[Senate Hearing 115-320]
[From the U.S. Government Publishing Office]
S. Hrg. 115-320
HEARING ON PENDING LEGISLATION
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
JULY 11, 2017
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
28-513 PDF WASHINGTON : 2018
-----------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected].
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
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
----------
July 11, 2017
SENATORS
Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........ 1,10
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana...... 11
Hirono, Hon. Mazie K., U.S. Senator from Hawaii.................. 14
Cassidy, Hon. Bill, U.S. Senator from Louisiana.................. 14
Sanders, Hon. Bernard, U.S. Senator from Vermont................. 14
Boozman, Hon. John, U.S. Senator from Arkansas................... 43
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 46
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 49
Manchin, Hon. Joe, III, U.S. Senator from West Virginia.......... 53
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 106
WITNESSES
Baldwin, Hon. Tammy, U.S. Senator from Wisconsin................. 1
Prepared statement........................................... 3
Flake, Hon. Jeff, U.S. Senator from Arizona...................... 4
Prepared statement........................................... 5
Inhofe, Hon. James M., U.S. Senator from Oklahoma................ 6
Prepared statement........................................... 7
Strange, Hon. Luther, U.S. Senator from Alabama.................. 8
Prepared statement........................................... 9
Yehia, Baligh R., M.D., Deputy Under Secretary for Health for
Community Care, Veterans Health Administration, U.S. Department
of Veterans Affairs; accompanied by Tom Lynch, M.D., Assistant
Deputy Under Secretary for Health Clinical Operations, VHA;
Brad Flohr, Senior Advisor for Compensation Services, Veterans
Benefits Administration; and Carin Otero, Associate Deputy
Assistant Secretary for Human Resources Policy and Planning,
Human Resources and Administration............................. 16
Prepared statement........................................... 17
Response to posthearing questions submitted by Hon.
Richard Blumenthal......................................... 55
Celli, Louis, Director, National Veterans Affairs and
Rehabilitation Division, The American Legion................... 57
Prepared statement........................................... 59
Webb, Amy, National Legislative Policy Advisor, AMVETS........... 70
Prepared statement........................................... 72
Atizado, Adrian, Deputy National Legislative Director, Disabled
American Veterans.............................................. 79
Prepared statement........................................... 80
Stultz, Gabriel, Legislative Counsel, Paralyzed Veterans of
America........................................................ 91
Prepared statement........................................... 93
APPENDIX
Crapo, Hon. Mike, U.S. Senator from Idaho; prepared statement.... 111
Flake, Hon. Jeff, U.S. Senator from Arizona; letters from
constituents and organizations................................. 113
Association of American Medical Colleges (AAMC); prepared
statement...................................................... 130
American Academy of PAs (AAP); prepared statement................ 136
American Federation of Government Employees, AFL-CIO (AFGE);
prepared statement............................................. 137
Currie, Col. James T., USA (Ret.) Ph.D., Executive Director,
Commissioned Officers Association of the U.S. Public Health
Service (USPHS); letter........................................ 141
Fighting for Veterans Healthcare, Association of VA Psychologist
Leaders, Association of VA Social Workers, and Nurses
Organization of Veterans Affairs; prepared statement........... 143
Augustine, Lauren, Director of Government Relations, Got Your 6
(GY6); prepared statement...................................... 149
Porter, Tom, Legislative Director, Iraq and Afghanistan Veterans
of America (IAVA); prepared statement.......................... 154
Military Officers Association of America (MOAA); prepared
statement...................................................... 158
Stier, Max, President and CEO, Partnership for Public Service
(PPS); prepared statement...................................... 163
Urgent Care Association of America (UCAO); prepared statement.... 166
DaSilva, Rubina, MBA, PA-C, President, Veterans Affairs Physician
Assistant Association (VAPAA); prepared statement.............. 166
Fuentes, Carlos, Director, National Legislative Service, Veterans
of Foreign Wars of the United States (VFW); prepared statement. 169
Wounded Warrior Project (WWP); prepared statement................ 182
HEARING ON PENDING LEGISLATION
----------
TUESDAY, JULY 11, 2017
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:32 p.m., in
room 418, Russell Senate Office Building, Hon. Johnny Isakson,
Chairman of the Committee, presiding.
Committee Members Present: Senators Isakson, Boozman,
Heller, Cassidy, Rounds, Tillis, Tester, Sanders, Brown,
Blumenthal, Hirono, and Manchin.
HON. JOHNNY ISAKSON, CHAIRMAN,
U.S. SENATOR FROM GEORGIA
Chairman Isakson. I call this meeting of the Senate
Veterans' Affairs Committee to order. Welcome to our Members
and our guests today as well as all others that will testify.
As is always the tradition of the Committee, we will
recognize visiting Senators who are here to testify first. They
will be recognized for up to 5 minutes. There will be no Q&A,
and you are welcome to leave afterwards, or if you want to
stay, you can move to the back of the room--that is fine--or
come up here and sit with me. It does not matter. [Laughter.]
You can do anything you want to. We are all United States
Senators.
We are delighted to have you here at the Veterans' Affairs
Committee, look forward to your input, and just--I will
reserve--we will reserve opening statements until after these
Senators speak.
We will, first of all, ask unanimous consent that the
statement submitted for the record by Senator Crapo, who was
going to testify and then could not come, be put in the record.
Without objection.
[The prepared statement of Senator Crapo appears in the
Appendix.]
Chairman Isakson. So, starting with Sen. Baldwin, we will
recognize her up to 5 minutes. Welcome.
STATEMENT OF HON. TAMMY BALDWIN,
U.S. SENATOR FROM WISCONSIN
Senator Baldwin. Thank you so much. Thank you, Mr.
Chairman. Thank you, Ranking Member Tester. I really want to
thank you for the opportunity to testify today on bipartisan
legislation that I have introduced, the Veterans ACCESS Act,
and I was pleased to work across the aisle with Senator Moran
on this bipartisan reform.
Together with the Disabled American Veterans, The American
Legion, AMVETS, the Paralyzed Veterans of America, we are
working to help ensure that no matter where they receive
treatment, our veterans will find the quality health care that
they need, deserve, and have earned.
The simple premise of this legislation is that a health
care provider who is suspended or fired from the VA should not
be able to then serve veterans seeking care through the Choice
Program or other care-in-community programs.
This is a common-sense reform. If a doctor cannot treat our
veterans at a VA facility, that doctor should not be able to
treat our veterans under their own shingle in the community.
Currently, a loose patchwork of VA regulations intend to
stop fired or suspended VA providers from participating in VA-
administered community care programs; however, VA's lack of
consistent implementation of national standards at the local
level, including in Wisconsin, demonstrates that Congress must
act and not leave veterans' health and safety to chance.
The Veterans ACCESS Act would require the VA Secretary to
deny or revoke the eligibility of a health care provider to
participate in community programs if that provider is fired
from the VA, violates his or her medical license, has a
Department certification revoked, or breaks the law.
In Wisconsin, a doctor was suspended from treating patients
at the VA while under investigation for deadly prescribing
practices for which he was later fired. However, in the
intervening time between his suspension and firing at the VA,
he opened a private practice and was alleged to have been
trying to see former VA patients.
I wrote to the VA to ensure that he could not see patients
through the Choice Program, and the VA responded that since his
Wisconsin medical license was suspended, he could not see any
patients. However, that temporary suspension was later
overturned by a State administrative law judge, and from April
2016 until January 2017, this doctor had a valid Wisconsin
medical license.
At last year's appropriations legislation--or in last
year's appropriations legislation, at my request, Congress
directed the VA to report back on existing VA policies to
ensure that no health care providers removed for misconduct
subsequently become providers through community care programs.
The VA sent back a laundry list of regulations without ever
answering the very simple, central question of whether or not a
health care provider removed from the VA could see a patient
through the Choice Program.
Our legislation will ensure that the answer to this
question is no, and it will provide Congress the needed
oversight to ensure that the VA successfully implements
congressional intent.
I look forward to working with the Committee to address any
concerns that arise from today's hearing, and I want to thank
the veterans service organizations testifying later for their
support of this bipartisan legislation, including Disabled
American Veterans, The American Legion, AMVETS, and the
Paralyzed Veterans of America.
Thank you, Mr. Chair, Ranking Member, and all Members of
the Committee.
[The prepared statement of Senator Baldwin follows:]
Prepared Statement of Hon. Tammy Baldwin, U.S. Senator from Wisconsin
Chairman Isakson and Ranking Member Tester, I want to thank you for
the opportunity to testify before the Senate Veterans' Affairs
Committee on bipartisan legislation that I have introduced, the
Veterans ACCESS Act.
I am proud to be working across party lines with Senator Moran on
this bipartisan reform.
Together, with the Disabled American Veterans, the American Legion,
AMVETS and Paralyzed Veterans of America, we are working to help ensure
that no matter where they receive treatment, our veterans will find the
quality health care they need, deserve and have earned.
The simple premise of this legislation is that a health care
provider who is suspended or fired from the VA should not be able to
serve veterans seeking care through the Choice Program and other care
in the community programs.
This is a commonsense reform. If a doctor can't treat our veterans
in a VA facility, that doctor shouldn't be able to treat our veterans
in their own communities as well.
Currently, a loose patchwork of VA regulations intend to stop fired
or suspended VA providers from participating in VA-administered
community care programs.
However, VA's lack of consistent implementation of national
standards at the local level, including in Wisconsin, demonstrates that
Congress must act and not leave veterans' health and safety to chance.
The Veterans ACCESS Act would require the VA Secretary to deny or
revoke the eligibility of a healthcare provider to participate in
community programs if that provider is fired from the VA, violates his
or her medical license, has a Department certification revoked, or
breaks the law.
In Wisconsin, a doctor was suspended from treating patients at the
VA while under investigation for deadly prescribing practices for which
he was later fired.
However, in the intervening time between his suspension and firing
at the VA, he opened a private practice and was alleged to have been
trying to see former VA patients.
I wrote to the VA to ensure that he could not see patients through
the Choice Program and the VA responded that since his Wisconsin
medical license was suspended, he could not see any patients. However,
that temporary suspension was later overturned by a state
administrative law judge and from April 2016 until January 2017, this
doctor had a valid Wisconsin medical license.
In last year's appropriations legislation, at my request, Congress
directed the VA to report back on existing VA policies that ensure no
healthcare providers removed for misconduct subsequently become
providers through community care programs.
The VA sent back a laundry list of regulations without ever
answering the very simple question of whether or not a healthcare
provider removed from the VA could see a patient through the Choice
Program.
Our legislation will ensure that the answer to this question is
unquestionably ``no,'' and it will provide Congress the needed
oversight to ensure that the VA successfully implements Congressional
intent.
I look forward to working with the Committee to addressing any
concerns that arise from today's hearing and I want to thank the
Veteran Service Organizations testifying later today for their support
of this bipartisan legislation--including Disabled American Veterans,
the American Legion, AMVETS and Paralyzed Veterans of America.
Thank you.
Chairman Isakson. Thank you, Senator Baldwin. We appreciate
your work with the Committee and your interest in our veterans
and their affairs and the hard work you did on opioids in the
last legislation that we passed through the Committee. Thank
you very much.
Senator Flake.
STATEMENT OF HON. JEFF FLAKE,
U.S. SENATOR FROM ARIZONA
Senator Flake. Thank you, Mr. Chairman, Ranking Member
Tester, and other Members of the Committee. I am pleased to
speak today in support of the Veterans Treatment Court
Improvement Act. I am pleased to have joined the Ranking Member
to introduce this sensible piece of legislation.
Let me take the opportunity to introduce the bill now and
to thank the veterans service organizations that support the
bill, including The American Legion, AMVETS, Disabled American
Veterans, Paralyzed Veterans of America, each of whom will
testify here later.
Mr. Chairman, with your consent, I will submit for the
record, letters from these four organizations----
Chairman Isakson. Without objection.
Senator Flake [continuing]. As well as several others that
support the bill.
[These letters appear in the Appendix.]
Senator Flake. As you likely know, the State of Arizona has
about a half a million veterans. These brave men and women have
served in every conflict since World War II to present-day
operations in the Middle East, and we are obviously proud to
call them Arizonans.
Ofttimes, when these soldiers return home from conflicts
abroad, the transition back to civilian life proves to be its
own battle, and with the support of family and friends and the
tireless work of veterans service organizations, most are able
to surmount these challenges.
For those that lack a support system, these issues could
run into--or lead to run-ins with the law. While there is no
justification, obviously, for criminal behavior, it is
important to recognize that certain actions may be symptomatic
of the harrowing experiences that these veterans have endured
during their time of service.
By not providing treatment that actually addresses the
underlying service-connected issues, our criminal justice
system can create a vicious cycle.
Now, to address the absence of veteran-specific treatment
in our criminal justice system, the Department of Veterans
Affairs created the Veterans Justice Outreach Program in 2009.
That program established specialty courts that remove veterans
from the regular criminal justice process and provide tailored
treatments for underlying issues like Post Traumatic Stress and
substance abuse.
Veterans treatment courts have a proven track record of
preventing initial incarceration and reducing recidivism, and
the lifeblood of this program are the Veterans Justice Outreach
specialists who link veterans to available court services.
These outreach specialists identify veterans in jails and in
local courts, assess their health status, and help to develop a
rehabilitation program that is tailored to each of their needs.
In April, I had the opportunity to observe the veterans
docket and to see some of the most dedicated specialists while
visiting the Mesa Municipal Court in Arizona. Let me tell you,
there is no experience--or no substitute for seeing this
experience firsthand.
Even though it is a courtroom setting, there is a comradery
and collaboration that you just do not see in a traditional
courtroom setting, and that comes from having a judge and the
hardworking staff there having served in the military
themselves. They understand that coming home is not always
easy, and though the program has experienced remarkable
success, the demand for outreach specialists is outpacing the
program's ability to serve all eligible veterans. This means
that future veterans treatment courts cannot be established,
existing courts go understaffed, and veterans go unserved.
To ensure that we have--that our veterans receive swift and
appropriate access to justice, I have introduced the Veterans
Treatment Court Improvement Act. It will provide 50 additional
outreach specialists for veterans treatment courts nationwide.
By increasing the number of dedicated specialists at these
facilities, it will decrease the number of veterans who end up
getting lost in the criminal justice system.
I am committed to work with the Committee on this common-
sense legislative fix that will connect more veterans with the
treatments that they have earned through their service.
Thank you again, Mr. Chairman, Mr. Ranking Member, and
Members of the Committee.
[The prepared statement of Senator Flake follows:]
Prepared Statement of Hon. Jeff Flake, U.S. Senator from Arizona
Thank you Chairman Isakson and Ranking Member Tester for allowing
me to speak today in support of the Veterans Treatment Court
Improvement Act. I am pleased to have joined with the Ranking Member to
introduce this sensible piece of legislation.
I would also like to take the opportunity now to thank the Veterans
Service Organizations that support the bill, including The American
Legion, AMVETS, Disabled American Veterans, and Paralyzed Veterans of
America, each of which have a member testifying here today.
Mr. Chairman, with your consent I will submit for the record
letters from these four organizations, as well as several others, in
support of the bill.
As you likely know, the state of Arizona is home to more than half
a million veterans. These brave men and women have served in every
conflict from World War II to present day operations in the Middle
East. I am proud to call them Arizonans.
But, oftentimes, when these soldiers return home from conflicts
abroad, the transition back to civilian life proves to be its own
battle. With the support of family and friends, and the tireless work
of Veterans Service Organizations, most are able to surmount these
challenges.
For those who lack a support system, these issues could lead to
run-ins with the law. While there is no justification for criminal
behavior, it is important to recognize when certain actions may be
symptomatic of the harrowing experiences a veteran has endured during
years of service.
By not providing treatment that actually addresses the underlying
service-connected issues, our criminal justice system can create a
vicious cycle. To address the absence of veteran-specific treatment in
our criminal justice system, the Department of Veterans Affairs created
the Veterans Justice Outreach program in 2009.
The program established specialty courts that remove veterans from
the regular criminal justice process and provide tailored treatments
for underlying issues like post-traumatic stress and substance abuse.
Veterans treatment courts have a proven track record of preventing
initial incarceration and reducing recidivism. The lifeblood of the
program are the Veterans Justice Outreach specialists who link veterans
to available court services. These outreach specialists identify
veterans in jails and local courts, assess their health status, and
help to develop a rehabilitation treatment program specific to each
veteran's needs.
In April, I had the opportunity to observe the veterans docket and
meet with some of these dedicated specialists while visiting the Mesa
Municipal Court in Arizona. Let me tell you, there is just no
substitute for seeing this process firsthand. Even though it's a
courtroom setting, there is a comradery and collaboration that you just
don't see in traditional courtroom proceedings. That comes from having
a judge and hardworking staff who have served in the military
themselves. They understand that coming home isn't always easy.
Though the program has experienced remarkable success, the demand
for outreach specialists is outpacing the program's ability to serve
all eligible veterans. This means that future veterans treatment courts
cannot be established, existing courts will go understaffed, and
veterans will go unserved.
To ensure that our veterans receive swift and appropriate access to
justice, I introduced the Veterans Treatment Court Improvement Act.
This legislation will provide 50 additional outreach specialists for
veterans treatment courts nationwide. By increasing the number of
dedicated specialists at these facilities, we will decrease the number
of veterans who will end up getting lost in the criminal justice
system.
I am committed to working with the Committee on a commonsense
legislative fix that would connect more veterans with the treatments
they have already earned with their service.
Thank you.
Chairman Isakson. Well, thank you, Senator Flake.
I can tell you from my firsthand experience in Cobb County,
GA, which is my home residence, where we have a drug court, the
work that has been done in the drug treatment court is just
amazing. The lives that have been changed is just amazing. It
is a lot like the Court-Appointed Special Advocate Program for
youthful offenders. It is a second chance, so to speak, to get
a first impression for the veterans. I appreciate your emphasis
and your work on that. I am glad you have introduced the
legislation, and it will get a fair hearing.
Senator Flake. Thank you.
Chairman Isakson. Senator Inhofe.
STATEMENT OF HON. JAMES M. INHOFE,
U.S. SENATOR FROM OKLAHOMA
Senator Inhofe. Thank you, Mr. Chairman.
I would ask how you guys would feel if you experience what
I experienced December 22, 2015. I picked up the USA Today
paper, and on the front page above the fold was an article
about how Oklahoma is doing such a lousy job with their
veterans.
We have had a lot of complaints. We have two major areas in
Oklahoma--Muskogee and Oklahoma City--and we had felt it was
mostly because of leadership.
Anyway, the problems were very serious, and we investigated
hundreds of inquiries, as you guys do, every time something
like this might happen. Our veterans had been subjected to
insufficient and possibly negligent care or denied access to
rightfully-earned benefits.
Now, we have been helped by Ralph Gigliotti. Ralph
Gigliotti is one of the VISN directors, I guess, VISN 19
director, and I could not have been happier with him. He came
in, and he agreed with the problems that we had. He has been
very supportive of us in the changes that we have to have on
the ground to take care of the--and we solved the problems.
There were two problems that took a long time for us to get
around. One has been taken care of already, and that was the
bill that gives a VISN the authority to come in and fire
someone, fire them on the spot. If they come in and then find
out that they have to wait 6 months before they get rid of
somebody, it takes away all of the problems that otherwise can
be handled by quickly getting with them. Of course, we took
care of that in the legislation that we just passed recently
giving them that authority.
Now we have two new directors in both Oklahoma City and in
Muskogee, and because of Gigliotti's and the new directors'
leadership, Oklahoma's facilities are now really improving. In
fact, they have gone from one-star to three-star facilities
already since that happened in December 2015.
Now, we were holding--in order to bring in a third party,
which the VA did not want to do, I actually, Mr. Chairman, had
to go down to the cloakroom and put a hold on our own
President's nominee for IG. It took about 2 weeks after that
before they would agree to finally let some third party come in
with him. They did that. A great job was done by the third
party. That happened to be--what was the name of that group?
The Joint what? You have got to talk louder.
Attendee. Joint Commission.
Senator Inhofe. Very good. Joint Commission.
They came in to investigate and really did a great job. Now
the standards are going up and all that, but the problem is
having that authority to go and seek this.
So, the problem that I have in Oklahoma is not just in
Oklahoma. I think it is probably in each State that is
represented on the panel here. So, this is something that I
cannot imagine anyone would be opposed to.
Now, we address this along with my junior Senator, James
Lankford, by introducing S. 1266, the Enhancing Veteran Care
Act. It provides permanent authority for VISN directors, like
Ralph Gigliotti, and medical center directors to contract with
outside entities to do these kinds of investigations. There is
no better way of getting through than to have another party
looking over the shoulder of those who are doing
investigations.
It is something that is--I cannot imagine anyone would be
opposed to and certainly is one that we will make sure that we
give the right treatment to our veterans. I was hoping that you
will be able to bring this up and pass it for our veterans'
sake.
[The prepared statement of Senator Inhofe follows:]
Prepared Statement of Hon. James Inhofe, U.S. Senator from Oklahoma
I would like to address the Committee on some of the VA health
clinic challenges we have had in my state of Oklahoma.
We have had serious problems at both VA centers in Oklahoma--
Muskogee and Oklahoma City. My office has investigated hundreds of
inquiries from Oklahoma veterans who have been subjected to
insufficient, and possibly negligent care, or denied access to
rightfully earned benefits.
We have been helped by Ralph Gigliotti, our VISN 19 director, who
is outstanding. He has been very supportive of ensuring the changes
that need to happen on the ground in Oklahoma actually take place.
Both OK VA centers now have new directors, Wade Vlosich and Mark
Morgan. Because of Gigliotti and the new directors' leadership, the
Oklahoma facilities are implementing new processes and procedures that
will improve care. The OKC center has gone from a one-star to a three-
star facility in the last year alone.
It was only after I held the VA IG nomination on the Senate floor
last year that the VA ensured us that they would send a third-party to
investigate these facilities. The VA contracted with the Joint
Commission to do an investigation of Oklahoma's facilities in
conjunction with the VA Inspector General.
It's important we hold care providers accountable to the highest
standards of excellence for our veterans. Having this outside entity
come in and compare the VA facilities to private sector health care
facilities is helping identify clear problems for the local and
regional directors to go after and fix. A fresh set of eyes, from
outside the VA, will enhance everyone's efforts to ensure our VA
facilities are world class.
This is not just a problem in Oklahoma. Across the Nation, veterans
have become all too familiar with the unsatisfactory care being
provided through the VA health care system. Too often, internal VA
reports and investigations do not match the facts on the ground, and
the regional directors know this. As a result, many veterans and VA
employees have lost faith in the agency and are not receiving the
proper care they deserve.
To address this I, along with the junior Senator from Oklahoma,
James Lankford, introduced S. 1266, the Enhancing Veteran Care Act,
which provides permanent authority for VISN directors, like Ralph
Gigliotti, and medical center directors to contract with outside
entities to do these kinds of investigations.
There is no better group to give this contracting authority to than
the regional VA directors who know firsthand the issues their medical
facilities face and are directly responsible for bringing about change
in the midst of excessive bureaucracy. I believe this to be an
important authority that needs to be explicitly provided to them, so
that more of the VA health center problems, which we hear about far too
often, can be fully addressed.
Thank you for having me today and I encourage swift passage of this
important legislation.
Chairman Isakson. We appreciate your introduction and you
being here today. We will give it every due consideration. We
are trying to make sure that we get everything out of the
Committee before July recess or August recess or whenever the
recess is----
Senator Inhofe. You tell us. [Laughter.]
Chairman Isakson [continuing]. And then get finished by the
end of the year. We appreciate your effort very much, Senator
Inhofe.
Senator Inhofe. Yes, sir.
Chairman Isakson. Senator Strange, welcome.
STATEMENT OF HON. LUTHER STRANGE,
U.S. SENATOR FROM ALABAMA
Senator Strange. Thank you, Mr. Chairman and Ranking Member
Tester.
I would first like to thank the Committee for the ongoing
work it is doing to champion the interests of our Nation's
veterans. All the proposals here that have been presented are
very noble bills that I think would make a difference. I know,
as a former Attorney General, the veterans courts are
particularly satisfying and effective in this area.
There are lots of issues, of course, that divide us, but I
am glad that we all come together when it comes to the care of
the veterans who have served this country so long and hard.
For so many who have served, the VA is what they rely upon.
It is the face of the promise the Nation made to them to take
care of them. It is critical that the VA facilities stand ready
to meet the needs of that population.
I am here today to introduce a bill that will improve the
quality of service and care available to veterans by
implementing needed reforms to the VA hiring and employee
management systems.
As the Members of this Committee know well, we are up
against significant challenges in this effort. You know that a
2016 Best Places to Work survey ranked the VA second to last
among large agencies, second to last in executive leadership,
and dead last in pay.
It is vital that our veterans can count on high-quality
services and care, and the first step in restoring that
accountability is ensuring that the VA is equipped with
talented professionals ready to meet their needs.
The VA Quality Employment Act of 2017 would build on
progress made already by the VA Accountability and
Whistleblower Protection Act, which President Trump signed into
law just last month. It would take a number of important
additional steps to enable the agency to attract and retain top
talent, hold poor performers accountable, and deliver services
worthy of our Nation's heroes.
First, it would establish health care and benefits
fellowship programs connected to the private sector to train
and retain a top-notch, service-oriented workforce. In today's
evolving workforce providing opportunities for professional
advancement and development is critical in motivating talented
caregivers and administrators to commit to the VA.
Second, the bill would provide for training human resource
professionals on recruiting and retaining Veterans Health
Administration employees and would create a database of VA job
openings. Too often, the right candidates are unaware of the
opportunities that desperately need filling.
Third, it would direct the VA to conduct annual performance
plans for political employees to ensure that the agency is in
the hands of a high-quality leadership. Veterans should never
be subjected to subpar care because politics got in the way of
public service.
In March, a companion bill, H.R. 1367, passed the House of
Representatives unanimously by a vote of 412 to zero, a rare
occurrence in Congress these days. The millions of veterans who
rely on the VA deserve swift and decisive action in the Senate
as well.
So, I would like to urge my colleagues here today to
recognize the need to improve the care we promise to those who
protect our freedoms and join me in support of this legislation
that will fill the urgent need and help the VA keep its
covenant with our Nation's heroes.
Mr. Chairman and Senator Tester, thank you again for the
courtesy you have extended for allowing me to speak today, and
I look forward to working with each one of you to advance this
bill through the process. Thank you very much.
[The prepared statement of Senator Strange follows:]
Prepared Statement of Hon. Luther Strange, U.S. Senator from Alabama
Chairman Isakson, Ranking Member Tester, I would first like to
thank the Committee for its ongoing work to champion the interests of
our Nation's veterans.
There are a lot of issues that divide us these days, but taking
care of those who have served must continue to be a unifying cause.
For so many Americans who have served, Veterans Affairs' employees
are relied upon as the face of a promise the Nation made to take care
of them, and it is critical that VA facilities stand ready to meet the
needs of our veteran population.
I'm here today to introduce a bill that will improve the quality of
services and care available to veterans by implementing needed reforms
to the VA hiring and employee management systems.
As Members of this Committee, you are each well aware of what we're
up against in this effort. You know that a 2016 Best Places to Work
survey ranked the VA second to last among large agencies, second to
last in executive leadership, and dead last in pay.
It is vital that our veterans can count on high-quality services
and care, and the first step in restoring that accountability is
ensuring that the VA is equipped with talented professionals ready to
meet their needs.
The VA Quality Employment Act of 2017 would build on the progress
made by the VA Accountability and Whistleblower Protection Act, which
President Trump signed into law just last month. It would take a number
of important additional steps to enable the agency to attract and
retain top talent, hold poor performance accountable, and deliver
services worthy of our Nation's heroes:
First, it would establish healthcare and benefits fellowship
programs connected to the private sector to train and retain a
top-notch, service-oriented workforce. In today's evolving
workforce, providing opportunities for professional development
is a critical component in motivating talented caregivers and
administrators to commit to the VA.
Second, the bill would provide for training human resource
professionals on recruiting and retaining Veterans Health
Administration employees and create a database of VA job
openings. Too often, the right candidates are unaware of the
opportunities that desperately need filling.
Third, it would direct the VA to conduct annual performance
plans for political employees to ensure that the agency is in
the hands of high-quality leadership. Veterans should never be
subject to sub-par care because politics got in the way of
public service.
In March, a companion bill, H.R. 1367, passed the House of
Representatives unanimously by a vote of 412-0. The millions of
veterans who rely on the VA deserve swift and decisive action in the
Senate, as well.
I would like to urge my colleagues here today to recognize the need
to improve the care we promise to those who protect our freedoms. Join
me in support of legislation that will fill urgent needs and help the
VA keep its covenant with our Nation's heroes.
Mr. Chairman, Mr. Ranking Member, thank you again for the courtesy
you've extended in allowing me to speak today. I look forward to
working with each of you to deliver this important bill for our
Nation's veterans.
Chairman Isakson. Thank you very much, Senator Strange,
Senator Inhofe, and to all the members who came and gave their
time. Thanks for your interest in our veterans. We will be
getting back to you shortly in trying to work together to see
this all can become law. So, thank you.
Senator Strange. Thank you very much.
OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, U.S.
SENATOR FROM GEORGIA
Chairman Isakson. We have two panels today to talk about
the legislation that is before us, but before we do, I want to
make a brief opening statement, as does the Ranking Member.
Let me thank the Members of the Committee that are here
today and make note that more often than not, attendance at the
Veterans' Affairs Committee is better by percentage than almost
any committee in the Senate, and I want to thank the Members of
the Committee for their active engagement so far this year and
allowing us to accomplish any number of things.
To that end, there is an article that appeared in The New
York Times about this Committee and the amazing amount we have
accomplished in the last year together as Republicans and
Democrats, to the credit of the Ranking Member who has worked
so hard with me to make sure that we did not forget about each
other while we kept our veterans first. Further, in the few
challenges we have before this year is over, we are going to
demonstrate once again we can find common ground to meet those
challenges to confront both the VA and what is required of it
as well as our veterans themselves.
I want to let all the Members know, and, for the record,
say publicly that it has been a complete team effort, with
everybody on the Committee making an effort to contribute,
Republican and Democrat alike. I am proud of what we have been
able to do, and I think the rest of it is within our reach as
long as we keep the same attitude, the same spirit, and same
commitment of work that we have in the last few months.
I want to thank the Ranking Member for his support. He
called me from his tractor Saturday returning my call on
something we are going to be talking about today, just to make
sure we had every I dotted and T crossed. We try to communicate
that well, so we do not ever catch each other by surprise. I
want every Member to know how much we appreciate your effort
and what you do.
Ahead of us, before this year is out, is to make sure we
deal with the Choice shortfall, dealing with modernization of
the Choice Program for standards and requirements, dot the I's
and cross the T's to make sure the appeals process gets put to
bed, which is about done, and work with the House Members on
the shortfall in terms of Choice to make sure it gets funded
before the year is out in an appropriate way.
That is a big lift that in many years would have seemed
impossible and not in our reach, but this year, because of the
work of the Committee, the spirit of the Committee, and the
commitment to getting the job done for our veterans, I just
believe we are going to do it. I am very proud to be a part of
it.
I want to thank everybody on the Committee for their effort
and introduce the Ranking Member for his opening statement.
OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S.
SENATOR FROM MONTANA
Senator Tester. Well, thank you, Mr. Chairman. I want to
thank you for calling maybe the most important hearing that we
are going to have this year.
Before I get into my prepared remarks, I just want to say
thank you for your leadership. Your commitment to solid
communication and making it so there are no surprises, has been
critically important on this Committee to move the ball ahead.
I think it is important that we recognize what we have
accomplished, but I think it is also important to recognize
what we have yet to accomplish. That is why this hearing today
is so very, very important, because there are fewer things more
important to an individual than their health.
We are seeing the access to health care issues play out day
in and day out here in the Senate, in the media, and back home.
Today that discussion comes to the Veterans' Affairs Committee.
The issue of where a veteran receives care and how that process
is constructed has been looming over this Committee for years,
and today we will hopefully get constructive feedback and
guidance that moves us forward to a final product.
I have had listening sessions back in Montana. Those
veterans told me that the Choice Program has not improved
access to care in Montana. In fact, if anything, it has made it
worse. In the process, it has caused a lot of veterans and
community providers to lose faith in the VA, and we have got a
lot of work to do to win those folks back. We need a dramatic
revamp of VA's community care program, and we need to be
thoughtful in our approach.
I said many times that I think we should be taking our cues
from the veterans, and I believe that my community care bill
does exactly that. Rather than just giving the veteran a card
to seek care in the private sector, I believe the VA must
continue to serve as a coordinator and primary provider of care
while the private sector fills in the gaps in care after the VA
takes into account the specific needs of an individual veteran.
That is exactly what my discussion draft, the Improving
Veterans Access to Community Care Act of 2017, would do. It
would put the decision of where a veteran received care in the
hands of a patient and provider, which is exactly where it
should be. In my view, a doc and a veteran should talk about
that veteran's specific needs and any challenges that veteran
faces in receiving care. This approach understands that one
size does not fit all when it comes to health care and outlines
factors that could be considered when the docs and patients
have that discussion. Those factors are not meant to be binding
or cumbersome; they are meant to be a jumping-off point for the
doc and the veteran to have a conversation about what that
veteran needs.
This common-sense approach takes the needs of the veterans
in places like Montana under consideration, where local
providers are often unable to absorb those veterans or to
provide the specialized care that is required. Do not get me
wrong. There is an important role for community care in the
delivery of veterans' health, but when a veteran goes into the
community for care, it should be based on what is best for the
veteran. And sending veterans into the private sector does not
absolve the VA of its responsibility for the care and benefits
that veteran received. The VA can transfer that care, but it
can never transfer the ultimate responsibility for that
veteran's well-being. That is why my bill would treat
disabilities incurred as a result of care received in the
private sector just like disabilities that result from care
received at the VA.
I believe the VA is just as responsible when a veteran has
had a bad experience with their local civilian facility as they
are if that veteran was at a VA hospital. We cannot let VA lose
oversight of the quality of care the veterans receive,
regardless where it is. While we are focusing on where veterans
get their care, we also need to address how we work to bolster
VA's internal capacity to provide better care.
That is where my Better Workforce for Veterans Act comes
in. This workforce bill supported by my sometimes friend and
foe----
Is he here? Damn it. I hate to waste good comments.
[Laughter.]
Senator Tester [continuing]. Focuses on recruiting, hiring,
and retaining a talented workforce for the VA. The VA has some
well-known human capital challenges, and my bill begins to
address them, legislation that I think makes a lot of sense,
given the Office of Inspector General's findings that physician
assistants are one of the top six critical-need occupations at
VA is also on today's agenda.
The Grow Our Own Directive: Physician Assistant Employment
and Education Act of 2017 allows the Government to continue
reaping returns on our investment in training medics and
corpsmen by keeping these individuals in Government service. I
introduced this legislation earlier this year with the support
of Senators Brown and Moran, among others. It provides training
and education opportunities for veterans who served as medics
and corpsmen who agree to serve the VA in underserved areas.
Once these veterans are certified as physician assistants, they
would be required to work at the VA for at least 3 years.
My bill also includes physician assistants in the Nurse
Locality Pay System. Once we have these folks on board, we need
to keep them there by paying them on par with what a PA in a
local community is making.
VA needs more PAs, and my legislation will help bring them
on board and keep them there serving veterans. While we are
examining these big-picture issues on where veterans get their
care and how to improve VA workforce-related issues, we need to
also make sure that we are improving the services VA provides
to veterans in making sure programs that tend to help veterans
evolve with the times. That is why, I along with Senator
Murkowski and on this Committee, Senators Blumenthal, Brown,
and Murray, introduced the Servicemembers and Veterans
Empowerment and Support Act of 2017. The fact that anyone in
uniform has to deal with sexual assault or harassment during
the course of their service to our country is unacceptable.
Following reports that nude photos of female servicemembers
were posted on Facebook and other websites without the
servicemembers' knowledge or consent, we introduced legislation
to make it clear that servicemembers and veterans who have
experienced online sexual harassments are able to access VA
counseling and benefits.
Mr. Chairman, earlier this year I was pleased that we would
come together in a bipartisan manner to make some much needed
changes to Choice. I really think we have an opportunity to do
that again by coming to agreement on a path forward for
community care. As we continue to work toward a compromise on
community care legislation, I am hopeful that this hearing will
help inform that effort in a big way.
Thank you, Mr. Chairman. I also want to thank the Members
of this Committee.
Chairman Isakson. Thank you, Senator Tester. I am confident
we can come to that agreement to make Choice work, make it work
even better, and solve those problems that confront us today.
Before we go to our panels, I see Senator Cassidy is here
and has two bills that are on the agenda today. Senator Hirono
is here and has one that carries her name, and Senator Heller
was here, but he disappeared when I looked the other way a
minute ago. So, I do not know if he is coming back or not.
Did you want to say anything about yours, Senator Cassidy
or Senator Hirono?
Senator Cassidy. I yield, Mr. Chairman.
STATEMENT OF HON. MAZIE K. HIRONO,
U.S. SENATOR FROM HAWAII
Senator Hirono. Well, let me add my thanks to you and the
Ranking Member for the bipartisan work that we do in this
Committee; this is well-deserved recognition.
Regarding my bill, I am glad that the VA is supportive as
well as the veterans organizations across the country, because
we have a lot of veterans who need long-term care, and we want
to keep those facilities supported.
Thank you.
Chairman Isakson. Senator Cassidy?
STATEMENT OF HON. BILL CASSIDY,
U.S. SENATOR FROM LOUISIANA
Senator Cassidy. I only have one bill. You threw me for a
little bit of a loop. I was thinking, ``Wait a second; do I
have two?''
So, ours is the Veterans Emergency Room Relief Act of 2017,
where if a veteran has an urgent care need and he does not live
near a VA hospital or if the VA hospital emergency room line is
long, this would allow him or her to go to that urgent care
center which the VA was contracted for a reasonable rate and
for the veteran to receive their care there.
The idea is that emergency rooms are roughly twice the cost
of urgent care centers at least, and this would allow the
veteran to receive the care at a lower-cost setting than in an
emergency room. We think that it would save the VA money. It
would also allow someone who might be dissuaded from receiving
care because of long lines in an ER to perhaps receive that
care that would be vital to health; because the line was
shorter, it was more efficient to go through. It gives the
veteran greater access to health care in their community.
We also have a basic cost-sharing mechanism for urgent care
visits and allowing the VA to establish some sort of cost
sharing but excluding conditions such as service-related, those
which require an admission, or other hardship for the veteran,
et cetera, and then for the Secretary of Veterans Affairs to
submit a report every 2 years regarding both urgent care
utilization and the impact upon ER facilities. We think it is a
good bill, and it has support of many of the veterans service
organizations.
Chairman Isakson. Thank you, Senator.
Senator Sanders?
STATEMENT OF HON. BERNIE SANDERS,
U.S. SENATOR FROM VERMONT
Senator Sanders. Thanks, Mr. Chairman.
I just wanted to say a few things. I think most
importantly, what this Committee has got to do--and I think we
do a pretty good job at it--is listen to the veteran service
organizations and listen to the veterans of this country. What
they tell us over and over again: ``The VA is not perfect. The
VA has problems.'' But, what they are telling us is that the VA
provides very high-quality care to veterans who are in the
system. The veterans organizations want to see the VA
strengthened. They want to see, among other things, the tens of
thousands of vacancies which currently exist within the VA--
doctors, nurses, other medical personnel--they want to see
those vacancies filled.
I think when we talk about filling vacancies and attracting
doctors, which is a difficult problem all across this country,
especially in primary care, I want to reiterate my belief that
we have got to expand the debt forgiveness program to attract
more doctors and nurses and other personnel into the VA.
I think there has been a lot of discussion--I know Senator
Boozman has been involved in this--on the feeling that we do
not want to see our veterans overmedicated. There are too many
drugs. Opioids are used. We want to find other ways to ease
pain, and I think the VA in general has done a pretty good job.
I want to see that expanded, so those are some of the concerns
that I am going to be focusing on, Mr. Chairman.
Chairman Isakson. Well, I appreciate those comments.
Senator Baldwin, who was here a little bit earlier, and
Senator Johnson did a great job in terms of the Tomah problem,
which was the lead problem on opioid overuse and over-
prescription at the VA. This Committee took strong action to
give the VA the power it needed to see to it that operation was
shut down and that practice was stopped. We find ourselves
continuing to focus on opioids, as we will, because it is a
major problem throughout the country.
Your comment about the VSOs, I am very proud that at every
hearing we have had in the 3 years that I have been on the
Committee as Chairman, we have always had a panel of the VSOs
represented. They will be here today on our second panel. I
could not do the job I am called upon to do without their
effort and their work. I acknowledge and appreciate their input
every single day that we get it.
As far as the empowerment of the Veterans Administration
and the Veterans Health Administration, I think we have made
some of the greatest steps forward, one in David Shulkin who
was approved unanimously by the Senate, the only Presidential
Cabinet appointee approved unanimously and who has demonstrated
what he has done. He shows a love and respect for the veteran,
a knowledge of health care, and a commitment to see to it the
VA is everything it needs to be to serve our veterans and their
health care needs in the years to come. I support that 150
percent, and I appreciate your acknowledgment of those
challenges. We are going to continue to work on those every
single day.
Does any other Member of the Committee have a comment to
make before we go to the first panel? [No response.]
Chairman Isakson. If not, Doctor, are you ready?
Dr. Yehia. I am ready.
Chairman Isakson. I always want to call him ``Dr. Yehia,''
and I think that is right, isn't it?
Dr. Yehia. It is right.
Chairman Isakson. I finally got it right this time.
Dr. Yehia from the Veterans Administration, accompanied by
Dr. Tom Lynch, Brad Flohr, and Carin Otero. We are glad to have
you all here today. You have got plenty of support, Dr. Yehia.
You are recognized for your testimony.
STATEMENT OF BALIGH R. YEHIA, M.D., DEPUTY UNDER SECRETARY FOR
HEALTH FOR COMMUNITY CARE, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY TOM LYNCH, M.D.,
ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH CLINICAL
OPERATIONS, VHA; BRAD FLOHR, SENIOR ADVISOR FOR COMPENSATION
SERVICES, VETERANS BENEFITS ADMINISTRATION; AND CARIN OTERO,
ASSOCIATE DEPUTY ASSISTANT SECRETARY FOR HUMAN RESOURCES POLICY
AND PLANNING, HUMAN RESOURCES AND ADMINISTRATION
Dr. Yehia. Good afternoon. Thank you, Mr. Chairman, Ranking
Member Tester, and Members of the Committee. Thank you for
inviting us here today to present our views on veterans' access
to VA's programs and services.
My written statement provides VA's detailed views on 11 of
the bills on the agenda today, and in the interest of time, I
would like to briefly touch on several of these bills before
us.
I did want to note that there are two bills that the
Department was unable to provide views at this time, and we
will get back to the Committee after the hearing.
So, first, we support Senate Bill 115, which would allow VA
to better care for veterans receiving live organ transplants.
We also support increasing access to care through hiring
more physician assistants, as broadly outlined in Senate Bill
426, and extending VA's authority to provide nursing home care
to certain severely disabled veterans, as Senate Bill 683 would
do.
We also appreciate Senate Bill 833, which is intended to
improve access to care and benefits for a veteran and
servicemembers who experience military sexual trauma.
Ensuring that we hire and retain the highest-quality
providers is critical to providing care to veterans, which is
why we support many of the provisions in Senate Bill 1325, the
Better Workforce for Veterans Act of 2017.
We also support the intent of Senate Bill 1261, the
Veterans Emergency Room Relief Act of 2017, which attempts to
simplify and consolidate access to emergency and urgent care.
However, there are several other bills on the agenda today
that address important topics but, as written, would limit our
ability to effectively manage VA programs and resources. For
example, VA is already taking steps to hire more justice
outreach specialists as would be required in Senate Bill 946,
the Veterans Treatment Court Improvement Act of 2017.
We are very committed to ensuring that veterans have access
to care, both inside and outside the Department, which is why
we support the principles in Senate Bill 1153, the Veterans
ACCESS Act, although we are concerned that this bill could
actually create some administrative burdens that would limit
high-quality providers joining our community care network.
We also do not support some of the provisions in Senate
Bill 1266, the Enhancing Veteran Care Act. VA already has
demonstrated an ability to provide comprehensive reports on
quality care over several decades, and we think this
legislation might be a little bit duplicative.
Last, I want to focus on The Veterans Choice Act of 2017
and the Improving Veterans Access to Community Care Act of
2017. Let me say that we understand that the future of VA's
community care program is one of the most important and
possibly one of the most difficult items on the legislative
agenda. We want to work with everyone to ensure that this
legislation is as strong as possible. We believe that the law
that is ultimately enacted should embrace a few broad
principles. These principles are based on lessons learned
through VA's existing community care programs, including the
Choice Program, and discussions with their key stakeholders.
First and foremost, the future community care program must
empower the veteran and their care team so that the veteran
gets the right care at the right time from the right provider.
Second, the Department must be able to establish a high-
performing network of VA and community providers who can
furnish the very best care. To do this, we must have
flexibility, flexibility in payment rates and the type of
agreements we form with providers. In addition, we must have
flexibility in our ability to simplify our interactions with
community providers so we can pay timely and accurately and
that we can share information more easily between the two.
Third, it is important that VA retain flexibility to adjust
and adapt to an evolving health care landscape. Legislation
that is too prescriptive in terms of rules, responsibilities,
or processes can only limit our options in the future, which
would lead to frustration from our veterans, our community
providers, and VA employees. With the Choice Program, we have
had five separate law changes in just under 3 years. That is
not really a sustainable model. We believe that the best
legislation would provide broad, general authority that VA
could define and implement through regulation, policies, and
contracts.
Last, it is critical that the legislation provide VA with
sufficient time to develop and lead to implementation. We know
from our efforts in the Choice Program that a short period of
implementation will not help veterans. Ideally, we would like
to have a full year to establish provider networks, draft
regulations, and build the necessary relationships and systems
that will empower our veterans, community providers, and VA
staff to deliver the best health care to our Nation's veterans.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions that you or Members of the Committee
would have.
[The prepared statement of Dr. Yehia follows:]
Prepared Statement of Baligh R. Yehia, M.D., Deputy Under Secretary For
Health For Community Care, Veterans Health Administration, U.S.
Department of Veterans Affairs
Good morning, Chairman Isakson, Ranking Member Tester, and Members
of the Committee. Thank you for inviting us here today to present our
views on several bills that would affect the Department of Veterans
Affairs' (VA or Department) programs and services. Joining me today is
Dr. Tom Lynch, Assistant Deputy Under Secretary for Health Clinical
Operations, Veterans Health Administration (VHA); Brad Flohr, Senior
Advisor for Compensation Services, Veterans Benefits Administration;
and Carin Otero, Assistant Deputy Assistant Secretary for Human
Resources Policy and Planning, Human Resources and Administration.
This written statement includes VA's views on eleven significant
bills on important topics. Because of the timing of receipt of two of
the bills, we are not able to provide formal views in this statement on
S. 1279, the Veterans Health Administration Reform Act of 2017 or the
draft bill, ``The Department of Veterans Affairs Quality Employment Act
of 2017.'' We also will follow up with the Committee on one section
(section 10) of the Veterans Choice Act of 2017. We look forward to
providing views at a later time and discussing these bills with you
today.
s. 115, veterans transplant coverage act
S. 115 would add section 1788 to Title 38, authorizing the
Secretary of Veterans Affairs (Secretary) to provide for an operation
on a live donor to carry out a transplant procedure for an eligible
Veteran, notwithstanding that the live donor may not be eligible for VA
healthcare. VA would be required to provide to a live donor any care or
services before and after conducting the transplant procedure that may
be required in connection with the transplant.
VA supports S. 115, contingent on the provision of additional
resources to support implementation, although we recommend some
clarifications in the bill language. We believe it would be appropriate
to limit the duty and responsibility to furnish follow-on care and
treatment of a living donor to two years after the procedure is
performed by a VA facility. This would be consistent with the
recommendations of the United Network for Organ Sharing and the Organ
Procurement and Transplant Network. We further recommend that the duty
to provide follow-on care and treatment should be limited to that which
is ``directly related to'' the living donor procedure (rather than what
``may be required in connection with such procedure,'' as the bill
would provide).
There are other potential issues related to organ transplantation
that the bill does not address that we would be pleased to discuss with
the Committee in its contemplation of this proposal.
We estimate the bill as written would cost $1.8 million in Fiscal
Year (FY) 2018, $9.7 million over 5 years, and $21.5 million over 10
years.
s. 426, grow our own directive: physician assistant employment and
education act of 2017
S. 426 would provide new authorities for VA to provide educational
assistance and other benefits to support physician assistants (PA).
Section 2 would require VA to carry out a pilot program to provide
educational assistance to certain former members of the Armed Forces
for education and training as PAs.
Having a pilot program will help alleviate the healthcare workforce
shortages in VA by requiring scholarship recipients to complete a
service obligation at a VA healthcare facility after graduation and
licensure/certification. Additionally, scholarships will enable
students to gain academic credentials without additional debt burdens
from student loans. Future benefits are gained in reduced recruitment
costs as scholarship recipients will have obligated service agreements
to fulfill. These service agreement obligations secure the graduates'
services for up to three years, which reduces turnover and costs
typically associated with the first two years of employment.
While VA supports section 2, contingent on the provision of
additional resources to support implementation, we believe that the
Congress should provide more flexibility in implementation. The bill is
very specific, including in areas such as directing the management
structure of the pilot program and the specific criteria for
participant eligibility. VA should be afforded the flexibility to
implement such a program in a manner that can minimize any unintended
consequences and promote consistency across Title 38 programs.
We recommend removing language in paragraph (j) that would require
the positions of Deputy Director for Education and Career Development
for Physician Assistants and Deputy Director of Recruitment and
Retention to be filled by a Veteran and a current employee. The
limitation of filling the proposed Deputy Director positions with
Veterans only (as opposed to employing Veteran preference) would
significantly limit the pool of applicants with the necessary
experience and skill sets necessary to successfully carry out the
responsibilities of the positions, as well as potentially run afoul of
Merit Systems Principles.
The total cost of administering the pilot program under section 2
would be $546,000 in FY 2018 and $2.9 million over 5 years.
Section 3 would add a new section 7618A that would ensure that not
fewer than 25 new scholarships in the Health Professional Scholarship
Program are awarded each year to individuals for education and training
to become physician assistants. It would also add a new section 7676
that would similarly require that 25 new scholarships in the Employee
Incentive Scholarship Program be awarded for education and training to
become physician assistants.
While VA supports section 3 in principle, and contingent on the
provision of additional resources to support implementation, VA already
has the authority to dedicate scholarships toward these professions.
Similar to section 2, providing these scholarships will help VA address
workforce shortages through the required service obligation.
The total cost of section 3 of the Health Professional Scholarship
Program (HPSP) with HPSP Stipend cost for 175 awards (35 per year) over
five years would be $10.2 million.
Section 4 would require the Secretary of Veterans Affairs to
establish standards for the Department for using educational assistance
programs to educate and hire PAs. This provision would require that the
standards ensure that VA's Educational Debt Reduction Program (EDRP) is
available to participants in the PA pilot program. To the maximum
extent practicable, VA would be required for each year over a five year
period to increase the scholarships amounts under subchapters II and VI
of chapter 76, Title 38, and any other relevant educational assistance
programs offered by VA for courses of education or training to become
physician assistants.
VA does not support this section because EDRP assistance is
targeted for specific positions that are designated as difficult to
recruit and retain. In order to meet local Veteran population needs,
local medical centers have the flexibility to determine the positions
that have the most critical need for EDRP awards and advertise
accordingly. Loan repayment awards are an attractive tool; however,
EDRP is a limited resource and offering EDRP to an entire occupational
series would be contrary to the statutory mission of the program and
would set a precedent for other occupations to seek similar authority.
The PA occupation is recognized as a top 5 mission-critical
occupation within VA, ranking fourth and tied with physical therapy,
according to the January 2015 VA Office of Inspector General report
after medical officer (physician), nurse, and psychologist.
Over the last several fiscal years, the number of new PA hires has
fluctuated between 250-350 annually. The number of EDRP awards made for
newly hired PAs has gradually increased from 26 to 45 (62 percent
increase) from FY 2014 to FY 2015, and currently comprises 13 percent
of all new PA hires. In the FY 2015 EDRP award cycle, the average EDRP
award for PAs was $63,000. Current projections estimate similar awards
for the PA occupation based on qualifying student loan debt. Overall,
the OIG's top 5 occupations represented 82 percent of all EDRP awards
made in FY 2015.
EDRP awards are typically five year awards. If EDRP was offered to
every new PA hire, nearly $4.6M would be needed each year for new
awards, and additional funding would be required to sustain current
participants.
Including EDRP in all announcements, as would be required by the
mandated standards, would also give interested candidates for hire the
impression that EDRP would be available. EDRP awards are not made until
after qualifying student loan debt can be confirmed with education
institutions and lenders, which can take several months and occurs
after employees are onboard. Without significantly increasing EDRP
funding, including EDRP in all PA vacancy announcements will prevent
facilities from offering the award to other positions that are more
difficult for recruitment and retention locally. Advertising EDRP in
all PA announcements, without significantly increasing funding, is
misleading and likely to disenfranchise new employees early in their VA
career.
Advertising EDRP for an entire occupation sets a precedent that
will likely encourage other occupations to seek the same. Such costs
are not only unsustainable, but in conflict with the statutory mission.
PAs are nationally ranked as a mission-critical occupation; however,
certain facilities report no issues recruiting PAs (i.e., Michael E
DeBakey VA Medical Center in Houston, TX, has a strong PA program with
academic affiliates and reports no issues hiring PAs). Requiring all
facilities to advertise EDRP for positions would deny the facility the
ability to make awards for other positions that are the most critical.
Alternative approaches may be better suited for strengthening the
PA occupation within VA, such as making compensation of PAs the primary
driver in recruitment and retention.
VA supports section 5 of the bill, contingent on the provision of
additional resources to support implementation, which seeks to
eliminate the pay disparity between VA and the private sector.
The cost for 5,250 new EDRP awards over 5 years would be $68.2
million. Salary and development costs are estimated at an additional
$792,451, bringing the total cost of this proposal (including cost of
living adjustments) to $69 million.
s. 683, keeping our commitment to disabled veterans act of 2017
S. 683 would amend 38 U.S.C. Sec. 1710A to extend until
December 31, 2018, the period in which the Secretary shall provide
nursing home care to certain Veterans.
VA supports this provision, which would ensure that Veterans in
need of nursing home care for a service-connected disability and any
Veteran who has a service-connected disability rated at 70 percent or
more are eligible to receive nursing home care.
If the authority in section 1710A continues to be extended, VA
estimates the cost would be $4.73 million in FY 2018, $25.13 million
over 5 years, and $53 million over 10 years.
s. 833, servicemembers and veterans empowerment and support act of 2017
Section 2(a) of S. 833 would amend 38 U.S.C. Sec. 1720D(a)(1) to
authorize VA to provide a Veteran with counseling and care and services
determined (by a VA mental health professional) to be needed to
overcome psychological trauma resulting from cyber harassment of a
sexual nature.
VA supports this subsection in principle, but we do not believe it
is necessary because of VA's current authority. Under section 1720D, VA
is authorized to provide counseling and treatment for trauma resulting
from sexual harassment (defined as ``repeated, unsolicited verbal or
physical contact of a sexual nature which is threatening in
character''), and this can include sexual harassment that is conducted
through verbal or cyber contact, including the use of Internet social
media services. We also note that the phrase ``cyber harassment of a
sexual nature'' is ambiguous, and it is unclear exactly what the
drafter intends to cover. It would also be helpful to clarify whether
the bill is intended to extend eligibility to those who were the victim
of cyber harassment in only one instance or if, as is the case with the
definition of sexual harassment in 38 U.S.C. Sec. 1720D(f), the
harassment must be ``repeated.'' As drafted, we presume the intent is
to allow VA to define this term through rulemaking, but if there are
specific parameters the drafter wishes to ensure are specified,
including them in the bill text would be advisable.
Additionally, it is unclear if the language as drafted would cover
all of the types of cyber harassment incidents that are intended. As
amended, section 1720D would still require that the cyber harassment
occur while the Veteran or Servicemember was on active duty, active
duty for training, or inactive duty training. However, it may not be
clear exactly when the harassment occurs. For example, the harassment
could occur when the content is created (e.g., a photograph or video is
made), when the content is posted online, when the individual discovers
the content is online, or when content that was posted with permission
is shared with others without permission (e.g., if a photo or video
that was only intended for a limited number of parties is made
available to others). Depending upon which standard controls, different
Veterans and Servicemembers would be eligible. Due to the intricacies
of the subject, it would be beneficial if the legislation addressed
``cyber-harassment'' in a separate subsection of section 1720D. We
believe it would be prudent to phrase this authority in a way to ensure
it does not become outdated by changes in technology. We would be happy
to assist the Committee in exploring these issues further and in
developing technical assistance to ensure the legislation reflects the
drafter's intent.
Section 2(b) would amend section 1720D(a)(2) to permit VA to
provide without a referral needed counseling, care, and services for
sexual trauma that was suffered by Servicemembers, including members of
the National Guard and Reserves, during periods of active duty, active
duty for training, or inactive duty training. Current law authorizes VA
to provide services under this authority only to Servicemembers,
including members of the National Guard and Reserve, who are serving on
active duty.
VA supports section 2(b), but notes this support is contingent upon
additional resources to support implementation. While this provision is
discretionary and could only be implemented in consultation with the
Secretary of Defense, this subsection has potentially significant cost
and workload implications that, without additional resources, could
jeopardize VA's ability to provide timely services to Veterans.
It is difficult to estimate the new demand for care that would be
produced by section 2, as VA has no data currently available on how
many members of the National Guard and Reserve (as well as other
members of the Armed Forces) experienced military sexual trauma while
on active duty, active duty for training, or inactive duty training.
Similarly, it is impossible to know how many of these persons would
seek care from VA, and how many would continue to seek care on an
ongoing basis. While VA currently furnishes care to Servicemembers
through sharing agreements and other arrangements, the Department of
Defense (DOD) reimburses VA for such care. It is unclear if DOD would
do so when the Servicemember is no longer in active duty, active duty
for training, or inactive duty training.
Section 3(a) would amend 38 U.S.C. Sec. 1154 by adding a new
subsection (c). The current subsection (b) of section 1154 provides a
liberal approach to evaluating claimed disabilities based on a
Veteran's engagement in combat with the enemy. This provision
acknowledges the disruptive ``circumstances, conditions, or hardships''
of combat, and the resulting incomplete record keeping, as the basis
for a liberal approach to evaluating claims. The newly proposed
subsection (c)(1) would establish a liberal standard of proof to ``any
Veteran who claims that a covered mental health condition was incurred
in or aggravated by military sexual trauma during active military,
naval, or air service.''
VA appreciates the purpose of section 3 but does not support it as
written. Under subsection (c)(1) of 38 U.S.C. Sec. 1154, as proposed to
be added, the military sexual trauma stressor/event would be required
to be ``consistent with the circumstances, conditions, or hardships of
. . . service'' in order to be associated with a current covered mental
health condition. Although this language, as used in current section
1154(b) in relation to conditions allegedly incurred or aggravated in
combat makes sense for the specific disruptive circumstances of combat
as a potential Post Traumatic Stress Disorder (PTSD) stressor, there
are no specific circumstances, conditions, or hardships of service that
are associated with military sexual trauma, which can occur at any time
and any location during the period of service.
Section 3(b) would add a new section 1164 to title 38 that would
codify VA's current liberal approach for evaluating PTSD/military
sexual trauma claims under its regulation at 38 CFR 3.304(f)(5). While
VA supports this provision in principle, it would be preferable to
allow VA the flexibility to revise its regulations based on experience
without the need to seek statutory amendments, as would be required if
the current regulation is codified in statute.
VA does not have a cost estimate for this section at this time.
Section 4 would require the Secretary of Defense to inform members
of the Armed Forces of the eligibility of such members for services at
VA's Vet Centers. The Secretary of Defense would be required to ensure
that DOD's Sexual Assault Response Coordinators advise members of the
Armed Forces who report instances of sexual trauma about their
eligibility for services from VA's Vet Centers.
While VA defers to the Secretary of Defense on the specific
obligations this bill would impose, we support this section in
principle. VA currently provides counseling for military sexual trauma
to active duty Servicemembers and is pleased to do so. Informing
Servicemembers of the benefits for which they are eligible is important
to ensuring they receive the care and services they need. We note there
may be technical issues with some of the bill language, but we would be
happy to discuss this with the Committee with DOD's input as well. In
addition, additional resources to support implementation may be
required.
s. 946, veterans treatment court improvement act of 2017
S. 946 would require VA to hire additional Veterans Justice
Outreach (VJO) Specialists to provide treatment court services to
justice-involved Veterans. Specifically, S. 946 would require that VA
hire not less than 50 VJO Specialists and place each such VJO
Specialist at an eligible VA medical center (VAMC). The bill would
require that the total number of VJO Specialists employed by the
Department not be less than the sum of (a) the VJO Specialists employed
on the day before the enactment of this provision; and (b) the number
of VJO Specialists hired under this bill. The bill would require that
the Secretary prioritize placement of the VJO Specialists at facilities
that will create an affiliation with a Veterans treatment court that is
established on or after the date of enactment of the bill, or one that
was established prior to enactment but is not fully staffed with VJO
Specialists. The bill would require the Secretary to submit a report to
Congress on the progress and effects of implementing these provisions
within one year, with new reports submitted annually after that. The
bill would also require the Comptroller General to submit to Congress a
report on the implementation of this authority and the effectiveness of
the VJO Program. The bill would authorize to be appropriated $5.5
million for each of fiscal years 2017 through 2027, and would require
the Secretary to submit to Congress a report that identifies such
legislative or administrative actions that would result in reduction in
expenditures by the Department that are equal to or greater than the
amounts authorized to be appropriated.
VA supports the intent of this bill and is already working to hire
more than the 50 additional VJO Specialists in FY 2017. However, the
bill could ultimately result in a reduction of $5.5 million in funding
to other programs (including possibly programs for homeless Veterans).
Because of this potential reduction in funding, VA does not support the
legislation as drafted. Demand for VJO Specialists has grown
considerably over the past several years, partly as a result of the
adoption of the Veterans Treatment Court model in new jurisdictions.
Limited VJO staff resources have affected VA's ability to partner
effectively with Veterans Treatment Courts, especially those newly
established.
As a technical matter, we note that provisions of section 2(e) of
the bill concerning the authorization of appropriations may not
accomplish the intended objective. We understand this provision is
intended to ensure that the Secretary identifies offsets to fund the
program required by this bill. However, the bill only requires the
Secretary to report to Congress on legislative or administrative
actions that would result in a reduction of expenditures equal to or
greater than $5.5 million. To the extent that the Secretary identifies
legislative actions that would result in a reduction of expenditures,
there is no guarantee that Congress would take such actions. We further
note that the offsets would likely affect adversely VA's ability to
implement and run other programs, which could result in delays in the
provision of benefits, healthcare, and other critical services to
Veterans and other beneficiaries. Ultimately, we do not believe this is
an appropriate mechanism for funding the program required by this
section.
We also note that the definition of ``local criminal justice
system'' in section 2(f)(3) of the bill would exclude Federal law
enforcement issues. We understand there are some Federal district
courts that have Veterans treatment courts, and these would not be
supported under this bill.
While we estimate the hiring of 50 additional VJO Specialists would
cost $5.5 million in FY 2018, because the bill would require VA to
identify offsets, we believe the ultimate cost would be $0 in FY 2018
and over both 5 and 10 years. We again caution that the costs for
implementation would involve reductions to other VA programs.
s. 1153, veterans acquiring community care expect safe services
(access)
act of 2017
S. 1153 would require the Secretary of Veterans Affairs to deny or
revoke eligibility of certain healthcare providers to provide non-VA
healthcare services to Veterans. The bill would, in general, require
that the Secretary deny or revoke the eligibility of a healthcare
provider to provide non-Department healthcare services if the Secretary
determines that: (1) the provider was removed from employment at VA due
to conduct that violated a policy relating to the safe and appropriate
delivery of healthcare; (2) the provider violated the requirements of a
medical license; (3) the provider had a Department credential revoked
that would impact that provider's ability to provide safe and
appropriate healthcare; or, (4) the provider violated a law for which a
term of imprisonment of more than one year may be imposed. The bill
would permit, but not require, the denial, revocation, or suspension of
the eligibility of a healthcare provider to furnish non-Department
healthcare when the Secretary has a reasonable belief that such action
is necessary to immediately protect the health, safety, or welfare of
Veterans and: (1) the provider is under investigation by the medical
licensing board of a State in which the provider is licensed or
practices; (2) the provider has entered into a settlement agreement for
a disciplinary charge related to the practice of medicine; or, (3) the
Secretary otherwise determines that such action is appropriate under
the circumstances. The bill would require that the Secretary suspend
the eligibility of a healthcare provider to provide non-Department care
if that provider is suspended from serving as a healthcare provider of
the Department. The bill also would require that the Secretary review,
within one year of enactment, each non-Department healthcare provider
to identify whether he or she was an employee of the Department to
determine if the provider meets any of the criteria for denial,
revocation, or suspension of eligibility. Finally, the bill would
require the Comptroller General to submit a report to Congress within 2
years of enactment on the implementation of these authorities and its
effects.
VA supports the proposed legislation in principle and would
appreciate the opportunity to work with Congress to develop a proposal
that builds upon similar requirements already in place without creating
the unnecessary administrative burdens we believe the bill would
produce, as these burdens could negatively impact Veterans' access to
quality care. Currently, VA procures most community care using Third
Party Administrators (TPA), under Patient Centered Community Care
(PC3)/Choice contracts, which include the development and maintenance
of an adequate provider network of high quality, credentialed/certified
healthcare providers. VA monitors adherence by performing quality
checks through the use of a Quality Assurance Plan (QASP). As part of
the QASP, VA utilizes a ``three lines of defense'' model to oversee the
credentialing and certification process of network healthcare
providers. These lines of defense involve both VA and the TPA
performing ongoing reviews to ensure the quality of the providers in
the network. Additionally, VA requires the contractor to report to VA,
not more than 15 days after being notified, of the loss of or other
adverse impact to a network provider's certification, credentialing,
privileging, or licensing. Future acquisitions will carry similar
criteria as they pertain to review of provider licensure and
credentialing, as VA remains committed to developing contracts for high
performing networks.
Because of the measures already in place to ensure that VA only
utilizes the highest quality providers in the community, VA is
concerned that the administrative requirements of this legislation as
written would have the potential to adversely impact Veteran access to
community care as well as limit current and future contractors' ability
to timely recruit and retain qualified providers within their networks.
VA also has concerns relating to due process protections under the
bill. To the extent VA relies on any fact that had not been established
through a complete and fair process satisfying the requirements of due
process (e.g., a criminal conviction, or a full investigation and
determination by a State licensing board), the Agency's decision should
be appealable. VA does not have an existing process that could
accommodate such appeals. Affected providers must be given notice and
an opportunity to be heard to contest such determinations or beliefs in
order to satisfy due process requirements, but it is unclear how VA
would provide for this.
VA is unable to provide a cost estimate for this proposal as
currently written because it is unclear what additional administrative
requirements would be needed to ensure appropriate review and
protections are in place.
s. 1261, veterans emergency room relief act of 2017
Section 2(a) of S. 1261 would add a new section 1725A to Title 38.
This new section would require the Secretary to enter into contracts
with urgent care providers under which the Secretary would pay the
reasonable cost of urgent care provided to eligible Veterans. Eligible
Veterans would be defined as Veterans who are enrolled in VA healthcare
and who have received healthcare under chapter 17 during the preceding
two year period. The bill would also require the Secretary to establish
a cost-sharing amount that eligible Veterans would pay to the Secretary
when receiving urgent care under this section. This cost-sharing
measure would not apply to Veterans who are admitted to a hospital
after the provision of urgent care or to Veterans receiving urgent care
for a service-connected disability. VA would be the primary payer for
care provided under this section. Section 2(b) would require the
Secretary to establish a cost-sharing amount that Veterans would pay
for the receipt of care at a VA emergency room, unless the Veteran is
receiving care for a service-connected disability, is admitted to a
hospital for treatment or observation after receiving emergency care,
or meets a hardship exception established by the Secretary for purposes
of this section. Under section 2(c), the Secretary could not require a
Veteran to pay multiple cost-sharing amounts if the Veteran sought
urgent care under section 1725A and at a VA emergency room for the same
condition within a period of time determined by the Secretary. Finally,
section 2(d) of the bill would require VA to submit a report to
Congress within two years of enactment, and not less frequently than
once every two years thereafter, on the use of urgent and emergency
room care by Veterans.
VA supports the intent of this bill, contingent on the provision of
additional resources to support implementation. We would like the
opportunity to work with the Committee on this proposal to ensure
Veterans have access to timely and urgent care.
We estimate the bill as written, with certain limiting assumptions,
would cost $287.3 million in FY 2018, $1.525 billion over 5 years, and
$3.298 billion over 10 years.
s. 1266, enhancing veteran care act
S. 1266 would authorize the Secretary to contract with a nonprofit
organization that accredits healthcare organizations and programs to
investigate a VAMC to assess and report deficiencies of the facility.
The Secretary would be required to delegate this contracting authority
to the Director of the Veterans Integrated Service Network (VISN) in
which the medical center is located or to the VAMC Director. Before
entering into a contract, the VISN Director or VAMC Director would be
required to notify the Secretary, the VA OIG, and the Comptroller
General of the United States to ensure that the investigation conducted
by the contracted entity is coordinated with any investigation
conducted by one of these entities. Nothing in this bill would be
construed to prevent the OIG from conducting any review, audit,
evaluation, or inspection, or to modify the requirement that employees
assist with any review, audit, evaluation, or inspection of the OIG.
VA does not support S. 1266. VA believes that this legislation is
unnecessary and runs counter to long-standing procedures governing
quality of care investigations. Within the VHA, the Office of the
Medical Inspector (OMI) and other offices, including the Office of
Compliance and Business Integrity, the National Center for Ethics in
Healthcare, and the Office of Internal Audit and Risk Assessment, are
integral elements of VHA's oversight and compliance program, with
responsibility for assessing the quality of VA healthcare through site-
specific investigations and system-wide assessments. Through
coordination of all of these resources, VA is able to carry out a wide
range of investigations of whistleblower allegations, patient
complaints, compliance violations, and ethics questions, among other
issues. VA is also equipped to produce comprehensive reports with
actionable recommendations and to follow-up with line managers to
ensure fulfillment of corrective actions. VA has successfully managed
the volume of cases. Furthermore, the OIG has the statutory
responsibility for conducting assessments, reporting deficiencies, and
ensuring corrective actions at VA facilities. Given these existing
functions within VHA and OIG, the bill would mandate an unnecessary
additional function.
VA has demonstrated an ability to manage a large caseload and
provide comprehensive reports. VA has the infrastructure in place to
conduct timely quality-of-care investigations in VA health facilities
and a professional staff with decades of experience in conducting such
reviews. Many of our investigators have worked in VA medical centers
and are intimately familiar with their operations, policies,
procedures, and unique culture. We are concerned that requiring the
organizations that perform accreditations to investigate the same
medical facilities they accredit could result in a potential conflict
of interest. Accrediting organizations do not routinely conduct
investigations of the type envisioned by the bill. VA believes that by
relying on its internal systems and specific experience in these types
of investigations, the intended objective of the bill can be achieved
in the most efficient and Veteran friendly way possible.
We are unable to provide a cost estimate for this bill, as it is
unclear how often and when such investigations would occur, or how much
they would cost.
s. 1325, better workforce for veterans act of 2017
The draft bill, ``Better Workforce for Veterans Act of 2017,''
contains a number of provisions intended to improve the authorities of
the Secretary to hire, recruit, and train employees of the Department.
Section 101(a) would create a new section 718 that would authorize
the Secretary to recruit and appoint qualified recent graduates and
post-secondary students to competitive service positions within the
Department, notwithstanding certain provisions of Title 5. The
Secretary would only be authorized to appoint no more than a number
equal to 15 percent of the number of hires made into professional and
administrative occupations at the GS-11 level or below (or equivalent)
during the previous fiscal year. The Secretary would be required to
develop regulations governing this authority. To the extent
practicable, the Secretary would be required to publicly advertise
positions available under this section within certain constraints.
VA supports the concept of this provision, but also would like to
note that the Administration authored a similar proposal that would be
applicable to all agencies, and transmitted it for consideration in the
FY 2018 National Defense Authorization Act (FY 2018 NDAA). This would
provide greater flexibility to hire students and recent college
graduates, providing an immediate opportunity for new employees to
begin their careers with VA. The Administration would prefer a
Government-wide solution that would provide a significant recruitment
benefit if all agencies were able to utilize it.
Section 101(b) would create a new section 719 that would require
the Secretary to prescribe regulations to allow for excepted service
appointments of certain students and recent graduates leading to
conversion to career or career conditional employment.
VA defers to OPM on implementation of this provision as an
important element to implementing the program authorized by section
101(a) for certain students and interns. OPM would be best suited to
provide any necessary technical drafting assistance to align these
authorities with OPM's current Government-wide Pathways Program.
Section 102 would amend section 3304(a)(3)(B) of Title 5 to permit
the Secretary to appoint directly for positions for which there is a
severe shortage of highly qualified candidates. OPM would have the
authority to determine what positions would qualify, as well as having
the ability to delegate the authority to make those determinations.
VA supports this provision as this would provide greater
flexibility to directly reach applicants when we have a severe shortage
of highly qualified candidates. This would help the Department address
some of its most critical vacancies.
Section 103 would create a new section 712 to authorize the
Secretary to appoint a former Federal employee to a high-demand
position within the Department for which the former Federal employee is
highly qualified without regard to provisions concerning competitive
appointments. The former Federal employee could be appointed to a
position at a higher grade or with more promotion potential than the
position the employee previously held. Within 18 months of enactment,
the Inspector General of the Department would be required to conduct an
audit of the use of this authority by the Secretary and report to
Congress on the results of that audit.
VA defers to OPM on this provision. Currently, we could hire
someone non-competitively to a position at the same level they
previously held, while this provision would allow VA to hire someone to
a higher level than they previously held. Therefore, implementation
would need to be measured, with appropriate controls in place to
prevent misuse.
Section 104 would create a new section 720 to require the Secretary
to develop and implement a resume-based application method for
applications for appointment to senior executive positions within VA.
The application would have to be, to the extent practicable, comparable
to the resume-based application method for the Senior Executive Service
(SES) developed by the Office of Personnel Management (OPM), and would
have to be used for initial applications for a position as a senior
executive to the extent such use will be more efficient and effective
and less burdensome for all participants. The Secretary would be
authorized to make an initial career appointment of an individual to a
position as a senior executive if a review board convened by VA
certifies the executive and managerial qualifications of the
individual.
At this time, VA does not support this provision because we do not
believe it is necessary. Resume-based application is allowed under
current rules, and VA would like to maintain flexibility in hiring and
assessment. VA currently uses a resume-based system for executive
recruitment for its medical center Director positions, and with the
recently enacted Department of Veterans Affairs Accountability and
Whistleblower Protection Act of 2017 (Public Law 115-41), signed
June 23, 2017, VA now has direct hiring authority for these and VISN
Director positions. We continuously evaluate our hiring methods,
timeframes, and outcomes to identify opportunities for improvement, and
we would be happy to share our findings with the Committee.
Section 105 would establish a new section 721 that would require
the Secretary to establish and periodically review a single database
that lists each vacant position in VA that the Secretary determines is
critical to VA's mission, difficult to fill, or both. If the Secretary
determines that an applicant for a position listed in the database is
qualified for such position, but the Secretary does not select such
applicant, the Secretary, at the election of the applicant, would be
required to consider the applicant for other, similar vacant positions
listed in the database. If the Secretary did not fill a vacant position
listed in the database after an appropriate time (as determined by the
Secretary), the Secretary would be required to ensure that applicants
who were not selected for other positions but who meet the
qualification requirements are considered. The Secretary would also be
required to use the database to assist in filling such positions.
Within one year of enactment, the Secretary would be required to submit
a report to Congress on the use and efficacy of the database
established under this section.
We support the concept of identifying and maintaining a database of
vacancies, but do not support this particular provision. VA completed
the implementation of a commercial software product as the core
foundation to our new enterprise automated human resources system. We
will implement an enhancement in FY 2018 to manage positions, which
will provide real-time vacancy information. With the systems we
currently have in place and in development, we believe we can meet the
intent of this provision without legislation, and in a way that is less
administratively burdensome.
Section 106 would create a new section 722 that would require the
Secretary to measure and collect information on indicators of hiring
effectiveness concerning certain identified factors related to
recruiting and hiring candidates, as well as the satisfaction of
employees, newly hired employees, and applicants. To the extent
practicable, and in a manner protecting personally identifiable
information, the Secretary would be required to collect and report data
disaggregated by facility and VISN to ensure the data is collected from
human resources offices throughout VA. The Secretary would be required
to submit an annual report to Congress on the information collected,
and to make such information publicly available.
As written, we do not support this provision. We are concerned the
vagueness of the language could result in application to virtually
every aspect of the recruitment process. The terminology in this
provision includes subjective terms, and we believe some provisions may
be inconsistent internally. In addition, these provisions could be
inconsistent with other agencies' recruitment and hiring information.
We have a number of technical comments and recommendations and would be
glad to share those with the Committee. We also would request that the
Committee solicit OPM for technical drafting assistance on this
provision.
Section 107 would create a new section 723 requiring the Secretary
to develop and carry out a standardized, anonymous, voluntary exit
survey for career and non-career employees who voluntarily separate
from VA. The survey would have to ask questions regarding the reasons
for leaving, any efforts made to retain the individual, the extent of
job satisfaction and engagement, the intent of the employee to remain
in or leave Federal employment, and other matters considered
appropriate by the Secretary. The Secretary would be required to share
the results of the survey with the directors and managers VA facilities
and VISNs, and the Secretary would be required to report annually on
the aggregate results of the exit survey.
We do not support this provision because we believe it is
unnecessary, given that we already use exit surveys that capture almost
all of the content this legislation would require.
Section 108 would amend section 2108(1) of Title 5 concerning
Veteran preference so that any Veteran who served a total of more than
180 days would qualify, rather than only those who served more than 180
consecutive days.
We note that this provision would amend title 5 and apply to the
entire Federal Government. As a result, we defer to OPM on this
provision.
Section 109 would amend section 705(a) of the Veterans Access,
Choice, and Accountability Act of 2014 to clarify that recruitment,
relocation, or retention incentives are not subject to the limitations
on awards and bonuses available in the Department.
VA supports this provision. Currently, the limitations on awards
and bonuses include recruitment, retention, and relocation incentives,
which have severely limited the Department's ability to offer
incentives to hire and retain critical positions. Under these
limitations, the Department has attempted to reserve the bulk of the
funds that are available to provide incentives to positions,
particularly medical professionals with specialized skills and
expertise that would be difficult or impossible to replace. This has
resulted in an inequitable treatment among employees, as there are
fewer resources available for those otherwise deserving and equally
dedicated employees.
If this authority were enacted, VA would reallocate funds already
appropriated for recruitment and retention of highly qualified
employees.
Section 110 would amend section 7309 of Title 38 to remove the
requirements that the Chief Officer of VA's Readjustment Counseling
Service (RCS) must have at least 3 years of experience providing direct
counseling services or outreach services through RCS, as well as 3
years of experience administrating direct counseling services or
outreach services through RCS.
VA supports this provision. This would provide greater flexibility
to appoint the Chief Officer of RCS, which oversees VA's Vet Centers, a
critical component to providing Veterans and Servicemembers
readjustment counseling and other services.
There would be no costs associated with this provision.
Section 111 would require, within 120 days of the date of the
enactment of this Act, the Secretary to submit a report to Congress on
vacancies within the Veterans Health Administration. This report would
have to include vacancies of personnel appointed under section 7401 of
title 38, vacancies of human resource specialists in VHA, a description
of any impediments to filling certain vacancies, and an update on the
implementation of several plans and reports.
We do not believe section 111 is necessary, but we do not oppose
this requirement. Until the system enhancement previously mentioned is
implemented in FY 2018, collecting this information is a manual and
intensive effort. As a result, we are concerned that the 120 day
deadline would be difficult to meet. We believe that we would be in a
better position to gather this information within the next year.
Section 201 would create a new section 724 providing that for any
reduction in force by VA, competing employees would be released with
due effect to the following in order of priority: tenure of employment,
military preference, efficiency or performance ratings, and length of
service.
We do not oppose section 201 because this would only change the
order of consideration for how reductions in force would occur.
However, we would defer to OPM, to ensure that reduction in force
procedures remain consistent across the Government. We note that for
hybrid title 38 positions, we think it would be appropriate to also
consider the level and type of licensure, as well as the scope of
practice, in making such determinations.
Section 202 would create a new section 725 authorizing the
Secretary to arrange, with the agreement of a private-sector
organization, for the temporary assignment of VA employees to such
organization to occupy a position in that organization and for the
private sector employee who held that position to temporarily occupy
the position of the VA employee. In essence, these employees would be
trading positions for a temporary period. The VA employee would return
to work for the Department, and if either employee failed to carry out
the agreement, the employee would be liable to the United States for
payment of all expenses of the assignment, with certain exceptions;
such liability would be a debt that could be waived if the Secretary
determined collecting it would be against equity and good conscience
and not in the best interests of the United States. The VA employee
would be prohibited from using pre-decisional, draft deliberative, or
other information for the benefit or advantage of the private sector
organization. Assignments would be for periods between 3 months and 4
years. VA employees assigned to the private sector organization would
be considered, during the period of assignment to be on detail to a
regular work assignment in the Department for all purposes. The private
sector employee assigned to VA employment would generally not be
considered a Federal employee with certain exceptions and would have
other constraints imposed upon the scope of that employee's work with
the Department. The private sector organization would be prohibited
from charging VA, as direct or indirect costs under a Federal contract,
for the pay or benefits paid by the organization to the employee
assigned to VA. The Secretary would be required to take into account
certain considerations in operating this program.
In theory, VA supports the concept of rotational assignments for
professional development, and notes that the Administration submitted,
in the context of the FY 2018 NDAA, a similar proposal to provide
governmentwide authority for industry exchange programs. We note,
however, that the potential for conflicts of interest in this provision
are significant, notwithstanding the language in the bill attempting to
limit this. There are several areas where this provision is ambiguous,
and we would appreciate the opportunity to discuss this further with
the Committee prior to taking a position on this section. We would
recommend that the Committee work with the Office of Government Ethics
on the appropriate language to address issues related to conflicts of
interest.
Section 203 would amend section 7306 to allow for the appointment
of VISN Directors in addition to medical center Directors to suit the
needs of the Department. It would also remove the requirement for these
Directors to be qualified doctors of medicine, or doctors or dental
surgery or dental medicine. It would further amend that section to
allow the Secretary to establish qualifications for these Directors and
appoint them under this authority. The Secretary and the Director would
be required to enter into an agreement that permits employees appointed
under this authority to transfer to SES positions in other Federal
agencies and to be deemed career appointees who are not subject to
competition or certification by a qualifications review board.
Section 207 of the Department of Veterans Affairs Accountability
and Whistleblower Protection Act of 2017 (Public Law 115-41), signed
June 23, 2017, significantly amended VA's authority to hire directly
VISN and medical center Directors. In this context, we would like the
opportunity to discuss this proposal further with OPM and the Committee
to consider the effects of these proposed changes before taking a
position on this section.
Section 204 would create a new subchapter VII in chapter 74
concerning pay for medical center Directors and VISN Directors. The new
section 7481 would provide that pay for these Directors would consist
of basic pay and market pay, which would be determined by the Secretary
on a case-by-case basis and consist of pay intended to reflect the
needs of the Department with respect to recruitment and retention of
such Directors. The bill would impose other requirements in terms of
determining market pay under this section. The Secretary would be
required, not less frequently than once every 2 years, to set forth
within defined parameters Department-wide minimum and maximum amounts
for total pay for Directors, and to publish such limits in the Federal
Register. Pay under this section would be considered pay for all
purposes, including retirement benefits. A decrease in the pay of a
Director resulting from an adjustment in market pay could not be
considered an adverse action, while a decrease resulting from an
involuntary reassignment in connection with a disciplinary action would
not be subject to appeal or judicial review. The OPM Director would be
required to undertake periodic reviews of the Secretary's
determinations and certify to Congress each year whether or not the
market pay is in accordance with the requirements of this section. If
the Director determined the amounts were not in accordance with the
requirements of this section, the Director would report to Congress on
such determination as soon as practicable after making such
determination.
We appreciate the Committee's interest in this regard. Similar to
section 203, we note that given the recent change (Public Law 115-41)
in our appointment authority for VISN and medical center Directors, we
would like to discuss this proposal further with OPM and the Committee
prior to taking a position on the specific provisions in this section.
We anticipate there would be additional costs to implement this
section.
Section 205 would create a new section 7413 that would require the
Secretary to provide to VHA human resources professionals training on
how best to recruit and retain VHA employees. The Secretary would
provide such training in a manner considered appropriate considering
budget, travel, and other constraints. The Secretary would be required
to ensure that each VHA human resources professional received such
training as soon as practicable after being hired and annually
thereafter. The Secretary would be required to ensure that a medical
center Director, VISN Director, or senior officer at Central Office
certified that the professional completed such training. The Secretary
would be required to report annually on the training provided under
this authority, including the cost of such training, and the number of
professionals who receive such training.
We do not support section 205 because VA already has the authority
to conduct such training. VA provides training to human resources
professionals currently, and we are concerned that the specific
requirements in this provision could constrain our ability to adapt
training to emerging needs. We also have some technical concerns with
this provision that we will share with the Committee.
Section 206 would require the Secretary to include education and
training of marriage and family therapists and licensed professional
mental health counselors in carrying out the education and training
programs conducted under section 7302(a)(1). The Secretary would be
required, to the degree practicable, to ensure that the licensing and
credentialing standards for therapists and counselors participating in
this program are the same as the licensing and credentialing standards
for eligibility of other participants in the program. Finally, the
Secretary would be required to apportion funding for education and
training equally among the professions included in the program.
In general, we currently have the authority to carry out this
section. VA has already established training programs for licensed
professional mental health counselors and marriage and family
therapists. We are concerned with the potential effect this could have
on the quality of the education and training standards, and we would
appreciate the opportunity to discuss this further with the Committee.
We are also concerned that the language, particularly in subsection (c)
of this provision, is too prescriptive and could limit VA's flexibility
to adjust training needs and resources to meet operational needs.
Section 207 would require, within 180 days of the date of enactment
of this Act, the Secretary and the Surgeon General to enter into a
memorandum of understanding (MOU) for the assignment of not fewer than
500 commissioned officers of the Regular Corps of the Public Health
Service to VA. The Secretary would reimburse the Surgeon General for
expenses incurred in assigning commissioned officers to VA. Within 1
year of enactment, the Secretary and Surgeon General would each be
required to submit to Congress a report on the MOU and the commissioned
officers assigned under this authority.
We do not support this provision because it is unnecessary. VA and
the Department of Health and Human Services (HHS) signed an MOU earlier
this year to allow for commissioned officers of the Public Health
Service to serve in VA. We would like the opportunity to discuss this
further with the Committee and HHS to determine what, if any,
legislative authority we need in this area.
Section 208(a) and (b) would require, within 1 year of the date of
enactment of this Act, the Under Secretary for Health to develop a
comprehensive competency assessment tool for VHA human resources
employees to assess the knowledge of such employees on how employees
appointed under section 7401(1) are treated differently than employees
appointed under other authorities. Within 2 years of the date of
enactment of this Act, and once every 2 years thereafter, the Secretary
would have to submit a certification to Congress as to whether an
assessment of all VHA human resources employees was conducted and
whether such employees used the results of such assessment to identify
and address competency gaps. Within 18 months of the date of enactment
of this Act, the Under Secretary for Health would be required to
evaluate the extent to which these training strategies are effective at
improving the skills and competencies of VHA human resources employees.
Section 208(c) would require, within 1 year of enactment, the Under
Secretary for Health to establish clear lines of authority that provide
the Assistant Deputy Under Secretary for Health for Workforce Services
the ability to oversee and hold the heads of the human resources
offices of VA medical centers accountable for implementing initiatives
to improve human resources processes and for ensuring employees
undertake the assessment required under subsection (a). Within 1 year
of enactment of this Act, the Secretary would be required to clarify
the lines of authority and processes for the Under Secretary for Health
and the Assistant Secretary for Human Resources and Administration with
respect to overseeing holding the VISN and VA medical center Directors
accountable for the consistent application of Federal classification
policies.
Section 208(d) would require the Secretary to ensure the Under
Secretary for Health and the Assistant Secretary for Human Resources
and Administration are responsible for monitoring the status of
corrective actions taken at human resources offices of VA medical
centers and that such actions are implemented.
Section 208(e) would require the Secretary to ensure that
meaningful distinctions are made in performance ratings for VHA
employees.
Section 208(f) would require, within 1 year of enactment of this
Act, the Under Secretary for Health and the Assistant Secretary for
Human Resources and Administration to develop a plan to implement a
modern information technology (IT) system to support employee
performance management processes.
Section 208(g) would require, within 1 year of enactment of this
Act, the Under Secretary for Health to establish clear lines of
authority and accountability for developing, implementing, and
monitoring strategies for improving employee engagement across VHA. The
Under Secretary for Health would be required to report to Congress on
whether VHA should establish an employee engagement office at the
headquarters level with appropriate oversight of VISN and VA medical
center employee engagement initiatives.
We do not believe this section is necessary. We are currently
implementing the requirements of these provisions based on the
recommendation of a Government Accountability Office (GAO) report (GAO
17-30). We also have some technical concerns we believe need to be
addressed, and we will be glad to provide those to the Committee.
Section 208(h) would require, within 1 year of enactment, the
Comptroller General to examine the overlapping functions of human
resource structures within VHA and the Office of the Assistant
Secretary of Human Resources, whether there are opportunities to
centralize offices and tasks that are duplicative, and whether the use
of multiple hiring structures has had an effect on the speed with which
VA hires new employees. The Comptroller General would report to
Congress on the Comptroller General's findings.
VA defers to the Comptroller General on this provision.
Section 209 would require, within 120 days of enactment of this
Act, the Secretary to report to Congress on the effect the freeze on
the hiring of Federal civilian employees ordered by the President on
January 23, 2017, has had on the ability of VA to provide care and
services to Veterans.
We do not believe this is necessary, and do not support it, as the
hiring freeze was only in effect, at most, for a limited number of
positions not related to patient care or access. We also do not believe
it would be possible to identify to any meaningful degree any effects
that may have occurred as a result of the hiring freeze.
Section 210 would require, within 180 days of enactment of this
Act, the Secretary to report to Congress on how the Secretary plans to
implement the portions of the plan of the OPM Director to reduce the
size of the Federal workforce through attrition as it pertains to VA.
We believe this provision is unnecessary. VA is working to
implement an agency reform plan, consistent with the OMB Director's
requirements. We are looking at how we will be filling administrative
positions that become vacant, along with other potential actions, and
will be updating these plans and assessments in the future. We would be
happy to share with the Committee the plan the Department submits to
OMB when it is available.
Section 211 would require, within 180 days of enactment of this
Act, the Secretary to publish online information on staffing levels for
nurses at each VA medical facility. The head of each medical facility
would be required to update the information as changes to the staffing
level of nurses at the facility occur. The Secretary would be required
to consult with Centers for Medicare & Medicaid Services in developing
the information required by this section. The Secretary would be
required to submit a report to Congress discussing and assessing the
use by medical center Directors of authorities to provide nurses pay
that reflects market conditions, the adequacy of training resources for
nurse recruiters, the key recruitment and retention incentives of VHA
for nurses, and other factors.
We do not support this provision for two major reasons. First, the
staffing levels referenced in the bill are not defined. Second, the
actual number of nurses varies on an almost daily basis given the
volatility in terms of staffing. It would be incredibly cumbersome to
maintain this information and update it in real time. We already report
to Congress each year on efforts to provide nurses greater pay, and
this report would be duplicative of that effort.
Section 212 would require, within 1 year of enactment of this Act,
the Secretary, in consultation with the OPM Director, to ensure that
the job description, position classification, and grade for each
position as a police officer or firefighter in VA are in accordance
with standards for the classification of such positions prepared by
OPM. The Secretary would be required to develop a staffing model for
the positions of police officers and firefighters within the
Department. The VA Inspector General would be required to conduct an
audit of VA's efforts to recruit and retain police officers and
firefighters and report to the Secretary and Congress on the audit's
findings. Finally, the Secretary would be required to report to
Congress on the use by medical center Directors of special pay
incentives to recruit and retain trained and qualified police officers
and the steps the Secretary plans to take to address the critical
shortage of police officers throughout the Department.
We have some concerns with this provision. We believe the reviews
required by this section could require a considerable amount of
resources. We would like the opportunity to discuss this proposal
further with the Committee and OPM to determine what we may be able to
do currently to address the Committee's concerns and interests in this
matter.
Section 213 would require, within 1 year of enactment of this Act,
the VA Inspector General to complete a study on how VHA communicates
its directives, policies, and handbooks to the field, including the
compliance with such documents, and the effectiveness of each VISN in
disseminating information to employees within the Network and Veterans
served by the Network.
The Department defers to the Inspector General on this provision.
As noted above, VA will be providing follow-up views for the record
on S. 1279, the Veterans Health Administration Reform Act, the draft
Department of Veterans Affairs Quality Employment Act of 2017, and
section 10 of the Veterans Choice Act of 2017.
s. xxxx, veterans choice act of 2017
The draft Veterans Choice Act of 2017 contains a number of
provisions intended to improve VA's community care program. Community
care has helped significantly expand access to care for Veterans
nationally and plays an important role in VA's effort to build a
modern, integrated healthcare network.
Section 3(a) of the bill would amend section 1703 of title 38 to
authorize the Veterans Choice Program. Under this Program, all enrolled
Veterans would be eligible to elect to receive hospital care, medical
services, mental health services, and certain diagnostic services,
outpatient dental services, and diagnostic services from specified
eligible providers. These services could be provided through
telemedicine, at the election of the Veteran. The Secretary would be
required to enter into consolidated, competitively bid regional
contacts with healthcare organizations or third party administrators to
establish networks of eligible providers for the purpose of providing
sufficient access to care and services. The bill would define various
responsibilities for these organizations or administrators, including
enrolling covered Veterans, conducting referrals and authorizations,
customer service, and maintaining an interoperable electronic health
record. These parties would be required to leverage advanced technology
to allow Veterans to make their own appointments, including online and
through smart phone applications. Veterans who need assistance making
their appointments could receive assistance from the organization or
administrator or the Secretary. The organizations or administrators
would be required to meet capability, capacity, and access standards
established by the Secretary, including those established pursuant to
sections 9 and 10 of this bill. Providers who currently furnish care or
services under another authority would be offered the opportunity to
furnish care and services through this Program.
Under the Veterans Choice Program, the rates paid for care or
services could not exceed the Medicare rate, except in highly rural
areas, in the State of Alaska, in a State with an All-Payer Model
Agreement that became effective on January 1, 2014, or at other rates
established by the Secretary if no Medicare rate exists. The Secretary
would be authorized to recover from a third party for any care
furnished for a non-service-connected disability, and the Secretary
would be responsible for paying the copayment, deductible, or
coinsurance charged to the Veteran for care or services. Veterans could
not be required to pay a greater amount for receiving care or services
than they would if they had received comparable care or services at a
VA medical facility or from a VA medical provider.
The proposed amendments to section 1703 would impose other
requirements. For example, VA would have to ensure the Veterans Health
Identification Card issued to every enrolled Veteran includes the words
``Choice eligible'' and additional information needed to serve as an
identification card for the Program. Additionally, the Secretary would
be required to monitor a number of quality and access standards related
to the care furnished under this Program. These changes would become
effective upon the termination of the current Veterans Choice Program
operated pursuant to section 101 of the Veterans Access, Choice, and
Accountability Act of 2014.
We support many of the principles in the proposed section 1703. We
appreciate that the section's eligibility criteria would be simple to
administer by making every enrolled Veteran eligible to participate. We
also appreciate the flexibility in terms of eligible providers, and the
regional network model generally matches our current plans with the
Community Care Network solicitation. We also appreciate the section's
recognition of the importance of ensuring quality care is furnished to
Veterans through this Program.
However, we have some significant concerns with certain provisions
of proposed section 1703. In many areas, there are provisions that are
overly prescriptive and that would narrow the Secretary's authority to
adjust to evolving situations. For example, the Secretary would be
prohibited from directing Veterans to certain health care providers.
While we support Veterans' choosing their own providers, we understand
that many Veterans do not express a specific preference for an
individual provider, and this language could restrict our ability to
direct Veterans to high-performing providers who are available. Also,
the responsibilities of the regional networks are too specific--we
would prefer the language be silent on these matters so that we can
adjust responsibilities between VA and our regional networks to ensure
the best services are available for Veterans. Furthermore, the language
concerning payment rates is too limiting. There will be situations
where VA will need to pay more than the Medicare rate other than in
highly rural areas, the State of Alaska, and States with All-Payer
Model Agreements. We have serious concerns with the language in
proposed 1703(h), which would require the Secretary to pay the amount
of a Veteran's copayment, deductible, or coinsurance. This would be
inconsistent with private sector and VA's current practice. Section
1729 currently provides that Veterans are not required to pay a
copayment, deductible, or coinsurance required under the terms of their
health insurance for care and services furnished by the Department.
Moreover, requiring the Department to pay a Veteran's copayment,
deductible, or coinsurance could significantly increase the
Department's expenses, including its administrative costs, in ways that
we cannot currently project given the variability in insurance plans
and payment responsibilities for the millions of Veterans with such
insurance. While we support the principle of ensuring quality care, we
are concerned that some of the language in proposed 1703(l) would be
too prescriptive, and we would prefer more general language.
Requiring that the words ``Choice eligible'' appear on a Veterans
Health Identification Card (VHIC), as provided for in proposed section
1703(k), would create redundancy and be extremely costly. The bill
would make any enrolled Veteran eligible for Choice, and all enrolled
Veterans are issued VHICs, so any person with a VHIC would already
establish his or her eligibility by virtue of having the VHIC.
Requiring Veterans to have a VHIC with the words ``Choice eligible''
would also produce greater demands on Veterans who would have to come
to a VA facility to receive an updated version of their VHIC.
Finally, we are concerned that there is no transition period
contemplated by section 3(a)(3). The new 1703 would take effect
immediately upon the expiration of the current Veterans Choice Program,
based on the exhaustion of the Veterans Choice Fund. We believe that
either a clear timeline (such as one year from enactment) or an event
within the Department's control (such as the publication of
regulations) would be preferable for the transition between the current
Choice Program and the future Choice Program. We also may encounter
problems where individual authorizations made under the current 1703
would no longer have any legal authority for payment upon this
transition, as this provision would completely rewrite section 1703.
While the Department would try to reduce the potential for this issue,
we would not be able to eliminate this problem.
Section 3(b) would prohibit VA from entering into or renewing any
contract or agreement under a non-Department provider program, which
would include the current Veterans Choice Program; the Patient-Centered
Community Care (PC3) program; the Project Access Received Closer to
Home (ARCH) program; VA's retail pharmacy network; agreements entered
into with DOD, IHS, or other Federal agencies; agreements entered into
with academic affiliates of VA; agreements to furnish care, including
on a fee basis; or agreements with non-governmental entities. If the
Secretary continued to administer any of these programs after the date
on which the new Veterans Choice Program begins, they could only be
administered under that Program. The Secretary would be required to
ensure continuity of care by making services available through regional
contracts or other agreements entered into under the new Veterans
Choice Program.
We are very concerned with this provision and do not support it. It
would require VA to renegotiate, reissue, or terminate every agreement
and contract, regardless of the terms or conditions of such an
agreement permitting extensions or other flexible authorities. We
believe this could affect such agreements as those with DOD, IHS, and
tribal health programs, as well as with our academic affiliates and
contractors. This would include thousands of agreements, would be very
difficult and costly to do, and would not produce any clear, tangible
benefit. If these agreements would also now be subject to the
limitations in proposed section 1703, this provision could put
conditions on these agreements that would be unacceptable to certain
providers or in certain areas. This could also potentially impact our
relationships with certain providers, such as IHS and tribal health
programs, which require consultation prior to changes. We also note,
given the breadth of section 3(b)(4)(E), that extended care services
procured from the community would be included, but note that the
language for the Veterans Choice Program in section 1703 does not
address such services; as a result, it is unclear what terms and
conditions would apply to these services.
Section 4 would establish a new section 1703A authorizing VA to
enter into Veterans Care Agreements (VCA). VCAs could be entered into
when the Secretary is not feasibly able to furnish hospital care,
medical services, or extended care services at VA facilities or when
such care or services are not available under the Veterans Choice
Program. Providers could opt to enter into a VCA, at the discretion of
the eligible provider. The eligibility of Veterans for care would be
the same as if they received care in a VA facility. The Secretary would
be prohibited from directing Veterans seeking care or services to
healthcare providers who have entered into contracts or sharing
agreements under different authorities, except for Veterans Choice
Agreements authorized under section 101 of the Veterans Access, Choice,
and Accountability Act of 2014 or under the regional contracts or other
arrangements made under section 1703, as revised by section 3 of this
bill.
The Secretary would be required to establish a process for the
certification of eligible providers. VCAs would have to include certain
terms, including accepting payment at Medicare rates (except in highly
rural or underserved areas), accepting payment as payment in full, and
other terms and conditions. Each VCA would permit the provider to
submit to the Secretary clinical justification for any services
furnished without authorization when seeking payment, and the Secretary
would review these submissions on a case-by-case basis in determining
whether or to pay the provider for such services. The Secretary would
be required to review periodically VCAs of a material size to determine
whether it is feasible and advisable to furnish the care and services
at a VA facility or through contracts or sharing agreements. VCAs would
not be subject to laws requiring competitive procedures in selecting
the party with which to enter the agreement. Parties entering into a
VCA would not be treated as a Federal contractor by the Office of
Federal Contract Compliance Programs (OFCCP) of the Department of
Labor, and they would not be subject to any laws that such a provider
would not be subject to under the original Medicare fee-for-service
program under Parts A and B of title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.), except for laws applying to integrity,
ethics, fraud, or that subject a person to civil or criminal penalties.
Title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000c et seq.)
would apply to parties entering into a VCA. The Secretary would be
required to establish a system or systems, consistent with those used
by the Centers for Medicare and Medicaid Services, to monitor the
quality of care provided and would be required to establish
administrative procedures for dispute resolution. The Secretary would
be required to prescribe an interim final rule within 1 year of
enactment to carry out this section.
We generally support this provision, but have some concerns we
would like to address. In particular, proposed section
1703A(a)(2)(A)(ii) would prohibit the Secretary from entering into a
VCA if care or services are available under the new Veterans Choice
Program. Although we appreciate the intent of this provision, we
believe there may be situations where the clinical need of the Veteran
will require the use of a VCA notwithstanding the availability of such
services under the Choice Program. For example, a Veteran may require a
certain type of orthopedic procedure, and while orthopedics in general
are ``available'' under a contract, the specific procedure or a
specialist may not be included within the contract, or would only be
available at a lesser quality. In other situations, a Veteran may elect
to receive care from a certain provider that would be ideally suited to
furnishing the care required, but who is not a member of the network.
We want to ensure we have flexibility in situations like these to
deliver the care the Veteran requires in a timely and appropriate way.
We also note these provisions apply for when the Secretary may ``enter
into'' agreements, rather than ``use'' agreements. We have found,
through our experience with the current Veterans Choice Program that it
is more efficient to enter into these agreements before they are needed
to ensure that there is no delay in the receipt of care by eligible
Veterans. We believe the language could be modified slightly to impose
restrictions on the utilization of VCAs to ensure the integrity and use
of the network of providers under the new Veterans Choice Program.
Proposed section 1703A(e)(2) is unclear, and depending upon what
the intent is, we may or may not support it. If the provision is
intended to simply allow providers to submit claims for care that was
unconnected or unrelated to the services VA originally authorized, we
are concerned this could create situations where VA pays for services
that were neither authorized nor clinically needed. This would create a
significant administrative burden on both the providers and VA. If, on
the other hand, this is intended to apply only in limited circumstances
for care that VA would have authorized, then we have no objection to
it.
Regarding proposed section 1703A(g), VA agrees with the idea of
monitoring how VCAs are utilized by VA. However, we are concerned that
the threshold for when an agreement for the purchase of extended care
services is considered to be of ``material size,'' i.e., exceeding
``$1,000,000 annually,'' is too low. Costs for long term extended care
and nursing home care costs can easily exceed this level. The threshold
also does not account for providers who may have a national presence.
Section 5(a) would establish a new section 1703B concerning payment
of non-Department healthcare providers. Specifically, VA would be
required to comply with the provisions in this section and in chapter
39 of title 31 (the Prompt Payment Act). Non-Department providers would
be required to submit a claim for reimbursement within 180 days, and
the Secretary would have to pay claims according to specified time
standards or else interest would accrue on the amount owed. If a
provider submits a clean claim, VA would have to pay the claim within
30 days if it was submitted electronically or 45 days if it was
submitted other than electronically. If a claim were not clean, the
Secretary would have to inform the provider within 10 days on the steps
that would be needed to make it clean. By January 1, 2020, the
Secretary would only be authorized to accept claims electronically
except in certain circumstances.
We generally support section 5(a), but have some concerns with a
few of the provisions. For example, we think there should be more
flexibility to accept paper claims from smaller providers, such as
Homemaker/Home Health Aides. We are also concerned that, as written,
this language could require that late payments of providers who have
entered into contracts with the Regional Networks could subject VA to
interest payments, even though VA has no privity of contract with these
providers and is paying the Network on time. Finally, we do not believe
the Committee had transactions between VA and other Federal entities in
mind when it included a prompt payment standard in the draft bill. An
exception could be added in this section to address this issue.
Section 5(b) would require the Secretary, not later than 2 years
after the date of the enactment of this Act, to enter into an agreement
with a third-party entity to process claims for reimbursement through
an electronic interface.
We are concerned about the intended scope of this provision. If the
electronic interface processing the claims is only preparing them for
adjudication and approval by VA, we do not support this provision
because VA is currently working on a process internally that would
perform this function. If the term ``process'' is intended to cover
adjudication and payment as well, we would like to discuss with the
Committee our reservations about such an arrangement and propose
potential alternatives instead.
Section 6 would amend section 1745 to authorize the Secretary to
enter into agreements with State Veterans Homes that would not be
subject to laws requiring competitive procedures in selecting the party
with which to enter the agreement. State Homes entering into these
agreements would not be subject to any laws that such a provider would
not be subject to under the original Medicare fee-for-service program
under Parts A and B of title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.), except for laws applying to integrity, ethics,
fraud, or that subject a person to civil or criminal penalties. Title
VII of the Civil Rights Act of 1964 (42 U.S.C. 2000c et seq.) would
apply to State homes entering into these agreements. These changes
would become effective upon the Secretary's publishing regulations to
implement these new authorities.
We generally support section 6, although, we have similar concerns
to those we expressed regarding section 4 with respect to the
applicability of certain laws.
Section 7 would amend section 1705 to require the Secretary, upon
the enrollment of a Veteran in the VA healthcare system, to assign the
Veteran to a dedicated primary care provider of the Department, unless
the Veteran elects to choose a primary care provider from among the
healthcare providers furnishing care in the network established under
the new Veterans Choice Program.
We do not support section 7 because this would require all enrolled
Veterans to be enrolled in provider panels, even if we do not furnish
care to those Veterans. We typically only assign Veterans to a panel
once they have expressed interest in receiving care from the
Department. We are concerned that assigning other Veterans to panels
will complicate our projection models for demand and our estimates for
resources for our facilities. We are also concerned that the ability of
a Veteran to elect to choose a primary care provider from among VA's
network of community providers could allow for the control and
coordination of care, including the authorization of care (and the
obligation of Federal funds), to move to a non-Federal agent, which
presents issues concerning the proper use of appropriated funds.
Section 8 would require the Secretary to enter into national
contracts with private healthcare providers to make dialysis treatments
available in the community. Veterans would be able to choose the
provider from which they would receive dialysis services. Under
subsection (c), the Secretary could not pay more than the Medicare rate
for the same dialysis services or treatment.
While we support the intent of this proposal, we are concerned that
this could potentially limit the Department's ability to furnish
dialysis care. This provision would limit VA to paying the Medicare
rate; we currently pay more than the Medicare rate in certain
circumstances, and it is unclear if we could enter into contracts for
the same care at a reduced rate. If we were unable to enter into these
contracts, VA would not be able to provide this essential clinical
service.
Section 9 would require VA to establish a demand profile with
respect to each health service furnished under the laws administered by
the Secretary. The demand profile would have to include various
factors, such as the number of requests for services, the number of
appointments (both in VA and the community), the capacity of the
Department to provide such services, and an assessment of the need for
community care for the service. The Secretary would use these profiles
to inform the capability and capacity of the provider networks
established in the new Veterans Choice Program. Within 120 days of the
date of enactment of this Act, the Secretary would be required to
submit to Congress a strategic plan with a 5 year forecast on the
demand for care and the Department's capacity and capability to satisfy
that demand within its facilities. The Secretary would have to update
the strategic plan annually.
VA agrees in concept with the provisions in section 9; however, we
believe this provision is not necessary as VA has currently embarked
upon a national market-by-market assessment effort that will produce
the same level of information called for in the bill. VA's market-by-
market assessment is in response to a requirement in section 240 of
Division A of Public Law 114-223, the ``Military Construction, Veterans
Affairs, and Related Agencies Appropriations Act, 2017.'' That law
requires VA to develop a national realignment strategy. As a result,
the assessment of VA's 98 marketplaces across the United States is
currently underway.
Section 10 would require the Secretary to establish uniform access
standards for furnishing healthcare services, including through
community providers, for urgent care, routine care, referral or
specialty care, and wellness or preventive care. These access standards
would have to include the average time a Veteran is expected to wait to
receive an appointment, the average time a Veteran is expected to drive
to arrive at an appointment, the average time a Veteran is expected to
wait at a facility to receive healthcare services, and such other
factors as the Secretary considers appropriate. The Secretary would be
required to coordinate with DOD, the Department of Health and Human
Services (HHS), private entities, and other non-governmental entities
in establishing these standards. The Secretary would be required to
submit a report to Congress within 120 days of the date of the
enactment of this Act detailing the standards established under this
section.
We do not have views on section 10 at this time.
Section 11 would require the Secretary, within 1 year of enactment,
to procure a commercial, off-the-shelf electronic health record
platform that conforms to the standards of interoperability required
under section 713 of the National Defense Authorization Act for Fiscal
Year 2014. The bill would define a number of requirements for this
system, including its interoperability with DOD's systems and private
sector systems and compliance with national standards identified by the
VA and the DOD Interagency Program Office in collaboration with HHS'
Office of the National Coordinator for Health Information Technology.
VA does not believe section 11 is necessary because the Secretary
has already announced his intention to procure a commercial system for
VA's Electronic Health Record capability. Similar to our concern with
other provisions, we note that the specificity in this provision could
limit the Secretary's ability to ensure this new system is responsive
to Veterans' needs.
Finally, section 12 would make various conforming amendments to
reflect the changes made by section 3 of this bill by updating
references in other statutes to VA's community care authorities.
We support section 12 as a measure to consolidate VA's community
care programs.
We are unable to provide cost estimates on the bill at this time
but will follow up after the hearing with any estimates we can develop
and our thoughts on the potential budget implications. We will also
provide technical comments for your consideration.
s. xxxx, improving veterans access to community care act of 2017
The draft Improving Veterans Access to Community Care Act of 2017
also contains a number of provisions intended to improve VA's community
care program.
Section 101(a)(1) would create a new section 1703A, establishing
the Veterans Community Care Program. Many of the terms and conditions
governing this Program would be similar to those applicable to the
existing Veterans Choice Program. Under this new Program, hospital care
and medical services would be furnished to eligible Veterans at the
election of the Veteran through contracts or agreements with eligible
providers. The Secretary would be responsible for coordinating care and
services, including ensuring that an eligible Veteran receives an
appointment for care and services within the wait-time goals of the
Veterans Health Administration (VHA). To be eligible under the Program,
Veterans would have to be enrolled in VA healthcare and meet one of the
following criteria: reside in a location, other than Guam, American
Samoa, or the Republic of the Philippines that requires the Veteran to
travel by air, boat or ferry to reach a VA medical facility; be
enrolled in Project ARCH; the Veteran and the Veteran's VA provider
determine the Veteran should be eligible based upon the eligibility
criteria in the current Veterans Choice Program, namely being unable to
schedule an appointment within the clinically indicated timeframe,
residing more than 40 miles driving distance from the nearest VA
medical facility with a full-time primary care physician, residing
within a State without a full-service VA medical center, or facing an
unusual or excessive burden in accessing services from a VA medical
facility. The Veteran and provider could also determine whether the
Veteran should be eligible under the Program based upon a compelling
reason that the Veteran needs to receive care and services from a non-
Department facility. The Secretary would be required to establish a
process to review any disagreement between Veterans and their
providers, and the Secretary would make the final determination as to
the eligibility of the Veteran.
While we appreciate the intent of the eligibility criteria for
Veterans, we are concerned with how this program is structured. We
fully agree that the provider-patient relationship should be the basis
for eligibility to receive community care. However, the draft bill
would combine this approach with the current administrative eligibility
criteria in the Choice Program. We believe this would result in an
ultimately confusing ``hybrid'' standard that would be difficult for
providers to apply. In addition, we believe continuing to use
administrative criteria would be inappropriate, as they are arbitrary
in nature and not informed by the patient-provider relationship. The
proposed approach would also be unduly limiting in terms of the types
of clinical factors that a provider could consider; for example, a
Veteran who lived across the street from a full-service VA medical
center with no wait times and who was fully ambulatory would not appear
to qualify under any of these provisions, and yet the Veteran may
require a certain type of service that would be best delivered by a
community provider. We would like to work with the Committee to better
understand the underlying issue that proposed subsection (b)(2),
concerning the review of provider determinations, is intended to
address.
Under section 1703A, providers would have to meet the same
eligibility criteria in the current Veterans Choice Program to
participate in the new Program, including maintaining the same or
similar credentials and licenses as VA providers. The Secretary would
be authorized to create a tiered provider network, but would not be
able to prioritize providers in a tier over providers in any other tier
in a manner that limits the choice of an eligible Veteran to select
that provider. The Secretary would be required to enter into contracts
with eligible providers for furnishing care and services, but before
entering into such a contract, the Secretary would be required, to the
maximum extent practicable and consistent with the requirements of this
section, to furnish care and services with eligible providers pursuant
to sharing agreements, existing contracts, or other processes available
for procuring care. In this section, the term ``contract'' would have
the definition given that term in subpart 2.101 of the Federal
Acquisition Regulations. Providers would be paid under a negotiated
rate that, to the extent practicable, would not exceed the Medicare
rate, with limited exceptions for highly rural areas, Alaska, and
States with an All-Payer Model Agreement. Eligible providers would be
prohibited from collecting any amount greater than the negotiated rate.
The Secretary would be authorized in negotiating rates to incorporate
the use of value-based reimbursement models to promote the provision of
high-quality care. The Secretary would be authorized to collect from
third-parties the costs of furnishing care for non-service-connected
disabilities under this section, and such collections would be
deposited into the Medical Community Care account and remain available
until expended.
We do not support the provision requiring providers to maintain the
same or similar credentials and licenses as VA providers; while this is
a requirement in the current Veterans Choice Program, we have found it
to be administratively difficult (and at times impossible) to implement
in certain situations. We believe strongly in the importance of
ensuring our providers furnish quality care, but recommend a different
approach than this obligation. We are also concerned that some of the
language regarding the terms of the agreements with providers
contemplates a direct relationship between VA and the providers, rather
than a relationship between VA and a network administrator, and a
separate relationship between the administrator and the provider.
Similarly, we do not support the provision that would require the
deposit of collected funds into the Medical Community Care account.
Funds collected by VA under sections 1725 and 1729 of title 38, and
section 2651 of title 42 are currently deposited in the Medical Care
Collections Fund, where they may be used to support both VA and
community care. We believe creating a separate collection account would
be duplicative and would limit our funding flexibility. Finally, we
note that referencing the definition of ``third party'' in section 1729
produces a narrower effect than if the definition in section 1725 were
referenced.
The Secretary would be required to provide Veterans information
about this Program upon their enrollment and when they become eligible
based on a determination between the Veteran and his or her provider.
The Secretary would be required to ensure that follow up care,
including specialty and ancillary services deemed necessary, are
furnished through the Program at the election of the Veteran. Veterans
would be required to pay a copayment for care under this Program, but
the copayment could be no more than what the Veteran would owe if such
care or services were furnished directly by the Department. The
Secretary would also be required to establish a claims processing
system to ensure prompt and accurate payment of bills and claims for
authorized care. Under subsection (j), a Veteran's election to receive
care under this Program would serve as written consent for purposes of
section 7332(b)(1), which governs the disclosure of certain protected
health information. Providers would be required under subsection (k)(1)
to submit copies of the Veteran's medical records upon the completion
of the provision of such care and services, but these records could not
be required prior to reimbursement. Under subsection (m), the Secretary
would be required to track missed appointments to ensure the Department
does not pay for care or services that were not rendered.
We note that subsection (j) is no longer needed given the
amendments to section 7332 made by Public Law 115-26. In terms of
subsection (k)(1), we believe it would be better for the records to be
required as determined by the Secretary to ensure that the records are
provided in a timely fashion and that care provided by VA and others is
informed. We also recommend against including subsection (m), regarding
the tracking of missed appointments, as our experience with the current
Veterans Choice Program has proven this difficult to implement. We have
taken other precautions to ensure the Department is not paying for care
and services that were not provided, and we believe this approach is
more suitable for the legislation's intent.
Section 101(a)(3) would terminate the current Veterans Choice
Program authority and make other conforming amendments.
We do not support this provision, as the Department will need a
transition period during which it can prepare for the future of
community care while still ensuring Veterans receive care through the
current Choice Program.
Section 101(a)(4) would require a report within 1 year of the date
of enactment of this Act providing information about services rendered
under the new Program.
We note that subparagraph (D) of this provision would require a
report on the results of a survey of Veterans who have received care or
services under this program. Given the time it may take us to develop a
survey, VA may not be able to gather meaningful information in the time
between OMB approval of the information collection and the reporting
deadline. Regarding subparagraph (E), which would require an assessment
of the effect of furnishing care and services under new section 1703A
on wait times, we have not found reliable data that would support a
firm assessment through the current Choice Program, and we believe we
would encounter the same issues under this proposal.
Section 101(b) would provide that services under various programs
and authorities be considered services under the Veterans Community
Care Program established under the new section 1703A, including PC3,
contracts through VA's retail pharmacy network, VCAs, and healthcare
agreements with other Federal and non-Federal agencies.
We are not sure exactly what it means for services under another
program to be ``considered'' services under the Veterans Community Care
Program. If this would require that all of the agreements and programs
identified in this subsection meet the terms and conditions of the
Veterans Community Care Program, we would not support that requirement.
Section 101(c) would state that all amounts required to carry out
the new Program would be derived from the Medical Community Care
account, and that all amounts in the Veterans Choice Fund would be
transferred to the Medical Community Care account. Section 802 of the
Veterans Access, Choice, and Accountability Act of 2014 would be
repealed, and conforming amendments would be made to section 4003 of
the Surface Transportation and Veterans Health Care Choice Improvement
Act of 2015.
We agree with the importance of consolidating funding for community
care, but we recommend that the transfer of funds from and the repeal
of the Veterans Choice Fund only apply to unobligated funds and provide
a delayed effective date to support the transition from the current
program to the future program.
Section 101(d) would require, within 90 days of the enactment of
this Act, the Secretary to establish consistent criteria and standards
for furnishing non-Department care, including the eligibility
requirements of providers and reimbursement rates (which, to the extent
practicable, would be the Medicare rate). These standards would not
apply to the Veterans Community Care Program established under section
101(a)(1).
We support the intent of subsection (d). We have minor technical
recommendations that we would be pleased to discuss with the Committee.
Section 101(e) would require the Secretary to establish a working
group to assess the feasibility and advisability of considering under
subsection (b) services under healthcare agreements with healthcare
providers of the Indian Health Service (IHS) and tribal health programs
to be provided under the Veterans Community Care Program. The working
group would include representatives of IHS, tribal health programs, and
Veterans who receive services from either IHS or tribal health
programs. Within 180 days of enactment of this Act, the working group
would be required to submit a report to the Secretary on the
feasibility and advisability of considering such services to be
services under the Veterans Community Care Program, and within 90 days
of receiving this report, the Secretary would be required to submit a
report to Congress on the feasibility and advisability of implementing
the working group's recommendations.
We do not oppose greater coordination and discussion with IHS or
tribal health programs, but we do not believe the timelines in the
legislation are realistic. We also do not believe it is necessary to
require this coordination in law, as we are already working with these
groups to improve cultural understanding and resource sharing. We also
note that the Federal Advisory Committee Act (FACA) would likely apply
to the working group, given the inclusion of non-government personnel.
Section 102(a) would create a new section 1703B regarding prompt
payment of providers. It would require substantially the same things
required by section 5(a) of the draft Veterans Choice Act of 2017, with
a few exceptions. For example, this bill would authorize the Secretary
to accept claims and medical records submitted other than
electronically if the Secretary determines the provider is unable to
submit claims or medical records electronically. It would also
authorize the Secretary to accept non-electronic claims if the
Secretary determines doing so is necessary for the timely processing of
claims due to a failure or serious malfunction of the electronic
interface of the Department (required in section 102(b)) for submitting
claims.
As discussed with respect to section 5(a) of the draft Veterans
Choice Act of 2017, we generally support these provisions and
appreciate the flexibility contained in this version.
Section 102(b) would require, not later than January 1, 2019, the
Chief Information Officer of the Department to establish an electronic
interface for healthcare providers to submit claims for reimbursement
under section 1703B. The bill would define various requirements in
terms of functions of the interface and protection of information. By
January 1, 2018, or before entering into a contract to procure or
design and build such an interface, the Secretary would be required to
conduct an analysis to determine whether it would be better to build or
buy such an interface and submit a report on such analysis to Congress.
The bill would define various requirements of this analysis and report,
and the Secretary would not be authorized to spend any amounts to
procure or design and build the electronic interface until 60 days
after the required report is submitted to Congress.
We are concerned about the intended scope of this provision. If the
electronic interface processing the claims is only preparing them for
adjudication and approval by VA, we do not support this provision
because VA is currently working on a process internally that would
perform this function. If the provision is intended to cover
adjudication and payment as well, we would like to discuss with the
Committee our reservations about such an arrangement and propose
potential alternatives instead. We also caution that the deadline in
subsection (b)(2) of January 1, 2018, for making a decision to
internally design and build or enter into a contract to procure an
electronic interface is likely too soon, given the uncertainty
regarding community care funding, continuing developments of the design
of the new EHR, and the potential implications to other information
technology projects.
Section 103 would amend 38 U.S.C. Sec. 1151(a) by adding a
paragraph that would require VA to pay compensation if a Veteran's
disability or death was caused by hospital care or medical services
furnished under proposed section 1703A of title 38, United States Code,
and the proximate cause of the disability or death was carelessness,
negligence, lack of proper skill, error in judgment, or similar
instance of fault by the provider or an event not reasonably
foreseeable.
VA fully supports ensuring that Veterans have access to high
quality care, and that they are made whole in the event of a medical
error. However, VA does not support this provision as written based on
several concerns. First, section 103 would expand section 1151(a) to
require VA benefit payments where the ``proximate cause'' of a
Veteran's disability or death was the negligence of a non-Department
healthcare provider or an unforeseeable event occurring during
treatment by such a provider. The ``term 'proximate cause' is used to
label generically the judicial tools used to limit a person's
responsibility for the consequences of that person's own acts. At
bottom, the notion of proximate cause reflects 'ideas of what justice
demands, or of what is administratively possible and convenient.'''
Holmes v. Sec. Investor Prot. Corp., 503 U.S. 258, 268 (1992) (quoting
W. Keeton, D. Dobbs, R. Keeton, & D. Owen, PROSSER AND KEETON ON LAW OF
TORTS Sec. 41, p. 264 (5th ed. 1984)). Section 103 would make the
Federal Government liable for disability or death that is the proximate
result of a non-Department medical provider's negligence or an
unforeseeable event. This is contrary to the basic principle of
American law, which holds an individual legally responsible for
injuries caused by his or her negligent conduct.
Second, VA adjudicators would be required to develop evidence
regarding care that is not provided by VA employees or in VA
facilities, including DOD and other Federal healthcare providers and
academic affiliates, and to determine whether a Veteran's disability
was proximately caused by negligence on the part of the community
provider or an unforeseeable event occurring during non-Department
medical care. See 38 U.S.C. Sec. 5103A. This would entail gathering
medical and other records from community providers as well as expert
medical opinions about whether the event that occurred during the non-
Department treatment was not foreseeable. This development burden of
obtaining and evaluating evidence from non-Department providers and
facilities can be expected to slow the adjudication of other Veterans'
claims for benefits and potentially add to the disability compensation
backlog.
Third, under 38 U.S.C. Sec. 1151(b), a recovery under the Federal
Tort Claims Act as a result of a judgment or settlement for a
disability or death for which compensation is awarded under 38 U.S.C.
Sec. 1151(a) results in a suspension of the section 1151 benefits until
the amount of the judgment or settlement is recouped. In contrast,
section 103 does not provide for a suspension of compensation for any
recovery by a Veteran or Veteran's survivors from the non-Department
provider as a result of a private lawsuit based upon the same
disability or death. As a result, a Veteran or a Veteran's survivor
could receive a recovery of both section 1151 benefits and tort damages
based upon a judgment or settlement. This would create an inequity by
allowing duplicative recovery for the same disability or death for
persons whose entitlement is based on care furnished by community
providers.
We have not yet had time to estimate the costs for section 103.
However, we do know that, in FY 2016, 2.2 million Veterans received
care from community providers under existing VA statutory authorities.
During the first three quarters of FY 2017, 1.2 million Veterans have
received such care. VA purchases care from more than 500,000 community
providers, and the number continues to grow. VA's FY 2018 budget
requests a 13 percent increase in funding for community care. As a
result, VA could potentially be liable for section 1151 benefits for
any of these 2 million Veterans who suffer additional disability or
death due to negligence or an unforeseeable event caused by community
care provided by community providers despite the absence of a causal
connection between the additional disability or death and VA medical
treatment.
Section 104 would add a sunset provision to section 1703 of title
38 terminating that program on December 31, 2018. It would make other
conforming amendments similar to those proposed in section 12 of the
draft Veterans Choice Act of 2017.
We support section 104.
Section 201 would add a new section 1703C to authorize the
Secretary to enter into VCAs, similar to the authority that would be
provided under section 4 of the draft Veterans Choice Act of 2017.
However, there are a few differences in the proposed section 1703C that
section 201 would create. First, the draft Veterans Choice Act of 2017
would require that care be unavailable under the Veterans Choice
Program established in that draft bill prior to entering into a VCA,
while the Improving Veterans Access to Community Care Act of 2017 has
no such limitation. The draft Veterans Choice Act of 2017 would
authorize providers to opt out of a VCA, but the Improving Veterans
Access to Community Care Act of 2017 does not include this provision.
The draft Veterans Choice Act of 2017 would limit the ability of the
Secretary to direct patients to providers that have entered into
contracts or agreements under other authorities, while the Improving
Veterans Access to Community Care Act of 2017 does not include such a
restriction. The draft Improving Veterans Access to Community Care Act
of 2017 would include greater flexibility in terms of the Medicare rate
through inclusion of the phrase ``to the extent practicable'' in
prescribing the rates the Secretary would pay under VCAs. While we
believe the draft Veterans Choice Act of 2017 would allow the
Secretary, on a case-by-case basis, to determine whether or not to pay
for care not authorized, the Improving Veterans Access to Community
Care Act of 2017 would allow the Secretary to pay a provider who
provides services in the course of treatment pursuant to an agreement
with the Secretary but is not a party to the agreement. Finally, the
draft Veterans Choice Act of 2017 would state uniformly that the OFCCP
would not have authority over parties to a VCA, while, through section
205, the Improving Veterans Access to Community Care Act of 2017 would
apply the limits established for the TRICARE Program in Directive 2014-
01 of OFCCP to any healthcare provider entering into an agreement or
contract with VA under section 1703A, 1703C, or 1745.
We support section 201 and prefer those provisions that differ from
the draft Veterans Choice Act of 2017.
Section 205 would apply the OFCCP moratorium to VA, and VA supports
that provision. We recommend against including a specific deadline, as
that would allow flexibility in the event that the OFCCP Directive is
further revised. Many of the technical concerns we identified with the
draft Veterans Choice Act of 2017 regarding VCAs apply here as well,
and we look forward to working with the Committee and the Department of
Labor to address concerns.
Section 202 would modify VA's authority under section 1745 and is
identical to section 6 of the draft Veterans Choice Act of 2017.
VA's views on that provision apply here as well.
Section 203 would amend section 106 of the Veterans Access, Choice,
and Accountability Act of 2014 to require that, at the beginning of
each fiscal year, the Secretary to transfer to VHA an amount equal to
the estimated amount required to furnish hospital care, medical
services, and other healthcare through non-Department providers during
the fiscal year. The Secretary would be authorized to make adjustments
to the amount transferred to accommodate variances in demand for such
care and services from non-Department providers.
We support section 203 because this would provide greater
flexibility to adjust resource allocations based upon actual demand.
Section 204 would create a new section 1730B, which would allow the
Secretary, notwithstanding sections 1341(a)(1) and 1501 of title 31, to
record an obligation of the United States for non-Department care on
the date on which a claim for payment is approved, rather than the date
on which the care or services are authorized.
VA understands this provision is intended to bring the Department
closer to industry practices in terms of allocating resources for care
and developing better estimates concerning our community care
liabilities. VA appreciates the Committee's willingness to engage on
this issue given our prior discussions on this, and we look forward to
working with you further on this proposal.
Section 205 of the bill is discussed above in the analysis of
section 201, and the Department's views on this provision are provided
in that discussion.
We are unable to provide cost estimates on the bill at this time
but will follow up after the hearing with any estimates we can develop
and our thoughts on the potential budget implications. We will also
provide technical comments for your consideration.
Mr. Chairman, this concludes my statement. I would be happy to
answer any questions you or Members of the Committee may have.
Chairman Isakson. Thank you for your testimony. I want to
start out with where you ended up talking about Choice, because
that is the critical thing we have facing us.
I want to start off by saying in every meeting you and I
have had or every meeting you have been in where I have been
and vice versa, it is patently clear that this Committee's
commitment is for a robust VA health system for our veterans.
Is that not correct?
Dr. Yehia. That is correct.
Chairman Isakson. I have not yet seen a proposal from the
VA that did anything to undermine that being the case. In fact,
that is what you want too.
Dr. Yehia. That is right.
Chairman Isakson. That being the end, there have been some
who feared the Choice Program might be a route away from VA
health care to a privatized health service. Is that not true?
Dr. Yehia. Some have that concern.
Chairman Isakson. Nothing we have done would either ratify
that concern or in any way indicate that is the way we are
moving. In fact--and you do not have to agree with anything I
say if you do not want to, by the way. [Laughter.]
But, in fact, it acts as a force multiplier to give us
professionals to handle the needs of veterans in a timely
fashion and a route for our veterans to get timely health. Is
that not correct?
Dr. Yehia. Mm-hmm.
Chairman Isakson. You said you needed four or five things,
but most importantly, it was flexibility and time; flexibility
to deal with the differences that the various regions of the
country would offer, which probably is the number 1 place you
need flexibility, as well as the time to put it in place. It is
true that a lot of the problems in the initial Choice bill,
simply we did not have enough time, and we over-bureaucratized
the decisions to the point that it made it more cumbersome than
smooth. Is that not correct?
Dr. Yehia. That is correct.
Chairman Isakson. So, you all have been working at the VA
hard and long to come up with the type of systems that will
give you the satisfaction that we have the discipline that we
need without the over-bureaucratization of the process. Is that
not true?
Dr. Yehia. Yeah.
Chairman Isakson. Most important in that is your number 1
item, which is to enhance the experience of the veteran and the
decisions to be made by the veteran and their doctor within the
VA. Is that not correct?
Dr. Yehia. That is correct.
Chairman Isakson. I think that is an important point for
all of us to understand. A lot of these cases are not a one-
time doctor's visit for a sore throat. Many of them are a
condition that is going to take treatment over time, and with
the VA doctor being a quarterback and the veteran in
consultation with the doctor making the decisions on their
health care, you have the perfect pairing. Is that not correct?
Dr. Yehia. Yes. It is that dyad of the doctor and the
patient together to determine what makes the best sense for
that veteran in front of them.
Chairman Isakson. I intend, as one Member of the Committee
in anticipation on what we do to lead up to the completion of
the improvement in Choice, to see to it that you do have the
flexibility and the time, and that we never diminish the role
of the Veterans Administration's health services and the lives
of our veterans today or the lives of our veterans in the
future.
I want to personally thank you for the countless hours you
have spent on some of the challenges we have been trying to
meet over the last few months to lead us to a point in time to
make the right decisions as far as that is concerned.
Dr. Yehia. Thank you, Chairman.
Chairman Isakson. I have one other question. That was more
of a statement than a question, but I have one other thing I
would like to ask you about. How many different community care
programs do we fund out of the VA right now for choice?
Dr. Yehia. We gave about seven to eight different programs.
Chairman Isakson. Is there any reason those could not be
consolidated into one?
Dr. Yehia. We would prefer that they be consolidated into
one.
Chairman Isakson. This is not a setup by the way. I know
this is going to sound like a setup, but Dr. Yehia is so smart,
he just led me right into this. So, I am playing straight man.
Is it not true that if they were all one, we would not have
these periodic crisis problems where we have run out of money
when we really have not run out of money?
Dr. Yehia. That is exactly right. We need one program with
a set of rules that is flexible enough, puts the veteran in the
middle, and we want to move toward one pot of money to
administer that program.
Chairman Isakson. The important thing I am trying to make
in this statement is that we have got a situation right now
where we are running out of money, but we are running out of
money in one fund. So, we have got to take it out of another
fund, where if it was all in the same fund, you would better
manage your money. You would better have accountability on your
money, and you would not have the type of crisis problems that
we have had.
Dr. Yehia. That is right.
Chairman Isakson. That is one thing we want to try to be
sure we fix in terms of Choice as we work toward that at the
end of this year.
All right. Let us see. I guess the Ranking Member is gone.
Senator Sanders?
Senator Sanders. Thanks, Mr. Chairman, and thank you, Dr.
Yehia.
Well, I am one of those people, as you know, Mr. Chairman,
who believes that in the Congress, there are those who believe
that we should privatize Social Security, privatize Medicare,
privatize Medicaid, privatize the Postal Service, and want to
go after the Veterans Administration. I do not think that is
hyperbole; I think that is a fact. I think there are folks who
spend hundreds of millions of dollars in the political process
who want to do just that, so I have that concern.
But, here is my concern now. I think we can deal with this
problem, and I think Dr. Cassidy made a good point a few
minutes ago. It is not a complicated issue, which I think there
is a lot of agreement.
Number 1, there is some veteran in South Dakota or Vermont
who lives a zillion miles away from a VA hospital. Should that
person be able to get the health care across the street in
their community? Who would argue against that?
If Dr. Cassidy mentioned the VA has a long waiting line,
people cannot even get in, so their choice is going to an
emergency room, which is double the price of other types of
health care. What is the problem with that? I do not see any.
But, here is the problem I see, Mr. Chairman, and that is
while we want to give veterans choice, we do not want to do it
in a way which dismantles the VA. What I worry about is that at
a time when the VA has 45,000 vacancies, when many parts of
this country are understaffed, there may well be funding coming
out of the VA to fund the Choice Program, and that does concern
me very, very much.
I think the answer is that we want to, first of all, given
the fact that there is overwhelming--Dr. Yehia, I do not know
if you have this information or not, but every internal poll--
and maybe the service organizations have more on hand, but
every internal poll that they do seems to indicate tremendous
support for the VA, the desire to maintain the VA, desire not
to see the VA privatize. Does that sound familiar to you?
Dr. Yehia. Yes.
Senator Sanders. All right. So, we want to maintain the
strength of the VA, and what we do not want to do is, piece by
piece, dismantle the VA and put that money into the Choice
Program.
I have no problem with when people want to have the
opportunity, need the opportunity to get care outside of the VA
when it is reasonable. Count me in. That is common sense. I
will not allow the VA to be dismembered.
Last point. It is very easy to criticize the VA. They are
the largest integrated health care system in this country. You
have got 131 medical centers, hundreds and hundreds of CBOCs,
et cetera, et cetera? Every day there is going to be a problem.
We forget that the private health care system is somewhat
dysfunctional in America today.
We forget that today in the private-sector system, hundreds
of people will die because of medical malpractice in hospitals,
care they are not getting or mistakes that are being made, and
that very often--we heard from Dr. Shulkin, you will recall at
the last hearing, that recent studies from--I think it was JAMA
or the AMA indicated that on studies that are on many of these
issues, the VA ends up doing better than the private sector.
So, our job is to strengthen the VA, to make it the best
that it can, and where appropriate, to make sure that people do
have the opportunity to go outside of the VA.
Thank you very much, Mr. Chairman.
Chairman Isakson. Well, thank you for your statement,
Senator Sanders.
And, let me just say for the record, the first challenge I
was handed when I became Chairman was the Denver hospital,
which was being closed and unfinished, finished at about 40
percent. We are finishing that hospital, spending $1.4 billion
on an opening, and it is a VA hospital. If there was ever an
intent of anybody to go from VA to a privatized situation, that
would have been it, but we made it work. We found the funds. We
got it done.
You look through everything that we have done. There is a
total commitment on the part of this Committee and its Members
to make sure veterans' health services is the best health
service they can be and our veterans get the best services they
can get, or else we would not be here right now. I agree with
you 100 percent.
If there is an enemy out there somewhere, we will watch out
for them together. OK?
That said, Senator Boozman.
HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you much, Mr. Chairman. I appreciate
you and the Ranking Member for going forward with this hearing
so that we can discuss these bills.
I understand the Senator's concern, Senator Sanders,
regarding, again, any effort to dismantle the VA. I do think
that the changes that we have done so far are being very
positive, especially in rural States like mine, like Arkansas,
where the reality is that people have to travel extended
distances.
I think we can be very, very proud of that. I think we need
to build on it, again, making sure that we do protect the VA
infrastructure that we have and make sure that it works as well
as it can for the benefit of our veterans.
A couple weeks ago, there were news articles about the
significant shortage of critical nursing staff at our VA
medical facility in Little Rock, and I say that because it is
not just in my State, but it is throughout the country. Can you
speak to the broader state of nursing staffing nationwide, what
we are doing in that regard?
Senator Sanders said we have got that problem in the VA. We
have got that nationwide, as far as he mentioned, incentives to
try and get nurses to practice in the VA versus private care.
Probably the pay is not as good in the VA, so----
Dr. Yehia. Yeah. I am going to turn it over to my
colleague, Dr. Lynch.
Dr. Lynch. I could not agree with you more, Senator. I
think nursing has been a problem for all of health care.
We have been working aggressively in Little Rock. We have
had our chief nursing officer working with the facility to
identify staff and nursing to get to the facility, but we have
also been looking at our system as an enterprise and
identifying where we have the opportunity to look for pay
supplements that can make us competitive with the private
sector. But, it is a problem, and it is one that we share with
the health care sector, and we have to be on top of it.
Senator Boozman. I agree totally, and again, it is
something that because it is a problem nationwide in the
private sector also, you all can have a tremendous influence
and be a leader in the direction forward.
I would like to talk a little bit, Dr. Yehia, about the
Veterans Treatment Court Improvement Act, sponsored by Senators
Flake, Manchin, Tester, and Tillis. I have seen a number of the
veterans courts, and they do a tremendous job.
In fact, today I was visiting with the Association of Drug
Court Professionals, and they tell me that 92.5 percent do not
reoffend within 3 years. That statistic is amazing compared to
other alternatives.
But, in doing that, having success, long-term success and
also short term, where you have got the veterans who do not
have to go off someplace to serve time--they are there in the
community that they are from--when they go off--invariably
these folks many times are helping to support the family--you
leave the family destitute.
I know you have said that you have some concerns about
perhaps that affecting the homeless programs and things like
that. Can you talk a little bit about that and tell us why it
is not a great idea to support the drug courts all that we can?
Dr. Lynch. Let me take that one, if you would, Senator.
Number 1, we already have plans to hire 50 or more new
Veterans Justice Outreach representatives for VA. Our concern
with the bill is the requirement for an offset for that salary
of $5.5 million. We have already committed to hire. We would
prefer not to have to offset against other parts of our
program, such as homeless, to find funds for that $5.5 million
when, in fact, we have already committed to hire those
individuals. That is our concern, not the hiring of the
individuals, not the good work that the program is doing, but
we are trying not to harm other programs within VA by the
required offset.
Senator Boozman. Yeah. Hopefully, we can work on that. Many
of the homeless are having problems with drugs, alcohol, and
other things, but I would argue that the human cost, the cost
to the VA, again, in not rehabilitating these individuals, them
going off and coming back with the same problem, because they
are not going to have the 97 percent success rate that we see,
is going to cost you a heck of a lot more money down the line.
So, let us work with you. I hope we can get that worked out
because it really is a very, very important program. It is
doing a tremendous job.
Dr. Lynch. Absolutely.
Senator Boozman. Thank you.
Chairman Isakson. Thank you, Senator Boozman.
Senator Hirono.
Senator Hirono. Thank you, Mr. Chairman.
I would like to thank Senators Collins, King, and Markey
for their close sponsorship of S. 683, my Keeping Our
Commitment to Disabled Veterans Act, which would ensure
coverage for around 350 veterans in Hawaii, some 20,000
veterans across the country, and in Hawaii at non-public and
private nursing home care facilities across the State who
depend on VA reimbursement for their health care needs.
On February 17, I visited Hale Makua Health Services on
Maui, which operates the only two freestanding nursing homes on
that island. They would be impacted by a lapse in the program
that I just mentioned. Wes Lo, who is the CEO of Hale Makua,
said that passing this bill is needed so that more veterans on
Maui will be able to receive around-the-clock nursing care and
supervision in his facilities.
We must keep our commitment to these veterans, which is why
I am grateful to the VA and the veterans service organizations
here today for their testimony in support of the bill.
I wanted to ask you, Mr. Yehia, could you share with the
Committee how a lapse in the support for this program, funding
for this program, would impact the veterans at Hale Makua and
the over 20,000 veterans in facilities across the country with
VA reimbursement, and what would VA do if such a lapse
occurred?
Dr. Yehia. Well, we are definitely very supportive of the
bill, and Dr. Lynch can provide a little bit more context on
what would happen.
Dr. Lynch. We run in or have run into problems with lapses
in the past. These are not good things to have.
Senator Hirono. Mm-hmm.
Dr. Lynch. We have to look for workarounds to keep the
veteran in the nursing home and to give them the care that they
need. So, anything we can do to continue legislation that keeps
the veteran in the nursing home and provides the care they need
is strongly supported by the VA. We do not want to be in a
position where a bill would lapse.
Senator Hirono. Do you feel pretty confident that we will
not let this program lapse? Because otherwise you have to have
a Plan B.
Dr. Lynch. I am hoping with the support from your
colleagues----
Senator Hirono. Yes.
Dr. Lynch [continuing]. That we can pass the legislation
and we do not face that problem.
Senator Hirono. Yes.
Dr. Lynch. If we face the problem, VA will work to solve
it.
Senator Hirono. The 350----
Dr. Lynch. But, I am hoping we do not get there.
Senator Hirono [continuing]. Veterans in Hawaii, that is
really a large number of veterans who would be impacted.
Dr. Yehia, in your testimony, you state that if the
disabled veteran nursing home care authority continues to be
extended, VA estimates the cost would be $4.73 million in
fiscal year 2018, $25.13 million over 5 years, and $53 million
over 10 years. What would you attribute to the bulk of this
increasing cost? Is it that we have more veterans who will need
this kind of care? Is it that the cost of the care is rising or
a combination?
Dr. Lynch. Cost of health care is going up across the
country, and so we have to allow for that increase.
But, generally, it is a rising population. We know if we
look at our geriatric population, we are seeing an increase
over the next 20 years. It is the Silver Tsunami, and we have
to be prepared to address those veterans.
Senator Hirono. When you say Silver Tsunami, that is an age
group of what?
Dr. Lynch. That could be an age group, depending upon who
you are and what your age is, anywhere from 50 to 75.
Senator Hirono. So, that is a growing group of veterans
that will need----
Dr. Lynch. The geriatric population is one of our most
rapidly growing sets of populations within the VA. Yes.
Senator Hirono. There is a certain percentage of them who
will need this kind of intensive----
Dr. Lynch. Our goal, quite honestly, as you bring up the
point--our goal is to try to keep people out of institutions
and to try to keep them in their home or home environment. But,
there are some veterans, regardless of the support that we can
provide, that are going to need nursing homes. Yes.
Senator Hirono. Let me turn to the Veterans Choice Act, and
at some point, maybe I will submit a question to you as to what
would be the top three changes that you would make to the
Choice Program to make it better.
I know that you are very concerned with the provisions of
the draft Veterans Choice Act of 2017 that would require VA to
renegotiate, reissue, or terminate every agreement and
contract, regardless of the terms or conditions of such an
agreement permitting extensions or other flexible authorities.
Your testimony states that this provision would affect such
agreements as those with the Department of Defense, Indian
Health Services, and Tribal Health Programs, as well as with
your academic affiliates and contractors.
Could you confirm whether this provision would also impact
the existing agreement that VA has under the Choice Program
with the Native Hawaiian Health Centers, and if so, what would
VA do to renegotiate the contract you have with the Native
Hawaiian Health Centers?
Dr. Yehia. Our partnerships with our Indian Health Service
and the Tribal Health Partners is outside of the Choice Act, so
we have different arrangements with them. As we consider
consolidating community care, that is--those are some of the
relationships we want to ensure that we maintain. So, I think
this will be important as we come up with a draft legislation
that does not harm some of those key partners that we have and
ensuring that we have the flexibility to partner wherever we
need to with some governing rules overarching them.
Senator Hirono. I think it is important, since the need is
great, that the kind of contracts you have will enable the
Indian Health Services and the Native Hawaiian Health Services
to continue to be a part of the providing of services. So,
thank you.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you.
Senator Rounds.
HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA
Senator Rounds. Thank you, Mr. Chairman.
We are fortunate in South Dakota that we have three VA
facilities: one in Sioux Falls, one in Hot Springs, one in
Sturgis. Last year all three received five-star ratings. This
year two of the three have five-star. One is a four. But, there
is about a 300-mile spread between the facilities, and for that
reason, we had a real interest in seeing Choice not only be
successful, but be improved. That is one of the reasons we had
authored a proposal that made the VA a primary payer rather
than a secondary, and that cleaned up a lot of the challenges
that we had in some of the rural parts of the United States.
Dr. Yehia, the discussion draft for the Veterans Access to
Community Care Act--Senator Tester is the primary--affords
substantially less choice to veterans than the discussion draft
for the Chairman's proposal. I am open-minded on the issue of
finding some common ground, but so far, I just do not see a
downside to giving the veteran the final say on where he or she
gets their health care.
I think of a veteran that lives in Miller, SD, or in
Winner, SD, more than 150 miles away from another facility. To
suggest to them that they need to go to a facility in order to
get permission to see their family physician in a local area
seems to be a little bit challenging. I would just like your
thoughts on it, please.
Dr. Yehia. Sure. The Secretary articulated this as little
bit, maybe about a month or so ago, in front of the Committee.
What we are talking about really is that relationship
between a patient and their doctor. I am a practicing provider
in the VA system, and my patients want to know who is the best
cardiologist in the community, where they should get their
health care. We believe it is important for that dialog to
occur because it actually empowers a veteran to make an
informed decision about where they should best get their health
care. We want to provide them with some guidance based on if we
offer the service, is it accessible, and is it feasible for you
to drive to receive that care.
In the construct, though, as described, I think we are more
about how do we empower the veteran with information to make
the best decision that is right for them.
Senator Rounds. I think the idea of providing the veteran
with an opportunity is very appropriate, but I think requiring
permission from the VA to make that is probably where I would
have a concern. Would you see a difference between or would you
see a different approach, perhaps, than what you would find
within the bill today?
Dr. Yehia. So, two items there. I think the intent is not
to have them drive to have that discussion, and I think there
are many different avenues, whether it is through a phone call
or virtual or email or an in-person visit. I think that is
important, that you can get in contact with your care team,
more than just driving over there.
In my experience as a clinician, for the most part, there
is high degree of concordance between the patient and the
doctor.
Senator Rounds. One of the reasons--excuse me.
Dr. Yehia. Yeah.
Senator Rounds. One of the reasons why the Choice Program
was actually put in place in the first place is because not
only do people live more than 40 miles away, but also because
they were waiting for more than 30 days to actually make
contact with the physician. It seems to me that what we are
going back to is something similar to that, once again, where
we are saying in order to get your local care, you need to have
that contact. How do we assure them that they have that contact
when they need it?
Dr. Yehia. Yeah.
Senator Rounds. Would it not seem more appropriate to offer
it, make it available, encourage it, but still allow that
individual to be able to access local care when they feel it
necessary, and would not that be even more empowerment for that
veteran to make that decision?
Dr. Yehia. I think some of the challenges that we have been
facing with the current Choice Program are these 30 and 40
rules, which are very administrative. When I went to medical
school, there was nothing about 30 days or 40 miles.
Senator Rounds. Yeah.
Dr. Yehia. There are certain patients that I need to be
seeing in 2 days, not in 30 days, and the law does not allow
for that. Or there might be folks that live 15 miles away from
the VA, but if they are getting chemotherapy every day, it
might make sense for them to get it closer to their home.
We are actually looking for more flexibility and empowering
that veteran, that veteran patient, and their care team to make
those decisions, because I actually think there are situations
that arise today where the Choice Act is not able to allow
access to the community as much as it should.
Senator Rounds. Well, I most certainly want to make sure
that that veteran has the ability to access local care in a
timely fashion, and I like the idea of having access to a VA
physician where there is an opportunity to do so. But, as you
recall, the reason for the Choice Program in the first place
was the failure of the VA to be able to provide those services
in a timely fashion.
Dr. Yehia. Yeah.
Senator Rounds. I hate to lose the protections that our
rural VA members have received through Choice. I would not want
to go back on that arrangement right now and lose those
protections and those capabilities that they have got right
now.
Dr. Yehia. Well, I look forward to working with you and
others because I think there are opportunities there to figure
out how to craft and ensure that those veterans, especially the
highly-rural veterans, continue to receive the care that they
need.
Senator Rounds. Thank you.
Dr. Yehia. Yeah.
Senator Rounds. Thank you, Mr. Chairman.
Chairman Isakson. Excellent point, Senator Rounds. I
appreciate your pointing that out. That is one thing we are
going to be dealing with as we get to the final decisions on
this Choice Program, making it work, but not forgetting what
got us to Choice in the first place, which was people not
getting appointments within 30 days and sometimes 90 days.
People who lived 40 miles away could not get an appointment at
any time. So, we have got to remember why we got to where we
are and not allow ourselves to slip back and get there again.
Senator Tillis.
HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA
Senator Tillis. Thank you, Mr. Chair. Thank you all for
being here.
Just a real quick one. I want to go back to some questions
related to Senator Boozman's comments around the Veterans
Treatment Court Improvement Act. I am a cosponsor of that bill.
I appreciate Senator Flake's work on it. The VSOs, I think,
support--all the VSOs support it. You all support it with
provisions.
Could you drill down a little bit more on things that we
need to work on that cause you concern?
Dr. Lynch. Senator, I think, number 1, we support it, and
in fact, we are already in the process of hiring 50 or more
specialists to work in the Veterans Justice Outreach Program.
Our main concern is the requirement for an offset to the
salary. We already have committed to the hire. We are concerned
that if we have to offset that salary, we may have to take it
from other wraparound programs that we provide to veterans,
perhaps the homeless, perhaps in social work or caregiver.
Senator Tillis. So, it is purely the pay-for?
Dr. Lynch. Right now the main concern is having to pull
money when we do not think we need to do that, sir.
Senator Tillis. I want to go back also the discussion we
are having about maybe different directions on what some people
refer to as Choice 2.0. You are familiar with some of the
proposals out there.
How do we bridge the gap? I think there are some legitimate
concerns that have been expressed on both sides, but how do we
bridge the gap, and how do we provide you all with flexibility?
I want you to answer that question, but I have to go back to
something that I do in every one of these committees.
Some believe that there is an effort to privatize the VA. I
have to continue to say that the hospitals that I have in North
Carolina, the health care centers that I have in North
Carolina, the brick-and-mortar presences of the VA are
critically important elements to anything that we do in the
future. This is about figuring out how to redouble our efforts
with non-VA care, which it still continues to be a significant
amount of how we have provided care for quite some time, and
then getting choice right.
Can you give us some thoughts on how we bridge the gap and
get to a bill that has bipartisan support and gets to the
President's desk?
Dr. Yehia. Absolutely. One of the things that I noticed for
every bill, on the Choice bills today on the docket, what I
have noticed when I was looking through them is that they are
touching on the key important aspects that need to be
addressed. They are addressing eligibility. They are addressing
how we design the network. They are addressing provider
payments. They are addressing provider agreements. So, I think
that is a very good step forward. For the most part, the key
elements that need to be there are there.
We just need to figure out how--every one of them has
different strengths and weaknesses.
Senator Tillis. If you were to--if you were to back off of
maybe the universe of ideas to the specific things that you
think that you need the authority to move forward with, what
would that look like?
Dr. Yehia. I think that, just very broadly, there are a
couple of key things that would help us continue to improve the
program. One is we have learned through our experience of
Choice today that being overly prescriptive ends up hampering
us, and that is one of the reasons why in partnership, the
Congress has passed more than five legislative changes to the
program.
Ensuring that there is enough flexibility to allow us to
adjust to different geographies, different veteran populations,
and different types of providers will be key. Some of the bills
that are on discussion today are very prescriptive of you can
only pay the Medicare rate and nothing above that. Well, there
might be certain areas of the country that that is not the
going rate, and we might lose on high-quality providers. So,
there are a number of those sort of examples that I think with
a couple tweaks here and there, we can get to a more robust
place that allows this new modernized single program to adapt
to the different veteran populations across the U.S.
Senator Tillis. Yeah. I think that is one thing that is
important, is for you all to provide feedback. I would be happy
to meet with you, but the folks who are moving the bill, to a
certain extent, sometimes I think we have gone too far. Then,
the reworks that you have talked about have cost us time and
possibly money and resources that could be spent on other areas
that you are working on. So, it would be very helpful to get
ahead of that and say it is a great thought but a potential
distraction based on what we need to accomplish on a more
immediate basis.
Dr. Yehia. That is right.
Senator Tillis. I appreciate the opportunity to speak with
you all about that. Thank you very much.
Dr. Yehia. We would be happy to do that.
Senator Tillis. Thank you, Mr. Chair.
Chairman Isakson. Thank you very much, Senator Tillis, and
thanks to the members of the VA for your being here for this
panel. We appreciate your testimony.
Senator Tester. I got to go yet.
Chairman Isakson. Oh, I am sorry.
Senator Tester. That is all right.
Chairman Isakson. I thank you for----
Senator Tester. I tell you, there goes the relationship
right down the tubes. [Laughter.]
Chairman Isakson. Senator Tester.
Senator Tester. It is perfectly all right.
Chairman Isakson. Take as much time as you want.
Senator Tester. No, no, no. It is perfectly all right.
First of all, thank you for being here. I do have a few
questions.
I think what gives some people (at least on this side)
heartburn, but I think it gives you guys heartburn too on the
other side, is the President came out and said guys ought to
have a card, let them go wherever they want. The ultimate end
result of that would be a VA that no longer exists, maybe not
in the short term, but certainly in the long term. So, I think
that is where part of the heartburn comes from.
I think, Senator Rounds, when you look at the VA, you look
at it from a South Dakota rural perspective, which is the way
you should, so I do not think we are this far off. I mean, I
think we are--you are looking at it as a challenge like
somebody who has to drive 300 miles, and other people are
looking at the VAs sitting there and there is another facility
right beside it and should the VA be involved in those
decisions. So, hopefully, we can get to a point on that.
Look, a couple things I want to talk to you, Dr. Yehia,
about, and one of them is responsibility. I said it before on
this Committee that you can outsource the service, but I do not
know that you can outsource responsibility. I just want to know
your perspective on that in that whether you think the VA
should be held responsible in the end for somebody that you
guys are going to--I cannot remember the word--you are going to
certify them as being somewhere that the veteran can go and
ends up getting bad service. What should be the role of the VA
in that under Choice 2.0?
Dr. Yehia. Let me provide some broad comments, and I will
turn it over to Mr. Flohr to provide a little bit more detail.
Senator Tester. Sure.
Dr. Yehia. So, in general, we absolutely agree that the
network that VA builds, whether it is inside or outside, needs
to deliver high-quality care, which we are responsible for
building that network, ensuring top quality providers, and
helping the veteran navigate and coordinate that care. So, I
think, in general, from a principle perspective, that is the
case.
I know that in one of the provisions of the bill, there is
specific language about if there is a veteran that gets injured
or harmed from a malpractice or not getting the right service
in the community, what sort of--how are they made whole again?
Senator Tester. Right.
Dr. Yehia. Now, I will ask Mr. Flohr to just comment a
little bit on that from VBA.
Senator Tester. Yeah. Go ahead.
Mr. Flohr. Thank you.
Yes. It is VBA that makes decisions----
Senator Tester. Yeah.
Mr. Flohr [continuing]. On whether or not a veteran has
been harmed through----
Senator Tester. Right.
Mr. Flohr [continuing]. Medical care in VHA.
Senator Tester. Yep.
Mr. Flohr. I just saw this bill in the last couple of days.
Senator Tester. Yeah.
Mr. Flohr. I have not really had a chance to study it. I am
not sure how that would--I do know that I did a little
research, and I found that approximately 47 percent of
clinicians have been sued at one point or another in their
lives and their career.
Senator Tester. Yeah.
Mr. Flohr. How that would impact a private provider in
terms of the insurance that they have, their malpractice
insurance, whether that would go up if they were seeing more
patients or veterans----
Senator Tester. Veterans.
Mr. Flohr [continuing]. So, I just do not know at this
time.
Senator Tester. Yeah.
Mr. Flohr. I do not know what the impact would be on our
workload.
Senator Tester. Yep. Well, look, I mean, I guess I see your
hesitancy for it because you do not know how that is going to
impact your budget going forward.
Mr. Flohr. Correct.
Senator Tester. But, on the other side, when the rubber
hits the road, it is your responsibility. They signed up. You
said you are going to give VA care. It is your responsibility.
Mr. Flohr. Bottom line is we are here to assist veterans--
--
Senator Tester. That is right.
Mr. Flohr [continuing]. And make sure they get all the
care----
Senator Tester. So----
Mr. Flohr [continuing]. And benefits they need.
Senator Tester. Let me ask you how this--would this be part
of the accreditation process with the hospitals? You have got
electronic medical records or medical records, period, even if
they are not electronic. Is there something we need to be doing
in this bill to ensure that that information, what work has
been done on that veteran outside the VA is wholly transferable
to inside the VA?
Dr. Yehia. Luckily, both bills have some of those
provisions in there, which is what are the criteria for a
provider to enter into the network, and I call that really the
first line of defense----
Senator Tester. Good.
Dr. Yehia [continuing]. Because having a medical license
and credentialing is really the first one.
Then, we want to go above that and look at what are the
outcomes, what is the service, and make that as transparent as
possible to a veteran so they can choose between providers,
which one is best for them.
Senator Tester. The only thing I would caution you on is
some of the same concerns that Senator Rounds had. In some of
the more frontier areas, these are very small hospitals that
oftentimes do not have access to enough money, especially
depending on what we do with health care here at this level.
So, be aware of that.
The last thing I would ask you, before I turn it back to
the Chairman, is cost. We are paying the bill whether it is
done inside the VA or outside the VA. Have you guys or any of
your sharp-penciled people--I will call them that--done any
assessments on cost compared to VA-delivered health care,
whether it would be up, down, static?
Dr. Yehia. You mean a delivery of VA services----
Senator Tester. Yep.
Dr. Yehia [continuing]. Versus the community?
Senator Tester. VA versus community care and what those
costs might be because--and the Chairman remembers we got into
a pretty vibrant discussion with one of our Members as to what
the cost for community care is from the Congressional Budget
Office, I believe. So, have you guys done any of that kind of
work?
Dr. Yehia. From an apples-to-apples way of looking, if a
colonoscopy is done in the VA versus the community, I do not
have that off the top of my head, but there have been a lot of
cost estimates that have been done on what would happen if
there was full access, full choice between the VA and the
community.
Senator Tester. Yeah.
Dr. Yehia. The Secretary mentioned this about a month or so
ago. It could add up to about $20 billion more a year. The
Commission on Care had a range from about $5 billion to $35
billion additional per year.
Senator Tester. Is that per year or over 10 years?
Dr. Yehia. Per year.
Senator Tester. OK.
Dr. Yehia. There have been some other studies that have
looked at that, so that is an important consideration.
Senator Tester. OK. Have you guys picked a favorite of the
three bills that are up there between Isakson, myself, and
Crapo? [Laughter.]
Dr. Yehia. We have not picked a favorite. I think each of
them has, like I said before, really--they are addressing the
key issues, which is important, and there is strength and
weakness for all.
So, I think across the three, there is real goodness there
to move us to that consolidated program that we need.
Senator Tester. All right. Thank you, Mr. Chairman.
Chairman Isakson. Spoken like an excellent politician. We
appreciate that. [Laughter.]
Senator Manchin.
HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA
Senator Manchin. Thank you, Mr. Chairman. Thank you all.
There is a fundamental debate around the third-party
administrators, and one argument in the VA is--one argument is
that the VA cannot handle the task of scheduling and
administering a non-VA care program, so the private sector has
got to step in.
The second argument is that third-party administrators do
not take care of our veterans, plus we cannot do oversight over
them. This may be the biggest fight in a non-VA care debate
that we are going to be encountering. I will tell you that when
I visit veterans in Beckley or in my Clarksburg VA hospitals,
they really do not like the third-party administrators because
veterans do not think those docs know them, do not know their
concerns, their needs, and how to take care of them.
So, my question is, are you all capable and ready to
administer a robust non-VA care program and on their own if
that is the path that we are going to go down? How are you
going to get them up to speed of the care that the VA and the
veteran needs?
Dr. Yehia. So, I think there is a need and a role for third
parties as we move into the future.
I think one of the lessons learned from our various town
halls, interacting with veterans and community providers is we
outsourced the relationship, and that has been critical.
Veterans want a relationship with their VA provider or between
doctors; sometimes that was hampered during our existing
relationships today with a contractor.
So, moving forward, I think what would be important is for
those veteran-facing and community-facing functions, it is
important that those relationships interact between a doctor
and a doctor or between a patient and a doctor and do not have
someone else in there. A case in point has really been in our
pilots in Alaska and in Fargo that have really shown that--and
soon to be in Montana--that having that relationship is
critical.
Now, I do want to say that----
Senator Manchin. How are you preparing--how are you
preparing a non-VA caregiver to understand this veteran and
understand their care? I speak specifically to opiates.
Dr. Yehia. Sure.
Senator Manchin. We got a lot of pill mills. We got a lot
of doctors pushing pills.
Dr. Yehia. So----
Senator Manchin. What guarantees that you are not going to
be sending one to one of these pill mills?
Dr. Yehia. Exactly. That is part of the discussion that we
were just having about ensuring that there are high-quality
providers in the network.
Senator Manchin. Who does that?
Dr. Yehia. It is really a two-step process. One is we want
to ensure we set the standards. Some of them are actually in
the current bills we are discussing today of who can enter the
network, and then we need oversight from our contracting
partners to----
Senator Manchin. Doctor, what I am asking is who in--are
you capable in the VA of qualifying and overseeing these
people? Do you have continuing education? What are you doing to
ensure that if we send a veteran from Beckley and Clarksburg--
--
Dr. Yehia. Sure.
Senator Manchin [continuing]. Outside of their arena, they
are going to not be getting somebody taking advantage of them
and has basically the skill sets to take care of them?
Dr. Yehia. So, we rely on our contracting partners to
ensure that we have quality providers, and then what we do
offer is CME, continuing medical education, free of charge that
the VA has put on to not only address things such a opioids----
Senator Manchin. Is it mandatory, or is it----
Dr. Yehia. It is voluntary right now for the community
providers.
Senator Manchin. Why would it be voluntary?
Dr. Yehia. There are a lot of various State rules that look
at--some are more mandatory, depending on the State that you
are in.
Senator Manchin. Yeah, but you got the paycheck. You got
the pay--I mean the checkbook. If you tell me I got to do
something in order to qualify, I am going to do it.
Dr. Yehia. Well, in some areas, we definitely have that
market power where they are seeing a lot of veterans, but in
some--in other areas, especially in highly-rural, if you put a
lot of burdens on the community providers and they are seeing a
few, handful of veterans, they just will not sign up.
Our goal is to be more of having a carrot rather than a
stick. We would like to really identify those providers that
have completed that training, that are providing high quality,
and say, you know, ``These are our preferred providers. We
would like you to consider them.'' So we have to be cognizant
of really the amount of market share that we have in each area
and not putting overly prescriptions on the docs, because then
they might not want to take care of our veterans.
Senator Manchin. Can we bring that to a higher profile so
we can identify those people that do and do not?
Dr. Yehia. Absolutely.
Senator Manchin. I mean, the community is going to have to
get involved.
Dr. Yehia. Yeah.
Senator Manchin. We all talk a good game. We are all out
here showing all of our support for the VA during election
time. During the non-election time, these people still need the
same care.
Dr. Yehia. Yeah. I think there is a lot----
Senator Manchin. That is community involvement.
Dr. Yehia. I agree with you. I think there is a lot of
opportunity to get the hospital associations, the medical
groups, all kind of involved in helping educate not only about
military culture competency, but specifically opioids and
prescribing. Happy to work with you on that.
Chairman Isakson. Thank you, Senator Manchin.
Thanks to all the panelists for being here today. Thanks
for your time, Dr. Yehia. We appreciate it very much.
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
to Baligh R. Yehia, M.D., Deputy Under Secretary for Health for
Community Care, Veterans Health Administration, U.S. Department of
Veterans Affairs
The Choice Program is not working for health care providers or
veterans. A primary challenge with Choice is that patients are unable
to effectively connect with their providers, and authorizations for
care are delayed. Veterans can end up waiting for health care services,
and providers wait for payment in a way that defeats the entire
intended purpose of cutting wait times for treatments.
Dr. Yehia, I'd like to share the story from one provider at the
Hospital for Special Care in New Britain, Connecticut with you:
The Hospital for Special Care Pulmonary Rehabilitation program
provides therapy that can reduce hospitalizations and exacerbations for
patients with lung disease. This New Britain hospital offers a
multidisciplinary, ``gold standard'' pulmonary rehab program that
addresses quality of life, anxiety and depression, nutrition, and other
concerns for patients with chronic lung disease.
Prior to the VA Choice program, there was a functioning system in
place to facilitate referrals. At the Newington VA, the Non-VA Care
Department ensured that private providers had all documentation
necessary, including referral, agreement as a payor, and medical
records. They were very efficient and cooperative, and understood the
medical necessity of Pulmonary Rehab.
But, after VA Choice, providers at the Hospital for Special Care
have expressed concerns. In the case of one patient treated for chronic
lung disease, the physician's note stated that he wanted this patient
to attend the Hospital for Special Care Pulmonary Rehabilitation
Program. VA Choice delayed the sending of authorization paperwork and
during that time, the patient was hospitalized twice. The referral was
discontinued on two occasions, even though the physician's notes stated
that he wanted the patient to attend our program. At this point, my
Connecticut office intervened to get this veteran the health care that
he required.
Question 1. Dr. Yehia, such barriers to care are exactly the
opposite of what Congress intended with the Veterans Choice Program.
Which legislation on the hearing agenda today do you believe will best
address the shortcomings of the current Choice Program?
Response. We appreciate the opportunity to work with the Committee
to review proposed legislation to improve VA community care for
Veterans. A principle we all agree on is making sure that VA is
organized around and focused on the needs of Veterans. This means
making community care simple to understand and easy to administer,
which is our vision for this program. With that in mind, while we
support many of the provisions in the three proposed bills on the
agenda, as explained in our testimony, there are some provisions that,
while well-intended, we believe would create added complexity or impose
restrictions that would reduce our flexibility and ability to
efficiently meet Veterans' health care needs.
The future of VA's community care program is one of the most
important and possibly most difficult items on the legislative agenda.
We want to work with everyone to ensure the legislation that shapes
this future is as strong as possible. VA is working on developing its
proposal and intends to share this with the Committee in the near
future.
Question 2. What else should Congress do to cure this failure?
Response. In regards to the current program, VA has worked closely
with Congress to enact changes to the original law which have created
more flexibility in the Veterans Choice Program and enabled more
Veterans to use the program. VA has also worked closely with our
contracting partners to modify the contracts and business processes.
This has enabled the contractors to make payments to community
providers more timely and provide more timely appointments for
Veterans. VA has also developed and implemented tools to assist in
sharing health information with the community providers to ensure
better care coordination for Veterans.
We believe the legislation that is ultimately enacted should
embrace a few broad principles; these principles are based on lessons
learned through VA's community care program and the Veterans Choice
Program.
The future community care program must empower the Veteran and his
or her provider to get the right care at the right time from the right
provider. VA must be able to establish a high-performing network of VA
and community providers who can furnish the very best care for
Veterans. To do this, we must have flexibility in terms of payment
rates and the types of agreements we form with providers. In addition,
we must also have the flexibility to simplify our interactions with
providers to ensure we pay them on time, and can easily share
information with them.
It is also imperative that VA retain flexibility to adjust and
adapt to an evolving health care landscape. Legislation that is too
prescriptive in terms of rules, responsibilities, or processes can only
limit our options, leading to frustration by Veterans and community
providers alike. The law establishing the Choice Program was amended
five times in less than three years. That is not a sustainable model.
We believe the best legislation in this area would provide broad,
general authority that VA could further narrow and implement through
regulations, policy, and contracts. We have been working with your
staffs and our VSO partners over the past 15 months on these proposals
and will continue to do so once legislation is enacted to ensure that
the best ideas are incorporated in the new program.
Last, it is critical that the legislation provide VA sufficient
time for development and implementation. We know from our efforts with
the current Choice Program that a rushed period of implementation will
not help Veterans or VA. Ideally, we would have a full year to
establish provider networks, draft regulations, and build the
relationships and systems that will empower Veterans, VA, and community
providers to offer the very best health care services to our Veterans.
Chairman Isakson. It is time for our second panel. Will
they please come forward. [Pause.]
Well, thank you for being here today. We appreciate your
patience, and as was said about you during the hearing, we
greatly appreciate the VSOs' support, their counsel, and their
input, which will be very valuable and important to us as we go
forward on the legislation pending here. We are glad to have
you today, and we appreciate you coming to testify.
Our four witnesses from the veterans service
organizations--first of all, Mr. Lou Celli. Lou, we are glad to
have you back; we always appreciate the input of The American
Legion. I just sent my dues check in last week, by the way, so
I am good for another year.
Mr. Celli. We are going to check.
Chairman Isakson. Please do. [Laughter.]
Amy Webb of AMVETS. Amy, we are glad to have you here
today. Adrian Atizado is back with us, the Disabled American
Veterans; and Gabriel Stultz, legislative counsel, Paralyzed
Veterans of America. Thank you all for being here.
We will start with you, Lou.
STATEMENT OF LOUIS CELLI, DIRECTOR, NATIONAL VETERANS AFFAIRS
AND REHABILITATION DIVISION, THE AMERICAN LEGION
Mr. Celli. The American Legion is proud to support the
slate of bills being considered today and will touch briefly on
them as we move toward the discussion on the future of Choice.
As we all know, it is the big topic coming up for today's
discussion.
Chairman Isakson, Ranking Member Tester, and distinguished,
dedicated defenders of veterans who proudly serve on this
Committee, on behalf of Charles Schmidt, the national commander
of the largest veterans service organization in the United
States of America, representing more than 2.2 million dues-
paying members, combined with our American Legion family, whose
numbers exceed 3.5 million voters living in every State and
American territory, it is my duty and honor to present The
American Legion's position on the bills being discussed here
today.
The American Legion supports the Veterans Transplant Act.
We appreciate that VA is concerned about the increase in
administrative burden that this will cause, but The American
Legion believes this is imperative to be able to track and
monitor the biological implants that are being surgically
inserted into our veterans' bodies. Infectious trends, possible
recalls, longevity studies all require tracking. It just makes
sense.
Senate Bill 426, the draft bill to improving hiring
efficiencies all have our full support. Keeping VA staffed with
equal medical and support staff is critical to ensuring VA can
operate efficiently, effectively, and be the best possible
steward of the taxpayers' dollars.
Every vacancy at VA pushes appointments further behind and
care into the community, a trend that needs to be monitored
closely. VA has some of the most advanced resources in the
country and in the world and should be an employer of choice
for rising physicians building their career. We need to ensure
that VA and the Secretary have the tools necessary to properly
staff their agency.
Senate Bill 683, the VA nursing home care is a no-brainer.
Senate Bill 833, VA has an obligation to care for us who
suffer illness or injury based on their honorable service, but
when their honorable service is disrespected and denigrated by
fellow servicemembers, we not only have an obligation to
support and defend our comrades by prosecuting offenders to the
fullest extent of the law, we have an obligation to apologize
for not protecting them and to ensure we care for them with
every available resource that we have, and at a minimum, that
includes VA health care. I am surprised that this even needs
legislation to accomplish it in the first place, and yes, we
support it.
The American Legion has always supported veteran treatment
courts, and this bill will help provide the liaison services
that veterans and the judicial system need to support this
important program. The American Legion supports Senate Bill
946.
The Veterans ACCESS Act simply closes a loophole that puts
veterans at risk. If a physician gets fired from VA for not
being able to perform his or her job, why would it be OK for VA
to then contract with them and send veterans to them, anyway?
We support keeping bad actors away from our veterans, and we
support this bill.
The Enhancing Veteran Care Act is an interesting concept
and probably what the VA OIG should be doing but, sadly, does
not. VA tells us that they have tiger teams that descend on
poorly performing facilities to help rehabilitate them. An
ounce of prevention is worth a pound of cure. The American
Legion has been doing this for a very long time, over 10 years,
visiting facilities, working with leadership, rendering
reports, and sharing best practices through our System Worth
Saving Program. We support Senate Bill 1266 because the bill
exposes a need within the structure of the system that
currently is unmet, but we still think that this should be a
function of the Inspector General's office.
In our written testimony about the Draft Quality Employment
VA bill, The American Legion discusses this proposed
legislation extensively, but in short, we want to highlight to
this Committee that the VA has a variety of authorities and
resources at their disposal that can increase competitive
staffing levels at VA without the need for additional
legislation. We call on VA to start exploring these options.
This includes residency programs, public-private partnerships,
and space-sharing programs instituting a VA medical school,
temporary physician-sharing assignments between Level 1 and
Level 3 facilities, and more that are all within VA's authority
to execute now.
In our written presentation, The American Legion outlines
the need for consolidation and unification of community care
contracting practices, recommendations for public-private
partnerships, suggestions on ways to increase capacity and
innovations that will support VA sustainability, and ensure VA
remains a world leader in education, science, and health care,
their three statutory pillars that VA was built on.
Over the past year, VA has worked closely with this
Committee and veterans service organizations to come up with a
plan on where the future of VA health care is headed. Through
all of this, we believe the Secretary's CARE Plan most closely
represents what The American Legion supports: consolidated,
integrated, heads-up health care. We call on this Committee to
work with the Secretary and the VSO community to put a plan in
place that is comprehensive, sustainable, affordable, and
veteran-centric, and we believe that the CARE Plan hits all of
those points.
We look forward to our continued work together with this
Committee and the Secretary to build a 21st century world-class
VA health care system that your Nation's warriors have earned.
[The prepared statement of Mr. Celli follows:]
Prepared Statement of Louis J. Celli, Jr., Director, National Veterans
Affairs and Rehabilitation Division, The American Legion
------------------------------------------------------------------------
Bill # Bill Name or Subject Position
------------------------------------------------------------------------
S. 115 The Veterans Transplant Support
Coverage Act
------------------------------------------------------------------------
S. 426 Grow Our Own Directive
Physician Assistant Employment Support
and Education Act of 2017
------------------------------------------------------------------------
S. 683 Keeping Our Commitment to Support
Disabled Veterans Act of 2017
------------------------------------------------------------------------
Draft To improve the hiring, Support
Bill training, and efficiency of
acquisition personnel and
organizations of the
Department of Veterans
Affairs, and for other
purposes
------------------------------------------------------------------------
S. 833 Servicemembers and Veterans Support
Empowerment and Support Act of
2017
------------------------------------------------------------------------
S. 946 Veterans Treatment Court Support
Improvement Act of 2017
------------------------------------------------------------------------
S. 1153 Veterans ACCESS Act Support
------------------------------------------------------------------------
S. 1261 Veterans Emergency Room Relief Support
Act of 2017
------------------------------------------------------------------------
S. 1266 Enhancing Veteran Care Act Support
------------------------------------------------------------------------
S. 1279 Veterans Health Administration Refer to Choice Program-
Reform Act of 2017 Community Care Option
Section
------------------------------------------------------------------------
Draft Veterans Choice Act of 2017 Refer to Choice Program-
Discussio Community Care Option
n Section
------------------------------------------------------------------------
Draft Improving Veterans Access to Refer to Choice Program-
Discussio Care in the Community Act of Community Care Option
n 2017 Section
------------------------------------------------------------------------
S. 1325 Better Workforce for Veterans Support
Act of 2017
------------------------------------------------------------------------
Discussio The Department of Veterans Support
n Draft Affairs Quality Employment Act
of 2017
------------------------------------------------------------------------
When The American Legion testified at the June 7, 2017 Senate
hearing, we went on record stating The American Legion believes in a
strong, robust veterans' healthcare system that is designed to treat
the unique needs of those men and women who have served their country.
As we testify today, The American Legion's commitment to helping
Congress and VA build a strong robust veterans' healthcare system is
even stronger.
Chairman Isakson, Ranking Member Tester, and distinguished Members
of the Committee; On behalf of our National Commander, Charles E.
Schmidt, and the over 2 million members of The American Legion, we
thank you for this opportunity to testify regarding The American
Legion's position on pending legislation before this Committee. We
appreciate the Committee focusing on these critical issues that will
affect veterans and their families.
s. 115: the veterans transplant coverage act
A bill to amend Title 38, United States Code, to authorize the
Secretary of Veterans Affairs to provide for an operation on a
live donor for purposes of conducting a transplant procedure
for a veteran, and for other purposes.
The Department of Veterans Affairs (VA) Veterans Health
Administration (VHA) has been providing transplant services since 1961
when Dr. Thomas E. Starzl, performed the first-ever transplant of a
human liver at the Denver VA hospital on May 5, 1963.
This bill, if enacted into law, would authorize the Secretary of
Veterans Affairs to provide organ transplants to veterans from a live
donor regardless of whether that donor is a veteran. This bill would
allow veterans who are waiting a lengthy amount of time for VA
transplant services to receive those services out in the community at
VA expense.
In 2015, the VA Office of Inspector General (VAOIG) issued Report
No. 15-00187-25, Alleged Program Inefficiencies and Delayed Care, VHA's
National Transplant Program. VAOIG substantiated that some patients
referred for liver transplant evaluations at all VATCs experienced
delays. VAOIG estimated that 6.9 percent of emergency referrals were
not responded to in VHA's electronic transplant referral system within
48 hours, as required (95 percent confidence interval (CI): 1.67-
24.42). Among stable patient referrals, VAOIG estimated that 9.6
percent of referrals were not responded to in VHA's electronic
transplant referral system within 5 business days, as required (95
percent CI: 6.36-14.28). About half of stable patients who were deemed
eligible for further evaluation did not receive an initial patient
evaluation within 30 days, as required.\1\
---------------------------------------------------------------------------
\1\ VAOIG Report No, 15-00187-25 (Nov 2015): Alleged Program
Inefficiencies and Delayed Care, VHA's National Transplant Program
---------------------------------------------------------------------------
According to statistics obtained from the Department of Health and
Human Services, as of June 30, 2017, there were 117,636 people needing
a lifesaving organ transplant (total waiting list candidates).\2\ Of
those, 75,958 people are active waiting list candidates. In accordance
with VHA Policy Directive 2012-018, Solid Organ and Bone Marrow
Transplantation, VA can only accept living donors into VA's transplant
program.
---------------------------------------------------------------------------
\2\ Organ Procurement and Transplantation Network: https://
optn.transplant.hrsa.gov/
---------------------------------------------------------------------------
Through American Legion Resolutions No. 25, The American Legion
Support of the VA Organ Transplant Program The American Legion supports
a system of organ distribution that will ensure that veteran patients
receive equitable consideration when in need of transplants, and No.
46, Department of Veterans Affairs (VA) Non-VA Care Programs, that the
Department of Veterans Affairs (VA) develop a well-defined and
consistent non-VA care coordination program, policy and procedure that
includes a patient-centered care strategy which takes veterans' unique
medical injuries and illnesses as well as their travel and distance
into account.\3\ \4\
---------------------------------------------------------------------------
\3\ The American Legion Resolution No. 25 (May 2004): The American
Legion Support of the VA Organ Transplant Program
\4\ The American Legion Resolution No. 46 (Oct. 2012): Department
of Veterans Affairs (VA) Non-VA Care Programs
---------------------------------------------------------------------------
The American Legion supports S. 115.
s. 426: grow our own directive: physician assistant employment and
education act of 2017
A bill to increase educational assistance provided by the Department of
Veterans Affairs for education and training of physician
assistants of the Department, to establish pay grades and
require competitive pay for physician assistants of the
Department, and for other purposes.
S. 426 will authorize the Grow Our Own Directive (GOOD) Pilot
Program for five years to advance training and education opportunities
for participants of the Intermediate Care Technician (ICT) program who
agree to work in VA facilities in underserved states, and former
servicemembers with military health experience. Once these veterans are
certified as Physician Assistants, they will be required to work at the
VA for at least three years.
Physician Assistants are one of the most in-demand positions at the
VA. In 2016, it was reported that there is a 23 percent vacancy rate in
the VA for physician assistants. According to the Veterans Affairs
Physicians Assistants Association, there are an estimated 30,000 open
Physician Assistant positions in the United States, making it difficult
for the VA to recruit and retain physician assistants.\5\
---------------------------------------------------------------------------
\5\ USA Today (Aug 20, 2015): Half of critical positions open at
some VA hospitals.
---------------------------------------------------------------------------
Reports from our legionnaires who are involved in VA facilities at
the state level suggest that the reason for this is not a lack of
quality candidates, but rather process and pipeline barriers. For a
Veterans Health Administration (VHA) facility to hire one person for a
clinical position it can involve up to 18 steps--from getting approval
for the job posting, to running credential checks--and can take from
four to eight months to complete. By that time, candidates have often
accepted a job elsewhere.
The ICT program is a common sense initiative for the VA to fill
these vacancies. Created in 2012, the scope of practice for the role of
an ICT is more advanced than a traditional VA EMT. ICTs are configured
for the medic and corpsmen skill set and provide a high level clinical
support to nurses and physicians. Additionally, the position was
designed as an initial entry springboard for qualified veterans to
explore further career opportunities in healthcare. Unfortunately, the
program continues to suffer from a lack of training opportunities for
participants to utilize to advance their careers at the VA.
S. 426 would provide this training by establishing the Grow Our Own
Directive (GOOD) Pilot Program for 5 years, which would provide
scholarships to cover the cost of obtaining a master's degree in
Physician Assistant Studies. This would make good on the promise and
potential of the ICT Program in leveraging the skill sets of our medics
and corpsmen, as well as help solve long-standing recruitment issues
facing VHA.
Through American Legion Resolution 338: Support Licensure and
Certification of Servicemembers, Veterans and Spouses resolves that The
American Legion supports efforts to eliminate employment barriers that
impede the timely and successful transfer of military job skills to the
civilian labor market.\6\
---------------------------------------------------------------------------
\6\ The American Legion Resolution No. 338 (2016): Support
Licensure and Certification of Servicemembers, Veterans and Spouses
---------------------------------------------------------------------------
The American Legion supports S. 426.
s. 683: keeping our commitment to disabled veterans act of 2017
A bill to amend Title 38, United States Code, to extend the requirement
to provide nursing home care to certain veterans with service-
connected disabilities.
Public Law 114-228, Section 1710A, Required Nursing Home Care, was
signed into law September 29, 2016, and is due to expire December 31,
2017.\7\
---------------------------------------------------------------------------
\7\ Public Law 114-228 (114th Congress): https://www.gpo.gov/fdsys/
pkg/PLAW-114publ228/ html/PLAW-114publ228.htm
---------------------------------------------------------------------------
The American Legion Resolution No. 377, Support for Veteran Quality
of Life, supports any legislation and programs within VA that will
enhance, promote, restore or preserve benefits for veterans and their
dependents, including, but not limited to, the following: timely access
to quality VA health care; timely decisions on claims and receipt of
earned benefits; and final resting places in national shrines and with
lasting tributes that commemorates their service.\8\
---------------------------------------------------------------------------
\8\ The American Legion Resolution No. 377 (Sept. 2016): Support
for Veteran Quality of Life.
---------------------------------------------------------------------------
By extending the date and not allowing this critical authority to
expire, the lives of veterans with service-connected disabilities will
continue to be enhanced.
The American Legion supports the passage of S. 683.
s. 833: servicemembers and veterans empowerment and support act of 2017
A bill to amend Title 38, United States Code, to expand health care and
benefits from the Department of Veterans Affairs for military
sexual trauma, and for other purposes.
The American Legion supports safe and dignified service for all
servicemember regardless of pay category, period if service, or duty
assignment. The Department of Defense has instituted a zero tolerance
policy for sexual harassment cases, and The American Legion agrees.
Unfortunately, despite existing laws and military regulations, sexual
harassment still happens far too much, and when it does servicemembers
should be able to receive appropriate counseling and care from the
Department of Veterans Affairs to overcome any health-related
conditions related to sexual harassment or assault. For this reason,
The American Legion passed Resolution No. 67 Military Sexual Trauma and
Resolution No. 15, Support Veteran Status for National Guard and
Reserve Servicemembers.\9\ \10\
---------------------------------------------------------------------------
\9\ The American Legion Resolution No. 67 (August 26, 2014):
Military Sexual Trauma
\10\ The American Legion Resolution No. 15 (August 30, 2016):
Support Veteran Status for National Guard and Reserve Servicemembers
---------------------------------------------------------------------------
The American Legion supports S. 833.
s. 946: veterans treatment court improvement act of 2017
A bill to require the Secretary of Veterans Affairs to hire additional
veterans justice outreach specialists to provide treatment
court services to justice-involved veterans, and for other
purposes.
When veterans return from combat, some turn to drugs or alcohol to
cope with mental health issues related to Post Traumatic Stress
Disorder (PTSD) and/or Traumatic Brain Injury (TBI). Thus, many
returning veterans are entering the criminal justice system to face
charges stemming from these issues. In 2008, a judge in Buffalo, NY,
created the first Veterans Treatment Court after seeing an increase in
veterans' hearings on his dockets. Veteran Treatment Courts are a
hybrid of drug and mental health courts. They have evolved out of the
growing need for a treatment court model designed specifically for
justice-involved veterans to maximize efficiency and economize
resources while making use of the distinct military culture consistent
among veterans.
In 2016, The American Legion approved Resolution No. 145, Veteran
Treatment Courts which specifically calls for continuing to fund and
expand Veterans Treatment Courts and hire more staff to expand the
Veterans Justice Outreach program and policies.\11\
---------------------------------------------------------------------------
\11\ The American Legion Resolution No. 145 (August 30, 2016):
Veteran Treatment Courts
---------------------------------------------------------------------------
The American Legion supports S. 946.
s. 1153: veterans access act
A bill to prohibit or suspend certain health care providers from
providing non-Department of Veterans Affairs health care
services to veterans, and for other purposes.
The American Legion plays a lead role in VA healthcare reform by
working with providers, patients, the public and other stakeholders in
communities to improve access, quality and accountability.
This bill, as written, would protect veterans seeking care through
VA community care programs like the Choice Program, from being treated
by doctors who have been terminated or who have been suspended by the
VA.
The American Legion System Worth Saving (SWS) facility visits and
Regional Office Action Reviews (ROAR) provide unequaled firsthand
knowledge of the challenges and opportunities VA faces in the
communities it serves. The American Legion's national staff also
closely monitors reports from the Government Accountability Office,
Congress, VAOIG, media and multiple other sources to identify
facilities that are experiencing challenges so solutions can be found
together.
There are numerous reasons a physician can lose their license to
practice. If a VA physician hired to care for a veteran is terminated
by VA for any reasons cited in this bill, The American Legion agrees
with Congress, VA should not be permitted to refer veterans outside the
department to these non-VA providers. No veteran should be put in a
position of being referred to a non-VA physician who was terminated
from the VA due to negligence of duties.
The American Legion Resolution No. 3, Department of Veterans
Affairs Accountability, supports any legislation that provides the
Secretary of Veterans Affairs the authority to remove any individual
from the Department of Veterans Affairs if the Secretary determines the
performance of the individual warrants such removal.\12\ Once a VA
physician is removed from VA due to performance, The American Legion
believes Congress and VA has a sacred duty to ensure that our Nation's
veterans are protected and receive the best health care available
regardless of whether the care is provided by VA or a non-VA physician.
---------------------------------------------------------------------------
\12\ The American Legion Resolution No. 3 (August 2016): Department
of Veterans Affairs Accountability
---------------------------------------------------------------------------
The American Legion supports S. 1153.
s. 1261: veterans emergency room relief act of 2017
A bill to amend Title 38, United States Code, to require the Secretary
of Veterans Affairs to pay the reasonable costs of urgent care
provided to certain veterans, to establish cost-sharing amounts
for veterans receiving care at an emergency room of the
Department of Veterans Affairs, and for other purposes.
This bill would create a new section, 1725A, Payment of reasonable
costs of urgent care.
Through American Legion Resolution No. 46: Department of Veterans
Affairs (VA) non-VA care programs, The American Legion calls on the
Department of Veterans Affairs (VA) to develop a well-defined and
consistent non-VA care coordination program, policy and procedure that
includes a patient-centered care strategy which takes veterans' unique
medical injuries and illnesses.\13\ Additionally, through American
Legion Resolution No. 377, Support for Veteran Quality of Life, The
American Legion urges Congress and the Department of Veterans Affairs
(VA) to enact legislation and programs within the VA that will enhance,
promote, restore or preserve benefits for veterans and their
dependents.\14\ The American Legion believes including urgent care as
an option in VA's Community Care program will enhance veterans care.
---------------------------------------------------------------------------
\13\ The American Legion Resolution No. 46 (October 2012):
Department of Veterans Affairs non-VA care programs
\14\ The American Legion Resolution No. 377 (August 2016): Support
for Veteran Quality of Life
---------------------------------------------------------------------------
The American Legion supports S. 1261.
s. 1266: enhancing veteran care act
A bill to authorize the Secretary of Veterans Affairs to enter into
contracts with nonprofit organizations to investigate medical
centers of the Department of Veterans Affairs.
Dating as far back as 2003, The American Legion has been involved
in conducting System Worth Saving (SWS) site visits to VA Health Care
facilities to better understand the challenges veterans face when
accessing VA health care. Each year, The American Legion visits
anywhere between 12 to 15 VA health care facilities. Prior to each site
visit, a town hall meeting is held so veterans can have an opportunity
to share firsthand their VA experience. After each visit, a report is
written identifying best practices and challenges. Challenges are
followed up with recommendations and the report is shared with the
medical center to assist them in overcoming their challenges. Prior to
The American Legion National Convention, the site visit reports are
compiled into an Executive Summary, which is shared with the House and
Senate Veterans' Affairs Committees, the VA Secretary, Under Secretary
of Health and the President of the United States.
Through American Legion Resolution No. 105, Reiteration of the
System Worth Saving Program, The American Legion supports visiting and
investigating VA medical centers for the purpose of identifying gaps in
services, best practices, and areas that need improvement.\15\ The
American Legion would also want to ensure that the nonprofit
organizations selected to investigate are certified, qualified, and
fair and equitable. They should work closely with VA and Veteran
Service Organizations to establish a criteria for investigation with a
responsible metric for evaluation and data collection that highlights
best practices as well as deficiencies and areas that need improvement.
---------------------------------------------------------------------------
\15\ The American Legion Resolution No. 105 (Sept. 2015):
Reiteration of the System Worth Saving Program
---------------------------------------------------------------------------
The American Legion supports S. 1266.
s. 1279: veterans health administration reform act of 2017
A bill to amend Title 38, United States Code, to furnish health care
from the Department of Veterans Affairs through the use of non-
Department health care providers, and for other purposes.
(See below)
draft discussion: veterans choice act of 2017
A bill to amend title 38, United States Code, to permit all veterans
enrolled in the patient enrollment system of the Department of
Veterans Affairs to receive health care from non-Department of
Veterans Affairs health care providers, and for other purposes.
(See below)
draft discussion: improving veterans access to care in the
community act of 2017
A bill to amend Title 38, United States Code, to establish the Veterans
Community Care Program of the Department of Veterans Affairs to
improve health care provided to veterans by the Department, and
for other purposes.
(See below)
choice program-community care options
Even in the best of circumstances, there are situations where the
VA health care system cannot keep up with the healthcare needs of the
growing veteran population requiring VA services, and the veteran must
seek care in the community. Rather than treating this situation as an
afterthought, or an add-on to the existing system, The American Legion
has called for the Veterans Health Administration (VHA) to ``develop a
well-defined and consistent non-VA care coordination program, policy
and procedure that includes a patient-centered strategy which takes
veterans' unique medical injuries and illnesses as well as their travel
and distance into account.''
Over the years, VA has implemented a number of non-VA care programs
to manage veterans' health care when such care is not available at a VA
facility, could not be provided in a timely manner, or is more cost
effective through contracting vehicles. Programs such as Fee-Basis,
Project Access Received Closer to Home (ARCH), Patient-Centered
Community Care (PC3), and the Veterans Choice Program (VCP) were
enacted by Congress to ensure eligible veterans could be referred
outside the VA for needed, and timely, health care services.
Congress created the VCP after learning in 2014 that VA facilities
were falsifying appointment logs to disguise delays in patient care.
However, it quickly became apparent that layering yet another program
on top of the numerous existing non-VA care programs, each with their
own unique set of requirements, resulted in a complex and confusing
landscape for veterans and community providers, as well as the VA
employees that serve and support them.
Therefore, Congress passed the Surface Transportation and Veterans
Health Care Choice Improvement Act of 2015 (VA Budget and Choice
Improvement Act) in July 2015 after VA sought the opportunity to
consolidate its multiple care in the community authorities and
programs. This legislation required VA to develop a plan to consolidate
existing community care programs.
On October 30, 2015, VA delivered to Congress the department's Plan
to Consolidate Community Care Programs, its vision for the future
outlining improvements for how VA will deliver health care to veterans.
The plan seeks to consolidate and streamline existing community care
programs into an integrated care delivery system and enhance the way VA
partners with other Federal health care providers, academic affiliates
and community providers. It promises to simplify community care and
gives more veterans access to the best care anywhere through a high
performing network that keeps veterans at the center of care.
Generally, The American Legion supports the plan to consolidate
VA's multiple and disparate purchased care programs into one New
Veterans Choice Program (New VCP). We believe it has the potential to
improve and expand veterans' access to health care.
The American Legion has carefully reviewed each of the three bills
and we would like comment on a few provisions of the bills. Under
Subsection (a) of Senator Tester's bill, the bill would establish
section 1703A, Veterans Community Care program, which authorizes the
Secretary to furnish an eligible veteran hospital care and medical
services through the Veterans Community Care program. To be eligible, a
veteran must be enrolled in the VA Health Care System, which is
consistent with the requirments in Senator Crapo's and Senator's
Isakason's bill. However, The American Legion is concerned that under
subsection (d) of Senator Tester's bill, it would require the Secretary
to (Shall) enter into contracts with eligible providers for furnishing
care and services to eligible veterans. The bill defines the term
contracts has the meaning given that term in subpart 2.101 of the
Federal Acquisition Regulation. Under section 201, it would creat a new
section, 1703C, referred to as Veterans Care Agreements. This section
would provide the Secretary discretionary (May) authority to establish
providers agreements. The American Legion believes these two sections
may create challenges for VA when deciding what type of care should
fall under the mandatory (Shall) authority and what type of care should
fall under the discretionary (May) authority.
Section 2 of Senator Crapo's bill would amend Title 38 U.S.C.
1703's heading from ``Contracts for Hospital Care and Medical Services
in Non-Department facilities'' to ``Care in the Community Program'' The
American Legion believes the current heading gives a false impression
that this is a contracting authority, and by retitling 38 U.S.C. 1703,
it would avoid this false impression. Senator Crapo's bill would also
authorize reimbursement for urgent care provided at a non-Department
facility in accordance with regulations prescribed by the Secretary and
would also establish a new section, titled 1703A, which would require
the Secretary to enter into purchase agreements with non-Department
health care providers to furnish care and services to enrolled
veterans. At The American Legion 2016 National Convention, Resolution
No. 114, Department of Veterans Affairs Provider Agreements with Non-VA
Providers, was passed which supports legislation that would allow the
Department of Veterans Affairs (VA) to enter into provider agreements
with eligible non-VA providers to obtain needed health care services
for the care and treatment of eligible veterans.\16\
---------------------------------------------------------------------------
\16\ The American Legion Resolution No. 114 (Aug. 2016): Department
of Veterans Affairs Provider Agreements with Non-VA Providers
---------------------------------------------------------------------------
All three bills includes provisions for repealing obsolete non-VA
community care authorities.
The American Legion along with other Veteran Service Organizations
have been working diligently with VHA to help with language to
streamline their Non-VA purchase care program in order to come up with
a replacement for the Choice program. While each bill is somewhat
different, when you consider all three bills together, The American
Legion believes they have what is needed to address the many challenges
VA face in building a robust community care program.
The American Legion would like to direct this Committee's attention
to the Draft Veteran Coordinating Access & Rewarding Experiences (CARE)
plan, and urges this Committee to develop future legislative proposals
with this proposal in mind.
The American Legion wants to thank Senator's Isakson, Tester, and
Crapo for taking the lead in drafting these three bills and calls on
them to work together and with The American Legion to deliver a single
bill that includes all the great work each senator has contributed in
their sponsored bill to make VA's Community Care program successful.
s. 1325: better workforce for veterans act of 2017
A bill to amend Title 38, United States Code, to improve the
authorities of the Secretary of Veterans Affairs to hire,
recruit, and train employees of the Department of Veterans
Affairs, and for other purposes.
This draft bill will direct VA to expand its workforce, leading to
more timely and efficient healthcare for veterans. The American Legion
supports legislation that will increase employee capabilities at the
VA. We feel that recent graduates and veterans bring much needed new
talent into the VA and increased hiring will lead to improved
employment opportunities for veterans within the VA. The American
Legion supports policies that boosts the percentage of veterans hired
in all agencies, specifically the VA, to 50 percent or above.\17\
---------------------------------------------------------------------------
\17\ The American Legion Resolution No. 346 (Aug. 2016): Support an
Investigation of Hiring Practices in the Federal Government
---------------------------------------------------------------------------
The American Legion believes that an increase in VA workforce will
lead to; reduced patient waiting times, improvement in employee vacancy
rates, decreased senior VA medical center leadership turnover, helping
ensure timely claims processing, help to reduce homelessness, minimize
improper burials at VA cemeteries and; provide better assurance and
compliance with national policies, rules and laws enacted to assist
veterans and their families.
The American Legion has tracked and reported staffing shortages at
every VA medical facility across the country since the inception of the
System Worth Saving (SWS) program in 2003. The Veterans Health
Administration (VHA) is still struggling to achieve the appropriate
balance of primary care and medical specialists across the country. If
VA continues to struggle with retention and recruitment, the trend of
closures (or continued closures) for multiple departments within VA
health-care systems nationwide will continue.
Numerous reports cite VA's staffing issues. For example, in
January 2015, the VA's Office of Inspector General released its
determination of the ``Veterans Health Administration's Occupational
Staffing Shortages,'' as required by Section 301 of the ``Veterans
Access, Choice and Accountability Act of 2014.'' With this report, the
Inspector General determined the five occupations with the largest
staffing shortages were medical officers, nurses, physician assistants,
physical therapists and psychologists.\18\ \19\
---------------------------------------------------------------------------
\18\ The American Legion Legislative Agenda (March 1, 2017)
\19\ The American Legion Resolution No. 317 (Aug. 2016): Enforcing
Veterans' Preference Hiring Practices in Federal Civil Service
---------------------------------------------------------------------------
In another study conducted by Federal H.R. experts AVUE
Technologies, this legislation seeks to make it easier for the
Secretary of the VA to manage his workforce, including hiring,
retention, and overall talent management. There are many elements of
the legislation that will be helpful to the Secretary however, there
are elements that, with improvement, would contribute to making a
difference in a more substantial way, such as the focus on VA first
responders which is long overdue--in particular the VA Police Officers.
The VA Police Officers have been targeted by the VA's Chief Human
Capital Officer (CHCO) and the CHCO's subordinates for downgrade VA-
wide. The VA has taken the position that VA Police Officers should be
no higher graded than GS-5 (they are currently GS-6) and that they do
not perform work of law enforcement officers because the VA believes
they are primarily engaged in patrols and low level security work
instead of higher graded police officer or law enforcement work. In an
independent study by Federal H.R. experts, the experts found this to
completely mischaracterize the day-to-day work of the VA's police
force. Instead the study found that for Police Officers, the full-
performance level should be GS-7 in all locations where the following
units are found:
Medical Centers that provide in-house, inpatient acute
medical and surgical services and procedures and acute psychiatric
services in addition to outpatient services.
Vet Centers that provide readjustment counseling and
outreach services to all veterans who served in any combat zone.
Domiciliary that provide a variety of care to veterans who
suffer from a wide range of medical, psychiatric, vocational,
educational, or social problems and illnesses.
The study found no justification to downgrade or cap the grades of
these positions on a universal basis. While certain locations like
CBOCs may not exceed GS-5, that grade would misclassify other Police
Officer positions in other locations. VA police offers were found to
perform police patrol work and crime and incident investigation.
Contrary to the VA's assertions, the study found that the police
officers were engaged in responding to reports of crimes in progress;
pursuing and apprehending offenders fleeing a crime scene or attempting
to resist arrest; apprehending offenders and making judgments regarding
the arrest, citation, or release of suspects/offenders; advising
persons of their constitutional rights; advising employees of their
Weingarten rights; conducting frisks and searches; responding to duress
calls and interceding in physical assaults or other incidents clearly
requiring police intervention to minimize the possibility of injury to
all involved parties; subduing unruly individuals who pose a threat to
the officer and other individuals; and subduing individuals through
physical force and/or the use of non-lethal and lethal weapons, as the
situation dictates.
Additionally, with regard to crime and incident investigations, the
following duties, among others, were identified:
Conducts investigations in order to: (1) determine if a
crime has been committed; (2) identify the perpetrator; (3) apprehend
the perpetrator; and (4) provide evidence to support a conviction in
court. Conducts initial discovery and response after being dispatched
to a crime scene or location of a victim. Completes the initial
investigation, including the immediate post-crime activities as the
responding police officer arriving on the crime scene. Secures and
processes accident, crime, or disaster scenes. Interviews witnesses and
questions suspects at the scene. Searches the scene for evidence and
collects, preserves, and documents the chain of custody of evidence.
Diagrams crime and accident scenes. Estimates values of stolen or
recovered goods. Recovers and inventories lost or stolen property.
Transports property or evidence.
Conducts follow-up investigations, as required, over
multiple shifts. Investigates accidents, crimes against persons and
property, and complaints of drug law violations. Collaborates with
internal and external sources to obtain necessary information to
further investigations. Reviews information on criminal activity within
jurisdictional and surrounding areas. Locates and interviews witnesses
to a crime and interrogates and/or question suspects. Conducts
surveillance of individuals and/or locations. Checks on status of
stolen property, criminal histories, and warrants through computer
network. Records and/or reviews records and pictures to aid in
investigations.
Furthermore, there was no basis to lower Leader or Supervisory or
Managerial positions based on the downgrades of subordinate positions.
In fact, in many locations the supervisory structure may warrant a
higher grade based on these new full-performance levels. For VA police
officers at the locations listed above it was found that the positions
not only meet all the requirements to sustain their current GS-6 grade
but also, for at least some, the GS-7 level in addition to meeting all
of the requirements for 6c coverage. In accordance with OPM regulation
Cabinet Level Secretaries may make the determination as to which
positions are eligible for 6c coverage and this is fully within the
current authorities of the Secretary. Doing so will improve retention
in a manner that no other action would and recognition that the work
performed by the VA's police officers warrant a higher grade will
similarly improve retention.\20\
---------------------------------------------------------------------------
\20\ The American Legion Resolution No. 20 (Oct. 2016): Oppose
Efforts to Downgrade Low-Level Wage Positions within the Department of
Veterans Affairs
---------------------------------------------------------------------------
The bill informs the VA that OPM should be engaged to review the
police officer positions. This is problematic for two reasons. One, OPM
is chartered with writing all of the classification and qualification
standards for the Federal Government. Even Title 38 positions are
classified using Title 5 classification standards issued by OPM. The
classification standard for Police Officers was last updated in 1988.
Through American Legion Resolutions No. 20, Oppose Efforts to
Downgrade Low-Level Wage Positions within the VA that The American
Legion vigorously opposes any downgrading of lowest wage positions GS7
and below, and WG-4 and below, No. 317, Enforcing Veterans' Preference
Hiring Practices in Federal Civil Service that The American Legion seek
and support any legislative or administrative proposal that will
mandate the use of automated recruitment, hiring and retention system
that safeguard against hiring malpractice in the application and the
hiring process, and Resolution No. 346, Support an Investigation of
Hiring Practices in the Federal Government that The American Legion
supports remedial legislation, as may be needed, to increase the
percentage of veterans hired in all Federal agencies; specifically, the
Department of Veterans Affairs to 50 percent or above.
The American Legion supports S. 1325.
discussion draft: the department of veterans affairs quality employment
act of 2017
To improve the authority of the Secretary of Veterans Affairs to hire
and retain physicians and other employees of the Department of
Veterans Affairs, and for other purposes.
This draft bill will direct VA to expand its workforce, leading to
more timely and efficient healthcare for veterans. The American Legion
supports legislation that will increase employee capabilities at the
VA. We feel that recent graduates and veterans bring much needed new
talent into the VA and increased hiring will lead to improved
employment opportunities for veterans within the VA. The American
Legion supports policies that boosts the percentage of veterans hired
in all agencies, specifically the VA, to 50 percent or above.
The American Legion believes that an increase in VA workforce will
lead to; reduced patient waiting times, improvement in employee vacancy
rates, decreased senior VA medical center leadership turnover, helping
ensure timely claims processing, help to reduce homelessness, minimize
improper burials at VA cemeteries and; provide better assurance and
compliance with national policies, rules and laws enacted to assist
veterans and their families.
This draft legislation will create more accountability and
efficiency within the VA's workforce management, including hiring,
retention, and overall talent management. There are many elements of
the legislation that will be helpful to the Secretary.\21\
---------------------------------------------------------------------------
\21\ The American Legion Testimony (March 16, 2016)
---------------------------------------------------------------------------
The American Legion has tracked and reported staffing shortages at
every VA medical facility across the country since the inception of the
SWS program in 2003. As far back as 1998, The American Legion expressed
concerns regarding VA physicians and medical specialists staffing
shortages within the Veterans Health Administration (VHA). This was
accomplished by monitoring the progress in establishing patient
centered primary care within each Veterans Integrated Service Network
(VISN), including both rural and urban localities as well as ensuring
that the model of care features both the quality and efficient
combination of medical professionals that are tailored to the needs of
the local veteran's population.
As in previous testimony, The American Legion urges the VA to
develop an aggressive strategy to recruit, train, and retain medical
professionals to meet the inpatient and outpatient health care needs of
veterans. The American Legion fully supports such programs, such as the
VA's education-assistance programs for APNs, RNs, LPNs, and NA's. We
also urged VA to provide equitable and competitive wages for their
medical professionals.\22\
---------------------------------------------------------------------------
\22\ The American Legion Resolution No. 305 (Aug. 2016): Support
the Development of Veterans On-The-Job Training
---------------------------------------------------------------------------
VA medical centers in rural areas have often faced challenges
trying to recruiting and retaining qualified medical and clinical
providers due to their inability to compete with medical centers in
large metropolitan areas. In The American Legion's 2012 System Worth
Savings (SWS) Report on Rural Healthcare, The American Legion found
that: ``Department of Veteran Affairs Medical Centers (VAMCs) in rural
America, recruitment and retention of primary and specialty care
providers has been a constant challenge. Some clinicians prefer to
practice in more urban settings with more research opportunities and
quality of life that urban settings provide.'' \23\
---------------------------------------------------------------------------
\23\ The American Legion System Worth Saving Report (2012): Rural
Healthcare
---------------------------------------------------------------------------
As an example, at the time of our December 2016 visit to the
Pacific Island Health Care System, the director, and chief of human
resource position were both vacant. At the time of our January 2017
visit to the Greater Los Angeles VA Health Care System, the medical
center director had been in his position for less than a year, and the
associate director, chief, and assistant chief, human resource
positions were ALL vacant. During a follow-up call last month, the VA
Pacific Island Health Care System told us that all their top management
positions, except for the Director position have now been filled and
that the chief of human resources position has been filled with a
permanent manager who is highly experienced in human resources.
These staffing shortages are contributing to physician and staff
burnout which was reinforced during our Saint Cloud, Minnesota visit.
As The American Legion continues to conduct System Worth Saving Site
visits across the VA health care system, we see the trend of VA
staffing shortages declining rather than improving.
Things that are working well include the significant contribution
of the VA's Academic Residency Program. As one of the VA's statutory
missions, the VA conducts an education and training program for health
profession students and residents to enhance the quality of care
provided to veterans within the VHA healthcare system. For almost sixty
years, in accordance with VA's 1946 Policy Memorandum No. 2, the VA has
worked in partnership with this country's medical and associated health
profession schools to provide high quality health care to America's
veterans and to train new health professionals to meet the patient
health care needs within VA and the Nation. This partnership has grown
into the most comprehensive academic health system partnership in
American history.
While the VA's Academic Residency Program has made significant
contributions in training VA health care professionals, upon
graduation, many of these health care professionals choose a career
outside the VA health care system. With these realities, the VA will
never be in a position to compete with the private sector as it is
currently set up. To this end, The American Legion feels strongly that
VA should begin looking into establishing its own VA Health
Professional University and begin training their medical health care
professionals to serve as a supplement to VA's current medical
residency program. Conceivably, medical students accepted into VA's
Health Professional University would have their tuition paid in full by
VA and upon graduation, the graduate would be required to accept an
appointment at a Federal health facility at a starting salary
comparable to what a new medical graduate would be paid by VA based on
their experience and specialty. Similar to a military service academy,
a VA medical school will be highly selective, competitive, and well
respected. Applicants can be nominated by their congressional
representative, teaching staff can be sourced organically as well as
nationally, and real estate is plentiful. This will help ensure the VA
will have an adequate number of healthcare professionals to meet the
growing number of veterans and their healthcare needs.
In 2014, The American Legion published a SWS report titled ``Past,
Present, and Future of VA Healthcare,'' which noted several challenges
VA still faced regarding recruiting and retention such as:
Several VAMCs continue to struggle to fill critical
leadership positions across multiple departments.
These gaps have caused communication breakdowns between
medical center leadership and staff that work within these departments.
During our 2013 site visit to the Huntington VA Medical Center in
Huntington, West Virginia, we recommended that, ``VHA conduct a rural
analysis for hard to recruit areas and look into different options to
support VAMCs in getting talent they need to better serve veterans.''
VHA needs to ensure that veteran health care is consistent across each
Veterans Integrated Service Network (VISN).
In 2015, during our SWS site visit to the VA Medical Center in St.
Cloud, Minnesota, providers expressed concerns about the number of
physician vacancies, and how the additional workload is impacting
morale at the medical centers. During the same visit, one veteran
expressed concern noting ``every time [I] visit the medical center, [I
am] assigned a new primary care provider because [my] last provider
either quit or transfer to another VA.''
There have been numerous reports citing VA's staffing issues, for
example in January 2015, the VA's Office of Inspector General (VAOIG)
released their determination of the ``Veterans Health Administration's
Occupational Staffing Shortages,'' as required by Section 301, of the
``Veterans Access, Choice and Accountability Act (VACAA) of 2014.''
With this report, VAOIG determined that the five occupations with the
largest staffing shortages were Medical Officers, Nurses, Physician
Assistants, Physical Therapists, and Psychologists. The OIG recommended
that the ``Interim Under Secretary for Health continue to develop and
implement staffing models for critical need occupations.'' Ultimately,
if the VA continues to struggle with retention and recruitment, the
trend of closures (or continued closures) for multiple departments
within VAMCs nationwide will continue.
As The American Legion continues to conduct System Worth Saving
Site visits across the VA health care system, we see VA staffing
shortages getting worse rather than improving. One reason VA may
sometimes struggle to provide care within the Veterans Health
Administration (VHA) is directly related to staffing. One in six
positions nationally for some critical jobs remain vacant, and critical
needs like psychiatric workers can see vacancy rates of 40-64
percent.\24\
---------------------------------------------------------------------------
\24\ USA Today (Aug. 20, 2015): Half of critical positions open at
some VA hospitals
---------------------------------------------------------------------------
Even when VA is hiring an additional 9 percent of their workforce
they are losing a similar amount to attrition. Some of this could be
improved with better hiring incentives and more competitive wages,
particularly in key fields of need such as psychiatric care,
physician's assistants, nurses and physical therapists.\25\
---------------------------------------------------------------------------
\25\ VAOIG Report No. 15-03063-511: OIG Determination of Veterans
Health Administration's Occupational Staffing Shortages (Sept. 2015)
---------------------------------------------------------------------------
As the Office of the Inspector General recommended, VA also bears
additional responsibility in the form of the development of better
staffing models and examining the red tape and bureaucratic burdens
that stretch hiring out into a process that can take nine months or
longer. Additional examination of where VA can better incentivize
prospective applicants to decide on a career serving veterans would be
helpful. We need to ensure VA has proper funding to get the best and
brightest team members on their medical and psychological staffs
serving veterans.
The VA can further help improve their staffing, especially in
leadership positions, with better succession planning for VA employees
to rise to leadership levels within the organization. As an
organization of advocates that has worked hand in hand with VA for
decades, The American Legion notes the training programs VA had in
place during the 1990's were better suited to creating the next
generation of leadership than the current programs in place. The VHA
training programs of the 1990's were specifically built to prepare
administrative employees to assume mid-level management programs at the
department level. This could include personnel, fiscal, medical
administration, associate director training and other leadership
training. The programs were replaced, over time, with VA's current
Leadership Development Programs, but feedback The American Legion has
garnered from interacting with VHA personnel during visits from our
System Worth Saving Task Force has indicated these programs are not
providing the tools the employees need to be the next generation
leaders of VA and to lead from within.
The American Legion understands that filling highly skilled
vacancies at premiere VA hospitals around the country is challenging.
We also expect VA to do whatever is legally permissible to ensure that
veterans have access to the level of quality healthcare they have come
to expect from VA. VA has a variety of creative solutions available to
them without the need for additional legislative action. One such idea
could involve the creation of a medical school, another would be to
aggressively seek out public private partnerships with all local area
hospitals. VA could expand both footprint and market penetration by
renting space in existing hospitals where they would also be able to
leverage existing resources and foster comprehensive partnerships with
the community. Finally, VA could research the feasibility of
incentivizing recruitment at level 3 hospitals by orchestrating a
skills sharing program that might entice physicians to work at level 3
facilities if they were eligible to engage in a program where they
could train at a level 1 facility for a year every 5 years while
requiring level 1 facility physicians to spend some time at level 3
facilities to share best practices. Currently, medical staff are
primarily detailed to temporarily fill vacancies. This practice fails
to incentivize the detailed professional to share best practices and
teach, merely hold down the position until it can be filled by a
permanent hire.
The American Legion through Resolution No. 317, Enforcing Veterans'
Preference Hiring Practice in Federal Civil Service believes additional
consideration to revamping this portion of training, and ensuring this
training is properly funded, could be a key component to reducing VA's
reliance on the complicated process of hiring from outside VA and
ultimately reduce the number of unfilled leadership positions.\26\
---------------------------------------------------------------------------
\26\ The American Legion Resolution No. 317 (Aug. 2016): Enforcing
Veterans' Preference Hiring Practices in Federal Civil Service
---------------------------------------------------------------------------
The American Legion supports the Discussion Draft.
Conclusion
As always, The American Legion thanks the Senate Committee on
Veterans' Affairs for the opportunity to explain the position of the
over 2 million veteran members of this organization. For additional
information regarding this testimony, please contact Mr. Derek
Fronabarger at The American Legion's Legislative Division.
Chairman Isakson. Thank you very much, Mr. Celli.
Ms. Webb?
STATEMENT OF AMY WEBB, NATIONAL LEGISLATIVE
POLICY ADVISOR, AMVETS
Ms. Webb. Good afternoon, Chairman Isakson, Ranking Member
Tester, and Members of the Committee. AMVETS is truly pleased
to be invited to testify today.
Of the many bills being considered at this hearing, all of
which are intended to improve lives of veterans, we support all
but two. Before discussing those, I would like to mention that
Senator Flake's Veterans Treatment Court Improvement Act speaks
loudly to one of our key legislative priorities.
Many veterans have specific needs and challenges related to
their military service, and AMVETS has been involved with
veterans treatment courts since their inception. At that time,
that was with our then Commander J.P. Brown, who worked with
Judge Robert T. Russell in Buffalo, NY. Commander Brown took
that knowledge and helped create a very active veterans
treatment court in his own homestate of Ohio, and AMVETS
appreciates that S. 946 would add more Veterans Justice
Outreach specialists, particularly since there are so many
solid systems in place to help veterans, but none will properly
function without adequate staffing.
The two bills that we are unable to support center around
Choice, and I think that some of the remarks we have prepared
have already been said today by a couple of the Senators. But,
allowing veterans the open-ended ability to seek care in the
private sector is a concern.
On the one hand, Choice sounds like a great proposition,
but on the other, we are concerned that implementing a broader
Choice Program will either intentionally or unintentionally
dismantle the VA health care system. This, we oppose.
As you know, Choice is currently in need of more than $4
billion in emergency appropriations or in a shift of funds
between VA accounts in order for the program to continue
providing the often life-saving health care to our Nation's
veterans.
We have recently heard that due to funding shortfalls
within the Choice Program, that veterans are again being
stacked in a line each day rather than receiving care in the
community. The fact that veterans are again being forced to
wait for health care, even within the program designed
specifically to alleviate that, is quite a red flag. Something
is broken here, and Choice is not fixing it.
Late last month, this Committee received a joint VSO letter
that included AMVETS, which outlined our collaborative deep
concerns. While AMVETS supports the funding needed to continue
Choice through fiscal year 2018, we do not support expanding
the program. It is imperative that funds are used to invest
back into the VA system of care in order to remedy capacity
issues and fill the over 40,000 job vacancies, so the system is
able to consistently care for enrolled veterans in a timely
fashion.
The joint VSO letter also noted that there are at least 27
VA health care facility leases and dozens of construction
projects requiring billions of dollars in funding in order to
sustain and expand VA's capacity for care. Why not invest in a
system of care that has already been designed to meet the needs
of veterans? Pushing veterans further and further into the
private sector is not going to solve anything, whether in cost
savings or in health outcomes. We have only been able to
ascertain that the national health care spending is growing at
quite a fast clip, and the system is rife with quality and
access-to-care issues.
We mentioned in our written testimony that currently over
30 percent of veterans receive their health care through fee
basis and community care, and the proposed measures to expand
Choice will potentially break the VA health care system, which
polls do show is superior to care received in the private
sector once the veteran can get in.
While AMVETS absolutely supports the public-private
partnership where it makes sense, often in the rural and highly
rural areas, in order to serve the health care needs of
veterans, what we hear is that veterans want VA health care to
work for them. Pushing the funding to the private sector
instead of within this large system of specialized care seems
more like a bleed-em-dry strategy that concerns us.
We look forward to working with this Committee to address
the many issues facing our veterans in today's complex and
challenging health care environment, and thank you again for
the opportunity to testify today. I am open to answer any
questions you may have.
Thank you.
[The prepared statement of Ms. Webb follows:]
Prepared Statement of Amy Webb, National Legislative Policy Advisor,
AMVETS
Chairman Isakson. Thank you, Ms. Webb.
Mr. Atizado?
STATEMENT OF ADRIAN ATIZADO, DEPUTY NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
Mr. Atizado. Chairman Isakson, Ranking Member Tester, and
Members of the Committee, I want to thank you for inviting DAV
to testify on the legislation and draft bills under
consideration for today's hearing.
DAV is a non-profit veterans service organization dedicated
to a single purpose, which is to empower veterans to lead high-
quality lives with respect and dignity.
Today's hearing is critically important to DAV's 1.3
million wartime service-disabled veterans. Most of them choose
and rely heavily or entirely on the VA health care.
For the sake of brevity, I will limit my comments to a few
of those bills which DAV supports on the agenda today.
DAV endorses S. 683, the Keeping our Commitment to Disabled
Veterans Act of 2017, which would extend until 2018, the
requirement for VA to provide nursing home care to certain
service-connected disabled veterans. As Senator Hirono had
mentioned, over 22,000 severely disabled service-connected
veterans would benefit from this bill.
DAV supports S. 833, the Servicemembers and Veterans
Empowerment and Support Act of 2017, which would expand
military sexual trauma counseling and treatment and ease some
of the evidentiary requirements for veterans filing claims for
service connections, for conditions related to military sexual
trauma.
DAV supports S. 946, the Veterans Treatment Court
Improvement Act, which would require VA to hire additional
Veterans Justice Outreach Specialists to provide treatment
court services. As an organization, DAV recognizes the
importance of veterans treatment courts and are pleased to
inform you, this Committee, that many of our DAV members across
the country have and continue to volunteer to serve as mentors
for justice that involve veterans in these courts.
DAV supports S. 1261, the Veterans Emergency Room Relief
Act. This would require VA to include urgent as well as
emergency care as part of VA's medical benefits package. To
further strengthen this important measure, we ask the Committee
to consider inserting language, allowing VA to also enter into
agreements in addition to contracts with urgent care providers.
Finally, DAV is pleased to support the draft bill titled
``Improving Veterans Access to Community Care Act of 2017,''
this pursuant to DAV Resolution 238. Mr. Chairman, that
resolution calls on the Nation to honor the service and
sacrifices of our Nation's ill and injured veterans by
strengthening, reforming, and sustaining a modern, high-
quality, accessible, and accountable VA health care system. It
also asks that in order to provide timely and convenient access
to enrolled veterans, the VA health care system must evolve. It
must become and it must create integrated health care networks
with high-quality community providers where needed. This
includes DOD and academic affiliates as VA acting as a network
coordinator and principal provider. This is to ensure
integrated, high-quality, comprehensive, and veteran-focused
health care for our Nation's veterans.
Our members recognize that despite improvements in the VA
health care system over the years, some veterans are
experiencing uneven and delayed access to quality veteran-
centered care. Even before the Choice Program was implemented,
VA's legacy purchased care programs were both cumbersome and
operated as local endeavors. The problems with these include no
central support structure to track not only how long it took
for veterans to get care in the community, but whether the care
they received in the community is equivalent to the care that
they receive in VA, that it is a positive impact on veterans'
health outcomes and whether the veterans are satisfied with
that care.
The Improving Veterans Access to Community Care Act of 2017
contains many provisions and aligns with the overall approach
proposed by DAV, the Independent Budget, other VSOs, as well as
the Commission on Care, and the VA. While there are some
improvements we would recommend and work with the Committee on,
this bill seeks to preserve those critical components of the VA
health care system beyond just delivering care. VA has other
missions such as research, education, and training. Members
here just talked about the problems with health care staffing
in the Nation, of which VA plays a critical role in supplying
that to the Nation's patient population. This bill allows VA to
modernize, which must happen if it is to be a true partner in
an integrated, high-performing health care network.
Mr. Chairman, there is so much more to discuss. We look
forward to working with you and your staff to address this
issue as well as improve other VA health care services for our
Nation's veterans.
This concludes my statement. I would be happy to answer any
questions you or other Members of the Committee may have.
Thank you.
[The prepared statement of Mr. Atizado follows:]
Prepared Statement of Adrian Atizado, Deputy National Legislative
Director, Disabled American Veterans
Chairman Isakson, Ranking Member Tester, distinguished Members of
the Committee: Thank you for inviting DAV (Disabled American Veterans)
to present our views on the bills under consideration at today's
hearing. As you know, DAV is a non-profit veterans service organization
comprised of nearly 1.3 million wartime service-disabled veterans. DAV
is dedicated to a single purpose: empowering veterans to lead high-
quality lives with respect and dignity.
s. 115, the veterans transplant coverage act
Depending where a veteran resides in relation to a Department of
Veterans Affairs (VA) Transplant Center, the Department may only cover
transplant procedures for veterans from deceased donors limiting the
possibility of finding an organ match from relatives. Additionally, VA
national policy indicates VA will only cover the transplant-related
round-trip travel and lodging costs for the living donor and a support
person. Unless the veteran is the live donor, post-transplant care is
not provided by VA.\1\
---------------------------------------------------------------------------
\1\ VHA Directive 2012-018, Solid Organ and Bone Marrow
Transplantation; VHA Handbook 1102.1, National Surgery Office;
---------------------------------------------------------------------------
This bill authorizes VA to provide veterans coverage for live donor
transplant operation procedures at any health care facility if the
veteran qualifies for the VA Choice Program. The VA would be required
to fully fund all care and services before and after the transplant
procedure.
DAV has no resolution from our membership to support this draft
bill; however, its purpose appears beneficial for veterans in need of
this specialized care; therefore, we have no objection to its favorable
consideration by this Committee.
s. 426, the grow our own directive: physician assistant employment and
education act of 2017
If enacted, this bill would direct VA to carry out a pilot program
to provide educational assistance to certain veterans with the goal of
employment as VA physician assistants.
Under this bill, the pilot program would target veterans with
experience gained in medical or military health care while serving, and
who had received a certificate, associate degree, baccalaureate degree,
master's degree, or post-baccalaureate training in a science related to
health care, and had participated in the delivery of health care
services or related medical services.
The bill would require VA to provide educational assistance,
including no fewer than 25 scholarships, to participants employed each
year of the pilot program. VA would be required to reimburse their
costs of obtaining master's degrees in physician assistant studies or
similar master's degrees, consistent with VA's existing health
professions scholarship program authorized in Chapter 76 of title 38,
United States Code. The bill would require VA to make available mentors
for participants at each VA facility and would require VA to establish
partnerships with other government programs and with a specific number
of educational institutions that offer degrees in physician assistant
studies. It would also require selectees to agree to an obligated work
period.
The bill also would require VA to establish standards to improve
the education and hiring of VA physician assistants, and implement a
national plan for the retention and recruitment of VA physician
assistants.
The bill would establish a series of new, mandatory positions in
VA's national Office of Physician Assistant Services in VA Central
Office, including a Deputy Director for Education and Career
Development, a Deputy Director for Recruitment and Retention, a
designated recruiter of physician assistants, and an administrative
assistant to support these functions. The bill would outline their
major duties.
The bill would re-designate not less than $8 million in funds
appropriated prior to the passage of this bill to carry out its
purposes. The bill is silent on sources of additional funding that
might be needed to meet its mandates.
Finally, the bill would align VA physician assistant pay grades
equivalent to the pay grades of VA registered nurses.
DAV does not have a resolution from our membership specific to VA
recruitment, training or employment of physician assistants as a single
employment category, but we recognize the value of this bill in
improving health provider manpower in the VA, and especially in
addressing shortages being observed today in VA's primary care provider
workforce. On this basis DAV would not object to enactment of this
bill.
s. 683, the keeping our commitment to disabled veterans act of 2017
DAV endorses S. 683 and calls for swift enactment of this
legislation based on DAV Resolution 142, which calls for enactment of
legislation to expand the Department of Veterans Affairs (VA)
comprehensive program of long-term supports and services (LTSS),
including nursing home care, for service-connected disabled veterans.
This bill would extend an expiring requirement under law that the
VA provide nursing care for certain veterans with service-connected
disabilities. VA is legislatively mandated by the Veterans Millennium
Health Care and Benefits Act (Public Law 106-117) to provide continuing
nursing home care for enrolled veterans who have a 70 percent or
greater service-connected disability, as well as those who need such
care for a service-connected disability, or who have a rating of total
disability based on individual unemployability.
According to VA, there were around 21,300 veterans nationwide who
met the legislative mandate for nursing home care in fiscal year (FY)
2016. VA estimates there will be over 21,800 veterans treated under
this legislative mandate in 2017 and this number is projected to
increase to over 22,200 in FY 2018 and over 22,600 in FY 2019. Without
extension of the current mandate by Congress beyond December 31, 2017,
VA would no longer be required to provide this critical LTSS coverage
to service-disabled veterans.
Unlike other modeled services, reliance on certain LTSS does not
decline after Medicare eligibility, due to limited Medicare coverage
for long-stay nursing home services and in-home and community based
services. Currently, World War II and Korean War era enrollees are in
the age bands that are the highest users of LTSS. Likewise, Vietnam era
veterans will be needing and seeking a greater share of LTSS, with most
having aged beyond 75 over the next ten years.
S. 833, the Servicemembers and Veterans Empowerment and Support Act
of 2017
Section 2 of S. 833, the Servicemembers and Veterans Empowerment
and Support Act of 2017, would expand eligibility for VA counseling and
treatment for sexual trauma, to include ``cyber harassment of a sexual
nature'' to the definition of MST. It also expands the authority of the
Secretary to provide counseling and care to members of the Armed Forces
who suffered MST and are currently on ``active duty for training,'' or
``inactive duty training'' in addition to servicemembers on active
duty.
Section 3 of the measure seeks to relax the standard of proof for
MST-related claims by amending Section 1154 of title 38, United States
Code (U.S.C.) by adding a new section. Specifically, the bill would
require that a veteran who claims that a mental health condition began
in, or was aggravated by MST during active service the VA shall accept
as sufficient proof for service-connection: 1) a diagnosis of the
mental health condition by a mental health professional along with
satisfactory lay evidence or other evidence of such trauma, 2) and an
opinion by the mental health professional that the mental health
condition is related to such MST if consistent with the circumstances,
conditions, or hardships of service even without an official record of
such incurrence or aggravation in service. Furthermore, the bill would
require VA to resolve every reasonable doubt in favor of the veteran
with the reasons for granting or denying service-connection recorded in
full.
Under this bill, a covered mental health condition would be defined
as Post Traumatic Stress Disorder (PTSD), anxiety, depression, or other
mental health diagnosis described in the current version of the
Diagnostic and Statistical Manual of Mental Disorders published by the
American Psychiatric Association, that the Secretary determines to be
related to MST. MST is defined as a physical assault of a sexual
nature, battery of a sexual nature, or sexual harassment which occurred
during active military service.
S. 833, codifying existing regulations related to the evaluation of
claims for compensation involving MST and requires the Secretary to
ensure that non-military sources of evidence that may support the claim
are specified and used in adjudication of the claim. Examples of such
evidence include: records from law enforcement authorities; rape crisis
centers; mental health counseling centers; hospitals and physicians;
pregnancy tests and tests for sexually transmitted diseases; statements
from family members, roommates or other members of the Armed Forces or
veterans and clergy. Evidence of behavioral changes can also be
considered in support of a claim for service connection to include, a
request for transfer to another duty assignment; deterioration of work
performance; substance abuse; episodes of depression; panic attacks or
anxiety without an identifiable cause; and unexplained economic or
social behavior changes.
The bill requires that VA may not deny a claim of a veteran for
compensation for PTSD that is based on an assault, battery, or
harassment without first advising the veteran that evidence described
above may constitute credible corroborating in their claim and allow
the veteran an opportunity to furnish such evidence or advise the
Secretary of potential sources of that evidence.
S. 833 also requires the VA to report to Congress not later than
March 1, 2018 and once a year afterward to 2027, on claims covered in
this section submitted during the previous fiscal year. Reports are
required to identify and track claims decision trends across regional
offices. Each report shall include: the number of claims submitted; of
those claims the number and percentage submitted by sex; the number of
claims denied, to include the number and percentage of those denied
claims for each sex; the number and percentage of claims that were
approved, disaggregated by sex, of claims assigned to each rating
percentage. The bill also requires VA include the three most common
reasons for denials to include the number of denials that were based on
failure of a veteran to report for a medical examination.
Section 4 of the bill directs the VA to ensure that DOD Sexual
Assault Response Coordinators advise members of the Armed Forces who
report an incident of MST that counseling services are available at VA
Vet Centers.
For decades, VA treated claims for service connection for mental
health problems resulting from MST in the same way it treated all
claimed conditions--the burden was on the claimant to prove the
condition was related to their military service. These types of claims,
without validation from medical, investigative or police records, were
routinely denied.
More than a decade ago, VA relaxed its policy of requiring medical
or police reports to show that MST occurred. 38 CFR 3.304 (f)(5)
provides for a liberalization of requirements for establishment of
service connection due to personal assault, including MST, even when
documentation of an ``actual stressor'' cannot be found, allowing
evidence in other records to serve as a ``marker'' indicating that a
stressor may have occurred instead. Nevertheless, since 2002, VA has
denied many claims for mental health conditions resulting from MST
because claimants were unable to produce evidence that an assault or
harassment occurred. Between 2008 and 2012, VA verified that grant
rates for PTSD resulting from MST were 17 to 30 percent below grant
rates for PTSD resulting from other causes.
Unfortunately, for various reasons including fear of potential
retaliation, personal shame or embarrassment and impact on career,
survivors of MST often do not report sexual trauma to medical or law
enforcement authorities. Lack of reporting results in a
disproportionate burden placed on veterans to produce evidence of MST.
Full disclosure of incidents occurring during service tend to be
reported years after the fact, making proof of service connection for
PTSD and other mental health conditions even harder to establish.
Demonstrating a causal relationship between certain injuries and later
established disability can be daunting due to lack of records or human
factors that obscure or prevent documentation or even basic
investigation of such incidents after they occur.
Sexual trauma during military service is ever more recognized as a
hazard of service for one percent of men and 20 percent of women who
have served. It often later manifests in heavy burdens of mental health
conditions for veterans and the need for complex care and specialized
treatment required from VHA. An absence of documentation of military
sexual trauma in the personnel or military unit records of individuals
often prevents or obstructs adjudication of claims for disabilities of
this group veterans suffering the devastating after-effects of sexual
trauma associated with military service.
Enacting this legislation would expand MST counseling and treatment
and ease some of the evidentiary requirements for veterans filing
claims for service-connection for conditions related to the after-
effects of a MST. DAV supports S. 833, the Servicemembers and Veterans
Empowerment and Support Act of 2017, in accordance with DAV Resolution
No. 027 to improve the process for determining service connection for
conditions related to sexual trauma.
s. 946, the veterans treatment court improvement act
The bill requires the VA to hire additional Veterans Justice
Outreach (VJO) specialists to ensure veterans have greater access to
effective and tailored treatment. VA created the VJO program to provide
veterans with timely access to VA services and engage justice-involved
veterans in specialty treatment courts. The veterans' treatment court
model removes veterans from the regular criminal justice process and
helps to address symptoms that are unique to veterans, including Post
Traumatic Stress Disorder and substance abuse disorder. In a veterans'
treatment court, the presiding judge works alongside the veteran and
the VJO specialist to establish a structured rehabilitation program
that is tailored to the specific needs of that veteran.
The bill would authorize $5.5 million for each fiscal year
beginning in FY 2017 through 2027 to hire 50 additional VJO
Specialists. Funding priority would be given to VA facilities that work
with newly established or exiting but understaffed veterans' treatment
courts. VA is required to annually report on the implementation of the
bill and its effect on the VJO program. The Government Accountability
Office is also required to review and report on the implementation of
the bill and the overall effectiveness of the VJO program for justice-
involved veterans.
DAV supports S. 946 based on DAV resolution 124 calling for the
continued growth of veterans' treatment courts. We recognize the
importance of this program and are pleased to inform you that DAV
members across the country have volunteered to serve as mentors in
veterans' treatment courts.
s. 1153, the veterans access act
DAV supports this legislation that would require the Secretary to
make ineligible any non-VA health care provider seeking to provide care
to veterans through any of VA's purchased care authorities if the
provider had been removed from VA employment or had a VA credential
revoked because they endangered the health or safety of patients, or if
they had violated any other medical licensure requirements. The
legislation would also give the Secretary authority to make ineligible
any provider under investigation by a medical licensing board, or who
has entered into a settlement agreement for disciplinary action related
to their medical practice, if the Secretary deems them a threat to the
health, safety or welfare of veterans. In addition, the legislation
requires the Secretary to suspend eligibility of any health care
provider to provide non-Department health care services to veterans if
the health care provider has already been suspended from practicing
within VA.
DAV Resolution 238 calls for, ``. . . strengthening, reforming and
sustaining a modern, high-quality, accessible and accountable VA health
care system; AND . . . creating integrated networks with high-quality
community providers where needed . . .'' S. 1153 would contribute to
improving the quality of providers within such integrated networks by
helping to preclude certain health care providers when VA is aware they
have a documented record of endangering patient health or safety.
s. 1261, the veterans emergency room relief act of 2017
Mr. Chairman, DAV supports S. 1261, the Veterans Emergency Room
Relief Act of 2017, in accordance with DAV Resolution 240 which calls
upon Congress to authorize urgent care as part of VA's basic health
benefits package. VA provides a comprehensive health benefits package,
yet the availability of urgent care has remained problematic because,
in many locations, VA health care services are not offered on weekends,
holidays, evenings and nights. The prudent layperson standard VA has
used as one of the criteria to establish eligibility for VA
reimbursemennt for emergency care and the rules for contacting VA to
ensure veterans are reimbursed for such care are confusing to veterans
and inconsistently applied by VA staff responsible for completion of
these claims. These factors frequently result in denial of
reimbursement for emergency room care and create a significant
financial hardship for many disabled veterans.
This bill, authorizing VA to provide reimbursement to veterans who
receive urgent care services, fills an important coverage gap for
veterans who rely upon VA for care. It also has the potential to create
cost savings for VA by allowing veterans to seek care in non-VA urgent
care centers which are less costly than hospital emergency rooms. The
National Center of Health Statistics found that almost half of
emergency room patients (48%) came there because their primary care
doctors were not available. Urgent care fills the gap between the truly
emergent care for conditions that may result in the loss of life or
limb (which require advanced trauma care treatment), and less complex
acute conditions, such as respiratory and skin infections, sprains,
back pain or other minor injuries, that require attention and
treatment, but would normally be addressed by primary care doctors if
they were available. To further strengthen this important measure, we
ask the Committee to consider inserting language allowing the VA to
enter into agreements in addition to contracts with urgent care
providers.
This measure requires the Secretary to establish co-payments for
urgent care services for certain veterans. However, veterans who are
hospitalized as a result of their urgent care visit and veterans
seeking care for a service-connected condition in addition to veterans
meeting criteria for hardship exceptions would be exempt from
copayments.
DAV supports this legislation to include urgent and emergency care
as part of VA's medical benefits package, consistent with DAV
Resolution No. 240.
s. 1266, the enhancing veteran care act
S. 1266, the Enhancing Veteran Care Act, would authorize the
Secretary of Veterans Affairs to enter into contracts with qualified
nonprofit organizations to investigate VA medical centers for the
purposes of assessing and reporting any deficiencies identified.
This measure requires the Secretary to delegate the authority to
contract for an investigation to the director of the Veterans
Integrated Service Network (VISN) in which the medical center is
located or the director of the medical center. Before entering into a
contract the VISN or medical center director would be required to
notify the VA Secretary, the VA Inspector General and the Comptroller
General of the United States to ensure there is coordination of any
ongoing investigations.
DAV has no resolution from our membership regarding the specific
topic of this legislative proposal and takes no formal position on the
bill.
s. 1279, the veterans health administration reform act of 2017
The Veterans Health Administration Reform Act of 2017 would rewrite
VA's existing purchased care authority by establishing a new ``Care in
the Community'' program with streamlined eligibility when VA determines
it is in the veteran's clinical best interest, including consideration
of timeliness, or when the veteran faces undue access burdens, such as
excessive driving distance, or when VA determines it is not economical
to directly provide the care. The bill requires VA to reach agreements
with the Department of Defense, Indian Health Services and other
federally qualified health centers for the provision of care to
eligible veterans. It also authorizes provider agreements for VA to
engage community health care providers. Administration of the program
and coordination of veterans health care would remain within VA.
S. 1279 also seeks to improve timely access to care by authorizing
reimbursement for emergency and urgent care services, improving
coordination of care for veterans eligible to use Medicare and
Medicaid, and making other changes to educate veterans and VA about
access options for enrolled veterans.
Although DAV does not have resolutions regarding some of the
innovative ideas in the legislation, we support the overall intent of
the legislation to strengthen and expand options for veterans to
receive care from community providers when VA is unable to directly
provide timely, high quality care, as called for in DAV Resolution 238.
s. 1325, the better workforce for veterans act of 2017
S. 1325, the Better Workforce for Veterans Act of 2017, a
comprehensive measure to streamline and strengthen hiring practices at
the Department of Veterans Affairs (VA) includes provisions to address
chronic workforce shortages by improving recruitment efforts, hiring
practices, and training and retention of quality employees.
The bill would allow direct hiring of students and recent graduates
into competitive and excepted services and would provide authority for
VA to hire former Federal employees for certain high demand positions.
It would authorize VA to hire senior executives using resume-based
hiring techniques and require VA to determine the effectiveness of
recruiting and hiring activities as well as the creation of a
standardized exit survey for VA employees. We do note that in creating
new flexibilities, caution must be taken to ensure that VA still
adheres to existing merit review principles including veteran,
minority, and disability status of job candidates and new hires.
S. 1325 would require that reductions in force consider performance
and the establishment of a process for public-private talent exchange.
The bill also requires a report on workforce vacancies within the
Veterans Health Administration (VHA); evaluation of pay for medical
center directors and VISN directors; and the establishment of a human
resources academy within VHA. We note that experts and panels, such as
the congressionally established Commission on Care, recommended VA
further review and amend its own policies to streamline and reduce
redundancies and inefficiencies in its recruitment and hiring
processes. We are pleased to see the emphasis on the development of the
VA's human capital management talent in this bill and we encourage the
Committee to hold VA accountable for reform from within the agency.
DAV Resolution No. 244, in part, calls for modernization of VA's
human resources management system to enable VA to compete for, recruit
and retain qualified employees needed to provide comprehensive quality
health care services to our Nation's sick and disabled veterans. While
we do not have a resolution from our membership related to all of the
specific provisions in this bill, we support the overarching goal of
S. 1325, aimed at helping VA to fill important health professional
staff vacancies, including key leadership positions within VHA, which
is integral and essential for providing veterans timely access to
quality care.
draft bill, department of veterans affairs quality employment act of
2017
This draft bill, the Department of Veterans Affairs Quality
Employment Act of 2017, contains provisions that are aimed at improving
the Department of Veterans Affairs' (VA) authority to hire and retain
physicians and other employees. The bill would establish an executive
management fellowship program, require a process for assessing the
performance of political appointees, allow VA to directly hire
physicians who have satisfactorily completed residency training in the
Veterans Health Administration (VHA); establish mechanisms to improve
human resources activities including, recruitment, hiring and retention
of quality employees and require that the Government Accountability
Office review succession and workforce planning within the Department.
As we noted with regard to S. 1325 above, DAV supports the goal of
this bill in accord with DAV Resolution No. 244, which, in part, calls
for modernization of VA's human resources management system to enable
VA to compete for, recruit and retain qualified employees needed to
provide comprehensive quality health care services to our Nation's sick
and disabled veterans. While we do not have a resolution from our
membership related to all of the specific provisions in this bill, we
support the overarching goal of this draft bill.
discussion draft, the veterans choice act of 2017
DAV Resolution 238 calls on the Nation to:
``. . . honor the service and sacrifices of our Nation's ill
and injured veterans by strengthening, reforming and sustaining
a modern, high-quality, accessible and accountable VA health
care system; AND . . . in order to provide timely and
convenient access to enrolled veterans, the VA health care
system must evolve by creating integrated networks with high-
quality community providers where needed, including the
Department of Defense and academic affiliates, with VA acting
as the network coordinator and principal provider to ensure
integrated, high-quality, comprehensive and veteran-focused
health care.''
As currently drafted, the Veterans Choice Act of 2017 is not in
alignment with the goals contained in DAV Resolution 238. Although
there are some provisions within the measure that DAV could support,
DAV opposes the draft bill because the overall effect would lead to
fragmented and uncoordinated care for millions of enrolled veterans,
leading to worse health outcomes. Further, the enormous cost of
unfettered choice proposed by the bill, as well as the resultant impact
on VA's ability to maintain the critical mass necessary to provide a
full continuum of care to enrolled veterans, particularly disabled
veterans, would endanger the long term viability of the VA health care
system.
The draft bill would require VA to pay for private sector care for
every enrolled veteran seeking any health care service from any
qualified health care provider without any authorization or even
consultation required from any clinical entity responsible for
coordinating their care. The congressionally-mandated Commission on
Care (Commission) considered and debated similar unfettered choice
proposals during the last Congress, but ultimately rejected them
because they concluded such proposals were both clinically unsound for
veterans and financially unfeasible for VA or the Federal Government.
Our main objection to the draft bill is that it would create a
separate and operationally-distinct community care network in which VA
is simply a payer of care, a concept we strongly disagree with because
it would lead to uncoordinated and fragmented care for millions of
veterans. The final report by the Commission on Care concluded that,
``veterans who receive health care exclusively through VHA generally
receive well-coordinated care, yet care is often highly fragmented
among those combining VHA care with care secured through private health
plans, Medicare, and TRICARE. This fragmentation often results in lower
quality, threatens patient safety, and shifts cost among payers.'' \2\
Furthermore, VA's primary care (medical home) model with integrated
mental health care has proven more likely to prevent and treat
conditions unique to or more prevalent among veterans, particularly
those with disabilities or chronic conditions. For these reasons, DAV,
our partners in the Independent Budget, other VSOs, the Commission on
Care and Secretary Shulkin all favor the approach of building
integrated networks with a modernized VA health care system acting as
the coordinator and primary provider of care, along with other Federal
and community providers offering high quality health care options for
veterans, whenever and wherever necessary.
---------------------------------------------------------------------------
\2\ Commission on Care. (2016). Commission on Care: Final Report.
Page 28. Accessed July 5, 2017 from https://s3.amazonaws.com/sitesusa/
wp-content/uploads/sites/912/2016/07/Commission-on-Care_Final-
Report_063016_FOR-WEB.pdf
---------------------------------------------------------------------------
Although no cost estimates for the draft bill were made available
to us, economists working for the Commission did analyze a number of
similar proposals that offered varying levels of choice, including
unfettered choice, and their projections provide benchmarks. The
Commission recommended an option in which enrolled veterans could
choose their primary care providers from within an integrated network,
but limited their choices for specialty care. The Commission noted that
in establishing integrated networks, VA ``. . . must make critical
tradeoffs regarding their size and scope. For example, establishing
broad networks would expand veterans' choice, yet would also consume
far more financial resources . . .'' By contrast, the draft measure
does not appear to contemplate any such tradeoffs in terms of network
size or veteran choice.
The Commission's economists estimated that the recommended limited
choice option would increase VA spending by at least $5 billion in the
first full year, though they cautioned that it could be as high as $35
billion without strong management control of the network. The
Commission's economists also analyzed an unfettered choice option to
allow veterans the ability to choose any VA or non-VA provider--without
requiring them to be part of any defined network. The economists
estimated such a plan could cost up to $2 trillion more than current
projections for VA expenditures over the first ten years. Based on the
premise that the draft bill would provide unfettered choice for all
enrolled veterans, create an extremely broad--almost universal--
network, and lacks any effective coordination mechanisms, it seems
likely the costs to implement such a proposal would be significant,
somewhere between the estimates for the two Commission options
discussed above. In today's fiscal environment, it seems unrealistic
such dramatic spending increases would be appropriated or sustained,
and even if approved, the cost shift and patient migration to private
care would ultimately endanger the viability of the VA health care
system.
It is imperative that any veterans health care reform measure must
improve the overall delivery of high-quality care to enrolled veterans,
both directly by VA and by community partners. To accomplish this goal,
as Secretary Shulkin has repeatedly testified, it is essential to
modernize the VA health care system in numerous ways, including, but
not limited to addressing: challenges in recruiting, hiring and
retaining the best and brightest; deficiencies in capital
infrastructure--beginning with VA leases which have not been authorized
since 2012; critical gaps in VA's medical care benefits package,
particularly access to urgent care in the community; the need to change
VA's authority to provide veterans greater access to telemedicine;
inadequate clinical grievance and appeals processes available to
veterans when there is a difference of opinion between the patient and
provider; and budget, appropriations and internal accounting processes
that impede fully funding and efficiently utilizing resources provided
to VA health care.
These are but some areas identified in the sweeping 4,000-page
Independent Assessment Report issued in 2014 and the subsequent
Commission on Care report of 2016, both of which recommended taking an
integrated systems approach to addressing challenges hindering VA's
consistent delivery of timely, high-quality health care to our Nation's
veterans. These reports and other independent experts agree that care
delivered by VA is in many ways comparable or better in clinical
quality to that generally available in the private sector, however it
is inconsistent from facility to facility, and can be substantially
compromised by problems with access, service, and poorly functioning
operational systems and processes. If left unaddressed, problems with
staffing, facilities, capital needs, information systems, procurement
and health disparities threaten the long-term viability of VA care and
the health and well-being of millions of veterans who choose VA to meet
their health care needs.
The Commission, VA and the VSO community all agree that building an
integrated, high performing VA health care network should focus on the
most cost-effective, compatible, and highest quality community
partners, specifically the Department of Defense (DOD), the Indian
Health Service (IHS), and other Federal health systems, as well as
university hospitals that have existing academic affiliations with VA,
followed by the best of private providers. Utilizing these providers
first would capitalize on the cultural and military competence
inculcated in VA health and offered by Federal partners and academic
medical centers affiliated with VA. It is important to note that VA's
relationship with U.S. medical schools and teaching hospitals has
benefited our Nation's ill and injured veterans and serves this
Nation's medical education system by helping train more than 20,000
individual medical students and more than 40,000 individual medical
residents within VA facilities. In fact, the VA health care system
represents the largest training site for physicians, and funds
approximately 10 percent of national graduate medical education costs
annually. Strengthening VA's relationships with academically-affiliated
medical centers supports this critical pipeline of clinicians that
serves not just veteran patients but the U.S. patient population in
general.
To ensure the overall quality of health care provided to enrolled
veterans, VA must retain responsibility as the coordinator and
principal provider of veterans care. Decisions about veterans' access
to community network providers should be based on clinical
determinations and veteran preferences. Such shared decisionmaking
would involve veteran patients as active partners with the clinician in
treatment decisions, to clarify acceptable medical options and choose
appropriate treatments. While not all patients want to play an active
role in choosing a treatment, most want clinicians to inform them and
take their preferences into account. The draft bill, however, would
result in a system in which veterans who choose to use community care
are often left on their own to make critical decisions about health
care treatment options, without clinical guidance.
The draft bill also lacks mechanisms to assess the value of care VA
purchases from non-Department providers, to review the quality of
community care veterans receive, how it impacts veterans' health
outcomes, and veterans' satisfaction in the same manner as the care VA
directly provides veterans. Without such metrics it is difficult, if
not impossible, to ensure the highest levels of quality and safety for
veterans. Moreover, because the draft bill lacks strong coordination
between VA and community providers, the quality of care could be
adversely affected if important clinical information is not promptly
and clearly communicated between VA, Federal and community providers.
Mr. Chairman, although DAV opposes the draft bill in its current
form, we remain committed to working with you and the Committee to
develop long-term health care solutions so that ill and injured
veterans have increased access to timely, high quality, cost-effective
care in a high performing, integrated VA health care network.
discussion draft, improving veterans access to community care act of
2017
Pursuant to DAV Resolution 238 calling for strengthening, reforming
and sustaining the VA health care system, DAV is pleased support this
measure which would improve access to care in the community, while
preserving and enhancing the unique benefits and vital services VA
provides to DAV members and all eligible veterans. The draft bill
includes many of the recommendations put forward by DAV, other VSOs, VA
and the Commission on Care, and embodies the shared approach of
building integrated networks with a modernized VA health care system
acting as the coordinator and primary provider of care, along with
other Federal and community providers offering high quality health care
options for veterans, whenever and wherever necessary.
DAV and our Independent Budget (IB) partners have proposed a
comprehensive framework to reform VA health care based on the principle
that it is the responsibility of the Federal Government to ensure that
disabled veterans have proper access to the full array of benefits,
services and supports promised to them by a grateful Nation. In order
to achieve this goal, our comprehensive framework has four pillars--
Restructure, Redesign, Realign, and Reform. We offer our views on
specific provisions of this draft bill, the Improving Veterans Access
to Community Care Act of 2017, which we believe fit within this
framework and recommend it be part of the final legislation this
Committee passes to reform VA health care.
I. Restructure our Nation's system for delivering health
care to veterans, relying not just on a Federal VA
and a separate private sector, but instead creating
local Veterans-Centered Integrated Health Care
Networks that optimize the strengths of all health
care resources to seamlessly integrate community
care into the VA system to provide a full continuum
of care for veterans.
Veterans-Centered Integrated Health Care Networks
To this end, we believe the health care network contemplated in
this draft measure would most likely yield the local Veterans-Centered
Integrated Health Care Networks. Like private sector health care plans
and larger provider systems that offer health coverage, the proposed
section 1730A(c)(4) of this measure will allow VA to create a tiered
network that would best meet the expectations of veteran patients at
the local level.
This kind of integrated network should provide veterans information
they would need to make informed decisions. For example, information
about the quality of the community providers in this network will give
veterans the ability to discern between those community providers that
are more knowledgeable about the veteran experience and unique needs,
information about the satisfaction rating from other veterans who have
seen that provider, and whether there is a good working relationship
with the VA that facilitates care coordination.
This integrated network would create and preserve the kind of
community-VA provider partnership that mirrors the care our members
value most in the VA health care system. We also support the provision
that would prohibit VA from limiting veterans to receiving care or
services from an entity in a specific tier.
To that the formation of local Veterans-Centered Integrated Health
Care Networks leads to an overall high performing network, our
framework places VA as the coordinator and principal provider of care,
which is discussed in detail below. The development of VA's current
primary care (medical home) model with integrated mental health care
has proven more likely to prevent and treat conditions unique to or
more prevalent among veterans, particularly those with disabilities or
chronic conditions.
II. Redesign the systems and procedures by which veterans
access their health care with the goal of expanding
actual, high-quality, timely options; rather than
just giving them hollow choices:
Care Coordination
We strongly urge the Committee to preserve the organizational model
required in Section 106 of the Veterans Access, Choice, and
Accountability Act of 2014 (Public Law 113-146; title 38, United States
Code, 1701 note) in any future consolidation of VA's purchased care
authorities. Section 106 effectively created a ``wall'' that separated
the financial and clinical operations of the current Choice program,
which better insulated front-line clinicians, such as VA Community
Health Nurse Coordinators, social workers, or other VA health care
professionals against the fiscal pressures that have been known to sway
clinical decisions and delay or deny community care to veterans.
DAV also strongly urges the Committee to discontinue the current
arrangement under the Choice program that has effectively removed a
critical part of the care coordination responsibility away from VA
front-line clinicians. VA Community Health Nurse Coordinators are the
veteran's case manager and coordinators of care who work with the
veteran's health care team to provide for the veteran patient's
medical, nursing, emotional, social and rehabilitative needs as close
to and/or in the veteran's home.
While VA Community Health Nurse Coordinators are now better able to
exercise their clinical authority due to the Section 106
reorganization, they are frustrated having lost their ability under the
current Choice program to act as a liaison between community providers
and VA and as an advocate for their veteran patients--who themselves
have unsuccessfully tried to exercise their Choice option and asked for
assistance from their VA nurse coordinator--to get the care they need
in the community.
We strongly support the proposed section 1730A(a)(2) in this bill
that requires VA coordinate veterans care especially if that care is
provided in the community and paid for by the Department.
Community Care Eligibility
For veteran patients, waiting for a health service begins when the
veteran and the appropriate clinician agree to a service, and when the
veteran is ready and available to receive it. We believe it is time to
move toward a health care delivery system that keeps clinical decisions
about when and where to receive care between a veteran and his or her
doctor--without bureaucrats, regulations or legislation getting in the
way. We urge the Committee to consider that as the new local Veterans-
Centered Integrated Health Care Networks are fully phased in, decisions
about providing veterans access to community network providers should
be based on clinical determinations and veteran preferences, rather
than arbitrary time or distance standards that exist in the current
Choice program.
While this measure proposes a standardize eligibility criteria for
veterans to receive clinically necessary care in the community, we
stand ready to work with the Committee to ensure veterans, and
especially service-connected veterans are not any more encumbered in
receiving care in a reformed VA health care system. For example, if
clinical access to a primary care provider is to be used, we recommend
language employing a full-time primary care ``provider'' rather than
``physician.'' \3\ This would ensure uniformity with the private sector
practice of using non-physician providers in primary care settings. We
also support the provision making eligible to receive care in the
community those veterans enrolled in Project ARCH so they do not
experience a disruption in the care they have been receiving when the
authority for the program is consolidated.
---------------------------------------------------------------------------
\3\ Proposed section 1730A(b)(1)(B)(ii)
---------------------------------------------------------------------------
DAV is supportive of VA's approach in determining when veterans
should be given the option to receive care in the community through
shared decisionmaking leveraging the relationship between a veteran and
their doctor, and using business intelligence about clinical
performance and quality of care. This new focus will strike a better
balance in using community care to fill gaps in service than unfettered
choice. This approach is more likely to be sustainable, a hallmark of
good governance, as well as garner higher patient satisfaction.
Veterans Care Agreements
Section 201 of this draft measure would authorize the establishment
of ``Veterans Care Agreements,'' and would prescribe the types of
providers eligible for participation. We support the establishment of
such agreements, but we are concerned that VA would be required to
first exhaust other acquisition strategies before being allowed to
pursue such agreements. In addition, different terms are used for
paragraph (4) in both bills. We appreciate the use of the term
``provider'' be used rather than ``health care provider'' for
consistency and ease of implementation of this section by the
Department. We agree with VA's assessment regarding the need for this
authority to be enacted into law without further delay and applaud the
inclusion of this provision.
Emergency and Urgent Care
DAV recommends this measure includes provisions to make urgent care
part of VA's medical benefits package and to better integrate emergency
and urgent care with the overall health care delivery system. DAV
believes a health care benefit package is incomplete without provision
for both urgent and emergency care. We note S. 1261, the Veterans
Emergency Room Relief Act of 2017, is on today's agenda and refer to
our comments on that bill as it pertains to these critical health care
services.
Emergency Care Defined
Carrying out the multiple and complex authorities\4\ for VA to pay
or reimburse emergency care under title 38 are a source of continuous
complaints and can drive ill and injured veterans and their families to
financial ruin.
---------------------------------------------------------------------------
\4\ 38 U.S.C. Sec. Sec. 1703, 1725 and 1728
---------------------------------------------------------------------------
According to VA, ``in FY 2014, approximately 30 percent of the 2.9
million emergency treatment claims filed with VA were denied, amounting
to $2.6 billion in billed charges that reverted to Veterans and their
[Other Health Insurance]. Many of these denials are the result of
inconsistent application of the ``prudent layperson'' standard from
claim to claim and confusion among Veterans about when they are
eligible to receive emergency treatment through community care.''
One of the by-products of Emergency Medical Treatment and Labor Act
(EMTALA) was the prudent layperson standard in response to a critical
payer issue of the day--payment denials for the lack of prior
authorization. To address the inconsistent application of the prudent
layperson standard, DAV recommended the ``emergency condition'' be
defined using EMTALA, with a minor amendment to include behavioral
conditions, so that the definition of an emergency condition for VA
purposes would be:
``A medical [or behavioral] condition manifesting itself by
acute symptoms of sufficient severity (including severe pain)
such that the absence of immediate medical attention could
reasonably be expected to result in placing the individual's
health [or the health of an unborn child] in serious jeopardy,
serious impairment to bodily functions, or serious dysfunction
of bodily organs. With respect to a pregnant woman who is
having contractions that there is inadequate time to effect a
safe transfer to another hospital before delivery, or that
transfer may pose a threat to the health or safety of the woman
or the unborn child.''
Claims Processing and VA as Primary Payer
In addition, VA's processing of claims has been a significant
weakness to the Department's community care programs resulting in
costlier care, inappropriate billing of veterans and strained
partnerships with community providers. Government Accountability Office
reports throughout the years have consistently highlighted disturbing
limitations in the Department's claims processing system as having
unnecessary manual operations rather than automatically applying
relevant information and criteria to determine whether claims are
eligible for payment and notifying veterans and community providers
about the results of the determination, payment, and appeal procedures.
Many veterans worry about claims that are not paid promptly or are
left unpaid, and they are left in a difficult position of trying to get
claims paid or be put into collections. These delays or denials create
an environment where community providers are hesitant to partner with
VA for fear they will not be paid for services provided. Hospitals and
community providers have also expressed concern that prompt payment
laws do not apply to care that is provided to veterans if they do not
have a contract with VA.
Having heard complaints from veterans regarding section 101(e) of
the current Choice program, which places on them greater financial
burden and emotional stress while trying to recover from injuries and
illnesses. Congress passed Public Law 115-26 reverting back the
responsibility of the government as first-payer and prompt payer for
care and services. We appreciate this measure reaffirming this policy.
Thus, DAV supports the required claims processing in Section 102 of
this draft measure, which would apply the prompt payment act to all
services under the new Veterans Community Care Program and would allow
VA to continue accepting paper claims. Ostensibly, the quicker
processing of electronic claims could act as an incentive for community
providers to submit claims electronically. This section would mandate
the establishment of an electronic interface to enable private
providers to submit electronic claims as required by the section. We
appreciate the provision in this draft measure requiring an eligible
provider to submit claims to VA within 180 days of furnishing care or
services. These factors are critical elements in high performing
Veterans-Centered Integrated Health Care Networks particularly with
community providers who do not have the resources to dedicate solely to
electronic claims processing.
First and Third-Party Collections
We urge this Committee to include language statutorily requiring VA
to offset a veteran's copayment debt with monies VA receives from
billing the veteran's health insurance plan. Under current law,
service-connected veterans are required to pay their share of costs
created as a result of medical treatment rendered as inpatient,
outpatient, extended care, or medication for a nonservice-connected
disability or condition. VA is also authorized by law to recover the
reasonable cost of medical care furnished to a veteran for the
treatment of a nonservice-connected disability or condition when the
veteran or VA is eligible to receive payment for such treatment from a
third-party.
While the law allows VA to recover reasonable costs, the Department
has had a long-standing practice of applying all third-party payments
first to the corresponding co-payment to extinguish the veteran's share
of costs before the government's. The veteran is billed for the portion
of the co-payment not covered by the insurance reimbursement and the
portion of the co-payment.
Recently however, VHA issued a memo (VHA Notice 2017-40) rescinding
this long-standing practice. It is unconscionable that VA is placing
its interest before that of service-connected veterans by requiring
them to pay copayments in addition to collecting reimbursements from
their health plan without offsetting the veteran's copayment debt.
III. Realign the provision and allocation of VA's resources
so that they fully meet our national and sacred
obligation to make whole those who have served.
Section 203 is in line with our recommendation to maintain the
financial and clinical reorganization under Section 106 of the Veterans
Access, Choice, and Accountability Act of 2014 (Public Law 113-146;
title 38, United States Code, 1701 note). We believe it is beneficial
to require, rather than make discretionary, the transfer of funds and
payment of services to the Chief Business Office of the VHA. This would
help ensure transparency and accountability to a single entity when
conducting oversight. Moreover, we believe Section 204 is beneficial in
addressing known issues with VA purchasing care in the community and
allowing the Department to better manage its resources.
In conclusion Mr. Chairman, DAV supports this draft measure, the
Improving Veterans Access to Community Care Act of 2017, which contains
many provisions and aligns with the overall approach proposed by DAV,
the IB, other VSOs, the Commission on Care and VA. Further, it embodies
the goals of DAV Resolution 238, which calls for strengthening,
reforming and sustaining a modern, high-quality, accessible and
accountable VA health care system, while expanding access to care by
creating integrated networks, with VA acting as the coordinator and
principal provider of care, and community partners providing access
whenever and wherever necessary.
This concludes my testimony, Mr. Chairman. I would be pleased to
respond to any questions from you or the Committee Members concerning
our views on these bills.
Chairman Isakson. Thank you very much.
Mr. Stultz?
STATEMENT OF GABRIEL STULTZ, LEGISLATIVE COUNSEL, PARALYZED
VETERANS OF AMERICA
Mr. Stultz. Chairman Isakson, Ranking Member Tester, and
Members of the Committee, on behalf of Paralyzed Veterans of
America, thanks for the opportunity to offer our views on
legislation affecting the delivery of veteran health care.
I recognize that there are numerous bills on the agenda
today, but I am going to focus my comments on the Choice
Program.
Should veterans have unfettered choice in when and where
they receive health care? Three bills being considered dealing
with the Choice Program diverge primarily on this question.
About a week ago, I heard Senator Cruz comment during a
town hall with Concerned Veterans for America that nobody
understands your health care needs better and cares more about
you and your family than you do. You are in the best position
to make the decision about where to get the best health care.
Any veteran sitting in a hospital waiting room would
naturally feel this way. It feels right, it makes sense, and it
is hard to argue with. But, what he is really trying to say is
that veterans know better and care more than the rigid
bureaucracy, the red tape, incomprehensible rules that fail to
take into account a particular veteran's circumstances when
determining how that veteran can access care.
He cannot seriously be suggesting that doctors, clinicians,
social workers, and other aspects of a care team do not play a
critical role in educating veterans and ensuring that they
fully understand the specific health care services that they
actually need. For some reason, this part is always left out of
the talking points.
We and our VSO partners have constantly stressed the
importance of coordinated care, regardless of who provides it,
because it has proven to lead to better health care outcomes
for patients. That is why we have long called for moving away
from arbitrary wait time and distance standards toward a
clinically based determination that takes a full look at each
individual veteran's unique circumstances.
We support the Secretary's attempt to move the VA in this
direction. As he said in a recent budget hearing, his hope is
to provide care when veterans need it and where they need it,
which includes the community. Developing an integrated, high-
performing network is the fiscally responsible way to achieve
this. It will get us to a place where veterans have meaningful
choices while maintaining an apparatus that facilitates access
and prevents fragmented care that can result in disastrous
consequences.
For some of our members, Choice works well. One of our
veterans who normally uses VA for comprehensive care in his
annual evals used Choice to treat a recent bout of pneumonia
close to home, a condition that can easily be fatal for someone
with a spinal cord injury. His care was excellent, but not
everyone can easily navigate the system.
We recently represented a paralyzed Army veteran who also
suffered from an opioid addiction and Traumatic Brain Injury.
After VA cut back his access to opioids, he made a conscious
but ill-fated decision to seek care elsewhere through the
Choice Program. After years of patchwork-style care in the
private sector, he reached back out to VA. Days before his
appointment, he was found dead outside of his apartment,
bleeding from his feet. With his specific comorbidities, ones
commonly associated with combat veterans, VA was uniquely
suited to treat him in a holistic manner. In hindsight, Choice
was not the answer for him.
While that situation illustrates an uninformed choice, we
cannot forget that in some areas, there simply is not a choice
for catastrophically-disabled veterans. When comparable care
does not exist in the community, our members are simply stuck
waiting. This is why it is essential that as we expand
available options, we give VA the tools it needs to strengthen
its specialized services and compete with the private sector.
We are seeing early signs of VA taking steps to invest in
its foundational services, such as spinal cord injury and
blinded rehab, while expanding care in the community. The
Secretary authorized the hiring of 800 to 1,000 more nurses in
these areas, and he is going to do it by eliminating
redundancies at VA Central Office to free up resources. These
are the kinds of actions that show VA is serious about getting
its own house in order and building a system that cares for all
veterans, including those who may not be best served through
care in the community.
So, as we debate expanding choices for veterans and
reforming the way VA delivers health care, what do we owe our
veterans? I think we owe them the support to make an educated
choice. We owe them a coordinated choice that ensures
appropriate follow-up care is delivered, a choice that ensures
each doctor you see has the full picture of your medical
history, not just a snapshot, and we owe them a choice that
does not bankrupt us with a price tag that clears over a
trillion dollars in the first 10 years.
I am borrowing words when I say this, but it is an
important point. Congress owes our veterans a system that is
optimized for those who need it most, not those who want it
least. Let us not forget that.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions that you have.
[The prepared statement of Mr. Stultz follows:]
Prepared Statement of Gabriel Stultz, Legislative Counsel,
Paralyzed Veterans of America
Chairman Isakson, Ranking Member Tester and Members of the
Committee, On behalf of Paralyzed Veterans of America (PVA), I would
like to thank you for the opportunity to testify today on the
legislation being considered by the Committee. There is no doubt that
the bills addressing the Choice program could have a significant impact
on the delivery of health care services to veterans going forward.
Additionally, many of the bills on the agenda can improve access to
critical services needed by veterans.
the ``veterans choice act''
the ``improving veterans access to community care act''
s. 1279, the ``veterans health administration reform act''
There are three bills that directly address the next iteration of
the Choice Program. We appreciate the Committee's significant efforts
in this matter and the Senators for sponsoring the legislation being
considered during today's hearing. To better construct a debate on
their merits, we will address the bills together in one discussion.
PVA strongly supports the concept of developing an integrated,
high-performing network that would seamlessly combine the capabilities
of the Department of Veterans Affairs (VA) health care system with both
public and private health care providers in the community. This
approach has gained consensus among stakeholders, including the most
recent and current VA Secretaries, the Independent Budget (IB), most
major Veteran Service Organizations (VSO), the Commission on Care, and
congressional leadership. As stakeholders continue to coalesce around
this concept, though, the dynamics that govern the boundaries of this
network need to be thoroughly explored.
These three bills collectively demonstrate the need for scrutiny--
how the network is developed and governed is limited only to the
imagination. The devil is in the details; they are critical and will
have a dramatic impact on VA's future health care landscape. Our
philosophy is that the development of VA's network of providers should
be locally driven, contemplating demographics, demand and availability
of resources within that particular area. It is more, though, than just
filling access gaps. Quality, both within VA and in the community, is
inextricable from this analysis. It should be a critical factor in
determining whether VA should continue to offer a service or if it
should capitalize on segments of the community that are already
delivering that service with excellent results. Similarly, just because
VA is offering poor quality in a particular service line does not
automatically mean there is a second choice available in the community.
VA is obligated to raise the quality in its own house in those
circumstances.
A well-balanced network that supplements service gaps in VA's
system sets a natural boundary for the network. It is efficient and
preserves VA core competencies and specialized services such as spinal
cord injury and disorder care.
Establishing appropriate eligibility standards will be an integral
part of a sustainable network. This is the most significant point on
which these three proposals diverge. Chairman Isakson's draft proposal,
the ``Veterans Choice Act,'' provides unfettered choice to all veterans
enrolled in the VA health care system. However, it remains unclear how
this proposal would be funded. The cost is staggering, and the impact
on VA and its ability to serve veterans who most need care is
predictable. The Commission on Care's economists found that the cost of
unmitigated choice throughout a loosely-managed network, a concept most
closely reflected by the ``Veterans Choice Act,'' would yield a price
tag of well over $1 trillion over a decade. In a case such as this
proposal, it will not be enough to simply say that VA has enough
resources to manage this option. That is an absolutely false
assumption.
In recent months, proposals such as billing veterans' other health
insurance for service-connected care, Medicare subvention, and
elimination of Individual Unemployability payments to service-connected
disabled veterans over the age of 62 have been floated to potentially
offset the $3 billion price tag of the Choice Program. If the
administration had to consider taking from the most vulnerable groups
of veterans to meet this projected cost, where can we expect to find
the money for this expansion? What money would be left to sustain VA's
foundational services, let alone general health care services for the
veterans who choose VA as their provider?
Alternatively, Ranking Member Tester's draft proposal, the
``Improving Veterans Access to Community Care Act,'' and Senator
Crapo's bill, the ``Veterans Health Administration Reform Act''
(S. 1279), structure eligibility standards in line with PVA's vision of
employing a clinically-based determination. This is also the path the
Secretary wishes to take. This approach requires us to confront the
difficult question of how a decision is reached in the absence of
arbitrary, but clear, delineations for eligibility. As we mentioned,
variations in how liberally access is granted to community care
providers can have a drastic impact on cost.
These two proposals call for case-by-case determinations and
include a variety of parameters for VA practitioners to consider when
consulting with the veteran. Providers should be able to sit down with
a veteran and consider circumstances such as access and availability of
services and the urgency of that veteran's situation. The veteran
should also have the opportunity to voice concerns over how a certain
care plan will adversely or inadvertently impact him or her. Access to
transportation, geographic distance and travel time can often present
unreasonable obstacles to care for veterans. For example, a 30-mile
trip to a VA facility might seem reasonable on paper, but a doctor
administering a treatment plan that requires the veteran to commute
three times per week may have good grounds to object to that
determination.
Providers should have the ability to help educate veterans and make
decisions in the context of the patient's specific circumstances. They
should be able to take action when it is clear that VA offers a needed
service, but a particular veteran's situation requires a higher level
of expertise than what that doctor or facility can offer. Arbitrary
standards should not prevent a doctor from sending a veteran out to the
community when the need is urgent and VA is not prepared to administer
the care in a timely fashion.
Some veterans might have reservations about their provider, i.e.
VA, having the final say in whether they are eligible to utilize the
Choice Program, but it is a marked improvement over the current process
where bean-counting bureaucrats make decisions behind closed doors for
veterans who appear to be just another number in the queue. A more
pointed concern is the past institutional bias exhibited by VA
employees for administering care directly in VA at all costs. VA has
long had authority to contract for care, but in prior years employees
demonstrated a reluctance to utilize this tool to the point that it
eventually prevented timely access to care for many veterans. This
behavior, though, was largely attributed to mid-level bureaucrats
making decisions driven by how the funding was administered. The
current funding arrangement under the Choice Program produced a welcome
side-effect of removing the incentive to avoid contracting care out to
the community. Over the last two years, VA's institutional behavior has
been modified to a degree, and it has become more comfortable with
contracting for care when the need exists.
Once the clinical parameters are determined, eligible veterans will
have meaningful choices among the options developed within the high-
performing network and the ability to schedule appointments that are
most convenient for them. When you pair this decisionmaking process
with a well-managed, integrated network and the structural
flexibilities discussed above, it becomes possible for VA to be a
competitive and sustainable enterprise.
We applaud Senator Tester's explicit provision extending medical
malpractice protections under 38 U.S.C. Sec. 1151. This is an
especially important signal to veterans that Congress and VA are not
abandoning oversight and responsibility for the quality of care
delivered in the community. When veterans receive treatment at a VA
medical center, they are protected in the event that some additional
disability or health problem is incurred. Under Sec. 1151, veterans can
file claims for disability as a result of medical malpractice that
occurs in a VA facility or as a result of care delivered by a VA
provider. This protection currently does not attach to a veteran during
outsourced care. The veteran must pursue standard legal remedies
instead of VA's non-adversarial process. Adding insult to literal
injury, veterans who prevail in a private action are limited to
monetary damages instead of enjoying the other ancillary benefits
available under Title 38 intended to make them whole again. These
include treating the resulting injuries as service-connected
conditions, such as a botched spinal surgery resulting in paralysis. It
also includes access to adaptive housing and adaptive automobile
equipment benefits should the veteran require these features.
Furthermore, the limits on these monetary damages vary from state to
state leading to disparate results for similarly-situated veterans. To
keep all veterans on equal footing, we insist that this provision be
incorporated in any legislation that moves forward. We recognize that
there will be questions on the mechanics of this protection and to what
extent this provision would expand VA's liability exposure. We stand
ready to have that conversation and to assist the Committee in sorting
through these issues.
S. 1279 offers a unique idea for expanding choices for veterans by
allowing VA practitioners to refer Medicare-eligible veterans to
Medicare providers. It also encourages greater information sharing
efforts between the two systems. In addition to capitalizing on an
already-existing network of providers, this adjustment to the law could
reduce instances of fragmented care for veterans who normally use VA
for primary care but take advantage of Medicare to receive specialty
care for a non-service-connected condition close to home. We certainly
recognize the value in shifting some of the financial burden that would
otherwise be absorbed by VA on to the Medicare rolls, but we are
concerned that a turf war between these two financially-stressed
systems will likely result. An additional concern is also the potential
for Congress to simply reduce funding for VA in an amount that
corresponds to any cost savings realized instead of allowing VA to
reinvest that money in its own medical services.
These three proposals contain the tools necessary to achieve an
end-state at VA where veterans have meaningful choices and quick access
to quality care. As the Committee moves toward a final bill, we will
continue to support measures that encourage VA to retain ownership and
responsibility for care provided to veterans, no matter where it is
received. VA's role in care coordination, no matter how expansive the
network, must be clear. It is one of the most important features that
makes VA care not only competitive with the private sector, but in many
segments better. Simply listing in statute that a third-party
administrator is responsible for ``managing the network'' is not enough
to identify where that responsibility lies.
We will yet again raise the most important questions for our
members: What are Congress and VA doing to ensure that as the Choice
Program expands, VA's foundational services remain competitive? What
steps are being taken to deal with scenarios where access to care in
specialized services is dismal, but there are no comparable services
offered in the community to fill the void? Is VA focused on ensuring
that VA specialized services are staffed appropriately based on demand,
or is it more focused on providing ever-greater convenience to veterans
who already have options? We have stated on multiple occasions before
this Committee that care delivered in the community is an essential
component of VA's health care system. But it is simply that, a
component. This Committee needs to demand comprehensive answers to
these questions, on the record, instead of settling for platitudes and
vague promises to ``take care of that later.'' A member of the
Commission on Care warned against designing a health care system that
is ``optimized for people who do not rely on veteran-specific health
care.'' \1\ The Commissioner captured our perspective, as
representatives of the highest per-capita users of VA and its
specialized services, when he stated, ``[w]e must design our veteran
health care system for those who need it most, not for those who want
it least.'' \2\
---------------------------------------------------------------------------
\1\ Blecker, Michael. ``Explaining decision not to sign the Report
of the Commission on Care.'' Letter to Commission on Care.
29 June 2016. Available at https://s3.amazonaws.com/sitesusa/wp-
content/uploads/sites/912/2016/07/Commissioner-Alternative-Viewpoints-
06302016.pdf. (Last accessed July 7, 2017).
\2\ Id. (Emphasis added).
---------------------------------------------------------------------------
s. 115, the ``veterans transplant coverage act''
PVA supports S. 115, the ``Veterans Transplant Coverage Act.'' This
legislation gives VA the authority to provide organ transplants to
veterans from a live donor regardless of veteran status of the donor or
the facility they are in. Under the current Choice program, veterans in
need of organ transplants are denied due to the program's eligibility
requirement. If a living donor is not a veteran, the transplant
coverage is denied if the surgery is not performed at a VA facility.
However, due to the very access problems that prompted the Choice
program--long distance travel, inaccessible transportation, etc.--these
veterans are unable to receive the care they so desperately need.
Whether or not a veteran receives a necessary organ transplant should
not depend on who or where the donor is.
s. 426, the ``grow our own directive: physician assistance employment
and education act of 2017''
PVA supports S. 426, the ``Grow Our Own Directive: Physician
Assistance Employment and Education Act of 2017.'' This bill would set
up a five year pilot program to provide education assistance to
veterans training as physician assistants (PAs) in VA. The goal is to
train veterans with medical or military health experience to be readily
employable physician assistants at VA. Section 2 of the bill explains
the prioritization of veteran participants who are in the Intermediate
Care Technician Program and those individuals who plan to work in
medically underserved states with a high population of veterans. To
meet these goals the bill provides funding and support staff to the
Office of Physician Assistance Services. It would also require VA to
establish a strategic plan to recruit and retain PAs and adopt the
standards leading to competitive pay for PAs employed by VA. Currently
the vacancy rate of PAs at VA is 25 percent, the third largest shortage
throughout the health care system. Recruiting and retaining PAs at VA
is critical to improving access to high quality care. Further, this
bill will provide job opportunities for veterans with medical work
histories that are hard to translate to the civilian sector.
s. 683, the ``keeping our commitment to disabled veterans act of 2017''
PVA supports S. 683, the ``Keeping Our Commitment to Disabled
Veterans Act of 2017.'' This legislation would extend the requirement
to provide nursing home care to certain veterans with service-connected
disabilities to December 31, 2018. Without an extension, VA
reimbursement of nursing home care will end December 31, 2017.
s. 833, the ``servicemembers and veterans empowerment and support act
of 2017''
PVA strongly supports S. 833, the ``Servicemembers and Veterans
Empowerment and Support Act of 2017.'' This legislation would expand VA
coverage of counseling and treatment for military sexual trauma (MST).
This bill would codify the idea that MST does in fact include the
experience of ``cyber harassment of a sexual nature.'' Currently, these
victims are ineligible for VA counseling and benefits. The experience
of cyber harassment is varied for its victims and distressingly unclear
in our laws. But the intent of a perpetrator, as in any sex crime, is
the assertion of power over someone and the degradation of their
humanity. Most often the harassment takes the form of ``revenge porn,''
nude or sexual photos or videos, taken with or without consent, and
used to harm its subject. The possessor of the material may blackmail,
control and/or threaten the victim. Often it is used for humiliation by
sending the material to the victim's family or coworkers, or, like
`Marines United,' to buildup a culture of male camaraderie by degrading
and threatening the safety of their female peers.
The goal of cyber harassment is to cause maximum distress. While
someone may not be interpersonally exploitable, that effort can be
exacted through social media, to greater and longer lasting effect. To
be the victim of cyber harassment of a sexual nature is to be exploited
by thousands of people, forever unknowable. Such an experience denies
any hope of accountability or acknowledgement of injustice.
Recent qualitative analyses of mental health effects on the
civilian victims of cyber harassment of a sexual nature consistently
reveal very serious effects; high prevalence of PTSD, anxiety,
depression, suicidal ideation and increased likelihood of physical
assault. Only 34 states and the District of Columbia have laws
criminalizing the practice of cyber harassment. The Uniform Code of
Military Justice does not directly address this issue. Veterans who are
victims of this kind of sex crime will often have no recourse. This
bill is a greatly needed step to ensure VA is able to meet the needs of
those who served honorably and came home carrying wounds ignored for
too long.
s. 946, the ``veterans treatment court improvement act of 2017''
PVA firmly believes in the rule of law and that anyone convicted of
a crime should be held accountable. Our criminal justice system,
though, has long recognized the existence of aggravating and mitigating
circumstances that play an important role in influencing the
administration of penalties. While advocacy before a sentencing judge
following conviction is critical, prosecutorial discretion is also
vast. Veterans Justice Outreach Specialists can help veterans use their
honorable service, as well as mitigating circumstances arising from
that service, to ensure both the prosecutor and judge see more than
just a rap sheet when making decisions.
If the specialist demonstrates that the veteran is entitled to
health care or disability benefits, the judge or prosecutor might be
able to fashion a sentence or plea offer that incorporates utilization
of these services in lieu of imposing solely punitive sanctions. It
could also lead to an outright deferment of prosecution conditioned on
the veteran exploring and obtaining all services available to him or
her. This scenario is especially enticing to the judicial system given
the constant struggle to find resources, particularly for in-patient
substance abuse rehabilitation programs and mental health care.
For some veterans, this path might help them avoid being
permanently stigmatized with a criminal conviction. For others, it
might be the ticket that lifts them out of homelessness and the
corresponding criminal recidivism, specifically with petty and/or
vagrancy crimes. It is no secret that some veterans go years before
realizing they were entitled to certain benefits that might have helped
them avoid poverty and dejection. A court order pointing the veteran to
the Department of Veterans Affairs can sometimes turn into a life-
changing event. At the least, more veterans touched by this program
will re-engage productively with society. That is a goal worth
pursuing.
s. 1153, the ``veterans acquiring community care expect safe services
act of 2017''
PVA generally supports S. 1153, the ``Veterans Acquiring Community
Care Expect Safe Services Act of 2017,'' or ``Veterans ACCESS Act.''
This legislation would deny or revoke the eligibility of a health care
provider to be a community care provider if they have been fired from
VA, violated their medical license, had a department credential
revoked, or were imprisoned for one year or more.
s. 1261, the ``veterans emergency room relief act of 2017''
PVA supports S. 1261, the ``Veterans Emergency Room Relief Act of
2017.'' This legislation would require VA to contract with urgent care
providers and pay reasonable costs for care provided to veterans who
are enrolled at VA and have received care there within the preceding
two years. It would also establish cost-sharing amounts for certain
veterans receiving care at a VA emergency room. We have consistently
advocated for adding urgent care services to the standard medical
benefits package to help fill the gap between routine primary care and
emergency care. This is consistent with current health care trends, and
greater utilization could provide a relief valve to VA emergency
services, the Choice Program, and the system as a whole. It would help
address issues of long distance travel for veterans needing immediate
attention, and mitigate long term costs for VA by providing quick
attention to medical needs that would otherwise compound in both cost
and severity if the veteran were to wait to be seen at VA.
Additionally, this has the potential to decrease the current burden at
VA emergency rooms, freeing up capacity to properly address their
patient loads.
We do, however, continue our opposition to any requirement that a
veteran have received VA care within the preceding 24 months in order
to qualify for emergency and urgent care benefits. The strict 24-month
requirement is problematic for newly enrolled veterans, many of whom
have not been afforded the opportunity to receive a VA appointment due
to appointment wait times, despite their timely, good-faith efforts to
procure one. This barrier has caused undue hardship on veterans and has
resulted in some receiving unnecessarily large medical bills through no
fault of their own. Additionally, this provision discriminates against
healthier veterans who otherwise do not need as much health care as
other veterans and may go more than two years without being seen. This
bill's authorization to impose cost-sharing should be enough to
compensate for dropping the 24-month requirement as a cost control
mechanism.
s. 1266, the ``enhancing veteran care act''
PVA generally supports S. 1266, the ``Enhancing Veteran Care Act.''
This legislation would authorize the Secretary of Veterans Affairs to
enter into contracts with nonprofit organizations to investigate
medical centers and report deficiencies. This legislation allows the
Secretary to delegate the contracting authority for an investigation to
the VISN director or the director of the medical center to be
investigated. The Office of Inspector General has at times demonstrated
a bureaucratic rigidity too cumbersome to address localized needs for
investigation. This bill ostensibly aims to meet that need. While the
Secretary is already able to contract with third party investigators,
this bill extends that ability to lower leadership positions. We also
believe it is an appropriate step to require the Secretary, Inspector
General and Comptroller General of the United States be notified of an
investigation for the purposes of coordination.
s. 1325, the ``better workforce for veterans act of 2017''
PVA supports S. 1325, the ``Better Workforce for Veterans Act of
2017.'' This legislation would improve the authorities of the Secretary
to hire, recruit, and train employees at VA. In order to transform the
culture and timeliness of care, Congress must enable VA to quickly hire
a competent workforce with competitive compensation that ensures VA is
a first-choice employer among providers.
The access to care issues plaguing Department of Veterans Affairs
(VA) can almost always be traced back to staff shortages, and the
systemic consequences of those shortages, within the health care
system. The current 45,000 vacancies are a result of improper staffing
decisions, a lack of sufficient resources, and the misallocation of
existing resources. No reformation of staffing or capital
infrastructure processes will increase access without appropriate
resources.
No one is more affected by provider shortages than those veterans
with complex injuries who rely on VA to treat their specialized needs.
Unfortunately, VA has not maintained its capacity to provide for the
unique health care needs of severely disabled veterans--veterans with
spinal cord injury/disorder, blindness, amputations, and mental
illness--as mandated by Public Law 104-262, the ``Veterans' Health Care
Eligibility Reform Act of 1996.'' As a result of this law, VA developed
policy that required the baseline of capacity for Spinal Cord Injury/
Disease System of Care to be measured by the number of available beds
and the number of full-time equivalent employees assigned to provide
care.VA was also required to provide Congress with an annual
``capacity'' report to be reviewed by the Office of the Inspector
General. This reporting requirement expired in 2008, and was reinstated
in last year's ``Continuing Appropriations and Military Construction
and Veterans Affairs Appropriations Act for FY 2017.'' This report, a
critical tool of oversight, should be made available to Congress by
September 30 of this year. We suspect this report will verify the
willful disregard for staffing shortages that exist in our most
critical specialties.
It is worth noting that the SCI/D System of Care is the only
specialty service line with its own staffing mandate, implemented in
2000, as a standardized method of determining the number of nursing
staff needed to fulfill all points of patient care. VA has not met this
statutory mandate. For years, PVA has identified chronic staff
shortages, resulting bed closures, and denied admissions. Since 2010,
VA has operated at only 60% of the capacity mandate. Further still, the
mandate itself is 17 years old, and in need of an update to reflect the
aging population of veterans. Such an update would provide a starker
picture of unmet need for the most vulnerable population of veterans.
A modernized and effective human resources operation is vital to
any organization, especially one as large as VA. The multiple
authorities governing the VHA personnel system are incompatible with a
high-performing health care system. Hiring managers and their employees
must attempt to understand the end-to-end hiring process under four
separate rules systems. This unnecessarily adds complexity to the
hiring system which is difficult for both the potential employee and
the human resources staff to navigate. The unnaturally slow hiring
process also ensures VA loses talented applicants. It is not reasonable
to expect a quality provider to wait up to six months for VA to process
an application. Similarly, when an employee announces his or her
forthcoming retirement or departure from VA, H.R. is unable to begin
the recruiting or hiring process for that position until it is actually
vacated. This not only causes an unnecessary vacancy, exacerbated by
the lengthy hiring time, but it also prevents a warm handoff between
employees and any chance for training or shadowing.
Mid-level management at the VISN level seems to have obfuscated all
responsibility for clinical staff shortages, while maintaining
themselves handsomely. The 21 VISNs, managed by directors and senior
managers control the funding for all 1,233 VA health facilities, and
are required to oversee the performance for their VA facilities and
providers. Currently a nominal appointment, this structure was intended
to decentralize decisionmaking authority and integrate the facilities
to develop an interdependent system of care.
In 1995 the total number of VISN staff was 220. In fiscal year
2011, the total number of VISN employees had climbed to 1,340, a 509%
increase, while bedside clinician and nurse staffing in specialized VA
services plateaued, then fell behind demand. Meanwhile, the VA failed
to request from Congress the resources to meet health care demand,
particularly in specialized services such as spinal cord injury and
disorder care and inpatient mental health.
PVA believes that veterans have suffered from VA's inability to be
competitive with its private sector health care counterparts who do not
face the same restrictions on pay and benefits. In the face of a
nationwide provider shortage, and an aging generation of baby boomers,
VA must be competitive now in order to have any chance of meeting the
needs of veterans.
While the personnel challenges facing VA, are numerous, and often
frustrating, it is important to remember these staffing issues and how
they are resolved will have an immediate impact on the life and well-
being of catastrophically injured veterans. For the thousands with
complex needs, there is no private sector alternative where they can
seek care until VA's access problems are solved.
draft bill, the ``department of veterans affairs quality employment
act of 2017''
PVA supports the proposed draft legislation the ``Department of
Veterans Affairs Quality Employment Act of 2017.'' This legislation
would improve the authority of the Secretary of VA to hire and retain
physicians and employees at VA. PVA is particularly interested in a
couple sections included in the bill. Section 3, which would require
the Secretary to select at least 18, but no more than 30, employees to
participate in a one year fellowship with a private sector company or
entity that administers or delivers health care or other services
similar to those provided within VBA and VHA. PVA generally supports
this idea. In the current environment there could be a benefit to
sending VA senior executives into the private sector to better
understand best practices from both sides. At the same time, sending
already limited resources and talent outside of VA could further
undermine the existing training programs within the Department.
Section 4 would require the Secretary to conduct an annual
performance plan of VA's political appointees. The plan would be
similar to those employees who are members of the Senior Executive
Service and would assess recruitment and retention of qualified
employees, engagement and motivation, and performance and
accountability. While surprised there is not already a performance plan
for VA political appointees, PVA considers this a reasonable provision.
Section 5 would allow the Secretary to noncompetitively reappoint a
former VA employee to any position within the Department as long as the
position is not more than one grade higher than their former position
and as long as the employee left the Department voluntarily within the
prior two years and maintained necessary licensures and credentials.
PVA has concerns about bringing back a former employee to a higher
grade through a noncompetitive process. While PVA supports the intent
to easily fill critical vacancies, we are not convinced hiring former
employees through a noncompetitive process is the most appropriate path
to filling those vacancies.
Section 6 would require the Secretary to create a single recruiting
database to list any vacant positions the Secretary determines are
critical to the mission of VA, or difficult to fill, or both. It would
keep information on applicants not selected for initial positions but
who are qualified for other positions in the department. The Secretary
would be required to use the database to fill any vacant positions. PVA
questions whether such a recruiting database is necessary. Presumably,
the `mission critical' positions the proposed database would house are
currently residing in USAJobs.gov.
Section 7 would improve training for Human Resources professionals
and include virtual training. The development and implementation of
defined goals for recruitment and retention (to include promotions,
continuing education, etc.) should be components of H.R. staff's
performance plans. VA H.R. management staff are not accountable to
direct service providers. PVA believes they should be held accountable.
H.R. performance is not measured by the degree to which they meet
hiring and recruitment goals. As a consequence, failure to fill a
critical vacancy in a timely manner carries no adverse effect on the
involved H.R. staff.
VA must be able to recruit and retain qualified staff by providing
competitive compensation and opportunities for professional and
technical development. The Association of American Medical Colleges
estimates the United States will have a shortage of 130,600 physicians
by 2025. Today, the most vulnerable populations, including rural
communities and veterans with specialty needs, are the first to feel
the effects. While VA recruitment efforts are improving, the
inexcusably long process it takes to bring an employee onboard continue
to turn away highly qualified candidates. VA must provide its human
resources management staff with the resources and training necessary to
correct these issues.
Mr. Chairman, thank you for the opportunity to offer our
organizations views on these bills. We would be happy to answer any
questions you or your colleagues may have.
Chairman Isakson. Well, thank you very much for your
testimony, and to all of you, thank you very much for your
patience and for your input, which was absolutely phenomenal,
as we move toward dealing with the issue of choice.
You have all raised some points that I want to refer to
real quickly, if I can.
Mr. Stultz, let me just thank you for mentioning
coordinated care. You talked about the Secretary's desire to
give the veterans the care they need where they need it. You
need a coordinated care system where the veteran who needs the
care and the doctor who is providing it are responsible and the
VA cooperate together to see to it they get the very best
possible care that they can.
I think Dr. Yehia, in some of his conversations before,
that is exactly what he was referring to. The patient or the
veteran and the doctor are a team, and their goal together is
the best health care possible for the veteran that they serve.
That is exactly what all of us on this Committee want to see
happen too, whether it is a rural or urban veteran or whatever
it might be.
Ms. Webb, you made a number of outstanding points. One, the
letter from the VSOs, which we received some time ago, thank
you very much for that joint letter. We paid a lot of attention
to that.
We do recognize that some people are suspicious that there
is an attempt to bleed the system dry. I think that is the
terminology you used. There is no game plan on this Committee
whatsoever to bleed any system dry, but there is one to make
sure we have a realistic and highly visible funding system.
You referred to the--you did not call it seven; it is
seven--different funding baskets out of which VA pays for the
benefits and how we have these constant crises with that. We
run out of money in one; we have money in others, but we are
running out of money. So, everybody ends up in panic mode.
I am committed, as I indicated in my question to Dr. Yehia
earlier in the testimony, to get all that money in one pot, to
have one central source that will be accessible, and see to it
if we are running out of money, we are really running out of
money. It is not just some fake crisis that somebody put up.
One of the biggest problems we have had is in that area,
and one of the biggest things I want to try and address is to
see to it that that is corrected. I really appreciate your
testimony and your input and what you had to say.
In terms of the 2.2 million dues-paying American Legion
members, of which I am, as I told you earlier today, still one
of them because I paid my dues again, thank you for the input
that you all made. But, I have a question that I want to ask of
you.
Do you poll or in any other way survey, on an annual basis
or on an issue basis, your veterans with regard to the veteran
health services?
Mr. Celli. We do. As a matter of fact, we conduct several
visits a year, somewhere between 10 and 13 at different VA
medical centers around the country. We hold town halls. We
speak to the patients who are actually in the VA hospitals, and
we speak to the providers to figure out what challenges that
they are having. We use that information in a best practices
report that we issue not only to the VA, but we also send it up
here to Congress and to the President of the United States.
So, we do speak to them on a regular basis through our town
hall meetings. Of course, we get calls, just like all the other
VSOs do, every single day, but our System Worth Saving Program
is our boots-on-the-ground access to our veteran's voice.
Chairman Isakson. How responsive is the VA health system to
you when you give them input from these polls?
Mr. Celli. They are extremely responsive. As a matter of
fact, whenever we--I mean, we deal directly with Dr. Yehia. We
deal directly with Dr. Alaigh. We deal directly with the
Secretary. Our access is pretty much unfettered. We enjoy a
great partnership with the Department of Veterans Affairs and a
great partnership with our veterans. When there is a problem,
we bring that to their attention and they work tirelessly to
ensure that that problem is satisfied.
Sometimes it is a perceived problem by the veteran, in
which case we just have to recognize that the veteran may or
may not have access to what it is that they want, but more
times than not, it is a payment problem like with Choice or it
is an access-to-care problem because they have been waiting too
long, and we are able to get those satisfied.
Chairman Isakson. How long have you been doing the job you
do at The American Legion?
Mr. Celli. About 5 years now.
Chairman Isakson. Have you seen any trend line in terms of
that responsiveness over the last 5 years?
Mr. Celli. I think it has gotten extremely better over the
past 2 years. The access and the transparency has gotten
extremely better over the past couple years.
Chairman Isakson. We did not talk before this hearing, did
we?
Mr. Celli. Not at all. [Laughter.]
Chairman Isakson. The reason I made that comment, as I was
listening to you talk--and I think this should go back to the
Secretary, Doctor, as well--there is a visible improvement in
the VA's responsiveness--as a Committee Member, I think Senator
Tester would agree with the same thing--to us as well as I
sense to the VSOs. As we move forward to fix Choice and fix
veterans' health care and ensure veterans get the health care
they need, where they need it, and when they need it, which is
the goal of the Secretary, that we would be responsive to the
problems that are brought to us by the VSOs and be responsible
to the veterans who come to us with those. If we do that, we
will have a 21st century health care system for the 21st
century veterans of the United States of America.
Thank you, all of you, for your testimony.
Senator Tester.
Senator Tester. Thank you, Mr. Chairman.
I would just add that I think the VA has been very
responsive, except in one area, and that is funding for the
Choice Program, because we have ping-ponged all over the place,
and I think that I need to bring that up because, as a
Committee, we need more time than what we received on this.
We were supposed to be funded through November or October,
and then it was June, and then it was August. You get my drift.
Other than that, good job.
I want to go off of a script for a second from these bills
that are on the agenda today. I want to talk about a different
bill, and so I would just ask for your attention just for a
minute--it is not that complicated--because I want to get your
opinion on it.
Earlier today--first of all, you guys all know that Choice
needs additional funding for fiscal year 2017 and 2018. Right?
[No response.]
Earlier today, I dropped a bill that would get the
Department the money that it needs for the Choice Program. It
would bolster VA's internal capacity to provide care. It would
make it easier for VA to provide care to vets closer to home by
authorizing leases and getting pre-9/11 caregivers the help
that they have needed for decades.
So, I would like to have your reaction to this legislation,
because there are some folks that do not believe that we should
be tackling internal VA care and caregivers in the same
legislation as providing funds for private care on an emergency
basis. Remember what I just said. They do not believe we should
be tackling internal VA care and caregivers in the same
legislation as providing funds for private sector care on an
emergency basis, that is.
I am going to start with you, Mr. Celli. Could you give me
your perspective on that bill, whether you think it is good,
bad, or----
Mr. Celli. Well, thank you, Senator. The challenges that
you face are administrative on your end. We absolutely support
your bill. We support the caregiver portion of the bill. We
support paying for it and whatever means is necessary.
Senator Tester. OK.
Mr. Celli. We support pre-9/11 caregivers getting the same
services and the same benefits and the same access to resources
that post-9/11----
Senator Tester. OK. Ms. Webb?
Ms. Webb. I was able to glance over that this morning and
have not had a chance to read the entire bill, but all the
provisions that you lay out sound----
Senator Tester. OK.
Ms. Webb [continuing]. Acceptable and like AMVETS, we would
support.
Senator Tester. I guess the big question is, would you guys
support building VA capacity on an emergency basis? That is
really the question.
Ms. Webb. Yes.
Senator Tester. OK.
Mr. Atizado. Senator Tester, thank you for that question.
You know, Ms. Webb had mentioned the letter that the VSOs
had sent over----
Senator Tester. Yes.
Mr. Atizado [continuing]. To the Senate, and I think that
covers a little bit of your question about what our opinion as
a reaction is to----
Senator Tester. Yep.
Mr. Atizado [continuing]. Some of this perspective, and I
think it is an emergency.
Senator Tester. Thank you.
Mr. Atizado. You know, for many years now, we have been
talking about how veterans are not getting access to care from
VA, and it is not because VA does not want to give them care.
They do not have the people. They do not have the capacity, and
frankly, sometimes they do not have the authority. I think this
has constituted an emergency, such as the Congress' response to
the access crisis in Arizona. I think this comes to that level
as well.
Senator Tester. Got you.
Mr. Stultz?
Mr. Stultz. I would really want to know who they are
because I think it says a lot about priorities, and for us, I
represent veterans with the most catastrophic disabilities. As
I have said repeatedly, whether in written statements or here
in front of the Committee, there are no comparable services
everywhere.
Senator Tester. Yeah.
Mr. Stultz. The Choice Program is not the fix for
everybody. For us, internal capacity has to get better----
Senator Tester. Yep.
Mr. Stultz [continuing]. With the Choice Program.
Senator Tester. Yep. Especially with the population that
you represent, absolutely critical.
I just got to ask something--this is off script--but it
goes to your statement, Ms. Webb. When I was in Missoula, MT,
having a veterans listening session, one of the people that I
had on my panel--and I did not pre-read anything that they had
to say--stood up and said, ``The best thing you guys on the VA
Committee could do would be to disband Choice and put every
dollar into the VA and focus on the VA.'' How many of your
members would have that same feeling? Could you tell me that
without putting you too much on the spot?
Ms. Webb. Well, I think that there is a lot of nuance that
we try to communicate with our members, and I think there is
room and there is a need for a public-private partnership.
The point for us is the expansion of Choice. We do not
support that because I think any of that extra money should be
invested back into VA.
Senator Tester. OK.
Ms. Webb. But, there is some need for some of the funding
to go elsewhere.
Senator Tester. Yeah. I have got several other questions,
but we have got other Members present, so, I yield Mr.
Chairman.
Chairman Isakson. Senator Tillis.
Senator Tillis. Thank you, Mr. Chairman, and, Mr. Chairman,
I meant to mention in the first round that The New York Times
article we talked about briefly today at lunch. I want to thank
you and the Ranking Member for creating a distinctive
environment on this Committee that is producing some really
consequential legislation on a bipartisan basis. I thank you
both for that.
Mr. Stultz, I have a question for you, which relates to
that situation about the veteran who passed away after he opted
out. Have you done much work in looking at the electronic
medical record implementation that we are working on? How we
would ultimately extend that to the broader caregiver community
and implement intervention strategies to make sure that at the
end of the day, the VA will still continue to own, I think, the
responsibility for a good health care outcome? Has your
organization given any thought to how we could do that by
having that holistic model of care that veteran may be
receiving if they choose to go outside of the VA?
Mr. Stultz. Are you asking for specific implementation or
the ramifications of tighter integration between the community
and VA?
Senator Tillis. Well, I am saying if we have that tighter
integration, we may know what is occurring once they go out----
Mr. Stultz. Right.
Senator Tillis [continuing]. Of the VA to either a non-VA
provider or to a Choice option. I am assuming that a part of
the--and I am looking forward to seeing the details of the
electronic medical record strategy, but it is then fully
exploiting that 360 view of the medical activities that that
veteran may be going through. I was just curious if your
organization has thought that through, because in your
particular case, that is where having the absolute latest
information may actually require an outreach to a veteran to
say, ``We know you made this decision at some point, but
perhaps there is a better option now.'' I would think that has
got to be key to some of the things we are doing for longer-
term managed care and better access to medical information.
Mr. Stultz. I think that is a great point, sir, and if you
look back at VA's Choice Consolidation Plan from, I think, over
a year ago now at least, one of the pieces that they discussed
was care coordination. They had an idea that they would--if
care went out into the community, based on the acuity level of
your care and the needs that you had--this gentleman, for
example--they would stay involved, even though they were not
administering the actual care. So, tools like this can really
make those ideas go a long way to prevent things like this.
Senator Tillis. Well, I hope as we get information back
from the VA that that does become--you have got to get the
baseline in place, which has to become a priority, because I
think that will help make the Choice Program work, and also
make them aware of options and service levels where either non-
provider care or VA-centered care will work.
Mr. Celli, you made a comment that I want to come back to.
I do not want to parse your words, but it is something that I
think is important. I have said it. I know you have been in the
Committee hearing when I have said it before, and it was with
respect to one of Senator Tester's comments about the
caregivers bill, I think. You said we need to fund it by all
means necessary. I do not think you meant at the expense of
something else that you think needs to be funded by all means
necessary.
Mr. Celli. Senator Tillis, thank you for pointing that out.
That is true. I do not mean by cannibalizing existing programs
within the VA. I mean that there are funds available through
emergency means that as to Gabe's point would be appropriate to
fund this program.
Senator Tillis. I think the key here is so that when we
move forward on things that I happen to agree with as a matter
of policy, that we provide sustainable, predictable funding, so
that a crisis does not emerge, which causes us to make some
sort of knee-jerk reaction for other programs that we think are
equally important.
I have said before to the VSOs, you may hear me be cool to
a net new idea, not because I oppose the idea, but I want to
make absolutely certain we were talking about that with the
veterans treatment court that we are doing it in a way that
pays for itself, not at the expense of something else that you
all have fundamentally supported.
Ms. Webb, I wanted to go back. The Chair brought it up, but
in North Carolina it is really interesting because I hear the
States that are urban States talk about what their priorities
are and I hear the rural States talk about what their
priorities are. In North Carolina, we are literally 51 percent
urban, 49 percent rural. When we get rural in North Carolina,
we get really rural. I know it is hard to imagine, but if you
go in western North Carolina or eastern North Carolina, there
are all kinds of challenges there.
I, for one, just want to give you some assurance that
someone like me who believes that there are things that we can
do to really make Choice a key piece of the puzzle. I see the
whole outside of that puzzle always continuing to be the VA,
whether it is brick-and-mortar presence, where men and women
who have the sorts of profound injuries that Mr. Stultz's
organization would represent have that environment that is
unique to the situation that they have experienced. There are
very few people who have not served that could possibly
understand or comprehend. They congregate with caregivers; they
congregate with other soldiers or veterans. I think that is
critically important. The therapeutic value of that alone means
that we have to maintain that full circle of care and
visibility, and I think most of the Members here get it.
So, as we move forward with the discussion on getting the
Choice Program right, I think that you have a consensus among
these Members that we have got to get that right too. Thank you
all for your time here today.
Ms. Webb. Thank you.
Chairman Isakson. Thank you, Senator Tillis.
Senator Blumenthal?
HON. RICHARD BLUMENTHAL, U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thank you, Mr. Chairman, and thank you
all for being here today. You are here constantly at our
hearings, and we are grateful to you for your presence, your
insightful testimony, and your service to our Nation.
I want to focus on the criteria and decisionmaking process
for Choice, because I think we are all in agreement that we
want the Choice Program to provide the best possible care.
There should be alternatives outside the VA system where
necessary, and necessary should be defined as being in the best
interest of the veteran; that is, where the veteran can receive
care that is the most timely and expert. Obviously, timeliness
depends on difficulty of access, geographic distance, as well
as waiting times, and quality depends on the expertise; for
example, criteria of professional qualifications at federally
qualified health centers or Medicare providers or the VA
facilities themselves that may approve certain providers.
Should these decisions be made by the VA in setting
criteria and choosing outside providers, or should there be
some independent means of doing so?
Mr. Celli. So, Senator Blumenthal, time and time again, we
focus on the smaller picture like Choice rather than the bigger
holistic picture of where VA health care is going.
You have asked the Secretary to sit down and come up with a
comprehensive plan on where the future of VA health care should
go, and he has done that. He has got together with his team. He
has run it past the veterans service organizations, and he has
come up with a comprehensive program. CARE is probably not the
acronym we would have used, but the program itself is solid.
The recommendations in there look at exactly what it is that
you just touched on, which is how do we come to these
decisions, how has VA grown over the past several years, what
lessons have we learned from the Phoenix scandal? The outcome
of that has been a more coordinated and comprehensive care
model that we all support.
So, to continue to throw up the word ``Choice'' I think
just misses the bigger picture, and I think we are all ready to
move on.
Mr. Atizado. Senator Blumenthal, thank you for that
question.
To your point and question about where VA should be in
regards to when a veteran will be able to access a community, I
think VA needs to be exactly where it has been but empowered
more.
VA providers tend to be--tend to spend a lot more time with
veteran patients as a whole. Part of the recruitment tool for
clinicians is that they tell these budding and new doctors that
we want our providers to spend more time, 30 minutes on average
as opposed to 20 minutes, in the private sector. That extra 10
minutes actually allows that doctor to sit down and know their
patients, because VA as an organization firmly believes in a
lifelong relationship with veterans.
In that relationship, the VA has to be, I guess, a force
multiplier. They need to help guide the veteran to inform them,
to educate them, to be the best consumer of health care they
can be, to not only be healthy, but to lead a better life.
I think they have to play a role, sometimes more active
depending on the situation and sometimes a little bit more
passive, but certainly not far from the side of the veteran
when they make that decision.
Senator Blumenthal. Let me ask you on a related topic. You
mentioned the Phoenix scandal. Have you been satisfied with the
results of the Inspector General investigation?
Mr. Celli. It is a complicated question; there are a lot of
things that went wrong that caused Phoenix to happen. A lot of
those things have not yet been fixed. The scheduling program,
the IT, the software that runs that--what we have done is taken
the focus away from incentivizing no wait times, and we have
encouraged the employees to be more forthright and honest.
While I do not want to take anything away from what happened
and the depravity of veterans not being seen when they need to
be seen, we also need to recognize that the secret wait list,
if you will, was the scheduler's ways of trying to take care of
a veteran when their supervisors told them that they cannot.
So, there is a lot that went wrong, a lot that went right, and
a lot that we have learned from that.
Am I satisfied with where we are today? I think it is still
a work in progress.
Senator Blumenthal. Thank you very much.
Thank you, Mr. Chairman.
Chairman Isakson. Senator Tester.
Senator Tester. Thank you, Mr. Chairman.
Adrian, I am going to go to you because I am going to read
from your testimony, and I want you to comment on this. Talking
about the commission that the Choice Act made happen:
The Commission's economists estimated that the
recommended limited choice option would increase VA
spending by at least $5 billion in the first full year,
though they cautioned that it could be as high as $35
billion without strong management control of the
network. The Commission's economists also analyzed an
unfettered choice option to allow veterans the ability
to choose any VA or non-VA provider--without requiring
them to be part of any defined network. The economists
estimated such a plan could cost up to $2 trillion more
than current projections for VA expenditures over the
first ten years. Based on the premise that the draft
bill would provide unfettered choice for all enrolled
veterans, create an extremely broad--almost universal--
network, and lacks any effective coordination
mechanisms, it seems likely the costs to implement such
a proposal would be significant, somewhere between the
estimates for the two Commission options discussed
above. In today's fiscal environment, it seems
unrealistic such dramatic spending increases would be
appropriated or sustained, and even if approved, the
cost shift and patient migration to private care would
ultimately endanger the viability of the VA health care
system.
Those are your words. Talk to me about them.
Mr. Atizado. Senator, thank you for pointing out that
section of our testimony.
I think what we are trying to do here is find a reasonable
and sustainable solution for VA care, and it really stems from
the idea that as Congress, this Committee considers legislation
to expand access--more access points for veterans to receive
care in the community--costs will go up. We have seen that in
the Choice Program.
Depending on how that structure is set up from unfettered,
which is literally give a veteran a card to go forth and be on
your own and find your own way, that has not only tremendous
cost implications, but it has some human costs as well. Private
sector--the long debate in Congress about U.S. health care and
the delivery of care tells us that when providers do not work
together with patients as a team, that can be quite disastrous,
not only costly for the patient in terms of money and life, but
on the economy of the U.S. health care system.
So, when you have a system where you have unfettered choice
and veterans can go anywhere, the costs will go up, which is
clearly not sustainable. It does not serve us well, when we
know there are better ways to construct a way for VA to allow
veterans to get care in the community.
Senator Tester. Thank you.
Mr. Stultz, I want to talk about VA accountability. I just
want to go with you very briefly, and then if anybody has
something to add--I pointed this out to Dr. Yehia in the
questions to the previous panel that if we are going to have
community care programs, I think the VA can transfer that care.
However, I do not think they can ultimately transfer the
responsibility for the veteran's well-being.
You are dealing with paralyzed veterans. You talked about
an instance where the pneumonia treatment was successful. You
talked about another one where the veteran ended up dying.
Could you tell me what happens in the VA when something
goes wrong? Then tell me what happens in the private sector
when something goes wrong for a veteran.
Mr. Stultz. In the VA, you have a non-adversarial process.
You submit it like a disability claim. They adjudicate it. They
are not working against you. In the private sector, you are
going through standard litigation and subject to all those
rules in the adversarial process. VA also comes with the added
package of service-connected treatment for that and things like
adaptive equipment for your car, adaptive equipment for your
house. For the rest of your life, they take care of the fact
that you have become more disabled based on whatever care you
got.
Senator Tester. Right. How long does the process through VA
normally take versus how long it would take in the private
sector----
Mr. Stultz. That is a----
Senator Tester [continuing]. To get your----
Mr. Stultz [continuing]. A very interesting question
because I like to talk about appeals reform. [Laughter.]
It can range for a number of years, but at the same time,
collecting a judgment in the civilian world can take a number
of years as well. So, the tradeoff is there. I am not sure on
time or really what we are after.
Senator Tester. OK, OK.
Anybody else like to comment on that? Mr. Celli? Amy?
Mr. Celli. So, I mean, real quick, I mean, to your
question, Senator----
Senator Tester. Yep.
Mr. Celli [continuing]. It could happen in a matter of
weeks if you had a fully-developed claim.
Senator Tester. Yep.
Mr. Celli. The VA would be on the hook to make sure that
they cared for that veteran and those with increased
disabilities for the rest of their life. That does not exist in
the private sector, so it could happen quickly, or it could
take years.
The one thing that I just wanted to touch on when you were
talking to Mr. Atizado is----
Senator Tester. Sure.
Mr. Celli [continuing]. Including the increased cost, the
risk of increased cost to privatization, something would have
to give. We cannot continue to just pay more and more. What
would ultimately happen is we would start restricting
availability and veterans would not be able to have the same
access to care that they have today.
Senator Tester. That is a solid point, and I am glad you
said that, because I think, ultimately, in the end, what
everybody on this Committee wants to have is we live up to the
promises made when you signed the dotted line. I think there
will come a time, if we are not smart today, where tomorrow,
veterans may not be able to be on the list that are fully
deserving of the benefits.
I want to thank you all for being here today. Thank you
very much.
Chairman Isakson. Thank you, Jon.
Let me say, Mr. Stultz, I want to--you prompted me to think
of something for a minute. Are you familiar with Project SHARE
in Atlanta?
Mr. Stultz. I am not.
Chairman Isakson. At the Shepherd Spinal Center?
Mr. Stultz. Yes. I am sorry.
Chairman Isakson. I just was going to say we were talking
about VA care and private care and Choice and things of that
nature, and in your self-introduction, you said you represented
the most profoundly injured veterans that we have who have the
most unique special circumstances.
One thing I want to be sure to mention is, we just
dedicated in Atlanta, thanks to the gift of Bernie Marcus, the
founder of Home Depot, the largest center dedicated to veterans
that I know of anywhere in the country that is taking veterans
that VA can no longer help and were really falling between the
cracks and not getting the best care possible.
So, if you ever get a chance to come to Atlanta to visit
Project SHARE at the Shepherd Spinal Center, it will warm your
heart and also show you what a combination of private-sector
and public money can do to help our veterans.
Thank you for what you do. We appreciate it.
Mr. Stultz. Thank you, sir.
Chairman Isakson. It is a pleasure to serve with Jon
Tester, the Ranking Member. We are going to find common ground
in the next few months and get a Choice bill that works for
everybody, which ensures the longevity and the future of the VA
health services with the expansion of access to care that is
needed to bring about the Secretary's dream, and that is better
care for veterans who have care accessible to them.
Thank you all for being here. We will leave the record open
for a week for any additional submissions.
We stand adjourned.
[Whereupon, at 4:40 p.m., the Committee was adjourned.]
A P P E N D I X
----------
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of the American Academy of PAs
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of American Federation of Government Employees, AFL-
CIO
The American Federation of Government Employees, AFL-CIO and its
National VA Council (AFGE) appreciates the opportunity to submit a
statement for the record on the bills under consideration today. AFGE
represents nearly 700,000 employees in the Federal and D.C. government
including 250,000 rank and file employees at the Department of Veterans
Affairs who provide vital care and services for our veterans.
s. 1153--veterans access act
S. 1153 would bar providers from participating in VA purchased care
programs if they have been fired from the VA for certain misconduct,
violated requirements of their medical license, lost a VA credential,
or committed certain crimes.
AFGE supports S. 1153. When VA privatizes care, the standards must
be as high as they are inside the VA.
s. 1261--veterans emergency room relief act
AFGE opposes S. 1261 as currently written. Absent specific
guidelines for when veterans can use non-VA urgent care centers, this
bill could lead to more fragmented and uncoordinated care, and lead the
VA further down the road of privatization. In addition, too many
veterans are already subjected to harsh collection practices through
Choice and through VA third party collection processes.
AFGE urges the Committee to first conduct an inventory of emergency
departments and urgent care centers within VA medical centers; a number
of facilities have closed emergency departments over the years without
adequate justification. This study should also examine the feasibility
of expanded urgent care centers within VA medical centers. Urgent care
provided directly by the VA will be far more veteran-centric than
urgent care provided in the private sector.
s. 1266--enhancing veteran care act
This bill would give the VA authority to contract with non-VA
entitles to investigate deficiencies at VA medical centers.
AFGE opposes S. 1266. The VA has adequate internal capacity to
investigate its medical centers, alone or in conjunction with other
independent governmental entities. Contracting out this responsibility
is likely to be used to lay the groundwork for further privatization.
s. 1279--veterans health administration reform act of 2017
AFGE opposes S. 1279 because the criteria that would be used to
determine if a veteran can seek care outside the VA are too vague (e.g.
clinical best interest, undue burden, not economical). VA medical
centers across the Nation continue to be deprived of adequate staff and
resources to provide all veterans with the timely, veteran-centric care
they have earned and that they prefer. The conditions resulting from
chronic underfunding and short staffing need to be addressed by
strengthening the VA rather than further depleting resources away from
the VA to provide more fragmented, nonspecialized care to veterans.
s. 1325--better workforce for veterans act of 2017
AFGE concurs that it is critical to fill the reportedly 49,000
vacancies at the VA. However, in AFGE's view, some of the provisions in
the underlying bill--as currently written--fall short of improving
hiring, recruiting, and training efforts within the VA and may have
unintended consequences
Sections 101 and 102 of the bill gives the Secretary more direct-
hire authority to fill current staff level vacancies. AFGE has serious
concerns about how this increase in direct-hire authority will impact
current Federal employees. If this bill were to become law, AFGE fears
that an unintended consequence could be preferential treatment given to
outside candidates, thereby bypassing current VA employees who seek a
promotion. Without adequate protections in place for current Federal
workers who have worked diligently to move up the VA ladder, the bill
could have a negative impact on efforts to strengthen the VA workforce.
Section 106 of the underlying bill directs the VA to collect data
on hiring effectiveness and Section 107 calls for the VA to design a
standardized exit survey that would be voluntarily administered to
outgoing employees. AFGE wants to stress the importance of having
stakeholder input throughout the process of developing these
mechanisms. It is critical that the VA consult with labor organizations
who represent their employees as well as the many Veterans Service
Organizations (VSOs) whose members rely on the VA for vital care and
services when developing these survey tools. By incorporating input
from both labor and the VSO community, the VA will be able to develop
tools that adequately address issues at the worker, manager, and
patient level.
One goal that appears throughout the underlying bill is the notion
of transparency. AFGE appreciates the inclusion of this provision in
the bill and the acknowledgment that the VA should be more transparent
as it relates to staffing levels and vacant positions. With that in
mind, AFGE would like to see the bill go further by posting not just
nurse staffing levels, but all staffing levels at every VA facility. In
addition to the VA being transparent with its current workforce, AFGE
would like to see the VA be transparent with posting job openings. AFGE
highlighted its concern with new direct-hire authority above, and in
that vein, wants to express its desire that necessary oversight is
exercised so that the Secretary does not use this new direct-hire
authority to fill positions without those jobs being publicly posted
with an open announcement.
Another area where AFGE has significant concern with the underlying
bill relates to the proposed use of non-Federal employees to provide
care and services to our Nation's veterans. As it's currently written,
Section 202 of the bill would allow the VA and private sector companies
to essentially swap employees for a period that can range from three
months to four years. AFGE has long opposed allowing the private sector
to enter the Federal Government and then return to their original job
outside of the government. This is an unnecessary step down the path to
privatization, and AFGE opposes the section in its entirety.
AFGE opposes Section 204 as currently written. Section 204
establishes a two-tier payment system of base pay and market pay for
directors of medical centers and Veterans Integrated Service Networks
(VISN). The bill would set market pay for directors on a case-by-case
basis through a process that requires the Secretary to consult at least
two national surveys and takes into account managerial experience,
complexity of the facility, and labor market conditions among other
considerations.
Under Section 204, medical center and VISN directors--who would no
longer have to be physicians themselves (as a result of Section 203)--
would gain a significant right that was taken away from every VA
physician and dentist last year. Public Law 114-315 repealed the
requirement enacted in 2004 that ``the Secretary shall consult two or
more national surveys of pay'' (Public Law 108-445).
In addition, Public Law 114-315 eliminated the requirement to set
market pay through peer-based compensation panels, a valuable system
for ensuring pay fairness, that protected providers from abuse of
discretion by managers. According to reports from our physician
members, the Secretary has not established any new policies to replace
the compensation panels.
AFGE is ready and willing to work with the Committee to amend
Section 204 to ensure that VA physicians and dentists reacquire
adequate market pay protections, which in turn will strengthen
recruitment and retention and enable the VA to provide medical care to
more veterans on a timely basis.
AFGE also opposes Section 207 of the bill that would allow the
Secretary to enter into a Memorandum of Understanding (MOU) with the
Surgeon General to allow not less than 500 Public Health Service (PHS)
commissioned officers to enter the VA. Allowing PHS to come into the VA
would erode frontline workers collective bargaining rights and move the
VA one step closer to privatization. PHS does not appear to have any
significant expertise in treating veterans. In addition, Congress has
provided VA with ample tools over the last two decades to recruit and
retain nurses within the Federal workforce. The VA should be focused on
recruiting, hiring, and retaining high quality medical professionals
who will make a career out of serving veterans, not finding creative
stop-gap measures. The United State Government must keep the promise it
made to our veterans by rewarding their dedication and sacrifice with
the best care and services imaginable, and the only way to do that is
through hiring staff at every level who will be there long-term to care
and provide for our veterans. AFGE opposes this section of S. 1325 in
its entirety.
AFGE opposes Section 212 as currently written. Section 212 would
require a review of the job descriptions, position classifications and
grades for all VA police officers and firefighters to ensure compliance
with Office of Personnel Management (OPM) classification standards.
This section also mandates the development of staffing models and an
audit of recruitment and retention efforts for both positions, and a
report to Congress regarding the Department's use of special pay to
address its critical shortage of police officers.
AFGE shares the concerns of lawmakers and veterans' groups that the
outdated police officer job duties increase safety risks to the VA
community. However, after consultation with classification experts,
AFGE strongly urges the Committee to adopt a more comprehensive and
aggressive approach to modernizing the VA police officer position, i.e.
mandating that the Secretary exercise his existing statutory authority
to convey law enforcement officer (LEO) status to all VA police
officers. Only this major overhaul of VA police officer positions will
ensure that VA has the capacity to adequately respond to the wide range
of violent and non-violent incidents that arise on a regular basis at
its facilities.
A recent expert analysis of VA police officer duties indicates that
VA police officers already meet the statutory definition of law
enforcement officer based on their primary duties and training
requirements (5 CFR 831.902; 5 CFR 842.802).
AFGE previously requested that former VA Secretary Robert McDonald
exercise this authority. AFGE stands ready to work with bill sponsors
and other Members of the Committee to develop a stronger statutory
solution to this significant VA safety issue.
s. _____--discussion draft, the veterans choice act of 2017
AFGE strongly opposes the Veterans Choice Act of 2017. This bill
would vastly increase the use of non-VA care through a massive
expansion of the Choice Program. Like the Concerned Veterans of America
plan that was soundly rejected by the Commission on Care, this bill
would erode the critical core of the VA health care system and put such
an enormous financial strain on the VA so as to threaten its very
survival.
The bulk of veterans' care, and all primary care and mental health
care must continue to be provided within the VA system, to ensure that
veterans continue to receive the world-class integrated care they have
earned and prefer. Only the VA, as the coordinator of care, can ensure
that non-VA care is used in a smart way to ensure that veterans can
receive the most appropriate care for their circumstances.
In contrast, this bill would not result in a smart use of non-VA
care but rather an unlimited use of non-VA care that would likely lead
to worse care for veterans in both the short and long term, and the
severe weakening of our Nation's leader in health care training and
research.
AFGE also opposes this bill because it would not ensure the VA is
the primary coordinator and arranger of non-VA care.
s. _____--discussion draft, improving veterans access to community care
act of 2017
AFGE generally supports the Improving Veterans Access to Community
Care Act of 2017. This bill enables the VA to modernize its services,
which will both allow the VA to better integrate a truly smart use of
non-VA care with VA's own world class services, but also allow the VA
to meet increased demand from higher functioning and consolidated non-
VA care programs.
AFGE also supports this bill's provisions for ensuring that the VA
is the primary coordinator of non-VA care. The integrated networks
created by this bill would allow veterans to more seamlessly move
between the VA and non-VA providers when the use of non-VA care to
supplement VA's own care is warranted.
The VA has made great progress in making needed improvements to its
health care system and other operations over the past three years. This
bill ensures that veterans will continue to be well served by the VA
and integrated networks providing non-VA care when the VA cannot meet
the need itself. This bill also is the far better option for protecting
the critical resources that the VA must retain in order to keep its
promise to veterans.
s. _____--the department of veterans affairs quality employment act of
2017
AFGE does not support this bill as a whole, though it includes
several positive management improvement provisions included in previous
legislation.
Like some of the provisions that raised concerns from AFGE in
S. 1325, as already discussed, this bill relies too heavily on the
private sector to improve the Department. For example, Section 3 would
provide management training to VBA and VHA employees in a private
sector setting. VA managers need to learn the best practices of other
VA managers and when applicable, exemplary managers from other
agencies. That is why AFGE supports management improvement provisions
that strengthen VA's own managers through better training and
performance evaluation.
AFGE supports a public database on vacancies, but the database in
Section 6 of this bill has too narrow a scope. Veterans, the public,
employee representatives, and all stakeholders need access to complete
data about vacancies throughout the Department, not just vacancies that
are determined to be critical by the Secretary.
The human resources training proposed by Section 7 is greatly
needed, but to ensure that it is truly effective, labor
representatives, and other stakeholders must have regular input in the
design and delivery of training curriculum. Without the perspective of
front line employees, any H.R. training will continue to fall short.
AFGE has similar concerns in this bill regarding provisions for
exit surveys and succession planning studies as we have for S. 1325,
i.e. it is essential that these workforce improvement efforts reflect
the regular input of representatives of front line employees.
Thank you for the opportunity to share the views of AFGE.
______
Letter from Col. James T. Currie, USA (Ret.) Ph.D., Executive Director,
Commissioned Officers Association of the U.S. Public Health Service
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement Developed by Fighting for Veterans Healthcare,
Association of VA Psychologist Leaders,* Association of VA Social
Workers,* and Nurses Organization of Veterans Affairs*
* An independent organization, not representing the Department of
Veterans Affairs
Proposals for the Veterans Choice Program Redesign and their
Impact on Veterans' Health Care
background
Over the last decade, as the rising demand for veterans' healthcare
services outpaced the Veterans Health Administration (VA)'s capacity to
meet it, excessive delays developed at some VA facilities. In 2014,
Congress enacted the temporary Veterans Choice Program whose goal was
to reduce delays by offering non-VA options to veterans who had to wait
long or travel far for care. To date, over 1.6 million veterans have
utilized the program.\1\
---------------------------------------------------------------------------
\1\ Budget Request for Fiscal Year 2018: Presentation before the
House Committee on Veterans' Affairs, House, 114th Cong. 1 (May 24,
2017) (Testimony of David Shulkin).
---------------------------------------------------------------------------
The demand for veterans' healthcare services is predicted to
continue to climb during the next several years.\2\ There are two basic
ways to address VA's lack of capacity to meet this demand--bolster the
VA by augmenting its number of clinicians and support staff, or
purchase more services in the private sector. Those two options offset
each other, since increases in Choice would be carved out of the VA.
---------------------------------------------------------------------------
\2\ Eibner, C., Krull, H., Brown, K., Cefalu, M., Mulcahy, A. W.,
Pollard, M., . . . Farmer, C.M. (2015). Current and Projected
Characteristics and Unique Health Care Needs of the Patient Population
Served by the Department of Veterans Affairs [Product Page]. Retrieved
June 8, 2017, from https://www.rand.org/pubs/research_reports/
RR1165z1.html
---------------------------------------------------------------------------
As Congress deliberates Choice program redesign, policymakers
should consider not only the plan's ability to remedy access problems,
but also its broad impact. Congress must ensure that the next Choice
program does not compromise VA's overall quality of health care--care
that has been demonstrated, with geographic variations, to be at least
equal to and often superior to non-VA care. Congress must ensure that
the VA's innovative, integrated care model is preserved. It must assure
that the system for clinically training the majority of U.S. healthcare
professionals is maintained. It must make sure that the VA is able to
sustain its research mission that benefits not only veterans, but also
every American. It must ensure that the private sector has the capacity
to absorb an influx of veterans in a timely manner, and delivers
excellent care. Given that non-VA care is more expensive than VA care,
Congress must ensure that Choice is used judiciously so that there is
no reduction in the level of services available to veterans. Finally,
it must ensure that the VA is improved, not dismantled, because that's
what veterans overwhelmingly prefer, and have been promised by
administration and Congressional officials. Our analysis of major
policy ideas for the next version of Choice concludes that only one
proposal does all this.
proposals for veterans choice program renewal
At least four ideas for modifying Choice have been proposed by
policymakers and veterans' stakeholders. One--which we endorse--would
fortify VA-delivered care and its management of the network of Choice
providers. The other three concepts, although structured differently
and still lacking specific details, would eliminate distance and wait
time requirements, purchase far more care in the private sector, cut VA
services and incrementally privatize veterans' healthcare.
The following are the four ideas, and their potential impact on
veterans' healthcare if enacted:
1. Strengthen VA Delivered Care
The VA eliminates third party administrators and assumes direct
management of high performing, integrated networks. Disparities
between supply and demand are addressed first by resourcing
VAs. External providers are used only to fill in gaps that
local VAs cannot provide. Eligibility for Choice is based on
distance and wait time criteria that are convenient for the
veteran.
Impact:
Builds and strengthens the VA system for the long term.
- Hires VA front line and support staff in locations where
demand outstrips supply.
- Increases VA appointment capacity.
- Maintains quality assurance.
Supplements care when needed.
- Ensures that when timely, nearby VA care is not available,
care is outsourced to the community.
Is fiscally efficient.
- Eliminating 3rd party administrative middlemen saves money
and streamlines initiation of Choice care, when needed.
- Hiring VA staff rather than purchasing more expensive private
sector care reduces costs.
- Gives VAs the ability to manage utilization and control
expenses.
Supports the comprehensive integrated care approach.
- VA generalists treat veterans in primary care clinics and
then walk them down the hall to meet with a behavioral health
professional, pharmacist, social worker, nutritionist or other
specialist.
- The VA's coordinated, integrated care is not only more
effective than the private sector's, it's far more convenient
to veterans because everything is handled in one location.
2. Make Choice Cards Universal
Allow eligible veterans to seek unrestricted care from any outside,
certified provider, without needing to obtain pre-
authorization.
Impact:
Fragments, diminishes and delays quality care.
- Relies on community providers who are not vetted for quality
and/or are less knowledgeable about veteran specific healthcare
issues.
- Increases wait times in the private sector for veterans as
well as non-veterans. There aren't enough primary care,
specialist, or mental health services in the community. By
2030, the U.S. will face a shortage of between 40,800 to
104,900 physicians.\3\
---------------------------------------------------------------------------
\3\ IHS Markit, The Complexities of Physician Supply and Demand
2017 Update: Projections from 2015 to 2030. Prepared for the
Association of American Medical Colleges. Washington, DC: Association
of American Medical Colleges. February 28, 2017
---------------------------------------------------------------------------
- Because many physicians are unwilling to accept Choice
payment rates,\4\ veterans may have difficulty finding a
qualified provider.
---------------------------------------------------------------------------
\4\ Bishop, T, Press, M.J., Keyhani, S. & Pincus, H.A. (2014).
Acceptance of Insurance by Psychiatrists and the Implications for
Access to Mental Health Care. JAMA Psychiatry, 71(2), 176-181.
---------------------------------------------------------------------------
- Creates uncoordinated administrative structures in which
accountability is diminished.
- Spreads treatment across the private sector, thereby reducing
care coordination and integration. The Commission on Care Final
Report \5\ (page 28) recognized: ``Veterans who receive health
care exclusively through VHA generally receive well-coordinated
care, yet care is often highly fragmented among those combining
VHA care with care secured through private health plans,
Medicare, and TRICARE. This fragmentation often results in
lower quality, threatens patient safety, and shifts cost among
payers.''
---------------------------------------------------------------------------
\5\ Commission on Care. (2016). Commission on Care: Final Report.
Retrieved from https://s3.amazonaws.com/sitesusa/wp-content/uploads/
sites/912/2016/07/Commission-on-Care_Final- Report_063016_FOR-WEB.pdf
---------------------------------------------------------------------------
- The private sector virtually never screens for PTSD, MST or
many other veteran problems, so many cases will be missed and
untreated.
- Suicide prevention programs in the community are generally
far less comprehensive than in the VA.
Leads to downsizing of VA delivered care.
- Allows veterans to bypass the VA for services and send the
bill to the VA for payment, even if the VA can provide prompt
care that is closer and of higher quality. VA would cover the
expenses of outsourced care by reducing their staff, programs,
and services.
- Allows eligible veterans who previously have been receiving
care outside the VA using their own health insurance to send
their bills directly to the VA for payment. That will further
drain the VA budget.
- Impairs VA's ability to continue to outperform the public
sector, since funds are diverted to pay for Choice.
- Secretary Shulkin's testimony at the June 7, 2017 Senate
Committee on Veterans Affairs hearing affirmed: ``Just giving
veterans a card, a voucher, and let them go wherever they want
to go . . . is appealing to some but it would lead to
essentially the elimination of the VA system altogether. It
would put veterans with very difficult problems out into the
community with nobody to stand up for them and to coordinate
their care, and the expense of that system is estimated to be
at the minimum $20 billion dollars more a year than we
currently spend on VA healthcare.'' \6\
---------------------------------------------------------------------------
\6\ Examining the Veterans Choice Program and the Future of Care in
the Community. Presentation before the Senate Committee on Veterans'
Affairs, 114th Cong. 1 (June 7, 2017) (Testimony of David Shulkin).
3. Limit the VA's Core Mission To Foundational Conditions
Redefine the VA's core mission as focusing on the treatment of
foundational conditions, such as PTSD, Traumatic Brain Injury,
polytrauma, blindness, spinal cord injury, pain, limb loss and
mental health. Outsource most of the remaining care to
providers in the private sector.
Impact:
Diminishes the quality and comprehensiveness of veterans'
healthcare.
- Outsourcing services to the private sector could mean many
veterans may not receive high quality care. In study after
study that contrasts private sector services to those of the
VA, (including again in Definitive Healthcare's 2017 summary
\7\), the quality of government-run VA care has been shown to
be as good as and often better than private sector care. That's
true across the spectrum, including for diabetes, heart
disease, geriatric care, serious mental illness, PTSD,
depression, safety practices, preventive care, surgical
complications, infection control, hospital readmissions,
hospital mortality and medication
compliance.\8\-\14\
---------------------------------------------------------------------------
\7\ Foltz, W. (2017, April 24). The VA Healthcare System--
Definitive Healthcare. Retrieved June 8, 2017, from https://
www.definitivehc.com/hospital-data/the-va-healthcare-system-a-broken-
system-with-superior-quality
\8\ Farmer, C. M., Hosek, S. D., & Adamson, D. M. (2016). Balancing
Demand and Supply for Veterans' Health Care [Product Page]. Retrieved
February 14, 2017, from http://www.rand.org/ pubs/research_reports/
RR1165z4.html
\9\ Association of VA Psychologist Leaders. (2016, March 23).
Comparison of VA to community healthcare: Summary of research 2000-
2016. Retrieved from http://avapl.org/advocacy/pubs/
FACT%20sheet%20literature%20review%20of%20VA%20vs%20Community%20Heath%20
Care% 2003%2023-16.pdf
\10\ O'Hanlon, C., Huang, C., Sloss, E., Price, R., Hussey, P.,
Farmer, C., & Gidengil, C. (2017). Comparing VA and Non-VA Quality of
Care: A Systematic Review. Journal of General Internal Medicine, 32(1),
105-121. https://doi.org/10.1007/s11606-016-3775-2
\11\ Ho, P.M., Lambert-Kerzner, A., Carey, E.P., Fahdi, I.E.,
Bryson, C.L., Melnyk, S.D., . . . Del Giacco, E. J. (2014).
Multifaceted intervention to improve medication adherence and secondary
prevention measures after acute coronary syndrome hospital discharge: a
randomized clinical trial. JAMA Internal Medicine, 174(2), 186-193.
https://doi.org/10.1001/jamainternmed.2013 .12944
\12\ Tanielian, T., Farris, C., Batka, C., Farmer, C.M., Robinson,
E., Engel, C.C., . . . Jaycox, L.H. (2014). Ready to Serve: Community-
Based Provider Capacity to Deliver Culturally Competent, Quality Mental
Health Care to Veterans and Their Families. Santa Monica, CA: RAND
Corporation. Retrieved from http://www.rand.org/pubs/research_reports/
RR806.html
\13\ Kavanagh, K.T., Abusalem S., & Calderon, L.E. (2017). The
incidence of MRSA infections in the United States: Is a more
comprehensive tracking system needed? Antimicrobial Resistance &
Infection Control, 6(34)DOI: 10.1186/s13756-017-0193-0
\14\ Nuti, S.V., Qin, L., Rumsfeld, J.S., Ross, J.S., Masoudi,
F.A., Normand, S.-L.T., . . . Krumholz, H.M. (2016). Association of
Admission to Veterans Affairs Hospitals vs. Non-Veterans Affairs
Hospitals With Mortality and Readmission Rates Among Older Men
Hospitalized With Acute Myocardial Infarction, Heart Failure, or
Pneumonia. JAMA, 315(6), 582-592. https://doi.org/10.1001/
jama.2016.0278
---------------------------------------------------------------------------
- Private sector providers have less expertise in detecting and
treating underlying conditions to which veterans are highly
vulnerable. For example, a general practitioner is less likely
to explore PTSD as the reason for chronic insomnia, the impact
of Traumatic Brain Injury on mood and decisionmaking, or that a
particular condition--asthma induced by burn-pits or diabetes
produced by Agent Orange exposure--is related to military
service.
- Many veterans have comorbid physical and mental health
problems, which require integrated care. This is especially
true of the large number of aging veterans.
Increases wait times for veterans and non-veterans in the
private sector.
- As in #2, this plan leads to longer wait times in the private
sector, which is already is struggling to keep up with demand.
There aren't enough private sector doctors available to treat
veterans or willing to accept Choice payment.
Severely impacts poor, mentally ill and homeless veterans.
- The VA has substantial programs that have had a significant
impact on veteran homelessness. VA actively attempts to locate
homeless veterans and ensure they are housed and cared for. The
VA employs peer specialists who routinely reach out to veterans
diagnosed with schizophrenia and other serious mental illness
who have stopped showing up to appointments. Few private sector
facilities offer the level of robust wrap-around psychosocial
services that are standard in the VA.
Reduces VA clinics and access for veterans who value and
choose VA.
- Major segments of VA healthcare would be outsourced to the
private sector.
4. Allow Choice Eligibility Based On A Composite Community Standard
Metric
Bases eligibility for Choice on a community standard metric, which will
be a composite of patient satisfaction, wait time and quality
measures. Where the composite score for a local VAMC non-
foundational service line falls below that number, all veterans
in that local clinic will automatically be eligible for Choice.
Independent of whether VAMC service lines exceed that number,
individual veterans can be granted Choice once they discuss VA
and Choice options with their VA provider. Uses high-performing
integrated networks for outsourced care.
Impact:
Changes Choice eligibility to be based on a composite
measure (comprised of wait time + patient satisfaction + quality
metrics).
Individual veteran level eligibility: Once veterans and their
providers discuss and compare VA and community alternatives,
veterans may be granted Choice. However:
- Neither the VA's Access and Quality Tool website http://
www.accesstocare.va.gov/ nor Medicare's Hospital Compare
website https://www.Medicare.gov/hospitalcompare/search.html
have the data that veterans need to make informed decisions. In
most cases, comparative metrics don't exist.
- There is no available data on a facility's effectiveness in
reducing symptoms or functional deficits.
- There is no data on outpatient care.
- Many diagnoses aren't included.
- There is no data on use of evidence-based psychotherapies.
- There is no data about private practitioners.
- Although wait times at VA facilities are published, community
wait times are unknown.
Clinic level eligibility: When a VA non-foundational service
line's composite score falls below their community's score, all
veterans in that clinic will automatically be eligible for
Choice for that service. However:
- The algorithm to compute this composite metric has not been
developed.
- Including patient satisfaction in this metric is inherently
problematic, since patient satisfaction scores have not been
found to relate to the provision of good health care.\15\ \16\
---------------------------------------------------------------------------
\15\ Fenton, J.J., Jerant, A.F., Bertakis, K.D., & Franks, P.
(2012). The cost of satisfaction: a national study of patient
satisfaction, health care utilization, expenditures, and mortality.
Archives of Internal Medicine, 172(5), 405-411. https://doi.org/
10.1001/archinternmed.2011.1662
\16\ Brookes, L. (Interviewer) & Fenton, J. J. (Interviewee).
(2014). Patient Satisfaction and Quality of Care: Are They Linked
[Interview Transcript]. Retrieved from Medscape News and Perspectives
site: http://www.medscape.com/viewarticle/826280_5
---------------------------------------------------------------------------
- Comparing VA with community composite scores is misleading,
since they are not apples-to-apples comparisons. Private sector
statistics are based on non-veteran patients who, on average,
are younger and have fewer medical and mental health conditions
than do veterans.\17\ \18\
---------------------------------------------------------------------------
\17\ Klein, S. (2011, September). The Veterans Health
Administration: Implementing patient-centered medical homes in the
Nation's largest integrated delivery system. The Commonwealth Fund.
Retrieved from http://www.commonwealthfund.org/ /media/files/
publications/case-study/ 2011/sep/1537_klein_veterans_hlt_admin_case-
study.pdf
\18\ U.S. Department of Veteran Affairs. (2016). Restoring trust in
Veterans health care: Fiscal year 2016 annual report. Retrieved from:
https://www.va.gov/HEALTH/docs/VHA_AR16.pdf
---------------------------------------------------------------------------
- Metrics can confuse mathematical differences with meaningful
clinical differences. A difference between a 14-day and a 16-
day wait may not be justification for more expensive private
care.
Increases costs and decreases productivity.
- Reduces VA's ability to control costs if veterans have the
prerogative to opt for private sector care even when the local
VA is able to provide treatment that is less expensive,
clinically superior, quicker and/or closer.
- Requires VA providers to devote extra time mastering
knowledge of private sector scores and going over those with
patients. This decreases clinician productivity and increases
wait times.
- Is more expensive overall than the current VA system.
Incrementally removes option of the VA for veterans
seeking VA as their home.
- There will be a steady flow of funds out of the VA and into
private sector care. If funds that could have been used to make
improvements are diverted to pay for Choice, VA facilities that
lag behind will never be able to catch up. Even high performing
VA's will falter when funds diminish.
- Dozens of VA service lines are already identified as falling
below the metric, qualifying all of the clinic veterans to be
automatically eligible for Choice.
Fragments care.
- Encourages the VA to provide foundational services and
outsource other services to the private sector.
- Bi-directional, interoperable sharing of VA and private
sector electronic medical records does not exist.
Expands provider network where needed.
- Aims to develop high-performing networks that link the
private sector to the VA over time, although they are not yet
available.
analysis
Making significant, lasting improvements in the VA's ability to
provide high quality care without serious delays is unquestionably the
right thing to do. It honors the sacred obligation we owe to veterans,
to care for those who have borne the battle. In our analysis, idea #1
optimally achieves what Choice was intended to do--remedy wait time
delays by outsourcing care when the VA doesn't have prompt or existing
services--without collateral damage to the unique advantages, superior
quality, cost-effectiveness and integration within the VA healthcare
system. It observes the guiding principle for healthcare systems and
doctors, ``first, do no harm.''
In a fixed pot, every dollar spent on Choice would be subtracted
from local VA budgets. Choice care is paid first and the VA makes do
with what's left. Expansion of Choice inherent in ideas #2, 3 and 4
sets in motion a hollowing out, in which over time, local VAs will have
less money, vacant positions won't be filled, medical services will be
cut back and clinics closed. As the availability of VA's services
diminish, more veterans will opt for or be placed into Choice, leading
to more VA cuts in a vicious cycle. These models degrade the quality of
options that already exist. They inexorably privatize veterans'
healthcare, with the conversion occurring quickly in ideas #2 and 3,
and gradually in idea #4. Idea #1 impedes privatization.
Idea #1 best supports the VA's integrated care model. The VA's one-
stop approach facilitates the immediate identification and referral of
a variety of problems, for example, when a veteran hints at feeling
suicidal during an optometry appointment and is walked down the hall to
a mental health clinician. It best supports the VA's holistic approach
that incorporates the physical, psychological, social, and economic
aspects of health and the impact these factors have on treatment
compliance. Care provided in ideas #2 and 3, and to some degree in #4,
is more fragmented, and limited to just the patient's chief complaint.
Further, there is no ability at present to bi-directionally coordinate
VA-community care via electronic medical records.
Idea #1 is the only one that assures continuity of the VA's 71-
year-old statutory education mission. More than two-thirds of all U.S.
doctors, not just VA doctors, receive their training at VA facilities.
So do 40 other healthcare professions. Ideas #2, 3 and 4 lead to
reductions in the number of VA attending supervisors, case volume,
resident rotations and specialty training programs. A decline in VA
training opportunities will be calamitous, given the shortages that
already exist. There is no large-scale capacity in the private sector
to train knowledge and skills of practitioners.
Idea #1 most effectively fosters groundbreaking research that has
been the hallmark of the VA. More than 60% of VA researchers are
clinicians, and their studies originate from daily interactions with
veterans.\19\ The VA has the largest integrated electronic medical
record system in the world, uniquely enabling research questions to be
pursued. Studies aimed at better understanding and treating veterans'
conditions will be nearly impossible if care is scattered across the
community.
---------------------------------------------------------------------------
\19\ U.S. Department of Veteran Affairs. (2016). Restoring trust in
Veterans health care: Fiscal year 2016 annual report. Retrieved from:
https://www.va.gov/HEALTH/docs/VHA_AR16.pdf
---------------------------------------------------------------------------
Although ideas #1 and #4 are similar in some respects, there are
key differences between them.
#1 grants Choice options on a case-by-case circumstance.
#4 does this too, but also grants Choice to large groups of veterans in
identified clinics.
#1 upholds the VA as a system treating a full complement
of conditions. In #4, the VA emphasizes the provision of foundational
services.
While there have been important concerns raised about the
use of distance and wait times to determine Choice eligibility in #1,
these criteria allow the VA to manage Choice utilization and costs. The
substitute composite metric in #4 is still unformed and untested.
The best information to date shows that community care is likely
more expensive than VA's.\20\ To offset added systemic costs for Choice
care in plans #2, 3 and 4, it's likely that some current or future
veterans would no longer be served, and/or charged higher deductibles
and out of pocket expenses. Cutting benefits to disabled unemployable
veterans to pay for Choice expansion was proposed in the original FY
2018 VA budget, although policymakers scrapped that idea recently and
are now searching for a substitute.\21\
---------------------------------------------------------------------------
\20\ Congressional Budget Office. (2014, December). Comparing the
costs of Veterans' health care system with private-sector costs.
Retrieved from https://www.cbo.gov/sites/default/files/113th-congress-
2013-2014/ reports/49763-VA_Healthcare_Costs.pdf
\21\ https://www.stripes.com/news/va-backs-off-budget-proposal-to-
cut-benefits-for-disabled- unemployable-vets-1.473551#.WUKEHnXysdV
---------------------------------------------------------------------------
There is a myth that the only way the VA will be motivated to excel
is if it is forced to compete with the private sector for its
customers. This in spite of the reams of studies that show the VA--
without relying on market-based incentives--already delivers care that
is equal or superior to that provided in the private sector. The sense
of mission to serve veterans is what motivates VA employees, and with
convincing effect.
Ideas #2, 3 and 4 contradict what veterans overwhelmingly want--
that the VA's clinical care and breadth of services be fixed and
strengthened, not dismantled.\22\ That's especially true for those
veterans who use the VA.
---------------------------------------------------------------------------
\22\ VFW. (2017). Our Care 2017: A report evaluating Veterans
health care. Washington D.C.: VFW. Retrieved June 7, 2017, from https:/
/www.vfw.org/news-and-publications/press-room/ archives/2017/3/vfw-
survey-veterans-want-va-fixed-not-dismantled
---------------------------------------------------------------------------
We recommend other considerations for Choice redesign:
Build VA capacity first.
- Sustain budgets that assure all VA facilities have sufficient
capability to provide comprehensive, high performing care. Such
resources include staff, space and IT support. It would be a
mistake to expand the Choice Program without first increasing
the capacity for care at VA facilities where demand for
services exceeds supply.
- Enhance telehealth resources (in VA's FY 2018 budget request)
so that veterans have expanded access to VA providers without
needing to go outside the VA.
Guarantee a high level of coordinated, integrated care.
- Mandate that Choice providers/facilities be able to bi-
directionally exchange electronic VA medical records before
they are accepted into the Choice program.
- Mandate that Choice providers engage in the same treatment
recommendation process expected of VA providers, i.e. for them
to understand what medical and mental health services are
available at their local VAs and refer their veteran patients
to the VA when the VA renders higher quality care.
Strengthen the VA brand.
- Include only high quality providers in the network. Choice
should not mean that VA relies on partners simply because they
are willing to accept payment, without adhering to the same
high quality standards. Stipulate in Choice contracts that
providers meet VA's elevated standards, use evidence-based
treatments, have knowledge of military culture and competence
in veteran-specific problems, engage in ongoing measurement of
progress, and perform screenings, such as for PTSD, Military
Sexual Trauma and Suicide Prevention.
- Expand opportunities for the VA to publicize and advertise
what it does well. The public remains grossly uninformed about
its successes, innovations and overall superior quality.
______
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Urgent Care Association of America
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Rubina DaSilva, MBA, PA-C, President, Veterans
Affairs Physician Assistant Association
Chairman Isakson, Ranking member; Senator Tester and other members
of the Senate Veterans' Affairs Committee, On behalf of the entire
membership of the Veterans Affairs Physician Assistant Association
(VAPAA) we appreciate the invitation to submit this testimony for the
record. We thank bipartisan Members of this Committee for critical
legislation for Physician Assistant (PA) Workforce issues before you
today in the VA System with sponsoring ``Grow Our Own Directive:
Physician Assistant Employment and Education Act of 2017.'' (S. 426)
and we thank Senator Tester for his leadership on this bill.
The Physician Assistant (PA) profession has a special unique
relationship with veterans. The very first classes of physician
assistants to graduate from PA educational programs were all former
Navy corpsmen and Army medics who served in the Vietnam War and wanted
to apply their knowledge and experience in a civilian role in 1967.
Today, there are approximately 2,178 PAs employed by the Department of
Veterans Affairs (VA), making the VA the largest single Federal
employer of PAs. These PAs provide high quality, cost effective quality
health care working in hundreds of VA medical centers and outpatient
clinics, providing medical care to thousands of veterans each year in
their clinics. Physician Assistants work in Primary Care and Lead PACT
teams of nursing, pharmacist, social workers, dieticians, and
rehabilitation services.
The Veterans Affairs Physician Assistant Association (VAPAA)
maintains that Physician Assistants are a critical component of
improving VA health-care delivery, and have consistently recommended
that VHA include them in all health-care national strategy staffing
policy plans. PAs have remained on the OIG Top Ten critical occupation
2015 and 2016 tied at number 3 and have remained a top ten critical
occupation on the Workforce Succession Planning from 2010 -2016. The
occupation 0603 Physician Assistant--there were 640 vacancies,
representing a 23% vacancy rate.
In 1990, VA turnover for registered nurses was 20%, because of
continued problems, Congress enacted the Nurse Pay Act of 1990 (Public
Law 101-366) requiring VA to establish a locality pay system for nurse.
The acts primary intent was to make VA salary rate competitive with
those in the private sector health care facilities in the same
communities. VA implemented the locality pay system on April 7, 1991,
about 8 months later after the passage of the act.
Workforce Management Consultant (WMC) in 2016 stated that
Converting Physician Assistant (PA) pay structure to the Nurse Locality
Pay System (LPS): ``it is unknown if converting Physician Assistants to
the Nurse Locality Pay System will improve recruitment and retention at
those facilities.'' This, despite acknowledging that Congress and VA
enacted the Nurse Pay Act of 1990 (Public Law 101-366) for a vacancy
rate of 20% for nurses.
VA WMC acknowledge the recommendation to convert PAs to the nurse
Locality Pay System (LPS) was incorporated in VHA's 2015 Strategic
Workforce Plan and that the Secretary has the authority to place PAs on
the LPS--but USH and Secretary have not done so, thus continuing the
problems with recruitment and retention of PAs which directly impacts
access to veteran care.
On April 20, 2016, Dr. McCarthy Assistant Deputy under Secretary
for Health for Patient Care Services Veterans Health Administration
testified:
The PA occupation has been a difficult to recruit and retain
occupation for several years. A major barrier to recruitment
and retention of physician assistants is the significant pay
disparity between private sector market pay and VA pay
schedules for PAs. Although Special Pay rate authority exists
at the medical center level to address these disparities, it is
antiquated and vastly underutilized. Salary surveys performed
during FY 2015 by several VA medical facilities has resulted in
establishment or adjustment in local special salary rates for
the PA occupation resulting in significant increases in
salaries. This is an indication of the existing salary
disparity overall. Including the PA occupation as a covered
occupation under the Locality Pay System in VA would be an
important element in addressing recruitment and retention
difficulties.
Not including PAs in the LPS is an unsuccessful business and
medical model for the VA as is it eliminating one third of its
applicant pool that can provide care to veterans; it is creating an
artificial and sustaining staffing shortage which is limiting Veteran
access to care.
Costs such as recruitment, retention, relocation, bonuses,
scholarships, employing locum tenens, and locality pay are
substantially increased with higher overhead for two profession vs
three self-sustaining professions--Physicians, PAs and NPs.
WMC (Workforce Management) rebuts that giving nurse locality to
PAs, then VA is obligated to give LPS to every profession. If Congress
or VA gives podiatry locality it only helps the recruitment of
podiatrist. If locality is given to PA's it will improve recruitment
and retention of PA while increasing access to veterans in all VHA
facilities and CBOCs within VHA as PAs carry their own veteran panels
and practice in all areas of medicine. They work in both ambulatory
care clinics, emergency medicine, CBOC's in rural health, and in a wide
variety of other medical and surgical subspecialties including mental
health, Women's Health, Compensation and Pension, Rehabilitation
Services, Medical Home, Cardiology, Gastroenterology, Orthopedics,
Dermatology, Rheumatology, Endocrinology, Emergency Services,
Hospitalists, Intensivist, ENT, Radiology, Nuclear Medicine, Urology,
Occupational Medicine, Renal, General Surgery, Cardiothoracic Surgery,
Home Based Primary Care (HBPC), Community Living Centers, VHA Nursing
Home
In the VA system about a quarter of all primary care patients
treated are seen by a PA1. Approximately 33% of PAs today employed by
VHA are veterans, retired military, or currently serving in the
National Guard and Reserves.
Not one profession; Physician, PA or NP can sustain a local
workforce as the VHA must compete with the private sector as the local
demand recruits each profession which creates a delay in veteran
access.
It is only within the VA that you see the disparity of VHA PA pay
and the private sector pay. Large health care systems such as Kaiser
Permanente, Mayo, and Cleveland clinic have competitive salary.
The 2015 Workforce Succession Planning Report showed that 12 out of
the 22 VISN (85 main facilities not including respective CBOCs) stated
that the reason they could not hire PAs was because they could not
compete with the private sector. These VISNs had in their plan to
conduct salary surveys to seek parity with private sector. However,
upon recent review from 1/2014-2/2015 of submissions for PA special
salary rates to VA Compensation Office, less than 8% submitted such
requests.
July 2017 review of facilities submitting Special Salary
Adjustments (SSA) have shown that the pay disparity between VHA PA pay
was an average of 18% below local market pay with the highest being
34%. The data further supported facilities that sought out special pay
rates were then able to immediately fill all positions which resolved
the difficulty recruiting PAs. This demonstrates the strong correlation
between seeking parity with the private sector and hiring hard to
recruit PA positions within VHA.
The PA workforce has grown far less than other medical provider
positions within the VHA, very little is being done about it;
therefore, what should be a warning signal of serious retention and
recruiting problems is being left to local VAMCs to manage. Despite
increasing discrepancy in salary levels, benefits, and education debt
reduction programs between the civilian sector and the VAMCs often
tells our members there is no problem. Inclusion of Physician
Assistants into the Nurse LPS within Grow Our Own Directive S. 426 will
allow for salary adjustments so that the VHA can be competitive.
VAPAA is also concerned that the use of recruitment incentives
within the VA is at the discretion of the hiring facility and is not
standardized across the VA system. During 2012-2013 only 44 Physician
Assistants have received $319,074 in funding to further their education
in comparison to Seven hundred five registered nurses seeking to become
Nurse Practitioners receiving scholarship awards totaling over
$11,842,919 in support of NPs and NP programs. VA should implement
recruitment and retention tools targeting Employee Incentive
Scholarship Program by including PA as a hard to recruit occupation at
the facility level to reflect WSP and OIG findings. Include Employee
Debt Reduction Program funding to include PAs and make it available to
all advertised PA vacancy announcements as EDRP cannot be issued unless
it is advertised in the initial vacancy announcement. VISN and VA
medical center directors must be held accountable for the failure to
utilize these recruiting tools.
S. 426 also provides another solution for meeting the healthcare
workforce challenges while providing support to unemployed Post-9/11
combat veterans and a career path for returning veterans who had served
as medics and corpsmen with combat medical skills; like those of
returning Vietnam War veterans with these skills. This legislation
takes veterans with medical and military experience and provides them
with educational assistance to become certified PAs for employment at
the VA, where they can continue to serve their fellow veterans.
By serving where the VA needs are the greatest, the veteran PAs can
increase access to care by serving in rural and underserved areas.
Recommendations: We ask that the Committee recognize the advantages
to the Recruitment and Retention of Physician Assistant (PA) Workforce
in the VA System by supporting enactment and supported by the veteran
service organizations at the November 18, 2015 hearing on S. 2134 and
call attention the VHA witness Dr. Carolyn McCarthy testified in favor
of this legislation ``Grow Our Own Directive: Physician Assistant
Employment and Education Act of 2015.'' (S. 2134) and (H.R. 3974).
A. Restructure VHA Handbook 1020--Employee Incentive Scholarship
Program (EISP).
B. Include PAs at all facility level to reflect Workforce
Succession Planning and the OIG Top 5 as a hard to recruit occupation
as this is the qualifying factor for EISP funding.
C. Include Education Debt Reduction Plan in all PA job postings.
D. Include targeted scholarships for the ICT program OIF OEF Grow
Our Own returning veterans, and mandate VHA shall appoint PA ICT
National director to coordinate the educational assistance necessary
and be liaison with PA university programs.
E. S. 426 would direct new Physician Assistant director position to
work within the National Healthcare Recruiter, Workforce Management &
Consulting VHA Healthcare Recruitment & Marketing Office.
a. This position then can develop targeted recruiting plans
with 187 PA programs, working in a way that the local Human
Resource Officer (HRO) often will not; due to lack of staffing.
F. The VA employed PA national Healthcare Recruiter would develop
improvements in finding qualified candidate in a matter of days not
months.
G. VHA must incorporate new PA consultant manager into this
National Healthcare Workforce program office.
H. Health Professional Scholarship Program.--The Health
Professional Scholarship Program (HPSP) provides scholarships to
students receiving education or training in a direct or indirect health
care services discipline. Awards are offered on a competitive basis and
are exempt from Federal taxation. In exchange for the award,
scholarship program participants agree to a service obligation in a VA
health care facility. The Committee believes strongly that ample
resources exist within the Department to ensure that hard to fill Top 5
OIG occupations are not excluded from participation.
I. Establish PA Pay Grades I-V, to continue be competitive with the
civilian job market
conclusion
Chairman Isakson and Ranking Member Senator Tester, and other
Members of SVAC, as you strive to ensure that all veterans receive
timely access to quality healthcare and as you build increased capacity
for delivery of accessible high-quality health care, and demand more
accountability into the VA health care system, I strongly urge the full
Committee to review the important critical role of the PA profession
and ensure legislatively that VHA takes immediate steps to address
these longstanding problems and continue to work with VAPAA in
supporting our Nation's veterans.
______
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, I would like to
thank you for the opportunity to testify on today's pending
legislation.
s. 115, veterans transplant coverage act
This legislation would authorize the Department of Veterans Affairs
(VA) to provide live donor transplants to veterans eligible for VA
health care regardless of the live donor's eligibility for care at VA.
Currently, VA provides care to non-veterans who fall under one or more
of the eight categories in which they are authorized to provide medical
coverage. These categories range from survivors and dependents of
certain veterans, newborn children of women veterans and in cases of
humanitarian care.
By authorizing VA to perform medical care on non-veteran live
donors in situations of medically necessary transplants for veterans,
more veterans will be able to obtain lifesaving surgery in a timelier
manner. The VFW strongly supports this legislation.
s. 426, grow our own directive: physician assistant employment and
education act of 2017
This legislation would build on the success of the Intermediate
Care Technician (ICT) pilot program. Launched in December 2012, the ICT
pilot program recruited transitioning veterans who served as medics or
corpsmen in the military to work in VA emergency departments as
intermediate care technicians. The ICT program offered transitioning
medics and corpsmen, who have extensive combat medicine experience and
training, the opportunity to provide clinical support for VA health
care providers without requiring them to undergo additional academic
preparation.
This legislation would go a step further by affording transitioning
medics and corpsmen the opportunity to become physician assistants.
With the continued drawdown of military personnel, more medics and
corpsmen will be leaving military service and transitioning into the
civilian workforce. The VFW strongly supports efforts to leverage their
medical knowledge and experience to meet the health care needs of our
Nation's veterans.
s. 683, keeping our commitment to disabled veterans act of 2017
This legislation would extend, for one year, the requirement for VA
to provide nursing home care to certain veterans with service-connected
disabilities.
As the veteran population continues to age, the need for nursing
home care continues to rise. Nursing home care within VA is considered
the ``safety net'' for their outpatient services such as residential
care, respite care, hospital-based home care, adult day health care,
homemaker/home health aide services and other extended care programs.
Yet the eligibility requirements for nursing home care and inpatient
hospital care are inconsistent with standard medical practice and do
not support continuity of care for veterans.
The VFW supports the intent of this legislation, but believes a
standard for VA nursing home entitlement must be established for all
veterans--not just veterans with a disability rating of 70 percent or
higher.
s. 833, servicemembers and veterans empowerment and support act of 2017
This legislation would expand health care and benefits from VA for
veteran survivors of sexual trauma. While the VFW agrees with the
intent of this legislation, there are concerns as well. The VFW
strongly supports the expansion of coverage to include survivors of
cyber harassment. As technological capabilities have continued
expanding and becoming more accessible, many have fallen victim to
sexual harassment and assaults of a sexual nature on the Internet and
by other technological means. Survivors of cyber harassment should not
fall victim again by being pushed to the wayside due to legal
definitions not being inclusive of them. Regardless if an individual is
sexually harassed or assaulted in a physical nature, or by means of
technology, they deserve the right to seek counseling and treatment.
Section 2 would also expand the population who can use VA for
counseling and treatment beyond the current restriction of only those
who were assaulted while serving on active duty. It is the duty of
Congress and VA to take care of every veteran who served, regardless of
their duty status.
The VFW supports codifying the standard of proof for sexual trauma,
as current law only regulates combat veterans. Yet, there are concerns
with some portions of this section. Some inconsistencies can be found
throughout section 3, which begins by saying it is covering all
veterans making a claim of ``a covered mental health condition'' either
due to, or aggravated by, military sexual trauma (MST). While this term
is later defined, further into section 3 there are inconsistencies
where only Post Traumatic Stress Disorder is referenced for the
nonmilitary sources of evidence, as well as under the notice and
opportunity to supply evidence portion.
The VFW has long advocated for nonmilitary sources of evidence to
be able to be used by veterans filing disability claims with VA.
Particularly for MST claims, as survivors may not have felt comfortable
talking with military law enforcement, medical personnel or their
commands. By expanding what veterans can submit as evidence for MST
claims, to include records for non-military law enforcement, rape
crisis centers, physicians and statements from others, this would
greatly reduce the barriers of proof for survivors seeking treatment
through VA. Yet, the VFW is concerned that by saying the Secretary
shall accept nonmilitary evidence, but also saying the Secretary may
seek a credible opinion during the review of evidence, will contradict
and further complicate the benefits of allowing outside evidence.
This legislation would also expand notifications of opportunity to
supply evidence for disability claims. The VFW is concerned that by
providing veterans submitting MST claims the opportunity to submit more
evidence after a claim is submitted, and before the Secretary is able
to deny the claim, will create a double standard. While the VFW
supports improving the disability claims process for veterans claiming
MST, providing them a benefit others do not have in their claims
process would be unfair to other veterans. There should be equity for
all veterans in not just health care, but in benefits and applications
as well.
This legislation would also require reports on claims for
disabilities incurred or aggravated by military sexual trauma. One of
the reporting requirements would be a description of training that the
Secretary provides to employees of the Veterans Benefits
Administration. The VFW believes this reporting requirement should not
be limited to strictly employees, but should also include contractors
and affiliates of the Veterans Benefits Administration. This would
include contract physicians' compensation and pension exams, as well as
Veteran Service Organizations assisting in benefit claims.
The VFW supports section 4, which would ensure Sexual Assault
Response Coordinators (SARCs) from the Department of Defense advise
members of the Armed Forces reporting instances of sexual assault or
harassment that they are eligible for services at Vet Centers. The VFW
would like to see this section expand to ensure this information is
provided during sexual assault awareness training as well as
incorporated into training for the Sexual Assault Prevention Response
Office.
s. 946, veterans treatment court improvement act of 2017
The VFW supports this legislation, which would require VA to hire
50 additional Veterans Justice Outreach (VJO) Specialists to provide
treatment court services to justice-involved veterans. These
specialists serve as an invaluable asset in ensuring the VJO program
helps veterans avoid unnecessary criminalization of mental illness and
receive treatment in lieu of incarceration.
Outreach specialists for VJO make sure veterans within the program
have access to VA services, provide outreach, and handle case
management for justice-involved veterans. By requiring VA to not allow
their number of employed VJO Specialists to go lower than the number
currently within the system the day this legislation would go into
effect, as well as increasing that number by 50, more veterans in need
of assistance and guidance through this unique and live-saving program
will have access to Veteran Treatment Courts.
s. 1153, veterans access act
This legislation would suspend or prohibit certain non-VA providers
from providing community care health services to veterans. The VFW
supports the intent of this legislation, but has concerns that must be
addressed before passing.
The Veterans ACCESS Act has four factors which would result in the
denial or revocation of eligibility of a health care provider to
provide non-VA health care services to veterans. One of those factors
categorized under section 2 of this legislation would authorize the
Secretary to revoke eligibility of a medical provider who violated a
law for which a term of imprisonment of more than one year may be
imposed. This particular part of the legislation has nothing
specifically to do with medical licensing and is incredibly vague. The
VFW agrees if a crime results in a medical provider losing their
license that they should not be able to practice medicine, but that is
already covered in this legislation.
The VFW also has concerns with language stating that the Secretary
may deny, revoke, or suspend the eligibility of health care providers
under investigation by the medical licensing board of a state in which
the provider is licensed or practices. This denies the providers their
right to due process, as they are only under investigation and no
verdict has been reached.
Last, this legislation provides no means for health care providers
who may have their eligibility revoked, but want to come back as a
community care provider for VA patients. Particularly in rural areas,
these community providers are crucial in allowing veterans timely
access to care. If health care providers are not able to provide care
to veterans using VA, the department should be required to explain to
them how long they are revoked or suspended. In instances where
providers are revoked, they must be informed of what they may do to
provide community care again, as well as when they may reapply.
s. 1261, veterans emergency room relief act
The VFW strongly supports expansion of emergency treatment and
urgent care in the community. However, we oppose the requirement to
have VA establish copayments for community urgent and emergent care
that is different from copayments charged for VA care. This proposal
also makes no exception for veterans with service-connected
disabilities or who are currently exempted from co-payments. Veterans
currently exempted from co-payments should not be required to bear a
cost-share for emergency and urgent care services.
As an alternative, VA should consider establishing a national nurse
advice line to help reduce overreliance on emergency room care. The
Defense Health Agency (DHA) has reported that the TRICARE Nurse Advice
Line has helped triage the care TRICARE beneficiaries receive.
Beneficiaries who are uncertain if they are experiencing a medical
emergency and would otherwise visit an emergency room, call the nurse
advice line and are given clinical recommendations for the type of care
they should receive. As a result, the number of beneficiaries who turn
to an emergency room for their care is much lower than those who
intended to use emergency room care before they called the nurse advice
line. By consolidating the nurse advice lines and medical advice lines
many VA medical facilities already operate, VA would be able to emulate
DHA's success in reducing overreliance on emergency room care without
having to increase cost-shares for veterans.
s. 1279, veterans health administration reform act of 2017
This legislation would, among other things, consolidate VA's
community care authorities, expand VA's authority to provide emergency
room and urgent care, and improve VA community care. The VFW supports
this legislation and would like to offer suggestions to strengthen it.
The VFW strongly believes that veterans have earned and deserve
timely access to high quality, comprehensive, and veteran-centric
health care. In most instances, VA care is the best and preferred
option, but we acknowledge that VA cannot provide timely access to all
services to all veterans in all locations at all times; that is why VA
must leverage private sector providers and other public health care
systems to expand viable health care options for veterans.
The VFW supports section 2, but would like to offer recommendations
to strengthen it. This section would build on lessons learned from the
Veterans Choice Program to reform the way veterans access community
care. When the Choice Program was first implemented, the VA wait time
standard required a veteran to wait at least 30 days beyond the date a
veteran's provider deemed clinically necessary--the clinically
indicated date--before being considered eligible for the Choice
Program. This meant that a veteran who was told by a VA doctor that he
or she needs to be seen within 60 days was only eligible for the Choice
Program if he or she was scheduled for an appointment that was more
than 90 days out, or more than 30 days after the doctor's
recommendation.
After the VFW expressed concern that veterans' health may be at
risk if they are not offered the ability to receive care within the
timeframe their doctors deem necessary, Congress amended Public Law
(PL) 113-146, the Veterans Access, Choice, and Accountability Act of
2014, to require VA to offer veterans the option to receive care
through the Choice Program if VA is unable to provide an appointment
before the clinically indicated date.
The VFW strongly believes that when and where veterans receive
their health care is a clinical decision made by veterans and their
doctors. This bill would rightfully base eligibility for the proposed
Care in the Community Program on whether receiving care through
community providers is in the clinical best interest of the veteran.
Another lesson learned from the Choice Program is that geographic
accessibility is difficult to define because it means different things
in different locations and changes depending on the health care needs
of the veteran concerned. That is why the VFW supports basing access to
community care on whether a veteran would experience an undue burden if
the veteran seeks care from VA. However, the VFW believes it necessary
to authorize VA and veterans to work together to define what is
considered an undue burden instead of establishing systemwide
definitions that do not account for local variances.
This bill would also require VA to place veterans on an electronic
waiting list. Instead of placing veterans on electronic waiting lists,
the VFW recommends VA provide veterans an appointment that is beyond
the wait time standards of the department and offer veterans the
opportunity to receive community care. When veterans accept an
appointment in the community, their VA appointments must be canceled to
prevent no-shows. However, this would require VA to track community
care appointments better than they have with the Choice Program.
This bill would charge VA with scheduling and coordination of
community care appointments and management of the community care
networks. In so doing, it would also limit VA's ability to use a third
party administrator for the proposed Care in the Community Program. The
Choice Program has experienced many issues because VA elected to simply
contract virtually every aspect of the community care process. However,
not every issue that the Choice Program has faced is the fault of the
third party administrators, and there is no guarantee that VA would not
have experienced the same issues without a third party administrator.
What is clear from the VFW's continued evaluation of the Choice Program
is that the third party administrators have the capability to
accomplish certain tasks more efficiently than VA. For example, the VFW
does not believe VA has the capability to manage a network of hundreds
of thousands of private sector health care providers.
The VFW supports utilizing VA community care staff to schedule
Choice Program appointments when possible, but it is unreasonable to
expect VA to be able to hire enough staff to keep pace with the
expanded use of community care or downsize after surges have passed.
For that reason, the VFW recommends VA build on its co-located staff
model and rely on contracted staff to support VA's community care staff
when demand for community care spikes. To ensure veterans are not
negatively impacted when they are rolled over to contract staff, VA
must ensure the contracted staff has access to the same systems as VA
community care staff.
The VFW supports section 3, which would establish a VA provider
agreement authority. Authorizing VA to enter into non-Federal
acquisition regulation (FAR) based agreements with private sector
providers, similar to agreements under Medicare, would ensure VA is
able to quickly provide veterans with care when community care programs
like the Choice Program are not able to provide the care.
Provider agreements are particularly important for VA's ability to
provide long-term care through community nursing homes. The majority of
the homes who partner with VA do not have the staff, resources, or
expertise to navigate and comply with FAR requirements, and have
indicated they would end their partnerships with VA if required to bid
for FAR contracts. In fact, VA's community nursing home program has
lost 400 homes in the past two years and will continue to lose 200
homes per year without provider agreement authority. This means
thousands of veterans are forced to leave the place they have called
home for years simply because VA is not able to renew agreements with
community nursing homes.
However, the VFW urges the Committee to amend section 3 of the bill
to make it clear that provider agreements may only be used if VA is
unable to schedule an appointment at its medical facilities or through
the Care in the Community Program. Authorizing local medical facilities
to enter into provider agreements with providers who are in or are
being perused to join the community care network would erode the
networks, and could result in such networks failing to meet needed
coverage and size requirements.
The VFW supports section 4, which would reform VA emergency and
urgent care options for veterans. The VFW continues to hear from
veterans that VA refuses to pay the cost of their emergency room
visits, which may have saved their lives or was their only option for
receiving the urgent care they needed. That is why the VFW supports
this legislation's expansion of emergency and urgent community care.
Specifically, the VFW is pleased to see that this legislation would
ensure copayments associated with emergency and urgent community care
would be equal to the copayments paid by veterans at VA medical
facilities. This would ensure veterans are not punished for using
community care.
However, this legislation would require veterans to have received
VA care with the past 24-months in order to be eligible to receive
reimbursement for the cost of community emergency and urgent care,
which is similar to the eligibly requirements under VA's current
emergency care reimbursement program. This barrier to access has caused
undue hardship on veterans who enroll in VA health care, but have been
denied access due to wait times, and subsequently require emergency
services. VA is aware of this problem and has requested the authority
to make an exemption to the 24-month requirement for veterans who find
themselves in this situation. The VFW recommends that the Committee
amend this legislation to ensure veterans who face long appointment
wait times are not precluded from seeking the emergent and urgent care
they need.
The VFW strongly supports section 5, which would require VA and the
Centers for Medicare and Medicaid (CMS) to enter into a memorandum of
understanding. The VFW has long supported Medicare subvention, because
our members see no logical reason VA lacks the ability to bill their
Medicare plans for the cost of providing non-service-connected care.
This section would require VA and CMS to do the next best thing--
coordinate referrals. By requiring Medicare providers to accept
referrals from VA doctors, this section would enable veterans who want
to use private sector doctors but maintain all their records and health
care management at VA the ability to do so.
The VFW support sections 6 and 7, which would establish education
programs to teach veterans, community care providers and VA employees
about VA's community care programs. The VFW believes that community
care providers must also have the opportunity to obtain military
competency training and continuing medical education (CME) on how to
provide veteran-centric care. That is why we recommend the Committee
expand section 7 by requiring VA to also provide CME on veteran-
specific health care and military competency training.
s. 1325, better workforce for veterans act of 2017
The VFW strongly supports this bill and thanks the Committee for
including it in the agenda. If enacted, this bill would significantly
improve VA recruitment and retention authorities. When the VFW asked
veterans how they would improve the VA health care system in our latest
survey of VA health care entitled ``Our Care 2017,'' the most common
suggestion was to hire more health care staff to reduce wait times.
The VFW thanks the Committee for recognizing that VA's ability to
hire and retain high quality employees is important. Considering that
more than 30 percent of VA employees will be eligible for retirement by
2020, it is vital that Congress focuses on ways to improve VA's hiring
and retention authorities to ensure veterans have timely access to the
care they have earned.
Title I of this important bill would improve VA recruitment and
hiring practices. It would improve authorities for quickly hiring
students who complete their residency or internships at VA. With more
than 70 percent of America's health care workforce receiving some or
all of its training at VA, it should be easy for VA to develop a
pipeline of students who become employees. However, VA's cumbersome
human resources (HR) requirements limit its ability to recruit the
students it trains. The VFW supports eliminating such H.R. barriers to
ensure VA is able to quickly hire the high quality health care
professionals it trains.
The VFW is also pleased this bill takes steps toward improving
veterans preference to ensure veterans who served in the National Guard
and Reserve are afforded the same hiring preferences as their active
duty counterparts. Currently, veterans who served after September 11,
2001, are required to have served at least 180 consecutive days on
active duty. Due to our all-volunteer military and the nature of the
wars in Iraq and Afghanistan, the Guard and Reserve have been utilized
much more than they have during past conflicts.
However, not all Guard and Reserve servicemembers receive active
duty orders for more than 180 days. Thus, many veterans that deployed
into harm's way in support of the wars in Iraq and Afghanistan are not
eligible for veterans hiring preferences. Changing the eligibility for
veterans preference from ``180 consecutive days'' to ``for a total of
more than 180 days,'' ensures Guardsmen and Reservists are afforded the
same opportunity to obtain meaningful civilian employment after
military service as their active duty brothers and sisters.
This important bill also makes several administrative changes to
VA's H.R. processes. The VFW strongly supports amending VA's reduction
in force procedures to make certain VA ranks its employees based on
performance instead of tenure. Doing so would ensure the highest
quality employees would remain to care for our Nation's veterans if VA
is required to implement a reduction in force.
discussion draft, the veterans choice act of 2017
This legislation would expand the Choice Program, establish VA
provider agreements authority, require VA to assign each veteran a
primary care provider, and establish demand capacity analyses, among
other things. The VFW supports sections 4, 5, 6, 9, 10 and 11; supports
the intent of section 7; has serious concerns with section 3; and takes
no position on sections 8 and 12.
The VFW has serious concerns with section 3 as written and would be
forced to oppose the underlying bill if changes are not made to the
bill before it is advanced by the Committee. While the Veterans Choice
Program has made significant progress since it was implemented in
November 2014, it has yet to achieve what Congress envisioned when it
passed the Veterans Access, Choice, and Accountability Act of 2014. The
purpose for this landmark program was to address the national access
crisis that has plagued the VA health care system, where veterans wait
too long or travel too far for the care they need. The VFW has made a
concerted effort to ensure the program works as intended by evaluating
what aspects of the program are working and identifying common sense
solutions to aspects that are not working well. We have done this
because we agree that VA must leverage its community care partners in
order to fulfil its obligation to our Nation's veterans. However, we
firmly believe that community care must complement, not supplant or
compete with, the high quality, comprehensive and veteran-centric care
veterans receive from their VA health care system.
Section 3 would make any veteran enrolled in VA health care
eligible for the Choice Program. The VFW is seriously concerned that
such a significant expansion of eligibility would result in veterans
receiving disparate and uncoordinated care. Medical research has
determined and the Commission on Care has reiterated that integrated
and managed health care systems provide better health care outcomes
than fee-for-service systems. That is why the majority of high
performing health care systems, including VA, have implemented the
patient-centered medical home model of delivering health care, which
ensures patients receive the care they need when they need it.
While the idea that veterans should be free to choose between VA
and community care providers whenever they want and every time they
seek care sounds enticing, it is unsustainable because of the cost, and
the VFW would vehemently oppose any future efforts to pass that cost
onto veterans. The Commission on Care estimated that the cost of a
proposal very similar to Choice Program eligibility proposed by section
2 would have ranged from $156 billion to $237 billion once fully
implemented. The VFW is not concerned that veterans will flee VA
medical facilities for private sector doctors. To the contrary, VFW
health care surveys show that nearly 60 percent of veterans who use VA
health care prefer it, despite having other health care options. Yet,
the increased reliance on VA health care due to such a generous benefit
and VA's inability to keep pace with the increase in demand would
require Congress to shift already strained and insufficient
appropriations from direct care to community care. Such a shift of
resources would further limit VA's ability to update its aging
infrastructure, hire needed health care professionals, compete with the
private sector, and would lead to the gradual erosion of the VA health
care system.
The VFW is also concerned that a ``choose your own adventure''
approach to health care would lead to veterans receiving fragmented
health care that the Commission on Care found would lower health care
outcomes and endanger patient safety. Veterans deserve the highest
quality health care possible, not fragmented care that fails to meet
their health care needs. The VFW urges the Committee to amend this
section by ensuring veterans who are unable to receive a VA appointment
by a clinically indicated date, or within a distance an enrolled
veteran and such veteran's health care provider agree is reasonable,
are offered community care options.
The VFW supports provisions which authorize VA to enter into
regional contracts to establish and manage networks of health care
providers, schedule appointments, process claims and payments, and
collect medical documentation. However, the VFW believes the specific
processes that are completed by the contractor should be determined by
VA in consultation with Veterans Service Organizations, the current
third party administrators and entities interested in becoming a third
party administrator.
VA has worked on this process for the past year, and has determined
that it is best for VA community care staff to schedule Choice Program
appointments when feasible, and to turn to the third party
administrators when local facilities are unable to timely process
appointments. While different parts of the country have experienced
mixed results with the current third party administrators, the VFW does
not believe it would be in the best interest of veterans for every
aspect of the Choice Program to be managed by a third party
administrator or VA. By evaluating issues the Choice Program has faced,
and with increased communication and management of the current third
party administrators, VA must strike the right balance between what is
handled internally and what can be contracted out. The most important
factor is that veterans must have a seamless transition from VA care to
community care and vice versa.
This section would also prohibit VA from using tiered networks to
direct veterans to specific providers. While the VFW agrees that
veterans must not be forced to receive care from specific community
care providers, VA must have the authority to recommend providers in
higher tiers to incentivize network providers who show dedication to
developing military competency and veteran-centric health care
practices. The VFW recommends the Committee amend this section to
prohibit VA from requiring veterans to obtain care from specific
doctors, but still make recommendations based on a provider's tier
level.
The VFW supports the provision to authorize VA to collect
reasonable charges from a veteran's other health care plans. Doing so
would ensure VA is able to offset some of the costs of providing
community care to veterans. Specifically, the VFW is glad this bill
would not impose a financial penalty on veterans who may not be aware
that their other health care coverage has changed. We do, however,
recommend that the Committee expand the definition of other health care
coverage to include Medicare. VFW members who pay for Medicare coverage
see no justifiable reason for VA to be treated differently than private
sector providers when a Medicare- enrolled veteran receives non-
service-connected care from a VA doctor. Doing so would further offset
the cost of providing community care.
The VFW supports section 4, which would authorize VA to enter into
provider agreements. Specifically, the VFW is glad this bill would
require VA to provide care through its facilities or the Choice Program
before considering provider agreements. This would ensure provider
agreements do not impact the integrity of the Choice networks or VA's
ability to provide direct care.
Section 7 would require VA to assign each enrolled veteran a
primary care provider. It would also authorize veterans to freely
choose a community primary care provider when such veteran enrolls into
the VA health care system. The VFW supports including community care
options when veterans seek primary care and, to ensure continuation of
care, veterans must be given the opportunity to receive all their
primary care from their assigned community primary care provider.
However, the VFW does not support giving veterans a list of providers
and leaving them to fend for themselves to find a community primary
care provider who is accepting new patients and is willing to see them.
Instead, VA must work with every veteran who requests primary care to
determine what option and doctors are best for each individual veteran.
Furthermore, the VFW recommends the Committee require community
primary care providers give VA the right of first refusal when
referring veterans to specialty care. Under the current Choice Program,
community care providers do not have they ability to refer veterans
back to VA for specialty care or follow-up care. Doing so would ensure
proper utilization of VA resources and strengthen the relationship
between VA and local community care providers.
The VFW strongly supports section 9, which would require VA to
conduct demand capacity analyses. The VFW believes that community care
networks and VA's footprint must be tailored to each health care
market. There are some areas in this country were wait time for private
sector care is much greater than VA. In other areas, VA is duplicating
services that are readily available in the private sector or through
other public health care systems. By conducting periodic demand/
capacity analyses, VA would be able to determine when it should
leverage the capabilities of its community care partners and when it
must expand internal access. Doing so would ensure VA devotes its
finite resources to capabilities the community lacks.
discussion draft, improving veterans access to community care act of
2017
This legislation would consolidate VA's community care authorities
and improve VA community care, among other things. The VFW supports
sections 102, 103, 201, 202, 204 and 205; has concerns with section
101; and agrees with the intent of section 203.
The Choice Program has faced a number of challenges since it was
implemented in November 2014. The VFW has made a concerted effort to
evaluate what aspects of the program have worked and identify common
sense solutions to aspects that have not worked as intended. That is
why we are pleased to see that this legislation would incorporate many
of the lessons learned from the implementation of the Choice Program
and other community care programs, such as consolidating all of VA's
community care authorities to ensure veterans, VA employees and private
sector providers understand how to navigate VA's community care
program.
Section 101 would reconstitute and make a number of improvements to
the Choice Program, to include ensuring a veteran's continuation of
care is not interrupted by bureaucratic rules. The VFW supports
provisions to allow veterans who receive authorized care from a
community care provider to continue to see their community care
provider or another community care provider to complete an episode of
care, or enter into follow-up treatment without the need to request
additional authorization.
The VFW is glad to see that this legislation includes recent
improvements to the eligibility criteria in the proposed Veterans
Community Care Program, such as the Secretary's authority to determine
that there is a compelling reason for a veteran to use community care
in lieu of VA care. However, the VFW is concerned that the bill
continues the flawed 40-mile and 30-day eligibility criteria to
determine when veterans are afforded the opportunity to access
community care. The VFW believes that the distance a veteran is
required to travel or how long a veteran is required to wait for health
care must be a clinical decision made by the veteran and his or her
health care provider.
Another lesson learned from the Veterans Choice Program is that VA
provides health specialties that do not have a Medicare rate, including
obstetrics and gynecological care. While the VFW understands the need
to set limits on the amount VA is authorized to reimburse community
care providers, the VFW believes that a consolidated community care
program should authorize VA to provide community care options for every
health care specialty it delivers. That is why we are glad to see the
legislation would authorize VA to establish a fee schedule for services
it provides that do not have a Medicare rate. It would also authorize
VA to negotiate rates, which the VFW supports.
This section would also authorize VA to establish tiered networks
to operate the Veterans Community Care Program. The VFW supports
establishing tiered networks to incentivize community care providers to
develop military competency and veteran-centric health care practices.
However, a veteran's choice of community care provider should not be
limited by a specific tier. Each veteran should be given the
opportunity to work with VA to determine what community care options
are best suited to the veteran's clinical needs and preferences.
The VFW supports section 102 which would require VA to comply with
prompt payment requirements. The VFW continues to hear from veterans
that they have been billed for care that VA is responsible for paying
simply because the community care provider VA sent them to was unable
to collect payment from VA in a timely manner, so the provider elected
to bill the veteran instead. Prompt payment is vitally important to
ensuring VA's community care network is able to attract and maintain
high quality private sector health care providers.
The VFW supports section 103, which would expand medical
malpractice protections to veterans who use VA community care. Veterans
who receive care at VA medical facilities are eligible for disability
compensation and other benefits if they have been injured or negatively
impacted by VA care. Veterans who use the Choice Program are not
offered the same opportunity and are required to seek legal action in
order to be compensated for malpractice.
The VFW agrees with the intent of section 203, which would
authorize VA to transfer resources between its medical services and
community care accounts. If veterans receive care from community care
providers or VA, health care facilities must be determined at the local
level by each veteran and his or her health care team, not by Congress
or VA bureaucrats who favor one option over the other. That is why the
VFW supports authorizing VA to transfer resources between its internal
care and community care accounts based on demand. Instead of
implementing this section, the VFW would recommend doing away with the
community care appropriations account and simply require VA to report
on the use and cost of community care, rather than continuing to fence
off certain appropriations for community care.
The VFW supports section 204, which would authorize VA to obligate
funds when care is approved, not when VA authorizes community care. If
enacted, this provision would enable VA to better forecast community
care expenditures and reduce the amount of resources it is required to
deobligate, because it obligated more money than it was required to pay
in an effort to prevent the department from violating anti-deficiency
laws.
the department of veterans affairs quality employment act of 2017
The VFW strongly supports this legislation which would improve
employment practices at VA. If VA is not able to quickly hire high
quality employees, it will lack the staff needed to accomplish its
mission. In its report, ``Hurry Up and Wait,'' the VFW highlighted
deficiencies in VA Human Resources practices. The VFW recommended
Congress ease Federal hiring protocols for VA health care professionals
to ensure VA can compete with private industry to hire and retain the
best health care providers in a timely manner.
In their review of VA's scheduling system and software development
as required by the Veterans Access, Choice and Accountability Act of
2014, the Northern Virginia Technology Council (NVTC) reinforced the
VFW's concerns that VA's hiring process moves too slowly. NVTC
suggested that for VA to be successful, it must aggressively redesign
its human resources processes by prioritizing efforts to recruit,
train, and retain clerical and support staff. This important bill would
make many needed improvements to the way VA hires and retains high
quality employees.
The VFW strongly supports the creation of an Executive Management
Fellowship Program. This ideas was advocated by a VFW-Student Veterans
of America fellow. In his proposal, ``Connecting America's Best to
Serve America's Best,'' Karthik A. Venkatraj highlighted how a private-
public partnership program such as the Executive Management
Fellowship--where VA leaders are detailed to a private sector company
and vice versa--can infuse private sector expertise and disciplines
into VA governance and management. The proposed fellowship would also
grant private, non-profit and academic institutions the ability to
immerse its leadership in the highest levels of our Nation's public
policy to better understand how the public and private sector can learn
from each other and work together to improve the lives of America's
veterans.
This bill includes other ideas the VFW has suggested and supported
in the past, such as expedited hiring authority for students enrolled
in a VA residency or internship program and recent graduates who are
being poached by private sector health care systems, because VA's
hiring process is to too long and cumbersome. It also includes a
requirement for VA to conduct and use exit surveys to determine why its
medical professionals are leaving. Doing so would ensure VA is able to
address retention issues, which is one of the biggest reasons behind VA
staff shortages.
______
Prepared Statement of John Rowan, National President,
Vietnam Veterans of America
Good morning 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 for
your consideration our Statement for the Record on pending legislation
before this Committee
S. 115, the Veterans Transplant Coverage Act, introduced by Senator
Dean Heller (R-NV). This bill would authorize the Department of
Veterans Affairs to provide for an operation on a live donor to carry
out a transplant procedure for an eligible veteran, notwithstanding
that the live donor may not be eligible for VA health care.
According to the Health Resource Services Administration (HRSA),
the demand for organs far outweighs the number of donors. Living
donations offer another choice and extend the supply of organs. Of the
28,954 organ transplants performed in the U.S. in 2013, more than one-
fifth (5,989) were living donor transplants.
While VVA has no objection to this bill, as it provides another
avenue for veterans who receive transplants in the VA, the bill does
not address potential liability issues for the department concerning
operating on someone who is not eligible for VA health care. This would
create a situation that will have to be addressed should S. 115 be
enacted.
S. 426, the Grow Our Own Directive: Physician Assistant Employment
and Education Act of 2017, introduced by Senator Jon Tester (D-MT).
This bill would increase assistance provided by the VA for education
and training of physician assistants of the department, and establish
pay grades and require competitive pay for physician assistants.
VVA supports this important bill. Access to safe, quality health
care has always been critical to veterans. Physician Assistants (PAs)
play a significant role in the Veterans Health Administration's model
for delivering comprehensive health care. Yet in September 2016, the VA
Inspector General reported that PAs ranked third among health
professions experiencing troubling provider shortages (psychologists
were tied with PAs in this ranking).
This bill would provide scholarships to veterans who have medical
or military health experience. Upon completion of training and
education, a new PA would be required to work for the VA in a medically
underserved area and in a state with a per capita veteran population of
more than 9 percent (according to the National Center for Veterans
Analysis and Statistics and the US Census Bureau).
Importantly, the bill also establishes pay grades for PAs as well
as competitive pay requirements, and mandates that the VA implement a
national strategic plan for the retention and recruitment of physician
assistants.
S. 683, the Keeping Our Commitment to Disabled Veterans Act of
2017, introduced by Senator Mazie Hirono (D-HI). This bill would extend
the requirement for the VA to provide nursing home care to certain
veterans with service-connected disabilities through December 31, 2018.
VVA fully supports this extension.
S. 833, the Servicemembers and Veterans Empowerment and Support Act
of 2017, introduced by Senator Jon Tester (D-MT), would expand VA
health care and benefits for Military Sexual Trauma.
VVA supports this legislation. It is no secret that incidents of
cyber-harassment of a sexual nature are on the rise. Earlier this year,
it was reported in the San Diego Tribune that a private Facebook forum
called Marines United allowed postings of sexually suggestive or
explicit photos of female servicemembers, often without their knowledge
or consent. Members of the forum, both active-duty military and
veterans, made lewd and offensive remarks. When some of the victims
learned about this and complained, they were bullied and/or subjected
to threats.
This bill seeks to expand the coverage of counseling and treatment
for military sexual trauma to include cyber-harassment of a sexual
nature and relax the standard of proof for service-connection of mental
health conditions related to MST. The expanded coverage would include
members serving on active duty, active duty for training, as well as
inactive duty for training.
VVA understands that the devil is in the details and we extend to
the Committee an offer to work with staff to refine and clarify this
legislation.
S. 946, the Veterans Treatment Court Improvement Act, introduced by
Senator Jeff Flake (R-AZ), would require the Secretary of Veterans
Affairs to hire additional Veterans Justice Outreach specialists to
provide Veterans Treatment Court services to justice-involved veterans.
Justice-involved veterans too often are forgotten by the Nation
they once served. They did wrong; they do time. Yet the VA does not
abandon these vets. Its Veterans Justice Outreach program specialists
play a crucial role not only in assisting many to reintegrate into
society but in helping others avoid incarceration. They are vital cogs
in the workings of Veterans Treatments Courts.
Senator Flake's well-conceived bill recognizes the value of the
work done by VJO specialists, and affirms the need to ensure that this
program is available throughout the VA. And S. 946 is not an unfunded
mandate: it would appropriate $5,500,000 to support this program for
each fiscal year through 2027. Hence, VVA endorses this bill without
reservation.
S. 1153, the Veterans ACCESS Act, introduced by Senator Tammy
Baldwin (D--WI), would prohibit or suspend certain health care
providers from providing non-VA health care services to veterans.
VVA has no objection to this bill. Ensuring that health care
providers are fully vetted before integrating them into the VA
healthcare system is the standard VVA expects from the department. Too
often, however, some less-than-honorable healthcare providers fly below
the disciplinary radar before something in their past catches up to
them.
This bill authorizes the Secretary to review the status of each
non-VA clinician. The review would include the history of any
employment with the department to determine if they have violated one
of several criteria as laid out in the legislation.
S. 1261, the Veterans Emergency Room Relief Act, introduced by
Senator Bill Cassidy (R-LA), would require the Secretary of Veterans
Affairs to pay reasonable costs of urgent care provided to certain
veterans, and establish cost-sharing payments for veterans receiving
care at a VA emergency room.
VVA supports the inclusion of urgent care services as a choice for
veterans to receive health care. Many urgent care clinics are
conveniently located in communities where veterans live and seek
treatment. This is generally consistent with what VA proposed as part
of their community care program.
VVA has no objection to the establishment of cost-sharing for
emergency room care at a VA facility. However, there is no floor or
ceiling as to how much of the cost-sharing payment for which the
veteran would be responsible, nor how this figure might be arrived at,
although this is a detail perhaps best left to the regulation that
would follow enactment of this bill.
The VA has struggled to implement emergency care services as
established by the Millennium Act with regards to non-service-connected
conditions. Eligibility of the veteran for what services, inappropriate
denials of payment, and who should pay for what services are just a few
of the problems reported by the GAO as recently as March 2014. GAO's
report, ``Actions Needed to Improve Administration and Oversight of
Veterans' Millennium Act Emergency Care Benefit,'' was not flattering
for the VA and demonstrated that, nearly 15 years after enactment, VA
emergency care services are still in need of repair.
VVA urges the Committee to provide hardcore oversight of the VA on
their emergency care services in general, with the goal of making it
easier for both the employees and veterans understand the benefits
offered at VA emergency rooms.
S. 1266, the Enhancing Veteran Care Act, introduced by Senator
James Inhofe (R-OK). This bill would authorize the Secretary of
Veterans Affairs to enter into contracts with nonprofit organizations
to investigate VA medical centers.
VVA does not object to the concern behind this legislation.
However, VA health care is far more transparent generally than health
care in the private sector is. And we question just what circumstances
would warrant an outside investigation as opposed to requesting the VA
OIG to step in--or asking for firm yet fair oversight on the part of
Congress.
S. 1279, the Veterans Health Administration Reform Act of 2017,
introduced by Senator Mike Crapo (R-ID), would permit furnishing health
care for eligible veterans by non-VA healthcare providers.
This legislation, which is similar to the trio of draft bills up
for discussion, would establish a Care in the Community Program through
contracts, care agreements, or other laws or practices administered by
the VA. We feel compelled to point out that, while we appreciate the
eligibility criteria outlined in this bill for such a program, VA
medical centers have long engaged outside clinicians to engage in care
that the VA cannot provide, and under the guidance by the current VA
Secretary and under the critical--and watchful--eye of you here in
Congress, the VA is developing and implementing what we trust will be a
vibrant community care program navigated by the VA, and one in which
outside providers will be carefully vetted.
However, this legislation does not address the assignment of a
primary care physician upon enrollment, which is essential to ensuring
that care is coordinated through and navigated by the VA. Primary care,
in our view, must remain in the VA.
We also must point out that, while ``choice'' has been the go-to
word in Congress in recent years, patients don't usually have
``choice'' available to them in the private sector; rather, they take
the advice of their doctor, or the recommendation of a friend or
relative or colleague. Such ``choice'' for VA patients, if ordered by
law, has the very real possibility of causing considerable
consternation--on the part of veterans seeking to go to clinicians who
do not or cannot provide the quality of care the VA would demand; on
the part of the VA, which would have to tell a veteran that s/he cannot
use a particular clinician with the VA footing the bill; which would
only cause major headaches to Members of Congress when veterans
complain about the VA having rejected the clinician they have
``chosen.'' Besides, ceding unfettered choice outside the VA was never
a recommendation of the Commission on Care
VVA, though, is supportive of the provider agreement language in
this bill, the authority for which the VA has asked for previously.
Provider agreement authority is essential in any care in the community
program.
S. 1325, Better Workforce for Veterans Act, introduced by Senator
Tester, seeks to improve the authorities of the Secretary of Veterans
Affairs to recruit, hire, train, and retain employees.
For years, the VA has struggled to recruit, then hire and retain
employees, particularly the clinicians so essential to the provision of
quality health care. VVA has no objection to the improvements of
authorities and reporting requirements set forth in this legislation.
We note that the VA has reported critical staffing shortages across the
system, aggravating an already stressed access issue. The VA OIG
reported in September 2016 on the top five occupational staffing
shortages for VHA. In order ranked as most critical is Medical Officer,
followed by Nurse, Psychologist and Physician Assistant (tied), and
Physical Therapist and Medical Technologist (also tied).
Title II of this legislation addresses accountability, oversight,
transparency, and personnel matters. VVA has a long history of
advocating for stronger programs on all of these issues.
Section 204 would establish pay for medical center directors and
VISN directors. The Secretary would be required to consult not fewer
than two national surveys on pay for similar positions to determine
market pay. Additionally, the Secretary would be required to set forth
a department-wide minimum and maximum for total annual pay once every
two years. Pay inequity is one of the biggest barriers to recruiting
and retaining high-quality employees to oversee the health care
facilities where veterans receive care. VVA believes this reform is
long overdue.
Sections 205 and 208 address long-standing problematic issues. The
VA has reported a critical shortage of trained Human Resources
professionals, which only adds to the already glacial hiring practice
that exists across the Federal bureaucracy.
Section 205 would establish a Human Resources Academy in VHA to
provide annual training for and insights on how to best recruit and
retain employees. While this is a solid approach to the problem, we
offer this caveat: vigilant oversight by Congress and the VSOs of the
establishment and implementation of this will be needed.
Section 208 requires the Secretary, via the Under Secretary for
Health, to develop a comprehensive assessment tool to measure
competency within the H.R. ranks, and to ensure that the knowledge
gained by the training provided at the academy is effectively employed.
Section 208 also requires the establishment and clarification of lines
of authority within VHA to conduct proper oversight at all levels of
the H.R. process. This is a critical piece in ensuring the responsible
parties are held accountable for any failure to comply.
S.____ Discussion Draft: The Veterans Choice Act of 2017 (Isakson)
would permit all veterans enrolled in the patient enrollment system of
the Department of Veterans Affairs to receive health care from non-VA
health care providers.
Section 3 of this draft establishes the Veterans Choice Program and
goes on to delineate how that establishment would take place. Of note
to VVA are a few issues we would like to bring to this Committee's
attention:
Chairman Isakson's bill would authorize the Secretary to enter into
consolidated, competitively bid regional contracts to establish
networks of health care providers, who would be responsible for
everything with the exception of the maintenance of interoperable
Electronic Health Records. This construct is very similar to the
current third-party administrator model that has been a source of
problems at every level. The Secretary has expressed his desire to keep
in-house the scheduling of the appointments for veterans, which this
section would not allow. It is not clear to us why the legislation
prohibits VA from using a tiered network. As the Committee is well
aware, development of a tiered network model is the basis for VA's care
in the community vision going forward and was outlined in VA's care
consolidation plan in October 2015. We do, however, appreciate the
inclusion of language that would require a veteran to be assigned a
primary care provider upon enrollment. This is of course necessary for
effective and efficient care coordination.
The authorization for provider agreements is a welcome addition and
would enhance the delivery of care to veterans, including those
residing in state homes. This has been an ongoing legislative priority
for VA moving forward with community care once the dollars remaining in
the current Choice Program run out. Medicare and TRICARE use provider
agreement authority to bypass Federal acquisition regulations. There is
no reason why the VA cannot be afforded the same.
Section 9 would require the Secretary to assess the demand for
health care services furnished by the department. The VA should already
be doing this. It would help to inform their budget projections with
real-time information. VVA supports this requirement.
Section 11 directs the Secretary to procure a COTS EHR platform for
health care services that conforms to the standards of interoperability
with DOD. Billions of dollars have been spent, and wasted, over the
past decade to get the two agencies together on the interoperability
issue. VVA supports this section as well.
S.____ Discussion Draft: Improving Veterans Access to Community
Care Act of 2017 would establish the Veterans Community Care Program of
the Department of Veterans Affairs to improve health care provided to
veterans by the VA.
Similar to the previous draft, ``The Veterans Choice Act of 2017,''
this draft legislation establishes the Veterans Community Care Program.
This draft legislation, however, takes a decidedly different approach.
It would require the VA's Non-VA Care Coordination Program to
coordinate the care, which would embrace the scheduling of appointments
for eligible veterans. Additionally, it does allow for the development
of a tiered network construct, but prohibits the Secretary from
prioritizing providers in one tier over providers in any other tier if
it limits the veteran's choice of a clinician in a particular
specialty.
VVA would note that the eligibility criteria outlined in this draft
are complicated, somewhat arbitrary, and will pose a nightmare for both
VA employees and veterans to figure out eligibility. The Secretary has
expressed many times that he is attempting to shift away from an
administrative system to one that is clinical in nature. The goal, as
VVA understands it, is for a clinical decision be arrived at between
the veteran and the doctor as to where the best care for that veteran
resides. Which is as it should be.
Section 102 addresses payment of health care providers and
compliance with the Prompt Payment Act. This is very similar to other
legislative language included on the agenda today and for which VVA has
no objection to this section.
VVA supports Section 103, which amends Section 1151 (a) by adding a
new paragraph addressing benefits for persons disabled by treatment
under the Veterans Community Program.
Section 201 authorizes Veterans Care Agreements. The language is
similar to that in other pieces of legislation on today's agenda. VVA
fully supports giving the VA the authority to enter into such
agreements, including with state homes.
S.____ Discussion Draft: The Department of Veterans Affairs Quality
Employment Act of 2017 seeks to improve the authority of the Secretary
to hire and retain physicians and other employees.
This draft legislation sets forth a number of requirements to
improve the quality and competency of VA employees. It also addresses
recruiting, retention, and training of personnel through the
establishment of recruiting databases for critical position vacancies
and mental health vacancies. VVA has no objection to this draft
legislation.
In conclusion, we note that there are many provisions in the bills
and drafts that seek to accomplish the same goal, albeit not quite in
the same way. We would encourage this Committee and your counterpart in
the House to evaluate the different approaches, continue to work with
all of the stakeholders, including the VA, and put a comprehensive
package together that strengthens the Department of Veterans Affairs
and improves health care delivery and services for veterans.
Thank you for the opportunity to submit VVA's views on these very
important pieces of legislation.
______
Prepared Statement of Wounded Warrior Project
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
[all]