[Senate Hearing 115-8]
[From the U.S. Government Publishing Office]




                                                          S. Hrg. 115-8
 
   NOMINATION OF HON. DAVID J. SHULKIN, M.D., TO BE SECRETARY, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            FEBRUARY 1, 2017

                               __________

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Richard Blumenthal, Connecticut
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                Tony McClain, Democratic Staff Director
                
                            C O N T E N T S

                              ----------                              

                            February 1, 2017
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........   1,3
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     4
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................   169
Rounds, Hon. Mike, U.S. Senator from South Dakota................   173
Sanders, Hon. Bernard, U.S. Senator from Vermont.................   176
Tillis, Hon. Thom, U.S. Senator from North Carolina..............   179
Boozman, Hon. John, U.S. Senator from Arkansas...................   181
Brown, Hon. Sherrod, U.S. Senator from Ohio......................   183
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........   187
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................   189
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........   191
Murray, Hon. Patty, U.S. Senator from Washington.................   195
Heller, Hon. Dean, U.S. Senator from Nevada......................   198
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................   200
Moran, Hon. Jerry, U.S. Senator from Kansas......................   201

                               WITNESSES

Toomey, Hon. Patrick J., U.S. Senator from Pennsylvania..........     1
Shulkin, Hon, David J., M.D., Nominee, Secretary, U.S. Department 
  of Veterans Affairs............................................     6
    Prepared statement...........................................     8
    Response to prehearing questions submitted by:
      Hon. Johnny Isakson........................................    10
      Hon. Jon Tester............................................ 16,32
      Hon. Jerry Moran...........................................    33
      Hon. Patty Murray..........................................    39
      Hon. Bernard Sanders.......................................    43
      Hon. Richard Blumenthal....................................    45
      Hon. Sherrod Brown.........................................    47
    Response to posthearing questions submitted by:
      Hon. Jon Tester............................................ 49,55
      Hon. Jerry Moran...........................................    55
      Hon. John Boozman..........................................    67
      Hon. Bill Cassidy..........................................    69
      Hon. Thom Tillis...........................................    70
      Hon. Mike Rounds...........................................    72
      Hon. Dan Sullivan..........................................    73
      Hon. Patty Murray..........................................    81
      Hon. Sherrod Brown.........................................    91
      Hon. Richard Blumenthal....................................    95
      Hon. Mazie K. Hirono.......................................   100
      Hon. Joe Manchin III.......................................   101
    Questionnaire for Presidential nominees......................   108
    Letters from the Office of Government Ethics.................   163
    Letter from the nominee to the Office of General Counsel, 
      U.S. Department of Veterans Affairs........................   166

                                APPENDIX

Casey, Hon. Robert P., Jr., U.S. Senator from Pennsylvania; 
  letter.........................................................   215
Walz, Rep. Tim, Ranking Member, U.S. House Committee on Veterans' 
  Affairs; prepared statement....................................   216
Thevenot, Laura, Chief Executive Officer, American Society for 
  Radiation Oncology (ASTRO); letter.............................   219
Rausch, William J., Executive Director, Got Your 6; letter.......   221
Reeves, Randy, President, The National Association of State 
  Directors of Veterans Affairs, Inc. (NASDVA); letter...........   222


   NOMINATION OF HON. DAVID J. SHULKIN, M.D., TO BE SECRETARY, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                      WEDNESDAY, FEBRUARY 1, 2017

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:50 p.m., in 
room 106, Dirksen Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Heller, Cassidy, 
Rounds, Tillis, Sullivan, Tester, Murray, Sanders, Brown, 
Blumenthal, Hirono, and Manchin.

                HON. JOHNNY ISAKSON, CHAIRMAN, 
                   U.S. SENATOR FROM GEORGIA

    Chairman Isakson. We are in the midst of what may be as 
many as five votes on the floor, and in order to keep the 
Committee moving quickly and have this hearing over with as 
expeditiously but as thoroughly as possible, we are going to 
start off in a little bit different order. I will introduce 
Senator Toomey from Pennsylvania to make an introduction of Dr. 
Shulkin. Then we will have an opening statement by the Ranking 
Member, an opening statement by myself, and then we will begin 
to go to the hearing with the Members present.
    Is that satisfactory with everybody? Is that OK with you, 
Jon?
    Senator Tester. You bet.
    Chairman Isakson. With that being the case, I introduce the 
distinguished Senator from Pennsylvania for the purposes of 
remarks about the Secretary-to-be.

             STATEMENT OF HON. PATRICK J. TOOMEY, 
                 U.S. SENATOR FROM PENNSYLVANIA

    Senator Toomey. Thank you very much Chairman Isakson, 
Ranking Member, Tester, Members of the Committee. I appreciate 
this opportunity to briefly introduce Dr. Shulkin before the 
Committee.
    You know, Washington, D.C., has long been a city that 
focuses a lot on titles. When Dr. Shulkin arrived in Washington 
to help take charge and reform a troubled Veterans Health 
Administration, he got a new 8title. He was ``Honorable'' Under 
Secretary of the Veterans Administration. Yet there is another 
title which I think is more important to him, and by which he 
is very well-known in Pennsylvania, and that is doctor.
    Despite the challenges which he has faced, and with which 
he has been entrusted, he has never forgotten his focus on 
medicine and his focus on serving others. As a fellow 
Pennsylvanian, it is an honor for me to be able to introduce 
him to this Committee today.
    You know, Pennsylvania has a very large number of veterans, 
nearly a million across our commonwealth. We have eight VA 
medical centers, 31 VA community-based outreach clinics. I have 
said many times, our veterans should be first in line for the 
best quality health care in America.
    In Pennsylvania and across our country in recent years, 
that has not always been the case, but in recent years the VA 
and Congress have worked to address some of the challenges and 
issues, and we have made progress.
    There is more work to be done. It is my hope that after 
confirmation, Dr. Shulkin will be leading that charge. I think 
he is the right man for this moment.
    He has got a very, very impressive and distinguished 
background. He is a graduate of the Medical College of 
Pennsylvania, now part of Drexel. He did his residency and 
fellowship at the University of Pittsburgh. He ended up back in 
Philadelphia at the University of Pennsylvania, where he played 
numerous roles, working his way up to become Chief Medical 
Officer and Chief Quality Officer for the University of 
Pennsylvania Health System. Dr. Shulkin then went on to Temple, 
then Drexel, managing those schools' hospitals in various 
capacities. He then left for New York and became the President 
of the Beth Israel Medical Center. He later became President of 
the Morristown Medical Center, which is part of the Atlantic 
Health System.
    In 2015, Dr. Shulkin got the call that the VA needed his 
experience to help address some of the problems that we were 
facing there, and as the Committee knows, in 2014 the VA was 
embroiled in major scandals. Well, despite the difficult 
circumstances, Dr. Shulkin agreed to accept the position, 
accept the challenges, and he was confirmed by the Senate 
without objection. He then began to fix the implementation of 
the Choice Act, which had significant problems.
    Last week, Dr. Shulkin and I met and had a very 
constructive, great conversation about many things, including 
the ongoing implementation challenges of the Choice Act. I was 
very, very impressed with his extensive knowledge and his 
insights. I think those--that knowledge and insights have been 
forged by a career as a top administration in some of the 
Nation's largest hospital systems, but it is also informed by 
his personal experience as a physician, which I think is 
invaluable.
    I look forward to continuing our work together to help our 
Nation's veterans. It is an honor for me to be able to 
introduce Dr. David Shulkin to the Veterans' Affairs Committee 
today. He is a great Pennsylvanian. I believe he will be a 
great leader of this essential organization.
    I thank you very much Mr. Chairman and Ranking Member 
Tester.
    Chairman Isakson. Senator Toomey, thank you very much for 
being here. I know your time is tight and I appreciate your 
remarks about Dr. Shulkin. I appreciate all the work you have 
done to help the Veterans' Affairs Committee. You will be 
excused. We will not hold it against you because you have got 
to vote; so do we.
    Senator Toomey. Thank you very much.
    Chairman Isakson. Thank you.
    Dr. Shulkin, we are going to have brief remarks by me, then 
the Ranking Member, then it will be your turn at the 
microphone.

      OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 
                   U.S. SENATOR FROM GEORGIA

    Chairman Isakson. I want to tell everybody about the first 
time I met Dr. Shulkin. It was on a Delta airplane, flying to 
Washington, DC, where I have met most of the people I know in 
my life, it seems like, between Georgia while coming to 
Washington, DC. I had just come from a meeting in my office 
with an anesthesiologist in Georgia, who had a concern and a 
question about the VA and anesthesiology and nurse anesthetists 
and all those types of things--a complicated issue, which is 
not the most important part.
    The important part is that Dr. Shulkin recognized me and 
came over and gave me his card and said, ``I am David 
Shulkin.'' I said, ``Well, I know who you are. We are going to 
have you before the Committee pretty soon.'' He said, ``Yeah. 
On Tuesday.'' That is when we had his confirmation hearing as 
Under Secretary.
    I said, ``Well, I will tell you what. Let me give you this 
card that I just received in my office from this 
anesthesiologist who has a concern with VA and anesthesia. 
Would you call him if you get a chance?''
    I got to the office the next morning. Dr. Shulkin had not 
only called him but he had called him and spent about 3 hours 
on the phone with him, and when I got to the office I had a 
call from Dr. Shulkin to let me know he had talked to him, plus 
a call from the doctor to tell me how satisfied he was that Dr. 
Shulkin cared enough to call him.
    That is what I look for. That is the tender, loving care 
that we look for in all executives that is rarely ever there, 
and in a job like veterans' health care, that type of service 
and attitude is important. I also want to remind Dr. Shulkin of 
what he did that day, and that was my first day I knew if I 
could cast a good vote for him, I would.
    Now, let me just make these remarks, because all of the 
Members are going to have a lot of questions later on, and I 
know Sen. Tester is going to make remarks after I do.
    It is very important that we complete the task of getting 
open accessibility to our veterans to health care, but we make 
everybody understand we are not about privatizing health care 
for veterans. We are about making health care more available to 
veterans through implementation of the private sector with the 
Veterans Administration. We do not want to privatize it; we 
want to empower it.
    Further, we know that we still have wait times far too long 
on appeals. If we have one goal after getting Choice fixed, if 
we have one goal we have got to have, that is to get the wait 
time on appeals down, and I mean way down. I think it is doable 
if we, on the Committee, do our job, working with the 
appropriators, and if the VA does its job in telling us what it 
really needs to do to speed up that process, whatever it might 
be. I am committed to accomplishing those two things in this 2-
year term on the Committee.
    With that said, I am really lucky, as a Chairman, to have 
had a great Ranking Member in Richard Blumenthal the last 2 
years. He helped the whole Committee unanimously pass through 
the U.S. Senate the Jeff Miller and Richard Blumenthal Veterans 
Health Care and Benefits Improvement Act last year, the last 
day of the session before Christmas. We made a lot of steps 
forward, but we did not make the ones we needed to, we did not 
make all of them.
    Now Jon Tester will replace Richard Blumenthal as Ranking 
Member, so I still am blessed to have the best Ranking Member I 
could possibly have. He is a good friend. He cares about 
veterans. I enjoy working with him a lot. With that said I will 
introduce Sen. Jon Tester of Montana.

  OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S. 
                      SENATOR FROM MONTANA

    Senator Tester. Well, thank you, Chairman Isakson. I look 
forward to working with you, too. You are very kind. Thank you.
    Dr. Shulkin, welcome to this Committee.
    Dr. Shulkin. Thank you.
    Senator Tester. As you may have noticed, you are operating 
on a little bigger stage than what you operated on before, in 
more ways than one.
    I appreciate you accepting the responsibility that comes 
with the duties of the Secretary of the Department of Veterans 
Affairs. It is my hope, and I believe the hope of this 
Committee, that you are up to this task. The way in which you 
answer our questions today will help many of us make that final 
determination.
    Amidst an impressive career as a health care executive in 
the private sector, you were brought into the VA about 18 
months ago to help transform the administration and delivery of 
veterans' health care. The wait time scandals that arose from 
Phoenix, back in 2014, were something that none of us could 
tolerate.
    After Secretary Robert McDonald took the helm of the 
Department, a number of senior leaders were replaced and a 
number of transformational reforms were initiated, many of 
which you were a part of. Meanwhile, Congress, in a rare 
demonstration of bipartisanship, enacted the Veterans Access, 
Choice and Accountability Act of 2014. This legislation sought 
to bolster the capacity of the VA to better directly serve 
veterans, and to expand veterans' access to community care when 
the VA was incapable of providing that care in a timely manner. 
Now, 2\1/2\ years later, the VA is confronted with looming and 
dramatic funding shortfalls and a so-called Choice Program 
that, at least in Montana, has only left veterans with the 
choice of waiting longer for care or not getting it at all.
    Just a couple of weeks ago, a veteran from Helena, MT, 
wrote me: ``Trying to get a cardiologist and working with the 
Choice Program was one of the most stressful parts of my heart 
attack incident. It took 19 days from the time the Choice 
Program was contacted with my urgent case for me to get to the 
specialist. I was concerned the entire time that I was going to 
have a heart attack while I was waiting.''
    This is unacceptable. I can share dozens of similar 
stories, from frustrated veterans, family members, and even 
front-line VA employees in Montana, not to mention community 
providers in my State and across the country that continue to 
drop out of the Choice Program because of the bureaucracy 
involved and the time it takes to get reimbursed through this 
program.
    Look, I get it. Some of it is how that law was written, and 
some--actually, a lot in my State--is on the part of the third-
party administrator. But, a lot also has to fall on the VA, and 
as the head of the Veterans Health Administration for the last 
2 years, a lot of that responsibility falls directly with you.
    We often look at the numbers and the statistics up here, to 
try to determine whether a program or an agency is effective, 
but behind every statistic, behind every number is a person and 
a story. And the story I hear every time I go back to Montana, 
which is almost every weekend, is that the Choice Program is 
making a difficult problem even worse.
    The VA has endorsed an effort to simply extend the life of 
that program, but I will tell you, if anyone wants to extend 
the life of that program, without also taking the steps needed 
to make it work better for veterans, you are going to have to 
go through me. And I will oppose you every step of the way. I 
relayed that message to you during our last conversation in my 
office. It is my understanding that we are on the same page. I 
appreciate you being up-front about that.
    I also know that you will be fighting a war on multiple 
fronts. While trying to carry out the Department's mission, you 
will have to deal with a Congress that has not proven itself to 
be the most productive or cooperative partner. You will have to 
deal with the new President, who has taken some public 
positions on everything from privatization to personal opinions 
about the VA workforce that are in stark contrast to the 
positions that you have taken.
    Sooner then later you will come to a crossroads. You will 
have to choose whether to pursue what you think is best for 
veterans or what the President tells you is best for veterans. 
I want you to succeed. It is critically important. But, there 
was a reason it took so long to find someone to sit in your 
chair here today.
    In a conversation with VSO representatives a couple of 
weeks ago, Bob Wallace, the VFW Executive Director, described 
Bob McDonald's job, your predecessor, as trying to turn around 
the Titanic in a bathtub, in as little time as possible.
    Under Secretary McDonald's leadership there is no question 
that VA has made some meaningful and tangible progress on 
critical priorities like connecting more veterans to care, 
ending veterans' homelessness, and getting the disability 
claims backlogged under control. Though the overall veteran 
population has decreased in recent years, more and more 
veterans are enrolled in VA health care and are receiving 
critical benefits like disability compensation or educational 
benefits.
    As we move forward, more veterans will come out of the 
shadows. The veteran population will age, and their already 
complex medical conditions will become even more complex. These 
folks will turn to the VA and it is critical that you earn 
their trust by demonstrating that you can meet their needs in 
not only a timely but a thorough manner.
    So, the question of the day is whether you can build upon 
VA's successes and continue delivering for veterans and their 
families, while also taking steps to address the systemic and 
chronic challenges that impede the Department's ability to 
carry out its mission.
    In short, I hope you are up for the job. We need to know 
that you are the right person to lead this department at a 
critical time, because there is far too much at stake.
    I look forward to this discussion today and I want to thank 
you again for your willingness to serve on behalf of our 
Nation's veterans and their families.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Tester. I appreciate 
your service and I appreciate your thorough opening statement.
    Now we are getting ready to see what a Congressional 
shuffle is all about. We had our second vote called. You saw a 
couple of Members leave to go over. They will come back so I 
can go over and replace them. We are going to go back and forth 
and play ping pong for about an hour and one-half. That is not 
to diminish a single question that we need to ask, and if we 
have to pause for a minute to get everybody back, we will do 
that, Dr. Shulkin.
    Dr. Shulkin, would you please stand and raise your right 
hand?
    Do you solemnly swear or affirm that the testimony you are 
about to give before the Senate Veterans' Affairs Committee is 
the truth, will be the truth, the whole truth, and nothing but 
the truth, so help you God?
    Dr. Shulkin. I do.
    Chairman Isakson. Thank you. You may be seated.
    You are welcome to have the floor for 5 minutes or so, a 
little more if you want it, and if you have got any family 
members or anyone you want to introduce in the audience, please 
do so.

    STATEMENT OF HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE 
         SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Shulkin. OK. Well, Chairman Isakson, thank you for your 
remarks, and Ranking Member Tester, thank you for your remarks, 
and to all the distinguished Members of the Committee, and 
everyone here who joined us who cares deeply about veterans, I 
want to thank you for being here today.
    I have gotten to know all of you over the past 18 months, 
and I have a great respect for this Committee and the work you 
do. I happen to think it is the best committee in the Senate. 
It works in a bipartisan way on the behalf of veterans.
    It has been a privilege to serve as the Under Secretary for 
Health for the past 18 months, and it is my highest 
professional honor to be considered for the Secretary of 
Veterans Affairs.
    I am also grateful to my wife, who is here today, Dr. Merle 
Bari, somewhere--that way. OK. We met in medical school. We 
have been married for 29 years. It has been her continuous 
support and encouragement during my first confirmation process, 
and now, almost 2 years later, when we started that, her 
commitment to veterans that has really inspired me. My two 
children, Danny and Jenny, are probably watching too, and I 
think all of you know our jobs are really family affairs.
    Our country's sacred obligation to fully honor our 
commitments to our veterans is deeply personal to me. I was 
born on an Army base. My father was an Army psychiatrist--he is 
probably watching too. Both grandfathers were Army veterans, 
and my paternal grandfather served as the Chief Pharmacist at 
the VA hospital in Madison, WI.
    As a young doctor I trained in several VA hospitals. I view 
my service at VA as a duty to give back to the men and women 
who secured the uniquely American freedoms and opportunities we 
all enjoy because of the sacrifices they made.
    I came to VA at a time of crisis, when it was clear that 
veterans were not getting timely access to high-quality health 
care they deserved. I soon discovered that it was years of 
ineffective systems and deficiencies in workplace culture that 
led to these problems. I concluded it would take years to fix 
these problems, but because veterans' lives were at stake, 
there was no time to waste. That is why I focused on meeting 
the most urgent health care needs of our veterans first, and 
reorganized our approach to reflect that.
    As a result, we have dramatically reduced the number of 
people waiting for urgent care. The VA now has same-day 
services in primary care and mental health at all of our 
medical centers, to make sure veterans get the urgent care they 
need, when they need it most.
    Over the past 18 months, I have had the opportunity to 
travel across the country to hear directly from veterans, their 
service organizations, and stakeholders about their concerns 
with VA. I appreciate both the candor of these conversations 
and the overwhelming support and commitment I have received 
from so many in improving VA. The opportunity to spend with and 
learn about the needs of the veterans we serve was the best 
preparation I could have had for this nomination.
    VA has been working hard to act more as an integrated 
enterprise, and toward that end I have worked closely with my 
colleagues in Veterans Benefit Administration and the National 
Cemetery Administration. I understand that veterans see us as 
one VA and not as three separate administrations. Creating a 
seamless experience for veterans accessing benefits and 
services is critical to fulfilling our mission. If confirmed, I 
would build upon my foundational understanding of these issues 
to accelerate change across all three administrations.
    VA is a unique national resource that is worth saving, and 
I am committed to doing just that. One thing I want to be 
especially clear on is that VA has many dedicated employees 
across the country, and our veterans tell us just that every 
day. It is unfortunate that a few employees who have deviated 
from the values we hold so dear have been able to tarnish the 
reputation of so many who have dedicated their lives to serving 
those who have served.
    There should be no doubt that if confirmed as Secretary, I 
will seek major reform and a transformation of VA. There will 
be far greater accountability, dramatically improved access, 
responsiveness and expanded care options, but the Department of 
Veterans Affairs will not be privatized under my watch. If 
confirmed, I intend to build a system that puts veterans first 
and allows them to get the best possible health care wherever 
it may be, in VA or in the community.
    I have demonstrated my commitment to moving care into the 
community where it makes sense for the veteran. When I began my 
tenure as Under Secretary for Health, 21 percent of care was 
delivered in the community, but today that figure stands at 31 
percent. But, veterans tell us that even with the ability to 
seek care in the community, they want VA services. Of the more 
than 1 million veterans who took advantage of the Choice 
Program, only 5,000 have sought care solely in the community. 
The rest used both VA and the community.
    Should I be confirmed, I intend to build an integrated 
system of care that would strengthen services within VA that 
are essential for veteran well-being, and use services in the 
community that can serve veterans with better outcomes and 
value to the taxpayer. We will need to work closely together to 
extend and reform the Choice Program to ensure veterans are 
able to seek the care in the community they need.
    We have made significant progress in suicide prevention, 
including hiring more mental health professionals, implementing 
a predictive tool to identify those at the greatest risk, and 
fixing the Veterans Crisis Line so it better serves our 
veterans. We must also continue our progress in addressing the 
unique needs of women veterans by expanding women's health 
services and ensuring our facilities are welcoming to women. I 
also want to recognize the importance of supporting the efforts 
of families and caregivers who are involved in the care of our 
veterans.
    We have to continue our work to eliminate the disability 
claims backlog, and we need legislation that would allow us to 
reform the outdated appeals process. We must continue the 
progress we have made in reducing veterans' homelessness, and 
modernize our IT systems to improve our services and 
efficiencies. We have to address infrastructure issues and take 
a closer look at facilities that no longer serve a useful 
purpose. We must explore expansion of public-private 
partnerships rather than continue to build medical centers that 
have large cost overruns and take too long to build.
    With the support of the Members of this Committee and 
others in Congress, veterans and their service organizations, 
the dedicated employees of VA, and the American people, we can 
fulfill President Lincoln's promise and our sacred mission ``to 
care for him''--and now for her--``who shall have borne the 
battle.'' There is no nobler mission or higher calling for me, 
and it would be my distinct honor and privilege to lead this 
effort. Our veterans deserve the very best, and with your 
support, I am confident we will succeed.
    Thank you and I look forward to your questions.
    [The prepared statement of Dr. Shulkin follows:]
Prepared Statement of Dr. David Shulkin, Nominee to be Secretary, U.S. 
                     Department of Veterans Affairs
    Chairman Isakson, Ranking Member Tester, Distinguished Members of 
the Committee on Veterans' Affairs, and everyone here today who cares 
deeply about our Veterans: Thank you for the opportunity to address 
you. I have gotten to know many of you over the past 18 months, and I 
have great respect for this Committee and the work you do. It has been 
a privilege to serve as Under Secretary for Health over the past 18 
months. It is my highest professional honor to be nominated for 
consideration as the next Secretary of Veterans Affairs.
    I'm grateful to have my wife, Dr. Merle Bari, with me here today. 
We met in medical school and have been married for 29 years. Her 
continuous encouragement and support since my first confirmation 
process almost two years ago, as well as her commitment to our 
Veterans, have inspired me.
    Our country's sacred obligation to fully honor our commitments to 
our Veterans is deeply personal to me. I was born on an Army base. My 
father was an Army psychiatrist, both grandfathers were Army Veterans, 
and my paternal grandfather served as Chief Pharmacist at the VA 
hospital in Madison, Wisconsin. As a young doctor, I trained in VA 
hospitals. I view my VA service as a duty to give back to the men and 
women who secured the uniquely American freedoms and opportunities we 
all enjoy because of the sacrifices they made. I came to VA during a 
time of crisis, when it was clear Veterans were not getting the timely 
access to high-quality health care they deserved. I soon discovered 
that years of ineffective systems and deficiencies in workplace culture 
had led to these problems. I concluded it would take years to fix the 
problems, but because Veterans' lives were at stake, there was no time 
to waste. That is why I focused on meeting the most urgent health care 
needs of our Veterans first, and reorganized our approach to reflect 
that. As a result, we've dramatically reduced the number of people 
waiting for urgent care. The VA now has same-day services in primary 
care and mental health at all our medical centers to make sure our 
Veterans get the urgent care they need, when they need it most.
    Over the past 18 months, I have had the opportunity to travel 
across the country hearing directly from Veterans, service 
organizations, and stakeholders about their concerns with VA. I 
appreciate both the candor of these conversations and the overwhelming 
support and commitment I have received from so many for improving VA. 
The opportunity to spend time with and learn about the needs of the 
Veterans we serve was the best preparation I could have had for this 
nomination.
    VA has been working hard to act more as an integrated enterprise, 
and toward that end, I have worked closely with my colleagues in VBA 
and NCA. I understand that Veterans see us as one VA and not three 
separate administrations. Creating a seamless experience for Veterans 
accessing benefits and services is critical to fulfilling our mission. 
If confirmed, I would build on my foundational understanding of these 
issues to accelerate change across all three administrations.
    VA is a unique national resource that is worth saving, and I am 
committed to doing just that. One thing I want to be especially clear 
on is that VA has many dedicated employees across the country, and our 
Veterans tell us that every day. It is unfortunate that a few employees 
who deviated from the values we hold so dear have been able to tarnish 
the reputation of so many who have dedicated their lives to serving 
those who have served.
    But, there should be no doubt that if confirmed as Secretary, I 
will seek major reform and a transformation of VA. There will be far 
greater accountability, dramatically improved access, responsiveness 
and expanded care options, but the Department of Veterans Affairs will 
not be privatized under my watch. If confirmed, I intend to build a 
system that puts Veterans first and allows them to get the best 
possible health care wherever it may be--in VA or with community care.
    I've demonstrated my commitment to moving care into the community 
where it makes sense for the Veteran. When I began my tenure as Under 
Secretary for Health, 21 percent of care was delivered in the 
community, today that figure stands at 31 percent. But, Veterans still 
tell us that even with the ability to seek care in the community, they 
want VA services. Of the more than 1 million Veterans who have taken 
advantage of the Choice program, only about 5,000 have sought care 
solely in the community. The rest used both VA and community services.
    Should I be confirmed, I intend to build an integrated system of 
care that would strengthen services within VA that are essential for 
Veteran well-being, and use services in the community that can serve 
Veterans with better outcomes and greater value to the taxpayer. We 
will need to work closely together to extend and reform the Choice 
program to ensure Veterans are able to seek the care in the community 
they need.
    We have made significant progress in suicide prevention, including 
hiring more mental health professionals, implementing a predictive tool 
to identify those at greatest risk, and fixing the Veterans Crisis Line 
so it better serves our Veterans. We also must continue our progress in 
addressing the unique needs of our women Veterans by expanding women's 
health services and ensuring our facilities are welcoming to women. I 
also want to recognize the importance of supporting the efforts of 
families and caregivers who are involved in the care of our Veterans.
    We have to continue our work to eliminate the disability claims 
backlog, and we need legislation that would allow us to reform the 
outdated appeals process. We must continue the progress we have made in 
reducing Veteran homelessness, and modernize our IT systems to improve 
our services and efficiencies. We also have to address infrastructure 
issues and take a closer look at facilities that no longer serve a 
useful purpose. We must explore expansion of public-private 
partnerships rather than continue building medical centers that have 
large cost overruns and take too long to build.
    With the support of the Members of this Committee and others in 
Congress, Veterans and their service organizations, the dedicated 
employees of VA, and the American people, we can fulfill President 
Lincoln's promise and our sacred mission ``to care for him who shall 
have borne the battle.'' There is no nobler mission or higher calling 
for me, and it would be my distinct honor and privilege to lead this 
effort. Our Veterans deserve the very best, and with your support, I am 
confident we will succeed. Thank you and I look forward to your 
questions.
                                 ______
                                 
 Response to Prehearing Questions Submitted by Hon. Johnny Isakson to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
    Question 1.  Dr. Shulkin, after serving at the Department of 
Veterans Affairs (VA) for about 20 months, what do you see as the most 
significant challenges facing VA and what would be your highest 
priorities if confirmed as Secretary?
    Response. Our most significant challenge will be to address the 
systemic challenges that face VA. Over the past 18 months that I have 
served as USH we have been focused on addressing the acute issues that 
VA inexperienced with the crisis in access and the erosion of 
confidence with the American people. We have made real progress, and 
have turned the corner in numerous areas. However, it is now time to 
address the systemic issues that are required in business 
transformation.
    My highest priority would be to work with the Administration and 
Congress to develop a sustainable plan for VA's transformation. This 
would involve working together to create a true integrated network of 
care, a system supported by an engaged workforce and modern technology 
solutions,and accountable for improving outcomes and efficiencies.
    Specifically, I would target improvements to ease of the use of our 
services by decreasing non value added rules and regulations, implement 
industry best practices that lead to improved quality and efficiencies. 
I also want to accelerate our efforts in suicide prevention, 
homelessness, women's healthcare, continue to decrease the claims 
backlog and work on appeals modernization.

    Question 2.  Dr. Shulkin, would you please detail what experiences 
you have had while serving as Under Secretary for Health that you 
believe have helped prepare you for this broader role at VA?
    Response. Most significant in preparing for the role of SECVA has 
been the opportunity to visit, spend time listening and learning about 
the needs of the veterans we serve. During my 18 months as USH I have 
seen firsthand the unique services and programs that VA offers to 
Veterans. As a practicing VA physician, I have been able to use and see 
the systems our clinician rely upon to treat Veterans. With this 
opportunity, I have learned what works and what needs to be changed. I 
have also seen all too often where we have fallen short of the trust 
and confidence that veterans has placed in us
    VA has been working hard to act more as an integrated enterprise 
and in doing so I have worked closely with my colleagues in VBA, NCA 
and the Board of Veterans Appeals. I understand that veterans see us 
all as one VA and not separate administrations and therefore having a 
seamless experience is critical to us fulfilling our mission. During my 
time as USH, I have been able to contribute to efforts that improve 
services to veterans who utilize VBA and NCA. If confirmed, I would 
buildupon my foundational understanding of these issues to accelerate 
change in all three administrations.

    Question 3.  Since 2010, veteran homelessness has decreased by 47 
percent. If confirmed, how do you intend to continue to prioritize 
efforts to prevent and end veteran homelessness?
    Response. While these statistics indicate tremendous progress in 
ending Veteran homelessness and that the efforts of VA and its partners 
are producing successful outcomes for many Veterans, more must be done 
to accelerate progress. No one entity can end homelessness among 
Veterans alone. To achieve this goal, we need continued urgency and 
commitment from leaders in every community. There has been 
unprecedented support from the Administration, Congress, and state and 
local leaders to provide both the funding and human resources needed to 
end Veteran homelessness and much of our progress has come from the 
VA's collaboration with community leaders focusing efforts on the 
implementation of evidence based proven practices that are reducing 
homelessness among Veterans. But we know that ending Veteran 
homelessness is not a single event in time; rather, it is a deliberate 
effort made to achieve the goal, and continued follow-up efforts to 
make sure that progress toward achieving the goal is maintained.
    We must continue our commitment to our efforts around rapid 
rehousing and permanent supportive housing for Veterans who fall into 
homelessness so that their homelessness is rare, brief, and 
nonrecurring. The ultimate goal is to make sure that every Veteran has 
permanent, sustainable housing with access to high-quality health care 
and other supportive services and that Veteran homelessness in the 
future is prevented whenever possible.
    But housing Veterans is not the end of the journey. These Veterans, 
especially Veterans who have experienced chronic homelessness, need 
ongoing intervention and case management. Therefore, we must commit to 
continue to fully support our homeless programs such as HUD-VASH and 
Supportive Services for Veteran Families (SSVF) and the current efforts 
to transform our homeless Grant and Per Diem (GPD) program. These 
programs provide data driven essential services designed to support 
Veterans with obtaining and maintaining housing stability. With our 
full commitment to stay the course that has proven successful to date, 
we can and will end Veteran homelessness and provide the blueprint for 
solving all homelessness.

    Question 4.  Legislation was enacted last fall to authorize VA to 
implement its master plan for the West Los Angeles campus. This new 
model for the campus, with a focus on housing and supportive services 
for veterans, could become a model for future VA campuses. If 
confirmed, how would you safeguard against mismanagement, which has 
occurred in the past, and ensure the master plan is implemented in a 
transparent, responsible way that best serves veterans and that will be 
an example for other VA campuses?
    Response. In September 2016, Congress passed the West Los Angeles 
Leasing Act of 2016, which is historic legislation essential to VA's 
ongoing effort to revitalize the West Los Angeles campus. Through such 
legislation, VA envisions providing approximately 1,200 permanent 
supportive housing units and Veteran focused services on the campus, 
particularly for homeless, severely disabled, aging, and female Veteran 
populations. Within the next 30 days, we plan to execute the first 
Enhanced-Use Lease agreement for the campus, which will provide 
approximately 55 new housing units for Veterans.
    Enactment of this legislation was based on unprecedented 
collaboration and cooperation between the Department, Congress, Veteran 
Service Organizations, the community, and other stakeholders. Our 
ultimate goal is to fully revitalize the campus, so that it is both a 
21st Century facility that provides convenient healthcare, benefits, 
and services, and serves a home for our Veterans and their families. As 
noted in the framework Draft Master Plan that Secretary Bob McDonald 
publicly announced in January 2016, VA is working to ensure that future 
third-party land-use agreements are Veteran focused and provide fair 
market value, from both a monetary and in-kind consideration 
standpoint.
    Currently, the West Los Angeles Leasing Act of 2016 requires VA to 
notify Congress 45 days before entering or renewing any leases or 
sharing agreement on the campus. The bill also requires VA to provide 
annual reports to Congress for the leases and sharing agreements 
carried out at West LA. In that regard, we have instituted a process 
where all proposed land-use agreements undergo thorough review of 
subject matter experts at both the medical center and VA headquarters, 
before approval and execution. And as required under the legislation, 
any revenues generated from such agreements will remain on campus, to 
maintain and renovate facilities to serve Veterans of greater Los 
Angeles. Additionally, the legislation expressly prohibits VA from 
disposing of any of the land at West LA. We are also required to submit 
annual audits to Congress, for any leases and Sharing Agreements 
executed on the campus.
    Through this process, VA has recently executed new agreements with 
our local medical affiliate, the University of California at Los 
Angeles, as well as the Brentwood School, and the city of Los Angeles. 
These agreements are part of our overall intent, to create irreversible 
momentum in a collaborative and transparent manner, where the campus is 
used consistent with the principles of the 1888 deed, which conveyed 
the property to the United States.
    We have established a new Community Veteran Engagement Board for 
the campus, where pertinent Veteran organizations and representatives 
will meet regularly, to discuss any and all matters of interest 
regarding our mission and operation of serving Veterans on the campus; 
to include the framework Master Plan and campus development.
    A number of efforts are underway to support the implementation of 
the framework Draft Master Plan. In October, 2016, VA hired Concourse 
Federal Group (CFG) to assist with project management. CFG and their 
team of subject matter experts provide daily, on the ground support to 
VA for campus optimization and utilization, land use matters, and 
external communications. In December 2016, we also formed a VA 
Integrated Project Team, to begin the next phase of working to finalize 
the master plan for the campus. Experts from pertinent offices such as 
VHA; VA's Office Of Construction And Facilities Management; Office Of 
Asset Enterprise Management, Office of General Counsel, and the Office 
of the Secretary, will be working in unison, to ensure that the next 
steps such as environmental, historic, traffic, and utilities due 
diligence, occurs in an open and inclusive process. VA will continue to 
hold town hall and public hearing events, to enable us to receive 
valuable input from Veterans, Veteran service organizations, our 
community partners, and local neighbors. Through this process, we 
envision a campus that includes not just permanent supportive housing 
units for Veterans and their families, but complimentary services to 
promote Veteran wellness, education, vocational training, 
rehabilitation, and peer interaction.
    We are also working with local philanthropists, specifically a 
501(c)(3) entity known as the ``1887 Fund,'' to allow them to raise 
funds and provide donated expertise to restore the historic Wadsworth 
Chapel, and other landmark historic facilities on the campus.
    In coordination with the Los Angeles National Cemetery, we are 
working to commence the planned columbarium expansion project at the 
campus, to provide up to 10,000 new niches for Veterans wishing for the 
campus to serve as their final resting place.
    We are also pleased to advise that the campus is under new 
leadership. In February 2016, Ann Brown was appointed to serve as the 
Medical Center Director at West LA. Before coming to the campus, she 
served as the Director at the Jesse Brown VA Medical Center in Chicago, 
Illinois. Before that, she was the Director in Martinsburg, West 
Virginia; the Acting Deputy Network Director for VISN 9; the Associate 
Director for Operations in Nashville, Tennessee, and the VISN 23 
Business Office Manager in Lincoln, Nebraska. Through her leadership 
and during her brief tenure, the West LA campus now has a new Acting 
Associate Director, a Chief of Staff, an Associate Director for Patient 
Care Services, and an Assistant Director. We look forward to Ann 
continuing to build her team at the campus, to successfully carry out 
the charge we have for her and other VA personnel, which is to continue 
to put Veterans at the center of everything we do.
    Our sustained focus, commitment, and collaboration with the 
Department of Housing & Urban Development, the Department of Labor, 
local housing authorities, the former plaintiffs to the West LA 
litigation, local philanthropists, Veteran stakeholders, and the local 
community, has resulted in a 57% decline in Veteran homelessness in 
greater Los Angeles, since 2011. We know that in order to end Veteran 
homelessness nationwide, we must end it in Greater LA. Through our 
continued and collective efforts, I am confident that West LA will 
become a 21st-century, state-of-the-art model for other campuses 
nationwide, and make us all proud as we continue to serve and honor our 
nations Veterans.

    Question 5.  Women constitute an ever-growing segment of the Armed 
Forces and, consequently, the overall veteran population. What do you 
see as the primary challenges to appropriately treating and serving 
women veterans in VA facilities?
    Response. The primary challenges to caring for women Veterans in VA 
facilities include: ensuring providers are well-trained to provide 
women's health services, ensuring an open and welcoming culture, 
including environment of care/facility issues, and outreaching to women 
Veterans prevent suicide.
Access
     Since 2014, VA has made tremendous strides in providing 
enhanced services and access for women.
         - 100% of medical centers and 90% of Community Based 
        Outpatient Clinics have Designated Women's Health Providers
         - 130 VA medical centers have gynecology services on-site
         - VA tracks quality by gender and has reduced or eliminated 
        several key disparities
                o On some important quality measures, VA is better than 
                the private sector (breast and cervical cancer 
                screening)

     To meet increasing demand, VA needs to hire and train 
additional Designated Women's Health Providers per year.
         - Convincing VA providers to train in Womens Health is 
        difficult due to:
                (1) increased provider workload;
                (2) few incentives for those who have been seeing only 
                men for decades.
         - Recruiting external providers is difficult due to:
                (1) shrinking national workforce of Primary Care 
                physicians;
                (2) persistent perception of limited opportunity to 
                care for women in VA settings.
Culture
     VA is now engaged in an enterprise-wide effort to ensure 
its language, practice, and culture is inclusive of women Veterans.
     A 2015 national survey of women Veterans showed high 
satisfaction for those in VA care, perceived lack of Womens Health 
services among those not in VA care.
     VA has launched multiple campaigns aimed at inclusivity 
and recognition for women Veterans.
Suicide Among Women Veterans
    In 2014, an average of 20 Veterans died by suicide each day. Six of 
the 20 were users of VHA services.
     Between 2001 and 2014:
         - The age-adjusted rate of suicide climbed much more rapidly 
        for women Veterans than for women in the civilian population.
         - The rate of suicide for women Veterans in VA care, however, 
        climbed more slowly than did the rate for those not using VA 
        services.

VA's Office for Suicide Prevention partners with organizations to 
target services to women Veterans and ensures all outreach materials 
are inclusive.

    Question 6.  In response to the mismanagement and cost overruns at 
the new Denver VA Medical Center, Congress mandated that all major 
construction projects over $100 million be managed by the US Army Corps 
of Engineers. Additionally, VA made numerous changes to its policies 
and procedures for major construction projects. If confirmed, would you 
make it a priority to continue these and additional reform efforts to 
ensure that VA major construction projects are on budget and on 
schedule?
    Response. VA's Office of Construction & Facilities Management (CFM) 
is responsible planning, designing, constructing and acquiring major 
facilities, and setting design and construction standards. VA 
recognizes that there is a need for continued improvement in the 
management of its major construction program and for adopting best 
practices to avoid cost overruns and lengthy delays encountered on some 
recent major projects.
    Since 2014, VA has put in place sound construction management 
processes based on best practices from private industry and other 
Federal agencies including recommendations from the Government 
Accountability Office, VA's Office of Inspector General, and the US 
Army Corps of Engineers (USACE). VA has also partnered with, and 
embarked on process improvements based on recommendations from 
construction industry partners such as the National Institute of 
Building Sciences and the Associated General Contractors of America. 
The following improvements were put in place to ensure future success 
in the major construction program:

     Incorporating integrated master planning to ensure 
projects address gaps and meet agency goals;
     Requiring major medical construction projects to achieve 
at least 35% design prior to establishing cost and schedule estimates 
or requesting funds;
     Implementing rigorous requirements control and change 
management processes, and structured decisionmaking at key acquisition 
milestones;
     Using a Project Management Plan for delivery--from 
planning to activation--to ensure clear communication throughout the 
life of every project;
     Conducting pre-construction reviews of major construction 
projects throughout the design, to evaluate design and engineering 
factors and ensure constructability within given budget and schedule 
parameters;
     Integrating Medical Equipment Planners into construction 
project teams from concept through activation; and
     Putting in place metrics tools that will help monitor and 
manage performance and identify and mitigate emerging risks on large 
projects.

    By accepting and incorporating best practices and recommendations 
from these organizations, CFM has been on a path of continuous 
improvement with the goal of achieving successful execution of our 
major construction projects.
    Additionally, VA and USACE have a long history of working together 
to advance VA's facility construction program and share best practices. 
VA has engaged USACE to support our non-recurring maintenance and minor 
construction programs at more than 70 of our medical centers and 
national cemeteries across the enterprise. In December 2014, VA entered 
into an agreement to transition the Denver project to USACE for 
completion. Since then, VA has entered into agreements with USACE that 
now include VA utilizing USACE as Construction Agent on several major 
construction projects. This partnership continues to develop and 
mature, and the two agencies are working together to ensure the success 
of those partnered projects.
    VA continues to address concerns from Congress and other entities 
and will continue to work to ensure the VA construction program is 
delivering quality, sustainable facilities on-time and on-budget into 
the future. VA is also interested in improving the planning and 
execution of its entire capital program to better address its aging 
infrastructure and meet the needs of Veterans with state-of-the art 
facilities and services

    Question 7.  What do you see as the role of this Committee in 
conducting oversight regarding VA and what steps would you take to 
ensure that the Committee is promptly notified of any emerging trends, 
issues, or developments at VA?
    Response. The Committee's responsibility to the American public is 
to provide oversight of the Veterans Administration on all Veterans 
affairs issues to include budget, health care, benefits and cemetery 
affairs. If confirmed, I would seek to increase communication and 
collaboration with the Committee and its members and reduce the 
internal barriers that delay our responses and partnership with SVAC. I 
would also seek to make available my senior leaders and subject matter 
experts to answer your questions and be a resource that you need to do 
your job.
    Since joining the VA as Under Secretary, I have worked to provide 
quality and timely responses that meets the needs of the Committee. I 
will ensure that we notify your committee of concerning issues, trends 
and developments in a timely manner. We will continue our work on 
decreasing case work response time and ensure that you have the 
information you need to provide oversight necessary.

    Question 8.  The National Cemetery Administration (NCA) has 
repeatedly earned the highest customer satisfaction score among the 
private or public sectors, yet the American Customer Satisfaction Index 
ranked the Department of Veterans Affairs third last in customer 
satisfaction among Federal agencies for 2015. What factors set NCA so 
far apart from the rest of VA and how would you leverage their best 
practices to improve customer satisfaction across the rest of the 
department?
    Response. NCA continues to perform at a high level and builds its 
customer service culture around VA's core values, ICARE-Integrity, 
Commitment, Advocacy, Respect, and Excellence. In 2016, NCA received 
the highest ranking for any organization-public or private-on the 
American Customer Satisfaction Index (ACSI). With an index score of 96, 
NCA scored 28 points higher than the aggregate Federal Government score 
of 68.The following is a brief overview of the key processes underlying 
NCA's high customer satisfaction ratings.

    1. Commitment from top leadership to be the best.
    2. Define Excellence using input from all levels of the 
organization.
          a. NCA has established a formal Organization and Assessment 
        (OAI) program to assess performance and the overall 
        organizational health of National Cemeteries, Memorial Service 
        Networks (MSNs), and Central Office components. Using Malcolm 
        Baldrige National Quality Award criteria as a management 
        framework, it enables NCA to document, track, monitor, and 
        report progress toward successful achievement of NCA 
        Operational Standards and Measures in the key cemetery 
        operational areas of interments, grounds maintenance, 
        headstone/marker operations, equipment maintenance, facility, 
        maintenance, and safety.
          b. NCA applies OAI to each organizational entity annually and 
        records performance as a scorecard.
          c. Long Range Plan (FY 2016-2021) developed which focuses on 
        five specific goals that will enhance service to Veterans and 
        their families.
    3. Train employees on how excellence is defined and provide tools 
to succeed.
          a. Conduct front-line training at NCA's National Training 
        Center in St. Louis
                  i. 48-week Cemetery Director intern program
                  ii. Cemetery Caretaker training
    4. Hold employees and management accountable.
          a. Cascade performance expectations in performance plans.
    5. Establish continuous customer feedback loop and adjust OAI 
surveys.
          a. Quarterly Customer Satisfaction Surveys
          b. Refresh operational standards and measures based on 
        feedback
                  i. Annual Lessons Learned Conference
                  ii. Communities of Practice website
    6. Commitment to employing Veterans.
          a. Workforce embodies the culture of Veterans serving 
        Veterans
                  i. Almost 75% of NCA employees are Veterans
                  ii. Over 28% are disabled Veterans

The Veterans Health Administration (VHA) does, in fact, utilize the 
American Customer Satisfaction Index (ACSI) to understand how Veterans 
who have used VA healthcare services rate their customer experience, 
and compares that experience with that of private sector hospitals. For 
over a decade, VHA ACSI scores have outpaced that of the private sector 
(see Table 1 below). Many factors undoubtedly influence those scores--
but certainly the high quality of VHA services along with their 
affordably are powerful drivers. But VHA is not content to rely solely 
on the ACSI to judge its performance, and we believe that the best way 
to compare ourselves is not with other Federal agencies, but rather, 
the U.S. health care system at large. Across private hospitals, 
physician groups, and plans in this Nation, the principal measure of 
patient experience is the Consumer Assessment of Health Providers and 
Systems (CAHPS) survey, which VA administers using an outside 
contractor. Our CAHPS surveys indicate VHA does have more work to do in 
the area of Access, although other areas, such as Comprehensiveness of 
Care, i.e., care for Veterans that focuses on all of their needs and 
preferences are, in fact, superior.
    Regarding best practices, while I was Under Secretary, I 
commissioned the Diffusion of Excellence initiative as an endeavor that 
focuses on achieving consistency of best practices throughout the VHA. 
During my first few months in office, I visited a number of facilities 
that had very unique ways of engaging both veterans and the employees 
who served them--even in sites that struggled to perform overall. I 
knew that if we identified the practices that worked best for 
veterans--both clinical and business-related--that we would be able to 
improve customer satisfaction throughout the system.
    The Diffusion model has not only identified over 100 best practices 
within VHA alone for improving the veteran experience--it actually 
provides a framework that allows us to replicate those change efforts 
in other areas throughout the system.
    As of today, these best practices have been replicated over 300 
times across different sites in the system. The Diffusion model has 
gained traction, and is featured in an article that I wrote for the 
Journal of the American Medical Association, published just a couple of 
weeks ago.
    In addition, a major enabler of establishing and spreading these 
best practices is an electronic platform (called the Diffusion Hub) 
that not only helps with implementing methodologies--it also provides a 
library of tool kits for specific solutions that we would like to see 
everywhere. This platform not only includes projects within VHA--but 
projects that originated out of NCA and VBA, for spread in other 
administrations as appropriate. As of now, there are already several 
best practices in customer engagement that NCA has contributed to this 
platform through Secretary McDonald's Leaders Developing Leaders (LDL) 
initiative.

                         Table 1: VHA Trends in the American Customer Satisfaction Index
----------------------------------------------------------------------------------------------------------------
                                      2005   2006   2007   2008   2009   2010   2011   2012   2013   2014   2015
----------------------------------------------------------------------------------------------------------------
VHA Inpatients.....................     83     84     83     85     84     85     85     84     84     81     86
VHA Outpatients....................     80     82     83     81     83     82     83     82     82     79     80
Private Sector Hospitals...........     71     74     77     75     77     73     76     76     78     76     74
----------------------------------------------------------------------------------------------------------------


 Table 2: VA comparisons on Consumer Assessment of Health Providers and
                                 Systems
     (adjusted for differences in age, education, and health status)
------------------------------------------------------------------------
          CAHPS Composite                   VA vs. Private Sector
------------------------------------------------------------------------
2Access (based on % always getting  6 points lower than private sector
 carewhen needed)0.
Communication.....................  About the same
Provider Discusses Medical          About the same
 Decisions.
Self-Management Support...........  About the same
8Comprehensiveness (attending to    6 points higher than private sector
 mental and emotional health as
 well as physical health)0.
Office Staff......................  About the same
------------------------------------------------------------------------


    Question 9.  The Veterans Choice Program, created by section 101 of 
Public Law 113-146, the Veterans Access, Choice and Accountability Act 
of 2014, would expire August 7, 2017, without Congressional action. 
Going forward, how do you envision expanding veterans' access to non-VA 
care while preserving within the Veterans Health Administration (VHA) 
the care and services VHA performs well?
    Response. One of the most critical needs facing our Veterans is 
access to community care. VA's long-term vision for the future state is 
delivering timely, high-quality community care. It will make it easier 
for Veterans to access community care and easier for community 
providers to work with VA.
    Our goal is to deliver community care that is easy to understand, 
simple to administer, and meets the needs of Veterans and their 
families, community providers, and VA Staff. VA has developed a long-
term strategy as a starting point that allows for a balance between 
community care and care in the VA, purchasing community care when VA 
does not provide the service or cannot provide it when clinically 
needed. VA needs local market assessments to determine the availability 
of care both in the VA and in the community to ensure the appropriate 
mix of care.
    We are making immediate improvements today, while seeking longer-
term solutions. Together with Congress's support and funding, VA will 
continue working to streamline and transform VA Community Care to 
improve the community care experience.
                                 ______
                                 
 Response to Prehearing Questions Submitted by Hon. Jon Tester to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs

    Question 10.  Dr. Shulkin, what is your view on the role of the 
Secretary of Veterans Affairs? If confirmed, would you seek to be an 
independent advocate for veterans or would you be the executor of the 
Administration's policies relating to veterans?
    Response. The Secretary of VA is responsible to ensure that our 
Nation's veterans receive the highest level of service and care that we 
can provide. The Secretary also serves to ensure that the President and 
Congress' policies and laws are carried out to the best of their 
ability. If confirmed, as Secretary, I would work tirelessly to see 
that these objectives are fulfilled. As Secretary, if confirmed, I 
would be a strong and independent advocate for veterans and for 
policies that would support the interests of veterans. Once laws and 
policies are put in place, the Secretary should serve to ensure that 
these are carried out to the best of his or her ability

    Question 11.  Dr. Shulkin, what are your top three goals as 
Secretary of Veterans Affairs?
    Response. If confirmed, my top goals as Secretary would be:

    1) To ensure that the right people are in place to serve veterans, 
whether that be senior management or front line staff.
    2) To ensure that the right resources, tools, and systems are in 
place to deliver these services to our veterans
    3) To ensure that veterans are receiving the highest quality and 
character of services that they have earned and deserve.

    Question 12.  Dr. Shulkin, after serving nearly two years as Under 
Secretary for Health, how will you broaden your focus for VHA to the 
entire organization? What do you foresee as your biggest challenge in 
that endeavor?
    Response. If confirmed, my goal for VA is to work as a seamless 
organization to meet the needs of our veterans. From a veterans 
perspective, they do not care if their services come from VHA, VBA, or 
NCA, but rather they care their issues are being addressed. The real 
strength of VA comes from the ability to meet physical, social, 
economic, and the holistic needs of the veteran.
    VA has been working hard to act more as an integrated enterprise 
and in doing so I have worked closely with my colleagues in VBA, NCA 
and the Board of Appeals. I understand that veterans see us all as one 
VA and not separate administrations and therefore having a seamless 
experience is critical to us fulfilling our mission. During my time as 
USH I have been able to contribute to efforts that improve services to 
veterans who utilize VBA and NCA. If confirmed, I would buildupon my 
foundational understanding of critical issues to accelerate changes in 
all three administrations and implement a singular veteran centric 
service model for VA.
    The largest challenge to working as an integrated enterprise is the 
ability to accelerate our journey to be a veteran centric organization 
and to challenge the status quo.

    Question 13.  Dr. Shulkin, one of the Secretary's major roles on an 
annual basis is developing and then defending VA's budget for a given 
year. Please explain your role in this endeavor under Secretary 
McDonald.
    Response. My role was to develop, submit and defend the budget for 
VA's Medical Care appropriations--the Medical Services, Medical 
Community Care, Medical Support and Compliance, and Medical Facilities 
accounts, as well as for the Medical and Prosthetic Research 
appropriation.
    The VA Medical Care budget is largely driven by the VA Enrollee 
Health Care Model, an actuarial model that estimates demand for health 
care services for the more than nine million Veterans enrolled with VA.
    One of our challenges in developing this budget is that many 
Veterans have multiple options for health care, including Medicare, 
TRICARE, and employer health insurance.
    We estimate that enrolled Veterans get a little more than one third 
of their total health care from the VA; however, this demand level can 
change rapidly based on economic conditions and availability of VA 
services.
    We have seen steady growth in Veteran reliance on VA health care 
over the last several years, and anticipate that trend will continue in 
the future.
    In addition to the modeled amounts, we developed estimates for 
other significant requirements, including:

     State Home programs
     Homeless prevention programs
     Readjustment Counseling Services (Vet Centers)
     Non-Recurring Maintenance for VA's aging health care 
facilities
     Activation of new health care facilities (initial 
outfitting of equipment, furniture and supplies, and new staff when 
applicable)
     Medical information technology support requirements, 
including VistA Evolution
     CHAMPVA and related programs (Spina Bifida, Foreign 
Medical Program, and Children of Women Vietnam Veterans)
     Caregivers support programs
     Indian Health Service agreements
     Health care services for Veterans exposed to toxic water 
at Camp Lejeune
     Medical and Prosthetic Research programs
    a. Do you anticipate working within the limits established by the 
Office of Management and Budget or going to the President to advocate 
for the level of funding that is needed to fully fund the Department in 
the coming year?
    Response. It is essential that the Secretary be a strong advocate 
for the resources that are required to do the job of serving our 
country's veterans. It is also essential that the Secretary ensure that 
those resources that are allocated are spent in an efficient and 
effective manner.
    As I know you understand, the Office of Management and Budget must 
balance the needs of all Federal Government agencies against the total 
annual budgetary resources established by Congress. Therefore, 
increases in the VA budget may need to come at the expense of other 
agencies.

    Question 14.  Dr. Shulkin, if confirmed, what will be your plan to 
work with employee unions? Do you believe they play an important role 
in bridging communication between VA employees and management?
    Response. As the USH, I have seen the value in working to engage 
with the employee unions and there have also been challenges The five 
national unions within the VA represent approximately 285,000 VA 
employees. VA has also negotiated master collective bargaining 
agreements with four of the national unions. Therefore, engaging with 
the unions, including bargaining on some policies that change 
employees' conditions of employment, is not only a statutory or 
contractual requirement, but when done effectively it creates a labor-
management environment that enhances VA's ability to communicate our 
policies and initiatives to our employees.

    Question 15.  Dr. Shulkin, what is your view on the role of 
whistleblowers? If confirmed, will you encourage whistleblowing by the 
Department's employees?
    Response. I support the Whistleblower Protection Act of 1989. VA 
has established a Whistleblower Protection Program that ensures 
employees, contractors, and grantees who disclose allegations of 
serious wrongdoing or gross mismanagement are free from fear of 
reprisal for their disclosures. If confirmed, will you encourage 
whistleblowing by the Department's employees? Yes. Leaders are 
responsible for establishing a workplace atmosphere in which employees 
are comfortable highlighting and sharing their successes--as well as 
identifying areas in which we can improve. Whether that means notifying 
managers and supervisors of isolated gaps or bringing attention to 
larger, systemic issues that impede excellence, it is important that 
all employees are encouraged to report deficiencies in care or services 
we provide to Veterans. Relatively simple issues that front-line staff 
may be aware of can grow into significantly larger problems if left 
unresolved. In the most serious cases, these problems can lead to and 
encourage improper and unethical actions.
    Across VA, I expect workplace environments that enable full 
participation of employees. I expect employees to bring to the 
attention of their managers and supervisors shortcomings in the 
delivery of our services to Veterans or any perceived violations of law 
or official wrongdoing--including gross waste, fraud, or abuse of 
authority. And I will make clear that intimidation or retaliation 
against whistleblowers--or any employee who raises a hand to identify a 
legitimate problem, make a suggestion, or report what may be a 
violation of law--is absolutely unacceptable. I will not tolerate it. 
Protecting employees from reprisal is a moral obligation of VA leaders, 
a statutory obligation, and a priority for this Department. We will 
take prompt action to hold accountable those engaged in conduct 
identified as reprisal for whistleblowing, and that action includes 
appropriate disciplinary action.

    Question 16.  Last Congress, this Committee considered a number of 
legislative proposals that would have provided the Department with 
authority to sanction employees--both general schedule and Senior 
Executives--that is not available to other Federal agencies. Do you 
believe that, in order to best manage the Department's workforce, it 
needs expedited firing authority that would reduce an employee's right 
to appeal?
    Response. What we need is an employee discipline and appeal process 
that provides enough due process to pass constitutional muster but 
allows us to take action faster than we can under the current process 
and affords more deference to the Agency's decisions than Merit Systems 
Protection Board judges often do. Ideally we'd like to see an overall 
reform of employee discipline and appeals rules throughout the Federal 
Government, not something that singles out VA employees for harsher 
treatment than their peers in other agencies, because we want to be 
able to attract and retain good people from all over rather than lose 
them to other agencies. We'd like to see a change in the agency's 
burden of proof on appeal to the MSPB, so we can sustain our actions 
based on substantial evidence rather than the higher and harder-to-
prove preponderant evidence standard that applies today. That small 
change would allow us to take discipline more expeditiously and sustain 
our well-founded actions on appeal.

    Question 17.  Dr. Shulkin, have you spoken to the President-elect 
about your vision for the rest of the leadership team at VA? What is 
that vision?
    Response. Yes, I have spoken to President Trump about my vision for 
the leadership team at VA. We seek to fill our leadership positions 
with people that have outstanding values and ethics, people that are 
passionate about serving veterans, people with superb experience and 
competence, and people who understand the needs of veterans.

    Question 18.  Dr. Shulkin, will you commit to quarterly meetings to 
update this Committee on progress the Department has made on 
recommendations from OIG, GAO, OSC, and other investigative reports? 
Who is responsible within VA for tracking and ensuring that these 
recommendations are implemented?
    Response. Yes, I will commit to these quarterly updates. Each 
Administration is responsible for tracking and ensuring recommendations 
are implemented. If confirmed I would ask that the Office of 
Congressional and Legislative Affairs be responsible for communicating 
the recommendations from these reports and the resulting actions taken 
by VA to comply with these recommendations.

    Question 19.  Dr. Shulkin, the President-elect's vision to reform 
VA included the following statement, ``Ensure our veterans get the care 
they need wherever and whenever they need it. No more long drives. No 
more waiting backlogs. No more excessive red tape. Just the care and 
support they earned with their service to our country.'' If confirmed, 
how will you achieve this vision--do you have more specifics on the 
President's 10-Point plan for reforming and modernizing VA for the 21st 
Century?
    Response. If confirmed, I will immediately begin working to define 
the options that would work toward the improvements in VA that the 
President, Congress, and the American public seeks. In terms of the 10 
point plan, I am still studying the various proposals and options that 
have been laid out by the President.

    Question 20.  Secretary McDonald has been lauded by Veterans 
Service Organizations and military service organizations for his 
attentiveness to their concerns.
    a. Please describe your past VSO and MSO interactions.
    Response. My interactions with Veteran Service Organizations (VSOs) 
and Military Service Organizations (MSOs) have been very positive and 
collaborative in nature. I have met with the Big 6 VSOs (Disabled 
American Veterans, The American Legion, Veterans of Foreign Wars, 
Paralyzed Veterans of America, AMVETS and Vietnam Veterans of America) 
as well as Iraq and Afghanistan Veterans of America (IAVA) on a monthly 
basis to share best practices and proactively address major VSO issues. 
Senior VA leaders have also met with the Post-9/11 VSO Groups: Got Your 
Six, Team Rubicon, Team Red, White and Blue (RWB), Student Veterans of 
America, Travis Manion Foundation and many MSOs such as Military 
Officers Association of America (MOAA) and Fleet Reserve Association 
(FRA) to build coalitions and address Veteran issues as well. VA 
Leaders have traveled to the major conventions and annual meetings and 
met individually with each of the VSO groups on a routine and 
reoccurring basis to solicit feedback and opportunities that VA can 
take to improve services for Veterans. On the local level, VA medical 
center facilities meet with our VSO partners on a monthly basis to 
capture feedback and improve the care and delivery of health care 
services to Veterans in the community.
    Some of the initiatives that we have worked closely with MSOs/VSOs 
included MyVA Transformation, MyVA Access and Suicide Prevention. A 
direct measure of the improvement that we have made with our MSO/VSO 
partners is with rebuilding trust. Nearly 60 percent of Veterans 
surveyed in June 2016 ``trust VA to fulfill our country's commitment to 
Veterans'' which is up from 47 percent in December 2015.
    b. Please give specific examples of how you anticipate involving 
the VSOs and MSOs.
    Response. We expect the same level of partnership and engagement 
with our VSOs/MSOs colleagues to continue as we work to continue the 
progress/momentum that we have gained with MyVA Transformation.

    Question 21.  Dr. Shulkin, will you commit to making data public, 
including the Monday morning workload report and wait times by medical 
facility?
    Response. I am a strong believer of transparency of data. I am 
committed to making public our wait times by medical facility and our 
patient satisfaction scores related to access by facility. I am not 
familiar with the workload report, but if confirmed would be willing to 
consider looking at this suggestion.

    Question 22.  Dr. Shulkin, if confirmed, will you direct your 
agency to timely and fully respond to all reasonable Freedom of 
Information Act requests submitted by the American people?
    Response. Yes, as stated earlier I believe in transparency.

    Question 23.  Dr. Shulkin, will you commit to sharing with 
committee staff VA organizational charts, for the administrations and 
staff offices, which include names and contact information, so that 
staff can get timely answers to concerns?
    Response. Yes

    Question 24.  Dr. Shulkin, as you know, RAND recently reported that 
VA health care is as good or better than health care provided by the 
private sector. After nearly two years as Under Secretary of Health at 
VA, do you agree with this finding? Please explain.
    Response. Statements related to the comparison of quality between 
VA and the private sector has been studied by numerous independent 
research groups. These research finding speak for themselves. My 
interpretation of these studies is that clearly in some areas, VA 
outperforms the private sector. Areas of superior performance generally 
include the comprehensive nature of VA care and include measures 
related to health screening, primary care, outpatient measures, safety 
and behavioral health. However, there are other areas of healthcare 
performance where VHA lags. If confirmed as Secretary, I would continue 
to focus my efforts on improving the quality and safety of VA 
healthcare, and continue to pursue improvement efforts utilizing 
private sector benchmarks.

    Question 25.  Many veterans, especially those with complicated 
health issues, rely upon the specialized services of the VHA. Many of 
these services, like spinal cord injury, blind rehabilitation, and 
prosthetics, are not widely available in the private sector. In an era 
of declining budgets and decentralization of funds, please describe 
your views on VA's responsibility to maintain capacity in these 
programs. What is your perspective on the future of VA specialized 
services (spinal cord injury, polytrauma, blinded rehabilitation, 
mental health)?
    Response. With regard to mental health care, VA comprises an 
unparalleled system of comprehensive treatments and integrated services 
to meet the needs of each Veteran and the family members who support 
the Veteran's care. These services support Veteran resilience, identify 
and treat mental health conditions at their earliest onset, address 
acute mental health crises, and provide recovery-oriented treatments. 
VA provides a continuum of forward-looking outpatient, residential, and 
inpatient mental health services across the country. In FY 2016, more 
than 1.6 million Veterans received specialized mental health treatment 
from VA; This number has risen each year from over 900,000 in FY 2006. 
VHA provides mental health care integrated within its Primary Care 
clinics at VHA medical centers and large and very large community 
clinics with 15% more Veterans receiving Primary Care Mental Health 
Integration services in 2016 than in 2014. The integration of mental 
health services into primary care settings is designed in part to help 
overcome some Veterans' reservations about seeking mental health 
services. It also provides an opportunity to deliver mental health 
services to those who may otherwise not seek them and to identify, 
prevent, and treat mental health conditions at the earliest 
opportunity. Through the Measurement Based Care in Mental Health 
Initiative, VA is working toward the nationwide implementation of 
measurement based care (MBC). Fifty-eight champion sites, representing 
18 Veterans Integrated Service Networks, have been selected to help 
develop and refine the infrastructure for this implementation. With 
MBC, Veterans assess their wellness through a standardized set of 
questions, with the resulting data then used to individualize and 
enhance their mental health care. To our knowledge VA is the largest 
mental health system implementing MBC.
    A key VHA strategic principle is to ensure access, continuity, and 
quality for special emphasis and vulnerable populations in VHA, such as 
Veterans with spinal cord injuries and disorders (SCI/D), where VHA has 
expertise not found in the community. VA provides world class care to 
Veterans with SCI/D so they can achieve the highest possible health, 
independence, quality of life, and productivity throughout life.
    A unique strength of the VA SCI/D System of Care, not found 
elsewhere in the private sector, is that the full continuum of care is 
provided to Veterans with SCI/D throughout life. This includes 
rehabilitation, acute care, ongoing primary care, preventive care 
(including comprehensive annual evaluations), lifelong medical 
management, outpatient care, home care, telehealth, respite care, long-
term care, and end of life care. That care is coordinated through a hub 
and spokes model; similar coordination is not available outside of the 
VA.
    There is no better place for Veterans with an SCI/D to get care 
than one of the 24 regional VA SCI/D Centers, where care is provided 
through highly dedicated and committed teams of knowledgeable and 
skilled professionals from different disciplines. In addition, VA 
facilities without an SCI Center have trained SCI/D teams that work 
closely with SCI Centers to deliver primary and limited specialty care. 
This hub and spoke model of care provides integrated and coordinated 
regional and local care throughout the US. Geographical access is 
further enhanced by dedicated SCI/D home care and telehealth programs. 
There are unique dedicated SCI/D long-term care units in VA that are 
not available anywhere else in the country. There are superior critical 
services provided in VA, such as prosthetics, bowel and bladder care, 
ventilator care, Home Improvement and Structural Modifications (HISA) 
grants, and travel.
    In 2000, a report ``VA Spinal Cord Injury and Disorders: A 
Comparison of Program Data Collected Across Four Modes of Care'' 
demonstrated that the VA SCI/D System of Care was more comprehensive 
and offered superior resources, care, and training as compared with 
other large SCI Systems of Care in the U.S. and in Europe. Analyses of 
outcome data collected since then show that VA provides care that meets 
or exceeds internal and external benchmarks in all areas, including 
outcomes related to quality of life. Over the past 20 years, studies, 
surveys, anecdotal evidence, and behavior have demonstrated that 
Veterans with SCI/D highly value VA care.
     A will maintain our commitment to ensure these Veterans 
receive the specialized services they need. Such services are not 
widely available in the private sector--if at all.
     VA has established programs and systems of care to 
maintain and ensure the provision of lifelong specialized care and 
services for these severely disabled Veterans
     VA's systems of care for Polytrauma/Traumatic Brain Injury 
(TBI), Amputation, Spinal Cord Injury and Disorders, and Blind 
Rehabilitation are strong:

         - Specialized services are provided across tiered networks of 
        specialty rehabilitation centers that serve as regional 
        referral centers for acute inpatient rehabilitation for severe 
        injuries.
         - Ongoing care and services are provided for Veterans in VA 
        facilities with specialized interdisciplinary teams closer to 
        the Veteran's home community.
     These VA programs uphold the highest standards of 
rehabilitation, such as CARF (Commission on Accreditation of 
Rehabilitation Facilities) accreditation for inpatient rehabilitation 
facilities, and participating in HHS `Model Systems' for VA's TBI and 
SCI programs (consortium of premiere private and academic 
rehabilitation centers).
     VA is further committed to ensuring Veterans continue to 
receive the prosthetic items and services they need. In FY 2016, VA 
expended $2.8 Billion to provide 20 million medical items, prosthetic 
devices and items to 3.3 million Veterans.
     With regard to mental health care, VA comprises an 
unparalleled system of comprehensive treatments and integrated services 
to meet the needs of each Veteran and the family members who support 
the Veteran's care.
     These services support Veteran resilience, identify and 
treat mental health conditions at their earliest onset, address acute 
mental health crises, and provide recovery-oriented treatments.
     VA is committed to ensuring continuing access to a full 
spectrum of mental health care for our Veterans.

    Question 26.  VHA has made undeniable progress over the past two 
years in integrating more community care into the VA health care 
system. Do you believe that a veteran's primary care clinician should 
continue to be part of the VA system or can s/he be any clinician a 
veteran chooses?
    Response: VA has developed a model of personalized, proactive, 
primary care for Veterans. It provides a comprehensive approach to 
caring for the Veteran. Every Veteran is assigned to a primary care 
provider when they begin participating in VA health care to ensure 
their care is coordinated. This approach is critical to ensuring the 
Veterans health. However, in many parts of the country, Veterans live 
too far or face other obstacles in getting to the VA for their primary 
care. If Veterans receives primary care in the community, VA needs to 
ensure that all of the care is coordinated and the provider quality is 
the same or better than the VA.

    Question 27.  As we have discussed on numerous occasions, the roll-
out and execution of the Veterans Choice Program in Montana and many 
other states has been nothing short of a disaster. In fact, the same 
issues have remained largely unresolved for two years and have left 
veterans, community providers and VA employees frustrated and angry. As 
many of these issues remain the responsibility of the Third Party 
Administrators in Choice, what are you going to do to hold them 
accountable for a continued failure to meet the terms of their 
contract, and to meet the basic expectations of veterans? Do you 
continue to believe that VA becoming the primary payer of Choice for 
all veterans and community care spending flexibility are critical to 
ensuring that the Choice program operates as intended?
    Response. The VA uses several strategies to evaluate contractor 
performance and imposes penalties on contractors when they fail to meet 
the terms of their contracts. The Quality Assurance Surveillance Plan 
(QASP) is a recurring assessment of contractor performance throughout 
the term of the contract. When contractors fail to meet the metrics 
established in the QASPs, letters of correction and financial 
penalties, also called equitable adjustments, are assessed against the 
contractor. Equitable adjustments have been, and will continue to be, 
used to move the contractor toward meeting the metrics outlined in the 
contract.
    Congress can assist in simplifying the claims processes through a 
change in the law that makes the VA the primary payer. This change 
would lead to greater efficiencies in claims submission by our 
community providers and subsequent payment by our contracting partners. 
This change would also eliminate the labor intensive process of 
identifying and communicating other insurance coverage on the front 
end. A transition back to VA being primary payer should be a relatively 
smooth transition since the original framework of our Consolidated 
Patient Account Centers (CPAC) was built upon this premise. This change 
will allow our CPACs to operate as originally designed by recouping 
costs from third-party payers after care has been rendered.

    Question 28.  Dr. Shulkin, the Commission on Care rejected the idea 
of granting veterans who use the VA unfettered choice in seeking care 
outside of the VA. Do you agree with this position, or do you believe 
that a veteran who is eligible for VA health care ought to be provided 
with a voucher to seek care wherever s/he chooses, with VA footing the 
bill?
    Response. My belief is that every veteran that relies upon VHA for 
their healthcare must have access to the best quality healthcare in a 
timeframe that meets their clinical needs. We must utilize care within 
the VA and outside the VA to meet this objective. In terms of total 
unfettered access, I think given the models considered by the 
Commission and the subsequent economic modeling done by their 
economists, that the Commission came up with the reasonable 
conclusions. However, if confirmed, I would plan to explore different 
options that would allow veterans greater choice while maintaining the 
unique character and services of VHA. These proposals will require 
additional analysis before they can be fully considered.

    Question 29.  Dr. Shulkin, are you in favor of the Commission on 
Care recommendation that would grant veterans with other-than-honorable 
administrative discharges eligibility to access VA health care on at 
least a temporary basis?
    Response. If confirmed, I would take a serious look at such a 
proposal and confer with both the White House and Congress about ways 
that we might address this population.
    a. Have you spoken to President-elect Trump about how he intends to 
handle services for veterans in need who have bad paper discharges?
    Response. No

    Question 30.  President-elect Trump's plan for veterans talks about 
embedding satellite VA clinics within other health care facilities in 
rural and other underserved areas. With existing government 
acquisition, leasing, and contracting laws, how do you intend to make 
this happen quickly?
    Response. The Department has various means for providing care or 
embedding ``clinics'' in affiliates or other healthcare facilities to 
provide healthcare for Veterans in rural and other underserved areas:

    VA providers only--VA provides healthcare out of non-VA's 
healthcare sites through the sharing of staff/resources, not real 
property. This is a similar model to how VA partnered with the 
Department of Defense (DOD) to do exit exams. A VA doctor would perform 
exams in a DOD facility, but VA would not have real property interest 
in the site, it would be purely resource sharing.
    Real Estate Solutions--VA could utilize tools such as revocable 
licenses and permits as quick, short-term real estate agreements to 
occupy third-party space for VA providers. Such agreements do not have 
to be competitively sourced but can only provide a interim solution--up 
to 5 years in certain circumstances but typically much shorter. For any 
type of long-term, presence, VA would acquire space from a third party 
through leasing. With current competitive requirements, it may take 
longer to go through the process. VA would lease a portion of space and 
staff it with VA personnel as a standard clinic. The competitive 
procurement process would dictate the final location from within a VA 
specified geographic area, but requirements could be written to help 
narrow down the scope. This issue could be streamlined with legislative 
changes to allow sole source leasing with affiliates and state and 
local governments. In that case, it would still be a lease, but could 
be non-competitive if it were with an affiliate location or applicable 
local government.

    Question 31.  Dr. Shulkin, do you intend to modify Secretary 
McDonald's MyVA priorities or ``breakthrough initiatives?''
    Response. The MyVA priorities were established through 
consultations with VA management and staff, veterans service 
organizations, community groups and The MyVA advisory Committee. 
Progress has been made in many of these areas and in some cases the 
goals have been achieved. If confirmed as Secretary, I would continue 
progress in those areas where progress is still needed, establish new 
and bold goals for other priority areas, and continue to consult with 
veterans and the organizations that represent their interest to modify 
and evolve these initiatives.

    Question 32.  In your opinion, what more do you believe needs to be 
done to improve personnel recruitment and retention at VA health care 
facilities?
    Response. VHA is continually striving to improve personnel 
recruitment and retention at VA health care facilities, and has a 
robust and multi-pronged approach to recruitment. Local facilities have 
in-house human resources departments, as well as nurse recruiters, who 
reach out to and coordinate with applicants on a local level, including 
outreach to nearby training programs and hosting open houses when 
needed to facilitate hiring. Facilities also produce job advertisements 
in local, state and national publications, journals, newspapers, radio 
advertisements, hold local career/job fairs, and attend local and 
regional job fairs. VHA also has a National Recruitment Program (NRP), 
100 percent staffed by Veterans, that employs private sector best 
practices to fill VHA's top five most critical clinical and executive 
positions.
    Our major challenge is the unnecessary hiring complexity caused by 
VA having three different hiring authorities. As Secretary, I'd like to 
continue to explore with the Congress establishing an Alternative Human 
Resources (HR) System for VA, converting VA to Title 38. Additionally, 
for our clinicians, a single Federal credentialing system, coupled with 
national reciprocity for credentialing, would greatly improve our 
ability to hire and retain clinicians, improve the hiring process from 
the applicant's perspective, and allow us to more easily deploy our 
clinicians to meet surge needs as the may arise across VHA.
    Finally, the prudent use of recruitment, retention and relocation 
incentives has been an important tool for VHA hiring and retention. 
Removing these incentives from the CARA award caps would restore our 
ability to appropriately deploy these important flexibilities to 
improve our ability to compete with the private sector.

    Question 33.  There has been increasing pressure in recent years 
for VA to contract for services in local--especially rural--communities 
where VA facilities are not easily accessible. Mental health is one 
area of particular emphasis in this regard. What do you believe is VA's 
responsibility for meeting the needs, including mental health needs, of 
rural veterans? If confirmed, what emphasis would you place on this 
issue?
    Response.

     VHA is committed to meeting the health care needs, 
including mental health, of all Veterans, regardless of where they 
live.
     Rural Veterans deserve a special focus as they have a 
higher risk of suicide than Veterans in urban areas.
     Other challenges of rural Veterans include:

         - Provider shortages
         - Geographic barriers
         - Lack of transportation options
         - Rural community hospital closures
     VHA is taking steps to address mental health provider 
shortages in rural areas by establishing regional telemental health 
hubs
     In 2016 VHA established four regional telemental health 
(TMH) hubs to enhance Veteran access to mental health care for Veterans 
residing in rural areas
         - The four hubs are in South Carolina, Utah, Pennsylvania, and 
        Washington-Oregon area.
         - Six additional hubs are planned to come online in 2017.
         - This will extend mental health services to up to 200 sites 
        of care where more mental health capacity is needed.
     VHA has also expanded capacity to serve rural Veterans at 
home, issuing tablets for the delivery of care, including mental 
health, to nearly 3,000 Veterans.
     Standardized training on suicide prevention guidelines in 
face-to-face clinical settings and during telephone contacts 
specifically for clinicians who work with rural Veterans
     Integrating evidence-based practices and existing VA 
programs (e.g., suicide risk management in primary care, crisis 
support, firearm safety, and the Home-Based Mental Health Evaluation 
program) into a comprehensive portfolio of best practices to prevent 
rural Veteran suicides.
     We recognize there are workforce shortages in rural areas 
and will continue to pursue strategies to meet these workforce gaps, 
including:

         - Expanded scope of practice for advanced practice registered 
        nurses
         - Expanding workforce training programs in rural VA locations
         - Leveraging the VA ECHO (Extension for Community Health
    Outcomes) program to ensure primary care providers in rural sites 
can access specialty training and consultation
         - Hiring of highly trained Veteran combat medics and corpsmen

    Question 34.  What is the appropriate level of oversight and 
responsibility that VA has for the care veterans receive from community 
providers?
    Response. VA needs to ensure we provide a full network of care, 
including appropriate quality in the network. The Request for Proposal 
(RFP) that was released on December 28, 2015 includes requirements for 
the networks to be accredited and for providers to be credentialed. The 
contractor must establish a variety of quality, network adequacy, 
patient experience and operational efficiency plans. There are over 20 
in total that will be required as part of the contract. In addition, VA 
will establish certain quality measures to be included based on 
industry standards. A Quality and Patient Safety Model and Framework 
was created to establish the baseline for moving to a value-based model 
of care, based on the Institute of Medicine (IOM). These measures will 
move the VA forward in ensuring appropriate quality when community care 
is provided.

    Question 35.  Female veterans are the fastest growing population in 
the VA today and will continue to grow over the next several years. The 
President-elect has stated his intent to better meet the needs of 
female veterans, which I support.
    a. During your time at VA, what have you done to improve the 
physical and mental health care access, quality of care, and address 
privacy, security, as well as the transition for female veterans?
    Response.

Physical and Mental Health Care Access
     Since 2014, VA has made tremendous strides in providing 
enhanced services and access for women.
         - 100% of medical centers and 90% of Community Based 
        Outpatient Clinics have Designated Women's Health Providers
         - 130 VA medical centers have gynecology services on-site
         - VA offers a full continuum of gender-sensitive mental health 
        services to women Veterans
         - VA has deployed large scale initiatives to train current VA 
        physicians on Women's Health core curricula and priority 
        topics, including Mental Health
         - All Primary Care and Mental Health providers are also 
        trained in the care of Veterans who have experienced Military 
        Sexual Trauma
Quality of Care
     VA tracks quality by gender and has reduced or eliminated 
several key disparities
     On some important quality measures, VA is better than the 
private sector (breast and cervical cancer screening)
Privacy and Security
     VHA has committed to ensuring all facilities meet Privacy 
Standards--to include physical and auditory privacy--and to increasing 
the accountability of facilities to follow these standards.
     By policy, all Veterans' personalized health information 
is protected with the same level of privacy and security regardless of 
gender.
     VA's focus also goes beyond physical security to ensure 
the entire experience of women Veterans is positive.
     VA has launched multiple campaigns aimed at recognizing 
the service of women Veterans and is now launching an even more direct 
effort to increase civility and respect through the ``End Harassment'' 
campaign.
    b. Will the President-elect's desire to ``fully equip'' every VA 
hospital with women's health services bump other projects for the SCIP 
list to achieve this goal?
    Response. For the past several years, one of VHA's goals has been 
to incorporate women's health into various aspects of our capital 
initiatives. Just a few of our numerous examples include dedicating a 
women's health exam room into the PACT design model; converting 
existing multi-bed inpatient rooms to single bed inpatient rooms; 
updating VA's Women's Health Design Standard and Guide for separate 
women's clinics; and including a women's health sub-criteria in the 
Strategic Capital Investment Planning (SCIP) scoring process to 
increase points for any capital initiative focusing on women's health.
    In addition, in the SCIP 2018 cycle, VHA narrowed the first year 
capital initiative focus to only include leases and projects under the 
following umbrellas: Women's Health, Inpatient Medical/Surgical Bed 
Conversion to Single Beds, Primary Care and Outpatient Mental Health, 
Safety, and Infrastructure. The impact of this focus for first year 
projects and leases resulted in approximately a 1/3 reduction in 
capital initiatives compared between the SCIP 2017 cycle final list and 
SCIP 2018's preliminary list. This allowed women's health type projects 
and leases to better compete for limited construction and leasing 
funding.
    VHA plans to continue this narrowed focus with the same categories 
for the SCIP 2019 cycle in an effort to continue to support VHA's 
goals, which includes converting existing deficient space and/or adding 
more space, resulting in state-of-the-art, modern environments for VA 
to provide women's health.

    Question 36.  During your time at VA, what have you specifically 
done to reduce the number of veteran suicides? What do you still hope 
to accomplish if confirmed as Secretary?
    Response. Accomplished:

     Convened a Call to Action on Preventing Veteran Suicide in 
February 2016--included Congressional members, Federal partners, non-
profits, VSOs, survivors of suicide prevention; led to recommendations 
that have been implemented throughout VA and communities
     Completed most comprehensive analysis of Veteran suicide 
to date: ``Suicide Among Veterans and Other Americans''--examining more 
than 55 million Veteran records from 1979 to 2014 from all 50 states 
and 4 territories.
     Convened several public-private partnership strategic 
planning sessions to seek input and dialog about our partnership 
strategy.
     Signed Memoranda of Agreement with Johnson & Johnson, Give 
an Hour, Bristol Myers Squibb Foundation, IBM, Wounded Warrior Project, 
Psych Armor, and Project Hero expanding the reach of VA mental health 
programing.
     Developed and implemented REACH VET (Recovery Engagement 
and Coordination for Health--Veterans Enhanced Treatment), to identify 
and intervene with Veterans who are at a statistically elevated risk 
for suicide and other adverse outcomes.
     Designated the month of September for Suicide Prevention 
Awareness and led ``Be There'' campaign across Federal, VSO, and 
corporate partners.
     Elevated VA's suicide prevention efforts and redirected 
resources, and personnel to create a new Office for Suicide Prevention 
to reach across entire department and lead a comprehensive strategy on 
suicide prevention
In Progress
     Implement state-of-the-art best practices for risk 
assessment, treatment, crisis management and quality improvement for 
VHA users in all clinics that treat Veterans at elevated risk.
     Continue to deploy comprehensive solutions, including 
targeted screening, risk assessment, predictive analytics, outreach, 
and innovative programming to identify Veterans at elevated risk and 
offer care as appropriate.
     Enhance enterprise-wide awareness and training of all 
staff (clinical and non-clinical) in recognition and intervention for 
Veterans at risk for suicide.
     Ensure ease of Veteran experience and quality of clinical 
care in VCL-Suicide Prevention Coordinator care continuum. Expand 
programming of Suicide Prevention Coordinators (SPCs) based on 
identified areas of need.
     Execute a public-private partnership program to increase 
coordination of available suicide prevention resources for Veterans not 
enrolled in VA.
     Expand existing outreach campaigns to target highest-risk 
Veterans and increase overall reach.
     Create new and update existing IT infrastructure to 
provide rapid access to data that inform suicide prevention effort
     Develop data-sharing strategies specific to Veteran 
suicides to engage our Federal, non-profit, and corporate partners to 
work together on better understanding Veteran suicide

    Question 37.  Veteran homelessness decreased by 47 percent between 
2010 and 2016, largely due to funding from Congress and the hard work 
of local communities, yet on any given night, nearly 40,000 veterans 
remain homeless. Ensuring veterans have permanent housing is incredibly 
important.
    Response. While there has been tremendous progress in ending 
Veteran homelessness and the efforts of VA and its partners are 
producing successful outcomes for many Veterans, there is still work to 
be done to ensure that no Veteran is without a place to call home. We 
know that ending Veteran homelessness is not a single event in time; 
rather, it is a deliberate effort made to achieve the goal, and 
continued follow-up efforts to make sure that progress toward achieving 
the goal is maintained. We must continue our commitment to our efforts 
around rapid rehousing and permanent supportive housing for Veterans 
who fall into homelessness so that their homelessness is rare, brief, 
and nonrecurring. The ultimate goal is to make sure that every Veteran 
has permanent, sustainable housing with access to high-quality health 
care and other supportive services and that Veteran homelessness in the 
future is prevented whenever possible.
    While several states and nearly 40 communities have met the Federal 
benchmarks and criteria for ending veteran homelessness, I have heard 
from communities that have reached the goal earlier that maintaining a 
system that can rapidly house newly homeless veterans takes nearly the 
same level of effort and resources as housing unsheltered veterans to 
meet the goals. Even as the number of unsheltered veterans decreases, 
will you commit to evaluating resource needs based on existing 
populations and projections as you consider budget proposals for these 
programs?
    a. If confirmed, will you commit to ensuring that this work remains 
a priority at VA?
    Response. I am committed to ending Veteran homelessness and if 
confirmed it will remain a priority at the VA.

    Question 38.  According to the VA's National Center on Homelessness 
Among Veterans, the fastest growing subpopulations of homeless veterans 
are female veterans and those who have deployed to Afghanistan and Iraq 
under OEF/OIF/OND in the last decade and a half. What will you do to 
ensure that VA homelessness programs address the needs of these 
specific groups?
    Response. Last year, the National Center on Homelessness Among 
Veterans conducted a study to look at population projections of 
Veterans likely to either be a risk of or actually become homeless and 
access VA care over the next 10 years. Women Veterans and Veterans who 
had served in the OEF/OIF era were identified as two subpopulations 
projected to grow in number while those older than age 55 were 
projected to decline. It should be noted that even with this growth, 
the majority of homeless Veterans is still projected to be 
predominantly single and male (85-90% in 2025). The National Center has 
commissioned two subsequent studies to map both current need profiles 
of homeless women Veterans served within VA and outcomes associated 
with different program utilization patterns. We expect to have results 
from these studies within the next six months which will be essential 
to accurately mapping where we need to strategically direct resources 
to address this projected demand. At this time, we do feel that current 
VHA program capacity, particularly in the Supportive Services for 
Veterans and Families (SSVF) and HUD-VASH programs which provide the 
bulk of services for women Veterans who are homeless or at-risk for 
homelessness, is sufficient to support these projections for at least 
the near term.

    Question 39.  Over the last 15 years, Congress has worked to 
improve health care, benefits, and care coordination for our most 
seriously wounded, ill and injured servicemembers, veterans, and their 
caregivers/family members to ensure a seamless transition between the 
DOD and VA systems and to provide continuity in care and services. How 
do you plan to strengthen collaboration and cooperation between these 
two agencies and improve upon the existing health and benefit systems?
    Response.
     VA, in partnership with DOD, has taken significant steps 
to address the transition of seriously wounded, ill and injured 
Servicemembers and Veterans. We will continue to build on this work by:

         - Leveraging the VA/DOD Interagency Care Coordination 
        Committee (IC3), a subcommittee under the VA/DOD Joint 
        Executive Committee, was formed to improve care coordination 
        and reduce transition gaps.
         - Enhancing care coordination through the Lead Coordinator 
        role who serves as the primary point of contact for 
        Servicemembers and Veterans and their caregivers during 
        recovery and transition between DOD and VA;
         - Community of Practice--connecting the DOD and VA clinical 
        and non-clinical case managers of recovering Servicemembers and 
        Veterans enabling collaboration and best practices to be 
        shared;
         - Implementing Interagency Comprehensive Care Plans--serves as 
        a single, interoperable, individualized plan that assists 
        managing the patient's goals thus reducing the need to retell 
        their story as they transition and relocate. We will work to 
        establish an IT solution for the Interagency Comprehensive 
        Plan.
         - Enhancing health information exchange:

     A Veteran's complete health history is critical to 
providing seamless, high-quality integrated care and benefits.
     Today, more than 220,000 VA health care and benefits 
professionals have access to Joint Legacy Viewer, which VA and DOD 
clinicians can use to access the health records of Veterans and Active 
Duty and Reserve Servicemembers
     We are currently deploying EHMP (Electronic Health 
Management Platform) which will integrate health data from VA, DOD, and 
community care partners into a customizable interface that provides a 
holistic view of each Veteran's health records.
         - Disability claim filing pathways: (not sure this is the 
        right place, but including here just in case)
     VA and DOD are dedicated to improving the processes for 
individuals in the IDES and Separating Servicemember (SSM) disability 
claim filing pathways.
     The Service Treatment Record (STR) is the common data 
information source critical to support both claimant groups.
     Efforts are actively underway to ensure the STR can be 
electronically transferred from the DOD to VA systems, relieving the 
need for the Servicemember to hand-carry their records to VBA for claim 
support.
     VA and DOD have re-engineered the Separating Servicemember 
claims workflow and it will be piloted by DOD and VA facilities in the 
National Capital area starting in March 2017.

    Question 40.  Accurate forecasting of usage of veterans benefits is 
essential in planning for resources to administer those benefits. If 
confirmed, what would you do to ensure that VA provides accurate and 
timely forecasts of the need for additional staffing resources so that 
Congress is able to appropriate resources in a timely manner?
    Response. A workforce analysis is the foundation of any good 
workforce plan as it directly aligns the organization's needs with 
outcomes. VBA's workforce analysis is an ongoing effort, and as new 
data becomes available (such as the Veterans Benefits Management System 
(VBMS) transactional-level data and National Work Queue (NWQ) post-
implementation data), it is incorporated in VBA's Resource Allocation 
Model (RAM) which is a systematic approach to distributing field 
resources each fiscal year.
    The RAM utilizes a weighted model to assign compensation and 
pension Full Time Equivalent (FTE) resources based on regional office 
(RO) workload, including rating inventory; and rating, non-rating, and 
appeal receipts. The RAM incorporates several variables to accurately 
align with VBA's transformation to a paperless, electronic environment, 
where receipts can be assigned and managed at the national level. These 
variables include station efficiency (claims completed per FTE), 
quality, and RO capacity.
    VBA leaders use the model as a guide, making adjustments for 
special circumstances or missions performed by individual ROs. Special 
missions include:

     the Appeals Management Office (AMO),
     Benefits Delivery at Discharge (BDD) sites,
     Integrated Disability Evaluation System (IDES) processing 
sites,
     Quick Start processing locations,
     National Call Centers (NCCs),
     foreign claims processing locations,
     radiation processing locations,
     Camp Lejeune Contaminated Water (CLCW) processing 
locations, and
     Pension Management Centers (PMCs).
    With the exploration and analysis of future workload management 
functionality, VBA will work closely with DOD to collaborate on 
drawdown estimates and aggregate demographics of forces so VA has an 
early picture of the Veteran population profile. Data will be assessed 
at a more granular level to understand employee production and 
prioritize the integration of additional enhancements in the NWQ. VBA 
submits its annual Staffing Levels report to Congress in late March, 
detailing the staffing levels at each RO.

    Question 41.  The current appeals process for veterans benefits is 
broken. More than 450,000 appeals are pending. The current appeals 
process is complex, inefficient, and confusing. Most importantly, it no 
longer serves veterans and their families. In 2016, VA worked with 
eleven VSO and non-VSO stakeholders to create a framework to reform the 
appeals process. Do you support reforming the current appeals process? 
If confirmed, will you prioritize reforming the current appeals 
process? Do you support the 2016 framework as described above?
    Response. I fully support reforming the current appeals process. 
Comprehensive reform is necessary to replace the current lengthy, 
complex, confusing VA appeals process with a new appeals framework that 
makes sense for Veterans, their advocates, VA, and stakeholders. This 
reform is crucial to enable VA to provide the best service to Veterans 
and, if confirmed, I will prioritize reforming the current appeals 
process.
    I support the framework developed collaboratively by VA and a wide 
spectrum of stakeholder groups in 2016. I believe that the engagement 
of the organizations that participated in development of the new 
framework ultimately led to a stronger proposal, as we were able to 
incorporate their feedback and experience having helped Veterans 
through the complex appeals process.
    The current VA appeals process takes too long. Appeals have no 
defined endpoint or timeframe and require continuous evidence gathering 
and re-adjudication. On average Veterans are waiting 3 years for a 
resolution on their appeal. For cases that reach the Board of Veteran's 
Appeals (Board), Veterans are waiting on average 6 years and thousands 
of Veterans are waiting much longer. The current appeals process is 
also too complex. Veterans do not understand the process, it contains 
too many steps and it is very challenging to explain to Veterans. 
Additionally, accountability does not rest with one appellate body; 
rather, jurisdiction over appeals is split between the Veterans 
Benefits Administration (VBA) and the Board.
    The new framework, which I fully support, steps away from an 
appeals process that tries to do many unrelated things inside a single 
process and replaces it with differentiated lanes, which give Veterans 
clear options after receiving an initial decision on a claim. For a 
claim decision originating in VBA, for example, one lane would be for 
review of the same evidence by a higher-level claims adjudicator in 
VBA; one lane would be for submitting new and relevant evidence with a 
supplemental claim to VBA; and one lane would be the appeals lane for 
seeking review by a Veterans Law Judge at the Board. In this last lane, 
intermediate and duplicative steps currently required by statute to 
receive Board review, such as the Statement of the Case and the 
Substantive Appeal, would be eliminated. Furthermore, hearing and non-
hearing options at the Board would be handled on separate dockets so 
these distinctly different types of work can be better managed. As a 
result of this new design, the agency of original jurisdiction (AOJ), 
such as VBA, would be the claims adjudication agency within VA, and the 
Board would be the appeals agency.
    This new design would contain a mechanism to correct any duty to 
assist errors by the AOJ. If the higher-level claims adjudicator or 
Board discovers an error in the duty to assist that occurred before the 
AOJ decision being reviewed, the claim would be returned to the AOJ for 
correction unless the claim could be granted in full. However, the 
Secretary's duty to assist would not apply to the lane in which a 
Veteran requests higher-level review by the AOJ or review on appeal to 
the Board. The duty to assist would, however, continue to apply 
whenever the Veteran initiated a new claim or supplemental claim.
    This disentanglement of process would be enabled by one crucial 
innovation. In order to make sure that no lane becomes a trap for any 
Veteran who misunderstands the process or experiences changed 
circumstances, a Veteran who is not fully satisfied with the result of 
any lane would have 1 year to seek further review while preserving an 
effective date for benefits based upon the original filing date of the 
claim. For example, a Veteran could go straight from an initial AOJ 
decision on a claim to an appeal to the Board. If the Board decision 
was not favorable, but it helped the Veteran understand what evidence 
was needed to support the claim, then the Veteran would have 1 year to 
submit new and relevant evidence to the AOJ in a supplemental claim 
without fearing an effective-date penalty for choosing to go to the 
Board first.
    To fully enable this process and provide the appeals experience 
that Veterans deserve, VBA, which receives the vast majority of 
appeals, would modify its claims decisions notices to ensure they are 
clearer and more detailed. This information would allow Veterans and 
their representatives to make informed choices about whether to file a 
supplemental claim with the AOJ, seek a higher-level review of the 
initial decision within the AOJ, or appeal to the Board.
    The new framework would not only improve the experience of Veterans 
and deliver more timely results, but it would also improve quality. By 
having a higher-level review lane within the VBA claims process and a 
non-hearing option lane at the Board, both reviewing only the record 
considered by the initial claims adjudicator, the output of those 
reviews would provide a feedback mechanism for targeted training and 
improved quality in VBA.
    The legislation should be enacted now. It has wide stakeholder 
support and the longer we wait to enact the Appeals Reform legislation 
more and more appeals will enter the current, broken system. The status 
quo is not acceptable for our Nation's Veterans and taxpayers. The new 
framework will provide much needed comprehensive reform to modernize 
the VA appeals process and provide Veterans a decision on their appeal 
that is timely, transparent, and fair.

    Question 42.  There was a recent Congressional Budget Office report 
released that suggested that significant savings could be realized in 
VA compensation expenditures by streamlining who is considered service-
connected. Of particular note, the report suggests that a number of 
presumptive conditions, such as Multiple Sclerosis, should not in fact 
be presumptively considered for service-connection. Do you support the 
recommendations offered by CBO targeting service-connected disabled 
veterans compensation?
    Response. This recommendation would alter the fundamental 
principles of the VA disability compensation program, specifically the 
definition of ``line of duty'' as it relates to determing service-
connection for diseases or injuries related to military service. While 
this principle has been debated and studied over the years, VA still 
believes and Congress has historically maintained support for the 
current definition of line of duty. That is, servicemembers who 
contract any injury or illness while on duty or on authorized leave, 
that is not the result of willful misconduct or drug and alcohol abuse, 
are entitled to service-connection for such conditions. The basic 
premise is that Servicemembers are on duty 24 hours a day, seven days a 
week and such individuals are subject to the Uniform Code of Military 
Justice at all times and in all places, including while on leave. VA 
believes that the government should continue to support those who have 
made enormous sacrifices and answered the call to defend their country 
by maintaining the current definition of line of duty.
    Additionally, VA does not support eliminating the presumption of 
service-connection for certain conditions such as Multiple Sclerosis. 
The establishment of presumptive disabilities is based on extensive 
medical evidence and sound scientific research which identifies certain 
medical conditions that manifest years after the Veteran's exposure. VA 
believes these individuals are justly considered for service-connected 
benefits as it relates to these conditions.

    Question 43.  VA's FY 2017 budget request for major and minor 
construction of $1.025 billion is a significant decrease from FY 2016 
request of $1.675 billion. The Department testified that it was taking 
a ``strategic pause'' regarding construction awaiting the report by the 
Commission on Care. Now that the report has been published, what do you 
think the Department should do to modernize and replace its aging and 
substandard facilities?
    Response. In FY 2017 the Department did not request funding for any 
new construction projects. Instead, VA's FY 2017 budget request focused 
on fixing what we have by directing resources to fund the continuation 
or completion of minor construction and non-recurring maintenance (NRM) 
projects initiated in prior fiscal years.
    The reason for not funding any new projects was because VA was 
waiting to receive the recommendations from the Commission on Care 
(which we received in July to determine if resources would need to be 
reallocated or requested to implement infrastructure strategies 
accordingly. In addition, VA wanted to ensure maximum future 
flexibility by not committing to a long term solution prior to the 
release of the report.
    In August 2016, the President and VA responded to the Commission's 
report. The Department agreed that the Commission's facilities 
recommendations were critical to enable a successful transformation of 
VA's healthcare system to an integrated network to serve Veterans. VA 
stated that a strong suite of capital planning programs, tools, and 
resources would be needed to be able to fully realize the benefits and 
Veteran outcomes expected from implementing an integrated healthcare 
network.
    Currently, VA is working toward the goal of high performing 
networks that take into account current and expected future services by 
developing a structure to integrate community care and VA-provided 
healthcare on a market by market basis. The Department kicked-off an 
effort with private sector healthcare experts to design an approach for 
integrated healthcare delivery decisions based on Veteran population, 
demand, internal capacity, and external public and private sector 
health care resources and capacity. Once the approach is validated, 
tested, piloted, and deployed nationwide, a national infrastructure 
realignment strategy will be developed accordingly to establish an 
objective process to appropriately realign VA's capital infrastructure. 
Through this process, VA will also identify the resources, tools, and 
authorities that are needed to enable the divestiture of assets and to 
streamline capital project execution. VA is committed to pursuing the 
appropriate capital resources to serve Veterans and ensure that a 
successful realignment strategy is implemented.

    Question 44.  VA's vocational rehabilitation and employment program 
is one of the smallest, yet most important, programs within the 
Department. It is the linchpin for helping veterans who incur service-
connected disabilities achieve a fulfilling and gainful future. I am 
deeply committed to making sure that this program lives up to its full 
potential, especially when individuals who have sustained serious 
injuries in combat are concerned.
    What are your thoughts on the role that vocational rehabilitation 
plays in terms of the total rehabilitation of an individual recovering 
from severe combat-related injuries and on how VA's current efforts 
might be improved?
    Response. ``What are your thoughts on the role that vocational 
rehabilitation plays in terms of the total rehabilitation of an 
individual recovering from severe combat-related injuries'':

     - The Vocational Rehabilitation and Employment (VR&E) program 
provides comprehensive services and assistance to enable Veterans and 
Servicemembers with service-connected disabilities to include physical, 
cognitive, mental, and emotional disabilities as well as an employment 
handicap to prepare for, find, and maintain suitable employment. For 
Veterans with service-connected disabilities so severe that they cannot 
immediately consider work, the VR&E program offers services to improve 
their ability to live as independently as possible in their homes and 
communities Nearly one quarter or more of VR&E participants recently 
studied, by cohort, have a primary rating for Post-Traumatic Stress 
Disorder (PTSD). (VR&E Longitudinal Study Annual Report 2016, 2015). 
VR&E participants in the longitudinal study also reflect an average 
disability rating of 60%; participants have a range of physical and 
emotional barriers and disabilities.
     - VR&E's service delivery model works to best support Veterans 
where Veterans are located. VR&E employs over 1,000 professional 
Vocational Rehabilitation Counselors (VRCs) and Employment Coordinators 
(EC). These personnel provide services to Veterans and transitioning 
Servicemembers through a network of over 350 locations. VR&E's service 
delivery model include operations at 56 regional offices (ROs); the 
National Capital Region Benefits Office; approximately 142 out-based 
offices; 71 Integrated Disability Evaluation System (IDES) 
installations and 94 VetSuccess on Campus (VSOC) schools/sites. VR&E is 
also able to provide individualized services based on the Veteran or 
Servicemember's unique individualized needs.
     - VR&E has two special missions focused on reaching critical 
populations via targeted outreach and support--IDES and VSOC. VR&E 
actively collaborates with the Department of Defense to provide VR&E 
services to Servicemembers through the IDES program. Vocational 
Rehabilitation Counselors are located on 71 military installations and 
work directly with transitioning Servicemembers to provide VR&E 
services. VR&E is committed to ensuring that the needs of seriously 
injured Veterans and Servicemembers are met in a timely manner by 
providing priority processing of applications for these populations. 
Automatic entitlement to VR&E services for wounded, ill and injured 
Servicemembers, a provision of Public Law 110-181(NDAA; Congress has 
renewed annually), allows for streamlined support and assistance for 
this critical population. Veteran Success on Campus (VSOC) Counselors 
provide on-campus access to VA benefits and services/support for 78,000 
Veteran students on 94 campuses across the country.
    Response. ``How could VA's current efforts be improved''
     - As part of ongoing VR&E Transformation, VR&E has several 
initiatives currently in development to improve service delivery to 
Veteran clients. VR&E Service is currently developing a new case 
management system and process that will be fully electronic and 
paperless, with planned pilot/deployment in FY 2017. VR&E also deployed 
tele-counseling Nation-wide in 2015, and continues to work to increase 
the use of this enabling technology to better serve both Veterans and 
their counselors. VR&E is also working on initiatives to streamline 
administrative processing and support for VR&E in the VR&E program.
     - To continue to better understand the VR&E population, VR&E 
continues to execute the congressionally mandated 20-year VR&E 
Longitudinal Study of Veterans who began their VR&E programs in 2010, 
2012, and 2014. Reports are submitted to Congress annually on the long-
term benefits of participating in the VR&E program. The study allows 
VR&E to continuously analyze trends among participants receiving 
services, and respond with initiatives that improve and adapt services 
to their changing needs.

    Question 45.  VA granted the presumption of service-connection for 
conditions associated with exposure to Agent Orange to recipients of 
the Vietnam Service Medal until 2002 when criteria was restricted to 
those who had ``boots on the ground.'' What are your views on granting 
the presumption of service-connection to veterans who served in the 
bays, harbors, and territorial seas?
    Response. VA honors the service and dedication of U.S. Navy and 
Coast Guard Veterans who served aboard ships on the offshore waters of 
Vietnam. However, current laws are intended to compensate Veterans for 
Agent Orange exposure related diseases when there was an actual 
potential for such exposure. That potential existed for Veterans who 
served within the land boundaries of Vietnam, including its inland 
waterways, where Agent Orange use occurred.
    The United States Court of Appeals for the Federal Circuit upheld 
this definition in Haas v. Peake (2008). Available evidence does not 
support such potential exposure existed for service aboard ships 
operating on Vietnam's open water bays, harbors, and territorial seas. 
The distinction is based on the fact that aerial spraying of Agent 
Orange and other tactical herbicides over Vietnam was used to destroy 
enemy food crops, reveal enemy positions by defoliating jungle and 
riverbank cover, and create vegetation-free security zones around 
military bases. No such use of Agent Orange occurred over the offshore 
waters of Vietnam.
    To better understand possible Agent Orange exposure among Navy 
Vietnam Veterans, VA tasked the National Academies of Science (NAS) 
with investigating and determining whether there were any potential 
routes of exposure, such as through aerial spray drift or sea water 
contamination from river water runoff. The NAS report, Blue Water Navy 
Vietnam Veterans and Agent Orange Exposure (2011), determined that 
there was insufficient evidence to confirm that these potential routes 
resulted in any significant exposure. U.S. Navy and Coast Guard 
activity during the Vietnam War involved large open water ships 
conducting operations off the coast of Vietnam [often referred to as 
the ``Blue Water Navy''] and smaller vessels conducting operations on 
the inland bays and river system of Vietnam [often referred to as the 
``Brown Water Navy'']. Some Blue Water ships temporarily entered 
Vietnam's inland waterways to conduct naval gunfire support of ground 
operations or to deliver supplies.
    Although there is insufficient scientific evidence to grant a 
blanket presumption of Agent Orange exposure for all U.S. Navy Vietnam 
Veterans, VA has a liberal policy of presuming exposure for all 
Veterans who served aboard Brown Water vessels operating on Vietnam's 
inland waterways and for those Veterans serving aboard Blue Water ships 
that temporarily entered the inland waterways. Additionally, if 
evidence shows that a Blue Water ship off the Vietnam coast sent crew 
members ashore for duty or visitation, any Veteran on the ship at that 
time will receive the presumption of exposure if they state that they 
personally went ashore. The Veterans Benefits Administration (VBA) 
maintains a list of ships that entered Vietnam's inland waterways or 
otherwise sent crew members ashore for duty or visitation. This list is 
based on evidence found in ship histories or deck logs, which are 
received from the Department of Defense's Army and Joint Services 
Records Research Center (JSRRC) or other credible sources. The list is 
available online and can be quickly updated by VBA's Compensation 
Service to reflect the most up-to-date research.

    Question 46.  VA currently uses the criteria of 170,000 un-served 
veterans within a 75-mile radius for purposes of establishing new 
national cemeteries. In the past, the Senate has supported this 
standard and has authorized new cemeteries based upon VA's 
recommendations. Do you believe this should continue to be the standard 
practice? In the absence of a VA recommendation, do you believe 
Congress should legislate the location of new national cemeteries?
    Do you believe this should continue to be the standard practice?
    Response. VA changed the criteria used to establish new national 
cemeteries in FY 2011. The current standard, which was approved by 
Congress, reduced the Veteran population threshold required to build a 
new national cemetery from 170,000 to 80,000 within a 75-mile radius. 
As a result of this change, VA will construct 5 new national cemeteries 
designed to serve over 550,000 Veterans.
    In addition, VA established burial access policies in 2011 and 2013 
that will allow for construction of five Columbarium-only national 
cemeteries in certain urban locations where time and distance barriers 
make it difficult for Veterans to use the existing national cemeteries. 
VA will also establish a national cemetery presence in eight rural 
areas where the Veteran population is less than 25,000 within a 75-mile 
service area. The proposal targets those states in which: 1) there is 
no open national cemetery within the state; and 2) areas within the 
state are not currently served by a state Veterans cemetery or a 
national cemetery in another state.
    In the absence of a VA recommendation, do you believe Congress 
should legislate the location of new national cemeteries?
    Response. VA opposes any legislative action that would direct the 
location of a national cemetery. The placement of national cemeteries 
is based on objective criteria that address the maximum number of 
unserved Veterans in a given area. This approach has been very 
successful. To date, 91.7% of the total Veteran population--
approximately 20 million Veterans--has convenient access to a burial 
option. When all planned national and state Veteran cemeteries 
currently in queue are opened, 95% of the Veteran population will be 
served.

    Question 47.  What is the future of VHA's electronic health record?
    Response. The future of VHA's electronic health record (EHR) is a 
modern system that improves health outcomes for Veterans on a platform 
that can seamlessly adopt technological advances.
    VA is carefully considering the future of VistA. In the context of 
current budgetary constraints, we are evaluating all options from 
adopting a commercial off the shelf (COTS) EHR to retaining an enhanced 
and standardized VistA. We are actively gathering key information and 
expert feedback, and recruiting a Chief Health Informatics Officer with 
extensive commercial EHR experience to help VHA craft an informed EHR 
strategy within the first 100 days of the new Administration. The goal 
is to make a decision that will best serve Veteran's needs.
    OI&T has been working in partnership with VHA to develop the 
foundation for a modern health platform--the Digital Health Platform 
(DHP). This new initiative successfully completed a proof-of-concept. 
Over time, this approach will address the interoperability and 
integration challenges for Veterans by integrating information gathered 
from mobile applications, devices, wearable technology, along with data 
from Veterans' VA, military and commercial electronic health records in 
real-time.
    We are not waiting for a decision to enhance the care Veterans are 
receiving today. Interoperability between VA and DOD is better today 
than at any point in the history of the Departments with the deployment 
of the Joint Legacy Viewer (JLV). JLV is not a vision for the future or 
a plan on paper. JLV is available to all clinicians in every VA 
facility in the country. It is a web based user interface that provides 
the clinician an intuitive interface to display DOD and VA healthcare 
data on a single screen. Providers from a variety of specialties have 
provided positive feedback and user stories are proving that we are 
successfully sharing information seamlessly between the departments. We 
have also invested in a longer term interoperability solution known as 
the Enterprise Health Management Platform (eHMP).
    eHMP builds on the interoperability success of JLV, and is a modern 
web based user-interface that will improve access to health information 
by integrating health data from VA, DOD, and community care partners 
into a customizable interface that provides a holistic view of each 
Veteran's health records. A version of eHMP has been installed at 130 
sites.
                                 ______
                                 
 Additional Prehearing Questions Submitted by Hon. Jon Tester to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs
    Question 48.  In response to question 11, you note that you are 
still studying the various proposals and options that have been laid 
out by the President. At this point, how would you recommend fleshing 
out his plan?
    Response. If confirmed as Secretary, I would immediately engage 
with the Administration to discuss ways to implement the President's 
plan. It is my understanding that the transition team has formulated 
some approaches already, but these have not yet been shared with me, as 
I have not yet been confirmed. If confirmed, I would then engage with 
both the Senate and House as well as others such as Veteran Service 
Organizations to gain their perspectives and suggestions for improving 
healthcare to veterans. I have gone on record about my belief that we 
must develop an integrated system of care, utilizing what is best about 
VA and best from the private sector. My commitment in this process is 
to be open to new ideas and approaches as long as they improve access 
and quality of care for veterans. I would ensure that any solutions 
that I would recommend for consideration would be consistent with my 
values to support policy that is in the best interest of our veterans 
and advances our system toward higher levels of performance.

    Question 49.  In response to question 12, you note that VA will 
expect the same level of partnership and engagement with the VSOs and 
MSOs to continue the progress/momentum that VA has gained with the MyVA 
Transformation. Can you please provide specific examples of the 
partnership and engagement you anticipate having with the VSOs and 
MSOs? For example, will you continue to have monthly meetings with the 
groups outlined in your response?
    Response. I am committed to full transparency, cooperation and 
coordination with our MSO/VSO partners to maximize input from the 
widest range of appropriate stakeholders and to facilitate an open 
exchange of opinion from diverse groups to improve our programs to 
assist Veterans. During my tenure as USH, I engaged and solicited input 
and feedback from MSOs/VSOs on key issues, best practices or 
opportunities to improve policies, programs, service quality and meet 
Veteran needs.
    We host monthly VSO breakfast meetings with our senior leadership 
team, have participation and representation of VSOs on our workgroups 
and planning teams within our VA Program offices and also meet with 
VSOs on a frequent basis as specific issues or needs arise. In 
addition, I personally traveled to each of their national conventions 
and meetings last year. All of these engagements are necessary and will 
continue as VSOs are an important partner in helping us understand what 
improvements we can make to better deliver care and services to our 
Nation's Veterans.

    Question 50.  With regard to question 20, can you please clarify 
what options you are considering in order to provide veterans with 
greater choice than they have now?
    Response. The Choice program has been essential for VA to have made 
improvements in access to care. However, we have learned that the 
program as it currently exists is too complex and as a result is not 
working well enough for many veterans. We must fix this. Furthermore, 
in designing a healthcare system, it would not be my recommendation to 
use mileage and wait times as the criteria for determining eligibility. 
My goal is to design a system that is both easier to use and supports 
greater choice for our veterans. However, we must do this in a way that 
ensures that veterans are receiving high quality care and that is 
affordable to the taxpayer. If confirmed, I would present several 
specific options on how to achieve these goals by improving upon the 
design of our current Choice system and in recommending alternative 
eligibility criteria to mileage and wait times. I would not want to 
prematurely offer specifics on these proposals at this time as I 
believe they must first be studied and modeled and appropriate input 
from stakeholders must be obtained before these are discussed in a 
public forum.

    Question 51.  With regard to question 25, can you please provide 
what emphasis you would place on meeting the needs, including mental 
health needs, of rural veterans?
    Response. I am committed to meeting the health care needs of all 
Veterans, regardless of where they live. Rural Veterans face unique 
challenges in accessing care and it would be my priority to refine 
telehealth, community care, and home health options as a means of 
providing these Veterans access to health care when and where they need 
it.

    Question 52.  With regard to question 27, can you please reference 
what you have done, during your tenure at VA, to improve the physical 
and mental health care access, quality of care, and address privacy, 
security, as well as the transition for female veterans?
    Response. During my tenure as Undersecretary for Health, VHA 
committed to ensuring all facilities met Privacy Standards--to include 
physical and auditory privacy--and to increasing the accountability of 
facilities to follow these standards. VHA created a policy to ensure 
that personalized health information is protected with the same level 
of privacy and security regardless of gender. We also launched multiple 
campaigns aimed at recognizing the service of women Veterans and will 
be soon launching an even more direct effort to increase civility and 
respect through the ``End Harassment'' campaign.

    Question 53.  In response to question 34, can you please clarify 
your personal belief?
    Response. My read of the statutory language at title 38 U.S.C. 
section 105 leads me to the conclusion that any disability resulting 
from injury incurred in or aggravated by service shall be service-
connected. There is no requirement of causation. This conclusion has 
been reviewed by Federal courts and found to be accurate.
    At times, both the Congress and VA have established presumptions of 
service connection for certain disabilities and diseases that are shown 
by sound scientific and/or medical evidence to have resulted from 
exposure to a contaminant while in service or, in the case of 
amyotrophic lateral sclerosis (ALS), service itself. All such 
disabilities are covered unless it is a result of willful misconduct or 
an abuse of alcohol or drugs. Multiple sclerosis is one example of this 
type of disease.

    Question 54.  In response to question 35, please describe what you 
believe the Department should do to modernize and replace its aging and 
substandard facilities.
    Response. As stated in VA's FY 2017 Budget Request, based on the 
current mission, the Department has an identified need of approximately 
$41 to $50 billion to close critical performance gaps in the areas of 
safety, security, utilization, access, seismic safety, facility 
condition, space, parking, and energy. Once the Department develops and 
implements its integrated healthcare delivery model, a national 
infrastructure realignment strategy will be developed to align VA's 
infrastructure to match the approach to provide care to Veterans. At 
that time, VA will determine what inpatient and outpatient facilities 
are needed, as well as what renovation/construction is needed to 
implement the realignment. Depending on the realignment, a significant 
portion of the $41 to $50 billion infrastructure gap will still need to 
be addressed through renovation or replacement. This effort will 
require a combination of substantial investment in VA-owned and 
operated infrastructure and disposal/reuse of unneeded facilities. This 
effort will require a combination of substantial investment in VA-owned 
and operated infrastructure and disposal/reuse of unneeded facilities 
and continued reliance on care in the community.

    Question 55.  In your response to question 39, you note that VA is 
actively ``gathering key information and expert feedback`` to help VHA 
craft an informed EHR strategy within the first 100 days of the 
Administration. You note that you are recruiting a Chief Health 
Informatics Officer to help in this effort. How will the hiring freeze 
impact the recruitment of the Chief Health Informatics Officer?
    Response. I have had discussions with the White House on the hiring 
freeze, at this time those discussions have centered on ensuring that 
we are able to hire for positions that require direct patient care. If 
confirmed, I will evaluate other positions to see if others would 
require a request an exception to the freeze.

    Question 56.  With regard to question 13, given the level of depth 
provided in other areas of this questionnaire on issues and items not 
currently within your direct purview of Under Secretary of Health, can 
you please review the tracking mechanism of disability claims 
production widely-known as the Monday Morning Workload Report and 
respond to whether under your leadership you would continue to make 
public this report?
    Response. Yes, The Monday Morning Workload Report is a public 
report. It is our transparent communication to share with the public 
how VA is performing in our mission to deliver benefits to our Nation's 
Veterans.
                                 ______
                                 
Response to Prehearing Questions Submitted by Hon. Jerry Moran to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs
    Question 57.  Dr. Shulkin, how would you describe the culture and 
functionality of the highest echelon in the VA Central Office? What 
changes would you make in the VA Central Office? Please be specific and 
candid.
    Response. Over the past 18 months as Under Secretary of Health, I 
have come to understand the issues involving VA management and 
organization of our Central Office. While I have made several important 
organizational changes, I made a deliberate decision not to undergo 
large scale organizational changes, I wanted the organization to focus 
on addressing our wait time issues and other organizational priorities 
that I had established. Organizational change in important, but it can 
also be very distracting, and I wanted the organization to know our top 
priority was to address the clinical needs of our veterans. Also during 
my tenure as Under Secretary, I named 20 new senior leaders to my top 
22 management positions. Each leader has been instructed to assess 
their organization and to present their assessments. We have begun a 
formal organizational review and assessment. If confirmed, I am 
prepared to make the necessary changes at VACO and the field to ensure 
more efficient and effective operations. Specifically I plan to address 
the separation between policy and operations at VACO which has resulted 
in duplicative and sometimes confusing direction to the field.

    Question 58.  Dr. Shulkin, what distinguishes you from the current 
VA leadership team? Do you plan to lead and manage the VA differently 
than the current VA leadership team? What are the differences? Please 
be specific.
    Response. The Secretary of VA is responsible for ensuring that our 
nations veterans receive the highest level of service and care that we 
can provide. The Secretary also serves to ensure that the President and 
Congress' policies and laws are carried out as intended to the best of 
their abilityIf confirmed, as Secretary, I would work tirelessly to see 
that these objectives are fulfilled.
    With a new Administration and Congress, we have the opportunity to 
address systemic issues that have not been fully addressed in the last 
Administration. If confirmed, I would seek to work collaboratively with 
the new Administration, Congress, and Veteran organizations to 
implement systemic changes for VA that would improve service, quality 
and value. Given that there will be new leadership in place at the 
White House, Congress, and VA, this will be different than the last 
Administration. The mandate from the country to do better for our 
veterans is clear and now is the time to take on the tough issues and 
propose bold solutions. I am ready for this opportunity and challenge.

    Question 59.  Dr. Shulkin, once the replacement for a new 
Undersecretary of the Veterans Health Administration (VHA) has been 
identified, what are the top three priorities that individual should 
consider in this position overseeing the VHA? What are the biggest 
challenges facing the VHA?
    Response. As Under Secretary for Health, I established five 
priorities for VHA. I firmly believe that these priorities are critical 
to the continued improvement of VHA. These five priorities were 1) 
Improve Access to Care, 2) Improve employee engagement and filling VA 
management vacancies, 3) Implementing industry best practices, 4) 
Developing a integrated network of care between VA and community care, 
and 5) Enhancing trust among veterans.
    My instructions to a new Under Secretary for Health will be to 
prioritize Quality. Quality involves three important components of 
care: access, clinical outcomes, and service levels. Specifically with 
the focus on quality, we want to accelerate efforts in suicide 
prevention and treatment of behavioral health conditions, and women's 
healthcare.

    Question 60.  How many rural VA facilities have you visited? Please 
identify the locations.
    Response I have visited a number of rural facilities: Dublin, 
Georgia; Augusta Maine; Bangor Maine, Caribou Maine, and Lebanon, 
Pennsylvania. In addition I conducted a number of listening sessions in 
Alaska during my visit there in 2015. I also practice internal 
medicine, via telehealth, in Grants Pass Oregon, which is a rural area 
that has a shortage of primary care physicians.

    Question 61.  How many VA employees are currently on administrative 
leave? Of those currently on administrative leave, how much has the VA 
exhausted on their salaries while they have been on administrative 
leave and unable to fulfill the duties for which they were hired?
    Response. Attached for your review are the personnel actions as of 
12/16/2016.

    [Privileged and Confidential for use by US Government only, which 
cannot be printed in the public record.]

    Question 62.  Dr. Shulkin, in your experience in the VA Central 
Office, are there VA employees you believe are toxic, corrosive or 
indifferent to VA culture reform? If so, would you remove some or none 
of these individuals from the VA? If so, what authorities do you 
possess and would utilize to remove these individuals from the VA? If 
you believe you do not have the authority to remove them, explain why. 
If you believe you need additional authority to remove them, explain in 
detail the authority you believe is required.
    Response. Yes, I believe that there are employees that have 
deviated from the values that are essential for us to serve veterans. 
As Secretary, I would work to remove these employees from our 
workforce. The process to remove employees is currently too long and 
too cumbersome. While it is essential that there is due process, I 
would seek the authority to remove these individuals in a more 
expedited manner.

    Question 63.  Please provide information regarding the Office of 
General Counsel, to include: FY09-FY 2017 funding levels, full-time 
personnel and their duty station, and job descriptions for the 
positions within the Office of General Counsel. Please also describe 
and explain the breadth of the Office of General Counsel's work and 
advisement. If the Office of General Counsel advises you take a 
position or make a decision that is counter to President-elect Trump's 
positions and commitments to reform the VA, will you follow the 
advisement of the Office of General Counsel? Is the Secretary of the VA 
required by law to execute the position or decision advised by the 
Office of General Counsel? Explain options available to the Secretary 
of the VA to take a position or make a decision counter to the 
advisement of the Office of General Counsel.
    Response. OGC's annual budget of approximately $114M ($94M BA, $20M 
RA) supports +/- 700 FTE. Roughly 400 of OGC's personnel work in the 
District Chief Counsel Offices that provide legal support to VA's 
Medical Centers, Regional Offices, National Cemeteries, and other field 
operations; approximately 85 represent the Department in litigation 
before the US Court of Appeals for Veterans Claims; and the balance are 
assigned to VA Central Office and provide subject-matter-specific legal 
support to VA leadership on all issues arising from VA policies and 
programs, including information law, personnel law, procurement law, 
real estate law, Veterans' benefits law, torts and administrative law. 
The OGC workforce includes approximately 480 attorneys and 220 non-
attorneys, including paralegals, legal assistants, and other 
administrative staff.
    OGC's authorizing statute, 38 U.S.C. Sec. 311, provides for the 
appointment of a General Counsel by the President, with the advice and 
consent of the Senate, to serve as the chief legal officer of the 
Department and to provide legal assistance to the Secretary concerning 
the programs and policies of the Department. OGC's authorizing 
regulations, provided in 38 CFR Part 14, provide that the General 
Counsel is responsible to the Secretary for the following:

    (a) All litigation arising in, or out of, the activities of the 
Department of Veterans Affairs or involving any employee thereof in his 
or her official capacity.
    (b) All interpretative legal advice involving construction or 
application of laws, including statutes, regulations, and decisional as 
well as common law.
    (c) All legal services, advice and assistance required to implement 
any law administered by the Department of Veterans Affairs.
    (d) All delegations of authority and professional guidance required 
to meet these responsibilities.
    (e) Maintenance of a system of field offices capable of providing 
legal advice and assistance to all Department of Veterans Affairs field 
installations and acting for the General Counsel as provided by 
Department of Veterans Affairs Regulations and instructions, or as 
directed by the General Counsel in special cases. This includes 
cooperation with U.S. Attorneys in all civil and criminal cases 
pertaining to the Department of Veterans Affairs and reporting to the 
U.S. Attorneys, as authorized, or to the General Counsel, or both, 
criminal matters coming to the attention of the Regional Counsel.
    (f) Other matters assigned.

    OGC provides advice and counsel to the Secretary and other VA 
officials regarding the legal framework within which those officials 
may act. Because actions taken in contravention of applicable laws may 
put the Department at unnecessary risk of litigation or other adverse 
outcomes, OGC endeavors to provide an analysis of available options 
rather than to simply advise for or against a single course of action. 
OGC strives to give useful, practical advice, couched in terms of 
``yes, if . . .'' rather than ``no, because.'' This approach generally 
avoids putting the Secretary in the position of having to choose 
between carrying out the President's agenda and complying with the law. 
As Secretary, I intend to work with my General Counsel to identify 
legally defensible means of accomplishing the reforms to which the 
President-elect has committed for the benefit of Veterans and 
taxpayers.

    Question 64.  If the VA Inspector General (IG) provides a report 
with findings of wrongdoing and criminal action, do you intend to 
notify Congress prior to or in tandem with the disclosure of the IG's 
report? In detail, please explain the authorities and actions you will 
execute to hold accountable the employees identified in the IG's 
report. Regarding similar instances under the leadership of Secretary 
McDonald, he refused to execute and utilize authorities provided to 
him. Do you intend to break with this precedent and use the authorities 
granted to the Secretary of Veterans Affairs?
    Response. With respect to utilizing the statutory authorities for 
employee accountability that are at my disposal, I am aware that the 
expedited Senior Executive removal authority contained within the 
Veterans' Access, Choice, and Accountability Act of 2014 has come under 
question in the courts and may be found to be unconstitutional. Because 
the Choice Act authority supplemented rather than replaced other, more 
defensible authorities for holding employees accountable, Secretary 
McDonald chose to use the other authorities rather than the Choice Act 
once the constitutional issue became clear. We do still have a number 
of options for holding employees accountable, including traditional 
processes under Title 5 and Title 38 and the expedited process that 
came with the Choice Act. As frustrating as it is for me as a leader 
and for Congress as an authorizing body to see that authority 
challenged, it really doesn't serve Veterans or taxpayers well if we 
take an action that we know we'll have trouble defending in court. So 
while I will consider all of the authorities at my disposal to hold 
misbehaving and under-performing employees accountable, I will approach 
each case with an eye toward ensuring that the action taken will 
withstand appeal.

    Question 65.  In July 2015, the VA requested authorities from 
Congress to transfer $3.5 billion from the Choice Program to fund a 
shortfall in non-VA health care. Despite knowledge of such a debt as 
early as February 2015, VA officials waited until July to disclose the 
situation, providing a one-month notice of the potential lapse in 
health care for veterans due to insufficient funds. Do you agree with 
the VA's strategy to leave Congress little time to assess and address 
the $3.5 billion shortfall? If not, please explain how this situation 
should have been handled? If a shortfall scenario were to occur again 
as some have insinuated, what can we expect you to do differently from 
previous VA leadership?
    Response.

     VA's budget plan early in FY 2015 was based on the Choice 
Program being operational more quickly than what was ultimately 
possible and a higher anticipated use by Veterans of Choice Program 
funds. VA pushed forward with plans for providing Care in the Community 
as part of the effort to improve Veterans access to care. The planned 
increase in workload was not able to be supported within the Choice 
Program operations established at that time. As a result, VA's non-
Choice Care in the Community program's increased execution was at a 
rate that exceeded the 2015 plan. Program execution visibility was 
hampered by limitations of the financial management systems as well as 
the uncertainty of the program's cost in 2015 from both unreported 
obligations and over-obligations associated with medical 
authorizations.
     Regrettably, the process to clearly define the specific 
shortfall required more time than would have been preferred and 
significantly shortened the response time made available to the 
Congress. Secretary McDonald was made aware of the shortfall in 
May 2015 when VA staff confirmed there would be funding shortfalls in 
Care in the Community. Congress was informed in briefings in June and 
July that the non-Choice Care in the Community account was executing at 
a rate well beyond the 2015 funded plan.
     In June 23, 2015 letters to the Committees on Veterans 
Affairs and the Appropriations Committees and subcommittees, VA 
requested authority to use available Choice Act funding and to transfer 
existing funds from other medical programs to address the shortfall in 
non-Choice Community Care requirements.
     VA requested Congressional flexibility to use section 802 
funds on a limited authority basis in the amount of $2.5 billion as the 
estimated cost exceeding the Care in the Community 2015 budget and use 
$500 million for Hepatitis C treatments. VA could also make a $348.5 
million transfer from Medical Facilities to the Medical Services 
account for Community Care, all totaling $3.48 billion.
     Congressional action provided VA the authority to use up 
to $3.3485 billion of Choice Act funds to meet the shortfall in the 
non-Choice Care in the Community FY 2015 budget.
    What is different now?
     Significant advancements have been made in refining 
processes for the utilization of Choice Program funds.
     VHA is completing monthly Financial Management System--Fee 
Basis Claims System (FMS-FBCS) reconciliations that are certified by 
VISN directors and Chief Financial Officers.
     For FY 2017, VA requested and received a separate 
appropriation for Community Care which will improve transparency and 
Congressional oversight.
     The FY 2017 appropriation provided VA with new authority 
to transfer funds to the Medical Community Care account from other VA 
discretionary accounts.
     VA is in the process of modernizing the Financial 
Management System, which along with improvements in methods and 
processes in the various automation systems that feed into the 
financial management system, will give VA senior management the ability 
to more easily identify this type of problem in the future.
     A congressional action that would assist VA is legislative 
language allowing VA to record the costs of Care in the Community at 
the time of payment, like some other Federal agencies, as opposed to 
the current practice requiring funds to be obligated at the time of 
authorization for care.
    The planning and budget execution review processes that are now in 
place, will provide the necessary early warning of any similar funding 
issues and will allow for possible internal corrections. Additionally, 
I will be provided with the necessary information regarding the 
development of such an issue and will inform the Congress of it in a 
much more responsive manner.

    Question 66.  If the Senate Veterans' Affairs Committee requests 
the presence of VA employees to testify regarding a matter that was 
investigated by the Inspector General, will you make those personnel 
available to testify? Would you refuse to make VA employees available 
and advise they invoke their Fifth Amendment right against self-
incrimination as Deputy Secretary Sloan Gibson did with several VA 
employees that the IG found were manipulating the VA system regarding 
relocation and financially benefited. Would you have made these 
employees available to testify before the House Veterans' Affairs 
Committee? What would you have done in this specific situation?
    Response. I am committed to sharing information about VA policies, 
programs and activities with the oversight committees. The issue 
sometimes is one of timing: would testimony before the Committee during 
an active IG investigation potentially compromise a criminal 
proceeding, or violate an individual witness's Constitutional right 
against self-incrimination? We have to balance those competing 
interests in an effort to do the right thing in each case.
    In the VBA relocation cases, it is my understanding that those 
employees retained private attorneys who advised them to invoke their 
Fifth Amendment rights. The Fifth Amendment right against self-
incrimination is personal to individuals, not subject to invocation or 
waiver by one's employer, including the Deputy Secretary.
    The problem in that case was timing. At the time that the 
employees' testimony was requested, the IG had referred the case to the 
Department of Justice for possible criminal prosecution, and DOJ had 
not yet determined whether it would take the case. As a result, HVAC's 
demand for those employees' testimony on the same issues that had been 
referred for potential criminal prosecution posed a real--not 
hypothetical--threat to their constitutional right against self-
incrimination. In the interest of providing the Committee the 
information it needed, the Deputy Secretary asked the Committee to 
defer the hearing until after DOJ disposed of the case so the 
employees' Fifth Amendment rights would not be implicated. When the 
Committee declined to postpone the hearing, the employees invoked their 
right against self-incrimination.

    Question 67.  How do you define unusual and excessive burden as it 
relates to the clause within the Choice Act? Do you consider it is an 
unusual and/or excessive burden for an 80 year old veteran without a 
vehicle to arrange transportation for a 200 mile drive to receive a 
shingles shot at a VA hospital facility? In this specific case, would 
you permit this veteran access to a shingles shot in his community by 
utilizing the unusual and excessive burden clause in Choice?
    Response. As defined in the Veterans Access, Choice and 
Accountability Act (VACAA), the Unusual or Excessive burden provision 
is for a Veteran who resides 40 miles or less from the closest VA 
medical facility and the Veteran faces an unusual or excessive burden 
in accessing such a facility. If the Veteran lives 200 miles from the 
closest VA medical facility, they would be able to use the Choice 
program for all of their care under the distance provision of VACAA. If 
the Veteran lived 40 miles or less from the closest VA medical facility 
and has a medical condition that impacts his ability to travel to that 
facility, the Veteran would be eligible to receive all of their care 
through VACAA. The Unusual or Excessive burden provision did not 
account for transportation issues in making a determination regarding 
eligibility. The Unusual and Excessive burden provision does not take 
into account the availability of services in local market. VA believes 
that eligibility requirements should allow for the use of community 
care in instances where clinicians have determined there is need and VA 
cannot provide the service or provide the service timely.

    Question 68.  Do you believe the Choice Program should be extended? 
Should the criteria for eligibility be altered? Do you have 
recommendations to improve Choice? If so, please provide a summary.
    Response. Yes, VA would recommend that the Choice Act be amended to 
make full expenditure of the Choice Fund the sole basis for the 
expiration of the Veterans Choice Program (VCP) while utilizing 
existing eligibility criteria. This change would serve as an interim 
measure while Congress continues to consider VA's long term plans as 
well as the recommendations of the Commission on Care.
    VA's long term plan would consolidate all of its community care 
programs (both VCP and other programs, since VCP is only about 25% of 
total community care) into a single program that meets the needs of 
Veterans, their families, and community providers. This new program 
would clarify eligibility requirements, build on existing 
infrastructure to develop a high-performing network, streamline 
clinical and business processes, and implement continuum of care 
coordination services. This new program will provide enrolled Veterans 
increased flexibility, greater choice and faster access to health care 
in the community.
    VA has also identified several shorter-term legislative measures 
that offer immediate improvement for VCP. Those proposals include 
making VA the primary payer for VCP. We urge Congress to enact those 
changes, as well as adjust the termination provisions in the Choice 
Act. Addressing the sunset date issue in the coming weeks will 
accomplish three significant objectives that VA believes all 
stakeholders can agree on: 1) allowing Veterans to benefit from every 
dollar already appropriated by Congress to improve Veterans' access to 
care; 2) providing the new 115th Congress, the new incoming 
Administration, and Veteran stakeholders more time to chart the course 
for the future of community care, including ensuring the financial 
resources are available to carry out that course; and 3) time for VA to 
work with Congress and stakeholders to ensure a smooth transition with 
minimal disruption for Veterans moving from VCP to VA's new 
consolidated community care program.

    Question 69.  Do you consider front-line medical facility 
positions, including direct patient care positions, to be positions 
that are low risk and do not require a heightened sensitivity level to 
conduct an investigation and/or criminal background check? Do you 
believe the policies within 5 CFR 731 that govern suitability of 
covered positions in the VA provides sufficient guidance and specific 
direction to determine whether an individual is ``favorable'' to hire 
and should be in contact with veterans? What would you change in the VA 
credentialing process, please be specific, to better protect veterans 
from individuals who may cause them harm
    Response. Provision of high-quality, safe patient care is the 
foremost mission of the VA. A critical component of providing safe care 
is the hiring and appointing of qualified healthcare providers. This 
begins before the provider is offered a position through the intense 
onboarding process.
    The onboarding process is comprised of many steps which are all in 
place to ensure the applicants have the qualifications to meet VA 
standards and perform the duties for which they are being hired. The 
onboarding process includes the Human Resource process of investigating 
background to reveal criminal convictions, civil judgments, and 
exclusions from participation in Federal and State Health Care 
Programs, qualifications and basic eligibility determination, 
interviews, reference checks, and at minimum, a National Agency Check 
with Written Inquiry (NACI) level background investigation.
    Another distinct and separate component of the onboarding process 
is the credentialing and privileging of the provider. This is an 
extensive process in which the training, education, work history, 
clinical references, and licensure are primary source verified. During 
the credentialing process the National Practitioner Data Bank (NPDB) is 
queried as well as the Federation of State Medical Boards (FSMB) (for 
physicians) to identify any licensure actions, medical malpractice 
payments, adverse clinical privileges actions, health care-related 
criminal convictions and civil judgments and exclusions from 
participation in Federal or state health care programs. Licensed 
Independent Practitioners, such as physicians and dentists, are also 
enrolled in the NPDB's continuous query program and FSMB's Disciplinary
    Alert Service so that the facility is instantly notified if any 
report is made by any entity (VA or non-VA) to either organization so 
that immediate action can be taken as necessary.
    VA utilizes an electronic credentialing software platform, VetPro, 
in which the primary source verified credentials for over 300,000 
licensed, registered, or certified healthcare provider are stored and 
maintained. These files are easily shared and transferred between VA 
facilities to expedite the credentialing process for providers who move 
within the agency. The sharing of these files also assists in ensuring 
providers who have had substantiated clinical care concerns do not 
easily move throughout the system as their VA clinical history is 
available to anyone with access to their file.
    The selecting official at the facility level has all of this 
information to review and consider when making a decision of whether or 
not to hire the provider and if they are a good fit for the patient 
care needs of the facility.
    Once hired, all Licensed Independent Practitioners are continuously 
monitored through a Focused Professional Practice Evaluation process 
and then through an Ongoing Professional Practice Evaluation process. 
These are screening tools (required for any Joint Commission Accredited 
facility) used to evaluate all providers who have been granted 
privileges and to proactively identify quality of care issues.
    VA is committed to the thorough vetting of all providers who will 
treat our patients and we will continue to provide education, guidance, 
and tools to help the leaders at the VHA facilities make informed 
hiring decisions. VA meets and exceeds the Joint Commission 
accreditation standards for credentialing of healthcare providers that 
are utilized by healthcare organizations throughout the country.
                                 ______
                                 
Response to Prehearing Questions Submitted by Hon. Patty Murray to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs

    Question 70.  What steps will you take to establish a fully 
interoperable record-sharing system between the Department of Defense 
and the Department of Veterans Affairs, and to move beyond the use of 
the Joint Legacy Viewer to trade screenshots of records?
    Response. In accordance with requirements in the FY 2014 National 
Defense Authorization Act, DOD and VA were required to be interoperable 
by December 2016. This was certified ahead of schedule on April 8, 
2016.
     The DOD/VA Joint Legacy Viewer (JLV) is a clinical 
application that provides an integrated, chronological display of the 
complete longitudinal health record from DOD, VA, and Community Care 
providers in a customizable viewer.
     JLV is not a ``screenshot'' sharing technology. It uses 
and displays (near real-time) computable data that can be organized as 
each user requires for their current and future workflow needs.
     JLV shows all patient data, regardless of the source (VA, 
DOD, community partners) in one place.
     Veterans Benefits Administration (VBA) offices use JLV to 
expedite benefit claim processing, and other staff from Office of 
Inspector General (OIG), Office of Medical Legal Affairs (OMLA), and 
Office of General Counsel (OGC).
    Today, more than 228,000 VA health care and benefits professionals 
have access to JLV and have used it to view more than 2 Million Veteran 
records. A preliminary VHA review found that patients reported 14% 
higher customer satisfaction when providers were using JLV because they 
were more familiar with their medical history.
    Next steps in interoperability--eHMP:

     JLV has been a critical first step in connecting VA and 
DOD health systems with a read-only application, however, it is limited 
in its functionality.
     VA has developed Enterprise Health Management Platform 
(eHMP) which will deliver urgently-needed clinical functionality, while 
incorporating all of the data interoperability achieved with JLV.
     Through eHMP (which is a platform and not an EHR), 
clinicians will have a powerful Google-type record search that 
encompasses VA, DOD, and Community partners, as well as the ability to 
write notes, order laboratory tests, and communicate with improved 
tracking to ensure follow through on tasks.
     VA has deployed the initial version of eHMP (version 1.2) 
across the entire VHA enterprise.
     By ``sitting'' on top of the VA's 130 separate VistA 
EHR's, eHMP can maintain a consistent user interface while the 
supporting EHR systems underneath are modernized and/or changed.

    Question 71.  Do you support overturning the decades-old ban on 
allowing VA to cover the costs associated with in vitro fertilization 
and other assisted reproductive technology services?
    Response. VA's goal is to restore and improve the quality of life 
for Veterans in accordance with evidence based medical standards and to 
the greatest extent the law will permit.
     In the past, IVF has been legislatively excluded from the 
medical benefits package.
     Recent passage of Pub. L. 114-223 enables VA to provide 
counseling and treatment using Assisted Reproductive Technologies 
(ART), including IVF to Veterans (and their respective spouse) with a 
service-connected (SC) condition that renders them unable to have 
children without the use of fertility treatment.
     VA subsequently amended its regulation with publication of 
an interim final rule on January 19, 2017 that authorizes the same. VA 
will provide ART treatment, including IVF, to these affected Veterans 
and spouses.
     VA estimates that nearly 400 total Veterans will be 
provided ART (including IVF) treatment over the remainder of this 
fiscal year and FY 2017.
    Note: The most common single cause of battle injuries is explosive 
devices (36.3%). Such trauma frequently results in genito-urinary 
injuries. For example, 1 in 5 warriors were evacuated from Operation 
Enduring Freedom combat in October 2011 with a genito-urinary injury.

    Question 72.  What is your assessment of VA's protections against 
retaliation for reporting sexual assault within the VA system?
    Response. VA's protections against retaliation for reporting sexual 
assault within the VA system is deeply rooted in its commitment to 
creating a culture, embedded in our mission and core values, which 
engages and inspires employees to their highest possible level of 
performance and conduct.
    Sexual harassment in the workplace is prohibited by law, and sexual 
assault is a serious form of sexual harassment. Reporting sexual 
harassment (or harassment on the basis of race, color, religion, 
national origin or age) is an activity that is protected by law. 
Retaliation against any individual for reporting such conduct is 
prohibited. VA managers at the highest and lowest level and employees 
are prohibited by law from retaliating against any employee for 
reporting sexual assault. There are consequences for engaging in such 
behavior.
    In VA's Office of Resolution Management, there is an enterprise-
wide Anti-Harassment Office (AHO), which provides centralized tracking, 
monitoring and reporting to proactively respond to all allegations of 
harassment. The AHO ensures that all harassment allegations are 
reported to VA leadership. Such a report outlines prompt corrective 
measures taken to decrease harassing behavior in the workplace. The AHO 
is committed to establishing transparency and accountability at every 
level of employment.
    VA has also established enterprise-wide anti-harassment policies 
and procedures to ensure that an allegation of harassment, including 
sexual assault and retaliation for reporting sexual assault, receives a 
prompt, thorough and impartial investigation; and that VA takes 
immediate and appropriate corrective action when it determines that 
harassment has occurred.
    By doing this, VA can proactively prevent harassing conduct before 
it becomes severe or pervasive. The EEO complaint process is also 
designed to make individuals whole for discrimination, that has already 
occurred, through damage awards and equitable relief, and to prevent 
the recurrence of the unlawful discriminatory conduct. While the EEO 
complaint process does not require an agency to discipline its 
employees, VA through the AHO, requires that immediate and appropriate 
corrective actions are taken to eliminate harassing conduct regardless 
of whether the conduct violates the law or whether an employee pursues 
an EEO complaint. The AHO focuses solely on whatever action is 
necessary to promptly bring the harassment to an end or to prevent it 
from occurring at all.
    An employee who believes that he or she has been subjected to 
harassing conduct, for reporting sexual assault or for any other 
reason, can report the matter to his or her immediate supervisor (or 
second-line supervisor if the immediate supervisor is the alleged 
harasser); to the Anti-Harassment Coordinator (AHC) for his or her 
specific office; or to the AHO. Employees who witness potential 
harassment are encouraged to report it. Supervisors or managers who are 
notified of harassment or witness potential harassment are required to 
report it immediately, and also to assess the situation immediately in 
consultation with the AHO or AHC.
    All reports of hostile or abusive conduct and related information 
is maintained on a confidential basis to the greatest extent possible. 
The identity of the employee alleging violations of the Anti-Harassment 
Policy will be kept confidential except as necessary to conduct an 
appropriate inquiry into the alleged violations or when otherwise 
required by law. Anonymous allegations of harassment will also be 
investigated and monitored to the fullest extent possible.
    VA is dedicated to protecting its employees from retaliation for 
reporting sexual assault and all other unlawful discrimination, and VA 
has in place an effective mechanism and policy to ensure that our 
employees are protected. For the sake of everyone, including the 
Veterans we serve, we want to provide a safe working environment for 
every VA employee.

    Question 73.  Do you support expanding the caregivers program to 
cover caregivers of veterans from all eras? What is your assessment of 
the program as it stands and how can it be further streamlined and 
improved?
    Response.

     The Caregivers and Veterans Omnibus Healthcare Services 
Act of 2010 allows VA to provide services to qualified family 
caregivers of eligible Post-9/11 Veterans who incurred or aggravated a 
serious injury in the line of duty, including a monthly stipend paid 
directly to designated primary family caregiver, and coverage under 
CHAMPVA if eligible.
     VA has developed multiple public/private partnerships in 
support of family caregivers of Veterans to provide training, 
education, and support to caregivers of Veterans of all eras.
     The Caregiver Support Program is currently involved in 
program review and evaluation with VA researchers to evaluate the 
short-term impacts of the Program of Comprehensive Assistance for 
Family Caregivers (PCAFC) and the Program of General Caregiver Support 
Services by assessing the impact of current programming on the health 
and well-being of Veterans and caregivers. This work is ongoing and 
will impact current as well as future programming.
     According to RAND's report ``Hidden Heroes,'' the needs of 
family caregivers of Pre 9/11 Veterans are different than the Program 
of Comprehensive Assistance for Family Caregivers provides.
     Based on current budget models, VA estimates the annual 
cost of expansion to be approximately $3 billion annually.
     I would support providing equitable programming for 
caregivers of Veterans, regardless of the Veteran's era of service or 
the reason why the Veteran requires assistance from a family caregiver. 
I would welcomes collaboration with Congress to make enhancements, 
including legislative changes, to the current program which may allow 
for expansion to caregivers of Veterans from eras.

    Question 74.  What is your assessment of the program as it stands 
and how can it be further streamlined and improved?
     As it stands, the Program of Comprehensive Assistance has 
provided services to more than 30,000 family caregivers of Veterans, 
far exceeding the original vision.
     Despite the attention focused on the Post-9/11 Program, VA 
has very successfully implemented many other services and supports to 
family caregivers who do not qualify for the Comprehensive Assistance 
Program, including multiple trainings, peer support, and a very active 
telephone support line.
         - 350 Full Time Caregiver Support Coordinators at medical 
        centers across country
         - 4,000 caregivers of Veterans of all eras have completed 
        self-care training
         - Active peer support mentoring program, telephone education 
        groups, on-line trainings
         - Caregiver Support Line has received more than 276,000 calls, 
        continuing to average more than 250 calls per day
     The legislation could be improved. One specific example is 
the use of the word ``injured,'' in the Law, which excludes caregivers 
of Veterans with ALS, MS, and other debilitating illnesses.
     Another idea for improvement may be focusing the caregiver 
support for aging Veterans in need of home-based care which may help 
delay long-term institutional care.

    Question 75.  With the policy change last year to open all military 
professions to women and to allow transgender individuals to serve, 
what steps must VA undertake to ensure the system is prepared to handle 
an increasingly diverse veteran population?
    Response.

     VA must continue education and training of providers
     VHA's LGBT (LGBT), Health Program, Women's Health, Center 
for Women Veterans, Center for Minority Veterans, and Office of Health 
Equity have led national campaigns to raise awareness about the 
healthcare needs of lesbian, gay, bisexual and transgender women, 
African Americans, and rural Veterans.
         - The VHA LGBT Health Program has developed fact sheets for 
        Veterans and providers on LGBT Veteran health care available 
        here: (http://www.patientcare.va.gov/LGBT/VA_LGBT_Outreach.asp)

     VHA strongly supports training for providers so they can 
have tools to deliver clinically and culturally competent care for our 
diverse group of Veterans.
         - The VHA LGBT Health Program has developed and promoted 
        several clinical trainings for providers in sexual health, 
        transgender healthcare, as well as lesbian, gay, and bisexual 
        Veteran healthcare (http://www.patientcare.va.gov/LGBT/
        LGBT_Veteran_Training.asp).
         - A national transgender e-consultation program and a 
        transgender SCAN-ECHO program has been implemented. To date, 55 
        interdisciplinary healthcare teams encompassing nearly 400 
        providers have been trained
         - The VHA LGBT Health Program has been working with Pentagon 
        officials about training military healthcare providers in 
        transgender care utilizing the VA model.

     In 2016, VA established an LGBT Veteran Care Coordinator 
at every facility. These Coordinators help train local staff and ensure 
that the facility provides appropriate clinical services for LGBT 
Veterans.
     A demographic field for Self-Identified Gender Identity 
(expected Feb 2017) in the electronic health record will help providers 
and staff better communicate with a diverse veteran population.

    Question 76.  What benefits has VA seen from its Child Care Pilot 
Program and what steps could be taken to permanently establish this 
program at VA facilities around the country?
    Response. The Caregivers Act of 2010 required a Child Care Pilot 
program be established in at least three VISNs over two years. The VHA 
sites selected were:

     Buffalo, New York; opened 10/2011
     Northport, NY; opened 4/2012
     American Lake-Puget Sound (American Lake), Washington; (9/
2012)
     Dallas, TX became an additional pilot site in 3/2013

    The four pilots have continued to provide child care services with 
congressional authority extensions, most recently the Department of 
Veterans Affairs Expiring Authorities Act of 2016, authorizing services 
through December 31, 2017.

     VHA is not able to conclusively demonstrate a relationship 
between use of the child care pilot sites and impact on no-show rates
         - However, despite limited data, Veterans did voice this 
        service improved access to their appointments.
         - The pilot program is highly successful based on Veteran 
        satisfaction with child care provided and allowed Veterans 
        greater access to appointments.
         - While women Veterans are the most frequent users, it is 
        notable that male Veterans users also use the service.

     VA is on record as asking for permissive authority 
legislation. There is no legal authority to expand the pilots or to add 
additional childcare in VA.
     In order to expand the program, Congress would need to 
enact legislation granting permanent discretionary authority to the 
Secretary to provide child care assistance for Veterans accessing 
health care at facilities. The Secretary's authority should include the 
ability to establish the types of child care providers to participate 
in this program, the scope of child care assistance, and the location 
of child care services.

    Question 77.  The Integrated Disability Evaluation System (IDES) 
integrates the Department of Defense (DOD) and Department of Veterans 
Affairs (VA) disability systems to improve and expedite processing of 
servicemembers through the disability evaluation system.
    a. What is your assessment of the need to further streamline and 
improve the IDES?
    Response. The Integrated Disability Evaluation System (IDES) is a 
joint DOD/VA Program that can certainly be presented as a success story 
of integrated, inter departmental cooperation. This program is designed 
to assist the DOD in determining whether wounded, ill, or injured 
Servicemembers (SMs) are fit for continued military service or if found 
unfit by the DOD, separate or retire the SM for their service-connected 
disability. IDES further showcases the unified efforts of DOD and VA 
working together to ensure all medically required evaluations, medical 
supportive services and full VA entitlements are made available to SMs 
found to be unfit. From the Program's Initial Operating Capabilities 
(IOC) to date, over 190,061 Servicemembers have been processed via the 
IDES Program. In FY 2016, the IDES program averaged approximately 2453 
cases per month. By continuing to provide this expeditious, yet 
comprehensive level of service to our SMs participating in the IDES 
Program, potential opportunities for continued improvement and 
streamlining include:

         - Ongoing early identification and thorough evaluation by DOD 
        of SMs that may not meet the retention standards established by 
        their specific military service.
         - Offering enrollment in VA Healthcare to all IDES Program 
        participants as a mechanism for maintaining uninterrupted 
        access/healthcare coverage post separation from military 
        service.

    SMs approaching normal separations/discharge or retirement from the 
service may also be eligible for VA benefits. These SMs may apply for 
VA benefits and compensation after they have separated from the service 
or may file a claim for VA compensation and benefits while still in the 
service by participating in the VA's Benefits Delivery at Discharge 
(BDD) or the Quick Start Program.
    BDD allows a Servicemember to submit a claim for disability 
compensation 60 to 180 days prior to separation, retirement, or release 
from active duty or demobilization. BDD can help the SM receive VA 
disability benefits sooner, with a goal of within 60 days after release 
or discharge
     Separation Health Assessment (SHA) Initiative. Although 
part of the BDD Program, VA and DOD commenced an initiative in 2013 
that further assists SMs by allowing them to choose which Department 
(DOD or the VA) will conduct their final separation from service 
examination. If a SM chooses to have their SHA examination performed by 
the VA, they must file a claim for benefits no later than 90 days prior 
to their scheduled separation. Once completed, the examination results 
are provided to the DOD, who in turn will review and accept the 
examination results as the final separation from service examination. 
The goal of this initiative is to provide VA disability benefits to the 
SM within 60 days after release or discharge.
         - Quick Start allows a Servicemember to submit a claim for 
        disability compensation 1 to 59 days prior to separation, 
        retirement, or release from active duty or demobilization. By 
        submitting a disability compensation claim before discharge 
        makes it possible to receive VA disability benefits as soon as 
        possible after separation, retirement, or demobilization. SMs 
        with 1-59 days remaining on active duty or full time Reserve or 
        National Guard service, or SMs who do not meet the Benefits 
        Delivery at Discharge (BDD) criteria requiring availability for 
        all examinations prior to discharge, may apply through Quick 
        Start.

    b. If confirmed, how would you work with the DOD Secretary to 
ensure both DOD and VA ensure that veterans move smoothly through the 
multi-step disability evaluation process?
    Response. Our approach would include continued holistic reviews of 
the IDES program, specifically focusing on a more robust feedback 
process from current and former participants of IDES and their families 
to ascertain:

         - Transition improvements that can be made to the Program. 
        Conduct a comprehensive review of all phases of the program and 
        re-evaluate the challenges faced by both the SMs and their 
        supporting chain of commands to remove or modify administrative 
        processes identified as ``very challenging'' by Program 
        participants and commanders alike.
         - Review current services, programs and assistance provided by 
        both the VA and DOD with a specific focus on the families of 
        separating SMs, to better prepare them for their spouse's 
        transition from military service.
                                 ______
                                 
 Response to Prehearing Questions Submitted by Hon. Bernard Sanders to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs

    Question 78.  Dr. Shulkin, as Under Secretary for Health, you 
stated to Virginia's Daily Press that privatization ``would be a 
terrible mistake, a terrible direction for veterans and for the 
country, to essentially systematically implement recommendations that 
would lead to the end of the VA health-care system,'' As Secretary of 
the Department of Veterans Affairs, would you continue to oppose 
efforts to reduce the Federal role in providing health care services to 
veterans?
    Response. I have consistently stated my support for an integrated 
system of care for veterans. I wrote about this in my New England 
Journal of Medicine article in 2016. This integrated network would 
support and enhance services that are essential to veterans within the 
VA that either cannot be readily found in the private sector. The 
integrated system would also utilize care in the community that may be 
more accessible or higher quality of care than found in the VA. It is 
my firm belief that this integrated system of care will provide the 
best outcome for our veterans and the best value for taxpayers. Each 
community has different needs and capabilities and therefore such a 
system will require local needs assessments. Nationally, VA currently 
utilizes 31% of its' care in the community, demonstrating that we are 
able to both support a strong VA and work effectively with community 
providers.
    I also believe that the VA health care system is essential to 
fulfilling our commitment to our Nation's veterans. All of my efforts 
would be directed to making our system work better on behalf of our 
veterans. I do believe that with thoughtful and proactive planning we 
can enhance and strengthen services, and eliminate waste and 
duplication by accelerating our efforts through an integrated system of 
care that serves veterans.

    Question 79.  In respect to the Choice Program, I hear two main 
concerns from Vermont veterans. First, is that there are delays in 
third party administrator (TPA) authorizations for care, which have led 
to critical medical appointments being delayed or missed entirely. 
Second, miscommunications between VA and the TPA on authorizations and 
billing have led to multiple Vermont veterans being sent to collections 
by local health care providers. As Secretary, how would you address 
these issues to ensure veterans get the care they need when they need 
it, without their credit being adversely impacted?
    Response. VHA is committed to ensuring that all Veterans have 
timely access to care. In June 2016, the Office of Community Care 
implemented a contract modification to improve the appointing 
requirements and processes for Veterans
    Choice Program services. In accordance with the modification, the 
initial appointment for an episode of care must be scheduled within 
five (5) business days of the contractor's receipt of a 10-0386 ``VHA 
Choice Approval for Medical Care'' form (or similar VA-generated 
request), all applicable clinical documentation, and the Veteran has 
opted in for VCP. The appointment must take place within 30 calendar 
days of the initial scheduling unless the desired appointment date is 
otherwise noted on the referral.
    VHA continues to work with the contractors and VA staff to ensure 
clear and concise communication is the utmost importance to for our 
Veterans to have timely access to care. The Office of Community Care 
has worked on the development and modifications of the VHA form 10-0386 
to make the request for care clear and concise for our Veterans. The 
form has several mandated fields that require VA staff members to 
ensure the request has all the pertinent information needed for the 
contractors to provide the best care to our Veterans.
    VA understands that any situation resulting in delayed payments or 
accumulation of debt due to inappropriately billed claims is stressful 
for Veterans and unacceptable. We are working hard to correct these 
errors and offer assistance to our Veterans immediately.
    We were able to pull the following data specific to VISN 1 and 
Vermont: In the past 90 days (Oct-Dec 2016), Community Care received a 
total of 139 Adverse Credit Reporting (ACR) requests for VISN 1.

    Question 80.  Treatment courts can play an important role in 
ensuring veterans with histories of substance misuse get a second 
chance. What do you see as VA's role in ensuring veterans can benefit 
from these programs?
    Response. Incarceration as an adult male is the most powerful 
predictor of homelessness. VA services for justice-involved Veterans 
are therefore provided through two dedicated national programs, both 
prevention-oriented components of VA's Homeless Programs: Health Care 
for Reentry Veterans (HCRV) and Veterans Justice Outreach (VJO). Known 
collectively as the Veterans Justice Programs (VJP), HCRV and VJO 
facilitate access to needed VA health care and other services for 
Veterans at all stages of the criminal justice process, from initial 
contact with law enforcement through community reentry following 
extended incarceration.
    VJO Specialists serve Veterans at earlier stages of the criminal 
justice process, with a three-pronged focus on outreach to community 
law enforcement, jails, and courts. All VJO Specialists must be 
licensed independent clinicians, and the vast majority are social 
workers. Differences (in size, structure, openness to outside 
partnerships and to treatment-based criminal justice interventions, 
etc.) between local criminal justice systems, as well as the 
partnership-driven nature of the work, mean that the VJO program can 
look significantly different from one location to the next. VJO 
Specialists at each VAMC work with Veterans in the local criminal 
courts (including but not limited to the Veterans Treatment Courts, or 
VTCs), conduct outreach in local jails, and engage with local law 
enforcement by delivering VA-focused training sessions and other 
informational presentations.
    VA supports VTCs through the participation of its VJO Specialists 
as members of VTC treatment teams, and through the health care services 
it provides to Veteran defendants, most of whom would otherwise receive 
care at county expense. The Specialists assess Veteran defendants' 
treatment needs, assist as needed with the VA eligibility and 
enrollment process, link Veterans with appropriate VA treatment 
services, and (with the Veterans' permission) provide regular updates 
to the court on their progress in treatment. The VJO Specialists' (and 
VA's) role in a VTC is limited to the treatment-related aspects of the 
court process; although VA eligibility may be a court-imposed 
requirement for admission, VA does not decide which Veteran defendants 
should be admitted to a VTC or define the level of offenses (e.g., 
misdemeanor vs. felony) that a VTC will accept. VJO Specialists work 
closely with justice system partners as they plan new VTCs, informing 
the partners about VA services that would be available to Veterans 
defendants locally or regionally. However, as with all VJO-related 
services, the Specialists do not advocate specifically for the use a 
particular model or set numerical targets for desired VTC growth, but 
instead encourage communities to plan proactively to meet the needs of 
justice involved Veterans using approaches that best fit local 
circumstances. VA also does not provide grant funding or other 
financial support to VTCs or other Veteran-focused courts.

    Question 81.  It can sometimes be challenging for rural veterans, 
like those in my home state of Vermont, to have all their health care 
needs met. Under your leadership, how would VA maximize its telehealth 
capabilities to ensure rural veterans can assess quality VA-provided 
care closer to--or even in--their home?
    Response. Telehealth is a key component of the strategy to address 
access issues, especially in rural areas where it can be difficult to 
hire providers.
     VA is expanding services through enterprise-wide 
initiatives, including by the expansion of Primary Care, Tele-Mental 
Health, and specialty care hubs that each service many sites of care.
     In Fiscal Year 2016, VA provided more than 2 million 
Telehealth visits to over 700,000 Veterans across more than 50 
specialties.
         - Approximately 315,000 of these Veterans were located in 
        rural areas, including approximately 1,500 in rural areas of 
        Vermont.
     While most Veterans currently access Telehealth services 
in their local VA Community-Based Outpatient Clinic, VA's Veteran-
centric approach has led the Department to pursue expansion of services 
directly into Veterans' homes.
         - VA Video Connect, VA's home Telehealth program, provided 
        more than 39,000 encounters direct to Veterans' homes last 
        year, of which over 40% were rural.
         - For Veterans without an Internet-connected device at home, 
        VA has implemented a system to provide tablets for home 
        Telehealth use.
     As VA works to expand established Telehealth services, the 
Office of Rural Health and Office of Connected Care also partner with 
clinical program offices to foster innovative Telehealth programs that 
specifically increase access for rural Veterans.
         - In FY 2016, rural Telehealth programs provided care to over 
        85,000 Veterans in remote areas across the country. This number 
        is expected to increase to the hundreds of thousands in FY 
        2017.
                                 ______
                                 
 Response to Prehearing Questions Submitted by Hon. Richard Blumenthal 
     to Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. 
                     Department of Veterans Affairs
    Question 82.  As of December 31, 2016, there were over 450,000 
cases pending in VA's appeals system. Last year, Secretary McDonald 
convened a group of stakeholders including VSOs to attend a multi-day 
event to collaborate on how to fix the VA appeals system. Department of 
Veterans Affairs Appeals Modernization Act of 2016, which I introduced 
last Congress put the results of that collaboration into legislation 
and the Disabled American Veterans, the American Legion, the Veterans 
of Foreign Wars, the Paralyzed Veterans of America, AMVETS, the 
Military Officers Association of America, the National Association of 
County Veterans Service Officers, and the National Association of State 
Directors of Veterans Affairs supported the legislation.
    Do you support the reforms contained in that legislation as a path 
forward for improving the appeals process, if not, why not, and how 
would you reform the process?
    Response. I fully support reforming the current appeals process. 
Comprehensive reform is necessary to replace the current lengthy, 
complex, confusing VA appeals process with a new appeals framework that 
makes sense for Veterans, their advocates, VA, and stakeholders. This 
reform is crucial to enable VA to provide the best service to Veterans 
and, if confirmed, I will prioritize reforming the current appeals 
process.
    I support the framework developed collaboratively by VA and a wide 
spectrum of stakeholder groups in 2016. I believe that the engagement 
of the organizations that participated in development of the new 
framework ultimately led to a stronger proposal, as we were able to 
incorporate their feedback and experience having helped Veterans 
through the complex appeals process.
    The current VA appeals process takes too long. Appeals have no 
defined endpoint or timeframe and require continuous evidence gathering 
and re-adjudication. On average Veterans are waiting 3 years for a 
resolution on their appeal. For cases that reach the Board of Veteran's 
Appeals (Board), Veterans are waiting on average 6 years and thousands 
of Veterans are waiting much longer. The current appeals process is 
also too complex. Veterans do not understand the process, it contains 
too many steps and it is very challenging to explain to Veterans. 
Additionally, accountability does not rest with one appellate body; 
rather, jurisdiction over appeals is split between the Veterans 
Benefits Administration (VBA) and the Board.
    The new framework, which I fully support, steps away from an 
appeals process that tries to do many unrelated things inside a single 
process and replaces it with differentiated lanes, which give Veterans 
clear options after receiving an initial decision on a claim. For a 
claim decision originating in VBA, for example, one lane would be for 
review of the same evidence by a higher-level claims adjudicator in 
VBA; one lane would be for submitting new and relevant evidence with a 
supplemental claim to VBA; and one lane would be the appeals lane for 
seeking review by a Veterans Law Judge at the Board. In this last lane, 
intermediate and duplicative steps currently required by statute to 
receive Board review, such as the Statement of the Case and the 
Substantive Appeal, would be eliminated. Furthermore, hearing and non-
hearing options at the Board would be handled on separate dockets so 
these distinctly different types of work can be better managed. As a 
result of this new design, the agency of original jurisdiction (AOJ), 
such as VBA, would be the claims adjudication agency within VA, and the 
Board would be the appeals agency.
    This new design would contain a mechanism to correct any duty to 
assist errors by the AOJ. If the higher-level claims adjudicator or 
Board discovers an error in the duty to assist that occurred before the 
AOJ decision being reviewed, the claim would be returned to the AOJ for 
correction unless the claim could be granted in full. However, the 
Secretary's duty to assist would not apply to the lane in which a 
Veteran requests higher-level review by the AOJ or review on appeal to 
the Board. The duty to assist would, however, continue to apply 
whenever the Veteran initiated a new claim or supplemental claim.
    This disentanglement of process would be enabled by one crucial 
innovation. In order to make sure that no lane becomes a trap for any 
Veteran who misunderstands the process or experiences changed 
circumstances, a Veteran who is not fully satisfied with the result of 
any lane would have 1 year to seek further review while preserving an 
effective date for benefits based upon the original filing date of the 
claim. For example, a Veteran could go straight from an initial AOJ 
decision on a claim to an appeal to the Board. If the Board decision 
was not favorable, but it helped the Veteran understand what evidence 
was needed to support the claim, then the Veteran would have 1 year to 
submit new and relevant evidence to the AOJ in a supplemental claim 
without fearing an effective-date penalty for choosing to go to the 
Board first.
    To fully enable this process and provide the appeals experience 
that Veterans deserve, VBA, which receives the vast majority of 
appeals, would modify its claims decisions notices to ensure they are 
clearer and more detailed. This information would allow Veterans and 
their representatives to make informed choices about whether to file a 
supplemental claim with the AOJ, seek a higher-level review of the 
initial decision within the AOJ, or appeal to the Board.
    The new framework would not only improve the experience of Veterans 
and deliver more timely results, but it would also improve quality. By 
having a higher-level review lane within the VBA claims process and a 
non-hearing option lane at the Board, both reviewing only the record 
considered by the initial claims adjudicator, the output of those 
reviews would provide a feedback mechanism for targeted training and 
improved quality in VBA.
    The legislation should be enacted now. It has wide stakeholder 
support and the longer we wait to enact the Appeals Reform legislation 
more and more appeals will enter the current, broken system. The status 
quo is not acceptable for our Nation's Veterans and taxpayers. The new 
framework will provide much needed comprehensive reform to modernize 
the VA appeals process and provide Veterans a decision on their appeal 
that is timely, transparent, and fair.
                                 ______
                                 
  Response to Prehearing Questions Submitted by Hon. Sherrod Brown to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
    Question 83.  As a result of the Veterans Access, Choice and 
Accountability Act of 2014, veterans have been charged fees for seeking 
care in the community through the Choice Program. In some cases these 
fees have been turned over to collection agencies, putting the 
veteran's credit score and sometimes livelihood at risk. Under your 
direction what steps will the VA take to ensure that veterans have a 
clean financial bill of health?
    Response. The Choice Act requires VA to be secondary payer when a 
Veteran receives community care for a non-service-connected condition 
and has other health insurance (OHI). In these cases Veterans are 
responsible for their co-pay or deductible as part of their 
participation with their OHI.
    There have been cases when the delayed payment to the community 
care provider is inappropriately billed to the Veteran directly. The 
Choice contracts clearly identify billing timeframes for the Choice 
contractors and VA. The contractors have 30 days to pay a submitted 
claim or to deny the claim with an explanation of additional 
information needed to process. VA has 14 days to pay the contractors--
this is a new addition to the contract in order to address the backlog 
of payments.
    VA understands that any situation resulting in delayed payments or 
accumulation of debt due to inappropriately billed claims is stressful 
for Veterans and unacceptable. We are working hard to correct these 
errors and offer assistance to our Veterans immediately.

    a. Additionally, I hear concerns from medical providers who have 
had reimbursements delayed by the VA for months. This has caused 
providers to stop taking veterans, many of whom live in rural areas and 
are in need of care. Under your direction, what steps will the VA take 
to improve reimbursements rates for care in the community?
    Response. Currently there are no reports of providers refusing to 
see Veterans as a result of non-payment from VA. We have however 
received reports of providers who are refusing to see Veterans because 
of non-payment from the third party contractors. We are 100% current 
with Choice payments to the TPAs and have been for over 4 weeks.
    In February 2016, the Office of Community Care created the Provider 
Rapid response Team. The purpose of this team is to quickly respond to 
any issue with provider payment or anything else that might affect 
Veteran's access to care in the community. This team liaises directly 
with leadership with the contractors to quickly and effectively solve 
provider issues.

    Question 84.  The Diffusion of Best Practices initiative has shown 
promise in standardizing veterans' care and experience at VA medical 
facilities. If confirmed as VA Secretary, what is your vision for 
continuing to build on that process?
    Response. Diffusion of Excellence is an initiative that carried out 
one of my major priorities as Under Secretary: achieving consistency of 
best practices across the system. In your home state, Cleveland has a 
simple but impactful best practice that involves non-clinical employees 
spending time with veterans throughout their journey through the 
hospital: with this program, employees not only witness the experience 
of veterans firsthand, but they also get to know the veterans more 
closely and hear their stories throughout their service.
    If confirmed I would ask Dr. Elnahal and his team to build the 
Diffusion of Excellence initiative out for the entirety of VA. This is 
an easier endeavor than it might seem: throughout the last 18 months, 
hundreds of best practices have been compiled with an online 
information sharing tool called the Diffusion Hub, which included many 
projects commissioned over the last year at VBA and NCA during a major 
leadership development initiative. We will establish a similar 
performance improvement and governance framework for the entirety of 
VA, and strategically target areas where we need the most improvement.
    Appendix: Diffusion Activities occurring in Ohio:

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
        

    Question 85.  In your current role, you continue to hold medical 
appointments with veterans. Why is that important to you and what have 
you learned from that experience that would enhance your ability to 
lead VA?
    Response. During my career as a healthcare executive I have always 
maintained an active practice of internal medicine. I have found it is 
the best way for me to remain connected to the mission of helping those 
in need and in learning how systems of care actually work. Being a 
practicing physician also allows me to understand and communicate 
better with our staff and to understand how the system allows them, or 
fails them in their job to care for veterans. Practicing medicine at 
the VA, in both New York City and via telehealth in Grants Pass Oregon, 
has allowed me to better understand the needs of the veterans that we 
serve and how our system of care is different than what I have 
experienced in the private sector. It has given me firsthand knowledge 
of the integrated nature of our system, that provides not just physical 
care, but also addresses the social, psychological and economic needs 
of our veterans. I've also come to appreciate the specialized services 
offered by VA such as prosthetics and adaptive sports programs that are 
essential to the well being of many of the veterans that we have the 
honor of serving.

    Question 86.  With each new generation of warfighters confronts 
issues of exposure to toxic and hazardous materials during service. 
Will you commit to addressing the full scope of health issues faced by 
veterans and their families as the result of exposure to things like 
Agent Orange, burn pits, or nuclear material?
    Response. The Department of Veterans Affairs (VA) honors the 
national service and sacrifice of our Veterans and is committed to 
providing compensation and health care benefits for disabilities that 
were incurred or aggravated by that service. This includes any 
disability resulting from exposure to environmental toxins or hazardous 
materials.
    VA regulations and policies have long addressed environmental 
exposure issues that include World War II-era radiation from atomic 
bomb use and testing; Vietnam-era Agent Orange herbicide use; Gulf War 
desert particulate matter and burn pit toxins; and Camp Lejeune 
contaminated water during the 1950s-1980s.
    Specifically, these regulations govern and address benefits for:

    (1) Radiation exposure-related disabilities and for participation 
in radiation-risk activities and exposure to ionizing radiation;
    (2) Diseases associated with exposure to Agent Orange herbicide for 
those Veterans who served in or visited Vietnam, or on its inland 
waterways, between January 9, 1962 and May 7, 1975; for service in a 
military unit operating on the Korean demilitarized zone between 
April 1, 1968 and August 31, 1971; for regular and repeated contact 
with a post-Vietnam C-123 aircraft used for aerial spraying of Agent 
Orange in Vietnam; and for involvement with testing, storage, 
transport, or other use of Agent Orange;
    (3) Disability patterns associated with service in the Southwest 
Asian Persian Gulf War theater. These include undiagnosed illnesses and 
diagnosable medically unexplained chronic multi-symptom illnesses, as 
well as certain infectious diseases. In addition, our regulations also 
provide benefits for other diagnosable conditions associated with burn 
pit and Southwest Asia desert hazards; and
    (4) Disabilities associated with service at the US Marine Corps' 
Camp Lejeune, NC, based on evidence of exposure to contaminated water 
from the mid-1950s to the mid-1980s. Free health care is already 
available for certain associated diseases and a VA regulation is 
pending that would provide presumptive service connection for eight 
diseases.

    VA will continue to work with the Department of Defense to monitor 
and respond to any indication of toxic or hazardous environmental 
exposures experienced by Veterans during their military service and 
provide benefits for any resulting disabilities.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Jon Tester to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs
    Question 1.  During your nomination hearing, you stated with regard 
to President Trump's Hiring Freeze, that the most important factor was 
having the resources to hire the people you need to take care of our 
veterans. You added that you felt very comfortable about where VA is 
after receiving all of the hiring freeze exemptions you requested from 
the White House. What would it take for you to ask for exemptions for 
the Veterans Benefits Administration and the Board of Veterans' 
Appeals? What metrics would you use to determine whether hiring 
exemptions are necessary for VBA and BVA?
    Response. There is no doubt that if the hiring freeze were to 
continue for an indefinite period of time that we would begin to see a 
real degradation of service levels of Veterans I would be specifically 
concerned that if there was a delay in new enrollments for benefits 
that access to healthcare may be impacted, which would be unacceptable. 
As I mentioned in my hearing I have spoken to the Acting Under 
Secretary for Benefits, Thomas Murphy. He is prioritizing new 
enrollments and will inform the Secretary if significant changes occur 
as a result of attrition that may be impacting service levels. If there 
is a significant change in the number of days that Veterans are waiting 
for benefits the Acting Secretary of VA would address this with the 
White House and request an exemption from the hiring freeze. Currently, 
VBA is in the process of submitting an exemption request to permit the 
hiring of direct labor occupations to ensure reduced impact on VBA's 
ability to serve Veterans.
    Regarding appeals, while staffing is important we will not 
significantly impact the pending inventory without appeals 
modernization legislation that discontinues the flow of appeals into 
the current broken process and a temporary surge of additional 
resources. During the 114th Congress, VA worked with VSOs and other 
stakeholders to design a new appeals process that is fair, transparent, 
and timely. This new framework for appeals was introduced in several 
bills in the 114th Congress and has been reintroduced in the 115th 
Congress. VA intends to address its need for a temporary surge of 
additional resources to eliminate its current inventory of appeals in 
the annual budget process.

    Question 2.  How hands-on of a leader have you been in problem 
solving on controversial issues that VA has faced since your arrival--
for instance, high-profile suicide incidents, Veterans Crisis Line 
issues, or the aftermath of the Tomah opioid crisis. What was your 
personal role in resolving these challenges?
    Response. My management style is one that leads by example. In 
response to the access crisis I began seeing patients in the walk in 
access clinic in New York and by telehealth in Grants Pass, Oregon. In 
our homeless programs I participated in our midnight point in time 
counts in LA and in both years I have been here at our homeless stand-
down's in DC. I personally called for and led our urgent call to action 
to prevent suicides among Veterans that we help with Members of 
Congress in 2016. In issues such as VA's response to the opioid crisis 
I led public forums with our elected Members of Congress and the 
Surgeon General to address the issue and then wrote up our approach to 
opioid reduction for publication in a major medical journal. These are 
just examples, but I believe they demonstrate my belief that leaders 
must get personally involved in issues that matter and it is essential 
that leaders be seen as having personal involvement in areas that they 
want the organization and the community to effectively address.

    Question 3.  VA has been criticized for how it distributed medical 
staff hired under the Veterans Access, Choice and Accountability Act of 
2014. Please discuss your role in these decisions and if you had no 
role, what you would have done differently?
    Response. I did not arrive at VA until July 2015. However, in 
September 2014, VHA completed a Nation-wide data call to identify 
staffing needs for clinical and medical support staff, with a special 
emphasis on Primary Care, Mental Health, and Specialty Care. After 
further analysis, VHA identified the need for 10,682 additional Full-
Time Equivalent Employee (FTEE) to be hired by September 2016. VHA 
directed a prioritization of the VACAA 801 funds distribution to 33 
VAMCs experiencing the greatest challenges with Veterans access. Since 
access remained a critical priority across the entire VA Health Care 
System, the remaining funds were distributed proportionally across all 
sites, based upon the Veterans population to be served. This decision 
was made by the Acting Under Sectary for Health, Dr. Carolyn Clancy. By 
December 31, 2015, VHA had achieved 102% of the VACAA target, having 
hired 10,854 FTEE. Primary Care, Mental Health, and Specialty Care 
areas were VHA's most urgent needs at the time and were appropriate for 
prioritization of the VACAA staffing allocations.

    Question 4.  It seems to me that technology is the underpinning of 
success at VA and things are pretty far behind--there still is no new 
scheduling system, no decision on EHR, no consistency of systems 
between processing of initial claims and appeals on those claims. With 
respect to the various important and pressing IT needs facing the 
Department, how do you intend to prioritize? Where do you stand on 
VISTA Evolution vs. DOD and VA simply using the same system?
    Response. The goals of the VistA Evolution program are improving 
the efficiency and quality of Veterans' health care by modernizing VA's 
health information systems; increasing data interoperability with DOD 
and private sector care partners; reducing the time it takes to deploy 
new health information management capabilities; and continuing to 
provide safe, efficient health care IT tools to VA medical providers so 
they can continue to deliver Veteran-centric, team-based, and quality-
driven care. The VistA Evolution Program manages the development of 
what is known as VistA 4 which is a collection of approximately 60 
projects and initiatives focused on VA's interoperability efforts with 
DOD and the private sector; the flagship Enterprise Health Management 
Platform (eHMP) and Joint Legacy Viewer (JLV) projects and other 
projects. Among many achievements, the work of the VistA Evolution 
Program has enabled VA to certify to Congress, together with Department 
of Defense (DOD), that VA had met the FY 2014 National Defense 
Authorization Act (NDAA) interoperability standards.
    As of January 2017, the VistA Evolution Program had completed 
approximately 27 projects and 31 remain to be finished by the end of FY 
2018. The investments and work of the VistA Evolution Program have and 
continue to deliver value for Veterans and VA providers regardless of 
whether VA's path forward is to continue with VistA, shift to a 
commercial EHR platform as DOD is doing, some combination of both or 
other alternatives. VA is currently reviewing options regarding long-
term EHR modernization courses of action.

    Question 5.  Same Day Access has been one of your initiatives. What 
is your definition of Same Day Access?
    Response. In primary care, when a Veteran contacts a VA about a 
healthcare need, VA will either address that need the same day or 
schedule appropriate follow up care. Veterans with urgent issues will 
be provided care the same day. VA may address the needs of Veterans by 
providing a face to face visit at a VA medical center, returning a 
phone call, arranging a telehealth or video care visit, responding by 
secure email or scheduling a future appointment. For mental health, if 
the Veteran is in crisis or has another need for care right away, the 
Veteran will receive immediate attention from a health care 
professional at the VA medical center.

    Question 6.  Are you satisfied with the level of communication 
between VA central office and the field? If yes, how quickly did you 
find out about problems in the field, and if no, what have you done to 
improve communication?
    Response. As one of my first steps as Under Secretary I sought 
candid feedback about the adequacy of communication with the field. 
What I consistently heard was that the communication was 
unidirectional, in that the field would get directives from central 
office but they did not feel that their input into directives and other 
policies was being adequately considered. I sought to improve these 
communications, and to make the discussions bi-directional by having 
more forums in which to communicate with the field. This has included 
quarterly town hall meetings, the use of an intranet communications 
tool (called Pulse) that has close to 100,000 users from the field, 
regular and frequent calls with the field and Central office where I 
participate in many of these, and regular videos and emails that I send 
to the field to communicate important priorities, events, and 
milestones. In addition, our leaders developing leaders program has 
helped to improve communication with the field among thousands of our 
field staff and central office staff. Having detailed some of the 
progress we have made, we have much more work to do to close the 
deficits that have long existed between central office and the field. 
We have prioritized our efforts in internal communications and will 
continue to work on this as a priority. I can commit that if confirmed 
as Secretary that improved communications will be a vital element for 
my leadership team.

    Question 7.  Do you share my belief that Bob McDonald was an 
effective and successful VA Secretary? In your testimony, you said you 
would seek ``major reform and a transformation of VA.'' How does your 
vision of ``transformation and reform'' differ from Bob McDonald's?
    Response. Secretary McDonald entered VA in 2014 at a time of 
crisis. His leadership allowed VA to begin a path of recovery and he 
was able to lay the foundation for the transformation of VA. As such, 
yes I believe that Secretary McDonald was both effective and 
successful. My vision of transformation and reform can buildupon the 
good work that Secretary McDonald began. I do believe that for VA to be 
successful we must now begin to address some of the long term systems 
problems that VA faces. First is our need to act as an integrated 
enterprise both within our three separate administrations and across 
the country. This will allow us to take advantage of VA's economies of 
scale and also begin to deliver a more consistent experience for our 
Veterans. We must also modernize many of our systems that have been 
long neglected. We must address the need for greater integration of our 
services between VA and the private sector and other Federal entities, 
whether this relates to healthcare or to building and maintaining our 
current infrastructure and facilities. This action will take dedicated 
focus by our leadership but I believe can be accomplished and will 
result in meaningful improvements for our Veterans.

    Question 8.  As VA Secretary, what are you going to do to make VA a 
more attractive place to work--whether we're talking about Montana or 
Georgia?
    Response. VA is undergoing one of the most ambitious Department-
wide initiatives to transform its workplace culture in its history, 
known as MyVA. The MyVA initiative is predicated on five foundational 
strategies, one of which is Improving the Employee Experience. This 
core strategy is aimed at fundamentally changing the VA culture to 
focus on two key and inextricably linked goals: improving leadership 
and increasing employee engagement in every corner of the Department. 
To that end, we have implemented a new ILEAD campaign that promotes 
leadership development for leaders at every level, characterized by 
principle-based leadership and demonstrated though ``servant leader'' 
behavior. These two powerful concepts shift the emphasis from self-
serving behaviors and blindly following bureaucratic rules, to behaving 
in ways that put principles first, and service to others as the driving 
force. With respect to employee engagement, I will reply on feedback 
from our employees through the OPM Federal Employees Viewpoint Survey 
and the VA All Employee Survey. As a result of these surveys I am 
committed to:

     Moving pay setting for our healthcare employees to a 
market-based pay system
     Working with the Committee to establish an alternate 
personnel system for all VHA personnel, and proposals that will allow 
VA to offer more competitive pay (special rate increase, elimination of 
dual compensation waiver, and changes to Physician and Dentist Pay)
     Implementing changes to the Title 38 leave system for 
Physicians and other ``24/7'' providers, creating more flexible work 
schedules that will address critical staffing needs while being more 
desirable to Physicians.

    In addition, I need the ability to use all recruitment and 
retention tools and flexibilities; however the CARA Act has 
significantly reduced VA's ability to offer recruitment, relocation, 
and retention incentives.

    Question 9.  What are you going to do differently than your 
predecessor to make the Choice program work better in states like mine?
    Response. VA has worked to make many changes and improvements to 
the Veterans Choice Program and will continue to do. We now have 
completed over 60 contract modifications with Health Net and TriWest to 
improve the program from the original implementation. VA has improved 
communications with the contractors by developing a standardized 
referral form for care. The referral form, VHA 10-0386 ``VHA Choice 
Approval for Medical Care,'' provides a set format for VA facilities to 
request needed care, and helps to avoid any miscommunication and 
misdirected to inappropriate specialties. VA has embedded contractor 
staff in facilities to assist in resolving questions and issues timely. 
In addition, VA implemented Provider Agreements to assist Veterans in 
receiving timely care. Provider Agreements have been utilized in to 
provide care to Veterans, when the contractors were unable to schedule 
such care timely. The Provider Agreements are initiated at the VA 
medical center level, and allow Community Care providers to work 
directly with VAMC to schedule care for referrals that have been 
returned in certain circumstances from the contractors. These 
agreements have augmented the care provided under contractors to ensure 
Veterans receive timely community care.

    Question 10.  In response to question 6 of my pre-hearing 
questions, you raised VA's Whistleblower Protection Program. As you may 
know, section 247 of the Continuing Appropriations and Military 
Construction, Veterans Affairs, and Related Agencies Appropriations Act 
of 2017 (P.L. 114-223) directs VA to establish a new process for VA 
employees to file whistleblower complaints. Section 247 of Public Law 
114-223 is based on legislation, the VA Patient Protection Act of 2016, 
which was considered before the Senate Veterans' Affairs Committee in 
November 2015. According to testimony from VA, VAOIG, and the U.S. 
Office of the Special Counsel, the new process established by section 
247 is unworkable, unnecessary, and may undermine current whistleblower 
protections. What are your views on section 247? If confirmed, will you 
work with the Senate Veterans' Affairs Committee to ensure that 
whistleblower protections in the Department are effective?
    Response. I have several concerns about section 247.
    First, I believe strongly that VA employees should be entitled to 
the same whistleblower protections as other Federal employees, to 
include an easy-to-access and easily understood process for disclosing 
concerns about safety or about fraud, waste, or abuse in the workplace 
and about retaliation they may encounter after making a disclosure. 
Section 247 imposes on VA, alone among Federal agencies, an additional 
set of rules and requirements around disclosures and retaliation 
complaints that are frankly confusing for employees, duplicative of 
existing processes, and expensive to carry out from a manpower 
perspective. It also imposes on VA supervisors, alone among Federal 
supervisors, a more draconian set of penalties for retaliation.
    I would prefer to see the whistleblower protection rules apply 
equally across the entire government. Rather than impose this unfunded 
mandate on VA to handle these matters differently than anyone else 
does, I'd prefer to see Congress properly resource the Office of 
Special Counsel, which is in essence the Central Whistleblower Office 
for all Federal employees, and VA's Inspector General, which has the 
mandate and the expertise to investigate many of the concerns that VA 
whistleblowers raise.
    Another concern I have about section 247 is the burden in places on 
VA's first-line supervisors--many of whom are doctors or nurses who 
supervise in addition to caring for Veteran patients, or are claims 
processors or cemetery workers who serve Veterans directly while also 
supervising. Section 247 says that when an employee submits a 
whistleblower claim under this new process, the supervisor has to stop 
what he or she is doing in support of Veterans to carry out this 
complicated process of determining whether the claim meets the legal 
definition of whistleblowing and, if it does, to provide a formal 
written response back to the employee within four days. That is not the 
best use of our supervisory health care providers or claims 
representatives or cemetery staff, and I think it will create an 
unhelpful formal or even adversarial dynamic between our supervisors 
and their employees.

    Question 11.  VA's fiscal year (FY) 2017 budget request states that 
there is a direct and proportional correlation between the number of 
employees at the Board of Veterans' Appeals (Board) and the resolution 
of claims for VA benefits that reach the Board. As you acknowledged in 
your confirmation hearing, today there are over 450,000 appeals 
pending. To address the appeals inventory, VA's FY 2017 budget called 
for an increase of full-time equivalent (FTE) employees in fiscal years 
2017 and 2018. For FY 2017, the Board received funds from Congress to 
hire 242 FTEs. I fought to get VA these funds.If confirmed, will you 
ensure that the President's across-the-board hiring freeze does not 
negatively impact VA's ability to meaningfully address the over 450,000 
appeals that are pending?
    Response. I am committed to addressing VA's pending appeals 
inventory. As of January 31, 2017, there are over 469,000 appeals 
pending in the Department, with over 135,000 pending with the Board. VA 
is grateful for the additional funds received in FY 2017, enabling the 
Board to hire 242 FTEs, for a total of 922 cumulative FTE. The Board 
has been aggressively hiring and onboarding staff to a current level of 
738 cumulative FTE, but has many more FTE to hire and onboard to reach 
its FY 2017 FTE goal. While a hiring freeze would negatively impact the 
Board's ability to provide appeals decisions to Veterans regarding 
appeals, VA cannot significantly impact its pending inventory without 
appeals modernization legislation that discontinues the flow of appeals 
into the current broken process and a temporary surge of additional 
resources. I would note, for clarification, that although the Board 
projected continued FTE growth in FY 2018 as part of its workload 
projections in VA's FY 2017 budget, we are aware that any increase in 
resources above the FY 2017 baseline will be contingent on annual 
budget appropriations.

    Question 12.  In the 2016 Commission on Care report, the Commission 
projected that by 2034, 60 percent of veteran users could be using 
private care. Under your vision for the future of VA health care, would 
this be acceptable? Are you concerned about the impact on specialized 
services such as spinal cord injury, prosthetics, Traumatic Brain 
Injury, Post Traumatic Stress Disorder, and other mental health needs, 
given the more costly private sector is not as equipped to provide 
these services to veterans? Please discuss.
    Response. Under my vision for the future of VA health care, I would 
project that although 100 percent of enrolled Veterans could be using 
either VA or Community care, because they would have a real choice, 
that we would still see a majority of enrolled Veterans choosing to use 
VA for integrated primary care and mental health services, along with 
most of the specialized services designed for people who served in the 
military. We would use community care often for specialty care that 
does not require tailoring for the military, like obstetrical care, 
optometric services and care for management of chronic disease for 
veterans who live where it would not be convenient to reach VA care.
    You make an excellent point in your question that many of these 
services tailored to the needs of prior servicemembers are simply not 
available in most communities, but are quite costly when they are. For 
those reasons, and because so many Veterans prefer to receive these 
services alongside comrades who served, I am not too concerned that use 
of an integrated VA/community care network will erode our ability to 
provide these specialized services to America's heroes.

    Question 13.  What is your plan to support VA's Office of Tribal 
Government Relations, in their efforts of continued collaboration and 
outreach to Native American Veterans in their communities?
    Response. I will rely on the support and counsel of our Office of 
Tribal Government Relations (OTGR) to coordinate the agency's tribal 
consultation efforts, and to ensure both the Secretary and other senior 
VA leadership are engaged in communicating and working with tribal 
leaders as part of the enduring government to government relationship 
that exists between the United States and Indian tribes. We also rely 
on OTGR to assist the VA enterprise with cultivating informed, trusting 
relationships with tribal leaders, national intertribal organizations 
and service providers to identify opportunities for sharing of 
resources and pursuing partnerships that ensure access to care for our 
Veterans living within or near tribal communities.
    It is our expectation that OTGR will play a key role in leading 
VA's efforts to connect VA, other members of the Federal family, state 
governmental organizations, private and non-profit organizations, with 
tribal communities. Additionally, I will rely on OTGR to coordinate the 
agency's response to the identified priorities which include access to 
medical care, addressing housing and homelessness, treatment for PTSD 
and mental health, understanding benefits, including benefits for 
families and transportation. By recognizing and adhering to these 
culturally specific requests, VA will be informed, demonstrate 
trustworthiness and continue to understand the nuances of working 
within Indian Country. An organization that understands the people and 
population it serves has the best odds of success.

    Question 14.  What are your thoughts on the proposed consolidation 
of the Indian Health Service and Tribal Reimbursement Program into one 
standard program?
    Response. Consolidation of the agreements with the IHS and Tribal 
Health Programs into one program could make the program more 
straightforward to administer; however, given VA values its 
relationships with these partners, we would recommend consultation with 
these stakeholders be initiated to determine what tribes' concerns and 
recommendations may be regarding the potential impact of a 
consolidation with Indian Health Service.. This could also have 
implications for tribal health programs who opt to serve as community 
care providers that deliver care to non-native Veterans because IHS is 
fairly limited to delivering care to IHS-eligible patients. This would 
also continue to multiply the different ways VA purchases community 
care rather than consolidating and streamlining into one overall 
program for the VA.

    Question 15.  What is your plan to ensure the Department of Housing 
and Urban Development-Veterans Affairs Supportive Housing program, 
Tribal HUD-VASH, is permanently funded in order to combat homelessness 
of Native American Veterans who live on tribal lands?
    Response. Tribal HUD-VASH is an important and necessary joint 
effort between HUD and VA, with HUD providing the housing vouchers and 
VA providing the necessary case management. To date, Tribal HUD-VASH 
has 26 tribal grantees and each tribal grantee is funded for one case 
manager. VA includes case management funding in its overall budget 
requests for HUD-VASH and it is included in our FY 2017 appropriation, 
and we expect to continue to fund the positions in subsequent years. 
For the continued support of the Tribal HUD-VASH program, HUD has 
requested $7 million in its FY 2017 Budget, a request both the House 
and Senate Committees on Appropriations supported in their draft fiscal 
year 2017 appropriations bills. In a similar show of support, Congress 
included a Tribal HUD-VASH funding anomaly for HUD in the second FY 
2017 Continuing Resolution (CR) to ensure program continuity of 
operations during the CR period.

    Question 16.  How do you intend to work with the National 
Association of State Departments of Veterans Affairs?
    Response. I will continue to prioritize working closely with our 
state partners and with NASDVA. NASDVA President Randy Reeves and I 
have already been in frequent contact and I look forward to building 
upon the great relationship between VA and NASDVA that my predecessors 
have forged before me. Additionally, I also intend to reaffirm VA's 
commitment to partnering with the states by signing a new Memorandum of 
Agreement between VA and NASDVA at their winter conference later in 
February.

    Question 17.  Please describe your plan to address national 
physician assistant recruitment and retention issues.
    Response. The National Recruitment Program (NRP) provides a 
centralized in-house team of skilled professional recruiters employing 
private sector best practices to fill the agency's most critical 
clinical and executive positions. The national recruiters, all of whom 
are Veterans, work directly with executives, clinical leaders, and 
local human resources departments in the development of comprehensive, 
client-centered recruitment strategies that address both current and 
future critical needs. At facility request, NRP targets hard-to-fill 
recruitments in their regions.
    VHA markets directly to direct patient care providers through 
partnerships such as National Rural Recruitment & Retention Network 
(3RNet), a national network of non-profit organizations devoted to 
health care recruitment and retention for underserved and rural 
locations, as just one example. Through these partnerships, VHA has 
access to a robust database of candidates interested in working for 
VHA. National Recruiters routinely post VHA practice opportunities on 
career sites such as www.vacareers.gov.

    Question 18.  At your hearing, you said that colleges that engage 
in deceptive and misleading recruiting practices would ``not be 
tolerable.'' In May 2016, 23 major national veterans and military 
organizations wrote a letter to the VA Secretary requesting action on 
this critical issue. Would you commit to reporting back to this 
Committee within three months with your recommendation for practical 
and realistic steps VA can take to ensure student veterans are 
protected from predatory and deceptive practices and given the 
information they need to make an informed choice about their college?
    Response. Yes

    Question 19.  On behalf of the National Alliance on Mental Illness, 
Montana, I submit the following question: According to a March 2016 
report prepared by the Veterans Legal Clinical at Harvard Law School, 
approximately 125,000 post-9/11 veterans cannot access basic VA 
services, such as mental health care because of Other Than Honorable or 
``Bad Paper'' discharges. The report details that VA has never 
evaluated the service of 90 percent of the veterans in this category, 
many having sought healthcare or housing services from VA, only to be 
turned away without any Character of Discharge review. Even more 
alarming, about 22,000 veterans with service-connected mental illness 
have received Other Than Honorable discharges since 2009. If confirmed, 
will you commit to thoroughly reviewing each of these cases, and where 
necessary allow veterans to receive the VA services, including mental 
health care, they deserve?
    Response. Yes I will, Veterans with OTH discharges can potentially 
receive VA care, including MST-related care, upon review of their 
discharge by the Veterans Benefits Administration (VBA). Following this 
review, VBA issues a decision as to whether or not the Veteran's 
discharge is a bar to receipt of health care benefits. VA has taken 
steps to ensure staff are aware that Veterans with OTH discharges are 
potentially eligible for some services and that there have been no 
shifts in policy to tighten eligibility requirements.
                                 ______
                                 
  Response to Additional Posthearing Questions Submitted by Hon. Jon 
 Tester to Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. 
                     Department of Veterans Affairs

    Question 20.  Many individuals that participate in the VA 
Caregivers Program for severely wounded veterans are working 
dramatically reduced hours outside the home or have left the workforce 
completely. This reduction in outside earnings can result in 
significant difficulties meeting financial obligations, including 
student loan debt held by the caregiver. How do you plan to identify 
and assist such caregivers facing financial hardship due to student 
loan debt?
    Response. Family Caregivers participating in VA's Program of 
Comprehensive Assistance for Family Caregivers (PCAFC) receive an 
average stipend amount ranging from $624.84 to $2,372.22 in 
December 2016, based on the Veteran's level of required assistance and 
geographic location. Eligibility for PCAFC is based on the Veteran's 
required level of assistance and not on financial need. VA does not 
have the authority to request or monitor this type of personal 
financial caregiver information for participation in PCAFC or any of 
VA's Caregiver Support Programs. Because there is no requirement for 
Caregivers to report financial status, I anticipate that family 
Caregivers will oppose providing information to VA about their student 
loan debt.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Jerry Moran to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs

    Question 21.  What role do you see the VSO community playing under 
your leadership? Please give at least five (5) specific examples of how 
you anticipate involving the VSOs.
    Response. Veterans Service Organizations (VSOs) will play an 
integral role under my leadership. I am committed to transparency, 
cooperation and coordination with our VSO partners to maximize input 
from the widest range of appropriate stakeholders and to facilitate an 
open exchange of opinion from diverse groups to improve our programs to 
assist Veterans. During my tenure as USH, I engaged and solicited input 
and feedback from VSOs on key issues, best practices or opportunities 
to improve policies, programs, service quality and meet Veteran needs.
    I host monthly VSO breakfast meetings with our senior leadership 
team, have participation and representation of VSOs on our workgroups 
and planning teams within our VA Program offices and also meet with 
VSOs on a frequent basis as specific issues or needs arise. In 
addition, I personally traveled to many of their national conventions 
and meetings last year. All of these engagements are necessary and will 
continue as VSOs are an important partner in helping us understand what 
improvements we can make to better deliver care and services to our 
Nation's Veterans.
    There are several areas of planned collaboration and ongoing 
communication between VA and the VSO community going forward to include 
Appeals Modernization, MyVA Access, Care in the Community, Patient 
Experience and partnering on communications at the national, regional 
and local level to share success stories/best practices as well to 
address opportunities for improvement.

    Question 22.  What are your top three goals as Secretary of 
Veterans Affairs?
    Response.

    (1) Getting the right people in place in management positions at VA 
in order to have the biggest impact across the organization. These 
positions include the Secretary's direct reports, VISN Directors, 
Medical Center Directors and clinical leaders. This then cascades down 
throughout their respective organizations to get the right employees 
who are serving our Veterans.
    (2) Addressing the critical access issues in the system. While we 
have made real progress in improving access for the urgent care needs 
of our Veterans, much work still needs to be done. We must have a 
system that fully addresses the needs of Veterans at the time that they 
need those services.
    (3) Restoring the trust of Veterans in VA through creating a 
Veteran centric organization. Everything we do must be focused on 
serving our Veterans and as we begin to move in this direction I 
believe we will see that our Veterans will increasingly have confidence 
and trust in VA.

    Question 23.  The Veterans Health Administration has made 
undeniable progress over the past two years in integrating more 
community care into the VA healthcare system. Do you believe that a 
veteran's primary care clinician should continue to be part of the VA 
system or can s/he be any clinician a veteran chooses?
    Response. Our goal is to provide all eligible Veterans with access 
to an integrated, high-performing network that allows Veterans to 
achieve the best health outcomes and patient experiences possible. This 
network takes the best of VA and the best of the private sector and 
combines them together. VA wants to ensure that all Veterans have a 
primary care provider to coordinate their care in the high performing 
network. In those cases where VA cannot provide a primary care 
provider, than Veterans should be able to select a primary care 
provider from the high performing network.

    Question 24.  The Commission on Care rejected the idea of granting 
veterans who use the VA unfettered choice in seeking care outside of 
the VA. Do you agree with this position, or do you believe that a 
veteran who is eligible for VA health care ought to be provided with a 
voucher to seek care wherever s/he chooses, with the VA footing the 
bill?
    Response. Our goal is to provide all eligible Veterans with access 
to an integrated, high-performing network that allows Veterans to 
achieve the best health outcomes and patient experiences possible. This 
network takes the best of VA and the best of the private sector and 
combines them together. Today, 80% of Veterans already have a choice 
between VA and private sector care as they have other health insurance 
options. Last year 1/3 of all of our appointments were in the 
community, up from 20% less than two years ago. The Commission on Care 
considered a few options and rejected the idea of unfettered choice. 
Given what they were considering I do agree with their decisionmaking. 
However, if confirmed as Secretary I would consider a number of new 
alternatives to a system restricting care based upon wait times and 
mileage. I believe that there are new models that need to be considered 
that are clinically based and that maximizes the strengths of VA and 
the private-sector, is mindful of taxpayer dollars, and puts the 
Veteran at the center of decisionmaking. I would welcome the 
opportunity to work with you further to ensure that we consider all of 
the options available to us to ensure that Veterans are getting the 
care that they need.

    Question 25.  Are you in favor of or are you opposed to 
Recommendation 17 of the Commission on Care, which would grant veterans 
with other-than-honorable administrative discharges eligibility to 
access VA health care on at least a temporary basis? VBA
    Response. If confirmed, I would commit to using the regulatory 
authority available to the Secretary to ensure that Veterans with other 
than honorable discharges are getting access to care. In the situation 
where we need legislative change I would work with both the White House 
and Congress about ways that we can address this population.

    Question 26.  What specific plans can you offer to reduce the 
number of veteran suicides, which are unacceptably high?
    Response. VA's comprehensive, integrated, data-driven approach to 
preventing Veteran suicide connects Veterans to an array of resources 
and support in order to reach Veterans before challenges become crises. 
VA's Office for Suicide Prevention (OSP) is using findings from 
completion of the most comprehensive analysis of Veteran suicide data 
to date examining more than 55 million Veteran records from 1979 to 
2014 from all 50 states and 4 territories to inform suicide prevention 
activities:

     Providing immediate outreach and enhanced care to Veterans 
found to be at highest risk for suicide (top 0.1%) through predictive 
analytics; rapidly expanding this program to include outreach to 
Veterans who are at moderate risk for suicide
     Increasing staffing and resources for Suicide Prevention 
Coordinators integrated at every VAMC and large CBOC (over 300 
nationwide who solely work on Veteran suicide prevention efforts)
     Training every VA employee to specifically respond to 
Veterans at risk for suicide and crisis, including staff at VBA, NCA, 
VACO, and Vet Centers
     Rapidly disseminating evidence-based treatments 
(Dialectical Behavioral Therapy, Collaborative Assessment and 
Management of Suicide, Cognitive Behavioral Therapy) for Veterans 
experiencing suicidal ideation across VA's healthcare system
     Engaging all U.S. Governors to prioritize combatting 
Veteran suicide in every state; immediately coordinating with 5 states 
with highest rates of Veteran suicide to develop suicide prevention 
initiatives to include strategic partnerships, targeted outreach, and 
enhanced care for all Veterans who may be at risk for suicide
     Distributing gun locks, gun safes, and other safe storage 
resources to at-risk Veterans and their families
     Disseminating nationally community toolkits for safe 
firearm storage in partnership with National Shooting Sports Foundation 
(NSSF) and other firearms stakeholders
     Developing comprehensive OSP-DOD Transition program to 
identify and follow all Servicemembers who may be at risk for suicide 
upon separation
     Establishing partnerships to train employers of large 
concentrations of Veterans (e.g. IBM, Johnson & Johnson, Homeland 
Security, etc.) in recognizing and responding to suicide risk and help 
employers understand specific assets and needs of Veterans to retain 
them in the workforce
     Improving the performance and capacity of the Veterans 
Crisis Line by opening a second call center and reducing calls that go 
to backup centers to nearly 0%. Over 2.6 million calls have been 
answered since VCL opened in 2007
     Immediately convening a VA Secretary Advisory Board on 
Suicide Prevention to include Congressional members, Veteran Service 
Organizations, Federal Partners, Non-profit Partners, Family Members, 
Veteran Suicide Attempt Survivors, and others to inform and enhance 
VA's suicide prevention initiatives.

    Question 27.  What specific recruitment and retention plans can you 
offer to increase the organizational capacity of VA mental health 
clinicians and support personnel?
    Response. VHA has added 3,946 additional mental health providers 
over the past 5 years and has increased the number of patients provided 
mental health treatment by 355,500 (28%). VHA offers education loan 
assistance via the Education Debt Reduction Program (EDRP) to mental 
health providers in hard to recruit/retain positions and locations. 26% 
of physicians receiving EDRP are psychiatrists. In the EDRP pilot 
program established by the Clay Hunt Act, the amount of the annual 
award will be increased and the program will be extended to 
psychiatrists in their final year of their residency training. VHA is 
helping to build a pipeline of highly-trained mental health 
professionals. VHA's Office of Academic Affiliations trains roughly 
6,400 trainees in mental health occupations per year, and roughly 70 
percent of VA psychiatrists and psychologists received some of their 
clinical training at a VA facility. VHA's Mental Health Education 
Expansion Initiative, a new five-year commitment, will increase 
clinical education in mental health professions. In the first year, 
Academic Year 2013-2014, over 200 training positions were added. In the 
second year, Academic Year 2014-2015, 126 positions at 45 different 
sites were added. VHA has increased mental health training 
opportunities for several years through increases in mental health 
training positions and approval of new sites for training. For example, 
as of July 2014, VHA psychology internships are present in 49 states, 
Puerto Rico, and the District of Columbia. There has been some targeted 
expansion in training in rural and highly rural facilities. VA had the 
first accredited Psychology residency program in the state of Alaska. 
In FY 2016, VA awarded eighteen pre-degree Licensed Professional Mental 
Health Counselor internship positions to seven VA medical centers. For 
FY 2017, VA awarded 3 pre-degree Marriage and Family Therapist 
internship positions at one site.

    Question 28.  During the 114th Congress, I was proud to sponsor the 
Veterans Mobility Safety Act (PL: 114-256) (hereinafter ``the Act''). 
The purpose of the Act is to require certain safety and quality 
standards of providers of automobile adaptive and special adaptive 
equipment so that disabled veterans, and the driving public, are safer 
on the roads. Providing quality care for disabled veterans is something 
that I have taken very seriously as both a member of the U.S. Senate 
Committee on Veterans' Affairs, and the Chairman of the U.S. Senate 
Appropriations Subcommittee on Military Construction, Veterans Affairs, 
and Related Agencies.
    In your new role as the Secretary of the U.S. Department of 
Veterans Affairs (hereinafter ``VA''), will you commit to providing 
disabled veterans with the highest quality of care that you, and the 
VA, can possibly provide?
    Response. Yes, absolutely. VA will maintain our commitment to 
ensure disabled Veterans receive the specialized services they need. In 
addition to the longstanding Automobile Adaptive Equipment benefit, and 
VA Driver's Training Program, VA has established programs and systems 
of care to maintain and ensure the provision of lifelong specialized 
care and services for these severely disabled Veterans. VA's systems of 
care for Polytrauma/Traumatic Brain Injury (TBI), Amputation, Spinal 
Cord Injury and Disorders, and Blind Rehabilitation are well 
established. Specialized care and services are provided across tiered 
networks of specialty rehabilitation centers that serve as regional 
referral centers for acute inpatient rehabilitation for severe 
injuries. Ongoing care and services are provided for these Veterans in 
VA facilities with specialized interdisciplinary teams closer to the 
Veteran's home community. These VA programs uphold the highest 
standards of rehabilitation, such as CARF (Commission on Accreditation 
of Rehabilitation Facilities) accreditation for inpatient 
rehabilitation facilities, and participating in Department of Health 
and Human Services `Model Systems' for VA's TBI and SCI programs 
(consortium of premiere private and academic rehabilitation centers). 
VA is further committed to ensuring Veterans continue to receive the 
prosthetic items and services they need. In FY 2016, VA expended $2.8 
Billion to provide 20 million medical items, prosthetic devices and 
items to 3.3 million Veterans. Finally, VA maintains its priority and 
visibility for these Veterans in partnership with our Federal Advisory 
Committee for Prosthetics and Special Disabilities--the longest 
standing Federal advisory committee serving the VA. Established by 
Congress in 1992, this Committee advises the Secretary on VA prosthetic 
and special disabilities programs that serve Veterans with spinal cord 
injury, blindness or visual impairment, amputation, deafness or hearing 
impairment, and other serious disabilities. An annual report is also 
provided to Congress regarding this Committee's recommendations and 
VA's actions taken in response to those recommendations. Finally, the 
Office of Quality, Safety, and Value will ensure that these veterans 
are receiving the highest quality medical care with our multiple 
mechanisms for tracking safety and quality metrics for these complex 
patients.

    Question 29.  On February 2, 2017, the VA filed a ``Notice of 
Inquiry'' in the Federal Register to ``request information and comments 
from interested parties to help inform VA's development'' of a quality 
and safety policy for providers of modification services under the 
Automobile Adaptive Equipment program. However, the Act requires that 
the Secretary develop this comprehensive policy in ``consultation'' 
with different stakeholders, including the National Highway 
Transportation Safety Administration, and industry representatives.
    Unfortunately, in VA's Notice of Inquiry, VA confirms that it is 
going to use this notice as the platform to receive the aforementioned 
required consultation. This is entirely unacceptable, as the law 
requires consultation, and should not be misinterpreted as merely a 
comment period for the Notice. Moreover, I believe that a robust 
consultation with different stakeholders will provide superior safety 
and quality standards. If you do indeed believe that disabled veterans 
deserve a high quality of care, in your new role as Secretary of the 
VA, will you follow the clear language of the statute and require 
consultation with specific stakeholders?
    Response. Yes, VA fully intends to comply with establishing this 
program in consultation with stakeholders and AAE entities across the 
national and state level, and public sector. VA has already been in 
contact with many of these stakeholders, and in doing so has discovered 
a number of entities with established quality and safety programs 
related to automobile adaptive equipment. Given the short suspense to 
implement this comprehensive program and supporting policy, and in 
order to be as broadly inclusive as possible, VA issued this public 
notice to expeditiously gather information from across all entities. 
Once this information is coalesced, VA will be fully informed about, 
and will have identified, all stakeholders for subsequent extensive 
consultation. This plan will then be presented in proposed regulation 
to all for review/public comment.

    Question 30.  Will the major Information Technology (IT) 
modernization projects and programs currently underway at the VA lead 
to improvements in VA vendor reimbursement? More specifically, will the 
aforementioned IT projects produce a reliable system for ensuring the 
prompt and accurate payment of VA vendor invoices?
    Response. Yes, the Community Care Reimbursements Systems (CCRS) 
Project align with industry standard claim reimbursements to fully 
automate and integrate with other business systems including Referral 
and Authorization, Revenue, Fraud, Waste, and Abuse (FWA), data 
analytics and financial systems. This system will align with the future 
state, highly-integrated Community Care model, supporting both 
contracted Community Care Networks and Out of Network claims 
processing.

    Question 31.  During a July 2016 hearing, the need for VA IT 
modernization and pursuit of a commercial off-the-shelf (COTS) HER was 
discussed and you stated ``We reached consensus . . . that looking at a 
commercial product is the way to go. It has to be done recognizing the 
unique needs of our community and providers.''
    Can you provide an update in pursuing a COTS solution, please 
describe in detail and include projected timing on this effort?
    Response. VistA was one of the first broadly used Electronic Health 
Records (EHR) in the country. It has been recognized for effectiveness 
and is still a high quality EHR used as the primary tool across the 
country. VA is proud of VistA, but we recognize the need for 
improvements.
    We will complete the next iteration of the VistA Evolution 
Program--VistA 4--in fiscal year (FY) 2018, in accordance with the 
VistA Roadmap and VistA Lifecycle Cost Estimate. VistA 4 will bring 
improvements in efficiency and interoperability, and will continue 
VistA's award-winning legacy of providing a safe, efficient health care 
platform for providers and Veterans.
    We have made substantial progress in delivering new capabilities 
leveraging VistA, while also strategizing for our future needs. VA is 
considering the future of VistA and VA's EHR as one component of a 
Digital Health Platform (DHP). The previous Administration delivered a 
Business Case for DHP, which included 3 options for the EHR component. 
This Business Case needs to be evaluated and a decision will be made on 
our path forward with respect to DHP and our EHR modernization efforts. 
However, the success of the digital health platform is not dependent on 
any particular EHR.
    The issue of moving away from VistA to a commercial EMR has been a 
subject of discussion at VA for years. VA has not always been clear on 
the future direction with regards to a COTS solution. I believe it is 
time that we make a firm decision and once a decision is made we will 
need to work closely with the Administration and Congress to define the 
path toward a successful outcome. If confirmed as Secretary I will 
commit to a decision on the COTS vs. Vista upgrade by July 1, 2017. The 
time leading up to July will be required to do a full assessment of the 
options in the context of the Digital Health Platform and work that is 
still required to make an informed decision.

    Question 32.  The Commission on Care's Final Report included a 
recommendation to ``modernize VA's IT systems and infrastructure to 
improve veterans' health and well-being and provide the foundation 
needed to transform VHA's clinical and business processes.'' 
(Recommendation #7). Further recommending, ``the VHA procure and 
implement a comprehensive, commercial off-the-shelf (COTS) information 
technology solution to include clinical, operational and financial 
systems that can support the transformation of VHA as described in this 
report.'' Former Secretary McDonald, recommended to former President 
Obama that the VA found this recommendation feasible and advisable.
    Do you agree with this recommendation? What are the barriers to 
implementing this recommendation?
    Response. Yes. Approximately 90% of OI&T's budget goes toward 
sustaining our aging infrastructure and applications, compared to 
around 60% in the private sector. OI&T has sacrificed modernizing these 
legacy systems and turning off older applications in exchange for 
adding incremental improvements and new capabilities. OI&T has 
developed a comprehensive strategy to substantially decrease its legacy 
system footprint and sustainment costs moving forward. A cornerstone of 
that strategy is VA's cloud implementation, which will improve 
efficiency and reduce costs. Implementing new functions like cloud will 
decrease sustainment costs because it requires significantly less 
maintenance.

    Question 33.  Although DOD has just begun its implementation of a 
new COTS solution, they reportedly carried out a successful procurement 
and testing process. How closely have you worked with DOD to learn from 
their experiences and processes? Will you pursue working with the DOD 
to capitalize on the COTS experience?
    Response. Yes, I have been told that VA has been working with DOD 
throughout the entire process and is learning from DOD's experiences 
while also helping to continue to advance on our Interoperability 
efforts. O I and T was did not report to me directly as Under 
Secretary, although we worked closely together on many projects. If 
confirmed as Secretary, I would work directly with DOD to determine how 
we might work closer together to leverage their work in this area.

    Question 34.  Do you believe that VISTA can manage the business and 
clinical commitments of Care in the Community or the idea and concepts 
embedded in the VA Choice Program? Does the VHA currently have the 
ability to create an electronic longitudinal health record that 
veterans simultaneously incorporates the care of veterans at the VA and 
in the community?
    Response. Yes. The VistA Evolution Program manages the development 
of a collection of approximately 60 projects and initiatives. Many of 
these are focused on VA's interoperability efforts with DOD and the 
private sector.
    The VistA 4 work managed by the VistA Evolution Program was first 
funded in FY 2014 and is scheduled to be completed by the end of FY 
2018 (September 30, 2018). However, just because I believe VistA is 
capable of performing these functions, does not mean that the best 
ultimate decision is to stay with VistA. As stated above we will have a 
decision on a COTS product vs. VistA by July 1, 2017.

    Question 35.  In the 114th Congress, provisions from the Toxic 
Exposure Research Act were signed into law as subtitle C of H.R. 6416. 
Simultaneously, the VA entered into a contract with the National 
Academy of Medicine to conduct a study on the health conditions of 
descendants of veterans exposed to toxins during the Gulf War. This is 
an important step forward, however, the aforementioned legislation that 
is now law requires a broader application and does not stipulate a 
certain conflict, time periods, group of veterans or type of exposure. 
The law requires the VA to contract with the National Academy of 
Medicine to conduct a review of health conditions potentially related 
to the toxic exposure of veterans who may have been exposed during 
their military service, which is intended to address veterans from any 
or all conflicts where they may have been exposed regardless of 
timeframe and locale. As Secretary, will you incorporate this statute 
into the currently contracted National Academy of Medicine study? It 
would seem redundant and duplicative to execute this statute at a later 
date when the VA has contracted with the National Academy of Medicine 
to conduct similar but limited work.
    Response. At the time VA contracted with the National Academy of 
Medicine (NAM) for both Gulf War & Health, Volume 11 and Veterans & 
Agent Orange, Volume 11, VA subject matter experts (SMEs) were well 
aware of Congress' upcoming legislative requirement and wrote the two 
contracts accordingly--to have major focus on intergenerational health 
effects. With the final passage and signing into law of the Toxic 
Exposure Research Act, VA SMEs took further steps to discuss with NAM 
staff each of these two contracts and the exact language of the Act to 
ensure that NAM would be able to deliver reports which met the explicit 
requirements of Congress. On 12 January, 2017 VA SMEs took the 
additional step of discussing with the seated NAM ad hoc committee for 
Gulf War & Health, Volume 11 both the charge to the Committee (from the 
contract) and the language from the Act. VA SMEs will do the same with 
the NAM ad hoc committee for Veterans & Agent Orange, Volume 11 in 
March 2017. Both of these NAM reports are due to be completed in early 
2019. Both of these reports, but especially Gulf War & Health, Volume 
11, will have broad applicability to all Veteran cohorts and their 
descendants.
    VA does oppose additional legislation on this matter as we feel 
that we have this legislative requirement covered. The NAM has already 
empaneled ``top scientists, epidemiologists, clinicians, and 
investigators to research the literature on health conditions'' for the 
Committee preparing the Gulf War & Health, Volume 11 report.

    Question 36.  Would you favor or oppose legislation that would 
require the VA to extend its contract with the National Academy of 
Medicine (formerly the Institute of Medicine) to empanel top 
scientists, epidemiologists, clinicians, and investigators to research 
the literature on health conditions associated with exposure not only 
to Agent Orange but to other toxic agents as well?
    Response. VA does oppose additional legislation on this matter as 
we feel that we have this legislative requirement covered. The NAM has 
already empaneled ``top scientists, epidemiologists, clinicians, and 
investigators to research the literature on health conditions'' for the 
Committee preparing the Gulf War & Health, Volume 11 report, and NAM 
will soon do so for the Veterans & Agent Orange, Volume 11 committee. 
Both committees will address the key elements of the Toxic Exposure 
Research Act.

    Question 37.  How do you plan to address improving the quality of 
benefits claims decisions and appeals? With public pressure to decrease 
the backlog of both claims and appeals, there is an increasing 
preference for adjudicating claims speedily at the expense of the 
quality and thoroughness of decisions. What are your specific ideas for 
how you expect to improve the quality of claims decisions that will 
ensure that veterans are provided all the due process and duty to 
assist rights afforded them under the law?
    Response. VBA has emphasized the importance of completing claims 
decisions in a timely and accurate manner. Quality is a critical 
performance element for all claims processors as is productivity. VBA 
has developed a multi-faceted approach to continuous quality 
improvement. Quality reviews completed on a national level provide data 
for error correction and tracking, targeted employee training, and 
station performance metrics. Consistency studies are regularly 
administered to claims processing employees to assess consistency of 
decisionmaking and provide training and feedback on any targeted areas 
of concern identified. Local offices complete systematic quality 
reviews on individual employees and quality checks on cases during the 
adjudication process. The results of these reviews are used for error 
trend analysis, targeted training and individual employee performance 
evaluations.
    With regard to appeals, a critical flaw in the current appeals 
process is that VBA's initial claim adjudicators do not receive 
effective quality feedback from VBA appeal decisions or from Board of 
Veterans' Appeals decisions. This is because the appeals process 
features an open record and continuous duty to assist and it generally 
takes several years to finally decide an appeal. As a result, a 
resolved appeal is based on a record that is different than the record 
considered by the initial VBA adjudicator. To address this concern, VA 
worked with VSOs and other stakeholders to design a new appeals process 
that features two quality feedback loops based upon a review of the 
same record, one in VBA and one from the Board. In addition, under the 
new framework, appeals to the Board will feature a more concise record 
that is easier to review. VA expects that this design will improve the 
quality of its initial decisions and reduce appeals. This new appeals 
framework was introduced in several bills in the 114th Congress and 
reintroduced in the 115th Congress. In addition, VBA has realigned all 
of its appeals operations and policy under a new organization, its 
Appeals Management Office, for improved oversight and quality 
assurance. The Board has also changed its quality assurance process to 
focus on known areas of concern and expanded the scope of its review to 
allow for identification and improvement of issues in all parts of the 
appeals system.

    Question 38.  Do you endorse or oppose the creation of a fourth 
entity within the VA, a Veterans Economic Opportunity Administration?
    Response. While VA appreciates the focus on improving employment 
services for Veterans by consolidating various programs, we do not 
support the creation of a separate Veterans Economic Opportunities 
Administration (VEOA). The current Veterans Benefits Administration 
(VBA) structure reflects the Under Secretary for Benefits' overall 
responsibility for Veterans benefit programs, including compensation, 
pension, survivors' benefits, VR&E, educational assistance, home loan 
guaranty, and insurance. A separate Administration for economic 
opportunity programs would negatively impact Veterans and would result 
in a redundancy of management support services. Additional staff would 
be required to support the administrative and management functions for 
the new administration which would be at the expense of direct FTE 
associated with the delivery of benefits, which would reduce support to 
Veterans. In 2011, the Office of Economic Opportunity (OEO) was 
established in VBA under the authority of the Under Secretary of 
Benefits to directly oversee Education Service, VR&E Service, Loan 
Guaranty Service, and Economic and Employment Initiatives. We believe 
there is currently an appropriate management structure in which there 
is internal collaboration among these program offices to oversee 
Veteran programs related to economic opportunities. We are concerned 
that dividing the benefit programs between two Administrations will 
result in a redundancy of management support services and add an 
administrative burden.

    Question 39.  The Choice Act authorized the Secretary of the VA to 
seek the removal or transfer of Senior Executives based on poor 
performance or misconduct. To date, the VA has used its authority to 
fire only six senior executives. Last year, the VA and the Justice 
Department informed Congress that it would no longer enforce the 
removal provisions of the Choice Act. In addition, previous VA 
leadership vigorously opposed congressional efforts to enact additional 
accountability measures on non-senior executive VA employees:

    a. Do you agree with the previous administration's refusal to 
enforce the removal provisions of the Choice Act?
    b. If confirmed, will you use your powers Congress has given you 
under the Choice Act to remove Senor Executives who fail to serve our 
Nation's veterans?
    c. If confirmed, will you work with Congress to enact additional 
accountability measures to hold all VA employees accountable?
    Response. The Department of Justice is frankly in a much better 
position than I am to determine whether a particular statute is or is 
not consistent with the U.S. Constitution. The issue DOJ has flagged in 
this case is a fairly nuanced legal issue, and it's not really up to me 
to say whether their analysis is right or wrong. That said, I want to 
be sure that we can sustain through the appeal process any action we 
take against an executive who failed to serve Veterans well or who has 
acted inconsistent with our values. If that means we need to amend the 
Choice Act to correct the issue DOJ flagged, I am supportive of that. 
At the same time, we should consider adding language to the statute 
that directs the Merit Systems Protection Board to defer to VA's 
actions unless our actions are arbitrary or illegal in some way. 
Ideally Congress would look at ways to improve the accountability and 
appeals processes for all Federal employees rather than singling VA 
employees out for different treatment. I look forward to working with 
Congress to identify and implement whatever solutions we need get this 
critical process right. If confirmed I would use my full powers as 
Secretary to remove Senior Executives that have failed in their 
responsibility to care for our veterans.

    Question 40.  Your predecessor frequently claimed that 90 percent 
of VA medical centers have ``new leadership teams.'' Please provide 
detailed analysis that justifies this figure. If analysis does not 
exist to justify this statistic, please provide your own, personal 
assessment of how many ``new leadership teams'' exist. However, those 
who have engaged in misconduct and are transferred from one VA facility 
to another do not factor in this equation. Most of these senior 
employees have appeared to avoid any accountability for their actions:

    Response. Unfortunately, the 91% was an erroneous estimate that was 
mistakenly included in VA's March 2015 Accountability Fact Sheet. The 
correct fact at that time should have read as follows:

    Since June 2014, 84% of our medical facilities and VISNs have newly 
placed leaders or leadership team members onboard. This percentage is 
inclusive of both newly placed and permanent leaders. The leadership 
team is defined as the Medical Center Director, Chief of Staff, 
Associate Director, Assistant Director, Nurse Executive, and Deputy 
Medical Center Director, Network Director, Chief Medical Officer, and 
Deputy Network Director. (Source: VHA Executive Recruitment Quad Report 
as of 12/3/2015; Timeframe: June 2014 to February 2015).
    I have not quoted statistics like this as I am not sure it is the 
most meaningful way to determine if we are getting the right management 
teams on board. What is more important to me is to make sure that our 
searches for medical center leadership are bringing us the best 
candidates. I am not in favor of continuing with the same ways that we 
have recruited leaders in the past. I have publicly stated on numerous 
occasions that I am looking for a mix of leaders that come from VA who 
are promoted for the right reasons into management positions but to 
also bring in outside leaders who are familiar with private sector 
practices. I believe that the selection of new leaders for our 
organization is among the highest priorities for the Secretary.
     If confirmed, will you commit to ending the practice of 
merely transferring VA leaders when they engage in misconduct and 
instead ensure they are really held accountable for their actions?
    Response. Beginning in 2014, allegations of misconduct or poor 
performance by a Medical Center Director or other senior VA leader have 
been referred to the Office of Accountability Review, an independent 
investigative body aligned within VA's Office of General Counsel but 
with dotted-line reporting to the Secretary through the Deputy 
Secretary and Chief of Staff. When OAR substantiates that a Director 
has engaged in misconduct or failed to act in accordance with our 
values, OAR has made recommendations for appropriate action to the 
Chief of Staff and Deputy Secretary. We do not move bad actors around--
we take whatever action is warranted, up to and including removal. If 
confirmed as Secretary, I will make sure that several things are done. 
I would be seeking faster decisions on disciplinary actions of senior 
executives to either clear them of the allegations or to remove them 
from service. Of course, anything we do must be consistent with the 
current law and uphold the employee's due process. I am not in favor of 
routinely transferring employees to other positions (detailing) or in 
using paid administrative leave.

    Question 41.  For fiscal year 2015, the Office of Special Counsel 
(OSC) processed 2,165 cases from the VA. The agency with the next 
highest case load was the Department of Defense (DOD), with 1,322 
cases--despite the fact that the DOD has twice as many civilian 
employees as the VA. Last Congress, OSC testified that the overwhelming 
volume of VA complaints presented numerous challenges to the agency 
charged with investigating and enforcing our Nation's whistleblower 
protection statutes.
    a. Do you agree that the VA has a cultural problem with respect to 
reprisal on whistleblower?
    b. How will you improve the culture of the VA with respect to 
whistleblowing?
    c. If confirmed, how will you work with the Office of Special 
Counsel to investigate whistleblower claims and ensure that VA 
whistleblowers are protected?
    d. If confirmed, will you commit to holding managers that engage in 
whistleblower retaliation accountable?
    Response. We have made a lot of progress since Fiscal Year 2015 in 
the way we approach whistleblower disclosures and whistleblower 
retaliation claims. We've been working with OSC in closer collaboration 
than I think any other Federal agency does, working jointly with them 
to train our supervisors and managers on the whistleblower laws, to 
expedite relief to employees who may be experiencing retaliation, and 
to improve the sense of psychological safety that we need our employees 
to have so they feel comfortable speaking up when some aspect of our 
service to Veterans is in some way flawed. We've also reorganized the 
functions within VA that investigate whistleblower disclosures and 
retaliation claims, as well as the functions that track referrals we 
receive from OSC and from our Inspector General's office, to provide 
greater visibility over these issues and ensure we are thorough and 
consistent in our approach.
    With respect to the volume of disclosures and retaliation 
complaints that OSC receives from VA employees, I do think we need to 
be mindful that only a small percentage are substantiated, but of 
course OSC needs to review all of them to be sure VA's programs are 
being conducted properly and our employees are being treated fairly. I 
am hopeful that Congress will continue to properly resource OSC to do 
this critical work. If confirmed, I would hold mangers accountable for 
whistleblower retaliation.

    Question 42.  If confirmed, how will you work with the VA Office of 
Inspector General to investigate whistleblower claims and ensure that 
VA whistleblowers are protected?
    Response. I would refer any whistleblowers claims of serious 
misconduct to the OIG and would implement any recommendations that 
result from that review. As well as ensure any disciplinary actions are 
taken by any misconduct identified by the OIG. Also, I will take the 
necessary steps to ensure the whistleblowers identity is kept 
confidential, if so requested.

    Question 43.  There have been several instances when VA employees 
who are also veterans blow the whistle on wrongdoing at their 
facilities, they have had their private medical records improperly 
accessed by coworkers and used to discredit their claims.
    a. Do you believe that HIPPA provides enough protections for VA 
employees that encounter these experiences? If not, will you work with 
us to enact additional protections into law?
    Response. Yes, I believe that HIPPA provides the necessary 
protections. I would be willing to consider and work with you on 
additional protections if they are necessary.

    b. Will you commit to ensuring that employees that VA employees who 
improperly access VA whistleblowers' medical records as a means of 
retaliation are held accountable?
    Response. Working collaboratively with OSC and the Privacy officer 
here within VHA, we have developed a new process to investigate and 
deal with issues of this type. I don't think we need any additional 
statutory protections to address this issue; we just need to keep 
enforcing the statutes and other legal authorities we already have. I 
will of course commit to ensuring that whistleblowers are protected 
from all manner of retaliation, including improper access to their 
medical records, and to holding accountable anyone who engages in 
retaliatory conduct.

    Question 44.  In August 2016, the VA released its comprehensive 
report on veteran suicides after analyzing 3 million records in only 20 
states, with the result being 20 veterans a day taking their life. 
Another study commissioned by the Senate VA committee in 2013 directly 
linked the prescription of psychiatric drugs to an increase in the 
veteran suicide rate, and it cited a report that Health and Human 
Services and Centers for Medicare and Medicaid Services published in 
August 2013, stating, ``Antidepressant medications have been shown to 
increase the risk of suicidal thinking and behavior.''
    In the 114th Congress, I was visited by a veteran and his service 
dog, who informed me of the training his dog received to help with his 
specific symptoms of PTSD. He prvided a peer-reviewed study from 
researchers at Purdue University and the Human Animal Bond Research 
Initiative on the efficacy of service dogs for suicidal veterans with 
positive results. Shortly after the meeting, I cosponsored the PAWS 
Act, which would provide VA-supervised service dogs to our nations 
veterans as a complementary or alternative method of treatment. Will 
you commit to exploring this option during your tenure as Secretary, 
and more broadly commit to research involving other alternative methods 
of treatment in an effort to continue reducing the tragically high rate 
of veteran suicides?''
    Response. VA is aware of the interest in the potential therapeutic 
value of service dogs in the treatment of PTSD and other mental health 
disorders. That is why, on my initiative, VA's Center for Compassionate 
Innovation has launched a pilot program pairing Veterans with Mental 
Health Mobility Service Dogs. At the same time, VA is in the process of 
completing a landmark study on service dogs in the treatment of PTSD. 
We are also continuing to work with your office on the PAWS Act and 
look forward to coordinating with you on next steps in this direction. 
I will gladly commit to further research involving this and other 
alternative methods of treatment during my tenure as Secretary.
    We are committed to evaluating the impact of service dogs on the 
quality of life for Veterans with mental health conditions in the 
following three ways:

     Animal Assisted Therapy programs where Veterans are part 
of the training process for service dogs, particularly around 
socialization of the service dogs in different settings
         - Socialization of the dog in crowds, on elevators, in public 
        places, etc. necessitates the Veteran involved in the training 
        to be in these settings
         - Allow the Veteran to apply coping strategies learned in 
        therapy to real-life situations while training the dog
         - Gives the Veteran a sense of purpose and `giving back' to 
        others since the dogs are ultimately paired with another 
        Veteran with a physical disability
         - Several programs across the country; program at Palo Alto 
        has been in place almost 9 years with many success stories

     Mental Health Mobility Impairment Service Dog Initiative 
where Veterans with substantial mobility limitation secondary to a 
mental health condition are eligible for the veterinary health benefit
         - Evaluation by a multidisciplinary team, including a mental 
        health clinician, determines that a service dog is the optimum 
        intervention to overcome or mitigate the mobility limitation
         - Mobility limitation may include difficulty navigating public 
        spaces, completing the activities of daily life such as 
        shopping in a grocery store, and coming into the clinic for 
        appointments
         - Center for Compassionate Innovation, Mental Health, and 
        Prosthetics and Sensory Aid Services are teaming up to evaluate 
        quality of life and satisfaction outcomes from 100 Veterans 
        under this initiative
         - 7 Veterans have been approved for the veterinary benefit, 4 
        have dogs and 3 are in the process of being paired with a 
        service dog, and 20 are going through the evaluation process 
        with their multidisciplinary teams

     PTSD Service Dog Study
         - Recruitment is at greater than 80%; recruitment anticipated 
        to be completed by spring
         - Fully staffed with all dog trainers (on board). Two per 
        study site at three study sites equal six (6) trainers. A 
        seventh trainer serves as the supervisor

    VA supports a range of studies on post-deployment mental health 
concerns such as PTSD, depression, anxiety, substance abuse, and 
suicide. Research aims to:

     describe the incidence and prevalence of mental health 
disorders,
     identify their risk factors, including pre- and post-
deployment assessments,
     quantify effect of deployment on future health outcomes
     understand the basic mechanisms underlying disorders,
     identify new effective treatments, and
     develop models of care that will deliver effective 
treatments more quickly, widely, and reliably to Veterans in need.

    During the last 18 months, VA and other Federal research funding 
agencies have worked together to address the mental health needs of 
Veterans through the National Research Action Plan (NRAP), developed in 
response to President Obama's Executive Order 13625. The plan outlines 
the vision for PTSD, TBI, and suicide prevention research and describes 
requirements intended to help the agencies successfully reach important 
research goals over the next few years.
    VA also participates in developing cross-agency priority goals for 
Veterans' mental health. These goals, coordinated by the Office of 
Management and Budget (www.performance.gov), will establish common data 
elements for PTSD and suicide prevention, which will improve the 
coordination of research efforts across Federal agencies. Earlier 
efforts produced common data elements for TBI and substance use.
    VA is also implementing a randomized program implementation: Block 
randomization or step-wedge design techniques, is a method by which one 
can assess the efficacy of a program during and after implementation, 
which is the strength of randomized clinical trials. This technique, if 
it can be made to work on a large scale, is much more reliable as a 
program assessment tool than the use of historical controls or pilot 
projects. This research work stream will attempt to use randomized-
program implementation in several program rollouts to determine 
feasibility and barriers to implementation of this approach in the VA 
healthcare system. The function of assessment tools will depend upon 
the output of the Measurement Science work stream; and the rollout 
strategy employed may benefit from output of the Operations Research 
work stream. Current randomized program implementation initiatives have 
been launched to determine effective approaches for suicide prevention, 
opioid prescribing, telehealth, and home-based geriatric services.
    VA is also studying the use of service dogs for Veterans with PTSD. 
A multisite study will provide eligible Veterans with either an 
emotional support dog or a service dog that has been specifically 
trained to perform tasks that mitigate PTSD. Researchers will look for 
improvements in participants' PTSD symptoms, quality of life, 
participation in society, and employment status.
    As of the second week in December 2016, 180 of 220 Veterans (82%) 
have been recruited and assigned to receive either a service dog or an 
emotional support dog. At the current rate of recruitment, the 
remaining 40 Veterans should be enrolled by May 2017.

    Question 45.  Do you believe the VA can benefit from public/private 
partnerships, specifically with existing healthcare facilities and new 
construction?
    Response. Yes. Public private partnerships can support the right 
sizing and adaptation of VA's owned infrastructure that could realize a 
better return on investment for Veterans and taxpayers. Partnerships 
can take various forms and should be evaluated against VA's needs and 
on a lifecycle cost basis compared to a traditional public sector 
project.
    VA is presently exploring up to five infrastructure partnerships 
pursuant to the Communities Helping Invest through Property and 
Improvements Needed for Veterans (CHIP IN) Act that passed in late 
December 2016. VA enjoys collaborations with numerous healthcare 
affiliates, universities and community hospitals, which could be 
enhanced with the ability to share space and facilities that is limited 
by current laws and regulations. VA has also had success through its 
enhanced use lease (EUL) partnership program to leverage private 
investment with little or no government funding. Further flexibility, 
including expanding EUL legislation and a broader authority for public 
private partnerships will provide VA the potential partnerships to 
build or lease new or renovate/reuse existing facilities.

    Question 46.  The VHA has been attempting to address the issues of 
interoperability with other departments, including Defense and HHS 
along with the general healthcare community. With the growth of the 
Choice Act, what is your plan to achieve interoperability with these 
diverse entities?
    Response. One of the goals of VA Community Care is to establish a 
clear process for Veterans to seamlessly transition between VA, DOD, 
HHS and community providers. In order to improve the coordination of 
care and reduce administrative burden, VA will implement integrated 
administrative systems for eligibility, referral, authorizations, 
provider payments and customer service. To that end, we will leverage 
technology to:

    (1) Provide easy to understand eligibility information to Veterans, 
community providers and VA staff
    (2) Provide Veterans timely access to a community provider by 
automating referral and authorization process
    (3) Provide tools to ensure access to high-quality care inside and 
outside VA
    (4) Coordinate care through seamless health information exchange
    (5) Increase automation to support accurate and timely payment of 
community providers
    (6) Provide tools for quick resolution of questions and issues for 
Veterans, community provider and staff.

    These improvements will be implemented through a system of systems 
approach which involves the design, deployment, and integration of 
systems. Implementation of this approach will be executed through rapid 
cycle deployment using agile methodologies. This will allow VA to fix 
the most pressing issues with community care today, while making 
continuous updates to promote a learning health system that evolves 
with the needs of the Veteran population.

    Question 47.  The Choice Act has shown the need for outside 
providers to service veterans, at least those geographically removed 
from department operated sites. How do you envision creating a better 
system for coordinating care and services of veterans utilizing the 
choice program and monitoring the outcomes of choice providers and 
ensuring all veterans receive the same excellent level of care and 
services wherever they go?
    Response. VA's high performing network will have preferred 
providers that meet quality, safety and reliability metrics to ensure 
excellent level of care for all Veterans. Our contracted network TPAs 
will work collaboratively with the VA provider relations office, and 
local VAMCs to ensure local and regional community care partners join 
the network to meet the unique needs in a Veteran's community. We will 
also have regional quality and peer review committees with membership 
from both our contractors and the VA. We will match as closely as 
possible community standard quality metrics and VA metrics to ensure 
Veterans receive excellent quality of care within our integrated 
network which includes VA and our community partners. VA is also 
creating tools for the secure and seamless exchange a vital health 
information. These tools are currently being tested in the field at 
several VAMCs and their community partners.

    Question 48.  The private sector has made many advances in both 
technology and procedures in the medical field. How do you implement 
these advances into the department? Will you implement these through 
pilot projects to better evaluate their applicability to the Veteran 
environment? How will you encourage private entities to bring their 
innovations to the department in a timely manner?
    Response. VA must take advantage of technology advances in the 
private sector to improve care and services for Veterans. OI&T has 
shifted its mindset from complex customized acquisitions to leveraging 
the best of private sector existing technology and innovative 
mechanisms like public private partnerships. This not only improves 
speed to market, but allocates resources efficiently, and ensures VA is 
using the best technology available. Our strategic sourcing approach 
consolidates VA's IT purchasing power to obtain and deliver the best 
solutions to our Veterans from the best industry talent at the best 
price. Strategic Sourcing will provide access to best-in-class 
suppliers; ensure strong contractual performance through continuous 
monitoring; improve our speed to market, product compliance, and 
quality; ensure our compliance with Federal Information Technology 
Acquisition Reform Act (FITARA); provide greater technical capabilities 
for VA and our Veterans; and foster the most responsible allocation of 
taxpayer dollars.
    Initiatives like this have been proven successful in efforts such 
as the Digital Health Platform (DHP) proof of concept, which utilized 
the public private partnership construct with an academic partner. DHP 
is a first-of-its-kind public-private partnership that will redefine 
the concept of ``interoperability.'' DHP is a cloud-based platform. It 
is not hampered by software updates and changing technology. It is 
flexible and open. DHP already works with existing health platforms 
such as VistA, Cerner, Epic, and more. Future developments can be 
sourced industry wide.
    Additionally, we are utilizing private sector solutions through 
VA's Center for Innovation (VACI). The work of VACI is driven by a 
strong commitment to a Veteran-centered approach to service delivery, 
and dedication to data-drive decisionmaking, design thinking, and agile 
development. We do this through competitions, special projects, human 
centered design, innovators network, open innovation, and fellowships.

    Question 49.  I request specific data regarding the number of VA 
employees who are currently or were held on administrative leave due to 
offenses of misconduct. Of those, how much has the VA exhausted on 
their salaries while on administrative leave and unable to fulfill the 
duties for which they were hired?
    I requested this information as an advance question prior to your 
hearing but it was not answered. Your response was a 29-page 
spreadsheet listing individuals with ``proposed actions'' and ``actions 
taken'' regarding their ``sustained offenses.'' There is no data 
regarding the number of days each individual was on administrative 
leave due to the ``sustained offenses'' and just as important the 
dollar amount exhausted on administrative leave during the time period 
when the individual was put on administrative leave and when they were 
reinstated, if at all. The response also does not include a summary 
clearly explaining the total number of VA individuals and total cost 
incurred by the Federal Government. Please furnish this data and if 
there is no method by which the VA has tracked and collected this data, 
please explain why and how intend to furnish this data.
    Response. In response to your request for specific data regarding 
the number of VA employees placed on administrative leave related to 
misconduct, and the salary costs associated with such administrative 
leave, the attached table lists 25 employees who are/have been placed 
on administrative leave during the current Fiscal Year. The table lists 
the total number of days each employee was on administrative leave, the 
salary dollar value of the administrative leave, and date the 
administrative leave period ended.
    I am aware of a newspaper article that recently quoted a much 
higher number of VA employees that have been placed on administrative 
leave. I have not been able to have this data confirmed by the VA 
Department of Human Resources. I will continue to ask VA to provide me 
with the comprehensive data that would substantiate this number. The 
issue that I am told is difficult to do is that administrative leaves 
are recorded for many reasons other than disciplinary issues. 
Regardless of the difficulty in reporting this data, if confirmed as 
Secretary I would use my office to ensure that the practice of paid 
administrative leave is used as little as possible and only when 
absolutely required.
    Finally, by way of context, at VA, as at other Federal agencies, 
administrative leave may be used to take an employee out of the 
workplace while agency management or another entity (such as the Office 
of Inspector General) investigates to determine whether the employee 
has engaged in misconduct warranting adverse action. Employees may also 
be placed on administrative leave during the time period between the 
delivery of a proposed removal or other adverse action and the issuance 
of a final decision on the proposal.

 
----------------------------------------------------------------------------------------------------------------
               Factors                                              Mitigation Plan
----------------------------------------------------------------------------------------------------------------
Increasing Demand/Lack of Providers    Active recruitment of health care providers and clinic staff--VA
 and Clinic Staff.                     increased provider and nursing staffing by approximately 12% over the
                                       past two years
                                       Granting full practice authority for Advanced Practice Nurses
                                       Increase use of telehealth for Primary Care and Mental Health
                                       Use of community care resources when unable to recruit providers
                                       Increased use of extended clinic hours
----------------------------------------------------------------------------------------------------------------
Inefficiencies in clinic practices..   Implemented Clinic Practice Management Program across VA--in this
                                       program all facilities have at least one group practice manager to
                                       oversee and optimize administrative clinic activities
                                       Validating clinic grids to achieve optimal clinic capacity
                                       Focus on improving productivity--increased productivity by 16%
                                       over past two years
                                       Developed strategies for reducing ``no show'' rates, and
                                       redesigning clinic space
                                       Implemented standardized face to face Clinic Clerk Training for
                                       optimal scheduling of patients
                                       The above efforts have resulted in an increase in 12,000
                                       appointments daily in 2016 when compared to 2014
----------------------------------------------------------------------------------------------------------------

                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. John Boozman to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
    Question 50.  Dr. Shulkin, you have rightly stated that the VA 
should stop doing the things the VA doesn't do well. I think many would 
agree that the VA does not have the strongest track record when it 
comes to VA led IT solutions, to include software development. 
Countless iterations of VISTA and a currently disjointed scheduling 
system are cases in point.
    Yet, the VA is again pursuing what appears to be a VA solution to 
scheduling software with VSE. This is concerning, when there are many 
commercially available, proven and affordable off-the-shelf solutions. 
Even more concerning is at the hearing yesterday you also referenced an 
additional VA scheduling tool, called MASS. I am very concerned the VA 
is moving forward with multiple scheduling tools, at great cost, 
without giving adequate thought to commercially available solutions, 
interoperability and effectiveness. An even greater, overarching 
concern is the scheduling solutions you describe did not mention how 
they would integrate into an even larger EHR transition. Lack of 
preparation and the absence of a coordinated strategy are what led to 
the disjointed IT architecture VA has now.

    a. Please describe how you have arrived at multiple software 
solutions, the respective capabilities and objectives of VSE and MASS, 
anticipated costs, as well as what consideration has been given to 
ensuring interoperability with existing platforms and needs.
    Response. Improving the tools to support accurate and timely 
scheduling is a top priority for VA and critical to our ongoing efforts 
to expand and improve access. VA's current legacy scheduling 
application successfully schedules millions of appointments, but it is 
cumbersome to use, does not have a modern look-and-feel, and does not 
include functions that can drive improved operational efficiencies. VA 
is focused on providing our workforce with modern scheduling tools. 
Please find additional details below.
                                  vse
    VistA Scheduling Enhancements (VSE) is a cost-effective, interim 
solution to bring an urgently needed modern interface to the antiquated 
VistA scheduling package. VSE is currently being piloted in multiple 
clinical settings at five VA facilities. If the pilot is successful, 
VSE will be implemented nationally until a permanent and complete 
solution is available. The ``go /no go'' decision related to VSE is 
anticipated by February 10, 2017 after feedback from the pilot sites. 
The costs for the pilot sites are less than 10 million. The anticipated 
spending on VSE through FY 2019 is $36 million, which includes 
development, enhancement and national deployment costs.
                                  mass
    In addition to VSE, VA awarded a contract for the Medical 
Appointment Scheduling System (MASS). The Medical Appointment 
Scheduling Solution (MASS)is a best-in-class Commercial off the shelf 
(COTS) resource-based scheduling tool. MASS is being piloted in
    Boise, Idaho as a potential long term solution to VA's scheduling 
needs. The future potential deployment costs and approach will be 
clarified through this MASS pilot. As you note in your question, 
scheduling decisions must be made as part of a broader view of Health 
IT strategy at VA. The anticipated spending on MASS through FY 2017 is 
$19.5 million, with the total spending to be determined after 
completion of the pilot. However, if VSE is determined to meet the 
needs of our schedulers and a decision is made to proceed with a 
national rollout then the Mass pilot could be stopped and the cost of 
the pilot would be significantly less.

    b. Please explain how these tools affect the self-scheduling pilot 
project required by the Faster Care for Veterans Act.
    Response. The Faster Care for Veterans Act requires a full and open 
competition for a Commercial Off-the-Shelf Solution (COTS) self-
scheduling application for use by Veterans. The Request for Proposal 
(RFP) to acquire that application is on-track for release by 
February 14, 2017 with an anticipated contract award date of April 17, 
2017, as required by the Act. The Act stipulates that these self-
scheduling solutions must integrate with VA's current scheduling 
platform, VistA, or any future scheduling platform.
    Prior to the Faster Care for Veterans Act, VA developed the Veteran 
Appointment Request (VAR) self-scheduling application through a 
contract. VAR allows Veterans to self-schedule Primary Care 
appointments with their Patient-Aligned Care Team and to request 
assistance in booking both Primary Cary and Mental Health appointments 
at VA facilities where they receive care. As of February 3, 2017, VAR 
is operating in 42 VA medical centers and expansion to additional sites 
is planned.

    c. Please provide specific details regarding the RFI that was 
recently issued regarding the Faster Care for Veterans Act pilot, to 
include justification as to why the VA has imposed such restrictive 
requirements which exceed congressional intent and may impede full 
consideration of available, commercial off-the-shelf solutions.
    Response. The intent of the RFI is to conduct market research and 
ensure that VA is in a position to gather the best information on 
commercial-off-the-shelf (COTS) solutions that will meet the 
requirements specified in the legislation. In addition, the RFI 
provides VA with the information to determine if the procurement must 
be set aside for competition among Veteran-owned-small-businesses 
(VOSB) in compliance with the June 16, 2016, U.S. Supreme Court 
decision regarding Kingdomware Technologies, Inc. v. United States 
(Kingdomware) case.
    In order to ensure the solution is scalable, reliable, and 
sustainable, the RFI questions sought to determine the range of options 
available. In addition, the RFI included questions that provided 
additional information to determine the stability of the recommended 
solution.
    The questions on case studies allowed the supplier to demonstrate 
that the proposed solution is fully operational, and supports the 
intent of the legislation. It should be noted, that the VA has received 
8 responses, several of which are not current VA contractors. This will 
provide excellent input to the next phase--the release of the RFP by 
February 14, 2017.

    d. Will you ensure, as the Faster Care for Veterans Act requires, 
that the RFP is free and open and not limited to existing VA 
contractors? How will you ensure that a pilot is launched quickly and 
safely without unreasonable customization?
    Response. Yes, we fully expect it will be a full and open 
competition as required by the Act. We expect the RFI market research 
will demonstrate that VA is not required to restrict the competition to 
SDVOSB or VOSB vendors in accordance with Public Law 109-461 (38 U.S.C. 
8127 and 8128) ``Kingdomware decision.'' There have been eight 
respondents to the RFI; several of which were not current VA 
contractors. It is in both VA's and the taxpayer's interest to select a 
partner that can offer a product that does not require extensive 
customization in order to meet the criteria set out in the law.
    The RFP is not restricted to those who responded to the RFI, and VA 
expects many more suppliers can provide their solutions during the RFP 
solicitation process.
    The requirements included in the RFP are being reviewed to ensure 
they are sufficient to meet critical VA needs, including security, 
privacy, VistA integration, and identification of patient eligibility 
without exceeding the capabilities specified in the Act. VA is prepared 
to move forward once a successful award is made, and the pilot is 
planned to begin shortly after contract award (on-target for April 17, 
2017).

    e. Finally, please describe how you are standardizing functions 
across the entire VA enterprise and leveraging other large EHR 
implementations to prepare for such a large transition to a fully 
functioning electronic health record.
    Response. VA is currently reviewing options regarding long-term EHR 
modernization which include continuing to upgrade VistA, shift to a 
commercial EHR platform, some combination of both, among other 
alternatives.
    In order to enhance our clinical practice standardization, VA will 
leverage the Enterprise Health Management Platform (eHMP), which is now 
deployed and in pilot testing throughout the VA system. It provides a 
structured interface for standardization of clinical processes and can 
be utilized with our current legacy systems or a commercial EHR.
    In addition, the VA has developed a Digital Health Platform concept 
that has a goal of standardizing functions across the entire VA, and 
provide a comprehensive end-to-end model for integrating healthcare 
across an individual's lifespan enabling interoperability among systems 
much more efficiently than traditional system integration efforts. VA 
is actively reviewing all of the above technology approaches and 
frameworks so as to make future-looking Health IT modernization 
decisions that provide cutting edge technology to VA medical providers 
serving Veterans in the most cost-effective manner.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Bill Cassidy to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
                             toxic exposure
    Question 51.  Dr Shulkin, in 2002 the VA stopped granting the 
presumption of Agent Orange exposure to those veterans who served in 
the bays, harbors and territorial seas of the Republic of Vietnam 
despite the fact that there is strong evidence of infiltration of 
toxins into those harbors and bays. In 2015, the Court of Appeals for 
Veterans Claims (Gray v. McDonald) found that the VA had excluded the 
bays and harbors from the definition of ``inland waters,'' and ordered 
that the VA rewrite the regulation based upon the probability of 
exposure due to river discharge.
    The VA currently continues to exclude these bays and harbors from 
the definition of inland waters. We all agree the rivers were 
contaminated and rivers run into the harbors and bays. Maritime traffic 
and anchoring kept that area in a state of flux and the Institute of 
Medicine has also confirmed a plausible pathway for the dioxin to have 
entered the shipboard potable water system via the shipboard 
distillation system, which actually enriheds the dioxin. Will you be 
taking action to restore benefits to these veterans?''
    Response. This case (Gray v. Acting Secretary) remains under 
litigation. VA believes its revised policy, in response to this 
litigation, is consistent and fair, as it clearly delineates between 
inland waterways and offshore waters. In addition, this policy is 
consistent with evidence concerning the spraying of Agent Orange in 
Vietnam.
    VA previously extended the presumption of exposure to herbicides to 
Veterans serving aboard U.S. Navy and other vessels that entered Qui 
Nhon Bay Harbor or Ganh Rai Bay. In the interest of maintaining 
equitable claim outcomes among shipmates, VA will continue to extend 
the presumption of exposure to Veterans who served aboard vessels that 
entered Qui Nhon Bay Harbor or Ganh Rai Bay during specified periods 
that are already on VA's ``ships list.'' VA will no longer add new 
vessels to the ships list, or new dates for vessels currently on the 
list, based on entering Qui Nhon Bay Harbor or Ganh Rai Bay or any 
other offshore waters.
    VA will continue to look at additional evidence and adjust policy 
as appropriate.
                              telemedicine
    Question 52.  Dr. Shulkin, do you view telemedicine as a platform 
that could improve access and quality for the critical health care 
needs of our Veterans? If so could you please elaborate on the role 
telemedicine might play in the future of the VA and care in the 
community.
    Response. Telemedicine represents a key component of VA's strategy 
to enhance access to the highest quality medical services for our 
Telemedicine represents a key component of VA's strategy to enhance 
access to the highest quality medical services for our Veterans. VA 
completed 2.1 million telemedicine visits across 50 specialties last 
year, providing service to more than 700,000 Veterans. VA will continue 
to leverage and expand Telemedicine programs to share valuable clinical 
resources across the healthcare system, facilitating support from large 
and academically affiliated VA facilities to Veterans in rural and 
underserved areas. VA has initiated or expanded projects for 8 Primary 
Care and 10 tele-mental health hubs to serve Veterans in regions where 
demand exceeds capacity, and 45% of telemedicine visits last year were 
delivered to Veterans in rural areas. VA is also building its capacity 
to support Veteran access to specialized care that is in short supply 
in some areas of the country, including tele-genomics, tele-ICU, tele-
dermatology and tele-rehabilitation services. In addition, VA delivered 
more than 39,000 clinical video visits to Veterans' homes last year, 
and home telehealth programs have produced a reduction in hospital 
admissions. Continued expansion of mobile and home telehealth programs 
is planned.
    Currently, telemedicine in Community Care is only in San Diego. VA 
hopes to expand in other markets once we get it up and going. VA 
completed 2.1 million telemedicine visits across 50 specialties last 
year, providing service to more than 700,000 Veterans. VA will continue 
to leverage and expand Telemedicine programs to share valuable clinical 
resources across the healthcare system, facilitating support from large 
and academically affiliated VA facilities to Veterans in rural and 
underserved areas. VA has initiated or expanded projects for 8 Primary 
Care and 10 tele-mental health hubs to serve Veterans in regions where 
demand exceeds capacity, and 45% of telemedicine visits last year were 
delivered to Veterans in rural areas. VA is also building its capacity 
to support Veteran access to specialized care that is in short supply 
in some areas of the country, including tele-genomics, tele-ICU, tele-
dermatology and tele-rehabilitation services. In addition, VA delivered 
more than 39,000 clinical video visits to Veterans' homes last year, 
and home telehealth programs have produced a reduction in hospital 
admissions. Continued expansion of mobile and home telehealth programs 
is planned.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Thom Tillis to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs
                               va leases
    Question 53.  As you know, Congress has not, through a regular 
process, authorized Department of Veterans Affairs (VA) major medical 
facility leases since a 2012 change in budgetary scoring of these 
leases by the Congressional Budget Office (CBO). This change in 
budgetary scoring has resulted in VA major medical facility leases 
receiving large, up-front spending scores, despite the fact that actual 
spending would not increase. This issue has prevented Congress from 
authorizing two dozen major medical facility leases in 15 states, 
including in Virginia and North Carolina, states with some of the 
fastest growing populations in the Nation. If confirmed as Secretary of 
Veterans Affairs, what are your plans to address this problem? How can 
we, as elected officials, better assist VA in finding a solution to the 
lease authorization issue?
    Response. If confirmed, I will work diligently with the 
Congressional Budget Office (CBO) and Congress to come to a resolution 
in order to move the 24 pending leases forward. These leases are 
critical to providing care to Veterans and represent 2.7 million annual 
clinic visits. Specifically, I will work with CBO to highlight the key 
changes VA is currently implementing to standardize our leasing process 
and requirements to further demonstrate that the leases are not similar 
to government purchases of facilities built specifically for VA's use. 
It is paramount that we all work together to find a solution.
                       community care network rfp
    Question 54.  When the VA put together its plan for the community 
care network, did the Department consider the disruption to veterans 
from these changes--including in the urgent and emergent pharmacy 
program? If so, what methodology did you use and most importantly, what 
are you planning to do to ensure veterans do not see a disruption in 
their access to critical medicines?
    Response. Changes to prescription fulfillment processes for the 
Community Care Network (CCN) combine existing requirements for the PC3 
program, the Choice program and the approximately 75 regional and local 
``first fill'' pharmacy contracts. The changes were made considering 
the impact on Veterans and were specifically designed to improve 
services by:

    a. Expanding the number of urgent/emergent drugs available.
    b. In comparison to approximately 75 existing regional and local 
first fill contracts, the urgent/emergent drugs available under the CCN 
is in some cases a reduction but in many cases it is an expansion.
    c. Eliminating the out-of-pocket costs Veterans must now pay for 
their PC3 and Choice urgent/emergent prescriptions.
    d. Eliminating the need for Veterans to seek reimbursement from VA 
for PC3 and Choice urgent/emergent prescriptions.
    e. Ensuring continuity of care by making urgently needed 
medications not listed on the CCN drug list to be available via a prior 
authorization process.
    f. This feature is not currently available uniformly across the VA 
system.
    g. The changes to non-VA prescription fulfillment processes were 
developed with significant input from field-based VA pharmacists who 
were charged with improving access, patient safety and the customer 
experience. VA's formulary management process is dynamic, updated 
continuously to meet the needs of Veterans and the evolving health 
system. In the unlikely event the changes result in disruption of 
services to Veterans, VA has the ability to modify the process to avoid 
the disruptions.
                      faster care for veterans act
    Question 55.  Late last year, the Faster Care for Veterans Act was 
signed into law by President Obama. As you may know, the legislation 
directs the VA to establish a pilot program to test commercial off-the-
shelf scheduling solutions, such as cloud-based applications and 
services, to allow veterans to book their own appointments online or on 
a mobile device, in real-time, 24-7. The goal is to help the VA rebook 
the 18 percent of appointments that are generally wasted due to last 
minute cancellations, scheduling changes, and no-shows, enabling more 
veterans to access timely care.
    As you know, the VA has a long history of trying to build 
scheduling solutions in-house. Will you prioritize solutions that are 
already proven to work at scale in the private sector?
    Response. Yes, VA's OI&T has implemented a buy-first strategy, 
which is utilized whenever possible.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mike Rounds to Hon. 
  David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department of 
                            Veterans Affairs
           the va and certified registered nurse anesthetists
    As you know, on December 14, 2016, VA issued the final rule 
providing full practice authority for advanced practice registered 
nurses with an effective date of Jan. 13, 2017, which excluded 
Certified Registered Nurse Anesthetists (CRNAs).

    Question 56.  What is the VA's rationale for excluding Certified 
Registered Nurse Anesthetists (CRNAs) in the final rule?
    Response. Amending this regulation increases VA's capacity to 
provide timely, efficient, and effective primary care services, as well 
as other services. This increases Veteran access to needed VA health 
care, particularly in medically-underserved areas and decreases the 
amount of time Veterans spend waiting for patient appointments.
    CRNAs play a critical role in providing care for our Veterans. We 
did not find that VA had immediate and broad access challenges in the 
area of anesthesia that would require including CRNAs in the final 
rule. If VA learns of access problems in the area of anesthesia care in 
specific facilities or more generally that would benefit from FPA, now 
or in the future, or if other relevant circumstances change, we will 
consider a follow-up rulemaking to address granting FPA to CRNAs. VA 
CRNAs that are granted full practice authority by their state license 
will continue to practice in VA in accordance with their state license 
and subject to credentialing and privileging by their VA medical 
facility's medical executive committee. VA will not restrict or 
eliminate these CRNAs' full practice authority.

    Question 57.  Would the VA experience cost savings by hiring CRNAs 
and thereby increasing the capacity of the VA to administer anesthesia 
instead of using non-VA anesthesia practitioners in some cases?
    Response. VA believes a team-based approach to anesthesia care 
provides the best outcomes to Veterans. Cost is not the primary driver 
in making decisions on behalf of Veterans. We do employee CRNA's as 
part of the team and believe we are cost effective. Contracting cost is 
not necessarily more expensive than having VA paid Full-Time Employee 
Equivalents. This is complex and involves the use of anesthesia 
residents (allowed to work for 80 hours/week) in many locations, and is 
considerably cheaper than Physician Assistants and Nurse Practitioners 
in the ICUs, as an example. Additionally, some contracting is for 
specialty services that are not needed on a full-time basis (e.g., 
coverage of evoked potential surgery, coverage of liver transplants). 
Because of this complexity, it is very difficult to estimate the 
system-wide effect.

    Question 58.  Despite the VA assessing no anesthesia workforce 
shortage overall, would a local VA facility potentially benefit from 
more hiring flexibility to fill anesthesia workforce positions?
    Response. There could always be some benefit in more hiring 
flexibility in order to improve access to care for Veterans. If VA 
learns of access problems in the area of anesthesia care in specific 
facilities or more generally in VHA facilities that would benefit from 
advanced practice authority, now or in the future, or if other relevant 
circumstances change, VA will consider a follow-up rulemaking to 
address granting FPA to CRNAs.
            traumatic brain injury and post-traumatic stress
    Question 59.  If confirmed, how will you work to prioritize 
research and the development of new treatments for PTS and TBI, two 
devastating and life-threatening conditions that disproportionately 
affect veterans long after they are in combat?
    Response. If confirmed as Secretary, I would work toward advancing 
VA's core research mission. While there is much more to learn, VA is 
already a world leader in research on PTSD and TBI. VA was, in fact, 
established to take on the mission of studying and treating the health 
consequences of military service. No other health system has the 
mandate, the research portfolio or the clinical expertise to carry out 
this mission. VA researchers developed and fielded the gold standard 
tools in PTSD research and are pioneering new diagnostic and treatment 
approaches to TBI. As demonstrated in our recent Brain Trust 
Conference, VA knows that, as good as we are we cannot accomplish the 
mission alone. VA is highly focused in our research program to test, 
confirm and implement new treatments for PTSD and TBI, working closely 
with partners in other research agencies. A specific highlighted new 
activity is concentrating on launching studies of new medications and 
other therapies for PTSD where we will be establishing public private 
partners (PTSD Psychopharmacology Initiative). I stand committed to 
work with the best within VA and synergize our efforts with researchers 
across the country and around the world to meet the health needs of our 
Nation's Veterans.

    Question 60.  With public and private partners, studies on post-
mortem brain tissue from the VA's National Center for PTSD Brain Bank, 
have improved our understanding of how TBI and PTS affect the brain and 
helped discover potential targets for new treatments. How can the VA 
continue to support these successful efforts and work to close research 
gaps?
    Response. As you note, VA's National Center for PTSD Brain Bank, 
the first of its kind, was established to significantly advance our 
understanding of how the health effects of military service affect the 
brain and to develop new treatments to improve the lives of Veterans. I 
am committed to supporting the efforts of VA's world-class research and 
clinical teams and of integrating their efforts with those of public 
and private partnerships to identify and tackle the next breakthroughs 
in research and treatment. We will maintain VA's new Office of Public 
Private Partnerships and participate in engagement programs such as 
Stand Down on Suicide Prevention, VA Brain Trust Conference and meet 
with leaders of major pharmaceutical companies to ensure that the right 
people and the right teams are closing those gaps and identifying the 
next research horizons. VA Research has a long history of working in 
partnership to move evidence for new treatments forward. We are 
currently launching new treatment trials under our PTSD 
Psychopharmacology Initiative, however, efforts are ongoing to continue 
to improve understanding and advance treatment for TBI and PTSD in a 
robust portfolio of clinical trials, epidemiology, and health services.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Dan Sullivan to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
    Question 61.  Do you believe the current hiring process within the 
VA is as timely and efficient as it could be? If not, what do you 
believe should done in order to improve the current system so that 
hiring high-quality personnel occurs as expeditiously as possible?
    Response. There are a number of efforts that will need to continue 
in order to improve the hiring processes and lessening the time to fill 
jobs. The hiring metric established by the Office of Personnel 
Management for filling jobs open to the general public is 80 days. The 
VA hiring metric for filling jobs open to the current Federal workforce 
is more aggressive and is 60 days; I support this goal. VA's hiring 
managers and human resources offices take every opportunity to fill 
jobs quickly by using noncompetitive hiring authorities when there are 
qualified and eligible applicants, such as Veterans. In addition, I 
believe we will improve the timeliness and efficiency of the hiring 
process by:

     Ensuring better collaboration between the H.R. 
professional and the Hiring Manager when developing the position's 
requirements and the skills needs for the job that is to be filled;
     Sharing selection certificates between H.R. offices within 
VA and with other Federal agencies that may have posted job ads with 
similar job skills which minimizes the need to continually post jobs; 
and
     Establishing standing applicant files for mission critical 
occupations.

    Question 62.  I am asking this question on behalf of my 
constituent, Ross Bieling: ``Dr. Shulkin, as Under Secretary to the VA 
during the Obama administration, during your tenure, please provide 
examples where you have implemented meaningful ideas resulting in 
positive change within the VA system that have directly or indirectly 
benefited all veterans. And if not, why not?''
    Response. Mr. Bieling, thank you for your question. I would be glad 
to share several examples that started as ideas and moved into 
meaningful benefits for our Veterans. I will share four ideas here that 
all relate to improving access to care. They are: 1) reorganizing our 
approach to wait times to a clinically meaningful approach toward 
urgent care; 2) access stand downs; 3) same day services; and 4) best 
practice adoption.
    When I came to VA 18 months ago, the biggest issue I believe we 
faced was access to care for our Veterans. However, from the way that 
VA was approaching access I did not believe that we could develop an 
effective solution to the problems we faced. I, therefore, instructed 
our team to reduce our clinicians' way of ordering consults from 31 
different ways to just 2 ways: either routine or urgent. That allowed 
us to see which Veterans needed care the most. It also allowed us to 
focus our efforts on these urgent health care needs. Once we did that, 
we went to our second idea--that is to have national access stand 
downs. This was a mandatory event that occurred in every single medical 
center to focus the entire staff on reducing urgent care needs. This 
effort is described in an article I wrote, http://catalyst .nejm.org/
va-stand-down-resolved-56000-plus-urgent-care-consults/.
    After we reduced our urgent consults, we then implemented the next 
idea--same day access. We have implemented same day services for 
primary care and mental health in every one of our medical centers in 
the country. The final idea implemented is our Diffusion of Excellence 
initiative. In this initiative, we are taking the best practices in 
access from around the country and sharing them to adopt these 
practices. All of these ideas have led to a significant improvement in 
access for our Veterans.

    Question 63.  I am asking this question on behalf of my 
constituent, Capt. Bob Pawlowski: ``Given the effort to revamp the VA 
and the important focus on health care and services for our veterans, 
what do you propose to improve the perception in our veterans minds 
that this is a `new VA' and you are `here to serve?' ''
    Response. Captain Pawlowski--thank you for your question. The 
design of the ``new VA'' as you stated is already underway. Since my 
arrival 18 months ago, we have been working to define a Veteran-centric 
experience. This is about changing the culture of VA, and setting new 
expectations for our employees. Our ICARE values define the ``new VA:'' 
Integrity, Commitment, Advocacy, Respect, and Excellence (ICARE).
    We have asked all employees to sign a commitment pledge to 
upholding these values and we have now trained over 100,000 of our 
leaders in how to manage to these values. We are teaching a 
``principle'' based management style rather than a ``rules'' based 
style that had begun to characterize much of VA in the past. If 
confirmed as Secretary, I will continue to lead through these values 
and make sure that all employees are working to honor our Veterans 
through the adoption of these principles. The ultimate judge of our 
success will be our Veterans.

    Question 64.  I am asking this question on behalf of my 
constituent, Charles Wilson: ``I was told my entire military career 
that if I stay in and retire, I would be given medical benefits at no 
cost. I was actually shocked, when I retired, to learn that I had to 
pay for that benefit. Why? Is there any relief in sight to this 
tragedy, or are we going to be asked to suck it up once again?''
    Response. Mr. Wilson, let me start by thanking you for your 
service. I am aware of a 2003 decision by the United States Court of 
Appeals for the Federal District held that promises of lifetime health 
care made decades ago by recruiters to entice people to serve in the 
military for at least 20 years were not valid and we have also learned 
that the recruiters did not have the authority to make them. I would 
also encourage you to call the following number to determine your 
eligibility for VA services 1-877-222-8387.

    Question 65.  I am asking this question on behalf of my 
constituent, Bejean Page: ``Will you [as VA Secretary] seek out 
veterans and ask them what they need?''
    Response. Mr. Page, if confirmed as Secretary I will absolutely do 
this. In fact, as Under Secretary for Health I can assure you that we 
have begun to do this now. We seek direct Veteran feedback about what 
they need in several ways.Let me name four of these ways. First, we 
speak to our Veterans all of the time. Whenever I do visits to our 
medical centers around the country I make sure I meet with Veterans to 
get their candid feedback. In addition, I actually practice medicine in 
the VA system and care for patients (who do not know I am the Under 
Secretary) so I hear it straight from them. Second, we ask our Veterans 
directly all the time. We do hundreds of thousands of satisfaction 
questionnaires and we pay attention to what we hear and we also ask our 
patients on our kiosks (we call it Vetlink) about their experience and 
how we can do better. Third, Veterans contact us every day with their 
issues and we not only listen, but we respond. I get dozens of these 
emails myself directly from Veterans and I can assure you I pay 
attention to what I am hearing. And remember, 33% of our employees are 
Veterans and many use our services so we listen to our employees as 
well. Finally, we have established a formal Veteran insights panel of a 
few thousand Veterans that we run ideas by and ask their thoughts. We 
also use our Veteran Service Organizations in a similar way and ask 
them what they think. As you know they represent collectively millions 
of Veterans.

    Question 66.  I am asking these questions on behalf of my 
constituent, D.A. Anderson: ``What is your vision for the VA in going 
forward? How can the VA be run more like a business that has 
accountability for its actions and treats the veterans of this country 
with fairness and respect?''
    Response. I have a background in business and in running leading 
healthcare organizations.My approach to running VA is similar to 
running these other organizations. Successful businesses must be 
responsive to their customers or they fail. My vision for VA is to be 
the system of choice in the country and to have healthcare and services 
that are second to none anywhere. VA must not only be responsive to 
Veterans (and their families and caregivers) but also be responsible to 
taxpayers. This means that both the quality of the services and the 
efficiency of the services must be competitive with private sector 
options. Accountability in my opinion is set by having clear 
expectation, clear metrics and feedback, and clear consequences. I am 
committed to do just this.

    Question 67.  I am asking this question on behalf of my 
constituent, Jason Nesslage: ``There is discussion in our veterans 
ranks regarding concurrent receipt of retired pay and disability pay. 
There is not one veteran that wants this to return to the past, where a 
retired servicemember chose whether he/she wanted the VA offset pay or 
their retirement pay. These are clearly two different entitlements that 
should never be up for discussion again. What are your thoughts?''
    Response. Mr. Nesslage, while I agree that Servicemembers and 
Veterans should be entitled to the maximum benefits allowable as 
established under law, by statute, VA is not able to pay both 
disability compensation benefits and military retirement payments in 
certain instances. Congress recently expanded entitlement to receive 
concurrent payment for individuals who have a disability rating of 50 
percent or more. We will continue to implement any future legislation 
on this issue.

    Question 68.  I am asking this question on behalf of my 
constituent, Ross Bieling: ``Do you believe that the current VA 
structure for purchasing, ensures that new products and equipment are 
considered for purchasing at the lowest competitive price possible 
ensuring that budget dollars are spent wisely and effectively? Please 
describe in detail the current system utilized within the VA for 
purchasing and if or how you would restructure it under your leadership 
ensuring that veterans will ultimately benefit within these important 
areas.''
    Response. Mr. Bieling, we need to look at all of our support 
systems and structures to ensure that what we are doing is actually 
supporting our Veterans while providing value for taxpayers. There is a 
current initiative underway to improve our supply chain which would not 
only leverage spending with the input of clinicians, but will also 
improve inventory management and business processes.
    Five initiatives were set in place for the supply chain and 
purchasing modernization effort: standardize processes and data to 
establish enterprise-wide management practices; centralize purchasing 
for cost avoidance; establish a life-cycle management system to ensure 
consistent availability and correct usage of supplies and equipment; 
create a national supply chain formulary for improved ordering and 
recordkeeping; and standardize positions and work responsibilities of 
acquisition and logistics staff.
    Central to the effort was establishing a new list of medical 
supplies and equipment to be purchased through a centralized system, 
using one of four regional ``prime vendors.'' This list, or formulary, 
includes over seven thousand items and continues to expand, as have the 
number of facilities using this list. The modernization effort 
centralizes purchasing authority, streamlines ordering, tracking and 
procurement of equipment and supplies by providing an efficient, just-
in-time distribution process. It also enables VA to leverage its scale 
to order items at a negotiated rate to avoid costs.
    By modernizing these processes, VA's supply chain is successfully 
reducing excess inventories and leveraging purchasing power, 
guaranteeing medical facilities have the right supplies, in the right 
amounts, at the right place, right when they are needed for Veterans' 
care.

    Question 69.  I am asking this question on behalf of my 
constituent, Tony Molina: ``Would the VA consider establishing a 
special help desk for VSO's and Tribal Veteran Representatives, so when 
a family member asks for a copy of their DD214, we can receive it as 
quickly as possible? I have been given many answers but there is still 
no quick way for us to attain a DD214 with one phone call and online 
takes forever.''
    Response. Mr. Molina, currently, we allow authenticated VSOs to 
request DD Form 214s through our general benefits line without a 
written request, thus allowing the VSO to obtain the document as 
quickly as possible. Additionally, this service is also provided by 
chat agents to properly authenticated VSOs. Agents can provide the 
requested document via U.S. Mail or by fax. Additionally, on 
February 21, 2017, a new rule will take effect under 38 CFR 14.628 that 
will allow tribal nations to apply for VSO status in the same manner as 
if they were a state and once they are properly accredited, VA will be 
able to provide this same service to their organizations as well.

    Question 70.  I am asking this question on behalf of my 
constituents, Mike and Sandy Coons. ``Why is it that retired veterans 
who have served 20+ years for our Nation are required to put up with 
waiting for an authorization for medical care for weeks, much less 
days? Retired military or vets with 100% disability have the retired 
military ID card. We have earned our free medical and dental that was 
promised to us, yet we have to pay into TRICARE, we have to get a 
`mother may I?' for physical therapy, lab tests, radiological testing 
when all we should be doing is showing our ID to the doctor's office 
and the doctor's office bills the VA. All we want is for the government 
to honor the promises made that we fulfilled on our end!''
    Response. For many of the VA community care programs, especially 
Choice, VA is following the criteria Congress set out in law. I 
recognize that it is not always easy for Veterans to move between 
programs or access certain types of care. This is exactly the reason 
why in the future streamlining is necessary to eliminate some of the 
bureaucracy. Veterans eligible for enrollment in VA's Health Care 
System are eligible to receive all medically necessary care available 
through VA health care programs. Veterans, who are eligible for health 
care from both VA and TRICARE, are free to choose whether they want to 
receive care from VA or TRICARE.

    Question 71.  I am asking this question on behalf of my 
constituents, Mike and Sandy Coons. ``Why can't vets with 20+ years or 
100% disability, get full dental coverage for all needs, routine 
cleanings, fillings, crowns, dentures, partials, etc.?''
    Response. Veterans who have service-connected disabilities rated 
100% disabled, or are unemployable and paid at the 100% rate due to 
service-connected conditions, are eligible for comprehensive dental 
care.

    Question 72.  I am asking this question on behalf a constituent. 
``My niece is a retired veteran with lupus and has to wait months for 
an appointment. In addition, the VA is not as familiar with this 
specific disease as other doctors. Therefore, I believe my niece does 
not receive the best care, even after serving our country. If a patient 
cannot receive prompt attention and appropriate care, will the VA pay 
for a doctor outside of the network?''
    Response. If an enrolled Veteran is not able to receive care in a 
timely manner or requires specific care that is not available at VA, 
the Veteran can be seen in the community through the Veterans Choice 
Program (VCP) or other community care programs. The Veteran can speak 
with the Choice Champion at the facility she attends if she wants to 
talk someone in person to explain her options. She can also call the 
Choice Call Center at 1-866-606-8198, or visit the VCP internet site 
at: http://www.va.gov/opa/choiceact/.

    Question 73.  I am asking this question on behalf of my 
constituent, Ric Davidge. ``The demand for mental health professionals 
in Alaska has been long and well known. We just need more. A suggestion 
is that the VA through the US Public Health Service focus on this 
highly needed professional group and then put them in Alaska for two 
years.''
    Response. Thank you for the suggestion. VA and HHS are exploring 
any and all possible avenues to fully staff our hospitals and clinics 
with an emphasis on Veterans Access. VA and HHS leadership are 
developing a partnership between our agencies for Public Health Service 
medical officers to serve as clinicians in VHA medical facilities, to 
include mental health professionals. The mental health needs of our 
Veterans are a priority and we will take your suggestion into 
consideration.

    Question 74.  I am asking this question on behalf a constituent. 
``I have observed three instances of what could be determined as HIPAA 
violations since 2014. My husband and I have received two pieces of 
unrelated medical correspondence for veterans who live somewhere else: 
one, a faxed a prescription for a VA pharmacy for a veteran who lives 
elsewhere, the second was a piece of correspondence pertaining to a 
medical appointment for a veteran who lives in Texas, (the appointment 
was set for a provider in Texas.) I made the VA and the Choice Program 
aware of these two instances.
    ``The third instance was revealed to have impacted my husbands' 
benefits claim directly. We received a copy of his Disability Benefits 
Questionnaires which contained medical history of another veteran that 
had been erroneously inserted into my husband's claim. This other 
veteran is older and had been seen at a VA for dizziness which my 
husband now suffers from as well. However, this medical appointment 
date was 1986 when my husband was just a freshman in high-school and 
did not suffer dizziness until his Traumatic Brain Injury (TBI) 
sustained while performing USAF work duties in Plattsburgh, NY in 1990. 
This 1986 VA visit was cited as the reason for denying his C & P rating 
increase claim in 2014. An appeal was filed in a timely manner and the 
second rating doctor reviewed this rating file and used the original 
rating doctor's decision as the reason to also deny the benefit rating 
increase claim. Neither of these doctors referred James for follow up 
evaluation of TBI related issues.''
    ``How will the workflow processes be improved to end these 
potentially life-altering mistakes? Would Dr. Shulkin be open to having 
an audit of workflow processes in an effort to identify gaps and 
unnecessary duplicitous steps in order to streamline the process?''
    Response. Yes, I am open to any improvements that could mitigate 
risks as well as streamline workflow processes. The inappropriate 
access of patient health records is unacceptable and in violation of 
privacy laws and regulations, VA policies and procedures, and our 
principles. We recognize that access to current health information is 
critical in order to support care coordination and delivery of high-
quality care. Currently, each VAMC has unique processes and procedures 
for requesting, retrieving, and processing returned documentation as 
well as general workflows related to handling and uploading returned 
documentation and closing consults. Establishing standardized processes 
and responsibilities will improve the availability of clinical 
documentation for providers, enhance continuity of care, and streamline 
the approach to manage incoming documentation. We are committed to 
keeping our Veterans health information secure.

    Question 75.  I am asking this question on behalf a constituent. 
``I currently have a claim for service-connected Hepatitis C that has 
been denied twice at the local level and now it is under review at the 
national level. Will the VA acknowledge the transmission of HCV by jet 
injector?''
    Response. We have heard feedback from Veterans regarding a possible 
relationship between the hepatitis C virus infection and immunization 
with jet injectors. Although we currently do not have a documented case 
of hepatitis C transmitted by a jet injector, it is biologically 
plausible. Any Veteran enrolled in the VA health care system who has 
concerns about hepatitis C infection, because of jet injectors or any 
other potential blood exposure during military service, is welcome and 
encouraged to request testing and evaluation for hepatitis C at the 
nearest VA hospital.

    Question 76.  I am asking this question on behalf a constituent. 
``My husband tried to get just medical assistance from the VA in 2004 
for Hepatitis C. He believed he got HCV at boot camp, or Korea during 
the war from air guns. The VA turned him down for medical treatment and 
he died in 2008. He did not know much about it, like everyone else. 
I've have had an appeal since 2008. I have HCV that I believe I got 
from [XXXXX]. I'm pretty healthy, except I need treatment, like he did. 
He was proud to be in the Army. I am trying to get DIC benefits, but 
the VA is fighting it. I have letters from friends, doctors, etc. I 
have been fighting since 2008.''
    Response. Mrs. [XYZ]--After looking into your case, I was advised 
that the regional office did grant you entitlement to DIC benefits in 
September 2016. The regional office is in the process of awarding 
benefits pending recoupment of a previous overpayment and payment of 
attorney fees.

    Question 77.  I am asking these questions on behalf of my 
constituent, D.A. Anderson. ``Because you have been a part of the VA 
system in the last administration, would you consider that a liability 
or an asset and why? Do you think that being a non-veteran will affect 
your effectiveness in any way?''
    Response. I have been at VA for 18 months. I consider this an 
asset. Since I was new to the VA system, it took me several months to 
learn about the system, identify the ways of getting management 
initiatives accomplished, and developing relationships and trust with 
employees, Veteran groups, and community organizations. Eighteen 
months, however, is not long enough to have become engrained in the 
system about doing things the same way as we always have.My current 
knowledge of the system allows me, if confirmed, to have the ability to 
move the system forward without a new learning curve and with the 
ability to know how to implement these changes.
    In terms of being a non-Veteran, I have spoken to dozens and dozens 
of Veterans about what they want in a new Secretary. What I have 
consistently heard is that the most important thing they want is a 
Secretary who knows how and who will make the system work better for 
them. I believe my experience will allow me to do this. Since I have 
worked in the system for the past 18 months, I do believe that I have 
developed a good understanding of the Veteran perspective. However, by 
not being a Veteran, I know that I will need to try even harder to make 
sure I am including the Veteran perspective in everything I do. I plan 
to accomplish this by building a strong management team that has strong 
representation from Veterans, and in constantly asking for feedback and 
input from Veterans.

    Question 78.  I am asking this question on behalf of my 
constituent, Carol [XYZ]. ``When is the VA going to pay their bills? I 
had to find another podiatrist due to the VA being behind on paying the 
bills.''
    Response. As the relationship between VHA and the network 
contractors continues to mature, the timeliness and effectiveness of 
payments to community providers improves. The most recent reports 
indicate that over 90% of clean claims are processed within 30 days; a 
great step forward since program inception.
    Simultaneously in traditional community care, claims staff members 
have worked tirelessly to reduce the overall backlog of overdue claims 
within the past 18 months. In July 2015, there was an overall claims 
inventory of nearly two million claims with prompt payment rate of 67%. 
These numbers have steadily been reduced to a total inventory of 
660,000 with a prompt payment rate of nearly 80%.
    We are keenly aware of some providers threatening to leave the 
Network. There is no more critical service we provide then to ensure 
timely and consistent care for our Veterans. To that end, in 
February 2016, the VHA Office of Community Care Provider Rapid Response 
Team (PRRT) was created to facilitate the expedited resolution of 
ongoing individual billing and payment cases. Since its creation, the 
PRRT has received a total of 263 cases, resolving 236. The average time 
to resolve an individual case is between 7 and 10 days.
    Despite these successes, tremendous room for improvement still 
exists. VHA leaders engage in weekly meetings with Health Net and 
TriWest leadership reviewing key areas of performance. The Request for 
Proposal (RFP) for the new Community Care Network addresses incentives 
to encourage prompt payment by contractors to providers. This RFP was 
released on December 28, 2016, and will provide stronger oversight in 
ensuring timely payment to providers.

    Question 79.  I am asking this question on behalf a constituent. 
``Since those of us who qualify for boots on the ground, why do we have 
to go through so many hoops to share a buddy letter or to show through 
our experiences that we do have PTSD, no matter what our MOS was?''
    Response. VA no longer requires that an in-service stressor be 
documented in personnel records--rather, if the stressor is related to 
combat or fear of hostile military or terrorist activity, then the 
stressor can be proved merely by lay testimony (a Veteran's statement) 
that the event occurred. Veterans may still submit buddy statements to 
show the current severity or existence of a disability and the 
statements can be considered in assigning an evaluation. For military 
sexual trauma (MST) leading to a diagnosis of PTSD, only corroborating 
evidence (``markers'') is needed.
    For stressors that do not fall under an exception to the 
evidentiary standard (i.e., they must be proven by the facts of the 
case) a buddy statement can be used to help show that the stressor 
occurred. However, even in those situations, a buddy statement is only 
one piece of evidence that can be submitted to prove that a stressor 
occurred.

    Question 80.  I am asking this question on behalf of my 
constituent, Capt. Trevor Sayer. ``I am a USMC Captain retiring this 
summer. I am retiring from a joint command in Arizona, and begin my 
terminal leave in March. The VA pre-discharge claims enrollment program 
(BDD) allows active duty to submit claims 120 days out. However, if you 
are leaving the state in which you file before the claim is processed 
and your appointment for your initial medical exams are not made in 
time then the claim has to start over in the new state. Now in my case, 
I am in Arizona and going home to Ketchikan. I could start my claim now 
in Arizona but I am told it could delay processing by months because 
the claim would need to be transferred to Alaska then arrangements for 
me to fly from Ketchikan to a VA med center in Anchorage would need to 
be made in order to do initial medical screenings. There simply isn't 
time within this 120 day window to do all the evaluations in AZ before 
I depart. The alternative being to forego terminal leave in order to do 
medical screening prior to going to Alaska or wait till I get home to 
Ketchikan and submit a fully developed claim once my retirement is 
effective thus eliminating the benefit of the pre-discharge program. 
What if the VA had a mobile outreach program in Alaska?''
    Response. Servicemembers are highly encouraged to initiate their 
claims during the pre-discharge stage to afford the earliest effective 
date possible for any award of benefits. Currently, participation in 
the Benefits Delivery at Discharge (BDD) program requires being 
available for examination at the Servicemember's last duty station. 
However, if the Servicemember is not available for examination at their 
last duty station, the claim is transitioned to the Quick Start 
program. Quick Start claims are also considered priority VA claims. The 
VA examination for the claim would then be completed near the post-
separation site where the Servicemember/Veteran resides and is 
available for examination.
    Based on your specific scenario, it is recommended for you to file 
your claim as soon as possible and we can expedite the scheduling of 
your examination at the most appropriate location convenient to you.

    Question 81.  I am asking this question on behalf of a constituent. 
``We called one of the VA phone numbers and they said on the recording 
that if there was someone who was feeling suicidal, to call a hotline 
number or call 911. So why is it that the VA phone systems cannot give 
an immediate option to press a number to go immediately to the hotline 
or to the 911 services?''
    Response. Earlier this year we implemented a feature that allows 
callers to VA medical centers to ``press 7'' to be directly connected 
to the Veterans Crisis Line. We are exploring expanding that feature to 
other VA entities. The option of direct connection to 911 services is 
more complex and we are studying it now. Due to its complexity, we do 
not have a timeline for when, or if, it will be implemented.

    Question 82.  I am asking this question on behalf of constituents. 
``Issues like the flu, sinus infections, migraines and items like that 
it is much easier for us to go to a local hospital and use our TriWest 
in the urgent care department and pay the co-pays. As far as we know, 
we can't go to urgent care at the local hospital and use our VA. Is 
this where Choice would come in? Also, going in for urgent care or 
emergency care in a regular hospital could they streamline the VA 
Choice like it is with the TRICARE (TriWest) so we don't have to call 
prior to treatment for authorizations?''
    Response. The Veterans Choice Act expanded VA's ability to provide 
timely access to care for Veterans from sources in the community. While 
this much-welcomed expansion of authority provides VA with another 
means with which to provide routine care for Veterans who cannot 
otherwise be seen within a VA facility, the requirement for VA pre-
authorization of care under this program does not lend itself to being 
an effective tool for management of medical care during instances of 
urgently or immediately-required medical attention. VA is seeking 
additional authority from Congress to consolidate its community care 
programs and to provide expanded urgent/emergency care coverage to 
eligible Veterans.

    Question 83.  I am asking this question on behalf of my 
constituents. ``We travel out of Alaska to Florida for our winter time 
for three months. So when we arrive in Florida, we can use the urgent 
care or the emergency room at Bay Pines VA Medical Center in Seminole, 
Florida and those services are really pretty good. However, we have to 
go into module A and wait because we do not have a VA primary doctor 
down here in Florida. We have noticed that our records and annotations 
from Alaska and records and annotations here in Florida do not always 
make it into the same record files on My Health in a timely manner. Why 
is that? One example is the echocardiogram my husband had at the Bay 
Pines VA medical center on Friday a week later, it is still not on the 
My Health records. This was a specialist referral that was requested in 
Anchorage that we asked to be conducted in the VA Gainesville thoracic 
surgeon's office so we would be close to family in case a surgery was 
needed.''
    Response. For some data from the Electronic Health Record (e.g., 
lab test results), information becomes available within My HealtheVet 
three calendar days after is has been verified. This delay enables the 
provider to communicate with the patient if needed, for example to 
discuss an abnormal test result. The example you provided of an 
echocardiogram is something that is not currently sent to My 
HealtheVet, but is something we are working on for the future.

    Question 84.  I am asking this question on behalf of my 
constituents. ``We think every VA center, especially in Alaska, needs 
to have an emergency room or agreements need to be worked out with 
local hospitals to service-disabled veterans by using the VA Choice for 
emergency services at local hospitals.''
    Response. The Veterans Choice program was designed and implemented 
to expedite access to care for those Veterans who do not have a VA 
facility reasonably available to provide required treatment in a 
primary care or urgent care environment. Because of the nature of the 
administrative requirements included in the Choice Act, utilization of 
it as a means to provide emergency care is not feasible and would add 
confusion or delay to Veterans in seeking or receiving care during an 
emergency. As it pertains to emergency care, the primary consideration 
of VA is the safety and well-being of the Veteran.
    As such, VA provides emergency treatment to Veterans via Community 
Care programs that remove administrative prerequisites, such as calling 
a third-party administrator or VA, and encourages Veterans to proceed 
directly to a source where they can receive the care and services 
required. VA agrees that all Veterans should be aware of actions to 
take during an emergency as well as the benefits available to them. As 
part of plan to improve and consolidate community care programs, the 
variation in emergency care would also be addressed.

    Question 85.  I am asking this question on behalf of my 
constituents. ``It is extremely difficult to see the VA primary care 
doctors more than once a year face-to-face. A lot of our interaction 
takes place on phone calls with nursing staff. When dealing with 
specialized health issues, that once a year face-to-face is not 
sufficient. We need to be able to go into our primary care when we're 
dealing with being moved from specialty clinic to specialty clinic in 
order to discuss the next course of action.''
    Response. Primary care plays an important coordinating role for 
patient care, particularly for the patient with complex medical issues 
requiring involvement of one or more specialists. These Veterans may 
require frequent interactions with the primary care provider in 
addition to other health care team members. The kind of interaction 
will vary depending upon both the medical needs and preferences of the 
patient, and includes face-to-face visits as well as telephone care and 
secure messaging. Primary Care policy (VHA Handbook 1101.10, Patient 
Aligned Care Team (PACT) Handbook) provides flexibility for the team to 
decide with the patient both the type and frequency of these 
interactions. Patients are encouraged to discuss their preferences with 
their Patient Aligned Care Team (PACT) to ensure that they are 
accommodated in the treatment plan. In occasional instances, these 
discussions can be facilitated by the patient advocate if specific 
concerns of the patient remain unaddressed.

    Question 86.  I am asking this question on behalf of my 
constituents. ``We have both have talked to several dependent wives 
whose spouses are suffering from PTSD that served in the war zone and 
that they are not able to get help while they're serving at their 
current assignment. They feel like they have to get out of the service 
and they need to cope with it on their own, as the upper supervision 
has impressed upon them that they don't have a problem and they don't 
need to go get help for it. There is still a high need for more 
treatment and education in the upper management levels for them to 
understand and to help their troops suffering with PTSD without taking 
away peoples jobs or the stigma of this. Especially special ops or 
infantry. Our military and our veterans have served well, they have 
fought well, but they are struggling because they're being told that 
they should not identify themselves with PTSD issues because they might 
lose their jobs. Also, a lot of the dependent wives are having to cope 
with PTSD with their husbands that they don't fully understand how they 
can handle it, how they can walk through it with them, and how they can 
encourage them. We suggest that there needs to be a PTSD assistance and 
education program for spouses of military members/veterans to help the 
families as well. Also, recommend offering co-counseling services for 
dependent spouses that have walk-through documented PTSD incidences 
with their veteran husbands or their wives.''
    Response. I agree that PTSD or any mental health issue is best 
addressed within the context of the family. Since 1979, VA's 
Readjustment Counseling Service (also known as the Vet Center Program) 
has been offering couples and family interventions as a core service. 
Unfortunately, there are currently legislative obstacles to involving 
family members in VA mental health services. If confirmed as Secretary, 
I will seek Congress' action in updating legislation in order to allow 
VA clinicians to provide robust involvement of family members in the 
care of all Veterans seeking VA care.
    Vet Centers provide readjustment counseling to any Veteran, active 
duty Servicemember, and those in the National Guard and Reserve Forces 
who served in a combat zone or area of hostility. The family members of 
these individuals are also eligible to receive counseling when it is 
found to aid in the readjustment of their loved one or to help the 
family cope with a deployment in the absence of their Servicemember. 
Services to family members can consist of individual, group, and family 
counseling and focus on psycho-education, reducing the symptoms 
associated with PTSD, or any other goal the Veteran or Servicemember 
has identified. All Vet Center services are provided regardless of the 
character of discharge, to include dishonorable discharge.
    To help reduce the stigma associated with receiving counseling, Vet 
Centers maintain the highest levels of confidentiality. Vet Center 
Counseling Records are released only through the signed consent of the 
eligible individual or to avert a crisis such as serious suicide 
ideation or attempt.

    Question 87.  I am asking this question on behalf of my 
constituents. ``There appears to be some pretty significant delays in 
the referral management office to get referral appointments. We believe 
that part of the problem is a lack of sufficient personal for referral 
management offices to handle and swiftly process those referrals 
outside of the VA to a specialist. If a specialist is seen (like a 
pulmonary doctor) and refers to another specialist (thoracic surgeon), 
we have to go back to the VA referral process system again into a 
holding pattern to get the request from the specialist that requested 
we see another specialist or series of tests that results in further 
delays. And we have to wait for the primary nurse practitioner to 
approve it before we can even get to the other specialist who is a 
doctor. We also find that we have to make routine phone calls to follow 
up on those actions, like the `squeaky wheel gets greased first.' ''
    Response. We developed an operating model that improves efficiency 
in the referral process including direct communication with our 
community providers via our portal, the creation of standard episodes 
of care (EOC). This model is currently being rolled out and is now in 
use in Alaska. Many of these include the authority for a Veteran to see 
several providers or receive several tests as part of a complete EOC. 
For example, a complete EOC for a Veteran with a pulmonary nodule could 
allow a community pulmonologist to see the Veteran, diagnose a lung 
cancer and then send that veteran to a thoracic surgeon to perform a 
partial lobectomy. This should assist in getting Veterans access to 
specialty care more timely.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
                   va puget sound health care system
    Question 88.  As you know, many Seattle area veterans receive their 
care through the VA Puget Sound Health Care System--specifically at the 
Seattle campus. Unfortunately, in meetings with individual veterans as 
well as Veteran Service Organizations in Washington state, we regularly 
hear of obstacles that veterans face in accessing care. My colleagues 
and I have worked to identify some of the root causes of these issues, 
which seem largely to stem from unfilled management positions, an 
overreliance on ``acting'' roles that lack decisionmaking authority, 
and frequent turnover in leadership.
    On October 26, 2016, you spoke with my colleague Congressman Adam 
Smith, whose district includes the VA Puget Sound Healthcare Center in 
Seattle. During that call, Mr. Smith specifically noted the multiple 
leadership issues that plague the Seattle VA facility, including 
ongoing problems with open, unfilled positions. It is my understanding 
that both you and Congressman Smith agreed that sending a management 
improvement team was warranted, and would be beneficial to Seattle area 
veterans. Your staff in Washington, DC, confirmed this in an 
October 28, 2016 message.
    Unfortunately, on November 14 last year, Congressman Smith's office 
was informed that this commitment was being rescinded, and VA officials 
have so far refused to explain why. The leadership problems continue, 
and have only worsened with President Trump's recent Executive Order 
directing a Federal hiring freeze. Clearly, the need for assistance 
remains.
     To that end, will you commit to sending a management 
improvement team to the VA Puget Sound Health Care System?
    Response. I am disappointed to hear this and I was not aware of any 
decision to rescind a team from going to VA Puget Sound. I will commit 
that a team of Human Resources experts will be on site within 60 days 
to assist VA Puget Sound Health Care System hiring efforts and further 
instruct the team that no one but me would be allowed to rescind this 
commitment.
                        impact of hiring freeze
    Question 89.  Dr. Shulkin, you said in your nomination hearing, 
``the most important thing to me is that we have the resources to hire 
the people that we need to take care of our veterans. We have requested 
that from the White House and we have gotten that.'' You further 
claimed that there are 45,000 positions open within VA, of which 37,000 
are exempt, but that still leaves 7,000 positions vacant. Additionally, 
those numbers only apply to positions in the Veterans Health 
Administration. There are another 688 vacancies within the Veterans 
Benefits Administration, none of which are exempt. So the hiring freeze 
will clearly have a very real impact on veterans' access to services 
and care.
    For example, data from VA Portland Health Care System, which 
provides benefits and treatment to veterans in Washington State, shows 
that on average they processed more than 500 claims for beneficiary 
travel program every business day in 2016. As a result of this high 
volume, the travel reimbursement claims processing time is backlogged 
to about six weeks for most claims and up to eight weeks or more for 
complex claims. Portland VA had hoped to address this backlog by hiring 
additional staff for their Veterans Transportation Program. 
Unfortunately, although the authorized number of staff for the VTP was 
raised to nine employees, the hiring freeze has blocked this VA from 
hiring the staff it needs to quickly provide this important benefit to 
our veterans.
     How can you say that you have received all the resources 
you need to take care of our veterans when close to 700 positions 
related to providing our veterans with benefits remain vacant and how 
are you going to address the delays in processing veterans' benefits 
with so many open positions at VBA?
    Response. If confirmed as Secretary my focus would be to address 
any barrier that prevents us from delivering the services needed to our 
Veterans. At this point in time, my primary concern is to ensure the 
health and safety of our Veterans. I believe we have the exemption for 
hiring that allows us to do that. VBA continues to offer overtime on an 
optional basis to employees processing compensation rating claims. 
Additionally, VBA has authorized overtime for specific pension and non-
rating work. VBA is considering all options, to include mandatory 
overtime, to ensure that Veterans are getting the best care and 
services possible while the hiring freeze is in effect.

     If confirmed, will you exempt VBA positions from the 
hiring freeze?
    Response. I stated in my testimony that I had spoken to the current 
Acting Under Secretary for Benefits and asked him to closely monitor 
the situation with clear metrics to make sure that we are not seeing a 
significant deterioration of service levels. It is my understanding 
that VBA is in the process of submitting an exemption request to permit 
the hiring of direct labor occupations to ensure reduced impact on 
VBA's ability to serve Veterans. If I am confirmed as Secretary I would 
give full consideration to this request.

    Question 90.  As VA Secretary, it will be your job to advocate on 
behalf of all policies that affect veterans. That means that you must 
advocate not just for access to health care but also for veterans' 
ability to access all the benefits that have been provided to them in 
return for their service. One of those benefits is the hiring 
preference veterans receive when applying for Federal positions. I am 
very concerned that President Trump's hiring freeze will impact these 
veterans, who apply for Federal positions in disproportionate numbers 
compared to non-veterans.
     If confirmed, what work will you do with the 
Administration to make sure that veterans are not disadvantaged in 
their effort to seek Federal employment?
    Response. VA provides first consideration to all qualified 
preference eligible Veterans when filling jobs open to the general 
public. When filling jobs that are only open to current Federal 
employees, VA also accepts applications from Veterans who are currently 
not part of the Federal workforce, but are eligible for hire using 
special hiring authorities. A large percentage of the Veteran workforce 
at VA, 32.57%, was hired using a variety of special hiring 
flexibilities, such as the Veterans Recruitment Act, Veterans 
Employment Opportunity Act, Schedule A Authority for People With Severe 
Physical Disabilities, Psychiatric Disabilities, and Intellectual 
Disabilities, and the 30% or More Disabled Veteran Public Law. To the 
maximum extent possible, if confirmed as Secretary, VA will continue to 
fill jobs with qualified Veterans.
    The VA also has an established Veterans Employment Services Office 
to monitor our progress with regard to employment of Veterans and to 
advise me on Veteran recruiting and retention strategies. I am proud of 
the work we've done to assist Veterans seeking Federal employment, and 
I remain committed to those efforts. Over 120,000 of our employees are 
Veterans, including over 50,000 of whom are Disabled Veterans.
    I look forward to the opportunity to serve as co-chair, with the 
Secretary of Labor, of the Veteran's Employment Council to ensure the 
Federal Government maintains its momentum in providing employment 
opportunities for Veterans both in the Federal Government and in the 
private sector.
                 under other than honorable discharges
    Question 91.  I am concerned about the increasing number of 
servicemembers who leave the service not knowing their VA eligibility 
status. A 2016 report from Swords to Plowshares showed that under other 
than honorable (UOTH) discharges often result from minor infractions 
that relate to PTSD or other conditions that prevent them serving as 
expected. The report noted that Post-9/11 veterans in particular are 
three times more likely than Vietnam Era veterans to receive an under 
other than honorable discharge, and that veterans with an under other 
than honorable discharge are twice as likely to commit suicide, twice 
as likely to be homeless, and 50 percent more likely to get caught up 
in the criminal justice system.
    The brave men and women who volunteer to serve in our military 
should not be left without healthcare or basic workers' compensation 
for injuries in service. Thankfully, the issues surrounding UOTH 
discharges have gained public and media attention, and increasing 
attention from this Committee, including a media event that the 
Chairman hosted last month.
    Current law allows former servicemembers to get basic veteran 
services if their conduct was not dishonorable. However, it is often up 
to VA discretion when it comes to providing services to a veteran with 
an UOTH discharge. Over the past several years, VA has taken steps to 
address this problem, including preserving homeless housing eligibility 
while corrective legislation was prepared; improving the internal 
processes for deciding eligibility in these cases; improving internal 
communication to VA staff to make sure every veteran has an opportunity 
to access services; and making a commitment to this Committee last year 
that it would revise its regulations to better take mental health and 
other factors into account. These are great first steps, but there is 
much more that must be done to properly care for veterans with an UOTH 
discharge.
    If confirmed, what specific steps do you plan to undertake to 
provide services and care to eligible veterans with UOTH discharges?
     In particular, will VA follow through on its commitment to 
issue new regulations this fiscal year amending the criteria for 
``under other than dishonorable'' service, regardless of President 
Trump's executive order that would require agencies to revoke two 
regulations for every new rule they want to issue?
     If confirmed, will VHA revise its military sexual trauma 
program instructions to ensure that no veteran is denied access to 
military sexual trauma care, regardless of circumstances of discharge?
    Response. If confirmed as Secretary, I would work to use the full 
regulatory authority available at VA to serve as many Veterans as 
possible including those with other than honorable (OTH) discharges. If 
there are statutory requirements that prevent us from doing this, I 
would come to you to ask for your assistance. Currently, an OTH 
discharge is not necessarily a bar to receiving MST-related health 
care. It is my understanding that Veterans with OTH discharges can 
currently receive VA care, including MST-related care, upon review of 
their discharge by the Veterans Benefits Administration (VBA). 
Following this review, VBA issues a decision as to whether or not the 
Veteran's discharge is a bar to receipt of health care benefits. VA has 
taken steps to ensure staff are aware that Veterans with OTH discharges 
are potentially eligible for MST-related services and that there have 
been no shifts in policy to tighten eligibility requirements. I am 
committed that no Veteran with MST would be denied access to care.
                            pain management
    Question 92.  The VA, with Committee oversight and support, has 
taken important steps to improve pain management throughout the VA 
system. These include implementation of a ``step care'' model that 
matches appropriate therapies to the unique needs of individual 
patients, particularly for veterans with complex chronic pain problems 
of long, sometimes lifelong, duration. There has also been 
collaboration with the Department of Defense to allow servicemembers 
transitioning to VA care to have their pain management coordinated 
across the systems. Furthermore, VA researchers have worked with the 
National Institute of Health and other research partners on new 
treatments, particularly those that could be alternatives to the use of 
opioids for chronic pain. Despite progress, a lot remains to be done.
    a. What is your position on alternative methods of pain management?
    Response. I have always been a strong believer in the importance of 
complementary and alternative methods in pain management. As the CEO of 
Beth Israel Medical Center in NYC we developed one of the largest 
private sector Complimentary Care Programs in the country.At VA, we 
have an extensive commitment to complementary care under the leadership 
of Dr. Tracy Gaudet. Dr. Gaudet prior to coming to VA led Duke 
University's programs in Complimentary Care.

    b. If confirmed, how specifically will you continue prioritizing 
these efforts?
    Response. In response to Section 932 of the Comprehensive Addiction 
and Recovery Act (CARA), passed in July 2016, the VHA has developed an 
ambitious plan to expand research, education, and clinical delivery of 
complementary and integrative health approaches for pain management as 
well as mental health and overall well-being over the coming three 
years. On the clinical side, the Integrative Health Coordinating Center 
in the Office of Patient Centered Care & Cultural Transformation is 
working to make the evidence-based CIH approaches--including 
acupuncture, chiropractic, yoga, tai chi, meditation, and massage--more 
widely available to Veterans nationally. Our commitment is that every 
medical center will offer at least two of these therapies routinely for 
Veterans with pain, and one ``flagship'' site in each VISN will offer 
the entire range of therapies. Our new Community Care contract will 
also make these complementary therapies available to Veterans in the 
community if they are not available through the medical center.
    To support this increased access to CIH therapies for pain we are 
actively working to revise VA medical policies and regulations to 
facilitate delivery and evaluation of CIH approaches as part of the VA 
medical benefits package. We are also rolling out a large scale 
educational initiative through our Employee Education Service to 
increase awareness among clinical staff of the role of evidence-based 
CIH approaches for pain, so that our clinicians will begin to utilize 
these approaches more actively with Veterans. Finally, our Office of 
Research Development is collaborating with the National Center of 
Complementary and Integrative Health at NIH and the DOD to fund a large 
research initiative supporting demonstration projects developing the 
most effective ways to deliver CIH for pain in our military 
populations.
                   veterans ability to raise concerns
    Question 93.  I have heard from many veterans in Washington state 
that it is very difficult to get a concern or complaint addressed that 
is not specifically related to an appeal or claim. I have also heard 
that former Secretary McDonald's open door policy, including the 
establishment of town halls, was well received by veterans. I 
understand that veteran advocates are intended to help veterans with 
complaints, but my office continues to receive complaints from veterans 
who do not feel their advocates are actually addressing their concerns, 
perhaps a consequence of the structure in which veterans advocates work 
with local VA but do not raise the concerns to the Department in D.C.
     If confirmed, can you assure me that you will continue the 
open-door policy established by former Secretary McDonald, and that you 
will create an avenue through which veterans can raise their concerns 
and complaints higher than a veterans advocate if they feel the 
complaint has not been addressed?
    Response. Secretary McDonald and I share many of the same values in 
how to run organizations, but of course our styles are not identical. 
My record at VA shows that I have also been accessible to Veterans and 
many organizations as well. I hold town hall meetings, speak at 
numerous events where I interact with Veterans and organizations that 
represent them, and take advantage of as much interaction as I can. My 
career has been focused on allowing the voice of the patient to be 
heard as a primary means for improving healthcare. I've started 
companies that allow patients to be more empowered and I've written a 
book called ``Questions Patients Need to Ask'' to allow patients to be 
more informed about being a knowledgeable consumer of services. I would 
plan to continue with this philosophy of patient empowerment if 
confirmed as Secretary.

    Question 94.  While I have heard support for the VA town hall 
program, I have also received complaints from veterans in rural 
communities who have not been able to attend these meetings because 
they only take place in the greater Seattle area.
     If confirmed, can you assure me that you will keep the VA 
town hall program going, and that you will expand it to reach parts of 
the country outside major metropolitan cities?
    Response. Yes.
                             bremerton cboc
    Question 95.  I wanted to follow up on the conversation we had 
regarding the Bremerton CBOC. As I mentioned, for the last decade, my 
office has been working with VA, the local community, and the Navy to 
find an appropriate relocation site for the CBOC in Bremerton, 
Washington, which is significantly undersized. In your written response 
to questions you cited multiple tools to solve real estate problems, 
some of which were not effective in resolving the Bremerton CBOC issue. 
This facility has experienced two failed relocation efforts, the last 
of which means a new facility won't open until 2019 at the earliest. I 
understand it is VA's opinion that this location is not opening as a 
result of the building not being renovated in compliance with seismic 
regulations. However, this community has been without adequate care 
capacity for ten years, so I am less interested in what has gone wrong 
than how you intend to fix it.
    a. What immediate steps will you take to provide additional 
outpatient resources to the growing veteran population in Bremerton?
    Response. The VISN 20 Network Director during an update call with 
your staff on February 2, 2017, committed to seeking clinical space in 
a non-VHA healthcare facility into which could be placed an additional 
PACT Team to increase primary care while work to relocate the Bremerton 
CBOC is completed. VA has already identified two possible locations: 
one at the new Harrison Hospital in Silverdale; a second in the 
Franciscan Medical Building in Port Orchard. Opening an additional PACT 
team at a satellite location in the Bremerton area is contingent on our 
ability to timely recruit the PACT medical team professionals required 
to provide this service. In the meantime, all new Veterans seeking 
enrollment for Primary Care Services in the Kitsap County area are 
offered the option to enroll with a Choice primary care provider. There 
are approximately 153 Primary Care Choice providers in Kitsap County--
sufficient to provide the primary care needs of our Veterans in the 
Bremerton area.

    b. What changes will you make to prevent this from happening again?
    Response. The delays associated with moving the Bremerton CBOC to a 
new and larger location were related to the contractor that was 
selected for this project. This raises the issue of Federal contracting 
law and the ability to select the best contractor for the job to ensure 
that this type of issue does not arise again. If confirmed as Secretary 
I would undertake a review of our contracting rules and make 
recommendations on how we can improve and prevent issues like this from 
recurring. In the meantime, please be assured that the Bremerton CBOC 
relocation project has the personal attention of the VISN 20 Network 
Director and VA Deputy Under Secretary for Health for Operations and 
Management.
                access to women's health in rural areas
    Question 96.  Dr. Shulkin, women make up the fastest growing 
veterans population in the United States. In response to pre-hearing 
questions, you noted that since 2014, 100 percent of medical centers 
and 90 percent of CBOCs have Designated Women's Health Providers 
(DWHP). Those are commendable numbers, but I would like to see 100 
percent of CBOCs have a DWHP, especially since so many veterans live in 
rural areas where their only access to VA care is through their local 
CBOC. In fact, a report released this January by the U.S. Census Bureau 
found that roughly half of all veterans live in rural areas. In my home 
state of Washington, more veterans lived in rural areas than non-
veterans.
    a. With VA projections showing that the number of women veterans is 
expected to rise to 15 percent of the entire living veteran population, 
how will you, if confirmed, ensure that 100 percent of CBOC's have a 
Designated Women's Health Provider?
    Response. VA recognizes that the population of women Veterans has 
grown dramatically and will continue to rapidly expand. For FY 2017, VA 
has set a Secretary's Management Initiative focus on women Veterans' 
access, trust and satisfaction. Specifically with regard to access in 
CBOC's we will conduct additional trainings this year gaining an 
additional 500 providers through our Mini Residency trainings. The 
attendees are selected specifically targeted to gaps in providers, 
particularly for CBOCs. In addition, we are launching a new traveling 
education for rural sites to deliver the curriculum to CBOC providers. 
VA has identified where the gaps in providers exist, we strive to have 
Designated Women's health Providers at every facility and CBOC.VA, just 
as for all of health care, continues to be challenged in hiring Primary 
Care Providers. To assist with recruitment, Workforce Management and 
Consulting (WMC) is developing new recruitment tools to entice more 
women's health providers into VA employment.

    b. What else will you do, specifically, to care for the growing 
population of women veterans?
    Response. With regard to ongoing access, VA Office of Community 
Care has recently added analysis of referrals for women and provider 
availability. Approximately 33% of women go out into community care 
each year, thus an important focus had been adequacy of referral 
networks. In house, we have expanded Mammography to 52 sites and will 
continue to add locations that reach the critical minimum number of 
women at that site. VA Office of Women's Veterans Health has developed 
IT tools for management of breast cancer cases. Also added is a 
tracking system that allows follow up of tests ordered for women, 
whether seen in the VA or in the community.
    VA recognizes ongoing challenges for women Veterans using VA care 
and benefits. Despite many gains in culture change, women Veterans 
report feeling less welcome at VA than men, and overall do not report 
high trust in VA. We have launched a new campaign to enhance respect of 
Veterans and to end harassment of women Veterans by other Veterans. The 
full campaign will roll out it waves throughout this year.
                               caregivers
    Question 97.  As I have long believe, you stated in your meeting 
with me on Tuesday that the Caregivers program may actually be cost 
effective. However, you also stated that it would cost $3 billion 
annually in your answer to my pre-hearing questions. When we discussed 
this further you said that you would be interested in doing a cost-
benefit analysis of the Caregivers program, or something similar, to 
determine if it is a cost effective program for VA to utilize, which 
could result in the actual cost of the program being much less than $3 
billion.
     Do I have your assurance that you will conduct a cost 
benefit analysis of the Caregivers program to determine if it is 
actually cost effect? Once this analysis is complete will you work with 
CBO to update the estimated costs associated with the Caregivers 
program?
    Response. You have captured our conversation correctly. I do 
believe that support of additional Caregivers, particularly to older 
Veterans, may be cost-effective. This may be especially true in the 
area of cost avoidance of institutional care. I would be very 
interested in seeing the results of a study that would allow us to make 
a decision regarding the value of expanding the program. Rather than 
committing to a study right now, I would first want to make sure that 
such a study has not already been done for us to learn from. If not, I 
would want to speak to our researchers in VA to see if we have the 
ability to do such a study and if not I would want to speak to an 
outside group to determine the cost, time required and scope of such a 
study. Finally, I would want to confer first with CBO to make sure that 
we are asking the right questions up front to ensure that the results 
of the study would be meaningful to them.
                      impact of increased military
    Question 98.  President Trump has said he wants to substantially 
increase the size of the U.S. military, with an addition of 60,000 
active duty soldiers, an unspecified number of additional sailors to 
man the 78 naval vessels he would like to build, another 12,000 
Marines, and additional personnel to man at least another 100 combat 
aircraft for the Air Force. These servicemembers will one day become 
veterans who will rely on VA to provide them timely access to the 
benefits and care they earned through their military services. A Brown 
University study showed that the cost of caring for veterans peaks 30 
to 40 years after a conflict has ended, and that future costs 
associated with the Iraq and Afghanistan veterans will likely be 
between $600 billion and $1 trillion. If President Trump is serious 
about increasing the size of our military, he must also be serious 
about providing resource to VA to ensure that all veterans can access 
the services and benefits they have earned in a timely matter.
    a. How are you preparing VA so it can afford the impending influx 
of veterans from the Iraq and Afghanistan wars?
    Response. As Secretary McDonald stated in testimony from FY 2017 
budget hearings, forty years after the Vietnam War ended, the number of 
Vietnam Era Veterans receiving disability compensation has not yet 
peaked. VA anticipates a similar trend for Gulf War Era Veterans, only 
27 percent of whom have been awarded disability compensation. As the 
demand for benefits and services from Veterans of all eras continues to 
increase, VA will ensure budget requests to Congress reflect the 
necessary resources to handle influxes in workload and benefit 
payments.

    b. Have you had conversation with President Trump about the 
possibility of increased funding for VA concurrent with the increase in 
the number of servicemembers? If not, do I have your assurance that you 
will have periodic conversations with President Trump if funding 
shortfalls continue to impact VA's ability to provide benefits?
    Response. I have not had this conversation with President Trump. VA 
will continue to coordinate with the White House as well as DOD 
leadership to ensure workload forecasts and funding requests reflect 
the latest information available regarding separating Servicemembers. 
This ongoing coordination will ensure VA and Veterans are not impacted 
by a funding shortfall. If confirmed as Secretary, I would commit to 
raising issues to the President that impact on our ability to deliver 
necessary services to our veterans.
                              homelessness
    Question 99.  You stated in your response to a pre-hearing question 
that you believe the current spending levels for key programs that 
combat homelessness among our veterans, particularly HUD-VASH and 
Supportive Services for Veterans and Families, are sufficient to 
address this serious issue.
    However, the Department of Housing and Urban Development estimates 
that nearly 40,000 veterans are homeless on any given night.
     Can you please explain how there is no need for additional 
resources to address veteran homelessness with so many of our veterans 
sleeping in the streets each night?
    Response. The 2017 President's Budget includes $1.6 billion for VA 
programs that prevent or end homelessness among Veterans including 
funding for case management support for the nearly 80,000 existing 
Housing and Urban Development-VA Supportive Housing (HUD-VASH) 
vouchers, grant funding for community-based prevention and rapid 
rehousing services provided through the Supportive Services for Veteran 
Families (SSVF) program, clinical outreach and treatment services 
through Health Care for Homeless Veterans (HCHV), service intensive 
transitional housing through the Grant and Per Diem (GPD) and 
prevention services to justice involved Veterans in the Veteran Justice 
Program (VJP); and employment supports in Homeless Veterans Community 
Employment Services (HVCES).
    We believe that through prevention and housing retention efforts 
that our current capacity allows us to provide we will be able to 
continue to reduce the inflow of veterans becoming homeless or 
returning to homelessness. Those Veterans who are currently homeless 
often require enhanced efforts at engagement and support to help them 
achieve housing. The reduction in the overall number of homeless 
Veterans allows us to re-direct the services and programming to those 
more complex Veterans with greater needs. We believe we have the 
capacity to do this within our current programming while continuing to 
decrease the number of Veterans identified in our PIT counts. We do, 
however, need to ensure that funding levels are sustained so that 
communities can meet the goal of ending Veterans homelessness, and once 
there, they will be able to sustain it and not jeopardize the progress 
to date or recreate the levels of homelessness among Veterans prior to 
the investment.
                               education
    Question 100.  Throughout my time in the Senate, protecting our 
servicemembers and veterans enrolled in higher education has been one 
of my top priorities. Unfortunately, our military students and their 
families have not always been treated well by their colleges and 
student loan servicers. One such company was ITT Educational Services, 
Inc., (``ITT'') which closed last September after enforcement actions 
by the Department of Education. ITT had been subject to investigations 
by numerous state attorneys general, the Securities and Exchange 
Commission, the Department of Justice, and the Consumer Financial 
Protection Bureau for illegal recruitment practices, scamming students 
into taking out expensive private loans, and other misconduct. 
According to data provided to my office by the Workforce Training & 
Education Coordinating Board, there were approximately 215 veteran 
students in Washington State enrolled in ITT programs at the time the 
school abruptly closed. I want to make sure that we do everything we 
can to avoid putting our veterans at risk for future abuses by 
unscrupulous actors. Do you commit to withdrawing program approval for 
GI Bill Benefits when an institution of higher education is found by 
any other Federal or state entity to have committed fraud, including 
deceptive or misleading recruitment?
     If confirmed, will you commit to working with other 
Federal agencies to crack down on ``bad actor'' colleges that deceive 
veterans?
    Response. Yes. We have already forged and continue to strengthen 
relationships focused on enforcement with the FTC, DOD, Dept of 
Education, Consumer Financial Protection Bureau, and DoJ. Additionally 
we are collaborating on these issues with the State Approving Agencies.

    Question 101.  As you may know, our financial aid rules permit for-
profit colleges to receive up to 90 percent of their total revenue from 
Federal aid, which is known as the ``90/10'' rule. However, a loophole 
in Federal law does not technically ``count'' educational programs for 
veterans and servicemembers, including Post-9/11 GI Bill benefits and 
Military Tuition Assistance, as ``Federal aid.'' These benefits are 
therefore excluded from the 90 percent cap. I am very concerned that 
this loophole drives unnecessarily aggressive marketing and recruitment 
of our military students and their families. But regardless of whether 
you share my opinion on whether Congress should close this loophole, I 
hope we can agree on the facts.
     Do you consider Department of Veterans Affairs Post-9/11 
GI Bill, and Department of Defense Tuition Assistance benefits, both of 
which are paid for by American taxpayers, to be Federal aid?
    Response. Yes

    Question 102.  Last year, the Department of Education worked with 
the Department of Veterans Affairs to publish full estimates on the 
amount and percentage of VA and DOD funding that is received by 
institutions of higher education from each Federal educational program, 
including Post-9/11 GI Bill benefits and Military Tuition Assistance. I 
had been pressing for some time for this data to become publicly 
available as a useful tool to know which institutions have a healthy 
level of outside, non-Federal investment.
     Do you believe this is important consumer information for 
the U.S. Department of Education to continue making available to our 
veterans and servicemembers?
    Response. Yes as it provides quantifiable impact of any proposed 
changes to the 90/10 rule.

    Question 103.  I believe it is essential to ensure that student 
veterans have the resources they need to succeed in their educational 
pursuits.
    a. Do you believe that veterans who were attending a school that 
closed before they could complete their education deserve to have their 
eligibility for GI Bill benefits restored, just like students who 
receive Pell Grants and student loans?
    Response. VA has supported proposed legislation (S. 2253) that 
would reduce the negative impact on student Veterans and their 
dependents of abrupt school closure to include some amount of 
entitlement restoral.

    b. Additionally, do you believe that student veterans who are using 
their GI Bill benefits when their school closes should see their living 
stipends extended for at least a short period?
    Response. VA has supported legislation (S. 2253) that would provide 
a limited continuation of the housing stipend in cases of abrupt school 
closure.

    Question 104.  The conflicts in Iraq and Afghanistan have led to a 
tremendous number of veterans returning home to get an education using 
their Post-9/11 GI Bill benefits. But unfortunately, as noted by former 
Consumer Financial Protection Bureau official Holly Petraeus, many 
colleges see these veterans as nothing more than a ``dollar sign in 
uniform.''
    In the last few years, the Department of Veterans Affairs, Defense, 
Education, and the Consumer Financial Protection Bureau have begun to 
implement Executive Order 13607, Establishing Principles of Excellence 
for Educational Institutions Serving Servicemembers, Veterans, Spouses, 
and Other Family Members. The ``Principles of Excellence'' allow the VA 
to make law enforcement referrals to crack down on bad actors, 
particularly for-profit colleges, like Corinthian and ITT.
     If confirmed as VA Secretary, will you support the law 
enforcement community by following the Principles of Excellence and 
actively making referrals to other agencies in order to protect 
veterans and curb waste and abuse of education benefits provided by 
taxpayers?
    Response. Yes, VA already has and will continue to refer schools 
and incidents to other Federal agencies to ensure compliance with all 
applicable laws and regulations.
                                 lgbtq
    Question 105.  When Vice President Mike Pence was running for 
Congress in 2000, his website included multiple statements that are 
shamefully discriminatory against the LGBTQ community. In addition to 
opposing gay marriage and anti-discrimination laws that protect LGBTQ 
individuals, a section of his website included a statement that has 
been interpreted as an endorsement of conversion therapy, a discredited 
practice that falsely purports to change a person's sexual orientation 
or gender identity. While Vice President Pence has denied this 
accusation, I remain deeply concerned about this Administration's 
treatment of LGBTQ individuals.
     If confirmed as VA Secretary, can you assure me that you 
will never deny care to any veteran on the basis of his or her sexual 
orientation or gender identity?
     Can you further assure me that you will continue to 
protect LGBTQ employees from discrimination based on their sexual 
orientation or gender identity?
    Response. I am committed to diversity and inclusion in both patient 
care and the VA workforce. In fact, VA is among the leaders in the 
Federal Government in the area of LGBT protections. With respect to 
Veteran patient care, on July 1, 2014, VHA issued a policy memorandum 
ensuring that all our LGBT Veteran patients receive quality and 
respectful patient care, ``in an environment and culture that is 
informed, welcoming, and empowering for the LGBT Veterans and families 
whom we serve.'' The specific guidance on care for transgender Veterans 
can be found in VHA Directive 2013-003: Providing Health Care for 
Transgender and Intersex Veterans. VHA also established an Office of 
Health Equity to address the different and specific health care needs 
of diverse populations, including the LGBT community. To ensure that 
these services are delivered by culturally competent health care 
providers, VA has had a longstanding commitment and explicit policy 
protecting all of its employees from discrimination and harassment on 
the basis of gender identity and sexual orientation, long before these 
protections became embedded in Federal policy or law. We complement 
these policy protections with mandatory and elective EEO, cultural 
competency and unconscious bias training in the area of LGBT awareness 
for all our employees, including health care providers and supervisors. 
The VA is close to issuing a Transgender Employee Workplace Transition 
Guidance as a resource for our employees to address these issues 
appropriately and sensitively in the VA workplace; I will ensure this 
gets published. I commit to you that VA will continue to support these 
and other protections for our LGBTQ Veterans and employees.
    ACA
    Question 106.  Dr. Shulkin, I am deeply concerned about the impact 
that dismantling the Affordable Care Act may have on our veterans. A 
study released last September by the Urban Institute found that the 
ACA's combined coverage expansions reduced the uninsured rate among 
non-elderly veterans by 42 percent. The number of non-elderly veterans 
without health insurance has declined from 12 percent in 2013 to 8.6 
percent in 2014 as a result of the ACA. If ACA is repealed without a 
comprehensive replacement plan the most likely scenario at this time is 
that many veterans currently insured through the ACA will turn to VA 
for health care.
     As Republicans rush to rip apart the civilian healthcare 
system by repeal, increase uncompensated care at rural hospitals, 
threaten to gut Medicaid and take away the guarantee of full coverage 
under Medicare, what conversations have you been a part of to ensure no 
veterans lose health insurance?
     During your confirmation hearing you said that VA will do 
all it can to care for all veterans; could you provide specific answers 
to how, if confirmed, you will handle a possible increase in the number 
of veterans seeking VA care if they lose coverage through ACA repeal?
    Response. The Urban Institute's analysis of 2011-2015 American 
Community Survey data that noted a decline in the number of uninsured 
Veterans between 2013 and 2014 is encouraging news for efforts to 
promote Veteran's access to care. Within this context, it is possible 
that both the ACA and VA's outreach to encourage enrollment in the VA 
health care system contributed to this reported decline in uninsured 
Veterans. Regardless of future national health reform policies, the VA 
will continue to plan for providing high quality health care to our 
Nation's Veterans that are eligible for VA health care services. If 
more Veterans seek care in VHA as a result of an ACA repeal or any 
other reason, as Secretary I would seek the resources necessary to make 
sure we honor our commitment to serve these Veterans.
                             sexual assault
    Question 107.  Sexual assault continues to be a pervasive issue in 
our military. Reports suggest that as many as 1 in 10 servicemembers 
experience sexual assault or harassment. In 2014, 62 percent of those 
who reported they were assaulted also said they experienced 
retaliation. While the Department of Defense has undergone commendable 
efforts to tackle this distressing problem, we have a long way to go to 
ensure that the brave men and women in our military are provided the 
resources they need, and VA plays an integral role in supporting 
survivors of sexual assault.
     If confirmed as VA Secretary, what specific steps will you 
take to ensure that survivors of sexual assault and harassment receive 
the specialized care they need and are entitled to?
    Response. All Veterans seen for health care services are screened 
for experiences of MST (sexual assault or repeated threatening sexual 
harassment). This is an important way to ensure that Veterans are aware 
of and offered the free MST-related care available through VHA. Every 
VA medical center provides MST-related services including evidence-
based psychotherapies that target the mental health diagnoses that are 
associated with MST. MST is an experience, not a diagnosis or a 
condition in and of itself. Every VA medical center has a designated 
MST Coordinator who can assist Veterans with accessing MST-related 
health care. Beginning in FY 2012, VHA mental health and physical care 
providers must complete a one-time mandatory training that is 
accredited for continuing education. The MST Support Team in Mental 
Health Services coordinates a wide range of other national specialized 
MST-related training initiatives for VHA clinicians.

    Question 108.  During your time as President of Morristown Medical 
Center you withdrew counselors from Morris County Sexual Assault 
Center, which provided important resources to survivors. In an Op-Ed 
concerning this decision you suggested that ER services would be 
adequate.
     If confirmed, will you commit to putting all the resources 
necessary to support survivors of sexual assault in the military, 
including ensuring that survivors have access to counseling services to 
treat long-term trauma?
    Response. Your statement about what happened at Morristown is not 
accurate. I would be glad to discuss the specific circumstances with 
you at the appropriate time, but the facts show that when I learned 
about this I restored these services. In regards to your question, the 
MST Support Team in Mental Health Services completes an annual report 
to determine whether each VA health care system (HCS) has adequate 
capacity to provide MST-related care. The most recent report found that 
100 percent of VA HCS were at or above the established benchmark for 
MST-related mental health staffing capacity. All Veterans seen for 
health care services are screened for experiences of MST (sexual 
assault or repeated threatening sexual harassment). This is an 
important way to ensure that Veterans are aware of and offered the free 
MST-related care available through VHA. Every VA medical center 
provides MST-related services including evidence-based psychotherapies 
that target the mental health diagnoses that are associated with MST. 
The VA offers a continuum of MST-related care that ranges from 
outpatient to mental health rehabilitation and treatment programs (MH 
RRTPs) and inpatient programs for Veterans who need more intense 
treatment and support.
                       medical legal partnerships
    Question 109.  Research indicates that genetics, medical care, and 
personal choices account for 40 percent of an individual's health 
outcomes while 60 percent of health outcomes are determined by social 
and environmental factors. This is particularly true for veterans who 
often face barriers to safe housing, benefits appeals, and employment 
that negatively affect their health. The VA's annual CHALENG survey of 
homeless veterans has shown that four of homeless veteran's top 10 
unmet needs are legal needs including eviction and foreclosure issues, 
child support and family law, outstanding warranties and fines, and 
restoring drivers' licenses. Medical-legal partnerships (``MLPs'') 
between legal services and medical providers can help to address these 
issues by integrating legal solutions into medical settings.
     In recognition of the importance of MLPs, the VA recently 
launched the MLP Expansion Initiative to expand the number of MLPs in 
VA sites in order to identify and identify veterans' legal needs that 
effect health outcomes and to improve physician quality of care. If 
confirmed as VA Secretary, will you commit to continuing the MLP 
Expansion Initiative to increase veterans' access to legal services in 
VA facilities?
    Response. Medical-legal partnerships (MLPs) allow VA to help 
Veterans address not only their health-related needs but also their 
health-harming legal needs, by providing access to legal services that 
VA itself cannot offer. There are now 13 MLPs in VA facilities, and I 
am committed to fostering such partnerships elsewhere in our health 
care system. The VA MLP Expansion Initiative will therefore continue 
its work on this important issue.
     VHA Directive 2011-034 encourages VA medical centers to 
make space available for legal services providers to assist veterans. 
Approximately 120 legal pro bono clinics staffed by outside legal 
providers are currently given space to operate in VA centers. Do you 
commit to keeping VHA Directive 2011-034 in place? What additional 
steps will you take to ensure veterans have access to legal services, 
to support existing MLPs, and to create new partnerships between health 
facilities and legal service providers?
    Response. VHA will soon issue a new directive to replace the 
expiring VHA Directive 2011-034. This new directive will restate VHA's 
commitment to facilitating Veterans' access to legal services, and 
provide expanded operational guidance to VA facilities. It is in the 
final stages of pre-publication review in VHA, and once released it 
will guide VHA's continued efforts to assist Veterans with unmet legal 
needs. Although VA does not have the authority to provide or fund legal 
services, we will continue to seek out and develop new partnerships to 
improve Veterans' access to needed legal services.
                certified registered nurse anesthetists
    Question 110.  In your response to pre-hearing questions, you 
recognized workforce shortages at VA and promised to continue pursuing 
strategies to meet such gaps, which included expanding the scope of 
practice for advanced practice registered nurses. On December 14, 2016, 
VA issued the final rule providing full practice authority for advanced 
practice registered nurses with an effective date of January 13, 2017. 
However, the final rule excluded Certified Registered Nurse 
Anesthetists (CRNAs) from receiving full practice authority, which the 
draft rule did not. This is despite supportive evidence in favor of 
full practice authority for CRNAs in research journals and 
recommendations from numerous independent entities, including the 
Commission on Care. Additionally, the exclusion of CRNAs from the VA 
final rule is inconsistent with the full practice authorities that 
exist in other Federal health care systems in the military and the 
Indian Health Service. I understand that VA's rationale behind 
excluding CRNAs from the final rule was that there is no shortage of 
anesthesia providers in the VA system. However, a RAND study 
commissioned by this Committee published in 2015 found that a lack of 
anesthesia services and support directly affects VA's ability to 
provide care. It seems like the research evidence, recommendations from 
independent entities, and policies of Federal health systems outside VA 
should have been sufficient to include CRNAs in the final rule, which I 
fully support.
     Can you please provide a comprehensive explanation as to 
how you came to the conclusion you did, including fully identifying and 
explaining the criteria you used for providing APRN full practice 
authority and how this criteria was applied equitably across the four 
APRN categories?
     Will you commit to revisiting VA's rule on nursing full 
practice authority to further assess whether CRNAs should be included 
if confirmed?
    Response. I appreciate your point of view on this issue. VA first 
began to look at changing its' policy on advanced practice nurses over 
9 years ago. As Under Secretary I committed to making a decision and I 
did so. We have received hundreds of thousands of comments and I have 
personally taken dozens of meetings and sessions to hear people 
thoughts and input on this topic. I tried to make the best decision I 
could at the time, with the information I had available.
    The truth is that I believe CRNAs play a critical role in providing 
care for our Veterans. In fact we hire at VA many more CRNA's than we 
do anesthesiologists. We also believe that it is a team based approach 
to anesthesia care that serves our Veterans best, with the best 
outcomes. A team based approach to care includes CRNA's working with 
anesthesiologists. In making our final rule, we did not find that VA 
had immediate and broad access challenges in the area of anesthesia 
that would require a change to our current approach to anesthesia care, 
that is a team based approach. If VA learns of access problems in the 
area of anesthesia care in specific facilities or more generally that 
would benefit from FPA for CRNA's, now or in the future, or if other 
relevant circumstances change, we will consider a follow-up rulemaking 
to address granting FPA to CRNAs. VA CRNAs that are granted full 
practice authority by their state license will continue to practice in 
VA in accordance with their state license and subject to credentialing 
and privileging by their VA medical facility's medical executive 
committee. VA will not restrict or eliminate these CRNAs' full practice 
authority. Amending this regulation increases VA's capacity to provide 
timely, efficient, and effective primary care services, as well as 
other services. This increases Veteran access to needed VA health care, 
particularly in medically-underserved areas and decreases the amount of 
time Veterans spend waiting for patient appointments.
                                smoking
    Question 111.  As a physician, I'm sure you know that smoking poses 
a significant threat to the health of our veterans, in addition to 
costing the VA healthcare system billions of dollars every year. You 
may also be aware that over half of current smokers (57%) report that 
they had tried quitting within the past year and, according to the 
Centers for Disease Control and Prevention, as of 2010 nearly 70% of 
adult smokers wanted to quit.
     If confirmed as VA Secretary, what policies and practices 
will you put in place to ensure that all veterans have affordable and 
comprehensive access to the help they need when they want to quit?
    Response. VA is a leader in smoking and tobacco use cessation 
treatment with a range of evidence-based interventions. Today, the 
smoking rate of Veterans in VA care is 16.8%, the lowest ever and a 49% 
decrease from fiscal year 1999. VA is committed to maintaining current 
programs and to build on their success through the development and 
implementation of new innovative treatment models that will ensure that 
any Veterans who want assistance with quitting smoking will receive 
comprehensive and effective care.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
    Question 112.  For-profit colleges are able to leverage the Higher 
Education Act's 90/10 loophole to go after veterans with GI Bill 
benefits, using those funds to compensate for the gap these 
institutions face due to a lack of Federal fund.
    a. Do you support closing the 90/10 loophole?
    Response. While VA defers to the Department of Education on the 90/
10 calculation, I am supportive of including the Post-9/11 GI Bill in 
the 90 percent limit on Federal funding or related proposals. Under the 
present structure, some institutions may be targeting Veterans because 
the Federal education benefits they receive are treated the same way as 
private funds in the 90/10 calculation.
    Modifications to the 90/10 rule could provide additional tools to 
assist in this area. However, it is understood that such a change could 
cause some schools to exceed the 90 percent threshold and be at risk of 
losing eligibility to receive Federal student aid. Therefore, in order 
to ensure that Veterans are not adversely affected, the manner in which 
such a change would be implemented is important. VA would welcome the 
opportunity to work collaboratively with the Department of Education 
and Congress as it considers changes in this area.

    b. What actions are you prepared to take to ensure VA's compliance 
with 38 U.S.C. 3969?
    Response. The VA Education Service is postured to formally request 
the Secretary to leverage his authorities outlined in the public law 
when an institute of higher learning (IHL) is in violation of the 
law.VA has recently made two referrals to FTC for potential violations 
of section 3696.

    c. What is your plan to hold colleges accountable to properly using 
the GI Bill benefits veterans sacrificed for?
    Response. VA will continue to work with all State Approving 
Agencies and our Federal partners to ensure compliance and enforcement 
of all GI Bill statutory and regulatory requirements.

    d. What is your strategy for communicating to colleges the 
standards for compliance with the VA Advisory Committee on Education's 
VA Principles of Excellence initiative?
    Response. Since the inception of the Principles of Excellence (POE) 
in 2012, the standards for compliance with POE are communicated to the 
institutes of higher learning via the VA GI Bill web site and reviewed 
during the over 5000 annual compliance visits with schools.

    e. Please outline your plan to collaborate with other Federal 
entities to address colleges that take advantage of veterans and their 
benefits.
    Response. We have developed strong relationships with the 
Department of Education, Federal Trade Commission, Department of 
Justice, Department of Defense, Consumer Financial Protection Bureau 
and VA's Office of Inspector General. Regular meetings are ongoing and 
as needed virtual communications are leveraged as warranted. In 2017, 
VA will further strengthen these collaborations in order to ensure 
schools that engage in any activities that negatively impact our 
student veterans are addressed appropriately and in accordance with 
applicable laws and regulations. These include but are not limited to 
deceptive marketing, deceptive recruiting, and accreditation of IHL 
programs and schools.

    Question 113.  How will you implement the Career Ready Student 
Veterans Act, legislation aimed at blocking GI Bill benefits going to 
programs that, due to low-quality or lack of accreditation, do not 
result in veteran-graduates earning state certifications and licenses?
    Response. The State Approving Agencies, who are charged with 
enforcing the requirements for initial and continued GI Bill program 
approval, will be at the forefront of the implementation effort, as 
they have expertise in GI Bill approval requirements and state 
licensure and certification requirements. VA has had a number of 
discussions with the State Approving Agencies (SAAs) on these new 
provisions and we are currently in the process of drafting guidance. 
Both VA and the SAAs strongly believe that vocational and occupational 
programs should meet the requirements in the state in which the 
educational institution is located so that GI Bill beneficiaries are 
well-prepared upon completion of these programs.

    Question 114.  As Governor of Indiana, Vice President Pence wrote 
to VA officials, including Secretary McDonald, urging the Department to 
compensate student veterans for lost GI Bill benefits used at shuttered 
ITT Tech and Corinthian College locations. These student veterans were 
taken advantage of by institutions looking to profit from their 
sacrifice.
    a. How will you ensure that these veterans' GI Bill benefits are 
restored?
    Response. Currently, VA does not have the statutory authority to 
restore a student's GI Bill benefits due to a school closure. VA has 
provided technical assistance to Congress on draft legislative language 
that would allow for such benefit restoration and will continue to 
provide any additional assistance that may be needed.

    b. Do you believe that when VA and other Federal entities designate 
that an institution of higher education displays signs of instability? 
If so, what is your plan to communicate to student veterans when an 
institution shows such potential, as ITT Tech and Corinthian Colleges 
did prior to their closing?
    Response. VA uses a web based Comparison Tool with an appropriate 
Caution Flag to make student Veterans aware of indicators VA or other 
Federal agencies have determined potential students should pay 
attention to and consider before enrolling in a program of education. 
The VA is also very proactive in sending emails to individual students 
attending such institutions which explain the potential impact to their 
education benefits. For example VA has sent six different email 
communications to ITT students providing information and resources to 
assist them.

    Question 115.  Knowing the risks posed by colon cancer, the second-
most common cause of death from cancer for men and women collectively, 
and the opportunities for patients through early screening and 
detection, will you ensure that all available colorectal cancer 
screening methods endorsed by the U.S. Preventative Services Task Force 
are employed to serve the healthcare needs of veterans?
    Response. Yes I will. The VHA is proud to have just received an 
achievement award from the National Colorectal Cancer Roundtable for 
surpassing an 80% screening rate for colorectal cancer (http://
nccrt.org/tools/2017-80-by-2018-national-achievement-awards/). However, 
we are continuing efforts to further expand screening and to ensure 
appropriate and rapid follow up of every Veteran. Specifically, we have 
developed and are deploying an IT tool to automate the reminder for the 
appropriate screening and tracking of every veteran. VA is currently 
updating its recommendations for colorectal cancer screening and is 
carefully considering the recommendations of the U.S. Preventive 
Services Task Force.

    Question 116.  In your testimony you said that VA needs to be able 
to hold its employees accountable. What did you mean by that, and what 
metrics would you use to hold employees accountable?
    Response. I know that the vast majority of the VA workforce is 
highly professional and motivated to take care of our Veterans. There 
are times when employees get off track and need help in either getting 
back on track or moving out of the VA. While we already have and 
leverage existing laws to help move off track employees out of the 
workforce, additional legislation is needed. More specifically:

     The Choice Act VA needs to be modified, specific to SES 
removal procedures, to ensure constitutionality.
     The Merit Systems Protection Board needs to be directed to 
a lower burden of proof and deference to the agency's choice of 
penalty.
     We need the authority to use indefinite suspensions where 
there is reasonable cause to believe an employee has done something to 
harm or endanger a patient or a coworker.
     5 U.S.C. 7511(a)(1)(A), (B), and (C) and 5 CFR 752.401(2), 
(3) and (5) need to be modified to allow those individuals serving a 
probationary period or on a temporary appointment to be separated 
without full due process and appeal rights.

    Question 117.  Last December, ProPublica and The Virginian-Pilot 
issued a report, based on data gathered from VA's Agent Orange 
Registry, which assess that children born to servicemembers who had 
self-reported Agent Orange exposure during or after the Vietnam War 
were 34 percent more likely to have a birth defect than children born 
to servicemembers who had not self-reported exposure.
    a. On Tuesday I received a response from VA-that you signed and 
your letter said VA recommended to ProPublica that the report be peer 
reviewed, but my question to you is if VA had been collecting this 
information for over 40 years, why didn't VA initiate its own study?
    Response. As was mentioned in the letter ``a voluntary registry 
such as the Agent Orange Registry, may have bias, or a systematic 
deviation, that results if those who volunteer are not representative 
of the entire population of concern.'' Any research based on or 
conclusions drawn from this flawed dataset are immediately suspect for 
this reason. Desiring quality data and study design, VA has initiated 
the Vietnam Era Health Retrospective Observational Study (VE-HEROeS).

    b. Why did it take a FOIA request to produce a study on data that 
VA already had at its finger tips?
    Response. As stated above, the voluntary Agent Orange Registry did 
not provide a quality data set for research. VA has initiated the 
Vietnam Era Health Retrospective Observational Study with the aim to 
aim to develop scientific, peer-reviewed evidence that will inform 
policy decisions.

    c. What is the timeline for VA's Agent Orange working group to 
review whether to include bladder cancer, hypothyroidism, Parkinson's-
like symptoms, and hypertension to the list of presumptive conditions?
    Response. A VA Technical Working Group has reviewed the National 
Academy of Medicine's Veterans and Agent Orange, Update 2014 and is in 
the process of drafting recommendations for the Secretary of Veterans 
Affairs.

    d. I know VA has had the information from the Agent Orange Registry 
for years, yet VA says more research is needed, particularly from male 
servicemembers. These veterans and their families have waited too long 
for VA to do the right thing. Is the only reason VA isn't acting 
because of funding?
    Response. VA relies on scientific, peer-reviewed evidence to inform 
policy decisions, and such evidence for transgenerational effects due 
to Agent Orange exposure does not currently exist, as reported in the 
most recent Veterans & Agent Orange Report issued by the National 
Academy of Medicine. However, VA continuously monitors the development 
of new scientific approaches that may provide additional insight.

    Question 118.  Many of the issues veterans face as they transition 
from active duty into the community is because of a lack of 
connectivity and collaboration between the Department of Defense and 
VA.
    a. What steps would you take as Secretary to fix this?
    Response. The Departments of Veterans Affairs (VA) and Defense 
(DOD) partner with other agencies to administer the Transition 
Assistance Program. This inter-agency cooperation provides coordinated 
information, counseling, and support to transitioning Servicemembers. 
This includes one-on-one counseling with military service 
representatives experienced in the transition process, enhanced VA 
benefits briefings that are designed to provide individuals with 
information about education and employment programs; training vehicles 
on VA benefits and services that can improve a transitioning 
Servicemembers' overall quality of life, as well as, overviews of other 
benefits to assist in building and maintaining a stable home 
environment.
    VA and DOD have developed a robust relationship to improve the 
experience for separating Servicemembers as they transition into 
civilian life. Under the auspices of the Joint Executive Committee, 
which provides senior leadership a forum for collaboration and resource 
sharing, both departments have worked closely to remove barriers and 
challenges that impede collaborative efforts, assert and support 
mutually beneficial opportunities to improve business practices, ensure 
high quality cost-effective services for VA and DOD beneficiaries, and 
facilitate opportunities to improve resource utilization. As Secretary, 
I will work to strengthen the role of the Joint Executive Committee as 
it provides the strategic direction for the joint coordination and 
sharing efforts between the two Departments and oversees the 
implementation of those efforts.

    b. Will you make the single electronic health record from active 
duty to VA a priority?
    Response. Yes, we continue to make this a priority. We are actively 
exploring a few ways to accomplish this. The recent development of a 
prototype of the Digital Health record has created a new opportunity to 
make this a cost-effective mechanism to accomplish this.

    Question 119.  In 2010, the Federal Government adopted Opening 
Doors: The Federal Strategic Plan to Prevent and End Homelessness. 
Opening Doors set out goals for ending homelessness for families and 
youth, the chronically homeless, and veterans. Through a combination of 
increased Federal investment--in both HUD-VASH vouchers and VA 
programs--and better practices, the Federal Government has made 
significant progress toward that goal. Since 2010, we've reduced 
homelessness among veterans by 47 percent.
    But more needs to be done to ensure that no veteran is homeless. 
Last year, Congress enacted key provisions from the Veterans Housing 
Stability Act of 2015, which I cosponsored, to keep moving us toward 
this goal. Among other things, the bill would increase veterans' access 
to permanent housing options by increasing outreach to landlords to 
encourage renting to veterans and expand the definition of ``homeless 
veteran,'' so more veterans, including those facing domestic abuse, can 
access housing assistance.
    If confirmed, will you work expeditiously to implement these 
provisions?
    Response. Yes. The Jeff Miller and Richard Blumenthal Veterans 
Health Care Act and Benefits Improvement Act of 2016, Public Law 114-
315, was signed into law on December 16, 2016. Section 701 of this Act 
expands the eligibility to participate in the GPD program to persons 
fleeing domestic violence and interpersonal violence. VHA is working to 
incorporate the statutory changes as they relate to eligibility under 
the GPD program as quickly as possible following the standard agency 
protocols for inclusion of new statutory elements and notification to 
the field. Additionally, Our HUD-VASH regulations further define 
homeless as any individual or family who is fleeing or is attempting to 
flee domestic violence, dating violence, sexual assault, stalking, or 
other dangerous or life-threatening conditions in the individual's or 
family's current housing situation, including where the health and 
safety of children is jeopardized and who have no other residence and 
lack the resources or support networks to obtain other permanent 
housing.
    Regarding outreach to landlords, VA in partnership with HUD and the 
United States Interagency Council on Homelessness (USICH) have embarked 
on a coordinated outreach effort to engage and recruit landlords, and 
the trade and professional associations to which they belong to provide 
affordable housing for Veterans exiting homelessness. The goal is an 
increased willingness to work with government and community providers 
to help these Veterans locate and maintain permanent and permanent 
supportive housing.

    Question 120.  Are you familiar with Opening Doors? If confirmed, 
will you commit to requesting the resources and pursuing policies 
necessary to achieving the goal of ending veterans' homelessness?
    Response. Yes, Opening Doors is the Federal Strategic Plan to 
Prevent and End Homelessness among all populations--Veterans being a 
priority sub-population. I am proud to say that since its inception in 
2010, Veteran homelessness has decreased by nearly fifty percent--far 
more than any other sub-population. One reason for this significant 
decrease has been the targeted resources that have been appropriated to 
combat Veteran homelessness. The 2017 President's Budget includes $1.6 
billion for VA programs that prevent or end homelessness among 
Veterans. These funds are critical to ensure that once communities meet 
the goal of ending Veterans homelessness they will be able to sustain 
it and not jeopardize the progress to date or recreate the levels of 
homelessness among Veterans prior to the investment. I will continue to 
request appropriate levels of funding to ensure that Veteran 
homelessness is rare, brief, and nonrecurring.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
     to Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. 
                     Department of Veterans Affairs
    Question 121.  Improper Accreditation of schools and use of 
regulations in VA. During the hearing, I asked about implementation of 
the unanimously passed Career-Ready Student veterans Act and you 
committed to implementing that law.
    a. To the extent that such implementation requires the use of 
regulations, how will you comply with President Trump's recent 
executive order requiring the elimination of two regulations for every 
new regulation that is promulgated?
    Response. The Career-Ready Student Veterans Act as enacted is now 
Section 409 of the Jeff Miller and Richard Blumenthal Veterans Health 
Care and Benefits Improvement Act of 2016. There are many elements of 
this part of the law that can be implemented without regulations. 
However, where regulations are needed, we will work with the Director 
of the Office of Management and Budget to navigate the process. I am 
committed to implementing the Career Ready Student Veterans Act.

    b. Do you believe that Executive Order will impact your ability to 
run VA, which has used the regulatory process to provide care to 
veterans?
    Response. The Department of Veterans Affairs will certainly have to 
adjust the way we have historically managed our programs through the 
use of regulations. However, I am confident that the VA will continue 
to accomplish its mission. I also look forward to the opportunity to 
remove some of the outdated and unnecessary regulations that do not 
allow us to best target our resources to those areas that benefit 
Veterans most.
    Jerry Falwell Jr. has announced that President Trump has asked him 
to lead a White House Task Force on higher education reform. Falwell 
has been very critical of accreditation standards and gainful 
employment rules that have been required by the Obama Administration 
for schools receiving Federal dollars, including GI bill benefits.

    c. If confirmed, will you commit to ensuring GI Bill benefits are 
used to help veterans attend high-quality schools and then get good 
jobs or start their own businesses, consistent with recently passed 
legislation, regardless of what Falwell or others might recommend?
    Response. Yes. VA will continue to faithfully enforce the laws 
applicable to the GI Bill benefits.
                             patient safety
    Question 122.  The Veterans Health Administration has historically 
been a leader in patient safety making its current place on the U.S. 
Government Accountability Office (GAO) High Risk Report as a result of 
``risks to timeliness, cost-effectiveness, quality and safety of 
veterans' health care'' particularly concerning. Under previous 
leadership, the National Center of Patient Safety reported directly to 
the Undersecretary for Health, but now it resides in the Office of 
Quality, Safety and Value. I believe it is important that patient 
safety remains a top priority for the entire Department of Veterans 
Affairs.
    If confirmed, will you commit to aggressively working to get VA off 
of the High Risk List including resolving all of the issues regarding 
patient safety at VA that GAO identified?
    Response. Yes, as a former chief medical officer and an executive 
who has always focused on quality and safety, I have always prioritized 
patient safety as the foundation of health care delivery. I feel the 
same way about care for our Veterans. As you know, numerous external 
assessments, including a report by the RAND Corporation, have reported 
that VA care matches or exceeds patient safety and quality in the 
private sector. Regardless, patient safety is a pursuit that should 
always be prioritized, and you have my utmost commitment to this.
    One goal that I have in continuing to enhance patient safety is to 
create a system for quality and safety governance that ensures the 
right resources and policies are in place that directly impact front-
line clinicians and improvement teams. Regarding the placement of the 
National Center for Patient Safety (NCPS)--which is a support structure 
for leadership and front line teams in facilities--I believe its 
effectiveness is enhanced under a structure that directly connects 
identified risks for preventable harm (the focus of NCPS) with parts of 
the organization that focus on quality improvement. The Office of 
Quality, Safety and Value does just that, and you have my commitment to 
support and enhance the structure of this office to meet our needs over 
time. This is consistent with the contemporary approach to patient 
safety and quality in private sector organizations.
    I am committed to addressing all underlying risks (ambiguous 
policies; fragmented oversight; inadequate information technology; 
siloed training; and the need to enhance allocation of resources to 
meet Veterans' needs) identified by the GAO when they placed VA Health 
Care on the High Risk List because this work is imperative to complete 
the transformation of the Veterans Health Administration. You have my 
full commitment that we will continue our work to remove VHA from the 
high-risk list as quickly as possible.
              information technology and interoperability
    Question 123.  If you are confirmed as VA Secretary, you will be 
responsible for both VHA and OI&T. Just yesterday, a VA Office of the 
Inspector General Report released a report on the $2 million that OI&T 
spent on a cloud brokerage service contract that was supposed to all VA 
employees to access computing resources over the Internet on a pay-for-
use basis.
    The project, however, provided limited functionality for providing 
computing resources over the Internet for and the Inspector General 
also found that VA did not have adequate project management controls in 
place to ensure the contract met VA's IT needs and provided an adequate 
return on investment.
    a. If confirmed, what will you do to improve return on investment 
for VA's IT purchases?
    Response. I have not yet had a chance to review this IG report, but 
I would agree that this is concerning and if confirmed as Secretary I 
would be looking to see what recommendations the IG has made to ensure 
that issues like this do not occur again. It is important that we do 
better.
    OI&T, through its Strategic Sourcing function, has consolidated its 
IT purchasing power to obtain and deliver solutions to our Veterans 
from industry at the best price. Strategic Sourcing will provide access 
to best-in-class suppliers; ensure strong contractual performance 
through continuous monitoring; improve our speed to market, product 
compliance, and quality; ensure our compliance with Federal Information 
Technology Acquisition Reform Act (FITARA); provide greater technical 
capabilities for VA and our Veterans; and foster the most responsible 
allocation of taxpayer dollars.

    b. Do you believe that the Veterans Health Administration and the 
Office of Information and Technology have made adequate progress in 
addressing the IT challenges at VHA?
    Response. I believe that progress has been made but we need to do 
much better. The Veterans Health Administration and the Office of 
Information & Technology continue to collaborate as partners in 
improving the Health Information Technology (HIT) at VA. Through this 
partnership, VHA has received a number of critical improvements to HIT 
at VA while recognizing that our work together is ongoing so as to keep 
pace with the needs of VA's medical providers serving Veterans as well 
as putting modern HIT tools in the hands of Veterans.
    As Secretary, I would be looking for faster decisionmaking and more 
meaningful outcomes for our Veterans. The Commission on Care and the 
Independent Assessment have made a number of recommendations that 
require changes in the way that we currently operate. I would support 
an aggressive plan to ensure the necessary changes are implemented.

    c. Are you satisfied with the degree of health record 
interoperability between DOD and VA?
    Response. A Veteran's complete health history is critical to 
providing seamless, high quality integrated care and benefits. Our 
interoperability work with DOD and the private sector has made great 
strides and we are working daily to expand on our capabilities. On 
April 2016, VA and DOD were proud to certify to Congress, including 
this Committee, that VA had met the FY 2014 National Defense 
Authorization Act (NDAA) interoperability standards. Using the VA/DOD 
Joint Legacy Viewer (JLV), more than 220,000 VA health care and 
benefits professionals have access to real-time electronic health 
record information on a single screen from all VA, DOD and VA external 
partner facilities where a patient has received care. More than 2.5 
Million records have been viewed in JLV by VA staff. Overall, 1.5 
million data elements are currently being shared daily between the DOD 
and VA. These tools help those VA employees delivering health care and 
as well as those who process disability benefits claims who also need 
access to a patient's health record. The VA's Enterprise Health 
Management Platform (eHMP) incorporates JLV's capabilities and provides 
even greater interoperability and clinical tools.
    While we did achieve interoperability and we are working on tools 
that will provide even better integration with DOD, today I am not 
fully satisfied. We have obtained a read only interoperability and that 
is not enough in my opinion.
                          bad paper discharges
    Question 124.  I am also concerned that the warm hand-off between 
DOD and VA that is essential for veterans to get off on the right foot 
is failing for too many individuals with so called `bad paper 
discharges.'
    a. If confirmed, will you commit to working with Secretary Mattis 
to ensure that no Veteran falls through the cracks?
    Response. I agree this is very important and yes, I will meet with 
Secretary Mattis on this matter.
    VA has regularly met with the Department of Defense (DOD) to better 
understand each other's processes and collaborate to make certain that 
any proposed changes will not have negative unintended consequences for 
DOD's discharge process and will continue to do so moving forward.
    I also understand that there was a commitment last year by Sloan 
Gibson to conduct a rulemaking process regarding VBA's processes and 
procedures for character of discharge determinations to update the 
definitions regarding ``moral turpitude'' and ``willful and persistent 
misconduct.'' I think taking this step will help things greatly for 
veterans who would otherwise be unable to access VA health care and 
benefits.

    b. Is VA still committed to updating that regulation and if 
confirmed, will you commit to updating the regulation as rapidly as 
possible?
    Response. VA remains committed to pursuing policy changes to 
character of discharge (COD) determinations. VA is actively working to 
update 38 CFR 3.12, the regulation governing determinations of former 
servicemembers' COD for individuals with other than honorable (OTH) and 
punitive discharges. These changes will address ill-defined terms in 
the existing regulation, such as ``moral turpitude'' and ``willful and 
persistent misconduct,'' as well as provide guidance on consideration 
of mitigating circumstances that relate to Veteran status. Given that 
this proposed regulatory update will impact basic eligibility 
requirements for Veterans benefits, VA wants to ensure any proposed 
rulemaking reflects adequate research and deliberation. VA has already 
met with the Department of Defense (DOD) to better understand each 
other's processes and collaborate to make certain that any proposed 
changes will not have negative unintended consequences for DOD's 
discharge process and will continue to do so moving forward.
    Pursuant to the Administrative Procedure Act, rulemaking requires 
time for public notice and comment, as well as Office of Management and 
Budget (OMB) review. VA anticipates publishing a proposed rule to 
update 38 CFR 3.12 by the end of calendar year 2017.
                             long-term care
    Question 125.  Recognizing that VA provides a continuum of care 
that is unmatched in the private sector, and an increasing number of 
older and disabled veterans are coming to VA for care. In Connecticut, 
VA projects the number of veterans age 65 or older will be nearly 
100,000 this fiscal year. As you know Medicaid is the largest single 
payer of long-term care in the United States and almost half of all 
state Medicaid spending goes to home and community-based services. 
However, VA's spending for home and community-based services has 
remained at about 30 percent and is perhaps reflective of an 
intuitional bias toward nursing home care. Aging Veterans want the 
option of living at home with appropriate supports and services.
    a. What will you do as VA Secretary to meet the increasing long-
term care needs for veterans with serious chronic diseases and 
disabling conditions?
    Response. I will continue the Department's focus on optimizing the 
health, function, and well-being of Veterans facing the challenges of 
aging, disability, or serious illness by honoring their preferences for 
care by increasing access to home and community based services (HCBS). 
Since FY 2010, VHA has grown total spending for HCBS by 190%, from $810 
million in FY 2010 to $2.3 billion in FY 2015. Furthermore, total HCBS 
spending as a ratio of total Long Term Services and Supports (LTSS) 
spending has almost doubled from FY 2010-2015, from 16% in FY 2010 to 
31% in FY 2015, with commensurate decreases noted in the proportion of 
the LTSS budget spent on nursing home care going from 84% to 69%.
    VA's efforts to provide long term care in home and community based 
settings will reduce nursing home admissions and preventable 
hospitalizations. However, we also want to ensure access to high 
quality nursing home care for Veterans when it is required through our 
community living centers, contract community nursing homes, and State 
Veteran Homes. In order to achieve these goals, VA needs Congressional 
support for VA authority to purchase care using provider agreements.
    VA is poised to lead the Nation in the care of older Americans. VHA 
will continue to use data to support efficient and effective growth for 
home and community based services. VHA has recently completed a study 
that found many additional VHA users would benefit from VA's Home Based 
Primary Care (HBPC). This program has been shown to reduce total VA and 
Medicare costs by 12%. As a result, VHA has initiated efforts to expand 
HBPC access to meet the additional need for this program. VHA is also 
committed to expanding the Medical Foster Home Program as an 
alternative to institutional placement. Previous studies have shown 
that Medical Foster Homes can reduce Veteran total health care costs by 
40%. In addition, VHA is conducting a national study to quantify long 
term care demand among Veterans, with an emphasis on measuring nursing 
home and HCBS demand and identifying rural and highly rural areas in 
most need of additional access. Findings from this study will be 
available in early 2018 and will be used to guide expansion of home and 
community based services to Veterans in most need of additional 
supports.
    VHA expanded access to the Veterans-Directed Home & Community Based 
Services (VD-HCBS) Program in FY 2016. The goal is to make the program 
available at every VA medical center within the next three years. 
Through VD-HCBS, the Veteran has the opportunity to manage a monthly 
budget based on functional and clinical need, hire family members or 
friends to provide personal care services in the home, and purchase 
goods and services that will allow him or her to remain in the home. 
VD-HCBS is administered through a partnership with Health and Human 
Services Administration for Community Living (ACL) and has proven to be 
a program that can meet the needs of some of VA's most vulnerable 
populations, including many who would likely be placed in nursing home 
without this option. The number of Veterans served increased from 1,281 
to 1,751 in FY 2016, a 37% increase.
    VHA's ability to enhance and grow access to VD-HCBS has been 
greatly enhanced by changes in the Veterans Choice Program. In FY 2016, 
81 VD-HCBS Providers have entered into VA Choice Provider Agreements 
with VAMCs offering VD-HCBS. Additionally, 30 new VD-HCBS Providers 
have been approved to deliver VD-HCBS services to Veterans, which has 
expanded access to HCBS for Veterans in over 130 rural and highly rural 
counties. VHA plans to focus on increasing VD-HCBS access in rural and 
highly rural areas where there is limited supply of traditional home 
care agencies that meet VA requirements to participate in the Veterans 
Choice Program.
    VHA will continue to implement effective strategies based on 
measuring Veteran need for increased access to HCBS, creating an 
appropriate balance of HCBS and nursing home care, ensuring Veterans 
needing long term care are able to stay in the own homes for as long as 
possible. VHA will monitor progress of VISNs toward meeting performance 
measures that focus on rebalancing long term care. VHA will also 
continue to increase access to HCBS, primarily through expansion of 
HBPC and VD-HCBS, while leveraging opportunities under the Veterans 
Choice Program.

    b. Have you considered how any efforts to restrict Medicaid, either 
through block granting or increasing requirements for eligibility, 
would impact veterans who may rely on Medicaid for long-term care or 
other health care needs?
    Response. It is unclear what impact any such changes would have on 
Veterans needing long term care or other health care needs. As reforms 
are pursued, VA will need to evaluate the implications carefully and 
keep Congress informed of our findings.

    c. Do you believe VA is prepared to step in and provide care that 
would not be available to veterans if Medicaid is block granted? If so, 
what is currently being done with that excess capacity?
    Response. If policy changes at the national level occur that result 
in a new influx of Veterans that seek care, VA would do its' best to 
meet these needs. As has been our approach over the past 18 months, we 
would prioritize urgent care needs. However, if such a new influx of 
Veterans were to come to VA I would seek additional funding to be able 
to adequately care for all of our Veterans. I do not believe that VA 
has current significant unused capacity at this time.
                          caregivers supports
    Question 126.  All the VSOs are advocating for caregivers of 
severely ill and injured veterans of all eras to be eligible for 
comprehensive caregiver services and supports. I'm very supportive of 
Senator Murray's bill to expand program for caregivers of veterans from 
all eras, but paying for that expansion proved problematic last 
Congress. I do hope that this Committee and Congress will find a way to 
get around the previous roadblocks to passing that bill in the very 
near future.
    In the meantime, one program that could help address part of this 
inequity is the Veteran Directed Care program that allows all severely 
ill and injured veterans to support their family caregiver and continue 
living in their community. However, this program is not available at 
all VA facilities. In Connecticut for example, this program is only 
available at one (West Haven) of the two VA medical centers.
     What will you do to improve VA's support for family 
caregivers of veterans from all eras in the absence of expansion 
legislation?
    Response. VSOs have been advocating for caregivers of severely ill 
and injured Veterans of all eras to be eligible for comprehensive 
caregiver services and supports. I'm supportive of Senator Murray's 
bill to expand program for caregivers of Veterans from all eras, but 
paying for that expansion proved problematic last Congress. I do hope 
that this Committee and Congress will find a way to support that bill 
in the very near future. We are looking into further study that may 
help us gain a better understanding of the true costs associated with 
caregivers.
    In the meantime, one program that could help address part of this 
inequity is the Veteran Directed Care program that allows all severely 
ill and injured Veterans to support their family caregiver and continue 
living in their community. However, this program is not currently 
available at all VA facilities.
                          appeals legislation
    Question 127.  You expressed support to reforming the appeals 
process and the new framework that was developed by VA and stakeholders 
in 2016. As you mentioned, there is a wide spectrum of support for the 
new framework among stakeholders.
    Do believe that the stand-alone appeals reform legislation that was 
introduced in the Senate in the 114th Congress (S. 3328) should be 
modified? If you do, please discuss your views.
    Response. No. Among the bills introduced in the 114th Congress, VA 
preferred S. 3328 because it was a standalone bill, contained an 
effective date provision that allowed for an 18-month implementation 
period, included our clarification of the options available to Veterans 
after an initial decision on a claim, and had the support of VSOs and 
other stakeholders.
                        agent orange and the dmz
    Question 128.  In March 2016, I wrote to then Secretary Bob 
McDonald regarding the qualifying period for the presumption policy 
related to Agent Orange Exposure to all veterans who served in the 
Korean Demilitarized Zone (DMZ). In May 2016, Secretary McDonald 
responded indicating that VA would consult with the Department of 
Defense (DOD) about whether veterans were exposed to a herbicide agent 
in or near the DMZ prior to April 1, 1968.
    If that consultation has not yet happened, will you commit to doing 
so if confirmed, and to following up with me as to whether VA will 
expand the qualifying period per my initial request?
    Response. VA has reached out to DOD to make sure there are no 
records of usage of Agent Orange (AO) before April 1, 1968. Current 
records available to VA indicate no AO was sprayed before that date. VA 
is committed to having the most accurate records possible. If as 
Secretary I was to learn of new information that is different from what 
we know now, then I would act upon this information to make the right 
decisions on behalf of Veterans.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs

    Question 129.  Dr. Shulkin, the Veterans Choice and Accountability 
Act of 2014 provided the VA with $2.5 billion to add critically needed 
physicians and other medical staff. However, there have been recent 
reports that there has been no bump in VA hiring that would indicate 
staffing had increased beyond normal hiring and there has been priority 
given to those VA hospitals with the largest wait times. Please answer 
the following questions:
    a. Has the $2.5 billion been used to increase staffing beyond 
normal hiring patterns?
    Response. Yes, the Choice Act funding increased staffing. Choice 
Act funding increased the rate of hiring in VHA and resulted in a 6.3% 
net increase of more than 18,800 additional onboard staff. During the 
17 months of the Choice Act hiring initiative (August 1, 2014-
December 31, 2015), VHA hired 56,965 employees, of which 11,287 (20%) 
were hired using Choice Act funding. The total hires in this timeframe 
represented a 13% increase over the level of hiring in the previous 17-
month period (March 2013-July 2014).

    b. Was there any priority given to those VA facilities that had the 
longest wait times?
    Response. This decision predates my arrival at VA, it was shared 
with me that VHA requested input from that each of our Medical Center 
Directors. Medical Directors submitted their needs based upon wait 
times and need for personnel. VHA collected this information and 
matched it against data showing where need was greatest. The VACAA 801 
funds were distributed to 33 VAMCs that were experiencing the greatest 
challenges with Veterans access. While this was not a direct match to 
wait times there was an attempt to try to make sure that the funds 
distributed were appropriate. Since access remained a critical priority 
across the entire VA Health Care System, the remaining funds were 
distributed proportionally across all sites, based upon the Veterans 
population to be served.

    c. Did the hiring reflect critical needs, for example in areas that 
had acute provider shortages in their Cardiology departments was there 
an emphasis on increasing cardiology staffing or was hiring done 
without consideration of targeted need?
    Response. There was a special emphasis on hiring Primary Care, 
Mental Health, and Specialty Care providers. In addition, each local 
facility targeted recruitment efforts toward their hardest to fill 
positions.

    d. What plans are there to hire in the VA in a way that reflects 
need-prioritizing not only locations with shortages but particular 
specialties that are the highest priority.
    Response. Each Medical Center is responsible to determining their 
needs for personnel that is required to meet the needs of the Veterans 
that they serve. This data is then reviewed by the VISN before being 
submitted for approval. Medical Centers must also consider the 
availability of services in the community as many Veterans are able to 
access care in the community when these specialties are not available 
at the VA.
    The National Recruitment Program (NRP) provides a centralized in-
house team of skilled professional recruiters employing private sector 
best practices to fill the agency's most critical clinical and 
executive positions. The national recruiters, all of whom are Veterans, 
work directly with executives, clinical leaders, and local human 
resources departments in the development of comprehensive, client-
centered recruitment strategies that address both current and future 
critical needs. At facility request, NRP targets hard-to-fill 
recruitments in their regions.
    VHA markets directly to direct patient care providers through 
partnerships such as National Rural Recruitment & Retention Network 
(3RNet), a national network of non-profit organizations devoted to 
health care recruitment and retention for underserved and rural 
locations, as just one example. Through these partnerships, VHA has 
access to a robust database of candidates interested in working for 
VHA. National Recruiters routinely post VHA practice opportunities on 
career sites such as www.vacareers.gov.

    e. How much of the $2.5 billion has been used and how has it been 
used?
    Response. The VACAA 801 Spending Plan, submitted to Congress on 
December 3, 2014 provided the breakdown of funding for hiring, leases 
and other purposes. Of the $5B provided by VACAA, $2.213B was dedicated 
to the hiring of clinicians and medical support staff by the end of FY 
2016.

    Question 130.  Dr. Shulkin, following up from the question on the 
Palo Alto pilot which allows veterans to access care at pharmacy 
clinics, what is the timeline and path forward on expansion of the 
program? What additional requirements would improve the program's 
accessibility for veterans?
    Response. The Veterans Health Information Exchange (VLER) is 
connected to all CVS Minute Clinics across the Nation for bidirectional 
exchange via the eHealth Exchange. The technical capability to roll 
this out nationally is in place. Further rollout for access to these 
clinics will be determined by the local need of each facility. Many VA 
medical centers now have same day access to primary care which would 
make the need for these services much less. However in areas where 
there is not a Medical Center nearby these clinics may be an important 
way to ensure timely access. The Office of Community Care is working 
with VA contracting partners to allow for access to care at community 
pharmacy clinics, with initiation of this pilot under the Choice 
program at the Phoenix VAMC in the next quarter. Different from the 
Palo Alto pilot which does not use Choice funding, the eligibility 
criteria under Choice does limit its usage; however with the assistance 
of triage nurses at the facility level, Veterans will be able to be 
directed to these clinics with wider hours of operation for their 
immediate needs and therefore allow for diversion of care from VAMC 
emergency rooms and primary care clinics. We expect the rollout beyond 
the Palo Alto and Phoenix pilot sites later this year.

    Question 131.  Dr. Shulkin, telehealth services are an important 
part of the VA's health care delivery system. What additional resources 
are required to expand the existing system and how can the program be 
used to fill the gaps in care for veterans who live in rural 
communities?
    Response. The VA is currently leveraging Telemedicine to share 
clinical resources across VA facilities and states, providing the 
opportunity for large or academically affiliated VA facilities to fill 
Veteran clinical service needs in rural and underserved areas.
    The development and maintenance of successful Telemedicine services 
rely on the coordinated efforts of information technology, telehealth, 
engineering, and clinical provider staff as well as the availability of 
a robust information technology network, modern equipment, and a 
supportive legal and policy environment.
    From a legislative perspective, express authority for a VA provider 
to care for a Veteran, using a state license, irrespective of the 
location of the provider or patient in would, itself, help accelerate 
Telehealth expansion.
    Expansion of Telemedicine is dependent on the investment in these 
key areas, with limits defined primarily by the level of investment.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin, III to 
 Hon. David J. Shulkin, M.D., Nominee to be Secretary, U.S. Department 
                          of Veterans Affairs
    Question 132.  As of February 1, 2017, per the VA's website, there 
are 388,364 pending claims in VA's queue waiting for a decision. Of 
those, there are 97,119 backlogged rating-related claims backlogged. 
Please elaborate on your plan to:

    a. Get these backlogged claims processed within the next 60 days,
    b. Reduce the backlog to zero?
    c. Ensure all new and pending claims are processed within 125 days?

    Response. VBA makes every effort to work claims in a timely manner. 
We recognize that some pending claims require additional time to 
process to ensure VA meets its legal obligations to assist Veterans in 
the development of their claims. Complex claims (involving multiple 
body systems or a high number of claimed contentions) do tend to take 
longer as VA considers additional evidence and/or new medical 
conditions throughout the claims process. Additionally, late evidence 
or new contentions stop the momentum made in processing the claim, 
since they usually require a new round of evidence-gathering, medical 
examinations, and analysis, thus prolonging the determination of a 
decision. VBA is focused on resolving specific rating claims--our 
oldest claims, fully developed claims, and special interest claims 
(homeless, extreme financial hardship, former prisoners of war, 
terminally ill, etc.). Based on claim characteristics that make a claim 
more complex as well as VA's responsibility to help Veterans develop 
their claims, VA expects some claims to take longer than 125 days. One 
of VBA's published strategic targets is to reduce the disability rating 
claims backlog to less than 10 percent of the total rating inventory by 
FY 2021.

    Question 133.  Mandatory overtime of Veterans Benefit 
Administration employees has previously been used to reduce claims. 
While the current ``hiring freeze'' executive order is in effect, is 
the Department allowed to institute mandatory overtime if the claims 
backlog reaches a certain threshold? Do you anticipate that you will 
need to require mandatory overtime in the next 90 days?
    Response. VBA continues to use overtime for employees processing 
compensation rating claims. Additionally, VBA has authorized overtime 
for specific pension and non-rating work. VBA is considering all 
options, to include mandatory overtime, to ensure that Veterans are 
getting the best care and services possible.

    Question 134.  Is there ever a reason why a veteran would be taken 
off the Agent Orange Registry? If so, what are the parameters that the 
Department of Veterans Affairs uses to make such a judgment?
    Response. There is no reason that a Veteran should be taken off the 
Agent Orange Registry.

    Question 135.  You have mentioned in previous public statements 
that eradicating veterans homelessness is not a single event; it 
requires a long term commitment. Now that the number of homeless 
veterans has diminished, how do you plan to reach the remaining 
population of homeless veterans who are so difficult to reach? 
Additionally, are there specific initiatives in place to handle female 
veteran homelessness?
    Response. VA will continue until the goal of all Veterans having 
permanent, sustainable housing with access to high quality health care 
and other supportive services is met. While significant advances have 
been made in reducing Veteran homelessness, there are sub-populations 
of homeless Veterans who are hard to reach and engage in services 
(e.g., chronically homeless, those with serious mental illness, and 
justice involved, and those not eligible for VHA health care services). 
The 2017 President's Budget includes $1.6 billion for VA programs that 
prevent or end homelessness among Veterans including funding for case 
management support for the nearly 80,000 existing Housing and Urban 
Development-VA Supportive Housing (HUD-VASH) vouchers, grant funding 
for community-based prevention and rapid rehousing services provided 
through the Supportive Services for Veteran Families (SSVF) program, 
clinical outreach and treatment services through Health Care for 
Homeless Veterans (HCHV), service intensive transitional housing 
through the Grant and Per Diem (GPD) and prevention services to justice 
involved Veterans in the Veteran Justice Program (VJP); and employment 
supports in Homeless Veterans Community Employment Services (HVCES).
    All of our homeless programs serve woman Veterans and we continue 
to evaluate additional service options for this important and growing 
population. Last year, the National Center on Homelessness Among 
Veterans conducted a study to look at population projections of 
Veterans likely to either be a risk of or actually become homeless and 
access VA care over the next 10 years. Women Veterans and Veterans who 
had served in the OEF/OIF era were identified as two subpopulations 
projected to grow in number while those older than age 55 were 
projected to decline. The National Center has commissioned two 
subsequent studies to map both current need profiles of homeless women 
Veteran served within VA and outcomes associated with different program 
utilization patterns. We expect to have results from these studies 
within the next six months which will be essential to accurately 
mapping where we need to strategically direct resources to address this 
projected demand. At this time, we believe that current VHA program 
capacity, particularly in the Supportive Services for Veterans and 
Families (SSVF) and HUD-VASH programs which provide the bulk of 
services for women Veterans who are homeless or at-risk for 
homelessness, is sufficient to support these projections for at least 
the near term.

    Question 136.  The pernicious nature of post-traumatic stress is 
especially traumatic for rural veterans who do not always have access 
to high quality mental health and/or cannot receive care in a timely 
manner. Please elaborate on you plan to improve treatment, wait times, 
and increase options for rural Veterans with PTSD to ensure their 
safety and health.
    Response. VA's Office of Rural Health has collaborated with VA 
Connected Care and Mental Health to establish a regional telemental 
health hub network to enhance access to care for Veterans residing in 
rural areas and/or in areas with identified access challenges. These 
regional hubs leverage VA's established and successful use of 
telemental health to provide staffing solutions to facilities that are 
particularly access challenged. Four hubs were initiated in June 2016 
and are located in South Carolina, Utah, Pennsylvania, and the 
Washington-Oregon area. Six additional hubs were approved to come 
online in 2017. Regardless of their location, the hubs are available to 
provide services to Veterans and VA clinics throughout the country. The 
regional hubs provide a variety of services to include consistent, 
timely access to a full episode of treatment (e.g., evidence-based 
psychotherapy, pharmacotherapy, and primary care mental health 
integration services) for commonly seen conditions including Post 
Traumatic Stress Disorder, depression, and substance use disorders.
    VA's National Center for PTSD also offers a variety of resources to 
improve the treatment of PTSD, including a Consultation Program to 
build competency for treating PTSD among Community Providers. 
Consultation is available free of charge, and it offers education, 
training, and other information to non-VA health professionals who 
treat Veterans with PTSD. The services are consistent with evidence-
based practices for PTSD and VA consensus statements such as the VA/DOD 
Clinical Practice Guidelines for PTSD. The goal is to improve the care 
available to all Veterans with PTSD regardless of where they receive 
services.

    Question 137.  How is the Department of Veterans Affairs currently 
differentiating treatment options, as well as facilities, for female 
victims of Military Sexual Trauma? Are there policy alternatives 
regarding treatment and facility structure being considered now that 
are different than the status quo?
    Response. VHA policy requires that mental health services be 
provided in a manner that recognizes that gender-sensitive issues can 
be important components of care. VA recognizes that some Veterans will 
benefit from treatment in an environment where all the Veterans are of 
one gender. This may help address a Veteran's concern about safety and 
may improve a Veteran's ability to disclose, address gender-specific 
concerns, and engage fully in treatment; however, VA also recognizes 
that mixed-gender programs have advantages. This may help Veterans 
challenge assumptions and confront fears about the opposite sex in a 
protected environment and may provide an emotionally corrective 
experience. Given these considerations, VA does not promote one model 
as universally appropriate for all Veterans; the needs of a specific 
Veteran dictates which model is clinically most appropriate. Gender-
sensitive mental health care contains these key components:

     Comprehensiveness: Includes full continuum of service 
availability for women;
     Choice: Considers treatment modality (e.g., mixed-gender, 
women-only service options);
     Competency (of clinician): Addresses women's unique 
treatment needs; and
     Innovation: Provides creative options and settings for 
subgroups of women, especially when caseloads of women are small.

    Question 138.  Will you continue to advance the MyVA concepts and 
programs put into place under Secretary McDonald's leadership? Are 
there components of MyVA that you will differ from?
    Response. MyVA is an initiative to drive continuous improvement 
across the entire VA enterprise-as opposed to driving change from 
within each of the three administrations (Cemeteries, Benefits and 
Health). I believe this is important to continue as Veterans view VA as 
one organization and not three separate organizations. The MyVA 
initiative set organizational priorities, established metrics and 
timelines, and assigned accountable managers. With this approach, VA 
has improved numerous processes that have resulted in meaningful 
differences to Veterans. If confirmed as Secretary, I would continue 
with efforts for continuous improvement and accelerate our efforts to 
make meaningful changes on behalf of Veterans. Almost certainly VA's 
organizational priorities will change and evolve under a new Secretary. 
It would be my hope that we would have goals that were bold and would 
be realized through our transformational change that we plan to 
undertake within VA.

    Question 139.  You have previously stated that you do not and will 
not support a whole sale privatization of the Veterans Health 
Administration, and rather, you support an ``integrated'' model. Please 
elaborate on what you mean by ``integrated'' model.
    Response. By an ``integrated'' model, I am referring to a system 
that integrates the best of what the VA offers Veterans and the best of 
what the private sector can offer together. A successful VA system 
would be more than just the intersection of VA and the private sector 
but it would have additional value added for Veterans. By using VA's 
considerable capabilities in care coordination, case management, and 
quality oversight, VA can make sure that Veterans receive an integrated 
experience and do not have the gaps in care that too many Americans 
experience in the our health care system. I believe such an integrated 
model of care can provide our Veterans with healthcare outcomes that 
will be the best care available anywhere. Please see my article that I 
published in the New England Journal of Medicine where I described this 
model for the country. www. nejm.org.doi/full.10.1056/NEJMp160

    Question 140.  What statutory authorities do you need to remove 
employees who are low-performing and/or not working in the best 
interest of America's veterans?
    Response. I know that the vast majority of the VA workforce is 
highly professional, motivated to taking care of our Veterans and the 
cream of the crop. There are times when employees get off track and 
need help in either getting back on track or moving out of the VA. 
While we already have and leverage existing laws to help move off track 
employees out of the workforce, additional legislation is needed. More 
specifically:

     The Choice Act VA needs to be modified specific to SES 
removal procedures to ensure constitutionality.
     The Merit Systems Protection Board need to be directed to 
a lower burden of proof and deference to the agency's choice of 
penalty.
     We need the authority to use indefinite suspensions where 
there is reasonable cause to believe an employee has done something to 
harm or endanger a patient or a coworker.
     5 U.S.C. 7511(a)(1)(A), (B), and (C) and 5 CFR 752.401(2), 
(3) and (5) need modified to allow those individuals serving a 
probationary period or on a temporary appointment to be separated 
without full due process and appeal rights.

    Question 141.  The Veteran Success on Campus (VSOC) program has 
been widely successful and there are many campuses, like West Virginia 
University, that meet the requirements for VSOC, but still are on the 
wait list. Will you commit to supporting additional funding in The 
President's FY 2018 budget that will make it so more of our Nation's 
veterans have access to this program?
    Response. Vocational Rehabilitation and Employment (VR&E) Service 
currently maintains a list of 175 schools that have expressed an 
interest in becoming a VetSuccess on Campus (VSOC) site. We are looking 
at opportunities to fill select additional VSOC positions if this 
approved in the FY 2018 budget.

    Question 142.  Both Healthnet and TriWest have a footprint in West 
Virginia and my office has received complaints about the inability to 
reach a representative by phone and the lengthy approval process. 
Lengthy approval times often lead to a financial burden on the veteran 
and their family. Please elaborate on what VA is currently doing and 
what you envision VA will do when contracting with third party 
administrators in the future?
    Response. VA recognizes that there have been issues with customer 
service and timeliness of authorizations for care into the community. 
VA is actively engaged with both Third Party Administrators (TPAs) to 
improve service and reach our united goal of providing the best health 
care experience for our Veterans and the providers who care for them. 
In October 2016, VA and Health Net agreed to an expedited payment plan 
to assure community providers can continue serving our Nation's 
Veterans. VA has also formed a provider rapid response team to address 
provider issues brought to the attention of Community Care. The team's 
goal is to respond to providers within 72 hours, and the team engages 
individually with each provider to resolve problems and works with the 
TPAs to complete payments where appropriate. VA is also offering more 
Provider education on how the billing and payment processes work to 
help reduce problems. Since late 2016, all correctly submitted/clean 
provider claims are being paid timely (within 30 days). Claims that are 
rejected and denied due to errors require additional interaction on 
both sides and result in delays and reprocessing of claims.
    VA has partnered with the TPAs to embed staff in over 40 VA medical 
centers to improve the communication and coordination of care for 
veterans. We continue to grow that number and we will certainly look 
into creating this type of service in West Virginia.
    Daily monitoring of the contract via VA contract officer 
representatives and the TPA operations staff occurs to resolve issue 
and ensure Veterans are receiving timely access to health services. VA 
representatives are engaging in weekly correspondence with each 
contractor on issues of performance not meeting contract 
specifications. VA will also continue to issue letters of corrections 
in areas where performance is subpar.
    The future Community Care Network returns the Veteran 
communications, scheduling, customer service, and care coordination to 
the VAMCs. Based on lessons learned with the current contracts, VA will 
utilize the new contracted networks to assure that Veterans receive 
care in the community while not relying on other parties for these very 
important functions.

    Question 143.  What do you believe are the factors that create 
appointment wait times and how do you plan on mitigating those factors 
to ensure timely, quality care for our Nation's veterans?
    Response. Contributing factors to appointment wait times include 
increasing patient requirement for care, staffing levels of providers, 
nurses and schedulers unable to keep up with the demand for care, and 
inefficiencies in clinic practices.
    VA has been working mitigate these factors to ensure timely, 
quality care for the Veterans we serve. VA's greatest effort is to 
focus on ensuring timely care for Veterans with the most urgent needs. 
In July 2015, when I joined the VA as Under Secretary of Health, I 
identified the first challenge to be the inability to identify patients 
with the highest and most urgent clinical needs. I tasked senior 
leadership to take on different tactics to simplify our clinical 
processes. This included consolidation of the over 30 different ways of 
scheduling a specialist consult to two ways, classifying the 
appointment as either stat or routine. This resulted in identifying 
around 57,000 urgent consult referrals to specialists waiting over 30 
days for an appointment. VHA executed an emergent call to action with 
national Stand Downs in November 2015 and in February 2016. During 
these endeavors, staff from each medical center contacted targeted 
Veterans waiting for care, triaged them for clinical care needs and 
connected them with the appropriate services. Around the time of the 
stand-downs, VA also implemented a standardized process for facility 
staff to review in real-time, referrals to specialists with more urgent 
needs. These efforts have led to an ongoing reduction of Veterans 
waiting over 30 days to see a specialist from the 57,000 in 
November 2015 to about 200 as of February 2017.

                                        Other Elements in Mitigation Plan
----------------------------------------------------------------------------------------------------------------
               Factors                                              Mitigation Plan
----------------------------------------------------------------------------------------------------------------
Increasing Demand/Lack of Providers    Active recruitment of health care providers and clinic staff--VA
 and Clinic Staff.                     increased provider and nursing staffing by approximately 12% over the
                                       past two years
                                       Granting full practice authority for Advanced Practice Nurses
                                       Increase use of telehealth for Primary Care and Mental Health
                                       Use of community care resources when unable to recruit providers
                                       Increased use of extended clinic hours
----------------------------------------------------------------------------------------------------------------
Inefficiencies in clinic practices..   Implemented Clinic Practice Management Program across VA--in this
                                       program all facilities have at least one group practice manager to
                                       oversee and optimize administrative clinic activities
                                       Validating clinic grids to achieve optimal clinic capacity
                                       Focus on improving productivity--increased productivity by 16%
                                       over past two years
                                       Developed strategies for reducing ``no show'' rates, and
                                       redesigning clinic space
                                       Implemented standardized face to face Clinic Clerk Training for
                                       optimal scheduling of patients
                                       The above efforts have resulted in an increase in 12,000
                                       appointments daily in 2016 when compared to 2014
----------------------------------------------------------------------------------------------------------------


    Question 144.  Will you commit to ensuring that VA continues to 
invest in the veteran transportation program?
    Response. Yes, I commit to continuing the Veterans Transportation 
Service that transports Veterans to and from their appointments, 
especially, in rural areas where both community care and VA care are 
less available. This is an area in which we have been able to partner 
with our VSO groups.

    Question 145.  With VA's expertise on substance abuse and the 
Department's robust Office of Research and Development, I believe that 
you are well equipped to be on the forefront of alterative pain therapy 
research for the entire country. Please elaborate on how you will 
increase the number of alternative treatments for pain management. What 
investments will you make and are there authorities you need from 
Congress?
    Response. In response to Section 932 of the Comprehensive Addiction 
and Recovery Act (CARA), VA developed an ambitious plan to expand 
research, education, and clinical delivery of complementary and 
integrative health (CIH) approaches for pain management as well as 
mental health. The Integrative Health Coordinating Center in the Office 
of Patient Centered Care & Cultural Transformation is working to make 
the evidence-based CIH approaches--including acupuncture, chiropractic, 
yoga, tai chi, meditation, and massage--more widely available to 
veterans nationally. Our commitment is that every medical center will 
offer at least two of these therapies routinely for Veterans with pain. 
In addition, the Office of Research and Development is collaborating 
with the National Center of Complementary and Integrative Health at NIH 
and the DOD to fund a large research initiative supporting 
demonstration projects developing the most effective ways to deliver 
CIH for pain in our military populations.

    Question 146.  The Department of Veterans Affairs is often charged 
with having a corrosive culture that breeds unethical, and sometimes 
unlawful, behavior that is not veteran-centric. While there have been 
improvements under Secretary McDonald's leadership, there is still work 
to be done. What are specific actions that you will implement to ensure 
that the culture of VA will continue to improve?
    Response. Employees want to work in an environment where they have 
the tools and resources they need to be able to serve their patients. 
As a health care executive this is what the type of environment I 
strive to have for our staff and their patients. Employees want a place 
that has systems that work, co-workers that are well trained and 
supported, and a culture of respect. If confirmed as Secretary, I would 
work hard to have a work environment that supports our staff and allows 
them to do their best for our Veterans. Part of what is needed is to be 
able to support, retain, and recognize those employees that share the 
organization's values and are high performers and to be able to remove 
those that have strayed from these values. When people are allowed to 
remain in the workplace, despite poor performance or bad behavior, it 
is demoralizing to all employees.

    Question 147.  Please elaborate on specific ways the Department of 
Veterans Affairs and Congress can work together to improve the claims 
backlog.
    Response. We appreciate Congress's ongoing support for our budget 
for staffing, and information technology advancements and sustainment. 
We fully expect that as the needs arise for legislative intervention 
that we will be able to collaborate with Members of Congress to ensure 
that the needs of our Nation's Veterans and their families are met with 
the highest level of care and compassion.

    Question 148.  Do you support an expansion of the Caregivers 
programs beyond post-9/11 veteran era?
    Response. I support programming for all caregivers of all Veterans, 
regardless of the Veteran's era of service or the reason why the 
Veteran needs the assistance of a caregiver. I cannot, however, support 
the expansion of the current Program of Comprehensive Assistance for 
Family Caregivers without considerable concern for how the cost will 
impact other services and supports to Veterans. VA welcomes 
collaboration with Congress to establish a sustainable program that 
provides assistance and support to all caregivers. I am exploring the 
option of a study to determine the cost avoidance that may be seen with 
the expansion of Caregivers to give us a better understanding of the 
true costs involved in expanding the program.

    Question 149.  Do you believe there are improvements or changes 
that need to be made in the way VA determines service-connected 
disabilities? Would you be open to reexamining the compensation and 
pension exam process?
    Response. VA agrees, in principle, that there is a need for 
revision of the 1945 regulations that are found in 38 CFR Part 4, the 
VA Schedule for Rating Disabilities (VASRD). While VA has undertaken 
several changes, in the past, to update and clarify regulations for 
individual sections of 38 CFR Part 4, VA has not had major revision of 
VASRD that can be viewed as a complete modernization of its evaluative 
criteria.
    In 2009, the Veterans Benefits Administration (VBA) Under Secretary 
for Benefits (USB), on behalf of the Secretary for Veterans Affairs 
(VA), directed the revision and update of the 15 body systems that are 
contained in the VASRD, under the authority of 38 U.S.C. Sec. 1155. To 
date, VA has published for notice and commented on six of the VASRD 
regulations, which are currently under review for final publication. VA 
is working to publish proposed updates to the Federal Register for the 
remaining body systems. VA plans to complete these regulations by the 
end of 2018. Additionally, VBA continues to work to modernize efforts 
related to the disability evaluation process, to include accessibility 
to Veteran's benefits and system and procedural enhancements to improve 
the timeliness and quality of rating decisions.
    We have consistently taken steps to improve the compensation and 
pension examination process. We now receive disability benefit 
questionnaires (DBQs) from Veterans seen by their private providers. We 
have increased the type of examinations that can be done by medical 
disability examination contract providers as well as by VHA clinicians. 
And we are working to implement system enhancements that more 
efficiently and quickly process evidence through automation. Finally, 
in FY 2016, VBA and VHA collaborated on a multi-prong Breakthrough 
Initiative to Improve the C&P Exam Process, and these efforts are 
ongoing. This included providing training to individuals involved in 
the C&P exam process in VBA and VHA as well as educating Veterans on 
what to expect before, during, and after their C&P examination.

    Question 150.  The difficulty veterans face in scheduling 
appointments is a frequent complaint to my office. Please elaborate on 
ways to improve scheduling to make it easier both for VA scheduling 
staff and the veteran.
    Response. VistA Scheduling Enhancements (VSE) is a cost-effective, 
interim solution built in partnership with the private sector to bring 
an urgently needed modern interface to the antiquated VistA scheduling 
package. VSE makes it easier for schedulers to schedule and coordinate 
follow up appointments with other Veteran appointments, keep track of 
Veteran appointment preferences, and reduce scheduling errors all via a 
simplified point and click process. VSE is currently being piloted in 
multiple clinical settings at five VA facilities. If the pilot is 
successful, VSE will be implemented nationally until a permanent and 
complete solution is available.
    VA provides uniform face to face training that teaches all 
schedulers how to optimally meet all of the scheduling needs of 
Veterans. This training includes simulation using VA's computerized 
system, working through real life challenge scenarios and focusing on 
optimization of customer service.
    Based upon Veteran feedback, VA is implementing ``patient centered 
scheduling,'' whereby Veterans are offered the option to schedule 
follow-up appointments upon leaving clinic even when appointment needs 
are a year or more into the future--this replaces the ``recall system'' 
that constrained Veterans to only schedule their appointment as it got 
closer to their appointment date.
    VA also implemented call centers for Veterans to more easily 
request and cancel appointments by phone.
    The Veteran Appointment Request (VAR) Mobile App enables Veterans 
to self-schedule appointments or request someone call them to make an 
appointment via either a smart phone or desktop computer. The system is 
currently being utilized at 21 sites and is being evaluated for 
possible expansion.
    Finally, VA has awarded a contract for a commercial scheduling 
package, called MASS. Mass is now being implemented in a pilot site 
within VA to determine how it functions and compares to the 
alternatives detailed above.A off the shelf system, while more costly, 
might be the best solution to VA's long standing scheduling issues.

    Question 151.  What are ways that you would like to see access to 
Mental Health improve? What is being done to help prevent the 
overprescribing of opioids and benzodiazepines?
    Response. Timely access to high-quality mental health care is an 
imperative for VHA. As of December 31, 2016, every VA Medical Center 
endorsed their capability to provide same-day mental health services to 
Veterans in urgent need. This represents a critical first step in our 
MH access plans but it is only the beginning. Veterans do not only need 
access to an appointment, they need access to a full episode of care 
which may require a succession of appointments over a short period of 
time. VHA is already the Nation's leader in integrating mental health 
services in primary care teams, an effort we continue to expand. In 
addition, we are rapidly expanding telemental health care across the 
system to expand capacity as well as making improvements in the CHOICE 
program when community providers are the best match to a Veteran's 
needs. Such demands can be a major obstacle to seeking care for many 
Veterans and can be overcome by delivering telemental health services 
directly to their homes, offices, or even to their parked cars. 
Finally, we are ensuring that expanded access means high quality, 
evidence-based, compassionate care which ensures a steady increase in 
trust, compliance, continuity, satisfaction and clinical outcomes. This 
will require additional hires, expansion of available Mental Health 
disciplines (including the current `mission critical occupations' of 
psychologists and psychiatrists, as well as Licensed Professional 
Mental Health Counselors, Marriage and Family Therapists, Social 
Workers, Vocational Rehabilitation Specialists, Addictions Specialists, 
Advance Practice Mental Health Nurses, Psychiatric Physician 
Assistants, and Clinical Pharmacists). Full staffing, a full array of 
services, and enhanced availability across the Nation are key 
components of VA's Mental Health Access improvement plan.
    The Opioid Safety Initiative was instituted nationally in the VA in 
2013. Since then there has been a decrease in patients receiving 
opioids (27% reduction), a decline in the use of long term opioids (33% 
reduction), an increase in the use of safe prescribing practices such 
as patient signed consents, prescription drug monitoring program (PDMP) 
checks, use of urine drug screens (increased 48%) , and avoidance of 
unsafe combination therapies. The combined use of opioids and 
benzodiazepines has decreased by 51% from 2012 to 2017. There is a need 
to treat Veterans with pain, and the VA is focused on using 
conventional and alternative therapies to address pain and enable a 
reduction in opioid use.

    Question 152.  In the past, you have stated that you would not have 
used the ``40 mile'' and ``30 day'' rule if you had designed the Choice 
program. Please elaborate on how you would like to see Choice fixed and 
what measures you would use in considering eligibility for referral to 
care in the community?
    Response. I know of no health system that has designed a system 
around mileage and wait times. The reason I believe we must look at 
alternatives to these criteria is that mileage and wait times do not 
differentiate between Veterans that need urgent care and Veterans that 
desire elective care. Such a system also does not differentiate between 
those that have other healthcare options available to them and those 
that have none. We are embarking upon an exploration of a number of 
different models that would propose alternative criteria and then we 
would need to get Veteran input into these models. We also need to do 
economic modeling of these models to determine the cost of new options. 
Once we have completed this initial work we would begin to socialize 
our ideas with Veterans, Veteran Service Organizations, Members of 
Congress and the Administration, and our staff.

    Question 153.  A frustration that many veterans have is that even 
though there is a VA regional office in their community, they have to 
contact a call-center to get an update on the status of their claim or 
to ask questions. How can the Veterans Benefits Administration be more 
accessible to veterans directly? Furthermore, have you considered 
embedding VBA counselors in VA medical centers to help veterans and 
their families understand their benefits during a hospitalization?
    Response. Besides our national call centers; every regional office 
has a public contact team that can assist Veterans and claimants with 
submitting claims for benefits or getting a status on their claim. VA 
continues to look for ways to increase access to Veterans. Many of the 
VA medical centers do have VBA personnel onsite on an ad hoc basis to 
assist with claims related questions. Any expansion would require 
balancing of available resources. Finally, VA cultivates close 
partnerships with Veterans Service Organizations, which help Veterans 
and their families understand and navigate VA benefit programs.
                                 ______
                                 
    [The Committee questionnaire for Presidential nominees from 
David J. Shulkin, M.D., submitted twice, follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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    [Letters from the Office of Government Ethics follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
   
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    [Letters from David J. Shulkin, M.D., to the Office of 
General Counsel, U.S. Department of Veterans Affairs:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




    Chairman Isakson. We appreciate your service and your 
testimony.
    For the Members' purposes, we are going to have at least 
two rounds of questions. We are going to make sure everybody 
has plenty of time to ask. We have a little bit of a gymnastics 
that is going on right now, so we will make sure everybody has 
time.
    I would like for every member of the VSOs or the VSO 
representatives who are in the audience to please stand. The 
Veterans of Foreign Wars. [Applause.]
    I want you all to understand something. You are the reason 
we are here. We are not the reason you are here. You are the 
reason we are here, to make sure we get the VA working as well 
as we can, as efficient as we can, and we thank you for your 
service to the country.
    Now, I am going to ask Dr. Cassidy to come up and take my 
place in the chair until either Senator Moran gets back or I 
get back, and we will go back and forth, and my staff will tell 
you who to call on next. We will try our best to go Democrat, 
Republican, Democrat, Republican.
    If you all do not mind, I am going to turn it over to Dr. 
Cassidy.
    Senator Cassidy [presiding]. OK.
    Senator Sullivan.

                      HON. DAN SULLIVAN, 
                    U.S. SENATOR FROM ALASKA

    Senator Sullivan. Thank you, Mr. Chairman and Dr. Shulkin. 
Welcome. Congratulations. I very much appreciate your service, 
your desire to continue to serve. I appreciate your family's 
service. I know it is a team effort and thank you.
    You know, Alaska, my State, we have more vets per capita 
than any State in the country, and I appreciate very much your 
continued commitment, or your commitment as the Under 
Secretary, to come up to Alaska. I think you and I--it is safe 
to say we had a memorable trip up there. We met with hundreds 
of Alaskan veterans. I think you saw the deep patriotism that 
is embedded in the heart of every one of my constituents, the 
toughness, but also a lot of the unique challenges which you 
have been working with us on. I very much appreciate it.
    Let me begin by trying to get a few commitments that relate 
to that. You came up as part of your Under Secretary 
confirmation process to the State, but if confirmed, can I get 
a commitment from you to come back to Alaska, and for you and I 
to spend some time, not only in the urban areas but some of the 
more very, very rural parts of the State, where, again, we have 
veterans all over?
    Dr. Shulkin. Senator, we had a very good trip and there is 
nothing I would enjoy more than doing it again with you.
    Senator Sullivan. Great. I take it that is a yes.
    Dr. Shulkin. Yes.
    Senator Sullivan. Great.
    If confirmed, will you continue to work on the Alaska Pilot 
Program, which you initiated, in part, because of our trip 
together, which worked on addressing some of the unique 
challenges? I want to commend you for your focus on that, but 
as you know we still have work to do. Will you commit to me, if 
confirmed, to continue to work on those unique challenges that 
we have in the State?
    Dr. Shulkin. Well, Senator, first of all, I want to thank 
you, because you have been tireless in insisting that we get 
the program working. So, many of the pilots that we began, that 
are now spread throughout the country, actually started in 
Alaska, and I think we have demonstrated that it is now working 
better because of many of the initiatives that you started.
    Senator Sullivan. Well, it is a team effort.
    Dr. Shulkin. Yes.
    Senator Sullivan. I am glad that you and I worked together 
on these, and I want to continue to do that if you are 
confirmed.
    You know, speaking of a team effort, you and I have had the 
opportunity, particularly on a lot of plane flights and things 
in Alaska, and hearings and office visits, to talk about a lot 
of issues, Alaska-related, national-related.
    One of the things I did for this confirmation process was I 
reached out directly to the veterans in my State, and said, 
``Hey, what questions would you want to ask the incoming 
Secretary?'' So, as you can imagine, we had dozens of 
responses, which I am going to relay a few here. The ones that 
we do not have time to discuss in the hearing we will submit 
for the record.
    The first one meant a lot to me. It is from an Alaska 
veteran by the name of Bob Thoms. Cajun Bob is his nickname. He 
lives in the Mat-Su Valley. This is somebody who has bled for 
his country. This is a Marine who has received six Purple 
Hearts, Silver Star, he was on the cover of Life magazine 
during the Battle of Hue City, Vietnam veteran. He is a hero 
among us.
    I am sure a lot of the veterans in the audience can relate 
to this. He indicated, you know, an interest, certainly, in the 
issue, but still a deep distrust of VA. He is nervous that your 
appointment as Secretary is going to be more of the same, 
because, as you know, there has been promises and promises and 
promises, generations of promises. His focus has been where 
people are not held accountable and veterans are stuck in a 
system that works against them and not for them.
    His question regarding your nomination, and vets like him, 
is he said he was hoping for someone who--and forgive the 
language here; it is a Marine--would kick ass and take names 
with regard to being the Secretary.
    How can you assure veterans like Cajun Bob and others, not 
only in Alaska but throughout the country, that some of the big 
focuses that President Trump has talked about, on really 
shaking up the VA, are going to happen under your watch, when, 
to be honest, you have been part of the outgoing 
administration? This concern was a common theme from a lot of 
the questions we received. If you can answer that I would be 
very appreciative, and I know Cajun Bob would too.
    Dr. Shulkin. Well, first of all, I think when you and I go 
back to Alaska we should go meet with Cajun Bob. I think he 
would love that.
    Senator Sullivan. You would love that.
    Dr. Shulkin. Yes.
    Senator Sullivan. I would love that.
    Dr. Shulkin. Yes, and we will ask him how we are doing.
    But, look. I think what Cajun Bob is saying is really 
important. If you do not have trust in the group that is 
empowered to take care of you and provide you services, you 
cannot do your job very well. So, ----
    Senator Sullivan. Do you think the VA has trust right now?
    Dr. Shulkin. I think that trust was eroded, particularly 
with the wait time crisis in April 2014, and many people lost 
trust. We know, when we first began to measure this last year, 
our trust level with veterans was at 41 percent. Today it is at 
61 percent. So, I think that we are slowly regaining trust, but 
we have a long way to go.
    What I would say to Cajun Bob is that, look, I approach 
things first as a doctor, and as a doctor I know no matter how 
smart I think I am, or if I, you know, did the best in my 
medical school class, if my patient does not trust me, they are 
not going to listen to what I have to say, then I am not going 
to be able to help them. So, I think that is very important.
    As a health care executive, I look at our system in VA and 
I say if we do not have a modern system that is responsive to 
our veterans' needs, that we cannot perform our function. One 
of the things that I think most people would tell you about me 
is I do not have a lot of patience, and I am going to be 
serious about making these changes and regaining that trust. If 
I do not do it, I should be held accountable and you should 
replace me.
    Senator Sullivan. Thank you. Thank you, Mr. Chairman.
    Senator Cassidy. Ranking Member Tester.
    Senator Tester. Yes. Thank you, Senator.
    When you interviewed for this job, and had to visit with 
the President, and you agreed to take the job, were there any 
conditions attached?
    Dr. Shulkin. I did have a chance to speak to President 
Trump, President-Elect at that time, about this position, and 
what we spoke about, he asked me several questions. He said, 
``Tell me what is your view on what is happening in VA now--''
    Senator Tester. OK.
    Dr. Shulkin [continuing]. ``What you think needs to be done 
and what are the things that have to essentially occur?''
    Senator Tester. Yep.
    Dr. Shulkin. We shared the common vision that we have to do 
a lot better for our veterans.
    Senator Tester. Gotcha.
    Dr. Shulkin. We did not have specific preconditions in this 
job, and he knows that I would follow my values and do what I 
think needs to be done.
    Senator Tester. So, there were no conditions attached?
    Dr. Shulkin. There were no conditions.
    Senator Tester. Did you talk about privatization at all?
    Dr. Shulkin. Yes, we did.
    Senator Tester. What was his definition of privatization 
and what is yours? Are they the same?
    Dr. Shulkin. Well, I did not ask him his definition. I told 
him what I thought needed to happen, and----
    Senator Tester. Tell me what that definition is.
    Dr. Shulkin. What I told him is that I am a strong advocate 
for the VA, that the services that are available in VA are not 
available in the private sector, and that my view of where VA 
needs to go is an integrated system of care----
    Senator Tester. OK.
    Dr. Shulkin [continuing]. Taking the best of VA and the 
best in the community, and that is what I would work toward.
    Senator Tester. OK. You have mentioned before that the wait 
time or the mileage is what you would use. So, give me your 
definition. If I am a veteran and I have got a problem--say I 
have a cold--and I want to go to my local doc. Are you going to 
let me do that, or are you going to say, ``No. Go to the 
nearest VA facility,'' if there is one down the block?
    Dr. Shulkin. Well, I think there are two parts to your 
question, because it is really the key issue. How do you design 
a health care system that works for veterans? I would not have 
designed it based upon mileage and on wait time.
    Senator Tester. OK. That is fine.
    Dr. Shulkin. OK? I would design it based upon clinical 
need. What we really want to do is make sure that the veteran 
can get to the services that they need in health care in a 
timely fashion. That is why I focused on urgent care issues. 
That is why there is now primary care, same-day access and 
mental care--mental health same-day access in every VA across 
the country.
    For somebody who needs to see their doctor that day, they 
should be seen. If they cannot be seen in the VA, they should 
be seen in their community.
    Senator Tester. That goes for any condition? If they cannot 
be seen that day--so of the docs in a hospital or a CBOC are 
booked up and somebody comes in and has the flu, if they cannot 
get in you send them to the doc--send them to local hospital or 
local clinic?
    Dr. Shulkin. Senator, what I am talking about is a clinical 
definition of urgent care.
    Senator Tester. OK. Gotcha.
    Dr. Shulkin. I do not want any veteran in this country----
    Senator Tester. That is--the urgent care----
    Dr. Shulkin [continuing]. In harm.
    Senator Tester. Yeah, I gotcha.
    Dr. Shulkin. OK? For a cold, OK, now you are----
    Senator Tester. That is----
    Dr. Shulkin [continuing]. Getting a doctor's advice----
    Senator Tester. Yeah, yeah.
    Dr. Shulkin [continuing]. We may be able to help you over 
the telephone through telehealth, et cetera.
    Senator Tester. OK. That is fine.
    So, can you talk a little bit about the Choice Program and 
what has--because, I mean, that has kind of been your baby, 
right? Can you tell me why a veteran, for example, in 
Plentywood, MT, would be on a telehealth screen to a doc within 
a clinic or CBOC, and that doc tells that veteran that he needs 
a chest x-ray, and then they have to go through the VA to get 
confirmation that that chest x-ray actually is going to be 
taken care of the by the VA, and 2 weeks later that person gets 
a chest x-ray?
    Dr. Shulkin. Yeah. I cannot tell you that that makes any 
sense. What we did in the Choice Program was we added a layer 
of additional administrative complexity, where instead of the 
VA being able to help the veteran, as they always did, you now 
had to go through a third-party administrator. That led to a 
delay in care, in many cases, too many cases.
    Senator Tester. Yeah.
    Dr. Shulkin. You have been describing a few already.
    Senator Tester. Yeah.
    Dr. Shulkin. We need to take that layer of complexity out. 
The VA needs to take back the customer service----
    Senator Tester. OK.
    Dr. Shulkin [continuing]. And the scheduling.
    Senator Tester. Excuse me, because I framed it wrong. I am 
not even talking about the ones who go to the Choice Program. I 
am talking about the ones that have VA care, where a VA doc 
looks at them and says, ``You need an x-ray,'' yet it takes 2 
weeks to get that x-ray. This is in a private facility, by the 
way, that is contracted with the VA, and it takes 2 weeks to 
get the x-ray done. I mean, that makes no sense whatsoever.
    Dr. Shulkin. It makes no sense whatsoever.
    Senator Tester. What can we do to fix it?
    Dr. Shulkin. Well, what we have to do is, first of all, we 
do know the Choice Program has added complexity. If what you 
are saying is there is a delay in getting contracted care--
right?
    Senator Tester. Right.
    Dr. Shulkin. When a doctor orders an x-ray, there should 
not be a lot of intermediary steps there. We should be able to 
go directly and be able to get that x-ray.
    Senator Tester. I gotcha. What can be done to fix it, 
though? Then I will kick it off----
    Dr. Shulkin. Well----
    Senator Tester [continuing]. Because I am out of time.
    Dr. Shulkin [continuing]. We are going to remove the 
bureaucracy in between, because there is no benefit to that 2-
week delay.
    Senator Tester. We will get to Choice on the next round. 
Thank you, Mr. Chairman.
    Senator Cassidy. Yes.
    Next is Senator Rounds.

                       HON. MIKE ROUNDS, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Rounds. Thank you, Mr. Chairman.
    Dr. Shulkin, first let me begin by just saying that I 
appreciated the opportunity to visit with you in my office the 
other day. I shared with you then that I appreciated the way 
that you came into the VA. You are one of the guys that came in 
when--even in the campaigns they were not talking about 
Washington as a swamp yet. They were talking about the fact 
that--and on several occasions, with Mr. McDonald, Secretary 
McDonald, we talked about the fact that you two guys came in 
knowing that you were in the middle of something that you had 
to fix. It was at a time in which you had a billion-dollar 
overcost or an overrun on one single hospital in Colorado, yet 
you guys came in, and you came in with the intent of fixing and 
making things better for veterans, and I appreciate that.
    At the same time, I want to just touch on a couple of 
issues that you and I have talked about in the past, that I 
want to get into a little bit more today, as we said we would 
during that meeting in my office.
    First of all, the Black Hills VA system in Hot Springs, SD, 
where, as you know, there is a host of individuals there that 
have--for literally since that town was created--serviced 
veterans in in-treatment facilities. They have also made it 
very clear that they want to continue that. As a matter of 
fact, they are one of your five-star facilities in the United 
States.
    Secretary McDonald had suggested some significant changes 
there. In our meeting the other day, you indicated a 
willingness to take a look at finding something that will work 
for the community of Hot Springs in their desire to serve 
veterans. Would you expand on that a little bit, and once again 
just commit that you will take a second look at it and see what 
we can do to make this work, for the veterans, to make it 
better for them, in that whole area? It is not just South 
Dakota. It is Wyoming. It is Colorado. It is Nebraska as well.
    Dr. Shulkin. Yeah. I think it was the afternoon after we 
met, I already had a chance to get on the phone with the VISN 
director and the facilities director out in that area, and I 
had them go through their rationale about how they got to their 
decisionmaking. I had some additional questions, much like you, 
and I appreciate you bringing those to my attention.
    We are going to re-look at this. There were actually a 
couple of options on the table, all that I can understand how 
they got to where they got to, but I think that there are some 
additional questions. So, I have begun the process of looking 
at that and will get back to you and discuss with you about 
what some of those options are. I actually want to get your 
thoughts on how we can serve the veterans in that area best.
    Senator Rounds. Very good. I think the veterans in that 
area, and most certainly the community of Hot Springs, as I 
say, that community came into existence, really, to serve 
veterans, and it is one of the oldest in the United States. I 
appreciate that and your interest in working with us.
    The second item is one that I think is probably a little 
less comfortable in discussing, and that is the Emergency Care 
Fairness Act, that was passed by this Congress in 2009, and 
signed by the President in 2010. What this was, for the benefit 
of folks out there that may not understand it, this basically 
said that if a veteran ends up going to an emergency room, even 
if they wanted to go to a VA center, if the emergency care was 
delivered at a non-VA facility, the VA would pick up the cost 
of that emergency room treatment.
    Shortly after that occurred, rules were revised within VA 
that did exactly the opposite, indicating that they would act 
as a secondary payer only. Even with veterans who have 
Medicare, any deductibles or copays, the VA has said, ``Sorry. 
That is a secondary payment and we are not responsible for 
it.'' So, they have not made any of those payments. In fact, I 
think the total costs on that are into the billions of dollars 
now, which are on the backs of veterans.
    Now, Congress' intent was pretty clear and, in fact, not 
only has there been one court case on it, which went in favor 
of the veterans, there has now been an appeals case, which 
ruled that VA is wrong. In fact, let me just quote this to 
you----
    Dr. Shulkin. Mm-hmm.
    Senator Rounds [continuing]. This is the way that it comes 
up. This is in the case of Staab v. McDonald which says, ``And 
the VA needs to find a way to pay for it.''
    So, let me just lay this out for you. This particular 
product is one in which the court said the VA is wrong, and the 
VA needs to pay these copays and deductibles for those 
facilities that are outside of a VA facility, which was the 
direction from Congress.
    Now that is two court cases right in a row. My 
understanding is that you have had a chance to take a look at 
this.
    Dr. Shulkin. Mm-hmm.
    Senator Rounds. The reason why it came to my attention is 
we had two different times in which there were requests to 
hotline bills in the Senate, suggesting unanimous consent items 
that would have reversed that law, which would have taken VA 
out of paying literally billions of dollars, and it would have 
dumped it on the backs of veterans, after the fact.
    Now, we stopped both of them.
    Dr. Shulkin. Mm-hmm.
    Senator Rounds. What I would like to know, sir, is your 
opinion on the bill and where you see us going from here, with 
getting that resolved.
    Dr. Shulkin. Yeah. Well, right now my opinion does not 
matter because this is law. The judges have ruled, and you have 
accurately described the situation. I have instructed VA to 
start putting together--and they are doing this now--the 
regulations that it is going to take to be able to start paying 
these bills, these emergency room bills, and every day that we 
delay, veterans are being put in the middle, and that is really 
unfair to them.
    Senator Rounds. Dr. Shulkin, here is the reason why people 
get discouraged with this. This is exactly the conversation 
that you and I had, and that was my understanding. Yet just 
today, in my office, I received a letter. I was surprised to 
receive a letter from the VA, in reply to our letter, which we 
had sent in asking the VA to reconsider their position. In 
today's letter it stated that the current status of the bill is 
still active, on appeal, and requires an opening brief to be 
submitted on February 6, 2017----
    Dr. Shulkin. Yes.
    Senator Rounds [continuing]. Indicating they continue to do 
battle on this in the courts.
    Dr. Shulkin. Let me clarify our position.
    Senator Rounds. OK.
    Dr. Shulkin. I have already said--your facts are correct. 
This is law and we are moving forward to start paying these 
bills. However, VA does not believe that the court interpreted 
the statute correctly. So, the Department of Justice--and this 
is since you and I had a chance to meet--has just decided to 
accept the appeal. So, the Department of Justice will appeal 
this, and we will see what happens.
    In the meantime, I am not going to allow veterans to be put 
in the middle, like we have been continuing to do. We are going 
to move forward and we will do it with speed, to make sure that 
we start paying these bills as soon as we possibly can. But, 
there will be--the Department of Justice has decided to take up 
this case.
    Senator Rounds. Just for the record, I understand--I know 
that I am going over my time, Mr. Chairman, but this is in 
terms of more than $3 billion, and in some cases estimated at 
more than $10 billion of debt which veterans will have if the 
VA does not pay it. Dr. Shulkin, you do not have the money in 
your budget. Are you prepared to ask this Congress for the 
appropriate funds to get the bill paid if----
    Dr. Shulkin. Well, I will try to be brief as well. The 
concern that VA has--having said we are moving in the direction 
that I think you are comfortable with--the concern is this is a 
new interpretation of a benefit for veterans who have other 
health insurance and who are not service-connected. If we do 
not get additional funds authorized, that money will come from 
the services that we provide today to veterans, and they will 
have less health care available.
    So, yes, we will come to you and ask you to help support, 
with additional funding, this new benefit if it is not 
overturned in an appeal by the Department of Justice.
    Senator Rounds. Let me note that it was a benefit that was 
directed by Congress----
    Dr. Shulkin. Yes.
    Senator Rounds [continuing]. In 2009, and signed into law 
in 2010.
    Dr. Shulkin. You are correct, sir.
    Senator Rounds. Thank you, sir.
    Dr. Shulkin. Yes.
    Senator Rounds. Appreciate it.
    Senator Cassidy. Senator Sanders.

        HON. BERNARD SANDERS, U.S. SENATOR FROM VERMONT

    Senator Sanders. Thank you, Mr. Chairman, and Dr. Shulkin, 
thanks for dropping in the other day and thanks for being here. 
Thanks for all the veterans and veterans' organizations for 
being here.
    Let me just jump into a couple of issues. There is an 
effort, and probably being led by the Koch brothers, to 
privatize virtually every government agency. Will you oppose 
the privatization of the VA?
    Dr. Shulkin. I have been clear. I am opposed to the 
privatization of the VA.
    Senator Sanders. Let me pick up on a point that Senator 
Rounds just made a moment ago and broaden it a little bit.
    No agency of government can do its job unless it has an 
adequate budget. Will you be 100 percent honest in coming 
before this Committee and telling us what the needs are of the 
VA, in terms of making sure that every veteran in this country 
who goes to VA has the quality care that he or she needs?
    Dr. Shulkin. Senator Sanders, I see that as one of the 
primary responsibilities of a Secretary. I absolutely will do 
that.
    Senator Sanders. So, you do understand that there will be 
pressure on you; that, generally, administrations, no matter 
what they may be, try to tell heads of agencies to tamp down on 
their requests. But, what I think is needed is, speaking for, I 
hope, the whole Committee, is that we want you to ask for what 
you need.
    Dr. Shulkin. Yeah. I have not been in Washington as long as 
you, but in my short time I have already figured out exactly 
what you are saying. Yes, I will commit to that.
    Senator Sanders. Thank you.
    In our chat the other day, you told me something that I did 
not know--I did not know and I do not know that other Members 
of the Committee know, so, correct me if I am wrong. You told 
me that there are now 45,000 vacancies just in VA health, not 
to mention other parts of the system. Is that correct?
    Dr. Shulkin. There are 47,230 vacancies now throughout VA.
    Senator Sanders. Throughout VA.
    Dr. Shulkin. Throughout VA. Most are in health.
    Senator Sanders. OK.
    Dr. Shulkin. Not all.
    Senator Sanders. I have to believe that with that number of 
vacancies that has an impact on the quality of care and the 
timeliness of care that veterans receive.
    Dr. Shulkin. We believe it does.
    Senator Sanders. Do you have the resources now to fill 
those vacancies?
    Dr. Shulkin. Yes. Yes. Our budget--every position that we 
are recruiting for--those are active recruitments--has a budget 
associated with it. Yes, sir.
    Senator Sanders. As I understand it, President Trump's 
freeze on Federal hires will not impact you?
    Dr. Shulkin. I have been very pleased that after the freeze 
memo came out we went immediately back to the White House and 
said that this would impact us, and we got an exception for all 
of the positions that are critical related to health and 
safety. I feel very comfortable with that. Of the 47,230 that 
we are actively recruiting for, about 37,000 right now are 
excepted.
    Senator Sanders. OK.
    There is no question, I think primarily for political 
reasons, the VA has been beaten up a whole lot in recent years, 
by politicians, by the news agencies, and so forth. That is not 
to say that the VA does not have serious problems, but it does 
say that our entire health care system has serious problems, 
not just the VA.
    Now, when I was Chair of this Committee, we had a meeting 
right in this room, right at that table. We had the leadership 
of every major veterans' organization in the country, where I 
asked a pretty simple question. It was, ``If and when people 
get into the system, understanding there are unacceptable waits 
to get in, but once they get into the system, do you believe 
that the quality of care that veterans are receiving is good?''
    What I will not forget, and I want to ask you that same 
question, is, without exception, every leader of every major 
veterans' organization, from The American Legion, VFW, DAV, on 
down, said once people get into the system, by and large the 
quality of care is good, very good, excellent. What do you 
think?
    Dr. Shulkin. Well, even more important than what I think, 
there have been numerous independent studies by academic 
centers and other groups that have studied this, and 
consistently they have found that the quality of VA care, 
particularly when it relates to mental health, primary care 
measures, screening measures, safety measures, quality measures 
in general, is actually superior in the VA system to the 
average of the private health care system. I do want to add, 
though, that does not mean that we are perfect. About 5 to 6 
percent of our hospitals in the VA system are actually below 
where they need to be.
    Senator Sanders. That is a fair point. But, let me just 
reiterate that for the benefit of all three of us who are 
here----
    [Laughter.]
    Senator Sanders [continuing]. Which is, every person here 
wants the VA to do better. I do not think there is a partisan 
division on that.
    Dr. Shulkin. Yes.
    Senator Sanders. But, I think it is also important that 
before we go beating up VA every day, run to CNN or all the 
newspapers, anyone, saying VA is terrible, that we understand--
and you correct me if I am misreading this--there was a recent 
report that came out in RAND----
    Dr. Shulkin. Yes.
    Senator Sanders [continuing]. Which is an independent think 
tank, which I think was actually commissioned by legislation 
that we passed.
    This is what it said; and tell me if you agree with the 
quote. ``In a tally of 83 different measures, covering a 
variety of types of care, including safety and effectiveness of 
treatment, the quality of VA health care exceeded that of non-
VA care.'' End of quote.
    Do you think that is a valid----
    Dr. Shulkin. I read the same study you did and I think that 
has been shown by other groups as well.
    Senator Sanders. Just on one issue, in terms of mental 
health, that I hope, Mr. Chairman, we can work on. Right now, 
if a veteran needs mental health care from VA, as I understand 
it, he or she can get that care, but amazingly enough, he 
cannot bring in his wife or girlfriend or spouse or whatever it 
may be. I am not quite sure how you treat an individual without 
bringing family members in.
    Is that something you think we should--I know that is the 
case by law now. Is that something we might want to look at?
    Dr. Shulkin. Well, I think what we do know is when we send 
a soldier off to battle, we are sending the whole family off, 
and so often many of these issues that are so difficult to deal 
with have to be dealt with in the family unit, which is very 
important. I do think that if our goal is--and I know it is our 
shared goal, to be able to help treat and address this issue--
we need to think about different ways of doing that, and 
including the family as part of that, I think, is going to be 
an important way to find solutions.
    Senator Sanders. Mr. Chairman, I would hope that we could 
work together on that issue.
    Chairman Isakson [presiding]. We certainly will. And we are 
going to work at sticking to 5 minutes so we can have enough 
rounds to get everything in.
    Thank you, Senator Sanders.
    Before I rotate the turn, because Senator Tillis is going 
to be next, let me just ask this. Dr. Shulkin, do you know of 
any health care systems in the country that have more than 6.5 
million patients and 314,000 personnel?
    Dr. Shulkin. I am not aware of one, sir.
    Chairman Isakson. Is not that the right numbers for the VA?
    Dr. Shulkin. Yes.
    Chairman Isakson. So, in answer to your question, we have 
got 314,000 personnel delivering medical services to 6.5 
million veterans. Those are the biggest numbers in the country. 
You are going to have a slip-up every now and then.
    Yet, there are good stories out there. We are going to do 
two things. We are going to fix the slip-ups--you know, no more 
terrible stories like finding maggots in somebody's wound or 
things like that, which are sensationalized. Senator Tester and 
I have talked about making statements on the floor about every 
2 weeks, telling the good stories of the VA, so you better be 
having some. If there are bad stories, we want to tell those 
too, including how we have corrected them, so we dispel what is 
happening right now, where the media is just making a story out 
of anything that comes out of VA.
    With that said, Senator Tillis, you are in charge.
    Senator Tillis. Well, thank you, Mr. Chair.
    Chairman Isakson. For 5 minutes.

       HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA

    Senator Tillis. Oh. First off, just for those of you out 
here, all the Members on this VA Committee are interested in 
this hearing. They happen to be playing the dance that we are 
doing right now. I, for one, am missing a vote right now, and I 
have asked them to go ahead and call the vote so they can get 
to the next one, so that I could have this discussion.
    Dr. Shulkin, and Mr. Chair, I do not even know if this is 
allowed within the roles, so I will not do it, but I am just 
curious, with the number of VSOs who stood up here, I would be 
really curious if they were willing to do this without a 
request from me. How many of them would raise their hand to the 
idea of we want to completely and utterly privatize the VA? 
[Pause.]
    I did not break the rules but it seems to me that there are 
not a whole lot of people who are behind this. I know that you 
are not.
    Dr. Shulkin. Right.
    Senator Tillis. The reason that I mention that is I am 
tired of some of the suggestions by Members of Congress who say 
that there is some plot out there, or agenda, to do it. It is 
simply not true.
    We need to get Choice to work. We have had discussions 
about that. We have to recognize that 30 to 40 percent of all 
VA care comes from non-VA providers. Then, we just need to get 
it right, so the brick-and-mortar presence is exactly where it 
needs to be to provide the best care to the veteran.
    Anyone in this body who tells you that there is a movement 
afoot to privatize the VA has either been mislead or they are 
trying to mislead you, and I am not going to be a part of that, 
nor am I going to stand for it.
    I think you are great. I have already told you I am going 
to vote for your confirmation. You have done a great job in 
your current capacity. You have got about as many friends in 
Alaska as polar bears. I am glad to hear that. [Laughter.]
    You have been down to North Carolina.
    Dr. Shulkin. Yes.
    Senator Tillis. I like the idea that the Administration 
showed wisdom in bringing somebody in who has a bird's-eye view 
of the transformation plan. A lot of what Secretary McDonald 
was trying to accomplish makes sense. Some of it we can make 
better. I know that I have your commitment to follow through 
and build on those 12 breakthrough priorities, putting pressure 
on Congress to take action, which we have not yet, to enable 
you to actually execute those priorities.
    Are you going to come before this body and commit to me 
that you will be shooting straight with us, to say for us to 
get the work done so that you can fulfill a commitment to 
transform the VA?
    Dr. Shulkin. Yes. Absolutely. First of all, your 
involvement in helping us, and along with----
    Senator Tillis. Senator Tester.
    Dr. Shulkin [continuing]. Senator Tester as well, we really 
appreciate. I could not agree with you more. There is a lot of 
very, very good work that has been done that we want to build 
upon, but as Secretary, it would be my job to make sure that 
you allow me to have the tools and the resources and the 
authority to be able to get this work done, to make the 
progress that we need to make. And I expect to be held 
accountable if you give me that authority and I am not getting 
the job done.
    Senator Tillis. Thank you. I also meant to mention that I 
have thoroughly enjoyed having Senator Tester over in our 
office, talking with the VA over the last year. He has shown up 
every time. We have had great discussion and I look forward to, 
with the Chair's indulgence, of allowing us to continue to do 
that with you all.
    Two things I want to get to very quickly. One, as close to 
a yes-no answer would be great. The Community Care RFP, or 
request for proposal, that was issued in December--I think 
December 28--in some ways some people are viewing that as kind 
of a midnight rule that we would have liked to have spent some 
time talking under the new Administration about the priorities 
of that RFP. What are your plans, as Secretary, with this RFP?
    Dr. Shulkin. We have instructed a group, in the next 2 
weeks, to give us their assessment on whether this RFP has 
enough flexibility to allow us to do the types of 
transformation that we need to do or whether we need to take a 
pause. So, in 2 weeks we are going to have an answer to that.
    Senator Tillis. We would like to get that report as soon as 
possible----
    Dr. Shulkin. Yes.
    Senator Tillis [continuing]. Because, obviously, this may 
or may not fall under things that we could do with a resolution 
of disapproval. I do not think that is productive. We would 
make sure--I would like to make sure that our Members are 
consulted and those who may not be familiar with it know the 
implications of your assessment.
    The last thing that I want to talk about, we spoke about in 
my office earlier. We need to have you come back and tell the 
Congress when we are the main reason why you cannot do what you 
want to do. We need to have some frank discussions about limits 
that we are placing on you. I shared with you, in my office, a 
situation where the VA were making a good decision to 
consolidate a presence in very close proximity and you were not 
allowed to do something that would have improved the care and 
access in an area that I went to visit.
    I hope I have your commitment to come before this body and 
say, ``We will do this because you have told us to, but it is 
at the expense of an improved level of access and care,'' 
wherever that may be. I think we cannot have it both ways. We 
cannot constrain what, in your best judgment, is the best way 
to serve veterans and then come up here and quietly prevent you 
from doing that.
    Do I have your commitment to have that open dialog with us?
    Dr. Shulkin. Absolutely. I think if we continue the status 
quo, that is not going to get us where we need to go.
    Senator Tillis. Unless we want to put a mirror down there 
at the witness stand and blame us for suboptimizing what we can 
do for the veterans.
    Then, a part of that also has to be making the tough 
decisions about the inventory of brick-and-mortar presences 
that no longer make sense. We have got to make sure that the 
focus is on the veteran. It is not on a job or two here and 
there, which is important but it is not near as important as 
making sure that we have optimized our presence and our 
footprint in every State in the Nation.
    Thank you. I look forward to working with you.
    Dr. Shulkin. Thank you, Senator.
    Chairman Isakson. I am sorry. We will go to Senator Boozman 
and then Senator Brown.
    Senator Brown. No. We are not going back and forth, Mr. 
Chairman.
    Chairman Isakson. Well, I am trying to do, time-wise, the 
best I can, and some we are doubling up, in some cases. I will 
make sure you have plenty of time.
    Senator Brown. Thank you, Mr. Chairman.

         HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Mr. Chairman.
    The Choice has really been very effective in Arkansas. 
Alone, over 4,500 community providers are providing veterans 
with quality care, with close to 13,000 individual veterans 
being served between July 2015 and November 2016. That is 
really a good story and we really do appreciate the efforts, 
and I know you have been right in the middle of that.
    The IG report that came out, you know, talked about 
cumbersome authorization and scheduling. Can you talk a little 
bit about both of those things, and really, in particular, the 
scheduling aspect? That is something that I know, with your 
background, you are very, very familiar with----
    Dr. Shulkin. Mm-hmm.
    Senator Boozman [continuing]. It is a solvable problem. Can 
you talk a little bit about how we do a better job of getting 
that done?
    Dr. Shulkin. Senator, the two things on the IG report, on 
Choice and on scheduling. Is that correct?
    Senator Boozman. Yes, sir.
    Dr. Shulkin. OK. The IG report, which just recently came 
out on the Choice Program, covered a time period from November 
2014 to September 2015, and it described, I think accurately, a 
program that was in disarray. Since then, we have made, with 
your help, four changes to the law, 50 contract modifications. 
We have completely changed the ability, so now VA employees can 
make outbound calls. We have changed the episode from 60 days 
to a year.
    We have made this a much, much different program than it is 
today, and we can see the result. More veterans are able to 
schedule appointments. We now have over a million Choice 
appointments that have been scheduled by veterans, which is a 
good thing--or a million veterans have used the Choice Program; 
6 million appointments.
    In terms of scheduling, we still have not given our 
employees the right tools to be able to do their job well. They 
are using what I would call old blue DOS screens to schedule, 
and I do not know how they even do their job. Thank God they 
are so good at what they do.
    We need to give them new tools. I have asked, and we are 
moving forward with a commercial scheduling product for 
scheduling. It is called MASS. We also have an internal 
scheduling program. We call it--because everything has an 
acronym in VA--called VSE. That will be ready for a decision on 
February 10, whether it is a go, no-go. It is deployed to about 
10 sites where it is being tested by our employees, and we are 
going to make a decision on that as well.
    So, the bottom line is we need a new scheduling system. We 
have known that for years. We are finally going to do it.
    Senator Boozman. Good. Very good.
    One thing that has come up, I know that, you know, we have 
struggled forever with the process disability compensation 
claims, to try and get those done in a timely manner. I have 
been on the Committee now for--in the House and the Senate for 
15 or 16 years, and this is something that just has always been 
a problem. I know that you have worked on it really hard and 
the numbers have come down. That is a good thing.
    Particularly, the backlog to receive medical disability 
exams, and I think at one time it was 600,000.
    Dr. Shulkin. Mm-hmm.
    Senator Boozman. We are down now to closer to 60,000, and 
moving in the right direction.
    I guess recently we have redone the contracts and things?
    Dr. Shulkin. Mm-hmm.
    Senator Boozman. There is some concern that, you know, the 
people that did such a good job getting it in this situation. 
We have got new folks coming in and there is concern that they 
do not have the resources to actually, in a timely fashion, get 
set up and get the job done.
    What we do not want to do is get ourselves back in the 
situation of having the--can you just talk about that and kind 
of talk about the concerns?
    Dr. Shulkin. I think you are correct. We have decided to 
take on a new contact, to outsource a contract to a vendor. We 
awarded that. That was protested by two companies that did not 
win the award. The GAO actually took a look at our process and 
said that VA did things correctly. But, this is now being 
considered through a court process, and we heard today that we 
are likely to hear back on that protest through the courts in 
June.
    Until then, we have a bridge contract. I spoke to our 
Acting Under Secretary today, our Acting Under Secretary of 
Benefits, who assures me that veterans are getting the C&P 
exams that they need, that we are not seeing a delay, because 
we are able to use the bridge contract as well as those 
clinicians who work in VHA.
    So, we have to wait until June and we will see what the 
resolution is through the courts.
    Senator Boozman. Very good. One further thing, and then we 
are running out of time.
    You are a private sector guy. You have run all kinds of 
operations, been very, very successful. You have had the 
ability, in those entities, to hold people accountable. Can you 
talk a little bit about what you need to do and what tools we 
need to give you? Marco Rubio has a bill.
    Dr. Shulkin. Mm-hmm.
    Senator Boozman. Others have bills.
    Dr. Shulkin. Mm-hmm.
    Senator Boozman. Tell us a little bit about that. That is 
just a basic component of running a----
    Dr. Shulkin. Absolutely. When I talk about the tools that a 
Secretary needs to do their job, a basic function of any chief 
executive is to be able to get the right people working in the 
organization, and those that do stray from the values that we 
hold have to leave the organization. We do not currently have 
that right on either side, so I see this as a dual-pronged 
process.
    For those employees that really do not belong in the 
organization, the Secretary needs the ability to be able to 
remove them. We have--we were given expedited authority to 
remove employees through the Choice Act, which you gave us. 
Unfortunately, it was determined to be unconstitutional, and 
now the Department of Justice did not choose to go and to 
defend that.
    So, we are going to need new tools, and I am going to need 
to come back to you, and we need to figure out a way that we 
can make what you wanted to happen work better and make it 
constitutional.
    On the other side, a Secretary also needs the ability to 
retain, reward, and recruit those types of employees that we 
all want serving veterans, and we have been hampered in our 
ability to use the tools that we once had to be able to retain 
and recruit the very, very best. And, fortunately, the vast 
majority of our employees are people that we are all proud of. 
I am proud to work with them, I am going to stand behind them 
as Secretary, and I want the tools that we can make sure that 
we have the very best people in this country serving our 
veterans.
    Senator Boozman. Good. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Boozman.
    Senator Brown.

           HON. SHERROD BROWN, U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, Mr. Chairman. Thanks, Dr. 
Shulkin. It is nice to see you again. I enjoyed our 
conversation.
    First, Senator Tillis talked about the paranoia, it seems 
like, on their side of the aisle, that the people at the VA 
might want to privatize. Well, the fact is the President has 
talked about privatization. The fact is the President spoke out 
against changing Medicare: voucherizing, privatizing, raising 
the retirement age, the eligibility age; and then is trying to 
put a Secretary of Health and Human Services in who has devoted 
his Congressional career to privatizing, voucherizing, raising 
the eligibility age.
    So, I think it is important that all the VSOs here 
represented, all the people that care about veterans, all the 
people on both sides of the aisle here that think the VA should 
remain a public system with the Choice Act, understanding it 
not be privatized, continue to speak out. That is why I am 
pleased that Dr. Shulkin has said that in response to Senator 
Tillis and that Dr. Shulkin has said to me, privately, and to 
many others, that he will absolutely resist privatization.
    I am also concerned because I know the President has 
advisors, paid and unpaid, who are pushing him hard on 
privatization of the VA, so it is important that we all be 
vigilant.
    That is, anyway, all I wanted to say there.
    The hiring freeze, you spoke about it yesterday. I am 
concerned about the hiring freeze, what it does to the 400,000 
pending disability compensation and pension claims at the VBA. 
I wanted you to just answer yes or no, because of us getting 
back for votes and all. You are committed, I assume, to VBA 
processing claims quickly, speeding that up? Yes or no.
    Dr. Shulkin. Yes.
    Senator Brown. How many vacancies exist at VBA for claims 
processing?
    Dr. Shulkin. I do not have the specific number. There are 
47,230 across VA. We have an exception for 37,000. VBA is not 
part of that exception, so I spoke to the Acting Under 
Secretary today, who has assured me he has metrics on what is 
happening to these claims. If we are seeing a big concern with 
that, I do plan on going back and addressing that.
    The problem is without getting your benefits you cannot get 
access to health care, so these two are connected.
    Senator Brown. Well, they are connected, too, in the sense 
that the President's freeze, while there are exemptions, the 
understanding is the exceptions do not include human resource 
specialists. I do not know how you hire enough medical 
professionals. I hope that you will go back to the White House 
and explain this, from fruits to nuts, so they understand what 
damage this is doing to processing those claims and elsewhere 
in the VA system.
    Dr. Shulkin. I do plan on that.
    Senator Brown. Thank you.
    I want to talk briefly about something. In Dayton, last 
December, the Secretary signed a memorandum of agreement with 
the city of Dayton, OH, and local organizations, to establish 
VA's History, Research and National Heritage Center. You are 
familiar with this MOA?
    Dr. Shulkin. Yes.
    Senator Brown. I need your commitment to fully implement 
it. This project has taken longer than it should have, almost 7 
years. Please review it and begin implementation as quickly as 
possible.
    Dr. Shulkin. It is a terrific program. Yes, sir.
    Senator Brown. Thank you. Thanks. It means a lot to that 
community.
    Last question. In my State, in Ohio, 11 million people, 
25,000 veterans, 12,000 of their family members gained coverage 
because of the Affordable Care Act, because of Obamacare, 
either the federally run exchange or Medicaid expansion. I want 
your support to guarantee health care for our Nation's veterans 
and their families, including those that would be harmed by an 
ACA repeal.
    Dr. Shulkin. Well, that is why the VA is here, and that is 
our mission. So, we will do everything that we can, if there is 
an influx of veterans into our system. Yes, sir.
    Senator Brown. Does that mean that you will use your seat 
in the Cabinet, as you sit around the table with perhaps 
Secretary Price and the President of the United States and the 
Vice President of the United States, all who have campaigned on 
repealing the Affordable Care Act? Does that mean you will use 
your seat at the Cabinet table to push back on the 
Administration's attempts to limit access to care for all of 
them, including those 25,000 veterans?
    Dr. Shulkin. Senator, if I am confirmed, my sole focus is 
going to be on making sure that veterans' needs are met and on 
veterans getting the services that they need. That is going to 
be my role in the Cabinet. I see that as a very important 
responsibility, and I am going to speak up on behalf of 
veterans.
    Senator Brown. OK. Thank you for the way you said that. My 
fear is that if the Affordable Care Act is repealed, 22 million 
people lose their coverage. There is no plan that anybody has 
come up with yet to replace it. I care about all 22 million of 
those. I especially care, as I know you do, about the 25,000 
veterans and 12,000 family members who would also lose coverage 
if that is done. So, I ask you to speak out, as difficult as it 
might be when you may be the only one in the room speaking out, 
not just for primarily those veterans but how they will fall 
through the cracks if they do not really replace the repeal of 
the Affordable Care Act.
    Dr. Shulkin. I appreciate that.
    Senator Brown. Thank you.
    Chairman Isakson. Just for a clarification, the repeal of 
the Affordable Care Act would not affect a veteran, because the 
Veterans Administration is open for business and operated by 
the VA.
    Senator Brown. Mr. Chairman, respectfully, the ACA did 
insure 25,000 veterans and 12,000 family members that were not 
insured prior to the ACA, because they fell through the cracks 
at the VA.
    Chairman Isakson. But, we have made clear there is no 
privatization of the VA and there is no diminishing of the VA. 
We are not going to do that, nor are we going to take away any 
of their valuable current holders. [Pause.]
    We have a fourth vote and then a fifth vote, which is 
coming up, and I am going to make both of those votes. I am 
going to ask Senator Rounds to fill in for me as Chair. Senator 
Manchin--have you asked questions yet, Senator Manchin?
    Senator Manchin. No sir.
    Chairman Isakson. Well, what we will do, if that is OK 
with--are you ready? Do you want to ask yours now, Dan?
    Senator Sullivan. If that is OK, Mr. Chairman.
    Chairman Isakson. Dan has got to go back, and you have 
got--I will go with Dan and then you. [Pause.]
    OK. Well, I think we can get both of them in before the 
last vote is over. I will make sure--the cloakroom is looking 
for you, so we will hold it open. [Pause.]
    Senator Sullivan, come forward. Oh, go ahead, Senator 
Rounds.
    Senator Sullivan. Thank you, Mr. Chairman, and my good 
friend from West Virginia, thank you.
    Dr. Shulkin, you know, you were talking about 
accountability, which you and I have had that discussion, and 
you have already had a lot of questions on that. The authority 
that was provided you in the Choice Act, you welcome that, do 
you not?
    Dr. Shulkin. Yes.
    Senator Sullivan. So, you mentioned it was determined it 
was unconstitutional--just--I believe a court determined it was 
unconstitutional. Did not the Justice Department say it was 
unconstitutional?
    Dr. Shulkin. My understanding of this, and I am not a 
lawyer--I know you are, so I am on dangerous grounds----
    [Laughter.]
    Dr. Shulkin [continuing]. My understanding is a court did 
determine----
    Senator Sullivan. OK.
    Dr. Shulkin [continuing]. That this was unconstitutional. 
The Department of Justice failed to accept our request to 
appeal that, so we were pretty much stuck and we were 
overturned.
    Senator Sullivan. OK. Well, we want to work with you 
because I think that is a bipartisan area of agreement that the 
trust that you were talking about, with regard to our veterans, 
is undermined when you have these stories. I am not saying--as 
you know, most of the VA officials do a great job and really 
care about the veterans community that they serve. But, there 
have been some reports, I think very legitimate reports, where 
there has been malfeasance and actions that deserved to be 
punished or relieved. When that does not happen, it undermines 
the trust from our veterans.
    I think that is a bipartisan commitment. We all want to 
work with you on that, to restore that authority, make it 
constitutional, of course.
    Dr. Shulkin. Yes.
    Senator Sullivan. But, I had my doubts on where that was.
    Let me go back again to another veteran constituent asked 
about how will the VA increase its presence in isolated 
communities and communities that are very rural? What are your 
ideas for that? And a related question, in Alaska, do you see 
the Alaska Tribal Health System playing an important role in 
that area with regard to Alaska Native veterans, or non-Native 
veterans?
    Dr. Shulkin. Yeah. I see our ability to address the health 
care professional shortage in rural areas in three ways. First, 
and most important, to work with the community providers, as we 
have been doing, particularly in rural areas. In the case of 
Alaska, working with the tribal consortiums and the Indian 
Health Service has been absolutely critical, and I am pleased 
to say we just signed a 2.5 year extension to make sure that 
there is continuity of care for our veterans, and using them.
    Senator Sullivan. Thank you for that. I know that was a 
focus.
    Dr. Shulkin. Right. So, that is number 1.
    Number 2 is, we have to use technology in areas where we 
are not able to recruit all the health care professionals we 
need. Most people do not realize, nobody in this country is 
using telehealth technology the way that the VA is. We did 2.1 
million telehealth visits last year. That was 700,000 veterans. 
Nobody comes close, and we are doing it terrifically.
    I actually practice medicine, from here in Washington to 
Grants Pass, OR, where I take care of patients using 
telehealth. I can tell you, I was skeptical, but it works well, 
and the patients like it, too.
    Third is, we do need these tools to recruit and to use, 
frankly, financial incentives to get health care professionals 
to areas that we need them to care for veterans, because we are 
competing against the community, like in Mat-Su Valley, which 
you and I were talking about, we have been 2 years without a 
primary care doctor, and that is just not acceptable.
    Senator Sullivan. We want to work with you. Again, I think 
that is an area of bipartisan concern. Getting a doctor out in 
the Mat-Su Valley in Alaska is going to be very important, and 
I appreciate your commitment on that.
    Let me ask my final question, the broader issue that, 
again, I know the Chairman talked about in his opening remarks. 
But, what is your plan to tackle the current backlog and the 
process as it relates to appeals, because as you know, that has 
been a big challenge. There are some appeals that have been 
hanging out there for years--5, 6, 7, 8, 9, 10 years.
    Dr. Shulkin. Right. The appeals process is broken. The 
system was designed in 1933, and every now and then you have to 
update it, and we are way past that. We need an appeals 
modernization act, I think, that several people--I know Senator 
Blumenthal, Senator Rubio has proposed legislation. We will not 
fix this problem without legislation to fix it.
    Let me just update you on a few figures. The average appeal 
in the board is 6 years. We have one appeal that is now going 
on beyond 30 years, and the reason is you can constantly add 
new evidence at any point in the process and it starts over.
    So, this process needs to be fixed. We are really fortunate 
that Members of Congress, the VA, and our veteran service 
organizations lock themselves in a room until we came up with a 
solution that we think works, and that is now pending before 
you. We hope it is reintroduced into this Congress and we hope 
that you will pass it.
    Senator Sullivan. Thank you. Thank you, Mr. Chairman, and 
Dr. Shulkin, I look forward to your swift confirmation.
    Dr. Shulkin. Thank you.
    Senator Sullivan. Thank you again for your willingness to 
serve.
    Senator Rounds [presiding]. Senator Manchin.

     HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. Thank you, Mr. Chairman, and thank you, 
Dr. Shulkin, for being here and also for being willing to 
serve. You have done a great job in the year and one-half you 
have been there and I appreciate very much your service.
    I want to thank you, basically, for working as you did, 
well, trying to make the changes we needed to make. I think we 
are on a positive role there and a positive movement.
    Second, I would like to invite you to come to West Virginia 
and see our facility. I do not know if people know this but, 
you know, we are one of the most patriotic States with more 
veterans than most any. Out of 1,800,000 people that live in my 
State, 9.2 percent are veterans. Almost 10 percent of my 
population are veterans, which is unbelievable.
    With that, my concern, as you know, has been with opioid 
addiction.
    Dr. Shulkin. Yes.
    Senator Manchin. Not just in my State, but nationwide there 
has been an epidemic. It is also within veterans. In my veteran 
corps it has been very detrimental to them.
    A story ran in the Wall Street Journal that said 66,000 
veterans were treated for substance abuse disorder just in the 
last fiscal year--66,000. It detailed that there is a shortage 
of VA in-patient, residential rehab beds, and that the VA often 
relies on non-VA facilities to treat addicted veterans. To give 
you an example of how under-bedded we are, under-supplied for 
the needs that we have, there are only 906 VA in-patient drug 
rehab beds nationwide--only 906 for a population which is in 
desperate need.
    With that, Congressman Price, who has been considered for 
DHHS, has not committed to the funding that would support these 
types of rehab centers, that would help people get off of these 
prescription and lethal drugs. I did not know what your thought 
was, because right now you do not have the ability to pick up 
without the private sector support. If the Affordable Care Act 
goes down, we are dead. If he does not make a commitment from 
DHHS, we are dead again, and then you do not have the ability 
or the funding mechanism to pick up the slack.
    So, I do not know how you feel about that, just to get your 
input. I am not trying to put you on the spot, but what do you 
make of this and how does this addiction--how are we doing on 
the addiction fight?
    Dr. Shulkin. This is an area, opioid addiction, that I am 
very proud that VA recognized, frankly, before the rest of the 
country did; recognized it as a crisis and began to take 
action. In 2009, VA put a comprehensive program in place. It is 
why, while the rest of the country has seen opioid use go up, 
we have seen a 22 percent reduction since 2010. We are doing 
things that, quite frankly, we think are working and that the 
rest of the country can learn from.
    It does not mean, as you are suggesting, that we do not 
have to do more and that we should not do more. But, our work 
in making patients sign informed consents, our work in taking 
back medications that they are not using, in academic 
detailing, where we are teaching our doctors about the 
appropriate way, when to use opioids and when not to, our use 
of complementary care, so that we use alternatives to pain 
management--these are the things that are working, because what 
we know works best is to not start a patient, do not allow them 
to get addicted, which is going to help. But, for those that 
are there, we know that substance abuse is a big issue among 
veterans. We have to get them the right treatment.
    Senator Manchin. You and I have met now--I appreciate you 
coming to the office and the conversation we had was quite 
enlightening. We talked about something that I found out was a 
problem, I found out through the VAs, and especially with the 
addiction problem. A lot of the hospitals have told me that if 
an addicted person comes and they do not get what they ask 
for--and they usually know exactly what they want, not what is 
prescribed for them but what they want--they will call their 
Congressman or Senator and complain about bad treatment they 
are receiving, which puts you all on alert that you are not 
getting satisfactory services from that clinic, whether it be 
one of my CBOCs or whether it is going to be one of my 
hospitals.
    What I have asked for--and I do not know how the other 
committees feel about this--but what I asked for is that when 
it comes to dispersing opiates, the addictive opiates that are 
killing people right and left, including our veterans, that the 
hospitals and dispensing from the VA should not be--should not 
be calculated in that chain of satisfaction, basically because 
they are not getting the pill they want. Everything else, yes, 
we know if they are not getting the service. But on that one 
there, that puts them, and puts our hospital systems basically 
in the position to where they get reimbursements, you know, 
basically cut and severed if they do not get good, high ratings 
from their patients. An addicted person is not going to give 
you a good, complimentary evaluation if they do not get what 
they want. It just makes common sense. You all, I hope, have 
the ability to do that, or I hope you would look into that.
    Dr. Shulkin. Yeah. Look, even if we get scored poorly, we 
are going to do the right thing for the veteran, and that is 
most important. But, I do appreciate you bringing this up as an 
issue.
    I spoke this morning to Dr. Clancy, who heads up our 
quality area, who is responsible for this scoring, and she has 
said that we can actually calculate our scores without those 
questions in it, so we can do it with and without----
    Senator Manchin. Right.
    Dr. Shulkin [continuing]. And actually learn about what you 
are talking about.
    Senator Manchin. You would lead the charge nationwide and 
it would be a great help for the society.
    I want to thank you for the job you have done in the VA, 
because you all have turned it around. It is moving in the 
right direction. A lot more needs to be done, but my veterans 
appreciate it very much. Thank you, sir.
    Dr. Shulkin. Thank you.
    Senator Rounds. Senator Cassidy.

         HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA

    Senator Cassidy. Dr. Shulkin, nice to see you.
    Dr. Shulkin. Nice to see you.
    Senator Cassidy. Again, I have always--since you started I 
have admired the work you have done and the commitment you have 
made.
    I did not forget, you and I, in a private conversation, I 
mentioned a physician colleague in the VA who said that some of 
the research positions are not going to young clinician 
researchers. So, for the record, he did say I could connect 
you, give you his name.
    Dr. Shulkin. Great.
    Senator Cassidy. We will communicate that to your staff.
    Dr. Shulkin. Excellent. Thank you.
    Senator Cassidy. Now, Senator Manchin just brought up the 
problem of opioid addiction. My concern is that we hide 
problems by speaking of a mean. You have decreased opioid 
addiction by 22 percent. That is system-wide. You are a big 
system. I bet you there are some hospitals where it has 
actually increased--increased despite a recognition of the 
problem.
    Dr. Shulkin. Mm-hmm.
    Senator Cassidy. So, you are saying yes, which I take as an 
agreement.
    Dr. Shulkin. Yes.
    Senator Cassidy. How do we know which facilities are bad 
apples----
    Dr. Shulkin. Mm-hmm.
    Senator Cassidy [continuing]. If, since 2010, despite the 
mean going down, we know, therefore, some going up are really 
going up, that their weighting, still, the mean goes down? What 
specific interventions are being done in those facilities, and 
how quickly do you identify--you see the set of questions I am 
going after?
    Dr. Shulkin. We not only have the data by facility, like 
you are suggesting, we actually have it by prescriber, and that 
is one of the reasons why we have been able to drive down the 
use. Every prescriber gets their prescribing use compared to 
other prescribers in the VA system, and then we mandated--it is 
not a voluntary or optional process--academic detailing, which 
means that everybody needs to be able to sit down with their 
prescribing, with an advance teacher, and sit down and talk 
about what they could be doing better.
    Senator Cassidy. Are there physicians, or prescribers, who 
have been outliers on the upside--they are not oncologists, 
they are not pain doctors, so we do not think they have a 
reason to be prescribing a lot----
    Dr. Shulkin. Yes.
    Senator Cassidy [continuing]. Rather they are just--I am 
suspecting you have some that continue to be outliers on the 
upside.
    Dr. Shulkin. We do.
    Senator Cassidy. Now, if you can identify them, what is 
being done?
    Dr. Shulkin. Well----
    Senator Cassidy. Since this has been going on since 2010--
--
    Dr. Shulkin. Yes.
    Senator Cassidy [continuing]. You know, it is not so much 
we are going to detail them because clearly they continue to 
prescribe.
    Dr. Shulkin. Right. Right. As you know, from being a 
practicing physician, when you get this type of data, there are 
processes on how to do that, and this is not bureaucratic. This 
is what happens in every hospital across the United States. We 
tend to use a peer review process, where you get to sit down 
with your colleagues, who also practice, and have to explain 
why you are continuing to practice that way. If the explanation 
is not good, they actually can be de-credentialed and de-
privileged with their ability to see----
    Senator Cassidy. Now in the past year----
    Dr. Shulkin. Yeah.
    Senator Cassidy [continuing]. How many physicians have been 
de-credentialed for overprescribing opioids?
    Dr. Shulkin. I am not aware of any, specifically.
    Senator Cassidy. How many physicians would be two standard 
deviations above the mean, in terms of--not an oncologist, not 
a pain doctor----
    Dr. Shulkin. Yeah.
    Senator Cassidy [continuing]. How many would be two 
standard deviations above the mean, in terms of prescribing?
    Dr. Shulkin. I am not familiar enough that I want to start 
giving you wrong information, but I suspect, just because I 
think you and I have been doing this long enough, that there 
are some. I do think that addressing that issue, that the VA 
really has begun to do this, through its medical staff and its 
chiefs of staff, but I do not have specific numbers for you.
    Senator Cassidy. Yeah, I get that, and there is a 
specificity here. On the other hand, you can hide a lot of 
stuff within speaking about the mean.
    Dr. Shulkin. Absolutely.
    Senator Cassidy. Now, I think, and I typically find that 5 
percent of every group you ought to take out back and dispose 
of. Right? Not Senators, of course. [Laughter.]
    Not on this side of the aisle. [Laughter.]
    That said, I think I spoke to Dr. Clancy when I first 
joined the Senate, about the specificity, and was told, yes, 
you can go that specifically.
    Dr. Shulkin. Yes.
    Senator Cassidy. The fact that you still have those two 
standard deviations above suggests to me that this process of 
academic detailing and peer review is either too cumbersome, 
too fenced around with protections, or something, but there are 
still veterans getting addicted because of inappropriate 
prescribing.
    Dr. Shulkin. I am sure--in everything that we are doing, I 
am sure we can do this better, and we will take this back and 
take a look at it. But overall--and you are right, we are 
talking about means, and I agree with your statistical analysis 
here--but overall, we are actually doing things that many in 
America have not begun to do. We have begun to write this up 
and speak about it at national conferences, and we think there 
is a lot to learn from it. That does not mean that we cannot do 
it better, and we will look at this.
    Senator Cassidy. And although I am frustrated, I will 
return to where I started. I appreciate the good work you and 
many of the physicians have done. We wish to support you. But I 
will, when you come back, continue to ask about the 
specificity.
    Dr. Shulkin. Right.
    Senator Cassidy. To what degree are we using data analytics 
to specify those prescribers who really are outliers, and 
really probably should not be allowed to prescribe narcotics?
    Dr. Shulkin. OK. Very good. Thank you.
    Senator Rounds. Senator Blumenthal.

                   HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Senator Rounds. I want to 
begin where Senator Cassidy finished, first to thank you for 
your service. You have done great work so far in your present 
position. You have brought new leadership and vision to an 
agency that needs it. I also look forward to your coming back 
here, as Senator Cassidy has alluded to. You have been 
extraordinarily accessible and responsive to all of us, I feel, 
and I want to thank you for that.
    Particularly for me, we had a productive conversation 
yesterday, and you committed to helping me with a number of 
issues in Connecticut, including getting us Wi-Fi in our 
facilities, most especially West Haven, where I have been 
working, and working, and working to accomplish that end, and 
billing problems in Connecticut that are impacting some 
veterans when the VA fails to pay a provider, and a number of 
other areas where you have been extremely responsive. So, I 
thank you for that very good beginning.
    I would like to ask you, first of all, on an issue that we 
discussed yesterday, the appeals reform. I think you and I 
agree that this measure is extraordinarily necessarily because 
claims have been delayed and backlogged and gridlocked for far 
too long, and the appeals process needs to be better 
strengthened with resources and streamlined. Would you agree?
    Dr. Shulkin. Yeah, and, Senator, while you were probably 
doing your fourth or fifth vote, we recognized and thanked you 
for your leadership in introducing into the last Congress, and 
hope that you will reintroduce it. We desperately need appeals 
modernization and this issue will not get fixed without it.
    Senator Blumenthal. I plan to champion it again. Thank you 
for your support.
    The American Legion included, in its legislative 
priorities--and I thank them for doing so--the need to protect 
student veterans from predatory schools.
    Dr. Shulkin. Yes.
    Senator Blumenthal. In 2016, the Yale Law School issued a 
report entitled ``VA's Failure to Protect Veterans From 
Deceptive Recruiting Practices,'' which showed that the VA is 
not complying with 38 U.S. Code 3696, which requires the 
disapproval of GI Bill funding when the VA finds that colleges 
have engaged in deceptive and misleading college recruiting.
    This topic is very close to my heart, having two sons who 
have served, and knowing many, many student veterans. If 
confirmed, will you commit to cracking down on colleges that 
are essentially lying to our veterans, and cheating them and 
the taxpayers out of veterans' hard-earned GI Bill support, 
including by using all resources and authorities available to 
you, as the head of the VA, as well as working with other 
Federal agencies to crack down on these abuses?
    Dr. Shulkin. Yes, Senator. This situation that you 
described would not be tolerable to me, and absolutely, I would 
commit to that.
    Senator Blumenthal. I would pledge to you my total and 
complete support, at whatever level, in whatever way that I can 
help.
    Dr. Shulkin. Mm-hmm.
    Senator Blumenthal. I want to second what I think is 
Senator Murray's cause here. She has been such a champion of 
IVF treatment for veterans, and I hope that you will lend your 
complete support to that program as well.
    Dr. Shulkin. Yeah. On January 19th, this became a final 
interim rule, so we are moving ahead with coverage for service-
connected IVF treatment. It is absolutely--it is long overdue.
    Senator Blumenthal. Great. And in light of your own medical 
background, I am sure you appreciate the need and importance of 
this program.
    And finally, because my time is running out and we have one 
more vote, a 2015 report from the Veterans Education Success 
Fund found that 20 percent of 300 GI Bill-approved programs, in 
licensed occupations, left the graduates ineligible to work.
    In the last Congress we joined in a bipartisan, bicameral 
effort to unanimously pass the Miller and Blumenthal Veterans 
Health Care and Benefits Improvement Act. One component was the 
Career-Ready Student Veterans Act, which requires the VA to 
disapprove GI Bill benefits for programs that lack the 
appropriate accreditation for graduates to earn State licenses 
and certification. It sounds highly technical but in the real 
world can have a tremendous impact on enabling our veterans to 
get to work, and I hope that you will commit to rapidly 
implementing this important bill.
    Dr. Shulkin. Yes. Thank you for your leadership on that.
    Senator Blumenthal. Thank you. I very much appreciate your 
leadership and I look forward to working with you.
    Dr. Shulkin. Thank you, Senator.
    Senator Blumenthal. Thank you.
    Chairman Isakson [presiding]. Senator Blumenthal, you were 
not here at the beginning of the testimony and I wanted you to 
know I bragged about you and appreciated very much your 
leadership last year in co-chairing the Committee with me, 
leading to the stuff we passed at the end of the session. I 
just wanted to acknowledge that publicly.
    Senator Blumenthal. Thank you. Well, I appreciate that, Mr. 
Chairman, and I was proud to be among your supporting cast. 
Thank you.
    Chairman Isakson. Well, any time the Committee can pass out 
a bill 15-0, something is going right, and we appreciate your 
help.
    Senator Blumenthal. Thank you.
    Chairman Isakson. OK. Who is going to interpret these notes 
for me? Are you next, Mike?
    Senator Rounds, and thank you Senator Rounds for filling in 
for me.
    Senator Rounds. Thank you, Mr. Chairman. I would like to 
talk about the Choice Act, and just reconfirm your thoughts 
about some directions we have got to go.
    Last year, this Committee passed out an amendment to the 
Choice Act which would have made the VA the primary, rather 
than the secondary, payer in the Choice Act, which would clear 
up a whole lot of stuff out there. Would you commit, once 
again, your support to moving this from secondary payer to 
primary payer in the Veterans Choice Act?
    Dr. Shulkin. Yeah. Senator, I think the way that we are 
using the term ``primary payer,'' absolutely. We want to take 
the veteran away from being caught in the middle and then being 
caught in this credit swap. I want to make sure that when we 
write this that we write it correctly, because we do not want 
to add to the expense of the Choice Act. We want to use our 
funds most judiciously, and to the benefit of the taxpayers and 
veterans.
    So, yes, we think we need to do it differently. As you 
know, in Community Care, VA is the primary payer. In Choice, we 
are the secondary payer. It makes no sense to have two 
different ways of paying bills for the same veterans. So, we 
want to get it to one program that makes sense. I think you and 
I would describe that as primary payer, but there is some 
technical language in there I want to make sure is in the bill.
    Senator Rounds. But the idea would be that, under the 
Choice Program, when a VA goes to their physician, following 
the rules, that the VA would pick up the bill, and then if 
there was other insurance, the VA would then go back and----
    Dr. Shulkin. That is the exact idea.
    Senator Rounds. OK.
    Dr. Shulkin. Yes.
    Senator Rounds. Second item. With regard to the costs 
involved, I just want to hear your thoughts on this. In some of 
the work that we have done, we find some rather disturbing 
costs involved in the administration, not just of the Choice 
Act, but really the cost of administering the claims process.
    Dr. Shulkin. Yeah.
    Senator Rounds. Let me just lay out what we are finding. 
Now, the VA's average cost to process one claim is 
approximately 10 times the cost of a TRICARE claim--10 times. 
VA/VHA, not just the Veterans Choice Act but VA current 
programs, $15.91 per claim. Now compare that with TRICARE at 
$1.50 per claim for paper, or $0.40 per claim for electronic. 
Even Medicare, at $0.80 per claim.
    We have got to have a better way of delivering that 
administrative service because that is money that, right now, 
rather than going into veterans' care is going into 
administrative thing that is clearly out of date, and out of 
proportion with what the rest of the industry is going to.
    Would you like to share a little bit about--I mean, you 
have seen it now for a couple of years.
    Dr. Shulkin. Yes.
    Senator Rounds. And I know you are aware of it. Can you 
talk a little about how you see your vision----
    Dr. Shulkin. Yeah.
    Senator Rounds [continuing]. And how we start to address 
this?
    Dr. Shulkin. Certainly our goal is to get the 
administrative costs down to as low as possible. Our RFP that 
we had talked about earlier is redefining the way that a third-
party administrator's role would be, and the idea would be to 
get the administrative costs down. That is the objective.
    The numbers that you are talking about, when the Choice 
Program got stood up, and so we were just enrolling patients, 
the administrative costs were astronomical, because we were 
building a brand new administrative infrastructure and using 
third parties to do that, and so the administrative costs were 
sky high. Since May 2016, our administrative costs in the 
Choice Program are now 10 percent. That is not bad, compared to 
industry managed care standards. We think we can do better than 
that.
    TRICARE, the comparison you made, has been up and running 
for years and years, so, you know, the comparisons were not 
exactly equal. Your observation about that any cost that goes 
to administration is not going to benefit directly a veteran, 
that is what we want to get as small as possible.
    Senator Rounds. Very good. Thank you, Mr. Chairman. I will 
yield back my time.
    Chairman Isakson. Thank you again for filling in while I 
was out.
    Before I introduce Senator Murray, for the benefit of 
everybody at the dais now, we are going to hold the record open 
until 6 p.m. tomorrow for you to submit any questions after the 
hearing you want to submit. Dr. Shulkin, we are going to ask 
you have them answered by 6 p.m. next Monday. We want to get 
you confirmed, unless you have a bad answer to any of those 
questions.
    Dr. Shulkin. You do know it is Super Bowl Sunday, right?
    Chairman Isakson. I have got the Falcons pin on right here. 
OK. [Laughter.]
    But on Monday, it is Shulkin Monday. It may be the Falcons 
on Sunday but it is still----
    [Laughter.]
    Chairman Isakson. OK. OK. Unless you plan on doing some 
celebrating that we did not want to know about. [Laughter.]
    I am aware, and since you asked, the Falcons are playing on 
Sunday at 6:30 p.m., Fox television. [Laughter.]
    It is going to be Tom Brady today. [Laughter.]
    We are finally going to get him one of these days.
    Senator Murray.

        HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you very much, Chairman Isakson, and 
to our Ranking Member, Senator Tester.
    I want to recognize all the VSOs here. It is an amazing 
turnout and it shows how much you care about this nomination 
and this department, and I appreciate that.
    Dr. Shulkin, welcome. We had a chance to talk yesterday 
about what I think needs to be done to provide better care for 
all of our military families, and you know where I stand on a 
lot of things, from privatization to the urgent need to improve 
access to care.
    You also know that I believe the problems at VA are not 
always about money, but about the need for strong leadership, 
so I want to get right to my questions, since I know my time is 
limited here, since I know the Chairman does want to go to a 
game on Sunday.
    Chairman Isakson. If Sunday is the deadline, it is Monday. 
[Laughter.]
    Senator Murray. Dr. Shulkin, I think Senator Blumenthal 
asked about this, but after a very long fight Congress finally 
passed a bipartisan provision to give the VA legal authority to 
cover IVF for veterans and their spouses through fiscal year 
2018. Despite some technical holdups, I have been assured that 
the VA will implement this consistent with the intent of that 
law, but I am very concerned that the Trump Administration, in 
some reckless attempt to just reverse regulations, will prevent 
that from happening.
    I wanted to ask you specifically, do I have your assurance, 
yes or no, that veterans and their spouses will have access to 
this service through fiscal year 2018?
    Dr. Shulkin. Yes. It was an interim final rule on January 
19. Done.
    Senator Murray. OK. And can I count on your continued 
support for access to IVF for those veterans?
    Dr. Shulkin. Yes.
    Senator Murray. Great. Dr. Shulkin, President Trump last 
week issued a hiring freeze on Federal workers, which does 
affect the agency you may lead, as well as more than 800 
positions at VA facilities in my home State of Washington. Now 
I know the VA has responded with some exemptions, to try and 
make sure care is not compromised, but there are still open 
positions.
    Do you agree with the President's hiring freeze, which is 
now affecting those open positions at the VA?
    Dr. Shulkin. Senator, the most important thing to me is 
that we have the resources to hire the people that we need to 
take care of our veterans, and we have requested that from the 
White House and we have gotten that. So, the openings, we have 
37,000 positions exempted right now that we are actively 
recruiting for, and that we desperately want to fill. I am very 
comfortable with where we are at this point.
    Senator Murray. OK. Well, are you going to make sure the 
President understands that this freeze is actually 
counterproductive at the VA?
    Dr. Shulkin. Everything that we have asked for from the 
administration right now has been granted, so I feel 
comfortable that we have what we need. I do commit that if 
confirmed as Secretary, I would be a tireless advocate to ask 
the President for everything that we need to make sure that our 
veterans are getting both the health care and services that 
they deserve and that I would be here to protect, because if I 
am Secretary I am going to have their back.
    Senator Murray. OK. We will hold you to that.
    Now, I have heard from a lot of veterans in my State and 
across the country who are actually outraged by President 
Trump's executive order that unfairly banned refugees from 
Muslim-majority countries and created a religious test as to 
how Federal agencies treat Americans, their families, and those 
seeking a better life here in the United States. I stand with 
them, and I believe what Republicans and President Trump are 
doing is un-American and unconstitutional.
    Can you assure me that as VA Secretary under this 
administration that when pressed by President Trump to carry 
out an unconstitutional act, such as denying medical services 
and benefits, or making a hiring decision based on race, 
ethnicity, or religion, that you will never withhold care or 
treat a veteran different as a result of their ethnicity or 
religion?
    Dr. Shulkin. Senator, look. I very, very much value the way 
that this Committee works, which is in a bipartisan way. Our 
total focus is on veterans. As Secretary of VA, if I am 
confirmed, my sole focus is going to be on making sure that 
every veteran who has earned the right to be cared for as a 
veteran, through VA, gets that, regardless of anything, and 
nothing will get in the way of giving a veteran the services 
that they deserve and the health care that they need, and the 
other services. So, that would be----
    Senator Murray. Including ethnicity and religion?
    Dr. Shulkin. Veterans are not religions and Democrats and 
Republicans, they all bleed red, and as far as I am concerned 
they are all the same. They all deserve the same exact access 
to services and health care.
    Senator Murray. OK. Well, President Trump also said that he 
is going to conduct a wide-scale investigation of voting issues 
pertaining to the recent Presidential election, despite the 
fact there is no evidence of voter fraud. And now, as you know, 
veterans and servicemembers are often registered in multiple 
States, which alone is, by the way, not a crime unless the 
individual actually votes in multiple States.
    I am very concerned that this misguided effort could lead 
to veterans and servicemembers being stripped from voter roles 
in every jurisdiction they are registered in, which is 
especially egregious given, of course, their service to our 
country.
    As Secretary, what are you going to do to make sure 
veterans, servicemembers, and their families do not have their 
rights robbed by this process?
    Dr. Shulkin. I do not know that the issue related to 
voters' rights and some of the things that you are describing 
are in the purview of the Secretary of the VA, but certainly 
everything that is in the purview of the Secretary of the VA 
that I can do to advocate on behalf of veterans, I am going to 
make sure that I do.
    Senator Murray. Well, I appreciate that. Well, I hope that 
when you hear the President make a wide-scale whatever, that he 
seems to be doing, that you remind him that veterans also are 
impacted by this. When he says that he is going to go after 
voter fraud across the country, as I said, many of our veterans 
and their families are registered, by virtue of their service 
in several States. They are not voting in two different States 
or three different States, but they are registered so they can 
participate as citizens.
    I expect you to stand up and remind the President, when he 
makes these broad, wide-range executive actions, that veterans 
have to be thought about in that process.
    Dr. Shulkin. Yes.
    Senator Murray. Thank you.
    Chairman Isakson. I just want to inject, as kind of an 
after--not an afterthought but a primary thought, that we have 
so many foreign nationals who fight in our military. I think 15 
percent of our military is made up of people who are foreign 
nationals who are here on permits.
    Diego Rincon of Colombia was the first lost Georgian who 
lost his life in Iraq. His portrait hangs over my desk in my 
office, and he volunteered for the United States military, to 
later become a citizen. And our military has had a great open 
policy for recruiting both domestic American citizens as well 
as overseas citizens of other countries who have come here to 
become U.S. citizens.
    We have a tremendous commitment to any of those people, 
regardless of where they are from or who they are. If they sign 
for us to fight and risk their lives, they deserve every 
benefit unfettered that we promise them when they sign up, and 
we are going to always see to it that is the case. I am sure 
Dr. Shulkin will, and I will too.
    Dr. Shulkin. Yes.
    Chairman Isakson. With that said--let us see, did Jerry 
come back? Have you asked any questions yet?
    Senator Moran. I have not.
    Chairman Isakson. OK. Who--and we just had Patty.
    Have you asked any questions yet? Have you got time to wait 
for him?
    Senator Moran. Mm-hmm.
    Chairman Isakson. Dean Heller.

           HON. DEAN HELLER, U.S. SENATOR FROM NEVADA

    Senator Heller. Mr. Chairman, thank you, and to the new 
Ranking Member, I look forward to working with both of you.
    Dr. Shulkin, congratulations.
    Dr. Shulkin. Thank you.
    Senator Heller. I am pleased for you and your family and 
those that are perhaps watching today's hearing. I appreciate 
the visit you made to my office yesterday, where we talked 
about some numbers and some statistics that were important to 
me. I told you I may bring them up in today's hearing, so here 
we are. I want to thank all the VSOs and all those that are in 
attendance today for sharing and expressing your concern for 
this particular position, which is important to all of us.
    I want to compare some of the numbers of today when it 
comes to backlog claims, and I apologize if this has been a 
topic discussed prior to me getting in here, but the backlog 
claims today versus December 2013.
    Today, we have a 28 percent backlog, about 1,235 to be 
exact, versus December 2013 it was 67 percent. So, you can see 
that we have made some progress and I appreciate the men and 
women back in Nevada that are working for us and doing a great 
job back there to reduce this backlog.
    Today, the total pending claims is 4,416 versus in 2013, 
which was 6,622. The problem, of course, is in the appeals. We 
talked about this a little bit. Today, it is 2,731 versus 2013, 
where it was 1,140. That is a 140 percent increase since 2013.
    As you know, as we have pushed on the--and staff back in 
Nevada have pushed on this backlog claims for pending claims. 
Obviously the problem is that we are now seeing these appeals 
balloon.
    Dr. Shulkin. Yes.
    Senator Heller. What process? What process do you see in 
the near future that will address these appeals?
    Dr. Shulkin. Senator, first of all, thank you for 
recognizing the tremendous progress that the benefits team has 
done. This has been----
    Senator Heller. They have done a great job.
    Dr. Shulkin [continuing]. An example of modernization of VA 
that has taken the numbers down dramatically----
    Senator Heller. Yes.
    Dr. Shulkin [continuing]. Nationally from over 700,000 to 
today, about 80- or 90,000, and we are going to do better than 
that by the end of the year.
    Senator Heller. Good. Glad to hear that.
    Dr. Shulkin. But, in the appeals process, we have no hopes 
without a modernization act being passed through Congress to 
fix the appeals process. It is a broken process. It will not 
get better without your help, and we certainly hope that you 
and your colleagues will pass a modernization act this year.
    Senator Heller. The average days to complete now are 124 
days versus where it was in 2013. In Nevada, at least, it was 
433----
    Dr. Shulkin. Mm-hmm.
    Senator Heller [continuing]. Almost 434 days. So, you can 
see that there is some real progress there. I just want our 
veterans to know, back in the State of Nevada, how hard that 
office is working, the men and women that are committed to our 
veterans to make sure that they do get these benefits and 
services that they need.
    I would like to talk about doctor shortages for just a 
moment. We have, in the State of Nevada, felt a real impact. 
Nevada ranks 47th in the Nation for physicians per capita, and 
48th for nurses. And as you know, on top of that the VA is 
competing with the private sector for hiring.
    Given your experience, especially in running hospitals, 
what recruitment or retention efforts and initiatives will you 
be pushing to ensure that we get high-quality medical 
professionals joining and staying at the VA?
    Dr. Shulkin. Well, recruitment is our key issue, and I want 
people to know that working at the VA is a tremendous 
privilege. I see patients in the VA and I am proud to work with 
the men and women that serve in the VA. People read about all 
the bad press and the media events, and they say, ``Well, I may 
not want to work there,'' but I can tell you, when they come 
they see an environment that really is an extraordinary place 
to work. I want people to come.
    When you have given us the tools, like the Choice Act, we 
have hired 18,800 net new staff because of the authorization 
that you gave us. I hope, as Secretary, if I am confirmed, that 
you give me the ability to recruit and retain even further. So, 
when the CARA legislation passed, inadvertently, I believe, or 
at least I hope, our recruitment dollars were put into the CARA 
performance awards. So, it actually removed a tool that we used 
in the past to recruit and retain the very, very best, and I 
would like to have the ability to have what we had before, 
which is the dollars available to do what you are talking 
about.
    Senator Heller. Doctor, just----
    Dr. Shulkin. Yes.
    Senator Heller [continuing]. Because I am short on time----
    Dr. Shulkin. Yep.
    Senator Heller [continuing]. Can you give me your opinion 
on medical scribes, and do you believe that they will help 
these VA physicians and their workloads?
    Dr. Shulkin. We are looking at the medical scribe issue. 
The private sector has used it very successfully and we are 
starting some pilots in that. That is something that I think 
has some promise.
    Senator Heller. How about more doctors in rural areas?
    Dr. Shulkin. We need them, and we need to expand our 
graduate medical education programs in these rural areas. We 
would like to do that as well.
    Senator Heller. Thank you. Mr. Chairman, my time is out.
    Chairman Isakson. Thank you, Senator Heller. We will go to 
Ms. Hirono and then to Jerry Moran.

         HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII

    Senator Hirono. Thank you very much. It is good to see you 
again. I enjoyed the opportunity to talk with you and, in fact, 
just to reiterate, when I met with you I mentioned that three 
aspects of VA Administration that I am particularly interested 
in, and you committed to working with me on all of them, one 
is, of course, to improve access to health care for veterans 
and also to the various programs that support veterans. The 
second is to improve the communication between VA and the 
veterans, and the third is to smooth the transition from--for 
the veterans when they leave active service status.
    So, how we implement all of these areas are what we will be 
going forward on, should you be confirmed.
    I did have a question that I hope--a series of questions 
that I think should elicit very short answers from you. The 
first is that I was informed that there is a tool called the 
Blue Button----
    Dr. Shulkin. Yes.
    Senator Hirono [continuing]. That was born out of a 
veterans'--VA to empower patients with direct access to their 
medical data contained in the My Health, whatever----
    Dr. Shulkin. My Healthy Vet.
    Senator Hirono. Yes. OK--personal health record portal. 
Will you promise to support the ongoing development of the Blue 
Button tool and consider allowing more functions beyond viewing 
and downloading one's records?
    Dr. Shulkin. I will be brief. I think you are right. This 
was a success, the Blue Button, easily to download your EMR. We 
do have a digital services team that is looking at ways to be 
able to expand capabilities.
    Senator Hirono. Great. I have a number of questions 
relating to the care that they should receive. I know that you 
are aware of the bill that Senator Joni Ernst and I introduced. 
She introduced it. I am the lead Democratic cosponsor on 
veteran e-health and telemedicine, and I would like you to 
reiterate, for the record, that you believe that this is a very 
good thing, it would provide more avenues for care for 
especially our veterans who live in rural areas, and that you 
will work very closely, particularly to overcome some 
objections by the American Medical Association.
    Dr. Shulkin. Yeah. As I discussed with you, this bill is 
something that I strongly support, and we need this to take 
care of our veterans, particularly in our rural areas. I really 
hope that you will re-introduce that, and I will do everything 
possible to help support that bill.
    Senator Hirono. And, of course, we would like the Chair to 
be on board also.
    Another care question. The VA is currently collaborating on 
a pilot basis with pharmacies to provide walk-in services for 
common health care issues. The VA has a contract with CVS, 
which is everywhere, including in Hawaii. I think it would be a 
good thing if you would be willing to look at expanding the 
VA's collaboration with pharmacies to provide walk-in services, 
which would be so much more convenient for our veterans than to 
have to go to a VA facility.
    Dr. Shulkin. Yeah. This started with our Palo Alto VA and I 
would agree with you. It has been a successful pilot. We are 
looking at expanding but we will probably need to do that 
through an RFP to make sure that the process of giving out a 
contract is fair and complies with Federal rules.
    Senator Hirono. Another--this has to do with survivor 
claims. In the Veterans Health Care and Benefits Improvement 
Act, there was a provision to automate the survivor claims 
process, to just speed up the process, and I just would want to 
make sure that the implementation of this provision is 
occurring, so that the claims--claimants can get what they 
should be getting without going through all kinds of 
unnecessary hoops.
    Dr. Shulkin. Yeah. Senator, I agree, this is important to 
do. I do not have a specific timeline but I would be glad to 
get back to you with that.
    Senator Hirono. Thank you.
    Well, this goes to construction of facilities, because we 
still--the CBOCs are very important and there are a number of 
these facilities that are in the pipeline, including one in 
Hawaii, the Advanced Leeward Outpatient Healthcare Access 
Clinic, and State Veterans Home on Oahu. I would want to work 
with you to make sure that these projects are moving along, 
because they are already on the list of projects to build.
    Dr. Shulkin. I would be glad to do that.
    Senator Hirono. Then very specifically, we passed the 
Filipino Veterans Equity Compensation Fund and there are still 
some claims being made to the fund, and some of these veterans 
are having a hard time with providing all of the kind of 
records that they need. Some of the records have been 
destroyed, et cetera, and we would really want to work with you 
as World War II Filipino veterans are dying on a daily basis, 
and I will want to work with you so you can facilitate the 
decisions to support these veterans with just claims.
    Dr. Shulkin. Yes. You and I discussed that and I am 
supportive of doing what we can to get people who have earned 
the benefits the benefits that they deserve.
    Senator Hirono. Thank you. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Hirono. I appreciate 
your input and your questions.
    We will go to Senator Moran, followed by Senator Tester, 
followed by Senator Boozman.
    Senator Moran.

           HON. JERRY MORAN, U.S. SENATOR FROM KANSAS

    Senator Moran. Mr. Chairman, thank you very much. Dr. 
Shulkin, welcome to the Committee. Welcome back to the 
Committee. I congratulate you and your wife on your nomination 
and look forward to hearing your testimony today.
    Let me start by saying that we had a fine conversation in 
our office. I am looking for assurance that the VA is going to 
be different than it has been, in a more--this may sound 
provincial, about Congress, but a couple of things that have 
troubled me about the VA. One is that the outreach to Members 
of Congress, responsiveness, our ability to get VA attention on 
case work and individual veterans problems, in my view, has 
been miserable, and you assured me that things are going to 
change, and I assume if I asked you that question you would be 
politically adept enough to say yes again today. But the 
reality is, in my view, the VA is failing not just Congress but 
veterans that we are elected to serve and try very hard to care 
for.
    Another example of the VA's lack of concern for Congress is 
it seems to me, in way too many instances, perhaps all, in 
legislation that we passed, the VA then narrows the scope of 
that legislation, thwarting congressional intent. I just sat 
here listening to you testify and was thinking about three 
instances, just in the Choice Act. Remember the early days of 
40 miles in which it was as the crow flies. That is a way to 
deny veterans benefits that Congress intended for them to 
have--ultimately corrected, that is a good thing, but 
interesting to me that is where the VA started.
    The full-time position. What is the definition of a 
facility, and particularly as a CBOC, we tried to redefine what 
a CBOC is, based upon a full-time position. The VA then narrows 
it--not 40 hours as most of us would expect a full-time 
position to be, but something less than that. Again, thwarting 
the efforts of Congress, the intent of Congress to serve our 
veterans.
    The one that you and I talked most about in my office, 
which I am hoping that you have some good news, is the 
opportunity for us to correct this issue of unusual and 
excessive burden in which we indicated that you can go--you can 
have Choice, but then you narrowed it by--you, the VA--narrowed 
it by limiting the necessary procedures, the procedures that 
then qualified. Again, narrowing the opportunity for veterans 
to be served by Choice. And just three instances I thought, 
sitting here listening to your testimony.
    Any chance you can tell me good news, that you have looked 
at that and----
    Dr. Shulkin. Yeah. Senator, I can give you good news on 
that, that I believe--and I appreciate you and your staff 
pointing this out to us--those were meant to be examples. I 
think the field took them literally, that these are the only 
five conditions. So, we have gone out now, nationally, and 
clarified that, to give the flexibility that you need.
    But let me make the comment. This is complex business when 
we are making laws and implementing them. These examples are 
going to continue to come up. My commitment to you, if I am 
confirmed as Secretary, is we have to have these types of 
conversations and this type of communication, because you are 
hearing from constituents and you have information, and we need 
to get back to you in a timely fashion. That is why I am 
committed to that. Because we are going to continue to have 
these differences in interpretations. But in the end, we both 
want what is best for veterans, and I believe we will come up 
with the right solutions, like in this example where I just 
gave you good news.
    Senator Moran. That is good news, and I appreciate that, 
assuming that we then see a result.
    Dr. Shulkin. Yes.
    Senator Moran. In many instances in which the VA assures us 
that they have solved a problem, you get out to Kansas and 
nobody in the VISN or nobody in the hospital----
    Dr. Shulkin. Right.
    Senator Moran [continuing]. Knows any change. Your work is 
fully cut out for you, even when you make a decision that is 
advantageous to veterans.
    I am thinking about what you just said. We are going to 
have these kind of discussions--that is true. You are going to 
implement laws, but it does seem to me that in too many 
instances the goal has been to narrow the scope. I mean, the VA 
ought to be looking for ways to expand the opportunities, not 
narrow them. So, I hope your attitude and approach changes from 
what I saw in the past.
    I also asked you--and I do not think this happened so I do 
not think you can deliver good news--I asked you to have 
conversations with the VSOs--American Legion, VFW, Vietnam 
Veterans, and folks who are very interested in talking to you--
and again, I would encourage you in this setting to do so, if 
you become confirmed or whether you become confirmed.
    Dr. Shulkin. Yeah. You know, I think I have told you, but 
if not, I am absolutely clear, on the record, that the VSOs 
are--have been an absolute valued and treasured resource to me 
as a voice for veterans. I consider my relationships with them 
absolutely critical to the success of what I currently do, and 
certainly critical to the success of a Secretary. I meet with 
them on a regular basis. I e-mail with them. I take phone 
calls. My staff does too, so that commitment is absolutely 
there. If we need to do it more than we are doing it, then we 
will do it more than we are doing it.
    Senator Moran. I notice that President Trump, his words on 
Choice were--President Trump says, ``Ensure our veterans get 
the care they need, wherever and whenever they need it. No more 
long drives. No more waiting. No backlogs. No more excessive 
red tape. Just care and support they earned with their service 
to our country.'' And in regard to accountability, something I 
have yet to raise this morning, ``Fire the corrupt, incompetent 
VA executives who let our veterans down. Use the power of the 
presidency to remove and discipline the Federal employees and 
managers who have violated the public trust, and failed to 
carry out the duties on behalf of our veterans.''
    I assume you are, as a nominee, you are supportive of both 
President Trump's statements. I would ask you, just on a--how 
would you grade yourself? If you come to this Committee 6 
months from now, what would be the scorecard by which we could 
determine or I could determine whether you have met the goals 
of your service as the Secretary of the department?
    Dr. Shulkin. Well, we can talk about what the right time to 
come back and do that is, but, listen, there is only one goal 
that is important to me. Ask the veterans what they think of 
the services that they are getting, and what their trust level 
is of us, in terms of being able to deliver that. That is the 
most important outcome. We can define metrics on how to do 
that, but this is an organization--I think this is really what 
you have been saying all along--that has to be veteran-centric. 
That is the only reason we exist. That is the only reason why 
you have a Secretary, to make sure that they are advocating on 
behalf of them.
    So, let us ask them and let us see if we are doing a better 
job.
    Senator Moran. Well, that is fine.
    Mr. Chairman, I will conclude with this. Dr. Shulkin, you 
have the advantage of having served in the VA for 18, 20 
months.
    Dr. Shulkin. Mm-hmm.
    Senator Moran. It is also a disadvantage because I put you 
on a higher platform as somebody who cannot use the excuses, 
``I am going to go out and ask veterans what they need.'' You 
know the problems, and there ought not be a significant 
learning curve. Yours is not about conducting a town hall 
meeting and learning from veterans what the problems are. In my 
view, you have the ability, the background, to actually solve 
the problems.
    So, from my perspective, the answer to this question will 
not be ``we are still conducting a survey,'' and I do not think 
that is what you are saying. My point, in a sense, is to 
compliment you for your experience, but also to say that I 
think more is expected of you as a result of that experience.
    Dr. Shulkin. Yeah. Senator, you are not going to hear me 
asking for a learning curve. If you are moving toward 
confirmation, I hope you do it swiftly, because I am eager not 
to waste another day. I want to get on with this. I think the 
veterans deserve it. I think our employees deserve us building 
a system that meets their needs, so that they can serve 
veterans better, and there is not going to be a day wasted.
    Senator Moran. Thank you, Doctor. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Moran. We will go to 
Senator Boozman.
    Senator Boozman. Thank you, Mr. Chairman. I will be brief. 
We appreciate, again, you being here, and I had a very, very 
good visit with you in the office.
    I was going to ask you a question about the opioids that we 
talked about in the office, but instead of that, something that 
is related to that is we also talked about me being very 
supportive of the VA's adaptive sports programs, which I think 
should be expanded. Right now we have the big programs, but to 
expand them to the smaller communities, the smaller regions, in 
the sense that if we do those kind of things, then we will 
lessen the opioid problems and some of these other things that 
we are experiencing as a result of veterans just being in 
really difficult situations, where they need to get their minds 
off of things and into something positive.
    Can you tell us, are there plans to expand the program, 
perhaps on a smaller scale, to include these areas? And what 
constraints do you see in expanding the programs on the local 
and community level?
    Dr. Shulkin. Yeah.
    Senator Boozman. How can we help?
    Dr. Shulkin. I did not appreciate the importance of 
adaptive sports until I came to the VA, because, frankly, I 
have never been part of a health system that even thought about 
this as part of health care and well-being. But when I got into 
the mountains of Aspen with 400 veterans, and got them part of 
getting them out of their wheelchairs onto the mountains, it 
transformed my view of how we can help people.
    So, the stories that you talk about, about getting people 
off of medications, people who are suicidal, to regain a joy in 
their life and to start living again, were inspirational.
    I did it again this summer in San Diego with surfing with 
veterans. I had never surfed before. A pretty incredible 
experience.
    So, I am a big, big believer, because I have seen this. We 
need to do more of it. We need to get into the smaller 
communities. I am not looking for additional monies from the 
Federal Government. What I am looking to do is to get sponsors, 
corporate sponsors, which we have so many of. There are 
probably some in the room today and our VSOs, like DAV, who 
supports our efforts, and many of the other VSOs. I am looking 
for us to have other people see how vital this is in 
transforming people's lives. They are going to want to be part 
of it, once they experience it.
    Senator Boozman. Very good. Thank you, Mr. Chairman.
    Chairman Isakson. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. We have had some 
issues with third-party administrators in the State. You are 
aware of it. What can we do to hold them more accountable for 
their contractual obligations to the VA and to the taxpayer and 
to the veterans?
    Dr. Shulkin. Yep. I think it is called competition, 
Senator. When we brought the Choice Program up, we only had two 
bidders for the Choice Program, and we accepted both of them. 
And now that we are going out for an RFP, this is going to be a 
much, much better competition. We already have interest from 
many more vendors. Frankly, this is going to be an open 
process, and those who can deliver on doing the better job are 
going to win the contracts.
    Senator Tester. Well, to my knowledge there was only one 
that bid on Montana. And I will tell you that they have taken 
some things, they have embedded some people, they supposedly 
increased their call center, but they still do not know 
Montana.
    Is there any thought of having the VA be the administrator 
for that Choice Program?
    Dr. Shulkin. The redesign in the Choice Program that we are 
going to come back to you with allows the VA to do the things 
that it does well, which is dealing with veterans, doing 
customer service, making sure the veterans' needs are met. We 
outsourced that in the Choice Program and we learned that was a 
mistake. We are not going to do that again.
    But, on the other hand, VA is not good at many of these 
managed care functions, claims processing, and some of the 
network adequacy that you have to maintain. So, what we want to 
do is make the decision based upon what makes sense for the 
veterans, what needs to be in VA, and what needs to be done by 
private industry. We believe we can find that balance.
    Senator Tester. Yeah. I will just tell you, from my 
perspective, the VA might not be good, and may have room for 
improvement, and they do, but the third-party administrators 
are worse, truthfully, at least in our case.
    So, I would like to cut to the chase. There is a lady from 
Billings that said--she wrote me a note and said, ``What can 
David Shulkin do to ensure that all service men and women 
coming home from overseas duty get the medical attention they 
need, including mental health care?''
    Dr. Shulkin. Well, you know, we have to do a couple of 
things. The most important is access, and that has been our 
focus. That is why if you go to Billings you are going to find 
same-day services in mental health. But, we need more mental 
health professionals, which we are seeking to hire more mental 
health professionals. And we need to use our technology, like 
tele-mental health, that we are using for 336,000 veterans 
today. We need to continue to expand that. We have just 
established national hubs--ten national hubs of tele-mental 
health, so we can reach areas like Billings, that may not have 
the number of health care professionals it needs.
    So, we have a lot more to do but we think we are headed in 
the right direction, and we are committed, and we are not going 
to rest until we meet everyone who is returning to have their 
needs met.
    Senator Tester. OK. You come from the health care side.
    Dr. Shulkin. Mm-hmm.
    Senator Tester. OK? There has been some concern by some 
folks who are paying attention that the VBA side may suffer 
with you as Secretary of the VA. I am just being flat honest. 
You have commented about the freeze, and you did--and I 
congratulate you on that--get them to unfreeze, for the most 
part, the health care folks. But you still have a backlog on 
veterans' benefits.
    What is your intention to do there? Is this not a manpower 
issue?
    Dr. Shulkin. Yeah. First of all, it was not just health 
care that we got exempted. The National Cemetery too----
    Senator Tester. OK.
    Dr. Shulkin [continuing]. Because it is very important to 
be able to get people----
    Senator Tester. Gotcha.
    Dr. Shulkin [continuing]. The proper burial.
    Senator Tester. Thank you for that.
    Dr. Shulkin. What I firmly believe is, what I have learned 
over the 18 months, we are one VA, and you do not get health 
care if you cannot get benefits. And benefits is not going to 
suffer if I am confirmed as Secretary, because it is important 
to veterans and we have to focus on it.
    The issue of a 90-day freeze, I am working with our current 
Under Secretary, Tom Murphy----
    Senator Tester. Yes.
    Dr. Shulkin [continuing]. That if this really starts to 
impact our ability to get veterans benefits, that is something 
I am willing to address with the administration.
    I am not going to forget about it. I am going to advocate 
for what veterans need.
    Senator Tester. Over the course of the campaign, President 
Trump has said that the VA is a disaster, the most corrupt 
agency in the United States. Do you agree with that?
    Dr. Shulkin. The President and I spoke about where the VA 
needs to go, and that is where we focused all of our attention. 
I did not talk to him about his past comments, but he and I 
agree, absolutely, firmly aligned, that we need to do a lot 
better for our veterans. We agreed upon that moving forward, 
that the Secretary's role is going to be to get those changes 
made.
    Senator Tester. How do you feel about the workforce in the 
VA?
    Dr. Shulkin. I feel we have such a tremendous workforce. I 
am so proud of our employees. Just bear with me 1 second, 
because, you know, I just cannot stop thinking about this. When 
I was in St. Louis, I actually made a visit with Senator 
McCaskill--we visited the VA. They asked me to meet an 
employee, one of our employees, though she did not want to 
really talk to me because she was very humble.
    But what they told me about her is, the week before there 
was a veteran who had come 3 hours to his appointment in St. 
Louis, and they kept him waiting, so he missed his bus home. 
So, she is walking out to go home, with her coat, she sees this 
veteran in the waiting room, and she says, ``Can I help you?'' 
and he says, ``Well, I missed my bus. I have nowhere to go. I 
do not know St. Louis. I am worried about staying here 
overnight.'' She said, ``I will drive you home.'' He said, ``It 
is 3 hours.'' She said, ``Let's go,'' and she drove him home.
    These are our employees. These are the people that people 
do not hear about. They are there, not for the money. They are 
there despite the bad press. They are there because they are 
passionate about helping veterans. Thirty-five percent of our 
employees are veterans themselves. These are the best people in 
health care, and I am proud to serve with them.
    Senator Tester. Do you believe that beating the hell out of 
the entire VA workforce is productive?
    Dr. Shulkin. Beating them up?
    Senator Tester. Yeah.
    Dr. Shulkin. Oh, I think it is destructive. I think it has 
hurt our ability to recruit. It has demoralized our workforce. 
It demoralizes those of us who are trying to improve it, and it 
has got to stop. I appreciate the Chairman and you both helping 
us with that.
    Senator Tester. VA job applications are down by about one-
third. Is that correct?
    Dr. Shulkin. Even more, at the height of the crisis, they 
were down 78 percent. We are getting back.
    Senator Tester. Do you think that is part of the reason 
they are down by a third, because it has come in vogue to beat 
the hell out of the VA?
    Dr. Shulkin. A big part of the reason.
    Senator Tester. All right. A couple more questions, if I 
might.
    We would love to have you come out to Montana, for a number 
of reasons. We have got some great employees out there too. And 
make no mistake about it: the ones that are bad, we need to get 
rid of and get them out of the system. There is no doubt about 
that. But I will you there are some tremendous people out 
there.
    I am wondering if you could find it to come to our great 
State, which has 10 percent of the population of veterans, 
second-highest only to Sullivan's State, of veterans. So, we 
can take a look at what is out there and take a look at the 
distances and visit with some of the veterans and the staff.
    Dr. Shulkin. Well, after I go to Alaska and West Virginia, 
apparently----
    Senator Tester. We are kind of on the way to both of those 
places.
    Dr. Shulkin. There you go. [Laughter.]
    I will meet you there.
    Senator Tester. It is good.
    Senator Moran. Kansas is on the way, too.
    Senator Tester. All right.
    I will present some questions for the record, but in 
closing, Mr. Chairman, I will tell you that I was not as 
prepared for this meeting as I should have been; and I will 
tell you why. These lights are bright and the beam comes down 
and hits off of Paul Rieckhoff's head----
    [Laughter.]
    Senator Tester [continuing]. And increases the intensity, 
where I can hardly see David Shulkin. I am telling you, it is 
tough.
    Chairman Isakson. I thought that was a halo. [Laughter.]
    Thank you very much, Mr. Tester. I appreciate everything, 
Jon. As Ranking Member, I am looking forward to a great year, 
and I think we have already shared the common goals that I am 
going to talk about in just a second, but before I do, Jerry 
Moran has another question.
    Senator Moran. I did say one. I will ask three real 
quickly. Is that the same as one?
    Chairman Isakson. No. It is three times as many. 
[Laughter.]
    Senator Moran. First of all, I was pleased to hear 
something you said, Dr. Shulkin. I think it was in response to 
the Senator from Montana's questions. We introduced legislation 
in the past, Senate Bill 1463, and it is corresponding with 
exactly what you said. Our goal was to get rid of the 40 
miles--the issue we face is that people cannot use Choice 
because the VA has come up with reasons why they cannot, and we 
want them to be able to use Choice. So, it is whether the 
service is available----
    Dr. Shulkin. Yeah.
    Senator Moran [continuing]. Not whether there is a 
facility.
    Dr. Shulkin. I understand.
    Senator Moran. You said that, and that is the nature of how 
I think we improve choice, is to make certain that, again--
colonoscopy is an example I use, and a shingles shot is easy. A 
guy wants a shingles shot at home, the VA says, ``No, you 
cannot do that. You live within 40 miles of a CBOC,'' and the 
veteran says, ``Oh, no, no. That is fine. I have called them. 
They do not do shingles shots.'' The VA's answer is, ``It does 
not matter. There is a facility within 40 miles.''
    Dr. Shulkin. Right.
    Senator Moran. Those are things we can get rid of, and you 
indicated that in your response to Mr. Tester, and I appreciate 
that.
    Second, the authorities--you have responded to a letter of 
mine. Since the Chairman is critiquing the time, I would say I 
would still welcome an answer to this question. What 
authorities do you not have--what specific authority do you 
need to discharge the kind of people that Jon Tester just said 
we need to get rid of? And the example that we used with you, 
and the letter you responded to me, is the physician assistant 
who committed sexual acts against PTSD patients at Fort 
Leavenworth, the hospital, and he was allowed to retire. That 
has those victims of those crimes wondering, how did the VA let 
this happen in the first place, but second, why would not this 
person be fired instead of retired? And we still do not know 
the answer of what has transpired there, and I do not know that 
you will tell me that today, but I am still anxious in knowing.
    Dr. Shulkin. Yeah. Yeah. I look forward to working with you 
on that, because I do not want to be overseeing an agency that 
allows that to continue to happen.
    Senator Moran. And the final thing I would say--Mr. 
Chairman, I am anxious to help you in any way I can as we try 
to make certain that the VA does its job well, to support these 
Secretary and the employees at the VA. I look forward to 
working with you as the Chairman of MILCON/VA Appropriations 
Subcommittee to see that good things happen. And you can 
convince me that money is the issue, but first of all convince 
me that we are using the money that we get today in the very 
best way and we will be an ally.
    Dr. Shulkin. I agree. Thank you, Senator.
    Senator Moran. Thank you.
    Chairman Isakson. Thank you, Senator Moran. We are going to 
close--I am going to close out. I have not asked any of my 
questions yet and I have three or four to ask. But I want to 
make--for the record and for all the staff, for all the Members 
of the Committee, we are going to hold open the Committee 
records until tomorrow at 6 p.m. for any questions that any 
member feels they need to ask. They will have until six o'clock 
tomorrow night to submit those to us. Dr. Shulkin will be able 
to watch the Falcons beat the Patriots on Sunday, and then get 
his answers in by Monday at 6 p.m. Is that fair enough?
    Dr. Shulkin. That is good.
    Chairman Isakson. I am doing everything I can. I think you 
can see the Committee has been dedicated to this hearing. We 
have not had any of the monkey business, or whatever you want 
to call it, that we have heard going on at some of the other 
committees. We want to work this thing through, have your 
confirmation vote taken so you can get back to helping veterans 
and getting that done. So, be sure you get your answers back as 
quick as you can.
    Dr. Shulkin. We will.
    Chairman Isakson. We will finish our FBI review sometime 
before Monday is over, so we will have everything done. 
Hopefully we will be able to have a vote on confirmation, up or 
down, at the end of next week.
    Is that too soon? Did I say something wrong? We can do it 
by then, could we not?
    Staff. Yeah.
    Chairman Isakson. For once I was right. That is great. I 
usually get that wrong.
    Let me just say this. Dr. Shulkin, you have heard from Jon 
Tester, you have heard from Mr. Moran, you have heard from a 
number of the other members about Choice, and you have heard 
from me, and we have talked an awful lot about it. Choice needs 
to work, and it needs to be a real choice. It is the veteran's 
choice, not the VA's choice, or not the private sector's 
choice. We need to see to it that there are not limitations on 
who can go to a doctor in the private sector, that if they go 
to a doctor in the private sector we have accountability in the 
system to ensure the doctor does what they should.
    Second, we need to make sure that the rate that we pay does 
not have a differential in it. Right now, if I am not mistaken, 
there are doctors getting different levels of pay that are 
doing care in the community. Is that right?
    Dr. Shulkin. Yes. Depending upon the geography and whether 
it is a rural area or not, yes.
    Chairman Isakson. But it should be the Medicare rate, I 
think--is that right?
    Dr. Shulkin. Yes, in most parts of the country.
    Chairman Isakson. If it is rural, is there a special 
dispensation for rural?
    Dr. Shulkin. Exactly.
    Chairman Isakson. As long as it is because of the mileage, 
the distance, or whatever, that is fine. But we do not need 
competition in metro areas----
    Dr. Shulkin. Right.
    Chairman Isakson [continuing]. Where services are 
available, by reimbursing different levels of rates to doctors. 
It should be the same and it should be the Medicare rate.
    Dr. Shulkin. Yes.
    Chairman Isakson. Am I right that in 2016, there were 2 
million more veterans' appointments served at the VA than there 
were the previous year?
    Dr. Shulkin. 2.1 million. Yes, sir.
    Chairman Isakson. I think some--Choice contributed to that.
    Dr. Shulkin. Oh, absolutely.
    Chairman Isakson. It contributed to that by having more 
available places for veterans to get an appointment in a timely 
fashion.
    Dr. Shulkin. Yes.
    Chairman Isakson. I do not consider that--that was an 
increased cost of operation for the VA that only because the VA 
was being utilized, when before, they were not costing as much 
because they could not give the service----
    Dr. Shulkin. Right.
    Chairman Isakson [continuing]. Because we did not have 
enough personnel.
    So, for all this--wherever the people are that do the 
models back at CBO, that we have to base our legislation on, 
and we get our letters on, they need to understand that when 
they saw the amounts--the cost that went up, it was because 
veterans finally were getting the benefits they were supposed 
to get from their service. It was not an increase in the cost 
of the benefits. Is that right?
    Dr. Shulkin. I agree with that.
    Chairman Isakson. And the more--the better the Choice 
Program works, in terms of easy access and not so much 
paperwork, the less it is going to cost the Federal Government 
to run the Veterans Administration and the less pressure it is 
going to be on the VA to have office buildings, hospitals, and 
facilities, because we will have a utilization of private 
sector which has those things, which will help lower the 
pressure on the VA.
    Dr. Shulkin. Yeah.
    Chairman Isakson. The Denver hospital is the perfect 
example. The first challenge I tackled when I became Chairman 
was to find out we had a 1 billion--that is 1 billion with a 
B--dollar cost overrun in the construction of the Denver 
hospital. We went out to the hospital, Senator Blumenthal and 
I. Were you with us on that trip?
    Senator Tester. I was not.
    Chairman Isakson. We got there and when we opened Pandora's 
Box, which we did, we had a hospital that was 43 percent 
funded, 57 percent unfunded, and nobody knew what to do.
    Now, with the help of the entire Senate, Senator Blumenthal 
and I and the Committee, we got the money to finish that 
hospital, and part of it is now completed, as I understand. 
Part of it is now completed.
    The overrun is not $1 billion but it is pretty close, and 
when you get to something like that, you cannot just not finish 
it. You have got to finish it. But if you should not be 
starting it, you should not have started it either, and I think 
with Choice working the way it should, with good management of 
the VA, we will lessen the pressure on the VA to build 
hospitals and buildings, and raise the amount of money that is 
available for VA to provide services to veterans. And I think 
that is the perfect system you can have, because that is where 
I want the money going.
    Dr. Shulkin. Yeah.
    Chairman Isakson. I want to see to it the veterans getting 
the benefits that they have earned by serving their country.
    Last, and most importantly, I am sick and tired of turning 
on Fox television and CNN and whoever it is--I do not want to 
discriminate--all of them, I mean, whatever you call them. 
Every morning I get up at six o'clock to do my exercises, and I 
turn on my television set, and there is rarely a week goes by 
that at least one morning, and sometimes more, somebody has got 
a story about maggots being found in the wound of a veteran in 
a hospital, or drugs being dispensed in the wrong way to a 
veteran, almost like it is candy, or somebody doing something 
that just does not make any sense at all--Phoenix being the 
poster child for that all happening, by the way, I might add.
    I want to be a part of a news-free VA that only is making 
news because of the good things it is doing, not the few 
isolated bad things that happen. But those things should not 
happen, and the things I quoted were things that actually have 
happened in recent months. And I want to work with you and work 
with Jon Tester and work with the Committee to tell the good 
stories of the Veterans Administration on health care on the 
floor of the Senate, and in the travels that we will make in 
the next 2 years.
    But I want to make sure you commit to me that, when you 
have situations like this pop up, you will quickly tackle them, 
you will quickly respond to them, and you will do everything 
you can within your power to see to it the people responsible 
for it are reprimanded to the extent you have the ability to do 
that. Will you promise me that?
    Dr. Shulkin. You have my commitment, Senator.
    Chairman Isakson. Now, with me saying that, the last thing 
I want to say is this. When Richard and I worked so hard on 
the--and Jon, and everybody did last year--we got to the 
accountability portion, where we wanted to be able to fire 
people, and because of the Merit Systems Protection Board and a 
lot of other limitations, that could not be done.
    There are a lot of people who think that the Merit Systems 
Protection Board and some of the employee protections that 
exist in the government are there to keep them from getting 
fired and give them protection to do their job, but a lot of 
them it gives them cover not to do as much of a job as they 
want to--not a lot, but a few. We want to--I want to see if we 
can work through this year to find a way with labor, with our 
different interests from the two different parties, and 
everybody else will say, ``Is not there some way that Dr. David 
Shulkin could let his agency set goals, be tested, but his 
agency be monitored? And if there is someone--if there is 
someone--that does not respond to the goals that are set for 
them, does not respond to the care we want them delivering, 
that there is a way to then have a disciplinary action that 
brings about accountability.''
    I would like to see you--help you do that. It may not be 
reinstatement of the Merit Systems Protection Board. It may not 
be anything that I have talked about. But, there is some way we 
have got to give you the tools that you need to run an agency 
of 314,000 employees, and 6.5 million beneficiaries in the 
Veterans Administration.
    Dr. Shulkin. Yes. I agree, sir.
    Chairman Isakson. We will all work with you to try to do 
that. We do not want to fire anybody. We do not want to 
privatize the VA. We do not want to fire anybody. We do not 
want any of the stories that are going on to go around. But, we 
do want to start looking to solve the problems at the VA and 
see to it what it is to the public, what it is to us, and that 
is the best health care delivery system it could be for our 
veterans.
    With that said, do you have anything else to say, Jon? Jon, 
do you have anything else?
    Senator Tester. No. The only thing I would like to say, 
Johnny, is thank you. David, we look forward to working 
together to make this confirmation happen as quickly as you can 
get your stuff in. I also wanted to thank you for being here 
today, David, and putting yourself up for this position.
    Dr. Shulkin. Thank you. Thank you very much.
    Chairman Isakson. Questions for the record need to be in 
the office of the Committee by tomorrow night at 6 p.m. Answers 
from Dr. Shulkin, they need to be 24 hours after the Falcons 
win the game against the Patriots, which is Monday. [Laughter.]
    We appreciate your time. We appreciate your testimony----
    Dr. Shulkin. Thank you.
    Chairman Isakson [continuing]. And we appreciate your 
service to the country.
    Dr. Shulkin. Thank you.
    Chairman Isakson. This hearing is adjourned.
    [Whereupon, at 5:16 p.m., the Committee was adjourned.]

                            A P P E N D I X

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 Letter from Hon. Robert P. Casey, Jr., U.S. Senator from Pennsylvania
 


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    Prepared Statement of Rep. Tim Walz, Ranking Member, U.S. House 
                     Committee on Veterans' Affairs

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 Letter from Laura Thevenot, Chief Executive Officer, American Society 
                         for Radiation Oncology

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     Letter from William J. Rausch, Executive Director, Got Your 6

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Letter from Randy Reeves, President, The National Association of State 
              Directors of Veterans Affairs, Inc. (NASDVA)

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