[Senate Hearing 115-]
[From the U.S. Government Publishing Office]



 
     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2019

                              ----------                              


                         WEDNESDAY, MAY 9, 2018

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                   Washington, D.C.
    The subcommittee met at 2:30 p.m. in Room SD-124, Dirksen 
Senate Office Building, Hon. John Boozman (chairman) presiding.
    Present: Senators Boozman, Murkowski, Capito, Rubio, 
Schatz, Tester, Murray, Udall, and Baldwin.

                     DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF HON. RANDY C. REEVES, UNDER SECRETARY FOR 
            MEMORIAL AFFAIRS, NATIONAL CEMETERY 
            ADMINISTRATION
ACCOMPANIED BY:
        HON. JON J. RYCHALSKI, ASSISTANT SECRETARY FOR MANAGEMENT AND 
            CHIEF FINANCIAL OFFICER
        DR. CAROLYN C. CLANCY, M.D., EXECUTIVE IN CHARGE, VETERANS 
            HEALTH ADMINISTRATION
        THOMAS J. MURPHY, EXECUTIVE IN CHARGE, VETERANS BENEFITS 
            ADMINISTRATION


               opening statement of senator john boozman


    Senator Boozman. The subcommittee will come to order. Good 
afternoon, and thank you all for being here today to discuss 
the fiscal year 2019 and the fiscal year 2020 budget for the 
Department of Veterans Affairs.
    As far as Federal domestic spending goes, this budget 
request makes the Department of Veterans Affairs a very 
comfortable place. With a $6.6 billion or 8.3 percent funding 
increase for the Department, the budget request before us today 
is generous. I should note that this amount includes the $2.4 
billion budget amendment officially submitted by OMB. It does 
not, however, include the additional funds that we understand 
may be required for fiscal year 2019.
    How the Department spends these funds is really the real 
issue at hand, not the dollar amount. With the uncertainty over 
the amounts in the budget request and all the other changes at 
VA, it is more important than ever to hear from those in charge 
of the VA's major components about how they are planning to 
effectively and efficiently use the resources they are asking 
for. I want to hear from you today how VA plans to improve cost 
estimates, manage spending more prudently, and be more 
transparent with Congress.
    This hearing comes at an opportune time, as Congress 
continues to wrestle with the question of how to address the 
additional needs this year in community care discretionary 
spending and Veterans Choice Program mandatory spending. 
Progress is being made over on the authorizing side on this 
problem, literally, as we speak, efforts I will be involved in 
through my membership on the Senate VA Committee, but we are 
dangerously close to depleting the Choice account and I want to 
hear from you today how we can help you avoid situations where 
you don't have the funds needed to provide the care veterans 
expect.
    Additionally, we look forward to hearing about the status 
of the electronic health record system, the progress made to 
reduce incidents of veterans suicide and the over prescription 
of opioids, your efforts to address the appeals backlog by 
modernizing the disability claims appeals process, and also how 
we can help the VA access care through increasing internal VA 
care and improving care in the community. This, coupled with 
your efforts to increase telemedicine, is especially important 
for our rural veterans. These are all issues this subcommittee 
continues to care deeply about.
    [The statement follows:]
               Prepared Statement of Senator John Boozman
    The Subcommittee will come to order. Good afternoon. Thank you all 
for being here today to discuss the fiscal year 2019 and the fiscal 
year 2020 budget request for Department of Veterans Affairs.
    As far as Federal domestic spending goes, this budget request makes 
the Department of Veterans Affairs a very comfortable place. With a 
$6.6 billion or 8.3 percent funding increase for the Department, the 
budget request before us today is generous. I should note that this 
amount includes the $2.4 billion budget amendment officially submitted 
by OMB. It does not, however, include additional funds that we 
understand may also be required for fiscal year 2019. How the 
Department spends these funds is the real issue at hand, not the dollar 
amount. With the uncertainty over the amounts in the budget request and 
all the other changes at VA, it is more important than ever to hear 
from those in charge of the VA's major component administrations about 
how they plan to effectively and efficiently use the resources they are 
asking for. I want to hear from you today how VA plans to improve cost 
estimates, manage spending more prudently, and be more transparent with 
Congress.
    This hearing comes at an opportune time, as Congress continues to 
wrestle with the question of how to address the additional needs this 
year in community care discretionary spending and Veterans Choice 
Program mandatory spending. Progress is being made over on the 
authorizing side on this problem as we speak--efforts I will be 
involved in through my membership on the Senate VA Committee, but we 
are dangerously close to depleting the Choice account and I want to 
hear from you today how we can help you avoid situations where you 
don't have the funds needed to provide the care veterans expect.
    Additionally, we look forward to hearing about the status of the 
electronic health record system; the progress made to reduce incidents 
of veterans suicide and the over prescription of opioids; your efforts 
to address the appeals backlog by modernizing the disability claims 
appeals process; and also how we can help the VA increase access to 
care through increasing internal VA care and improving care in the 
community. This, coupled with your efforts to increase telemedicine, is 
especially important for our rural veterans. These are all issues this 
Subcommittee continues to care deeply about.

    Senator Boozman. With that, I'd like to turn it over to you 
for an opening statement.

               OPENING STATEMENT OF SENATOR BRIAN SCHATZ

    Senator Schatz. Thank you, Mr. Chairman. Thank you for 
holding today's hearing to review the VA's budget request for 
fiscal years 2019 and 2020. I also want to thank the witnesses 
for being here today.
    With the exception of DOD, Mick Mulvaney is asking almost 
every agency cut its funding. So it's good to see that VA is 
making a strong request for more than $85 billion, which is 
$3.9 billion over the 2018 enacted level, which includes badly 
needed investments in VA infrastructure. Our veterans should 
not be forced to get care in crumbling facilities not up to 
code.
    But I have some concerns about how this request will affect 
some of VA's most pressing challenges. The VA has taken steps 
to overhaul its electronic health records, and Congress has 
supported those steps. This committee sees the wisdom in the 
VA's decision to buy the same system as DOD, and we provided 
the funding to VA to get the system online. But the process has 
stalled, in part, because of the leadership vacuum at VA; 
contracting delays; and, finally, the need to align the VA and 
DOD rollout, given it's going to be the same system.
    Therefore, I don't understand why, if the VA hasn't spent 
the hundreds of millions of dollars that have already been 
appropriated for this new system, that the VA would then 
request $1.2 billion on top of it. We have a fixed amount of 
money in our allocation, and it makes little sense to give the 
VA more money for the Electronic Health Records (EHR) system so 
that it can sit in an account while this all gets sorted out. 
Instead, I'd like to see the VA request money that can 
immediately be spent to improve healthcare for veterans, and so 
I hope our witnesses can explain the request.
    I'm also concerned that this request appears to ask us to 
push VA towards privately provided care. Right now, Congress 
has the ability to make informed decisions about how much VA 
intends to spend on private care versus in-house care. But this 
request proposes to consolidate medical community care and 
medical services accounts, which would weaken this committee's 
ability to do oversight and obscure how the VA obligates money. 
The VA can and should ensure access to all veterans by relying 
on community providers where appropriate, and that's especially 
important for veterans who live in rural and remote areas. But 
it cannot come at the expense of VA's internal healthcare 
system.
    Finally, I'm concerned that no amount of money from 
Congress can fix the leadership issues at VA. The Department is 
losing qualified professionals, seemingly, by the day. That 
includes Scott Blackburn, the person overseeing the EHR 
transformation, who quit in April; Chris Vojta, the principal 
deputy undersecretary for health, responsible for helping run 
the VA's 1,200 hospitals and clinics, who quit last week; and 
Dr. Amy Fahrenkopf, the official working to streamline the 
Choice Program, who quit last Monday.
    If news reports are to be believed, political appointees 
have no interest in listening to career VA professionals who 
are there to help them to do their jobs. This is turning into a 
crisis for our veterans and for the 360,000 employees who serve 
them every day. There needs to be leadership, trust, 
collaboration, accountability, and stability, all of which are 
currently lacking.
    I am committed to working with you and the rest of the 
members of the committee, Mr. Chairman, to provide the VA with 
the fiscal ability it needs to continue to provide veterans 
with the high-quality care they deserve, and I hope that 
through congressional oversight, the VA can find its footing 
again.
    Thank you.
    Senator Boozman. Thank you very much.
    Let's introduce the panel: The Honorable Randy C. Reeves, 
Undersecretary for Memorial Affairs; The Honorable Jon 
Rychalski, the Assistant Secretary for Management and Chief 
Financial Officer; Dr. Carolyn Clancy, Executive in Charge, 
Veterans Health Administration; and Mr. Thomas Murphy, the 
Executive in Charge, Veterans Benefits Administration.
    We welcome you all, and we really do appreciate all of your 
hard work and your willingness to be here.
    I now recognize Mr. Reeves for your five-minute opening 
statement.

                  SUMMARY STATEMENT HON. RANDY REEVES

    Mr. Reeves. Chairman Boozman, Ranking Member Schatz, 
distinguished members of the subcommittee, thank you for this 
opportunity to be able to discuss VA's fiscal year 2019 budget. 
As the chairman said, I have with me Jon Rychalski, Assistant 
Secretary for Management and our Chief Financial Officer; Dr. 
Carolyn Clancy, our Executive-in-Charge of the Veterans Health 
Administration; and Tom Murphy, Executive in Charge of the 
Veterans Benefits Administration.
    President Trump's 2019 budget and 2020 advance 
appropriations request is a strong budget. It reflects the 
President's commitment to veterans and their families. It 
provides the resources necessary to continue modernizing VA and 
responding to veterans' changing needs with increased 
investments in foundational services, greater access to care, 
more effective management practices, and modernization of 
infrastructure and legacy systems.
    The President's 2019 budget requests $198.6 billion for the 
Department, which includes $88.9 billion in discretionary 
funding with medical care collections and $109.7 billion in 
mandatory benefits. We thank Congress for the passage of the 
2018 Omnibus funding bill, and, in particular, we appreciate 
the additional $2 billion made available in the caps deal in 
2018 to address our highest priority infrastructure needs. Our 
2019 capital request of $3.4 billion builds on the 2018 
investment and provides $1.1 billion in major construction 
funding as well as $707 million in minor construction.
    With respect to Medical Care, this budget requests $76.5 
billion to provide medical care to approximately 9 million 
enrolled veterans, including me. Suicide prevention, 
appropriately, continues to be VA's top clinical priority. This 
budget includes $8.6 billion for veterans' mental health 
services, enabling about 162,000 more outpatient visits in 2019 
than in 2018, and directing $190 million for suicide prevention 
outreach. It funds the new policy enacted in the 2018 Omnibus 
to provide mental health and/or behavioral health care services 
to members who were administratively discharged under other 
than honorable conditions and enables us to effectively 
implement the President's Executive Order that provides 
transitioning military members with mental health services 
during that first critical year after they leave active 
military service.
    We're also taking significant steps to address women's 
health, as women are one of the fasting growing veteran 
populations, by requesting a budget a of $5.7 billion for care 
for women veterans that specifically includes $511 million for 
gender specific care for women.
    In Information Technology, VA's planned investments 
prioritize the development of replacements for specific mission 
critical legacy systems. The budget includes $1.2 billion to 
advance implementation of a single, accurate, lifetime 
electronic health record.
    The 2019 budget also makes important investments in benefit 
services. For example, we will hire an additional 605 personnel 
for VBA's Appeals Management Office, an increase of 40 percent, 
to implement reforms, and we will also hire an additional 225 
fiduciary field examiners to ensure protection of our most 
vulnerable population.
    Veterans and their families deserve access, choice, and 
control over their healthcare. VA has communicated to Congress 
that we anticipate exhausting all Choice funds, and we expect 
the program will cease to be viable as early as May 31st unless 
additional funds are provided.
    We appreciate how extremely supportive the committees have 
been of VA, and we urge Congress to pass the VA Mission Act. I 
have seen firsthand how important flexibility and collaboration 
between VA and community partners is to our veterans.
    Last year, on August 23, 2017, I was on my way to join 
President Trump and leaders of our veteran service 
organizations in Reno for the signing of the Appeals 
Modernization Act of 2017 when I received a call from Ms. Kathy 
Ellis. At that time, I served as the Director of Veterans 
Affairs for the great state of Mississippi. Her son, a Navy 
veteran, was in need of a liver transplant. Matt was within 
days of death without treatment. I called VA, and the Memphis, 
Tennessee, VA Medical Center contacted the Ellis family and 
took the handoff for his care and provided treatment to get him 
healthy enough to receive a transplant. He was able to receive 
a new liver at the Vanderbilt transplant program and now gets 
his essential follow-up care at the Memphis VA.
    VA saved Matt Ellis' life because of its ability to 
coordinate the right care between VA and the community at the 
right time. VA does this every day, but the current system of 
coordinating care with our partners is cumbersome and requires 
the use of several different programs. We urge Congress to 
continue its bipartisan support as we believe swift passage of 
the VA Mission Act is critically needed to ensure timely access 
to the care America's veterans need and have earned.
    As a member of VA's leadership team, I feel compelled to 
advocate for the 360,000 dedicated career professionals who 
come to work every day to serve veterans. From our senior 
leaders down to our team members in the field, I can assure you 
that day to day, it is always all hands on deck to provide the 
care and services veterans have earned and that they deserve. 
The President's budget supports our mission at VA, and in the 
coming years, these priorities will help VA maintain our sacred 
commitment to care for America's veterans.
    Mr. Chairman, I look forward to working with you and the 
committee on doing what's right for America's veterans, and 
thank you for the committee's commitment to care for and serve 
our veterans. I and my colleagues here look forward to 
answering any questions that you may have.
    [The statement follows:]
                 Prepared Statement of Hon. Randy Reeves
    Good afternoon Chairman Boozman, Ranking Member Schatz, and 
distinguished members of the Subcommittee. Thank you for the 
opportunity to testify today in support of the President's fiscal year 
2019 Budget, including the fiscal year 2020 Advance Appropriation (AA) 
request. I am accompanied today by: Jon Rychalski, Assistant Secretary 
for Management and Chief Financial Officer; Dr. Carolyn Clancy, 
Executive-in-Charge of the Veterans Health Administration; and Thomas 
Murphy, Executive-in-Charge of the Veterans Benefits Administration. I 
also want to thank Congress for making 2017 a legislative success for 
Veterans. With the unwavering support and leadership of our VA 
committees, Congress supported and passed groundbreaking legislation on 
Department of Veterans Affairs (VA) accountability, appeals reform, the 
Forever GI Bill, Veterans Choice improvements, personnel improvements, 
and extended Choice funding twice. The 2019 budget request fulfills the 
President's strong commitment to all of our Nation's Veterans by 
providing the resources necessary to improve the care and support our 
Veterans have earned through sacrifice and service to our country.
                    fiscal year 2019 budget request
    The President's fiscal year 2019 Budget requests $198.6 billion for 
VA--$88.9 billion in discretionary funding (including medical care 
collections), of which $76.5 billion is requested as the fiscal year 
2019 AA for Medical Care including collections. The $76.5 billion is 
comprised of $74.1 billion previously requested (including 
collections), and an annual appropriation adjustment of $500 million 
for Medical Services for community care and $1.9 billion for the 
Veterans Choice Fund. This budget will sustain the progress we have 
made and provide additional resources to improve patient access and 
timeliness of medical care services for the approximately 9 million 
enrolled Veterans eligible for VA healthcare, while improving benefits 
delivery for our Veterans and their beneficiaries. The President's 
fiscal year 2019 budget also requests $109.7 billion in mandatory 
funding, of which $107.7 billion was previously requested, for programs 
such as disability compensation and pensions.
    For the fiscal year 2020 AA, the budget requests $79.1 billion in 
discretionary funding including collections for Medical Care and $121.3 
billion in mandatory advance appropriations for Compensation and 
Pensions, Readjustment Benefits, and Veterans Insurance and Indemnities 
benefits programs in the Veterans Benefits Administration (VBA).
    This is a strong budget request that fulfills the President's 
commitment to Veterans by ensuring the Nation's Veterans receive high-
quality healthcare and timely access to benefits and services while 
concurrently improving efficiency and fiscal responsibility. I urge 
Congress to support and fully fund our fiscal year 2019 and fiscal year 
2020 AA budget requests--these resources are critical to enabling the 
Department to meet the increasing needs of our Veterans.
    Through the fiscal year 2019 budget formulation process, we have 
critically assessed and prioritized our needs and aggressively pursued 
internal offsets, modernization reforms, and other efficiencies to 
provide Veterans the quality care they have earned while serving as a 
responsible fiscal steward. VA greatly appreciates Congress' ongoing 
support for VA, as demonstrated by consistent support for our 
legislative priorities and consistently generous enacted 
appropriations, including the recently enacted 2018 Omnibus. On behalf 
of the entire VA and the many Veterans we serve, we thank you for your 
unflagging commitment to our mission and in particular your support for 
our capital infrastructure needs. VA takes very seriously our 
obligation to you, the American taxpayer, and the Veterans who served 
our country so well.
                         veterans' medical care
    The fiscal year 2019 Budget includes $ 76.5 billion for Medical 
Care and $79.1 billion for the fiscal year 2020 AA. VA is committed to 
ensuring Veterans get high quality, timely, and convenient access to 
care that is affordable for future generations. As a result, VA is 
implementing reforms that will prioritize our foundational services 
while redirecting to the community those services that they can do more 
effectively and efficiently. These foundational services are those that 
are most related to service-connected disabilities and unique to the 
skills and mission of the Veterans Health Administration (VHA).

    Foundational Services include these mission-driven services, such 
as:

  --Primary Care, including Women's Health;

  --Urgent Care;

  --Mental Health Care;

  --Geriatrics and Extended Care;

  --Rehabilitation (e.g., spinal cord, brain injury/polytrauma, 
        prosthesis/orthoses, blind rehab);

  --Post Deployment Health Care; and

  --War-Related Illness and Injury Study Centers functions.

    VA facility and Veterans Integrated Service Network (VISN) leaders 
are being asked to assess additional community options for other health 
services that are important to Veterans, yet may be as effectively or 
more conveniently delivered by community providers. Local VA leaders 
have been advised to consider accessibility of VA facilities and 
convenience factors (like weekend hours) as they develop 
recommendations for access to community providers for Veterans in their 
service areas.
    While the focus on Foundational Services will be a significant 
change to the way VA provides healthcare, VA will continue to ensure 
that the full array of statutory VA healthcare services are made 
available to all enrolled Veterans. VA will also continue to offer 
services that are essential components of Veteran care and assistance, 
such as assistance for homeless Veterans, Veterans Resource Centers, 
the Veterans Crisis Line/Suicide Prevention, Mental Health Intensive 
Case Management, treatment for Military Sexual Trauma, and substance 
abuse programs.
    In order to provide Veterans and taxpayers the greatest value for 
each dollar, the Budget also proposes certain changes to the way in 
which we spend those resources. For example, our fiscal year 2019 
request proposes to merge the Medical Community Care appropriation with 
the Medical Services appropriation, as was the practice prior to fiscal 
year 2017. The separate appropriation for Community Care has restricted 
our Medical Center Directors as they manage their budgets and make 
decisions about whether the care can be provided in their facility or 
must be purchased from community providers. This is a dynamic 
situation, as our staff must adjust to hiring and departures, 
emergencies such as the recent hurricanes, and other unanticipated 
changes in the healthcare environment throughout the year. This change 
will maximize our ability to focus even more resources on the services 
Veterans most need.
    VA is committed to delivering timely and high-quality healthcare to 
our Nation's Veterans. Veterans now have access to same-day services 
for primary care and mental healthcare at the more than 1,000 VA 
clinics across our system.
    In fiscal year 2019, VA will expand Veteran access to medical care 
by increasing medical and clinical staff, improving its facilities, and 
expanding care provided in the community. The fiscal year 2019 Budget 
requests a total of $76.5 billion in funding for Veterans' medical care 
in discretionary budget authority, including collections. The fiscal 
year 2019 request will support nearly 315,688 medical care Full-Time 
Equivalent (FTE) employees.
    VA is implementing a VISN-level Gap Coverage plan that will enable 
facilities to request gap coverage providers in areas that are 
struggling with staffing shortages. It is a seamless electronic request 
that allows VISNs to focus resources where they are most needed 
according to supply and demand. Telehealth will be the principal form 
of coverage in this initiative, which is budget neutral.
    Suicide prevention is VA's highest clinical priority, and Veteran 
suicide is a national health crisis. On average, 20 Veterans die by 
suicide every day--this is unacceptable. The integration of Mental 
Health program offices and their alignment with the suicide prevention 
team and the Veterans Crisis Line is being implemented to further 
enhance VA's ability to effectively meet the needs of the most 
vulnerable Veterans. The fiscal year 2019 Budget Request increases 
resources to standardize suicide screening and risk assessments and 
expands options for safe and effective treatment for Veterans 
struggling with post-traumatic stress disorder and suicide.
    The fiscal year 2019 Budget requests $8.6 billion for Veterans' 
mental health services. It also includes $190 million for suicide 
prevention outreach. VA recognizes that Veterans are at an increased 
risk for suicide, and we have implemented a national suicide prevention 
strategy to address this crisis. VA is bringing the best minds in the 
public and private sectors together to determine the next steps in 
implementing the Ending Veteran Suicide Initiative. VA's suicide 
prevention program is based on a public health approach that is 
ongoing, utilizing universal, selective, indicated strategies while 
recognizing that suicide prevention requires ready access to high-
quality mental health services, supplemented by programs that address 
the risk for suicide directly, starting far earlier in the trajectory 
that leads to a Veteran taking his or her own life. VA cannot do this 
alone; 70 percent of Veterans who die by suicide are not actively 
engaged in VA healthcare. Veteran suicide is a national issue and can 
only be ended through a nationwide community-level approach that begins 
to solve the upstream risks Veterans face, such as loss of belonging, 
meaningful employment, and engagement with family, friends, and 
community.
           executive order to improve mental health resources
    On January 9, 2018, President Trump signed an Executive Order 
(13822) titled, ``Supporting Our Veterans During Their Transition From 
Uniformed Service to Civilian Life.'' This Executive Order directs the 
Department of Defense (DoD), VA, and the Department of Homeland 
Security (DHS) to develop a Joint Action Plan that describes concrete 
actions to provide access to mental health treatment and suicide 
prevention resources for transitioning uniformed Servicemembers in the 
year following their discharge, separation, or retirement.
    VA, along with DoD and DHS, continues to work closely with the 
White House on a comprehensive implementation and communication plan 
that has multiple points of contact with transitioning Servicemembers 
and Veterans beginning prior to separation and continuing throughout 
the first year. An initial progress report is due on July 9, 2018. VA 
also encourages all transitioning Servicemembers and Veterans to 
contact their local VA medical facility or Vet Center to learn about 
what VHA mental healthcare services may be available. We note that 
section 258 of Division J (the Military Construction, Veterans Affairs, 
and Related Agencies Appropriations Act, 2018) of the Consolidated 
Appropriations Act, 2018 (Public Law 115-141) requires VA to provide 
information on mental and behavioral healthcare services to individuals 
eligible under that authority within 180 days of enactment or 180 days 
of discharge. It further requires coordination with the Secretary of 
Defense to ensure Servicemembers and those separating are provided 
appropriate information about programs, requirements, and procedures. 
VA is working to implement this new authority.
                          reach vet initiative
    As part of VA's commitment to put forth resources, services, and 
technology to reduce Veteran suicide, VA initiated the Recovery 
Engagement and Coordination for Health Veterans Enhanced Treatment 
(REACH VET) program. Proactively addressing complex care needs, 
including mental health concerns, can lead to better recovery outcomes, 
lessen the likelihood of challenges becoming crises, and reduce the 
stress that Veterans and their loved ones face.
    REACH VET uses clinical and administrative data in Veterans' 
medical records to identify and proactively engage in care those who 
may be at risk for hospitalization, illness, suicide, and other adverse 
outcomes. In short, REACH VET works to help inform VA providers of the 
most vulnerable Veterans under their care. This program finished its 
first year of full implementation in February 2018 and has identified 
more than 30,000 at-risk Veterans. REACH VET uses a new predictive 
model to analyze existing data from Veterans' health records to 
identify those who are at a statistically elevated risk for suicide, 
hospitalization, illnesses, and other adverse outcomes, so that VHA 
providers can review and enhance care and talk to these Veterans about 
their needs. REACH VET was expanded to provide risk information about 
suicide and opioids, as well as clinical decision support to Veterans 
Crisis Line responders and is being further expanded to provide this 
important risk information to frontline VHA providers. REACH VET is 
limited to Veterans engaged in our healthcare system and is risk-
focused, so while it is critically important to those Veterans it 
touches, it is not enough to bring down Veteran suicide rates. We will 
continue to take bold action aimed at ending all Veteran suicide, not 
just for those engaged with our system.
                    other than honorable initiative
    We know that 14 of the 20 Veterans who, on average, died by suicide 
each day in 2014 did not, for various reasons, receive care within VA 
in 2013 or 2014. Our goal is to more effectively promote and provide 
care and assistance to such individuals to the maximum extent 
authorized by law. To that end, beginning on July 5, 2017, VA promoted 
access to care for emergent mental healthcare to the more than 500,000 
former Servicemembers who separated from active duty with other than 
honorable (OTH) administrative discharges. This initiative specifically 
focuses on providing access to former Servicemembers with OTH 
administrative discharges who are in mental health distress and may be 
at risk for suicide or other adverse behaviors. As part of this 
initiative, former Servicemembers with OTH administrative discharges 
who present to VA seeking emergency mental healthcare for a condition 
related to military service would be eligible for evaluation and 
treatment for their mental health condition. Such individuals may 
access the VA system for emergency mental health services by visiting a 
VA emergency room, outpatient clinic, Vet Center, or by calling the 
Veterans Crisis Line. Services may include assessment, medication 
management/pharmacotherapy, lab work, case management, psycho-
education, and psychotherapy. As of December 30, 2017, VHA had received 
3,241 requests for healthcare services under this program. In addition, 
in fiscal year 2017, Readjustment Counseling Services through Vet 
Centers provided services to 1,130 Veterans with ``Other than 
Honorable'' administrative discharges and provided 9,889 readjustment 
counseling visits.
                                  care
    Veterans deserve greater access, choice, and control over their 
healthcare. VA is committed to ensuring Veterans can make decisions 
that work best for themselves and their families. Our current system of 
providing care for Veterans outside of VA requires that Veterans and 
community providers navigate a complex and confusing bureaucracy. VA is 
committed to building an improved, integrated network for Veterans, 
community providers, and VA employees; we call these reforms Veteran 
Coordinated Access & Rewarding Experiences, or Veteran CARE.
    Veteran CARE would clarify and simplify eligibility requirements, 
build a high- performing network, streamline clinical and 
administrative processes, and implement new care coordination support 
for Veterans. Veteran CARE would improve Veterans' experience and 
access to healthcare, building on the best features of existing 
community care programs. This new program would complement and support 
VA's internal capacity for the direct delivery of care with an emphasis 
on Foundational Services. The CARE reforms would provide VA with new 
tools to compete with the private sector on quality and accessibility.
    Demand for community care remains high. The Veterans Choice Program 
comprised approximately 62 percent of all VA community care completed 
appointments in fiscal year 2017. We thank Congress for the combined 
$4.2 billion provided in Calendar Year 2017 to continue the Choice 
Program while discussions continue regarding the future of VA community 
care. Based on historical trends, current Choice funding is expected to 
run out in the first 2 weeks of June 2018, depending on program 
utilization. VA has partnered with Veterans, community providers, 
Veterans Service Organizations (VSO), and other stakeholders to 
understand their needs and incorporate crucial input into the concept 
for a consolidated VA community care program. The time to act is now, 
and we need your help. We believe we are in agreement that the 
legislation reforming the Choice Program and the Department's other 
Community Care Programs is our best course of action.
    In fiscal year 2019, the Budget reflects $14.2 billion in total 
purchasing power to support community care for Veterans. This includes 
an additional $2.4 billion in discretionary funding that is now 
available as a result of the recently enacted legislation to raise 
discretionary spending caps. Of this amount, $1.9 billion replaces the 
mandatory funding that was originally requested in fiscal year 2018 to 
be carried over into fiscal year 2019. This funding will be used to 
continue the Choice Program for a portion of fiscal year 2019 until VA 
is able to fully implement the Veteran CARE program. The remaining $500 
million will support VA's traditional community care program in fiscal 
year 2019. Since the time of the budget submission, VA has identified 
the additional need for continuing the Choice Program while 
transitioning to a new consolidated community care program. To ensure 
that the House and Senate Appropriations and Veterans' Affairs 
Committees are fully apprised of our funding requirements for both the 
Choice Program and traditional community care, VA has written to the 
leadership of all four committees to provide the detailed analysis. 
Further delay of enacted legislation beyond Memorial Day will result in 
substantially increased spending.
    In order to continue the Choice Program beyond the first 2 weeks of 
June 2018, VA requires $1.3 billion in fiscal year 2018 and an 
additional $2.0 billion to $3.6 billion (dependent on the time of 
enactment of the legislation) in fiscal year 2019. This assumes the 
Choice Program must continue for 12 months post-enactment of the CARE 
legislation to ensure seamless transition to the new program.
    In addition, VA could require an additional $1.6 billion to $2.1 
billion (dependent on the time of enactment of the legislation) above 
our request for the traditional community care program due to higher 
execution in fiscal year 2018, resulting in less carryover available in 
fiscal year 2019, and reimbursement at a higher rate than Medicare. 
Some of this additional need could be addressed within existing or 
requested fiscal year 2019 Medical Care resources.
    Finally, the Budget transitions VA to recording community care 
obligations on the date of payment, rather than the date of 
authorization. This change in the timing of obligations results in a 
one-time adjustment of $1.8 billion.
             electronic health record modernization (ehrm)
    The Budget invests $1.2 billion in EHRM. The health and safety of 
our Veterans is one of our highest national priorities. On June 5, 
2017, former Secretary Shulkin announced the decision to adopt the same 
electronic health record (EHR) system as DoD. This transformation is 
about improving VA services and significantly enhancing the 
coordination of care for Veterans who receive medical care not only 
from VA, but DoD and our community partners. We have a tremendous 
opportunity for the future with EHRM to build transparency with 
Veterans and their care providers, expand the use of data, and increase 
our ability to communicate and collaborate with DoD and community care 
providers. In addition to improving patient care, a single, seamless 
EHR system will result in a more efficient use of VA resources, 
particularly as it relates to healthcare providers. Given the magnitude 
of this transformation and the significant long-term costs and complex 
contracting needs, we requested a single separate account for this 
effort and thank Congress for establishing this account in the fiscal 
year 2018 Appropriations Act.
    The fiscal year 2019 Budget continues VA's investment in technology 
to improve the lives of Veterans. The planned Information Technology 
(IT) investments prioritize the development of replacements for 
specific mission critical legacy systems, as well as operations and 
maintenance of all VA IT infrastructure essential to deliver medical 
care and benefits to Veterans. The request includes $381 million for 
development to replace specific mission critical legacy systems, such 
as the Benefits Delivery Network and the Burial Operations Support 
System. Investments in IT will also support efforts and initiatives 
that are directly Veteran-facing, such as mental health applications to 
support suicide prevention, modifications of multiple programs to 
accommodate special requirements of the community care program, Veteran 
self-service applications (Navigator concept), education claims 
processing integration consolidation, and benefit claim appeals 
modernization. The Budget also invests $398 million for information 
security to protect Veterans' information.
    The fiscal year 2019 Budget request would increase the Department's 
ability to apply agile program management to the dynamics of modern IT 
development requirements. To do this, the Department proposes 
increasing the transfer threshold from $1 million to $3 million between 
development project lines, which equates to less than 1 percent of the 
Development account. Through the Certification process, Congress will 
maintain visibility of proposed changes.
                     improved management processes
    Another critical system that will touch the delivery of all health 
and benefits is our new financial management system, which is under 
development. The fiscal year 2019 budget requests $72.8 million in IT 
funds and $48.8 million in fair share reimbursable funding from the 
Administrations for business process re-engineering to support 
Financial Management Business Transformation across the Department. 
These resources support the continued modernization of our financial 
management system by transforming the Department from numerous 
stovepipe legacy systems to a proven, flexible, shared service business 
transaction environment. Even though the U.S. Department of Agriculture 
(USDA) is not moving forward as VA's Federal Shared Service Provider, 
VA continues to work with USDA to ensure a smooth transition. VA's 
Office of Finance continues to manage the program and the 
implementation is on schedule and within budget. In fact, I am pleased 
to report that the roll out of the first module, the Budget Formulation 
module, occurred as planned on March 26, 2018. This was the first major 
milestone and its success reflects the commitment of everyone involved.
    VA also has implemented an initiative to detect and prevent fraud, 
waste, and abuse (STOP FWA). In support of this initiative, VA (1) 
established the VA Prevention of Fraud, Waste, and Abuse Advisory 
Committee, which will provide VA insight into best practices utilized 
in the private and public sector; (2) is partnering with Centers for 
Medicare & Medicaid Services to replicate their investigation process 
and utilize their data to identify medical providers with performance 
issues; and (3) is working with the Department of the Treasury to 
perform a deep dive to move VA's Community Care Program closer to the 
industry best practices.
    Another critical system VA is significantly improving relates to 
employee accountability. The vast majority of employees are dedicated 
to providing Veterans the care they have earned and deserve. It is 
unfortunate that some employees have tarnished the reputation of VA 
while so many have dedicated their lives to serving our Nation's 
Veterans. We will not tolerate employees who deviate from VA's I-CARE 
(Integrity, Commitment, Advocacy, Respect, and Excellence) values and 
underlying responsibility to provide the best level of care and 
services to them. Last May, VA established the Office of Accountability 
and Whistleblower Protection. Between June 1, 2017, and December 31, 
2017, VA removed more than 900 staff (not including probationary 
terminations) and placed more than 250 staff on suspensions of 14 days 
or greater. We thank Congress for passing the Department of Veterans 
Affairs Accountability and Whistleblower Protection Act of 2017 (Public 
Law 115-41), so that new accountability rules for VA are now the law of 
the land.
    We are also focused on improving our unduly burdensome internal 
hiring practices. In the face of a national shortage of healthcare 
providers, VHA faces competition with the commercial sector for scarce 
resources. Over the past year, we reduced the time it took to hire 
Medical Center Directors by 40 percent and obtained approval from the 
Office of Personnel Management for critical position pay authority for 
many of our senior healthcare leaders. But there is much work left to 
do. We need Congress's help with legislation to reform recruitment and 
compensation practices allowing VA to stay competitive with the private 
sector and other employers.
              infrastructure improvements and streamlining
    I want to thank Congress for providing $2 billion in additional 
funding for VA's infrastructure in the fiscal year 2018 Omnibus. This 
funding, which was focused on minor construction, non-recurring 
maintenance, and State Home Construction Grants, will greatly enhance 
our ability to address critical infrastructure needs, including funding 
the first 52 of the 61 State Home Grants in funding order on the 
Priority List Group 1. In fiscal year 2019, VA will continue to focus 
on improving its infrastructure while we transform our healthcare 
system to an integrated network to serve Veterans. This budget requests 
$1.1 billion in Major Construction funding, as well as $706.9 million 
in Minor Construction, for priority infrastructure projects. This 
funding supports projects including the St. Louis, Missouri, Jefferson 
Barracks Medical Facility Improvements and Cemetery Expansion project; 
the Canandaigua, New York, Construction and Renovation project; the 
Dallas, Texas, Spinal Cord Injury project; and national cemetery 
expansions in Rittman, Ohio; Mims, Florida; and Holly, Michigan. VA is 
also requesting $972 million to fund more than 2,100 medical leases in 
fiscal year 2019 and $672.1 million for activation of new medical 
facilities.
    VA appreciates the support of Congress and is grateful for the 
passage of the VA Choice and Quality Employment Act of 2017 (Public Law 
115-46), which included authorization for 28 major medical leases, some 
of which had been pending authorization for approximately 3 years. The 
leases will establish new points of care, expand sites of care, replace 
expiring leases, and expand VA's research capabilities. In fiscal year 
2019, VA is seeking Congressional authorization of four new outpatient 
clinic leases to expand services currently offered at existing clinics. 
The requested leases would be located in the vicinities of Lawrence, 
Indiana; Plano, Texas; Baton Rouge, Louisiana; and Beaumont, Texas.
    The fiscal year 2019 Budget includes a new initiative to address 
VA's highest priority facilities in need of seismic repairs and 
upgrades. VA's major construction request includes $400 million that 
will be dedicated to correct critical seismic issues that currently 
threaten the safety of Veterans and VA staff at VA facilities. The 
seismic program would fund newly identified unfunded, existing, and 
partially-funded seismic projects within VA's major, minor, and non-
recurring maintenance programs.
    VA's fiscal year 2019 Budget includes proposed legislative 
requests, consistent with the Veteran Coordinated Access & Rewarding 
Experiences (CARE) Act draft bill that VA submitted last fall, which, 
if enacted, would increase the Department's flexibility to meet its 
capital needs. These proposals include: 1) increasing from $10 million 
to $20 million the dollar threshold for minor construction projects; 2) 
modifying title 38 to eliminate statutory impediments to joint facility 
projects with DoD and other Federal agencies; and 3) expanding VA's 
enhanced use lease authority to give VA more opportunities to engage 
the private sector and local governments to repurpose underutilized VA 
property.
    To maximize resources for Veterans, VA repurposed or disposed of 
131 of 430 vacant or mostly vacant buildings since June 2017. VA is on 
track to meet the goal that was set in June 2017 for VA to initiate 
disposal or reuse actions for all 430 buildings by June 2019.
    For over a decade, the National Cemetery Administration (NCA) has 
achieved the highest customer satisfaction rating of any organization--
public or private--in the country. They achieved this designation 
through the American Customer Satisfaction Index six consecutive times. 
The President's fiscal year 2019 Budget enables the continuation of 
this unprecedented success with a request for $315.8 million for NCA in 
fiscal year 2019. This request will support the 1,941 FTE employees 
needed to meet NCA's increasing workload and expansion of services. In 
fiscal year 2019, NCA will inter over 134,000 Veterans and eligible 
family members and care for over 3.8 million gravesites. NCA will 
continue to memorialize Veterans by providing 364,850 headstones and 
markers, distributing 677,500 Presidential Memorial Certificates, and 
expanding the Veterans Legacy Program to communities across the 
country. VA is committed to investing in NCA infrastructure, 
particularly to keep existing national cemeteries open and to construct 
new cemeteries consistent with burial policies approved by Congress. In 
addition to NCA's funding, the fiscal year 2019 request includes $117.2 
million in major construction funds for three gravesite expansion 
projects. The budget also includes $45 million for the Veteran Cemetery 
Grant Program to continue important partnerships with states and tribal 
organizations. Upon completion of these expansion projects, and the 
opening of new national, state, and tribal cemeteries, nearly 95 
percent of the total Veteran population --about 20 million Veterans--
will have access to a burial option in a national or grant-funded state 
Veterans' cemetery within 75 miles of their home.
              accelerating processing of disability claims
    Since 2013, VA has made remarkable progress toward reducing the 
backlog of disability compensation claims pending over 125 days. VBA's 
fiscal year 2019 budget request of $2.9 billion would allow VBA to 
maintain the improvements made in claims processing over the past 
several years. This budget prioritizes more timely review of 1.3 
million rating claims and 187,000 higher level reviews to decrease the 
amount of time Veterans wait for a resolution. It also prioritizes 
fiduciary care for vulnerable beneficiaries to ensure protection for 
VA's most vulnerable Veterans who are unable to manage their VA 
benefits. This budget supports the disability compensation benefits 
program for 4.5 million Veterans and 600,000 survivors.
    To continue improving disability compensation claims processing, 
VBA has implemented an initiative called Decision Ready Claims (DRC). 
The DRC initiative offers Veterans, Servicemembers, and survivors 
faster supplemental claims decisions through a partnership with VSOs 
and other accredited representatives to assist applicants with ensuring 
all supporting evidence is included with the claim at the time of 
submission, enabling the claim to be decided within 30 days of 
submission to VA. Since the program's inception in May 2017, VBA has 
received over 1,000 DRCs, which have received a rating decision in an 
average of 10.7 days. VBA remains committed to continued growth of the 
program.
                          decisions on appeals
    In August 2017, the President signed into law the Veterans Appeals 
Improvement and Modernization Act of 2017 (Public Law 115-55), which 
represents the most significant statutory change to affect VA claims 
and appeals in decades and provides much-needed reform. VA is in the 
process of implementing the new claims and appeals system by 
promulgating regulations, establishing procedures, hiring and training 
personnel, and developing IT systems. While the modernized appeals 
system will not be fully operative until February 2019, in an effort to 
provide some of the benefits of the new law's streamlined process, VA 
has initiated the Rapid Appeals Modernization Program (RAMP). This 
initiative will allow Veterans with appeals the option to have their 
decisions reviewed in the Higher-Level or Supplemental Claim Lanes, as 
outlined in the new law. Participation in RAMP is voluntary; however, 
Veterans can expect to receive a review of VA's initial decision on 
their claim much faster in RAMP than if they were to remain in the 
legacy appeals process. As of April 26, 2017, over 14,000 appellants 
have opted into RAMP. By February 2019, all requests for review of VA 
decisions will be processed under the new law, which will provide a 
more efficient claims and appeals process for Veterans, with 
opportunities for early resolution of disagreements with VA decisions.
    The fiscal year 2019 request of $174.8 million for the Board of 
Veterans' Appeals (the Board) will sustain the 1,025 FTE who will 
adjudicate and process legacy appeals while implementing the Appeals 
Improvement and Modernization Act. The Board is currently on pace to 
produce over 81,000 decisions, a historic level of production.
    In addition, VBA is also undertaking a similar, multi-pronged 
approach to modernize its appeals process through legislative reform, 
increased resources, technology, process improvements, and increased 
efficiencies. The requested $74 million for appeals processing 
increases VBA's appeals FTEs by 605.
    This increase comes after VBA realigned its administrative appeals 
program under the Appeals Management Office in January 2017, as part of 
an effort to streamline and improve performance in legacy appeals 
processing. The improved focus and accountability resulting from this 
realignment helped increase VBA appeals production by 24 percent, 
decrease its appeals inventory by 10 percent, and increase its appeals 
resolutions by 10 percent, resolving over 124,000 appeals during fiscal 
year 2017.
    Finally, Digital Service at VA worked closely with the Department 
to develop an appeal status tracker on Vets.gov. This tracker, which 
allows Veterans to obtain real-time information regarding the status of 
their benefit appeals, including an estimated wait time and place in 
line, went live in March 2018. In demonstrations to stakeholders 
initial responses have been positive. Digital Service is building 
infrastructure that will support the status update for the new 
modernized appeals.
                            forever gi bill
    The Harry W. Colmery Veterans Educational Assistance Act of 2017 or 
the Forever GI Bill contains 34 new provisions, the vast majority of 
which will enhance or expand education benefits for Veterans, 
Servicemembers, families, and survivors. Most notably, this new law 
removes the 15-year time limitation for Veterans who transitioned out 
of the military after January 1, 2013, to use their Post-9/11 GI Bill 
benefits. This law also restores benefits to Veterans who were impacted 
by school closures since 2015, expands benefits for certain Reservists, 
surviving dependents, and Purple Heart recipients, and provides many 
other improvements. Several of the 34 provisions were effective on the 
date of enactment, while the remaining provisions have future effective 
dates ranging from January 1, 2018, to August 1, 2022.
                                closing
    Thank you for the opportunity to appear before you today to address 
our fiscal year 2019 budget and fiscal year 2020 AA budget requests. 
These resources will honor the President's commitment to Veterans by 
continuing to enable the high-quality care and benefits our Veterans 
have earned and ensure that VA is a source of pride for Veterans, 
beneficiaries, employees, and taxpayers. I ask for your support in 
funding our full fiscal year 2019 and fiscal year 2020 AA budget 
requests and continued partnership in making bold changes to improve 
our ability to serve Veterans. We look forward to your questions.

    Senator Boozman. Thank you very much. Secretary Rychalski.
    Mr. Rychalski. I'm sorry. I have no prepared remarks. Thank 
you.
    Senator Boozman. Well, that was easy. I'm going to yield my 
time temporarily to the senator from Alaska, Senator Murkowski.

                    VETERANS IN THE PACIFIC ISLANDS

    Senator Murkowski. Thank you, Mr. Chairman, and thank you 
for the opportunity to speak to some issues that we all care 
about as they relate to our veterans.
    My first issue that I would like to raise stems not from an 
Alaska-related concern, but we in Alaska have connection and 
affinity for those who also are not part of the continental 
United States. I was recently out in the Pacific. I was in Guam 
and the Northern Marianas, as well as in Palau and the Marshall 
Islands. One of the concerns as it relates to our veterans is 
their ability to access healthcare in these remote locations. 
So it's not unlike what we face in Alaska.
    Guam has a VA hospital. The rest of the islanders either 
need to go to Guam or to Hawaii. Senator Schatz is okay with 
that. But they've asked me to ask you what needs to be done to 
certify the local hospitals on those islands to provide care to 
our veterans so that they don't have to go to the expense of 
traveling such long distances, and what other options might be 
out there.
    I also have a letter that I would like to submit to you 
all--and I'll do it through the record here--from the president 
of Palau, President Remengesau, who says that when the people 
from Palau serve in the armed forces, when they come back to 
Palau after completion of their service, they lose many of the 
benefits that are provided to them under the G.I. Bill, 
specifically to the issue of housing loans.
    So I have been asked--and I will share this letter with 
you--what these options are on making these veterans eligible 
for these G.I. benefits, whether they live in the United States 
or they return to their homeland. So in the interest of time, 
I'm putting that out to you. I would like those answers. I know 
that the delegates from the Islands would like to see that as 
well.
    [The information follows:]

    The Veterans Affairs (VA) Home Loan program is restricted 
geographically as stated in 38 CFR 36.4332 to guaranty or insure loans 
on real property that is situated within the United States, defined as 
``the several States, Territories and possessions, and the District of 
Columbia, the Commonwealth of Puerto Rico, and the Commonwealth of the 
Northern Mariana Islands.''
    Per the 1986 US-Palau Compact of Free Association, Palau is no 
longer a Territory of the United States and therefore real property 
located in Palau is not eligible for VA guaranty or insurance. It 
should be noted that eligible Veterans with certain service-connected 
disabilities who own or plan to purchase property anywhere in the 
world--including Palau--may apply for VA's Specially Adapted Housing 
grant program to construct, adapt, or modify a home to accommodate his 
or her disability. Any unused funds from the fiscal year 2018 
authorized $81,080 grant amount can later be applied to the Veteran's 
mortgage principal.

                        CARE FOR WOMEN VETERANS

    Senator Murkowski. I'd like to ask you--and I want to thank 
you, Mr. Reeves, for the comment that you have just provided 
about the focus on women in the military and women in the VA 
now, the numbers that we are seeing who are coming into a 
system that really was not set up for women. Many say--and 
Senator Murray and I just had a discussion about this, that the 
VA is a man's VA, and how we work to accommodate our female 
veterans. So the reference that you have just provided, $511 
million for gender specific care, I think is a good start. Know 
that I am certainly going to be pushing to make sure that we 
continue to do right in these areas.

                          HMONG BURIAL BENEFIT

    Let me ask about the Hmong veterans legislation. As you 
know, we had--in the Appropriations Act, we authorized the VA 
to bury certain members of the Hmong Special Guerilla Units who 
helped us in Vietnam. I've been trying to get this freestanding 
bill moved around. It's been kicking around for a long time. 
But I would hope that you could provide me some information in 
terms of how we're doing with implementation. We all know that 
these Hmong veterans are not getting any younger. So can you 
give me any quick update on where we might be with that?
    Mr. Reeves. Senator, on the legislation for the Hmong 
veterans or the Hmong fighters, we are currently working with 
the Department of Homeland Security to set up our procedures 
for verification of naturalized status and also will have in 
place before September our procedural guidance to implement the 
new eligibility.
    I will tell you that I actually have two requests from 
Hmong families requesting interments, and we're working through 
those very quickly with DHS, or with the Department of Homeland 
Security, right now. One of them is for an interment, and one 
of them is actually for a pre-need determination, which we'll 
be working through very, very quickly. But we are already on 
that with DHS, but the guidance will be in place before 
September.
    Senator Murkowski. I appreciate that.

                        VETERANS CHOICE PROGRAM

    Let me ask a quick question on the Choice Program and where 
we are with that. The report accompanying the 2018 
appropriations measures calls attention to the reimbursement 
conflicts that we have between VA's central office and our 
Alaska tribal health providers, and it basically encourages you 
to work it out. These agreements are expiring in 2019, so I 
would encourage the VA to begin that conversation now and to 
demonstrate the kind of flexibility that I think will allow our 
tribal providers to continue to address the gaps that we have 
with our VA care and just ensure that we've got a smooth track 
going forward. So I would ask for your assurance with that.
    Dr. Clancy. Senator, I'm happy to tell you our Acting 
Deputy Undersecretary for Community Care is actually in Alaska 
today.
    Senator Murkowski. Great.
    Dr. Clancy. Trying to work out a lot of these details. We 
didn't actually plan it to coincide with the hearing, but 
that's just how it worked out.
    Senator Murkowski. Works for me. Thank you. I appreciate 
the attention to it and know that it's, of course, a little bit 
different up there. But the flexibility that you have shown in 
working with this is greatly appreciated.
    Senator Murkowski. Thank you, Mr. Chairman. I appreciate 
it.
    Senator Boozman. Senator Schatz.
    Senator Schatz. Thank you.

                         COMMUNITY CARE FUNDING

    Mr. Rychalski, the VA's fiscal year 2019 request for its 
traditional community care programs is $8.9 billion, which is 
$1 billion below the $9.8 billion that we provided in the 2018 
Omnibus. So its $1 billion--what's in the current Omni? And now 
OMB is privately saying that the fiscal year 2019 request is 
potentially $1.6 billion short of what VA needs.
    So do you still stand by the $8.9 billion request? Are you 
going to be coming to us with a request for $1.6 billion? And 
then, finally, when did you know that OMB was going to come to 
you with that number? Because this thing--$8.9 billion--you may 
not have known it was exactly $1.6 billion, but you had to know 
that shorting it a billion was going to be a problem.
    Mr. Rychalski. Right. So let me explain sort of what 
happened. When we submitted the 2019 budget, we made several 
assumptions, and I think that if you look back, you'll agree 
that we, in our budget rollout and the information we 
provided--that we qualified that our budget was predicated on 
the passage of the Care legislation that allowed for Medicare 
rates, which is about a billion and a half a year. The other 
thing that we baked into this is--and this is not--that's an 
authorizing issue, right. That was not something that came to 
you.
    Senator Schatz. Let me just--let's go back to these 
questions. Do you agree with the $1.6 billion short?
    Mr. Rychalski. Yes.
    Senator Schatz. Did you know about that, or, roughly, did 
you know that you were going to be significantly short when you 
proposed $8.9 billion instead of $9.8 billion?
    Mr. Rychalski. At that time, no.
    Senator Schatz. Did you have no idea that you were going to 
be short? You figured $8.9 billion was going to be correct? 
Because none of us thought that that was the right number.
    Mr. Rychalski. Yes, we thought that was the right number, 
and it was the right number provided the CARE legislation 
passed and we had authorization to pay Medicare rates. When 
that didn't happen, and it didn't happen in the Omnibus, we 
knew we were going to be short.
    Senator Schatz. The budget process--excuse me--your budget 
proposes combining the Medical Community Care and Medical 
Services accounts, as I mentioned in my opening statement. I 
get that this may increase flexibility in the field, but I also 
worry that it may be hiding cuts to in-house care in favor of 
privatized care.
    For example, your advance request for Medical Care for 
fiscal year 2020 is $75.6 billion, $4.4 billion over the fiscal 
year 2019 request. But when you look closely, privately 
provided care gets a $5.5 billion increase over fiscal year 
2019, and all other in-house accounts are cut by $1 billion.
    So what can you do to reassure me that this combining of 
accounts is not to obscure a long-term policy goal to shift the 
balance of our appropriations from in-house care to what some 
people call community care, what I call privately provided 
care?
    Mr. Rychalski. So I'm not going to grandstand, but this is 
actually a very important point--it may be the most important 
thing we talk about today. I know that there is reticence to 
combine the accounts because it may--I think the thought is 
that it's going to enable us to further privatization. From our 
perspective, it allows for flexibility.
    But let me use a case maybe to sort of walk you through, 
because as I look at this more, in fact--and I was just talking 
with Mark Yow and Rachel Mitchell from Veterans Health 
Administration (VHA) this morning--I actually think it's having 
the opposite effect, or it's going to have the opposite effect. 
But just sort of follow me through this use case.
    Let's say that you are a director at a VA medical center. 
You have two pots of money, you have a provider that works for 
you, and a government employee, who decides to leave. So you 
want to replace this person, but it's not going to happen right 
away. So in the interim, you have to send that care downtown 
while you go out and recruit a provider, and so that workload 
and that money has flowed to the private sector, right, and so 
we're sending patients downtown, and you're recruiting, and we 
have two separate pots of money.
    Then you decide that--or you find someone that's willing to 
come on board. Unfortunately, all your money has been moved to 
Community Care or Choice, and you don't have access to that 
money. So when you come to me as a CFO and say, ``Hey, I've got 
this person lined up, and they're ready to start,'' and I'm 
like, ``Okay. We need to do a re-programming, and it's going to 
take me about 3 months to get that money back to you,'' you 
know right away that provider is not going to wait 3 months.
    What we're seeing is an increase--as people go downtown, 
we're seeing that it's harder to get them back in. There's not 
the flexibility to sort of make that tradeoff. What we're 
saying is if we have the flexibility, we can move the money 
where it's needed. I think the thing that I would recommend 
that you consider doing is putting in place the oversight and 
the controls and the desired outcomes that you want with 
respect to that money, but I think--and I'm being very 
serious--I think it's a bad idea to continue having them as two 
separate pots of money.
    This is something that we sort of saw in the military 
health system. As people went downtown, the money went with 
them, and they never came back, and I think the same thing can 
happen here, and I think that's really something you should 
consider very carefully. We can show you some data, some 
statistics that I believe support this. But I think it's 
actually having, the unintended consequence or a perverse 
incentive. When people go downtown, they can't get them back 
because we don't have access to the money rapidly to hire 
people back into the facility.
    Senator Schatz. So you'll provide information to the 
committee about how this counterintuitively is actually--should 
be reassuring to those of us who are worried about shifting the 
balance of appropriations towards privatized care.
    Mr. Rychalski. Yes.
    [The information follows:]

    The fiscal year 2019 Department of Veterans Affairs President's 
Budget proposes to merge the Medical Community Care and the Medical 
Services appropriations, as was the case prior to fiscal year 2017. The 
separate appropriation for Community Care required by Sec. 4003 of PL 
114-41 has restricted VA Medical Center (VAMC) Directors as they manage 
their budgets and make decisions about whether the care can best be 
provided within their facilities or must be purchased from community 
providers or Federal partners.
    This is a dynamic situation, as the loss of a key clinical staff 
position, such as a general surgeon, will require that the care they 
provided be temporarily shifted to the community until a replacement 
can be found and brought on board, which can be a lengthy process. This 
can also occur when VA facilities must be temporarily closed because of 
damage, such as from the recent hurricanes. This change will enable VA 
field staff to respond rapidly and effectively to unanticipated changes 
in the healthcare environment throughout the year, and will maximize 
VA's ability to focus our resources on the services Veterans most need.
    Conversely, if a position has been vacant for a period of time but 
time (but analysis shows that it would be more effective for Veterans 
to provide the care in-house) is successfully filled, the care should 
be realigned from the community back to the VAMC. This process was 
previously referred to as ``fee recapture'' and served as an incentive 
for VAMC Directors to identify areas where additional investment in 
VA's in-house capacity to provide healthcare for Veterans could be 
enhanced to provide expanded services at lower cost than those services 
could be purchased from community healthcare providers. This incentive 
was effectively eliminated by the mandate for a separate Community Care 
appropriation because of the administrative processing time required to 
transfer funds between appropriations. In short, rather than creating a 
pathway to increased privatization of VA healthcare, this proposal 
allows each VAMC Director to determine where they can effectively 
enhance the capability of their facilities with the confidence that 
funds will be available to accomplish that goal, with reduced total 
cost to taxpayers.
    The accounting structure to capture and identify care purchased 
from the community will remain in place to enable VA to identify and 
report separately on the costs of VA-provided care and for care from 
community providers and Federal partners. This will enable VA to 
continue to provide reports to Congress on the funds used to obtain 
care from community providers as is done under the current 
appropriation structure.
    In addition, VA is requesting modification of the current process 
required to manage funds for purchasing Community Care. Under Sec. 106 
of PL 113-146, all Community Care funds are centrally managed by the 
Deputy Under Secretary for Health for Community Care (DUSHCC, formerly 
the Chief Business Officer).
    Concurrent with the VA proposal to merge the Medical Community Care 
and Medical Services appropriations, each VAMC would receive all 
funding for its enrolled Veterans, thus providing an incentive to 
maximize the amount of care provided by the VA while eliminating the 
current perverse incentive to direct Veterans to potentially more 
expensive community care providers because such action does not 
currently impact VAMC budgets.
    This proposal would allow VA to establish a community care funding 
model that mirrors the successful model currently used for VA's 
Consolidated Mail Outpatient Pharmacies (CMOPs). Under this model, each 
VAMC and the DUSHCC would determine an estimated amount of funding for 
community care at the beginning of the fiscal year, and the VAMC would 
preposition those funds with the DUSHCC to manage the purchase of and 
payment for care purchased by the VA from community providers. During 
the course of the year, each VAMC and the DUSHCC would monitor the 
initial funding amount, and make appropriate adjustments based on 
changes in actual demand as the fiscal year progresses.
    Oversight of VA Medical Care budget execution will occur at all 
leadership levels, culminating at the Monthly Management Review chaired 
by the Deputy Secretary. VA would also be able to provide periodic 
execution reports, similar to the reports currently provided for Choice 
funding, to Congress if desired, to monitor the relative funding of 
care provided in VAMCs and purchased from community providers.
    This model would enhance each VAMC's ability to rapidly respond to 
changes in clinical staffing and readily realign funds to or from the 
DUSHCC to reflect changes in the VAMC's ability to efficiently provide 
the care in VA facilities as opposed to purchasing that care from the 
community. As with the request to combine the Medical Community Care 
and Medical Services appropriations, rather than creating a pathway to 
increased privatization of VA healthcare, this proposal allows VAMC 
Directors to enhance the capability and efficiency of their facilities 
with the confidence that funds will be readily available.
    An analysis of the data from fiscal year 2014, when the Veterans 
Access, Choice and Accountability Act established the Veterans Choice 
Program and directed separation of the Medical Community Care 
appropriation is compelling:

                         Amount of care in Choice, Community Care, and in VA Facilities
----------------------------------------------------------------------------------------------------------------
    Appointments (Thousands)       fiscal year 2014    fiscal year 2015    fiscal year 2016    fiscal year 2017
----------------------------------------------------------------------------------------------------------------
Choice..........................                   0               1,940              12,500              20,200
Community Care..................              18,600              21,700              18,300              12,500
VA Facilities...................              54,775              56,700              58,000              57,500
                                 -------------------------------------------------------------------------------
    Total.......................              73,375              80,340              88,800              90,200
----------------------------------------------------------------------------------------------------------------


 
----------------------------------------------------------------------------------------------------------------
             RVUs\1\               fiscal year 2014    fiscal year 2015    fiscal year 2016    fiscal year 2017
----------------------------------------------------------------------------------------------------------------
Choice..........................                   0             261,161          11,179,796          27,841,732
Community Care..................          29,711,798          38,689,677          38,787,469          45,586,546
VA Facilities...................         158,243,542         160,107,559         176,312,834         179,185,037
                                 -------------------------------------------------------------------------------
    Total.......................         187,955,340         199,058,397         226,280,099         252,613,315
----------------------------------------------------------------------------------------------------------------
\1\ ARVUs--Relative Value Units, an outpatient weighted workload measure


 
----------------------------------------------------------------------------------------------------------------
             DRGs\2\               fiscal year 2014    fiscal year 2015    fiscal year 2016    fiscal year 2017
----------------------------------------------------------------------------------------------------------------
Choice..........................                   0                  94             115,250             178,421
Community Care..................             273,122             297,817             317,748             380,694
VA Facilities...................             753,885             730,168             727,817             745,760
                                 -------------------------------------------------------------------------------
    Total.......................           1,027,007           1,028,079           1,060,815           1,204,875
----------------------------------------------------------------------------------------------------------------
\2\ ADRGs--Diagnosis Related Grousp, an inpatient weighted workload measure


 
----------------------------------------------------------------------------------------------------------------
        Cost ($Millions)           fiscal year 2014    fiscal year 2015    fiscal year 2016    fiscal year 2017
----------------------------------------------------------------------------------------------------------------
Choice..........................                  $0                 $17                $957              $4,163
Community Care..................               5,642               7,083               7,802              10,213
VA Facilities...................              44,327              47,999              49,892              51,822
                                 -------------------------------------------------------------------------------
    Total.......................             $49,969             $55,099             $58,651             $66,198
----------------------------------------------------------------------------------------------------------------

    At least in part because of a perverse incentive for VA Medical 
Centers to refer care to an appropriation for which they are not 
responsible and do not manage, the vast majority of the additional care 
provided to enrolled Veterans since the implementation of the Veterans 
Choice Program has occurred in care purchased from community providers 
rather than care provided in VA facilities. This has occurred in spite 
of comparable funding provided to the VA facilities over the same time 
period:

 
----------------------------------------------------------------------------------------------------------------
                           $Billions                                VA Facilities\1\     Community Care + Choice
----------------------------------------------------------------------------------------------------------------
fiscal year 14................................................                    $44.8                     $5.6
fiscal year 15................................................                     48.1                      8.0
fiscal year 16................................................                     51.5                      7.8
fiscal year 17................................................                     52.0                     12.9
----------------------------------------------------------------------------------------------------------------
\1\ Medical Services appropriation obligations at VISNs and VAMCs

    Relative shares of new workload and funding for VA facilities and 
care purchased from community providers from fiscal year 2014 to fiscal 
year 2017 is displayed in this chart:

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Re-combining the Medical Services and Medical Community Care 
appropriations, coupled with the implementation of a CMOP-like funding 
model for community care, will place financial responsibility for all 
funds with the VAMC Directors, and they will both be incentivized and 
have the flexibility to make the most cost effective decisions on how 
care is delivered to enrolled Veterans. The current process has 
resulted in behavior that is clearly shifting new workload to community 
care providers regardless of cost.

                         COMMUNITY CARE FUNDING

    Mr. Rychalski. Yes. I understand that concern, and I think 
the thing to do is to sort of build in the controls that you 
think will be satisfactory. But I think that in the long term, 
I think we're seeing the leading edge of this, and it can 
continue to where we unwittingly privatize the VA by sending 
people downtown and not having the flexibility.
    Senator Schatz. Well, I know I'm over time. But I'll 
suspend judgment on this. I'm not stipulating to anything that 
you said, but I am interested in what you're saying, and at 
least that you're saying the words that that's not the intent, 
I think, is at least preliminarily reassuring.
    Mr. Rychalski. We'd be very excited to show you this, 
because I think it's important.
    Senator Schatz. Thank you.
    Dr. Clancy. Senator, just briefly, we have the accounting 
structures built to be able to do that, to give you clarity and 
transparency about how the money is being transferred across 
accounts. So it's not that we would have to build it.
    Senator Boozman. Senator Udall I'm sorry.

                       COMMUNITY CARE LEGISLATION

    Senator Tester. That's what happens when you change 
committees. You forget all about me. It's all right. We'll take 
it. Thank you, Mr. Chairman. I appreciate it.
    Jon Rychalski, I was not going to go down this line, but I 
don't want my head to totally explode, and it deals off the 
question that the ranking member just asked you on the Choice 
Program and the fact that it's a $1.6 billion shortfall. If I 
heard you correctly, I heard you say the reason it's a $1.6 
billion shortfall is because you anticipated the Caring for Our 
Veterans Act was going to pass when you developed the budget.
    I'm just going to--for the record, I want to make this 
clear. That bill would have been passed last year if we could 
have got the VA's endorsement of that bill, so you know. The 
reason it was held up--and it was passed--we were going to pass 
that thing out by Veterans' Day, certainly could have had it 
done by the first of the year. We can take the rap on it not 
being in the Omnibus, but before that, it really is on you 
guys. So I wanted to point that out.

                    MEDICAL RECORD ACCESS IN MONTANA

    I just wanted to talk a little bit about IT. So had a staff 
member back in--a crack staff member back in Montana last week 
and was talking about the IT system--and whoever wants to can 
answer this. It takes 10 minutes to log into the system for 
each appointment. So every time you get a new veteran who walks 
through the door--10 minutes just to log into the system, in 
the 21st Century.
    I don't know if the problem should be solved at the local 
level or solved at your level, but it needs to be solved. This 
is, quite frankly, a real waste of time. Can you give me some 
assurance that you're either going to push it off to them to 
fix it, or that you'll get it fixed at the VISN level or get it 
fixed at the D.C. level?
    Dr. Clancy. We will get it fixed, because that is 
unacceptable and intolerable. But it is also support for why we 
need a new electronic record system, and we also know very, 
very much that we need a much better, swifter scheduling 
system.
    Senator Tester. Yes. I can see why doctors would get very 
frustrated. I mean, they're not--you know what I mean. Okay. I 
got it.

                              VA WORKFORCE

    So now I want to talk about workforce for a second. I also 
had my staff bring up the totals of when Patty Murray was 
chairman of this committee and how much the VA got--$79.6 
billion, where we're at $195.2 billion in this fiscal year. 
That's over double, well over double. It was put in for good 
reason, because we had been at war for some time when Patty was 
chairman back in 2007 and we continue in the same war. We've 
got Vietnam veterans getting older. There's more pressure on 
you guys, and that's why it was beefed up.
    I say this because, right now, VA Montana told us that 
they're nearly fully staffed. But when you go on the ground and 
talk, we hear that clinicians are fully booked. They're sending 
new patients directly into the community--a serious problem. 
We've got four Community-Based Outpatient Clinics (CBOCs) that 
only have access to Telehealth. We've got a lot of veterans 
that are walking through the door. They're getting general 
appointments taken care of by Telehealth, not by a real person, 
even in our hospital. So we combine that with mental health--
and, by the way, Montana has got the highest rate of veteran 
suicide in the country--and there isn't enough private 
clinicians to support it, especially on the mental health side 
of things.
    Can you tell me what's being done? We've plussed up your 
budget. We passed seven bills this last year with Johnny 
Isakson's leadership to get you guys rolling. Can you tell me 
what we're doing for these shortages? Because I'm telling you 
that it's killing the VA.
    Dr. Clancy. We are using targeted incentives as much as we 
can. We're also just about to launch the first ever deployment 
of Public Health Service commissioned officers to work in 
different facilities of our system and may have a lot more 
coming for short periods of time, which I think would be a big 
boon to some rural areas.
    Respectfully, Senator, Telehealth is a real person, and, in 
particular, for mental health for many veterans and other 
patients, it's actually more acceptable and less threatening.
    Senator Tester. I would not argue with you, Dr. Clancy, on 
mental health. But what I would argue on is we've got four 
CBOCs, we've got a Caring For Our Veterans Act bill that's got 
a component that will shut down unused facilities, and mental 
health aside--I take your point there--I don't think I want to 
go in and get a physical on a TV screen.
    Dr. Clancy. No, no. Some things you've got to be there for.
    Senator Tester. All right. Good.

                          ACCOUNTABILITY AT VA

    The other thing I would just say is we gave you an 
accountability bill. Mr. Reeves talked about it in his opening 
statement. We have been told--and it was done for the very best 
of reasons, to get rid of the driftwood, okay? But we have been 
told--I have been told, I should say, that this bill is being 
used to get rid of people for political reasons. Have you been 
told that? Could you do me a favor and make sure that it's not 
being used in that attempt?
    Dr. Clancy. Yes.
    Senator Tester. Okay. Thank you.
    Senator Boozman. Senator Murray.

                        HUD-VASH PROGRAM FUNDING

    Senator Murray. Thank you very much, Mr. Chairman.
    In fiscal year 2015, the VA was given a three-year surge of 
$207 million in the Supportive Services for Veterans Families 
(SSVF) funding to high-need communities to improve their 
ability to rapidly rehouse growing numbers of homeless 
veterans. That surge funding has now expired, and these 
communities are now seeing services decrease for veterans in 
their communities, and these communities have been saying they 
have relied heavily on that resource to decrease homelessness. 
While Congress has increased the annual SSVF authorization in 
the last year, we still have an $80 million gap.
    I wanted to ask why your budget, Dr. Clancy, did not 
include sufficient funding to maintain that program at its 
current operating level.
    Dr. Clancy. I would need to take that for the record to 
look at the year-on-year delta.
    Senator Murray. It was a three-year surge that was granted 
back then.
    Dr. Clancy. What I would say to you is we have a particular 
problem base. We're seeing progress in homelessness overall 
among veterans, with the exception of some selected cities on 
the West Coast, one of which is in your state.
    Senator Murray. Mine would be in that.
    Dr. Clancy. Seattle, L.A., San Francisco, and so forth. And 
working with HUD and our other partners, we all agree that we 
need a new strategy there, because it's very, very hard to get 
veterans housed. We have all the strategies in place to prevent 
homelessness, but we have landlords who don't want to take 
Section 8 vouchers and so forth.
    Senator Murray. Okay. Will you get back to me on that, on 
the budget request, then?
    Dr. Clancy. Yes.
    [The information follows:]

    The fiscal year 2017 actuals (fiscal year 2019 Presidents Budget, 
page VHA-158), for Supportive Services for Low Income Veterans and 
Families (SSVF) was $320 million. This is consistent with 38 USC 2044 
(e)(1)(e) that states $320,000,000 for each of fiscal 2015 through 
2017. VA is maintaining the SSVF program at the appropriate operating 
levels.

                     MEDICAL COMMUNITY CARE ACCOUNT

    Senator Murray. Okay. And I want to refer back--as the 
ranking member talked about, we know the Department is 
proposing to combine the Medical Services and Medical Community 
Care accounts. He asked it one way. I just want to say I am 
really concerned that that's going to lead to diverting funds 
the VA health system desperately needs in order to send 
veterans out to the private market.
    I did talk about this in our last Budget hearing in the 
Authorizing Committee. The Secretary did not have a sufficient 
answer at that time. So I just want to ask it this way. For 
this committee, I think, to consider this proposal, there has 
to be some very clear rules on how those funds are going to be 
used, requirements to fully fund the VA health system, and 
detailed reporting requirements.
    So I want to ask you, Dr. Clancy, Mr. Rychalski, are there 
specific rules or restrictions the VA would support so we do 
have transparency and VHA is not allowed to raid to fund the 
private sector?
    Mr. Rychalski. I would say absolutely, and I think, to my 
point earlier, it would be worthwhile for you to sort of see 
the data and sort of see what we're seeing so you can make a 
fully informed decision.
    Senator Murray. I like the story, but I really--I would 
prefer to have rules in place so we can see it, so there's 
transparency----
    Mr. Rychalski. We absolutely agree.
    Senator Murray. So the funds can't be raided, so it would 
put our concerns in a much better place.
    Mr. Rychalski. Absolutely.
    Senator Murray. And if we can get your recommendations back 
on what you would support, and I certainly hope that this 
committee will look at that as well.
    [The information follows:]

    VA already has an accounting structure in place that discretely 
identifies the funds allocated for and spent on Community Care. This 
structure would remain under the proposed merger of the Medical 
Services and Medical Community Care appropriations. This structure 
allows the VA to track, monitor and accurately report how and where 
Community Care funds are being utilized. VA can readily provide this 
report to Congress as frequently as desired. VA will continue to 
develop and evaluate a monthly Community Care Operating Plan that 
compares obligations against plan at the Veterans Integrated Service 
Network and VA Medical Center levels. This analysis is presented to the 
VA Deputy Secretary during the Monthly Budget Execution Reviews to 
monitor execution and determine the need for funding adjustments during 
the fiscal year. VA will also expand upon existing policies and 
procedures to develop decision criteria and an approval process for 
moving funds between Medical Services and Community Care that will be 
based on Veterans healthcare requirements by location.
    The following tables from the revised fiscal year 2019 
Congressional Justification volume display the detail available under 
the new proposal, which mirrors the detail currently reported for the 
separate Community Care appropriation.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                           CAREGIVERS PROGRAM

    Senator Murray. And I want to thank both the chairman and 
Ranking Member Schatz, who have been great supporters of the 
Caregivers Program over the years, and we've talked many times 
about the importance of the program and how it really makes a 
difference for our veterans and their families. We've heard a 
lot from the Veterans Service Organizations (VSOs), what a 
critical priority this is for them.
    So, Dr. Clancy, I wanted to ask you about the future of 
this program. Legislation that will finally accomplish the 
expansion of the Caregivers Program is moving towards passage, 
and that legislation really takes a responsible approach. It 
phases in eligibility over a number of years so we can make 
sure that VA can meet the demand and expand services as needed.
    So as we are getting close to passing this bill, what is 
your plan to implement that new legislation and make sure the 
VA is ready to meet the needs of those veterans?
    Dr. Clancy. So, first, Senator, we share your enthusiasm 
for this provision of the MISSION bill. You can't take care of 
older and sicker veterans without knowing how vital caregivers 
are to that fabric, and across VA and the people caring for 
veterans, it is truly amazing what people do. And at the same 
time, we've had this asymmetry between different cohorts of 
veterans with respect to providing stipend support, and this 
would end that, which is a terrific thing. Not only that, but 
we believe that it will allow more aging veterans and veterans 
with multiple needs to stay at home, if that's what they choose 
to do, which, from my knowledge of friends, relatives, and so 
forth, is what most people would choose over having to go to an 
institution.
    Right now, we're planning on what implementation would look 
like. As you know----
    Senator Murray. So you are looking--I appreciate your 
support, appreciate your right words. But I want to make sure 
the VA is ready to do this so--six months from now, a year from 
now, we can deal with it. If we add too many people, they're 
not able to apply all of those----
    Dr. Clancy. Yes. I can assure you the caregiver team is 
ready to roll right now.
    Senator Murray. To expand it.
    Dr. Clancy. Yes.
    Senator Murray. Okay. Thank you.
    Senator Boozman. Thank you. Senator Baldwin, I'm sorry.
    Senator Baldwin. I defer----
    Senator Boozman. Senator Rubio, you snuck in on me. Senator 
Baldwin, I'm sorry.
    Senator Udall. This is like musical chairs.
    Senator Rubio. And I want my time back if it's Udall.
    [Laughter.]
    Senator Udall. Marco, are you going?
    Senator Boozman. No, you're going.

                        RECRUITING AND RETENTION

    Senator Udall. Okay. Thank you all for being here and thank 
you for just fighting for our veterans. I mean, they really 
need it at this period of time, I think, with--I just see the 
leadership in the very top--that being vacant just hurts a lot, 
and so I really hope that we can get somebody over there that's 
going to provide the top leadership and give support.
    This subcommittee has heard me raise this issue many times, 
but the problem really persists. The Department of Veterans 
Affairs is not doing enough to hire and retain healthcare 
professionals, particularly in rural areas. Many of my 
priorities, like support for Telehealth and transportation 
funding, tries to address this problem. These are workarounds 
to some degree. More must be done to tackle the core issue of 
bringing doctors and nurses into rural areas.
    There are a number of examples in New Mexico, far too many. 
I'll just highlight a couple here. The Las Cruces VA Clinic has 
been operating for a year without a doctor. Care is being 
provided primarily by nurse practitioners. The Albuquerque VA 
Medical Center, although not rural, even has shortages in key 
areas including high turnover amongst nurse practitioners.
    I've been grateful for the opportunity to work with Andy 
Welch, the Director of the New Mexico VA, to address these 
problems as they arise. But now he has been temporarily 
reassigned to Loma Linda VA to fill a vacancy over there.
    This issue needs to be addressed more forcefully. New 
Mexico veterans face long wait times and lower quality care as 
the VA continues to lose administrators, doctors, and nurses. 
Two years ago, the average wait time for primary care in New 
Mexico was just under six days. Last month, that had nearly 
doubled to 10 days. The problem is national, and it's growing, 
particularly in the last month since Secretary Shulkin was 
fired.
    So my question to all of you is: What additional authority 
or resources do you need to get doctors to come and stay in VA 
facilities, particularly in rural areas? Medical school debt 
forgiveness? Waivers for direct hiring? Salary increases? There 
are many others. Please tell me what we need to do to get them 
in place and keep them?
    Dr. Clancy. So, Senator, it's a very important question, 
and I first want to say that we're hoping to keep Mr. Welch's 
reassignment as short and brief as possible. I do believe----
    Senator Udall. Please do that.
    Dr. Clancy. I do believe we've got applicants who have 
applied for the job in Loma Linda so he can go back to where 
he's been doing a great job.
    Senator Udall. Okay. Good.
    Dr. Clancy. Where you could help us right now is giving us 
some relief on the caps that we have for what we call the three 
Rs, or relocation, retention, and recruiting incentives. To 
make the budget before Comprehensive Addiction and Recovery Act 
(CARA) fit, we had caps instituted, and I will tell you that 
our leaders are vigorously using what resources they have to 
try to attract people to rural areas. But it makes a 
difference, particularly for new graduates who may need 
assistance with relocation and so forth.
    We also--frankly, courtesy of Senator Baldwin's provision 
in the original Veterans Access, Choice and Accountability Act 
(VACA) bill giving us more residency slots--have established 
new programs to train and recruit people from rural areas, 
because a large body of research shows that they're more likely 
to stay in rural areas.
    We're not going to leave any stone unturned. But that 
particular set of resources would be very helpful. I believe 
the House Appropriations mark gives us a little bit of relief 
on that front. But I just want to stress how important it is.
    Senator Udall. Thank you very much, and we'd like to work 
with the chairman and ranking member on those two issues. 
There's a minute left for any of you to comment on that also.
    Senator Udall. You're okay?
    Dr. Clancy. Yes.

                             PRIVATIZATION

    Senator Udall. Let me just see if I can ask one more quick 
question on privatization. We hear all of these rumors that the 
folks that are over there--and I think the ranking member and 
chairman may have raised this--that have been sent over there 
are trying to privatize veterans' care. Is that what's going 
on? Have you seen a big movement to privatize care and to close 
down veterans' hospitals? Is that what you intend to do?
    Mr. Reeves. Sir, to answer that, I'm one of those people 
that have been sent over there as an appointee, and I can 
absolutely tell you that that is not what people are trying to 
do. What we are trying to do is move in a direction where we 
can provide the right care at the right time, as I said, 
wherever that veteran may need it, using both community care 
and the assets we have in the VA. We need the flexibility to be 
able to do that to properly care for our veterans across the 
nation. That's what we're trying to do.
    Senator Udall. And thank you, Mr. Reeves, and you work with 
us and let us know if there's any problems there we can work 
with you on. Appreciate it.
    Thank you, Mr. Chairman.
    Senator Boozman. Thank you. Senator Rubio.
    Senator Rubio. Thank you.

                  CONTRACT EMPLOYEE BACKGROUND CHECKS

    I'll just start with Dr. Clancy. Last week, there was a 
Florida media investigation that revealed--there was a 
Pensacola area doctor who pled guilty to seven counts of tax 
fraud in 2015, and he was working as a VA subject matter 
expert, evaluating Camp Lejeune's toxic water exposure claims. 
So upon learning of those allegations, we contacted the 
Department for additional background, and we were told that the 
doctor was, in fact, not a VA employee but instead works for a 
VA contractor, and we were told, of course, that the VA had 
sent notice to the business to stop using this provider for 
conducting exams on behalf of the VA.
    I'm glad they took these steps, but now I think there's 
some questions that people are asking, and I have some 
questions about the VA's contracting practices when it comes to 
subject matter experts. So can I, I guess, in the limited time 
we have, just kind of get a brief understanding of the hiring 
policies for providers that are contracted by the VA through a 
third party vendor?
    Dr. Clancy. I'm going to turn this to my colleague, Mr. 
Murphy, because, actually, it comes under the Benefits 
Administration.
    Senator Rubio. Oh, it does. Okay.
    Mr. Murphy. It's called a Medical Disability Exam Contract, 
Senator, and the company is called Logistics Health In-Clinic 
Services (LHI). This doctor was working for them as a contract 
physician. In the contract, we spell out in great detail the 
medical requirements for a doctor. First priority is quality 
physicians doing quality work for veterans, and we believe 
that's the case here. In fact, after this doctor went back to 
the Florida Medical Board, they certified her and allowed her 
to keep her license because they saw no conflict of interest 
between her conviction and her ability to deliver medicine.
    Senator Rubio. Well, I guess the question is do we require 
third party vendors to undergo the same background checks and 
meet the same hiring standards a VA employee would?
    Mr. Murphy. To the extent of the examination of their 
medical credentials and the ongoing checks to ensure that those 
credentials are in place and----
    Senator Rubio. But, overall, there's not the same standard.
    Mr. Murphy. There is not a requirement in place that says 
this person must undergo a criminal background investigation. 
As you said a moment ago, VA paused--when we learned of it on 
April 30th, we immediately called the contractor and told them 
that that doctor was to do no further work for us while we went 
back in and reevaluated our policy to see if that's something 
we should have in place going forward.
    Senator Rubio. And, again, just to be clear about 
understanding this, if this individual was not a contractor, 
and they had applied for a job to get hired directly by the VA, 
they would have undergone a criminal background check.
    Mr. Murphy. That's a question for--Dr. Clancy would have to 
answer that one. We're crossing lines here in administration.
    Senator Rubio. Right. I understand. They would?
    Dr. Clancy. Yes, they would have.
    Senator Rubio. So a contractor does not have to undergo a 
criminal background check, only a professional check. A VA 
employee has to undergo both.
    Dr. Clancy. Yes, that is the case.

                 VA ``FOURTH ADMINISTRATION'' PROPOSAL

    Senator Rubio. The second thing I'd probably want to focus 
on here, if I could, is the VBA's administration of the 
Economic Opportunity and Transition Assistance Program. I 
recently introduced a bill called the VET OPP Act along with my 
colleague, Senator Hassan, which would reemphasize and 
prioritize this program, largely geared towards empowering 
these veterans in their civilian lives and enhance their 
economic opportunity.
    I'm not going to ask you to opine on the bill. You haven't 
seen it. I hope people will be supportive. I think there's real 
value in reorganizing the VA's existing Economic Opportunity 
and Transition Programs under a new administration within the 
VA. But I do want to understand a little bit.
    Describing the importance that these programs have in the 
process of all the other challenges that the VA is facing, is 
there any sense that they're receiving a sufficient amount of 
attention, given all these other challenges we face? And do we 
feel that they sufficiently adapt to the new 21st century 
transition needs of our veterans, given this growing, for 
example, skills gap that exists? We see that in America--all 
these job openings, all these people available to work, and yet 
somehow they're not meeting--part of it is the skills gap and 
the like. So where does that program stand, and where are there 
opportunities to make it better and more responsive? I think 
maybe to you, Mr. Murphy.
    Mr. Murphy. Yes, sir, it is. The Transition Assistance 
Program (TAP) is undergoing an extensive redesign now. We're 
not alone in this in VA. This is a cross-government thing, so 
it's got--the Department of Labor, the Department of Education, 
Small Business Administration, the Department of Defense are 
all players at the table with this. We've heard the cry loudly 
from the Department of Defense and from the veterans themselves 
that while the TAP Program that was in place a year ago was a 
far sight better than what was there 5 years ago that there's 
still more room to go. So we're in the process of redesigning 
that and expanding that and addressing, specifically, what you 
said, which is employing the veteran and how we make that 
transition into civilian life smoother.
    But I do have to comment on another part of that, which is 
the overall Office of Economic Opportunity, and that 
encompasses the Veterans' Readjustment and Employment (VRE) 
world, as well as education and the loan guarantee service. 
Those three services together comprise that office. The 
question was should we establish a fourth administration in 
order to ensure that those three business lines are delivering 
and meeting the needs of the veteran.
    There's been significant change--and I've got to give you a 
tale of two cities here. Four years ago, my answer to that 
would be yes, because, quite frankly, we took assets from those 
three organizations in order to deliver and chase what was 
going on in the backlog. But there's been dramatic changes put 
in place to ensure that that doesn't happen going forward, one 
being that the backlog is now under control, and we're about to 
hit record low numbers, at least for the last decade.
    But we isolated the education service and put all the 
assets in the education world under a single director, and 
nobody is allowed to touch that money, touch those people, and 
they do only education services. In the VRE world, we're 
undergoing right now a realignment of assets and a focus of 
more VRE counselors in the field making direct contact with the 
veterans. In the loan guarantee world, they just continue to 
operate.
    My point is this. If we put a fourth administration in 
place, we're going to pull people out of the field and direct 
contact and delivery of services to put them in headquarters 
here in Washington, D.C., and it'll be several hundred bodies. 
That's not the direction we should be going with this. We 
should be delayering and more consolidation in here, but at the 
same time protect the service and the point of delivery to the 
veteran. I think that's possible, given what we have today.

                  BACKGROUND CHECKS FOR VA CONTRACTORS

    Senator Boozman. Very quickly, while Senator Rubio is still 
here, the policy about the criminal background check--is that a 
statute or is that just to be a policy?
    Mr. Murphy. Can you answer that one, Carolyn?
    Dr. Clancy. I'll have to take it for the record. I believe 
that its VA policy, or I should more correctly say Office of 
Personnel Management policy. But we will take that for the 
record.
    [The information follows:]

    VBA does not contract directly with medical providers. VBA 
contracts with vendors who sub-contract with medical providers to 
conduct disability examinations. However, VBA does require that those 
vendors sub-contract with medical providers who have active, 
unrestricted medical licenses. In addition, VBA contracts with a 3rd-
party vendor to independently validate the current licensing and 
disciplinary status of the sub-contracted medical providers. We are 
currently acquiring information concerning potential background 
investigations for subcontractors.

    Senator Boozman. I think that's something we really need to 
look at, because if that's true, then those entities probably 
are a little bit of a safe harbor for individuals that have had 
problems, you know, that probably couldn't practice anyplace 
else.
    Senator Baldwin?
    Senator Baldwin. Thank you, Mr. Chairman and ranking 
member.

                     OPIOID PRESCRIPTION PRACTICES

    One of the highlights that I saw in the VA budget request 
was that the Administration once again requested full funding 
for the Jason Simcakoski Memorial and Promise Act. That is a 
law passed not so long ago which holds the VA accountable, 
strengthens oversight of their opioid prescribing practices, 
and provides safer care for our veterans.
    So speaking of that accountability, Dr. Clancy, I am hoping 
that you can give me an update on the latest statistics for the 
Tomah VA Medical Center on their opioid and benzodiazepine 
prescription rates.
    Dr. Clancy. I'm happy to do that--a facility I keep a 
particularly close eye on. For the number of patients on 
opioids--now, I'm comparing when we first launched and opioid 
safety initiative at the end of 2012 to where we are right now 
in fiscal year 2018--we've seen a 47 percent decrease in the 
number of veterans on chronic opioids in Tomah, which is a 
little bit ahead of the national average, because we've made 
great progress overall. For the proportion of patients who are 
on both benzodiazepine and an opioid, which has a very high 
risk of adverse events, the decrease at Tomah has been 76 
percent, which is, again, a little bit ahead of the national 
decrease and, frankly, a surprise to me. I thought that 
progress there would be much more difficult than it has been, 
but we've seen enormous progress.
    Senator Baldwin. As a follow-up and for the record, I will 
be requesting additional data for the Madison and Milwaukee VA 
Medical Centers and also some national data by year. But thank 
you for that.
    [The information follows:]

 
----------------------------------------------------------------------------------------------------------------
                                                National     VISN 12      Madison       Tomah        Milwaukee
----------------------------------------------------------------------------------------------------------------
Patients on Opioids (#)              Q4FY12       679,376       24,726        3,221        2,124           5,336
----------------------------------------------------------------------------------------------------------------
                                     Q2FY18       383,057       16,358        2,287        1,117           3,421
----------------------------------------------------------------------------------------------------------------
Decrease in Patients (#)                          296,319        8,368          934        1,007           1,915
----------------------------------------------------------------------------------------------------------------
Percent Change                                        44%          34%          29%          47%             36%
----------------------------------------------------------------------------------------------------------------


 
----------------------------------------------------------------------------------------------------------------
                                                National     VISN 12      Madison       Tomah        Milwaukee
----------------------------------------------------------------------------------------------------------------
Patients Dispensed Opioid &          Q4FY12       122,633        4,335          479          611           1,036
 Benzodiazepine (#)
----------------------------------------------------------------------------------------------------------------
                                     Q2FY18        34,171        1,508          187          147             357
----------------------------------------------------------------------------------------------------------------
Decrease in Patients (#)                           88,462        2,827          292          464             679
----------------------------------------------------------------------------------------------------------------
Percent Change                                        72%          65%          61%          76%             66%
----------------------------------------------------------------------------------------------------------------


 
----------------------------------------------------------------------------------------------------------------
                                                National     VISN 12      Madison       Tomah        Milwaukee
----------------------------------------------------------------------------------------------------------------
Patients on Long-Term Opioid         Q4FY12       438,329       16,845        1,942        1,411           2,782
 Therapy
----------------------------------------------------------------------------------------------------------------
                                     Q2FY18       223,541        9,447        1,309          751           1,616
----------------------------------------------------------------------------------------------------------------
Decrease in Patients (#)                          214,788        7,398          633          660           1,166
----------------------------------------------------------------------------------------------------------------
Percent Change                                        49%          44%          33%          47%             42%
----------------------------------------------------------------------------------------------------------------


 
----------------------------------------------------------------------------------------------------------------
                                                National     VISN 12      Madison       Tomah        Milwaukee
----------------------------------------------------------------------------------------------------------------
Patients on long-Term Opioid
 Therapy with UDS
Completed in the Last 365 Days       Q4FY12          36.6         23.5         16.8         32.1            31.9
 (%)
----------------------------------------------------------------------------------------------------------------
                                     Q2FY18          89.3         87.5         85.6         94.9            82.9
----------------------------------------------------------------------------------------------------------------
Percent Increase                                      53%          64%          69%          63%             51%
----------------------------------------------------------------------------------------------------------------


 
----------------------------------------------------------------------------------------------------------------
                                                National     VISN 12      Madison       Tomah        Milwaukee
----------------------------------------------------------------------------------------------------------------
Patients on >/= 100 MEDD             Q4FY12        59,499        1,916          282          274             445
----------------------------------------------------------------------------------------------------------------
                                     Q2FY18        21,997          938          136          113             178
----------------------------------------------------------------------------------------------------------------
Decrease in Patients (#)                           37,502          978          146          161             267
----------------------------------------------------------------------------------------------------------------
Percent Change                                        63%          51%          52%          59%             60%
----------------------------------------------------------------------------------------------------------------


                    SOCIAL SECURITY NUMBER REDUCTION

    Senator Baldwin. Now, I know we do not have anyone from the 
Office of Information and Technology here on the panel today. 
But I have a question that affects all areas of the VA. In the 
fiscal year 2018 Omnibus legislation, Senator Moran and I 
worked to include bill language requiring the VA to stop using 
social security numbers of veterans as identifiers for them. 
This practice puts veterans at risk for identity theft, and 
there are certainly better and more secure ways to identify 
veterans without putting their personal information and 
identities at risk.
    Senator Moran and I were pushing during the negotiations on 
the Omnibus for a much quicker turnaround time, but the VA said 
it needed 5 years for new claims and 8 years for all others. So 
I really have to say I don't understand why it would take so 
long to implement this particular change that simply serves to 
protect our veterans and their identities.
    So I would like to request a summary and a timeline of what 
actions the VA intends to take and what milestones they intend 
to reach as the VA plans to--actions they plan to take in the 8 
years the VA states that it will take to carry out this 
provision of the fiscal year 2018 Omnibus. I will add that when 
you send this information back to our subcommittee, I think I 
speak for myself and for Senator Moran when I say we would be 
happy to see that you could accomplish this in, say, half the 
amount of time that was negotiated.
    My question is: Can one of you on this panel today assure 
the committee that you can get us back this information?
    Dr. Clancy. Yes.
    [The information follows:]

    In accordance with the requirements of Public Law 115-59, Sec. 2 
(c), ``Social Security Number Fraud Prevention Act of 2017'', VA is 
restricted to include the Social Security Numbers (SSNs) on documents 
sent by mail and the Consolidated Appropriations Act, 2018, in Public 
Law 115-141, Section 240 (a) (b), requires the Department of Veterans 
Affairs (VA) to discontinue using Social Security account numbers to 
identify individuals in all information systems of the VA. VA is 
required by 38 U.S.C. Sec.  5103A, to request evidence from third 
parties on behalf of Veterans to support their claims. Many external 
entities holding Veterans' records, including DoD, other government 
agencies, and private parties, utilize SSNs as a primary identifier. VA 
will face significant challenges in obtaining these records on behalf 
of Veterans if precluded from using the SSN without legislative relief.
    As part of VA's initial plan, the SSN Reduction tool was 
implemented in May 2018. The SSN Reduction tool will help identify SSN 
use data which will be analyzed to determine instances of SSN use and 
the next step will be to develop strategies to eliminate SSN usage. The 
VA is in the process of establishing an Enterprise level SSN Reduction 
Committee which will be completed by August 2018. The Committee will be 
responsible for determining timelines and accomplishments to comply 
with the above SSN reduction related laws.
    The Veterans Health Administration (VHA), Veterans Benefits 
Administration (VBA), and National Cemetery Administration (NCA) have 
made tremendous progress in reducing the use of SSNs in their business 
practices (patient ID cards, forms, memorial applications, eBenefits 
portal, etc.). VHA has already eliminated the use of full SSNs on 
mailed appointment letters and National Cemetery Administration (NCA) 
does not use the full SSN on outgoing mail. Veterans Benefits 
Administration (VBA) is working on a contract to eliminate the use of 
SSNs on outgoing mail and replace it with barcodes. This project is 
currently on hold due to claims processing funding priorities. All 
relevant stakeholders will continue examining their business processes 
and make a determination on whether the continued use of the full SSN 
is necessary or warranted.
    Over the past several years VA has made significant progress in 
eliminating the usage of SSNs from its operations and this work 
continues. Collaboration is taking place between the Office of 
Information and Technology and the Veterans Relations Management 
Initiative to expand the Master Veteran Index (MVI) system and require 
MVI integration for every VA system. MVI assigns an Integrated Control 
Number (ICN), which is a unique identifier for Veterans, dependents and 
beneficiaries. The ICN is a sequentially assigned, non-intelligent 
number that does not divulge protected sensitive information about the 
Veteran in its use.
    VA has already initiated extensive SSN reduction efforts and will 
continue its endeavors to ensure compliance with the above SSN 
reduction statutes within the eight year timeframe.

    Senator Baldwin. Thank you.

                  OFFICE OF INSPECTOR GENERAL FUNDING

    Mr. Chairman, I would like to associate myself with remarks 
that Senator Murray made in the Authorizing Committee a few 
weeks ago about a letter that she received from the Office of 
Inspector General on their actual funding needs for fiscal year 
2019. I'd like to submit the letter she received for the 
record.
    Senator Boozman. Without objection.
    Senator Baldwin. Thank you.
    We need to fund the VA Inspector General at a level that 
aligns with their oversight responsibility and the growth of 
the VA's own budget and new initiatives. The President's budget 
request and now the House Appropriations Committee request that 
was passed--they passed a MILCON VA bill that each fund the VA 
Office of Inspector General at the level of $172 million.
    While this represents an increase from the fiscal year 2018 
appropriated funds, it is almost 8 percent in reduction from 
their actual fiscal year 2018 operating budgets of $179.9 
million. The reason for this discrepancy is a $15.9 million 
carryover of funding that they will not have access to this 
year. The Inspector General's letter states that if we fund the 
OIG at $172 million, he will likely require a reduction of 
about 28 OIG staff, and given the leadership turnover at the VA 
Central Office and billion dollar contract negotiations that 
are ongoing, I just don't think now is the time to be cutting 
back on the Office of the Inspector General.
    So, Mr. Chairman and ranking member, I hope that we can 
work together to make sure the OIG is adequately funded in our 
mark as we work through this process, and I will submit some 
additional questions for the record. Thank you.
    Senator Boozman. Thank you very much. Senator Capito.
    Senator Capito. Thank you, Mr. Chairman and the ranking 
member.
    Thank all of you for your service and for coming before us 
today. I'm sorry I missed the opening statements, but that's 
just sort of the way it is around here sometimes.

                     OPIOID PRESCRIPTION PRACTICES

    Pardon me if this question has been asked before, Dr. 
Clancy. I know Senator Baldwin and I have shared interests in 
this area. So you and I talked and had opportunities--and you 
came down to Beckley and met with all of our--the directors of 
our VA facilities, and I'm still very appreciative of that--but 
the scourge of opioids that's devastating our state, 
particularly within our veteran population.
    We've talked about steps that you're taking at the VA for 
overprescribing and more transparency. Could you just give me 
an update on how that's going and any changes that you might be 
making or what you're seeing across the veteran population in 
this area?
    Dr. Clancy. Sure. What we're seeing in the state of West 
Virginia is that three of the four facilities have made 
substantial progress, not quite as much as the Tomah VA, but 
significant decreases in the proportion of veterans on chronic 
opioids as well as the proportion of veterans on both 
benzodiazepine and a narcotic medication, and that progress has 
continued. So even the last quarter reflects improvements in 
the ball park of 14 percent, 11 percent, and 10 percent for 
those three facilities.
    The one facility that actually never had a very high rate, 
although they have reduced somewhat, is Martinsburg VA Medical 
Center. But they haven't backtracked or suddenly developed a 
new surge, which I think is good news.

                         ALTERNATIVE TREATMENTS

    Senator Capito. Are you employing--so in place of those 
prescriptions, are you, as a system, looking at alternative 
treatments for pain? What types of research are you finding 
there, or what kinds of things are working--nerve blocks or 
different kinds of options that we've heard about?
    Dr. Clancy. We make a wide array of options available, from 
yoga and tai chi to massage. Acupuncture is very, very helpful 
for many people. Not everything is available everywhere. But we 
now have a way of tracking that much more closely than we had. 
A couple of years ago, Dr. Shulkin, as undersecretary, actually 
hired a National Director for Complementary and Integrative 
Health Interventions, which has helped a huge array of 
veterans.
    We're also funding research with the National Center for 
Complementary and Integrative Health at the National Institutes 
of Health, trying to figure out how we can more precisely 
target those interventions. Right now, it's a little bit of you 
can try this and maybe that will help and so forth. What would 
be lovely would be to know how to be a little bit more precise 
with that on an individual basis for veterans out of the gate. 
But I think it's a hugely promising area.
    Senator Capito. I think so, too, and I think--I'm curious, 
sort of in the back of my mind, since we're so oriented to 
prescriptions. I'm sure there's some pushback at certain points 
from some veterans who feel like their pain is not going to get 
alleviated any other way. But I'm glad to know that you're 
dealing with that.
    I would just like to say to the panel, in general, that you 
probably don't get thanked as much as you might deserve. My 
brother-in-law was in the hospital, and the guy next to him had 
just had neurosurgery, and he said--when I walked in, he 
recognized me, and he said, ``I just want you to thank the VA, 
because I'm here from the VA Choice Program.'' He'd been to the 
Huntington facility, had a pretty major problem with his upper 
vertebrae, and he just was singing the praises of the Choice 
Program, of the physician that treated him, of the surgery that 
he was able to receive in his home hospital, which was 40 or 
50--well, I'd say 40 miles away.
    So I just want to let you know there are some very good 
success stories out there, and I ran right into one 
accidentally, and he wanted me to express his gratitude. So on 
behalf of that veteran, I say thank you. I know there's lots of 
issues with running out of money and all that, and I think 
we're going to be dealing with that.

                              AGRI-THERAPY

    Another thing I've run into in terms of dealing with our 
veterans that I think holds promise is this agricultural 
vocations or agri-therapy, something I'm interested in. I 
visited a beekeeper out in our state and could see the mental 
health pluses. He does quite a bit. We were able to get $4 
million into a pilot program to train veterans in agricultural 
vocations while also tending to their behavioral and mental 
health needs. I don't know if anybody on the panel here knows 
specifically anything about this yet.
    Dr. Clancy.
    Dr. Clancy. So our Office of Rural Health in the Veterans 
Administration has actually put out a targeted solicitation for 
this, and in some cases, we anticipate that we may have some 
opportunities to partner with the Administration for Memorial 
Affairs, where they've got adjacent land. So that part was 
brand new to me. But many people have found this to be very 
helpful, so we're pretty excited about it.
    Senator Capito. Yes, I'm excited about what I saw that day, 
so I'm glad that you all are embracing this, and that does 
sound like--I don't know--Mr. Reeves, did you want to talk 
about that with the Memorial's property issue?
    Mr. Reeves. This is just like a lot of other programs that 
we've got across the lines of our administrations. We do 
cooperate with our partners in the other administrations. This 
is something that I've been aware of even before through USDA--
was doing some things like that to encourage farming and that 
kind of thing for veterans. So this is something that we're 
really excited about.
    Senator Capito. Great. All right. Well, thank you all very 
much.
    Thank you, Mr. Chair.
    Senator Boozman. Thank you very much.

                 ELECTRONIC HEALTH RECORD MODERNIZATION

    Let me ask you a few things that I think are important that 
we've talked about but I think we need to just continue to talk 
about as we meet periodically. Last June, Secretary Shulkin 
announced a decision to adopt the same electronic health record 
used by DOD, which, again, I think is a very, very good idea. 
It makes all the sense in the world.
    At the time, he said VA would not need any additional 
funding in fiscal year 2018. However, by the end of October, VA 
submitted a formal reprogramming request in the amount of $782 
million needed to award the contract. It's now May 11th, months 
after Secretary Shulkin's initial announcement, 6 months after 
the first reprogramming request, and a month and a half after 
the subcommittee appropriated the $782 million, and there's 
still no action by VA.
    In light of the continued delays, can you give us an idea 
of the acquisition timeline and when you expect the contract to 
be finalized?
    Mr. Rychalski. So the way--in talking with Mr. Wilkie, what 
he has explained--to get to your point, he has said that he's 
going to make a decision by Memorial Day. He explains that when 
he came in, he sort of came in cold. He knew what was going on 
with DOD but not enough about the VA and felt he needed to do 
due diligence to make sure that he was comfortable in making a 
decision of this magnitude. So that's been sort of this second 
delay. I think before that, they were looking at the contract 
and the interoperability, which was probably worthwhile, 
because they came up with about 50 recommendations to improve 
it. With respect to the funding, for the $782 million, there's 
a three-year period of availability. I believe we'll have about 
$160 million that's not used this year. But between 2018 and 
2019, most of that money, like about $1.1 billion, is going to 
go approximately to the vendor. So I don't have much concern 
about being able to use it or to need it, frankly. It's the 
balance for infrastructure and equipment. But I still think, in 
talking with the Project Management Office (PMO), they have a 
plan for it, and I'm pretty confident that they're going to be 
able to execute.
    Senator Boozman. As you outlined, I think Secretary 
Wilkie's reasoning is valid, and he seems to be doing the due 
diligence. We just need to get this going. This prolonged delay 
in awarding the contract change the requirements in fiscal year 
2019. Can VA execute nearly $2 billion over the next year and a 
half?
    Mr. Rychalski. Yes, I believe we can. Again, a substantial 
amount of that is going to the prime vendor on this in 2018 and 
2019. The balance is for infrastructure and for equipment. I 
know that we will not use all of the $782 million this year. 
We're estimating $160 million will carry over to next year. But 
they do have a plan for it. They still have the same 
requirements. They're projecting the need, and it looks to me 
like they will be able to execute it according to plan.
    Senator Boozman. Very good.

                         MENTAL HEALTH SERVICES

    Dr. Clancy, we talked a lot about this both in this 
committee and in the Authorizing Committee. The fiscal year 
2018 Omnibus provided $8.4 billion for VA mental health 
services and programs. The committee provided additional funds 
for the Veterans Crisis Line, the National Center for Post-
Traumatic Stress Disorder, and to expand Clay Hunt pilot 
programs. The fiscal year 2019 request proposes nearly $8.6 
billion for these programs with $190 million specifically 
dedicated to suicide prevention. In spite of all these 
resources being devoted to address the issue, an average of 20 
veterans a day still take their lives.
    You know, I've been in the House and now in the Senate--you 
know, committees for many years, and it always seems we have 
the same number, unlike the good statistics that you were 
talking about in regard to the opioid epidemic that we faced 
and starting, I think, to turn the corner on. With $17 billion 
planned over this year and the next, I guess the question is: 
Why aren't we seeing a decline--what's your gut feeling as to 
why we aren't seeing a decline in our numbers? Are we able to 
measure--are our metrics good?
    Dr. Clancy. Our metrics are good. Understand that when 
we're looking at 20 a day, we are looking at all veterans, not 
just veterans enrolled in our system. So we have made some very 
important changes in direction that I think are very important, 
one being identifying veterans who get their care in our system 
who are at the highest risk so that they can get more intensive 
follow-up and services. That goes by the acronym of REACH VET, 
and I absolutely could not spell it out for you right at this 
moment, but it's based on very solid research.
    I think our big, big challenge is reaching the 14 of the 20 
who are not enrolled in our system. The highest number of 
veterans who are suiciding are actually in the older veterans 
group, not necessarily so easy to reach, right, and many do not 
have what might be called a web presence, so online approaches 
to reaching out to these individuals are going to be trickier.
    That said, recently, as you know, the President issued an 
Executive Order targeting another area of risk, which is the 
year after transition, and what I have learned is just how 
enthusiastic our VSO partners are about this. When I first told 
them about this, they said, ``Whoa, whoa, whoa. This story is 
not complete unless we're part of it,'' and started, you know, 
being very detailed about how they could help. We recently 
resubmitted a plan after extensive feedback back to the White 
House, and we'll look forward to telling you about that. It is 
tragic and it is frustrating, because we don't have a magic 
answer.

                          VETERANS CRISIS LINE

    I will say the Veterans Crisis Line story is one of 
positive news, because it is an area where even as recently as 
a year, year and a half ago, we had terrible IG reports and 
lots of problems with rollover, and now it is almost flawless. 
In fact, later this month, we will open our third center, and 
these two centers now and then three later this month--the 
third one will be in Topeka--actually work together seamlessly 
so if there's a power problem in Canandaigua, Atlanta picks it 
up and so forth, and the rollover now is less than 1 percent 
routinely. We have eyes on this daily.
    Senator Boozman. Very good. We look forward to working with 
you on this in the future. You mentioned a number of different 
stress relievers and pain relievers and things, and we have a 
number of different programs going on in relation to this, 
spending lots of money. What we'd like to do is help you 
identify the things that are doing very, very well and maybe 
some programs that aren't doing as well and push in that 
direction, and I know you all are, too.

              FINANCIAL MANAGEMENT BUSINESS TRANSFORMATION

    Very quickly, Mr. Rychalski, I understand VA's financial 
management system is 30 years old. VA had planned to partner 
with the Department of Ag to update and modernize the vitally 
important system, but USDA pulled out of the deal. What is the 
VA's plan to move forward without the Department of Agriculture 
as a partner? When will the new system begin implementation, 
and when will it be fully implemented? And will the new system 
be able to more accurately tell you what your resources are and 
where they are needed--hopefully so----
    Mr. Rychalski. Hopefully, right?
    Senator Boozman. Because I'm sure you'll spend a bunch of 
money on it----
    Mr. Rychalski. Yeah.
    Senator Boozman. And help you avoid the shortfall 
situations like the one VA repeatedly seems to find itself in 
community care.
    Mr. Rychalski. So first off, we're going to propose 
legislation to eliminate the use--Department of Agriculture, 
but we're not bitter. It's actually going well. We transitioned 
from USDA back to our own PMO. We've, I think, moved over the 
contracts and established a new contract, and so I feel good 
about it. We had our first rollout, which was very small, very 
modest--the budget module. This is a modern financial system. 
It's by a company called CGI. It's a Momentum product, and it 
was chosen, I think, popularly through testing different 
products.
    And in the end, yes, we're going to have a standard sort of 
financial structure, and we're going to have standardized 
reporting. To your point, it's not 30 years old. It's much more 
modern, much more flexible, I think will benefit the VA. We are 
under a number of different reviews with respect to our 
planning, our programming, and our execution of this, so I 
think you'll see some of the reports on it.
    So far, it's going pretty well. I know we have a couple of 
past attempts at this, so we're mindful of that, and we're 
taking it as it comes. But I feel pretty good about it. I was 
doing something similar to this in the military health system. 
We were implementing an SAP, and I think this is going just as 
well as that is. So, so far, so good.
    Senator Boozman. We look forward to hearing, again, you 
know, at some point it being fully implemented, and we'll be 
looking forward to visiting with you periodically.
    Mr. Rychalski. Right. And we won't have those excuses--we 
don't have the financial information. We'll have to think of 
something else.
    Senator Boozman. Okay.
    Senator Schatz.
    Senator Schatz. Thank you, Mr. Chairman.

                 ELECTRONIC HEALTH RECORD MODERNIZATION

    A couple of follow-up questions either for Dr. Clancy or 
Mr. Rychalski. This is about the EHR--$782 million in the Omni, 
a $1.2 billion request for 2019, so we're well over $2 billion 
in appropriated funds and in requests for appropriations. But 
we are delayed, and Stacy Cummings, the head of DOD's EHR 
acquisition, testified before the Defense Appropriations 
Subcommittee that the DOD will likely not make a decision on 
when to restart the rollout until the end of this calendar 
year.
    So, I guess, two questions. First of all, where are we in 
terms of timing? And, second of all, how should we adjust our 
funding? Because it seems to me, obviously, there's no--
ultimately, savings in pushing something to the right. But, on 
the other hand, there's no reason to appropriate $2 billion 
that's going to sit in a pile when we have other urgent needs. 
So can you give us more fidelity on the timing? And I think 
that'll inform our appropriations approach.
    Mr. Rychalski. So my understanding from working with the 
PMO is that they don't anticipate a substantial delay with 
the--I guess the first increment of this. You bring up a good 
point, though. I think that what we owe you is sort of a deep 
dive into the funding for 2018 and 2019 and explaining what our 
trajectory is and our spend plan so that we're both comfortable 
with it.
    I've worked with them. I mean, I think they're going to be 
on track with the spending. There is some, I think, flexibility 
in 2018 that's going to go at least into 2019. But what I would 
say is that we should sit down with you and sort of go through 
it so that we're both comfortable. I mean, I don't want to sit 
here and, commit my reputation to--that we're going to need 
every dime of it, because I'm just not there myself yet. It 
looks like they're on track, but I would be more comfortable, 
frankly, working with your staff, laying it out and making sure 
that we're both comfortable with it.
    Senator Schatz. Thank you.

                               TELEHEALTH

    Let's talk about Telehealth, Dr. Clancy. Last year, we had 
a hearing on Telehealth, and as a result of the hearing, we 
provided some additional funding, $5 million in the Omnibus, to 
expand Telehealth infrastructure, and I'm wondering if you can 
give me an update on how you're going to use the money.
    Dr. Clancy. So how we're using the money is we are 
allocating it to the field, and they have to commit to making 
sure that 20 percent of their mental health and primary care 
providers are equipped with everything they need to do 
Telehealth. In the overarching context of the anywhere-to-
anywhere legislation, which I think is going to be the killer 
app for us in terms of providing care and, frankly, in terms of 
recruiting people to our system because we are so far ahead of 
the rest of the healthcare system here, that regulation was 
sent to the Federal Register today after going back and forth 
with OMB, and we'll get started on that next month.
    But over the next 3 years, by 2020, it will be a routine 
expectation that all of our clinicians--Telehealth is part of 
the job. This is not a unique boutique activity. So we took the 
$5 million and invested it in equipment that we need right now. 
That can be web cams, additional computer screens, and so 
forth. But we're incredibly excited about this.
    Senator Schatz. Thank you.
    Senator Boozman. I want to thank all of you for being here 
today. We do appreciate all of your hard work. This is all 
about trying to make sure that we work with you in providing 
legislation that provides the right resources that you need to 
do not just a good job, but a great job taking care of our 
veterans.
    We've got some uncertainty right now in the Department, and 
we've got some uncertainty in leadership, but we've also got 
some uncertainty in healthcare, exactly what we're going to 
need in that regard. So we look forward to working with you to, 
again, make sure that we provide the right resources so that we 
can do a good job.

                     ADDITIONAL COMMITTEE QUESTIONS

    For members of the subcommittee, questions for the record 
should be turned in to the subcommittee staff no later than the 
close of business Wednesday, May 16th. With that, we are 
adjourned.
             Questions Submitted by Senator Mitch McConnell
    Question. It has been brought to my attention that some VA 
healthcare facilities lack the capability to provide care to meet the 
specific medical needs of women veterans. With this in mind, what 
efforts is the VA taking to ensure that all of its healthcare 
facilities are fully equipped to provide quality care to women 
veterans? What plans are being made to ensure that the new Louisville 
VA Medical Center is able to provide quality medical care to female 
veterans?
    Answer. In order to ensure we meet the needs for the increasing 
numbers of women Veterans, VHA is rapidly increasing access to trained 
designated women's health providers through large scale educational 
initiatives and has now trained over 5,000 providers since 2008. 
Educational efforts include hosting national mini-residency programs at 
training conferences each year; local mini-residency programs, and the 
newest training at rural sites. In fiscal year 2018, in partnership 
with the Office of Rural Health (ORH), Women's Health Services began 
providing a mini-residency for rural providers and nurses at 35 sites 
and up to 40 rural clinical sites per year going forward.
    VHA is also enhancing access to Women's Health Services through 
telehealth. VHA Telehealth Services uses health informatics, disease 
management, and telehealth technologies to target care and case 
management to improve access to care, improving the health of Veterans. 
The Virtual Integrated Multisite Patient Aligned Care Team is a 
nationwide initiative funded by ORH to provide virtual primary care 
coverage to facilities with provider shortages via primary care tele-
hub sites. In addition to the telehealth hub sites, there are 62 active 
women's health telehealth programs across the system.
    Not all VA healthcare systems have a gynecologist onsite, but all 
Veterans have access to gynecologic care as a basic component of high-
quality care. As of fiscal year 2017, 83 percent of VA medical 
facilities had a gynecologist on-site. Women at sites without a 
gynecologist receive needed gynecologic care through care in the 
community. VA medical facilities do not provide on-site obstetric care 
to pregnant Veterans. However, many female Veterans receiving their 
routine or gender-specific care through VA have their pregnancies 
diagnosed at a VA medical facility and receive further maternity care 
through community healthcare providers. Once a pregnancy is diagnosed, 
the VA maternity care coordinator (MCC) contacts and educates the 
Veteran on maternity benefits and the process for accessing maternity 
care throughout the pregnancy. The MCC answers Veterans' questions and 
remains in communication with pregnant Veterans throughout their 
pregnancy and postpartum care.
    Additionally, privacy and safety of women Veterans is a high 
priority. VA is working to improve standards and maintain facilities to 
provide gender-specific healthcare delivery in a sensitive and safe 
environment. VHA's Women's Health Service updated VHA Directive 1330.01 
to ensure clarity of environment of care requirements and VA's Office 
of Construction and Facilities Management (CFM) is developing facility 
design guide clarifications/revisions to reduce policy compliance 
variability at medical facilities.
    As part of continuing efforts to improve VHA's culture concerning 
women Veterans, the Women's Health Service is promoting respect for 
women Veterans and raising awareness on the issue of harassment, 
specifically, harassment that women Veterans experience when visiting 
VHA sites of care. An internal education and awareness campaign 
launched in August 2017 includes targeted messaging to VHA staff and 
Veterans that communicates our responsibility to provide healthcare to 
women Veterans in environments that attend to their dignity, safety, 
and privacy.
    VHA's Women's Health Service updated and published VHA Directive 
1330.01 on July 24, 2018 to ensure clarity of requirements and their 
measures. CFM has identified appropriate updates for Design Standards 
and released Design Alerts to the field in September 2018, which 
effectively updated the 2010 design standards to extend to all Veterans 
and clarify the standards to facilitate application in VHA facilities. 
The Design Alert will be followed by a systematic update of Design 
Guides, Equipment Lists, and related criteria. The VHA-chartered 
Improving Oversight of Care for Women Veterans Advisory Group will be 
meeting in October to formulate a multifaceted strategic implementation 
and compliance plan to include: communications, education, room 
assessments and tracking of corrective actions to ensure compliance by 
all medical facilities.
    The new Louisville VAMC will incorporate extensive Women's Health 
Serives design standards to accommodate the growing population of Women 
Veterans utilizing VA medical services.
    Question. As you may be aware, the opioid and heroin epidemics have 
hit Kentucky particularly hard and continue to be a challenge for many 
veterans. What programs have been implemented by the VA to treat 
substance use disorders, and particularly opioid abuse, by veterans? 
What programs have been most effective in providing successful 
treatment to veterans?
    Answer. Opioid use disorder (OUD) is a chronic brain disease with 
high associated mortality. Research shows that medication for opioid 
use disorder (OUD medication) saves lives by reducing risk of overdose 
death and mortality from all causes, yet most patients with OUD in the 
United States do not receive these life-saving medications.
    VHA has responded to growing demand for opioid use disorder 
treatment by increasing access to Medication-Assisted Treatment (MAT). 
MAT includes counseling or psychotherapy, close patient monitoring, and 
medication using buprenorphine/naloxone, methadone (administered 
through an Opioid Treatment Program), or extended-release injectable 
naltrexone. Buprenorphine/naloxone and extended-release injectable 
naltrexone are on the VHA National formulary. These are available at 
VHA facilities and through non-VA purchased care options in the 
community. Methadone is administered and dispensed through 32 VHA 
Opioid Treatment Programs across the Nation and through non-VA 
purchased care options at many facilities.
    VHA has been expanding access to MAT for patients with opioid use 
disorders. In Fiscal year 2018, VA treated 24,696 patients with MAT, up 
from 19,333 patients in fiscal year 2014, a 28 percent increase in 
patients treated. This expansion is the result of a comprehensive and 
integrated approach. The Medication Assisted Treatment in VA Initiative 
(originally the Buprenorphine in VA Initiative) provides clinician 
education through monthly webinars, newsletters, a SharePoint with 
educational resources, individual consultations, and a national 
community of practice supported by an e-mail group. The Psychotropic 
Drug Safety Initiative (PDSI) combines use of informatics tools, action 
planning, and a national quality improvement collaborative to improve 
theevidence-based use of psychotropic medications. One of the PDSI 
program's many impacts has been significantly increased rates of using 
medication assisted treatment among Veterans with OUD. In addition, VA 
Pharmacy's Academic Detailing Service has an Opioid Use Disorder 
campaign that provides patient and provider education, provider audit 
and feedback, and tools to increase Veteran access to MAT. As a result 
of these complimentary initiatives, the number of Veterans receiving 
these life-saving medications has continued to increase steadily, but 
the demand for OUD treatment continues to grow and is starting to 
outpace capacity in Subtsance Use Disorder (SUD) specialty care 
clinics.
    In order to improve Veteran access to OUD medication and to provide 
treatment services around the Veteran at his/her preferred point of 
care, VA is implementing a Stepped Care for Opioid Use disorder Train 
the Trainer initiative starting with a conference in August of 2018. 
VISN pilot teams are learning two models (i.e. David Fiellin's Medical 
Management and Colleen Labelle's Collaborative Care models) to 
integrate stepped care into Primary Care, General Mental Health, Pain 
and SUD Clinics at VA facilities. In the stepped care model, stable 
patients with less complex conditions receive chronic disease 
management in Primary Care and General Mental Health while specialty 
SUD clinic and Pain Clinics can provide comprehensive treatment and 
stabilization for less stable patients with more complex conditions. VA 
has deployed CARA-related funding to support the initial training 
conference in fiscal year 2018 where Dr. Fiellin and Ms. LaBelle 
trained one pilot team from each VISN to implement their models. The 
investigators have been funded through existing VA Quality Enhancement 
Research Initiative funding mechanisms to support implementation and 
evaluation of this initiative in fiscal year 2019 and fiscal year 2020. 
Additional funds for VISN-level training conferences and additional 
staff to implement the models are needed to facilitate the success of 
this initiative.
    Overall, quick access to MAT that spans across the continuum of 
care is critical in our effectiveness with OUD. Having all of these 
levels of care in one program allows for expedited access and increased 
communication among providers. To address the opioid epidemic, VISN 9 
has implemented VA's National Opioid Safety Initiative. Through this 
initiative, VISN 9 has achieved the following (comparing 4th quarter 
Fiscal year 2017 data with 3rd quarter fiscal year 2018 data):

  --Reduced the percentage of Veterans prescribed opioids from 12.5 
        percent to 8.9 percent; a 29 percent reduction.

  --Reduced the percentage of Veterans prescribed opioids and 
        benzodiazepines from 5.3 percent to 4.1 percent; a 23 percent 
        reduction. VISN 9 is top in the Nation on this metric.

  --Increased the percentage of Veterans on long-term opioids who have 
        had a urine drug screen from 89.2 percent to 91.1 percent; a 2 
        percent increase.

  --Reduced the percentage of Veterans receiving opioids in doses 
        greater than 100 MEDD from 4.7 percent to 4.04 percent; a 13 
        percent reduction.

  --Increased the percentage of Veterans who have signed an opioid 
        informed consent for long-term opioid therapy from 87.6 percent 
        to 90 percent; a 3 percent increase.

    Academic Detailing Clinical Pharmacy Specialists work in every VISN 
9 facility to educate providers about OUD identification and treatment, 
opioid prescribing, and the risk of combination opioid and 
benzodiazepine prescribing.
    Opioid Overdose Education and Naloxone Distribution were 
implemented in every VISN 9 facility. This includes education and 
training for patients on how to prevent, recognize, and respond to an 
opioid overdose. Naloxone (Narcan) is available for outpatient 
dispensing. Over the past year, VISN 9 facilities dispensed 6,314 
naloxone rescue kits to Veterans. VA Police carry naloxone while on 
duty to quickly respond to any opioid overdoses on site.
    VISN 9 providers query State Prescription Drug Monitoring Programs 
(PDMP) to identify Veterans who may be receiving controlled substance 
prescriptions outside VA. VA submits VA prescription data to State 
PDMPs increasing awareness of what controlled substances Veterans 
receive from VA. Use of PDMP improves patient safety and reduces the 
risk of Veterans receiving duplicate treatment. We appreciate Congress' 
enactment of section 134 of the VA MISSION Act of 2018, which created a 
new section 1730B in title 38, U.S.C., which should reduce barriers to 
VA clinicians' access to information from State PDMPs.
    Providing medications such as buprenorphine/naloxone (Suboxone) 
allows the patient to focus more readily on recovery activities by 
preventing withdrawal and reducing cravings. These medications help 
Veterans achieve the long-term goal of reducing opioid use and the 
associated negative medical, legal, and social consequences, including 
death from overdose.
    VISN 9 clinical providers reviewed the medical records of 2,349 
Veterans with a diagnosis of OUD to identify candidates for medication 
assisted therapy. All VISN 9 facilities have buprenorphine/naloxone 
(Suboxone) and long-acting naltrexone (Vivitrol) available to patients 
to help manage their OUD, if clinically appropriate and desired by the 
Veteran. Methadone treatment is made available, if needed, through 
referrals to the community.
    In the 3rd quarter of fiscal year 2018, 750 Veterans with OUD in 
VISN 9 received MAT, including Suboxone, methadone, and Vivitrol 
(LEX=174, LOU=99). VISN 9 is also participating in the VA Buprenorphine 
Initiative. Buprenorphine has been shown to be a safe and effective 
treatment of opioid dependence in non-specialized, outpatient, office-
based settings, including VA environments. Furthermore, buprenorphine`s 
availability has encouraged opioid-dependent patients who would not 
otherwise present themselves to an opioid agonist therapy program to 
access treatment.

Lexington VAMC:

  --Full evaluation for OUD, and, when appropriate, the initiation of 
        MAT, was expanded to both the inpatient and residential 
        treatment settings.

  --Prescribing Vivitrol for alcohol use disorder as well as OUD was 
        expanded to include Patient Aligned Care Team.

  --Primary care providers are authorized to obtain the qualifications 
        necessary to prescribe Suboxone while retaining Veterans in 
        their clinic.

  --Intensive outpatient therapy, which is for Veterans of higher 
        acuity, is available within the Substance Abuse Treatment 
        Program.

  --Veterans with a documented diagnosis of opioid abuse where 
        treatment is recommended also receive a direct-to-Veteran 
        mailer outlining information about OUD as well as treatment 
        options. Veterans are also continuously reviewed again and 
        encouraged to participate in treatment.

    The creation of programs allowing both inpatient teams as well as 
the residential teams to initiate MAT when appropriate has been the 
most effective method of providing successful treatment to Veterans at 
this point. Programs provide a more direct and effective continuum of 
care for Veterans which should lead to higher retention rates and 
improved outcomes for Veterans receiving MAT.

Robley Rex VAMC:

  --SUD treatment is offered in nearly all of the outpatient community-
        based outpatient clinics (CBOC) and at the main campus. This 
        evidence-based treatment includes group and individual 
        psychotherapy as well as medication assisted therapy for OUD 
        (including Vivitrol and Suboxone).

  --An Intensive Outpatient Program is offered at the main campus. The 
        program involves 2 hours of evidence-based treatment daily for 
        approximately 8 weeks. Individual psychotherapy and MAT for OUD 
        (including Vivitrol and Suboxone) are also offered at this 
        level of care.

  --A Substance Abuse Residential Rehabilitation Treatment Program is 
        offered at the main campus. This is our highest level of care 
        for substance abuse disorders and involves a 16-bed residential 
        program that lasts for approximately 1 month. Included in this 
        program are at least four daily evidence-based groups, 
        intensive individual psychotherapy, and medication assisted 
        therapy for OUD (Including Vivitrol and Suboxone).

  --Methadone treatment is made available, if needed, through referrals 
        to the community.

  --The SUD treatment program also provides a consultation service for 
        Veterans hospitalized in acute psychiatry or in medicine 
        service. A psychiatrist is involved in this consultation 
        service and medication assisted therapies can be started (if 
        appropriate) while Veterans are still inpatients.

    Question. As you know, a new Louisville Department of Veterans 
Affairs Medical Center (VAMC) was announced in 2006. Kentucky 
veterans--who have served our country so bravely--have waited far too 
long to begin receiving care at this announced facility. While I have 
never endorsed a specific location, I was encouraged when the VA signed 
a final Record of Decision for a new Louisville VAMC, indicating the 
long-delayed project would finally move forward. However, I was highly 
dismayed when I learned that the VA failed to request funds for this 
project in the President's fiscal year 19 budget. My expectation is 
that the VA will take all necessary steps to advance this project and 
ensure the new Louisville VAMC will be built expeditiously for the care 
and service of our veterans. Will you please provide an updated 
timeline for the design, construction, and completion of the facility 
and share what preliminary work can be accomplished during this interim 
period to expedite the project?
    Answer. VA signed and published the Record of Decision in the 
Federal Register in October 2017 to conclude the National Environmental 
Policy Act (NEPA) process. Phase 1 construction, currently 
appropriated, was scheduled to be advertised in October 2018 with award 
in April 2019 and start of construction in May 2019. Subject to funds 
being appropriated, VA would anticipate awarding phase 2 in January 
2020 with start of construction in February 2020 and completion of 
construction in March 2024.
    However, the pending litigation by the City of Crossgate, 
challenging VA's adherence to NEPA requirements, may delay solicitation 
and/or award of phase 1 construction. Resolution of the litigation is 
not anticipated before the end of fiscal year 2019. VA is working with 
the Department of Justice and the U.S. Army Corps of Engineers to 
determine the best options for moving forward with the solicitation and 
potential award of the phases.
    Question. To assist the VA as it continues with reform efforts to 
improve and expedite care for our nation's veterans, Congress passed 
and the President signed into law the Department of Veterans Affairs 
Accountability and Whistleblower Protection Act of 2017. This bill 
authorizes the creation of a new Office of Accountability and 
Whistleblower Protection and provides new authority for additional 
accountability measures. Will you please provide an update on the VA's 
implementation of these new authorities to ensure that veterans receive 
the quality care they deserve?
    Answer. As discussed in the Office of Accountability and 
Whistleblower Protection (OAWP) report of June 30, 2018, as of June 1, 
2018, OAWP received nearly 2,000 submissions of alleged wrongdoing 
within the Department. The nearly 2,000 submissions are further broken 
down by general category in the following chart:

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    A ``whistleblower disclosure'' is defined in 38 U.S.C. 323(g)(3) as 
``any disclosure of information by an employee of the Department or 
individual applying to become an employee of the Department which the 
employee or individual reasonably believes evidences--(A) a violation 
of law, rule, regulation; or (B) gross mismanagement, a gross waste of 
funds, an abuse of authority, or a substantial and specific danger to 
public health or safety.''
    A whistleblower disclosure is an allegation. Investigation is 
required to determine whether the allegation is substantiated or not.
    Allegations that do not satisfy an element of this definition are 
provided to the respective organization for awareness as a ``non-
whistleblower disclosure.'' Investigation of a ``non-whistleblower 
disclosure'' is at the discretion of the organization and no report is 
required to OAWP. Generally, non-whistleblower disclosures consist of 
Veteran or caregiver complaints, those are referred to VHA's Office of 
Client Relations. OAWP completed 128 investigations involving 236 
persons of interest (POIs). A POI is an employee in a senior leader 
role against whom an allegation of wrongdoing has been made. Seventy-
four of those investigations did not substantiate misconduct by the 
POIs. OAWP recommended disciplinary or adverse actions in 54 cases 
involving 58 unique POIs. Twenty-three of the recommended disciplinary 
or adverse actions were against individuals occupying senior executive 
positions under 38 U.S.C., section 713. Of that 23, 17 cases were 
either proposed or decided at a level lower than that recommended by 
OAWP. One of the cases was settled prior to a decision being issued and 
five were either not proposed or decided due to retirement/resignation.
    VA created and published implementation guidance for the new 
authorities contained in the Accountability and Whistleblower 
Protection Act, Public Law 115-41, in the form of four Human Resources 
Management Letters (to implement 38 U.S.C., section 714 and the changes 
to title 38 employment in section 208 of the Act) and a Corporate 
Senior Executive Management Office Letter (to implement 38 U.S.C., 
section 713). VA's Office of Human Resources and Administration 
developed and delivered, in coordination with VA's OGC, immediate 
training to field activities and staff offices regarding implementing 
the new authorities. OAWP and OGC continue to deliver orientation and 
training sessions throughout VA to educate supervisors and senior 
leaders regarding the provisions of the Act. We are also coordinating 
efforts with the administrations to include improve and expand training 
opportunities for frontline HR employees.
    Training to the workforce continues to be provided through the 
existing Notification and Federal Employee Antidiscrimination and 
Retaliation Act of 2002 (No-FEAR) mandated training while OAWP develops 
the expanded training directed in the Accountability and Whistleblower 
Protection Act (38 U.S.C., section 733).
    These efforts demonstrate the Department's commitment to improving 
the stewardship of VA by holding senior leaders accountable by 
thorough, impartial investigations into allegations of senior leader 
misconduct or poor performance and whistleblower retaliation.
                                 ______
                                 
               Questions Submitted by Senator John Hoeven
    Question. In response to North Dakota and western Minnesota 
Veterans concerns when scheduling appointments to receive VA community 
care, the VA implemented the Choice Program Care Coordination 
initiative at the Fargo VA Medical Center. This initiative allows Fargo 
VA staff to work directly with veterans and help them schedule and 
coordinate their community care appointments. The implementation of 
this initiative has significantly reduced waiting times for Veterans to 
have their primary care, specialty care, and mental health appointments 
scheduled. Recognizing its success in reducing scheduling times, the VA 
has extended this initiative to a VA facility in Montana. With the 
amount of success and impact this initiative has had on North Dakota 
and western Minnesota Veterans, as well as its extension into Montana, 
is the VA looking to further expand this initiative in other parts of 
the country?
    Answer. The Choice Program Care Coordination initiative will not 
expand further as a separate pilot program. Instead, VA continues to 
improve care coordination for Veterans through implementation of 
multiple process and technology deployments, the development and 
implementation of the MISSION Act, and future award of the Community 
Care Network (CCN) contract.
    Question. Since the implementation of the Veterans Choice Program, 
many Veterans have opted to seek care in their home communities. Many 
non-VA providers continue to have concerns about receiving prompt 
payments from third-party payers. These providers face a claims 
backlog, and may have long waiting times to speak with someone 
regarding payment issues. Congress has the potential to pass 
legislation that would consolidate and improve VA's community care 
programs. That being said, it is critical that the VA's third-party 
payers provide prompt and accurate payments so that these providers can 
better serve our Veterans. What actions has the Department taken in 
order to ensure that providers who are caring for our Veterans are 
being paid on time?
    Answer. Since January 2018, VA has increased emphasis on working 
with community providers to improve timeliness of payments. VA has 
reached out nationally to the top 20 providers based on billed charges. 
Rapid response teams are actively working reconciliation of inventory 
for top 20 providers, while concurrently educating providers through 
tailored training sessions and resolving underlying issues that lead to 
processing delays. VA has increased the numbers of claims processed 
through the use of vendors, as well as working towards IT improvements 
to streamline the claims processing functions. Through this claims 
resolution process, VA has helped clean up providers' VA accounts 
receivables (AR) and curbed systemic issues that cause providers to 
keep claims on their AR or submit unclean claims.
    VA continues to improve care coordination for Veterans through 
implementation of multiple process and technology deployments, the 
development and implementation of the MISSION Act, and future award of 
the CCN contract.
    Question. As our Veteran population ages, many of our Veterans, 
particularly those with service connected disabilities, are seeking 
greater access to high quality long-term care services closer to their 
family and friends. While the current Veterans Choice Program offers 
limited authority for the VA to enter into provider agreements, it does 
not include skilled nursing facilities. The VA MISSION Act of 2018, 
which was recently reported favorably to the House of Representatives, 
contains language that I helped secure that would allow the VA to enter 
into agreements with non-VA extended care providers. Does the 
Department continue to support these agreements? Should this 
legislation be signed into law, will the Department work with me to 
ensure the legislation is implemented in a manner that will allow long-
term care facilities, especially those located in rural areas, to serve 
our veterans without having to jump through unnecessary bureaucratic 
hoops?
    Answer. The VA MISSION Act of 2018 has been signed by the President 
(Pubic Law 115-182). VA is developing regulations that will enhance 
access to certain long term care facilities, particularly in rural 
areas, and should reduce the administrative burden of these facilities.
    Question. This year, the Department is expected to open North 
Dakota's first VA national cemetery, which will help to ensure that our 
state's Veterans receive the recognition they deserve for their 
service. With the groundbreaking of the cemetery occurring this spring, 
is the project still expected to be completed by the end of 2018?
    Answer. No, construction of the Veterans cemetery in Fargo, ND is 
expected to be complete in the summer of 2019.
    Question. Congress recently provided an additional $2 billion in 
funding for VA infrastructure. Some of this funding will be directed 
toward the first 52 projects on the fiscal year 2018 State Home 
Construction Grants Priority List. The VA State Home located in Lisbon, 
ND recently completed a renovation that will help them better serve our 
veterans. The project was ranked 42nd (31st in funding order) on 
Priority List Group 1. What is the expected timeline for this 
particular project to be reimbursed?
    Answer. The North Dakota renovation project was awarded August 21, 
2018. The Memorandum of Agreement has been mailed to the State. The 
reimbursement account takes 7-10 business days to set up and the state 
can request a reimbursement any time after the account has been 
established. After a reimbursement request has been made and approved 
by VHA staff, it takes about 5-7 business days for the funds transfer 
to be completed.
                                 ______
                                 
               Questions Submitted by Senator Marco Rubio
    Question. I'm encouraged to learn about the work being done to open 
cancer clinical trials at neighboring VA facilities. In these 
partnerships, faculty from National Cancer Institute (NCI)-designated 
Comprehensive Cancer Centers engage with VA medical staff to offer 
clinical trials inside the VA to veterans battling cancer. With access 
to clinical trials, veterans can benefit from cutting-edge new 
technologies in cancer care without leaving the VA. These partnerships 
enable our veterans to receive more effective personalized cancer care, 
such as those offered at NCI sponsored facilities. It also enables VA 
physicians to work alongside the top oncologists at NCI-designated 
cancer centers.

  --Besides the ``Navigate'' program, in which the National Cancer 
        Institute provides funding for certain clinical trials at a 
        handful of VA facilities, how is the VA making investments to 
        build the necessary infrastructure to facilitate partnerships 
        like this, which enhance the options available to veterans as 
        well as their chances of defeating cancer?

    Answer. To clarify, NAVIGATE does not provide funding for specific 
NCI clinical trials to VA facilities. VA facilities may participate in 
NCI trials without having received funding from NAVIGATE. In fact, 
there are VA facilities that continue to participate in NCI trials even 
though they were not selected for funding under the NAVIGATE program. 
VA has supported activities to enhance site capabilities and best 
practices for conducting clinical trials through its Cooperative 
Studies Program's Network of Dedicated Enrollment Sites. Additionally, 
VA has been partnering with stakeholders including its VA affiliated 
non-profit corporations, industry and patient advocacy organizations to 
facilitate the ability to conduct industry-sponsored trials, including 
ones related to cancer. While participation in non-VA funded activities 
is often a local decision at the particular VA facility, VA is working 
with various groups at the national level to enhance its capabilities 
for innovating and adopting best practices as part of the national 
clinical trials enterprise.
                                 ______
                                 
            Questions Submitted by Senator Patrick J. Leahy
    Question. I remain concerned about the frequent and abrupt 
leadership changes at the White River Junction VA Medical Center in my 
home state of Vermont. While the acting leadership team is working hard 
to maintain the highest possible quality of service for our veterans, 
the absence of a well-qualified permanent director will certainly 
hamper initiatives aimed at improving care. This is especially 
concerning to me at a time when the responsibility for the CHOICE 
program is transitioning back to the local medical centers. What are 
your current and future efforts to recruit and hire a director?
    Answer. VA is in a state of fundamental transformation not seen at 
this organization since the end of World War II. Such transformation 
will require substantial resources to meet the challenges of offering 
world-class customer service to Veterans and increase access to care 
through the VA Maintaining Internal Systems and Strengthening 
Integrated Outside Networks (MISSION) Act implementation. This 
organizational innovation and modernization cannot be successfully 
implemented without strong leadership at every level of the 
organization. The recruitment and hiring of a permanent Medical Center 
Director (MCD) at the White River Junction VA Medical Center is vital 
for such transformation to reach Veterans in Vermont. Both our current 
and future efforts to recruit and hire a MCD are focused on identifying 
a leader than can offer world-class customer service and increase 
access to care to Veterans in Vermont, especially in the wake of VA's 
current state of fundamental transformation and modernization.
    We are pleased to announce that a candidate was selected in the 
beginning of February 2019 and the Office of Human Resources and 
Administration is processing their paperwork. We are confident that the 
selected candidate will be a strong, long-term leader for the facility, 
especially in this time of transformational change at VA.
    Question. What obstacles are delaying or preventing you from moving 
forward to recruiting and hiring a director, and what initiatives will 
you undertake to encourage retention of that new director at the White 
River Junction VA Medical Center?
    Answer. The White River Junction VA Medical Center experienced a 
significant system shock following allegations brought forth in a 
Boston Globe article. While an unfortunate event, it provided the 
organization an opportunity to re-examine its commitment to maintaining 
the highest possible quality of service for our Veterans in Vermont. 
Since that time, we have worked diligently to ensure that leadership 
transitions are as smooth as possible and we focused on finding a well-
qualified, permanent MCD capable of ushering the sweeping innovation 
and modernization efforts at VA into the White River Junction VA 
Medical Center.
    This position has been vital in helping overcome delays and 
barriers associated with addressing the scope of the partnership 
between the White River Junction (VT) and Manchester (NH) Medical 
Centers. While discussions ranged from collaborations to mergers, VA 
had to finalize a decision before the White River Junction VA Medical 
Center could move forward with significant hiring efforts. In the end, 
VA decided on creating a partnership between the medical centers 
focused on close collaboration. We expect that the depth and breadth of 
services for each facility will inevitably be greater through the 
partnership rather than working independently.
    VA has made positive progress in the recruitment of highly 
qualified candidates for MCD positions. Tactics to mitigate recruitment 
challenges, continue to be updated, such as monthly national job 
announcements, eliminating extra steps in the hiring process, and 
reducing time to hire. However, one challenge to hiring is the DHA 
salary restriction cap at Exec Level V ($153,800). According to a 2014 
publication in the Journal of the American Medical Association: 
Internal Medicine, the average compensation for private sector hospital 
executives is approximately $600,000 annually.\1\
    VA has proposed a technical amendment to significantly increase MCD 
salary caps, authorizing VA to appoint MCDs at the Executive Level II 
($189,600) and Executive Level I ($210,700) for Critical Pay Positions. 
Such pay reform efforts could go a long way in recruiting and retaining 
quality MCDs in VA Medical Centers in Vermont and across the country.
    Question. I understand that the New Hampshire Task Force 
recommendations are currently under review by the VA Central Office. 
While thoughtful collaboration between the Vermont and New Hampshire 
medical centers may serve the veterans in both states, I have heard the 
perception from constituents that the discussion of a more integrated 
system appears to be driven by the problems at the Manchester VA, 
rather than by the leadership at the White River Junction VA Medical 
Center, which offers a higher level of care. What measures will you 
pledge to have your office take to solicit and integrate the concerns 
and input of Vermont veterans and stakeholder groups prior to 
considering if this proposal should move forward?
    Answer. VA's purpose is to serve those who served. As such, VA will 
ensure Vermont and New Hampshire Veterans alike have organizations 
keenly focused on their well-being. Preliminary planning efforts are 
now underway between the (Veterans Integrated Service Network) VISN 
senior leadership and the senior leadership teams at both Manchester 
and White River Junction. These efforts will focus on what meaningful 
collaboration could mean for each site. Two core principles of this 
work are that any collaboration should be of mutual benefit to patients 
of both facilities, and that there is frequent communication to 
Veterans and other stakeholders about our progress in this partnership.
    During this planning process, Veterans' input will be of the utmost 
importance. Manchester VA Medical Center (VAMC) hosted a series of open 
forums such as town hall meetings to specifically gain stakeholder 
feedback when formulating recommendations for the Manchester 2025 Task 
Force. These forums helped to inform the recommendations of that group. 
While White River Junction has not identified any specific service 
changes because of potential collaboration with Manchester, the 
relevant information such as White River Junction providing interim 
leadership in Manchester and exploring future collaboration has been a 
topic at their regular Veteran town hall meetings throughout 2018. 
Communication with Vermont Veterans and stakeholder groups will 
continue as the Manchester and White River Junction VAMC partnership 
continues to develop.
                                 ______
                                 
              Questions Submitted by Senator Tammy Baldwin
                            opioid rx rates
     Question. Dr. Clancy, please provide the Committee with the latest 
prescription rates of opioids and benzodiazepines for all Wisconsin 
VAMCs. In addition, please segregate these prescribing rates annually 
for 2015, 2016 and 2017, both nationally and for each Wisconsin VAMC.
    Answer. The most recent opioid and benzodiazepine prescribing rates 
available for Wisconsin VA Medical Centers (Table 1) is for the 1st 3 
quarters of fiscal year 2018 (from October 1, 2017 to June 30, 2018).

  Table 1. Opioid and Benzodiazepine Prescribing Rates for fiscal year 2018 (October 1, 2017 to June 30, 2018)
----------------------------------------------------------------------------------------------------------------
                                                                Patients Dispensed An    Outpatient
                                                                      Opioid and          Pharmacy
                      VA Medical Center                             Benzodiazepine        Patients    Percentage
                                                                  Prescriptions (#)         (#)
----------------------------------------------------------------------------------------------------------------
VISN 12 607 Madison, WI......................................                      404       29,948        1.35%
VISN 12 676 Tomah, WI........................................                      243       19,019        1.28%
VISN 12 695 Milwaukee, WI....................................                      728       45,951        1.58%
----------------------------------------------------------------------------------------------------------------

    Table 2 represents the opioid and benzodiazepine prescribing rates 
nationally and for the Wisconsin VA Medical Centers from fiscal year 
2015 to fiscal year 2017.

          Table 2. Opioid and Benzodiazepine Prescribing Rates forfiscal year 2015 to fiscal year 2017
----------------------------------------------------------------------------------------------------------------
                                                             Patients Dispensed
                                                                An Opioid and        Outpatient
         Fiscal Year                VA Medical Center          Benzodiazepine     Pharmacy Patients   Percentage
                                                              Prescriptions (#)          (#)
----------------------------------------------------------------------------------------------------------------
fiscal year 2015............                      National              173,044           4,951,897        3.49%
fiscal year 2015............       VISN 12 607 Madison, WI                  906              31,076        2.92%
fiscal year 2015............         VISN 12 676 Tomah, WI                  869              21,168        4.11%
fiscal year 2015............     VISN 12 695 Milwaukee, WI                1,886              49,263        3.83%
fiscal year 2016............                      National              141,628           4,993,889        2.84%
fiscal year 2016............       VISN 12 607 Madison, WI                  817              31,313        2.61%
fiscal year 2016............         VISN 12 676 Tomah, WI                  612              20,946        2.92%
fiscal year 2016............     VISN 12 695 Milwaukee, WI                1,585              48,692        3.26%
fiscal year 2017............                      National              107,630           5,027,011        2.14%
fiscal year 2017............       VISN 12 607 Madison, WI                  701              31,339        2.24%
fiscal year 2017............         VISN 12 676 Tomah, WI                  420              20,155        2.08%
fiscal year 2017............     VISN 12 695 Milwaukee, WI                1,143              48,247        2.37%
----------------------------------------------------------------------------------------------------------------

                      colorectal cancer screenings
    Question. Dr. Clancy, the fiscal year 18 Omnibus directed the VA to 
align with the more than 90 percent of U.S. health plans that utilize 
all seven colorectal cancer-screening strategies recommended by the 
United States Preventive Services Task Force. Can you tell me when the 
VA will come into compliance with this directive to offer all seven 
colorectal cancer-screening strategies for veterans?
    Answer. VA recommends and provides access to evidence-based 
colorectal cancer screening strategies for enrolled Veterans. VA 
established policies that mandate providers to offer screening to 
Veterans aged 50-75 years and to provide timely diagnostic evaluation. 
Performance metrics provide feedback to clinicians. This work is 
accompanied by a significant investment in research to determine the 
best ways to screen for colorectal cancer, including a large-scale 
comparative effectiveness study of the fecal immunochemical test and 
colonoscopy, to ultimately reduce colorectal cancer mortality. All 
seven United States Preventive Services Task Force recommended 
colorectal cancer screening strategies are recognized by VA. Clinicians 
are able to recommend any test that they deem appropriate for their 
patients.
                              mass program
    Question. Dr. Clancy, during your testimony before the Committee on 
May 9th, Senator Tester shared a story and frustration of significant 
delays in scheduling appointments. He shared a story of it taking 10 
minutes to simply sign into the system. You responded to Senator Tester 
that the delay was unacceptable and it reinforces the need to advance a 
new electronic health record (EHR) system. You additionally stated the 
VA needed a new scheduling system that was ``much better--swifter'' 
than is in place. I noticed in your response to Senator Tester you did 
not mention a current scheduling pilot project called the Medical 
Appointment Scheduling System (MASS) program could be deployed 
nationally by December 31, 2020. Please provide the status of the pilot 
and next steps. In addition, given that the VA EHR modernization 
project has been significantly delayed and a contract has not yet been 
signed, would you consider rolling out the MASS program to help address 
this pressing scheduling problem?
    Answer. VA signed a contract with Cerner on May 17, 2018 to 
modernize VA's legacy electronic health record (EHR) systems. VA will 
utilize Cerner's scheduling capabilities, which are tightly integrated 
into the Cerner Millennium EHR solution. In addition, VA is piloting a 
resource-based scheduling system (MASS) at the Columbus, OH VA Medical 
Center. This has been implemented, stabilized, and is under evaluation.
                              rare cancers
    Question. Dr. Clancy, are you aware of the lack of therapeutics 
available for veterans diagnosed with rare cancers? If so, what action 
is the VA taking to ensure service members have access to the most 
effective cancer treatments for their service-connected cancers?
    Answer. VA provides appropriate diagnostic testing and treatment 
for any cancer diagnosis, aligned with the most recent recommendations, 
regulations and clinical guidelines. Since rare cancers as a group are 
not rare in clinical practice, VA provides comprehensive care on a 
daily basis for Veterans with these cancer types including diagnosis 
and treatments (surgery, radiation, drug therapy). Remarkable progress 
in treatment has occurred for some rare cancers. For example, chronic 
myelogenous leukemia, a previously uniformly fatal disease, is now 
effectively treated with an oral medication resulting in more than 80 
percent of patients being alive 10 years after diagnosis.
    VA's National Precision Oncology Program provides molecular 
characterization of cancers, including rare cancers, to identify 
patient-specific therapies and clinical trial opportunities. VA is 
partnering with the National Cancer Institute (NCI) and others to 
accelerate access to clinical trials. If VA cannot provide specialized 
treatment to a specific Veteran, that Veteran is appropriately referred 
to a treatment center that can provide the needed care, in accordance 
with VA policy.
                            medical records
    Question. Dr. Clancy, on July 31, 2017 the VA Office of Inspector 
General released a report (No. 17-01846-316) on opioid prescribing in 
VA community care programs that found contract providers are not 
subject to many of the opioid safety reforms included in Jason's Law 
and implemented at VA. Furthermore, VA is not consistently tracking 
opioid prescriptions from community care programs due to significant 
information exchange gaps between VA and non-VA providers. Please 
provide the Committee with the updated status of all four 
recommendations made by the Inspector General in this report.
    In response to this report, Senators Capito, Moran and Tester 
introduced legislation with me to close this gap and it is included in 
Section 131 of the MISSION Act working its way through the House as we 
speak. More than 1.9 million Veterans have received care through the 
Veterans Choice Program thus far, so Dr. Clancy, I have two questions:
    Would you agree that since the VA is responsible for coordinating 
Veterans care, in the community and in-house, the VA's goal should be 
to have all medical records and prescription information for Veterans 
under their care?
    Answer. We look forward to implementing this and all the provisions 
of the MISSION Act as passed into law in June. VA is actively working 
to meet all required deadlines as provided by the Act. VA continues its 
roll out of HealthShare Referral Manager, which will enhance sharing of 
medical documentation between community care providers and VA partners, 
including documentation of opioid prescribing.
    Question. With a new Electronic Health Records contract potentially 
years away from being deployed, what is the VA doing today to ensure 
that veterans medical records are shared with outside providers and the 
VA's own records are updated when those veterans receive care outside 
of the VA?
    Answer. VA has multiple methods to send and receive medical records 
with community providers. These options include mail, fax, secure 
email, direct messaging and Health Information Exchange (HIE). If the 
Community Provider is part of an HIE network that VA has partnered 
with, VA will have access to that data real-time through HIE's 
supported capabilities to pull data as needed from a partner's EHR. 
However, if the Community Provider is not a member of a partnering HIE, 
a Provider may send documentation through VA's Community Provider 
portal, secure email, or electronic data interchange transaction, and 
VA will upload that documentation to Imaging and EHR viewer 
applications immediately upon receipt and approval of that 
documentation. In May 2017, VA deployed a new tool, Community Viewer, 
that allows community providers read only access to the VA medical 
record. In addition, VA has begun rolling out a portal capability that 
will allow for the medical records to be exchanged. The ability to 
attach medical records to the electronic claim submission will also be 
available at the beginning of fiscal year 2019.
                                 ______
                                 
           Questions Submitted by Senator Christopher Murphy
    Question. In the testimony you acknowledge this new provision 
(Section 258 of Division J of the 2018 Appropriation Act) and state 
that the ``VA is working to implement this new authority. What progress 
has the VA made on implementing the law?
    Answer. VA educated the field about this legislation in December 
2018 and January 2019. Implementation of this provision has taken place 
in conjunction with current efforts to achieve the goals set forth in 
Executive Order 13822, Supporting Our Veterans During Their Transition 
From Uniformed Serivce to Civilian Life, including notifying 
transitioning Service members of the mental healthcare services that 
may be available to them under new section 1720I of title 38, United 
States Code (U.S.C.), and other VA authorities. VA still needs to issue 
implementing regulations for this recent legislation, particularly to 
define certain terms in the law, and update applicable policies and 
protocols. The Office of Regulatory and Administrative Affairs, in 
consultation with the VA Office of General Counsel (OGC), is drafting 
the needed updates.
    Question. What is your timeline for fully completing the 
implementation of the law?
    Answer. VA has already been providing care for former 
Servicemembers with Other Than Honorable (OTH) discharges. In January, 
2019 VA fulfilled the added requirements under the 2018 Appropriations 
Act, particularly providing notice to individual Servicemembers with 
OTH discharges by the end of calendar year 2018.
    Question. To date have any veterans received treatment under this 
new provision in the law?
    Answer. VA now has multiple authorities under which it furnishes 
mental healthcare to individuals with OTH discharges. Since July 2017, 
more than 9,286 former Servicemembers with OTH discharges have 
registered in the Veterans Health Administration's (VHA) enrollment 
system. In fiscal year 2018, 2,350 individuals with OTH discharges 
received mental healthcare from VA healthcare facilities, the majority 
receiving outpatient services. Currently, VA is not able to track how 
many former Servicemembers are receiving treatment under this new 
provision in the law.
    Question. Per the testimony, as of December 30, 2017, VHA had 
received 3,241 requests for healthcare services under the previous 100-
day emergent mental healthcare program. What has the VA done in terms 
of notifying these newly eligible veterans under this new section in 
the law?
    Answer. In December 2018, VHA mailed approximately 475,000 letters 
to individuals who have an OTH discharge. There were approximately 
28,000 letters that did not pass the United States Postal Service 
Coding Accuracy Support System (CASS) validation. VHA Member Services 
is working with the Office of Data Governance and Analytics to provide 
correct addresses. The letters informed individals that Congress 
recently passed a law that allows VA to provide mental and behavioral 
healthcare to certain former Servicemembers with OTH dischages. The 
letter encouraged individuals to reach out to VA if they were 
interested in receiving VA mental healthcare. The letter also provided 
individuals with information about the Veterans Crisis Line.
    VA has a number of other resources available to transitioning 
Veterans. Concierge for Care was launched in October 2017 as a 
proactive outreach to Veterans shortly after military separation to 
inform them, in general, about the healthcare enrollment process.
    The Transition Assistance Program (TAP) supports transitioning 
Service members with the VA healthcare enrollment process. TAP guides 
(Instructor and Participant) were updated to clearly articulate the 
healthcare application and enrollment process. The ``Easy Button,'' 
completed in December 2018, provides mental health resources and a 
straight path into mental healthcare for Veterans in need.
    Question. The VA has just over 130 days left to notify all eligible 
veterans of this treatment under the new law. Have you identified a 
contractor or vendor to notify the close to 500,000 eligible veterans?
    Answer. Mechanisms to gather relevant information (names, phone 
numbers, addresses, etc.) and communicate were finalized and the 
notifications were sent in December 2018.
---------------------------------------------------------------------------
    \1\ Joynt, KE; etal. Compensation of Chief Executive Officers at 
Nonprofit US Hospitals. JAMA Intern Med. 2014;174(1):61-67.
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                          SUBCOMMITTEE RECESS

    Senator Moran. And with that, our hearing is adjourned.
    [Whereupon, at 3:46 p.m., Wednesday, May 9, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]