[Senate Hearing 114-233]
[From the U.S. Government Publishing Office]
S. Hrg. 114-233
THE FISCAL YEAR 2016 BUDGET FOR
VETERANS PROGRAMS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
FEBRUARY 26, 2015
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas Richard Blumenthal, Connecticut,
John Boozman, Arkansas Ranking Member
Dean Heller, Nevada Patty Murray, Washington
Bill Cassidy, Louisiana Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota Sherrod Brown, Ohio
Thom Tillis, North Carolina Jon Tester, Montana
Dan Sullivan, Alaska Mazie K. Hirono, Hawaii
Joe Manchin III, West Virginia
Tom Bowman, Staff Director
John Kruse, Democratic Staff Director
C O N T E N T S
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February 26, 2015
SENATORS
Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........ 1
Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from
Connecticut.................................................... 3
Moran, Hon. Jerry, U.S. Senator from Kansas...................... 44
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 47
Cassidy, Hon. Bill, U.S. Senator from Louisiana.................. 50
Murray, Hon. Patty, U.S. Senator from Washington................. 53
Prepared statement........................................... 53
Sullivan, Hon. Dan, U.S. Senator from Alaska..................... 56
Tester, Hon. Jon, U.S. Senator from Montana...................... 59
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 62
Sanders, Hon. Bernard, U.S. Senator from Vermont................. 64
Hirono, Hon. Mazie K., U.S. Senator from Hawaii.................. 67
Boozman, Hon. John, U.S. Senator from Arkansas................... 203
WITNESSES
McDonald, Hon. Robert A., Secretary, U.S. Department of Veterans
Affairs; accompanied by Carolyn M. Clancy, M.D., Interim Under
Secretary for Health; Hon. Allison A. Hickey, Under Secretary
for Benefits; Ronald E. Walters, Interim Under Secretary for
Memorial Affairs; Hon. Helen Tierney, Assistant Secretary for
Management and Chief Financial Officer; and Stephen W. Warren,
Executive in Charge and Chief Information Officer, Office of
Information and Technology..................................... 4
Prepared statement........................................... 9
Response to prehearing questions submitted by Hon. Johnny
Isakson.................................................... 31
Response to request arising during the hearing by:
Hon. Sherrod Brown......................................... 49
Hon. Patty Murray.......................................... 54
Response to posthearing questions submitted by:
Hon. Johnny Isakson........................................ 70
Hon. Richard Blumenthal.................................... 134
Hon. John Boozman.......................................... 159
Hon. Bill Cassidy.......................................... 165
Hon. Jon Tester............................................ 166
Independent Budget Representatives
Blake, Carl, Associate Executive Director for Government
Relations, Paralyzed Veterans of America....................... 168
Prepared statement........................................... 170
Ilem, Joy, Deputy National Legislative Director, Disabled
American Veterans.............................................. 174
Prepared statement........................................... 175
Kelley, Raymond C., Director, National Legislative Service,
Veterans of Foreign Wars of the United States.................. 181
Prepared statement........................................... 183
Other Veterans Service Organizations
de Planque, Ian, Director, National Legislative Division, The
American Legion................................................ 185
Prepared statement........................................... 186
Weidman, Richard, Executive Director for Policy and Government
Affairs, Vietnam Veterans of America........................... 190
Prepared statement........................................... 191
APPENDIX
Independent Budget; report....................................... 207
THE FISCAL YEAR 2016 BUDGET FOR VETERANS PROGRAMS
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THURSDAY, FEBRUARY 26, 2015
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:33 a.m., in
room 418, Russell Senate Office Building, Hon. Johnny Isakson,
Chairman of the Committee, presiding.
Present: Senators Isakson, Moran, Boozman, Heller, Cassidy,
Rounds, Tillis, Sullivan, Blumenthal, Murray, Sanders, Brown,
Tester, Hirono, and Manchin.
OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN,
U.S. SENATOR FROM GEORGIA
Chairman Isakson. I will call to order this meeting of the
Veterans' Affairs Committee of the U.S. Senate and welcome
everybody on a snowy, cold Washington day.
We are glad to have you, Mr. Secretary, Dr. Clancy, and all
the members of your staff here, and glad to have the veterans
service organizations in to talk about VA's budget request and
the current pending budget for the U.S. Department of Veterans
Affairs.
I am going to open--we changed the rules a little bit. We
are going to have an opening statement by the Chairman and an
opening statement by the Ranking Member. Then we are going to
let any other Member who wants to make a public statement make
a closing statement so we can go straight to your testimony and
give you all the time that you need to do so. We will receive
questions based on the early-bird rule and we will alternate
between Republican and Democrat in that order so we will be
fair and equitable and everybody here gets a chance to ask
questions.
I am going to be liberal with the time, because I think
this is a very important hearing and it is very important for
us to understand the Department's request. It is equally
important for the Department to understand what we really want
to see out of the Veterans Administration, so thank you for
being here.
Secretary McDonald. Thank you, Mr. Chairman.
Chairman Isakson. I thought last night, when I prepared for
what I might say this morning, about the last 2 years on the
Committee, because it has been a rough 2 years in a lot of ways
for the VA; a rough 2 years for us. There have been a lot of
increases in money to VA. There have been increases in
parameters. The Veterans Choice bill has passed and we are
trying now to implement that. We have had the challenges with
mental health, particularly with veterans' suicide rates. We
have had a lot of other problems with construction and other
departments within the Department.
So, you could look back and say, this thing is a mess. The
fact of the matter is that you have--with your estimate for
employees in fiscal year 2017, you are going to have 305,000
employees in the Veterans Administration health care, just the
health care system alone. That is a big organization, exceeded
only by the United States military in its totality as the
largest employer in government. So, you have a big organization
that could be--and sometimes is--unwieldy.
We, as a committee, want to try to make it work as
seamlessly as possible. We want the funding to be appropriate,
but not in the excess; and, we want our attitude and the
attitude of the Department to be equally focused on the veteran
and the veterans' health care, not on ourselves.
To that end, I did a little math last night--I am a Georgia
graduate, so I might be corrected by some of these people that
went to higher institutions than that--but I was trying to
figure out the ratio of employees to the number of
beneficiaries in the VA. There are 6.5 million veterans--I
believe that is the right number--who are using VA health care.
Is that correct?
Secretary McDonald. That is very close. Yes, sir.
Chairman Isakson. OK. And, there are going to be 305,000
employees in veterans' health systems if you get the number of
employees you want in 2 years?
Secretary McDonald. That is correct. Yes, sir.
Chairman Isakson. That is a ratio of 21 veterans to every
one employee in the VA. That is pretty good--that is a lot
better than the pupil-teacher ratio you have in public
education today. So, I am not sure that we have a shortage of
employees nearly as much as we have not every oar in the water
rowing in the same direction in terms of those that are
following you and your leadership, or in terms of us and the
support we are giving to you.
I am troubled by the lack of detail in some of your
request, and I want to get into that in the Q and A portion,
because I know there is a request for 5,000 more employees in
the VA over the next couple of years. I understand why it is
being asked for, but I ask the question, if the ratio is 21-to-
1 now, are we going to lower it to 19-to-1; and is that going
to improve anything, because more is not necessarily better in
any business. In fact, sometimes more can be more cumbersome
than it can be healthy.
Second, as I told The American Legion yesterday--we have
had a hearing with the Legion, we had the Disabled American
Veterans hearing--and in both hearings, the VSOs made it clear
that while they understood Veterans Choice, they wanted to make
sure we understood that they did not want Veterans Choice to
replace VA health care.
So, I want to repeat what I told the Commander from Kansas
and Nebraska yesterday at the end of the meeting. We need the
VSOs and the Veterans Administration putting their heart and
soul behind making Veterans Choice work, not as a replacement
for VA health care, but as a force multiplier for VA health
care, and to be the VA health care of the 21st century.
Veterans Choice was not designed to be a replacement. It was
designed to be a help us deal with the problem that existed in
the administration in the delivery of health care, in
appointments, in timeliness, and in proximity to specialized
care that veterans oftentimes need.
So, one of the things you are going to hear me say over and
over and over again, which I hope the Veterans Administration
employees and the VSO leaders are listening to this, they need
to get onboard and start going forward. There is an old saying
that a radio disc jockey in Atlanta had. ``Them that's going,
get in the wagon. Them that ain't, get out of the way.'' That
is what we need to do on Veterans Choice. We need to make it
work to address the problems that the VA health care has
experienced and get health care to our veterans in the most
timely and seamless way we can. I am dedicated and committed in
my service as Chairman to doing just that.
As I close my remarks--I have got coins for the Members, by
the way, which they will be getting when we come back next
week, that have the IDWIC acronym on it, ``I Do What I Can'' to
help with veterans health care. We want you to do what you can
to make it work for us. We welcome you today. We look forward
to your testimony.
I am pleased to now turn to the Ranking Member, Senator
Blumenthal.
OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, RANKING MEMBER,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thank you, Mr. Chairman, for that very
eloquent opening statement.
I am very eager to turn to our witnesses and to our
colleagues for questions, but let me just state right at the
outset, Secretary McDonald, I have welcomed many of the steps
that you have taken as a beginning toward MyVA, meaning all of
our VA, and you were hired to do a very dramatic turnaround.
And, as with many tremendous challenges, that turnaround will
take time and very likely stronger action than you have been
willing to devote so far.
The Congress responded to the debacle of delays and
inadequate health care in some facilities by approving a
measure that also is still a work in progress. The Choice Act
has been shockingly underutilized, as you and I have discussed.
The reasons are uncertain and unknown at this point.
What is really necessary now is better data and stronger
information. That has been one of the downfalls of VA to this
point: the lack of reliable, accurate, truthful information. It
was the downfall of your predecessor. Very simply, certain
people in the VA lied to us.
So, the oversight function of this body is tremendously
important to our work like demanding reliable, accurate data
and information for your decisions. As you know from being a
very successful chief executive in the private sector,
decisions are only as good as the information that underlies
it, which is why I have posed some questions to you in the last
couple of weeks. You have been very forthright and forthcoming
in seeking to respond to them. I recognize that some of them
will require time to answer.
I am hoping that we can answer them in order to better
know, for example, about some of the factors that are
contributing to the underutilization of the Choice program, the
illogical 40-mile interpretation--the American Legion Commander
characterized it yesterday as ``crazy,'' the confusing
clarification around the geographic barriers and the definition
of the term ``facilities'' in a meaningful way. Beyond the
health care issue, there are all kinds of questions as to the
backlog of disability claims, GI Bill benefits for education,
physical facilities, and infrastructure. These challenges are
more important than ever.
I look forward to your testimony today on what the VA is
doing and also how it can better connect with the Department of
Defense. One of the still important problems is the disconnect
in so many respects, whether it is information technology, or
drug formularies. I spent some time yesterday talking to
General Chiarelli about the formulary issue, which he has very
pointedly and importantly raised.
There are a variety of challenges ahead that this budget
seeks to address, and I welcome the partnership between your
team and the Congress in seeking to address them and, finally,
doing more about not only health care in general, but mental
health in particular. The Clay Hunt SAV Act was a proud
achievement of this Committee on a very bipartisan basis, and I
want to thank again the Chairman for putting it so high on the
list of priorities for this Committee to address.
Thank you very much, Mr. Chairman.
Chairman Isakson. Thank you, Senator Blumenthal.
We are going to recognize the Secretary. I told the
Secretary before the hearing that I am not going to run the
clock on him. I will gavel him down if he starts repeating
himself, but this is very important testimony and a very
important budget request. I want to give you the time to make
your request and make your points. You are recognized for your
presentation.
STATEMENT OF HON. ROBERT A. MCDONALD, SECRETARY, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY CAROLYN M.
CLANCY, M.D., INTERIM UNDER SECRETARY FOR HEALTH; HON. ALLISON
A. HICKEY, UNDER SECRETARY FOR BENEFITS; RONALD E. WALTERS,
INTERIM UNDER SECRETARY FOR MEMORIAL AFFAIRS; HON. HELEN
TIERNEY, ASSISTANT SECRETARY FOR MANAGEMENT AND CHIEF FINANCIAL
OFFICER; AND STEPHEN W. WARREN, EXECUTIVE IN CHARGE AND CHIEF
INFORMATION OFFICER, OFFICE OF INFORMATION AND TECHNOLOGY
Secretary McDonald. Thank you, Chairman Isakson and thank
you, Ranking Member Blumenthal, Members of the Committee.
Thanks for the opportunity to discuss VA's 2016 budget and 2017
advance appropriations requests. I appreciated the opportunity
to speak with many of you during the past few weeks to gather
your questions and to be able to try to address them. We
appreciate the partnership.
We also appreciate the President's and Congress' steadfast
support for veterans, their families, and survivors, as well as
the assistance of Veterans Service Organizations.
As VA emerges from one of the most serious crises the
Department has ever experienced, we have before us a critical
opportunity to improve care for veterans and build a more
efficient and more effective system. With your support, VA
intends to take full advantage of this opportunity.
Members of this Committee and VSOs share my goal to make VA
a model agency with respect to customer experience, an example
for other Government agencies. With efficient and effective
operations, we look to be comparable to the top private sector
businesses in order to best meet the Nation's obligations to
all veterans.
The cost of fulfilling our obligations to veterans grows
over time because veterans' demands for services and benefits
continue to increase even after wars end.
This chart (see Veterans Receiving Service-Connected
Disability Compensation on pg. 8 of 23) shows that 22 percent
of Vietnam veterans were receiving service-connected disability
claims in 2014, four decades after the war ended. We expect the
percentage will continue to increase.
It is worth remembering that today, almost 150 years after
the Civil War, VA is still providing benefits to the child of a
Civil War veteran.
We still have troops in both Iraq and Afghanistan, yet in
the last decade, we have already seen a dramatic increase in
the demand for benefits and care. This chart (see Percent of
Veterans Receiving Disability Compensation on pg. 10 of 23)
shows that from 1980 to 2000, the percentage of veterans
receiving VA compensation was stable at about 8.5 percent. But
in just the last 14 years, since 2001, the percentage has
dramatically increased to 19 percent.
Simultaneously, the number of claims and medical issues in
claims has soared. Look at this chart. As this chart shows (see
Claims and Medical Issues Completed on pg. 15 of 23), in 2009
VBA completed almost 980,000 claims. In fiscal year 2017, we
project we will complete over 1.4 million claims. That is a 47-
percent increase.
But there has been a more dramatic growth in the number of
medical issues in claims, 2.7 million in 2009 and a projected
5.9 million in 2017. That is a 115-percent increase in just 8
years.
Now, these increases were also accompanied by a rise in the
average degree of veterans' disability compensation. For 45
years, from 1950 to 1995, the average degree of disability was
30 percent. Since 2000, the average degree of disability has
risen to 47.7 percent, nearly 50 percent, as this chart (see
Average Degree of Disability on pg. 10 of 23) shows.
While it is true that the total number of veterans is
declining--and the total number of veterans is declining--the
number of those seeking care and benefits is increasing.
Fueled by more than a decade of war, Agent Orange-related
claims, an unlimited claims appeal process, increased medical
claims issues, far greater survival rates of those wounded,
more sophisticated methods for identifying and treating
veterans' medical issues and demographic shifts, and as we
said, the population is aging, veterans' demand for services
and benefits exceeded VA's capacity to meet them. It is
important that Congress and the American people understand why
that is happening.
The most important consideration is that America's veterans
are aging, and their health care requirements and demand for
benefits increase as they age and as they retire.
Look at this chart (see Number of Living Veterans on pg. 9
of 23). This chart reveals an astounding shift. Just 40 years
ago, only 2.2 million veterans were 65 years old or older. That
is 7.5 percent of the population, and you can see that in 1975
based on the size of the red bar.
But look at 2017. We expect 9.8 million veterans will be 65
years or older. That is 46 percent of veterans. Just look at
the size of the red bar from 1975, the year I graduated from
West Point, to what we project in 2017. So, we now serve an
older population with more chronic conditions who are less able
to afford private care.
Currently, 11 million of the 22 million veterans in this
country are registered, enrolled, or use at least one VA
benefit or service. More are demanding VA services and care
than ever before.
The requirement for women veterans and mental health care
has increased dramatically. Over 635,000 women veterans are now
enrolled for health care, and over 400,000 actively use VA.
That is double the number using the VA in the year 2000. Annual
increases in women veterans seeking care are about 9 percent,
and this trend will continue. Our Women Veterans Call Center
now connects with about 100,000 women veterans per year.
In 2014, over 1.4 million veterans with a mental health
diagnosis enrolled in VHA, and we had 19.6 million mental
health outpatient encounters. Those are increases of 64 percent
and 72 percent, respectively, since the year 2005.
Since its inception in 2007, the Veterans Crisis Line has
answered over 1.6 million calls and assisted in over 45,000
rescues. As veterans witness the results of the positive
changes VA is making and as the military downsizes, the number
of veterans choosing VA services will continue to rise. It
should, and they have earned it.
We are listening hard to what veterans, Congress,
employees, and VSOs are telling us. What we hear drives us to a
historic department-wide transformation, changing VA's culture
and making veterans the center of everything we do. We call it
MyVA, and it entails many organizational reforms to better
unify the Department's efforts on the behalf of veterans.
These are the strategies at MyVA. We have them listed in
our written testimony as our five major themes.
First, We are working to improve the veteran experience so
that every veteran has a seamless, integrated, and responsive
customer service experience every single time. We are working
with the very best companies in customer experience in the
private sector to do that.
Second, we are improving employee experience by eliminating
barriers to customer service and focusing on our people and
culture so we can better serve veterans. We have no hope of
taking care of veterans unless we take care of our employees.
Third, improving our internal support services, which is
where we think we can improve our productivity dramatically
and, therefore, get more resources to serve veterans.
Fourth, establish a culture of continuous improvement to
identify and correct problems faster and, importantly,
replicate solutions at all facilities.
And, number 5, enhance strategic partnerships. Strategic
partnerships, like the Choice Act, as the Chairman said, are a
force multiplier, and we want to take advantage of that.
MyVA revolutionizes culture and reorients VA around the
needs of veterans, measuring success by veterans' outcomes as
opposed to internal metrics. Reorganizing the Department
geographically is a first but substantial step in achieving
this goal.
In the past, VA had nine disjointed geographic organization
structures, one for each of our nine lines of business. Our new
unified organization framework has one national structure, as
shown on this chart (see pg. 5 of 23). The new structure has
just five regions, aligning VA's disparate organization
boundaries into a single framework. You will notice this
framework and these boundaries are by State lines, which they
were not previously. This facilitates internal coordination and
collaboration among business lines; it creates opportunities
for local level integration, pushing responsibility lower in
the organization. It promotes effective customer service.
Veterans will see one VA rather than individual, disconnected
organizations.
Last, MyVA is about ensuring sound stewardship of taxpayer
dollars. We will integrate management improvement systems such
as Lean Six Sigma across operations to ensure we balance
veteran-centric service with operational efficiency. But we
need the help of Congress. VA cannot be a sound steward of the
taxpayers' resources with the asset portfolio we currently
carry. No business would carry a portfolio like the one we
have. Veterans deserve better. It is time to close VA's old,
substandard, and underutilized infrastructure. We have 900 VA
facilities that are over 90 years old and more than 1,300 that
are over 70 years old. VA currently has 336 buildings that are
vacant or less than 50 percent occupied. That is 10.5 million
square feet of excess, costing an estimated $24 million
annually to maintain. These funds could be used to hire roughly
200 registered nurses for a year or to pay for 144 primary care
visits for veterans or to support 41,900 days of nursing home
care for veterans in community living centers. We need your
support to do the right thing.
MyVA reforms will take time, but over the long term, they
will enable us to better provide veterans the services and
benefits they have earned and that our Nation has promised
them. Our 2016 VA budget will allow us to continue transforming
the intent of MyVA. It requests $168.8 billion--$73.5 billion
in discretionary funds and $95.3 billion in mandatory funds for
benefit programs. The discretionary request is an increase of
$5.2 billion, which is 7.5 percent above the 2015 enacted
levels. This will provide resources to continue serving the
growing number of veterans seeking care and benefits. The
budget will increase access to medical care and benefits for
veterans. It will address infrastructure challenges, including
major and minor construction, modernization, and renovation. It
will end the backlog of claims and will end veterans'
homelessness by the end of 2015. It will fund medical research
and prosthetics research; and it will address IT infrastructure
and modernization needs.
The resources required in the 2016 budget request are in
addition to those Congress provided last year in the Veterans
Choice Act. The VA has fully implemented this act and will be
expanding our outreach and providing more information to
veterans with a nationwide public service announcement, which I
would be happy to show you sometime today during the hearing if
the Committee's time permits.
We do not know at this time how many veterans will use the
provisions of the act to seek non-VA care or how much that care
will cost. As this chart demonstrates (see pg. 11 of 23), there
is a high degree of uncertainty about resources required. Our
current estimates range from a demand low of about $4 billion
to a high of about $13 billion over the 3-year program.
We will need flexibility within our budget to ensure that
we have the right resources at the right places at the right
time to provide veterans the timely care they need, regardless
of wherever they choose to receive it.
As an example of this flexibility, we are currently
exploring options to review the 40-mile provision, as we have
talked, of the Choice Act to get more veterans the care that
they want and need. I look forward to and I want to continue to
work with the Committee Members on the redefinition of this 40-
mile limit and work with other Members of Congress and veteran
stakeholders on this critical issue as we gain more information
about how veterans are using the Choice Act.
We meet today at a historically important time for VA and
the Nation. Next Wednesday, March 4, will mark the 150th
anniversary of President Lincoln's solemn promise to care for
those who have borne the battle and for their families and
their survivors. That is VA's primary mission. It is the
noblest mission of supporting the greatest clients of any
agency in the country.
Mr. Chairman, Members of the Committee, thanks again for
your support for veterans, for working with us on these budget
requests, for your patience in listening to my presentation,
and for making things better for all veterans. We look forward
to your questions.
[The prepared statement of Secretary McDonald follows:]
Prepared Statement of Hon. Robert A. McDonald, Secretary, U.S.
Department of Veterans Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Response to Prehearing Questions Submitted by Hon. Johnny Isakson to
U.S. Department of Veterans Affairs
Question 1. The Secretary has undertaken an ambitious goal to
reorganize the Department of Veterans Affairs (VA) into a more veteran
centric organization. This initiative, called MyVA, intends to put the
veteran first and give them the opportunity to choose how and where
they are served. In addition, it is intended to integrate VA to
increase productivity and efficiency across the Department.
a. In total, how much funding is requested for the MyVA initiative
for fiscal year (FY) 2016 and for FY 2017?
b. If VA's budget is adopted, how many additional employees in
total would be hired in relation to the MyVA initiative?
c. Please provide the breakdown of where those employees would be
located, including how many would be located at VA's Central Office and
how many would be located in the field.
d. Please provide a breakdown of what categories of positions those
employees would fill.
VA Response (a-d). The 2016 Budget requests: (1) $3.5 million and
15 Full-Time Equivalent (FTE) employees for MyVA in the General
Administration account, and (2) $76.3 million and 204 FTE supported
from within the existing VA budget as reimbursable funded activities.
As the process continues and the specific policy and program changes
are identified, the Department will submit budget requests for
implementation, beginning in FY17.
Question 2. Within the Medical Support and Compliance account, VA
is requesting 5,006 new Full-time equivalent (FTE) employees and an
increase of $283.7 million to support the Secretary's MyVA initiative.
These new FTE would be in the field at the VA medical centers (VAMCs)
and Veterans Integrated Service Networks (VISNs).
a. Please describe the analysis performed to determine whether
5,006 new FTE were needed as opposed to whether the duties of these new
FTE could be performed as ancillary duties of existing employees.
Response. The Medical Support and Compliance FTE growth is not
associated with the Secretary's MyVA initiative.
The additional positions are being added to the Medical Centers and
VISNs to support and fulfill the Secretary's vision of becoming a more
Veteran-centric organization and to be able to provide top-level
customer service in a more efficient manner to our Veterans. These
personnel will support healthcare workers in order to deliver the
healthcare services that our Veterans expect.
Although the FY 2016 Revised Request estimate of 54,020 FTE is
5,006 more than the original FY 2016 Advance Appropriation estimate, it
is only 1,206 more than the FY 2015 Current Estimate. The FY 2015
Estimate is largely based on FTE Operating Plans submitted by the
Veterans Integrated Service Networks, and reflects a concerted effort
to provide more support staff to VA clinical staff to enhance Veterans
access to health care. The FY 2016 Revised Request increase of 1,206
FTE above the FY 2015 Current Estimate is a 2.3% increase, which is in
line with VA's estimated increase in health care demand.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
b. Please provide the full list of 5,006 positions, job
descriptions, and the General Schedule or Title 38 pay grade(s).
Response. See table below. It should be noted that these staffing
levels do not reflect the additional medical and clinical support staff
added under the Veterans Choice Act to increase Veterans' access to
medical care, which is accounted for separately in the budget.
------------------------------------------------------------------------
2016
--------------------------------
Description Advance Revised Increase/
Approp. Request Decrease
------------------------------------------------------------------------
Physicians............................. 611 651 40
Dentists............................... 15 10 (5)
Registered Nurses...................... 2,960 3,365 405
LP Nurse/LV Nurse/Nurse Assistant...... 90 105 15
Non-Physician Providers................ 235 227 (8)
Health Technicians/Allied Health....... 1,206 1,119 (87)
Wage Board/Purchase & Hire............. 903 993 90
All Other \1\.......................... 42,994 47,550 4,556
--------------------------------
Total.............................. 49,014 54,020 5,006
------------------------------------------------------------------------
\1\ All Other Category includes: Medical Records Clerk/Technician,
Budget/Fiscal, Contract Administrator, Supply Technician, Medical
Support Assistant, Administrative Support Clerk, Administrative
Specialist, Police, Personnel Management Specialist, Management and
Program Analyst, and other staff that are necessary for the effective
operations of VHA Medical Support and Compliance
c. Would the new FTE report to the VAMC and/or VISN directors? If
not, please provide the reporting structure for these positions.
Response. The majority of these new FTE will be supporting health
care workers at VA medical centers and would report through their
supervisory chain to the local Medical Center Director. Other FTE would
be added for VA Consolidated Activities, such as Consolidated Mail
Outpatient Pharmacies and Consolidated Patient Account Centers.
Question 3. The President's budget request indicates that ``[i]n
the coming months, the Administration will submit legislation to
reallocate a portion of Veterans Choice Program funding to support
essential investments in VA system priorities in a fiscally-
responsible, budget-neutral manner.'' How much of the Veterans Choice
Program funds, and to which programs, does the Administration propose
to reallocate?
Response. It is too early in the implementation of the Veterans
Choice Program to provide a detailed answer. VA is assessing Veterans'
utilization of the Choice Program while also examining where the
Veterans Choice funding could be utilized to meet the demand for
Veterans services in VA's base program. VA's highest priority is
ensuring that Veterans have timely access to high quality care. VA will
work with Congress on any legislative proposal to ensure that budgetary
resources are allocated in a way that maximizes Veteran access to care
and services.
Question 4. The budget request includes an increase of $1.3
billion to the FY 2016 advanced appropriations for medical care. The
majority of the increased funding would be for initiatives that are not
included in the Enrollee Health Care Projection Model.
a. Please explain in detail what changed with these initiatives
since the FY 2016 advanced appropriations request was sent to Congress
in March 2014?
Response. See the attachment. The primary drivers of the increase
were increased demand for health care services (which included the cost
of new lifesaving Hepatitis C treatments), increased demand for
Caregivers stipends, an increased estimate for the cost of activation
of new health care facilities, increased investment in programs to
assist homeless Veterans (largely increased HUD-VASH vouchers) and
increased investment in non-recurring maintenance.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
b. What metrics does VA use to ensure it is requesting the total
amount needed for these initiatives when the budget request is sent to
Congress?
Response. The FY 2016 advance appropriation funding level included
in the FY 2015 Budget submission focused on providing essential initial
funding for the advance appropriations year to ensure continuity of
veterans' health care services. Each year, Medical Care funding,
including funding for all non-modeled activities, is revisited during
the budget process for the next submission and is revised to reflect
updated information on funding requirements and budgetary resources,
including unobligated balances.
Question 5. The budget request for the FY 2016 medical care
appropriations and the FY 2017 advanced appropriations request include
a cost shift of $452 million and $733 million, respectively, due to
veterans using the Choice Program. Please explain the metrics used to
determine the amount for FY 2016 and FY 2017 and the number of veterans
it is estimated to provide care through the Choice Program.
Response. The Veterans Choice Program (VCP) may provide a measure
of short-term relief from the pressure of escalating health care
requirements as some current patients in the VA system elect to receive
their care through the program. The 2016 and 2017 requests for the
Medical Care appropriations assume that some veterans who would
otherwise receive care in the VA health care system will now receive
that care through the VCP, instead. This introduces a shift of health
care costs from the discretionary program to the new mandatory source
of funding in the Veterans Choice Fund, thereby reducing the
discretionary appropriations request by the same amount. The assumed
cost-shift is $452 million in 2016 and $733 million in 2017. These
estimates were developed prior to having program experience and will
need to be revalidated going forward.
Key assumptions that were used in the cost-shift model prior to
program implementation:
Consistent with the Regulatory Impact Analysis (RIA) for
the Veterans Choice Program Interim Final Rule, we split the population
into the two cohorts--(1) veterans living more than 40 miles from a VA
facility (or meeting the other geographic criteria); and (2) veterans
waiting more than 30 days for their scheduled appointment.
In general, we used the same assumptions that were
published in the RIA, wherever possible.
One of the most sensitive factors involves the assumption
about how many eligible veterans will participate in the VCP. It's
difficult to predict veterans' behavior in response to this new choice,
so we used a range of rates, from low to high.
As VA gains program experience we will revisit the methodology used
to develop the cost shift estimate.
Question 6. During a House Veterans' Affairs Committee hearing on
January 21, 2015, Deputy Secretary Gibson stated that the interim 90-
day contract for the Denver VA Medical Center has been funded with $70
million. Please provide a detailed expenditure report for the $70
million, including when it will be depleted.
Response. This interim contract for $70 million includes a $20
million allowance to settle subcontractor liabilities, and $50 million
for continued work on the project on a cost reimbursable basis. The $50
million is currently funding critical activities on the construction
site. VA has added an additional $30 million for continued work on the
construction for a total of $80 million. The $80 million is estimated
to fund construction activities through March 29, 2015. If additional
funds are not added to the contract VA will be forced to stop work on
the site and begin to demobilize the contractor.
Question 7. VA indicated that the interim Denver contract will
require an additional $300 million. Please provide a comprehensive list
of the major construction projects that will have funds transferred to
the Denver VAMC to pay for this increase and the specific amount taken
from each project.
Response. The following table shows the source of the funding for
the reprogramming actions to date:
------------------------------------------------------------------------
Source Amount
------------------------------------------------------------------------
VHA Working Reserve (No Bid Savings)....................... $27,109,829
Physically Complete Projects (Bay Pines, FL--Outpatient 3,897,215
Clinic (Lee County); Columbia, MO--Operating Suite
Replacement; San Juan, PR--Seismic Corrections; Tampa, FL--
Upgrade Essential Electrical Distribution System;
Murfreesboro, TN--Psychiatric Care Facility)..............
Funds Transferred from Line items:
Facility Security........................................ 8,401,000
Asbestos................................................. 12,951,956
Judgment Fund............................................ 3,240,000
VBA APF.................................................. 1,000,000
------------
Total.................................................. $56,600,000
------------------------------------------------------------------------
VA has not finalized which projects will have funds transferred to
the Denver project to pay for the next increase which is projected to
continue progress on the project until USACE has developed its cost
estimate and entered into a long-term contract with Kiewit-Turner
Construction.
Question 8. The FY 2016 budget request has TBD listed for the
total estimated cost and future requests for the Denver VA Medical
Center. Given that the facility has already had $825 million allocated
to it, when will a new total estimated cost for the facility be
complete?
Response. VA and the Army Corps of Engineers (USACE) are working
collaboratively on the current short-term contract with Kiewit-Turner
Construction, with the expectation of a long-term contract being
negotiated by the USACE. USACE continues to develop a cost estimate to
complete the effort and is tracking for a contract award summer 2015.
As additional steps are taken USACE and VA will continue to update our
stakeholders.
Question 9. For FY 2015, the West Los Angeles major construction
project received a $35 million appropriation but was not authorized.
The Long Beach major construction project received $101.9 million in
appropriated funds but was not authorized. The FY 2016 budget requests
authorization again for these projects, though it seems to reflect that
the FY 2015 funds have been received and possibly spent. What is the
status of the FY 2015 funds for the West Los Angeles and Long Beach
projects?
Response. Congress did not pass legislation to authorize any of the
major construction projects in FY 2015, including Long Beach, San
Diego, San Francisco, West LA, and Canandaigua. VA is asking Congress
to pass legislation to authorize these five projects expeditiously, in
addition to the six new authorization requests for major construction
projects are included in the FY 2016 Request.
None of the FY 2015 funds appropriated for the five projects have
been spent, because the projects require authorization prior to
obligation and expenditure.
The FY 2015 funds for West LA and Long Beach have been moved to the
project. VA is awaiting Congressional authorization action before
awarding a construction contract for either project. Currently, VA
plans to make awards by September 30, 2015, subject to receipt of
authorization.
Question 10. Women veteran gender-specific health care increased
$34.3 million or 8.3 percent between FY 2015 and FY 2016. Please break
out the amount allocated to each category included under gender-
specific health care for fiscal years 2014, 2015, and 2016 as well as
projections for FY 2017.
Response. See the following table.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 11. What percentage of women veteran specific care is
provided at VA facilities and what percentage is provided through non-
VA care? Please break out each category included under gender-specific
health care for fiscal years 2014, 2015, and 2016 as well as
projections for FY 2017.
Women Veterans: Gender-Specific Medical Care
(Share of total care provided at VA Facilities and by Non-VA providers)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 12. At a hearing before the House Committee on Veterans'
Affairs on February 11, 2015, VA testified that there has been a 25
percent increase in productivity per employee with respect to claims
processing.
a. Please provide the Committee with the details of how that
statistic was calculated, including the number of claims completed per
employee for the relevant time periods, the time period over which that
change was measured, and the categories of employees that were included
(for example, quality review teams, non-rating staff, appeals staff,
fiduciary staff, management, etc.).
Response. The 25-percent increase in productivity is calculated by
dividing the number of compensation and pension (C&P) claims completed
in FY 2014 by the number of direct C&P full-time equivalents (FTE) in
FY 2014, and then comparing this ratio to the same figure from FY 2012.
In addition to claims processing personnel, Direct FTE includes all
employees supporting C&P programs, such as fiduciary employees,
national call center employees, outreach personnel, military services
coordinators, etc. except for management support, which typically
comprises 11 percent of all C&P field staff.
However, a more accurate representation of VBA's increase in
productivity is at the issue-level rather than the claim-level.
Calculating productivity by the more simplistic output of ``number of
claims'' does not reflect the increase in workload VBA has experienced
since 2009. From 2009 to 2014, VBA's productivity at the issue-level
increased by 67 percent.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
b. In calculating that statistic, were claims completed during
overtime included in determining productivity per employee? If so, what
percent of claims were completed during overtime?
Response. All rating-related C&P medical issues were included in
the calculation of productivity per employee. Overtime has historically
been an important management tool for VBA, although at levels generally
lower than what has been used over the past three years. In FY 2014,
VBA estimates between 504,000 and 588,000 medical issues were completed
due to overtime.
c. Please provide that statistic--productivity per employee--
calculated in the same manner for the prior 10 years.
Response. The table below provides productivity figures per direct
FTE at the issue-level since 2009. Issue-based data prior to 2009 is
not readily available.
----------------------------------------------------------------------------------------------------------------
Average Issues Per
FY Completed Issues Issues Direct Direct
Claims Completed Claimed C&P FTE FTE
----------------------------------------------------------------------------------------------------------------
2009................................................. 977,219 2,744,962 2.8 11,868 231.3
2010................................................. 1,076,983 3,808,712 3.5 13,555 281
2011................................................. 1,032,677 3,284,234 3.2 14,039 233.9
2012................................................. 1,044,207 4,128,321 4.0 14,119 292.4
2013................................................. 1,169,085 5,703,976 4.9 14,473 394.1
2014................................................. 1,320,870 5,528,656 4.2 14,307 386.4
----------------------------------------------------------------------------------------------------------------
d. If VA's FY 2016 budget is adopted, what is the expected
productivity per employee during FY 2016 using the same manner of
calculation?
Response. If the average number of medical issues per claim remains
at 4.2 issues per claim, VBA expects productivity to increase to 397.5
issues per employee in FY 2016.
Question 13. Over the past few years, VA has used overtime to help
process disability claims.
a. Please provide the amount spent on overtime for claims
processing staff during FY 2014, the amount expected to be spent on
overtime during FY 2015, and the amount requested for overtime for FY
2016.
Response. In FY 2014, VBA spent $132.9 million in overtime pay,
including $122.8 million for the compensation and pension claims
processing, $6.2 million for education claims processing, and $3.9
million on all other programs.
The FY 2015 budget request included $65 million for overtime, and
at the start of the fiscal year VBA applied a portion of carryover
funding to increase the overtime budget to $83 million. In
January 2015, VBA reinstituted mandatory overtime for compensation and
pension claims processing. To date, VBA has spent $40 million on
overtime in FY 2015, including $37 million for compensation and pension
claims processing, $1.9 million for education claims processing, and
$1.1 million for all other programs. VA is assessing funding
alternatives to sustain current levels of overtime for claims
processing.
b. What portion, if any, of the overtime hours during FY 2014 were
used to handle non-rating work or appeals?
Response. Eliminating the rating claims backlog remains one of VA's
top priorities. Therefore, in FY 2014 and FY 2015, overtime has not
been utilized to process non-rating work or appeals.
c. To date during FY 2015, what portion of overtime hours have been
used to handle non-rating work or appeals?
Response. Eliminating the rating claims backlog remains one of VA's
top priorities. Therefore, in FY 2014 and FY 2015, overtime has not
been utilized to process non-rating work or appeals.
Chairman Isakson. Thank you, Mr. Secretary, and thank you
for the timeliness of your remarks.
I will be brief in my questions, but to the point. In 36
years in legislative office, in one office or another, either
in the State or the Federal Government, I have seen lots of
consolidations and lots of reorganizations. More often than
not, it means more government and more employees, less
efficiency, and does not work. So, do you think consolidating
the regions from nine to five will produce more efficiency and
less burden in terms of employees?
Secretary McDonald. Yes, sir. Right now, the average
employee at the lowest level working with veterans--and I have
gotten this from the roughly 100 facilities I have visited so
far--they feel they are a prisoner of a system that they cannot
control. So, many of the ideas we are coming up with in MyVA
are really the ideas of the employees who are trying to better
serve veterans.
What they see today is there are nine lines of business.
Each has their own geographic map. If you talk to one VA
employee in one facility, they will not be able to direct you,
largely, to the other eight lines of business. We have got to
stop that.
MyVA is about reorganizing and getting more resources
working with veterans. I do not expect it will be an increase
in head count for the Department over time. In fact, I expect
it will be a productivity improvement. That is one of the
reasons we are going to shared services, where many companies
have gotten significant benefit.
We plan to take those resources that we are able to gain
through shared services and apply them for better customer
service. Whether or not that reduces head count overall, I do
not know yet, but our intention is certainly not to raise the
head count of the Department.
Chairman Isakson. Well, I want to make sure the goal is
achieved in improving services and unifying the VA and the VA
employees but does not end up resulting in more payroll, more
employees, and more bureaucracy. I think streamlining the VA is
important to accomplish.
Secretary McDonald. Mr. Chairman, that is all of our goal.
Chairman Isakson. OK. On concurrent--I am going to show my
ignorance here, show my memory loss in my older age--but, we
changed concurrent receipt a few years ago because veterans
with disability were not able to get retirement, is that not
correct? And, we changed it to where if you had 50 percent
disability or more, you were eligible for both the disability
payment as well as your retirement, is that correct?
Ms. Hickey. That is correct, Chairman.
Chairman Isakson. Then, if I look at this chart that you
handed out about the average degree of disabilities increasing
since 2000, that corresponds with the time we changed the law,
if I remember correctly. So, by moving the eligibility
threshold for joint receipt of retirement and disability to 50
percent disability determination, did that have a force effect
to raise the number of determinations that were raised to 50
percent or higher?
Ms. Hickey. I think, Chairman, the way I would answer that
is there are multiple trigger points in the march up on the
levels of percentage of disability. Certainly, at 30 percent,
you achieve the opportunity to apply for dependency, meaning
you get additional funds for having family members. At 50
percent, you get the access to health care. When you get
upwards into the 70 percent marks, you start becoming more
eligible for something called ``individual unemployability,''
which raises you effectively up to the 100 percent. There are
different threshold marks in there that are--where new benefits
are triggered as a result of increases.
But, I will tell you that, clearly, in at least my data
analysis, the number 1 issue that is driving the volume of
work, that 5.5 million medical issues that you saw on the
chart, is the number of medical issues that people are filing
per claim----
Chairman Isakson. Right.
Ms. Hickey [continuing]. Has dramatically increased.
Chairman Isakson. Well, I supported concurrent receipt and
what we did, and I think it was the right thing to do, but I
think your answer confirms the fact that as you ratchet up the
threshold to qualify for benefits, inherently, you are going to
raise the cost of the services that you offer, and I am going
to----
Ms. Hickey. Chairman, I would also say, inherently, you are
probably also meeting a need for a more disabled veteran that
needs that need, as well.
Chairman Isakson. Exactly. That is exactly correct.
My time is almost up, so I will end with a comment.
Secretary McDonald, I was delighted that in your entire
presentation, which was not timed or limited, you did not talk
about moving money from VA Choice to non-VA health care or to
regular VA health care, which was originally a proposal you
talked about. Is that still in the budget request?
Secretary McDonald. Mr. Chairman, the--I found a better way
to articulate, I think, what I am talking about. What I am
talking about, a choice. What we have done is we have
implemented choice for the veteran, and what we want in VA is
for the veteran to be able to make that choice. All I am asking
for is flexibility that if the veteran does make a choice, that
I have the funds available to be able to pay for their care so
that we do not have what occurred in 2014.
We have over 70 line items of budget that do not allow us
to move money from one line item to another. A company would
never be run that way. Imagine at your home, if you had two
checkbooks, one checkbook for gasoline, one checkbook for food.
The price of gasoline falls by half while you are hungry and
you need more food, but you cannot move money from the gas
account to the food account even though that would be
appropriate for your family. That is the situation we face.
We look forward to working with you and making sure you are
totally aware of the data that we have so we can make sure the
money is there for veterans.
Chairman Isakson. Well, you are moving in the right
direction and I appreciate the articulation of the request.
Senator Blumenthal.
Senator Blumenthal. Thank you.
As I outlined earlier, Secretary McDonald, the Choice Card
Program basically seems to be not working. I think you and I,
in our conversations, have talked about the potential reasons
that it is so underutilized. A small fraction of the veterans
who are eligible to use it, in practical terms, are doing so.
The 40-mile rule may be a cause. But, I wonder what the VA is
going to do about it and what plans you have to act on the
current real gaps and deficiencies in that Choice Program. We
are now into the sixth month of a 3-year program, so there
should be more to show for it.
Secretary McDonald. Let me try to address it, and then,
also, if Carolyn has anything to add, she may want to add.
First of all, I would like to congratulate the Committee
and the Members of Congress for the Choice Program. I think it
is a great program. Even though we have been at this some time,
we need to remember that the last cards went out in January and
it is right now the end of February, so it is early yet. But,
as the Ranking Member mentions, and we spoke about last night,
we are working hard to make sure we gather data to really
understand and drill down into what is going on.
So far, we have gotten about a half million calls, but that
has translated only into about 30,000 appointments or
clearances. That seems like an awfully low ratio to us.
Second, we worked together to put in the geographic barrier
as an allowance. It would allow the Secretary to allow someone
to take advantage of the program. So far, we have only had less
than 50 people take advantage of that.
Senator Blumenthal. It is 44, you told me.
Secretary McDonald. Forty-four is the exact number. I
said--we do not know exactly why, so we need to figure that
out.
We are doing a number of things. One, we have gone back to
our third-party administrators and we said, here is some new
data that we need, because initially, we set up the
relationship to give us data, but now we are discovering the
data that we need to understand this situation. So, we are
doing that. Hopefully, over time, we will better get that data,
and then we will put together an algorithm that we will share
with you and alternatives that will show how we should redefine
that 40-mile restriction and reinterpret it so that more
veterans can take advantage of the Act.
Senator Blumenthal. But, if I may interrupt----
Secretary McDonald. Yes, sir.
Senator Blumenthal [continuing]. You know, I think data is
important, but meanwhile, the clock is ticking and real money
was authorized for this program. So, I think there is a sense
of urgency in the Committee. As I mentioned when you and I were
talking, if this were a product at Proctor & Gamble that had a
0.37 percent purchase rate as compared to what you expected, if
its marketing simply was not working, you would begin acting
right away, and I hope that you will take----
Secretary McDonald. We----
Senator Blumenthal [continuing]. Very strong and urgent
action.
Secretary McDonald. I certainly agree with you. Hence, one
of the things we have done is--we have got to do a better job
of marketing the program. So, we are making calls. We are
sending out brochures, and we have got a Public Service ad. I
do not know, Mr. Chairman and Ranking Member, if you would like
to see it, but we have posted an ad that we recently created
which is already out there on YouTube getting hits right now--
--
Senator Blumenthal. I have seen it, and I would like to see
it again, but not on the time that I have for questioning.
Secretary McDonald. OK, sir. [Laughter.]
Senator Blumenthal. Let me go to----
Secretary McDonald. Anyone who wants to see it, we want to
make sure that you get the opportunity.
Senator Blumenthal. Let me quickly go to----
Secretary McDonald. And, put it on your own Web sites,
please.
Senator Blumenthal. Sorry, again, for interrupting----
Secretary McDonald. That is OK. No, no.
Senator Blumenthal [continuing]. But, I want to be
respectful of my colleagues' time. The Inspector General--the
budget actually requests an amount of funding that would reduce
the number of full-time positions, which I think is
unacceptable. We have yet to see the Inspector General report
on the debacle that inspired the Choice Program. That delay, in
my view, is inexcusable. I requested that the Federal Bureau of
Investigations be involved, because I said at the time that the
Inspector General lacked sufficient resources to do a prompt
and effective job--nothing personal or professional about his
qualifications, but resources, as I know from my law
enforcement experience, are critical. To increase the budget by
so small a factor, 0.3 percent, where there is actually a
reduction in full-time positions, I think, is unacceptable.
Would you comment.
Secretary McDonald. Yes, sir. You are right. that was an
administrative error. We have gone back and talked to the
Inspector General, and when he testifies in front of you, he is
going to ask for a $15 million increase. We support him 100
percent on that. Right now, we have got a number of
investigations that are ongoing, and the sooner we get these
done, the happier we all will be.
Senator Blumenthal. Finally--I have a lot more questions,
but very little time--on the issue of medical research,
particularly into mental health, my understanding is that there
has been no requested increase for that research. Am I correct?
Ms. Tierney. For mental health, I will have to check, but
overall, the research budget goes up $33 million in our 2016
request.
Senator Blumenthal. Well, for the VA's National Center for
Post Traumatic Stress Disorder, which, as we all know, is the
signature wound of these 13 years of war, the funding is
stagnant. For centers like the Health Care System Medical Care
Center Campus at Westhaven, which is doing enormously promising
and critically important work, to leave this funding stagnant,
in my view, again, is unacceptable.
Ms. Tierney. Yes, sir. I think Dr. Clancy can probably
better address this. When we ran the model, we found that we
are having less very seriously injured people in the war coming
back and our costs are stabilizing in that arena, but let me
turn it over to Dr. Clancy.
Senator Blumenthal. Well, if I may say, with all due
respect, your injuries may be stabilizing because you are not
recognizing them----
Ms. Tierney. Thank you.
Senator Blumenthal [continuing]. And acknowledging their
existence. The military itself says that 30 to 50 percent of
our returning and separating men and women suffer from these
invisible wounds of war. We just passed new law, the Clay Hunt
SAV Act, recognizing the importance of providing mental health
care. The research into how to treat it is even more important,
or at least as important as providing funds for the treatment,
because we are now using pharmaceutical drugs that are actually
counterproductive, according to the experts in this area. So,
may I suggest respectfully that the research funds be increased
for this purpose.
Chairman Isakson. Thank you, Senator Blumenthal.
I might interject, since mental health was raised, I want
to congratulate VA on the recognition they received at the
Academy Awards for the VA Mental Health Hotline. I think you
have made a major move forward in getting the VA accessibility
to someone in a state of crisis, and you are to be commended
for that.
Secretary McDonald. Mr. Chairman, we would love to share
that video with anyone who wants to see it.
Chairman Isakson. There is going to be a time, but it is
going to be after everybody has their questioning.
Secretary McDonald. I am sorry. I meant the HBO program.
Chairman Isakson. Oh, OK. Good.
Senator Moran.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Mr. Chairman, thank you very much. Thank you
for your opening statement as well as Senator Blumenthal's.
Mr. Secretary, nice to see you again. I was thinking that
in the time that you have been the Secretary of the Department
of Veterans Affairs, I have had more opportunity to have
conversations with you than any other Cabinet Secretary. I
appreciate that. I will see you in the Appropriations Committee
on this topic again in a few weeks. Yet, I do not feel like the
circumstances that I keep explaining and expressing concern
about are being expressed.
Therefore, the problem is that while I have more time to
speak to you than I have had with any other Cabinet Secretary,
I must be failing in my ability to deliver the message that I
want to deliver because I have no doubt that you care about the
results that I am seeking. So, I am going to try one more time
to express to you as the Secretary, and to members of your
team, where I think we are still failing in hopes that my
communication skills this time are sufficient to get change at
the Department.
You would expect me to talk about the 40-mile issue, and I
will, but it is broader than that. What troubles me, and again,
I know you have been in office a short period of time, but I
will tell you, the complaints that I receive from veterans in
Kansas about the quality of the service, the timeliness of
their being seen by a physician, their ability to access care,
is no less today than it was a year ago.
I would tell you that the success of claims, that while
your numbers indicate that the length of time for which claims
over 125 days are pending is improving, the number of veterans
who come to me, to my staff, asking for helping with a long
pending claim is no different.
I worry that we are setting the stage for another kind of
scandal, similar to the one about the fake list, the waiting
list, because your numbers are affected by claims that are
being appealed. And, I think one of the things that is
happening at the VA is, while you have shortened the number of
claims that are pending, they are now just in a different
category, waiting appeal, and the end result is our veterans
are still waiting.
There is no sense of the employees at the Department of
Veterans Affairs that I visit with in hospitals and facilities
across Kansas, that there is any more direction from the
Department of Veterans Affairs in Washington, DC, directed to
them and how to manage their operations, or any more freedom to
make decisions at home than there was before. In a sense, there
is no change that emanates from Washington, DC, so that folks
who are on the front line of delivering care to veterans feel
like they know better what to do or have flexibility to make
the decision about what they should do.
There is no sense, to my knowledge--I mean, you can
convince me--that there has been accountability since the
scandals of a year ago, that we are still waiting for the
Department of Veterans Affairs to handle employees who
conducted themselves inappropriately, perhaps illegally.
When I raise topics of concern about a specific veteran in
a setting like this, my veteran gets attention, which I
appreciate, but I can tell you, as soon as the spotlight is
over, that veteran is back to the same position he or she was
in before I raised their claim with the Department of Veterans
Affairs. So, they get a moment of reprieve, but it does not
last.
Further, Mr. Secretary, when it comes to the 40 mile
issue--that background, I hope, suggests to you where I am
coming from in my skepticism about the Department's
implementation of the Choice Act--and 40 miles is a significant
component of that, but not the only aspect. It is not just the
40 miles, within the 40 miles, and it is, I do not know, 42
Senators that are in this. I am not the mile guy. Forty-two
Senators sent you a letter indicating our preference about how
this should be implemented and related to--this is Senator
Collins' letter--related to as the crow flies as well as to
whether a facility that does not provide the service that a
veteran needs should be counted as a facility. The problems are
beyond--in the implementation of the Choice Act--are beyond
just that 40-mile issue.
When a veteran signs up--and you indicated a half-a-million
veteran calls--the problem is, when they call, they are often
told they do not qualify. ``You are not on our list.'' But,
then, there is nothing the veteran can do about it to say,
``Wait a minute. I should be. I am.'' There is no appeal
process for a veteran who should be on the list to get on the
list.
You are requiring prepayment of copayments, causing
veterans to pay more money for their health care if they choose
the Choice Act, in a sense, discouraging that choice.
In addition to that, trying to get community providers
signed up for services--I have been trying for months to get
community mental health centers to be able to be one of the
providers of those services--unsuccessfully. We have a provider
who says, ``I am going to lose money, but I have decided I want
to do this, but I cannot get the VA to even approve me to be a
provider under the Choice Act.''
So, the concern I have is that the VA has a mentality
against outside care, even in the circumstances where one
cannot get service within 30 days or within 40 miles, and that
is highlighted by--just a couple more points, Mr. Chairman--
that is highlighted by the fact that when we attempted to
implement the ARCH Program, the VA was not at all interested in
seeing, in my view, its success. In fact, we came across an e-
mail from the VA in DC instructing the VA in Wichita not to
promote, market, or encourage participation in ARCH, suggesting
to me that there is this approach or attitude against outside
care.
Finally, Mr. Secretary, while you have been available, and,
in fact, you asked Deputy Secretary Gibson to come see me, the
President's budget request--you are going to artfully change
your words a bit today, and I appreciate that--but, the
suggestion that the money could be used for higher priorities
within the VA is troubling to me because it, again,
demonstrates the lack of interest in this program.
When Deputy Secretary Gibson came to see me, he told me we
could not do the 40 miles because we could not afford it. Now,
I am told we need to move the money out because it is, in a
sense, not a priority. But, then, I will tell you, a few days
later, Dr. Tushman was in our office indicating that the only
cost estimates of the Choice Act were on the back of a napkin.
We do not have the information to determine what the costs are.
So, we are told it is expensive by the Deputy Secretary. We
are told by the number 2 person at VA health, we do not really
have numbers.
I try to be very optimistic, and all this is couched in
terms of I thought and want great things to happen with your
arrival at the Department. I thought Congress finally got its
act together. We actually could function. Republicans and
Democrats come together and pass a piece of legislation that
has value and I want to see its success.
Mr. Chairman, thank you.
Chairman Isakson. That was over time, but that merits a
response.
Secretary McDonald. It does. I am going to try to do the
best I can, Senator Moran. If I am missing something, let us
get together later and talk about it.
We are for the Choice Program, and we are for outside care.
Over the last 12 months or so, we have had roughly 500,000
appointments in outside care which is up 48 percent--not Choice
but outside care. So, we already have a process for outside
care. The difference is that this is outside care we suggest to
the veteran, not that the veteran suggests to us.
So, we already have a culture of outside care, and while I
cannot say every employee would tell you that outside care is a
good thing, I can tell you the leadership believes that it is
the only way to go. We have got to have a combination of VA
care and non-VA care to properly care for our veterans. There
is no question about that.
When the law was passed and the law was designed, nobody
knew--and, arguably, as we talked with the Ranking Member--we
still do not exactly know how many veterans are going to choose
to use it. So, we are in a period of uncertainty, but we are
trying to get as much certainty as we can so we can go back as
quickly as possible and change the definitions of the 40 miles,
change the definitions of the geographic barrier, in order to
get more people in the program. We want more people in the
program, and I think if you see our public service ad, you will
see demonstrated that is our intent. Yet, we have got to figure
out why they are not there. And just like you would in
marketing anything, we have got to figure out how to get people
in.
So, we want to get people in, but if the situation exists
that they do not go in, all I am saying is that at some point
we will share with you how many people are in. We will do the
best we can to get them in. But, if they do not go in, what we
do not want to do is lose the budgetary flexibility if those
people stay in VA, because we made assumptions as to how many
people would leave VA care, and we took that money out of the
VA budget. That was the only point I was making. It is a point
of flexibility.
Relative to facilities in Kansas, I need to get there. You
know, as you know, I gave out my cell phone number publicly. I
get calls, I get e-mails, I get texts every single day. I am
seeing a change. I am still getting a lot of complaints, but I
am seeing a change. The Veterans Service Organizations are
telling me they are seeing a change. But if you are not seeing
a change in Kansas, that does not do the people in Kansas any
good. So, we will get out there, and we will take a look. We
will work with you.
Senator Moran. Mr. Secretary, thank you for working with
me. We would love to have you in Kansas. I look forward to your
support of the 40-mile-fix legislation that I know the Chairman
has visited with you about.
And the final thing I would say is that when Secretary
Shinseki resigned, one of the things that stuck with me in his
comments was, ``I was too trusting of some, and I accepted as
accurate reports that I now know to be misleading.'' Make
certain that what you are telling me today is backed up by
facts as you can know them, not by the culture or the
circumstances that you find with the people that surround you.
Secretary McDonald. Yes, sir. I would like to invite you
and other Members of the Committee to join us for our daily
stand-up, which is where we go through all of our data. We had
the Ranking Member and the Chairman there, and I think you
would find it to be very helpful.
Chairman Isakson. I think we have already got a date set in
June for the next opportunity for a town----
Secretary McDonald. I am thrilled. Let us do the stand-up
and the town hall together. That would be great.
Chairman Isakson. In fairness to all the Members, I am very
liberal with the gavel because the questions and the comments
have been excellent, but there is a point of patience that I
will use to----
Senator Moran. I feel sufficiently chastised, Mr. Chairman.
[Laughter.]
Chairman Isakson. I started with Mr. Blumenthal, and you
just added on.
Senator Brown?
Senator Brown. Thank you for starting the new impatience
rule with me, Mr. Chairman. [Laughter.]
HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Thank you, Mr. Secretary, and thank you for
your outreach and your accessibility. We have all commented on
that and all appreciate that.
We spoke yesterday about the Ohio NPR affiliate which
raised health concerns related to post-Vietnam dioxin exposure
to reservists who flew or worked on C-123 aircraft, as you
know. They do not fall under the Agent Orange presumptive
eligibility construct. I want to acknowledge the VA's efforts
regarding the Institute of Medicine's recent report. Can you
assure me that this will happen? And give us the timetable, if
you would.
Secretary McDonald. Yes, sir. We asked the Institute of
Medicine to do that analysis. The analysis came back positive.
We have looked at it, and we have looked at ways to identify
the people, and we are expecting to make an announcement next
week. Gen. Allison Hickey, Under Secretary of Benefits, will be
making that announcement next week.
Senator Brown. OK. Good. Thank you.
The Department I know has made ending the claims backlog by
the end of this year a priority. My growing concern is that
expediting claims processing has led to an increase in veterans
filing appeals to their claims, which in turn makes dealing
with the backlog more difficult. The Cleveland regional office,
as we have discussed, continues to have a backlog numbering in
the thousands of claims. The budget request has $85 million to
hire 770 new staff.
Could you walk us through what will happen with the new
staff, what their function will be, how quickly this happens,
and how it affects the backlog?
Secretary McDonald. Yes, sir, I will; plus I will ask
Allison to comment. I want to just give a short overview.
If you remember, when we put in our request for the Choice
Act, we had people in the Choice Act that would work in VBA to
work on claims and to work on non-rating claims, which is part
of the backlog issue. When the Choice Act was passed, that was
stripped out. We have had people working mandatory overtime in
order to get more and more claims done. We have also converted
most of the claims now to digital, and as a result, we are able
to have a national work stream.
We are at the point where we really need the people if we
are going to continue to make progress against the claims and
the appeals.
Allison?
Ms. Hickey. Let me just start by very quickly giving you
all a larger update since we last met. The inventory for all of
our claims is down 45 percent. The backlog is down, this
morning, 64 percent, from 611,000 to 222,000. The quality is up
9 percentage points, up to 92 percent at the claim level, and
at the medical issue level 96 percent. Believe it or not,
despite the fact that there are a volume of appeals increases,
not the rate; the rate has remained steady for more than 20
years. In fact, last year it actually went a little bit lower,
but not enough that I am going to statistically quibble
anything about that. But it has held steady at 11 percent.
But remember the chart that we showed you where we did 9
million versus 1.3 million record-breaking--or 900,000 4 years
ago versus 1.3 million this last year, which is record-breaking
for us; 11 percent against 1.32 million is many more.
Here is the situation for appeals: despite the fact we have
increased our production against it by 35 percent last year, we
still have two solutions to appeals. One is change the law. I
recognize there is little appetite for it, but I have submitted
the legislative request regardless. The second is throw a whole
lot more people at it. So, those are the only two provisions I
have, neither one of which I control. Why? Because it is so
wired, this appeals process is so wired in law. It is not like
the claims process where I could do 45 initiatives to drive
that excellent takedown in the claims backlog. I cannot do it.
There is one idea out there--and I am extremely
appreciative to the VSOs, specifically DAV who took the
leadership, and all the rest who signed on, for the fully-
developed appeals process. That will help at the margins. It
still requires a legislative fix, which we will need that in
order to proceed forward.
But at the end of the day, beyond that, two things will fix
the appeals process--legal changes to it or a whole lot more
people--and we have submitted that in this budget. There is in
this budget request for appeals, for non-rating, and for
fiduciary, all--which was a byproduct of a successful increase
in production and productivity as a result of the
transformation.
Senator Brown. One last brief question, Mr. Chairman. I
know from representing you in the Senate that P&G is one of
Ohio's great companies in labor-management relations, which was
always so important to you and that you honored your workers
and labor--union and non-union alike. I have been very
impressed with your reaching out both to AFGE and other unions,
their leadership and rank-and-file. My question--and we all
welcome your comments at the beginning of your testimony in
terms of upgrades and new construction and modernization of the
physical facilities. My question is simple: will you continue
to utilize project labor agreements in VA construction, in all
VA construction?
Secretary McDonald. I am not an expert in that topic, but
if--you said ``continue.'' If we have been doing it, certainly
we would. I have reached out to our labor union leaders, and I
have spoken at their national conventions. I honestly believe--
65 percent of our employees are union members. We cannot get
this change done without the employees leading it, because who
better to know what we need to change than those working with
veterans every single day? As a result of that, we have a very
strong relationship with J. David Cox, the AFGE president, and
others. We are working hard to do that. We will get back to you
on that.
Senator Brown. OK. Thank you for that.
[The information referred to follows:]
Response to Request Arising During the Hearing by Hon. Sherrod Brown to
Hon. Robert McDonald, Secretary, U.S. Department of Veterans Affairs
Response. Yes. VA is required to determine, through market research
and Impact Studies, if Project Labor Agreements (PLA) are appropriate
for construction procurements at or above $25 million. When beneficial,
VA provides the option for contractors to submit a proposal with PLA
and/or without PLA.
Senator Brown. One more point about that. The unions--the
AFGE and the other VA unions you negotiate with and work with
are not typically the unions that my question would be involved
with. These are construction trades that actually build the
facilities, as you know from expansions at Procter & Gamble
over the years. I appreciate your track record on this. I just
want to see it continue, and I want to see it everywhere. We
had some problems in VA before about the pay of workers, the
unionization rate of those workers, and I think it affected the
quality of construction. I know how much you care about that.
Secretary McDonald. I need to dig into that more. I will
learn from it and get back to you.
Senator Brown. Thank you.
Ms. Hickey. Senator Brown, if I can make one more comment;
Cleveland is doing phenomenally well. Their backlog is down 80
percent. Their quality is up into one of the highest in the
Nation at both claims level and issue level.
Senator Brown. Thank you.
Chairman Isakson. Senator Cassidy.
HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA
Senator Cassidy. Thank you. Clearly, patient access to care
is important. You have impressive statistics about the total
number of visits. Are no-shows--when somebody has an
appointment scheduled but does not show up--are those included
in your total number of visits?
Secretary McDonald. Yes, but I want--you are making a great
point. No-shows is a really big issue.
Senator Cassidy. So, really, we cannot interpret the number
of outpatient visits you list unless we know the percent of
those in which the patient did not actually show up. Do we know
the percent of those total number of visits?
Secretary McDonald. Yes. I was going to say, one of the
things we review every morning is the no-shows.
Senator Cassidy. So, what is that percent of total visits
which are ``no-shows?''
Ms. Hickey. It depends on the facility and the type of
appointment----
Senator Cassidy. I totally accept that. That is my next
question. Globally, what would you say of the--I think you had
80--some incredible number. What percent, 20 percent, 10
percent, 30 percent?
Dr. Clancy. I would say it is probably more in the ballpark
of 20 percent. I was literally on the phone with a physician
the other day from the great State of Montana, I might note,
who said that actually they had started calling and had reduced
it quite a bit. He was orthopedics, down from thirty----
Senator Cassidy. I get that. So, the next question is: are
these generally distributed throughout the system and
institutions? Or can you pinpoint institutions in which these
no-show rates are particularly egregious?
Dr. Clancy. It is not quite that pinpoint-able.
Interestingly, veterans who come from rural areas have a much
lower no-show rate, and the more rural, the highly rural have
the lowest no-show rates; rural a little bit higher than that,
and urban actually have----
Senator Cassidy. Now, let me ask, because when you
mentioned your daily stand-up of looking at data, really,
unless you can bring it down to ``This facility has a no-show
rate of 30 percent, not improving, and this one has 30 percent
but is down from 50, and this one was 10 but now it is 30.''
The same 30 percent rate has far different meaning in that
context. So, I am asking, in your stand-up meetings, are they
worth--and I do not mean to be disrespectful, but unless you
are able to interpret it in that means, what value are they?
Dr. Clancy. No. That is exactly what we are working on with
facilities, and I think as the Chairman and Ranking Member can
tell you, the day they came we actually had one facility
online. We had two lined up, but we ran out of time. And that
is the kind of deep dive that we are doing with facilities to
help them figure this out. We also have some electronic tools
to help them.
To get back to your initial question, we look at both
pending appointments as well as completed appointments, so we
are actually reflecting on the completed appointments who
showed up.
Secretary McDonald. This is the chart, Senator Cassidy. It
shows missed--we call it ``missed opportunities.'' And as
Carolyn says, it breaks it out by rural, urban, highly rural--I
am sorry Senator Moran is not here--and it also breaks it out
by specialty. And as you can see, as you would expect, mental
health is----
Senator Cassidy. Is that in here?
Secretary McDonald. No, sir. This is our daily stand-up----
Senator Cassidy. My eyes are 57 years old, man. I cannot
see that.
Secretary McDonald. Well, come on over. We would love to go
through this with you and get your advice.
Senator Cassidy. Sounds great.
Dr. Clancy. We would be delighted to give you a briefing.
Senator Cassidy. Now, once I sat on a plane next to someone
who--a physician, who told me he was in charge of a ``turnkey
operation'' in which the VA contracted for him to go, I think,
to the Thibodaux area in Louisiana. It was an outside group.
They set up all the nurses, all the docs. They rented the
space, started seeing patients, and they were held accountable
for quality by the VA. Poor quality, boom, you are out of here.
Poor turnover, boom. But good, you stay. Now, I have not seen
him since, do not know if that clinic is still turnkey. But do
we have a sense--if that is a model VA uses, do we have a sense
of both the no-show rates in those clinics versus the VA
traditional facility and the productivity of those clinics
versus a regular facility? I see Ms. Tierney nodding her head.
Dr. Clancy. We have about 850 community-based outpatient
clinics, or CBOCs, and then we have a couple hundred that are
contract. My general impression is that the quality and
timeliness has been variable in those contract operations, and
we are actually looking into that right now. I would be happy
to follow up with you.
Senator Cassidy. If you could, because it really--I mean,
the question is: do you have a model where there is
accountability by contracts and you lose the contracts if you
fail to perform, whether that is better than a traditional VA
model? Our endpoint is not preservation of VA. Our endpoint is
preservation of the veteran, and so we need to look for that
best model.
Dr. Clancy. Absolutely.
Secretary McDonald. We are going through that now. We
believe we have to take responsibility for wherever the veteran
gets the care.
Senator Cassidy. Now, there has been a lot of talk about
the veteran's electronic medical record (EMR). Do you have a
sense of the average time a physician in the VA system spends
entering data per clinic visit? Because, obviously, I think
Epic says it is 17 minutes per visit, which is obviously not
the time you are looking into the veteran's eyes to find out if
he or she is depressed. So, do you have--you do not have that?
Secretary McDonald. I do not have it with me, but we will
get it and get it to you. We certainly look at that, and
certainly as I go around to our different facilities, I hear
our providers talk about the need for people to put that data
into the medical record.
Senator Cassidy. I get you. I will tell you that talking to
my physician colleagues, I get a sense that they spend a lot of
time on your EMR and not as much time looking into the eyes and
saying, ``Are you depressed?''
Secretary McDonald. That is true, but for benefit of the
other Committee Members--because I know you know this--the EMR
also signals questions that the doctor should ask. If, for
example, a doctor wants to prescribe a drug, the record might
say back, ``Well, watch out, the compatibility of that drug
with another drug''----
Senator Cassidy. So, next, can I finish up? Because the
Chairman was so generous with time. There is a GAO report on
the improvements needed in monitoring antidepressant use for
major depressive disorders and increasing accuracy of the
suicide data that I am sure you are familiar with from November
2014, showing major deficiencies in the VA's database as
regards veterans suicide. I think I heard a report, but I am
saying it off the top of my mind, 22 veterans commit suicide a
day. That may be an overstatement. I am saying it off the top
of my head.
Now, here they found a number of deficiencies in data
collection. Theoretically an EMR would have done it
automatically, but indeed it does not. Can I ask you
specifically what is being done to address this issue?
Dr. Clancy. We have follow-up plans with the facilities and
networks that have the greatest opportunities for improvement.
An EMR can remind clinicians what is the right thing to do. As
you probably know from your own practice, there is no guideline
or recommendation that is 100 percent right for 100 percent of
patients. So, what we are trying to figure out is to what
extent are people making appropriate decisions and to what
extent are they actually just not paying attention.
Senator Cassidy. This is also about data collection,
though, for example, date of death being wrong on the form as
to the day the veteran committed suicide, as just a simple sort
of, ``Man, somebody did not do this right'' sort of thing.
Dr. Clancy. Yes.
Senator Cassidy. I am over time. Thank you very much. Thank
you for your service.
Chairman Isakson. Thank you, Senator Cassidy. It is nice to
have a doctor on the Committee.
Senator Murray?
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Mr. Chairman, thank you very much, and
welcome to all of our witnesses. Mr. Secretary, it is really
good to see you again. I do have an opening statement I would
like to submit for the record.
Chairman Isakson. Without objection.
Senator Murray. Thank you.
[The prepared statement of Senator Murray follows:]
Prepared Statement of Senator Patty Murray
Mr. Chairman, thank you for holding this hearing.
A budget is a statement of our values and priorities. And as the
daughter of a World War II veteran, I believe making sure our country
keeps the promises we've made to our Nation's heroes should be at the
top of our list of priorities, all of the time. Taking care of our
veterans when they come home is a fundamental part of who we are as a
Nation.
It is part of the cost of going to war. And making sure the VA has
the tools and resources it needs to provide care and support our
veterans is critical.
I was very pleased to see the President submit a strong budget
request for VA this year. In particular I am pleased to see VA
requested an increase of $34 million for gender-specific health care
for women veterans.
Also, I continue to hear from veterans about delays in processing
certain types of claims in the Seattle Regional Office, so VA's request
to hire another 770 employees nationally to help bring down those
processing times is very important.
However, the President's budget request also includes areas where
we are not investing strongly enough. With the continuing high rates of
suicide among veterans, and long wait times, we need to increase funds
for mental health care. I am also concerned that the request for the IG
is insufficient. Especially at this critical time when so much
oversight of VA hospitals is needed, we cannot afford to cut the Office
of Inspector General, which has been so vital in making sure veterans
get the timely, quality care we expect.
Even with an overall strong budget request, effective management
and oversight is critical to the Department providing for our veterans
the way we expect.
Mr. Secretary, from your experience in the private sector you know
as well as anyone here how difficult it is to change the culture of a
large organization. But change is essential. VA has struggled with
these types of efforts in the past, so you certainly have your work cut
out for you to make sure this time we are successful.
You are asking the right kinds of questions--how to move the
Department's focus from the bureaucracy to focus on the veteran's
experience--and taking a fresh look at how business services are
delivered. Human resources, contracting, I.T., and construction have
all been major problems for the Department for many years. I hope you
will stay focused on how to bring real reform to those offices.
Mr. Secretary, I am also looking forward to working with you on
some important legislation to improve the health care services for our
veterans.
I recently introduced S. 469, the Women Veterans and Families
Health Services Act, which will expand critical fertility services to
injured and ill servicemembers and veterans to help them realize their
dreams of having a family when they otherwise might not be able to
because of an injury in the line of duty. And I was very pleased to
work with Senator Heller to introduce S. 471, the Women Veterans Access
to Quality Care Act. That bill would greatly improve access to gender-
specific care for women veterans, and ensure VA is accounting for the
needs of the growing population of women in the construction planning
process.
Implementing the Veterans Access, Choice, and Accountability Act
will also be a critical issue this Congress. The $5 billion we gave to
build and strengthen VA for the long-term is already making a
difference. In my home state of Washington, two medical centers have
already announced they will hire a total of 324 new medical care staff
in the Puget Sound and Portland/Southwest Washington regions.
As for the Choice Program, I understand there are some initial
problems implementing the program, and I hope you will act quickly to
resolve them. But it's also time to start planning now for what the
future of non-VA care will look like.
There are now several different major authorities VA can use to
purchase care outside the system. They are often duplicative and
inefficient, and they are not consistent with each other.
The Choice Program was a temporary, emergency authority. When it
expires, VA needs to have a reformed program in place to help veterans
access care outside VA in a way that: complements services provided by
VA, provides coordinated care with strict quality of care requirements,
has consistent processes and eligibility rules, and is cost effective
Finally, I would also like to thank our representatives from the
veterans service organizations. Your hard work each year, especially on
the Independent Budget, is very important for us as we work to make
sure there are adequate resources to provide veterans the benefits and
care they have earned.
Thank you, Mr. Chairman.
Senator Murray. Secretary McDonald, as you know, and you
said in your opening statement, the population of women
veterans is increasing dramatically. It has doubled since 2001.
I was really pleased to work with Senator Heller to introduce
the Women Veterans Access to Quality Care Act to make sure that
the VA does have the services and facilities to meet the needs
of women veterans.
One of the key provisions of that bill is requiring
obstetrics and gynecology to be available at every medical
center. I wanted to ask you what resources and staff, including
support staff, will you need to meet that kind of requirement.
Secretary McDonald. Thank you, Senator Murray. We are very
much in favor of that approach. We are in the process of
putting women's clinics all over the country. We have a new one
here in Washington, DC, and I would like to invite the Members
of the Committee to visit it. It is in our Washington, DC,
facility. It is a women's clinic.
As you know, I have been out to about 12 medical schools,
talked to deans. We are hiring and we need to hire more
gynecologists.
Senator Murray. Do you know how many you would actually
need to do this?
Secretary McDonald. The exact number? I do not have an
exact number. I can tell you that in the past 9 months or so,
we have hired about 8,000 people. Of that, about 1,000 are
doctors, but I do not know how many of them are gynecologists.
We can get back to you with that number.
Senator Murray. OK. If you can get that back to me.
[The information referred to follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to
Hon. Robert McDonald, Secretary, U.S. Department of Veterans Affairs
Response. From April 1, 2014, to March 31, 2015, VHA's net onboard
for providers was over 1,017 physicians (4.5% increase). Of those, 13
were gynecologists (11.7% increase).
Senator Murray. I also wanted to bring up that the VA
policies--it is way past time to bring the VA policies up to
date with modern medicine and allow the VA to provide better
fertility treatment, including in vitro fertilization, for
seriously injured veterans who want to start a family. This is
a high priority for me. I think it is a high priority for our
veterans, and I want to work with you to get that done, as
well. So, I will be talking to you more about that.
Secretary McDonald. We are working on that.
Senator Murray. OK. I want to hear from you, what are you
doing to work on this?
Dr. Clancy. My staff briefed me recently in terms of how
many women might be eligible and what would be the specific
requirements----
Senator Murray. Well, it is women and men.
Dr. Clancy. Yes. And also compared what the Department of
Defense covers versus what we cover, or actually do not at the
moment. So, I sent them back with some more questions, which we
would be happy to follow up with you.
Senator Murray. OK, and I will submit some questions on
this, but I think this is absolutely critical for our men and
women who serve overseas and lose their capability, then we
have to make sure they can start a family. So, I will be
focused on this.
I also wanted to talk to you about the legislation that I
introduced last year to expand the caregiver support services
to VA, to all eras of veterans. I am going to be introducing
that again this year, and I want to be sure we are all working
together to strengthen that program so it will be ready to take
on the additional workload.
VA's budget request says that in fiscal year 2015 you
cannot hire any new caregiver support coordinators to help with
the overwhelming demand, and I hear already at some facilities
that providers refuse to help with doing initial evaluations or
home visits. To me that is just unacceptable. I wanted to ask
you what you are doing to bring in more caregiver support
coordinators.
Secretary McDonald. Let me start, and then I will ask
Carolyn to comment.
We are very much in favor of improving our caregiver
operation. In fact, in the last week, I met with Senator Dole
of the Elizabeth Dole Foundation. We are working very closely
with her.
First, what we have agreed to do is to set up a special
advisory committee for the Secretary on caregivers. We do not
have that, and I think we would benefit greatly from having
that--working with her, incidentally, working with her
foundation.
Second, we are talking about having a caregiver summit,
something where we could get everybody together, and we are
working together----
Senator Murray. For all eras or just----
Secretary McDonald. All eras. All eras, because, again,
Post-
9/11 is not enough.
Senator Murray. Yes.
Secretary McDonald. We want to work together with you on
this.
Senator Murray. OK. Well, I want to stay in touch with you
on that. Please keep me up to date on what they are doing.
Finally, I want to talk to you about a homestate issue, the
Spokane VA emergency room. They have seen a dramatic cutback in
operations simply because of staffing problems. I have to tell
you, as the daughter of a World War II veteran, this is
unacceptable to me. It is a very serious problem for veterans
in that area, and we have got to get it back to full-time
operation. I wanted to ask you today, When will the emergency
room at the Spokane VA start operating 24 hours a day again?
Dr. Clancy. Senator, we have had significant recruiting
problems. We had originally hoped to open it to 24/7 in April,
and it is now looking like that is going to get pushed back a
few months. However, I met with some colleagues from the
American Legion just a couple of days ago at their meeting, and
they have actually been out speaking to some of the other
hospitals in town who may be able to help us out.
The other area where we need help, I think, recruiting
emergency physicians is a legislative change that would allow
us to accommodate what many people who go into emergency
medicine want, which is greater flexibility for hours than the
current Federal H.R. policies allow.
Senator Murray. OK. Are you looking at every option?
Because we----
Dr. Clancy. Yes.
Senator Murray [continuing]. Have heard recruiting forever.
So, temporary providers, bringing in doctors from other
facilities, absolutely everything, because this is a critical
need in that community.
Dr. Clancy. I would agree with you, and we are looking at
all options, yes.
Senator Murray. OK. I want to follow up with you on that
so, let me know when and how and when we are going to see that
open again.
Thank you.
Chairman Isakson. Thank you, Senator Murray.
For the benefit of the Members, the order for questions
will be Sullivan, Tester, Rounds, Sanders, and Hirono, unless
somebody who was here comes back. Anybody argue with that? Is
that OK?
[Nodding in agreement.]
Senator Sullivan?
HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA
Senator Sullivan. Thank you, Mr. Chairman.
Mr. Secretary, your team, thanks for your testimony today
and your service. You know, I think there are a couple things
going on here that give a sense of frustration from the Members
on some of the big issues that I know you are working hard on,
and it goes without saying that in many ways it is just a
strong passion all of us feel in a very strong, bipartisan
sense. You have the disabled vets in town all week, and you see
that, you see what they have sacrificed with regard to our
country. It is hard not to get passionate about this. I know
you guys are passionate about this and, as you can imagine--you
and I have talked about it--in Alaska we are quite passionate
about it. We proudly wear the title of the State that has the
most veterans per capita of any State in the country.
A lot of what Senator Moran talked about I share in terms
of the frustration. And you mentioned getting out to Kansas. I
would welcome a commitment from you to come visit Alaska,
given, you know, our challenges there. While we were just on
recess, I was actually out in our new veterans' facility there
on Joint Base Elmendorf-Richardson, and had a briefing from
your team, which was quite informative. They did an outstanding
job.
We would love to get a commitment from you to come visit
our great State this year, if possible, with your team and look
at some of those issues.
Secretary McDonald. I would love to visit Alaska. I served
there and I would love to come back.
Senator Sullivan. OK, Outstanding. Then we will do that.
I wanted to also follow up on the appeals process. You
know, a big issue that I think would be helpful in terms of
your team testifying in front of this Committee, if you can
give us a very regular update on the backlog, both in terms of
the existing backlog and the appeals. You know, I think in many
ways that has been kind of a symbol of some of the challenges,
some of the problems. You can put a finger on it in terms of
the numbers, and I think there is concern in the Committee of
kind of having that bulging backlog kind of just move over to
the appeals.
Ms. Hickey, I know you were talking about the express
appeals process. I know a number of us are looking at legal
ways in which to move that. You mentioned that it would just
possibly move on the margins. We do not want to move on the
margins. We want to address this in a fulsome way.
Can we get your commitment to work with us on what would be
some of the ideas that we are working on to address that? We do
not want the backlog to be kind of a whack-a-mole issue. That
would be very devastating, I think, for our veterans. It is
really important that we put a lot of smart minds, not just
money but minds, to this. I would like your commitment on
working with us on that.
Ms. Hickey. Senator, I am more than willing to give our
commitment. We have done that repeatedly. And we keep thinking
about solutions. We have new, fresh minds to bring to the table
as well. This is one that will require the Congress' active
participation----
Senator Sullivan. Good.
Ms. Hickey [continuing]. Because of what I have described,
which are issues that are beyond our control.
Senator Sullivan. Great. Then we will--I know that the
Members of this Committee are very interested----
Secretary McDonald. Senator Sullivan, may I also add that
we will work with your staff on this. We put our data online
every 2 weeks, so it is open to Members of the Committee, and
we are doing that for a reason. I know there have been
questions about our data, but it is online every 2 weeks. Your
staff can get it and download it, and you can call us and ask
questions. We are trying to be as transparent as possible.
Senator Sullivan. OK, great.
Ms. Hickey. And in this case, I will tell you actually our
data is up every Monday. It is in the Monday morning workload
report. Congress last year asked us to add appeals information
to that. We did. It is in there. And I also have numbers of VBA
stat sessions that we run every month, which I would invite you
or your staffs to participate in some of those. We do very deep
dive data conversations with our RO directors and go through
each and every line of what they are doing and their
performance.
Senator Sullivan. Great. We look forward to working with
you on that.
I have two questions, and they are for you, Mr. Secretary.
You know, when you and I talked, you mentioned that the budget
of the VA has increased pretty dramatically over the last
several years. I forgot the number. I think you said something
along the lines of 60 percent over the past 6 years. That may
be a ballpark figure. So, my two questions are--and they are
unrelated, but I just want to get them in under the buzzer here
so I do not get reprimanded by the Chairman.
First, given your background, do you think the problems are
money versus culture? I mean, you can throw money at an
organization, drown it in money, but if you do not have the
culture to solve the problem, you are never going to solve the
problem.
Second, you talked about in your budget how we could end
veterans' homelessness. The term ``homeless veteran'' is a term
that I just choke on. I hate the term. I would love to get rid
of it in the English language. If you have a plan on ending
veteran homelessness, we are all ears.
Secretary McDonald. Well, let me go for homelessness first.
We are committed to ending veteran homelessness by the end of
this year. We do have a plan, and the plan is putting veterans
in homes first. There is not a lot of debate about this any
longer. The science in homelessness now is getting the veteran
in a home first and then providing all the treatment for them.
If you do not get them in a home first, you run into Maslow's
hierarchy of needs kinds of issues. It is best to get that out
of the way. Get them in a home. We have programs to do that. We
have several programs, more than a dozen programs to do that.
The most important thing is community involvement. That is
the reason I went out to Los Angeles. I ended a lawsuit that we
had there. I got the community together. Everybody has a role.
We in the Federal Government can provide a HUD-VASH voucher,
but if we do not have a local landlord willing to rent at that
rate, we cannot get the veteran in the home.
Senator Sullivan. Got it.
Secretary McDonald. So, it requires a 360-degree solution.
We know that we can do it. The mayor of New Orleans committed
to end homelessness, and in 6 months we had done it.
Now, admittedly, there are not as many people homeless in
New Orleans as there are in Los Angeles, but we know we can do
it and we know how to do it. We would be happy to work with you
on it.
Senator Sullivan. Great. Thank you.
Secretary McDonald. I forgot the second----
Senator Sullivan. Culture versus money.
Secretary McDonald. Culture. Obviously, culture is the most
important thing. In my leadership experience, the way we are
approaching this is we have got to change the culture. We have
to change the systems, if you know what I mean by--the
repetitive processes, because many of our employees feel like
they are prisoners of a system that is not right. We have to
change the strategies, and we are doing that.
Partnerships is a strategic change; and we have to change
leadership. Over 90 percent of our medical centers have either
new leaders or new members of the leadership team.
In fact, what I worry about as I am trying to go out and
recruit is all the bad press that we are getting; it makes my
recruiting job very difficult. And, if Congress is to pass laws
that affect VA employees only, it makes my recruiting job even
more difficult.
We are trying to show that we have a plan, there is a good
reason to join us, and we are getting a lot of takers. As I
said, our employment is up. So, we are making progress.
Senator Sullivan. All right. Thank you.
Thank you, Mr. Chairman.
Dr. Clancy. May I make one addition from your State.
Chairman Isakson. Quickly, if you will.
Dr. Clancy. Yes. In the short term we do need resources
because a lot of our clinicians, who are terrific, are actually
limited to one room per clinician, which means that affects
productivity and how many veterans can be seen and so forth.
So, I was thinking about the Nuka system in Alaska which has
been a huge inspiration for us, but we believe that some part
of their success was their ability to create a very, very
different space. MyVA and the shared services that the
Secretary is bringing about will help us get to a place that we
can do that more efficiently and expeditiously.
Chairman Isakson. Senator Tester.
HON. JON TESTER, U.S. SENATOR FROM MONTANA
Senator Tester. Yes, thank you, Mr. Chairman. I want to
thank the Secretary and your team for being here today.
I have been particularly proud of this Committee, to serve
on it, and particularly proud of the work the previous
Congresses have done. When I first got here, you had
discretionary funding in the VA; now it is mandatory. You had
year-to-year funding; now we have got forward funding. We
plussed up the budgets. We have had some great Secretaries from
Peake to Shinseki to yourself, and I appreciate that. And to
add to that, in Montana, I will tell you, you have some great
people on the ground. The veterans who get through the door
love the health care they get for the most part. There are a
few exceptions to that. And the reason they love the health
care they get is because of the health care professionals that
are on the ground. They like it better than the private sector.
That is why you do not see a lot of referrals out because they
want to see their doc within the VA.
That being said, we have got a problem, and that problem
has to do with vacancies. The Director for VA in Montana had
been an Acting Director for so long that he is no longer there
because the Acting Director time ran out, 240 days. It is a
huge issue. We have talked about it multiple times before. It
is parochial in nature, but I think it is bigger than that. I
think it happens in far, far too many regions. In fact, Dr.
Clancy and Mr. Walters are Acting.
When can we see a full-time Director in Montana? And when
can we see nominees for the two positions Dr. Clancy and Mr.
Walters have?
Secretary McDonald. We are hoping to get the full-time
Director in Montana within days.
Dr. Clancy. I was just checking my e-mail. We are actually
expecting some word today, so----
Senator Tester. Word today?
Dr. Clancy. Yes.
Secretary McDonald. We were hoping to have it by----
Dr. Clancy. We have a great candidate. That is not the
issue. It is some paperwork that is beyond VA.
Senator Tester. OK.
Secretary McDonald. I also have worked with the President.
We have nominations coming to the Senate very shortly. You will
probably get some nominations next week.
Senator Tester. OK. That will be good.
You had talked in your opening statement, Mr. Secretary,
about antiquated infrastructure, the fact that we need new
buildings, which I agree with.
At Fort Harrison, we have a new acute psychiatric wing. I
was there for the grand opening. Dr. Clancy's predecessor was
there when we cut the ribbon on the tape. Everybody was happy
about it. It was going to take care of issues that dealt with
PTSD and alcoholism and drugs. That facility--``closed'' is not
the right word, but it is not taking any patients; a fact, we
have been dealing with. A disabled vet with PTSD was turned
away because that facility was no longer accepting patients.
The county spent $2,400 to send him--but the bigger problem is
that the facility was built--it is brand new, yet we do not
have the staff. You just said hiring is up. You have got the
best staff in the country in Montana. Why can't we get some
people to Montana to help these folks out? Why can't we get
that facility open?
Secretary McDonald. I am hoping to learn more about that
when you and I go to Montana, and I am hoping during our trip
we can do some recruiting.
Senator Tester. I appreciate that. The problem is that I do
not know--we talked about culture, we talked about money. I
think you guys are great. I think the people you have got on
the ground in Montana are great. What is going on in the
middle? Why don't we have aggressive recruitment going on with
the folks down in Denver, in our region, and regions in the
country?
Secretary McDonald. They are aggressively recruiting.
Senator Tester. I do not see it.
Secretary McDonald. But we do not see it in your result, so
I have to get into it and learn about it.
Senator Tester. OK.
Secretary McDonald. Make a difference.
Senator Tester. All right. I have a question. There is a
group out there--it is my understanding a group called
``Concerned Veterans of America''--that is putting forth a
proposal today to reform the VA, among other things. It would
restrict the VA to only service-connected veterans. Could you
give me your thoughts on that?
Secretary McDonald. Well, as you know, the Department of
Veterans Affairs is committed to providing veterans the best
care they can get. They have earned it, and we want them to get
it wherever they want, whether it is in the VA or outside the
VA. The veteran is the core of our mission, and it is
fundamental of our purpose of MyVA, the reorganization we are
doing.
Unfortunately, many of the proposals that are coming up
today advocate contracting out what we consider to be a sacred
mission of those who have borne the battle. So, it is
important--we think there is an important role for outside care
in veteran health to supplement our own VA care. But, frankly,
we do not think that should diminish or obscure the role and
the importance of VA's health care program. That is what we
worry most about. Reforming VA health care cannot be achieved
by dismantling it or by preventing veterans from receiving the
specialized care and services that can be received only from
VA.
Our goal continues to be to provide timely, quality care
and benefits, and we want to work to improve access, wait
times. We want to find partners to help us. But we do not want
to dismantle the VA.
Senator Tester. One last question, if I might, Mr.
Chairman. I need you to provide me an update of the situation
in Tomah VA medical center in Wisconsin. It is not my State,
but it is very, very important. It is my understanding that
Senator Baldwin had asked you for a VA investigation last June.
It is also my understanding that the VA waited until January to
launch that investigation. Why?
Dr. Clancy. The Inspector General actually delivered a
report to the facility last spring and essentially told them
not to share the report with anyone, so we did not have
awareness of that for a number of months later.
Senator Tester. Why would they do that?
Dr. Clancy. They subsequently published it on February 6,
and they did not find very much to act on. They had reviewed
the practices of some clinicians whose practices were reported
to be under concern. They simply did not come up with any hard
findings to act on at that point in time. But, we did not have
awareness of that until sometime in January.
I am told that sometimes they close reports when it is more
or less a negative report. I am just trying to explain the
timeline. Right now we have completed the first phase of an in-
depth clinical review with a second phase that has just
launched, and the Office of Accountability and Review is also
vigorously evaluating reports of retaliation and bullying by
this one physician, who also happens to be the chief of staff.
The clinicians in question are not seeing patients. They are on
administrative detail, and they are also not able to prescribe
any kind of medications for patients.
We are taking this very seriously. We are reinforcing our
effort systemwide to promote the safe and effective use of
opioids. You want pain management, but at the same time we know
that opioids come with a very big price tag in terms of side
effects. So, we are not waiting for all the investigations to
be done to be able to move forward on improvements we can make
right now at Tomah and elsewhere.
Senator Tester. Fifteen seconds. I have been on this
Committee since I got to the Senate. I believe in the people
who serve this country, just as Senator Sullivan talked about.
We have great service on the ground, but I am more concerned
today than I have ever been in the past about what is going on
in Montana's VA, and that is what I am most familiar with. We
have got to do better. I think everybody on this Committee is
here to help you do better, but something is wrong. I am
telling you because it is a good outfit; people should want to
go to work there.
Thank you.
Chairman Isakson. Following up, I want to thank Senator
Tester for bringing up the Tomah issue. For the record, so
everyone knows, the House Committee is going to Tomah, as I
understand it--is that not correct?
Dr. Clancy. Yes.
Chairman Isakson [continuing]. On a site visit, and we are
trying to coordinate with them to do as much outreach as we
can. Our second hearing after the hearing on the 40-Mile Rule
will be on Tomah and on the overprescription of opiates.
With regard to the IG, I have great respect for the IG. I
think the IG provides a tremendous benefit to the Committee.
But, that benefit is only utilized when we have the reports. I
had the same question the Senator raised with regard to why
those reports were not in the hands of the Committee as well. I
will be working with the IG to see to it we have more
transparency on those reports for the Members of the Committee.
We may have to embargo them for reasons that you mentioned, Dr.
Clancy. But I think it is important that the Committee know and
not get caught by surprise.
Secretary McDonald. Mr. Chairman, may I make a very brief
comment? Concerning the report that is going to come out today
that you asked about, Senator Tester, I have not gone through
the details of the report, but I also want to--my statement is
not--I want to make sure that you know that I am reaching out
to a member of that committee to try to find out what there is
to learn about it, and I am open to any ideas anybody has. So,
I just want to make sure that you understand we are open to
other people's ideas.
Chairman Isakson. Senator Rounds.
HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA
Senator Rounds. Thank you, Mr. Chairman.
I would share that we had a very good meeting yesterday
with the South Dakota delegation and I appreciated your time
and your efforts in visiting about the Black Hills facilities,
including the hospital at Hot Springs. First, I want to just
briefly touch on that issue and then I would like to delve into
a couple of other items.
First of all, would you be able to assure the Committee
that the items in the fiscal year 2016 budget request regarding
the Black Hills Health Care System are not an indication of a
pre-determined decision for the Hot Springs Hospital?
Secretary McDonald. Yes, sir, Senator Rounds. As we talked
yesterday, the money that was in there for Rapid City is what
we need to do at Rapid City. There is no indication of any
decision being made on Hot Springs. I have made no decision. We
are still collecting data and the study is still being done,
and that is why we met with you.
Senator Rounds. Thank you, sir.
Look, I have listened as each member around here has
invited you to come in, and I know that we have talked about
coming to South Dakota. You have got more things on your plate
than I can imagine, and yet there seems to be kind of an
underlying current here, and that is that you have stepped into
a position in which you have got a huge and very unwieldy
agency/administration. You have started with a reorganization,
and you have got MyVA, and I notice that you have got some
charts laid out for us in here.
When you take a look at the organizational chart that you
have inherited--I had one of your employees come up to me and
lay out what they had kind of charted out. They had 13 layers
that they had been able to count. You cannot run an
organization that has got that kind of a program. So, number 1,
it looks like, what both Senator Tester and Senator Sullivan
are talking about, the issues way down deep, they suggest that
it is culture. I kind of go a little bit deeper and think that
you can have real good people working in an organization, but
if the organizational system, the layout, the map for getting
approval and so forth and making changes does not work, you can
have good people that just get frustrated and pretty soon, they
do not want to be there. You have got folks on the ground,
doctors that do a great job with individual veterans coming in,
and yet the frustration that they have with trying to get
changes made that they think would make it better, they become
part of the issue that you are walking into.
Can you talk a little bit about the organizational
structure and what you would like to see done; what progress
you have been able to make with regard to the organization; and
how that may impact the ability for those folks that are at
ground level to be able to respond.
Secretary McDonald. Your insight is absolutely right. As I
went around to the roughly 100 facilities I have been at, the
number 1 feedback I get from the lowest-level employee is, ``I
am a prisoner of a system I cannot change.'' So, what we are
trying to do is change the culture. We are trying to empower
people to know that they can create change.
We have stood up teams across the country that have people
with similar interests in working on various issues. We are
teaching them Lean Six Sigma technology so that they can make
changes to the processes they work.
Second, I have met with all the union leaders and I have
said--65 percent of our employees are unionized--that it is
their job to help us empower these people, and they have all
been right on with that.
Third, one of the things we do not do well is we are not a
connected organization. We have vertical silos in our nine
lines of business, but we also have horizontal silos, if I can
say it that way. That is one of the reasons we had to go from
the nine geographic maps, as a first step, to one. That is a
big enabler. Now, we can take on other things that we could not
take on. All of these things have to be sequenced.
The next point would be that in addition to changing the
maps, it is important that we change the organizational
structure. Today, when I go to the human resources leader of VA
and say, I would like the names of our top 50 development
candidates, she cannot produce that because our functions are
not connected from top to bottom in the organization.
Senator Rounds. It does not work.
Secretary McDonald. Companies do not run this way. So, we
have got to build those connections in. We are in the process
of doing that.
I am as frustrated--we are as frustrated as all of you are
that it takes time to create these changes, because the changes
all have to be sequenced; and we have to make sure the
employees are involved in creating those changes, that it is
just not top-down, because we have got to get at the stick.
I am bringing in the very best people I know from the
private sector to help us. We brought a Chief Customer Service
Officer in. We have brought in a person to work on strategic
partnerships. I am setting up an external advisory board, and
you will recognize many of the names on that board. They are
people who have done this before in the private sector. It is
all going to accelerate our process and our progress.
Senator Rounds. Can you give me a timeline?
Secretary McDonald. I wish I could. We are going to make
substantial progress in the next year.
Senator Rounds. OK.
Secretary McDonald. I think in the next year, you are going
to be able to--I do not think there will be anyone who will not
see the progress. And, you certainly will not be seeing the
same structure we are in today.
Senator Rounds. Thank you.
Secretary McDonald. You are welcome.
Senator Rounds. Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Rounds, very much.
The record should note the patience of former Chairman
Sanders. I appreciate your patience, and it is now your time
for questions.
HON. BERNARD SANDERS, U.S. SENATOR FROM VERMONT
Senator Sanders. You are going to give me 15 minutes for
that, right?
Chairman Isakson. I am not that appreciative, no.
[Laughter.]
Senator Sanders. Thank you, Mr. Chairman. Let me also thank
the Secretary and his staff for being here.
A funny thing happened on Tuesday. The Chairman and I and
other Members of the Committee were there to hear testimony
from the DAV, who do an extraordinary job representing disabled
veterans. Well, it turns out that when I asked Commander Hope
of the DAV his views about VA health care, what he said is
that, by and large, the care was very, very good. In fact, he
thought, representing his membership, that it is probably
better than private care.
So, the first point I want to make is that you run 151
hospitals. I suspect in every single one of them, there are
problems today. I suspect on any given day, the media will put
those problems on the front pages. You run 750 CBOCs. You run
Vet Centers. You have 6.5 million people coming in a year. And,
if you had 90 percent satisfaction, you would have a hell of a
lot of people who would be dissatisfied. So, you run an
enormous operation.
But, I think it is fair to say, in my view, talking to the
service organizations, that, by and large, given the context of
health care in America, which has enormous problems, that the
VA does a pretty good job for those folks who get into the
system.
Let me go on the record as to suggest--this is no great
secret that we live in a political world--there are some very
conservative organizations who do not believe in government.
Some of them are funded by the Koch Brothers. They do not
believe in Social Security. They do not believe in Medicare.
They do not believe in the VA. They want to dismember the VA.
Let me go on record to tell you that I will fight any
effort to dismember the VA, because I think when you talk to
the veterans of Vermont or the service organizations all over
this country, as I do often, they say, you know what, there are
problems--and I share the concerns that all Members here have
raised, as we want to make it a better system--but, by and
large, you have got a pretty good, cost-effective system.
Number 2, in the bill that Senator Isakson and I and others
worked very hard on, we put $5 billion into, in fact,
strengthening the VA. Now, what I am hearing from you and from
other members, you are having a hard time recruiting
physicians, and you know why? Because in this country--forget
the VA--we have a huge crisis in primary health care
physicians. I was told--Jon Tester told me something I never
knew. He explained that in Montana, and I suspect in other
rural States, in some hospitals they do not have any doctors? I
had never heard that in my life. In Kansas, you have that
problem, I believe, Senator Moran, right? It's unbelievable.
Now, one of the things that I insisted be in that bill is
debt forgiveness to make it possible to recruit doctors. Tell
me what you are doing, and the difficulties that you are
facing--and it is not just you, it is the Nation--and if you
think it is bad today, it is going to be a lot worse 15 years
from now. So, what are we doing to get young people out of
medical school into the VA and into primary care, for example?
Secretary McDonald. You are absolutely right. The debt
forgiveness provision in the Choice Act is a huge enabler, and
the debt provision in the Clay Hunt Act is a huge enabler. What
we have done is we have made sure that our recruiting team is
going out and talking about that. I can tell you from the
roughly 12 medical schools I have been to--you and I were
together in Vermont--that this is making all the difference in
the world. It is a huge enabler. The average medical school
student, my understanding, graduates with about $150,000 to
$180,000 in debt. The Committee and the Congress doubled the
former VA debt forgiveness, so it is making a huge difference.
It is one of the reasons November was our peak recruiting
month. So, we are getting better and better as we get the word
out.
Senator Sanders. But, my point is, this is not just a
crisis for the VA. This is a crisis for the United States of
America. All right.
Issue number 3. In the last 2 years, I think the major
concern is that many veterans were on horrendously long waiting
periods, all right. In fact, that precipitated a major crisis
within the VA. How are we doing in shortening, if we are, the
waiting periods? We do not want veterans to be waiting in lines
for months. Are you making any progress on that?
Secretary McDonald. Wait times are down about 18 percent
nationally, and on average, are roughly 30 days. But, of
course, that is an average, and we have wide variation, as you
can imagine, by location and by specialty. Anything you want to
add?
Dr. Clancy. I think one big, big point that has changed,
Senator Sanders, is that we are literally looking at data
almost on a daily basis to identify, as one of your colleagues
pointed out earlier, where there are very specific problems;
what we can do about that. One of the big assets we actually
have is a very large footprint in telehealth. So, when Denver
had huge problems in mental health waiting times, Salt Lake
City could step in and help them bring those wait times down.
Senator Sanders. What about Phoenix?
Dr. Clancy. Phoenix is improving. In fact, we were hoping
to make a visit with the Chairman and Senator McCain literally
tomorrow, but we are going to have to postpone that because of
other Senate business here, but look forward to doing that. We
have a very good Acting Director in there. We are recruiting
hard for a permanent----
Senator Sanders. But, we are making some progress----
Dr. Clancy. Absolutely.
Senator Sanders [continuing]. In some of the worst areas of
the country. You are focusing on those----
Dr. Clancy. Yes.
Senator Sanders [continuing]. Where the waiting times were
the longest.
Next, let me concur with Senator Murray about the
caregivers program. I think Congress several years ago
developed that program for post-9/11 veterans. I think
sometimes, Mr. Chairman, we forget that there are people out
there, often wives, sisters, others, family members, who have
devoted a large part of their lives to taking care of disabled
veterans. So, we made progress. I would hope that we expand
that program and I hope you, Mr. Secretary, will work with us.
Another area where I think we need a lot of work, we have
in this country not only a primary health care crisis, we have
a dental crisis. It is a huge issue. Right now, you do dental
work for service-connected veterans, and I, when I was
Chairman, went around the country and talked to a lot of folks.
There is a need, I think, to expand that program. Would you
comment on that, Dr. Clancy or Mr. Secretary?
Dr. Clancy. You are right that we only provide dental
services to a very small proportion of the veterans that we
serve. We are looking at partnerships. We also have a low-cost
dental insurance product that we have made available. But, we
facilitate veterans getting access to this--it is a kind of
partnership--and would be looking to expand in any way that we
could work with you on.
Senator Sanders. OK. The last point that I would make, we
have talked in this Committee a lot about opiates and the side
effects that opiates have. The VA, I think, has been--along
with the DOD, actually--leaders in this country in terms of
moving to complementary and alternative medicine. Dr. Clancy,
can you give me a report on that very briefly? Are we expanding
the program? If people want to come in and get acupuncture,
meditation, yoga, are they able to do that increasingly?
Dr. Clancy. Yes. First of all, we are expanding that,
period. Second, as part of the issue of pain management and
adaptation, oftentimes for a number of veterans, those
modalities are very helpful augmentations and help some
veterans actually transition to lower doses or actually off
opioids altogether. It does not happen instantaneously. But, I
can tell you that we are now looking at the practices of
individual clinicians and teams so we know where we can provide
the most assistance, who is having the most challenges. We have
got some virtual training that has demonstrated some phenomenal
results in Ohio and we are planning to spread that out
elsewhere.
Senator Sanders. All right. Thank you very much, Mr.
Chairman.
Chairman Isakson. Thank you, Senator Sanders.
Senator Hirono.
HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII
Senator Hirono. Thank you, Mr. Chairman, and Mr. Secretary,
it is good to see you again.
I have a couple of questions relating to the Choice Card
Program. I realize that there are some communication issues
regarding that card with the veterans who receive them not
quite understanding what it means, so I expect that you are
addressing those kinds of issues.
I did have one matter that was brought to me regarding the
veterans who use the Choice Card when they go to see an outside
doctor for a brace or a durable medical device, there is a
catch-22 there, because the VA has not updated their policy and
only issues items like a knee brace to veterans who have an
order from a VA doctor. So, even if they get to an outside
doctor who prescribes such items, they cannot get them. So, are
you making the necessary changes so that the veterans can get
the prosthetics and other devices that they need?
Secretary McDonald. I was unaware of that problem, so I
would like to--we would like to follow up with you and get into
that----
Senator Hirono. Thank you.
Secretary McDonald [continuing]. And make sure we address
it.
Senator Hirono. I realize that the VA is the second-largest
department in the entire Federal Government and so there are
huge complexities involved in the challenges that you are
facing, so I want to add my support to what you are doing to
change your culture, to change your organizational structure. I
realize it cannot be easy with the thousands and thousands of
employees that you have, so I commend you, all of you, for the
efforts that you are undertaking.
When I met with you, Mr. Secretary, you said that
eliminating veterans' homelessness is a top priority and that
you expect to eliminate homelessness among veterans by the end
of this year. You are working in particular with 25 identified
cities where there is a high veteran homeless population,
Honolulu being one of them. Can you describe particularly how
you are doing it, including--by the way, I think you mentioned
the HUD-VASH voucher program, but the new budget that was
submitted, I think, does not set aside vouchers specifically to
address veterans' housing. So, that may have a negative impact
on your ability to get the veterans into housing in these
cities.
So, could you just describe for me what you are doing. For
example, in Honolulu, you are working with the mayor of the
city and county. What is your expectation of what he is
supposed to be doing?
Secretary McDonald. The most important thing from our side
is our medical center directors need to know those mayors and
partner with those mayors. They cannot wait for me or for
Carolyn to go out there to do it. So, we have asked every one
of our medical center directors to make sure they are
partnering with those mayors and working with the mayors to
make the commitment to end homelessness by the end of this
year.
Then, we are bringing the tools to bear. You have mentioned
a couple of them. The HUD-VASH vouchers is one tool. Another
tool is a wonderful program called SSVF, which is about
supporting families. We had--we need some work by Congress to--
we had about half-a-billion dollars in the budget for the SSVF
program. Only $300 million of it was authorized. We need the
other $200 million to be able to complete the program. So, we
will be working with you on that. But, that is a wonderful
program. It allows us to work with a local partner in order to
get the families into housing, and it is the local partners
that become very important.
So, those are the steps we are taking. I have not been to
Honolulu yet in this capacity, although I have been there many
times before, and always enjoyed it----
Senator Hirono. I extend the invitation.
Secretary McDonald [continuing]. But, I would--the issue
that we are seeing is, for example, I was with the Mayor of New
Orleans the other day. We were holding a conference here and we
were teaching mayors how to get this done and we acknowledge
one of the things that is a problem is if you have a good
climate, chances are good when you house the homeless veteran,
you are going to have more homeless veterans because they are
going to good climates. As a result of that, I worry a little
bit about Honolulu----
Senator Hirono. Yes.
Secretary McDonald [continuing]. Places like Honolulu, New
Orleans, Los Angeles, San Diego. So, I would like to get
together with you and talk more about this.
Senator Hirono. I believe that Hawaii has the highest per
capita number of homeless, not just veterans----
Secretary McDonald. Not just veterans----
Senator Hirono. Yes. That is an issue.
You mentioned, regarding homelessness, that it is a whole
community approach. So, do you have some kind of a media
program that you are running that says to a community like
Honolulu that we are all coming together to eliminate
homelessness in our communities?
Secretary McDonald. Yes. In fact, we have a road map, a
plan, that we work with each mayor and community on. That was
what I was doing in Los Angeles. We had a press conference. I
did a ``Meet the Press'' segment on that and the work that we
did. So, yes, that is part of the plan, and we can sit down
with the mayors that you want us to and go through that plan.
Senator Hirono. I am wondering if there is a PSA or
something that can be shown in all of these cities. Do you have
such a thing?
Secretary McDonald. Yes. That is a great idea.
Dr. Clancy. I guess that I would just build on the
Secretary's leadership in striking a deal with partners in Los
Angeles, because we are planning to use that as a model that we
can then export lessons learned. So, we need people at our
facilities working very hard to meet the veterans' health care
needs and so forth and reaching out to make sure that they get
the right kinds of supportive services. But, we also very, very
much need community partners. So, we have got a terrific
individual leading this effort in Los Angeles with the idea
that he will then bring those lessons learned rapidly to the
other cities facing the greatest challenges, because the
Secretary has made it very, very clear there is no way that we
accomplish our stated goal in 2015 of getting close to
functional zero without a renewed effort, stepping on the gas,
if you will.
Senator Hirono. Thank you.
Ms. Hickey. And, Senator, if I might add, it is not just
the health. It is an all of VA response, because I have two
rather significant pieces that would contribute to the homeless
mission. One is the very biggest program on prevention that
exists out there, which is related to our Home Loan Guarantee
Program. In the last 4 years, we have kept 400,000 veterans and
servicemembers from foreclosure. So, we have kept them in their
homes by interjecting up front, as soon as we see--because we
are in a paperless environment, we can see the data, see you
have missed your mortgage payment, hear from a VSO or from you
directly that you are in trouble--we immediately throw our
great loan guarantee folks at that problem and see what we can
do to renegotiate the loan, keep you in your home. That is the
ambition of that.
Senator Hirono. Thank you.
Ms. Hickey. The second thing is, in our claims process and
in our appeals process, we have provisions for expediting
homeless veteran's both claims and appeals. We do that rather
regularly and that is another way we try to get additional
resources into their hands by the nature of what we can do on
the claims side or on the benefits side.
Senator Hirono. Thank you.
Secretary McDonald. May I add one more, Mr. Chairman,
Senator Hirono, because I am really glad you are on this topic:
Veterans Courts. A ticket to a homeless person means
incarceration; so what we are working to do is set up Veterans
Courts all over the country so that we avoid incarceration. We
know that if we avoid incarceration, we avoid homelessness. So,
this becomes another breakthrough for us to stop veterans'
homelessness.
Senator Hirono. Thank you very much. Keep up the good work.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Hirono. On that point,
that is another place where we have far more vacancies than we
need right now, because the importance of coordinating with a
Veterans Court for that veteran is critical and that
communication needs to be seamless and timely between the VA
and the judge in charge of that court.
As you can evidence by both the attendance and the
longevity of the questioning and the quality of the
questioning, there is no agency of the government that has more
challenges to meet than the VA. I think I speak for the entire
Committee, although only one Member is left here with me right
now, and that is to say we have your back. You have our
support. But, it is neither timeless nor unlimited. Now that we
have isolated the problems before us on Choice, on facilities,
on flexibility in funding, all the things you have talked
about, it is time for us to put our shoulder to the grindstone
and get the job done. We will not let the detractors tear us
down nor let the protractors protract it out, but instead work
together to improve the VA and make the VA better than it has
ever been before.
With that said, we will go to our second panel. This
hearing is not adjourned, but we will have an intermission.
Secretary McDonald. Thank you, Mr. Chairman.
Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
U.S. Department of Veterans Affairs
Question 1. In response to pre-hearing questions regarding the
analysis performed to determine whether the 5,006 new full-time
equivalent (FTE) employees under the Medical Support and Compliance
account are needed as opposed to whether the duties could be performed
as ancillary duties of existing employees, the Department of Veterans
Affairs (VA) stated:
The Medical Support and Compliance FTE growth is not associated
with the Secretary's MyVA initiative.
The additional positions are being added to the Medical Centers
and [Veterans Integrated Service Networks (VISNs)] to support
and fulfill the Secretary's vision of becoming a more Veteran-
centric organization and to be able to provide top-level
customer service in a more efficient manner to our Veterans.
These personnel will support healthcare workers in order to
deliver the healthcare services that our Veterans expect.
(Emphasis added.)
On December 18, 2014, VA briefed staff on the MyVA initiative.
According to slides handed out at that briefing, MyVA is about:
[E]mpowering employees and helping them deliver excellent
customer service to improve the Veteran experience * * * [and]
rethinking our internal structures and processes to become more
Veteran-centric and productive.
(Emphasis added.)
a. Please describe the analysis performed to determine whether the
5,006 new FTE under the Medical Support and Compliance account are
needed as opposed to whether the duties could be performed as ancillary
duties of existing employees.
Response. The Medical Support and Compliance (MSC) full-time
equivalent (FTE) growth is not directly associated with the Secretary's
MyVA initiative.
VA medical centers and Veteran Integrated Service Networks (VISN)
are adding additional MSC positions to support and fulfill the
Secretary's vision of becoming a more Veteran-centric organization and
to provide top-level customer service in a more efficient manner to our
Veterans. As a result, some of the following positions will be
increased: personnel management specialist, police, contract
administrator, voucher examiner, claims assistant, emergency management
series, medical records clerk/technician, health systems specialist,
administrative officer, and security clerical and assistants . These
positions directly support the Department of Veterans Affairs' (VA)
objective to manage and improve VA operations to deliver seamless and
integrated support. The additional personnel will support the delivery
of health care services that our Veterans expect. Though not originated
as part of MyVA, the FTE growth will improve the service VA provides to
Veterans, and will therefore support MyVA efforts.
Although the FY 2016 Revised Request estimate of 54,020 FTE is
5,006 more than the original FY 2016 Advance Appropriation estimate, it
is only 1,206 more than the FY 2015 Current Estimate. As displayed in
the table below, VA anticipates growth in FY 2015 Medical Support and
Compliance FTE. The FY 2015 Current Estimate of 52,814 FTE is 3,800
more than the FY 2015 Budget Estimate and 2,491 more than the FY 2014
Actual FTE. The FY 2015 Current Estimate is largely based on FTE
Operating Plans submitted by the VISNs, and reflects a concerted effort
to provide more support staff to VA clinical staff in order to enhance
Veterans' access to health care. The FY 2016 Revised Request increase
of 1,206 FTE above the FY 2015 Current Estimate is a 2.3 percent
increase, which is in line with VA's estimated increase in health care
demand.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
b. Please describe, in detail, the difference between the MyVA
initiative as it was defined to staff on December 18, 2014, and the
duties to be performed by the 5,006 new FTE in Medical Support and
Compliance.
Response. The requested Medical Support and Compliance (MSC)
resources would focus exclusively on medical centers and VISNs. Though
not originated as part of MyVA, the FTE growth will improve the medical
support VA provides to Veterans, and will therefore complement MyVA's
broader, enterprise-wide efforts.
``MyVA'' is our enterprise-wide transformation from VA's current
way of doing business to one that puts the Veterans in control of how,
when, and where they wish to be served. It will modernize VA's culture,
processes, and capabilities to put the needs, expectations, and
interests of Veterans and their families first. MyVA represents an
opportunity to affect fundamental changes in VA's systems and
structures to align with our mission and values. The MyVA vision is to
provide a seamless, unified Veteran Experience across the entire
organization and throughout the country.
Our plan has three integrated elements, or horizons. First, we plan
to leverage those existing programs and initiatives that are delivering
better services and benefits to Veterans. There is already a great deal
of positive transformation taking place in VA and those efforts must be
exploited and leveraged.
While these efforts provide a solid base to build from, the
improvements are not sufficient. Thus, the second horizon of the
transformation concentrates on a relatively small set of catalytic
efforts focused on five initial priorities. They will accelerate the
transformation now underway: expect to see significant and demonstrable
progress in these targeted areas between now and the end of 2016. These
initial priorities include:
Improving the Veterans experience. At a bare minimum, every
contact between Veterans and VA should be predictable, consistent, and
easy. But we're aiming to make each touch point exceptional.
Improving the employee experience. VA employees are the face
of VA. They provide care, information, and access to earned benefits.
They serve with distinction daily.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
While improving the Veteran and employee experiences are central to
our efforts, three complementary efforts will help build more robust
management systems, enhance productivity, and deliver more effective
results.
Achieving support services excellence will let employees
and leaders focus on assisting Veterans, rather than worrying about
``back office'' issues.
Establishing a culture of continuous performance
improvement will apply lean strategies to help employees examine their
processes in new ways and build a culture of continuous improvement.
Enhancing strategic partnerships will allow us to extend
the reach of services available for Veterans and their families.
The third horizon is optimizing and scaling successful initiatives
from the previous horizons, and growing small wins into big ones. This
horizon will extend into and beyond 2017.
Since the December 18th briefing that is referenced in the
question, the MyVA staff has discussed this transformational effort
several times with members and congressional staff. Specific meetings
include:
1/26/15--HVAC/SVAC/HAC/SAC Staff (teleconference)
1/26/15--VA 101 Brief to House Hill Staffers
2/6/15--SVAC MLA's
2/19/15--VA 101 Brief to Senate Hill Staffers
4/17/15--HVAC & SVAC Staff Update
4/28/15--Rep. Amodei (R-NV) Member-level brief
5/8/15--Sen. Crapo (R-ID) Staff-level brief
7/17/15--SVAC/HVAC Staff Update
On July 30, 2015, VA released the MyVA Integrated Plan that
describes the MyVA effort in more detail. It can be accessed at: http:/
/www.va.gov/opa/myva/docs/myva--integrated--plan.pdf
Question 2. In the fiscal year 2016 budget, VA indicates that it
is leveraging eBusiness initiatives to create ``efficiencies in the
billing and collections process'' for the Medical Care Collections Fund
(MCCF). These initiatives include: ``Medicare-equivalent Remittance
Advices; insurance verification; inpatient/outpatient/pharmacy billing;
and payments, including Electronic Funds Transfer.''
a. Please describe in detail each initiative and how each has
improved MCCF's billing and collections process.
b. What metrics does VA use to determine the performance of each
initiative in increasing collections of MCCF?
Response. Fiscal Year 2016 eBusiness Initiatives for the Medical
Care Collections Fund (MCCF). The MCCF Electronic Data Interchange
(EDI) Development builds the transaction platform infrastructure to
bill third party payers for non-service-connected care provided to
veterans. The development initiatives address changes in transaction
processing standards in the insurance and banking industry, those that
are mandated in published regulations as well as those defined by
Designated Standards Maintenance Organizations. The internal VA
transaction structure must conform to current transaction standards to
be able to securely communicate electronically with the commercial
healthcare industry in order to collect revenue. In addition to
mirroring the technology of the commercial healthcare industry, VA must
also update internal functionality to reflect new and emerging needs as
a result of years of iterative changes such as tracking system problems
and transaction irregularities, as well as, updating reporting
structures within VistA to support internal VHA organizational changes.
Specifically, now that VA has moved to a consolidated revenue structure
for billing and collections, the configuration of reporting within the
VistA system must be modified to provide new and varied configurations
for EDI system status and data analysis.
Medicare-equivalent Remittance Advices (eMRA). While the eMRA
initiative is an integral part of the MCCF EDI transaction platform,
there is no development needed or planned for FY 2016. VHA transmits
over 4.5 million eMRA requests to Medicare which is essential for
billing Medicare secondary payers. eMRA is a mature and stable part of
the VistA transaction platform with no development funding needs
anticipated at this time.
Insurance Verification. The electronic Insurance Verification (eIV)
module in VistA provides verification of patient health insurance and
Medicare eligibility, providing the essential data elements to process
a claim. VHA transmitted over 9.5 million electronic eligibility
transitions (HIPAA X12 270) in the last fiscal year (FY 2014). Medicare
eligibility was added and increased growth 31% since FY 2010. Real-time
electronic verification occurs in seconds (electronic inquiry,
response, and auto-update the information in the patient insurance
file). Volume metrics will continue to be collected through the testing
phase in FY 2016, into FY 2017 for national deployment, and continue
until the insurance identification/verification processes reach a
plateau in the MCCF EDI transaction platform.
A savings of over $6 million over the next decade will be
realized by the Medicare Direct Connection (between VA and CMS), which
eliminated the need to pay clearinghouses to process the Medicare
eligibility inquiry for MCCF.
Monthly cost savings are tracked and will be tracked
through FY 2016 and beyond. Since the first direct transmission in
August 2014, a total of 2,094,184 Medicare inquiries were processed,
saving $229,588 in transaction fees.
Future savings of over $7 million a year will be realized
when the current ``commercial off-the-shelf'' (COTS) insurance intake
and verification product is replaced with VA owned, GUI software, which
is currently in development. The testing phase for this project is
expected to begin in FY 2016, with savings to be realized after full
deployment. Insurance card images stored on a data storage platform
(SSOi) connecting all VA medical centers (VAMCs) and Community Based
Outpatient Clinics (CBOCs) (approximate 6,000 users) is in current
development--costs in supplies, manpower and time has not yet been
realized.
Inpatient/Outpatient Medical Billing. The electronic submission of
standard electronic Institutional and Professional inpatient and
outpatient claims to third-party payers increases the speed of the
billing and adjudication of claims, resulting in faster collections and
fewer rejections. Automation of billing processes enables accurate
billing to plans paying secondary to Medicare and other third party
payers who are considered primary payers. The eBilling initiative is
focused on industry compliance, and not efficiencies. Over 15 million
electronic billing transactions occur annually (including over 4.5
million eMedicare Remittance Advice requests to Medicare). With
electronic billing, communication methods are used to interact with
over 1,600 payers in a standard language, making messaging about health
care efficient and determination of payment fast and accurate. FY 2016
includes updates to Health Care Services Review (HCSR) transactions
(ASC X12 278) based upon industry-mandated biennial review and to
ensure VHA systems implement a streamlined work flow between
transactions and Utilization Review (UR) staff. A performance metric
for the 278 transaction will target a processing metric to third-party
payers of less than 5% rejects requiring manually submitted reviews for
all transactions processed. Updates to Health Care Claims Attachments
transactions are planned in FY 2016, based upon industry-mandated
biennial review and/or gaps identified in the implementation of
attachment transactions across payers. These updates will include the
ability for the end user to see the attachment that is associated with
the claim and payment, thus eliminating the mailing of a paper copy of
the required documentation. Claims Attachments is targeted to process
to third-party payers with less than 5% of those transmitted returning
with additional requests for manually submitted attachments.
Pharmacy Billing. Electronic pharmacy (ePharmacy) billing is the
automated submission of real-time electronic VA Outpatient Pharmacy
claims to third-party payers/Pharmacy Benefit Managers (PBM). All of
the work in support of pharmacy transactions is industry standard
compliance. Quarterly updates from the National Council for
Prescription Drug Programs (NCPDP) are planned through FY 2016 to
maintain electronic connectivity to PBMs which do not accept paper
claims. An 18-second response time has been achieved for these real-
time transactions. VHA submits over 11.7 million ePharmacy transactions
annually from 265 VHA pharmacies. Four million prescription fills and
claims are processed annually, without manual intervention. Drug
profile information, contained in the adjudication received from the
PBM, includes drugs prescribed and obtained outside of VA and paid for
by the PBM, increasing patient safety. Days to Bill for NCPDP
transactions in this fiscal year-to-date is 11.9 days, and will
continue to be tracked through FY 2016 to assure there is no
degradation in processing times. (Historically, the Days to Bill paper
claims average was 148.7 days.)
Payments. The electronic payments (ePayments) process is comprised
of the receipt of HIPAA-mandated Electronic Remittance Advice (ERA) and
Electronic Funds Transfer (EFT) transactions. Over $1.6 billion is
received annually through EFTs from over 150 third-party payers and
over $2 billion in ERA transactions is posted annually through
electronic accounts receivable processing. Payments processing by EFT
has already been developed and deployed for VA prior to the January 1,
2014 Patient Protection and Affordable Care Act of 2010 (ACA)
compliance deadline, which mandated use of the EFT across the industry.
Over 70% of all payments are currently received via EFT versus a paper
check. Having 70% of all revenue processed through EFT by FY 2017 is a
Revenue Collections Management objective set by the Commissioner of the
Department of the Treasury's Bureau of the Fiscal Service. VA's FY 2015
EFT measurement already exceeds U.S. Treasury's EFT throughput goal.
This metric will continue to be monitored through FY 2016 and beyond.
Auto-posting and auto-decreasing of third-party claim payments creates
an efficiency with minimal manual intervention in the payment posting
process, thus increasing accuracy and speeding the close of health care
claims receivables. Metrics will be developed to track the percentage
of auto-posting and exceptions.
Question 3. VA has started to integrate mental health into primary
care through its Primary Care Mental Health Integration (PCMHI)
initiative. According to the budget justification, the Veterans Health
Administration (VHA) has increased the penetration rate of PCMHI to 15
percent overall.
a. Please describe in detail the implementation plan, including key
milestones and estimated completion dates for each milestone.
Response. VA began formal implementation of Primary Care-Mental
Health Integration (PCMHI) by providing initial funding during fiscal
year (FY) 2007 to 92 facilities that expressed interest. Since FY 2009,
all VA medical centers and large and very large community-based
outpatient clinics (CBOC) have been required, under the Uniform Mental
Health Services Handbook, to have fully operational programs.
Substantial growth and development of PCMHI has continued throughout,
as evidenced by the following milestones and goals:
From FY 2007 to the present, PCMHI has been supported by
ongoing educational seminars and events and facility-based consultation
by national subject matter experts, with the more recent addition of
intensive, evidence-based facilitation through the Office of Mental
Health Operations.
In FY 2010, additional enhancement funding was provided to
facilities with identified need.
Access to mental health services occurs through various
pathways including PCMHI encounters. As of the third quarter of FY
2015, 23.4 percent of all Veterans enrolled in VA primary care had
mental health encounters including both specialty mental health and
PCMHI use.
As of the first quarter of FY 2015, 92.1 percent of sites
required to have PCMHI embedded in Patient Aligned Care Teams (PACT)
have established programs. This is an increase from 87.9 percent during
the first quarter of FY 2014.
The extent of PCMHI practice has grown steadily, from
183,048 encounters and a penetration rate (percentage of PACT patients
who have a mental health encounter within the primary care clinic) of
2.2 percent during FY 2008, to 991,773 encounters and a penetration
rate of 6.8 percent during FY 2014. In the first 4 months of FY 2015,
156,622 Veterans seen in primary care had at least one visit with an
integrated mental health clinician, compared to 342,081 during all of
FY 2014.
The overall PCMHI penetration rate increased by 15 percent
overall from FY 2013 to FY 2014 (from 5.9 percent to 6.8 percent). This
reflects the percentage of the primary care population receiving mental
health services as part of routine primary care. Many facilities have
penetration rates in the 10-12 percent range, and as continued
maturation of inter-professional care within PACT occurs we expect
penetration rates to continue to increase
An ongoing goal of the PCMHI program is to ensure that
services are available on a same-day basis to a primary care
appointment, when a new Veteran's needs are identified. To date, in FY
2015, 34 percent of Veterans new to PCMHI services were seen on the
same day, compared to 29.9 percent at this time in FY 2014 [note: this
is a cumulative rolling average].
An additional goal is ongoing enhancement of our
electronic platforms to support longitudinal follow-up and telephone
care management. To that end, the Behavioral Health Laboratory (BHL)
software that supports these functions has been installed at 98 VA
facilities (approximately 75 percent of currently eligible sites) as of
March 2015. Training and field support for its use are ongoing, and
software enhancements are in development for FY 2016 to promote
flexibility of use for both care management and for measurement-based
mental health care more broadly.
b. Please describe the oversight conducted to ensure the mental
health providers assigned to a Patient Aligned Care Team are provided
office or treatment space within the primary care setting.
Response. One requirement of PCMHI programs is the co-location of
mental health clinicians within the primary care setting. Given current
space constraints in many facilities, not all are yet co-located.
Questions related to co-location of providers are addressed in the
Office of Mental Health Operations site visit process. Additionally,
the PACT space design process now specifies identified space for co-
located mental health providers within primary care in all new and
renovated space configurations. Finally, continued development and
maturation of both care management platforms and telehealth
technologies will advance the extent and quality of care in a manner
that is less dependent on fixed infrastructure.
Question 4. Hepatitis C is more prevalent in VA's population than
in the general population. In 2013, VA estimated there were 174,000
veterans with Hepatitis C or about three percent of VA's unique patient
population. In recent years, new pharmaceuticals have been approved
that will cure Hepatitis C within a few weeks and without the
devastating side effects of previous medications. According to the
budget justification, VA has developed a model to determine the funding
needed for these new Hepatitis C drugs.
a. Please describe in detail the model developed and the
assumptions within the fiscal year 2016 and fiscal year 2017 budget
requests.
Response. The Department of Veterans Affairs (VA) developed an
actuarial model (Hepatitis C Model) that projects the number of
enrolled Veterans infected with the Hepatitis C virus (HCV), the number
of treatments for this population, and the costs associated with HCV
drug treatments. This model includes data on estimated HCV prevalence
rates in VA, demographics, genotype, advanced liver disease status,
course of treatment, estimated number of treatments per week, treatment
duration, average treatment cost per week by duration, assumed relative
mortalities, probabilities for Sustained Virological Response (SVR),
number of retreatments, and reinfection rates. Shifting prevalence of
HCV in the VA population was also modeled in a manner consistent with
enrollment projections from the VA Enrollee Health Care Projection
Model (EHCPM). Recent trends were used to project behaviors regarding
HCV infection rates and screening increases.
To estimate the additional drug acquisition costs associated with
providing HCV drug treatments from FY 2014 to FY 2017, the average cost
per treatment was applied to the total number of treatments expected to
be performed each fiscal year. The assumed cost for each course of
treatment was provided by VA's Pharmacy Benefit Manager (PBM) in
July 2014. The costs per treatment were assumed to stay constant over
time. New treatments that became available starting in FY 2015 were
assumed to be cost-neutral with regards to known treatments at the time
the cost assumptions were developed.
The projection model includes prescription drugs that are currently
available.
The primary treatment regimens that are currently being
prescribed include:
sofosbuvir/ledipasvir \ ribavirin 12-week;
ombitasvir/paritaprevir/ritonavir/dasabuvir \ ribavirin 12-
week;
sofosbuvir/ledipasvir 8-week;
sofosbuvir/ledipasvir 24-week; and sofosbuvir/ribavirin 24-
week.
The treatment regimens that became available in
October 2014 include:
sofosbuvir/ledipasvir 8-week;
sofosbuvir/ledipasvir 12-week; and
sofosbuvir/ledipasvir 24-week.
The treatment regimens that became available in
December 2014 include:
ombitasvir/paritaprevir/ritonavir/dasabuvir \ ribavirin 12-
week and 24-week.
Future regimens include Daclatasvir and Sofosbuvir 12-week
and 24-week.
The initial treatment projections from FY 2015 through 2023 were
developed to target approximately 13,000 treatment evaluations
annually, based on treatment starts in FY 2014. The estimated capacity
within VA to treat HCV patients at the time of approval of new
treatment regimens by the Food and Drug Administration was based on the
number of treatment starts in FY 2014, which was low due to long and
arduous treatment regimens available at the time. This estimated
capacity was considered as a constraint on the model when projecting
the 13,000 treatment evaluations. The variation in projected treatments
and costs between different Veteran Integrated Service Networks (VISN)
was related to the underlying patient demographics within each VISN,
differences in HCV provider treatment capacity, improved infrastructure
leading to differences in the numbers of Veterans started on treatment,
and differing approaches within VISNs to prioritization of patients at
different disease. Of note, a VA-wide prioritization plan based on
disease stage was implemented in May 2015 after FY 2015 funds to treat
HCV were exhausted in nearly all facilities.
Hepatitis C Model Projection Methodology and Assumptions
The Hepatitis C Model projects the HCV infection status of
enrollees year-over-year in a manner consistent with clinical
assumptions and enrollment estimates in each year. The model projects
the following Hepatitis C statuses for enrollees in each projection
year:
Uninfected--Veteran enrollees who have not contracted HCV
Undiagnosed Infected--Enrolled veterans with HCV who have
not yet been diagnosed as HCV positive
Diagnosed Infected--Enrollees infected with HCV who have
been diagnosed and are candidates for treatment
Infected Non-Candidates--Enrollees infected and diagnosed
with HCV but, through VHA evaluation, have been deemed not suitable for
treatment or have declined treatment
SVR--Enrollees who have effectively been ``cured'' through
treatment
In each year of the projections, treatments occur only within the
Diagnosed Infected population and are isolated to those enrollees who
are considered treatment candidates. It is assumed that approximately
30% of all enrollees are not considered candidates for treatment for a
variety of reasons, including clinical reasons and by individual
choice. If a patient receives treatment in a given year and fails to
attain SVR, the patient remains eligible for treatment in a future
year. However, if after two years of attempted treatment the patient
still fails to attain SVR, the patient is no longer a candidate for
treatment in the third year. It is possible that an HCV patient may
transition into the Diagnosed Infected population and receive treatment
in the same year.
In order to determine when a transition for treatment occurs, along
with other assumptions, a stochastic model is used to assign patient
statuses based on a probability distribution. Transitions and
treatments for each individual are determined by choosing a random
``seed'' number that dictates which of the available outcomes is
assumed to occur. Although this methodology is built upon a random
process, the large size of the modeled population ensures that the
proportion of individuals transitioning to each particular status will
approximately equal the assumed probability of that event occurring.
The model is also run 30 times and average results are used in order to
reduce the variability in results due to random fluctuation.
b. What are the long-term savings to VA in curing Hepatitis C?
Response. The Veterans Health Administration (VHA) is assessing the
short- and long-term impact on overall health costs associated with
treatment of Veterans' Hepatitis C. To assess these costs, VHA
evaluated 14,206 Veterans who received therapy beginning in FY 2005
with at least 5 years of time after finishing treatment. At 5 years
post-treatment, patients with SVR (vs. no SVR) had an average adjusted
mean cost savings of $5,200 per patient overall, $15,705 in cirrhotics,
and $3,501 in non-cirrhotics. The unadjusted mean cost savings was
$17,962 per patient overall, $22,857 in cirrhotics, and $14,204 in non-
cirrhotics using a 5-year follow up period, means VHA is not currently
able to assess the impact of newer Hepatitis C medications on long-term
savings. In the general population, the best available study shows an
adjusted cost savings of $2,648 per year in a similar large sample of
managed care patients with SVR vs. no SVR (Manos MM et al. Journal of
Managed Care Pharmacy, July/Aug 2013).
Question 5. In part, the President's Executive Order (E.O.) 13625,
``Improving Access to Mental Health Services for Veterans,
Servicemembers, and Military Families,'' directed VA to work closely
with the Department of Defense (DOD) and the Department of Health and
Human Services (HHS) to improve research on suicide prevention. To
carry out this E.O., VA, DOD, and HHS have partnered to implement the
Cross Agency Priority Goal (CAP Goal) and the 19 new Executive Actions
announced in August 2014 to ``improv[e] access and reduc[e] barriers to
mental health care.'' Please describe in detail how VA intends to
implement the CAP Goal and the 19 new Executive Actions.
Response. The Departments of Veterans Affairs (VA), Defense (DOD)
and Health and Human Services (HHS) have been working closely together
to enhance mental health services to Veterans, servicemembers and
military families. Accomplishments resulting from the President's 2012
Executive Order (#13625) are highlighted below:
Implemented a joint DOD/VA national suicide prevention
campaign and increased Veterans Crisis Line staffing by 50 percent.
Established the National Research Action Plan and invested
$107 million into two joint research consortia on Post Traumatic Stress
Disorder (PTSD) and the Chronic Effects of Neurotrauma.
Completed VA pilot partnerships with 24 community-based
mental health and substance abuse disorder treatment providers.
Expanded outreach campaigns to raise awareness and reduce
the stigma associated with seeking mental healthcare.
Launched training in military culture competence for VA,
DOD, and community healthcare professionals.
Established the Interagency Task Force to coordinate and
oversee interagency mental health activities, resulting in annual
interagency recommendations for improvement.
Added 1,669 mental health clinical providers and 973 peer
support staff in VA.
Established policies and implemented a process for
connecting Veterans in crisis to a mental health worker within 24
hours.
Interagency work in this area has continued under the auspices of
the Cross Agency Priority Goal (CAP Goal) on servicemember and Veteran
mental health, which was announced in March 2014. Immediately following
the announcement of the CAP Goal, each of the three departments
identified action officers and subject matter experts to develop 3-year
work plans consisting of actionable milestones and performance
indicators (metrics). Action officers for each department meet weekly
to discuss progress on the milestones and indicators. Progress is
tracked and reported quarterly on the public facing Web site
www.performance.gov. Detailed updates on the CAP Goal activities are
provided on a quarterly basis to executive branch leadership and posted
publicly on performance.gov. Notable highlights from the progress of
the CAP Goal efforts include the following:
Visits to the Make the Connection outreach campaign Web
site continue to trend upward (722,698 so far in FY 2015) and are on
track to substantially exceed the targeted 10% increase for this
year.Established an interagency workgroup to identify, expand, and
promote DOD, VA, and HHS efforts to reduce negative perceptions
associated with seeking mental health care and increase awareness of
resources.
``These Hands'' public service announcements (PSA) for the
Veterans Crisis Line/Military Crisis Line are in the top 5 percent of
PSAs being aired nationally.
Views of the VA Community Provider Toolkit
(www.mentalhealth.va.gov/ communityproviders/) also continue to
increase and content continues to be enhanced to meet the needs of
clinicians who are serving Veterans in the community.
Further building upon the activities of the EO #13625 and the CAP-
Goal, VA, DOD, and other Federal agencies have taken a number of steps
in response to the President's August 2014 Executive Actions (EA).
Similar to the CAP-Goal, the Departments have identified Action
Officers and subject matter experts for each of the 19 items and
collaborative work is underway. Highlights of interagency EA progress
to date include the following:
DOD's inTransition contract is in the process of being
modified to establish an automatic enrollment for Servicemembers
preparing for transition to Veteran status.
Military Culture Competence training is being disseminated
to community providers in coordination with the White House Joining
Forces initiative.
VA and IRS are providing Operation Save suicide prevention
training to volunteer tax preparers who are working with Veterans.
DOD, VA, and HHS are working together to address risk of
opioid overdose risk by increasing the availability of naloxone, a
medication that reverses the effects of opiates. VA policy was revised
in February 2015 to ensure that Servicemembers transitioning to VA care
will maintain access to medication prescribed by DOD providers.
Question 6. VHA has pointed to its use of and training in evidence
based psychotherapies (EBPs) and, according to the budget
justification, has provided training to more than 7,500 providers. The
justification also states: ``VHA will expand its efforts to * * *
evaluate the impact of training in and delivery of these therapies.''
Please describe in detail the metric used to evaluate the training and
delivery of EBPs.
Response. VHA's competency-based EBP training model includes two
key components designed to create mastery and promote successful EBP
implementation: (a) participation in an in-person, experientially-based
workshop, and (b) ongoing telephone-based clinical consultation on
actual therapy cases with a training program consultant who is an
expert in the particular EBP. Ongoing formative and summative program
evaluation is a central component of the VA EBP training programs and
focuses on both staff and Veteran outcomes. Additionally, alternative
training methods are being piloted and will be evaluated against the
current training standards.
Therapist Outcomes--For evaluating EBP therapists-in-training, the
EBP training programs use survey measures to collect data at several
points in time: before and after training; and during, immediately
after, and six months after the consultation phase. Variables assessed
include: therapists'-in-training ratings of (1) the trainers; (2)
training program quality; (3) self-rated knowledge and skills
acquisition; (4) intent to apply skills to their practice; (5) self-
efficacy in applying EBP skills; (6) attitudes regarding use of the
EBP; and more. In addition, expert EBP consultants assess the outcomes
of therapists-in-training by using an EBP-specific competency rating
scale to rate actual sessions. These ratings provide reliable and
detailed feedback on their EBP skills.
VHA program evaluation has shown that this intensive consultation,
combined with ratings of actual clinical cases, is crucial to improving
provider competencies. Consultation improves therapists' sense of
efficacy in delivering EBPs that are not evident when therapists only
attend a workshop.
Veteran Outcomes--The EBP training programs also assess Veterans'
responses to EBPs. To date, the VHA EBP program evaluation data
indicate that Veterans' improvements in target symptoms have been in
the medium-to-large or large range for Post Traumatic Stress Disorder,
insomnia, depression, and chronic pain. These results are quite
promising considering they come from Veterans, often with complex or
chronic problems, who are being treated by EBP therapists-in-training.
Program evaluation for some of the newer EBP training programs, which
focus on treating substance abuse and building motivation to change
problematic behaviors, are fully underway, but results are not yet
published.
Beyond symptom relief, Veterans have also shown significant
improvement in their quality of life (both psychologically and
physically) and in their therapeutic alliance scores, indicating that
Veterans agree with their therapists on the goals and tasks of therapy
and feel a bond with their therapists. VHA data indicate completion
rates of around 70 percent across treatments, relative to the mean
completion rate of 54 percent reported in studies of psychotherapy with
the general population. These findings indicate a high degree of
Veteran acceptance of these therapies, which may be in part due to the
strong emphasis the training programs place on building strong working
alliances between the trainers and their Veteran patients.
Increasingly, researchers are focusing on the effects of EBPs on
reducing medical utilization and health care costs. For example,
completion of EBPs for Post Traumatic Stress Disorder has demonstrated
a 30 percent reduction in mental health service utilization and about a
40 percent reduction in health care costs in the year following
treatment. Studies from the National Health Service in the United
Kingdom have demonstrated that EBP treatment for a wide variety of
mental health conditions results in net savings to the system above and
beyond the costs of training.
Delivery of EBPs--Previously, there was no mechanism for tracking
the delivery of EBPs using administrative data. In the first two
quarters of fiscal year 2015, VHA released nine sets of documentation
templates for the EBPs that treat Post Traumatic Stress Disorder,
depression, serious mental illness, insomnia, and relationship
distress. Six more sets are planned for release at the beginning of
next fiscal year. These documentation templates are for the EBPs that
treat chronic pain or substance use, increase motivation to change, and
track the offering of EBPs to Veterans. For the first time, VHA can
directly measure the delivery of the EBPs that have documentation
templates.
A beta version of a national dashboard was just released that
documents the number of unique Veterans who have had two or more
sessions of an EBP since the templates were deployed. Currently, the
EBP utilization data, available at the national, VISN, and facility
levels, can be viewed by any VA staff member. EBP data is displayed in
near real time. New parameters and reporting capabilities will continue
to be added as data definitions are developed and refined. The release
of the EBP documentation templates and the deployment of the national
EBP dashboard will greatly increase VHA's ability to focus
implementation efforts at sites with low EBP delivery and to learn the
best practices from high achieving sites.
Improving Access to EBP Training--The EBP training programs are
piloting alternative training methods that rely less on national in-
person workshops. During the piloting phase, the training programs will
be evaluating whether the alternative training methods are as effective
in terms of therapist and Veteran outcomes as the in-person workshops
that have demonstrated efficacy.
Recent restrictions on employee travel and conferences have
impacted VHA's ability to train providers. In order to adequately train
the VHA mental health workforce, as well as improve the implementation
and sustainability of EBPs, alternative training methods must be
developed. Since 2007, VHA has trained over 9,000 unique VA staff in
one or more EBP. Nevertheless, there is ongoing demand for EBP training
due to new staff joining VA, staff turnover, and changes in job
assignments.
In order to better meet this demand, two models are being piloted
and evaluated. One is a regional training model whereby the national
EBP training program train staff adept in an EBP to become trainer/
consultants. These trainer/consultants then conduct local or regional
trainings and provided the follow-up consultation within their VISNs.
This model is responsive to local needs and schedules but has the
disadvantages of trainers/consultants having to get local permission to
block their clinical schedules to provide training and consultation;
and local facilities having to fund travel within their regions. In the
current national model, the EBP training programs reimburse VA sites
for the percentage of time staff devote to national training efforts
and pay for training participant travel.
The other training model being piloted uses a blended learning
strategy whereby the didactic portions of the workshop are presented in
web courses, the experiential role-play training is conducted over
video conferencing technology in small cohorts led by an EBP expert,
and consultation is provided as it is currently (by nationally-funded
consultants who provide expert ratings of actual clinical cases and
give feedback to training participants on small group conference
calls).
In short, VA uses a wide variety of metrics to track the number of
therapists trained in EBPs, the therapist and Veteran outcomes with EBP
training cases, the efficacy of EBP training methods, and, now, the
numbers of Veterans engaged in various EBP treatments. In the near
future, VA plans to assess the offering of EBPs, completion rates, and,
eventually, clinical outcomes for Veterans in EBP.
Question 7. The revised estimate for the fiscal year 2016 advance
appropriations request for the Medical Support and Compliance
appropriations account indicates a $114.6 million decrease for VISN
headquarters and a $37.3 million increase for VHA Central Office
(VHACO).
a. What accounts for the change in funding for the VISN
headquarters and VHACO?
Response. The 2016 Revised Request adjusts the estimate for the
latest actual obligations (2014), as opposed to the 2016 Advance
Appropriation estimate (based on the 2013 actual obligations). The 2016
Revised Request for the VISN Headquarters reflects the funding
necessary to maintain the 2014 current service levels, allowing for
inflation; the proposed pay raise from 1 percent to 1.3 percent; and
changes in full-time equivalent employees (FTE). The 2016 Revised
Request for the VHACO reflects the funding necessary to maintain the
2014 current service levels, allowing for inflation; the proposed pay
raise from 1 percent to 1.3 percent; and FTE held steady at the 2014
level.
b. If the changes are due to the overall increase or decrease in
FTE, please describe in detail the justification for the increase or
decrease and whether the increase or decrease is a shift of FTE between
VISN headquarters and VHACO.
Response. Sixty-eight percent of the funding for Medical Support
and Compliance will go toward VAMCs, Other Field Activities, and VISN
Headquarters. The majority of the funding increase is due to additional
staffing requirements for field activities at the VA medical centers
and VISNs. The additional positions are being added to the Medical
Centers and VISNs to support and fulfill the Secretary's vision of
becoming a more Veteran-centric organization, and to be able to provide
top-level customer service in a more efficient manner to our Veterans;
as a result, some of the positions we are increasing are: Police,
Personnel Management Specialist, Contract Administrator, Voucher
Examiner, Claims Assistant, Emergency Management Series, Medical
Records Clerk/Technician, Health Systems Specialist, Administrative
Officer, Security Clerical & Assistance. These personnel are in direct
support of VA's objective to manage and improve VA operations to
deliver seamless and integrated support. These personnel will support
healthcare workers in order to deliver the healthcare services that our
Veterans expect. FTE estimates for VHA Central Office and VHA National
Consolidated Activities remain steady at their 2014 levels.
Question 8. VA's goal is to end veteran homelessness this year. If
that goal is not met, what is the plan for funding homelessness
programs for fiscal years 2016 and 2017? If that goal is met, will
funding need to be shifted to sustain preventative services? If so,
how?
Response. The goal of ending Veteran homelessness will be measured
according to the January 2016 Point in Time count, the results of which
are expected by summer 2016. Given the timing of this information, we
do not anticipate deviating from the current requested budgets for
fiscal years 2016 and 2017. Available funding has been prioritized
among our programs to achieve three objectives:
Maintain current case management services and provide
interventions as needed to those high-risk/high-need Veterans we have
been able to house, so that they do not return to homelessness;
Ensure resources are available to identify Veterans at-
risk for homelessness, and prevent these Veterans from falling into
homelessness; and
Provide immediate access to housing to Veterans who fall
into homelessness so that they are moved as rapidly as possible to safe
and stable settings, putting them on a path to permanent housing.
Medical Facilities
Question 9. The fiscal year 2016 advance appropriations for
medical facilities have been revised significantly in this year's
budget request. Numerous subaccounts, such as plant operations, leases,
and operating equipment maintenance, and repair, each have a revised
estimate of more than $200 million below the advance appropriations.
Conversely, recurring maintenance and repair and non-recurring
maintenance each have a revised estimate of more than $200 million
above the amount provided in advance appropriations.
a. Why were the fiscal year 2016 advance appropriations inaccurate?
Response. The 2016 advance appropriations estimates for plant
operations, leases, operating equipment maintenance and repair, and
recurring maintenance and repair reflect the most recent available
obligation data (2013 actuals). The estimates have been updated to
reflect the latest actual obligations (2014) and an inflationary
increase over the 2015 Current Estimate. Non-recurring maintenance
estimates were revised to address high priority emerging capital needs,
as identified through the Strategic Capital Investment Planning (SCIP)
process.
b. Please detail the process used to identify the advance
appropriated funds necessary for medical facilities.
Response. The 2016 advance appropriation took into account the
latest actual obligations (2013); estimates for Obligations by
Functional Area (Engineering and Environmental Management Services,
Plant Operations, etc.) and Obligations by Object Class (utilities,
rent, etc.); capital needs as identified through the SCIP process
(NRM); a one percent pay raise; and adjustments to funding availability
(transfers to Joint DOD/VA Medical Facility Demonstration Fund and
reimbursements).
Question 10. The Non-Recurring Maintenance (NRM) subaccount is
$708 million for fiscal year 2016, an increase of $247.4 million over
the amount provided in advance appropriations. The budget request
indicates that this is offset by a decrease of $311.4 million for
leases based on revised estimates.
a. What accounts for the $247.4 million increase in NRM?
Response. VA's NRM project list is greater than $9 billion. The
requested increase in NRM in FY 2016 above the Advance Appropriation
amount is an attempt to address more of these NRM projects within the
total requested resources in the President's Budget.
b. What accounts for the $311.4 million decrease in leases?
Response. The Veterans Choice Act Section 801 provided funding for
leases. VA projects that $313 million of Section 801 funding will be
used to support new leases in 2015 and 2016 and this amount was reduced
from our request. Also prior to this year's budget submission, VA
estimated medical facility lease costs based on historical trends in
the object classes in which lease obligations are recorded. Beginning
with this budget, VA has moved to a specific requirement by lease
rather than relying on overall trends.
Question 11. The NRM subaccount is projected to increase by $71.8
million or 11.2 percent between fiscal year 2015 and fiscal year 2016
and decrease by $247.4 million or 35 percent between fiscal year 2016
and fiscal year 2017.
a. The advance appropriation each year for the NRM subaccount is
$460.6 million and each year the revised estimate is significantly
higher. What metrics does VA use to determine the NRM funding request?
Response. VA's total capital investments are balanced across NRM,
Major Construction and Minor Construction by the Strategic Capital
Investment Plan (SCIP) process, and are balanced within the total
requested resources in the President's Budget Advance Appropriation
request.
b. Why does the 2017 advance appropriations request only include
Object Class 32 while the actual expenditures include Object Classes
10, 21-26, 31, 32, 41, and 43?
Response. Reported actual obligations for 2014 include errors in
the VA Financial Management System that were made too late in the year
to identify and correct before the required fiscal year close out
activities made those errors a part of the official financial record.
VA's budget request does not assume that those errors will be repeated
in future years.
Question 12. According to the fiscal year 2016 budget, VA will
spend $598 million to activate medical facilities in fiscal year 2016.
And, the estimate for activations for fiscal year 2016 increased by
$468 million over the amount provided in advance appropriations.
a. Please break out the $598 million by appropriations account.
VA Response:
Medical Services: $443 million
Medical Support & Compliance: $54
million
Medical Facilities: $101 million
b. Please provide a full list of the facilities that will be
activated with these funds, with the amount of funding estimated for
each facility broken down into non-recurring and recurring costs.
Response. See attached.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
c. Please provide a detailed explanation for the $468 million
increase above the advance appropriations amount for medical facility
activations for fiscal year 2016.
Response. See attached.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 13. VA cost estimates for new activations are $28 per
square foot for leases and new construction and $6,600 per new
employee.
a. Please provide a detailed breakdown of these cost estimates.
Response. The $28 per square foot is a GSA standard for office
space IT activation, we have no further breakdown. The $6,600 breakdown
is as follows:
------------------------------------------------------------------------
Estimated
Cost Cost Element
------------------------------------------------------------------------
$1,000 Computer
$1,200 License for Computer Software
$1,200 VOIP Phone
$800 Blackberry
$1,200 Blackberry Sustainment ($100/mo x 12 mos)
$200 Softphone Hardware/Software
$200 Softphone License
$100 Network Support ($100 per port)
$200 Wiring Infrastructure ($200 per jack)
$250 Storage and Server
$250 Email and security license
-----------
$6,600 Total
------------------------------------------------------------------------
b. How do these cost estimates compare to the private sector?
Response. We have no reliable source of information for comparison
to the private sector.
Question 14. Please detail the status of each of the 27 leases
included in Public Law 113-146, the Veterans Access, Choice, and
Accountability Act of 2014 (Choice Act). Please provide a timeline for
completion of Phases 1-4 of the leases.
Response. The table below shows the status and timeline for each of
the 27 leases included in the Choice Act.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 15. The Congressional Budget Office scored the leases in
section 601 of the Choice Act as direct spending. However, VA indicated
4 of the 27 leases are being funded through the $5 billion provided to
increase veterans access to care in section 801 of the Choice Act.
Please provide a breakdown of the funding source for each of the 27
leases.
Response. Of the 27 Major leases authorized in Section 601 of the
Choice Act, 4 are new leases (Lake Charles, LA in FY 2016; Johnson
County, KS in FY 2017; Phoenix, AZ in FY 2017; and Honolulu, HI in FY
2018) supporting access improvements and have supporting funding
identified in the plan developed for the Section 801 funds. The
remaining 23 are replacement or Research leases with support from
within existing VHA appropriated funding streams.
Question 16. In the fiscal year 2016 budget, VA requested
legislative language to pursue additional types of Enhanced-Use Lease
(EUL) agreements beyond creating supportive housing. At least two VA
Inspector General Reports in 2012 and a Government Accountability
Office (GAO) report in August 2014 show that VA needs to improve how it
tracks and monitors its current EUL agreements.
a. What changes has VA made to its tracking and monitoring of EUL
agreements?
Response. VA has developed an agile and modernized tracking program
and has made improvements to the oversight and monitoring of EUL
agreements after the Inspector General (IG)'s report in 2012. VA has
issued detailed and holistic guidance for the oversight and monitoring
of the EUL portfolio during the post-transaction stage of the EUL
lifecycle. This includes defining roles and responsibilities of EUL
stakeholders, both corporately and locally at the site where the EUL
resides, as well as defining recurring reviews for compliance and paths
for escalation should issues arise with a particular EUL. In addition,
VA has developed a new technology system (Enhanced Use-Lease
Information System) to help in the tracking and monitoring of
operational EULs. This technology enables improved collaboration with
on-site resources and serves as a common source of information for
recurring compliance tracking.
In addition to the improved oversight and tracking, VA also
developed a new methodology for estimating the benefits and costs
associated with the EUL program. This methodology has been in use for
the past three years and the results of the methodology are published
annually in VA's Congressional Budget Submission (Volume IV, EUL
Consideration Report). This report provides a transparent view of the
benefits to VA, Veterans, and local communities as a result of these
EUL projects.
As a result of these improvements, all recommendations in the IG's
report have been closed out. In regards to the GAO report in
August 2014, it focused on land-use agreements, but excluded EULs from
the audit. References to EUL in that report were only used to
illustrate how the EUL oversight program is structured, but GAO did not
actually assess the EUL program.
b. Would the system be able to handle an influx of new EULs should
this legislative language become law?
Response. Yes. The enhancements made to the EUL oversight and
monitoring process are fully scalable to accommodate new EULs. In
addition, the Enhanced Use-Lease Information System is fully
operational and capable of handling the influx of new EULs, should this
legislative language become law.
Long-term care
Question 17. More than half of the veterans seeking healthcare
through VA are over the age of 65. As the veterans population continues
to age, the Department will be faced with challenges of chronic health
conditions as well as increasing demand for long-term care services.
The fiscal year 2016 budget again requests $80 million for State
Veterans Homes grants, $10 million below the fiscal year 2015
appropriated level. How will the decrease in construction funding
impact the availability of beds for veterans seeking long-term care
through State Homes?
Response. The FY 2016 VA state home construction grant program
funding request of $80M is unchanged from the FY 2015 request. The
decrease in construction funding will have no impact on the current
level of available state beds. However, required funding supporting FY
2016 new bed construction is not fully predictable until States have
completed their application for the FY 2016 Priority List. States had
until April 15, 2015, to submit new applications. VA may have funds for
1-2 new construction projects in FY 2016 dependent upon an
appropriation of $80M and the total cost of FY 2016 safety projects.
The availability of these new beds will be realized following
completion of construction. This is typically a 2-3 year process based
on project size and complexity.
Women Veterans
Question 18. The Mental Health Medical Care account for fiscal
year 2016 is $7.5 billion. Please break out the amount allocated for
women-only programs.
Response. The total mental health medical care amount for women
Veterans in fiscal year 2016 is estimated at $700 million.
construction and capital assets
Question 19. The fiscal year 2016 budget request includes $1.14
billion for major construction projects, to include nine VHA projects.
The fiscal year 2015 total estimated cost of the Long Beach, CA,
project was $287.1 million. The fiscal year 2016 total estimated cost
for the project is now $317.3 million. What accounts for the $30.2
million increase?
Response. The construction cost increase on the Long Beach, CA
project is due to building area increases to meet updated design
criteria for the Community Living Center and additional cost escalation
as the project waits for full construction funding.
Question 20. Of the nine VHA major construction projects
requested, all but one project will need future funding in order to be
completed. Please detail each of the remaining eight projects,
including a breakdown of future budget requests and projected
completion dates.
Response. The completion dates of these projects are dependent on
when funding is received.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 21. The Advance Planning and Design Funds for VHA is
projected to increase by $23.7 million or 34 percent between fiscal
year 2015 and fiscal year 2016. What accounts for the $23.7 million
increase? Please detail the specific projects included in this
increase.
Response. VA's request for the Advanced Planning and Design Fund
(APDF) line item is based on the estimated need to support a project
and other requirements through this fund. The APDF provides funding for
schematic design, design development, and construction document phases
up to 100 percent of design for major construction projects. This
allows VA to complete 35 percent of total design prior to requesting
construction funds. It can be used to prepare facility master plans,
historic preservation plans, conduct environmental assessments and
impact studies, energy studies or audits, and design and construction-
related research studies including post-occupancy evaluations. The
funds are also utilized to maintain construction standards, such as:
design guides and standards, specifications, and space criteria.
The table below reflects the anticipated use of the APDF in fiscal
year (FY) 2016:
------------------------------------------------------------------------
Planned
Location/Project Description Amounts
($000)
------------------------------------------------------------------------
American Lake, WA--Buildings 81, 81AC and 18 Seismic 6,000
Corrections...............................................
Bay Pines, FL--Phase 4 Renovation.......................... 1,650
Livermore, CA--Realignment and Closure, Palo Alto.......... 5,500
Long Beach, CA--Mental Health and Community Living Center.. 300
Louisville, KY--New Medical Facility....................... 2,000
Omaha, NE--Replacement Medical Facility.................... 2,000
Palo Alto, CA--Ambulatory Care and Polytrauma Rehab........ 2,000
Portland, OR--Retrofit and Renovation...................... 17,000
Roseburg, OR--Seismically Upgrade and Renovate Building 2 5,000
and Replace Building 1....................................
San Francisco, CA--Seismic Retrofit Buildings 1,6 and 8/ 200
Replace Building 12.......................................
San Juan, PR--Seismic Corrections.......................... 100
St Louis, MO--Bed Tower Replacement........................ 5,380
Tampa, FL--Polytrauma Renovation/New Bed Tower............. 3,200
West Los Angeles, CA--Seismic Upgrade to 12 Buildings...... 3,200
Pre-planning for Strategic Capital Investment Planning 5,000
Projects..................................................
Historic Preservation, Environmental, Value Management, and 10,000
Cost Estimating Services (Various Projects)...............
Facilities Standards and Criteria.......................... 11,700
Integrated Strategic Master Plans (Various Locations)...... 38,000
------------
Total.................................................. $118,230
------------------------------------------------------------------------
Question 22. The fiscal year 2016 budget requests $5 million for
claims analyses, a $3 million or 150 percent increase over fiscal year
2015 levels. Please provide a list of the number of claims filed
against VA for fiscal year 2014 and to date in fiscal year 2015. What
specifically accounts for the $3 million increase?
Response. The table below lists the claims filed against VA during
FY 2014 and year-to-date for FY 2015.
VA Major Construction Claims
------------------------------------------------------------------------
Number of
Project Claims
------------------------------------------------------------------------
FY 2014
Abraham Lincoln National Cemetery, IL...................... 2
Pittsburgh Consolidation Building 29 Ductwork.............. 1
Orlando New Medical Center................................. 4
Las Vegas Photovoltaic System.............................. 1
Palo Alto.................................................. 1
----------
Total.................................................... 9
FY 2015
Fort Jackson National Cemetery............................. 1
New Medical Center, Aurora, CO............................. 140
----------
Total.................................................... 141
------------------------------------------------------------------------
Prior to the FY 2015 request, VA had not requested funds for this
line item since FY 2009. VA's use of this line item had remained
relatively limited from FY 2009 through FY 2013, averaging $98,000 per
year. In FY 2014, VA used $2.2 million, and in FY 2015 to-date, VA has
spent over $2 million. The growth in VA's request from
FY 2015 to FY 2016 is directly related to the recent increase in
claims from the Denver Replacement Medical Center.
Question 23. In Secretary McDonald's testimony, he indicated one
of his top priorities is to ``right-size'' VA's capital asset
portfolio. He indicated that VA currently has 336 buildings that are
vacant or less than 50 percent occupied, which costs VA $24 million
annually to maintain and operate.
a. Please provide a list of facilities VA intends to close.
Response. The 336 buildings referenced by Secretary McDonald in his
testimony do not represent facility closures. These are individual
buildings, located at VA medical centers across the county, that are no
longer in use. Disposal of these individual buildings would not impact
Veteran Services being delivered at that particular facility, but would
generate significant cost savings.
At this time, there are no plans to close any VA facilities. VA is
conducting a review of its facilities and considering options such as
possible realignments. These realignments may result in a partial or
full closure of a facility. VA stakeholders will be offered a briefing
once the plan becomes final.
b. How does VA plan to dispose of excess space while ensuring that
it does not affect veterans' access to care?
Response. As stated above, the 336 buildings referenced by
Secretary McDonald that are presently vacant or less than 50% occupied
do not represent any planned facility closure. Rather these are
individual buildings which are, through a combination of age, location,
need, and layout, no longer suitable for regular use by VA. Given this
fact, the disposal of these excess buildings should have no impact on
provision of services to Veterans as these assets are not being
utilized to provide services at this time.
In cases where VA has multiple buildings that are underutilized
(i.e. building is larger than need, so only a part of the building is
necessary), efforts can be undertaken to consolidate the services to a
single building, allowing for disposal of one or more buildings. This
disposal would only occur after consolidation occurs, so again, no
impact to Veteran services would be anticipated. The vacant buildings
that are no longer needed for patient care will either be planned for
demolition, given to a third-party developer to convert to homeless
housing via VA's Enhanced Use Lease (EUL) process (subject to
congressional authority), or they will remain mothballed due to
historic preservation considerations. Many of these buildings are too
old to efficiently house administrative services, let alone clinical
services that require additional floor load, heating and ventilation
requirements, upgraded electrical and plumbing, etc. Therefore,
disposal of these individual buildings would not impact Veteran's
services being delivered at any respective facility with these
buildings.
veterans benefits administration
Question 24. In the fiscal year 2016 budget, VA requested an
additional 320 employees to handle non-rating work.
a. Please provide the calculations used by VA to determine that 320
was the correct number of non-rating staff to request.
Response. VBA is grateful for the funding received in the FY 2015
and 2016 appropriations to support 420 additional non-rating FTE. VBA
completed a record 3.1 million non-rating claims in FY 2015, which was
a 16 percent increase over non-rating claims completed in FY 2014, and
a 37 percent increase over non-rating claims completed in FY 2013. The
additional 320 FTE in FY 2016 will enable VBA to continue to reduce the
non-rating inventory to below 800,000 and the average time a Veteran is
waiting for a non-rating decision from 345 days at the end of FY 2015
to an average of 280 days.
b. How many employees, in total, were dedicated exclusively to non-
rating work during fiscal year 2014 and how many employees, in total,
will be dedicated exclusively to non-rating work during fiscal year
2015?
Response. At the end of FY 2014, 789 employees were assigned to
non-rating teams, including 200 temporary employees. VBA is in the
process of hiring additional temporary non-rating employees utilizing
the increased funding for FTE received in 2015. This will increase the
number of staff dedicated to non-rating claims work to 1,009 in 2015.
Receipt of VBA's FY 2016 request for funds to support an additional 320
non-rating FTE will allow VBA to retain these temporary employees,
convert them to permanent positions, and also further increase non-
rating staffing levels. These additional resources are expected to
enable VBA to achieve a steady state of approximately 500,000 pending
non-rating claims/actions in FY 2017.
c. During fiscal year 2014 and to date during fiscal year 2015,
were non-rating employees required to work on the disability claims
backlog during regular hours or overtime hours? If so, how many non-
rating employees were used for that purpose and, on average, how many
regular hours and how many overtime hours per month were worked for
that purpose?
Response. All employees regardless of team assignment were required
to work disability rating claims during their mandatory 20 hours of
overtime each month. During fiscal year 2014, VBA's 854 non-rating full
time equivalent employees (FTE) worked approximately 19 hours of
overtime per month, and in fiscal year 2015, 1,059 FTE worked an
average of 15 hours per month. This 20-hour per month mandatory
overtime requirement was in place from January to August 2015, with
optional overtime offered in other months.
Often rating-related and non-rating related work are completed
concurrently. In these cases, employees are directed to take credit for
rating-related work instead of non-rating work, because the rating-
related work credit is assigned the greatest point value in VBA's
performance management system. Employees are instructed to work all
associated actions on a pending claim, but may not take dual credit for
both rating and non-rating work accomplished by the same action. On
average, disability rating claim work was approximately 20 to 25
percent of our non-rating FTEs' work completed in fiscal years 2014 and
2015 during their regular tour of duty, which averages to 22 to 28
hours per month per employee.
d. What metrics does VA use to determine the actual and expected
productivity per employee for non-rating staff?
Response. Non-rating claims generally include adjustments to
existing compensation and pension awards that are processed after the
initial award of benefits. As more rating claims are processed in FY
2015 and more Veterans begin receiving compensation and pension
benefits, there will be a similar increase in non-rating claims.
In addition to completing 1.32 million disability rating claims in
Fiscal Year 2014, VBA also completed 2.7 million non-rating claims and
other administrative actions, a 30 percent increase from FY 2012.
Productivity increased from 147.2 non-rating claims/actions per FTE in
FY 2012, to 188.7 claims/actions in FY 2014. Using the FY 2015 staffing
level of 14,765 direct FTE, VBA's non-rating production is currently
206.8 claims/actions per compensation and pension direct FTE. In
addition to claims processing personnel, direct FTE includes all
employees supporting compensation and pension programs, such as
fiduciary employees, national call center employees, outreach
personnel, military services coordinators, etc. This does not include
management support, which typically comprises 11 percent of all
compensation and pension field staff.
VBA continues to focus on the body of non-rating work while we
simultaneously eliminate the rating claims backlog As VBA hires
additional staff to address non-rating work, VBA will track non-rating
productivity as well as monitor the inventory of these claims as the
primary metrics for our improvement efforts.
e. Using those metrics, what was the productivity per non-rating
employee during fiscal year 2014 and what is the productivity per non-
rating employee to date during fiscal year 2015?
Response. VBA does not budget field FTE solely for rating or non-
rating work. Production per FTE is based on all compensation and
pension employees assigned to each regional office's claims processing
workforce. Please see the chart below with FY 2015 FTE prorated for
five months (14,479 direct FTE ceiling divided by 12 months and then
multiplied by five months):
------------------------------------------------------------------------
Non-Rating Claim
and Non-Rating
FTE Administrative Production
Actions Completed per FTE
------------------------------------------------------------------------
FY 2014..................... 14,307 2,699,264 188.7
FY 2015 (February).......... 6,033 1,247,695 206.8
------------------------------------------------------------------------
f. What would be the expected level of individual productivity for
non-rating staff, if the fiscal year 2016 budget is adopted?
Response. VBA forecasts that the additional 320 non-rating
employees would complete 145,000 to 165,000 non-rating claims/
administrative actions in FY 2016. However, the number of non-rating
claims completed per FTE will initially decrease because of the hours
devoted to training the new employees and the lower production levels
of these employees due to their inexperience. Production per FTE for
budgetary purposes is based on all compensation and pension FTE
assigned to claims processing in all regional offices, not just FTE
processing non-rating claims. In FY 2016, VBA expects non-rating claim
production per FTE to decrease slightly from the current average of 206
non-rating claims/actions per compensation and pension FTE.
g. What would be the expected timeline for bringing these new non-
rating employees on board, if the fiscal year 2016 budget is adopted?
Response. The 320 additional non-rating FTE will be hired in the
first quarter of FY 2016.
h. How would these new non-rating employees be allocated among the
regional offices?
Response. The new non-rating employees will be placed in a few
regional offices based on available seating. However, these additional
employees will be a national resource focused on challenged workload
areas within the non-rating workload of all regional offices, such as
drill pay adjustments and dependency claims.
i. Please provide any goals or milestones the Veterans Benefits
Administration (VBA) has established for reducing the number of pending
non-rating work items, including an estimation of when the level of
pending work will be reduced to a level that VBA considers acceptable.
Response. VBA's success in completing rating decisions has driven
an increase in non-rating claims. Despite completing a 20-year record
number of non-rating claims in FY 2014, this work continues to grow. In
FY 2015, VBA expects to receive 2.9 million non-rating claims and other
administrative review actions, an increase of 7.4 percent over 2014
(2.7 million) and 20.8 percent over 2013 (2.4 million). These
additional resources are expected to continue to reduce the non-rating
inventory in FY 2016 and enable VBA to achieve a steady state of
approximately 500,000 pending non-rating claims/actions in FY 2017.
j. During the remainder of fiscal year 2015 and during fiscal year
2016, will regional offices be permitted to use overtime hours to deal
with non-rating work?
Response. FY 2015 compensation and pension overtime efforts are
focused on the following priorities: backlog rating claims, priority
rating claims (Medal of Honor recipients, prisoners of war, homeless
Veterans, Veterans with hardship, terminally ill Veterans, fully
developed claims, etc.), and functions in support of continued
transformation into a paperless environment, such as centralized mail.
For the remainder of FY 2015, VBA will continue to focus on the
abovementioned priorities during overtime efforts. In FY 2016, overtime
use will be reassessed by VBA leadership.
k. During fiscal year 2016, does VBA intend to use the services of
any contractors to assist with non-rating work? If so, how much is
expected to be expended on those contractors and what level of
productivity is expected to be achieved as a result of use of those
contractors?
Response. On April 21, 2014, VA awarded a contract for assistance
in entering data from paper-based dependency claims into VA's
electronic rules-based processing system. The contractor enters the
information from the paper-based dependency claims just as a claimant
would enter information if filing the claim online using eBenefits. The
performance period is one base-year and two option-years. During FY
2016, VA will continue to utilize the contract to assist in reducing
the inventory of dependency claims. In FY 2016, funds for this contract
total $3.1 million, with approximately 400,000 dependency claim reviews
projected to be completed by the contractor. Because not all claims
reviewed by the contractor can be fully processed to completion through
VA's online rules-based processing system, manual processing of the
more complex dependency claims is still required.
Question 25. In the fiscal year 2016 budget, VA requested an
additional 200 employees to work on appeals.
a. Please provide the calculations used by VA to determine that 200
was the correct number of appeals employees to request.
Response. VBA is grateful for funding in FY 2015 and FY 2016 to
hire another 300 appeals FTE. However, these additional FTE are not
sufficient to address the existing or future appeals workload. Under
the appeals framework established by current law, Veterans are waiting
far too long for final resolution of their appeals. Legislation is
needed to streamline and modernize the appeals process. The 300 FTE
will assist VA in closing the gap, but without legislative change or
significantly greater increases in staffing, VA will face a soaring
appeals inventory, and Veterans will wait even longer for a decision on
their appeal.
In the FY 2017 President's Budget, VA sets forth a plan to provide
most Veterans with a timely and fair decision on their appeal within
one year of filing the appeal. VA looks forward to working with
Congress to secure the required resources to address the current
appeals workload and the legislative changes needed to provide Veterans
with a modern appeals process.
b. How many employees, in total, were dedicated exclusively to
appeals during fiscal year 2014 and how many employees, in total, will
be dedicated exclusively to appeals during fiscal year 2015?
Response. In FY 2014, VBA had 11,290 claims processors on board, of
which 950 employees were dedicated to processing appeals in regional
offices and 190 employees at the Appeals Management Center. In FY 2015,
VBA is dedicating the same level of resources to appeals. Additionally
in FY 2014 all of the Board of Veterans' Appeals 631 employees were
dedicated to processing appeals and in FY 2015all 642 employees were
dedicated to processing appeals.
c. During fiscal year 2014 and to date during fiscal year 2015,
were appeals employees required to work on the disability claims
backlog during regular hours or overtime hours? If so, how many appeals
employees were used for that purpose and, on average, how many regular
hours and how many overtime hours per month were worked for that
purpose?
Response. In FY 2014 nd FY 2015 appeals processors have been
focused on appeals workload. During this same period all appeals
processors were on mandatory overtime and required to complete 20 hours
of overtime per month.
d. What metrics does VA use to determine the actual and expected
productivity per employee for appeals employees?
Response. Production per FTE is based on all compensation and
pension employees assigned to regional offices. As VBA continues to
receive and complete record-breaking numbers of disability rating
claims in recent years (1.32 million claims completed in 2014), the
volume of appeals increases concomitantly. Using the FY 2015 staffing
level of 14,765 direct FTE, VBA's appeals productivity is currently
11.4 appeal actions (e.g., statements of the case, appeal
certifications) per FTE. As VBA hires additional FTE to address
appeals, VBA will track production, inventory, and average days pending
as the primary metrics of improvement efforts.
e. Using those metrics, what was the productivity per appeals
employee during fiscal year 2014 and what is the productivity per
appeals employee to date during fiscal year 2015?
Response. The complex appeal process defined in law involves
multiple reviews of the evidence considered in the original decision as
well as any new evidence received during the appeal. Please see the
chart below for VBA's total completed appeal actions (e.g., statements
of the case, appeal certifications) and appeals productivity:
------------------------------------------------------------------------
VBA FTE Appeal Actions Appeals
Completed Productivity
------------------------------------------------------------------------
FY 2014.......................... 14,307 176,991 12.4
FY 2015 (February)............... 6,033 69,073 11.4
------------------------------------------------------------------------
f. What would be the expected level of individual productivity for
appeals staff, if the fiscal year 2016 budget is adopted?
Response. VBA's key metrics for measuring appeals processing is the
completed appeal actions, inventory of notices of disagreement (NODs),
and the average days pending for this workload. In the first year, VBA
projects the completed appeal actions and appeal resolutions will
increase, while productivity per FTE will slightly decrease as the new
appeals employees become familiar with the entire appeals process. By
the end of the second year, productivity per FTE will return to the
current level, approximately 11 completed appeal actions per
compensation and pension direct FTE. As previously noted, productivity
per FTE is based on all compensation and pension employees assigned to
regional offices, not just FTE processing appeals.
To increase efficiency, VBA is working closely with the Board of
Veterans' Appeals, Veterans Service Organizations, and Congress to
identify legislative solutions to simplify the appeals process and
improve the timeliness of appeal decisions.
g. What would be the expected timeline for bringing these new
employees on board, if the fiscal year 2016 budget is adopted?
Response. In February of FY 2015, VBA had 11,290 appeal claim
processors on board, including approximately 950 employees dedicated to
processing appeals in regional offices and 190 employees at the Appeals
Management Center. VBA is in the process of adding 100 appeal claim
processor FTE in FY 2015, and as soon as full funding is provided in FY
2016, VBA will hire 200 additional appeal claim processor FTE.
h. How would these new appeals employees be allocated among the
regional offices?
Response. VBA's Resource Allocation Model (RAM) is a systematic
approach to distributing field resources each fiscal year. RAM utilizes
a weighted model to assign compensation and pension FTE resources based
on regional office workload which takes into account the following
factors:
number of rating claims pending
number of rating claims received,
number of non-rating claims received
and the number of appeals
Starting in FY 2014, RAM incorporated additional variables that
align with VBA's transformation to a paperless environment, where
receipts can be assigned and managed at the national level. These
variables include:
station efficiency (claims completed per FTE)
quality
each regional office's processing capacity
VBA uses the model as a guide and makes adjustments for special
circumstances or missions performed by individual regional offices.
Special missions include:
Appeals Management Center
Benefits Delivery at Discharge processing
Integrated Disability Evaluation System (IDES) processing
Quick Start processing
National Call Centers (NCCs)
foreign claims processing
radiation processing
Camp Lejeune Contaminated Water (CLCW) processing
and Pension Management Centers (PMCs).
i. Please provide any goals or milestones VBA has established for
reducing the number of pending appeals, including an estimation of when
the level of pending work will be reduced to a level that VBA considers
acceptable.
Response. Over the last 20 years, appeal rates have continued to
hold steady at between 11 and 12 percent of completed claims. As VBA
continues to receive and complete record-breaking numbers of disability
rating claims in recent years (1.3 million claims completed in FY
2014), the volume of appeals increases concomitantly. The number of
statements of the case and other appellate actions completed by VBA on
Veterans' appeals has increased 31 percent since 2011, from 135,000
actions to 177,000 actions. VBA currently has approximately 290,000
pending appeals.
VBA is working to reduce its pending appeals inventory to less than
one year of receipts by the end of FY 2017. In addition, VA is engaging
with its key partners and stakeholders to define and establish the
levels of service delivery that Veterans should be able to expect in
the appeal process and determine what legislative and resource changes
would be needed to meet those expectations.
j. During the remainder of fiscal year 2015 and during fiscal year
2016, will regional offices be permitted to use overtime hours to
handle pending appeals?
Response. In FY 2015 appeals processors were dedicated to working
appeals only during regular hours. VBA utilized overtime in both a
voluntary and mandatory capacity at various times in FY 2015 for all
claims processors, including those working appeals. However, during
overtime, appeals processors were focused on the following
prioritization targets: backlog claims and priority claims (Medal of
Honor recipients, prisoners of war, homeless Veterans, Veterans with
hardship, terminally ill Veterans, fully developed claims, etc.).
Overtime use in FY 2016 is being reassessed by VBA leadership.
Question 26. In the fiscal year 2016 budget, VA requests an
additional 85 fiduciary field examiners.
a. Please provide the calculations used to determine that 85 was
the correct number of fiduciary employees to request.
Response. In FY 2014, VBA's fiduciary program protected more than
172,800 beneficiaries, which is a 41 percent increase in the number of
beneficiaries from 2011 (122,271). An increase in the total number of
beneficiaries receiving VA benefits and an aging population are the
primary causes for this program growth. With this dramatic increase,
the fiduciary program's current staffing levels are inadequate to
properly oversee all beneficiaries. If sufficient resources are not
provided, beneficiary protection will be compromised with increased
intervals between visits.
From 2011 to 2014, the field FTE allocation increased 22 percent
(703 FTE to 855 FTE); however, staffing has not kept pace with program
growth. Even though fiduciary hubs are completing more work through FTE
increases and recent efficiencies, the backlog of pending field
examinations continues to grow. The following chart reflects the 19
percent growth in completed field examinations and the 16 percent
growth in pending field examinations experienced between 2012 and 2014.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In July of FY 2014, VBA notified Congress of a need to hire 1,618
FTE, including 307 FTE to address the increase in fiduciary workload.
VBA is grateful for funding in FY 2015 to hire 50 fiduciary FTE and is
asking for funding in FY 2016 to hire an additional 85 fiduciary FTE.
b. This information is included in the budget request for fiscal
year 2016: ``In May 2014, VBA began the process of evaluating the
current performance standards for field personnel by conducting a work
measurement study of all fiduciary work tasks. This study is under
contract and should be completed in June 2015.'' Once that study is
complete, will VBA re-evaluate the required number of employees for
fiscal year 2016?
Response. Yes, VBA will use data collected through the Work
Measurement Study (WMS) to refine fiduciary program resource
requirements. The fiduciary program has experienced tremendous growth
and significant revisions to policies and procedures. The WMS is
capturing work performance in the new fiduciary environment. With the
information provided through the WMS, VBA will more accurately define
and quantify the time involved in completing fiduciary program work.
Question 27. In volume 3 of the fiscal year 2016 budget request, a
chart on page VBA-205 indicates that, in fiscal year 2013, VBA received
168,745 work items labeled as ``compensation rating other'' and, in
fiscal year 2014, VBA received 568,057 work items with that label. That
chart also reflects that, in fiscal year 2013, VBA received 1.1 million
work items labeled as ``compensation non-rating other'' and, in fiscal
year 2014, VBA received 666,898 work items with that label.
a. What factors account for the large change in the number of these
types of work items received in those years?
Response. The two tables referenced from the FY 2016 budget request
regarding claims received and completed both have errors. In the FY
2015 budget request, similar tables attempted to explain the
distribution of claims received and completed in different categories
to provide a different perspective of VBA's workload. This year's
budget table incorrectly kept the row descriptions and FY 2013 column
from last year's budget narrative. The corrected tables to replace the
ones on page VBA-205 are provided below:
------------------------------------------------------------------------
2015 2016
Received Claims 2013 2014 Estimate Estimate
------------------------------------------------------------------------
Compensation Rating......... 897,396 963,834 1,135,905 1,231,617
Compensation Non-Rating..... 484,735 568,057 632,360 651,331
Compensation Controlled End 642,573 731,274 807,070 830,759
Products...................
Compensation Other End 584,742 666,898 710,454 731,767
Products...................
-------------------------------------------
Total Compensation 2,609,446 2,930,063 3,285,789 3,445,474
Workload...............
------------------------------------------------------------------------
------------------------------------------------------------------------
2015 2016
Completed Claims 2013 2014 Estimate Estimate
------------------------------------------------------------------------
Compensation Rating......... 1,017,513 1,145,607 1,212,597 1,230,819
Compensation Non-Rating..... 410,775 528,495 694,228 708,113
Compensation Controlled End 572,620 727,443 656,180 666,804
Products...................
Compensation Other End 554,974 633,614 713,225 729,944
Products...................
-------------------------------------------
Total Compensation 2,555,882 3,035,159 3,276,230 3,335,679
Workload Actions.......
------------------------------------------------------------------------
b. Were there any changes in how VBA categorizes this work?
Response. As noted in the response above, the tables in the FY 2016
budget request are different from those shown in the FY 2015 budget
request. VBA reverted to the traditional four groupings of compensation
work products, as defined in the narrative found on page VBA-205. The
figures presented in the above tables are corrected based on the same
definitions.
c. Please enumerate the specific types of work included in each
category.
Response. The FY 2016 budget narrative, on page VBA-205, discusses
the four groupings of compensation work, including:
1. Compensation Rating: Original disability claims with eight or
more contentions or medical conditions or with seven or fewer
contentions; supplemental disability claims; as well as requests for
future medical exams
2. Compensation Non-Rating: Dependency determinations that impact
the entitlement of the Veteran or his dependents/family members; and
other adjudicated decisions that impact entitlement to other VA or
Federal programs
3. Compensation Controlled End Products: Controlled correspondence
with a Veteran or beneficiary not requiring additional rating or
authorization decisions; required reviews of claims; and corrections of
claims
4. Compensation Other End Products: Verification of continued
eligibility or status; Freedom of Information Act and Privacy Act
requests; special correspondence involving Members of Congress or other
U.S. Government agencies; notices of upcoming determinations or reviews
that could affect a Veteran's status; eligibility for vocational
rehabilitation services; and other administrative actions
Question 28. In response to pre-hearing questions, VA stated that
$122.8 million had been expended on overtime hours during fiscal year
2014 to process compensation and pension claims and that VBA has
expended $37 million for that purpose to date during fiscal year 2015.
a. How much is VA requesting for fiscal year 2016 for overtime
hours to process compensation and pension claims?
Response. Of the $55 million requested for overtime in FY 2016, VBA
currently anticipates using approximately $47 million to fund overtime
for compensation and pension claims processing.
b. Please provide the number of claims (not issues) completed
during overtime hours during fiscal year 2014 and the number of claims
(not issues) expected to be completed during overtime hours during
fiscal years 2015 and 2016.
Response. VBA completes an estimated 1,700 rating claims for every
$1 million of invested overtime funding. Based on this calculation, in
FY 2014, an estimated 208,000 claims were completed due to the
additional overtime funding. In FY 2015, VBA estimates completing an
additional 127,500 claims with the budgeted $75 million overtime
funding. In FY 2016, VBA budgeted approximately $50 million for
overtime directed toward the completion of disability claims. This will
allow VBA to complete an additional 85,000 claims in FY 2016.
Question 29. In November 2014, GAO issued a report outlining
certain shortcomings with VBA's quality assurance program related to
claims processing. What changes are planned in response to that report,
what is the timeline for implementing those changes, and what level of
funding is requested for fiscal year 2016 in relation to those changes?
Response. In response to GAO's recommendations, VBA is making
numerous changes to the quality assurance program, including:
Beginning with claims completed in January of FY 2015, VBA
executed a revised sample methodology that uses each regional office's
output and claims processing accuracy to determine the number of cases
reviewed. No additional funding is required at this time.
Claims are being reviewed based upon the regional office
that worked the claim, which eliminates deselection of claims that are
transferred to another regional office for processing. Reporting of
these claims will include the confidence intervals for each regional
office. VBA will ensure this work, known as ``brokered work,'' is not
underrepresented in quality reviews. No additional funding is required
at this time.
VBA is currently drafting an abstract describing our
sampling, assessment criteria, accuracy calculation, and reporting
methodologies for claim and issue-level accuracy. This abstract will
accompany future performance documents and public reports to explain
key differences between the claim-based and issue-based accuracy rates.
VBA is utilizing a Knowledge Management portal to make all
guidance and reference materials available to claims processors. This
portal will include the Adjudication Procedures Manual, M21-1, as well
as other interim guidance in one searchable location. This project is
being funded with existing resources and is expected to become
functional within the current fiscal year.
VBA is currently designing a new system that will
incorporate all types of quality reviews, to include local regional
office reviews, Systematic Technical Accuracy Review (STAR), and
consistency studies, which will capture data at various stages of the
claims process. This system will provide VBA with increased data
analysis capabilities for accuracy review and improved tracking of
error trends.
Question 30. In recent years, Congress has provided funding for a
number of initiatives to improve VBA's ability to handle its claims
workload, including the Veterans Benefits Management System, eBenefits,
and the Stakeholder Enterprise Portal.
a. Are there any initiatives that are not yet having the expected
impact on productivity? If so, please quantify the future increases in
productivity expected as a result of these initiatives.
Response. VBA is retraining, reorganizing, streamlining business
processes, and building and implementing technology solutions based on
the newly redesigned processes to improve benefits delivery. VBA
expects several transformation initiatives, as described below, to
continue increasing the number of claims and issues completed per FTE.
It is difficult to extract the impact of each transformation initiative
from the combined people, process, and technology models that are being
concurrently implemented to determine individual initiatives'
contribution to productivity outcomes.
VBA's transformation progress is the result of an integrated series
of initiatives designed to eliminate the backlog. The FY 2016 budget
will allow VBA to continue building on the success of the following
initiatives:
Veterans Claims Intake Program (VCIP): VCIP streamlines processes
for receiving digital records and data into the Veterans Benefits
Management System (VBMS) and other VBA systems, transitioning VBA from
a paper-based claims environment to a digital operating environment. It
scans paper claims, converts them into digital format, and extracts
important data for input into electronic folders. VCIP has converted
and uploaded more than 1.3 billion images from paper. In addition to
supporting scanning operations for incoming claims, VBA's FY 2016
request of $140.8 million will allow the digital intake of military,
income, and employment records from other Federal agencies and private
providers. This will broaden electronic evidence exchange for
processing all types of claims more accurately and more rapidly by
building additional interfaces for Official Military Personnel Folders
(OMPF) from DOD and interfaces with health networks, hospitals, and
private clinicians.
Centralized Mail: Centralized mail consolidates inbound paper mail
from VA's ROs to a centralized intake site. This initiative expands
VBA's capabilities for scanning and conversion of claims evidence,
increases electronic processing capabilities, and assists in converting
100 percent of received source materials to electronic format. VBA has
deployed centralized inbound mail for all ROs. The FY 2016 budget
request of $18.3 million provides resources to sustain operations at
all 56 ROs and positions VBA to expand centralized mail operations to
other lines of business and centralize outbound correspondence to
Veterans.
Veterans Benefits Management System: VBMS, as VBA's key business
transformation initiative, provides a paperless claims-processing
environment and improved business processes to support timely, high-
quality decisions for Veterans and their dependents. National
deployment of VBMS was completed June of FY 2013 and provides access to
over 28,000 end users. VBMS allows VBA to centrally manage the claims
workload at the national level and direct cases electronically across
its network of ROs to more efficiently match claims demand with
available processing capacity. VBA went from touching 5,000 tons of
paper annually to now processing 95 percent of the claims inventory
electronically in VBMS. VBA has now completed over 1.32 million claims
in VBMS. In FY 2015, VBMS is focused on delivering the National Work
Queue (NWQ) and reducing reliance on legacy systems. In FY 2016, VBMS
enhancements will focus on the Integrated Disability Evaluation System,
appeals, and pension.
National Work Queue: VBA will distribute claims electronically from
a centralized queue based on RO capacity using the electronic NWQ, a
national workload management strategy. With all claims placed in the
electronic NWQ, Veterans' claims will be automatically directed across
all ROs to efficiently match claim demand with available expertise and
processing capacity regardless of RO jurisdiction, delivering benefits
to Veterans more quickly and accurately. The electronic inventory
provides real-time updates, no matter where the claim is assigned for
processing. Veterans are still able to receive assistance with their
claims by visiting their RO for personal assistance at the public
contact sites, going on-line through eBenefits, and utilizing VBA's
National Call Centers. In FY 2016, VBA is requesting $3.2 million to
provide the requisite funding to resource and support 13 employees to
manage the NWQ across the VBA enterprise.
Veterans Relationship Management: The VRM initiative continues to
facilitate an increasingly more Veteran-centric digital operating
environment. VRM is delivering a scalable, enterprise-wide, services-
based technology environment that will be the foundation for how
Veterans are served and how benefits and services are delivered. This
new model will provide VA an integrated services delivery platform with
the approach of placing the Veteran at the center of the service with
all business requirements and design being driven from the Veteran
perspective.
Components of VRM include eBenefits, the Stakeholder Enterprise
Portal (SEP), Customer Relationship Management solutions, Digits-to-
Digits, Knowledge Management, and Veterans Online Application Direct
Connect. Through the eBenefits portal, Veterans can submit claims for
benefits, administer their accounts, and receive status updates. The
eBenefits Web portal standardizes claim intake and enables
collaboration with VSOs to assist Veterans with all interactions with
VA. VA continues to expand the capabilities available through the
eBenefits portal as more Veterans use the site. Today eBenefits has 4.4
million registered users and over 48 million visits annually. VBA's FY
2016 request for $13.8 million, in addition to the $67 million
requested for VRM in the Office of Information Technology, will support
ongoing operations and continued efforts to pilot and deploy new
solutions for VBA mobile applications that expand access to self-
service tools and benefits/services information in VBA portal
environments; develop new service features in SEP for medical
providers, loan officers, fiduciaries, and funeral directors; and
integrate VetSuccess with Career Center for Veterans, enabling searches
for jobs posted by unique employers targeting Veterans.
b. What metrics does VA utilize to determine whether overall
efficiency is improving as a result of those investments? Do those
metrics take into account the percent of work completed during overtime
rather than during regular hours?
Response. Through VBA's claims transformation initiatives, the
number of claims completed per compensation and pension direct FTE
increased 25 percent from 2012 to 2014. An even more accurate
representation of VBA's increase in productivity is seen at the medical
issue-level rather than the claim-level. From 2009 to 2014, VBA's
issue-level productivity increased by 67 percent.
It is difficult to extract the impact of each transformation
initiative from the combined people, process, and technology models
that are being concurrently implemented to determine individual
initiatives' contribution to productivity outcomes. The productivity
metrics include work completed on overtime.
Question 31. The fiscal year 2016 budget request includes a
proposal to limit the circumstances under which VA is required to
provide a medical examination for a veteran seeking disability
compensation. Under that proposal, an examination would be provided by
VA only if there is ``objective evidence establishing that the Veteran
experienced an event, injury, or disease during military service.'' VA
estimates that this change would lead to cost savings of $438 million
over 10 years.
a. Please provide any available statistics on how frequently
disability claims are ultimately granted in the circumstances where an
examination has been provided even though the veteran did not have such
objective evidence. Alternatively, please provide any statistics on how
frequently a claim is ultimately denied under those circumstances.
Response. VA does not maintain data regarding grant rates based on
specific evidence that may or may not have been present. After
separation from service and with the passage of time, the rate VA
denies service-connected disability significantly increases. In FY
2013, VA denied 42 percent of issues for conditions that were not
caused by service for Veterans who submitted claims within one year of
discharge; 66 percent of issues submitted by Veterans who filed a claim
between 10 and 20 years after discharge were denied on this basis.
While claimants from both categories were provided medical examinations
to support their claims, the disproportionate number of denials seen
when a claim is filed longer after separation suggests a large portion
of medical examinations were scheduled unnecessarily.
b. Please provide the calculations and assumptions used to
determine the estimated cost savings of this initiative.
Response. The methodology to calculate cost savings was based on
data showing claims with an exam request that were denied because a
disability was not incurred in or caused by service or because there
was no diagnosis. Based on this data, VA assumed 30 percent of an
estimated 166,000 exams would result in a denial of claimed conditions
being associated with Veterans' military service. An estimated 75
percent of these denied exams could be presumed as savings under this
proposal since an exam would not be warranted.
general administration
Question 32. The Office of Small and Disadvantaged Business
Utilization's (OSDBU), Center for Verification and Evaluation (CVE) is
charged with verifying veteran businesses looking to take advantage of
veteran specific VA contracting preferences. There have been
legislative proposals presented to move CVE outside of VA or to another
office under the Secretary.
a. What are VA's views of proposals to move CVE to another Federal
agency and is the current organization best positioned to verify
veteran businesses?
Response. VA does not support moving CVE to another agency. CVE is
responsible for verifying the eligibility of VOSBs for the VA Veterans
First procurement preference program under 38 U.S.C. Sec. 8127. We do
not believe it appropriate to have important elements of a VA program
performed by other agencies. CVE is best positioned to verify Veteran
businesses as it resides in the Office of Small and Disadvantaged
Business Utilization, the organization responsible for promoting
Veteran access to contracting opportunities within VA. Since the
primary benefit of verification is to establish eligibility for VA
contracting opportunities, having the CVE verification function within
OSDBU appropriately places these closely related functions together.
b. Additionally, it has been suggested that other agencies do not
have the infrastructure in place to verify veteran businesses. What
analysis has VA performed on the budgetary implications of instituting
a governmentwide certification program for veterans in terms of cost
and FTEs required?
Response. There are no comparable authorities and thus no
comparable programs within the Federal Government. VA's verification
program is unique among government programs, although the closest
comparable programs are found within SBA. SBA has an SDVOSB program and
the 8(a) business development program. However, while the SBA's SDVOSB
program has similar regulations to VA's, entry into the program is
based on self-certification rather than an up-front verification of
eligibility of all applicants. SBA reviews SDVOSB eligibility only if a
protest is filed by an interested party against a prospective awardee,
and only a very small percentage of SDVOSBs are ever actually reviewed
to ensure compliance.
Second, while the 8(a) program does review its applicants before
granting admittance to the program, the requirements are different, and
concerns ``age out'' of the program. For example, since the 8(a)
program provides business development assistance, the program requires
applicants to show potential for success. Government and private sector
contracts are awarded to an 8(a) firm as part of the participant's
business plan for development. These criteria have no counterpart in
the VA verification program. The 8(a) program therefore not only sees
far fewer applications, but it also deals with a significantly smaller
database of participants at any time.
By contrast the VA has increased its infrastructure capacity, to
include professional development and training as well as contract and
legal support. VA has also refined and documented its processes. VA's
current processes are appropriate for replication and scale. VA has not
done analysis of the budgetary implications of a governmentwide
verification program as the Administration has not established a
position on such a program. Should a decision be made on governmentwide
verification, we believe that it would be most cost-effective to scale
up the CVE program by obtaining additional personnel to cover the
workload and apply already-existing processes and criteria, rather than
creating new infrastructure in other agencies.
c. Does VA have the capability to administer a governmentwide
certification program or would a more effective verification program be
housed outside of VA?
Response. VA's VOSB verification program has the capability to
rapidly increase and support the scale of a governmentwide program
expansion. VA could obtain additional personnel to cover the workload
and apply already-existing processes and criteria, whereas other
agencies would have to develop these capabilities.
d. What estimates does VA have of the current cost per applicant to
CVE and what are VA's estimates of those costs government wide?
Response. The estimated average cost to process one application
through CVE in FY 2015 is $1,242. We do not have an estimate of these
costs governmentwide. As noted previously, no other agency has a
similar verification function that can be used as a comparison.
Question 33. The chart, ``Summary of Employment and Obligations,''
for the Office of Acquisitions and Logistics Supply Fund does not
include FTE information specifically for CVE.
a. Please provide the Committee with the FTE requirements for CVE
for fiscal year 2016 and the preceding three years.
Response. The number of Federal FTE in CVE for the period 2013-
2016: 2013: 16 2014: 17 2015: 17 (one position vacant) Projected 2016:
21 (Requested addition of 4 Federal staff to review evaluations).
b. Please provide the Committee with a detailed budget for OSDBU
and CVE.
Response. The FY 2015 Budget for OSDBU and CVE is provided below:
2015 Approved Budget As of 05/07/2015
------------------------------------------------------------------------
(000s of dollars)
---------------------
CVE All OSDBU
------------------------------------------------------------------------
FTE............................................... 17 42
Obligations:
FTE............................................. $2,471 $6,660
Professional Services........................... $7,387 $17,214
Travel.......................................... $30 $102
Training........................................ $15 $54
Printing and reproduction....................... $1 $30
Contract Support................................ $5,843 $7,183
Supplies and materials.......................... $8 $48
Equipment....................................... $2 $80
Rents........................................... $301 $523
Security........................................ $20 $52
---------------------
Total obligations............................. \1\ $16,0 \2\ $31,9
78 46
------------------------------------------------------------------------
\1\ CVE budget includes an increase in budget authority of $4.511
million for contract support and professional services since January
2015.
\2\ OSDBU budget reflects the increases in CVE budget and an additional
authorization for non-CVE items of $1.736 million
information technology
Question 34. In the fiscal year 2016 budget, VA is proposing
raising from $1 million to $3 million ``the threshold at which a
request is required [to] be made from both Houses of Congress prior to
the transfer of funds between projects.''
a. Please provide further explanation for this request and what
specific projects would require a transfer of funds.
Response. Under current law, VA's IT Systems appropriations account
is divided into three subaccounts--pay/administration, operations and
maintenance, and development. The development subaccount is further
divided into a number (roughly a dozen) project lines. Each subaccount
and each project line are assigned a certain amount of funds. During
the course of the year as funds are executed, an under execution of
funds may occur for a variety of reasons; proper stewardship suggests
that these under-executed funds be reprogrammed to other high priority
needs. Historically, the annual appropriations act has included
language requiring that VA request and receive the approval of the
Committees on Appropriations of both Houses of Congress before
reprogramming funds among the three subaccounts and/or shifting funds
among development projects. The requirement has remained constant over
the years, while the IT Systems appropriations account has grown
significantly. This modest increase in the threshold at which
permission must be sought for reprogramming will allow for more
effective management of resources within the IT Systems Account.
b. Please provide a list of all transfer of funds VA has requested
for Information Technology (IT) projects for the past two fiscal years.
Response. The Re-programming letters for both FY 2013 and FY 2014
are attached, and include a list of projects that required funding
transfers.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 35. VA has requested $1.828 billion to maintain the
current IT infrastructure. Of that, $376.2 million is for IT support
contracts. This is approximately a $106 million increase from fiscal
year 2015. Please provide the Committee with a breakdown of current and
expected support contracts' vendors and costs.
VA Response, VA is making significant investments to improve IT
infrastructure to support the new IT capabilities developed over the
past 5 years. While the budget for IT Support Contracts increases in FY
2016, it is worth noting that the Department continues to strive for
providing the most effective and efficient support of its
infrastructure used to move data around the country as is possible. The
Department also continues its efforts to improve transparency and
accuracy in the classification of funds used to support the IT
infrastructure of VA. In developing its 2016 budget, VA also sought to
improve accuracy and transparency--some items in FY 2015 were IT
support contracts, but were not correctly classified as such. In
developing the FY 2016 budget, IT infrastructure contracts are properly
classified, with the effect that other lines in the IT infrastructure
category showed decreases between FY 2015 and 2016. The IT Support
contracts that will be supported by the $376.2 million request in FY
2016 are expected to require obligations on the same order in FY 2015.
The list of contracts for FY 2015 is below. This list is divided
into two parts. The first part identifies six large contract items for
$112 million. The second list documents some 289 small contracts, most
of which are on the order of a few hundred thousand dollars each--the
total of these is just over $264 million. The vendors that would
address these contracts in FY 2016 will be determined through
competitive processes consistent with Federal Acquisition Regulations.
------------------------------------------------------------------------
Planned Contracts
Large Contracts Total Required
------------------------------------------------------------------------
CRISP Surge................................... $12,106,232 1
Help Desk..................................... $52,984,797 2
PAID to the new HRIS SSC...................... $11,350,356 1
Testing Service Support....................... $23,689,992 1
VBMS.......................................... $12,000,000 1
-------------------------
Total..................................... $112,131,377 6
------------------------------------------------------------------------
------------------------------------------------------------------------
Planned Contracts
Other IT Support Total Required
------------------------------------------------------------------------
Electronic Health Record Interoperability..... $13,913,082 8
Health Administrative Systems--INTER.......... $759,456 1
Health Administrative Systems--MED............ $5,794,924 12
Health Provider Systems/Access to Care........ $568,542 2
Human Resources Information System (HRIS)..... $9,224,688 9
IT Support Contracts--BENE.................... $22,162,653 18
IT Support Contracts--ENT..................... $16,565,356 14
IT Support Contracts--MED..................... $88,204,720 128
Memorials Development......................... $2,000,000 7
New Models of Health care..................... $17,123,453 12
Veterans Benefits Management System (VBMS).... $38,151,800 20
Veterans Relationship Management (VRM)........ $49,732,864 58
-------------------------
Total..................................... $264,201,539 289
------------------------------------------------------------------------
Question 36. GAO recently outlined how Federal IT investments have
historically been plagued by failures and cost overruns resulting in
billions of dollars of taxpayer money wasted. Specifically, GAO cited
VA's Financial and Logistics Integrated Technology Enterprise program
and VA's Scheduling Replacement project as examples of waste. Please
detail what specific steps VA has taken to incorporate GAO's
recommendations for successful IT management.
Response. In order to address systemic IT project delivery
challenges, VA established the Project Management Accountability System
(PMAS) in June 2009. PMAS establishes a discipline which ensures the
customer, IT project team, vendors, and all stakeholders invested in an
IT project focus on a single compelling mission--achieving on-time
project delivery. PMAS facilitates relationships which ensure customer
needs are met, minimizes waste in IT investments and reduces project
management and technical risks. Additionally, PMAS rebalances IT
requirements with available staffing, focuses IT efforts by funding
only projects with adequate resources, and enables VA to intervene in
projects as soon as problems arise. In other words, under PMAS, VA can
easily determine that if VA IT projects are going to fail, they will
fail early and fail fast, allowing VA to more immediately correct or
close IT projects which are not succeeding.
PMAS also allows VA to actively address the nine critical factors
highlighted by GAO in GAO-15-290 ``High Risk Series: An Update.'' As
shown in the following table, VA's Information Technology (IT)
management methodology directly addresses the nine critical factors
identified by GAO to support the objective of improving the management
of large-scale IT acquisitions across the Federal Government:
VA's Implementation of GAO's Nine Critical Factors
------------------------------------------------------------------------
GAO's Nine Critical Factors VA's Implementation Steps
------------------------------------------------------------------------
(1) Program officials actively VA delivers IT capabilities
engaging with stakeholders through its Integrated Project Team
(IPTs); IPTs include the project
staff, the business sponsors and
stakeholders working together and
sharing responsibility for
delivering IT capabilities on time
Senior leaders review the
work of the IPTs at all Milestone
Reviews, which are gateways for
continued development
In VA, our term for program
officials is ``senior leaders".
Senior leaders constantly interact
with stakeholders, which are a part
of our project teams and business
sponsors
Senior leaders also engage
with stakeholders when projects
experience risk that could prevent
an on time delivery; project
managers and senior leaders meet
weekly to mitigate risk to get a
project or increment back on
schedule
------------------------------------------------------------------------
(2) Program staff having necessary VA ensures all IT Project
knowledge and skills Managers have completed the Federal
Acquisition Corp Project/Program
Management (FAC P/PM) certification
course and also provide them with
opportunities and support to earn
their requisite annual continuing
learning education credits.
In VA, senior leaders
review the composition of all IPTs
and do not approve the project to
proceed unless the IPT and project
team are staffed with individuals
that have the necessary knowledge
and skills to deliver the agreed to
IT capability on time
VA's Office of Information
& Technology (OI&T) provides a
resource management process that
enables project teams to request
staff members with the requisite
knowledge, skills and experience to
make the IPT successful
------------------------------------------------------------------------
(3) Senior department and agency VA's Chief Information
executives supporting the Officer (CIO) and all Deputy Chief
programs Information Officers (DCIOs) invest
significant time each week to
ensuring its IT management
framework is being fully and
completely executed
Weekly, senior leaders
review and approve projects which
believe they are ready for the next
phase of development
Weekly, senior leaders also
support the risk mitigation process
by participating in and providing
the intervention/resolution
requested to reduce risk
VA CIO reviews the progress
of execution weekly and monthly and
authorizes changes to the policy
and process as needed
------------------------------------------------------------------------
(4) End users and stakeholders The business sponsor/
involved in the development of customer creates and approves a
requirements Business Requirements Document
before starting IT development
Milestone Review Board will
not approve a project to move
forward without a signed BRD
Stakeholders, business
sponsors and any designated end
users are all members of the IPT
Milestone Review Board will
not approve a project to move
forward without an effective IPT
------------------------------------------------------------------------
(5) End users participating in Business sponsors and end
testing of system functionality users participate in reviews of
prior to end user acceptance code prior to also participating in
testing User Acceptance Testing (UAT),
which is an essential part of VA's
process for delivering IT
capabilities
The Agile methodology,
which is embedded in VA's IT
delivery approach, requires--and VA
enforces-near continual
participation of end users and
business sponsors as part of the
sprint delivery process
------------------------------------------------------------------------
(6) Government and contractor VA has re-structured the
staff being stable and consistent method by which it staffs projects.
VA uses a competency model to
ensure timely, efficient and
consistent staffing of all
projects.
Projects are not allowed to
start or continue work if they do
not have all required staff
assigned to a project
VA also requires all
projects to have stable, consistent
staffing of all IPTs
Milestone Reviews review
the composition of all IPTs and
inquire as to whether the project
manager is having any issues with
IPT staff composition
Project managers can seek
immediate help for any loss of
resources via the risk mitigation
process
OIT's staffs projects via a
resource management board to ensure
the fair and consistent assignment
of staff to projects
------------------------------------------------------------------------
(7) Program staff prioritizing VA's IT delivery framework
requirements requires the IPT members to work
together to develop an agreed set
of requirements; establishing the
priorities for these requirements
is an essential element of this
process and for creating and
approving the BRD
IPTs constantly review
their agreed set of requirements
and ensure over time that
priorities remain correct
Use of the Agile framework
also enforces the consistent
prioritization and re-
prioritization (as necessary) of
requirements
------------------------------------------------------------------------
(8) Program officials maintaining IPTs are the organizational
regular communication with the entity for ensuring program
prime contractor officials have regular
communications with the prime
contractor; representatives of the
prime contractor attend IPT
meetings and are responsive to the
project manager to provide
contractual deliverables
At a minimum IPTs meetings
are held bi-weekly; but most are
held weekly
------------------------------------------------------------------------
(9) Programs receiving sufficient No project can start or
funding continue work unless it has
sufficient funding for success
If funding is lost mid-
development, the project is paused
until a determination can be made
to either restore funding or cease
work
No project is expected to
be successful and make on-time
deliveries if funding is not
sufficient
------------------------------------------------------------------------
The preceding table defines the steps that VA has taken to
incorporate GAO's recommendations for successful IT management.
By following these steps, over the past five years (FY 2010--March,
FY 2015), VA has achieved an on-time delivery rate of 83% (through the
end of March 2015), and an overall delivery rate of 92%. As noted in
GAO-14-361 Report ``Information Technology: Agencies Need to Establish
and Implement Incremental Development Policies'' released on May 8,
2014, GAO reviewed five agencies' incremental development approaches.
Of the agencies surveyed, VA was the only Federal agency to meet all
three evaluation factors, which were delivery of functionality every 6
months, well-defined functionality, and defining a process for
enforcing compliance.
______
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
to U.S. Department of Veterans Affairs
health care
Non-VA Care
Question 37. What tangible steps has VA taken to ensure
coordination of non-VA care options, particularly in conjunction with
the new Choice Program that to date has seen low utilization?
Response. The Chief Business Office Purchased Care (CBOPC) will
continue bi-weekly calls with VA Medical Center staff and the Choice/
Patient-Centered Community Care Third Party Administrators (TPAs) that
address usage, utilization strategies, and communicating newly
implemented work flow processes associated with both programs. CBOPC
has increased the frequency of direct communications and onsite visits
with VA medical centers (VAMCs) that have low utilization of Choice and
PC3. In addition, CBOPC is communicating with VAMC Directors to keep
them informed of PC3/Choice provider network efforts, cost benefits,
and barriers to current utilization.
Public Law 114-41, the Surface Transportation and Veterans Health
Care Choice Improvement Act of 2015, included amendments to the
original Veterans Choice Program as well as instruction for VA to
review the statutory authorities VA has for purchasing Veteran
healthcare in the community and to recommend a plan to consolidate
these programs into a single program to be known as the ``Veterans
Choice Program.'' With this initiative VA assigned a special team of
subject matter experts to develop the plan for submission to VA
leadership, OMB and ultimately Congress. The outcome of this work is
expected to provide a more streamlined authority for VA to purchase any
care in the community.
Question 38. What level of funding included in the President's
budget request would be used to ensure VA is adequately communicating
with veterans and providers about the availability of non-VA care
options and how they work? How are veterans who don't meet the
eligibility criteria for the Choice Program informed of other fee-basis
care options?
Response. At this time, how much of the President's budget is used
to communicate with Veterans and providers regarding non-VA medical
care is unknown. However, CBOPC ensures that communication is available
to providers and Veterans. One avenue of such communication is the
CBOPC Web site, http://www.va.gov/PURCHASEDCARE. The CBOPC Web site
provides information for non-VA medical care providers on the
submission of claims and other pertinent information for their offices
and also contains many references for Veterans, including how to
request non-VA medical care. Additionally, VA facilities have pamphlets
and brochures that also describe non-VA medical care options.
Veterans who do not meet the Choice eligibility requirements may be
referred for non-VA medical care if the care needed is not available at
the VA facility. Once a Veteran has been referred for non-VA medical
care, the local Non-VA Care Coordination Office (NVCC) will make
contact and work with the Veteran to identify a non-VA provider. Once
the non-VA provider has been identified, the local NVCC office will
coordinate with Veteran and the non-VA medical provider to schedule an
appointment for the needed medical care. The NVCC office will continue
to coordinate with the non-VA medical care provider and the Veteran for
any additional needed medical care, whether through the non-VA provider
or the VA facility.
Question 39. Given the intense spotlight placed on exceptionally
long-wait-times thousands of veterans faced across the country last
year, what is VA doing to ensure local VHA staff are better informed
about how and when to use non-VA care?
Response. A Choice intranet site has been developed that includes
training material and a resource toolkit for VA employees. The resource
toolkit includes recorded training sessions, fact sheets, Frequently
Asked Questions (FAQs), and information for Veterans, Veteran Service
Organizations, and the Public. Additionally, each VA health care
facility has designated Choice Champions to provide VA staff and
Veterans with information and guidance on the Choice Program. To
support the Choice Champions, a Pulse Web site was created to provide a
forum for discussing questions and issues relating to Choice Program
implementation; a monthly call has been established (starting in
April 2015, it will be bi-weekly); and a Choice Champions email group
was developed to also address outstanding issues and to disseminate
timely information.
In addition, Veterans Health Administration (VHA) staff can find
information about the use of non-VA medical care on the CBOPC's
National Non-VA Medical Care Program Office (NNPO) intranet site.
Included on that site are policies, procedures, training, memorandums,
fact sheets, handbooks, directives, and access to a Question and Answer
(Q&A) database. Also located on the NNPO intranet site are copies of
the bi-weekly publication, The Bulletin, which contains articles
specifically for non-VA medical care staff at VHA health care
facilities. Moreover, NNPO conducts monthly calls with non-VA medical
care staff and also provides visits to VA health care facilities to
support Non-VA Medical Care Managers and Business Operations through
process improvement plans, training, data analysis, and communication
tools.
Finally, a Patient-Centered Community Care (PC3) intranet site is
available for VHA staff that includes presentations, training, fact
sheets, and reference guides. Bi-weekly meetings are held with
designated VHA staff aimed toward education and promoting the use of
PC3.
Formularies
Question 40. For soldiers transitioning from active duty,
continuity of health care, particularly as it relates to treatments for
mental health conditions can be extremely important. The VHA Directive
issued on January 20, 2015, indicates that VA providers are not to
discontinue mental health medications based solely on ``differences
between the VA and DOD drug formularies, VA Criteria-for-Use, or the
cost of the drug.''
a. Does VA have the necessary resources to implement this directive
by the March 13, 2015, and to provide appropriate oversight to make
sure that clinicians are conforming to the policy?
Response. Yes, VA has the necessary resources. The Directive
describes long-standing VHA practices which have been in place since
approximately 2006, so in essence the Directive is already implemented.
VHA recently conducted an in depth analysis of its practices to
continue mental health and pain medications in Servicemembers
transitioning from DOD to the VA healthcare system. This review found
very few exceptions where the practice that is now policy was not being
followed (21 exceptions of 2,000 Servicemembers evaluated). VA plans to
periodically repeat the analysis to ensure that the Directive is being
followed.
b. Does VA anticipate significant increased expenses due to paying
for these treatments which may be more expensive than what the
clinician would prescribe for a veteran who is outside of the
transition period?
Response. For the specific population impacted by the Directive
(i.e., Servicemembers transitioning their care from DOD to VA who are
receiving mental health medications from DOD) VA does not expect
significant increases because our practice has been to continue those
medications when clinically safe and appropriate. VA would only
anticipate large increases in expenses if this policy were expanded to
other drug classes and to all VA beneficiaries (i.e., not just
transitioning Servicemembers who are receiving mental health
medications from DOD).
Accountability
Question 41. If VA were given the authority to make a change to
the Title 38 Appointment and Compensation System for Medical Center and
Network directors, how does the Department intend to ensure these
individuals are meeting VHA's performance goals?
Response. The Department of Veterans Affairs (VA) intends to ensure
Medical Center Directors and Network Directors meet Veterans Health
Administration's performance goals through the existing performance
management process. A Title 38 appointment for senior executives will
not change the current Performance Management System. VHA's current
Title 38 executives are held to the same performance standards as
members of the Senior Executive Service (SES).
The Deputy Under Secretary for Health for Operations and Management
conducts quarterly reviews with Network Directors to evaluate their
performance and the performance of their organizations against desired
outcomes consistent with the senior executives' performance plans.
These reviews include assessment of leadership's capacity to promote
and support effective governance, integrity, and high reliability.
Other focus areas include: Quality Improvement, Patient Safety,
Environment of Care, Veteran Experience, Customer Service and Workforce
Training/Readiness.
VHA conducts a comprehensive performance review annually of each
senior executive, including SES and Title 38 SES Equivalents, in
accordance with VA Handbook 5027 and the VA SES and Title 38 SES-
Equivalent Performance Management Systems policy. VHA complies with law
and Department policy related to executive performance evaluation. The
SES or SES Equivalent prepares an assessment, which documents their
accomplishments throughout the performance year; the supervisor
provides an evaluation, and the Reviewing Official conducts a second
level review to rate the executive's performance. VHA's Performance
Review Committee reviews all VHA evaluations and makes rating
recommendations to the VA Performance Review Board (PRB). The PRB
reviews all VA SES and SES Equivalent performance appraisals and makes
rating recommendations to the Secretary, who has final decision
authority of the rating of record.
Question 42. Why has VA not set out more ambitious projections for
itself in the strategic framework outlined by VHA's National Leadership
Council, especially as it relates to satisfaction measures of veterans?
Response. The Department of Veterans Affairs (VA) is implementing
an historic department-wide transformation, changing VA's culture and
making the Veteran the center of everything we do. Transformation must
start with organizational reforms to better unify the Department's
efforts on behalf of Veterans. These reforms, which will take time,
center on the ICARE values. These reforms include the Department's
``MyVA'' initiative, which reorients VA around Veteran needs and
empowers employees to assist them in delivering excellent customer
service to improve the Veteran experience. VHA's Blueprint for
Excellence is aligned with the Department's Strategic Plan and supports
the ``MyVA'' initiative. The Blueprint lays out themes and supporting
strategies for the transformation to improve the performance of VA
health care now and offers a common framework for action with VHA's
Strategic Plan. The overarching principle is our focus on the Veteran
experience.
While VA is in a process of transformation, VHA is in the process
of developing performance measures and targets for 1) Veteran
experiences of Access to routine, urgent, and specialist care; 2) self-
management support; and 3) overall rating of their inpatient and
outpatient care and their VA provider. To achieve a high level of
performance, much work has to be done over a sustained period of time
to ensure we hire the right numbers of staff, build the right networks
of community-based providers, train our staff using the correct core
values and skills, and ensure the supporting infrastructure that
guarantees a high degree of reliability. Furthermore, how Veterans rate
their experience will also depend on the trust they place in us. We
recognize that rebuilding that trust takes time and we are committed to
providing high quality, proactive, personalized patient-drive care to
Veterans and strive to improve our services.
Antibiotic Resistance
Question 43. In January 2014, VA issued a Directive requiring VA
medical facilities to implement antimicrobial stewardship programs.
Addressing the urgent, growing problem of antimicrobial resistance will
require both the development of new antibiotic products and the
stewardship of existing products. VA facilities, as well as private
sector facilities, must implement meaningful stewardship programs to do
their part in avoiding unnecessary and very difficult to treat
infections.
a. What is the current status of the VA directive on antimicrobial
stewardship programs, and are there any plans to share data and lessons
learned from stewardship programs among facilities and with other
stakeholders?
Response. The Antimicrobial Stewardship Programs Directive (VHA
Directive 1031) requires all VHA facilities to implement, maintain and
evaluate an Antimicrobial Stewardship Program. A national field survey
has been developed to determine compliance with Directive 1031 and is
awaiting final approval from 10N for dissemination. Data and resources
are shared through educational webinars and made available on a VHA
SharePoint site for use by antimicrobial stewardship champions in the
field.
b. Does VA have resources available to address any changes that may
be necessary within facilities based on what is learned from
stewardship programs?
Response. This initiative has no designated funding and relies on a
core group of highly productive field volunteers, the National
Antimicrobial Stewardship Taskforce. There is no fenced facility-
specific funding for stewardship; such funding would fall under the
facility's general medical resources as part of patient care.
Women Veterans
Question 44. As more and more women are becoming veterans, it
becomes even more important that VA provides gender-specific services
such as obstetrical and gynecology specialty care. However it is also
important that VA services generally available are appropriate for
women. For instance, primary care, cardiology and mental health options
must be equally available to women as they are to men. How will the
funding in the President's budget request ensure that all appropriate
services available within VHA are accessible to women and that primary
care providers are counseling women veterans about risks specific to
women such as potential risk of birth defects associated with
prescribed medication?
Response. To provide the highest quality of care to women Veterans,
VA offers women Veterans assignments to trained and experienced
Designated Women's Health Providers (DWHP) who can provide general
primary care and gender-specific primary care in the context of a
longitudinal patient/provider relationship. Today, DWHPs are available
at 95 percent of VA medical centers (VAMC), and 84 percent of
community-based outpatient clinics in comparison to 2009 when women's
health providers were at only 33 percent of VAMCs. VA plan is that
whenever a woman Veteran enters the health care system, she will have
access to a DWHP. To meet this plan, VA must ensure that all new
primary care hires are proficient in the care of women as well as men.
VA is continuing to train and update skills of current VA primary care
and emergency providers in the care of women. Since 2008, VA has
provided intensive training to over 2,000 women's health providers and
provided over 50 different online, accredited women's health classes,
which can be taken 24/7 to enhance the flexibility of learning
opportunities for employees. The combination of educational offerings
provides not only basic training in women's health but advance courses
so that providers and other staff can keep their skills and knowledge
up-to-date.
VA is raising awareness of cardiovascular risk in women Veterans
through collaboration with the American Heart Association's Go Red for
Women Movement. VA's national Women's Veterans Cardiovascular Work
Group, published the State of Cardiovascular Health in Women Veterans
Report and in February, 2015 encouraged all sites to develop specific
cardiovascular risk reduction programs for women through a national Go
Red Challenge.
VA is raising awareness of preconception care for women Veterans
and VA providers by expanded training in preconception care to
providers serving high risk women and developing the Preconception Care
mobile application for providers as a tool to enhance and support the
integration of preconception care into primary care. By addressing
health and wellness before pregnancy, preconception care is an
essential component of well women care during the childbearing years.
VA has developed a national curriculum for primary care and mental
health providers addressing topics including the effects of pregnancy
and menopause on women's mental health and the effects of psychiatric
medications on reproductive health. Additionally, VA has developed a
national pharmacy order check that alerts providers of potentially
teratogenic medications through the computerized electronic medical
record. Later this year, a national Information Technology project, the
Notification of Teratogenic Drugs Project, will launch that will
enhance the current computerized order check. This will provide
enhanced electronic record functionality for providers to improve
patient safety when prescribing high risk medications to women of
reproductive age.
Question 45. Military Sexual Trauma (MST) has gained increased
recognition over recent years. VA estimates that of veterans receiving
VA health care, approximately one in four women and one in a hundred
men report experiences of MST during their military service. How much
does VA anticipate spending on treatment associated with MST? Please
describe how this funding would be utilized to adequately train all
appropriate staff, including schedulers and support staff on
sensitivity related to MST.
Response. VA's data on the prevalence of MST comes from its
universal screening program, which includes all Veterans seen for any
VA health care. It is important to note that not all Veterans who
disclose MST during screening need or are seeking MST-related
treatment, as many recover from their experiences without professional
care. Of those Veterans who are experiencing difficulties, their
presenting problems include a wide range of both mental and physical
health conditions. As such, the types and costs of MST-related care
will vary based on the specific health conditions for which Veterans
decide to seek treatment. The treatment provider makes the
determination whether a particular episode of care is MST-related for a
particular Veteran; this is indicated on a case-by-case basis in a
Veteran's medical record. Therefore the cost of providing MST-related
care is incorporated into broader health care costs for each VA
healthcare system; it is not feasible to treat MST as a separate line
item.
In FY 2014 VA reviewed Veteran utilization and cost data for
treatment episodes judged to be MST-related between FY 2009 and FY
2013, in order to estimate the total costs of VA outpatient and
inpatient care provided in those years. Projections for future costs in
years FY 2014-FY 2016 were also made based on utilization in past
years. These cost estimates (which include treatment for both female
and male Veterans) are provided in the table below.
Military Sexual Trauma Related Care
------------------------------------------------------------------------
Number of Male
and Female
Veterans
Year Receiving VA Obligations
MST-Related
Care
------------------------------------------------------------------------
FY 2009.................................. 65,264 $207,599,000
FY 2010.................................. 72,548 $256,193,000
FY 2011.................................. 80,688 $283,563,000
FY 2012.................................. 88,990 $308,156,000
FY 2013.................................. 96,807 $319,363,000
FY 2014*................................. 104,760 $346,913,000
FY 2015*................................. 112,814 $368,637,000
FY 2016*................................. 120,816 $389,527,000
------------------------------------------------------------------------
* Years FY 2014 through FY 2016 are based on projections of future costs
and therefore may be different than actual costs incurred in those
years.
MST-related education and training for VA staff MST training
initiatives occur at both the local and national level. At a local
level, every VA health care system has a designated MST Coordinator who
serves as a contact person for MST-related issues and can help Veterans
access VA services and programs. MST Coordinators help ensure that
local staff members receive mandated MST education and training, and
provide training as needed in clinics throughout the health care system
to ensure that staff members have the needed knowledge and skills to
work effectively with MST survivors. For example, MST Coordinators host
Grand Rounds and other educational presentations, distribute
informational materials, and provide clinical consultation. These
training duties are collateral to being full-time clinicians, so their
salary support comes from their primary role within their local VA
health care system.
Nationally, all VA mental health and primary care providers are
required to complete mandatory training on MST. Mental health providers
complete a web-based training on MST that provides a comprehensive
review of issues relevant to provision of mental health care to MST
survivors. Primary care providers must complete a web-based training
that reviews a range of issues including health conditions associated
with MST, screening sensitively for MST, how MST can affect a Veteran's
experience of healthcare, how to appropriately adapt care to address
the needs of MST survivors, and VA documentation requirements.
VA's national Mental Health Services program office funds a
national MST Support Team which is, in part, charged with coordinating
and expanding national MST-related training initiatives. For example,
the team hosts monthly continuing education calls on MST-related topics
that are open to all VA staff and available online afterwards. Since
2007, the MST Support Team has hosted an annual training focused on
MST-related program development as well as the provision of clinical
care to Veterans who experienced MST. The MST Resource Homepage is a VA
intranet community of practice Web site where VA staff can access MST-
related resources and materials, review data on MST screening and
treatment, and participate in MST-related discussion forums. In
addition, all VA staff have access to an online independent study
course on MST and other Web-based training materials.
The MST Support Team has also partnered with VA rollouts of
empirically-supported treatments for PTSD, depression, and anxiety to
include MST-specific information. These national initiatives train
therapists in evidence-based practices such as Cognitive Processing
Therapy (CPT), Prolonged Exposure (PE), Acceptance & Commitment Therapy
(ACT), and Cognitive Behavioral Therapy (CBT). Conditions targeted by
these treatments are strongly associated with MST, meaning these
national initiatives have been an important means of expanding MST
survivors' access to cutting-edge treatments.
The MST Support Team also conducts an ongoing National Review of
the Accessibility of MST Coordinators. This program is an innovative
``secret shopper'' initiative to survey the experiences a Veteran would
be likely to have in attempting to reach an MST Coordinator via
telephone. This initiative was expanded in FY 2014 in order to help
maintain improvements and continue progress toward the goal of ensuring
Veterans are able to reach the MST Coordinator at every health care
system. The latest round of this review is currently underway. In
conjunction with the review, MST Coordinators are encouraged to provide
training to frontline staff, such as clerks and telephone operators, on
how to appropriately and sensitively assist MST survivors. The MST
Support Team has developed handouts and tips sheets to support MST
Coordinators in these efforts.
Also, in conjunction with Sexual Assault Awareness Month (April)
2015, the MST Support Team is releasing a new MST sensitivity training
video titled, ``You can make a difference: Honoring Veterans who
experienced MST.'' To underscore the importance of being sensitive to
the needs of MST survivors, Secretary McDonald provides an introduction
to the video; Veteran Ruth Moore also appears in the video to share her
perspectives on how every VA staff member can assist Veterans who
experienced MST. The video and associated training materials are
applicable to all VA staff but particularly designed to target
frontline staff. MST Coordinators will use the video in awareness-
raising events during Sexual Assault Awareness Month, as well as in
ongoing efforts related to the National Review of the Accessibility of
MST Coordinators and training of frontline and support staff more
generally.
benefit programs
Disability Compensation Claims System
Question 46. Provide the methodology utilized to allocate
personnel and resources to the regional offices and specifically
address any refinements made to this methodology in the past fiscal
year. In discussing refinements made over the past fiscal year, please
specifically address VBA's Office of Strategic Planning efforts to
design a workforce capacity model.
Response. Please see the attached VBA Workforce Analysis submitted
to Congress on March 2, 2015.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 47. In 2009, VA began an effort to update the VA Schedule
for Rating Disabilities.
a. Provide an itemized list of funding expended in FY 2015 on the
rating schedule modernization.
Response. For FY 2015, VBA budgeted $3.1 million to update the VA
Schedule for Rating Disabilities (VASRD), including $956,000 for pay
and benefits, $30,000 for travel, $2.0 million for an earnings loss
study, $46,000 for rent; and $54,000 for supplies and other services.
b. Provide an itemized list of the requested funding in FY 2016 for
the rating schedule modernization. Also, include the number of FTE
assigned to or supporting this modernization effort.
Response. For FY 2016, VBA requests $3.1 million to update VASRD,
including $960,000 for pay and benefits, $30,000 for travel, $2.0
million for an earnings loss study, $46,000 for rent, and $54,000 for
supplies and other services. Five employees are currently assigned to
support the VASRD modernization effort.
c. Provide the Project Management Plan, the VASRD Update Operating
Plan and project schedule for the rating schedule modernization.
Response. Please see the attached Project Management Plan. VBA does
not have a VASRD Operating Plan. Table 2 in the Project Management Plan
shows the stages of concurrence for each body system. Since the Plan
was last updated, proposed rulemakings for several systems have been
published. VA understands the importance of updating the Rating
Schedule and will ensure the completion of updates as each system
proceeds through concurrence.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
d. Does the FY 2016 request include any funding to support updates
that will need to be made to IT solutions, including VBMS, disability
benefit questionnaires, rules-based calculators, or other initiatives
based on the current VASRD? How much funding does VA anticipate these
updates will require upon publication of final rules for the various
body systems?
Response. Yes, the FY 2016 request includes funding to support
updates that will need to be made to IT solutions, including VBMS,
related to the VASRD modernization project. This funding is included in
OIT's budget request for sustainment of IT systems.
Question 48. Provide the number of FTE assigned to or supporting
VA's accreditation program. Also, provide the following information for
calendar years 2014.
Response. The Office of the General Counsel's (OGC) accreditation
program currently has six full-time employees (two permanent GS-7
employees, two temporary GS-7 employees, one permanent GS-8 employee,
and one permanent GS-11 employee) assigned to the accreditation program
as well as three-fourths of a Deputy Chief Counsel position (formerly
titled as Deputy Assistant General Counsel) and approximately one-tenth
of a Chief Counsel position (formerly titled Assistant General
Counsel). In calendar year 2014, the program had three full-time
employees (one GS-7, one GS-8, and one GS-11 (from June 2014 to
December 2014)) assigned to the accreditation program as well as
approximately one-third of a GS-15 Deputy Assistant General Counsel
position and approximately one-tenth of an Assistant General Counsel
position. In addition, the Veterans Benefits Administration detailed
one employee to the program for the entire calendar year of 2014, and
temporarily detailed approximately eight other employees, for periods
lasting at least one month, to the program to assist with the backlog
of accreditation applications in calendar year 2014. VA has also
utilized legal externs working with OGC to assist with the program.
a. The number of individuals per year who have sought recognition
to represent individuals before VA broken down by representatives of
service organizations, attorneys or agents.
Response. VA's accreditation matters are tracked within OGC's
recordkeeping database, GCLAWS. The GCLAWS database is primarily a
recordkeeping and case-tracking database for legal matters, and is
somewhat limited in its ability to track certain types of information
for VA's accreditation program in a way that permits reliable targeted
searches of statistical programmatic data for that program. For
example, this database tracks accreditations and suspensions/
cancelations, but does not specifically track other data, such as the
number of accreditation applications received per year, the number of
applications denied, or the number of applications withdrawn or
abandoned. From the information available, we are able to estimate the
number of applications received per year from the number of
accreditation applications granted per year. With respect to attorneys
and service organization representatives, the number of applications
granted closely approximates the number of applications received,
because very few applications are denied in these categories, for
reasons discussed in paragraph (c) below. Accordingly, the estimates
provided below are based on the number of attorney and service
organization representative applications granted in calendar year 2014.
Additionally, we have estimated the number of agent applications based
on the number of cases attributable to the one VA employee who was
assigned exclusively to agent applications for calendar year 2014.
Accreditation Applications Received in Calendar Year
----------------------------------------------------------------------------------------------------------------
VSO Claim Agents
Calendar Year Representatives Attorneys Total
----------------------------------------------------------------------------------------------------------------
2014................................................. 3,150 1,940 680 >5,000
----------------------------------------------------------------------------------------------------------------
b. Of those requests for recognition, how many were granted and how
many were denied?
Response. In FY 2014, VA granted accreditation to 1,940 attorneys,
47 agents, and 3,150 service organization representatives.
Regarding the number of service organization representatives
accredited, we note that a service organization representative may be
accredited with more than one organization. This figure represents the
number of service organization representative accreditations granted,
not the number of individuals accredited.
Regarding the number of agent applications, as explained in greater
detail in response to question (c), the processing of an application
for accreditation as an agent has several additional steps compared to
processing of an application for accreditation as a service
organization representative or attorney. Some of these steps were
implemented at the beginning of calendar year 2014 in response to the
Government Accountability Office's (GAO) observations in its 2013
report VA Benefits: Improvements Needed to Ensure Claimants Receive
Appropriate Representation. Specifically, GAO noted that VA's then-
existent process for accrediting agents relied on (1) applicants to
self-report background information without independent verification,
and (2) character references that did not provide relevant information.
By the beginning of calendar year 2014, VA had modified its process for
accrediting agents to incorporate background checks and direct
questions to the applicants when potential areas of concern are
identified regarding the applicant's criminal or employment history as
well as the applicant's motivation for seeking accreditation by VA. In
some cases agent applicants withdraw or abandon their applications
because they realize that they initially applied for VA accreditation
for some purpose other than to represent veterans on their VA benefit
claims. In other cases the additional steps yield valuable information
that informs OGC's accreditation decision. VA does not currently track
the number of applications that are denied in comparison to the number
of applications that are closed because they are withdrawn or
abandoned. In addition, because the accreditation process for agents
takes more than a year, some of the applications received in calendar
year 2014 are still pending.
c. On average, how long does it take VA to process a request for
recognition?
Response. Applications for accreditation as a service organization
representative are generally processed in less than 60 days,
applications for accreditation as an attorney are processed in 60-120
days, and applications for accreditation as an agent take over one year
to process to completion. Agent applications take considerably longer
to process because there are several additional steps, such as the
frequent need to obtain additional information or clarification from
the applicant, conducting a background check, checking character
references, and scheduling schedule and reviewing the agent exam. As
part of the initial application, the character and fitness
qualifications of service organization representatives are attested to
by the certifying official of the organization and the character and
fitness qualifications of attorneys are presumed based on good standing
with the state bar. However, there is not an equivalent vetting process
inherent in the application for agents and, therefore, VA must
specifically examine the character and fitness and qualifications of
each of these applicants.
d. How many individuals had their recognition suspended or
canceled?
Response. The following table shows the number of cancelations that
occurred in FY 2014. The accreditation database does not track
disciplinary history, but rather whether the person is currently
accredited. Two of the attorney cancelations were due to action taken
by VA in response to a complaint. By regulation, service organizations
are permitted to request cancelation of the accreditation of one of
their representatives at any time, with or without stating a cause. If
the cancelation is due to misconduct or incompetence of the
representative, the regulations require the organization to inform VA
of the reasons for the cancelation. Three of the cancelations of
service organization representatives were for a stated cause. The
remainder of the cancelations shown below were either at the request of
the individual (such as an attorney or agent retiring) or at the
request of the service organization without a stated cause (such as
when an accredited veteran service organization representative's
employment ends).
------------------------------------------------------------------------
------------------------------------------------------------------------
Attorneys.................................................. 126
Agents..................................................... 4
Service Organization Representatives....................... 1318
------------------------------------------------------------------------
e. How many complaints were filed against individuals who are
recognized to represent claimants before VA, how many were found to
have merit, and how many were referred to the Inspector General, a law
enforcement agency, or other similar enforcement entity and how many of
the referred cases resulted in further enforcement, disciplinary or
legal action?
Response. VA received 47 complaints regarding individuals and
organizations assisting individuals with claims for VA benefits. The
complaints implicated the activities of approximately 44 accredited
individuals and 34 individuals and organizations that are neither
accredited recognized nor recognized by VA but are alleged to be
assisting individuals with VA benefit claims. Some complaints
implicated multiple individuals and organizations.
The majority of these individuals (21 accredited individuals and 23
unaccredited individuals and organizations) were brought to the
attention of VA based on their use of the same marketing materials to
market financial products to potential VA pension applicants residing
in California. VA referred this matter to the California Attorney
General and the California Insurance Commissioner for any action they
deemed appropriate under state law.
VA referred two matters involving using the VA logo to market
financial products to Veterans to law enforcement. One matter was
referred to the California Insurance Commissioner for any action he
deemed appropriate under state law and the other was referred to the VA
Office of the Inspector General.
In two matters, VA sent cease and desist letters and, based on
subsequent information provided to us, determined that no further
action was required.
Regarding three matters, VA has been unable to take further action
because the complainant has not provided VA with a privacy release
authorizing the release of information to the subject of the complaint.
The remaining complaints are pending. In the cases involving
accredited individuals, VA is currently gathering additional
information and determining whether disciplinary proceedings will be
necessary. For cases involving individuals who are not accredited, it
is VA's general practice to send a cease and desist letter and, if VA
concerns remain unresolved, to refer the matter to appropriate state
authorities.
Education Benefits and Implementation of Executive Order 13607
Question 49. I understand that there is a large backlog of
complaints pending in the GI Bill Feedback System. Does VA have the
necessary resources to respond to all the complaints about educational
institutions registered in the GI Bill Feedback System by veteran
students? How does VA plan to resolve this backlog? Is VA sharing
complaints registered with the GI Bill Feedback System with Federal and
state law enforcement agencies when the complaints are received?
Response. The GI Bill Feedback System was implemented in
January 2014 without additional FTE or funding resources. Despite this
limitation, VA has handled over 2,700 complaints from education
beneficiaries and has closed 1,900 complaints. Approximately 850
complaints are currently open and active, including 480 complaints with
responses from schools that have not been matched to the original
complaints for closure. The remaining 370 complaints are awaiting a
response from the school. This is a significant improvement from the
1,100 open and active complaints in January 2015 when additional staff
was assigned. VBA expects improvements to continue and will continue to
actively monitor workload to determine if additional resources are
necessary. VA provides complaints to Federal and state law enforcement
agencies through the Federal Trade Commission's Consumer (FTC) Sentinel
System.
Question 50. Is VA receiving updates from Federal and state law
enforcement on their investigations and legal actions to stop predatory
practices against veterans? If VA is receiving such updates, is VA
identifying patterns of deception and predatory practices against
veterans? How is VA protecting veterans from those practices?
Response. VA is routinely receiving updates from DOD and the
Department of Education on their compliance activities and findings,
but VBA's Education Service is not receiving updates directly from
Federal and state law enforcement with the exception of activities that
can be viewed through Consumer Sentinel. VA will suspend and/or
withdraw any institution's eligibility for VA education benefits when
it is found in violation of any element of the statutory approval
requirements, which generally refer to deceptive, erroneous, false and
misleading advertising practices. There are no references in the
statute to ``predatory practices.''
Question 51. Executive Order 13607 directs VA to institute uniform
procedures for referring potential matters for civil or criminal
enforcement to the Department of Justice and other relevant agencies.
Has VA implemented these procedures?
Response. Yes, VA has implemented these procedures through the GI
Bill Feedback system and its direct connection to FTC's Consumer
Sentinel database. Criminal matters are referred to VA's Office of
Inspector General.
homeless veterans
Question 52. Describe the methodology and criteria utilized to
determine whether and where to expand the domiciliary care for homeless
veterans program.
Response. The Department of Veterans Affairs' (VA) Veterans Health
Administration (VHA) methodology for determining where a Domiciliary
Care for Homeless Veterans (DCHV) program should be located emphasizes
two primary criteria. First, the location should be an urban center
with a significant homeless Veteran population. Second, the location
should have few, if any, VHA residential treatment programs. As part of
the VA Secretary's Transformation 21 (T21) plan to end homelessness
among Veterans, VHA identified five urban centers with significant
homeless Veteran populations and no residential treatment programs.
These locations included Philadelphia, Atlanta, Miami, Denver and San
Diego.
A suitable location to lease in Miami was not found after numerous
solicitations and the DCHV was subsequently moved to West Palm Beach,
FL as part of a minor construction project. Philadelphia, Atlanta,
Denver and San Diego are operational and the West Palm Beach building
is under construction.
The need to further expand or reduce DCHV beds may be initiated by
a Veterans Integrated Service Network (VISN) based on a regional review
of current and projected treatment needs using available projection
models. In accordance with VHA policy, VISNs are required to submit a
Business Plan that justifies a need to develop or reduce DCHV beds,
which must be approved by the Under Secretary for Health (USH). VISN 8
submitted a proposal to develop a 40-bed DCHV in San Juan, PR. This
proposal was approved and leased space is currently being solicited.
Question 53. Describe how staff in VA's new Homeless Veteran
Community Employment Services will interface with staff from the
Department of Labor's Homeless Veteran Reintegration Program.
Response. The Homeless Veteran Community Employment Services'
(HVCES) community employment coordinators (CEC) work with Department of
Veterans Affairs (VA) and non-VA partners to identify local gaps in
current competitive employment services and to develop new employment
opportunities targeting homeless and formerly homeless Veterans. It is
expected that CECs develop collaborative relationships with Department
of Labor's Homeless Veteran Reintegration Program staff at all sites
where these programs co-exist to prevent duplication of services and
improve employment outcomes for Veterans exiting homelessness.
construction and long range capital plan
Question 54. Provide a list of priority weights for the major
criteria and sub-criteria used to inform the FY 2015 Strategic Capital
Investment Plan decision plan.
Response:
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Question 55. The budget request contains a legislative proposal to
allow VA cemeteries to lease air rights above VA cemeteries. Please
provide a list of the cemeteries that would be able to lease air
rights, along with the total square footage available above each.
Response. Under the proposal, all cemeteries would be allowed to
lease air rights. NCA has no intention of encouraging air space usage
over cemeteries.
information technology
Question 56. Provide a list of criteria utilized to prioritize
information technology investments, along with a description of the
prioritization process.
Response. All items within the information technology account were
put through a two-stage prioritization process. The first stage
consisted of prioritization based on a three-dimensional taxonomy. The
second stage consisted of prioritization based on further defined
categories and how investments supported the Secretary's Agency
Priority Goals (APGs). Both stages are characterized below:
Stage 1: Consistent with the Secretary's direction, the taxonomy
was focused on three major dimensions: Veteran centered outcomes,
direct or indirect benefit to the Veteran, and whether these benefits
were quantifiable, qualitative, or neither. Due to the focus on
Veteran- centered outcomes, activities categorized as indirect or that
were not categorized were not funded. The taxonomy is shown below.
1. Quantified, direct Veteran centered outcome
2. Qualified, direct Veteran centered outcome
3. Direct Veteran centered outcome (asserted, but not quantified,
not qualified, nor well described)
4. Quantified, indirect Veteran centered outcome
5. Qualified, indirect Veteran centered outcome
6. Indirect Veteran centered outcome (asserted not quantified, not
qualified, nor well described)
7. Not prioritized
Stage 2: Within each of the prioritization criteria above, a
further refinement was applied and is shown below in priority order.
This priority is based on the Secretary's direction regarding the three
current APGs and how an investment supported each.
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Question 57. Please provide a copy of timeliness standards and any
guidelines associated with veteran notifications of data breaches
involving PII or health data.
Response. We are required by the HIPAA Breach Notification Rule to
notify Veterans within 60 days of discovery of any breach involving
unsecured protected health information, and VA Handbook 6500.2 requires
VA to make notification within 30 days from the date the incident
occurred for other breaches. We currently average 28 days to make
notification.
Question 58. What actions is VA taking to actively recruit
additional VLER Health partners to enhance access to clinical data and
improve clinical decisionmaking abilities for veterans?
Response. The Department of Veterans Affairs (VA) is actively
seeking additional Virtual Lifetime Electronic Record (VLER) Health
partners resulting to improve clinical decisionmaking abilities for
Veterans. VLER Health leadership understands and believes that pursuing
additional VLER Health non-VA partners is vital to improving clinical
decisionmaking abilities for Veterans. Our Exchange team has
established nearly 40 partners from across the country. Our Direct team
is working toward adapting use cases for sharing health data between VA
facilities and Veteran State Home federally Qualified Health Centers,
long term care facilities, and mental health providers. Our Regional
Health Information Exchange team is adopting and publishing a coherent
and reproducible Health Information Exchange approach for engaging
states, regions, and communities.
When researching potential new partners, every state in the Nation
is looked at from a variety of viewpoints and considerations including:
(1) Looking for the highest Veteran enrolled states; (2) Reviewing top
purchased care sites for VA from across the Nation; (3) Reviewing
coverage for VA's Rural Health locations; (4) Comparing VAMC
recommended list of potential partners; (5) Considering potential
partner referrals from HealtheWay and Social Security Administration;
(6) Reviewing potential partners that reach out to VA directly; (7)
Reaching out to Health Information Service Providers (HISPs) as well as
non-VA clinical partners; and (8) Increasing outreach and awareness to
non-VA partners via communications.
Bottom line: Adhering to an evaluation process that selects future
partners with the greatest likelihood of success by considering: (1)
areas of greatest need; (2) Veterans Affairs Medical Center (VAMC) and
partner collaboration; and (3) Health Information Exchange (HIE)
technical capabilities, is critical to improving Veteran care.
______
Response to Posthearing Questions Submitted by Hon. John Boozman to
U.S. Department of Veterans Affairs
Question 59. Secretary McDonald, private medical providers and
hospitals in Arkansas are having a very difficult time receiving
reimbursement for providing emergency medical care to veterans. In
Arkansas, we have cases that date back to 2012 and for some of our
smaller community hospitals, this is a serious financial burden. My
office has also received calls from the Louisiana Hospital Association
where they are experiencing similar problems and this appears to be
problem throughout VISN 16. What can be done to help these hospitals
and medical providers close out these claims?
Response. The Veterans Health Administration's (VHA) Chief Business
Office (CBO) has been focused on improving the timeliness of claims
processing. In December 2014, less than 36 percent of the Veterans
Integrated Service Network (VISN) 16 non-Veterans Affairs (VA) medical
care claims had been pending for less than 30 days. As of
February 2015, that number has improved to 50 percent. Currently, VISN
16 is processing approximately 55 percent of their claims within 30
days, and we expect this number to continue to improve.
On November 12th and 14th, 2014, CBO's Purchased Care (PC)
leadership met with members of the Louisiana Hospital Association (LHA)
onsite in Louisiana to discuss the recent consolidation, corrective
actions, and sustainment plan. Additionally, a focused review of
provider high dollar accounts was completed and contact information for
ongoing issues was provided. CBO's PC leadership also addressed the
backlog of claims, customer service issues, provider remittance
reports, and backlog of reconsiderations/appeals.
A Tiger Team visited VISN 16 the week of November 17-21, 2014. This
team addressed the claims payment backlog, operational issues, and
corrective actions required to improved vendor relations and claims
processing timeliness. Since this visit and implementation of a backlog
reduction strategy, VISN 16 has continued to process more claims than
received and has made ongoing improvements in their overall claims
inventory, as described above. In addition, a review of customer
service and provider relations was conducted by CBOPC Customer Service
Center (CSC) leadership. A plan to consolidate the VISN 16 Customer
Support Staff was implemented and this staff is now aligned directly
under the CBOPC CSC structure. Continued training and customer service
expectations are being provided to staff to further assist with
provider and veteran relations.
a. I bring this situation to your attention because I believe it
has ramifications that extend well beyond hospitals being reimbursed
for emergency medical care. The Choice Act relies upon the private
sector to accept and treat veterans and if these hospitals are
experiencing this much difficulty getting reimbursed, they may decide
that dealing with the VA and treating veterans under the Choice Act is
not worth it because of the financial uncertainty that it might entail.
Do you share this concern?
Response. The Department of Veterans Affairs (VA) shares this
concern. VA contracted with Health Net Federal and TriWest Healthcare
Alliance to implement the Choice Program. Health Net Federal and
TriWest Healthcare Alliance reimburse the contracted provider within
their networks for the services performed under Choice. Health Net
Federal and TriWest Healthcare Alliance, in accordance with their
contracts, then invoice the VA for services performed by the contracted
providers.
Question 60. Dr. Clancy, I am concerned about the projected
deficits within the VAMCs. I am being told that within the
Fayetteville, AR, VAMC they are projecting a $22M deficit and VISN 16
as a whole is projecting a $220M deficit for this fiscal year. To your
knowledge is this accurate?
a. What is the reason that these VAMCs are projecting deficits and
what can be done to address these shortfalls? Is this due to VA
projecting that the Choice Act would be used at a higher rate and
therefore less funding would be needed for VAMCs because more veterans
would be seeking outside care?
Response. As of August 19, 2015, VISN 16 has no projected deficits
at any of its VAMCs, including Fayetteville. VHA will continue to work
with VISN 16 to ensure that all resource needs are met to prevent
unnecessary delays in Veteran care.
Including the funding provided by the Veterans Access, Choice and
Accountability Act, VISN 16 has received a funding increase of 7.2
percent in FY 2015. This increase in funding contrasts the 5.8 percent
increase realized in the entire VHA FY 2015 budget. The Acting VISN 16
Director is to provide a detailed analysis of why VISN 16 has such a
large shortfall in view of the funding increase received this year. VHA
intends to report those findings back to the Committee once the data is
received and reviewed.
VISN and Medical Center Directors have a very challenging mission
balancing funding requirements in light of new patient care practices,
advances in medical technology, accounting for non-VA care, and
supporting an aging infrastructure. VHA is working closely with VISN
leadership to ensure that each VISN has the most appropriate funding
based on Veterans' demand for health care in their region.
b. As of now, do you anticipate submitting a reprogramming request
to Congress in which you will request transferring money from Choice
Act accounts into the medical care account?
Response. With respect to the $5 billion appropriated by section
801 of the Choice Act, VA does not currently anticipate deviating from
the spending plan that it previously submitted to Congress.
With respect to the $10 billion appropriated by section 802 of the
Choice Act, there is no legal authority that would permit VA to
transfer funds from the section 802 Veterans Choice Fund to the medical
care appropriations accounts, even with Congressional approval.
c. The FY 2016 budget request for VA in the Medical Care account is
$58.662B which is 5.12% above the FY 2015 appropriated amount. Is this
increase intended to address these projected deficits within the VAMCs?
Response. Compared to the enacted 2016 advance appropriations
level, as requested in the 2015 President's Budget, this year's 2016
request for VA health care services is $1.299 billion higher. This
request for additional funding is necessary to ensure the delivery of
high-quality and timely health care services to veterans and other
eligible beneficiaries. For the first time, VA is requesting an
increase above the enacted advance appropriation in all three Medical
Care accounts: $1.124 billion in Medical Services, $105 million in
Medical Facilities, and $70 million in Medical Support and Compliance.
The total net increase of $1.299 billion is due to the following
factors:
Ongoing health care services estimate increased by $599.9
million, driven largely by estimates of the cost of new Hepatitis C
treatments and updated actuarial trends based on the latest actual
data.
A reduction in projected base appropriations health care
costs due to enactment of the Veterans Choice Act; VA estimates that
$452 million in requirements will shift from the regular program as
Veterans who would otherwise receive care in the VA health care system
instead choose to participate in the new Veterans Choice Program, as
established in the Veterans Choice Act and funded by section 802 of the
Act.
Long-Term Services and Supports estimate has increased by
$51.1 million, reflecting trends in the most recent actuals and the
continued investment into non-institutional settings.
Ongoing health service programs not projected by the EHCPM
increased by $221.6 million. The Caregivers program cost estimate
increased by $249.4 million, driven largely by an increase in the
projected number of Caregivers receiving stipend payments. The combined
sum of the estimates for CHAMPVA, reimbursement to the Indian Health
Service and tribal health programs, caring for eligible Camp Lejeune
Veterans and families, and readjustment counseling decreased by $27.8
million based on updated actuals and revised assumptions in workload
for Camp Lejeune and Indian Health Service.
VA programs to end Veterans' homelessness increased by
$128 million, for a total of $1.393 billion. The increased estimate
allows VA to fully support projected utilization in its homeless
programs, including the Supportive Services for Veterans Families
(SSVF) program and the Department of Housing and Urban Development-VA
Supportive Housing program (HUD-VASH).
Healthcare Infrastructure Enhancements increased by $666.9
million. Facility activation costs have increased by $468.2 million
over the initial advance appropriation estimate of $130 million to
$598.2 million; the initial estimate was based on construction delays
that have caused under-execution of activations in recent years.
However, VA has made progress in resolving these issues, and as a
result has increased confidence that the additional funding will be
required in FY 2016. The cost estimate of supporting the Veterans
Integrated System Technology Architecture (VISTA) evolution project has
been revised downward from $208.3 million to $159.6 million. Estimated
non-recurring maintenance obligations grew from $460.6 million to
$708.0 million, to address high-priority emerging capital needs as
identified through the Strategic Capital Investment Planning (SCIP)
process; this increase excludes funding provided by the Veterans Choice
Act. See Volume 4, Chapter 7 for additional information on the SCIP
process and the NRM program.
The cost of VHA proposed legislation remains nearly
unchanged with an estimated cost decrease of $0.5 million. The 2016
budget includes estimates for Civilian Health and Medical Program of
the Department of Veterans Affairs (CHAMPVA) healthcare benefits for
beneficiaries up to age 26.
Additional budgetary resources decreased by $84.4 million
(collections, reimbursements and transfers). The estimate for the
Medical Care Collections Fund decreased by $26.3 million.
Reimbursements decreased by $51.0 million and transfers to the Joint
DOD/VA Medical Facility Demonstration Fund increased by $7.1 million.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
VISN and Medical Center Directors, many of whom, as you know, are
acting, have a very challenging mission balancing funding requirements
in light of new patient care practices, advances in medical technology,
accounting for non-VA care, and supporting an aging infrastructure. We
are working closely with the VISN leadership to ensure that each VISN
has the most appropriate funding based on Veterans' demand for health
care in their region.
Question 61. Secretary McDonald, within the VA's budget for major
and minor construction, this account has the largest increase in terms
of percentage: 46.64% increase in the FY 2016 request from what was
enacted for FY 2015. How much of this money does the department intend
to use to modify facilities so as to better accommodate and care for
our female veterans
Response. Based on the Veterans Health Administration's (VHA)
preliminary minor construction projects for FY 2016, VHA anticipates
providing design or construction funding for projects associated with
some form of privacy to accommodate women with total project costs
totaling $341 million. These projects include new and/or expanded
community living centers, inpatient mental health buildings, emergency
departments, outpatient clinics, inpatient units, etc.
Each of VHA's major construction projects, submitted in the FY 2016
budget, support some aspect of women's privacy in the project's overall
scope. In the FY 2016 budget request, there is over $508 million of
funding for construction projects that include some form of privacy.
These projects include the construction or renovation of community
living centers, a mental health clinic, an outpatient clinic, and
rehabilitation buildings.
The following table represents funding included in the FY 2016
budget request for major construction projects supporting our women
Veterans:
----------------------------------------------------------------------------------------------------------------
FY 2016 $ for
Location Request Women Description of Women's Health
----------------------------------------------------------------------------------------------------------------
Perry Point, MD............................----$83.7M---------*---Community Living Center: Dependent on the-----
number of women residents
----------------------------------------------------------------------------------------------------------------
West LA, CA Building 208................... $35M $35M Women's Homeless Housing
----------------------------------------------------------------------------------------------------------------
American Lake, WA.......................... $11M $0 NA--Engineering Admin/Shop
----------------------------------------------------------------------------------------------------------------
San Francisco, CA.......................... $158M $0 NA--Research
----------------------------------------------------------------------------------------------------------------
Long Beach, CA............................. $161M * Community Living Center: Dependent on the
number of women residents
----------------------------------------------------------------------------------------------------------------
Alameda, CA Site Prep...................... $70M $0 NA--Site work
----------------------------------------------------------------------------------------------------------------
Livermore, CA Stockton OPC................. $139M $880K Women's Specialty is part of Patient Aligned
Care Teams (PACT)
----------------------------------------------------------------------------------------------------------------
St. Louis (Jefferson Barracks), MO......... $90.1M * Women Veterans are seen throughout the entire
facility for all of their treatment
----------------------------------------------------------------------------------------------------------------
Louisville, KY............................. $75M $0 NA--Site work
----------------------------------------------------------------------------------------------------------------
National Cemetery Projects at Bayamon, PR; -- * The FY 2016 National Cemetery Administration
Portland, OR; Riverside, CA; and (NCA) major construction projects ensure
Pensacola, FL. eligible Veterans have access to burial
options within a reasonable distance from
their residence. These FY 2016 NCA major
construction projects support all eligible
Veterans and their families (to include
female Veterans and dependents) by providing
a final resting place.
----------------------------------------------------------------------------------------------------------------
* Amount of funding is dependent on the number of women Veterans served.
a. The FY 2015 enacted amount for construction was $1.057B and the
FY 2016 request is for $1.55B or an increase of $493M. How much of this
increase is due to the massive cost overruns on the Denver VA Hospital?
I ask this because the project is estimated to cost an additional $500M
to $1B more than original cost estimates.
Response. No funding in the FY 2016 budget is for the Denver
hospital.
Question 62. Dr. Clancy and Mr. Warren, I believe VA pharmacy
system has some major shortcomings, especially in the area of
information technology. For example, VA pharmacies are not networked
and when a veteran uses multiple VAMC/CBOCs or moves their home to a
new location, this often times is a problem. What is the VA doing to
help modernize the VA pharmacy system?
a. Do you have an estimate on what it would cost to network the VA
pharmacies in a manner that would resemble how many of the large retail
pharmacy (Wal-Mart) chains are networked?
Response. In many ways, the Department of Veterans Affairs' (VA)
pharmacies are already networked. They all use a single VA national
drug formulary; they all use VA's Consolidated Mail Outpatient
Pharmacies to process and mail non-urgent prescriptions; they all have
access to the same drug prices through the pharmaceutical prime vendor;
they all use the same Veterans Health Information Systems and
Technology Architecture (VistA) pharmacy software; and they all have
visibility of prescriptions filled at other VA medical facilities. VA
pharmacy staff is also currently able to see when a particular
prescription was last filled by VA and where it was filled.
VA pharmacies cannot currently refill a prescription issued at a
different VA facility automatically; deduct that refill from available
refills; and record the refill in the VistA record at the issuing
facility. VA pharmacies have developed workarounds over the years to
address the medication needs of traveling Veterans who run out of
medications; however, these workarounds take time and are inconvenient
to Veterans and staff because they generally involve generating a new
prescription and providing a new fill.
VA is currently working on an innovation project that will make the
prescriptions, that VA pharmacies can now only review, actionable for
refills. This will eliminate the need for workarounds, will make the
process easier and faster and will provide an audit trail of these
refills. This innovation is referred to as One VA Pharmacy.
VA is also exploring the possibility of establishing a network with
retail pharmacies for prescriptions filled in these pharmacies under VA
programs including PC3, CHOICE, ChampVA, CBOCs, etc. If this is
established, VA will be able to integrate non-VA pharmacy workload
records into VistA in the same way a prescription drug hub, like
Surescripts, can do.
b. Dr. Clancy, do you believe that having a modern integrated
pharmacy network would eventually yield cost savings in the way VA buys
and dispenses medication?
Response. As noted above, VA is also exploring the possibility of
establishing a network with retail pharmacies for prescriptions filled
in these pharmacies under VA programs including PC3, CHOICE, ChampVA,
and CBOCs. We believe this capability is analogous to the ``modern
integrated pharmacy network'' that is referred to in the question If
thisis established, VA will be able to integrate non-VA pharmacy
workload records into VistA in the same way a prescription drug hub,
like Surescripts, can do, providing VA prescribers with greater
visibility of the totality of prescription drug therapy for Veterans.
VA believes such improvements can result in better convenience and
the potential for better quality of care. Whether it would yield cost
savings cannot be determined, as that would depend on the detailed
capabilities of the system and the arrangements with retail pharmacies
struck under such a network.
c. Mr. Warren, is it correct to say that VA currently does not have
an electronic prescription capability? Something like Surescripts?
i. Is the VA considering investing in an electronic
prescription system?
ii. If so, would it be your intent to buy an already
available commercial off the shelf program or would VA design
their own system? Have you already explored this issue?
Response. (i) As noted above, VA is also exploring the possibility
of establishing a network with retail pharmacies for prescriptions
filled in these pharmacies under VA programs including PC3, CHOICE,
ChampVA, and CBOCs. We believe this capability is analogous to the
``modern integrated pharmacy network'' that is referred to in the
question If thisis established, VA will be able to integrate non-VA
pharmacy workload records into VistA in the same way a prescription
drug hub, like Surescripts, can do, providing VA prescribers with
greater visibility of the totality of prescription drug therapy for
Veterans. We assume this capability is what is being referred to in the
question as ``an electronic prescription system.''
(ii) VA would certainly consider using commercial off the shelf
programs, if they offered sufficient compatibility, interoperability,
and integration with VA's pharmacy infrastructure. However, VA has not
proceeded far enough into its considerations to come to any conclusion
on this question.
Question 63. Dr. Clancy, within VHA, there has been an effort to
reduce the use of psychotropic and opioid medication to treat mental
illness and chronic pain respectively. Many organizations and Members
of Congress want to see VA take a more holistic approach to treating
these conditions and not simply rely upon medication which has been
overprescribed and abused in the past. What new and existing programs
does VHA seek to fund to address this issue?
Response. The Department of Veterans Affairs' (VA) Veterans Health
Administration (VHA) currently supports two programs that address safe
and effective use of psychotropic and opioid medications across the
system, the Psychotropic Drug Safety Initiative (PDSI) and the Opiate
Safety Initiative (OSI). The Psychotropic Drug Safety Initiative (PDSI)
is a Nation-wide psychopharmacology quality improvement (QI) initiative
coordinated through the Office of Mental Health Operations (OMHO) in
collaboration with Mental Health Services (MHS) and Pharmacy Benefits
Management (PBM).
The PDSI aims to improve the safety and effectiveness of
psychopharmacological treatment in VHA by focusing on avoiding
overprescribing, addressing problems in clinical management,
eliminating misalignment between prescribing and diagnosis, and
decreasing missed opportunities for providing evidence-based care. The
PDSI supports local psychopharmacology QI initiatives at facilities
across the country by developing measures and providing data on
prescribing practices, providing feedback and guidance on QI action
plans, establishing a collaborative community of practice, and creating
tools to identify Veterans who may benefit from clinical review of
current psychotropic drug treatment.
The OSI is a multicomponent national intervention which consists
of: (1) tools to identify underutilized clinical practice guideline-
recommended pain treatments and opioid risk mitigations strategies for
local implementation at the facility level; (2) tools to facilitate
case review of higher risk patients at the provider level; (3)
innovative clinical education programs to improve pain management and
opioid prescribing practices (e.g. via SCAN-ECHO, webinar and academic
detailing based programs); and (4) national initiatives to implement
standardized informed consent practices and use of overdose education
and Naloxone distribution for patients receiving or using opioids.
Collaboration across the PDSI and OSI are coordinated through an
overarching steering team, which is made up of a multidisciplinary
group of leaders from mental health, pain management, and pharmacy. VHA
will monitor the effectiveness of these programs going forward to
determine if any additional initiatives are needed and to identify any
additional resource requirements.
a. Are there additional programs and initiatives that you would to
pursue but are unable to because of budget constraints? If so, what are
they?
Response. The Department of Veterans Affairs' (VA) Veterans Health
Administration (VHA) has begun adding licensed acupuncturists and
massage therapists to the list of VA occupations. VHA is also
developing the qualifications standards and guidance that will allow
local facilities to hire these types of providers as a means to augment
existing evidence based care.
The main barriers to adding programs is not budget, but the
scarcity of data to support expansion of complementary and integrative
practices in the management of conditions such as Post Traumatic Stress
Disorder. The current evidence supports these medical care services as
possible adjuncts to existing evidence based therapies. There is some
promising information for the use of complementary and integrative
practices as adjuncts in the management of pain. However, the strength
of the data to support these practices as well as the lack of
occupational classes for the hiring of complementary and integrative
providers are the major barriers to the expansion of this type of care.
______
Response to Posthearing Questions Submitted by Hon. Bill Cassidy to
U.S. Department of Veterans Affairs
Question 64. In testimony, it was stated that 20% of the reported
number of clinic visits across the VA system were actually ``no-
shows.'' A ``no-show'' is a missed appointment in which the patient
does not show up for the appointment. Dr. Clancy then said two things
which were contradictory. First, she said that the VA can only
determine no-show rates for the entire system and not by institution.
Then, she said that ``no show'' rates are higher for non-rural VA
facilities. This suggests that a facility-specific analysis is possible
and is being conducted. Please reconcile these differences and answer
the following questions.
a. If a facility-specific finding is not possible, how are the
cumulative statistics established/collected?
b. If facility specific statistics are truly not available, why are
they not collected? This seems like a simple query--sorting attendance
rates by facility to establish a ratio between ``no shows'' and the
total number of visits scheduled. Is the VA database unable to do this?
Response. No-shows (also called ``missed opportunities'') occur
when a patient scheduled for an appointment does not attend. The
Department of Veterans Affairs' (VA) databases hold information on each
individual appointment, including no-shows. The statistics are
collected through the Veterans Health Information System and Technology
Architecture (VistA) scheduling system when each appointment is
processed. Therefore, VA can calculate no-shows by individual patient,
clinic, facility, Veteran Integrated Service Network (VISN), etc. VHA's
highest facility no-show rates tend to be at large facilities in larger
urban areas.
Question 65. On August 11, 2014, FDA found safe and effective and
CMS authorized for Medicare coverage for a new DNA stool based non-
invasive colorectal cancer test. In January 2015 an application was
made to the Federal Supply Service (FSS) program for availability in
the VA health system. Based on study published in the New England
Journal of Medicine in April 2014 the test founded 94% of Stage I and
Stage II cancer and 69% of advanced pre-cancer. Currently VA relies on
a much less accurate non-invasive test (FOBT/FIT) that requires a
repeat of the test every year for five years. Peer review studies have
found that adherence to the test is very disappointing. By year 4 only
14% of the more than 300,000 veterans whose records were examined have
adhered to the test i.e. repeated it annually for four years. It takes
one year for VA to process any new medical item for inclusion in the
Federal Supply Schedule. The VA has been delegated the responsibility
for medical items by the General Services Administration (GSA). Given
VAs well documented problems with colorectal cancer screening, the
innovative nature of the test and the poor adherence to the existing
test, can the process be expedited on the basis of offering new
technology to our veterans?
Response. There is an active procurement action ongoing through the
FSS multiple award schedule program, which means more than one company
is awarded a contract for the same or similar products and/or services.
While this action occurs, this DNA stool-based colorectal cancer
screening test may be obtained by the medical centers as necessary, in
compliance with prescribed acquisition regulations and policies.
______
Response to Posthearing Questions Submitted by Hon. Jon Tester to
U.S. Department of Veterans Affairs
Question 66. Early in FY 2014 the Montana VA experienced a backlog
in inpatient claims. By the close of the fiscal year, a significant
backlog in payments to providers like Kalispell Regional Health, still
remained. To what extend did the VA carry a backlog of unfunded claims
into FY15?
Response. In June 2014, the Department of Veterans Affairs (VA)
held a meeting with the Montana Independent Hospital Association
partners. The non-VA care (NVC) claims processing manager collaborated
directly with the independent hospitals. During this meeting, a
discrepancy was discovered between VA processing center's recorded
claims and the independent hospital's aged accounts receivables. The
parties worked together to reconcile results and allowed the hospitals
to clear aged accounts. Recurring calls, began in June 2014, and
currently continue between the independent hospitals and the payment
processing center.
Average claim timeliness has increased slightly. In June 2014,
there was an average of 32 days to process a claim. Currently, the
average is 35 days.
As of March 19, 2015, Montana had 23,969 claims on hand. 90.40% of
those claims were under 30 days old. There were no claims over 365 days
old.
Question 67. Funding by the U.S. Treasury for FY 2014 claims in
Montana appears to be sporadic and incomplete. For Kalispell Regional
Health and other hospitals, these claims represent the oldest claims
and present the greatest impact to cash-flow and bond ratings. Some of
these claims have been awaiting payment for nearly one year, as
Kalispell Regional Health's own fiscal year closes in March 2015. Now
that FY 2014 is closed, how are the FY 2014 claims funded in FY15?
Response. There has been significant growth in the non-VA care in
the VA Montana Health Care System resulting in temporary backlogs.
Actual expenditures have exceeded the estimated costs for non-VA care.
Additional funds were identified in other accounts and supplemental
funding was requested and received to process fiscal year 14
obligations.
Question 68. Is there more we can do to support the VA to
facilitate fast, complete turn-around for full payment for these claims
by the Treasury? To what extend is the VA taking steps to work directly
with civilian providers to streamline and improve the claims process to
prevent future backlogs?
Response. The Department of Veterans Affairs (VA) has begun the
process of streamlining and improving non-VA medical care claims
processing to prevent future backlogs. VA has recently consolidated all
claims processing operations VA's Chief Business Office. The desired
outcome is a more consistent and effective claims processing division.
The payment of claims begins with non-VA providers timely filing a
complete bill. A complete bill includes accurate and complete claim
information along with any supporting medical documentation that has
been requested. The filing of a complete bill prevents the rejection of
the claim and a subsequent request for missing documentation. Non-VA
providers are also encouraged to submit their claims electronically to
expedite this process. If non-VA medical care providers are receiving
mailed paper checks from Treasury, enrolling in electronic funds
transfer (EFT) payments will eliminate several days for payment
receipts.
VA understands that partnering with non-VA medical care providers
is critical for successful claims processing. Therefore, VA has also
taken steps to educate our partners on a range of topics through our
Non-VA Medical Care Provider Web site (http://www.va.gov/PURCHASEDCARE/
programs/providerinfo/index.asp) and email distribution list. Locally,
Veterans Affairs Medical Centers (VAMC) provide continuous outreach to
medical providers to improve the claims processing system.
Question 69. What steps can civilian providers and the VA take to
work together proactively to prevent payment backlogs in 2015?
Response. The Department of Veterans Affairs (VA) believes that
effective communication between non-VA medical care providers and VA is
critical to prevent improper payments and backlogs.
To further prevent payment backlogs, non-VA medical care providers
should submit accurate and complete claim information along with any
supporting medical documentation that has been requested. Ensuring
accurate and complete claims are filed will prevent the rejection of
the claim and a subsequent request for missing documentation. Non-VA
providers are also encouraged to submit their claims electronically to
expedite this process. If non-VA medical care providers are receiving
mailed paper checks from Treasury, enrolling in electronic funds
transfer (EFT) payments will eliminate several days for payment
receipts.
VA's Chief Business Office's (CBO) Purchased Care (PC) department
maintains an external Web site with a designated provider page to
support VA's non-VA medical care partners (http://www.va.gov/
PURCHASEDCARE/programs/providerinfo/index .asp). This page delivers the
following useful information:
Provider guidebook that details what non-VA medical care
providers should expect in terms of authorizations, referrals, claims
payments, and the return of medical documentation back to the
authorizing VA medical center
Instructions on how to file a claim, including using the
Electronic Claims submission process
Detailed information on authorization for pre-authorized
care
Detailed information on claims processing for emergency
medical services
How to read a preliminary fee remittance advice report
(PFRAR)
Definitions of denial codes and reasons
VA has also launched an email distribution list so providers can
stay up to date with the non-VA medical care program. Helpful
information is provided to those on our community provider email
distribution list about doing business with the VA at least once per
month.
Additionally, local VA and non-VA medical care providers can
effectively communicate to address specific issues that arise. For
example, if a large volume of claims are being denied, VA and non-VA
providers can work together to assess why claims are being rejected and
ensure the needed information is submitted.
Question 70. Also, I understand that the VHA is considering
granting Full Practice Authority to Advanced Practice Registered Nurses
including Certified Registered Nurse Anesthetists and Nurse
Practitioners. This is a policy I support as it would follow
recommendations from the Institute of Medicine and align with current
practice in the Army, Navy, Air Force, Combat Support Hospitals and the
Indian Health Services. What is the current status is of the VHA
Nursing Handbook?
Response. The Department of Veterans Affairs' (VA) Veterans Health
Administration (VHA) is developing a draft nursing handbook proposing
the authorization of full practice authority (FPA) for advanced
practice registered nurses (APRN) without regard to individual State
Practice Acts, except for the dispensing, prescribing, and
administration of controlled substances. This proposed change to
nursing policy would standardize APRN practices throughout VA's health
care system and increase access to high quality care for all Veterans.
Implementation of FPA would increase patient access by alleviating the
effects of national health care provider shortages on VA staffing
levels and enable VA to provide additional health care services in
medically-underserved areas. VHA intends to implement this change to
our policy through regulatory action to ensure its enforceability and
allow the public the opportunity to provide comments. VHA is developing
a draft regulation that would recognize FPA for APRNs, including CRNAs.
The draft regulation will be published in the Federal Register as a
proposed rule for notice and comment. Following the public comment
period, VA will review the comments received and consider whether to
revise the regulation before publishing it as a final rule. VHA
believes in being transparent when making health care delivery
decisions and welcomes the opportunity to discuss policy concerns.
Chairman Isakson. The second panel will come forward,
please. [Pause.]
I apologize to the second panel for the length and duration
of the questioning of the Secretary, but we probably will not
have a more important time this year or this session of
Congress to deal with that, so I was liberal with time. That
said, I am going to make sure everybody's testimony gets in for
the record before we have to go for a vote or are interrupted.
I appreciate your patience, and please understand, the length
of that was in no way meant to contrive what you do, but we had
to see what the Secretary had to say.
What we are going to do is go straight to your testimony,
one after another, and we will take it all in. Then, as we have
time for questions afterwards, we will do that. I would ask you
to try to hold your comments within that 5-minute range, but if
you go over just a tad, that is all right until I rap the gavel
and call you to stop.
First will be Carl Blake, Paralyzed Veterans of America.
Next will be Ms. Ilem?
Ms. Ilem. Ilem.
Chairman Isakson. Ilem. It is a beautiful name for a
beautiful lady. We are glad to have you here today.
Mr. Kelley, we are glad to have you.
Mr. de Planque, I saw you a lot yesterday. It is good to
see you again. We are glad to have Ian--and it is de Planque,
right? I got it right?
Then, Richard Weidman of Vietnam Veterans of America, thank
you for being here today.
We will start with you, Mr. Blake.
STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR FOR
GOVERNMENT RELATIONS, PARALYZED VETERANS OF AMERICA
Mr. Blake. Thank you, Mr. Chairman. Let me begin by saying
I do not feel slighted by having the Secretary, who is the head
of a Cabinet-level agency, being elevated above the level of
the veterans service organizations for consideration, so we do
not have any problem with that.
I would like to thank you again for the opportunity to
testify. I am here to represent both Paralyzed Veterans of
America and the co-authors of the Independent Budget. We
released recently our Independent Budget report for fiscal year
2016 and 2017. With the Chairman and the Committee's
permission, we would like to submit that report into the
official hearing record.
Chairman Isakson. Without objection.
Mr. Blake. Thank you.
[The Independent Budget report can be found in the
Appendix.]
Mr. Blake. I would just say that we believe that the VA's
budget for this year is a very good budget. We appreciate the
fact that the administration seems, for the first time, in my
view, to have taken seriously their responsibility when it
comes to reviewing advanced appropriations and making necessary
revisions. This was the first year since it was enacted there
has been a substantial revision to the advanced appropriations
recommendations. The recommendations are fairly close even to
what the Independent Budget has recommended. The same would be
true for fiscal year 2017.
I have a number of other comments that I was going to make,
but I think I would rather turn my attention to some of the
discussion that has been held here today on a couple of topics.
Obviously, the hot topic has been the Choice Act. Something
you said at the beginning about getting on board, helping make
this program work, I can tell you, Mr. Chairman, that I believe
everybody at this table with many of the other veterans service
organizations were involved with the VA from the day that the
bill was passed last August to try to get this right in the
implementation. We had a number of meetings with the VA, talked
through all kinds of questions.
One of the common questions was the concept of 40 miles for
service versus 40 miles from a facility. I will tell you that
the bill specifically says, ``An eligible veteran is a veteran
who resides more than 40 miles from a medical facility of the
Department, including a community-based outpatient clinic, that
is closest to the residence of the veteran.'' That is the
specific language of the bill.
Obviously, there is some opening for interpretation.
Everybody would like to see it, I think, maybe in the direction
of service. It makes sense, we believe. However, what I would
say is--and Chairman Miller pointed this out yesterday.
Congress had a hard time with that concept because when CBO
tried to cost it, the potential cost for that concept was
astronomically higher than this bill as passed was. So, that is
a challenge, we believe, that Congress is going to have to
grapple with.
From the perspective of PVA, it is no secret that we have
not been a big proponent of privatizing VA care or purchasing
care outside the VA system. However, that being said, I am
disappointed Mr. Moran is not still here. Kansas is a case
study in the failing of the VA in the past in fee-based or
purchased care. It has boggled my mind for years because I have
listened to Senator Moran and I have listened to Mr. Huelskamp
on the House Committee, rail over and over again about why
veterans, particularly in western Kansas, but over a large part
of Kansas, cannot get access to care or are being forced to
drive 200, 300, and 400 miles in some cases to get care at a VA
facility. I just cannot even fathom how that could happen. Even
under the old rules of fee-based care, seemingly that
occurrence would not happen; yet, it did. So, it would stand to
reason that something like Choice would help alleviate some of
those problems.
We are interested in working with this Committee, with the
House Committee, and with the VA to get it right. But, there
are some steps that we believe Congress is still going to have
to take if it really wants to go the full step. And it has to
keep in mind that while Choice seems like a good idea for most
veterans--veterans like the membership that I represent--
veterans with spinal cord injury, do not really have a viable
choice. There are facilities around the country that exist in
the private system, but they do not provide care like the VA's
spinal cord injury system of care. So, you have to consider
that in any further decision about the future delivery of VA
health care.
The last thing I would comment on is there was a question
about the culture of VA and changed leadership. The Secretary
mentioned changed leadership. I would point out that two of the
three Under Secretaries for Health are in an interim status
currently. Dr. Clancy has been in this position since this
basically broke last summer and has been charged with helping
shepherd through a lot of monumental changes in the VA health
care system that her predecessor was not involved in. Her
predecessor had the opportunity to walk away, wipe his hands,
when the damage was already done. Dr. Clancy has done a great
job. PVA has already come out on the record saying Dr. Clancy
should be made the permanent Under Secretary for Health, but
somebody should be made the permanent Under Secretary for
Health.
I would also suggest that at a level lower than that, there
is still an acting position for the Chief Consultant for the
Spinal Cord Injury Service. That is the person charged with
making sure the policy and procedure that goes on within the
SCI system of care is appropriate, timely, efficient, and
delivers the best service for veterans. It makes no sense that
that person is not in a permanent status. It is time for that
to be corrected.
I think if you start putting people in place who have the
best interests of change in mind, then you can make change.
But, that is the only way you are going to get the culture to
turn around in any meaningful way.
With that, Mr. Chairman, I would like to thank you for the
opportunity to testify, and I would be happy to answer any
questions you have.
[The prepared statement of Mr. Blake follows:]
Prepared Statement of Carl Blake, Associate Executive Director for
Government Relations, Paralyzed Veterans of America
Chairman Isakson, Ranking Member Blumenthal, and Members of the
Committee: As one of the four co-authors of The Independent Budget
(IB), Paralyzed Veterans of America (PVA) is pleased to present the
views of The Independent Budget regarding the funding requirements for
the Department of Veterans Affairs (VA) for FY 2016 and advance
appropriations for FY 2017. The IB veterans service organizations
(IBVSO) recently released our report The Independent Budget for the
Department of Veterans Affairs for FY 2016 and FY 2017. This report
offers detailed recommendations for all of the principle line items of
the VA budget. We would ask to make that complete report part of the
official hearing record.
The IBVSOs believe that the VA's budget request this year is
largely a very good budget. We appreciate the fact that VA appears to
have made an honest assessment and revision to the medical care
accounts for FY 2016. Unfortunately, we believe the advance
appropriations amount for FY 2016 provided for by Congress in the ``FY
2015 Consolidated and Further Continuing Appropriations Act'' approved
in December 2014 is not sufficient to meet the full demand for services
being placed on the system. For FY 2016, the IB recommends
approximately $63.3 billion for total Medical Care. However, Congress
recently approved only $62 billion for total Medical Care (based on an
assumption that includes approximately $3.2 billion for medical care
collections). The VA has now revised their FY 2016 Medical Care
estimate to $63.2 billion. We encourage the Committee to give serious
consideration to these revisions and we will be calling on the Senate
Committee on Appropriations to address the shortfall that was
previously approved through advance appropriations.
Additionally, The Independent Budget recommends an advance
appropriation of approximately $66.4 billion for total Medical Care for
FY 2017. We are pleased to see that the Administration has requested
approximately $66.6 billion (including approximately $3.3 billion in
medical care collections) for advance appropriations for FY 2017. We
encourage the Committee to affirm these estimates in its Views &
Estimates to the Senate Committee on Appropriations.
The IBVSOs would also offer some concerns that we see with the
Administration budget. The Independent Budget recommendations focus on
recommendations at the point of service, but we believe that
administrative costs across the board must continue to be reined in. We
would highlight the clear differences between our recommendations for
such line items as Medical Support and Compliance, General
Administration and Information Technology (IT) to affirm this point.
These line items focus a great deal of resources on administrative
support, and all three of these accounts reflect significant increases
in resources for FY 2016 and in the FY 2017 advance appropriations for
Medical Support and Compliance. We encourage the Committee to do a
thorough analysis of those accounts specifically to ensure that dollars
appropriated for those accounts are allocated efficiently and
effectively.
funding for fy 2016
For FY 2016, The Independent Budget recommends approximately $51.6
billion for Medical Services. This recommendation is a reflection of
multiple components. These components include the following
recommendations:
Current Services Estimate..................................................................... $49,468,647,000
Increase in Patient Workload.................................................................. $1,489,858,000
Additional Medical Care Program Costs......................................................... $635,000,000
-----------------
Total FY 2016 Medical Services.............................................................. $51,593,505,000
=================
The current services estimate reflects the impact of projected
uncontrollable inflation on the cost to provide services to veterans
currently using the system. The estimate also assumes a 1.5 percent
increase for pay and benefits across the board for all VA employees.
Our estimate of growth in patient workload is based on a projected
increase of approximately 148,000 new unique patients. These new unique
patients include priority group 1-8 veterans and covered nonveterans as
well as additional new users as a result of veterans being removed from
the extended waiting lists and those whose decisions on healthcare
enrollment eligibility are made. We estimate the cost of these new
unique patients to be approximately $1.2 billion. The increase in
patient workload also includes a projected increase of 71,500 new
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
enrollees, as well as Operation New Dawn (OND) veterans at a cost of
approximately $282 million. The increase in utilization among OEF/OIF/
OND veterans is supported by the average annual increase in new users
from FY 2002 through the 4th quarter of FY 2014.
The Independent Budget believes that there are additional projected
medical program funding needs for VA. Specifically, we believe there is
real funding needed to address the array of long-term-care issues
facing VA, including the shortfall in institutional capacity; to
provide additional centralized prosthetics funding (based on actual
expenditures and projections from the VA's prosthetics service); as
well as funding necessary to improve the Comprehensive Family Caregiver
program; and funding to address needed improvements in programs
directed for women veterans.
The Independent Budget recommends $325 million directed toward VA
long-term-care programs. In order to support the continued rebalancing
of VA long-term care in FY 2016, $125 million should be provided.
Additionally, $95 million should be targeted at the VA's Veteran
Directed-Home and Community Based Services (VD-HCBS) program. The
remainder of the $325 million ($105 million) should be dedicated to
increasing the VA's long-term-care average daily census (ADC) to the
level mandated by Public Law 106-117, the ``Veterans Millennium Health
Care and Benefits Act.''
In order to meet the increase in demand for prosthetics, the IB
recommends an additional $150 million. This increase in prosthetics
funding reflects an increase in expenditures from FY 2014 to FY 2015
and the expected continued growth in expenditures for FY 2016. Our
additional program costs recommendation includes investing $70 million
in the Comprehensive Family Caregiver program in accordance with the
deficiencies identified during the hearing held by the House Veterans'
Affairs Subcommittee on Health in December 2014. The Medical Services
appropriation should also be supplemented with $90 million designated
for women's healthcare programs, in addition to those amounts already
included in the FY 2016 baseline. These funds would be used to help the
Veterans Health Administration deal with the continuing growth in
ensuring coverage for gynecological, prenatal, and obstetric care,
other gender-specific services, and for maintenance and repair of
facilities hosting women's care to improve privacy and safety of these
facilities where women seek care. The new funds would also aid the VHA
in making its cultural transformation to embrace women veterans and
welcome them to VA healthcare services, and provide means for VA to
improve specialized mental health and readjustment services for women
veterans.
For Medical Support and Compliance, The Independent Budget
recommends approximately $6.0 billion for FY 2016. Our projected
increase reflects an increase in current services based on the impact
of inflation on the FY 2015 appropriated level. For Medical Facilities,
The Independent Budget recommends approximately $5.7 billion for FY
2016, nearly $800 million more than the enacted advance appropriations
in December 2014. Our Medical Facilities recommendation includes the
addition of $900 million to the baseline for Non-Recurring Maintenance
(NRM). The Administration's request over the past two cycles represents
a wholly inadequate request for NRM funding, particularly in light of
the actual expenditures that are outlined in the budget justification.
While VA has actually spent on average approximately $1.3 billion
yearly for NRM, the Administration has requested only approximately
$460 million for NRM. This decision means that VA is forced to divert
funds designated for another purpose to meet this need.
advance appropriations for fy 2017
The Independent Budget once again offers baseline projections for
funding through advance appropriations for the Medical Care accounts
for FY 2017. For FY 2017, The Independent Budget recommends
approximately $54.2 billion for Medical Services. Our Medical Services
recommendation includes the following recommendations:
Current Services Estimate..................................................................... $51,937,260,000
Increase in Patient Workload.................................................................. $1,576,151,000
Additional Medical Care Program Costs......................................................... $670,000,000
-----------------
Total FY 2017 Medical Services.............................................................. $54,183,411,000
=================
Our growth in patient workload is based on a projected increase of
approximately 150,000 new unique patients. These new unique patients
include priority group 1-8 veterans and covered nonveterans. We
estimate the cost of these new unique patients to be approximately $1.3
billion. This recommendation also reflects an assumption that more
veterans will be accessing the system as VA expands its capacity and
services and we believe that reliance rates will increase as veterans
examine their healthcare options as a part of the option for choice.
The increase in patient workload also includes a projected increase of
74,225 new OEF/OIF, as well as OND veterans at a cost of approximately
$301 million.
As previously discussed, the IBVSOs believe that there are
additional medical program funding needs for VA. The Independent Budget
recommends $325 million directed toward VA long-term-care programs. In
order to support the continued rebalancing of VA long-term care in FY
2017, $125 million should be provided. Additionally, $95 million should
be targeted at the VA's Veteran Directed-Home and Community Based
Services (VD-HCBS) program. The remainder of the $325 million ($105
million) should be dedicated to increasing the VA's long-term-care
average daily census (ADC) to the level mandated by Public Law 106-117,
the ``Veterans Millennium Health Care and Benefits Act.'' In order to
meet the increase in demand for prosthetics, the IB recommends an
additional $165 million. Our additional program costs recommendation
includes continued reinvestment of $75 million in the Comprehensive
Family Caregiver program. Finally, we believe that VA should invest a
minimum of $105 million as an advance appropriation in FY 2017 to
expand and improve access to women veterans' healthcare programs.
Additionally, for FY 2017 The Independent Budget recommends
approximately $6.2 billion for Medical Support and Compliance. The
Independent Budget also recommends approximately $5.9 billion for
Medical Facilities for FY 2017. As with FY 2016, our FY 2017
recommendation includes the addition of $900 million to the baseline
for NRM. Last year the Administration's recommendation for NRM
reflected a projection that would place the long-term viability of the
healthcare system in serious jeopardy.
medical and prosthetic research
The Independent Budget co-authors have ongoing concerns about the
lack of investment in Medical and Prosthetic Research. We appreciate
the fact that this year the Administration recommended a substantial
increase in research funding. For FY 2016, the Administration
recommends approximately $622 million while the IB recommends
approximately $619 million.
The VA Medical and Prosthetic Research program is widely
acknowledged as a success on many levels, and contributes directly to
improved care for veterans and an elevated standard of care for all
Americans. The research program is an important tool in VA's
recruitment and retention of healthcare professionals and clinician-
scientists to serve our Nation's veterans. By fostering a spirit of
research and innovation within the VA medical care system, the VA
research program ensures that our veterans are provided state-of-the-
art medical care.
grants for state extended-care facilities
The State Veterans Home program (State Homes) is a very successful
Federal-state partnership in which VA and states share the cost of
constructing and operating nursing homes and domiciliaries for
America's veterans. Today, State Homes provide over 30,000 nursing home
and domiciliary beds for veterans, their spouses, and gold-star parents
of veterans. Overall, State Homes provide approximately 53 percent of
VA's long-term-care workload, for the very reasonable cost of only
about 12 percent of VA's long-term-care budget. On average, the daily
cost of care for a veteran at a State Home is less than 50 percent of
the cost of care at a VA long-term-care facility. This basic per diem
covers about 30 percent of the cost of care, with states responsible
for the balance, utilizing both state funding and other sources.
VA also provides states with construction grants to build,
renovate, repair, and expand both nursing homes and domiciliaries, with
states required to provide 35 percent of the cost for these projects in
matching funding. VA maintains a prioritized list of construction
projects proposed by State Homes based on specific criteria, with life
and safety threats in the highest priority group. Only those projects
that already have state matching funds qualify are included in VA's
Priority List Group 1 projects, which are eligible for funding. Those
who have not yet received assurances of state matching funding are put
on the list among Priority Groups 2 through 7.
In FY 2014, the estimated Federal share for proposed State Home
Construction Grants submitted by states was $928 million, of which $489
million had already secured the state matching funds required to put
them in the Priority Group List 1. In FY 2015, total estimated share of
State Home Construction Grant requests rose to $976 million, of which
$409 million already have state matching funding. The IBVSOs had
recommended $250 million to provide funding for about half of the
Priority 1 projects. The final appropriated funding for FY 2014 was
only $85 million and only $90 million for FY 2015. For FY 2016, the
IBVSOs recommend $200 million for the State Home Construction Grant
program, which we estimate would provide sufficient funding for
approximately half of the projects expected to be on the FY 2016 VA
Priority Group 1 List when it is released at the end of this year.
We encourage the Committee to scrutinize the VA's budget with
vigor. However, we believe than honest analysis will show that these
are the resource needs of VA. As such, we believe that the real focus
of the Committee should be on scrutinizing how the VA spends these
critically needed resources. It is imperative that these dollars ensure
that veterans receive timely, quality health care and claims decisions
that are right the first time.
In the end, it is easy to forget that the people who are ultimately
affected by wrangling over the budget are the men and women who have
served and sacrificed so much for this Nation. We hope that you will
consider these men and women when you develop your budget views and
estimates, and we ask that you join us in adopting the recommendations
of The Independent Budget.
This concludes our statement. I would be happy to answer any
questions you may have.
Chairman Isakson. Thank you for your testimony and for your
support of veterans and what you do for paralyzed veterans. We
appreciate it very much.
Ms. Ilem.
STATEMENT OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS
Ms. Ilem. Chairman Isakson, on behalf of DAV, I am pleased
to present the fiscal year 2016 recommendations of the
Independent Budget for the Veterans Benefits Administration.
Without question, over the past 5 years, VBA has achieved
some remarkable progress. The fully developed claims program,
disability benefits questionnaires, and the Veterans Benefits
Management System, known as VBMS, have all made significant
contributions. Five years ago, no claims were processed
electronically. Today, more than 93 percent of VBA's roughly
500,000 pending claims are fully electronic.
Likewise, VBA has made significant progress related to its
target goal of completing disability claims within 125 days,
with a 98-percent accuracy standard. From its peak in 2013, the
total number of pending claims has been reduced by 40 percent,
and the backlog claims pending over 125 days cut by over 60
percent. And I would mention at this point, as well, I think
General Hickey has done an excellent job. She has worked
tirelessly with the VSO community, and a lot of these changes
have been really put on her, and she has not let up during her
time.
At the same time, according to VBA, the accuracy of
decisions rose from 86.4 percent 2 years ago to 91 percent at
the beginning of this year.
Mr. Chairman, while it is unclear if VBA can achieve its
goals by the end of 2015, in our opinion the most critical
factor in VBA's ability to address the backlog is sufficient
staffing. Over the past several years, many VA regional offices
have required mandatory overtime and diverted some of their
senior employees from both quality review and appeals work to
focus on claims processing. The reliance on mandatory overtime
in this supplemental claims processing workforce is a clear
indicator to us that VBA is insufficiently staffed to handle
its current workload.
In order to increase productivity now while allowing for
future efficiencies from technology, we propose the VBA be
provided 1,700 additional full-time employees, half of them
permanent and the other half under a 2-year temporary
authority. At the end of the 2-year period, VBA could make
permanent the best of these temporary employees for positions
that may open from attrition.
While VBMS has generally been a success, current planning
at VBA has delayed development of some critical IT elements,
including the major modules to allow electronic transmission of
medical examinations and service treatment records. Therefore,
the IBVSOs have recommended a $60 million increase for IT
funding for VBMS and other critical IT enhancements.
While the claims backlog has been reduced, the backlog of
pending appeals is now rising. Last year, the board completed a
record over 55,000 appellate decisions, but there are still
nearly now 300,000 appeals in VBA at various stages working
their way toward the board. For these reasons, we recommend an
increase of 120 new full-time employees for the board.
In addition, the IBVSOs recommend that at least $15 million
be allocated for IT modernization to aid the board's transition
to digital processing of appeals.
Mr. Chairman, to address the issue of rising appeals, the
Independent Budget groups here, other VSO stakeholders, VBA,
and the board worked together collectively to develop a new
proposal called ``fully developed appeals,'' or FDA, modeled
after the fully developed claims program. The veteran would
agree to assemble private evidence and arguments to satisfy
their appeal, eliminate some VBA processing steps, and agree
not to request a hearing. In exchange, they could save up to 2
to 3 years of processing time. The FDA program would be
completely voluntary, and the veteran could withdraw from it at
any time without losing any right to a traditional appeal. We
think this option will help expedite many of these appeals and,
therefore, urge the Committee to move legislation to create a
new FDA pilot program.
Another critical program for veterans, particularly
disabled veterans, is the Vocational Rehabilitation and
Employment Service. In 2016, the IBVSOs project a nearly 10-
percent increase in that participant growth; therefore, we
recommend an additional 382 full-time employees be added to the
program, of which 277 would be dedicated as counselors and 105
dedicated to support services.
Finally, the IB policy agenda for the 114th Congress
contains a number of additional policy recommendations we hope
the Committee will consider, including the elimination of the
rounding down of the COLA for veterans and survivors' benefit
programs--or payments, and increasing Dependency and Indemnity
Compensation rates for survivors, eliminating the DIC and
Survivor Benefit Plan offsets, and allowing widows to have
their benefits continue or restored if they remarry after age
55.
That completes my statement. I am happy to answer any
questions.
[The prepared statement of Ms. Ilem follows:]
Prepared Statement of Joy Ilem, Deputy National Legislative Director,
Disable American Veterans
Chairman Isakson, Ranking Member Blumenthal and Members of the
Committee: On behalf of the DAV and our 1.2 million members, all of
whom were wounded, injured or made ill from their wartime service, I am
pleased to present recommendations of The Independent Budget (IB) for
the fiscal year (FY) 2016 budget related to veterans' benefits and the
Veterans Benefits Administration (VBA). The IB is jointly produced each
year by DAV, AMVETS, Paralyzed Veterans of America and Veterans of
Foreign Wars of the United States. This year's IB Budget Report as well
as the IB's Policy Agenda for the 114th Congress contain numerous
recommendations to improve veterans' benefit programs and the claims
processing and appeals system; however, in today's testimony I will
highlight just some of the most critical ones for this Committee to
consider, particularly those requiring new resources.
Mr. Chairman, five years ago the Veterans Benefits Administration
(VBA) set out to transform and modernize its systems and procedures for
processing veterans' claims for benefits, particularly for disability
compensation. Then-VA Secretary Shinseki announced ambitious
``aspirational goals'' for transforming the claims system, promising
that by the end of 2015 VBA would decide all claims for disability
compensation within 125 days and that they would be completed to a 98%
accuracy standard. This aspirational goal soon became enshrined as
VBA's bedrock strategic target, against which all of its plans and
progress would be measured.
Today, with less than a year remaining, there are questions about
whether either of those goals can be achieved.
vba has made progress in transforming claims processing
Mr. Chairman, unquestionably, over the past five years VBA has
achieved remarkable progress, much of it visible and measurable. A new
organizational model has been implemented, new technologies deployed
and new business processes adopted. The fully developed claims (FDC)
program started as a pilot test, and now about 40 percent of all claims
filed today are done through the FDC program. Standardized medical
evidence forms known as Disability Benefits Questionnaires (DBQ) are
now used universally, and are an essential component of creating an
automated claims processing system. And the development and deployment
of the Veterans Benefits Management System (VBMS) and its ``e-Folder''
have dramatically enhanced VBA's ability to manage the volume of
documents and information required to process over a million claims
yearly. Today, VA receives more claims, processes more claims, has
fewer claims pending in its inventory, has fewer claims in backlog
status, takes less time to process claims, and issues decisions that
are more accurate.
Five years ago, no claims were processed electronically; today with
VBMS fully deployed to all 58 regional offices, more than 93% of VBA's
roughly 500,000 pending claims are fully electronic. There have been
more than one billion images scanned into VBMS or other VA systems, and
both new and legacy claims documents and files continue to be converted
into digital documents and uploaded into VBMS. Veterans' e-Folders in
VBMS can be read at all VBA offices, including the Appeals Management
Center (AMC) and Board of Veterans' Appeals (Board), as well as at 148
VHA facilities and by VSOs that represent veterans. About 75 percent of
the rating schedule, which covers more than 93 percent of all rating
decisions, has been coded into ``calculators'' and embedded in VBMS to
assist Rating Veterans Service Representatives (RVSRs) make rating
decisions.
Both e-Benefits and the Stakeholder Enterprise Portal (SEP) allow
veterans and their authorized representatives to initiate, submit and
track their claims online. These technological advancements have
enabled VBA to make major improvements in the size of the backlog, the
timeliness of claims and the accuracy of decisions; however, analysis
of currently available data raises questions about whether the level
and trends of progress are sufficient to meet VBA's 2015 goals.
According to VBA's Monday Morning Workload Analysis reports, at its
peak early in 2013, the total number of pending claims for disability
compensation and pension rose to over 860,000, with the backlog (those
pending over 125 days) topping 600,000. As of last week, the total
pending workload of claims was reduced by more than 40 percent to just
under 500,000 and the number in backlog status was cut by over 60
percent down to about 230,000.
Based on data from the Aspire Dashboard, the timeliness of claims
has also improved; however, this performance remains far short of the
2015 goal of all claims being completed in less than 125 days. In
January 2013, the average processing time and the average days pending
metrics were both approximately 280 days. By January 2015, the average
days processing was down to about 200 days and the average days pending
was about 150 days. However, it is important to point out that both of
those timeliness measures are for ``average'' times, whereas VBA's 2015
target is based on all claims being completed with 125 days. To have
all completed in 125 days might require an ``average'' processing time
of 80 or 90 days. The current trends raise questions about whether this
target can be achieved by the end of 2015.
Finally, the most important metric of a properly functioning claims
processing system is the accuracy of decisions. After all, claims
completed rapidly do a veteran little good if the decision results in a
wrongful denial. In January 2013, VBA's claims accuracy based on its
Systematic Technical Accuracy Review (STAR) was 86.4 percent for the
12-month average, and 86.8 percent for the three month average. Over
the past two years, the accuracy rate had increased steadily reaching
91 percent for the 12-month measure ending in January 2015, and 91.5
percent for the 3-month measure. Among the reasons for these increases
were sharpened focus on training, testing and quality control,
including the creation of Quality Review Teams (QRTs), the dramatic
reduction of Veterans Claims Assistance Act of 2000 (VCAA) ``duty to
assist'' notification errors due to the inclusion of this notice
directly on application forms, and the elimination of errors due to
automation. However, whether it is possible to reach 98 percent
accuracy for claims remains an open question, particularly as the
average number of issues per claim continues to rise.
realistic goals are key to long-term success
Overall, VBA has made significant progress toward reaching the 2015
goals; however, with less than a year remaining to reach those goals,
VBA must openly and honestly assess whether those goals are still
appropriate and achievable. Vital lessons must be learned from the VA's
scandals last year of holding onto unrealistic and unachievable goals.
The Veterans Health Administration's (VHA) access standard that
outpatient appointments must be scheduled within 14 days of the
patient's desired date, was widely viewed as unrealistic considering
VHA's limited capacity to provide timely care to new patients. Faced
with the dilemma of an unreachable and unchangeable standard, some
employees made the decision to manipulate data and cover up true
waiting lists rather than be held accountable for failure to meet this
standard.
The critical question that VA and Congress must confront now is
whether the goals established five years are working to drive VBA's
performance in a positive direction or whether it would be better for
veterans and VA to review, reassess and if necessary, revise VBA's
target goals before they start to distort behavior in the chase to meet
these unreachable standards. If VBA concludes they are not, VBA must
work in a transparent and collaborative manner with Congress and its
VSO partners to set new goals, revise its strategies and plans, and
request new resources if needed to reach those goals.
permanently ending the backlog requires sufficient staffing
Recognizing that rising workload, particularly claims for
disability compensation, could not be addressed without additional
personnel, Congress provided the VBA with more than 3,000 full time
employee equivalents (FTEE) between 2008 and 2013, primarily in
Compensation Service. However, relative to VBA's total workload,
including appeals, these increases have not been sufficient to keep
pace with rising workload, including non-rating work and appeals work,
as evidenced by VBA's own resource allocation and personnel decisions.
VBA's largest increases in productivity--periods where the backlog
declined most markedly--occurred while VBA enforced a policy of
mandatory overtime for its workforce. During holiday periods, when
mandatory overtime was curtailed, production fell off measurably.
Furthermore, over the past couple of years many VA Regional Offices
(VARO) have diverted some of their senior employees from both quality
review and appeals work to focus on claims processing to drive down the
backlog. Specifically, both Decision Review Officers (DRO) and Quality
Review Specialists (QRS) have been performing claims development and
rating duties during both regular and overtime working hours at many
VAROs. The reliance on this supplemental claims processing workforce is
a clear indicator that VBA is insufficiently staffed to handle its
current workload.
A blend of technology and people will be necessary to provide
veterans and their dependents with timely accurate decisions. Although
this new claims processing system has the potential to transform the
delivery and accuracy of benefits, some additional time will be
required before the full effect of these changes will be realized.
Therefore, in order to increase productivity now, while allowing for
future productivity increases, the IBVSOs propose that VBA be provided
with 1,700 additional FTEE, half of them permanent and the other half
under a two-year temporary authority. The temporary FTEE request is
based on an approach included in the stimulus legislation that was
passed several years ago that allowed the VBA to hire several thousand
employees for temporary, two-year terms. At the end of those two years,
many of these temporary employees transitioned into permanent positions
through staff attrition.
Allowing VBA to again hire employees for two-year temporary terms
could supplement the staff and alleviate reliance on mandatory
overtime, and further reduce the backlog of disability claims. Such an
initiative would also provide an outstanding opportunity for VBA to
develop a generous pool of trained, qualified candidates for succession
of full-time positions vacated by employees leaving VBA.
While this infusion of resources is necessary to supplement the
current workforce, the IBVSOs continue to believe that a more accurate
staffing and production model is required to determine VBA's long-term
resource needs as new technology and business processes evolve.
In FY 2016, the IBVSOs recommend providing VBA's compensation
service with 850 new permanent FTEE and 850 two-year temporary FTEE.
These additions will require an increase in appropriations of $158.9
million.
it modernization must be accelerated
The most critical elements of VBA's claims processing
transformation are its new IT systems created over the past five years:
VBMS, e-Benefits and SEP. These three systems have led the way in
moving claims processing from an outdated paper-based system to the
modern digital system. Despite early challenges, the VBMS program has
proven to be an effective platform for processing claims in a digital
environment. The objective now is to fully integrate all elements of
the claims system, VSOs and other VBA business lines to create a
unified digital work environment.
Current planning at VBA calls for some critical elements of the
claims process, including major modules to allow electronic
transmission to VBMS of examinations and service treatment records from
the Department of Defense, other government agencies, private
businesses and other organizations, to be completed over the next
several years. Although VBA could use these modules immediately, budget
constraints have extended planning into future years. Similarly, plans
to expand VBMS, or another compatible IT solution, to all remaining VBA
business lines and the Board, are also being stretched out to future
years due to lack of budget availability. We believe that Congress must
provide sufficient resources to VBA now to allow these critical
elements of VBMS and associated IT systems to be accelerated.
VBA must also place greater emphasis on integrating VSOs into VBMS
and resolving lingering issues in SEP, both of which are essential to
maximizing the benefits that VSO service officers offer in resolving
claims more quickly and accurately.
The IBVSOs recommend increasing the amount of IT funding allocated
to the VBMS program in FY 2016 by $60 million to support the specific
IT enhancements.
claims reform must include appeals reform
While the claims backlog has dropped significantly as indicated
above, the backlog of pending appeals has risen over the past couple of
years. Despite the fact that the Board completed more than 55,000
appellate decisions in FY 2014, an increase of 10 percent over the
highest previous total, this improvement was primarily driven by an
increase of more than 100 new FTEE. However, the number of appeals at
various stages working their way through VBA toward the Board now tops
300,000. In order to address the pending workload in a reasonable
timeframe, the Board will need to utilize a multi-pronged approach that
includes increasing the size of staff, modernizing IT systems and
innovative programs to streamline work.
One essential element needed to permanently address the backlog of
pending appeals is to complete VBA's transformation and reform of the
claims process. As the claims error rate goes down, and as confidence
in the claims process grows, the percentage of claimants who later file
appeals would be expected to fall. However, as VBA increases its
productive capacity and the number of completed claims, an increase in
the number of appeals could occur even if the accuracy rate continues
to climb. Even accurate decisions may be appealed if they are
unfavorable to claimants.
board must increase staffing to meeting rising workload
After several years of reduction in workforce, the Board has
significantly increased its FTEE levels over the past three years,
rising from an average of 510 FTEE in FY 2012 to an authorized level of
640 FTEE in FY 2015. Significant training and orientation are required
for new Board attorneys to reach full productivity. The time taken away
to train and mentor these attorneys reduces appeals output; therefore,
some temporary losses in completed appeals may occur even with these
new staff resources.
As indicated above, over the past five years the Board has averaged
approximately 90 appeals dispositions per FTEE, producing a record
55,532 decisions in FY 2014. However, with the inventory of pending
appeals now topping 360,000 in various stages at both VBA and the
Board, there are simply not enough hands to do all the work that will
be required, even with further efficiencies gained through technology
and other reforms.
For FY 2016, the IBVSOs recommend an increase of 120 new FTEE, a 20
percent increase over the FY 2015 authorized level, which will require
an additional $17 million.
the board's it needs must be addressed now
While VBMS for compensation claims processing has received
virtually all of the IT attention and resources up to this point, the
extension and adaptation of VBMS for the Board's use has been pushed
back to future years due to limited budgets. While the Board has access
to e-Folders to review claims records, the Board is unable to process
appeals within a fully electronic environment. With the inventory of
pending appeals at both VBA and the Board growing, IT modernization at
the Board must move forward as a high priority.
The IBVSOs recommend that at least $15 million be allocated in FY
2016 for IT modernization to aid the Board.
vba must strengthen the decision review officer program
Another key approach to lowering the appeals workload for the Board
is to strengthen the DRO post-determination review process, which can
often be more effective or timely than the traditional appeals process
because it resolves appellate-related disputes at the VARO level. A DRO
has de novo authority, meaning he or she reviews the entire appeal file
with no deference given to the rating board decision. DROs can overturn
or uphold a previous decision, hold hearings and perform any activity
necessary to assemble evidence, including ordering medical
examinations. Even if a DRO is unable to grant the benefit sought on
appeal, any additional development work he or she performs could
potentially shorten the time required by the Board to produce a
decision.
For years, the IBVSOs have voiced concerns to VBA and Congress
regarding the erosion of the DRO program. The number of DROs in the
system is insufficient for the amount of DRO work generated in VAROs.
Also the assignment of initial claims processing work to DROs at
numerous VAROs further detracts from their intended work. Having DROs
perform claims processing work when there is more than enough appeals
work pending is merely shifting the weight of the backlog from one area
to another. Over the past year VBA leadership has made some efforts to
limit or eliminate the use of DROs in performing claims work; however,
we continue to observe DROs at many VAROs working on claims processing
activities. While we understand that VBA has limited resources but
seemingly unending claims work, it is imperative that VBA ensure that
DROs focus solely on appeals-related work. If additional personnel are
required to process pending and future claims in a timely manner, VAROs
must request additional resources, not repurpose DROs.
fully developed appeals pilot program
In order to seek new solutions that could improve the appeals
process for veterans, the IBVSOs, other VSO stakeholders, VBA and the
Board worked to reach consensus on a new proposal to create a ``fully
developed appeals'' (FDA) program modeled after the fully developed
claims (FDC) program. The premise of the FDA program is that the
appellant would assume responsibility for gathering all private
evidence necessary for the appeal and agree to eliminate some steps and
work required by VBA and the Board. In return the veteran would receive
a significantly quicker appeal decision by the Board with no diminution
in the quality or accuracy of that decision.
The FDA would become an additional option that the claimant could
choose any time during the one-year period allowed to file an NOD. When
veterans make the FDA election, they would be required to submit any
and all additional evidence they want considered as part of their
appeals and any arguments to support their appeals. They would also be
required to certify that they have been fully informed about the FDA
program, that they understand what they are required to do and not do,
what VBA and the Board are required to do and not do, and that they
consent to voluntarily filing their appeals in this manner. With this
certification, the veterans' rating decisions and complete files--
supplemented by any new evidence or argument submitted by veterans or
their representatives at time of filing their FDA--would be transmitted
directly to the Board and placed on a new FDA docket for date-ordered
review and decision. Unlike the traditional appellate process, no
Statement of the Case (SOC) would be created and issued, no VA Form 9
would be completed, no local VARO hearings or reviews would be
conducted, no Board hearings would be held, no Supplemental Statement
of the Case would be created, and no Form 8 certification process would
occur. The elimination of these steps alone could save two to three
years of processing at the VARO compared to a traditional appeals
process.
Similar to the FDC program, the FDA program would require the
veteran to certify that there is no additional private evidence
relevant to the appeal under consideration, and if the veteran later
submitted additional evidence after the date of filing, the appeal
would revert from the FDA program and return to the traditional appeals
process, without any loss of rights or options. The veteran could also
withdraw his or her appeal from the FDA process at any time for any
reason. The Board, however, would still be required to develop any
Federal evidence, examinations or independent medical evaluations
determined necessary for the Board to make its decision. The IBVSOs
believe it is important that the FDA program be a time-limited,
statutorily-authorized pilot program in order for VA to provide
Congress and stakeholders the ability to oversee the program's design,
implementation and operation, as well as to ensure that veterans'
rights are fully protected.
It is important to understand that the FDA proposal is not a
``magic bullet'' that will eliminate the backlog of pending appeals; it
is designed to be another option--one of many for veterans seeking to
overturn an incorrect or unfavorable claims decision. As discussed
above, the IBVSOs continue to strongly support the DRO process, and the
FDA program is neither a substitute nor replacement for it. Instead, it
will provide another option that each individual veteran and his or her
representative, if any, can consider in making decisions about the most
effective and timely process to resolve appeals.
resources for vocational rehabilitation and employment service
Vocational Rehabilitation and Employment Service, (VR&E), also
known as the VetSuccess program, provides critical counseling and other
adjunct services necessary to enable service-disabled veterans to
overcome barriers as they prepare for, find, and maintain gainful
employment. VetSuccess offers services through five tracks:
reemployment, rapid access to employment, self-employment, employment
through long-term services, and independent living. Another key program
helping to deliver VR&E assistance at a key transition point for
veterans is the VetSuccess on Campus (VSOC) program which is operating
at 94 college campuses. Additional VR&E services are provided at 71
military installations for active duty servicemembers undergoing
medical separations through the Department of Defense's (DOD) and VA's
joint Integrated Disability Evaluation System (IDES).
In order to meet the critical needs of veterans seeking employment,
careers or more independent living, staffing levels throughout VR&E
services must be commensurate with current and future demands. At the
end of FY 2013, VR&E employed a total of 1,343 FTEE. VBA projected an
increase in FY 2014 to an authorized level of 1,442 FTEE. In the FY
2015 budget request, VBA did not recommend increasing this staff and
was again authorized 1,442 for FY 2015, despite an increasing workload.
In order for VR&E to keep pace with demand, the IBVSOs project the
total number of VR&E participants at roughly 165,000 for FY 2016,
nearly 10 percent in participant growth. At present there are roughly
974 VR&E counselors managing an active client caseload of roughly
140,000 participants which averages a counselor-to-client ratio of
roughly 1 to 135. Ideally, a reasonable client-to-counselor ratio would
consist of one VR&E counselor for every 125 veterans as has been
advocated by the IBVSOs for the past several years. However, the
average can be misleading as there are higher and lower actuals
throughout VAROs. As an example, the Cleveland VARO's counselor to
client ratio is 206 cases for every VR&E counselor, and in the Fargo
VARO, 64 cases for each VR&E counselor. Therefore, it is essential that
staffing increases be properly distributed throughout all of VR&E to
ensure that counselors' caseloads are equitably balanced.
For FY 2016, the IBVSOs recommend an additional 382 FTEE, of which
277 would be dedicated as VR&E counselors and the remaining 105
employees dedicated to support services bringing VR&E's total FTEE
strength to 1,824. The additional funding required for VR&E for FY 2016
would be $41.8 million.
other priority benefit proposals
Eliminate rounding down of veterans' and survivors' benefit payments
In 1990, Congress, in an omnibus reconciliation act, mandated
veterans' and survivors' benefit payments be rounded down to the next
lower whole dollar. While this policy was initially limited to a few
years, Congress has continued to extend it every few years. Each year's
COLA is calculated on the rounded-down amount of the previous
year's payments. While not significant in the short run, the cumulative
effect over time results in a significant loss to beneficiaries.
The effect of rounding down monthly COLA increases has eroded
approximately $10 per month for every veteran or survivor. For example,
a veteran totally disabled from service-connected disabilities would
have received $1,823 per month in 1994 and today will be paid at $2,848
per month. Had that veteran received the full COLA each year for the
past two decades, he or she would receive about $120 extra this year,
and cumulatively over two decades would have received almost $2,000
more. The Independent Budget veterans service organizations note and
greatly appreciate that the most recent COLAs were not rounded down and
urge Congress not to return to a policy of rounding down veterans' and
survivors' benefits payments.
strengthen support for survivor benefits programs
Increase DIC rates
The current rate of compensation paid to the survivors of deceased
members is inadequate and inequitable when measured against other
Federal programs. Under current law, DIC is paid to an eligible
surviving spouse if the military servicemember died while on active
duty or the veteran's death resulted from a service-related injury or
disease.
DIC payments were intended to provide surviving spouses with the
means to maintain some semblance of economic stability after the loss
of their loved ones. All surviving spouses who rely solely on DIC,
regardless of the status of their sponsors at the time of death, face
the same financial hardships.
The IBVSOs recommend that the rate of DIC should be increased from
43 percent to 55 percent of a 100 percent disabled veteran's
compensation for all eligible surviving spouses.
Eliminate DIC and SBP offsets
The current requirement that an annuity under the DOD SBP be
reduced by an amount equal to DIC is inequitable because no duplication
of benefits is involved. A veteran of military service is compensated
for the effects of service-connected disability. When a veteran dies of
service-connected causes or following a substantial period of total
disability from service-connected causes, eligible survivors or
dependents receive DIC from the VA.
Career members of the Armed Forces earn entitlement to retired pay
after 20 or more years of service. Survivors of military retirees have
no entitlement to any portion of the veteran's military retirement pay
after his or her death, unlike many retirement plans in the private
sector. Under the SBP, deductions are made from military pay to
purchase a survivor's annuity. This benefit is not gratuitous but is
purchased.
Upon a retiree's death, the SBP annuity is paid monthly to eligible
beneficiaries. If the veteran died from other than service-connected
causes or was not totally disabled by service-connected disability for
the required time preceding death, beneficiaries receive full SBP
payments. However, if the veteran's death was a result of military
service or after the requisite period of total service-connected
disability, the SBP annuity is reduced by an amount equal to the DIC
payment. When the monthly DIC rate is equal to or greater than the
monthly SBP annuity, beneficiaries lose the SBP annuity in its
entirety.
The IBVSOs recommend that Congress repeal the inequitable offset
between DIC and Survivor Benefit Plan (SBP) because no duplication
occurs between these two separate and distinct benefits.
Allow remarriage after age 55
Current law allows retention of DIC upon remarriage at age 57 or
older for eligible survivors of veterans who die on active duty or of a
service-connected injury or illness. However, remarried survivors of
retirees of the Civil Service Retirement System, for example, obtain a
similar benefit at age 55. Equity with beneficiaries of other Federal
programs should govern Congressional action for this deserving group,
therefore Congress should lower the age required for remarriage for
survivors of veterans who have died on active duty or from service-
connected disabilities. This change in eligibility would also bring DIC
in line with Survivor Benefit Plan rules that allow retention with
remarriage at the age of 55.
Although the IBVSOs appreciate the action Congress took to allow
restoration of this rightful benefit, the current age threshold of 57
years should be lowered to 55 for all eligible surviving spouses,
consistent with other similar programs.
Mr. Chairman, that concludes our testimony and I will be happy to
answer any questions from you or other members concerning these issues.
Chairman Isakson. Thank you very much.
Mr. Kelley.
STATEMENT OF RAYMOND C. KELLEY, DIRECTOR, NATIONAL LEGISLATIVE
SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES
Mr. Kelley. Mr. Chairman, on behalf of Veterans of Foreign
Wars and our Auxiliaries, thank you for the opportunity to
testify today. The VFW is responsible for the construction
portion of the IB, so I will limit my remarks to that.
Gaps in access, utilization, and safety in VA's health care
system's infrastructure exacerbated the conditions that lead to
VA's unauthorized wait lists. VA currently sits at 119 percent
capacity and admits they need $14 billion just to close current
safety gaps. Every effort must be made to ensure these
facilities remain safe and sufficient environments to deliver
care. To do this, large capital investments must be made.
Presenting a well-articulated, completely transparent
capital asset plan, which VA has attempted to do, is important,
but not adequately funding that plan will prevent VA from
closing those current gaps and only cause them to grow.
Through Veterans Access, Choice, and Accountability Act of
2014 (VACAA), Congress provided VA $5 billion to begin closing
gaps in non-recurring maintenance and minor construction.
However, this is a one-time infusion of funds, and it cannot be
seen as a replacement for annual appropriations but, rather, an
investment to reduce the backlog of safety and access gaps.
VA and Congress must develop a long-term funding strategy
that addresses the four major components of capital
infrastructure, which are non-recurring maintenance, major and
minor construction, and leasing.
Non-recurring maintenance (NRM) projects are one-time
repairs, such as modernizing mechanical or electrical systems,
replacing windows and equipment, and preserving roofs and
floors.
For buildings to last their life cycle, annual investments
of non-recurring maintenance must occur. Over the past several
years, VA has requested just over $700 million annually for
NRM, barely half of what is needed to maintain facilities for
their full life cycle.
The IB estimates VA needs to invest $1.35 billion annually
in NRM as a baseline to ensure facilities are maintained in a
safe and efficient manner. VA will need to invest additional
funding to begin reducing the backlog of nearly 3,000 NRM
projects.
There are currently 45 major construction projects that are
partially funded dating back to fiscal year 2009. VA has also
identified 114 major construction projects they determine will
need to be completed within the next 10 years. While the IB is
concerned about these future projects, the most pressing issue
is finishing what they have already started.
Included in the 45 partially funded projects are 9 major
construction seismic deficiencies. It will require $4.7 billion
to close these safety gaps. VA must make efforts to close these
deficiencies in these properties.
The IB recommends that Congress appropriate $1.9 billion
for fiscal year 2016 to set VA on a course to close all
currently partially funded projects and begin funding the
remaining seismic deficiencies within the next 5 years.
VA has come close to keeping up with its minor construction
needs over the past few years. It is estimated that to close
all minor construction gaps that have been identified, VA will
need to invest between $7 billion and $9 billion over the next
10 years. Along with the funds that have been authorized for
minor construction projects over the next 2 years through
VACAA, the IB recommends an additional $575 million for fiscal
year 2016.
VA's capital leasing program allows VA to improve veterans'
access to health care by entering into multiyear leases that
provide the Department flexibility to increase and decrease the
size and scope of care that is delivered in more than 800
communities. Thanks to the passage of VACAA, 27 major medical
leases have been authorized. While funding these leases is a
step in the right direction, it will be nearly 2 more years
before the medical facilities see patients because of delays in
funding and the current contract authorization process.
Congress and VA must find a long-term solution to authorize
these leases so they can be funded quickly and contracts can be
filled without delay, so veterans do not wait years for these
facilities to be completed.
Mr. Chairman, this concludes my testimony, and I look
forward to any questions you or the Committee may have.
[The prepared statement of Mr. Kelley follows:]
Prepared Statement of Raymond C. Kelley, Director, National Legislative
Service, Veterans of Foreign Wars of the United States
Chairman Isakson, Ranking Member Blumenthal and Members of the
Committee, on behalf of the nearly 1.9 million members of the Veterans
of Foreign Wars of the United States (VFW) and our Auxiliaries, thank
you for the opportunity to testify before you today regarding the
Department of Veterans Affairs (VA) Fiscal Year (FY) 2016 budget
recommendations. The VFW works alongside the other members of the
Independent Budget (IB)--AMVETS, Disabled American Veterans and
Paralyzed Veterans of America--to produce a set of policy and budget
recommendations that reflect what we believe would meet the needs of
America's veterans. The VFW is responsible for the construction portion
of the IB, so I will limit my remarks to that portion of the budget.
Gaps in access, utilization and safety in VA's heath care system's
infrastructure exacerbated the conditions that lead to VA's
unauthorized wait lists, causing veterans to wait too long to receive
the care they need and deserve. VA currently sits at 119 percent
capacity and admits to needing $14 billion just to close current safety
gaps.\1\ Every effort must be made to ensure these facilities remain
safe and sufficient environments to deliver care. A VA budget that does
not adequately fund facility maintenance and construction projects will
continue to reduce the timeliness and quality of care for veterans.
---------------------------------------------------------------------------
\1\ Department of Veterans Affairs, FY 2015 Budget Submission
Construction and 10 year Capital Plan, Vol. 4 of 4, February 2014, p.
10.3-12, 9.3-11.
---------------------------------------------------------------------------
The vastness of VA's capital infrastructure is rarely fully
visualized or understood. VA currently manages and maintains more than
6,000 buildings and almost 34,000 acres of land with a plant
replacement value (PRV) of approximately $90 billion. Although VA has
decreased the number of critical infrastructure gaps, there remain more
than 4,000 gaps that will cost between $56 and $68 billion to close,
including $10 billion in activation costs.\2\
---------------------------------------------------------------------------
\2\ Department of Veterans Affairs, FY 2015 Budget Submission
Construction and 10 year Capital Plan, Vol. 4 of 4, February 2014, p.
1-4, 9.2-7.
---------------------------------------------------------------------------
Quality, accessible health care continues to be the focus of the
Independent Budget Veterans Service Organizations (IBVSOs), and to
achieve and sustain that goal, large capital investments must be made.
Presenting a well-articulated, completely transparent capital-asset
plan, which VA has attempted to do, is important, but not adequately
funding that plan will prevent VA from closing current access,
utilization and safety gaps and only cause those gaps to grow.
In August of last year, Congress provided VA $5 billion to begin
closing access gaps, by including funding for non-recurring maintenance
(NRM) and minor construction projects when it passed the Veterans
Access, Choice, and Accountability Act of 2014 (VACAA). VA has
identified approximately 400 minor and NRM projects that this funding
will complete, ensuring facilities are maintained and existing
facilities last for their projected life-cycle. However, this one-time
infusion of funds cannot be seen as a replacement for annual
appropriations, but rather an investment to reduce the backlog of
safety and access gaps.
VA and Congress must develop a long-term funding strategy that
addresses the four major components of capital infrastructure: non-
recurring maintenance, major construction, minor construction, and
leasing.
non-recurring maintenance accounts
Even though non-recurring maintenance is funded through VA's
Medical Facilities account and not through the construction account, it
is critical to VA's capital infrastructure. NRM embodies the many small
projects that together provide for the long-term sustainability and
usability of VA facilities. NRM projects are one-time repairs, such as
modernizing mechanical or electrical systems, replacing windows and
equipment, and preserving roofs and floors, among other routine
maintenance needs. Non-recurring maintenance is a necessary component
of the care and stewardship of a facility. When managed responsibly,
these relatively small, periodic investments ensure that the more
substantial investments of major and minor construction provide real
value to taxpayers and to veterans as well.
To maintain existing infrastructure, annual investments in non-
recurring maintenance must occur to ensure the building will last for
its projected life-cycle. Over the past several years, VA has requested
just more than $700 million for NRM, barely half of what is needed to
maintain facilities for their full life-cycle.
The IBVSOs estimate VA needs to invest $1.35 billion annually in
NRM as a baseline to ensure facilities are maintained in safe and
efficient manner. VA will need to invest additional funding to begin
reducing the backlog of nearly 3,000 NRM projects.
major construction accounts
There are currently 45 major construction projects that are
partially funded dating back to FY 2009. VA has also identified 114
major construction projects they determine will need to be completed
within the next 10 years to close gaps in veterans' access to care.
While the IBVSOs are concerned with these future projects, the most
pressing issue is finishing what has already been started.
Included in the 45 partially funded projects are nine major
construction seismic deficiencies. There are also four other seismic
projects that have not been funded at all. It will require $4.7 billion
to close these safety gaps. VA must make correcting these deficiencies
a priority and provide a plan to achieve these goals.
The IBVSOs recommend that Congress appropriate $1.9 billion in FY
2016 to set VA on a course to close all currently partially funded
projects and begin funding the remaining seismic deficiencies within
the next five years.
minor construction accounts
VA has come close to keeping up with its minor construction needs
over the past few years. It is estimated that to close all minor
construction gaps that have been identified, VA will need to invest
between $7 billion and $9 billion. Along with the funds that have been
authorized for VA's minor construction projects over the next two years
through VACAA, the IBVSOs recommend an additional $575 million for FY
2016 to ensure VA stays on track to close all its current and future
minor construction gaps.
capital leasing accounts
VA's capital leasing program allows VA to improve veterans' access
to health care by entering into multiyear leases that provide the
Department flexibility to increase and decrease the size and scope of
care that is delivered in more than 800 communities. Thanks to the
passage of VACAA, 27 major medical leases have been authorized. While
funding these leases is a step in the right direction, it will be
nearly two more years before these medical facilities see patients,
because of delays in funding and the current contract authorization
process.
Congress and VA must fund a long-term solution to authorize leases
so they can be funded quickly and contracts can be filled without
delay, so veterans do not wait years for these facilities to be
completed.
In conclusion, the Department of Veterans Affairs has improved its
capital infrastructure gap analysis through its Strategic Capital
Investment Planning (SCIP) process, but they have continually fallen
short of requesting the funds necessary to close these gaps and
Congress continues to appropriate the amount VA requests. VA must
present a long-term management plan than will connect the SCIP gap
analysis with appropriate funding requests that will design, build and
activate each project on time and on budget so access, utilization and
safety gaps are closed quickly and veterans can receive timely, quality
access to health care.
Mr. Chairman, this concludes my testimony, and I am prepared to
answer any questions you or the Committee members may have.
Chairman Isakson. Thank you very much, Mr. Kelley.
Mr. de Planque.
STATEMENT OF IAN DE PLANQUE, DIRECTOR, NATIONAL LEGISLATIVE
DIVISION, THE AMERICAN LEGION
Mr. de Planque. Good morning, Mr. Chairman. I want to
extend special thanks to you for taking the time not only to
sit down with our Commander after hearing our Commander's
testimony, but also to come out and address the members of our
organization and give them a little bit of your vision for how
this country can serve veterans in the 114th Congress and
beyond.
On behalf of that Commander, Commander Mike Helm, and the
2.3 million veterans who make The American Legion the largest
wartime veterans service organization, I appreciate the
opportunity to testify before you today.
I think everyone agrees our country has a responsibility to
make good on the promises we make to those who have defended
the Nation, but the country is a lot more than the budget of a
single agency or the people of a single agency. Taking care of
veterans requires efforts from all of us--VA, veterans,
Congress, every single stakeholder.
The past year brought hard truths to light. VA has
struggled to come to terms with admitting there were problems
with veterans' ability to access care. We needed to bring those
problems to the light to address them, and we have begun to
address them, but it is going to take more time and complete
transparency.
We are happy to see that VA has chosen to address
shortfalls in full-time workers and employees at the VBA. They
are requesting an additional 770 workers to address claims.
Regardless of whether the VBA eliminates the backlog this year
or any other year, it is quite clear that additional help is
needed. VBA workers have been working under mandatory overtime
policies for over 4 years now. Overtime for a few weeks is
indicative of a problem that needs a surge of assistance.
Overtime for 4 years is a big indicator you just do not have
the bodies to get the job done.
To be fair, more studies and a clearer picture of the
resource allocation would be helpful, especially for future
planning to determine whether VA needs help long in advance of
future backlogs. It is clear to everyone involved that VBA
needs help to help veterans with their claims, and The American
Legion strongly supports ensuring that they get the workers
that they need.
We were especially encouraged speaking with VBA officials
to hear they anticipate boosting employees at the decision
review officer level. Decision review officers have experience
and skills to resolve appeals more quickly at the regional
office before an appeal can begin a multiyear journey at the
Board of Veterans Appeals. Sadly, for the past few years, we
have seen firsthand in multiple offices that these decision
review officers have been pushed into other tasks and their
important work on appeals is falling by the wayside. Hopefully
this indicates a new commitment to solving problems at the
regional office level, fixing veterans' claims before they
descend into the lengthy appeals process.
American Legion members are dedicated to making the VA a
better place. Last year, over 7,000 American Legion members
contributed over 900,000 hours of community volunteer service
to the VA through the Veterans Affairs Voluntary Service (VAVS)
program, supported by The Legion since 1946. I know all of our
colleagues here at the table and their organizations make time
and contributions as well. The cost savings to the VA is
immeasurable, and the key point here is we are all invested in
this. We all have skin in this game. We are all working to do
this. But to make sure we put those resources in the right
place, we need to all communicate openly, honestly, and
completely transparently with one another. This only works when
we are all on the same page. We stress again the importance of
a publicly open and transparent planning process for all
stakeholders to work together to maximize what funds are
available and to make the system work for all veterans. This
only works when we all work together.
I would be happy to take questions, though I first want to
comment also specifically on what my colleague, Mr. Blake from
Paralyzed Veterans of America, has discussed about the Choice
Act and trying to make sure we get to those veterans within the
40-mile area. Just in January, I went out to Kansas myself to
speak with American Legion members there, and I could see
firsthand there are still a lot of problems. The numbers may
have been astronomically high with the initial assessments in
the budget, but we are seeing almost microscopically low
numbers of people choosing to use that right now. And I think
when we field calls, when we talk to veterans in The American
Legion--and we have talked to a lot of them--many of them are
confused and are having trouble accessing it because it is not
being very well explained to them. They do not really
understand why, if there is a facility 38 miles from them but
they still have to go 250 miles to get the treatment that they
need--maybe it is dialysis, maybe it is heart treatment--why
they are not eligible for that program.
When we spoke with Senator Blumenthal, the Ranking Member,
in his office yesterday, one of the things he talked about was
the intent of the program. I know the language of the bill is
very specific, and I know that that was perhaps an attempt to
address some of the concerns of the Congressional Budget
Office. But, we are interested in continuing to work with
Members of the Committee to make sure that veterans are getting
access.
The reason we came up with this was choice, and it is a
choice. Not every veteran is going to choose to use it. Many of
the veterans are going to choose to wait longer. But the ones
who want to get into that care and who need the access--there
are many ways VA has in the past used outside care, whether it
is PC3 or ARCH or other programs. Choice is another tool that
can help get those veterans into care, and we want to make sure
that it is implemented within the intent of the Committee and
the intent of the veterans service organizations who supported
it, which is to get those veterans access to care.
Thank you.
[The prepared statement of Mr. de Planque follows:]
Prepared Statement of Ian de Planque, Director, National Legislative
Division, The American Legion
Chairman Isakson, Ranking Member Blumenthal, and Members of the
Committee: On behalf of National Commander Michael Helm and the 2.3
million wartime veterans of The American Legion, we welcome this
opportunity to comment on the Federal budget, and specific funding
programs of the Department of Veterans Affairs (VA).
The American Legion is a resolution based organization; we are
directed and driven by the millions of active legionnaires who have
dedicated their money, time, and resources to the continued service of
veterans and their families. Our positions are guided by nearly 100
years of consistent advocacy and resolutions that originate at the
grassroots level of the organization--the local American Legion posts
and veterans in every congressional district of America. The
Headquarters staff of the Legion works daily on behalf of veterans,
military personnel and our communities through roughly 20 national
programs, and hundreds of outreach programs led by our posts across the
country.
The American Legion comes before this Committee in a unique state
of military affairs, as for the first time in over a decade, this
country is not officially engaged in combat operations in Afghanistan
or Iraq. Though combat operations in Afghanistan may have officially
ceased on December 28, 2014, there is no doubt the effects of these
wars will continue to be felt in the veterans' communities for many
decades, as has been the case with every previous war. The cost of war
does not end when the guns fall silent. To paraphrase Winston Churchill
this is not the beginning of the end, but rather the end of the
beginning.
We cannot allow focus and resources to be diverted from the VA
because the limelight fades and the news cameras have gone away. The
President's proposed budget would offer an increase of 7.5 percent over
the enacted level of Fiscal Year 2015 funding, a healthy increase even
as other agencies are forced to tighten belts under the effects of
sequestration. However, we cannot think that just because the numbers
go up that all of the money is being directed to the proper places.
Here is where the importance of true transparency from VA becomes
critical. This is where the importance of open and freely available
planning reports, such as those proposed in the ``Department of
Veterans Affairs Budget Reform Planning Act of 2015.'' (H.R. 216) This
legislation, recently recommended out of Committee in the House
Committee on Veterans Affairs, would be helpful to the entire community
of stakeholders. Many of the questions we will raise delve into matters
that would be more clear if VA was more open and straightforward with
stakeholders.
This process only works if everyone can see all the pieces on the
board. Taking care of veterans is the Nation's responsibility. That
includes not only the Federal Government, but state and county
governments, veteran and military service organizations, and the
citizens themselves. We have to all see how the pieces fit together and
we have to all be on the same page if this is going to work and we're
all going to maximize our efforts together.
There are areas of concern within the budget proposed by VA, but
all of these areas can be worked out if everyone is open and above
board.
the veterans benefits administration
This year, 2015, is to be the year the Veterans Benefits
Administration finally ``breaks the back of the backlog.'' To that end,
the budget request includes requests to add 770 additional full time
employees (FTEs) as claims processing workers and fiduciaries for the
pension program. Adding additional workers is an important and needed
step. VA employees have been directed to put in mandatory overtime work
dating back to at least 2011.\1\ Mandatory overtime may provide a
useful boost to push an organization through a tough patch, but four
straight years of mandatory overtime indicates an organization that's
not going through a tough patch, it's an organization that's clearly
understaffed.
---------------------------------------------------------------------------
\1\ http://www.stripes.com/va-workers-say-mandatory-overtime-won-
t-solve-benefits-backlog-1.221294
---------------------------------------------------------------------------
How many additional employees are appropriate? This is where it's
difficult to tell and where a study of VA's resource allocation models
would be helpful. At VA's budget roll out, VA officials indicated some
of this would be represented in making the Decision Review Officer
(DRO) process more robust, something The American Legion strongly
supports. DROs can often resolve appeals more rapidly than the appeal
process at the Board of Veterans Appeals (BVA) and with greater
accuracy and clarity than the average VA rater. Reports have indicated
in some offices the DROs have been reassigned to other tasks as the
pressure mounts to work on initial claims. It would be the hope of The
American Legion that renewed interest in hiring and increasing the DRO
force would allow DROs to return to their appeals duties, and help
prevent a rising backlog in the appeals area.
Whatever the case may be, better communication from VA to indicate
how they intend to use staffing levels to effectively combat the
backlog of claims is a must.
The American Legion strongly supports additional FTEs to improve
the VBA workforce.
the veterans health administration
One of the key lessons learned through last year's health care
access is that VA's reporting must be crystal clear to avoid the
problems that occur when things are hidden from the stakeholders. Had
VA employees not manipulated the wait time data a more bleak picture of
the ability to serve veterans would have been painted, but the key
stakeholders--veterans and Congress--would have known that additional
resources were needed and where. Ensuring proper distribution of
resources throughout VA depends on accurate reporting that is free from
fear of reprisal for not meeting goals. We cannot create an environment
where VA employees fear to report problem areas, for discerning where
those problem areas are occurring is the critical factor in determining
where resources need to go.
To be fair, Secretary McDonald has expressed a renewed interest in
openness and The American Legion believes VA is making a good faith
effort to increase honesty, although we would like more clarity
regarding the Secretary's request for more flexibility in use of the
funds designated for the Choice card program. VA's budget request
announces that they will be seeking more flexibility to retarget some
of the $10 billion allotted to the Choice card program with last year's
legislation to provide more choice and access in care.
Without an extremely specific accounting, which was not forthcoming
in initial presentations of this budget, it would be difficult to
support this request. The Choice program, which The American Legion
believes is an important temporary measure to address shortfalls in
VA's ability to treat veterans, needs to be properly funded to succeed.
To reprogram monies designated for this program so early into the
program, barely six months into a three year pilot, seems short
sighted. It would be the preference of The American Legion to see the
program implemented as intended, and if funds remain at the end of the
allotted time, then it would be appropriate to address what use those
funds could best be put to. If there is money left over, great; that
would mean VA was meeting their goal of addressing veterans' needs with
their in house resources, to include VA care as well as other assets in
their arsenal such as the PC3 program or ARCH, the very successful
rural health initiative.
Regarding other important VHA funding, The American Legion notes
that VA's budget for medical research is relatively consistent, but
positively notes the acknowledgement of the importance of additional
areas of Posttraumatic Stress Disorder (PTSD) research including
alternative therapies such as yoga, meditation and other treatments
alongside cognitive processing therapy (CPT) and prolonged exposure
therapy. The American Legion continues to devote extensive focus to the
treatment of PTSD and Traumatic Brain Injury (TBI) through the PTSD and
TBI Committee of the Veterans Affairs and Rehabilitation (VA&R)
Commission. The Commission's work included the production of ``The War
Within'' and a survey conducted in conjunction with the Data
Recognition Corporation which presented results last year at a
June 24th symposium entitled ``Advancing Care and Treatment for
Veterans with TBI and PTSD.'' \2\ \3\ Through that survey, it was
reported that nearly 60% of veterans undergoing treatment for PTSD and
TBI reported feeling no improvement or felt worse after the traditional
treatments.\4\ Clearly, there is still much room for improvement in
this area.
---------------------------------------------------------------------------
\2\ http://www.legion.org/sites/legion.org/files/legion/
publications/war-within.pdf
\3\ http://www.legion.org/veteranshealthcare/222891/legion-survey-
ptsdtbi-care-not-working
\4\ http://www.legion.org/veteranshealthcare/222891/legion-survey-
ptsdtbi-care-not-working
---------------------------------------------------------------------------
The American Legion supports VA becoming a robust leader in
complementary and alternative medicine for Posttraumatic Stress
Disorder and Traumatic Brain Injury.
construction and facilities
All stakeholders are aware of the much publicized struggles VA has
gone through with major construction projects, particularly in
Colorado, Florida, Louisiana and Nevada. VA recently came to an
agreement with the contracting firm in Colorado and work was able to
resume on the VA hospital project in Aurora. That work will likely cost
at least $234 million, and the budget for the project has spiraled from
approximately $600 million to over $1 billion.\5\ The money for these
overages has to come out of VA's construction budget, yet where the
money to backfill that budget and provide for future projects will come
from is still unclear.
---------------------------------------------------------------------------
\5\ http://kdvr.com/2014/12/17/va-announces-deal-to-start-work-on-
aurora-hospital/
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In February 2012, The American Legion presented the following
warning about insufficient funding in VA's construction budgets and
capital investment plans:
The SCIP planning process develops data for VA's annual
budget requests. These infrastructure budget requests are
divided into several VA accounts: Major Construction, Minor
Construction, Non-Recurring Maintenance (NRM), Enhanced-Use
Leasing, Sharing, and Other Investments and Disposal. The
Fiscal Year (FY) 2012 VA budget identified more than 5,000
capital projects needed to close all the identified
infrastructure gaps over the ten year period. The VA estimated
costs were between $53 and $65 billion.
The American Legion is very concerned about the lack of
funding in the Major and Minor Construction accounts. In FY
2012 The American Legion recommended to Congress that the Major
Construction account be funded at $1.2 billion and the Minor
Construction account be funded at $800 million. However,
Congress only appropriated $589 million and $482 million
respectively to those accounts. Based on VA's SCIP plan,
Congress underfunded these accounts by approximately $4 billion
in FY 2012. Clearly, if this underfunding continues VA will
never fix its identified deficiencies within its ten-year plan.
Indeed, at current rates, it will take VA almost sixty years to
address these current deficiencies.\6\
---------------------------------------------------------------------------
\6\ American Legion testimony before HVAC on the VA Budget,
February 15, 2012
Even before the setbacks in Colorado and Florida created holes in
the construction budgets, there were already grave concerns about the
ability to meet the needs that had been identified. Now that the
struggling major projects are depleting funds at a greater rate than
previously anticipated, the danger to future projects is even more
severe.
The American Legion urges Congress and VA to get on the same page
about fixing these budget holes before it's too late. We must act now.
Whether this will require supplemental appropriations to make the
troubled major construction projects whole again without jeopardizing
the rest of VA's construction needs, or whether this can be built into
the budget is still a topic for discussion. What is clear is that this
is going to present a major hurdle to ensuring VA's facilities are able
to handle the load. This is a problem that needs a solution.
The hospitals are not the only area of concern in terms of
facilities. Last year's Veterans Access, Choice and Accountability Act
(VACA) provided a respite for 27 Community Based Outreach Centers
(CBOCs). The CBOCs have been an effective tool in reaching veterans,
particularly in rural areas where a full scale hospital might not be
feasible. Changes in how the leases for these facilities were scored by
the Congressional Budget Office (CBO) jeopardized the future of CBOCs
within the VHA health care system.
VACA provided relief for the 27 identified CBOCs, but in a sense it
has only kicked the can a little further down the road. A long term
solution to the CBOC lease conundrum will be required.
The American Legion urges Congress to provide an annual or
permanent exemption for the Department of Veterans Affairs leases from
the Congressional Budget Office's scoring process, so as to give VA the
flexibility it needs to meet the health care needs of veterans.\7\
---------------------------------------------------------------------------
\7\ Resolution 282: Congressional Budget Office Scoring on
Department of Veterans Affairs Leasing--AUG 2014
---------------------------------------------------------------------------
conclusion
The past year has made it clear that VA cannot afford to be run as
an entity reactive to one crisis after another. Effectiveness stems
from long term planning, and to be truly effective that long term
planning needs to include all stakeholders. The American Legion has
been a strong and active supporter of the Department of Veterans
Affairs Voluntary Service (VAVS) since 1946 and today over 7,000
volunteers provide 900,000 hours of volunteer service at VA medical
centers, CBOCs, Vet Centers, state veterans' homes, and nursing homes
every year.\8\ With nearly a million hours of service provided, imagine
the cost savings to VA in terms of additional FTEs they do not have to
provide.
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\8\ http://www.legion.org/vavolunteers
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That kind of coordination only works with open transparency. The
American Legion urges VA to adopt an open and freely accessible
planning process such as the quadrennial review proposed in H.R. 216
and endorsed by many members on both sides of the aisle in the House of
Representatives. We would be happy to see the Senate take up
legislation of this type to ensure VA's planning process is robust,
includes all stakeholders, and is transparent to allow input and
analysis from all concerned parties.
Secretary McDonald has a daunting task ahead of him as he continues
to reform the VA and rebuild from the failures that led to last year's
crises. There is no reason to go it alone. Congress has long displayed
a willingness to provide VA with resources, increasing their budget
nearly 75 percent since 2009 alone, and The American Legion has already
gone out and conducted a dozen Veterans Crisis Centers and Veterans
Benefits Centers in the field to help link VA and veterans up to make
the system work. To be truly effective though, we all have to be
reading from the same page. This is something that can and will be
accomplished, and The American Legion looks forward to making that
happen.
Questions concerning this testimony can be directed to The American
Legion Legislative Division (202) 861-2700, or ideplanque@legion.org.
Chairman Isakson. Thank you very much for your testimony,
and you are right on point regarding Choice.
Vietnam Veterans of America.
STATEMENT OF RICHARD WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND
GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA
Mr. Weidman. Mr. Chairman, thank you for the opportunity
for VVA to present our testimony here today.
Our estimate for VHA only is that $71 billion is needed for
this coming fiscal year and 74 for the advanced appropriations.
We have come at it from a different direction that is much
more--takes into account that each veteran has many more
presentations, or things wrong with them, than the civilian
formula allows for. The formula that they use now is set up on
one to three presentations. Why? Because it was designed for
PPOs and HMOs and people who can afford to buy those kinds of
plans. That, by and large, is not necessarily who we see at VA
hospitals.
In regard to the wait times, I just wanted to give some
perspective here. In 2009, VVA testified before the Congress in
regard to the budget, ``We are more than a little skeptical
that, as the VA touts, the budget will provide resources to
virtually eliminate the patient waiting time by the end of
2009.'' That was 5 years ago, and they are still struggling
with it. If the formula is not working to tell you how many
clinicians you need, then you need to get a new formula, as
well as management improvements.
There are a couple of things I want to mention about the
Choice Card. VVA has always backed using fee-basis options when
it is a service that is available in the community and it is
otherwise a long commute for the veteran. But, the reason why--
I know the Secretary in his motivation, which is a laudable
one, to have a lot of flexibility in all of the fundings, but I
will tell you right now, if the Vet Centers had not had fenced
funding, they would not have been there when the OEF/OIF/OND
veterans came home. They would have gone, poof, up in smoke.
Recently, the QUERI groups around the country--those are
groups of clinicians who come up with the best practices and
come up with the best medicine or, excuse me, best evidence-
based medicine recommendations--all of their funding got swept
clean. A little bit of it was restored, but if you do not have
QUERI groups, you do not have evidence-based medical practice.
So, the reason for that is why the fences came up, because
things went awry at VA over time.
Another example is Hepatitis C. There are 175,000 veterans
within the VA system who have tested positive and we finally
have a cure. We finally know who they are and can move forward.
But, one of the reasons it has taken so long to get to that
point is every time that Congress gave fenced-off money to the
VA to address the problem of Hepatitis C, nobody could account
for the money, and we think that is crazy.
There are two things that really need to happen, and when I
say that we want strings on the appropriations, it is: one,
that they be able to tell you how many clinicians do they have
in Dublin, GA, who deal with PTSD and TBI at any given time
without having to send somebody out there to count; and, two,
that you know exactly what is happening, that they start
tracking veterans so you know what treatment modality is most
effective. All of those kinds of accountability mechanisms are
still lacking in the VA and need to get fixed.
Another example of something that needs real attention. The
National Vietnam Veterans Longitudinal Study, which was a
replication of the original study done in the mid-1980s, the
National Vietnam Veterans Readjustment Act, is finally done. It
was delivered to the VA Central Office in September 2014 and it
still has not reached the Congress. And, the reason is, quote-
unquote, a ``legal problem'' the General Counsel has because
they want to order the contractors to destroy the data of the
original study back in 1985. Had that been done--which they
wanted to do after the first one--there could not have been a
replication.
So, it is that kind of accountability that we need to bring
in and have a central place for a repository of data that
everybody trusts. We have such a thing. It was started after
World War II by General DeBakey, Dr. Roger [sic] DeBakey, and
its medical follow-up agency was part of the Institute of
Medicine of the National Academies of Sciences. We recommend,
one, that all things be turned over to them, whether ranchhand
information or the National Vietnam Veterans Longitudinal
Study, and, two, that VA set aside $4 million per year for
maintaining that data and cataloging it in modern computer
language.
Mr. Chairman, I thank you very much for the opportunity to
present here today.
[The prepared statement of Mr. Weidman follows:]
Prepared Statement of Richard Weidman, Executive Director for Policy
and Government Affairs, Vietnam Veterans of America
Chairman Isakson, Ranking Member Blumenthal and distinguished
Members of the Committee: On behalf of the Board of Directors, and
members, I thank you for giving Vietnam Veterans of America (VVA) the
opportunity to testify today regarding the President's fiscal year 2016
budget and 2017 advanced appropriations request for the Department of
Veterans Affairs. VVA thanks each of you on this distinguished panel,
on both sides of the aisle, for your strong leadership on issues and
concerns of vital concern to veterans and their families.
I want to thank you for recognizing that caring for those who have
donned the uniform in our name is part of the continuing cost of the
national defense. Caring for veterans, the essential role of the VA
and, for specific services other Federal entities such as the
Department of Labor, the Small Business Administration, and the
Department of Health and Human Services, must be a national priority.
This is poignantly clear when we visit the combat-wounded and ill
troops at military medical centers across the country.
overview
On the whole, this budget proposal is a good start, but the overall
requests for additional resources are just too low. With concerted work
however it can be the most viable budget and appropriations document we
have had in many years, of which we all can be proud.
VVA is still concerned that there will not be enough resources to
deal with the flood of troops that continue to separate and have
recently separated from the military and may present at VA with a range
of mental health as well as TBI and other physiological health issues.
The newer veterans, and the older ``new to VA'' veterans from previous
generations who are now using VA healthcare facilities and services
added to a volume of needs that was already taxing VA resources. This
set up the conditions whereby there were way too few clinicians for
increasingly too many clinical needs, which put pressure all the way
down the line to not have delays in seeing sick veterans. Because they
did not have the organizational capacity to do this, then the local
staff got into the business of making it appear that there were no wait
lists.
We do not say this in any way of excusing the lying and the
falsification of data. There is no excuse for that. However, if the
problem is to be fixed, then there simply needs to be a sharp increase
in the number of clinicians at VA, and a priority put on providing
enough appropriate clinical space at the earliest possible date. What
this means is that there must be construction funds for converting what
exists in the VA's older hospitals to accommodate a modern clinic
configuration. If they need to move executive and other offices to
temporary buildings outside of the main hospital building (s) in order
to have enough room, then let us get on with it.
While many do not like to focus on the fact that there are way too
few clinicians, that is the case now, as it has been for more than a
decade. As one example VVA said in testimony in 2009:
We are more than a little skeptical that, as the VA touts, the
budget will provide resources ``to virtually eliminate the
patient waiting list by the end of 2009.'' When have we heard
this before?
The ``wait list'' on the medical side, and the ``backlog'' on the
Compensation and Pension side of VA simply have to have more resources
(mostly people) if these problems are to be solved.
To us the key is to modify the formula that is used to estimate
clinical needs to reflect the veterans who are served. The number of
disability issues to be adjudicated in each claim has risen
dramatically in the last five years, even faster that the number of
veterans seeking both medical care and adjudication of legitimate
claims. That is mirrored in the sharp rise in the number of maladies in
veterans seeking medical care
Our recommendation is to change the formula to reflect reality of
veteran's health, and in the meantime fund VHA for at least $71 Billion
this year and Advance Appropriations for at least $74 Billion, with at
least $3 to 3.5 Billion in third-party medical care collections each
year. Even this estimate is likely an understatement of the need.
evidence based medicine
VA has a well-established system of ``QUERI'' groups that have
functioned reasonably well for some years to establish a baseline for
evidence based medicine within the VA. The budgets for these groups
were recently ``swept away'' by the Secretary. If there are efforts to
reorganize and improve this vital tool, then fine. But to virtually
cripple or to outright de-fund the QUERI groups signifies that VA is
going to not have a mechanism to know the standards for evidence based
medicine.
This situation needs to be corrected immediately and certainly in
the budget for the coming year.
mental health--need to increase organizational capacity for
substance abuse treatment
VVA urges that language be inserted in the Appropriations bill
before Congress to express concern that substance abuse disorders among
our Nation's veterans are not being adequately addressed by the
Veterans Health Administration (VHA). The relatively high rate of drug
and alcohol abuse among our Nation's veterans (much of which is self-
medication to deal with untreated PTSD), especially those returned from
service in Operations Enduring Freedom, Iraqi Freedom, and New Dawn is
causing significant human suffering for veterans and their families.
These folks can and will be stronger for their experience if we
only will deliver the effective care they need when they need it in a
way they will accept.
Further delay in moving to increase effective mental health and
substance abuse services will lead to poorer health and more acute
health care utilization in the out years, not to mention economic
opportunity cost to the Nation and needless suffering by these
veterans, and their families.
VVA urges the Congress to direct the Secretary to provide quarterly
reports beginning with a baseline report by each Veterans Integrated
Service Network (VISN) and each VA Medical Center (VAMC) on the number
and type of clinicians engaged in mental health, especially those
engaged in treating PTSD and substance abuse.
VVA also strongly urges the Senate to direct the Secretary of
Veterans Affairs to update the VHA Strategic Plan for Mental Health
Services, specifically to improve VA's treatment of TBI, PTSD and other
mental health conditions, as well as substance use disorders. These
reports will provide an ongoing indication of VHA's progress in the
implementation of its adopted Strategic Plan as described in section
1.2.8 of ``A Comprehensive VHA Strategic Plan of Mental Health
Services,'' May 2, 2005. In addition to baseline information, at
minimum these reports should include: the current ranking of networks
on their percentage of substance abuse treatment capacity along with
plans developed by the lowest quartile of networks to bring their
percentage up to the national average; and, the locations of VA
facilities that provide five days or more of inpatient/residential
detoxification services, either on site, at a nearby VA facility, or at
a facility under contract to provide such care; and, the locations of
VA health care facilities without specialized substance use disorder
providers on staff, with a statement of intentions by each such
facility director of plans to employ such providers or take other
actions to provide such specialized care.
We must continue to restore and enhance capacity to deal with
mental disorders, particularly with Post Traumatic stress Disorder and
the often attendant co-morbidity of substance abuse. In particular,
substance abuse treatment needs to be expanded greatly, and be more
reliant on evidence based medicine and practices that are shown to
actually be fruitful, and be held to much higher standards of
accountability, as noted above. The 21 day revolving door or the old
substance abuse wards is not something we should return to, but rather
treatment modalities that can be proven to work, and restore veterans
of working age to the point where they can obtain and sustain
meaningful employment at a living wage, and therefore re-establish
their sense of self-esteem.
national centers for ptsd
VVA also urges that additional resources explicitly be directed in
the appropriation for FY 2016 to the National Centers for PTSD for them
to add to their organizational capacity under the current fine
leadership. The signature wounds of the recently completed wars are
PTSD and Traumatic Brain Injury and a complicated amalgam of both
conditions. VVA believes that if we provide enough resources, and hold
VA managers accountable for how well those resources are applied, that
these fine young veterans suffering these wounds can become well enough
again to lead a happy and productive life.
separate funding line for the vet centers
The funds for the Vet Centers should be used to develop or augment
permanent credentialed staff at VA Vet Centers (Readjustment Counseling
Service or RCS), as well as coordinating with the PTSD teams and
substance use disorder programs at VA medical centers and clinician who
are skilled in treating both PTSD and substance abuse at the CBOC,
which will be sought after as more troops (Including demobilized
National Guard and Reserve members) return from ongoing deployments.
VA also urges that the Secretary be required to work much more
closely with the Secretary of Health and Human Services, and the
states, to provide counseling to the whole family of those returning
from combat deployments by means of utilizing the community mental
health centers that dot the Nation. Promising work is now going on in
Connecticut in and possibly elsewhere in this regard that could
possibly be a model. In addition, VA should be augmenting its nursing
home beds and community resources for long term care, particularly at
the state veterans' homes.
blind and low vision veterans need much greater resources and attention
With the number of blind and very low vision veterans of the
Nation's latest wars in need of services now, VVA strongly recommends
the Congress explicitly direct an additional $50 million for FY 2016 to
increase staffing and programming at the VA's Blind and Visually
Impaired Service (VIST) Centers, and to add at least one new center.
Further, VVA recommends that the Congress direct the Secretary to
implement an employment and independent living project modeled on the
highly successful ``Project Amer-I-Can'' that so successfully placed
blind and visually impaired veterans into work and other situations
that resulted in them becoming much more autonomous and independent.
That program was a cooperative venture of the New York State Department
of Labor, the Veterans Employment & Training Service (VETS), and the
Blind Veterans Association twenty years ago, but can still work now.
medical and prosthetic research
For medical and prosthetic research for fiscal year 2016, VVA
recommends $950 million. This would be the largest increase ever in
this part of the budget, but it is needed and should be ``with
strings'' that the VA start doing research that will stand up to peer
review in regard to toxins of all sorts that have affected US military
members and/or their families, especially their progeny.
VA's research program is distinct from that of the National
Institutes of Health because it was created to respond to the unique
medical needs of veterans. In this regard, it should seek to fund
veterans' pressing needs for breakthroughs in addressing environmental
hazard exposures, post-deployment mental health, Traumatic Brain
Injury, long-term care service delivery, and prosthetics to meet the
multiple needs of the latest generation of combat-wounded veterans.
nvvls
The National Vietnam Veterans Longitudinal Study (NVVLS) has been
completed at long last, and languishes at the VA Central office. The
General Counsel at VA says there is a ``legal problem'' with
transmitting this report to the Congress and the public. The so called
legal problem is that VA wants to destroy all of the data in the
original National Vietnam Veteran Readjustment Study (NVVRS). The VA
General Counsel first wanted to destroy that data right after that
study was first completed in the mid-1980s. Had they done so, there
could never have been this follow up study.
VVA urges the Committee to designate the Medical Follow Up Agency
(MFUA) as the repository of the data from NVVRS, NVVLS, and all other
such studies. Dr. Richard De Bakey was instrumental in founding MFUA
following World War II. Their database was used to finally be able to
identify Hepatitis C in 1987. VVA urges that all data from all such
large scale studies go to MFUA, along with funds to maintain and
properly automate and search said data.
VVA further urges that you ask for a specific line item of $4
million to go to MFUA this year and to direct VA to turn over all such
data to MFUA immediately.
Further, VVA strongly urges the Congress to mandate and fund
longitudinal studies to begin virtually immediately, using the exact
same methodology as the NVVRS, for the following cohorts: a) Gulf War
of 1991; b) Operation Iraqi Freedom; and, c) Operation Enduring
Freedom.
Please take action now so that these young veterans are not placed
into the same predicament Vietnam veterans find ourselves today.
homeless veterans
Homelessness is a significant problem in the veterans' community
and veterans are disproportionately represented among the homeless
population. While many effective programs assist homeless veterans to
become productive and self-sufficient members of their communities and
Congress must ensure that the Department of Veterans Affairs has
adequate funding to meet the needs of the homeless veterans who served
this country so proudly in past wars and veterans of our modern day
war.
homeless provider grant and per diem program
The Department of Veterans Affairs Homeless Grant & Per Diem
Program has been in existence since 1994. This program addresses the
needs of homeless veterans and supports the development of
transitional, community-based housing and the delivery of supportive
services. Because financial resources available to HGPD are limited,
the number of grants awarded and the dollars granted are restrictive
and hence many geographic areas in need suffer a loss that HGPD could
address. VVA recommends increasing the Homeless Grant and Per Diem
(HGPD) program to $250 million and increasing the Supportive Services
for Veteran Families (SSVF) program to $375 million for FY 2016.
hud-vash
The HUDVASH program was established as a partnership between the
Departments of Veterans Affairs and Housing and Urban Development to
combine permanent housing with supportive medical services. VVA
supported passage of Public Law 110-161 which included $75 million for
7,500 Section 8 vouchers for homeless and disabled programs. Under this
program, VA must provide funding for supportive services to veterans
receiving rental vouchers. The FY 2016 VA budget must reflect a
significant increase in funding these services.
The program ``housing first'' simply does not work over a
protracted length of time without significant and effective supportive
services. Historical data that shows each housing voucher requires
approximately six thousand dollars in supportive services--such as case
management, personal development and health services, transportation,
etc. Rigorous evaluation of this program indicates this approach
significantly reduces the incidence of homelessness among veterans
challenged by chronic mental and emotional conditions, substance abuse
disorders and other disabilities.
The Veterans Benefits Administration (VBA) continues to need
additional resources and enhanced accountability measures. VVA
recommends an additional 300 over and above the roughly 700 new staff
members that are requested in the President's proposed budget for all
of VBA.
compensation & pension
VVA recommends adding at least nine hundred staff members above the
level requested by the President for the Compensation & Pension Service
(C&P) specifically to be trained as adjudicators. Further, VVA strongly
recommends adding an additional $75 million dollars specifically
earmarked for additional training for all of those who touch a
veterans' claim, institution of a competency based examination that is
reviewed by an outside body that shall be used in a verification
process for all of the VA personnel, veteran service organization
personnel, attorneys, county and state employees, and any others who
might presume to at any point touch a veterans' claim.
vocational rehabilitation
VVA recommends that you seek to add an additional two hundred
specially trained vocational rehabilitation specialists to work with
returning servicemembers who are disabled to ensure their placement
into jobs or training that will directly lead to meaningful employment
at a living wage. It still remains clear that the system funded through
the Department of Labor simply is failing these fine young men and
women when they need assistance most in rebuilding their lives.
veterans economic opportunity administration at va
VVA strongly favors moving this function to VA in a new fourth
division of VA that deals solely with helping veterans become as
independent as possible. For those of working age, this means helping
them successfully enter the civilian workforce. While we will address
this in greater detail next week, this is a crucial aspect of the
budget and planning process.
VVA has always held that the ability to obtain and sustain
meaningful employment at a living wage is the absolute central event of
the readjustment process. Adding additional resources and much greater
accountability to the VA Vocational Rehabilitation process is essential
if we as a nation are to meet our obligation to these Americans who
have served their country so well, and have already sacrificed so much.
hepatitis c
Vietnam Veterans of America (VVA) urges you to allocate funds for
life-saving treatments for veterans suffering from the hepatitis C
virus (HCV) consistent with the Department of Veterans Affairs request
in the President's proposed budget.
The hepatitis C virus is one of the greatest health threats facing
American veterans. HCV is an infectious, blood-borne disease and the
leading cause of catastrophic liver damage, cirrhosis, liver cancer and
liver transplants. This potentially fatal disease can take years or
decades to present symptoms, and by the time individuals feel sick--
long after many veterans have left the battlefield--the disease has
often already taken its toll.
Veterans are at a disproportionately high risk for the hepatitis C
virus due to the potential for blood exposure in combat or medical
settings. While hepatitis C is a growing epidemic across the country,
where more than 3.2 million Americans are infected with the virus, it
is even more rampant among veterans. Prevalence of HCV among veterans
who receive care through the Veterans Health Administration is twice
the rate reported in the general population.
Approximately 175,000 VA enrollees have been diagnosed with HCV and
at least 30,000 have cirrhosis, a number that has doubled over the last
decade. In addition, because the infection is often asymptomatic, the
VA estimates that as many as 42,000 enrollees may be infected with the
virus but are undiagnosed.
Revolutionary new hepatitis C treatments have given veterans hope
of a cure for this deadly disease. Early detection of the hepatitis C
virus through screening and access to new, more effective HCV
treatments significantly decreases the progression of the disease to
cirrhosis, liver failure, liver cancer, and death.
The VA has placed a high priority on ensuring that all veterans
living with HCV have access to the treatments they need. We urge you to
allocate the funds necessary to help the VA provide care to those
affected and encourage the Agency to screen veterans to diagnose the
remaining 42,000 who do not know their status.
accountability at the va
There is no excuse for the dissembling and lack of accountability
in so much of what happens at the VA. It is certainly better than it
was a year ago, but there is a long way to go in regard to cleaning up
that corporate culture to make it the kind of system it should become.
VA must change so that it can be trusted to get the ``biggest bang for
the taxpayer's buck.'' It can be cleaned up and done right the first
time, if there is the political will to hold people accountable for
doing their job properly.
Thank you again, Mr. Chairman, for allowing VVA to be heard at this
forum. We look forward to working with you and this distinguished
Committee to obtain an excellent budget for the VA in this fiscal year,
and to ensure the next generation of veterans' well being by enacting
assured funding. I will be happy to answer any questions you and your
colleagues may have.
Chairman Isakson. Well, I want to thank all of you. And as
a testimony to the VA and its leadership, they are all sitting
behind you, listening to your testimony. I think that is a
credit to them and a credit to you, as well.
Let me just say first of all, I am sorry you had to wait so
long to testify, but I am grateful for the quality of your
testimony and I appreciate that very much.
Each one of you mentioned--you know, I sat here for two-
and-a-half hours. Nobody once questioned the quality of health
care in the Veterans Administration, not one statement. But,
the delivery of that health care is locked in the 19th century
while the quality of that health care is in the 21st century.
So, I think what we have got to do is make sure the delivery
system to our veterans is improved, the access is improved, and
it is a state-of-the-art system; that we work with the
Secretary to see to it that it happens. That is number 1.
Ms. Ilem, I agree with you on the fully-developed claim.
One of the big problems, as I understand it, on the appeals now
is they remain open many times and people file amendments to
those claims and supplements to those claims, which protracts
the decisionmaking process. I have become convinced that if we
will close those claims and force people to get all their
claims in and all their evidence and documentation in to have a
fully-developed claim ready for review, we can speed up the
system and improve the quality of claims adjudication. Would
you agree with that?
Ms. Ilem. I think we want to make sure that the VSOs work
with VA hand-in-hand to make sure that as many as possible
could be fully developed for the appeals, like we have with the
claims, which are now up to about 40 percent of us submitting
fully-developed claims. So, we want to be able to help them
make sure they have the appropriate evidence. But, I think we
still need--we would still need to have the out. If the veteran
needs to submit something else, it will revert back to a
traditional appeal.
Chairman Isakson. Mr. Kelley, I do not know anything about
anything except real estate. That is how I made a living for 33
years. You were right on target. The leasing mechanisms at the
VA are deplorable. The construction disciplines are deplorable.
And, a lot of it is because they simply have not modernized the
process they go through.
I have worked at locations of CBOCs in Georgia through
leasing. We have amended and expanded the hospital at Clairmont
Road. It is very important that we modernize the system of
maintenance and operation. We are costing ourselves more money
by letting deferred maintenance cause obsolescence than by
having an active maintenance process that goes all along. So, I
am going to work with the Secretary and the appropriate people
to do exactly that.
And, to all of you, thank you for your service. Thank you
for volunteering your testimony here today. It does not go
unnoticed nor unpublished. We will work with you to coordinate
and see to it that next year when we come back and have the
same type of hearing, we can report on the successes we had in
accomplishing some of the things you recommended today, to have
them implemented and in place next year.
With that said, Ranking Member Blumenthal, if you have any
questions or comments.
Senator Blumenthal. I have a couple of brief questions.
First of all, thank you for being here, thank you for your
service to our Nation in uniform and afterward, as well. And,
thank you for your insights in your testimony.
I think most of you--I believe all of you--were present
when the panel before you testified, and you may have heard
Secretary McDonald's testimony about the Choice Card Program.
My question to you is whether you can share with us any
insights as to why the program has been so underutilized. Is
it, in fact, the interpretation of the 40-mile rule? Is it the
facilities definition that may ignore whether or not, in fact,
care at that facility is available? Is it some other reason?
Maybe you can give us the benefit of your insights on that
question.
Mr. Kelley. I think it is a little bit of all of that. We
have to keep in mind that we are only a few months into this
program. VA had to implement it, begin training its personnel--
and it is a complicated process, as well--to train those people
to first know whether or not a veteran qualifies. How do they
get hold of the person to schedule the appointment? How does
that schedule get forwarded? So, it is a complicated process. I
think the training within VA to get those front-line schedulers
fully up to speed is critical.
I think the idea of expanding the 40 miles or going from a
geodesic distance to a driving distance, obviously, is going to
change and the population will increase. But, I think, until we
get training down and people are fully aware of how to
implement the process, it is still going to be much lower than
what we would want and what we expect.
Mr. de Planque. I am going to jump onto a couple of things
that my colleague just said, and yes, a lot of our initial
questions were confusion about eligibility. Am I eligible, is
what we have been hearing. And, this is all anecdotal at this
point. However, we have had a lot of people with concerns that,
as we mentioned before, I am 38 miles from a facility but it
does not have the service I need, so now I have to go 300 miles
for that. So, we want to make sure that those veterans are
going to be able to get the access to the care.
As The American Legion was involved in the process, as we
were all involved in the process of crafting this legislation
last year, we wanted to be able to look at these metrics over
the 3 years of the pilot program, where VA is having trouble
meeting the needs, and be able to take that to know where to
make VA more robust in the future; that we absolutely have seen
that there are veterans who need to get access to their care
and it is not being delivered through the system. It is not
that veterans have problems with the care within VA. It is that
they are having problems accessing it.
So, to be able to use a program like the Choice Program,
that we can get veterans into care, but also see through that,
this tells us that this area of the country needs to have a
more robust presence from VA and build that up for the future.
This is a tool that we can use to supplement, whether for the
pilot or other programs that we need to develop, to supplement
what is going on with VA, but still with the ultimate goal of
making that VA program--that VA Health Care System one that is
there to serve veterans and is built in the areas that they
need it.
Because there has been some comment this morning about, you
know, whether it is privatization or whether VA should only be
a system for service-connected disabilities, so let us just
address that right from the beginning. If you look at the
myriad of conditions that can be service-connected, it affects
all body systems. This is not--when I hear, it is only for
service-connected conditions, that is somebody who does not
understand service-connected conditions and does not understand
what the veteran population who is using VA looks like.
All of these conditions need to be within VA, and by
serving a community of veterans who may not be service-
connected for those issues, you are still building a community
of physicians that can treat those service-connected veterans
who have a lesser-known condition but that is still connected
to their service. So, I think it needs to be a system that is
robust enough to be comprehensive and to treat the entire
veterans' community that is out there.
I think we absolutely need to have a lot of focus on our
service-connected veterans and in making sure we do not make
problems worse for them. The VA system, it is a good system. It
is an unbelievably comprehensive system that delivers great
medicine because it is looking at the entire veteran. It is
looking at how those service-connected conditions affect the
other body systems, and I think that is important, as well.
Senator Blumenthal. I appreciate both of those comments,
and what they highlight to me is that there is a need to better
implement this program. There is also a need to understand the
issues of delivery, as Senator Isakson has correctly
characterized them, as they relate to what is happening in the
private sector, as well. In other words, the VA is not the only
one where there are delays between the time you ask for an
appointment and the time you get one. That happens to many of
us who rely on private doctors.
What really is one of the overriding challenges here to
modern American medical care is the shortage of primary care
physicians, nurses, and professionals in this area. The VA is
reflecting those shortages, much like the canary in the mine.
Unfortunately, in the VA, there was falsification of records
and cooking the books that led to the investigation that is
ongoing in the Inspector General, which, as I have said before,
I am going to say it again, I hope comes to conclusion
tomorrow. That is when we need the result.
I appreciate your making the distinctions that you do, that
I think are very important for the future of VA health care,
and, in effect, saying, here is where the issues are. Let us
target the problems. Let us not just abandon the system. Let us
make Choice work where it is needed.
I could make a pretty good legal argument that under the
existing statute, that 40-mile rule could be reinterpreted. I
could make a pretty good lawyer's argument, but there is an
argument on the other side, too. A lot of people wish there
were lawyers with only one hand so they would not say, ``On the
one hand, and on the other hand.'' [Laughter.]
I think what is necessary is clarity from the Congress to
give direction that the 40-mile rule should be interpreted with
common sense, not just the narrow technical wording of the
statute. The intent of Congress was to provide as broad an
access as possible, and that is what is perhaps lacking right
now.
Thank you so much for being here. Thanks for your patience
in listening to all of us, and thanks for your great work for
the veterans of America.
Chairman Isakson. Since time is of the essence, I am not
going to get into my opinion of lawyers, so----
[Laughter.]
Senator Blumenthal. I am very grateful for that, Mr.
Chairman.
Chairman Isakson. I have a great one to my right and to
your left in Richard Blumenthal----
Senator Blumenthal. Thank you.
Chairman Isakson [continuing]. Who is a great Ranking
Member, who I appreciate.
I am going to introduce Senator Moran and turn the gavel
over to Senator Moran, as well, because I have a pending
appointment that I am about 45 minutes late for. I want to
thank you for being here.
The record will be held open for 7 days to amplify your
comments, correct your comments, or respond to questions that
were raised or anything else you would like to submit. Thank
you for your attendance today and thank you for your service to
the country.
Senator Moran, it is all yours.
Senator Moran [presiding]. Mr. Chairman, what a great
opportunity. I only wish this had been the case when Secretary
McDonald was--oh, he is still here, which I very much
appreciate.
Mr. Chairman, thank you very much for this hearing. I
appreciate what I just heard the Ranking Member, Senator
Blumenthal, say. I, too, have the opinion that the
interpretation could be made by the Department of Veterans
Affairs, but, as you know, there is legislation to make clear
that the definition of a facility would not include a facility
that cannot provide the services that the veteran needs, even
though it may be within the 40 miles of where the veteran
lives.
Let me ask that question. Is there something that I am
missing here? You were all here during my conversation with
Secretary McDonald. I assume that it makes sense for the
Department to do everything possible to make certain that
Choice works before we ultimately make a determination about
how valuable it is or how many dollars and resources are
necessary to fund it. Was there something I should have asked
the Secretary that I did not ask in this regard? Does anybody
have suggestions for something else that needs to be pursued in
regard to implementation of the Choice Act?
Mr. Weidman. Senator Moran, we believe that it is the devil
you know versus the devil you do not know, and this is a new
thing that people have not gone through this before. Those who
have gone through trying to get the bill paid on fee-basis
services in the past and have finally ended up paying it
themselves or going bankrupt, with that in mind, they have a
hard time thinking, I am going to go outside and I am going to
be liable if the VA does not pay for this.
The second thing is that, because of that same thing, some
outside physicians do not want to take it, just like some do
not want to take Medicare anymore.
The last thing is--in the military, we used to have a
saying. You have got to tell them, you have got to tell them
again, you have got to tell them that you told them, and et
cetera, remind them that you told them that you told them. It
takes a while for things to become familiar enough that people
will step outside of what they already know very well.
Senator Moran. Thank you. Anyone else?
Mr. Blake. Senator Moran, one question we would like to
have answered as it relates to the Choice Program as it
eventually and hopefully gets implemented widespread and
appropriately, is something we have heard anecdotally, also, is
that veterans are choosing Choice, taking advantage of the
opportunity to go out and get purchased care in the private
sector, and some veterans are returning to VA because they are
finding that the option is not there even in the private sector
in the areas that they live in, or that the wait times are just
as long. We have expressed this to some of the folks at VA who
are monitoring this, too, and we would like to know where you
are seeing that problem and how prevalent it is, because it
speaks a little bit to--if we have a concern, it is that there
seems to be this inherent assumption that, well, the private
sector can help us fix this problem. I am not sure that is
wholly a true answer.
Senator Moran. Well, it allows me to soapbox on the ARCH
Program, which was designed in advance, in a sense, of the
Choice Act to create the pilot program to figure out how to fix
some of the problems that might arise, such as medical records,
communications between the VA and the outside provider. It does
not seem to me that the VA has adequately utilized ARCH as a
pilot program to determine how best to now, in a sense,
implement the Choice Act.
There is no one here who would--that is a leading question.
No one would disagree with me that if----
[Laughter.]
Senator Moran [continuing]. If you are a veteran that lives
within 40 miles of an outpatient clinic that does not provide a
colonoscopy, that you ought to be able to get those services at
home, if they are provided and if that is what you want, and
not be denied simply because there is an outpatient clinic
within that 40 miles, even though it does not provide the
service that you need. Is that--does everyone agree with that?
Mr. Blake. Senator, I explicitly remember the question
being asked in one of our many meetings we had with VA about
the question of, if the service is not available, how will that
be handled? Clearly, VA has taken the strict interpretation of
the law as it is written. If I looked up facility--somebody
suggested, you know, is a facility defined as a place that
cannot provide the service, well, it probably does not have any
kind of definition relating to that if you looked it up in the
dictionary. So, that is a challenge. This question has been
asked before we were at November 5, the implementation date. I
am not sure anybody is purely satisfied at this point.
Mr. Kelley. We also have to remember that there are other
non-VA care programs that VA can use at a local level. Those
need to be used. PC3 could very easily have been used. There
needs to be logic to this. That is what bothers veterans, is
there is a lack of logic across the board. They do it here, but
they do not do it here. How about this place, and that place?
We need to find that logic, and that is based in
standardization.
Senator Moran. I would take what you just said and tell the
Department of Veterans Affairs there are many programs--ARCH,
PC3, now Choice Act. Ultimately, there ought to be a program in
which they are all organized, combined, to facilitate the
providing of service in a logical, responsible way, and those
programs give greater opportunity, not less, for the VA to
actually meet the needs of the veteran, and I think that is
what we are all interested in.
The example that is so bad that it makes no sense is, the
veteran calls from Hoxie, KS, who needs his eyeglasses
adjusted. Hoxie is 3\1/2\-4 hours from Wichita, 3\1/2\, 4, 5
hours from Denver. But, the VA is insisting he goes to Wichita
to get his eyeglasses adjusted. He is a World War II veteran.
He is not going to do it. There is an optometrist in the town
of 2,000 people that could do it.
Ultimately, we convinced the VA to do it, but that ought
not--I certainly welcome the calls. My staff are there to help
veterans. There needs to be a system that addresses this. It is
like the light bulb goes off. Well, here is the logical thing
to do. We have got all these array of options, Mr. Kelley, that
you outlined, one of which is the PC3. There is a way to fix
this, and there ultimately was, but it ought to be the norm,
not the exception.
Mr. Weidman. It begins with General Counsel, and we said to
the new Secretary numerous times, we need to get beyond the
``General Counsel of No.'' When somebody does not want to do
something in the VA, they just say, ``Well, the General Counsel
will not let us.'' I said, really? Is that the cousin of
General Elevator and General Confusion? Who in the General
Counsel's Office? We ask, all of us, very often, can we see the
written opinion, and there is not one.
So, what happens within VA, all the way down to the local
level, is ``no'' becomes the default answer instead of the
default answer, ``yes,'' what is good for the vet. How do we
find a way to take care of this vet? That is absolutely a
cultural change, but it is also something that only stems from
people who have line authority over people saying, we are going
to do this different. Default is not ``no'' anymore.
Senator Moran. Thank you.
Mr. de Planque. I was going to say, you brought up the same
question yesterday and our Commander, a fellow Kansan, as you
know, he referred to it as crazy. He literally put it out
there. When we spoke with the Ranking Member, Mr. Blumenthal,
he agreed with that. I think it is a common sense thing that
seems like it is going beyond crazy. If you are sitting there
on one side of a lake and 38 miles across that lake is a
facility, but you have to drive 150 miles of roads to get
around that, or in some of the very rural States, you know,
Vermont, where you just--the roads do not go that way, and so
we have got to look at a common sense way to get this
interpreted and get the veterans the access to the care that
they need.
I think what we have seen is that there is a willingness on
Capitol Hill to continue to work with the VSOs, as we get the
feedback from veterans we are trying to get, to make sure we
get this ironed out and interpreted in a way that we are going
to get the veterans the care. I think all of us, the VA, I
think the members up here of both committees in the House and
Senate, I think the VSOs that are up here, we still have the
same intent that we had at the beginning, which is how do we
get the veterans the care, and we are trying to do that now and
I think these are things that are going to help.
Senator Moran. Mr.--I can pronounce Ian. I cannot pronounce
de Planque.
Mr. de Planque. De Planque, just like ``walk the plank.''
Senator Moran. Thank you. Mr. de Planque, The American
Legion has endorsed the legislative solution, and I appreciate
that, although it would be nice if, on the record, you will say
that.
Mr. de Planque. I will say that for you on the record. We
have endorsed your legislative solution to the problem.
Senator Moran. Thank you very much.
Mr. Weidman. So, does Vietnam Veterans of America.
Senator Moran. Thank you very much. I appreciate that.
Before I change topics, let me just say this. While we seem
to focus on the 40 miles, and I recognize I do that, part of
what someone said earlier is the expectation of whether or not
veterans can--they have tried this before and it did not work
and, therefore, they are reluctant to go try it again. That is
why this is a broader issue than the 40 miles. It is, can we
implement this law, the Choice Act, in a way that sends a
message to veterans that we have finally got a system in
process--in place that processes their claims and their health
care, and the skepticism begins to disappear. That is why this
is so important to get it right early so that we do not dash
the hopes of good things happening at the Department of
Veterans Affairs.
The final thing I would say, and I apologize to my
colleague, Mr. Blumenthal, although ever since he said that the
Chairman was his favorite Chairman----
[Laughter.]
Senator Moran [continuing]. I have lost some level of
regard for your----
Senator Blumenthal. No, I was referring to the Acting
Chairman.
Senator Moran. Oh, it still is. All right. Thank you. I now
understand. [Laughter.]
Senator Blumenthal and I are--he is the Ranking Member and
I am the Commerce Committee Chairman, but one morning in here
he announced that Senator Isakson was his favorite Chairman, so
I have taken offense ever since.
I just wanted to thank the Vietnam Veterans for their
efforts in regard to toxic substances. It is a topic that
deserves more attention. Senator Blumenthal and I are
cosponsors of legislation in the last Congress that we are
getting ready to reintroduce in the new Congress and we want to
work with all of you to make certain that many of our veterans
who have experienced dramatic health consequences due to the
presence of toxic substances during their term of service are
cared for, but in addition to that, the concern that we have
about having the necessary medical research to be then able to
take care of children and grandchildren and those that follow.
I think it is a hugely important topic that Senator Blumenthal
and I care a lot about, and the Vietnam Veterans have been
front and center with that, and I appreciate it.
Mr. Weidman. We thank you and Senator Blumenthal for your
leadership, sir.
Senator Moran. I actually thought I was going to get to
adjourn the meeting, but with the arrival of Senator Boozman, I
would recognize him.
HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS
Senator Boozman. I did that on purpose. [Laughter.]
No, I just wanted to apologize for not being here during
the entire meeting and really wanted to thank all of you. I
have enjoyed working with you so much through the years. Time
goes by. In fact, Jerry and I served over on the House Veterans
Committee together and now are here, and again, I just
appreciate you for your advocacy, really tireless advocacy. It
is everybody working together, which you can be very proud,
because of your efforts, hard work, and your memberships. You
really have pushed things along and that is a great thing.
One of the things that I am concerned about seeing in
Arkansas is, the Choice Act and trying to make it easier on
veterans. One of the concerns is that prior to that, when you
had veterans with emergent care going and accessing a hospital
or whatever, the VA was not paying the bill for that, or paying
it very, very late. That should not be. Now we are able to
intervene and the VA on an individual basis has been good about
working with us.
A concern is that as we go forward with this other program,
that you have situations where the hospital wants to get paid.
They are hounding the veteran. They are hounding the VA. The VA
is deciding. Next, the bill collectors are out there, I guess.
Can you all comment about that?
The other problem with that, also, is if you have that
reputation, and we saw this with TRICARE and some other things,
I can get people out of a sense of patriotism to participate in
programs. Where they get in trouble is if they are hassled with
unnecessary regulation or things that they have to do as far as
extra paperwork or this or that. Again, everybody likes to get
paid at some point, even if they are taking a lesser fee.
Can you guys comment about that, because what we do not
want to do is make it such that if we leave a bad taste in our
providers, then it makes it more difficult than ever for them
actually to participate in the first place.
Mr. Kelley. The good thing about the Choice Program is that
the contractors will pay the provider and then VA will
reimburse them. That really streamlines the process. That is a
great standardization. There are some good processes in place
for that. We need to figure out how to do that across the
board, across all non-VA care delivery.
Mr. de Planque. One of the things as we were jumping into
working on developing the Choice Program was to be able to get
that kind of feedback and metrics as we see how things work,
and it is going to watch how this is working and see if it can
be applied across to other programs, because, as you mentioned,
there have been big problems with some of the VA contracted
care programs in the past, getting money to doctors, and so we
want to make sure that that was part of the thing with Choice,
is that we can look at this as, perhaps, a model for how to
make other programs work better.
Mr. Weidman. I would like--I am sorry, Joy.
Ms. Ilem. I would just add, we are also very interested in
the coordination of that care; the complete coordination of
that care, whether it be the payment or making sure the records
get back, you know, and making sure that the veteran then gets
referred back to the VA when that episode of care is done, if
need be, or that there is still that continuum of care and that
connection for VA in the best interests of the veteran.
Mr. Weidman. It is experience. People will--vets will
believe another vet who has had a successful experience, simple
as that. Until you hit that critical mass where enough people
have gone, you are going to have to, at each facility, walk
people through the process, so that if they have confidence in
the staff member, they will trust them to do it, and then they
start to spread the word. Vets will believe another vet before
they will believe the government by ten country miles.
Senator Boozman [presiding]. Right. No, in fact, one of the
things we are seeing is the underutilization of the Choice Act,
which I think is a reflection on the VA brand and the fact that
there is tremendous loyalty. I think the VA can be very proud
of that.
I see the Secretary sitting back there, and we appreciate
you staying. I think that sends a great message, and we do
appreciate your hard work.
I do want to thank you all. Like I said, I figured out a
way how to become the Chairman. [Laughter.]
With that, we are adjourned.
[Whereupon, at 12:19 p.m., the Committee was adjourned.]
A P P E N D I X
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