercial insurance, etc.).
The fiscal year 2015 growth in enrollee reliance was largely in
Care in the Community, with the 40-mile group generating a more
significant increase in care:
--In fiscal year 2015, enrollees' reliance on VA healthcare increased
by 0.7 percent overall. Reliance for the 40-mile group
increased by 2.8 percentage points from 32.5 percent to 35.3
percent.
--The increase in reliance was mostly driven by growth in Care in the
Community. Cost sharing levels in VA are lower than what is
typically available elsewhere, which provides an incentive for
enrollees to use VA-paid Care in the Community.
Enrollee reliance on VA healthcare is expected to continue to
increase in 2016 and beyond to service the unmet demand that the Choice
Act was enacted to address.
On October 30, 2015, VA provided Congress with a plan for the
consolidation and improvement of all purchased care programs into one
New Veterans Choice Program (New VCP). Consistent with this report, the
2017 budget includes legislative proposals to streamline and improve
VA's delivery of Community Care.
Caregiver Support Program
Caregivers give their time and love in countless behind-the-scenes
ways. Whether they are helping with transportation to and from
appointments, helping the veteran apply for benefits, or helping with
meals, bathing, clothing, medication, the spectrum of care is wide and
compassion runs deep.
The 2017 budget requests $725 million for the National Caregivers
Support Program to support nearly 36,600 caregivers, up from about
30,600 in fiscal year 2016. Funding requirements for caregivers are
driven by an increase in the eligible veteran population, with
caregiver enrollment increasing by an average of about 500 each month.
ending veteran homelessness
The ambitious goal of ending veteran homelessness has galvanized
the Federal Government and local communities to work together to solve
this important National problem. Our systems are designed to help
prevent homelessness whenever possible, and our goal is a systematic
end to homelessness, meaning that there are no veterans sleeping on our
streets and every veteran has access to permanent housing. Should
veterans become homeless or be at-risk of becoming homeless, there will
be capacity to quickly connect them to the help they need to achieve
housing stability.
The 2017 budget supports VA's commitment to ending veteran
homelessness by emphasizing rescue for those who are homeless today and
prevention for those at risk of homelessness. The 2017 budget requests
$1.6 billion for VA homeless-related programs, including case
management support for the Department of Housing and Urban Development
(HUD)-VA Supportive Housing program (HUD-VASH), the Grant and Per Diem
Program, VA justice programs, and the Supportive Services for Veteran
Families program.
In fiscal year 2015 and fiscal year 2016, VA committed more than
$1.5 billion annually to strengthen programs that prevent and end
homelessness among veterans. Communities that have reached the goal or
are close to effectively ending homelessness rely heavily on VA
targeted homeless resources. Communities that have a sustainment plan
are depending on those resources to be available as they continue to
tackle homelessness and sustain the support for veterans who have moved
into permanent housing, ensuring that they maintain housing stability
and do not fall back into homelessness.
VA will continue to advocate for its continuum of homeless services
to address the needs associated with preventing first-time
homelessness, as well as the needs of those who return to homelessness,
and focus on the root causes associated with homelessness, including
poverty, addiction, mental health, and disability.
Congress has an important role, as well, in ensuring adequate
resources to meet the needs of those most vulnerable veterans by
enacting authorizations and other legislation to provide VA with a full
complement of tools to combat homelessness--including legislation that
is a prerequisite to carry out dramatic improvements to our West Los
Angeles campus centered on the needs of veterans.
benefits programs
The 2017 budget requests $2.8 billion and 22,171 FTE for VBA
General Operating Expenses, an increase of $93.4 million (3.4 percent)
over the 2016 enacted level. The request includes an additional 300
full-time equivalent (FTE) employees for non-rating claims.
With the resources requested in the 2017 budget, VA will provide:
--Disability compensation and pension benefits for 5.3 million
veterans and survivors, totaling $86 billion;
--Vocational rehabilitation and employment benefits to nearly 141
thousand disabled veterans, totaling $1.4 billion;
--Education benefits totaling $14 billion to more than one million
veterans and family members;
--Guaranty of more than 429,000 new home loans; and
--Life insurance coverage to 1.0 million veterans, 2.2 million
servicemembers, and 2.8 million family members.
Improving the quality and timeliness of disability claim decisions
has been integral to VBA's transformation of benefits delivery. VBA
successfully streamlined a complex and paper-bound compensation claims
process and implemented people, process, and technology initiatives
necessary to optimize productivity and efficiency. In alignment with
the MyVA transformation, VBA is working to further improve its
operations with a focus on the customer experience. We are implementing
enhancements to enable integration across our programs and
organizational components, both inside and outside of VBA.
VBA has processed an unprecedented number of rating claims in
recent fiscal years (nearly 1.4 million in 2015, and more than 1
million per year for the last 6 years). However, its success has
resulted in other unmet workload demands. As VBA continues to receive
and complete more disability rating claims, the volume of non-rating
claims, appeals, and fiduciary field examinations increases
correspondingly.
--Non-rating claims. VA completed nearly 37 percent more non-rating
work in 2015 than 2013--and 15 percent more than 2014. The 2017
budget requests $29.1 million for an additional 300 non-rating
claims processors to reduce the non-rating claims inventory and
provide veterans with more timely decisions on non-rating
claims.
--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, the volume of appeals
correspondingly increases. As of December 31, 2015, there were
more than 440,000 benefits-related appeals pending in the
Department at various stages in the multi-step appeals process,
which divides responsibility between VBA and the Board of
Veterans' Appeals (Board)--355,803 of those benefits-related
appeals are in VBA's jurisdiction and 85,682 are within the
Board's jurisdiction.
Under current law, VA appeals framework is complex, ineffective,
and opaque, and veterans wait on average 5 years for final
resolution of an appeal. The 2017 budget supports the
development of a Simplified Appeals Process to provide veterans
with a simple, fair, and streamlined appeals procedure in which
they would receive a final appeals decision within 365 days
from filing of an appeal by fiscal year 2021. The 2017 budget
provides funding to support over 900 FTE for the Board and
proposes a legislative change that will improve an outdated and
inefficient process which will benefit all veterans through
expediency and accuracy. We look forward to working with
Congress, veterans, and other stakeholders to implement
improvements.
--Fiduciary program. The fiduciary program served 29 percent more
beneficiaries in 2015 than it served in 2014. Program growth is
primarily due to an increase in the total number of individuals
receiving VA benefits and an aging population of beneficiaries.
Additionally, in 2015 the fiduciary program changed the way it
captures beneficiary population data and now reports all
beneficiaries served during the course of the fiscal year. In
2015, fiduciary personnel conducted more than 84,000 field
examinations, and VBA anticipates field examination
requirements will exceed 97,000 in 2017.
--Housing program. The 2017 budget includes $34 million for the VA
Loan Electronic Reporting Interface (VALERI) to manage the 2.4
million VA-guaranteed loans for veterans and their families.
VALERI connects VA with more than 320,000 veteran borrowers and
more than 225,000 mortgage servicer contacts. VA uses the
VALERI tool to manage and monitor efforts taken by private-
sector loan servicers and VA staff in providing timely and
appropriate loss mitigation assistance to defaulted borrowers.
Without these resources, approximately 90,000 veterans and
their families would be in jeopardy of losing their homes each
year, potentially costing the Government an additional $2.8
billion per year. VALERI also supports payment of guaranty and
acquisition claims.
The budget requests the following advance appropriations amounts
for 2018: $90.1 billion for compensation and pensions, $13.7 billion
for readjustment benefits, and $107.9 million for insurance and
indemnities. VA will continue to closely monitor workload and monthly
expenditures in these programs and will revise cost estimates as
necessary in the Mid-Session Review of the 2017 budget, to ensure the
enacted advance appropriation levels are sufficient to address
anticipated veteran needs throughout the year.
the simplified appeals initiative
The current VA appeals process is broken. The more than 80-year-old
process was conceived in a time when medical treatment was far less
frequent than it is today, so it is encumbered by some antiquated laws
that have evolved since WWI and steadily accumulated in layers.
Under current law, the VA appeals framework is complex,
ineffective, confusing, and understandably frustrating for veterans who
wait much too long for final resolution of their appeal. The current
appeals system has no defined endpoint, and multiple steps are set in
statute. The system requires continuous evidence gathering and multiple
re-adjudications of the very same or similar matter. A veteran,
survivor, or other appellant can submit new evidence or make new
arguments at any time, while VA's duty to assist requires continuous
development and re-adjudication. Simply put, the VA appeals process is
unlike other standard appeals processes across Federal and judicial
systems.
Fundamental legislative reform is essential to ensure that veterans
receive timely and quality appeals decisions, and we must begin an
open, honest dialogue about what it will take for us to provide
veterans with the timely, fair, and streamlined appeals decisions they
deserve. To put the needs, expectations, and interests of veterans and
beneficiaries first--a goal on which we can all agree--the appeals
process must be modernized.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The 2017 budget proposes a Simplified Appeals Process--legislation
and resources (i.e., people, process, and technology) that would
provide veterans with a simple, fair, and streamlined appeals process
in which they would receive a final decision on their appeal within 1
year from filing the appeal by fiscal year 2021.
The 2017 budget requests $156.1 million and 922 FTE for the Board,
an increase of $46.2 million and 242 FTE above the fiscal year 2016
enacted level. This is a down-payment on a long-term, sustainable plan
to provide the best services to veterans. This policy option also
represents the best value to taxpayers (as outlined in the chart,
Analysis of Alternatives).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Without legislative change or significant increases in staffing, VA
will face a soaring appeals inventory, and veterans will wait even
longer for a decision on their appeal. If Congress fails to enact VA's
proposed legislation to simplify the appeals process, Congress would
need to provide resources for VA to sustain more than double its
appeals FTE, with approximately 5,100 appeals FTE onboard. The prospect
of such a dramatic increase, while ignoring the need for structural
reform, is not a good result for veterans or taxpayers.
While the Simplified Appeals proposal would require FTE increases
for the first several years to resolve the more than 440,000 currently
pending appeals, by 2022, VA would be able to reduce appeals FTE to a
sustainment level of roughly 1,030 FTE (including 980 FTE at the Board
and 50 at VBA), a level sufficient to process all simplified appeals in
1 year. Notably, such a sustainment level is 1,135 FTE less than the
current 2016 budget requires, and is 4,070 FTE less Department-wide
than would be required to address this workload with FTE resources
alone. In addition, this reform would essentially eliminate the need
for appeals FTE at VBA, allowing these resources to be redirected
within VBA to other priorities.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In 2015, the Board was still adjudicating an appeal that originated
25 years ago, even though the appeal had previously been decided by VA
more than 27 times. Under the Simplified Appeals Process, most veterans
would receive a final appeals decision within 1 year of filing an
appeal. Additionally, rather than trying to navigate a multi-step
process that is too complex and too difficult to understand, veterans
would be afforded a transparent, single-step appeal process with only
one entity responsible for processing the appeal. Essentially, under a
simplified appeals process, as soon as a veteran files an appeal, the
case would go straight to the Board where a Judge would review the same
record considered by the initial decision-maker and issue a final
decision within 1 year; informing the veteran whether that initial
decision was substantially correct, contained an error that must be
corrected, or was simply wrong. If a veteran disagrees with any or all
of the final appeals decision, the veteran always has the option of
filing a new claim for the same benefit once the appeal is resolved, or
may pursue an appeal to the Court of Appeals for Veterans Claims.
Rapid growth in the appeals workload exacerbates this challenge. As
VBA has produced record-setting claims-decision output over the past 5
years, appeals volume has grown commensurately. Between December 2012
and November 2015, the number of pending appeals rose by 34 percent.
Under current law with no radical change in resources, the number of
pending appeals is projected to soar by 397 percent--from 437,000 to
2.17 million (chart, Status of Appeals)--between November 2015 and
fiscal year 2027.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
VA firmly believes that justice delayed is justice denied. In the
streamlined appeals process proposed in the fiscal year 2017
President's budget (chart, Proposed Simplified Appeals), there would be
a limited exception allowing the Board to remand appeals to correct
duty to notify and assist errors made on the part of the Agency of
Original Jurisdiction (AOJ) prior to issuance of the initial AOJ
decision.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
medical and prosthetic research
The 2017 budget continues VA's program of groundbreaking, high
standard research focused on advancing the healthcare needs of all
veterans. The 2017 budget requests $663 million for Medical Research
and supports the President's Precision Medicine Initiative (PMI) to
drive personalized medical treatment and the evolving science of
Genomic Medicine--how genes affect health. In addition to the direct
appropriation, Medical Research will be supported through $1.3 billion
from VA's Medical Care program and other Federal and non-Federal
research grants. Total funding for Medical and Prosthetic Research will
be more than $2.0 billion in 2017.
VA research is focused on the U.S. veteran population and allows VA
to uniquely address scientific questions to improve veteran healthcare.
Most VA researchers are also clinicians and healthcare providers who
treat patients. Thus, VA research arises from the desire to heal rather
than pure scientific curiosity and yields remarkable returns.
For more than 90 years, VA research has produced cutting-edge
medical and prosthetic breakthroughs that improve the lives of veterans
and others. The list of accomplishments includes therapies for
tuberculosis following World War II, the implantable cardiac pacemaker,
computerized axial tomography (CAT) scans, functional electrical
stimulation systems that allow patients to move paralyzed limbs, the
nicotine patch, the first successful liver transplants, the first
powered ankle-foot prosthesis, and a vaccine for shingles. VA
researchers also found that one aspirin a day reduces by half the rate
of death and nonfatal heart attacks in patients with unstable angina.
More recently, VA investigators tested an insulin nasal spray that
shows great promise in warding off Alzheimer's disease and found that
prazosin (a well-tested generic drug used to treat high blood pressure
and prostate problems) can help improve sleep and lessen nightmares for
those with post-traumatic stress disorder.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Beyond VA's support of more than 2,200 continuing research
projects, VA will leverage our Million Veteran Program (MVP)--already
one of the world's largest databases of genetic information--to support
several Precision Medicine Initiatives. The first initiative will
evaluate whether using a patient's genetic makeup to inform medication
selection is effective in reducing complications and getting patients
the most effective medication for them. This initiative will focus on
up to 21,500 veterans with PTSD, depression, pain, and/or substance
abuse.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The second initiative will focus on additional analysis of DNA
specimens already collected in the MVP. More than 438,000 veteran
volunteers have contributed DNA samples so far. Genomic analysis on
these DNA specimens allows researchers to extract critical genetic
information from these specimens. There are several possible ``levels''
of genomic analyses, with increasing cost.
Built into the design of MVP and currently funded within the VA
research program is a process known as ``exome chip'' genotyping--the
tip of the iceberg in genomic analysis. Exome Chip genotyping provides
useful information, but newer technologies promise significantly
greater information for improving treatments. VA proposes conducting
the next level of analysis, known as ``exome sequencing,'' on up to
100,000 veterans who are enrolled in MVP. This exome sequencing
analyzes the part of the genome that codes for proteins--the large,
complex molecules that perform most critical functions in the body.
Sequencing efforts will begin with a focus on veterans with PTSD and
frequently co-occurring conditions such as depression, pain, and
substance abuse, and expand to other chronic illnesses such as diabetes
and heart disease, among others. This more detailed genetic analysis
will provide greater information on the biological factors that may
cause or increase the risk for these illnesses.
VA's research and development program improves the lives of
veterans and all Americans through healthcare discovery and innovation.
other priorities
Information Technology
The 2017 budget demonstrates VA's commitment to using cutting-edge
information technology (IT) to support transformation and ensure that
the veteran is at the center of everything we do. The budget requests
$4.28 billion--an increase of $145 million (3.5 percent) from the 2016
enacted level--to help stabilize and streamline core processes and
platforms, eliminate the information security material weakness, and
institutionalize new capabilities to deliver improved outcomes for
veterans. The request includes $471 million for new efforts to develop,
improve, and enhance clinical and benefits systems and processes and
supports VA's strategy to replace FMS. The 2017 budget was developed
through Federal IT Acquisition Reform Act (FITARA) compliant processes
led by the Chief Information Officer (CIO), in concert with the Chief
Financial Officer and Chief Acquisition Officer.
In fiscal year 2015, the Office of Information and Technology (OIT)
developed an IT Enterprise Strategy and an Enterprise Cybersecurity
Strategy. These strategies support OIT's vision to become a world-class
organization that provides a seamless, unified veteran experience
through the delivery of state-of-the-art technology. OIT is
implementing a new IT Security Strategy to improve VA's security
posture and eliminate the Federal Information Security Management Act/
Federal Information System Controls Audit Manual material weakness.
The 2017 budget includes $370.1 million for information security,
an increase of 105 percent over the fiscal year 2016 funding level. In
addition, the 2017 budget includes $50 million to launch a new Data
Management program to use data as a strategic resource. Under this
program, VA will inventory its data collection activities--with the
objective of requesting data from the veteran only once--and dispose
expired information in a secure and timely way. These two aspects will
reduce VA costs for data storage and support safeguards for veterans'
information.
National Cemetery Administration
The National Cemetery Administration (NCA) has the solemn duty to
honor veterans and their families with final resting places in national
shrines and with lasting tributes that commemorate their service and
sacrifice to our Nation. The 2017 budget requests $286 million, an
increase of $15 million (5.5 percent) to allow VA to provide perpetual
care for more than 3.5 million gravesites and more than 8,800 developed
acres. The budget supports NCA's efforts to raise and realign
gravesites and repair turf in order to maintain cemeteries as national
shrines. The budget also continues implementation of a Geographic
Information System to enable enhanced accounting of remains and
gravesites and enhanced gravesite location for visitors. The budget
positions NCA to meet veterans' emerging burial and memorial needs in
the decades to come by ensuring that veterans and their families
continue to have convenient access to a burial option in a National,
State, or Tribal veterans cemetery and that the service they receive is
dignified, respectful, and courteous.
va infrastructure
The 2017 budget requests $900.2 million for VA's Major and Minor
construction programs. The budget invests in infrastructure projects at
existing campuses that will lead to seismically safe facilities,
ensuring that veterans are safe when they seek care. The capital asset
budget request 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 and secure facilities
for veterans. The 2017 budget also requests funding to ensure that VA
has the ability to provide eligible veterans with access to burial
services through new and expanded cemeteries, and prevent the closure
to new interments in existing cemeteries.
VA acknowledges the transformation underway in the landscape for
healthcare delivery. Our future space needs may be impacted by the
changes we are already implementing in how we deliver care for
veterans. In addition, we plan to potentially incorporate any
recommendations from the Commission on Care and their impact on our
changing service delivery into our long-term infrastructure strategy.
Leasing provides flexibility and enables VA to more quickly adapt
to changes in medical technology, workload, new programs, and
demographics. VA is also looking to Congress for authorization of 18
leases submitted in VA's fiscal year 2015 and 2016 budget requests. The
pending major medical facility lease projects will replace, expand, or
create new outpatient clinics and research facilities and are critical
for providing access for veterans and enhancing our research
capabilities nationwide. The 2017 budget includes a request to
authorize six additional replacement major medical facility leases
under VA's authority in 38 U.S.C. Sec. Sec. 8103 and 8104 and with the
anticipated delegation of leasing authority from the General Services
Administration. The Department is awaiting authorization of its request
to expand the definition of ``Medical Facilities'' in VA's authorizing
statutes to allow VA to more easily partner with other Federal
agencies. Another proposal that deserves attention is authorization of
enhanced use lease (EUL) authority to encompass broader possibilities
for mixed-use projects. This change would give VA more opportunities to
engage the private sector, local governments, and community partners by
allowing VA to use underutilized property that would benefit veterans
and VA's mission and operations.
Major Construction
The 2017 budget requests $528.1 million for Major Construction. The
request includes funds to address seismic problems in facilities in
Long Beach, California, and Reno, Nevada. These projects will correct
critical safety and seismic deficiencies that pose a risk to veterans,
VA staff, and the public. Consistent with Public Law 114-58, the
Department must identify a non-VA entity to execute these two projects,
as they are more than $100 million. We have identified the U.S. Army
Corps of Engineers as our construction agent to execute these projects.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We must prevent the devastation and potential loss of life that may
occur because our facilities are vulnerable to earthquakes--such as the
one that occurred in 1971 in San Fernando, California. As shown, 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.
These images show 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]
The request also includes funding for new national cemeteries in
western New York and southern Colorado, and national cemetery
expansions in Jacksonville, Florida and South Florida. These cemetery
projects support NCA's goal to ensure that eligible veterans have
access to a burial option within a reasonable distance from their
residences.
--The new western New York national cemetery will establish a
dignified burial option for more than 96,000 veterans plus
eligible family members in the western New York region.
--The new southern Colorado national cemetery will establish a
dignified burial option for more than 95,000 veterans plus
eligible family members in the southern Colorado region.
--The Jacksonville National Cemetery expansion will develop
approximately 30 acres of undeveloped land to provide
approximately 20,200 gravesites.
--The South Florida National Cemetery expansion will develop
approximately 25 acres of undeveloped land to provide
approximately 21,750 gravesites.
Minor Construction
In 2017, the budget requests $372 million for Minor Construction.
The requested amount would provide funding for ongoing projects that
renovate, expand and improve VA facilities, while increasing access for
our veterans. Examples of projects include enhancing women's health
programs; providing additional domiciliaries to further address
veterans' homelessness; improving safety; mitigating seismic
deficiencies; transforming facilities to be more veteran-centric;
enhancing patient privacy; and enhancing research capabilities.
The Minor Construction request will also provide funding for
gravesite expansion and columbaria projects to keep existing national
cemeteries open, and will support NCA's urban and rural initiatives. It
will also provide funding for projects at VBA regional offices
nationwide and will fund infrastructure repairs and enhancements to
improve operations for the Department's staff offices.
Leasing
The 2017 budget includes a request to authorize six replacement
major medical facility leases located in Corpus Christi, Texas;
Jacksonville, Florida; Pontiac, Michigan; Rochester, New York; Tampa,
Florida; and Terre Haute, Indiana. These leases will allow VA to
provide continued access to veterans that are served in these
locations.
myva transformation
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
MyVA puts veterans in control of how, when, and where they wish to
be served. It is a catalyst to make VA a world-class service provider--
a framework for modernizing VA's culture, processes, and capabilities
to put the needs, expectations, and interests of veterans and their
families first. A veteran walking into any VA facility should have a
consistent, high-quality experience.
MyVA will build upon existing strengths to promote an environment
where VA employees see themselves as members of one enterprise,
fortified by our diverse backgrounds, skills, and abilities. Moreover,
every VA employee--doctor, rater, claims processor, custodian, or
support staffer, or the Secretary of Veterans Affairs--will understand
how they fit into the bigger picture of providing veteran benefits and
services. VA, of course, must also be a good steward of public
resources. Citizens and taxpayers should expect to see efficiency in
how we run our internal operations.
The fiscal year 2017 budget will make investments toward the five
critical MyVA objectives:
1. Improving the veteran experience: At a bare minimum, every
contact between veterans and VA should be predictable, consistent, and
easy; however, we are aiming to make each touchpoint exceptional. It
begins with receptionists who are pleasant to our veteran clients, but
there is also a science to this experience. We are focusing on human-
centered design, process mapping, and working with leading design firms
to learn and use the technology associated with improving every
interaction with clients.
2. Improving the employee experience--so we can better serve
veterans: VA employees are the face of VA. They provide care,
information, and access to earned benefits. They serve with distinction
daily. We cannot make things better for veterans without improving the
work experience of our dedicated employees. We must train them. We must
move from a rules/fear-based culture to a principles/values-based
culture. I learned in the private sector that it is absolutely not a
coincidence that the very best customer-service organizations are
almost always among the best places to work.
3. Improving internal support services: We will let employees and
leaders focus on assisting veterans, rather than worrying about ``back
office'' issues. We must bring our IT infrastructure into the 21st
century. Our scheduling system, where many of our issues with access to
care were manifest, dates to 1985. Our Financial Management System is
written in COBOL, a language I used in 1973. This is simply
unacceptable. It impedes all of our efforts to best serve veterans.
4. Establishing a culture of continuous improvement: We will apply
Lean strategies and other performance improvement capabilities to help
employees examine their processes in new ways and build a culture of
continuous improvement.
5. Enhancing strategic partnerships: Expanding our partnerships
will allow us to extend the reach of services available for veterans
and their families. We must work effectively with those who bring
capabilities and resources to help veterans.
Breakthrough Priorities for CY 2016
While we have made progress, we are still on the first leg of a
multi-year journey. We have narrowed down our near-term focus to 12
``breakthrough priorities.''
Many of these reflect issues which are not new--they have been
known problems, in some cases, for years. We have already seen some
progress in solving many of them. However, we still have much work to
do.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The following are our 12 priorities and the 2016 outcomes to which
we aspire. We understand that it will be a challenge to accomplish all
of these goals this year, but we have committed ourselves to producing
results for veterans and creating irreversible momentum to continue the
transformation in future years.
Veteran Facing Goals
1. Improve the Veteran Experience.
-- Breakthrough Outcome for 2016:
-- Strengthen the trust in VA to fulfill our country's
commitment to veterans; currently measured at 47 percent,
we want it to be 70 percent by year end.
-- Establish a Department-wide customer experience measurement
framework to enable data-driven service improvements.
-- Make the Veterans Experience office fully operational.
-- Expand the network of Community Veteran Engagement Boards to
more than 100.
-- Additionally, in order to deliver experiences to veterans
that are effective, easy, and in which veterans feel
valued, medical centers will ensure that they are fully
staffed at the frontline with well-prepared employees who
have been selected for their customer service.
Functionally, this means new frontline staff will be
assessed through a common set of customer service criteria,
hired within 30 days of selection, and provided a
nationally standardized onboarding and training program.
2. Increase Access to Health Care.
-- Breakthrough Outcome for 2016:
-- When veterans call or visit primary care facilities at a VA
Medical Center, their clinical needs will be addressed the
same day.
-- When veterans call for a new mental health appointment, they
receive a suicide risk assessment and immediate care if
needed. Veterans already engaged in mental healthcare
identifying a need for urgent attention will speak with a
provider the same day.
-- Utilizing existing VistA technology, veterans will be able
to conveniently get medically necessary care, referrals,
and information from any VA Medical Center, in addition to
the facility where they typically receive their care.
3. Improve Community Care.
-- Breakthrough Outcome for 2016: Improve the veterans'
experience with Care in the Community. Following enactment of
our requested legislation, by the end of the year:
-- VA will begin to consolidate and streamline its non-
Department Provider Network and improve relationships with
community providers and core partners.
-- Veterans will be able to see a community provider within 30
days of their referral.
-- Non-Department claims will be processed and paid within 30
days, 85 percent of the time.
-- Healthcare claims backlog will be reduced to less than 10
percent of total inventory.
-- Referral and authorization time will be reduced.
4. Deliver a Unified Veteran Experience.
-- Breakthrough Outcome for 2016:
-- Vets.gov will be able to provide veterans, their families,
and caregivers with a single, easy-to use, and high-
performing digital platform to access the VA benefits and
services they have earned.
-- Vets.gov will be data-driven and designed such that the top
100 search terms will be available within one click from
search results. The top 100 search terms will all be
addressed within one click on the site.
-- All current content, features and forms from the current
public-facing VA websites will be redesigned, rewritten in
plain language, and migrated to Vets.gov, in priority order
based on veteran demand.
-- Additionally, we will have one authoritative source of
customer data; eliminating the disparate streams of
Administration-specific data that require veterans to
replicate inputs.
5. Modernize our Contact Centers (Including Veterans Crisis
Line).
-- Breakthrough Outcome for 2016:
-- Veterans will have a single toll free phone number to access
the VA Contact Centers, know where to call to get their
questions answered, receive prompt service and accurate
answers, and be treated with kindness and respect. VA will
do this by establishing the initial conditions necessary
for an integrated system of customer contact centers.
-- By the end of this year, every veteran in crisis will have
his or her call promptly answered by an experienced
responder at the Veterans Crisis Line.
6. Improve the Compensation & Pension (C&P) Exam Process.
-- Breakthrough Outcome for 2016:
-- Improved veteran satisfaction with the C&P Exam process. We
have a baseline satisfaction metric in place and have
established a goal for significant improvement.
-- VA will have a national rollout of initiatives to ensure the
experience is standardized across the Nation.
7. Develop a Simplified Appeal Process.
-- Breakthrough Outcome for 2016:
-- Subject to successful legislative action, put in place a
simplified appeals process, enabling the Department to
resolve 90 percent of appeals within 1 year of filing by
2021.
-- Increase current appeals production to more rapidly reduce
the existing appeals inventory.
8. Continue Progress in Reducing Veteran Homelessness.
-- Breakthrough Outcome for 2016:
-- Continue progress toward an effective end to veteran
homelessness by permanently housing or preventing
homelessness for an additional 100,000 veterans and their
family members.
VA Internal Facing Goals
9. Improve the Employee Experience (Including Leadership
Development).
-- Breakthrough Outcome for 2016:
-- Continue to improve the employee experience by developing
engaged leaders at all levels who inspire and empower all
employees to deliver a seamless, integrated, and responsive
VA customer service experience.
-- More than 12,000 engaged leaders skilled in applying LDL
principles, concepts, and tools will work projects and/or
initiatives to make VA a more effective and efficient
organization.
-- Improve VA's employee experience by incorporating LDL
principles into VA's leadership and supervisor development
programs and courses of instruction.
-- VA Senior Executive performance plans will include an
element that targets how to improve employee engagement and
customer service, and all VA employees will have a customer
service standard in their performance plans.
-- All VA supervisors will have a customer service standard in
their performance plans.
-- VA will begin moving from paper-based individual development
plans to a new electronic version, making it easier for
both supervisors and employees.
10. Staff Critical Positions.
-- Breakthrough Outcome for 2016:
-- Achieve significantly improved critical staffing levels that
balance access and clinical productivity, with targets of
95 percent of Medical Center Director positions filled with
permanent appointments (not acting) and 90 percent of other
critical shortages addressed--management as well as
clinical.
-- Work to reduce ``time to fill'' hiring standards by 30
percent.
11. Transformation the Office of Information & Technology (OIT).
-- Breakthrough Outcome for 2016: Achieve the following key
milestones on the path to creating a world-class IT
organization that improves the support to business partners and
veterans.
-- Begin measuring IT projects based on end product delivery,
starting with a near-term goal to complete 50 percent of
projects on time and on budget.
-- Stand up an account management office.
-- Develop portfolios for all Administrations.
-- Tie all supervisors' and executives' performance goals to
strategic goals.
-- Close all current cybersecurity weaknesses.
-- Develop a holistic veteran data management strategy.
-- Implement a quality and compliance office.
-- Deploy a transformational vendor management strategy.
-- Ensure implementation of key initiatives to improve access
to care.
-- Establish one authoritative source for veteran contact
information, military service history, and veteran status.
-- Finalize the Congressionally mandated DOD-VA
Interoperability requirements.
12. Transform Supply Chain.
-- Breakthrough Outcome for 2016:
-- Build an enterprise-wide integrated Medical-Surgical supply
chain that leverages VA's scale to drive an increase in
responsiveness and a reduction in operating costs. More
than $150 million in cost avoidance will be redirected to
priority veteran programs.
We are rigorously managing each of these ``breakthrough
priorities'' by instituting a Department level scorecard, metrics, and
tracking system. Each priority has an accountable and responsible
official and a cross-functional, cross-Department team in support. Each
team meets every other week in person with either the Secretary or
Deputy Secretary to discuss progress, identify roadblocks, and problem
solve solutions. This is a new VA--more transparent, collaborative, and
respectful; less formal and bureaucratic; more execution and outcome-
focused; principles based, not rules-based.
legislative priorities
The Department is grateful for your continuing support of veterans
and appreciates your efforts to pass legislation enabling VA to provide
veterans with the high-quality care they have earned and deserve. We
have identified a number of necessary legislative items that require
action by Congress in order to best serve veterans going forward:
1. Improve Care in the Community: We need your help, as discussed
on many occasions, to help overhaul our Care in the Community programs.
VA staff and subject matter experts have communicated regularly with
congressional staff to discuss concepts and concerns as we shape the
future plan and recommendations. We believe that together we can
accomplish legislative changes to streamline Care in the Community
programs before the end of this session of Congress.
2. Flexible Budget Authority: We need flexible budget authority to
avoid artificial restrictions that impede our delivery of care and
benefits to veterans. Currently, there are more than 70 line items in
VA's budget that dedicate funds to a specific purpose without adequate
flexibility to provide the best service to veterans. These include
limitations within the same general areas, such as healthcare funds
that cannot be spent on healthcare needs. These restrictions limit VA's
ability to deliver veteran care and benefits based on demand, rather
than specific funding lines. The 2017 b`udget proposes appropriations
language to provide VA with new authority to transfer up to 2 percent
of the discretionary appropriations for fiscal year 2017 between any of
VA's discretionary appropriations accounts, excluding Medical Care.
This new authority would give VA greater ability to address emerging
needs and overcome artificial funding restrictions on providing
veterans' care and benefits.
3. Support for the Purchased Health Care Streamlining and
Modernization Act: This legislation would clarify VA's ability to
contract with providers in the community on an individual basis,
outside of Federal Acquisition Regulations (FAR), without forcing
providers to meet excessive compliance burdens, while maintaining
essential worker protections. The proposal allows this option only when
care directly from VA or from a non-VA provider with a FAR-based
agreement in place is not feasibly available. Already, we have seen
certain nursing homes not renew their agreements with VA because of the
excessive compliance burdens, and as a result, veterans are forced to
find new nursing home facilities for residence.
VA further requests your support for our efforts to recruit
and retain the very best clinical professionals. These include, for
example, flexibility for the Federal work period requirement, which is
inconsistent with private sector medicine, and special pay authority to
help VA recruit and retain the best talent possible to lead our
hospitals and healthcare networks.
4. Special Legislation for VA's West Los Angeles Campus: VA has
requested legislation to provide enhanced use leasing authority that is
necessary to implement the Master Plan for our West Los Angeles Campus.
That plan represents a significant and positive step for veterans in
the Greater West Los Angeles area, especially those who are most in
need. We appreciate the Committee's hearing in December 2015 on
legislation to implement that Master Plan, and VA urges your support
for expedited consideration of this bill to secure enactment of it in
this session of Congress. Enactment of the legislation will allow us to
move forward and get positive results for the area's veterans after
years of debate in the community and court action. This bill would
reflect the settlement of that litigation, and truly be a win-win for
veterans and the community. I believe this is a game-changing piece of
legislation as it highlights the opportunities that are possible when
VA works in partnership with the community.
5. Overhaul the Claims Appeals Process: As mentioned earlier, VA
needs legislation that sets out structural reforms that will allow VBA
and the Board to provide veterans with the timely, fair, and quality
appeals decisions they deserve thereby addressing the growing inventory
of appeals.
Lastly, let me again remind everyone that the vast majority of VA
employees are hard workers who do the right thing for veterans every
day. However, we need your assistance in supporting the cultural change
we are trying to drive. We are working to change the culture of VA from
one of rules, fear, and reprisals to one of principles, hope, and
gratitude. We need all stakeholders in this transformation to embrace
this cultural transformation, including Congress. In fact, I think
Congress, above all, recognizes the policy window we have at hand and
must have the courage to make the type of changes it is asking VA and
our employees to make. Congress can only put veterans first by caring
for those who serve veterans.
Our dedicated VA employees, if given the right tools, training, and
support, can and go out of their way to provide the best care possible
to our veterans and their families.
closing
VA exists to serve veterans. We have spent the last year and a half
working to find new and better ways to provide high quality care and
administer benefits effectively and efficiently through responsible use
of taxpayer dollars. We will continue to face enormous challenges, and
this budget request will provide the resources needed to continue the
transformation of this Department.
This budget and associated legislative proposals will allow us to
streamline care for veterans and improve access by addressing existing
gaps, develop a simplified appeals process, further the progress we
have made to eliminate the VBA claims backlog and end veteran
homelessness, and improve our cyber security posture to protect veteran
and employee data. It will also allow us to continue implementing MyVA
to guide overall improvements to VA's culture, processes, and
capabilities.
I have pledged that VA will 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. I am proud to continue
this work and recognize there is much left to be done. We have made
great strides and are grateful for the support of Congress through this
transformation.
Thank you for the opportunity to appear before you today and for
your continued steadfast support of veterans. We look forward to your
questions.
HINES VAMC SCHEDULING MANIPULATION INVESTIGATION
Senator Kirk. Let me start the questions here, and say, Mr.
Secretary, Ms. Germaine Clarno is a social worker at the VA
hospital in Hines, Illinois. She has been calling for the VA to
fix failures at the hospital for years.
I introduced you to Germaine in Chicago in January of 2015
and again in my office on April 21, so you know her. It was 11
months after I asked your predecessor, General Shinseki, to
investigate the allegations of Ms. Clarno at the Veterans
Hospital in Hines similar to the scandal at the Phoenix VA, all
to acquire bonuses and promotions.
This is why I called for the resignation of Joan Ricard,
the person who led the Hines VA, and then she retired.
Fourteen months after my call to General Shinseki on July
20, 2015, your chief of staff, Rob Nabors, concluded that the
Inspector General investigation had ``thoroughly addressed the
concerns of the complainant Germaine Clarno'' as summary number
one. In response, both Germaine and the Office of Special
Counsel (OSC) asked for the full Inspector General
investigation report. That was 7 months ago.
Summary number two of the Inspector General investigation
on Hines' scheduling manipulation also came from the Inspector
General on September 8. And in response, 2 weeks ago, the OSC
wrote President Obama on the Hines investigation that the
report was ``incomplete'' and ``not responsive,'' did not
respond to the whistleblower's concerns raised and ``did not
meet the statutory requirements,'' and was, ``not responsive to
the serious allegations of significant wait times and delays in
the veterans' access at Hines.'' It also said, ``it
demonstrated hostility'' toward Ms. Clarno apparently for
having spoken publicly, as well as an attempt to minimize her
allegations.
Again, summary number three was released, but not a report
with the VA's instructions for change.
Secretary McDonald, the VA-MilCon section of the funding
bill of the omnibus did require all ``work products'' to be
transmitted to the Appropriations Committee. I would ask you if
you have brought this full report, and I would like you to
bring the full report to the subcommittee as required by law,
which would really help Ms. Baldwin on the candy factory at
Tomah to get the complete Inspector General report, as required
by law. I have also discussed this with our ranking member, Mr.
Tester.
Secretary McDonald. Mr. Chairman, we want all of the
Inspector General reports to be released. In fact, as you
properly pointed out, I have met with Ms. Clarno on numerous
occasions. We appreciate her coming forward and describing what
was wrong at Hines.
As you properly pointed out, these investigations occurred
in the middle of 2014 before I was confirmed. The President has
nominated a new Inspector General, and we would like the Senate
to immediately confirm that new Inspector General, Mike Missal,
because we have a lot of work to do with the Inspector General
to get these reports out.
Also, in the letter that you referenced from the Inspector
General, if you read the next paragraph, the Inspector General
says that she is optimistic that this new Inspector General
will conduct more thorough investigations in a more appropriate
and comprehensive direction for the Department.
Our Deputy Secretary is digging into all of these issues
and sorting out the differences in opinion between the
Inspector General report and between the Office of Special
Counsel. We are working with both parties to do that. As soon
as we are done doing that, we will get back to [you]
immediately.
But again, I just want to say we appreciate Ms. Clarno
pointing these things out.
Senator Kirk. She is sitting right behind you there.
Let's keep going. Mr. Tester.
Senator Tester. Thank you.
INSPECTOR GENERAL CONFIRMATION
Just very quickly, Secretary McDonald, what you are saying
is that if Mike Missal can get confirmed, you could get that
information to us quicker?
Secretary McDonald. Yes, sir. I think we have been short-
staffed at the Inspector General since the Inspector General
retired.
Senator Tester. So it is important. I believe he is cleared
on our side and so if, Mr. Chairman, if you and the other
members of this subcommittee can make that plea to your caucus
to take off the hold so we can get him confirmed, it could make
a big difference.
I think it is important we get this report. I think we need
to get the good information on this report and get it as soon
as possible, so I support the chairman's efforts here, but you
guys need the tools to be able to do that. So please help.
BETTER CARE IN THE COMMUNITY LEGISLATION
As I said in my opening, I am working on a bipartisan piece
of legislation, a number of issues including provider
agreements, spending flexibility that will allow you to provide
better care in the community in a timely manner.
Can I get a commitment from you, Mr. Secretary, that you
will help get this bill across the finish line, particularly
with the VA Committee?
Secretary McDonald. Yes, sir. I believe we are doing that
Tuesday.
Senator Tester. Would you agree that if we do not get that
bill done, that it could have a dramatic impact or continue the
kind of impacts we are having on veterans right now with
Choice?
Secretary McDonald. Yes, sir. One of the reasons our
service is so bad with a third-party administrator, like Health
Net, is resolved in this bill.
Senator Tester. Okay, good. That is good. Thank you for
that.
2018 ADVANCE APPROPRIATION
Last week, when Dr. Shulkin was here, we questioned him
about a gaping hole in the fiscal year 2018 advance
appropriations for medical care. You are going to get a second
bite at this apple, but this is going to be a big bite.
My understanding is the VA's future costs for all hires
under the Choice Act is $1.3 billion and the future costs for
leases and activation is about $318 million. None of these
costs have been built into that 2018 advance request. Is that
correct?
Secretary McDonald. Yes, sir.
Senator Tester. Okay. So on top of that, between the Choice
Act funds and discretionary appropriations, I think you are
planning on spending about $12 billion on Care in the Community
in fiscal year 2017. Your head is nodding, so I assume that is
correct.
But in 2018, the advance appropriations request for Care in
the Community is about $9.4 billion. I hope you can track these
numbers. You know them. That is almost a $3 billion reduction,
and Choice funding will probably be exhausted by then. How are
you going to make up the difference?
Secretary McDonald. I think, again, you mentioned the
second bite idea, but I think the issue here, Senator Tester,
is we have to know what we are actually going to provide before
we can cost it out. That is why Tuesday's hearing with the
authorizing committee is so important, because if we can deal
with your bill, your consolidation bill, consolidation of Care
in the Community from the seven different methods to one, we
will know exactly how to cost it out.
But as you know, there are choices within that bill, there
are choices available, so we are waiting to see what the
authorizers authorize. Then we will know exactly what the cost
will be.
Senator Tester. So you know, and I think you probably know
this, the nondefense discretionary cap is going to be $3
billion lower than it is this year, so we are going to get a
double whammy off this thing, if you know what I mean.
So we look forward to making sure we do not have a
shortfall in your monies.
SES EXECUTIVES TO TITLE 38
Mr. Secretary, you put forth a proposal that would allow
the VA to move all of its senior executives to title 38. Can
you explain how this move will impact the accountability at
your Department?
Secretary McDonald. The idea of moving our Senior Executive
Service staff to title 38 was to help us recruit, because we
would have direct hiring authority. It was to help us pay more
competitively. Most of our medical center directors make less
than 50 percent of what they can get from the private sector,
because they are Readjustment Counseling Service (RCS)
employees.
It would also have the appeal authority for disciplinary
actions within the Department, so I would be the appellate
authority rather than the Merit Systems Protection Board
(MSPB).
In working within the executive branch, we have come to the
point of view that that is appropriate for medical people in
the Veterans Health Administration (VHA), but there is some
pause whether or not we should apply that it people in the
[Veterans] Benefits Administration.
Senator Tester. Would it make a difference in
accountability?
Secretary McDonald. We are coming up with a proposal, which
we will share with you on Tuesday, that would make a difference
in accountability, yes, sir.
SIMPLIFIED APPEALS PROCESS PROPOSAL
Senator Tester. Okay. You put forth a proposal, very
quickly, on the appeals process.
Secretary McDonald. Yes, we have.
Senator Tester. Have you contacted the Veterans Service
Organizations (VSOs) on that proposal?
Secretary McDonald. We have had people locked in the room
this week, including Veterans Service Organizations, AHF
members, working on the proposal.
Senator Tester. So you cannot tell me whether they support
it or not at this point in time?
Secretary McDonald. I think it is safe to say that they
support most of the elements in the proposal. I think the most
difficult element in that proposal is freezing the form 9,
which would cause a veteran to reapply.
Senator Tester. All right. Thank you.
Thank you, Mr. Chairman.
Senator Kirk. Ms. Collins.
Senator Collins. Thank you, Mr. Chairman.
ACCESS RECEIVED CLOSER TO HOME
Mr. Secretary, welcome. We have discussed many times the
ARCH (Access Received Closer to Home) program, which exists in
northern Maine, which is one of the five pilot sites across the
country. This program, as you well know, allows veterans in
rural areas to receive exceptionally high-quality care close to
home, close to their families, and when they need it.
It has a 90 percent patient satisfaction rate. And
according to the VA's own figures, the average cost per veteran
in Maine using the ARCH program is less than the average cost
for the VHA direct care.
This is a program that has been very well-received. It has
been extremely well-operated. And it contrasts sharply with the
experience that Maine veterans have had with the Choice program
where fewer than 50 percent of eligible Choice program patients
in Maine have received the appointments they need when they
need it. And the contractor chosen by the VA, Health Net, has
performed very poorly in my State.
Given the huge success of the ARCH program and how happy
our veterans are with it, and how cost effective it is, I do
not understand the resistance of the VA to preserving the
program.
I hear all of this discussion of folding ARCH into the
Choice program. To me, ARCH ought to be the model for the
Choice program. ARCH is working, working well. The Choice
program is not working well.
So will you consider extending the ARCH program in its
current form, so that we are not taking a program that is
working well and breaking it by folding it into a program that
is not working well?
Secretary McDonald. Senator Collins, the new program that
we are talking about, taking the seven different ways of
achieving care in the community, including ARCH, and
consolidating them into one is not consolidating them into the
old Choice program. It is creating a whole new program that
takes the benefits, the things we learned from the ARCH pilot,
and folds them into a wholly new program that provides care in
the community in one way with one reimbursement rate.
So I think we should look at the bill Senator Tester has
authored and others in our authorization committee have all
have authored as a wholly new program that will take everything
we have learned from Choice and from ARCH and actually
consolidate it in a new program that will make things easier
for veterans and make things easier for our employees.
David, would you like to comment?
Dr. Shulkin. Senator Collins, I think you are accurate. The
ARCH program predated Choice. It has worked extremely well.
As you know, it is a relatively small number of veterans. I
think in the State of Maine, it is about 1,400 veterans. It is
pretty small.
So that idea of expanding the ARCH program to be this
consolidated program is one that we have looked at. But the
cost of that would be extraordinary because, as you know, ARCH
was meant to get veterans access in rural areas, in areas where
there are provider shortages. So we tend to have a
reimbursement rate for providers that would be really
unsustainable for the rest of the country.
So we are trying to preserve what has worked in ARCH in
this new Veterans Choice program.
Senator Collins. Well, let me just point out that the
hospital, Cary Medical Center, that is administering the ARCH
program is paid at Medicare reimbursement rates. And according
to the VA's own figures, the average cost per veteran in Maine
using ARCH is $2,708.70--a pretty precise number--which is less
than the VHA direct care.
So my concern is that you are going to cause disruption in
a program that has been cost-effective and has worked very
well. That is what I am really worried about.
I just cannot overstate how satisfied the veterans are with
this program.
My time has expired, and I know we have a vote. I have an
important question on the opioid problem and the prescriptions
that are prescribed by the VA. The risk of death by accidental
overdose among patients at the VA facilities is nearly twice
that of nonveterans, so I would ask to submit that question and
others for the record.
Thank you.
Senator Kirk. I think since we have a vote that has just
been called, we will take a short recess.
[Recess.]
Senator Murkowski [presiding]. At this time, I will turn to
Senator Hoeven.
VETERANS CHOICE IMPROVEMENT ACT
Senator Hoeven. Thank you, Madam Chairman.
Mr. Secretary, good to have you here.
We need to improve the Veterans Choice Act. That is why I
have worked with Senator Burr and others to introduce the
Veterans Choice Improvement Act. We are looking to combine that
with the work that the VA Committee has already done, which
includes legislation that I have crafted relative to long-term
care and in-home care, combine that with healthcare.
We are looking to bring all this together and move it as
soon as we can. You and I have talked about this.
Secretary McDonald. Yes, we have.
Senator Hoeven. But this provides the important flexibility
so that you can not only provide quality institutional care
within the VA for veterans that want to access that, but also
so that we make the Veterans Choice Act work.
We have a big problem with these third-party service
providers, like Health Net, that are not providing quality
service, and that is giving Veterans Choice a bad name.
So we have an opportunity here to make this thing work, but
we have to figure out how to do it. This legislation empowers
you to do that.
CHOICE THIRD PARTY SERVICE PROVIDERS
So what I would like you to respond to is how you intend to
handle these third-party service providers.
Secretary McDonald. Over time, I think what we need to do,
and this is why a change in legislation is so important, is
change the contractual relationship with third-party service
providers.
I think we can't outsource customer service. In my opinion,
that was the big mistake with the original Choice Act. We
basically just outsourced customer service to the third-party
providers. So the third-party provider, we would literally just
give the veteran a phone number to call. That is just not
right.
I mean, we are in the customer service business. Our vision
is to be the best customer service organization in government.
We should not be outsourcing customer service.
We have to change that relationship. That is part of what
the new law, that we are very appreciative for, would do.
David.
Dr. Shulkin. Senator, the other thing I would say is, as
you know, the Choice program, we had to bring it from
conception to start in 90 days, so it was a very short time
period. What we have been doing since then is we have been
meeting with private industry, mostly the managed care industry
and the outsourced industry, and getting the very best
practices and the very best thoughts so that we can develop a
request for proposal (RFP) when we go out under the new
Veterans Choice program to have a much better program that is
really state-of-the-art.
Senator Hoeven. Then one of the keys is that this
legislation will also give you the ability to provide that
service directly. In other words, the VA itself work with
veterans to go to private healthcare providers. I think that is
a very important piece.
For example, in our State, with the Fargo VA Health Care
Center, which serves all of North Dakota and most of Minnesota,
they have a very good reputation for providing quality care.
You have a director there, Lavonne Liversage, who has people in
her customer service area that can work with private healthcare
providers, and she is willing to do that. Thank you for
committing to come out and help us set that up.
So, one, are you willing to let us set up that kind of
approach to show that it works? I think you have already done
it in Alaska, in Montana. We need to be able to do it.
Then will you keep that option, which we allow you to do
under the legislation? So if you want to go bid for a service
provider and not work for somebody, well, that may be okay, but
we can also do it directly so we can ensure that our veterans
get that access to quality care, whether it is at the VA or
through a private healthcare provider.
Secretary McDonald. Senator, that is exactly what we want
to do. We envision an optimized network of great providers all
across the country, so that the issues that Senator Murkowski,
for example, has raised in Alaska, where the Choice program cut
out the Alaska Native Health system, we can get them back in,
because they are great providers, they are great partners of
us, and we would like to be able to develop that optimized
system rather than only having one entrance door for the
veterans, which is ``call this phone number.''
So that is exactly what we have in mind. We appreciate your
advocacy for it.
Senator Hoeven. Than the other piece, if you would touch on
for a minute, is we have worked to include legislation that
enables nursing homes and other providers of long-term care,
including in-home care, the ability to get provider status in a
way that works for them without a lot of red tape and
bureaucratic complications.
LONG-TERM AND HOME CARE
Are you willing to support that and help us institute that?
That is going to give veterans long-term care and in-home care
in their communities. They can still go to the veteran center
in their State if they want, but it gives them that access to
care in the community, long-term care.
Secretary McDonald. We are very much appreciative for you
introducing that bill. We need these provider agreements. Right
now, we have providers around the country who are refusing to
do business with us because of the Federal Acquisition Rules,
and the cost, the red tape that that adds to their operation.
These small businesses can't afford that. We have, in some
cases, where they are literally threatening to throw our
veterans out of their homes because they do not want to do this
red tape.
So this bill would give us the ability to continue to do
business with them and lessen the Federal Acquisition Rules red
tape for them.
Senator Hoeven. Thank you, Mr. Secretary.
And, Dr. Shulkin, thank you as well. I appreciate it.
Senator Murkowski. Thank you, Senator Hoeven.
Senator Cassidy.
VA HEALTHCARE STAFFING PRODUCTIVITY TO PRIVATE SECTOR
Senator Cassidy. Dr. Shulkin and I had a conversation the
other day regarding best practices, productivity, mental
health. But again, kind of continuing on the theme that I speak
to colleagues, physician colleagues, who work in VAs around the
country, I am told by some that they may see two patients an
hour.
So I mentioned your staffing, some of your budget for
staffing, and their productivity is far less than private
practice. Now, that is important, because obviously the doc
is--but I am sure it is true for the nurse practitioner (NP)
and physician assistant (PA), et cetera.
So first question is, to what degree is the physician
productivity, the PA, the NP productivity, less than the
private sector, both on an average per doc and then
collectively across the system?
And then I guess the next step would be, as we are talking
about staffing, it seems like the better step would be to first
get your systems down so that the physician is seeing 20 or 30
patients a day instead of 14 patients a day, which I gather it
is sometimes even less than that.
So I will toss that out.
Secretary McDonald. Senator Cassidy, we measure
productivity, and we track it very closely. We use the common
industry practice of relative value units (RVUs). Our
productivity is up roughly 9 percent to 10 percent over the
last year.
I would argue that the reason, on an absolute level, we may
seem more less productive is, one, our patients have much more
complex situations.
Senator Cassidy. Now can I challenge you a little bit on
that?
Secretary McDonald. Surely.
Senator Cassidy. Because you are going to have in the mix
the follow-up. I used to see very complex patients and so for
one I would have booked out a 45-minute or even an hour visit,
but it would later come back as a 5-minute visit or even my
nurse walking in, giving the results, and me making sure there
are no questions. So that we I could see four patients in an
hour, five patients in an hour.
Some I am going to challenge you little bit, because they
are not very complex every single time.
Secretary McDonald. I agree. They are not very complex
every single time.
Also, our providers work on a team basis in order to do a
lot of alternative therapies that you would not see in the
private sector.
For example, if our primary care physician and our mental
health professional discover the person has posttraumatic
stress, they may then work with them to get them into
acupuncture or yoga or some----
Senator Cassidy. But that can only be--this limited time,
so I am sorry to interrupt.
That can only be 5 percent or even 10 percent of your
patients. Most of it is going to be straightforward diabetes,
hypertension, cholesterol check, lab check.
Secretary McDonald. Well, when I look over the productivity
numbers, this is what I see.
David practices, so maybe he has a different point of view.
Dr. Shulkin. Yes, Senator Cassidy. First of all, we do
measure on RVUs. The Secretary is correct.
We have increased productivity 10 percent over the past 2
years. But now I have some greater insights into what you are
talking about, since I now have begun to practice as an
internist in the VA.
I get 30 minutes for a follow-up, an hour for new patient.
What you see when you practice in the VA is we are doing a much
more comprehensive approach toward preventative care, screening
for depression, screening for opioid abuse, substance abuse.
So the care that we are delivering in the VA is one of the
reasons why we have such better quality metrics than in the
private sector.
Senator Cassidy. So can I ask?
Dr. Shulkin. Yes.
Senator Cassidy. So again, just going to my field, which
was managing ascites, for example, sometimes I would see them
every 2 to 3 weeks, just to counsel on whether they are on a
sodium restriction, checking creatinine, et cetera.
If I got 30 minutes for every visit every 2 weeks, that
would just gobble up my schedule.
Dr. Shulkin. Right.
VA PATIENT SCHEDULING SYSTEM
Senator Cassidy. So is it automatic, because in your GUI,
by example, graphical user interface, it has a 30-minute block
for everybody. So no matter the complexity, is it possible to
make three patients each 10 minutes or is every single patient
30 minutes?
Dr. Shulkin. Our scheduling system is pretty fixed.
Senator Cassidy. So that, I have to tell you, I used to do
a pretty good job of preventive health, so I will not concede
that you must be so wasteful with time in order to accomplish
everything. Would you agree with that?
Dr. Shulkin. I agree, and I do think it is worth us looking
at that, having a brief visit.
Senator Cassidy. I have to imagine that you could increase
the productivity of your physicians dramatically in both number
of patients per physician as well as--we do not need to hire
more, by golly, we now have it, just by kind of allowing
somebody to say this is really just a follow-up to make sure
they are taking their fluid pills.
Dr. Shulkin. I think we are looking at all of these things
since access is our top priority. So you are identifying
something that absolutely is worth looking at.
I think the Secretary is also correct. What most of our VA
doctors are saying to us is, give us some additional team-based
help. Give us the RNs, the pharmacists, the social workers to
be able to use our time more productively, to be able to get
patients through faster. So it is going to be multifactorial.
I can assure you, we are laser-focused on increasing access
and productivity right now, and we are going to take your
comments back about seeing whether we can adjust for some brief
visits as well, because I agree with you. There are many
patients who come back for simple reasons.
Senator Cassidy. Okay. I yield back. Thank you.
Senator Murkowski. Thank you, Senator Cassidy.
I am now going to turn to Senator Baldwin, and I am going
to pop out and go vote. I am sure we have other members who are
coming back, so you may get more than 5 minutes.
Senator Baldwin. [Presiding.] Oh, terrific. I hope everyone
is as pleased as I am about that opportunity.
Secretary McDonald. We are.
JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT
Senator Baldwin. Especially since I want to start with a
thank you, Mr. Secretary. I very much appreciate your support
for the legislation that I drafted, along with Senator Capito.
I know you are well-familiar with the Jason Simcakoski
Memorial Opioid Safety Act that passed out of the Veterans'
Affairs Committee late last year. I will also note that the
chairman of this subcommittee, Ranking Member Tester, Senator
Murray, are also cosponsors of the bill.
We hope that this bill will pass the Senate and become law
in short order, and I hope that we can count on you for your
continued support and advocacy, Mr. Secretary, to help us move
this across the finish line.
Secretary McDonald. For sure. I believe that we have a
leading role to play in American medicine in showing the way
forward on reducing opioid use and also in preventing suicide.
Senator Baldwin. I appreciate that very much.
I want to turn your attention to an issue that has recently
been subject of many media accounts in my State.
When I am not the only person here, I will ask unanimous
consent to add a number of articles for the record, or maybe I
can just----
Secretary McDonald. I think you are the chairwoman right
now.
Senator Baldwin. I am in charge, so I ask unanimous consent
to enter several news articles in the record. We will hold the
record open so somebody can object if they would like, but I
doubt it.
[The information follows: the requested information was not
available at the time this publication went to print.]
SOCIAL SECURITY NUMBERS AS IDENTIFIER TO VETERANS' RECORDS
Senator Baldwin. Anyways, quite seriously, these articles
detail an incident that occurred last year in Wisconsin when a
VBA employee sent to VSOs at the Wisconsin Department of
Veterans Affairs a spreadsheet that identified 638 veterans
whose claims had been recently closed.
Mr. Secretary, because the spreadsheet contained veterans'
names and Social Security numbers, it was encrypted before
transmission.
I apologize [that I] am going to get into the weeds here,
because I really want to make sure that the facts of what
happened become a part of this record.
Thereafter, one of the VSOs who received the spreadsheet
from the VA forwarded that email to a number of State and
county VSOs so that they could reach out and offer assistance
to the veterans listed. Because the recipients were not
affiliated with the VA and did not have VA email addresses to
which encrypted emails could be sent, the VSO's message was
sent unencrypted.
In addition, although the VA security tools and procedures
generally prevent the emailing of personally identifiable
information without encryption, this transmission was
nevertheless successful because the content did not meet the
criteria that would have otherwise prevented transmission.
One recipient included a veteran who is not a VSO or a
representative of any of those listed individuals. That
individual and his representative alerted the Wisconsin
Department of Veterans Affairs, the media, and my office
concerning the problem.
Mr. Secretary, we can certainly have quite a back-and-forth
about whether the VA bears some responsibility for what
happened, but what I would like to see is the VA discontinue
using Social Security numbers to identify individuals in all
information systems. Until that is done, veterans will be at
risk for identity theft and fraud.
I am going to ask you, Mr. Secretary, what your thoughts
are on this proposition.
Secretary McDonald. I would have to take a closer look at
it, but I can tell you that we take the disclosure of personal
information very, very seriously, even to the point that we
always fault on the side of the veteran. So this is a very
unfortunate circumstance.
I know there was an issue with our software that if the
numbers were strung together without the hyphens, and you and I
are both getting into the weeds on this, that it could go out,
even though it is a Social Security number.
Senator Baldwin. Right.
Secretary McDonald. I know we have taken immediate steps to
fix that, but going all the way to using some other mechanism
other than Social Security numbers to identify an individual, I
would have to get back to you on that.
[The information follows:]
[From Channel3000.com, WISC-TV, News 3, Madison, Wisconsin]
_______________________________________________________________________
(By Adam Schrager)
MADISON, Wis.--The Social Security numbers of Wisconsin veterans
are being sent via email without encryption despite numerous Federal
laws and U.S. Department of Veterans Affairs regulations requiring
personally identifiable information be password-protected.
It partly explains how a random Wisconsin veteran received an
unsolicited email on April 1 with the Social Security numbers and
disability claim information of hundreds of Wisconsin veterans. Since
the Vietnam War, veterans' file numbers or disability claim numbers
have been their Social Security numbers.
``I got up, was working at the computer and had an email from the
Department of Veterans Affairs in Wisconsin. Not knowing what it was, I
opened up the attachment and I panicked,'' the veteran said. ``It was
nine-digit numbers. There were no hyphens. It wasn't like 111-11-111.
It was nine numbers straight.''
A Wisconsin Department of Veterans Affairs spokesperson said the
software program, Ironport, which is used by the Federal VA,
intentionally does not flag nine-digit numbers without dashes because
of the concern that there would be too ``many false positives.'' She
said nine-digit number sequences where dashes are used would require
the person sending the email to encrypt it before it could be sent or
to remove the nine-digit number sequence with the dashes.
The veteran who received the email immediately notified the
Wisconsin Department of Veterans Affairs of its error. He forwarded it,
with the attachment, to his advocate, a retired colonel who used to
work for the WDVA. Together, they notified numerous elected officials
and the Federal VA about what had happened.
``There is absolutely no reason in the world for me to have this
information,'' he said. ``We were told it was an error. We should not
have received that.''
The veteran and his advocate sent an email to the WDVA a week after
the privacy breach stating they would assure the department that they
``(had) not forwarded this very confidential information.'' Kim
Michalowski, who was in charge of the WDVA office that sent the email,
thanked them in a follow-up email for their ``assurances.''
However, any good will between the parties soured when the WDVA,
and subsequently the Wisconsin Attorney General's Office, demanded the
veteran and his advocate destroy all records associated with the
privacy breach. The veteran responded in an email obtained by News 3
that multiple groups were investigating the matter and he wanted to
know if he was being asked to ``destroy evidence.''
His answer came less than a month later when he and his advocate
were sued in Dane County Circuit Court, in an effort to compel them to
destroy all evidence of the email and the attachment. The veteran and
his advocate sought legal counsel, paid to completely scrub their
computers and were forced to sign an affidavit that they had no record
any more of the email and its attachment before the lawsuit was
subsequently dismissed.
``We were told we had to clean them off the computer, off all
servers, off the cloud. My God, how do I do that? I can barely turn on
a computer,'' said the veteran, who is remaining unidentified because
he is fearful of further retaliation. ``I believe the process needs to
be rectified. We have very dedicated veterans out there who need to
have their privacy, their security, respected, and when this kind of
information is released unsolicited, that's a travesty.''
Nine days after the email was sent, WDVA Secretary John Scocos sent
a note to the 637 veterans whose names and file numbers were in the
attachment offering credit monitoring for a year and said the incident
was a ``one-time disclosure to one unauthorized individual, who is a
Veteran.'' However, less than a week after that, the department's own
investigator determined that the data report inappropriately sent on
April 1 had also been sent to ``unaccredited recipients.''
``The email filter, on the U.S. Department of Veterans Affairs
computer network, which typically alerts the sender to this type of
disclosure did not block the sensitive data in this instance,'' WDVA
Communications Director Carla Vigue wrote in a statement emailed to
News 3. ``When we contacted the USDVA Network Security Operations
Center regarding this occurrence, they were already aware of the
problem of certain emails making it past the filter.''
News 3 has learned the April 1 incident is not an isolated one. On
at least three other occasions (June 1, 2014, Oct. 1, 2014 and Dec. 1,
2014), the same data report was also sent unredacted to ``unaccredited
recipients,'' or as defined by the VA, people who are not trained to
view such personally identifiable information. In fact, the
administrator doing the internal investigation is himself
``unaccredited,'' according to USDVA documents, and thus, not supposed
to look at personally identifiable information of Wisconsin veterans
such as the material erroneously sent.
Combined, the four data reports contained the disability claim
numbers of nearly 2,000 Wisconsin veterans. An open records request to
learn who received the emails from June 1, 2014-April 1, 2015, has not
been answered by the WDVA.
``The WDVA has tightened protocols regarding privacy to safeguard
sensitive information,'' Vigue wrote. ``We no longer share the report
in question.''
The internal investigation recommended Michalowski and his
subordinate, Colin Overstreet, who actually sent the email, be
suspended for one day. Both have since left their positions at the
WDVA. Neither Michalowski nor Overstreet agreed to comment on what
happened.
Multiple requests for an on-camera interview with Scocos were
denied. An on-camera interview with his deputy, Kathy Marschman, was
canceled less than two hours before it was scheduled. In a meeting to
discuss an interview, Marschman said protecting the personally
identifiable information of Wisconsin veterans was one of the
department's top priorities, but a review of the department's 2015-16
strategic plan does not mention that.
Secretary McDonald. Danny, do you have any?
Mr. Pummill. The only thing I would add, Senator, is that
when the list was sent out unencrypted, we should not have
relied just on the computer software to catch the serial number
sequences of the Social Security numbers and stop it. The
individual should not have sent out an unencrypted list to
anybody with Social Security numbers on it.
We put extra emphasis on that. We check it constantly now,
and we reiterate to everybody that it is personal
responsibility. You do not rely on software. Under no
circumstances do you send a Social Security number unencrypted.
But we are looking at other ways of modifying it. As you
know, the VA claim number is actually the Social Security
number of the individual, and we are trying to find an
alternate way of doing that.
Senator Baldwin. I hope to work with you in that process.
Other major governmental agencies have made the change from
using Social Security numbers as identification numbers to
alternatives. I understand the scope of that undertaking with
agencies as large as the VA.
But I just want you to know that we are drafting
legislation and seeking your technical assistance. We are
getting that technical assistance, and I hope that we can be
partners in this effort as we move forward.
Secretary McDonald. May I say, Senator, that one of the
things we are undertaking right now is we do not have a single
data backbone within VA, so if you are a veteran and you want
to change your address, you have to do it in about eight
different places, nine different places. One of the things we
have taken on with our new Chief Information Officer (CIO),
LaVerne Council, who is sitting behind me, is creating that
single data backbone.
That would be a great opportunity to move away from Social
Security numbers, because we could put some other kind of
identifier there, and it would simplify everything.
Senator Baldwin. Well, I am all for seizing opportunity, so
I look forward to continuing to work together on that.
As temporary chair of the subcommittee, I would be happy to
now recognize my colleague, Tom Udall, for questions.
Senator Udall. Thank you very much, Senator Baldwin.
Secretary McDonald, it is so good to see you here, and
accompanied by Dr. Shulkin and Mr. Pummill. Thank you, all of
you, for your service to the country and to our veterans. There
could not be a more important task that we undertake.
I fully respect the fact that you took this assignment, Mr.
Secretary, at a difficult time during great publicity around a
serious scandal. Working with Congress and additional
resources, I think you have made some good progress, including
yesterday's announcement that the VA is now able to fund care
for all veterans with hepatitis C. That is a very, very welcome
development there.
We are going to have to keep that up to regain and maintain
the trust of America's veterans, and I know that you all are
committed to that.
I was pleased to meet with you 2 weeks ago and talk about
some of the issues with VA care in New Mexico.
I am also glad to see that the VA budget justification
specifically supports research and exposure to airborne
particulate matter from burn pits. I look forward to an update
on this research as it moves forward on how we can ensure
veterans get the treatment they need for such exposure.
The hearing today is important to discuss ways to improve
the department and its services for veterans. The subcommittee,
as you know, funds your agency and we ensure that this
essential care is ready to support more veterans and, in
particular, the new veterans who are coming home from
Afghanistan and Iraq. We need to make sure that there is a
seamless transition there.
RECRUITMENT OF VA MEDICAL STAFF
Now, my first question, as you know, access is essential
and can be particularly difficult in rural areas like New
Mexico, partially due to problems with retaining practitioners.
How does this budget aim to recruit talented medical staff in
VA facilities? And what can be done, in your opinion, to either
incentivize or streamline the process to hire new doctors and
nurses?
Secretary McDonald. Senator Udall, as you and I have talked
before, having the providers in place is hugely important. I
have been to over two dozen medical schools myself recruiting,
and we have hired over 1,400 doctors since I have been
Secretary.
Nevertheless, I think we have a shortage of medical schools
in this country and one of the things I think also, VA has a
shortage of osteopathic doctors, which is a lost opportunity.
So I would like David to talk about this. We are
increasing, ramping up, our recruiting of osteopathic doctors
and all kinds of doctors nationally in order to recruit them
and get them to particularly operate in rural areas. We know
that osteopathic doctors are more willing to live in rural
areas. They are also more primary care than specialty, which is
exactly what we need.
Senator Udall. Dr. Shulkin, please proceed.
Dr. Shulkin. Yes, thank you.
I think the Secretary is right. We are looking to explore
all avenues. The osteopathic physicians are certainly one
avenue that we are really working hard at, making those
relationships.
We have added new residency affiliations with osteopathic
medical schools, and we are looking to enhance those
relationships. We now have about 300 osteopathic trainees in
the VA healthcare system, and we are looking to expand that.
In addition, because of your support through the Veterans
Access, Choice and Accountability Act (VACAA) legislation, we
have been able to expand residencies desperately needed for
American medicine. When they have a great experience in the VA,
they tend to want to stay in the VA healthcare system. So we
are working on that.
We are using educational debt reduction programs to help
young physicians come in and stay in the VA. That is an
incentive.
And we are looking at our compensation pay tables to make
sure that we are adjusting the pay, particularly for physicians
that we have a very difficult time recruiting in rural areas.
But any help that you could provide us, any ideas that you
have that we are not exploring, particularly with primary care
and mental health in rural areas, we really could use
additional help.
Senator Udall. I was very excited to hear that you all are
working with medical schools and standing up medical schools
and additional residencies, which really make a difference.
As I have told you, we have a new osteopathic school that
is about ready to get going in southern New Mexico that we hope
you will work with.
INSPECTOR GENERAL MISSAL NOMINATION FOR APPROVAL
I want to shift over here to the Inspector General, because
you have asked, and Senator Tester has said, and other others
on the subcommittee have said, how important the Inspector
General is. I would echo what the others have said.
We have to approve your Inspector General. Nothing pushes
that idea more than the fact of what happened as you were
coming in.
I worked in New Mexico, I had many people approaching me
and saying there are problems going on, there are scheduling
problems, there is this, there is that. We did not have the
expertise to deal with it, but we were able to take the
information, work with the complainants, get them into the
Inspector General, and then have the Inspector General work
with them and do a report to you. So I think we need to find a
way.
I would call on everybody to remove those holds and put the
Inspector General in place for the Veterans Administration.
How do we strengthen employee trust in the VA Office of
Inspector General (OIG) operation?
Secretary McDonald. One of the things we have done is
through our Leaders Developing Leaders program, which I
discussed earlier, we have taken our top 450 leaders offsite.
We have done 3 days of training. Part of that training is in
values and, importantly, in the values of the Inspector General
and the role the Inspector General plays.
We have also tried to partner with the Inspector General,
so we are working together. So we are helping the Inspector
General identify trouble spots, because during the time of
change, like we are having with the transformation, the MyVA
transformation, that can create challenges for us. So we want
the Inspector General to be vigilant on where those challenges
are.
But just for an example, we have had over 110
investigations just on scheduling alone. Of those 110-plus,
only 77 have been completed. Of those 77, we have had roughly
10 sites that have been discovered problematic, and 28
individuals that we have had disciplinary action against.
So it shows you the enormity of what we are talking about
and also the fact that we are not done yet. We still have a lot
of work to do.
ALBUQUERQUE VAMC MEDICAL INVESTIGATION REPORT
Senator Udall. Secretary McDonald, just one more brief
question. I understand that you recently signed off on a
medical investigator report pertaining to the Albuquerque VA
medical center. Can you provide the details of the three
recommendations contained in the report? And when will you be
able to share that report with me and release it publicly?
Secretary McDonald. I think David has the report, Senator.
Dr. Shulkin. This is concerning allegations with the
appropriate use of using psychological testing, particularly
for traumatic brain injuries. We have seen the initial draft
report.
We will be able to get you a specific date that it will be
able to be released to you and make sure that we do that. In
fact, I think we may be able to get you a redacted report even
sooner than its official release date. We will be glad to do
that.
I will tell you that when I have reviewed the report, I am
comfortable with the findings in terms of what was
substantiated and what was not substantiated, so that we do not
feel at VA that we need to take immediate action right now for
patient safety, or else we would be taking that action.
[The information follows: the requested information was not
available at the time this publication went to print.]
Senator Udall. Great. Thank you, Dr. Shulkin, very much.
I will submit my additional questions for the record,
because my time has expired. One is on 3-D printing and the
other is on Comp and Pen, which I think you all have discussed
very thoroughly here.
I yield back, Mr. Chairman.
Senator Kirk [presiding]. Thank you, Mr. Udall.
HINES VAMC WAIT TIMES DATA
I requested all documents the VA had about wait time abuse
at Hines VA. Did you bring those documents?
Secretary McDonald. I do not have them with me, Senator,
but we will get them to you.
David may have them.
Dr. Shulkin. Senator, I apologize. I did not see a specific
request from you, but I do have the current wait times data at
Hines VA that I will be glad to leave with you and share with
you.
Senator Kirk. Thank you.
HINES VAMC INSPECTOR GENERAL INVESTIGATION
As I mentioned earlier, the Office of Special Counsel wrote
to the President in defense of Germaine Clarno, that the
Inspector General investigation was ``incomplete'' and ``failed
to address the whistleblower's legitimate concern about access
to care for mental health patients at Hines.''
Let me tell you what this means in real life. My
constituent Army specialist Tom Young served twice in Iraq with
the 10th Mountain Division. At Hines, he asked for help with
his posttraumatic stress disorder (PTSD). Two times, Hines
turned Tom away because he was ``not suicidal.''
After a suicide attempt, Tom went back to Hines, and they
did not have room for him. Tom laid down on the Metra tracks in
Prospect Heights on July 20, 2015.
Two days after Tom killed himself, your own Office of
Accountability Review said no additional investigation is
required of Germaine's complaints that were addressed by the
Inspector General. The Chief of Staff agreed.
Another constituent of mine, Army veteran Michael Swan
waited over a year to see a neurologist and a year to see an
endocrinologist. Even worse, doctors gave him a clear
colonoscopy report showing no polyps. He then went to a
civilian doctor later, and the doctor found 130 polyps.
The VA is saying that Germaine is wrong about Hines wait
times in the mental health department, yet the Office of
Special Counsel has criticized the Inspector General, saying it
was ``willfully ignorant about the allegations.''
Do you still stand by your Office of Accountability Review
report on this matter?
Secretary McDonald. First, I think it is important to say
that any veteran suicide is unacceptable. We all take it deeply
personally, all of us, myself, yourself, being veterans.
So that is one of the reasons we held the suicide
prevention summit that we held in February, to see what more we
can do, what more can all us do as a community in order to
eliminate the possibility of any veteran committing a suicide.
It was March 8, just a couple days ago, where we put out a
press release of the steps we are going to take in order to
increase our suicide prevention program. It is incredibly
important.
Relative to mental health at Hines, the average wait time
is 4.3 days. If that differs from what Germaine thinks it is, I
would love to talk with her again.
As I told you, we have our Office of Medical Inspector at
Hines now, trying to reconcile the difference between the
Inspector General reports and what the Office of Special
Counsel found. Our Deputy Secretary is digging deeply into
this. We will contact Germaine to get more information.
[The information follows: the requested information was not
available at the time this publication went to print.]
Senator Kirk. Thank you.
Secretary McDonald. Yes, sir.
VETERANS CRISIS LINE CONTRACTOR
Senator Kirk. Let me follow up with Dr. David Shulkin.
You were here last week and testified about the veterans'
crisis line putting new people in charge. I wanted to get the
name of the contractor who was handling that voicemail that
dealt with my constituent. Do you have the name of that
contractor?
Dr. Shulkin. I do. Link2Health, with the number two,
Link2Health.
Senator Kirk. Link2Health. Are they still working on the
veterans' crisis line?
Dr. Shulkin. Yes, they are a backup contractor.
Senator Kirk. And since they have messed up Tom's call, why
are they still hired?
Dr. Shulkin. Well, after the issue was discovered with the
voicemails, we went back to them and we put in new stringent
requirements as part of the contract, and they have been
adhering to that. There is no voicemail being used today.
Senator Kirk. Good. Thank you.
Ms. Murkowski.
CHOICE PROGRAM IN ALASKA
Senator Murkowski. Thank you, Chairman.
Secretary, I think this is the first time that we have seen
one another since you visited us in Alaska. I appreciate your
willingness to be there in Wasilla at an open mike. I think you
got it unfiltered from our veterans.
You had some time since that visit to kind of process not
only what Alaska veterans have said, but obviously veterans
around the country.
Dr. Shulkin was here before the subcommittee last week. We
had an exchange back and forth about the failings of the Choice
program in Alaska.
Kind of the short sum of it was that Alaska VA healthcare
system had long been resistant to sending patients to community
facilities. They viewed that a better alternative was to send a
vet all the way down south to Seattle rather than just using
the services there at the Fairbanks Memorial.
Your predecessor, Secretary Shinseki, worked with us. We
really thought we were on the road to that model VA health
system. Then the Phoenix incident comes around.
Now, our veterans are saying very clearly, very loudly, our
VA health system in Alaska is a mess. I referred to it last
week as chaotic.
Without exception--without exception--the veterans who are
talking to me say we need to ditch Choice, we need to go back
to what we had built where VA have identified community
providers, wrote referrals, paid the bills. It was a system
that worked.
So I am concerned with the various proposals out there that
we are seeing that ``consolidate community care.'' We do not
want to participate in a national consolidated program. Those
are all the buzzwords that just do not work for us.
We need a program that is like what we had, which is
custom-developed for the fact that we are noncontiguous; we are
highly rural; we have a mismatch between demand for providers,
which is very, very high, and the supply of providers, which
is, unfortunately, terribly low; and because our medical
community is really self-sustained within the State.
So we do not want to be part of this consolidated national
program. It scares me to death.
Given what you heard in Alaska, given the conversations
that we have with Dr. Shulkin, how can we do this? How can we
draw outside the lines, because that is what we have to do with
Alaska? That is what we have to do, I think you know--a way we
can figure out this integrated system of VA health system that
works for Alaska.
I do not expect you to have the full answer in 2 minutes,
but we need to have a better understanding as to where we are.
Secretary McDonald. Believe it or not, I do have an answer,
because as we put this program together, consolidated care,
this network of great providers, it is with the learnings from
Alaska as part of it.
We need to have in that network the Alaska Native Health
System. We need to return to all the things we had before
Choice. The problem with Choice was it created--it was well-
intentioned----
Senator Murkowski. It was non-Choice.
Secretary McDonald. It was non-Choice. It created a single
entry point call to a third-party administrator where you had
the veteran given a phone number. And I know that does not
work. I mean, I was in Alaska. I went up to Point Hope to watch
how the Alaskan health system worked.
We need to get back to where we were in Alaska. This bill
will do to that or we are not advocating it. So that certainly
is our intention.
Senator Murkowski. Well, okay. You are saying that this
bill gets us there. I need to know that we are all in agreement
as to where there is, because your words are good. I think you
recognize it and you see. But again, part of the frustration
that our veterans have right now is that they saw how we had
corrected a system that had failed our vets for years.
We built it, and then it was disassembled literally in a
matter of months. So what I need to hear from you is that you
agree that where we were before Choice came on is where we can
get back to, and that is the direction that you want to take a.
Secretary McDonald. That is certainly the direction I want
to take it, and I am going to make sure that is built into any
bill, because I thought the Alaska system, and it worked. It
was Choice. It did provide choice.
David, do you want to say anything?
Dr. Shulkin. I think, very specifically, we want to bring
back the customer service piece. The Alaska VA staff had a
great relationship with Alaska providers, the Southcentral
Foundation, as well as the Indian Health Service, and other
Federal programs up there.
We also had a great relationship with our veterans, and we
want that back.
Senator Murkowski. You know that you do not have it now.
Dr. Shulkin. No, we are working hard to repair all the
damage that happened up there, and there has been a done a lot
of damage. There is no question. Both the Secretary and I heard
this personally when we were up there.
VA HEALTHCARE OPERATIONAL ISSUES IN ALASKA
Senator Murkowski. Let me ask about that then, just with
regard to the day-to-day operations, because I think this
really goes a long way to improving that relationship, to
rebuilding that credibility.
We are sitting with a situation where, once again, we do
not have a permanent director. We have not had one since Susan
Yeager left. I personally think it was a tragedy that we could
not keep her. I do not think I have met the director of the
Northwest network.
We are having a difficult time with provider attrition. We
are still having serious issues with provider recruitment.
Again, it is not that we can't figure this out. The Alaska
Native Health Care System has figured it out. They seem to be
up to keeping folks. VA cannot keeping folks. I do not
understand why.
On a month-to-month basis, we do not know how well or how
poorly our community-based outpatient clinics (CBOCs) are
operating. We have a revolving door of providers there. We have
low morale. We have fear of retaliation.
So I hear what you are saying about what we have to do, but
you have a whole series of strikes against you right now that
are going to make it hard to ensure that that veteran feels
like, okay, we are back on the right track.
At a minimum, it seems to me that we have to have some kind
of framework for measuring the performance of what is going on.
I do not know on a month-to-month basis whether our local VA
system is improving or whether it has just entirely collapsed.
So is that something that you are considering and trying to
put in place as you are looking at the bigger picture of how we
get back to where we once were?
Dr. Shulkin. Senator, I do not think that we have the time
to go into the very specifics now. I will say that your
assessment of the local VA situation is probably somewhat
different than mine. We do have a lot of metrics. We have an
excellent acting director, Linda Boyle, there. I would love to
have you spend some time with her.
Senator Murkowski. I know Linda well.
Dr. Shulkin. Right. We have a search going on. We will name
a permanent director in the very near future.
I have been there. The care at the VA is truly excellent.
We have statistics we will be glad to show you.
The problem is our reputation has been hurt incredibly, and
you are hearing it from the veterans because the Choice program
has not worked. That is what we are working very, very hard
right now to repair with TriWest. They have been working very
hard with us to do that.
But we need these legislative fixes to fix the program once
and for all.
So we will reach out to your staff and sit down and review
those statistics with you. We have a lot of data on Alaska.
Senator Murkowski. Well, I appreciate the statistics. But I
also know that when I am sitting on an airplane with a veteran,
he is not talking statistics. He is talking about his care. He
is talking about how he was treated. He is talking about what
it meant for him to basically feel like there was no response.
So I appreciate statistics. I know that we have to be
paying attention to that. But I need to make sure that we have
providers that we can recruit and we can retain. I need to make
sure that we have a level of responsiveness that is more than
just scheduling an appointment. It is one thing to say, yes, I
got an appointment. It is another thing to get the care that
our veterans have clearly earned.
So know that we need to stay very closely engaged with
this, and we certainly intend to do that.
Secretary McDonald. Senator, I would like to send over our
team working on this new bill and make sure that we are
aligned, that this will include the Alaska Native Health System
and all the needs that we were able to address with the
previous system.
Senator Murkowski. I would look forward to sitting down
with your folks. I appreciate that.
Thank you, Mr. Chairman.
Senator Kirk. I would like to ask Secretary McDonald for
you, when you come to Chicago, to meet with Germaine and the
Hines staff. I would like you to commit to that.
Secretary McDonald. I have not been to Hines yet. I would
like to go.
ADDITIONAL COMMITTEE QUESTIONS
Senator Kirk. Thank you.
I think with that, we will thank our witnesses and thank my
partner, Senator Tester.
The hearing record will remain open until the close of next
week. Members may submit questions at any time they want, until
that time.
[The following questions were not asked at the hearing, but
were submitted to the Department of response subsequent to the
hearing:]
Questions Submitted to Hon. Robert A. McDonald
Questions Submitted by Senator Mitch McConnell
Question. I am very concerned about the recent reports of
dysfunction and wrongdoing at the Cincinnati VA Medical Center,
particularly as a number of my constituents rely on this facility for
medical care. I understand the former VISN 10 Director recently
resigned and the former Director of the Cincinnati facility has been
removed. Are either of these individuals receiving benefits or
salaries? What steps is the VA undertaking to correct the failures of
leadership at this facility to ensure veterans are receiving the
quality care they were promised and deserve?
Answer. The previous Director of the Cincinnati VA Medical Center
(VAMC), Linda D. Smith, retired December 2, 2014, and she receives
retirement benefits commensurate with her service. John Gennaro became
Director of the Cincinnati VAMC in July 2015, but he recently accepted
an assignment to another facility as Director. Mr. Gennaro was not
implicated in any allegation of wrong doing, and he currently receives
a salary and benefits as appropriate to his new position. The current
interim Director of the Cincinnati VAMC, Glenn Costie, is not
implicated in any allegation of wrong doing.
The former Director of Veterans Integrated Service Network 10, Jack
Hetrick, retired February 24, 2016, and receives retirement benefits
commensurate with his service.
To ensure quality care for our Veterans through our leadership
means sustainable accountability in them and our supervisors. We will
recognize what is going well and provide coaching and re-training where
improvements are necessary. We will train our leaders to lead and our
employees to exceed expectations and if not take corrective action when
it's warranted and supported by evidence.
Question. Please provide an updated timeline for the design and
construction phases of the Louisville VAMC--and ultimately for the
facility's completion. This project was announced in 2006, and
Kentucky's veterans have had to wait for too long to begin receiving
care at this new facility.
[Clerk's Note: The Department was unable to submit a response to
this question.]
Question. In June 2014, the VA Office of Inspector General (OIG)
was directed to conduct investigations of more than 100 VA medical
facilities regarding potential scheduling manipulation practices,
including at Kentucky's Fort Knox and DuPont VA facilities. What is
that status of the OIG investigations of these facilities, and when
will they be completed? I would ask that you please share any available
information with my office regarding the investigation findings at
these Kentucky facilities.
Answer. VA's OIG Report on Kentucky facilities was released, and
summaries are provided below. VA's OIG did not find evidence to
substantiate the allegations.
------------------------------------------------------------------------
------------------------------------------------------------------------
Louisville KY-2014-2890-DS-53.......... No intentional manipulation
substantiated.
------------------------------------------------------------------------
Louisville KY-2014-2890-DS-56.......... No intentional manipulation
substantiated.
------------------------------------------------------------------------
Question. As the VA continues with reform efforts to improve and
expedite healthcare for our Nation's veterans, does the agency need any
additional authority from Congress to remove bad actors from the VA?
Answer. On March 23, 2016, the Secretary of Veterans Affairs
submitted a legislative proposal to Congress entitled, ``Department of
Veterans Affairs Accountability Enhancement Act.'' This legislation
would provide VA with the authority it needs to recruit, compensate,
appraise, and, when necessary, discipline career healthcare executives
to ensure that VA can operate as a values-based, high performance
organization.
Question. Mental health issues remain a significant concern for
many veterans. Are there any additional resources or authorities that
the VA needs from Congress in order to provide effective treatment and
care to veterans with mental health issues?
Answer. With the current resources and authorities, VA continues to
be the largest integrated healthcare system in the United States, with
numerous reports validating the quality of mental healthcare services.
This is the result of a long history of research, academic
affiliations, and a deep commitment to training and recruitment. For
example, Psychiatric Services, a peer-reviewed journal of the American
Psychiatric Association, has published a report comparing the quality
of mental healthcare provided by VA to Veterans with a comparable
population in the private sector. According to the study, ``in every
case, VA performance was superior to that of the private sector by more
than 30 percent. Compared with individuals in private plans, Veterans
with schizophrenia or major depression were more than twice as likely
to receive appropriate initial medication treatment, and Veterans with
depression were more than twice as likely to receive appropriate long-
term treatment.'' \1\
---------------------------------------------------------------------------
\1\ The Quality of Medication Treatment for Mental Disorders in the
Department of Veterans Affairs and in Private-Sector Plans, Katherine
E. Watkins, Brad Smith, Ayse Akincigil, Melony E. Sorbero, Susan
Paddock, Abigail Woodroffe, Cecilia Huang, Stephen Crystal, and Harold
Alan Pincus Psychiatric Services 2016 67:4, 391-396.
---------------------------------------------------------------------------
Additional resources and authorities are needed from Congress in
order to maintain this leadership and to provide effective treatment
and care to Veterans with mental health problems. Among other
priorities, VA needs to explore all potential resources for recruiting
and retaining high caliber mental health providers, including the
availability of education debt reduction programs (EDRP). Most
recently, through the Clay Hunt Suicide Prevention for American
Veterans Act, new EDRP efforts have focused on psychiatry, but no
additional funding was provided. Further, such incentives need to be
broadened to other clinical specialties in short supply including
psychologists. Funding EDRPs is a partnership between VA Central Office
and local VA healthcare facilities.
The delivery of effective mental health treatment and care is best
managed within a predictable funding strategy matched to the evolving
needs of Veterans. Legislative requirements without additional
appropriations not only limit VA's ability to act upon new mandates but
also limit VA's ability to focus on/implement solutions in response to
other key priorities. The Clay Hunt Act, as an example, did not provide
additional appropriations while imposing multi-million dollar,
multiyear obligations which could only be met by diverting funding from
other important projects including suicide prevention projects.
VA recognizes that to be effective in reducing Veteran suicide, VA
must continue to develop Federal and community strategic collaborations
that reach deep into all Veteran communities. To support this effort,
VA stood up the Office of Suicide Prevention. The VA Suicide Prevention
Office will create new inter-agency and public- private collaborations
in order to reach each of our Nation's 22 million Veterans.
VA recognizes Congress as an important partner in preventing
suicides. This partnership will be supported by reoccurring
congressional briefings on the Office of Suicide Prevention's plans of
action. Congress' feedback as well as working with their local
districts across the Nation will be crucial to this effort.
VA practitioners report that they value being able to employ the
full spectrum of their clinical skills and using interventions that are
evidence based while practicing in VA. This requires an on-going
requirement to train staff on emerging practices and create teams of
providers to allow everyone to work within the scope of their unique
area of competence. Over recent years, the addition of Peer Specialists
has brought an additional resource to the healthcare team, has helped
to combat any stigma associated with asking for mental healthcare, and
has provided the opportunity to reach Veterans and Servicemembers (for
example, Active Duty members seeking care after Military Sexual Trauma)
who may otherwise go untreated.
Ongoing training and education of VA mental health practitioners
and Peer Specialists contributes to staff retention and helps to ensure
that Veterans have access to state of the art mental healthcare.
Question. It has been brought to my attention that some VA
healthcare facilities lack the capability to provide care that meets
the specific medical needs of female veterans. With this in mind, what
efforts is the VA taking to ensure that all of its healthcare
facilities are fully equipped to provide care to female veterans? What
plans are being made in this regard for the new Louisville VA Medical
Center?
[Clerk's Note: The Department was unable to submit a response to
this question.]
Question. Many Kentucky veterans have expressed concerns that as
the VA continues its efforts to reduce the agency's backlog of pending
claims that there is now a growing backlog of claims appeals. What
efforts is the VA taking to continue reducing the claims backlog while
also ensuring that veterans' appeals are processed in a timely fashion?
Does the VA need any additional authority from Congress to assist with
the reduction in either of these backlogs?
Answer. The Veterans Benefits Administration (VBA) has reduced the
number of disability compensation claims pending more than 125 days by
87 percent, from a peak of 611,000 in March 2013 to a historic low of
79,004 claims, as of March 31, 2016. VBA's process and enhanced
technology improvements, such as the Veterans Benefits Management
System (VBMS) and the National Work Queue (NWQ), continue to provide
increased efficiencies in the electronic claims process. By modernizing
to an electronic claims processing system, VBA has increased claim
productivity per claims processor by 25 percent since 2011 and medical
issue productivity by 82 percent per claims processor since 2009. To
continue this progress in 2017, VBA will build on the success of its
transformation initiatives to further streamline and modernize the
claims process with enhanced automation through VBMS, electronic
workload management through NWQ, centralized mail, and the Veterans
Claims Intake Program, which aims to further streamline and modernize
the claims process.
With VBA's completion of record-breaking numbers of disability
rating claims in recent years, a concomitant increase in the volume of
appeals resulted. While VBA continues to prioritize rating claims, it
is also placing additional focus on appeals. VBA is grateful for the
funding that allowed us to hire 100 appeals full-time equivalents (FTE)
in fiscal year 2015 and 200 appeals FTEs in fiscal year 2016. As of
February 2016, VBA has increased its appeals workforce from 1,195
employees to over 1,490 employees and allocated $10 million in overtime
funds to support the appellate workload. In addition, we are leveraging
our technology initiatives in support of modernizing the appeals
process. However, VA will not be able to provide Veterans with timely
decisions on their appeals without legislative reform to streamline and
modernize the current appeal system. In the President's budget for
fiscal year 2017, VA requested resources to lower the pending inventory
of appeals and proposed legislation to simplify the appeals process. VA
is working closely with Veterans Service Organizations, other Veteran
stakeholders, and Congressional staff to develop legislative proposals
that would achieve our shared goal of timely and high quality appeal
decisions.
Question. In the summer of 2016, the Army is scheduled to begin
construction of a new medical facility to replace the Ireland Army
Community Hospital (IACH) at Fort Knox, Kentucky. Does the VA have a
plan to replace the Fort Knox VA facility currently located at IACH to
ensure area veterans see no disruption in care currently provided at
this facility?
Answer. This new VA Clinic is necessary as a result of the Army's
plans to build a new healthcare facility to replace the existing
Ireland Army Community Hospital (IRACH). Currently, VA occupies space,
via a sharing agreement, within the existing IRACH. However, VA will be
unable to co-locate services within the Army's new healthcare facility
because DoD and VA are not allowed to share appropriated funds for
joint facility projects. In order to continue to provide healthcare to
Veterans, VA seeks to obtain a permit from the Army and then build a
separate clinic adjacent to the new Army healthcare facility. VA
contemplates that the VA Clinic will be physically connected to the new
Army health facility, through a covered walkway or other structure, and
offer primary care and mental health services to Veterans in the Fort
Knox area.
Current law does not allow for detailed planning/design,
construction, or leasing of shared medical facilities that are not
specifically under the jurisdiction of the Secretary, or for
appropriated funds to be transferred to, or retained from, DoD or other
Federal agencies for use in joint capital projects with VA. VA has
proposed legislation (described in VA's fiscal year 2016 and fiscal
year 2017 budget submissions and developed in consultation with DoD)
that would provide for the inherent authority to do more detailed
planning and design, leasing, and construction of joint facilities in
an integrated manner. However, such legislation has not been enacted.
Accordingly, VA lacks the authority to permit capital investment for
shared medical facilities.
Earlier this year, VA began negotiating a permit with the Army to
provide VA with the necessary access to the Army's land for
construction and occupancy. The permit is for four acres in order to
accommodate the building footprint and necessary parking. The Army has
taken the lead on drafting the permit. A design-build contract was
awarded to the United States Army Corps of Engineers (USACOE) for the
construction of the VA CBOC in September 2016. An Architectural-
Engineer (A/E) firm is drafting the final request for proposal (RFP) to
be completed by March 2017.
Question. Substance abuse disorders, particularly opioids, continue
to be a challenge for many veterans. What steps are being taken by the
VA to improve education, monitoring and treatment of addiction? Does
the VA need any additional authority from Congress to better coordinate
care for veterans with substance abuse issues?
Answer. Providing additional funding to expand recruitment
incentives, such as loan repayment for psychiatrists and other mental
health providers, would be helpful in attracting and retaining
addiction treatment providers in what is currently a highly competitive
market in many locations.
Currently, VA is engaged in multiple efforts to improve education,
identification and monitoring for substance use disorder (SUD) in
patients, including those Veterans with chronic pain. VA has been
working to expand access to evidence-based pharmacological and
psychosocial addiction treatment services. This includes national
training initiatives in evidence-based psychotherapies, such as
cognitive behavioral therapy for substance use, motivational
interviewing, and motivational enhancement therapy, which have been
shown to effectively treat substance use disorders. VA, in concert with
the 2011 Institute of Medicine (IOM) Report, Pain in America, and the
National Pain Strategy from the Department of Health and Human Services
(HHS), published in 2016, has recognized that improved competency in
pain treatment across our health systems will lead to less reliance on
opioid therapy, less exposure to the potential harms of opioid therapy,
and better patient outcomes. To support these goals, VA and the
Department of Defense (DoD) have developed the Joint Pain Education
Program for primary care providers, a 31 module, evidence-based,
comprehensive pain management curriculum that includes training in the
appropriate screening for SUD in Veterans with chronic pain, and
training in the safe use of opioids, including SUD monitoring.
VA, as part of its Opioid Safety Initiative (OSI), has created
multiple tools and processes to help clinicians identify SUD in
Veterans being treated for chronic pain before and during treatment
with opioid analgesics, to monitor their clinical outcomes, and ensure
referral to appropriate treatment to reduce risk of activating SUD, or
to manage SUD when it is co-morbid with chronic pain. Such tools and
procedures include:
--The Opioid Therapy Risk Report (OTRR), which provides detailed
metrics on all the risks and strategies for managing risk for
Veterans prescribed long-term opioid therapy for pain. The OTRR
metrics are available in the clinic on the electronic medical
record to support providers' efforts to monitor and manage
risks when caring for patients with chronic pain who are
prescribed long-term opioids.
--VA developed predictive model-based clinician decision support
tools which are available nationally. The Stratification Tool
for Opioid Risk Mitigation tracks patients receiving opioid
analgesics or with opioid use disorders, estimates risk of
overdose or other adverse events, flags prior non-fatal
overdose and suicide-related events, identifies personal risk
factors, and suggests and tracks use of patient-tailored risk
mitigation strategies and non-pharmacological pain treatments.
Suggestions include a variety of guideline recommended
strategies, including avoidance of high dose prescribing and
risky medication combinations; timely follow-up; medication
reconciliation; side-effect management; screening for substance
use; ensuring mental health assessment and addiction treatment
when needed; and use of physical therapy, Integrative Health,
and behavioral therapies. It additionally provides information
about patients' care providers and appointments to facilitate
care coordination. The tool can be used to improve the safety
of care for individual patients, or on a population level to
facilitate systematic application of specific risk mitigation
strategies to patients with the greatest risk of overdose or
suicide-related events.
The OSI Toolkit, developed and maintained by an interdisciplinary
expert pain task force provides evidence-based guidance and trainings
to help clinicians manage pain and opioids safely, including clinical
guidance on safe medication tapering.
Additionally, VA has been working to expand access to medication-
assisted treatment (MAT) for opioid use disorders since fiscal year
2000. VA efforts have included specific funding for hiring Addiction
Medicine specialists to expand MAT access in under-served areas,
clinical mentorship programs to support newly trained buprenorphine
prescribers, a technical assistance program consisting of monthly
webinars and email consultation, and on-going management monitoring,
attention, and action planning regarding meeting needs for MAT
services. As a result, VA has substantially expanded access to MAT from
just under 12,000 patients (27 percent of those diagnosed with opioid
use disorders (OUD)) in fiscal year 2010 to over 20,000 patients (30
percent of those diagnosed with OUD) in fiscal year 2015. In the fourth
quarter of fiscal year 2015, 35.4 percent of OUD patients received MAT
(methadone, buprenorphine or injectable naltrexone). Prioritization of
expansion of MAT services is encouraged by inclusion of MAT access
measures on leadership performance plans and as part of VA's
Psychotropic Drug Safety Initiative. VA continues to work to expand MAT
access in locations with lower capacity or barriers to access to
services (e.g. rurality), including through innovative models such as
group practice visits and telemental health models.
The Ryan Haight Online Pharmacy Consumer Protection Act generally
requires that VA telehealth providers must have at least one in-person
medical evaluation prior to prescribing controlled substances via
telemedicine.
This can be a problem when VA telehealth providers are not located
close to the Veteran or when the Veteran's provider retires and another
provider needs to begin furnishing care to the patient. We believe that
the Drug Enforcement Administration could assist VA with this issue
through the regulatory process; however, Congress could also assist by
granting VA telehealth providers special authority to prescribe
controlled substances without having conducted a prior in-person
medical evaluation.
We note that on July 22, 2016, the President signed into law the
Comprehensive Addiction and Recovery Act of 2016 (Public Law 114-198),
which authorizes a range of measures intended to combat opioid
addiction and overdoses. We are working to implement the provisions of
this law affecting VA. For example, the law requires all practitioners
(including VA) to certify certain information when registering to
prescribe controlled substances; VA must establish guidance that each
provider must use the Opioid Therapy Risk Report tool before initiating
opioid therapy to treat a patient; VA must require all employees
responsible for prescribing opioids to receive education and training
on pain management and safe prescribing practices; and Each VA medical
facility director must identify and designate a pain management team of
healthcare professionals. We will alert the Committees if we identify
any legislative changes that are needed as a result of these new
authorities.
______
Questions Submitted by Senator Susan M. Collins
dysfunctional continuum of care--choice program
Question. I have heard from veterans, veteran services
organizations, and VA officials that the Choice Program's continuum of
care process is broken and dysfunctional.
Last month, the entire Maine congressional delegation sent you a
letter regarding the VA's incredibly flawed administration of the
Choice Program in our State. According to the Department's own data,
fewer than 50 percent of eligible Choice Program patients in Maine have
received the appointments they need and have requested. The contractor
chosen by the VA, Heath Net, has performed poorly. The process to
correct many of the issues with Choice may take years. In the meantime,
there are veterans in rural communities waiting to receive access to
desperately needed care.
Can you provide an assurance regarding when these veterans can
expect to receive the appointments they need?
Answer. VA is continuing to examine how VCP interacts with other VA
health programs, including the delivery of direct care. In addition, VA
is evaluating how it will adapt to a rapidly changing healthcare
environment and how it will interact with other health providers and
insurers. VA anticipates improving the delivery of community care
through incremental improvements as outlined in the October 30, 2015,
Plan to Consolidate Community Care Programs, building on certain
provisions of the existing VCP. Implementation of these improvements
requires balancing care provided at VA facilities and in the community,
and addressing increasing healthcare costs. VA is committed to
improving Veteran's health outcomes and experience, as well as
maximizing the quality, efficiency, and sustainability of VA's health
programs.
Relevant to Maine Veterans, the ARCH program expired on August 7,
2016. Veterans who participated in the ARCH program will continue to
receive care under VCP and will be eligible for same services that ARCH
offered. Veterans who did not previously participate in the ARCH must
meet the Choice eligibility criteria (living 40 miles away from a VA
facility with a full time primary care physician or a VA facility is
not able to provide needed care within the wait time goals of the
Department (30 days)). VCP should work to expand the availability of
hospital care and medical services for eligible Veterans. We continue
to work with our VCP contractor in Maine, HealthNet, to recruit more
eligible VCP providers to improve VCP and help us ensure that all
Veterans in Maine have access to care. VA has also begun using VCP
Provider Agreements in Maine to improve our ability to get our Veterans
timely appointments with eligible community care providers.
Effective care coordination is critical to enabling a Veteran-
centric care experience and supporting positive health outcomes through
clear continuity of care and appropriate care and disease management.
Under VA's ``Plan to Consolidate Community Care Programs,'' VA would
define a clear process for transfer of medical documentation between VA
and community providers when Veterans are referred into the community.
VA would also establish objectives, roles, and processes for care
coordination to enable a smooth Veteran experience across VA and
community providers. The care coordination process would be centered on
Veterans' relationships with their PCP. The PCP and supporting
coordinator staff, whether at a VA facility or in the community, would
assist Veterans with basic care coordination and patient navigation
regarding scheduling appointments and seeking appropriate follow-up
care. Veterans receiving care from community PCPs that do not have the
capacity or capability to provide required coordination would be able
to rely on VA for those services. For Veterans requiring more robust
care coordination, regardless of whether they see a VA or community
PCP, VA would provide programs for care and disease management and case
management, as appropriate. This model would integrate with and utilize
established and evolving care coordination models at VA, such as the
Patient Aligned.
va participation in prescription drug monitoring program
Question. Prescription opioid and heroin abuse has reached epidemic
proportions in our communities. A recent study estimated that nearly
one million veterans are taking prescription opioids and more than half
use them ``chronically'' or beyond 90 days. Although these
prescriptions may be necessary to a patient's care, another study noted
that the risk of death by accidental overdose among patients at
Veterans Administration facilities is nearly twice that of the non-
veteran population.
Prescription drug monitoring programs, or ``PDMPs,'' are one of the
most important tools available to confront and prevent prescription
opioid abuse. These State systems can give doctors crucial information
about a patient's prescription drug history, particularly when patients
are receiving care both inside and outside of the VA system. VA
healthcare providers have the authority to share information with State
PDMPs, but they are not required to do so, and participation varies
widely across the country. For example, in Maine the VA Health Care
System reports to and queries the State PDMP, but this was a long time
coming and is not the practice in all States.
Has the VA considered establishing standards for PDMP use among
prescribers and pharmacies in the VA system?
Answer. Prescription opioid and heroin abuse has reached epidemic
proportions in our communities. A recent study estimated that nearly
one million veterans are taking prescription opioids and more than half
use them ``chronically'' or beyond 90 days. Although these
prescriptions may be necessary to a patient's care, another study noted
that the risk of death by accidental overdose among patients at
Veterans Administration facilities is nearly twice that of the non-
veteran population.
Prescription drug monitoring programs, or ``PDMPs,'' are one of the
most important tools available to confront and prevent prescription
opioid abuse. These State systems can give doctors crucial information
about a patient's prescription drug history, particularly when patients
are receiving care both inside and outside of the VA system. VA
healthcare providers have the authority to share information with State
PDMPs, but they are not required to do so, and participation varies
widely across the country. For example, in Maine the VA Health Care
System reports to and queries the State PDMP, but this was a long time
coming and is not the practice in all States.
Question. Has the VA considered establishing standards for PDMP use
among prescribers and pharmacies in the VA system?
Answer. The Veterans Health Administration (VHA) is developing a
policy, VHA Directive, Querying State Prescription Drug Monitoring
Programs, which will govern the querying of State PDMPs by VA
providers. The policy will establish a minimum standard for querying
PDMPs and ensure compliance with applicable Federal and State laws. It
is anticipated that this policy will be published in mid-fiscal year
2017.
In addition, VA's Virtual Lifetime Electronic Record Health program
continues to actively partner with the eHealth Exchange to encourage
PDMPs to move towards the use of national standards for the exchange of
opioid prescription information. As PDMPs adopt these national
standards, it will enable a bi-directional exchange of information,
improving access by VA and non-VA clinicians nationwide to prescription
history for their patients in order to make the most appropriate and
safe treatment decisions.
______
Questions Submitted by Senator Tammy Baldwin
use of social security numbers as identifiers for veterans
Question. Mr. Secretary, I would like to see VA discontinue using
social security numbers to identify individuals in all VA information
systems. Until that is done, veterans will be at risk for identity
theft and fraud. What are your thoughts on this proposition? Is the VA
currently working to discontinue the use of social security numbers to
identify individuals? If not, why not? If the absence of a single data
backbone at VA is a barrier to achieving the discontinuation of social
security numbers, please provide a status update on the Department's
efforts to create a single data backbone and what additional resources
are needed to fully bring it online.
Answer. VA's primary uses of Social Security Numbers (SSNs) are to:
(1) locate Veterans and their dependents to ensure correct
identification associated with the delivery of benefits and services,
and (2) identify employees for employment-related record keeping. As
mistaken identity in the delivery of healthcare can result in
catastrophic and tragic outcomes, VA must ensure 100 percent accuracy
in patient identification. Until such time when a comprehensive and
equally accurate means to do this is established and implemented, the
use of SSNs remains the single best means of ensuring patient
identification. In addition, SSNs must be used if required by law or
regulation, for purposes such as:
--Background investigations;
--Security checks for validation purposes, such as computer matching
of records between government agencies; and
--Support of unique identification.
VA currently relies on the SSN to ensure that the correct records
are obtained and utilized to determine eligibility for VA benefits such
as compensation, disability, education, and rehabilitation. VA is
required by law (38 U.S.C. 5103A) to request evidence from third
parties on behalf of Veterans to support their claims. In these
requests for evidence, VA must sufficiently identify the party for whom
it is seeking information. Many entities holding Veterans' records,
including the Department of Defense (DoD), other government agencies,
and private parties, continue to utilize SSNs as a primary identifier.
As such, VA will face substantial challenges in obtaining records from
these entities on behalf of Veterans if precluded from identifying
Veterans by their SSNs. This will negatively impact Veterans by
delaying the time required to process their claims and possibly even
preventing VA from obtaining the records needed to establish Veterans'
eligibility to benefits.
VA's success rate in matching records with other Federal and non-
Federal organizations is over 85 percent when the SSN is available
compared to 20 percent when the SSN is not used. VA providers will not
have access to important outside care information and could order
redundant tests, slow decisionmaking, or make incorrect and even
harmful decisions when such data is unavailable. VA also participates
in Health Information Exchanges with DoD, Walgreens, Kaiser Permanente,
etc., and without the use of the SSN to positively identify the
Veteran, critical health information will not be available leading to
poor healthcare decisions and slower treatment.
Elimination of SSN use is not solely a function of information
technology (IT). The business processes used by the Veterans Health
Administration (VHA), Veterans Benefits Administration, and other VA
offices require a complete overhaul in how they establish absolute
identity verification inside VA and most importantly outside of VA. IT
solutions to eliminate SSN use can only occur after the integrated and
comprehensive review of the prevalence and inter-connectedness of SSN
use is complete.
SSN Reduction Effort
VA recognizes the growing threat posed by identity theft and the
impact on Veterans, dependents and employees. In 2009, VA created and
implemented the enterprise-wide Social Security Number Reduction (SSNR)
effort, in response to the Office of Management and Budget Memorandum
07-16, ``Safeguarding Against and Responding to the Breach of
Personally Identifiable Information (May 2007). The key goal of the
SSNR is to reduce or eliminate the unnecessary collection and use of
SSNs as the Department's primary identifier, while maintaining the 100
percent requirement for proper Veteran-Patient identification. For
example:
--VHA eliminated the use of SSNs on appointment letter correspondence
and the Veterans Health Identification card.
--VBA is currently evaluating the elimination of SSNs from
correspondence.
--The National Cemetery Administration has reviewed and reevaluated
all of its forms requiring SSNs.
--VA/DoD health information exchange Joint Legacy Viewer is using the
Integration Control Number (ICN), Electronic Data Interchange
Personal Identifier and other demographics for trait matching
while phasing out use of the SSN.
--VHA is utilizing a SSNR tool to collect VHA's SSN holdings data but
it has limitations due to outdated technology. The Office of
Information & Technology (OIT) is currently developing a new
SSNR tool for VA wide use which is expected to be completed by
September 2017.
Master Veteran Index System
As VA works to migrate away from the use of SSNs as the sole means
of Veteran identification, OIT is collaborating with the Veterans
Relationship Management Initiative to create the Master Veteran Index
(MVI) system and require MVI integration for every VA system. MVI
serves as the authoritative identity service within VA. MVI assigns an
ICN, a unique identifier, for each Veteran. The ICN is a sequentially
assigned, non-intelligent number that, in itself, does not provide any
protected sensitive information about the Veteran-patient. The ICN is a
means to accurately and securely track the individual and confirm their
identification. ICNs conform to the American Society for Testing and
Materials International standard for a universal healthcare identifier.
MVI now has information on over 26 million Veterans and beneficiaries
who have applied for healthcare. While additional work remains to fully
extricate SSNs from Veteran identification, including re-engineered
business processes and legacy system upgrades, programs like MVI have
made significant progress towards the goal of SSN reduction.
Conclusion
VA has made considerable progress in implementing the SSN reduction
initiative since the Office of Management and Budget's mandate in 2007.
VA continues ongoing activities to either eliminate or reduce the use
of SSN's with the goal to replace the SSN with an alternative primary
identifier. The timeframe to implement an alternate primary identifier
would be contingent upon laws, business needs, technology upgrades, and
funding.
disposition of final reports on tomah
Question. Mr. Secretary, I want to emphasize to you my belief that
the Office of Accountability Review's investigation of accusations of
widespread retaliation against whistleblowers and the culture of fear
at the Tomah VA Medical Center must be made publically available so
that veterans, VA employees and the American public are assured that
the Department has uncovered and addressed the troubling events at the
Tomah VA and related issues nationwide. The same goes for the outside
clinical review, which is being done in follow-up to the Agency's
initial review of the incidents at Tomah.
I have previously discussed this issue with other members of the VA
leadership team. I want to reiterate its importance to you as I did
with the Deputy yesterday.
When will VA make public its findings on these matters? I would
like to know the timeline of VA's plan for transparency on:
--The OAR investigation of accusations of widespread retaliation
against whistleblowers and the culture of fear at the Tomah
VAMC and
--The outside clinical review.
Answer. As of June 10, 2016, litigation is pending for one of the
subjects of the Administrative Investigation Board (AIB). Consequently,
we are currently unable to release the AIB Report.
choice program
Question. Mr. Secretary, in early February, I wrote to VA
expressing my frustration with the Choice Program. Recently, there has
been an alarming increase in the number of complaints from my
constituents about their interactions with HealthNet, the 3rd Party
Administrator for the area in which my constituents receive their
healthcare services. For example, a veteran recently shared with me
that after months of delay at VA, he was referred to the Choice Program
and scheduled for surgery at a non-VA hospital. When he called to
confirm the surgery with the hospital, it had no record of him or a
surgery being scheduled for him. A month later he received the surgery
at a different hospital. It is not uncommon for a veteran to call me
after spending many frustrating hours on the phone trying to get an
appointment scheduled.
What is the Department doing to address these problems and improve
the administration of and veteran experience with Choice?
Answer. The purpose of the Veterans Choice Program (VCP) was to
improve access to care for Veterans by allowing them to seek care in
the community if they were eligible based on certain criteria specified
in statute.
Since the implementation of VCP on November 5, 2014, a number of
amendments to the law and to VA's regulations have further expanded the
number of Veterans eligible for VCP.
VA recognizes there have been and continue to be challenges
implementing VCP. We are identifying those challenges, implementing
immediate fixes where we can, and building long-term solutions, as
needed. VA's overarching plan for community care is to consolidate
programs and simplify eligibility criteria and processes. VA is
continuing to examine how VCP interacts with other VA health programs,
including the delivery of direct care. In addition, VA is evaluating
how it will adapt to a rapidly changing healthcare environment and how
it will interact with other health providers and insurers. VA
anticipates improving the delivery of community care through
incremental improvements as outlined in the October 30, 2015, Plan to
Consolidate Community Care Programs, building on certain provisions of
the existing VCP. Implementation of these improvements requires
balancing care provided at VA facilities and in the community, and
addressing increasing healthcare costs. VA is committed to improving
Veteran's health outcomes and experience, as well as maximizing the
quality, efficiency, and sustainability of VA's health programs. While
VA can implement some of the provisions from the Plan within the
constraints of the current budget, there are certain provisions that
require legislation. The Plan identified key legislative changes needed
to consolidate the community care programs and standardize Veteran
eligibility for community care. While some legislation has been
proposed, none has been passed into law as of October 2016. Without the
legislation identified in the Plan, full consolidation cannot be
achieved.
Among other improvements, the Veterans Health Administration (VHA)
simplified the scheduling procedures and published a Deputy Under
Secretary for Health for Operations and Management memorandum on June
9, 2015, which revised procedures to require providers to write a
return-to-clinic order and schedulers to enter the date contained in
that order as the clinically indicated date (CID). This new process
keeps future appointment decisionmaking with the provider and patient,
rather than the scheduler. Associated training was provided to
schedulers at that time. Additionally, VHA uses the ``scheduling
trigger tool'' database to identify and notify facility leadership of
scheduling irregularities. Of note, a root cause of scheduling errors
is the highly manual, 30-year old scheduling software. VistA Scheduling
Enhancement (VSE) has been deployed to about 30 clinics at 5 sites and
is planned for national deployment starting in February 2017. VHA
anticipates this new scheduling software will reduce the number of
scheduling errors.
Several initiatives are planned for VHA's ``Summer of Scheduling,''
including:
--National Rollout of VSE: The rollout of VSE will be achieved
through a train the trainer or ``Super User'' approach,
developing local experts to train others. The rollout began in
May 2016 and is planned for national deployment starting in
February 2017, with ongoing associated training.
--Hire Right, Hire Fast: This project's goal is to ensure that every
facility has the right number of Medical Support Assistants
(MSA), with the right skills, who can provide the right
experience for Veterans.
--Own the Moment: VA knows that every interaction between an employee
and a Veteran matters. This project reinforces the importance
of serving with a focus on principles and values, empowering VA
employees to pursue what's right for the Veteran when
procedures serve to limit services.
--Standardized MSA Onboarding/Training: New MSA onboarding would
include a two-week training program that draws its curriculum
from scheduling rules for technical training, customer
experience training, and medical center policies. The
onboarding will provide a mentor for all new MSAs and use the
VSE ``Super Users'' model. Deployment will follow the national
rollout of VSE.
va graduate medical education (gme) expansion and staffing
Question. The 2014 VA reform law was a comprehensive response to
system-wide barriers to veterans' access to care. The law's Choice
Program is an important step to remove those barriers through non-VA
care, but it is no substitute for increasing the internal provider
capacity of the VA. The VA reform law included a provision I authored
to increase by 1,500 over 5 years the number of graduate medical
education residency positions. Can you please provide me an update on
VA's plans for ensuring that the goal of 1,500 positions is met?
I note in your testimony that in fiscal year 2015, VHA hired 41,113
employees, for a net increase of 13,940 healthcare staff. What did you
do to bring all those people on board? Can you also please briefly
discuss the Department's efforts to attract qualified physicians to VA
to care for our veterans? I know that in Tomah, VA increased the pay
available for hard-to-fill positions.
Answer. To help reach the goal of up to 1,500 new residency
positions, VA is conducting outreach and providing consultative
services, and strategic and targeted funding to assist VA facilities
and academic affiliates when addressing the complex and time intensive
process of GME residency expansion. VHA has authorized more than 372
new GME positions during the first 2 years of the 5 year program. In
addition:
--The accreditation process for each new GME residency program can
take up to 3 years and is managed by our affiliated partners
(the program sponsors).
--Once a program is accredited, incremental expansion to full
capacity takes 3 to 4 additional years.
--Since VA residency positions are rotational and complementary to
other clinical experiences, each full-time VA position is
occupied by three to four unique medical residents; thus, the
affiliated academic program sponsor must secure additional
support for the remaining portion of the residency training
outside of VA, and this support may be limited by existing
Medicare program ``caps.''
VA encourages all stakeholders, including Members of Congress
working with community stakeholders, to use this unique opportunity to
help Veterans improve access to care by identifying potential new
affiliates, while VA facilities expand their existing VA GME programs
or create new ones.
female veterans
Question. Your request includes $372 million for Minor Construction
and would provide funding for ongoing projects that renovate, expand
and improve VA facilities, while increasing access for our veterans. My
understanding is one emphasis for this funding will be projects that
enhance women's health programs. Can you please describe these
projects?
I met with several veterans groups recently who were concerned with
the lack of women healthcare professionals at VA. I support hiring more
female healthcare professionals for the growing population of women
veterans using VA primary care and mental healthcare clinics. Many
women prefer receiving healthcare services from female providers. My
understanding is that since 2003, women veterans' healthcare usage at
VA facilities has increased by more than 100 percent. What is the
Department doing to bring more female healthcare professionals to VA?
Answer. Approximately 98 percent of Women's Health providers are
women. VHA's NRP is available to provide recruitment support for
Women's Health providers (Primary Care and Obstetrics/Gynecology).
Also, there is no longer a prohibition on specifically targeting female
PCPs to consider women's health careers in VHA through recruitment
marketing/advertising.
In addition to hiring, VHA is focused on training to enhance skills
of its workforce to provide care for women Veterans. VHA has provided
training to nearly 2500 primary and emergency room providers through a
2\1/2\-day intensive review of gender specific women's healthcare that
includes training hands-on training for breast and pelvic examination.
The majority of providers trained are women. One hundred percent of
Medical Centers and 90 percent of Community Based Outpatient Centers
have Designated Women's Health Providers.
VA provides a full range of services to women Veterans, including
comprehensive primary care, gynecology care, maternity care, specialty
care, and mental health services. VA has focused on improvement of its
facilities to meet the needs of the growing numbers of women Veterans
we serve.
In order to review facilities in terms of accommodations for women
Veterans, including required privacy and security, VHA has adopted
Environment of Care (EoC) standards. These standards are now
incorporated into a tablet-based EoC survey that is conducted monthly.
The Women Veteran Program Manager is a member of the team conducting
this survey monthly. All deficiencies detected must have a remediation
plan attached, and the correction of these is tracked electronically.
The EoC data is rolled up to the facility and the Veterans Integrated
Services Network (VISN) monthly, and is the responsibility of the VISN
Capital Asset Manager.
When there is a need for remodeling or construction to enhance the
facilities, the VISN submits plans through the Strategic Capital
Investment Planning (SCIP) process. The SCIP Board reviews and
prioritizes the requests, and projects that include the needs of women
Veterans are given additional points in the prioritization. The VHA
Office of Women's Health Services subject matter expert support for
reviews related to women's needs within the SCIP process. This allows
for input on the specific facility needs for accommodations for women
Veterans.
VA is proud of high quality healthcare for women Veterans. VA is on
the forefront of information technology for women's health and is
redesigning its electronic medical record to track breast and
reproductive healthcare. Many women Veterans entering the VA system are
of child-bearing age. VA provides full gynecological care, including
maternity care, and 7 days of newborn care for all women Veterans
either on-site or through Care in the Community, paid VA. VA is
implementing a policy that requires maternity care coordinators at all
VA medical centers that stay in contact with women during their
pregnancies to support and coordinate their care.
Quality measures show that women Veterans using VA healthcare are
more likely to receive breast cancer and cervical cancer screening than
women in private sector healthcare. VA also tracks quality of care by
gender and, unlike other healthcare systems, has been able to reduce
and eliminate gender disparities in important aspects of health
screening, prevention, and chronic disease management. Some of our
national accomplishments include the following:
--VA completed two mobile applications for Women's Health, Caring for
Women Veterans and Pre-Conception Care, that are available for
providers in the community to download when caring for women
Veteran patients.
--Maternity Care Coordination Telephone Care Program provided care
coordination services to over 2000 unique pregnant Veterans,
over 20 percent of whom resided in rural zip codes.
--Breast Care Registry to enhance care coordination of breast cancer
screening and treatment for women Veterans.
--Women Veterans Call Center (WVCC), created to contact women
Veterans to inform them about eligible services. As of February
2016, WVCC received 30,399 incoming calls and made 522,038
outbound calls, successfully reaching 278,238 women Veterans.
--An enhanced provision of care to women Veterans by focusing on the
goal of developing Designated Women's Health Providers (DWHP)
at every site where women access VA. One hundred percent of VA
medical centers and 90 percent of VA community based outpatient
clinics have DWHPs
--The training of nearly 2,500 providers in women's health and
continued training of additional providers to ensure that every
woman Veteran has the opportunity to receive her primary care
from a DWHP.
--Pursuant to Veterans Access, Choice, and Accountability Act,
expanding the eligibility for Veterans in need of mental
healthcare due to military sexual trauma (MST) experiences of
sexual assault or sexual harassment that occurred during their
military service. All MST-related healthcare is provided
without copayment requirements.
VA is enhancing facilities, training healthcare staff, and
improving access to services to meet the current and future healthcare
needs of women Veterans.
exempting copayment requirements for naloxone rescue kits and education
Question. Please explain why the Department believes it is so
critical to veteran patient safety to eliminate copayments for naloxone
kits and related education.
Answer. Patients who are told by their medical providers that they
are at high-risk for drug overdose often still do not believe that
overdose will happen to them. During efforts to implement the Overdose
Education and Naloxone Kit program nationally in VA, numerous
healthcare providers have reported that patients who are considered at
high-risk for drug overdose have refused the naloxone kits because they
do not believe they will need it and therefore, they are unwilling to
pay the co-pay for the medication. We greatly appreciate Congress'
enactment of provisions eliminating copayment requirements for
medication and education and counseling for opioid antagonists in
section 915 of the Comprehensive Addiction and Recovery Act of 2016
(Public Law 114-198), and we are working to implement these changes as
quickly as possible.
SUBCOMMITTEE RECESS
Senator Kirk. The next meeting of the subcommittee will be
on Thursday, April 7.
We will stand adjourned. Thank you, Mr. Secretary.
[Whereupon, at 12:20 p.m., Thursday, March 10, the
subcommittee was recessed, to reconvene Thursday, April 7, at a
time subject to the call of the Chair.]