[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]





 
LEGISLATIVE HEARING ON H.R. 2787; H.R. 3696; H.R. 5521; H.R. 5693; H.R. 
               5864; H.R. 5938; H.R. 5974; AND H.R. 6066

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH


                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        WEDNESDAY, JUNE 13, 2018

                               __________

                           Serial No. 115-66

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                            ______
                              
               U.S. GOVERNMENT PUBLISHING OFFICE 
 35-729                 WASHINGTON : 2019       
        
        
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                      NEAL DUNN, Florida, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
BILL FLORES, Texas                       Ranking Member
AMATA RADEWAGEN, American Samoa      MARK TAKANO, California
CLAY HIGGINS, Louisiana              ANN MCLANE KUSTER, New Hampshire
JENNIFER GONZALEZ-COLON, Puerto      BETO O'ROURKE, Texas
    Rico                             LUIS CORREA, California
BRIAN MAST, Florida

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                        Wednesday, June 13, 2018

                                                                   Page

LEGISLATIVE HEARING ON H.R. 2787; H.R. 3696; H.R. 5521; H.R. 
  5693; H.R. 5864; H.R. 5938; H.R. 5974; AND H.R. 6066...........     1

                           OPENING STATEMENTS

Honorable Neal Dunn, Chairman....................................     1
Honorable Julia Brownley, Ranking Member.........................     2

                               WITNESSES

The Honorable Vicky Hartzler, U.S. House of Representatives, 4th 
  District; Missouri.............................................     3
    Prepared Statement...........................................    27
The Honorable Brad Wenstrup, U.S. House of Representatives, 2nd 
  District; Ohio.................................................     4
    Prepared Statement...........................................    28
The Honorable Clay Higgins, U.S. House of Representatives, 3rd 
  District; Louisiana............................................     6
    Prepared Statement...........................................    29
The Honorable Mike Bost, U.S. House of Representatives, 12th 
  District; Illinois.............................................     7
    Prepared Statement...........................................    30
The Honorable Jenniffer Gonzalez-Colon, U.S. House of 
  Representatives, Puerto Rico...................................     9
    Prepared Statement...........................................    31
The Honorable Jeff Denham, U.S. House of Representatives, 10th 
  District; California...........................................    10
    Prepared Statement...........................................    32
The Honorable Matt Cartwright, U.S. House of Representatives, 
  17th District; Pennsylvania, prepared statement only...........    33
The Honorable Marcy Kaptur, U.S. House of Representatives, 9th 
  District; Ohio, prepared statement only........................    33
Roscoe Butler, Deputy Director for Health Care, Veterans Affairs 
  and Rehabilitation, The American Legion........................    11
    Prepared Statement...........................................    35
Jeremy Villanueva, Associate National Legislative Director, 
  Disabled American Veterans.....................................    13
    Prepared Statement...........................................    39
Kayda Keleher, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States..................    15
    Prepared Statement...........................................    44
Jessica Bonjorni MBA, PMP, SPHR, Acting Assistant Deputy Under 
  Secretary for Health for Workforce Services, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............    16
    Prepared Statement...........................................    47

  Accompanied by:

    Dayna Cooper MSN, RN, Director, Home and Community-Based 
        Programs, Veterans Health Administration, U.S. Department 
        of Veterans Affairs

                        STATEMENT FOR THE RECORD

AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO (AFGE)......    53
American Orthotic and Prosthetic Association.....................    54
Military Officers Association of America (MOAA)..................    57
Paralyzed Veterans of America (PVA)..............................    60


LEGISLATIVE HEARING ON H.R. 2787; H.R. 3696; H.R. 5521; H.R. 5693; H.R. 
               5864; H.R. 5938; H.R. 5974; AND H.R. 6066

                              ----------                              


                        Wednesday, June 13, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                     Subcommittee on Health
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 3:00 p.m., in 
Room 334, Cannon House Office Building, Hon. Neal P. Dunn 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Dunn, Higgins, Gonzelez-Colon, 
Brownley, Kuster, and Correa.
    Also Present: Representative Bost.

            OPENING STATEMENT OF NEAL DUNN, CHAIRMAN

    Mr. Dunn. The Subcommittee will come to order.
    Before we begin I would like to ask unanimous consent for 
Congressman Mike Bost from Illinois to sit on the dais and 
participate in today's proceedings. Without objection, that is 
so ordered.
    I want to thank you all for joining us.
    This afternoon we will be discussing eight bills that have 
been referred to the Subcommittee on Health. These bills are 
sponsored by Committee Members and our non-committee colleagues 
alike from Members on both sides of the aisle.
    I am grateful to each of the bills' sponsors for their 
interest in ensuring that the Department of Veterans Affairs is 
the best equipped to provide high quality care and services 
that our Nation's veterans have earned and certainly deserve.
    The bills that we will be discussing this afternoon cover a 
wide variety of topics. For example, our agenda includes bills 
that pertain to noninstitutional long-term care and clinical 
productivity, efficiency, and medical waste management. Also, 
some of the bills on our agenda today address some aspects of 
recruitment and retention. The considerable challenges that VA 
has faced in recent years when it comes to hiring have been 
well documented in this Subcommittee.
    Next Thursday we will be holding another hearing to 
evaluate what, if any, progress the VA has made with the 
additional authorities that this Congress has provided to 
improve the VA's abilities to recruit new hires, bring them on 
board, and retain them over the course of their careers.
    I hope that that hearing reveals headway in meeting 
staffing needs across the VA health care system. However, as 
long as the staffing concerns remain a problem for the VA, this 
Subcommittee will continue to prioritize finding innovative 
ways to ensure that the VA is able to hire doctors and nurses 
and other providers that our veterans need.
    Once again I want to thank the bill sponsors for 
introducing their thoughtful proposals and for their attendance 
here today.
    I also want to thank the veterans service organizations who 
will be testifying or who have submitted statements for the 
record and for their willingness to lend their opinions and 
insights to us this afternoon.
    Mr. Dunn. And finally, I am grateful to the witnesses from 
the VA for being here to provide the Department's perspective 
on these bills.
    That said, I do want to note my disappointment that despite 
being provided with several weeks' notice of this hearing, VA's 
testimony did arrive late to the Committee staff.
    We read your testimony carefully. We consider it seriously. 
And we would like to have more than 48 hours to study it. I 
found the testimony to be very useful once it was received, and 
I hope the next time we will be able to get that in a little 
more timely fashion.
    I now yield to Ranking Member Brownley for any opening 
statement that she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Well, thank you, Mr. Chairman, and I am 
looking forward to this hearing.
    And I wanted to welcome back my friend, Dr. Wenstrup. We 
worked very closely together on this Subcommittee.
    So welcome back.
    And I, too, want to thank the VA and our veterans service 
organizations for being here today. We have some great 
legislation that we are considering, and your expertise and 
input is so valuable to us as we consider what changes need to 
be made to best help our veterans.
    The bills before the Subcommittee today are practical 
solutions to issues affecting veteran's nation-wide. In 
particular, I am concerned about the persistent number of 
vacancies at the VA and feel that we must do more to bring 
qualified doctors, nurses, and other medical providers into the 
VA system.
    Hiring and retention within the VA has long been 
problematic, and today a number of the bills seek to assist VA 
in attracting qualified health care providers to treat our 
veterans.
    While we know VA offers a high quality of care, it is often 
a lack of access that can be frustrating for our veteran 
patients. By focusing on VA's HR department and premedical 
school training programs, we can ensure VA has a pipeline of 
providers entering the VA and the staff to ensure they are on 
board in a timely manner.
    I look forward to further discussions of these bills and 
welcome any suggestions on how we can improve upon them. I 
thank all of our colleagues for being here and for their work 
supporting veterans.
    Thank you, Mr. Chairman, and I yield back.
    Mr. Dunn. Thank you very much, Ms. Brownley.
    I will now introduce our first panel. It is a pleasure to 
be joined today by several of our bills' sponsors. With us are 
Congresswoman Vicky Hartzler from Missouri and Congressman Brad 
Wenstrup from Ohio. And he is former Chairman of this 
Committee, Dr. Wenstrup. I will introduce the other witnesses.
    Actually, we also have Congressman Mike Bost from Illinois 
is going to be a witness on the panel, and also Congressman 
Clay Higgins from Louisiana.
    I appreciate all of you taking time out from your afternoon 
here to discuss your legislation.
    Mrs. Hartzler, you are now recognized for 5 minutes.

           STATEMENT OF THE HONORABLE VICKY HARTZLER

    Mrs. Hartzler. Well, thank you, Chairman Dunn and Ranking 
Member Brownley and distinguished Members of the Subcommittee. 
I appreciate you allowing me time to testify on H.R. 5521, the 
VA Hiring Enhancement Act.
    Our veterans deserve the best. Unfortunately, top notch 
care is often hampered by a shortage of doctors at the VA.
    I believe that this bill, which I introduced along with 
Congressman Correa and Congressman Bost, will help the VA to 
fill some of these vacancies.
    Our bill has three main provisions.
    First, it would allow physicians to be released from 
noncompete agreements only for the purpose of serving in the VA 
for at least 1 year. Noncompete agreements are supposed to 
prevent a physician from building up a patient base and then 
taking those patients with them as they set up their own 
practice. A physician moving to the VA simply does not fit this 
description.
    This proven provision would ensure that a noncompete 
agreement is never used to keep a physician from serving 
veterans at a VA facility and only applies to such a 
circumstance.
    Second, our bill updates the minimum training requirement 
for VA physicians. Completion of a medical residency is widely 
accepted as standard comprehensive training for clinical 
physicians in the United States; however, current law only 
requires that a physician be licensed in order to treat 
veterans. In the case of some medical specialties, the 
difference between licensing and completing residency can 
represent 6 years of training.
    Some have suggested this provision would exacerbate the 
shortage of physicians at the VA by shrinking the pool from 
which the VA can hire; however, the VA currently hires almost 
exclusively those physicians which have completed residency 
training, so this provision would not result in such an impact.
    Others have rightly submitted that veterans are largely 
satisfied with the quality of care they receive at the VA. 
They, therefore, submit that we do not need a legislative fix 
to a higher standard. I contend that as long as Congress sees 
fit to impose any standard on the VA regarding those caring for 
veterans, we have a duty to ensure that that standard is 
appropriate.
    Completion of residency training is the accepted standard 
in this Nation, and we should never expect veterans to accept 
anything less. This is a commonsense update to something 
Federal law already addresses and ensures that only fully 
trained physicians care for those who served our Nation.
    Finally, our bill would place veterans' hospitals on a 
level playing field with the private sector when it comes to 
recruiting timelines. Often, private sector health care 
providers begin recruiting medical residents as they begin 
their final year of residency, sometimes even earlier. Most 
residents have school debt they need to start paying off, an 
average of $190,000. During residency they treat patients and 
work upwards of 80 hours a week, sometimes with single shifts 
up to 28 hours.
    These residents, rightfully motivated to secure a post-
residency job with better pay and better hours, often accept a 
solid job offer from the private sector before VA recruiters 
are able to get their recruiting process even started.
    Our bill authorizes VA recruiters to make job offers to 
physicians up to 2 years prior to fulfilling all of the VA's 
requirements contingent on meeting all requirements before they 
begin treating veterans. It offers job security to medical 
residents who want to work at the VA when they complete their 
training. And it allows VA facilities and recruiters to shore 
up appointments further in advance, helping them to plan and 
forecast medical workforce needs.
    VA recruiters are already pitching a great opportunity for 
physicians, and we owe them policies that make them as 
competitive as possible with private sector recruiters. I 
believe that advancement of this legislation will help begin to 
fill the VA's many vacant health care position needs.
    We have worked closely with this Committee's staff, VA 
recruiters, and VSOs on this bill, and I am pleased to report 
that it has garnered wide support, including formal endorsement 
from the American Legion and Paralyzed Veterans of America. It 
is my hope we can work together to move this bill to the House 
floor soon.
    Thank you again for allowing me this time, and I yield 
back.

    [The prepared statement of Vicky Hartzler appears in the 
Appendix]
    Mr. Dunn. Thank you very much Representative Hartzler.
    We now recognize Dr. Wenstrup for 5 minutes.

          STATEMENT OF THE HONORABLE BRAD R. WENSTRUP

    Mr. Wenstrup. Thank you very much, Mr. Chairman, Ranking 
Member Brownley. It is good to be with you all again. I 
appreciate the opportunity to be with you today.
    As a Member of the House Veterans Affairs Committee for 
many years, one of my frustrations was the inability to use 
metric-driven standards to comprehensively examine and improve 
how the VA was using its resources to deliver health care.
    We often hear, ``When you have seen one VA, you have seen 
one VA,'' and that stands to reason in many ways. But every 
time I sat where you sit now and ask VHA's past leadership if 
they were able to provide metrics on health care delivered for 
resources expended, I wasn't able to get an answer. I was told 
the numbers existed, but they never seemed to materialize. And 
some would say, ``Well, it costs more to do this, it costs more 
to do that,'' but they really had no metric of explaining how.
    The goal, I think, for our VA health care system should be 
to deliver quality care efficiently in a timely fashion. If you 
are determined to deliver health care to all of those veterans 
that are eligible for care in a timely fashion, you want to 
make sure that you can be the most efficient.
    So my legislation, H.R. 6066, seeks to ensure that actual 
data, based on the measure of relative value units, will ensure 
we can best serve our veterans.
    What is a relative value unit? It is something assigned. 
CMS uses it. And it gives us a value to what procedure you have 
just performed or what function you just performed. There are 
more RVUs for an open heart surgery than there is for an 
incision and drainage of an abscess, as you might imagine.
    So recently the VA began tracking productivity metrics 
across more than 30 specialties, but significant gaps still 
exist and persist in the effectiveness and completeness of the 
current reporting.
    Last year a GAO report that is cited in my written 
testimony found that current VA productivity metrics, including 
RVUs, called RVUs, are not complete and may not be accurate. 
Clinical specialties are siloed, certain patient work is not 
measured, and contract providers go unmeasured. So the data 
that we have is not really useful because it is not complete.
    And recording an RVU and scoring an RVU when you perform a 
procedure is very simple. You have certain procedures in your 
specialty that you do every day, and you document it in your 
note, and you can just simply point out, ``I did this and I did 
that.'' And then that can be scored.
    So this is legislation to tackle the GAO's recommendations 
by tracking RVUs across all providers and providing more 
comprehensive and systematic review to put the data to work, 
and by doing this accurately we can figure some things out. In 
the private sector, obviously, the more RVUs you produce, the 
more you get paid. It is different in the VA. You are paid the 
same anyway.
    But what we want to do is measure productivity. If you have 
two practitioners operating at the same time, doing the same 
type of work, and one is producing twice as much as the other, 
you can evaluate that by knowing how many RVUs you produced.
    So what do you do with that? In our practice if we saw it 
we would say, you know, well, this doctor has a physician 
assistant or two medical assistants as opposed to your one, and 
if we do that we can increase the productivity. That doesn't 
decrease doctor time. It actually will increase doctor time 
with patients.
    So these are things that I want to bring to light. It also 
can affect how you are scheduling. You can learn so much. You 
may need to know that you need one more treatment room to be 
more efficient.
    So this is an adequate way of really determining how 
productive someone is or a clinic is or a hospital is and can 
guide us on where we may need to make changes to be more 
effective.
    Last year, working with the Committee, we drafted the 
language found in the bill in response to the May 2017 GAO 
report and recommendations and from years of observation from 
the dais where you now sit. This language was included in H.R. 
4242 when it passed out of this very Committee last November, 
though it did not make it into the final VA MISSION Act. That 
is why I am introducing this language as a standalone bill.
    The VA, like all government agencies, is operating in a 
resource-constrained environment. It is our obligation to make 
sure that the resources we do have are directed at the veterans 
that need care. If we can't measure this we can't improve it.
    None of us can claim to have a monopoly on good ideas. So I 
stand ready work with all interested parties to make sure that 
every dollar we spend within the Veterans Health Administration 
is being used to effectively deliver care to our veterans.
    Thank you, and I yield back.

    [The prepared statement of Brad R. Wenstrup appears in the 
Appendix]
    Mr. Dunn. Thank you very much, Dr. Wenstrup.
    I now recognize Captain Clay Higgins from Louisiana for 5 
minutes.

            STATEMENT OF THE HONORABLE CLAY HIGGINS

    Mr. Higgins. Thank you, sir.
    Chairman Dunn, Ranking Member Brownley, thank you for 
considering H.R. 5693, the Long-Term Care Veterans Choice Act.
    My bill, H.R. 5693, authorizes the Department of Veterans 
Affairs for 3 years to cover the cost of long-term care at 
medical foster homes for up to 900 veterans otherwise eligible 
for nursing home care through the VA.
    Medical foster homes are private homes in which a caregiver 
provides services to a small group of individuals who are 
unable to live without day-to-day assistance, and are an 
alternative to nursing homes for those who require nursing home 
care but prefer a noninstitutional setting with fewer 
residents.
    For many young veterans in need of round-the-clock care, 
medical foster homes can provide a more age-appropriate, 
independent setting than traditional nursing homes.
    The U.S. Department of Veterans Affairs has run its medical 
foster home initiative since the year 2000, and today VHA 
oversees more than 700 licensed caregivers caring for nearly 
1,000 veterans in 42 States.
    To be eligible to provide care for veterans, a VA medical 
foster home provider must provide a background check, complete 
80 hours of initial training and 20 hours annually afterwards, 
and cannot work outside of the home.
    Unfortunately, while the VA will cover the cost of home-
based primary care for eligible veterans living in medical 
foster homes, the VA does not cover the cost of medical foster 
home living arrangements for veterans otherwise eligible for 
nursing home care through the VA. Instead, these veterans must 
pay for medical foster home services out of pocket or through 
private insurance.
    Costs associated with medical foster home services range 
between $1,500 and $3,000 a month, which is significantly lower 
than the nearly $7,000 per month the VA might otherwise pay per 
patient at a State VA nursing home.
    In my home State of Louisiana, the VA operates state-of-
the-art veterans' homes that provide residents a high quality 
of care in an understanding, supportive environment. This is 
understood. In my district I have toured and visited the 
Southwest Louisiana Veterans Home in Jennings, Louisiana, and I 
can personally attest to the high quality of care and sense of 
well-being among veterans there.
    But much like in the civilian world, there is no one-size-
fits-all standard of care for veterans. Veterans should be 
afforded flexibility to use the benefits they righteously 
earned and that best suits their own individual needs. H.R. 
5693, the Long-Term Care Veterans Choice Act, gives much-needed 
choice and personal dignity back to these brave men and women 
who have selflessly sacrificed for our Nation.
    I look forward to the support of my colleagues on this 
bill.
    Mr. Chairman, Madam Ranking Member, thank you for allowing 
me to speak on this bill, and I yield the balance of my time.

    [The prepared statement of Clay Higgins appears in the 
Appendix]
    Mr. Dunn. Thank you very much, Representative Higgins.
    I now recognize former U.S. Marine Representative Mike Bost 
from Illinois for 5 minutes.

              STATEMENT OF THE HONORABLE MIKE BOST

    Mr. Bost. Thank you, Chairman Dunn and Ranking Member 
Brownley, for providing me the opportunity to testify before 
the Subcommittee on Health on my legislation, H.R. 5864, the VA 
Hospitals Establishing Leadership Performance Act, or VA HELP 
Act.
    The mission of the Department of Veterans Affairs is to 
care for those who shall have borne the battle. When our heroes 
transition from the military they deserve to have access to 
quality health care and service.
    Unfortunately, the VA continues to fall short on that 
promise due in part to failures in human resource management 
and operations. VA's internal assessment and those by the 
Government Accountability Office and VA inspector general have 
identified serious human capital challenges and weaknesses 
within the VHA's human resources operations.
    Most recently, we all heard about the inadequate staffing 
and human resources management deficiencies that contributed to 
the failures at the Washington, D.C., VA Medical Center.
    This issue hits very close to home for me after the VA 
National Center for Patient Safety surveyed the Marion VA 
Medical Center. The Marion VA's Patient Safety Culture Survey 
showed a considerable decline in key factors, such as 
communications between management and staff and the frequency 
of reporting problems to management.
    During the site visit, multiple employees raised concerns 
about poor management and poor communications, distrust between 
leadership and management, and the lack of accountability.
    These factors helped measure the culture at the VA 
facility, and it was clear that the employees were unsatisfied 
with their work environment.
    Following this report, General Bergman and I sent a letter 
to then-Secretary Shulkin requesting that the VA further 
investigate this matter. The effort was followed up by an 
Oversight and Investigations Subcommittee staff visit to the 
Marion VA Medical Center in order to get a firsthand look at 
the issues at the facility.
    A report of the Subcommittee's findings confirmed a lack of 
accountability, improper communication, and a lack of standards 
to measure the success of the H.R. department. We also learned 
that there are limited education qualifications required to be 
chief of human resources in the VA.
    I do not know of any health system that has a chief of HR 
without a college degree overseeing thousands of employees and 
responsible for negotiating job offers and proposing 
disciplinary action. I also do not know of any health care 
system that would hire or promote an individual to manage and 
oversee a human resources department without requiring a 
college degree.
    During my time on the Committee, I have seen that it is 
common in the VA to move problem employees into higher-level 
jobs, with greater responsibility, without assessing their 
prior leadership experience and performance.
    Unfortunately, despite the Subcommittee's findings and 
several efforts to encourage the VA headquarters leadership to 
address these problems, limited actions have been taken. My 
office continues to receive complaints about the mistrust of 
the medical center leadership, confusion and inconsistencies in 
its disciplinary process, and failures to track employee 
performances and outcomes.
    Human resources management is a critical part of delivering 
quality health care. HR is responsible for recruiting and 
retaining highly qualified personnel and professionals, and the 
current status quo within the VHA's HR offices cannot continue.
    H.R. 5864, the VA HELP Act, will ensure that the VA 
addresses deficiencies within its human resources department by 
giving it the ability to compare the performance of the 
departments across the VHA and to measure their successes.
    This straightforward legislation instructs the Secretary of 
the VA to establish qualifications for human resources 
positions within the Veterans Health Administration. It also 
requires the VA to establish standardized performance metrics 
for human resources positions.
    These commonsense reforms will ensure that the human 
resources departments at the VA medical centers are operating 
on a uniform standard and that it is clear who qualifies to 
hold such important positions.
    In closing, I would like to thank Representative Sinema for 
her helping to introduce this legislation, and would like to 
thank you, Mr. Chairman and Ranking Member Brownley, for 
allowing me to testify before the Subcommittee. I hope that we 
can work together on H.R. 5864 to ensure that our Nation's 
veterans are being provided for with the best possible care 
from our VA employees.
    And with that, Mr. Chairman, I yield back.

    [The prepared statement of Mike Bost appears in the 
Appendix]
    Mr. Dunn. Thank you, Representative Bost.
    I now recognize for 5 minutes Congresswoman Jenniffer 
Gonzalez-Colon.

      STATEMENT OF THE HONORABLE JENNIFFER GONZELEZ-COLON

    Miss Gonzalez-Colon. Thank you, Chairman Dunn and Ranking 
Member Brownley, for having this hearing today, and all Members 
here. And thank you for including H.R. 5938, the Veterans 
Serving Veterans Act, as part of the agenda for this afternoon.
    As previously stated on several occasions before this 
Committee, the Department of Veterans Affairs suffers chronic 
staffing challenges that complicate the delivery of proper and 
timely care. These challenges are often exacerbated by a time-
consuming hiring process.
    The VA facilities within my district are no exception to 
that. As a matter of fact, this issue never fails to come up 
during meetings with veterans in Puerto Rico.
    Therefore, as an effort to identify a remedial option, my 
bill seeks to amendment Section 208 of the Choice and Quality 
Employment Act of 2017 to include military occupational 
specialties of soon-to-be-discharged servicemembers that 
correspond to vacant positions in the VA in the recruiting 
database, as well as servicemembers' contact information and 
the date of discharge.
    Employment after separating from the military is beneficial 
for veterans from a psychological and financial perspective.
    My bill would require the VA to first coordinate with the 
Department of Defense to identify soon-to-be-separated 
servicemembers with military occupational specialties needed by 
Veterans Affairs and obtain their date of separation and basic 
contact information.
    Second, to maintain a database searchable by VA personnel 
for purposes of hiring soon-to-be-separated servicemembers.
    And third, implement direct hiring and appointment 
procedures for vacant positions listed on the database for 
servicemembers who apply for these positions.
    Another objective of this bill will require the VA to 
implement a program to train and certify former DoD health care 
technicians as intermediate care technicians, or ICTs, and to 
address the large demand for health care providers at the 
Veterans Health Administration.
    Currently, these very skilled technicians, trained by the 
Department of Defense at significant taxpayer expense, have 
difficulty gaining employment in their field after separating 
from the Armed Forces due to the lack of a certification. At 
the same time, the Veterans Health Administration has 
significant shortages of providers.
    VHA instituted the Intermediate Care Technician Pilot 
Program in 2013 to train and utilize ICTs at the VA facilities 
in a variety of roles. The program has since then received 
remarkable satisfaction rates and helped fill a void of medical 
providers.
    Implementing a program to train and certify eligible 
veterans to work as ICTs will help formalize the process, as 
well as provide for continued program support and expansion, 
ensure rigor in curriculum development, competency assessment, 
program monitoring, and allow the pool of eligible ICTs to 
continue growing to meet veterans' health care needs.
    Mr. Chairman and Members of this Committee, it is important 
to keep in mind that servicemembers are a remarkable asset upon 
transitioning from military service. This bill seeks to further 
close the gap between transitioning members and the VA by 
helping them occupy positions currently in demand and provides 
an opportunity for greater access to medical care. Moreover, it 
allows for veterans to be cared for by fellow veterans in ways 
that are most needed by the VA.
    As a former State legislator in Puerto Rico, I am aware 
that no bill is set in stone, and legislation is often the 
product of several reviews and revisions, and I look forward to 
receiving the feedback of this panel and welcome any comments 
or suggestions on ways that we can move this forward. But I 
want to thank the people from the American Legion and the 
Disabled American Veterans and the Military Officers 
Association of America for their support for this bill.
    With that, I yield the balance of my time.

    [The prepared statement of Jenniffer Gonzalez-Colon appears 
in the Appendix]
    Mr. Dunn. Thank you, Representative Gonzalez-Colon.
    I will now recognize former United States Air Force veteran 
Representative Jeff Denham from California for 5 minutes.
    You are recognized.

             STATEMENT OF THE HONORABLE JEFF DENHAM

    Mr. Denham. Thank you, Mr. Chairman. It is good to be back 
with the Committee that I spent a number of years on, as well, 
fighting for America's veterans. Thank you for this opportunity 
to speak on H.R. 5974, the VA COST SAVINGS Enhancement Act. I 
introduced this bipartisan bill to improve care for our 
veterans and ensure we are using the latest cost-saving 
technology.
    Specifically, this deals with VA medical waste in 
facilities across the entire country, resulting in huge savings 
within the next 5 years. System-wide, this will save the VA 
millions of dollars each year and directly improve safety and 
health care for our veterans.
    The medical waste, known as red bag or biohazardous waste, 
is infectious waste produced at VA facilities and hospitals. 
Since this waste is contaminated by bloody and bodily fluids it 
poses a risk of transmitting an infection and has to be handled 
in a special way.
    If a VA facility was doing this on-site sterilization 
through these large machines, this waste can be not only 
disinfected immediately, but also avoiding costly off-site 
movements. Meaning that this waste, which can't be compacted, 
fills trucks very, very quickly, ends up with a lot of trucks 
on the road. And as we have seen from other national disasters, 
this infectious waste could end up in the wrong areas within 
our community.
    So handling it on-site is not only a huge cost savings, but 
handling it on-site is also much safer for our veterans, as 
well as the communities that this would normally be trucked 
through.
    On the cost side, currently technologies can treat waste 
for 7 to 9 cents per pound compared to 30 to 60 cents off-site. 
So again, we are wasting millions of dollars each year shipping 
this infectious waste around the country. This bill stops that.
    The VA recognizes the benefits of this technology, and 
approximately 20 percent of the VA facilities already have 
these machines on-site, but, unfortunately, they have been very 
slow in expanding these across the country.
    In 2016 the MilCon-VA appropriations bill acknowledged the 
huge cost savings, as well as the beneficial environmental 
impacts and the energy savings associated with on-site medical 
waste treatment. The VA developed a blanket purchase agreement 
to streamline the purchasing of these machines, but, 
unfortunately, again implementation has been very slow.
    It is time to realize the full benefits of this technology 
and bring the VA into the 21st century. Our veterans deserve 
the highest quality of care we can provide. And this technology 
improves the crisis readiness and is safer, more efficient, 
more cost effective and environmentally friendly than 
traditional medical waste disposal.
    Installing these machines immediately can begin the savings 
of millions of dollars for the VA and directly improve our care 
for our veterans.
    I urge my colleagues to support this policy.

    [The prepared statement of Jeff Denham appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Representative Denham.
    Once again, I thank all of you for being here and for 
sponsoring these bills on our agenda this afternoon. The first 
panel is now excused. I will pause while the members of the 
second panel settle themselves here at the table.
    Mr. Dunn. I will now welcome the second panel to the 
witness table. Joining us on the second panel is first Mr. 
Roscoe Butler, the deputy director for health care, veterans 
affairs and rehabilitation for the American Legion; Jeremy 
Villanueva, the associate national legislative director for 
Disabled American Veterans; Kayda Keleher, the associate 
director for national legislative service for the Veterans of 
Foreign Wars of the United States; and Ms. Jessica Bonjorni, 
acting assistant deputy Under Secretary for health for 
workforce services for the Veterans Health Administration of 
the U.S. Department of Veterans Affairs. And joining Ms. 
Bonjorni is Dayna Cooper, the director of home and community-
based programs for the Veterans Health Administration.
    We will begin this afternoon with Mr. Butler.
    You are now recognized for 5 minutes.

                   STATEMENT OF ROSCOE BUTLER

    Mr. Butler. Thank you.
    According to a March 2017 study commissioned by the 
Association of American Medical Colleges, there will be a 
shortage of more than 100,000 doctors by 2030. According to a 
September 2017 VA OIG report, the largest staffing shortages in 
the Veterans Health Administration were medical officers, 
nurses, psychologists, physician assistants, and medical 
technologists.
    Many of the bills being discussed today are designed to 
address the VHA staffing crisis, and the American Legion thanks 
this Subcommittee for holding this important hearing.
    Good afternoon, Chairman Dunn, Ranking Member Brownley, and 
distinguished Members of the Subcommittee on Health. On behalf 
of the national commander, Denise H. Rohan, and the American 
Legion, the country's largest patriotic wartime veterans 
service organization, comprising over two million members and 
serving every man and woman who has worn the uniform for this 
country, we thank you for the opportunity to testify on behalf 
of the American Legion's position on the following pending and 
draft legislation.
    H.R. 2787, the Veterans-Specific Education for Tomorrow's 
Medical Doctors Act. This bill will establish a pilot clinical 
observation program within the Department of Veterans Affairs 
for premed students preparing to attend medical school.
    The American Legion is deeply troubled by staffing 
shortages within the Department of Veterans Affairs, 
particularly within the Veterans Health Administration, and has 
consistently voiced concerns since the inception of our System 
Worth Saving Program in 2003.
    The American Legion has identified and reported staffing 
shortages at every VA medical center and reported these 
critical deficiencies to Congress, VA's central office, and the 
President of the United States. The American Legion believes 
this bill will make a difference and supports H.R. 2787.
    H.R. 3696, the Wounded Warrior Workforce Enhancement Act. 
The American Legion believes, due to the shortage of physicians 
in critical specialized areas, such as orthotics and 
prosthetics, Congress must ensure resources and funding are 
available to support continuing education and training of such 
physicians.
    We know as the number of veterans needing orthotics and 
prosthetic services increases there will be a continuing need 
for clinicians at the master's degree level to meet this 
increasing demand. For this reason, the American Legion 
supports H.R. 3696.
    H.R. 5521, the VA Hiring Enhancement Act. The American 
Legion has long expressed concerns about staffing shortages at 
Department of Veterans Affairs Veterans Health Administration 
medical facilities, to include physicians and medical 
specialist staffing.
    We, the American Legion, believe the VA Hiring Enhancement 
Act will help ensure when a qualified physician who is an 
applicant for an appointment to a position in the Veterans 
Health Administration has entered into a covenant not to 
compete with a non-department facility, the individual will not 
be barred from accepting an appointment to a position in the 
Veterans Health Administration.
    The American Legion believes enforcing noncompete 
agreements to VA hires is overly broad and should be 
unenforceable under public policy. Traditional reasons behind 
noncompete agreements to bar competitive advantages to protect 
sensitive information simply do not exist in this context. For 
this reason, the American Legion supports 5521.
    The American Legion also supports H.R. 5693, the Long-Term 
Care Veterans Choice Act, and H.R. 5938, the Veterans Serving 
Veterans Act of 2018.
    However, the American Legion does not have an official 
position on H.R. 5864; the VA COST SAVINGS Enhancement Act; and 
the draft bill to improve the productivity of the management of 
Department of Veterans Affairs health care, and for other 
purposes.
    In conclusion, the American Legion thanks this Subcommittee 
for the opportunity to voice the position of the over two 
million veteran members of this organization, and I am 
available to answer any questions that you and the Subcommittee 
may have.

    [The prepared statement of Roscoe Butler appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Mr. Butler.
    Mr. Villanueva, you are now recognized for 5 minutes.

                 STATEMENT OF JEREMY VILLANUEVA

    Mr. Villanueva. Thank you. Chairman Dunn, Ranking Member 
Brownley, and Members of the Subcommittee, thank you for 
inviting DAV to testify at this legislative hearing of the 
Subcommittee on Health.
    DAV, a nonprofit veterans service organization comprised of 
over one million wartime service-disabled veterans, is 
dedicated to a single purpose: empowering veterans to lead high 
quality lives with respect and dignity. As a service-disabled 
veteran myself and one who uses the VA health care system, I am 
pleased to be here to present DAV's views on the bills under 
consideration by the Subcommittee.
    H.R. 5521, the VA Hiring Enhancement Act, would render 
noncompete agreements between an applicant for VA employment 
and a previous employer nonapplicable with regard to VA 
employment. Employees appointed with this understanding would 
be required to serve at least 1 year in their position or the 
remainder of their noncompete agreement, whichever is longer.
    The bill would also authorize VA to hire on a contingency 
basis physicians completing residencies not later than 2 years 
after appointment. If the contingent employee has not satisfied 
VA requirements for the position in that time, that individual 
will not be appointed to the position.
    DAV supports efforts to recruit, retain, and develop a 
skilled clinical workforce to need the needs of veterans. We 
thereby share the goal of this legislation in creating as large 
as possible an applicant pool for qualified medical 
professionals to treat our service-disabled veterans in the VA.
    DAV Resolution No. 228 calls for effective recruitment, 
retention, and development of the VA health care workforce. 
Because this measure attempts to reduce barriers for the VA to 
hire physicians, we support the intent of this bill.
    We thank the Subcommittee for considering H.R. 5693, the 
Long-Term Care Veterans Choice Act, that would improve VA's 
medical foster home program.
    Medical foster homes enable those veterans with serious 
chronic conditions that meet nursing home level of care to 
remain in a residential environment instead of being 
institutionalized. Participation in this program is voluntary, 
and veteran residents have reported very high satisfaction 
ratings.
    Currently, veterans who wish to reside in a medical foster 
home but are unable to pay the approximately $1,500 to $3,000 
per month are not able to utilize this program, so many are 
placed in nursing homes at much greater cost to the VA. 
Moreover, VA would pay more than twice as much for nursing home 
care than if the VA was granted this bill's proposed authority 
to pay for VA medical foster homes.
    Mr. Chairman, we must be fully cognizant of our aging 
veteran population's need for programs such as this. DAV's 
Resolution No. 227 calls for legislation that increases access 
and improves long-term services and supports for service-
connected disabled veterans.
    To allow a veteran to stay in their community while 
receiving the best quality of care and maintaining a semblance 
of independence would in some small way show this Nation's 
gratitude to those who have sacrificed for it. DAV strongly 
supports this legislation and calls for swift passage.
    H.R. 5864, the VA Hospitals Establishing Leadership 
Performance Act, would establish qualifications for each human 
resource position with the VHA, establish standardized 
performance metrics for each such position, and submit to 
Congress a report that details the actions taken.
    The VA has long needed improvement in the performance of 
their human resources staff. This has been noted by 
organizations such as the Commission on Care and the GAO. Each 
organization has indicated that administration-wide improvement 
requires systemic changes that would fundamentally alter the 
operations, leadership, and guidance of the current human 
capital management system.
    We believe that H.R. 5864 offers a good starting point for 
the fundamental overhaul of VA's human capital management 
system, but it is only a start. VA also needs to look at 
streamlining and simplifying its recruitment and hiring 
practices. It needs to look at different programs and practices 
for staff retention, development, employment benefits, and 
performance management to maximize employee engagement.
    Most importantly, human capital management reform will 
require a long-term commitment from VA's leadership and 
Congress. However, the intent of H.R. 5864 will likely not be 
fully realized if VA is incapable of hiring or developing the 
human talent necessary to fill these positions.
    DAV supports this legislation, in accordance with DAV 
Resolution No. 228, which calls for a simple-to-administer 
alternative VHA personnel system in law and regulation which 
governs all VHA employees, applies best practices from the 
private sector to human capital management, and supports pay 
and benefits that are competitive with the private sector; and 
Resolution No. 221, which supports VA's use of meaningful and 
clearly articulated measures to gauge employees' performance.
    Mr. Chairman, this concludes my testimony, and I would be 
pleased to address any questions related to the bills discussed 
today.

    [The prepared statement of Jeremy Villanueva appears in the 
Appendix]

    Mr. Dunn. Thank you, Mr. Villanueva.
    Ms. Keleher, you are now recognized for 5 minutes.

                   STATEMENT OF KAYDA KELEHER

    Ms. Keleher. Chairman Dunn, Ranking Member Brownley, and 
Members of the Subcommittee, it is my honor to represent the 
women and men of the VFW and our Auxiliary.
    The VFW agrees with the intent of the Wounded Warrior 
Workforce Enhancement Act, but it has some serious concerns 
which prevent our organization from providing support at this 
time.
    One of VA's four statutory missions is to educate and train 
health professionals to enhance the quality of care provided to 
patients within VA. VA accomplishes this through coordinated 
programs and partnerships with affiliated academic 
institutions.
    Section 2 of this legislation would require VA to provide 
grants to orthotics and prosthetics graduate programs which are 
accredited by the National Commission on Orthopedic and 
Prosthetic Education in cooperation with the Commission on 
Accreditation of Allied Health Education Programs. These grants 
would be eligible for use at the selected institutions to 
expand sites, build infrastructure, supplement salaries, 
provide financial aid, or purchase equipment.
    While providing this in such ways, these grants could be of 
value to VA and VA patients, but the VFW does not believe this 
legislation would be of value in the way it is currently 
written. This is because the grants may be paid to institutions 
without any tie to VA.
    Priority for grant recipients would go to institutions 
partnered with VA, but is not a requirement. For institutions 
applying for the program they must show a willingness to 
participate with VA, but, again, they are not required to 
actually participate.
    The VFW believes for these institutions to receive these 
grants they must agree to some level of partnership and 
participation with VA.
    Section 3 of this legislation would provide a larger grant 
to one institution to become a center of excellence for 
orthotics and prosthetics. VA and DoD already have these 
facilities, which provide those best practices to veterans. 
This grant would also not require any form of partnership or 
participation from these institutions with VA.
    The VFW cannot justify outsourcing valuable VA resources to 
bolster a non- VA entity that would not benefit veterans.
    The VFW is pleased the VA Hiring Enhancement Act would 
remove noncompete contracts for providers who want to work for 
VA and supports removing this barrier to employment, though the 
VFW cannot support the remaining provisions within Section 3, 
which would limit VA's hiring pool for health care providers as 
well as duplicate current law providing VA the authority to 
make job offers to current residents.
    We are all aware that VA currently has 38,000 job 
vacancies. These vacancies must be significantly reduced before 
the VFW feels more restrictions may be put upon VA regarding 
who the agency may hire. To address quality of care, which VFW 
members prefer from VA, we must address access to care.
    The VFW agrees with the intent of the Veterans Serving 
Veterans Act of 2018, but has concerns with the legislation as 
it is currently written.
    This legislation would establish a database worked on by 
DoD and VA, and this technology would withhold information of 
individuals currently serving in the military with job 
positions which are needed within VA.
    Servicemembers wanting to opt out of this database and 
having their personally identifiable information shared with an 
array of VA employees would be required to submit a letter. 
This database would then be used by VA to recruit potential 
employees for DoD before they exit from service.
    Aside from our concerns over the access to this personal 
information, the VFW believes these servicemembers should have 
to opt into the database, and that they would also still be 
subjected to experiencing bureaucratic difficulties while 
switching from DoD to VA.
    The VFW agrees that DoD and VA need to work together to 
identify medical professionals currently serving who are 
interested in coming over to VA and that these individuals need 
to have their credentials streamlined so that the day they 
receive their DD 214 in hand they can walk into their new 
office at VA.
    The VFW agrees with the intent of the draft legislation to 
improve productivity of the management of VA health care, but 
has some concerns with it as currently written.
    RVUs are used as a national standard for determining budget 
expenses, cost benchmarks, and productivity within the private 
sector. They are primarily used in the private sector to 
determine provider payments, something that is not an issue for 
VA providers on a government salary.
    The VFW believes there is a value to tracking RVUs within 
VA, and our organization also believes that as funding 
increased, and hopefully continues to increase, that the RVUs 
would show an increase in productivity.
    With that said, the private sector is not required to 
publicly report most data that VA is required to publicly 
report, and that includes RVUs. While this legislation would 
take into account nonclinical duties, the VFW is concerned 
about more double standards possibly being held to VA.
    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee, this concludes my testimony. Thank you again for 
the opportunity to represent the Nation's largest combat 
veteran's organization, and I look forward to taking your 
questions.

    [The prepared statement of Kayda Keleher appears in the 
Appendix]

    Mr. Dunn. Thank you, Ms. Keleher.
    Ms. Bonjorni, you are now recognized for 5 minutes.

                 STATEMENT OF JESSICA BONJORNI

    Ms. Bonjorni. Good afternoon, Chairman Dunn, Ranking Member 
Brownley, and Members of the Subcommittee. I am accompanied 
today by Ms. Dayna Cooper, director of home and community care 
from the Office of Geriatrics and Extended Care. We appreciate 
the opportunity to discuss VA's views on pending health care 
legislation, much of which is aimed at bolstering VA's critical 
workforce management programs.
    There is one bill, the draft VA COST SAVINGS Enhancement 
Act, for which we are unable to provide views at this time 
because it came late to the agenda, but we will follow up with 
the Committee as soon as possible.
    Chairman Dunn, we appreciate the Committee's focus on the 
topic of human resources as a key to filling the Department's 
mission of serving veterans. We are grateful for the human 
capital authorities extended to the VA in the recently passed 
VA MISSION Act and in last year's VA Choice and Quality 
Employment Act.
    As just one example of how those new laws have helped VA, 
we have recently developed a joint program with the Department 
of Defense called the Military Transition and Training 
Advancement Course, which is an entry-level program that allows 
transitioning servicemembers to be trained in occupations 
before they separate and then make a seamless transition into 
the VA. We are trying this right now in the national capital 
region.
    In the interest of being brief, I will highlight a few 
points regarding the bills on the agenda today, and of course 
our written testimony provides further details.
    VA supports the intent of H.R. 2787, the VET MD Act, to 
develop a clinical observation pilot program within VA for 
premedical undergraduate students to shadow physicians. 
However, we do note in our testimony concerns about high 
unfunded costs, implementation challenges, and suggestions for 
improvements.
    VA continues to recommend providing clinical observation 
opportunities for all pre-health occupation students, rather 
than focusing exclusively on premedical students. In addition, 
VA recommends including both undergraduate and 
postbaccalaureate students, since these students have displayed 
interest in pursuing health careers.
    We would be glad to discuss further with the Committee how 
we believe the bill can be improved.
    H.R. 3696, the Wounded Warrior Workforce Enhancement Act, 
calls for establishing a new or expanding existing prosthetic 
or orthopedic graduate programs and the establishment of one 
prosthetic/orthotic research center of excellence.
    VA does not support this bill because we believe VA already 
fulfills the intent, using interdisciplinary teams that provide 
rehabilitation services to veterans' unique needs. VA offers 
these in-house services at 84 laboratories across VA. In 
addition, VA contracts with more than 600 specialized vendors.
    Through both in-house staffing and contractual 
arrangements, VA is able to provide state-of-the-art, 
commercially available items ranging from advanced myoelectric 
prosthetic arms to specific custom-fitted orthoses.
    H.R. 5521, the VA Hiring Enhancement Act, would give VA 
additional tools in the hiring of title 38 employees, and in 
particular physicians.
    Noncomplete clauses often prevent VA from freely hiring 
physicians from the local medical community. Exempting VA from 
these restrictive and nonapplicable covenants would prove 
beneficial. VA would hope to restrict this section to 
physicians hired under 7401(1) of this title.
    Section 3 of the bill would permit VHA to make a contingent 
appointment as a VHA physician on the basis of a physician 
completing their physician residency training. VA endorses 
Sections 1 and 2 of this bill, however, has concerns with 
Section 3 and requests the opportunity to discuss with the 
Committee.
    We appreciate the vision and compassion outlined in H.R. 
5693, the Long-Term Care Veterans Choice Act, which will help 
VA meet the escalating demand for nursing home care, which is 
projected to double over the next decade for Priority 1A 
veterans, while also providing veterans a choice.
    VA covers 100 percent of their nursing home costs. However, 
if these veterans with highly service-connected conditions 
would prefer to receive their care in a VA medical foster home 
they must pay out of pocket at an average cost of $2,400 per 
month because VA does not currently have the authority to pay.
    This bill will help VA meet this increasing demand for 
nursing home care by offering the option of a VA-approved 
medical foster home while simultaneously reducing the need to 
build more nursing homes or double VA's nursing home 
expenditures.
    H.R. 5864, VA HELP Act, proposes to standardize 
qualification requirements and performance metrics for human 
resources positions.
    VA does not support the intent of this bill, but does 
support efforts to professionalize the H.R. function throughout 
government.
    Creating VA-specific standards would negatively impact VA's 
ability to retain current staff or recruit H.R. professionals 
from other Federal agencies. VA is currently developing 
standardized performance metrics for HR specialists to be 
implemented in fiscal year 2019.
    If a decision is made to proceed with the bill, VA requests 
the opportunity to meet with the Committee to propose revisions 
of language to address our concerns.
    Regarding the draft Veterans Serving Veterans Act of 2018, 
VA supports the intent of this bill. However, we believe VA is 
able to accomplish the content of this bill with existing 
authorities.
    Efforts are already underway to target transitioning 
military members for mission-critical and difficult-to-fill 
positions by using data contained in a VADIR database that 
already exists. The resource has resulted in a recruitment 
pipeline that will now allow VA to reach out directly to 
transitioning servicemembers.
    Finally, the draft bill to improve the productivity of VA 
health care calls for VA to track relative value unit 
production standards and includes other associated 
requirements.
    VA does not support the bill as we already track RVUs for 
licensed independent providers, and performance standards and 
productivity targets are established with annual reviews 
currently in place at a minimum.
    VA has significant concerns about the mandatory training 
required in the bill, which would take providers away from 
providing direct patient care. VA would like to discuss this 
bill with the Committee.
    Mr. Chairman, this concludes my testimony. My colleagues 
and I are prepared to answer questions.

    [The prepared statement of Jessica Bonjorni appears in the 
Appendix]

    Mr. Dunn. Thank you, Ms. Bonjorni.
    And I thank the entire panel for being here. We will move 
to the questioning portion of the panel now.
    I do want to make mention that votes may have been moved 
up, maybe as early as 4:15, so I am going ask the Members of 
the panel to make their questions succinct to give the panel 
witnesses maximum time to answer. And I am also going to ask 
the witnesses on the panel to try to be concise in your answers 
so that we can get as many questions in as we possibly can.
    I now yield myself 5 minutes.
    I will start with Ms. Bonjorni and Ms. Cooper. Many of the 
bills on today's agenda have financial scores that will require 
offsets before they can potentially move to the floor. Will you 
commit to working with the Subcommittee to find offsets within 
our jurisdiction for the proposals that you support?
    Ms. Bonjorni. Yes, we will.
    Mr. Dunn. Excellent.
    Again, Ms. Bonjorni, when do you expect to have a cost 
estimate for H.R. 5521, the VA Hiring Enhancement Act, 
available for us to look at?
    Ms. Bonjorni. I believe we will be able to have that within 
the next 2 weeks, if not sooner.
    Mr. Dunn. Okay. Excellent. We will be looking for that.
    Ms. Bonjorni, your opposition to Section 3, H.R. 5521, the 
Hiring Enhancement Act, is based on the fact that you think the 
VA already has rules requiring completion of residency. The 
wording of that is such that it is residency or its equivalent. 
What is the equivalent to completion of a residency in VA 
standards?
    Ms. Bonjorni. The equivalent is something that is 
determined by the professional standards board to have met the 
intention of a residency program. It is extremely rare for us 
to hire people who have not gone through a residency program.
    Mr. Dunn. Would not it be more transparent and easier to 
simply require the staff physician, in order to be a staff 
physician in a VA facility, you have to complete residency 
training, just say that outright?
    Ms. Bonjorni. It may be.
    Mr. Dunn. All right. We think it might be, too.
    Ms. Keleher, your opposition to Section 3, H.R. 5521, was 
that you thought it might be duplicative of current law. We 
looked at that same law. We thought that it did not apply to 
physicians, but rather other professionals in the VA. Do you 
interpret that law differently than we do?
    Ms. Keleher. Yes, Mr. Chairman, we do.
    Mr. Dunn. You feel pretty confident in that?
    Ms. Keleher. Yes, sir.
    Mr. Dunn. All right. Well, let's talk about that.
    Ms. Bonjorni, how many more veterans do you think would 
elect to receive--let me change the order of these questions.
    How many of the veterans currently in medical foster homes 
would otherwise be entitled to VA-paid nursing home care?
    Ms. Bonjorni. I am going to defer that question to Ms. 
Cooper.
    Mr. Dunn. Excellent.
    Ms. Cooper. Currently, there are just under 300 veterans in 
medical foster homes that are paying for their care that would 
be eligible to receive the payment under this bill. There are 
approximately 15,000 Priority 1A veterans that are receiving 
care in a nursing home. We anticipate that there would be 
approximately 5,000 of those that would down the road be 
choosing a medical foster home.
    Mr. Dunn. So you anticipate a future demand of 
approximately 5,000 veterans--
    Ms. Cooper. Based on our current--
    Mr. Dunn [continued].--if we were to open this up?
    Ms. Cooper. Correct.
    Mr. Dunn. All right. Well, that answered my next question.
    And I think I will be careful with the Committee's time, 
and I will yield now to Ms. Brownley, the Ranking Member.
    Ms. Brownley. Thank you, Mr. Chairman.
    I wanted to talk a little bit about H.R. 6066.
    So, Mr. Villanueva, could you talk to me a little bit 
about--I know you have already said something about this 
particular bill--but with regards to how your membership feels 
and sort of trying to outline for the Committee some of the 
differences between VA delivery of health care and productivity 
and private providers?
    Mr. Villanueva. Thank you for that.
    Ms. Brownley. This is the RFUs measurement for 
productivity.
    Mr. Villanueva. Right, right. And thank you for that 
question. It is indeed my pleasure to answer that.
    Essentially, we don't have a position on this bill as of 
yet. We do believe that there are still some clarifications 
that need to be made, specifically what exactly these RVUs 
would be used for, how they would receive them from the private 
care community, and how they would be comparing them.
    Because we do believe that with the VA being a capitation 
system and the private care community not, that it would be 
essentially, like I believe one of my colleagues at this table 
has said, be tantamount to comparing apples to oranges.
    Ms. Brownley. And, Ms. Keleher, do you have any comments 
relative--
    Ms. Keleher. Yes, thank you.
    As my colleague next to me has stated, we do have concerns 
with the apples-to-oranges comparison. I think everybody has 
kind of beat it over the head here with VA, and their 
productivity varies compared to the private sector not just 
based on income, but also on quality of care.
    VFW has conducted multiple, multiple surveys in recent 
years and we get consistent feedback from our members.
    Some quotes. We have a World War II veteran from Florida 
who said, ``VA doctors listen to me and take time to explain 
the answers to my questions.'' Or we have others who say, 
``They treat me like a hero and give me the time that I 
actually need.'' That was a Vietnam veteran.
    With that said, the number three problem that our members 
say they face when using non-VA care is actually timeliness, 
and they feel rushed with their providers. So we don't want 
that to be an unintended negative outcome.
    Ms. Brownley. I think in some way we are going to have to 
figure out how to measure productivity, but also putting a 
value on the fact that doctors, medical professionals within 
the VA spend time with veterans to answer their questions. We 
are asking more and more for doctors to screen for various 
other things that they might not have an appointment for.
    And I think we place a value on that. But somehow 
understanding that we are placing a value on that, but also 
being able to properly measure our efficiencies and 
productivities as well. So somehow, some way, we are going to 
have to figure that one out.
    Mr. Higgins, by the way, I like your bill. I think it is a 
good bill.
    Mr. Higgins. Thank you, ma'am.
    Ms. Brownley. And to Mr. Butler, so is this a bill that is 
important to your membership? And I think it is, but if you 
would express to us why.
    Mr. Butler. The medical foster home?
    Ms. Brownley. Yes.
    Mr. Butler. Currently right now VA is not eligible to pay 
for care for veterans. They just refer veterans to a foster 
home. So any veteran who is eligible for nursing home care, 
this bill gives VA the authority to pay for their care in 
medical foster homes, which could result in a significant cost 
savings to the VA and the government.
    So we fully support the bill because we believe that any 
money saved is a benefit to our Nation's veterans and the 
American taxpayer.
    Ms. Brownley. And this is for any of the VSOs. Do you feel 
an increased demand for a program like this amongst your 
veterans?
    Ms. Keleher. I personally have not heard specifically from 
VFW members, but as--
    Ms. Brownley. Do you think they know about the program?
    Ms. Keleher. Personally, probably not, but I do hope they 
do.
    As we see the population of veterans continuously age, I 
think we can all agree that we are going to see them not only 
knowing the program more and more, but requiring it as well. 
And I would assume that the quality outcomes are much better 
than putting them in an institutionalized setting.
    Ms. Brownley. Anybody else have a comment?
    No?
    With that, I will yield back.
    Mr. Dunn. Thank you very much, Representative Brownley.
    We now recognize Congressman Higgins for 5 minutes.
    Mr. Higgins. Thank you, Mr. Chairman.
    Ms. Bonjorni, thank you for your service to your country, 
madam.
    Do you see my bill, 5693, as a net win for America and 
America's veterans?
    Ms. Bonjorni. Yes. Thank you for the question, sir.
    Mr. Higgins. That is the short answer. We can stop there. 
Mr. Chairman, I yield back. I yield the balance of my time. 
America wins. Veterans win, baby. That is why we are here, 
right?
    Mr. Dunn. Well, I thank you, Congressman Higgins. Let me 
say that, as a veteran, when you retire and you need care, I 
will give you care in my own home. How is that?
    We now recognize Representative Kuster for 5 minutes. Thank 
you.
    Ms. Kuster. Thank you very much, Mr. Chairman.
    And thank you to our panel and to all of our colleagues 
introducing these bills. This is a great array of bills. And I 
particularly appreciate the help from the VSOs and from the VA 
as we sort them out.
    I want to start by focusing my attention on Dr. Wenstrup's 
bill, because we had a roundtable this morning with Dr. Roe. We 
were talking about the issue of general medical education and 
increasing the number of physicians being trained at the VA 
going forward. And we were talking about what I would consider 
to be unintended consequences of Dr. Wenstrup's concept about 
measuring these RVUs as they are measured in the public domain, 
in the public--I am sorry, in private medicine--and trying to 
compare that to the VA.
    And in particular, I think the VFW testimony talked about 
there is value in tracking, but you have to be careful because 
of the nonclinical burdens on VA health care providers.
    In particular, could you comment--and to the VFW, but if 
anyone else wants to comment--on the obligation of supervising 
medical training? And so, for example, during residency, Dr. 
Roe talked at length about the amount of time that that takes 
and that you are not as efficient when you are doing that.
    Could you comment on that? And also the specifics about 
other elements that are different. For example, the physical 
facilities, you don't have the same ratio of rooms for medical 
appointments that you do in the private sector. You don't have 
the same ratio of support staff that you do in the private 
sector. How do these factors change the equation from trying to 
compare apples to apples with RVUs?
    Ms. Keleher. Thank you for the question. I will try to go 
in order of the way that you did ask.
    In regard to training, VA does provide ample training to 
America's providers, whether they end up at VA or not. And that 
is clearly very time consuming.
    I use VA for all of my health care. And I have had many 
times where my provider asks before the appointment if it is 
okay if they have new residents come in, because they are going 
through and explaining things more by process. There are 
chances that the resident is not going to be as understanding 
of things.
    So that is a clearly very timely constraint on VA. And if 
they are taking in more residents and doing more training than 
in the private sector, that would be one great example of how 
the RVUs could have a negative comparison.
    VA also does a lot of research. They don't, as you said, 
have all of the staff that in the private sector they may. And 
the Subcommittee and the Committee at large have been wonderful 
at trying to address those needs within VA. We are just a 
little off still on the timing.
    We do believe that the RVUs could provide great outcomes. 
We do think that you are going to see the productivity 
continuously increasing for VA.
    But we are concerned about the way that will be used. Is 
that going to be used for appropriation purposes? Are we going 
to have a journalist pick it up and want to do another big 
article about VA being less proficient, maybe, than the private 
sector, when the private sector isn't publicly making that data 
available simply because they don't have to, so why would they?
    So it is something that we definitely are interested in 
continuing to talk about with the Committee.
    Ms. Kuster. Thank you very much.
    And I do want to say on the record, I am all for efficiency 
and would like to have further conversations about that.
    I do want to make sure to get on the record that I support 
Mr. Denham's bill with regard to medical waste. I am a 
cosponsor of that bill. And just experience that I have on the 
private sector with disposal of medical waste, I would like to 
work with you all going forward to pass that bill.
    And then, my time is very limited, but I did have a quick 
question on--if I can get it in. I may have to take it for the 
record. But this was on the whole issue about--I am sorry, 
excuse me--the performance. But my time is up, so I will come 
back another round. Thank you.
    Mr. Dunn. Thank you, Representative Kuster.
    I will now recognize Congresswoman Gonzalez-Colon for 5 
minutes.
    Miss Gonzalez-Colon. Thank you, Mr. Chairman.
    I will go directly with Ms. Bonjorni.
    First of all, I want to say that I do support Mr. Higgins' 
bill. I don't know if you could so you can have both.
    Anyway, you say that you have underway some of the proposal 
of the bills under the Veterans Administration. I want to know 
how many of those veterans or servicemembers were not working 
anymore at the Armed Forces have already been hired at the 
Veterans Administration. Do we have a rate?
    Ms. Bonjorni. How many veterans are we hiring?
    Miss Gonzalez-Colon. No, no. You say that you already have 
the database, you are sharing the information from the 
Department of Defense with the VA, correct?
    Ms. Bonjorni. Yes.
    Miss Gonzalez-Colon. You are having that effort already 
undergoing.
    Ms. Bonjorni. We have just received access to the data, and 
so our targeted marketing toward specific occupations will be 
starting by the end of this month.
    Miss Gonzalez-Colon. Okay. So how long will it take for you 
to make the whole program work? Because you said in your 
written statement that it will take at least 180 days to make 
that happen?
    Ms. Bonjorni. Yes. So thank you for the question.
    I think that in looking at what was actually the initial 
draft of what is in the current law for the VA Choice and 
Quality Employment Act, we are right now using our existing 
personnel database to fulfill that requirement.
    The data that we are receiving from DoD is specific to the 
transitioning servicemembers. Right now that is not linked, the 
two systems aren't linked. And so we would need some time, if 
that is the long-term intent, to link those two sources of 
information. But right now we are able to go ahead and use the 
data about the transitioning servicemembers to market.
    Miss Gonzalez-Colon. So it could be less time?
    Ms. Bonjorni. Yeah.
    Miss Gonzalez-Colon. Okay. So I like that answer.
    And then my second question will be, you are saying that 
there is intent of the administration to use, not just the 
Department of Defense data, but using the whole government to 
make that happen, correct?
    Ms. Bonjorni. Could you elaborate on your question?
    Miss Gonzalez-Colon. You said that the administration wants 
to extend the database portion of the act of government-wide 
intention to have access to the rest of the government instead 
of using just the Department of Defense.
    Ms. Bonjorni. I am not certain what other--what you are 
allowing to be authorized.
    Miss Gonzalez-Colon. In your written statement that is the 
implication, that is what I read in that statement, that the 
intention was not just the Department of Defense using the 
database, but extending that to the rest of the government.
    Ms. Bonjorni. As a long-term plan.
    Miss Gonzalez-Colon. Exactly.
    Ms. Bonjorni. But the VA is not actively pursuing that 
right now, yes.
    Miss Gonzalez-Colon. But it is on your written statement. 
So maybe a long-term option is there, right?
    Ms. Bonjorni. Yes.
    Miss Gonzalez-Colon. So I do understand that this bill that 
we just filed could be the best pilot program to have in the 
public law to be enforced, and you already are having those 
kind of ideas undergoing, but including--I mean, I think having 
veterans serving veterans is the first thing. Saving taxpayers 
money is the second biggest implementation of this bill.
    Third, I think having the opportunity to cut the staffing 
shortages that we have in the VA, the hiring process that is 
always so difficult. We are facing that problem in Puerto Rico, 
as a matter of fact.
    And, of course, having the certifications for the ICTs that 
you already have in place with remarkable reviews in so many 
areas. Why not having that as not just a choice of public 
policy in between the agency, but as a mandate of Congress?
    And that is the reason of this bill, and I do support it. 
And as you just said in your written statement, I do believe 
that you are in support of it.
    Ms. Bonjorni. Yes, we are in support.
    Miss Gonzalez-Colon. Thank you. I yield back. I will do the 
same thing that Mr. Higgins did.
    Mr. Dunn. Thank you, Representative Gonzalez-Colon.
    And we now recognize for 5 minutes Congressman Correa from 
California.
    Mr. Correa. Mr. Chairman, we will try to make it in 2. How 
is that?
    I just wanted to very quickly say I also support Mr. 
Higgins' legislation. And wanted to also say that I joined 
Representative Hartzler in introducing H.R. 5521 to address the 
issue you are talking about, which is the physician shortage 
and the ever-increasing physician shortage.
    And I know that, Ms. Keleher, I know the VFW has some 
issues, maybe some concerns. I hope we can work through those 
issues and make sure they are all on board, because getting 
good docs into the VA is an important goal. And I hope all of 
us can work towards that.
    With that, Mr. Chairman, I yield the remainder of my time.
    Mr. Dunn. You have been very kind with the Committee's 
time, Congressman Correa. Thank you very much for that.
    Votes have been called, so the panel is going to be winding 
down.
    I do want to make the editorial comment that the use of 
relative value units is not intended to be punitive. It is 
intended to be a measure of productivity and efficiency. And I 
think we have to get there somehow. Somehow we have to measure 
our efficiency given the amount of the people's treasure that 
has been entrusted to us in this Committee.
    With that, I want to thank the panel for the time that you 
have put in and for coming up here and being willing to see us 
and talk to us and answer our questions.
    The Subcommittee is adjourned.

    [Whereupon, at 4:14 p.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

           Prepared Statement of Congresswoman Vicky Hartzler
    Chairman Roe, Ranking Member Walz, and distinguished Members of the 
Committee, thank you for allowing me this time to testify about HR 
5521, The VA Hiring Enhancement Act.
    Our veterans deserve the best. Unfortunately, top-notch care is 
often hampered by a shortage of doctors at the VA. I believe that this 
bill, which I introduced along with Congres7smen Correa and Congressman 
Bost will help the VA to fill some of these vacancies.
    Our bill has three main provisions. First, it would allow 
physicians to be released from non-compete agreements only for the 
purpose of serving in the VA for at least one year. Non-compete 
agreements are supposed to prevent a physician from building up a 
patient base, and then taking those patients with them as they set up 
their own practice. A physician moving to the VA simply does not fit 
that description. This provision would ensure that a non-compete 
agreement is never used to keep a physician from serving veterans at a 
VA facility, and only applies to such a circumstance.
    Second, our bill updates the minimum training requirements for VA 
physicians. Completion of a medical residency is widely accepted as 
standard comprehensive training for clinical physicians in the United 
States. However, current law only requires that a physician be licensed 
in order to treat veterans. In the case of some medical specialties, 
the difference between licensing and completing residency can represent 
six years of training.
    Some have suggested that this provision would exacerbate the 
shortage of physicians at the VA by shrinking the pool from which the 
VA can hire. However, the VA currently hires almost exclusively those 
physicians which have completed residency training, so this provision 
would not result in such an impact.
    Others have rightly submitted that veterans are largely satisfied 
with the quality of care they receive at the VA. They therefore submit 
that we do not need to legislate a higher standard. I contend that as 
long as Congress sees fit to impose any standard on the VA regarding 
those caring for veterans, we have a duty to ensure that the standard 
is appropriate. Completion of residency training is the accepted 
standard in this nation, and we should never expect veterans to accept 
anything less. This is a common-sense update to something federal law 
already addresses, and ensures that only fully trained physicians care 
for those who have served our nation.
    Finally, our bill would place veterans' hospitals on a level 
playing field with the private sector when it comes to recruiting 
timelines. Often, private sector health care providers begin recruiting 
medical residents as they begin their final year of residency, 
sometimes even earlier.
    Most residents have school debt they will need to start paying off-
an average of $190,000. During residency they treat patients and work 
upwards of 80 hours a week, sometimes with single shifts up to 28 
hours. These residents-rightfully motivated to secure a post-residency 
job with better pay and better hours-often accept a solid job offer 
from the private sector before VA recruiters are able to get their 
recruiting process started.
    Our bill authorizes VA recruiters to make job offers to physicians 
up to 2 years prior to fulfilling all of the VA's requirements, 
contingent on meeting all requirements before they begin treating 
veterans. It offers job security to medical residents who want to work 
at the VA when they complete their training, and allows VA facilities 
and recruiters to shore up appointments further in advance, helping 
them to plan and forecast medical workforce needs.
    VA recruiters are already pitching a great opportunity for 
physicians, and we owe them policies that make them as competitive as 
possible with private sector recruiters. I believe that advancement of 
this legislation will help begin to fill the VA's many vacant health 
care positions.
    We've worked closely with this Committee's staff, VA recruiters, 
and VSOs on this bill, and I'm pleased to report that it has garnered 
wide support, including formal endorsement from the American Legion and 
Paralyzed Veterans of America. It's my hope we can work together to 
move this bill to the House floor soon. Thank you again for allowing me 
this time, I yield back.

                                 
            Prepared Statement of Congressman Brad Wenstrup
    Chairman, Members of the Health Subcommittee, thank you for 
welcoming me back today.
    As a Member of the House Veterans' Affairs Committee for many 
years, one of my reoccurring frustrations was an inability to use 
metric-driven standards to comprehensively examine and improve how the 
VA was using its resources to deliver health care.
    An axiom I heard often when I started on the Committee was that 
``when you've seen one VA, you've seen one VA.''
    My frustration grew every time I sat where you sit now, and asked 
VHA's past leadership if they were able to provide metrics on health 
care delivered per resources expended.
    I was often told the numbers existed, but metrics never seemed to 
materialize.

Reports

    In foreshadowing the VA wait list crisis that became evident in 
2014, VA's Office of the Inspector General issued a report in 2012, 
entitled Audit of Physician Staffing Levels for Specialty Care 
Services, finding that:
    ``VHA did not have an effective staffing methodology to ensure 
appropriate staffing levels for specialty care services. Specifically, 
VHA did not establish productivity standards for all specialties and VA 
medical facility management did not develop staffing plans. This 
occurred because there is a lack of agreement within VHA on how to 
develop a methodology to measure productivity, and current VHA policy 
does not provide sufficient guidance on developing medical facility 
staffing plans. As a result, VHA's lack of productivity standards and 
staffing plans limit the ability of medical facility officials to make 
informed business decisions on the appropriate number of specialty 
physicians to meet patient care needs, such as access and quality of 
care.'' \1\
---------------------------------------------------------------------------
    \1\ https://www.va.gov/oig/pubs/VAOIG-11-01827-36.pdf

---------------------------------------------------------------------------
The OIG went on to recommend that VHA:

    ``establish productivity standards for at least five specialty care 
services by the end of FY 2013 and approve a plan that ensures all 
specialty care services have productivity standards within 3 years. We 
also recommended that the Under Secretary provide medical facility 
management with specific guidance on development and annual review of 
staffing plans.''
    Five year later, the VA now tracks productivity metrics across more 
than 30 specialties, but significant gaps persist in the effectiveness 
and completeness of the current reporting. This inhibits their ability 
to optimize resources to better deliver care to our veterans.
    Last year, the GAO released a report entitled Improvements Needed 
in Data and Monitoring of Clinical Productivity and Efficiency \2\. 
This report found that current VA productivity metrics, including 
relative value units, are not complete and may not be accurate. 
Clinical specialties are siloed, certain inpatient work is not 
measured, and contract providers go unmeasured. Data is not always 
usefully accessible, and remediation plans do not rise above the VISN 
level.
---------------------------------------------------------------------------
    \2\ https://www.gao.gov/assets/690/684869.pdf

---------------------------------------------------------------------------
This GAO report contained four recommendations:

    ``1. expand existing productivity metrics to track the productivity 
of all providers of care to veterans by, for example, including 
contract physicians who are not VA employees as well as advance 
practice providers acting as sole providers;

    2. help ensure the accuracy of underlying staffing and workload 
data by, for example, developing training to all providers on coding 
clinical procedures;

    3. develop a policy requiring VAMCs to monitor and improve clinical 
efficiency through a standard process, such as establishing performance 
standards based on VA's efficiency models and developing a remediation 
plan for addressing clinical inefficiency; and

    4. establish an ongoing process to systematically review VAMCs' 
remediation plans and ensure that VAMCs and VISNs are successfully 
implementing remediation plans for addressing low clinical productivity 
and inefficiency.''

H.R. 6066

    H.R. 6066 is legislation to tackle these recommendations by 
tracking relative value units across all providers and providing a more 
comprehensive and systematic review and reaction to the tracked data.
    By more accurately tracking the work all our VA physicians and 
health care providers conduct, we can better use existing resources to 
deliver more care to our veterans. The GAO reported just a few examples 
of how this data can help inform administrators, from reconfiguring 
appointment scheduling to reprioritizing procedures to ensure the most 
care possible can be delivered.
    In my own career as a health care provider, I know that 
productivity metrics, such as RVUs, can alert the caregiver that they 
may be less efficient than they could be. This metric may bring to 
light the need for greater medical assistance or more treatment rooms 
being available.
    Last year, working with the Committee, we drafted the language 
found in this bill in response to the May 2017 GAO report and 
recommendations, and from years of observation from the dais where you 
now sit.
    At that time, we worked to incorporate feedback from stakeholders, 
including flexibility towards value-based care and accounting for non-
clinical duties. This language was included in H.R. 4242 when it passed 
out of this very Committee last November, though did not make the final 
VA MISSION Act.
    That is why I am introducing this language as standalone bill. Our 
veterans and our doctors deserve to know that all the VA's resources 
are being optimized to deliver care.
    The VA, like all government agencies, is operating in a resource 
constrained environment. It is our obligation to make sure that the 
resources we do have are directed at the veterans that need care. If we 
can't measure this, we cannot improve.
    In closing, I look forward to hearing input and perspective from 
Members of the Committee, the VA, and VSOs on this legislation. None of 
us can claim to have a monopoly on good ideas, and I stand ready to 
work with all interested parties to make sure that every dollar we 
spend within the Veterans Health Administration is being used to 
effectively deliver care to our veterans.

    Thank you.

                                 
             Prepared Statement of Congressman Clay Higgins
    Mr. Chairman,

    My bill, HR 5693, the Long Term Care Veterans Choice Act, 
authorizes the Department of Veterans Affairs (VA) for three years to 
cover the cost of long-term care at medical foster homes for up to 900 
veterans otherwise eligible for nursing home care through the VA.
    Medical Foster Homes (MFH) are private homes in which a caregiver 
provides services to a small group of individuals who are unable to 
live without day to day assistance, and are an alternative to nursing 
homes for those who require nursing home care but prefer a non-
institutional setting with fewer residents. For many young veterans in 
need of round-the-clock-care, MFHs can provide a more age-appropriate, 
independent setting than traditional nursing homes.
    The US Department of Veterans Affairs (VA) has run its medical 
foster home initiative since 2000, and today the Veterans Health 
Administration oversees more than 700 licensed caregivers caring for 
nearly 1,000 veterans in 42 states. To be eligible to provide care to 
veterans, VA medical foster home providers must already pass a 
background check, complete 80 hours of initial training and 20 hours 
annually afterwards, and cannot work outside the home.
    Unfortunately, while the VA will cover the cost of Home Based 
Primary Care for eligible veterans living in MFHs, the VA does not 
cover the cost of MFH living arrangements for veterans otherwise 
eligible for nursing home care through the VA. Instead, these veterans 
must pay for MFH services out of pocket or through private insurance. 
Costs associated with MFH services range between $1500 - $3000 a month, 
which is significantly lower than the nearly $7,000 VA would otherwise 
pay per patient at a state VA nursing home.
    In my home state of Louisiana, the VA operates state of the art 
Veterans Homes that provide residents a high quality of care in an 
understanding, supportive environment. Last summer I toured the 
Southwest Louisiana Veterans Home in Jennings and I can personally 
attest to the high quality of care and sense of well-being among 
veterans. But much like in the civilian world, there is no one-size-
fits-all standard of care for veterans. Veterans should be afforded 
flexibility to use the benefits they righteously earned in a manner 
that best suits their individual needs.
    HR 5693 gives much needed choice and personal agency back to these 
brave men and women who have selflessly sacrificed for our nation.

    Thank you.

                                 
              Prepared Statement of Congressman Mike Bost
H.R. 5864 - VA Hospitals Establishing Leadership Performance Act

Script

    Thank you Mr. Chairman and Ranking Member Brownley for providing me 
the opportunity to testify before the Subcommittee on Health on my 
legislation, H.R. 5864, the VA Hospitals Establishing Leadership 
Performance Act or VA HELP Act.
    The mission of the Department of Veterans Affairs is to care for 
those ``who shall have borne the battle.'' When our heroes transition 
from the military, they deserve to have access to quality healthcare 
and services.
    Unfortunately, VA continues to fall short on that promise, due in 
part to failures in human resources management and operations. VA's 
internal assessments, and those by the Government Accountability Office 
and VA Inspector General, have identified serious human capital 
challenges and weaknesses within VHA's Human Resources operations. Most 
recently, we all heard about inadequate staffing and human resource 
management deficiencies that contributed to failures at the Washington 
DC VAMC.
    This issue hit close to home for me after the VA National Center 
for Patient Safety surveyed the Marion VA Medical Center.
    The Marion VA's Patient Safety Culture Survey showed a considerable 
decline in key factors such as communication between management and 
staff and the frequency of reporting problems to management. During the 
site visit, multiple employees raised concerns about poor management 
and poor communication, distrust between leadership and management, and 
the lack of accountability.
    These factors help measure the culture at VA facilities, and it was 
clear that employees were unsatisfied with their work environment.
    Following this report, General Bergman and I sent a letter to then 
Secretary Shulkin requesting that the VA further investigate this 
matter. This effort was followed-up by an Oversight and Investigations 
Subcommittee staff visit to the Marion VAMC in order to get a firsthand 
look at the issues at the facility.
    A report of the Subcommittee's findings confirmed a lack of 
accountability, improper communication and a lack of standards to 
measure the success of the HR department. We also learned that you do 
not need a college degree to be a Chief of Human Resources in the VA. I 
do not know of any health system that has a Chief of HR without a 
college degree overseeing thousands of employees and responsible for 
negotiating job offers and proposing disciplinary actions. I also do 
not know of any health system that would hire or promote an individual 
to manage and oversee a human resources department without requiring a 
college degree.
    During my time on this Committee I have seen that it is common in 
VA to move problem employees into high-level jobs with greater 
responsibility, without assessing their prior leadership experience and 
performance.
    Unfortunately, despite the Subcommittee's findings and several 
efforts to encourage VA Headquarters leadership to address these 
problems, limited actions have been taken. My office continues to 
receive complaints about the mistrust of medical center leadership, 
confusion and inconsistencies in disciplinary processes, and failures 
to track employee performance and outcomes.
    Human resource management is a critical part of delivering quality 
healthcare. HR is responsible for recruiting and retaining highly 
qualified professionals, and the current status quo within VHA's HR 
offices cannot continue.
    H.R. 5864, the VA HELP Act will ensure that the VA addresses 
deficiencies within its Human Resources departments by giving it the 
ability to compare the performance of departments across VHA and 
measure their success.
    This straightforward legislation instructs the Secretary of 
Veterans Affairs (VA) to establish qualifications for Human Resources 
positions within the Veterans Health Administration (VHA). It also 
requires the VA to establish standardized performance metrics for Human 
Resources positions. These commonsense reforms will ensure that the 
Human Resources departments at VAMCs are operating on a uniform 
standard, and that it is clear who qualifies to hold such an important 
position.
    In closing, I would like to thank Representative Sinema for helping 
to introduce the legislation and would like to thank you, Mr. Chairman 
and Ranking Member Brownley, for allowing me to testify before the 
Subcommittee. I hope that we can work together on H.R. 5864 to ensure 
that our nation's veterans are being provided the best possible care 
from VA employees.

                                 
      Prepared Statement of The Honorable Jenniffer Gonzalez-Colon
    Chairman Neal Dunn, Ranking Member Julia Brownley, thank you for 
this afternoon's legislative hearing and thank you for including H.R. 
5938, the Veterans Serving Veterans Act as part of the agenda. I would 
also like to thank the panel for their testimony.
    Mr. Chairman, as previously stated on several occasions before this 
Committee, the Department of Veterans' Affairs (VA) suffers chronic 
staffing challenges that at times complicate the delivery of proper and 
timely care. These challenges are often exacerbated by a complex and 
time-consuming hiring process that extends the time in between the need 
for a position, and filling it with appropriate staff members. VA 
facilities within my district are no exception. As a matter of fact, 
this issue never fails to come up during meetings with veterans in 
Puerto Rico. Therefore, as an effort to identify a remedial option, the 
Veterans Serving Veterans Act seeks to amend section 208 of the Choice 
and Quality Employment Act of 2017 to include Military Occupational 
Specialties (MOS) that correspond to vacant positions at the VA in the 
recruiting database, as well as service member's contact information, 
date of discharge, and the MOS they have acquired.
    Employment after separating from the military is beneficial for 
veterans from a psychological and financial perspective. A process for 
identifying separating service members with military occupational 
specialties that match VA position needs and matching them with open 
positions will be valuable for both the service member and the VA. 
Therefore, H.R. 5938 will require VA to:

      Coordinate with DOD to identify soon to be separated 
service members with military occupational specialties needed by VA and 
to obtain their military specialties, date of separation, and contact 
information.
      Maintain a database searchable by VA personnel for 
purposes of hiring soon to be separated service members; and,
      Implement direct hiring and appointment procedures for 
vacant positions listed in the database for service members who apply 
for these positions.

    Lastly, Section 3 of H.R. 5938 is designed to assist our veterans 
by requiring VA to implement a program to train and certify former 
Department of Defense healthcare technicians as Intermediate Care 
Technicians (ICTs), and to address the large demand for healthcare 
providers at the Veterans Health Administration (VHA). Currently, these 
very skilled technicians, trained at significant taxpayer expense, have 
difficulty gaining employment in their field of specialization after 
separation from the Armed Forces due to lack of a certification. At the 
same time, VHA has a significant shortage of providers.
    VHA instituted the Intermediate Care Technician Pilot Program in 
2013 to train and utilize ICTs at VA facilities in a variety of roles. 
In March 2015, the program was expanded and has since then received 
remarkable satisfaction rates and helped fill a void of medical 
providers within VA medical centers. As of April 2017, 25 VA Medical 
Centers are utilizing ICTs, are in the process of hiring ICTs, or have 
indicated the intent to hire ICTs. 34 ICTs have been hired since the 
end of the pilot.
    Despite the high success rate of the program, it is currently 
operating in a case by case basis, contingent on availability of funds 
at individual medical centers, and with a limited number of training 
centers. Implementing a program to train and certify eligible veterans 
to work as ICTs will provide for continued program support and 
expansion, ensure rigor in curriculum development, competency 
assessment, and program monitoring, and allow the pool of eligible ICTs 
to continue growing to meet veterans' healthcare needs.
    Mr. Chairman, it is important to keep in mind that service members 
are a remarkable asset upon transitioning from military service. The 
Department of Defense invests millions of dollars in their training, 
and they develop skills that have proven valuable to the Department of 
Veterans' Affairs. This bill seeks to further close the gap between 
transitioning members and the VA by helping them occupy positions 
currently in demand at the Department and provides an opportunity for 
greater access to medical care. Moreover, it allows for veterans to be 
cared by fellow veterans in ways that are most needed by the VA at this 
moment.
    Again, thank you for including it in today's agenda. I look forward 
to receiving feedback from our panel and fellow colleagues on ways to 
move forward with this bill.

    Thank you.

                                 
              Prepared Statement of Honorable Jeff Denham
HR 5974, the VA COST SAVINGS Enhancements Act

    Mr. Chairman: Thank you for the opportunity to speak in support of 
HR 5974, the VA COST SAVINGS Enhancements Act.
    I introduced this bipartisan bill to improve care for our veterans 
and ensure we are using the latest cost-saving technology.
    Specifically, it directs the VA to install on-site medical waste 
treatment systems in facilities where this will result in a cost-
savings within 5 years.
    System-wide, this will save the VA millions of dollars each year 
and directly improve safety and healthcare for our veterans.
    Medical waste, also known as ``red bag'' or ``biohazardous'' waste, 
is infectious waste produced at VA facilities and hospitals.
    Since this waste is contaminated by blood or bodily fluids, it 
poses a risk of transmitting an infection and has to be handled in a 
special way.
    If a VA facility has an on-site sterilization machine, this waste 
can be disinfected immediately. Otherwise, it must be taken to a 
special facility off-site.
    On-site sterilization machines, or autoclaves, are steam 
sterilizers that use temperature and pressure to compact waste and 
destroy all microbial life.
    This process renders a completely safe byproduct that can be 
disposed of as normal waste.
    This technology is vetted by the EPA, and is considered a best 
practice by the Centers for Disease Control and Prevention (CDC) and 
World Health Organization (WHO).
    So, this policy brings the VA in line with the medical community's 
recommended practices.
    When VA facilities do not treat waste on-site, they have to load it 
in trucks and drive it to regional waste disposal centers. This is both 
inefficient and expensive.
    It can't be compacted otherwise infections will spread, so the 
trucks fill up fast.
    Additionally, contracting with third parties to ship this waste is 
expensive.
    In a report to Congress, the VA found that on-site treatment costs 
half as much as hauling waste off-site. Often much less.
    Current technologies can treat waste for 7 to 9 cents per pound, 
compared to 30 to 60 cents off-site.
    We are wasting millions of dollars each year shipping infectious 
waste around the country. My bill stops that.
    In addition to the enormous cost savings, this technology is safer, 
more environmentally friendly, and increases crisis readiness.
    Safety is paramount when caring for out vets, and treating waste 
on-site prevents the spread of infections. That is why the CDC 
recommends this technology.
    It also reduces carbon emissions.
    HR 5974 eliminates the need for hundreds of trucks to be on the 
road, and stops VA hospitals from shipping infectious waste back 
through the communities they serve.
    Furthermore, it enhances operational stability and improves 
disaster response.
    In the event of an earthquake or flood, transportation 
infrastructure can be compromised and prevent trucks from reaching a 
facility.
    This ends reliance on outside contractors and ensures medical waste 
can be immediately dealt with in a disaster scenario.
    The VA recognizes the benefits of this technology and approximately 
20% of VA facilities have already installed on-site sterilization.
    The 2016 Military Construction and Veterans Affairs Appropriations 
bill acknowledges `there are cost savings as well as beneficial 
environmental impacts and [energy] savings associated with on-site 
medical waste treatment.''
    Accordingly, the VA developed a Blanket Purchase Agreement to 
streamline purchasing of these machines. Unfortunately - implementation 
has been slow.
    It is time to realize the full benefits of this technology and 
bring the VA into the 21st century.
    Our veterans deserve the highest-quality care we can provide.
    This technology improves crisis-readiness, and is safer, more 
efficient, more cost-effective, and more environmentally friendly than 
traditional medical waste disposal.
    Installing these machines will immediately begin saving the VA 
millions of dollars per year, and directly improve care for our 
veterans.
    I urge my colleagues to support this policy.

                                 
           Prepared Statement of Congressman Matt Cartwright
    Chairman Dunn, Ranking Member Brownlee, and Members of the 
Committee, thank you for including H.R. 3696, the Wounded Warrior 
Workforce Enhancement Act, as part of the hearing today and for the 
opportunity to speak to the Committee about this very important piece 
of legislation.
    Additionally, I would like to thank the American Orthotics and 
Prosthetics Association as well as Senator Durbin as they have been 
instrumental in focusing attention on this critical issue facing our 
nation's veterans.
    The field of orthotics and prosthetics is at a critical tipping 
point in terms of the future viability of its workforce and the ability 
of those professionals to provide the best-tailored care to our 
nation's service members and veterans.
    The American Orthotics and Prosthetics Association has stated that 
there has an approximately 300% increase in the number of veterans with 
amputations served by the VA since the year 2000.
    Unfortunately, currently only 7100 practitioners specially trained 
in O&P nationwide serve more than 80,000 vets with amputations. Of 
those trained practitioners, one in five is either past retirement age 
or eligible to retire in the next five years.
    However, there are only 13 schools around the country with master's 
degree programs in this field with the largest program supporting less 
than 50 students.
    With the growing demand of amputee treatment outpacing the number 
of new practitioners trained to replace an aging workforce, it is clear 
that we must act now to meet our moral obligation of providing our 
heroes with the best health care available.
    The Wounded Warrior Workforce Enhancement Act is a cost-effective 
approach to assisting universities in creating or expanding accredited 
master's degree programs in orthotics and prosthetics.
    Specifically, the bill addresses these issues by authorizing a 
competitive grant of program of $5 million per year for 3 years to help 
colleges and universities develop master's degree programs focusing on 
orthotics and prosthetics.
    The bill also requires the VA to establish a Center of Excellence 
in Prosthetic and Orthotic Education to provide evidence-based research 
on the knowledge, skills, and training clinical professionals need to 
care for veterans.
    These prosthetic and orthotic treatments serve soldiers who 
suffered limb loss injuries because they put their bodies on the line 
for our country, and as a result, have their lives forever changed. 
With Veterans Day just last week, it is a very good reminder just how 
much we owe our wounded warriors.
    Thank you again Chairman Dunn, Ranking Member Brownlee, and Members 
of the Committee for your consideration of this bill today and for 
bringing attention to the important issue of providing veterans with 
the best possible prosthetic and orthotic treatment possible. I look 
forward to working with you and your staff on advancing this important 
piece of legislation.

                                 
        Prepared Statement of The Honorable Marcy Kaptur (D-OH)


Concerning

H.R. 2787, the Veterans-Specific Education for Tomorrow's Medical 
    Doctors (VET MD) Act

    Chairman Dunn, Ranking Member Brownley, and members of the 
Subcommittee, thank you for the invitation to appear before you today. 
I truly appreciate the opportunity to join you to discuss how we can 
increase opportunities for future physicians interested in veterans' 
health care. At the same time, we have the potential to address the 
critical physician shortage facing the Veterans Health Administration.
    Thank you for including in today's hearing, bipartisan legislation 
I introduced to create a shadowing program for pre-medical 
undergraduate students who need to gain clinical observation 
experience. H.R. 2787, the Veterans-Specific Education for Tomorrow's 
Medical Doctors (VET MD) Act, would expose America's future physicians 
to the unique needs faced by our veteran population. This exposure 
would better prepare future physicians to provide veteran-centered care 
no matter where they choose to practice.
    Several years ago, two pre-medical undergraduate students 
highlighted to my team the struggles disadvantaged, minority, and other 
young people who lack personal and familial connections in medical 
communities face as they apply for medical school. Through their own 
struggle to access clinical observation experience, they realized an 
immense opportunity.
    In the current medical school admissions system, 73 percent of 
medical schools either highly recommend or require applicants to have 
clinical observation experience. \1\ In fact, medical schools recommend 
applicants have 40 hours of observation experience at minimum. However, 
there is no formal system through which students can apply to shadow or 
observe clinicians in hospital or clinical settings.
---------------------------------------------------------------------------
    \1\ Association of American Medical Colleges. (2016). Clinical 
Experiences Survey Summary. Retrieved from https://www.aamc.org/
download/474256/data/gsa-coa-clinical-shadowing-experience-executive-
summary.pdf
---------------------------------------------------------------------------
    More than 87 percent of medical schools report that applicants 
without clinical observation experience may be at a disadvantage in the 
admissions phase and that preference tends to be given to applicants 
with observation experience. \2\ Further exacerbating the situation, 
opportunities for clinical observation are very limited. Students from 
or who attend schools outside major cities and whose families lack 
connections to the medical community are at a significant disadvantage 
in the search to find clinical observation opportunities.
---------------------------------------------------------------------------
    \2\ Association of Medical Colleges, Ibid.
---------------------------------------------------------------------------
    In 2015, the percentage of Black or African American medical school 
graduates was 6 percent and Hispanic or Latino medical school graduates 
was 5 percent. \3\ Whites and Asians continue to represent the largest 
proportion of medical school graduates with 58.8 percent and 19.8 
percent respectively. \4\ Yet, as the American population becomes more 
diverse, the same trends are anticipated of our veteran population too. 
In the next thirty years, the number of veterans who are non-Hispanic 
White is expected to drop from 77 percent to 64 percent. The number of 
Hispanic veterans is expected to nearly double from 7 percent to 13 
percent, while the number of Black veterans is expected to increase 
from 12 percent to 16 percent. \5\ It is vital we work to find 
solutions to build and increase the diversity of the physician 
pipeline. We know that a more diverse medical profession means better 
care for a diverse America, especially for our veterans.
---------------------------------------------------------------------------
    \3\ Association of American Medical Colleges. (2016). Current 
Trends in Medical Education. Retrieved from http://
aamcdiversityfactsandfigures2016.org/report-section/section-3/
    \4\ Association of American Medical Colleges, Ibid.
    \5\ Bialik, K. (2017, November 10). The changing face of America's 
veteran population. Retrieved from http://www.pewresearch.org/fact-
tank/2017/11/10/the-changing-face-of-americas-veteran-population/
---------------------------------------------------------------------------
    After working closely with experts at the VA, their recommendations 
were included in the discussion draft to ensure the pilot program is 
more manageable for VA hospitals, clinicians, and participating 
students and we prioritize student applicants from Minority-Serving 
Institutions. These revisions do not change the underlying intent of 
the original bill, to create a pilot program for undergraduate pre-
medical students to participate in clinical observation opportunities.
    While the primary purpose of this bill is to provide a pathway for 
pre-med students to gain valuable shadowing hours, an important 
secondary goal is to address the physician shortage at the VA. Not only 
does the VA have a high demand for physicians, a critical needs 
occupation according to the VA Office of Inspector General (OIG), 
recruitment and retaining of physicians are both especially 
challenging. In an FY17 report from the VA OIG, total gains in critical 
needs occupation were offset by total losses. \6\ As you all are 
acutely aware, the VA is facing many staffing challenges.
---------------------------------------------------------------------------
    \6\ Department of Veterans Affairs Office of the Inspector General. 
(2017, September). OIG Determination of VHA Occupational Staffing 
Shortages FY2017. Retrieved from https://www.va.gov/oig/pubs/VAOIG-17-
00936-385.pdf
---------------------------------------------------------------------------
    In a 2017 Government Accountability Office (GAO) report about 
physician staffing at the VHA, the GAO identified incomplete data 
issues which prevented the VHA to accurately count the number of 
physicians who provide care at VA Medical Centers. This report also 
identifies that the VHA is unable to estimate their own staffing 
shortages due to data collection issues. \7\ However, the United States 
overall will face a physician shortage of between 40,000 and 104,000 by 
2030, according to the Association of American Medical Colleges. \8\ 
Even though the VA's share of that immense shortage is unknown, Members 
of Congress must be able to craft creative solutions to make a dent in 
those enormous numbers.
---------------------------------------------------------------------------
    \7\ U.S. Government Accountability Office. (2017, October 19). 
Veterans Health Administration: Better Data and Evaluation Could Help 
Improve Physician Staffing, Recruitment, and Retention Strategies. 
Retrieved from https://www.gao.gov/products/GAO-18-124
    \8\ Research Shows Shortage of More than 100,000 Doctors by 2030. 
(2017, March 14). Retrieved from https://news.aamc.org/medical-
education/article/new-aamc-research-reaffirms-looming-physician-shor/
---------------------------------------------------------------------------
    Creating a pipeline of physicians with veteran specific exposure at 
an early point in medical training is incumbent upon us as 
policymakers. As health professionals serving within the VHA are well 
aware, men and women who have served in the armed forces have specific 
medical needs such as exposure-based conditions and mental health 
issues.
    A deeper understanding of veterans' specific health needs and 
experiences is critical for these health professionals. This pilot 
program has great potential to train the next generation of VHA 
physicians. Our number one priority is to ensure that our veterans, 
those who have sacrificed so much for their country, receive high 
quality health care from highly trained physicians. We have a 
responsibility as Members of Congress to guarantee that health 
professionals who serve those who served us, are highly trained in 
practicing medicine and in veteran centered care.
    Thank you again for inviting me to testify regarding H.R. 2787, the 
VET MD Act. This legislation will allow the VA to create a pilot 
program for pre-med students to gain the observation experience they 
need to become qualified medical school applicants. I look forward to 
working with you to move this bill forward and am happy to answer any 
questions you may have.

                                 
                  Prepared Statement of Roscoe Butler
    Chairman Dunn, Ranking Member Brownley and distinguished members of 
the Subcommittee on Health; on behalf of National Commander Denise H. 
Rohan and The American Legion, the country's largest patriotic wartime 
veterans service organization, comprising over 2 million members and 
serving every man and woman who has worn the uniform for this country, 
we thank you for the opportunity to testify on the following pending 
and draft legislation.

H.R. 2787 - Veterans-Specific Education for Tomorrow's Medical Doctors 
    Act

    To establish in the Department of Veterans Affairs a pilot program 
instituting a clinical observation program for pre-med students 
preparing to attend medical school.

    The American Legion is deeply troubled by the Department of 
Veterans Affairs (VA) leadership, physicians and medical specialist 
staffing shortages within the Veterans Health Administration (VHA). 
Since the inception of our System Worth Saving program in 2003, The 
American Legion has identified, and reported staffing shortages at 
every VA medical facility and reported these critical deficiencies to 
Congress, the VA Central Office (VACO), and the President of the United 
States.
    In 2018, VA reported there were more than 33,000 full-time 
vacancies. \1\ Many of these vacancies included hard-to-fill clinical 
positions, as well as occupations identified under 38 U.S.C. 7412. 
These findings were reinforced by a VA's Office of Inspector General 
(VAOIG) report determining the largest critical need occupations are 
medical officers, nurses, psychologists, physician assistants, and 
medical technologists. \2\ The VA needs to identify and attract as many 
qualified candidates as possible as soon as possible.
---------------------------------------------------------------------------
    \1\ VA Vacancies - https://www.washingtonpost.com/world/national-
security/trump-says-veterans-wait-too-long-for-health-care-vas-33000-
vacancies-might-have-something-to-do-with-that/2018/04/10/d20bc890-
3ccf-11e8-974f-aacd97698cef--story.html?noredirect=on&utm--
term=.58facbebf668
    \2\ VAOIG Report 17-00936-835
---------------------------------------------------------------------------
    This bill requires the Secretary of the Department of Veterans 
Affairs to carry out a pilot program to provide undergraduate students 
a clinical observation experience at VA medical centers.
    Currently, VHA provides care at more than 1,233 healthcare 
facilities, including 168 VA medical centers and 1,063 VHA outpatient 
clinics. \3\ The American Legion believes access to basic healthcare 
services, offered by qualified providers, should be broadly available 
and staffed with the best personnel. Establishing a clinical 
observation program for premedical students preparing to attend medical 
school can serve as a recruiting tool to attract individuals who may 
not have considered VHA. VA recognizes the value of such programs as 
they already conduct the largest education and training programs for 
health professionals in the United States. \4\ VA has affiliations with 
more than 1,800 educational institutions; more than 70 percent of all 
doctors in the U.S. have received training in the VA healthcare system. 
\5\
---------------------------------------------------------------------------
    \3\ VHA: Where do I get the care I need?:https://www.va.gov/health/
findcare.asp'
    \4\ VA News Release dated February 12, 2016: https://www.va.gov/
opa/pressrel/includes/viewPDF.cfm?id=2747
    \5\ Id.
---------------------------------------------------------------------------
    Through American Legion Resolutions No. 115, Department of Veterans 
Affairs Recruitment and Retention, \6\ and No. 377, Support for Veteran 
Quality of Life, we support legislation addressing recruitment and 
retention challenges, and any legislation or programs within VA that 
enhance, promote, restore or preserve benefits for veterans and their 
dependents, including, but not limited to, the following: timely access 
to quality VA health care, timely decisions on claims and receipt of 
earned benefits, and final resting places in national shrines with 
lasting tributes that commemorate their service. \7\
---------------------------------------------------------------------------
    \6\ The American Legion Resolution No. 115 (2016): Department of 
Veterans Affairs Recruitment and Retention
    \7\ The American Legion Resolution No. 377 (2016): Support for 
Veteran Quality of Life

---------------------------------------------------------------------------
    The American Legion supports H.R. 2787.

H.R. 3696 - Wounded Warrior Workforce Enhancement Act

    To require the Secretary of Veterans Affairs to award grants to 
establish, or expand upon, master's degree programs in orthotics and 
prosthetics, and for other purposes.

    The American Legion believes, due to the shortage of physicians in 
certain specialized areas, such as orthotics and prosthetics, Congress 
must ensure resources and funding are available to support their 
continued education and training. We know there will be a continual 
increasing need for clinicians at the master degree level to meet this 
demand as the number of veterans needing orthotics and prosthetics 
services increases. \8\
---------------------------------------------------------------------------
    \8\ American Orthotic and Prosthetic Association Testimony 
www.aopanet.org/wp-content/.../AOPA-VA-Health-Subcommittee-Testimony-
5.2.pdf
---------------------------------------------------------------------------
    According to May 2, 2017 testimony provided by the American 
Orthotic and Prosthetic Association, in past wars 3 percent of 
servicemembers injured required amputations in previous wars; of those 
wounded in Iraq, 6 percent have required amputations. In the year 2000, 
the VA served 25,000 veterans with amputations, according to the VHA 
Amputation System of Care figures. By 2016, that number had more than 
tripled to 89,921. Between 2008 and 2013, VA performed an average of 
7,669 new amputations for veterans every year; in 2016, the number of 
amputation surgeries rose to 11,879.
    This bill would authorize the Secretary of the VA to award grants 
to eligible institutions enabling schools to establish a master's 
degree program in orthotics and prosthetics; or to expand upon an 
existing master's degree program in orthotics and prosthetics, 
including; by admitting more students, further training faculty, 
expanding facilities, or increasing cooperation with VA and the 
Department of Defense. This Wounded Warrior Workforce Enhancement Act 
recognizes the ever-increasing need for specialists in orthotics and 
prosthetics.
    Through American Legion Resolution No. 311, The American Legion 
Policy on VA Physicians and Medical Specialist Staffing Guidelines, we 
support this bill. \9\ VA will benefit from the medical professionals 
who complete the program and continue to serve veterans at medical 
centers around the world.
---------------------------------------------------------------------------
    \9\ The American Legion Resolution No. 311 (1998): The American 
Legion Policy on VA Physicians and Medical Specialists Staffing 
Guidelines

---------------------------------------------------------------------------
    The American Legion Supports H.R. 3696.

H.R 5521 - VA Hiring Enhancement Act

    To amend title 38, United States Code, to provide for the non-
applicability of non-Department of Veterans Affairs covenants not to 
compete to the appointment of certain Veterans Health Administration 
personnel, to permit the Veterans Health Administration to make 
contingent appointments, and to require certain Veterans Health 
Administration physicians to complete residency training.

    The American Legion, as previously stated, has long expressed 
concern about staffing shortages at VA/VHA medical facilities to 
include physicians and medical specialist staffing.
    The VA Hiring Enhancement Act will help address the shortcomings in 
recruitment and retention of highly qualified physicians. The bill 
allows VA to make binding job offers up to 2 years prior to completion 
of medical residency, eliminating much of the bureaucratic red tape 
that slows the hiring of newly recruited individuals. This legislation 
allows physicians completing their education to immediately begin 
treating veterans. By allowing VA to make binding offers, veterans will 
receive treatment by qualified physicians that have completed their 
residency. This bill aligns the hiring practices of VA to those of the 
private sector ensuring top quality healthcare is provided to our 
veterans.
    Further, this bill also releases physicians from ``non-compete 
agreements'' for the purpose of serving in the VHA. The American Legion 
believes enforcing non-compete agreements to VHA hires is over-broad 
and should be unenforceable under public policy. Traditional reasoning 
behind non-compete agreements to bar competitive advantages or protect 
sensitive information simply do not exist in this context.
    Through American Legion Resolution No. 115, Department of Veterans 
Affairs Recruitment and Retention, we support legislation addressing 
the recruitment and retention challenges of the Department of Veterans 
Affairs. \10\ We support legislation that addresses pay disparities 
among physicians and medical specialists who are providing direct 
health care to our nation's veterans.
---------------------------------------------------------------------------
    \10\ The American Legion Resolution No. 115 (2016): Department of 
Veterans Affairs Recruitment and Retention

---------------------------------------------------------------------------
    The American Legion supports H.R. 5521.

H.R. 5693 - Long-Term Care Veterans Choice Act

    To amend title 38, United States Code, to authorize the Secretary 
of Veterans Affairs to enter into contracts and agreements for the 
placement of veterans in non-Department medical foster homes for 
certain veterans who are unable to live independently.

    Veterans Health Administration directive provides specific policy 
and guidance for establishing and operating a Medical Foster Home (MFH) 
Program under the standards of the Department of Veterans Affairs 
Community Residential Care (CRC) Program, of which it is a sub-
component. Medical Foster Homes serve as an alternative to nursing home 
care for veterans unable to live without day-to-day assistance, while 
also providing a non-institutional setting with fewer residents.
    Currently, veterans enrolled in Home Based Primary Care through the 
VA may elect to receive their care at MFHs. However, veterans eligible 
for nursing home care through the VA are not eligible to receive their 
care at MFHs, nor does the VA cover the cost of these living 
arrangements. Instead, these veterans must pay for MFH services out of 
pocket or through private insurance. Costs associated with MFH services 
are significantly lower than what the VA would otherwise pay per 
patient at a state VA nursing home.
    This bill would require the Secretary of the VA, beginning on 
October 1, 2019, to provide nursing home care under section 1710A, at 
the request of a veteran. The Secretary may then place the veteran in a 
medical foster home that meets Department standards, at the expense of 
the United States, pursuant to a contract or agreement entered into 
between the Secretary and the medical foster home for such purposes. A 
veteran who is placed in a medical foster home under this authority 
shall agree, as a condition of such placement, to accept home health 
services furnished by the Secretary under title 38 U.S.C. 1717.
    Medical Foster Homes are private homes in which a caregiver 
provides services to a small group of individuals who are unable to 
live without day to day assistance. MFHs are an alternative to nursing 
homes for those who require nursing home care but prefer a non-
institutional setting with fewer residents. When one or more eligible 
veterans reside in a MFH, the VA ensures that the MFH caregiver is 
well-trained to provide VA planned care.
    Allowing veterans to exercise greater flexibility over their 
benefits ensures that their individual needs are best met. This 
legislation offers a cost-saving alternative to nursing home care, 
while providing veterans with more personal, quality health services. 
This is reflective of our overall effort to provide veterans with 
greater choice and freedom over their benefits while preserving the VA 
system.
    Through American Legion Resolution No. 114, Department of Veterans 
Affairs Provider Agreements with Non-VA Providers, we support 
legislation allowing the Department of Veterans Affairs to enter into 
provider agreements with eligible non-VA providers to obtain needed 
healthcare services for the care and treatment of eligible veterans. 
\11\ The VA must be authorized to obtain healthcare services from non-
VA providers, particularly when it is most effective for the veteran 
and the taxpayer.
---------------------------------------------------------------------------
    \11\ The American Legion Resolution No. 114 (2016): Department of 
Veterans Affairs Provider Agreements with Non-VA Providers

---------------------------------------------------------------------------
    The American Legion supports H.R. 5693.

H.R. 5864 - VA Hospitals Establishing Leadership Performance Act

    To direct the Secretary of Veterans Affairs to establish 
qualifications for the human resources positions within the Veterans 
Health Administration of the Department of Veterans Affairs, and for 
other purposes.

    The provisions in this bill fall outside the scope of established 
resolutions of The American Legion. The American Legion does not have a 
resolution that addresses qualification standards and performance 
metrics for VHA human resource positions. As a large, grassroots 
organization, The American Legion takes positions on legislation based 
on resolutions passed by our membership. With no resolutions addressing 
the provisions of the legislation, The American Legion is researching 
the material and working with our membership to determine the course of 
action that best serves veterans.

    The American Legion has no position on H.R. 5864.

H.R. 5938 - Veterans Serving Veterans Act of 2018

    To amend the VA Choice and Quality Employment Act to direct the 
Secretary of Veterans Affairs to establish a vacancy and recruitment 
database to facilitate the recruitment of certain members of the Armed 
Forces to satisfy the occupational needs of the Department of Veterans 
Affairs, to establish and implement a training and certification 
program for intermediate care technicians in that Department, and for 
other purposes.

    On August 12, 2017, Congress passed and the President signed into 
law, Public Law 115-46, the VA Choice and Quality Employment Act of 
2017. This law established a recruiting database covering every vacancy 
in VA, with the ability to select applicants for positions other than 
the one for which they originally applied. The Veterans Serving 
Veterans Act of 2018 will expand the existing database to include 
members of the Armed Forces in the talent pool to meet the Department's 
occupational needs.
    The American Legion strives to ensure our veterans and their 
families receive the support and recognition they deserve. Every member 
of our organization is a wartime veteran, so we understand the value of 
our fellow citizens' support during and after our military service. 
Saying thank you is only the beginning of how we should honor America's 
newest generation of warriors and veterans. This bill recognizes 
servicemembers require continued support and recognition of their 
unique skills and needs.
    The database, to be known as the Recruitment Database of the 
Department of Defense and the Department of Veterans Affairs, would 
provide the military occupational specialty or skills that corresponds 
to each vacant position, in consultation with the Secretary of the 
Department of Defense, as well as with each qualified member of the 
Armed Forces who could be recruited to fill the position before their 
separation from active service. This bill would require the Secretary 
of the VA to implement direct procedures for hiring and appointment for 
the vacant positions that appear in the database for qualified members 
of the Armed Forces that apply to these positions.
    Further, The Veterans Serving Veterans Act of 2018 also requires 
the Secretary of VA to implement a program to train and certify covered 
veterans to work as Intermediate Care Technicians (ICTs) in the 
Department. A ``covered veteran'' will be defined as a veteran who the 
Secretary determines served as a basic health care technician while 
serving in the Armed Forces. This recognizes our warfighters within all 
branches of the Armed Forces with training and experience in medical 
care, but do not have a civil certification to continue providing these 
services once they are separated from the military.
    The American Legion has long recognized the need for certification 
of skills earned in the military since it championed the Veterans 
Skills to Jobs Act, signed into law in 2012. Legionnaires at the state 
and post levels have, and will continue to demand their legislatures 
and general assemblies pass new licensing and credentialing laws in 
their states affirming skills of separating servicemembers. The 
economics are easy to understand. The military and the taxpaying public 
have already paid for these veterans to be trained. Forcing veterans to 
spend taxpayer-funded education benefits on certification classes is 
the equivalent of paying them to be trained twice, and it places an 
unnecessary burden on veterans trying to make the transition to 
civilian careers.
    Through American Legion Resolution No. 115, Department of Veterans 
Affairs Recruitment and Retention, we support legislation addressing 
the recruitment and retention challenges of the Department of Veterans 
Affairs. \12\ We support legislation calling on VA to work more 
comprehensively with community partners when struggling to fill 
critical shortages within VA's ranks. Adding qualifying members of the 
Armed Forces who may be recruited to fill positions in the VA before 
the member of the Armed Forces has been discharged and released from 
active duty fulfils these criteria as well as supports our nation's 
warfighters transitioning out of the military.
---------------------------------------------------------------------------
    \12\ The American Legion Resolution No. 115 (2016): Department of 
Veterans Affairs Recruitment and Retention

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    The American Legion supports H.R. 5938.

H.R. 5974 - VA COST SAVINGS Enhancement Act

    To direct the Secretary of Veterans Affairs to use on-site 
regulated medical waste treatment systems at certain Department of 
Veterans Affairs facilities, and for other purposes.

    The provisions in this bill fall outside the scope of established 
resolutions of The American Legion. The American Legion does not have a 
resolution that addresses on-site regulated medical waste treatment 
systems at certain Department of Veterans Affairs facilities. As a 
large, grassroots organization, The American Legion takes positions on 
legislation based on resolutions passed by our membership. With no 
resolutions addressing the provisions of the legislation, The American 
Legion is researching the material and working with our membership to 
determine the course of action that best serves veterans.

    The American Legion has no position on H.R. 5974.

Draft Bill

    To amend title 38, United States Code, to improve the productivity 
of the management of Department of Veterans Affairs health care, and 
for other purposes.

    The provisions in this bill fall outside the scope of established 
resolutions of The American Legion. The American Legion does not have a 
resolution that addresses this issue. As a large, grassroots 
organization, The American Legion takes positions on legislation based 
on resolutions passed by our membership. With no resolutions addressing 
the provisions of the legislation, The American Legion is researching 
the material and working with our membership to determine the course of 
action that best serves veterans.

    The American Legion has no position on the Draft Bill.

Conclusion

    Chairman Dunn, Ranking Member Brownley and distinguished members of 
this critical Committee, The American Legion thanks this Subcommittee 
for the opportunity to elucidate the position of our 2 million veteran 
members of this organization. For additional information regarding this 
testimony, please contact Assistant Director of the Legislative 
Division, Larry Lohmann, at (202) 861-2700 or [email protected]

                                 
               Prepared Statement of Jeremy M. Villanueva
    Mr. Chairman and Members of the Subcommittee:

    Thank you for inviting DAV (Disabled American Veterans) to testify 
at this legislative hearing of the Subcommittee on Health of the House 
Veterans' Affairs Committee. As you know, DAV is a non-profit veterans 
service organization comprised of more than one million wartime 
service-disabled veterans that is dedicated to a single purpose: 
empowering veterans to lead high-quality lives with respect and 
dignity. DAV is pleased to offer our views on the bills under 
consideration by the Subcommittee.

H.R. 2787, the Veterans-Specific Education for Tomorrow's Medical 
    Doctors Act or VET MD Act

    H.R. 2787 would establish a three-year pilot project instituting a 
clinical observation program for students enrolled in a ``pre-med'' or 
science curriculum who plan to attend medical school. Students would 
spend a certain number of hours observing a practicing physician to 
expose the student to a variety of health care experiences. The pilot 
would be established at no fewer than five Department of Veterans 
Affairs (VA) medical centers. The goal of the pilot is to increase 
awareness among America's future physicians related to veterans' 
issues. It is also intended to raise cultural awareness and sensitivity 
in addressing their specific health care concerns, as well as engender 
interest in pursuing medical careers, in general, and particularly, 
within the Department, in these students. Following the program, 
participants would be asked to fill out a ``reflection'' survey, 
developed by VA, about their experience.
    Mr. Chairman, DAV has no resolution on the development of such a 
program within VA, but believes the intent of this legislation is in 
keeping with the goals of developing a more robust field of candidates 
for medical professions employed by the VA and ensuring more medical 
professionals in the community have some awareness and understanding of 
veterans' unique medical issues. We therefore have no objection to this 
legislation's favorable consideration.

H.R. 3696, the Wounded Warrior Workforce Enhancement Act

    H.R. 3696 would require the VA Secretary to award grants to 
educational institutions of $1 million to $1.5 million to create or 
expand master's degree programs in orthotics and prosthetics. An 
appropriation of $15 million would be made available through the end of 
fiscal year (FY) 2020 with unexpended obligations returned to the U.S. 
Treasury at that time. Initially, VA would be required to establish a 
request for proposal for awarding these grants. Only educational 
institutions that have accreditation by the National Commission of 
Orthotic and Prosthetic Education and ones that demonstrate the ability 
to meet accreditation requirements would be eligible to receive grants. 
Priority for grants would be given to programs that establish clinical 
rotations with the VA. The Secretary may also require an institution to 
demonstrate its commitment to continue the program after the VA grant 
expires. Finally, the bill would require the Secretary to award a grant 
of $5 million to establish a Center of Excellence in Orthotic and 
Prosthetic Education in the private sector.
    DAV notes the need to develop additional orthotic and prosthetic 
expertise in the private sector based on the Bureau of Labor Statistics 
projection of a 22 percent growth in need for these professionals 
between 2016 and 2026 due to the aging of ``baby boomers'' who are 
prone to diabetes and cardiovascular conditions that may cause limb 
loss and be in need of these specialized services.
    However, the Veterans Health Administration (VHA) is not reporting 
difficulty in recruiting or retaining orthotists and prosthetists and 
notes its training capacity (about 20 residents in 2017) is adequate to 
serve the needs of the Department. In contrast, the Department does 
have notable shortages in medical officers, nurses, psychologists and 
medical clerks. Dedicating $15 million to train students who will 
primarily provide care to patients outside of VA may further impair 
VHA's ability to hire more in demand care providers. Additionally, VA 
currently has five centers of excellence in prosthetic research 
associated with academic affiliates which creates a number of 
opportunities for interns and students from affiliated institutions to 
provide care to veterans in VA.

    For these reasons, DAV is unable to support H.R. 3696 at this time.

H.R. 5521, the VA Hiring Enhancement Act

    H.R. 5521, the VA Hiring Enhancement Act, would render ``non-
compete'' agreements between an applicant for VA employment and a 
previous employer non-applicable with regard to VA employment. 
Employees appointed with this understanding would be required to serve 
out the length of their non-compete agreement within their VA position 
or serve in that position for at least one year (whichever is longer). 
The bill intends to allow VA, on a contingent basis, to begin 
recruiting and hiring physicians up to two years before they complete 
their residency, as well as physicians who have completed their 
residencies leading to board certification. These contingent appointed 
physicians must satisfy VA's requirements to receive a permanent 
appointment.
    DAV fully supports efforts to recruit, retain and develop a skilled 
clinical workforce to meet the needs of veterans. We appreciate the 
goal of this legislation aimed at creating as large an applicant pool 
for qualified medical professionals to treat our service disabled 
veterans as possible in VA. DAV Resolution No. 228 calls for effective 
recruitment, retention and development of the VA health care workforce. 
Because this measure attempts to reduce barriers for employment at VA 
for physicians; we are pleased to support the bill's passage.

H.R. 5693, the Long-Term Care Veterans Choice Act

    In accordance with DAV Resolution No. 227, calling for legislation 
to improve the comprehensive program of long-term services and supports 
for service-connected disabled veterans regardless of their disability 
ratings, DAV supports this measure.
    If enacted, this measure (H.R. 5693) would provide veterans who are 
no longer capable of living independently an alternative to nursing 
home care, in which the veteran would continue to receive the care that 
they need in an intimate home-like environment through VA's Home-Based 
Primary Care program, and the Medical Foster Home (MFH) attendant. 
Medical Foster Homes are a type of Community Residential Care by which 
veterans with serious chronic disabling conditions requiring nursing 
home level care and coordination of services are able to receive these 
services in a non-institutional setting. Patient participation in the 
MFH program is voluntary and veteran residents report very high 
satisfaction ratings.
    Currently, the administrative costs for VA per veteran in the MFH 
program, including the cost of Home Based Primary Care, medications and 
supplies average less than $63 per day. However, veterans who qualify 
for nursing home care fully paid for by the government, must pay the 
full cost for room, board, and personal assistance out of their own 
pocket, which averages to be about $110 per day to live in a MFH.
    Veterans who wish to reside in a Medical Foster Home but are unable 
to pay approximately $1,500 to $3,000 per month are not able to avail 
themselves of this benefit, so many are placed in nursing homes at much 
greater cost to VA. This measure would address this inequity by giving 
VA a three-year authority to pay for veterans, who would qualify for 
VA-paid nursing home care placement, so they can reside in a VA-
approved MFH.
    As the veteran population continues to age, the need for long-term 
care services will continue to grow. Home-based community programs like 
MFHs will enable VA to meet the needs of aging veterans in a manner 
closer to independent living than institutionalized care. With the 
passage of this bill, veterans would have the option of care that more 
closely aligns with their independence while maintaining their quality 
of life.

H.R. 5864, to direct the Secretary of Veterans Affairs to establish 
    qualification for the human resources positions within the Veterans 
    Health Administration

    H.R. 5864, the VA Hospitals Establishing Leadership Performance Act 
would require the Secretary of Veterans Affairs to establish 
qualifications and standardized performance metrics for each human 
resources position within the Veterans Health Administration within 180 
days of enactment. Upon establishing such qualifications and 
standardized performance metrics for these positions, VA would be 
required to submit a report to Congress. The Comptroller General would 
then be required to submit a report describing implementation of the 
qualifications and performance metrics and assess the quality of such 
measures within 180 days.
    DAV supports this legislation in accordance with DAV Resolution No. 
228, which calls for a simple-to-administer alternative VHA personnel 
system, in law and regulation, which governs all VHA employees, applies 
best practices from the private sector to human capital management, and 
supports pay and benefits that are competitive with the private sector 
and DAV Resolution No. 221, which supports VA's use of meaningful and 
clearly articulated measures to gauge employees' performance.
    VA acknowledges the need for reforming its human capital management 
system, but leadership has not always provided strong guidance, 
oversight or resource support to carry out such reforms. VA's human 
capital management is also hampered by the Department's current IT 
systems that provide organizational data and by its real and perceived 
need to comply with a collection of byzantine laws, regulations, and 
internal policies that guide its functions.
    In VA's latest Strategic Plan, it states: ``A robust human capital 
management capability is paramount to VA's ability to effectively and 
efficiently employ its workforce in service to Veterans.'' \1\ The plan 
identifies several strategies to modernize its human capital management 
capabilities objective including:
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    \1\ Department of Veterans Affairs: Strategic Plan 2018-2024. P. 30

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    1.Standardize Human Capital Policies Enterprise-wide

    2.Improve Staffing to Ensure a Qualified VA Workforce is in Place

    3.Improve Leadership and Workforce Competency

    4.Institute Manpower Management to Optimize VA Human Capital 
Resources

    Many organizations have opined about improving VA's competency and 
performance of human resources staff including the Commission on Care, 
the Government Accountability Office and the CMS Alliance to Modernize 
Healthcare Federally Funded Research and Development Center who 
produced the Congressionally mandated Independent Assessment of the 
Health Care Delivery Systems and Management Processes of the Department 
of Veterans Affairs. All indicate that system-wide improvement requires 
systemic change which would fundamentally alter the current operations, 
leadership, and inputs (including informatics and policy guidance) of 
the current human capital management system.
    DAV believes H.R. 5864 offers a good starting point for the 
fundamental overhaul of VA's human capital management system needed 
within the Department, but it is just a start. While standardized 
position descriptions with corresponding performance measures must be 
developed, VA also needs to ensure that it streamlines and simplifies 
policies surrounding such practices as recruitment and hiring. It must 
create specialists within the system who are informed by best practices 
in such functional areas as recruitment, retention, staff development, 
employee benefits, and performance management as well as expertise in 
important clinical staff professions such as doctors, nurses, allied 
health professionals and clinical support staff.
    As long as VA must work with four personnel hiring authorities, 
each with its own requirements, specialists within VA's Central Office 
or the VISN must understand the intricacies of each. These specialized 
experts can serve as consultants to field level specialists who are 
actually performing the functions. VA human resources professionals 
will certainly require better informatics and many may require training 
to overcome deficits in core competencies to meet the minimal 
qualifications of new position descriptions. Most importantly, Human 
Capital Management Reform will require a long-term commitment from VA's 
leadership and Congress. The core position descriptions developed under 
H.R. 5864 will not be valuable if VA is unable to hire or develop the 
human talent necessary to fill these positions.
    Congress should maintain oversight and continue to work on ways to 
simplify personnel policies and procedures for the Department, 
including working toward a system that administers personnel matters 
under a single system and is driven by best practices within the 
federal government and private sector. This will limit the need for 
expertise in so many systems and may make VA more responsive to market 
factors that affect hiring and retaining the best talent. Only when a 
systemic approach to reform is taken, will VA be able to optimize human 
capital management to identify more effective ways to use its scarcest 
resource-well trained and compassionate people who effectively provide 
care to our nation's veterans.

H.R. 5938, the Veterans Serving Veterans Act

    This bill would establish a vacancy and recruitment database to 
facilitate the recruitment of certain members of the Armed Forces to 
satisfy the occupational needs of the VA and establish a training and 
certification program for intermediate care technicians within the 
Department. We support H.R. 5938 based on DAV Resolution No. 228, which 
calls for effective recruitment, retention and development efforts 
within VA.
    This bill also recognizes the service member's military vocational 
training as being valuable in the civilian workforce. DAV Resolution 
No. 248 calls for the elimination of employment barriers that impede 
the transfer of occupations to the civilian labor market. This bill is 
in the spirit of that goal.
    DAV and our Independent Budget (IB) partners have also urged 
Congress to support improvements to the VA's human capital management 
systems by providing the necessary funding and authorities to implement 
system reform and for VA to utilize the broad-based recruitment and 
employment incentives available in order to attract workforce talent 
and to remain competitive in various workforce markets.
    The IB partners acknowledge that VA's HR system is complicated and 
therefore demands a holistic approach to workforce development that 
allows VA to recruit, train, and retain a high-quality workforce of 
talented and compassionate professionals capable of caring for our 
veterans, while simultaneously ensuring that VA has the authority to 
properly reward and hold employees accountable. This must include 
acknowledging that employee experience is equally vital to its 
transformation efforts. If Congress is intent on helping VA transform 
its culture and workforce, we suggest the Department is provided the 
leverage to hire employees more quickly and offer compensation that is 
competitive and commensurate with their skill levels.
    In addition, it should be noted that this bill could help the 
transition process from military to civilian life, a process that can 
be difficult for many separating service men and women. By allowing the 
VHA to directly hire separating service members, it allows the 
Department to inquire about an applicant's skills and qualifications 
that would likely otherwise go unnoticed in the current process and 
would provide the veteran employment from day one aiding in a 
successful transition from military to civilian life.
    With passage of this measure, Congress would ensure that the VA is 
hiring highly skilled and culturally invested applicants and would 
showcase the military as one of the nation's finest providers of 
vocational training.

H.R. 5974: The VA COST SAVINGS Enhancement Act

    The VA COST SAVINGS Enhancements Act would require VA to conduct a 
cost analysis model to determine if the installation and use of an on-
site medical waste treatment system, in selected VA medical facilities, 
will result in a cost-savings over a 5 year period.
    Currently, biohazardous medical waste, specifically items 
contaminated by body fluids and deemed potentially infectious, must be 
disposed of off-site at specially designated regional disposal centers. 
This bill proposes the use of on-site sterilization machines to compact 
``red bag'' medical waste to destroy microbial life, thus rendering the 
hazardous bio-waste material safe for routine disposal.

    DAV does not have a resolution specific to this issue and takes no 
position on the bill.

Draft bill, to improve the productivity and management of VA health 
    care facilities

    This bill would amend current law requiring the VA Secretary, in 
managing the VA health care system, to establish a new management 
authority tracking relative value units (RVU) for all VA providers, 
provide training for all VA providers on clinical procedure coding, and 
establish performance standards to evaluate clinical productivity based 
on nationally recognized RVUs for each profession and each VA medical 
facility.
    Public Law 107-135 mandated that VA establish a nationwide policy 
to ensure medical facilities have adequate staff to provide 
appropriate, high-quality care and services. In this regard, VA's 
current policy outlines productivity and staffing for Specialty Group 
Practice providers, Mental Health and Emergency Medicine. Of the total 
RVU, which consists of three components: work performed (wRVU), 
practice expense (peRVU), and malpractice (mpRVU) expense, VA's policy 
on productivity measurement only uses wRVU, which is perhaps the best 
known and most-often utilized RVU component. When VA specialty provider 
group practices are out of production range for its specialty and peer 
grouping, remediation plans are required to be developed, reviewed, 
receive concurrence from leadership, and implemented to improve 
specialty physician group practice productivity.

    Previous testimony before this Subcommittee on factors affecting 
clinical productivity noted the following:

    1)The number of patients assigned to VHA general primary care 
providers is 12 percent lower than the private sector benchmark for 
patients of a similar acuity.

    2)With respect to specialty providers, [ ] analysis shows that VHA 
specialists are less productive than their private sector counterparts 
on two industry measures - encounters and work relative value units 
(wRVUs). Many specialties fall in the 50th percentile of private sector 
providers; others are as low as the 25th percentile. However, when 
encounters (visits) are used as a measure, the gap shrinks and VHA 
specialty care compares more favorably to the private sector. In a 
system as large and varied as VHA, we did find variation in the 
relative productivity of providers. For instance, specialty care 
providers at the most complex facilities were found to be more 
productive than their peers, and the most productive VHA providers 
(those at the 75th percentile of VHA providers) are often more 
productive than the private sector. Mental health provider productivity 
at VHA was calculated to be in the 100th and 72nd percentiles as 
measured by both wRVUs and encounters, compared to industry benchmarks.

    Because relative value units may not capture other factors that 
impact health care productivity (compared to the private sector, VA 
providers have a lower room-to-patient ratio and have significantly 
fewer nurses and administrative support staff), we urge the 
Subcommittee consider these proximate factors in requiring VA to track 
productivity. VA's own management tool, the Specialty Productivity 
Access Report and Quadrant, recognizes this in part by including some 
support staff ratios in assessing productivity and staffing standards. 
Supporting infrastructure issues are addressed in remediation plans.
    Moreover, recognizing the methods to measure and determine 
productivity, budgeting, allocating expenses, and cost benchmarking 
continue to evolve, as well as VA's work to address four 
recommendations in the June 23, 2017, Government Accountability Report, 
we recommend the Subcommittee consider under paragraph 2 to include 
subparagraph ``(c) other productivity measures and models determined 
appropriate by the Secretary.''
    Finally, we recommend the Subcommittee make clear whether the 
remediation plan required by this bill is intended to affect the 
remediation plan in Section 109 of S. 2372, the John S. McCain III, 
Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems 
and Strengthening Integrated Outside Networks Act of 2018 or the VA 
MISSION Act of 2018.
    Mr. Chairman, we must acknowledge that the VA health care system is 
unlike most private sector health care systems in that its resources 
are distributed by a capitation system to more equitably allocate funds 
across a health care system that spans this nation and its territories. 
While all funding models have strength and weaknesses, in a capitation 
model there is strong incentive to conserve resources to focus more on 
value than volume unlike fee schedule or other retrospective payment 
models.
    Policy proposals to manage inpatient and outpatient clinical 
productivity in such a health care system must recognize and work 
within these specific operating environments to achieve the appropriate 
balance of efficiency and effectiveness while preserving the high 
quality care VA provides to our nation's ill and injured veterans.
    This concludes my testimony, Mr. Chairman. DAV would be pleased to 
respond for the record to any questions from you or the Subcommittee 
Members concerning our views on these bills.

                                 
                  Prepared Statement of Kayda Keleher
    Chairman Wenstrup, Ranking Member Brownley, and members of the 
Subcommittee, on behalf of the women and men of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to provide our remarks on legislation pending before this 
Subcommittee.

H.R. 2787, Veterans-Specific Education for Tomorrow's Medical Doctors 
    Act or the VET MD Act

    The VFW supports the Veterans-Specific Education for Tomorrow's 
Medical Doctors Act, with suggestions to improve the legislation. This 
legislation would mandate VA carry out a pilot program at no less than 
five Department of Veterans Affairs (VA) facilities to provide a 
diverse selection of undergraduate students with clinical observation 
experience. The goals of this clinical observation pilot would be to 
increase awareness and knowledge of veterans' health care of future 
medical professionals and increase the diversity of future medical 
professionals.
    While VA facilities across the country are already allowing 
students to observe clinical hours, this program would be a practical 
way to expand this practice. The VFW also finds it to be valuable that 
the legislation includes consideration of areas with staffing shortages 
within VA, in an attempt to hopefully later recruit new providers. 
However, the VFW would find this to be more advantageous if the 
language also included projected staffing shortages within VA. The VFW 
suggests including veterans as a priority along with those who live in 
an area with a shortage of health care professionals and/or are first 
generation college students.
    The VFW also suggests more precisely defining the term ``timely 
manner'' under ``Other Matters'' regarding the notification to 
Congress, as the term can be too loosely defined and may result in 
Congress receiving notification at a much slower rate than intended. 
Lastly, the VFW recommends including metrics to determine how many 
students who took part in the program go on to a graduate medical 
program for fields determined to have a staffing shortage within VA.

H.R. 3696, Wounded Warrior Workforce Enhancement Act

Section 2

    The VFW agrees with the intent of this section, but cannot support 
the language as written. This section would mandate that VA provide 
grants to research programs with orthotic and prosthetics education 
programs accredited by the National Commission on Orthotic and 
Prosthetic Education in cooperation with the Commission on 
Accreditation of Allied Health Education Programs.
    One of VA's four statutory missions is to educate and train health 
professionals to enhance the quality of care provided to veteran 
patients within VA. This is accomplished through coordinated programs 
and partnerships with affiliated academic institutions.
    The Wounded Warrior Workforce Enhancement Act would not require any 
form of partnership, yet would provide millions of dollars in grants 
for non-VA institutions to expand, build, supplement salaries, provide 
financial aid, or purchase equipment for graduate level orthotic and 
prosthetics programs for very specifically defined institutions. While 
the language does state that schools that are partnered with VA would 
be prioritized for grants, and schools that apply must show a 
willingness to participate; that is not enough. The VFW believes this 
must be tied back to delivery of care for veteran patients within VA. 
If VA is to fund grants such as this, veterans must see a positive 
outcome from which they can benefit.

Section 3

    The VFW opposes this section, which would require VA to provide a 
grant to build a non-VA center of excellence for orthotics and 
prosthetics at a graduate orthotic and prosthetics program accredited 
by the National Commission on Orthotic and Prosthetic Education in 
cooperation with the Commission on Accreditation of Allied Health 
Education Programs. Aside from the same concerns as in Section 2 
regarding the lack of partnership or contracts with VA, this section 
would ultimately require VA to fund this non-VA entity that is not only 
unnecessary as VA and the Department of Defense (DOD) lead the way in 
orthotics and prosthetics, but would again have no direct tie to care 
provided to veterans.
    It is imperative that America's providers are able to treat 
patients for orthotics and prosthetics. There are currently five 
Polytrauma Rehabilitation Centers and 21 Polytrauma Network Sites 
within VA--that does not include the Polytrauma Support Clinic Teams, 
Polytrauma Points of Contact or Department of Defense prosthetic 
centers of excellence and other clinics. With this in mind, the VFW 
cannot justify outsourcing valuable VA resources to bolster a non-VA 
entity that would not benefit veterans. The grant for this program, 
which would be substantial, would again be eligible for use toward 
training, salary supplementation, financial aid, building renovations 
and equipment purchases.

H.R. 5521, VA Hiring Enhancement Act

Section 2

    The VFW supports this section which would remove barriers for 
employment of health care providers who were required to sign a non-
compete contract with previous employers. By removing this barrier more 
medical professionals who want to treat veterans would be able to 
pursue a career at VA medical facilities.

Section 3

    This section would require VA to hire health care providers who are 
board eligible. The Choice Act required VA's Office of Inspector 
General to annually determine the top five hiring shortages. Since this 
enactment in 2014, medical officers have been ranked as the number one 
staffing need within VA. With nearly 38,000 current job vacancies 
within VA, the VFW cannot support limiting VA's hiring pool.
    As determined by studies such as Comparing VA and Non-VA Quality of 
Care: A Systematic Review, published by the RAND Corporation in the 
Journal of General Internal Medicine, 2016, VA either outperforms or 
performs on par with non-VA care. So while this legislation is intended 
to limit applications to the most highly qualified, the VFW feels this 
is not a necessary precaution at this time.
    Lastly, this section's attempt to provide VA the authority to hire 
residents is redundant with current law. In Section 206 of VA Choice 
and Quality Employment Act of 2017 the secretary received authority to 
hire students and recent graduates.

H.R. 5693, Long-Term Care Veterans Choice Act

    The VFW supports this legislation which would authorize VA to enter 
into contract agreements for non-VA medical foster homes. By expanding 
this option of long-term care to veterans who are unable to live 
independently but do not want to be institutionalized, Congress would 
be providing veterans with the ability to receive the care they need 
while also maintaining a higher quality of life. The VFW urges Congress 
to pass this legislation, which would provide more options for veterans 
to decide what form of long-term care is right for them.

H.R. 5864, VA Hospitals Establishing Leadership Performance Act

    The VFW supports this legislation which would establish 
qualifications for human resources positions within the Veterans Health 
Administration. In doing so, this legislation would assure standardized 
performance metrics and require VA to report the established 
qualifications and metrics, as well as the implementation and quality 
of the metrics.

H.R. 5938, Veterans Serving Veterans Act of 2018

    The VFW agrees with the intent of this draft legislation, but has 
very serious concerns with its impact on privacy. This draft 
legislation would establish a vacancy and recruitment database to 
facilitate recruitment of members of the armed forces to fill open 
positions within VA.
    Requiring VA and DOD to work together to establish a functional and 
correct database of individuals actively serving in the military with 
military occupational specialties that would link individuals with 
corresponding vacant positions within VA, would require excessive 
amounts of time, funding and technology. While the desired goal of 
filling desperately needed positions is commendable, establishing a 
database is neither realistic nor the right way to do it.
    The VFW also has concern with how this legislation would allow 
those in the armed forces to elect not to be listed in the database, 
but requires the member to submit this request in writing with no other 
options or outreach directive to assure they are properly notified of 
this option. Once on the list, the secretary of VA would have authority 
to determine who within the department has access to the information. 
These options are listed as offices, officials and employees. The VFW 
believes that VA must be more selective with who has access to the 
name, contact information and other personal information of 
transitioning service members.

H.R. 5974, Department of Veterans Affairs Creation of On-Site Treatment 
    Systems Affording Veterans Improvements and Numerous General Safety 
    Enhancements Act

    The VFW supports this legislation which would direct VA to use on-
site regulated medical waste treatment systems. At this point in time, 
most VA facilities are contracting out medical and biohazardous waste 
disposal. These contracts come with a high price tag and require the 
transportation of infectious waste such as blood, microbiological 
cultures, body parts, used dressings and more. In areas where it would 
result in cost savings, there is absolutely no reason why VA should not 
be discarding their own medical waste instead of using contractors.

Draft Legislation to improve productivity of the management of 
    Department of Veterans Affairs health care, and for other purposes.

    The VFW agrees with the intent of this draft legislation but has 
some concerns that must be addressed before we are able to support. 
This legislation would require VA to reports its relative value units 
(RVUs). RVUs are a national standard used for determining budget, 
expenses, cost benchmarking and productivity, which was first 
introduced by the American health care systems by Centers for Medicare 
and Medicaid Services in 1992. While the private sector has found RVUs 
to be statistically reliable, they are at times flawed - and 
predominantly used to determine provider payments.
    There would most certainly be value to tracking RVUs and the levels 
of productivity within VA. The VFW believes it would provide data 
showcasing that as funding increases within VA, so does productivity. 
With this said, there are still concerns regarding comparison to the 
private sector and maintaining the level of care that veterans prefer.
    The private sector is not required to make data publicly available 
the way VA is required, which at times causes an unsettling double 
standard. VFW members report in surveys time and time again that one of 
the reasons they prefer VA is due to increased face time with their 
providers. VA providers typically spend more time with patients, which 
leads to higher patient satisfaction and better quality care. Veteran 
patients who use VA are also statistically sicker than patients who do 
not use VA. This requires more time between patients and their 
providers. These and other factors are not reflected in RVUs. The VFW 
is grateful this legislation would take into account non-clinical 
duties, as VA providers conduct more research and training than private 
sector providers. However, the VFW would like to know how Congress 
intends to use RVUs before supporting this bill. The VFW warns against 
basing legislation or appropriations on how VA RVUs compare to private 
sector RVUs. Doing so would fail veterans and the system specifically 
created to meet their health care needs.
    Mr. Chairman, this concludes my testimony. I am prepared to take 
any questions you or the Subcommittee members may have.

                                 
                 Prepared Statement of Jessica Bonjorni
    Good morning Chairman Dunn, Ranking Member Brownley, and Members of 
the Subcommittee. I appreciate the opportunity to discuss the 
Department of Veterans Affairs' (VA) views on pending legislation, 
including H.R. 2787, H.R. 3696, H.R. 5521, H.R. 5693, H.R. 5864, and 
two draft bills related to the Veterans Serving Veterans Act and the 
improvement of VHA productivity and efficiency. Due to the delay in 
notification regarding the draft ``VA COST SAVINGS Enhancements Act'', 
we are unable to provide views on that bill at this time, but will 
follow up with the Committee as soon as possible. I am accompanied 
today by Ms. Dayna Cooper, Director, Home and Community-Based Programs, 
Veterans Health Administration.

H.R. 2787: Vet MD Act

    The VA supports the intent of this bill to develop a nation-wide 
pre-health shadowing program within VA for undergraduate students who 
want to have a healthcare career. This bill, H.R. 2787, is an almost 
exact duplicate of H.R. 6187 from 2016. At that time, VA worked on 
extensive technical assists to improve the bill, improving the 
likelihood it could be implemented easily and at the lowest cost within 
VA. Unfortunately, the new bill contains nearly all the same technical 
limitations of H.R. 6187 and does not reflect prior feedback.
    The bill focuses on pre-medical students to the exclusion of all 
other health occupations. VA has previously advised that the bill 
should apply to all pre-health students and include both undergraduate 
students and post-baccalaureate students, since all such students 
already display a high level of interest in pursuing a health career.
    The bill describes a three-year pilot program that would start no 
later than August 15, 2020. Unfortunately, this program would require 
VA to promulgate regulations and depending on the bill passage, that 
start date would be very challenging to meet. The bill also requires 
surveys of all participants both pre- and post- observation, curriculum 
development at all sites to ensure a standardized experience, and 
18,000 observation hours within VA clinical sites (5 centers x 20 
students/center x 60 hours of observation, repeated three times a 
year).
    One of the largest technical hurdles to the bill is the requirement 
to have an applicant online portal developed to take student 
applications. The USAJOBS/USA Staffing system could be used for this 
initiative, but it would require customization of the applicant system 
for these student observers. On the other hand, to alleviate the time-
intensive and therefore costly applicant selection process, VA has 
previously recommended using the Deans' offices of VA-affiliated 
educational institutions to provide applicant reference letters and to 
screen applicants rather than hosting an applicant portal by whichever 
Information Technology (IT) mechanism is least costly.
    The bill essentially requires VA to act as an educational 
institution by creating ``standardized application, assessment, 
selection and processing requirements.'' VA does not believe that it 
should independently develop a student applicant rating and ranking 
system, but rather should rely on pre-health advisors at affiliated 
institutions to refer best qualified candidates.
    The Congressional notification requirements include notifying 
Congress of sites chosen in a timely manner. The reporting burden is 
significant, and includes, not later than 60 days before completion of 
the three-year pilot, reporting on the number and demographics of all 
applicants, selectees, and all that completed the program, and before 
and after participant survey results.
    For the bill as written, the expected timeline would be as follows:

      Fiscal Year (FY) 2019 - Bill passes; staff recruitment 
process begins. IT dollars for customization of applicant portal in USA 
Jobs/USA Staffing awarded;
      FY 2020 - Staff hired mid-way through year (1/2 salary 
support). Regulation development begins. Customization of USA Jobs/USA 
Staffing begun;
      FY 2021 - Regulations completed. Applicant portal 
completed. RFP process begins and ends for medical center sites. Sites 
recruit for and hire GS-12 Site Coordinators;
      FY 2022 - Pilot begins;
      FY 2023 - Second year of pilot starts;
      FY 2024 - Third year of pilot starts;
      FY 2025 - Pilot ends; Evaluation and analysis begin;
      FY 2026 - VA staff complete work including Congressional 
report and are re-assigned if initiative is not authorized to continue.

    VA would require major staff support to implement this bill as 
written. We assume one Nurse IV Program Manager, one General Schedule 
(GS)-14 Management Analyst, one GS-13 Education Program Specialist, and 
one GS-11 Staff Assistant to manage this program. We also assume a GS-
12 site coordinator at each of the five medical centers starting in 
2021 after the sites are chosen. We assume that in FY 2020 we incur 
half the cost of VA Full-time Equivalent (FTE) due to recruitment 
delays. In addition, we would require IT dollars to modify the USAJOBS 
/ USA Staffing system for customization for this initiative over a two-
year period.
    We estimate the total cost of this bill as follows: $436,453 One 
Year Total; $7,068,192 Five Year Total; and $9,363,343 Ten Year Total.

H.R. 3696: Wounded Warrior Workforce Enhancement Act

    Two sections of this bill call for establishing new or expanding 
existing prosthetic/orthotic graduate programs (total limit of $15 
million and site limit of $1.5 million), and the establishment of one 
prosthetic/orthotic research Center of Excellence (CoE) ($5 million).

Section 2 of the bill requires the expansion of prosthetic/orthotic 
    graduate programs.

    VA does not support this bill because VA already provides 
rehabilitation services to Veterans with a mix of providers, including 
physical medicine and rehabilitation physicians, physical therapists, 
occupational therapists, prosthetists and orthotists, all of whom work 
with the Veteran to enable the best possible rehabilitation given the 
individual's needs. VA offers in-house orthotic and prosthetic services 
at 84 laboratories across VA; in addition, VA contracts with more than 
600 vendors for specialized orthotic and prosthetic services. Through 
both in-house staffing and contractual arrangements, VA is able to 
provide state-of-the-art commercially available items ranging from 
advanced myoelectric prosthetic arms to specific custom fitted 
orthoses.
    Nationally, VA has approximately 340 clinical orthotic and 
prosthetic staff. VA offers one of the largest orthotic and prosthetic 
residency programs in the nation. In FY 2017, VA's Office of Academic 
Affiliations allocated $894,838 to support 20 Orthotics/Prosthetics 
residents at 13 Veterans Affairs Medical Centers. The training consists 
of a yearlong post-master's residency, with an average stipend of 
$44,000 per trainee. In recent years, VA has expanded the number of 
training sites and the number of trainees. From this pool of advanced 
trainees, we are able to employ orthotists and prosthetists without the 
burden of supporting trainees though their full graduate training.
    Much of the specialized orthotic and prosthetic capacity of VA is 
met through contract mechanisms. Direct grants to schools to start or 
expand masters or doctoral training programs would serve the private 
sector rather than VA or Veterans. VA does not currently serve as a 
granting authority for educational programs, and therefore VA does not 
presently have regulations which would oversee these activities. 
Rather, VA provides focused clinical practica at or near the end of 
formal training. This bill would establish a precedent for other 
educational institutions to receive grant funds to establish or enhance 
their own educational programs with no clear-cut benefit or linkage to 
VA's needs. In the future, Congress and VA might be pressured to 
provide grants to educational institutions for an additional 40 health 
professions.
    Section 3 of the bill would require VA to award a grant to an 
eligible institution to enable that institution to establish a CoE in 
Orthotic and Prosthetic Education and enable that institution to 
improve orthotic and prosthetic outcomes for Veterans, Service members, 
and civilians by conducting evidence-based research. VA would be 
required to give priority in the award of a grant to an eligible 
institution that has in force, or demonstrates the willingness and 
ability to enter into, a Memorandum of Understanding (MOU) with VA, the 
Department of Defense (DoD), or another appropriate Federal agency, or 
a cooperative agreement with an appropriate private sector entity that 
provides for the provision of resources to the Center and assistance to 
the Center in conducting research and disseminating the results of such 
research. The grant awarded under this section could not exceed $5 
million. Within 90 days of the date of the enactment of this Act, VA 
would have to issue a request for proposals from eligible institutions 
for the grant available under this section. The grantee would be 
required to use the grant to develop an agenda for orthotics and 
prosthetics education research, fund research in orthotics and 
prosthetics education, and publish or otherwise disseminate research 
findings relating to orthotics and prosthetics education. The grantee 
could use the funds of the grant for a period of 5 years from the date 
of the award of the grant. To be eligible for the grant, an institution 
would have to: have a robust research program; offer an orthotics and 
prosthetics education program accredited by the National Commission on 
Orthotic and Prosthetic Education in cooperation with the Commission on 
Accreditation of Allied Health Education Programs; be well recognized 
in the field of orthotics and prosthetics education; and have an 
established association with a VA medical center or clinic and a local 
rehabilitation hospital. There would be authorized to be appropriated 
for fiscal year 2018 $5 million to carry out this section.
    VA does not support section 3 because we do not believe that a new 
Center is necessary. DoD has an Extremity Trauma and Amputation Center 
of Excellence, and VA and DoD work closely to provide care and conduct 
scientific research to minimize the effect of traumatic injuries and 
improve outcomes of wounded Veterans suffering from traumatic injury. 
VA is already a world leader in prosthetics/orthotics research. VA has 
five Rehabilitation Research and Development Centers that conduct 
research related to prosthetic and orthotic interventions, amputation, 
and restoration of function following trauma:

    1. Center for Limb Loss Prevention and Prosthetic Engineering in 
Seattle, WA.

    2. Center for Wheelchairs and Associated Rehabilitation Engineering 
in Pittsburgh, PA.

    3. Center for Functional Electrical Stimulation in Cleveland, OH.

    4. Center for Advanced Platform Technology in Cleveland, OH.

    5. Center for Neurorestoration and Neurotechnology in Providence, 
RI.

    These Centers provide a rich scientific environment in which 
clinicians work closely with researchers to improve and enhance care. 
They are not positioned to confer terminal degrees for prosthetic and 
orthotic care/research, but they are engaged in training and mentoring 
clinicians and engineers to develop lines of inquiry that will have a 
positive impact on amputee care. Moreover, VA would not have oversight 
of the Center.
    VA is already investing a great deal into advancing prosthetic 
technology, and these Centers incorporate our interns and residents as 
well as graduate students from affiliated academic institutions. Each 
Center is funded with a base budget of nearly $1 million, but they are 
further required to seek VA or agency research funding. With these 
Centers and staffing in place, VA is additionally bringing in grants of 
approximately $10 million per year. As VA has already established 
internal research resources in this domain, the value to VA and 
Veterans for establishing a sixth non-VA research center does not seem 
warranted.
    Finally, we believe the requirement to issue a request for 
proposals (RFP) within 90 days of enactment would be very difficult to 
meet as VA would first need to promulgate regulations prior to being 
able to issue the RFP.
    We note that the language in section 3(a)(2), regarding how VA 
would give priority in the award of a grant, refers to at least some 
types of arrangements that could not exist. For example, VA does not 
have legal authority to enter into an MOU for the provision of 
resources, whether in cash or in-kind, to an institution; similarly, we 
are unsure as to whether the bill means to refer to a ``cooperative 
agreement'', as that term is used in Federal procurement, but we would 
appreciate the opportunity to discuss this further with the Committee. 
We would be happy to work with the Committee to revise this language to 
reflect the intended effect.

    When considering implementation, VA provides the following training 
proposal assumptions:

      Enabling regulations would be developed and published 
within the first two FYs;
      Legal clarification between ``grants'' and the prescribed 
``RFP'' methodology is achieved;
      Sufficient interest from accredited schools of Orthotics/
Prosthetics;
      Sufficient VA staff hired to plan, execute and monitor 
the program;
      Contracting to support program and evaluation services to 
assess quality of the two components of this initiative;
      The proposal mentions an implementation in the current 
FY. We assume this is referring to the year this bill is passed, 2019 
or later; and
      While the bill does not state the desired number of 
programs, with a site limit of $1.5 million and an overall cap of $15 
million, this would cap the program at eight facilities, with 
additional funding being used for program administration.

    Regarding the research proposal, VA provides the following 
assumptions:

      VA would develop and publish enabling regulations in the 
first two years FY 2019-2020;
      Staff would begin reaching out to potential academic 
partners;
      A quality assessment plan for both programs would be 
established and periodic site visitation would be conducted;
      During FY 2020, the RFPs for academic programs (up to 8 
sites) would be developed, released, and an expert peer-review panel 
would make funding recommendations. Awards would be distributed in FY 
2021;
      Enabling regulations would be developed and published 
within the first two fiscal years; and
      In 2020, the RFP for the Research CoE (one site) would be 
developed, released, and an expert peer-review panel would make the 
funding recommendation, with funds to be distributed in 2021.

    We estimate the total cost of this bill as follows: $183,811 One 
Year Total and $20,604,079 Five/Ten Year Total.

H.R. 5521: VA Hiring Enhancement Act

    Section 2 of this bill would amend title 38, United States Code, to 
restrict the applicability of non-VA covenants not to compete to the 
appointment of certain VHA personnel, specifically those appointed 
under 38 U.S.C. Section 7401. Section 2 would further require an 
individual appointed to such a position to agree to provide clinical 
services at VA for a duration beginning from the date of their 
appointment and ending on the latter of either one year after the date 
of appointment, or the termination date of any covenant not to compete 
that was entered into between the individual and the non-VA facility. 
The Secretary would have the authority to waive this particular 
requirement.
    VA has concerns with section 2 of this proposed bill and requests 
the opportunity to discuss the bill further with the Committee.

    Section 3 of the bill would permit VHA to make a contingent 
appointment as a VHA physician on the basis of the physician completing 
their residency training.
    VA also has concerns with this section and requests an opportunity 
to further discuss. With regard to section 3, VA recommends removing 
the language regarding the completion of a residency leading to board 
eligibility, subsection (b)(1)(B)(i), since the requirement for 
residency training is provided in the published Department of Veterans 
Affairs (VA) physician qualification standard (VA Handbook 5005, Part 
II, Appendix G2). Physicians must have completed residency training or 
its equivalent, approved by the Secretary of VA in an accredited core 
specialty training program leading to eligibility for board 
certification. Approved residencies are:

      Those approved by the accrediting bodies for graduate 
medical education, the Accreditation Council for Graduate Medical 
Education (ACGME) or American Osteopathic Association (AOA), in the 
list published for the year the residency was completed, or
      Other residencies or their equivalents which the local 
Professional Standards Board determines to have provided an applicant 
with appropriate professional training. The qualification standard also 
allows for facilities to require VA physicians involved in academic 
training programs to be board certified for faculty status.

    VA also recommends removing the language regarding an offer for an 
appointment on a contingent basis, subsection (b)(1)(B)(ii), since VA 
may currently provide job offers to physicians pending completion of 
residency training. There are no restrictions in statute or VA policy 
on making job offers contingent upon completing residency training and 
meeting other requirements for appointments as physicians within VHA. 
If this needs to be clarified in statute, VA suggests including the 
information in a new subsection (h) as follows: Section 7402 of title 
38, United States Code, is amended by adding at the end the following 
subsection (h): ``(h) The Secretary may provide job offers to 
physicians pending completion of residency training programs and 
completing the requirements for appointments under subsection (b) by 
not later than two years after the date of the job offer.''

    At this time, VA does not have a cost estimate for this bill.

H.R. 5693: Long-Term Care Veterans Choice Act

    H.R. 5693, the Long-Term Care Veterans Choice Act, would amend 
section 1720 of title 38 U.S.C. to add a new subsection (h) providing 
authority for the Secretary to pay for long-term care for certain 
Veterans in medical foster homes (MFH) that meet Department standards. 
Specifically, the draft bill would allow Veterans, for whom VA is 
required by law to offer to purchase or provide nursing home care, to 
be offered placement in homes designed to provide non-institutional 
long-term supportive care for Veterans who are unable to live 
independently and prefer to live in a family setting. VA would pay MFH 
expenses by a contract or agreement with the home. VA would be limited 
to furnishing care and services to no more than 900 veterans placed in 
a medical foster home before or after the date of the enactment of this 
subsection. One condition of providing support for care in a MFH would 
be the Veteran's agreement to accept home health care services 
furnished by VA.
    VA endorses the concept of using MFHs for Veterans who meet the 
appropriateness criteria to receive such care in a more personal home 
setting. VA endorsed this idea in its Fiscal Year (FY) 2018 and 2019 
budget submissions and appreciates the Committee's consideration of 
this concept. Our experience has shown that VA-approved MFHs can offer 
safe, highly Veteran-centric care that is preferred by many Veterans at 
a lower cost than traditional nursing home care. VA currently manages 
the MFH program at over two-thirds of our medical centers; partnering 
with homes in the community to provide care to nearly 1,000 Veterans 
every day. Our experience also shows that MFHs can be used to increase 
access and promote Veteran choice-of-care options.
    While VA fully supports the MFH concept, we would look forward to 
working with you to resolve a few technical issues in this bill. For 
example, the limitation in proposed subsection (h)(2), regarding a 
limit of 900 Veterans receiving care, is ambiguous; it is unclear 
whether this is intended to be an average daily census limitation, or 
if this is intended to be a hard cap on the total number of Veterans 
who could receive care under this program during the entire 3-year 
period. Moreover, while VA currently provides care through MFHs to 
approximately 1,000 Veterans, most of these are not Veterans who would 
qualify for care under section 1710A of title 38. Another change we 
recommend is to revise the language in subsection (h)(1) to refer to 
``contracts, agreements, or other arrangements.'' VA would like to work 
with the Committee to ensure VA can effectively incorporate MFHs into 
the continuum of authorized long-term services and support available to 
Veterans. We are happy to provide the Committee with technical 
assistance on this matter and are available for further discussion.
    VHA estimates that, if enacted, this bill would cost $37.2 million 
in FY 2019, $50.64 million in FY 2020, and a total of $150.2 million 
over three years. Additionally, this bill could potentially divert 
approximately $24.47 million in FY 2019, $33.34 million in FY 2020, and 
a total of $98.90 million over 3 years from VA nursing home care costs, 
depending on whether those beds are backfilled.

H.R. 5864: VA Hospitals Establishing Leadership Performance Act (``VA 
    HELP Act'')

    This bill proposes to standardize qualification requirements and 
performance metrics for human resources positions.
    VA does not support the intent of this bill, but does support 
efforts to modernize and professionalize the HR function throughout the 
Government, including addressing the special needs of agencies that 
employ physicians and other clinical professionals. The Human Resources 
Management - GS-0200 series is under Title 5 and as such, is covered by 
the Office of Personnel Management's (OPM) General Schedule 
Qualification standards. These standards are broadly written for 
Government-wide application and are not intended to provide detailed 
information about specific qualification requirements for individual 
positions at a particular agency. The HR occupation remains on the 
Government Accountability Office's high risk list and have been 
identified as a skills gap. To address this issue, OPM currently is 
developing competencies for each HR specialty, and these competencies 
will be linked with training. In addition, as part of the President's 
Management Agenda, OPM will review and develop competency-based 
standards for the HR occupation, and these standards also will be used 
Government-wide. VA would support OPM addressing the issue across the 
federal government by creating higher standards for the HR Specialists, 
as government-wide surveys have found federal managers express the 
lowest satisfaction with the quality of their HR services, more than 
any other mission-support function.
    It is important to note that all Federal agencies use OPM-approved 
qualification standards, and creating VA specific standards would 
negatively impact VA's ability to retain current staff, as well as to 
recruit human resources (HR) professionals from other Federal agencies. 
OPM states that such information (i.e., a description of any 
specialized experience requirements that an agency may deem necessary 
for a particular position) should be included in the vacancy 
announcements issued by the agency. As such, rather than standardized 
qualification requirements across VA, individual vacancy announcements 
are customized to reflect the specialized experience (qualification 
requirements) for the particular position itself. VA already utilizes 
this method of applying specialized qualification requirements in all 
HR job announcements. Additionally, performance standards are developed 
on an annual basis for each HR position in the Department. These 
performance standards are aligned with the specific functions and 
specialized area of HR being performed by each HR professional.
    While VA does not support the bill as written, if a decision is 
made to proceed with the bill, VA requests the opportunity to meet with 
the Committee to propose revisions to the language to address our 
concerns. A few examples include:

      Clearly define references to ``each human resources 
position'' to identify occupation specific series.
      The GS-200 Human Resources Management series currently 
has numerous individual occupational series and title codes, of which 
many have varying specialized experience requirements;
      Revise references to VHA throughout the bill to reflect 
VA is not limiting applicability to VHA.

    Should this bill be revised as suggested, we would convene a 
workgroup led by the Office of Human Resources and Administration and 
would include subject matter experts (SMEs) from the three VA 
administrations. This workgroup would meet regularly and would be 
similar to the SME workgroups currently working on the development of 
new Hybrid Title 38 qualification standards. The review and proposed 
revisions would potentially take less than one year to complete. No new 
FTE would be required. The VA anticipates minimal cost to the 
Department if this bill is passed with suggested revisions.

H.R. 5938: Veterans Serving Veterans Act of 2018

    Efforts are already underway to target transitioning military 
members for mission critical and difficult to fill positions by 
utilizing data contained in the Veterans Affairs/Department of Defense 
Identity Repository (VADIR) database. Directly targeting transitioning 
service members for mission critical and hard to fill VA positions 
should result in more transitioning military members choosing to work 
for VA and serve as a pipeline to fill critical vacancies. That said, 
because of the level of coordination required with DoD, VA requests 
that the bill be amended to require an implementation plan within 180 
days, instead of requiring the establishment of a database within that 
timeframe. Additionally, the Administration requests that the Act be 
extended Government-wide. Leveraging this effort would both support 
efforts to hire more veterans into Government, and assist agencies that 
face similar hiring barriers.
    An Intermediate Care Technician (ICT) training program has already 
been implemented at 23 VA Medical Centers (VAMC) with ICTs on staff. We 
are currently pursuing the establishment of an ICT Program at 
additional VAMC locations which will meet the requirements outlined in 
the bill. The ICT program has been considering the creation of 
``centers'' at medical facilities to train and certify Veterans to work 
as ICTs. The ICT program is currently evaluating whether to designate 
one (or two) VAMCs as VA National ICT Training sites. These sites would 
be utilized as the entry point for all VA-hired ICTs. After completing 
a prescribed training curriculum, the ICTs would then proceed to the 
VAMC that hired them. The ICT program is considering the elements 
listed in the proposed bill when evaluating a possible National ICT 
Training site, including the experience and success of VAMCs in 
training ICTs and resource support for the ICTs or the ICT program at 
individual VAMCs.
    The estimated costs do not include the cost of hiring and training 
an ICT, since that will depend on geographic location and the number of 
ICTs hired by each VAMC. With that in mind, we estimate the total cost 
of this bill as follows: $220 thousand in FY 2020 Total; $598 thousand 
over five years; and $1.2 million over 10 years.

Draft Bill to Improve the Productivity of VA Health Care

    This bill calls for VA to track relative value unit production 
standards; requires all Department providers to attend training on 
clinical procedure coding; mandates establishment of standardized 
performance standards based on nationally recognized relative value 
unit production standards; and requires submission of a report on the 
implementation of the bill's requirements.
    VA does not support this bill as written, and would like to discuss 
the bill with the Committee to further refine the language. In support 
of VA's position, it should be noted that VA already tracks relative 
value units for Department Providers (Licensed Independent Providers 
(LIP) as defined by the bill). A six-module online training program in 
Clinical Procedure Coding is in development with a target release date 
of late FY 2018. VA is concerned about the implementation of this 
component in that the time required to train providers in coding will 
significantly reduce their availability to provide timely health care 
to Veterans.
    Additionally, requiring LIPs to learn and become proficient in 
skills not essential to direct patient care will have a detrimental 
impact on the timely delivery of health care. VA is also concerned 
about whether mandatory training of providers is the most effective and 
efficient means to create system improvements. Also, VA has performance 
standards in place, broken out by provider type and location. Specialty 
specific productivity targets are established and are reviewed annually 
at a minimum. Remediation plans are developed for provider practices 
that do not meet minimum thresholds. Lastly, VA currently has the tools 
in place to create the required report.

    Pending VA meeting with the Committee to further discuss the coding 
training requirement for LIPs, VA is not able to accurately develop 
costs. Primary topics impacting the cost estimate include:

      Determining the number of LIPs who would be impacted.
      The time LIPs would be taken away from direct patient 
care, and
      Determining the number of Contract LIPs who would be 
needed to fill the gap created when providers are required to use duty 
hours to attend extensive training.

    Mr. Chairman, this concludes my testimony. My colleagues and I are 
prepared to answer any questions the Subcommittee may have.

                                 
                       Statements For The Record

          AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO
    Chairman Wenstrup, Ranking Member Brownley and Members of the 
Subcommittee:

    The American Federation of Government Employees, AFL-CIO (AFGE) and 
its National Veterans Affairs Council (NVAC) appreciate the opportunity 
to submit a statement for the record on pending legislation.
    AFGE represents nearly 700,000 federal employees, including 250,000 
front-line employees at the Department of Veterans Affairs (VA) 
providing medical care, mental health treatment and other essential 
services to our nation's veterans.

H.R. 6066, To improve productivity of the management of Department of 
    Veterans Affairs health care, and for other purposes

    AFGE and NVAC strongly oppose expanding management authority to 
measure VA provider productivity through relative value units (RVUs). 
RVUs fail to measure the many essential services that bring value to 
the VA's mission of treating the complex needs of our wounded warriors, 
including coordination of care, clinical research, palliative care, 
triage, clinician training, dietary counseling, chemotherapy teaching, 
and pre-op and post-op care among many other routine VA medical center 
activities.
    This bill ignores that far greater urgency of filling the thousands 
of unfilled VA provider positions that have placed VA providers under 
tremendous pressure to care for veterans with complex needs while 
operating with excessive panel sizes, large numbers of unassigned 
patients, and daily additional responsibilities such as responding to 
computer view alerts and following up on lab reports.
    In addition, as GAO noted in its May 2017 report on clinical 
productivity and efficiency (GAO-17-480), VA could achieve significant 
increases in productivity through the hiring of additional support 
staff and improved infrastructure including both exam and procedure 
rooms and adequately equipped facilities.
    In the words of one of our discouraged VA front line physicians 
``When RVUs are applied to physicians it places quantity over quality 
of care. People are not widgets and the principles of mass production 
should not be applied to patient care or we unduly increase the risk of 
adverse patient outcomes''.
    Veterans using the VA deserve better. Only the VA provides them 
with adequate time to be properly diagnosed, treated, and referred to 
the appropriate additional care. RVUs were designed for for-profit 
health care and have absolutely no place in the VA health care system. 
As another frontline clinician commented, ``Billing codes and encounter 
codes don't capture the veteran's care accurately. You can't quantify 
this unique type of care with coding.''
    Furthermore, the unilateral use of RVUs to measure VA in-house 
provider productivity would exacerbate the double standard already in 
place that fails to measure the quality and access of private sector 
care, thus depriving veterans of making an informed decision about 
whether to seek care in the VA or use a Choice provider.

H.R. 2787, the Veterans-Specific Education for Tomorrow's Medical 
    Doctors Act

    AFGE supports H.R. 2787. This bill would increase opportunities for 
pre-medical undergraduate students to gain clinical observation 
experiences at VA medical facilities. The intent of the bill is to 
expose future physicians to veteran-centric care, increase the 
diversity of the medical profession and address the nation's physician 
shortage. AFGE supports H.R. 2787.

H.R. 3696, the Wounded Warrior Workforce Enhancement Act

    AFGE and NVAC take no position on H.R. 3696, a bill to award 
educational grants to expand master's degree programs in orthotics and 
prosthetics.

H.R. 5521, the VA Hiring Enhancement Act

    AFGE and NVAC take no position on H.R. 5521, a bill that would make 
preexisting non-compete clauses nonapplicable to VA health care 
personnel appointed under Title 38, and that would authorize physician 
appointments on a contingent basis prior to the completion of medical 
training.

H.R. 5693, the Long-Term Care Veterans Choice Act

    AFGE and NVAC take no position on this bill on medical foster 
homes.

H.R. 5864, the VA Hospitals Establishing Leadership Performance Act

    AFGE and NVAC support this bill to establish standards and 
performance measures for all Veterans Health Administration human 
resources (HR) positions, but we also urge additional training and 
modernization of the Department's HR workforce to reduce the widespread 
violation of workplace rights and compensation laws applicable to VA 
employees.

H.R. 5938, the Veterans Serving Veterans Act of 2018

    AFGE and NVAC take no position on this bill expanding VA job 
opportunities for active duty personnel.

H.R. 5974, the Department of Veterans Affairs Creation of On-Site 
    Treatment Systems Affording Veterans Improvements and Numerous 
    General Safety Enhancements Act

    AFGE and NVAC take no position on this bill on VA medical waste 
treatment systems but commends the intent of the bill to reduce costs 
by taking steps to insource this function back to VA medical centers 
and reduce reliance on costly contractors.

    Thank you.

                                 
             AMERICAN ORTHOTICS AND PROSTHETICS ASSOCIATION
    Chairman Dunn, Ranking Member Brownley, and Members of the 
Committee,
    Thank you for inviting the American Orthotic and Prosthetic 
Association to offer its perspective on the need to expand our pool of 
highly educated clinicians who can offer prosthetic and orthotic care 
to Wounded Warriors who have lost limbs or sustained chronic limb 
impairment on the battlefield. We thank you for including HR 3696, the 
Wounded Warrior Workforce Enhancement Act, in this hearing.
    AOPA represents over 2,000 orthotic and prosthetic patient care 
facilities and suppliers that evaluate patients for and design, 
fabricate, fit, adjust and supervise the use of orthoses and 
prostheses. Our members serve Veterans and civilians in the communities 
where they live, and our goal is to ensure that every patient has 
access to the highest standard of O&P care from a well-trained 
clinician. It is not widely known that 80-90% of prosthetic/orthotic 
care delivered to Veterans is provided in a community-based setting, 
outside the walls of a VA Medical Center. The vast majority of your 
constituents who are Veterans and who need a prosthesis or orthosis 
received a device that was provided and maintained by an AOPA member.
    The VA contracts with community-based providers to offer Veterans 
timely, convenient and high quality prosthetic and orthotic care near 
the locations where they live and work. Because such a high percentage 
of care is delivered by community-based providers, the private sector 
workforce and procurement relationships with the VA must be a part of 
any discussion of lower extremity prosthetic and orthotic care for 
Veterans.

Wounded Warriors Need Orthotic and Prosthetic Care

    Traumatic Brain Injury (TBI) and amputation are signature injuries 
of the wars in Iraq and Afghanistan. Traumatic Brain Injury often 
manifests in the same way as stroke, with orthotic intervention needed 
to address drop foot and other challenges balancing, standing and 
walking. The Defense and Veterans Brain Injury Center has reported that 
by the start of calendar year 2018, more than 379,500 service members 
had suffered a TBI.
    Although the death rate from conflicts in Iraq and Afghanistan is 
much lower than in previous wars, the amputation rate doubled. The 
Department of Defense and the Department of Veterans' Affairs have 
reported that in past wars, 3% of service members injured required 
amputations; of those wounded in Iraq, 6% have required amputations. 
The DoD Surgeon General reported to CRS more than 1,600 service-related 
amputations from 2001-2016. More than 80% of amputees lost one or both 
legs. Concussion blasts, multiple amputations, and other conditions of 
war have resulted in injuries that are medically more complex than in 
previous conflicts. The majority of these amputees are young men and 
women who should be able to live long, active, independent lives - 
sometimes even return to active duty - if they receive timely, high 
quality, and consistent prosthetic care.

Senior Veterans Need Orthotic and Prosthetic Care

    Most Americans are unaware that the majority of Veterans with 
amputations undergo the procedure as a result of diabetes or 
cardiovascular disease. According to VA statistics, one out of every 
four Veterans receiving care has diabetes; 52% have hypertension; 36% 
are obese. These conditions are associated with higher risk for stroke, 
neuropathy, and amputation.
    These underlying health conditions are the reason that the number 
of Veterans undergoing amputation is increasing dramatically, and is 
expected to increase at an even more rapid pace in the future. VHA 
Amputation System of Care figures show that, in the year 2000, 25,000 
Veterans with amputations were served by the VA. By 2016, that number 
had more than tripled to 89,921. Between 2008-2013, an average of 7,669 
new amputations were performed for Veterans every year; in 2016, 11,879 
amputation surgeries were performed. 78% of the Veterans undergoing 
amputation last year were diabetics. 42% had a service-connected 
amputation condition.

Demand for High Quality Care is Growing While Provider Population 
    Shrinks

    From the battlefield to the homeland, medical conditions requiring 
prosthetic and orthotic care have become more complex and more 
challenging to treat. New prosthetic and orthotic technology is more 
sophisticated, and offers potential for greater functional restoration. 
To ensure professional, high quality care that responds to these 
shifts, earlier this decade the entry-level qualifications for 
prosthetists and orthotists were elevated from a bachelor's degree to a 
master's degree.
    Veterans need and deserve clinicians who can successfully respond 
to their battlefield injuries and service-related health conditions 
with appropriate, advanced technologies. As the population of amputees 
grows, many experienced professionals who were inspired to enter the 
field to care for Vietnam Veterans are retiring. Currently, only 13 
American universities offer master's degrees in prosthetics and 
orthotics. The largest progra admits fewer than 50 students each year. 
The majority of programs enroll fewer than 20 students. Despite 
receiving multiple qualified applicants for every seat, fewer than 250 
students are able to enroll in all 13 programs combined each year. 
Providing high quality care to our Wounded Warriors and Veterans with 
limb loss and impairment is going to require more master's degree 
graduates from American universities to be the next generation of 
practitioners.
    The National Commission on Orthotics and Prosthetics Education 
(NCOPE) joined with AOPA to commission an independent study of the O&P 
field, which was completed in May of 2015. The study found that in 
2014, there were 6,675 licensed and/or certified orthotists and 
prosthetists in the United States. It concluded that, by 2025, 
``overall supply of credentialed O&P providers would need to increase 
by about 60 percent to meet the growing demand.'' Subsequent analysis 
conducted by NCOPE and AOPA suggests that the current number of 
providers is closer to 5,500, an even more significant shortage than 
than previously predicted.
    Current accredited schools will barely graduate enough entry-level 
students with master's degrees to replace the clinicians who will be 
retiring in coming years. Class sizes simply aren't adequate to meet 
the growing demand for O&P care created by an aging population and 
rising incidence of chronic disease.
    Positions as licensed, certified prosthetists and orthotists are 
good jobs. Nationally, the average wage exceeds $65,000. These jobs pay 
good wages, support a family, and can't be outsourced overseas. Most 
importantly, they help improve the health and quality of life for our 
Veterans. Veterans need care. The providers who care for them need high 
quality employees. People want fulfilling careers, and feel great about 
caring for the men and women who have so nobly served our country. 
Schools are getting more applicants for O&P programs than they can 
accept. Where is the imbalance?

The Wounded Warrior Workforce Enhancement Act

    O&P master's programs are costly and challenging to expand. The 
need for lab space and sophisticated equipment, and the scarcity of 
qualified faculty with PhDs in related fields, contribute to the 
barriers to expanding existing accredited programs. There are currently 
no federal resources available to schools to help create or expand 
advanced education programs in O&P. Funding is available for 
scholarships to help students attend O&P programs, but do not assist in 
expanding the number of students those programs can accept.
    One way to address this problem is by passing The Wounded Warrior 
Workforce Enhancement Act, introduced in the House by Representative 
Cartwright with bipartisan support. This bill is a limited, cost-
effective approach to assisting universities in creating or expanding 
accredited master's degree programs in orthotics and prosthetics. It 
authorizes $5 million per year for three years to provide one-time 
competitive grants of $1-1.5 million to qualified universities to 
create or expand accredited advanced education programs in prosthetics 
and orthotics. Priority is given to programs that have a partnership 
with Veterans' or Department of Defense facilities, including 
opportunities for clinical training, to ensure that students become 
familiar with and can respond to the unique needs of service members 
and Veterans. The bill was endorsed by Vietnam Veterans of America and 
VetsFirst, which recognize the need for additional highly qualified 
practitioners to care for wounded warriors.
    In May of 2013, the Senate Committee on Veterans Affairs held a 
hearing to consider the Wounded Warrior Workforce Enhancement Act and 
other Veterans' health legislation. The VA testified that the grants to 
schools were not necessary because it did not anticipate any difficulty 
filling its seven open internal positions in prosthetics and orthotics. 
The VA testified that its O&P fellowship program, which accepted 
nineteen students that year, was a sufficient pipeline to meet its need 
for internal staff. The VA offered similar testimony at a House 
Veterans Affairs Health Subcommittee hearing in November 2015.
    The Senate rejected the VA's argument. Acknowledging that most 
prosthetic and orthotic care to Veterans is provided by community-based 
facilities, the Committee concluded that nineteen students could not 
meet the system-wide need. Committee members also agreed that Veterans 
and the VA would benefit from a larger pool of clinicians with master's 
degrees, whether those graduates were hired internally at the VA, or by 
community-based providers. The Committee included provisions of the 
Wounded Warrior Workforce Enhancement Act in S. 1950, which passed 
Senate VA Committee unanimously in 2013. Due to factors unrelated to 
O&P, the omnibus bill did not advance. Related provisions were included 
in the Senate's omnibus package Veterans' legislation in 2016, but were 
not included in the final conferenced bill.
    AOPA looks forward to working with you to expand the number of 
highly qualified prosthetists and orthotists who can meet the needs of 
Veterans with limb loss and limb impairment, and to reducing the 
barriers to timely, appropriate lower extremity care. No Veteran should 
suffer from decreased mobility or independence because of lack of 
access to high quality care, regardless of where it is provided.

A Proud History of Caring for Veterans in the Community Is Under Threat

    AOPA commends the VA for its historical leadership in ensuring that 
Veterans who have undergone amputations have access to appropriate, 
advanced prosthetic technology, often before the same technology is 
made available to patients in the private sector. For example, when the 
first microprocessor-controlled knee came to market, it was initially 
considered beneficial for the fittest, most active amputees. Fred 
Downs, then National Director of the Prosthetic and Sensory Aids 
Service, was himself a Vietnam Veteran who lost an arm in combat. He 
had the idea that the greater stability offered by microprocessor 
control might be even more beneficial to older, less active Veterans 
with limb loss who were less steady on their feet. After testing the 
computer-controlled knees with older Veterans undertaking activities 
such as walking in the community and riding Metro escalators, the VA 
became the first payor to approve microprocessor-controlled knees for 
older and less active patients. Today, following the VA, Medicare and 
private insurance companies widely accept that microprocessor-
controlled knees improve safety and increase activity levels for 
patients with limb loss across a wide spectrum of activity levels.
    O&P care is unusual in providing care to Veterans largely through 
contracts with private sector providers - often family-owned, small 
businesses. There are multiple advantages to the VA, and to Veterans, 
from this long-time public-private partnership in O&P. With a private 
sector network of O&P clinics supplementing care available from VA 
employees, wait times are reduced and Veterans receive the care they 
need more quickly than if they were relying solely on overburdened VA 
facilities and federal employees. Community-based providers are often 
closer to Veterans' homes or workplaces. Frequently, they offer 
Veterans more convenient care, with less travel time and expense, less 
time away from work, and less interruption to their daily lives.
    It is in part because of this strong history of providing high 
quality care in the community to Veterans who need it that AOPA is 
deeply concerned by the October 16, 2017 Federal Register Notice and 
proposed rule regarding ``Prosthetic and Rehabilitative Items and 
Services.'' Under the proposed rule, the Veterans' Administration, not 
the Veteran, would decide if a Veteran can receive care from a local 
provider or if that Veteran must drive - sometimes for hours, over 
hundreds of miles - to receive care in a VA facility. In fact, the 
proposed policy states that, if the VA has the materials in-house, care 
shall be provided in the VA. The policy, which is described in the 
Federal Register as a ``clarification,'' in fact upends decades-long 
precedent allowing Veterans to choose to receive prosthetic and 
orthotic care in the community. AOPA is grateful to Representatives 
Walberg and Rutherford, who recently offered an amendment prohibiting 
use of appropriated funds to finalize the proposed policy. AOPA joins 
with Veterans' Service Organizations that have called for the VA to 
withdraw this proposal immediately, and urges the VA instead to 
affirmatively rebuild the public-private partnership that has provided 
such high quality care.
    AOPA is also deeply concerned about the impediments the coding 
policies of the Centers for Medicare and Medicaid services are posing 
with respect to the development of new, more advanced technologies 
needed by prosthetic and orthotics patients, and Veteran access to 
these advanced technologies. The VA recently announced that it would 
reverse its longstanding practice of making payments for new prosthetic 
technologies under a ``Not Otherwise Classified'' code. This decision, 
and other related policies, appear to be limiting Veterans' access to 
newer, advanced and more effective prosthetic and orthotic 
technologies. The VA has never provided a comprehensive explanation for 
its policy changes. We are grateful to former Subcommittee Chairman 
Wenstrup for his work on this issue, including his work on a joint 
hearing or round table with the House Ways and Means Committee.
    Chairman Dunn, Ranking Member Brownley, and members of the 
Committee, we know you share our belief that Veterans who have suffered 
limb loss or limb impairment as a result of their military service, or 
as a result of service-connected illness, deserve the best possible 
care that a grateful country can provide. We look forward to working 
with you to ensure that all Veterans continue to receive that care.

                                 
                MILITARY OFFICERS ASSOCIATION OF AMERICA
    CHAIRMAN DUNN, RANKING MEMBER BROWNLEY, and Members of the 
Subcommittee on Health, the Military Officers Association of America 
(MOAA) is pleased to submit its views on pending legislation under 
consideration.
    MOAA does not receive any grants or contracts from the federal 
government.

EXECUTIVE SUMMARY

    On behalf of the 350,000 members of the Military Officers 
Association of America, the largest military service organization 
representing the seven uniformed services, including active duty and 
Guard and Reserve members, retirees, veterans, and survivors and their 
families, thank you for your commitment and enduring support of our 
nation's servicemembers, veterans and their families.
    MOAA offers our position on the following bills.

      H.R. 2787, Veterans-Specific Education for Tomorrow's 
Medical Doctors Act
      H.R. 3696, Wounded Warrior Workforce Enhancement Act
      H.R. 5693, Long-Term Care Veterans Choice Act
      H.R. 5864, VA Hospitals Establishing Leadership 
Performance Act
      DRAFT Bill, Veterans Serving Veterans Act

    MOAA takes no position on: H.R. 5521, VA Hiring Enhancement Act; 
H.R. 5974, VA COST SAVINGS Enhancement Act; and, the draft bill To 
Improve the Productivity and Management of VA Health Care Facilities. 
These bills are outside of our scope of expertise.

PENDING LEGISLATION

    H.R. 2787, Veterans-Specific Education for Tomorrow's Medical 
Doctors Act (VET MD Act). MOAA supports this legislation. However, we 
urge Congress to commit the necessary resources and funding to execute 
the program.
    The VET MD Act would allow the VA to establish a pilot program 
instituting a clinical observation program for pre-med students 
preparing to attend medical school.
    The association is grateful to Representatives Kaptur, Jones, and 
Ryan for introducing the bill and for the Subcommittee's consideration 
of this important piece of legislation. Like lawmakers, MOAA is eager 
for the VA to try new and innovative approaches growing the agency's 
medical workforce and eliminating the current 30,000-plus vacancies 
across its health care system. This legislation would introduce 
prospective medical students to the kinds of health care conditions 
common to the veteran population and help the VA encourage students to 
choose a career in medicine, particularly in occupational fields with 
high staffing shortages, such as women's health care and psychiatric 
care and/or consider a career in veterans' health care at the agency.
    While the legislation only requires the VA to establish procedures 
to track students participating in the clinical observation program to 
determine if the student was accepted into medical school, MOAA 
recommends this Subcommittee consider adding a provision requiring the 
VA to continue tracking these students through medical school and 
residency programs in an effort to secure medical professionals for VA 
employment and to ascertain the effectiveness of the clinical 
observation program to individuals deciding on a career in medicine who 
are interested in treating the veteran population.
    H.R. 3696, Wounded Warrior Workforce Enhancement Act. MOAA supports 
this legislation and requests Congress provide the associated funding 
needed to support the legislative requirements of this bill.
    The Wounded Warrior Workforce Enhancement Act would require the VA 
to award grants to establish or expand upon master's degree programs 
with academic medical institutions in the fields of orthotics and 
prosthetics. Further, the VA shall award a grant to an eligible 
institution to establish a Center of Excellence in Orthotic and 
Prosthetic Education to conduct evidence-based research and to improve 
health outcomes for veterans, servicemembers, and civilians.
    The legislation also allows grants to eligible institutions 
planning to expand their existing master's degree program in these two 
fields by admitting more students or adding faculty to the program, 
expanding existing facilities, or by increasing cooperative 
partnerships with the VA and DoD.
    Military service today has unique occupational demands and hazards. 
Servicemembers are required to carry heavy rucksacks and body armor in 
physically demanding training and harsh combat environments. Increased 
exposure to improvised explosive devices has resulted higher rates of 
injury among Post-9/11 troops, including amputations, and lower 
extremity conditions. Veterans are also presenting in increasing 
numbers for foot and ankle ailments, conditions complicated by 
diabetes, and neuropathy often associated with Agent Orange exposure, 
orthopedic, or vascular problems.
    MOAA believes H.R. 3696 would provide the VA an additional tool it 
needs to address staffing shortages in the area of orthotics and 
prosthetics and help the agency attract high quality providers to meet 
current and future needs of veterans needing these important services 
within VA's integrated network of care.
    H.R. 5693, Long-Term Care Veterans Choice Act. MOAA supports this 
bill as long as the requisite associated funding is provided for 
implementation.
    The Long-Term Care Veterans Choice Act would authorize the VA to 
place veterans who are unable to live independently in private medical 
foster homes at the expense of the government.
    Many veterans live with complex chronic diseases or disabling 
traumatic injuries and over time these individuals may be unable to 
live independently or their health care needs become such their family 
caregiver may no longer be able to manage their care. In recent years, 
the VA has established a medical foster home program to prevent this 
population of veterans being institutionalized or delay entering 
nursing home care, instead allowing for them to be placed in a home in 
their community as a more acceptable alternative of care for the 
veteran. Veterans are placed in a home with other veterans and have a 
live-in qualified caregiver to support their medical needs 24/7.
    While VA is required to provide institutional care, such as nursing 
home services to veterans who qualify for health care and have a 
service-connected disability rating of 70 percent or higher or are 
considered unemployable and have a disability rating of 60 percent or 
higher, the agency cannot directly pay for care through the medical 
foster home program. Veterans participating in the foster home program 
typically pay for these services from monthly VA disability 
compensation and Social Security payments and personal saving accounts.
    VA recognizes the positive health outcomes and costs savings 
associated with veterans receiving care and services through the foster 
home program. This legislation would provide VA the mechanism to pay 
for the care directly so veterans and their families would not have to 
forfeit earned benefits to pay for care they would otherwise be 
entitled to if they were receiving institutionalized care.
    H.R. 5864, VA Hospitals Establishing Leadership Performance Act. 
MOAA supports this legislation.
    H.R. 5864 would require the VA to establish qualifications and 
standardized performance metrics for each human resources position 
within the veterans' health care system and submit a report to Congress 
on these qualifications and standards. The Comptroller General is 
required to follow up with a report on how the VA implemented the 
requirement to include an assessment of the quality of the 
qualifications and performance metrics adopted by the agency.
    MOAA is pleased to see the legislation put forth to improve and 
strengthen VA's human resources system. Effective transformation will 
require leaders at all levels of the organization to be responsible and 
accountable for improving organizational health and staff engagement. 
Such transformation must include reforming and modernizing the VA's 
leadership and human capital management systems across the enterprise. 
While MOAA would like to see more comprehensive human resources 
strategy for system change along with the technology, resources, and 
funding to support the overhaul, H.R. 5864 is a foundational element to 
begin the massive overhaul needed to recruit, retain, and sustain a 
viable workforce. If we are to address the ongoing medical staffing 
shortages within the VA, then securing and sustaining high quality 
human resource professionals is essential.
    DRAFT Bill, Veterans Serving Veterans Act. MOAA supports this 
legislation.
    The Veterans Serving Veterans Act would permit the department to 
establish a database to capture specialties and skills of medical 
members of the Armed Forces to facilitate recruitment and address the 
occupational workforce needs of the VA.
    The legislation would also require the department to establish and 
implement a training and certification program for veterans to work as 
medical technicians in VA.
    The database, to be called the ``Department of Defense and Veterans 
Affairs Recruitment Database,'' is intended to be a single, searchable 
platform by which the two departments can exchange information on 
military occupational specialty or skills of consenting members of the 
Armed Forces who might be qualified after being discharged and released 
from active duty to fill medical vacancies in the VA. VA would be 
authorized to use direct hiring and appointment authorities and may 
authorize a relocation bonus to expedite hiring.
    Just as H.R. 5864 listed above offers an opportunity to address 
critical workforce shortfalls, the Veterans Serving Veterans Act is 
equally important in identifying and securing critical medical 
professionals who may be qualified and interested in serving in the VA. 
MOAA has advocated for years for more collaboration and communications 
between DoD and VA as one of many ways to address VA's critical 
professional and technical medical staffing shortages. MOAA is pleased 
to support this important legislation and is confident DoD and VA can 
implement the provisions in this bill with minimal cost to either 
department as the database should be considered a standard tool and 
requirement for use by human resources professionals.
    MOAA thanks the Subcommittee for considering these important pieces 
of legislation and we look forward to working with members of Congress 
in making the necessary changes listed above and to move the bills 
quickly through the Congress for final passage.

                                 
                     PARALYZED VETERANS OF AMERICA
    Chairman Dunn, Ranking Member Brownley, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to submit our views on the broad array of 
pending legislation impacting the Department of Veterans Affairs (VA) 
that is before the Subcommittee. No group of veterans better 
understands the full scope of care provided by the VA than PVA's 
members-veterans who have incurred a spinal cord injury or disease. 
Most PVA members depend on VA for 100 percent of their care and are the 
most vulnerable when access and quality of care is threatened. Several 
of these bills will help to ensure veterans receive timely, quality 
care and services.

H.R. 2787, the ``Veterans-Specific Education for Tomorrow's Medical 
    Doctors Act''

    PVA supports H.R. 2787, the ``Veterans-Specific Education for 
Tomorrow's Medical Doctors Act.'' This bill would establish a pilot 
program in the VA for pre-med students to experience clinical 
observation before attending medical school. The pilot would be carried 
out for a three-year period at no more than five medical centers. The 
goals of this clinical observation pilot would be to increase awareness 
and knowledge of veterans' health care for future medical professionals 
and increase provider diversity. While VA does already allow for 
clinical observation, this pilot would assist in enhancing the 
awareness of veteran-specific needs among future medical professionals. 
Each session would allow for no fewer than 20 students and 60 
observational hours with three sessions per calendar year. In selecting 
which medical centers and specialties are to participate, the Secretary 
may select those with the largest staffing shortages. PVA recommends VA 
provide the participating students with information regarding 
employment at VA, including educational opportunities and loan 
repayment programs.

H.R. 3696, the ``Wounded Warrior Workforce Enhancement Act''

    PVA supports the goal of this legislation to the extent that it 
attempts to rejuvenate a declining orthotics and prosthetics workforce. 
We have a concern, however, as to whether the veteran community will 
truly capitalize on the return on this investment if the legislation 
does not require some level of service commitment from student 
beneficiaries.
    Quality orthotic and prosthetic care is of the utmost importance to 
PVA members. No group of veterans understands the importance of 
prosthetics and orthotics more than veterans with spinal cord injury or 
disease. The Independent Budget Veteran Service Organizations (IBVSOs) 
maintain that the VA must ensure that prosthetics departments are 
staffed by certified professional personnel or contracted staff that 
can maintain and repair the latest technological prosthetic devices. A 
key component to this is continued support for the VA National 
Prosthetics Technical Career Program which aims to address the 
projected personnel shortages.
    In June of 2015, the National Commission on Orthotic and Prosthetic 
Education (NCOPE) released its analysis projecting orthotics and 
prosthetics workforce supply and patient demand over the next ten 
years. The analysis showed that the overall number of credentialed O&P 
providers will need to increase approximately 60 percent by 2025 to 
meet the growing demand. This is in part due to the fact that attrition 
rates from the profession will surpass the graduation rates of those 
entering the field, ultimately resulting in a decreasing supply of 
orthotics and prosthetics providers. Failure to address both the 
decreasing supply of providers and the increasing demand for their 
services will very likely cause the workforce to shift toward non-
credentialed providers. Our veterans deserve to be cared for by 
competent and highly trained individuals.
    This legislation is an important step toward ensuring that our 
veterans continue to be treated by credentialed providers. It promotes 
the expansion of a qualified teaching and faculty pool which will 
provide the foundation to accommodate and train a growing number of 
students seeking to become providers. In addition to the expected 
dissemination of best practices and knowledge from the proposed Center 
of Excellence, the legislation also provides eligible institutions 
built-in flexibility to tailor and use the funds for educational areas 
where they can achieve the goal of expanding the orthotics and 
prosthetics workforce most effectively. PVA also supports the proposed 
veterans' preference in the admissions process. As the IBVSOs have 
stated before, employing veterans in this arena will ensure a balance 
between the perspective of the clinical professionals and the personal 
needs of the disabled veterans.
    PVA's concern, though, is that the bill misses an opportunity to 
capture a more predictable and tangible return on investment. Requiring 
scholarship recipients to serve a commitment with the VA is a way to 
strengthen the precision with which these funds are allocated without 
reducing the previously mentioned institutional flexibility. The goal 
of this legislation is, after all, to expand the orthotics and 
prosthetics workforce in order to better serve veterans. While the 
proposed approach of expanding the overall pool of qualified service 
providers within the community writ large might have a trickle effect 
of ensuring that the VA continues to offer certified providers, we 
believe this suggested change would have a stronger and more immediate 
impact.

H.R. 5521, the ``VA Hiring Enhancement Act''

    PVA supports H.R. 5521, the ``VA Hiring Enhancement Act.'' The bill 
would amend title 38 to provide for the non-applicability of non-VA 
covenants not to compete to the appointment of certain Veterans Health 
Administration personnel. It would also permit VHA to make contingent 
appointments and require VA physicians to complete residency training. 
This bill intends to fill vacancies and make VA more competitive by 
authorizing VHA to begin the recruitment and hiring process up to two 
years prior to the completion of required training. This would allow 
for physicians to quickly begin work at VA medical centers upon the 
completion of their education. This could help to stem the flow of the 
ever recurring stories of young clinicians who wished to serve veterans 
but were unable to endure the months of an uncertain onboarding 
process. Veterans deserve the best this country can offer. Congress 
should explore every means to ensure VA does not lose out on young 
professionals due to inefficient hiring practices.

H.R. 5693, the ``Long-Term Care Veterans Choice Act''

    PVA supports H.R. 5693, the ``Long-Term Care Veterans Choice Act.'' 
This bill proposes to amend title 38 to authorize the VA to enter into 
contracts or agreements for the transfer of veterans to non-VA adult 
foster homes for certain veterans who are unable to live independently. 
PVA believes that VA's primary obligation involving long-term support 
services is to provide veterans with quality medical care in a healthy 
and safe environment.
    As it relates to veterans with a catastrophic injury or disability, 
it is PVA's position that adult foster homes are only appropriate for 
disabled veterans who do not require regular monitoring by licensed 
providers, but rather are able to maintain a high level of independence 
despite needing assistance due to having a catastrophic injury or 
disability. When these veterans are transferred to adult foster homes, 
care coordination with VA specialized systems of care is vital to the 
veterans' overall health and well-being. The drafted text of this bill 
requires the veteran to receive VA home health services as a condition 
to be transferred. As such, PVA believes that if a veteran with a 
spinal cord injury or disease (SCI/D) is eligible and willing to be 
transferred to an adult foster home, the VA must have an established 
system in place that requires the VA home-based primary care team to 
coordinate care with the VA SCI/D Center and the SCI/D primary care 
team that is in closest proximity to the adult foster home. When caring 
for a veteran with a catastrophic injury or disability this specialized 
expertise is extremely important to prevent and treat associated 
illnesses that can quickly manifest and jeopardize the health of the 
veteran. When catastrophically injured or disabled veterans who receive 
services from one of the VA's specialized systems of care are placed in 
a non-VA adult foster home they must be regularly evaluated by 
specialized providers who are trained to meet the needs of their 
specific conditions.

H.R. 5864, the ``VA Hospitals Establishing Leadership Performance Act''

    PVA supports H.R. 5864, the ``VA Hospitals Establishing Leadership 
Performance Act'' that would direct the Secretary to establish 
qualifications for the human resources positions within VHA. It would 
also require VA to standardize performance metrics and report the 
findings to Congress. There currently are no such requirements.

H.R. 5974, the ``Department of Veterans Affairs Creation of On-Site 
    Treatment Systems Affording Veterans Improvements and Numerous 
    General Safety Enhancements Act''

    PVA supports H.R. 5974, the ``Department of Veterans Affairs 
Creation of On-Site Treatment Systems Affording Veterans Improvements 
and Numerous General Safety Enhancements Act.'' This legislation would 
direct the Secretary to use on-site regulated medical waste treatment 
systems at certain VA facilities.
    Currently, most VA facilities dispose of medical and biohazardous 
waste by contracting for its removal by truck. This method is 
expensive, and poses inherent risk by loading waste, such as blood, 
microbiological cultures, body parts, dressings, etc., onto vehicles 
that must travel to disposal sites. The opportunity for accidents, 
spillage, and exposure to the public are ever present. This legislation 
would allow, where it results in savings, for VA to discard its own 
waste using on-site regulated medical waste treatment systems.

H.R. 5938, the ``Veterans Serving Veterans Act of 2018"

    PVA supports the intent of this legislation. However, we have some 
concerns regarding the level of interagency cooperation it would take 
to enact this legislation. We are eager to learn the position of VA and 
the Department of Defense (DOD) regarding this bill. Additionally, we 
have some concerns regarding privacy.
    The draft bill would establish a vacancy and recruitment database 
to facilitate the recruitment of soon to separate members of the Armed 
Forces in order to fill vacant positions at VA. To do so, it requires 
DOD to provide the names and contact information of every member of the 
Armed Forces whose military occupational specialty or skill corresponds 
to an employment vacancy at the VA. We are unconvinced the current 
employment databases are so insufficient to navigate that it justifies 
this degree of interagency upkeep as well as the upfront provision of 
the names, contact information, and skillsets of individuals soon to 
leave the military. Most concerning, this database of DOD information, 
to be maintained by VA, would automatically submit service members' 
information and require one to opt-out, rather than opt-in, in writing. 
While PVA commends the intent of this legislation, to fill vacancies 
and provide suitable employment to newly separated service members, we 
recommend privacy and efficiency concerns be addressed.

Draft legislation, ``to improve productivity of the management of 
    Department of Veterans Affairs health care, and for other 
    purposes''

    PVA supports the intent of this draft legislation. As written, the 
draft would require VA to track relative value units (RVU) for all VA 
providers. It would also require all providers to attend training on 
clinical procedure coding. In addition, it would direct the Secretary 
to establish for each facility standardized performance standards based 
on RVUs that are applicable to each specialty, as well as remediation 
plans for low productivity and clinical inefficiencies.
    RVUs, a private sector standard used to determine productivity 
against expenses, has been a widely used tool by the Centers for 
Medicare and Medicaid Services for decades. The primary purpose of 
which is not to enhance patient outcomes but to determine provider 
payments. While RVUs could be useful, they are not perfectly applicable 
for a holistic health system like VA.
    PVA strongly supports the use of any tool that betters the care 
veterans receive. If legislation proposed a tool that would both 
increase quality and save the taxpayer, we would support it. However, 
we are not convinced the RVU measure will motivate providers at 
facilities appropriately. A private sector model is not applicable to 
veteran centric, complex care provided at VA. As the private sector 
rarely discloses their own performance under such measurement, we are 
hesitant to support a flawed comparison between the two systems that 
benefits neither.
    As is often noted, VA providers spend far more time with patients 
compared with the private sector, to the increased satisfaction of the 
veteran. And since providers are not compensated by quantity of 
patients seen, the incentive to spend quality time with a patient is 
encouraged. We are eager to learn VA's position on this bill.
    PVA would once again like to thank the Subcommittee for the 
opportunity to submit our views on the programs affecting veterans. We 
look forward to working with you to ensure our catastrophically 
disabled veterans and their families receive the medical services and 
supports they need.