- THE FISCAL YEAR 2018 BUDGET FOR VETERANS' PROGRAMS

[Senate Hearing 115-276]
[From the U.S. Government Publishing Office]

S. Hrg. 115-276

THE FISCAL YEAR 2018 BUDGET FOR
VETERANS' PROGRAMS

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HEARING

BEFORE THE

COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE

ONE HUNDRED FIFTEENTH CONGRESS

FIRST SESSION

__________

JUNE 14, 2017

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Printed for the use of the Committee on Veterans' Affairs

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Available via the World Wide Web: http://www.fdsys.gov

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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

Thomas G. Bowman, Staff Director \1\
Robert J. Henke, Staff Director \2\
Tony McClain, Democratic Staff Director

Majority Professional Staff
Amanda Meredith
Gretchan Blum
Leslie Campbell
Maureen O'Neill
Adam Reece
David Shearman
Jillian Workman

Minority Professional Staff
Dahlia Melendrez
Cassandra Byerly
Jon Coen
Steve Colley
Simon Coon
Michelle Dominguez
Eric Gardener
Carla Lott
Jorge Rueda

\1\ Thomas G. Bowman served as Committee majority Staff Director
through September 5, 2017, after being confirmed as Deputy Secretary of
Veterans Affairs on August 3, 2017.
\2\ Robert J. Henke became the Committee majority Staff Director on
September 6, 2017.
C O N T E N T S

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Wednesday, June 14, 2017
SENATORS

Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........ 1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana...... 2
Moran, Hon. Jerry, U.S. Senator from Kansas...................... 66
Sanders, Hon. Bernard, U.S. Senator from Vermont................. 69
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 72
Manchin, Hon. Joe, III, U.S. Senator from West Virginia.......... 73
Heller, Hon. Dean, U.S. Senator from Nevada...................... 75
Murray, Hon. Patty, U.S. Senator from Washington................. 78
Boozman, Hon. John, U.S. Senator from Arkansas................... 80
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 82
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 83

WITNESSES

Shulkin, Hon. David J., MD, Secretary of Veterans Affairs, U.S.
Department of Veterans Affairs, accompanied by: Edward Murray,
Acting Assistant Secretary for Management and Chief Financial
Officer; Richard Chandler, Deputy Assistant Secretary, IT
Resource Management; Mark Yow, Chief Financial Officer,
Veterans Health Administration; James Manker, Acting Principal
Deputy Under Secretary for Benefits, Veterans Benefits
Administration; and Matthew Sullivan, Deputy Under Secretary
for Finance and Planning and Chief Financial Officer, National
Cemetery Administration........................................ 4
Prepared statement........................................... 7
Response to prehearing questions submitted by Hon. Johnny
Isakson.................................................... 15
Response to posthearing questions submitted by:
Hon. Johnny Isakson........................................ 110
Hon. Jon Tester............................................ 121
Hon. Bill Cassidy.......................................... 134
Hon. Patty Murray.......................................... 135
Hon. Joe Manchin III....................................... 136
Hon. Mazie K. Hirono....................................... 138

Independent Budget Representatives

Blake, Carl, Associate Executive Director, Government Relations,
Paralyzed Veterans of America.................................. 88
Prepared statement of IBVSOs................................. 90
Acosta, LeRoy, Assistant National Service Director, Disabled
American Veterans.............................................. 94
Prepared statement........................................... 96
Fuentes, Carlos, Director of the National Legislative Service,
Veterans of Foreign Wars of the United States.................. 99
Prepared statement........................................... 100

Other Veterans Service Organizations

Rowan, John, National President, Vietnam Veterans of America..... 103
Prepared statement........................................... 105

APPENDIX

Chenelly, Joseph R., National Executive Director, AMVETS
(American Veterans); prepared statement........................ 141

THE FISCAL YEAR 2018 BUDGET FOR VETERANS' PROGRAMS

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WEDNESDAY, JUNE 14, 2017

U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:41 p.m., in
room 418, Russell Senate Office Building, Hon. Johnny Isakson,
Chairman of the Committee, presiding.
Present: Senators Isakson, Moran, Boozman, Heller, Rounds,
Tillis, Tester, Murray, Sanders, Brown, Blumenthal, and
Manchin.

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

Chairman Isakson. I call this meeting of the Senate
Veterans' Affairs Committee to order. I apologize again for
being a little bit late, but I wanted to make sure we were on
the right track and I did not mess anything up.
I want to welcome Secretary Shulkin, who has had a great
start. I do not think anybody in this administration started
out with a unanimous vote he received. You cannot do any better
than unanimous when you get confirmed. I think the vote last
week on accountability was extraordinary, and the way we got to
the decision, working together hand in hand, was extraordinary.
I commend the Ranking Member on his help in doing the same.
We have got some other things to do today to talk about,
budget-wise, and we will have some other decisions to make. We
can keep the same tempo, same discipline, and the same
commitment to making sure we all know what each other knows
before they happen rather than finding out after the fact,
which we will all be an awful lot better off.
I welcome Dr. Shulkin and the other members of the VA staff
that are here today. I appreciate all that they had done in our
meeting the other day to explain where we are going with the
Veterans Administration, which is upward and outward and
further ahead all along.
I am not going to make a long statement at all, except to
say a couple of things. I do not want to make this David
Shulkin Day, but one other thing I have to brag about, the
Cerner decision and getting our electronic medical records
issue solved after years of unwillingness to address it is
extraordinary. I think, from what I have heard, there are
already signs that people are coming together who in the past
had not been together to make sure this happens and works
efficiently for our veterans and for the Department of Defense
and the Department of Veterans Affairs at the same time.
It was silly to have two different agencies in the same
government serving the same soldiers, fighting for the same
country and the same Constitution that had two medical systems
that were not interoperable, one to the other, and where our
veterans who fought for us would literally fall in a hole going
from active duty from the Department of Defense to Veterans
Affairs. I think this move to Cerner is going to prove to be a
tremendous move economically for the VA and benefit-wise for
our veterans. There is no possible way to do any better than
that. So, I commend you on that decision as well.
With that, instead of getting into details, I am going to
ask for an opening statement from the Ranking Member, Jon
Tester.

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

Senator Tester. Thank you, Mr. Chairman, and thanks for
having this hearing. I think it is important to say that our
thoughts are with the colleagues who were with the victims this
morning. We wish a speedy recovery for Congressman Scalise and
everybody else who was injured, and a big, big thank-you to the
Capitol Police officers who work every day to make sure this
place is a safe place. Our thoughts are with them.
Now, Secretary Shulkin, I want to thank you for being here,
and I want to thank you for being here with your VA team. We
spoke last week at some length about the future of the Choice
Program, and I hope I made my perspective clear: the Choice
Program was intended to supplement care, provided, directed by
the VA, not replace it, not now and not into the future.
I worry that the budget proposed by this administration
starts us down a path of unfettered choice that will hollow out
the VA. In doing so, it proposes to increase funding for
community care by a third, while proposing that the VA's own
hospitals receive an increase that is less than half of the
medical inflation rate--not much.
Further, the budget does absolutely nothing to address VA's
aging infrastructure. If we are starving VA's hospitals for
funding used to hire staff and actually provide care for
veterans while also denying them money to address the
environmental care concerns, we know what that outcome is going
to be. Soon enough, there will not be any quality VA hospitals
staffed by quality providers, and the VA care will become
nothing more than a voucher plan to send veterans into the
private sector to hunt for a doctor who has the time and the
capacity and the knowledge to treat them. That is not what our
veterans need, and it is not what the veterans want to happen.
For a rural State like Montana, it would truly be a disaster.
We need to be honest. Each year, more and more rural
hospitals are at the risk of closing, and if there are
rollbacks to recent Medicaid expansions, it is likely that
these closures would accelerate. We cannot assume that private
care will work in rural communities where there are no
providers in the first place or where the third-party
administrators (TPAs) do not have sufficient networks.
We know that the vast majority of veterans using Choice
over the last 2 years are eligible due to long wait lines, not
because they live too far from a VA facility. Data shows that
rural veterans are not just choosing Choice as much, but they
actually do depend on VA care.
Now, based on your request yesterday, we may have to shift
additional funds around and out of VA care accounts to get the
Choice Program through the fiscal year. For months, we have
been asking about the Choice Program spend rate and the amount
of funds, the amount of remaining funds. We were never provided
with those answers we needed to make informed decisions, and
now we are in a difficult spot.
Mr. Secretary, no one wants to delay care for veterans--no
one--and we will act appropriately and in a timely manner to
solve this problem. But, for that to happen this late in the
game is a bit frustrating to me, and my frustration is
compounded by a budget that cuts services that veterans rely
on, makes cuts to education oversight, makes cuts to
information technology (IT), which impact every business line
and how the department operates. I am most concerned that it
appears that these cuts are being made in order to pay for
certain veterans to get private care.
The new policies proposed in this budget to pay for private
care are simply untenable. To put forward a proposal that
would, without warning, stop earned benefits payments to
severely disabled vets is unacceptable. In this case, we are
not talking about folks milking the system for government-
funded compensation that they do not need or do not deserve. To
get the individual unemployment benefit payment, it must be
determined that a veteran is unable to engage in substantive
work as a direct result of service to their country.
President Trump's budget proposes that we just stop paying
these veterans at a time when more Americans are having to work
longer in their lives to make ends meet and all in the name of
finding more money for Choice. That is a nonstarter, and I hope
we can get your commitment today to keep this important benefit
in place.
I look forward to working with my colleagues on both sides
of the aisle to address these concerns and look forward to
hearing from you and how you intend to prioritize funding for
veterans who get care and benefits direction from the VA.
Finally, I would like to wish the U.S. Army a happy
birthday.
I look forward to your testimony, Secretary Shulkin.
With that, thank you, Mr. Chairman.
Chairman Isakson. Secretary, welcome. Let me introduce
those you brought with you to back you up and accompany you
along the way, which we appreciate them being here too. Edward
Murray, thank you for being here today as Acting Assistant
Secretary for Management and Chief Financial Officer; Richard
Chandler, Deputy Assistant Secretary, Resource Management; Mark
Yow, Chief Financial Officer, Veterans Health Administration;
James Manker, Acting Principal Deputy Under Secretary for
Benefits; and Mr. Matthew Sullivan, Deputy Under Secretary for
Finance and Planning and Chief Financial Officer, National
Cemetery Administration.
Secretary Shulkin, the floor is yours.

STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY EDWARD MURRAY,
ACTING ASSISTANT SECRETARY FOR MANAGEMENT AND CHIEF FINANCIAL
OFFICER; RICHARD CHANDLER, DEPUTY ASSISTANT SECRETARY, IT
RESOURCE MANAGEMENT; MARK YOW, CHIEF FINANCIAL OFFICER,
VETERANS HEALTH ADMINISTRATION; JAMES MANKER, ACTING PRINCIPAL
DEPUTY UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS
ADMINISTRATION; AND MATTHEW SULLIVAN, DEPUTY UNDER SECRETARY
FOR FINANCE AND PLANNING AND CHIEF FINANCIAL OFFICER, NATIONAL
CEMETERY ADMINISTRATION

Secretary Shulkin. Well, thank you, Chairman Isakson,
Ranking Member Tester, and other Members of the Committee.
As you can see, I brought a big team with me because I know
you are going to have lots of questions, in particular, with
the opening statements, I really do look forward to having a
meaningful discussion and getting to some solutions and some
closure on some of these issues.
I also did want to echo the Ranking Member's concern that
this is a sad day for the Nation where public servants who work
as hard as I know all of you do have to worry about their
personal safety, and our thoughts and prayers are with the
Congressman and the staff and the Capitol Police as well.
Thank you again for allowing us to be here today. What we
want to talk about today is the 2018 President's budget and the
2019 advanced appropriations, and all of this is in way of
showing support for veterans. We appreciate the legislation
that recently had been passed. As you know, you passed just
within the past week, the accountability bill, and that went
through the House yesterday. We are looking forward to actually
next Tuesday bringing it for a signature for the President,
which is good news.
We also appreciate your support for the Veterans Choice
Improvement Act that you supported and for providing us, really
for the first time in a long time, the full 2017 budget. This
has really allowed us to make real progress for veterans, and
we are, again, grateful for that support.
I have submitted the full written statement for the record,
so let me just start by thanking you again for allowing us to
participate in the hearing last week. It seems like we were
just here with you, but I thought it was an excellent hearing,
a good discussion on Choice. That type of discussion and dialog
is going to allow us to help get it right for veterans.
When I testified before the House Veterans' Affairs
Committee on March 7, we had $2.0 billion in the Choice
account. Less than a month and a half later, when the President
signed the Choice Extension Act into law, our Choice account
was at $1.5 billion. Today, that account is at $821 million.
As we know, more veterans than ever are using Choice. We
have authorized 8.2 million Community Care appointments since
January of this year. That is 2.6 million more than last year
or a 46 percent increase. In fact, March, April, and May were
the largest months ever for Choice, and frankly, that happened
because we fixed so many of the problems that we have all been
working to fix with Choice. We have been increasing our use of
Choice. One of the reasons why is the 2017 budget, as you may
remember, actually had $2 billion less in Community Care, so we
have been putting more through Choice.
Two years ago--I am sure you are going to remember in July
2015, we had too little money in our Community Care accounts
within the VA, which we solved with your help by accessing
unused funds in the Choice account, so we transferred money
from Choice into Community Care. We now have too little money
in the Choice account, which we are working to solve, again,
working with you, with legislative authority to replenish funds
into the Choice account.
This is the situation that we have described before, where
for a single purpose of providing care in the community, we
have two checking accounts, and I will tell you, I wish it were
easier than it is. We have to figure out how to balance these
two checking accounts at all times. Obviously, it is not a
science; it is an art. We are having difficulty with that once
again. That is why we need to work with you to solve it.
The Veterans CARE Program that we outlined for you last
week will solve this recurring problem permanently by
modernizing and consolidating all of the Community Care
accounts, including Choice. The President's budget in 2018 and
2019 provides additional funds for Choice and the resources
necessary to continue the ongoing modernization of VA. It
requests $186.5 billion for VA, $104.3 billion in mandatory
funding, and $82.1 billion in discretionary funding, for a
total increase of $6.4 billion or 3.6 percent over 2017.
It provides $2.9 billion in mandatory funding to continue
the Choice Program in 2018 plus a 7.1 percent increase in
discretionary funding for VHA to improve patient access and
timeliness of care.
It supports the strengthening of foundational services as
well as modernization in consolidating VA Community Care
through the Veteran CARE Program announced last week, so
veterans can make the right decisions about their care together
with their physician or provider, giving them yet another
reason to choose VA.
This budget reflects the President's strong personal
commitment to the Nation's veterans. It is also a budget we
need to achieve my five priorities as Secretary: providing
greater choice for veterans; modernizing our systems; focusing
our resources toward what is most important for veterans;
improving the timeliness of our services; and suicide
prevention.
We are already taking steps to meet the challenges that we
face. At the President's direction, we have established a VA
Accountability Office. The recent decisions made by the Senate
and the House will help us with that.
We have recently removed two medical center directors and
three other senior executive service leaders. We simply will
not tolerate employees who act counter to our values or put
veterans at risk.
I recently announced a new Fraud, Waste, and Abuse
Prevention Advisory Committee, which will be set up and running
later this summer.
I have also directed the VA Central Office remain under a
hiring freeze--those are for administrative positions--as we
consolidate program offices, implement shared services, and
realign overhead to get more money back to the field.
We now have same-day services for primary care and mental
health at all of our medical centers. Veterans can now access
wait-time data for their local VAs using an online easy-to-use
tool to understand access and quality. No other health system
in the country has this type of transparency.
We have made it easier for veterans to fill online health
care applications, so much easier, in fact, that since last
summer, we have received eight times as many online
applications than the year before.
Last month, we were able to process a disability claim in
just 3 days--I said that right: a disability claim processed in
3 days--using a new process called Decision Ready Claims. We
will be introducing Decision Ready Claims nationally
September 1.
At our regional offices, we will be completely paperless
for claims by mid-2018.
A few months ago, the Veterans Crisis Line had a call
rollover rate of more than 30 percent. Today, that rate is less
than 1 percent.
We have launched a new predictive modeling tool called
REACH VET allowing VA to provide proactive support for veterans
who are at higher risk for suicide.
We are also launching a new initiative this summer, Getting
to Zero, to help us end veteran suicide. This is my top
clinical priority.
But, to keep moving forward, we are going to need your
help. We have identified over a thousand facilities that are
either vacant or underutilized, and we are working now to move
forward with 142 of those facilities. With your help, we could
do more of the same.
We need Congress to fund our IT modernization to keep our
legacy systems from failing and to replace VistA with the
system already in use by the Department of Defense. This will
ultimately put all patient data in one shared system, enabling
seamless care between the VA and DOD, without manual and
electronic exchange and reconciliation of data between separate
systems.
We also need Congress to authorize and overhaul our broken
and failing claims appeals process. We have worked closely with
VSOs and other stakeholders to draft a proposal to modernize
the system, and we were pleased to see the House unite behind
the bill last month. Now we just need the Senate to act.
Most of all, we need Congress to ensure the continued
success of Choice for veterans. Veterans are responding to our
modernization efforts by choosing VA more than before. To keep
up with those choices, we need to fully fund Choice and help us
modernize and consolidate VA Community Care through the
Veterans CARE Program. The Veterans CARE Program will
coordinate care so that veterans get the right care at the
right time with the right provider, whether in a VA facility or
from a high-performing VA Community Care provider. We just need
your help to make it happen, including funding, to keep up with
veterans as they choose VA.
Thank you, and we look forward to your questions today.
[The prepared statement of Secretary Shulkin follows:]
Prepared Statement of Hon. David J. Shulkin, M.D., Secretary,
U.S. Department of Veterans Affairs
Good afternoon, Chairman Isakson, Ranking Member Tester, and
Distinguished Members of the Senate Committee on Veterans' Affairs.
Thank you for the opportunity to testify today in support of the
President's 2018 Budget and 2019 Advance Appropriation (AA) Request and
to define my priorities to continue the dynamic transformation within
the Department of Veterans Affairs (VA). I am accompanied today by
Edward Murray, Acting Assistant Secretary for Management and Acting
Chief Financial Officer; Richard Chandler, Deputy Assistant Secretary,
IT Resource Management; Mark Yow, Chief Financial Officer for the
Veterans Health Administration; James Manker, Acting Principal Deputy
Under Secretary for Benefits in the Veterans Benefits Administration;
and Matthew Sullivan, Deputy Under Secretary for Finance and Planning
for the National Cemetery Administration. I also want to thank Congress
for providing the Department its full 2017 budget prior to the start of
the Fiscal Year--this is significant and has been extremely beneficial
to our ability to provide services and care to Veterans. The 2018
budget request fulfills the President's strong commitment to all of our
Nation's Veterans by providing the resources necessary for improving
the care and support our Veterans have earned through sacrifice and
service to our country.
fiscal year (fy) 2018 budget request
The President's 2018 budget requests $186.5 billion for VA--$82.1
billion in discretionary funding (including medical care collections),
of which $66.4 billion was previously provided as the 2018 AA for
Medical Care. The discretionary request is an increase of $4.3 billion,
or 5.5 percent, over 2017. It will improve patient access and
timeliness of medical care services for over 9 million enrolled
Veterans, while improving benefits delivery for our Veterans and their
beneficiaries. The President's 2018 budget also requests $104.3 billion
in mandatory funding, of which $103.9 billion was previously provided,
such as disability compensation and pensions, and for continuation of
the Veterans Choice Program (Choice Program).
For the 2019 AA, the budget requests $70.7 billion in discretionary
funding for Medical Care and $107.7 billion in 2019 mandatory advance
appropriations for Compensation and Pensions, Readjustment Benefits,
and Veterans Insurance and Indemnities benefits programs in the
Veterans Benefits Administration. The budget also requests $3.5 billion
in mandatory budget authority in 2019 for the Choice Program.
This budget request will ensure the Nation's Veterans receive high-
quality health care and timely access to benefits and services. I urge
Congress to support and fully fund our 2018 and 2019 AA budget
requests--these resources are critical to enabling the Department to
meet the increasing needs of our Veterans.
modernizing va
As you all know, I was part of the VA team for the last year and a
half prior to being confirmed as the Secretary of Veterans Affairs. 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 led to these problems. I know that the organization
has made significant progress in improving care and services to
Veterans. But I also know that VA needs more changes to the way we do
business for Veterans and the country as a whole, in order for all to
say, ``That is a different organization now.'' VA needs to continue to
fix numerous areas of the business, including access, claims and
appeals processing, and many of our core functions, to ensure that the
basics are done correctly. Beyond that, VA has to deliver to Veterans
revolutionary leaps in care, benefits, and services. Congress, along
with our VA employees, Veterans Service Organizations (VSO), and
private industry, will play a critical role in making those
revolutionary leaps a reality.
Focus on Execution
Above all else, VA needs to perform its core functions well. When
Veterans arrive at a VA facility for care, they must be treated with
respect, see a clean and modern facility, be seen by their provider on
time, and understand what the next steps for their care will be.
Veterans should be able to receive clear and accurate information about
their claims and understand where they are in the process. We must
ensure that this is every Veteran's experience every time they interact
with VA. Where we fall short, we will hold employees accountable,
ensure we are good stewards of the taxpayer dollar, and ask for
Congress's support for legislative fixes where needed.
Make Bold Change
We know it is paramount that we increase our focus and intensify
the efforts to improve how we execute our mission--Veterans should and
do expect that from us. We also recognize that incremental change is
not sufficient to achieve the additional improvements VA and Veterans
need and demand for restoring the trust of Veterans and the American
public.
As I have noted, VA is a unique national resource that is worth
saving, and I am committed to doing just that. Veterans have unique
needs, and the services VA provides to Veterans often cannot be found
in the private sector. The Veterans Health Administration (VHA)
provides support to Veterans through primary care, specialty care, peer
support, crisis lines, transportation, the Caregivers program,
homelessness services, vocational support, behavioral health
integration, medication support, and a VA-wide electronic medical
record system. These services and supports are unparalleled. We also
know that VA hospitals perform well on quality compared to non-VA
hospitals. In a study published in the Journal of American Medical
Association (JAMA) Internal Medicine in April, researchers compared
hospital-level quality data on 129 VA hospitals and 4,010 non-VA
hospitals obtained through the Centers for Medicare and Medicaid's
website. They found VA hospitals had better outcomes than non-VA
hospitals on six of nine patient safety indicators, and there were no
significant differences on the other three indicators. VA hospitals
also had better mortality and readmission rates than non-VA hospitals.
With the continued support of Congress, VA will supplement its services
through private-sector health care, but we realize it is not a
replacement for the services VA provides to Veterans.
We are already implementing bold changes in the agency. We are
working hard to ensure employees are held accountable to the highest of
standards and working with Congress to provide us with greater
authority and flexibility to do that. We are also working with Congress
on appeals reform and on a long-term solution for providing greater
community care options. I will discuss these efforts in greater detail
below.
five priorities
As I prepared for my confirmation hearing earlier this year, I
identified my top priorities to address as Secretary. These areas have
shaped the first several months of my tenure and provide focus for our
attention and resources, and the foundation for rebuilding trust with
our Veterans. We will also use the budgeting process to support our
strategy by shifting resources toward our ``foundational services''
that make VA unique while maintaining support to our strategic
priorities.
Priority 1: Greater Choice for Veterans
The Choice Program is a critical program that has increased access
to care for millions of Veterans. Coming into this new administration,
extending the Choice Program was one of my top priorities for quick
action, as VA anticipated that based on Veteran program participation,
there would be an estimated $1.1 billion in unobligated funds left on
the original expiration date of August 7, 2017. On April 19, 2017, the
President signed into law the Veterans Choice Program Improvement Act
(Public Law 115-26), allowing the Choice Program to continue until the
Veterans Choice Fund is exhausted. Without this legislation, VA would
have been unable to use funding specifically appropriated for the
Choice Program by Congress, so we commend Congress for passing this
legislation swiftly and in a bipartisan manner. This legislation also
provides VA and Congress more time to develop a long-term solution for
community care.
Since the start of the Choice Program, over 1.6 million Veterans
have received care through the program. In FY 2015, VA issued more than
380,000 authorizations to Veterans through the Choice Program. In FY
2016, VA issued more than 2,000,000 authorizations to Veterans to
receive care through the Choice Program, more than a fivefold increase
in the number of authorizations from 2015 to 2016.
Looking at early data for 2017, it is expected that Veterans will
benefit even more this year than last year from the Choice Program. In
the first quarter of FY 2017, we have seen a more than 30 percent
increase from the same period in FY 2016 in terms of the number of
Choice authorizations. In addition to increasing the number of Veterans
accessing care through the Choice Program, VA is working to increase
the number of community providers available through the program. In
April 2015, the Choice Program network included approximately 200,000
providers and facilities. As of March 2017, the Choice Program network
has grown to over 430,000 providers and facilities, a more than 150
percent increase during this time period.
As these numbers demonstrate, demand for community care is high. In
2018, VA plans to spend a total of $13.2 billion to support community
care for Veterans. Community care will be funded by a discretionary
appropriation of $9.4 billion for the Medical Community Care account
($254 million above the enacted advance appropriation), plus $2.9
billion in new mandatory budget authority for the Choice Program. This,
combined with an estimated $626 million in carryover balances in the
Veterans Choice Fund, provides a total of $13.2 billion in 2018 for
community care.
VA will continue to partner with Congress to develop a community
care program that addresses the challenges we face in achieving our
common goal of providing the best health care and benefits we can for
our Veterans. We have also worked with and received crucial input from
Veterans, community providers, VSOs, and other stakeholders in the
past, and we will continue doing so going forward. However, we do need
your help.
One such area is in modernizing and consolidating community care.
Veterans deserve better, and now is the time to get this right. We are
committed to moving care into the community where it makes sense for
the Veteran. The ultimate judge of our success will be our Veterans,
and our only measure of success will be our Veterans' satisfaction.
With your help, we can continue to improve Veterans' care in both VA
and the community.
Empower Veterans through Transparency of Information
We are also increasing transparency and empowering Veterans to make
more informed decisions about their health care through our new Access
and Quality Tool (available at www.accesstocare.va.gov). This Tool
allows Veterans to access the most transparent and easy to understand
wait-time and quality-care measures across the health care industry.
That means Veterans can quickly and easily compare access and quality
measures across VA facilities and make informed choices about where,
when, and how they receive their health care. Further, they will now be
able to compare the quality of VA medical centers to local private
sector hospitals. This Tool will take complex data and make it
transparent to Veterans. This new Tool will continue to improve as we
receive feedback from Veterans, employees, VSOs, Congress, and the
media.
Priority 2: Modernizing our System
Infrastructure Improvements and Streamlining
In 2018, VA will focus on fixing VA's infrastructure while we
transform our health care system to an integrated network to serve
Veterans. This budget requests $512.4 million in Major Construction
funding as well as $342.6 million in Minor Construction for priority
infrastructure projects. This funding supports projects including a new
outpatient clinic in Livermore, CA, as well as gravesite expansions in
Sacramento, CA; Bushnell, FL; Elwood, IL; Calverton, NY; Phoenix, AZ;
and Bridgeville, PA. VA is also requesting $953.8 million to fund more
than 2,000 medical leases in FY 2018, an increase of $141.9 million
over the FY 2018 AA, and $862 million for activation of new medical
facilities. In 2018, VA is seeking Congressional authorization of 27
major medical leases. The majority of these leases have been included
in previous budget requests, some dating back to the FY 2015 budget
submission. These major medical leases are vital to establish new
points of care, expand sites of care, replace expiring leases, and
expand VA's research capabilities.
The 2018 budget submission includes proposed legislative requests
that if enacted, would increase the Department's flexibility to meet
its capital needs. These proposals include: 1) increasing from $10
million to $20 million the dollar threshold for minor construction
projects; 2) modifying title 38 to eliminate statutory impediments to
acquiring joint facility projects with DOD and other Federal agencies;
and 3) expanding VA's enhanced use lease (EUL) authority to give VA
more opportunities to engage the private sector and local governments
to repurpose underutilized VA property.
The Department is also a key participant in the White House
Infrastructure Initiative to explore additional ways to modernize and
obtain needed upgrades to VA's real property portfolio to support our
continued delivery of quality care and services to our Nation's
Veterans. We are excited about the opportunity to transform the way we
approach our infrastructure.
Electronic Health Record Interoperability and IT
Modernization
The 2018 Budget continues VA's investment in technology to improve
the lives of Veterans. The planned IT investments prioritize the
development of replacements for specific mission critical legacy
systems, as well as operations and maintenance of all VA IT
infrastructures essential to deliver medical care and benefits to
Veterans. The request includes $358.5 million for new development to
replace four specific mission critical legacy systems, including the
Financial Management System, and establish an Integrated Project Team
to develop the requirements and acquisition strategy for a new
enterprise health information platform. It also invests $340 million
for information security to protect Veterans' information and improve
VA's information networks' resilience.
The 2018 budget submission includes a proposed legislative request
that if enacted, would increase the Departments ability to apply agile
program management to the dynamics of modern Information Technology
development requirements. To do this, the Department recommends
advancing the transfer threshold from $1 million to $3 million between
development project lines, which equates to less than 1 percent of the
Development account. Through the Certification process, Congress will
maintain visibility of proposed changes.
VA recognizes that a Veteran's complete health history is critical
to providing seamless, high-quality, integrated care, and benefits.
Interoperability is the foundation of this capability, by making
relevant clinical data available at the point of care and enabling
clinicians to provide Veterans with prompt, effective care. Today, VHA,
the Veterans Benefits Administration (VBA), and the Department of
Defense (DOD) share more medical information than any public or private
health care organization in the country. We have developed and
deployed, in close collaboration with DOD, the Joint Legacy Viewer
(JLV). JLV is available to all clinicians in every VA facility. It is a
web-based user interface that provides clinicians with an intuitive
display of DOD and VA health care data on a single screen. VA and DOD
clinicians can use JLV to access the health records of Veterans, Active
Duty, and Reserve Servicemembers from all VA, DOD, and any third party
community providers who participate in Health Information Exchanges
where a patient has received care. Multiple releases of Community Care
applications, including JLV-Community Viewer, Community Provider
Portal, and Virtru Pro Secure Email have enhanced care coordination
with Community Providers through multiple methods of exchanging health
records and multiple modes of communication improving the care the
Veteran receives and allowing Community Providers not in Health
Information Exchanges the ability to share medical documentation.
VA will complete the next iteration of the VistA Evolution Program,
VistA 4, in 2018. 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. VistA Evolution funds have enabled investments in systems and
infrastructure that support interoperability, networking and
infrastructure sustainment, continuation of legacy systems, and efforts
such as clinical terminology standardization. These investments are
critical to the maintenance and deployment of the existing and future
modernized VistA and essential to operational capability. That said our
current VistA system is in need of major modernization to keep pace
with the improvement in health information technology and
cybersecurity, and software development.
I promised a decision on our EHR system by July 1st, and I have
honored that commitment by announcing that, after much deliberation, VA
will adopt the same EHR system as DOD, now known as MHS Genesis, which
at its core consists of Cerner Millennium. VA's adoption of the same
EHR system as DOD will ultimately result in all patient data residing
in one common system and enable seamless care between the departments
without the manual and electronic exchange and reconciliation of data
between two separate systems. Still, VA has unique needs and many of
those are different from the DOD. For this reason, VA will not simply
be adopting the identical EHR that DOD uses, but we intend to be on a
similar Cerner platform. VA clinicians will be very involved in how
this process moves forward and in the implementation of the system.
Another critical system that will touch the delivery of all health
and benefits is our new financial management system, which is under
development. The 2018 budget continues modernizing our financial
management system by transforming the Department from numerous
stovepipe legacy systems to a proven, flexible, shared service business
transaction environment. The budget requests $83 million in Information
Technology funds and $61.6 million for business process re-engineering
to support Financial Management Business Transformation (FMBT) across
the Department.
Priority 3: Focus Resources More Efficiently
Strengthening of Foundational Services in VA
VA is committed to providing the best access to care for Veterans.
To deliver the full care spectrum as defined in VA's medical benefits
package, VA will focus on its foundational services--those areas in
which it can excel--and build community partnerships for complementary
services. VA developed the following guiding principles, centered on
improving the health, well-being, and experience of Veterans receiving
care from VA and in the community. These principles include:

Enabling VA to provide access to high-quality care for
Veterans, by balancing services provided by VA and the community given
changing demands for care and resource limitations;
Promoting operational efficiency and simplicity, while
supporting VA's clinical care, education, and research missions; and
Allowing facilities to meet the changing needs of Veterans
in a flexible way.

High-performing organizations cannot excel at every capability and
thus must make decisions about how best to invest its resources. VA
will therefore further define and grow its foundational services to
excel in the provision of clinical care to Veterans.
Investing in foundational services within the Department is not
limited to only health care. For over a decade, VA's National Cemetery
Administration (NCA) has achieved the highest customer satisfaction
rating of any organization--public or private--in the country. They
achieved this designation through the American Customer Satisfaction
Index six consecutive times. The President's 2018 Budget recognizes the
need to nurture and advance this unprecedented success with a request
for $306.2 million for NCA in 2018, an increase of $20 million (7
percent) over 2017. This request will support the 1,881 FTE needed to
meet NCA's increasing workload and expansion of services. In 2018, NCA
will inter approximately 133,600 Veterans and eligible family members,
care for over 3.7 million gravesites, and maintain 9,400 acres. NCA
will continue to memorialize Veterans by providing 366,000 headstones
and markers, distributing 702,000 Presidential Memorial Certificates
and expanding the Veterans Legacy program to communities across the
country. VA is committed to investing in NCA infrastructure,
particularly to keep existing national cemeteries open and to construct
new cemeteries consistent with burial policies approved by Congress. In
addition to NCA's funding, the 2018 request includes $255.9 million in
major construction funds for six gravesite expansion projects. When all
new cemeteries are opened, nearly 95 percent of the total Veteran
population--about 20 million Veterans--will have access to a burial
option in a Veterans' cemetery within 75 miles of their home.
VA/DOD/Federal Coordination
VA has proposed legislation to eliminate certain statutory
impediments to VA more effectively pursuing joint projects with other
Federal agencies, including DOD. Today, medical facilities that are not
specifically under the jurisdiction of the Secretary require specific
statutory authorization for optimal collaboration. I look forward to
working with Congress to: (1) enhance our ability to coordinate with
DOD and other Federal agencies; (2) improve the access, quality, and
cost effectiveness of direct health care provided to Veterans,
Servicemembers, and their beneficiaries; (3) permit joint capital asset
planning and capital investments to design, construct, and utilize
shared medical facilities; and (4) provide authority for VA to procure
the use of joint medical facilities for itself and other Federal
agencies like DOD, and to transfer funds between VA and other Federal
agencies for such initiatives.
Deliver on Accountability and Effective Management
Practices
Another critical area in which VA is serious about making
significant changes relates to employee accountability. The vast
majority of employees are dedicated to providing Veterans the care they
have earned and deserve. It is unfortunate that certain employees have
tarnished the reputation of VA and so many who have dedicated their
lives to serving our Nation's Veterans. We will not tolerate employees
who deviate from VA's I-CARE values and underlying responsibility to
provide the best level of care and services to them. We support
Congress' ongoing efforts to provide VA with the tools it needs to take
timely action against employees who perform poorly or engage in
misconduct. Where employees engage in inappropriate behavior, do not
perform the duties of their job, are engaged in illegal activities, or
otherwise do not meet the standards we expect of VA employees, we want
the ability to ensure they can be promptly removed. Certain laws hamper
our ability to optimally hold our employees accountable and remove
those individuals that run afoul of my intent for the Department to
function as a high-performing organization. We support legislation that
is consistent with the following principles:

Increase flexibility to remove, demote, or suspend VA
employees for poor performance or misconduct;
Provide authority to recoup bonuses of employees for poor
performance or misconduct;
Enable recovery of relocation expenses that occur through
fraud or malfeasance; and
Ensure that VA has the ability to retain high performers
by paying them a salary that is competitive with the private sector and
performance awards that are commensurate with other Federal agencies.

We thank the Senate for passing critical accountability
legislation, S. 1094,--all signs point to new accountability rules for
VA being the law of the land soon, but while that process continues, we
are also focused on updating internal hiring practices. VHA is the
largest health care system in the United States, and in an industry
where there is a national shortage of health care providers, VHA faces
competition with the commercial sector for scarce resources.
Historically, VA has followed hiring practices that have proven unduly
burdensome. Over the past year, VHA's business process improvement
efforts have resulted in a more efficient hiring process. We were able
to reduce the time it took to hire Medical Center Directors by 40
percent and obtained approval from the Office of Personnel Management
(OPM) for critical position pay authority for many of our senior health
care leaders. We recognize there is much work left to do. As we strive
to find internal solutions, we look forward to working together on
legislation to reform recruitment and compensation practices to stay
competitive with the private sector and other employers.
To ensure that VA's management practices are effective, I have
announced a major initiative to improve our ability to detect and
prevent fraud, waste, and abuse within VA. The initiative includes:

forming a fraud, waste, and abuse advisory committee
comprised of experts from the private sector and other government
organizations;
identifying cutting edge tools and technologies available
in the private sector; and
coordinating all fraud, waste, and abuse detection and
reporting activities through a single office.

With these improvements, VA has the potential to save millions of
taxpayer dollars and more effectively serve America's Veterans. I look
forward to updating you in the future regarding this initiative.
Priority 4: Improve Timeliness of Services
Access to Care and Wait Times
VA is committed to delivering timely and high quality health care
to our Nation's Veterans. Veterans now have same-day services for
primary care and mental health care at all VA medical centers across
our system. I am also committed to ensuring that any Veteran who
requires urgent care will receive timely care.
In March 2017, 96.82 percent of appointments, 5.15 million
appointments, were completed within 30 days of the clinically-indicated
or veteran's-preferred date, and as of April 15, 2017, VHA has reduced
and the Electronic Wait List from 56,271 entries to 22,383 entries, a
60.2 percent reduction between June 2014 and April 2017. The Electronic
Wait List reflects the total number of all patients for whom
appointments cannot be scheduled in 90 days or less.
In 2018, VA will expand Veteran access to medical care by
increasing medical and clinical staff, improving its facilities, and
expanding care provided in the community. The 2018 Budget requests a
total of $75.2 billion in funding for Veterans' medical care, which
includes the following:

$69.0 billion in discretionary budget authority ($2.65
billion above the 2018 AA enacted level of $66.4 billion and a $4.6
billion (7.1 percent) increase over the 2017 enacted level);
$2.9 billion in mandatory budget authority to continue the
Veterans Choice Program; and
$3.3 billion in medical care collections.

The 2018 request will support nearly 315,000 medical care staff, an
increase of over 7,000 above the 2017 level.
Through the Choice Program, VHA and its contractors created more
than 3.6 million authorizations for Veterans to receive care in the
private sector from February 1, 2016 through January 31, 2017. This
represents a 23 percent increase in authorizations when compared to the
period February 1, 2015 through January 31, 2016. When looking at
overall appointment data not specific to the Choice Program, the
March 15, 2017, pending appointment data set shows VA has increased the
number of overall pending appointments ``in house'' by nearly 1.8
million over the same data the prior year. According to the same data,
the number of appointments scheduled greater than 30 days from the
Veterans clinically indicated data or preferred date has decreased by
3.9 percent (19,645) since the beginning of FY 2017.
Accelerating Performance on Disability Claims
Since 2013, VA has made remarkable progress toward reducing the
backlog of disability compensation claims pending over 125 days and is
working to use more effectively the resources provided by Congress.
VBA's 2018 budget request of $2.8 billion allows VBA to maintain the
improvements made in claims processing over the past several years.
This budget supports the disability compensation benefits program for
4.6 million Veterans and 420,000 Survivors. VBA implemented new
professional standards for Veterans Service Representatives (VSR) on
March 1, 2017. In May 2016, VBA implemented the National Work Queue
(NWQ) process. This allows VBA to prioritize and quickly distribute
disability compensation claims according to processing capacity within
VBA's regional footprint, regardless of the Veteran's place of
residence. The NWQ process enables VA to more effectively balance the
workloads nationally, relative to the productive capacity at each
regional office. This means that Veterans who live in a location where
claims decisions take longer, VBA can appropriately adjust capacity to
match the changes in claims volume. In FY 2017, VBA added non-rating
related claims to the NWQ. VBA has completed nearly 1.7 million non-
rating claims from October 2016 through the end of April 2017. The
effort to address non-rating claims has resulted in a 269,000 claim
reduction in the dependency claims inventory since August 2015, from
359,000 to less than 90,000.
To continue improving disability compensation claim processing, VBA
is currently piloting an initiative called Decision Ready Claims (DRC).
The DRC initiative offers veterans and survivors faster claims
decisions in which VSOs and other accredited representatives assist
Veterans with ensuring all supporting medical evidence is included with
the claim at the time of submission. The DRC initiative empowers
Veterans by allowing them to receive medical examinations as early as
possible in the claims process. This initiative also enhances
partnerships with VSOs by improving access and capabilities to assist
with gathering all required evidence and information to accelerate
claims decisions. Submission of claims submitted through the DRC
process will result in claim decisions within 30 days of submission to
VA.
Decisions on Appeals
The current VA appeals process undoubtedly needs further
improvements for our Nation's Veterans. As of April 30, 2017, VA had
470,546 pending appeals. The average processing time for all appeals
resolved by VA in FY 2016 was approximately 3 years. For those appeals
that were decided by the Board of Veterans' Appeals (the Board) in FY
2016, on average, Veterans waited at least 6 years from filing their
Notice of Disagreement until the Board's decision was issued that year.
The 2018 request of $155.6 million for the Board continues the
funding level enacted for 2017, which was a 42 percent increase over
2016. In combination with carryover resources from 2017, the requested
funding will support a total of 1,050 FTE, an increase of 164 FTE above
the 2017 estimate of 886 FTE. This request maintains the increased
budgetary authority the Board received in 2017. In addition, VBA's
request of $185 million for appeals processing maintains its current
level of appeals FTE at 1,495. This funding level in tandem with
sweeping legislative reform initiates a long-term strategy aimed at
improving the timeliness of appeals for Veterans and is the best policy
option for taxpayers.
Without significant legislative reform to modernize the appeals
process, Veteran wait times and the cost to taxpayers will only
increase. Comprehensive legislative reform is necessary to replace the
current lengthy, complex, confusing VA appeals process with a new
process that makes sense for Veterans, their advocates, VA, and other
stakeholders. This reform is crucial to enable VA to provide the best
service to Veterans and is one of my top priorities.
VA worked collaboratively with VSOs and other stakeholders to
design this new process for Veterans who disagree with a VA decision.
The result of that work was a legislative proposal that was introduced
in the 114th Congress and has been reintroduced in the 115th Congress.
The proposed process: (1) establishes multiple options for Veterans
instead of the single option available today; (2) provides early
resolution of disagreements and improved notice as to which option
might be best; (3) eliminates the inefficient churning of appeals that
is inherent in the current process; (4) features quality feedback loops
to VBA; and (5) improves transparency by clearly defining VBA as the
claims agency and the Board as the appeals agency in VA. This clear
definition between VBA and the Board also provides workload
transparency for better workload/resource projections, and efficient
use of resources for long-term savings.
The new process, described in the legislation currently pending,
will provide a modernized process going forward. However, VA is also
committed to concurrently reducing the pending inventory of legacy
appeals. VA has worked collaboratively with stakeholders to identify
opt-ins that would make the new process available to Veterans who would
otherwise have an appeal in the legacy process. After assessing these
various options, and collaborating with our partners, we have
identified two opt-ins that we intend to implement to address the issue
of the legacy appeals inventory.
The legislation must be enacted now to fix this process. It has
wide stakeholder support and the longer we wait to enact this
legislative reform, the more appeals enter the current, broken system.
The status quo is not acceptable for our Nation's Veterans. The new
process 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.
Priority 5: Suicide Prevention--Eliminating Veteran Suicide
Every suicide is tragic, and regardless of the numbers or rates,
one Veteran suicide is too many. Suicide prevention is VA's highest
clinical priority, and we continue to spread the word throughout VA
that ``Suicide Prevention is Everyone's Business.'' The 2018 Budget
requests $8.4 billion for Veterans' mental health services, an increase
of 6 percent above the 2017 level. It also includes $186.1 million for
suicide prevention outreach. VA recognizes that Veterans are at an
increased risk for suicide and implemented a national suicide
prevention strategy to address this crisis. VA is bringing the best
minds in the public and private sectors together to determine the next
steps in implementing the Eliminating Veteran Suicide Initiative. VA's
suicide prevention program is based on a public health approach that is
ongoing, utilizing universal, selective, indicated strategies while
recognizing that suicide prevention requires ready access to high
quality mental health services, supplemented by programs that address
the risk for suicide directly. VA's strategy for suicide prevention
requires ready access to high quality mental health (and other health
care) services supplemented by programs designed to help individuals
and families engage in care and to address suicide prevention in high-
risk patients.
As part of VA's commitment to put forth resources, services, and
technology to reduce Veteran suicide, VA initiated the Recovery
Engagement and Coordination for Health Veterans Enhanced Treatment
(REACH VET). This new program was launched by VA in November 2016 and
was fully implemented in February 2017. REACH VET uses a new predictive
model in order to analyze existing data from Veterans' health records
to identify those who are at a statistically elevated risk for suicide,
hospitalization, illnesses, and other adverse outcomes. Not all
Veterans who are identified have experienced suicidal ideation or
behavior. However, REACH VET allows VA to provide support and pre-
emptive enhanced care in order to lessen the likelihood that the
challenges these Veterans face will become a crisis.
Other than Honorable Expansion
We know that 14 of the 20 Veterans who on average commit suicide
each day did not, for various reasons, receive care within VA. Our goal
is to more effectively promote and provide care and assistance to such
individuals to the maximum extent authorized by law. In that regard, VA
intends to expand access to emergent mental health care for former
Servicemembers, who separated from active duty with other than
honorable (OTH) administrative discharges. This initiative specifically
focuses on expanding access to former Servicemembers with OTH
administrative discharges who are in mental health distress and may be
at risk for suicide or other adverse behaviors. VA estimates there are
more than 500,000 former Servicemembers with OTH administrative
discharges. As part of this initiative, former Servicemembers with OTH
administrative discharges who present to VA seeking mental health care
in emergency circumstances for a condition the former Servicemember
asserts is related to military service would be eligible for evaluation
and treatment for their mental health condition. Such individuals may
access the system for emergency mental health services by visiting a VA
emergency room, outpatient clinic, Vet Center, or by calling the
Veterans Crisis Line. Services may include: medication management/
pharmacotherapy, lab work, case management, psycho-education, and
psychotherapy. We intend to carry this initiative out within our
existing resources because it is the right thing to do for Veterans.
closing
Thank you for the opportunity to appear before you today to address
our 2018 budget and 2019 Advance Appropriations budget requests and to
provide you with the priorities that I am taking to ensure VA is viewed
with pride from Veterans and beneficiaries for the services provided to
them. I ask for your steadfast support in funding our full FY 2018 and
FY 2019 AA budget requests and continued partnership in making bold
changes to improve our ability to serve Veterans. I look forward to
your questions.
______

Response to Prehearing Questions Submitted by Hon. Johnny Isakson to
Hon. David Shulkin, Secretary, U.S. Department of Veterans Affairs
appeals reform
Question 1. In June 2016, then Deputy Secretary Sloan Gibson sent a
letter regarding VA's proposed appeals reform legislation to the Senate
Committee on Veterans' Affairs, including several attachments. One
attachment contains this information:

Is the legislation enough to solve the current appeals problem
without new money?

. . . . The legislation is an effective fix for new appeals,
but alone is insufficient to resolve the current pending
inventory.
In execution, if VA received no new funding for legacy appeals,
VA must either keep the promise of the new legislation (125
day/365 day processing) and allow legacy appeals to languish OR
prioritize legacy appeals, some of which will have been pending
for years when the legislation takes effect, and delay action
on the new framework appeals--which will impact the Board [of
Veterans' Appeals] and also increase [the Veterans Benefits
Administration's] pending rating claim inventory and claims
backlog.
The answer is NO. The legislation alone frees up some existing
resources to work appeals, but these resources are insufficient
to clear the legacy inventory alone.
(Emphasis added.)

a. If the appeals reform legislation is enacted this calendar year,
what level of funding would VA need to ensure that legacy appeals will
not ``languish'' and by what date would VA need to have that funding
made available?
Response. In fiscal years (FY) 2015 and 2016, Congress provided
funding for additional staff that included a total of 300 full-time
equivalent (FTE) employees for appeals processing at the Veterans
Benefits Administration (VBA). In FY 2017, the Board of Veterans'
Appeals (Board) received funding for an additional 242 FTE. As the
result of hiring falling short of goals, the Board projects to have
carryover of $15,609,600 from FY 2017, which the Board intends to
utilize for personnel costs in FY 2018. By utilizing carryover, the
Board's FY 2018 annualized FTE level is estimated to be 1,050, which is
164 FTE higher than the FY 2017 current estimate. VA continues to
assess the current and future allocation of FTE to work appeals to
ensure that the pending legacy appeals inventory is addressed in a
timely and efficient manner. Whether VA will need additional resources
for appeals after enactment of appeals reform legislation is contingent
upon resource allocation decisions made by the Department of Veterans
Affairs and the Administration during the annual budget process and
cannot be predicted at this time.

b. What steps--other than potentially adding resources--is VA
taking to speed up processing of legacy appeals, such as information
technology improvements or making sure appeals staff work only on
appeals, and what impact are those initiatives expected to have on the
inventory of legacy appeals?
Response. VA is committed to reducing the pending inventory of
legacy appeals. In January 2017, VBA realigned its appeals policy and
oversight of its national appeals operations under a single office, the
Appeals Management Office (AMO). The realignment promotes increased
accountability of appeals performance and establishes a clear division
of labor between claims and appeals work, with dedicated appeals FTE.
Under this realignment, specific guidance has been disseminated
instructing field offices that appeals staff must maintain authorized
staffing levels and complete appeals production work exclusively. VBA's
appeals productivity through May 31, 2017, has increased by 32% over FY
2016 production during the same period. This realignment allows VBA to
focus on internal people, process and technology appeals initiatives,
and implementation of appeals reform legislation if enacted. Unlike
VBA, which adjudicates both claims and appeals, the Board only
adjudicates appeals. The Board monitors its personnel resources to
ensure they are focused on the Board's mission of holding hearings and
deciding appeals.
Additionally, we have worked with our congressional committees and
stakeholder partners to modify the design of the draft appeals reform
legislation to provide opportunities for Veterans who would otherwise
have an appeal in the legacy process to opt-in to the new process. The
availability of these opt-ins ensure that as many Veterans as possible
benefit from the streamlined features of the new process, while
simultaneously assisting with the elimination of the inventory of
legacy appeals.
The Board is also committed to modernizing appeals processing
technology to optimize efficiency to best serve Veterans and their
families and to ensure the seamless transfer of appeals between
jurisdictions by leveraging industry best practices and Human Centered
Design principles. The Board is fortunate to have Digital Service at VA
leading the technical approach to this effort. While modernized
technology is part of increasing efficiency in appeals processing,
comprehensive legislative reform is required to ensure Veterans receive
a timely decision on their appeal, which is why the opt-ins that allow
Veterans who would otherwise have a legacy appeal to enter the new
process offer a good potential opportunity to speed processing of the
pending legacy appeals inventory.

Question 2. In May 2017, the Congressional Budget Office provided a
cost estimate regarding H.R. 2288, the Veterans Appeals Improvement and
Modernization Act of 2017, which includes this information: ``VA also
expects that the efficiencies of the new system would allow the agency
to continue processing legacy appeals under the current system, very
gradually reducing the existing backlog, without the need for
additional employees. (Reducing the backlog in a more expedited manner
would require more employees and would have a substantial cost.)''

a. Please clarify whether VA intends, if the appeals reform
legislation is enacted, to ``very gradually'' reduce the inventory of
existing appeals or to address them in a ``more expedited manner.''
Response. If the appeals reform legislation is enacted, VA remains
committed to reducing the pending inventory of legacy appeals as
quickly and efficiently as possible. VA intends to resource the
modernized system to maintain timely processing in the new process and
then allocate all remaining appeals resources to address the inventory
of legacy appeals. VA also worked collaboratively with stakeholders to
identify opt-ins that will make the new process available to more
Veterans. The opt-in features of the legislation will assist VA with
more quickly and efficiently addressing the legacy appeals inventory.

b. In response to post-hearing questions in May 2016, VA indicated
that, if the appeals reform proposal is enacted without added
resources, ``at least 214,837 appeals will take longer than 9 years to
be resolved'' and ``some of these legacy appeals will take 28 years to
be resolved.'' Is this in line with what would be expected if VA ``very
gradually'' reduces the inventory of legacy appeals? If VA has more
recent modeling data on this scenario, please provide copies.
Response. Depending upon legislative reform and available
resources, VA intends to address the legacy appeals inventory as
quickly and efficiently as possible. Without significant legislative
reform to modernize the appeals process, VA projects that Veteran wait
times and the cost to taxpayers will continue to increase over time.
The goal is to eliminate the inventory of legacy appeals in a timely
manner following enactment of the appeals modernization legislation,
while also maintaining timely processing in the new process.
Prioritization, assessment of resource requirements in the annual
budget process, and the opt-in features of the new process will assist
VA in accomplishing that goal. However, due to the nature of the
complex, inefficient and outdated legacy process, VA projects that
there will be an inventory of legacy appeals for a substantial amount
of time, regardless of the amount of resources made available to legacy
appeals processing. VA continues to refine its forecast modeling, to
include based on annual budget levels.
medical care
Question 3. The Budget Justification shows an aggregate number of
full-time equivalent employees (FTE) in the Medical Support and
Compliance account for fiscal years 2016 through 2019. For each office
within the Medical Support and Compliance account, please provide the
total number of FTE for fiscal year 2016 and the estimate number of FTE
for fiscal years 2017 through 2019.
Response. See ``FTE by Program Office'' table.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

Question 4. In 2017 the Veterans Health Administration (VHA)
consolidated three Veterans Integrated Service Networks (VISN). Please
provide the number of FTE within each of those VISN's prior to
consolidation and the total number of FTE in the new consolidated VISN.
Response. See attached file

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

Question 5. The Budget Justification indicates that VHA created a
new office, the Medical Center Solutions (MCS) office. Please describe
in detail the duties of this office, the number of FTE associated with
this office, and the estimated budget request for MCS.
Response. Member Services-Medical Center Solutions (MCS) office
will provide for and support the development of comprehensive VA
Medical Call Center capability solutions with applicability across the
VHA enterprise. MCS, the first of its kind in VHA, will provide
leadership and management for the purposes of improving access to
clinical care and services by positively affecting the myriad of
complexities associated with VA Medical Center and VISN-wide call
centers. When activated effective 1QFY 2018, MCS will initially provide
primary care appointment scheduling and call center-based nurse triage
call center support for all (8) VISN 1 VA medical centers with the
intent of expanding services to remaining VA Health Networks. This will
result in system-wide, standardized improvements in access to clinical
care and services, improved first contact resolution and an improved
Veteran experience. The FY 2018 transition is being effected by a
planned transfer of existing resources and FTEE from VISN 1 to MS-MCS
that when combined with existing MS-MCS resources (1 FTEE and $2.691M)
will establish the needed capability to provide comprehensive call
centers services to VISN 1 while providing the basis for expanding
services to remaining VISNs. The consolidation of VISN1 call center
operations under MCS represents an organizational realignment and is
FTEE and cost neutral.

Question 6. The Veterans Access, Choice, and Accountability Act of
2014 gave VHA the authority to enter into provider agreements to
provide Veterans with care in the community. While the vast majority of
that care is provided through the Patient Centered Community Care (PC3)
contract, in 2016 VHA started using the provider agreement authority by
entering into local agreements at the VA medical centers (VAMC).
a. Please provide the total number of provider agreements VHA has
entered into broken out by VAMC.
Response. Please see spreadsheet that follows:

Count of Active Provider Agreements as of June 6, 2017
------------------------------------------------------------------------
Count of
Station Provider
Agreements
------------------------------------------------------------------------
(402Togus, ME 681
(405White River Junction, VT 361
(518Bedford, MA 60
(523VA Boston HCS, MA 183
(608Manchester, NH 158
(631VA Central Western Massachusetts HCS 168
(650Providence, RI 112
(689VA Connecticut HCS, CT 180
(528 A4Batavia, NY 1
(528 A8Albany, NY 21
(528Bath, NY 9
(528Canandaigua, NY 22
(528Syracuse, NY 107
(528Western New York, NY 60
(526Bronx, NY 6
(561New Jersey HCS, NJ 210
(620VA Hudson Valley HCS, NY 33
(630New York Harbor HCS, NY 10
(632Northport, NY 136
(460Wilmington, DE 192
(503Altoona, PA 258
(529Butler, PA 71
(542Coatesville, PA 139
(562Erie, PA 142
(595Lebanon, PA 104
(642Philadelphia, PA 67
(646Pittsburgh, PA 371
(693Wilkes-Barre, PA 145
(512Baltimore HCS, MD 139
(517Beckley, WV 79
(540Clarksburg, WV 70
(581Huntington, WV 73
(613Martinsburg, WV 83
(688Washington, DC 140
(558Durham, NC 177
(565Fayetteville, NC 60
(590Hampton, VA 65
(637Asheville, NC 108
(652Richmond, VA 222
(658Salem, VA 38
(659Salisbury, NC 95
(508Atlanta, GA 240
(509Augusta, GA 112
(521Birmingham, AL 129
(534Charleston, SC 235
(544Columbia, SC 188
(557Dublin, GA 174
(619Central Alabama Veterans HCS, AL 193
(679Tuscaloosa, AL 41
(516Bay Pines, FL 215
(546Miami, FL 71
(548West Palm Beach, FL 144
(573Gainesville, FL 401
(672San Juan, PR 160
(673Tampa, FL 201
(675Orlando, FL 72
(596Lexington, KY 45
(603Louisville, KY 40
(614Memphis, TN 104
(621Mountain Home, TN 160
(626Middle Tennessee HCS, TN 129
(506Ann Arbor, MI 145
(538Chillicothe, OH 74
(539Cincinnati, OH 126
(541Cleveland, OH 179
(552Dayton, OH 142
(757Columbus, OH 105
(515Battle Creek, MI 441
(553Detroit, MI 28
(583Indianapolis, IN 330
(610 A4Ft. Wayne, IN 156
(610Northern Indiana HCS, IN 1
(655Saginaw, MI 279
(537Jesse Brown VAMC (Chicago), IL 69
(550Danville, IL 57
(556Captain James A Lovell FHCC 1
(578Hines, IL 310
(585Iron Mountain, MI 288
(607Madison, WI 55
(676Tomah, WI 39
(695Milwaukee, WI 76
(589 A4Columbia, MO 250
(589Eastern KS HCS, KS 192
(589Kansas City, MO 101
(589Wichita, KS 43
(657 A4Poplar Bluff, MO 140
(657 A5Marion, IL 58
(657St. Louis, MO 168
(667Topeka, KS 1
(502Alexandria, LA 39
(520Gulf Coast HCS, MS 85
(564Fayetteville, AR 123
(580Houston, TX 203
(586Jackson, MS 93
(598Little Rock, AR 54
(623Muskogee, OK 120
(629New Orleans, LA 113
(635Oklahoma City, OK 162
(667Shreveport, LA 202
(504Amarillo, TX 24
(549Dallas, TX 15
(671San Antonio, TX 45
(674Temple, TX 29
(740VA Texas Valley Coastal Bend HCS 4
(756El Paso, TX 21
(501New Mexico HCS 96
(644Phoenix, AZ 195
(649Northern Arizona HCS 144
(678Southern Arizona HCS 73
(436Montana HCS 316
(442Cheyenne, WY 53
(554Denver, CO 184
(575Grand Junction, CO 92
(660Salt Lake City, UT 576
(666Sheridan, WY 90
(463Anchorage, AK 21
(531Boise, ID 51
(648Portland, OR 257
(653Roseburg, OR 102
(663VA Puget Sound, WA 399
(668Spokane, WA 105
(687Walla Walla, WA 64
(692White City, OR 67
(459Honolulu, HI 175
(570Fresno, CA 65
(612N. California, CA 164
(640Palo Alto, CA 376
(654Reno, NV 103
(662San Francisco, CA 110
(593Las Vegas, NV 129
(600Long Beach, CA 24
(605Loma Linda, CA 401
(664San Diego, CA 415
(691Greater Los Angeles HCS 144
(437Fargo, ND 334
(438Sioux Falls, SD 175
(568Black Hills HCS, SD 62
(618Minneapolis, MN 176
(636 A6Des Moines, IA 119
(636Iowa City, IA 314
(636Nebraska-W Iowa, NE 316
(656St. Cloud, MN 132
---------------
Total 20,215
------------------------------------------------------------------------
Source: VCP Provider Agreement Sharepoint
Only displaying agreements in an active status

b. What processes are in place to ensure the provider agreements do
not duplicate care available in the PC3 contract?
Response. Currently Provider Agreements may only be used under the
Veterans Choice Program (VCP) to provide medical care to our Nations
Veterans. Provider Agreements are used to provide care and services
that are not available through the contractor network. There are
instances, when Provider Agreements are used to provide services that
may be available through the PC3 Contract for Choice, those
circumstance occur when the contractor has returned referrals they are
unable to schedule. In addition, recently the Office of Community Care
has allowed facilities to utilize Provider Agreements when a facility
has identified a certain percentage of returns from the contractor for
specific categories of care and the facility has identified they have
active provider agreements for those categories of care and adequate
staffing to schedule the Veterans identified, this new process ensures
Veterans are receiving the medical care needed in a more timely manner.

Question 7. The Budget Justification identifies the creation of a
VHA transitional care program office as one of its 2017-2019 goals.
Please describe in detail the duties of this office, the number of FTE
associated with this office, the estimated budget request for this
office, and a projected timeline for its creation.
Response. VHA had the goal of realigning the Federal Recovery
Coordination Program (FRCP) under Care Management and Social Work (CM/
SW), and Transition and Care Management Services, to integrate care
coordination services under one leadership. At this time, a new VHA
transitional care program office is not under development. VA continues
to provide assistance to transitioning Servicemembers and Veterans (SM/
V) and their families through Transition and Care Management Services
and the FRCP. These programs work in coordination to assist wounded SM/
V to navigate the recovery care continuum.
Transition and Care Management (TCM) Services leads two national
programs:

The VA Liaison Program consists of 43 VA Liaisons for
Health Care at 21 Military Treatment Facilities (MTF) to facilitate
ongoing VA health care for ill and injured Servicemembers transitioning
from Department of Defense (DOD) to VA. Since the inception of the
program, VA Liaisons for Healthcare have coordinated over 84,000
transitions. In fiscal year (FY) 2016, VA Liaisons for Healthcare
coordinated 11,130 transitions; provided 22,906 professional
consultations and 2,412 briefings; and ensured Servicemembers
transitioning from DOD to VA received timely access to care by ensuring
100 percent of Servicemembers who wanted VA healthcare had an initial
VA appointment scheduled at the VA healthcare facility of their choice;
89 percent had appointments scheduled prior to leaving the MTF.
The TCM Program consists of a TCM team at each VA Medical
Center to provide comprehensive and specialized transition assistance
and ongoing case management services to Post-9/11 Veterans as they
reintegrate into their home communities and into VA health care. VA has
approximately 400 TCM case managers nationwide providing case
management services to almost 30,000 Veterans. In FY 2016, 90 percent
of these Veterans were contacted regarding their individualized care
management plan, resulting in over 347,000 contacts.

The FRCP was developed as a joint program by VA and DOD, in
January 2008, to provide care coordination services to SM/V who were
severely wounded, ill, or injured after September 11, 2001. The program
utilizes Federal Recovery Coordinators (FRCs), either social workers or
nurses funded by VA Central Office, to monitor and coordinate clinical
services, including facilitating and coordinating medical appointments;
and non-clinical services, such as providing assistance in obtaining
financial benefits or special accommodations needed by program
enrollees and their families.

Question 8. The Comprehensive Addiction and Recovery Act of 2016
requires naloxone prescriptions and related education to be provided
free of charge to Veterans.

a. The Budget Justification does not clearly state whether or not
this reduction in co-pays is reflected in the estimated medical care
collections. Please provide a detailed analysis of the expected
reduction in estimated medical care collections for 2017 and 2018,
including any impact caused by the reduction in copays for naloxone
prescriptions.
Response. The Naloxone prescriptions and related education analysis
was performed after the FY 2017 and FY 2018 medical care collections
budgets were formulated. As such, there was no reduction explicitly
incorporated into the FY 2017 & FY 2018 budgets as a result of the
elimination of copayments for Naloxone prescriptions or outpatient
visits pertaining solely to the education. Further, the number of
Naloxone kits dispensed to Veterans has remained stable over the past
three years with the percent of billable prescriptions assumed stable
through FY 2026. The resulting impact of the copayment on the Pharmacy
portion is only 0.03% of the FY 2017 First Party Rx estimated
collections. These impacts will be explicitly incorporated into the
baseline collections forecasting when using FY 2017 data for future
medical care collections budgets.

b. The Budget Justification states that over 50,000 naloxone kits
have been dispensed as of January 2017 and that naloxone distribution
will continue to expand. However, the 2017 current estimate for
naloxone distribution is listed as $0. For 2018 and 2019, the Budget
Justification includes $25 million a year for naloxone distribution.
Please provide additional details on the expected naloxone kit
distribution for 2017 and provide details for the $25 million
requested, to include expected number of Veterans receiving overdose
education and the estimated number of naloxone kits to be distributed.
Response. See table below.

----------------------------------------------------------------------------------------------------------------
Distribution/
Fiscal Year Naloxone Kits Drug Cost Dispensing Total Cost
Distributed Cost
----------------------------------------------------------------------------------------------------------------
FY-16.......................................... 48,462 $8,622,450 $169,925 $8,792,375
FY-17*......................................... 62,037 $7,310,048 $225,194 $7,535,242
FY-18**........................................ 68,241 $9,174,283 $259,316 $9,433,599
FY-19**........................................ 75,065 $10,091,710 $296,507 $10,388,217
----------------------------------------------------------------------------------------------------------------
* FY-17 estimated based on YTD distribution
** FY-18/19 assume 10% increase in usage and current contract price stabilization

Question 9. Please provide a sample of the preconception care
counseling template found in the Computerized Patient Record System
described in Volume II, VHA-191.
Response. Attached is the sample of the preconception care
counseling template found in the Computerized Patient Record System
described in Volume II, VHA-191 requested below.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

Question 10. What percentage of women veteran gender-specific care
is provided at VA facilities and what percentage is provided through
non-VA care? Please break out each category included under gender-
specific health care for fiscal year 2017 as well as projections for
fiscal year 2018.
Response. See table below.

Question 11. Please provide an updated list of VA medical
facilities that have a gynecologist on staff and whether they are full-
time, part-time, or contracted.
Response. See attached.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

Question 12. Current law allows VA to cover care for newborns of
eligible women Veterans for the first seven days after birth. Please
provide a breakout of the average number of days VA has covered care
for newborns and the total cost of this care in fiscal year 2017 and
projections for fiscal year 2018.
Response. To reiterate this data only relates to the newborn care,
it does not include any expenditure for services provided to the
mother. On average, VA authorizations in FY 2017 covered 3 days for
inpatient newborn care. Please refer to the table below.

----------------------------------------------------------------------------------------------------------------
Average Length of
Neonates Stay Obligations $m
----------------------------------------------------------------------------------------------------------------
Actual FY 2016............................................. 2,705 3.44 $19.82
Annualized FY 2017......................................... 2,264 3.10 $16.67
Estimated FY 2018.......................................... 2,176 3.02 $16.04
----------------------------------------------------------------------------------------------------------------

construction
Question 13. The Budget Justification requests authorization for 27
leases in 2018. Twenty-one of these leases were submitted in prior
years but were not authorized. Six are new lease requests. Three leases
in Pontiac, Michigan; Birmingham, Alabama; and Mission Bay, California
were requested in previous budgets but are not included in the 2018
request. Please provide additional details for removing these three
leases from the Budget Justification.
Response. In preparing the FY 2018 Budget Request, lease
requirements previously authorized but not yet in the solicitation
process were reviewed and validated to assure optimum use of
alternatives. The following three leases pending authorization were
removed from the request after this review.
1. Outpatient Clinic Lease Birmingham, AL--Expanding
community care and additional efficiencies realized at the
local medical center mitigate the need for this 89,900 Net
Useable Square Feet (NUSF) lease.
2. Research Lease Mission Bay, CA--Use of available space on
the medical center campus and private partnering solutions are
being pursued to meet this research space need.
3. Outpatient Clinic Lease Pontiac, MI--This replacement/
expansion lease is being re-scoped which will reduce the size
of the lease under the Major Lease threshold.

Question 14. Please provide a detailed breakout of the judgment
fund payments for 2017 and the estimated judgment fund payments for
2018.
Response. On January 25, 2017, VA reimbursed the Department of the
Treasury for Contract Disputes Act Claims in the total amount of $9
million as follows:

(1) $4,019,844.67--For a claim against the Menlo Park, CA, Seismic
Corrections project.
(2) $4,050,306.54--For two claims against the Denver, CO, New
Medical Facility project.

In FY 2018, VA will use the Judgment Fund to reimburse the
Department of the Treasury for Contract Disputes Act Claims in the
amount of $10 million for claims related to the Menlo Park, CA, project
and the Orlando, FL, New Medical Facility project.

Question 15. For the major construction staff request, please
provide the total number of FTE for fiscal year 2016 and the estimated
number of FTE for fiscal years 2017 and 2018.
Response. For the major construction staff request, the total
number of FTE in FY 2016 was 115. The estimated number for FY 2017 is
139 FTE, and for FY 2018 the estimate is 197 FTE. Note the
appropriation language was changed in FY 2017 to allow major
construction staff funding to include support for contracting officers
working directly on major construction projects to ensure alignment
with the program they are supporting.

Question 16. Please provide a list of the non-recurring maintenance
projects included in the $1.9 billion request for 2018. Specifically
break out the projects included in the ``second bite'' $1.3 billion
portion of the request for 2018 advance appropriations.
Response. Attached is the list of ``first bite'' and ``second
bite'' NRM projects for FY 2018. NRM projects that have had design
funded in years prior to SCIP 2018, and only needing construction
funding to complete, are mostly funded in the ``first bite.'' Design of
newly scored SCIP projects is funded in the ``second bite,'' as well as
some projects prior to FY 2018.

Planned 2018 Non-Recurring Maintenance Projects
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total Planned
Estimated FY 2018 "First "Second
VISN Location ST Project Type Project Name - Short Description Cost Obs Bite" Bite"
($000) ($000) ($000) ($000)
--------------------------------------------------------------------------------------------------------------------------------------------------------
1Newington CT BT Emergency Generator #7.......... 678 600 600
1Newington CT SCIP 2018 Replace the Boilers and Systems 9,700 970 970
for Newington VAMC, Phase 1.
1Newington CT SCIP 2018 Demolish Buildings 6,7, & 8..... 2,561 256 256
1West Haven CT BT Yard Drain Tunnel Refurbishment. 685 500 500
1West Haven CT BT West Haven SPS Chiller.......... 825 750 750
1West Haven CT CSI Fisher House Infrastructure and 3,500 3,200 3,200
Prep.
1West Haven CT SCIP 2016 Renovate Mental Health Inpatient 6,571 5,863 5,863
Unit.
1West Haven CT SCIP 2015 Replace and Upgrade Electrical 2,300 2,070 2,070
Supervisory Control and Data
Acquisition System.
1West Haven CT SCIP 2018 Refurbish Building Exterior For 6,300 630 630
Building 1.
1Bedford MA SCIP 2018 Replace Water Mains............. 3,300 330 330
1Boston (JP) MA SCIP 2016 IT infrastructure upgrades JP... 2,200 2,000 2,000
1Boston (JP) MA SCIP 2018 Install Site Security Systems 7,150 715 715
Campus Wide Jamaica Plain.
1Boston (WR) MA SCIP 2013 Building 5 Fire and Safety 2,400 2,200 2,200
Improvements.
1Boston (WR) MA SCIP 2012 EM Infrastructure Backup Water 1,650 1,500 1,500
supply.
1Boston (WR) MA BT FCA Window Replacement.......... 766 701 701
1Boston (WR) MA SCIP 2013 Site Security Installation WR... 7,600 7,000 7,000
1Boston (WR) MA SCIP 2015 FCA HVAC Upgrade PH3............ 5,060 5,400 5,400
1Boston (WR) MA SCIP 2015 FCA Electrical Upgrade WR, PH 3. 4,840 4,356 4,356
1Boston (WR) MA SCIP 2018 IT infrastructure upgrades WR... 3,300 330 330
1Boston (WR) MA SCIP 2018 Construct Central Chiller Plant 9,850 985 985
West Roxbury.
1Brockton MA SCIP 2013 Install Sprinkler System........ 2,000 1,800 1,800
1Brockton MA SCIP 2013 FCA Replace Damaged Doors and 2,200 2,050 2,050
Upgrade Card Access System
Phase 2.
1Brockton MA SCIP 2016 Improve Site Parking Roadway and 3,410 3,100 3,100
Drainage Systems.
1Brockton MA SCIP 2018 Central Chiller Plant Phase 1... 9,900 990 990
1Northampton MA Pending OOC Water System Improvement & 4,981 4,000 4,000
Legionella Prevention Phase 1.
1Northampton MA Pending OOC Replace HVAC System Building 4 3,800 3,500 3,500
Upper.
1Northampton MA Pending OOC Upgrade Building 5 Electrical 1,600 1,500 1,500
and HVAC Systems.
1Northampton MA Pending OOC Exterior Site Improvements...... 4,396 4,000 4,000
1Northampton MA BT Exterior Wayfinding............. 720 650 650
1Northampton MA BT Occupational Therapy wing 40 28 28
Asbestos Abatement.
1Northampton MA BT Ward 4 Lower Upgrades........... 778 670 670
1Northampton MA Pending OOC Electrical Distribution System 5,050 4,600 4,600
Upgrade Phase I.
1Togus ME CSI Provide Infrastructure to Fisher 1,351 1,351 1,351
House.
1Togus ME SCIP 2016 Install Legionella Mitigation 4,235 3,876 3,876
Infrastructure.
1Togus ME SCIP 2018 Relocate Primary Care Clinic to 5,500 550 550
B205.
1Togus ME SCIP 2018 Correct Stormwater System 3,710 371 371
Deficiencies throughout Campus.
1Togus ME SCIP 2018 Replace Damaged Roofs and 4,845 485 485
Masonry.
1Togus ME SCIP 2018 Repair Damaged Windows and 4,405 441 441
Entranceway Doors.
1Manchester NH BT Replace OR Suite Doors.......... 360 300 300
1Manchester NH SCIP 2016 Replace Aboveground Storage 1,164 1,063 1,063
Tanks.
1Manchester NH BT Building #2 demolishing......... 495 425 425
1Manchester NH SCIP 2018 Renovate Building 1, 3rd Floor 2,914 291 291
for Dental.
1Providence RI SCIP 2015 Renovate Wing 2C & 3C for 9,210 8,560 8,560
Dentistry.
1Providence RI SCIP 2013 Renovate Space for Relocation of 2,237 2,013 2,013
Inpatient Pharmacy.
1Providence RI SCIP 2014 FCA Pavement Repairs............ 2,600 2,507 2,507
1Providence RI BT Repair and Upgrade 5B and 6B 670 600 600
Isolation Suite HVAC System.
1Providence RI SCIP 2016 Install Legionella Remediation 3,500 3,250 3,250
System.
1White River Junction VT Pending OOC Renovate Clinical Lab........... 6,200 6,026 6,026
1White River Junction VT SCIP 2017 Underground Utility Replacement. 7,700 7,000 7,000
1White River Junction VT BT Acute Mental Health PH2......... 990 900 900
1White River Junction VT SCIP 2015 Repair and Upgrade Building 1 5,227 4,758 4,758
Heating, Ventilation, and Air
Conditioning (Phase II).
2East Orange N BT Upgrade men's bathrooms& 889 800 800
Drinking Fountains.
2East Orange NJ Pending OOC Improve outpatient Environment 2,854 2,594 2,594
(4D).
2East Orange NJ BT Storage Building................ 440 400 400
2East Orange NJ BT Legionella Plumbing Field Study. 140 140 140
2Lyons NJ BT Tuckpoint & Waterproofing B 1, 350 315 315
2, 53.
2Lyons NJ BT Repair & Repave Roadways........ 540 500 500
2Lyons NJ BT Demolish Bldg 18................ 440 400 400
2Lyons NJ BT Replace Porch Roofs & Woodwork 577 525 525
Bldg 10, 11.
2Lyons NJ BT Repair Brick Facade--B-135...... 550 500 500
2Lyons NJ BT Repair Sidewalks Phase II....... 450 450 450
2Lyons NJ BT Replace Steps & Railings........ 550 500 500
2Lyons NJ CSI Digital Radiography Room (K113 500 500 500
LY).
2Lyons NJ BT Upgrade Generator & Transfer 605 550 550
Switches.
2Albany NY BT Structural Repairs at Chapel 116 101 101
Windows.
2Albany NY BT Roof Improvements & Misc Work... 669 669 669
2Albany NY SCIP 2017 Radiology Master Plan........... 3,740 3,400 3,400
2Albany NY SCIP 2015 Renovate 6B for Dialysis........ 7,262 6,631 6,631
2Albany NY Pending OOC Renovate for CLC phase 4........ 5,741 473 473
2Batavia NY SCIP 2016 Replace Fire Alarm System....... 3,150 2,700 2,700
2Batavia NY SCIP 2016 Replace Roofs Batavia........... 2,950 2,700 2,700
2Batavia NY SCIP 2018 Improve Potable Water 2,300 2,070 2,070
Distribution Systems Batavia,
Bldgs #1 & 5.
2Bath NY BT Upgrade 104 Sprinklers and Hot 935 850 850
Water.
2Bath NY SCIP 2017 Replace Roof/Renovate Wood 1,225 1,125 1,125
Molding, B76.
2Bath NY SCIP 2017 FCA Renovate Main Kitchen, B24.. 1,375 1,250 1,250
2Bath NY OOC Renovate CLC 3.................. 5,200 4,750 4,750
2Bath NY BT Improve Accessibility & Install 20 20 20
2nd Floor Handicap Accessible
Bathroom, B-32.
2Bath NY SCIP 2018 B76 Renovations................. 3,000 300 300
2Bronx NY Pending OOC Combined Heat & Power Plant 18,000 18,000 18,000
Construction.
2Bronx NY Pending OOC Renovate CLC for Polytrauma Ph 3 4,380 3,900 3,900
2Bronx NY SCIP 2016 Modernize ER.................... 4,194 3,724 3,724
2Bronx NY OOC Renovate CLC Recreation & Dining 3,850 3,500 3,500
Area.
2Bronx NY SCIP 2017 Renovate ICU.................... 4,900 4,500 4,500
2Bronx NY OOC Correct Safety Deficiencies at 2,750 2,500 2,500
Loading Dock.
2Bronx NY OOC Replace Air Handling Units, 5,400 5,100 5,100
Phase 4.
2Bronx NY SCIP 2013 Replace Air Handler Units, Phase 3,150 2,500 2,500
3 (for GG, 2B, 2C, 2G).
2Bronx NY SCIP 2014 Renovate for New Learning Center 5,335 4,850 4,850
2Bronx NY OOC Replace Existing Boilers #1 & 2. 4,300 4,000 4,000
2Bronx NY SCIP 2016 Replace/Install Parking Lot/ 2,950 2,600 2,600
Street Lights Ph 2.
2Bronx NY BT Install 20 KW Roof-Mounted Wind 594 500 500
Turbine System.
2Brooklyn NY SCIP 2015 Install Secondary Main Water 1,540 1,400 1,400
Supply Line.
2Brooklyn NY SCIP 2017 Renovate Outpatient Pharmacy(SA) 1,040 950 950
2Brooklyn NY SCIP 2017 Upgrade Elevators............... 3,000 3,000 3,000
2Brooklyn NY SCIP 2017 Bldg 2 Replace Pressure Relief 1,200 1,080 1,080
Valve and Condensate Pumps.
2Brooklyn NY SCIP 2015 Upgrade Life Safety/Critical 7,260 7,260 7,260
Branch Electrical Distribution.
2Brooklyn NY BT Replace Air & Vacuum Compressor. 935 850 850
2Brooklyn NY BT Laundry Plant Storm Disposal.... 805 750 750
2Brooklyn NY Pending OOC Renovate C3 and D3 Ward(SA)..... 6,545 5,950 5,950
2Brooklyn NY OOC Laundry Mechanical Room Upgrade 2,100 1,910 1,910
(SA).
2Buffalo NY SCIP 2016 Replace High Pressure Water 1,600 2 2
Risers, Bldg #1.
2Buffalo NY SCIP 2017 Fuel Oil Tanks Replacement...... 1,095 975 975
2Buffalo NY Pending OOC Improve Potable Water Systems... 2,420 2,200 2,200
2Buffalo NY Pending OOC Upgrade HVAC SPS................ 1,320 1,200 1,200
2Buffalo NY BT Sub-Basement Safety Improvements 275 250 250
2Buffalo NY SCIP 2018 Renovate 9th Floor B Wing....... 4,650 465 465
2Canandaigua NY BT Upgrade HVAC B3................. 250 200 200
2Canandaigua NY BT Heating Upgrades for B7 and B8.. 475 400 400
2Canandaigua NY BT Design and Install Backflow 950 800 800
prevention on campus.
2Canandaigua NY BT Provide Electrical Upgrades..... 800 800 800
2Canandaigua NY SCIP 2017 Replace Roofs Stationwide....... 1,350 1,350 1,350
2Canandaigua NY BT Fire Department Upgrades........ 860 750 750
2Canandaigua NY BT Renovations to Support Swing 50 50 50
Space Development.
2Canandaigua NY BT Relocate Grounds and 595 500 500
Transportation.
2Canandaigua NY OOC Renovate 6A for Member Services. 6,500 6,000 6,000
2Canandaigua NY SCIP 2018 Replace Primary Electrical 2,500 250 250
Distribution System.
2Castle Point NY SCIP 2016 Renovate STP Replace Trinkling 1,480 1,200 1,200
Filter.
2Castle Point NY SCIP 2018 Upgrade Central Air Conditioning 4,400 440 440
Plant Chilled Water Units and
Distribution Main.
2Montrose NY SCIP 2014 Install Elevator Building 29.... 1,800 1,500 1,500
2Montrose NY SCIP 2013 Replace aging steam distribution 3,795 3,450 3,450
equipment for Buildings 3. 4 &
12.
2Montrose NY SCIP 2016 Correct Deficiencies with SPS 1,285 1,090 1,090
Area in Building 7 FDR.
2Montrose NY SCIP 2018 Install new Temperature, pH, and 2,465 247 247
Flow measuring devices on
Domestic Water Systems at FDR.
2New York NY Pre-SCIP Admitting Area/ ER Expansion 3,850 3,500 3,500
Phase 2.
2New York NY SCIP 2017 Replace Chiller Phase II........ 3,800 3,430 3,430
2New York NY SCIP 2015 Renovate Research Area/ Animal 5,500 4,090 4,090
Lab.
2New York NY SCIP 2017 Correct Accessibilities Ph I.... 5,375 3,400 3,400
2New York NY SCIP 2018 Correct Accessibility 5,375 538 538
Deficiencies PH1.
2Northport NY SCIP 2015 Replace Primary Electrical 9,971 9,063 9,063
Distribution Phase 1.
2Northport NY OOC Upgrade Sewage Treatment Plant, 2,860 1,230 1,230
Phase 1.
2Northport NY SCIP 2015 Renovate Roads Project 4........ 4,695 4,268 4,268
2St. Albans NY SCIP 2013 Laundry Heat Recovery SA........ 1,975 1,800 1,800
2Syracuse NY BT Demolish Abandoned Piping in Sub 295 265 265
Basement.
2Syracuse NY OOC Upgrade Chiller Plant Switchgear 2,525 2,300 2,300
2Syracuse NY SCIP 2015 Laboratory Renovations.......... 3,510 3,150 3,150
4Wilmington DE SCIP 2017 Replace AHU's Serving Nuclear 1,100 1,000 1,000
Medicine and the Lab.
4Wilmington DE SCIP 2017 Correct ICU Heat and Facility- 2,200 2,000 2,000
Wide Humidification.
4Wilmington DE SCIP 2017 Renovate Building 13............ 3,850 3,500 3,500
4Wilmington DE Pending OOC Renovate the Auditorium......... 1,100 1,000 1,000
4Wilmington DE Pending OOC Renovate 2 East................. 2,200 2,000 2,000
4Wilmington DE SCIP 2017 Provide Chiller Plant Redundancy 2,200 2,000 2,000
4Wilmington DE SCIP 2016 Convert the Special Procedures 4,400 4,000 4,000
Room to an Operatory.
4Wilmington DE Pending OOC Evaluate and Replace Roofs 2,200 2,000 2,000
Throughout the Facility.
4Wilmington DE SCIP 2014 Study and Correct Domestic Water 5,540 4,200 4,200
Storage.
4Wilmington DE SCIP 2014 Renovate the First Floor of 6,600 6,000 6,000
Building 1 for Primary Care.
4Wilmington DE SCIP 2017 Assess and Replace Steam and 3,300 3,000 3,000
Condensate Distribution Piping.
4Altoona PA BT Make Fire Safety Improvements... 356 324 324
4Altoona PA BT Correct Air Conditioning 160 146 146
Deficiencies in Biomedical Shop
& Mailroom.
4Altoona PA SCIP 2017 Replace Keying System For 1,745 1,587 1,587
Outbuildings.
4Altoona PA BT Provide For Green Environmental 500 455 455
Management (GEM), Phase 1.
4Altoona PA BT Facility Chlorination System.... 300 270 270
4Altoona PA BT Provide Security Upgrades, Phase 605 550 550
2.
4Altoona PA BT Replace Space Signage........... 622 566 566
4Altoona PA BT Provide Electronic Signage...... 398 362 362
4Altoona PA BT Paint Walls..................... 242 220 220
4Altoona PA SCIP 2017 Correct Retro-commissioning 3,722 3,384 3,384
Discrepancies Phase 2.
4Butler PA SCIP 2015 Renovate Building 6............. 3,045 1,750 1,750
4Coatesville PA Pending OOC Renovate Building 58............ 8,800 8,000 8,000
4Coatesville PA BT Update Campus Water Lines....... 490 190 190
4Coatesville PA SCIP 2018 Correct Electrical Deficiencies 2,225 2,000 2,000
(PH2).
4Coatesville PA BT Remove Fuel storage tanks....... 470 400 400
4Coatesville PA Pending OOC Hospice Oxygen System........... 1,100 900 900
4Coatesville PA BT FCA Repairs Bldg 14............. 485 425 425
4Coatesville PA BT Tree Management & Sidewalks Oval 495 450 450
1.
4Coatesville PA Pending OOC SPS Satellite Storage Rooms..... 1,100 900 900
4Coatesville PA SCIP 2015 Replace Steam & Condensate 3,000 2,700 2,700
Mains--Oval 2 & Outlying
Branches.
4Coatesville PA SCIP 2017 Upgrade HVAC System B/57........ 2,200 1,690 1,690
4Coatesville PA BT Correct FCA Deficiencies 350 300 300
Building 10.
4Coatesville PA BT Roof Fall Protection Systems 600 500 500
Evaluation & Upgrades.
4Coatesville PA SCIP 2017 Exterior Signage & Wayfinding 1,870 1,750 1,750
Campus Wide.
4Coatesville PA SCIP 2018 Renovate Building 58--A Floor... 4,950 495 495
4Coatesville PA SCIP 2018 Correct Electrical Deficiencies-- 2,225 2,002 2,002
Phase 2.
4Erie PA SCIP 2016 Renovate Exterior Building-- 2,200 2,000 2,000
Masonry, Windows, Sunshades.
4Erie PA Pending OOC Replace Roofs................... 1,815 1,650 1,650
4Erie PA SCIP 2015 New Central Chiller Plant....... 9,680 8,800 8,800
4Erie PA SCIP 2013 Renovate Fourth Floor (Design).. 4,950 4,500 4,500
4Erie PA SCIP 2015 Correct Retro-Commissioning 1,100 100 100
Project Findings.
4Lebanon PA SCIP 2015 Renovate 1-4C for Multi-purpose 2,200 2,200 2,200
Area.
4Lebanon PA OOC Replace Electrical Substation... 4,500 4,000 4,000
4Lebanon PA Pending OOC Correct Physical Security Issues 3,300 3,000 3,000
4Lebanon PA OOC Renovate Food Service Kitchen... 3,830 3,500 3,500
4Lebanon PA SCIP 2015 Renovate Primary Care/Specialty 1,950 1,750 1,750
Clinic Building 17.
4Lebanon PA SCIP 2017 Replace Chillers................ 3,850 3,500 3,500
4Lebanon PA SCIP 2017 Renovate Bldg. 22............... 5,000 4,500 4,500
4Lebanon PA SCIP 2015 Renovate 1-4C for Patient 2,200 1,900 1,900
Activity Area.
4Lebanon PA SCIP 2015 Renovate for MOVE! program...... 3,300 3,000 3,000
4Lebanon PA SCIP 2018 Correct Physical Security Issues 3,300 2,970 2,970
Phase 1.
4Lebanon PA SCIP 2018 Correct Facade Issues Phase 3... 3,300 330 330
4Lebanon PA SCIP 2018 Retro-Commissioning Corrections. 3,300 330 330
4Philadelphia PA SCIP 2017 Modernize Dental Exam Rooms..... 1,884 1,713 1,713
4Philadelphia PA BT Relocate On-Call Rooms.......... 550 500 500
4Philadelphia PA Pre-SCIP Correct Building Facade 8,000 7,800 7,800
Deficiencies.
4Philadelphia PA SCIP 2017 Architectural Improvements for 2,973 2,543 2,543
Wards 5 and 6.
4Philadelphia PA BT Upgrade Toilets 1st Floor....... 225 200 200
4Philadelphia PA CSI Upgrade CLC Unit C Ph 2......... 4,400 4,000 4,000
4Philadelphia PA SCIP 2017 Correct FCA for Lightning 1,100 737 737
Protection.
4Philadelphia PA SCIP 2017 Renovate Building 1 7th Floor 3,190 2,900 2,900
for Mental Health.
4Philadelphia PA SCIP 2017 Address EmergencyPower0 4,600 4,200 4,200
Deficiencies in Building 1.
4Philadelphia PA CSI Women's Imaging Center.......... 2,200 2,000 2,000
4Philadelphia PA BT Install Security Fencing at 278 216 216
Parking Garage Bldg 28.
4Philadelphia PA SCIP 2016 Renovate Specialty Clinics...... 3,500 3,300 3,300
4Philadelphia PA OOC Upgrade Patient Environment NHCU 1,700 1,200 1,200
4Philadelphia PA CSI Replace Catheterization Lab..... 1,100 1,000 1,000
4Philadelphia PA SCIP 2017 Upgrade Halls and Wall Phase 1.. 2,200 2,000 2,000
4Philadelphia PA BT Radiology Rooms................. 563 500 500
4Pittsburgh PA SCIP 2018 Renovate Building One-10 East 5,250 525 525
for Architectural, Mechanical
and Electrical Deficiencies.
4Pittsburgh PA SCIP 2018 Replace Elevators in Building 51 3,420 342 342
and Building 50 at Heinz
Division.
4Pittsburgh PA SCIP 2018 Replace Air Handling Units 9,600 960 960
serving Operating Rooms (AC12 &
AC13).
4Pittsburgh (UD) PA SCIP 2015 Install Wayfinding Signage at UD 5,500 5,000 5,000
and HZ Campuses.
4Pittsburgh (UD) PA SCIP 2017 Replace Domestic Water Branch 22,000 20,000 20,000
Piping at UD and HZ.
4Wilkes-Barre PA OOC Replace Exterior Windows........ 4,800 4,400 4,400
4Wilkes-Barre PA SCIP 2015 Improve Wayfinding and Signage.. 1,650 1,500 1,500
4Wilkes-Barre PA SCIP 2015 Renovate 2 West Rehab........... 5,600 5,000 5,000
4Wilkes-Barre PA SCIP 2017 Correct FCA Electrical 4,400 4,000 4,000
Deficiencies.
4Wilkes-Barre PA SCIP 2015 Construct New Chiller Plant..... 6,000 5,000 5,000
4Wilkes-Barre PA SCIP 2013 Renovate 8 East for Nursing 3,800 3,455 3,455
Administration.
4Wilkes-Barre PA Pending OOC Building 1 HVAC, Phase 2........ 4,950 4,500 4,500
4Wilkes-Barre PA OOC Improve Landscaping............. 1,000 900 900
4Wilkes-Barre PA SCIP 2017 Install Fence and Gates......... 2,200 180 180
4Wilkes-Barre PA SCIP 2017 Renovate 2 North- Radiology..... 3,300 300 300
5Washington DC SCIP 2018 Correct FCA Infrastructure 4,295 430 430
Deficiencies and Functional
Deficiencies in Research B4 ,
Phase IV.
5Washington DC SCIP 2018 Replace Walk-In Refrigerators 2,765 277 277
and Freezers in Patient
Kitchen, Morgue, Pharmacy, Lab
and Research.
5Washington DC SCIP 2018 Replace and Upgrade Room Air 1,962 196 196
Distribution Terminal Devices
and Controls to Correct FCA
deficiency.
5Washington DC SCIP 2018 Renovate MICU 4B for Patient 9,617 962 962
Privacy and Correction of FCA
Deficiencies.
5Washington DC SCIP 2018 Correct Seismic, Structural, and 2,745 275 275
Facility Condition Deficiencies
in Building 1.
5Washington DC SCIP 2016 Correct NFPA 70 (NEC) Code 3,028 2,750 2,750
Deficiencies in all Secondary
Distribution Panels and
Separate Branch Circuits for
Critical, Life Safety and
Equipment Branches.
5Washington DC SCIP 2014 Renovate Research Labs, Phase 3. 2,691 2,427 2,427
5Washington DC SCIP 2016 Replace and Upgrade Outside 3,700 3,400 3,400
Distribution for Site Storm and
Sanitary Sewer System.
5Washington DC SCIP 2016 Upgrade Sprinkler System for 2,462 2,262 2,262
Building #6.
5Washington DC SCIP 2016 Upgrade Chiller Plant and 8,800 8,000 8,000
Cooling Tower.
5Baltimore MD BT Upgrade and Repair CLC Heating 450 450 450
Boilers.
5Baltimore MD OOC Upgrade Emergency Switchgear and 200 1,800 1,800
Distribution.
5Baltimore MD BT Replacement of Exterior 715 650 650
Breezeway Precast Concrete
Paver Sidewalk System.
5Baltimore MD SCIP 2013 Convert Semi-Private Beds to 8,800 8,000 8,000
Private 3A.
5Baltimore MD BT Upgrade SPD Closet HVAC......... 770 700 700
5Baltimore MD BT Loch Raven Drainage Corrections. 770 700 700
5Baltimore MD SCIP 2017 Upgrade and Renovate OR Suite... 6,710 6,100 6,100
5Baltimore MD SCIP 2016 Convert 6A Semi-Private Mental 8,290 7,461 7,461
Health Beds to Private.
5Baltimore MD SCIP 2018 Upgrade Building Air Handler 5,170 517 517
Units and Improve Heating,
Ventilating, and Air
Conditioning Systems.
5Baltimore MD SCIP 2018 Convert 3B Semi Private Beds to 7,040 704 704
Private.
5Perry Point MD BT Expand Fire House for EMS....... 330 300 300
5Perry Point MD SCIP 2016 Upgrade Fire Alarm System Campus 7,416 6,674 6,674
Wide--Phase 1--Patient
Buildings.
5Perry Point MD BT Emergency Steam Condensate 550 500 500
System Repairs.
5Perry Point MD Pending OOC Improvements to Bldg 361 Urgent 5,060 4,600 4,600
Care Clinic (UCC).
5Perry Point MD BT PP Enhanced Dining.............. 660 600 600
5Perry Point MD SCIP 2014 Convert Bldg 364B for 2,640 2,400 2,400
Residential Rehabilitation
Treatment Program.
5Perry Point MD BT Waterproof Tunnel to Bldg 364... 880 800 800
5Perry Point MD SCIP 2016 Replace Boiler No. 2 at Perry 1,484 1,336 1,336
Point.
5Perry Point MD SCIP 2016 Upgrade Medical Gas Systems..... 1,912 1,721 1,721
5Perry Point MD SCIP 2018 Replace Main Transformers and 1,276 128 128
Switchgear at Perry Point
Substation.
5Perry Point MD SCIP 2018 Renovate Building 15H for Mental 4,040 404 404
Health Homeless Staff and
Voluntary Service.
5Perry Point MD SCIP 2018 Replace Chilled Water along 4,796 480 480
Avenue D to Correct FCA
Deficiency.
5Perry Point MD SCIP 2018 Upgrade HVAC at Bldg 4H to 2,751 275 275
Correct FCA Deficiency.
5Beckley WV SCIP 2018 Upgrade Boiler Plant System..... 3,850 385 385
5Beckley WV SCIP 2018 Correct High Voltage 4,840 484 484
Deficiencies.
5Beckley WV SCIP 2018 Corrections to Medical Gas 1,600 160 160
System.
5Beckley WV SCIP 2018 Correct Domestic Water Supply 3,025 303 303
System.
5Clarksburg WV OOC Modernize Specialty Clinics..... 6,380 5,844 5,844
5Clarksburg WV OOC Construct Replacement Chiller 7,976 7,251 7,251
Plant.
5Clarksburg WV SCIP 2018 Replace Deficient Domestic Water 2,200 220 220
Riser Building 1.
5Huntington WV SCIP 2018 Upgrade and Correct FCA 6,278 628 628
Deficiencies for Campus
Building Management System.
5Huntington WV SCIP 2018 Repair and Upgrade Buildings 23 7,069 707 707
and 23R to Correct FCA
Deficiencies.
5Huntington WV SCIP 2018 Improve Facility Safety and 2,700 270 270
Security.
5Huntington WV SCIP 2015 Construct Secondary Access Road. 2,905 2,600 2,600
5Huntington WV SCIP 2016 Correct Boiler Plant Steam 3,005 2,705 2,705
Deficiencies.
5Huntington WV SCIP 2016 Replace Mechanical Systems Bldg 4,235 3,850 3,850
4.
5Huntington WV SCIP 2015 Replace Air Handling Units Bldgs 2,109 1,900 1,900
1&1S.
5Huntington WV BT Improve Signage and Wayfinding.. 999 850 850
5Huntington WV CSI Construct RRTP Building......... 4,840 4,400 4,400
5Huntington WV SCIP 2015 Replace Windows Bldg 1S......... 1,500 1,500 1,500
5Martinsburg WV SCIP 2018 Relocate Electrical Feeder for 2,785 279 279
Physical Security Compliance.
5Martinsburg WV SCIP 2018 Repair Steam Piping from 1,534 153 153
Buildings 217, 318 & 328 to
Boiler Plant.
5Martinsburg WV OOC Renovate Building 305 for Fiscal 1,540 1,400 1,400
5Martinsburg WV BT Construct Internet Cafe Healing 710 600 600
Garden.
5Martinsburg WV BT Renovate 217 for Veterans' Music 890 800 800
Room.
5Martinsburg WV OOC Renovate Building 317, Post 2,075 1,900 1,900
Theater.
6Durham NC Pending OOC Correct High Priority FCA 3,850 3,500 3,500
Deficiencies.
6Durham NC Pending OOC Install Security Fence.......... 1,100 1,050 1,050
6Durham NC BT Renovate Utility Space in 545 500 500
Basement.
6Durham NC BT Renovate Access Improvement 570 570 570
Spaces.
6Durham NC Pending OOC Expand PACU..................... 2,870 2,600 2,600
6Durham NC BT Correct Life Safety Deficiencies 395 350 350
6Durham NC Pending OOC Pharmacy Processing Renovation.. 1,925 1,925 1,925
6Durham NC BT Install Lightning and Fall 700 700 700
Protection.
6Durham NC BT Renovate OR Locker Rooms........ 715 650 650
6Durham NC Pending OOC Replace Roofs Phase II.......... 2,300 2,150 2,150
6Fayetteville NC SCIP 2018 Renovate Intensive Care Unit.... 5,028 4,528 4,528
6Fayetteville NC SCIP 2017 Renovation of 1A corridor and 790 700 700
offices.
6Fayetteville NC SCIP 2017 Renovate Nursing Area 1A........ 1,114 1,000 1,000
6Fayetteville NC SCIP 2014 Replace AHUs in A-wing Basement. 2,500 2,250 2,250
6Fayetteville NC SCIP 2014 Replace Windows Bldg 1.......... 2,400 2,160 2,160
6Fayetteville NC SCIP 2013 Renovate Lab, Radiology and 3,520 3,200 3,200
Pharmacy High Traffic Areas.
6Salisbury NC SCIP 2018 Renovate Building 2 for Medical 6,002 5,402 5,402
Surgical Modernization.
6Salisbury NC SCIP 2014 Install New Steam Control Valves 1,665 1,498 1,498
at Existing Convectors
Buildings 2, 3, and 4.
6Salisbury NC SCIP 2014 Replace Chilled Water Lines 2,080 1,872 1,872
Building 3.
6Salisbury NC SCIP 2016 Replace Campus Fire Alarm System 4,285 3,900 3,900
6Salisbury NC SCIP 2013 Construct Water Tower........... 3,250 2,925 2,925
6Salisbury NC SCIP 2018 Renovate Building 2 for Medical 6,002 5,452 5,452
Surgical Modernization.
6Salisbury NC BT Resurface Station Roadways and 992 992 992
Repair Sidewalks.
6Salisbury NC BT Road Access Modifications at 300 300 300
Building 3.
6Salisbury NC SCIP 2016 Correct Information Technology 3,500 3,100 3,100
FCA Deficiencies.
6Hampton VA BT Access Control Prime Clinics.... 165 150 150
6Hampton VA SCIP 2013 Implement Master Plan Design and 8,900 8,091 8,091
Building Systems Upgrade,
Building 110.
6Hampton VA SCIP 2016 Improve Data Distribution/ 1,650 1,500 1,500
Security/Infrastructure.
6Hampton VA OOC Replace Natural Gas Line and 1,730 1,655 1,655
Initial ESPC Pay Down.
6Hampton VA CSI Construct New MRI Facility...... 900 819 819
6Hampton VA BT Renovate Prime Clinics for PACT 153 140 140
Alignment.
6Richmond VA SCIP 2018 Upgrade Pharmacy to USP 800..... 1,045 105 105
6Richmond VA BT Pharmacy Giant Omni-Cell........ 15 15 15
6Richmond VA BT Parking Access Improvement...... 550 500 500
6Richmond VA SCIP 2016 Renovate for Operating Rooms.... 8,725 7,900 7,900
6Richmond VA BT Secure 3D with PACS............. 75 75 75
6Richmond VA BT Radiology Mobile MRI Awning..... 150 150 150
6Richmond VA BT Roof Replacement................ 750 750 750
6Richmond VA OOC Replace Air Handlers SCI........ 2,725 2,450 2,450
6Richmond VA BT Canteen Renovations............. 550 500 500
6Richmond VA BT Remodel Admin Space............. 996 905 905
6Richmond VA BT Remodel Support Spaces.......... 945 900 900
6Richmond VA BT Fisher House Exterior Painting.. 15 15 15
6Richmond VA SCIP 2014 Improve Patient Privacy 4B...... 3,700 3,370 3,370
6Richmond VA OOC Renovate Spinal Cord Injury Unit 5,720 5,200 5,200
for Privacy.
6Richmond VA Pending OOC Replace HVAC Systems 2 and 5.... 1,980 180 180
6Richmond VA Pending OOC SPS/OR Vertical Transportation.. 1,650 150 150
6Salem VA SCIP 2016 Replace Roofs and Tuckpoint..... 6,000 5,480 5,480
6Salem VA BT Renovate Basement Building 8.... 750 675 675
6Salem VA BT Construct Simulation Center 938 900 900
Building 4.
6Salem VA BT Replace Finishes Various 550 550 550
Buildings.
7Birmingham AL SCIP 2018 Correct Critical Mechanical and 5,500 550 550
Plumbing Deficiencies by
Replacing Aging and
Deteriorating Steam
Distribution Systems.
7Birmingham AL SCIP 2014 Install New Interior Finishes-- 3,850 3,500 3,500
Blind Rehabilitation Center.
7Birmingham AL SCIP 2016 Replace Information Technology 2,200 1,980 1,980
Cabling Infrastructure.
7Birmingham AL SCIP 2016 Replace/Upgrade Pressure Piping 6,600 5,940 5,940
and Hot Water Distribution
System.
7Birmingham AL SCIP 2016 Replace Air Handling Units-- 4,400 3,960 3,960
Phase IV.
7Birmingham AL BT Upgrade Negative Pressure Rooms. 830 750 750
7Montgomery AL BT Renovate Building 90 Therapeutic 330 300 300
Pool for Fitness Center.
7Montgomery AL BT Replace Air Handling Equipment 825 750 750
and add Generator, Bldg. 1.
7Montgomery AL BT Upgrade Restrooms with Water 820 734 734
Conservation Measures, Phase 2.
7Montgomery AL SCIP 2018 Renovate Inpatient Medicine Unit 9,290 929 929
for privacy--Building 1, floor
4..
7Tuscaloosa AL SCIP 2018 Masonry Restoration............. 5,960 596 596
7Tuscaloosa AL BT Improve Building 12 (Warehouse). 239 206 206
7Tuscaloosa AL SCIP 2016 Replace HVAC Systems............ 2,807 2,359 2,359
7Tuscaloosa AL SCIP 2017 Improve in Building 3........... 2,580 862 862
7Tuscaloosa AL BT Improve Courtyard Building 1.... 283 265 265
7Tuscaloosa AL BT Install Legionella Precautions.. 858 780 780
7Tuscaloosa AL SCIP 2016 Electrical Upgrades............. 1,664 1,498 1,498
7Tuscaloosa AL OOC A/E Legionella Survey/Assessment 6,700 6,200 6,200
Design Phase II Tuscaloosa.
7Tuskegee AL BT Improve Facility Condition 985 895 895
Assessment Findings-Plumbing
Upgrades.
7Tuskegee AL SCIP 2018 Repair the Roof on Buildings 2,204 220 220
#3,#3A,#4A,#65,#83,#88,#97,#120
and #129.
7Tuskegee AL SCIP 2018 Repair FCA Electrical 1,795 180 180
Deficiencies in Buildings
#5,#12,#14.
7Tuskegee AL SCIP 2018 Repair Electrical FCA 2,260 226 226
Deficiencies in Buildings #65
and #68.
7Tuskegee AL SCIP 2018 Replace Refrigeration Equipment 1,426 143 143
for Building #120 and #97.
7Atlanta GA SCIP 2018 Correct Infrastructure, Patient 9,930 993 993
Safety, and FCA Deficiencies in
Mechanical, Electrical, and
Architectural in Research and
the Medical Center.
7Atlanta GA SCIP 2018 Replace Campus Fire Alarm System 2,370 237 237
7Atlanta GA BT Bariatric Bedroom............... 350 290 290
7Atlanta GA OOC Correct Emergency Care 7,145 6,255 6,255
Deficiencies.
7Atlanta GA BT Correct Piping Deficiencies, 810 736 736
Phase II.
7Atlanta GA SCIP 2016 Renovate and Expand Oncology 3,350 3,015 3,015
Medical Specialty Services.
7Atlanta GA SCIP 2016 Renovate and Expand Medical/ 6,576 5,918 5,918
Surgical Inpatient Services on
6th Floor Building 1C Nursing
Tower.
7Atlanta GA OOC Upgrade Elevators Building 1A & 3,700 3,350 3,350
1B.
7Augusta GA OOC Renovate and Upgrade Operating 9,995 9,086 9,086
Rooms, Phase 1.
7Augusta GA SCIP 2016 Replace Emergency Generator 2,814 2,558 2,558
Systems Uptown.
7Dublin GA SCIP 2014 Implement Retro Commissioning 1,815 1,650 1,650
Recommendations.
7Dublin GA SCIP 2016 Correct Information Technology 1,814 1,656 1,656
Infrastructure Deficiencies.
7Dublin GA SCIP 2016 Install Emergency Power 3,780 3,500 3,500
Generator.
7Dublin GA SCIP 2016 Renovate 26A for Swing Space 2,354 2,150 2,150
Functions.
7Charleston SC SCIP 2018 Replace E&F Buildings and 9,887 989 989
Building Frame Seismic.
7Charleston SC SCIP 2018 Fire alarm Ph 2 /life safety 9,977 998 998
improvements removal fire
dampers, quick response head
replacement, dry system
replacement.
7Charleston SC SCIP 2018 Expand/Replace Direct Digital 5,486 549 549
Control.
7Charleston SC SCIP 2018 Address Potential Legionella 9,991 999 999
Issues (Phase II).
7Charleston SC SCIP 2018 Correct Structural Seismic 9,901 990 990
Deficiencies to the Medical
Center (Building 1).
7Charleston SC SCIP 2018 Renovate electrical/telephone 9,890 989 989
closet upgrades (separation of
ENG and IT).
7Charleston SC SCIP 2018 Update Mechanical Systems....... 9,842 984 984
7Charleston SC SCIP 2016 Renovate Canteen Kitchen........ 1,000 900 900
7Charleston SC SCIP 2016 Construct Patient Surgical 2,500 2,250 2,250
Elevator.
7Charleston SC SCIP 2017 Correct/Repair External 6,380 5,800 5,800
Architectural Barriers and
Structures.
7Charleston SC SCIP 2016 Renovation of Common and Support 5,000 4,500 4,500
Areas in Building 1.
7Charleston SC SCIP 2016 Overhaul/Replace Elevators...... 2,500 2,250 2,250
7Charleston SC SCIP 2017 Remove ACM throughout VAMC...... 1,128 1,000 1,000
7Charleston SC SCIP 2015 Correct Security Deficiencies... 3,195 2,700 2,700
7Columbia SC SCIP 2018 Replace Hot Water Piping........ 2,182 218 218
7Columbia SC SCIP 2016 Upgrade Elevator Systems........ 1,685 1,450 1,450
7Columbia SC BT Implement Lab Energy 660 600 600
Conservation Measures.
8Bay Pines FL SCIP 2014 Replace Air Conditioning System 1,764 1,210 1,210
B-102 PH I (Multi-Phase).
8Bay Pines FL SCIP 2014 Replace Roof Building 102....... 1,221 1,221 1,221
8Bay Pines FL SCIP 2012 Renovate Patient Wards B100, 3C 8,262 7,511 7,511
& 4A.
8Bay Pines FL SCIP 2017 Resolve SPS Temp, Humidity, Air 3,513 3,193 3,193
Change and Air Flow
Deficiencies.
8Bay Pines FL SCIP 2018 Replace Domestic Water Mains.... 3,839 384 384
8Gainesville FL OOC Install Parking Garage Fall 2,210 714 714
Protection.
8Gainesville FL OOC Renovate Ambulatory Care Area... 6,300 5,670 5,670
8Gainesville FL SCIP 2018 Replace Air Handler Unit No. 3.. 9,950 995 995
8Gainesville FL SCIP 2018 Replace Air Handler Unit No. 2.. 9,900 990 990
8Lake City FL SCIP 2018 Renovate Common Area Restrooms.. 2,750 275 275
8Lake City FL SCIP 2018 Replace Windows and Weather 9,900 990 990
Protection.
8Lake City FL SCIP 2018 Expand Electrical Distribution.. 9,900 990 990
8Lake City FL SCIP 2018 Replace Site Water Distribution. 7,000 700 700
8Miami FL SCIP 2018 Replace pneumatics with direct 9,079 5,530 5,530
digital control.
8Miami FL BT Renovate locker and rest rooms 901 901 901
for staff.
8Miami FL SCIP 2017 Replace coolers and 2,020 1,087 1,087
refrigerators.
8Miami FL SCIP 2018 Replace Duct work and piping and 8,346 7,199 7,199
conduct duct cleaning building
1.
8Miami FL SCIP 2017 Renovate Ambulatory surgery..... 1,418 882 882
8Miami FL SCIP 2017 Renovate inpatient Mental Health 6,104 5,535 5,535
4th Floor A & B.
8Miami FL BT Renovate Room B1023............. 32 32 32
8Miami FL BT Update spinal cord injury 352 317 317
outdoor rehabilitation area.
8Orlando FL BT Add Variable Air Volume and 864 786 786
Environmental Controls at Viera
OPC.
8Orlando FL BT Correct Access and Stormwater 925 836 836
Deficiencies--Viera.
8Orlando FL SCIP 2017 Renovate Building 500 for 4,400 4,000 4,000
Administration Space.
8Orlando FL SCIP 2014 Renovate Building 500 for 3,962 3,660 3,660
Veterans Benefit Administration
Space.
8Tampa FL SCIP 2017 Upgrade Facility Security....... 4,600 4,000 4,000
8Tampa FL SCIP 2017 Replace and Consolidate Domestic 6,112 5,557 5,557
Water Distribution, Bldg 1.
8Tampa FL BT Contractor Area Renovation...... 45 31 31
8Tampa FL SCIP 2018 Replace Air Handler Units 12, 8,600 860 860
20, 65 and 66, Building 1.
8Tampa FL SCIP 2018 Replace Chilled Water System for 9,100 910 910
Building #1.
8West Palm Beach FL BT Replace Air Cooled Chillers in 669 669 669
Operating Rooms.
8West Palm Beach FL SCIP 2017 Provide Return Ducts and 1,090 990 990
Controllers on Air Handler
Units (AHU).
8San Juan PR SCIP 2012 Provide New Environmental 3,610 3,310 3,310
Integrated Waste Center.
8San Juan PR BT Replace Air Handling Units at 946 880 880
Various Sites.
8San Juan PR SCIP 2017 Upgrade Perimeter Fence Upgrade. 2,300 1,414 1,414
8San Juan PR BT Repair Paver System and Add 507 461 461
Canopy at Administrative
Building.
8San Juan PR BT Replace Reheat System........... 890 800 800
8San Juan PR BT Replace Exhaust Fans............ 739 688 688
8San Juan PR CSI Site Prep for New Linear 2,209 2,008 2,008
Accelerator.
8San Juan PR BT Install Non Structural 955 875 875
Components and Equipment
Seismic Correction and Remove
Asbestos at Basement Area.
8San Juan PR SCIP 2018 Correct Nonstructural Components 3,800 380 380
at OPA.
9Lexington--Leestown KY SCIP 2018 Renovate B29, 2nd Flr, for 7,400 6,730 6,730
Women's Health, C&P and Primary
Cary.
9Lexington--Leestown KY BT Chiller Plant Improvements...... 310 310 310
9Lexington--Leestown KY SCIP 2016 Renovate Building 28 for 9,474 8,641 8,641
Specialty Care.
9Lexington--Leestown KY BT Construct Additional Parking B28 561 510 510
9Lexington (CD) KY BT Replace Boiler Controls and 437 378 378
Burners.
9Lexington (CD) KY BT Repair Pkg Garage Deck.......... 880 800 800
9Lexington (CD) KY SCIP 2013 Upgrade Physical Access Control 7,124 4,577 4,577
System (PACS) and Site Security.
9Lexington (CD) KY BT Activate OR for CT Surgery...... 550 500 500
9Lexington (CD) KY BT Renovate Chemo Infusion Ante- 446 401 401
Room.
9Louisville KY BT Install Closed Circuit Security 500 500 500
at Louisville Community Based
Outpatient Clinics.
9Louisville KY BT Upgrade Motors Project.......... 78 78 78
9Louisville KY BT Renovate Area for Emergency 374 340 340
Department Fast Track.
9Louisville KY BT Renovate Building 3 for PRRC.... 494 450 450
9Louisville KY SCIP 2016 Replace AHUs, Ph 5.............. 2,500 2,250 2,250
9Louisville KY SCIP 2016 Replace Fire Alarm System....... 5,500 5,000 5,000
9Louisville KY BT Replace TIP Units in 23 IT 354 354 354
Closets.
9Louisville KY OOC OR Anesthesia Supply Head 1,328 1,195 1,195
Replacement Rooms 1--6.
9Louisville KY BT Replace Steam Traps............. 90 90 90
9Louisville KY BT Upgrade 6 South Reheats......... 440 400 400
9Memphis TN SCIP 2018 Correct Plumbing Piping and 9,185 919 919
Replace Fixtures.
9Memphis TN SCIP 2018 Renovate Clinical Lab........... 7,409 741 741
9Memphis TN BT Renovate Surgical Service....... 619 619 619
9Memphis TN BT Install Equipment Pad for 30 30 30
Voluntary Service Carts.
9Memphis TN Pending OOC Renovate Building 1 for Primary 9,879 8,989 8,989
Care.
9Memphis TN Pending OOC Renovate Building 1 Clinical Lab 9,945 9,050 9,050
9Memphis TN BT Replace Building 10 Rooftop AC 55 55 55
Units.
9Memphis TN BT Upgrade Elevators for Oil 189 189 189
Coolers and UV.
9Memphis TN BT Replace Automatic Doors......... 978 978 978
9Memphis TN BT Renovate Physical Medicine & 871 785 785
Rehabilitation Pool Area.
9Memphis TN OOC Upgrade Spinal Cord Injury 1,678 1,526 1,526
Patient Bathrooms.
9Memphis TN BT Replace Building 1 and 1A 250 225 225
Medical Vacuum Pump.
9Memphis TN BT Replace Finishes for Halls and 950 950 950
Walls.
9Memphis TN BT Replace Flooring and Ceilings 964 877 877
for Safety and Infection
Control.
9Mountain Home TN BT Replace Building 200 Roof....... 950 893 893
9Mountain Home TN OOC Replace AHU 3 For SPD Building 1,672 1,520 1,520
77.
9Mountain Home TN BT Renovate Building 160 Main Lobby 901 825 825
9Mountain Home TN BT Replacement of Signs Bldg 200/ 900 895 895
204/205/77/160.
9Mountain Home TN SCIP 2015 Correct Bldg 20 Condition & 1,439 1,316 1,316
Environment Deficiencies for
Clinical/Support Staff
Recruitment & Training.
9Mountain Home TN BT Modify Pharmacy HVAC System for 825 750 750
USP 800 & USP 797 Compliance.
9Mountain Home TN BT Replace Facility Condition 935 935 935
Assessment Deficient Elevators,
Building 160.
9Mountain Home TN BT Renovate CLC Dining Room........ 968 880 880
9Mountain Home TN BT Renovate Halls & Walls, Building 929 851 851
200 Phase I.
9Mountain Home TN BT Correct Facility Condition 988 899 899
Assessment Exterior and
Structural Deficiencies for
Historic Chapel, Bldg 13.
9Mountain Home TN BT Implementation of Electrical 948 862 862
Infrastructure Upgrades--Phase
2.
9Mountain Home TN BT Replace AHU and Upgrade Duct 957 870 870
System in Primary Care, Bldg.
160.
9Murfreesboro TN BT Renovate Bathrooms.............. 896 800 800
9Murfreesboro TN BT Replace Air Handling Unit 12.... 840 750 750
9Murfreesboro TN BT Replace Nuclear Medicine Air 728 650 650
Handling Unit 4.
9Murfreesboro TN BT Upgrade Elevator Building 5..... 840 750 750
9Murfreesboro TN SCIP 2016 Upgrade Security Measures....... 1,760 1,600 1,600
9Murfreesboro TN SCIP 2016 Upgrade Corridors and Waiting... 1,980 1,800 1,800
9Murfreesboro TN BT Replace Flooring and Abatement.. 658 658 658
9Murfreesboro TN SCIP 2016 Abate Asbestos.................. 1,000 900 900
9Murfreesboro TN SCIP 2018 Renovate Ward 1A................ 8,330 833 833
9Nashville TN BT Cardiology Improvements......... 762 680 680
9Nashville TN BT Replace AHU-3A for Sterile 840 750 750
Processing Supply.
9Nashville TN BT Reconfigure Sterile Processing 358 300 300
Supply Scope Processing.
9Nashville TN BT Improvements for Surgical Clinic 909 810 810
9Nashville TN BT Expand Clinical Support......... 498 464 464
9Nashville TN SCIP 2016 Upgrade Public Corridors and 1,980 1,710 1,710
Waiting Rooms.
9Nashville TN SCIP 2016 Install Boiler System Condensing 1,205 1,105 1,105
Economizer.
9Nashville TN SCIP 2016 Upgrade Energy Management System 1,100 990 990
Infrastructure.
9Nashville TN SCIP 2016 Upgrade Electrical Distribution. 3,300 3,000 3,000
10Fort Wayne IN BT Increase Fort Wayne Site 775 705 705
Accessibility.
10Fort Wayne IN SCIP 2018 Remodel West Wing, 3rd Floor.... 4,035 404 404
10Indianapolis IN SCIP 2018 Modify Water Systems for 2,750 275 275
Legionella Prevention.
10Indianapolis IN SCIP 2015 Replace Air Handling Units and 9,240 8,400 8,400
Correct Deficiencies.
10Indianapolis IN BT Install Entrance Gate System.... 200 175 175
10Indianapolis IN BT Install A-Wing Reheat Victaulic 687 625 625
Fittings.
10Indianapolis IN BT Upgrade Fire Suppression System. 990 900 900
10Indianapolis IN BT Reconfigure Waiting Rooms....... 990 900 900
10Indianapolis IN SCIP 2015 Upgrade Building 1 for 9,900 9,000 9,000
Accessibility.
10Indianapolis IN Pending OOC Renovate Space for Veteran 1,045 950 950
Centered Care.
10Marion IN SCIP 2017 Renovate 4th Floor, Building 138 9,600 8,640 8,640
10Marion IN BT Improve Infrastructure Building 990 990 990
65.
10Marion IN SCIP 2015 Demolish Buildings 7, 10, 11, 8,800 8,000 8,000
18, 24, 60, 75, CC-2.
10Marion IN BT Renovate Atrium, Building 172... 620 564 564
10Marion IN BT Remodel Medication Rooms, 307 279 279
Building 185.
10Marion IN BT Replace Roof, Building 138...... 770 700 700
10Marion IN SCIP 2018 Demolish Buildings 25, 42 and 4,537 454 454
122, Marion.
10Ann Arbor MI SCIP 2018 Upgrade Electrical Switchgear 2,200 220 220
and Distribution.
10Ann Arbor MI SCIP 2016 Renovate Intensive Care Units... 8,672 7,805 7,805
10Ann Arbor MI BT Renovate Outpatient Pharmacy for 885 770 770
Ambulatory Care Clinics.
10Ann Arbor MI BT Upgrade HVAC for SPS............ 945 850 850
10Ann Arbor MI BT Chiller Plant Optimization...... 885 800 800
10Ann Arbor MI BT Renovate Lab Service............ 900 750 750
10Ann Arbor MI BT Install Gypboard Ceiling in SPS. 475 402 402
10Battle Creek MI BT Repair Gutters and Downspouts... 705 624 624
10Battle Creek MI SCIP 2015 Install ADA Access, Various 1,971 1,760 1,760
Buildings.
10Battle Creek MI BT Replace Water Heaters Various 666 555 555
Buildings.
10Battle Creek MI BT Install Energy Efficient HVAC, 621 550 550
B84.
10Battle Creek MI BT Install Water Monitoring System. 572 500 500
10Battle Creek MI SCIP 2016 Replace Windows, Various 2,528 2,257 2,257
Buildings.
10Battle Creek MI SCIP 2015 Renovate B83--2 for Patient 5,577 4,979 4,979
Privacy.
10Battle Creek MI SCIP 2018 Replace Roofs, Various Buildings 2,750 275 275
10Battle Creek MI SCIP 2018 Correct Water Distribution 4,950 495 495
Deficiencies for Legionella.
10Detroit MI SCIP 2018 Upgrade Fire Alarm Notification 2,750 275 275
System.
10Detroit MI SCIP 2018 Replace Poz Loc Fire Sprinkler 2,240 224 224
Piping, Phase II.
10Detroit MI SCIP 2016 Install Electrical Switchgear 6,700 6,000 6,000
Enclosures.
10Detroit MI BT Installation of Simulation Lab 500 450 450
for Education.
10Detroit MI BT Renovate Hallway A4 and B4...... 390 350 350
10Saginaw MI SCIP 2016 Renovate 3rd Floor Building 1... 6,225 5,600 5,600
10Saginaw MI SCIP 2015 Pharmacy Renovation............. 1,500 1,390 1,390
10Saginaw MI Pending OOC Medical Center Security and 3,292 3,000 3,000
Controls Upgrades.
10Saginaw MI Pending OOC Building 22 Sprinkler 1,600 1,500 1,500
Replacement.
10Saginaw MI SCIP 2015 Electrical Deficiencies and 1,000 875 875
Improvements.
10Chillicothe OH SCIP 2018 Improve Water System to Reduce 9,999 1,000 1,000
Risk of Legionella
Contamination and Patient
Injury.
10Chillicothe OH BT Renovate Student Housing 988 889 889
Buildings 15 and 16.
10Chillicothe OH BT Sanitary Sewer inspection and 500 425 425
Repair.
10Chillicothe OH BT Upgrade IT Infrastructure to 550 484 484
Support VoIP Phone System.
10Chillicothe OH OOC Demolish Buildings 2, 6, 10 & 11 1,300 1,170 1,170
10Chillicothe OH SCIP 2016 Renovate Building 25 to Improve 3,720 3,348 3,348
Efficiency.
10Chillicothe OH SCIP 2016 Address and Resolve Hazmat 2,860 2,540 2,540
Deficiencies.
10Cincinnati OH SCIP 2018 Improve Exhaust System.......... 4,875 488 488
10Cincinnati OH SCIP 2018 Replace Hospital Steam Heating 3,355 336 336
Systems, Phase II.
10Cincinnati OH SCIP 2017 Relocate PM&R to Basement of 1,200 1,072 1,072
Building #2.
10Cincinnati OH SCIP 2017 Upgrade Water Systems for 1,200 1,056 1,056
Legionella and Improve Water
Efficiency.
10Cincinnati OH BT Upgrade UPS and AC in Computer 605 550 550
Room.
10Cincinnati OH BT Replace Operating Room Chillers. 880 795 795
10Cincinnati OH BT Install PA Systems in Trailers.. 242 220 220
10Cleveland OH SCIP 2018 Replace Air Handling Unit AC- 6,900 690 690
17&18.
10Cleveland OH SCIP 2018 Upgrade Fire Alarm System....... 4,000 400 400
10Cleveland OH SCIP 2018 Replace CARES Tower Roof and 5,950 595 595
Repair Overhangs.
10Cleveland OH BT Renovate Boiler Plant Heat 385 325 325
Recovery System.
10Cleveland OH BT Replace Automatic Transfer 250 225 225
Switch 15 in Energy Center.
10Cleveland OH BT Provide Chiller Plant Automatic 275 250 250
Transfer Switch.
10Cleveland OH BT Consolidate Chaplain Services... 440 400 400
10Cleveland OH BT Expand Emergency Department 440 400 400
Parking Area.
10Columbus OH BT Remodel Pharmacy IV Prep Room- 915 800 800
FCA.
10Columbus OH BT Add Domestic Water Pressure 208 190 190
Booster.
10Columbus OH BT Construct temporary chiller 510 464 464
connection.
10Columbus OH SCIP 2015 Construct Chiller Plant......... 9,100 8,190 8,190
10Columbus OH BT Increase Size of Smoking Shelter 100 90 90
10Columbus OH BT Expand Existing Emergency 783 712 712
Distribution Panel Board and
Add Cooling to Substation Room.
10Dayton OH SCIP 2018 Renovate Laboratory, Building 8,602 860 860
310.
10Dayton OH SCIP 2018 Renovate Infrastructure for 4,400 440 440
National Historical Archives,
Building 116.
10Dayton OH SCIP 2018 Renovate TCU/ICU Space.......... 4,950 495 495
10Dayton OH SCIP 2016 Improve Campus Access and 4,500 4,100 4,100
Security.
10Dayton OH BT Correct Arc Flash Deficiencies.. 438 393 393
10Dayton OH SCIP 2017 Renovate B410 East Wing......... 4,400 3,660 3,660
12Chicago IL BT Renovate Sterile Processing..... 970 900 900
12Chicago IL SCIP 2016 Remodel Patient Admitting....... 3,750 3,500 3,500
12Chicago IL BT Replace Fire Pump Controller in 210 185 185
Building #1-Damen.
12Chicago IL BT Replace ATS for Elevators in 185 135 135
Building #1-Damen.
12Danville IL SCIP 2017 Remediate Legionella Station 4,087 3,700 3,700
Wide Phase 1.
12Danville IL BT Building 98 Exterior Ductwork 178 178 178
Insulation.
12Danville IL SCIP 2014 Renovate 58-5 Endoscopy Suite... 1,871 1,750 1,750
12Danville IL BT Legionella Continuous 160 160 160
Temperature Monitoring System.
12Danville IL BT Demolish Quarters 31, 32, 33.... 600 450 450
12Hines IL BT Remodel Resident Kitchen, Bldg. 56 50 50
221.
12Hines IL SCIP 2017 Legionella Suppression--Task 3,450 3,000 3,000
Order #1.
12Hines IL BT Install Patient Lifts, Multiple 522 381 381
Locations.
12Hines IL BT Correct HVAC Central Supply and 598 500 500
Storage Rooms.
12Hines IL Pending OOC Upgrade Chilled Water System, 9,914 9,013 9,013
Bldg. 200.
12North Chicago IL SCIP 2018 Upgrade Water Distribution 6,500 650 650
System.
12North Chicago IL SCIP 2018 Improve Facility Accessibility.. 4,815 482 482
12North Chicago IL BT Construct Hemodialysis Area 275 250 250
Building 133.
12North Chicago IL BT Renovate Occupational Health 330 300 300
Bldg 133.
12North Chicago IL BT Oncology Renovation USP 800 330 300 300
Requirement.
12North Chicago IL BT Building 135 HR Renovation...... 165 150 150
12North Chicago IL SCIP 2017 Facility Roofs.................. 3,300 3,300 3,300
12North Chicago IL BT Chilled Water Efficiency Part 2. 900 900 900
12North Chicago IL BT Prosthetics Renovation.......... 550 500 500
12North Chicago IL SCIP 2017 Renovate Building 131-4 ``A'' 1,100 1,100 1,100
Wing.
12North Chicago IL OOC Renovate Audiology.............. 1,320 1,200 1,200
12North Chicago IL OOC Replace Chiller #5.............. 1,650 1,500 1,500
12North Chicago IL CSI Construct Space for 1.5T MRI.... 3,969 3,500 3,500
12North Chicago IL BT Modify Chilled Water System 500 500 500
Valves.
12North Chicago IL BT Construct Misc Catwalks......... 120 120 120
12North Chicago IL BT Repair Misc. Fire Suppression 50 50 50
Systems in Various Bldgs.
12North Chicago IL OOC ATFP Measures--Gates and Fencing 3,000 300 300
12North Chicago IL BT Expand Police Area Bldg. 133.... 220 20 20
12Iron Mountain MI BT Install Server Room AHU......... 170 150 150
12Iron Mountain MI BT Upgrade OPC Heat Exchangers..... 255 225 225
12Iron Mountain MI BT HVAC Pressurization Study....... 638 600 600
12Iron Mountain MI SCIP 2017 Install Potable Water Mixing 1,330 1,250 1,250
Valves and Control Upgrades.
12Iron Mountain MI Pending OOC Renovate 5 West................. 2,000 1,850 1,850
12Madison WI OOC Renovate 3B for Inpatient Ward.. 4,918 4,500 4,500
12Madison WI SCIP 2015 Renovate 3A/3C.................. 6,146 5,246 5,246
12Madison WI SCIP 2018 Renovate 4B..................... 6,550 655 655
12Milwaukee WI Pending OOC 112 Replace (3) Boilers......... 9,900 9,000 9,000
12Milwaukee WI SCIP 2016 Upgrade HVAC V9, S1, S4 in Bldg 7,260 6,600 6,600
111.
12Milwaukee WI BT Replace Refrigerant Units 285 285 285
Various Locations.
12Milwaukee WI SCIP 2015 Correct FCA Sanitary 3,300 3,000 3,000
Deficiencies Grounds Phase 1.
12Milwaukee WI BT Upgrade Elevators Buildings 5 748 680 680
and 6 A Wing.
12Milwaukee WI SCIP 2016 Replace Security Card Readers 1,552 1,384 1,384
and Upgrade Security.
12Milwaukee WI BT Repair Campus Steam Tunnel and 500 450 450
Structural Supports.
12Milwaukee WI BT Replacement of Structural Floor 485 425 425
Slab for Building 43 Dining
Room Mental Health.
12Tomah WI SCIP 2016 Renovate South End of Building 2,783 2,530 2,530
406, 2nd Floor.
12Tomah WI CSI Construct Warehouse............. 4,600 4,250 4,250
15Marion IL BT Install Ventilation Corrections 150 130 130
for Sterile Processing.
15Leavenworth KS SCIP 2018 Renovate Infrastructure of 5,000 500 500
Laundry Building 153.
15Leavenworth KS SCIP 2018 Replace Steam/Condensate Lines 2,650 265 265
throughout the facility.
15Topeka KS SCIP 2017 Renovate Bldg 6, Wing B of 4,990 4,456 4,456
Existing CLC.
15Topeka KS OOC Renovate Space For VA Call 9,000 8,100 8,100
Center At Fort Riley For VHA
Member Services.
15Topeka KS BT Upgrade Oncology For Pharmacy-- 390 350 350
Topeka.
15Topeka KS BT Relocate Gastrointestinal 899 800 800
Laboratory.
15Topeka KS BT Repair Boiler Plant Chimney..... 360 320 320
15Topeka KS BT Repair Surgery Ventilation 625 550 550
System and Connect to Emergency
Power.
15Wichita KS CSI Construct Substance Abuse 4,730 4,300 4,300
Residential Rehabilitation
Treatment Building 59.
15Wichita KS BT Correct Mechanical Deficiencies, 500 450 450
Building 26.
15Columbia MO BT Replace Air Handler (AC -S2).... 880 800 800
15Columbia MO BT Renovate Vacated Surgery, Ward 6 890 800 800
15Kansas City MO BT Replace Central Boiler Plant 900 800 800
Control System.
15Kansas City MO BT Replace Building 26 Roof........ 500 475 475
15Kansas City MO BT Extend Chilled Water Loop 900 800 800
Building 15 and 26.
15Kansas City MO CSI Expand Outpatient Mental Health 2,200 2,000 2,000
Clinic.
15Poplar Bluff MO OOC Replace Boilers, Building 7..... 3,000 2,700 2,700
15Poplar Bluff MO SCIP 2017 Replace Station 518,000 Volt 1,315 1,206 1,206
Amps Electrical Life Safety
Generator.
15Poplar Bluff MO BT Create Exterior Secure Storage 250 200 200
Area.
15Poplar Bluff MO BT Correct Legionella Deficiencies 900 810 810
Phase 1.
15St. Louis MO OOC Renovate Operating Rooms and 6,120 5,943 5,943
Support Spaces.
15St. Louis MO CSI Demolish Sextro Warehouse, John 4,100 4,000 4,000
Cochran Division.
15St. Louis MO BT Prepare Site for X-Ray Units.... 640 640 640
16Fayetteville AR SCIP 2018 Renovate B9 Laundry............. 1,925 193 193
16Fayetteville AR SCIP 2018 Replace Eaves, Soffit, Integral 1,855 186 186
Gutters and Fascia, Multiple
Buildings.
16Fayetteville AR BT Replace Primary Care Elevator 80 80 80
Controls.
16Little Rock AR SCIP 2016 Provide 100% Emergency Power.... 9,900 9,000 9,000
16Little Rock AR SCIP 2018 Develop Private/Semi-Private Bed 8,360 836 836
Spaces.
16Alexandria LA SCIP 2016 Emergency Generator Replacement. 4,950 600 600
16Shreveport LA SCIP 2018 Correct Electrical Deficiencies, 7,300 730 730
Building 1.
16Shreveport LA SCIP 2018 Abate Central Chase/Replace Fire 1,320 132 132
Main Risers.
16Shreveport LA BT Renovate Morgue, Building 1..... 407 370 370
16Shreveport LA SCIP 2017 Replace Primary Switch Gear..... 1,557 1,410 1,410
16Jackson MS OOC Renovate Ground Floor Community 8,505 7,667 7,667
Living Center--Bldg. 7.
16Jackson MS BT Continuous Monitoring of Potable 200 200 200
Water Engineering Controls.
16Jackson MS BT Replace Cable TV System......... 150 150 150
16Jackson MS BT Repair Employee Parking Lot Area 550 550 550
I.
16Jackson MS OOC Upgrade HVAC System 9B.......... 5,335 4,850 4,850
16Jackson MS BT Upgrade Auto Transfer Switches/ 935 850 850
Emergency Generator Control
Units.
16Oklahoma City OK SCIP 2018 Renovate Pharmacy for Chapter 1,760 176 176
797/800 Compliance.
16Oklahoma City OK SCIP 2018 Correct Domestic Hot Water 1,980 198 198
Distribution System
Deficiencies.
16Oklahoma City OK SCIP 2018 Renovate to Separate OIT and 1,878 188 188
Engineering Closets.
16Oklahoma City OK SCIP 2018 Renovate 6 North for Patient 2,715 272 272
Privacy.
16Houston TX SCIP 2018 Renovation of Pathology and 6,000 600 600
Laboratory- Phase 1.
16Houston TX Pending OOC Replace Elevators B-100......... 6,000 5,250 5,250
16Houston TX SCIP 2017 Renovate/Expand ER Building 100. 6,500 1,800 1,800
17Amarillo TX SCIP 2016 Replace HVAC Components for 3,800 3,500 3,500
Energy Savings Building 28.
17Amarillo TX SCIP 2016 Replace HVAC Components for 2,750 2,000 2,000
Energy Savings Building 1.
17Amarillo TX BT Repair Medical Air & Vacuum 150 150 150
Systems.
17Amarillo TX OOC Renovate Building 28 Medical 3,372 3,322 3,322
Ward for Privacy.
17Big Spring TX BT Renovate fifth floor Nursing 825 700 700
Station and Corridor.
17Big Spring TX BT Relocate & Expand Audiology..... 599 544 544
17Big Spring TX BT Replace Deficient HVAC Fan Coil 975 850 850
Units.
17Big Spring TX BT Renovate Street Entrance........ 455 400 400
17Big Spring TX OOC Replace Roofs on Building 1..... 3,350 3,200 3,200
17Big Spring TX BT Construct Restrooms for 375 300 300
Education Training Center.
17Big Spring TX BT Replace Flag Pole............... 410 350 350
17Big Spring TX OOC Renovate Administration for 2,530 2,300 2,300
Physical Therapy and
Prosthetics.
17Big Spring TX BT Correct Facade Deficiencies..... 95 50 50
17Big Spring TX OOC Install Perimeter Fencing Around 2,700 2,500 2,500
Campus.
17Big Spring TX OOC Upgrade Electrical Panels....... 2,250 2,000 2,000
17Big Spring TX BT Replace HVAC in Bldg 4 & 7...... 800 725 725
17Big Spring TX SCIP 2015 Remove Dead Leg Water Lines in 1,150 1,035 1,035
the Facility.
17Bonham TX SCIP 2016 Replace HVAC Bldg 1 & 2......... 2,170 2,000 2,000
17Bonham TX OOC Replace Pipe Support Stands..... 2,303 2,100 2,100
17Bonham TX SCIP 2015 Replace Bonham Fire Alarm System 3,200 3,000 3,000
17Dallas TX BT Roof Top Chiller Pressurized 874 800 800
System.
17Dallas TX OOC Renovate Building #60 Bed & Bath 3,600 3,500 3,500
Rooms B Wing.
17Dallas TX BT Correct B.70 Deficiencies....... 990 900 900
17Dallas TX BT Replacing Bldg. 6 & 8 AHU System 550 500 500
17Dallas TX BT Replace/Repair Roof Bldg.60..... 550 500 500
17Dallas TX OOC Replace Patient Exterior and 3,000 3,000 3,000
Interior Signage.
17El Paso TX OOC Repair FCA Deficiencies......... 1,650 1,500 1,500
17Harlingen TX OOC Upgrade HVAC.................... 2,750 2,500 2,500
17Harlingen TX OOC Repair Parking Lot Corpus 550 500 500
Christi Outpatient Clinic.
17San Antonio TX BT Activate Emergency Well Water @ 666 600 600
ALMD.
17San Antonio TX BT Conduct Legionella Study........ 440 400 400
17San Antonio TX SCIP 2016 Replace 1000kw Generator and 2,200 2,000 2,000
Fuel Storage Tank.
17San Antonio TX SCIP 2018 Replace main switch gear........ 2,200 220 220
17Temple TX Pending OOC Reconfigure Specialty Clinics 2,838 2,580 2,580
4th Floor Teague Tower.
17Temple TX SCIP 2018 Relocate Mental Health to Dom C- 9,686 4,860 4,860
Wing.
17Temple TX SCIP 2018 Relocate Mental Health to Dom D- 7,578 4,440 4,440
Wing.
17Temple TX BT Construct 2nd Cardiac Cath...... 491 450 450
17Temple TX OOC Replace Air Handler Units Bldg 4,075 3,705 3,705
163 Tower.
17Temple TX SCIP 2017 Convert Bldg 44W to Admin....... 1,650 1,500 1,500
17Temple TX OOC Prevention of Legionella--Temple 3,377 3,070 3,070
17Temple TX OOC Replace Medium Voltage 3,232 3,000 3,000
Switchgear.
17Waco TX SCIP 2017 Relocate Canteen Bldg 202....... 2,299 2,090 2,090
17Waco TX OOC Upgrade Electrical Secondary 2,200 2,000 2,000
Distribution System.
17Waco TX BT Replace Building 1 HVAC......... 817 777 777
17Waco TX OOC Prevention of Legionella--Waco.. 2,742 2,493 2,493
19Denver CO OOC Replace CBS West AHU............ 2,321 2,121 2,121
19Grand Junction CO Pending OOC Energy Audit Finding Corrections 1,118 1,026 1,026
19Grand Junction CO BT Correct Building 33 FCA 229 208 208
Deficiencies.
19Grand Junction CO SCIP 2016 Replace AHU 9 AND 10............ 1,680 1,500 1,500
19Grand Junction CO Pending OOC Ventilate and Expand IT Closets. 1,090 1,000 1,000
19Grand Junction CO SCIP 2017 Replace Boilers and Controls, 7,616 7,201 7,201
Phase 2.
19Grand Junction CO Pending OOC Renovate 4E/4W and Upgrade 2,150 1,980 1,980
Mechanical AHU.
19Grand Junction CO SCIP 2013 Elimination of Substandard Beds 3,740 3,400 3,400
on 3rd Floor.
19Grand Junction CO BT DR Site Prep.................... 175 160 160
19Ft Harrison MT SCIP 2017 Replace Penthouse HVAC Systems.. 2,420 2,150 2,150
19Ft Harrison MT BT Digital Security Enhancements... 935 850 850
19Ft Harrison MT OOC LED Lighting Phase I............ 1,100 990 990
19Ft Harrison MT SCIP 2017 Building 141 Heating............ 1,452 1,280 1,280
19Muskogee OK BT Replace & Upgrade DW1 Cart 375 375 375
Elevator.
19Muskogee OK Pending OOC Replace Surveillance System..... 2,050 1,900 1,900
19Muskogee OK SCIP 2015 Install Energy Retrofits for Air 5,445 4,901 4,901
Handling Units, Controls, and
Lighting.
19Muskogee OK BT Upgrade Roofing Systems Phase 2. 800 800 800
19Oklahoma City OK CSI Remodel Cath Labs............... 1,450 1,300 1,300
19Oklahoma City OK SCIP 2016 Renovate 7 East for Patient 3,215 2,700 2,700
Privacy.
19Oklahoma City OK SCIP 2016 Renovate Canteen Food Court and 1,628 1,480 1,480
Office Suite.
19Oklahoma City OK SCIP 2016 Increase Electrical Capacity to 1,540 1,400 1,400
9th Floor Server Room.
19Oklahoma City OK OOC Upgrade Interior Fixed Equipment 2,075 1,850 1,850
19Oklahoma City OK CSI Site Prep for New 80 Slice CT... 660 500 500
19Salt Lake City UT SCIP 2017 Upgrade Public Address Mass 4,750 4,300 4,300
Notification System (PAMNS).
19Salt Lake City UT BT B.7, B.35, B.37 Research 880 800 800
Renovation.
19Salt Lake City UT OOC Legionella--Mixing Valves, 1,870 1,700 1,700
Schematics, Controls.
19Salt Lake City UT SCIP 2017 Chilled Water Distribution Line 1,980 1,800 1,800
Ph. 6.
19Salt Lake City UT SCIP 2017 Upgrade Fire Alarms............. 1,527 153 153
19Salt Lake City UT SCIP 2016 Site Electrical Replacement..... 1,000 100 100
19Salt Lake City UT SCIP 2016 Solar PV Parking Garage......... 4,180 380 380
19Cheyenne WY SCIP 2016 Improve Facility Security Phase 1,000 988 988
1.
19Cheyenne WY BT FCA Improve Wayfinding.......... 135 135 135
19Cheyenne WY BT Potable Water Improvements...... 990 900 900
19Cheyenne WY Pending OOC Renovate Pharmacy & SPS, Phase 2 1,090 90 90
19Sheridan WY BT Demo 30,34,39 & 83.............. 700 700 700
19Sheridan WY BT Replace O2 Tanks................ 580 580 580
19Sheridan WY Pending OOC Site Prep Sheridan MRI.......... 1,700 1,700 1,700
19Sheridan WY BT Porch and Roof Corrections...... 682 592 592
19Sheridan WY BT Boiler Upgrade Ph3.............. 960 850 850
19Sheridan WY Pending OOC IT Comm Closet Upgrades Ph 1.... 2,080 1,900 1,900
19Sheridan WY BT Replace B64 Parking Lots........ 958 860 860
19Sheridan WY SCIP 2018 IT Communication Closets Upgrade 2,180 218 218
Phase I.
20Anchorage AK BT Surgical Suite Steam 600 520 520
Humidification System.
20Anchorage AK BT Building 100 Site Improvements.. 440 400 400
20Boise ID BT Replace Officer's Row Road...... 335 300 300
20Portland OR SCIP 2017 Upgrade and Replace condensate 2,750 2,500 2,500
and steam infrastructure (V).
20Portland OR BT Upgrade Building 18 TLU HVAC.... 880 800 800
20Portland OR BT Simulation Lab Relocation....... 335 300 300
20Roseburg OR SCIP 2016 Upgrade Campus Security......... 3,300 3,000 3,000
20Roseburg OR SCIP 2017 Renovate Building 1 to Relocate 1,936 1,760 1,760
Short Stay.
20Roseburg OR BT Replace Campus PA System........ 715 650 650
20Roseburg OR BT Update Wayfinding Signage campus 980 900 900
wide.
20Roseburg OR BT Replace Nurse Call System 275 250 250
Building 81.
20Roseburg OR BT Replace Quonset Huts T6, T7, T8, 832 772 772
T15 & T19.
20White City OR SCIP 2016 Renovate Space, Building 210 2,200 1,980 1,980
Upper South for Clinical Areas.
20White City OR SCIP 2016 Retrofit Campus Wide 7,900 7,200 7,200
Infrastructure Systems--Water,
Sewer, & Storm.
20American Lake WA BT Replace Building 148 Boiler..... 550 500 500
20American Lake WA BT VCS Coffee Shop in Building 2... 198 143 143
20American Lake WA OOC Expand Blind Rehabilitation 1,485 1,376 1,376
Building 2.
20American Lake WA SCIP 2016 Am Lake Replace Boilers for 3,300 2,970 2,970
Energy Efficiency.
20Seattle WA BT Replace Flooring in B100 First 220 200 200
Floor Core/Lobby.
20Seattle WA BT Renovate Main Entrance Canopy 275 250 250
and Demo Smoking Shelter/Canopy.
20Seattle WA BT Replace Ceiling and Flooring in 165 150 150
Bldg 23.
20Seattle WA BT Replace Flooring in Bldg 11 OR 115 100 100
Rooms and Corridor.
20Seattle WA BT Renovate Rooms in Bldg 34 for 286 260 260
Veterinary Treatment.
20Seattle WA BT Replace Flooring in Bldg 34 65 50 50
First Floor.
20Seattle WA BT Building 1 Sterilizer 385 350 350
Installation.
20Seattle WA BT Renovate SCI Bathrooms.......... 660 600 600
20Seattle WA BT OR Mechanical Upgrades.......... 550 500 500
20Seattle WA SCIP 2015 Renovate and Expand Seattle 7,797 7,019 7,019
Sterile Processing Service.
20Seattle WA BT Replace 2 West Corridor Flooring 115 100 100
20Seattle WA SCIP 2016 Renovate Seattle B37 First Floor 1,654 1,489 1,489
for VA Police.
20Seattle WA SCIP 2017 4W Surgical Specialty Care 4,686 4,296 4,296
Clinic Expansion.
20Seattle WA BT Install Wi-Fi in Patient Areas.. 825 750 750
20Seattle WA SCIP 2018 Replace Roofs--Seattle VA....... 4,675 468 468
20Spokane WA CSI Site Prep for Nuke Med SPECT/CT. 660 630 630
20Spokane WA BT Demolish Building 32............ 60 50 50
20Spokane WA CSI Site Prep for MRI Replacement... 250 200 200
20Spokane WA SCIP 2015 Correct Electrical and 3,900 3,510 3,510
Communication Infrastructure
Deficiencies.
20Spokane WA BT Install Hot Water Recirculation 495 450 450
Loop for Acute Psychiatric Unit.
20Spokane WA BT CLC Remodel and Portico......... 714 650 650
20Spokane WA BT Replace Elevators in Bldg 1 and 990 900 900
27.
20Spokane WA SCIP 2016 Replace Boiler Plant............ 11,000 9,900 9,900
20Walla Walla WA BT Replace Steam Traps............. 440 400 400
21Fresno CA BT Repair Mechanical Systems, 755 700 700
Building 1 Sub-Basement.
21Fresno CA BT Remodel ED for Observation Beds. 550 200 200
21Fresno CA CSI Expand Mental Health Center, 4,950 4,540 4,540
Building 27.
21Fresno CA SCIP 2016 Expand Chilled Water Capacity... 9,600 8,800 8,800
21Fresno CA BT Install Skytron Ceiling Mount 375 300 300
Booms in Surgical Suite, 3rd
Floor, Building 1.
21Fresno CA BT Install USP800 Chemo Compounding 410 360 360
Room, 3rd Floor, Building 24.
21Fresno CA BT Remodel Building 24, 1st Floor.. 990 800 800
21Fresno CA SCIP 2018 Renovate Outpatient Clinic 5,010 501 501
Basement for Emergency
Department Observation Bed
Suite.
21Livermore CA BT Repair Main Water Line, LVD..... 65 65 65
21Martinez CA BT Renovate Outpatient Clinic 880 800 800
Office Space, Building 778,
Fairfield.
21Martinez CA SCIP 2014 Correct Campus Security 2,000 1,800 1,800
Deficiencies and Renovate for
Sterile Storage Supply.
21Martinez CA Pending OOC Investigate Seismic Capacity 3,100 100 100
Building 21.
21Menlo Park CA BT Renovate Tele radiology, Bldg 870 800 800
334.
21Palo Alto CA OOC Create 60kV Substation and 30,000 30,000 30,000
Infrastructure.
21Palo Alto CA BT Expand Emergency Preparedness 550 500 500
Capabilities, PAD Campus.
21Palo Alto CA BT Construct Bump Out for Major 550 500 500
Construction Team.
21Palo Alto CA BT Create Surface Parking at 800 750 750
Stockton.
21Palo Alto CA SCIP 2017 Construct Consolidated Fisher 3,575 2,300 2,300
House Central Reception
Building.
21Palo Alto CA SCIP 2015 Replace Chillers in Building 100 4,824 4,000 4,000
21Palo Alto CA SCIP 2013 Improve Emergency Sustainment 2,788 2,600 2,600
capabilities -South Campus
Generator.
21Palo Alto CA BT Create Additional Patient & 950 850 850
Staff Parking at PAD.
21Sacramento CA BT Renovate for Clean Room 560 500 500
Expansion, Building 652.
21San Francisco CA BT Upgrade Sanitary System on East 990 890 890
Side of Campus.
21San Francisco CA Pending OOC Replace Building 3, 200 2,076 1,750 1,750
Chillers, insulate ductwork.
21San Francisco CA OOC Replacement of Bldg. 200 Roof 1,500 1,500 1,500
System.
21San Francisco CA SCIP 2015 Renovate and Consolidate 3,685 3,500 3,500
Clinical Programs on the Ground
Floor of the Main Hospital.
21San Francisco CA OOC Renovate and Upgrade Patient 1,500 1,200 1,200
Restrooms in Bldgs 200 and 203.
21San Francisco CA BT Correct Non-structural 700 700 700
Components of B. 200 and 203.
21San Francisco CA CSI Site Preparation for Bi-Plane... 1,000 1,000 1,000
21Honolulu HI BT Renovate Pharmacy............... 700 600 600
21Honolulu HI BT Finish Parking Structure 558 475 475
Basement.
21Honolulu HI BT Replace Fire Alarm Panels....... 575 575 575
21Honolulu HI BT Upgrade Center For Aging HVAC 990 990 990
System.
21Honolulu HI BT Install Real-time Water 235 175 175
Monitoring System--Legionella.
21Las Vegas NV Pending OOC CLC Patient Lift Installation... 1,757 1,757 1,757
21Las Vegas NV SCIP 2017 Modify Main Entrances in 1,841 1,690 1,690
Building 1.
21Las Vegas NV BT Back Up Cooling System for 879 790 790
Critical Care Areas.
21Las Vegas NV BT Environmental Controls and 572 520 520
Monitoring.
21Las Vegas NV SCIP 2017 Water Line Improvement/Bypass... 1,950 960 960
21Las Vegas NV OOC Radiology and Surgical UPS...... 2,114 1,995 1,995
21Las Vegas NV OOC Stairwell Safeguards............ 1,540 1,400 1,400
21Reno NV BT MRI Upgrade Site Prep........... 400 400 400
21Reno NV BT Upgrade Mental Health 253 200 200
Interlocking Doors (Study).
21Reno NV BT Demolish Buildings 15, 138, F 646 600 600
and K.
21Reno NV BT Convert Room for Blood Draw..... 15 15 15
21Reno NV SCIP 2017 Expand Emergency Power Capacity 1,390 1,300 1,300
at the Boiler Plant.
21Reno NV SCIP 2018 Replace damaged piping in 5,500 550 550
clinical Building 1D..
21Reno NV SCIP 2018 Repair critical electrical 3,850 385 385
deficiencies in Clinical
Building 1D.
22Phoenix AZ CSI Renovate and Expand Women's 4,400 4,000 4,000
Health Clinic.
22Phoenix AZ SCIP 2018 Replace AHUs at CLC and Main 3,300 330 330
Building.
22Phoenix AZ SCIP 2016 Renovate Inpatient Ward 2C...... 4,504 4,104 4,104
22Phoenix AZ OOC Renovate 6D for Inpatient Ward.. 4,000 3,600 3,600
22Phoenix AZ BT OI&T Electrical Upgrades........ 990 900 900
22Phoenix AZ Pending OOC Remodel Dietetics Kitchen....... 3,411 3,029 3,029
22Phoenix AZ SCIP 2016 Site Stormwater Correction...... 1,760 1,600 1,600
22Prescott AZ SCIP 2014 Perform Retro-commissioning and 825 750 750
Repair of Building Control
Systems.
22Prescott AZ SCIP 2016 Repair/Resurface Roads, Ph 4.... 1,107 992 992
22Prescott AZ Pending OOC Renovate Buildings 12-17 1,400 1,300 1,300
(Thermal Envelope).
22Prescott AZ BT Replace Heating Systems for 940 880 880
Outer Buildings, Phase 1.
22Prescott AZ OOC Repair/Replace Main Steam Riser 1,050 900 900
from Boiler Plant.
22Tucson AZ BT Replace Air Handlers (B60)...... 990 900 900
22Tucson AZ BT Correct Safety Deficiencies, B4. 401 350 350
22Tucson AZ SCIP 2017 Legionella DOM Water Loop 1,200 950 950
Repairs, B-30 & B-67.
22Tucson AZ OOC Renovate for Pathology Morgue 2,420 2,200 2,200
and IT, B-38 Basement.
22Tucson AZ OOC Replace Air Handling Units for 3,300 3,000 3,000
Critical Care and Sterile
Processing.
22Tucson AZ OOC Upgrade Information Technology 1,815 1,650 1,650
Server Room.
22Tucson AZ OOC Replace Ancillary Boiler Plant 1,430 1,345 1,345
Equipment & Controls.
22Tucson AZ BT Replace SPS and Logistics 655 600 600
Dumbwaiters (B-57).
22Loma Linda CA BT Renovate 4SW Bathrooms.......... 880 800 800
22Loma Linda CA BT Correct Steam Distribution 801 720 720
Deficiencies.
22Loma Linda CA BT Renovate Stairwells............. 600 550 550
22Loma Linda CA SCIP 2016 Replace Main Stormwater, Waste & 3,000 2,700 2,700
Vent Piping.
22Loma Linda CA SCIP 2018 Correct Environmental Controls & 2,500 250 250
Security Deficiencies in IT
rooms.
22Long Beach CA SCIP 2015 Physical Security Access Control 1,650 880 880
22Long Beach CA OOC Correct Carpet-Wall Finish 3,960 3,600 3,600
Deficiency B150 SCI.
22Long Beach CA SCIP 2012 Install Emergency Management 5,498 5,000 5,000
Generator, Phase 2.
22Long Beach CA OOC B126OP Basement-Correct FCA 4,015 3,650 3,650
Deficiencies and Remodel.
22Long Beach CA SCIP 2016 B126 Renovate & Upgrade 4,950 4,455 4,455
Hemodialysis Infrastructure.
22Long Beach CA BT Metasys System.................. 800 720 720
22Long Beach CA SCIP 2018 Correct Legionella Deficiencies-- 4,400 440 440
Bldg 1.
22Long Beach CA SCIP 2018 Correct Electrical Site Security 5,203 520 520
Deficiencies.
22Long Beach CA SCIP 2018 Renovate ICU Bldg 126 3rd Floor. 6,600 660 660
22Long Beach CA SCIP 2018 Renovate Bldg 126 8th Floor 9,200 920 920
North for Private/Semi Private
Beds.
22Los Angeles CA BT Replace Fire Alarm System in 910 821 821
LAACC.
22Los Angeles CA SCIP 2018 Replace Water Main and Valves... 3,795 380 380
22San Diego CA SCIP 2016 Bldg 2 Remodel- Emergency Bus 9,020 8,200 8,200
&Switchgear Modifications.
22San Diego CA SCIP 2017 Emergency Department Exterior 2,310 2,100 2,100
Access & Signage.
22Sepulveda CA SCIP 2016 Upgrade Information Technology 1,650 1,500 1,500
Closets Sepulveda.
22West Los Angeles CA BT Replace B158 Fire Alarm......... 770 700 700
22West Los Angeles CA SCIP 2016 Upgrade Information Technology 1,500 1,350 1,350
Closets WLA North Campus Six
Buildings.
22Albuquerque NM OOC Abate Asbestos B-41............. 1,760 1,600 1,600
22Albuquerque NM OOC Install Legionella Corrections.. 2,500 2,250 2,250
23Des Moines IA SCIP 2015 Design/Construct Security Gates. 1,660 1,500 1,500
23Des Moines IA BT Repair Roads/Walks for Safety... 820 672 672
23Des Moines IA SCIP 2016 Upgrade OR Chilled Water Cooling 1,756 800 800
System.
23Des Moines IA SCIP 2016 Install New Emergency Generator 1,900 1,750 1,750
System.
23Des Moines IA CSI Site Prep to Replace Two CTs.... 1,080 930 930
23Des Moines IA SCIP 2015 Upgrade Existing and Construct 3,990 3,600 3,600
New Elevators.
23Des Moines IA SCIP 2018 Renovate and Expand Primary Care 1,240 124 124
Infusion and Oncology Center.
23Iowa City IA Pending OOC Replace Deficient Mechanical 2,200 2,000 2,000
Systems (AHU).
23Iowa City IA SCIP 2017 Modernize Existing Chillers..... 3,850 3,450 3,450
23Iowa City IA SCIP 2015 Replace Defective Steam Traps 6,100 5,500 5,500
and Correct Condensate Over
pressurization.
23Iowa City IA OOC Upgrade and Expand Hospital 2,250 2,050 2,050
Security Systems.
23Iowa City IA OOC Correct Life Safety Deficiencies 9,900 9,000 9,000
23Minneapolis MN SCIP 2018 Renovate Outpatient Mental 4,300 430 430
Health (1L).
23Minneapolis MN SCIP 2018 Recommission of Main Hospital 1,000 100 100
HVAC Systems.
23Minneapolis MN CSI Site Prep--Multi-Site DR Rooms.. 5,000 4,000 4,000
23Minneapolis MN SCIP 2017 Construct Clinical Research 3,300 3,000 3,000
Wings.
23Minneapolis MN CSI Upgrade Cath Labs 2 and 3....... 2,200 2,000 2,000
23Minneapolis MN SCIP 2016 Renovate Inpatient Mental Health 2,600 2,300 2,300
23St Cloud MN SCIP 2018 Renovate Primary Care Clinic 8,203 820 820
Building 4.
23St. Cloud MN SCIP 2016 Renovate Building 4 Basement for 7,150 6,500 6,500
Sterile Processing Services and
Sterile Processing and
Distribution.
23St. Cloud MN SCIP 2017 Relocate Rehab Functions........ 6,204 564 564
23St. Cloud MN SCIP 2016 Upgrade Information Technology 4,965 4,500 4,500
Closets for Security.
23St. Cloud MN OOC Install Ground Source Heat Pump 5,433 5,000 5,000
System for Building 28.
23St. Cloud MN SCIP 2016 Renovate Building 4 East Side 2,900 2,636 2,636
for Women's Clinic.
23St. Cloud MN SCIP 2015 Renovate Building 2, First Floor 4,987 4,545 4,545
for Residential Rehabilitation
Therapy Program.
23St. Cloud MN SCIP 2014 Replace Windows, Buildings 4, 8 1,580 1,500 1,500
& 9.
23Fargo ND CSI Perform Site Prep for Urology 316 287 287
Equipment in OR #4.
23Fargo ND BT Install Instrument Air and RO 202 182 182
Water in SPS.
23Fargo ND BT Replace N&FS Ceiling System..... 220 200 200
23Fargo ND SCIP 2015 Renovate 2nd Floor Bldg 46 for 2,640 2,400 2,400
Medical Specialties.
23Fargo ND SCIP 2017 Replace Boiler Plant............ 8,250 7,500 7,500
23Fargo ND SCIP 2017 Renovate Bldg 1 First Floor for 4,840 4,400 4,400
PT/OT and Prosthetics.
23Omaha NE BT Construct SPS Scope Processing 206 186 186
Area.
23Omaha NE SCIP 2016 Construct Central Energy Plant.. 36,027 35,640 35,640
23Omaha NE BT Replace Overhead Paging Systems-- 30 30 30
Omaha and Grand Island.
23Fort Meade SD BT Upgrade Boiler Plant Automation 330 300 300
Equipment.
23Fort Meade SD SCIP 2016 Renovate and Consolidate 7,490 6,590 6,590
Inpatient Function Building 113.
23Fort Meade SD SCIP 2016 Relocate Sterile Processing 5,265 4,778 4,778
Service and Endoscopy.
23Hot Springs SD BT Canteen Entry Upgrades Design... 175 150 150
23Sioux Falls SD BT Electrical and Fire Suppression 700 500 500
Upgrades.
23Sioux Falls SD SCIP 2015 Renovate 5th Floor Surgery...... 3,909 3,519 3,519
23Sioux Falls SD Pending Mechanical Upgrades............. 2,200 200 200
Various Various Below Threshold/Urgent Projects. 121,374 121,374
-----------------------------------------------
Total VHA Planned NRM 2,549,939 1,870,000 600,000 1,270,000
Projects.
--------------------------------------------------------------------------------------------------------------------------------------------------------

Question 17. Please provide a list of the projects and their
associated funding levels included in the $862 million for the
activation of new and enhanced health care facilities. Specifically
break out the additional projects included in the $364 million ``second
bite'' for 2018 advance appropriations.
Response. See attached list of projects.

Planned 2018 Non-Recurring Maintenance Projects
----------------------------------------------------------------------------------------------------------------
Actual or
Estimated
Construction
VISN Project Name FY 2018 New or Replacement? Completion/
Lease
Acceptance
Date
----------------------------------------------------------------------------------------------------------------
1Boston, MA--Community-Based Outpatient $7,945,835 Replacement....................... 7/31/2018
Clinic Lease
2Syracuse, NY--Spinal Cord Injury $986,452 Replacement....................... 6/1/2013
2Brick, NJ--Community-Based Outpatient $10,986,303 Replacement....................... 6/1/2020
Clinic
2Manhattan, NY--Hospital Restoration and $1,819,563 Replacement....................... 10/31/2019
Renovation
2Canandaigua, NY--New Construction and $3,890,735 Replacement....................... 1/31/2023
Renovation Phase1
2Rochester, NY--Health Care Center--Major $13,614,553 Replacement....................... 9/30/2019
Lease
4Butler, PA--Health Care Center Lease $1,398,248 New............................... 6/12/2017
5Perry Point, MD--Replacement Long Term $1,200,000 Replacement....................... 7/31/2021
Care
6Fayetteville, NC--Health Care Center $12,489,421 New............................... 9/30/2016
Lease
6Charlotte, NC--Health Care Center Lease $27,008,337 New............................... 2/28/2016
6Winston-Salem, NC--Health Care Center $28,702,513 New............................... 12/31/2015
Lease
7Expand Cobb City, AL--Community-Based $7,599,157 New............................... 6/1/2020
Outpatient Clinic
7Birmingham, AL--Clinical Annex/ $4,884,076 New............................... 7/31/2015
Outpatient Clinic Lease
7Huntsville, AL--Outpatient Clinic Lease $5,590,275 Replacement....................... 12/15/2015
7Savannah, GA--Community-Based Outpatient $9,058,563 Replacement....................... 2/1/2017
Clinic Lease
8New Port Richey, FL--Lease Consolidation $2,311,438 Replacement....................... 6/1/2020
8Bay Pines, FL--Mental Health/Inpatient- $8,329,187 Replacement....................... 8/30/2020
Outpatient Improvements
8Tallahassee, FL--Outpatient Clinic Lease $21,491,622 Replacement....................... 7/31/2016
8Brandon (South Hillsborough), FL-- $20,946,907 New............................... 10/1/2018
Outpatient Clinic (Tampa) Lease
8Orlando, FL--New Medical Facility $63,549,984 New............................... 11/30/2015
8Tampa, FL--Polytrauma and New Bed Tower $36,230,637 New............................... 1/31/2021
9Louisville, KY--Replacement Med Center/ $1,195,634 Replacement....................... 1/6/2023
Regional Office
10Terre Haute, IN--Health Care Center $200,000 Replacement....................... 2/1/2022
10St Joseph County VA Clinic, IN-- $26,100,912 New............................... 10/31/2017
Outpatient Clinic
12Green Bay, WI--Health Care Center $37,326,024 Replacement....................... 8/10/2015
15St. Louis, MO--Med Facility Improve & $5,951,843 Replacement....................... 11/15/2018
Expansion
15St. Louis, MO--Clinic $773,726 Replacement....................... 10/31/2017
15Cape Girardeau, MO--Clinic Expansion $773,726 Replacement....................... 5/31/2019
16Mobile, AL--Outpatient Clinic Lease $8,332,515 Replacement....................... 12/1/2018
16Biloxi, MS--Building 1 & 2 Renovation $3,240,933 Replacement....................... 5/31/2018
16New Orleans, LA--Restoration/Replacement $134,346,907 Replacement....................... 2/28/2018
Medical Facility
16Springfield, MO CBOC $23,256,953 New............................... 6/30/2018
16Lafayette, LA--Outpatient Clinic Lease $4,864,834 New............................... 9/30/2016
17San Antonio, TX--Polytrauma Renovation $6,931,830 Replacement....................... 12/31/2013
Project
17McAllen, TX--Outpatient Clinic $17,059,566 New............................... 4/28/2014
19Missoula, MT--CBOC Lease $95,736 Replacement....................... 1/31/2022
19Denver, CO--Replacement Medical Center $87,487,356 Replacement....................... 7/1/2018
Facility
20American Lake, WA--Seismic Corrections $240,000 Replacement....................... 9/4/2023
of Building81
20Seattle, WA--B101 Mental Health $1,857,268 Replacement....................... 3/22/2018
20Walla Walla, WA--New OPC and Renovation $1,100,000 Replacement....................... 1/6/2020
86
20East Portland, OR--Community Based $3,074,444 Replacement....................... 8/1/2016
Outpatient Clinic
20Eugene, OR--Community-Based Outpatient $6,541,941 Replacement....................... 12/31/2015
Clinic Lease
20Seattle, WA--Correct Seismic $80,000 Replacement....................... 5/19/2016
Deficiencies B100
20Honolulu, HI--ALOHA (459) $6,500,000 New............................... 5/1/2020
21Las Vegas, NV--New Medical Facility $43,565,383 Replacement....................... 3/7/2016
21Chico, CA--Replace Lease for Expiring $4,079,638 Replacement....................... 4/1/2020
CBOC
21Redding, CA--Replace Lease for Expiring $15,421,608 Replacement....................... 6/1/2020
CBOC
21Reno, NV--Building 1 Seismic $200,000 Replacement....................... 4/26/2021
21San Francisco, CA--Correct Seismic $14,823,000 Replacement....................... 9/1/2022
Deficiencies in Buildings 1,6,8 & 12
21Livermore, CA--Livermore Realignment $500,000 New............................... 7/4/2023
(Palo Alto)
21Palo Alto, CA--Polytrauma (Polytrauma- $2,000,000 New............................... 6/30/2017
Ambulatory Care Center)
21Palo Alto, CA--Radiology (Polytrauma- $500,000 Replacement....................... 7/2/2018
Ambulatory Care Center)
21Palo Alto, CA--Research (Polytrauma- $4,300,000 Replacement....................... 4/1/2019
Ambulatory Care Center)
21Monterey, CA--Health Care Center Lease $1,500,000 New............................... 2/28/2017
21San Jose, CA--Outpatient Clinic Lease $15,700,000 Replacement....................... 12/31/2017
21Mission Valley, CA--Clinic $21,365,246 New............................... 6/1/2020
22San Diego, CA--Spinal Cord Injury/Long $31,959,139 Replacement....................... 9/15/2025
Term Care
22Chula Vista, CA--Clinic $7,483,329 Replacement....................... 5/31/2019
22Loma Linda, CA--Health Care Center Lease $5,140,552 New............................... 6/30/2016
22Long Beach, CA--Out Patient 126 $7,104,443 Replacement....................... 11/1/2019
22Long Beach, CA--Seismic Correction-- $1,871,545 Replacement....................... 7/13/2021
Mental Health & Community Living Center
22Los Angeles, CA--Seismic Corrections--12 $6,571,450 Replacement....................... 12/24/2024
Buildings
22West Los Angeles, CA--New Bed Tower $1,581,592 Replacement....................... 2/15/2030
22Bakersfield, CA--Community-Based $5,018,194 Replacement....................... 5/1/2021
Outpatient Clinic Lease
-----------------
Subtotal $858,051,072 ................................
VA Central Office Direct Field Support $4,115,722 ................................
(PCAC/VACASE)
-----------------
Grand Total $862,166,794 ................................
----------------------------------------------------------------------------------------------------------------
Note 2: Activation Funding (AF) covers multiple requirements to bring these projects into full operational
status; i.e., furniture, fixtures, equipment, and support to plan and outfit each health care facility.
Additionally, AF is utilized to cover additional clinical and administrative staff to provide new and
expanded services, and supports other operating expenses; i.e., utilities, maintenance, etc. Based on the
scope and complexity of the project, AF typically is allocated 2-3 years prior to the construction start
date, and 2-3 years post construction completion date based on the activation phasing schedule. Within the
VHA portfolio of activation projects, there are some projects that require activation support and funding
beyond the typical period of activation funding allocation. These are activation funding estimates and may
require adjustments based on changes in the construction and activation schedules.

Question 18. Please provide the weights assigned to the criteria
and sub-criteria in the Strategic Capital Investment Planning Process
Decision Model contained on Page 10-3 of Volume IV of the Budget
Justification.
Response. Below are the definition and weights associated with the
criteria and sub-criteria of the SCIP 2018 Decision model.
strategic capital investment planning process decision criteria
Improve Safety, Compliance, and Security: VA is dedicated to
ensuring its Clients (Veterans) and Customers (VA Staff) are being
served and/or work in a safe and secure environment. Mitigating the
destruction and injury caused by natural or manmade disasters
(including seismic, hurricane, flooding, blast, etc.); ensuring
problems or injuries caused by the potential failure of critical
building systems are avoided; improving compliance with safety and
security laws, Federal Information Security Management Act (FISMA)
standards, building codes, and regulations (including operating room,
supply processing and distribution, inpatient privacy standards, PACT,
and Research functional deficiencies for VHA; counselor offices,
hearing rooms, and public/non-public separation for VBA and equipment
rooms for OIT); mitigating threats to persons (physical security) on a
VA facility (duress alarms for VBA); and ensuring VA mission critical
buildings are able to provide service in the wake of a catastrophic
event are of paramount importance.
The three sub-criteria that projects are measured against with
respect to Improving Safety and Security are:

Safety/Compliance (Excludes Seismic)
Physical and Building Security/Emergency Preparedness
Seismic

Fixing What We Have (making the most of current infrastructure/
extending useful life): VA is committed to managing its buildings in
order minimize the extent to which deficiencies in infrastructure
(including IT infrastructure) and other areas impact the delivery of
benefits and services to Veterans, such as Central Office rent
reduction efforts, depletion dates for National Cemeteries and VBA's
Transformation Initiative. For infrastructure deficiencies, facility
condition assessments (FCA) evaluate the condition of VA buildings
using scores A through F and the criticality of building sub-systems.
The three sub-criteria projects are measured against with respect
to Fixing What We Have are:

Reduce Facility Condition Assessment Deficiencies
(critical)
Reduce Facility Condition Assessment Deficiencies (non-
critical)
Other Self-Identified Gaps (gaps not defined in existing
criteria)

Increasing Access: Serving Veterans is at the core of VA's mission.
We strive to increase access for Veterans (our Clients) by reducing the
time and distance a Veteran must travel to receive the best quality
services and benefits; ensuring Veterans have access to National
Cemeteries, providing virtual access to benefits); providing adequate
supporting structures at VA facilities, such as parking facilities and
gravesite locators; by increasing our ability to handle workload; and
by enabling VA staff (our Customers) to work more efficiently.
The four sub-criteria that projects are measured against with
respect to increasing access are:

Client (Veteran) Access to Services
Customer (Internal) Access to Services
Support Structures (includes parking deficiencies)
Utilization/Workload

Right-Sizing Inventory: In order to provide the highest quality
service to Veterans at the right time and in the right place, VA is
managing its space inventory by removing excess VA-owned space via
demolition, sale or transfer, building new space, collocating (VHA,
VBA, NCA, and Staff Offices using the vacant or underutilized space of
another office), leasing new space, converting underutilized space of
one type to another type, to better suit its mission, and using space
efficiency strategies such as but not limited to teleworking, cubicle
reconfiguration, converting to new space standards, and expanded office
hours to reduce the need for space.
The four sub-criteria projects are measured against with respect to
Right-Sizing Inventory are:

Space--New Construction/Renovation/Conversion/Lease
Space--Disposal (via demolition, sale, or transfer only)
Space--Collocation
Space--Space Efficiency Strategies

Ensure Value of Investment: As a steward of the public's trust VA
is responsible for making capital investments in the most cost-
effective way possible by ensuring new capital investments optimize
operating and maintenance costs, in order to create the best value.
The two sub-criteria that projects are measured against with
respect to Ensure Value of Investment are:

Cost Saving Strategies--identification, quantification,
and description any cost savings realized with the implementation of
this project.
Best Value Solution--completion of a cost-effectiveness
analysis (CEA) on the Status Quo and required alternatives is mandatory
for Major Construction, Minor Construction, and Lease projects; if the
chosen option does not have the best net present value (NPV) an explain
for why the chosen option is the better value is also required

Departmental Initiatives: For improved management and performance
across the Department, capital projects should contribute to
performance goals from the Department's strategic plan, including DOD
collaboration and complying with energy standards established in law
and Executive Orders.
The five sub-criteria that projects are measured against with
respect to Strategic Requirements are:

Empower Veterans to Improve Their Well-being
Enhance and Develop Trusted Partnerships
Manage and Improve VA Operations to Deliver Seamless and
Integrated Support
DOD Collaboration
Energy Standards

office of transition, employment and economic impact
Question 19. Please provide the number of Direct and Management
Direction and Support FTE for the Office of Transition, Employment, and
Economic Impact (OTEEI) for fiscal year 2017 and the request for fiscal
year 2018.
Response. For FY 2017, OTEEI was allocated 40 full-time employees
(FTE) with 10 slots designated as supervisors or program managers. On
November 1, 2016, OTEEI was realigned under VBA's Benefits Assistance
Service (BAS) and the Office of Economic Opportunities (OEO). Of this
total, 23 FTE were realigned under BAS, 7 FTE were realigned under OEO,
and the remaining FTE were realigned to other mission essential
functions. No FTE was allocated for FY 2018 as OTEEI no longer exists.

Question 20. Please provide the total administrative costs for
OTEEI for fiscal year 2017 and the request for fiscal year 2018.
Response. OTEEI was provided $199,000 in operating budget for FY
2017. These funds were reallocated to BAS and OEO, to support mission
functions. In FY 2018, there was not a separate budget submission for
OTEEI as those duties have been dispersed between other business lines
in VBA.

Question 21. Please provide a list of the programs and other
functions for which OTEEI is responsible, including the annual cost or
expenditure per program, for fiscal year 2017 and the request for
fiscal year 2018.
Response. OTEEI is no longer an existing organization. BAS assumed
responsibilities for the Transition Assistance Program while OEO
continues to collaborate with Department of Labor (DOL), non-profits,
and the private sector with the goal of helping Veterans reach their
full economic potential.
education service
Question 22. The Budget Justification noted that Education Service
has indefinitely delayed implementation of the Veterans Approval,
Certification, Enrollment, Reporting, and Tracking System (VA-CERTS)
due to funding constraints.

a. What functions would VA-CERTS provide to Education Service and
to school certifying officials?
Response. VA-CERTS would provide a modernized way for schools to
send enrollment information to VA. Training institutions would be able
to access VA data to include chapter 33 eligibility percentages, which
is not currently available in the existing legacy system. With the
completion of VA-CERTS, it would allow VA to consolidate two legacy
systems into one agile and accessible system.

b. How would VA-CERTS improve the administration of education
benefits compared to the current system?
Response. Improvements would allow for schools to have the ability
to see VA data in order to verify that schools were paid the correct
tuition and fees rates. VA-CERTS would also incorporate the ability to
certify multiple enrollments for students at one time, as opposed to
entering one enrollment at a time. In addition, a newer system would
eliminate the need for duplication of work for VA employees by
combining the Web Enabled Approval Management System and VA-ONCE.
Currently, VA employees have to enter similar information into both
systems.

c. What is the cost to complete and fully implement VA-CERTS, and
when will VA make a decision on completing it?
Response. The cost to implement VA-CERTS is not known at this time.
When initially conceived in 2014 its estimated cost of completion was
$39M. Currently, the Office of Information and Technology is in the
process of re-engineering education systems--eliminating the Business
Delivery Network (BDN), a 51-year-old COBOL-based mainframe system and
consolidating all education processing and payments into Long Term
Solution (LTS) and VETSNET/FAS (Financial Accounting Services). This
elimination of a critical legacy system and the resulting consolidation
of capabilities, beginning now and running through 2018, will greatly
facilitate VA's ability to conduct system enhancements going forward.
Due to the aggressive timeline for accomplishing this work, it is
vitally important to not introduce additional changes or enhancements
during this period to avoid additional complexity and risk.
Implementation of VA-CERTS capabilities could begin once this initial
effort is complete. VA will be in a better position to estimate costs,
timing and how to best implement the capabilities conceived for VA-
CERTS at the end of this calendar year once the engineering plan for
the initial effort is solidified and implementation well underway.

Question 23. The Budget Justification stated VA is working toward
``a fully automated system for all education claims.''

a. What is Education Service's goal for automating original claims
in the Long Term Solution?
Response. The current average processing time for original claims
is 22 days. By fully automating original claims, VA would be able to
provide even faster service for some beneficiaries. VA's long-term goal
is for a beneficiary to be able to obtain an eligibility determination
electronically, as opposed to waiting until VA manually adjudicates a
claim and then mails a letter regarding the eligibility determination.
By full automating the original claims process, there would be a
savings to the government because it would eliminate the costs of
paper, postage, envelopes, and mail handling.

b. What is the cost to complete development of the Long Term
Solution in order to fully automate all education claims?
Response. The cost to complete development of LTS is not known at
this time. We have, however, included projections of $37.5M in our
budget planning for FY19-21. Currently, the Office of Information and
Technology is in the process of re-engineering education systems--
eliminating the BDN, a 51-year-old COBOL-based mainframe system and
consolidating all education processing and payments into LTS and
VETSNET/FAS. This elimination of a critical legacy system and the
resulting consolidation of capabilities, which is beginning now and
will run through 2018, will greatly facilitate VA's ability to conduct
system enhancements going forward. Due to the aggressive timeline for
accomplishing this work, it is vitally important to not introduce
additional changes or enhancements during this period to avoid
additional complexity and risk. Implementation of LTS enhancements
could begin once this initial effort is complete. VA will be in a
better position to estimate costs, timing and how to best implement LTS
enhancements at the end of this calendar year once the engineering plan
for the initial effort is solidified and implementation well underway.

c. How many man hours were spent processing original claims in
fiscal year 2016 and how many are expected to be spent in fiscal year
2017 and fiscal year 2018? What is the average cost of a man hour to
process original claims?
Response. VA does not track the specific number of man hours that
are spent processing various types of claims. However, we track the
number of claims that are processed, and in 2016, we processed 356,756
``original'' claims of all benefit types combined. Our current time to
process an original claim is approximately 22 days.
Prior to automating supplemental claims in September 2012, the
average timeframe for processing a claim was 21 days for supplemental
and 36 days for originals; presently we are operating at 8 days for
supplemental and 22 days for original claims. We would expect a similar
benefit to our timeliness if we automate original claims.

Chairman Isakson. Thank you, Dr. Shulkin. We appreciate
your attendance today.
I want to start off with my questions on the appeals
process. I have consistently said that any change in the
process to improve it must include an acceleration in dealing
with the 470,000 veterans whose claims are pending today at the
VA. Would you agree with that?
Secretary Shulkin. I would like to see that happen.
Chairman Isakson. Well, I am going to give you the same
question, once we give you a chance to make a commitment on
that.
If both appeals reform and budget requests are adopted in
this budget, would VA be able to begin accelerating decisions
for those 470,000 appeals that are pending?
Secretary Shulkin. The appeals that are in the Board of
Appeals are the ones that we are most concerned about. If the
Senate votes to move the appeals modernization forward, as I
think you are saying, Mr. Chairman, we will have a process to
expedite those from the time that the law passes moving
forward.
You are asking about the legacy claims----
Chairman Isakson. Right.
Secretary Shulkin [continuing]. And appeals. We do not have
a plan to make significant progress on those. We are going to
have to whittle away at them. The budget this year will add 142
more staff to the board. That will allow us to make incremental
progress, but I think to deal with the backlog, we would be
looking at 2026 before we dealt with the backlog.
The one hope that I have, Mr. Chairman, rather than adding
a large number of staff to deal with the backlog, is that we
will give current veterans who are in the appeals process the
option of opting into the new process, and if they choose to
opt in--but it is going to have to be their choice--they would
be able to have their appeal dealt with in the expedited
fashion, in the faster fashion.
It is my hope to be able to accelerate the backlog, to
encourage veterans, who unfortunately right now would have to
wait years to get decisions, to opt into the new process.
Chairman Isakson. Well, first of all, let me commend you
because you just gave a patently honest answer to my question,
not that I had expected anything else.
Secretary Shulkin. Mm-hmm.
Chairman Isakson. But it is easy for a department head
sometimes to talk department-ese----
Secretary Shulkin. Mm-hmm.
Chairman Isakson [continuing]. Where we think we heard one
thing and we heard something else, but what I heard you say, in
effect, as far as those legacy appeals are concerned, this
really is not going to do much, even if it is adopted, to take
those legacy claims and move them forward.
Secretary Shulkin. Yes.
Chairman Isakson. Which means we will still have 470,000
veterans claims out there that are old. One of them is 25 years
old. I know that.
Secretary Shulkin. At least. At least.
Chairman Isakson. That is the oldest legacy claim.
Secretary Shulkin. Yes.
Chairman Isakson. Eventually, he will die, and we will get
that one solved, but we have got 469,999 more we have got to.
I hate to--I am going to quote now what I have heard
secondhand, and I will say up front this is secondhand. I have
been told that the VA recently told the Congressional Budget
Office that VA's plan is to, ``very gradually,'' address the
470,000 legacy appeals if appeals reform is passed. Is that the
plan, and how long would that take? I heard your answer being
yes, it is probably going to be very gradual, and yes, it would
be 2026 before we got to it?
Secretary Shulkin. Yes, yes. Mr. Chairman, let me just add
that we share that frustration. I find it really difficult to
tell people who have submitted into the appeals process that
they have 6 years to wait on average to get a response.
So, I have asked the question: how much more would it take
to get that backlog address?
Chairman Isakson. And the answer is?
Secretary Shulkin. I am not sure you want to know because I
was astounded by how much it was.
Chairman Isakson. I want to know.
Secretary Shulkin. Around $800 million.
Chairman Isakson. Senator Sanders, Senator Tester, Senator
Heller, Senator Boozman, Senator Moran, everything we do as a
Committee--Senator Manchin--will pale in comparison to the hell
we are going to catch if it is going to cost $800 million to
handle those claims before 2026. The appeals, we are going to
clean up appeals prospectively in the future with what this
budget proposes, but for the legacy appeals that sit out there,
they are going to still be out there.
Secretary Shulkin. Yes.
Chairman Isakson. The anger is going to get louder and the
frustration deeper. So, we really need--you need to know the
number--$800 million will do it--and we need to be prepared to
try to find some way to do that because all that--all that is
going to happen is there are a lot of people that are going to
get worse, more and more anguish, less and less service, and it
is going to cause us more and more problems with our new
programs we try to bring in place.
Thank you for being candid about that. I want all of us to
be aware as Members of this Committee what we are dealing with,
and we have got to make the hard decisions. One of them is
going to be to get those legacy claims done and not let them
build up in the future because when you do put your new program
in that is going to solve all the problems prospectively--it
sure as hell better!--because if we fix the ones that are back
there and then we have another buildup, we are going to be
madder than a wet hornet. Is that not right, Jon?
Senator Tester. That is a fact.
Secretary Shulkin. Mm-hmm.
Chairman Isakson. Now, very quickly--I took much time on
that, but I thought that ought to be out on the table.
When a veteran, when an American citizen signs up in the
United States military and commits themselves to a period of
service, carries out that service, and it meets the
qualification necessary for them to go for VA health care in
their retirement or when they leave the service, then we are
obligated as a nation to pay for those benefits. Is that not
correct?
Secretary Shulkin. That is correct.
Chairman Isakson. Does anybody up here at the dais disagree
with that? [No response.]
This is not a trick, by the way. I am just trying to get
everybody engaged.
We did Choice, and Senator Sanders and Senator McCain did a
great job of leadership 36 months ago on that. We did Choice to
address the appointment backlog, the wait time periods, and
things of that nature. We did some good things, which brought
about some problems, which we have illuminated and have begun
to solve.
We are now in a situation--and you alluded to it in your
remarks--where you need to find some money to finish out Choice
in this current budget period by moving some money from one
part of the VA budget to the other.
I just want to make sure I am right on this. You have seven
accounts that fund health care benefits; is that correct?
Secretary Shulkin. Community Care.
Chairman Isakson. Community Care, but there are seven
accounts?
Secretary Shulkin. Yeah, seven. Right.
Chairman Isakson. One of those is Choice. One of those is
Community Care, care in the community. So, you have enough
money; you are not asking for new money to be given to you by
appropriators or by the Congress. You are asking to move
existing appropriated money for health care benefits under one
stovepipe in the VA to another stovepipe to achieve balance,
but there is no new appropriation. Am I correct?
Secretary Shulkin. That is correct. We have enough money to
be able to make sure that all veterans will get the care that
they need.
We need your help to figure out the best solution about how
to get more money into the Choice account.
Chairman Isakson. I am raising this only as a good talking
point for all of us on the Committee to have a discussion,
which I am sure we will have on this, but I want to get that
point also. We sometimes get bogged down in legi-speak, words
like ``mandatory'' and ``discretionary'' and this acronym and
that acronym, when it is all the same money in the case you are
talking about. It is for veterans health care benefits. It is
in your current appropriations. It is not any new money. We are
not raising any expenditure to the taxpayer. We are just trying
to meet our obligation to our veterans.
So, we need to find the way to do that on not just a stop-
gap manner but permanently, and one of those ways might be to
see to it that all the veterans benefits for health care are
paid out of one account and is under the Secretary of the VA.
Is that not correct?
Secretary Shulkin. That would make sense to me, Mr.
Chairman.
Chairman Isakson. Senator Tester.
Senator Tester. Thank you, Mr. Chairman.
Once again, thank you for being here, Dr. Shulkin.
You talked about--and I want to just follow up on the
Chairman's questions. You talked about in your opening
statement Choice being down to $821 million and the fact that
there was additional dollars in Community Care that you wanted
to transfer over.
You had put out a rule or edict. I do not know what you
want to call it. What is it called?
Secretary Shulkin. A directive?
Senator Tester. A directive. That is better. A few days ago
that directive said you wanted to go to the original intent on
Choice, which would dry up a lot of how the dollars were spent.
Then, a day or two later, you rescinded that.
Thank you for the breakfast yesterday. We had a great
breakfast, and we talked yesterday about potentially doing a
fix legislatively.
I was told today that another directive was put out today
that reinstated that rule to go back to the initial. Is that
correct?
Secretary Shulkin. Let me try to be accurate about what
happened. We noticed that there was an imbalance in our two
checking accounts.
Senator Tester. Yes.
Secretary Shulkin. On Friday, we sent out a directive
saying----
Senator Tester. Right.
Secretary Shulkin [continuing]. Stop spending from this
account.
Senator Tester. Right.
Secretary Shulkin. OK. Start spending from this account.
Senator Tester. Correct.
Secretary Shulkin. We were afraid after seeing that
directive that we were going to confuse the field----
Senator Tester. Bingo.
Secretary Shulkin [continuing]. And so we rescinded that
memo.
Senator Tester. That is correct. Right.
Secretary Shulkin. The field, once we rescinded the memo,
said, ``OK. We get it. You are rescinding the memo, but will
you give us some direction about how we should spend out of
both of these accounts? because we still do have money in the
Choice account. We have more money in Community Care.''
So, we sent out four principles about the appropriate use
of Choice and the appropriate use of Community Care funds,
while we are working with you to figure out the best solution
about how to get the appropriate money in each of those
checking accounts.
Senator Tester. Did those four principles--I do not have a
problem here.
Secretary Shulkin. Yeah.
Senator Tester. All I want is predictability because I
think it is important.
Did those four principles tell the folks to go back to the
original use of Choice?
Secretary Shulkin. It told them--it told them to use Choice
for the appropriate use of Choice, which is clearly as you
legislated, which is 40 miles, 30 days, and to use Community
Care for the original use that they were using it for.
Senator Tester. OK. With all due respect, the directive was
put back in place, and by the way, I do not have a problem with
the first directive. I do not have a problem with staying the
way it was. It has got to be driving your folks on the ground
and it is going to be driving our veterans crazy if it is yes,
no, yes. Then, in a week, when we fix this, it will be no
again, so that is all I ask.
That uncertainty, by the way--and I will not speak for
everybody on this Committee, but I have a notion that it will
be this way for everybody on the Committee--does not add
confidence to the VA moving forward. I will just tell you. Do
you get my drift?
Secretary Shulkin. Absolutely. Let me just say and----
Senator Tester. Yes.
Secretary Shulkin. Listen, I would not disagree or argue
with you.
Senator Tester. Yes.
Secretary Shulkin. The Choice Program has been difficult to
administer----
Senator Tester. Yeah, yeah.
Secretary Shulkin [continuing]. Difficult to understand----
Senator Tester. Yep.
Secretary Shulkin [continuing]. And very complex.
The first memo was rescinded----
Senator Tester. Yeah.
Secretary Shulkin [continuing]. And remains rescinded
because what it said is ``Do not go to Choice.'' We do not mean
that. What we have tried to do is provide guidance to say,
``You can use choice, and we want you to use Choice
appropriately, but we have Community Care funds. We want you to
use those.''
We understand----
Senator Tester. OK.
Secretary Shulkin [continuing]. But it is different than
the first memo.
Senator Tester. OK. I would just say this, communication is
a very good thing, we need to have communication. The breakfast
we had yesterday was very, very important.
Secretary Shulkin. Mm-hmm.
Senator Tester. I think everybody who was at that breakfast
will do it, and hopefully, we can have more of them. But, there
was never an indication of this happening at the breakfast
yesterday, or we could have talked about it some more. I do not
want to micromanage the VA.
Secretary Shulkin. Mm-hmm.
Senator Tester. It is your baby. You would hang me out to
dry if I tried to do that, and rightfully so. We just need
predictability, that is all.
By the way--when I say we, I mean this Committee--but more
importantly are the people sitting behind you who need that
predictability.
Secretary Shulkin. Mm-hmm. Absolutely.
Senator Tester. Otherwise things are going to go upside-
down pretty quick.
I have got a bunch more questions, but I will refer to the
next person in line.
Secretary Shulkin. OK.
Chairman Isakson. Senator Moran.

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

Senator Moran. Chairman, thank you. I want to be in the
position agreeing with Senator Tester and disagreeing with
Senator Tester.
Senator Tester. Uh-oh.
Senator Moran. The memos are different, and there is a
significant consequence to the difference.
Secretary Shulkin. Yes.
Senator Moran. When we visited about the first memo, the
consequence of that would be that the third-party
administrators would have no role to play, and the networks
potentially could go away. Lie dormant?
Secretary Shulkin. Exactly.
Senator Moran. The second memo says Choice is alive and
well----
Secretary Shulkin. Absolutely.
Senator Moran [continuing]. And it is to be used in these
circumstances, which are the ones that were defined by the
original Choice Act.
Secretary Shulkin. Right.
Senator Moran. I do not actually know what--why that is
different than how it was being used. How is Choice being used
different than 40 miles and 30 days?
Secretary Shulkin. Because we were also putting everything
that we could through Choice, especially services that were not
being offered at the VA.
So, Senator Moran, you have it correct. That was exactly
what we tried to do between the first and second memos. Senator
Tester is pointing out that we have some work to do in getting
our communications a little bit better.
Senator Moran. That is the part I was going to agree with
Senator Tester.
Secretary Shulkin. Yes. I agree with him too.
Senator Moran. Because on that point----
Secretary Shulkin. Yes.
Senator Moran [continuing]. I would make the case on behalf
of Senator Tester that----
Secretary Shulkin. Right.
Senator Moran [continuing]. We had a hearing on Wednesday
on Choice.
Secretary Shulkin. Yes.
Senator Moran. Your first memo goes out on Thursday or
Friday.
Secretary Shulkin. Friday.
Senator Moran. This conversation never occurred with people
who care a lot about Choice but care a lot about veterans.
Secretary Shulkin. I will say everything that both of you
have said is accurate, and I will tell you--and I hope that
you----
Senator Sanders. You are quite the politician, I must
confess. [Laughter.]
Secretary Shulkin. Yeah.
I will tell you that, look, my integrity is very important.
On Wednesday, Senator, I did not know this information. I
learned about it on Thursday.
Senator Moran. I assumed that was the case.
Secretary Shulkin. Yes. Thank you.
Senator Moran. Let me then again try to highlight why
keeping Choice in existence--and it is not just a matter of
transferring. How we transfer the money or what pot of money it
comes from is an important issue, and that revolves around
whether or not Choice has a future today and again when we
potentially reauthorize its existence into the future.
When I say that it matters, because if Choice is not being
used, then our intermediaries are not being paid, the network
that has been established under Choice goes away, and you have
Community Care but no Choice and no network, no third-party
intermediary. It is not just a matter of transferring money
back and forth. It is a matter of making sure that Choice is
viable so that the network stays in place. Does that make
sense?
Secretary Shulkin. Yes. We worked very hard to do that, and
I agree with you. We want to keep that in place.
Senator Moran. A part of this that I still am confused
about, because your response in regard to Chairman Isakson was
that we just need transfer authority. I certainly have been in
these hearings enough to know that you have said that more than
once, and I think that is something that we are interested in.
It makes no sense to have unneeded barriers.
Secretary Shulkin. Mm-hmm.
Senator Moran. We also need to make certain that this issue
of mandatory is handled in a way that, again, Choice is
mandatory, and that money has to stay available so that the
program stays viable.
Here is what I wonder, is that just--and, again, in
response to the Chairman, I think you said, ``We are not asking
for any new money.''
Secretary Shulkin. Right.
Senator Moran. My understanding is that you have about $2
billion in the Community Care account. Is that an accurate
number?
Secretary Shulkin. Unobligated, yes.
Senator Moran. Unobligated. So, at some point in time--and
I do not know how soon that is, maybe the VA does--that money
becomes scarce. The fix can only last so long before both the
Choice account and the Community Care account are insufficient
to meet the community, the health care needs through Community
Care. Is that true?
Secretary Shulkin. We have enough money to get us through
the end of the fiscal year in both--if we could balance the
accounts correctly, we could make it through till the end of
the year to get Community Care paid for in both Choice and
internal Community Care.
Senator Moran. So, the $2.9 billion in the fiscal year 2018
Budget Request is not needed until fiscal year 2018?
Secretary Shulkin. I am going to defer to my CFO, but I
would have said yes.
Mr. Yow. Yes, sir. That is a requirement that is for next
year. Now, the one caveat is in the budget, we assumed we were
going to carry over $626 million of this year's Choice money
into next year. Our actual requirement for 2018 is $3.5
billion. We are going to consume that $626 million, we think
now, before the end of this year, so we will have a hole next
year of about $600 million.
Senator Moran. That hole exists in mandatory dollars, not
discretionary dollars?
Mr. Yow. Yes, sir.
Senator Moran. Which then means this Committee has to act
to authorize additional mandatory spending for whatever the
account is then called.
Mr. Yow. Yes, sir.
Senator Moran. Is that true?
Mr. Yow. Unless we were to find some other offset somewhere
in our direct appropriated discretionary funds.
Senator Moran. I guess my takeaway is, assuming that your
budget numbers are right, Mr. Yow and Mr. Secretary, that there
is no emergency is what you are telling us? That Choice will
continue between now and the end of the fiscal year without any
additional input of money as long as there can be a transfer
of, I suppose, discretionary spending into the mandatory
account.
Secretary Shulkin. Yeah.
Senator Moran. Is that true?
Secretary Shulkin. The last part that you said is true, but
if there is no action at all by Congress, then the Choice
Program will dry up by mid-August.
Senator Moran. You have no ability, in your view, to fix
the transfer issue, the discretionary and the mandatory, two
components, to combine those into an account without
legislative authorization?
Secretary Shulkin. That is correct.
Senator Moran. So, the emergency is not more money.
Secretary Shulkin. Right.
Senator Moran. The emergency is changing the law to allow
you to spend money that you have, although it certainly sounds
like it creates a likelihood of fiscal shortfall, dollar
shortfall in fiscal year 2018, even if we appropriate the $2.8
billion in the President's request.
Secretary Shulkin. I think everything you said is correct,
and as Mr. Yow said, we are not seeking, though, additional
monies. If we needed to, we will identify the offset to the
$600 million for 2018.
Senator Moran. The Chairman has his finger on the----
Chairman Isakson. No.
Senator Moran. I think I have had my fair shot. We may have
another chance. Thank you.
Chairman Isakson. Well, that is very helpful, and I
apologize, Senator Sanders. I am going to take 1 minute just to
clarify a couple of points.
Dr. Shulkin, I am a veteran. I served in the military in
Afghanistan. I served my years to necessarily make me eligible
for VA health care. I am a veteran. I am in VA health care. If
I go to the VA hospital for a medical need related to my
service or to just regular health care, you are obligated as
head of the VA to pay for it and deliver that health care to me
the best possible way possible. Is that not right?
Secretary Shulkin. Yes.
Chairman Isakson. So, it is mandatory that you do that. You
do not have the discretion as director of the VA to not provide
me with health care because you did not get enough money?
Secretary Shulkin. Correct.
Chairman Isakson. You have the obligation to manage the
money you have, and if you need more come to get more money
appropriated. Is that not correct?
Secretary Shulkin. Yes.
Chairman Isakson. That is why when we talk about mandatory
and discretionary; I do not think it is a matter of discretion
if a veteran's health care is at risk for not having enough
money. We have got to find the money, and it is mandatory that
we provide that money.
Secretary Shulkin. I would agree.
Chairman Isakson. What you are talking about in
transferability is after we decide to put X number of dollars
in however many accounts that are in the VA, you want to be
able to take money out of any of those accounts to pay for the
benefit of that veteran without having to go to a secondary
step within the VA to get money removed--moved by somebody else
because something is named ``mandatory'' or named
``discretionary.''
Secretary Shulkin. Correct.
Chairman Isakson. Is that correct?
Secretary Shulkin. Yes.
Chairman Isakson. I just want to make sure I had that
right. I am not sure I said it right, but----
Secretary Shulkin. You said it perfectly.
Chairman Isakson. It is clear to me now. Clear as mud,
anyway.
Secretary Shulkin. OK.
Chairman Isakson. Senator Sanders.

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

Senator Sanders. Thank you very much, Mr. Chairman.
Dr. Shulkin, great to see you.
On page 3 of your testimony, you point out, I think, what
most veterans organizations and veterans know, by and large,
the VA has a pretty good health care system. You quote a study
published by the Journal of the American Medical Association
(JAMA), where researchers compared hospital-level quality care
on 129 VA hospitals with over 4,000 non-VA hospitals, and you
found that you have better outcomes in the VA on six of nine
patient safety indicators, and the other three were about the
same. That is pretty good. I mean, that speaks pretty well for
the system that you are running, despite all of the criticism
we hear every day. True?
Secretary Shulkin. Yes. Yes, sir.
Senator Sanders. Let me ask you a question that has always
fascinated me. Maybe you can give me an answer. I held a
hearing a few years ago on the Health Committee talking about
preventable deaths in American hospitals. According to--I am
looking at an article right now in the New England Journal of
Medicine, and they say that hospital medical errors are the
third leading cause of death in the United States. 700 people
every single day die in this country from hospital medical
errors. How is the VA doing compared to non-VA hospitals on
that issue?
Secretary Shulkin. Well, as the article in JAMA suggested,
the VA is actually performing better on patient safety--and
patient safety is defined by medical errors--than, on average,
the private sector. Of course, every hospital in America,
including VA, are always looking for ways to get better, but
the VA has systems in place that help it perform better than
many of the private-sector hospitals.
Senator Sanders. Well, congratulations for that. I know
that the veterans appreciate that, which takes me to the point
that Senator Tester made a moment ago, and that is what we hear
every time there is a hearing with veterans, they like VA
health care.
Secretary Shulkin. Mm-hmm.
Senator Sanders. What I do not want to see--and I think
Senator Tester--many of us do not want to see the shifting of
funds that go to traditional VA health care moved to the Choice
Program. Regarding the Choice Program, we have had long
discussions. We will continue to discuss that.
I am a little bit distressed that a significant amount of
money in President Trump's budget is going to Choice, not quite
so much going to traditional VA.
Another question. You mention on page 9 what is obvious.
You say that VHA is the largest health care system in the U.S.
in an industry where there is a national shortage of health
care providers. We have a major doctors crisis, especially in
certain areas: primary health care relief, maybe psychiatry/
psychology.
Secretary Shulkin. Those are the two biggest, yes.
Senator Sanders. OK. A couple of years ago when I helped
work on the major veterans bill, we put--we expanded a program
for medical education. It was the Section 302 of the Health
Professionals Educational System Program. What that does,
essentially, Mr. Chairman, is--what it does is help. As you
know, medical school is now outrageously expensive, which is a
very serious problem.
I talk to young doctors who are $3-400,000 in debt. OK?
They are probably not going to go to work at the VA. They are
going to go work where the money is. I would like to see that
program expanded. What it does is provides debt forgiveness.
You want to work for the VA for X number of years; we will
forgive the debt that you have incurred at medical school. Is
that an idea that makes sense to you?
Secretary Shulkin. Senator Sanders, both of the ideas that
you said and that the Ranking Member talked about make a great
deal of sense to me. I do not want to see VA care diluted
because we are getting more veterans treated in the community.
I want to see more veterans treated in the community because
they need the care and VA cannot provide it right now.
So, what we are proposing and hoping to work with you in
this new Choice Program are the two things you have talked
about. Right now, we are restricted to a 1 percent transfer
from care in the community back into the VA or vice versa. We
would like to see that aperture open so that we could actually
take money that was in the budget for sending veterans out and
reinvesting more of it into the VA. We think that is very
important. It should be done at the local level when every
local VISN makes its decision about what services the VA needs
to strengthen in.
On the GME issue, graduate medical education, I could not
agree with you more. The program that you were helpful in
crafting was a great success.
Senator Sanders. Is it working well?
Secretary Shulkin. It is. It is. We need to do more of it.
We are proposing exactly what you are saying, which is creating
more GME spots. The country needs them. VA would pay for them,
and in exchange, it would be like the military or public health
service.
Senator Sanders. Or the National Health Service Corps.
Secretary Shulkin. Or the National Health Service Corps.
Afterwards, they would give 5 years back to the VA.
Senator Sanders. Right.
So, Mr. Chairman, this is an issue where I think we can go
a long way in attracting excellent physicians and nurses,
perhaps----
Secretary Shulkin. Yeah.
Senator Sanders [continuing]. Into the VA by doing a debt--
expanding the debt forgiveness program, which I understand is
already working well. I would look forward to working with you
on that.
Last question is--I am quoting from a publication called
Families USA: ``Cutting Medicaid would hurt veterans. Efforts
in Congress to cut Medicaid jeopardize a critical source of
health coverage for veterans. Approximately 1.75 million
veterans, nearly 1 in 10, have Medicaid as a source of
coverage.''
If the Republican health care plan goes through--and I am
going to do everything I can to see that it does not, but if it
does go through and Medicaid is cut by over $800 billion in a
10-year period, I assume that means that a lot more veterans
are going to be flocking into the VA. Am I correct on that?
Secretary Shulkin. I would think so. We are a safety-net
organization, and we tend to have veterans without other health
access come to the VA. I do not want to sound like a
politician, but, you know, as the Chairman said, our role is to
provide that care. We would need to do that.
Senator Sanders. So, if veterans lost their Medicaid, there
is a reasonable possibility, many of them would turn to the VA
for care.
Secretary Shulkin. I believe so.
Senator Sanders. And you need additional health to
accommodate that large number of veterans?
Secretary Shulkin. Yes.
Senator Sanders. Thank you very much.
Chairman Isakson. Thank you, Senator Sanders.
Senator Rounds.

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

Senator Rounds. Thank you, Mr. Chairman.
Mr. Secretary, last week, we had a rather--I guess I would
call it a spirited discussion about the Emergency Care Fairness
Act, and under the VA's Fiscal Year 2018 budget proposal, a
budget line to pay for emergency care is still lacking.
However, the VSOs' Independent Budget has included a
recommendation of $1 billion for 2018.
I guess my question, sir, would be, what is the status of
the Staab appeal, which is the appeal on the Emergency Care
Fairness Act, the way that it is being interpreted, and at what
point will the VA formally request the necessary funds to pay
for the emergency care for our veterans?
Secretary Shulkin. Well, first of all, Senator, I
appreciated the interchange that you and I had. I think that
you were making excellent points, and you were actually on the
right side of this issue.
We have done two things since we talked last. First, we
have completed all of the regulations to be able to move
forward with payment of the Staab claims, and we have now
transmitted them to the Office of Management and Budget. That
part is complete, so that is moving forward.
Senator Rounds. That is good news.
Secretary Shulkin. The second thing is that after
considering what you said and also I think Senator Blumenthal,
I have decided to voluntarily withdraw the appeal to the Staab
case.
Senator Rounds. Oh, that is great news, Mr. Secretary. I
think what that means is the last time we checked, there were
370,000 claims outstanding that now can expect to receive
payment for the emergency room care that they have expected
since 2010?
Secretary Shulkin. Well, we still have to go through the
rulemaking process. That is why we transmitted those rules to
OMB, and they need to go through the process. I do not want to
set time expectations, but yes, we are moving in that direction
to adhere to the judge's ruling on this.
Senator Rounds. That is a very positive development. For
those 370,000 individuals, this is great news. Any possibility
of expediting that rulemaking process?
Secretary Shulkin. We did. We got the rules over there very
fast, and what happens now, we will certainly encourage the
administration and be supportive of that.
Senator Rounds. I cannot tell you how glad I am to hear
that. I appreciate the fact that you have taken the time to get
personally involved in this and to work through that issue. I
think that is what veterans want to see coming from the VA, to
be focused on what the veterans need, what the veterans care
should be, and then when we make a promise, we honor that
promise. I think that is what veterans are expecting from the
VA, and I think this is a major first step in that. Thank you
very, very much for your work on it, your attention to this,
which I think will pay dividends for the entire organization
for years to come, so thank you.
Mr. Chairman, I would yield back time.
Thank you, sir.
Secretary Shulkin. Thank you.
Senator Rounds. That is great news.
Secretary Shulkin. Good.
Senator Boozman [presiding]. Thank you, Senator.
Senator Manchin.

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

Senator Manchin. Thank you, Mr. Chairman.
Secretary Shulkin, recently, you announced that you would
be scrapping the current electronic health care record system
(EMR) and adopting the same system that DOD uses from the
Cerner Corporation based in St. Louis. While I am certainly in
favor of making it easier on veterans transitioning from DOD to
VA, my concern is that speed of this decision will have second-
and third-order effects that could be detrimental. My questions
to you are: are you concerned that there will be increased risk
in having one company manage all these records? What if Cerner
becomes the Health Net of electronic health records?
Secretary Shulkin. Wow. Well, first of all, I think in
making a decision of this magnitude, there are absolutely risks
involved with it. I have to tell you, I thought the risks were
greater to do nothing.
Senator Manchin. OK.
Secretary Shulkin. That considering the maintenance
required on VistA, the expense that will be required, and our
lack of ability to maintain qualified software developers
within VA, the risk of doing nothing was worse.
I think that DOD went through a strong due diligence
process. I think that they selected a stable platform. We have
benefited a lot from their due diligence and expertise, and
that was one of the reasons why I went in that direction. There
is always a risk, Senator, especially when you transfer
systems, so----
Senator Manchin. Here is another part.
Secretary Shulkin. Yeah.
Senator Manchin. I have got two more parts to this.
Secretary Shulkin. Yeah.
Senator Manchin. By waiving the bidding process, which you
just spoke about, how are you guaranteeing Cerner is not taking
the VA for what we would consider a little bit of a ride?
Secretary Shulkin. Well, because all that I have done is
start the process of negotiations. We have not committed to any
funding. We have not committed to the contractual----
Senator Manchin. How will you know if the price is
competitive if you have nothing to compare it to?
Secretary Shulkin. Well, we certainly know the price that
DOD paid. We know the price that we are currently paying to
maintain our systems, and we are going to be seeking the best
way to do this for taxpayers.
Now, most of the cost of a transfer of system is actually
in internal change management, not in software licensing
prices.
Senator Manchin. I notice it is not in your budget right
now.
Secretary Shulkin. Right.
Senator Manchin. I was going to ask, how are you going to
absorb the cost?
Secretary Shulkin. We are going to have to go to the
appropriators and lay out a plan so that they could decide
whether they believe this is also a good decision.
Senator Manchin. Well, we know this hearing is about care
in the community. While ensuring the records transfer between
DOD and VA, it is important we must also ensure that records
transfer and their operability between VA and non-VA providers
is just as seamless. Will Cerner be undertaking that as well?
Secretary Shulkin. Yes. What I said in the decision on the
EMR is that while it is a decision to move forward with a
common platform with DOD, this will not be the DOD system. VA's
needs are much different in that we have to be interoperable
with our community partners, and many, many--in fact, 80
percent of our community partners are not necessarily on the
Cerner platform. So, we are going to have to create a system
that does several things that the DOD does not. We are not
going to be scrapping VistA. We are going to have to connect
into and maintain our 30-year database, and we are going to
have to be interoperable with community partners.
Senator Manchin. Very quickly, I have one more, and then I
have a real quick question. There is no Assistant Secretary of
IT, nor is there an Under Secretary for Health. So, how are you
undertaking this without those positions filled?
Secretary Shulkin. Well, fortunately, we have very
competent acting people in those roles, but we look forward to
getting those roles permanent.
Senator Manchin. You feel like you have the personnel to do
it?
Secretary Shulkin. I feel like we are very lucky to have
very competent acting people, but I need to have permanent
people in those roles soon.
Senator Manchin. My other question is concerning the opioid
epidemic, which is the number 1 problem I have in my State----
Secretary Shulkin. Yes.
Senator Manchin [continuing]. Not just with the general
population, but my veterans----
Secretary Shulkin. Yeah.
Senator Manchin [continuing]. With my veteran community.
What I am concerned about, what the new non-VA care redesign
looks like, I am looking for assurances that when we do new
provider agreements on any contracts with non-VA care
providers, we are going to be making sure that they understand
that VA will not tolerate the over-prescription of opioids.
More or less, we have a lot of pill mills; they get these
people hooked, and they keep them hooked. How are you going to
ensure or how--what is your oversight? Are you prepared for
this?
Secretary Shulkin. Well, I have to say I do not think we
are doing a good enough job in this. I think the country needs
to do a lot better.
Senator Manchin. We have challenges within the VA ourself.
Secretary Shulkin. Yes.
Senator Manchin. We know that, and you all have been
addressing that----
Secretary Shulkin. Right, right.
Senator Manchin [continuing]. And I appreciate it. A lot
more needs to be done. You have very little control when you go
out into the private sector.
Secretary Shulkin. I think we have really made good
progress in the VA on the oversight. We have seen the 33
percent reduction in opioid use since 2010. We monitor patterns
of prescribing. I have the concern about going out into the
community that you have.
Senator Manchin. What I am saying is the contracts that you
write, if I am a provider----
Secretary Shulkin. Yeah.
Senator Manchin [continuing]. If I am a non-VA provider,
where the new act lets that person come to me, I contract with
the VA to take care of these people.
Secretary Shulkin. Mm-hmm.
Senator Manchin. Are there conditions on that if I
prescribe? Do I have to follow prescription guidelines? Are you
going to be monitoring that as far as opioid prescription
guidelines?
Secretary Shulkin. Today, there are not those requirements.
I think this is a really good area for us to come back to you
with some thoughts on.
Senator Manchin. Sir, we need your help on this----
Secretary Shulkin. I know. Yep.
Senator Manchin [continuing]. Because you are on the front
lines.
Secretary Shulkin. Thank you.
Senator Manchin. Thank you.
Thank you, Mr. Chairman.
Chairman Isakson [presiding]. Thank you, Senator Manchin.
Senator Heller.

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

Senator Heller. Mr. Chairman, thank you.
Mr. Secretary, thanks for being here.
Secretary Shulkin. Thank you. Sure.
Senator Heller. Glad to have you here.
I want to talk about the budget for just a minute, if I
may; specifically, I want to talk about the individual
unemployability (IU) cuts.
Secretary Shulkin. Yeah.
Senator Heller. Can you explain the rationale of the
thought process that reduced this?
Secretary Shulkin. Yes, Senator Heller, my starting point
on this is that we always have to do better for our veterans,
and we have to deliver on our commitments that we have to our
veterans. The President's budget includes significant increases
in both discretionary and mandatory funds and makes Choice a
permanent part of funding.
But, we have a responsibility to use our current funds in a
way that makes the best sense for veterans and for taxpayers.
So, we proposed a part of the process that would revise the
individual unemployability benefit.
The budget is a process, and this was part of a menu of
opportunities that we had for thinking how we could make the
budget process better. As I began to listen to veterans and
their concerns--VSOs in particular--it became clearer that this
would be hurting some veterans and that this would be a
takeaway from veterans who cannot afford to have those benefits
taken away. I am really concerned about that.
So, what I would like to say is that this is part of a
process. We have to be looking at ways to do things better, but
I am not going to support policies that hurt veterans. I would
look forward to working you and all the Members of the
Committee on figuring out how we can do this better. We have
budget numbers and targets that we have to hit, but we should
not be doing things that are going to be hurting veterans that
cannot afford to lose these benefits.
Senator Heller. I appreciate hearing that. Do you know how
many veterans would have been affected by this change?
Secretary Shulkin. Yes. We have 300,000, Jamie?
Mr. Manker. Yes. There are 300,000 that are in receipt of
IU, about 330,000. About 210,000 of those are over the age of
60 and, therefore, would have been affected.
Senator Heller. Would have been.
Secretary Shulkin. Yeah.
Mr. Manker. Correct.
Senator Heller. It would not have been--it would have been
retroactive?
Mr. Manker. It would have been point forward, but to
include all veterans in receipt of IU. So, when you say
retroactive, I do not believe we would pull any benefits that
we have distributed back. However----
Senator Heller. Right. No, no. I am just saying that if you
had the benefit, you could lose the benefits----
Secretary Shulkin. Yes. Yes.
Mr. Manker. Yes, sir. That is correct.
Senator Heller [continuing]. Even if you are currently
receiving it?
Mr. Manker. That is correct.
Secretary Shulkin. Yes. That was the proposal, and--but we
do look forward to working with you to figure out how we could
do this better.
Senator Heller. I appreciate your concern for that.
Do you know what the average is per veteran on this IU,
what the average intake is?
Mr. Manker. The average payment?
Senator Heller. Yeah.
Mr. Manker. It is roughly $1,600.
Senator Heller. Roughly $1,600.
Mr. Manker. Yes, sir. That is on top of--you have to be
rated between 60 percent to 100 percent, and it takes you to a
temporary 100 percent. Sixteen percent is--or beg your pardon--
60 percent is roughly $1,600.
Senator Heller. All right.
Mr. Manker. It is about 13 or more.
Senator Heller. You can understand the financial burden
that $1,600 may pose for an individual, and what I am more
concerned about is, of course, their long-term retirement. They
may have not prepared or been prepared if in believing that
that $1,600 might be there is I think the concern.
Secretary Shulkin. I think that is the issue, and this is
why we had identified this as an opportunity. I think if we
were designing this system from the beginning, we would not
have used unemployment insurance to fund people's retirement. I
think that was the conflict.
The end result is that is the benefit, and to withdraw this
benefit from people who rely on that money is something that
would be very difficult to do.
Senator Heller. Well, I appreciate your concern for this.
Can I change topics for just minute----
Secretary Shulkin. Mm-hmm.
Senator Heller [continuing]. And make sure I understood
this correctly? Did you say that you had a decision-ready claim
in 3 days?
Secretary Shulkin. We have had 12 of them so far, I think.
Yes.
Senator Heller. Twelve of them.
Secretary Shulkin. Yes. So, on September 1 we are going to
be rolling that out across the country.
Senator Heller. I mean, that is big news.
Secretary Shulkin. That is big news.
Senator Heller. I am glad because I have been working with
this issue for years; and to think that you could actually turn
one around in 3 days is pretty incredible.
Mr. Manker. That is a big deal. We are piloting in St. Paul
right now, again, with a couple of our VSOs. If the VSO brings
in the claim ready to be decided, we know----
Senator Heller. Right. It has got to be ready. I get it.
Mr. Manker. No further development and we decide the claim.
Senator Heller. We had a previous Secretary who said that
he could get the claims down to zero by--I think it was 2015.
What is the status now? If this works as well as----
Secretary Shulkin. I can tell you I will not say that.
[Laughter.]
No. I mean, so----
Senator Heller. No predictions. No predictions----
Secretary Shulkin. Yeah.
Senator Heller [continuing]. On where the claims will be.
Secretary Shulkin. No. We right now--we are at about
90,000?
Mr. Manker. As of this morning, it was 94,000 that we had.
Senator Heller. Yeah. That is about what my notes say, too.
Secretary Shulkin. Yeah.
Senator Heller. There are about 1,200 of them in Nevada.
Secretary Shulkin. Yeah, yeah. I think our goal, Jamie, is
by the end of the calendar year to about 70,000?
Mr. Manker. That is right. That is right.
Secretary Shulkin. These decision-ready claims, we think
will take 10 to 15 percent of them off. So, we will not start
rolling them out till September, but that will begin to whittle
that down. We hope in 2 years to be down below around half of
where we are now.
Senator Heller. OK, OK.
Mr. Secretary, thank you, and, Mr. Chairman, thank you for
the time.
Chairman Isakson. Thank you, Senator Heller.
Senator Murray.

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

Senator Murray. Thank you, Mr. Chairman, and thank you all
for being here.
Secretary Shulkin, in last year's budget request, the VA
estimated that it would need $725 million in fiscal year 2017
and $840 million in 2018 for the Veteran Caregiver Program, yet
in the first budget of the Trump administration, you plan to
only use $521 million in 2017 and $604 million in 2018. Those
are cuts of about 30 percent. Meanwhile, I am hearing from so
many of my constituents, as I am sure everybody is, of
caregivers being dropped from the program with no explanation
and no justification. An investigation by NPR found the
Charleston Medical Center actually dropped 94 percent of its
caregivers; 83 percent in Prescott, AZ; and 83 percent in
Augusta, GA.
It seems to me, watching this, that this is just another
way the Administration is balancing its budget on the backs of
veterans in need. How do you explain those numbers?
Secretary Shulkin. Well, let us just talk about the three
things quickly that you said. What was reported on in
Charleston is completely unacceptable; 95 percent of revocation
of caregiver benefits, unacceptable. That is why we suspended
the program, and today, there are no revocations across the
country going on until we get the guidelines better understood
and in better shape.
Senator Murray. That is the freeze that you are talking
about?
Secretary Shulkin. That is the--right, right. That is the
freeze.
Senator Murray. That is only a temporary measure----
Secretary Shulkin. It is a temporary measure----
Senator Murray [continuing]. And I think you did the right
thing.
Secretary Shulkin [continuing]. Until we revise policy,
because I will not accept giving benefits and then taking 94
percent of them away. That is ridiculous.
The second thing is, is that on the right amount of money
to request? We only spent--even though $750 million was in the
budget, we only spent $521 million. So, in budget planning for
next year, they requested $600 million, which is a modest
increase from where we are.
Our hope, as you know--and you have been a tireless
advocate for this--is to expand caregiver benefits, and we do
plan on working with you with that. We hope by expanding
caregiver benefits, particularly to older veterans, who today
are not getting the benefit the way that they should, that we
actually find that that is going to be cost effective, because
remember we pay for long-term care.
Senator Murray. Right.
Secretary Shulkin. My plan is to be responsible to
taxpayers. I am going to seek to expand caregiver benefits to
older veterans, but I am going to pay for it myself without
asking the taxpayers to increase the bill.
Senator Murray. OK. Well, the Ranking Member and I wrote to
you a couple months ago suggesting a series of important
reforms. Those issues have not been addressed, and I would just
like to see the freeze extended until all of those issues in
that letter were discussed. Can you do that?
Secretary Shulkin. Yeah. Do you happen to have the date of
the letter? If not, I will find it.
Senator Murray. It was about 2 months ago.
Secretary Shulkin. Two months ago. Of course, absolutely.
Senator Murray. OK. Let me go to the shortfall in the
Choice Program. I know that you wrote to TriWest and Health Net
telling them to return referrals for care, including for
veterans that are currently waiting for care. How many veterans
are going to be affected by that?
Secretary Shulkin. We ask--when they cannot appoint an
appointment within a period of time in the contract, we ask
them to return it. They are returning large numbers to us.
Do you know, Mark?
Mr. Yow. I do not. I am sorry.
Secretary Shulkin. This is an ongoing process. Before, they
would just wait until--it took weeks and weeks to give an
appointment. We have said, ``If you cannot give an appointment
within 5 business days for a routine appointment, return them
to the VA so we can take care of the veteran.'' It is a big
percent that we get back.
Senator Murray. It is a big percent?
Secretary Shulkin. Yeah.
Senator Murray. Do you know how long care is going to be
delayed for veterans as a result of that?
Secretary Shulkin. Well, this is actually speeding up care.
Rather than letting a veteran stay out there in the Choice
Program, schedulers return them to the VA, and then the VA
Community Care Program goes out and tries to find an
appointment.
Senator Murray. OK. Well, I am very concerned about where
the money is going to come from, from this----
Secretary Shulkin. Yeah.
Senator Murray [continuing]. And how you are going to get
the money to continue non-VA care. It seems to be two different
stories here. Transfer authority is what I am hearing from this
year? Correct? Well, if you transfer money from this year, then
what you are doing is impacting what you thought----
Secretary Shulkin. Yes.
Senator Murray [continuing]. Was going to be a carryover
for next year. So, will you not need additional money for next
year?
Secretary Shulkin. Yeah. Look, the problem of having these
two separate checking accounts and predicting where you need
the money is, frankly, impossible. That is why we want to work
to get the program into a single Community Care account.
We are going to--these guys are going to help make the best
predictions possible. Mr. Yow is going to help us understand
the right amount of money to transfer over to predict it, but--
--
Senator Murray. But, it will impact 2018, so we need real
numbers here. We cannot do our job if we do not know what the
costs are.
You know, I am already hearing from veterans in my State
about the delays and burdens they are seeing as a result of
this. I had veterans in Walla Walla who are being told they
will have to drive 8 hours round-trip to Portland or Seattle
just for some simple imaging tests as a result of this. I am
hearing a lot more. We are happy to get those to you, but this
is having an impact. I want you to know that and we want to
know where this money is coming from. So, we will follow up
with you on that, but I think this Committee needs to be aware
of that.
Secretary Shulkin. OK.
Senator Murray. OK. I am running out of time--or I am way
over time. I have other questions, Mr. Chairman, which I will
submit for the record. But, I am deeply concerned about that.
Secretary Shulkin. Yes.
Chairman Isakson. Listening to all these questions about
checking accounts and authorities reminds me of the question I
was asked yesterday on my 49th wedding anniversary. Somebody
asked my wife and I to what we would attribute 49 years
together. I said we never had a joint checking account where
both of us had to sign, so we never had those arguments. Let us
not ever get in that situation with the VA either.
Secretary Shulkin. OK.
Chairman Isakson. Senator Boozman.

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

Senator Boozman. Thank you, Senator Isakson and Senator
Tester.
Thank you for being here, and we appreciate our veterans'
advocates who are going to testify shortly for being here also.
Senator Sanders talked to you about the problem with the
fact of providers, and so many people are at the age now where
a big group of baby boomers that are aging out, they practice
because they like, and medicine has gotten more complicated and
stuff. I think we are going to see a bunch of those actually
decide to do something else or not do anything.
The idea of increasing--well, first of all, I agree that
the fact that we can reward people for going in is a great
idea, and I think it actually would work. I think we have good
evidence of that.
The problem is actually creating new slots versus taking
slots away for veterans. If you could work with some of your
counterparts--and the VA is a huge entity.
Secretary Shulkin. Mm-hmm.
Senator Boozman. This is a huge problem for the country,
besides the VA, but if you could craft a situation where you
could actually increase the medical school classes and then
also the residencies, which are a huge problem too, that would
be a great deal.
Secretary Shulkin. Yes.
Senator Boozman [continuing]. With your relationship with
the teaching hospitals----
Secretary Shulkin. Right.
Senator Boozman [continuing]. I think that could be done.
It is going to take some work, but that truly could be a great
legacy.
Secretary Shulkin. Right. We are focused on the residency
spots. The medical schools have actually increased the number
of medical school spots because they have tuition that pays for
it, so it is to their benefit.
The residency spots, as you know, are capped by Medicare.
Senator Boozman. Right.
Secretary Shulkin. What you did in the Choice Program that
Senator Sanders help lead was expand those graduate medical
education spots. That is what we need desperately.
Senator Boozman. Yeah, very much so.
Secretary Shulkin. Yeah.
Senator Boozman. And, again, we need to do that----
Secretary Shulkin. Yes.
Senator Boozman [continuing]. With whatever it takes in the
future or we are going to get ourselves in trouble.
$8.4 billion in mental health, 6 percent increase. That is
great. Mental health has improved so much in the VA in the last
years. We are not at the point where we are just writing
prescriptions like so many providers, not just in the VA, but
throughout the country giving a prescription. That simply does
not work.
On the other hand, we need to go farther. How are we going
to prioritize that 6 percent as far as increasing our ability
to provide good care?
Secretary Shulkin. Well, we have targeted to hire a
thousand mental health professionals. This year to date we are
seeing 58,000 more mental health appointments than we did last
year at this time.
We are expanding our tele-mental health programs. We have
just, as you know, this past year given full practice authority
to our advanced practice nurses. Many of them will be putting
their skills to work in behavioral health and expanding the
training. As Senator Sanders said, psychiatry and psychology
and nursing, all are areas of shortages that we can use more
help in, not only in the VA, but the entire country, quite
frankly.
We need to do a lot more. I think you are right. We have
prioritized mental health, but it is an area that needs a lot
more help.
Senator Boozman. You talked about the core mission of the
VA, the foundational services that make the VA unique. Can you
walk us through those or what you feel those are?
Secretary Shulkin. Yes. These are the services that make me
so strongly believe that a strong VA is essential for veterans
and for the country, because I believe that without the types
of services that the VA provides, you cannot find those in the
private sector. If we just turned our veterans over to the
private sector, they would really be lost.
These are services that veterans have a high predilection
for: post-traumatic stress, behavioral health issues, spinal
cord injury, prostheses or orthotics, polytrauma. Comprehensive
primary care and behavioral health care services are clearly
foundational as well. Environmental exposures, blind rehab--I
do not want to leave out a group because I know I will offend
them, but these are things that the VA does extraordinarily
well that you would not find easily, except in very specialized
geographies where there are centers of excellence. So, it is
important that we keep those strong.
Senator Boozman. In your testimony also, you talked about
Community Care and how doctors will make decisions on providing
care in VA facilities versus in the community due to clinical
need and what is best for the veteran. How do we--how do you do
this? How do you make sure that with--we have an institution,
somewhat of--well, we have a bureaucracy. How do you make sure
that those decisions are based on what is best for the veterans
as opposed to what is best for the facility?
Secretary Shulkin. Well, I think--I wish that there was an
easy answer to that.
What we have to do as an organization is get out of the way
of the doctor and the provider making those decisions together,
so we need to get rid of the administrative rules and the third
parties in between. That is what we saw in the Choice Program.
We were having veterans call Call Centers of people who did not
know them, and that was frustrating the veteran. What we have
learned is to de-layer the process, get it back into the exam
room or now, in more modern terms, you know, the tele-monitors.
Let the doctor, the patient, the provider of the patient make
the decisions together in a partnership about what is best for
them. That is the system we are trying to design now.
Senator Boozman. Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Boozman.
Senator Tillis.

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

Senator Tillis. Thank you, Mr. Chair. Mr. Chair, I am going
to be married 30 years, 2 weeks from today. We have a slightly
different approach to longevity. We do have a joint account; I
just do not have access to it. [Laughter.]
Chairman Isakson. That works also.
Senator Tillis. I am not even allowed to go out of network
to get an ATM withdrawal.
Thank you all for being here. I am actually running between
committees. We have an Acting Committee going on right now, and
we are talking about supporting caregivers, the Hidden Heroes
Project that Senator Dole is heading up, and it is critically
important. I will not spend time talking about it here, but one
thing that was striking in Senator Dole's opening testimony was
the fact that there is about $14 billion a year in caregiving
being donated by these husbands and wives and sons and
daughters that we need to find a way to provide support over
time.
I understand that in order for us to do that, we have to
talk about the resources and make sure that we are not shifting
our attention away from so many other pressing things, but it
is something I look forward to talking about in a future
hearing.
Dr. Shulkin, I want to know how we are doing. Some of the
estimating, I have got to believe some of the uncertainty with
respect to accounts, and how much we need in one or the other--
one thing----
Secretary Shulkin. Yeah.
Senator Tillis [continuing]. It is a fluid situation based
on factors that are different across the country. Another one
may have to do with having the right resources in place so that
you can actually get to that information pretty quickly. How
are we doing on getting your--I understand the CIO nominee, I
think, has withdrawn their name from consideration. How are we
doing on trying to get that administration stacked up so that
you have got a good organization, permanent organization under
you?
Secretary Shulkin. Well, not only the CIO, but the CFO
candidate. If we are attracting a good viewing audience, we
need help. We need people to want to come and help serve.
Senator Tillis. A permanent CFO is going to be pretty
important to get in some of your financial----
Secretary Shulkin. It really will.
Senator Tillis [continuing]. Financial planning in order
and getting your financial processes and planning processes in
order, so----
Secretary Shulkin. Yes.
Senator Tillis. I think you have touched on something
important. Hopefully, somebody can step forward.
Secretary Shulkin. Yes.
Senator Tillis. I know it is a sacrifice and you need
somebody that is highly skilled, but we have got to get those
positions filled. I, for one, think it will be one of the ways
we can get back on track for the transformation effort.
I am not going to spend much more time because I am going
to get back to the other Committee, but I am going to echo
again what I said in the last Committee. I am sure that there
are various factors that led to the shortfall in one account
versus another.
Secretary Shulkin. Yes.
Senator Tillis. There are probably other things that we
need to do to make sure that we are facilitating the process
and not giving you additional distractions or uncertainty as
you go through the financial planning. Please speak candidly to
the Committee Members----
Secretary Shulkin. Thank you.
Senator Tillis [continuing]. And make sure when there are
things that we can do or should not do that are getting in the
way of you giving us definitive answers, so we can count on it
also.
Secretary Shulkin. Yeah.
Senator Tillis. I also want to reiterate what--Senator
Murray made several very good points. I agree with all of them.
I think that she is absolutely right. The sooner you articulate
what your funding levels are, the better, so that we can go and
be advocates for it.
Secretary Shulkin. Yeah. Thank you.
Senator Tillis. Thank you, Mr. Chair.
Chairman Isakson. Thank you, Senator Tillis.
Senator Boozman--Senator Blumenthal. I am sorry.

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

Senator Blumenthal. Thank you, Chairman.
First of all, I want to express my appreciation on the
Richard Staab v. McDonald case.
Secretary Shulkin. Thank you.
Senator Blumenthal. I join my colleague, Senator Rounds,
in----
Secretary Shulkin. Yes.
Senator Blumenthal [continuing]. Expressing my appreciation
for your decision to withdraw the appeal and also join with him
in asking for a quick rulemaking, which I know you will do.
On the VA's Vocational Rehabilitation and Employment
Program, as you know, it provides career counseling and
rehabilitative services to veterans with service-connected
disabilities to overcome employment barriers. It also assists
with postsecondary training at educational institutions.
I have been told by Connecticut University that there are
delays in vocational rehab housing and education payments for
service-disabled veterans. The VA has previously attributed
those delays to lack of vocational rehabilitation counselors at
the Hartford Regional Benefit Office and nationwide staffing
shortages. The VA's purported goal ratio of vocational rehab
counselor to client is one counselor per 125 veterans, but the
average ratio in July 2015, I am told was one counselor to
every 139 veterans, despite the payment delays and the VA's
inability to meet the ratio.
The fiscal year 2018 budget makes cuts to this program;
Vocational Rehabilitation is $13.8 million. You are probably
more familiar with these numbers than I am, so I apologize for
telling you something you already know. This decrease in
requested funding seems unacceptable, particularly for those of
us in Connecticut who see the results already of underfunding.
I would like to know whether you plan to address the delays and
your view of the apparent underfunding of this very valuable
program.
Secretary Shulkin. Senator, first of all, thank you for
your outspoken leadership on the Staab case.
On terms of Vocational Rehab and Education, we may have
different numbers, so I would like to go over it with you. We
see a $1.5 million increase in the President's budget for these
programs, but there are some staffing issues and delays in the
Hartford region that we do want to get improved and we do want
to fix. We think this is an important program. We believe in
it, and we believe the President's budget adequately funds it.
But if you have different numbers and we are wrong, we will
want to address that.
Senator Blumenthal. Well, I would like my staff perhaps----
Secretary Shulkin. Yes.
Senator Blumenthal [continuing]. To get together with you
all, but I think the overriding issue here is not necessarily
even the numbers, because even if there is a slight increase,
this is----
Secretary Shulkin. Small.
Senator Blumenthal. This program is so valuable, it ought
to be a major increase and certainly not a reduction.
Secretary Shulkin. Right.
Senator Blumenthal. Again, this is not a criticism of the
VA. In fact, on the contrary, it is saying you are doing great
work. We do not want to see it diminished. We see these delays
in Hartford and we would like your help in solving them.
Secretary Shulkin. Yes. OK. We will follow up with you.
Senator Blumenthal. I thank you.
Secretary Shulkin. Yes.
Senator Blumenthal. I do not know whether it has been
asked, but I wonder if I could ask you again about the Veterans
Benefit Administration, whether you see real progress in
reducing the claims backlog. I am guessing someone has asked
about it already, and I apologize for bringing it----
Secretary Shulkin. No. No, that is not a problem.
Senator Blumenthal. What is your prognosis?
Secretary Shulkin. Well, I will briefly just tell you we
are at 94,000 now. We hope by the end of the year to be at
approximately 70,000, and then a year following that or 2 years
from now below about half the level, so 45,000.
We just announced that we have done 12 claims so far in 3
days, called ``decision-ready claims.'' We are going to roll
that process out nationally September 1. That will impact
around 10 to 15 percent of our claims because they have to have
all the information ready, they are presented, and we give a
decision in 3 days. So, I think that we are making some
progress.
We are trying to actually look at some breakthrough ways to
do better, but as of today, I have given you the most accurate
information we have.
Senator Blumenthal. The progress that you are making is the
result of a different--reforms in the process----
Secretary Shulkin. Yeah.
Senator Blumenthal [continuing]. Or is it more resources or
a combination?
Secretary Shulkin. The budget--the budget stays flat for
next year, so it is not in VBA. It is not necessarily more
resources, although they have added in the past couple of
years.
I would say the major changes are process improvements.
There is something called the National Work Queue, which is
really allowing productivity adjustments. Therefore, you can
distribute the workload across the country evenly. They have
just enhanced and increased their productivity standards for
the people who work in VBA, and they are doing a terrific job.
We have a great staff who work in VBA, who are up to the
challenge, and we are seeing improvements. It is mostly process
improvement, but over the past couple of years, they had added
to their staff.
Senator Blumenthal. Well, I want to thank you for your
focus. As you know, this is a problem that has continued to----
Secretary Shulkin. Mm-hmm.
Senator Blumenthal [continuing]. Bedevil us over many
years, so I am glad that you are making those process changes.
And there may be some breakthrough----
Secretary Shulkin. Yes.
Senator Blumenthal [continuing]. Changes in the foreseeable
future?
Secretary Shulkin. Yes, yes.
Senator Blumenthal. Thank you.
Secretary Shulkin. Thank you.
Senator Blumenthal. Thank you, Mr. Chair.
Chairman Isakson. Thank you, Mr. Blumenthal.
I have been asked by Senator Sanders and Senator Tester to
be able to make brief statements, so I am going to waive any
time I might have and recognize Senator Tester and then Senator
Sanders for their statement and/or question.
Senator Tester. Thank you, Mr. Chairman.
I have beaten this horse in the past. We have to beat it
one more time. OK?
Secretary Shulkin. Sure.
Senator Tester. The VSOs we are going to hear from next
want to have the VA as a primary care provider. I have heard it
over and over again. Senator Sanders talked about it. Others
have talked about it in this Committee.
I have been in public life long enough to know that if you
want to know where things are headed, you follow the money.
Secretary Shulkin. Mm-hmm.
Senator Tester. The fact that we have 1.2 percent increase
for in-house medical care and 33 percent for outside medical
care is disturbing.
Moving forward, because you have said over and over again
to me, ``Do not worry about this, Jon. It is going to be fine.
We are going to make the VA the best it can be, and the VA is
going to fill in the gaps,'' we just need to drive that point
home because we are going to hear from a panel of VSO
representatives. I have got a notion that they are going to
talk about VA care, and they are going to be reasonably
complimentary and talk about other ways we can fix it.
Number 2, this is an authorization committee. Concerning
electronical-IT funding, you have got $200 million in this
budget. You should be asking this Committee to plus that budget
up. You need to do it so it represents the money that you are
going to be dumping out to Cerner for the DOD electronic
platform that we all support you doing, by the way.
Secretary Shulkin. Mm-hmm.
Senator Tester. I think it is really important that we are
honest with ourselves, and I will tell you why. I happen to be
on both Committees, and I do not want to get nailed and say,
``You know what? The Authorization Committee did not do that,
and these spendthrift appropriators are just dumping money
in.'' I would just say we need to have a budget that accurately
reflects what we need to do. In this case, we know this IT
thing is going to cost some dough.
Secretary Shulkin. Mm-hmm.
Senator Tester. So, we need to act accordingly.
The last thing is we are going to have Carl Blake from
Paralyzed Veterans of American (PVA), LeRoy Acosta from
Disabled American Veterans (DAV), Carlos Fuentes from Veterans
of Foreign Wars (VFW), and John Rowen from Vietnam Veterans of
America (VVA), up here in a second. I just want to thank those
guys for their service. We had said earlier that we need to
take our direction from the VSOs. I am not going to be able to
be here, although I am going to try to get back before the end,
and we do need to take the direction from the veterans. I think
it is critically important, so thank you all.
Secretary Shulkin. Senator Tester, thank you, and, you
know, the one thing is we are always clear on where you stand
and appreciate that.
I do want to try to work with you and your staff because we
have different numbers than you have in terms of the Community
Care and internal care. You know, we have an interest in making
sure the VA is the best system.
The ability to transfer more--right now, we are limited at
1 percent--would help us a great deal, and that is something we
will continue to work with you on.
Senator Tester. I would just say, we are going to work with
you on that, too. Johnny and I both agreed to that.
I think that, as I said to you at the breakfast yesterday,
you can outsource care, but you cannot outsource
responsibility.
Secretary Shulkin. No, that is right.
Chairman Isakson. Senator Sanders.
Senator Sanders. Thanks very much.
I want to touch on briefly what is a terrible, terrible
national crisis, and that is the opioid epidemic. I think in
the past, the DOD and the VA were criticized for an
overdependence on opioids.
Secretary Shulkin. Sure.
Senator Sanders. I know that there has been some
significant changes. I have been pleased to go to VA hospitals
around the country and see very robust programs regarding
alternative complementary medicine--yoga, nutrition, and so
forth and so on.
Secretary Shulkin. Yes.
Senator Sanders. Can you say a word about how the VA can
lead this country away from opioids, although obviously
sometimes they are necessary, into less type of dependent drug
approaches?
Secretary Shulkin. Yeah. I will try to do it briefly, but I
will tell you I published an article on this 4 or 5 months ago
in the Journal of the American Medical Association about the
VA's approach, because I think it is a national example that
others can learn from.
We started this work in 2010, where we identified problems
before the rest of America did, as the VA often does, and we
did this through a multifactorial approach. We essentially now
monitor the patterns of all of our providers, and we give them
feedback on how they perform compared to their peers.
Senator Sanders. If they are overprescribing.
Secretary Shulkin. If they are overprescribing.
We do academic detailing, where pharmacists go out and
actually teach our providers the ways to use opioids
appropriately.
We have our patients sign informed consent, so that they
are part of the process when they get an opioid.
We participate in the State prescription data monitoring
programs. It is mandatory that our providers do that.
We are providing alternatives such as you said,
complementary care. In fact, the best practice for us in the
country--I do not know if you know this--is actually White
River Junction, where we have a 50 percent reduction in opioid
use, using those exact techniques, complementary medicine.
Senator Sanders. Acupuncture.
Secretary Shulkin. Acupuncture, yoga, mindfulness,
biofeedback. I mean, you know, mind-body type of techniques,
and so we are trying to get others to be as good as we are
doing in White River Junction.
We are working in a number of these areas, and of course,
we are trying to work on research with the FDA and NIH on non-
addictive narcotics as well, because we think that is
important.
Senator Sanders. Good. Thank you very much.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Sanders.
Thanks to all of you. It has been very helpful and
informative.
I would ask you to be excused, and our second panel may
come forward.
Secretary Shulkin. Thank you.
[Pause.]
Chairman Isakson. Let me thank Secretary Shulkin and his
staff for their testimony and their support and the continued
response to Committee. We are very grateful for that.
Let me welcome our second panel, and I will begin with the
introductions: Mr. Carl Blake, Associate Executive Director,
Government Relations, Paralyzed Veterans of America; Mr. LeRoy
Acosta, Assistant National Service Director, Disabled American
Veterans; Mr. Carlos Fuentes, Director, National Legislative
Service, Vietnam--Veterans of Foreign Wars; Mr. John Rowan,
National President, Vietnam Veterans of America.
Mr. Blake.
You are each recognized for 5 minutes.

STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR,
GOVERNMENT RELATIONS, PARALYZED VETERANS OF AMERICA

Mr. Blake. Mr. Chairman, thank you for the opportunity to
testify today. With your approval and the Committee's approval,
we would like to submit our fiscal year 2018 Independent Budget
Report into the official hearing record.
Chairman Isakson. Without objection.

[The report can be found online at: http://
www.independentbudget.org/2018/FY18_IB_BudgetBook_6.6.17.pdf]

Mr. Blake. Thank you.
I think I would like to spend my time talking a little bit
about what we have heard today rather than just specifically
the recommendations that are included in our budget report.
Let us recap. I appreciate Senator Heller bringing up the
question about IU. Although I would say it is not readily
apparent, the VA has said for sure that it is going to drop
that proposal altogether, it sounds like the Secretary is
willing to discuss it further and see where this goes from
here.
I appreciate Senator Manchin and also Senator Tester for
bringing up the question about the electronic health record
(EHR) modernization and Cerner.
Senator Rounds continues to beat the drum about the Staab
ruling.
Senator Moran really started to probe at the question about
holes that seemed to be appearing in the VA's budget.
I appreciate that the Secretary has made the commitment he
has as it relates to the EHR modernization, doing the right
thing on the Staab ruling, and trying to address issues like
the caregiver expansion. It is not an easy job. I do not envy
the position he is placed in.
Let us forget for minute, let us just set aside the fact
that it sounded like to me, we may be staring a budget
shortfall right in the face just for this current fiscal year
based on this transferability problem and moving money between
Community Care and Choice. All those things historically have
added up to a shortfall somewhere.
Let us look at fiscal year 2018. I think that is a good way
to sort of snapshot the bigger hole that VA has to deal with.
Senator Heller mentioned IU. IU and its proposal was
presumably going to fund a large majority of Choice going
forward, in perpetuity as it were, at least $3.2 billion. If we
assume that that is not going to happen, that is $3 billion in
Community Care under Choice that has to be addressed somehow.
It is not addressed in the discretionary part of the VA's
budget.
It is all well and good to say we have enough money; $3
billion is a lot of money to say that we have enough.
Senator Manchin and Senator Tester mentioned the Cerner
decision. I think on policy, that is probably the right
decision to make for VA and for DOD, but I read an article
recently that said the Department of Defense's obligation under
Cerner is something on the order of $9 billion, I think, in the
life cycle of that program. It also said that VA's obligation
will be at least three to four times that great. How does the
VA's budget rationalize that point? I am sure it does not.
Senator Rounds mentioned Staab. It is the right thing to
do, what the Secretary said. I think he knows it, and he is
acting upon that. I was actually sort of amused that he said
they expedited the rulemaking process. I think he said it went
to OMB. That is where the expedited process goes to die. He
said last week it might take 9 months. OMB will be on the clock
for the next 9 months, I am sure, knowing their track record.
That aside, the Staab ruling has already left VA with an
obligation in previous years of at least $2 billion. Where is
that money which is going to pay for that issue?
The average in subsequent years is a billion dollars, 1.1,
1.08, something in that range. Where is that money? It is not
in the VA budget either.
Now we are keeping score. We have a $3.2 billion IU hole
for Choice. We have an approximately $1 billion hole for Staab,
and then we have the Cerner issue. We do not even know what
that hole looks like.
I could also make the argument that looking out into fiscal
year 2019 that budget is certainly short because the Community
Care account in that budget alone is less than the projection
for 2018, and the Choice plan has it at exactly the same dollar
figure, approximately $3.5 billion. Are we going to decrease
Community Care usage in 2019? I think we all at this table know
that is not going to happen.
Right now, the VA could be staring at a huge hole in its
budget for 2018, and we have expressed this to the
appropriators. Unfortunately, because of the timing and
everything, the appropriators have already moved forward on the
House side. They are going to mark up their MILCON/VA bill
tomorrow, and none of these questions are answered, yet the VA
is left with billions of dollars in unanswered questions. It is
not enough to simply say, ``We have enough money. We can move
it around.'' That is not true. That is just simply not true.
Mr. Chairman, I appreciate the opportunity to testify. I
would be happy to answer any questions you may have.
[The prepared statement of Mr. Blake follows:]
Prepared Statement of Carl Blake, Associate Executive Director of
Government Relations, Paralyzed Veterans of America
Chairman Isakson, Ranking Member Tester, and Members of the
Committee, As one of the co-authors of The Independent Budget (IB),
along with DAV and Veterans of Foreign Wars, Paralyzed Veterans of
America (PVA) is pleased to present our views regarding the funding
requirements for the delivery of health care for the Department of
Veterans Affairs (VA) for FY 2018 and advance appropriations for FY
2019. On the following page, we have included a side-by-side comparison
of funding recommendations previously appropriated for FY 2017
recommended by the Administration by the IB for FY 2018, as well as the
advance appropriations for FY 2019.

VA Accounts for FY 2018 and FY 2019 Advance Appropriations
----------------------------------------------------------------------------------------------------------------
FY 2018 FY 2018 FY 2018 FY 2018 IB
FY 2017 Advance Admin FY 2018 IB Advance Advance
Appropriation Approps Revised Approps Approps
----------------------------------------------------------------------------------------------------------------
Veterans Health Administration (VHA)
Medical Services................... 45,505,812 44,886,554 45,918,362 64,493,555 49,161,165 69,450,838
Medical Community Care............. 7,246,181 9,409,118 9,663,118 8,384,704
--------------------------------------------------------------------------
Subtotal Medical Services........ 52,751,993 54,295,672 55,581,480 64,493,555 57,545,869 69,450,838
Medical Support and Compliance..... 6,524,000 6,654,480 6,938,877 6,657,955 7,239,156 6,793,408
Medical Facilities................. 5,321,668 5,434,880 6,514,675 5,796,343 5,914,288 6,562,579
--------------------------------------------------------------------------
Subtotal Medical Care, 64,597,661 66,385,032 69,035,032 76,947,853 70,699,313 82,806,825
Discretionary...................
Medical Care Collections........... 3,558,307 3,627,255 3,271,000 3,277,000
Choice Program**................... 2,900,000 3,500,000 3,500,000
--------------------------------------------------------------------------
Total, Medical Care Budget 68,155,968 70,012,287 75,806,032 76,947,853 77,476,313 82,806,825
Authority (including
Collections)....................
--------------------------------------------------------------------------
Medical and Prosthetic Research.... 675,366 640,000 713,200
Millions Veterans Program.......... 65,000
----------------------------------------------------
Total, Veterans Health 68,831,334 70,012,287 76,446,032 77,726,053
Administration..................

General Operating Expenses (GOE)
Veterans Benefits Administration... 2,856,160 2,844,000 3,134,540
General Administration............. 345,391 346,891 406,454
Board of Veterans Appeals.......... 156,096 155,596 158,196
----------------------------------------------------
Total, GOE....................... 3,357,647 3,346,487 3,699,190

Departmental Admin/Misc. Programs
Information Technology............. 4,278,259 4,055,500 4,361,502
National Cemetery Administration... 286,193 306,193 291,085
Office of Inspector General........ 160,106 159,606 162,545
----------------------------------------------------
Total, Dept. Admin/Misc. Programs 4,724,558 4,521,299 4,815,132

Construction Programs
Construction, Major................ 528,110 512,430 1,500,000
Construction, Minor................ 372,069 342,570 700,000
Grants for State Extended Care 90,000 90,000 300,000
Facilities........................
Grants for State Vets Cemeteries... 45,000 45,000 46,000
----------------------------------------------------
Total, Construction Programs..... 1,035,179 990,000 2,546,000
Other Discretionary................ 201,000 180,214 203,000
----------------------------------------------------
Total, Discretionary Budget 78,149,718 85,484,032 88,989,375
Authority (including Medical
Collections)....................
----------------------------------------------------------------------------------------------------------------
**Choice Program funding for FY 2018 includes the expected carryover of $600 million from the previous fiscal
year as well as $2.9 billion in new funding for the program. All Choice program funding is currently scored as
a mandatory cost for VA.

The IB's recommendations include funding for all discretionary
programs for FY 2018 as well as advance appropriations recommendations
for medical care accounts for FY 2019. The full budget report, released
by The Independent Budget in March, addressing all aspects of
discretionary funding for the VA can be downloaded at
www.independentbudget.org. The FY 2018 projections are particularly
important because previous VA Secretary Robert McDonald admitted last
year that the VA's FY 2018 advance appropriation request was not truly
sufficient and would need significant additional resources provided
this year. We hope that Congress will take this defined shortfall very
seriously and appropriately address this need. Our own FY 2018
estimates affirm this need.
We appreciate the fact that the Administration's recently released
budget request for FY 2018 includes some increases in discretionary
dollars for the Medical Care accounts above what had been previously
provided through advance appropriations. Before addressing our specific
budget recommendations, it is important for us to address the notion
that VA does not need any additional resources, based on the expansive
growth of overall VA expenses in the last 10 years. These ideas are not
grounded in thorough analysis of demand and utilization of VA health
care. Perhaps Congress can explain how the VA can take on significantly
more demand for services both inside VA and in the community, and yet
meet that demand and utilization with less resources--an assertion
peddled by some organizations. While VA has seen substantial growth in
its funding needs over the last decade, much of that is reflected in
mandatory benefits to include the implementation of the Post-9/11 GI
Bill. The fact is demand for health care services and actual
utilization continue to rise at a significant rate. It may be possible
to wring some efficiency savings out of VA to free up additional
resources to address growing demand, but history has proven that
process will not be sufficient to provide all of the resources VA needs
to deliver on its promise to the men and women seeking health care and
benefits.
We also believe it is necessary to consider the projected
expenditures under the Choice program authority that the previous
Administration planned in FY 2017 and how that impacts the baseline
that will dictate the funding needs for FY 2018. The previous
Administration assumed as much as $5.7 billion in spending through the
Choice program in FY 2017, on top of the Medical Services discretionary
funding and the newly created Medical Community Care account. That
amount was revised to approximately $2.9 billion. This means that the
VA projected to spend more than $59.0 billion in Medical Services and
more than $71.0 billion in overall Medical Care funding in FY 2017.
These considerations inform the decisions of The Independent Budget to
establish our baseline for our funding recommendations for both FY 2018
and FY 2019.
Earlier this year, the Administration also indicated that it
intends to request as much as $3.5 billion in additional funding for
the Choice program to keep it operating at least through the end of FY
2018. That amount has since been revised to $2.9 billion for FY 2018
(actually $3.5 billion when considering the already available $600
million left over from the original authorization), as well as $3.5
billion for FY 2019 and beyond. However, this recommendation begs the
question: does this recommendation suggest that the Choice program as
currently designed should continue in perpetuity? Certainly no
reasonable person supports that idea. We believe that Congress must
reject continued funding of this program through a mandatory account
and place it in line with all other community care funded through the
discretionary Community Care account established previously. This will
eliminate competing sources of funding for delivery of health care
services in the community, while maintaining visibility on spending
through the Choice program.
Moreover, we strongly oppose the decision to curtail Individual
Unemployability (IU) benefits for veterans with significant service-
connected disabilities simply as a means to fund the continuation of
the Choice program. It is beyond comprehension that the Administration
would propose such a benefit reduction in order to pay for a flawed
funding mechanism for a program (Choice) that sometimes provides health
care access to non-service-connected disabled veterans. Does this
Committee really believe that veterans with disabilities rated between
60 percent and 90 percent should be the source of funding for the
Choice program? Eliminating IU benefits for veterans over the age of 62
provokes numerous questions for us. Will veterans who have statutorily
protected evaluations (the 20-year rule) also be subject to reduction?
Will those dependents using Chapter 35 education benefits based on
their sponsor's IU rating be forced to drop out of school? Will those
veterans on IU who are covered by Service-Disabled Life Insurance at no
premium be forced to now pay premiums in order to keep coverage? What
about state benefits, such as property tax exemptions or state
education benefits that are based on 100 percent VA disability ratings?
How will this proposal affect efforts to combat veteran suicide and
homelessness? We hope that you will reject this proposal in the
strongest terms.
For FY 2018, the IB recommends approximately $77.0 billion in total
medical care funding. Congress previously approved only $70.0 billion
in total medical care funding for FY 2018 (which includes an assumption
of approximately $3.6 billion in medical care collections). The
Administration's budget request includes a not-insignificant overall
medical care funding recommendation of approximately $75.2 billion.
However, we remain concerned that this level of funding will not keep
pace with the continually increasing demand and utilization. The IB's
recommendation also considers the approximately $1 billion VA is
expected to have remaining in the Veterans Choice Fund and expected
demand for care, including community care, that will not diminish or go
away if the Choice Program expires. The Independent Budget recommends
approximately $82.8 billion in advance appropriations for total Medical
Care for FY 2019.
medical services
For FY 2018, The Independent Budget recommends $64.5 billion for
Medical Services. This recommendation includes:

------------------------------------------------------------------------

------------------------------------------------------------------------
Current Services Estimate............................. $60,897,313,000
Increase in Patient Workload.......................... 1,595,242,000
Additional Medical Care Program Cost.................. 2,001,000,000
-----------------
Total FY 2018 Medical Services.................... $64,493,555,000
------------------------------------------------------------------------

The current services estimate reflects the impact of projected
uncontrollable inflation on the cost to provide services to veterans
currently using the system. This estimate also assumes a 1.5 percent
increase for pay and benefits across the board for all VA employees in
FY 2018. It was previously reported that the new Administration would
like to consider a 1.9 percent Federal pay raise.
Our estimate of growth in patient workload is based on a projected
increase of approximately 90,000 new unique patients. These patients
include priority group 1-8 veterans and covered non-veterans. We
estimate the cost of these new unique patients to be approximately $1.4
billion. The increase in patient workload also includes a projected
increase of 58,000 new Operation Enduring Freedom and Operation Iraqi
Freedom (OEF/OIF) enrollees, as well as Operation New Dawn (OND)
veterans at a cost of approximately $242 million. The increase in
utilization among OEF/OIF/OND veterans is supported by the average
annual increase in new users through the third quarter of FY 2016.
Additionally, The Independent Budget believes that there are
medical program funding needs for VA that must be considered. Those
costs total approximately $2.0 billion.
Long-Term Services and Supports
The Independent Budget recommends $535 million for FY 2018. This
recommendation reflects the fact that there was a significant increase
in the number of veterans receiving Long Term Services and Supports
(LTSS) in 2016. Unfortunately, due to loss of authorities--specifically
fee-care no longer being authorized, provider agreement authority not
yet enacted, and the inability to use Choice funds for all but skilled
nursing care--to purchase appropriate LTSS care particularly for home
and community-based care, we estimate an increase in the number of
veterans using the more costly long-stay and short-stay nursing home
care.
Prosthetics and Sensory Aids
In order to meet the increase in demand for prosthetics, the IB
recommends an additional $320 million. This increase in prosthetics
funding reflects a similar increase in expenditures from FY 2016 to FY
2017 and the expected continued growth in expenditures for FY 2018.
Women Veterans
The Medical Services appropriation should be supplemented with $110
million designated for women's health care programs in FY 2018. These
funds will be used to help the VA deal with the continuing growth in
women veterans coming to VA for care, including coverage for
gynecological, prenatal, and obstetric care, other gender-specific
services, and for expansion and repair of facilities hosting women's
care to improve privacy and safety of these facilities. The new funds
would also aid VHA in making its cultural transformation to ensure
women veterans are made to feel welcome at VA, and provide means for VA
to improve specialized services for preventing suicide and homelessness
and improvements for mental health and readjustment services for women
veterans.
Reproductive Services (to Include IVF)
Last year, Congress authorized appropriations for the remainder of
FY 2017 and FY 2018 to provide reproductive services, to include in
vitro fertilization (IVF), to service-connected catastrophically
disabled veterans whose injuries preclude their ability to conceive
children. The VA projects that this service will impact less than 500
veterans and their spouses in FY 2018. The VA also anticipates an
expenditure of no more than $20 million during that period. However,
these services are not directly funded; therefore, the IB recommends
approximately $20 million to cover the cost of reproductive services in
FY 2018. We are pleased to see that the Administration does retain the
authority to provide reproductive services in its budget proposal.
Emergency Care
Recently, the VA has received serious scrutiny for its
interpretation of legislation dating back to 2009, which required it to
pay for veterans who sought emergency care outside of the VA health
care system. The Richard W. Staab v. Robert A. McDonald ruling handed
down by the US Court of Appeals for Veterans Claims last year, places
the financial responsibility of these emergency care claims squarely on
the VA. Although VA continues to appeal this decision, it is not
expected to prevail in this case leaving itself with a more than $10
billion dollar obligation over the next 10 years. The Staab ruling is
estimated to cost VA approximately $1.0 billion in FY 2018 and about
$1.1 billion in FY 2019, which the IB has included in our
recommendations. We are disappointed to see that the Administration's
proposal continues to ignore its growing obligation to cover the cost
of emergency care as dictated by the Staab decision.
fy 2019 medical services advance appropriations
The Independent Budget once again offers baseline projections for
funding through advance appropriations for the Medical Care accounts
for FY 2019. While the enactment of advance appropriations for VA
medical care in 2009 helped to improve the predictability of funding
requested by the Administration and approved by Congress, we have
become increasingly concerned that sufficient corrections have not been
made in recent years to adjust for new, unexpected demand for care. As
indicated previously, we have serious concerns that the previous
Administration significantly underestimated its FY 2018 advance
appropriations request. This trend cannot be allowed to continue,
particularly as Congress continues to look for ways to reduce
discretionary spending, even when those reductions cannot be justified.
For FY 2019, The Independent Budget recommends approximately $69.5
billion for Medical Services. Our Medical Services advance
appropriations recommendation includes:

------------------------------------------------------------------------

------------------------------------------------------------------------
Current Services Estimate............................. $66,334,946,000
Increase in Patient Workload.......................... $1,589,892,000
Additional Medical Care Program Cost.................. $1,526,000,000
-----------------
Total FY 2019 Medical Services.................... $69,450,838,000
------------------------------------------------------------------------

Our estimate of growth in patient workload is based on a projected
increase of approximately 78,000 new patients. These new unique
patients include priority group 1-8 veterans and covered nonveterans.
We estimate the cost of these new patients to be approximately $1.3
billion. This recommendation also reflects an assumption that more
veterans will be accessing the system as VA expands its capacity and
services and we believe that reliance rates will increase as veterans
examine their health care options as a part of the Choice program. The
increase in patient workload also assumes a projected increase of
62,500 new OEF/OIF and OND veterans, at a cost of approximately $272
million.
As previously discussed, the IBVSOs believe that there are
additional medical program funding needs for VA. In order to meet the
increase in demand for prosthetics, the IB recommends an additional
$330 million. We believe that VA should invest a minimum of $120
million as an advance appropriation in FY 2019 to expand and improve
access to women veterans' health care programs. Our additional program
cost recommendation includes continued investment of $20 million to
support extension of the authority to provide reproductive services to
the most catastrophically disabled veterans. Finally, VA's cost burden
for paying emergency care claims dictated by the Staab ruling will
require at least $1.1 billion in FY 2019 alone.
medical support and compliance
For Medical Support and Compliance, The Independent Budget
recommends $6.7 billion for FY 2018. Our projected increase reflects
growth in current services based on the impact of inflation on the FY
2017 appropriated level. Additionally, for FY 2019 The Independent
Budget recommends $6.8 billion for Medical Support and Compliance. We
have concerns about the significant growth in these administrative
account functions recommended by the Administration (nearly $300
million in FY 2018 and an additional $300 million in FY 2019) as these
areas have been shown to be bloated on numerous occasions in the past.
These dollars could certainly be better spent providing direct care
services to veterans.
medical facilities
For Medical Facilities, The Independent Budget recommends $5.8
billion for FY 2018. Our Medical Facilities recommendation includes
$1.35 billion for Non-Recurring Maintenance (NRM). Likewise, The
Independent Budget recommends approximately $6.6 billion for Medical
Facilities for FY 2019. Our FY 2019 advance appropriation
recommendation also includes $1.35 billion for NRM. We are pleased to
see the Administration recommending real funding for this account in FY
2018 (approximately $6.5 billion), but we are concerned that the Budget
Request reflects the continued trend of reducing the recommendation in
the advance appropriation year ($5.9 billion in FY 2019) in order to
seemingly hold down discretionary projections.
medical and prosthetic research
We are very disappointed to see the major cut in funding for the
Medical and Prosthetic Research program in the Administration's Budget
Request--from $675 million in FY 2017 to $640 million in FY 2018. The
VA Medical and Prosthetic Research program is widely acknowledged as a
success on many levels, and contributes directly to improved care for
veterans and an elevated standard of care for all Americans. We
recommend that Congress appropriate $713 million for Medical and
Prosthetic Research for FY 2018. Additionally, under the President's
Precision Medicine Initiative, the IBVSOs recommend $65 million to
enable VA to process one quarter of the MVP samples collected, for a
total research appropriation of $778 million.
Thank you for the opportunity to submit our views on the FY 2018 VA
Budget Request. We would be happy to answer any questions the Committee
may have.

Chairman Isakson. Thank you very much for your testimony.
Mr. Acosta.

STATEMENT OF LEROY ACOSTA, ASSISTANT NATIONAL SERVICE DIRECTOR,
DISABLED AMERICAN VETERANS

Mr. Acosta. Mr. Chairman, Members of the Committee, as co-
author of the Independent Budget (IB), along with VFW and PVA,
DAV is pleased to present our views regarding fiscal year 2018
funding requirements for veterans' benefits programs.
Today, I will focus on critical funding needs for VBA's
Compensation Service, Vocational Rehabilitation and Employment,
and the Board of Veterans Appeals. I will also cover our strong
opposition to a couple of ill-conceived and unacceptable
administration proposals to scale back veterans' disability
compensation.
Mr. Chairman, the IB recognizes that VBA has made
significant progress in reducing the disability claims backlog.
VBA is processing more claims than ever before, yet workload
continues to rise. To manage current and future workload, the
IB recommends an additional 1,750 FTEE for VBA's Compensation
Service, which would require an increase of approximately $183
million.
VA's Voc Rehab Service also needs additional funding. Over
the past few years, program participation has increased by 15
percent overall, and based on historical trends, it would
increase by another 5 percent in fiscal year 2018. To meet
rising demand and to achieve and sustain the 1-to-125
counselor-to-client ratio established for Voc Rehab by law, the
IB recommends an additional 266 FTEE, which would require a $32
million increase.
Overall, the IB recommends total funding for VBA be
increased by $278 million, a 10 percent increase in order to
fund these two staffing increases and maintain current service
levels for the rest of VBA.
Unfortunately, the administration has recommended an
outright cut in funding for VBA of $12 million. For overall
funding, that is $300 million less than that recommended by the
IB.
We urge the Committee to support our recommended funding
levels to continue VBA's progress in delivering earned benefits
to veterans, their families, and survivors.
Mr. Chairman, VBA has made significant progress on its
claims backlog. One consequence has been an alarming increase
in a backlog of appeals for denied claims. Today, there are
over 450,000 appeals pending either at VBA or the board, and it
takes almost 6 years on average for a decision by the board.
Fortunately, the IBVSOs have been part of a stakeholder
work group with VA to develop and enact comprehensive reform of
the appeals process. S. 1024, the Veterans Appeals Improvement
and Modernization Act of 2017, is built upon the stakeholder
framework and has received broad bipartisan support.
We urge you to move forward expeditiously and pass this
legislation. The House has passed similar legislation earlier
this year. Enactment of this legislation would lead to a more
modern, responsive, and flexible appeals system, one that will
provide veterans with quicker decisions on appeals while fully
protecting veteran's due process rights. Even with passage of
appeals reform, however, the board will continue to require
resources commensurate with workload.
Last year, Congress authorized the board to increase this
FTEE by 242 to an authorized staffing level of 922 FTEE. The
board has not yet filled all those positions. For fiscal year
2018, the IB expects the board to continue hiring, to fill all
authorized positions, and we do not recommend further staffing
increases while this new legislation is being approved and
implemented.
Moving forward, the board and Congress must carefully
monitor implementation of a new appeal system to ensure that
staffing remains adequate to meet future workload demands.
Finally, Mr. Chairman, DAV and the IB enthusiastically
oppose two legislative proposals in the administration's
budget. First, we strongly oppose the proposal to round-down
COLAs for 10 years, which would hurt our Nation's injured and
ill veterans, their families and survivors. The cumulative
effect of this proposed tax would cost beneficiaries nearly
$2.7 billion over 10 years. We urge this Committee and the
entire Congress to soundly reject it.
Furthermore, we adamantly object to the proposal that will
cut off eligibility for VA's individual unemployability, or IU,
simply because disabled veterans reach an age in which they
might qualify for Social Security retirement benefits.
Mr. Chairman, total compensation for IU is not a retirement
benefit. It is provided for as compensation for veterans who
suffer lifelong service-connected disabilities and are
determined unable to work. Furthermore, this would also lead to
veterans losing ancillary benefits that result from a total
disability rating, such as dependents educational assistance,
CHAMPVA, commissary and exchange privileges, and in many cases,
State benefits such as property tax exemptions.
We call on Members of this Committee and the entire
Congress to soundly reject these dangerous proposals that would
be harmful to disabled veterans.
That concludes my testimony. I would be happy to respond to
any questions that you or Members of the Committee may have.
[The prepared statement of Mr. Acosta follows:]
Prepared Statement of Leroy Acosta, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman and Members of the Committee: As one of the co-authors
of The Independent Budget (IB), along with Veterans of Foreign Wars
(VFW) and Paralyzed Veterans of America (PVA), DAV is pleased to
present our views regarding fiscal year (FY) 2018 funding requirements
to support the Department of Veterans Affairs (VA) ability to process
and deliver timely, accurate benefits to veterans, their families and
survivors.
general operating expenses (goe)
Veterans Benefits Administration $3.135 billion

The Veterans Benefits Administration (VBA) account is comprised of
six primary divisions. These include Compensation; Pension; Education;
Vocational Rehabilitation and Employment (VR&E); Housing; and
Insurance. The increases recommended for these accounts primarily
reflect current services estimates with the impact of inflation
accounting for most of the increase. However, the IB recommendations
for Compensation and VR&E also reflect a significant increase in
requested staffing to meet the rising demand for those benefits. The IB
recommends approximately $3.135 billion overall for VBA for FY 2018, an
increase of approximately $279 million over the enacted FY 2017
appropriations level. The IB recommendation includes an increase of
$183 million above current services in the Compensation account, and
approximately $32 million above current services in the VR&E account to
provide for approximately 2,000 new full-time equivalent employees
(FTEE) to address rising workload.

Compensation Service Personnel 1750 New FTEEs $183
million

VBA continues to produce record numbers of claims while maintaining
an emphasis on quality. Over the past few years, VBA has made
significant progress in reducing the disability compensation backlog,
which at its peak, stood at over 600,000 claims in March 2013. Today,
the claims backlog stands at just over 90,000 claims, a decrease of
more than 85 percent from its peak. However, there has recently been a
rise in the overall disability claims inventory and the amount of time
it takes to process both claims and appeals. These increases can be
attributed to multiple factors, including an increase in the number of
claims and appeals being filed, the lack of adequate resources to keep
pace with demand and the curtailing of mandatory overtime to reduce the
claims backlog.
In 2009, VBA issued claims decisions on 2.74 million medical
issues; that number more than doubled to 5.76 million in FY 2016, but
was less than FY 2015 when it issued 6.35 million decisions on medical
issues. In March 2013, VBA required roughly 282 days to process a
claim. At the close of FY 2016, VBA reported that on average, it took
123 days to process a claim; however, in FY 2015, VBA reported that it
took, on average, 92 days to complete a claim. In FY 2015, total
inventory stood at about 352,000 claims; today VBA has a total
inventory close to 400,000 claims. Furthermore, VBA has an inventory of
nearly 584,000 non-disability rating claims, such as, claims for
changes in dependent or marital status.
It will require a combined focus on technology and staffing levels
for VBA to provide veterans and their dependents with more timely and
accurate claims decisions. For FY 2018, the Independent Budget veterans
service organizations (IBVSOs) recommend an additional 1,750 FTEE to
manage VBA's overall rising workload. Furthermore, since VBA stopped
utilizing mandatory overtime for claims processing, the true need for
additional personnel has become more evident. Of the overall increase
in personnel, we recommend 1,000 FTEE be dedicated to processing
appeals pending at VBA in an effort to eliminate the backlog of 380,000
appeals in VBA over the next three years. Depending on progress this
year, further personnel increases may be necessary to reduce the
appeals backlog at VBA. In addition, we recommend 350 FTEE be dedicated
to addressing the growing backlog of non-rating related work, such as
dependency claims. An additional 300 FTEE should be dedicated for
claims processing to address the incremental rise in the claims
inventory and backlog and 100 FTEE dedicated to staffing the Fiduciary
program to meet the growing needs of veterans participating in VA's
Caregiver Support programs. This recommendation is based on a July 2015
VA Inspector General report on the Fiduciary program that found, `` . .
. Field Examiner staffing did not keep pace with the growth in the
beneficiary population, [and] VBA did not staff the hubs according to
their staffing plan . . . .''

VR&E Service Personnel 266 New FTEEs
$32 million

The Vocational Rehabilitation and Employment Service (VR&E), also
known as the VetSuccess program, provides critical counseling and other
adjunct services necessary to enable service-disabled veterans to
overcome barriers as they prepare for, find, and maintain gainful
employment. VetSuccess offers services on five tracks: re-employment;
rapid access to employment; self-employment; employment through long-
term services; and independent living.
VR&E also operates its VetSuccess on Campus (VSOC) program at 94
college campuses.
Over the past few years, program participation has increased by 15
percent overall: increasing by 7.3 percent in FY 2015, 3.8 percent in
FY 2016, and an estimated 4 percent in FY 2017. As VBA continues to
expand VR&E eligibility to more veterans, due to increased claims
processing and the award of new service-connected disabilities due to
new presumptive disabilities, we project that total program
participation for FY 2018 will grow by at least 5 percent for total
caseload of close to 155,000.
Last year, Congress enacted Public Law 114--223, which authorizes
the Secretary to use appropriated funds to ensure the ratio of veterans
to full-time employment equivalents does not exceed 125 veterans to one
full-time employment equivalent, a goal that VA has not met for many
years. In July 2015, VR&E reported that its average Vocational
Rehabilitation Counselor (VRC)-to-client ratio had risen to 1:139.
However, in both FY 2016 and FY 2017, the Administration flat-lined the
VR&E request for direct personnel at 1,442. In order to achieve and
sustain a 1:125 counselor-to-client ratio in FY 2018, we estimate that
VR&E would need 266 new FTEE, for a total workforce of 1,550 FTEE, to
manage an active caseload and provide support services to 155,000 VR&E
participants. At a minimum, three-quarters, of the new hires should be
VRCs dedicated to providing direct services to veterans. This increase
in personnel would address expected growth in VR&E claim filings and
program participation, as well as collateral duties performed by VRCs
outside of general case management. It is also essential that these
increases be properly distributed throughout all of the VR&E program to
ensure that VRC caseloads are equitably balanced among VA Regional
Offices.
general administration
Board of Veterans' Appeals $158 million

Faced with a rising appeals backlog that could no longer be
ignored, last year Congress authorized the Board of Veterans' Appeals
(Board) to increase its FTEE by 242 over FY 2016 levels, bringing their
total authorized staffing to 922 FTEE for FY 2017; however, the Board
has not yet hired to their full authorized level. For FY 2018, the
IBVSOs recommend no additional increases in FTEE; but note, the Board
must be permitted to hire its full complement of 922 FTEE. Further, as
the number of claims processed annually continues to rise as a result
of the increased capacity of VBA, the number of appeals filed annually
will grow commensurately. In order for the Board to keep pace with this
new incoming workload alone, not including those appeals already in the
system, FTEE levels will have to be adjusted accordingly, though
appeals reform legislation could alleviate some of that need in the
future.
The IBVSOs thank Chairman Isakson, Senators Blumenthal, Tester and
the other cosponsors for introducing the Veterans Appeals Improvement
and Modernization Act of 2017 (S. 1024), legislation that would
fundamentally reform and streamline the overall appeals process.
Similar legislation, H.R. 2288, was introduced and passed in the House.
These measures include provisions that reflect significant efforts and
the consensus of a working group formed in March 2016 that consisted of
the IBVSOs, other VSO stakeholders, and leaders within VBA and the
Board. Regardless of potential passage of this legislation the Board
will continue to require resources commensurate with workload,
especially to process legacy appeals remaining at the time of enactment
of new appeals reform legislation. Further, the Board must be funded
and empowered to continue pursuing information technology (IT)
modernization solutions that best meet the specific workflow needs of
the Board, while ensuring it also supports seamless integration with
the Veterans Benefits Management System and other IT systems used by
VBA and the Court of Appeals for Veterans Claims. Given the potential
for significant and positive impact this would have on veterans'
ability to receive more timely decisions, we look forward to the
Committee passing appeals modernization, followed swiftly by enactment.
cost of living round down
The Administration's budget proposal released on May 23, 2017,
contains a provision that would round down cost-of-living adjustments
(COLAs) for our Nation's injured and ill veterans and their families
and survivors for a period of 10 years. DAV and our IB partners are
strongly opposed to this rounding down provision. Veterans and their
survivors rely on their compensation for essential purchases such as
food, transportation, rent, and utilities. It also enables them to
maintain a marginally higher quality of life.
Rounding down veterans' COLAs unfairly targets disabled veterans,
their dependents and survivors to save the government money or offset
the cost of other Federal programs. The cumulative effect of this
provision of law would, in essence, levy a 10-year tax on disabled
veterans and their survivors, reducing their income each year. When
multiplied by the number of disabled veterans and recipients of
Dependency and Indemnity Compensation or DIC, hundreds of millions of
dollars would be siphoned from these deserving individuals annually.
All totaled, VA estimates, this proposed COLA round down would cost
beneficiaries close to $2.7 billion over 10 years. Congress must reject
this ill-conceived proposal.
individual unemployability and social security offset
We also note there is, unfortunately, a new proposal included in
the President's budget that would impact the VA's Individual
Unemployability or IU program which allows VA to pay certain veterans
disability compensation at the 100 percent rate, even though VA has not
rated their service-connected disabilities at the total level.
Specifically, the proposal would terminate existing IU ratings for
veterans when they reach the minimum retirement age for Social Security
purposes (62), or upon enactment of the proposal if the veteran is
already in receipt of Social Security retirement benefits. The IBVSOs
vehemently oppose this proposal.
As the Members of this Committee know, Congress delegated to the
Secretary of Veterans Affairs the authority to adopt and apply a
schedule of rating disabilities pursuant to section 1155 of title 38,
United States Code. In accordance with VA regulation promulgated by the
Secretary, total disability exists when any veteran is determined by VA
to be unable to secure and maintain substantially gainful employment by
reason of service-connected disability, regardless of age. (See 38 CFR,
section 4.16(b).) IU is based on the impact of the individual's own
circumstances and it is an exception to the ``average person standard''
of the rating schedule. As a prerequisite for an IU rating, a veteran
generally must have a disability rated 60 percent or higher under the
rating schedule.
Total compensation for IU is not a retirement benefit. Properly
applied, the rules require a factual showing that the service-connected
disability is such as to be incompatible with substantially gainful
employment, regardless of age. Today, many people, including the
President, members of the Cabinet and members of Congress, work well
beyond the minimum or ``normal'' retirement age. Some continue to work
because they love their job, while others may be forced by financial
requirements to continue to work.
This proposal is especially detrimental to the well-being of ill
and injured veterans and their families because it forces a totally
disabled veteran to take their social security benefits at the minimum
age of 62, when the benefit is a small fraction of what he or she would
receive at normal retirement age (65 to 67) or at age 70. Further,
since the level of social security benefits is based on what an
individual has paid into the fund, a veteran who was severely or
totally disabled at a young age may not have paid sufficient funds to
receive a level of benefits at the minimum age, or any age for that
matter, to live a comfortable life because of reduced earnings due to
service-related disabilities.
We also remind the Committee that the loss of IU for many veterans
would also have a negative impact on a veteran's family due to the
concurrent loss of ancillary benefits. Once the total disability rating
for IU is reduced at age 62, the veteran and his or her family will
lose Chapter 35 benefits for Dependents Education Assistance program,
essential health care benefits from the Civilian Health and Medical
Program of the VA (CHAMPVA) for dependents, Commissary and Exchange
privileges and, in many cases, state benefits such as property tax
exemptions. This damaging proposal should be rejected by Congress as it
lacks compassion for the men and women who served our country and were
severely disabled as a result of that honorable service.
In summary, a final point I would like to make is that benefits
received from the VA, or based on military retirement pay and other
Federal programs have differing eligibility criteria as compared with
the earned payments of Social Security. Reducing a benefit provided to
a disabled veteran in receipt of IU due to receipt of a different
benefit offered through separate Federal benefit program is simply an
unjust forfeit of an earned, necessary benefit.

Mr. Chairman, thank you for the opportunity to submit testimony and
to present the views of the IBVSOs regarding FY 2018 funding
requirements to support the VA's ability to process and deliver
benefits to veterans, their families and survivors. I would be happy to
respond to any questions that you or Members of the Committee may have
regarding this statement or our recommendations.

Chairman Isakson. Thank you very much, Mr. Acosta.
Mr. Fuentes.

STATEMENT OF CARLOS FUENTES, DIRECTOR OF THE NATIONAL
LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED
STATES

Mr. Fuentes. Chairman Isakson and Members of the Committee,
on behalf of the men and women of the VFW and its Auxiliary, I
would like to thank you for the opportunity to present our
views on VA's budget.
The VFW is glad the administration has proposed a 6 percent
increase in VA's discretionary budget. We certainly support the
continued focus on expanding access to health care; expediting
decisions on benefits, claims, and appeals, increased focus on
combating veteran suicide and addressing the stigma associated
with mental health; ensuring VA is ready and able to care for
women veterans who are the fastest-growing cohort of the
veteran population. However, I would like to make it clear the
VFW strongly opposes efforts to claw back benefits from our
most severely disabled veterans to pay for such improvements.
In the past week, nearly 40,000 letters and e-mails from
VFW members and supporters have been sent to Members of
Congress opposing the administration's proposal to revoke
individual unemployability benefits for veterans who are unable
to work because of their service-connected disabilities. The
VFW opposes the IU proposal and the COLA round-down proposal
and other measures to balance the budget on the backs of our
Nation's veterans.
We are also concerned with the administration's request to
make the Veterans Choice Program a permanent mandatory program,
which could possibly lead to the gradual erosion of the VA
health care system.
The continued failure by Congress to eliminate
sequestration has forced the administration's proposed cuts to
veterans programs in order to expand the Choice Program under
mandatory spending instead of including it in discretionary
Community Care accounts.
Sequestration and draconian spending caps limit our
Nation's ability to provide servicemembers, veterans, and their
families the care and benefits they have earned. The VFW calls
on this Committee to join our campaign and finally end
sequestration and do away with Federal budget processes based
on arbitrary budget caps.
In partnership with our Independent Budget co-authors, DAV
and PVA, I would like to focus some of my remarks on VA's
construction and National Cemetery administration budget
request. For more than a decade, the IBVSOs have warned
Congress and VA that perpetual underfunding has allowed VA's
infrastructure to erode while its capacity has swelled from 81
percent in 2004 to as high as 121 percent in 2012. We continue
to believe that this need for space and chronic underfunding of
major construction projects could force VA to ration care.
VA's budget request says that improving the condition of
VA's facilities through major construction projects accounts
for the largest resource need to keep pace with the growing
demand for VA outpatient care, yet the administration's major
construction request only funds one VHA major construction
project.
The IBVSOs believe that VA has requested an adequate amount
for its fiscal year 2018 major medical leases needs; however,
Congress must find a way to quickly authorize leasing projects.
There are now 27 major medical facility leases awaiting
congressional authorization, 18 of which have been waiting
since 2015. Delays in authorization of these leases has a
direct impact on VA's ability to provide timely care to
veterans.
The National Cemetery Administration has a sacred duty to
provide our Nation's veterans a final resting place that honors
their service. In 2016, NCA entered more than 130,000 veterans
and eligible family members. The number of interments is
expected to increase until 2022. Other factors have placed
additional demands on NCA, and the IBVSOs are glad to see the
administration's request for NCA as higher than our
recommendation, which I believe may be one of the only ones. We
commend VA for continued commitment to NCA's mission.
Mr. Chairman, this concludes my testimony. I am happy to
answer any questions that you and the Members of the Committee
may have.
[The prepared statement of Mr. Fuentes follows:]
Prepared Statement of Carlos Fuentes, Director, National Legislative
Service, Veterans of Foreign Wars of The United States
Chairman Isakson, Ranking Member Tester and Members of the
Committee, On behalf of the men and women of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, thank you for the
opportunity to present the VFW's views on the Department of Veterans
Affairs' (VA) Fiscal Year (FY) 2018 appropriations and FY 2019 advance
appropriations.
The VFW is glad to see President Trump has proposed a six percent
increase in VA's FY 2018 discretionary budget compared to FY 2017.
However, we feel his proposal falls short of what VA needs to keep pace
with demand for health care and benefits. The VFW thanks the
Administration for its commitment to community care, long-term care,
mental health care, woman veterans and efforts to prevent and eliminate
veteran homelessness.
However, we are very concerned that the Administration's request to
make the Veterans Choice Program a permanent mandatory program could
lead to a gradual erosion of the VA health care system. What is more
concerning is that the Administration has chosen to make permanent a
flawed program by ending Individual Unemployability benefits for
certain severely disabled veterans who are unable to work due to their
service-connected disabilities and round down cost of living disability
pay increases, a proposal which the VFW has opposed in the past and
continues to strongly oppose.
The Administration has also proposed a cap on the amount of tuition
and fees that may be paid under the Post-9/11 GI Bill for programs of
education in which a public institution of higher learning enters into
an agreement with another entity to provide such education. Currently,
third party training programs that contract with public schools are
able to charge unlimited fees since public schools have no set dollar
amount cap.
A couple of years ago, it came to light that some contracted flight
training programs were charging exorbitant fees, which far exceeded the
cost of an average in-state education. The VFW supports the
Administration's proposal to place a reasonable cap on these sorts of
training programs.
The continued failure of Congress to eliminate sequestration has
forced the Administration to propose cuts to veteran benefits and cap
GI Bill expenditures in order to expand the Choice Program under
mandatory spending instead of including the program in its
discretionary community care account. In testimony before the Senate
and House Committees on Appropriations, Secretary of Veterans Affairs
David J. Shulkin has indicated that VA would like all its community
care money to come from one account, instead of having two separate
accounts for the same purpose and not having the flexibility to use
both accounts in accordance with veterans' demand for community care.
The VFW agrees with Secretary Shulkin and urges Congress to consolidate
VA's community care programs and to fund such programs through VA's
discretionary appropriations account.
Sequestration and its draconian spending caps limit our Nation's
ability to provide servicemembers, veterans, and their families the
care and benefits they have earned and deserve. The VFW calls on the
Committee to join our campaign to finally end sequestration and do away
with a Federal budget process based on the arbitrary budget caps, which
significantly limit the government's ability to carry out programs that
experience spikes in demand, such as VA health care. To the VFW,
sequestration is the most significant readiness and national security
threat of the 21st century, and despite almost universal congressional
opposition to such haphazard budgeting, Congress has failed to end it.
The VFW, in partnership with our Independent Budget (IB) co-
authors--Disabled American Veterans (DAV) and Paralyzed Veterans of
America (PVA)--produces annual budget recommendations for each of VA's
discretionary appropriation accounts and compares them to the
Administration's request. PVA has submitted testimony covering Veterans
Health Administration (VHA) appropriation accounts and DAV has covered
the IB's recommendations for the Veterans Benefits Administration
accounts. I will focus my remarks on VA's construction and National
Cemetery Administration (NCA) appropriations.
Major Construction:

FY 2018 IB Recommendation--$1.50 billion
FY 2018 Administration Request--$512 million
FY 2017 Appropriations--$528 million

For more than a decade, the IB Veterans Service Organizations
(IBVSOs) have warned Congress and VA that perpetual underfunding has
allowed VA's infrastructure to erode while its capacity has swelled
from 81 percent in 2004 to as high as 120 percent in 2010. We continue
to believe that this need for space and chronic underfunding of medical
services could lead VA to ration care.
The IBVSOs are working with VA to reform its construction process
so facilities can be delivered on time and on budget. Previous errors
must be corrected to ensure the issues in Aurora, Colorado, never occur
again. However, Congress and the Administration must not ignore the
growing capital infrastructure needs of the Department's health care
system.
When VA asked its Veteran Integrated Service Networks (VISN) to
evaluate what they need to improve its facilities to meet the increased
outpatient demand, VA determined that ``improving the condition of VA's
facilities through major construction projects (96) accounted for the
largest resource need.'' \1\ Yet the Administration's major
construction request for VHA is 36 percent less than FY 2017 and 85
percent less than actual expenditures in FY 2016.
---------------------------------------------------------------------------
\1\ Department of Veterans Affairs 2018 Budget and 2019 Advance
Appropriations Requests, Volume IV: Construction, Long Range Capital
Plan and Appendix. Long Range Capital Plan, page 8.3-8.
---------------------------------------------------------------------------
When asked why VA is taking a strategic pause on major construction
for VHA when its capital infrastructure continues to age and demand
continues to increase, VA informed the IBVSOs that it simply did not
receive the request that it needed for major construction because of
sequestration budget caps. Congress must not allow VA's inability to
invest in its VHA's major construction to limit veterans' access to the
health care they have earned and deserve by forcing veterans onto VA's
community care programs and eliminating the choice to receive care at
VA medical facilities.
Currently, VA has 24 major construction projects that are partially
funded--some of which were originally funded in FY 2004--that need a
clear path to completion. An additional three projects are in the
design phase. Outside of the partially funded major projects list are
major construction projects at the top of the FY 2017 priority list
that are seismic in nature. These projects cannot take a strategic
pause while Congress and VA decide how to manage capital infrastructure
long-term. VA will need to invest more than $3.5 billion to complete
all 24 partially funded projects. Of the top five projects on the
priority list, two are seismic deficiencies, two support the core
mission of VA--a mental health clinic and a spinal cord injury center--
and one is an addition to an existing facility. The total cost of these
five projects is $1.2 billion.
The IBVSOs recommend that Congress appropriate at least $1.5
billion for major construction in FY 2018. This amount will fund either
the ``next phase'' or fund ``through completion'' all existing
projects, and begin advance planning and design development on six
major construction projects that are the highest ranked on VA's
priority list.
Minor Construction:

FY 2018 IB Recommendation--$700 million
FY 2018 Administration Request--$343 million
FY 2017 Appropriations--$372 million

In FY 2017, Congress appropriated $372.1 million for minor
construction projects. Currently, approximately 600 minor construction
projects need funding to close all current and future year gaps within
ten years. To complete all of these current and projected projects, VA
will need to invest between $6.7 and $8.2 billion in minor construction
over the next decade.
In August 2014, the President signed the Veterans Access, Choice,
and Accountability Act of 2014 (Public Law 133-146). In this law,
Congress provided $5 billion to increase health care access by
increasing medical staffing levels and investing in infrastructure. VA
has developed a spending plan that obligated $511 million for 64 minor
construction projects over a two-year period.
While this infusion of funds has helped, there are still hundreds
of minor construction projects that need funding for completion. It is
important to remember that these funds are a supplement to, not a
replacement of, annual appropriations for minor construction projects.
The IBVSOs recommend that Congress fund VA's minor construction account
at $700 million in an effort to close all identified gaps within ten
years.
leasing
Historically, VA has submitted capital leasing requests that meet
the growing and changing needs of veterans. VA has again requested an
adequate amount--$270.1 million for its FY 2018 major medical leasing
needs. While VA has requested adequate resources, Congress must find a
way to authorize and appropriate leasing projects in a way that
precludes the full cost of the lease being accounted for in the first
year. There are now 27 major medical leases awaiting congressional
authorization, 18 of which have been waiting since FY 2016 and six from
FY 2017 that Congress must still authorize. Delays in authorization of
these leases have a direct impact on VA's ability to provide timely
care to veterans in their communities. Congress must authorize these
leases.
National Cemetery Administration:

FY 2018 IB Recommendation--$291 million
FY 2018 Administration Request--$306.2 million
FY 2017 Appropriations--$286 million

The NCA, which receives funding from eight appropriation accounts,
has the sacred duty to provide the brave men and women who have worn
our Nation's uniform a final resting place that honors their service.
In a strategic effort to meet the burial and access needs of our
veterans and eligible family members, the NCA continues to expand and
improve the national cemetery system, by adding new and/or expanded
national cemeteries. Not surprising, due to the opening of additional
national cemeteries, the NCA is expecting an increase in the number of
annual veteran interments through 2016 to more than 136,000, up from
125,180 in 2014; this number is expected to slowly decrease after an
expected peak of 138,000 in 2022. This much needed expansion of the
national cemetery system will help to facilitate the projected increase
in annual veteran interments and will simultaneously increase the
overall number of graves being maintained by the NCA to 3.7 million in
2018 and 4 million by 2021.
Even as the NCA continues to add veteran burial space to its
expanding system, many existing cemeteries are exhausting their
capacity and will no longer be able to inter casketed or cremated
remains. That is why the VFW is glad the see the Administration's FY
2018 budget request for the National Cemetery Administration is higher
than what the IBVSOs have recommended and includes a seven percent
increase from FY 2017 appropriations.
Factors that have placed additional demand on the NCA include an
increase in the issuance of Presidential Memorial Certificates, which
is expected to increase from approximately 654,000 in 2013 to more than
870,000 in 2017; the expected increase in the burial of Native
American, Alaska Native, and Pacific Islander veterans; and the
possible increase, thanks to local historians and other interested
stakeholders, in requests for headstones or markers for previously
unidentified veterans. That is why the IBVSOs are glad to see the
Administration has requested $256 million in FY 2018 to fund six
national cemetery expansion projects which would provide more than
161,000 new burial spaces for veterans.
With the above considerations in mind, The Independent Budget
recommends $291 million for FY 2018 for the Operations & Maintenance of
the NCA. The IBVSOs believe that this should include a minimum of $20
million for the National Shrine Initiative. The IBVSOs laud the
Administration for providing NCA the first increase in this important
initiative since FY 2013.
Mr. Chairman, this concludes my testimony. I will be happy to
answer any questions you or the Committee members may have.

Chairman Isakson. Thank you, Mr. Fuentes. We appreciate it.
Mr. Rowan.

STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, VIETNAM VETERANS
OF AMERICA

Mr. Rowan. Thank you, Mr. Chairman. Senator Sanders, nice
to see you. Nice to see you, Senator. It is good to see you
back. I missed you when I had my annual testimony this year.
Chairman Isakson. I missed you more than you might think.
[Laughter.]
I am glad to be vertical again.
Mr. Rowan. Yeah. Well, me too. I was coming out of the
hospital when you were going in, I think.
Anyway, I would like to, first of all, thank you for the
Accountability Act. It is an issue we have been dealing with
since we started VVA, frankly, 35 years ago, calling upon
Congress to take full accountability of all the VA operations,
and hopefully, this will work. We support that bill.
IU, as was noticed, has got to be rescinded. That whole
proposal is a classic budget-tier proposal that has no idea how
it impacts on people. It is just a dollar amount to somebody in
OMB, with effects beyond even what everybody understood the
first time with this whole nonsense that Social Security was
going to pick up the amount of money lost on IU, not even
talking about the effects on the family members--the loss of
dental care, the loss of CHAMPVA, loss of local benefits. As
was mentioned earlier, tax abatements in New York City--we just
got the expansion of our tax abatement for real estate, which
would be cut significantly by that. So, that this has just got
to be--one of the things we are calling upon, we would like--
since the Secretary has alluded to the fact that they may agree
with the idea that this should be shelved, we would love to see
a joint effort between the VA and the leadership in both the
Senate and the House Veterans' Affairs Committee publicly
denouncing this idea and saying we are not going to pass it, so
that we can tell all those scared people out there, who have
been sending me e-mails and letters about all of the horrors
that they are concerned about. Let them know they have nothing
to worry about. We have got to bring these people down about
ten notches because they are climbing the walls right now. I
mean, that is something I hope that the Committees, both in the
Senate and the House, and the VA would take into consideration
so they could publicly acknowledge that this was one bad idea.
The Choice Program is not a choice. It is a false choice,
and I think we need to understand how it is done. I just came
back from Idaho, where I met with my State council up in
Sandpoint in northern Idaho. Almost everybody there utilizes
the Choice Program because they are hundreds of miles from any
VA facility, but they also can tell me all the problems they
have with Choice in finding doctors who will take Choice, who
will take the VA's money, who will even sign on because of
problems. Now, we know they are trying to resolve those
problems, but it is going to be a big issue for that.
The other thing is doctors. Where are they coming from? I
can tell you, I live in New York City. My dermatologist that I
had in my private medical program for 25 years just retired on
me. I managed to outlive him and that was great. He is retired.
I am still sick, and I have to go see the doctor. I called up
my EmblemHealth, which is one of the largest health care
providers in the country, and they could not find me a
dermatologist that I could talk to--at the earliest in August,
and really they were talking about October. That is a false
choice. That is dermatology, which I think I could throw a
stick out of my window and hit a dermatologist in New York
City, but they are not there because they do not sign up with
the VA. They will not take the VA's payments, just like we have
seen in Medicare and Medicaid with problems with doctors not
signing on. We are concerned about that. It really needs to be
rethought significantly because the private sector is not ready
whatsoever to take on the VA patients, no way.
The last thing--a couple of things I would--my other point
also, the R&D budget has been cut. It should not be cut. It
should be increased. We need more R&D for all of the programs
that we have. We need to get more evidence-based programs
testing on PTSD and how do we really handle it.
I cannot tell you all the different programs where folks
tell me what a great panacea they have for PTSD; it sounds
great. You know, I love my dogs, and yeah, they are helpful.
Yes, they help some veterans, but without counseling, that does
not end their problem. We need to get more evidence-based
actions, research into these programs.
I am also concerned--we passed a bill last year that would
look into the effects of toxic exposure on the children of
Vietnam veterans and veterans that came after us. Where is that
money going to come from if the R&D budget is cut? We got a
nice bill passed after we fought for years. Where is the money?
We need the money, and if the VA's budget is not there, how are
we going to get that done?
Last, let me just say one quick thing about the Board of
Veterans Appeals and the whole appeals process. It would go a
lot quicker if the VA took outside doctors' opinions and did
not have to redo everything that somebody came in with, with an
outside doctor's opinion. That would be nice.
The other thing is we need to blow up the Board of Veterans
Appeals. It just does not function. Nobody should lose 70
percent of the time, which the VA does every year. I have been
in this position 12 years, and in 12 years, every year, our
VSOs, 70 percent of the time, either get a remand or a direct
payment from the Board of Veterans Appeals on cases we bring
in--70 percent. We win; VA loses. Year after year after year,
and I guarantee you, that is the same percentage with the rest
of the gentlemen at this table. I will bet all of their VBA
cases are around the same percentage. That is ridiculous.
The other problem is no precedence. Carl can put in a
claim. I can put in a claim for the exact same thing. He gets
Judge A. I get Judge B. We get two different opinions. They
both go down. He wins; I lose. Too bad. His opinion does not
account for anybody that follows after them if they have been
approved, and neither does mine, for that matter. The denial
does not either. It just keeps regurgitating the same programs
over and over and over again, the same problems over and over
and over again. We need to get the issue of precedence, like in
any other court. Frankly, now that we understand the Court of
Veterans Appeals, we are going to be very happy to look at
them, the idea of doing class-action lawsuits at the Court of
Veterans Appeals.
I would be happy to answer any and all questions that
anybody may have. Thank you.
[The prepared statement of Mr. Rowan follows:]
Prepared Statement of John Rowan, National President,
Vietnam Veterans of America
Good afternoon, Chairman Isakson, Ranking Member Tester, and other
exemplary members of the Senate Veterans' Affairs Committee. Vietnam
Veterans of America is pleased to have the opportunity to present our
views on the President's Fiscal Year 2018 Budget and 2019 Advanced
Appropriations Request for the Department of Veterans Affairs.
First off, VVA is pleased that the VA warrants increased funding to
help meet the needs of the department and the veterans it assists in an
array of areas designed to restore, as much as possible, those who have
given of themselves--often at great cost to their health, to their
sense of well-being, to their families. We know that you, the members
and staff of this most important and hard-working committee, recognize
this, and that you will be true to the sacrifices these men and women
have made so that we all may live in a free society.
We do, however, want to commence our remarks with the one issue in
the budget proposal that has been the source of great consternation not
only to VVA but to the multitude of VSOs and MSOs. This is a proposal
that has unleashed a firestorm of protest, of questions, concerns, and
fears, by veterans and their spouses who have come to depend on this
income.
individual unemployability termination and elderly veterans
First and foremost, the Administration's proposal that would cap IU
benefits for veterans rated 60-100 percent disabled at age 62 and
terminate this benefit for those veterans currently receiving Social
Security must be a non-starter. It is unfair and simply wrong to
characterize IU and Social Security as duplicative. Veterans have
earned both benefits, IU by virtue of their service in uniform and
Social Security through working and contributing into the system.
The logic behind this proposition, which seems to arise from the
depths of the Office of Management & Budget (OMB) every eight years or
so, often at the beginning of a new administration, is that, at age 62,
veterans can avail themselves of their Social Security benefits. This
does not take into account, however, that if a veteran has been
receiving IU for several years, there's a pretty good chance, if indeed
not a likelihood, that s/he does not qualify for any serious Social
Security income because s/he has not had a significant work history.
This piece of the Administration's budget proposal, if approved,
would impact nearly every Vietnam-era veteran and their family whose
survival depends on the income received from this earned benefit. This
proposed change would cut the compensation of a married disabled
veteran receiving 100% by dint of IU compensation to about $1,300 a
month from just over $3,000 per month. Should any Member of Congress
exhibit political naivete and vote to eliminate IU at age 62, tens of
thousands of Vietnam veterans in their late sixties and seventies would
be in jeopardy of not being able to meet their basic needs, which would
lead, for many, to impoverishment, homelessness, even suicide.
According to the budget proposal, this provision would ``save'' the
Compensation and Pensions account in the Veterans Benefits
Administration an estimated $3.2 billion in 2018; $17.9 billion over
five years; and $40.8 billion over ten. The savings would go toward
funding the Veterans Choice program, which at present is confusing
endeavor in many areas, which many veterans neither understand nor
embrace.
Furthermore, there are 238,000 veterans 62 and older currently
receiving 100% by dint of IU, and of those 178,000 are 67 and older.
The plain fact is that the VA disability rating schedule for mental
health, and particularly for Post Traumatic Stress Disorder (PTSD) has
for many years been grossly unfair. In order to be rated at 100% for
PTSD a veteran would need to be exhibiting symptomology of full blown
dementia (which has nothing to do with PTSD!). Since these veterans
should have been rated at 100% for PTSD, but were not because the
rating schedule was faulty, they have continued to draw service-
connected compensation at the 100% level. They have been unable to
work, so have not paid much, if any,into Social Security. Social
Security is NOT akin to service-connected compensation, but rather it
is analogous to an annuity. The more you pay in to Social Security, the
more you get out of it in monthly increments. The less you pay into the
Social Security Trust fund, the less your monthly payments. VVA has
talked to numerous Vietnam veterans who have not been able to work
since they were blown up in the Vietnam War, but paid into Social
Security before Vietnam, so that their monthly payments are as little
as $25 per month.
The so-called ``savings'' achieved by means of this ruse would be
illusory, because nearly every veteran in this situation would
immediately re-apply seeking 100% service-connected disability without
IU. This would result in a flood of claims at VA, and would once again
create backlogs in processing of claims.
We strongly urge the Committees on Veterans Affairs to issue a bi-
partisan declaration that his ill-advised move will not happen on your
watch.
va health care
The President's budget request for medical care is $4.6 billion
greater than the FY'17 budget, representing a 7% increase in
discretionary spending; also, $2.9 billion in new mandatory budget
authority to continue, and to enhance, the so-called Choice Program.
Undergirding this increase is the need to continue to improve access to
care for the 6.8 million of the 9.2 million veterans enrolled in the VA
healthcare system.
Now, we understand that Secretary Shulkin embraces funding for
Choice which, if you'll recall, was never meant to be a solution to the
long-standing problem of access to quality care for veterans who seek
services from the VA. His goal is to integrate Choice into a local/
regional program of Community Care, with significantly greater funding
for the FY'19 budget.
We want to focus attention on two issues: collections from third
party payers, and privatization.
In the recent past, the VA put forth overly optimistic assessments
of the number of dollars it could recoup via third party collections
(along with all the million$ that would be saved through ``management
efficiencies''). We hope this is not the case again.
The persistent call by some for privatization of VA health care
should be quelled by a successful initiation and operation of the
Community Care program. We know there is an unfortunate number of
vacancies for clinicians--not only in the VA healthcare system but in
private and public venues as well. It makes eminent good sense to bring
in qualified, credentialed professionals to fill voids caused by, in no
particular order: retirement and/or resignation of VA clinicians;
increased demand in certain VA medical centers; delayed delivery of
care, and other problems.
choice 2.0
VVA is concerned that the proposed budget does not provide enough
funding for the new Choice currently in development. The Secretary is
redesigning the program, altering it from an administrative system to a
clinical one. We have some concerns, too, over the impact of proposed
organizational changes in care delivery to veterans; how the high
performing networks will function; and how this will then ease health
care access. We understand that under the new proposal, providers will
bring their networks with them, modeled after the Defense Department's
Tri Care system.
Additionally, VVA has concerns about the consolidation of care
authorities, a legislative ask that has been a priority for the agency.
This authorization is needed, according to the VA, to move Choice
forward, and yet this step has yet to be accomplished. The gist behind
consolidating the care authorities was to make it simpler for veterans,
employees, and providers to determine eligibility, and pay to providers
more promptly, with less paperwork. The establishment of a mandatory
pot of money for the Choice Program, with more than $2 billion in
funding, seems to defeat the purpose of the care consolidation
legislation.
caregivers expansion
The budget for FY'18 shows the Caregivers program cost estimate
decreased by $235.9 million due to a revision in the projected number
of caregivers receiving stipend payments. VA dis-enrolled 7,000
caregivers earlier this year. VVA was stunned to hear that these dis-
enrollments were seemingly haphazard and conducted in an effort to
bring down the cost of the program. While the Secretary committed to do
a look-back on some 300 cases to evaluate the accuracy of the actions
of those in the field, the review has been extended for six weeks as he
juggles priorities. There still has been no commitment to do a ``look
back'' on all 7,000 cases, which VVA believes is demanded by simple
justice. We, and you, must continue to monitor the progress of review
and its outcome.
As we testified on March 9, 2017, we will work with legislators to
enact a bill that encompasses qualified caregivers of veterans who
served before 9/11. We are aware that this is a relatively expensive
program. However, it is a bargain when compared to the cost of caring
for many of these same veterans in an institutional setting.
national center for ptsd
VVA strongly supports the Center (NCPTSD), which leads the Nation
(and indeed the world!) in research focused on war-induced PTSD and
related mental health illnesses, and serves as the Nation's front-line
resource center for information and education about PTSD research, not
only for the VA and other mental health professionals, but for affected
families and the general public. A strong and independent NCPTSD is
essential.
mental health
VVA also supports additional funding for the development and
implementation of scientific, evidence-based, integrated psychosocial
mental health programs, substance abuse recovery treatment programs,
and suicide-risk assessment programs for all veterans, especially since
Secretary Shulkin has publicly stated that veteran suicide is the VA's
top clinical priority.
medical and prosthetic research
VVA notes that the funding for Medical and Prosthetic Research for
the 2018 budget request suffered a decrease of over $30 million. VVA
has strong reservations concerning this decrease and recommends instead
a significant increase instead. VA's research program is distinct from
that of the National Institutes of Health in that it was created to
respond to the unique medical needs of veterans. In this regard, it
should seek to fund veterans' pressing needs for breakthroughs in
addressing hazardous environmental exposures, post-deployment mental
health issues, TBI, long-term care service delivery, and prosthetics to
meet the multiple needs of the latest generation of combat-wounded
veterans.
We respectfully thank you for the opportunity to present our views,
and will be pleased to respond to any questions you might want to put
to us.

Chairman Isakson. Thank you for your testimony.
I do not have a question. I have a proposition for you,
though. I would like to find a time--and I would like my staff
to listen to this--find time you and I could have lunch 1 day
in the next 3 weeks or month because you piqued an interest in
my mind. Your comments about the IU earlier, unemployment
compensation recommendation, which is a nonstarter with you,
and I think anybody else would tell you that is pretty much a
nonstarter too. It is not hard to pass benefits. It is hell to
take them back, and once you pace past them, you are not going
to take them back, or if you do, you lose a lot more than what
you get.
I also heard the comment, I think Mr. Acosta may have
referred to his organization. Somebody did. Mr. Fuentes may
have, about the COLA round-down. There are lots of things out
there that over the period of years of the Veterans
Administration and its existence and benefit existence and
health care, where times have changed, things have changed. We
probably ought to look at everything that we have out there,
because there may be some pearls of wisdom. There may be some
benefits in the scheme of things that are going to help us a
lot more, applied a different way today than they were when
they were passed. We need some folks who do not have any agenda
except to help our veterans and solve our problems rather than
going to court, to sit down and talk.
I will call you, and we will have that lunch.
Mr. Rowan. I would love to.
Chairman Isakson. I am not avoiding you, Mr. Acosta or Mr.
Fuentes. Bigger than everybody, I am not going to avoid him or
Mr. Blake either. You made the comment that piqued the
interest, so we will do that, because I think if we open a
little one-on-one dialog, there may be in some of these things
that we bring up, because staff brings them to us or the OMB
brings it up or your organization. You are looking out for the
best interest to your organization and its members, and I
appreciate that. I serve them as a master, but I also serve the
taxpayers as a master and other people. We ought to start
having some meetings and talk some of this stuff through. We
may end up finding no common ground anywhere; yet, we might
find some pearls of wisdom. If we do, I would love to work with
you and anybody else on doing that. We will try to set that up,
Mr. Rowan.
Senator Sanders.
Senator Sanders. Thanks, Mr. Chairman.
I should have known, but I had thought that we got rid of
this round-down thing finally. I have been hearing about it
probably from my first day in Congress. I was Chairman. We got
rid of it. The idea of nickel-and-diming veterans did not seem
a lot--so what you are telling me, Mr. Acosta or Mr. Fuentes,
it is back again?
Mr. Fuentes. Yes, sir. Thank you very much for your
leadership while you were Chairman of this Committee by really
eliminating that COLA round-down or that practice.
Now the President's proposal, as Carl laid out, proposed to
reinstate the COLA round-down as a way to pay for expansion of
the Choice Program as a mandatory program.
Senator Sanders. So, this is actually taking money away
from VA benefits and using it in another purpose. How much
would this--if this were implemented, how much would it cost
veterans? Anyone know?
I think, Mr. Acosta, you mentioned.
Mr. Acosta. Yes. The cumulative effect of this proposed tax
would cost beneficiaries close to $2.7 billion.
Senator Sanders. Over what? A 10-year period?
Mr. Acosta. Over 10 years.
Senator Sanders. Wow. All right.
Mr. Chairman, I do not think we should be nickel-and-diming
veterans. I mean, we have been through this for years. I
thought we got rid of it, and it is sad to see that it is
coming back.
Let me ask what I think is the elephant in the room, and
that is the concern--and I know the numbers seem to be disputed
and not quite the clarity we would like; but, the increase in
appropriations for the Choice Program and the very, very modest
increase for traditional VA care. Who wants to comment? Is that
a concern of you guys? Mr. Blake, is that a concern? We will
start with you.
Mr. Blake. Well, I think one of the concerns is--and the
Secretary sort of addressed this in his comments. There were a
lot of talks about our marriages and checkbooks. I think the
bottom line is we believe that all of the Community Care should
be streamlined under one authority, one account, and manage it
that way.
I think I understand why they put Choice over here on the
mandatory side. There are a number of reasons, things like
discretionary caps that are holding down discretionary spending
that place that at risk, but from the Independent Budget
perspective, we believe they are still shorting even the larger
discretionary pot. The differences for construction, in
particular, which are tremendous, and when you take into
account that outside of the health care accounts, virtually
every other line item in the VA's budget takes a reduction of
some type----
Senator Sanders. Right, right. Let me get other comments,
if I could.
Anybody else want to comment?
Mr. Acosta. Well, I concur with Mr. Blake.
Senator Sanders. OK.
Mr. Fuentes. I would also just like to add, this whole
notion of having a mandatory program and discretionary issues
and not being able to transfer, I think it is more about, as
Carl said, having one checkbook instead of requiring VA to have
to balance both.
Ultimately, you are absolutely right, Senator. We cannot
forget the need to invest in VA's ability to provide direct
care, hire more physicians, expand facilities, because,
ultimately, that is the preferred choice of veterans, and we
need to continue that.
Senator Sanders. John?
Mr. Rowan. Yeah, I would just like to add, look, I have
studied privatization. I worked for the city of New York as a
manager for 26 years and the last 2 in the City Council in the
Controller's office looking at all of those kinds of programs.
I watched them privatize all kinds of things that never worked,
because once you go outside and privatize, you are adding
layers of bureaucracy and cost. You are not going to give it--
you are not going to a doctor. You are going to a plan. The
plan is going to be administrated by somebody who is making $2
million a year, and thank God our VA people are not paid that
much. They maybe should be, as I will tell you in my hospital
care that I got at the VA Manhattan Hospital. But, that is not
what we should be doing.
Senator Sanders. OK. Let me ask you for your very brief
thoughts on a crisis that is impacting Vermont, NH, and the
whole bloody country, which is this opioid epidemic. My
impression is that the VA is trying to do the right thing. What
are your thoughts on that? Who wants to jump in there? Mr.
Fuentes?
Mr. Fuentes. It is certainly an epidemic that must be
addressed. We hear about anecdotes where veterans are being
overmedicated.
One of our concerns, though, I think would be the reverse
as well because what we have heard is cutting off veterans
without proper alternatives, and we certainly do not want that
either. We do not want an overcorrection, but we do want to
eliminate overmedication.
Senator Sanders. Other thoughts?
Mr. Acosta. I agree.
Senator Sanders. OK. Mr. Chairman, thanks very much.
Chairman Isakson. Thank you, Senator Sanders. I want to
again thank all our VSO members for coming. I know when you go
after the big guy and he testifies and we take 2 hours grilling
him and then everybody is gone and you are stuck with me and
the Secretary, which I want to commend the Secretary for
staying through both panels. We really appreciate it. Your
words are heard. We appreciate your input. We look forward to
working with you toward providing the benefits that are earned
and deserved for our veterans and doing it in the most
efficient way possible for the taxpayer. That is our ultimate
goal as a Committee.
We thank you very much for your attendance today. The
record will stay open for 7 days for any additional information
you may want us to have. Now this Committee meeting stands
adjourned.
[Whereupon, at 4:39 p.m., the Committee was adjourned.]
Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
Affairs
information technology
Question 1. One of the Department of Veterans Affairs' (VA)
motivations in moving to Cerner for the VA Electronic Health Record was
the speed with which VA will be able to implement this solution. Please
provide the Committee a broad timeline of VA's expectations in
implementing the new system.
a. How is VA planning to utilize the Department of Defense to learn
from their experience implementing a large information technology (IT)
acquisition?
Response. VA is judiciously balancing the speed of implementation
with risks to cost, schedule and performance objectives, and of course
the care of our Veterans and other beneficiaries. VA has been working
closely with DOD and ensuring alignment with commercial implementation
best practices to optimize our prospective schedule. VA will be looking
to go faster as our learning increases, and change management,
training, and governance strategies take hold in support of greater
deployment/implementation efficiencies. As an additional barometer of
how aggressive VA is in their plan, DOD is deploying over a 7-year
period under its 10-year contract with less than one-third of the size
and substantially less complex than VA. VA will assess our full
deployment (FD) strategy upon completion of Initial Operating
Capabilities (IOC) roll-out over the first 18 months, and incorporate
schedule efficiencies as warranted.

b. How much additional funding does VA anticipate requesting for
the transition of Electronic Health Records?
Response. The VA requested to transfer $782 million in FY 2018 to
implement the EHRM contract, PMO efforts and support infrastructure.

c. Given the large number of ongoing IT contracts that VA has, how
does VA plan to evaluate the current projects to determine if they are
necessary after the transition to Cerner?
Response. As part of the overarching EHRM effort, the Veterans
Health Administration (VHA) and the Office of Information and
Technology (OI&T) are evaluating health IT and related area projects
and contracts currently underway to determine which efforts should
continue, be paused, modified or canceled.

d. From an acquisition standpoint, does VA have the ability to
modify contracts post-award, based on internal preferences, to change
out solution components or team members that were selected under
specific Request for Proposal criteria?
Response. Yes. This is a firm-fixed price contract with clearly
delineated and discrete deployment schedules, timelines, and
milestones. Though there are no ``built-in'' penalties, the VA
Contracting Officer and Program Management Office (PMO) are authorized
to withhold payments for failure to perform contracted services or
deliver contracted capabilities in accordance with the terms and
conditions of the contract. The issuance of task orders will be
judiciously managed to ensure excessive risk to the achievement of
cost, schedule and performance objectives is not injected into the EHR
modernization portfolio.

e. If so, how does that affect liability and the burden of risk in
the underlying contract? Do changes post-award shift the burden of risk
from the prime contractor and team that was selected over to VA since
the modification was made after the contract and terms were already
awarded?
Response. Post-award contractual changes may shift the burden of
risk; however, since task orders are intended to stay within the
general scope of the basic contract, VA should be protected against
liability claims. Moreover, and as detailed above, since VA does not
intend to mandate the use of a specific product, partner or methodology
in order to meet contractual requirements, it will be further protected
against liability claims. If the use or incorporation of a particular
product or methodology is required, then the parties will work toward a
bilateral agreement whereby the prime contractor will maintain the
burden of risk and the adherence to the requisite performance
parameters.

f. How does VA plan to address elements such as time or cost
overruns and increased protests due to requirements changes post-award,
thus impacting the ability to provide timely solutions to our veterans
for improving healthcare services?
Response. VA is already operating on the Veterans Health
Information Systems and Technology Architecture (VistA) platform
delivering the requisite capabilities. In the event of a protest, VA
will continue to utilize the VistA platform to support Veterans until a
protest is formally adjudicated. The indefinite delivery and indefinite
quantity (IDIQ) type contract and site surveys in advance of deployment
will support the identification of issues that could cause scope creep
or negatively impact schedule in advance of committing resources.
construction
Question 2. VA's testimony submitted for the hearing highlights
VA's participation in the White House Infrastructure Initiative to
explore ways to modernize and obtain upgrades to VA's real property
portfolio. Please provide additional details on VA's participation in
this initiative and the process VA is using to examine its real
property portfolio.
Response. VA is participating in the White House Infrastructure
initiative, and is working with the Office of Management and Budget
(OMB) to explore methods to enhance the delivery of high quality care
and services for Veterans in VA facilities. The Department will
continue to keep Congress informed as the Infrastructure Initiative
evolves.

Question 3. The fiscal year 2018 budget request includes $255
million for construction of six cemetery projects.
a. In terms of locations across the country and types of
interments, please describe some the most immediate priorities for
increasing veterans' access to National and State veterans cemetery
options.
b. What would those needs be over the next decade if this funding
request for expansion in fiscal year 2018 is provided?
Response. The National Cemetery Administration (NCA) administers
burial and memorial benefits to Veterans and eligible family members
worldwide. Currently, VA operates and maintains 135 national cemeteries
in 40 states, and Puerto Rico, and is in the process of establishing
new cemeteries. VA has also funded the establishment, expansion, or
improvement of 105 state and tribal Veterans cemeteries in 47 states,
Guam, and the Northern Mariana Islands (Saipan), through the Veterans
Cemetery Grant Program (VCGP). Combined, these cemeteries provide
burial options to approximately 91.7 percent of the total Veteran
population in all 50 states, Puerto Rico, and the U.S. Island Areas.
NCA's near term focus is establishing congressionally approved and
planned cemeteries, increasing availability of state and tribal
Veterans cemeteries, and keeping existing national cemeteries open
through expansion.
New burial policies approved by the Congress in 2011 and 2013
support NCA's Long Range Plan for 18 new national cemeteries--including
in urban and rural locations. Additionally, VA is establishing five new
columbarium-only cemeteries to enhance burial access for approximately
2.4 million Veterans residing in densely populated areas. Moreover, NCA
is improving burial access for Veterans residing in sparsely populated
rural areas not meeting the criteria for new national cemeteries, and
which are unlikely to receive a grant for a state Veterans cemetery.
Eight such identified locations will serve an additional 133,000
Veterans.
Four of the 18 new cemeteries have already opened at Yellowstone
County, MT (2014); Cape Canaveral, FL (2015); Tallahassee, FL (2015);
and Omaha, NE (2016). NCA plans to open the remaining 14 (listed below)
by 2021 at which point over 3 million Veterans and their families will
have new access to burial options.

----------------------------------------------------------------------------------------------------------------
Uniquely
Served
City State Veterans Type Interments
within 75
Miles*
----------------------------------------------------------------------------------------------------------------
Cities with at least 80,000 Unserved Veterans within a 75 Mile Service Area
----------------------------------------------------------------------------------------------------------------
Colorado Springs....................... Colorado.................. 278,137 All Burial Options
Western New York (Buffalo)............. New York.................. 87,538 All Burial Options
----------------------------------------------------------------------------------------------------------------
Cities Targeted for Rural Initiative
----------------------------------------------------------------------------------------------------------------
Twin Falls............................. Idaho..................... 12,789 All Burial Options
Machias................................ Maine..................... 3,381 All Burial Options
Elko................................... Nevada.................... 4,964 All Burial Options
Fargo.................................. North Dakota.............. 24,855 All Burial Options
Cedar City............................. Utah...................... 15,904 All Burial Options
Rhinelander............................ Wisconsin................. 19,109 All Burial Options
Cheyenne............................... Wyoming................... 17,103 All Burial Options
----------------------------------------------------------------------------------------------------------------
Cities Targeted for Enhanced Service (Urban Initiative)
----------------------------------------------------------------------------------------------------------------
Los Angeles............................ California................ 539,163 Columbarium only
San Francisco.......................... California................ 444,434 Columbarium only
Chicago................................ Illinois.................. 557,861 Columbarium only
Indianapolis........................... Indianapolis.............. 250,245 Columbarium only
New York............................... New York.................. 782,139 Columbarium only
----------------------------------------------------------------------------------------------------------------
* The Veteran populations cited above are based on the Vet Pop 2016 model.

VA also helps fund new or expanded state and tribal Veterans
cemeteries through the VCGP. NCA currently has no plans to establish
more national cemeteries beyond the planned 18, but is committed to
providing reasonable access to burial options through VCGP grants for
state and tribal Veterans cemeteries. In total, we anticipate that by
the end of 2018, 92.3 percent of the total Veteran population (over 20
million Veterans) will have access to burial options in national, state
or tribal Veterans cemeteries, within 75 miles of their home. Shown
below is a list of planned expansion and establishment VCGP projects
funded through FY 2018.

2017 Grants for Construction of State Veterans Cemeteries
------------------------------------------------------------------------
Cemetery State Type of Grant
------------------------------------------------------------------------
Rocky Gap............ Maryland........... Expansion
Knoxville-2.......... Tennessee.......... Expansion
Higginsville......... Missouri........... Expansion
King................. Wisconsin.......... Expansion
Springfield.......... Montana............ Expansion
Middletown........... Connecticut........ Expansion
Hopkinsville......... Kentucky........... Expansion
Milledgeville........ Georgia............ Expansion
Radcliff............. Kentucky........... Expansion
Gallup............... New Mexico......... Establishment
Cass Lake............ Minnesota.......... Establishment
Fort Yates........... North Dakota....... Establishment
Middle town.......... Connecticut........ Operations and Maintenance
Maui................. Hawaii............. Improvement
Lanai................ Hawaii............. Improvement
Killeen.............. Texas.............. Improvement
Mission.............. Texas.............. Improvement
Hilo II.............. Hawaii............. Improvement
------------------------------------------------------------------------

2018 Grants for Construction of State Veterans Cemeteries
------------------------------------------------------------------------
Cemetery State Type of Grant
------------------------------------------------------------------------
West Hawaii.......... Hawaii...................... Expansion
Spanish Fort......... Alabama..................... Expansion
Garrison Forest...... Maryland.................... Expansion
Spring Lake.......... North Carolina.............. Expansion
Black Mountain....... North Carolina.............. Expansion
Killeen.............. Texas....................... Expansion
Suffolk.............. Virginia.................... Expansion
North Little Rock.... Arkansas.................... Expansion
Boscawen............. New Hampshire............... Expansion
Saipan............... Northern Mariana Islands.... Expansion
Jennings............. Louisiana................... Establishment
Angel Fire........... New Mexico.................. Establishment
------------------------------------------------------------------------

Existing Cemeteries:
In addition to increasing access through new national and grant-
funded cemeteries, NCA maintains access at existing cemeteries through
major and minor construction projects to develop additional gravesites
and columbaria, or by acquiring more land. Requested funding for these
initiatives varies based on projected burial workload and gravesite
depletion forecasts. The FY 2018 budget includes $255.9 million in
Major Construction funding for gravesite expansion at six national
cemeteries, and advance planning and design activities. Gravesite
expansion projects at National Cemetery of the Alleghenies, PA; Florida
National Cemetery, FL; Abraham Lincoln National Cemetery, IL; National
Memorial Cemetery of Arizona, AZ; Sacramento Valley National Cemetery,
CA; and Calverton National Cemetery, NY will enable these cemeteries to
remain open. Together, these cemeteries provide over two million
Veterans with access to burial options. FY 2018 funding will be used to
complete master planning, design, and construction in time for
necessary modifications prior to the anticipated depletion of burial
options, and to avoid a temporary closure at one or more cemeteries.
The FY 2018 request includes $98 million for minor construction
projects to develop additional gravesites at existing cemeteries,
support the urban and rural initiatives, acquire land, and make
infrastructure improvements. NCA relies heavily on minor construction
funding to develop additional gravesites for smaller scale projects to
keep existing cemeteries open.
The enclosure provides information related to depletion of
gravesites for national cemeteries projected to deplete gravesites
within the next 10 years. Projects in italics represent those with an
immediate need to prevent a burial option from closing. This list does
not include gravesite expansion projects that are funded, currently
underway, or not projected to deplete within 10 years.

c. What would those needs be over the next decade if this funding
request for expansion in fiscal year 2018 is provided?
Response. The enclosure provides information related to depletion
of gravesites for those national cemeteries projected to deplete
gravesites within the next 10 years. This information includes cemetery
names, current operating status, and years in which specific burial
options are projected to deplete. The projected depletion dates account
for, and assume the completion of current, in-progress gravesite
expansion construction projects on schedule. The depletion dates do not
account for any potential future gravesite expansion construction
projects. Bold highlights are the six cemetery expansion projects
included in the 2018 Major Construction request of $255.9 million.
medical care

Question 4. VA's testimony submitted for the hearing indicates
that, after becoming the Under Secretary for Health, Secretary Shulkin
``discovered that years of ineffective systems and deficiencies in
workplace culture led to [the access] problem.'' While VA has made
strides in improving care to veterans, more work is needed.
a. What were some of the ineffective systems and deficiencies that
contributed to the access issue?
Response. VA identified several factors that contributed to
extended appointment wait times, including:

1. Increased patient requirements for care coupled with inadequate
staffing levels of providers, nurses, and schedulers led to inability
to keep up with the demand for care;
2. Inefficient clinic practices, lack of adequate training, and
complicated legacy software led to high rates of scheduling errors; and
3. Lack of national oversight and local monitoring systems meant
access red flags were not responded to in time and proactive strategies
were not set in place.

b. What specific changes have been made to improve the system?
Response. Since 2015, VA embarked on its largest access
transformation, a major part of which was the MyVA Access improvement
endeavor. Subject matter experts across VA were sequestered for 4 weeks
to identify ineffective systems and deficiencies contributing to VA
access shortfalls, standardize national guidance, and implement strong
practices. Through MyVA Access, VA developed a comprehensive approach
toward systemic access improvements. Specific changes related to the
aforementioned reasons are as follows:

1. Increased patient requirement for care coupled with inadequate
staffing levels of providers, nurses, and schedulers led to
inability to keep up with the demand for care.
Provider Recruitment and Productivity: VA prioritized active
recruitment of healthcare providers and clinic staff--supported by the
Veterans Access, Choice and Accountability Act of 2014. This resulted
in increasing provider and nursing staff by approximately 12 percent
over the past 2 FYs. Additionally, on January 13, 2017, VA full
practice authority went into effect for all Advance Practice Registered
Nurses (APRNs). This rule is expected to continue to grow and fill gaps
with access coverage. VA also focused on improving productivity for
existing providers. By assessing clinical workload by the community
standard of work RVUs (work relative value units), VA marked a 13
percent increase in total clinical productivity (wRVUs) produced and an
increase in physician productivity, wRVU per clinical full-time
equivalents (FTE), of 9 percent from FY 2014 to April 15, 2017.
Utilizing internal resources: VA focused on increasing the use of
telehealth for Primary Care and Mental Health. As a result, 12 percent
of Veterans (727,000) receiving VA care from obtained 2.18 million
telehealth appointments. VA has also expanding telehealth ``hubs''--
medical centers that easily hire providers to deliver telehealth to
another part of the country where a provider shortage exists. As of the
end of 2017, VA has nine fully operational hubs in Primary Care and 11
in Mental Health. Additionally, some Veterans Integrated Service
Networks (VISNs) have been setting up their own hubs.
VA is also working to implement VA Video Connect, a simplified
mobile and web-based application connecting Veterans with providers
using encrypted video. It allows Veterans to see and talk to their
health care team from anywhere using their smart phone, iPad or desktop
computer, making appointments more convenient and reducing travel and
wait times. VA is in the process of implementing this across VA.
2. Inefficient clinic practices, lack of adequate training, and
complicated legacy software led to high rate of scheduling
errors.
Clinic Practice Management: Beginning in early 2016, VA implemented
a Clinic Practice Management program at each VA Health Care System
based upon private sector and DOD best practices to optimize
administrative activities. This program monitors data and oversees
timeliness and accuracy of Veteran appointments. Each VA system has at
least one Group Practice Manager as well as a Clinic Practice
Management team. A user-friendly Clinic Practice Management dashboard
allows the Group Practice Managers as well as facility leadership to
monitor clinic activities. This dashboard includes scheduling
performance data down to each individual scheduler.
Scheduler Training: VA recognized its scheduler training in the
past was ineffective. To reduce scheduling errors, VA enhanced its
training and identification of scheduling error warning signs. In
December 2016, VA commenced system-wide mandatory face-to-face
scheduler training, including hands-on supervised practice scheduling
sessions. All newly hired schedulers must successfully complete this
training. Over 30,000 schedulers have completed the training.
Scheduling Directive: Revisions and clarifications on national
guidelines were included in VHA Directive 1230, Outpatient Scheduling
Processes and Procedures, published on July 15, 2016. VA completed over
70,000 episodes of directive-related training for over 50,000 staff who
schedule appointments. Using Lean methodology, VA is also in the
process of simplifying the scheduling process, which was initiated
based upon input from front-line staff including schedulers. This is
expected to result in a simplified update to scheduling and consult
directives.
VistA Scheduling Enhancement: Using 1980's technology, VA's current
scheduling system is inefficient, results in scheduling errors, and
creates barriers to optimize clinician productivity. Until the time a
comprehensive resource-based scheduling system can be deployed VA is
implementing VistA Scheduling Enhancement (VSE) as an interim solution.
This improved user interface makes it easier to view available
appointment times and reduces entry errors. The VistA Scheduling
Enhancement has been implemented in 97% of facilities within VA.
3. Lack of national oversight and local monitoring systems meant that
red flags were not responded to in time.
New National Establishments: The Office of Veteran Access to Care,
a national level program office, was created in 2016. The office
provides oversight and direction for policy and operations for
optimization of Veteran access to health care. This office is led by an
executive-level Assistant Deputy Under Secretary for Health for Access
to Care who directly reports to the Deputy Under Secretary for Health
for Operations and Management, and also has a platform for interaction
and feedback with the Secretary, Deputy Secretary, Under Secretary for
Health and Principal Deputy Under Secretary for Health.
VA established a Health Improvement Center to track trends in
quality, safety, access, and Veteran experience across multiple
indicators. Sites that display anomalies or unfavorable trends are
contacted and, where it is determined sub-par performance exists, the
new Office of Reporting, Analytics, Performance Improvement, and
Deployment, within the VHA Office of Organizational Excellence,
mobilizes a team of experts to visit the site and provide on-site
training and consultation, with follow-up to assure that progress is
made.
Scheduling Triggers and Audits: Using advanced statistical
techniques, Scheduling Triggers were implemented as an early warning
sign to alert leadership about inconsistencies with scheduling
procedures and timeliness of care. Additionally, a mandatory
standardized Supervisory Audit Tool was implemented June 1, 2017 to
ensure every scheduler is audited at least twice annually. Audit
results lead to direct feedback and coaching of individual schedulers,
and is used by Facility, VISN and National leadership to ensure
compliance, and assist with identifying opportunities for improvement.
4. Additional Improvements to improve access.
Timely Care: VA has made it a priority to focus on ensuring that
the urgent care needs of Veterans are met in a timely manner. VA held
two stand downs in November 2015 and February 2016 to reduce backlogs
and ensure Veterans with urgent needs received timely care.
Additionally VA worked to deliver same-day services for Primary Care
and Mental Health. As of December 31, 2016, same-day services were
achieved at all VA medical centers and as of November 2017, same day
services is now available at the more than 1000 outpatient clinics
across VA.
VA also standardized processes to ensure new referrals to
specialists are screened for urgent needs. In FY 2014, the average time
it took to complete the most urgent referrals to a specialist was 31.3
days. As of December 2017, the average time was 2.6 days. In support of
the focus on urgent consults, VA instituted a weekly national consult
management call whereby scheduling experts provide technical assistance
to the field to ensure the timeliness of scheduling. The calls
commenced in 2015 and have become a driving force supporting timely
scheduling and completion of urgent consults.
To ensure the timely follow-up care for Veterans with urgent needs,
in December 2016 VA implemented a process for providers to indicate
priority level for follow-up appointments to ensure that Veterans'
timely follow-up needs are met. Providers flag these time-sensitive
appointments in the return to clinic order to signal the scheduler to
arrange for the follow up appointment no later than the provider
recommended date. Since implementation through the end of FY 2017,
128,000 time-sensitive appointments were completed across VA and of
those about 90 percent have been completed by the provider recommended
date. Over the first 3.5 months of FY 2018, almost 80,000 such
appointments have been completed and of those, 94.8% have been
completed by the provider recommended date.
Veteran Control: VA is working to empower Veterans to schedule the
care they need. The Veterans Appointment Request App enables Veterans
to schedule or cancel Primary Care appointments, and has been deployed
to 1 14 sites since January 2017. VA also instituted Direct Scheduling
allowing Veterans to request routine audiology, optometry, and
nutrition appointments without having to obtain a referral from a
Primary Care Provider. This not only decreased the wait time for
services, it freed up primary care capacity. VA is working to expand
Direct Scheduling options to podiatry, prosthetics, wheelchair,
screening mammography, smoking cessation, and weight management
appointments as well.
Access and Quality in VA Healthcare website: In April, VA launched
the ``Access and Quality in VA Healthcare'' website at
www.accesstocare.va.gov to promote transparency. Through this tool,
Veterans, their families, and caregivers can view data related to:

Patient wait times at VA facilities in their area;
Veterans experiences scheduling primary and specialty
care;
Available options for same day services; and,
Quality of healthcare delivered at every medical center.

Question 5. The fiscal year 2018 budget request estimates a
reduction in medical care collections for fiscal year 2017 and fiscal
year 2018. Please explain in detail what factors contributed to this
estimated decrease in collections.
Response. There are several key factors that contribute to the
stable/declining collections estimate for 2017 and 2018:

1. Tiered Medication Copayments: Effective February 27, 2017, VA
amended its regulations governing copayments for certain Veterans for
medication required on an outpatient basis to treat non-service-
connected conditions. Prior to this change, the medication copayment
was $8 per fill for Veterans in Priority Groups 2--6 with an annual out
of pocket cost cap of $960. For Veterans in Priority Groups 7 & 8, the
medication copayment was $9 per fill and there was no out of pocket
cost cap. Under current policy, per fill copayments are $5 for Tier 1
medications, $8 for Tier 2 medications, and $11 for Tier 3 medications;
with an annual out of pocket cost cap of $700 applicable to Priority
Groups 2--8. Under the revised regulations, the average copayment per
prescription is less than in the past. Thus, VA estimates collections
for these pharmacy copayments will be lower in 2017 and into the
future.
2. Third Party Collection or Recovery: Changes in the healthcare
landscape have caused payers to adjust rates and/or reimbursement
methodologies to minimize expenditures. 38 CFR 17.101 permits health
plan contracts to pay billed charges or the amount they would pay for
care or services furnished by providers in the same geographic area.
Historically, many health plan contracts paid VA 100 percent of billed
charges or above market rates. During the last six months of 2016, five
large payers reduced reimbursement rates, or requested a decrease to
align VA with what they are paying other providers in their respective
markets. Additionally, VA has been tracking six payers identified as
being at ``high risk'' for reducing payments based upon high
reimbursement rates. These payers may request reductions in
reimbursement rates with 30 to 120 days' notice.
Additional factors: VA's Third Party reasonable charges are
projected to decrease in CY 2017 by an average of 3 percent, which
translates to a negative impact on collections; in particular for
payers reimbursing on a percent of charge basis. Pursuant to 38 CFR
17.101, outpatient charges are calculated at the 80th percentile of
various data sources such as Fair Health, MarketScan and Medpar for the
Centers for Medicare & Medicaid Services (CMS)/Medicare data. In 2017,
VA experienced a decrease in outpatient charges as a result of
decreased charges in the Fair Health data as well as decreased charges
for Durable Medical Equipment (DME) in the CMS data.
education
Question 6. One of VA's priorities is to improve timeliness of
service, and VA has made it a goal to fully automate claims for
veterans' education benefits and consolidate outdated enrollment
certification systems. This would produce faster decisions, reduce
labor and administrative costs, and improve accuracy of claims. Is the
decision to postpone this development due to a lack of IT resources or
are there other practical considerations for waiting?
Response. VA is prioritizing the retirement and replacement (when
warranted) of its legacy information technology systems due to the
increased cost, risks with maintaining these systems, and the need to
modernize our business processes to improve service delivery. For
example, the Benefits Delivery Network (BDN) is the claims processing,
payment, tracking, and disposition system used for education programs
but consists of antiquated mainframe systems and is in need of
replacement. VA is currently working on a solution to address its
enterprise IT challenges, and is prioritizing accordingly to ensure
that replacement systems meet the needs of all users and Veterans. Once
these systems are replaced VA can redirect its focus on newer systems.
For example, enhancing the Long Term Solution to provide functionality
such as automated certificates of eligibility for original claims;
electronically generated letters; expanded automation of supplemental
claims; issuance of advance payments; monthly certification of
attendance; and improved business analytics for reporting purposes.
appeals

Question 7. At the hearing, Secretary Shulkin testified that VA
would need an additional $800 million in order to address the 470,000
legacy appeals.
a. Please provide copies of the modeling data and assumptions used
in reaching that conclusion.
Response. VA is committed to addressing the pending inventory of
legacy appeals. Since the Secretary's testimony, several enhancements
to VA's appeals process have influenced the assumptions VA uses to
inform resource decisions. Following enactment of the Veterans Appeals
Improvement and Modernization Act on August 23, 2017 VA immediately
began implementation. By February 2019, all requests for review of VA
decisions will be processed under the new, multi-lane process. VA is
also continuing work to address the pending inventory of legacy appeals
through an approach that focuses resources on legacy appeals processing
while also allowing Veterans to enter the new appeals system.
VA established a new program on November 1, 2017, the Rapid Appeals
Modernization Program (RAMP), to provide those Veterans who are waiting
on the legacy appeals process, an opportunity for early participation
in the new system. The administration of RAMP allows VA the opportunity
to quickly resolve legacy appeals and to test certain facets of the new
appeals system. VA will refine the new system based upon actual data
prior to full implementation. VBA will direct appeals resources to
maintain RAMP claims processing within prescribed timeliness goals as
well as continue to process legacy appeals.
VA will also utilize the legal authority for Veterans who receive
Statements of the Case or Supplemental Statements of the Case after the
effective date of the legislative change to elect to participate in the
new system and transition from the old process.
Once the new system is implemented, VA intends to allocate
resources in an efficient manner that will establish timely processing,
and utilize all remaining appeals resources to address legacy appeals.
The Board will focus its resources on its core mission and will work to
maximize efficiencies in appeals processing, to include technological
and process improvements. This will enable the Board to also meet
timeliness goals in the new system and devote all remaining resources
to processing legacy appeals.
The rate at which the legacy appeals inventory can be resolved is
dependent on a number of factors, including the rate of election into
the new framework process of claimants with appeals pending in the
legacy system. As VA gathers data, and creates a forecasting model
based upon actual Veteran behavior and employee productivity, this will
inform resource needs and help establish achievable goals and
milestones for reducing the number of pending legacy appeals, including
the expected number of appeals, remands, and hearing requests at VBA
and the Board.

b. Please explain what steps VA has taken or will take to identify
or secure any resources necessary to address the backlog of legacy
appeals.
Response. VA remains committed to reducing the pending inventory of
legacy appeals as quickly and efficiently as possible. In January 2017,
the Veterans Benefits Administration (VBA) realigned its appeals policy
and oversight of its national appeals operations under a single office,
the Appeals Management Office (AMO). This realignment allows VBA to
focus on internal people, process and technology appeals initiatives,
and implementation of the appeals reform legislation. Under this
realignment, VBA's appeals productivity through May 31, 2017, has
increased by 32 percent over FY 2016 production during the same period.

Question 8. According to the fiscal year 2018 budget request, the
Board of Veterans' Appeals (Board) had 660 employees in fiscal year
2016, expects 886 employees in fiscal year 2017, and requests 1,050
employees for fiscal year 2018. The budget request also reflects that
the Board issued 52,000 decisions in fiscal year 2016, expects to issue
nearly 66,000 decisions in fiscal year 2017, and expects to issue over
80,000 decisions in fiscal year 2018.
a. As of March 2017 (half way through the fiscal year), the Board
had issued about 19,000 decisions. Is the Board still expecting to
issue over 66,000 decisions in fiscal year 2017? If not, please outline
the factors that have contributed to not meeting that target and how
many decisions the Board now expects to issue during fiscal year 2017.
Response. The Board is committed to its mission to hold hearings
and decide appeals for Veterans and their families. Unfortunately, due
to a variety of reasons, the Board did not meet its FY 2017 goal. There
were a number of contributing factors, to include, hiring falling short
of goals; the impact of revised attorney performance standards; time
spent training and mentoring new attorneys; time attorneys spend on
FMLA/leave and on official time; outdated technology; complexity of
cases; and Veterans Benefits Management System user difficulties. As of
June 25, 2017, the Board issued 32,598 decisions. compared to the
37,490 that it had issued during the same time period in the prior
fiscal year. As more Board attorneys complete training and become fully
productive, the Board projects increased productivity in the remaining
weeks of FY 2017. We anticipate that the Board will decide at least
50,000 appeals by the end of FY 2017.

b. In a June 8, 2016, memorandum to stakeholders about appeals
reform, VA noted as a risk factor that ``staffing ramp at the Board is
steep and challenging.'' What challenges has the Board faced since 2016
in hiring additional employees; what steps is the Board taking to
address those challenges; and what impact has that hiring had on
overall productivity at the Board?
Response. In FY 2017, Congress provided an additional $45.7 million
to the Board to facilitate hiring additional personnel. To support the
Board's aggressive hiring in FY 2017, the Center of Excellence Pilot
Program for hiring legal professionals was established with VA's Office
of Human Resources and Administration (HRA). The Board made great
progress in hiring early in FY 2017, consistent with the budget, but
was slowed by the hiring freeze. On March 13, 2017, the Secretary
approved exemptions for eight occupations directly involved in appeals
processing. Since that time, the Board resumed its aggressive hiring
plan and, as of June 29, 2017, the Board had 882 FTEs employees on
board, compared to 667 FTEs at the start of FY 2017. Additionally, the
Board is in the process of filling approximately 100 additional
attorney positions, as well as other key vacancies. As more Board
attorneys completed training and became fully productive, the Board
projected an increased productivity in the remaining weeks of FY 2017.
At the end of FY 2017, the Board issued 52,661 appeals decisions.

c. Would the Board expect to encounter similar difficulties in
hiring an additional 164 employees during fiscal year 2018? If so,
please outline what steps would be taken to mitigate those risks.
Response. The Board does not anticipate difficulties in hiring
additional employees during FY 2018. The Board has worked successfully
with the Center of Excellence to on board over 200 new attorneys in FY
2017 to date. Based on this proven ability to hire and on board a large
number of new employees, the Board does not anticipate difficulties in
hiring additional employees in FY 2018. We plan to continue to work
closely with HRA to accomplish our hiring objective.

d. When would the Board expect to realize an overall increase in
productivity as a result of employees hired during fiscal years 2017
and 2018?
Response. The Board has a 6-month period during which new attorneys
receive training and develop the necessary skills to effectively
produce quality decisions in a timely manner. Therefore, new Board
attorneys are not fully productive until after they have completed
their 6-month training period. The Board anticipates that we will see
incremental increases in productivity as new employees complete this
training period. We would project all employees to be fully productive
6 months after we complete our FY 2018 hiring plan. Notably, while
Board attorneys are on production after 6 months, most cannot handle
and are not given the most challenging cases until their 2-year point.

e. What steps--other than hiring new employees--is the Board taking
to improve overall productivity; what is the cost of each such
initiative; and what impact is each such initiative expected to have on
productivity?
Response. The Board is committed to improving productivity. The
Board is modernizing appeals processing technology to optimize
efficiency to best serve Veterans and their families, and to ensure the
seamless transfer of appeals between jurisdictions by leveraging
industry best practices and Human Centered Design principles. The Board
is fortunate to have Digital Service at VA (DSVA) leading the technical
approach to this effort. Specifically, DSVA is developing several
attorney-specific tools, including a document review tool for claims
file review; a Decision Builder; and eFolder Express, providing a one-
click download of the eFolder. These tools are intended to assist
decision-writing attorneys in reviewing the record and drafting
decisions more efficiently. The Board revised its attorney performance
standards in October 2016. After using these standards for one quarter
and evaluating their effectiveness in enabling the Board to meet its
mission, the standards were revised again, effective January 15, 2017.
The Board continually monitors performance, and during FY 2017 was in
negotiations with the union about revising the attorney performance
standards, to best position the Board to meet its goal of deciding
appeals. As a result, new standards went into effect at the start of FY
2018. There are no anticipated additional costs to the Board for the
technological changes being developed by DSVA, because their
development work is ongoing and all funding for these changes is
covered by the existing Appeals Modernization budget.
______

Response to Posthearing Questions Submitted by Hon. Jon Tester to
Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
Affairs
Question 9. Does this budget allow for VA to accommodate those
Veterans who are currently not enrolled in VA care but who may lose
their other health insurance if Obamacare is repealed?
Response. Any impacts on Veterans or VA would depend on the
specific changes to the Affordable Care Act enacted by Congress.

Question 10. I am concerned that the President has not accurately
projected in-house demand for health care services. Can you explain the
utilization and reliance projections for FYs 18 and 19? Please also
provide data showing budget projections and actual utilization and
reliance statistics for FY 2013, 14, 15, 16, and 17 (as available).
Response. The following information on utilization and reliance is
from the 2017 VA Enrollee Health Care Projection Model (EHCPM), which
supported VA's 2018 Budget. The table below shows historical and
projected annual change in utilization for ambulatory and inpatient
services as modeled using the EHCPM. It separately shows data for
Veterans eligible for the Choice Program based on the 40-mile distance
criterion.
Utilization in VA facilities and of community care
increased significantly from FY 2013 to FY 2014, in part due to VA
capacity issues that led to passage of the Veterans Access, Choice, and
Accountability Act of 2014 (Choice Act).
Choice Act funding helped VA sustain growth in community
care from FY 2013 to FY 2014 and continue growth into 2015.
From FY 2015 to FY 2016, utilization of community care
increased significantly for Choice Program eligible Veterans based on
residence. Utilization by eligible Veterans based on other criteria
also increased but to a lesser extent.
The historical and projected decline in total inpatient
days is due to a number of factors, including transition of inpatient
care to ambulatory facilities (a general trend in health care across
the Nation), VA's efforts to reduce avoidable in VA's management of
inpatient care, and changes in the enrollee demographic mix.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

The graph below shows historical and projected average reliance
across all services (excluding LTSS). Reliance refers to the portion of
an enrollee's total health care he/she is expected to receive through
VA rather than other health care sources.

The projected reliance reflects the impact of all known
factors that affect enrollee reliance on VA health care, including
economy, demographic changes in the enrolled Veteran population, and
the anticipated impact of recent VA initiatives and changes in
legislation and policy.
The FY 2018 Budget request assumes that reliance by
Veterans eligible for the Choice Program based on distance is assumed
to increase by 10 percent per year until it reaches 50 percent by
approximately 2021. (We assume all of these Veterans will elect to
receive care in the community).
Changes in the enrollee demographic mix results in
slightly lower reliance in 2018 and 2019. New enrollees tend to be
healthier and less reliant on VA than the enrollees who are dying.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

Question 11. What projection methods are you using to anticipate
costs of deciding not to appeal the court's decision in Staab?
Response. To implement the Staab decision, VA published Interim
Final Rule- AQ08 on January 9, 2018 to establish a payment methodology
that will apply to claims where partial payment was made by the
Veterans' health insurance plan. The regulation incorporates the
statutory limitation that VA unable to provide reimbursement for any
copayment, coinsurance, deductible, or other similar payment a Veteran
is responsible for under a health plan contract. VA's current cost
estimates for implementing the decision are based on this methodology
and projected claim volume for outpatient and inpatient emergency
treatment, including transportation.

Question 12. GAO continues to list VA health care on its high-risk
list. Explain how this budget addresses concerns raised by GAO.
Response. VA continues to work diligently to mitigate the
Government Accountability Office (GAO) High Risk concerns. VA is also
addressing GAO High Risk List issues through Modernization efforts. VA
leveraged FY 2017 resources to exercise an option year of an existing
federally Funded Research Development Center (FFRDC) to aid in
designing and implementing a strategy to mitigate the risks outlined by
GAO. Under consideration for VHA will be the possibility of funding
further support effort with the FFRDC for GAO High Risk List work. In
May 2017, a Root Cause Analysis (RCA) presented to GAO was met with
positive response. VA also met with GAO on Jan 11, 2018 regarding the
root causes for the five risk area; this also was met with a positive
response. VA is currently updating action plans for the five high risk
areas based on the enterprise RCA and anticipates FY 2018 resources
will support these efforts. There are no existing discretionary line
items in the FY 2018/FY 2019 budget to specifically address the five
individual high risk areas. Requests for additional budgetary
consideration will be driven by the corrective action plans. A VHA
Office of Internal Audit and Risk Assessment, designed to conduct
independent and objective risk-based audits to enhance oversight and
accountability, has been funded and has achieved initial operating
capability.

Question 13. The President's Budget Request includes $751 million
for HEP C drugs. How many veterans have you treated? How many have you
identified that still need treatment? What are you efforts to reach
those who need treatment but may not be taking advantage of treatment
at VA? What resources are you expending to provide education to
veterans to avoid the spread of HEP C?
Response. The President's Budget Request includes $751 million for
hepatitis C virus (HVC drugs. Since January 2014 through December 31,
2017, VA treated over 100,000 Veterans with new direct-acting
antivirals, with cure rates between 90-95 percent. As of the end of
December2017, there were approximately 40,000Veterans in VA care who
needed hepatitis C treatment. Attempts have been made to contact most,
if not all, of these patients by phone, letter, or direct provider
contact, and many have refused treatment or were unable to be engaged
in treatment. VA providers are continuing to reach out to these
patients to ensure all who are interested and able receive treatment.
VA estimates approximately 15,000-20,000 of patients who need HCV
treatment may be difficult to engage in care and treat due to treatment
refusal, inability contact and, treatment-limiting medical, mental
health, or substance use co-morbidities
VA's outreach efforts include:

1. Field-based VISN Hepatitis Innovation Teams deploying system
redesign/LEAN at the majority of facilities to address gaps in HCV
testing and treatment, including outreach to at-risk populations
2. National and local clinical informatics tools are in place
across VA's health care system for tracking all patients diagnosed with
HCV
3. VA encourages all Veterans who think they may have hepatitis C
to get tested, and if eligible for VA care, to come in to VA for
treatment. VA has an ongoing HCV testing and treatment ad campaign in
18 high prevalence cities in the US: www.hepatitis.va.gov/campaign-
test-treat-cure.asp VA encourages all Veterans who think they may have
hepatitis C to get tested, and if eligible for VA care, to come in to
VA for treatment. VA has an ongoing HCV testing and treatment ad
campaign in 18 high prevalence cities in the US: www.hepatitis.va.gov/
campaign-test-treat-cure.asp

Resources for HCV prevention education include:

1. Prevention information, including transmission risk and what to
do if you test negative or positive for HCV, are included in the
resources on the Veteran Portal of VA's hepatitis website:
www.hepatitis.va.gov
2. More direct HCV prevention patient education materials are
available at: https://www.hepatitis.va.gov/products/patient/hcv-
prevention-factsheet.asp.
3. Treatment as Prevention (TasP) is a successful intervention for
the prevention of HIV transmission, which has shown that people with
HIV who have an undetectable viral load (e.g., are successfully on
antiviral treatment) have an incredibly low, if any, possibility of
transmitting the virus to another person. This is also true for HCV
treatment as an intervention for HCV prevention, particularly given
cure rates of over 90-95 percent among Veterans treated in VA in care.

While not explicitly focused on prevention, VA's national hepatitis
awareness campaign messaging on hepatitis C testing includes
transmission risk information: www.hepatitis.va.gov/campaign-test-
treat-cure.asp.

Question 14. According to the OIG's 2016 report on staffing
shortages, Physician Assistants are one of the top five occupations in
greatest need. What are you doing to fill PA positions and others
identified as having the greatest need?
Response. Several strategies have been employed to address the PA
occupation shortage and to enhance recruitment and retention. The
policy governing PA practice is currently under review to identify and
eliminate barriers to PA practice in order to promote greater patient
access, as well as making VHA a more attractive practice environment.
Critical access disciplines such as primary care and mental health have
been targeted for increased training and PA utilization. For example,
the PA Post-Graduate Patient Aligned Care Team (PACT) Primary Care
Residency has been successful in providing advanced training in the
PACT Patient Centered Medical Home model of care and incorporating
graduates into VA's clinical workforce. The recent expansion of PA
postgraduate residencies in Mental Health has been highly successful in
attracting trainees, and has added to VA's mental health clinicians.
Establishment of additional PA residency programs in other critical
specialties is currently under consideration. Nationwide, the PA
profession has experienced a robust growth in demand with a resultant
increase in salaries. The American Academy of Physician Assistants 2016
Salary Survey, confirmed by the Department of Labor, Bureau of Labor
Statistics, reports the average annual starting pay for PAs is over
$100,000. In contrast, current starting salary under the U.S. Locality
Pay Schedule is $49,765.
Local facilities prioritize hard to recruit and retain occupations
based on local workforce needs. Medical Center Directors are authorized
to approve special salary rates for PAs when recruitment or retention
of occupations or individuals with specialized skills is difficult. VA
is also considering using the Secretary's existing authority to include
PAs as a covered occupation in the Locality Pay System to transition
PAs to a market based pay system.
Facility leadership also determines which occupations are eligible
for consideration of other existing recruitment tools such as the
Education Debt Reduction Program and the Employee Incentive Scholarship
Program.

Question 15. Over the last few years, VA has taken action to
create qualification standards to enable the recruitment of Licensed
Professional Mental Health Counselors as well a Marriage and Family
Therapists. The number of licensed professional mental health
counselors employed by the VA declined from 72 in FY 2015 to 64 in FY
2016 and the number of marriage and family therapists increased from
only 15 in FY 2015 to 24 in FY 2016. This data suggest that VA's
efforts to expand hiring of these occupations is not succeeding. What
new initiatives is VA undertaking to hire more counselors and MFTs?
What aspects of the President's Budget support this effort?
Response. The addition of Licensed Professional Mental Health
Counselors (LPMHCs) and Marriage and Family Therapists (MFTs) to the VA
mental health workforce has expanded VA facilities' staffing options.
The number of LPMHCs employed by VA increased from 189 at the end of FY
2015 to 284 as of December 2017, similarly, the number of MFTs
increased from 122 to131 over the same period. This data suggest VA's
efforts to expand hiring of LPMHCs is working, however, is still
experiencing challenges hiring MFTs.
As VA's demand for mental health professionals grows, we expect
that VA will continue to successfully recruit LPMHCs and MFTs i.
Because LPMHCs and MFTs are relatively newer professions within VA, and
decisions to hire into these occupations are made at a local level, the
pace of hiring may vary from site to site.
To promote the MFT and LPMHC professions throughout the country,
VA's Mental Health Offices also created a marketing plan to target
stakeholders including: Mental Health hiring officials, Human Resources
staff and VISN and Medical Center leadership. The marketing plan
focused on the benefits of hiring LPMHCs and MFTs, including their
contribution to inter-professional mental health teams and their cost
effectiveness.

Question 16. The VA requested separate occupational series from
OPM for LPMHCs and MFTs in 2011. Considering VA's hiring challenges for
other mental health providers and the Secretary's focus on veteran
suicide, will VA reprioritize the creation of occupational series for
LPMHCs and MFTs? If not, please explain how the lack of the series does
not inhibit hiring efforts.
Response. Beginning September 28, 2010, VA facilities were
authorized to hire LPMHCs and MFTs as specialty mental health providers
after Congress recognized these as occupational categories of mental
health specialists in the Veterans Benefits, Health Care, and
Information Technology Act of 2006. VA has an approved occupational
series and title codes for this occupation under Hybrid Title 38.
Although a standalone occupational series for this occupation does
not exist, this has not complicated hiring within VA. VA has developed
and established a specific qualification standard and would continue to
use this standard even if OPM developed a standalone series; therefore,
the creation by OPM would not have a bearing on VA's recruitment or
retention. Qualified candidates have successfully searched, applied
for, and been hired for VHA positions announced for this occupation as
established under Hybrid Title 38 with the official title of Marriage
Family Therapist or Licensed Professional Mental Health Counselor
within the GS-0101 Series.

Question 17. Please provide information on the number of social
workers and psychologists hired by the VA in FY 2015, FY 2016, and FY
2017 to date, as well as the number of social workers and psychologists
participating in Office of Academic Affiliation internships in FY 2015,
FY 2016, and FY 2017 to date.
Response. Please see table below for data through May 31, 2017.
(Note: VHA's data pull for mental health occupations includes
psychologists and social workers. However, social workers include all
hires, even though they may not work in mental health specifically).

------------------------------------------------------------------------
FY 2017
Occupation FY 2015 FY 2016 thru May Total
------------------------------------------------------------------------
Psychology.................... 670 680 204 1,554
Psychiatrist.................. 351 348 169 868
Licensed Prof Mental Health 72 64 43 179
Counselor....................
Marriage Family Therapist..... 15 24 7 46
Peer Support.................. 121 68 23 212
-----------------------------------------
Total Mental Health Hires. 1,229 1,184 446 2,859
Registered Nurse.............. 7,700 6,531 4,101 18,332
Social Work................... 1,887 1,173 783 3,843
------------------------------------------------------------------------
RN and Social Work hires are provided separately since all RNs and
Social Workers are not assigned to a mental health area.

Question 18. One of the Department's goals is to change the
culture of VA to be more welcoming to women. What in the President's
Budget Request supports that goal?
Response. Women Veterans currently comprise 9.6 percent of the
Veteran population and that is expected to increase to 10.5 percent by
2020. We are committed to providing increased access to gender-specific
health care (genitourinary care; female cancer screening; osteoporosis;
pregnancy and childbirth; care in a women's clinic) in a safe and
welcoming environment. The 2018 President's Budget shows an increase of
$33.5M for women's gender-specific care from $471.2M in 2017 to $504.7M
in 2018.
VA provides health care services to women Veterans, including
primary care, gynecology care, maternity care, specialty care, and
mental health services. VA has also focused on improving its facilities
to meet the needs of women Veterans.
In order to review facility accommodations for women Veterans VHA
has adopted Environment of Care (EoC) standards. These are incorporated
into a tablet-based survey that is conducted regularly. The facility
Women Veterans Program Manager is a member of the EoC team. EoC data is
shared with each facility and VISN monthly, and is the responsibility
of the VISN Capital Asset Manager.
When a need arises to enhance facilities, the VISN follows the
Strategic Capital Improvement Process (SCIP). The VHA Office of Women's
Health Services participates in this process and provides input on
specific facility needs for women Veterans. Currently, there are 21
projects in process (either in design, solicitation/bid, or
construction) specific to women Veterans' health.
VA has enhanced the provision of care to women Veterans through
Designated Women's Health Primary Care Providers (WH-PCP). By the end
of FY 2016, VA had trained over 3,000 WH-PCPs, and has at least one at
all of VA's health care systems. In addition, 90 percent of community
based outpatient clinics (CBOCs) had a WH-PCP in place. VA is training
additional providers to ensure every woman Veteran has the opportunity
to receive primary care from a WH-PCP.
VA is proud of its high quality health care for women Veterans. VA
is on the forefront of information technology for women's health and is
redesigning its electronic medical record to track breast and
reproductive health care. Quality measures show that women Veterans are
more likely to receive breast cancer and cervical cancer screening than
women receiving their care in the private sector. VA also tracks
quality by gender and, unlike other health care systems, has been able
to reduce and eliminate gender disparities in important aspects of
health screening, prevention, and chronic disease management.

Question 19. Does this budget support the new initiative to cover
Veterans with other-than-honorable discharges, and how much do you
anticipate that it will cost? Considering that you are unable to
provide these veterans with beneficiary travel compensation and access
to non-VA care, how will you provide services under this initiative to
veterans who do not live near a VA facility?
Response. Effective July 5, 2017, VA began implementing an
initiative to expand urgent mental health care to former Servicemembers
with other than honorable (OTH) administrative discharges who believe
their mental health condition is related to military service. This
marks the first time VA has implemented an initiative specifically
focused on expanding these services to former Servicemembers with OTH
administrative discharges who are in mental health distress and may be
at risk for suicide or other adverse behavior. Under this initiative,
former Servicemembers with an OTH administrative discharge may receive
care for their mental health emergency for an initial period of up to
90 days, which can include inpatient, residential, or outpatient care.
If after 90 days, the former Servicemember still requires emergency
mental health services, he/she may receive another 90 day episode of
care within the VA or be transitioned to services. Each VISN has
developed their own protocol for requesting an additional 90-day
episode of care, which must be approved by the VISN CMO.
This initiative is focused on reducing suicide among those who
served their Nation. VA will work to maximize existing capacity in
support of this initiative. Because this initiative began after the
budget request was submitted, VA did not include an estimate in the FY
2018 Budget. However, VA currently estimates the cost of this
initiative to be $200 million in FY 2018 and is funding it within
existing resource levels.

Question 20. As the mental health-diagnosed veteran population
continues to age and veterans develop age-related diseases such as
dementia, please describe the Department's efforts to develop long-term
care options for these veterans. How is the Department monitoring
changes in state-operated facilities that house this population of
veterans? Please provide the Department's projections for changes in
state-operated bed numbers over the next 10 or 20 years and how it
plans to make up any gaps.
Response. The growth in the aging Veteran population with multiple
medical, mental, and neurocognitive disorder comorbidities is expanding
the need for additional services for these patients. The ``Complex
Patient'' Care Implementation Task Force (``Task Force''), launched in
August 2016, is focused on providing safe and effective care for this
growing group of Veterans, and to follow up on recommendations made by
the Inpatient Care for Veterans with Complex Cognitive, Mental Health
and Medical Needs Task Force (``Care of Veterans with Complex Needs
Report'').
The Task Force was created in response to multiple, repeated
requests from field leadership and also the Congressionally-mandated
Federal Advisory Committee for Geriatrics and Gerontology. The Task
Force has created a definition for Veterans with complex problems and
conducted a national needs assessment of all 138 facilities with
inpatient settings. Through the effort, several innovative inpatient
promising practices for this patient population have been identified.
Additional efforts include building Community Living Center (CLC)
capacity to care for aging Veterans with serious mental illness (SMI),
and/or neurocognitive disorders, including integration of mental health
professionals on all CLC teams, a range of dementia training programs,
including STAR-VA, and development of a SMI toolkit. Additional efforts
include National Investment Center for Seniors Housing & Care programs
that support long-term care in the home and integration of mental
health professionals in Home Based Primary Care, and Community
Residential Care (CRC) and Medical Foster Homes. Relatedly, there are
ongoing efforts to support family caregivers to care for Veterans with
SMI and/or neurocognitive disorders (e.g., REACH-VA and other caregiver
support programs) to support long-term care in the home.
State operated beds or nursing home care of any type is generally
not preferred by Veterans. Appropriate use of home and community based
services provided by VHA can reduce the need for such nursing home beds
in the future. Available data suggest the projected need for additional
nursing home care for Veterans over the next 15 years can be met in
Medicare and Medicaid-certified community nursing homes; however, VA is
having difficulty accessing many community nursing homes because of
Federal Contract requirements. Community nursing homes frequently cite
complexity of the Federal contracting process as an issue along with
the requirement to comply with the Service Contract Act. VA is working
on identifying best practices for managing these Veterans to honor
their preferences for care whenever possible in home and community
based settings.
VHA Geriatrics and Extended Care is conducting a study of Long Term
Services and Supports to understand Veteran needs for these services
through 2030, and how they differ by rural and urban status. Moreover,
the study is expected to provide policy options for addressing gaps in
projected future needs.

Question 21. Data provided to the Committee in April 2017
indicated that the Asheville, North Carolina and Salem, Virginia
Medical Centers in VISN 6 were unable to hire psychiatrists,
psychologists, social workers, and nurse practitioners due ``to budget
constraints.'' Please provide an update on their hiring abilities, as
well as a list of any other mental health positions at any VA facility
that are under a similar hold.
Response. There are no mental health vacancies on hold due to
budgetary constraints. The budget supports hiring actions for clinical
positions vacated over the course of the FY. All Mental Health Service
clinical vacancies are in an auto-fill status to expedite the
recruitment process.

Question 22. You have spoken about adding thousands of new mental
health providers. Can you please update us on these efforts as well as
the retention of existing employees?
Response. VHA is making steady progress toward reaching the
Secretary's goal of a net increase of 1,000 Mental Health Providers by
December 31, 2018. We have increased our net onboard of psychiatrists,
psychologists, and mental health counselors by 258 as of November 30,
2017, and we are embarking upon a national recruitment and marketing
campaign to attract the best mental health providers to meet our goal.
VHA utilizes the Education Debt Reduction Program (EDRP) to repay
education loans for healthcare professionals, including mental health,
in critical positions where recruitment and retention is difficult. The
EDRP, authorized by the Veterans Programs Enhancement Act of 1998, and
implemented in 2002, as amended, allows participants to receive
education debt reduction payments up to $120,000 for up to 5 years.
EDRP is one of VHA's most effective tools for filling critical
positions, however, it is a limited resource. Local medical centers are
responsible for identifying and prioritizing positions that are the
most critical for recruitment and retention based on local needs and
funding. Since the implementation of the new maximum award amount
authorized under Public Law 113-146, VHA has awarded nearly 2,500 new
EDRP awards. Occupations identified in the FY 2015 Office of Inspector
General Mission Critical Occupation Report (physicians, registered
nurses, psychologists, physical therapists and physician assistants)
account for nearly 79 percent of all new awards in FY 2015-2016.
Physicians and registered nurses (including advance practice nurses)
receive the most EDRP awards, at 37 percent and 23 percent,
respectively.
VA also utilizes other programs to recruit and retain highly
qualified employees to mental health and other specialties. For
example, the Student Loan Repayment Program (SLRP) improves recruitment
and retention by offering assistance which enables VA to provide up to
a lifetime total of $60,000 with a maximum of $10,000 per year in
payments to the lending institution. Full-time VA employees may also be
eligible for loan forgiveness through the Public Service Loan
Forgiveness (PSLF) program. Only the entity that holds a loan may
forgive outstanding loan balances, therefore the authority for the PSLF
resides with the Department of Education.

Question 23. What lasting impacts did the hiring freeze have on
your ability to recruit high quality staff?
Response. Minimal impact. Four days after the Presidential
Memorandum VA provided exemptions for its most critical positions; more
specifically, patient care positions, safety positions in activation of
leases and construction projects, and those supporting burial benefits.
Since then, the Secretary has allowed the Administrations to fill
positions they deem necessary to meet mission requirements. The
prioritization of filling vacancies is determined by the requesting
organization, in coordination with the servicing human resources
office.

Question 24. VA has articulated on multiple occasions that the
flip side of accountability is the importance of recruiting high
quality staff. It's my understanding that much of that work with
candidates is done through HR. So you can imagine that it seems
somewhat counterintuitive that you have not ended the hiring freeze for
H.R. professionals, and now you have flat funded them for 2018. How do
these factors align?
Response. VA is undertaking a comprehensive Department-wide
analysis at how to provide all internal support services, to include
Human Resources (HR), in the most efficient manner. We are determined
to provide a single enterprise-wide efficient and effective approach to
HR. In light of this process, we are being deliberative in hiring H.R.
professionals. At this time, frontline (i.e., those supporting a
medical center) H.R. offices are able to hire against vacant H.R.
positions.
Once we fully understand our H.R. approach for the future, we'll be
in a better position to align budget requirements.

Question 25. Can you explain the differences between the services
provided by VA human resources and VHA human resources, and tell us why
we need to fund both? They seem duplicative in many ways. Would there
be cost savings for the Department if the two were consolidated?
Response. In accordance with OMB Memorandum M-17-22, VA is
undertaking a comprehensive Department-wide review of its support
services, including HR.
The mission of VA's HRA is to develop and implement enterprise
human capital management strategies, policies, and practices. Program
offices comprising HRA focus on policy and programs such as Human
Resources Management, Diversity and Inclusion, Labor-Management
Relations, Equal Employment Opportunity complaints, and Senior
Executive Management. HRA is closely reviewing where potential
efficiencies may exist.
In addition, each Administration, to include VHA, operates on-the-
ground H.R. offices that provide daily operational and advisory
functions for managers, supervisors, and employees. These include, but
are not limited to, classification, recruitment, on-boarding, personnel
actions processing, employee development, benefits, separation
management, employee relations, performance management, etc.

Question 26. Can you explain why the H.R. office is flat funded
from last year, but the FTE level is effectively cut in half? Where is
the funding going, and where will the staff go?
Response. HRA's FY 2018 budget request reflects no increase in the
level of Budget Authority from 2017. Most of HRA funding is generated
by reimbursable authority funding from other VA entities. Among the
largest reimbursable services is the handling of EEO complaints by the
Office of Resolution Management (ORM). The reduction in staff reflected
in FY 2018 is based on the plan that 296 ORM staff positions will be
re-aligned to the Office of Accountability and Whistleblower
Protection. After further review by the Department, it was determined
that ORM FTEs should remain in the organizational structure of HRA.

Question 27. I note that FTE for Acquisitions and Construction
management is increasing by over 60 people in your budget request for
this year. I expected to see a cut, frankly. Major construction is
taking a ``strategic pause,'' and the construction that is happening is
being managed by the Army Corps of Engineers. What cuts have been made
to reflect the Corps' role, and why do you need additional staff in
that office?
Response. For the major construction staff request, the current
estimated FTE number for FY 2017 is 139 and for FY 2018 the estimate is
197. The original estimate for FY 2017 was 177. The combination of
project slippages and the hiring freeze have reduced the number needed
and VA's ability to hire staff still required for its major
construction projects.
VA will have 26 ongoing projects valued at $4.15B in FY 2017/FY
2018 and six new projects (primarily national cemeteries) totaling
$0.24B. It will also be overseeing the execution by the Army Corps of
Engineers (USACE) of 13 projects valued at $6.474B. There are four
other projects in planning valued at over $2B that requires contracting
officer support.
It should be noted that the partnership between VA and USACE
includes VA responsibilities to coordinate with USACE during
construction and provide the interface with the medical center, as well
as the on-site knowledge of VA technical requirements. VA believes
Resident Engineer and Contracting Officer positions were not
sufficiently staffed in the past. VA's 2018 Budget reflects staffing to
appropriate levels by following the model established by the Defense
Health Agency in providing support and guidance to the USACE
construction management team, and ensuring that the project meets the
VA programmatic requirements.
It should be noted that the appropriation language was changed in
FY 2017 to allow major construction staff funding to include support
for contracting officers working directly on major construction
projects to ensure alignment with the program they are supporting. The
inclusion of contracting officers accounts for 35 of the 197 FTEs in FY
2018 with 162 resident engineers comprising the remainder of the FTEs.
Since FY 2016, significant cuts have been made to the General
Administration funding that provides support to Major Construction via
project/program managers, planners, architect/engineers and other
support personnel.

Question 28. Your Budget rescoped and resized several major
medical lease projects as well as eliminated two leases that had
previously been proposed for authorization. Please provide specific
information regarding any services that have been eliminated or reduced
from these clinics. Please provide specific information that explains
the underlying analysis VA used to determine these services or spaces
were no longer needed. If the Department determined that the community
would be able to take on this extra demand, please provide information
that explains how the Department determined that capacity exists in the
community.
Response. Prior to the finalization of the FY 2018 Budget, VHA
reviewed 28 Major Lease initiatives. Out of these, 9 included reduction
of Specialty Care services and associated square feet because it was
determined such services were more readily available through community
providers and/or at the parent VA Medical Center. VHA utilizes the VA
Health Systems Planning Application, Veterans Choice Locator and other
available databases, to project demand and match that to capacity, both
in house and through community providers. This process helps ensure
appropriate and sufficient services are available. In no cases were
services removed because they were no longer required, and in all cases
services will be available to Veterans.

Question 29. Does this request take into account the partnerships
you have with other agencies, such as HUD? Did you know, for example,
that the HUD budget for supporting HUD-VASH vouchers decreased by 8%?
Will the Administration be able to serve the same number of Veterans?
Response. VHA has been in communication with the Department of
Housing and Urban Development (HUD). If HUD does not receive additional
funding for HUD-VASH in FY 2018, it would not impact the availability
of existing FY 2008-FY 2017 awards, which mean VHA must continue to
provide case management for recipients of nearly 90,000 existing
vouchers, as required by statute. If HUD does not receive new funding
in FY 2018, VHA will not need to add staff to support new vouchers, but
will need continued funding to support existing vouchers.

Question 30. Does VA have the resources in this budget to provide
the wrap-around services that are so critically important to doing more
than just addressing a crisis situation? (VHA)
Response. The FY 2018 budget request supports an additional 5,500
HUD-VASH vouchers from the FY 2017 HUD budget. HUD-VASH staff provides
clinical case management and supportive services primarily in the
community or the home, and which vary based on the needs of the
Veteran. There are five basic levels of case management--intensive,
stabilization, maintenance, preparation for discharge, and graduation/
discharge. Each level has varied levels of engagement with Veterans in
HUD-VASH.

Question 31. Granted great progress has been made in the last five
years on ending homelessness among veterans, but given that there are
still 40,000 homeless Veteran nationwide, why has VA decided to put
less emphasis on this core VA mission?
Response. VA remains steadfast in its commitment to ensuring
Veterans are able to obtain permanent, sustainable housing and have
access to high quality health care and other supportive services.

Question 32. Do you agree that consistent resources need to be
dedicated to VA counter-homelessness programs in order to get as close
to zero homeless veterans nationwide as we can?
Response. Yes.

Question 33. I was concerned by a recent military times article
indicating VA has shifted its goals on veteran homelessness from zero
to what you referred to as functional zero, and I quote here ``12,000
to 15,000 that despite being offered options for housing and getting
them off the street, there are a number of reasons why people may not
choose to do that.'' The 2016 PIT count included just over 13,000
unsheltered veterans, and your homeless programs are operating at the
same pace, as I believe they should. Can you explain how you arrived at
this specific range as your goal for unsheltered veteran homelessness,
and can I get your commitment to reducing veteran homelessness,
especially unsheltered homelessness, as much as possible and to
ensuring that all of the administration's programs are collaborating
effectively with each other, and community partners, to make veteran
homelessness rare, brief, and nonrecurring?
Response. VA remains fully committed to ending and preventing
Veteran homelessness, and continues to operate with the urgency to
ensure it is rare, brief and non-recurring, especially for unsheltered
Veterans.

Question 34. Your own studies demonstrate the importance of
research opportunities to recruiting and retaining clinical staff. In
addition to VA's own research cuts, other agencies are cutting their
contributions to VA research also. Do you have an estimate of the
impact that this overall Trump budget will have on your hiring efforts?
Response. At this time, VA does not have the ability to predict a
detrimental impact on hiring, although, many clinicians view the
ability to conduct research as advantageous to a well-rounded clinical
experience.

Question 35. What percentage of the work on appeals currently sits
with the VBA in the appeals management center? Is there a reason that
addressing the existing appeals with additional staff was not a
priority?
Response. As stated above, in January 2017, VBA realigned its
appeals policy and oversight of its national appeals operations under
AMO. The realignment promotes increased accountability of appeals
performance and establishes a clear division of labor between claims
and appeals work, with dedicated appeals FTE. This realignment allows
VBA to prioritize appeals by focusing on internal people, process and
technology, and implementation of appeals reform legislation if
enacted. Under this realignment, specific guidance has been
disseminated instructing field offices that appeals staff must maintain
authorized staffing levels.
In 2015 and 2016, Congress provided funding for additional staff
that included a total of 300 FTE employees for appeals processing at
VBA. VBA's appeals productivity through May 31, 2017, has increased by
32 percent over FY 2016 production during the same period. As of
June 30, 2017, the Appeals Resource Center, the centralized processing
resource for appeals remanded from the Board of Veterans' Appeals, had
35.8 percent of the remand workload in VBA and 3.3 percent of the total
appeals workload.
VA continues to assess the current and future allocation of FTE
employees to work appeals to ensure that the pending legacy appeals
inventory is addressed in a timely and efficient manner. Whether VA
will need additional resources for appeals since the August 23, 2017,
enactment of appeals reform legislation is contingent upon resource
allocation decisions made by the Department and the Administration
during the annual budget process and cannot be predicted at this time.

Question 36. Fiduciaries are some of the most vulnerable of the
Veteran population and it is currently taking more than TRIPLE the time
it should in order for a field examination to happen so that a
fiduciary can be appointed. How is your budget, which flat funds this
program, helpful in addressing this problem?
Response. In 2017, VBA allocated an additional 51 FTEs to meet the
program's oversight responsibilities in order to avoid delays in the
initial appointment of fiduciaries, and the FY 2018 President's Budget
codifies those additional FTEs. As of May 2017, VBA has reduced the
average days to complete initial appointments to 151.1 days--down from
287 days in FY 2016--and we are making progress toward the goal of 82
average days to complete initial appointments by FY 2018 and 76 days by
FY 2022.

Question 37. If VA does not plan to hire additional FTE for the
VR&E program how does VA intend to assist veterans in critically
understaffed regions?
Response. Staffing requirements for the Vocational Rehabilitation
and Employment (VR&E) program are influenced by many factors.
Currently, we are supplementing our Vocational Rehabilitation
Counselors (VRCs) workload with the expanded use of and augmentation of
tasks through National service contracts for the execution of certain
VRC tasks, such as vocational assessments. We recently developed and
deployed targets for these contracts by Region/District based on
workload density to better serve Veterans and VRCs. Additionally, VBA
is continually looking at VR&E system and process improvements to
reduce administrative burden on VRCs. Current efforts include working
to deploy a new case management system (in development), and examining
ways to centralize VR&E administrative tasks like invoice processing.

Question 38. In the past two years, ITT and Corinthian College
both closed and left tens of thousands of veterans in an unacceptable
and precarious position. We've also seen other predatory behavior by
for-profit schools looking to take advantage of Veterans and their
beneficiaries. Are you confident that the levels of staffing supported
by this budget, and the amount of oversight that staff is able to do,
will prevent these practices in the future? We want to identify these
schools before we have a situation where a school is shut down, rather
than after. Moreover, we want to ensure that VA has the resources to
communicate with veterans far ahead of any school closure in order to
facilitate the transfer of the GI Bill beneficiary to an alternate
school for the completion of their degree.
Response. Based on the staffing levels requested for FY 2018, VA
will facilitate proper oversight of GI Bill benefits. Since the closure
of these schools, the Department has focused on improving the quality
of the oversight process, increased communication and information
sharing activities with other Federal agencies with oversight of post-
secondary educational institutions, and has increased outreach
activities and assistance to beneficiaries enrolled in ``at risk''
schools.

Question 39. Will the staffing levels for these Education programs
support continued rates of original and supplemental claim completion
within a reasonable amount of time?
Response. VBA has approximately 800 FTEs processing claims with a
current Fiscal Year-to-Date timeliness for original claims at 22.8 days
and supplemental claims at 8.0 days. At the beginning of FY 2017, VBA
redirected 75 Atlanta Regional Processing Office employees from
processing education claims to processing compensation claims. This
increased the workload at the three remaining Regional Processing
Offices. Also, during the fall peak enrollment period from August 2017
to October 2017, VBA received an increase in education claims. This
year, VBA received a 24 percent increase in claims for FY 2017 compared
to FY 2016. Last, other factors (i.e., legislative changes and system
changes) may impact future processing times. VBA did not meet its
Fiscal Year To Date goal for original claims with an average days to
complete (ADC) of 24.66 days; however, VBA did achieve the goal for
supplemental claims with an ADC of 8.6 days. In addition, VBA continues
to utilize overtime and a national brokering strategy to balance the
workload and reduce the time it takes to process a claim.

Question 40. Can you give us a timeline for the plan to modernize
VA's infrastructure you're developing and hoping to pilot?
Response. VA is committed to developing high performing healthcare
networks that consider current and future Veteran demand for medical
care, and responsive services by integrating VA-provided healthcare,
community care, and telehealth services. VA is partnering with private
sector healthcare experts to conduct objective assessments, based on a
piloted methodology, to develop local health system optimization plans.
A contract was awarded in September that will enable VA to recommend
health system optimization plans in all 96 VA healthcare markets. Our
current target is to complete this by the 3rd quarter of FY 2019.

Question 41. Your budget includes a proposal that would allow VA
to more easily transfer funding for infrastructure between agencies.
How does that authority play into the modernization plan you're
developing?
Response. The proposed legislation would allow VA to pursue joint
projects with other Federal agencies, including DOD. Joint facility
projects between VA and other Federal agencies (i.e., medical
facilities not specifically under the jurisdiction of the Secretary)
currently require specific statutory authorization. The proposed
legislation would: (1) enhance VA's ability to coordinate with DOD and
other Federal agencies; (2) improve access, quality, and cost
effectiveness of direct health care provided to Veterans,
Servicemembers, and their beneficiaries; (3) permit joint capital asset
planning and capital investments to design, construct, and utilize
shared medical facilities; (4) provide VA authority to procure the use
of joint medical facilities for itself and other Federal agencies like
DOD, and transfer funds between agencies for such initiatives.

Question 42. Please explain what legislative barriers exist that
prevent the Department from disposing of the roughly 1,100 facilities
that are described as underutilized and vacant buildings.
Response. To clarify, at this time VA is only pursuing disposal or
reuse of 430 vacant buildings. The underutilized buildings will be
reviewed, as VA works to determine where additional efficiencies can be
identified and reinvested in Veterans' services, and will be considered
when VA completes the market area optimization assessments and plans.
Occasionally, there are impediments that delay disposal or reuse
stemming from environmental factors and/or the historic nature of a
building. Impediments do not specifically prevent disposal/reuse, but
can significantly slow the process. The National Historic Preservation
Act (specifically, Section 106 consultation requirements) as well as
the National Environmental Policy Act provide statutory requirements
which VA must adhere to when pursuing this process.
Additionally, other authorities would provide greater reuse
flexibility of unneeded assets, and help improve services for Veterans.
For example, VA's FY 2018 Budget request proposed to expand VA's
enhanced use lease authority beyond the scope of supportive housing.
This authority would provide more opportunities for VA to successfully
repurpose underutilized and vacant properties nationwide, for uses that
are consistent with VA's mission and operations.

Question 43. We understand that VHA is conducting a series of
market-based analyses examining VA capacity and private sector capacity
nationally. What role is OALC playing in these analyses?
Response. VA's Office of Construction & Facilities Management (CFM)
is working closely with VHA to conduct market-based assessments
nationwide. Previous VA Integrated Planning efforts did not
comprehensively assess the optimal balance of services for VA to
provide in its facilities, versus those that can be provided in the
community. The market-based Service Delivery Planning will focus on
community care providing additional services other than foundational
and essential services (e.g. Primary Care, Mental Health and associated
Rehabilitation). CFM will manage the planning process in partnership
with VHA, once a contract has been awarded.

Question 44. Please explain what factors go into determine SCIP
ratings. What weights does each category and subcategory receive? How
often does the Department update those needs?
Response. The Strategic Capital Investment Planning (SCIP) process
is reviewed each year to consider changes in medical delivery,
technology, Departmental and Congressional mandates, and local or
regional projections. Changes, related to VA's Construction and Lease
program, inform updates to the criteria and weights. The SCIP Board is
comprised of nine senior management members from the three
Administrations and the offices of six Assistant Secretaries. The Board
works on a Departmental level with each member applying their
specialized knowledge to discussions. The SCIP Panel, which is
comprised of one staff member representing each Board member, supports
the Board.
Decision criteria and sub-criteria priority weights are developed
using a multi-attribute decision methodology--the analytic hierarchy
process (AHP). This methodology facilitates the development of criteria
and sub-criteria weights, by allowing multiple evaluators to consider a
number of diverse criteria when setting weights. Within the AHP,
priority weights are set using the Pairwise Comparison method, which
asks each Board member to rate the importance of criteria, one pair at
a time, reducing the likelihood of inconsistent ratings. The results of
the Pairwise Comparison exercise are the criteria weights. Priority
weights for each group of sub-criteria are developed that same way.
The Board presents a recommendation to the SCIP process, including
criteria and priority weights, through a formal executive review
process. That process is developed through senior management, with
approval of the Secretary to ensure consistency with the Department's
strategic goals.
Below is the SCIP 2018 Decision model and criteria and sub-criteria
weighting.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

Question 45. The Department projects a large drop in the resources
needed to support facility activations, dropping from an estimated $862
million in FY 2018 to $744 million in FY 2019. Please provide a list of
facilities that are projected for activation in FY 2018 and FY 2019.
Additionally, the request explains that VA has taken steps to better
synchronize resources. Please provide further details of these steps.
Response. Attached is the activations report that has been
submitted to Congress. VA's Office of Construction & Facilities
Management and VHA are working to improve communication of updated
project schedules for Major Construction and Major Lease projects, to
help ensure improved activation project scheduling. Additionally, VA
Facility Activation Project Management teams have been established to
coordinate and synchronize resources.

Question 46. We understand that VA has never before utilized a
public interest exception to a full and open procurement. In fact, the
exception has only been used in national security situations. The last
time Congress was assured by VA that a contract was guaranteed and
solid, VA lost badly in court and we were forced to provide an
emergency appropriation to complete construction of the Denver VA
Medical Center. What guarantee can you give the Committee that this
procurement method will be the best value for taxpayers and veterans?
Response. VA is taking the necessary precautions to ensure that the
scope of this effort is well-defined, feasible, and will further the
public interest of providing seamless care for our Veterans.

Question 47. Your budget requests funding for a further review of
the EHR decision through an IPT. Is this request still valid? Can you
explain what new information this team will be looking at that wasn't
previously available? Or are these resources that can be shifted?
Response. The June 5, 2017, announcement of the Determinations and
Findings (D&F) by Secretary Shulkin supporting direct negotiations by
the VA with Cerner Corporation alleviated the requirement for such an
IPT. These costs and efforts are being supported by the present PMO
budget requirements. In addition, VA has extensive testing, change
management and data migration strategies to be fielded during the
Initial Operating Capability phase and will leverage lessons learned
from DOD.

Question 48. Your budget projects essentially flat staffing for
OIT in FY 2018. It is our understanding that part of the MyVA project
was looking at the OIT staffing levels present at VHA, VBA, and NCA
facilities in order to provide proper IT support at those facilities.
Can you update the Committee on the development of these staffing
models?
Response. OI&T is working on the draft for a Comprehensive Staffing
Model that will perform an analysis of existing workforce, project
needs and examine how to address identified gaps. As part of the
Secretary's initiative to increase efficiency, OI&T is currently
reviewing existing workforce structuring and identifying positions that
can be realigned to direct customer facing support. Starting in FY
2018, OI&T will work with VA customers to balance between service level
requirements and industry best practices for IT staffing.

Question 49. What resources are allocated in the Budget Request
for the development of the Digital Health Platform?
Response. The Digital Health Platform concept has transformed to be
more inclusive, creating a gateway and interfaces for benefit,
memorial, and corporate systems as well. The systems requiring
interfaces and the resources of this Digital Veteran Platform will fund
its development.

Question 50. What VistA enhancement projects will this Budget
Request support in FY 2018? In what ways has this roster of projects
changed as a result of the decision to procure Cerner's EHR?
Response. The FY 2018 budget includes a request for development
funding for the following VistA related activities as summarized below.
Dollars in Thousands:
NMOC (Medical MyHeV) $15,000
MHV Infrastructure and Interface Enhancements
Phase 2 $10,000
MHV Veteran-Facing Enhancements Phase 2 $5,000
VistA Module Enhancement $9,000
Fileman 24 DME $5,000
VistA Data Access (VDA) Phase 2 $4,000
Access to Care (Medical Core) $2,495
Veteran Self-Scheduling Appointment System
Faster Care for Veterans Act $2,495
Health Provider Systems $2,400
CPRS Enhancements Phase 2 $2,400
Registries $1,410
Veterans Integrated Registries Platform (VIRP)
$1,410

Based on the Secretary's June 5, 2017, announcement regarding VA's
path forward for VA's EHRM, proposed health development and sustainment
investments are being reviewed to ensure they are in full alignment
with the Secretary's decision. Many projects will continue until VA
systems can be transitioned to the new EHR system. To minimize the
impact to Veterans and the providers who use VistA to document care,
the decommissioning of VistA and other legacy systems will be done
along a structured timeline that ensures there are no compromises to
Veteran patient privacy and continuity of care.
The EHRM decision that the Secretary announced on June 5, 2017,
comprises a large and complex replacement of VA's EHR which would take
place over a multi-year period. While VA is conducting an ongoing
review to ensure all current projects included in VistA Evolution and
beyond are aligned to the Secretary's June 5 decision, it is clear that
many projects will continue for a period of time because VA will need
to continue to maintain its existing system until VA systems can be
transitioned in an organized way to the new EHR system. Again, VA will
be reviewing all relevant ongoing or planned projects to ensure they
are aligned with the Secretary's June 5 decision.
______

Response to Posthearing Questions Submitted by Hon. Bill Cassidy to
Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
Affairs
Question 51. The VA's several affiliations with academic medical
institutions provide a significant opportunity to incorporate the input
of the person who is actually treating the veteran. This process would
eliminate many of the mistakes being made when it comes to more complex
and advanced technology in the med-surg items and device space.
Processes and procedures driven from the top down cannot overcome a
lack of informed decisionmaking from the beginning.
What is the VA doing to better incorporate physician and clinical
practitioner feedback into their procurement process, especially with
regards to the Next Generation--Med- Surg Prime Vendor (NG-MSPV)
program?
Response. VA has embraced Clinically Driven Sourcing (CDS) to
better incorporate physician and clinical feedback. Under the CDS
concept clinicians identify, review and select products to be made
available for their use under national, regional, or local contracts.
Next-Generation Medical/Surgical Prime Vendor (NG-MSPV) provides a good
example of this concept. Before products are made available through the
NG-MSPV they are reviewed by a multi-disciplinary integrated team that
includes clinicians familiar with the products that are candidates for
inclusion in the NG-MSPV formulary. The clinician's role on the team is
to select the products that meet their needs.

Question 52. a. Last year, the VA established a new pre-
authorization requirement for the procurement of certain medical
products, with the stated goal of getting a contracting officer
involved prior to a surgical case to ensure the government pays fair
pricing for the products used.
Response. In April 2016, VA started the pre-authorization process
by establishing a not-to-exceed order, and then a post-procedure
consult with VA contracting to finalize the purchase order (PO). In
that process, pre-authorization consults are performed by VA
clinicians/staff to identify implant components and pricing, which are
then used by contracting staff to establish a price and product ceiling
on the order (the ``not-to-exceed'' level). Following a procedure,
vendors and VA staff confirm what products were implanted in the
patient (units, cost, quantities, serial numbers, contract number,
etc.), which is then submitted to VA contracting (the post-procedure
consult).
As understood, if a post-procedure consult is not submitted to
contracting within 24 hours of the procedure, it is considered an
``unauthorized commitment,'' and is subject to a ratification process
that can significantly delay vendor receipt of a PO. Overall, I have
heard numerous reports that this new process has indeed resulted in a
significant backlog of payments to manufacturers for devices already
implanted in Veterans.

b. What is being done to establish an improved process that
includes appropriate procurement safeguards but also ensures
appropriate efficiencies in payments to manufacturers providing
critical medical technologies to our veterans?
Response. For clarification, a delay in a post-procedure consult
does not result in an ``unauthorized commitment'' and is not subject to
ratification; however, it does delay payment. VA is continuing to
refine the implant contracting process to include changes to improve
submittal timeliness for post-procedure consults, and the requirements
for ratification to include expediting the process through completion
of payment to the vendor. We are also monitoring payment timeliness,
numbers of ``unauthorized commitments'' and ratification speed to
determine if our improvements are effective.
______

Response to Posthearing Questions Submitted by Hon. Patty Murray to
Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
Affairs
medical and prosthetic research
Question 53. VA's medical and prosthetic research has contributed
many vitally important advances in medicine. Yet, medical and
prosthetic research is cut five percent in the President's Budget
Request. With cuts being made across President Trump's budget to other
Federal sources of research funding, such as the draconian cuts to the
National Institutes of Health, critical Federal investments in
lifesaving medical research will be eliminated. What specific research
would be eliminated or curtailed under the Department's request?
Response. At this time we are unable to determine which projects
may be impacted. VA's Office of Research and Development will continue
to perform robust research in priority areas and those of unique
healthcare needs for Veterans such as:

Suicide prevention
PTSD
TBI/Neurotrauma and Neurotechnology
Chronic Pain and Opiate Abuse
Spinal Cord Injury
Precision Medicine and Patient-Centered Care
Access, Choice and Coordination of Care
Implementation and Spread of Innovation
Limb Loss
Million Veteran Program

Research program areas that would be curtailed includes:

Disorders of Aging
Musculoskeletal Disorders
Neurodegenerative Diseases

Question 54. For years VA has been citing problems with
recruitment and retention as a problem within the VHA system. VA
studies have shown that 80 percent of VA clinicians cited research
programs as a factor in coming to VA, and over 90 percent cited it as a
reason for staying at VA. How will these cuts impact VA's ability to
remain competitive in recruiting and retaining quality researchers and
physicians?
Response. The All Employee Survey data indicates that job
satisfaction for physicians is closely linked to academic activities
including involvement in research and teaching; however, VA is unable
to predict any potential outcomes recruiting and/or retention that may
result from any decreases.
homeless veterans
Question 55. Since 2009 it has been the goal of VA to end veteran
homelessness. Since that time, great progress has been made in
addressing veteran homelessness. But this progress has only come from
complete VA dedication to that goal and the utilization of an array of
Federal resources. Earlier this month, you announced that zero homeless
veterans is no longer an agency priority, and President Trump's budget
would cut the HUD budget for supporting HUD-VASH vouchers decreased by
88 percent.

What impact will these decisions have on homeless veterans
trying to access VA services?
What impact will these decisions have on veterans
currently utilizing the HUD-VASH program?
What services will VA offer to veterans that are adversely
impacted by any change in homeless veteran services?

Response. If HUD does not receive additional funding for HUD-VASH
in FY 2018, it will not impact the availability of existing FY 2008-FY
2017 awards, which means that VHA must continue to provide case
management for recipients of nearly 90,000 existing vouchers, as
required by statute.
______

Response to Posthearing Questions Submitted by Hon. Joe Manchin III to
Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
Affairs
Question 56. Originally, our understanding was that the VA
anticipates that funds for the Choice Program will exhaust in November/
December of this year. However, that is not the case. What is the
actual date that Choice will run out of money?
Response. In August 2017, the President signed the VA Choice and
Quality Employment Act of 2017, which authorized an additional $2.1
billion for the Veterans Choice Program (VCP). These funds represent a
short-term, temporary funding solution that will enable Veterans to
continue receiving care through VCP while a replacement program is
developed.
A number of fluctuating variables influencing program utilization
will dictate actual obligation rate. VA will continue to analyze
program utilization trends and will refine funding projections as
future utilization patterns become better defined and will stay in
close communication with our Committees to apprise all members of
current status.

Question 57. Your budget asserts that ``the number of VR&E
participants has steadily increased and is expected to continue to
increase over time.'' In fact, program participation has increased by
15% since 2015. However, in your budget you propose a cut to the
program of $13.8 million or 4.2%. If the VA does not plan to hire
additional full-time employees for the VR&E program, how does the VA
intend to support veterans in critically understaffed regions, like
West Virginia?
Response. VA utilizes several mechanisms to allocate resources to
support VR&E programs, including the expanded use of and augmentation
of tasks through National service contracts, which help to balance the
caseloads for Vocational Rehabilitation Counselors (VRCs). We recently
developed and deployed targets for the use of these contracts by
Region/District based on workload density, in order to better serve
Veterans and VRCs. Additionally, VBA is continually looking at VR&E
system and process improvements in order to reduce administrative
burden on counselors. Current efforts include working to deploy a new
case management system now in development, and examining ways to
centralize VR&E administrative tasks like invoice processing.

Question 58. It is my understanding that even though the hiring
freeze has been lifted, VA has done a self-imposed hiring freeze.

a. How are you reviewing which positions are exempted?
b. What is your process?
Response. Consistent with OMB Memorandum M-17-22, VA removed hiring
restrictions for field positions at VHA's medical facilities (for
medical and non-medical positions), and for VBA regional and field
offices. NCA had no restrictions and this remains unchanged. Hiring
restrictions were also removed for the following Executive level
positions: Medical Center Directors; Network Directors; Cemetery
Directors; and VBA Regional Office Directors. This allowed the
Administrations to fill positions they deemed necessary to meet mission
requirements.
For all other positions, VA is following a process that requires
thorough review before hiring, and which also requires an approval at
the appropriate Under Secretary level. VA Central Office and all other
Executive level hiring must be approved by the VA Chief of Staff.

Question 59. In March, you announced that veterans with other-
than-honorable or ``bad paper'' discharges will be allowed to be
receive mental health treatment.

a. How do you ensure that access for an honorably discharged
veteran is not diminished with this policy?
b. If a veteran shows up at an emergency room today and says he is
suicidal how will you treat him differently today than when your plan
is in effect?
c. We were told that we would have a comprehensive plan for
implementation by June. Where is that plan?

VA Response A-C: Effective July 5, 2017, VA began implementing an
initiative to expand the provision of urgent mental health care to
former Servicemembers with other than honorable (OTH) administrative
discharges who believe their mental health condition is related to
military service. This marks the first time VA has implemented an
initiative specifically focused on expanding these services to former
Servicemembers with OTH administrative discharges who are in mental
health distress, or may be at risk for suicide or other adverse
behavior.
This initiative is focused on reducing suicide among those who
served the Nation.
Under the initiative, which utilizes existing legal authorities, if
a former Servicemember with an OTH administrative discharge presents to
a VHA Emergency Department and self-identifies as being in mental
health distress, a provider will conduct a clinical assessment and
determine the appropriate course of action in conjunction with the
former Servicemember. Under this initiative, former Servicemembers with
an OTH administrative discharge may receive care for a mental health
emergency for an initial period of up to 90 days, which can include
inpatient, residential, or outpatient care. In addition to presenting
at an Emergency Department, individuals make seek help by calling the
Veterans Crisis Line or visiting a VA Urgent Care Center or Vet Center.
Regarding the implementation plan, VHA and VBA developed a joint
action plan addressing required policy updates, internal and external
communications, IT modifications to CPRS, field education and support.
The field was notified of the OTH Initiative via memos dated 3/20/17
(Access for Mental Health Services for Other Than Honorable Discharged
Servicemembers), 4/19/17 (Validating VA Mental Health Plan to Meet the
Needs of Other Than Honorable (OTH) Discharged Servicemembers), and 6/
26/17 (Eliminating Veteran Suicide: Emergency Services for Other Than
Honorable Discharges). A training PowerPoint presentation was developed
in May, 2017 for field staff who register OTH Servicemembers in the
electronic health record (EHR). VHA Directive 1601.02A was updated on
June 7, 2017 to include information about providing care to this
population. A Communications Plan was completed in June, 2017, which
included internal and external PowerPoint presentations and Fact Sheet.
In addition to external presentations to VSO groups and congressional
partners, a series of national webinar calls was completed for VA field
education.VA began implementing this initiative on July 5, 2017. In
September, 2017, the IT contract was awarded to develop and implement
necessary computer upgrades for the EHR, which will allow the field to
track the 90-day episode of care.
______

Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
Affairs
va health care outcomes
Introduction: Despite the bipartisan investments made in the VA
each year, there continues to be basic failings that impact the
experience of Veterans: issues in accessing benefits, communications
with the VA, problems with VA medical care, and others.

Question 60. What will be different next year in how you address
just one of those issues--for example, health care access? Under this
budget how will access to care be different for veterans next year in
how they get it through the VA or outside it? How will the average
veteran feel these proposals in their everyday interaction with VA?
Response. VA continues to work to ensure all eligible Veterans have
their urgent care needs met in a timely fashion. A year ago, VA
implemented same day services at all medical centers and some of its
community based outpatient clinics. On January 12, VA announced that
100 percent of its more than 1,000 medical facilities across the
country now offer same-day services for urgent primary and mental
health-care needs. . VA is also working to ensure new referrals to
specialists are screened for urgent needs, and that these Veterans are
referred for timely care. Since FY 2014, the average wait time to
complete the most urgent consults decreased from 31 days to 2.8 days
during December2017. VA is also working to ensure follow-up
appointments for time-sensitive issues are managed in a timely fashion.
In late 2016, VA also implemented a process to ensure timely follow-up
appointments for time-sensitive medical needs. Since then, over 200,000
such appointments have been completed. A year ago 90% of such
appointments being no later than the provider recommended appointment
date. Over the past 3 months, this number increased to 95%.
Patient Self-referral Direct Scheduling, the ability for Veterans
to schedule a routine appointment without a consult from a primary care
provider, was implemented in Optometry and Audiology in 2016. In 2017,
it was implemented in all nutrition clinics and is nearing full
implementation in podiatry, amputee and wheelchair clinics. In 2018, VA
will be adding direct scheduling in cancer Care (Veterans new to VA or
transferring their care to VA with a known cancer diagnosis), smoking
cessation, mammography (when provided at VA), weight management, social
work and pharmacy clinics.
Expansion of telehealth services continues to be a priority for
improving access to care particularly to parts of the country where
there is a shortage of providers. The use of a national hub and spoke
model in VA for Telehealth allows virtual medical appointments to occur
in sites that may be rural or have difficulty recruiting providers,
where otherwise Veterans would not be able to access care as quickly.
As of the beginning of this CY, VA has 11 fully operational Mental
Health Hubs and 9 fully operational Primary Care Hubs. Additionally,
some of our VISNs are setting up their own hubs. Additionally VA is in
the process of implementing a tele-urgent care initiative in five VISNs
this year. The initiative is designed to enhance first call resolution,
properly addressing the Veteran's need the first time they call to
prevent the need for a second or follow up call.
VA is also working to implement VA Video Connect, a simplified
mobile and web-based application connecting Veterans with providers via
encrypted video, is also being implemented. It allows Veterans to see
and talk to their health care team from anywhere, making appointments
more convenient and reducing travel and wait times. VA is in the
process of implementing this across the Department.
VA has also been implementing Veterans Scheduling Enhancement in
all of its healthcare facilities. This system eliminates many of the
previously occurring scheduling errors and improves the scheduling
experience for the Veteran.
In April, VA launched the ``Access and Quality in VA Healthcare''
website at www.accesstocare.va.gov. The website promotes transparency
and enables Veterans, their families, and caregivers to view data
related to:

Patient wait times at VA facilities in their area;
Veteran experiences scheduling primary and specialty care;
Available options for same day services; and,
Quality of healthcare delivered at every medical center.

The contracts through which we purchase care in the community are
undergoing significant changes based on lessons learned. New contracts
will be significantly different based on experiences with current
contractors and their performance (e.g. access, coverage, etc.). VA
followed a methodical approach to receive, categorize, analyze and
incorporate feedback from all stakeholders.
The new Community Care Network will increase the number of service
areas from two to four, divided by state boundaries, thus allowing each
new contractor to provide more local flexibility, improved customer
service and increased access to care. Responsibilities for care
coordination and scheduling of appointments, which were once assigned
to the contractor, will return to VA field sites, unless there is the
exercise of an optional task. Interactions with Veterans will be
maintained by VA staff on a more face-to-face and timely basis.

Question 61. Do the investments outlined in this budget provide
any particular support for veterans in rural communities--like Hawaii--
where geography and generational differences in the veteran community
require different outreach and communications strategies?
Response. The FY 2018 budget supports Veterans residing in rural
communities. VHA's Office of Rural Health (ORH), in concert with VHA
national program offices, diligently works to create enterprise wide
initiatives and create new and innovative programs that are increasing
access to care for rural Veterans. Examples include: Tele-Primary Care
and Tele-Mental Health Hubs, Clinical Pharmacy Staffing, and Rural
Veteran Transportation Services.
Ensuring access to timely and high-quality care is one of VA's
highest priorities. VA Research works to identify and evaluate
innovative strategies to improve access and quality, especially for
rural Veterans.

Question 62. Will the fact that you are not using the exact
platform used by DOD lead to interoperability issues at implementation?
What conversations have you had with Secretary Mattis about ensuring
interoperability with community providers or CHOICE providers?
Response. With the decision to acquire and implement the same
Cerner system that DOD is currently implementing will address the
interoperability challenges between the VA and DOD. VA is working with
the Department of Defense (DOD) and other subject matter experts, both
in government and in the private sector, to ensure our new system will
be interoperable with that of community partners. The exact mechanics
of the interoperability will be addressed to provide seamless care
across a common system is critical to providing the best care for
Veterans. VA also realizes the importance of interoperability with our
community care partners and educational institutions, and is
determining how best to meet this need and will update the Committee
soon.

Question 63. Secretary Shulkin you have said that ``we're still
looking at a multi-year process'' and reducing the number of homeless
veterans nationwide from roughly 40,000 to 10,000 or 15,000 is an
``achievable goal.'' What is this Administration's specific goal to
reduce homelessness and how will this budget help achieve that?
Response. VA is committed to ending Veteran homelessness. While
significant progress has been made to reduce Veteran homelessness,
there are sub-populations of homeless Veterans who are hard to reach
and engage (e.g., chronically homeless Veterans, those with serious
mental illness, justice involved Veterans, and those ineligible for VHA
health care services).
The 2018 President's Budget includes $1.7 billion for VA's Veteran
homelessness programs, including case management support for
approximately 93,000 existing HUD-VASH vouchers, grant funding for
community-based prevention and rapid rehousing services provided
through the Supportive Services for Veteran Families program, clinical
outreach and treatment services through Health Care for Homeless
Veterans, service intensive transitional housing through the Grant and
Per Diem Program and prevention services to justice involved Veterans
in the Veteran Justice Program; and employment supports in Homeless
Veterans Community Employment Services.
status of maui community based outpatient clinic replacement
construction
Question 64. Secretary Shulkin, it is my understanding that the VA
has received a land donation offer for the Maui CBOC replacement from
the State of Hawaii and is currently going through review and
concurrence in VA's Central office. What is the current status of this
review and concurrence process and when can we expect the concurrence
process to be completed? The project is very important to veterans on
Maui. Can you ensure that this process is completed as quickly as
possible?
Response. The donation of a ground lease from the State of Hawaii
was approved by the Office of Construction & Facilities Management on
June 23, 2017. VA's local contracting office is now able to proceed
with the project.

A P P E N D I X

----------

Prepared Statement of Joseph R. Chenelly, National Executive Director,
AMVETS (American Veterans)
Mr. Chairman Isakson, Ranking Member Tester and Members of the
Committee: As the largest veterans service organization open to all
veterans who served honorably, regardless of when or where they
served, it is a pleasure to present our views on the fiscal year 2018
budget for the U.S. Department of Veterans Affairs (VA).
On behalf of AMVETS National Commander Harold Chapman, we are proud
to fully support the requests for funding as outlined in The
Independent Budget (IB). It is crucial that the VA Secretary has all
the resources needed to successfully, efficiently and responsibly run
the many facets of the Department.
One area of great concern that AMVETS wants addressed immediately
is the White House's proposed cut to Individual Unemployability (IU)
compensation for veterans eligible for Social Security.
AMVETS National Headquarters has received thousands of emails,
calls and messages over the past two weeks from veterans decrying the
proposal to steal 225,000 Social Security eligible aged veterans the
U.S. Department of Veterans Affairs' IU compensation program if they
have paid into Social Security at any point during their life.
Individual Unemployability is a VA program for veterans who cannot
work because of their service-connected disabilities. These veterans
are rated below 100 percent per the VA rating schedule. But each
recipient of IU has been through an exhaustive verification process to
ensure they are unable to earn wages above Federal poverty guidelines
because of their wounds, injuries or illness.
Cutting this earned and needed benefit would ``save'' $3.2 billion
in 2018 and $41 billion over the next decade, which is slated to go
toward an expanded VA Choice program, which has yet to be fully
developed. We feel if President Trump knew of the serious
repercussions, he would have not included this in his budget request.
These veterans earned a lifetime disability benefit for their
service to this Nation. They did not ask to become disabled or to
become unemployable as a result of their injuries or wounds. Our nation
owes it to them to keep its promise, so they may continue to make ends
meet.
If veterans lose their IU, it would trigger the loss of:

- Civilian Health & Medical Program of the VA (CHAMPVA)
- Dependency and Indemnity Compensation (DIC)
- Chapter 35 Educational Benefits for the family
- Commissary privileges
- Property tax relief
- VA Dental & Vision Care
- Vehicle exemption fees

We firmly believe that if this measure of the budget passes, that
it would put the lives of these veterans at serious risk. VA's most
recent report on suicide notes that about 65% of all veterans who died
from suicide were aged 50 years or older.
We urge your committee to reject this dangerous part of the
President's budget and not include any cuts to IU in your budget. Every
day those who would be affected are growing more distressed. They
deserve to keep this earned benefit and live their senior years with
some peace of mind knowing that the country they served is not
deserting them in the time of their greatest need.
AMVETS is grateful for the Committee's hard work to provide
oversight and the resources necessary for our Federal Government to
keep its promises to veterans, their families and survivors. Any
questions or need for additional information may be addressed to AMVETS
National Legislative Adviser Ms. Amy Webb.

[all]