[Senate Hearing 115-631]
[From the U.S. Government Publishing Office]
S. Hrg. 115-631
THE STATE OF THE VA: A 60-DAY REPORT
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 26, 2018
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
35-429 PDF WASHINGTON : 2022
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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
Patrick McGuigan
Maureen O'Neill
David Shearman
Jillian Workman
Minority Professional Staff
Dahlia Melendrez
Cassandra Byerly
Jon Coen
Steve Colley
Simon Coon
Michelle Dominguez
Amy Smith
C O N T E N T S
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September 26, 2018
SENATORS
Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........ 1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana...... 3
Moran, Hon. Jerry, U.S. Senator from Kansas...................... 17
Heller, Hon. Dean, U.S. Senator from Nevada...................... 21
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 23
Reports for the record....................................... 24
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 26
Murray, Hon. Patty, U.S. Senator from Washington................. 28
Boozman, Hon. John, U.S. Senator from Arkansas................... 30
Hirono, Hon. Mazie K., U.S. Senator from Hawaii.................. 32
Sullivan, Hon. Dan, U.S. Senator from Alaska..................... 34
Manchin, Hon. Joe, III, U.S. Senator from West Virginia.......... 36
Cassidy, Hon. Bill, U.S. Senator from Louisiana.................. 38
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 42
WITNESSES
Wilkie, Hon. Robert L., Secretary, U.S. Department of Veterans
Affairs........................................................ 6
Prepared statement........................................... 10
Response to request arising during the hearing by:
Hon. Patty Murray.......................................... 29,30
Hon. Joe Manchin III....................................... 37
Response to posthearing questions submitted by:
Hon. Jon Tester............................................ 45
Hon. Jerry Moran........................................... 48
Hon. Dean Heller........................................... 48
Hon. Patty Murray.......................................... 49
Hon. Bernie Sanders........................................ 61
Hon. Sherrod Brown......................................... 64
Hon. Mazie K. Hirono....................................... 66
Hon. Joe Manchin III....................................... 68
APPENDIX
Stier, Max, President and CEO, Partnership for Public Service;
prepared statement............................................. 73
THE STATE OF THE VA: A 60-DAY REPORT
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WEDNESDAY, SEPTEMBER 26, 2018
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 3 p.m., in room
418, Russell Senate Office Building, Hon. Johnny Isakson,
Chairman of the Committee, presiding.
Present: Senators Isakson, Moran, Boozman, Heller, Cassidy,
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 the Veterans' Affairs Committee of
the U.S. Senate to order and thank everybody for being here
today, particularly Secretary Wilkie, who hit the ground
running a few weeks ago and has not stopped. We slowed him down
enough to come in today to testify.
We really appreciate your being here today----
Secretary Wilkie. Thank you, sir.
Chairman Isakson [continuing]. And the other Members of the
VA staff that are here and our friends in the VSOs and everyone
else that is here. We are going to have good attendance from
our Members. Do not let the poor numbers right now throw you
because there are a lot of them working on stuff they are going
to come in and ask the Secretary about because they have been
asking me about it.
But, I do want to set the table for 1 second. I want
everybody to listen very closely so you can tell the other
Members who are not here yet that I covered this already.
The biggest issue for 3 or 4 years has been can we get the
VA functional. We have put up with front-page stories where
they lost stuff, veterans could not get services, everything
known to man.
We have done a great job and the VA has done a great job of
addressing that. When you hear the Secretary talk today, he
will talk about his four key priorities for the VA. Customer
service is number 1.
I have gotten letters from my district, unsolicited,
veterans who used to write me about why we were not worth
anything because we could not get anything done to thanking me
for the efficient way the operation works now.
We are not perfect, and I do not want the Secretary to rest
on his laurels and think the hard part is over. The hard part
has just started, but no journey starts without the first
steps. That is an old Chinese proverb. We took the first step
with Secretary Wilkie, and he has taken the step of making
customer care and veterans care and the importance to the
veteran the number 1 priority of his administration at the VA.
So, we have got a long way to go on that. We have got
Cerner software to get installed. We have got lots of changes
to make. We have got lots of things to come to reality, and we
are working on them.
But, if you ask anybody that is sitting here in this room
in this audience if there is another problem that needs to be
addressed, they would tell you it is Blue Water Navy.
I spend a lot of my time sitting with a lot of you, some of
you in the VSOs and some of the other activist organizations
and some of the loved ones' parents and the like that are
veterans. They said, ``You guys need to fix that.''
Well, I have been working on it, and I want to commend the
Committee, every Member, Republican and Democrat, because at
one time or another I have talked to each one of them about
this, and I think I know where every one of them stands. Every
one of them has been supportive to find a way to do it. Also, I
have tried to talk to, beginning with the Secretary whom I
started talking to a month ago; I have started bouncing various
ideas off of him to see where we could come to some kind of
solution.
The Secretary is right--and the reasons he has been
opposed--to just doing Blue Water Navy, period, but he is not
wrong about how we get to it. We need to get to it with you,
together as a Committee, and the VA Secretary is a principal
member of the VA.
The veterans who think they deserve that benefit ought to
get it. We ought to realize that we do not need to run a
Veterans Administration that does not have standards in terms
of new benefits that come along. This is not a new benefit. It
is a new benefit to some because they never heard of it before,
but this is a benefit that existed until 1999. Then with an
administrative change, the eligibility was taken away for
certain veterans.
So, you have got the situation if you are on the ground,
you are inone category; if you are on the water, you are in
another category. If you are this, you are one category; if you
are that, you are another category.
We do not have scientific conclusive proof, which you
seldom do in a scientific discussion, as to exactly what the
solution is or what the problem is, but we do know there is a
problem. We know that non-Hodgkin's lymphoma and certain other
diseases with presumptive eligibility in other cases is
something we have to address.
We need to look at the facts and let us see where they lead
us, and we need to look at being right and fair to the
veterans. We should not have two classes of veterans who
fought, just because one of them was on water and one of them
was on land, if it was the same conflict, the same exposures,
then the same difficulties.
But, we should not also hand out benefits just because we
think we ought to. We ought to hand them out because it is the
right thing to do for the veterans; we do it in the right way.
We set a template for what is going to happen in the future. If
another situation comes up, we have to evaluate it.
That is not just me talking; that is all the Members of the
Committee I have talked to. They feel the same way. They want
to get this problem solved, but they also do not want to create
a problem. That is why working with the Secretary to find a
solution, rather than the Secretary just saying no or me just
saying no or me saying, ``Yes, we are going to do it.'' We are
not going to act that way.
We are going to work together as a team. We are going to
decide what we need to do. We are going to decide where we need
to go, and we are going to get this problem solved. I have told
you all in every beginning year or ending of the 2-year cycles
that we have gone through that we had goals to accomplish, and
my goals were Caregivers. My goals were getting the MISSION Act
done. My goals were doing a lot of things. I know what Jerry's
goals have been. I know what Jon's goals have been. I do not
think anybody has been excluded. Everybody on the Committee has
gotten ideas into the law, but we have now got to deal with
this problem.
I do not need to try to cajole you or put it off and not
deal with it. I need to do everything I can to see that it gets
done.
So, I want to just set the table at this hearing with the
Secretary present to thank him for giving me the time he has
given me in the last month to talk about this. I appreciate
what his attitude is about customer service being the principal
foundation of his administration in VA.
And, for all of you in the VSOs and all of you of various
interests--Blue Water Navy or any other benefit anywhere--know
this is a Committee and a VA that will tackle your problems and
try to do it as fairly and equitably and as right for everybody
as we can. However, we are not going to get bulldozed into a
corner, and we are not going to bulldoze somebody into the
corner either. I want to bring that up because that is going to
take care of a lot of questions. I hope it does.
Again, I want to thank the Secretary for the time he has
given me and the time we are going to be sharing together in
the weeks ahead. I now turn it over to the Ranking Member for
any comments he might have.
OPENING STATEMENT OF HON. JON TESTER,
RANKING MEMBER, U.S. SENATOR FROM MONTANA
Senator Tester. Well, thank you, Mr. Chairman. Thank you
for your comments, and I want to thank Secretary Wilkie for
being here today. Welcome.
I have intentionally stayed away from your office as much
as possible to be able to give you time to get oriented and get
your team together and move the VA in a direction I think we
all want to see it go.
In your written testimony, you shared five real-life
stories of individuals in the VA who are really making a
difference. We do not hear enough about the good things the
agency does day in and day out, so thank you. There is a reason
why an overwhelming number of veterans prefer the health care
that the VA delivers, and there is a reason why thousands of
men and women across this country work tirelessly every single
day to provide veterans with the care and benefits that they
have earned.
I am talking about the physician assistant in Montana, the
claims processor in Georgia, the cemetery taker in North
Carolina, and countless others.
The VA means a great deal to these folks, and it means a
great deal to this country. So, today, I am hopeful we can talk
about what is right with the VA, while I am also hopeful that
we can address the challenges that the VA has and what needs to
be done to improve it.
Mr. Chairman, in terms of numbers and scopes of bills we
signed into law, this Committee has been under your leadership,
historicly, but there is much more to do.
We do need to pass a Blue Water Navy Veterans Act. We need
to move on a number of other critical bills, and I know you
addressed that in your opening statement.
I will tell you that I remember having the conversation
with you when Patty Murray brought in the caregivers bill, and
you said, ``I made a promise to get this done, and I am going
to get it done,'' which you did.
The challenge we have here is the House is leaving town
tomorrow, and the Blue Water Navy folks are out there. I trust
you unequivocally to get this done, but we do need to get it
done. We have been talking about it for far too long.
Just as important, we need to ensure that the reforms of
the previous 2 years are implemented appropriately by the VA as
Congress intended, as the veterans deserve.
Mr. Secretary, as you highlighted in your testimony, this
is not business as usual. This is a fundamental transformation
not seen in the VA since just after World War II.
Because the stakes are so high, collaboration and
partnerships are more critical than ever. Collaboration and
partnerships are more critical than ever. Whether it is the VA
and the VSOs working together, whether it is Congress and the
VA and the VSOs working together, or whether it is Congress and
the VA working together. That triangle needs to have good,
solid communication.
Unfortunately, in my opinion, it looks as if the VA may be
headed in the opposite direction--disengaging with veteran
stakeholder groups when it should be more engaged than ever
with this transformation and becoming less transparent when it
needs to be more transparent. I hope that I am wrong.
Let me tell you why I believe what I just said. When the
negotiation process for the MISSION Act started nearly 2 years
ago, this Committee worked in good faith with the VA to develop
legislation that made the most sense for the veterans,
community providers, and the taxpayers--veterans, community
providers, and the taxpayers.
I cannot overstate the amount of collaboration that went on
between Congress and the VA to get that bill across the finish
line.
Now 3 months have passed since that bill has become law,
and the most that we have received is a 40,000-foot view of the
offices responsible for implementing the program, really
nothing of substance.
It took a letter signed by the leadership of the Senate and
House Veterans' Affairs Committees after a planned briefing was
unilaterally canceled by the VA to start getting some answers.
In my opinion, that is a problem. It is not the way we have
done business in the past, and it should not be the way we do
business in the future.
With that in mind, Mr. Secretary, there were a couple of
lines toward the conclusion of your written statement that gave
me some serious pause. You state that the VA cannot stop
everything that it is doing to provide updates or respond to
inquiries if we are serious about getting to our destination.
Providing updates and responding to inquiries about
implementation of the laws that we fought hard as hell to pass
may not always be convenient, and it may not always be
pleasant, but it is really how the democracy works.
As a longtime congressional staffer, you have been on this
side of the dais. You know that the only way we get information
is we have to do our job; we have to get information. That job
is to provide oversight of the second largest agency in the
Federal Government, an agency that will spend more than $200
billion next year during what we both agreed are
transformational times.
I strongly believe in your nomination. I continue to
believe that you are the right person for this job. Our
Nation's veterans are counting on you. I sincerely--and I mean
this--I want you to succeed, man. I really want you to succeed.
After your confirmation, you deserve some space to get your
bearings, and you need to get your team in place. You need to
bring some stability to the agency. It has been 60 days, and I
think we can all acknowledge that the honeymoon is over.
Moving forward, I am hopeful that the VA can be more
transparent, engage more constructively with the stakeholders,
and work more collaboratively on critical issues for veterans.
For me, medical workforce vacancies, workforce vacancies are at
the top of the list.
I know the shortage of medical personnel is a national
problem, and it is just not a VA problem. It is truly a
national problem, but I also know that the Secretary before you
and the one before him and the one before him all sat in that
chair and asked this Committee for new authorities and
additional resources to better recruit and retain folks needed
by the VA to serve our veterans. You know what? Congress
delivered every single time, including the additional funding
in next year's appropriations bill and the newest authorities
that you now have in the VA MISSION Act.
Mr. Secretary, today you will be receiving a letter from me
that requests more information about how the VA is utilizing
those additional authorities. It is not an exercise to create
additional paperwork. It is so that this Committee, both sides
of the aisle, can have a better idea of what is working and
what is not so that we can focus our efforts. It is critically
important.
Since vacancies continue to be the biggest barrier to
primary, specialty, and mental health care for veterans across
this country, I think it is a very reasonable request. I hope
that we can work closely together moving forward on this issue.
We have got a lot of ground to cover. I look forward to
getting started.
Mr. Secretary, I want to thank you for being here today. I
have been looking forward to this hearing, I am going to tell
you, for a long time.
Mr. Chairman, I would like to include a written statement
for the Partnership for Public Service in the record today,
with your permission.
Chairman Isakson. Without objection.
[The statement can be found in the Appendix.]
Senator Tester. Their statement underscores the need for
the VA to maintain a collaborative relationship with Congress,
this Committee, and highlight the importance of employee
engagement within the VA.
With that, Mr. Chairman, I appreciate your leadership and
look forward to this hearing.
Chairman Isakson. Thank you, Senator Tester. I appreciate
your comments. I have two things to say before we turn it over
to the Secretary.
One is I would like Mr. Brett Reistad to stand up. He is
the new American Legion National Commander.
Brett, will you stand up, please? Give him a round of
applause. [Applause.]
What is your State, sir?
Mr. Reistad. Virginia, sir.
Chairman Isakson. Virginia. Well, you are close to home, so
that is good. We are glad to have you and appreciate The
American Legion and all they do.
Mr. Reistad. Thank you for having us, sir.
Chairman Isakson. Who in my Committee is in charge of the
air conditioning? [Laughter.]
Anybody in this room who is going to admit to that?
OK. You go find them and tell them it is hot in here.
We want to cool this place off a little bit. We want to
make it right and comfortable.
Senator Moran. It is Tester's fault.
Chairman Isakson. Tester's fault. That is right.
Senator Tester. We do not want this to be a heated hearing.
[Laughter.]
Chairman Isakson. Secretary Wilkie, we appreciate you being
here today. We appreciate the access you have given us in the
past and look forward to working together and appreciate you
being here today.
STATEMENT OF HON. ROBERT L. WILKIE, SECRETARY,
U.S. DEPARTMENT OF VETERANS AFFAIRS
Secretary Wilkie. Well, thank you very much, Mr. Chairman
and Senator Tester and distinguished Members of the Committee.
I want to thank you for this first opportunity to discuss the
state of the Department of Veterans Affairs and for the many
courtesies that you have shown me in the last few months, my
first iteration as the Acting Secretary and now 7 weeks into
the term as the confirmed Secretary.
I am happy to tell you that the state of the VA is better,
and it is better, as Senator Tester said, because of the work
of this Committee and the attention paid to our Department by
the administration.
It is also better because, a Senator Tester pointed out in
conversations with me, we now have a fully-experienced
leadership team in place at all levels. It is better because we
have a workforce dedicated to the care of veterans, their
families, caregivers, and survivors. I will say better because
the turmoil of the first half of 2018 is now in the rearview
mirror.
What this means in terms of leadership is that our new team
is on the same page, speaking with one unified voice on behalf
of veterans, moving out and delivering the mandate of this
Committee.
I also want to thank the Veterans' Affairs Committee for
its quick movement on our nominees for leadership in the Office
of Accountability and Whistleblower Protection as well as the
CIO.
Mr. Chairman, you and I have discussed that there are two
Departments in the Federal Government that must always be above
partisan politics. I have been fortunate to serve in both--the
Department of Defense and the Department of Veterans Affairs--
and this Committee proves that postulate.
Now more than ever, we are seeing the need for DOD and VA
to work together to provide quality care for our Nation's
servicemembers and veterans, and now more than ever, we are
seeing the benefit of strong bipartisan support for our DOD/VA
partnership in the many major acts of Congress passed in the
last few years.
Mr. Chairman, you and the ranking member have equipped the
Department with a $200 billion budget. You have passed the
Accountability Act to shake up complacency, and you have passed
the MISSION Act to strengthen our ability to ensure that
veterans have access to the best care available when and where
they need it.
As Secretary Mattis said when the Congress passed his
budget, there are no more excuses. The future now is up to the
Department. I look forward to working with the Committee and
the Congress to carry forward the work of that transformation,
and I pledge to you to make efforts as transparent as possible
to give you and the veterans of our Nation the best service
possible.
In the past 6 weeks, I have met personally with the leaders
of nine veterans service organizations, attended several
conventions, and visited 12 VA hospitals from Boston to Las
Vegas plus two claims processing centers, two national
cemeteries, and a veterans treatment court in Maryland. From
what I have seen and heard, it is clear to me that the veterans
population and their needs are changing faster than we even
realize.
For the first time in 40 years, half of our veterans are
now under the age of 65. Of our 20 million veterans, 10 percent
are now women, and the number of women veterans receiving VA
care has tripled since 2000.
The new generation of veterans is computer-savvy and
demands 21st century service, service that is easy to access,
efficiently delivered, and available where needed. For the VA
to thrive as an integrated benefits and health care delivery
system, it must be agile and adaptive.
I have also seen the wonderful examples of VA
accomplishments that Senator Tester pointed out. They deserve
more attention than they have received. We are on the cutting
edge of medical care and rehabilitative services, prosthetics,
Traumatic Brain Injury, spinal cord treatment, opioid and
mental health, telehealth, and community care, where one-third
of our appointments reside.
The VA health care system continues to outperform the
private sector in the quality of care and patient safety for
our veterans.
Our National Cemetery Administration has dedicated its
136th cemetery in Colorado Springs.
Fifty-two State veterans' homes received construction and
renovation funds this year, and for the first time in many
years, our overall VA customer satisfaction rate is steadily on
the rise.
Thanks to the unprecedented series of legislative actions
aimed at reforming the Department and improving care and
benefits for our heroes, we are now tackling issues that have
vexed VA for decades: giving veterans more choice in their
health care decisions with the passage of MISSION; increasing
accountability for misbehaving employees and protecting
whistleblowers with our Office of Accountability and
Whistleblower Production; improving transparency by becoming
the first hospital system in the Nation to post online wait
times, opioid prescription rates, accountability, settlement
information, and chief executive travel.
We are adopting the same electronic health record at DOD,
so there is a seamless transfer of medical information for
veterans leaving the service and are implementing the Appeals
Modernization Act while reducing wait times for those with
appeals already pending.
As the Ranking Member said, we are on the cusp of the most
important era in the history of the Department. This is not
business as usual. This is fundamental transformation not seen
since World War II when Omar Bradley headed the Veterans
Administration.
As you said, Mr. Chairman, my number 1 priority is customer
service. When an American veteran comes to VA, it is not up to
the veteran to employ a team of lawyers to get VA to say yes.
It is up to VA to train and equip its employees to get that
veteran to yes, and that is customer service.
Second, we will implement the MISSION Act, a landmark
achievement of this Congress that will fundamentally transform
health care by consolidating all of VA's community care efforts
into a single program that is much easier to navigate for
veterans, families, VA employees, and community providers. As
Senator Murray worked so hard for, this Act also expands VA's
family giver programs, caregiver programs, to provide much
needed assistance to the people who care for our most needy
veterans day in and day out.
Third, we will replace our aging electronic health record
system with the system in use by the Department of Defense to
modernize our appointment system, automate our disability
claims and payment claims systems, and connect VA to DOD,
private health care providers, and private pharmacies, finally
creating a continuum of care organized around the veterans'
needs.
What I see in the future is that we will never have a
veteran, as my father was, carrying around an 800-page paper
record. The new system will allow for best practices to be
shared and implemented across the network and empowering us to
turn the corner, hopefully, on opioid abuse and suicide
prevention. Implementation of this system will be ongoing and
iterative, and I look forward to working with the Members of
this Committee throughout the process.
Fourth, we must transform our business systems processes to
modernize our management of human resources, finance, and just
as important, our supply chain. This means giving people more
leeway to manage their budgets and recruit, retain, and
relocate the staff they need to serve veterans in their areas.
It also means entering into more robust partnerships with our
State and local communities to address veterans' homelessness
and suicide prevention.
At the same time, we will continue our recent progress on
many other important issues. For example, to accommodate the
rapid growth in America's women in the service, VA has expanded
services and sites of care across the country. We now have at
least one women's health primary care provider at all of VA's
health care systems.
In addition, 90 percent of the community-based outpatient
clinics have a women's health primary care provider in place.
Gynecologists are on-site at 133 facilities, and mammography is
on-site at 60. VHA is in the process of training additional
providers so every woman veteran has an opportunity to receive
her primary care at VA.
We are also working to fill the gaps in our ranks. VA has
had a net gain of 7,423 employees in fiscal year 2017, and so
far in fiscal year 2018, we have seen a net increase of more
than 9,500, including 3,600 in the mission-critical position
Senator Tester mentioned. Our average annual turnover rate is
9.2 percent, which beats the 11 percent average of Cabinet-
level agencies in the last 2 years as well as the 20 to 30
percent turnover rate in the health care industry in America.
We are providing more health care appointments than ever
before, having authorized 32.7 million appointments in 2017,
which was nearly 2 million more than in the previous year.
All VA health care facilities now provide same-day primary
and mental health care services for veterans in urgent need.
Finally, Mr. Chairman, I want to bring to your attention
something that was very important to me, and I think I am
speaking for my former boss, Senator Tillis. I want to thank
the Department of Veterans Affairs for the round-the-clock
efforts that they provided to serve and protect our veterans
across the Carolinas. Without a hitch, we were able to evacuate
patients in the danger zone and provide fuel, food, and oxygen
to hospitals we had to keep open, in spite of deteriorating
conditions and the communities they served being cut off from
the rest of the country.
What is not known to many of our fellow citizens and some
in our own Department, we were the foundational emergency
responders for our foundational emergency Federal response. We
were the part of the Government providing incident command
centers, sending doctors, nurses, and engineers plus mobile
pharmacies, clinics, and nutrition centers into the hardest-hit
areas. America should be proud of their citizens at VA.
So, as I said, we are embarking on the most comprehensive
improvements to veterans' care and benefits since World War II.
We have more work to do, and thanks to you and the Members of
this Committee, we now have the resources to complete the work.
Mr. Chairman, again, I thank you for your many courtesies
to me and I look forward to working with this Committee as we
work for the betterment of veterans across the country. I thank
you for your courtesy.
[The prepared statement of Secretary Wilkie follows:]
Prepared Statement of Hon. Robert Wilkie, Secretary,
U.S. Department of Veterans Affairs
Chairman Isakson, Senator Tester, distinguished Members of the
Committee: Thank you for my first opportunity to discuss the current
state of the Department of Veterans Affairs (VA) and my vision for the
future of America's Veterans.
I am happy to say that the state of the VA is better--better
because of the work of this Committee; better because of the attention
paid to Veterans Affairs by the President; better because we have a
functioning, experienced leadership team in place at all levels; better
because we have a workforce dedicated to the care of warriors; and
better because the turmoil of the first seven months of 2018 is in the
rearview mirror.
Mr. Chairman, while all executive branch departments and agencies
must carry out their missions without consideration or influence of
partisan politics, I have said in my visits across the department--
visits that in the last five weeks cover ten VA hospitals from Boston
to Las Vegas--that there are two departments of the Federal Government
that must be especially careful to rise above partisan politics: the
Department of Defense (DOD) and the Department of Veterans Affairs--
this Committee is proof of that postulate.
Now more than ever we are seeing the need for DOD and VA to work
together to provide quality care for the Nation's Servicemembers and
Veterans. And now more than ever we also are seeing the benefit of
strong bipartisan support for our DOD/VA partnership in the many major
acts of Congress passed in the recent years. Mr. Chairman, Congress has
infused VA with a $200 billion budget. You have passed the
Accountability Act to shake up complacency, and you have passed the
MISSION Act to strengthen VA's ability to ensure Veterans have access
to the best care available when and where they need it. As Secretary
Mattis said when this Congress passed a $700 billion defense budget,
there are no more excuses. The future now is up to the department. I
look forward to working with the Committee and Congress to carry
forward that work of transformation, and I pledge to make our efforts
as transparent as possible to you, to Veterans, and to the American
people.
Mr. Chairman, I would also be remiss if I did not mention the round
the clock efforts of our VA employees to serve and protect our veterans
during this great time of need across the Carolinas. Without a hitch,
we were able to evacuate patients in the danger zone; provide fuel,
food and oxygen to hospitals we had to keep open in spite of
deteriorating conditions in the communities they serve; and what is not
known to many of our fellow citizens and some in this Congress--we were
the foundational emergency responders for our government providing
incident command centers and sending doctors, nurses and engineers plus
mobile pharmacies, clinics and nutrition centers into the hardest hit
areas. America should be proud of their fellow citizens.
initial assessment
As Acting Secretary and Secretary of Veterans Affairs, I met
personally with the leaders of nine Veterans Service Organizations
(VSOs), spoke at four VSO events, hosted two VSO breakfasts, and
attended one White House VSO meeting. I have met with the combined
leadership of VA's three administrations--Benefits, Health, and
Memorial Affairs--and I have visited 14 VA medical facilities, two
claims processing centers, and two national cemeteries, as well as a
Maryland Veterans Treatment Court. From what I have seen and from what
I have been told by Veterans' advocates, it is clear to me that the
Veteran population is changing faster than we realize. For the first
time in over 40 years, half of our Veterans are now under the age of
65. Of America's 20 million Veterans, 10 percent are now women. We face
some persistent problems: increasing demand for care, vacancies in
critical specialties, aging facilities, antiquated management systems,
and a new generation of computer-savvy Veterans who expect and deserve
21st-century service--service that is quick, diverse, and close to
home.
I have also seen wonderful examples of VA accomplishments that
deserve more attention than they get. Many of them are the result of
collaborations with our public and private sector partners, such as our
consultation with the National Football League on Traumatic Brain
Injury. And I've seen VA making groundbreaking progress, particularly
in the areas of accountability, transparency, and efficiency, thanks to
an unprecedented series of legislative actions aimed at reforming the
department and improving care and benefits for our Nation's heroes.
Most inspiring to me have been the many exceptionally competent and
caring VA employees I have met who truly live by VA's core ``I CARE''
values: Integrity, Commitment, Advocacy, Respect, and Excellence:
Not long after I rejoined VA, The Washington Post
ran a story about the people who answer phones for the White
House VA Hotline. I was touched by the patience and compassion
of one of the call takers--an Army widow named Mary Hendricks--
that I called to thank her and her co-workers for the work they
do.
Then there were the four employees of the Phoenix VA
medical center who talked a homeless man out of committing
suicide. They were on their way to work when they saw him about
to jump from an I-10 overpass. One VA employee did not see the
homeless man at first, but he did see his co-workers trying to
help the man, so he stopped to help them, and together they
saved a life that day.
Last month, Alethea Varra, a regional director of
VA's National Tele-mental Health network, met with Ajit Pai,
Chairman of the Federal Communications Commission (FCC), to
impress upon him the importance of extending high-speed
Internet access to rural Veterans. Varra introduced Pai to a
Veteran who lives two hours from the nearest VA clinic but is
able to keep weekly appointments with mental health counselors
over the Internet. Advocacy is one of our core I-CARE values;
Alethea Varra lived up to that value by connecting Pai with
Veterans in need.
There's Dr. Joseph Potkay, a researcher at the
University of Michigan who is also a biomedical engineer at the
VA in Ann Arbor, and who is working to create a microfluidic
artificial lung using a high-resolution 3D printer. If it
works, it could revolutionize the treatment of Veterans with
lung disease.
Finally, for the past two years, VA health
professionals in West Palm Beach and Miami, Florida, have been
treating an Army Veteran with melanoma named John Johnson. This
summer--after radiation, surgery, and immunotherapy--Johnson
was able to realize his dream of bicycling the mountainous
route followed by the Tour de France. He later told us, ``I owe
the West Palm Beach VA a huge debt of gratitude for making
[this ride] possible. . . . There are great people who work
here, and they deserve thanks and attention. They're fantastic,
and they should all be told, `You're fantastic.' ''
These are just a few examples of the people who make me truly
thrilled to be part of VA at just this time in its history. They are
exceptionally competent and dedicated people, and with the support of
the President, the Congress, and our many partners, they are now
tackling head-on issues that have lingered for years, including:
Giving Veterans more choice in their healthcare
decisions with passage of the historic MISSION Act,
Increasing accountability for misbehaving employees
and protecting whistleblowers with the establishment of the
Office of Accountability and Whistleblower Protection,
Improving transparency by becoming the first
hospital system in the Nation to post online our wait times,
opioid prescription rates, accountability, settlement
information, and chief executive travel,
Adopting the same electronic health record as DOD so
there is a seamless transfer of medical information for
Veterans leaving the service, and
Overhauling our claims and appeals processes to
create a simplified system for filing to provide Veterans with
clear choices and timely decisions.
This is not business as usual. This is fundamental transformation,
not seen at VA since just after World War II, when General Omar Bradley
headed the VA.
my vision for va
Many of the issues I encountered as Acting Secretary and more
recently as Secretary were not with the quality of medical care but
with getting our Veterans through the door to reach that care. Those
problems are both administrative and bureaucratic. Alexander Hamilton
said that the true test of a good government is its aptitude and
tendency to produce a good administration. That is where VA must go.
Our first challenge is to improve the culture to focus our
attention and efforts on offering world-class customer service through
all our operations. Our second challenge is increasing access to care
and benefits through MISSION Act implementation and business
transformation, which includes adopting a new electronic health records
system, implementing a new claims appeals process, and modernizing our
human resources, financial management, construction program, and supply
systems.
Priority 1: Customer Service (CX)
My prime directive is customer service. When a Veteran comes to VA,
it is not up to him to employ a team of lawyers to get VA to say yes.
It is up to VA to get the Veteran to yes, and that is customer service.
VA receives 140 million phone calls a year. Ten million people
contact VA online each month. We have 348 contact centers, hundreds of
websites, and dozens of databases. Veterans think of VA as a single
entity, but we deliver services in silos, forcing the Veteran to figure
out which VA phone number to call, website to search, or office to
visit. For many, finding the right office to access the right benefit
or service is a fractured, frustrating experience.
Driven by customer feedback, we are integrating VA's digital
portals, contact centers, and databases so that Veterans easily find
what they need no matter which channel they choose. We have planned a
re-launch of our VA.gov website on Veterans Day, and we are unifying
Veteran data, adding customer preferences for electronic correspondence
to our new Vet360 database and integrating the Vet360 profile service
with mobile apps. We are also establishing a governance structure to
involve senior VA leadership in the customer-service effort.
Our goal is to make accessing VA services seamless, effective,
efficient, and emotionally resonant. The delivery of excellent CX is my
responsibility and the responsibility of all VA employees. When the
interactions between VA employees and our Veteran customers in these
areas are positive, our Veterans will trust and Choose VA, for their
care, benefits, and memorial services across their lifetime.
Customer service must start with VA employees not talking at each
other but with each other across all office barriers and across all
compartments. If we don't listen to each other, we won't be able to
listen to our Veterans and their families and we won't be able to
provide the world-class customer service they deserve. We must be a
bottom-up organization, with energy flowing upward from those who are
closest to those we are sworn to serve. It is from our dedicated
employees that the ideas we carry to the Congress, to the Veterans
Service Organizations, and to America's Veterans will come. Anyone who
sits in this chair and tells you he or she has the answers is in the
wrong business.
To help us become the best customer-service team in Government, and
earn the trust of our Veterans and their families, caregivers, and
survivors, I have issued a policy statement outlining how VA will
achieve this goal along three key pillars: CX Core Capabilities and
Framework; CX Governance; and CX Accountability. I am holding all VA
executives, managers, supervisors, and employees accountable to foster
this climate of excellence in customer service. I have also pledged the
shared services and support of VA's Veterans Experience Office as a key
enabler to help us all achieve this climate of customer service for
both those we serve, and to those we serve alongside.
Priority 2: MISSION Act Implementation
The MISSION Act is landmark legislation that will fundamentally
transform VA health care and improve Veterans benefits and services. To
ensure VA meets all of the provisions within the MISSION Act, we have
established an enterprise program management office, with integrated
project teams to implement each specific MISSION Act provisions, led by
Acting Deputy Secretary Jim Byrne.
Community Care
The MISSION Act consolidates all of VA's community care efforts
into a single program that is much easier to navigate for Veterans,
families, VA employees and community providers. This will ensure our
Veterans receive the best healthcare possible, whether delivered in VA
facilities or in the community. To implement requirements under the
MISSION Act for the consolidated VA community care program, VA began
drafting the required regulations immediately. Several significant
regulations are targeted for publication in the summer of 2019. In the
meantime, the MISSION Act includes an additional $5.2 billion in
funding for the Veterans Choice program to continue until June 6, 2019,
while VA develops the regulations to implement the new consolidated
community care program.
Caregivers Expansion
The MISSION Act also expands eligibility for VA's Program of
Comprehensive Assistance for Family Caregivers (PCAFC) beyond post-9/11
Veterans to include eligible Veterans from all eras of service. VA's
Caregiver Support Program (CSP) will oversee the expansion, which will
occur in two phases:
Veterans who incurred or aggravated a serious injury
in the line of duty on or before May 7, 1975, will begin
integrating into the program first.
Veterans who incurred or aggravated a serious injury
in the line of duty between May 7, 1975 and September 11, 2001,
will begin integrating into the program two years later.
The timeline for incorporating all eligible Veterans is still under
development. To meet the needs of incoming Veterans, CSP must develop
and implement a new information technology system to support
administrative and recordkeeping needs. CSP will soon submit a report
to Congress with a timeline for implementation.
VA supports this expansion and recognizes the sacrifice and value
of Veterans' family caregivers not only through this program but
through its first Federal Advisory Committee for Veterans Families,
Caregiver and Survivors and its new Center of Excellence for Veteran
Caregiver Research. Caregivers and Veterans can learn about the full
range of available support and programs by visiting
www.caregiver.va.gov or by contacting the Caregiver the Caregiver
Support Line toll-free at 1-855-260-3274.
Priority 3: Business Transformation
Business transformation is essential if we are to move past
compartmentalization of the past and empower our employees serving
Veterans in the field to provide world-class customer service. This
means reforming the systems responsible for claims appeals, GI Bill
benefits, human resources, financial and acquisition management, supply
chain management, and construction. Office of Enterprise Integration
(OEI) is charged with coordination and oversight for these efforts.
Appeals Modernization
The Veterans Appeals Improvement and Modernization Act of 2017 was
signed into law on August 23, 2017, and takes full effect in
February 2019. VA is on track to implement the law by that timeframe.
The Appeals Modernization Act transforms VA's complex and lengthy
appeals process into one that is simple, timely and fair to Veterans.
The new appeals process will feature three decision-review lanes:
Higher-Level Review Lane: A senior-level claims
processor at a VA regional office will conduct a new look at a
previous decision based on the evidence of record. Reviewers
can overturn previous decisions based on a difference of
opinion, or return a decision for correction.
Supplemental Claim Lane: Veterans can submit new,
relevant evidence to support their claim and a claims processor
at a VA regional office will assist in developing evidence.
Appeal Lane: Veterans will have the option to appeal
a decision directly to the Board of Veterans' Appeals (Board).
The law created the Rapid Appeals Modernization Program (RAMP),
which allows Veterans with a pending disability compensation appeal to
participate immediately in the new appeals process. About 48,000
Veterans with more than 57,000 appeals have opted into RAMP so far, and
VA has paid over $66 million in retroactive benefits as of August 2018.
While focusing on the timely implementation of the Appeals
Modernization Act, the Board has also completed a record number of more
than 81,000 decisions to Veterans for Fiscal Year 2018. The Board is
focused on developing and updating information technology systems for
the new claims and appeals process, developing and refining meaningful
metrics, providing training across VA for employees, adding appropriate
resources for deployment and collaborating with stakeholders throughout
the implementation process.
Forever GI Bill
Since the law was signed last August, VA has implemented 28 of the
law's 34 provisions. Twenty-two of the law's 34 provisions require
significant changes to VA information technology systems, and VA has
200 temporary employees in the field to support this additional
workload. Sections 107 and 501 of the bill change the way VA pays
monthly housing stipends for GI Bill recipients and VA is committed to
providing a solution that is reliable, efficient and effective. Further
system changes and modifications are being made and testing is ongoing
on the IT solution for Sections 107 and 501. VA will announce a
deployment date upon completion of testing. Pending the deployment of a
solution, Veterans and schools will continue to receive GI Bill benefit
payments as normal.
Financial Management Systems
VA's financial management system is 30 years old and continued
reliance on it presents an enormous risk to VA operations. The
technical and functional ability to support these legacy applications
gets more difficult with each passing year. Our Financial Management
Business Transformation (FMBT) program will replace VA's financial
management and acquisition system with new systems that will increase
transparency, accuracy, timeliness, and reliability of financial
information across VA, improving fiscal accountability to taxpayers and
enabling VA employees to better care for and serve Veterans. FMBT will
provide a modern, Integrated Financial and Acquisition Management
System (iFAMS), an acquisition solution with transformative business
processes and capabilities that enable VA to meet its goals and
objectives in compliance with financial management legislation and
directives.
Supply Chain Transformation
Effective management of the supply chain is a major differentiate
between high- and low-quality healthcare systems, yet the 2016
Commission on Care concluded that the Veterans Health Administration
(VHA) could not modernize its supply chain to overcome cost
inefficiencies because it is burdened with confusing organizational
structures, lack of expert leadership, antiquated IT systems that
inhibit automation, bureaucratic purchasing requirements and
procedures, and an ineffective approach to talent management. In
response, VHA has embarked on a supply chain transformation program
designed to build a lean, efficient supply chain that provides timely
access to meaningful data focused on patient and financial outcomes. To
date, VHA has established a standardized supply chain organizational
structure, a robust supply-chain training and development program, an
integrated data analysis capability, and a comprehensive equipment
lifecycle management program. VHA is continuing to work on data
standardization and governance, supply chain innovation center, and a
clinically driven strategic sourcing program.
Priority 4: VA/DOD Collaboration
Electronic Health Record Modernization (EHRM)
VA has made a historic decision to modernize its electronic health
record (EHR) system to provide our Nation's Veterans with seamless care
as they transition from military service to Veteran status and whether
they choose to use VA care or community care. To that end, VA has
established the Office of Electronic Health Record Modernization
(OEHRM) to ensure VA successfully prepares for, deploys and maintains
the new EHR solution and the health IT tools dependent upon it. The
OEHRM Executive Director is Mr. John Windom, who has been with the
effort since its inception and has the necessary expertise and
institutional knowledge to effectively lead this initiative. Prior to
joining VA, Mr. Windom was a Program Manager for the Program Executive
Office of the Defense Healthcare Management Systems (DHMS). He led his
team to acquire, test, integrate and deploy a new EHR system to replace
DOD's legacy EHR system in support of over 9.6 million military
servicemembers and other beneficiaries.
OEHRM is working closely with DOD to ensure we are deploying an EHR
that is fully interoperable. Veterans Integrated Service Network (VISN)
20 in the Pacific Northwest has been selected as the first Initial
Operating Capability (IOC) site to deploy and test VA's new EHR
solution. Engaging front-line staff and clinicians is a fundamental
aspect in ensuring we meet the program's goals and we have begun work
with the leadership teams in place in the Pacific Northwest. OEHRM has
established clinical councils from the field that will develop national
workflows and serve as change agents at the local level. The work at
the IOC sites will help VA identify efficiencies to optimize the
schedule, hone governance, refine configurations and standardize
processes for future locations. We are committed to a timeline that
makes sense and are also working with DOD to understand the challenges
and obstacles they are encountering, adapt our approach to mitigate
those issues, and identify efficiencies.
Suicide Prevention
Suicide prevention is a top priority for VA. Of the twenty (20)
Veterans, active-duty Servicemembers and non-activated Guard or Reserve
members who died by suicide, fourteen (14) have not been in our care.
That is why we are implementing broad, community-based prevention
strategies, driven by data, to connect Veterans outside our system with
care and support. In June, VA published a comprehensive national
Veteran suicide prevention strategy that encompasses a broad range of
bundled prevention activities to support the Veterans who receive care
in the VA healthcare system as well as those who do not come to us for
care.
Preventing suicide also requires closer collaboration between VA
and DOD. To that end, President Trump issued an executive order
January 9, 2018, to assist Servicemembers and Veterans during their
transition from uniformed service to civilian life, focusing on the
first 12 months after separation from service, a critical period marked
by a high risk for suicide, during which--
Servicemembers will learn about VA benefits and
start enrollment before becoming Veterans.
Any newly transitioned Veteran can go to a VA
medical center or Vet Center and start receiving mental health
care right away.
Former Servicemembers with other than honorable
discharges can receive mental health care from VAMCs in the
first 12 months after separation.
Transitioning Servicemembers and Veterans will be
able quickly to find information online about their eligibility
for VA care.
Every day, more than 400 Suicide Prevention Coordinators (SPC) and
their teams--located at every VA medical center--connect Veterans with
care and educate the community about suicide prevention programs and
resources. Through innovative screening and assessment programs such as
REACH VET (Recovery Engagement and Coordination for Health--Veterans
Enhanced Treatment), VA identifies Veterans who may be at risk for
suicide and who may benefit from enhanced care, which can include
follow-ups for missed appointments, safety planning, and care plans.
VHA has also expanded its Veterans Crisis Line to three call
centers and increased the number of Veterans served by the Readjustment
Counseling Service (RCS), which provides services through the 300 Vet
Centers, 80 Mobile Vet Centers (MVC), 18 Vet Center Out-Stations, over
990 Community Access Points and the Vet Center Call Center (877-WAR-
VETS). In the last two fiscal years, Veterans benefiting from RCS
services increased by 31 percent, and Vet Center visits for Veterans,
Servicemembers, and families increased by 18 percent.
We are committed to advancing our outreach, prevention, and
treatment efforts to further restore the trust of our Veterans and
continue to improve access to care and support inside and outside VA.
Additional Priorities
Accountability
Everyone recognizes that VA has struggled in the past to hold
employees accountable when they violated the public trust and to
protect whistleblowers from retaliation. That is why last year
President Trump signed an executive order establishing VA's Office of
Accountability and Whistleblower Protection (OAWP). The first office of
its kind in the Federal Government, OAWP has changed dramatically the
way VA handles accountability and whistleblower issues, ensuring
adequate investigation and correction of wrongdoing throughout VA while
also protecting employees who lawfully disclose wrongdoing from
retaliation.
OAWP is dedicated and empowered to provide transparency and build
public trust and confidence in VA. The office improves the performance
and accountability of VA senior executives and employees through
thorough, timely, and unbiased investigation of all allegations and
concerns. When allegations are substantiated, OAWP recommends actions
to be taken, which can include removal, demotion, or suspension based
on poor performance or misconduct.
OAWP has worked a full range of case since its inception, receiving
2,000 disclosures in its first year. In that year, the average
investigation cycle time declined from 163 days to 100 days. From
June 23, 2017, through June 1, 2018, OAWP completed 128 senior-leader
investigations involving 236 persons; discipline was recommended in 54
cases involving 58 persons.
Women's Health
VA has made significant progress in serving women Veterans in
recent years and now provides full services to women Veterans,
including comprehensive primary care, gynecology care, maternity care,
specialty care, and mental health services. For severely injured
Veterans, we also now offer in vitro fertilization services through
care in the community and adoption services.
The number of women Veterans using VHA services has tripled since
2000, growing from 159,810 to 484,317. To accommodate the rapid growth,
VHA has expanded services and sites of care across the country. VA now
has at least one Women's Heath Primary Care Provider (WH-PCP) at all of
VA's healthcare systems. In addition, 90 percent of community-based
outpatient clinics (CBOCs) have a WH-PCP in place. VHA now has
gynecologists on site at 133 sites and mammography on site at 60
locations.
VHA is in the process of training additional providers so that
every woman Veteran has an opportunity to receive her primary care from
a WH-PCP. Since 2008, 5,800 providers have been trained in women's
health. This fiscal year, 756 Primary Care and Emergency Care Providers
were trained in local and national trainings. VA has also developed a
mobile women's health training for rural VA sites to better serve rural
women Veterans, who make up 26 percent of women Veterans.
VA is at the forefront of information technology for women's health
and is redesigning its electronic medical record to track breast and
reproductive health care. Quality measures show that women Veterans who
receive care from VA are more likely to receive breast cancer and
cervical cancer screening than women in private sector health care. VA
also tracks quality by gender and, unlike some other healthcare
systems, has been able to reduce and eliminate gender disparities in
important aspects of health screening, prevention, and chronic disease
management. We are also factoring care for women Veterans into the
design of new VA facilities and using new technologies, including
social media, to reach women Veterans and their families. We are proud
of our care for women Veterans and are working to increase the trust
and knowledge of VA services of women Veterans so they choose VA for
benefits and services.
Community Living Centers (CLC)
This is the first year VA has compiled ratings for our nursing
homes using the Center for Medicare and Medicaid Services rating
system. We are now able to present an apples-to-apples comparison of VA
homes with private facilities. The data show that, overall, VA's
nursing home system compares closely with the private sector, even
though VA cares for sicker patients--with conditions such as prostate
obstruction, spinal cord injury, mental illness, homelessness, PTSD,
combat injury, terminal illness--in its homes than do private
facilities. Private-sector nursing homes also admit patients
selectively, whereas VA cannot refuse service to any eligible Veteran,
to the extent resources are available. These factors make achieving
quality ratings comparable to the private sector more challenging.
Hiring and Vacancies
VHA's workforce challenges mirror those of the health care industry
as a whole. There is a national shortage of healthcare professionals,
especially for physicians and nurses. VA remains fully engaged in a
fiercely competitive clinical recruitment market and has increased its
number of clinical providers including hard-to-recruit-and-retain
physicians such as psychiatrists. Additionally, VHA is taking a number
of key steps to attract qualified candidates, including:
Mental Health and other targeted hiring initiatives
Leveraging flexible pay ranges resulting in
competitive physician salaries
Utilization of recruitment/relocation and retention
(3Rs) incentives and the Education Debt Reduction Program
(EDRP)
Targeted nationwide recruitment advertising and
marketing
The ``Take A Closer Look at VA'' trainee outreach
recruitment program
Expanding opportunities for telemedicine providers
DOD/VA effort to recruit transitioning
servicemembers
Exhibiting regularly at key health care conferences
and job fairs
Critical Position Hiring and Vacancies
VA had a net gain of 7,423 employees in FY 2017. So far in FY 2018
(October 1, 2017 to July 31, 2018), VA has seen a net increase of more
than 9,500 employees, including 3,600 in mission-critical occupations.
As of June 30, VA had 45,239 overall vacancies, out of a total of
419,353 full-time authorized and budgeted positions. From the start of
fiscal year 2014 to the end of FY 2017, VA achieved a growth rate of
12.5 percent and an average annual turnover rate of 9.2 percent. VA
turnover rates compare favorably with other large cabinet-level
agencies, which averaged 11 percent in FY 2017.
Wait Times
VA is providing more healthcare appointments than ever before,
authorizing 32.7 million appointments in FY 2017, nearly two million
more than in the previous year. All VA health care facilities now
provide same-day urgent primary and mental health care services for
Veterans who need them. In June 2018, VA completed 95.18 percent of
appointments within 30 days of the clinically indicated or Veteran's
preferred date; 83.46 percent within 7 days; and 20.29 percent the same
day. The average time it took to complete an urgent referral to a
specialist has decreased from 19.3 days in FY 2014 to 3.2 days in FY
2017 and 2.0 days in FY 2018--this number continues to improve and is
now down to 1.3 days during July 2018.
Blue Water Navy
VA's view is that the commitment to science and an evidence-based
approach to creating or expanding presumptions should be maintained.
Presumptions of exposure and/or medical causation should always be
supported by historical, scientific, and/or medical evidence about the
specific population of Veterans affected. While VA continues to study
the science of exposure, we do not believe the available scientific
evidence currently supports a presumption of service connection in this
case.
We are also concerned that congressionally mandated presumptions
not supported adequately by evidence would erode confidence in the
soundness and fairness of the Veterans' disability benefits system,
creating the impression that the system can be gamed by political
activism. Such statutory presumptions will lead to increased pressure
on VA to create or expand additional presumptions administratively,
under a similarly liberal approach favoring less deserving but
politically demanding Veterans over more deserving Veterans who trust
VA to do the right thing for all Veterans.
VA estimates a total cost of $6.7 billion over ten years associated
with such a presumption, including $5.7 billion for mandatory benefit
payments, $625 million for health care costs, and $357 million for
discretionary costs to administer benefit payments. Such a presumption
would also impact VA's ongoing efforts to reduce the appeals and claims
processing backlogs. The accomplishments VA has made with Congressional
assistance will be stymied by VA's requirement to verify and study in
great detail over 30,000 previously-denied claims in the first year
alone and adjudicate more than 230,000 claims over 10 years, adding
time to our 125-day claims processing goal.
conclusion
Mr. Chairman, I would like to again thank Congress for passing VA's
FY 2019 funding bill. Starting the fiscal year with our full year's
appropriations in place is extremely important as we implement the laws
Congress has passed.
As I mentioned, we have instituted new management processes that
will facilitate successful implementation of these laws. This will be a
long journey that will not be accomplished overnight. I am committed to
providing you with regular updates on our progress and the challenges
that arise. However, I respectfully ask for time to implement and
evaluate the programs. We cannot keep changing course, or stop
everything we are doing to provide updates or respond to inquiries if
we are serious about getting to our destination. I need your help on
this.
As we look to the next few years and full implementation of the new
Veterans Community Care Program and an expanded Caregivers Program, VA
will need to resolve the necessary funding requirements to meet
Congress's intent. We are embarking on the most comprehensive
improvements to Veterans care and benefits since World War II. We will
need the resources to complete this work and I look forward to working
with you on that.
Mr. Chairman, I look forward to working with you and this Committee
and appreciate your many courtesies to me. I am also eager to continue
building on the reform agenda I was privileged to work along with
Senator Tester and Senator Tillis. The mission of this Committee is
clear--you help remind all Americans why they sleep soundly at night
because of those who sacrificed in uniform. There is no more noble
mission in all of government.
Thank you.
Chairman Isakson. Thank you very much, Mr. Secretary.
What I am going to do on the questions, I am going to
reserve mine until the end. We have got Members coming, so I am
going to try to get everybody in. We will take you while you
are here. If you have got another meeting to go to, we will let
you go.
I will start out on our side, and I am going to waive my
time. I will go to Senator Moran.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Mr. Chairman, thank you very much for that
courtesy. Thank you for you and Senator Tester having this
hearing.
Mr. Secretary, welcome. Let me also join what the Chairman
did in welcoming the new American Legion National Commander.
Let me take that a step further. Thank you for your visit to
Kansas last week. A significant number of posts across our
State where you visited I know were well received. I appreciate
the message you brought to veterans in our State.
Mr. Secretary, thank you for joining us today. I think you
would know that one of my biggest priorities of this Congress
was the MISSION Act and making certain that we achieved
legislation that was more than just a reauthorization of the
Choice Program.
In my view, the MISSION Act or that reauthorization was a
choice and an opportunity for real reform at the VA, one that
we could not waste and that we ought to use as a chance to fix
the very real problems that existed with Choice and reform the
entire VA health care system to better serve our veterans
really for decades to come.
I think that, largely, we were successful in that effort,
and a number of the reforms that I fought to have included in
this legislation were put in place. You are now preparing to
implement them.
My focus is on implementation, how you are going to do
that. One of the provisions we fought to have included requires
the VA to regularly consult with Congress during the
development of rules and regulations that govern the program,
particularly with the development of access standards, which
will largely be used to determine when a veteran is eligible to
receive community care.
I am out across my State. We are about to complete our
105th town hall meeting at the 105 counties in our State. I
raise this topic, and I want my veterans to know that there was
a Choice Program that is becoming something different. I need
to make certain that it does become something different than
what many of them experienced that did not work for them.
Next week, October 4, marks the first time the VA is
required to consult with us, Congress, in developing those
standards, and I want to make certain that it is a veteran-
centric approach. I want the standards to be easy to understand
and utilized for all parties involved--the VA, the veterans,
the community providers--and I am anxious to see what is
presented next week to see that the VA is on the right track.
One area that I want to highlight for you, bring to your
attention, is this definition of ``episode of care.'' It is my
hope that once a veteran is sent to community care for
conditions, they are able to see their community provider
through the entirety of their care for that condition.
For example, a veteran needs eye surgery. It does not mean
that you get the eye surgery under the MISSION Act and then you
are required to come back to the VA for follow-up care and
treatment.
Mr. Secretary, my question is, how do you expect that
complex care that requires numerous appointments for a certain
condition will be structured?
Let me highlight this because one of the problems we had
with Choice is a veteran was referred to community care by the
VA and then was told once that provider needed a lab test, an
x-ray, back to the VA for additional authorization. That is a
component of this, but also the continuum of care that is
needed for a particular condition.
Thank you.
Secretary Wilkie. Well, thank you, sir. I also want to
thank you for making your staff available, as I have gotten
into my job for discussions with them.
My view of Congress' thrust in MISSION is to do exactly
what you said. It is to give that veteran choice and allow that
veteran to continue with the choice that he or she is most
comfortable with.
I think we have a continuum of issues that will come
together to provide that--electronic health record, getting our
access standards, as you said, understandable and available to
everyone. Particularly, as I have said before, we still do not
understand the scale of the American West, west of the
Mississippi. I think our changes when they come for access
standards will revolutionize veterans care.
It is my goal to make sure that that veteran will
experience the continuum of service where he or she desires,
and I think that is one of the more revolutionary changes that
comes out of MISSION.
I will also say in response to your last comment about
briefing, we will have that 120-day briefing for you tomorrow.
I think we are a little ahead of schedule. I will take
responsibility for not coming the last day of August when I
think the first 60-day period came because I did not get--know
what was in it, but I can assure you that we will get a very
comprehensive briefing up here tomorrow. We will meet the first
hurdle that I am fully responsible for, in response to Senator
Tester's comments, tomorrow.
Senator Moran. Mr. Secretary, I thank you, and I look
forward to further conversations with you. We will talk about
budgeting and the ability for the VA to predict the costs and
levels of care required.
Secretary Wilkie. Thanks.
Senator Moran. Thank you, Mr. Chairman.
Chairman Isakson. Senator Tester.
Senator Tester. Thank you, Mr. Chairman.
I want to thank you once again for being here, Secretary
Wilkie.
Is that your wife behind you?
Secretary Wilkie. Yes.
Senator Tester. Welcome, Julia. I do not know that we have
ever had the Secretary of the VA come with his wife. That is
pretty sweet. Appreciate you being----
Secretary Wilkie. We came to see you and not Tillis.
Senator Tester. Oh, yeah. Right. That is it. [Laughter.]
So, look, I visit with veterans groups all the time, and
yesterday was no exception. I visited with a number of them to
hear their concerns, one of the things they said was VA's
communication on EHR has gotten better, so thank you. Thank you
for that.
I am not going to overstate this because if this changes we
will not bring this up again. But, overall, they expressed
alarm with what they perceived as increasing disengagement with
VSOs in several areas.
I have said in this Committee meeting many, many times, we
take our cues from the VSOs and from the veterans. So, as we
implement the MISSION Act and as these men and women as
veterans are going to utilize it and they are represented by
VSOs back here, who need to be a part of the equation, in my
opinion.
So, talk to me about the Department's engagement for those
who really helped frame the community health care bill, the
VSOs, and tell me what you are doing, what you have done, what
you intend to do. I know there are a number of them, but I
think they are critically important to your success.
Secretary Wilkie. Well, absolutely, which goes back to what
the Chairman said about customer service. My view of Government
is that the only way Government can be efficient is if it is
closer--closest to the people it serves.
I will take a step back and give you my agenda in the last
6 weeks. I have gone to the Paralyzed Veterans Health Summit. I
have addressed The American Legion, AMVETS, Jewish War
Veterans, other groups. I have been making the rounds, as I
promised you, to walk the post.
Friday, we will have our first comprehensive all-day
briefing for VSO leaderships under my tenure. It will be a
regular feature of----
Senator Tester. How regular, if I might ask?
Secretary Wilkie. I believe it is going to be every 2
months, but that can be augmented as needed.
Senator Tester. OK.
Secretary Wilkie. I will get back on the schedule, a series
of regular breakfasts that the VSOs were used to two
Secretaries ago, and I continue to go out and talk to as many
veterans organizations as I can. That is the promise, and I
will make sure I inform the Committee that I am keeping that
promise.
Senator Tester. OK. I am going to use the next question as
a recommendation, not a question, because you are a smart man.
Your confirmation hearing was one of the most impressive things
I have seen with anybody that we have confirmed in any
Committee.
I would hope that your conversations with the VSOs is not
one way. I hope it is not an information dump. I hope it is a
consultation, an opportunity to tell them what you are doing
and hear from them how they see it working.
Secretary Wilkie. I agree with that completely, and I will
say that in my presentations across the country, I have pointed
out that my own military service has been modest.
I would have been very comfortable sitting in front of
Senator Tillis' subcommittee on SAS without any notes because
that was my world. I will be honest and say I am still in the
process of learning, and part of that education, a large part
of it, comes from talking to veterans across the country,
including many that I have grown up around.
Also, I will just mention this. We may talk about the
subject of burn pits. I had a conversation with someone I have
known since I was a child about that, General Petraeus.
So, I am looking to talk to veterans in the VSOs and
veterans who just want to offer an opinion.
Senator Tester. That is good, and I would tell you that the
burn pit discussion may not be a lot different than the Blue
Water discussion, so we need to get our arms around that, too.
I am just going to ask you real quick because I have only
got 30 seconds left. You come out of the DOD. The EHR is a
shared effort between the DOD and the VA. Have you or somebody
within your organization had fairly high-level conversations
with Secretary Mattis to make sure that DOD is paying
attention, or would you recommend that we have a joint hearing
with SAS on this issue?
Secretary Wilkie. Well, I think that would be valuable in
the future and hopefully in the near future.
I am in discussions, the Department is in discussions with
the Department of Defense. I am waiting for information to come
back from the latest series of engagements, and then I will
engage Secretary Mattis.
At my confirmation hearing, you asked me about that
symbiotic relationship, and I will say on the electronic health
record--and there was a lot of criticism in the press about
being too closely tied to the Department. If we do not get the
front end of a servicemember's service right with the
electronic health record, it really does not help us when that
veteran comes into our system.
One of my goals is to make sure that the DOD end works. I
know that is something that Secretary Mattis believes in. I
have the advantage of having been responsible for that, that
program, when I was Under Secretary as well.
Senator Tester. Thank you.
Thank you, Mr. Chairman.
Chairman Isakson. I understand Senator Boozman wants to
switch places with Senator Heller.
Senator Heller, you are recognized.
HON. DEAN HELLER, U.S. SENATOR FROM NEVADA
Senator Heller. Thank you, Mr. Chairman. I appreciate that,
and I appreciate my colleague for accommodating.
Secretary Wilkie, thank you for being here today, and I
also especially want to thank you for coming out to Las Vegas
last week.
Secretary Wilkie. Thanks.
Senator Heller. I thought that was a great experience, and
in conversations through your nomination process, I asked you
to try to get out to Las Vegas, spend some time before the end
of the year. Just to have you there, it meant a lot to me.
Secretary Wilkie. Thanks.
Senator Heller. It meant a lot to our veterans in the
State.
Mr. Chairman, the President and Secretary Wilkie came out
to Las Vegas and signed the appropriations for the VA and the
military construction. I think it is the first time in history
that a President has gone to a facility, a VA facility, to
actually sign the appropriations bill for veterans, and it was
done with great fanfare and interest. Our veterans very much
were supportive, and I want to thank you----
Secretary Wilkie. Thanks.
Senator Heller [continuing]. For taking that time. It was
wonderful.
Like most of us here on this panel, I do a roundtable, and
I had a veterans roundtable in Reno. Obviously, a lot of
important issues are raised. We talked about mental health,
homeless veterans, veterans employment opportunities, and the
gamut of issues that are important to our men and women.
But, most of all, I heard about our Blue Water Navy Vietnam
veterans. There is a gentleman in Nevada from Elko. His name is
Joe, and he is a Blue Water Navy veteran, who has been
diagnosed with terminal prostate cancer. It is a disease that
is associated with Agent Orange, but he is not eligible for
compensation because he is a Blue Water Navy veteran.
My concern is I think we are turning our back on Joe, and
before I go much further, I would like to have you clarify your
position on compensation for our Blue Water Navy Vietnam
veterans.
Secretary Wilkie. Thank you, Senator.
Let me start from an emotional position. I probably have
experienced the effects of Vietnam in a way that few people my
age could. I certainly did not fight there, but I saw my father
and his comrades fight there. My father was gravely wounded in
Southeast Asia, and some of my classmates' parents did not
return. So, I have an emotional attachment to the cause of
Vietnam veterans that I think is unique at this time.
I have also said that I do not like the term ``greatest
generation.'' I think that could have only been said by someone
who has never put on a uniform because soldiers all have the
same hopes, dreams, and fears. It does not matter what era they
fight in. So, that is the emotional premise.
I agree with Chairman Isakson. I want to make sure that we
get it right, that we get it right for all of our veterans. I
pledge to work with the Chairman. We have had many discussions.
I will say I do want to make clear what is happening in VA.
There are about 40,000 Vietnam veterans across the country who
served in the Navy who are eligible for VA benefits. It is not
as if--Agent Orange-type conditions, I should say--it is not as
if the VA is turning people around--turning people out. We are
going to continue to do that.
My pledge to the Chairman is to work with the Committee to
ensure that we are just, we are equitable, equitable on both
ends.
I think the Committee received a letter from four of the
largest VSOs supporting the legislation but also saying, ``We
have a question about the funding mechanism,'' a funding
mechanism that puts a burden on young active-duty
servicemembers who are getting their first home. It also puts a
burden on disabled American veterans who live in higher-cost
areas like Charlotte or Atlanta. So, we want to look at that,
too.
My pledge is to work to make sure that we get it right, and
that is something I believe in sincerely and emotionally.
Senator Heller. Let me just ask a quick follow-up because
my time is almost out, but to get it right, in your opinion, if
you get it right, will Joe from Elko be compensated?
Secretary Wilkie. Well, yes. I mean, if we get it right,
anyone who fought, anyone who was exposed and deserves
attention from us will get it. That is my pledge to work as
hard as I can to see that nobody slips through the cracks.
I will say if your staff wants to get me any information--
--
Senator Heller. OK.
Secretary Wilkie [continuing]. On Joe, I will see to it. He
may even qualify and not know it.
Senator Heller. Mr. Secretary, thank you, and again, thanks
for coming to Las Vegas.
Secretary Wilkie. Thank you. Appreciate it.
Chairman Isakson. Two things, Senator Heller. First of all,
do what he just said about giving him a call. There may be a
way they can help.
Senator Heller. Good, good.
Chairman Isakson. You missed my opening statement.
Senator Heller. I did. I apologize.
Chairman Isakson. But, you did not miss--no, you do not
need to apologize. [Laughter.]
You did not miss the conversation you and I had on the
floor 2 days ago because you were right there.
I told this--everybody that is here, all the Members that
were here, the people in the audience here, the VSOs here--the
issue of dealing with Blue Water Navy is no longer going to be
a question. How we do it is the only question.
I told the Secretary and worked with him in various
meetings to get us to a position we can do a vehicle of some
description that is unanimously approved by everybody, to be
sure the veterans who deserve a benefit, that have been denied
or could not get it, that we do not open the door or set a
precedent down the road for something else that would run away.
I know Sherrod Brown has had conversations with some of the
Members. I have. Senator Tillis has worked with me on a lot of
stuff we have done talking about this. Senator Boozman. I have
talked to Patty Murray about it. Jon and I have talked a lot
about it. So, it is not a subject we are not dealing with.
I know other people in the audience that have a very vested
interest, including yourself and including your veterans.
So, we set the table this morning in my opening remarks,
and he just confirmed what I said without me coaching him
because he is down there and I am up here. He has agreed to
work with us to make that happen. So, we are going to do it.
Senator Heller. Thank you. I appreciate that. The veterans
appreciate that.
Chairman Isakson. You betcha.
STATEMENT OF HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Thank you, Mr. Chairman.
I thank you, Secretary Wilkie.
Chairman Isakson. Indians finally won a game.
Senator Brown. They did. They did. Won one. Thank you for
pointing that out. [Laughter.]
When the Indians beat the Braves in the World Series, you
will think a little differently. Thank you. Being a Cleveland
sports fan is tough business.
Thank you, Mr. Secretary, and thank you for not starting
the clock yet either, Mr. Chairman.
I want to follow Senator Heller's remarks and the
Chairman's and the Secretary's. I do not blame anybody
personally. I do not take any of this personally, but I want to
keep the pressure on the Blue Water Navy issue because I know
that--I think I mentioned to the Secretary in my office that I
knew a gentleman early as a lawyer that fought Agent Orange
cases one by one by one, and veterans from Vietnam died while
they were being litigated. Then, the bitterness grew, which
Congress understood that later, rather than sooner, but
admirably, it was a victory for Government doing the right
thing with the VA and on behalf of these veterans. You can
always do it faster.
Veterans are dying, as Senator Heller said, while we--we
are not fiddling while Rome burns. Again, I know that the
Secretary wants to do the right thing. I know the Chairman and
I have had a number of conversations on the floor and in this
Committee, formally and informally about this. I just want to
keep the pressure on.
To a lot of Blue Water Navy veterans, it sounds like the VA
is standing in the way of our efforts to pass this legislation.
I do not think you see it that way. I am not sure I see it that
way, but I want to again emphasize the importance of this.
The Blue Water Navy veterans in my State--I have, like so
many of you, done a number of roundtables, and my staff has
done a number. We have done close to a dozen in the last
several months. Blue Water Navy veterans comes up in every
single one of these in every part of my State.
They have read the Institute of Medicine reports. They know
the science inside and out. They see the VA, in their minds,
turning their back on them. Again, I know that is not your
intent, yet, I think to them, it looks that way.
I wonder, Mr. Chairman, if I can enter the IOM reports into
the record?
Chairman Isakson. Without objection.
[The submitted reports, due to their volume, are not being
reproduced here, but can be accessed at http://nap.edu/13026
and http://nap.edu/12662.]
Senator Brown. Thank you.
I know the letter, the September letter that you sent to
the Chairman, there is inconsistent evidence that Blue Water
Navy veterans were at higher or lower risk than shore-based
veterans. Mention the presumption of exposure of military
personnel serving in those vessels is not unreasonable. I know
about the 12-mile limit. I know that is an issue here.
I also know the battles that on presumptive eligibility,
not just the beginning, but every time with Secretary Shulkin
and his predecessors, your predecessors, we added to the
presumption eligibility list.
I know that most of us around this diaz will not let this
drop; we will keep the pressure on you. It is part of your job
as a public official. You used to keep the pressure on the VA
when you sat here with Senator Tillis and prior to that in your
job. I think that there are a few things this Committee can do
that are more important than that.
I appreciate Senator Tester's guidance on this and his
relentlessness also, so thank you for that.
In the last couple of minutes, I want to--on a different
topic, Mr. Chairman--raise my concern about--and I mentioned
this in my office too--how the VA has implemented the
Accountability and Whistleblower Act. We moved this legislation
last year. We intended for VA to use the authority to
discipline employees who had egregious offenses, as VA should.
I have some concerns that VA has used this new authority to
fire low-level employees with marginal offenses, not the senior
managers who have had egregious offenses. 2,700 employees have
been fired since last July. I am not arguing that most of them
did not deserve it. I am arguing, though, that the focus needs
to be on the most responsible, committing the most egregious
offenses, that had the most impact, and that is almost by
definition, in many cases, the senior members.
I have heard facilities are no longer using performance
improvement plans or progressive disciplines. I ask if you
would commit the VA will once again use these tools to address
employee performance instead of firing for a single offense.
Secretary Wilkie. We are going to hold our employees to the
highest professional standards. I am looking at new ways to
evaluate performance.
I do want to say that we are unique--and I apologize for
taking more time. We are a unique Federal Department. We have
three offices that are symbiotic, but they all are focused on
the same thing. We have a general counsel. We have an Inspector
General, and we have the Office of Accountability and
Whistleblower Protection that was set up by this
administration.
They are all designed to address employee misconduct. They
are also designed to protect employees from retaliation who
legitimately blow the whistle on bad acts.
Let me talk quickly about the Office of Accountability and
Whistleblower Protection. That is designed to deal with
employees at the GS-15 level and above.
Right now, I believe there are about 280 investigations of
GS-15-level employees and above. I am proud of that because I
think that also meets the intent of the Congress.
Last year, about 2,500, as Senator Brown said, 2,500
employees were dismissed. I will also note that we do have
different conditions here, and I do not mean to cast aspersions
on my friends who work at the Department of Labor, the
Department of Commerce.
When a junior employee who is responsible for sweeping the
floors does not sweep the floors or does not sterilize an
instrument, that is all right at the Department of Labor
because nobody will notice. If they do not do that in our
hospitals, the consequences could be catastrophic. So, we have
to hold employees at that level to the highest professional
standards.
That said, I am going to ensure that our Office of
Accountability and Whistleblower Protection continues to
evaluate and reevaluate those employees at GS-15 and above.
That has the double advantage of keeping their feet to the
fire, but also sending a message down the ranks that there
are--as we say in the military, ``There are not different
spanks for different ranks.''
Senator Brown. Thank you.
Mr. Chairman, if I could have 20 seconds just to sum up.
Thank you.
You know what--it is because you know so much about the VA
even before you took this job. You know the importance of
whistleblowers in Cincinnati and Dayton; and those were
terrible situations. Because the whistleblowers came in and the
meetings that my office had and those I personally had in hotel
rooms and in all kinds of places to talk about the problems
with safety and to talk about the problems of accountability
made a huge difference.
The VA was helpful in it, but it was the whistleblowers
that drove it. They were of all ranks, and protecting them is
essential. Many of them were veterans, as you know. It really
did make the VA hospitals in those two cities operate more
smoothly and more efficiently and more humanely for veterans,
so thank you.
Secretary Wilkie. Yes, sir, I agree.
Chairman Isakson. Senator Tillis.
HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA
Senator Tillis. Thank you, Mr. Chair.
And, Secretary Wilkie--I will refer to Robert Wilkie real
quick. The fact that your wife is here does not mean this is a
date. [Laughter.]
I am sorry I was not here for your opening testimony. I am
co-chairing a committee hearing on cyber and personnel.
The one thing I want to say about the discussion on blue
water, I fully expect the past is prologue, and when you were
in my office, you were very much a part of the effort to get us
to the right place on the Camp Lejeune toxic substances. That
is an area where we were at odds with the VA. That is an area
where we looked to outside expertise to come up with a rational
basis for a presumption, and we made progress there. I hope it
is in that same spirit that you are able to make progress and
also address the legitimate concerns of some of the VSOs with
respect to once we identify what the need is and once we start
expanding presumptions, that we also fund it in a way that is
not at odds with other promises that we have made that we need
to fulfill for our veterans.
Secretary Wilkie. First of all, Senator Tillis, thank you.
I will add that there was an addendum to that agenda that
you had. You and Senator Klobuchar were responsible for
creating the registry for those who were exposed to burn pits
in Iraq and Afghanistan. We worked across the aisle to set the
stage for science and funding for those who were exposed to
that.
I mentioned, I think before you came in, to Senator Tester
that I have spoken to General Petraeus about the burn pit
legislation.
So, the same standards that you apply, the same standards
that you had me apply in development of the Camp Lejeune
situation and the burn pit legislation apply here.
Senator Tillis. I also want to thank you about Hurricane
Florence. We received a call, and we were concerned with the
storm headed toward Wilmington and other areas, like your
hometown of Fayetteville, with very high veteran populations.
We were concerned with whether or not those receiving care
there--dialysis and a number of other things--if we were going
to have continuity of care, and the Department was well ahead
of it. I commend you for doing that. That has not always been
the case in every disaster response.
One question I would have for you is that after action, if
you take a look at the areas that are most prone to these sorts
of storms, they happen to be the States with some of the
highest concentrations of veterans.
So, what did you learn from that? Maybe what other things
should we look at in terms of authorities or things that we can
do to be as prepared for the next storm as you all were for
Florence?
Secretary Wilkie. Well, I do want to say that I was amazed,
being a North Carolinian, of the response, by the Federal
Government and the State government. I told Governor Cooper
that as well.
I am actually going down to Wilmington on Monday to take a
look at our clinic. It was under water, and I am going to
evaluate what the future is there. The same applies to Morehead
City.
I think we need to do a close look at where some of our
facilities are located. We have the benefit in Fayetteville
when the Cape Fear crested at 63 feet above flood stage, the VA
hospital was at 142 feet above the river. That does not always
happen.
But, I want to take a look at the way we position our
clinics. That might involve looking more closely at the
opportunity to lease facilities away from the danger zone, and
I also want our people to take a close look at our facilities
and their ability to withstand storms.
The good news in North Carolina is that other than
Wilmington, two clinics in Jacksonville, and then one in
Morehead City, everybody else is up and running.
We did send three mobile medical units to Wilmington, so
they are addressing the needs of the veterans there. I am very
proud of the response VA gave.
Senator Tillis. Well, thank you for that.
I also wanted to briefly touch on the electronic health
record. The governance structure you have here is something
that I am familiar with. I am glad to see that.
I think that I would also probably just submit a question
for the record, or perhaps you and I can just talk. I am also
interested in the MISSION Act and some of the change management
initiatives that you have going, separate from the electronic
health record, but I know you are taking a look at what I think
are some fundamental changes in organizational structure that
is going to be helpful for the whole of VA.
So, tell me a little bit now about the DOD/VA relationship;
how well that is going. We have got a learning over in DOD from
the electronic health record. We are going to have an
opportunity to see a life-cycle view of a soldier to a veteran
after this gets implemented. Can you give me a little idea of
how that collaboration is working and how we are for the
Pacific Northwest VISN 20 implementation?
Secretary Wilkie. Well, you see, I think this was a chart
that Senator Cassidy has. You do see that there is now cross-
pollination. We are in the process of formalizing a structure,
and before we finish formalizing that, I will make sure the
Committee has insight into that and will be able to review it.
I said during my confirmation hearing, my instructions
from--and I will call him General Mattis now--when I left the
Department was that we needed to be joined at the hip on this.
General Mattis uses the VA in Washington State, and he has a
personal commitment to making sure that this works. I do
envision us being joined together because it will not work if
one of the two halves inchoate.
So, I will get back to the Committee. Our two staffs are
working on this. I will sit down with Secretary Mattis and
begin the formalization of the structure fairly soon.
Senator Tillis. Thank you.
Chairman Isakson. Mrs. Murray.
HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Mr. Chairman.
Thank you, Mr. Secretary. Thank you for being here.
Let me just start with a huge frustration of mine, and that
is with ongoing delays in the construction of new clinics in
Washington State. It has taken almost 9 years--9 years to get a
new CBOC opened on the Kitsap Peninsula.
The needs of community have changed, and the VA now expects
this facility to be at complete capacity on the day it opens.
Our veterans have been waiting for years to get this open, and
they have heard promise after promise after promise from the VA
over these years.
Can you personally make sure that this and other facilities
are completed right away and review the Department's
performance on this as well? Because we have got to hold people
accountable for this.
Secretary Wilkie. Yes, Senator. I am actually headed to
Washington State in a couple of weeks to look.
Senator Murray. At the Kitsap Peninsula CBOC in particular?
Secretary Wilkie. I did not hear the last part.
Senator Murray. Kitsap Peninsula CBOC in particular?
Secretary Wilkie. I will be discussing that with the VISN
leadership.
Senator Murray. OK.
Secretary Wilkie. I think that is important because people
think of the Southeast as the growth sector for VA, but
Washington State in the Pacific Northwest has a very
important--and I think unmet--need.
Walla Walla is a continuing issue. Actually, Walla Walla
was the reason I said at one of the VA conventions that we have
to give our directors in the regions more authority to relocate
and evaluate and then change----
Senator Murray. OK. Well, on this one in particular, if you
are going to be out there----
Secretary Wilkie. Yeah.
Senator Murray [continuing]. I want to find out what you
said to them.
Secretary Wilkie. Yeah, absolutely.
Senator Murray. I need to get this done.
OK. Let me ask you about a completely different direction.
Six weeks ago, I sent you a letter about my concerns over the
reports of private well-connected individuals known as the
``Mar-a-Lago crowd,'' who are exercising wildly inappropriate
influence over the VA.
It is entirely unacceptable for the VA to put those
people's interests before what is in the best interest of our
veterans. I believe that is something you agree with. So, we
need to see steps taken to correct that right away.
Plus, the Department has to be transparent about this. So,
I wanted to ask when I would get a response to my letter.
Secretary Wilkie. Well, I did not know it was in the works,
but I will give you my response right now.
I agree with you about outside influences. I also listen to
a lot of people with opinions. A lot of those stories took
place before I became the Secretary.
Senator Murray. Right. I know.
Secretary Wilkie. I am also committed to making sure that I
am the sole person responsible to you.
Senator Murray. OK. Are there any VA officials consulting
with the Mar-a-Lago crowd now?
Secretary Wilkie. Not that----
Senator Murray. Have you met with them?
Secretary Wilkie. Not that I know of.
I have met--I met with them once for an hour when I was at
Palm Beach, the first week I was Acting. I have had no
connection with them since then.
Senator Murray. OK. So, the question is, can you assure
this Committee that there will be no inappropriate
interference?
Secretary Wilkie. Absolutely.
Senator Murray. OK. That is important to all of us.
And, if you can respond to my letter----
Secretary Wilkie. Yes.
Senator Murray [continuing]. I am looking to the data and
records on that as well.
Response to Request Arising During the Hearing by Hon. Patty Murray to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
Response. Secretary Wilkie's September 14, 2018, response to
Senator Murray indicated: ``This is in response to your August 17,
2018, letter to the Department of Veterans Affairs (VA). I want to
assure you that VA takes very seriously its responsibilities to comply
with the law and its obligation to respond appropriately to
Congressional requests for information. The matters about which you
inquired in your letter are the subject of ongoing litigation alleging
violations of the Federal Advisory Committee Act and, therefore, not
appropriate for release at this time.''
Senator Murray. Let me ask you about homelessness, which I
know is something you care deeply about, and is a priority for
you to end veteran homelessness, but I am really concerned
about the VA's focus on this issue because it has fallen off in
recent years.
We have seen the VA now try to divert funding away from
homeless programs. Program providers actually in my homestate
are losing funding, and despite some of the VA's promises to
help target Seattle by surging resources to the area, we are
not seeing that come through on the ground.
I was really troubled to learn at many of the facilities in
Washington are failing to actually use the HUD-VASH vouchers
often, and they tell me it is because they do not have enough
case managers.
So, this has got to change, and I wanted to know when we
are going to see the plan and resources in particular to
address Seattle's serious needs and how you are going to make
sure there are enough case managers.
Secretary Wilkie. The case managers are part of a larger
issue that we have in retaining those people particularly in
the social work field, and that is a target for us when it
comes to hiring.
I will tell you that we are going to put the word out that
we need to make maximum use of those HUD vouchers.
I have a meeting coming up with Secretary Carson, I
believe, in the next week or so to discuss that.
Senator Murray. OK. Can you get back to me on that?
Secretary Wilkie. Yeah.
Senator Murray. Because that is critically important, and I
am deeply concerned that they are not being used. Then, the
report back is that they do not need them. That is not the
case. So, we need that rectified.
Response to Request Arising During the Hearing by Hon. Patty Murray to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
Response. Please see the answers to Question 1 above, which
addresses the plan for Seattle as well as for addressing hiring and
voucher use in HUD-VASH.
[Specific voucher use figures are in the posthearing responses.]
Senator Murray. I will also add my concerns about the
electronic health records. As you know, my State was one of the
first locations to deploy that with the Department of Defense,
which was a $4 billion investment. I heard about misdirected
referrals, long waits, staffs that could not open the programs
in a timely manner. There was inadequate training. There was
consideration of taking money out of local budgets to supply
the implementation training, which was really not done well and
lives were really put at risk.
I just want to make sure that the problems at DOD are not
repeated as you move forward. We are going to be following this
really closely and expect to be kept up to date on any
challenges that you have to assist this implement.
Thank you.
Secretary Wilkie. Thank you.
Chairman Isakson. Senator Boozman.
HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you, Mr. Chairman.
Thank you, Mr. Secretary, for being here. We appreciate
your continued commitment to serving. I know that you are
working very, very hard in that direction.
We have seen reports detailing challenges veterans face
when using the GI Bill. In some instances, the VA underpaid
some 340,000 GI Bill beneficiaries for their housing allowance.
In your testimony, you mentioned that IT challenges
contributed to the situation, and that there is an ongoing task
to find a suitable solution. When can we anticipate the
conclusion of the testing, and how quickly will a solution be
implemented?
Also, in the meantime, what is the plan and subsequent
timeline for compensating those students who are underpaid, and
will any student who received an overpayment through no fault
of their own--are we going to go back and are they going to
face a debt owed to the VA?
Secretary Wilkie. Senator, the GI Bill issue is an
important one.
In the issue of full disclosure, my son uses the post-9/11
GI Bill.
Let me tell you what has happened in terms of benefits
flowing to beneficiaries. The housing payments are still going
out. What is not going out is the increase, the cost-of-living
increase, which comes out at about a half of 1 percent. So, the
GI Bill beneficiaries are being paid their housing allowance,
but it is on 2017 levels.
When we get the computer system right, we will repay those
GI Bill beneficiaries. I think it will come out to about $69 a
month because it is, as I said, it is zero--it is half of 1
percent.
This points to a problem that Senator Tester mentioned at
the beginning of the hearing. We received the instructions from
Congress on the Colmery Act, and those instructions were--they
attempted to implement them on a 50-year-old computer system.
Even something as simple as changing the percentages broke the
system. It is part of a larger issue that we have to get right.
I will also say that one of the benefits of the GI Bill
that this Committee worked on--and it is a good news story--is
those veterans, both active and veteran, who are part of a
college program or a pay-for-fee program that fails, we will
not penalize them. We will make them whole. They will not lose
those months. We will make sure that they can get the best
education that they can, and that is the other part of the
story that we are working on.
Senator Boozman. Very good.
Senator Heller mentioned that the President signed the VA
MilCon bill. In it was included $1.25 billion more than the VA
requested for medical services and medical community care.
The new legislation requires the Department to provide
monthly reports to the Committees, identifying obligations for
the medical community care program against available
appropriations, as well as anticipated funding needs based on
the developing program structure.
As you noted, the MISSION Act provided $5.2 billion to
continue the Choice Program through June 6, 2019. Based on the
VA's current estimates, is this funding, combined with the
recent appropriation, sufficient to support medical community
care through the fiscal year? If not, how does the VA intend to
address any possible shortfall?
Secretary Wilkie. Yes, sir. I will tell you I believe it is
sufficient for this fiscal year.
When we begin the series of briefings, I believe we will
begin to talk about all the changes that will come that will
affect fiscal year 2020 and beyond, but, no, I believe it is
sufficient right now.
We have to get a handle on, as Senator Tester sent to me in
a letter I believe last week, overpayments and underpayments
which affect community care. That is something I am working on
now.
Senator Boozman. Very good.
Thank you very much. We do appreciate your service.
Secretary Wilkie. Thank you, sir.
Chairman Isakson. Senator Hirono.
HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII
Senator Hirono. Thank you, Mr. Chairman.
I realize that the VA continues to be against the Blue
Water vets being included in the presumptive eligibility list,
but when Congress enacts such legislation, can we get your
commitment that you will do everything possible to enable and
facilitate these veterans to get the care that they need?
Secretary Wilkie. Well, Senator, I grew up in this
institution, and you reminded me of that at my confirmation
hearing. Article I is gospel. What the Congress says, I will
carry out.
Senator Hirono. OK, good. A strong yes.
You were asked by Senator Murray about this, but some of us
also wrote a letter to the Chairman that we would like to have
a hearing, an oversight hearing regarding reports of ongoing--
what we would consider inappropriate influence of your
Department with the few people from Mar-a-Lago.
So, I am going to take this opportunity to ask you some
questions about the interactions with Ike Perlmutter, Marc
Sherman, Bruce Moskowitz.
You noted that you met with them for 1 hour, but when you
were confirmed as Secretary, Mr. Sherman was--on the first day
of your being Acting Secretary, Mr. Sherman was waiting for you
in your office. Can you tell us what was discussed at that
meeting with Mr. Sherman?
Secretary Wilkie. What was discussed was somebody I had
never met before who was standing there and told me for whom he
worked, and I listened. I said, ``Thank you.'' I am always
happy to listen to anyone who wants to talk about veterans.
I was not familiar with what was going on. Again, it was my
first day, and in terms of a formal meeting, I believe I spent
an hour when I was down at the Palm Beach VA at my first week.
Senator Hirono. So, what was that 1-hour meeting about?
Secretary Wilkie. That was actually about the electronic
health records, and if I am going to believe the media stories
that the folks I talked to were against it, then I went against
their wishes because I approved it 2 weeks later.
Senator Hirono. So, was Dr. Moskowitz at that meeting?
Because he had some interest in the electronic health records.
That subject must have come up.
Secretary Wilkie. Yes. There were several--I think there
was a Marine general and a couple of other veterans there.
Senator Hirono. So, you are going ahead, obviously, with an
electronic health records program that is long in coming.
You just testified right now that you had no further
interactions with these three people; by the way, when you met
with any of them, did the subject of privatizing VA come up?
Secretary Wilkie. No.
Senator Hirono. Since you yourself have not had any further
interactions with them, though, have any of your other high-
level decisionmakers at the VA been having meetings with these
three people?
Secretary Wilkie. Not that I know of.
As I mentioned at the beginning, we have a completely new
leadership team in place; everyone from the chief of staff to
the Under Secretaries, so a completely new--completely new
leadership team.
Senator Hirono. So, as far as you know, none of your high-
level leadership people have been meeting with these folks.
So, does the type of interactions with members of Mar-a-
Lago reported by ProPublica violate appropriate standards of
transparency? Because you have testified that transparency is
very important and accountability at the VA is very important
to you.
Secretary Wilkie. Well, that is right, and I believe I have
laid out everything that went on as a result of my meeting and
went against what they were advocating.
Senator Hirono. Well, I hope that is made clear to them
because it certainly seems as though they just weighed in as
though they ran the place.
As Secretary, you are responsible for managing over $1
billion in funding to assist homeless veterans and their
families, and we have made progress. But, we are not there yet.
You did not mention homelessness in your testimony. Could
you provide to the Committee where this issue of veterans
homelessness falls on your list of priorities and what your
plan is to end veteran homelessness and also improve the
transition process to prevent homelessness of veterans?
Secretary Wilkie. Well, it is very important, and I
mentioned earlier that on the issue of Blue Water Navy, our
veterans homelessness problem impacts a community that I am
very familiar with and very close to, more than any other, and
that is Vietnam era.
We are working with HUD. We are also working with State and
local communities on the issue of homelessness. We are funding
homes and projects across the country to get homeless veterans
off the street.
In North Carolina Senator Tillis and I worked on the
creation of a program that gets them off the street and gets
them sober and with a job.
Senator Hirono. Can you tell me right now how many homeless
veterans there are?
Secretary Wilkie. I cannot tell you that number because it
changes every day.
Senator Hirono. I do realize that, but give and take, the
number?
Secretary Wilkie. No, I cannot because we do not know. We
just do not know.
We have the same problem with homelessness that we have
with suicide. The tragedy in our Department is that every day
22 veterans commit suicide, yet 14 of those veterans are
outside of our purview.
Senator Hirono. I think that, Mr. Chairman, if you do not
mind, because this is an area that we really need to provide,
as far as I am concerned, more focus. Whatever efforts you are
making to reach out to the veterans, I think that is important.
I would like to know what you are doing along those lines----
Secretary Wilkie. Yes.
Senator Hirono [continuing]. And some numbers----
Secretary Wilkie. Right.
Senator Hirono [continuing]. As to how many veterans----
Secretary Wilkie. I will get you----
Senator Hirono [continuing]. Are being helped.
While I am at it, I just would like to have you continue to
make sure that you implement the VA telehealth bill that
Senator Joni Ernst and I were really pushing for.
Secretary Wilkie. Very important for mental health.
Senator Hirono. Thank you, Mr. Chairman.
Chairman Isakson. Thank you very much.
I want to introduce Colonel Sullivan of the U.S. Marine
Corps who was yesterday promoted in the Mansfield Room. I
happened to be there, and he looked great in his uniform, with
all his family. We are proud of you.
Before you start, I want to get up for a second because I
have got to make a phone call. So, in case I am not back when
you finish, Senator Boozman is going to conduct the rest of the
meeting.
HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA
Senator Sullivan. Well, thank you, Mr. Chairman. I
appreciate you being there and so many of my other colleagues.
Mr. Secretary, welcome back. I am glad you are on the job.
I know it is not an easy job and probably one of the hardest
jobs in Washington, if not the hardest job in Washington, but
probably one of the most important jobs. I personally am glad
you are there.
I want to talk to you about a couple of specific Alaska
issues. One of the things that you committed to me on is
getting up to the State, my State, soon in your tenure. I know
your staff and my staff have been looking at possibly
confirming dates for the third week of October, and as luck
would have it, that is when the Alaska Federation of Natives is
going to be meeting in Anchorage. So, that is the large--AFN is
an annual meeting. It has all of our--thousands and thousands
of Alaska Natives, who constitute almost 20 percent of the
population in my State, meet together.
Very importantly from the VA perspective, these are some of
the most patriotic Americans in the country. They serve at
higher rates in the military than any other ethnic group, such
as Native Hawaiians and American Indians. Decade after decade,
even though, let us face it, after World War II or Korea or
Vietnam, they came home to a country that did not always treat
them so well.
So, I would welcome your commitment to participate in this
conference, whether by giving a speech, or convening in that
Native Alaskan veterans roundtable with me, or both. Of course,
we will coordinate with the executive director of that
organization, but I think they would be excited, particularly
given how many veterans you will see. You will have an
opportunity to meet literally with thousands of Alaska's
finest, most patriotic citizens.
Secretary Wilkie. Senator, I am planning to be in Alaska
for several days, including that conference. I will actually be
in Anchorage the day before the conference convenes, and I am
looking forward to that. So, I will be there for a while.
Senator Sullivan. OK. Well, let us try to work together and
get--it is a great opportunity, and it is fortuitous timing.
Let me talk about another issue, both kind of at the
national level, but again, also an Alaska issue. One of the
important issue that we addressed in the MISSION Act was prompt
payment for providers, which has been an issue that has
bedeviled the VA. As you know, it has a real negative domino
effect because you have these providers who want to serve
veterans, and then they are not getting paid on time. They have
problems meeting their own payrolls, and the next thing you
know, they are turning away veterans, even though they do not
want to turn away veterans.
So, the MISSION Act establishes a prompt payment standard.
I want to get your views on how you think that is going.
Granted, we just passed the bill. The President signed it just
a couple months ago.
More specifically, I have a constituent, Joyce Abangan, and
her husband, who is a 21-year veteran, lieutenant colonel, U.S.
Army, two combat tours. They are small business owners in
Alaska. They have an operating home health agency that has a
backlog of pay of over $100,000 with the VA, and they are
getting ready to do what other providers have to do, which is
turn away veterans because they are almost--you know, they are
having a hard time.
I would like to get your commitment to work with me and my
staff on that specific one, but more broadly for this hearing
and the other Senators here, how is that going? It is such an
important issue. I know you cannot turn on a dime on it, but,
boy, it is really important. Now, it is in law. I mean, you
have to do it, so I would like an update on that.
Secretary Wilkie. Senator, now we are turning. MISSION does
not work unless we have that relationship with particularly
small-town providers, small-town community hospitals.
Senator Tester sent me a letter about Health Net, and I
think this change answers in part his concerns, which is a
concern particularly for the West.
That provider is on the way out. They stopped getting new
authorizations 2 months ago. VA has had to pick up the slack. A
few months ago, VA was adjudicating 100,000 of these small
provider claims. We are now up to 700,000 a month. We are
working as quickly as we can to do that, and that will
hopefully accelerate when we get a new vendor on board. But, it
is a terrible problem, and if it does not work, MISSION does
not work.
Senator Sullivan. Well, let me just real quick on that--we
have TriWest. I do not know if it has the same issues as
HealthNet, but it is part of the network. If I can get your
commitment, your staff's commitment to help my staff and I work
with this one group, it is exactly the kind of people we want
to keep in the system, not have them walk away. They are
veterans themselves, and 100 grand for a small business is----
Secretary Wilkie. It is devastating.
Senator Sullivan. Yeah, devastating.
Let me ask just one final question. How is morale overall?
The one thing I always liked--you come in here a lot of times
and get the crap kicked out of you and everything, as do the
other employees. But, the vast majority of the VA, the vast
majority of the employees who care are focused on vets. I know
that is the case in Alaska.
A big part of leadership is morale, so how is it with
regard to your employees? Because we need to know that, too.
Secretary Wilkie. I will let others make a more definitive
statement.
I will say that VA is calm. A lot of my first objectives
was to do what Marines do--Air Force guys do not do it as
much--that is, walk the post. That is why I have been across
the country, to be seen and to talk to the people who work in
VA.
They have gone through a lot. I am going to refer back to
something Senator Tester said in the debate on my confirmation
on the floor. Their lives have been upset by an agency that has
been run by--I think you said anecdote--and the individual
story that sometimes does not apply across the Department.
I will continue to walk the post, and when the opportunity
presents itself, I will tell the good news stories. I will also
tell the truth. As I said at the beginning, the state of VA is
better. I did not say good or excellent. It is better, and I do
think we are headed in the right direction.
Senator Sullivan. Great. Thank you.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you.
HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA
Senator Manchin. Thank you, Mr. Chairman.
Secretary Wilkie, it is good to have you. I wanted to say
that my reports have been excellent, the job you are doing, the
changes you have made, and basically the care that you have
shown for the Vietnam veterans.
With that, I just wanted to discuss--a couple of subjects,
basically. We are all concerned about the Blue Water Navy. We
all have Vietnam veterans. West Virginia has more,
unfortunately, veterans on the Vietnam Wall than any State per
capita. So, we have all given.
Anyway, I want to talk to you about the number of
electronic health records, things that we have done over the
years that have not seemed to work that well. I think you know
that. They include the joint program of DOD called--the new one
now called the Integrated EHR to replace the separate EHR
system with a single shared system.
On that, the integrated system was abandoned in 2013, and
the Secretaries of VA and DOD announced that they would not
continue or develop this joint system.
Once again, VA has announced its intentions to establish an
electronic health record system that is interoperable with DOD,
and that is through a $16 billion contract, as you know, with
Cerner Corporation. However, the DOD's initial rollout of
Cerner's system in four medical facilities was plagued with
significant problems.
So, with the way that this is rolling out--VA is starting
with the rollout on the West Coast and moving East. By the time
it gets to West Virginia, that will be 2023.
So, we have to work with the system at hand, which is the
VistA system, and I need to know how are you all working with
that. Are you able to maintain and keep that system up until
you integrate the other system?
Secretary Wilkie. EHRM is an iterative process, and it is
going to take time to get it online. We will have the other
systems in place to mitigate.
Senator Manchin. VistA will stay in place?
Secretary Wilkie. I believe. I will have to get----
Senator Manchin. You can get back with me. I know, yeah.
Secretary Wilkie. Yeah, I will have to get back with you on
that as to what exactly will happen.
Response to Request Arising During the Hearing by Hon. Joe Manchin III
to Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans
Affairs
Response. Yes, VistA will stay in place until the Cerner rollout is
completed.
Secretary Wilkie. I will say something about the failures
of the testing in the Pacific Northwest. My last job at DOD
was--I was the head of Secretary Mattis' close combat task
force, and we were evaluating weapon systems and computer
systems that we would deploy with Marine infantry, Army
infantry. We would not give them a weapon or a system unless we
tested it. And, we tested it for mistakes.
My understanding of what went on, on the DOD side, is that
they were testing it for mistakes, and they found them. I would
rather find them there than down the line after we spent the
$16 billion that you talked about.
My pledge is that we are going to be joined with DOD to
make sure that this works and not just interoperable between
DOD and VA, but if we are going to make MISSION work, we have
to make the electronic health record interoperable with private
pharmacies, small town doctors, hospitals in the community.
Without that, MISSION does not work. So, we will be giving you
regular updates.
Senator Manchin. Let me roll into something else because
you know my really major concern has been the opioid addiction
that we have and our veterans have been plagued with. I think
we all know how some of that has perpetuated.
A study published August 2018 in the Journal of Health
Services Research examined the numbers and times of opioid
prescriptions filled for post-9/11 veterans at VA and non-VA
pharmacies. They used the ones in the State of Oregon. It was a
small study, but it was basically a study. It found that 15
percent of our veterans who filled a prescription for opioids
at a VA pharmacy had also dually filled a prescription in a
non-VA, and that is not just veterans. I mean, everyone, when
they get addicted, they will do whatever it takes.
The likelihood of having those concurrent opioid
prescriptions increased if the veteran was enrolled in the
veterans Choice Program. You are aware of that. OK.
So, given the expansion of the community care expected with
the VA MISSION Act, I guess, what does the VA plan to do to
monitor prescriptions of potentially dangerous drugs?
Here is the thing that we said. I found out when I went to
the veterans hospital--we have four in West Virginia--one, in
particular, I was talking to the head nurse and I said, ``How
is our problem here?'' and she said, ``It is the same
everywhere. It is severe.'' She says, ``If you all would quit
calling and raising Cain about what we do and let us do our
job, we can cure this a little bit better.''
So, what happens is an addicted veteran calls a Senator or
Congressperson raising holy Cain that they are not getting what
they demand. So, we took that--we have taken that away from
where we are rating how our VA veteran hospitals are going
along with our regular hospitals. They get rated on
reimbursement of Medicaid and Medicare.
Can you just check on that, sir? I know this is something
new, but this opioid addiction is affecting our veterans. They
should never be in this position to where we cannot get them
back into a useful, productive life.
Secretary Wilkie. I agree with you.
Mr. Chairman, may I have a minute or so to fully answer?
Chairman Isakson. Let me say this. Senator Blumenthal just
came in.
Secretary Wilkie. OK.
Chairman Isakson. He is going to have his chance. Senator
Cassidy has been waiting a long time, and a lot of people got
here early and took care of their business. So, let us be as
quick as our 5 minutes as possible and be respectful for the
people who have stayed.
Secretary Wilkie. Yes, sir. I will do it fast.
That is one of the beauties of electronic health record as
I see it----
Senator Manchin. Yes.
Secretary Wilkie [continuing]. Is that with the
interoperability, a veteran will no longer be in the position
of getting opioids from a private doctor or hospital and then
going to the VA and getting Ambien or another opioid because
once that happens, a system kicks in, and red flags are raised.
VA knows that that veteran is now on the spectrum.
Second part is I am talking to the President's opioid
conference on Friday. I am going to talk about the good news at
VA. We are doing groundbreaking work in getting our veterans
off of opioids using things as simple as aspirin and Advil--
they work just as well--and also rehabilitative therapies,
orthopedic therapies.
We are getting the opioid addiction down in the VA system,
and we still have a lot more work to do.
Senator Manchin. I appreciate this. This is a serious
problem.
Secretary Wilkie. Thank you, sir.
Chairman Isakson. Thank you, Senator Manchin.
Senator Cassidy.
HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA
Senator Cassidy. Yeah, several things. First, Secretary
Wilkie, good to see you.
I thank the Chair for acknowledging the Blue Water issue at
the outset and look forward to its resolution.
I also want to thank you. Again, you do take a fair amount
of fecal material, as Colonel Sullivan said, but----
Secretary Wilkie. That is how the Air Force would describe
it. He would say it is something different as a Marine.
[Laughter.]
Senator Cassidy. But, again, thanks for your support in the
Preventing Veterans Death of Despair Act, which I will be
introducing shortly. Your guys have worked extensively with us;
it is a common mission, so thank you for collaborating.
Now, there has been a lot of conversation here on EHR. As a
doc, of course, I am interested in it. I am just going to touch
on a couple of things since you and we have all discussed the
history so much, and then I would like to go a little more
deeply because part of it involves what we, the Congress, have
directed, which does not seem to be fulfilled. Not your
problem--no, not your fault, but now your problem.
Just a couple things to point out. 2008, the NDAA
established a joint Interagency Program Office, the IPO, to act
as a ``single point of accountability for the electronic health
care exchange efforts.'' Fast forward, we have expanded it over
time.
In February 2014, GAO reported that the VA and DOD had not
addressed management barriers to effective collaboration. The
IPO lacked effective control over central resources, such as
funding and staffing, and decisions by both the VA and DOD had
diffused responsibility for achieving integrating health care
records, potentially undermining the IPO's role as a single
point of accountability, so VA and DOD diffusing authority,
even though Congress said IPO should have that authority.
Now, in May 2018, OMG, the VA gives Cerner a contract for
$10 billion within this context of diffused responsibility.
In September 2018, GAO reported to HVAC that the IPO has
not been effectively positioned to be the single point of
accountability as mandated by the NDAA fiscal year 2008.
Now, their recommendations, the Secretary of Veterans
Affairs should ensure that the role and responsibilities of the
Interagency Program Office are clearly defined within the
governance plans for acquisition of the VA's new electronic
health care record.
So, I can now kind of wrap this up and bring it into your
comments.
May I see the chart, please?
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Cassidy. This was given to HVAC by the VA, and, Mr.
Chairman, if you do not have a copy of this--you can see that
there is a blend here. This is facilitated by the IPO, and this
is the joint work between the two, the VA and the DOD. There is
no dotted line going up to the VA executive committee. It is
operating merely as ``Hey, do you mind giving somebody a
call?''
Similarly, the DOD/VA executive committee does not appear
to have you or your deputy on it. So, this is not within the
highest reaches at least in the VA regarding responsibility.
Even like the language ``facilitated by IPO'' is not
exactly what Congress had in mind. They wanted it to be the
single point of authority and not a facilitator who I tend to
think of as lacking authority, except why do we not all do it
together?
So, I did not mean to bump you. I am sorry.
First, what is your response to the GAO's assertion that
there is a critical need for a single point of accountability
for VA and DOD's interoperability to be successful?
Second, why is the VA/DOD executive committee, the highest
joint committee, not the top leadership of the two Departments?
This is a $10 billion contract, just for one of them. Best I
can tell, your office is not on that crew.
Third, how do you respond to the GAO's assessment that the
IPO's role and responsibilities is not clearly defined and not
effectively positioned to be the single point of
accountability?
And, last, what are your plans to strengthen IPO's position
to be that congressionally mandated single point of
accountability and standardization, et cetera?
Secretary Wilkie. Senator, when I came to VA, I realized
that it was, as you said, an organization of dotted lines. An
organization like that is anathema to someone who has been
raised in the military.
My objective----
Senator Cassidy. The only thing worse than that is no
dotted line.
Secretary Wilkie. So, we are in discussions, as we speak,
with the Department of Defense to hopefully--I cannot be
definitive right now, but we are working on it--make those
solid lines and create that one single point of authority.
As to the issue of the deputy, I was able to get an acting
deputy just a few weeks ago, put him in charge of our response.
I have stated that my goal is to take the ideas that our
working group with DOD is working on and take those to
Secretary Mattis, so that we come to you with a plan that you
all will see and hopefully bless because you are absolutely
right. Dotted lines do not work; no lines, worse. We have to
have a single point of contact that is responsible to the two
Secretaries and makes this----
Senator Cassidy. It is my experience that unless you
empower that IPO person, she or he will continue to be
ineffective, and granted, they theoretically would have more
authority than you. But, practically speaking, it is going to
be you and Mattis.
Secretary Wilkie. Right.
Senator Cassidy. It is going to be, frankly, your
responsibility to make sure that she or he, when they walk down
the hall, people give them the right of way because I
understand that she or he represents you. Does that make sense?
Secretary Wilkie. Yes, it does. Yes, sir.
Senator Cassidy. Then, it is fair to say that your
conversations with Mattis will be along those lines to give
whomever this is----
Secretary Wilkie. Yes.
Senator Cassidy [continuing]. That authority?
Secretary Wilkie. Yes. I do not know what we are going to
call it, but it is in line, I believe, with the dictates of
NDAA from several years ago in that it will have that single
office with DOD and VA running the show jointly.
Senator Cassidy. Then just heads-up--and I know you will do
this, but just to say those will be the kind of subjects of my
questions going forward.
Secretary Wilkie. Yes, sir.
Senator Cassidy. Thank you, sir.
Secretary Wilkie. Thanks, sir.
Chairman Isakson. Senator Blumenthal.
HON. RICHARD BLUMENTHAL,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thanks, Mr. Chairman.
I know that you talked to Senator Tester briefly about
vacancies, and he emphasized to you--and I share this view
strongly--that the VA should use resources given to it by
Congress to fill those vacancies. Each of us on this Committee
are aware of really staggering statistics regarding VA
vacancies, 45,000 of them nationwide, 40,000 within the
Veterans Health Administration. They are incredibly alarming,
and they undermine VA care and services. This challenge has
been longstanding in the VA, not new, and in fact, the numbers
fail to articulate or portray the real-life impact.
Recently, a VFW district commander in Connecticut contacted
me after his counseling session at the Norwich Vet Center. He
explained that the center was short a director, an office
manager, an outreach worker, and a counselor, and he said to
me--and I am quoting--``I feel these staffing shortages
directly and adversely affect the well-being and delivery of
veterans counseling services to men and women veterans living
in this area.''
I would like you to commit that the Norwich Vet Center will
be fully staffed and capable to delivering effective and
efficient counseling services to Connecticut veterans.
Secretary Wilkie. Yes, sir. Senator, you and I talked about
Norwich in your office before my confirmation hearing. I do
intend to get up to Connecticut and take a look. I am not
familiar with all of the details.
I will say on the 40,000 number, on its face, is
staggering.
I will also say that if we try to fill all 40,000, we would
never get where we need. The issues that you have just
highlighted, we have to concentrate on, I think, four areas:
primary care; internship, internists; mental health workers;
and women's health.
The MISSION Act gives us the tools to help that situation--
the repayment of educational debt, our ability to set new
salary levels that you would not otherwise have to do in the
other areas of the Federal Government. But, the three R's for
us are recruit, retain, and relocate. We have to give our
leadership in VA the authority to relocate to places like
Norwich. So, it is something I am very concerned about. I agree
with you.
Senator Blumenthal. Well, I am going to take that as a yes,
that you will make that commitment, and I would welcome your
visit to Connecticut to see the VA; that as a yes that you will
make that commitment. I would welcome your visiting Connecticut
to see the VA Center in Norwich but also in West Haven, where
,as you know--and I thank you--the VA has allocated $17 million
to invest in new sterilization equipment in the department
which will help resolve the current challenges--I will put it
euphemistically--in the sterilizing and surgical commitment due
to outdated infrastructure.
I would suggest to you more than just that sort of Band-Aid
is necessary. There has to be a rebuilding and a refitting. In
fact, there are many more infrastructure challenges to follow
at West Haven, and West Haven is only one example of the
infrastructure challenges faced by the VA.
As you work with the White House on the President's Budget
Request for fiscal year 2020, I hope you have a plan and
specific actions for the next 5 to 10 year to invest. It cannot
be just 1 year. It has to be a multiyear investment in the
bricks and mortar of the veterans' health care system.
Secretary Wilkie. Yes, sir. And, the other thing--I agree
with that, and I am taking a close look at the Office of
Construction and Logistics. I have made a commitment during my
confirmation hearing that I would not produce budget numbers
that appear to take from places like VHA to pay for other
things.
It is going to be a fine balancing act, but I am going to
do my best to make sure that we are balanced.
Senator Blumenthal. Let me ask you finally about the Blue
Water Navy Vietnam Veterans Act. I know that you have discussed
it with Senators Brown, Heller, Tester, and Tillis.
In the Institute of Medicine 2008 report, as you know, the
Committee states, ``Given the available evidence, the Committee
recommends that members of the Blue Water Navy should not be
excluded from the set of Vietnam-era veterans with presumed
herbicide exposure.''
I want to be clear. You agree with that recommendation,
correct?
Secretary Wilkie. I agree that I am going--I am not a
doctor, and what I have talked with the Chairman about is that
we are going to do everything we can to make sure that those
veterans are taken care of with funding and science, and I
pledge to work with the Committee.
My concerns were not one of saying absolutely no, because I
grew up with those folks who fought in Vietnam as certainly
part of my family. I just want to make sure we get it right
because we have burn pits that we need to deal with--Camp
Lejeune--and I pledge to you to give this my best effort.
Senator Blumenthal. Well, I have to acknowledge that I am
somewhat disappointed that you cannot give a yes or no.
Chairman Isakson. Let me help you. Can I help you a little
bit on this point?
Senator Blumenthal. Absolutely, Mr. Chairman. I always
welcome help.
Chairman Isakson. You and I have had some conversations,
and I have had conversations with every Member of the
Committee, I think.
Senator Blumenthal. I know what the conversations have
been, Mr. Chairman, and I am really looking for a somewhat less
equivocal answer.
Chairman Isakson. Oh, I know, but let me get to where I was
going.
In my opening statement today--the Secretary and I have met
on numerous occasions in the last 6 weeks. I have told him we
need to fix the Blue Water problem. He has agreed to work with
us to do that.
I realize there are scientific questions. There are policy
questions. There are all kinds of questions, but that is an
administrative decision the VA made in 1999 and 2002, where
people who served in Vietnam in certain places got benefits and
other places did not. We need to fix it so that it is equal for
everybody, and we are going to do that. He has committed to
doing that, working with us to do that.
What I want to do--and I want everybody to hear this loud
and clear--I want to do something we can do under a unanimous
consent where nobody objects. I do not want to do something
that becomes a circus. I do not want to do something that
forestalls the decision. I want to do right.
He has agreed to work with us and do that, and I believe
the Administration will do the same. I am going to see this
thing through, and I am not trying to cut you off. You missed
that part of the meeting. I wanted to let you know that was the
first item of business we talked about.
Senator Blumenthal. I very much appreciate that point, Mr.
Chairman, and I would like to join you in working toward that
end, which also recognizes the need of veterans who suffer from
other kinds of toxins and poisoning, where, as a matter of
fact, you and I have worked together on legislation to achieve
that goal because the modern-day battlefield is filled with
poisons and toxins and so forth. I recognize that the Blue
Water Navy Veterans Act--the Vietnam Veterans Act is just the
tip of the problem. But, I do hope we can make some progress on
it.
Chairman Isakson. Well, we are going to do what I said. We
are going to address the Blue Water Navy, and that is going to
get done. I am going to see to it. The Secretary is going to
work with us, and I hope you will help us get there.
But, I will tell you this. I do not want to open the door
to a multiplicity of debates over other things that end up
causing us not to get something done. So, we are going to do
Blue Water Navy being sympathetic to anything else that is
going on. We are going to get that finished because that has
been a drag for some time. The House has acted, and it is time
we figure out a way that we could work it out so it is the best
that we can possibly do and get it done.
Senator Blumenthal. I thank you. By the way, Mr. Chairman,
I do not think there is such a thing as beating this horse too
much. I do not think--and I say that for the benefit of my
friend, Senator Tester, to use the farming analogy.
Chairman Isakson. Vernacular. I understand.
Senator Blumenthal. But, I open with a quote to the
Institute of Medicine, which is a scientific body----
Chairman Isakson. Right. I realize that.
Senator Blumenthal [continuing]. To the effect that their
recommendation is that members of the Blue Water Navy should
not be excluded from the coverage here.
Chairman Isakson. I agree with that.
Senator Blumenthal. I just want to close, Mr. Chairman--
because I am over my time, and you have been very gracious--by
saying that I hope that data privacy and security against
foreign influence campaigns is high on your list of priorities,
Mr. Secretary, because there is certainly evidence that during
the election, Russia promoted disinformation that specifically
targeted our military and veterans. As we go into this next
election, it is highly relevant and important.
I hope that the VA cooperates with social media and tech
platforms to address these threats.
Thank you.
Secretary Wilkie. Thank you, sir.
Chairman Isakson. Thank you, Senator Blumenthal.
Thank you, Mr. Secretary, for your attendance and your
thoroughness. We appreciate it very much. I look forward to
working with you ahead on Blue Water Navy and the other things
we have to do together for the men and women who have served
and represent so well.
Is there anything you want to say, Ranking Member?
Senator Tester. Just one thing, which has to do with the
MISSION Act implementation and the Under Secretary for VHA. Do
you have somebody in mind, and when do you anticipate we will
see them in front of this Committee?
Secretary Wilkie. I am looking. I am very happy with the
executive in charge. You all have met Dr. Stone, Army general.
Senator Tester. Yeah.
Secretary Wilkie. I have pledged to you that I would get
somebody in that position as quickly as I could. I did, and now
we are working on the confirmation.
Senator Tester. OK. Thank you very much.
Chairman Isakson. We stand adjourned.
[Whereupon, at 4:49 p.m., the Committee was adjourned.]
------
Response to Posthearing Questions Submitted by Hon. Jon Tester to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
Question 1. VA health care has been on GAO's High Risk List since
2015 for a variety of reasons, including inadequate oversight and
accountability, information technology challenges, and ambiguous
policies and inconsistent processes. In a letter to you in April, when
you were Acting Secretary, GAO highlighted 26 priority recommendations
that VA has yet to implement, 17 of which were carried over from 2017.
Response. VHA is responsible for 14 of the 26 High Priority
recommendations; 2 are closed, 4 are pending a closure decision from
GAO, 5 have target completion dates within the next 60 days, 3 have
target completion dates in the future and are on track for completion.
Question 2. Since GAO wrote to you in April, VA has only
implemented 3 of GAO's 26 priority recommendations. These are just the
priority recommendations. VA also has about 100 other open GAO
recommendations that remain unaddressed. GAO tells me that VA has yet
to submit a satisfactory action plan to address its high risk status in
the almost 4 years that have passed since GAO put them on the list.
What specific progress has been made during your tenure as Secretary?
VA Response:
VA Actions on GAO's high risk listing titled ``Managing
Risks and Improving Veterans Health Care'':
- FY 2015: Established VA's GAO High Risk List (HRL) Area
Task Force (Task Force) and provided GAO with an initial
Strategy for Health Care High Risk Management that linked
actions to the MyVA Initiative. Conducted listening sessions to
gain field insights and potential solutions. GAO found this
information interesting but not sufficient for an action plan.
- FY 2016: Conducted root cause analyses for each of the five
areas of concern and enterprise root causes. GAO found the root
cause analyses acceptable and a good start to an action plan.
- FY 2017: Work groups developed action plans for each of the
five risk areas, and continued work to resolve the risk areas.
- FY 2018: Work groups completed action plans and presented
them to GAO on March 15, 2018. GAO considered the action plan
to be a good start, and requested more clarification on
metrics, and integration with modernization efforts.
- FY 2019: VHA merged GAO high risk work with its Management
Review Service to leverage strong liaison functions with GAO,
improve communications, and build routine operations into
management of the GAO HRL. VHA partnered with the Office of
Strategic Integration to apply robust project management
discipline to all GAO HRL projects. VHA partnered with the
National Center for Organizational Development to apply robust
change management to GAO High Risk List. VHA partnered with
Office of Enterprise Integration to incorporate modernization
efforts into the GAO High risk plan.
Status of Open GAO recommendations to VHA:
- At the close of FY 2018, VHA has 113 open GAO
recommendations; 61 are new recommendations made in FY 2018; 47
were closed this fiscal year. VHA has completed work on 26
recommendations and awaits GAO's decision regarding closure.
- Over the past 3 years, GAO averaged 50 new recommendations
per year and averaged 51 closures per year--essentially no net
decrease in recommendations despite constant actions toward
completing actions.
Question 3. At your confirmation hearing, you affirmed the
statutory independence of the Inspector General, after Acting VA
leadership claimed that the IG is the Secretary's subordinate. It's
essential that all VA employees know that you will continue to support
and uphold this independence. It's also critical for veterans and
taxpayers to know that an independent body exists to conduct oversight
and help improve VA. Can you tell the Committee what you have done
since taking the job to help reinforce and uphold the IG's
independence?
Response. As I stated during the hearing, I view the Inspector
General as a partner and not subordinate to the Secretary. The
Inspector General works closely with the Office of Accountability and
Whistleblower Protection and the Veterans Health Administration's
Office of Medical Inspector to investigate allegations of misconduct or
other improprieties. In my previous position, I worked with the
Department of Defense Inspector General and plan to foster that same
working relationship with Mr. Missal. I was asked during the hearing if
I would commit to not interfere or hinder the independence of the
Inspector General and be transparent with requested information. I
would like to state again that I am committed to that. I have met with
Mr. Missal as recently as October 5, 2018, and it is my goal to
regularly meet with him for updates and discussion. I strongly support
the Inspector General's investigations and mission.
Question 4. The Committee continues to receive concerns from
whistleblowers and other employees about the implementation of the
Accountability Act. Do you find it appropriate that facilities are
investigating whistleblower complaints against themselves? Do you
believe this can be done fairly? Do you believe that whistleblowers
should have access to the findings of the reports and investigations
conducted into their inquiries? What are the timelines given to OAWP,
or by OAWP to administrations, within which they need to conduct
investigations into reports of whistleblowers?
Response. The Department has developed a robust system of checks
and balances related to the receipt, review, and reporting regarding
whistleblower disclosures. The process ensures each disclosure is
investigated thoroughly, timely, and impartially. The Office of
Accountability and Whistleblower Protection (OAWP) has received
approximately 3,100 submissions since its inception on June 23, 2017,
with the signing of the VA Accountability and Whistleblower Protection
Act, through October 1, 2018. Upon receipt, each submission is assigned
to an OAWP Triage Division Case Manager. The Case Manager sends the
disclosing party (if not submitted anonymously) an acknowledgement
message that includes the date the submission was received and a
tracking number. OAWP thoroughly reviews each submission to determine
if a submission satisfies the Act's definition of a ``whistleblower
disclosure.'' Of the 3,100 submissions, OAWP determined approximately
1,000 met the definition of a ``whistleblower disclosure'' for
referral. Once a submission is determined to be a ``whistleblower
disclosure'' the disposition of the disclosure depends on its content.
The definition of ``whistleblower disclosure'' is found in 38
U.S.C. Sec. 323(c)(1)(G)(3):
The term `whistleblower disclosure' means any disclosure of
information by an employee of the Department or individual
applying to become an employee of the Department which the
employee or individual reasonably believes evidences:
(A) a violation of a law, rule, or regulation; or
(B) gross mismanagement, a gross waste of funds, an abuse of
authority, or a substantial and specific danger to public
health or safety.
The VA Accountability and Whistleblower Protection Act requires
OAWP to refer whistleblower disclosures to the appropriate
investigative entity. Disclosures involving clinical matters are
referred to the Office of the Medical Inspector (OMI). Disclosures
involving potentially criminal conduct are offered to the Office of the
Inspector General (OIG); however, if the OIG declines the disclosure it
is returned to OAWP for further disposition. If the disclosure alleges
misconduct or poor performance by a senior leader, the disclosure is
referred to OAWP's Investigations Division. If the disclosure involves
an allegation of whistleblower retaliation by a supervisor, it is
likewise referred to OAWP's Investigations Division. If the disclosure
does not fall within any of the aforementioned criteria, it is referred
to the appropriate Administration or Staff Office for investigation and
reporting.
Of the approximately 1,000 whistleblower disclosures received, they
have been referred for investigation as follows:
Allegations of misconduct or poor performance by a senior
leader or whistleblower retaliation by any supervisor investigated by
OAWP: 354
Allegations involving potential criminal wrongdoing
accepted by the OIG: 13
Allegations involving clinical matters referred to OMI: 8
All other allegations referred that are not included in
the above:
- VHA: 570
- VBA: 31
- NCA: 1
- Staff Offices: 26
The remainder of this response only addresses those disclosures
referred to an Administration or Staff Office.
Each disclosure referred to an Administration or Staff Office is
referred with an instruction memo describing the requirements and
standards for review and reporting. The timeframe for a responsive
report is 30-days, although extensions can be granted with sufficient
justification. The instructions describe the limitations on who may
conduct the investigation and the specific items that must be addressed
in the resulting report. OAWP also sends a template for the required
report that describes the reporting requirements in detail. Each
referral includes the prohibition:
All investigations must be conducted by a neutral party who is
not named or involved in any of the disclosures. It is not
acceptable to send the referral notice to a party named in a
disclosure as part of any investigation method you choose.
Once the completed report is submitted by the Administration or
Staff Office to the OAWP Case Manager who reviews the report for
technical adequacy based on the instruction memo and reasonableness of
the response. If the Case Manager accepts the report, it is reviewed by
the Case Manager's supervisor for concurrence and, if satisfactory, the
disclosure is closed. A closure notice is provided to the disclosing
party. The notice explains that the disclosure was investigated and is
now closed. If the disclosing party has further questions, the closure
notice directs them to the Administration or Staff Office point-of-
contact. If a disclosing party seeks a copy of any of the investigatory
materials or report, they are referred to the appropriate Freedom of
Information Act Office.
Question 5. Please provide the Committee with the PowerPoint Slide
deck titled, ``Next Steps for Agent Orange Benefits, including Navy
Veterans in Territorial Water,'' which was produced by VBA on
November 24, 2017.
Response. This deck cannot be shared externally as it was used for
internal deliberate discussions regarding policy choices. The documents
requested consist of internal policy discussions by and amongst VA
employees regarding decisions on issuance of grant benefits and/or
proof presumptions to groups of Veterans, including benefits related to
Agent Orange and to groups of Veterans who served in waters in the
vicinity of Vietnam. The confidentiality of these communications is
critical to VA employees' faith in their ability to hold frank
discussions regarding highly publicized and controversial issues such
as these without such communications being disclosed to public.
______
Response to Posthearing Questions Submitted by Hon. Jerry Moran to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
There's been much discussion about the poor implementation of the
Choice program in terms of delays in scheduling, lack of robust
provider network, and inability for participating community providers
to get paid. In the midst of this bad news, I want to recognize and
applaud VA's direct contracts with dialysis providers. This is a good
example of VA's successful engagement of dialysis providers where
Veterans receive high quality, timely dialysis care and 23 dialysis
vendors are paid in a timely manner to provide a robust dialysis
provider network with coast-to- coast coverage.
The direct dialysis contracts that are in place today are set to
expire soon. VA has advised this Committee that there will be 6-month
bridge contract to ensure that there's no disruption in dialysis care
for Veterans. VA further informed this Committee of their plans to
recompete the direct dialysis contracts that would be a total of 5
years in duration.
Question 6. Does the VA intend to include dialysis in the Community
Care Network contracts that will be awarded in the coming months, or
will the VA preserve the direct dialysis contracts as the sole path for
acquiring dialysis services under the new MISSION Act?
Response. The new Nationwide Dialysis Services contracts (NDSC)
will be separate from the Community Care Network contracts. VA issued a
Request for Proposals (RFP) on October 29, 2018 and estimates award of
the contracts no later than January 31, 2019.
______
Response to Posthearing Questions Submitted by Hon. Dean Heller to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
Question 7. Secretary Wilkie--during your confirmation, we talked
about getting a full-time doctor in a clinic in Pahrump. It was a great
day two years ago to be there for the opening of this clinic--but we
need to make sure it has the staff the veterans need. Can you provide a
status update on getting a full-time doctor out to the Pahrump clinic?
Response. The last full-time physician who was employed in Pahrump,
resigned January 31, 2017. Since that time, the position was re-posted
October 1, 2017 and has remained posted since that date. This posting
has yielded 1 candidate who was selected, but due to licensure issues,
was unable to complete the hiring process. Two additional candidates
were received, however, neither were viable candidates. Recruitment
continues with the inclusion of recruitment incentives. Physicians
applying for the position in Pahrump are being offered a higher salary
than physicians in the Las Vegas metro area.
The VISN 21 physician recruiter has also been actively seeking
physicians for Pahrump since January 2017. However, these efforts have
yielded no viable candidates. VA patients in Pahrump are treated and
managed through the following methods:
a. One full-time Nurse Practitioner (Monday through Friday);
b. One full-time Physician Assistant (Monday through Friday);
c. VA Southern Nevada Healthcare System Primary Care has
collaborated with San Francisco's V-IMPACT program to provide one full-
time physician via Telehealth, which started September 4, 2018. This
program also provides an additional one week of face-to-face physician
coverage each quarter; and
d. If San Francisco is unable to see patients due to illness we
have back up available via telehealth.
Question 8. Secretary Wilkie--As part of the VA MISSION Act, I
secured a provision that requires the VA to implement a pilot program
for the use of medical scribes. I believe Las Vegas would be a great
location for this pilot program given we have a busy Emergency
Department where scribes could be very helpful. Do you have a status
update on when that pilot program will be implemented? Can you provide
a timeline for implementation?
Response. Planning for implementation of the medical scribe pilot
program is currently underway. Section 507 of the VA MISSION Act of
2018 is fairly prescriptive in the requirements for the program
concerning such issues as selecting pilot site locations, hiring and
distributing scribes, reporting, and evaluation. VA's timeline for
implementation is still in development, but VA plans to complete site
selection, scribe hiring and training, and to begin implementation over
the course of FY 2019.
______
Response to Posthearing Questions Submitted by Hon. Patty Murray to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
homelessness
HUD-VASH
Question 9. Data from the Department of Housing and Urban
Development showed that there was an increase in veteran homelessness
in 2017, and a significant increase in my home state of Washington.
Secretary Shulkin 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 have been made
available, any proposed programmatic changes, and a timeline for
implementation.
Response. Since the 2017 Point in Time (PIT) Count results showing
a significant increase in the number of homeless Veterans in
Washington, and particularly in Seattle/King County, were announced,
the Homeless Program Office (HPO) has provided targeted resources and
technical assistance to the area. HPO assigned its National Director of
Clinical Operations to work with the Director of the Homeless Programs
at VA Puget Sound to develop strategies and identify resource needs.
Resources and technical assistance provided over the past year include
the following:
New HUD-VA Supportive Housing (HUD-VASH) voucher
allocations to increase permanent supportive housing resources:
- FY 2017 award: 362 to Puget Sound (150 to Seattle/King
County).
- FY 2018 award (Round 1): 134 to Puget Sound (69 to Seattle/
King County).
- FY 2018 award (Round 2) not yet announced but expected to
be: 54 to Puget Sound (44 to Seattle/King County).
New lease signed for expanded, centrally-located Community
Resource and Referral Center in Seattle (anticipated opening Spring
2019), to enhance homeless Veteran access to services.
Two new Grant Per Diem (GPD) programs (Orting State
Soldier's Home: 40 beds; expansion of Salvation Army William Booth
Center by 14 beds).
Expansion of Health Care for Homeless Veterans (HCHV)
Contract beds (Seattle/King County) from 20 to 30 beds (Sept. 2018).
Supportive Services for Veteran Families (SSVF) Rapid
Resolution/Diversion Pilot (Seattle/King County).
Continued, innovative collaboration with non-profit, local
governmental, and Continuum of Care (CoC) partners to streamline
services for homeless Veterans across the region, including King County
to ensure a targeted utilization of King County Senior, Veterans, and
Human Services Levy (VSHSL) funds to complement services provided
through VA and fill identified gaps in care.
Close collaboration with all CoCs to create and maintain
``By Name'' or ``Master Lists'' of homeless Veterans across our region,
to better ensure that resources are optimally targeted based on need
and availability.
To help fill vacant case manager positions, VA assigned
staff from VA Central Office Workforce Management and Consulting to
assist in recruitment efforts, reducing the lag time associated with
filling vacant positions.
In terms of timeline for implementation, unless otherwise
indicated, all resources and technical assistance listed above are
ongoing.
These efforts resulted in a 31 percent reduction in
Veteran homelessness as identified by the 2018 PIT Count. This result
provides concrete evidence of the effectiveness of the resources and
technical assistance listed above.
Question 10. Unfilled case manager positions and un-used vouchers
throughout Washington state continue to hamper efforts to help
veterans. From discussions with local staff in the VA, housing
authorities, and non-profit providers, it seems that the hiring process
remains tedious and inefficient. Also, HUD and VA tracking systems are
not able to communicate with one another, slowing down the rapid-
rehousing process and potentially resulting in some veterans falling
through the cracks.
What will you do to ensure a streamlined hiring process
and the filling of critical case manager positions?
Response. As noted above, VA assigned staff from VA Central Office
Workforce Management and Consulting to assist in recruitment efforts.
This addition of staff to assist in hiring will reduce the lag time
associated with filling vacant positions.
Question 11. What will you do to ensure HUD and VA are able to
coordinate more effectively?
Response. HUD and VA have recently implemented a shared data
dashboard that is presented monthly at the Strategic Decision and
Consultation Team meeting, a monthly meeting with the US Interagency
Council on Homelessness (USICH). This process has ensured that HUD and
VA establish shared data definitions which has enhanced the sharing of
data at the Headquarters level.
Over the past two years, VA has also taken many steps to enhance
the ability to share data across HUD and VA systems at the local level.
These steps include but are not limited to the following:
VA adopted HUD's Universal Data Elements into its data
collection system and matching data elements related to housing
outcomes wherever possible
VA established a process by which staff may share
protected health information across VA and HUD systems through an
encrypted email system which complies with all privacy and security
requirements.
VA released extensive guidance requiring VAMC staff to
participate in local coordinated entry efforts.
VA is piloting use of cloud-based software to enhance VA medical
center (VAMC) staff ability to participate in community data sharing
efforts using the cloud.
Question 12. What is the long-term VA plan to get ahead of
increasing rates of veterans experiencing homelessness in areas with
fast increasing populations?
Response. In brief, the long-term plan is to address these areas on
both the demand and supply side. On the demand side, VA currently does
and will continue to target resources to the areas that need them most.
VA uses a sophisticated gap analysis model to predict homeless Veteran
population growth and uses the results of this model to guide resource
allocation in many of its key programs, including HUD-VASH, SSVF, and
GPD. This ensures that resources go where they are needed most. On the
supply side, VA is working closely with HUD and external partners to
increase the available housing stock for permanent supportive housing
and affordable housing. This includes targeted use of Project Based
Vouchers in HUD-VASH, use of VA property through the Enhanced Use Lease
(EUL) process, working with cities and counties on methods to incentive
development of units dedicated to homeless Veterans, and working with
landlords and developers to promote the need for the same.
Question 13. Please provide a national by-facility breakdown of:
i. The number of case managers
ii. Number of case manager vacancies
iii. Number of vouchers each case manager is responsible for
iv. How many vouchers are not in use
v. How many vouchers expired at the end of fiscal year 2018 and had
to be reissued
vi. How many veterans are waiting for vouchers
Response. Please see the attached spreadsheet and the responses
below:
i. The number of case managers:
Tab 1 (VA Staff) column D of the attachment shows
the total number of case manager positions in HUD-VASH.
ii. Number of case manager vacancies:
Tab 1 (VA Staff) column C of the attachment shows
the total number of case manager vacancies in HUD-VASH. Please
note that many of these positions were just created, due to the
recent FY 2018 voucher allocations.
iii. Number of vouchers each case manager is responsible for:
It is not possible to obtain this number for each
case manager, due to the unique make-up of case management
teams at each VAMC. Nationally, however, there are
approximately 3,100 VA case managers plus 273 contracted case
managers, for a total of 3,373 staff providing case management
for approximately 85,500 vouchers. This yields a ratio of
roughly 25 vouchers for each case manager. The data showing the
staffing breakdown by VAMC is in Tab 1 (VA Staff) and Tab 2
(Contracted CM) of the attachment.
iv. How many vouchers are not in use:
Tab 3 (Voucher Utilization) column C of the
attachment shows the number of vouchers not in use (i.e.,
available for use) by VAMC. Please note that in some cases many
of these unused vouchers were just recently allocated by HUD.
Negative numbers indicate that VAMCs have admitted more
Veterans to HUD-VASH than there are available vouchers. This is
a recommended practice to offset expected attrition prior to
voucher issuance, similar in concept to airline
``overbooking.''
v. How many vouchers expired at the end of fiscal year 2018 and had
to be reissued:
We do not collect data on this at the VACO level and
are thus unable to report it here.
vi. How many veterans are waiting for vouchers:
Tab 3 (Voucher Utilization) column D of the
attachment shows the number of Veterans awaiting vouchers. This
is the number of Veterans who have been referred to the Public
Housing Authority (PHA) for a voucher but have not yet received
the voucher. This number does not include Veterans admitted to
the HUD-VASH program who have not yet been referred to the PHA.
VA Staff (Tab 1)
------------------------------------------------------------------------
Facility Filled Vacant Grand Total
------------------------------------------------------------------------
(1V01) (402) Togus, ME HCS....... 5 6 11
(1V01) (405) White River 6 5 11
Junction, VT HCS................
(1V01) (518) Bedford, MA HCS..... 22 1 23
(1V01) (523) Boston, MA HCS...... 41 9 50
(1V01) (608) Manchester, NH HCS.. 13 1 14
(1V01) (631) Central Western 21 6 27
Massachusetts HCS...............
(1V01) (650) Providence, RI HCS.. 14 3 17
(1V01) (689) Connecticut HCS..... 24 9 33
(1V02) (526) Bronx, NY HCS....... 31 5 36
(1V02) (528) Western New York HCS 11 - 11
(1V02) (528A5) Canandaigua, NY 8 - 8
HCS.............................
(1V02) (528A6) Bath, NY HCS...... 5 1 6
(1V02) (528A7) Syracuse, NY HCS.. 12 2 14
(1V02) (528A8) Albany, NY HCS.... 12 4 16
(1V02) (561) New Jersey HCS...... 22 5 27
(1V02) (620) Hudson Valley, NY 9 - 9
HCS.............................
(1V02) (630) New York Harbor HCS. 41 2 43
(1V02) (632) Northport, NY HCS... 16 3 19
(1V04) (460) Wilmington, DE HCS.. 9 4 13
(1V04) (503) Altoona, PA HCS..... 2 2 4
(1V04) (529) Butler, PA HCS...... 6 - 6
(1V04) (542) Coatesville, PA HCS. 18 1 19
(1V04) (562) Erie, PA HCS........ 7 - 7
(1V04) (595) Lebanon, PA HCS..... 14 - 14
(1V04) (642) Philadelphia, PA HCS 24 11 35
(1V04) (646) Pittsburgh, PA HCS.. 15 - 15
(1V04) (693) Wilkes-Barre, PA HCS 7 2 9
(1V05) (512) Baltimore, MD HCS... 46 2 48
(1V05) (517) Beckley, WV HCS..... 6 - 6
(1V05) (540) Clarksburg, WV HCS.. 2 - 2
(1V05) (581) Huntington, WV HCS.. 10 - 10
(1V05) (613) Martinsburg, WV HCS. 6 2 8
(1V05) (688) Washington, DC HCS.. 41 12 53
(1V06) (558) Durham, NC HCS...... 21 - 21
(1V06) (565) Fayetteville, NC HCS 12 4 16
(1V06) (590) Hampton, VA HCS..... 32 3 35
(1V06) (637) Asheville, NC HCS... 13 1 14
(1V06) (652) Richmond, VA HCS.... 9 6 15
(1V06) (658) Salem, VA HCS....... 4 - 4
(1V06) (659) Salisbury, NC HCS... 28 1 29
(2V07) (508) Atlanta, GA HCS..... 75 13 88
(2V07) (509) Augusta, GA HCS..... 10 1 11
(2V07) (521) Birmingham, AL HCS.. 24 1 25
(2V07) (534) Charleston, SC HCS.. 31 7 38
(2V07) (544) Columbia, SC HCS.... 17 6 23
(2V07) (557) Dublin, GA HCS...... 8 - 8
(2V07) (619) Central Alabama HCS. 14 2 16
(2V07) (679) Tuscaloosa, AL HCS.. 10 1 11
(2V08) (516) Bay Pines, FL HCS... 52 8 60
(2V08) (546) Miami, FL HCS....... 42 - 42
(2V08) (548) West Palm Beach, FL 23 2 25
HCS.............................
(2V08) (573) Gainesville, FL HCS. 61 9 70
(2V08) (672) San Juan, PR HCS.... 11 4 15
(2V08) (673) Tampa, FL HCS....... 38 2 40
(2V08) (675) Orlando, FL HCS..... 56 - 56
(2V09) (596) Lexington, KY HCS... 11 - 11
(2V09) (603) Louisville, KY HCS.. 21 - 21
(2V09) (614) Memphis, TN HCS..... 19 1 20
(2V09) (621) Mountain Home, TN 14 2 16
HCS.............................
(2V09) (626) Middle Tennessee HCS 28 7 35
(3V10) (506) Ann Arbor, MI HCS... 17 5 22
(3V10) (515) Battle Creek, MI HCS 19 5 24
(3V10) (538) Chillicothe, OH HCS. 8 1 9
(3V10) (539) Cincinnati, OH HCS.. 23 4 27
(3V10) (541) Cleveland, OH HCS... 41 4 45
(3V10) (552) Dayton, OH HCS...... 11 1 12
(3V10) (553) Detroit, MI HCS..... 30 3 33
(3V10) (583) Indianapolis, IN HCS 20 5 25
(3V10) (610) Northern Indiana HCS 16 4 20
(3V10) (655) Saginaw, MI HCS..... 8 2 10
(3V10) (757) Columbus, OH HCS.... 13 3 16
(3V12) (537) Chicago, IL HCS..... 50 5 55
(3V12) (550) Danville, IL HCS.... 7 1 8
(3V12) (556) North Chicago, IL 7 - 7
HCS.............................
(3V12) (578) Hines, IL HCS....... 28 - 28
(3V12) (585) Iron Mountain, MI 1 1 2
HCS.............................
(3V12) (607) Madison, WI HCS..... 15 1 16
(3V12) (676) Tomah, WI HCS....... 7 2 9
(3V12) (695) Milwaukee, WI HCS... 21 2 23
(3V15) (589) Kansas City, MO HCS. 16 4 20
(3V15) (589A4) Columbia, MO HCS.. 6 - 6
(3V15) (589A5) Eastern Kansas HCS 16 2 18
(3V15) (589A7) Wichita, KS HCS... 10 1 11
(3V15) (657) St. Louis, MO HCS... 16 1 17
(3V15) (657A4) Poplar Bluff, MO 6 1 7
HCS.............................
(3V15) (657A5) Marion, IL HCS.... 2 1 3
(3V23) (437) Fargo, ND HCS....... 10 - 10
(3V23) (438) Sioux Falls, SD HCS. 5 - 5
(3V23) (568) Black Hills, SD HCS. 9 2 11
(3V23) (618) Minneapolis, MN HCS. 24 6 30
(3V23) (636) Nebraska-W Iowa HCS. 15 2 17
(3V23) (636A6) Central Iowa HCS.. 7 2 9
(3V23) (636A8) Iowa City, IA HCS. 6 2 8
(3V23) (656) St. Cloud, MN HCS... 2 2 4
(4V16) (502) Alexandria, LA HCS.. 12 1 13
(4V16) (520) Gulf Coast, MS HCS.. 29 5 34
(4V16) (564) Fayetteville, AR HCS 14 1 15
(4V16) (580) Houston, TX HCS..... 71 10 81
(4V16) (586) Jackson, MS HCS..... 17 4 21
(4V16) (598) Little Rock, AR HCS. 16 5 21
(4V16) (629) New Orleans, LA HCS. 35 3 38
(4V16) (667) Shreveport, LA HCS.. 11 2 13
(4V17) (504) Amarillo, TX HCS.... 7 2 9
(4V17) (519) Big Spring, TX HCS.. 8 1 9
(4V17) (549) Dallas, TX HCS...... 53 6 59
(4V17) (671) San Antonio, TX HCS. 24 1 25
(4V17) (674) Temple, TX HCS...... 22 8 30
(4V17) (740) Texas Valley Coastal 9 2 11
Bend HCS........................
(4V17) (756) El Paso, TX HCS..... 10 3 13
(4V19) (436) Montana HCS......... 12 5 17
(4V19) (442) Cheyenne, WY HCS.... 7 3 10
(4V19) (554) Denver, CO HCS...... 55 9 64
(4V19) (575) Grand Junction, CO 5 2 7
HCS.............................
(4V19) (623) Muskogee, OK HCS.... 18 - 18
(4V19) (635) Oklahoma City, OK 11 5 16
HCS.............................
(4V19) (660) Salt Lake City, UT 22 6 28
HCS.............................
(4V19) (666) Sheridan, WY HCS.... 4 2 6
(5V20) (463) Anchorage, AK HCS... 11 2 13
(5V20) (531) Boise, ID HCS....... 10 1 11
(5V20) (648) Portland, OR HCS.... 47 17 64
(5V20) (653) Roseburg, OR HCS.... 13 7 20
(5V20) (663) Puget Sound, WA HCS. 64 19 83
(5V20) (668) Spokane, WA HCS..... 20 1 21
(5V20) (687) Walla Walla, WA HCS. 12 4 16
(5V20) (692) White City, OR HCS.. 12 4 16
(5V21) (459) Honolulu, HI HCS.... 37 7 44
(5V21) (570) Fresno, CA HCS...... 29 3 32
(5V21) (593) Las Vegas, NV HCS... 57 4 61
(5V21) (612A4) N. California HCS. 56 18 74
(5V21) (640) Palo Alto, CA HCS... 79 7 86
(5V21) (654) Reno, NV HCS........ 20 2 22
(5V21) (662) San Francisco, CA 44 22 66
HCS.............................
(5V22) (501) New Mexico HCS...... 22 2 24
(5V22) (600) Long Beach, CA HCS.. 34 26 60
(5V22) (605) Loma Linda, CA HCS.. 39 14 53
(5V22) (644) Phoenix, AZ HCS..... 40 14 54
(5V22) (649) Northern Arizona HCS 16 1 17
(5V22) (664) San Diego, CA HCS... 58 5 63
(5V22) (678) Southern Arizona HCS 31 4 35
(5V22) (691) Greater Los Angeles, 175 108 283
CA HCS..........................
--------------------------------------
Grand Total.................. 3,100 632 3,732
------------------------------------------------------------------------
Contracted Case Managers (Tab 2)
------------------------------------------------------------------------
Contracted
Facility Case
Managers
------------------------------------------------------------------------
(1V02) (526) Bronx, NY HCS................................ 14
(1V02) (561) New Jersey HCS............................... 13
(1V02) (620) Hudson Valley, NY HCS........................ 3
(1V02) (630) New York Harbor HCS.......................... 14
(1V02) (632) Northport, NY HCS............................ 7
(1V04) (503) Altoona, PA HCS.............................. 1
(1V05) (688) Washington, DC HCS........................... 13
(5V20) (653) Roseburg, OR HCS............................. 4
(5V20) (663) Puget Sound, WA HCS.......................... 6
(5V21) (662) San Francisco, CA HCS........................ 13
(5V22) (678) Southern Arizona HCS......................... 1
(5V22) (691) Greater Los Angeles, CA HCS.................. 184
-------------
Grand Total........................................... 273
------------------------------------------------------------------------
Voucher Utilization (Tab 3)
------------------------------------------------------------------------
Veterans
Vouchers Vouchers Waiting
Facility Allocated Available for a
for Use Voucher
------------------------------------------------------------------------
(1V01) (402) Togus, ME HCS....... 216 -19 2
(1V01) (405) White River 204 19 1
Junction, VT HCS................
(1V01) (518) Bedford, MA HCS..... 544 10 3
(1V01) (523) Boston, MA HCS...... 918 82 0
(1V01) (608) Manchester, NH HCS.. 281 6 1
(1V01) (631) Central Western 645 35 7
Massachusetts HCS...............
(1V01) (650) Providence, RI HCS.. 376 -5 3
(1V01) (689) Connecticut HCS..... 818 32 4
(1V02) (526) Bronx, NY HCS....... 1,339 -36 3
(1V02) (528) Western New York HCS 323 -3 0
(1V02) (528A5) Canandaigua, NY 201 5 0
HCS.............................
(1V02) (528A6) Bath, NY HCS...... 125 2 5
(1V02) (528A7) Syracuse, NY HCS.. 257 18 0
(1V02) (528A8) Albany, NY HCS.... 350 -20 6
(1V02) (561) New Jersey HCS...... 957 0 20
(1V02) (620) Hudson Valley, NY 349 17 0
HCS.............................
(1V02) (630) New York Harbor HCS. 1,776 -39 17
(1V02) (632) Northport, NY HCS... 464 2 0
(1V04) (460) Wilmington, DE HCS.. 217 6 3
(1V04) (503) Altoona, PA HCS..... 83 7 4
(1V04) (529) Butler, PA HCS...... 125 2 0
(1V04) (542) Coatesville, PA HCS. 479 23 0
(1V04) (562) Erie, PA HCS........ 121 7 0
(1V04) (595) Lebanon, PA HCS..... 284 -38 0
(1V04) (642) Philadelphia, PA HCS 926 16 0
(1V04) (646) Pittsburgh, PA HCS.. 422 5 0
(1V04) (693) Wilkes-Barre, PA HCS 219 -27 6
(1V05) (512) Baltimore, MD HCS... 944 -69 18
(1V05) (517) Beckley, WV HCS..... 143 -6 0
(1V05) (540) Clarksburg, WV HCS.. 67 -6 0
(1V05) (581) Huntington, WV HCS.. 215 12 1
(1V05) (613) Martinsburg, WV HCS. 172 2 2
(1V05) (688) Washington, DC HCS.. 1,495 -14 10
(1V06) (558) Durham, NC HCS...... 480 3 0
(1V06) (565) Fayetteville, NC HCS 366 -3 4
(1V06) (590) Hampton, VA HCS..... 747 53 0
(1V06) (637) Asheville, NC HCS... 338 -10 6
(1V06) (652) Richmond, VA HCS.... 369 23 1
(1V06) (658) Salem, VA HCS....... 98 -6 0
(1V06) (659) Salisbury, NC HCS... 744 20 33
(2V07) (508) Atlanta, GA HCS..... 1,955 111 48
(2V07) (509) Augusta, GA HCS..... 237 -11 4
(2V07) (521) Birmingham, AL HCS.. 606 -19 1
(2V07) (534) Charleston, SC HCS.. 649 5 0
(2V07) (544) Columbia, SC HCS.... 549 -20 12
(2V07) (557) Dublin, GA HCS...... 200 5 2
(2V07) (619) Central Alabama HCS. 306 -10 0
(2V07) (679) Tuscaloosa, AL HCS.. 267 -15 5
(2V08) (516) Bay Pines, FL HCS... 1,309 45 6
(2V08) (546) Miami, FL HCS....... 1,038 56 11
(2V08) (548) West Palm Beach, FL 560 1 4
HCS.............................
(2V08) (573) Gainesville, FL HCS. 1,688 -20 15
(2V08) (672) San Juan, PR HCS.... 197 23 0
(2V08) (673) Tampa, FL HCS....... 987 -12 22
(2V08) (675) Orlando, FL HCS..... 1,262 58 0
(2V09) (596) Lexington, KY HCS... 302 2 0
(2V09) (603) Louisville, KY HCS.. 475 55 1
(2V09) (614) Memphis, TN HCS..... 492 -46 8
(2V09) (621) Mountain Home, TN 355 37 0
HCS.............................
(2V09) (626) Middle Tennessee HCS 763 -31 13
(3V10) (506) Ann Arbor, MI HCS... 450 38 2
(3V10) (515) Battle Creek, MI HCS 557 11 5
(3V10) (538) Chillicothe, OH HCS. 228 13 0
(3V10) (539) Cincinnati, OH HCS.. 548 -7 12
(3V10) (541) Cleveland, OH HCS... 955 16 12
(3V10) (552) Dayton, OH HCS...... 225 13 3
(3V10) (553) Detroit, MI HCS..... 912 113 0
(3V10) (583) Indianapolis, IN HCS 641 45 27
(3V10) (610) Northern Indiana HCS 427 25 12
(3V10) (655) Saginaw, MI HCS..... 219 8 0
(3V10) (757) Columbus, OH HCS.... 372 -22 0
(3V12) (537) Chicago, IL HCS..... 1,220 -2 1
(3V12) (550) Danville, IL HCS.... 226 9 1
(3V12) (556) North Chicago, IL 194 13 0
HCS.............................
(3V12) (578) Hines, IL HCS....... 609 17 0
(3V12) (585) Iron Mountain, MI 36 -1 0
HCS.............................
(3V12) (607) Madison, WI HCS..... 276 8 0
(3V12) (676) Tomah, WI HCS....... 161 2 4
(3V12) (695) Milwaukee, WI HCS... 628 -7 7
(3V15) (589) Kansas City, MO HCS. 397 4 6
(3V15) (589A4) Columbia, MO HCS.. 153 30 0
(3V15) (589A5) Eastern Kansas HCS 400 11 4
(3V15) (589A7) Wichita, KS HCS... 238 16 2
(3V15) (657) St. Louis, MO HCS... 370 8 7
(3V15) (657A4) Poplar Bluff, MO 129 -4 0
HCS.............................
(3V15) (657A5) Marion, IL HCS.... 90 8 0
(4V16) (502) Alexandria, LA HCS.. 263 9 3
(4V16) (520) Gulf Coast, MS HCS.. 652 14 5
(4V16) (564) Fayetteville, AR HCS 241 -15 4
(4V16) (580) Houston, TX HCS..... 1,919 60 7
(4V16) (586) Jackson, MS HCS..... 447 20 3
(4V16) (598) Little Rock, AR HCS. 398 40 1
(4V16) (629) New Orleans, LA HCS. 801 45 10
(4V16) (667) Shreveport, LA HCS.. 282 15 0
(4V17) (504) Amarillo, TX HCS.... 240 2 0
(4V17) (519) Big Spring, TX HCS.. 213 5 6
(4V17) (549) Dallas, TX HCS...... 1,330 -113 46
(4V17) (671) San Antonio, TX HCS. 719 -31 8
(4V17) (674) Temple, TX HCS...... 779 51 0
(4V17) (740) Texas Valley Coastal 239 -1 2
Bend HCS........................
(4V17) (756) El Paso, TX HCS..... 294 -15 0
(4V19) (436) Montana HCS......... 410 14 1
(4V19) (442) Cheyenne, WY HCS.... 235 15 1
(4V19) (554) Denver, CO HCS...... 1,359 62 21
(4V19) (575) Grand Junction, CO 187 6 0
HCS.............................
(4V19) (623) Muskogee, OK HCS.... 336 -10 10
(4V19) (635) Oklahoma City, OK 372 0 2
HCS.............................
(4V19) (660) Salt Lake City, UT 601 40 17
HCS.............................
(4V19) (666) Sheridan, WY HCS.... 112 8 2
(5V20) (463) Anchorage, AK HCS... 311 4 2
(5V20) (531) Boise, ID HCS....... 221 11 4
(5V20) (648) Portland, OR HCS.... 1,210 -90 12
(5V20) (653) Roseburg, OR HCS.... 503 40 6
(5V20) (663) Puget Sound, WA HCS. 1,893 -101 44
(5V20) (668) Spokane, WA HCS..... 411 -17 8
(5V20) (687) Walla Walla, WA HCS. 396 -7 9
(5V20) (692) White City, OR HCS.. 385 40 5
(5V21) (459) Honolulu, HI HCS.... 742 13 27
(5V21) (570) Fresno, CA HCS...... 545 29 4
(5V21) (593) Las Vegas, NV HCS... 1,419 159 19
(5V21) (612A4) N. California HCS. 1,465 -9 14
(5V21) (640) Palo Alto, CA HCS... 1,997 -128 72
(5V21) (654) Reno, NV HCS........ 483 27 7
(5V21) (662) San Francisco, CA 1,593 -33 20
HCS.............................
(5V22) (501) New Mexico HCS...... 548 17 2
(5V22) (600) Long Beach, CA HCS.. 1,508 121 45
(5V22) (605) Loma Linda, CA HCS.. 1,082 -16 0
(5V22) (644) Phoenix, AZ HCS..... 1,103 232 6
(5V22) (649) Northern Arizona HCS 327 7 6
(5V22) (664) San Diego, CA HCS... 1,641 68 32
(5V22) (678) Southern Arizona HCS 810 45 7
(5V22) (691) Greater Los Angeles, 6,189 892 36
CA HCS..........................
(3V23) (437) Fargo, ND HCS....... 244 23 2
(3V23) (438) Sioux Falls, SD HCS. 151 4 0
(3V23) (568) Black Hills, SD HCS. 205 13 2
(3V23) (618) Minneapolis, MN HCS. 651 -24 8
(3V23) (636) Nebraska-W Iowa HCS. 494 38 6
(3V23) (636A6) Central Iowa HCS.. 200 -3 0
(3V23) (636A8) Iowa City, IA HCS. 176 -13 2
(3V23) (656) St. Cloud, MN HCS... 74 0 2
--------------------------------------
Grand Total.................. 85,461 3,402 975
------------------------------------------------------------------------
facilities
Yakima CBOC
Question 14. The Yakima CBOC funds were allocated in 2016. After a
delay on construction due to a contested bid, we do not have a current
estimate for date of construction beyond a vague assertion of 18 months
to two years. Please provide a more detailed account of projected
construction timeline.
Response. In order to address prior protests associated with what
has been determined to be a geographic area of consideration that was
too restrictive, the Yakima lease area of consideration has been
revised. The updated lease solicitation will be issued no later than
December 2018 and an award is anticipated by Fall 2019 or earlier. Upon
award, the new lease may take 18-24 months to be completed for VA
occupancy. The lessor's construction timeline depends on what type of
space lessor offers and VA leases, existing space to be renovated or
new construction.
Bremerton CBOC
Question 15. The Bremerton CBOC was slated to be updated nine years
ago. A month ago the notice to proceed was finally obtained and
construction has begun on a new facility in neighboring Silverdale. The
timeline for construction is now 18 months. Since the authorization of
funding, the needs of the community have changed and the slated
construction of a site that can serve 7,200 veterans will not meet the
needs of the area given the rate of growth in the veteran population,
the number of beds being added to the new facility, and the expected
return of veterans who have gone to the Choice program due to backups
at the current facility.
Please provide a full timeline of construction and
expected end date.
Please provide details on most recent assessment of
community capacity and needs.
Please provide assessment of recently announced Auburn
and Olympia facilities as well and explain rationale for different
sizes.
The Bremerton CBOC still lacks a Women's Care Team
despite Secretary Shulkin assuring me in 2016 that one would soon be
there. Please update me on the timeline for this team to be operating
in the clinic.
VA Response:
Please provide a full timeline of construction and
expected end date. The lease was awarded on July 7, 2017 and in
August 2018 VA issued the lessor a Notice to Proceed with construction
per VA approved clinic design. The lessor is currently scheduled to
complete construction of the building October 2019.
Please provide details on most recent assessment of
community capacity and needs. Currently, Market Assessments are being
planned for all facilities nationwide. A contract was let to accomplish
this starting this fiscal year. These assessments will analyze both in-
house workload and do a comprehensive review of community capacity and
needs.
Please provide assessment of recently announced Auburn and
Olympia facilities as well and explain rationale for different sizes.
Newly approved CBOC leases in Auburn and Olympia, Washington are
similarly sized at approximately 25,272 and 25,179 net usable square
feet respectively. Both sites intend to provide PACT Primary Care,
Primary Care Mental Health Integration (PCMHI) and Specialty Mental
Health services, along with basic laboratory and diagnostic imaging
services. Differences in programing space can occur based on the number
of staff, number of rooms or the size of a room.
The Bremerton CBOC still lacks a Women's Care Team despite
Secretary Shulkin assuring me in 2016 that one would soon be there.
Please update me on the timeline for this team to be operating in the
clinic. The current Bremerton CBOC has four designated Women's Health
(WH) Providers. Two of them have been WH providers since 2016. The most
recent ones have been on station since August 2017. The New Silverdale
CBOC has space designated for WH.
Tonasket Rural Medical Clinic
Question 16. As of May 2017, the VA intended to close the Tonasket
Rural Health Clinic, located within the North Valley Hospital, and
roughly a year ago they did. More than 850 veterans relied on that
clinic to receive care from the VA. Without the clinic, they are forced
to travel either two hours each way to Wenatchee, or three hours each
way to the Mann-Grandstaff VA Medical Center (MGVAMC) in Spokane. The
medical center has been unable to provide an accurate picture of the
status of the replacement clinic, and previously told my office an
award was expected in February 2018. As of last week, medical center
had no update or information on this extended delay due to a lack of
transparency in contracting.
Please provide a full details of current status of Tonasket
reopening, including a firm date for the clinic to be operational.
Response. Tonasket Contract Clinic proposals have been received and
are currently under review. Upon award and notice to proceed, the
contract clinic is to be operational within 120 days.
Puget Sound VA
Question 17. During his confirmation hearing in 2017, Secretary
Shulkin committed to following up on concerns I raised about the
condition of the VA Puget Sound Health Care System and obstacles
Washington veterans faced in accessing care. The problem then seemed to
stem from unfilled management positions and frequent turnover in
leadership. A management improvement team was sent to the facility, and
measures have been taken to ensure physician and nurse positions are
filled, but many problems persist. The problems again seem to center on
unfilled rolls and overburdened existing staff. I am very concerned
with low levels of support staffing overall, specifically in the
maintenance and human resources departments and the effects this
understaffing is having on patient care.
I ask that you investigate these issues and take action
expeditiously to resolve these problems. In particular, if additional
staff or resources are necessary for patient care or for human
resources in order to expedite hiring of providers, I ask that you take
all necessary actions to meet those needs, including temporarily
detailing staff to the facility.
I also ask that you undertake a review of the long-term
feasibility of hiring in this region. With increasing costs of living
and significant competition for employees among hospitals in the
Seattle area, VA will have to be sure it can recruit and retain the top
talent. Please describe whether and how VA can keep pace with the
market and any additional authorities that are necessary.
I am also specifically concerned about reports I have received
about deficiencies in the radiology department, especially in light of
reports of hundreds of thousands of radiology consults being improperly
closed, potentially putting veterans at risk. The specific concerns
raised about Puget Sound include the lack of an efficient scheduling
system and lack of compliance with scheduling policy, lack of
sufficient clerical staff, as well as possible mishandling of patient
images including CDs being stored unsecured or improperly, images not
being entered into the medical record, or patient images being deleted.
Please investigate these concerns and take appropriate corrective
action.
Response. VA Central Office's H.R. Team is supporting the Puget
Sound facility with direct impact to hiring is actively filling
vacancies. Currently, this team has vacancies for two H.R. Specialist
and one H.R. Assistant which are expected to be filled within the next
90 days. Additionally, an additional nurse recruiter (part-time) was
supported for hire in Patient Care Services this year to assist with
recruitment in this area. The following strategies are being employed:
Utilization of Recruitment and Retention flexibilities
(recruitment, relocation and retention incentives, student loan
repayment, education debt reduction, accelerated leave accrual) for
hard-to-fill occupations for the facility, including human resources.
Pay authorities such as above-minimum entry and highest
previous rate are also applied, as appropriate, to assist in achieving
and offering salaries commensurate with an applicant's qualifications
and/or in recognition of prior Federal service.
Telework options have been leveraged in an effort to
recruit and retain H.R. staff while maintaining a customer-service
focus to support medical center operational needs.
In January 2018, OPM authorized direct hire authority to
VA for 15 critical occupations to include Human Resources Specialist
and Human Resources Assistants, which we are actively using as a
flexibility to hire.
H.R. consolidation to the VISN is actively moving forward
to create a more efficient, effective and standardized means to deliver
H.R. services in VHA.
Adjusted salary rates or new special salary rates
established for numerous occupations to create more competitive wages.
VISN 20's compensation team has been providing assistance in this area
and will continue to support the facilities, including Puget Sound.
Utilizing non-competitive hiring authorities available to
fill positions, appropriately, with qualified quality candidates
(trainees, VRA, schedule A, 30%+ Veterans)
Policy changes are creating greater efficiencies and
flexibilities (i.e. physician market pay review, Title 38 hybrid
conversions, elimination of professional standards boards, etc.)
Continued Barriers/Challenges:
The Seattle-Tacoma labor market is unique, since the
greater Seattle area was minimally affected by the economic downturn
and the area has been a major hub for growth in both technology and
healthcare over the last decade. In addition, the minimum wage for the
Seattle area is $15.00 per hour. This is slightly below the annual rate
of an employee at GS-4, Step 1 on the Seattle-Tacoma locality scale.
The local minimum wage has limited our competitiveness, since it
provides a higher hourly rate than that paid to a GS-3, a grade widely
used in our hiring for the same region.
VA Puget Sound, Seattle campus, is in a prime location and
property with a high growth rate and cost of living. Competition is not
only with private sector hospitals but also with other Federal agencies
as the area is saturated with other agencies.
Available flexibilities are not available to recruit and
retain personnel at VA, if they are existing Federal employees or
taking an opportunity with another agency. Limited funding for
education reimbursement.
Length of job posting--15 business days as negotiated by
the union is often too long to leave a position open if you have a
viable pool of applicants.
Professional Standards Boarding timeliness presents a
delay with some Title 38 and Title 38 Hybrid occupations, with emphasis
on those at a regional or national level.
Required use of multiple systems for same or similar
purposes that do not talk to each other causing additional admin work
for H.R. team and users.
- Downgrading of positions such as H.R. Specialists,
Engineers, Radiation Safety Officer, Credentialing Assistants,
Administrative Officers of the Day (AOD), and other
occupations.
While there have been positive regulatory and policy
changes occurring to support a more effective and efficient hiring
process, it frequently increases the workload required of the local
H.R. team members to enact.
Question 18. I have also received troubling reports about
insufficient staffing and operations in the emergency department.
Please provide an update on staffing levels and vacancies, by position
type, and describe any barriers to achieving full staffing and
retaining ED staff.
Response. As of 9/26/18, there are 570.7 approved-budgeted
vacancies for VA Puget Sound HCS. Of these, there are 185 selections to
fill positions ranging from administrative support to direct patient
care, 40% of these selectees have a firm Entry on Duty between October-
December while the others pending are undergoing the pre-employment
process.
The ED currently has the following vacancies:
4 Physicians
1 Physician Assistant
1 Advanced Registered Nurse Practitioner
6 Registered Nurses
6 Nursing Assistants
2 Medical Support Assistants
Question 19. a. Please describe wait times at the ED over the year
to date, and any instances of bed shortages. b. What impacts are
projected as flu season begins, and what mitigation steps are being
taken? (VHA 10NC)
Response. During FY 2017, VA Puget Sound's average time from the
decision to admitting the patient was 178 minutes, compared to the
national average time of 130 minutes at other VA hospitals. The average
time in FY 2018 is slightly longer at VA Puget Sound at 197 minutes,
compared to a national average of 131 minutes. Some of the ongoing ways
we are actively addressing these challenges include patient flow
assessment projects, daily huddles to optimize available beds, planned
discharges, admissions, surgeries and staffing, and continuous process
improvement to enhance quality, efficiency, safety and the overall
Veteran experience.
b. What impacts are projected as flu season begins, and what
mitigation steps are being taken?
Response. Flu season will increase the volume of Emergency
Department patient encounters and subsequently the number of inpatient
admissions, in particular, for vulnerable populations such as the
elderly and those with chronic disease. Patients with suspected flu
will need respiratory isolation to prevent the nosocomial spread of
infection. There will be an increase in staff illness during the flu
season which will decrease workforce productivity.
Risk mitigation steps include:
We have hired additional staff in the Emergency
Department, with approved and budgeted additional increases in process.
We have hired additional staff in the inpatient medical
units, with approved and budgeted additional increases in process.
We have a contract with a nurse staffing agency for short
term nurse staffing increases.
We have improved processes around timely discharges to
increase available isolation beds for patients with influenza.
We have designed a process for continual and proactive
assessment of bed availability that raises awareness and shares
resources across units at times of high hospital census.
We have met with local area hospitals (Madigan Army
Medical Center) to improve collaboration around patient transfer at
times of high hospital census.
We have coordinated a robust staff influenza vaccination
campaign.
va programs
IVF
Question 20. It has been two years since Congress gave VA the
authority to provide IVF and other necessary fertility treatments for
ill or injured veterans and their spouses. These treatments can help
veterans realize their dream of starting a family, but access to this
care promised to our veterans is still limited. We should not cut
corners when it comes to our veterans and their families. Consistent
and nationwide access to this program is essential to meet the
commitments we have made, and the dreams for which these veterans
fought so hard.
Please describe how you are currently working to ensure
additional providers are enrolled into the program and any other
necessary steps taken to make sure our veterans have easy access to
this treatment in the country. What steps can the Department take to
more quickly enroll providers? Please also discuss how provision of ART
will be incorporated into the Department's planning and implementation
of the new Veterans Community Care Program.
Please describe how VA is ensuring veterans and spouses
receiving such treatments or about to start such treatments are not
adversely impacted by repeated changes in non-VA care programs and
contractors.
Response. IVF services are a very specialized medical procedure,
and as such are only provided by a discrete number of clinicians around
the country. When an IVF provider is needed by a Veteran and/or his or
her family, VA's third party administrators actively work to bring the
clinician into the community care network, if they are not already part
of it. Active outreach is being performed for couples either approved
for VA IVF health care benefits or those who are eligible for VA IVF
health care benefits but whom we know are actively receiving IVF care
outside our health care system. In the latter case, the couples can
decide if they wish to transfer responsibility for their future/
continuing IVF care and services to a VHA-authorized provider(s). VA
has developed a mechanism to track these patients to ensure care
coordination (including identification of preferred providers) for
these Veterans and their families. Identifying these Veterans as early
in the process as possible will help ensure more timely access to
providers and the IVF care. IVF care that cannot be provided in-house
will continue to be purchased in the community (invoking available
contract or similar purchase authority.)
Electronic Health Records
Question 21. According to the reports from this spring, the Defense
Department's $4.3 billion Cerner medical record system failed to
achieve many of its initial goals at the first hospitals that went
online and transition systems seamlessly. Technical problems and poor
training resulted in numerous errors and reduced the number of patients
who can be treated, according to interviews with more than 25 military
and VA health IT specialists and doctors, including six who work at the
four Pacific Northwest military medical facilities that rolled out the
software over the last year. Recently, DOD has added a $1.1 billion
contract to extend Leidos' work order to include EHR standardization
since the VA had hired Cerner as its prime contractor. This is in
addition to the original $4.3 billion Leidos- Cerner contract. A recent
briefing to Congressional staff by VA Puget Sound cited Madigan Army
Medical Center experiencing a 50 percent drop in clinician productivity
during the transition. Clearly, already overburdened VA hospitals
cannot afford to see this same effect.
a. Please provide a detailed description of the measures you are
taking to ensure the VA EHR implementation will not fall victim to
similar problem that the DOD implementation did.
Response. To mitigate possible impacts to the deployment of VA's
new EHR in VA hospitals, VA is leveraging DOD's lessons learned from
their IOC sites. Several examples of efficiencies VA is leveraging
include: revised contract language to improve trouble ticket resolution
based on DOD challenges; optimal VA EHRM governance structure; fully
resourced PMO with highly qualified clinical and technical oversight
expertise; effective change management strategy; and, utilizing Cerner
Corporation as a developer and integrator consistent with commercial
best practices.
b. Please provide an updated timeline for EHR implementation in VA
Puget Sound and VA Tacoma.
Response. By implementing the same electronic health record (EHR)
solution as the Department of Defense (DOD), the Department of Veterans
Affairs (VA) is not only taking advantage of a commercial solution and
industry's best practices, but VA is also able to leverage lessons
learned from DOD. These lessons learned are tracked to proactively
reduce and address challenges at VA Initial Operating Capability (IOC)
sites. As challenges arise throughout the deployment, VA will work
urgently to mitigate the impact to Veterans health care.
Furthermore, there have not been any changes made to the deployment
timeline provided to your staff on October 23, 2018, which includes the
timeline for EHR implementation in VA Puget Sound and VA Tacoma.
______
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
Question 22. Mr. Secretary, as you stated in your testimony
provided ahead of the hearing, one of your priorities is to address the
45,000 vacancies at the VA. One of the ways I proposed to address this
issue was to increase the maximum amount the VA will provide to
participants in the Education Debt Reduction Program, a measure I was
proud to have included in the VA MISSION Act. Can you expand upon the
measures you mentioned in your testimony on how you and your staff are
addressing this crisis, and how you hope to recruit and retain the best
candidates to these positions?
Response. The Education Debt Reduction Program (EDRP) is one of
VHA's most viable tools for recruiting and retaining critically needed
healthcare providers. VA is looking forward to implementing additional
flexibilities authorized by the MISSION Act, specifically the increase
in the maximum EDRP award amount to $200,000 and the establishment of a
program targeted to recruit recent medical school graduates, residents
and fellows by repaying student loans in exchange for service at VA.
VHA will also be expanding the Health Professions Scholarship Program
to include offers of medical school scholarships for 50 individuals as
required under the MISSION Act.
Question 23. Mr. Secretary, I'm sure you know that today, veterans
with no service-connected disabilities who have higher incomes are not
able to get care from the VA. My office gets calls from Vermont
veterans who know they don't qualify for VA health care, but want to
get their care there. Many have even suggested that they'd be willing
to pay to access VA health care. I think this idea makes a lot of
sense. Do you think that all veterans--regardless of income--should be
able to choose VA if they want? Are you willing to work with me on
figuring out what it would take to give these veterans the choice of VA
health care?
Response. The Veterans' Health Care Eligibility Reform Act of 1996
(Public Law 104-262) mandated that VA deliver services to Veterans in
accordance with statutory requirements who have service-connected
conditions, to Veterans unable to pay for necessary medical care, and
to specific groups of Veterans, such as former prisoners of war. The
legislation permitted VA to offer services to all other Veterans to the
extent that resources and facilities were available; it also required
VA to develop and implement an enrollment system to facilitate the
management and delivery of health care services. This has been
accomplished through the establishment of eight (8) Priority Groups
with Priority Group 1 (Veterans who are 50 percent or more service-
connected and medal of honor awardees) and Priority Group 8 which
includes Veterans whose incomes are above certain thresholds.
In 2003, VA made the difficult decision to stop enrolling new
Priority Group 8 Veterans in order to ensure the provision of timely
and quality medical care. However, on June 15, 2009 regulations were
issued that allowed VA to reopen enrollment for VA health care to
Veterans whose previous calendar year's household income exceeded the
current VA national income thresholds or Geographical Means Test
Thresholds by 10% or less. While this new provision did not remove
consideration of income, it did increase established income thresholds
allowing more Veterans to qualify for enrollment in VA's health care
system. Also, in 2015 VA eliminated the use of net worth as a
determining factor for both health care programs and copayment
responsibilities. This change made VA health care benefits more
accessible to lower-income Veterans
Question 24. Mr. Secretary, I know we've had a lot of conversations
around choice and privatization. VA remaining strong is central to the
whole idea of ``choice''--that veterans should have the choice of where
they go for care because VA must be one of the choices given to the
veteran. I am worried, however, that right now--even with the changes
from the MISSION Act--the VA is set up to fail as an organization, and
fail our veterans, because of the current bureaucracy we've set up. Let
me walk you through what I mean by that.
Take a veteran, who calls the VA CBOC in Burlington, my home town,
for an appointment--let's say it's a dermatology appointment. The
veteran is told the next available appointment is in 60 days, making
her eligible for Choice. So she is referred to the UVM Medical Center,
where the wait is 12 MONTHS for a new patient. So, two months at VA--12
months in the community. At that point, the veteran has two choices--
call VA back and say she wants the appointment at the VA CBOC in 60
days, or make the appointment for community care in a year. There are
two problems with this: First, we're relying on the veteran to
understand this nuance--that she still has the choice of VA care--and
relying on her to take the extra step of calling the VA back and
setting up the appointment. But here's the second problem: If the
veteran does that--calls back the VA and sets up the appointment for
two months from now, that VA appointment ends up making the CBOC's wait
times look bad, because they're not hitting their wait time goals. That
leaves the CBOC to decide between either doing what's good for the
veteran but knowing it will mess up their numbers, or doing the wrong
thing for the veteran but what looks better administratively for them.
Mr. Secretary--Do you really think this makes sense? How will you
make sure that VA medical centers and clinics aren't ultimately hurt
when they do the right thing for their patient?
Response. VA is working toward taking back community care
scheduling and care coordination from contractors. VAMCs will be
responsible for scheduling and care coordination activities. Owning
customer service is a top priority for VA and the third-party
administrator will only assist with these activities when a VA facility
has requested the support. VA is developing a tool that allows the
Veteran and VA to see the average wait time for the community care
appointment. VA's plan is to phase in the use of this tool prior to
MISSION act implementation so Veterans may make a more informed
decision on the best location to receive the requested care.
Question 25. Mr. Secretary, last month VA testified on my
legislation to expand access to dental care for veterans. I want to
thank you for supporting the idea of expanding access to veterans for
dental care. I'm glad this is something the VA supports. Now, I
understand you're worried about the cost. First, this Committee doesn't
get to make the decisions about how much money the VA gets--that is the
job of the appropriations committee. But let me promise you that I will
do everything I can to make sure the VA gets the money needed to
accomplish any expansion that this Committee approves. And I hope we
can work together on that. Will you work with me on that?
Response. To be clear, VA did not support many of the sections in
the draft legislation presented at the August 1, 2018, Senate Veterans'
Affairs Committee hearing, as several were unnecessary given our
current authority and other provisions either required significant
additional resources or relied on unproven approaches to treatment.
With that said, we are always ready to provide technical help. We agree
the preventive model of dental care is the most cost-effective. Section
3 of the draft bill would have required VA to assess the feasibility
and advisability of furnishing dental services and treatments to
Veterans enrolled in VA health care but who are not eligible for such
care under other authorities. We note that expansion of dental benefits
would create a surge of new patients who we believe would have unmet
dental needs due to their prior lack of dental care. These previous
unmet needs would be more involved with a higher associated cost to
treat and take more dentist time. We expect the increased demand and
time would create access to care hurdles based on our current resource
allocation. In the short-term, we expect an initial surge in demand for
dental care and individual costs would stabilize over time. Of the 9.1
million Veterans enrolled for VA health care, only 1.2 million are
currently eligible for dental care, and approximately 530,000 of those
Veterans received dental care through VA in fiscal year 2018. We expect
that a 758 percent increase in dental eligibility would create a
significant short-term spike in resources needed to meet the increased
demand. Following the short-term spike, VA would need a substantial
increase in resources for the long-term due to the sheer number of
newly eligible Veterans. There may be opportunities to explore
expansion of dental benefits to these 8 million Veterans who currently
are not eligible or have not used dental benefits in the past, in a way
that is considerate of financial impact in both the short-term and
long-term, and we would be happy to discuss any such options with you.
Question 26. Mr. Secretary, to my mind, VA is already spending this
money on dental care--it's just that you're spending it on the back
end, when costly health care problems have already occurred rather than
on the front end, preventing these problems in the first place. Let me
give you some data, which you might find helpful. UnitedHealthCare--a
private insurance company, which you probably won't hear me site very
often--did a study where they found that--and I quote: ``individuals
with chronic conditions who regularly received recommended dental care
. . . had medical claims that averaged nearly $1,500 lower annually
than those with chronic conditions who received . . . no dental care at
all.'' Given the especially high rates of veterans with chronic
conditions, I think it's reasonable to assume this same cost savings of
$1,500 per person would easily translate to the veteran population.
That is to say, by providing dental care to veterans, we'd actually
have the opportunity to save money, not spend more. So, Mr. Secretary--
can you tell me that if we can show that providing dental care wouldn't
actually cost the VA more money, that you'd support it?
Response. Yes, VA will work closely with Congress to estimate
utilization and work toward implementing any legislation that is
approved. The President's FY 2018 budget of $1.2 billion for VA dental
care covered oral health care services for the 530,000 Veterans that
were served. The budget is approximately $2,300 per year per Veteran.
As previously stated, these dental needs will be more complicated with
a higher associated cost to treat for newly eligible Veterans. Our
research found no data to estimate utilization of new benefits such as
those proposed for an additional 7.9M Veterans. Published data on
dental utilization varies ranging from 35% to 60%. The higher usage is
associated with those that have third-party dental benefits. If
eligibility is expanded, the Office of Dentistry will collaborate
within VHA to works toward the goal of using dental care to improve
Veterans' overall health care.
Question 27. Mr. Secretary, I have always believed that the cost of
war must also include taking care of our veterans when they return
home. To my mind, this includes providing benefits to those who may
have been exposed to dangerous chemicals in service to our country,
such as Agent Orange. While the VA provides benefits to these veterans,
the burden of proof is much higher for those who served in Vietnam's
territorial waters compared to their counterparts who served on the
ground. I have heard from many Vermonters that this increased burden of
proof has negatively impacted their ability to receive the care they
need. Mr. Secretary, will you work with me and the overwhelming
majority of Congress who want to create a more lenient burden of proof
for our Blue Water Navy veterans, and ensure they receive the care they
need due to their service?
Response. VA stands ready to work with Congress to ensure the
equitable administration of disability compensation for all Veterans
including Blue Water Navy Veterans. VA's current regulatory definition
of service in Vietnam excludes service in the offshore waters of
Vietnam unless the conditions of service involved duty or visitation in
the Republic of Vietnam. This is because there is not sufficient
scientific evidence showing that individuals who served in the offshore
waters risked exposure to Agent Orange. However, VA has developed
procedures for Veterans who served in the offshore waters to ensure
that each case is reviewed individually on a facts-found basis. This
procedure allows adjudicators to grant benefits for presumptive
service-connected conditions when the evidence demonstrates that a ship
operating in the offshore waters:
1) temporarily enters an inland waterway,
2) docks to a pier or shore, or
3) sent personnel or supplies ashore.
VA has established a lenient burden of proof for the latter as a
statement provided by the Veteran saying he went ashore would be
sufficient to grant benefits.
Question 28. Mr. Secretary, as you know, the White River Junction
VA Medical Center has been without a permanent director for some time
now. Now that we have a new VISN 1 Director, will you commit to working
with me and Mr. Lily to quickly fill the White River Junction director
role with someone who will be there for the foreseeable future?
Response. We recognize your concerns about filling the Medical
Center Director position at White River Junction VA Medical Center.
Strong medical center leadership is critical to maintaining the high
standards and quality of care of Veterans being served by this system.
You can be assured that VA is committed to hiring the best qualified
candidate for the Director position as soon as possible. The position
was announced on September 12, 2018 and closed on September 26, 2018.
VA's selection of Senior Executive Service (SES) leaders is a thorough
and rigorous process. We anticipate completing the hiring process for
this position as soon as possible.
______
Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
agent orange
Question 29. Your letter to the Committee neglects to mention
several sections of the ``Blue Water Navy Vietnam Veterans and Agent
Orange'' report issued by IOM in 2011, which corroborates the
Australian report finding ``that in experiments simulating the water-
distillation systems used on Navy Ships the systems had the potential
to enrich TCDD concentrations.'' You also ignore IOM's Veterans and
Agent Orange 2008 Update, published in 2009 that states, ``a
presumption of exposure of military personnel serving on those vessels
is not unreasonable.'' The effort to cherry-pick details from the
report undercuts your opposition to extending presumption of service
connection to Blue Water Navy veterans. Does the Department dispute the
science behind the IOM and Australian studies related to distillation?
Why does VA refuse to act when IOM presents the Department with
scientific evidence linking health conditions, such as bladder cancer,
Parkinson's like conditions, etc. to herbicide exposure, as was clear
in the 2016 release report?
Response. Advocates for Blue Water Navy Veterans have framed the
issue as there being a lack of science from the National Academy of
Medicine, as well as other sources, to exclude these Veterans from a
presumption of Agent Orange exposure. However, this is a
mischaracterization of the standards for determining that exposure
occurred. When Congress passed the Agent Orange Act, it required that
there be ``sound medical and scientific evidence'' to support such
exposures.
VA has determined that this threshold has not been met. In 2011,
the Institute of Medicine (IOM), now the National Academy of Medicine,
reviewed all available scientific evidence and concluded that exposure
among Blue Water Navy Veterans ``cannot reasonably be determined.'' The
IOM's report indicated that Agent Orange was destroyed by sunlight
within hours of application and any that survived would rarely make it
out to the South China Sea because of the major dilution factor.
Media and several Veterans Service Organizations supporting the
legislation have relied on an Australian study from 2002 that was
designed to mimic Royal Australian Navy distillation policies and
procedures; however, this study is irrelevant to U.S. Navy policy and
practice. U.S. Navy ships were required to draw up seawater for
conversion to shipboard potable water at least 12 miles offshore from
any river, a distance at sea where the presence of Agent Orange was
highly unlikely. As points of reference, 12 cubic miles of water is
equal to 13.2 trillion gallons, and 1 trillion gallons of water flow
over Niagara Falls in a single month. Thus, the dilution factor would
have been significant. IOM considered the Australian study in its 2011
review and stated the significance of the study's findings was highly
uncertain for U.S. Blue Water Navy ships.
VA continues to study the science behind this issue. In late 2019,
VA will publish the peer-reviewed Vietnam Era Health Retrospective
Observational Study. The study will compare the health and morbidity of
deployed Vietnam Veterans versus a cohort of non-deployed Veterans and
similarly-aged U.S. residents who never served in the military. VA
collected data from nearly 43,000 participants including nearly 1,000
Blue Water Navy Veterans. VA believes it is necessary to be informed by
the finding of this study before further action is taken.
Question 30. What is the timeline for VA and OMB to act on the IOM
recommendation regarding bladder cancer, Hypothyroidism, Parkinson's-
like conditions, and hypertension?
Response. The National Academy of Medicine (NAM) issued a
contracted Veterans & Agent Orange report in March 2016. VA organized
work groups and deliberated, as it had under the Agent Orange Act. The
workgroups made recommendations to then-Secretary Shulkin. Secretary
Wilkie is currently reviewing the recommendations made to Secretary
Shulkin. A new NAM on Veterans & Agent Orange was issued November 2018
and is also currently under review. The timeline for this review is
expected to extend to this summer.
electronic health record
Question 31. a. Please discuss how patient information will be
housed under the new Electronic Health Record between DOD and VA?
VA Responses: Patient information for the Department of Defense
(DOD) and the Department of Veterans Affairs (VA) will be physically
housed at the Cerner Federal Hosted Enclave, which is comprised of two
facilities. One facility serves as the failover and continuity of
operations (COOP) back-up for the other. Data is encrypted at rest and
in transit, before it leaves the facility. Connectivity between the two
facilities is achieved via fully redundant with no single points of
failure high-speed networks.
b. How will VA ensure that patient data is shared between community
providers and VA? How will you ensure that the data is protected
against cyber intrusion?
VA Responses: VA's new EHR will have the capability to connect and
securely exchange patient data with community care providers,
specifically, but not limited to, CommonWell Health Alliance and
DirectTrust by supporting their specifications, security, and content
specifications. Once the VA EHR is deployed, the solution will
participate in a Health Information Network (HIN) or Qualified Health
Information Network (QHIN) that has agreed to the terms of the Trusted
Exchange Framework and Common Agreement (TEFCA). Participation is
defined as being in production with HIN or QHIN, under a participation
agreement that aligns with the TEFCA.
c. Do you think that you have the appropriate team in place to
implement the Cerner contract?
VA Responses: VA will deploy DOD authorized security boundary
protections using a combination of Cybersecurity Service Provider
(CSSP) services and joint Department cybersecurity operations centers
(CSOC) visibility and incident response capabilities. The joint
electronic health record (EHR) system is stored within the DOD-
authorized enclave (MHS GENESIS) hosted at Cerner Corporation. MHS
GENESIS risk management and continuous monitoring activities are
supported through Defense Health Agency (DHA), DOD Health Management
System Modernization (DHMSM) Program Management Office (PMO), and
Office of Electronic Healthcare Record Modernization (OEHRM) unified
interagency cybersecurity programs.
d. Will you commit to keeping the Committee informed about the
implementation of the contract?
VA Responses: Yes, VA understands the importance of transparency
and will continue to keep Congress informed about the Department's new
EHR rollout. VA meets quarterly with with staff from the House and
Senate Appropriations and Veterans' Affairs Committees to brief on the
progress of the EHRM development and implementation.
office of inspector general
Question 32. Several Members of the Committee have voiced concerns
regarding the independence of the Office of the Inspector General; in
fact, we approved an amendment to affirm the role of the Inspector
General and to preclude VA from impeding in any IOG investigation.
Since your confirmation, have you met with IG Missal? Have you
reaffirmed VA's commitment to providing OIG with any and all
documentation the office requests for investigations?
Response. As I stated during the hearing, I view the Inspector
General as a partner and not subordinate to the Secretary. The
Inspector General works closely with the Office of Accountability and
Whistleblower Protection and the Veterans Health Administration's
Office of Medical Inspector to investigate allegations of misconduct or
other improprieties. In my previous position, I worked with the
Department of Defense Inspector General and plan to foster that same
working relationship with Mr. Missal. I was asked during the hearing if
I would commit to not interfere or hinder the independence of the
Inspector General and be transparent with requested information. I
would like to state again that I am commitred to that. I have met with
Mr. Missal as recently as October 5, 2018, and it is my goal to
regularly meet with him for updates and discussion. I strongly support
the Inspector General's investigations and mission.
personnel
Question 33. Currently there the Deputy Secretary and Under
Secretary of Health Affairs positions are filled with someone in an
acting capacity. How are you working with the Administration to find
individuals to fill these senior leadership positions?
Response. To fill the Under Secretary for Health (USH) position
there is a process that includes forming a commission which is convened
under the provisions of 38 U.S.C. Section 305. The commission consists
of the Deputy Secretary of VA along with specific members who have
experience in various areas of the Health Administration fields. VA's
Corporate Senior Executive Management Office (CSEMO) begins the process
by gathering all the applicants' resumes and conducting a minimum
qualifications review. After that, the remaining candidates are
referred to a Subject Matter Expert (SME) panel, who then provides a
rating and ranking of the candidates' applications. The scores are then
compiled, and a ``best qualified'' list is then presented in the form
of a binder (with all supporting documents) to the Commission, which
conducts the interviews. We are currently at the stage where we are
compiling the scores to identify those best qualified. We expect to
present the list to the Commission and have the interviews conducted
during the last week of November. After those interviews are conducted,
the Commission will make a recommendation of at least three individuals
to the Secretary. The Secretary will then forward the recommendations
to the President with appropriate comments for the President's
consideration.
Currently, there is a permanent Principal Deputy Under Secretary
for Health (PDUSH) in place (Dr. Richard Stone) and he is currently
serving as the Executive in Charge of VHA. Because of his role, there
is an ``Acting'' in place for the PDUSH position, but that is only
until a new USH is identified and onboarded. After that, Dr. Stone will
resume his duties as PDUSH.
patient safety
Question 34. Does VA leadership review OIG reports related to
patient safety with adverse outcomes? And if leadership does review
these reports, are the recommendations and findings applied throughout
the entire VA healthcare system?
Response. VA and VHA leadership reviews OIG reports and involves
the National Center for Patient Safety to ensure any findings that risk
harm to Veterans are assessed and used to inform system wide
improvements.
In general, VA leadership learns of adverse outcomes to patients
through communications with facility or VISN leadership and takes
actions as soon as possible upon learning of a potential risk to
patient safety. Understandably, if a serious safety issue has been
reported to the OIG, VA cannot (and does not) wait for the OIG to
complete its review and publish its investigative report before
assessing the situation on the ground and determining what corrective
action, if any, is needed to eliminate any actual or potential patient
safety risks. In other words, VA does not delay any needed corrective
action but acts promptly in the interim. Typically, the OIG will
assess, as part of its investigation or review, any interim corrective
action taken by VA and its sufficiency. Patient safety is paramount.
In response to reported adverse events for which there may be
systemic root causes, VHA's National Center for Patient Safety assesses
patient safety findings, usingindustry standards. If a safety risk is
of nationwide concern, the National Center for Patient Safety issues a
nationwide alert that informs the field both of the problem, affected
facilities or service-lines, and the follow-up actions to be taken in
response. See VHA Handbook 1050.01 for a fuller discussion of the
Patient Safety Program.
va mission act
Question 35. As VA begins to implement the VA MISSION Act, can you
discuss what metrics you will use to ensure care that veterans receive
in the community is the same standard and timely? What metrics will you
use to track whether community providers are trained in veteran
specific conditions?
Response. Section 133 of the MISSION Act requires VA to develop
competency standards for community providers in which VA has clinical
expertise. At this time, the Section 133 group is still working out the
metrics that will meet the spirit of Section 133. Currently, this
includes all community providers completing an overview course covering
military culture, caring for Veterans, suicide prevention, and other
resources. Moreover, required training for sub-specialty providers in
the areas of Traumatic Brain Injury (TBI), post-traumatic stress
syndrome (PTSD), and Military Sexual Trauma (MST) is also being
reviewed by the Section 133 team.
As for tracking the completion of the courses previously discussed
and opioid training through Section 131 of the MISSION Act, the courses
will be accessed through VHA TRAIN, which is the external system that
houses community provider training. At this time, VA currently tracks
community provider completion of opioid training and additional courses
will be added (as noted above). Once a training course is uploaded into
VHA TRAIN, course completion will be cross-referenced with a master
list of community providers the VHA Office of Community Care maintains
for tracking and reporting.
______
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
va under secretary for health vacancy
Question 36. President Trump has yet to nominate someone for the
important role of Under Secretary for Health. The Veterans Health
Administration has a lot on its plate in the coming years including
implementation of the new Veterans Community Care Program and
Electronic Health Record modernization so a permanent, stable leader is
vital. However, instead of moving toward a permanent lead, Dr. Carolyn
Clancy, Acting Under Secretary for Health, was replaced in mid-July by
Dr. Richard Stone. Could you please provide an explanation for that
staffing change and an update on any progress toward a permanent Under
Secretary?
Response. To fill the Under Secretary for Health (USH) position
there is a process that includes forming a commission which is convened
under the provisions of 38 U.S.C. Section 305. The commission consists
of the Deputy Secretary of VA along with specific members who have
experience in various areas of the Health Administration fields. VA's
Corporate Senior Executive Management Office (CSEMO) begins the process
by gathering all the applicants' resumes and conducting a minimum
qualifications review. After that, the remaining candidates are
referred to a Subject Matter Expert (SME) panel, who then provides a
rating and ranking of the candidates' applications. The scores are then
compiled, and a ``best qualified'' list is then presented in the form
of a binder (with all supporting documents) to the Commission, which
conducts the interviews. We are currently at the stage where we are
compiling the scores to identify those best qualified. We expect to
present the list to the Commission and have the interviews conducted
during the last week of November. After those interviews are conducted,
the Commission will make a recommendation of at least three individuals
to the Secretary. The Secretary will then forward the recommendations
to the President with appropriate comments for the President's
consideration.
Currently, there is a permanent Principal Deputy Under Secretary
for Health (PDUSH) in place (Dr. Richard Stone) and he is currently
serving as the Executive in Charge of VHA. Because of his role, there
is an ``Acting'' in place for the PDUSH position, but that is only
until a new USH is identified and onboarded. After that, Dr. Stone will
resume his duties as PDUSH.
mar-a-lago
Question 37. On April 20, 2018, as Acting Secretary, you traveled
to West Palm Beach and attended a meeting with the ``Mar-a-Lago Crowd''
at Mar-a-Lago, a property owned by President Trump. Chief of Staff
Peter O'Rourke also traveled with you on that trip. In documents
obtained by ProPublica through the Freedom of Information Act, Mr.
O'Rourke's expense report for the trip details that he stayed at Mar-a-
Lago the night of April 19, 2018 at a cost of $195. Mr. O'Rourke also
incurred lodging fees of $202.27 for that same night at a Holiday Inn,
the original hotel that was canceled late on the same day as check in,
resulting in a charge of one night's stay. In an email, it is explained
that Mr. O'Rourke was ``redirected by a White House task after the 24-
hour cancellation period.'' Could the Department please provide
additional information regarding what official task Mr. O'Rourke was
directed to carry out that required him to redirect to one of the
president's properties, at additional cost to taxpayers?
Response. The COS was redirected to stay at this lodging in order
to facilitate his attendance at a required meeting with the then-Acting
Secretary of Veterans Affairs.
provider recruitment and retention
Question 38. The most recent data from the VA Office of the
Inspector General shows that nationwide the VA is still dealing with
staffing shortages. In Honolulu, psychiatry is the number one shortage
and there are 42 clinical shortage areas. Can you provide an update on
what VA is doing to improve provider recruitment and retention in
Hawaii and nationally?
Response. In response to a Government Accountability Office Report
in March 2018, VA Pacific Islands HCS (VAPIHCS) organized a
multidisciplinary systems redesign group to review and evaluate
strategies to promote physician recruitment and retention. The group
identified a list of best practices (some of which were already being
utilized by VAPIHCS) that have proven beneficial at other VA
facilities, including the use of a task force to explore options for
improving recruitment and retention. In May 2018, VAPIHCS appointed a
physician recruitment and retention taskforce aimed at identifying
additional actions that could be taken to improve physician recruitment
and retention. To date, the task force has identified several
recommendations, which are currently being implemented:
1. Initiate the hiring process immediately after being notified of
an upcoming vacancy
2. Utilize open continuous recruitment
3. Expedite the credentialing and privileging process
4. Maximize use of Recruitment/Retention/Relocation incentives (``3
Rs'')
5. Maximize use of the Education Debt Reduction Program (EDRP)
6. Present salary offer early in the hiring process
7. Utilize other recruitment events in addition to USA Jobs
In addition, VAPIHCS authorized more than $200,000 in relocation and
retention funds for physicians. Of the nine physicians who received
funds on 2018, eight are still on staff at VAPIHC.
______
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to
Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
Question 39. Each generation of veterans have had their own form of
toxic exposure, whether Mustard Gas, Agent Orange, or any number of
chemicals and hazardous environments our service personnel work in
today.
a. What efforts are currently being undertaken to identify and
track toxic exposures?
Response. There are several Department of Veterans Affairs (VA)/
Department of Defense (DOD) collaborative activities aimed at improving
the identification and tracking of toxic exposures. The primary
initiative, which has been 25 years in the making, is the development
of the web-based solution, Individual Longitudinal Exposure Record
(ILER). The ILER pilot was launched on October 1, 2018. ILER addresses
a critical gap in current readiness and healthcare capabilities to
assess and better document individuals' service related exposure.
ILER will bridge this gap by providing an easily accessible and
searchable electronic record of a servicemember's occupational and
environmental exposures (garrison- and deployment-related) from initial
entry to end of service.
ILER will enable improvement of exposure knowledge, healthcare,
epidemiological assessments of exposures, exposure-related medical
research, and disability evaluation and claims processes for
servicemembers and veterans.
ILER will leverage and collate the exposure and deployment data
available to present the most relevant information to DOD and VA. The
ILER Pilot version 1.0.0.0 will leverage information provided from the
following sources:
Defense Occupational and Environmental Health Readiness
System--Industrial Hygiene (DOEHRS-IH)
Military Exposure Surveillance Library (MESL)
Military Health System (MHS) Data Repository (MDR)
Armed Forces Health Surveillance Branch (AFHSB)
Defense Manpower Data Center (DMDC)
Defense Enrollment Eligibility Reporting System (DEERS)
Contingency Tracking System (CTS)
These systems will provide the initial data source of the pilot and
will provide a person-centric record that can be utilized by
Clinicians, Claims/Benefits Processors, Program and Policy Analysts,
Researchers and Informatics/Analytics Professionals to enhance medical
care and perform a more comprehensive health surveillance.
b. What steps can be taken to prepare the Department of Veterans
Affairs and the next generation of veterans with toxic exposures for
the next 20 years?
Response. Please see efforts described in response to (a) above.
c. Is the tracking of toxic exposures being considered in the
design of the new Electronic Health Record?
Response. Yes, VA will track self-reported toxic exposures to
Veterans with its new EHR. The EHR will utilize a commercial population
health platform, HealtheIntent, which provides registries as part of
its suite of capabilities. Migration of current VA self-reporting
registries, such as Traumatic Brain Injury (TBI), military sexual
trauma (MST), airborne hazards and open burn pit registry (AHOBPR),
will be transitioned into the HealtheIntent platform as part of VA's
data migration efforts.
Question 40. The Departments of Defense and Veterans Affairs
previously attempted to replace their separate EHR systems with a
single shared system through the Integrated EHR (iEHR) initiative,
unfortunately this effort was abandoned in 2013. Communication and
collaboration between the two departments will be essential for the
success of the current, interoperable EHR rollout.
Please detail the current structures in place to facilitate
communication and collaboration between the two departments. What
systems and structures are planned to be put in place as the rollout
continues?
Response. VA and DOD are continuing to work closely together to
advance transparency and hone governance through an interagency
decisionmaking perspective through the DOD/VA Interagency Program
Office (IPO) established by Congress. The Departments' Secretaries
recently announced a joint statement reconfirming their commitment to a
joint and interoperable EHR rollout. VA is currently working with DOD
and IPO to analyze and assess prospective additional efficiencies that
may optimize the utilization of other resources across VA, DOD, and
IPO's organizational EHR implementation and modernization portfolios.
Question 41. It was reported that the DOD's rollout of the Cerner
system in the Pacific Northwest was plagued with problems that
significantly impacted patient care. Any rollout of a new EHR system is
going to experience significant challenges, but it is important to
learn from those and adjust future strategies.
a. Does the VA have detailed reports on the problems encountered
during the DOD's initial Cerner EHR rollout?
Response. Yes, DOD lessons learned were shared with VA during the
alpha contract negotiations phase with Cerner Corporation. These
lessons learned were immediately leveraged to improve the quality of
the Indefinite Delivery, Indefinite Quantity contract that was
ultimately signed on May 17, 2018 between VA and Cerner Corporation. VA
maintains a running log of lessons learned, and incorporates regular
feedback from DOD, DHA, and DHMS PEO into its lessons learned
documentation. By learning from DOD, VA will be able to proactively
address challenges and further reduce potential risks at VA's IOC
sites.
b. What were the underlying causes of those problems? Which of
these underlying causes are likely to impact deployment of a Cerner EHR
system in VA hospitals?
Response. To mitigate possible impacts to the deployment of VA's
new EHR in VA hospitals, VA is leveraging DOD's lessons learned from
their IOC sites. Several examples of efficiencies VA is leveraging
include: revised contract language to improve trouble ticket resolution
based on DOD challenges; optimal VA EHRM governance structure; fully
resourced PMO with highly qualified clinical and technical oversight
expertise; effective change management strategy; and utilizing Cerner
Corporation as a developer and integrator consistent with commercial
best practices. For additional specificities on DOD's lessons learned,
VA recommends reaching out to DOD.
c. What office will be responsible for cataloguing the ``lessons
learned'' from the DOD rollout and who will be leading that office?
Response. VA, specifically the Office of Electronic Health Record
Modernization (OEHRM), is responsible for cataloguing and utilizing
DOD's lessons learned to mitigate potential challenges throughout its
deployment.
Question 42. One in ten Veterans Affairs jobs are currently
unfilled. As of September 26th, there are 128 positions posted in
USAJOBS for West Virginia Hospitals and Benefits offices, including for
many important clinical and social work positions. Vacancies have the
potential to increase the burn out rate of employees as well increase
the number of veterans that need to be sent out into the community for
care.
a. In the 60 days that you have been in office, has there been
discussion of developing and/or implementing a vacancy action plan?
b. If no such plan is in place will you commit to working on one
and reporting back to us?
Response. I understand your concern about vacancies in VA. It is
important to note that staffing plans consider workforce turnover and
growth, and built into those staffing plans, is the expectation that
there will always be vacant positions in some stage of recruitment. We
know that Veterans receive the same or better care at VA medical
centers as patients at non-VA hospitals. Vacancies reflect a hiring
demand signal, but do not indicate significant shortages in most
instances. In areas where vacancies are higher due to factors such as
rurality, high cost geographic areas, and market competition, VA
utilizes the authorities granted under the VA MISSION ACT to partner
with community care providers. The best indicators of adequate staffing
levels are Veteran access to care and health care outcomes, and we are
continuing to make substantial progress on these measures.
Question 43. We are pleased to see that the VA is implementing an
appeals improvement and modernization plan. However, our office alone
is currently working with the department on 200 cases. Some
constituents are dealing with claims that have been lost or put off for
over 5 years.
a. What have you observed that could improve the appeals process?
Response. The current appeal process for VA benefit claims does not
serve Veterans well, with resolution times for veterans averaging 3 to
7 years depending upon whether the Veteran appeals to the Board of
Veterans' Appeals (Board). To improve this process, VA worked closely
with its stakeholders (including Veterans Service Organizations,
private attorneys, and Congressional staff) to develop a new, more
efficient, decision-review process for claims. The President signed
this process into law as the Veterans Appeals Improvement and
Modernization Act in August 2017. VA is on track to implement it in
February 2019 for claimants who receive decisions on their claims after
the February implementation date.
The new law provided VA several options to improve the appeals
process by increasing efficiencies in established practices and by
providing Veterans with opportunities to opt into a new system that
provides claimants with the opportunity to file supplemental claims
based on new evidence, have higher-level adjudicators review prior
decisions, or appeal directly to the Board.
b. What steps are you taking to better address the initial veteran
claim process to ensure there is not a backlog of appeals?
Response. Historically, Veterans consistently initiate appeals of
claim decisions at a rate of 10 to 12 percent. The solution to
effectively managing disagreements is through more review options and
timely decisions under the new statute, which has replaced the long,
complex, and confusing legacy appeals process.
VA remains committed to resolving its legacy appeals as quickly as
possible by adding additional appeal processing resources both in VBA
and at the Board, and implementing RAMP. As noted above, RAMP provides
Veterans with legacy appeals an opportunity to opt into the process
authorized by the Modernization Act. If they elect to participate in
RAMP, Veterans have access to the key features of the new process, to
include more review options, quicker decisions, protection of the
effective date for payment of benefits regardless of the review option
chosen, protection of favorable findings made in VA decisions, and
processes that are easier to understand.
Beyond the legal changes that will go into effect in February, VBA
is looking to increase operational efficiencies. Accordingly, effective
October 1, 2018, VBA established three new Decision Review Operations
Centers (DROCs) at the St. Petersburg and Seattle Regional Offices, as
well as the former Appeals Resource Center in Washington, DC. The DROCs
will consolidate the processing of all Board remands, Board full grants
under the new system, and higher-level reviews under the new system.
Question 44. The VA Office of the Inspector General reported that
the claims backlog only covers about 79 percent of relevant cases, with
a host of others misclassified, mistakenly excluded and, in some cases,
only acknowledged as overdue after the files had finally been
processed. What steps are being taken to more accurately count and
report the number of claims awaiting decision for more than 125 days?
Response. The VA Office of Inspector General (OIG) reported, and
the Veterans Benefits Administration (VBA) acknowledged, that VBA's
claims backlog has historically and consistently included only a set of
rating-related end products that grant entitlement to disability
compensation and pension benefits. OIG notes that additional claims are
not counted in the backlog that, in their opinion, should be, because
they require a rating decision. The relevant claims identified by OIG
that are not counted in VBA's rating claim inventory or backlog but do
require a rating decision, are those that do not consider entitlement
to the core disability compensation and pension benefits. Examples of
these end products are provided by OIG and include technical
corrections to rating decisions (where a rating-related end product had
already been completed by the agency) and entitlement to special
housing benefits.
Additionally, OIG identifies a very small number of claims missing
from backlog reporting due to human error. OIG identified situations
where some claims are erroneously excluded from the backlog and other
situations where claims are erroneously counted as backlog, when they
are in fact not. However, OIG also acknowledged that VBA staff who
discovered these errors made the necessary adjustments to properly
reflect the backlog status. VBA has concurred in principle with the
OIG's recommendation to consider revising which claims are included in
VBA's reported disability claims backlog and will engage with
stakeholders to ensure that any proposed changes are well understood.
VBA is currently reviewing how best to supplement or adjust reporting
on the rating-related backlog, which has followed consistent rules
since the backlog was defined and reporting began in 2009.
Question 45. The most recent data from HUD found that the number of
homeless veterans increased by almost 2 percent from 2016 to 2017, the
first time the number has risen since 2010. Meanwhile, over the past
year, VA has issued and subsequently reconsidered proposals to
terminate or reallocate funding within programs like Grant Per Diem and
HUD-VASH. This has left providers in West Virginia concerned about
whether their grants will be renewed and forced difficult decisions on
staffing and capacity.
How do you plan to keep local providers informed of changes
relevant to their grant programs in a timely manner?
Response. The GPD National Program Office provided regular
communication regarding the grant selection timeline, notifications of
conditional selection and non-selection of applicants, as well as the
transition process for non-selected applicants who had grants that
would be ending September 30, 2018.
May 14, 2018--GPD National Program Office held a
conference call reviewing the anticipated timeline regarding the grant
selection process. This included the plans for notification via
correspondence which was to occur at the end of the month of May.
Presentation slides for this call were subsequently posted on the GPD
provider website https://www.va.gov/HOMELESS/GPD_ProviderWebsite.asp
May 29, 2018--Correspondence was mailed to all applicants
noting whether their application was conditionally selected or non-
selected. Additional correspondence was sent to non-selected applicants
that had a GPD grant award that would be ending on September 30, 2018,
which provided instructions for winding down their grant projects. This
included working with the local VA medical center to ensure the
placement of any homeless Veterans in the program to permanent housing
or alternative services by September 30, 2018. In addition the GPD
National Program Office was in communication with the Directors of
VHA's other homeless programs to alert them of coming changes and
coordinate support with these program services to assist homeless
Veterans as needed.
June 11, 2018--GPD National Program Office held a
conference call to review the notification correspondence that had been
sent to grant applicants, as well as to review the status of grantees
who were eligible for an option year renewal in Fiscal Year 2019. The
presentation slides were posted on the GPD provider website.
The GPD National Program Office also responded to
inquiries from applicants via phone call and a special email group
available to communicate with the grant office.
In addition to the notifications of grantees, the GPD
National Program Office was in communication with the Network Homeless
Coordinator for VISN 5 and the GPD liaison in Martinsburg, WV (where
Potomac Highlands Supported Services, a non-selected applicant with
grant ending September 30, 2018 is located) to monitor the status of
all the Veterans residing there and to ensure these Veterans were
successfully placed. All the Veterans in the program were successfully
placed by September 5, 2018.
Question 46. Staffing shortages are a persistent challenge at the
VA as well as many other Federal agencies. In order to fulfill its
vital missions it is important that the VA is adequately staffed with
well trained and highly motivated employees, in both clinical and non-
clinical positions. A recently released Office of the Inspector General
report stated the most commonly cited challenges to staffing at VHA
facilities fit into three categories: (1) lack of qualified applicants,
(2) non-competitive salary, and (3) high staff turnover. In a letter to
congressional leaders announcing there would be no pay increases for
Federal Employees in 2019 President Trump stated ``These alternative
pay plan decisions will not materially affect our ability to attract
and retain a well qualified Federal workforce.''
Do you agree with the President's assessment that canceling
scheduled pay increases will have no material effect on recruitment and
retention of well-qualified VA employees?
Response. I understand your concern about vacancies in VA. It is
important to note that staffing plans consider workforce turnover and
growth and the expectation that there will always be vacant positions
in some stage of recruitment. We know that Veterans receive the same or
better care at VA medical centers as patients at non-VA hospitals.
Vacancies reflect a hiring demand signal, but do not indicate
significant shortages in most instances. The best indicators of
adequate staffing levels are Veteran access to care and health care
outcomes, and we are continuing to make substantial progress on these
measures. Cancelling the scheduled annual pay adjustment for 2019 will
make it even more challenging for VA to recruit and retain staff in
clinical and non-clinical positions. In most, it not all of the rural
locations, and even in some major cities, VA salaries lag significantly
behind the local labor market for some occupations. In addition,
several clinical occupations with special rates continue to have
recruitment and retention problems due to VA's inability to offer
competitive salaries.
A P P E N D I X
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Prepared Statement of Max Stier, President and CEO,
Partnership for Public Service
Chairman Isakson, Ranking Member Tester and members of the Senate
Committee on Veterans' Affairs, Thank you for the opportunity to offer
the views of the Partnership for Public Service on the progress the
department is making during the first 60 days of Secretary Wilkie's
leadership. As a nonpartisan, nonprofit organization that strives for a
more effective government for the American people, we help agencies
attract mission-critical talent, advocate for systemic changes to
modernize government's outdated personnel system and develop high-
performing Federal leaders. The topic of leadership is core to the
Partnership's mission and one that we know to be crucial to agency
mission success.
Secretary Wilkie and his leadership team have a big job ahead of
them and limited time in which to do it. The secretary is responsible
for leading an organization of over 300,000 employees, 145 medical
facilities, one-hundred-plus burial sites, dozens of benefits offices
and 9 million veteran patients with just a handful of years to lay out
a vision and set a course.\1\ There will be strong incentives to focus
on policy implementation at the expense of strengthening the management
systems that are the groundwork for the department's long-term success.
To position the VA to meet the needs of current veterans while setting
itself up for the future, Secretary Wilkie and his team must
effectively collaborate with Congress, the veterans community and other
key stakeholders, promote greater accountability at all levels of the
department and assume responsibility for the overall health of this
organization that is so important to the millions of veterans they
serve.
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\1\ Statement of Hon. Michael J. Missal Inspector General of the
Department of Veterans Affairs before the Committee on Veterans'
Affairs U.S. House of Representatives Hearing on ``The Curious Case of
the VISN Takeover: Assessing VA's Governance Structure,'' 115th Cong.,
13 (2018).
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Congress is an essential stakeholder and steward of the
government's solemn commitment to veterans and their families. The
Partnership believes that the VA performs best when it is supported by
and accountable to the legislative branch. The Committee deserves
recognition for the way it has conducted rigorous bipartisan oversight,
promoted constructive dialog with the department's leaders and
committed itself to the difficult work of transforming the department.
The commitment of this Committee to proactive and thorough oversight of
the VA's management and programs sets a positive example for other
committees to follow.
An ongoing area of emphasis for the Committee has been personnel,
and for good reason--dedicated, mission-driven employees are critical
to VA's success. While this Committee has focused on the need for the
department to hold its employees accountable for their performance, and
understandably so, we believe it is equally important to learn from the
hundreds of thousands of Americans, many of whom are veterans
themselves, who accomplish great things for veterans and on behalf of
veterans every day as department employees. The secretary and the
Committee can learn from their success, and find ways to replicate it
throughout the department.
The Partnership's Service to America Medals (Sammies) program is an
annual event that recognizes incredible civil servants who have led
significant accomplishments on behalf of the American people, and VA
employees are well-represented among our honorees. These individuals
each demonstrate just some of the incredible work of the department's
employees and their dedication to serving veterans.
One such employee is Marcy Jacobs, the executive director for VA's
Digital Service Team, who worked with her team to enhance the Vets.gov
website to help veterans apply for, track and manage their benefits. By
giving veterans a single point of contact, her team has made it easier
for veterans to access the department's services, with more than 1.6
million veterans having logged into an account. Another honoree, Dr.
Rory Cooper, led the VA's Human Engineering Research Laboratories to
help improve mobility and quality of life for hundreds of thousands of
disabled veterans. Dr. Cooper and his team spearheaded innovations that
include wheelchairs with robotic arms, improved motorized wheelchairs,
and other features that have earned his team 25 separate patents.
VA employees are also on the front lines of addressing homelessness
among the veteran population. Dr. Thomas O'Toole of the Providence VA
Medical Center helped found the National Center on Homelessness Among
Veterans, which helps veterans access the comprehensive medical care,
housing assistance and social services they need to reclaim their
lives. Another VA employee, Anne Barker Dunn, created two programs that
provided support to incarcerated veterans that offered access to
critical services and assisted with substance abuse and housing needs.
We recommend that the Committee do more to engage the secretary and
the department's staff in understanding why these civil servants are
able to innovate and solve problems, and how those lessons learned can
be applied across the department. While the passage of the Veterans
Affairs Accountability and Whistleblower Protection Act of 2017
represents a significant shift in the department's approach to
addressing accountability and leadership challenges, the cultural
changes this Committee would like to see at the VA will not occur
simply by firing underperforming employees. As the stories above
demonstrate, the VA's employees are the department's greatest asset-not
a cost to be borne. The focus of VA's leaders should be on supporting,
encouraging and engaging high-performing employees and building a
culture of excellence. This is hard work and requires a critical view
of every aspect of the organization-accountability is simply one part.
Perhaps most critical is the need to examine the effectiveness of the
department's most senior political and career leaders who are charged
with motivating, inspiring and managing each of the VA's three hundred
thousand-plus employees.
Capable leadership is essential to a healthy organizational
culture. Research by the Partnership for Public Service as part of our
Best Places to Work in the Federal Government Rankingsr has found that
leadership is the single biggest driver of employee satisfaction and
commitment across government and within the Department of Veterans
Affairs specifically. The rankings show that in 2017 VA ranked second
to last among large agencies in employee satisfaction with senior
leaders and last in satisfaction with supervisors.\2\ I strongly
encourage the Committee to take a hard look at VA's All-Employee Survey
and the non-VA Federal Employee Viewpoint Survey to assess the impact
of last year's accountability legislation and the administration's
progress in turning around the department's culture. As the
administration's nominee for the Office of Accountability and
Whistleblower Protection, Tamara Bonzanto, told the Committee earlier
this month, ''[I]f you improve the culture and employees are satisfied
with their environment that they're working in and they feel safe
working in that environment in reporting concerns, hopefully, we can
get improvement in customer services'' and, ultimately, better care for
veterans.
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\2\ ``Department of Veterans Affairs.'' Best Places to Work in the
Federal Government. 2017. Accessed September 25, 2018. http://
bestplacestowork.org/BPTW/rankings/detail/VA00#tab_ category_tbl.
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Undergirding the transformation pursued by the Committee and
Secretary Wilkie must be a commitment to the stewardship of the
Department of Veterans Affairs as an organization--in other words, the
management systems, infrastructure, and employees who make the
department's success possible. The VA's leaders, particularly its
political appointees, must assume a sense of ownership for the long-
term health of the institution. Secretary Wilkie should, even now, be
thinking beyond his tenure at the department to the department he will
be leaving to the individual who follows him as secretary. As a
practical matter, such leader ownership requires prioritizing the VA's
organizational health by building a pipeline of future leaders,
connecting management to performance outcomes using data,
institutionalizing key reforms, and holding leaders at every level
accountable, including through the use of performance plans as required
by the VA Choice and Quality Employment Act.\3\
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\3\ Section 203 of S. 1094, 115th Cong. (2017) (enacted).
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I believe the priorities Secretary Wilkie laid out during his
nomination hearing-to improve the department's culture, to focus on
customer service and access to care, to strengthening mission support
functions like information technology and human resources-are the right
ones. Secretary Wilkie can promote a sense of ownership while
effectively addressing those priorities by taking advantage of
promising practices and innovations already occurring within the VA.
For example, the Veterans Health Administration's Innovators Network
promotes and spreads promising practices initiated by frontline
employees across the VHA healthcare system. Innovative ideas developed
by employees include using 3D printing to help surgeons prepare for
procedures and interviewing veterans about their lives so that their
stories can help medical providers offer improved care.\4\ While these
improvements are occurring in pockets of the agency, the department can
do more to promote innovation widely: data from the 2017 FEVS found
that just 32.4 percent of employees believed that the VA rewarded
creativity and innovation.
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\4\ Ogrysko, Nicole. ``How the VHA Innovators Network Is 'changing
Narrative' of Complacency.'' FederalNewsRadio.com. September 12, 2018.
Accessed September 25, 2018. https://Federalnewsradio.com/veterans-
affairs/2018/09/how-the-vha-innovators-network-is-turning- changing-
narrative-of-complacency/.
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The department has the talent, resources, and commitment to mission
that it needs to allow innovation in the service of veterans to thrive.
The secretary set the right tone in his initial address to VA employees
in July, stating that ''[I]t is from you that the ideas we carry to the
Congress, the VSOs and to America's Veterans will come.'' \5\ It will
be up to Secretary Wilkie and other leaders across the department to
follow through and create an environment in which that is truly the
case.
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\5\ Wilkie, Robert. ``A Message to VA's Workforce from Secretary
Wilkie.'' VAntage Point. August 03, 2018. Accessed September 25, 2018.
https://www.blogs.va.gov/VAntage/50910/a-message- to-vas-workforce-
from-secretary-robert-wilkie/.
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Congress and this Committee can and should play an important role
in supporting innovation and promoting a sense of ownership and
accountability in spirit and practice. Through its oversight, the
Committee can look for bright spots within the VA and ways to replicate
them across the department. The Committee can ensure that the VA is
maximizing the use of new personnel and programmatic authorities
granted to it over the last several years to improve service and care.
Finally, it can continue to work with Secretary Wilkie, his leadership
team, and others in the department in a collaborative spirit. I believe
Ranking Member Tester's words during Secretary Wilkie's confirmation
hearing, that ``if there is good communication between you and the
Members of this Committee, particularly the chairman and myself, I
think we can smooth a lot of those rough waters.'' \6\ I urge the
Committee to continue in that spirit.
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\6\ Hearing on the Nomination of Robert Wilkie to be Veterans
Affairs Secretary before the Committee on Veterans' Affairs, U.S.
Senate, 115th Congress. 2 (2018), https://www. veterans.senate.gov/
hearings/pending-nomination_-secretary-06272018
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Chairman Isakson, Ranking Member Tester and Members of the
Committee, thank you for the opportunity to share the Partnership's
views on the opportunities and challenges confronting the Department of
Veterans Affairs as Secretary Wilkie begins his tenure and the next
chapter in the story of the VA's transformation. Success now and in the
future will require close collaboration between the VA and Congress, a
focus on engagement as well as accountability, leaders taking ownership
of the department as an institution, and a continuing commitment to
innovation. It is an important way to honor our shared commitment to
America's veterans.
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