[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.
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\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.]