[Senate Hearing 115-537]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 115-537

 THE STATE OF THE VA: A PROGRESS REPORT ON IMPLEMENTING 2017 VA REFORM 
                              LEGISLATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 17, 2018

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman

Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Richard Blumenthal, Connecticut
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia

                    Robert J. Henke, Staff Director
                Tony McClain, Democratic Staff Director

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

                      Minority Professional Staff
                            Dahlia Melendrez
                            Cassandra Byerly
                                Jon Coen
                              Steve Colley
                               Simon Coon
                           Michelle Dominguez


                            C O N T E N T S

                              ----------                              

                            January 17, 2018
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......    16
    Prepared statement...........................................    17
Moran, Hon. Jerry, U.S. Senator from Kansas......................    13
Boozman, Hon. John, U.S. Senator from Arkansas...................    57
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    60
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    64
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    66
    Letter for the record........................................    67
Heller, Hon. Dean, U.S. Senator from Nevada......................    78
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    80
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    83
Murray, Hon. Patty, U.S. Senator from Washington.................    88
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    90

                               WITNESSES

Shulkin, Hon. David J., M.D., Secretary, U.S. Department of 
  Veterans Affairs, accompanied by Peter Shelby, Assistant 
  Secretary for Human Resources Administration; Cheryl Mason, 
  Chairman of the Board of Veteran Appeals; Dr. Amy Fahrenkopf, 
  Acting Deputy Under Secretary for Health for Community Care; 
  Dave McLenachen, Director of Appeals Management; Peter 
  O'Rourke, Executive Director of the Office of Accountability 
  and Whistleblower Protection; and Robert Worley, Director of 
  Education Services.............................................     2
    Prepared statement...........................................     4
    Response to requests arising during the hearing by:
      Hon. Jerry Moran........................................... 13,14
      Hon. Jon Tester............................................ 57,78
      Hon. John Boozman.......................................... 58,59
      Hon. Richard Blumenthal....................................    71
      Hon. Bill Cassidy 




    Response to posthearing questions submitted by:
      Hon. Johnny Isakson........................................    97
      Hon. Jon Tester............................................   101
      Hon. Jerry Moran...........................................   109
      Hon. Dean Heller...........................................   110
      Hon. Bill Cassidy..........................................   111
      Hon. Thom Tillis...........................................   112
      Hon. Dan Sullivan..........................................   115
      Hon. Patty Murray..........................................   116
      Hon. Sherrod Brown.........................................   122
      Hon. Mazie K. Hirono.......................................   125
      Hon. Joe Manchin III.......................................   125

                                APPENDIX

National Organization of Veterans' Advocates, Inc. (NOVA); 
  prepared statement.............................................   129
Fuentes, Carlos, Director, National Legislative Service, Veterans 
  of Foreign Wars of the United States (VFW); prepared statement.   131

 
 THE STATE OF THE VA: A PROGRESS REPORT ON IMPLEMENTING 2017 VA REFORM 
                              LEGISLATION

                              ----------                              


                      WEDNESDAY, JANUARY 17, 2018

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

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

    Chairman Isakson. I call this meeting of the Senate 
Veterans' Affairs Committee to order. I appreciate Secretary 
Shulkin being here today and all his hard work.
    The Ranking Member is on his way. I am going to start with 
my brief opening statement, and by the time that is over 
hopefully he will be here for his brief opening statement, upon 
which we will immediately go to Secretary Shulkin and then to 
the Members of the Committee for questions and answers.
    Let me say, at the outset, that this meeting is not about 
what has happened in the past. It is about what is happening 
right now, to correct some of the things that have happened in 
the past. This is an accountability hearing. I have told the 
Secretary that we want to really take the legislation that we 
passed last year on accountability, appeals, all the things 
that we passed, and give the VA the tools to address the 
significant problems confronting the veterans of America, the 
VSOs of America, and this Committee. We want to begin moving 
away from the problems of the past and toward the solutions of 
the future, in particular on: appeals; accountability; the GI 
Bill; all those things that are important to the veterans and 
their families; plus the leadership of the VA, as well.
    I also want to thank Secretary Shulkin. I have always been 
complimentary of him. A lot of people say, ``You are too nice 
to him.'' I am not too nice to him, as he has been good to the 
veterans and I am going to be good to him. He has been a 
forthright leader that the administration is lucky to have, I 
believe the veterans are lucky to have, and I feel like this 
Committee is lucky to have. Now, we are at the time where there 
are no excuses. There are no excuses for why we do not correct 
the problems we have had with hiring. There are no excuses for 
why we do not correct the problems we have had with information 
technology. There is no excuse for not correcting the problems 
we have with veterans appeals, and other areas.
    So, this is all about accountability. It is all about 
standing forward. It is all about looking at the past and what 
we did and looking for the results that are to come in the 
future, so that we do a good job for the veterans of the United 
States of America.
    Mr. Secretary, I am going to swear you in for the purposes 
of this hearing. If you will stand and raise your right hand.
    Do you solemnly swear or affirm that the testimony you are 
about to give before the Senate Committee on Veterans' Affairs 
will be the truth, the whole truth, and nothing but the truth, 
so help you God?
    Secretary Shulkin. I do.
    Chairman Isakson. You may be seated.
    Mr. Secretary, I am going to recognize you for your 5 
minutes, when the Ranking Member shows.
    Secretary Shulkin. OK.
    Chairman Isakson. Welcome.
    Secretary Shulkin. Thank you.

   STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY PETER SHELBY, 
ASSISTANT SECRETARY FOR HUMAN RESOURCES ADMINISTRATION; CHERYL 
   MASON, CHAIRMAN OF THE BOARD OF VETERAN APPEALS; DR. AMY 
   FAHRENKOPF, ACTING DEPUTY UNDER SECRETARY FOR HEALTH FOR 
     COMMUNITY CARE; DAVE MCLENACHEN, DIRECTOR OF APPEALS 
MANAGEMENT; PETER O'ROURKE, EXECUTIVE DIRECTOR OF THE OFFICE OF 
   ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION; AND FINALLY, 
         ROBERT WORLEY, DIRECTOR OF EDUCATION SERVICES

    Secretary Shulkin. Chairman Isakson, Senator Moran, Senator 
Boozman, thanks for inviting me here to talk about VA's 
program. More important, on behalf of the veterans the VA 
serves and our employees who serve them, thank you for your 
staff's tireless, bipartisan work. It is has been great.
    We certainly appreciate and respect your leadership, Mr. 
Chairman, and partnership in establishing those issues that we 
are trying to tackle at the VA head-on. Some of them, as you 
have said, we know have lingered for years. I have always said 
I think we have the best committees in Congress and that is in 
large part due to the leadership.
    Chairman Isakson. We agree with that, by the way.
    Secretary Shulkin. Yeah. Well, I would not say it if it was 
not true. I took an oath. So----
    [Laughter.]
    Joining me today, seated behind me--I just wanted to 
introduce you in case I need a lifeline and get some help 
today--Peter Shelby, who is our Assistant Secretary for Human 
Resources Administration; Cheryl Mason, who is our Chairman of 
the Board of Veteran Appeals; Dr. Amy Fahrenkopf, who is our 
Acting Deputy Under Secretary for Health for Community Care; 
Dave McLenachen, who is our Director of Appeals Management; 
Peter O'Rourke, who is the Executive Director of the Office of 
Accountability and Whistleblower Protection; and finally, Mr. 
Robert Worley, who is our Director of Education Services.
    A year ago, at my confirmation hearing before this 
Committee, I testified that I would seek major reform and 
transformation of VA. Today, to guide VA reform and 
transformation we are focused on five priorities. The first, 
which is to provide greater choice for veterans; second, to 
modernize our systems; third, to focus our resources on what is 
most important to veterans; fourth, to improve the timeliness 
of how we deliver our services; and fifth, prevent veteran 
suicide, which is our top clinical priority. The President's 
Executive order last week, which supported transitioning 
military members with mental health services during that first 
critical year as veterans is an important step.
    Thanks in large part to your leadership, which helped us 
pass the legislation in 2017, the legislation I hope we will be 
discussing today, we are making progress on all five of those 
priorities. Appeals reform would be a good example. It is about 
modernizing antiquated systems and focusing resources while 
giving veterans more timely services and greater choice.
    Accountability and whistleblower protection is essential to 
our unwavering commitment to honoring veterans. It too is about 
sensible response of modern systems that process and support 
our people to make VA better. The Forever GI Bill gives 
veterans greater choice. More profoundly, it is about greater 
opportunity, especially for veterans returning to communities 
to pursue careers and fulfill dreams.
    Beyond these reforms, we have announced same-day services 
for primary care and mental health at every VA facility across 
the country. We have extended mental health to veterans with 
other-than-honorable administrative discharges. So far, we have 
disposed of 111 out of 430 vacant or underutilized buildings. 
We published data publicly on wait time, quality data, customer 
satisfaction data, and last week we published our opioid 
prescription rates across the country. There are no other 
health systems in the country that publish this type of data.
    And, because of that--I hope it is because of that--we are 
earning our veterans' trust back. At the end of this last year, 
70 percent of veterans who responded to our survey said that 
they felt like valued customers at VA. That is up from 46 
percent in 2014.
    Mr. Chairman, Members of the Committee, we are deeply 
grateful for your role in supporting all those changes and 
others like them. They are immensely important. But, when I 
look back over this year, we are still largely managing through 
incrementalism, patching and repairing old systems and 
processes and reacting to crises. VA still is far short of the 
kind of bold transformational change that we need to serve 
veterans in the decades ahead. From health care to benefits, we 
have to fundamentally and holistically change our service 
delivery paradigm.
    My objective, when it comes to health care for our 
veterans, is to have a fully-integrated, interoperable, 
operationally-efficient health care system that is easy for 
veterans, employees, and community partners to navigate. A full 
spectrum of care for veterans that capitalizes on our 
foundational services, delivering on our promise to provide 
world-class services. We need a consistent, seamless experience 
for veterans at every VA facility across the country. We need a 
national network of modern facilities that meets the changing 
needs of veterans locally. We need simple, convenient choice 
for eligible veterans among a network of high-quality community 
providers in a single consolidated program.
    Mr. Chairman, I applaud your efforts to get this done. Your 
draft legislation that passed out of this Committee is highly 
responsive to the needs of veterans, and we are all grateful 
for the work that you and the Committee have done so far to 
make this a reality.
    Benefits are a gateway to VA services and we need benefit 
determinations to be simpler. Veterans should know what to 
expect and have more predictability. They should not have to 
endure the burden of filing claim after claim after claim. 
Benefits should better enable lifetime of independence and 
success for veterans, economic opportunity, physical and mental 
well-being, and financial security for the severely disabled. 
In short, we need to begin an earnest dialog with stakeholders 
about veterans' benefits.
    Mr. Chairman, in the days and months ahead, I invite and 
welcome your support and leadership in helping us define and 
then pursue the kind of worthy, transformational change the VA 
needs so we can all achieve what we hope to achieve. I look 
forward to your questions today.
    [The prepared statement of Secretary Shulkin follows:]
     Prepared Statement of Hon. David J. Shulkin, M.D., Secretary, 
                  U.S. Department of Veterans Affairs
    Good afternoon, Chairman Isakson, Ranking Member Tester, and 
Distinguished Members of the Senate Committee on Veterans' Affairs. 
Thank you for the opportunity to testify today about the successes the 
VA team is achieving for the Nation's Veterans, their families, and 
advocates with the valuable legislative tools you provided to us in 
2017.
                             accountability
    The Department of Veterans Affairs took expedient action to 
implement the Secretary's new authority to hold employees accountable 
provided for in the Department of Veterans Affairs Accountability and 
Whistleblower Protection Act of 2017. Within weeks of the enactment of 
the law, the Secretary developed and effected guidance to ensure both 
VA managers and employees are held to the highest standards of 
performance, integrity, and conduct.
    The Department developed four Human Resources Management Letters as 
guidance to managers and Human Resources personnel on how to implement 
several of the disciplinary provisions. Training was provided to 
managers, H.R. personnel, and the Office of General Counsel on the 
provisions of the Act, and how it would be implemented.
    Additionally, the Department developed several resources to assist 
H.R. personnel in understanding and applying disciplinary provisions of 
the Act, such as flow charts outlining the requirements of the 
accountability authorities available to the Department, comparison 
guides between requirements under the Act and VA bargaining unit 
obligations, and frequently asked question guides. The Department 
continues to modify guidance and update Human Resources Letters as 
needed and as adverse action cases are heard before the Merit Systems 
Protection Board.
    The VA's Office of Accountability and Whistleblower Protection 
(OAWP) was established and the head of the OAWP was appointed on 
May 12, 2017 under the authority of the President's Executive Order. 
OAWP is currently being led by an SES executive director who reports to 
the Secretary.
    The executive director provides clarification and advice related to 
accountability, whistleblower disclosures and retaliation issues to the 
Secretary and other leadership throughout VA. OAWP sends a senior team 
to raise awareness of accountability and whistleblower issues to 
executive leadership councils and other leadership meetings at VA 
facilities across the country.
    On June 12, 2017, OAWP began receiving whistleblower disclosures 
from employees into the Central Whistleblower Office authorized under 
The Patient Protection Act of 2016 (PL 114-223). After enactment of the 
Department of Veteran Affairs Accountability and Whistleblower 
Protection Act of 2017 (PL 115-41), the OAWP enhanced its whistleblower 
capabilities, developing a new Whistleblower Disclosure Form (VA Form 
10177) to streamline the process and integrate disclosure intake into 
the Office's new Triage Division. OAWP developed a triage, tracking, 
and referral process to ensure all disclosures are managed and resolved 
centrally. When appropriate, OAWP engages with the Office of Special 
Counsel (OSC) and the Office of Inspector General to refer disclosures 
and accept referrals for action. As of January 8, 2018 OAWP has 
received and validated 1,029 disclosures since June 2017.
    OAWP is protecting whistleblowers by utilizing its authority to 
place a temporary hold on personnel actions in cases where 
whistleblower retaliation is alleged or a disclosure is unresolved. 
Working with the OSC, OAWP ensures that the ability to seek corrective 
action is preserved. As of January 8, 2018 OAWP has held 72 actions.
    On December 14, 2017, OAWP began discussions with the Department's 
Executive Secretary to begin providing oversight of OSC's referred 
disclosures. OAWP is working on value-added processes and procedures to 
ensure all OSC disclosures are investigated and resolved appropriately. 
OAWP is also working closely with OSC to ensure whistleblower 
retaliation cases are investigated and employees are protected.
    OAWP is evaluating methods, procedures, and information technology 
solutions for the systematic recording, tracking, reviewing, and 
confirming implementation of recommendations from audits and 
investigations carried out by the Office of Inspector General, Medical 
Inspector, Special Counsel, and the Comptroller General of the United 
States. Also being evaluated are the technological requirements for 
analyzing data produced by OAWP and the Office of Inspector General's 
telephone hotlines and whistleblower disclosures in order to identify 
trends and reports to the Secretary.
    Since establishment, OAWP has been receiving, reviewing, and 
investigating allegations of misconduct brought against senior 
executives; employees in a confidential, policy-determining or policy-
advocating position; and supervisors; when the allegation involves 
whistleblower retaliation. As of January 8, 2018 OAWP has completed 77 
investigations involving 149 persons of interest. OAWP's current 
inventory is 139 investigations involving 228 persons of interest.
                             appeals reform
    The Veterans Appeals Improvement and Modernization Act of 2017, 
enacted on August 23, 2017, is the most significant statutory change in 
decades affecting VA claims in the appeals process. It provided much 
needed reform for Veterans, and VA is committed to the law's full 
implementation.
    VA developed an implementation plan, which was collaboratively 
prepared by the Board of Veterans' Appeals (Board) and the Veterans 
Benefits Administration (VBA) with input from other components of VA 
involved in the implementation of the Veterans Appeals Improvement and 
Modernization Act. VA initiated this plan immediately after the law's 
enactment, and fully expects to implement the new claims and appeals 
process by February 2019. VA is utilizing the 18-month period to 
promulgate regulations, establish procedures, hire and train personnel, 
implement information technology system changes, conduct outreach in 
order to train stakeholders on implementation of the new law, and 
gather data for trends analyses and metrics reporting. Due to the 
magnitude and scope of the statutory changes, VA is using a governance 
structure to oversee and document appeals modernization implementation 
and using dedicated project management experts to institute key project 
management tools and deliverables. To track implementation progress, 
the plan includes timelines, interim goals and milestones, risk 
mitigation strategies, reporting requirements, and deadlines that were 
established to ensure timely execution.
    VA has also undertaken enterprise-wide efforts to modernize the 
appeals process through improvements in technology. As part of this 
effort, information technology funds were used to develop and optimize 
paperless functionality in VA appeals processing. With Fiscal Year (FY) 
2017 IT funding, VA began a multi-phase process of enhancing appeals 
functionality in the paperless environment. Initial key appeals-
specific functionality in the paperless environment will focus on 
seamless integration of systems, and key accountability and work 
efficiency features. Digital Service at the VA (DSVA) launched Reader 
at the Board in November 2017, is working with the Board to launch 
enhanced appeals on Vets.gov appeals by March 2018, and will begin 
testing Caseflow at the Board in the second quarter of 2018 with 
subsequent BVA-related enhancements and additional user groups.
    The Board is currently on pace to produce over 81,000 decisions 
during FY 2018 which would represent a historic level of production. In 
FY 2018, the Board will also gain efficiencies by issuing a new 
decision template in February 2018, exploring new case review 
techniques throughout the spring and summer of 2018 and allowing 
delivery of decisions in close proximity to a Veteran's hearing 
beginning in February 2018. The Board will begin to train all staff on 
the new appeals process in April 2018, and outreach training with 
Veterans Service Organizations in the summer of 2018.
    The Veterans Appeals Improvement and Modernization Act will also 
permit VA to test assumptions in the implementation of a new claims 
appeals system. Accordingly, VA has decided to carry out a pilot 
program during the implementation period, the Rapid Appeals 
Modernization Program (RAMP). The program, which was launched on 
November 1, 2017, allows eligible participants with pending disability 
compensation appeals in VBA the voluntary option to have their 
decisions reviewed in the higher-level or supplemental claim review 
lanes outlined in the new law. RAMP provides Veterans early access to 
the benefits of the new system, while also allowing VA to better 
position itself for full implementation in February 2019. Since 
disability compensation-related appeals account for the vast majority 
of all pending appeals, the program allows most Veterans with pending 
compensation benefit appeals to participate.
    VA will use the data collected during RAMP to create a capacity 
model based upon actual data. During this program, VA will gather data 
and conduct trends analyses on aspects of Veterans' behavior, to 
include their decision to opt--in to the new system, employee 
productivity, processing timeliness, and inventory measures. VA will 
use that data to assist in developing future resource requirements as 
part of the annual budget process. VA intends to update the model when 
actual data can be used to replace projected data, when assumptions are 
shown to be no longer accurate, or based on any change in resources 
resulting from annual budget appropriations.
    With RAMP, VA has already made great strides toward implementing 
the new process; for instance, DSVA was able to support VA to design 
the Caseflow Intake application as a solution for managing Veterans' 
elections to participate in the RAMP process using agile development 
technology. In addition, after garnering input from Veterans Service 
Organizations, VA deployed and is in the process of refining a more 
detailed decision notice for compensation appeals, as well as the RAMP 
election notice. Furthermore, with the implementation of RAMP, VA is 
documenting enhancements to VBMS that allow higher-level adjudicators 
to capture duty to assist error data.
                            forever gi bill
    VA has taken significant steps in the five months since the Colmery 
Act was enacted to implement thirteen provisions that were effective 
immediately, so that Veterans and beneficiaries could take advantage of 
their expanded benefits. In early November, VA notified nearly 8,000 
beneficiaries that they may be potentially eligible for restoration of 
entitlement under a Special Application provision. To date (as of 
January 5, 2018), VA has received and processed close to 600 
applications and restored over 3,500 months of entitlement to students, 
granting them the opportunity to continue to pursue their academic and 
education goals. VA is sending an explanatory letter and choice of 
election form to almost 3,200 individuals who lost their eligibility to 
the Reserve Educational Assistance Program (REAP), but now, because of 
the Colmery Act, can elect to have their qualifying active duty service 
periods credited toward establishing eligibility under the Post-9/11 GI 
Bill Program.
    The most notable and recognized change to the GI Bill benefit by 
the Colmery Act is the removal of the 15-year time limitation for 
Veterans who transitioned out of the military after January 1, 2013, 
and eligible dependents, to use their Post-9/11 GI Bill benefits. As of 
December 20, 2017, all newly issued GI Bill Certificates of Eligibility 
and manually processed award letters are updated to notify eligible 
beneficiaries that they no longer have an expiration date to use their 
GI Bill benefit. By the end of January 2018, VA will have sent an email 
notification to over half a million Post-9/11 GI Bill beneficiaries 
informing them that they can now use their remaining entitlement when 
the time is right for them and their families.
    An extensive outreach and promotional campaign is well underway to 
ensure that all Veterans and beneficiaries are aware of the Colmery 
Act's enhancements to the GI Bill. VA's Facebook posts on the Colmery 
Act including those related to the permanent authorization of the work-
study allowance have reached almost half a million individuals, a 
Twitter Town Hall received 173,000 views and 1,800 engagements, and VA 
has sent multiple mass emails to over 1 million recipients to amplify 
its communications platform for the Colmery Act. During the 
December 12, 2017, Forever GI Bill hearing by the House Committee on 
Veterans' Affairs, Subcommittee on Economic Opportunity, VA live-
tweeted pertinent information to be transparent and share news in real 
time. In late November 2017, VBA's Deputy Under Secretary for Economic 
Opportunity conducted interviews with 23 radio and TV stations reaching 
an audience of over 3.5 million. Additionally, VA has briefed 
stakeholders ranging from School Certifying Officials to Veterans 
Service Organizations to encourage their involvement and support in 
getting the word out about the Forever GI Bill.
    VA is working closely with State Approving Agencies (SAAs) on 
changes that impact them because of the Colmery Act and has notified 
SAAs that they may now authorize independent study programs at certain 
educational institutions, like career and technical education schools. 
SAAs and VA are collaborating to redesign compliance reviews for 
oversight purposes, and VA has allocated increased SAA funding for FY 
2018.
    VA will deliver by March 1, 2018 to Congress an implementation plan 
outlining IT system improvements to maximize the automation of 
educational claims processing, and VA's Digital Services team has 
partnered with Education Service to collect priority enrollment 
information from schools for display on the GI Bill Comparison Tool.
    A few provisions of the Colmery Act already aligned with policies 
and procedures in effect. Examples include codification of the 
VetSuccess on Campus program, allowing Veterans participating in the 
Vocational Rehabilitation and Employment program to extend eligibility 
if called to active duty in certain cases, and providing School 
Certifying Officials additional flexibility when a course start date 
does not align with that of an academic term.
    A great deal of work remains to be done with 18 provisions slated 
to go in effect on August 1, 2018, including sections 107 and 501. 
These sections change the way VA pays monthly housing stipends by 
aligning payment to the location where students physically attend the 
majority of their classes and removing the exemption to the Department 
of Defense's one percent reduction to housing allowance. While VA's 
Office of Information and Technology has committed to implementing an 
IT solution for these two critical sections, it is resource challenged 
in balancing efforts related to the remaining 20 Colmery Act provisions 
with IT needs and the overall goal to decommission the antiquated 
Benefits Delivery Network, which is the system that currently handles 
much of Education claims processing and payments. With this 
consideration in mind, VA is optimistic that all 22 provisions with an 
IT requirement will have an IT solution in place by the end of FY 2019. 
To mitigate any impact to Veterans and beneficiaries using their 
education benefits, by May 2018, VBA will have hired 200 temporary 
field employees, and reallocated senior staff and experienced claims 
processors to specialized teams to account for increased workload and 
new programs related to the Colmery Act. VA will continue to regularly 
assess workload demands and resource needs, and adjust its staffing 
levels in order to properly deliver education benefits to Veterans and 
beneficiaries.
    In the coming months, VA will continue planning and working toward 
finding IT solutions and revising and developing sensible policies and 
procedures for implementation. VA will stay committed to its ambitious 
outreach campaign to include targeted messaging and engagement to 
thousands of Purple Heart recipients, who starting August 1, 2018 will 
be entitled to Post-9/11 GI Bill benefits at the 100-percent benefit 
level for up to 36 months, regardless of their time in service. 
Additionally, VA will communicate to Reservists and National Guard 
members their expanded access to GI Bill benefits as these individuals 
will now be able to use time spent on authorized medical care and 
certain orders as creditable toward GI Bill entitlement. VA remains 
steadfast in its effort to raise awareness of the Colmery Act's broad 
impact to Veterans and beneficiaries so they are given the opportunity 
to take advantage of their expanded and enhanced benefits.
                         workforce improvements
    VA is making progress in implementing the provisions of Title II 
(Personnel Matters) of the VA Choice and Quality Employment Act of 2017 
to improve hiring authorities of the Department. Two of the most 
critical focal points of this title are: 1) Section 210--Plan to hire 
directors of medical centers; and 2) Section 213--Expansion of direct-
hiring authority. We have developed and implemented a plan for hiring 
highly qualified directors for each of our medical centers. As a 
result, we continue to make progress in staffing these positions. 
During calendar year 2017, we reduced the time to hire Medical Center 
Directors (MCDs) by about 23%. Currently, 125 of 140 MCD positions are 
filled. Of the remaining 15 positions under recruitment, 10 have a 
potential hire identified and are either going through the OPM approval 
process or have an established entrance on duty date.
    Consistent with Section 213 of the Act, we are collaborating with 
the Office of Personnel Management (OPM) to expand direct-hire 
authority (DHA). We have submitted a formal request to OPM to receive 
DHA for 15 occupations because of our urgent critical hiring need to 
meet mission requirements. This need is in direct support of the 
Administration's charge to improve the quality of and access to care 
for our Nation's Veterans and their dependents. We must use options 
such as DHA to assist in meeting the unique recruitment challenges that 
we face over the next few years.
                 community care and funding for choice
    Demand for community care remains high, with over 32.7 million 
outpatient medical care appointments completed in FY 2017. In FY 2017, 
VA community care appointments for outpatient medical care were 
approximately 36% of all such appointments provided through VA, a 4 
percentage point increase from FY 2016.
    Over 1.1 million Veterans utilized the Veterans Choice Program in 
FY 2017, an increase of about 35,000 Veterans from FY 2016. Outpatient 
appointments for VA medical care in the Choice Program comprised 
approximately 50% of all such VA community care completed appointments 
in FY 2017.
    In August 2017, with Choice Program poised to run out of funding 
and no successor program yet in place, Congress appropriated $2.1 
billion in emergency funding to continue the Choice Program. In 
December 2017, Congress included an additional $2.1 billion for the 
Choice Program in the continuing resolution package while discussions 
continue regarding the future of VA community care.
    Although more still can be done, VA continues to make progress 
toward business process improvements to streamline the delivery of 
community care for Veterans. We have implemented tools to share health 
information, when permitted by law, with community providers via 
encrypted email, through a web-based application, as well as through 
industry standard health information exchanges. We have introduced 
tools for our staff to ensure standardized authorizations for community 
care, including specification of the services to be provided. We 
continue to work toward awarding new community care network contracts 
to purchase community care.
    Earlier this month, VA announced a series of immediate actions to 
improve the timeliness of payments to community providers. The actions 
will address the issue of delayed payments head-on and produce 
sustainable fixes that solve ongoing payment issues that affect 
Veterans, community providers and other VA partners.
    On January 9, 2018, VA published a rulemaking that allows it to 
process claims for reimbursement of the reasonable costs of emergency 
treatment for non-service-connected conditions when only a portion of 
those costs were paid by a Veteran's other health insurance. These 
regulations will authorize VA to reimburse emergency treatment costs in 
more instances.
    In October and November 2017, VA submitted the Veteran Coordinated 
Access & Rewarding Experiences (CARE) Bill to Congress. Veteran CARE is 
Veteran-centric and focuses on Veteran clinical needs. VA appreciates 
that Congress has developed legislation which includes many of the 
provisions included in CARE. We need Congress to pass legislation to 
give Veterans a system that works and that meets or exceeds the best 
the private sector has to offer. This is about building a VA that 
Veterans choose for their care--we want Veterans to Choose VA. The 
Administration's bill included $4 billion in spending authority, fully 
offset, to ensure a smooth transition to the new, consolidated 
community care program when implemented in FY 2019. We continue to urge 
the inclusion of offsets against any new mandatory spending to promote 
fiscally responsible stewardship of the taxpayer dollar.
    Consistent with the Administration's proposal, VA believes that the 
future of community care should include the following tenets:

     Improve Veterans' choice of community providers in meeting 
their healthcare needs.
     Simplify Veteran eligibility with a focus on Veterans' 
clinical needs.
     Pave the way for consolidation of all community care 
programs.
     Add convenient care benefits.
     Set timely payment standards.
     Include provider agreements with flexible payment rates 
that streamline how we pay for care, including care in State Veterans 
Homes.
     Permit medical records sharing in the network when needed 
for Veteran care.
     And address clinical staffing shortages through expansion 
of graduate medical education and by improving VA hiring and retention 
of staff.
                 disability compensation claims backlog
    VA is committed to providing Veterans with the care and services 
they have earned and deserve. For the eighth consecutive year, VBA has 
completed over a million disability claims and anticipates completing a 
record number of claims in FY 2018.
    The VBA's disability claims backlog continues to fluctuate at a 
relatively steady state between approximately 70,000 and 85,000 claims. 
VBA ended the calendar year with just over 80,000 backlog claims 
pending and is committed to reducing the backlog further. In the past, 
VBA focused claims processing resources on significant investments in 
staffing and overtime, as our claims volume far exceeded the relative 
timelines of claims actionability. However, as VBA has reduced the 
pending claims inventory, we remain focused on continuous deployment of 
incremental process improvements and technology initiatives to identify 
actionable inventory which will help further reduce our backlog and 
increase the timeliness of claims processing.
    VBA's primary intent within backlog reduction is three-fold: 
ensuring the current system works efficiently by evaluating throughput 
metrics, ensuring efficient staff utilization by confirming appropriate 
actions are completed, and identifying additional actionable workload 
through process reviews. Our throughput metrics make sure our 
workloads, especially backlog claims, are processed timely and 
efficiently. Additionally, VBA has initiated focused quality reviews to 
detect human errors, found potential system-wide and employee-level 
improvements in initial claim actions, and identified procedural 
improvements. We also continue to proactively deploy effective workload 
management practices and explore other process enhancements.
    VBA is similarly looking to reduce backlog via the expansion of 
VBA's contracted medical exam authority. Beginning in FY 2017, Congress 
granted VA the discretion to expand the Contract Medical Disability 
Examination (MDE) program from 15 regional offices to as many as the 
Secretary considers appropriate. The main purpose of this expanded 
contract Compensation and Pension (C&P) exam authority is to provide 
timely exams for Veterans residing in both the US and abroad. Contract 
exam expansion enables VBA to supplement Veterans Health 
Administration's (VHA's) internal C&P exam capacity to deliver faster 
claims decisions to Veterans and reduce the number of claims pending 
over 125 days.
                         decision ready claims
    As part of VA's continued efforts to improve Veterans' experience 
with the disability claims process, VA has developed the Decision Ready 
Claims (DRC) initiative--an extension of Fully Developed Claims. DRCs 
are claims for disability compensation submitted with the help of 
accredited VSOs, who certify that all supporting evidence (e.g. medical 
exam, military service records, etc.) is included with the claim at the 
time of submission to VA. Veterans who choose to submit their claim 
under DRC can expect to receive a decision within 30 days from the time 
VA receives the formal claim. DRC enables VBA to focus resources on 
reducing claims pending over 125 days as well as improving timeliness.
    In addition to claims for increased disability compensation 
(commonly known as claims for increase), as of December 2017, DRC was 
expanded to certain claims for direct service connection, presumptive 
service connection, secondary service connection, and Dependency and 
Indemnity Compensation. Transitioning servicemembers can use the DRC 
process to file pre-discharge claims less than 90 days from leaving the 
military.
                        infrastructure-28 leases
    VA is pleased to report that the 28 leases authorized in the 2017 
Choice Act are moving forward expeditiously. VA is utilizing a 
streamlined set of contract documents that more closely align with 
General Services Administration (GSA's) model in procuring these 
leases. VA is also adjusting its physical security, sustainability, and 
construction standards to more closely align with other Federal 
agencies, as well as private-sector healthcare, to increase speed to 
market, and cost-savings. Finally, VA is leveraging an enhanced 
partnership with GSA to procure 7 of the 28 leases.
    The following seven (7) leases are being procured through the VA-
GSA partnership: Pittsburgh, PA; Hampton Roads, VA; Tampa-Lakeland FL; 
Tampa, FL; Corpus Christi, TX, Denver, CO, and Rapid City, SD. GSA is 
reviewing the requirements packages and is in the process of assigning 
staff for execution of these projects.
    The remaining 21 leases are being procured by VA through its Office 
of Construction & Facilities Management, Office of Real Property, using 
a delegation of GSA's leasing authority. All of these projects have 
started in earnest. All advertisements for the Choice Act leases under 
procurement by VA are slated for release by the end of Spring 2018, 
with issuance of the VA Request for Lease Proposals in the Summer/Fall 
2018, and award slated for Spring/Summer 2019.
                        electronic health record
    On December 13, 2017, a strategic pause was announced in the 
Electronic Health Record (EHR) acquisition process; the purpose of the 
pause is to conduct an additional and external assessment of national 
interoperability language contained in the Request for Proposal that 
would ultimately support an EHR contract award.

    MITRE Corporation was selected to coordinate and lead an 
independent assessment of the aforementioned contract language. The 
independent review was held on January 5, 2018, and consisted of a 
diverse, distinguished and highly respected group of Clinicians, Chief 
Information Officers and Executives, well-versed in national 
interoperability challenges/issues, from across the healthcare 
industry.

    MITRE is in the process of capturing the recommendations and 
comments provided during the January 5, 2018 interoperability forum and 
will submit a final report to the VA Secretary and other stakeholders 
for review by the end of January 2018.
    Thank you for the opportunity to appear before you today to provide 
you with VA's progress on implementing the legislation in these 
important areas. This concludes my testimony, and I welcome any 
questions that you or other Members of the Committee may have.

    Chairman Isakson. Thank you, Secretary Shulkin. I 
appreciate those remarks very much, and I hope the Ranking 
Member is coming. Is he still coming? [Pause.]
    He is. OK.
    I will start--you can start the clock on me. Let me make 
somewhat of what may appear to sound like an announcement at 
the beginning of the hearing. The Secretary and I have been in 
a lot of conversations over the past month or so, and I want to 
thank him for his stated support for what the Committee passed 
out of Committee. As we all know, we had a 14-to-1 vote, and as 
we all know we had some differences of opinion on the Veteran's 
Choice bill and the Care bill that we passed out of Committee. 
I did everything I could to try to bring about unanimous common 
ground, but I did not get that totally done.
    So, I made a phone call to the White House and talked with 
the President, and, I believe, if I am not mistaken, the 
Secretary was on that phone call, as well as a number of other 
people of interest. The President--and this is my repeating 
what I remember him saying to me--he said, ``You are all good 
guys. You have got good solutions on both sides. You all see if 
you cannot work it out.'' We tried to get together a couple of 
meetings to work it out, but that did not materialize for one 
reason or another.
    My goal, as Chairman of the Committee, is to find a 
positive resolution no matter what problem I confront, and not 
because it comes from my wisdom, but my persistence to see to 
it we keep our eye on the goal. Of course, the goal is choice 
for our veterans, better quality health care, and a more 
accountable VA.
    It is my understanding the President and the Administration 
is going to send our Committee, in the next couple of days, 
some suggestions that they are looking at, that might help us 
bring about a resolution. I intend to work with Senator Moran, 
the other Members of the Committee, and the full Committee, to 
see if we cannot do that, so we can take to the floor a 
unanimously-supported bill, or a bill that at least everybody 
had their chance to support and can have their chance to amend 
on the floor.
    One way or another, it is time our veterans had a veterans' 
policy that serve their choices, gave them the choices they 
need, funded them so they were not subject to the last-minute 
``we are out of money'' routines, which this bill does, by the 
way. We consolidate the stovepipes from seven to one. Correct, 
Mr. Secretary?
    Secretary Shulkin. Mm-hmm.
    Chairman Isakson. To get those things done that we have to 
do.
    So, I want to announce up front that that is forthcoming. 
When it gets here I will get it to the Committee, we will begin 
work on it, and try and get ourselves in the regular order to 
find a bill that we can unanimously get to the floor, one way 
or another, and if we cannot, I then will have known I made 
every effort to do so. I will do everything I can to take it in 
regular order and have it debated and fully amended on the 
floor, if that is necessary.
    Whatever the case, our veterans deserve the best of us; the 
best of us is to pass a bill that we can agree on, and the best 
of us is to find the common ground to set up that meeting. So, 
I intend to do that and I appreciated the input the 
administration has given us, and I look forward to continuing 
to work with them.
    I am going to extend--and I have got a little time left. 
You know, there are three or four things I want to talk about, 
Mr. Secretary. One thing that concerns me deeply is the four 
positions that remain unfilled at the Department. One is your 
former position. We plucked you out of VA leadership to become 
the leader of VA. That was a good idea. The bad idea is it 
still does not have anybody in your place, where you were in 
terms of Under Secretary of Health.
    The Assistant Secretary of Accountability and Whistleblower 
Protection is not in place. That person needs to be in place. 
The Under Secretary for Benefits, which is a critical position 
at the VA, needs to be in place. The Assistant Secretary for 
Information Technology, which is absolutely critical, 
particular with the Cerner technology coming in, has got to be 
filled somewhere sooner rather than later.
    I have asked these questions privately and have looked--and 
I know you are trying. But this is one of those things where 
we--A for effort is not good enough. We have got to find a way 
to get the best people in the United States of America in these 
disciplines, working for the Veterans Administration and 
working for our veterans.
    Can you tell us what progress you have made and what you 
are doing on those four posts, in particular?
    Secretary Shulkin. Yes. Let me give you a quick update on 
that. For the CIO candidate, we have made a selection and that 
person is now going through a vetting process at the White 
House. Our indications are that that is moving along smoothly.
    For the Under Secretary of Benefits we had a commission--as 
you know, by law we need to form a commission. They selected 
three candidates. We made our top choice. That person withdrew 
and we have now gone on to our second choice--fortunately, all 
three candidates are excellent candidates--and that person has 
also gone through vetting at the White House, and they 
understand the critical nature of this.
    On the Under Secretary of Health, we have--this is now 
going to be our third commission. We have had two commissions 
prior that did not select a candidate. The third commission 
will be chaired by Deputy Secretary Bowman on January 25 and 
26. We have 11 candidates who have applied for that. We hope to 
have a successful selection out of that third commission 
process by January 26, of which we would then forward three 
names on to the President for consideration, that would go 
through vetting.
    On the Assistant Secretary for Accountability and 
Whistleblower Protection, Mr. O'Rourke is the executive in 
charge of the Accountability and Whistleblower Protection 
Office. He is here today.
    Chairman Isakson. That prompts me to tell you what happened 
this morning in the HELP Committee. We had testimony on 
disasters and preparedness, and out of the blue one of the 
chief people in charge of that for our country made a point to 
compliment the Veterans Administration and what the veterans 
hospitals and medical personnel did to help in the rescue of 
senior citizens in Houston during the terrible flood that we 
had, which magnified, for me, the importance of remembering 
that the VA health care system is a huge delivery system that 
serves, by the nature of its definition, our veterans, a more 
senior population. I wanted to compliment you and the doctors 
on what they did to earn that praise, because that is a real 
good thing to have.
    Secretary Shulkin. Thank you.
    Chairman Isakson. From a standpoint of accountability, I 
want to see some accountability with regard to the appeals 
process. I read your report and I read your remarks. I know you 
are working on a demonstration project on appeals. Is that 
correct?
    Secretary Shulkin. Yes.
    Chairman Isakson. What timetable do you have, are you 
working toward, to move away from a demonstration project to a 
project that is fact-of-the-matter; exactly how we are going to 
handle these appeals in the future, to stop the backlog from 
growing and begin to dissipate the backlog?
    Secretary Shulkin. Well, today the backlog stands at 
470,000 appeals, so we have a lot of work to do. Because of 
your legislation, we are now implementing a new process, of 
course. That will be fully implemented in early 2019, but we 
have actually started to make major improvements already.
    This year, we are on track to do 81,000 appeals. That would 
be 30,000 more than last year. At this period right now, of 
this fiscal year, we are at 21,000 appeals. That is 10,000 more 
than this time last year. So, we are getting better and faster, 
and we have brought on new staff.
    Second, we have begun--and this was actually because of the 
feedback that we got the last time that we were together--we 
have begun to offer veterans now the choice, in their legacy 
appeals, to opt into the new process, so they do not have to 
wait. We have had 3 percent of veterans opt in. These are 
people with long appeals who opted into--this is the pilot 
project--the new project. And, here is the good news. They are 
getting their decisions within 30 days, and 75 percent of those 
decisions are going in favor of the veteran.
    So, it is actually a pretty good deal. Instead of waiting 5 
or 6 years, if they opt in for a 30-day decision, 75 percent 
approval rate, which is beginning to address those legacy 
appeals. I am hoping, through our veteran service organizations 
and through your offices, we will encourage more veterans to 
consider--because this is an elective option--to choose to opt 
into the new process. They will get faster decisions and we 
hope accurate, good decisions for them.
    Chairman Isakson. My time is up, but as it ends I want to 
say this. I know our VSOs are represented here today. We did 
not ask them to testify because this was Dr. Shulkin's day. The 
VSOs are going to have their chance to address the entire House 
and Senate Committees in a few weeks----
    Secretary Shulkin. Mm-hmm.
    Chairman Isakson [continuing]. In the Dirksen Building, in 
our annual report, and we look forward to their input.
    Yet, I hope the VSOs and the agencies will do everything 
they can to disseminate the fact that our veterans who have had 
pending appeals are given the option to opt out and go into the 
new, modernized program. Three percent of them have done so, 
and those that have done so have gotten a response in 30 days. 
That is a light-years improvement in terms of appeals, and I 
commend you on what you started. Let us help him finish it by 
getting our veterans a timely appeal answer.
    Senator Moran.

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

    Senator Moran. Mr. Chairman, thank you very much. Let me 
start with just a--well, let me first say that I am going to 
depart our hearing as soon as my questions have been answered, 
and I would pay honor in this setting to Senator Bob Dole, who 
we will all be in the Capitol to honor today. In Kansas, and 
perhaps the country, there is no more esteemed public servant, 
but in my view, while his public service was tremendous, his 
military service, and then his commitment to those with 
disabilities and the veteran community is exemplary. No one 
meets that standard, so I pay a tribute to Senator Dole.
    Let me just raise a few points and I am going to make a 
comment and ask a question, Mr. Secretary. First, I want to 
note that your cancellation of the contract for Region 4, for 
Community Care, troubles me. I understand that Senator Heller 
is also going to raise this topic with you today. You have a 
request from the Subcommittee on Appropriations to explain what 
happened in that regard, and I look forward to that answer.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Jerry Moran and 
   Hon. Dean Heller to Hon. David J. Shulkin, M.D., Secretary, U.S. 
                     Department of Veterans Affairs
    Please provide information regarding the reasoning for the 
cancellation of the Region 4 CCN contract
    Response. VA received proposals in response to the Community Care 
Network (CCN) solicitation on June 30, 2017 and performed evaluations 
in accordance with the criteria established in the solicitation. VA 
took the following four factors into consideration for award decisions 
for CCN Region 4: (1) Technical, (2) Past Performance, (3) 
Socioeconomic Concerns, and (4) Price. The evaluations resulted in the 
need to conduct negotiations. After negotiations were held, VA received 
the final proposal revisions on December 14, 2017 and immediately began 
conducting evaluations of these revisions. Award decisions must result 
in a contract that represents the ``best value'' to VA. After 
evaluations were completed, it was determined that final proposal 
revisions for Region 4 did not provide the ``best value'' to VA, all 
factors considered, or for our taxpayers. VA amended the solicitation 
to remove Region 4 since a contract award was not possible.

    Senator Moran. Second, I will be submitting several 
questions for the record. I am interested in knowing the VA's 
efforts in regard to full implementation of the Toxic Exposure 
Research Act, something that Senator Blumenthal and I sponsored 
and became law in December 2016.

    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Jerry Moran to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Please provide an update on VA's full implementation of the toxic 
exposure research act (PL 114-315)
    Response. VA, through the Post Deployment Health Services office, 
has contracted with the National Academy of Science to meet the 
requirements specified in section 632 of the law. This consensus report 
is expected to be completed by NAM by early 2019. As to the research 
oriented Federal Advisory Committee and accompanying research, as 
outlined in section 633 and 634 respectively, VA has yet to form the 
charter and begin work as these next steps would be contingent upon the 
findings of the report.

    Senator Moran. Finally, you have had conversations with me 
about electronic health records, originally about a 
reprogramming. Now I see that there are other reasons that you 
are not proceeding, and I am concerned about what is taking 
place here. I have sent you a letter which I would ask you to 
respond to.
    Then let me talk about the topic that the Chairman 
mentioned, in regard to the bill that passed the Committee. I 
want to direct this not to the Chairman but to you, Secretary 
Shulkin. I have been working closely, in my view, with the 
Chairman and the Ranking Member, other Members of this 
Committee, and those in the VA that you designated for me to 
work with, and with the White House, to make certain that the 
future of Community Care for veterans works and works well for 
veterans and the providers who serve those veterans.
    It is of utmost importance to me to reform Choice and to 
pass the right policies that will work for veterans in 
accessing health care that they deserve. It is also critical 
that Members of Congress continue to push for a change in the 
VA culture and to promote implementation of policies directed 
by Congress instead of the VA often narrowing the scope and 
thwarting the intent of Congress. This is, in fact, the 
conversation that you and I had, almost exclusively, during 
your confirmation hearing in February 2017.
    Pushing for a culture that transforms the VA, in my view, 
we have to hold you and other VA leaders accountable, and in my 
view too often commitments and pledges that are made to this 
Committee and to individual Members regarding legislative 
efforts on behalf of our veterans, the follow-up, the 
experiences are typical of what I have found with 
implementation of congressional past legislation. The VA 
changes course and it thwarts the intent of Congress. You and I 
had this conversation during your confirmation hearing.
    On numerous occasions, you and I have met in my office, we 
have had numerous telephone conversations, and in those 
meetings, and in those telephone conversations, you expressed 
support for access standards in the eligibility of Choice 
reform. In every instance, in my view, you led me to believe 
that you and I were on the same page. What I have--what I 
remember you saying is this: the need for specificity in 
legislation is there, and then I quote you, ``If it is left to 
the reg process, nothing in the VA will change.'' You told me 
that.
    I learned, though, that you have said something quite 
different to the Chairman and to the Ranking Member. I am of 
the opinion that our inability to reach an agreement is, in 
significant part, related to your ability to speak out of both 
sides of your mouth--doubletalk. My understanding is that 
others have had this experience and there is a shared 
frustration about the circumstance.
    So, Mr. Secretary, you have been sworn to give testimony 
today. I am looking for a straightforward answer. A yes or no 
would be good. Do you believe that the eligibility criteria to 
determine if a veteran can receive care in their community 
ought to be explicitly linked to the access standards? Yes or 
no?
    Secretary Shulkin. Of course, I believe that eligibility 
criteria should be explicitly linked to access standards, and I 
believe that those access standards need to be developed by the 
VA.
    Senator Moran. Mr. Chairman, let me ask the Secretary, do 
you support the access standards that are in our bill? You have 
told me that. True?
    Secretary Shulkin. I support the access standards that are 
in the bill that the Senate committee passed 14 to 1.
    Senator Moran. Those access standards are very similar. The 
issue is whether they are then tied to eligibility. Why would 
you not tie the access standards to eligibility? Why have 
access standards if they do not matter who is eligible for 
Community Care?
    Secretary Shulkin. Well, Senator Moran, first of all, I 
applaud your efforts to get this right. I think it is grossly 
unfair to make the characterizations that you have made of me, 
and I am disappointed that you would do that. But, I think that 
you have--I do not disagree with where you want to get to. I do 
believe that it is our job to give veterans more choice about 
how and where they get their health care.
    I think the issue is that I am trying to do this in a way 
that will work for veterans and work for VA. I have seen, as 
you said before, Congress passed legislation that makes it more 
complicated and that makes it not work for veterans, and what I 
am trying to do is give you my best advice about how this 
works. The best way that I know how to do it is the way that 
the Committee, 14 to 1, passed their vote, and I do believe 
that because of your efforts we can make those eligibility 
criteria, those access standards, clearer to veterans so they 
understand it--that should be our goal--and then make sure that 
they do have choices based upon their clinical needs of their 
condition. That is what you do in a health care system. That is 
what I am driving to get at.
    I do not believe that we are at a faraway position here. We 
are now talking about the best way to implement what we all 
want for veterans, which is the best care and giving them the 
most choice that they can get in that care.
    Senator Moran. Well, Mr. Secretary, I am sorry that you 
take--you are disappointed in my approach to this hearing 
today. I chose my words intentionally.
    Secretary Shulkin. Mm-hmm.
    Senator Moran. I believe it to be the case. I think you 
tell me one thing and you tell others something else, and that 
is incompatible with our ability to reach an agreement and to 
work together. I intend to be a Member of Congress who holds 
you accountable for what you tell me.
    I hope the next step is--the Chairman indicated that the 
White House was sending language. I certainly would welcome a 
conversation, a discussion among the Members of this Committee, 
the Ranking Member and the Chairman, the White House, and you. 
This is, as you say, not that difficult, but it is an important 
issue. It is not one that is just a matter of a few words. It 
matters in the result that we get for accountability at the VA.
    Mr. Chairman, thank for the opportunity to question the 
witness.
    Chairman Isakson. Thank you for your attendance. I now want 
to do two things. First of all, I want to echo your praise for 
Senator Dole. A great American, a great American hero. A guy 
whose campaign I ran in the Southeastern United States in 1988, 
I might add. I have always been proud of it. I kind of got the 
political itch because of it. He is a great humanitarian and a 
great human being.
    I appreciate the Secretary and Senator Moran's candor in 
their feelings about what we are trying to do. What I am trying 
to do, as Chairman, is get us to a point where our dirty 
laundry is clean, it is folded, it is in the cabinets, and what 
we are doing works for the veteran. You do that when everybody 
gets their chance to have their say, when every fact is on the 
table, and we are all willing to work together. That is what 
this is all about, that is what we are going to do, and what I 
hope comes from the White House will be a catalyst in the next 
few days, which is why I wanted to tell everybody about that. I 
found out about it today. You found out about it today. So, 
when we get it in a couple of days you will get notice from me 
as to when we have the hearing.
    Thank you, Senator Moran, for your input.
    Senator Moran. Mr. Chairman, I welcome that.
    Chairman Isakson. Please tell the Dole family we all get 
there if I shut my mouth. So----
    Senator Moran. Thank you.
    Chairman Isakson. Thank you.
    Senator Tester, you have got a choice. You can answer 
questions or you can go to opening statement, or, as big as you 
are, you can do whatever you want. [Laughter.]

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

    Senator Tester. No. That is all right. I will just ask some 
questions. The opening statement will be for later, and I 
apologize to the Members. I usually kick it over to you, but I 
have another committee I have got to get to very quickly.
    [The prepared statement of Senator Jon Tester follows:]
        Prepared Statement of Hon. Jon Tester, Ranking Member, 
                       U.S. Senator from Montana
    Secretary Shulkin, thank you for being here. Mr. Chairman, thank 
you for your dedication to our Nation's veterans. Largely due to your 
leadership, this Committee had a historic year in terms of the number 
and scope of bills we've had signed into law. A great deal of credit 
also goes to each member of Committee, as well as the tremendous 
advocacy of the VSOs in attendance and across the country.
    Mr. Secretary, last year, you came before this Committee and made a 
dramatic and urgent appeal for us to modernize the appeals process. We 
acted.
    You came to us and said you needed more tools to hold bad actors at 
the VA accountable, and to protect whistleblowers. We acted.
    You came to us multiple times when the Choice Program was running 
out of money. We acted. And then we acted again. And then we acted 
again.
    For months, you also came to us and pitched ideas about how to 
scrap the Choice Program. And how to replace it with a community care 
program that puts veterans and their doctors in charge of where to 
receive care. We turned those ideas into a bill that passed this 
Committee 14-1 and with the support of 26 VSOs. And I don't want to let 
this moment pass without saying in the clearest terms how disappointed 
I am that you did not publicly announce your support for a bill on 
which we collaborated for months.
    If VA is not going to publicly advocate for its legislative 
priorities, you should not expect this Committee or this Senator to do 
so.
    Nevertheless, I am still committed to working with you and this 
administration to address the continued challenges of veterans and 
their families. Those challenges are daunting. They require action, not 
words. And they require us all working together.
    In recent months, the VA and the Administration have rolled out a 
number of initiatives, most of which I have agreed with, but many of 
which have included little or no substance. We can help you make them 
successful, but there's little we can do if we're given no notice and 
no information.
    And I'm afraid VA will continue to spin its wheels until you 
address the dramatic staffing vacancies that impact everything from the 
delivery of health care to the safeguarding of veterans' personal 
information. This is a fight I have waged for years. Nearly every time 
we have spoken, or I have spoken with your predecessors of both 
parties, I have asked for specific things that can be done to help 
recruitment and retention efforts.
    And nearly every time, I have delivered--whether it was more 
flexibility, additional resources or additional authorities.
    Yet here we are--somewhere between treading water and drowning. And 
veterans in places like Montana can't access the timely care they need 
and have earned.
    These vacancies must be a higher priority for you and the 
Department. Otherwise, VA won't be able to fulfill its mission, and 
will setting itself up for failure as it moves forward on 
implementation of the many reforms that have come out of this 
Committee. We have a lot of ground to cover, and I look forward to 
getting started. Thank you.

    Senator Tester. First of all, welcome, Mr. Secretary. When 
it came to the Caring for Our Veterans bill, we had consulted 
with the VSOs, and, in fact, got support of 26 of the VSOs. We 
actually consulted with you and the VA to make sure this stuff 
would work, including Members on this Committee and members off 
this Committee.
    In your written testimony you said the VA believes that the 
future of Community Care should include eight tenets. Those 
tenets are: improve veterans' choice of community providers in 
meeting their health care needs; to simplify veterans' 
eligibility with a focus on veterans' clinical needs; to pave 
the way for consolidation of all Community Care programs; add 
convenient care benefits; set timely payment standards; include 
provider agreements with flexible payment rates and streamline 
how we pay for care, including care in State veterans' homes; 
permit medical record-sharing in the network when needed for 
veterans' care; and addresses clinical staffing shortages 
through extension of graduate medical education and by 
improving VA hiring and retention of staff.
    I would just tell you that the Caring for Our Veterans Act 
checks every one of those boxes, and it checks every one of 
those boxes because when we drafted it we had those tenets in 
mind. So, I would really look forward, and I think look forward 
to a strong press release in support of this bill, and I will 
tell you why--because there is a certain amount of frustration, 
as you can tell----
    Secretary Shulkin. Of course.
    Senator Tester [continuing]. From Senator Moran, the 
Chairman, myself, and others on this Committee, that you have 
been silent. OK?
    Secretary Shulkin. Mm-hmm.
    Senator Tester. So, thank you.
    Section 211 of the Accountability Act requires the VA to 
track the usage of new authorities granted, and we have given 
you a lot of new authorities----
    Secretary Shulkin. Mm-hmm.
    Senator Tester [continuing]. Over the past year, thanks to 
the good work of the Chairman. When will we see this report?
    Secretary Shulkin. The report was due in December 2017, so 
I apologize that it is not there. The staff has had extreme 
difficulty tracking what you have required in that report, 
prior to the implementation of the Accountability Act.
    Senator Tester. So what----
    Secretary Shulkin. I have instructed them to give whatever 
data they have to you and tell you what data they cannot 
collect.
    Senator Tester. So, when can we expect it?
    Secretary Shulkin. I am going to say, is it reasonable to 
ask for 2 weeks?
    Senator Tester. Two weeks it is. We will hold you to it.

    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Jon Tester to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Please provide, within two weeks, a report regarding the tracking 
of new authorities granted as required in section 211 of the 
accountability act.
    Response. The Section 211 Report did not ask for any data post 
implementation of the Act. It was all tied to the 3-year period prior 
to the Act (which we included in the June 30 Report to Congress on the 
1st anniversary of OAWP, attached). It was broken down by categories of 
713 (senior leaders) and 714 (workforce).
                            Attached Report

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Senator Tester. Your predecessors have testified that 
leadership includes working with underperforming employees to 
make them better at their jobs, rather than just firing them. 
Is that your philosophy too?
    Secretary Shulkin. Yes, it is, that every good manager 
works with their employees to make them better, to give them 
feedback. When an employee deviates from a professional, moral 
standard, sometimes you cannot coach them. Sometimes you have 
to help them find----
    [Overlapping speakers.]
    Senator Tester. Do you believe that your leadership is 
doing that within the VA?
    Secretary Shulkin. Yes. Well, I think that we have room for 
improvement, because when you look at our employee engagement 
scores, they are not improving the way that I believe that they 
should. So, we are relooking at our efforts to do that better.
    Senator Tester. OK. On the Choice Bill that was passed last 
August, Congress expanded your direct hiring authority for 
positions for which there was a shortage of highly qualified 
candidates. Am I correct that the VA has still not used this 
authority to hire?
    Secretary Shulkin. Yeah. When you look at--my 
understanding, Senator, is that the direct hire authority as 
given to us----
    Senator Tester. Yep.
    Secretary Shulkin [continuing]. For medical center 
directors and network directors----
    Senator Tester. Yes.
    Secretary Shulkin [continuing]. And I think, 
unintentionally, it capped the salary that we are able to offer 
at a salary that is lower than what we currently offer. So, we 
have not been able to utilize----
    Senator Tester. OK.
    Secretary Shulkin [continuing]. The direct hire authority 
in the way that I believe it was intended to be used.
    Senator Tester. So, how can that--how can that be fixed?
    Secretary Shulkin. It is a very small----
    Senator Tester. You can do it by rule?
    Secretary Shulkin [continuing]. Technical fix.
    Senator Tester. Can you do it by rule?
    Secretary Shulkin. No. You are going to have to do it 
legislatively, but it is a very small technical change that we 
have given some technical----
    Senator Tester. OK. And----
    Secretary Shulkin [continuing]. Advice.
    Senator Tester. And it gave you authority on those 
positions----
    Secretary Shulkin. Yeah.
    Senator Tester [continuing]. But it also gave you authority 
for employees that you would deem critical.
    Secretary Shulkin. Yes, and we have gone to OPM with 15 
different critical occupations that they have agreed to move 
forward with us on direct hire authority that I believe we will 
start to implement in the next several weeks.
    Senator Tester. OK. We have had the conversation before. At 
a town hall meeting in Great Falls, MT, Monday, I will tell you 
the first question that came up was workforce vacancies. This 
is just Montana----
    Secretary Shulkin. Mm-hmm.
    Senator Tester [continuing]. I'm sorry about being self-
centered on this. I just want to tell you that we are in a 
crisis. We may be in a crisis in Alaska, and we may be in a 
crisis in North Carolina, and every other State, too. I do not 
know that, but I can tell you in Montana, we are in a crisis.
    Let me give you an example. Billings, MT, is supposed to 
have seven docs in that clinic; we have got four, and two of 
those are looking for another position.
    Secretary Shulkin. Yep.
    Senator Tester. When you overwork employees, they tend to 
hit the road.
    Secretary Shulkin. Yep.
    Senator Tester. So, my question is, what is the problem? I 
have talked to you many times. I know you are committed to 
this, yet it does not seem--it seems like it is getting worse. 
In fact, it does not seem like it, in my State it is getting 
worse.
    Secretary Shulkin. Yeah. Well, in Montana, as you know, you 
have an 11.2 percent turnover rate of your employees, but for 
physicians it is 23 percent. That is a problem. You have a 24 
percent vacancy rate for practical nurses.
    Senator Tester. I have got all that.
    Secretary Shulkin. So----
    Senator Tester. So, what can we do to fix it?
    Secretary Shulkin. Here is what we----
    Senator Tester. What are you doing to fix it?
    Secretary Shulkin. Here is what we are doing. First of all, 
we have to hire more staff and we have to make sure that we 
keep them. We have announced, for Montana, an increase of up to 
$120,000 for primary care physicians in educational debt 
reduction----
    Senator Tester. Yes.
    Secretary Shulkin [continuing]. For nurses--I am sorry--for 
psychologists and nurse practitioners, a $10,000 hiring bonus, 
and for social workers a $5,000 hiring bonus. That is a 
beginning to start to address people to look at the VA as a 
place to come to work. Then we have to, as you said, if we 
cannot fully staff the clinic, it puts more pressure on our 
current staff that are there, and so it is a vicious cycle. So, 
we are working to recruit.
    Senator Tester. Thank you for that, but time is of the 
essence. I do not speak for Senator Rounds; he will speak for 
himself on this.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. But, as you well know, there was a House 
bill that was going to have a Base Realignment and Closure 
(BRAC) done. They could literally shut down damn near every 
facility in Montana if they did a BRAC, because we have got no 
staffing.
    Secretary Shulkin. Right.
    Senator Tester. This is really, really, really important.
    Secretary Shulkin. It is.
    Senator Tester. OK.
    Secretary Shulkin. It is. It is. Absolutely.

    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Jon Tester to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Please provide a list of five specific things that VA is doing 
above and beyond what is currently being done to address clinical 
vacancies in Montana.
    Response. Montana has taken the following actions address clinical 
vacancies in Montana:

1. Participation in Hiring Fairs:

    a. 12/15/17: Focused hiring fair for Medical Support Assistants in 
Missoula. Included on the spot interviews and tentative offers on the 
spot. Currently have made 23 offers.
    b. 3/21/18: Participating in Billings Job Jamboree in partnership 
with Sheridan VAMC.
    c. 4/15/18: Kalispell Health Expo 2018.

2. Institutionalized use/increased emphasis for hiring incentives:
    a. Emphasis on the following:

     Use of Recruitment and Relocation incentives
     Permanent Change of Station allowances
     Student Loan Repayment Program
     Increased Education Debt Reduction Program funds for 2018

3. Process improvement/Reduced Hiring Bureaucracy:

    a. Speeds up hiring process when vacancy identified.

4. Authorized 3 new Human Resources positions and 1 lead specifically 
dedicated to recruitment in foundational services.

    Senator Tester. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Tester. Let me just 
say, for the record, the Ranking Member's cooperation 
throughout the process of working on the Choice legislation has 
been stupendous. I appreciate his help very much, and we are 
going to get to the finish line in large measure because of his 
support and the support of the members of his caucus as well as 
ours, for this good legislation, and I appreciate it very much.
    Mr. Boozman. Senator Boozman.

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

    Senator Boozman. Thank you, Mr. Chairman, and thank you, 
Secretary, for being here. We do appreciate your hard work.
    I would like to talk to you a second about a bill, the VET 
TEC Act, which we were able to include in the Forever GI Bill. 
It is a technical education pilot. I know that we do not have a 
Deputy Under Secretary for Economic Opportunity. He has 
retired. I would like to know who is going to be responsible 
for implementing it and how we are doing.
    Secretary Shulkin. Yeah.
    Senator Boozman. Talk a little bit more about----
    Secretary Shulkin. Yeah. Well----
    Senator Boozman [continuing]. Who is going to fill that 
spot, and again, you might also elaborate even more about how 
we can help you with these really key, you know, things that 
are deficient in the sense of not being able to fill your 
staff.
    Secretary Shulkin. Right. Well, first of all, I think you 
helped a great deal with the Forever GI Bill. I think this is a 
great success story of what this Committee was able to do in 
2017. As you know, of the GI Bill, the Forever GI Bill, we have 
enacted already 13 of 34 of the provisions. But, the one that 
you are talking about, the TEC Act, which is more the STEM, the 
scientific, technical training, that is going to require--that 
is one of the ones that we have not yet implemented because it 
is going to require some IT solutions. What we are doing is, we 
have a Request for Information out now to look to how we can 
get private industry to help us implement that. Otherwise, we 
are going to need to build that in-house, which is going to be 
more expensive.
    So, we are looking for the best way to get that implemented 
and committed to getting it implemented. But, on many of these, 
the 34, 22 of the provisions require IT assistance.
    Senator Boozman. How will you determine the courses that 
are eligible, such as coding, things like that?
    Secretary Shulkin. Under the TEC Act? Well, you asked who 
is responsible for it. Our Acting Under Secretary for Benefits, 
Mr. Tom Murphy----
    Senator Boozman. OK.
    Secretary Shulkin [continuing]. Has accountability under 
that area. Rob Worley, who is here with us today, is the 
Director of Educational Benefits.
    Senator Boozman. OK. So, we will follow up with them.
    Secretary Shulkin. Yes.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. John Boozman to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    What challenges does VA face implementing the VET TEC program, how 
does VA plan to overcome those challenges, and what will be the 
timeline?

    Response. Veterans Affairs (VA) requires a legal determination 
regarding the need to award VET TEC via Federal acquisitions or if VA 
is able to leverage its authority to approve via the normal process. 
Both options provide timely awards to training programs for 
participation in the 5-year pilot. VA is currently gathering necessary 
information to assist VA's Office of General Counsel (OGC) with 
finalizing their legal opinion.
    VA estimates that as many as 50 percent of prospective applicants 
may not meet necessary skills screening by training institutions. 
Reputable IT training providers will conduct applicable screening 
criteria to all applicants. We recognize that if a Veteran does not 
meet initial screening they may benefit from various upskilling 
opportunities in an effort to better position them for future 
application windows. VA is working with a large coalition of partners 
to establish a series of no-cost public-private partnerships that will 
create a ``hope pathway'' for Veterans seeking to upskill. This pathway 
will leverage existing services by the Department of Labor (DOL), in 
addition to free community college programs and mentorship tools.
    The VET TEC pilot program has not previously been attempted at this 
scale; therefore the criteria for selection of prospective VET TEC 
providers will require extensive market research prior to the 
implementation of the pilot program. VA will evaluate programs using 
industry best practices to ensure effective design, implementation and 
evaluation of the pilot.
    The requirement of 50 percent of vendor payment taking place upon a 
Veteran's job placement is one of the more difficult aspects of 
implementation and may deter providers from participating. VA plans to 
establish ``employer coalitions'' in partnership with DOL, VA's 
Vocational Rehabilitation and Employment, and the VET TEC training 
institutions to ensure Veteran job placement satisfies criteria for 
payment.
    Timely hiring of staff is critical to proper implementation. VA is 
in the process of making appropriate staffing determinations and 
authorization of necessary staff hiring. We should complete hiring of 
this staff by May 2018.
    VA anticipates receiving a legal opinion from OGC within the next 
60 days and expects to initiate or start the official pilot program by 
February 2019.

    Senator Boozman. Thank you. According to the VA OIG report 
on the consolidated patient account centers, in 2015, the VA 
billed third-party payers approximately $7.2 billion for 
medical treatment. I think we collected about $2.5 billion. The 
Department considers third-party collections as revenue in its 
annual budget projections.
    How does the VA project its expected collections for each 
year, and how does that match up with what we are actually 
collecting?
    Secretary Shulkin. We do give our projected collections as 
part of our budget request, because, as you have said, it is an 
offset to essentially our--what is given to us in our budget. 
Our finance team does the projections based upon actuals of 
last year and then sets a target for improvement. This is 
something that we have targeted, to improve collections. One of 
the provisions that I think is being considered under the 
current legislation is a requirement to disclose third-party 
insurance, because that is part of the challenge that we have. 
If we do not know a veteran has other insurance it is very hard 
for us to go and to collect it. So, that is something that we 
are working on.
    Senator Boozman. Right. I believe we have a pilot program 
going on in five areas----
    Secretary Shulkin. Yes.
    Senator Boozman [continuing]. In relation to this. Do you 
have any----
    Secretary Shulkin. On the third-party collection efforts.
    Senator Boozman. Exactly.
    Secretary Shulkin. Yeah, yeah.
    Senator Boozman. I know that is not done. Do you have any 
preliminary things that you can talk to us about?
    Secretary Shulkin. I do not have an update and I do not 
know if anybody behind me has an update on that. I do not think 
there is an expert on that, but we can get you that update.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. John Boozman to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Please provide preliminary data/information regarding the third-
party collection effort pilot program that is set up in five areas.
    Response. As an effort to further improvements and accountability, 
Section 201 of the Choice Act mandated a comprehensive examination of 
Veteran Affairs (VA) ability to deliver accessible high-quality health 
care to Veterans. These assessments evaluated the areas of staffing, 
training, facilities, business processes, and leadership.
    The focus of Revenue Transformation is to implement new or enhance 
existing industry best practices and eliminate any inefficiency in VA's 
business processes specific to the revenue cycle. As a result of 
Revenue Transformation, VA has recognized an increase in collected 
revenue and the protection of other revenue that would be impacted by 
the changing healthcare landscape.
                          key accomplishments
    Registration: The goal of the Registration portfolio is the 
comprehensive and timely identification of Veteran insurance 
information. Currently, the portfolio has increased education to 
Veterans and VA staff on insurance capture which resulted in decrease 
in front-end denials by over 75% at five test sites. It has also 
improved Veteran education on the importance of providing insurance at 
test sites, leading to the achievement of an insurance capture rate 
that is 8% higher than the national average. The portfolio developed a 
standardized dashboard to assist VA managers in monitoring the success 
of VA's insurance capture efforts.
    Clinical Documentation: The Clinical Documentation portfolio team 
is improving accuracy and timeliness of clinical documentation through 
streamlined processes and innovative solutions. The portfolio has 
developed a dashboard to monitor third-party billings and collections 
at the provider level to improve visibility and awareness. 
Additionally, the portfolio developed two standardized interactive 
templates (primary care and inpatient) focused on improving clinical 
documentation accuracy.
    Coding: The Coding portfolio is focused on reducing outpatient 
revenue coding backlogs. Consolidation of resources and work assignment 
has resulted in the coding of an additional 94,944 encounters, 
resulting in a net reduction of 33,376 coding encounters pending at our 
test sites. The Coding Portfolio team has assisted in reducing coding 
pending volumes at test sites by 35% since January 2017.
    Charge Capture: The Charge Capture portfolio is implementing 
process improvements to enhance operational efficiency and improve 
revenue collections. By developing enhanced billing methods for 
Community Care the total number of claims submitted to Other Health 
Insurance (OHI) has increased by 30,070, resulting in a $1,466,889 
increase in total collections from May 2017 to December 2017. The 
portfolio has also launched an initiative to capture and submit the 
National Drug Codes for injectable procedures performed in an office 
setting to OHI at test sites and has reduced denials for these 
procedures by 10%.
    Billing & Collections: The Billing & Collections portfolio is 
identifying inefficiencies in the existing revenue cycle to implement 
methods to improve overall collectability. The portfolio has developed 
and deployed net collections performance to align with industry best 
practice and replace collections to billing. The national net 
collections rate for the last 3 months is as follows: October--95.9%; 
November--96.2%; December--96.8%. A new function/process to increase 
the efficiency of payer analysis reviews in facilities was implemented. 
A contract to perform recovery audit services of collected and closed 
claims was initiated and an award is anticipated in the third quarter 
of Fiscal Year 2018.
    Denials Management: The Denials Management portfolio is refining 
the existing denials process through innovative technology, procedures, 
and training materials for VA staff. Overall Enterprise Denials Rate, 
based on First Run Yield, has gone down from 12% in January 2017 to 
8% by December 2017.
    Revenue Integration Portfolio: The Revenue Integration Portfolio is 
consolidating functionality to streamline processes across the VA 
revenue cycle. The team has completed a nationwide review of the clinic 
set up for potential high dollar clinics. The review resulted in an 
additional 351 Cardiology clinics and 518 Radiology clinics now being 
designated high dollar, which drives 3rd party billing activities. This 
has resulted in increased collections of $1,446,687 from July 2017 to 
December 2017.

    Senator Boozman. OK. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Boozman, and before I 
go to Senator Manchin, let me just take the liberty, if I may, 
of asking Gretchan Blum to stand up behind me. Gretchan?
    Gretchan has been with the Committee since I came to the 
Committee as Chairman 3 years ago. She is going to greener 
pastures in Oregon, which is a beautiful coastline. Lots of 
veterans, lots of good people. She has been a tremendous help 
to our veterans and this Committee. We want to acknowledge and 
thank you for your service.
    [Applause.]
    Chairman Isakson. Senator Manchin.

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

    Senator Manchin. Thank you, Mr. Chairman. I appreciate it. 
Thank you, Dr. Shulkin, for being here.
    I need to bring something of a local interest to your 
attention. On December 20, a high-risk veteran contacted my 
office after his bypass surgery was canceled while he was 
laying on the operating table in the Clarksburg VA, which is 
the Louis A. Johnson VA medical center. It is a great hospital. 
The reason for cancellation being that spots were found on the 
tools processed by the autoclave. That is the reason.
    Now let me tell you how time elapsed.
    We have been told that they have estimated it will be at 
least 10 weeks before a temporary--just before a temporary--
sterilization unit will be operational, but it will also take a 
whopping 16 to 18 months to replace the one that is deficient. 
It has been reported--I understand up to what the Region 5, the 
VISN 5 level. That is your region. I do not know if it has ever 
gotten to you all. There has got to be something, doctor, when 
something this egregious happens. We cannot do any--we are 
done, and this is a big hospital, of course, so we need your 
help.
    Secretary Shulkin. Right.
    Senator Manchin. Thank you for your help on that.
    Next of all, I sent a letter last week, after reading the 
New York Times story that reported that the Oregon VA medical 
center has tried to improve their quality metrics. Well, we 
start looking into this, how it affects us in our State, and, 
for example, I have found that the emergency department medium 
time for administering pain medication, statistic on the 
HospitalCompare.gov website, it is listed as not available, and 
is also footnoted as no cases met the criteria for this 
measure. That seems unacceptable to me in emergency--for an 
emergency department.
    How are you equipping local VA medical center staff to 
track and record these types of vital data, and who in West 
Virginia VAs are responsible for collecting the data. We could 
not find out----
    Secretary Shulkin. Yes.
    Senator Manchin [continuing]. From my office.
    Secretary Shulkin. On HospitalCompare.gov, which is run out 
of the Department of Health and Human Services----
    Senator Manchin. Are you all working with it? Try, OK.
    Secretary Shulkin. VA used to have all its data up there--
--
    Senator Manchin. Uh-huh.
    Secretary Shulkin [continuing]. And due to contract issues 
with the Department of Health and Human Services, not VA, they 
lost the ability to take VA data. They are now actively working 
to get it back up by the end of this year. They will have all 
that data back up. We still collect and product all that data 
and we publish the data ourselves on accesstocare.va.gov. So, 
we do have that data, we do make our comparisons to local 
hospitals. We would be glad to share that with you. We wish it 
were up on the HospitalCompare site because we think it is a 
great site, and by the end of the year HHS will have that back 
up for us.
    Senator Manchin. Opioid addiction. You know about opioid 
addiction in my State, in West Virginia, but also throughout 
the entire veterans' community. It is something of great 
concern. The President basically declared a medical----
    Secretary Shulkin. A public health emergency.
    Senator Manchin [continuing]. Public health. I have told 
him I am very appreciative of that. I wish it would have gone 
farther, but I am very appreciative of what we are getting----
    Secretary Shulkin. Mm-hmm.
    Senator Manchin [continuing]. But we have not gotten 
anything yet. I do not know how it is affecting you all, with 
your fight on opioid addiction, or how that will help you if we 
can get this money to start flowing. We are asking the money to 
flow not based on population but based on need, where the 
greatest occurrences are.
    Secretary Shulkin. Mm-hmm.
    Senator Manchin. Have you seen any changes there? Have you 
gotten any help whatsoever? Also, you all need to be--you need 
to be recognized in an affirmative way for basically not 
allowing your VA patients to dictate the dispensing as part of 
the overall care they are getting and what quality of care, 
which could penalize your hospitals. I thank you all to change 
that.
    Secretary Shulkin. Mm-hmm.
    Senator Manchin. You have helped that move all the way 
through the whole----
    Secretary Shulkin. Mm-hmm.
    Senator Manchin [continuing]. Department of Human Services.
    Secretary Shulkin. Mm-hmm. Right. Well, first of all, I 
participated in the President's commission.
    Senator Manchin. Right.
    Secretary Shulkin. I think it is important. We brought the 
Members of the Committee to the Cleveland VA that has a 3 
percent prescribing rate, the lowest in the country, to see the 
best practices, and that did make it into the report.
    Senator Manchin. Right.
    Secretary Shulkin. Last week, we started to publish, at VA, 
every medical center's prescribing rate for opioids. No other 
system in the country, no other hospital in the country does 
this. It is available now, so everybody can see.
    Senator Manchin. It is on your website?
    Secretary Shulkin. It is on our website, the opioid 
posting.
    Senator Manchin. OK.
    Secretary Shulkin. Finally, let me just say, we have made a 
41 percent reduction since our efforts began in 2010, with our 
Opioid Safety Initiative.
    Senator Manchin. Mm-hmm.
    Secretary Shulkin. We have more work to do. What this 
website says, it shows us where we have a lot more work to do. 
But remember, the key is not just simply withdrawing opioids.
    Senator Manchin. Sure.
    Secretary Shulkin. These are patients who are in pain. The 
question is----
    Senator Manchin. We recognize that.
    Secretary Shulkin [continuing]. Before we start opioids, 
before you reach for it first, are there alternatives that you 
can do to help relieve pain and not put your patient at risk of 
addiction? So, that is what we are really focused on. A lot of 
the veterans think this is about we have targets to withdraw 
opioids. We do not. We want doctors to continue to eliminate 
pain, but we want them to make smart choices, give veterans 
informed choice.
    Senator Manchin. Right. We are doing the same thing, and we 
do not want any patient to think they are being penalized 
whatsoever----
    Secretary Shulkin. Right.
    Senator Manchin [continuing]. Being without their other 
alternative methods too, not the alternative drugs that are 
being developed right now----
    Secretary Shulkin. Absolutely.
    Senator Manchin [continuing]. That are not addictive.
    With that being said, the one that still haunts me and 
bothers me more is homelessness----
    Secretary Shulkin. Yep.
    Senator Manchin [continuing]. Which we have had an increase 
in homelessness----
    Secretary Shulkin. Yeah.
    Senator Manchin [continuing]. From 2016 and 2017.
    Secretary Shulkin. Yes.
    Senator Manchin. I cannot even fathom how any veteran 
should ever not have a roof over their head----
    Secretary Shulkin. Right.
    Senator Manchin [continuing]. And a place to sleep, for 
what they have done for us.
    Secretary Shulkin. Right.
    Senator Manchin. What is happening there? Is it----
    Secretary Shulkin. Right.
    Senator Manchin. So, as you know, from 2010 until now, we 
have had a 46 percent reduction in homeless veterans. We still 
have 40,000 homeless veterans--way, way too many. Females have 
gone up----
    Secretary Shulkin. Yes.
    Senator Manchin [continuing]. Female veterans homelessness 
is up 7 percent.
    Secretary Shulkin. Last year their rate went up 2 percent--
--
    Senator Manchin. Yeah.
    Secretary Shulkin [continuing]. Which is going the wrong 
direction.
    Senator Manchin. Overall.
    Secretary Shulkin. If you take a look, there are five major 
cities in the country, but Los Angeles and Seattle are the two 
that went up the most. So, what we are doing is we need a 
reboot of our program. This is not less money in the program; 
we actually want more in this program. We need to do this 
better. We are focused and prioritizing doing this better. We 
are going to target Seattle and Los Angeles, in particular, but 
not give up on progress everywhere else. We are going to be 
coming out with a new, improved approach, but it is not less 
resources. It is going to be more resourced and more focused.
    Senator Manchin. Let me just--I am so sorry. I just wanted 
to follow up real quick.
    Secretary Shulkin. Yeah.
    Senator Manchin. For us to know how many homeless veterans 
we have, we have to have them in our records somewhere.
    Secretary Shulkin. Yes.
    Senator Manchin. There has to be contact.
    Secretary Shulkin. Right.
    Senator Manchin. With that--it is not like saying, well, 
they just dropped off and they have fallen off the records.
    Secretary Shulkin. We actually now know, by name, who most 
of the homeless veterans are. We do, once a year, what is 
called a Point In----
    Senator Manchin. We have caseworkers with that----
    Secretary Shulkin. Absolutely. We have caseworkers for our 
homeless veterans. We do what is called a Point In Time Count--
--
    Senator Manchin. Uh-huh.
    Secretary Shulkin [continuing]. A PIT count. We are going 
to do it here in Washington, January 28. I will be out there at 
midnight----
    Senator Manchin. OK.
    Secretary Shulkin [continuing]. With other people, making 
sure we accurately do that assessment. I did it in Los Angeles 
2 years ago. Then, after we do our Point In Time counts, we 
will be able to know what----
    Senator Manchin. Uh-huh.
    Secretary Shulkin [continuing]. The progress for, if there 
are more veterans----
    Senator Manchin. Right.
    Secretary Shulkin [continuing]. Who are homeless. But, we 
are committed to continuing to stay at this until we end 
veteran homelessness.
    Senator Manchin. Thank you.
    Chairman Isakson. Thank you, Senator Manchin.
    Senator Tillis.

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

    Senator Tillis. Thank you, Mr. Chair. Thank you to 
Secretary Shulkin.
    One thing you mentioned in your opening comments I just 
wanted to get a little bit more information on is--I knew, and 
I was glad that the Department is showing some latitude in 
providing services to veterans with other-than-honorable 
discharge. Can you tell me a little bit about the scope of that 
and maybe the numbers of people that have been served at this 
point?
    Secretary Shulkin. Yep. Yep. As you know, with trying to 
decrease veteran suicide and doing the right thing for our 
veterans, when you take a look at where our highest risk for 
veteran suicide is, it is in several categories. Homelessness 
and homeless veterans who do not have access to care, clearly, 
which is why we are targeting an end to that. Our other-than-
honorable discharge veterans are very high risk as well, 
because they do not have access to services. So, what we have 
provided them with is an emergency mental health benefit, that 
provides--all they have to do is show up. We are going to give 
them 90 days' worth of emergency mental health care, make sure 
we stabilize the crisis, and get them into longer-term 
treatment, if that is what is required.
    So far, we have treated, and have come to us for help, 
3,200 veterans with other-than-honorable discharge. We were 
actually hoping the numbers are higher.
    Senator Tillis. Over what period of time?
    Secretary Shulkin. Since we started this. I think it was 
one of the early things I did as Secretary, so I would say 10 
months ago, maybe.
    Senator Tillis. OK.
    Secretary Shulkin. We are actually hoping the numbers would 
get higher, so we continue to get that message out, that if you 
are a veteran with that type of other-than-honorable discharge 
and you need help, please come; we are going to help you.
    Senator Tillis. Now what happens if you get somebody to 
maybe a stable----
    Secretary Shulkin. Yep.
    Senator Tillis [continuing]. Position, and you improve 
their condition. This is emergency mental health benefit. What 
next? Let us say they get sick, and it does not relate to the 
mental health illness.
    Secretary Shulkin. Right. Oh, when it does not relate to 
the mental health illness.
    Senator Tillis. Yeah.
    Secretary Shulkin. Well, we have not extended a general 
health benefit. That is something that we would be glad to work 
with you or other Members of Congress on. That would be 
something that we would have to work on legislatively. I do not 
feel I have the authority to be able to do that.
    Senator Tillis. I did not think you did.
    Secretary Shulkin. Yeah.
    Senator Tillis. We had a hearing in the Personnel 
Subcommittee for Senate Armed Services and it was focused on 
concussions----
    Senator Manchin. Mm-hmm.
    Senator Tillis [continuing]. And more data that we are 
getting, that at least could make you argue that perhaps 
discharges, in some cases, for bad behavior, actually related 
to----
    Secretary Shulkin. Mm-hmm.
    Senator Tillis [continuing]. Other circumstances. So, I 
think this is a good step----
    Secretary Shulkin. Mm-hmm.
    Senator Tillis [continuing]. Because the first thing is to 
try to stem any real tide of suicides----
    Secretary Shulkin. Yeah.
    Senator Tillis [continuing]. Through the emergency mental 
health service. But, I think we need to talk more about----
    Secretary Shulkin. Mm-hmm.
    Senator Tillis [continuing]. How we would manage this, and 
consider the full life cycle. What we talked about, there are 
the probabilities this sort of job that a man or woman did in 
the military were exposed to events that now the science 
suggests could have actually had an impact on their mental 
faculties or perhaps behaviors that led to their discharge.
    Secretary Shulkin. Mm-hmm.
    Senator Tillis. That would be something I would like to 
talk with you more about.
    And maybe you could just give me a quick update on--I know 
the medical health record project is going to go through phases 
and take a while to get done, but it looks like you are using a 
template similar to the DOD, and you have got resources in 
there. So, in that case, just tell me what we could do to help 
you, because I think that is a very important project that we 
want to see to conclusion. And you need to make sure you tell 
us when we set a new priority that potentially taps your 
ability to deliver on some of the commitments you are making.
    But what about other--you mentioned in your opening 
comments----
    Secretary Shulkin. Mm-hmm.
    Senator Tillis [continuing]. About, do you still feel like 
you are making incremental----
    Secretary Shulkin. Mm-hmm.
    Senator Tillis [continuing]. Not breakthrough things. What 
are we likely to see from you, to get from some of the 
incremental that needs to be done? But, you know, what are the 
breakthrough things that you are looking at that may actually 
require our help to get it moving?
    Secretary Shulkin. Well, I think what I am doing is trying 
to put out there that we need those breakthrough ideas, and I 
want to see an opportunity to get those ideas from you, as well 
as our veteran advocacy groups, like veteran service 
organizations and others who have those ideas. I think they can 
come in many different ways. They could come technologically, 
they could come through management practices, or they could 
come through policy and legislation.
    We have seen some of them, legislatively, that I think this 
Committee has been in the lead during this past year, like 
appeals modernization. That is going to make a difference. I 
think--and I have said this--that we need to reorganize the way 
that we do business at VA, from having a large central 
bureaucracy to being able to give people in the field more 
authority and accountability, which goes along that way. And, 
we need to change some of our management practices that, 
frankly, have grown stale.
    What is happening in the private sector on health care and 
technology is the type of transformation that I think needs to 
happen within government as well, and we are going to need to 
do that collaboratively.
    Senator Tillis. Thank you. Thank you, Mr. Chair.
    Chairman Isakson. Thank you, Senator Tillis.
    Senator Blumenthal.

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

    Senator Blumenthal. Thank you, Mr. Chairman. Thank you, Dr. 
Shulkin, and thank you to the men and women of the VA for all 
of their extraordinary, dedicated work.
    I am going to be sending you, today, a letter that cites 
the need for stronger protections to the post-9/11 veterans 
under the Post-9/11 GI Bill benefits. I raised this issue with 
you during your confirmation hearings in January of last year.
    It has been almost a year--in fact, on February 13 it will 
be a year since your confirmation--and, quite honestly, I am 
deeply dissatisfied with the lack of action under existing 
authority, 38 U.S. Code, Section 3696, to crack down on the 
predatory practices of for-profit schools, like Corinthian and 
ITT, that have exploited our veterans. This letter sets forth, 
in detail, what those actions have been and why I think that 
the lack of action by the VA has been troubling. I know that 
you are sympathetic to this cause, but I would like to see good 
words followed by action, and I will appreciate a response to 
my letter. I ask that it be made part of the record, Mr. 
Chairman.
    Chairman Isakson. I am sorry.
    Senator Blumenthal. I am asking that my letter to Secretary 
Shulkin, of today, be made a part of the record.
    Chairman Isakson. Without objection.
    [The letter follows:]

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]   

    Senator Blumenthal. I want to focus right now on a deeply 
troubling, in fact, appalling incident in West Haven. I am sure 
you are aware of it by now. The West Haven VA has been sued by 
a veteran who is alleging apparently a truly egregious act of 
malpractice. The veteran claims that a scalpel was left in his 
abdomen during a 2013 surgery and it was discovered only after 
years of pain and dizziness. It was removed in April 2017, 
after an MRI by the VA.
    On June 6, 2017, the veteran said that he initiated an 
administrative claim under the Federal Tort Claims Act, 
regarding this case of medical negligence. Over 6 months later, 
the VA has still not responded, incredibly, to the claim, 
beyond a simple acknowledgement of its receipt. So, the veteran 
has now filed suit in Federal court.
    My first question to you is, is the Department 
investigating these specific allegations?
    Secretary Shulkin. Yes. Yes. First, on this case, I think 
the way that you characterized it is accurate. It is an event 
that should never happen, and I am deeply sorry that any 
veteran should have to undergo this.
    Of course, this was inadvertent on the surgeon's part. When 
the surgeon discovered this, he, who is extraordinarily well 
trained, on the Yale faculty, practices not only at the VA but 
at Yale New Haven Hospital, went to the veteran with the 
Chairman of Surgery at the VA, and acknowledged their mistake 
and apologized and takes responsibility for it.
    While this is an extremely rare event, it happens in the 
country 1,500 times a year. In the VA it does happen. It 
happened 12 times in the VA. That is a rate, in the VA, much 
less than what happens outside the VA. That is no excuse. This 
should never happen. We are looking and a root cause analysis 
has been done. It has actually been presented at the Yale New 
Haven Mortality and Morbidity Conference so that this could be 
evaluated by peers who are surgical peers across the Yale New 
Haven system.
    So we do acknowledge responsibility for this. This veteran 
has suffered enough. Fortunately, his first surgery, which was 
done, was a successful surgery, but he should not have to go 
through any more hassle in being acknowledged for what 
happened, and we will take responsibility for that.
    Senator Blumenthal. Part of taking responsibility is to 
acknowledge and act on his claim----
    Secretary Shulkin. Absolutely.
    Senator Blumenthal [continuing]. And to, in fact, respond 
positively to the request that he made for relief, under the 
Federal Tort Claims Act----
    Secretary Shulkin. I agree with that.
    Senator Blumenthal [continuing]. Administrative procedure. 
It does not require any court proceeding.
    Secretary Shulkin. Yes.
    Senator Blumenthal. The VA has an administrative and moral 
responsibility to respond, and I am disappointed that it has 
not done so. Will you commit to doing so?
    Secretary Shulkin. Everything you are saying, I share your 
sentiments, and absolutely, we will commit to that.
    Senator Blumenthal. I know, because of your own background, 
professionally, as head of the University of Pennsylvania 
medical system and other positions that you note, you are----
    Secretary Shulkin. Sure.
    Senator Blumenthal [continuing]. Very, very attentive to 
the standards of professional responsibility. I would also like 
a commitment that the VA protocol and practices will be 
reviewed so that, in fact, this incident can be a teaching 
moment.
    Secretary Shulkin. You have that commitment. Patient safety 
is my passion. I personally spoke to the Chairman of Surgery at 
the West Haven VA. I know that she, and this surgeon, have 
taken this extremely seriously and are using this for the way 
that you and I both believe we should learn. The VA does have a 
practice across the VA system for x-rays to be done in some 
high-risk cases. We are re-evaluating whether we should be 
doing more on top of that, because these events should never 
happen. We are going to be committed to making it a safer 
environment.

    [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Richard 
 Blumenthal to Hon. David J. Shulkin, M.D., Secretary, U.S. Department 
                          of Veterans Affairs
    Please act on the administrative claim from the Connecticut Veteran 
who had a scalpel left in his abdomen after a surgery at VA.
    Response. The Department has acted on the claim and it is currently 
pending litigation.

    Senator Blumenthal. I appreciate your being so 
forthcoming----
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal [continuing]. And I am going to follow 
up----
    Secretary Shulkin. Yes.
    Senator Blumenthal [continuing]. And stay on it----
    Secretary Shulkin. Thank you.
    Senator Blumenthal [continuing]. Banking on you----
    Secretary Shulkin. Yes.
    Senator Blumenthal [continuing]. Because I know you are 
committed to it.
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal. I have seen the x-ray----
    Secretary Shulkin. Yes, so have I.
    Senator Blumenthal [continuing]. Showing the scalpel, and, 
frankly, I was appalled and stunned----
    Secretary Shulkin. Sure.
    Senator Blumenthal [continuing]. And surprised and grateful 
that this veteran is still alive.
    Secretary Shulkin. Yes.
    Senator Blumenthal. Thank you for your responses to my 
question.
    Secretary Shulkin. OK. Thank you, sir.

    [Information on operating room directives at VA follows:]
    Response to Request Arising During the Hearing by Hon. Richard 
 Blumenthal to Hon. David J. Shulkin, M.D., Secretary, U.S. Department 
                          of Veterans Affairs
    Please review the patient safety protocols as a result of a scalpel 
left inside a Connecticut Veteran following a surgery at VA.
    Response. Directive 1103, Prevention of Retained Surgical Items, 
provides policy to prevent incidents of surgical items being retained 
in a patient following surgery. It is VHA policy that the surgical team 
must apply a standard approach to the prevention of retained surgical 
items when the operative procedure being performed is one in which 
there is any possibility for retention of a surgical item. This 
standard approach/patient safety protocols have been reviewed. This 
policy provides clear direction and guidance for Operating Room staff 
regarding the required responsibilities and actions. A copy of the 
directive is attached for your reference.
                               attachment

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


    Senator Blumenthal. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Blumenthal.
    Senator Heller.

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

    Senator Heller. Mr. Chairman, thank you. Thank you for 
holding this hearing and I want to thank the Secretary for 
being here also. I think this Committee has done a great job 
and I want to thank both you and the Ranking Member. I think we 
have passed out of Committee, I think, in this session, 10 
pieces of legislation, some of which have been mine and all of 
them have contained my priorities.
    I just want to tell both of you I really do appreciate 
being part of this Committee, and for the leadership that we 
have this Committee has passed, legislation, for example, that 
have already been mentioned, like the GI Bill for life, access 
to STEM programs in education, which was also mentioned, also 
the appeals process for faster disability claims efforts. I 
want to thank you, Mr. Secretary, for your hard work and effort 
on that, but clearly the work is not over. This Committee has 
probably already shared that with you a few times.
    Secretary Shulkin. Mm-hmm.
    Senator Heller. You are getting to your first-year 
anniversary. I actually believe it is February 14. I do not 
know what you will be doing on February 14, but that will be 
your 1-year anniversary. How do you like the job? Tell me. We 
have had several discussions and I know you have been with the 
VA for a while, but not in the capacity as the Secretary. How 
was your first year? How do you feel about the work that is 
progressing?
    Secretary Shulkin. You know, Senator, look. First of all, 
it is an honor and a privilege to be able to serve our 
veterans. That is why I am here. I am a tough grader. I am a 
tough grader on myself and my staff, and I am impatient. I know 
all of you are too. There is a lot of work to be done and we 
have to make more progress, and we are going to stick with it 
to be able to do that.
    But, I do believe a lot of the credit goes to you and to 
the House, who is also doing good work on their side, to be 
able to make the progress that we are making, but I think we 
can all do better.
    Senator Heller. I appreciate your visits to my State, which 
has been very, very helpful to the 300,000 veterans that we 
have in the State of Nevada. Now I happened to be traveling 
around a little bit last weekend----
    Secretary Shulkin. Mm-hmm.
    Senator Heller [continuing]. In some of the rural portions, 
where they have expressed some concerns. Probably the one that 
caught my attention the most--and, frankly, for that matter, my 
staff--was the cancellation of the----
    Secretary Shulkin. Yes.
    Senator Heller [continuing]. Community Care Network----
    Secretary Shulkin. Yeah.
    Senator Heller [continuing]. For Region 4. For those who do 
not know, Region 4 is quite a big region. The Ranking Member is 
in that region, as is Nevada, but so is Alaska, Hawaii, and 
California. We can go down the list but it is quite the region.
    Can you explain to me----
    Secretary Shulkin. Yeah.
    Senator Heller [continuing]. What the situation is and why 
my staff and congressional offices did not hear about this? We 
found out on Friday.
    Secretary Shulkin. Yeah.
    Senator Heller. I do not know if it was out earlier than 
that, but we found out on Friday.
    Secretary Shulkin. Yeah. Yeah. I also found out last week 
too. The Federal contracting process is a complex process, one 
that is difficult sometimes to understand. It is designed to 
keep the people that run the business, like myself, out of 
negotiating these contracts. That is why I found out the same 
week that you did.
    In this case, we divided the country up into four regions. 
This was hopefully our first award in Region 4. So, I am 
disappointed that we were not able to award it, as well.
    I will tell you the reason why we were not able to award it 
is because our contracting officers did not believe that it was 
in the interest of taxpayers to proceed with that contract. 
That means they did not believe that they should be paying the 
price that was being bid out there. They did not feel it was 
reasonable.
    This is going to be rebid, and we hope--and we have spoken 
to those that have bid--that they will bid again, because we 
believe that the quality of the contractors were there. It just 
was not--we were not able to reach something that made sense 
for the taxpayers.
    Senator Heller. So, it is my understanding that the 
competitive process has been closed down. Is that correct?
    Secretary Shulkin. Yes, we have put it--yes.
    Senator Heller. So, what does it mean short term, for 
someone who lives in Elko or Ely or Eureka, for these veterans 
who have to travel long distances, of course, to get health 
care if they are not provided in their communities?
    Secretary Shulkin. Well, we are talking about, right now, 
your veterans are being served by a third-party administrator 
that runs many of the aspects of the Choice program, and that 
will continue. We think that that contractor right now is doing 
a good job, improving its service to your veterans. We have 
been in direct contact about issues and they have been very 
responsive about fixing them.
    So, business as usual. It will continue to be to serve the 
veterans. I know the contractor currently is committed to that. 
We hope to have a competitive rebid process that will result in 
a good outcome for veterans, contractors, but, importantly, the 
taxpayers.
    Senator Heller. Mr. Secretary, my time has run out but I 
again want to thank you, again, for coming to the State----
    Secretary Shulkin. Mm-hmm.
    Senator Heller [continuing]. Spending time with our 
veterans, your accessibility, your understanding of the issues 
and problems we have, and willingness to work to improve the 
issues that we have in front of us. I think this Community Care 
contract is one of them----
    Secretary Shulkin. Mm-hmm.
    Senator Heller [continuing]. And I look forward to working 
with you, trying to solve this particular problem.
    Secretary Shulkin. Thank you.
    Senator Heller. Thank you.
    Secretary Shulkin. Thank you very much.
    Senator Heller. Mr. Chairman.
    Chairman Isakson. Thank you, Senator Heller.
    Senator Hirono.

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

    Senator Hirono. Thank you, Mr. Chairman. The fact that the 
VA has a large number of vacancies throughout the country, and 
not just in Montana but also in Hawaii, and you were given 
tools--VA was given tools to make the hiring process work a lot 
more efficiently, and yet we seem to be continuously behind the 
8-ball.
    So, have you put your finger on why it is so hard? I 
realize there are, you know, a lack of certain kinds of medical 
professionals, et cetera, if that is the overall problem. Are 
there additional tools that we can give the VA to enable you to 
hire the necessary people?
    Secretary Shulkin. Well, yes, I do think that there is more 
we can do, but let me--Senator, let me tell you. Last year, we 
actually made progress. We have a net increase of 8,303 
employees. We hired close to 40,000 but it is a net increase of 
8,303.
    Senator Hirono. Mm-hmm.
    Secretary Shulkin. But, we know where we have critical 
vacancies, and that is where we want to move toward a direct 
hire authority that Senator Tester had talked about.
    Senator Hirono. Mm-hmm.
    Secretary Shulkin. OPM has been very helpful to us and 
indicated their support in doing that. There is this technical 
fix that we talked about, that will help us implement your 
intent last year, when you gave us direct hire authority for 
medical center directors and network directors.
    Senator Hirono. Do you need additional tools?
    Secretary Shulkin. We do. We do. We want to continue to--
right now we have three hiring authorities that we have to hire 
employees under--it is complicated--Title 5, Title 38, and a 
hybrid system. And the more that we can move, for our health 
care employees, toward a Title 38, it makes the process faster 
and more competitive with the private sector.
    Senator Hirono. So, is that going to take legislation?
    Secretary Shulkin. It is something that I think we have the 
authority to do ourselves, and that is what we are moving 
toward. But we have come to you in the past for help. You have 
always helped us with that, and we will continue to ask you if 
we need additional help.
    Senator Hirono. Well, please let us know.
    Secretary Shulkin. Yes.
    Senator Hirono. Because I know, for a fact, that in Hawaii 
we have something like 166 medical staff vacancies that need to 
be addressed.
    Last week, the White House released an Executive order 
supporting our veterans during their transition to civilian 
life, and ensuring access to mental health care and suicide 
prevention, which you had talked about, as a priority. So, one 
of the provisions calls for access for veterans to receive 
mental health care, and I want to know whether you have enough 
mental health care professionals. What do you plan to do to 
devote additional resources to recruit and retain mental health 
professionals, because I assume that is one of your shortage 
categories.
    Secretary Shulkin. Right. Right. Well, first of all, thank 
you for acknowledging the Executive order, because if you look 
at any group that is at high risk for suicide it is that 12-
month period from transition.
    Senator Hirono. Yes.
    Secretary Shulkin. So, this is targeted to providing every 
single transitioning servicemember with a mental health 
benefit. I think that is critically important.
    In order to do that, VA does need more mental health 
professionals. You know, Senator Tester certainly made this 
point as well. We have identified a need for 1,000 mental 
health professionals. Unfortunately, the country at large----
    Senator Hirono. Yes.
    Secretary Shulkin [continuing]. Has a shortage of mental 
health professionals, so this is going to be difficult. But, we 
are committed to increasing the number of trainees in mental 
health residency programs. We work very hard with nurses, 
social workers, as well as psychologists and psychiatrists, to 
train as many as we can. We want to do more. We will continue 
to use efforts like our recruitment bonuses and to acknowledge 
that VA is actually a terrific place to work if you are a 
mental health professional. Hawaii would be a great place to 
be.
    Senator Hirono. Yes. So----
    Secretary Shulkin. So, we are going to do whatever we can.
    Senator Hirono. Thank you. I want to discuss the IG report 
that showed overpayments and payment errors in the Choice 
program. Since I am running out of time, clearly, we need to be 
assured that you are taking the appropriate steps to make sure 
that you have processes in place so that these kinds of 
overpayments and erroneous payments are not occurring.
    Secretary Shulkin. Yes.
    Senator Hirono. So, I need your assurance that you are 
doing that.
    Turning to homelessness, your predecessor made a commitment 
that he would end veteran homelessness, and as mentioned by 
Senator Manchin, we seem to be going in the wrong direction 
here, particularly with regard to women veterans who are 
homeless. Why is it that we are heading in the wrong direction 
and what are you doing about it? By the way, where is ending 
homelessness in your order of priorities for the VA?
    Secretary Shulkin. Well, the commitment to ending veteran 
homelessness I think you correctly said was made in 2010, and 
we absolutely are committed to that. We will not back down from 
that goal, and we will continue to drive to do everything we 
can to end veteran homelessness. So, there is the same firm 
commitment.
    What I have said is because of this last year, where we 
actually went up 2 percent, we have to rethink our effort. Any 
good business looks at what they are doing and says ``if there 
is a better way to do it, we should.'' So, we are going to come 
out with a new approach that doubles down on the things that 
are working and maybe uses resources from things that are not 
working as well.
    Here is what we know is working, and I will tell you what 
is not working. When veterans get jobs, it keeps them in 
sustainable housing.
    Senator Hirono. Mm-hmm.
    Secretary Shulkin. It helps in so many ways. So, we are 
going to re-double down on working with employers around the 
country to find our homeless veterans and train them and get 
them jobs. Number 2, the HUD-VASH voucher program works really 
well.
    Senator Hirono. Mm-hmm.
    Secretary Shulkin. We want to continue that partnership 
with HUD, and we look toward areas--Hawaii is one, but Los 
Angeles and Seattle too--where the--with the current value of 
the HUD-VASH voucher, we cannot find people who want to rent us 
apartments.
    Senator Hirono. Yeah.
    Secretary Shulkin. So, we have to continue to increase the 
value of that, which we are working on.
    We have a shortage of affordable housing units, so we need 
to partner with construction people and landlords, and actually 
create more inventory of low-inventory housing, so that is 
going to work. We also need more community partnerships. We 
just--because VA cannot do this alone. HUD cannot do this 
alone. This is a country-wide commitment.
    So, we are going to double down on the things that work and 
we are going to come out with a fresh, new approach here. We 
would like to work with you on this, because I am not satisfied 
with the progress we are making.
    Senator Hirono. Yeah, and let us know how that is going, 
especially Hawaii which has, per capita, the highest number of 
veteran homeless in the entire country.
    Secretary Shulkin. The housing market there, you know, it 
is so expensive. So, thank you.
    Chairman Isakson. Senator Cassidy.

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

    Senator Cassidy. Hello, Secretary Shulkin, how are you?
    Secretary Shulkin. Hey.
    Senator Cassidy. A lot of what I am going to be asking you 
today references a Newsweek article written in October of last 
year, authored by Mr. Levine. Are you familiar with it?
    Secretary Shulkin. Yes.
    Senator Cassidy [continuing]. The article is about how the 
VA fueled the national opioid crisis and is killing thousands 
of veterans.
    Secretary Shulkin. Yeah.
    Senator Cassidy. As you might guess from the title, it is 
critical of VA.
    Secretary Shulkin. Yes.
    Senator Cassidy. So, I heard today, or read, that you have 
now published facility-specific statistics regarding those 
prescriptions.
    Secretary Shulkin. Yes.
    Senator Cassidy. I have been interested in this data, in 
terms of applying to the VA, and knowing facility specificity. 
However, we have had challenges receiving the data requested 
and expect to receive it shortly. The article addresses 
Huntington, WV, where the local VA prescribes take-home opiates 
to roughly 18 percent of its patients, a rate that is 230 
percent higher than the national average, for all adult male 
patients.
    I have not looked at the statistics you referenced earlier, 
but does this VA still prescribe a rate that exceeds the 
national average by 230 percent?
    Secretary Shulkin. What we published now, and, Senator 
Cassidy, I hope you will appreciate this, no other system has 
ever published this data. We are hoping that they will join us, 
because we believe, like you, that this is how you get better, 
by sharing your data and understanding it.
    What you will see, for every single one of our VA 
facilities, not only what the rate is now but what it was in 
2012, and whether they have made improvements. Every single 
site, except for one, has made improvements in their 
prescribing rates in opioids. The one that did not may be 
somewhat unique. It is in the Philippines. It is Manila. But 
every domestic site in the VA has made improvements. Some made 
a lot more than others, and that is where we hope that they are 
going to learn from each other.
    I do not recall Huntington, WV's, improvement rate but I 
know it has improved.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Bill Cassidy to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Are 18 VA state programs not reporting prescribing data with PDMPs, 
is this still the case?
    Response. 48 states and the District of Columbia are activated for 
PDMP data transmission, receiving data from the VA.
    Missouri just recently established a statewide PDMP by executive 
order. Nebraska's program has transitioned to Appriss Health's PMP 
AWARxE and work is underway to initiate transmissions; the state is 
working to implement FIPS 140-2 cryptography required for Federal data 
sharing.

    Senator Cassidy. Got it. Another issue which I asked about 
last time is if the VA is sharing its prescribing data with the 
PDMPs?
    Secretary Shulkin. Yes.
    Senator Cassidy [continuing]. The article by Mr. Levine 
states that by the end of last year, 2016, 18 State VA 
healthcare programs were still not reporting to the State 
PDMPs. Is that still the case, now that we are a year out from 
this?
    Secretary Shulkin. I do not believe that that is the case 
anymore. I am going to want to confirm with you that we are in 
100 percent compliance, because that is our commitment. If we 
are not in 100 percent compliance, I am going to want to know 
about that, because we have committed to that and we should be.
    Senator Cassidy. Thank you. The article also suggests that 
VistA, your electronic medical record program, is incapable of 
flagging drug interactions between benzodiazepines like Valium, 
and opioids, and details--gives anecdotes of people who are 
given polypharmacy with Ritalin along with everything in every 
class, as well as one patient who got 130 morphine tabs. Yes, 
it is very disturbing. Why would a veteran patient get so much?
    Is VistA capable of flagging this? Are the pharmacy 
programs incapable of seeing these drug interactions and 
flagging them?
    Secretary Shulkin. We do measure and follow the statistics 
on patients who are on both benzodiazepines and opioids, 
because of the danger. I am not able to tell you right now. We 
do have drug interactions that come up on VistA. I see them 
when I use VistA. I am not able to tell you why we would not be 
able to do that.
    Senator Cassidy. The pharmacist is quoted in this article.
    Secretary Shulkin. Yeah. Yeah.
    Senator Cassidy [continuing]. The pharmacist said that it, 
VistA, does not flag it.
    Secretary Shulkin. Yeah.
    Senator Cassidy. And he, apparently, testified to that 
under oath.
    Secretary Shulkin. Yes. Again, I just do not know the 
answer to that. I would like to--and I would be glad to confirm 
with you, very shortly, whether that is the case or not or 
whether that has been fixed. I do not know a technological 
reason why we would not be able to do it, but----
    Senator Cassidy. OK.
    Secretary Shulkin [continuing]. I may not understand it.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Bill Cassidy to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Is VISTA incapable of flagging drug interactions?
    Response. VISTA is capable of generating drug interaction checks.

    Senator Cassidy. Let me ask, you have mentioned how many 
fewer patients are now prescribed opioids.
    Secretary Shulkin. Yes.
    Senator Cassidy [continuing]. If the opioid dosing is going 
down, does the VA have any spot checks as to how many veterans 
have gone from receiving prescription opioids to perhaps 
seeking out illicit sources of opioids? Have we just had an 
apparent victory or is it documented to be a real victory?
    Secretary Shulkin. Yeah. I do not know what they are doing 
illicitly. I mean, we just do not have a way of tracking that.
    Senator Cassidy. Do we have, for example, drug screens of 
patients that theoretically have been taken off of opioids, but 
a drug screen might show that they are still taking?
    Secretary Shulkin. Right. Those that return and had been 
started on opioids sign a patient informed consent that says 
that we will do the urine screening. We do the urine screenings 
and we report on that, in terms of general statistics. But, if 
a veteran does not return to us, we do not have any way of 
tracking that.
    Senator Cassidy. Do we have any sense of the number or the 
percent of opioid overdoses in people whom, theoretically, are 
no longer taking opioids?
    Secretary Shulkin. That is a good question. I have never 
seen the statistic reported that way. We do track Narcan use, 
and we distribute a lot of Narcan. That hopefully would be a 
measure of people who have overdosed that we have been able to 
resuscitate. But, I have never seen the data broken down in the 
way that you have asked.
    Senator Cassidy. I think that would be helpful.
    Secretary Shulkin. Yeah.
    Senator Cassidy. It would be helpful to the Committee, 
because it would provide critical information----
    Secretary Shulkin. Yeah.
    Senator Cassidy [continuing]. On whether or not we really 
are making progress to end the opioid crisis.
    Secretary Shulkin. Yeah.
    Senator Cassidy. We need to know whether it is more 
apparent than real.

    [The information requested during the hearing follows:]
Response to Requests Arising During the Hearing by Hon. Bill Cassidy to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    1. Does VA screen those patients who were taken off of prescribed 
opioids for illicit drug use?
     Secretary Shulkin responded that there was screening and 
that VA could provide a report on the results.
    Response. Patients on opioid therapy for chronic pain receive 
annual urine drug testing (OSI metric, 89 percent as of Q1fy18). 
Patients on opioid agonist treatment for opioid use disorder receive 
quarterly urine drug testing (sud 17 SAIL metric, currently 94.3%).
    All other urine drug testing is at provider discretion based on 
clinical presentation.

    2. Does VA have statistics on opioid deaths from those Veterans who 
were not prescribed opioids?
    Response. The latest cause of death data available is FY 2014. The 
following table includes the statistics related to Veteran overdose 
deaths that year, and whether those patients received an outpatient VA 
prescription for an opioid analgesic in the year of their death. Note 
that overdoses were not restricted to overdoses involving opioids, but 
instead include all accidental and intentional overdoses on any drug or 
substance. The cohort of VHA users includes all persons using VHA 
services since 2000; users may not have used VHA health care in FY 
2014.

 
----------------------------------------------------------------------------------------------------------------
                                                                                              VHA Users who did
                                                                       VHA Users receiving     not receive an
                                                                         an outpatient VA   outpatient VA opioid
  Cause of death among VHA users that died in FY2014    All VHA users    opioid analgesic         analgesic
                                                                         prescription in       prescription in
                                                                              FY2014               FY2014
----------------------------------------------------------------------------------------------------------------
Any overdose mentioned in cause of death information.          2,193                  801                 1,392
----------------------------------------------------------------------------------------------------------------


    Senator Cassidy. Finally, is the VA using medication-
assisted therapy for those who are addicted?
    Secretary Shulkin. Yes. Suboxone and other medication-
assisted treatment. We are seeing a rise in that, and certainly 
we are keeping up with the contemporary literature on that.
    Senator Cassidy. Correct. A rise could be from a very small 
baseline----
    Secretary Shulkin. Yeah.
    Senator Cassidy [continuing]. Which could still be very 
small. Can you perhaps submit, for the record, the percent of 
patients whom you think have opioid addictions----
    Secretary Shulkin. Yeah.
    Senator Cassidy [continuing]. To include disuse orders, and 
how many have been transitioned, et cetera?
    Secretary Shulkin. Yeah. I would be glad to get you those 
statistics. My impression is--although I have not looked at 
this in detail recently--that your representation is probably 
correct, starting from a small baseline, beginning to use it 
more, probably still underutilized, and an opportunity for us 
to do better.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Bill Cassidy to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Percentage of patients who were transitioned from opioids
     Secretary Shulkin noted that this is done but that it was 
probably ``underutilized''
     Can VA provide what it currently is doing and/or what it 
will do track this for the future?
    Response. As of 4thQFy17, VA serves 6.29 million Unique Patients. 
(Source: VSSC VHA Pocket Card https://securereports2.vssc.med.va.gov/
ReportServer/Pages/ 
ReportViewer.aspx?%2fMgmtReports%2fPocketCard%2fPocketCard&rs:Command= 
Render)
    A subset of the Unique Patient population is the number of Veterans 
receiving opioid prescriptions dispensed through the VA pharmacies. As 
of Q4Fy17, 418,895 patients are receiving opioids; this is 260,481 
fewer patients or a 38 percent reduction than when the data was 
benchmarked in Q4Fy17. The latest data for patients receiving opioids 
is Q1FY 2018 in which 398,899 Veterans received opioids, a 41% 
reduction. Both quarter's data are included to allow a comparison to 
the VSSC data. These reductions represent the number of patients that 
have been transitioned from opioids.
    VA currently reports on the Opioid dispensing data on the website 
https://www. data.va.gov/story/department-veterans-affairs-opioid-
prescribing-data. This data will continue to be tracked and updated on 
the website semi-annually. The website additionally includes regional 
comparison data to CMS reports on opioid prescribing rates by state.
                         additional information
    After reviewing the hearing recording it appeared Senator Cassidy 
(at time 1:17) was interested in Medication Assisted Treatment. Quote 
from hearing ``he asks ``is the VA using medication assisted treatment 
for addiction.'' In response to this question VHA is providing the 
following additional information:

Medication Assisted Treatment for Opioid Use Disorders

    VHA has responded to growing demand for opioid use disorder 
treatment by increasing access to Medication-Assisted Treatment (MAT). 
MAT includes counseling or psychotherapy, close patient monitoring, and 
medication using buprenorphine/naloxone, methadone (administered 
through an Opioid Treatment Program), or extended-release injectable 
naltrexone. Buprenorphine/naloxone and extended-release injectable 
naltrexone are on the VHA National formulary. These are available at 
VHA facilities and through non-VA purchased care options in the 
community. Methadone is administered and dispensed through 32 VHA 
Opioid Treatment Programs across the Nation and through non-VA 
purchased care options at many facilities.
    VHA has been expanding access to MAT for patients with opioid use 
disorders. In the year ending in FY17Q4, VA treated 24,069 patients 
with MAT, up from 19,333 patients in the year ending in FY14Q4, a 24% 
increase in patients treated in just 3 years. This expansion is the 
result of a comprehensive and integrated approach. The Buprenorphine in 
VA Initiative provides clinician education through monthly webinars, 
newsletters, a SharePoint with educational resources, individual 
consultations, and a national community of practice supported by an e-
mail group. The Psychotropic Drug Safety Initiative (PDSI) combines use 
of informatics tools, action planning, and a national quality 
improvement collaborative to improve the evidence-based use of 
psychotropic medications. One of the PDSI program's many impacts has 
been significantly increased rates of using medication assisted 
treatment among Veterans with Opioid Use Disorder. In addition, VA 
Pharmacy's Academic Detailing service is developing an Opioid Use 
Disorder campaign using informatics tools and individual provider 
support to increase Veteran access to MAT.
    VHA offers several medication assisted treatments for opioid use 
disorder. Opioid Agonist Treatment includes prescription of methadone 
or buprenorphine delivered either in a licensed clinic or office-based 
setting. Opioid Antagonist Treatment includes prescription of 
injectable depot naltrexone. Only opioid agonist treatment was tracked 
until FY 2014.

 
------------------------------------------------------------------------
                                                            Number of
                                          Number of       patients that
                                        patients that    received Opioid
                Year                   received Opioid     Agonist or
                                           Agonist         Antagonist
                                          Treatment         Treatment
------------------------------------------------------------------------
FY 2006                                     8,091                NC
------------------------------------------------------------------------
FY 2007                                     8,581                NC
------------------------------------------------------------------------
FY 2008                                     9,694                NC
------------------------------------------------------------------------
FY 2009                                    10,564                NC
------------------------------------------------------------------------
FY 2010                                    11,887                NC
------------------------------------------------------------------------
FY 2011                                    13,493                NC
------------------------------------------------------------------------
FY 2012                                    14,412                NC
------------------------------------------------------------------------
FY 2013                                    16,306                NC
------------------------------------------------------------------------
FY 2014                                    17,575            19,333
------------------------------------------------------------------------
FY 2015                                    19,971            21,915
------------------------------------------------------------------------
FY 2016                                    22,103            22,606
------------------------------------------------------------------------
FY 2017                                    23,406            24,069
------------------------------------------------------------------------

    Senator Cassidy. I yield back. I apologize for going over 
my time.
    Chairman Isakson. Senator Murray.

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

    Senator Murray. Thank you very much, Mr. Chairman. Mr. 
Secretary, thank you for being here today.
    Last year, the Department tried to quietly take money away 
from some really essential programs--HUD-VASH, childcare, 
treatment for women veterans--and move the money to general 
purpose accounts where it could be spent on literally anything. 
Meanwhile, over the last year, you have come to us repeatedly, 
sometimes with just days or weeks left, saying VA will run out 
of funding for the Choice program earlier than expected.
    The Department has to start being transparent with 
Congress--it has to--about its budget needs and not keep 
raiding critical programs to cover these shortfalls; to give 
us, finally, a realistic picture of Community Care spending. 
Those are really basic expectations--how much you are spending 
and to ask for what you really need.
    I wanted to ask you today, will there be any changes in how 
VA manages its business operations, or is it time to consider a 
new approach to these functions?
    Secretary Shulkin. Well, first of all, I think those are 
fair criticisms, and I have to take responsibility for some of 
the observations that you have. I will tell you that there is 
no desire to do anything underhanded or hide things. This is a 
system where we are trying to do so much so fast that we are 
obviously making some mistakes, and we have to do better at 
that.
    So, let me just address things. First of all, the 
projections on the Choice program, financial projections, are 
very, very complex to do, largely because--not only, but 
largely because of this issue that we hope to get fixed, with 
your Committee's bill, that we have to obligate the money at 
the time that we order the service, not when it was rendered. 
So, it is a little bit of a guessing game that makes financial 
projections hard.
    But, we are doing better. We projected that the money which 
was left in the Choice program before you renewed it, right 
before the break, was going to run out the first or second week 
in January. It ran out the first or second week in January. You 
gave us $2.1 billion. Today we have $2 billion left, which 
means we have spent $100 million already of what you gave us.
    So, I think we are getting better. We have a brand-new CFO 
who was just confirmed, thanks to you, in the last 2 weeks. 
But, it is a hard job to do it, and we are never going to be 
totally accurate unless we get some of these rules changed.
    On this issue of us doing something like taking money away 
from HUD-VASH vouchers or women's services, it was absolutely 
never, never our intent to spend less money for women's 
services or HUD-VASH or mental health, or anything else. Here 
was our intent, which I stopped because of the reason that you 
said--it was not accurately being rolled out or communicated. 
So, it is not happening now. But, let me just tell you what my 
intent was, because if you disagree with it, I would like to 
talk to you.
    Right now, everything is controlled out of Washington, out 
of a central office. We tell people across the field, this is 
how much you get and this is where you need to spend it. My 
idea of management is, you let the people closer to where you 
are serving the veteran be more involved in how they should 
spend their money, and they have to be accountable for the 
results--treating more women veterans, getting more homeless 
veterans off the street. You allow them to understand what is 
better in Seattle versus what is better in Honolulu.
    I was trying to advocate a management philosophy that has 
worked for me that I believe in. It was not rolled out well, so 
I stopped it. But, we are going to think about how to make this 
system work better--that was in my opening statement. We need 
to do more. We need to do better, and I am going to continue to 
try to do it. I am going to commit--we are going to do a better 
job of being transparent and collaborative with you, because--
--
    Senator Murray. OK. Well, that is what we will be watching.
    Secretary Shulkin. I got it. That is fair.
    Senator Murray. So, you know, we have had a rough year, but 
that is what we will be watching for.
    Secretary Shulkin. That is fair.
    Senator Murray. Let me move to another topic. An Inspector 
General report from December found in six of seven medical 
centers it reviewed primary care provider panels were 
significantly below required levels, and that VHA did not 
provide oversight of that requirement. That resulted in 
decreased access for our veterans, and hundreds of millions of 
dollars of waste in appointments that were not filled.
    That report also found, once again, that VA's reported wait 
times are misleading, and in this case, by the IG's 
calculation, more than half of the newly-enrolling veterans 
waited longer than 30 days for their first appointment.
    Another IG report found that the Eastern Colorado Health 
Care System is still keeping secret waiting lists for group 
mental health care therapy. And finally, according to VA data 
from November, there are more than 35,500 vacancies in VHA.
    Those are senior-level shortcomings across the system that 
end up with reducing access to our veterans for care and 
wasting taxpayer dollars. So, I just want to know, who is 
accountable here?
    Secretary Shulkin. Well, I am accountable, but--and there 
is no but about the accountability--the statistics that you are 
reporting--and this is not being defensive; I just want you to 
understand what they are. The 35,000 vacancies. We have 370,000 
employees. That makes a 9 percent vacancy rate, which is not 
overly high. So, you are always going to have 40,000 vacancies 
during the course of the year. The 35,000 are part of that 
turnover rate, and as I already mentioned, we had a net gain of 
8,303 employees last year. So, we are not only keeping up----
    Senator Murray. OK. But we have got secret waiting lists 
for group mental health care, wait times. This is all from the 
IG. I am not making this up.
    Secretary Shulkin. No. No, I have got it. We have a big 
system. Secret wait times, we have clearly said to all of our 
leadership are not to occur, not acceptable. If we find them, 
there are disciplinary actions.
    In Colorado, I think that this was one clinic, and it was--
I believe, and I may stand corrected--I believe that the 
facility actually identified that and dealt with that issue. 
So, that was there. It was dealt with. It was a deviation that 
is not acceptable. This is not representative of what is 
happening across the country.
    Wait times we continue to struggle with. We have made 
progress, there is no doubt, The data says we have made 
progress, but we are not anywhere near where we need to be.
    Senator Murray. No, we are not.
    Secretary Shulkin. I agree. and we are working on it. We 
are making progress every day. What we have indicated--our 
progress in is in matching clinical urgency and need to access.
    Senator Murray. OK, well----
    Secretary Shulkin. But--yeah.
    Senator Murray [continuing]. This goes back to my original 
question. We need you to tell us how much you are spending----
    Secretary Shulkin. Yes.
    Senator Murray [continuing]. And what you are asking us for 
these veterans.
    Secretary Shulkin. Yes.
    Senator Murray. We need to know that.
    Secretary Shulkin. Yep.
    Senator Murray. OK.
    Secretary Shulkin. Thank you.
    Chairman Isakson. Senator Sullivan is recognized for the 
patience-of-Job award.

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

    Senator Sullivan. Thank you, Mr. Chairman. Mr. Secretary, 
good to see you. I am going to start with just some thanks and 
kudos to you and your team. We finally passed out of the 
Committee here the Serving Our Rural Veterans Act, which was 
Senator Tester and I's bill, but you were kind of the 
brainstorm on that when you and I were in Alaska. So, your team 
and I--we all worked together well on that. Hopefully we get 
that across the Senate floor. So, I want to thank you for 
really helping inspire the idea and having the team.
    I also want to thank you, Dr. Ballard. Alaska is doing a 
great job.
    Secretary Shulkin. Good.
    Senator Sullivan. We have added over 100 employees----
    Secretary Shulkin. Mm-hmm.
    Senator Sullivan [continuing]. Including two docs, at the 
CBOC in the Mat-Su Valley----
    Secretary Shulkin. Wow.
    Senator Sullivan [continuing]. Which has been--we have not 
had a doctor there in 5 years.
    Secretary Shulkin. I am impressed. That is great.
    Senator Sullivan. It was kind of the crisis situation that 
Senator Tester was talking about. We filled it. I know you had 
a focus on that, so I appreciate that.
    I was in the Kenai Peninsula yesterday with some 
constituents, actually having coffee; been doing a lot of that. 
One of them asked me, ``Hey, what are we doing, Senator, on 
suicide?'' From, you know, an older gentleman, just really 
concerned. I talked about the Clay Hunt Suicide Prevention Act. 
I talked about some of the other issues. So, could you 
literally talk to this constituent right now and say, ``Hey, 
here is what else we are focusing on?'' Because I know you are 
focused a lot, but sometimes it does not always get out, and I 
thought, you know, having the Secretary here to answer----
    Secretary Shulkin. Yeah.
    Senator Sullivan [continuing]. A constituent of mine would 
be beneficial.
    Secretary Shulkin. Yeah. Real briefly, last week the 
President signed an Executive Order where 100 percent of 
transitioning servicemembers are going to have a mental health 
benefit for 12 months.
    Senator Sullivan. Right.
    Secretary Shulkin. We have expanded mental health services, 
emergency services, for those that are other-than-honorable. We 
are making sure our Veterans Crisis Line is being answered--now 
less than 1 percent of dropped calls and the calls answered 
within 11 seconds. We are adding 1,000 mental health 
professionals. We have offered same-day services for mental 
health in any one of our facilities where people present.
    We are using predictive analytics, and a program called 
Reach Vet to identify those at highest risk by going out and 
actually contacting them, then bringing them in. We are using 
community partnerships like Give an Hour and the Cohen Veterans 
Network as a way to supplement the types of services available 
to our veterans. Our Vet Centers are open for walk-in services. 
We can see family members as well as veterans, to be able to 
help them. We are also looking at a number of other things that 
can help reduce this crisis, quite frankly.
    Senator Sullivan. Well, thank you for that. I know the 
Committee is very interested. We have a lot of bipartisan 
support on that.
    Let me ask another, you know, Senator Hirono talked about 
homelessness, and I know we are all focused on it. Probably one 
of the best ways to deal with homelessness is grow the economy, 
and I think the administration deserves credit and a lot of 
kudos on that, right? We are probably going to have a fourth 
quarter of last year that is probably going to be another 
really strong 3 percent, maybe even 4 percent GDP growth, 
right?
    Secretary Shulkin. Yep.
    Senator Sullivan. I mean, we have not grown like that in 
over a decade.
    Secretary Shulkin. Yep.
    Senator Sullivan. I mean, there is a lot the VA can do, but 
if you do not have a strong economy, you are going to have more 
homelessness. So, I commend the administration for its focus on 
that.
    Let me turn to an Alaska-specific issue. You know the 
uniqueness of our State. You have been up there, and I look 
forward to getting you up there again, as the Secretary. But, 
the VA central office has made a policy call which would change 
the reimbursement rates for military partnerships to be in line 
with Medicare rates, and this would have a very negative impact 
on our VA partnerships with some of our DOD partners, the 673rd 
Medical Group there at Joint Base Elmendof-Richardson.
    Can you commit to me to make sure that you are taking 
feedback from all local VAs--you know how unique many of them 
are throughout the State--and ensure that they understand the 
kind of ramifications of this policy change? As you know, in 
this country of ours, one size never fits all. What works in 
Alaska does not work in Connecticut or other places, and vice 
versa. So, can you just make sure--can I get your commitment on 
this issue before there is some kind of big change? You will 
look at it for the ramifications in Alaska and other places, 
plus get feedback from leaders, like Dr. Ballard and others, 
before you guys make kind of a one-size-fits-all call, which my 
folks back home are saying would be very negative, at least in 
terms of Alaska?
    Secretary Shulkin. Absolutely. I think you have always been 
effective at describing the situation in Alaska and other parts 
of the country that need different types of programs in it, and 
we certainly are open to that feedback. We will reach out to 
you to make sure that we are connecting with the people you 
think we should connect with.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Dan Sullivan to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Prior to making any changes please commit to receive feedback from 
local VA facilities regarding the ramifications of the VACO policy that 
would change the reimbursement rates of military partnerships to be in 
line with Medicare rates.
    Response. The Department will solicit feedback prior to making 
changes.

    Senator Sullivan. Great. I appreciate that.
    This is just really more of a comment. I know, earlier in 
the hearing, you talked about, and the Chairman asked about 
making sure that we get the other Senate-appointed--or 
Presidential-appointed, Senate-confirmed positions.
    Secretary Shulkin. Yeah.
    Senator Sullivan. You know, we need to get those from you. 
I would ask my colleagues on this side of the aisle, on the 
other side of the aisle, though, none of the games, right? We 
have had historic records of just holding up nominees for no 
other reason than to just hold them up on the other side.
    So, you guys get them out and I ask my colleagues here, no 
footsies with these nominees. Let us get them confirmed, let us 
get them going. We do not need 40 hours of debate on some of 
these. They are not going to be controversial. Delays and 
delays and delays on, you know, Senate, or Presidential-
appointed nominees, particularly as it relates to the VA----
    Secretary Shulkin. Right.
    Senator Sullivan [continuing]. Would be a shame. So, we 
want to work with you on that, and I certainly hope everybody 
on this Committee wants to do that.
    Secretary Shulkin. Senator, yes. I do not think you were 
here when I said I think we have the best Committee in the 
Senate. We have not seen any of those games. You guys have done 
everything that we have asked. We owe you the nominees, and 
then I am sure----
    Senator Sullivan. I agree with that.
    Secretary Shulkin [continuing]. That you will do your job.
    Senator Sullivan. Good point on the Committee.
    Secretary Shulkin. Yeah. Yeah.
    Senator Sullivan. Those games do not occur on this 
Committee.
    Secretary Shulkin. Yeah.
    Senator Sullivan. The games occur on the floor of the 
Senate, where this administration's nominees----
    Secretary Shulkin. Yeah.
    Senator Sullivan [continuing]. Have been----
    [Overlapping speakers.]
    Secretary Shulkin. Fortunately, not with VA.
    Senator Sullivan [continuing]. Delayed in ways----
    Secretary Shulkin. Right.
    Senator Sullivan [continuing]. That have been unfortunately 
historic----
    Secretary Shulkin. Yeah.
    Senator Sullivan [continuing]. And should not happen at 
all, but it definitely should not happen with nominees to go 
fill senior VA positions.
    Secretary Shulkin. That is right. Thank you.
    Senator Sullivan. All right. Thank you. Thank you, Mr. 
Chairman.
    Chairman Isakson. Thank you very much for your service, and 
thank you. By the way, I will point out our Secretary was the 
only Cabinet member who was unanimously approved in his 
nomination and confirmation, which is a testimony to him and 
the job the VA is doing.
    I think Senator Blumenthal and Senator Tester have another 
question or two. I would ask that they be as brief as possible 
and succinct, to get to the point.
    Who wants to be first?
    Senator Tester. Go ahead, Senator Blumenthal. Go ahead.
    Chairman Isakson. Senator Blumenthal.
    Senator Blumenthal. Thank you very much, Mr. Chairman, and 
thank you for spending the extra time with us and being so 
forthcoming in your responses.
    I want to come back to some of the questions that have been 
asked about the vacancies----
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal [continuing]. And the 9 percent turnover 
that you described.
    Secretary Shulkin. Yes.
    Senator Blumenthal. Has the composition of that turnover, 
or the vacancies, changed at all? In other words, are there 
more positions? Are they more psychiatrists? I know we have 
talked about the difficulty of recruiting people, in 
particular, specialty providers to the VA.
    Secretary Shulkin. They do and they change by location. In 
Montana, our biggest vacancy is physician assistants, a 36 
percent vacancy rate. We have about 15 occupations that we see 
as critically hard to hire right now. They are the ones that we 
have gone to OPM, Office of Personnel Management, for direct 
hire authority, that they are working with us on. We have 
difficulty--we have 2,428 vacancies for physicians right now. 
Last year we had a net gain of 266. So, while we are making an 
improvement, it is only about 10 percent of the improvement we 
need. We have 5,507 nurse vacancies right now. Last year we had 
a gain of 1,494. Nursing assistants, we have 1,268 open, and 
they vary by region.
    So, that is how we recruit by region. We had a recruitment 
problem in Little Rock last year, where we were desperately 
short of nurses. We had a hiring fair where we hired 87 nurses 
in a single day. So, we are approaching this by a regional 
effort, but the most important part is for us to know where our 
shortages are, and we do have that data.
    Senator Blumenthal. I also want to ask about the education 
issue that I mentioned.
    Secretary Shulkin. Mm-hmm. Yeah.
    Senator Blumenthal. Could you give me some idea of what 
action has been taken----
    Secretary Shulkin. Yeah.
    Senator Blumenthal [continuing]. What is the plan, and so 
forth?
    Secretary Shulkin. Yeah. So, the biggest thing that we have 
done--and I really think you got it right. I do want to do 
something on this. I think that there is an issue, and I know 
you believe that too. We have put caution flags up on our 
comparison tool for veterans. Meaning when a veteran goes to 
our education site and looks at what their options are, there 
are actually caution flags for deceptive marketing and some of 
the other practices. We do about 5,000 compliance visits a year 
to these schools, and where we find concerns, the way that I 
know you have them, we actually share that information with our 
veterans.
    Now a lot of veterans still go on and choose to enroll in 
those schools, and as long as they have a State accreditation 
our current policy is that we will continue to pay for that. We 
have been battling, sometimes publicly, with schools that have 
struggled with their State accreditations, and we are trying to 
hold firm to protecting veterans and doing the right thing.
    Do I think we can do more? I do, and would look forward to 
working with you on that.
    Senator Blumenthal. I would welcome that work.
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal. To be absolutely frank, I have been 
unhappy----
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal [continuing]. With some of the laggard 
and lacking action on the part of the Department of Education--
--
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal [continuing]. Which has much bigger 
impact on these practices and predatory actions of for-profit 
schools around the country. So, I very much welcome your 
dedication to this cause.
    Secretary Shulkin. Yes.
    Senator Blumenthal. Thank you.
    Secretary Shulkin. Thank you.
    Senator Blumenthal. Thanks, Mr. Chairman.
    Chairman Isakson. Thank you. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman, and thank you for 
being here, Secretary Shulkin. I would just add on to Senator 
Sullivan's comments that you continue to put forth good people, 
some of which are behind you, that we have confirmed. We will 
continue to get them out of this Committee as quickly as 
possible. I will put pressure on my side of the aisle to get 
them through the Senate as soon as possible. We have not done 
that here, but you have put forth good candidates, which I 
think is the key.
    Look, I have an editorial comment very quickly. Timing for 
the allocation of dollars for services for the new Community 
Care program is in the Caring for Our Veterans Act. The fix to 
the medical director hiring provision that we talked about----
    Secretary Shulkin. Yeah.
    Senator Tester [continuing]. When they did the first round 
is in the----
    Secretary Shulkin. Yes, it is.
    Senator Tester [continuing]. Caring for Our Veterans Act. 
The Serving Rural Veterans Act that you worked hard on with 
Senator Sullivan is in the Caring for Our Veterans Act. We 
talked about the shortage of docs nationwide, the 1,500 
residency slots are in the Caring for Our Veterans Act. Yet, a 
number of another reasons why we hope to get your support of 
this bill publicly, because I think this bill would have been 
passed already----
    Secretary Shulkin. Yes.
    Senator Tester [continuing]. If we could have gotten you on 
board.
    Secretary Shulkin. Yes.
    Senator Tester. Look, I do not want to be hardcore about 
this, but I am going to be hardcore about this. I would really 
like to get a list of about five specific things that the VA 
central office is going to do above and beyond what you are 
currently doing to address the clinical vacancies in our State. 
My staff says they wanted it done by the end of the week but it 
is already Wednesday. Could you get that to me in a week?
    Secretary Shulkin. Yes.
    Senator Tester. Perfect.
    Secretary Shulkin. Yes.
    Senator Tester. You know, I sent out for online questions 
for you----
    Secretary Shulkin. Yeah.
    Senator Tester [continuing]. And I think it is important.
    Secretary Shulkin. Your Facebook page.
    Senator Tester. Yes. We got a bunch of excellent questions, 
but I just picked this one. What have you done to remove the 
barriers for women's health care and how are you responding to 
veterans with MST?
    Secretary Shulkin. Well, I believe that we have done a lot 
to remove barriers for women's health care, but we have a lot 
more to do. One of the things that we are doing is we are 
continuing to train more providers in specialty-specific 
practices to care for women veterans, so that we can expand our 
access. So, I believe we are holding a conference in the very 
near future in Orlando to train another 332 VA providers in 
women-specific care, in which they will be certified to be able 
to go out to expand practices throughout the country. I think 
that is critical. We continue to look at sites that are not 
providing women's health care clinics, and making sure that 
they are developing them as well.
    Women are our fastest-growing demographic.
    Senator Tester. Yep.
    Secretary Shulkin. We know our culture has not 
traditionally been as sensitive to them as needed. That is why 
we have FACA, a Federal advisory committee, telling us how we 
can do a better job for women veterans. We are listening to 
their advice. We have a director at the Center for Women 
Veterans and we are trying to do as much as we can. If you 
think that there is more we can do, or you--anybody is making 
suggestions, please let us know.
    Senator Tester. We will do that, and thank you for that.
    One last thing. We talked about opioids. It is a huge 
problem, and we all know it is a huge problem. Within the VA, 
outside the VA, it is a problem. I know that Attorney General 
Sessions has said no more marijuana. It is going to be nowhere. 
Montana is one of those States that said it would legalize it 
for medical purposes.
    Look, I am not enamored with the crap--I will just tell you 
that--but the VA is a big dog, OK?
    Secretary Shulkin. Mm-hmm.
    Senator Tester. If marijuana helps people that have chronic 
pain, we ought to be doing research on it, and you guys do the 
research.
    Secretary Shulkin. Yep.
    Senator Tester. I know you came out with a statement that 
said no more research.
    Secretary Shulkin. No. Actually, let me clarify that.
    Senator Tester. Perfect. I want to hear the clarification.
    Secretary Shulkin. OK. OK. What I said is that, first of 
all, VA has done research on marijuana----
    Senator Tester. Yeah.
    Secretary Shulkin [continuing]. But it has not been 
dispensing marijuana and testing its impact.
    Senator Tester. Yes.
    Secretary Shulkin. It has been observational, or, let us 
say, for data analysis.
    Senator Tester. Right.
    Secretary Shulkin. VA can do research on marijuana, but I 
said that we are restricted, because it is a Class 1 substance, 
so we have to go through multiple agencies, and it is very 
challenging to work our way through that process. We do have 
the ability to do it. I have said I am in favor of exploring 
anything that will help our veterans and be able to relieve 
some of their suffering.
    So, it is challenging to get through that process. Our 
researchers are working through that process right now. If 
Congress made it easier to go through the process it would 
probably happen faster.
    Senator Tester. Well, I would just tell you this. Look, I 
do not have chronic pain. I know people that do. I do not care 
if it is marijuana or sagebrush or thistle or cactus. I do not 
give a damn so long as it helps them.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. Especially when we are fighting the opioid 
crisis----
    Secretary Shulkin. Yes.
    Senator Tester [continuing]. We are today, we ought to be 
doing research to make sure it is real. That is all.
    Secretary Shulkin. I agree.
    Senator Tester. Thank you, Mr. Chairman, for your 
flexibility.
    Chairman Isakson. Thank you, Senator Tester. I appreciate 
your contribution and the contribution of all Committee 
Members.
    I want to wish Gretchan Blum the very best in her wishes, 
and thank you very much for what you have done for the 
Committee and our veterans.
    I thank all of you who came here today, particularly our 
VSO representatives who will be heard from at great length in 
February, when we have the VSO meetings, which we appreciate.
    The record will be kept open for 7 days for any Member who 
would like to include their written statement or ask questions 
for the record, or any other comments we might want to have.
    We have a long to-do list, a lot of things to do. This is a 
hearing to reflect on what we talked about and we wanted to do, 
the bills we passed to cause it to happen, and now the 
accountability phase, where, not just at this meeting, but 
every year we want to analyze where we have been and where we 
are going. Hopefully, we are always improving the services to 
our veterans, lessening, wherever possible, the cost to our 
taxpayers, but most importantly, making sure we pay back those 
who have given so much to our country, the veterans of the 
United States of America.
    With that said, is there any other business to come before 
the Committee? My staff--have I forgotten anything?
    We are good. This meeting is adjourned. Thank you.
    [Whereupon, at 3:46 p.m., the Committee was adjourned.]
 Response to Posthearing Questions Submitted by Hon. Johnny Isakson to 
                  U.S. Department of Veterans Affairs
    Question 1. I have consistently said that efforts to overhaul VA's 
appeals process must include efforts to address the over 470,000 
existing appeals. In VA's Comprehensive Plan for Processing Legacy 
Appeals and Implementing the Modernized Appeals System that was 
submitted to Congress in November 2017, it states that VA plans to 
allocate resources to establish ``timely processing in the new system 
and will allocate all remaining appeals resources to address the 
inventory of legacy appeals.''
    a. What does ``timely processing'' mean and what are VA's specific 
goals?
    Response. VA has committed to an average processing time goal of 
125 days to complete higher-level reviews and supplemental claims under 
the new appeals process, and 365 days to complete appeals to the Board 
of Veterans' Appeals (Board) in which there is no additional evidence 
and no request for a hearing. The Board is working collaboratively with 
the Veterans Benefits Administration (VBA), VA Program Management 
Professionals, and US Digital Service (USDS) on establishing timeliness 
goals for the remaining two dockets in the new process. VA will 
continue to gather data and conduct trend analyses on aspects of 
Veterans' behavior, to include their decision to elect to participate 
in the new process, the distribution of elections among the new process 
lanes, claims processing timeliness, and individual employee 
productivity. The Rapid Appeals Modernization Program (RAMP) test 
program will provide better data and trend analysis for capacity 
modeling the resources needed for these other dockets prior to the 
implementation date. The Board will use the actual data obtained 
regarding appellant behavior in the new system to assist in developing 
future resource requirements as part of the annual budget process.
    The 2017 Government Accountability Office report recommended that 
VA conduct additional sensitivity analyses of its forecast modeling to 
more accurately estimate future appeals inventories, timeliness, and 
cost factors. VA has developed a more robust, scalable model that 
allows for the recommended analysis. The model may serve several 
specific purposes, to include:

     Estimating the legacy inventory remaining as 
implementation of appeals modernization approaches;
     Determining the impact of the claim disagreement rate on 
the new system inventory;
     Determining the distribution of resources given Veterans' 
choices among new system lanes;
     Determining the efficiency of the new process and the 
allocation of resources based on estimated employee productivity rates 
across the various new system decision review and appeal lanes; and
     Adjusting, as needed, resources required to eliminate the 
legacy inventory as quickly as possible, while also meeting established 
timeliness goals in the new system.

    VA will continue to verify and validate the model to ensure the 
accuracy of its outputs and its utility in VA's appeals modernization 
forecasting.
    Besides forecast modeling, the Board will also continue to refine 
and improve its process model to capture additional changes aimed at 
improving the timeliness of appeals under the new system.

    b. Does VA have timeliness goals for the inventory of legacy 
appeals?
    Response. VA tracks appeals processing goals under certain cycle 
measures. These measures track both inventory and timeliness at stages 
in the appeals process. As noted in VA's May 2017 Annual Performance 
Plan and Report, among the appeals measures that VA tracks are the 
following: Notice of Disagreement (NODs) pending inventory, NODs 
average days pending, Substantive Appeals to the Board (Form 9) pending 
inventory, Substantive Appeals to the Board (Form 9) average days to 
complete, and Substantive Appeals to the Board (Form 9) average days 
pending. For a listing of all appeals measures, to include Board 
measures, that VA tracks, please see the full report, available at 
https://www.va.gov/budget/docs/VAapprFY2018.pdf.
    While VA tracks appeals processing goals under certain cycle 
measures, VA is unable to set a realistic and comprehensive timeliness 
goal that measures legacy appeals processing from the date the appeal 
is filed to when it is finally resolved. This is because appeals in the 
current legacy process has no defined endpoint and can cycle through 
various steps, several times, before moving to the next phase in the 
process. The current multi-step process is too inefficient; splits 
jurisdiction for processing appeals between the agency of original 
jurisdiction and the Board; and features an open record and ongoing 
duty to assist. As a result, the continuous evidence gathering and 
readjudication prolong the ability to reach a final decision.
    The rate at which the legacy appeals inventory can be resolved is 
dependent on a number of factors and variables, including funding made 
available to appeals processing through the annual budget 
appropriations process in future years and the rate of election of 
claimants with legacy appeals pending who opt-in to the new process.
    The Board is working with program management staff and Digital 
Service partners to develop milestones for the reduction of the legacy 
inventory, considering such dependencies as the opt-in rate from RAMP 
and statutory mechanisms, current resource levels, trends in 
adjudication of legacy appeals at the agencies of original 
jurisdiction, and increases in productivity resulting from the 
strategies discussed above.

    c. Does VA plan to prioritize new appeals over legacy appeals?
    Response. No. VA's goal is to eliminate the inventory of legacy 
appeals as quickly as possible while also maintaining timely processing 
in the new system. The opt-in features, whereby Veterans with a pending 
legacy appeal can elect to participate in the new process, will assist 
VA in accomplishing that goal.
    The Board is working with Digital Services partners to ensure that 
Caseflow functionality includes the ability to continuously adjust the 
case distribution ratio between all Board dockets based on actual data. 
Adjusting the case distribution ratio will allow the Board to meet its 
365-day average processing time goal for cases on the direct docket, 
while ensuring fair treatment of legacy appeals and appeals on the new 
system's hearing and evidence dockets by distributing cases from the 
other dockets proportionate to the scale of each docket's inventory.

    Question 2. VA began a Rapid Appeals Modernization Program (RAMP) 
to pilot parts of the new Appeals system and to work on the existing 
appeals backlog.
    a. Under RAMP, what specific parts of the new appeals process is VA 
testing?
    Response. RAMP will assist the Department in testing a number of 
elements of the Veterans Appeals Improvement and Modernization Act of 
2017 (Modernization Act). The initiative, which was launched on 
November 1, 2017, allows eligible participants with disability 
compensation appeals pending with VBA the voluntary option to have 
their decisions reviewed in the higher-level review or supplemental 
claim lanes outlined in the Modernization Act. RAMP gives Veterans 
early access to the benefits of the new system, while also allowing VA 
to better position itself for full implementation in February 2019.
    During RAMP, and with feedback from Veterans, Veterans Service 
Organizations (VSOs), and congressional stakeholders, VA is testing the 
new process from intake to issuance of a decision. This includes 
testing the election opt-in notice, the new decision notice that meets 
the requirements outlined in the statute, as well as internal standard 
operating procedures. In addition, VA is testing information technology 
solutions for managing Veterans' opt-in elections and capturing duty to 
assist error data identified during higher-level reviews. During this 
program, VA will gather data and conduct trend analyses on aspects of 
Veterans' behavior, to include their decision to elect to participate 
in the new process, the distribution of elections among the new process 
lanes, and individual employee productivity. In addition, the data will 
inform VA as to appropriate work credit, workload and resource capacity 
estimates, as well as processing timeliness and quality metrics for the 
new process.

    b. What lessons have been learned so far?
    Response. Although it is still too early in the process to glean 
any meaningful lessons learned, to date, VA has seen lower than 
expected opt-in rates from Veterans. That is in part because VA 
initially extended the invitation to participate in RAMP to Veterans 
who have the oldest appeals pending and may have reservations in 
participating in the new process. As a result, VA is currently 
reassessing its outreach and marketing campaign regarding RAMP. Also, 
starting in February 2018, VA will open up the elections to newer 
appeals, and will work with VSOs in reviewing processes that will allow 
Veterans to opt-in at a faster rate.

    c. When will this pilot program conclude?
    Response. VA plans to invite most Veterans with pending legacy 
appeals to participate in RAMP by February 2019 when it fully 
implements the Modernization Act.

    d. Why has VA decided to not pilot RAMP at the Board of Veterans 
Appeals and test all aspects of the system?
    Response. Currently, Veterans who receive a RAMP decision have the 
option of appealing to the Board by filing a NOD. In October 2018, the 
Board will begin adjudicating the first of these appeals in a phased 
implementation to test processes and technology. Implementing RAMP will 
allow the Board to identify and address potential issues and risks 
relating to implementation of the new framework.

    e. To date how many individuals with legacy appeals have opted in 
to RAMP?
    Response. As of May 14, 2018, 15,645 individuals, with a total of 
19,208 legacy appeals pending, have opted to participate in RAMP.

    f. Are there any concerns that RAMP may not be an adequate solution 
to drive down the pending legacy appeal inventory?
    Response. VA believes it is too early to conclude that RAMP is not 
an adequate solution. Since the inception of RAMP, in November 2017, 
15,645 individuals, with 19,208 appeals have decided to opt in to RAMP. 
In addition, the earlier requirement that Veterans need to be 
``invited'' into RAMP was removed on April 2, 2018, and now any 
eligible Veteran with a pending disability compensation appeal can 
choose to opt in to RAMP, and benefit from the faster review process. 
RAMP allows Veterans and appellants with pending disability 
compensation appeals not yet activated at the Board the choice for 
early resolution of their appeals at VBA. RAMP provides Veterans and 
appellants the choice to opt into the benefits of the new appeals 
framework and will reduce the number of appeals under the current, 
legacy system. Thus, VA is working closely with VSOs, and external 
stakeholders to encourage participation in RAMP. VA's legacy reduction 
plan includes RAMP and initiatives to improve appeals production.

    g. Are there other solutions VA is looking at?
    Response. VA is working with its VSO partners in assessing ways to 
increase individual RAMP opt-in rates. In addition, VA is continuously 
evaluating ways to increase efficiencies. For instance, VBA is 
considering plans to consolidate processing of all remands at the 
Appeals Resource Center. The Board is completing its hiring plan in 
fiscal year (FY) 2018, seeking opportunities to enhance training and 
employee engagement for all staff, and working with a VA Program 
Management team and IT/Digital Service staff to re-engineer processes 
and implement technological upgrades promoting increased decision 
production. The Board is already seeing positive results from our 
multi-faceted approach to reducing the pending legacy inventory. To 
date in FY 2018, the Board has signed 24,468 decisions, which is an 
increase of 13,073 signed decisions over the same time period in FY 
2017. VA will consider recommendations of the Committee.

    Question 3. Under the new Appeals Act, Congress deliberately gave 
VA the flexibility to take the needed amount of time to get the new 
system right, but also gave the Secretary the responsibility for 
signing off that the new system is ready before it fully replaces the 
existing system.
    a. Although it is still early in the implementation process, does 
VA anticipate launching the new system in February 2019 or taking more 
time?
    Response. VA anticipates launching the new appeals system in 
February 2019.

    b. What specific indicators will you look for when deciding to move 
ahead or take more time?
    Response. VA will look at the following indicators when assessing 
its readiness for full implementation:

     Status of the rulemaking: If public comments prompt 
extensive revisions to draft regulations, VA may need more time to make 
the revisions, gain stakeholder buy-in, and complete the approval 
process.
     Lessons learned from processing of higher-level reviews 
and supplemental claims in RAMP: Should VA's experience in RAMP 
indicate significant problems with the new processes and/or systems, VA 
could potentially require more time to resolve these issues. However, 
VA does not anticipate encountering any significant issues.
     Status of IT systems development: If VA encounters 
unanticipated delays in updating IT systems to support the new appeals 
framework, VA may require more time to implement. However, at this 
time, VA anticipates that the updates will be completed on time. The 
Board has established timelines for development of necessary IT 
systems, training and hiring of personnel, and publication of 
regulations, among other dependencies. The Board is working with a VA 
Program Manager to ensure that all dependencies are on track for full 
implementation. In particular, the Board's progress in the areas of IT 
systems, training, and publication of regulations will serve as strong 
indicators as to VA's readiness to implement the new system.

    Question 4. The Accountability and Whistleblower Protection Act 
gave VA authority to remove unsuitable employees and authority for 
direct hire of some critical positions.
    a. What metric does VA use to determine how well it is doing at 
removing unsuitable employees? What are those numbers currently?
    Response. These are the two metrics that appear in the VA 2020-2024 
Strategic Plan that will be used to measure VA compliance with the 
Accountability and Whistleblower Protection Act. We have not performed 
analysis based on these metrics. Performance-based action will be taken 
against all proven poor performers within 90 days of substantiation of 
poor performance. Appropriate disciplinary or adverse action will be 
initiated against all employees within 90 days of substantiation of 
misconduct.

    b. How many employees has VA fired in 2017? How many of those were 
allowed to retire or resign? How many were terminated during an initial 
probationary period?
    Response. There were 1,582 removals between June 23 and 
December 31, 2017. Of these, 960 were removals of regular employees and 
622 were terminations of probationary employees.

    c. How many employees has VA hired under its new direct hire 
authority for Veterans Integrated Service Networks (VISNs) and medical 
center directors?
    Response. In September 2017, VA hired one Medical Center Director 
(Shreveport, Louisiana) using direct hire authority. No VISN Directors 
were hired using the direct hire authority.

    Question 5. What direct outreach has VA done to inform school 
certifying officials about changes enacted in the Forever GI Bill? What 
future plans does VA have for direct outreach to this group?
    Response. On November 29, 2017, VA's Education Service conducted a 
School Certifying Official (SCO) webinar on the Forever GI Bill and 
provided information on our progress toward implementation. The webinar 
also included a question and answer session in which Education Service 
responded to questions from SCOs. VA sent targeted emails to SCOs on 
the removal of the delimiting date for eligible beneficiaries and the 
expansion of approvable Independent Study programs. In early 
February 2018, Education Service held a focus group with stakeholders 
including SCOs on its implementation plan for Section 107, and will 
continue to engage with SCOs through regularly scheduled webinars, 
targeted emails, state, regional, national conferences and serve as 
resource to SCOs as they educate students at their facility on the 
Forever GI Bill.

    Question 6. How does VA plan to fill the role of Deputy Under 
Secretary for Economic Opportunity in the Veterans Benefits 
Administration and what is your timeline for noticing the position and 
reviewing candidates?
    Response. In response to Executive Order 13781 and the Office of 
Management and Budget (OMB) Directive M-17-22, VA has a comprehensive 
modernization effort underway. While VA is continuing its efforts to 
modernize its infrastructure and focus resources more efficiently, we 
must evaluate the position and responsibilities of the Deputy Under 
Secretary for Economic Opportunity (DUSEO) in accordance with our 
modernization goals.
    VBA has a newly appointed Under Secretary for Benefits, Dr. Paul R. 
Lawrence. One of his top priorities is providing Veterans with the 
benefits they have earned in a manner that honors their service. Under 
his leadership, VBA is taking a comprehensive look at the layers of 
oversight and organizational alignment to determine the most effective 
and efficient manner to oversee the delivery of timely and accurate 
benefits. To ensure continuity of operations and appropriate support, 
the business lines that fall under the Office of Economic Opportunity 
are reporting directly to the Principal Deputy Under Secretary for 
Benefits.

    Question 7. Do you expect any changes to the role of the Deputy 
Under Secretary for Economic Opportunity or any significant changes to 
the Office of Economic Opportunity?
    Response. VBA is currently evaluating the role of the Deputy Under 
Secretaries. As neither the Deputy Under Secretary for Economic 
Opportunity or the Deputy Under Secretary for Disability Assistance are 
encumbered at this time, all business lines that previously reported 
those Deputy Under Secretaries are reporting directly to the Principal 
Deputy Under Secretary for Benefits. This allows the business line 
leaders direct access to top leadership. We will continue to assess if 
this type of oversight is sustainable long-term and make adjustments to 
positions and/or roles and responsibilities as necessary.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                  U.S. Department of Veterans Affairs
    Question 8. I made it quite clear that I thought the Federal hiring 
freeze was a bad decision for the President to make, but even after 
that concluded, you've made the decision to continue a hiring freeze of 
sorts at VA. Do you still believe that is the right decision, and do 
you intend to continue it?
    Response. Consistent with OMB Memorandum M-17-22, effective 
April 26, 2017, VA removed hiring restrictions for field positions 
located in the Veterans Health Administration's medical facilities (for 
medical and non-medical positions), and for VBA regional and field 
offices. The National Cemetery Administration had no restrictions, and 
that remained unchanged. Hiring restrictions were also removed for the 
following Executive level positions: Medical Center Directors; Network 
Directors; Cemetery Directors; and VBA Regional Office Directors. This 
allowed the Administrations to fill the positions they determined as 
necessary to meet mission requirements.
    Although the hiring freeze was lifted, the Secretary did direct 
that managers be deliberative in the hiring actions taken to ensure VA 
is postured for success as we implement overall Modernization efforts 
and reform plans, in accordance with OMB Memorandum M-17-22, that 
improve and ensure the more efficient and effective delivery of 
services to Veterans, while identifying opportunities to reduce 
duplication or overlap. To this end, VA maintains a process that 
requires a thorough review before hiring all other positions outside of 
those listed in the preceding paragraph. Hiring for all other positions 
in the Administrations requires the appropriate Under Secretary level 
approval. Recruitment for positions at VA's Central Office and all 
other Executive level hiring requires approval by the VA Chief of 
Staff.

    Question 9. Last month, a VA official testified at HVAC that the 
hiring freeze made it difficult for VA to keep up with purchasing 
needed medical equipment. We also heard this month that the 
administration's hiring freeze played a significant role in USDA 
pulling out of the agreement to support VA's financial management 
business transformation. In addition to these instances, do you believe 
that veterans or programs serving veterans were harmed by the hiring 
freeze?
    Response. As referenced in the response to Question 8, VA leaders 
are authorized to fill the positions they determine are necessary to 
meet mission requirements. While hiring managers are expected to obtain 
approval at the appropriate level in their chain of command prior to 
filling certain positions (non-medical/clinical positions), this should 
not have an adverse impact on the delivery of services to Veterans.

    Question 10. The latest data from VA shows that in your continuing 
hiring freeze, there are: 100 non-exempt vacancies in Human Resources, 
and more than 2,700 non-exempt vacancies in VHA.
    a. How many of those VHA vacancies are within VHA's workforce 
management or human resources office?
    Response. As referenced in the response to Question 8, VA leaders 
are authorized to fill the positions they determine are necessary to 
meet mission requirements. This includes H.R. positions across VHA. 
While hiring managers are expected to obtain approval at the 
appropriate level in their chain of command prior to filling certain 
positions, VHA's Workforce Management and Consulting (WMC) Office has 
been successful in getting approval to fill critical H.R. vacancies.

    b. Do you believe addressing vacancies of positions that focus on 
recruitment and retention would help address ongoing hiring challenges?
    Response. Generally, the filling of H.R. vacancies can impact the 
organization's ability to recruit and retain employees. It is 
imperative that H.R. departments have the necessary staffing for its 
organization in order to help mitigate overall hiring challenges. WMC 
has submitted its vacancies for hiring exemption waivers and they have 
been approved. As referenced in Question 8, the Under Secretary is 
authorized to approve hiring for vacant positions that are necessary to 
meet mission requirements. That includes vacant H.R. positions that are 
required to support critical hiring needs.
    Additionally, on January 24, 2018, the Office of Personnel 
Management approved VA's request for Direct Hire Authority (DHA) for 15 
occupations. H.R. Specialists (GS-201 series) and H.R. Assistants (GS-
203 series) are included on the list occupations approved for DHA. This 
will assist the VA in filling these mission critical positions.

    Question 11. Nearly two years ago, the National Academy of Medicine 
released its final Agent Orange update, recommending three new 
presumptions of service connection for Bladder Cancer, Hyperthyroidism, 
and Parkinson-like conditions. I wrote to you in September with some 
colleagues and asked for a decision from VA. In November you released a 
statement stating your intent to ``explore new presumptive 
conditions.'' Given the length of time since the National Academy of 
Medicine released their recommendations, when can we expect these 
veterans to be able to receive the health care and compensation they 
earned?
    Response. Once the President's nominee has been confirmed and sworn 
in as Secretary, VA will examine the current policy, complete a full 
review on this issue and provide new guidance on this issue as needed.

    Question 12. Is there a treatment protocol in place at VA for 
veterans with symptoms of Gulf War Illness? What is VA doing to advance 
their care and treatment?
    Response. VA has put considerable efforts into the diagnosis, 
research and treatment of Gulf War Illness (GWI) also referred to as 
Chronic Multi-symptom Illness. One of the most comprehensive documents 
on treatment was a joint effort by VA and DOD entitled: The Management 
of Chronic Multisymptom Illness (CMI) 2014. This Clinical Guideline 
provides comprehensive evidence based recommendations incorporating 
current information and practices for practitioners throughout the DOD 
and VA Health Care systems. The guideline is intended to improve 
patient outcomes and management of patients with CMI. The guideline is 
available at: https://www.healthquality.va.gov/guidelines/MR/cmi/.
    Post-Deployment Health Services/War Related Illness and Injury 
Study Center (WRIISC) led the development of an extensive e-learning 
module for clinicians on GWI available at: https://www.train.org/main/
course/1074205/. This e-learning module provides health care providers 
with the knowledge needed to recognize, evaluate, manage and treat GWI 
in Veterans and be able to apply the VA/DOD Clinical Practice Guideline 
for Chronic Multi Symptom Illness. VA also oversees the Gulf War 
Registry whereby thousands of Veterans get evaluated each year for 
health conditions.
    Recent research led by either the WRIISC and/or the Office of 
Research and Development, focused on the treatments of GWI, has 
included the topics of yoga, acupuncture, tai chi, dietary supplements 
such as coenzyme Q10, cognitive behavioral therapy, light therapy, 
exercise, inflammatory markers for diagnosis, and nasal continuous 
pressure to alleviate sleep disorders in Gulf War Veterans.
    VA also has a Research Advisory Committee (RAC) on Gulf War 
Veterans' Illnesses that advises VA on studies that include potential 
treatments. For more information, please visit https://www.va.gov/rac-
gwvi/. Gulf War RAC membership includes: Academics, Researchers, 
Veterans, VA staff, VSOs and Scientists. For a list of members, please 
visit https://www.va.gov/RAC-GWVI/Members_and_ Consultants.asp. There 
is currently no accepted single clinical case definition for GWI/CMI. 
VA contracted with the National Academy of Medicine (NAM) to evaluate 
existing case definitions. In 2014, the NAM released a report noting it 
was unable to find a single definition. VA has developed a plan to 
create a single, validated case definition and will be initiating 
research this year in execution of this plan.

    Question 13. This summer, you stood with me in Montana and 
announced that you would issue new regulations to help rural 
communities build nursing homes for veterans. When will those be 
released?
    Response. VA is currently reviewing the proposed regulations. Upon 
completion of the review, the regulations will be published as a 
proposed rule, followed by a 60-day public comment period, and a final 
rule that responds to public comments and makes the changes effective. 
VA anticipates the proposed rule process may take 6 to 9 months.

    Question 14. VA has nearly 1,000 open recommendations: 772 from the 
OIG and 215 from GAO. Further, VA health care has been on the GAO High 
Risk List for the past 3 years, and according to GAO, is not likely to 
be removed any time soon.
    a. What is your approach to addressing these open recommendations?
    Response. VA is working to implement all open Government 
Accountability Office (GAO) recommendations. Additionally, VA is 
working with GAO to leverage GAO best practices to improve the 
Department by the most effective and efficient means.
    VA continuously works to address deficiencies identified by GAO 
with an aim to resolve recommended actions within 3 years of report 
publication.
    Currently, 83 percent of VHA's open GAO recommendations were made 
within that 3 year timeframe; 47 percent of them were made within the 
past 12 months. VHA has requested GAO consider closure on 28 percent of 
our open recommendations. In FY 2017 GAO closed 56 recommendations to 
VHA and made 46 new recommendations.
    Each Administration and Staff office within the Department is 
responsible for providing the status on open Office of the Inspector 
General (OIG) recommendations. The OIG process is to obtain updates 
every 90 days until recommendations are closed. Each office works with 
the OIG to close recommendations as quickly as possible.

    b. Can you assure me that VA is using a strategic approach to 
respond to these recommendations?
    Response. Yes, the Department is using a strategic approach to 
respond to recommendations. In FY 2017, for the first time, GAO 
provided all Federal Agencies with a list of priority recommendations. 
GAO identified 22 high-priority recommendations for VA, and the 
Department is working to implement them. The Office of Enterprise 
Integration considers open recommendations as they move to 
strategically transform the Department.

    Question 15. In response to a question after your confirmation 
hearing, you agreed to provide quarterly briefings to staff on the 
status of the Department's open recommendations from OIG, GAO, OSC and 
others. When can we look forward to beginning those briefings?
    Response. VA is in the process of analyzing various trends in GAO/
OIG/OSC reports and the Department looks forward to providing quarterly 
briefings in the future.

    Question 16. Do you have any data to demonstrate whether the 
Department's removal actions under the new accountability law are 
increasing across all grades, or whether you're seeing lower-level 
employees disproportionately affected?
    Response. The Office of Accountability and Whistleblower Protection 
(OAWP) does not have visibility on all personnel actions. OAWP's scope 
for actions are the Senior Executive Service (SES), SES equivalents, 
and program managers at many levels that run major programs that have 
an impact across VA. Actions taken with lower grade employees are 
predominantly facility level actions.

    Question 17. Mr. Secretary, in September the IG released a 
memorandum detailing concerns with payment errors in the Choice 
Program. The timeframe for the review of claims was November 1, 2014, 
through September 30, 2016. Without yet getting into the December IG 
report, my very narrow question for you is--what did you do in response 
to that September memorandum?
    Response. Through use of internal audit and assessment tools, VA 
had identified overpayments to Third Party Administrators (TPAs) 
through Veterans Choice Program prior to the issuance of the 
September 2017 OIG memo and corrective actions were initiated before 
its publication. Duplicate payments were identified to be a particular 
area of vulnerability and, as a result, VA's Office of Community Care 
implemented an automated internal control to identify and prevent 
potential duplicate Choice payments prior to payment in the bulk 
payment environment. Since implementation in July 2017, over $35 
million in potential duplicate overpayments have been prevented.
    As noted in the September 2017 memo, VA completed an extensive 
analysis of prior Choice payments made in the bulk environment in the 
summer of 2017 and identified more than $80 million dollars in 
potential overpayments. This information was shared with the Choice 
TPAs and VA OIG. VA continues to work closely with the VA OIG, VA OGC, 
and other government stakeholders to ensure that overpayments through 
the Choice program are identified and recovered.

    Question 18. In December, a more exhaustive report was released by 
the IG expanding on its earlier memorandum. My question for you is: 
where are we today? If the IG's office were to knock on your door 
today--would it find the same problems?
    Response. The December 2017 OIG audit report focused on claims 
processing using the Fee Basis Claims System (FBCS), a highly manual 
claims processing system that is no longer utilized to process Choice 
claims. The process that followed, known as bulk payments, involved 
payments to TPAs in bulk form and was implemented to address delays in 
payments to TPAs and maintain critical provider networks in the Choice 
program. It was understood that this process would require post-payment 
reviews and, as noted in response to Question 17, VA has since 
implemented a process for preventing potential duplicate payments prior 
to payment and has conducted, and will continue to conduct, post-
payment analyses to identify overpayments.
    Starting in February 2017, VA's Financial Services Center (FSC) 
began processing Choice claims and utilize an automated payment system 
to conduct pre and post-payment analyses and to pay TPAs timely, 
reducing the burden of manual work that previously was required using 
the FBCS system. As of December 2017, more than 99 percent of clean 
claims received by the FSC were paid within 30 days of receipt.
    As noted in response to Question 17, VA continues to closely 
collaborate with the VA OIG, VA OGC, and other government stakeholders 
to ensure that overpayments made through the Choice program are 
identified and recovered.
    Looking forward, VA has incorporated many lessons learned from the 
Choice Program into its Community Care Network request for proposal 
(RFP) and future contracts will include stringent requirements for 
timeliness and accuracy of claims payments by TPAs. In parallel, VA 
will continue to strengthen its internal abilities to improve accuracy 
of payments and detect and prevent fraud, waste, and abuse (FWA). VA's 
Office of Community Care is currently working collaboratively with 
other government agencies including CMS and the Department of Treasury 
on joint initiatives to reduce FWA. In addition, a Federal Advisory 
Committee consisting of national experts in FWA detection and 
prevention is advising VA and VA's Office of Community Care is working 
closely with this Committee to identify further opportunities to reduce 
FWA in VA's Community Care Programs.

    Question 19. I am pleased to see that after much prodding from 
Congress the Department has finally decided to more aggressively 
address delayed payments to community providers. What took so long for 
VA to become more aggressive on this issue? What are the changes 
community providers can expect?
    Response. VA has been proceeding with individual solutions to 
address individual provider needs as our teams become aware. We believe 
that this more comprehensive approach is needed to ensure that VA is 
committed to resolving the provider payment issues. VA is taking the 
following multi-pronged approach to resolve these issues:

    First, VA is optimizing staffing levels and labor mix to increase 
claims output and enhancing Contact Center capabilities. Customer 
service functions performed by the claims processors will be 
transitioned to the Contact Center over the next year. This will allow 
additional claims to be processed as the staff transition. The Contact 
Center will also utilize email to increase the number of inquiries they 
can field from providers
    Focus on provider education on Vendor Inquiry System, which allows 
providers direct access to claims status via a website.
    Second, VA is increasing workload of claims processing vendors and 
dedicating teams to resolving outstanding claims with major providers. 
VA is shifting more claims to vendors over the next several months. The 
target is to increase to 840,000 per month by March 2018. This 
represents about 40 percent of incoming claims volume. VA has also 
created rapid response teams to develop tailored resolutions working 
with the top 20 providers. Outreach has begun with a target of 
resolving outstanding issues by April 3, 2018. After this effort is 
completed, the teams will move onto other providers.
    The third prong is to continue to make implement IT solutions to 
improve productivity. Existing claims processing systems has two 
enhancements to reduce manual processing that will be implemented by 
September 2018. We are also implementing a process to convert paper 
claims to electronic, reducing manual entry of claims. In addition, a 
new claims processing system will be in use at the end of 2019.

    Question 20. We've received a lot of enthusiastic feedback from 
veterans about the Edith Norse Rogers STEM scholarship, which provides 
additional GI Bill benefits to students in programs of study that are 
STEM or a field which the Secretary has identified as a national need. 
Despite this enthusiasm we have not yet received any feedback on how 
this benefit will be implemented, or how the Department will use this 
new authority to identify fields of study which are a national need. 
When can we expect to see VA's implementation plan for the Edith Norse 
Rogers STEM Scholarship?
    Response. VA is analyzing statutory requirements to develop 
planning documents for the STEM scholarship, which does not go into 
effect until August 1, 2019. The requirements for this provision do not 
conform to VA's current technology and business rules for the Post-9/11 
GI Bill; therefore, VA has identified the VA Regional Processing Office 
in Buffalo, NY, as the sole site dedicated to processing and tracking 
the STEM Scholarship. VA expects a more fully developed plan with 
regulatory, communication and program requirements to be drafted by 
December 2018.

    Question 21. The Forever GI Bill appropriates $30 million to the 
secretary for changes and improvements to the information technology 
systems used to administer veterans education benefits. Please provide 
us with a description of the IT requirements that VA has to improve 
their IT systems and a detailed spending plan for that $30 million?
    Response. Section 115 of the Colmery Act authorizes $30 million 
specifically for the automation of the remaining supplemental claims 
and original claims processing. To date, no funding has been 
appropriated. Notwithstanding the absence of resources, the Office of 
Information Technology (OIT) in coordination with Education Service has 
committed to address those provisions of the Act that are most 
critical. Those include Sections 107, 501 and 112. This work is being 
absorbed into ongoing education systems modernization effort focused on 
the retirement of the Benefits Delivery Network (BDN) that was already 
underway.
    Additionally, VBA's Education Service and OIT are partnering to 
explore managed services opportunities to deliver all education 
benefits. We are targeting FY 2019 (after the BDN decommissioning is 
largely complete) for a potential managed services implementation.
    If this approach is successful, we should be able to integrate the 
remaining Forever GI Bill provisions needing an IT solution into 
Education IT systems in FY 2019 through managed services. If a managed 
services solution is deemed not feasible we will employ a traditional 
development approach, subject to the availability of funding.
    In summary, this approach, achieved through VBA/OIT partnership 
ensures that all Forever GI Bill provisions are implemented on time for 
Veterans, while enabling VA/OIT to best position the supporting IT 
environment for the future.

    Question 22. State Approving Agencies provide the on the ground 
workforce that ensures VA education benefits are being used on quality 
programs of study. The Forever GI Bill appropriated an additional $3 
million to be provided to the State Approving Agencies for fiscal year 
2019 and another $2 million for each fiscal year after that. Can you 
provide details for the Committee on how you plan to work with the SAAs 
to divide that money amongst each state? Will you ensure that states 
which currently only receive enough funding to hire one full time 
employee will be prioritized to ensure that no state is left with 
funding for ``1.5'' full time employees?
    Response. The Forever GI Bill authorized an additional $2 million 
for FY 2018 for State Approving Agencies (SAA) funding, which increased 
the funding from $19 million to $21 million. An additional $2 million 
will be authorized in FY 2019, increasing the total funding from $21 
million to $23 million and allowing for a cost of living allowance 
increase.
    Currently, VA is using an engineered model that distributes the SAA 
funding based on workload, training, size and type of schools, and 
approval and compliance requirements. VA will continue to work with the 
Contract Committee of the National Association of State Approving 
Agencies (NASAA) regarding the SAA allocation model and formulas. VA 
anticipates a thorough review of the allocation model prior to FY 2019, 
with potential contractor analysis, to ensure appropriate and equitable 
funding distribution.
    The current allocation model determines the individual SAA funding 
based on the workload required and distributes the overall funding 
(currently $21 million) based on the number of full-time employees 
(FTE) needed to perform the work. The model may determine that a state 
requires two FTE, and allocates $200,000 toward the staffing costs. 
However, due to fluctuations in state salaries and benefits packages 
that amount may be sufficient in one state to hire three FTEs; in 
another state, two FTEs; and in another state, one FTE. VA does not 
dictate to an SAA how they must utilize the funding provided; the SSA 
determines how many FTEs they can hire with the funding provided.

    Question 23. VA provided committee staff information on the number 
of students who applied to have their benefits restored in the wake of 
the ITT closure. VA stated that they received 441 applications, and 
have restored benefits for 302 students. 441 students responding when 
over 12,000 veterans attended ITT in the 2016-2017 school year alone is 
not a good response rate. What outreach is VA using to reach impacted 
students? What are examples of outreach they've done to reach them? And 
finally, why have 140 veterans applied but not had their benefits 
restored?
    Response. During the week of November 9, 2017, VA provided 
notification to 8,000 students identified as potentially eligible to 
have benefits restored under the Special Application provision of 
Section 109. Of those, approximately 80 percent received an email with 
a letter, instructions, and a form to apply for restoration. The 
remaining 20 percent received the same documentation via postal mail. 
As of January 26, 2018, VA has received over 700 applications and 
restored over 4500 months of entitlement to almost 450 individuals.
    To reach the population of students impacted by this closure, VA 
announced through its social media outlets instructions for restoring 
entitlement, established a new webpage with additional information 
(https://benefits.va.gov/gibill/fgib/ restoration.asp), and issued 
three email missives to over 1.2 million individuals VA is committed to 
restoring benefits to all eligible Veterans and will continue to 
promote and encourage Veterans to apply for restoration through all 
available outlets including Facebook and Twitter. VA plans a 90-day 
follow-up communications effort.
    VA was not able to restore benefits for all Veterans who applied as 
they did not meet the criteria for restoration. In most instances, it 
was because the beneficiary was not enrolled in the closed school 
within 120 days of its closure, or the beneficiary transferred credits 
to a comparable program at a new school thereby making them ineligible 
for restored benefits.

    Question 24. In a question taken for the record from your 
confirmation hearing you committed to reporting back to this Committee 
within three months with your recommendation for practical and 
realistic steps VA can take to ensure student veterans are protected 
from predatory and deceptive practices and given the information they 
need to make an informed choice about their college. What is the status 
of your report to the Committee?
    Response. VA was asked to report on the steps used to actively 
prevent and detect the utilization of predatory and deceptive practices 
by institutions approved for GI Bill benefits. VA now completes a 
three-step process to identify and remove predatory and deceptive 
practices and ensure student Veterans are given the information they 
need to make an informed choice about their college:

    1. Program Approval: VA has been collaborating with SAAs to ensure 
that advertising and recruiting materials are thoroughly vetted for 
accuracy during the approval process. The SAA and VA complete initial 
training and follow up training with the school officials and provide 
continuous updates to ensure new laws and policies are implemented 
timely for school enrollment certifications. Furthermore, the VA and 
SAAs monitor and provide guidance as school's update or change their 
academic programs.
    2. Online Resources: VA has updated information, functionality, and 
options to the GI Bill Comparison Tool (i.e., new types of ``caution 
flags,'' to alert prospective students about judgments, settlements, 
and lawsuits regarding such prohibited practices) to ensure Veterans 
make informed choices about their benefits. In addition, VA continues 
to use the GI Bill Feedback System to receive student feedback about 
schools and to identify trends and risk indicators of ``bad actor'' 
schools to trigger targeted, Risk-Based Reviews. Finally, VA offers an 
online tutorial called Choosing the Right School that educates users on 
the steps to take to make sure they find a school that is the right 
fit. The tutorial provides resources to gauge and evaluate interests, 
pay scales, accreditation, and Veteran support.
    3. Compliance Surveys: VA and SAAs conduct, on average, more than 
5,000 compliance reviews per year, which includes examination of a 
school's advertising and recruiting materials. VBA's Education Service 
and NASAA recently established a Risk-Based Review Workgroup comprised 
of VA and SAA staff to analyze and implement policy change and to 
provide guidance regarding SAA coordination and completion of Risk-
Based Reviews, all aimed at preventing fraudulent and misleading 
practices.

    VA does not expect to complete a report at this time.

    Question 25. HUD recently reported an increase in homeless veterans 
last year and this month HUD will conduct a Point-in-Time count of 
homeless veterans across the country. Likewise, the number of homeless 
female veterans increased last year by 7 percent. A survey conducted by 
the National Coalition for Homeless Veterans found that women veterans 
are likely to access services from mainstream resources, instead of VA-
funded assistance resources. How are you going to specifically reach 
out to women veterans at risk of, or currently experiencing, 
homelessness?
    Response. Local services and resource gaps may vary from site to 
site. However, with the recent development and dissemination of VA 
policy outlining specific expectations of VA medical centers (VAMCs) 
regarding their participation in local coordinated entry systems, VA 
homeless programs are required to coordinate with local community 
providers. Such coordination is to conduct enhanced outreach efforts, 
as well as facilitate VA services for female Veterans, regardless of 
where they first seek services in that community. The outreach 
activities, which will be coordinated with community partners, will be 
conducted at programs, community centers, and specifically VAMCs as 
well as other sites not typically identified as `homeless service 
provider facilities. With the VAMC full participation in coordinated 
entry in each community, our efforts will broaden engagement of 
homeless women Veterans, or those at-risk for homelessness with VA 
homeless services.

    Question 26. Dr. Shulkin, the Nation and veterans are waiting 
eagerly for VA to sign the EHR contract and begin the 8-year process to 
fully deploy the new EHR. So, it's been 7 months since your 
announcement, and a month since the procurement pause because of VA's 
confusion about the contract's interoperability language. Can you 
confirm whether your self-imposed December delay will lead to any price 
increase?
    Response. VA signed a contract with Cerner on May 17, 2018, to 
modernize VA's legacy electronic health record (EHR) systems. The 
Department is balancing the implementation timeline of the new EHR with 
potential risks to cost, schedule, and performance minimizing potential 
impacts to Veterans care. VA is also working closely with DOD to ensure 
alignment with best practices from their commercial EHR implementation.

    Question 27. Do you have the technical experts on-board to manage 
the implementation of the contract?
    Response. The terms and conditions of the 10-year Cerner contract 
with VA calls for the delivery of all services and capabilities 
necessary to successfully replace the disparate VistA EHR systems 
across the entire VA enterprise over a 9-year and 6-month deployment/
implementation period. To ensure the field is represented and involved 
in the management of the implementation, VHA is supporting the 
Electronic Health Record Modernization (EHRM) by providing experts to 
develop new workflow processes and using staff from the Office of Chief 
Medical Officer. It is critical that we have engagement from frontline 
staff (e.g. medical clinicians) in this process to ensure successful 
implementation.
    As an important cost control measure during the transition from the 
VistA-based EHR solution to the Cerner product, VA will utilize 
personnel transitioning from the legacy systems to train with, augment, 
and then ultimately replace many of the Cerner contracted employees. We 
believe this methodology enhances our integration posture and stability 
of our workforce, which in turn enriches our overall change management 
efforts. This transition will be a well-coordinated, documented, 
controlled, and approved transition process with a clear understanding 
that the quality of care to our Veterans must not be compromised. It is 
anticipated these personnel would be transitioned in the out-years 
(years 6 through 10).
    VA is providing industry competitive compensation to attract highly 
trained technical experts in the EHRM Program Management Office (PMO), 
charged with providing oversight of Cerner contract. PMO employs highly 
trained Government and Contractor personnel to provide this expert 
oversight in a myriad of professional disciplines including: clinical, 
technical, engineering, information assurance, security, testing, 
acquisition, contracting, data migration, communication, independent 
validation and verification, training, change management, governance 
and many more. Together, these technical disciplines will manage the 
contract's adherence to cost, schedule, and performance objectives, and 
the corresponding management of associated project risks.
    Additionally, functional and technology leads, and necessary 
support staffs, were assigned by DOD at the inception of contract 
negotiations to foster inclusion of the requisite lessons learned 
throughout the VA contract negotiation process and will continue post-
contract award throughout EHR deployment/implementation.

    Question 28. I think I speak for all of us in saying that we look 
forward to you providing us more information on what the recent 
Executive Order on mental health will mean for veterans in the long 
run. There are news reports saying that VA will enroll all veterans for 
a year. We also understand from press reports this effort will require 
hundreds of millions of dollars.
    a. Please provide information about how you are planning to handle 
the strain on staff and your budget?
    Response. VA estimates as much as $100 million from VA's existing 
budget will be used to support implementation of the Executive Order 
(EO), by realigning funds to support suicide prevention as one VA's 
core priorities.

    b. What initiatives will you NOT be able to complete due to 
reallocation of dollars to this new effort?
    Response. VHA is not setting aside any current initiatives in 
attaining the full implementation of the EO.

    Question 29. We are concerned about the risks faced by veterans who 
received bad paper, many of whom received those discharges as a result 
of conduct resulting from injuries they sustained in service. With 
regard to the EO, what is the justification for excluding them from 
this year of care?
    Response. Currently, in some situations, VHA is bared by statute 
from providing care, beyond emergency services/stabilization. With 
respect to character of discharge, a transitioning Servicemember 
generally is not eligible for VA benefits, to include mental health 
care, if he or she is subject to a bar to benefits. Individuals bared 
from receiving benefits include those who, unless considered insane, 
were discharged or released as a conscientious objector or deserter, by 
reason of general court-martial, or as a result of AWOL for a certain 
period unless exempted. See 38 U.S.C. 5303(a), 38 C.F.R. 3.12(c). If 
bared, VA may refer the individual to community resources (not at VA's 
expense). For an individual ineligible for readjustment counseling 
under 38 U.S.C. 1712A, VA provides referral services to assist the 
individual in obtaining mental health care and services outside VA, and 
if pertinent, advises the individual of his/her right to apply for a 
review of the individual's discharge or release. See 38 U.S.C.1712A(c).

    Question 30. The VA Choice and Quality Employment Act required VA 
to establish a database that lists vacancies for critical, difficult-
to-fill, and mental health positions at VA.
    a. What is the current status on implementing that system?
    Response. VA has H.R. SMART, the VA's personnel data system, to 
track vacancies for critical, difficult-to-fill, and mental health 
positions at VA. We have also engaged in a VA-wide effort to validate 
the data in the system. In February 2018, VA completed the Position 
Vacancy Reconciliation Project, an extensive cleansing of vacant 
position data in H.R. SMART. As a result, VA now has the ability to 
identify vacancies for mission critical, including mental health, 
positions.

    b. Does the system ensure that folks who were qualified for, but 
were not offered, a position are considered for other positions at VA?
    Response. The system leverages USAJobs and USAStaffing in order to 
generate a list of qualified candidates for positions. If a candidate 
is qualified, but was not offered a position, the system does not 
automatically allow the applicant to be considered for other positions 
at VA. We are working with the Office of Personnel Management (OPM) on 
system enhancements to USAStaffing to further improve/streamline this 
process.

    Question 31. Please provide a list of the 15 occupations that the 
Department has submitted to OPM for consideration for use of the direct 
hire authority.
    VA Response:

                        15 Occupations included in VA's Request for Direct Hire Authority
----------------------------------------------------------------------------------------------------------------
                                                                                                    Geographic
                  Position Title                         Occupational Series and Grade(s)            Location
----------------------------------------------------------------------------------------------------------------
Accountant*                                        GS-0510-9/11/12/13/14/15                          Nationwide
----------------------------------------------------------------------------------------------------------------
Biomedical Equipment Support Specialist            GS-1601-9/11/12                                   Nationwide
----------------------------------------------------------------------------------------------------------------
Boiler Plant Operator                              WG-5402-9/10/11/12                                Nationwide
----------------------------------------------------------------------------------------------------------------
General Engineer                                   GS-0801-5/7/9/11/12/13                            Nationwide
----------------------------------------------------------------------------------------------------------------
Health Science Specialist (Veterans Crisis Line)   GS-0101-5/7/9/11/12                               Nationwide
----------------------------------------------------------------------------------------------------------------
Health Technician                                  GS-0640-4/5/6/7                                   Nationwide
----------------------------------------------------------------------------------------------------------------
Histopathology Technician                          GS-0646-5/6/7/8/9                                 Nationwide
----------------------------------------------------------------------------------------------------------------
Human Resources Assistant                          GS-0203-5/6/7                                     Nationwide
----------------------------------------------------------------------------------------------------------------
Human Resources Specialist                         GS-0201-7/9/11                                    Nationwide
----------------------------------------------------------------------------------------------------------------
Information Technology Specialist**                GS-2210-7/9/11/12/13/14/15                        Nationwide
----------------------------------------------------------------------------------------------------------------
Personnel Security Specialist                      GS-0080-7/9/11/12/13                              Nationwide
----------------------------------------------------------------------------------------------------------------
Police Officer                                     GS-0083-5/7/9/11/12/13                            Nationwide
----------------------------------------------------------------------------------------------------------------
Realty Specialist                                  GS-1170-9/11/12/13/14                             Nationwide
----------------------------------------------------------------------------------------------------------------
Utility Systems Operator                           WG-5406-8/9/10/11                                 Nationwide
----------------------------------------------------------------------------------------------------------------
Utility Systems Repair                             WG-4742-9/10/11                                   Nationwide
----------------------------------------------------------------------------------------------------------------
* Accountant Specialty Areas--General, Accounting Officer, Cost, Staff, and System.
** Information Technology Specialty Areas--Network Services, Enterprise Architecture, Data Management, Systems
  Administration, Operating Systems, Application Software, Systems Analysis, Customer Support, Internet, Policy
  and Planning, and Project Management.

                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Jerry Moran to 
                  U.S. Department of Veterans Affairs
    Dr. Shulkin, the Committee and I need clarity on one of your 
answers provided in the hearing January 17, 2018. When asked whether 
eligibility criteria to determine if a veteran can receive care in 
their community ought to be explicitly linked to the access standards, 
you stated, ``of course I believe that eligibility criteria should be 
explicitly linked to access standards.'' However, you present a 
different and conflicting position with the follow-on statement, ``I 
support the access standards that are in the bill that the Senate 
committee passed 14-1.''
    As you know, the bill that the Senate committee passed (S. 2193) 
would establish access ``guidelines'' versus ``standards,'' which is 
different than your support for access standards. In addition, the bill 
passed by the Committee would ``establish localized benchmarking 
guidelines that can inform provider and veteran clinical 
decisionmaking.''
    Question 32. Do you believe ``benchmarking guidelines that can 
inform provider and veteran clinical decisionmaking'' constitutes a 
requirement for providers to use such guidelines to determine if a 
veteran can receive care in their community?
    Response. Benchmarking guidelines do not constitute a requirement 
that providers must use. Future VA policy will require providers to 
refer to the guidelines, but as part of one of many pieces of 
information that will be used to make clinical decisions (unless 
otherwise stated).

    Question 33. How will you oversee the community care program with 
guidelines that ``can inform'' decisions but does not guarantee the 
guidelines will be used?
    Response. VA will provide criteria for eligibility, and guidelines 
to inform decisionmaking by both VA medical facilities and providers. 
VA will closely monitor utilization patterns of community care as well 
as wait times and access standards at VA medical facilities to provide 
proper oversight.

    Question 34. How will you prevent inconsistent experiences for 
veterans without strong, data driven standards that are required to be 
used by providers when determining if a veteran receives care in the 
community?
    Response. We believe there is even more we can do for our Veterans, 
through internal VA policies and guidelines, such as:

     Provide increased transparency to Veterans regarding 
eligibility, access, and quality guidelines, through both the Federal 
Register and public websites.
     Provide clarity to Veterans around how they can start the 
process of pursuing community care as well as explain the appeals 
process.
     Provide additional eligibility triggers for certain types 
of care (urgent care, routine x-rays) as long as they are clinically 
necessary.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Dean Heller to 
                  U.S. Department of Veterans Affairs
    Question 35. A few months ago, a Nevadan came into my office from a 
military aviators group known as the River Rats. Over the years, many 
of these fighter pilots have been diagnosed with varying forms of 
cancer.
    They have begun studying the high rate of cancer in fighter pilots, 
potentially due to toxic exposure.
    We know that toxic exposure severely impacts our veterans and can 
harm their children and grandchildren. The U.S. has a responsibility to 
investigate these issues and determine whether there is a link between 
their service and these diseases.
    This issue needs to be looked at by the VA and the appropriate 
health agency.
    How will you make that happen? What is the process for veterans to 
address concerns about exposure and its connection to cancer?
    Response. Veterans who have concerns about potential toxic 
exposures during service and the possible connection to development of 
cancer are advised to speak with their primary care provider. They may 
also contact and the Environmental Health Clinician and Coordinator at 
their local VAMC. The Environmental Health Coordinators can help make 
the connection to care; the state by state index with contact 
information for Coordinators is found at https://
www.publichealth.va.gov/ exposures/coordinators.asp.
    However, for many Veterans, particularly those of the Vietnam and 
the Persian Gulf Wars, it appears that reliable occupational and 
environmental health surveillance data just do not exist. To the extent 
that such data are available, DOD shares them with VA as needed. DOD 
has much better surveillance data available for more recent conflicts 
and events.
    A major emphasis of the DOD/VA Deployment Health Work Group (DHWG) 
is on Servicemembers with military environmental exposures. DHWG also 
coordinates initiatives related to Veterans of all eras. Joint efforts 
continue to increase sharing of health surveillance information and 
review of relevant literature on hazardous environmental exposures. 
DHWG analyzes complex clinical medicine, toxicology, and policy aspects 
to develop synchronized DOD and VA actions. DHWG provides ongoing 
oversight of the development of the Individual Longitudinal Exposure 
Record (ILER) project. The goal of ILER is to create a complete record 
of every Servicemember's occupational and environmental exposures over 
the course of their career. ILER will mine several existing DOD data 
systems that contain in-garrison and deployment exposure-related 
information. It will link career, location, and year with exposure data 
and will be available to DOD and VA health care providers to help 
inform diagnosis and treatment, and to VBA claims adjudicators to help 
establish service connection.
    In addition, VA conducts ongoing surveillance of VA health care 
utilization through systematic reviews and investigation of diseases 
treated. This surveillance drives in-depth investigation of areas of 
special concern. These studies enable VA to identify potential adverse 
health effects associated with deployment, including cancer, and follow 
them over time.
    With regard to the health of descendants, VA has contracted with 
the National Academy of Medicine (NAM) to assess areas requiring 
further scientific study on the descendants of Veterans with toxic 
exposures. Formally the Committee is charged with producing the report 
titled ``Gulf War and Health, volume 11.'' The NAM committee will 
further assess the scope and methodology required to conduct research 
on such descendants to identify current or possible health effects in 
the Veterans' descendants. The resulting plan and recommendations 
should help to identify for VA the way forward to best address the 
issue of intergenerational concerns. The NAM report is expected to be 
completed by early 2019.
    Additionally, VA has an additional contract with NAM, whose 
committee is studying a broad range of conditions that Agent Orange 
might have affected the health of Veterans. NAM's report is due to VA 
by January 2019. The Committee's charge includes looking at descendant 
health and in particular, the Committee was asked to pay special 
attention to the potential risk of parental transmission of disease 
conditions to descendants.

    Question 36. Under the new Rapid Appeals Modernization Program 
(RAMP), what are the criteria used by VA to determine which veterans 
will receive an ``invitation'' to participate in this quicker appeals 
process?
    Response. Eligible Veterans have a pending compensation appeal in 
one of the following stages of the legacy appeals process:

     Notice of Disagreement;
     Substantive appeal to the Board (Form 9);
     Certified to the Board (not activated); and
     Remand from the Board.

    While VA had initially provided the invitations to appellants with 
the oldest appeals pending in these stages, as VA has received some 
initial data from RAMP elections, it has begun to test various 
assumptions on Veteran behavior. As of February 2018, VA continued to 
mail invitations to the oldest appellants in each of the stages 
identified above, but also sent approximately 12,000 invitations to 
Veterans with newly established appeals. This allows VA to test the 
assumption whether the age and stage of a pending appeal impacts the 
election rate.

    a. How many Nevada veterans have been invited to participate?
    Response. As of May 15, 2018, VA has mailed 1,239 invitations to 
Veterans with an appeal pending under the jurisdiction of the Reno 
Regional Office. Of that number, 109 Veterans have opted into the 
program. Additionally, the earlier requirement that Veterans need to be 
``invited'' into RAMP was removed on April 2, 2018, and now any Veteran 
with an eligible pending disability compensation appeal can choose to 
opt in to RAMP, and benefit from the faster review process. As of 
May 15, 2018, VA has identified 2,479 Nevada Veterans that are eligible 
to opt into RAMP.

    b. Will you start expanding this program to ensure veterans from 
Nevada have the option to participate?
    Response. The earlier requirement that Veterans need to be 
``invited'' into RAMP was removed on April 2, 2018, and now any Veteran 
with an eligible pending disability compensation appeal can choose to 
opt in to RAMP, and benefit from the faster review process.

    c. Under the new program, how long has it taken to decide an appeal 
on average?
    Response. As of May 15, 2018, VA processed higher-level reviews in 
an average of 69.1 days and supplemental claims in an average of 53.9 
days. VA's response pertains to all RAMP completed claims as of May 15, 
2018, and is not specific to Nevada residents.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Bill Cassidy to 
                  U.S. Department of Veterans Affairs
    Question 37. On January 18th the National Governor's Association 
noted its recommendations on how the Nation can address the opioid 
crisis. The National Governor's Association recommended the need to 
ensure that electronic health records and state prescriptions drug 
monitoring programs are interoperable. Is VA committed to ensuring that 
this will be a component in VA's future solutions to interoperability?
    Response. VA is committed to finding better ways to manage pain in 
Veterans, while limiting the risk of long-term opioid therapies. VA 
pharmacy currently participates in State Prescription Monitoring Data 
bases by transmitting (sharing/sending) data on controlled substance 
prescriptions dispensed from VA pharmacies as indicated by several 
legislative requirements, most recently Public Law No: 115-86. This 
data originates from our current EHR, or more specifically, the VistA 
Outpatient Pharmacy application package. The requirement to share data, 
similar to any network of pharmacies, remains in place regardless of 
the pharmacy system being used to process and dispense these 
prescriptions. The technical requirements for VA's future EHRM Platform 
will be interoperable with State Prescription Monitoring Programs.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Thom Tillis to 
                  U.S. Department of Veterans Affairs
                     forever gi bill implementation
    Question 38. Mr. Secretary, most of us here understand the critical 
role that State Approving Agencies (SAA) play in protecting and 
enhancing Veterans' education benefits. I understand that the GAO is 
presently conducting a study into the role of SAAs and how the VA 
partners with them to protect veterans. Can you share with us your 
ideas and plans pertaining to SAAs, particularly in regard to their 
funding level and their role in the oversight of institutions through 
conducting risk based surveys, as mandated and updated by the Colmery 
Act?
    Response. Strong oversight by SAAs helps protect Veterans in 
several ways. First, oversight ensures that the approved programs 
continue to meet all the statutory criteria in 38 U.S.C. Chapter 36, as 
well as any individual state requirements the SAAs used in their 
assessment to initially approve a course for Veteran's training.
    Second, SAAs are familiar with the responsibilities of SCOs. SCOs 
are responsible for certifying students' enrollments to VA, to ensure 
proper payment to individuals in receipt of VA benefits. Through 
oversight, SAAs can identify out-of-line situations that require 
additional training that VA or SAAs can provide; ensuring VA students 
are certified properly for payment, are in courses necessary for 
completion of their program, and that appropriate credit has been 
granted for their prior training. In this oversight review, the SAA may 
identify violations that could result in disapproval of programs.
    Finally, using information VA obtains from students through VA's GI 
Bill complaint system, SAAs can conduct an immediate risk-based 
unscheduled visit to the school to resolve issues, or to determine if 
there are violations that require disapproval of the program or 
suspension of enrollment. The following are areas of focus in the 
complaint system:

 
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
Recruiting/Marketing Practices                                 Quality of Education
----------------------------------------------------------------------------------------------------------------
Accreditation                                                  Grade Policy
----------------------------------------------------------------------------------------------------------------
Financial Issues (e.g. Tuition/Fee charges                     Release of transcripts
----------------------------------------------------------------------------------------------------------------
Student Loans                                                  Transfer of Credits
----------------------------------------------------------------------------------------------------------------
Post-Graduation Job Opportunities                              Refund Issues
----------------------------------------------------------------------------------------------------------------
Change in Degree Plan/Requirements                             Other (as identified by student)
----------------------------------------------------------------------------------------------------------------


    Prior to the Colmery Act, as part of VA's strong partnership with 
SAAs in our mutual oversight and compliance responsibilities, SAAs 
conducted approximately 30 percent of the targeted risk-based 
compliance reviews at schools where special risk indicators were 
discovered. These mutual efforts help ensure schools are held 
accountable and VA students are in proper programs for their 
educational objective, and are receiving proper payments.
    Regarding funding please see the response to Question 22 above.
                              procurement
    Question 39. How is clinical input from VHA incorporated in the 
contracting and procurement processes for healthcare acquisitions? Do 
you see areas in VA procurement where that input is particularly useful 
yet not fully incorporated?
    Response. The VHA Procurement and Logistics Office (P&LO) involves 
clinician subject matter experts throughout the acquisition process, 
from inception through award and performance monitoring. Clinicians are 
Integrated Project Team (IPT) co-chairs together with assigned Project 
Managers as requirements are developed. Clinicians remain fully engaged 
through technical product reviews to determine whether or not the 
vendor's proposal truly meets their requirements.
    VHA has initiated a process for Clinician Driven Strategic Sourcing 
(CDSS) that further codifies the clinical role in sourcing commodities, 
equipment and services. CDSS, once fully realized, will involve 
physicians and other clinicians in the strategic sourcing process to 
improve quality, outcomes and cost. These improvements will support 
identification of high quality preferred items, and reduce variation in 
products and clinical protocols. The CDSS program also facilitates 
better pricing, and streamlines the procurement and delivery of 
clinical equipment, and medical/surgical supplies and services 
throughout VHA. VHA's Clinical Program Offices will validate the 
requirements for their clinical specialties, and take the lead in 
managing the catalog of items and services available to their 
colleagues.

    Question 40. Is VA currently exploring ways to increase 
transparency, define the term ``best value,'' and eliminate contracting 
and administrative delays for healthcare acquisitions, notably high 
tech medical equipment?
    Response. VA continues to develop methods to increase transparency 
to industry. For each consolidation, VA develops milestones with 
planned execution dates, dependent on the number of requirements 
included in each consolidation, and provides these milestones to 
industry via public posting to the Federal Business Opportunities 
website. Although these dates are estimates and are subject to change, 
VA strives to meet all milestones. When necessary, VA provides updated 
milestones to reflect any changes, to keep industry informed on where 
VA is in the procurement process. VA has developed standard evaluation 
factors for High Tech Medical Equipment (HTME) requirements including 
1) Availability of Features (Technical and Functional), 2) Availability 
of Service, 3) Past Performance, and 4) Price, with all non-price 
factors when combined being significantly more important than price. By 
assigning significantly more weight to the non-price factors, VA 
ensures we can achieve the best technical solution via tradeoff in 
order to meet the needs of the customer. The contracting office is 
consistently striving to improve contracting processes, train 
personnel, and engage in open dialog with industry in order to minimize 
administrative delays, provide clarity on VA requirements, and maximize 
efficiency in the HTME procurement process.

    Question 41. How does the Department interpret the Kingdomware 
decision when considering whether or not to exercise option years in 
contracts that predate the Supreme Court decision? How is this 
information disseminated to local contracting officers to ensure 
consistency throughout VA?
    Response. VA has department-level policy, procedures, guidance, and 
instruction regarding the Veterans First Contracting Program. Policy as 
it relates to Exercising Contract Options is as follows:
     A single award contract is considered non-competitive. 
Therefore, the Rule of Two does not apply.
     Prior to exercising an option on existing multiple award 
Indefinite Delivery Indefinite Quantity contracts, the Contracting 
Officer (CO) will determine if there are two or more verified Veteran-
Owned Small Businesses (VOSB) awardees on the contract. If there are 2 
or more, the options for the verified Service-Disabled Veteran-Owned 
Small Business (SDVOSB)/VOSB contracts will be exercised, if 
appropriate. If the number of SDVOSBs/VOSBs is not sufficient to meet 
the needs of the agency, the CO will apply the Rule of Two to identify 
other SDVOSBs/VOSBs. If no additional SDVOSBs/VOSBs exist, the options 
for the other contracts may be exercised if it is in the best interest 
of the agency to do so.

    All contracting personnel were required to attend the 38 U.S.C. 
8127 implementation training. In addition, guidance on options was 
provided during the Acquisition Workforce Innovation Symposium in 
November 2016 and March 2017. Finally, a refresher webinar was held in 
December 2016 specifically for supervisors which also addressed options 
during this training session.
                     electronic health record (ehr)
    In the context of the ``strategic pause'' in awarding the EHR 
contract to study interoperability.

    Question 42. Do you view interoperability among and between VA 
facilities to be the chief objective? What about interoperability with 
DOD? What about interoperability with the Community Care Network?
    Response. VA will employ a multi-pronged strategy to achieve 
interoperability within VA, between VA and DOD, and amongst our 
contracted community care providers, and will leverage a technical 
solution that supports nationwide interoperability and enables data to 
be shared amongst healthcare facilities and providers.
    More specifically our approach consists of four stages that run in 
parallel:

    1. VA to VA Interoperability;
    2. VA to DOD Interoperability;
    3. Community Care Partner Interoperability; and
    4. National Interoperability.

    The EHRM Program Executive Office (PEO) is focused on and 
accomplishing 1-3, and a portion of 4. Therefore, (1) VA to VA 
Interoperability and (2) VA to DOD Interoperability are completely 
solved through EHRM and served as the basis for Seamless Care to the 
Veteran. (3) VA to Community Care Partners is provided by EHRM and 
works off the first two objectives so VA can provide Seamless Care for 
the Veteran. VA currently plans on completing the remaining portions of 
(4) with its upcoming Digital Veteran's Platform (DVP), where we expect 
participation of other commercial EHR providers (i.e., Epic, 
Allscripts, etc.) to contribute to the development of a national health 
information exchange platform and related Application Programming 
Interface (API) gateways in support of interoperability across the 
entire healthcare information exchange continuum. The adoption of open 
standards for information exchange such as SMART on FHIR (Fast 
Healthcare Interoperability Resource) framework by all EHR providers 
will be a key to national success. Aggressive interoperability-based 
terms and conditions will be included in any contract with Cerner to 
lead the advancement of this national interoperability objective as 
well as to align fully with the DVP and its respective API gateway 
requirements.
    Although the focus of VA's EHRM program is to establish intra-VA 
interoperability, VA/DOD interoperability, and VA-Community Care 
interoperability, each of these phases of interoperability allows VA to 
incrementally build toward and support nationwide EHR interoperability. 
Nationwide EHR interoperability amongst all healthcare providers will 
empower Servicemembers and Veterans to utilize their electronic health 
records to the fullest extent and equip providers to deliver safer and 
more efficient seamless care.

    Question 43. When looking at the full EHR ``software stack,'' are 
you considering Commercial Off the Shelf interoperability solutions 
that are separate from or in addition to the larger EHR contract?
    Response. For the EHRM Program, the only Commercial solutions which 
are planned for use are the D&F authorized Cerner Platform and its 
Interoperability software, and VA's Enterprise InterSystems HealthShare 
software. Separately, VA's API gateways plan to utilize commercial 
systems per the Secretary's direction for VA to get out of the software 
development business.
    The selection of Cerner Millennium does not eliminate VA's need to 
continue to assess the commercial market to identify additional 
software tools and products that may further enhance our overall 
interoperability and seamless care objectives. VA will be using the 
reciprocity process to fully leverage successful testing practices and 
results already solidified as part of the DOD deployment effort. 
However, under EHRM, there will be a comprehensive Test & Evaluation 
department reporting to the EHRM Program Executive that will be fully 
leveraging the breath of existing VA and Cerner test facilities to 
continue to not only test the 30 percent more capabilities being 
delivered under the VA contract, but also to stimulate introduction of 
more efficient/effective functional and technological industry 
advancements into the VA healthcare environment.
         office of accountability and whistleblower protection
    Question 44. Can you please provide an update on the vacancy of the 
Assistant Secretary for Accountability and Whistleblower Protection? 
Can you please highlight any challenges you are facing in sending 
Congress a nominee?
    Response. Once the President's nominee has been confirmed and sworn 
in as Secretary, VA will complete an assessment and provide a 
recommendation for a nominee as Assistant Secretary for Accountability 
and Whistleblower Protection.
                             va innovation
    Question 45. With respect to VA's ability to innovate and 
modernize, do you feel that the department currently has sufficient 
authority to proactively test out new approaches to care and payment 
that could increase efficiency and optimize care?
    Response. The Center for Compassionate Innovation was created to 
explore emerging therapies that are safe and ethical to enhance Veteran 
physical and mental well-being when other treatments have not been 
successful. The Center specifically evaluates innovations for special 
populations of Veterans who have not achieved optimal outcomes with 
traditional, evidence-based medicine including developing partnerships 
and collaborations with community-based organizations to optimize 
access to safe, innovative treatment.
    The Department has sufficient authority to proactively test out new 
approaches to care and payment that could increase efficiency and 
optimize care. As an example, for the first time in VA history, 
Veterans may receive hyperbaric oxygen therapy (HBOT) to treat Post 
Traumatic Stress Disorder (PTSD) symptoms. HBOT treatment for PTSD is 
considered off label use by the Food and Drug Administration and, 
therefore, is not a standard of care treatment option.
    The Center is not only using sharing and provider agreements for 
payment, it is also leveraging telehealth for care where feasible for 
certain treatments.

    Question 46. How would authorities contained in Section 402 of VA's 
CARE Proposal (Authority for VA Center for Innovation for Care and 
Payment) affect VA's ability to pursue these new and innovative 
approaches?
    Response. Section 402 would allow VA, with Congressional approval, 
to waive certain authorities found in Sections 1701-1730A of title 38 
that could otherwise limit VA's ability to identify and test new and 
innovative approaches to care and payment. We also note that section 
401 would allow for a pilot project to improve how VA and DOD furnish 
care to Veterans and Servicemembers. If this section were enacted, the 
VA and DOD Secretaries could determine the feasibility and advisability 
of sharing health care resources without entering into reimbursement 
agreements for such services.

    Question 47. What sorts of approaches would you pursue using this 
new authority?
    Response. Innovations would be focused on testing payment and 
service delivery models to determine whether such models improve the 
access to and quality, timeliness, and patient satisfaction of such 
care and services, as well as the cost savings associated with such 
models. VA would be able to consider changes to collections, 
copayments, payment rates, and contracting authorities.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Dan Sullivan to 
                  U.S. Department of Veterans Affairs
    Question 48. Regarding the recent decision on the Community Care 
Network Acquisition for Region 4,
    a. What were the contributing factors that led to the decision to 
not grant an award under the current solicitation?
    Response. VA received proposals in response to the Community Care 
Network (CCN) solicitation on June 30, 2017, and performed evaluations 
in accordance with the criteria established in the solicitation. VA 
took the following four factors into consideration for award decisions 
for CCN Region 4: (1) Technical, (2) Past Performance, (3) 
Socioeconomic Concerns, and (4) Price. The evaluations resulted in the 
need to conduct negotiations. After negotiations were held, VA received 
the final revised proposals on December 14, 2017, and immediately began 
conducting evaluations of revised proposals. After evaluations were 
completed, it was determined that final proposal revisions for Region 4 
did not provide the ``best value'' to VA, all factors considered, or 
for our taxpayers. VA amended the solicitation to remove Region 4 since 
a contract award was not made.

    b. What will the VA's new acquisition strategy for Region 4 be?
    Response. VA's Office of Community Care (OCC) is currently 
reviewing the requirements that were included in the CCN Performance 
Work Statement for Region 4. VA intends to issue a new solicitation, 
which will include revised requirements for Region 4. Once the 
contracting office has received the complete revised requirements, a 
detailed timeline concerning the re-procurement will be developed.

    c. What is the timeline for reopening competition?
    Response. Competition will be reopened in the next 2 to 3 months.

    d. Will you be proactive in notifying Members whose states are a 
part of this region on process and decisions regarding the acquisition 
moving forward?
    Response. Yes, VA will notify Members of Congress whose states are 
a part of this region on the process and decisions regarding the 
acquisition.

    Question 49. Regarding the VA/DOD National Resource Sharing 
Agreement (dated 12/16), the AK VA/DOD joint venture recently requested 
an exemption from the exchange rate citing adverse budgetary and 
staffing impacts due to variabilities among localities for CMS and 
CMAC--especially in Alaska that would negatively affect their 
partnership and Veteran healthcare. Will you commit to communicate with 
Alaska's VA leadership to fully understand the VA/DOD landscape in 
Alaska and possible impacts before implementing this change in my 
state?
    Response. VA and DOD have been committed to working with local VA 
and DOD facilities on this recent (December 2016) joint policy decision 
to standardize the VA/DOD sharing reimbursement rate. We are currently 
testing the methodology with the help of local VA/DOD partners to 
gather input prior to a phased National roll out. We recently learned 
of Alaska's concerns and requested the local VA/DOD sharing partners 
provide a briefing to the VA/DOD Health Executive Committees, Shared 
Resources Work Group (SRWG) for further consideration. SRWG is 
collaborating with various VHA and Air Force Surgeon General staff 
office experts to review Alaska's concerns and provide guidance as 
applicable.

    Question 50. What has the VA done regarding negotiations of new 
reimbursement rates for VA-IHS tribal sharing agreements in Alaska 
since current rates were last extended?
    Response. VA held a tribal consultation in September 2016 and a 
round table discussion in August 2017. During those meetings, VA and 
Tribal leaders discussed the future of Tribal Health Agreements in 
Alaska and the lower 48 states. This included potentially changing 
reimbursement rates to Performance Based Rates rather than the current 
rates, which are primarily based upon all-inclusive rates published by 
Indian Health Service annually. The tribes expressed major concerns 
about implementing new rates which are more complex to assess. 
Therefore, VA agreed to extend all current agreements through June 30, 
2019, while continued discussions with Tribes will take place to 
enhance care coordination and potentially negotiate rates that are 
based on the quality of care provided.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
                  U.S. Department of Veterans Affairs
                             mental health
    Question 51. Many critical details, and much of the major policy 
provisions, were left out of President Trump's recently signed 
executive order dealing with mental health for veterans. Please provide 
a comprehensive description of the changes that will be made pursuant 
to the executive order, especially--
    a. What veterans will be eligible, and for what type of care?
    Response. There are several legal authorities under which VA can 
provide mental health care, to include outpatient, inpatient, and 
residential services, to transitioning Servicemembers and Veterans. 
These authorities include:

     Emergency circumstances. If a transitioning Servicemember 
or Veteran presents to a VA medical facility with an emergency mental 
health need, VA may provide the treatment while the emergent health 
care need persists. Unless otherwise eligible, the emergency care would 
be provided to the individual on a humanitarian basis (38 U.S.C. 1784), 
or possibly under tentative eligibility (38 CFR 17.34(a)) if a former 
Servicemember presents at a VA facility seeking care for a mental 
health condition he or she asserts is related to military service. For 
emergency care provided on a humanitarian basis, and for emergency care 
provided to a former Servicemember under tentative eligibility who is 
later determined to be ineligible for VA health care, VA will bill for 
the care at a cost-based rate.
     Medical benefits package. Veterans enrolled in VA's system 
of patient enrollment, established under 38 U.S.C. 1705, may receive 
mental health care under the medical benefits package (38 CFR 17.38). 
VA encourages all former Servicemembers who may be eligible to apply 
for enrollment. Additionally, Veterans who have a service-connected 
disability or disabilities rated 50 percent or more can receive mental 
health care under the medical benefits package (38 CFR 17.38) without 
respect to enrollment. See 38 U.S.C. 1705(c)(2), 38 CFR 17.37(a).
     Other treatment authorities and bars to benefits. 
Transitioning Servicemembers and Veterans not eligible for enrollment 
or who elect not to enroll may still be eligible for mental health care 
through VA. Generally, to be eligible for enrollment in VA health care, 
a person must have been discharged or released from active military, 
naval, or air service under conditions other than dishonorable and, 
unless an exception applies, satisfy minimum active duty service 
requirement. Some Veterans may also be ineligible for enrollment 
because their income is over the applicable threshold.
     With respect to character of discharge, a transitioning 
Servicemember generally is not eligible for VA benefits, to include 
mental health care, if he or she is subject to a bar to benefits. 
Individuals barred from receiving benefits include those who, unless 
considered insane, were discharged or released as a conscientious 
objector or deserter, by reason of general court-martial, or as a 
result of AWOL for a certain period unless exempted. See 38 U.S.C. 
5303(a), 38 C.F.R. 3.12(c). If barred, VA may refer the individual to 
community resources (not at VA expense). For example, for an individual 
ineligible for readjustment counseling under 38 U.S.C. 1712A, VA (1) 
provides referral services to assist the individual in obtaining mental 
health care and services outside VA, and (2) if pertinent, advises the 
individual of his/her right to apply for a review of the individual's 
discharge or release. See 38 U.S.C.1712A(c).
     Authorities under which VA may provide mental health care 
to recently transitioned Servicemembers and Veterans who are not 
otherwise eligible include: 38 U.S.C. 1705(c)(2) (for service-connected 
and presumptive service-connected disabilities); 38 U.S.C. 1702 and 38 
CFR 17.109 (presumptive eligibility for psychosis and other mental 
illness); 38 U.S.C. Sec. 1720D (related to military sexual trauma); and 
38 U.S.C. Sec. 1712A and 38 CFR Sec. 17.2000 (readjustment counseling). 
These authorities are discussed below, along with a discussion of 
eligibility for former Servicemembers with other than honorable 
administrative discharges.
     Service-connected and presumptive service-connected 
disabilities. Under 38 U.S.C. 1705(c)(2), VA is required to provide 
hospital care and medical services without respect to enrollment for 
(1) Veterans seeking care for a service-connected disability, and (2) 
for the 12-month period following their discharge or release from 
service, Veterans whose discharge or release from active military, 
naval, or air service was for a disability that was incurred or 
aggravated in the line of duty for that disability. This means that VA 
must provide mental health care to any Veterans seeking mental health 
care for a service-connected disability. Additionally, as may be more 
applicable to the EO, Veterans whose discharge or release from active 
military, naval, or air service was for a disability that was incurred 
or aggravated in the line of duty may receive VA mental health care for 
that disability, without respect to enrollment, for the 12-month period 
following their discharge or release from service.
     Presumptive eligibility for Veterans with psychosis and 
other mental illness. In general, VA can provide treatment for an 
active psychosis or other active mental illness without copayments for 
recently-discharged or released Veterans who developed such psychosis 
or mental illness within 2 years after discharge or release from the 
active military, naval, or air service. See 38 U.S.C. 1702, 38 CFR 
17.109. Such treatment is available without respect to enrollment or 
eligibility for enrollment (38 CFR 17.37(k)), without respect to 
whether the Veteran served in combat, and without regard to the 
Veteran's length of active duty service. These Veterans do not have to 
file a claim for service-connection or have received a formal grant of 
service-connection from VBA to receive treatment under this authority.
     Military sexual trauma. VA provides counseling and 
appropriate care and services under 38 U.S.C. 1720D to Veterans who VA 
determines require such counseling and care and services to overcome 
psychological trauma, which in the judgment of a VA mental health 
professional, resulted from a physical assault of a sexual nature, 
battery of a sexual nature, or sexual harassment which occurred while 
the Veteran was serving on active duty, active duty for training, or 
inactive duty training. VA refers to these experiences as military 
sexual trauma (MST). Care for MST-related mental and physical health 
conditions is provided without copayments. Veterans are not required to 
enroll in VA's system of patient enrollment, file a disability claim, 
be service-connected, or provide evidence of the sexual trauma to 
receive MST-related care.
     Readjustment counseling. VA provides readjustment 
counseling to eligible Veterans and certain members of the Armed Forces 
under 38 U.S.C. Sec. 1712A and 38 CFR Sec. 17.2000 through its Vet 
Centers. The specific categories of individuals eligible for 
readjustment counseling are set forth in law, and include Veterans and 
members of the Armed Forces who served on active duty in a theater of 
combat operations or an area at a time during which hostilities 
occurred in that area. Vet Centers maintain confidential records 
independent from any other VA or DOD medical records; Vet Centers will 
not disclose such records without a voluntary, signed authorization, or 
a specific exception permitting their release. Readjustment counseling 
is available without respect to enrollment and without copayment 
requirements. For more information or to find a Vet Center near you, go 
to https://www.vetcenter.va.gov or call 1-877-WAR-VETS 
(1.877.927.8387).
     Other than honorable administrative discharges. Former 
Servicemembers with other than honorable (OTH) administrative 
discharges who present to VA seeking mental health care may be eligible 
for mental health services under the OTH initiative, which is based on 
VA's authority in section 2 of Public Law 95-126 (38 U.S.C. 5303 NOTE) 
and 38 CFR 3.360 (service-connected health care); 38 U.S.C. 1702 and 38 
CFR 17.109 (psychosis and mental illness presumptions); and 38 CFR 
17.34 (tentative eligibility). Notwithstanding any other provision of 
law, VA provides former Servicemembers with other than honorable 
administrative discharges the type of health care and related benefits 
authorized to be provided under chapter 17 of title 38, U.S.C., for any 
disability incurred or aggravated during active military, naval, or air 
service in line of duty, with the exception of (1) any disability 
incurred or aggravated during a period of service terminated by a bad 
conduct discharge, or (2) when a bar to benefits (discussed above) 
applies. See 38 U.S.C. 5303 NOTE, 38 CFR 3.360. Additional information 
is available on the OTH Fact Sheet (external link).

    b. Does VA have the excess capacity in mental health care to 
provide this treatment?
    Response. VHA continues to evaluate capacity and the regional 
impact the EO may have. VHA is continuing the Mental Health Hiring 
Initiative requested by Secretary Shulkin to add 1,000 net providers to 
the current workforce.

    c. What happens at the end of the year for veterans who still need 
treatment?
    Response. This will depend upon the legal authority for providing 
treatment. For example, if the Veteran is eligible under the Presumed 
Eligibility for Psychosis or Other Mental Illness, this care does not 
have maximum limit, and care will continue beyond 12 months. In other 
situations, where care is to be terminated, all mental health providers 
have the ethical responsibility to ensure a transfer of care is 
completed to a community provider. This transfer of care is completed 
as part of the patient-provider agreement, ensuring there is no Veteran 
left without clinically appropriate follow-up.

    d. Will VA request additional funds to cover the hundreds of 
millions of dollars a year the Administration estimates this will cost?
    Response. It was not VA's intention to request additional funding 
when the OTH Initiative was implemented. As VA expands healthcare 
eligibility, we will continue to work with Congressional partners in 
addressing fiscal impact as appropriate.
                                hud-vash
    Question 52. Data from the Department of Housing and Urban 
Development showed that there was an increase in veteran homelessness 
this year, and a significant increase in my home state of Washington. 
You stated before the Committee that VA will be implementing a new plan 
to address this issue in Seattle. Please provide a full description of 
what additional resources will be made available, any proposed 
programmatic changes, and a timeline for implementation.
    Response. The state of Washington saw an increase of over 600 
homeless Veterans in the 2017 Point in Time Count; an increase of 41 
percent over 2016. This statewide increase was caused almost entirely 
by increases in the Seattle/King County Continuum of Care, which saw an 
increase of 673 homeless Veterans; an increase of over 100 percent 
compared to 2016. The rest of the state actually saw a small net 
decrease.
    VA's Homeless Program Office (HPO) is actively engaged with the 
Puget Sound VAMC and with city, county and state officials to develop a 
comprehensive plan to address the increasing numbers of homeless 
Veterans in Seattle and King County. Planning sessions have included 
the following: a) VAMC-specific calls focused on internal operational 
challenges such as rapidly filling vacant homeless program positions, 
and maximizing available beds and vouchers; b) calls between HPO, the 
VAMC, and city and county officials focused on refining the ``By Name 
List'' and getting consensus across agencies on the current number of 
homeless and at-risk Veterans as well as understanding inflow rates in 
order to best address current and projected demand for resources; and 
c) calls between HPO, the Network Homeless Coordinator, and officials 
from the State Department of Veterans Affairs and the Governor's Office 
focused on strategies for development of additional beds and units to 
increase the stock of available housing.
    VA will continue to work with the VAMC and city, county and state 
officials to finalize a plan to decrease the number of homeless and at-
risk Veterans in Seattle/King County, and we will be happy to share the 
details of that plan once finalized.
    The Grant and Per Diem (GPD) program made the Seattle/King County 
Continuum of Care area a priority for funding in the current GPD Notice 
of Funding Availability.

    Question 53. I have received reports that at least one VA medical 
center in my state is proceeding with the redesignation of Specific 
Purpose funds to General Purpose funds, despite your statement that no 
changes would be made.
    a. Is there an effort underway to redesignate any Specific Purpose 
funds?
    Response. On February 6, 2018, a memo was issued to all Network 
Directors, Network Homeless Coordinators, and Medical Center Directors 
stating that there will be no conversion of Department of Housing and 
Urban Development--VA Supportive Housing (HUD-VASH) Program Specific 
Purpose funding to General Purpose funding during FY 2018. The memo 
goes on to clarify that HPO is currently disbursing HUD-VASH program 
Specific Purpose funding to VISNs and VAMCs based on the FY 2018 budget 
requests submitted by each VISN while adhering to the funding provided 
under the Advanced Appropriation. Once Congress passes the FY 2018 
budget the remaining annual funding will be disbursed. All HUD-VASH 
program requirements remain in place, including staffing, reporting, 
and program metrics.

    b. What directives or instructions have been issued to VISNs 
regarding changes in funding designation, including instructions not to 
move forward with redesignation? Please provide a copy of any 
information or instructions distributed within VA on this topic.
    Response. As requested, enclosed please find the January 8, 2018, 
memo regarding the delay transitioning Special Purpose non-core funds 
to General Purpose. Also enclosed is the February 6, 2018, memo 
referenced in the previous paragraph, noting that there will be no 
conversion of HUD-VASH program Specific Purpose funding to General 
Purpose funding during FY 2018.
                              vet centers
    Question 54. Vet Centers are one of the most important parts of 
VA's mental health service system. They provide care in a unique 
setting, and often see veterans who would not seek care from a 
traditional clinic. So preserving their unique culture and autonomy is 
very important.
    a. Does the Readjustment Counseling Service have all the resources 
and authorities they need to meet demand from veterans and successfully 
implement new initiatives?
    Response. Readjustment Counseling Service (RCS) is in the final 
stages of implementing single points of service for our Human Resource 
and Fiscal functions. This consolidation has allowed RCS to improve all 
budgeting projection processes. Subsequently, RCS has asked for 
increases in the FY 2018 and future FY budget submissions to meet 
current demand and projected demand through increasing access to 
services.
    In addition, RCS is in the 7th year (with extensions) of a pilot 
program to provide recently returning Women Veterans readjustment 
counseling through retreats. This has been accomplished utilizing the 
existing RCS Specific Purpose budget, with no request for additional 
funding. Those who have participated in these retreats have seen 
reduction in their symptoms associated with PTSD and increases in their 
coping abilities.
    There are currently three Bills pending in Congress that address 
readjustment counseling in a retreat setting:

     H.R. 91 Building Supportive Networks for Women Veterans 
Act (Sec. 2): This bill makes permanent the requirement for the 
Department of Veterans Affairs to carry out, through the Readjustment 
Counseling Service of the Veterans Health Administration, a program to 
provide reintegration and readjustment services in group retreat 
settings to women veterans who are recently separated from service 
after a prolonged deployment.
     S. 681 Deborah Sampson Act (Section 103): Provision of 
Reintegration and Readjustment Services to Veterans and Family Members 
in Group Retreat Settings. (Similar to H.R. 2452)
     H.R. 2452 Deborah Sampson Act (Section 103): Provision of 
Reintegration and Readjustment Services to Veterans and Family Members 
in Group Retreat Settings. (Similar to S. 681)

    RCS supports all three Bills, however firmly believes that all 
cohorts of combat Veterans and their families would benefit greatly 
from this modality.
                              data sharing
    Question 55. The IG has testified before this Committee previously 
regarding barriers to VA having access to the DOD suicide database that 
would help VA better design and target suicide prevention efforts. It 
is unacceptable to me that this data is not routinely provided to VA. I 
understand the Departments are working on an agreement to fix that 
problem.
    Response. VA has received data from DOD partners and DOD regularly 
shares summarized data analyses on an as needed basis with VA. The DOD 
and VA data sharing Memorandum of Agreement (MoA) will allow more 
timely sharing of Department of Defense Suicide Event Report data and 
enable broader VA utilization. The MoA is fully developed, and is going 
through VA and DOD privacy clearance prior to DHA and VA signature.

    Question 56. When will that agreement be completed and VA will 
start receiving the DOD suicide data?
    Response. The MoA is currently going through VA and DOD privacy 
clearance prior to DHA and VA signature. Once signed, the MoA will be 
complete and VA will start receiving DOD suicide data.
                            forever gi bill

    Question 57. Many student veterans who could benefit from 
provisions in the Forever GI Bill are still unaware of the changes that 
were made. How does VA plan to ensure veterans who are now eligible for 
expanded educational opportunities are properly informed of these 
recent changes and making decisions in their best interest?
    Response. VA has taken a multi-pronged approach to highlight and 
promote the Colmery Act to Veterans and beneficiaries. This includes an 
extensive social media campaign with regular posts on Facebook, a 
Twitter Town Hall, a satellite media tour that reached an audience of 
over 3 million, new websites, and posting Frequently Asked Questions 
for provisions with the most immediate impact on Veterans and 
beneficiaries.
    VA sent targeted emails and mail to individuals identified as 
eligible for Sections 109 and 106 of the Forever GI Bill, and sent an 
email to over 500,000 individuals who may no longer have a time limit 
to use their Post-9/11 GI Bill benefits. VA has briefed VSOs, attended 
the Student Veterans of America National Conference, and sent 
notifications to internal and external stakeholders on Forever GI Bill 
changes and impacts. As VA moves forward with implementing other 
provisions and making changes because of Forever GI Bill, it will 
continue to send out targeted notifications, and regularly and 
aggressively promote Forever GI Bill through all available mediums.

    Question 58. School Certifying Officials also tell my staff that 
they have not received any information from VA on recent changes from 
the Forever GI Bill. School certifying officials are the first persons 
student veterans turn to for information regarding their benefits. 
Without proper outreach from VA, school certifying officials are 
relying on other unverified sources for information on recent or 
pending changes. I am worried this could lead to misinformation and 
confusing messaging to student veterans. Mandatory training for school 
certifying officials is crucial, when will VA start implementing 
curriculum on the Forever GI Bill?
    Response. On November 29, 2017, the VA's Education Service 
conducted a SCO webinar on the Forever GI Bill and provided information 
on our progress toward implementation. The webinar also included a 
question and answer session in which Education Service responded to 
questions from SCOs. VA sent targeted emails to SCOs on the removal of 
the delimiting date for eligible beneficiaries and the expansion of 
approvable Independent Study programs. In early February 2018, the 
Education Service held a focus group with stakeholders including SCOs 
on its implementation plan for Section 107, and will continue to engage 
with SCOs through regularly scheduled webinars, targeted emails, state, 
regional, national conferences and serve as resource to SCOs as they 
educate students at their facility on the Forever GI Bill.
    VA is also meeting regularly with members and leaders from the 
NASAA and other internal and external stakeholders to discuss training 
development and implementation planning for Section 305.

    Question 59. Regarding the Forever GI Bill, a December memo from VA 
notes that VA has processed 600 applications out of potentially 8000 
beneficiaries (7.5 percent of those eligible) for the restoration of 
entitlement from former students of ITT Tech and Corinthian Colleges. 
How did VA conclude that there were only 8000 potential beneficiaries, 
and what type of notices is VA considering to ensure the benefits 
restoration reaches 100 percent of those eligible?
    Response. Through data analysis, VA identified approximately 8,000 
beneficiaries who attended a facility that met the school closure 
criteria between January 1, 2015, and August 16, 2017. During the week 
of November 9, 2017, VA provided notification to 8,000 students 
identified as potentially eligible to have benefits restored under the 
Special Application provision of Section 109. Of those, approximately 
80 percent received an email with a letter, instructions, and a form to 
apply for restoration. The remaining 20 percent received the same 
documentation via postal mail. As of January 26, 2018, VA has received 
over 700 applications and restored over 4,500 months of entitlement to 
almost 450 individuals.
    VA plans a 90-day follow-up via postal mail to those individuals 
that were sent an email, but not applied for restoration. Additionally, 
we will call a sample of those who have not applied to understand their 
choice and to verify receipt of the initial notification. VA will use 
this information to improve its communication efforts and continue to 
regularly post updates and notices across its social media platforms, 
website, and leverage its partners to ensure impacted students are 
aware that VA can restore lost entitlement.

    Question 60. Has VA placed any outbound calls to potential 
beneficiaries of the entitlement restoration who have not yet applied 
or been approved to notify them of their eligibility?
    Response. Please see our response to question 59 above.

    Question 61. Regarding the Forever GI Bill, the December update 
from VA notes that VA is ``collaborating with SAAs to redesign 
compliance reviews'' per the requirement to include risk-based surveys 
in State Approving Agency oversight activities. What guidance is VA 
providing on the potential risk factors that SAAs might use in their 
reviews?
    Response. VA partnered with SAAs to conduct targeted risk-based 
compliance reviews over the last 3 years, and has continued to examine 
and evaluate our compliance regimen. VA recently completed a year-long 
study of our compliance and liaison processes, organizational 
structure, and stakeholder engagement. Additionally, VA and NASAA 
constituted a working group to consider the findings from this study 
and section 310 of the Colmery Act. Among many other aspects, we will 
be collaborating on the issue of risk factors and resultant oversight 
and compliance actions.

    Question 62. What is VA's timeline for completing the collaboration 
with SAAs and seeing risk-based reviews implemented as required by the 
Forever GI Bill?
    Response. As the VA-NASAA joint working group was just implemented, 
no specific timeline has been established. VBA expects to begin 
implementing potential changes from this workgroup in FY 2019.

    Question 63. Regarding the Forever GI Bill, the updated provided by 
VA notes that VA is ``establishing IPT to develop requirements and 
processes'' for the High Technology Pilot Program. The Senate Committee 
report accompanying S. 1598 emphasized that ``the Committee seeks to 
ensure that veterans are protected against programs that will not allow 
them to obtain sustainable employment in the technology sector'' 
particularly given the closure of other technology programs, including 
coding ``boot camp'' locations, and listed specific indicators of risk 
for VA to consider when entering into contracts with providers of these 
programs, including financial stability and alignment to industry-
recognized certifications and credentials. How is VA planning to 
incorporate these defined outcome and quality expectations into its 
initial design of the High Technology Pilot Program?
    Response. The statutory requirements for the High Technology Pilot 
Program outline approval criteria and a payment schedule for 
contractors based on targeted milestones. VA will look to further 
expand on the approval criteria in consultation with SAAs, and will 
further clarify payment schedule milestones in the agreements it enters 
into with providers. These agreements will also include termination 
clauses and oversight measures for VA to perform compliance reviews.

    Question 64. Regarding the Forever GI Bill, the December update 
notes that VA is ``reviewing statutory requirements to develop 
appropriate safeguards and processes'' for the Edith Nourse Rogers STEM 
Scholarship. When does VA expect to conclude its review of the 
requirements, and what actions does it anticipate taking at the 
conclusion of this review?
    Response. VA is analyzing statutory requirements to develop 
planning documents for the STEM scholarship, which does not go into 
effect until August 1, 2019. The requirements for this provision do not 
conform to VA's current technology and business rules for the Post-9/11 
GI Bill; therefore, VA has identified the VA Regional Processing Office 
in Buffalo, NY, as the sole site dedicated to processing and tracking 
the STEM Scholarship. VA expects a more fully developed plan with 
regulatory, communication and program requirements to be drafted by 
December 2018.

    Question 65. The Senate Committee report on the Forever GI Bill 
specified that safeguards for the Edith Nourse Rogers STEM Scholarship 
should include a mechanism to ensure that schools or programs are not 
expanding the number of credit hours needed to complete a STEM program 
so they can receive additional tuition and fee payments from the Edith 
Nourse Rogers STEM Scholarship. Is VA capable of monitoring for changes 
in credit hour requirements and will VA ensure that it will examine 
whether additional semester or quarter hours are being required in non-
STEM fields or for non-GI bill beneficiaries?
    Response. VA has had preliminary discussions with SAAs regarding 
requirements of the STEM provision and will engage other appropriate 
stakeholders as we further develop the implementation plan.

    Question 66. Has VA communicated with accrediting agencies or SAAs 
requiring their ability to assist in gathering information regarding 
program length for those programs which may become eligible for the 
Edith Nourse Rogers STEM Scholarship?
    Response. Please see our response to question 65 above.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
                  U.S. Department of Veterans Affairs
    Question 67. How many student veterans has VA identified as 
eligible for restoration of benefits established in the Forever GI 
Bill? Please provide my office with updated numbers, disaggregated by 
institution, of veterans and their families from Ohio or attended for-
profit schools in Ohio who are eligible for GI Bill benefits 
restoration in light of the Forever GI bill.
    Response. For the Special Application provision we have identified 
three Ohio schools whose students would be eligible for restoration:

 
------------------------------------------------------------------------
                                                            Number of
                    Name of School                          students
------------------------------------------------------------------------
Brown Mackie College-North Canton.....................          12
Miami-Jacobs Career College-Sharonville...............           1
Sanford Brown College.................................           3
------------------------------------------------------------------------
Please note, this number does not include beneficiaries who may have
  resided in Ohio, and attended a school that closed out of state or
  online.


    a. What have you done to ensure that students impacted by the 
closure of ITT and Corinthian Colleges have the benefits that they have 
earned restored?
    Response. VA notified approximately 8,000 individuals, regarding 
their potential eligibility for entitlement restoration, of which, 
nearly 6,000 were ITT Tech or Corinthian students. VA created a 
dedicated webpage, https://benefits.va.gov/gibill/fgib/restoration.asp, 
which addresses restoration of entitlement and includes the form that 
beneficiaries can use to apply for benefit restoration. VA is using 
social media including Facebook and Twitter to let beneficiaries know 
that VA can now restore entitlement and encourage those potentially 
eligible to apply.

    b. What communication via phone, mail, email, and social media has 
VA sent to these veterans? What additional communication do you have 
planned?
    Response. Through data analysis, VA identified approximately 8,000 
beneficiaries who attended a facility that met the school closure 
criteria between January 1, 2015, and August 16, 2017. During the week 
of November 9, 2017, VA provided notification to 8,000 students 
identified as potentially eligible to have benefits restored under the 
Special Application provision of Section 109. Of those, approximately 
80 percent received an email with a letter, instructions, and a form to 
apply for restoration. The remaining 20 percent received the same 
documentation via postal mail. As of January 26, 2018, VA has received 
over 700 applications and restored over 4,500 months of entitlement to 
almost 450 individuals.

    c. What tools and resources are being expended to ensure all 
students who are eligible to have their benefits restored are fully 
informed and able to reclaim these benefits and continue their 
education?
    Response. VA is continuously looking to push its communications 
through new platforms and leveraging its partners to help get its 
message out. To that end, VA plans to host a Facebook Live event in 
partnership with a National Military Family Association and using 
Medium to publish blogs on the Forever GI Bill.

    d. Would student veterans happen if a for-profit college or 
university shuttered their doors abruptly tomorrow have the ability to 
get their GI Bill benefits restored?
    Response. The Forever GI Bill sections in Section 109 also allow 
restoration of entitlement for VA students if a school closes. This 
means that VA will not make a charge against students' entitlement for 
the portion of the period that the students did not receive credit 
toward their programs (or lost training time toward the completion of 
their program). For example, if a student was enrolled in a semester 
full-time, and the school closed 60 days after the semester started, 
the student would have used 2 months of their entitlement. VA will 
restore those two months back to the student and the student will have 
those 2 months available to use at another time.
    Additionally, for school closings on or after August 16, 2017 (date 
of bill enactment), VA may continue the housing allowance for Post-9/11 
GI Bill students beyond the date of closure up to the end of the term, 
quarter or semester, not to exceed 120 days. The law requires that VA 
begin making these payments of housing allowance on August 1, 2018. No 
charge to a student's entitlement will be made for the extended period 
of eligibility for housing allowance.

    Question 68. In addition to restoring GI Bill benefit eligibility 
to student veterans harmed by the precipitous closure of ITT Tech and 
Corinthian Colleges, this bill gives VA additional tools to provide 
oversight of programs to ensure that student veterans are using their 
benefits at reputable programs and institutions. State Approving 
Agencies approve, review, and monitor training and education programs 
that have access to VA education benefits. The Forever GI Bill 
authorized additional funding for State Approving Agencies (SAAs) and 
expanded SAA's oversight duties by charging SAAs to conduct risk-based 
program reviews.
    a. How has VA worked with SAAs on including risk-based reviews as 
part of their oversight efforts?
    Response. Over the last 3 years and well prior to the Colmery Act, 
as part of VA's strong partnership with SAAs in our mutual oversight 
and compliance responsibilities, SAAs conducted approximately 30 
percent of the targeted risk-based compliance reviews at schools where 
special risk indicators were discovered. The Executive Director of 
VBA's Education Service and the President of the National Association 
of State Approving Agency have constituted a Risk-based Review 
Workgroup comprised of VA and SAA staff to analyze and implement 
potential policy and procedural changes with respect to Risk-Based 
Reviews.

    b. How has VA worked to strengthen SAAs' ability to evaluate and 
monitor programs receiving GI Bill funds?
    Response. VA reduced the number of compliance surveys required for 
the majority of SAAs for FY 2017 and FY 2018 in order to ensure SAAs 
have the time and resources to focus on school and facility approvals, 
as well as referrals made to SAAs regarding school concerns and student 
complaints.

    Question 69. As you know Ashford University, the large for-profit 
school, was found to be out of compliance in November 2017. The school 
had 60 days to get in compliance. Earlier this month, Ashford announced 
it would seek approval from the California SAA to receive VA 
educational benefits and VA announced Ashford would continue to receive 
GI Bill dollars as the school pursues approval from the California SAA. 
Please outline statutory requirements and VA procedure for 
communicating with student veterans if their program is found to be out 
of compliance. Detail the communication VA had with student veterans 
since Ashford was found to be out of compliance last fall. Should the 
California SAA not approve Ashford's programs, what steps would VA take 
to protect student veterans and taxpayer investment in higher education 
and how would VA communicate that information with student veterans?
    Response. Section 3690(b)(3)(B)(iii) of title 38, United States 
Code, requires VA to notify beneficiaries enrolled in an affected 
program at least 30 days prior to suspending or disapproving benefits 
for failure to meet approval, recordkeeping or reporting requirements. 
Student notification requirements are also codified in VA regulations 
in section 21.4210(e)(2) of title 38, Code of Federal Regulations. In 
fulfillment of these statutory and regulatory notification 
requirements, VA identified current or recent GI Bill beneficiaries 
enrolled in Ashford University's online programs and notified them by 
email, or by letter if no email address was found, of the situation and 
of the fact that benefit payments for enrollment in Ashford's online 
programs could be discontinued in 30 days if corrective action was not 
taken by Ashford.
    Since Ashford University's online programs were approved by the 
Arizona SAA, VA has provided information and status updates on three 
separate occasions.

     November 10, 2017: Students were informed of VA's 
correspondence to Ashford University and the Arizona State Approving 
Agency that GI Bill benefits could potentially end in 60 days if 
corrective actions are not taken.
     December 13, 2017: Students were informed that GI Bill 
benefits could potentially end in 30 days if Ashford does not submit an 
application for approval to the California SAA by January 8, 2018, and 
support the approval process in good faith.
     January 23, 2018: VA sent an email informing beneficiaries 
that Ashford submitted a timely application to the California SAA, and 
that benefits would not be interrupted as long as Ashford continues to 
make a good faith effort to support the approval process in California.

    Unless Ashford University is determined to be fully compliant with 
program approval requirements, Federal law mandates that VA must 
ultimately discontinue benefits for enrollment in the school's online 
programs. Since June 2016, VA has notified GI Bill beneficiaries of the 
potential for disruption of benefits due to program approval issues at 
Ashford University on nine separate occasions in order to ensure that 
they are informed consumers and understand the potential risks of 
continued enrollment. In the event that VA is forced to discontinue 
benefits, we will work with schools, State Approving Agencies, and 
Veterans Service Organizations to identify educational alternatives and 
additional resources that can assist our beneficiaries in continuing 
their educational pursuits, and we will provide that information to 
affected students.

    Question 70. What kind of oversight efforts has VA anticipated 
needing to ensure that new offerings from Forever GI, including the 
STEM Scholarship and the High Tech pilot program, are actually serving 
veterans? Please provide a status update on those oversight efforts.
    Response. VA is currently analyzing the statutory requirements for 
both these provisions and developing planning documents for 
implementation. Both programs will require oversight and compliance 
efforts to ensure proper program administration and protection for both 
the taxpayer and beneficiary. To accomplish this task, VA is 
establishing specialized teams located at the VA Regional Processing 
Office in Buffalo, NY.

    Question 71. What is the timeline for the interagency to make a 
determination regarding Agent Orange presumptive conditions including 
bladder cancer, hypothyroidism, and Parkinson's-like symptoms?
    Response. Once the President's nominee has been confirmed and sworn 
in as Secretary, VA will examine the current policy, complete a full 
review on this issue and provide new guidance on this issue as needed.

    Question 72. What is the status of the National Academy of Medicine 
study regarding Agent Orange exposure on descendants? I know they held 
a meeting in November 2017, when do you anticipate a report to VA?
    Response. VA has a current contract with the National Academy of 
Medicine (NAM) to investigate the broad range of conditions possibility 
associated with exposure to Agent Orange. Included in this review is a 
review of the potential that Agent Orange may have affected the health 
of Veterans' descendants. The NAM's report is due to VA by 
January 2019. The Committee's charge includes looking at descendant 
health and in particular, the Committee was asked to pay special 
attention to the potential risk of parental transmission of disease 
conditions to descendants.

    Question 73. I support the recent executive action to provide 
mental health care for transitioning servicemembers. However, I am 
concerned that VA does not have the resources it will need to meet the 
additional demand.
    a. What steps are you taking to ensure that medical facilities 
staff mental health professional shortages?

    b. What additional resources-funding or personnel- are needed to 
meet this growing need, and how will propose bridging the gap?
    Response (73 a & b). VA has a Mental Health Hiring Initiative goal 
of hiring 1,000 providers by December 31, 2018, to enhance VHA's 
ability to provide mental health services. There is a nationwide 
shortage of psychiatrists and psychologists. Psychiatrists have been 
identified as the top hard to recruit and retain VHA physician 
specialty in FY 2016 and FY 2017. Psychologists have been identified as 
the fourth hardest to recruit and retain VHA occupation in FY 2016 and 
FY 2017.
    Despite national shortages in mental health providers, VHA 
outpatient mental health demand is anticipated to grow by 12 percent by 
2021. The recent Executive Order requires all new Veterans to receive 
mental health care for at least 1 year following their separation from 
service. Veterans choose to get more of their mental health care from 
VA than the private sector, so there is an expectation the demand will 
exceed the previous 12 percent estimate.
    VA is expanding the use of tele-mental health to reach areas of the 
country with a shortage of providers and working with community 
partners to provide care in the community. VA has increased the number 
of graduate medical education physician residency positions in mental 
health by 167.55 since 2014, with the newest cohort expected to begin 
training this July. However, VA needs additional resources such as 
funding for recruitment and retention incentives, Education Debt 
Reduction Program, and the Student Loan Repayment Program in order to 
aggressively compete with the private sector for this limited pool of 
mental health providers.

    Question 74. As of the hearing there were 1,321 vacancies in Ohio, 
with the following breakdown: Veteran Health Administration 1,204 
exempt 55 nonexempt, Veteran Benefit Administration 48 exempt 9 
nonexempt, Human Resources and Administration 2 nonexempt, Office of 
Information and Technology 3 exempt.
    a. Of those exempted positions, what is the average time to fill a 
vacancy?
    Response. The following Time to Hire (T2H) data is based on the 
data utilized for hiring metrics during the 1st quarter of FY 2018. The 
data provided represents hiring actions made via a job announcement and 
does not include hires made via the noncompetitive hiring process.
T2H Overview:

    The T2H metric is measured from the date the hiring need is 
validated to the actual start date. OPM's recommended T2H is 80 days.

     VA-wide average T2H: 73 days.
     VHA average T2H: 79 days.
     VBA average T2H: 44 days.
     NCA average T2H: 64 days.

    b. What is the breakdown of the VHA exempted vacancies by VAMC and 
specialty?
    Response. The Secretary removed the hiring freeze on VHA medical 
centers within days after expiration of the Federal hiring freeze. 
Medical centers are able to hire for all positions and occupations.

    Question 75. Does the Department support the SVAC-passed 
comprehensive health care bill?
    Response. VA finds much of value in S. 2193, as approved by the 
Senate Veterans' Affairs Committee on November 29, 2017, but an 
Administration position has not been established on the legislation. We 
look forward to continuing work with the Committee on this important 
effort.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
                  U.S. Department of Veterans Affairs
      gi bill eligibility for former corinthian colleges students
    With the passage of the Harry W. Colmery Act, also known as the 
``Forever GI Bill,'' VA has been given authority and resources to 
restore education benefits to student veterans who lost them following 
the closure of for-profit institutions like Heald College which 
operated in many states including Hawaii and approximately enrolled 192 
veterans at the time of its closure.

    Question 76. Secretary Shulkin, could you provide the Committee 
with an update on the number of affected student veterans VA has 
restored benefits for those who attended Corinthian Colleges in Hawaii 
and the total number across the country who attended for-profit 
institutions that closed down?
    Response. As of January 26, 2018, VA has received over 700 
applications and restored over 4,500 months of entitlement to almost 
450 individuals. Heald College, which operated in many states including 
Hawaii, had enrolled 192 Veterans at the time of its closure. Since the 
new passage of the law, 67 beneficiaries that attended a school in 
Hawaii could apply for restoration. Of those, only 7 students have 
applied. Six students were found ineligible and 1 student benefits was 
restored for 11 months and 12 days.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to 
                  U.S. Department of Veterans Affairs

    Question 77. In a January 5th interview with Federal News Radio, 
Secretary Shulkin proposed that a review and closure process of 
underutilized and vacant facilities, like the Department of Defense has 
with BRAC, would free up resources and do maintenance on its newer 
facilities.
    a. How does VA define `underutilized' in this context?
    Response. VA kicked off an initiative in June 2017 to reduce the 
burden of vacant buildings within its inventory. At the time, VA had 
430 vacant buildings that cost approximately $7 million a year to 
maintain. To date, VA has reused or disposed of 131 (30 percent) of the 
430 assets identified as vacant and is on track to meet its goal of 
initiating disposal or reuse actions for all 430 buildings by 
June 2019. On an annual basis, VA reports the number of underutilized 
buildings in its inventory. An underutilized building is defined as an 
individual building that is occupied and in use, but the function(s) 
housed there do not require the full amount of space in the building to 
operate. Essentially, the building is too big and not right-sized for 
the functions housed in it. While an underutilized building is not as 
efficient as it could be, the functions currently housed in it are 
still needed. VA is not reviewing or closing any underutilized 
facilities at this time. nor is VA initiating a Base Realignment and 
Closure (BRAC)-like process for these buildings.

    b. What criteria would be used in the evaluation process for 
determining which facilities would be susceptible to a BRAC?
    Response. The Department is neither planning, initiating, nor 
undergoing a BRAC-like process. VA has developed the methodology for 
completing market area health system optimization assessments in each 
of the 96 health care markets around the country, with the goal of 
assessing the current and future Veteran demand for health care, 
assessing the available Federal and non-Federal assets available to 
meet that demand in each market, and planning to match that capacity to 
the demand in modernized high performing networks using a data-driven 
approach. The primary drivers for decisionmaking in each market would 
be better access, better quality of care, and higher levels of Veterans 
satisfaction in each market, at a sustainable cost.
    These networks will be well-connected, comprehensive coalitions, 
led by experienced VA managers who will coordinate VA health care 
services, complemented where appropriate by DOD providers, VHA's 
academic affiliates, and other high quality private sector providers 
with competence in caring for veterans with service-connected 
conditions. Once the market assessments are complete and VA has market 
level, VISN level and regional or national level plans, the needs for 
capital investments for modernization, access, quality and Veteran 
satisfaction will be known. Similarly, the need for divestments of 
underutilized facilities may become apparent, where plans for the high 
performing local network would render an underutilized facility vacant. 
Until this process is completed in some VISNs, the facilities 
susceptible to renovation, modernization, repurposing or divestment 
will not be fully known.
    The VA MISSION Act of 2018, Section 203 requires the development of 
Criteria on the ``modernization or realignment of VHA Facilities.'' VHA 
will work with the Office of Asset Enterprise Management, which has 
existing criteria that has been used, most recently, in development of 
the list of vacant and underutilized buildings that was referenced by 
former Secretary Shulkin in January. Additionally, VHA Operations will 
also be included in the discussion to insure broad understanding and 
field impact to follow the requirements of this section of the MISSION 
Act.

    Question 78. In terms of the 110 quality metrics posted on VA 
webpages--
    a. How are you equipping local VA Medical Center staff to track and 
record these metrics?
    Response. These metrics are available to all VA staff through the 
Strategic Analytics for Information and Learning (SAIL) reporting 
system via the agency's intranet. SAIL includes drill-down tools that 
allow more detailed trending of individual metrics and access to 
diagnostic tools that can help facilities improve their performance. 
Employees with authorization to view Social Security Number-level data 
for their facility will also be able to identify the specific Veterans 
records that contributed to the quality measure.

    b. Who in the West Virginia VAMCs are responsible for collecting 
this data?
    Response. Data are collected via a centralized process for all 
VAMCs and are not dependent on local data collection efforts. This 
ensures the reliability of the data and reduces the likelihood of 
manipulation or ``gaming.'' The exact process of collecting data vary 
by the specific measure domain. For instance, patient experience data 
is collected via a survey mailed by an outside contractor to Veterans 
who have recently used VA inpatient services. That contractor conducts 
the survey, collates, analyzes, and reports results according to 
standard protocols established by the Centers for Medicare and Medicaid 
Services (CMS). Health outcomes data are calculated using CMS 
algorithms from electronic data derived from our EHR. Measures for 
timely and effective care are collected via standardized processes for 
medical record abstraction through VA's External Peer Review Program.

    c. In your hearing, you cited that an HHS contract issues resulted 
in VA data not being able to update information on Hospital Compare 
website. Can you please elaborate on the contract issues and what VA 
and HHS are doing to mediate this in the near term?
    Response. VA and CMS have been working together to include quality 
measure data on the Hospital Compare website. Revisions to an 
Interagency Agreement (IAA) with CMS were completed, and the new VA-CMS 
IAA was signed in April 2017. Subsequent to that, CMS has been updating 
its processes to incorporate VA data in the calculation of measures for 
the different domains of performance such as Outcomes, Safety, 
Timeliness and Effectiveness, and Patient Experience. Many quality 
measures for VA hospitals have been updated and are posted on Hospital 
Compare, such as hospital survey data and readmissions and mortality 
measure data. CMS is also working with the VA on additional measures 
that can be added to the website.

    Question 79. In light of President Trump's declaration of a public 
health emergency, what additional resources or authorities does VA need 
to more effectively combat the opioid crisis?
    Response. Action steps if new budget dollars were identified within 
VHA's budget:

     Enhanced Pain Management Teams with multi-modality 
approaches and increased consultative opportunities through SCAN-ECHO 
and Telehealth.
     Expand education opportunities and collaborations between 
VA, other Federal Agencies and private providers.
     Provide Academic Detailers and other VA developed training 
to private providers, especially those providing care to Veterans in 
the community.
     Increased capacity for high functioning primary care teams 
with timely access to pain specialty care for the most complex pain 
patients (stepped care).
     Fully integrated bidirectional State Prescription Drug 
Monitoring Programs (PDMP) and data storage allowing automated checks 
and data retrieval reducing the provider burden.
     National media campaign for STOP PAIN to enhance the 
awareness, availability, and utilization of VA developed best practices 
in the private section to include:

          - Stepped Care Model;
          - Treatment alternatives/complimentary care;
          - Ongoing monitoring of usage;
          - Practice Guidelines;
          - Prescription monitoring;
          - Academic Detailing ;
          - Informed consent for patients; and
          - Naloxone distribution.

    Question 80. In your written testimony, you cite that the 
December 2017 strategic pause of the Electronic Health Record 
Acquisition occurred so that additional and external assessments of 
national interoperability language contained in the request for 
proposal (RFP) would ultimately support an EHR contract award.
    a. Please describe specifically what assessments were done before 
the Cerner award was announced.
    Response. The MITRE Corporation was selected to coordinate and lead 
an independent assessment utilizing external clinical, technical, and 
executive-level interoperability experts to evaluate the contract 
language related to interoperability. After reviewing the assessment, 
the Department of Veterans Affairs (VA) adjudicated/reconciled each of 
MITRE's comments into the updated request for proposal (RFP).
    VA took an additional step utilizing a myriad of key leaders from 
the private sector (e.g., Johns Hopkins, Mayo Clinic, Intermountain, 
Cleveland Clinic, among others), who recently implemented a new 
electronic health record solution, to ensure there were no gaps in the 
RFP and lessons learned were captured from the private sector. The 
comments submitted were primarily high-level lessons learned from their 
own past experiences. VA effectively re-validated the RFP language 
based on these inputs.

    b. How much will this additional MITRE Corporation assessment cost?
    Response. The MITRE Corporation Interoperability Assessment (Task 
1) was awarded for $396,581.

    c. In the meantime, what are you doing to undergird the current EHR 
system to ensure patient care presently?
    Response. VA is committed to maintaining high-quality connections 
through health information exchanges. These connections, in turn, push 
further cooperation among the three dominant exchanges (CareQuality, 
CommonWell, eHealthExchange) and with regional health information 
exchanges.

                            A P P E N D I X

                              ----------                              


  Prepared Statement by National Organization of Veterans' Advocates, 
                                  Inc.
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, The National Organization of Veterans' Advocates (NOVA) 
would like to thank you for the opportunity to provide a statement in 
response to Secretary Shulkin's testimony regarding VA reform 
legislation passed in 2017. Our statement will focus on implementation 
of the Veterans Appeals Improvement and Modernization Act of 2017.
    NOVA is a not-for-profit 501(c)(6) educational membership 
organization incorporated in the District of Columbia in 1993. NOVA 
represents nearly 600 attorneys and agents assisting tens of thousands 
of our Nation's military veterans, their widows, and their families 
seeking to obtain their earned benefits from VA. NOVA works to develop 
and encourage high standards of service and representation for all 
persons seeking VA benefits. NOVA members represent veterans before all 
levels of VA's disability claims process, and handle appeals before the 
U.S. Court of Appeals for Veterans Claims (CAVC) and U.S. Court of 
Appeals for the Federal Circuit (Federal Circuit). In 2000, the CAVC 
recognized NOVA's work on behalf of veterans with the Hart T. Mankin 
Distinguished Service Award. NOVA operates a full-time office in 
Washington, DC.
    Attorneys and agents handle a considerable volume and growing 
number of appeals at the Board of Veterans' Appeals (BVA). In FY 2015, 
for example, attorneys and agents handled 14.9% of appeals before BVA. 
This number was fourth only behind Disabled American Veterans (28.1%), 
State Service Officers (16.5%), and American Legion (15%). U.S. 
Department of Veterans Affairs, Board of Veterans' Appeals Annual 
Report Fiscal Year 2015 at 27. In FY 2016, this number grew to 15.9%, 
third only to Disabled American Veterans (28.1%) and American Legion 
(19.6%). U.S. Department of Veterans Affairs, Board of Veterans' 
Appeals Annual Report Fiscal Year 2016 at 26. Similar statistics are 
available for FY 2017, with attorneys and agents representing 
appellants in 17% of cases, again third behind Disabled American 
Veterans (31%) and American Legion (18%).
    NOVA members have been responsible for significant precedential 
decisions at the CAVC and Federal Circuit. In addition, as an 
organization, NOVA has advanced important cases and filed amicus briefs 
in others. See, e.g., Henderson v. Shinseki, 562 U.S. 428 
(2011)(amicus); NOVA v. Secretary of Veterans Affairs, 710 F.3d 1328 
(Fed. Cir. 2013)(addressing VA's failure to honor its commitment to 
stop applying an invalid rule); Gray v. Secretary of Veterans Affairs, 
No. 16-1782 (Jan. 3, 2018)(amicus in support of petition for rehearing 
before the Federal Circuit); Robinson v. McDonald, No. 15-0715 
(July 14, 2016)(CAVC amicus).
    We detail below concerns that should be addressed to ensure 
implementation of the appeals reform legislation preserves the long-
standing intent of Congress: that the VA benefits adjudication and 
appeals process be veteran friendly and nonadversarial.
                                overview
    NOVA appreciated the opportunity to participate in the discussion 
of appeals reform that led to the passage of the Veterans Appeals 
Improvement and Modernization Act of 2017. We also applaud VA's ongoing 
inclusion of stakeholders in the discussion of its implementation 
plans, which has included opportunities to review draft regulations and 
documents related to its Rapid Appeals Modernization Program. NOVA 
remains committed to providing constructive feedback in response to 
these opportunities, and urges VA to consider and implement the 
recommendations of the stakeholder community.
    As we have previously noted, successful implementation will be key 
if appeals reform is truly to be the positive change veterans deserve 
and VA promises. Successful execution of VA's proposed process hinges 
on its ability to consistently meet its goals of adjudicating and 
issuing decisions in the 125-day window identified for supplemental 
claims and deciding appeals within the one-year period before BVA. As 
demonstrated with the prior backlog of original claims and scheduling 
of medical appointments, VA often struggles to meet its own internal 
goals to the detriment of veterans.
               rapid appeals modernization program (ramp)
    Relying on section 4 of Public Law 115-55, VA implemented the Rapid 
Appeals Modernization Program (RAMP) in November 2017. According to the 
Standard Operating Procedures (SOP) designed for RAMP, the Veterans 
Benefits Administration (VBA) ``will administer this pilot during the 
18-month period after enactment allowed for full implementation of the 
new process and continue processing elections by Veterans as long as 
necessary thereafter to continue to accelerate resolution of legacy 
appeals.'' SOP at 1. Based on VA's proposed rollout of this program, as 
of January 1, 2018, VA sent approximately 15,500 letters to veterans 
with appeals eligible for acceptance into RAMP. Secretary Shulkin 
testified that, to date, three percent of invited veterans have elected 
to opt into RAMP, and 75 percent of those decided have received a 
grant.
    As an initial matter, stakeholders need information and statistics 
on a regular basis to understand the current status of RAMP. How many 
appeals have been withdrawn from the legacy system and moved into RAMP, 
and what option was selected? What constitutes a grant? Have the 25 
percent who received denials chosen to take any additional action? We 
realize it is still early in the process and some statistics might not 
yet be available. However, such data is important to stakeholders to 
understand the current state of the program and provide the best advice 
to veterans and their families. Data is also a critical component of 
any true pilot program to measure its success, and VA must commit to 
regular updates so stakeholders can gauge progress and suggest 
improvements. Furthermore, VA should ensure its field staff is 
receiving regular communications and training on RAMP operations, as 
well as updates on its progress.
    From NOVA's perspective, there are a few reasons why there is a low 
opt-in rate to RAMP. First, VA chose not to extend the program through 
to BVA. Therefore, a veteran who withdraws his or her pending appeals 
(with no opportunity to return to the legacy system), is denied after 
either a higher-level review or supplemental claim, and wishes to 
appeal to BVA must now wait until the system is fully implemented--at 
the earliest in February 2019--to obtain BVA review. While VA has 
stated those veterans will be first in line for BVA review upon full 
implementation of the system, many representatives are reluctant to 
counsel an appellant to move into a program that does not extend to BVA 
and does not provide a full understanding of how the procedure will 
ultimately operate at BVA. Furthermore, VA's recently submitted 
implementation plan indicates that the ``average processing time goal 
for appeals under Sec. 7107 does not apply to appeals submitted to the 
Board in response to a decision under VBA's RAMP.'' U.S. Department of 
Veterans Affairs, Comprehensive Plan for Processing Legacy Appeals and 
Implementing the Modernized Appeals System 8 (November 2017).
    Second, VA is targeting the oldest appeals. While we understand 
this strategy is designed to be fair to those who have been waiting the 
longest, many veterans currently receiving invitations are close enough 
to a BVA decision that they do not wish to move into something new, 
particularly in light of Secretary Shulkin's welcome statement that BVA 
intends to decide 81,000 appeals in FY 2018.
    In addition, veterans with cases in remand status may be more 
likely to stay in the legacy system because BVA will retain 
jurisdiction over the appeal. The veteran will be entitled to expedited 
consideration upon return to BVA if he or she is not satisfied with the 
action taken on remand, as well as enforcement of the prior order.
    Finally, although NOVA appreciates VA efforts to ensure attorneys 
and agents receive copies of RAMP correspondence sent to veterans 
(required under its M21-1 Adjudication Procedures Manual for all 
correspondence), VA's mailing systems remain seriously flawed both for 
RAMP and overall adjudication procedures. NOVA receives nearly daily 
complaints from members that copies of correspondence are not being 
received. While VA has stated it plans to launch a centralized outgoing 
mailing system to rectify these issues, far too much correspondence has 
gone unmailed and unreceived. When VA fails to properly notify, 
important deadlines are missed and additional claims and appeals must 
be pursued to address VA's failures, resulting in yet more delay in the 
process.
    It is clear that VA is not fulfilling its responsibilities in this 
regard. In July 2017, the Government Accountability Office (GAO) 
completed a report addressing VA's outgoing mail deficiencies. U.S. 
Government Accountability Office, Report to the Chairman, Committee on 
Veterans Affairs, House of Representatives, Veterans Affairs: Actions 
Needed to More Effectively Manage Outgoing Mail, GAO-17-581 
(July 2017). In addition to finding VA has an outdated mail management 
policy directive and handbook, it noted that ``VA cannot ensure 
consistent mailing practices in its administrations and facilities 
because it has not provided mail managers with appropriate authority 
and responsibilities to oversee mail operations across the agency.'' 
GAO Report at 7; see also GAO Report at 15. VA must improve its mailing 
practices, so veterans and their representatives receive proper notice 
of claims and appeals processing.
        implementation of the veterans appeals improvement and 
                       modernization act of 2017
    As part of the reporting requirements imposed under Public Law 115-
55, in November 2017, VA submitted its first report, Comprehensive Plan 
for Processing Legacy Appeals and Implementing the Modernized Appeals 
System (hereinafter Comprehensive Plan). VA does not provide sufficient 
details for how it will handle legacy appeals in relation to modernized 
appeals once the new system is implemented. Based on several statements 
made in the report, it appears VA intends to devote resources first to 
modernized appeals and allocate ``leftovers'' to legacy appeals. See, 
e.g., Comprehensive Plan at 4 (``VA will allocate available resources 
to meet the timely processing goals in the new system, as outlined in 
section 3(a)(3), and remaining resources are then employed to process 
legacy appeals.''); Comprehensive Plan at 9 (``VA intends to allocate 
resources in an efficient manner that will establish timely processing 
in the new process and will allocate all remaining appeals resources to 
address the inventory of legacy appeals.''); Comprehensive Plan at 10 
(``VBA intends to allocate field resources in an efficient manner that 
will establish timely processing in the new process and will allocate 
all remaining resources to address the inventory of legacy appeals.''). 
VA needs to provide more details about how it will continue to process 
legacy appeals in a fair and timely manner while fulfilling its 
obligations under the new legislation, to include how it will address 
the substantial backlog of BVA hearing requests.
    Furthermore, in its implementation plan, VA stated it needs 
enhancements to the Veterans Benefits Management System (VBMS) to meet 
the statute's specifications. Comprehensive Plan at 15. Secretary 
Shulkin also testified to VA's ``enterprise-wide efforts to modernize 
the appeals process through improvements in technology.'' Statement of 
the Honorable David J. Shulkin, M.D., Secretary of Veterans Affairs, 
for Presentation Before the Senate Committee on Veterans' Affairs, The 
State of VA: Progress Report on Implementing 2017 VA Reform Legislation 
3 (January 17, 2018). Congress must ensure VBA and BVA continue to 
receive sufficient resources to implement necessary technological 
upgrades to its systems, particularly VBMS and Caseflow. VBMS was not 
designed with appeals processing in mind, and it lacks many features 
that would make work for VBA employees, BVA employees, and 
representatives easier and more efficient. VA should ensure VBMS 
enhancements continue, Caseflow is fully operational, and all 
representatives have access to as many features as appropriate to help 
them represent veterans as effectively as possible.
                               conclusion
    NOVA is committed to continue working with this Committee, VA, and 
fellow stakeholders to ensure the appeals process for veterans is fair, 
timely, and preserves veterans' due process rights. We again thank the 
Committee for allowing us to provide our views on implementation of 
appeals reform.
                                 ______
                                 
 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, it is a great 
pleasure to submit a statement for the record in response to Secretary 
of Veterans Affairs David J. Shulkin's state of the Department of 
Veterans Affairs (VA) testimony.
    First and foremost, the VFW would like to thank the Committee and 
VA for all the accomplishments in 2017. Thanks to the bipartisan 
leadership of this Committee, Congress passed ten important veterans 
bills to improve benefits and service for those who have worn our 
Nation's uniform and their families. While the VFW lauds the 
Committee's efforts, Congress still has a long list of unfinished 
business. The VFW looks forward to highlighting those topics when the 
VFW presents its legislative priorities before the Committee on 
March 7, 2018.
                             community care
    One item which should not be on the unfinished business list is 
S. 2193, the Caring for our Veterans Act of 2017, which was approved by 
committee nearly unanimously. This important bill would make much 
needed improvements to the way VA provides community and internal care 
to America's veterans. Furthermore, this important bill would also 
correct a serious inequity between veterans who served before 
September 11, 2001 (9/11) and their pre-9/11 brothers and sisters by 
expanding caregiver benefits to veterans of all eras.
    The VFW implores the Committee to move this important bill as soon 
as possible. A recent continuing resolution provided VA with additional 
Choice Program funding, which is estimated to last up to five months, 
but veterans cannot afford for Congress to wait until the 11th hour to 
act. Veterans who rely on the Choice Program for their care are 
directly impacted by Congress' inability to act swiftly on community 
care legislation. As we have seen in the past when funds were close to 
being depleted, when the Choice Program faces an immediate uncertainty 
veterans who are unable to receive VA care are forced to wait or travel 
long distances for the care they have earned and deserve simply because 
Congress has failed to act on comprehensive and permanent community 
care legislation.
    The VFW urges Congress to quickly pass the Caring for our Veterans 
Act of 2017, so we can finally put an end to the constant fear of 
budget shortfalls that leave veterans without timely access to the high 
quality and veteran-centric care they have earned.
                            forever gi bill
    The historic, bipartisan, and bicameral Forever GI Bill is the most 
significant improvement to veterans' educational benefits in nearly a 
decade. Thanks to the hard work of the Committee and its staff, the 
Forever GI Bill tiger team, and a broad coalition of veterans, 
military, and educational organizations, more veterans and their 
survivors have an opportunity to pursue their educational goals.
    Thanks to the Forever GI Bill, all Purple Heart recipients will 
have full access to their GI Bill benefits; veterans attending schools 
that close abruptly through no fault of the veterans will be able to 
complete their degrees; thousands of involuntarily activated Reservists 
and Guardsmen will finally receive their well-deserved GI Bill 
benefits; surviving family members will be able to accomplish their 
educational goals with having to incur crippling educational debt; and 
veterans will no longer have a 15-year limitation on their earned 
educational benefits, which means veterans truly have a lifetime to use 
their GI Bill.
    The VFW is pleased to hear VA has implemented 13 provisions of the 
Forever GI Bill and that it is committed to ensuring all veterans 
impacted by changes are fully informed of their new benefits. However, 
the VFW has received mixed feedback on VA's outreach efforts. VA has 
published informative websites and releases on the changes to VA 
education benefits. Yet, the veterans who are impacted tell us they 
have not been informed by VA about recent changes. Specifically, the 
VFW reached out to veterans who were impacted by recent school 
closures, and reported knowing they knew about the Forever GI Bill but 
had not been contacted by VA to have their educational benefits 
restored.
    Similarly, school certifying officials tell the VFW that they have 
not received any information from VA on recent changes to the GI Bill. 
School certifying officials are the first people student veterans turn 
to for information regarding their benefits. Without proper outreach 
from VA, school certifying officials are having to turn to other 
sources for information on impending changes. Doing so could lead to 
misinformation and confusing messaging to student veterans. VA must 
improve its outreach efforts and work with veterans organizations to 
make certain a uniform message is delivered to impacted veterans.
                         appeals modernization
    When the negotiation process began for what would become Public Law 
115-55, the Veterans Appeals Improvement and Modernization Act of 2017, 
it was made clear that the input and support of veterans service 
organization (VSO) was paramount to the enactment of the legislation.
    The VFW's goal with appeals modernization was to build a process 
that placed the veteran first, was easy to navigate, and protected a 
veteran's rights every step of the way. The VFW, along with several 
other organizations, has long advocated for appeals reform, and were 
honored to be a part of the process with the assurance that the level 
of engagement that existed during the bills development would be 
sustained when implemented.
    However, once the legislation was passed, we began having concerns 
almost about VA's implementation plans. As a result, in September, the 
VFW and DAV (Disabled American Veterans) sent a letter to Deputy 
Secretary of Veterans Affairs Thomas Bowman expressing our concerns 
with the speed of the roll out; the language used in the initial opt-in 
notification letter and phone script; and the overall lack of 
engagement that we, and other VSOs have been afforded up to that point.
    While VA has addressed of the issues identified on the joint 
letter, the VFW still has lingering concerns with regard to how VA is 
implementing these changes and communicating with VSOs regarding the 
progress that has or has not been made, and the data that supports that 
narrative.
    As an organization that represents a large portion of appellants 
with cases pending before the Board of Veterans Appeals (BVA), our 
clients depend on us to provide the most accurate advice in order to 
increase their chances of a successful appeal. We have been 
representing veterans for decades and have a good understanding of how 
the system works. Having researched the possible impact of the program 
on our clients, we have found that there are circumstances where 
opting-in may actually be detrimental to the veteran.
    Many of our clients have been waiting for years to have their cases 
heard at BVA. They have invested time and energy into appealing their 
claims, and many of them are appealing denials for extremely complex 
issues. For our organization to recommend that they opt-in to a program 
that is potentially faster, and may lead to their case being decided 
more quickly, but may also lead to them losing their place in line at 
BVA if they are denied would be reckless.
    As of this submission, we have not yet been shown concrete evidence 
from VA, or any of our clients that would suggest that Rapid Appeals 
Modernization Program (RAMP) will actually improve a veteran's chance 
of a favorable outcome. During the hearing, Secretary Shulkin reported 
that 75 percent of RAMP decisions ``are going in favor of the 
veteran.'' While 75 percent may seem to indicate RAMP is a good option 
for veterans, VA's testimony does not clarify how many appeals were 
adjudicated and what VA defines as favorable. To VA, issuing a zero 
percent service-connection may qualify as favorable. A veteran would 
disagree if the decision is for a debilitating condition that merits a 
higher rating. As a result, we have declined to recommend to veterans 
we serve that have received eligibility notices to participate in the 
program, and will continue to do so until we are provided with more 
thorough data from VA.
    The VFW urges Congress and VA to properly resource Veterans 
Benefits Administration (VBA) and the Board of Veterans Appeals to 
ensure they are able to timely adjudicate legacy appeals from veterans 
who do not opt into the new appeals process, and the potential influx 
of supplemental claims and higher level review requests at VA Regional 
Offices. VA must be empowered to manage its workload, and stakeholders 
must be properly informed if the new framework is expected to succeed.
              accountability and whistleblower protections
    The VFW strongly believes that proper accountability is vital to 
ensuring VA fulfills its mission to care for those who have borne the 
battle. VFW members across the country have firsthand experience with 
VA's inability to quickly discipline wrongdoers. That is why the VFW 
praised the enactment of S. 1094, the VA Accountability and 
Whistleblower Protection Act of 2017.
    The VFW is pleased VA has taken steps toward improving 
accountability and transparency by implementing S. 1094 and publically 
releasing accountability reports. However, VA still has a long way to 
go. The VFW continues to hear reports of employees who are allowed to 
disrespect veterans or provide poor customer service. VFW members also 
report that whistleblower protections are not working because both 
patients and employees continue to fear they will be retaliated against 
if they report malfeasances. One VA employee tells the VFW that he 
fears the enhanced accountability measures have worsened nepotism at VA 
medical facilities. The VFW urges Congress to closely monitor 
implementation of S. 1094 to ensure wrongdoers are swiftly held 
accountable, whistleblowers are protected, and nepotism is eliminated.
    However, Congress cannot simply focus on firing bad employees. It 
must also ensure VA is able to quickly hire high quality employees. If 
VA is not able to replace wrongdoers with high quality employees, it 
will lack the staff needed to accomplish its mission. The VFW urges the 
Committee to work with VA to address barriers in recruiting and 
retention of high quality professionals, who are willing to work at VA 
medical facilities.
    Specifically, the VFW continues to hear that VA's licensing and 
credentialing process is excessively long and should be modified to 
make certain VA is able hire high quality doctors on a timely basis. 
The VFW also heard from providers who work at VA that they face delays 
transferring to underserved areas because they are required to undergo 
credentialing procedures again even though VA policy authorizes 
transfers between VA medical facilities without having to undergo 
credentialing. Veterans want more doctors at their VA medical 
facilities, but requiring doctors who want to serve veterans to jump 
through hoops prevents this from happening.
    Congress must also ensure VA has the authority to timely hire front 
line staff. Due to the lack of support staff, many VA providers are 
required to spend time on administrative tasks instead of treating 
patients or spending more time with their patients. VA is in the 
process of streamlining its hiring process for medical scheduling 
assistants (MSAs) and has set the goal of hiring MSAs within 30 days, 
which is half the time it takes, on average, to hire support staff 
today. The VFW commends VA for its efforts, but it is time Congress 
expands direct hire authorities to all Veterans Health Administration 
staff, not just doctors and nurses. We fear that VA's workforce 
productivity could decline due to staffing shortages and low employee 
morale if Congress does not reform VA's hiring authorities.
                       homeless veterans programs
    The nearly 50 percent reduction in veteran homelessness is laudable 
and the holistic partnerships and approaches taken by VA, the 
Department of Housing and Urban Development (HUD) and the Department of 
Labor (DOL) are absolutely critical to that success. Success, however, 
could be diminished if funding fails to keep pace with demand. Congress 
cannot allow VA to stymie its homeless veterans by reducing much needed 
funding.
    Specifically, the VFW has great concerns with VA's decision to 
realign specific-purpose funds allocated for homeless programs as a 
means to provide VA health care facility directors with more individual 
control over their location's general funding needs. In theory, this 
could be a successful idea. But this theory will undoubtingly be a 
failure without the transparency and desire to work with VSOs and 
Congress, and that cost should most certainly not come at the expense 
of homeless veterans.
    After receiving negative feedback from VSOs, and a letter from the 
Senate Appropriations Subcommittee on Military Construction, Veterans 
Affairs, and Related Agencies, VA chose to put a temporary halt on this 
initiative. We ask that this Committee join us in closely monitoring 
VA's attempts to handicap its successful homeless veterans programs.
    Taking away the guaranteed specific-purpose funding for homeless 
veteran programs, such as the massive cut initially suggested by VA to 
HUD- Veterans Affairs Supportive Housing (VASH), would result in a 
guaranteed failure of the program. The specific funding for HUD-VASH is 
crucial to the ability of case managers within VA to properly perform 
their jobs and assist homeless veterans in all the ways they are 
intended to help. These case managers are like life coaches for 
homeless veterans getting their feet back on the ground. This program's 
case management is the embodiment of the holistic approach and the 
answer to successfully overcoming homelessness.
    Since VA has reconsidered and postponed the timeline to readjust 
this funding, the VFW has eagerly awaited the opportunity to have a 
transparent and open conversation with VA about the intent and how to 
responsibly move forward. Yet, just because the decision was put on 
hold for now does not mean there were no repercussions. The VFW's 
Department of California's Homeless Service Providers have found that 
VA's attempts to reallocate HUD-VASH funding has negatively impacted 
the program.
    The two primary concerns they have found thus far include 
employment rates of HUD-VASH case managers as well as individual state-
funded programs for homeless veterans. In communities across 
California, such as Kerr County, VA has not been able to hire enough 
HUD-VASH case managers even with current funding. This results in case 
managers taking on an average of 50 homeless veterans instead of VA's 
suggestion of 25 homeless veterans per case manager. While managing 
twice as many veterans as suggested, and with the travel requirements 
of case management, locations such as these are not able to utilize all 
the vouchers they receive. With a massive cut in funding, there is a 
major fear that employment rates for case managers will only get worse. 
It has also been rumored that voucher distribution will be halted in 
some communities, out of fear that they will run out.
    Also, various states that rely on HUD-VASH funding have implemented 
their own programs to assist in combating veteran homelessness. For 
example, California's Proposition 41, Veterans Housing and Homeless 
Prevention Bond, is heavily dependent on VA's Supportive Housing as a 
subsidy for the bonds used to provide for homeless veterans and their 
families. This serves as an example of how cutting HUD-VASH funding 
could have even more worrisome and unintended consequences that cut 
deeper than originally thought.
                          pre-discharge claims
    As the Nation's oldest major VSO, the VFW serves 24 military 
installations to help veterans navigate and understand their earned VA 
benefits. To the VFW, filing claims prior to separation from the 
military is one of the most important processes that a servicemember 
can complete during the transition process. Not only does this ensure 
timely delivery of benefits after discharge, but it also increases the 
likelihood of granting benefits, setting veterans up for future 
success.
    As transition programs evolve, Congress, the Department of Defense 
(DOD), and VA all seek to make changes to better suit the transition 
experience. Many times these changes result in improved service for the 
transitioning servicemember, such as the Transition Assistance Program 
mandate included in the VOW to Hire Heroes Act; DOD's deployment of the 
military lifecycle model for transition; VA's establishment of the pre-
discharge claims program; or the joint DOD/VA commitment to develop a 
single medical record for servicemembers and veterans.
    Unfortunately, sometimes changes have unintended consequences that 
may result in a degraded transition experience for the servicemember. 
This is where the VFW takes its responsibility as a veterans' advocate 
to inform the agencies of jurisdiction and the Committee of our 
concerns. Recently, VA made two significant changes to its pre-
discharge claims programs that make the VFW concerned about the future 
of this critical interaction and the professional services we provide 
to our transitioning military members. First, VA shifted its timelines 
for the Benefits Delivery at Discharge (BDD) program, only allowing 
servicemembers to submit BDD claims from 180-90 days prior to 
discharge. Second, VA eliminated the Quick Start (QS) claims program 
entirely, meaning veterans with 89 days or fewer left on active duty no 
longer have an option tailored to their unique circumstances to easily 
access their earned benefits.
    The VFW understands why VA wanted to shift the timeline for BDD to 
90 days. We understand that this allows VA to complete exams and 
propose rating decisions to deliver benefits as close to a 
servicemember's date of discharge as possible. In a vacuum, this is a 
positive step. However, coupled with the elimination of QS and the 
military's cumbersome transition timelines, the VFW believes this 
change would disqualify most servicemembers the VFW serves from easily 
accessing their benefits on their way out of the military.
    According to VA, the VFW's claimants on military installations who 
filed QS claims fluctuated between 33 and 50 percent over the past 
year. In visiting with our pre-discharge claims sites, we hear that 
most clients visit our offices with far fewer than 90 days left on 
active duty, meaning most of our past BDD clients would no longer be 
qualified for the program. Yes, VA still accepts these claims, but they 
are no longer processed expediently while the veteran still serves on 
active duty, and they are no longer tracked with a unique end product 
(EP) code specific to QS claims, formerly EP code 337.
    In the past, this EP code allowed the VFW to track pre-discharge 
claims work to perform rating reviews and ensure the best possible 
outcome for our transitioning servicemembers. Now, with the elimination 
of the QS EP code, claims we submit on behalf of transitioning 
servicemembers are assigned as any other claim in VA's National Work 
Queue. VA will argue that this is not a big deal and that VFW-
accredited representatives anywhere can conduct these rating reviews. 
While this is technically true, we lose optics on these claims and can 
no longer properly track and report how well VA is serving the 
transitioning servicemember population. If we cannot identify problems 
this early in the process, we are not setting up the servicemember for 
post-military success.
    As of this hearing, the VFW has six personnel stationed at the VA 
regional offices (VARO) responsible for pre-discharge claims 
adjudication whose sole responsibility is to review rating decisions 
and correct any possible errors. Our most recent data indicates that 
our rating review specialists catch VA adjudication errors in up to 20 
percent of pre-discharge claims and are able to resolve such errors 
prior to promulgation of the award.
    Several years ago, recognizing the unique needs of transitioning 
servicemembers, VA committed not to broker work from the consolidated 
pre-discharge claims worksites at the VAROs in Winston-Salem, Salt Lake 
City, and San Diego. VA reneged on this promise last year with its 
across-the-board implementation of the National Work Queue, as we have 
testified in the past, and we do not expect VA will go back to its old 
workflows since this has seemed to increase productivity and efficiency 
for VA. However, through unique EP codes and Station of Origination 
filtering in the Veterans Benefits Management System, our pre-discharge 
quality control team was able to track and review work regardless of 
the VARO of jurisdiction for adjudication. This was a satisfactory 
middle ground to meet both the needs of VA to broker its work and the 
VFW's need to maintain optics on transitioning servicemembers' claims 
for quality control purposes. However, with the elimination of the QS 
EP code, we lose optics on this work and can no longer fulfill our 
commitment to transitioning servicemembers to perform the proper 
quality controls on their claims.
    Moreover, VA exacerbated an already tenuous situation by notifying 
transitioning servicemembers with fewer than 90 days on active duty 
that they were ``disqualified'' from filing BDD claims. Since the 
change went into effect October 1, 2017, we have heard from all of our 
pre-discharge claims sites and several of our VARO worksites that 
veterans have called or visited the offices, concerned that something 
went wrong with their claim. We even have one report from our office at 
Walter Reed National Military Medical Center that a retiree received a 
BDD disqualification letter 92 days prior to separation.
    This is a situation where language is critical. When the VFW was 
first presented with this letter, we vehemently disagreed with VA's 
decision to send it as worded. This concern was ignored until the 
recent House Veterans' Affairs Disability Assistance and Memorial 
Affairs Subcommittee hearing, after which VA has agreed to review these 
notification letters with VSOs.
    The VFW calls on VA to put veterans, not appearances, first. It 
must accept claims prior to separation, instead of punishing 
transitioning servicemembers whose chain of command does not permit 
them the opportunity to begin their transition process 90 days before 
they separate from military service. At the very least, VA must 
reestablish an EP code for transitioning servicemembers who file a 
claim within 90 days of separation to ensure the VFW and other veterans 
organizations are able to assist veterans in successfully transitioning 
from military service back to civilian life, regardless of where they 
choose to call home.
    VA must also rework the disqualification letters to simply notify 
the veterans that their claims have been received, but cannot be worked 
until they separate from service and submit their DD-214 paperwork. 
These simple steps will once again ensure that the VFW and similarly-
structured organizations can continue to provide the advocacy our 
clients expect, and transitioning servicemembers will once again have 
peace of mind that VA is responsibly handling their pending benefits 
claims.
    Unfortunately, the VFW worries there is a larger objective with the 
recent changes to VA's pre-discharge claims programs. While VA asserts 
that moving the window to 90 days results in better claims service, the 
elimination of the QS EP code and the rapid deployment of programs like 
the Decision-Ready Claims process indicate to the VFW that VA's primary 
objective is to obfuscate the total pending workload.
    Based on the VFW's estimates, we would lose optics on up to 50 
percent of our pre-discharge workload simply by VA shuffling the BDD 
timelines and eliminating the QS EP code. The problem is not only that 
we lose optics on the claims, but VA will not formally establish the 
BDD-excluded claims until veterans formally submit their DD-214s after 
they separate from service. This means that any time from 89 days to 
the time of the veteran's submission does not count as pending work as 
it formerly counted when the claim was established under a QS EP code.
    To the VFW, the time when servicemembers transition off of active 
duty is one of the most significant changes they will experience in 
their lives. This Congress and the VSO community have dedicated 
substantial resources to make sure that we get this right. The VFW 
values the role that we are allowed to play in the process through both 
VA and DOD, and we are always looking for ways to improve. Our goal is 
that we can move forward together to ensure that our transitioning 
servicemembers have access to the programs, information, and services 
they need for a successful transition out of military life.

      

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